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Evaluation of effectiveness of calcium hydroxide and MTA as pulpotomy

agents in permanent teeth: A meta-analysis

Article in Pediatric Dental Journal · May 2019

DOI: 10.1016/j.pdj.2019.04.001

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Available online at www.sciencedirect.com

Pediatric Dental Journal

journal homepage: www.elsevier.com/locate/pdj

Research Paper

Evaluation of effectiveness of calcium hydroxide

and MTA as pulpotomy agents in permanent teeth:
A meta-analysis

Saumya Taneja*, Abhinav Singh

Department of Dentistry, All India Institute of Medical Sciences, Bhopal, India

article info abstract

Article history: Aim: To conduct a meta-analysis comparing the effectiveness of traditionally used calcium
Received 7 January 2019 hydroxide with MTA as pulpotomy agents for permanent teeth.
Received in revised form Materials and methods: Randomized Controlled Trials (RCTs) comparing calcium hydroxide
7 March 2019 and Mineral Trioxide Aggregate as pulpotomy agents for permanent teeth with follow up
Accepted 10 April 2019 periods of 6 and 12 months were included in the meta-analysis. A random effects model
Available online 1 May 2019 was used to generate pooled estimates. Odds ratio with a 95% confidence interval was
calculated for evaluating the success of pulpotomy with these two agents.
Keywords: Results: Five studies met the inclusion criteria. Success of pulpotomy using MTA was sta-
Pulpotomy tistically significant in comparison to calcium hydroxide both at 6 months (OR ¼ 0.31, 95%
Permanent teeth CI: 0.10e0.96; p ¼ 0.99; I2 ¼ 0%) and 12 months (OR ¼ 0.40, 95% CI: 0.16e0.97; p ¼ 0.63;
Calcium hydroxide I2 ¼ 0%). Value of I2 signifies that there was no heterogeneity among the selected studies.
MTA Conclusion: This meta-analysis suggests that MTA is a superior material for pulpotomy of
cariously exposed permanent teeth. Failure rate of pulpotomies is significantly higher with
Calcium hydroxide despite its bactericidal properties.
© 2019 Japanese Society of Pediatric Dentistry. Published by Elsevier Ltd. All rights reserved.

used as a treatment modality only for the teeth where the

1. Introduction
Pulpotomy is a vital pulp therapy, which involves complete
removal of coronal portion of dental pulp followed by place-
ment of suitable medicament that promotes healing and
preserves vitality of the tooth. Traditionally, pulpotomy was a
procedure of choice only for deciduous or young permanent
teeth with immature apices [1]. Although, numerous recent
studies have reported clinically acceptable success rates of
pulpotomy in mature permanent teeth as well [2e8]. This is
inflammatory response is limited to coronal pulp and radic-
ular pulp is still healthy. Pulpotomy of a mature permanent
tooth is carried out by removing 1e3 mm of inflamed pulpal
tissue till healthy pulp is reached. Bleeding at the site is
controlled and Calcium hydroxide or MTA is placed followed
by a restoration that seals the tooth.
The rationale behind preserving the vital pulp is the
inherent healing potential of infection free pulp that protects
the tooth from overload by protective feedback mechanism

