Journal of

Clinical Medicine

Review
Different Pulp Dressing Materials for the Pulpotomy
of Primary Teeth: A Systematic Review of
the Literature
Maurizio Bossù 1,† , Flavia Iaculli 2,† , Gianni Di Giorgio 2, *, Alessandro Salucci 1 ,
Antonella Polimeni 1 and Stefano Di Carlo 1
1 Department of Oral and Maxillofacial Science, “Sapienza” University of Rome, 00185 Rome, Italy;
[email protected] (M.B.); [email protected] (A.S.);
[email protected] (A.P.); [email protected] (S.D.C.)
2 Pediatric Dentistry School, Department of Oral and Maxillofacial Science, “Sapienza” University of Rome,
00185 Rome, Italy; [email protected]
* Correspondence: [email protected]; Tel.: +39-349-547-7903
† These Authors contributed equally to this work.




Received: 27 January 2020; Accepted: 16 March 2020; Published: 19 March 2020


Abstract: Background: Pulpotomy of primary teeth provides favorable clinical results over time;
however, to date, there is still not a consensus on an ideal pulp dressing material. Therefore, the
aim of the present systematic review was to compare pulpotomy agents to establish a preferred
material to use. Methods: After raising a PICO question, the PRISMA guideline was adopted to carry
out an electronic search through the MEDLINE database to identify comparative studies on several
pulp dressing agents, published up to October 2019. Results: The search resulted in 4274 records;
after exclusion, a total of 41 papers were included in the present review. Mineral trioxide aggregate
(MTA), Biodentine and ferric sulphate yielded good clinical results over time and might be safely
used in the pulpotomies of primary molars. Among agents, MTA seemed to be the material of choice.
On the contrary, calcium hydroxide showed the worst clinical performance. Although clinically
successful, formocreosol should be replaced by other materials, due to its potential cytotoxicity and
carcinogenicity. Conclusion: MTA seemed to be the gold standard material in the pulpotomy of
primary teeth. Promising results were also provided by calcium silicate-based cements. Further
randomized clinical trials (RCTs) with adequate sample sizes and long follow-ups are encouraged to
support these outcomes.

Keywords: biodentine; calcium hydroxide; ferric sulphate; MTA; primary teeth; pulpotomy

1. Introduction
Dental caries is an infective, chronic, degenerative and multifactorial condition that represents
the most prevalent chronic disease worldwide, mainly in children [1,2]. Tooth decay would seem to
be one of the major public health problems related not only to primary teeth but also to permanent
ones, and, despite the preventive strategies mostly adopted in developed countries, 2.4 billion adults
and 486 million children are affected by dental decay in the permanent and deciduous dentition,
respectively [3].
Early caries management should avoid the progressive destruction of dental hard tissue and
subsequent loss of dental vitality [4], inducing critical conditions in which premature tooth extraction
is required [5]. This is mostly true for primary teeth (due to anatomical considerations, reduced
rate of mineralization and high prevalence of risk factors) that show a rapid progression of tooth
decay [2,4,6]. Therefore, vital pulp therapy (VPT) has been proposed to preserve the pulp vitality of

J. Clin. Med. 2020, 9, 838; doi:10.3390/jcm9030838 www.mdpi.com/journal/jcm

J. Clin. Med. 2020, 9, 838 2 of 23

deciduous or young permanent teeth with immature roots affected by caries and without evidence
of radicular pathology [7,8]. Nowadays, treatment options of VPT are represented by indirect pulp
treatment (namely indirect pulp capping), direct pulp capping and pulpotomy [7]. Although clinically
successful in primary molars, direct capping is mainly recommended in the VPT of permanent young
teeth [9,10] and indirect capping seems to possess a relative effectiveness when compared to pulpotomy
procedures [11]. The latter provides favorable clinical survival rates over time and allows the vitality
of primary teeth until their natural exfoliation, avoiding pulpectomy procedures [2]. Pulpotomy
consists of elimination of the bacterial infection by the removal of the pulp in the pulp chamber; then,
the decontaminated tooth is filled with a medicament [11]. The most frequently used agents are
mineral trioxide aggregate (MTA), Biodentine (BD), formocresol (FC), ferric sulphate (FS) and calcium
hydroxide (CH). When compared, FC, FS and MTA seemed to provide significantly better clinical
and radiographic results as pulpotomy agents than CH after two years of follow-up; moreover, MTA
showed the best performance in respect to FC and FS over time [12]. Accordingly, Stringhini et al. [13]
reported that MTA yielded superior clinical and radiographical results in comparison to FC. On the
other hand, electrosurgery and FS showed similar success to FC, whereas CH did not show positive
evidence as medicament in pulpotomies of primary teeth [13]. In the same way, Asgary et al. [14]
further stressed that MTA demonstrated better long-term outcomes in pulpotomy of primary molars
when compared with FS.
More recently, bioactive endodontic cements have been introduced as valid alternatives to MTA in
VPT, showing promising clinical results [15]. In addition, calcium-silicate-based cement demonstrates
no difference when compared to MTA in the pulpotomies of primary teeth [4]; however, further
long-term studies with larger sample sizes are needed to confirm these preliminary outcomes.
To date there is still not an ideal pulp dressing material to be used in the pulpotomy of primary
teeth. Therefore, the aim of the present systematic review was to compare several pulpotomy agents in
order to establish a preferred material that performs better than others.

2. Materials and Methods

The present systematic review was conducted according to the PRISMA guidelines for Systematic
Reviews [16]. The focused question was structured according to the PICO format (Population,
Intervention, Comparison, and Outcome): is there a preferred material that performs better than others
when used in pulpotomy of vital carious-exposed primary molars?
Population: Children with extensive caries involving vital dental pulp in primary teeth.
Intervention: Pulpotomy performed using different materials (MTA, Biodentine, ferric sulphate,
calcium hydroxide).
Comparison: Between different materials applied in the same clinical conditions.
Outcome: Success of the therapy after at least 12 months of follow-up.

2.1. Search Strategy

An electronic search was conducted through the MEDLINE (PubMed) database to identify
publications that met the inclusion criteria. The search was performed up to October 2019 in order
to identify the studies that compare the performance of different materials in pulpotomy treatment
of primary teeth, using the following search terms and key words alone or in combination with the
Boolean operator “AND”: endodontics, pulpotomy, primary molars, deciduous teeth, primary teeth,
biomaterials, biodentine, MTA, mineral trioxide aggregate, ferric sulphate, ferric sulfate, calcium
hydroxide. Moreover, references of the eligible studies and relevant systematic reviews on the topic
were manually checked and screened.

2.2. Study Selection

Two independent operators (F.I., G.D.G.) screened the studies according to the following
inclusion/exclusion criteria:
J. Clin. Med. 2020, 9, 838 3 of 23

2.2.1. Inclusion Criteria

- Human in vivo studies written in English published in peer-reviewed journals;
- Comparative clinical articles reporting on different materials applied in pulpotomy of
primary teeth;
- Definitive restorations of the primary teeth;
- Clinical and/or radiographical follow-up of at least 12 months;
- Random allocation of the samples.

2.2.2. Exclusion Criteria

- In vitro studies on human and animals;
- Systematic reviews, case series, case studies, retrospective studies;
- Follow-up < 12 months;
- Clinical studies without random allocation of the samples;
- Non-comparative papers, namely reporting on only one material used in pulpotomy procedures;
- Papers evaluating other clinical procedures that involved the pulp, such as direct capping, indirect
capping, endodontic treatment.

After removing the duplicates, some papers were excluded subsequent to reading of the titles.
Two review authors (F.I., G.D.G.) independently screened the selected abstracts to identify relevant
studies according to the inclusion/exclusion criteria. In case of disagreement, a Senior Author (M.B.)
was consulted and agreement was reached. Then, full reports of the selected studies were retrieved
and a data extraction form was completed for each paper in an unblinded standardized manner, to
determine whether the article should be included or excluded. Excluded studies and reasons for
exclusion were reported.

2.3. Data Collection

Data extraction was performed by filling a form in with the following data: authors, title, publication
year, aim, group distribution, materials compared, intervention, evaluated outcomes, reported results
and conclusions.
After a preliminary evaluation of the selected papers, considerable heterogeneity was found
in the study design, adopted procedures, outcome variables and results. Therefore, a descriptive
analysis of the data was performed, since quantitative assessment and following meta-analysis could
not be conducted.

