what is literature review advantages and disadvantages

Advantages and disadvantages of literature review

This comprehensive article explores some of the advantages and disadvantages of literature review in research. Reviewing relevant literature is a key area in research, and indeed, it is a research activity in itself. It helps researchers investigate a particular topic in detail. However, it has some limitations as well.

What is literature review?

In order to understand the advantages and disadvantages of literature review, it is important to understand what a literature review is and how it differs from other methods of research. According to Jones and Gratton (2009) a literature review essentially consists of critically reading, evaluating, and organising existing literature on a topic to assess the state of knowledge in the area. It is sometimes called critical review.

A literature review is a select analysis of existing research which is relevant to a researcher’s selected topic, showing how it relates to their investigation. It explains and justifies how their investigation may help answer some of the questions or gaps in the chosen area of study (University of Reading, 2022).

A literature review is a term used in the field of research to describe a systematic and methodical investigation of the relevant literature on a particular topic. In other words, it is an analysis of existing research on a topic in order to identify any relevant studies and draw conclusions about the topic.

A literature review is not the same as a bibliography or a database search. Rather than simply listing references to sources of information, a literature review involves critically evaluating and summarizing existing research on a topic. As such, it is a much more detailed and complex process than simply searching databases and websites, and it requires a lot of effort and skills.

Advantages of literature review

Information synthesis

A literature review is a very thorough and methodical exercise. It can be used to synthesize information and draw conclusions about a particular topic. Through a careful evaluation and critical summarization, researchers can draw a clear and comprehensive picture of the chosen topic.

Familiarity with the current knowledge

According to the University of Illinois (2022), literature reviews allow researchers to gain familiarity with the existing knowledge in their selected field, as well as the boundaries and limitations of that field.

Creation of new body of knowledge

One of the key advantages of literature review is that it creates new body of knowledge. Through careful evaluation and critical summarisation, researchers can create a new body of knowledge and enrich the field of study.

Answers to a range of questions

Literature reviews help researchers analyse the existing body of knowledge to determine the answers to a range of questions concerning a particular subject.

Disadvantages of literature review

Time consuming

As a literature review involves collecting and evaluating research and summarizing the findings, it requires a significant amount of time. To conduct a comprehensive review, researchers need to read many different articles and analyse a lot of data. This means that their review will take a long time to complete.

Lack of quality sources  

Researchers are expected to use a wide variety of sources of information to present a comprehensive review. However, it may sometimes be challenging for them to identify the quality sources because of the availability of huge numbers in their chosen field. It may also happen because of the lack of past empirical work, particularly if the selected topic is an unpopular one.

Descriptive writing

One of the major disadvantages of literature review is that instead of critical appreciation, some researchers end up developing reviews that are mostly descriptive. Their reviews are often more like summaries of the work of other writers and lack in criticality. It is worth noting that they must go beyond describing the literature.

Key features of literature review

Clear organisation

A literature review is typically a very critical and thorough process. Universities usually recommend students a particular structure to develop their reviews. Like all other academic writings, a review starts with an introduction and ends with a conclusion. Between the beginning and the end, researchers present the main body of the review containing the critical discussion of sources.

No obvious bias

A key feature of a literature review is that it should be very unbiased and objective. However, it should be mentioned that researchers may sometimes be influenced by their own opinions of the world.

Proper citation

One of the key features of literature review is that it must be properly cited. Researchers should include all the sources that they have used for information. They must do citations and provide a reference list by the end in line with a recognized referencing system such as Harvard.

To conclude this article, it can be said that a literature review is a type of research that seeks to examine and summarise existing research on a particular topic. It is an essential part of a dissertation/thesis. However, it is not an easy thing to handle by an inexperienced person. It also requires a lot of time and patience.

Hope you like this ‘Advantages and disadvantages of literature review’. Please share this with others to support our research work.

