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OPEN Outcome of pulpotomy

in permanent teeth
with irreversible pulpitis:
a systematic review
and meta‑analysis
Amber Ather1, Biraj Patel2, Jonathan A. L. Gelfond3 & Nikita B. Ruparel2*

Treatment planning is key to clinical success. Permanent teeth diagnosed with “irreversible
pulpitis” have long been implied to have an irreversibly damaged dental pulp that is beyond repair
and warranting root canal treatment. However, newer clinical approaches such as pulpotomy, a
minimally invasive and biologically based procedure have re-emerged to manage teeth with pulpitis.
The primary aim of the study was to conduct a meta-analysis to comprehensively estimate the
overall success rate of pulpotomy in permanent teeth with irreversible pulpitis as a result of carious
pulp exposure. The secondary aim of the study was to investigate the effect of predictors such as
symptoms, root apex development (closed versus open), and type of pulp capping material on the
success rate of pulpotomy. Articles were searched using PubMed, Scopus, CENTRAL, and Web of
Science databases, until January 2021. Outcomes were calculated by pooling the success rates with
a random effect model. Comparison between the different subgroups was conducted using the z
statistic test for proportion with significance set at alpha = 0.05. A total of 1,116 records were retrieved
and 11 studies were included in the quantitative analysis. The pooled success rate for pulpotomy
in teeth with irreversible pulpitis was 86% [95% CI: 0.76–0.92; I2 = 81.9%]. Additionally, prognostic
indicators of success were evaluated. Stratification of teeth based on (1) symptoms demonstrated
that teeth with symptomatic and asymptomatic irreversible pulpitis demonstrated success rate of
84% and 91% respectively, with no significant difference (p = 0.18) using z-score analysis; (2) open apex
teeth demonstrated a significantly greater success rate (96%) compared to teeth with closed apex
(83%) (p = 0.02), and (3) pulp capping materials demonstrated that Biodentine yielded significantly
better success rates compared to Mineral Trioxide Aggregate (MTA), calcium hydroxide, and Calcium
Enriched Mixture (CEM.) Collectively, this is the first meta-analytical study to determine the clinical
outcome of pulpotomy for carious teeth with irreversible pulpitis and it’s predictors for success.
Moreover, we identify the stage of root development and type of biomaterial as predictors for success
of pulpotomy.

According to the Global Burden of Disease census, untreated dental caries in permanent teeth is the most
prevalent health ­condition1. Failure to treat dental caries can lead to the spread of bacteria and their toxins
into the dental pulp causing varying degrees of i­ nflammation2. From a clinical point of view, pulpal inflamma-
tion is dichotomously classified as “reversible” or “irreversible” based on the presumed ability of the pulp to
­heal3. According to AAE Consensus Conference Recommended Diagnostic T ­ erminology3, irreversible pulpitis
is defined as “A clinical diagnosis based on subjective and objective findings indicating that the vital inflamed
pulp is incapable of healing and that root canal treatment is indicated.”. As a result, pulp extirpation remains to
be the mainstay treatment option for teeth diagnosed with irreversible ­pulpitis3. However, the validity of the
diagnostic term “irreversible pulpitis” has come into question as an emerging body of evidence has shown that

1
Department of Endodontics, Virginia Commonwealth University School of Dentistry, Richmond, VA 23298,
USA. 2Department of Endodontics, University of Texas Health Science Center at San Antonio, 7703 Floyd Curl
Drive, San Antonio, TX 78229, USA. 3Department of Population Health Sciences, UT Health San Antonio, 7703
Floyd Curl Drive, San Antonio, TX 78229, USA. *email: ruparel@uthscsa.edu

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­ ulp4. It has been observed that even

