Vital Pulp Therapy in Permanent Teeth: A Systematic Review and Meta-Analyses

Purpose: To determine factors affecting permanent tooth vital pulp therapy (VPT) success from a systematic review (SR) and metaanalyses. Methods: SRs of databases were completed through June 2024, and the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used for the certainty of evidence. Results: The 24-month indirect pulp treatment (IPT), direct pulp capping (DPC), partial pulpotomy (PP), and full pulpotomy (FP) successes (91 to 97 percent) were not statistically different (P=0.19) in teeth diagnosed with normal pulp/reversible pulpitis (NP/RP). IPT (94 percent) versus DPC (87 percent) success at 36 months was not significantly different when calcium silicate cement (CS) was used for DPC in teeth diagnosed with NP/RP (P=0.10). PP success versus DPC was equal (96 percent) after 24 months in teeth diagnosed with NP/RP if CS was used for DPC. Teeth exhibiting symptomatic irreversible pulpitis (SIP) were defined as exhibiting spontaneous unprovoked pain, lingering thermal pain, or referred pain, and may have periapical pathosis/involvement or not. One study's data on the five-year success rate for FP in teeth with SIP was 78 percent, and teeth without PPI showed significantly increased success (P=0.04). PP/FP success (90 percent) in teeth with SIP was not significantly different versus PP/FP success (97 percent) in NP/RP teeth (P=0.054). Selective caries removal minimized pulp exposures in teeth with deep caries diagnosed with NP/RP. For teeth diagnosed with SIP or extremely deep caries, complete caries removal is recommended to expose the pulp. If pulpal bleeding is controlled, it is recommended to perform a full pulpotomy. Hemo- stasis within six minutes likely improves pulpotomy success. Mineral trioxide aggregate was found to discolor teeth significantly more (83 percent) than Biodentine (zero percent) containing no bismuth oxide (P<0.001) PP/FP were significantly more successful for traumatic pulp exposures than DPC (P ≤ 0.001). Root maturity did not affect PP/FP success for NP/RP teeth. Conclusions: All vital pulp therapy methods are successful for teeth diagnosed with normal pulp/reversible pulpitis. Teeth diagnosed with symptomatic irreversible pulpitis can be treated successfully with a full pulpotomy.