Clinical and Radiographic Outcomes Following Pulpotomy Using Biodentine in Carious Exposed Mature Permanent Teeth: A Systematic Review and Meta-analysis

ABSTRACT

Aim:

Vital pulp therapy is increasingly used in managing mature permanent teeth exposed to caries. Biodentine, a tricalcium silicate-based material, has emerged as a potential alternative to mineral trioxide aggregate (MTA) in pulpotomy procedures due to its favorable properties of handling and biocompatibility. The aim was to systematically evaluate and compare the clinical and radiographic outcomes of biodentine and MTA as pulpotomy agents in mature permanent teeth exposed to caries.

Materials and Methods:

This systematic review and meta-analysis was registered with International Prospective Register of Systematic Reviews (CRD4202457708) and followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. A comprehensive search of MEDLINE, Scopus, EBSCOhost, OpenGrey, and relevant journals was conducted up to August 31, 2024, to identify randomized controlled trials (RCTs). Studies comparing biodentine and MTA in mature permanent teeth with carious pulp exposure were included. The risk of bias was assessed using the Joanna Briggs Institute checklist, and statistical analysis was conducted using RevMan 5.4. The certainty of evidence was graded using the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) approach.

Results:

Seven RCTs were included in the systematic review, of which three were eligible for meta-analysis. The pooled results showed no significant difference between biodentine and MTA regarding clinical and radiographic success (odds ratio = 0.77; 95% confidence interval: 0.24–2.49; P = 0.66). Heterogeneity was low (I² = 0%), and no significant publication bias was detected. However, the GRADE assessment rated the certainty of evidence as low due to imprecision and potential risk of bias.

Conclusion:

Both biodentine and MTA demonstrate comparable clinical and radiographic success as pulpotomy agents in mature permanent teeth exposed to caries pulp. Given its advantageous handling and lower discoloration potential, biodentine may serve as a suitable alternative to MTA. Further high-quality trials are warranted to strengthen the current evidence base.

INTRODUCTION

Vital pulp therapy (VPT) focuses on preserving and maintaining the pulp tissue vitality affected by dental caries, trauma, or restorative procedures.[1] A crucial aspect of successful VPT is the selection of materials that promote healing with minimal toxicity to the pulp tissue.[2] Recent advancements in biomaterials and a deeper understanding of pulp biology have greatly enhanced VPT success rates, even in cases involving irreversible pulpitis in permanent teeth.[3] Bioactive endodontic cements, like mineral trioxide aggregate (MTA), have been widely used in VPT for their ability to promote hard tissue formation and maintain pulp vitality. The effects of MTA on pulp tissues are comparable to those of calcium hydroxide (CH) as CH is the main soluble component of MTA. Although MTA is highly effective, it has drawbacks including tooth discoloration, prolonged setting time, challenging manipulation, and high costs.[4] To address these limitations, Biodentine (Septodont Inc., France), a tricalcium silicate-based material, was introduced in 2009.[5] Biodentine exhibits mechanical properties similar to those of dentin and encourages the formation of reparative dentin by stimulating the production of tertiary dentin upon contact with the pulp tissue.[1] Its shorter setting time, superior handling characteristics, and reduced potential for discoloration have made it an attractive alternative to MTA in VPT procedures.[6]

Despite Biodentine’s growing use in VPT, systematic evaluations of its clinical and radiographic outcomes, especially in pulpotomy procedures for mature permanent teeth exposed to caries pulp, remain limited.

This systematic review aimed to evaluate and compare the clinical efficacy and radiological outcomes of Biodentine with other commonly used pulpotomy agents, namely, MTA, TotalFill, as well as CH, in permanent teeth exposed to caries, in adults. However, due to limited availability of comparable outcome data, the quantitative synthesis was restricted to studies directly comparing Biodentine with MTA. Apart from providing a comprehensive evaluation of Biodentine’s efficacy as an essential pulp therapy agent, this study aims to support evidence-based endodontic treatment decision-making.

MATERIALS AND METHODS

STUDY FRAMEWORK AND SEARCH STRATEGY

The current systematic review and accompanying meta-analysis adhered to the 27-point Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines and was registered in International Prospective Register of Systematic Reviews (PROSPERO) under the registration number CRD4202457708.