clinical diagnosis might not correlate with the histologic condition of the p
in advanced cases of inflammation with irreversible pulpitis, only isolated areas of pulp in the coronal aspect
had bacterial invasion with micro abscesses, whereas the underlying pulp continued to be free of i­ nflammation4.
Moreover, upon removal of the coronal pulp in direct contact with bacterial insult, the pulp represents a tissue
that demonstrates excellent regenerative ­potential5. Therefore, with advancements in the understanding of pulp
biology along with the introduction of bioceramic materials, the concept of “vital pulp therapy” (VPT) has been
revisited and there have been numerous reports of successful outcomes in teeth with carious pulp exposures
or ­pulpitis6–8. Amongst VPT modalities, pulpotomy has been demonstrated to be a more predictable and suc-
cessful intervention to manage teeth with carious pulp exposures compared to direct and indirect pulp capping
­procedures9.
Clinical data on the success of pulpotomy procedures in permanent teeth range from 82 to 100%8–11. Moreo-
ver, a recent systematic review demonstrated high success rates (> 90%) of coronal pulpotomy in mature teeth
with irreversible pulpitis at a 1-year time p­ oint12. However, the contribution of risk factors (e.g. preoperative
symptoms, stage of root development, and choice of pulp capping material) on the outcome of pulpotomy
present a large gap in knowledge. Therefore, a lack of meta-analytical data using predictors of success or risk
factors precludes the accurate prediction of clinical outcomes. Therefore, the primary aim of this comprehensive
systematic review and meta-analysis was to evaluate the success rate of pulpotomy in carious teeth diagnosed
with irreversible pulpitis at a minimum of 6 months post-treatment. The secondary aim of the study was to
investigate the effect of predictors such as symptoms, root apex development (closed versus open), and type of
pulp capping material on the success rate of pulpotomy. To our knowledge, this is the first study evaluating the
aforementioned variables on the outcome of pulpotomy for permanent teeth with irreversible pulpitis as a result
of carious pulp exposure.

Materials and methods

This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews
and Meta-Analyses (PRISMA) g­ uidelines13.

Focused question. This study adhered to the PIO framework to address the following clinical question:
“What is the success rate of pulpotomy in human permanent teeth with a diagnosis of irreversible pulpitis?”,
wherein the population (P) is “human permanent teeth with irreversible pulpitis as a result of carious pulp expo-
sure”; intervention (I) is “pulpotomy”; outcome of interest (O) is “success rate based on clinical and radiographic
criteria”.

Inclusion criteria.

1. Original clinical data namely, clinical trials, prospective and retrospective observational studies reporting
on pulpotomy in human permanent teeth
2. Teeth with carious pulp exposure and signs and symptoms suggestive of irreversible pulpitis
3. Studies that had appropriate use of both clinical and radiographic criteria to judge and report success rate.
Clinical success was defined as absence of clinical manifestations such as pain on percussion/palpation and
spontaneous pain, and devoid of need for further root canal treatment. Radiographic success was defined
as maintenance of normal periapical tissues (in case of absence of pre-operative lesions) or complete or
continued healing of periapical tissues (in case of presence of pre-operative lesions).
4. Minimum follow up period of 6 months
5. English language only

Exclusion criteria.

1. Case reports, case series, or review papers

2. Studies reporting on pulpotomy in deciduous teeth
3. Studies reporting on pulpotomy in teeth with trauma
4. Studies using lasers in pulpotomy
5. Studies not reporting on success rate or where raw data was not available to calculate success rate
6. Studies reporting on other vital pulp therapy procedures such as direct or indirect pulp capping

Search strategy. Electronic search was conducted by two independent reviewers (A.A. and B.P.) using
databases such as PubMed, Scopus, CENTRAL, and Web of Science. Keywords pertinent to the topic in question
were used in various combinations using Boolean operators to extract the relevant studies. Search strategy used
on PubMed was adapted for other databases (Supplementary Table S1). Articles published between January 1960
and January 2021 were included in the screening process. In addition, the bibliography of included articles and
review papers were screened to find any missing studies. The identified studies were then exported into Mende-
ley reference manager (Mendeley Desktop, version 1.17.11; Mendeley Ltd., George Mason University, Fairfax,
VA) and any duplicate articles were removed.

Study selection process. A two-phase search strategy was followed, wherein two independent reviewers
(A.A. and B.P.) screened the titles and abstract of all extracted articles in the first phase and subjected them to the
inclusion/exclusion criteria to perform preliminary elimination of ineligible studies. In the second stage, full text

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of the articles was retrieved and evaluated for inclusion in the meta-analysis. Any duplication of data presented
in studies was noted and eliminated for statistical analysis. Any disagreements in the search and screening pro-
cess between the reviewers was resolved by discussion.

Data extraction. Two independent reviewers (A.A., B.P.) performed data extraction from eligible stud-
ies using customized data retrieval forms on Microsoft Excel (Microsoft Office; Microsoft, Redmond, WA).
Extracted data included author/year, study design, sample size, diagnosis, root apex development (open or
closed), capping material, pulpotomy type (partial or full), proportion of successful cases, follow up period, and
recall rate. In cases of duplication of data amongst different studies, study with the maximum follow up period
was included for cumulative analysis. In studies reporting on mixed clinical scenarios, efforts were made to
extract raw data pertinent to the inclusion criteria and for evaluating secondary objectives of the meta-analysis.
In case of missing information, authors of the reports were contacted via email to gather further details.

