**3. Results**

#### *3.1. Study Selection*

Electronic searches retrieved a total of 272 titles through the database search. After manual assessment of title/abstract and removal of duplicates, 60 potentially eligible fulltexts were screened (Figure 1). Full-text screening excluded thirteen studies with reasons (Supplementary Table S2), resulting in thirty-five systematic reviews that fulfilled the inclusion criteria. Inter-examiner reliability at the full-text screening was recorded as high (kappa score = 1.00).

**Figure 1.** PRISMA flowchart of included studies.

#### *3.2. Study Characteristics*

In total, 33 systematic reviews [1–6,9–35] were included in the present umbrella review (Table 1). All SRs covered a defined timeframe; however, one did not mention such information [33]. Three systematics reviews failed to report a language restriction [2,10,11], seventeen restricted their search to studies in English [12–25], one restricted to English and Persia [26], and the remaining had no language restrictions [1,3–6,9,27–35].

*J. Clin. Med.* **2022**, *11*, 85


**Table 1.** Characteristics of included studies.


number of included studies; NRSI—Nonrandomized study of intervention; RCTs—randomized-clinical trials; SR—Systematic Review; ZOE—zinc oxide eugenol;

NI—no information; NR—not reported. \* Detailed information regarding the methodological quality assessment is present in Table 2.

#### *3.3. Methodological Quality*

Regarding the methodological quality of SRs, three studies were assessed as of critically low quality [12,27], nine as of low quality [2,6,15,19,21,25,31,35], seventeen studies as of moderate quality [5,9,10,13,14,18,20,22–24,26,28–30,32–34], and six as of high quality [1,3,4,11,16,17] (detailed in Table 2). None of the included SR fully complied with the AMSTAR2 checklist. Overall, SRs mostly failed on: reporting on the sources of funding for the studies included in the review (93.9%, *n* = 31); providing a satisfactory explanation for, and discussion of, any heterogeneity observed in the results (27.3%, *n* = 9); reporting any potential sources of conflict of interest, including funding sources (27.3%, *n* = 9); explaining their selection literature search strategy (20.0%, *n* = 7).

**Table 2.** Results of the methodological quality assessment via AMSTAR2.


0—No meta-analysis conducted, N—No, Y—Yes, PY—Partial Yes. 1. Research questions and inclusion criteria? 2. Review methods established a priori? 3. Explanation of their selection literature search strategy? 4. Did the review authors use a comprehensive literature search strategy? 5. Study selection performed in duplicate? 6. Data selection performed in duplicate? 7. List of excluded studies and exclusions justified? 8. Description of the included studies in adequate detail? 9. Satisfactory technique for assessing the risk of bias (RoB)? 10. Report on the sources of funding for the studies included in the review? 11. If meta-analysis was performed, did the review authors use appropriate methods for statistical combination of results? 12. If meta-analysis was performed, did the review authors assess the potential impact of RoB? 13. RoB accounted when interpreting/discussing the results of the review? 14. Did the review authors provide a satisfactory explanation for, and discussion of, any heterogeneity observed in the results of the review? 15. If they performed quantitative synthesis, was publication bias performed? 16. Did the review authors report any potential sources of conflict of interest, including funding sources?.

*3.4. Synthesis of Results*

3.4.1. Vital Pulp Therapy

Indirect Pulp Treatment (IPT)

In an IPT approach, the caries lesion is not fully removed during instrumentation to avoid pulp exposure, and the remaining affected dentin is then covered with a biocompatible material as a biological seal [4].

Dentin coverage with a liner provides no benefit to the IPT clinical success either using calcium hydroxide (CH) or inert materials (adhesive system or glass-ionomer cement [GIC] [4,22], and with a certain level of confidence as they are based on SRs of high [4] and moderate methodological quality [22].

Also, IPT demonstrates higher clinical success rate than pulpotomy, with low confidence [6]. The Hall technique (an adapted IPT approach) showed 78% success versus a 76% success of pulpectomy, with moderate confidence [5].

#### Direct Pulp Capping (DPC)

In the DPC approach, the pulp is exposed during caries removal and covered with a biocompatible material [3–5].

A high-quality SR concluded that DPC presents an 88.8%, success rate regardless of the applied material (CH, dentin bonding agents, MTA and FC) (Coll 2017). These results are corroborated by a moderate quality SR [18] and a high quality Cochrane SR [3]. MTA or enamel matrix proteins do not present uppermost efficacy than CH, and bonding agen<sup>t</sup> directly upon the exposed pulp without previous etching had no significantly different efficacy when compared to CH, MTA or calcium-enriched cement [34].

Also, DPC was shown to present lower clinical success than pulpotomy with moderate confidence [5].
