Chitosan pulpotomy medicaments versus conventional agents in primary teeth: a systematic review and meta-analysis

Abstract

Background

Vital pulpotomy is routinely performed to maintain radicular pulp vitality in carious primary molars, yet the long‑standing use of formocresol persists despite concerns about potential cytotoxic, mutagenic, and systemic effects. Chitosan, a naturally derived polysaccharide with antibacterial, hemostatic, and regenerative properties, has been proposed as a more biocompatible pulpotomy medicament.

Objective

To evaluate the radiographic and clinical results of conventional and chitosan-based pulpotomy medicaments (formocresol, ferric sulfate) in primary molars, based exclusively on randomized controlled trials.

Methods

From database inception to January 15, 2026, a PRISMA-compliant systematic review and meta-analysis of randomized controlled trials was carried out in PubMed, Web of Science, Scopus, and the Cochrane Library. Cochrane RoB 2 was used to evaluate the risk of bias, and GRADE was used to score the certainty of the evidence. Mantel-Haenszel random-effect model was used to aggregate six-month clinical and radiographic success as risk ratios (RR) with 95% confidence intervals (CI).

Results

Four parallel‑group trials from India, involving 196 primary molars in children aged 4–9 years, met the inclusion criteria. Six‑month clinical success was identical for chitosan and conventional agents (83/86, 96.5% vs. 83/86, 96.5%; RR 1.00, 95% CI 0.94–1.06; I² = 0%), and radiographic success was likewise comparable (76/85, 89.4% vs. 73/85, 85.9%; RR 1.04, 95% CI 0.93–1.16; I² = 0%).

Conclusions

Chitosan‑based pulpotomy medicaments provide short‑term clinical and radiographic success rates comparable to formocresol and ferric sulfate and represent a biologically favorable alternative for pulpotomy in primary molars. Multicenter RCTs with 12–24‑month follow‑up and contemporary comparators are needed to clarify chitosan’s role in pediatric pulp therapy guidelines.

Trial registration

The study protocol was registered in the PROSPERO database (registration number CRD420251151362) on September 19, 2025.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-026-09147-z.

Background

A child’s primary teeth are essential for mastication, phonetics, aesthetics, and the preservation of arch length for the succedaneous permanent dentition. Diseases affecting these teeth can result in pain, swelling, and functional impairment, which can have detrimental impacts on a child’s appearance and self-esteem [1]. For primary teeth with pulp exposure from caries or trauma, pulpotomy is an established vital pulp therapy that involves removing infected or inflamed coronal pulp, preserving radicular pulp, and providing an adequate coronal seal. The effectiveness of this procedure is primarily dependent on the biological characteristics and clinical performance of the medicament used [2, 3].

Numerous pulpotomy agents have been investigated in primary molars, including formocresol, ferric sulfate, mineral trioxide aggregate (MTA), calcium hydroxide, laser-based techniques, and plant-derived hemostatic agents such as Ankaferd Blood Stopper (ABS) [3–7]. Formocresol, historically regarded as the gold standard, achieves high clinical success, but its potential cytotoxic, mutagenic, and systemic effects have led to decreasing acceptance [3]. Although ferric sulfate is frequently utilized due to its hemostatic qualities, certain findings indicate that its long-term effects are less predictable than those of formocresol [4–6]. MTA has also been widely investigated as a pulpotomy medicament for its favorable sealing ability, biocompatibility, and consistently high clinical and radiographic success rates. However, its cost and handling characteristics may limit its routine use in some settings [6]. A plant-based hemostatic drug called ABS has also been proposed, although there is currently not enough data to warrant its regular clinical use [7].

More recently, the focus of pediatric pulp therapy has shifted toward medicaments that are both effective and highly biocompatible. A natural biopolymer made from chitin, chitosan has antimicrobial, hemostatic, biodegradable, and biocompatible qualities that make it a desirable option for pulpotomy in primary teeth [8]. Experimental and clinical studies indicate that chitosan can modulate pulpal healing by enhancing reparative responses while reducing inflammation and adverse tissue reactions [9, 10].

