Pulp Response to Materials Used in the Management of Deep Carious Lesions Without Pulp Exposure: A Systematic Review and Network Meta-Analysis.

BACKGROUND

Placing a pulp-capping material over the remaining dentine is integral to managing deep carious lesions in permanent teeth without pulp exposure. However, current guidelines do not favour any specific pulp-capping material, and there is no direct clinical evidence that pulp-capping materials maintain pulp vitality better than placing the restoration directly on dentine.

OBJECTIVES

To compare the effectiveness of various biomaterials, including pulp-capping materials and restorative materials applied directly over the remaining dentine, against one another in preserving pulp health in permanent teeth with deep carious lesions without pulp exposure.

METHODS

On June 9, 2024, MEDLINE, Embase, Scopus, and Web of Science were searched, supplemented by a screening of clinical trial registries, grey literature, and reference lists. Randomised controlled trials (RCTs) evaluating the effectiveness of indirect pulp capping in permanent teeth affected by deep carious lesions without pulp exposure were included. Risk of bias was assessed using the revised Cochrane risk-of-bias tool for randomised trials (RoB 2). Network meta-analyses and meta-regression were performed using a Bayesian approach and a random-effects model for the primary outcome (loss of pulp vitality), followed by an assessment of confidence in the evidence using the CINeMA framework.

RESULTS

Sixteen RCTs (19 reports; 1039 participants; 1093 teeth; seven biomaterials) were included. Most comparisons involving the dentine bonding agent (DBA; control) were supported by low-confidence evidence and lacked statistical significance; however, they always resulted in RRs favouring the pulp-capping materials. Notably, moderate-confidence evidence indicated that during the second follow-up year Biodentine (RR = 0.00; 95% CI: 0.00-0.53) and glass ionomer cement (GIC) (RR = 0.30; 95% CI: 0.00-0.99) outperformed the DBA. Moderate-confidence evidence also demonstrated that during the first follow-up year mineral trioxide aggregate (MTA) (RR = 0.30; 95% CI: 0.09-0.84) outperformed calcium hydroxide cement. Meta-regression found that neither study-level demographic covariates nor clinical-technique covariates were significantly associated with pulp-vitality outcome.

CONCLUSIONS

While most findings in this review were of low confidence, the evidence nevertheless supports the use of pulp-capping materials in permanent teeth with deep carious lesions. Among these materials, Biodentine, MTA, and GIC have the strongest supporting evidence for preserving pulp vitality.

TRIAL REGISTRATION: PROSPERO number: CRD42024507641.