2.4. Assessment of Heterogeneity

The following variables were checked to determine heterogeneity:

• Pulpotomy procedure
• Materials management
• Expertise of the clinician
• Restoration materials
• Outcome variables

2.5. Quality Assessment

The assessment of methodological study quality was performed by two independent authors (F.I.
and G.D.G.) following the recommendations for systematic reviews of interventions of the Cochrane
collaboration [17] focusing on the following criteria: random sequence generation and allocation
concealment (both accounting for selection bias), blinding of participants and personnel (performance
J. Clin. Med. 2020, 9, 838 4 of 23

bias), blinding of outcome assessment (detection bias), incomplete outcome data (attrition bias),
selective reporting (reporting bias), or other possible causes of bias.
Assessment of overall risk of bias was classified as follows: low risk of bias if all criteria were met;
unclear risk of bias if one or more criteria were assessed as unclear; or high risk of bias if one or more
criteria were not met [2].

3. Results

3.1. Search and Selection

The PubMed-MEDLINE search resulted in 4274 records. After duplicate removal, the titles and
abstracts were screened according to the inclusion/exclusion criteria and a total of 75 papers underwent
full-text reading. Thirty-four articles were excluded [18–51] since they did not meet the inclusion
criteria; reasons of exclusion have been reported within Table 1. A total of 41 papers [52–92] were
included in the present systematic review and processed for quality assessment and data extraction.
The search strategy has been reported in Figure 1.

Table 1. Excluded studies and reason of exclusion.

Author, Year Reason of Exclusion

Kathal et al. 2017 [18] The studied material did not present clinical evidence among scientific literature.
Alsanouni et al. 2019 [19] Authors compared the same pulpotomy dressing material.
Pratima et al. 2018 [20] Pulpotomy was performed by diode laser prior to MTA.
Kang et al. 2015 [21] Authors compared the same pulpotomy dressing material.
Akcay et al. 2014 [22] Sodium hypochlorite was applied prior to MTA and might act as a variable.
Fernández et al. 2013 [23] Internal root resorption was not considered as a failure.
Calcium hydroxide paste was mixed with other agents and the obtained material did not
Liu et al. 2011 [24]
present clinical evidence among scientific literature.
Holan et al. 2005 [25] Internal root resorption was not considered as a failure.
Nematollahi 2018 [26] Authors performed partial pulpotomy that is poorly reproducible and standardizable.
Musale et al. 2016 [27] The studied material did not present clinical evidence among scientific literature.
Atasever et al. 2019 [28] Sodium hypochlorite was used during pulpotomy procedure and might act as a variable.
Huth et al. 2005 [29] The paper reported on the same sample size of Huth et al. 2012.
Nguyen et al. 2017 [30] Pulpotomy was compared with root canal therapy.
Saltzman et al. 2005 [31] Pulpotomy procedures were different between the evaluated groups.
The success of the materials was evaluated on dentin thickness without reproducibility and
Grewal et al. 2016 [32]
standardization.
Hugar et al. 2017 [33] Incomplete data reported.
Kalra et al. 2017 [34] The studied material did not present clinical evidence among scientific literature.
Uloopi et al. 2016 [35] Pulpotomy procedures were different between the evaluated groups.
Yildiz et al. 2014 [36] No random allocation of the sample size.
Ansari et al. 2018 [37] Absence of rubber dam.
Gupta et al. 2015 [38] Pulpotomy procedures were performed by laser or electrosurgery.
Cantekin et al. 2014 [39] Authors compared the same pulpotomy dressing material.
Trairatvorakul et al. 2012 [40] Authors performed partial pulpotomy that is poorly reproducible and standardizable.
Zurn et al. 2008 [41] Pulpotomy was obtained by light-cured calcium hydroxide.
Corticosteroid/antibiotic solution was applied as therapeutic dressing and might act as a
Percinoto et al. 2006 [42]
variable.
Ghoniem et al. 2018 [43] No random allocation of the sample size.
Biedm-Perea et al. 2017 [44] Retrospective study and no random allocation of the sample size.
Airen et al. 2012 [45] Retrospective study and no random allocation of the sample size.
Frenkel et al. 2012 [46] No random allocation of the sample size.
Cardoso Silva et al. 2011 [47] No random allocation of the sample size.
Ibricevic et al. 2003 [48] Retrospective study.
Godhi et al. 2011 [49] No random allocation of the sample size.
Hugar et al. 2010 [50] No random allocation of the sample size.
Ibricevic et al. 2000 [51] No random allocation of the sample size.

3.2. Assessment of Heterogeneity

The data extraction of the included studies yielded a considerable heterogeneity between the
papers in terms of pulpotomy procedure, materials management, expertise of the clinician, restoration
materials, and outcome variables. To better standardize the study comparison, papers reporting
 Cardoso Silva et al.
No random allocation of the sample size.
2011 [47]

Ibricevic et al. 2003

Retrospective study.
[48]
J. Clin. Med. 2020, 9, 838 5 of 23
Godhi et al. 2011 [49] No random allocation of the sample size.

Hugar et al. 2010 [50] No random allocation of the sample size.

pulpotomy procedures different from the standard method were excluded (e.g., absence of the rubber
Ibricevic
dam, et al. 2000performed with laser ablation or electrosurgery, hemostasis obtained with several
pulpotomy No random allocation of the sample size.
[51]
agents that could act as bias on the clinical outcomes).

Flowchartofofthe
Figure1.1.Flowchart
Figure thereview
reviewprocess
processand
andsearch
searchstrategy
strategyaccording
accordingtotoPRISMA
PRISMAstatement.
statement.

Concerning materials management, the included studies evaluated several materials (e.g., MTA,
BD, FS, CH, FC) that were applied with almost with the same procedure according to the manufacturer’s
instructions; however, it should be considered that they were produced by various companies and might
have a slightly different composition. Accordingly, the restoration materials reported by the included
studies were different (composite, amalgam, glass ionomer cement, stainless steel crowns), however, in
order to avoid bias, papers reporting teeth restored with temporary materials were excluded. Regarding
the evaluated outcomes, all of the included studies assessed clinical and radiographical parameters;
the success criteria used among the articles were similar but not the same and, therefore, it was only
possible to make a descriptive comparison between the papers. Finally, the clinician expertise could
not be evaluated in each study and the follow-up range varied between 12 and 42 months. Therefore,
due to the lack of unequivocal data presentation, the results of the studies were reported separately.

3.3. Quality Assessment

Assessments of the risk of bias and of the methodological study quality have been reported in
Table 2. Overall risk of bias of the included studies showed high risk mainly in blinding of participants
and personnel (28/41 studies), followed by blinding of outcome assessment (12/41 studies) (Figure 2).
The lack of blind clinicians involved in the treatment as well as evaluation of the outcomes could affect
the interpretation of the reported results provided in each study, playing a central role in the variability
of study conclusions.
The inter- inter-examiner agreement between the two independent authors that performed the
quality assessment of the included studies was 0.95.
 [74]

Noorollahian 2008
Low Unclear High Low High Low
[75]

