Revisão Sistemática e Meta - HC em Cavidades Profundas

doi:10.1111/iej.
13034
REVIEW
Is a calcium hydroxide liner necessary in the
treatment of deep caries lesions? A systematic
review and meta-analysis
W. L. O. da Rosa, V. P. Lima, R. R. Moraes , E. Piva & A. F. da Silva

Graduate Program in Dentistry, Department of Restorative Dentistry, Federal University of Pelotas, Pelotas, RS, Brazil
Abstract performed in eight databases: PubMed (MEDLINE),

Lilacs, IBECS, BBO, Web of Science, Scopus, SciELO
da Rosa WLO, Lima VP, Moraes RR, Piva E, da Silva
and The Cochrane Library. A total of 17 studies
AF. Is a calcium hydroxide liner necessary in the treatment of
were included (15 in primary teeth, two in perma-
deep caries lesions? A systematic review and meta-analysis.
nent teeth). The overall risk difference for CH versus
International Endodontic Journal, 52, 588–603, 2019.
adhesive system in primary teeth was 0.06 [95% CI
The aim of this systematic review and meta-analysis 0.01 to 0.13], and the overall risk difference for
was to evaluate whether the use of calcium hydrox- CH versus GIC was 0.10 [95% CI 0.01 to 0.22],
ide (CH) liner improves the clinical success in the with no significant differences between materials. CH
treatment of deep caries lesions of primary and per- liner did not influence the clinical success of treat-
manent teeth. The review was reported in accor- ment for deep caries lesions of primary or permanent
dance with the PRISMA Statement. Only studies that teeth. Although the present analysis demonstrated
evaluated deep carious lesions treated with and with- that use of CH liner in deep caries lesions was
out a CH liner were included. The required outcomes unnecessary, the evidence was of moderate to very
had to be obtained by clinical, radiographic or low quality; thus, further well-designed, randomized
laboratory evaluations. Statistical analyses were and controlled clinical trials are necessary to provide
performed with the RevMan 5.2 program (The stronger recommendations.
Cochrane Collaboration, Copenhagen, Denmark) for
Keywords: calcium hydroxide, dental cavity lining,
randomized clinical trials with at least 12 months of
meta-analysis, pulp capping, vital pulp therapy.
follow-up, using fixed-effect models at a significance
level of P < 0.05. The literature search was Received 29 March 2018; accepted 31 October 2018
been suggested, such as leaving a layer of contami-

Introduction
nated carious tissue over the pulp, after selective or
The treatment of deep caries lesions continues to be stepwise removal of carious tissue (Innes et al. 2016,
challenging to clinicians. In an attempt to prevent Schwendicke et al. 2016a). Unlike selective removal,
pulp exposures, which can compromise the prognosis, stepwise removal is performed in two stages (Schwen-
conservative dentine-pulp complex therapies have dicke et al. 2016a). The first stage involves the same
carious tissue removal as in selective removal to soft
dentine, with a provisional restoration placed to last
for 6–12 months (Innes et al. 2016). In the subse-
Correspondence: Adriana Fernandes da Silva, Department of quent stage, the provisional restoration is removed
Restorative Dentistry, Federal University of Pelotas,
Goncßalves Chaves St., 457, room 503, Zip Code: 96015-
and followed by selective removal to firm dentine
560, Pelotas, RS, Brazil (Tel: +55 53 32256741; e-mail: (Innes et al. 2016, Schwendicke et al. 2016a). Long-
adriana@ufpel.edu.br). term studies have demonstrated a high success rate
588 International Endodontic Journal, 52, 588–603, 2019 © 2018 International Endodontic Journal. Published by John Wiley & Sons Ltd
13652591, 2019, 5, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/iej.13034 by CAPES, Wiley Online Library on [29/04/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
da Rosa et al. Calcium hydroxide liner in deep caries lesions – a meta-analysis
(healthy pulp status with positive sensitivity to cold

