Decision-ready evidence for vital pulp therapy: a network meta-analysis of bioactive materials in mature permanent teeth

Objectives – This network meta-analysis aimed to generate clinically credible, decision-ready evidence on the comparative effectiveness of bioactive materials used in vital pulp therapy (VPT) of mature permanent teeth with carious exposures, including symptomatic presentations. Materials and methods – Following PRISMA 2020 and PRISMA-NMA standards (PROSPERO: CRD420251074110), randomized controlled trials evaluating full pulpotomy (FP), partial pulpotomy (PP), direct pulp capping (DPC), and indirect pulp capping (IPC) were systematically identified across six databases. The primary outcome was composite success (clinical and radiographic) at 6, 12, 24, and 36 months. Arm-based Bayesian random-effects network meta-analyses and frequentist sensitivity models (REML–Hartung–Knapp) were performed. Certainty of evidence was graded using CINeMA. Results – The primary meta-analysis included a total of thirty-five RCTs with a total of 2906 teeth, of which a total of twenty-four RCTs involving mature/ permanent teeth were included. Success rates across all VPT types and time points of the 24 RCTs were generally comparable at >93%. Hydraulic calcium silicate materials (MTA & Biodentine) showed a greater likelihood of success than Ca(OH)2 in direct pulp caps and partial pulpotomy procedures. The difference was established with high-certainty evidence for the comparison of MTA vs. Ca(OH)2 and moderate-certainty evidence for the comparison of Biodentine vs. Ca(OH)2. In contrast, the comparisons of calcium silicate materials were frequently overlapped in their credible intervals with moderate certainty evidence; thus, no explicit difference was found between the calcium silicate materials (e.g., MTA & Biodentine). If adjunctive therapies (e.g., platelet-rich plasma & laser therapies) have a promising effect on success rates, they were supported with low-certainty evidence based on limited data and network sparsity. The meta-analysis met the requirement for network coherence (p > 0.10) and the amount of heterogeneity found was low (τ2 = 0.09). Conclusion – Vital pulp therapy in mature permanent teeth demonstrates consistently high success rates, particularly when using calcium silicate-based materials. These findings are supported by high-certainty evidence for comparisons with calcium hydroxide. However, differences among calcium silicate materials remain uncertain due to overlapping credible intervals and moderate certainty of evidence, while adjunctive therapies are supported by low-certainty evidence and should be interpreted cautiously. Systematic Review Registration – https://www.crd.york.ac.uk/PROSPERO/view/CRD420251074110, PROSPERO CRD420251074110.