Quality evaluation of included studies. The risk of bias of included studies was assessed based on the
study design. The non-randomized studies were assessed by modified Down and Black’s c­ hecklist14. This check-
list is based on 27 questions divided amongst 5 different sections: reporting, external validity, internal validity,
confounding and selection bias, and power of the study. The total score ranging from 0 to 28 was assigned to each
­study14. Randomized clinical trials were assessed using the Cochrane Risk of Bias 2 (RoB 2) ­tool15,16. This tool has
fixed domains with signaling questions which can derive information about key aspects of clinical trials relevant
to risk of bias. Studies can be rated as having “low”, “some concerns” or “high” risk of bias. The assessments were
performed by two examiners (A.A., B.P.). Any discrepancy in quality evaluation was resolved via discussion.

Data synthesis and statistical analysis. The primary outcome formulated after data collection was the
overall success rate of pulpotomy in cariously involved permanent teeth with irreversible pulpitis. The goal of the
subgroup analysis was to assess secondary outcomes which included comparison of success rate under different
clinical contexts. This included estimation of outcome based on symptoms (symptomatic versus asymptomatic),
stage of root apex development (closed versus open), and pulp capping material used.
All the outcomes were calculated by pooling the success rates with a random effect m ­ odel17. Heterogeneity
across the studies was assessed using Cochrane I2 statistic (I2 value of > 60% was considered as significant hetero-
geneity)18. Comparison between the different subgroups was conducted using the z statistic test for proportion
with significance set at alpha = 0.05. Publication bias was assessed using funnel plot and performing the Egger’s
­test19. In case of publication bias, trim and fill method was used to impute missing studies and adjust the effect of
­bias20. Comprehensive Meta-Analysis (Version 3; Biostat, Englewood, NJ) software package was used to perform
the meta-analyses and publication-bias analyses.

Grading of evidence. The Grading of Recommendations, Assessment, Development and Evaluation

(GRADEpro GDT: GRADEpro Guideline Development Tool; McMaster University, Hamilton, ON, Canada)
was used to assess the quality of ­evidence21. Two reviewers (A.A., B.P.) performed the quality analysis based on
the following domains: risk of bias, inconsistency of results, indirectness of evidence, imprecision, and publica-
tion ­bias21. In cases of disagreement, a consensus was reached by discussing with the third reviewer (N.B.R.).

Results
Selected studies. The study selection process is outlined in Fig. 1. The initial search yielded 1,116 records,
out of which 866 were screened based on title and abstract. After exclusion of 835 articles, 31 full text arti-
cles were retrieved and screened for eligibility. 11 studies met the inclusion c­ riteria7,22–31, and relevant data was
extracted for performing the meta-analysis. Reasons for exclusion of each full text article is listed in Supplemen-
tary Table S2. Overall, there were 5 randomized control t­ rials22,25,27–29, 5 prospective clinical s­ tudies23,24,26,30,31 and
one retrospective ­study7. The details and characteristics of included ­studies7,22–31 are outlined in Table 1.

Quality assessment. After analysis using modified Downs and black’s checklist, the quality assessment of
non-randomized ­studies7,23,24,26,30,31 revealed all studies to be of fair quality (Supplementary Table S3). For rand-
omized control trials assessed with the RoB 2 tool, 2 studies had “some concerns” with risk of b ­ ias27,28, whereas
22,25,29
3 studies had “low” risk of ­bias (Supplementary Table S4).

Primary analysis. Pooled success rate of pulpotomy in IP. After combining the results from 11 selected
­studies7,22–31 with random effects model, the overall pooled success rate of pulpotomy in carious permanent teeth
with irreversible pulpitis (asymptomatic and symptomatic) was 86% [CI: 0.76–0.92] with significant heterogene-
ity across the studies (I2 = 81.9%) (Fig. 2).