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References:

Jones, I., & Gratton, C. (2009) Research Methods for Sports Shttps://www.howandwhat.net/new/evaluate-website-content/tudies, 2 nd edition, London: Routledge

University of Illinois (2022) Literature review, available at: https://www.uis.edu/learning-hub/writing-resources/handouts/learning-hub/literature-review (accessed 08 May 2022)

University of Reading (2022) Literature reviews, available at: https://libguides.reading.ac.uk/literaturereview/starting (accessed 07 May 2022)

Author: M Rahman

M Rahman writes extensively online and offline with an emphasis on business management, marketing, and tourism. He is a lecturer in Management and Marketing. He holds an MSc in Tourism & Hospitality from the University of Sunderland. Also, graduated from Leeds Metropolitan University with a BA in Business & Management Studies and completed a DTLLS (Diploma in Teaching in the Life-Long Learning Sector) from London South Bank University.

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What is a Literature Review?

A literature or narrative review is a comprehensive review and analysis of the published literature on a specific topic or research question. The literature that is reviewed contains: books, articles, academic articles, conference proceedings, association papers, and dissertations. It contains the most pertinent studies and points to important past and current research and practices. It provides background and context, and shows how your research will contribute to the field. 

A literature review should: 

• Provide a comprehensive and updated review of the literature;
• Explain why this review has taken place;
• Articulate a position or hypothesis;
• Acknowledge and account for conflicting and corroborating points of view

From  S age Research Methods

Purpose of a Literature Review

A literature review can be written as an introduction to a study to:

• Demonstrate how a study fills a gap in research
• Compare a study with other research that's been done

Or it can be a separate work (a research article on its own) which:

• Organizes or describes a topic
• Describes variables within a particular issue/problem

Limitations of a Literature Review

Some of the limitations of a literature review are:

• It's a snapshot in time. Unlike other reviews, this one has beginning, a middle and an end. There may be future developments that could make your work less relevant.
• It may be too focused. Some niche studies may miss the bigger picture.
• It can be difficult to be comprehensive. There is no way to make sure all the literature on a topic was considered.
• It is easy to be biased if you stick to top tier journals. There may be other places where people are publishing exemplary research. Look to open access publications and conferences to reflect a more inclusive collection. Also, make sure to include opposing views (and not just supporting evidence).

Source: Grant, Maria J., and Andrew Booth. “A Typology of Reviews: An Analysis of 14 Review Types and Associated Methodologies.” Health Information & Libraries Journal, vol. 26, no. 2, June 2009, pp. 91–108. Wiley Online Library, doi:10.1111/j.1471-1842.2009.00848.x.

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What is it?

Literature reviews involve collecting information from literature that is already available, similar to a long essay. It is a written argument that builds a case from previous research (Machi and McEvoy, 2012). Every dissertation should include a literature review, but a dissertation as a whole can be a literature review. In this section we discuss literature reviews for the whole dissertation.

What are the benefits of a literature review?

There are advantages and disadvantages to any approach. The advantages of conducting a literature review include accessibility, deeper understanding of your chosen topic, identifying experts and current research within that area, and answering key questions about current research. The disadvantages might include not providing new information on the subject and, depending on the subject area, you may have to include information that is out of date.

How do I write it?

A literature review is often split into chapters, you can choose if these chapters have titles that represent the information within them, or call them chapter 1, chapter 2, ect. A regular format for a literature review is:

Introduction (including methodology)

This particular example is split into 6 sections, however it may be more or less depending on your topic.

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Literature reviews, what is a literature review, learning more about how to do a literature review.

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A literature review is a review and synthesis of existing research on a topic or research question. A literature review is meant to analyze the scholarly literature, make connections across writings and identify strengths, weaknesses, trends, and missing conversations. A literature review should address different aspects of a topic as it relates to your research question. A literature review goes beyond a description or summary of the literature you have read. 

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Literature Review & Research Skills Guide: What is a Literature Review?

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What is a literature review

Once you have defined your topic, the next step is to start a literature review. A literature review summarises, interprets and critically evaluates material that has already been published on a topic. The purpose is to establish current knowledge of a subject, identify gaps, inconsistencies and relations in the literature as well as outline areas for additional research and/or define a topic of inquiry.