Agamy et al. 2004

Unclear Unclear High Low Low Low
[76] 2020, 9, 838
J. Clin. Med. 6 of 23
Eidelman et al.
Low Unclear High High High Low
2001 [77]
Table 2. Assessment of risk of bias of the included studies.
Mettlach et al.
Low Unclear High Low High Low
2013 [78] Random Blinding of Blinding of Incomplete Selective
Allocation
Sequence Participants and Outcome Outcome Outcome
Durmus et al. 2014 Concealment
Generation Personnel Assessment Data Reporting
Unclear Unclear High Low Low Low
[79]
Çelik et al. 2019 [52] Low Unclear High Low Low Low
Malekafzali et al. 2011 [53] Unclear High High Low Unclear Unclear
Havale et al. 2013
Sakai et al. 2009 [54]
Unclear LowUnclear High High High Low
Unclear High
Low High
Low
[80]
Farsi et al. 2005 [55] Low Unclear Unclear Unclear High High
Carti et al. 2017 [56] Low High High Unclear Low Low
Huth Guven
et al. 2012
et al. 2017 [57]Low Low Low High Low
Low LowLow Low
Low Low
Low
[81]
Bani et al. 2017 [58] Low Unclear Unclear High Low Low
Juneja et al. 2017 [59] Low Unclear Unclear Low Low Low
Markovic etetal.al. 2016 [60]
Togaru Unclear High High High Low Low
Unclear Unclear High Unclear Low Low
2005 [82] et al. 2017 [61]
Rajasekharan Low Low Low Low Low Low
Cuadros-Fernández et al. 2016 [62] Low Unclear High High Low Low
Ozmen Silva
et al.et2017
al. 2019 [63] Low Low Low Low
Unclear High HighLow Low
Low Low
Low
[83]
Junqueira et al. 2018 [64] Low Unclear High Low High Low
Jamali et al. 2018 [65] Low Unclear Low Low High Low
FarsiYildirim
et al. 2015
et al. 2016 [66] Unclear Unclear High
Low Low Low LowHigh Low
Low Low
Low
[84] et al. 2015 [67]
Olatosi Unclear Unclear High High Low Low
Celik et al. 2013 [68] Low Low Low Low Low Low
JayamOliveira
et al. 2014
et al. 2013 [69] Low Unclear High Low Low Low
Unclear Unclear High High Low Low
Sushynski
[85] et al. 2012 [70] Unclear Unclear High Low Low Low
Erdem et al. 2011 [71] Unclear Unclear Low High Low Low
Srinivasan
Ansarietetal.
al. 2010 [72] Unclear Unclear High Unclear Low Low
Doyle
Unclear Unclear High LowLow Low Low
2011 [86]et al. 2010 [73] Low Low Unclear Unclear Low
Moretti et al. 2008 [74] Low Unclear High Low Low Low
El Meligy et al. 2008 [75]
Noorollahian Low Unclear High Low High Low
Agamy Low Low Low LowLow Low Low
2019 [87] et al. 2004 [76] Unclear Unclear High Low Low
Eidelman et al. 2001 [77] Low Unclear High High High Low
SunithaMettlach et al. 2013 [78]
et al. 2017 Low Unclear High Low High Low
Durmus Unclear Unclear High HighLow Low Low
[88] et al. 2014 [79] Unclear Unclear High Low Low
Havale et al. 2013 [80] Unclear Unclear High Unclear Low Low
Huthet
Fernandes et al.
al. 2012 [81] Low Low Low Low Low Low
Markovic et al. 2005 [82] Low Unclear
Unclear Unclear High High LowUnclear Low
Low High
Low
2015 [89]
Ozmen et al. 2017 [83] Low Unclear High High Low Low
Farsi et al.
Subramaniam et 2015 [84] Low Low Low Low Low Low
Jayam et al. 2014 [85]Low Unclear
Unclear Unclear High High HighHigh Low
Low Low
Low
al. 2009 [90]
Srinivasan et al. 2011 [86] Unclear Unclear High Low Low Low
SonmezEl Meligy et al. 2019 [87]
et al. 2008 Low Low Low Low Low Low
Unclear
Sunitha et al. 2017 [88] Unclear
Unclear Unclear High High HighHigh Low
Low Low
Low
[91]
Fernandes et al. 2015 [89] Low Unclear High Low Low High
Subramaniam et al. 2009 [90] Low Unclear High High Low Low
Fuks et al. 1997
Sonmez et al. 2008 [91]Low Unclear
Unclear Unclear High High Unclear
High Low
Low Unclear
Low
[92]
Fuks et al. 1997 [92] Low Unclear High Unclear Low Unclear

Figure2.2.Overall
Figure Overallrisk
riskof
ofbias.
bias.

3.4. Outcomes
Data and results reported by each of the included studies are summarized in Table 3.
J. Clin. Med. 2020, 9, 838 7 of 23

Table 3. Summary of the data reported in the studies included in the present systematic review.

Groups Type of Definitive Evaluated Outcomes Reported Outcomes

Material Follow-up Conclusions
Distribution Restorations Clinical Radiographical Clinical Radiographical
Absence of radiolucencies at
Absence of the inter-radicular and/or
spontaneous pain periapical regions, absence of
MTA = 100% success rate at 12, MTA = 100% success rate MTA and BD showed
MTA group and/ or sensitivity to pulp canal obliteration (fully
Çelik et al. 12, 18 and 18 and 24 months. at 12, 18 and 24 months. similar success rates without
MTA* vs. BD◦ (n = 24) IRM and SCC palpation/percussion; obliterated canals); absence
2019 [52] 24 months. BD = 89.4% success rate at 12, 18 BD = 89.4% success rate any statistically significant
BD group (n = 20) absence of fistula, of internal or external
and 24 months. at 12, 18 and 24 months. difference.
swelling, and/or (pathologic) resorption that
abnormal mobility. was not compatible with a
normal exfoliation process.
One and three cases of
pathologic external root
resorption were observed The study demonstrated
Swelling/abscess, Furcation radiolucency, in CEM and MTA groups favorable treatment
MTA group MTA = 100% success rate at 12,
SCC or amalgam sinus tract, periapical bone destruction, at 12-month follow-up, outcomes of CEM/MTA
Malekafzali et al. MTA* vs. (n = 40) 12 and 18 and 24 months.
depending on the cavity spontaneous pain, internal root resorption, and respectively, without pulpotomy in human
2011 [53] CEM§ CEM group 24 months CEM = 100% success rate at 12,
size and or pathological pathological external root significant difference. In primary molar teeth. CEM
(n = 40) 18 and 24 months.
mobility. resorption. the last follow-up as a new endodontic cement
(24 months) MTA and is a promising biomaterial.
CEM achieved 100%
radiographic success.
100% of the available The present data suggested
Absence of 100% of the available teeth were
MTA group Absence of internal root teeth were clinically and that PC might serve as an
Sakai et al. Grey MTA** 12, 18 and spontaneous pain, clinically and radiographically
(n = 15) IRM and GIC resorption or furcation radiographically effective and less expensive
2009 [54] vs. PC# 24 months mobility, swelling, successful during all the
PC group (n = 15) radiolucency. successful during all the MTA substitute in primary
fistula, or smell. follow-ups.
follow-ups molar pulpotomies.
Absence of internal root At the end of the study,
After 24 months, the FC group
Absence of pain; resorption; furcation the FC group showed
MTA vs. FC MTA group showed only one case reported
Farsi et al. IRM was placed prior to 12, 18 and swelling; sinus tract; radiolucency; periapical five cases with pulp MTA might be considered as
(both not (n = 60) pain. On the other hand, 100% of
2005 [55] restoration with SCC. 24 months mobility; or pain on radiolucency; or widening of pathosis (13.2%). MTA a valid alternative to FC.
specified) FC group (n = 60) teeth treated with MTA were
percussion. the periodontal ligament showed 100% of
considered clinically successful.
space. radiographical success.
Absence of internal–external
Absence of
resorption, The success rates were
- MTA group: GIC and palpation–percussion There was no statistically
periapical/interradicular 80% and 60% for MTA Both MTA and BD could be
SCC cemented with GIC. sensitivity, significant difference between
MTA (not MTA group bone destruction, and BD groups, used as pulpotomy agents,
Carti et al. - BD group: the cavity spontaneous pain, clinical success rates over time.
specified) vs. (n = 25) 12 months disintegration of the lamina respectively. There were but more long-term studies
2017 [56] was filled with BD and hot–cold sensitivity, In both groups one tooth was
BD◦ BD group (n = 25) dura, enlargement of the no statistically significant with larger sample sizes are
then restored by using a presence of extracted due to fistula
periodontal space, and differences between the required.
SCC cemented with GIC. fistula-swelling, formation at month 12.
radiological calcific groups.
pathologic mobility.
metamorphosis.
24-month: no clinical failure was This study found no
- MTA groups: GIC was
observed among groups. Total statistically significant
MTA-P group placed over the MTA.
success rates of the BD, MTA-P, Overall, seven teeth differences among
MTA-P*** vs. (n = 29) - BD group: permanent Absence of evidence of
Absence of swelling, PR-MTA and FS groups were demonstrated pulpotomy techniques;
Guvenet al. PR-MTA* vs. PR-MTA group restoration was 12 and internal or external
pain, fistula, or 82.75%, 86.2%, 93.1% and 75.86%, radiographic failure at however,
2017 [57] BD◦ vs. FS (n = 29) performed on the same 24 months resorption or periradicular
pathologic mobility. respectively. 24 months. calcium-silicate-based
(not specified) BD group (n = 29) session with GIC. radiolucency.
No statistically significant materials appeared to be
FS group (n = 29) - FS group: a ZOE base,
differences in total success rates clinically more appropriate
then GIC
were observed over time. than FS.
J. Clin. Med. 2020, 9, 838 8 of 23

Table 3. Cont.