Subgroup analysis. Pooled success rate of pulpotomy in teeth diagnosed with symptomatic and asymptomatic
irreversible pulpitis. The data were further analyzed to assess the outcome of pulpotomy in carious teeth with
symptomatic versus asymptomatic irreversible pulpitis. This resulted in 9 ­studies7,22–29 meeting the inclusion cri-
teria of symptomatic irreversible pulpitis, which were combined to yield a success rate of 84% [CI: 0.72–0.92],
with a significant heterogeneity across the studies (I2 = 83.3%) (Fig. 3). Data from 3 ­studies26,30,31 reporting on
asymptomatic irreversible pulpitis were combined to yield a success rate of 91.3% [CI: 0.80–0.96.5], with no
observed statistical heterogeneity across the studies (I2 = 0.00%) (Fig. 4). On comparing symptomatic versus

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Figure 1.  Flowchart for study selection process.

asymptomatic teeth, there was no significant difference observed in terms of pulpotomy success rate (z value for
proportion: −1.34; p = 0.18).

Pooled success rate of pulpotomy for irreversible pulpitis in teeth with closed versus open apex. The data were
stratified to identify the effect of closed versus open root apex on success rate of pulpotomy in carious teeth
with irreversible pulpitis. 8 ­studies23–28,30,31 were identified with pulpotomy performed in teeth with complete
root development (closed apex); after pooling these studies with random effects model, the overall success rate
of pulpotomy in teeth with irreversible pulpitis and closed apex was 83% [CI: 0.69–0.91], with significant het-
erogeneity amongst the studies (I2 = 82%) (Fig. 5). In comparison to teeth with closed apices, there were only 3
­studies24,26,29 reporting on pulpotomy in teeth with incomplete root development (open apex), which demon-
strated a cumulative success rate of 95.8% [CI: 0.81–0.99], with no evidence of heterogeneity across the studies
(I2 = 0.00%) (Fig. 6). Open apex teeth demonstrated a significantly higher success rate when compared to teeth
with closed apex (z value for proportion: 2.33; p = 0.02).

Pooled success rate of pulpotomy for irreversible pulpitis in teeth restored with various pulp capping materials. The
effect of pulp capping materials on success rate were compared with indirect comparisons between ­studies7,22–31.
Biodentine demonstrated a statistically significant higher success rate when compared to MTA, Calcium
Enriched Mixture (CEM), and calcium hydroxide. MTA yielded a significantly higher success rate when com-
pared to calcium hydroxide; however, it was not significantly superior to CEM. Similarly, there was no significant
difference observed between CEM and calcium hydroxide (Supplementary Table S5).

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Root apex Pulpal Capping Type of Follow up

Author, year Design Sample size development diagnosis material pulpotomy Success n/N (months) Recall rate (%)
22 Randomized Proroot MTA, 34/37 (MTA),
Uesrichai, ­2019 69 Mixed SIP Partial 32 ± 17.9 97
clinical trial BD 26/30 (BD)
23
Taha, ­2018 Prospective 20 Mixed SIP Biodentine Full 19/20 12 100
Taha, ­201824 Prospective 63 Closed SIP Biodentine Full 58/59 12 93.6
22/26 (MTA),
Randomized Proroot MTA,
Taha, ­201725 50 Closed SIP Partial 10/23 12–24 90
clinical trial Ca(OH)2
(Ca(OH)2)
Linsuwanont,
Retrospective 66 Mixed SIP = 25 ProRoot MTA Full 21/25 8–62 82
­20177
Qudeimat, 23/23 (IP), 21/21
Prospective 23 Mixed IP (SIP 21) ProRoot MTA Full 18.9–73.6 100
­201726 (SIP), 2/2 (AIP)
Randomized ProRoot MTA, 116/154 (MTA),
Asgary, ­201727 412 Closed SIP Full 60 74
clinical trial CEM 107/150 (CEM)
Randomized ProRoot MTA, 6/16 (Ca(OH)2),
Kumar, ­201628 54 Closed SIP Full 12 90
clinical trial Ca(OH)2 8/18 (MTA)
Randomized ProRoot MTA, 17/17 MTA,
Nosrat, ­201329 34 Open SIP Full 12 NR
clinical trial CEM 17/17 CEM
Caliskan, ­199530 Prospective 26 Closed AIP Ca(OH)2 Full 24/26 16–72 100
Caliskan, ­199331 Prospective 24 Closed AIP Ca(OH)2 Full 22/24 12–48 100

Table 1.  Characteristics of the included studies in the systematic review. IP—irreversible pulpitis, SIP—
symptomatic irreversible pulpitis, AIP—asymptomatic irreversible pulpitis, MTA—mineral trioxide aggregate,
BD—biodentine, CEM—calcium enriched mixture, Ca(OH)2—calcium hydroxide, n—successful outcomes,
N—sample size, NR—not reported.