Adopted from Charles Sturt University Library. (2017). Literature review.  Retrieved from http://libguides.csu.edu.au/review

Types of literature reviews

The type of literature review you write will depend on your discipline and whether you are a researcher writing your PhD, publishing a study in a journal or completing an assessment task in your undergraduate study.

A literature review for a subject in an undergraduate degree will not be as comprehensive as the literature review required for a PhD thesis.

An undergraduate literature review may be in the form of an annotated bibliography or a narrative review of a small selection of literature, for example ten relevant articles. If you are asked to write a literature review, and you are an undergraduate student, be guided by your subject coordinator or lecturer.

Often the term "review" and "literature" can be confusing and used in the wrong context. Grant and Booth (2009) attempt to clear up this confusion by discussing 14 review types and the associated methodology, and advantages and disadvantages associated with each review.   For research students, especially those in EEB501, ERP502 or doctoral students, they will be undertaking a critical literature review.

Grant, M. J., & Booth, A. (2009).  A typology of reviews: an analysis of 14 review types and associated methodologies . Health Information & Libraries Journal, 26 , 91–108. doi:10.1111/j.1471-1842.2009.00848.x

What is the purpose or aim of the literature review?

A literature review should demonstrate your knowledge of the research that has been conducted in the past and should place your research in the context of this work. A literature review can have a number of purposes within a research project. These include:

• demonstrating and clarify your understanding of your field of research;
• identifying patterns and trends in the literature;
• identifying gaps in the literature and seek new lines of inquiry;
• identifying similarities and differences in previous research and place your work in perspective;
• justifying your own research;
• increasing your breadth of knowledge of your subject area;
• identifying seminal and influential published works in your field;
• identifying relevant journals, publishers and conferences to search;
• providing the intellectual context for your own work, enabling you to position your project relative to other work;
• identifying experts working in your field (a researcher network is a valuable resource);
• carrying on from where others have already reached.

Onwuegbuzie, A. J., & Frels, R. (2016). 7 steps to a comprehensive literature review : a multimodal & cultural approach . London : Thousand Oaks, California: SAGE Publications.

Randolph, J. J. (2009).  A guide to writing the dissertation literature review . Practical Assessment Research & Evaluation. 14 (Article 13), 1-13.

An Introduction to Literature Reviews

Please watch the following video:

where to start a literature review

There are many different types of resources which might offer information on the topic you are researching, but you need to consider whether the source is scholarly or authoritative enough for a literature review. Typically literature reviews are conducted by using journal articles, conference papers, book chapters, websites or standards.  

In addition, there is a range of new information sources that you may not have come across before, such as: 

• Internet resources
• Tracking citation
• Using Social Media
• Interlibrary loans

To keep your information organised, you might like to consider using a reference manager.  There are a number of different reference managers available to use, and they all have their own advantages and disadvantages. See the EndNote tab   to find further information on Charles Sturt University's bibliographic management software EndNote.

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Literature Review: The What, Why and How-to Guide — Introduction

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What are Literature Reviews?

So, what is a literature review? "A literature review is an account of what has been published on a topic by accredited scholars and researchers. In writing the literature review, your purpose is to convey to your reader what knowledge and ideas have been established on a topic, and what their strengths and weaknesses are. As a piece of writing, the literature review must be defined by a guiding concept (e.g., your research objective, the problem or issue you are discussing, or your argumentative thesis). It is not just a descriptive list of the material available, or a set of summaries." Taylor, D.  The literature review: A few tips on conducting it . University of Toronto Health Sciences Writing Centre.

Goals of Literature Reviews

What are the goals of creating a Literature Review?  A literature could be written to accomplish different aims:

• To develop a theory or evaluate an existing theory
• To summarize the historical or existing state of a research topic
• Identify a problem in a field of research 

Baumeister, R. F., & Leary, M. R. (1997). Writing narrative literature reviews .  Review of General Psychology , 1 (3), 311-320.

What kinds of sources require a Literature Review?

• A research paper assigned in a course
• A thesis or dissertation
• A grant proposal
• An article intended for publication in a journal

All these instances require you to collect what has been written about your research topic so that you can demonstrate how your own research sheds new light on the topic.