Groups Type of Definitive Evaluated Outcomes Reported Outcomes

Material Follow-up Conclusions
Distribution Restorations Clinical Radiographical Clinical Radiographical
BD and MTA did not
differ significantly in
Absence of combined clinical and
Absence of internal or The 24-month follow-up
tenderness to The radiographic success radiographic success
MTA group external resorption; furcal or evaluations revealed that the
Bani et al. 12, 18 and percussion, rates at 24 months were after 24 months.
MTA* vs. BD◦ (n = 32) GIC and SCC periradicular radiolucency; clinical success rates were
2017 [58] 24 months swelling, pain, 93.6% for BD and 87.1% However, BD showed
BD group (n = 32) widening of periodontal 96.8% for both BD and MTA
fistula, or for MTA. slightly better
ligament spaces. groups.
pathologic mobility. radiographical results
after two years of
follow-up.
Radiographic success
100% of available teeth for
rate for the FC group at
Absence of pain, MTA and BD groups were
All teeth were 18 months follow up was
tenderness to clinically successful, and
MTA group immediately restored 73.3% for FC, 100% for
MTA* vs. BD◦ percussion/palpation, Absence of internal or 73.3% of the FC group. MTA and BD showed
Juneja et al. (n = 17) with IRM and GIC, then 12 and MTA and 86.6% for BD
vs. FC (not swelling, external resorption; furcal or There were statistically more favorable results
2017 [59] BD group (n = 17) were restored with 18 months group.
specified) intraoral/extraoral periradicular radiolucency. significant differences than FC.
FC group (n = 17) pre-formed metal There were statistically
sinus, pathologic between FC and MTA and BD
crowns. significant differences
mobility. at 12 and 18 months,
between FC and MTA at
respectively.
12 and 18 months.
12 months: MTA and BD
Absence of pain, provided 95.5% of
Absence of radiolucency in
tenderness on success rate. Pulpotomy treatment
MTA group Permanent restoration furcation/periapical area, 12 months: MTA and BD
Togaru et al. percussion, Radiographic using BD and MTA had
MTA* vs. BD◦ (n = 45) with GIC followed by 12 months internal or external root provided 95.5% of success
2016 [60] swelling and/or examination provided 1 similar success rates in
BD group (n = 45) SCC resorption, and widening of rate.
fistula, pathologic failure in both MTA and primary teeth.
periodontal space.
tooth mobility. BD groups. No statistical
differences were detected.
Absence of pain,
tenderness on
percussion,
swelling and/or
fistula, pathologic
Absence of radiolucency in After 18-month
tooth mobility, Radiographic success
MTA group furcation/periapical area, Clinical success was 95.24%, follow-up, there was no
chewing sensitivity, was 94.4%, 90.9% and
Rajasekharanet MTA* vs. BD◦ (n = 29) 12 and internal or external root 100% and 95.65% in the BD, significant difference
GIC and SCC gingival 82.4% in the BD, MTA
al. 2017 [61] vs. TP## BD group (n = 25) 18 months resorption, and widening of MTA and TP groups, between BD in
inflammation, and TP groups,
TP group (n = 27) periodontal space, variation respectively. comparison with MTA or
periodontal pocket respectively
radiodensity. TP.
formation, sinus
tract present,
premature tooth
loss due to
pathology.
The clinical success rate in the BD showed similar
Absence of pain, MTA yielded a
Absence of evidence of MTA group after 12 months clinical results as MTA
Cuadros-Fernández MTA group swelling or gingival radiographic success of
internal or external was 92% (36/39), whereas the with comparable success
C et al. 2016 MTA* vs. BD◦ (n = 43) IRM and SCC. 12 months inflammation, 97% (38/39). Use of BD
resorption or periradicular clinical success rate in the BD rates when used for
[62] BD group (n = 41) fistulation, or yielded a radiographic
radiolucency. group after 12 months was pulpotomies of primary
pathologic mobility. success of 95% (37/39).
97% (38/39). molars.
J. Clin. Med. 2020, 9, 838 9 of 23

Table 3. Cont.

Groups Type of Definitive Evaluated Outcomes Reported Outcomes

Material Follow-up Conclusions
Distribution Restorations Clinical Radiographical Clinical Radiographical
MTA** (only The association of CH
Radiographic analysis
gray), CH (not with PEG provided better
1-mm-thick layer of showed 100% treatment
specified) results than that of CH +
MTA group material was used for success using MTA, at all
with saline Lack of saline as a capping
(n = 15) capping, followed by Lack of internal or external follow-up appointments.
(CH+saline spontaneous pain, Clinical analysis showed 100% material for pulpotomy
Silva et al. CH+saline group another 1-mm-thick of a root resorption and furcation At 12 months of
group) and 12 months mobility, swelling, treatment success using MTA, of primary teeth.
2019 [63] (n = 15) layer of cement-cured radiolucency were indicative follow-up, the CH+saline
CH with or fistula in the at all follow-up appointments. However, both
CH+PEG group CH◦◦ employed as an of radiographic success. group had an increased
polyethylene treated tooth. associations
(n = 15) intermediate base for the incidence of radiographic
glycol demonstrated clinical
restoration GIC failure compared with
(CH+PEG and radiographic results
the MTA group.
group) inferior to those of MTA.
The radiographic success
Based on this study, both
Absence of internal root rate for both groups was
MTA and 15.5% FS are
resorption, inter-radicular 100% at 12 months. At
effective for pulpotomies
radiolucency and periapical the end of the 18-month
Absence of In both groups, 100% of the of primary teeth.
lesion were absent. Hard follow-up period, one
Junqueira et al. MTA** vs. MTA (n = 15) IRM was placed prior to 12 and spontaneous pain, available teeth were clinically Although MTA is
tissue barrier formation and tooth from FS group
2018 [64] FS§§ FS (n = 16) the restoration with GIC 18 months mobility, swelling successful during all the considered the first
stenosis were considered as presented a radiographic
or fistula. follow-up appointments. choice material, FS may
radiographic successes; tooth failure (inter-radicular
be a suitable alternative
discoloration was not radiolucency), but it was
when treatment cost is an
considered as a failure. not statistically different
issue.
from MTA group.
Absence of sinus
tract, tenderness to
The present study
palpation and The overall success rate
The overall success rate was showed that 3Mixtatin
percussion, was 78.9% for FC, 90.5%
78.9% for FC, 90.5% for can be utilized as a pulp
3Mixtatin group spontaneous pain for 3Mixtatin and 88.1%
Absence of external or 3Mixtatin and 88.1% for MTA capping material in
3Mixtatin vs. (n = 50) or pain of long for MTA group. There
Jamali et al. 12 and internal root resorption, group. There was no pulpotomy of primary
FC◦◦◦ vs. FC group (n = 50) IRM and amalgam duration, swelling, was no significant
2018 [65] 24 months inter-radicular radiolucency significant difference in teeth owing to its
MTA** MTA group pain of other difference in overall
and periapical lesion. overall success rate among the successful clinical and
(n = 50) sources mimicking success rate among the
groups after 24-month radiographic outcomes
irreversible pulpitis groups after 24-month
follow-up. after 24 months of
such as a gingival follow-up.
follow-up period.
problem, food
impaction, etc.
FC group (n = 35) Absence of radiolucency of
This study demonstrated
MTA group the periapical or furcation,
FC◦◦◦ vs. Absence of 24 months: FC = 96.9%, 24 months: FC = 96.9%, that MTA had better
Yildirim et al. (n = 35) 12 and and pathological external
MTA* vs. PC# GIC and SCC spontaneous pain, MTA = 100%, PC = 93.3%, MTA = 100%, PC = 93.3%, long-term clinical success
2016 [66] PC group (n = 35) 24 months root resorption, internal root
vs. EMP swelling, fistula EMD = 90.6%. EMD = 90.6%. rates than FC, PS and
EMP group resorption
EMP, respectively.
(n = 35)
MTA showed clinical and
Absence of The radiographic success radiographic success as a
Absence of periodontal
symptoms of pain, The clinical success rate at rates for MTA and FC dressing material
ligament widened, furcation
MTA group tenderness to 12 months was 100% and 81% were 96% and 81%, following pulpotomy
Olatosi et al. FC§§§ vs. or periapical radiolucency,
(n = 25) SSC 12 months percussion, for MTA and FC, respectively. respectively. There was procedure in primary
2015 [67] White MTA* active/progressing internal
FC group (n = 25) swelling or sinus The difference was statistically no statistically significant teeth, and it has a
root resorption, pathologic
tract, pathologic significant. difference between the promising potential to
external root resorption.
tooth mobility. two agents. become a replacement for
FC in primary molars.
J. Clin. Med. 2020, 9, 838 10 of 23

Table 3. Cont.

