Pulp Response to Materials Used in the Management of Deep Carious Lesions Without Pulp Exposure: A Systematic Review and Network Meta-Analysis
Fahad BaHammam, Sultan Aldakhil, Jamal Akhil, John Whitworth
First published: 01 December 2025 https://doi.org/10.1111/iej.70076
A review by Dr Richard S Kahan
This systematic review and network meta-analysis ultimately confirms what most clinicians already sense: using a proper pulp-capping material over deep dentine is better than simply bonding straight onto it. Across sixteen RCTs and seven materials, Biodentine, MTA and GIC repeatedly rise to the top, while the dentine bonding agent (DBA) arm consistently languishes at the bottom. Calcium hydroxide still works, but it no longer looks like the gold standard; hydraulic calcium silicates generally outperform it, especially at the one-year mark. Practically, the paper gives you a perfectly respectable, data-driven excuse to keep using Biodentine in deeper cavities – a conclusion you probably reached long before the statisticians rolled in.
Where the paper becomes rather entertaining is in its methodology. It’s a full statistical playground: Bayesian network meta-analysis with Markov chain Monte Carlo, Gelman–Rubin convergence checks, node-splitting diagnostics, cluster-adjusted sample sizes, CINeMA confidence ratings and ROB-MEN bias surveillance. Add in SUCRA values, league tables and Rank-O-Grams and you’ve essentially got a Champions League of pulp-capping materials. This is the sort of thing only a regression mathematician could truly love – intricate, rigorous, exquisitely technical, and almost entirely impenetrable to normal humans who just want to know what liner to put down.
To their credit, the authors don’t pretend the underlying evidence is better than it is. Most comparisons are supported by low or very low-confidence evidence, with small samples, short follow-up and the usual cocktail of methodological blemishes. A few signals rise to moderate confidence – MTA and Biodentine beating Ca(OH)₂ in the first year, and Biodentine/GIC outperforming DBA in the second – but the majority of conclusions fall into that familiar category of: “move on, not much to see here really”. It’s classic dental research: an elaborate statistical cathedral built on slightly wobbly foundations, ending with the obligatory plea for better trials.
Still, beneath the Bayesian glitter and the bias-seeking acrobatics, the clinical message is surprisingly steady. Don’t rely on DBA alone over deep dentine if you care about long-term pulp vitality. Do use a proper pulp-capping material. And if you reach instinctively for Biodentine as your liner in deep cavities, this paper not only agrees with you – it wraps that agreement in several hundred pages of statistical choreography to make the point look beautifully, if unnecessarily, complex.