Types of Literature Reviews

What kinds of literature reviews are written?

Narrative review: The purpose of this type of review is to describe the current state of the research on a specific topic/research and to offer a critical analysis of the literature reviewed. Studies are grouped by research/theoretical categories, and themes and trends, strengths and weakness, and gaps are identified. The review ends with a conclusion section which summarizes the findings regarding the state of the research of the specific study, the gaps identify and if applicable, explains how the author's research will address gaps identify in the review and expand the knowledge on the topic reviewed.

• Example : Predictors and Outcomes of U.S. Quality Maternity Leave: A Review and Conceptual Framework:  10.1177/08948453211037398  

Systematic review : "The authors of a systematic review use a specific procedure to search the research literature, select the studies to include in their review, and critically evaluate the studies they find." (p. 139). Nelson, L. K. (2013). Research in Communication Sciences and Disorders . Plural Publishing.

• Example : The effect of leave policies on increasing fertility: a systematic review:  10.1057/s41599-022-01270-w

Meta-analysis : "Meta-analysis is a method of reviewing research findings in a quantitative fashion by transforming the data from individual studies into what is called an effect size and then pooling and analyzing this information. The basic goal in meta-analysis is to explain why different outcomes have occurred in different studies." (p. 197). Roberts, M. C., & Ilardi, S. S. (2003). Handbook of Research Methods in Clinical Psychology . Blackwell Publishing.

• Example : Employment Instability and Fertility in Europe: A Meta-Analysis:  10.1215/00703370-9164737

Meta-synthesis : "Qualitative meta-synthesis is a type of qualitative study that uses as data the findings from other qualitative studies linked by the same or related topic." (p.312). Zimmer, L. (2006). Qualitative meta-synthesis: A question of dialoguing with texts .  Journal of Advanced Nursing , 53 (3), 311-318.

• Example : Women’s perspectives on career successes and barriers: A qualitative meta-synthesis:  10.1177/05390184221113735

Literature Reviews in the Health Sciences

• UConn Health subject guide on systematic reviews Explanation of the different review types used in health sciences literature as well as tools to help you find the right review type
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Writing an effective literature review

Lorelei lingard.

Schulich School of Medicine & Dentistry, Health Sciences Addition, Western University, London, Ontario Canada

In the Writer’s Craft section we offer simple tips to improve your writing in one of three areas: Energy, Clarity and Persuasiveness. Each entry focuses on a key writing feature or strategy, illustrates how it commonly goes wrong, teaches the grammatical underpinnings necessary to understand it and offers suggestions to wield it effectively. We encourage readers to share comments on or suggestions for this section on Twitter, using the hashtag: #how’syourwriting?

This Writer’s Craft instalment is the first in a two-part series that offers strategies for effectively presenting the literature review section of a research manuscript. This piece alerts writers to the importance of not only summarizing what is known but also identifying precisely what is not, in order to explicitly signal the relevance of their research. In this instalment, I will introduce readers to the mapping the gap metaphor, the knowledge claims heuristic, and the need to characterize the gap.

Mapping the gap

The purpose of the literature review section of a manuscript is not to report what is known about your topic. The purpose is to identify what remains unknown— what academic writing scholar Janet Giltrow has called the ‘knowledge deficit’ — thus establishing the need for your research study [ 1 ]. In an earlier Writer’s Craft instalment, the Problem-Gap-Hook heuristic was introduced as a way of opening your paper with a clear statement of the problem that your work grapples with, the gap in our current knowledge about that problem, and the reason the gap matters [ 2 ]. This article explains how to use the literature review section of your paper to build and characterize the Gap claim in your Problem-Gap-Hook. The metaphor of ‘mapping the gap’ is a way of thinking about how to select and arrange your review of the existing literature so that readers can recognize why your research needed to be done, and why its results constitute a meaningful advance on what was already known about the topic.