Groups Type of Definitive Evaluated Outcomes Reported Outcomes

Material Follow-up Conclusions
Distribution Restorations Clinical Radiographical Clinical Radiographical
The 24-month cumulative
radiographic survival
Based on the results of
probabilities of the
this study, P-MTA and
P-MTA, A-MTA, and CH
Comparisons using the A-MTA showed high
Absence of Absence of radiolucencies at groups were 0.974, 0.908,
MTA*(P-MTA) P-MTA group log-rank test showed that the clinical and radiographic
spontaneous pain, the inter-radicular and/or and 0.446, respectively.
vs. MTA** (n = 46) clinical survival probabilities success rates as
Celik et al. 12, 18 and sensitivity to periapical regions, pulp canal Most radiographic
(A-MTA) vs. A-MTA group GIC and amalgam of P-MTA and A-MTA were pulpotomy agents in
2013 [68] 24 months palpation/percussion, obliteration (fully obliterated failures were associated
CH (not (n = 45) similar and significantly primary molars. CH
fistula, swelling, canals), internal or external with internal resorption,
specified) CH group (n = 48) greater than that of the CH showed considerably less
abnormal mobility. resorption. which was observed in 23
group, respectively. clinical and radiographic
teeth in the CH group,
success than the MTA
compared to none in the
cements.
P-MTA and three in the
A-MTA groups.
MTA and PC might serve
as effective materials for
pulpotomies of primary
teeth as compared to CH.
CH† CH group (n = 15) Absence of Radiographically, the Although results are
Absence of internal root Clinically, the MTA and PC
Oliveira et al. vs. MTA** vs. MTA group 12 and spontaneous pain, MTA and PC groups encouraging, further
IRM and GIC resorption and furcation groups showed 100 % success
2013 [69] PC# (n = 15) 24 months mobility, swelling showed 100 % success studies and longer
radiolucency. rates at 12 and 24 months.
PC group (n = 15). and fistula. rates at 12 and 24 months. follow-up assessments
are needed in order to
determine the safe
clinical indication of
Portland cement.
Absence of internal root
Absence of mobility,
resorption
percussion or
(nonperforated/perforated); All teeth in the MTA group
chewing sensitivity, At the 24-month MTA demonstrated
external root resorption; were judged to be clinically
gingival follow-up 62/65 (~95%) significantly better
dentin bridge formation; successful (100%), whereas 1%
inflammation, molars of the MTA group radiographic outcomes
MTA group pulp canal of teeth in the DFC group
pathology, were radiographically vs. the DFC. However,
Sushynski et al. Gray MTA* vs. (n = 119) obliteration/calcific were judged to have failed
IRM and SSC 24 months periodontal pocket successful, while only both pulpal agents,
2012 [70] DFC DFC group metamorphosis; from 6 to 24 months (success
formation, 50/66 (~76%) molars of presented comparable
(n = 133) furcal/periradicular ~99%). The differences
spontaneous pain, the DFC group clinical outcomes after
radiolucencies, widening of between groups were not
sinus tract presence, demonstrated two years of follow-up.
the periodontal ligament significant at all follow-up
premature tooth radiographic success.
space; periapical bone points.
loss due to
destruction; physiological
pathology.
root resorption.
ZOE, as the only
pulpotomy medicament,
12 months success: 100% had a significantly lower
MTA group 12 months success: 100% for
Absence of Absence of internal root for MTA, FC and FS., and success rate than MTA.
MTA* vs. (n = 32) MTA, FC and FS., and 92% for
Erdem et al. 12 and spontaneous pain resorption and furcation 92% for ZOE. No significant differences
FS§§ vs. DFC FS group (n = 32) amalgam ZOE.
2011 [71] 24 months or after percussion, and/or periapical bone 24 months success: 96% were observed, among
vs. ZOE FC group (n = 32) 24 months success: 96% MTA,
mobility, swelling. destruction. MTA, 88% FS, 88% FC the 3 experimental
ZOE group (n = 32) 88% FS, 88% FC and ZOE 68%.
and ZOE 68%. materials (MTA, FC and
FS) at two years
follow-up.
J. Clin. Med. 2020, 9, 838 11 of 23

Table 3. Cont.

Groups Type of Definitive Evaluated Outcomes Reported Outcomes

Material Follow-up Conclusions
Distribution Restorations Clinical Radiographical Clinical Radiographical
The number of teeth judged Overall radiographic Pulpotomy of primary
Absence of pain, Absence of internal
MTA group as failed was six in the success at 24th month teeth performed with
Ansari et al. MTA* vs. 12 and presence of gingival resorption, radiographic
(n = 20) SSC FC-treated group with only was observed in > 95% of MTA demonstrated
2010 [72] DFC 24 months swelling and sinus signs of pathosis (periapical
FC group (n = 20) one failed case in the MTA group and 90% of comparable results of
tract. radiolucency).
MTA-treated group FC group FC-treated teeth.
MTA molars
FS group (n = 58)
Absence of SCC demonstrated
MTA group Absence of widening of the
MTA* vs. perforation, significantly fewer
(n = 57) periodontal ligament space, Eugenol-free FS molars MTA showed statistically
FS§§ vs. mobility, percussion radiographical changes
Doyle et al. Eugenol-free FS 12, 24 and furcal/periradicular demonstrated significantly significant better
Eugenol-free IRM and SSC sensitivity, than FS ones.
2010 [73] group 36 months radiolucencies, pulp canal lower survival rates than MTA performances than FS
FS§§ vs. palpation Eugenol-free FS showed
(n = 78) obliteration, internal or ones, over 6 to 38 months. and Eugenol-free FS
FS/MTA sensitivity, soft significantly more
FS/MTA group external root resorption.
tissue pathology. radiographical changes
(n = 77)
than MTA or FS/MTA.
Both groups showed
100% radiographical
success during all the
Both groups showed100% of
MTA group Absence of Absence of internal root follow-up appointments. MTA was superior to CH
MTA** vs. clinical success during all the
Moretti et al. (n = 15) 12, 18 and spontaneous pain, resorption, inter-radicular The CH group and equally effective to
CH◦◦ vs. DFC IRM and GIC follow-up appointments.
2008 [74] CH group (n = 15) 24 months mobility, swelling, bone destruction and demonstrated 64% DFC as a pulpotomy
The CH group demonstrated
DFC group (n = 15) fistula and smell. furcation radiolucency. success; in the same agent in primary molars.
64% of success.
group, internal
resorption was a frequent
radiographic finding.
After 24 months 100% of
DFC teeth were
Absence of pain MTA could be used as a
radiographically
symptoms, Absence of radicular safe pulpotomy agent in
successful. The
MTA* vs. MTA group tenderness to radiolucency, internal or After 24 months 100% of DFC cariously exposed
Noorollahian 12 and radiographic follow-up
DFC (n = 30) SSC percussion, external root resorption, and MTA teeth were clinically primary molars and
2008 [75] 24 months evaluation revealed one
DFC group (n = 30) swelling, fistulation periodontal ligament space successful. might be used as
failure (furcation
or pathologic widening. alternative to FC.
involvement) in 18
mobility.
molars treated with MTA
after 24 months.
At the 12-month
evaluation, 100% of
Gray MTA Absence of pain At the 12-month evaluation, In conclusion, G-MTA
G-MTA group G-MTA teeth were
(G-MTA) vs. symptoms; Absence of internal or 100% of G-MTA teeth were was superior to both
(n = 24) radiographically
Agamy et al. White MTA tenderness to external root resorption; clinically successful, while in W-MTA and FC as a pulp
W-MTA group IRM and SSC 12 months successful, while in the
2004 [76] (W-MTA) vs. percussion; periodontal ligament space the W-MTA group 3/18 dressing agent for
(n = 24) W-MTA group 3/18
FC (all not swelling; fistulation; widening. showed clinical failure as well pulpotomized primary
FC group (n = 24) showed radiographical
specified) pathologic mobility. as two teeth in FC group. molars.
failure as well as two
teeth in FC group.
J. Clin. Med. 2020, 9, 838 12 of 23

Table 3. Cont.