Materials and methods
and heat, absence of spontaneous pain, and absence
periapical lesion in radiographic examinations), rang- This review was reported in accordance with the Pre-
ing from 70% to 90% for selective or stepwise ferred Reporting Items for Systematic Reviews and
removal of carious tissue (Marchi et al. 2006, Fran- Meta-Analysis – PRISMA Statement (Moher et al.
zon et al. 2007, Casagrande et al. 2010, Maltz et al. 2009). The protocol was registered in the interna-
2012). tional database for systematic reviews PROSPERO
The maintenance of carious dentine is focused on (CRD42018089640). The research question was as
modifying the microenvironment and arresting the follows: Is a calcium hydroxide liner necessary in the
cariogenic process, which allows remineralization treatment of deep caries lesions?
of the lesion and the formation of tertiary dentine
(Hayashi et al. 2011, Pereira et al. 2017, Da Silva
Search strategies
et al. 2018). In both selective or stepwise removal
of carious tissue, calcium hydroxide (CH) continues The literature search was carried out by two indepen-
to be the lining material most commonly used over dent reviewers, in eight databases: PubMed (MED-
the carious tissue left in place, because of its alka- LINE), Lilacs, IBECS, Web of Science, BBO, Scopus,
linity, biocompatibility and capacity of inducing SciELO and The Cochrane Library, until 27th Febru-
pulp-dentine remineralization and decreasing bac- ary 2018. The search developed for PubMed (MED-
terial infection (Bjørndal et al. 2014, Pereira et al. LINE) and adapted for use in other databases is
2017, Da Rosa et al. 2018). The purpose of using a described in Table 1. The references of the articles
liner is to promote the formation of a dentine included were also manually checked. Duplicates were
bridge and tertiary dentine to protect pulp tissue removed in Endnote X7 software (Thompson Reuters,
from thermal and electrical stimuli, or chemical Philadelphia, PA, USA).
agents leached from adhesive systems (Schwen-
dicke et al. 2015). However, clinical, radiographic
Study selection
and microbiological evaluations have demonstrated
that simply sealing the cavity properly could lead The inclusion and exclusion criteria were as follows:
to inactivation of active deep carious lesions, even 1. Prospective or retrospective clinical trials were
when inert materials (i.e. wax or gutta-percha) included. Systematic reviews, review articles, case
were used as liners (De Oliveira et al. 2006, Pinto series, case reports, case–control and other types
et al. 2006). of studies were excluded.
It is not clear whether the long-term clinical suc- 2. All subjects had to have deep carious lesions trea-
cess rates of conservative approaches to treatment for ted with and without a CH liner. Studies in which
deep caries lesions are due to sealing the carious den- CH was applied after direct pulp capping or pulp
tine, or to the liner material placed over the remain- exposures were removed; so were studies that
ing tissue (B€uy€ ural & Cehreli 2008, Pereira et al.
ukg€ evaluated complete removal of caries tissue from
2017). A previous review conducted in primary teeth, the axial or pulpal wall of teeth with deep carious
which included three randomized clinical trials, lesions.
demonstrated that strong recommendations for using 3. The required outcomes had to be obtained by
cavity liners were unsubstantiated (Schwendicke et al. clinical, radiographic or laboratory evaluations
2015). Taking into consideration that there is no con- (histological, microbiological or physical–mechan-
sensus in the scientific literature regarding the need ical analysis). All included papers had to describe
to use CH liner in the selective or stepwise removal of the assessment of pulp status : sensitivity to cold,
carious tissue, the aim of this systematic review was heat, absence of spontaneous pain or periapical
to evaluate whether it is necessary to use a CH liner lesion in radiographic examinations. The unfa-
in the treatment of deep caries lesions of primary and vourable outcomes, according to previous studies
permanent teeth. The hypothesis tested was that CH (B€uy€
ukg€ural & Cehreli 2008, Maltz et al. 2018),
liner would have no beneficial effect on the clinical could include negative response to the cold test,
success of treatment of deep caries lesions without positive response to percussion, presence of spon-
direct pulp capping or pulp exposures. taneous pain or presence of periapical lesion.
© 2018 International Endodontic Journal. Published by John Wiley & Sons Ltd International Endodontic Journal, 52, 588–603, 2019 589
Calcium hydroxide liner in deep caries lesions – a meta-analysis da Rosa et al.
Table 1 Search strategy used in PubMed (MEDLINE) (selective or stepwise); type of cavity; groups evalu-
Search terms
ated; restorative procedures (Table 3); evaluation
methods; and main findings and whether or not the
#4 Search #1 AND #2 AND #3
CH liner was beneficial to the clinical success, for the
#3 ‘Calcium Hydroxide’ OR ‘Hydroxide, Calcium’ OR ‘Pulp
Capping Agents’ OR ‘Agent, Pulp Capping’ OR
purpose of summarizing the evidence found from each
‘Agents, Pulp Capping’ OR ‘Capping Agent, Pulp’ OR study (Table 4). If there was any information missing,
‘Capping Agents, Pulp’ OR ‘Pulp Capping Agent’ the authors of the papers included were contacted via
#2 ‘Dental Cavity Lining’ OR ‘Cavity Linings, Dental’ OR email to obtain the missing data.
‘Lining, Dental Cavity’ OR ‘Linings, Dental Cavity’ OR
‘Cavity Lining, Dental’ OR ‘Dental Cavity Linings’ OR
‘Varnish, Cavity’ OR ‘Cavity Varnish’ OR ‘Cavity Statistical analysis
Varnishes’ OR ‘Varnishes, Cavity’ OR ‘Cavity Lining