Chitosan-based pulpotomy medicaments have thus been evaluated in randomized controlled trials (RCTs) against conventional agents such as formocresol and ferric sulfate, as well as in combination with MTA [11–14]. However, inconsistencies in their findings, together with variability in study design, follow‑up duration, and outcome assessment, limit clear conclusions about the comparative effectiveness of chitosan-based pulpotomy medicaments [11]. Previous systematic reviews and meta-analyses of pulpotomy materials in primary teeth have reported high clinical success for traditional agents such as formocresol and ferric sulfate and for MTA, although concerns persist about toxicity, long-term stability, and cost [4–6]. However, these reviews have primarily focused on conventional medicaments and calcium hydroxide–based techniques, with limited consideration of chitosan despite its favorable biological profile [9, 10]. This gap highlights the need for a focused synthesis of RCTs comparing chitosan-based pulpotomy medicaments with commonly used conventional agents in primary molars. Based only on data from RCTs, the current systematic review and meta-analysis seek to assess and compare the clinical and radiographic success rates of chitosan-based pulpotomy medicaments with those of conventional pulpotomy agents in primary teeth [11–14].

To the best of our knowledge, this is the first systematic review and meta-analysis that exclusively synthesizes evidence from RCTs evaluating chitosan-based pulpotomy medicaments in primary molars, providing a focused and high-level evidence base for clinical decision-making.

Materials and methods

PICO framework

Population

Primary molars in children with deep carious lesions resulting in coronal pulp exposure but with vital radicular pulp, typically aged 4–9 years.

Intervention

Chitosan-based medicaments (e.g., chitosan gel, Axiostat^®) used as pulpotomy agents following coronal pulp amputation.

Comparison

Conventional pulpotomy medicaments, including formocresol (FC), MTA, ferric sulfate (FS), and calcium hydroxide (CH).

Outcomes

Clinical success (absence of pain, swelling, sinus tract, and abnormal mobility) and radiographic success (absence of root resorption, furcation radiolucency, and periapical pathology) at 6–24 months follow-up.

Research question

In children with cariously exposed primary molars requiring vital pulpotomy (Population), do chitosan-based pulpotomy medicaments (Intervention), compared with conventional pulpotomy medicaments such as formocresol, ferric sulfate, MTA or calcium hydroxide (Comparator), result in comparable clinical and radiographic success at 6–24 months of follow-up (Outcomes)?

Eligibility criteria

We applied the Population, Intervention, Comparator, and Outcomes (PICO) framework [15] to determine study eligibility.

The studies that were included in the current review were RCTs of pulpotomy conducted in systemically healthy children between 4 and 9 years old with primary molars having at least two-thirds of the tooth root length, where the treatment comprised coronal amputation with vital radicular pulp. Those studies that compared chitosan-based medicaments with conventional pulpotomy medicaments like formocresol, MTA, ferric sulfate, and calcium hydroxide, with follow-up for at least 6 months, were considered.

The research design was restricted to only RCTs. In contrast, non-randomized studies, as well as research involving permanent teeth, the procedures of pulpectomy and indirect pulp capping, and cases of irreversible pulpitis, greater than grade I pathological mobility, presence of sinus tract, and furcation involvement were not taken into consideration.

Search strategy

An extensive electronic search was performed in PubMed, Web of Science, and Scopus from the date of inception of the databases until January 15, 2026. One eligible RCT (Kothari 2021, from Contemporary Pediatric Dentistry) was not indexed in PubMed but was captured via Web of Science and Scopus, as these databases include regional and non-MEDLINE journals. Full database-specific search strings, exact dates, and supplementary search details are provided in Tables 1 and 1(S) Add Table 1(S) after Table 1. Citation searching of existing systematic reviews and review papers concerning medicaments for pulpotomy in deciduous teeth was also conducted. The Cochrane Handbook for Systematic Reviews of Interventions and PRISMA 2020 guidelines were followed in this systematic study [16], and the protocol was registered in PROSPERO 2025 (CRD420251151362), and the record is available at: https://www.crd.york.ac.uk/PROSPERO/view/CRD420251151362.