Groups Type of Definitive Evaluated Outcomes Reported Outcomes

Material Follow-up Conclusions
Distribution Restorations Clinical Radiographical Clinical Radiographical
MTA showed 100% of
radiographical success.
The evaluation of FC
MTA and FC showed 100% of
group, revealed only one
clinical success. MTA showed promising
failure (internal
Absence of internal root The follow-up evaluations clinical and radiographic
MTA vs. FC MTA group Absence of pain; resorption).
Eidelman et al. resorption; furcation revealed only one failure success as a dressing
(both not (n = 30) SSC 30 months swelling; sinus Pulp canal obliteration
2001 [77] radiolucency; periapical bone (internal resorption detected material in the
specified) FC group (n = 30) tract. was observed in 9 of 32
destruction. at 17-month postoperative pulpotomy procedure of
(28%) evaluated molars.
evaluation) in a molar treated primary teeth.
This finding was detected
with FC.
in 2/15 teeth treated with
FC (13%) and in 7/17
treated with MTA (41%).
One tooth in the MTA group
Authors stated that
Absence of pathologic was judged to be a clinical MTA group yielded a
clinical success was
nonperforated and failure (99% of success), and 95% of radiographical
MTA group scored based on Gray MTA performed
Mettlach et al. Gray MTA* vs. 12, 18, 24, 30, perforated internal root four teeth in the DFC group success, whereas DFC
(n = 119) IRM and SSC modified scales statistically better than
2013 [78] DFC 36, 42 months resorption; external root were judged to have failed group showed 79%. This
FC group (n = 133) adopted by Zurn DFC.
resorption; inter-radicular or (99% of success). There was difference was found to
and Seale.
periapical bone destruction. no significant difference be significant.
found between groups.
After 12 months, a
Pulpotomy performed
Absence of periapical After 12 months, a clinical radiographic success rate
Absence with FS and FC provided
radiolucency, widened success rate of 100%, 92.5% of 75%, 79% and 87% was
of spontaneous pain, comparable results.
DL group (n = 40) periodontal ligament space, and 97% was observed in DL, observed in DL, FS and
Durmus et al. DL vs. DFC GI and SCC percussion/palpation, Although DL pulpotomy
FC group (n = 40) 12 months pathologic internal/external FS and FC group, respectively. FC group, respectively.
2014 [79] vs. FS§§ abscess, swelling, seemed to offer
FS group (n = 40) root resorption, pathological No statistically significant No statistically
fistula, pathologic promising clinical
changes of the alveolar bone differences were detected significant differences
mobility. success, it yielded low
in the furcation area. between groups. were detected between
radiographic success rate.
groups.
Absence of widening of the
Absence of pain, periodontal ligament space,
Radiological success rates Although GA seemed the
FC group (n = 30) tenderness, internal root resorption, Clinical success was 96.7% for
Havale et al. FC### vs. GA in FC, GA, and FS groups most efficient, FS and FC
GA group (n = 30) SSC 12 months swelling, fistula external root resorption, FS, 86.7% for FC and 100% for
2013 [80] vs. FS§§ were 56.7%, 83.3% and did not show statistically
FS (n = 30) formation, pathological interradicular GA
63.3%, respectively. significant differences.
pathologic mobility. radiolucency, calcification of
canal.
After 36 months, CH was
Absence of the least effective
Absence of periapical or
FC group (n = 50) spontaneous pain, pulpotomy material, and
furcal radiolucency, After 36 months clinical Overall success after
DFC vs., Er:YAG group IRM and GI and SSC or tenderness to FS was the most effective;
Huth et al. 12, 18, 24 and pathologic external or success rates were: 92% for 36 months were: 72% for
Er:YAG vs. (n = 50) composite resin percussion, fistula, however, FS did not show
2012 [81] 36 months distinct internal root FC, 89% for Er:YAG, 75% for FC, 73% for Er:YAG, 46%
CH†† vs. FS§§ CH group (n = 50) restoration soft tissue swelling, significant differences
resorption, widened CH and 97% for FS. for CH and 76% for FS.
FS group (n = 50) pathological tooth with FC. The Er:YAG
periodontal ligament space.
mobility. laser showed comparable
outcomes to FC.
J. Clin. Med. 2020, 9, 838 13 of 23

Table 3. Cont.

Groups Type of Definitive Evaluated Outcomes Reported Outcomes

Material Follow-up Conclusions
Distribution Restorations Clinical Radiographical Clinical Radiographical
Absence of pathological
changes of the alveolar bone The clinical success rate at
FS pulpotomy provided
Absence of in the apical and/or furcation 18 months for the FC and FS
RX success: FC 84.4%, favorable clinical and
spontaneous pain, area (visible periapical or groups was 90.9% and 89.2%
FS§§ vs. CH FC group (n = 33) CH 76.5%, and FS 81.1%. radiographic success
Markovic et al. 12 and abnormal mobility, inter-radicular radiolucency), respectively. CH group
(not specified) CH group (n = 34) GIC and amalgam The differences between rates, comparable to FC
2005 [82] 18 months tenderness to integrity of lamina dura, showed an overall lower
vs. FC††† FS group (n = 37) groups were not pulpotomy. CH showed
percussion, fistula. pathological internal clinical success of 82.3%,
significant. the worse performance
resorption, external root although differences were not
among groups.
resorption. statistically significant.

Absence of
spontaneous or
Absence of furcal or
severe pain, Comparable success was
amalgam (in case of periapical radiolucency, At the end of 24 months, the
DFC group (n = 15) pathological achieved using ABS, FC
Ozmen et al. DFC vs. ABS Class I cavities) or SCC widened periodontal clinical success rates for ABS, RX success: DFC 80%,
ABS group (n = 15) 24 months mobility, swelling, and FS as pulpotomy
2017 [83] vs. FS**** (in case of Class II ligament spaces, internal or DFC and FS were 87%, 87% ABS 87%, FS 87%.
FS group (n = 15) sinus tract, agents of deciduous teeth.
cavities) external root resorption, loss and 100%, respectively.
tenderness to
of lamina dura.
percussion,
palpation.
Absence of internal root
Comparable results were
NaOCl group Absence of pain, resorption, furcation 18 months: rx success
NaOCl vs. 18 months: the clinical success obtained using NaOCl,
Farsi et al. (n = 27) ZOE and SCC cemented 12 and swelling, sinus tract, radiolucency, periapical rates were NaOCl 91.7%,
DFC vs. FS rates were NaOCl 83.3%, FC DFC and FS as
2015 [84] DFC group (n = 27) with GIC. 18 months mobility, pain on radiolucency, widening of FC 100%, FS 91.3%,
(not specified) 96%, FS 87%, respectively. pulpotomy agents for
FS group (n = 27) percussion. the periodontal ligament respectively.
primary molars.
space.
Absence of history
of pain, tenderness
to Absence of integrity of
MTA success rate was
MTA group palpation/percussion, lamina, radiolucencies in the MTA success rate was 100% in MTA provided promising
Jayam et al. white MTA** SCC and/or GI and 100% in comparison to
(n = 50) 24 months pathological apical or bifurcation areas of comparison to 90.48% success results as pulpotomy
2014 [85] vs. FC◦◦◦◦ amalgam. 90.48% success in FC
FC group (n = 50) mobility, intra- or tooth, pathological internal in FC group. dressing material.
group.
extra-oral swelling, or external root resorption.
intra- or extra-oral
sinus.
Absence of After 12 months, DFC clinical
Absence of abnormal root
spontaneous pain, success rate was 91.3%. In the Radiographic success MTA seemed to be
MTA group resorption, internal root
Srinivasan et al. MTA** vs. draining fistula, MTA group, no clinical signs rates were 78.26% and clinically and
(n = 50) SSC 12 months resorption, furcation
2011 [86] DFC swelling or abscess, and symptoms were noted; 95.74%, in DFC and MTA radiographically superior
DFC group (n = 50) involvement, periapical bone
mobility, premature thus, the clinical success was group, respectively. to FC.
destruction.
exfoliation, 100%.
BD and DFC pulpotomy
Absence of pain, The BD group had a techniques demonstrated
swelling, Absence of periodontal radiographic success rate favorable clinical and
El Meligy et al. DFC group (n = 50) tenderness to ligament space, periapical 100% clinical success rates for of 100% at 12-month radiographic results in
DFC vs. BD◦ SSC 12 months
2019 [87] BD group (n = 50) percussion, fistula, and furcation pathosis, both groups. follow-up, while the DFC primary teeth, after a
abnormal tooth internal resorption. group had a success rate 12-month follow-up
mobility. of 98.1% at 12 months. without any significant
differences.
J. Clin. Med. 2020, 9, 838 14 of 23

Table 3. Cont.