An in-depth search of relevant sources was undertaken across three major electronic databases: MEDLINE, Scopus, and EBSCOhost, in addition to Gray literature (OpenGrey) and manual searching of relevant journals. Studies indexed in the databases from their beginning till August 31, 2024, were included in the search. The search strategy involved a combination of keywords and Medical Subject Headings (MeSH) related to “biodentine,” “tricalcium silicate cement,” “pulp capping agent,” “pulpotomy,” “vital pulp therapy,” and “carious permanent teeth.” Additional eligible studies were identified through a manual search of the bibliographies of the included articles.

PICOS

The PICOS elements were structured as follows:

Population (P): Patients with carious teeth showing signs and symptoms of reversible or irreversible pulpitis.

Intervention (I): Biodentine as a pulpotomy agent.

Comparison (C): Other pulpotomy agents.

Outcome (O): Clinical and radiographic success, defined by the following: lack of clinical signs and symptoms of pulpal pathosis (such as pain or sensitivity to percussion), absence of radiographic evidence of root resorption or new furcal/periapical lesions.

Study design (S): Randomized clinical trials.

ELIGIBILITY CRITERIA

Criteria for inclusion were randomized controlled trials (RCTs) with a defined sample size, a minimum of 1 year’s follow-up, studies involving mature permanent teeth (closed apices) undergoing partial or full pulpotomy studies in which Biodentine was used as one of the pulpotomy agents and compared to other pulpotomy agents. And literatures were published in English.

The exclusion criteria were case reports, non-randomized trials, reviews, cross-sectional studies, cohort or case–control studies, partial or biased reporting of results, studies on immature or deciduous teeth, studies on traumatized teeth, studies in which biodentine is not used as one of the pulpotomy agents, and studies conducted in languages other than English.

DATA EXTRACTION

The data extraction process was performed independently by two reviewers (US and RS), who recorded the following details from each study: title, author(s), study design, journal name, publication year, tooth type and developmental stage, diagnosis, treatment approach, pulp capping material used, follow-up period, and clinical/radiographic outcomes. A third author (AG) reviewed the extracted data to ensure accuracy and consistency.

RISK-OF-BIAS ASSESSMENT

Quality appraisal of the included RCTs was performed using the Joanna Briggs Institute (JBI) Critical Appraisal Checklist for RCTs. Randomization, allocation concealment, group baseline similarity, participant blinding, operator blinding, treatment received, outcome assessor blinding, outcome reliability, follow-up, participant analysis in randomized groups, statistical analysis, and trial design were among the bias domains that were evaluated. Disagreements among the reviewers were settled by a conversation.

STATISTICAL ANALYSIS

Meta-analysis was performed using RevMan software version 5.4 from the Cochrane Collaboration, Copenhagen, Denmark.[7] Only studies that evaluated biodentine and MTA were considered for the meta-analysis. Using the Mantel–Haenszel statistical method in conjunction with a fixed-effect analysis model, the heterogeneity was evaluated between the studies using the chi-squared and I² tests. A significance level of P ≤ 0.05 was used. Meta-regression and subgroup analyses were intended to address the possible causes of heterogeneity, such as study design, follow-up period, and type of material used. However, since these analyses require a higher sample size to yield reliable results, they were not conducted, attributable to the insufficient number of studies included in the meta-analysis. A funnel plot was utilized to evaluate potential publication bias.

CERTAINTY OF EVIDENCE

The Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) system was employed to appraise the quality of evidence supporting the meta-analysis outcomes.[8] This assessment covered five domains: Risk of bias, inconsistency, indirectness, imprecision, and supplementary factors potentially affecting the credibility of the findings. Potential upgrades in certainty were incorporated into the assessment for the dose–response gradient and significant impact size.

RESULTS

STUDY SELECTION

Out of the 272 records retrieved through a detailed database search, 163 articles were retained after eliminating duplicates. During the screening of titles and abstracts, 10 records were excluded. The remaining 10 studies were sought for retrieval, but 1 could not be retrieved. Of the 9 full-text articles assessed for eligibility, 2 were excluded, one for using a combination of pulp capping agents and the other for lacking follow-up data, resulting in 7 studies being included in the final systematic review. Among these, three studies that directly compared Biodentine with MTA and reported comparable outcome measures were included in the meta-analysis. The study selection process is illustrated in the PRISMA flowchart [Figure 1].

Figure 1.