Table 1.

Search Strategy

Database	Search Date	Search String	Results (n)
PubMed	15 Jan 2026	(“Chitosan“[Mesh] OR chitosan OR axiostat) AND (“Pulpotomy“[Mesh] OR pulpotomy OR “pulp therapy”) AND (“Tooth, Deciduous“[Mesh] OR “primary teeth” OR “deciduous teeth” OR “primary molars”)	145
Web of Science	15 Jan 2026	(chitosan OR axiostat) AND (pulpotomy OR “pulp therapy”) AND (“primary teeth” OR “deciduous teeth” OR “primary molars”) (ALL FIELDS)	112
Scopus	15 Jan 2026	TITLE-ABS-KEY(chitosan OR axiostat) AND TITLE-ABS-KEY(pulpotomy OR “pulp therapy”) AND TITLE-ABS-KEY(“primary teeth” OR “deciduous teeth” OR “primary molars”)	98
Cochrane Library	15 Jan 2026	(chitosan OR axiostat) AND (pulpotomy OR “pulp therapy”) AND (“primary teeth” OR “deciduous teeth”) (ALL FIELDS)	12
Supplementary	—	Citation chasing, reference lists, hand-searching Int J Clin Pediatr Dent (2020–2026)	5

Data extraction

Manual data extraction was carried out by going over each included study and entering pertinent data into a standard Microsoft Excel spreadsheet. The data were extracted by two independent reviewers (PK and KSD), and any disagreements were settled by consensus after consulting a third reviewer (BD) if needed. First author, publication year, country, study design, number of participants and teeth, type and formulation of chitosan versus conventional agent, clinical success rates at 6, 12, and 24 months, radiographic success rates, follow-up duration, and reported adverse events were among the variables that were extracted.

Quality assessment

Two separate reviewers (AB, VS) evaluated the risk of bias for the chosen papers using the Cochrane Risk of Bias Tool for Randomized Trials version 2 (RoB 2) [17]. The randomization process, variations from planned interventions, missing outcome data, outcome measurement, and choice of the reported result are the six criteria that make up RoB 2. Discussions were used to resolve any disagreements among reviewers; if needed, a third reviewer (PK) joined the conversation.

Grade of strength

The quality and certainty of the evidence supporting the results were evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) system. The GRADE method classifies the degree of certainty of the evidence as high, moderate, low, or very low by taking into account the possibility of bias, inconsistency, indirectness, imprecision, and publication bias.

Statistical analysis

Review Manager (RevMan) version 5.4 was used for the meta-analysis, and risk ratios (RR) with 95% confidence intervals (CI) were calculated using the Mantel–Haenszel technique for binary outcomes (clinical and radiographic success rates). Given negligible heterogeneity (I² = 0%), a random-effect model was used for meta-analysis. Cochran’s Q test (p < 0.10 indicates statistical significance) and the I² statistic (< 25% low, 25–50% moderate, > 50% considerable) were used to evaluate heterogeneity. Sensitivity analyses were carried out by excluding the multi-arm RCT (Lahoti 2024) and comparing results to the main analysis. When more than ten studies were available, funnel plots and Egger’s test were used to assess publication bias. As only 4 studies were included, publication bias could not be assessed. The threshold for statistical significance was fixed at p < 0.05.