Many writers have learned that the literature review should describe what is known. The trouble with this approach is that it can produce a laundry list of facts-in-the-world that does not persuade the reader that the current study is a necessary next step. Instead, think of your literature review as painting in a map of your research domain: as you review existing knowledge, you are painting in sections of the map, but your goal is not to end with the whole map fully painted. That would mean there is nothing more we need to know about the topic, and that leaves no room for your research. What you want to end up with is a map in which painted sections surround and emphasize a white space, a gap in what is known that matters. Conceptualizing your literature review this way helps to ensure that it achieves its dual goal: of presenting what is known and pointing out what is not—the latter of these goals is necessary for your literature review to establish the necessity and importance of the research you are about to describe in the methods section which will immediately follow the literature review.

To a novice researcher or graduate student, this may seem counterintuitive. Hopefully you have invested significant time in reading the existing literature, and you are understandably keen to demonstrate that you’ve read everything ever published about your topic! Be careful, though, not to use the literature review section to regurgitate all of your reading in manuscript form. For one thing, it creates a laundry list of facts that makes for horrible reading. But there are three other reasons for avoiding this approach. First, you don’t have the space. In published medical education research papers, the literature review is quite short, ranging from a few paragraphs to a few pages, so you can’t summarize everything you’ve read. Second, you’re preaching to the converted. If you approach your paper as a contribution to an ongoing scholarly conversation,[ 2 ] then your literature review should summarize just the aspects of that conversation that are required to situate your conversational turn as informed and relevant. Third, the key to relevance is to point to a gap in what is known. To do so, you summarize what is known for the express purpose of identifying what is not known . Seen this way, the literature review should exert a gravitational pull on the reader, leading them inexorably to the white space on the map of knowledge you’ve painted for them. That white space is the space that your research fills.

Knowledge claims

To help writers move beyond the laundry list, the notion of ‘knowledge claims’ can be useful. A knowledge claim is a way of presenting the growing understanding of the community of researchers who have been exploring your topic. These are not disembodied facts, but rather incremental insights that some in the field may agree with and some may not, depending on their different methodological and disciplinary approaches to the topic. Treating the literature review as a story of the knowledge claims being made by researchers in the field can help writers with one of the most sophisticated aspects of a literature review—locating the knowledge being reviewed. Where does it come from? What is debated? How do different methodologies influence the knowledge being accumulated? And so on.

Consider this example of the knowledge claims (KC), Gap and Hook for the literature review section of a research paper on distributed healthcare teamwork:

KC: We know that poor team communication can cause errors. KC: And we know that team training can be effective in improving team communication. KC: This knowledge has prompted a push to incorporate teamwork training principles into health professions education curricula. KC: However, most of what we know about team training research has come from research with co-located teams—i. e., teams whose members work together in time and space. Gap: Little is known about how teamwork training principles would apply in distributed teams, whose members work asynchronously and are spread across different locations. Hook: Given that much healthcare teamwork is distributed rather than co-located, our curricula will be severely lacking until we create refined teamwork training principles that reflect distributed as well as co-located work contexts.

The ‘We know that …’ structure illustrated in this example is a template for helping you draft and organize. In your final version, your knowledge claims will be expressed with more sophistication. For instance, ‘We know that poor team communication can cause errors’ will become something like ‘Over a decade of patient safety research has demonstrated that poor team communication is the dominant cause of medical errors.’ This simple template of knowledge claims, though, provides an outline for the paragraphs in your literature review, each of which will provide detailed evidence to illustrate a knowledge claim. Using this approach, the order of the paragraphs in the literature review is strategic and persuasive, leading the reader to the gap claim that positions the relevance of the current study. To expand your vocabulary for creating such knowledge claims, linking them logically and positioning yourself amid them, I highly recommend Graff and Birkenstein’s little handbook of ‘templates’ [ 3 ].

As you organize your knowledge claims, you will also want to consider whether you are trying to map the gap in a well-studied field, or a relatively understudied one. The rhetorical challenge is different in each case. In a well-studied field, like professionalism in medical education, you must make a strong, explicit case for the existence of a gap. Readers may come to your paper tired of hearing about this topic and tempted to think we can’t possibly need more knowledge about it. Listing the knowledge claims can help you organize them most effectively and determine which pieces of knowledge may be unnecessary to map the white space your research attempts to fill. This does not mean that you leave out relevant information: your literature review must still be accurate. But, since you will not be able to include everything, selecting carefully among the possible knowledge claims is essential to producing a coherent, well-argued literature review.

