Outcome of vital pulp therapy with treatment based on various medicaments: a systematic review and meta-analysis

Background: Vital pulp therapy (VPT) is a biological procedure performed to maintain pulp vitality and function in teeth diagnosed with pulp exposure. The selection of medication is an important criteria to ensure successful treatment. Calcium hydroxide (CH) has been used in various formulations, but newer-generation biomaterials, including mineral trioxide aggregate (MTA) and Biodentine, have better sealing ability, biocompatibility, and clinical prognosis. The present review aimed to synthesize evidence for comparing various pulp-capping and pulpotomy medicaments to determine the most effective materials. Methods: A systematic search was made in MEDLINE, Embase and the Cochrane Library to identify studies pertaining to compare clinical and radiographic outcomes of vital pulp therapy using different medicaments. The major databases were searched in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. Inclusion criteria: Randomized clinical trials, prospective studies, and clinical studies that assessed the success of Vital pulp therapy (VPT) using Minteral trioxide aggregate (MTA), Biodentine, Calcium hydroxide (CH), or other biomaterials were included. Studies with insufficient outcome data, case reports, or reviews were excluded. The eligibility criteria were met in 13 studies. Data were extracted on study design, number of patients, medicaments used and length of follow-up. Results: MTA had a higher success rate than CH. There was no statistically significant difference in comparisons of MTA and Biodentine Biodentine showed a tendency to be superior to CH in different studies The subgroup analysis demonstrated that children had a greater pooled success rate (88%) than adults (82%), and the long-term follow-up group (>24 months) had a stable result. Conclusion: MTA was the most reliable medication for VPT. Biodentine has emerged as a viable alternative, especially considering its handling advantages, whereas CH demonstrated lower success rates. The PROSPERO Registration: The review was registered into PROSPERO (registration number: CRD420251137453).

Vital pulp therapy; Mineral trioxide aggregate; Biodentine; Calcium hydroxide; Pulpotomy; Pulp-capping

[1] Zhang W, Yelick PC. Vital pulp therapy-current progress of dental pulp regeneration and revascularization. International Journal of Dentistry. 2010; 2010: 856087.

[2] Duncan HF. Present status and future directions-vital pulp treatment and pulp preservation strategies. International Endodontic Journal. 2022; 55: 497–511.

[3] Colloc TNE, Tomson PL. Vital pulp therapies in permanent teeth: what, when, where, who, why and how? British Dental Journal. 2025; 238: 458–468.

[4] Fasoulas A, Keratiotis G, Spineli L, Pandis N, De Bruyne MAA, De Moor RJG, et al. Comparative efficacy of materials used in patients undergoing pulpotomy or direct pulp capping in carious teeth: a systematic review and meta-analysis. Clinical and Experimental Dental Research. 2023; 9: 1129–1148.

[5] Komora P, Vámos O, Gede N, Hegyi P, Kelemen K, Galvács A, et al. Comparison of bioactive material failure rates in vital pulp treatment of permanent matured teeth—a systematic review and network meta-analysis. Scientific Reports. 2024; 14: 18421.

[6] Soma U, Sharma R, Gupta A, Abraham D, Ahmad L, Neha N. Clinical and radiographic outcomes following pulpotomy using biodentine in carious exposed mature permanent teeth: a systematic review and meta-analysis. Journal of International Society of Preventive and Community Dentistry. 2025; 15: 313–322.

[7] Islam R, Islam MRR, Tanaka T, Alam MK, Ahmed HMA, Sano H. Direct pulp capping procedures—evidence and practice. Japanese Dental Science Review. 2023; 59: 48–61.

[8] Hilton TJ, Ferracane JL, Mancl L; Northwest Practice-based Research Collaborative in Evidence-based Dentistry (NWP). Comparison of CaOH with MTA for direct pulp capping: a PBRN randomized clinical trial. Journal of Dental Research. 2013; 92: 16S–22S.

[9] Hegde S, Sowmya B, Mathew S, Bhandi SH, Nagaraja S, Dinesh K. Clinical evaluation of mineral trioxide aggregate and Biodentine as direct pulp capping agents in carious teeth. Journal of Conservative Dentistry. 2017; 20: 91–95.

[10] Mente J, Hufnagel S, Leo M, Michel A, Gehrig H, Panagidis D, et al. Treatment outcome of mineral trioxide aggregate or calcium hydroxide direct pulp capping: long-term results. Journal of Endodontics. 2014; 40: 1746–1751.