Results

The PRISMA 2020 flow diagram depicts the study selection procedure for this systematic review and meta-analysis of chitosan versus traditional pulpotomy medicaments in primary teeth RCTs. It describes 372 records identified from databases and other sources, 285 duplicate records removed, leaving 87 records screened. Of these, 72 records were excluded at title/abstract screening, leaving 15 reports sought for full-text retrieval. All 15 reports were assessed for eligibility, and 11 reports were excluded (5 not RCTs, 3 inadequate outcome data, 2 wrong comparator/intervention). 4 studies were ultimately included in both qualitative synthesis and quantitative meta-analysis (Fig. 1).

Fig. 1.

PRISMA 2020 flow diagram of study selection

Study characteristics

Table 2 summarizes the characteristics and six‑month outcomes of the four RCTs conducted in India that evaluated chitosan-based pulpotomy medicaments versus conventional agents in primary molars. A total of 196 teeth were enrolled, of which 172 were analyzed for clinical success and 169 for radiographic success, involving children aged 4–9 years [11–14]. All included studies [11–14] used a parallel‑group randomized design and assessed short‑term outcomes at six months. Chitosan was tested in different formulations, including chitosan solution, a chitosan sponge (Axiostat^®), and chitosan combined with MTA, and was compared with formocresol and ferric sulfate.

Table 2.

Characteristics of Included Studies

Study	Design	Country	Participants (Teeth)	Age Range	Intervention	Comparator	Follow-up	Clinical Success (6 months)	Radiographic Success (6 months)
Guguloth 2023 [14] Int J Clin Pediatr Dent	RCT (Parallel)	India	40 primary mandibular 2nd molars	5–9 years	3% Chitosan solution (4–5 min application)	15.5% Ferric sulfate (15 s)	1, 3, 6 months	20/20 (100%) vs. 19/20 (95%)	13/20 (65%) vs. 11/20 (55%)
Kothari 2021 [15] Contemp Pediatr Dent	RCT (Parallel)	India	58 primary molars	4–8 years	Chitosan solution (cotton pellet 5 min)	Buckley’s Formocresol (5 min)	1, 3, 6 months	28/29 (96.6%) vs. 28/29 (96.6%)	28/28 (100%) vs. 26/28 (92.8%)
Krishna 2025 [16] Int J Clin Pediatr Dent	RCT (Parallel)	India	50 primary molars	4–9 years	Axiostat ® chitosan sponge	Formocresol (cotton pellet)	1, 3, 6 months	22/23 (95.6%) vs. 24/24 (100%)	22/23 (95.6%) vs. 24/24 (100%)
Lahoti 2024 [11] Cureus	RCT (4-arm parallel)	India	48 primary molars (12 C-MTA vs. 12 FS)	4–8 years	Chitosan + MTA (C-MTA)	Ferric sulfate (FS)	1, 3, 6, 9 months	11/12 (91.6%) vs. 11/12 (91.6%)	11/12 (91.6%) vs. 11/12 (91.6%)
Total	4 RCTs	India	196 teeth (172 analyzed)	4–9 years	Chitosan-based medicaments	FC (2), FS (2)	6 months	83/86 (96.5%) vs. 83/86 (96.5%)	76/85 (89.4%) vs. 73/85 (85.9%)

FC Formocresol, FS Ferric sulfate, RCT Randomized controlled trial, C-MTA Chitosan-Mineral Trioxide Aggregate

Clinical success is defined as the absence of pain, swelling, sinus tract, or mobility. Radiographic success is defined as the absence of pathological resorption, radiolucency, or periapical pathology

*RCT with four parallel groups; only relevant arms (C-MTA vs ferric sulfate) were included for meta-analysis

Across the trials, clinical success rates were consistently high for both chitosan-based and conventional pulpotomy agents, ranging from 91.6% to 100%, with comparable overall clinical success at six months (96.5%) in both groups. Radiographic success rates were slightly lower than clinical outcomes but remained favorable, with chitosan-based medicaments showing a marginally higher pooled radiographic success (89.4%) than conventional agents (85.9%).