Varnish’ OR ‘Varnish, Cavity Lining’ OR ‘Cavity Lining The analyses were performed with Review Manager
Varnishes’ OR ‘Varnishes, Cavity Lining’ OR Software version 5.2 (The Nordic Cochrane Centre, The
‘Cavity Liner, Dental’ OR ‘Cavity Liners, Dental’ OR
Cochrane Collaboration, Copenhagen, Denmark), con-
‘Liner, Dental Cavity’ OR ‘Dental Cavity Liners’ OR
‘Liners, Dental Cavity’ OR ‘Dental Cavity Liner’ OR
sidering the clinical and radiographic success rate of
‘Dental Pulp Capping’[Mesh] OR ‘Dental pulp capping’ teeth treated with, or without CH liner (Fig. 2a) with
OR ‘Pulp Capping, Dental’ OR ‘Pulp Capping’ OR data collected from randomized clinical trials (RCT) with
‘Capping, Pulp’ OR ‘Cappings, Pulp’ OR ‘Pulp Cappings’ at least 12 months of follow-up. Global analysis compar-
OR ‘Capping, Dental Pulp’ OR ‘Cappings, Dental Pulp’
ing CH with adhesive systems (total-etch and self-etch)
OR ‘Dental Pulp Cappings’ OR ‘Pulp Cappings, Dental’
#1 ‘Controlled Clinical Trial’ OR ‘Retrospective Studies’ OR
(Fig. 2a) and with glass-ionomer cements (GIC) (Fig. 2b)
‘Randomized Controlled Trial’ OR ‘Studies, was performed. Subgroup analysis considering 12, 24
Retrospective’ OR ‘Study, Retrospective’ OR and 50 months of follow-up was also performed
‘Retrospective Study’ OR ‘Prospective Studies’ OR (Fig. 2b–d). In the global analysis, teeth lost due to exfo-
‘Prospective Study’ OR ‘Studies, Prospective’ OR ‘Study,
liations or dropout patients were not included. Addition-
Prospective’ OR ‘Clinical Trial’ OR ‘Randomized
Controlled Trials as Topic’[Mesh] OR ‘Randomized
ally, a sensitivity analysis was performed, considering
Controlled Trials as Topic’ OR ‘Controlled Clinical Trials, exfoliations or dropouts as success or failures.
Randomized’ OR ‘Clinical Trials, Randomized’ OR ‘Trials, Pooled-effect estimates were obtained by comparing
Randomized Clinical’ OR ‘Randomized Controlled Trial’ the risk difference in each study with a 95% confi-
[Publication Type] OR ‘Randomized clinical trial’ OR
dence interval (CI). Fixed-effect model was used, and
((clinical[Title/Abstract] AND trial[Title/Abstract]) OR
clinical trials[MeSH Terms] OR clinical trial[Publication
heterogeneity was assessed by using Cochran’s Q test
Type] OR random*[Title/Abstract] OR random allocation and inconsistency I2 statistics, with values higher
[MeSH Terms] OR therapeutic use[MeSH Subheading]) than 50% being considered indicative of substantial
OR (randomized controlled trial[Publication Type] OR heterogeneity (Green et al. 2011).
(randomized[Title/Abstract] AND controlled[Title/
Abstract] AND trial[Title/Abstract]))
Quality assessment
4. Studies that compared CH liner only with another The methodological quality and risk of bias of each
liner (i.e. Mineral Trioxide Aggregate) were removed. study included were independently assessed by the
5. Only studies published in English language were two reviewers based on the Cochrane guidelines
included. (Green et al. 2011), according to the following param-
Full texts of all of the potentially relevant studies were eters: bias due to incomplete data, as well as selection,
identified, and those that appeared to meet the inclusion performance, detection and reporting bias. Other bias,
criteria, or for which there were insufficient data in the such as industry sponsorship bias, was also analysed.
title and abstract to make a clear decision, were selected Moreover, the evidence for outcomes evaluated for
for full analysis. Any disagreement was resolved by dis- failure in primary or permanent teeth was graded
cussion between the reviewers or by a third reviewer. according to the GRADE working group of evidence
using Grade Profiler 3.6 (Andrews et al. 2013). The
following aspects were considered for risk of bias
Data extraction
within the trials: unexplained heterogeneity, inconsis-
The two reviewers tabulated the data regarding study tency between trials, indirectness of comparisons,
design (Table 2); caries tissue removal method imprecision (few events) and risk of publication bias.
Table 2 Demographic data, study design, number of patients, age and follow-up of included studies
Author Study design Patients (n) Age Number of teeth (per group) Follow-up (months)
Primary teeth
Bressani et al. (2013) RCT 30 4–8 30 (CH:15; Inert: 15) 3
B€uy€
ukg€ural & Cehreli (2008) RCT 97 5–10 240 (CH:60; AD: 60 each) 24
Casagrande et al. (2008)a RCT 21 4–8 40 (CH:21; AD: 19) 24
Casagrande et al. (2009) RCT 11 3–5 48 (CH:23, AD:25) 60
Casagrande et al. (2010)a RCT 21 4–8 40 (CH:21, AD:19) 60
Dalpian et al. (2012)a RCT 21 4–8 17 (CH:10, AD:7) 60
Dalpian et al. (2014) RET 118 5.5 1.9d 254 (CH: 110; AD: 120; GIC: 24) 50
Duque et al. (2009) RCT 17 4–8 27 (CH: 8; GIC: 19) 3
Falster et al. (2002) RCT NI 3–5 48 (CH: 23; AD: 25) 24
Franzon et al. (2007)b RCT 20 4–7 39 (CH: 20; Inert: 19) 36
Franzon et al. (2009)b RCT 20 4–7 18 (CH: 6; Inert: 12) 71
Marchi et al. (2006)c RCT 17 4–9 27 (CH: 12; GIC: 15) 48
Marchi et al. (2008)c RCT 17 4–9 43 (CH: 4; GIC: 9; PC: 15; NC: 15) 3
Mathur et al. (2016) RCT 94 7–12 109 (CH: 35; GIC: 38; MTA: 36) 12
Pinto et al. (2006)b RCT 20 4–7 39 (CH: 20; Inert: 19) 7
Permanent teeth
Corralo & Maltz (2013) RCT 44 11–35 60 (CH: 20; GIC: 20; Inert: 20) 4
Pereira et al. (2017) RCT 98 15–30 98 (CH: 49; GIC:49) 3
abc
Same superscript letters indicate that studies evaluated different outcomes or follow-up evaluations from the same subjects.
d
Mean age and standard deviation.
AD, adhesive system; CCT, controlled clinical trial; CH, calcium hydroxide cement; GIC, glass-ionomer cement; MTA, mineral triox-
ide aggregate; NC, negative control; NI, not informed; PC, positive control; RCT, randomized clinical trial; RET, retrospective clini-
cal trial.
patients, included the greatest number of patients