Groups Type of Definitive Evaluated Outcomes Reported Outcomes

Material Follow-up Conclusions
Distribution Restorations Clinical Radiographical Clinical Radiographical
MTA was demonstrated
FC group (n = 50) Absence of pain, Absence of pathological root
FC (not to be a valid alternative
MTA group swelling or abscess, resorption, widening of Clinical evaluation: FC 94%; Rx success: FC 88%; PT
Sunitha et al. specified) vs. 12, 18 and to FC in pulpotomy
(n = 50) SSC sinus tract opening, periodontal space, PT 94%; MTA 100%; EMP 83%; MTA 94%; EMP
2017 [88] MTA* vs. 24 months procedures. PT and EMP
EMP group (n = 50) mobility, pain on bifurcation radiolucency, and 83%. 72%.
EMP vs. PT were also proven to be
PT group (n = 50) percussion. periapical radiolucency.
promising agents.
At 18 months follow-up, DFC provided the best
CH group (n = 15)
the radiographic success results over the follow-up
CH (not DFC group (n = 15) Absence of
Fernandes et al. Absence of internal or All the groups were clinically rate for the DFC group period. However, LLLT
specified) vs. LLLT group 12, and spontaneous pain,
2015 [89] IRM and GIC external root resorption and successful over the follow-up was 100%, 66.7% for CH might be considered as
DFC vs. LLLT (n = 15) 18 months mobility, swelling,
furcation radiolucency. period. group, 73.3% for LLLT an adjuvant alternative
vs. LLLT+ CH LLLT+ CH group fistula.
group, and 75% for LLLT for vital pulp therapy on
(n = 15)
+ CH group. human primary teeth.
Absence of pain,
At the 12th month of At the 12th month of
tenderness to Absence of internal root
MTA group evaluation a success rate of evaluation a success rate MTA provided highly
Subramaniam et al. MTA* vs. percussion, gingival resorption, external root
(n = 20) SSC 24 months 95% and 85% was seen in the of 95% and 85% was seen promising results as
2009 [90] FC◦◦◦◦ abscess, resorption, periapical/furcal
FC group (n = 20) MTA and FC groups, in the MTA and FC pulpotomy agent.
sinus/fistula, radiolucency.
respectively. groups, respectively.
pathologic mobility.
Absence of
symptoms of pain, The success rates of CH
MTA group Absence of periradicular or The success rates of CH CH appeared to clinically
DFC vs. FS tenderness to (46.1%) and MTA (66.6%)
(n = 15) amalgam (FS, DFC and interradicular radiolucency, (46.1%) and MTA (66.6%) be less appropriate than
Sonmez et al. (not specified) percussion, were lower than FC
CH group (n = 15) CH groups) IRM and 24 months internal or external root were lower than FC (76.9%) FC, FS and MTA as
2008 [91] vs. CH (vs. swelling, (76.9%) and FS (73.3%),
DFC group (n = 15) amalgam; (MTA group) resorption, periodontal and FS (73.3 %), although not pulpotomy dressing
MTA* fistulization, although not statistically
FS group (n = 15) ligament space widening. statistically significant. material.
pathological significant.
mobility.
Absence of internal root Total success rates of Total success rates of
12-35 months Absence of pain,
Fuks et al. DFC group (n = 38) resorption, furcation pulpotomies with FS and DFC pulpotomies with FS and FS and DFC provided
FC§§ and DFS IRM and SSC (mean swelling, sinus
1997 [92] FS group (n = 58) radiolucency, periapical bone were 92.7% and 83.8%, DFC were 92.7% and similar results.
20.5 months) tract.
destruction. respectively. 83.8%, respectively.

ABS: Ankaferd blood stopper, Ankaferd Health Products Ltd.; BD: Biodentine; CH: Calcium hydroxide; DL: Diode Laser; DFC: diluted formocresol, 20% or one-fifth strength; Buckley’s
Formocresol, Sulton Healthcare; EMP: enamel matrix protein, Emdogain, Straumann; FC: Formocresol; FS: Ferric sulphate; GA: glutaraldehyde, PSK Pharma, Karnataka; GI: glass-ionomer
restorative material, KetacÔ Molar, Easy MixÔ, 3M ESPE; GIC: glass ionomer cement, Vitremer® , 3M ESPE; IRM: Reinforced zinc-eugenol cement, Dentsply.; LLLT: Low Level Laser
Therapy; MTA: Mineral trioxide aggregate; NaOCl: Sodium hypochlorite; PT: Pulpotec, Products Dentaire – PD; SCC: stainless steel crown; ZOE: zinc-eugenol cement; * ProRoot MTA,
Dentsply; ** Ângelus, Londrina; *** MTA-Plus, Avalon Biomed Inc; **** Hemospad, Spad Laboratorie; ◦ Biodentine, Septodont; ◦◦ Biodinâmica Química e Farmacêutica Ltd.a; ◦◦◦ Sultan
Chemists, Englewood; ◦◦◦◦ Pharmadent remedies Pvt. Limited; § Calcium enriched mixture cement (CEM), BioniqueDent; §§ Astringedent – Ultradent Products Inc; §§§ Cresol Formalinan,
GHIMAS S.P.A; # Portland Cement (PC), Votorantim-Cimentos; ## Tempophore (TP), Septodont; ### Vishal Dentocare, Ahmedabad; † Biodinamica Quımica e Farmaceutica Ltd.a;
†† Calxyl® , OCO Präparate GmbH; ††† Ja pan Dental Pharmaceuticals, Co. Ltd.
J. Clin. Med. 2020, 9, 838 15 of 23

In order to ease the reading of the outcomes, the papers were further presented according to the
material that yielded the best result after comparison.

3.4.1. MTA
Almost 65% of the included papers (27/41) demonstrated that MTA provided comparable or
even better results over time when compared to other materials used in the pulpotomy procedures
of deciduous teeth. Specifically, MTA showed better performance than FC after 12 months of
evaluation [67,76,86], with a statistically significant difference reported in two out three of the evaluated
studies [67,86]. Moreover, better results of MTA in comparison to FC were observed after 24 months of
follow-up [55,70,72,85,90], although the differences did not reach a statistical significance except in
one study [55]. The same trend was maintained even after 30 [77] and 42 [78] months of evaluation,
respectively. In two additional studies [66,88], it was reported that FC showed slightly worse results
than MTA at a 24-month evaluation; however, it performed better than other materials assessed during
pulpotomy of primary teeth, such as Pulpotec and Emdogain [88], as well as Portland cement and
enamel matrix protein [66]. On the other hand, Jamali et al. [65] reported a superiority of MTA in respect
to FC after 24 months of evaluation, even though both groups yielded worse results when compared to
3Mixtatin (a combination of simvastatin and 3Mix antibiotic) (78.9% for FC, 90.5% for 3Mixtatin and
88.1% for MTA). However, the differences between groups were not statistically significant.
When solely compared to BD, MTA showed slightly better performances after 12 [56], 18 [61]
and 24 [52] months of assessment, without any statistically significant differences among groups. No
differences between MTA and BD were reported by Juneja et al. [59], evaluating pulpotomy procedures
on primary teeth performed also with FC. However, the authors observed that there were statistically
significant differences between FC and MTA at 12 and 18 months, both clinically and radiographically,
and between FC and BD at 12 and 18 months, only clinically [59]. Accordingly, Guven et al. [57]
demonstrated no differences between BD and MTA groups (total success rates at 24 months were
82.75% BD, 86.2% MTA-P and 93.1% PR-MTA); however, in the same study, primary teeth treated
with FS showed the lowest success rate (75.86%) at a 24-month follow-up, although this was not
statistically significant.
The comparison between MTA and FS yielded not significant differences after 18 [64] and
24 [71] months of evaluation; however, Doyle et al. [73] demonstrated a significantly lower survival
rate for primary teeth treated with eugenol-free FS than MTA, after a follow-up period of 38 months. It
should be noticed that Erdem et al. [71] not only reported the same performance for FS and FC (success
rate of 88% for both groups) at a 24-month follow-up, but also demonstrated a statistically significant
difference between MTA and a group of samples that underwent pulpotomy without use of any pulp
dressing agent (96% vs. 68% after 24 months), suggesting the importance of the traditional pulpotomy
procedure for the VTP of primary molars.
CH seemed to be the most ineffective material for pulpotomies of deciduous teeth and demonstrated
the worst results when compared with MTA [63] after 12 months, and with MTA and FC (MTA 100%,
FC 100%, CH 64%) [74], ProRoot MTA and MTA Angelus [68] and MTA and Portland cement [69] after
24 months of evaluation, respectively. In addition, the differences between CH and all tested materials
were significantly different at all follow-up points.
Finally, the comparison of MTA with other pulpotomy agents, such as calcium-enriched
mixture cement (CEM) [53] and Portland cement [54], provided the same clinical and radiographical
performances of all evaluated materials after a follow-up period of 24 months.

3.4.2. Biodentine
El Meligy et al. [87] clinically and radiographically evaluated 108 primary teeth that underwent
pulpotomy performed with BD or FC. After 12 months, the authors reported a 100% clinical success
rate in both groups and a radiographic success rate of 100% and 98.1% in the BD and FC groups,
respectively, although without any statistically significant difference.
J. Clin. Med. 2020, 9, 838 16 of 23

Three out of the 41 included papers reported the same [60] or even slightly better results [58,62] of
BD in respect to MTA. Specifically, after a follow-up period of 12 months, 39 pulpotomized primary
teeth treated with MTA showed a clinical success rate of 92% (36/39) and a radiographical success rate of
97% (38/39), whereas 39 teeth belonging to the BD group showed a clinical and radiographical success
rate of 97% (38/39) and 95% (37/39), respectively [62]. A 24-month follow-up evaluation revealed that
the clinical success rate of 62 primary molars that underwent pulpotomy was 96.8% (30/31) for both BD
and MTA groups and the radiographic success was 93.6% (29/31) for the BD group and 87.1% (27/31)
for the MTA group [58].
Therefore, although BD showed slightly better clinical results after one year [62] and radiographic
results after two years of follow-up [58], no statistically significant differences were found among groups.