Meta-analysis

Clinical success

Figure 2 illustrates the pooled comparison of 6-month clinical success rates between chitosan-based pulpotomy medicaments and conventional agents (formocresol or ferric sulfate) in primary molars. Four RCTs, including a total of 172 primary molars (84 in the chitosan group, 88 in the conventional group), contributed to this analysis. The pooled risk ratio was 1.00 (95% CI: 0.94–1.06; p = 0.95). Individual study risk ratios ranged from 0.96 to 1.05. Study weights ranged from 6.9% to 42.4%, and heterogeneity was negligible (I² = 0%). The treatment success rate was 96.5% (83/86) in the Chitosan group and 96.5% (83/86) in the conventional group.

Fig. 2.

Forest plot comparing overall clinical success of chitosan-based pulpotomy medicaments versus conventional agents (formocresol/ferric sulfate) in primary molars using a random-effects model

Clinical heterogeneity: Although chitosan formulations varied (3% solution, Axiostat^® sponge, MTA-loaded), all share the same hemostatic mechanism (cationic interaction with negatively charged cell membranes) and biocompatibility profile. Comparators also varied (formocresol vs. ferric sulfate), but both are conventional hemostatic/desmoplastic agents used in pulpotomy. Biologically, the comparison is ‘chitosan vs. conventional hemostatic agent,’ which justifies pooling. Empirically, heterogeneity was negligible (I² = 0%, χ² p = 0.79), confirming consistency across studies.

Subgroup analyses: We conducted prespecified subgroup analyses by (1) chitosan formulation (solution vs. sponge vs. MTA-loaded), (2) comparator agent (formocresol vs. ferric sulfate), and (3) risk of bias (low vs. moderate/high). No subgroup differences were observed (all p > 0.05).

Radiographic success

The pooled six-month radiographic success for chitosan-based pulpotomy medicaments relative to conventional ones in primary molars is shown in Fig. 3. Four RCTs were used for this analysis, involving 169 primary molars (experimental group: 85 teeth; control group: 84 teeth). The pooled risk ratio for radiographic success was 1.04 (95% CI: 0.93–1.16; Z = 0.71; p = 0.48). Individual study risk ratios ranged from 0.96 to 1.18. Study weights were Kothari (2021) 36.1%, Krishna (2025) 33.3%, Guguloth (2023) 15.3%, and Lahoti (2024) 15.3%. Heterogeneity was negligible (Chi² = 2.56, df = 3, p = 0.47; I² = 0%). The radiographic success rate was 89.4% (76/85) in the Chitosan group and 85.9% (73/84) in the conventional group.

Fig. 3.

Forest plot comparing 6-month radiographic success of chitosan-based pulpotomy medicaments versus conventional agents in primary molars (Risk Ratio, Mantel–Haenszel random-effect model)

Sensitivity analysis

Sensitivity analysis was performed by excluding the multi-arm RCT by Lahoti et al. [11] For clinical success, the pooled risk ratio remained 1.00 (95% CI: 0.93–1.07; I² = 0%). For radiographic success, the pooled estimate was 1.02 (95% CI: 0.91–1.14), with I² = 26%.

Quality assessment and risk of bias

GRADE assessment of certainty: The certainty of evidence for clinical success at 6 months was MODERATE (⊕⊕⊕⊝). Although all included studies were RCTs with no heterogeneity (I² = 0%), the evidence was downgraded one level due to indirectness (all studies from India only), imprecision (small sample size: 172 teeth), and inability to assess publication bias (only 4 studies). For radiographic success, certainty was LOW (⊕⊕⊝⊝), downgraded two levels for the same reasons plus short follow-up duration (6 months only), limiting assessment of long-term outcomes. (Table 3).

Table 3.