Results
(Dalpian et al. 2014). Considering all the studies in
primary teeth (without considering studies with the
Search strategy
same subjects evaluated), a total of 1036 teeth in 567
Initially, 1537 potentially relevant studies were iden- subjects between 3 and 12 years old were evaluated.
tified in all searched databases, as shown in Fig. 1. Of The follow-up times varied from 3 to 60 months.
the 20 studies retained for detailed review, three stud- Only two studies evaluated stepwise removal of car-
ies could not be included: one study did not use a CH ies (Duque et al. 2009, Bressani et al. 2013), while
cement as liner (Conrado 2004), another study evalu- the others evaluated selective removal of carious tis-
ated Class V restorations without carious lesions sue (Table 3). CH was compared with an inert mate-
(Costa et al. 2003), and a third study evaluated com- rial (wax or gutta-percha) in four studies (Pinto et al.
plete caries removal (Wegehaupt et al. 2009). A total 2006, Franzon et al. 2007, 2009, Bressani et al.
of 17 studies fulfilled all the selection criteria and 2013). Seven studies compared CH with adhesive
were included in the qualitative analysis. Among systems, of which four studies compared CH with
these, 15 studies were performed in primary teeth total-etch materials (Falster et al. 2002, B€
uy€ukg€ural
and two studies in permanent teeth. Six RCT in pri- & Cehreli 2008, Casagrande et al. 2009, Dalpian et al.
mary teeth were included in the meta-analysis. 2014) and four compared it with self-etch adhesives
(B€uy€ ural & Cehreli 2008, Casagrande et al. 2008,
ukg€
2010, Dalpian et al. 2012). In the majority of
Descriptive analysis
included studies, a resin composite was used as the
Primary teeth restorative material.
As shown in Table 2, 14 studies that evaluated CH Regarding the evaluation methods (Table 4), clini-
liner in primary teeth were RCT, while one was a ret- cal and radiographic evaluation was mainly used to
rospective study. Five studies evaluated different out- assess pulp status of teeth with deep carious lesions.
comes or follow-up evaluations of the same subjects. Colour, consistency, microhardness, histological and
The retrospective study in primary teeth, with 18 microbiological evaluations were also present. All
Table 3 Caries tissue removal, type of cavity, groups evaluated and restorative procedures of included studies
Selective
or
stepwise Calcium
removal hydroxide
Author of caries Cavity (CH) group Comparison group(s) Restorative procedure
Primary teeth
Bressani Stepwise Class I cavity CH cement Inert material (wax) Adhesive system (Scotchbond
et al. (2013) preparations (Dycal, Multipurpose) and resin
Dentsply, composite (Filtek Z250, 3M
USA) ESPE, USA)
Bu€ yu
€ kgu
€ ral Selective Class I cavity CH cement Total-etch adhesive system (Prime Amalgam (Permite, SDI,
& Cehreli preparations (Dycal, & Bond NT); self-etch adhesive Victoria, Australia) for CH
(2008) Dentsply, system (Xeno III); total-etch group, and all other groups
USA) adhesive system (Prime&Bond were restored with resin
NT) without prior acid etching composite (Dyract AP, DeTrey,
Dentsply, USA)
Casagrande Selective Class I and II CH cement Self-etching adhesive system Self-etching adhesive system
et al. (2008) cavity (Dycal, (Clearfil SE Bond, Kuraray, Japan) (Clearfil SE Bond, Kuraray,
preparations Dentsply, Japan) and resin composite
USA) (Filtek Z250, 3M ESPE, USA)
Casagrande Selective Class I cavity CH cement Total-etch adhesive system Adhesive system (Scotchbond
et al. (2009) preparations (Dycal, (Scotchbond Multipurpose, 3M Multipurpose) for CH group;
Dentsply, ESPE, USA) and resin composite (Filtek
USA) Z100, 3M ESPE, USA) for all
groups.
Casagrande Selective Class I and II CH cement Self-etching adhesive system Self-etching adhesive system
Dalpian Selective Class I and II CH cement Self-etching adhesive system Self-etching adhesive system
Dalpian Selective Class I and II CH cement Glass-ionomer cement (Vitremer, Adhesive system (Single Bond,
et al. (2014) cavity (Dycal, 3M ESPE, USA); total-etch 3M ESPE, USA) and resin
preparations Dentsply, adhesive system (Single Bond, 3M composite (Filtek Z350, 3M
USA) ESPE, USA) ESPE, USA) for CH group and
resin composite (Filtek Z350,
3M ESPE, USA) for adhesive
group
Duque et al. Stepwise Class I and II CH cement Glass-ionomer cement (Vitrebond, Teeth restored with modified
(2009) cavity (Dycal, 3M ESPE, USA); Glass-ionomer zinc oxide-eugenol cement
preparations Dentsply, cement (Fuji Lining LC, GC, (IRM, Dentsply, USA)
USA) Japan)
Falster et al. Selective Class I cavity CH cement Total-etch adhesive system Adhesive system (Scotchbond
(2002) preparations (Dycal, (Scotchbond Multipurpose, 3M Multipurpose) and resin
Dentsply, ESPE, USA) composite (Filtek Z100, 3M
USA) ESPE, USA) for both groups
Franzon Selective Class I and II CH cement Inert material (gutta-percha sheet) Adhesive system (Scotchbond
et al. (2007) cavity (Hydro C, Multipurpose) and resin
preparations Dentsply, composite (Filtek Z250, 3M
USA) ESPE, USA)
Franzon Selective Class I and II CH cement Inert material (gutta-percha sheet) Adhesive system (Scotchbond
et al. (2009) cavity (Hydro C, Multipurpose) and resin
USA) ESPE, USA)
Table 3 Continued
Selective
or
stepwise Calcium
removal hydroxide
Author of caries Cavity (CH) group Comparison group(s) Restorative procedure
Marchi Selective Class I cavity CH cement Glass-ionomer cement (Vitremer, Adhesive system (Scotchbond
et al. (2006) preparations (Dycal, 3M ESPE, USA) Multipurpose) and resin
Dentsply, composite (Filtek Z250, 3M
USA) ESPE, USA) for CH group
Marchi Selective Class I cavity CH cement Glass-ionomer cement (Vitremer, Adhesive system (Scotchbond
et al. (2008) preparations (Dycal, 3M ESPE, USA); Negative control: Multipurpose) and resin
Dentsply, no material; Positive control: composite (Filtek Z250, 3M
USA) sound teeth ESPE, USA) for CH group
Mathur Selective Class I and II CH cement Glass-ionomer cement (GC Fuji VII, Not reported
et al. (2016) cavity (Dycal, Fuji, Tokyo, Japan); MTA (ProRoot
preparations Dentsply, MTA; Dentsply Tulsa Dental
USA) Specialties, Dentsply International,
Inc. USA)