Figure 2.  Success rate of pulpotomy in carious teeth with irreversible pulpitis. ∫ corresponds to reference
number 23, whereas * corresponds to reference number 24.

Visual analysis of the funnel plot and Egger’s regression test (p < 0.04) indicated potential publication bias
(Supplementary Table S6). Using the “trim and fill” method, 4 studies were imputed to the left of the funnel
plot, which yielded a point estimate of 0.786 (95% CI: 0.66–0.87). This point estimate, subsequent to adjusting
for potential publication bias, indicates a 78.6% success rate of pulpotomy in teeth with irreversible pulpitis.

Grading of evidence. The certainty of evidence was graded as “very low” (Table 2), which means that the
true effect is probably markedly different from the estimated effect of 86% pooled success of pulpotomy in cari-
ous teeth with irreversible pulpitis.

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Figure 3.  Success rate of pulpotomy in carious teeth with symptomatic irreversible pulpitis. ∫ corresponds to
reference number 23, whereas * corresponds to reference number 24.

Figure 4.  Success rate of pulpotomy in carious teeth with asymptomatic irreversible pulpitis.

Discussion
Pulpotomy, an often-overlooked vital pulp therapy procedure, has now re-emerged as a minimally invasive,
biologically based treatment option for teeth diagnosed with pulpitis and involves partial/ complete removal
of coronal pulp tissue, following which a biocompatible material is placed onto the pulp tissue to promote
­healing6. Specifically, it was seldom used as a definitive treatment modality in teeth with symptomatic irreversible
pulpitis based on diagnostic modalities that predominantly serve to assess neuronal function as a measure of
pulpal ­health32. However, with recent advances in newer biocompatible, anti-inflammatory and osteo-inductive
biomaterials, the face of VPT has e­ volved32. Therefore, we conducted a systematic review and meta-analysis to
assess the outcome of pulpotomy in teeth with irreversible pulpitis using available clinical data. With very low
certainty, our study demonstrates pulpotomy to be a successful intervention for carious teeth with irreversible
pulpitis with a favorable outcome of 86%. Our results substantiate the findings by Cushley et al., wherein success-
ful outcomes were demonstrated in 88% of cases at 3-years12. Additionally, the present study computed success
rates using meta-analytical methods to include relative weight of each study and allows for random variation in
the success rate among studies. The present study also performed a comprehensive assessment of risk factors on
the outcome of clinical success. Our results of this subset analyses evaluated the following variables/risk factors:
teeth diagnosed with symptomatic versus asymptomatic irreversible pulpitis, teeth with mature (closed) versus
immature (open) root apex, and choice of pulp capping material used.
Based on the clinical presentation and diagnostic testing, irreversible pulpitis is classified as symptomatic
or ­asymptomatic3. In symptomatic cases, pulpotomy has traditionally been used as an emergency procedure to
relieve ­pain33. In addition, presence of acute preoperative symptoms is typically regarded as a negative outcome

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Figure 5.  Success rate of pulpotomy in carious closed apex teeth with irreversible pulpitis. ∫ corresponds to
reference number 23, whereas * corresponds to reference number 24.

Figure 6.  Success rate of pulpotomy in carious open apex teeth with irreversible pulpitis. ∫ corresponds to
reference number 23.

Certainty assessment Effect

Other № of Event Rate
No. of studies Study design Risk of bias Inconsistency Indirectness Imprecision considerations No. of events individuals (95% CI) Certainty
Publication
bias strongly
Randomized 74.3 per 100 ⨁◯◯◯ Very
5 Serious Very serious Not serious Serious suspected 363 488
trials (0.56 to 0.86) low
strong associa-
tion
Publication
bias strongly
Observational 92.6 per 100 ⨁◯◯◯ Very
6 Serious Very serious Not serious Serious suspected 167 177
studies (0.86 to 0.96) low
strong associa-
tion

Table 2.  Grading of recommendations assessment, development and evaluation approach to grade quality of
evidence. There are some concerns with the randomization process and in the measurement of outcome. There
are serious concerns with the inconsistency as evidenced by the significant heterogeneity amongst studies.
Total number of subjects with successful outcome is less than 400. There are some concerns with controlling
the confounding factors. Overall effect size is too large compared to the sample size.

