Is there a difference in the success rate of pulpotomies in primary teeth when using mineral trioxide aggregate (MTA) compared to other calcium-silicate cements (CSC)?

Abstract

A commentary on: Silva E J N L D, Pinto K P, Riche F N S J et al. Success of primary teeth pulpotomy using calcium silicate cements: a systematic review and meta-analysis of randomised clinical trials. Pediatr Dent 2024; 46: 373-395.

Introduction: This systematic review and meta-analysis of randomised clinical trials aimed to evaluate and compare the outcomes of pulpotomy procedures using Mineral Trioxide Aggregate (MTA) and other Calcium-Silicate Cements (CSCs).

Methods: The review protocol was registered with PROSPERO (CRD42023479322) and adhered to PRISMA 2020 guidelines. Two independent reviewers conducted a comprehensive systematic search across PubMed®, Cochrane Library, Scopus, Web of Science™, Embase®, and ScienceDirect®, supplemented by manual searches and OpenGrey. Eligible studies were selected according to the PICOS criteria, including only randomised clinical trials that reported clinical and radiographic evaluations of pulpotomies with a minimum follow-up period of six months. The certainty of evidence was appraised using the GRADE framework, evaluating domains such as risk of bias, inconsistency, indirectness, imprecision, and publication bias. Two reviewers independently assessed the severity of each domain. Meta-analyses were performed using RevMan 5.3, comparing clinical and radiographic success rates of MTA pulpotomies with those of alternative materials, based on dichotomous outcomes and patient recall. Risk of bias was assessed using the Cochrane RoB-2 tool, and the overall certainty of evidence was determined according to the GRADE methodology.

Results: A total of 662 articles were initially identified, with 26 studies included after screening and full-text review. Quality appraisal showed seven studies at low risk of bias, two with some concerns, and 17 at high risk, mainly due to poor randomisation, missing intention-to-treat analyses, and high attrition. Despite challenges in radiographic blinding, outcome and reporting biases remained consistently low. Meta-analyses compared pulpotomy outcomes in primary teeth treated with MTA versus other CSCs. No significant differences were observed between MTA and Biodentine™ in clinical success (P > 0.05), though MTA showed higher radiographic success at 12 months (P < 0.05). No significant differences were found between MTA and TheraCal® or Portland cement (P > 0.05). Data were insufficient for analyses by pulpotomy type, tooth type, or irrigant used. The overall quality of evidence was low, due to a serious risk of bias and imprecision. Publication bias appeared minimal, and studies were free from private sector funding.

Conclusion: This systematic review and meta-analysis demonstrated that mineral trioxide aggregate (MTA) and other calcium silicate-based cements (CSCs) are effective materials for managing pulpotomies in primary teeth. Although MTA exhibited superior treatment outcomes at 12 months compared to Biodentine™, no significant difference in overall efficacy was observed between the two materials at 24 months. However, the certainty of the evidence supporting these findings was assessed as low, underscoring the need for further research employing robust study designs and extended follow-up periods to achieve a more comprehensive understanding of pulpotomy outcomes with different materials.