Pinto et al. Selective Class I and II CH cement Inert material (gutta-percha sheet) Adhesive system (Scotchbond
(2006) cavity (Hydro C, Multipurpose) and resin
USA) ESPE, USA)
Permanent teeth
Corralo & Stepwise Class I and II CH cement Glass-ionomer cement (Vitromolar, Teeth restored with modified
Maltz (2013) cavity (Dycal, DFL, Brazil); Inert material (wax) zinc oxide-eugenol cement
preparations Dentsply, (IRM, Caulk/Dentsply, Brazil) for
USA) CH and wax group
Pereira Stepwise Class I cavity CH cement Glass-ionomer cement (Riva Light Glass-ionomer cement (Riva
et al. (2017) preparations (Dycal, Cure, SDI, Australia) Light Cure, SDI, Australia)
Dentsply,
USA)
studies reported that CH liner did not benefit the pulp tissue removal (Table 3). The CH cement was com-
status in the treatment of deep carious lesions. The pared with GIC in the two studies, and the teeth were
three studies (Franzon et al. 2007, Marchi et al. restored with a modified zinc oxide-eugenol cement in
2008, Dalpian et al. 2012) that evaluated microhard- one clinical trial (Corralo & Maltz 2013) and with
ness reported a mineral gain after application of CH GIC in the other trial (Pereira et al. 2017). The stud-
cement, GIC or self-etch adhesive, irrespective of the ies in permanent teeth performed clinical and micro-
material used. Furthermore, there was a decrease in biological evaluation (Table 4) in the short-term, and
bacterial counts for teeth treated with CH cement and both reported that treatments with CH or GIC resulted
an inert material (wax or gutta-percha) (Pinto et al. in dentine hardening, decreased contamination and
2006, Bressani et al. 2013). The thickness of the dentine reorganization, irrespective of the presence of
reparative dentine formed was also similar between a liner. Furthermore, one trial (Corralo & Maltz 2013)
teeth treated with a CH cement, or GIC (Mathur et al. demonstrated that the effect of the use of CH or GIC
2016). on the arrest of dentine caries was not superior to the
use of an inert material (wax). No RCT in permanent
Permanent teeth teeth revealed that CH liner was beneficial to pulp
Only two studies evaluated CH liner in permanent health in the treatment of deep carious lesions.
teeth, and both were RCTs. A total of 158 teeth of
142 subjects between 11 and 35 years old were eval-
Meta-analysis
uated in the included studies. Both studies evaluated
the short-term outcomes, with only 3 and 4 months A meta-analysis was performed with six RCT in pri-
of follow-up (Table 2) and performed stepwise caries mary teeth. Risk difference represents the amount of
Table 4 Evaluation methods and main findings of included studies
Was CH liner
beneficial to the
Author Evaluation methods Main findings clinical success?
Primary teeth
Bressani Clinical, radiographic, Parents and children reported no pain during 3 months No
et al. (2013) histological and and no cases of radiographic alterations in both groups.
microbiological evaluation Contamination changed significantly over time in both
groups without significant difference between them. CH
and wax arrested the carious process of the remaining
carious dentine, but CH showed superior dentine colour
and consistency after 3 months
B€uy€
ukg€
ural Clinical and radigraphic Despite the absence of pulpal protection, none of teeth No
& Cehreli evaluation without CH exhibited any significant clinical or
(2008) radiographic symptom during the study period.
Protection of the dentine–pulp complex with the tested
bonding protocols resulted in similar outcomes as
compared with CH. In total-etch adhesive system group,
four teeth presented infrequent episodes of sensitivity to
cold water at 1 month that decreased until the fourth
month. A comparison of postoperative sensitivity among
all treatment groups failed to show any significant
difference at 1–4 months
Casagrande Clinical and radiographic Similar clinical and radiographic success rates with no No
et al. (2008) evaluation statistical difference between the groups. Failures
occurred after 12-month follow-up
Casagrande Clinical, radiographic and Similar clinical and radiographic success rates and pulp No
et al. (2009) histological evaluation health status demonstrated in histological evaluation of
both groups
Casagrande Clinical, radigraphic and No statistical difference found between groups, and the No
et al. (2010) histological evaluation failures occurred after the first year of follow-up
Dalpian Microhardness All teeth showed the same microhardness, regardless of No
et al. (2012) the material used
Dalpian Clinical and radigraphic No differences were found between the use of CH cement, No
et al. (2014) evaluation adhesive system or GIC regarding clinical success.
Failures (19.7%) were mainly due to restoration failures
in 33 (13%) teeth and due to signs and symptoms of pulp
necrosis in 17 (6.7%) teeth
Duque et al. Clinical, radiogrphic, and None of the teeth presented any clinical symptoms and No
(2009) microbiological evaluation radiographic signs of pulpal and periapical pathologies
during the study period. Regarding the characteristics of
the remaining dentine, there was a significant difference
only for the CH and Vitrebond groups, exhibiting harder
and drier dentine over time than Fuji Lining LC group.
For the Fuji Lining LC group, no statistical significant
difference was shown for any clinical criterion evaluated.
There was a significant reduction in bacterial counts over
time for all material groups without significant difference
between them
Falster et al. Clinical and radigraphic None of the teeth included in this study was considered a No
(2002) evaluation failure based on the clinical examination, with no
significant difference regarding the clinical outcome
between the two conditions. The radiographic
examination revealed that most failures were due to pulp
necrosis; however, the incidence was similar for both
groups. None of the teeth presented postoperative
sensitivity
Table 4 Continued
Was CH liner
beneficial to the
Author Evaluation methods Main findings clinical success?
Franzon Clinical and radigraphic Four teeth failed in the CH group, with the radiographic No
et al. (2007) evaluation examination showing radiolucency in the periapical/