PRISMA flowchart

STUDY CHARACTERISTICS

Table 1 presents an overview of the key characteristics of the included studies, which assessed the clinical and radiographic outcomes of using Biodentine as a pulpotomy agent in comparison with materials such as MTA, TotalFill, Emdogain, and CH.

Table 1.

Characteristics of the included studies

Author and Year	Study Design	DOI	Teeth (Type & N)	Diagnosis	Treatment	Outcome	Materials Used	Follow-Up
Harakh Chand Baranwal, 2023	RCT	https://doi.org/10.4103/jcd.jcd_118_22	Mandibular molars, 66	Irreversible pulpitis	Partial pulpotomy and full pulpotomy	Success rate of partial pulpotomy-80.7%. Success rate of full pulpotomy-92.8%	Biodentine	3, 6, and 12 months
Nessrin A. Taha, 2023	RCT	https://doi.org/10.1016/j.joen.2023.04.001	Molars (upper and lower, first and second), 60	Irreversible pulpitis	Pulpotomy or root canal treatment	Success rate: pulpotomy-96.4% root canal treatment-96.7%	Biodentine	6–12 months
Lama Awawdeh, 2018	RCT	https://doi.org/10.1016/j.joen.2018.08.004	Incisors, premolars, molars, 68	Reversible pulpitis	Direct pulp capping, pulpotomy	Success rate at 1-year follow-up: Biodentine-96.0% Success rate with MTA- 100%	Biodentine or MTA	6 months and yearly for 3 years
Nessrin A. Taha, 2022	RCT	https://doi.org/10.1111/iej.13707	Molars, 193	Reversible and irreversible pulpitis	Full pulpotomy	Success rate: MTA—91.8% Biodentine-93.3% TotalFill-91.9%	ProRoot MTA, Biodentine, TotalFill	6 months and 1 year
Dev Veer Vikram Singh, 2023	RCT	https://doi.org/10.1007/s00784-023-05136-6	Molars, 100	Reversible pulpitis	Partial pulpotomy	Success rate: CH-91.30% MTA-91.66% Biodentine-100% EMD-100%	CH, MTA, Biodentine, Emdogain	1, 3, 6, and 12 months
Sneh Mishra, 2024	Prospective RCT	https://doi.org/10.4103/jcde.jcde_257_23	Maxillary or mandibular molars, 170	Irreversible pulpitis	Full pulpotomy	Success rate: Biodentine-91.4% Biodentine+lyophilized platelet concentrates-93.1% Biodentine+low-level laser therapy-95.5%	Biodentine, Biodentine + platelet concentrate, Biodentine + laser	3, 6, 12 months
E. Melvin Gabriel, 2024	RCT	https://doi.org/10.4103/jcde.jcde_63_24	Maxillary or mandibular first and second molars, 108	Reversible pulpitis	Indirect pulp capping and pulpotomy	Success rate: Indirect pulp capping-82.2% Pulpotomy-98%	Biodentine	15 days, 3, 6, 12 months

1. Awawdeh et al.[9] assessed the effectiveness of Biodentine and White MTA in adult teeth with carious exposure. The study found comparable success rates for both materials, with no statistically significant difference observed. The overall success rate was 93.3% at 6 months (Biodentine: 93.1%, MTA: 93.5%), escalating to 96.2% at 1 year and 100% at 2 years. The success rate slightly declined to 93.8% by the 3-year point (Biodentine: 91.7%, MTA: 96.0%). Both materials showed comparable success as pulpotomy agents in permanent teeth.

2. Taha et al.[6] employed ProRoot MTA, Biodentine, and TotalFill in order to analyze the comparative effectiveness for full pulpotomy in adult teeth with symptoms. The success rate at the 6-month period was 92.2% (144 out of 156 teeth), with MTA, Biodentine, and TotalFill having respective rates of 91.8%, 93.3%, and 91.9%. Analysis revealed no meaningful variation in outcomes between the materials.

3. Baranwal et al. (2023)[10] compared partial and full pulpotomy using Biodentine in symptomatic irreversible pulpitis–affected mature molars. At the 12-month follow-up, the study’s success rates for the two procedures were 92.8% for full pulpotomy and 80.7% for partial pulpotomy, with no significant difference.

4. Taha et al.[11] investigated the use of biodentine as a full pulpotomy agent as an alternative to endodontic treatment in carious-exposed teeth. Both treatments demonstrated similar success rates of 93%. The study highlighted that full pulpotomy was proven to be more successful in pain relief and improved patient satisfaction in terms of treatment time, cost, and intraoperative pain compared to endodontic treatment.