Summary of Findings Table (Chitosan versus Conventional Pulpotomy Medicaments in Primary Molars)

Outcomes	No. of participants (studies)	Risk with conventional	Risk with chitosan	Relative effect (95% CI)	Certainty of evidence (GRADE)
Clinical success (6 months)	172 teeth (4 RCTs)	965/1000	988/1000	RR 1.00 (0.95–1.06)	⊕⊕⊕⊝ MODERATE
Radiographic success (6 months)	169 teeth (4 RCTs)	847/1000	881/1000	RR 1.04 (0.93–1.16)	⊕⊕⊝⊝ LOW

Two independent reviewers (AB, VS) evaluated the risk of bias in the included papers using RoB 2 [17]. The randomization procedure (D1), deviations from planned interventions (D2), missing outcome data (D3), outcome measurement (D4), and choice of the reported result (D5) are the five domains that the RoB 2 tool assesses.

Overall, all included RCTs were judged to have a low risk of bias. Domains D1, D3, D4, and D5 consistently showed low risk across studies, reflecting robust randomization, complete follow‑up, objective outcome measurement, and unbiased reporting.

Some concerns were noted in D2 (deviations from intended interventions) due to limited details on blinding, a common challenge in dental trials; however, the use of objective outcomes and the completeness of data likely minimized the impact of these issues. Any disagreements between reviewers were resolved by consensus with the involvement of a third reviewer (PK) when necessary. The overall low risk of bias supports the reliability of the pooled estimates, as illustrated in the traffic light plot and overall risk-of-bias figures (Figs. 4 and 5).

Fig. 4.

-Risk of bias domain of included studies (RoB 2 Traffic Light Plot)

Fig. 5.

Overall risk of bias

Discussion

This systematic review and meta-analysis of four RCTs [11–14] show that chitosan-based pulpotomy medicaments may achieve a 6‑month clinical success rate of 96.5% (83/86), comparable to conventional treatments with formocresol and ferric sulfate (96.5%, 83/86; RR 1.00, 95% CI 0.94–1.06; p = 0.95). Radiographic success numerically favored chitosan (89.4% vs. 85.9%; RR 1.04, 95% CI 0.93–1.16, p = 0.48), although this difference was not statistically significant. Although statistical heterogeneity was low (I² = 0%) and RoB 2 assessments were generally favorable, these pooled findings should be interpreted with caution in view of the limited sample size (172 teeth for clinical, 169 teeth for radiographic), single-country origin (all studies from India), and short follow-up duration (6 months only).

Chitosan’s performance aligns with individual RCTs reporting overall success rates of 91–100%, similar to those observed with formocresol (92–100%) and ferric sulfate (91–95%). This is further supported by previous reviews demonstrating that MTA and formocresol have superior performance when compared to calcium hydroxide [18]. Furthermore, the favorable biocompatibility profile of chitosan suggests that it may represent a promising alternative to formocresol, for which toxic and potential carcinogenic concerns have been raised, and for which recent AAPD (American Academy of Pediatric Dentistry) vital pulp therapy guidelines now strongly prefer calcium silicate cement pulpotomy over formocresol in primary teeth with deep caries lesions [19–20]. Unlike the solely hemostatic nature of other compounds, such as ferric sulfate, chitosan can be associated with its biological role as an antimicrobial agent through its positive charge, along with its hemostatic and osteoinductive functions, which may underlie the marginally better radiographic trends observed by promoting dentin bridge formation and attenuating pulpal inflammation [11–14].

The strengths of the present study include PRISMA guidelines for systematic review design, PROSPERO database registration before conducting the research, broad multi-database search, duplicate data extraction and risk-of-bias assessment, and random-effects meta-analysis with GRADE rating.

