**1. Introduction**

4

Dental caries is the most common non-communicable disease in children with significant aesthetic, functional and quality of life deterioration [1]. Caries lesions can jeopardize the teeth vitality, as its progression cause infection, pain, and even early tooth loss [1,2]. Thus, a timely intervention is key to avoid unpleasant consequences for the child. Depending on the depth of caries (which may have pulp involvement), two approaches may be considered in the primary dentition: vital pulp therapy (VPT) or non-vital therapy (NPT) [1,3].

When the pulp is still recuperable, VPT may be an option and three options are available: indirect pulp treatment (IPT), direct pulp cap (DPC), and pulpotomy [1–5]. When the caries lesion progresses to the point where pulp necrotizes, then an NPT is performed, such as pulpectomy [3].

The efficacy of VPT and NPT has been widely researched [2–5]. However, the variability of designs, techniques, and material contributes to high heterogeneity regarding the evidence produced. IPT is a technique that leaves at the bottom of the cavity some deep caries to avoid pulp exposure, being covered with a biocompatible material to produce a biological seal [2,4,5]. DPC is a procedure in which there is a pulp exposure, being covered with a biocompatible material. There is a controversy about this method since it has shown

**Citation:** Lopes, L.B.; Calvão, C.; Vieira, F.S.; Neves, J.A.; Mendes, J.J.; Machado, V.; Botelho, J. Vital and Nonvital Pulp Therapy in Primary Dentition: An Umbrella Review. *J. Clin. Med.* **2022**, *11*, 85. https:// doi.org/10.3390/jcm11010085

Academic Editor: Massimo Amato

Received: 11 November 2021 Accepted: 22 December 2021 Published: 24 December 2021

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limited success [2–5]. Pulpotomy is an approach applied when there is a carious pulp exposure and where the entire coronal pulp is removed, hemostasis of the radicular pulp is accomplished, and the remaining radicular pulp is treated with a medicament [3,6]. In contrast, pulpectomy is a nonvital treatment (NVT), being a root canal treatment with irreversibly inflamed or necrotic pulp resulting from caries or trauma [1,3,5,6]. Due to the clinical interest of these procedures in endodontics, several systematic reviews (SRs) have been published. Thus, appraising all the available evidence-based information would be of grea<sup>t</sup> interest.

Therefore, this umbrella review aimed to appraise the existing evidence on VPT and NVT in primary teeth. Our main focus was to ascertain the overall clinical efficacy of each procedure and its quality of evidence.

#### **2. Materials and Methods**

We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline updated in 2020 [7] (Supplementary Table S1) and the guide for systematic reviews of systematic review [8]. The review protocol was approved a priori by all authors.

The Review question was: "How effective are VPT and NPT for treating deep carious lesion on primary dentition?".

The following PECO statements were set: Population (P)—Patients with deep caries on primary dentition; Exposure (E)—Clinical management; Comparison (C)—VPT (IPT, DPC and pulpotomy) and NPT (pulpectomy); Outcome (O)—Diagnosis and a variety of dental treatment types.

#### *2.1. Eligibility Criteria*

The inclusion criteria were as follows: (1) systematic review (with or without metaanalysis); (2) retrieving data from human studies; (3) addressing VPT and NPT on primary teeth. No restrictions to publication year or language were applied. Grey literature was searched through three appropriate databases (opensigle.inist.fr, https://www.ntis.gov/, https://www.apa.org/pubs/databases/psycextra, all accessed in June 2021).

#### *2.2. Information Sources Search*

Electronic data search was performed in seven electronic databases: PubMed (via Medline), Scopus, Cochrane Database of Systematic Reviews, Scielo (Scientific Electronic Library Online), EMBASE (The Excerpta Medica Database), LILACS (Latin-American scientific literature in health sciences), and TRIP (Turning Research Into Practise) up to June 2021. We merged keywords and subject headings in accordance with the thesaurus of each database and applied exploded subject headings, with the following syntax "(Primary teeth [MeSH] OR Pulp therapy [MeSH] OR Tooth [MeSH]) AND (Pulpotomy OR Pulpectomy OR Vital pulp therapy OR Deciduous teeth) AND (Systematic Review OR Meta-analysis)".

#### *2.3. Study Selection*

Two researchers (FV and CC) independently screened titles and abstracts. The agreement between the reviewers was assessed by Kappa statistics. Any paper classified as potentially eligible by either reviewer was ordered as a full-text and independently screened by the reviewers. All disagreements were resolved through discussion with a third reviewer (LBL).

#### *2.4. Data Extraction Process and Data Items*

Two researchers (FV and CC) independently extracted: authors and year of publication, objective/focused question, databases searched, number of studies included, type of studies included, main results and main conclusions. All disagreements were resolved through discussion with a third reviewer (LBL).

#### *2.5. Risk of Bias Assessment*

Two researchers (FV and CC) employed the MeaSurement Tool to Assess Systematic Reviews (AMSTAR 2) to determine the methodological quality of the included reviews [8]. AMSTAR 2 is a comprehensive 16-item tool that rates the overall confidence of the results of the review. According to the AMSTAR guidelines, the quality of the systematic reviews was considered as follows: High means 'Zero or one non-critical weakness'; Moderate means 'More than one non-critical weakness'; Low means 'One critical flaw with or without noncritical weaknesses'; and Critically low means 'More than one critical flaw with or without non-critical weaknesses. The estimation of the AMSTAR quality rate for each study was calculated through the AMSTAR 2 online tool (https://amstar.ca/Amstar\_Checklist.php).