3.4.3. Ferric Sulphate

A total of three out 41 included papers [80,83,92] demonstrated that FS performed better when
compared to FC in the pulpotomy of carious deciduous teeth, however without reporting statistically
significant differences. Specifically, after 12 months, a total success rate of 92.7% and 83.8% was reported
by Fucks et al. [92] and a clinical success rate of 96.7% and 86.7% was reported by Havale et al. [80] in
primary molars that underwent pulpotomy with FS and FC, respectively. The latest study [80] also
demonstrated a gradual decrease of radiological success rate over time, showing rates of 56.7% and
63.3% for FS and FC, respectively. Moreover, Ozmen et al. [83] compared three pulpotomy agents,
such as FC, FS and Ankaferd blood stopper (ABS), and reported a more favorable clinical success
rate for FS (100%) than other evaluated materials (87% for both ABS and FC) after a follow-up of
24 months. Concerning radiographical success, the same authors reported gradually reduced rates
that were comparable for FS and ABS (87%) and slightly lower for FC (80%).

3.4.4. Formocresol
According to the International Agency for Cancer Research, one of the main components of FC,
namely formaldehyde, has been classified as a human carcinogen [93]; due to this reason, FC was not
included as one of the keywords in the search strategy of the present systematic review. However, the
same material is still largely used and was reported in more than half of the included studies (23/41).
Among them, seven papers [75,79,81,82,84,89,91] reported similar or even better results of FC when
compared to other agents used in pulpotomy of primary teeth. Durmus et al. [79] reported a 12-month
clinical success rate of 97% and 92.5% of deciduous teeth pulpotomized and treated with FC and FS,
respectively, as well as comparable radiographical results (87% FC vs.79% FS), without any statistically
significant differences among groups. Moreover, FC and FS provided similar results in pulpotomy
procedures after 12 (clinical success: 96% FC and 95.7% FS; radiographic success: 100% both FC and
FS) and 18 months (clinical success: 96% FC and 87% FS; radiographic success: 100% FC and 91.3% FS)
of evaluation [84]. Markovic et al. [82] compared the 18-month clinical and radiographical success of
pulpotomies performed on 104 primary molars randomly divided into three groups and treated with
FS, FC and CH. FS and FC showed comparable radiographical and clinical success (89.2% and 90.9%,
respectively); on the other hand, the CH group demonstrated lower success than other groups (82.3%),
although this was not statistically significant [82]. Accordingly, comparing pulpotomies with FS, FC
and CH after 12, 24 and 36 months, CH showed the worst results after 24 and 36 months and, even
though the values did not reach statistical significance, the failure rate for the CH group was three
times higher than the FC one [81]. On the other hand, primary teeth treated with FC after pulpotomy
showed slightly better results than the FS group after 12 months of evaluation (96% FC vs. 86% FS),
and vice versa after 24 and 36 months of follow-up (85% FC vs. 86% FS and 72% FC vs. 76% FS,
respectively) [81]. Fernandes et al. [89] reported a significantly better radiographical success rate of
pulpotomy performed with FC compared to CH after 12 (100% FC vs. 50% CH) and 18 months (100%
FC vs. 66.7% CH), demonstrating that CH may not be considered suitable in pulpotomy treatment of
primary molars, even in combination with Low Level Laser Therapy [89]. Similar outcomes were also
J. Clin. Med. 2020, 9, 838 17 of 23

reported by Sonmez et al. [91], who observed 2-year follow-up success rates of 46.1%, 66.6%, 73.3% and
76.9% in 80 primary molars treated with CH, MTA, FS and FC, respectively. Although no statistically
significant differences were detected among groups, CH seemed to be less clinically appropriate than
other evaluated materials. Finally, Noorollahian [75] reported that, after 24 months of evaluation,
primary teeth treated with FC during pulpotomy provided better radiographical results than ones that
underwent MTA, although both groups yielded a 100% clinical success at the same follow-up point.

4. Discussion
VTP aims at preserving pulpal tissue and promoting repair of the mineralized tissue barrier
(dentin bridge) [94]. In addition, the success of this technique would avoid pulpectomy and subsequent
root canal obturation by several materials, that, on turn, could prevent the radicular resorption of the
primary molars and alter the development of the permanent teeth [11].
Since there is a lack of a general consensus regarding an ideal pulp dressing material, the aim of
the present systematic review was to establish a preferred agent to be used in the pulpotomy procedure
of primary teeth affected by deep caries, after raising a PICO question. The evaluation of the included
studies suggested that MTA seemed to be the material of choice after pulpotomies. Although it showed
successful clinical performances over time, the majority of the authors agreed on its drawbacks, such
as high costs, difficult storage and long setting time [4]. Therefore, in some cases, alternative materials
may be used. FC had historically been indicated as a valid option in the pulpotomy procedures of
primary molars; however, the evidence-based scientific literature has already demonstrated its potential
cytotoxicity and carcinogenicity [93]. Due to this reason, FC was not included in the search strategy
of the present systematic review; nevertheless, it is largely used and provides some good clinical
results. Thus, to supply a complete overview on the topic, papers that compared several materials
with FC were included. Seven studies [75,79,81,82,84,89,91] reported better clinical outcomes of FC
than FS. On the other hand, the comparison between FC and MTA [55,66,67,70,72,76–78,85,86,88,90],
yielded a better performance of the latter after 12, 24, 30 and 42 months of evaluation. Accordingly, El
Meligy et al. [87] observed slightly favorable clinical and radiographical outcomes of primary teeth
underwent pulpotomy performed with BD than FC, although no statistically significant.
FS yielded more favorable clinical results when compared to FC in 3/41 studies included in the
present review [80,83,92]. Even though it provided comparable or slightly worse outcomes than
MTA [64,71,73], when the pulpotomized primary molars are going to be replaced by permanent teeth,
FS may be used as a safe alternative [95].
In accordance with the scientific literature [95], the present review confirmed that CH seemed to
be the most ineffective material for pulpotomies of deciduous teeth and demonstrated the worst results
when compared with all tested materials, reaching statistically significant differences at all follow-up
points [52,63,69,74,81,89].
The introduction of calcium-silicate-based cements (such as Biodentine) appears to be promising
for VTP. Indeed, calcium-silicate-based cements seem to play a central role in regenerative endodontics,
inducing pulp regeneration, healing and dentin formation [96]. The present review confirms the
previously reported results [4,15], showing similar outcomes when MTA was compared to BD [52,56–62].
MTA and BD may be classified as bioactive endodontic cements, due to their bioactivity feature, despite
the differences in their chemical compositions [15]. The encouraging clinical properties as well as
biocompatibility of calcium-silicate-based cements indicate that they can be considered as a suitable
alternative to MTA for pulpotomies in primary molars. However, these preliminary results should be
supported by further studies.

Limitations
The main limitation of the present systematic review was the high heterogeneity of the included
studies. Although only randomized clinical comparative studies with at least 12 months of follow-up
were evaluated, the lack of univocal standard procedures made difficult a precise comparison of
J. Clin. Med. 2020, 9, 838 18 of 23

the data. Moreover, the use of several materials composition as well as slightly different outcomes
evaluation provided high variability in the interpretation of the results and could let to a misjudgment
in the Conclusions. Due to this reason, some “confounding” materials reported by several included
studies, such as sodium hypochlorite [84], Er:YAG laser [81], diode laser [79] and low level laser
therapy [89], were excluded in the evaluation of pulpotomy dressing agents.
It should be further considered the high variability given by the type of restoration material used,
although definitive, its interaction with the pulpotomy agent as well as the inconstant time between
the pulpotomy treatment and the physiological exfoliation of the same tooth, that would render very
hard to establish the success of pulpotomy procedure over time.
The quality assessment of the included studies showed an overall high risk of bias, mainly in blinding
of participants and personnel, followed by blinding of outcome assessment. This aspect highlighted the
inadequacies in the published studies, as previously reported by Gopalakrishnan et al. [97]. High quality
study design and standardized clinical and radiographical protocols are needed to prospectively assess
the performances of pulpotomy medicaments used in deciduous teeth.

5. Conclusions
Within the limitation of the present systematic review, MTA seemed to be the gold standard
material in the pulpotomy of primary teeth. Promising results were also provided by BD. On the
contrary, CH should be firmly avoided during pulpotomy procedures. Further RCT studies with
adequate sample sizes and long follow-ups are encouraged to confirm these outcomes.

Author Contributions: Conceptualization, M.B. and F.I.; methodology, G.D.G.; validation, M.B., F.I. and G.D.G.;
investigation, A.S.; data curation, G.D.G.; writing – original draft preparation, F.I.; writing – review & editing, A.P.;
supervision, S.D.C. All authors have read and agreed to the published version of the manuscript.
Funding: The authors deny any sources of funding.
Conflicts of Interest: The authors declare no conflict of interest.

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