* Corresponding author.
E-mail addresses: drsaumyataneja@gmail.com (S. Taneja), abhinav.dentalsurgery@aiimsbhopal.edu.in (A. Singh).
https://doi.org/10.1016/j.pdj.2019.04.001
0917-2394/© 2019 Japanese Society of Pediatric Dentistry. Published by Elsevier Ltd. All rights reserved.
 p e d i a t r i c d e n t a l j o u r n a l 2 9 ( 2 0 1 9 ) 9 0 e9 6
and prevents fractures due to damping property [9,10]. Ability
to control hemorrhage at the site of amputation and choice of
pulpotomy materials are critical factors that influence the
outcome of the procedure [11]. Healing is initiated after
placement of medicament which causes release of various
wound healing signals or growth factors due to its high pH.
High pH leads to a zone of necrosis, which initiates a wound
healing response and the formation of calcite crystals which
coalesce to form collagenous layer replaced later by bone like
tissue. New odontoblast like cells form after 2e3 weeks adja-
cent to that hard tissue layer leading to formation of dentinal
bridge. The only difference in the healing of immature and
mature pulpotomized teeth is the formation of hard tissue
barrier at the site of amputation for matured pulpotomized
teeth in contrast to hard tissue formation, both at the site of
amputation as well as at the apex in immature teeth. Healing
occurs at a faster rate in young permanent teeth due to high
vascularity [9,10].
Calcium hydroxide (Ca(OH)2) is a conventionally used
pulpotomy agent. It was introduced by Herman in 1936. In
spite of calcium hydroxide being a popular vital pulp therapy
material, its use as a pulpotomy agent is controversial. High
alkalinity (pH of 12) of material on one hand confers bacteri-
cidal effect and enhances the dentin bridge formation, but
Table 1 e PICO strategy in evaluating the scientific evidence.
Parameter
Population (P)
Intervention (I)
Comparison (C)
Outcome (O)
Total citations from electronic searches and
their references to evaluate all the studies
on pulpotomy of permanent teeth
(n= 321)
Randomized Controlled Trials (RCTs)
(n= 46)
Primary articles included in meta-analysis
(n= 5)
Fig. 1 e Flow diagram of study selection process.
91
also leads to superficial necrosis of the pulp and the tissues in
contact [12]. Other disadvantages of calcium hydroxide are
degradation with time, tunnel defects beneath dentinal
bridges and poor sealing [13].
Mineral Trioxide Aggregate (MTA) is a newer material
which has good physical characteristics, provides hermetic
seal, is resistant to dissolution, has better structural integrity,
is biocompatible and forms a thicker, more localized dentinal
bridge [14,15]. Setting of MTA is uninhibited by blood or water
and it has the potential to stimulate cytokine release and
interleukin production [16]. MTA instead of causing apoptosis
of pulp cells, induced proliferation of these cells [17]. There-
fore MTA is gaining wider acceptance for use as a pulpotomy
agent. The drawbacks of the material are its cost, availability
and difficult handling characteristics.
Amongst these two frequently used pulpotomy materials
there is still inconsistency regarding their effectiveness. There
are studies which still recommend Calcium hydroxide as the
choice of material for pulpotomy whereas others favor MTA.
Till date effectiveness of any one material over other hasn't
been substantiated due to lack of systematic reviews. Thus
the present paper provides a systematic review of effective-
ness of traditionally used calcium hydroxide with MTA as a
pulpotomy agent in permanent teeth.
Evaluation
Carious permanent teeth involving coronal pulp which are to be
pulpotomized.
Permanent teeth pulpotomized using Calcium hydroxide.
Permanent teeth pulpotomized using MTA
Clinically and radiographically successful pulpotomized teeth. (Clinical
success-absence of pain, swelling and sinus tracts)
(Radiographic success-absence of PDL widening, periapical radiolucency
and internal/external root resorption.)
Excluded articles (Case reports,
theoretical research, literature reviews)
(n= 275)
Citations excluded after review of title
and/or abstract (not meeting the inclusion
criteria)
(n=41)
92 p e d i a t r i c d e n t a l j o u r n a l 2 9 ( 2 0 1 9 ) 9 0 e9 6

2. Methods

Total failed cases at

12 months
0

9
PRISMA guidelines were followed and research strategy was

Ca(OH)2-

Ca(OH)2-

Ca(OH)2-

Ca(OH)2-

Ca(OH)2-
MTA- 1

MTA- 3

MTA- 0

MTA- 0

MTA- 4
formulated following PICO guidelines (Table 1).

2.1. Search strategy

A comprehensive search was conducted in Medline, Cochrane

database and Google Scholar for studies published up to
Total failed cases at

August 2018. Boolean Operator AND was used with keywords

Pulpotomy and Permanent teeth. References in selected pa-
6 months
0

8
Ca(OH)2-

Ca(OH)2-

Ca(OH)2-

Ca(OH)2-

Ca(OH)2-
pers were manually reviewed and retrieved if relevant. Two
MTA- 1

MTA- 3

MTA- 0

MTA- 0

MTA- 4
investigators conducted the search of literature indepen-
dently, involving the third investigator if discrepancy
occurred. Attempt was made to reach grey literature for un-
published articles and manual searching of non indexed
journals was done but no articles were retrieved.
No. of teeth

40

14

15

23

21

2.2. Study selection criteria

Ca(OH)2-

Ca(OH)2-

Ca(OH)2-

Ca(OH)2-

Ca(OH)2-
MTA- 44

MTA- 19

MTA- 15

MTA- 28

MTA- 25

Inclusion criteria were determined prior to literature search.

Only Randomized Control Trials evaluating both calcium hy-
droxide and MTA as pulpotomy agents for a duration of
Incisors Premolars, Molars

minimum 6 months were to be included in the study.