Characterizing the gap

Once you’ve identified the gap, your literature review must characterize it. What kind of gap have you found? There are many ways to characterize a gap, but some of the more common include:

• a pure knowledge deficit—‘no one has looked at the relationship between longitudinal integrated clerkships and medical student abuse’
• a shortcoming in the scholarship, often due to philosophical or methodological tendencies and oversights—‘scholars have interpreted x from a cognitivist perspective, but ignored the humanist perspective’ or ‘to date, we have surveyed the frequency of medical errors committed by residents, but we have not explored their subjective experience of such errors’
• a controversy—‘scholars disagree on the definition of professionalism in medicine …’
• a pervasive and unproven assumption—‘the theme of technological heroism—technology will solve what ails teamwork—is ubiquitous in the literature, but what is that belief based on?’

To characterize the kind of gap, you need to know the literature thoroughly. That means more than understanding each paper individually; you also need to be placing each paper in relation to others. This may require changing your note-taking technique while you’re reading; take notes on what each paper contributes to knowledge, but also on how it relates to other papers you’ve read, and what it suggests about the kind of gap that is emerging.

In summary, think of your literature review as mapping the gap rather than simply summarizing the known. And pay attention to characterizing the kind of gap you’ve mapped. This strategy can help to make your literature review into a compelling argument rather than a list of facts. It can remind you of the danger of describing so fully what is known that the reader is left with the sense that there is no pressing need to know more. And it can help you to establish a coherence between the kind of gap you’ve identified and the study methodology you will use to fill it.

Acknowledgements

Thanks to Mark Goldszmidt for his feedback on an early version of this manuscript.

PhD, is director of the Centre for Education Research & Innovation at Schulich School of Medicine & Dentistry, and professor for the Department of Medicine at Western University in London, Ontario, Canada.

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Conducting a Literature Review

Benefits of conducting a literature review.

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While there might be many reasons for conducting a literature review, following are four key outcomes of doing the review.

Assessment of the current state of research on a topic . This is probably the most obvious value of the literature review. Once a researcher has determined an area to work with for a research project, a search of relevant information sources will help determine what is already known about the topic and how extensively the topic has already been researched.

Identification of the experts on a particular topic . One of the additional benefits derived from doing the literature review is that it will quickly reveal which researchers have written the most on a particular topic and are, therefore, probably the experts on the topic. Someone who has written twenty articles on a topic or on related topics is more than likely more knowledgeable than someone who has written a single article. This same writer will likely turn up as a reference in most of the other articles written on the same topic. From the number of articles written by the author and the number of times the writer has been cited by other authors, a researcher will be able to assume that the particular author is an expert in the area and, thus, a key resource for consultation in the current research to be undertaken.

Identification of key questions about a topic that need further research . In many cases a researcher may discover new angles that need further exploration by reviewing what has already been written on a topic. For example, research may suggest that listening to music while studying might lead to better retention of ideas, but the research might not have assessed whether a particular style of music is more beneficial than another. A researcher who is interested in pursuing this topic would then do well to follow up existing studies with a new study, based on previous research, that tries to identify which styles of music are most beneficial to retention.

Determination of methodologies used in past studies of the same or similar topics.  It is often useful to review the types of studies that previous researchers have launched as a means of determining what approaches might be of most benefit in further developing a topic. By the same token, a review of previously conducted studies might lend itself to researchers determining a new angle for approaching research.

Upon completion of the literature review, a researcher should have a solid foundation of knowledge in the area and a good feel for the direction any new research should take. Should any additional questions arise during the course of the research, the researcher will know which experts to consult in order to quickly clear up those questions.

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Types of Literature Review — A Guide for Researchers

Table of Contents

Researchers often face challenges when choosing the appropriate type of literature review for their study. Regardless of the type of research design and the topic of a research problem , they encounter numerous queries, including:

What is the right type of literature review my study demands?