5. Singh et al.[12] assessed the utilization of CH, MTA, Biodentine, and Emdogain in mature molars with reversible pulpitis following partial pulpotomy in terms of clinical and radiographic performance, post-operative discomfort, and anti-inflammatory use. While Emdogain resulted in significantly less post-operative pain and medication use, no significant difference was observed in clinical or radiographic outcomes among the agents used. The study indicated the potential for consistently successful outcomes with any capping agent when following evidence-based guidelines.

6. Mishra et al.[13] conducted a clinical trial comparing three pulpotomy treatments in mature molars with irreversible pulpitis: Biodentine alone, biodentine with lyophilized freeze-dried platelet-rich concentrate, and biodentine with low-level laser therapy. Significant differences in post-operative pain were observed after 1 week, with the most pain reported in the biodentine alone group, followed by the platelet-rich concentrate + biodentine group, and the least pain in the laser therapy + biodentine group. Yet, the rate of success remained statistically unchanged among groups.

7. Gabriel et al.[14] examined the effects of indirect pulp capping with DyCal versus coronal pulpotomy with Biodentine for treating molars with moderate pulpitis over a 12-month period. The pulpotomy group had a higher number of patients, requiring no further intervention compared to the indirect pulp capping group.

METHODOLOGICAL QUALITY (RISK OF BIAS) ASSESSMENT

Using the JBI critical appraisal tool, the three included studies for meta-analysis were assessed to exhibit an overall low risk of bias [Table 2]. Each of the included studies applied proper methods for random sequence generation. Allocation concealment and participant blinding was unclear in one study, and in one study, the blinding of personnel was unclear [Figure 2]. No reporting bias or incomplete outcome data were identified in any of the included studies.

Table 2.

JBI critical appraisal checklist for randomized controlled trials

JBI critical appraisal checklist for randomized controlled trials	Lama Awawdeh (2018)	Dev Veer Vikram Singh (2023)	Nessrin A Taha (2022)
Was true randomization used for the assignment of participants to treatment groups?	Yes	Yes	Yes
Was allocation to treatment groups concealed?	Unclear	Yes	Yes
Were treatment groups similar at the baseline?	Yes	Yes	Yes
Were participants blind to treatment assignment?	Unclear	Yes	Yes
Were those delivering treatment blind to treatment assignment?	Yes	Unclear	Unclear
Were outcomes assessors blind to treatment assignment?	Yes	Yes	Yes
Were treatment groups treated identically other than the intervention of interest?	Yes	Yes	Yes
Was follow-up complete and if not, were differences between groups in terms of their follow-up adequately described and analyzed?	Yes	Yes	Yes
Were participants analyzed in the groups to which they were randomized?	Yes	Yes	Yes
Were outcomes measured in the same way for treatment groups?	Unclear	Yes	Yes
Was appropriate statistical analysis used?	Yes	Yes	Yes
Was the trial design appropriate, and any deviations from the standard RCT design (individual randomization, parallel groups) accounted for in the conduct and analysis of the trial?	Yes	Yes	Yes

Figure 2.

Forest plot

META-ANALYSIS

In assessing clinical and radiographic success characterized by no radiographic signs of root resorption or new periapical lesions, and no clinical indicators of pulpal disease such as pain or tenderness on percussion, the meta-analysis evaluated and compared the performance of Biodentine and MTA. An odds ratio (OR) of 0.77 (95% confidence interval [CI]:0.24–2.49; P = 0.66) revealed no statistically significant disparity between the two materials in the pooled data analysis. There was little heterogeneity (I² = 0%, P = 0.64, Chi-squared = 0.89, df = 2) [Figure 2].

The visual inspection of the funnel plot revealed a symmetrical distribution of studies, which may suggest a low risk of publication bias. However, considering the limited pool of studies (n = 3), the interpretive value of the funnel plot is highly limited. Funnel plots are generally considered unreliable when fewer than 10 studies are available, and therefore, any conclusions regarding publication bias should be interpreted with caution. [Figure 3].

Figure 3.