1st Mandibular Molars
Teeth included

Case reports, theoretical research, literature reviews were

excluded from the analysis. Duplicate publications, pulpot-
omy of deciduous teeth, pulpotomy involving either of the
interventional material or some other pulpotomy agent were
1st Molars

also excluded from the study.

Molars

Molars

2.3. Data extraction and quality assessment

Both the reviewers independently screened the title, key

Mean age group

6.8e13.3 years

words, abstract, and also applied inclusion and exclusion

17e61 years

20e59 years
7e10 years

6e12 years

criteria. Full text articles and their references were also read
for possible inclusion in the study. Differences in opinion were
resolved by discussion. Five studies were selected for the
Table 2 e Characteristics of studies included in meta-analysis.

meta-analysis, which met our study criteria. Analyses data

were extracted from all the included studies. The longevity of
the pulpotomy agent was assessed by the number of tooth
Duration of study

with failed treatment. The treatment was considered a failure

24 months

12 months

12 months

12 months

12 months

if there was a history of persistent pain, swelling, sinus tract,

tenderness to percussion or radiographic evidence of peri-
radicular or furcal radiolucency and root resorption. Quality
was assessed using Cochrane's tools for quality assessment
based on randomization, sequence generation, allocation
concealment and blinding [18]. Any adverse effects due to use
Chailertvanitkul et al., 2014

of the pulpotomy agents and attrition were also evaluated.

Author & Location

Qudeimat et al., 2007

2.4. Statistical analyses

Kumar et al., 2016

Meligy et al., 2006

Taha et al., 2017

Cochrane Program Review Manager (RevMan) version 5.3 was

used for conducting the meta-analysis. Random effects model
(Thailand)

(Kuwait)

(Jordan)

stratified by study design and quality was used to generate

(Egypt)
(India)

pooled estimates by Mantel Haenszel statistics. Study het-

erogeneity was assessed using I2 statistics, which if greater
than 75% suggests considerable heterogeneity. Odds ratio
S.No.

with a 95% confidence interval was calculated for evaluating

the success of pulpotomy with the two agents.
1.

2.

3.

4.

5.
 p e d i a t r i c d e n t a l j o u r n a l 2 9 ( 2 0 1 9 ) 9 0 e9 6 93

Table 3 e Quality assessment of studies included in meta-analysis.

S.No. Author Sequence Generation Allocation Concealment Blinding Attrition Adverse Effects
1. Chailertvanitkul et al., 2014 Yes None reported Yes 6.53% None reported
2. Kumar et al., 2016 Yes None reported Yes 24.08% None reported
3. Meligy et al., 2006 Yes None reported Yes 0% None reported
4. Qudeimat et al., 2007 Yes None reported Yes 20.4% None reported
5. Taha et al., 2017 Yes None reported Yes 4.38% None reported

However, the overall pooled results of the analysis with a

3. Results random effects model showed that MTA is a significantly su-
perior material for pulpotomy as compared to Calcium
The results of literature search are depicted in Fig. 1. A total of hydroxide.
321 articles was obtained, using Boolean operator AND with
keywords Pulpotomy and Permanent teeth. Forty six of them
were RCTs. All the 46 articles were evaluated, 41 articles didn't 4. Discussion
meet the inclusion criteria. Excluded trials either didn't use
both MTA and calcium hydroxide as pulpotomy agents or This meta-analysis is the first in the scientific literature which
were pulp capping procedures or pulpotomies of deciduous compares the effectiveness of MTA as compared to Calcium
teeth. A total of five studies was involved in the meta-analysis. hydroxide as pulpotomy agents in permanent teeth over a
Characteristics of studies included in the meta-analysis are period of 6 and 12 months. The review included 5 trials and
depicted in Table 2. Total number of failed cases at 6 and 12 demonstrated a significant success rate of pulpotomies per-
months duration using Calcium hydroxide and MTA as pul- formed using MTA both at 6 and 12 months.
potomy agents were compared and analyzed. Vital pulp therapies like pulpotomy which were considered
The quality of all the studies included in the analysis was favorable for deciduous or young permanent teeth are
assessed and is represented in Table 3. Allocation sequence becoming a procedure of choice for mature teeth as well [2e8].
was generated, but concealment has not been reported in any Aguilar and Linsuwanont (2011) conducted a systematic
manuscript. Blinding of the investigator and the patient was
done in all the trials. No adverse effects were reported after
conducting pulpotomy using calcium hydroxide or MTA.
Meta-analysis of RCTs for evaluating the success of MTA
pulpotomy in comparison to calcium hydroxide pulpotomy at
6 months is presented in Figs. 2 and 4. It was noted that 5 teeth
amongst a total of 131 teeth in MTA group failed treatment,
whereas 11 out of 113 teeth failed in the Calcium Hydroxide
group (OR ¼ 0.31, 95% CI:0.10e0.96,p ¼ 0.99; I2 ¼ 0%). Meta-
analysis of MTA versus calcium hydroxide pulpotomy at the
end of 12 months is shown in Figs. 3 and 5. At 12 months, 8
teeth out of 127 in MTA group were declared as treatment
failure in comparison to 15 among 109 in Calcium hydroxide
group (OR ¼ 0.40, 95% CI:0.16e0.97,p ¼ 0.63; I2 ¼ 0%). The value
of I2 represented that there was no heterogeneity between Fig. 3 e Funnel plot of trials included in meta-analysis for
trials. The individual studies concluded that there was no evaluating the success of MTA versus Calcium hydroxide
statistically significant difference between the two groups. pulpotomy at 6 months.