[11] El Saied NT, Awad SM, Alhosainy AY. Evaluation of direct pulp capping in carious primary molars: a 12-month randomized controlled clinical trial. Journal of Stomatology. 2024; 77: 253–262.

[12] Mubeena TA, Adyanthaya A, Raheema M, Anju RV, Karthik Nair D, Ismail A, et al. Assessment of Biodentine pulpotomy as an alternative to conventional root canal treatment for permanent teeth in children: an in vivo study. Medical Research Archives. 2023; 11: 1–9.

[13] Parinyaprom N, Nirunsittirat A, Chuveera P, Na Lampang S, Srisuwan T, Sastraruji T, et al. Outcomes of direct pulp capping by using either ProRoot Mineral Trioxide Aggregate or Biodentine in permanent teeth with carious pulp exposure in 6- to 18-year-old patients: a randomized controlled trial. Journal of Endodontics. 2018; 44: 341–348.

[14] Swarup SJ, Rao A, Boaz K, Srikant N, Shenoy R. Pulpal response to nano-hydroxyapatite, mineral trioxide aggregate and calcium hydroxide as direct pulp capping agents: an in vivo study. Journal of Clinical Pediatric Dentistry. 2014; 38: 201–206.

[15] Qudeimat MA, Alyahya A, Hasan AA. Mineral trioxide aggregate pulpotomy for permanent molars with clinical signs indicative of irreversible pulpitis: a preliminary study. International Endodontic Journal. 2017; 50: 126–134.

[16] Gabriel EM, Swathi PS, Anand IS, Geeth D, Chinnasamy R, Vaanjay M. Treatment outcome of coronal pulpotomy and indirect pulp capping in mature permanent molars with symptoms of moderate pulpitis: a randomized clinical trial. Journal of Conservative Dentistry and Endodontics. 2024; 27: 434–441.

[17] Jang Y, Song M, Yoo IS, Song Y, Roh BD, Kim E. A randomized controlled study of the use of ProRoot mineral trioxide aggregate and Endocem as direct pulp capping materials: 3-month versus 1-year outcomes. Journal of Endodontics. 2015; 41: 1201–1206.

[18] Çalışkan MK, Güneri P. Prognostic factors in direct pulp capping with mineral trioxide aggregate or calcium hydroxide: 2- to 6-year follow-up. Clinical Oral Investigations. 2017; 21: 357–367.

[19] Guagnano R, Romano F, Defabianis P. Evaluation of Biodentine in pulpotomies of primary teeth with different stages of root resorption using a novel composite outcome score. Materials. 2021; 14: 2179.

[20] Aeinehchi M, Eslami B, Ghanbariha M, Saffar AS. Mineral trioxide aggregate (MTA) and calcium hydroxide as pulp-capping agents in human teeth: a preliminary report. International Endodontic Journal. 2003; 36: 225–231.

[21] Parirokh M, Torabinejad M. Mineral trioxide aggregate: a comprehensive literature review—Part III: clinical applications, drawbacks, and mechanism of action. Journal of Endodontics. 2010; 36: 400–413.

[22] Li Z, Cao L, Fan M, Xu Q. Direct pulp capping with calcium hydroxide or mineral trioxide aggregate: a meta-analysis. Journal of Endodontics. 2015; 41: 1412–1417.

[23] Kunert M, Lukomska-Szymanska M. Bio-inductive materials in direct and indirect pulp capping—a review article. Materials. 2020; 13: 1204.

[24] Deng R, Xie Y, Chan U, Xu T, Huang Y. Biomaterials and biotechnology for periodontal tissue regeneration: recent advances and perspectives. Journal of Dental Research, Dental Clinics, Dental Prospects. 2022; 16: 1–10.

[25] Rajasekharan S, Martens LC, Cauwels RG, Verbeeck RM. Biodentine™ material characteristics and clinical applications: a review of the literature. European Archives of Paediatric Dentistry. 2014; 15: 147–158.

[26] Herbst SR, Pitchika V, Herbst CS, Kosan E, Schwendicke F. Effectiveness of calcium hydroxide compared to hydraulic calcium silicate cements for direct pulp capping in managing deep caries in vital permanent teeth: a systematic review and meta-analysis. International Endodontic Journal. 2025; 58: 1110–1125.