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predictor for long-term success of V ­ PT34, thereby precluding application of pulpotomy as a definitive treatment
modality. However, in this meta-analysis, we demonstrate a success rate of 84% of pulpotomy in teeth with SIP,
which was not significantly different from the outcome observed in teeth with asymptomatic irreversible pul-
pitis. Studies that included teeth with symptomatic irreversible pulpitis defined these cases as teeth with either
spontaneous pain and/or pain exacerbated by cold stimuli with prolonged episodes of pain even after the thermal
stimulus had been ­removed7,22–27.This favorable outcome in symptomatic irreversible pulpitis can be attributed
to the fact that pulpotomy procedures regulate immune responses and can reduce levels of pro-inflammatory
cytokines within the dental ­pulp35. In addition, histologic studies have demonstrated that in teeth with irreversible
pulpitis, the damage and inflammation was mostly confined to only a portion of the coronal pulp, with the rest
of the coronal and radicular pulp being intact and ­healthy4. Furthermore, anti-inflammatory properties of new
generation tricalcium silicate materials promote reversal of residual inflammation and maintenance of a healthy
pulp tissue ­thereafter36. Collectively, these above mentioned reasons suggest that the removal of the coronally
inflamed pulp might be sufficient to maintain viability and health of the radicular pulp, making pulpotomy an
effective emergency procedure as well as a definitive treatment modality in this subset of patient population.
Traditional VPT procedures were aimed at promoting continued root development (apexogenesis)37. There-
fore, clinically, teeth with fully formed apices (closed apex) were excluded from VPT case selection. However,
with the growing knowledge about the repair potential of the dental p ­ ulp38, VPT such as pulpotomy protocols
have been introduced to treat teeth with closed apex with a diagnosis of irreversible p ­ ulpitis12. The results from
this meta-analysis demonstrate that pulpotomy in teeth with closed apex yields a cumulative success rate of 83%.
In contrast, teeth with open apex demonstrated a significantly favorable outcome. This can be attributed to the
increased vascularity and cellularity of pulp in immature t­ eeth39. In addition, aging of dental pulp is associated
with reduced regenerative potential of dental stem c­ ells40. However, with a success rate of 83% in mature teeth
with irreversible pulpitis, pulpotomy should be considered a viable and definitive treatment approach in these
cases. These results are in accordance with the findings demonstrated by Tan et al.34 and Kunert et al.41, wherein
favorable success rates were reported for both young immature as well as mature teeth.
Pulp capping agents can affect the outcome of pulpotomy p ­ rocedures37. Traditionally, calcium hydroxide
has been the most popular pulp capping agent, owing to its antimicrobial nature and the capability to form a
hard tissue barrier; however, issues such as high solubility, lower mechanical resistance and presence of tun-
nel defects in the mineralized barrier were reported as concerns especially for vital pulp therapy p ­ rocedures42.
Tricalcium silicate-based materials such as MTA and alike have now become the material of choice for pul-
potomy because of several added advantages such as biocompatibility, reduced microleakage, ability to induce
a thicker dentinal bridge with fewer defects and ability to release growth factors from ­dentin36,41. MTA as a
pulp capping material has few disadvantages such as its potential to discolor tooth and high solubility owing
to the slow setting ­reaction43. Other bioceramic materials such as Biodentine and CEM have been introduced
to overcome these shortcomings of MTA. In contrast to MTA, Biodentine has been demonstrated to cause
lesser tooth ­discoloration44. CEM is another bioceramic material introduced in 2006 with properties similar to
MTA, however with better physical characteristics and shorter setting ­time45. We therefore wanted to evaluate
the success rate of pulpotomy in teeth with irreversible pulpitis based on the types of biomaterial used. In our
meta-analysis, Biodentine demonstrated to be superior to other pulp capping materials, in terms of success rate
for pulpotomy. This finding might be attributed to the ability of biodentine to cause a greater release of calcium
ions and bioactive growth ­factors46. MTA was found to be superior to calcium hydroxide, which corroborates the
results from study done by Li et al.32. Interestingly, CEM and calcium hydroxide demonstrated similar success
rates. Collectively, these data suggest that use of bioceramic pulp capping materials such as MTA and Biodentine
can lead to more favorable clinical outcomes in teeth with irreversible pulpitis. Our findings substantiate the
results of a recent systematic review by Sabeti et al., wherein a 93% success rate with VPT procedures utilizing
bioceramic pulp capping materials was o ­ btained47.
From a clinical and research point of view, there are several factors in vital pulp therapy, which still need
to be standardized. There is a lack of agreement regarding the indications for pulpotomy ­procedures48. This is
partly attributable to the diagnostic ambiguity of our current pulp testing methods to establish the true inflam-
matory status of p ­ ulp38. As for the choice of type of pulpotomy, there is some evidence that full pulpotomy is
more successful than partial pulpotomy especially in cases with irreversible p ­ ulpitis9. Interestingly, most of the
included studies in our meta-analysis employed full coronal ­pulpotomy7,23,24,26–31, therefore a subset analysis based
on type of pulpotomy was not performed. Traditionally, a minimum of 3–6 months follow up time has been
established to determine the prognosis of a vital pulp therapy ­procedure49–51. This follow up time point interval
is critical, as majority of the early failures present during this period and it has been demonstrated that pain or
symptoms during the first 3 months after VPT are associated with poor ­outcomes49. Accordingly, studies with at
least a 6-month follow up period were included in this meta-analysis7,22–31. The included studies had intra- and
inter- study variation in patient recruitment which led to a wide range of follow up periods. In addition, only
select studies reported on long term outcomes (> 2 years) of VPT ­procedures7,22,26,27,30. As a result, data was not
analyzed based on specific follow up time intervals. Regarding the coronal seal after pulpotomy, all the included
studies had either a permanent restoration placed immediately after the procedure or a glass ionomer liner
placement followed by a temporary restoration. None of the studies delayed the placement of final restoration
beyond a month’s ­duration7,22–31.
Our study has some limitations and should be interpreted with caution. One of the limitations was the
considerable heterogeneity across the included s­ tudies7,22–31. This heterogeneity could be attributed to multiple
factors such as variation in study design, patient selection, type of pulpotomy, choice of biomaterial, and follow
up period, to mention a few. However, we explored the reasons for heterogeneity in our meta-analysis by per-
forming subgroup analysis. No heterogeneity was reported when analysis was restricted to immature teeth and
asymptomatic teeth subgroups. None of the other studied variables could resolve the observed heterogeneity