Funnel plot

CERTAINTY OF THE EVIDENCE

The certainty of evidence was rated as low according to the GRADE framework, due to serious concerns regarding risk of bias, inconsistency, and imprecision [Table 3]. This rating reflects the unclear risk of bias in two of the included studies; the presence of clinical heterogeneity in terms of diagnosis, procedures, and follow-up durations—despite statistical homogeneity (I² = 0%)—and serious imprecision resulting from a small sample size and a wide CI that crossed the line of no effect.

Table 3.

Certainty of the evidence using grading of recommendations assessment, development and evaluation

Certainty Assessment							No of patients		Effect		Certainty	Importance
№ of studies	Study design	Risk of bias	Inconsistency	Indirectness	Imprecision	Other considerations	EFFICACY OF BIODENTINE	MTA as pulpotomy	Relative (95% CI)	Absolute (95% CI)
Efficacy of biodentine vs mta as pulpotomy agent
3	Randomized trials	Serious	Serious	not serious	Serious	strong association	88/94 (93.6%)	97/102 (95.1%)	OR 0.77 (0.24 to 2.49)	14 fewer per 1000 (from 128 fewer to 29 more)	⨁⨁◯◯ Low	IMPORTANT*

^*Outcome importance was categorized based on the GRADE approach, which categorizes outcomes as critical, important, or not important for clinical decision-making. Outcomes with a direct impact on clinical decision-making and patient health is considered as “critical,” while those that support interpretation but are not directly essential for the decision-making are considered as “important.” Outcomes with minimal or no expected impact on clinical-decisions were classified as “not important.” In this review, short-term clinical success of pulpotomy was rated as “important” as it reflects treatment efficacy but does not solely determine long-term prognosis or patient-centered outcomes.

DISCUSSION

The effectiveness of pulpotomy utilizing Biodentine as a pulpotomy agent in patients diagnosed with symptomatic reversible or irreversible pulpitis is examined in this comprehensive review and meta-analysis. By maintaining pulp vitality and offering several benefits to patients and practitioners, VPT presents a strong alternative to traditional root canal treatment.[15] While VPT has historically been linked to reversible pulpitis, research is beginning to indicate that it may also be used to treat irreversible pulpitis.[9] The first group to perform a series of cases on 14 adult human permanent molars with an irreversible pulpitis diagnosis was Eghbal et al. in 2009. The findings revealed no indications of inflammation, full dentinal bridge development, and intact pulp vitality.[16]

Several key factors contribute to the success of VPT, including accurate diagnosis, adherence to aseptic techniques, achieving hemostasis, and selecting appropriate pulp-capping materials.[17] Clinicians must navigate these elements to identify the most effective material for each case. Biocompatibility, mechanical strength, antibacterial characteristics, an efficient seal, and the tendency to encourage the creation of hard tissue and tissue repair are all desirable qualities in a pulp-capping agent.[18]

Biodentine, a tricalcium silicate-based material, has received attention recently owing to its diverse applications in restorative dentistry and endodontics. Its uses extend beyond pulpotomy, encompassing procedures such as root perforation repairs, apexification, and retrograde fillings.[19] Biodentine was developed to address the downsides of MTA, such as a prolonged setting period, staining of teeth, and challenging handling. As clinical use has expanded, heightened focus has been directed toward comparing the performance of Biodentine and MTA across various applications. The review comprised studies designed as RCTs investigating Biodentine as a pulp-capping agent for pulpotomy from 2018 to 2024.

The findings of this review align with previous systematic reviews. Ather et al. demonstrated that Biodentine yielded better outcomes than MTA, CH, and calcium-enriched mixture in VPT procedures.[20] Similarly, Tong et al. reported superior outcomes with Biodentine in both indirect and direct pulp capping, as well as pulpotomy.[21] The present systematic review complements the growing amount of data endorsing the use of Biodentine for VPT, especially when pulpotomy is included.

The Oxford Center for Evidence-Based Medicine ranks systematic reviews of RCTs as Level 1 evidence, which is crucial to the evaluation of the treatment efficacy of pulpotomy treatment.[22] A previous review by Parirokh and Torabinejad assessed various VPT procedures in both mature and immature teeth. However, this review included multiple treatment modalities, different interpretations of success, and pooled follow-up periods, leading to heterogeneity in their findings.[4] In a recent systematic review, compared to CH, MTA and Biodentine demonstrated improved outcomes with no statistically significant difference.[23]

Few more systematic reviews which included RCTs were either conducted on only immature teeth[21] or both mature and immature teeth.[3,20,24,25] Additionally, earlier meta-analyses comparing VPT medications in primary teeth suggested that MTA is the most effective pulpotomy agent.[26] Although in permanent teeth, CH outperformed MTA in partial pulpotomy. The comparison revealed no significant disparity between MTA and CH in full pulpotomy.[22] The incorporation of non-randomized studies contributed to a downside in the analysis and ambiguity in the findings.