furcation regions. One tooth showed a restoration failure,
which may explain the pulp injury. In the gutta-percha
group, one tooth presented internal root resorption;
however, it was still retained at the 36-month evaluation
period. Both materials showed similar clinical and
radiographic success at the 36-month follow-up
Franzon Microhardness No statistically significant difference among No
et al. (2009) microhardness measurements from all groups
Marchi Clinical and radigraphic Both groups showed no differences regarding clinical and No
et al. (2006) evaluation radiogrphic success. CH cement showed a success rate
of 88.8% and GIC of 93%
Marchi Colour, consistency and Both experimental groups showed mineral gain by the No
et al. (2008) microhardness analysis affected dentine regardless of the material used
Mathur Clinical and radigraphic A significant difference was obtained in the average No
et al. (2016) evaluation thickness values of reparative dentine at immediate
postoperative and 6-month postoperative evaluations in
all three groups. All three materials were shown to be
similar suggesting mineral gain
Pinto et al. Clinical and microbiological All bacterial counts decreased significantly by the end of No
(2006) evaluation treatment in both groups, and no differences were
observed between groups regarding dental tissue
preservation as well as pulp vitality
Permanent teeth
Corralo & Clinical (colour and CH, GIC and an inert material (wax) resulted in dentine No
Maltz (2013) consistency) and hardening, with a total or partial obliteration of dentinal
microbiological evaluation tubules, decreased bacterial numbers and dentine
reorganization, irrespective of the dentine protection
used. The effect of the use of CH or GIC on dentine
caries arrestment was not superior to the use of an inert
material
Pereira Clinical (colour and Irrespective of CH liner use, the study showed darker, No
et al. (2017) consistency) and harder, drier and less contaminated dentine after
microbiological evaluation 3 months, and dentine thickness remained unchanged.
CH liner during stepwise caries excavation and
provisional restoration did not provide any additional
benefit
risk, which decreased or increased when there was difference for CH versus GIC was 0.10 [95% CI 0.01
exposure compared with the risk without exposure. A to 0.22] (Fig. 2b), with no significant differences
positive risk difference value means increased risk due between groups (P = 0.08). When CH liner was com-
to the exposure, which was observed throughout the pared with only self-etch adhesives, the overall risk dif-
meta-analysis for CH liner group. Furthermore, this ference was 0.01 [95% CI 0.04 to 0.04], with no
meta-analysis revealed a non-significant risk difference significant differences between groups (P = 0.88; v2
for clinical success (health pulp status) of deep carious test, P = 0.75; I2 = 0%). Moreover, no difference was
lesions treatment with or without CH liner. The overall found when CH liner was compared with only total-
risk difference for CH versus adhesive systems was 0.06 etch adhesives (P = 0.39; v2 test, P = 0.05; I2 = 66%),
[95% CI 0.01 to 0.13] (Fig. 2a), meaning that CH with an overall risk difference of 0.07 [95% CI 0.09
and adhesive system had similar clinical success in the to 0.22].
treatment of deep carious lesions after selective removal Subgroup analysis at 12, 24 and 50 months of fol-
of carious tissue (P = 0.11). Moreover, the overall risk low-up also revealed CH, and control groups had
Figure 1 Search flow (as described in the PRISMA statement).
Figure 2 Forest plot for clinical success analysis in primary teeth: global analysis comparing the risk difference in calcium
hydroxide (CH) liner with adhesive systems (total-etch and self-etch) (a); global analysis comparing CH with glass-ionomer
cement (GIC) (b). No significant differences between CH and control groups were observed in all analysis (P > 0.05).
Figure 3 Subgroup analyses in primary teeth comparing CH with control groups after selective caries removal in deep caries
lesions at 12 months of follow-up (a); subgroup analysis at 24 months of follow-up (b) and subgroup analysis at 50 months of
follow-up (c). No significant differences between CH and control groups were observed in all analysis (P > 0.05).
similar clinical success rates considering healthy pulp bias (selective reporting), incomplete outcome data and
status (P > 0.05; Fig. 3a–c). The sensitivity analysis other biases. High risk of bias was observed for perfor-
considering exfoliations or dropouts as success mance (blinding of participants) and detection bias
showed the overall risk difference was 0.04 [95% CI (blinding of operators), in the majority of included stud-
0.01 to 0.09], with similar clinical success between ies. Regarding quality of evidence assessed by GRADE
groups (P = 0.12; v2 test, P = 0.35; I2 = 10%). More- (Table 5), low quality of evidence was considered,
over, the sensitivity analysis considering exfoliations when the failure in primary teeth with CH liner versus
or dropouts as failures showed the overall risk differ- inert material and with CH liner versus adhesive sys-
ence was 0.04 [95% CI 0.02 to 0.10], with similar tems were compared, due to limitations, imprecision
clinical success rates between groups (P = 0.16; v2 and inconsistency of the included studies. Moderate
test, P = 0.11; I2 = 40%). level of evidence was considered when CH liner was
compared with GIC. In addition, when the failures in
permanent teeth were analysed, a very low level of evi-
Risk of bias and evidence of studies included
dence was considered, due to the inclusion of only a
Concerning the quality assessment (Fig. 4), the few available studies, which also presented method-
included studies had low risk relative to selection bias ological limitations, imprecision and inconsistency, in
(sequence generation, allocation concealment), reporting addition to short-term evaluations.
Figure 4 Review authors’ judgements about each risk of bias item for each included study in primary and permanent teeth.
included studies, especially those with short-term fol-