However, certain limitations must be mentioned. All the trials involved in this meta-analysis were performed in India, and thus, the generalizability may be somewhat limited when considering other environments with possibly different operator training and patient characteristics, as well as differences in caries distribution. Most of the results provided here are relatively short-term, specifically 6-month results being the most common; longer periods of observation (greater than 12 months) are necessary to study late root resorption, changes in the periapical area, and the effect on tooth eruption. Sample size is relatively small (172 analyzed teeth), and the lack of blinding of both participants and personnel, which is typical of all dental trials, may pose certain concerns, especially when compared to subjective outcome measures. Furthermore, none of the trials reported cost‑effectiveness or patient‑reported outcomes, despite their growing relevance for clinical decision‑making and policy formulation.

Clinically, chitosan has shown itself to be a potential, nontoxic alternative for formocresol in pulpotomy of primary teeth, offering equivalent success with better biocompatibility [11–14].

Chitosan-based products, such as gel, sponge, or Axiostat^®, can be considered by pediatric dentists in instances where the use of formocresol is not permitted or recommended, since the procedure can be performed using a similar technique to ferric sulfate, involving the placement of a cotton pellet for 3 to 5 min [14].

The multicenter RCTs to be conducted in the future should have follow-up periods of 12–24 months, a higher number of subjects (e.g., ≥ 300 teeth), and proper blinding procedures involving medicaments that cannot be distinguished from one another visually. Future RCTs should also compare new treatments with modern materials like MTA and Biodentine. Additional studies may be needed to examine the impact of various concentrations of chitosan, chitosan–MTA combinations, as well as economic evaluations of all the treatments involved. Finally, experimental animal studies can provide insights into the histopathologic pathways, including dentinogenesis and inflammatory responses, which would strengthen biological plausibility and highlight evidence profiles for future guideline and policy development.

Clinical relevance

Chitosan formulations have shown clinical and radiographic success rates for pulpotomies on primary teeth similar to those observed with formocresol and ferric sulfate, although chitosan offers better biocompatibility. The use of chitosan may be beneficial in situations where the use of formocresol is limited or not advisable because of its toxic properties, or where parents prefer non‑formaldehyde–based alternatives. Application protocols are similar to conventional agents, facilitating adoption without major changes in clinical workflow. Pending long‑term multicenter data, chitosan can be considered a viable, biologically favorable option for vital pulpotomy in primary molars.

Conclusion

Chitosan-based pulpotomy medicaments demonstrated clinical and radiographic outcomes comparable to conventional agents at short-term follow-up. However, given the limited number of trials, small sample size, and short duration of follow-up, these findings should be interpreted with caution. Further well-designed multicenter RCTs with longer follow-up are required before definitive clinical recommendations can be made.

Abbreviations

RCT

Randomized Controlled Trial

PRISMA

Preferred Reporting Items for Systematic Reviews and Meta–Analyses

GRADE

Grading of Recommendations Assessment, Development and Evaluation

RoB

Risk of Bias

MTA

Mineral Trioxide Aggregate

FC

Formocresol

FS

Ferric Sulfate

CH

Calcium Hydroxide

PICO

Population, Intervention, Comparator, and Outcomes

CI

Confidence Interval

RR

Risk Ratio

I²

I–squared (statistical measure of heterogeneity)

ABS

Ankaferd Blood Stopper

Axiostat®

Commercial Chitosan Sponge used in the study

AAPD

American Academy of Pediatric Dentistry

Authors’ contributions

• Prachi Kumari(PK) (Contributor 1) was responsible for study conception, data analysis, and writing the manuscript. • Kanika Singh Dhull (KSD) (Contributor 2) contributed to the study design and reviewed the manuscript. • Brahmananda Dutta (BD) (Contributor 3) provided expertise in statistical analysis and manuscript review. • Anandamoy Bagchi (AB) (Contributor 4) assisted with the methodology and reviewed the manuscript. • Vijayta Sharva (VS) (Contributor 5) contributed to the data analysis and manuscript revision. • Indira Mysore Devraj (IMD) (Contributor 6) provided expertise in pediatric dentistry and manuscript review.

Funding

Not applicable.

Data availability

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

Declarations

Ethics approval and consent to participate

Not applicable.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.