In the present review, the meta-analysis revealed no statistically significant disparity in the clinical and radiographic outcomes between MTA and Biodentine as pulpotomy agents, with an OR of 0.77 (95% CI:0.24–2.49; P = 0.66). Heterogeneity among the selected studies was found to be minimal (Chi-squared = 0.89, df = 2, P = 0.64; I² = 0%), indicating consistency in the outcomes. The certainty of evidence, assessed using the GRADE framework, was rated as low, primarily due to certain limitations. While the included studies showed consistent treatment effects (I² = 0%), some concerns, such as unclear risk of bias in two studies, clinical variability, and a relatively small sample size with a wide CI contributed to this rating. These factors suggest that while the findings are promising, they should be interpreted with measured confidence. Additionally, the symmetrical funnel plot shows a low probability of publication bias; however, its interpretive value is inherently limited due to the few studies included, making it insufficient to derive conclusions.

While the meta-analysis did not reveal a statistically significant difference, it is crucial to interpret the findings with respect to their clinical relevance. A 10%–15% difference in success rates is commonly accounted for while making clinical decisions as the minimum change deemed clinically significant for endodontic procedures. The OR in the present study lies between 0.67 and 1.5, which is typically not considered clinically significant.

However, this review has few limitations. The included studies varied in terms of sample sizes, randomization methods, disease onset, and diagnosis (reversible vs. irreversible pulpitis), as well as differences in teeth type (maxillary vs. mandibular), pulpotomy procedures (partial vs. full), treatment protocols, and follow-up periods. Additionally, operator expertise and the accuracy of outcome assessments could influence the results. Also, the studies included were restricted to those published in English, which may introduce a language bias, resulting in the omission of relevant studies written in languages other than English. However, since English is the predominant language in scientific research literature, and the majority of high-quality studies in this field are published in English, the impact of this limitation on the overall findings is minimal. The conclusions of this review should be evaluated considering these factors.

CONCLUSION

Both Biodentine and MTA are sufficiently effective as pulpotomy agents in fully developed permanent teeth with carious pulp exposure. Since both Biodentine and MTA have equivalent success rates, Biodentine can be viewed as a suitable alternative to MTA, offering advantages such as improved handling and reduced discoloration potential. Long-term further investigation is recommended to confirm these results and examine additional uses of biodentine in endodontic procedures.

CONFLICT OF INTEREST

There are no conflicts of interest.

ETHICAL POLICY AND INSTITUTIONAL REVIEW BOARD STATEMENT

This systematic review and meta-analysis was registered with PROSPERO (CRD4202457708) and followed PRISMA 2020 guidelines.

PATIENT DECLARATION OF CONSENT

Not applicable

DATA AVAILABILITY STATEMENT

The dataset used in the current study is available on request to the corresponding author mail.

Authors contribution

Dr. Unnati Soma: Conceptualization, study design, definition of intellectual content, literature search, clinical studies, data acquisition, data analysis, manuscript preparation, manuscript editing, manuscript review, guarantor. Dr. Rajat Sharma: Conceptualization, study design, definition of intellectual content, literature search, clinical studies, data analysis, manuscript preparation, manuscript editing, manuscript review. Dr. Alpa Gupta: Conceptualization, study design, definition of intellectual content, literature search, clinical studies, data acquisition, data analysis, statistical analysis, manuscript preparation, manuscript editing, manuscript review. Dr. Dax Abraham: Conceptualization, study design, definition of intellectual content, literature search, clinical studies, data analysis, manuscript preparation, manuscript editing, manuscript review. Dr. Lubna Ahmad: Conceptualization, study design, definition of intellectual content, literature search, clinical studies, data acquisition, data analysis, manuscript preparation, manuscript editing, manuscript review. Dr. Neha: Conceptualization, study design, definition of intellectual content, literature search, clinical studies, data acquisition, data analysis, manuscript preparation, manuscript editing, manuscript review, guarantor.