Discussion
low-up evaluations (Duque et al. 2009, Bressani et al.
The hypothesis tested was accepted since no included 2013), the assessment of pulp status was not the pri-
study demonstrated a beneficial effect of the use of CH mary outcome measured, but it was evaluated, and
liner in the clinical success of deep caries lesion treat- therefore, the cited studies were included in the quali-
ments. Therefore, the treatment of deep caries lesions tative analysis. Although the primary outcome of
was not considered a material-dependent technique, Bressani et al. (2013) was dentine colour and consis-
with no essential role associated with the CH lining tency, the authors also evaluated the occurrence of
material (Schwendicke et al. 2015). The goal of apply- pain to assess the short-term success of the two treat-
ing a layer of CH liner over carious dentine is to ments. Furthermore, periapical radiographs were
induce remineralization and theoretically, to protect taken at the end of the trial to evaluate radiolucent
the pulp (Franzon et al. 2007, Schwendicke et al. areas in the furcation and periapical region that could
2015, Da Rosa et al. 2018). However, a good mar- be attributed to failure of the treatments. For Duque
ginal seal is paramount to prevent bacterial substrate et al. (2009), the primary outcome was dentine con-
infiltrating into the dentine and to control caries pro- sistency, colour and wetness. However, the study also
gression (Falster et al. 2002, Maltz et al. 2002, described that the failures relative to pulp vitality
Marchi et al. 2006). The high rate of clinical success were evaluated by sensitivity to cold, heat or sweet or
of either using or not using CH liner was probably spontaneous pain. In this review, these studies were
related to the careful diagnostic criteria of pulp condi- not included in the meta-analysis, but they were
tion used by included studies and marginal seal pro- included in the qualitative analysis because they also
moted by the restoration (Franzon et al. 2007, represented evidence of results regarding the use of
Pereira et al. 2017). CH liner in deep carious lesion treatment.
Some studies have reported that assessing pulp The use of adhesive systems could reduce bacterial
status through sensitivity testing may underestimate contamination through the action of acid etchants,
failures, and patients might not be satisfied with non- and/or the adhesive resins with low pH, enabling an
symptomatic failure, but prefer treatments to be pain- initial bactericidal effect similar to that of CH liner
less, short and affordable (Michaelson & Holland (Kopel 1997, Pinto et al. 2006). However, previous
2002, Whitworth et al. 2005, Schwendicke et al. reports have indicated that the use of acidic condi-
2015). In our review, the clinical success was defined tioners and adhesive resins in the absence of pulpal
as healthy pulp, which should be determined by the protection may lead to irreversible pulp reactions in
combination of the following characteristics: positive deep cavities (Gwinnett & Tay 1998, Pameijer & Stan-
response to the cold test, negative response to percus- ley 1998, Murray et al. 2001), especially if the
sion, absence of spontaneous pain, and absence of remaining dentine thickness is below 0.5 mm (Gwin-
periapical lesion (radiographic examination). In some nett & Tay 1998, Camps et al. 2000). Exact
Table 5 The overall quality of clinical recommendations for each of the main outcomes using the Grades of Recommendation,
Assessment, Development, and Evaluation (GRADE)
Calcium hydroxide liner in the treatment of deep caries lesions