MTA Calcium Hydroxide Odds Ratio Odds Ratio

Study or Subgroup Events Total Events Total Weight M-H, Random, 95% CI M-H, Random, 95% CI

Chailertvanitkul et al. 2014 0 44 0 40 Not estimable

Kumar et al. 2016 1 19 2 14 20.5% 0.33 [0.03, 4.10]
Meligy et al. 2006 0 15 0 15 Not estimable
Qudeimat et al. 2007 0 28 1 23 12.2% 0.26 [0.01, 6.77]
MTA Calcium Hydroxide Odds Ratio Odds Ratio
Study or SubgroupEvents Total Events Total
Weight
M-H, Random, 95% M-H,
CI Random, 95% CI
Chailertvanitkul et al.0 2014
44 0 40 Not estimable
Kumar et al. 2016 1 19 2 14 20.5% 0.33 [0.03, 4.10]
Meligy et al. 2006 0 15 0 15 Not estimable
Qudeimat et al. 2007 0 28 1 23 12.2% 0.26 [0.01, 6.77]
Taha et al. 2017 4 25 8 21 67.3% 0.31 [0.08, 1.24]
Total (95% CI) 131 113100.0% 0.31 [0.10, 0.96]
Total events 5 11
Heterogeneity: Tau² = 0.00; Chi² = 0.01, df = 2 (P = 0.99); 0.01
I² = 0%
0.1 1 10 100
Test for overall effect: Z = 2.03 (P = 0.04) MTA
Calcium Hydroxide

Taha et al. 2017 4 25 8 21 67.3% 0.31 [0.08, 1.24]

Total (95% CI) 131 113 100.0% 0.31 [0.10, 0.96]

Total events 5 11
Heterogeneity: Tau² = 0.00; Chi² = 0.01, df = 2 (P = 0.99); I² = 0%
0.01 0.1 1 10 100
Test for overall effect: Z = 2.03 (P = 0.04)
MTA Calcium Hydroxide

Fig. 2 e Meta-analysis evaluating the success of MTA versus Calcium hydroxide pulpotomy at 6 months.
94 p e d i a t r i c d e n t a l j o u r n a l 2 9 ( 2 0 1 9 ) 9 0 e9 6

MTA Calcium Hydroxide Odds Ratio Odds Ratio

Study or Subgroup Events Total Events Total Weight M-H, Random, 95% CI M-H, Random, 95% CI

Chailertvanitkul et al. 2014 1 41 0 37 8.5% 2.78 [0.11, 70.31]

Kumar et al. 2016 3 19 3 14 28.1% 0.69 [0.12, 4.06]
Meligy et al. 2006 0 15 2 15 9.1% 0.17 [0.01, 3.96]
Qudeimat et al. 2007 0 28 1 23 8.4% 0.26 [0.01, 6.77]
Taha et al. 2017 4 24 9 20 45.9% 0.24 [0.06, 0.98]

Total (95% CI) 127 109 100.0% 0.39 [0.15, 1.00]

Total events 8 15
Heterogeneity: Tau² = 0.00; Chi² = 2.56, df = 4 (P = 0.63); I² = 0%
0.002 0.1 1 10 500
Test for overall effect: Z = 1.95 (P = 0.05)
MTA Calcium Hydroxide