ABBREVIATIONS

• MTA Mineral Trioxide Aggregate

• PRISMA Preferred Reporting Items for Systematic Reviews and Meta-Analyses

• PROSPERO International Prospective Register of Systematic Reviews

• RCT Randomized Controlled Trials

• VPT Vital Pulp Therapy

• CH Calcium Hydroxide

• JBI Joanna Briggs Institute

• GRADE Grading of Recommendations, Assessment, Development, and Evaluations

SUPPLEMENTARY INFORMATION

Supplementary File 1.

List of studies excluded

Sr. No.	Title	Reason for exclusion
1	Outcome of partial and full pulpotomy in cariously exposed mature molars with symptoms indicative of irreversible pulpitis: A randomized controlled trial	Comparison between partial and full pulpotomy using a single agent
2	Pulpotomy in caries-exposed immature permanent molars using calcium-enriched mixture cement or mineral trioxide aggregate: a randomized clinical trial	Study on immature molars
3	Treatment outcomes of pulpotomy in primary molars using two endodontic biomaterials. A two-year randomised clinical trial	Comparison between calcium-enriched mixture (CEM) cement and mineral trioxide aggregate (MTA)
4	Pulpotomy of human primary molars with MTA and Portland cement: a randomised controlled trial	Study on primary molars
5	Calcium hydroxide vs mineral trioxide aggregates for partial pulpotomy of permanent molars with deep caries	Comparison between calcium hydroxide and MTA
6	Comparative Evaluation of Efficacy of Resin-modified Glass Ionomer Cement and Light-curable Tricalcium Silicate Cement as Indirect Pulp Capping Materials: A Randomized Clinical Trial	Comparison between resin-modified glass ionomer cement and light-curable tricalcium silicate cement
7	The outcome of full and deep pulpotomy in teeth with extremely deep carious lesion and symptomatic irreversible pulpitis: A non-inferiority randomized controlled trial	Only Mineral trioxide aggregate was used as a pulp capping agent
8	Clinical and radiographic evaluation of pulpotomies performed under intrapulpal injection of anaesthetic solution	Use of calcium hydroxide as pulp capping agent
9	Comparative evaluation of complete and partial pulpotomy in mature permanent teeth with symptomatic irreversible pulpitis: A randomized clinical trial	Only Mineral trioxide aggregate was used as a pulp capping agent
10	Vital pulp therapy following pulpotomy in immature permanent teeth with carious exposure	Study included immature teeth
11	Pulp survival and postoperative treatment needs following selective vs. total caries removal in mature permanent teeth with reversible pulpitis: A randomized clinical trial	Study comparing total vs selective caries removal.
12	Conservative Management of Mature Permanent Teeth with Carious Pulp Exposure	Use of calcium hydroxide And incomplete follow-up
13	Clinical Comparison of Three Indirect Pulp Capping Restorative Protocols: A Randomized Controlled Prospective Study	Comparison between TheraCal LC and Dycal

Supplementary File 2.

Database search strategy

Database	Search Strategy	n
PubMed	(((((((((((((biodentine) OR (tricalcium silicate based cement)) OR (tricalcium silicate based sealer)) OR (permanent dentine substitute)) OR (pulp capping agents)) OR (septodont)) OR (dentine substitute)) OR (bioactive dental cement)) OR (calcium silicate dental cement)) OR (bioceramic cement)) AND (pulpotomy)) OR (vital pulp therapy)) OR (vital pulp treatment)) AND (carious permanent teeth)	107
Scopus	(((((((((((((biodentine) OR (tricalcium silicate based cement)) OR (tricalcium silicate based sealer)) OR (permanent dentine substitute)) OR (pulp capping agents)) OR (septodont)) OR (dentine substitute)) OR (bioactive dental cement)) OR (calcium silicate dental cement)) OR (bioceramic cement)) AND (pulpotomy)) OR (vital pulp therapy)) OR (vital pulp treatment)) AND (carious permanent teeth)	138
Ebsco host	(((((((((((((biodentine) OR (tricalcium silicate based cement)) OR (tricalcium silicate based sealer)) OR (permanent dentine substitute)) OR (pulp capping agents)) OR (septodont)) OR (dentine substitute)) OR (bioactive dental cement)) OR (calcium silicate dental cement)) OR (bioceramic cement)) AND (pulpotomy)) OR (vital pulp therapy)) OR (vital pulp treatment)) AND (carious permanent teeth)	27

Funding Statement

Nil.