Patient or population: Selective or stepwise caries removal in teeth with deep caries lesions
Settings: clinical trials Intervention: Calcium hydroxide
Number of Quality of the
teetha evidence
Outcomes (Studies) (GRADE) Comments and recommendations (GRADE)
Failure in primary teeth (CH vs. 69 (4 studies) ⊕⊕⊝⊝ lowb,c Study limitations and imprecision.b,c Further research is
inert material) Follow-up up to very likely to have an important impact on our
36 months confidence in the estimate of effect and is likely to
change the estimate
Failure in primary teeth (CH vs. 417 (4 studies) ⊕⊕⊕⊝ Study limitations.b Further research is likely to have an
GIC) Follow-up up to 60 months moderateb important impact on our confidence in the estimate of
effect and may change the estimate
Failure in primary teeth (CH vs. 638 (6 studies) ⊕⊕⊝⊝ lowb,d Study limitations, inconsistency.b,d Studies show
adhesive system) Follow-up up to heterogeneity in the types of adhesive systems (total-etch
60 months and self-etch), depth of caries lesion and outcomes
evaluated. Further research is very likely to have an
important impact on our confidence in the estimate of
effect and is likely to change the estimate
Failure in permanent teeth (CH vs. 55 (3 studies) ⊕⊝⊝⊝ very Study limitations, imprecision, inconsistency.b,c,d We are
GIC) Follow-up up to 4 months lowb,c,d very uncertain about the estimate, and further studies
need to be performed
a
In studies with the same sample and different outcomes or follow-ups, the number of teeth evaluated was counted only once.
b
No blinding of participants or outcome assessment.
c
Small sample size.
d
Heterogeneity.
assessment of cavity depth and remaining dentine Cehreli 2008). In this study, no differences regarding
thickness is difficult, even for experienced clinicians post-operative sensitivity were found among CH liner,
(B€uy€ukg€
ural & Cehreli 2008). As selective removal to total-etch or self-etch adhesives. The other included
soft dentine is at present recommended for the man- studies that used adhesive systems did not report the
agement of deep carious lesions (Innes et al. 2016), occurrence of post-operative sensitivity.
the remaining dentine thickness could have only a Carious tissue removal may also have an impact on
minor influence on pulp reaction due to maintaining the clinical success of treatments for deep carious
carious dentine that protects the pulpal tissue. Fur- lesions. While selective removal of carious tissue was
thermore, previous reports have suggested that self- performed in the majority of included studies in pri-
etch adhesives could also be capable of stimulating mary teeth, in the few included studies in permanent
early pulp repair after selective removal of carious tis- teeth stepwise removal was performed. At present, for
sue (Da Silva et al. 2018). The study that evaluated deep caries lesions, selective removal restricted to soft
different total-etch and self-etch adhesive systems in dentine has been recommended, a procedure that has
primary teeth demonstrated that none of the teeth been associated with high clinical success rates of
without CH exhibited any significant clinical or radio- over 90% after 3 years (Maltz et al. 2012, Franzon
graphic failure during the study period of 24 months et al. 2014). For permanent teeth, stepwise removal is
(B€uy€ukg€
ural & Cehreli 2008). an option that can be considered (Schwendicke et al.
Total-etch and self-etch adhesive systems were only 2016a), which has also been associated with good
evaluated in primary teeth (Table 3), and in the clinical success rates of 74–91% in clinical trials
meta-analysis, no difference was found between CH (Bjørndal et al. 1997, Maltz et al. 2012). In the first
liner and the two types of adhesives. Additionally, stage of stepwise removal, the expectations are that
four teeth in the total-etch adhesive group were tertiary dentine would be formed, demineralized den-
reported to present infrequent episodes of sensitivity tine would be remineralized, and the number of viable
to cold water at 1 month, but this decreased until the bacteria would be reduced (Schwendicke et al.
fourth month of clinical follow-up (B€ uy€ukg€ural & 2016a). However, evidence has been shown that the
second stage would not be necessary in deep caries detected increased demineralized dentine hardness
lesions, as this procedure increased the risks of pulp that was not dependent upon the CH liner use (Dal-
exposure, added extra cost, time and discomfort to the pian et al. 2012). These findings indicated that clini-
patient, and would thus be detrimental to pulpal cal success was related to correct assessment of pulp
health (Maltz et al. 2012, Schwendicke et al. 2013a, status and cavity sealing, irrespective of CH liner use,
Ricketts et al. 2015). The presence of bacteria under which consequently restricted access to nutrition by
the restoration does not indicate the need for a sec- the residual bacteria under the restoration (Franzon
ond stage to remove the carious tissue completely, et al. 2007, Casagrande et al. 2008, 2010, Dalpian
and there is no evidence that bacteria remaining et al. 2012). In addition, dentine colour, consistency
under restorations lead to caries lesion progression and bacterial infection have been used as outcomes of
(Schwendicke et al. 2013b). Due the limited lifespan dentine caries activity, but some studies have reported
of teeth in the primary dentition, stepwise removal is no correlation between these variables (Kidd et al.
not considered necessary, and selective removal up to 1993, Lynch & Beighton 1994, Corralo & Maltz
soft dentine is recommended at present, for both pri- 2013). Thus, in the meta-analysis, clinical success
mary and permanent teeth (Schwendicke et al. was considered only when there were a healthy pulp
2016a). status and no periapical alteration shown in the
It is important to consider that in all the included radiographic evaluation.
studies, a proper and careful diagnosis of the pre- A factor associated with differences in pulp
operative inflammatory pulp condition was considered response is patient age. The age of patients from
essential for the successful outcome of the conserva- included studies in primary teeth varied from 3 to
tive pulp treatments performed. The indication for 12 years, while studies in permanent teeth were con-
selective or stepwise removal of carious tissue was ducted with patients up to 35 years old. Reports have
limited to teeth that have no signs of irreversible pulp indicated that ageing has implications in the pulp
pathosis (Franzon et al. 2007, Bjørndal 2011, Corralo ability to react in response to dental tissue damage
& Maltz 2013, Pereira et al. 2017). Studies that eval- (Iohara et al. 2014) and that older patients are more
uated the clinical characteristics of the residual den- at risk of developing irreversible pulpitis or necrosis
tine after a second intervention reported that this (Iohara et al. 2014, Pereira et al. 2017). Due to these
dentine usually became hardened, darkened and less findings, the results were limited to the age of patients
contaminated (Bjørndal et al. 1997, Bjørndal & Lar- from the included studies, and further studies with
sen 2000, Massara et al. 2002, Pinto et al. 2006, older patients may report different results. As regards
Wambier et al. 2007, Marchi et al. 2008, Duque et al. follow-up, evaluations from included studies varied.
2009), and that the radiopacity of the remaining cari- In the included studies with primary teeth, follow-up
ous lesion increased over time (De Oliveira et al. was performed at periods of up to 60 months, sug-
2006). Studies using scanning electron microscopy gesting a higher strength of evidence obtained in the
have also demonstrated the reorganization of dentine, long-term. While for permanent teeth, studies only
with partial obliteration of the dentinal tubules by evaluated teeth with deep caries lesions within a
hydroxyapatite crystals (Massara et al. 2002). short period (3–4 months) after placing the provi-
The use of an inert material allowed the treatments sional restoration. Despite this short period, the use of
to be evaluated after isolating the caries lesion from CH liner and GIC did not differ initially, on the basis
the oral environment, without the interference of a of the primary outcome of healthy pulp status (Per-
biomaterial, such as CH, adhesive system or GIC. The eira et al. 2017). One limitation of the present review
included studies that compared CH liner with an inert was with regard to follow-up, because some studies
material reported that in both groups, contamination on vital pulp therapy reported that failures mainly
was reduced over time (Bressani et al. 2013, Corralo occurred 2 years or longer after treatment (AI-Zayer
& Maltz 2013), and resulted in dentine hardening, et al. 2003, Dammaschke et al. 2010, Mente et al.
with obliteration of dentinal tubules and dentine reor- 2014, Schwendicke et al. 2016b), and only few
ganization (Corralo & Maltz 2013). CH liner and inert included studies evaluated the long-term clinical suc-
material (gutta-percha) also had similar clinical and cess of deep carious lesions treatment. Thus, long-
radiographic success rates in primary teeth in a fol- term RCT are needed to confirm whether the clinical
low-up period of up to 36 months (Franzon et al. success achieved with the two materials remains simi-
2007). In addition, microhardness assessments lar over time. Furthermore, improvements in the
study design are needed in order to improve the

Conflict of interest
quality of evidence available, such as sample size cal-
culation, blinding of participants and outcome assess- The authors have stated explicitly that there are no
ment, use of an inert material as negative control and conflict of interests in connection with this article.
longer follow-up time. It should also be emphasized
the necessity of using a liner directly on permanent
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Revisão Sistemática e Meta - HC em Cavidades Profundas

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doi:10.1111/iej.

W. L. O. da Rosa, V. P. Lima, R. R. Moraes , E. Piva & A. F. da Silva

Abstract performed in eight databases: PubMed (MEDLINE),

been suggested, such as leaving a layer of contami-

(healthy pulp status with positive sensitivity to cold

patients, included the greatest number of patients

Table 4 Evaluation methods and main findings of included studies

Figure 1 Search flow (as described in the PRISMA statement).

included studies, especially those with short-term fol-

Calcium hydroxide liner in the treatment of deep caries lesions

study design are needed in order to improve the

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