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in the meta-analysis. Another key limitation to note is the inconsistency of the included studies with the use of
sensibility testing at follow-up ­periods7,22–31. Only 4 studies utilized sensibility testing as a criterion at follow-up
appointments to evaluate ­success22,25,30,31. Therefore, while radiographic assessment satisfies one of the criteria
for disease-centered outcome, inclusion of vitality of treated teeth would define a true disease-centered outcome
and greatly increase the pragmatic significance to both, clinicians and patients.
There are several confounding moderators, which need to be taken into account and should be consistently
reported in future vital pulp therapy research. These include patient and tooth specific factors (such as age, gen-
der, tooth type), operator factors (investigator specialty and experience), technical factors (type of pulpotomy,
details of hemostatic agent used and time for hemostasis, choice of biomaterial and permanent restoration) and
data from recall appointments. Having these factors reported in future studies will help other researchers and
clinicians to understand the outcomes better and will also improve the applicability and generalizability of the
results.

Conclusion
The success rate obtained in this meta-analysis adds to the emerging body of evidence supporting the role of
pulpotomy as a definitive treatment modality in carious teeth with irreversible pulpitis. Given the potential of
pulpotomy in managing teeth with pulpitis and global rise in minimally invasive dentistry, there is a tremendous
need for conducting well-designed randomized clinical trials on this understudied topic.

Data availability
The datasets generated during and/or analyzed during the current study are available from the corresponding
author on reasonable request.

Received: 1 March 2022; Accepted: 20 September 2022

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Author contributions
A.A., N.B.R., and B.P. designed research; A.A., N.B.R. and J.G. conducted research and analyzed data; A.A.,
N.B.R., J.G. and B.P. wrote the manuscript; A.A. and B.P. evidence certainty assessment; A.A. and J.G. statistical
data; A.A., B.P. and N.B.R. analyzed and interpreted data; A.A. and N.B.R. had primary responsibility for final
content. All authors read and approved the final manuscript and all authors agree to be accountable for all aspects
of work ensuring integrity and accuracy.

Funding
This research work did not receive any specific grant from funding agencies in the public, commercial, or not-
for-profit sectors.

Competing interests
The authors declare no competing interests.

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