MINERAL TRIOXIDE AGGREGATE VERSUS CALCIUM HYDROXIDE IN INDIRECT PULP TREATMENT OF PERMANENT TEETH: A SYSTEMATIC REVIEW

Marwa Aly 1 , Dalia Moheb 1 , Osama Elshahawy 1 , Ahmed Abdelsamad 2 and Mervat Rashed 1 . 1. Pediatric Dentistry and Dental public health, Faculty of Oral and Dental Medicine, Cairo University –Egypt. 2. Oral Radiology, Faculty of Oral and Dental Medicine, Cairo University –Egypt. ...................................................................................................................... Manuscript Info Abstract ......................... ........................................................................ Manuscript History

Intervention: Indirect pulp treatment using Mineral trioxide aggregate Control/ Comparator: Indirect pulp treatment using Calcium hydroxide. Outcome measures: success rate and dentin bridge formation.
Research Question:-In deeply decayed permanent teeth, will indirect pulp treatment using CH in comparison to indirect pulp treatment using MTA differ in terms of success rate and dentin bridge formation?
Search Strategy:-In the present study, PubMed, Web of science, the Cochrane Library, Google and Ebsco were used as the electronic databases. The following key words were used: indirect pulp capping, indirect pulp cap, indirect pulp therapy, indirect pulp treatment, MTA, mineral trioxide aggregate, calcium hydroxide and Ca(OH)2. Additional search methods included a manual review of the reference lists of relevant studies. Inclusion Criteria:-1. Randomized controlled trials (RCTs), 2. Indirect pulp treatment on permanent teeth, 3. Studies comparing mineral trioxide aggregate and calcium hydroxide, 4. The success rate and or dentin bridge formation were recorded.

Data Extraction:-
Studies that fulfilled the inclusion criteria were processed for data extraction. Two authors independently extracted the necessary information. The following information were extracted from each study: year of publication, country of origin, study design, informed consent obtained, ethical approval, funding, setting, aim of the study, participants age, numbers and gender, inclusion and exclusion criteria, details of material, methods, restoration, duration of follow up, principal and secondary outcome measures, methods of assessing outcome measures and studies results.

Methodological Quality Appraisal:-
Assessment of the quality of included studies was performed using the Cochrane Collaboration's tool for assessing risk of bias.

Results of Methodological Quality Assessment:-
The three studies were assessed using the Cochrane Collaboration's tool for assessing risk of bias. Table 4, shows the findings for each risk of bias in each study. All studies revealed randomization, but they failed to define means for random sequence generation and did not sufficiently define allocation concealment. Blinding of the participants and personnel was mentioned in only one study that MTA and CH could be distinguished by the operator and so a double-blind clinical trial was not possible. Regarding the assessments of the outcomes in two studies, there was blinding of the assessor and detection bias was considered low risk. A description of withdrawals and dropouts was given in two studies. other sources of bias were not found in the three studies.    At 3 months, the clinical success rates of MTA and calcium hydroxide were 93% and 73%, respectively (P = 0.02). At 6 months, the success rate was 89.6% with MTA, and remained steady at 73% with calcium hydroxide (P = 0.63). The mean initial residual dentine thickness was 0.23 mm, and increased by 0.121 mm with MTA and by0.136 mm with calcium hydroxide at 3 months. At 6 months, there was an increase of 0.235 mm with MTA and of 0.221 mm with calcium hydroxide Sultana et al. 2016 Postoperative pain, the vitality of the pulp and formation of reparative dentin Pain assessment was performed according to VAS (Visual Analogue Scale) system. Pulp vitality was assessed by vitality test. Reparative dentin formation was assessed by means of intraoral periapical radiograph (IOAP). Reparative dentin formation was observed (present/absent) from the radiograph.
In all observation periods, MTA showed more capable of reducing pain and maintain pulp vitality which was statistically significant than that of calcium hydroxide. At12 months observation period, 24 teeth (96%) of MTA and 19 teeth76%) of calcium hydroxide showed reparative dentin (formation.

Conclusions:-
Due to presence of high risk of bias in the included studies, there is no conclusive evidence on the superiority of one material over the other.
Further, high quality and long span clinical trials for indirect pulp treatment materials are still required to assess the most effective material owing to the high risk of bias and the short-term follow-up in the available studies.