Fig. 4 e Meta-analysis evaluating the success of MTA versus Calcium hydroxide pulpotomy at 12 months.

review and concluded that partial and full pulpotomy in per-
manent teeth with cariously exposed pulps was successful
over a period of 3 years or more [19]. Success of pulpotomy is
attributed to removal of major part of inflamed pulpal tissue
[20]. Clinical studies with Calcium hydroxide as pulpotomy
agent in cariously exposed permanent teeth have showed
high success rate of 91e100% [3,21e25]. Due to caustic effects
and high solubility of calcium hydroxide, there arose a need
for search of a better material for pulpotomy. That was when
MTA came into light. Biological response and mechanism of
action of MTA is similar to Calcium hydroxide [3,26e32]. Also,
no histologically significant differences between both these
materials were seen [33,34].
Meligy et al. (2006) compared MTA with Calcium hydroxide
clinically and radiographically as pulpotomy agents for
immature permanent teeth. At 6 and 12 months there was
failure of 2 teeth treated with Calcium hydroxide pulpotomy
and none among the MTA group. Similarly, Qudeimat et al.
(2007) reported failure of treatment in 1 tooth among 23 teeth
in Calcium hydroxide group and none among the 28 allocated
to MTA group. Although MTA proved to be a better material,
there was no statistically significant difference between the
two [35,36]. Investigations by Chailertvanitkul et al., in 2014
Fig. 5 e Funnel plot of trials included in meta-analysis for
evaluating the success of MTA versus Calcium hydroxide
pulpotomy at 12 months.
noted that failure in MTA treated group of pulpotomy was 1
tooth out of the 41 that turned up for follow up after 1 year,
whereas all the teeth pulpotomized by Calcium hydroxide had
successful treatment outcomes. This study, thus favored
Calcium hydroxide as a pulpotomy agent [37]. Kumar et al., in
2016 carried out pulpotomy in 54 permanent mandibular
molars, analyzing the effectiveness of Calcium hydroxide &
MTA. At 6 months, 2 teeth treated with calcium hydroxide and
1 in MTA group presented failed treatment. But there was no
difference in failure rate amongst the two groups after 12
months [38]. Calcium hydroxide showed a significantly higher
failure rate as compared to MTA after 1 and 2 years in a study
conducted by Taha et al., in 2017 [39]. Chailertvanitkul et al.
and Taha et al. also found MTA to be an effective material at a
follow up period of around 2 years [37,39]. Due to lack of evi-
dence of superiority of any one material and contradictory
findings, we carried out this meta-analysis to establish which
among the two is a more effective pulpotomy agent.
A vital part of meta-analysis is to assess the consistency of
effects among the studies. Heterogeneity in an analysis can be
described as a variation in outcomes between studies. I2 value
signifies that the percentage variation across studies is due to
heterogeneity rather than chance. A value of 0% indicates no
heterogeneity between studies and larger values mean higher
heterogeneity. In present study, 0% heterogeneity was
observed at both 6 and 12 months interval which reflects a
consistency across studies.
Through our meta-analysis we concluded that MTA is a
significantly superior pulpotomy agent for permanent teeth as
compared to Calcium hydroxide, both at follow up period of 6
as well as 12 months. Since there were only few clinical trials
available for our meta-analysis, it is recommended that more
trials should be conducted to compare effectiveness of Cal-
cium hydroxide and MTA as pulpotomy agents in permanent
teeth.
We formulated a clinical question and performed exten-
sive search from multiple databases along with searching the
reference section as well. We also used broad search terms to
make our question adequately specific and sensitive. In order
to minimize selection bias, we included only randomized
 p e d i a t r i c d e n t a l j o u r n a l 2 9 ( 2 0 1 9 ) 9 0 e9 6
controlled trials. I2 value estimates reported in the study
reflect that there was absolutely no heterogeneity. Although
we chose only English articles, so there are chances of a lan-
guage bias.
5. Conclusion
This meta-analysis suggests that MTA is a superior material
for pulpotomy of cariously exposed permanent teeth. Failure
rate of pulpotomies is significantly higher with Calcium hy-
droxide despite its bactericidal properties. Further clinical
trials should be conducted comparing both these materials to
establish the effectiveness of each agent.
Acknowledgement
None.
Appendix A. Supplementary data
Supplementary data to this article can be found online at
https://doi.org/10.1016/j.pdj.2019.04.001.
Funding
None.
Conflict of interests
Authors declare that there is no conflict of interests regarding
the publication of paper.
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