• How do we gather the data?
• How to conduct one?
• How reliable are the review findings?
• How do we employ them in our research? And the list goes on.

If you’re also dealing with such a hefty questionnaire, this article is of help. Read through this piece of guide to get an exhaustive understanding of the different types of literature reviews and their step-by-step methodologies along with a dash of pros and cons discussed.

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What is a Literature Review?

A literature review provides a comprehensive overview of existing knowledge on a particular topic, which is quintessential to any research project. Researchers employ various literature reviews based on their research goals and methodologies. The review process involves assembling, critically evaluating, and synthesizing existing scientific publications relevant to the research question at hand. It serves multiple purposes, including identifying gaps in existing literature, providing theoretical background, and supporting the rationale for a research study.

What is the importance of a Literature review in research?

Literature review in research serves several key purposes, including:

• Background of the study: Provides proper context for the research. It helps researchers understand the historical development, theoretical perspectives, and key debates related to their research topic.
• Identification of research gaps: By reviewing existing literature, researchers can identify gaps or inconsistencies in knowledge, paving the way for new research questions and hypotheses relevant to their study.
• Theoretical framework development: Facilitates the development of theoretical frameworks by cultivating diverse perspectives and empirical findings. It helps researchers refine their conceptualizations and theoretical models.
• Methodological guidance: Offers methodological guidance by highlighting the documented research methods and techniques used in previous studies. It assists researchers in selecting appropriate research designs, data collection methods, and analytical tools.
• Quality assurance and upholding academic integrity: Conducting a thorough literature review demonstrates the rigor and scholarly integrity of the research. It ensures that researchers are aware of relevant studies and can accurately attribute ideas and findings to their original sources.

Types of Literature Review

Literature review plays a crucial role in guiding the research process , from providing the background of the study to research dissemination and contributing to the synthesis of the latest theoretical literature review findings in academia.

However, not all types of literature reviews are the same; they vary in terms of methodology, approach, and purpose. Let's have a look at the various types of literature reviews to gain a deeper understanding of their applications.

1. Narrative Literature Review

A narrative literature review, also known as a traditional literature review, involves analyzing and summarizing existing literature without adhering to a structured methodology. It typically provides a descriptive overview of key concepts, theories, and relevant findings of the research topic.

Unlike other types of literature reviews, narrative reviews reinforce a more traditional approach, emphasizing the interpretation and discussion of the research findings rather than strict adherence to methodological review criteria. It helps researchers explore diverse perspectives and insights based on the research topic and acts as preliminary work for further investigation.

Steps to Conduct a Narrative Literature Review

Source:- https://www.researchgate.net/figure/Steps-of-writing-a-narrative-review_fig1_354466408

Define the research question or topic:

The first step in conducting a narrative literature review is to clearly define the research question or topic of interest. Defining the scope and purpose of the review includes — What specific aspect of the topic do you want to explore? What are the main objectives of the research? Refine your research question based on the specific area you want to explore.

Conduct a thorough literature search

Once the research question is defined, you can conduct a comprehensive literature search. Explore and use relevant databases and search engines like SciSpace Discover to identify credible and pertinent, scholarly articles and publications.

Select relevant studies

Before choosing the right set of studies, it’s vital to determine inclusion (studies that should possess the required factors) and exclusion criteria for the literature and then carefully select papers. For example — Which studies or sources will be included based on relevance, quality, and publication date?

*Important (applies to all the reviews): Inclusion criteria are the factors a study must include (For example: Include only peer-reviewed articles published between 2022-2023, etc.). Exclusion criteria are the factors that wouldn’t be required for your search strategy (Example: exclude irrelevant papers, preprints, written in non-English, etc.)

Critically analyze the literature

Once the relevant studies are shortlisted, evaluate the methodology, findings, and limitations of each source and jot down key themes, patterns, and contradictions. You can use efficient AI tools to conduct a thorough literature review and analyze all the required information.

Synthesize and integrate the findings

Now, you can weave together the reviewed studies, underscoring significant findings such that new frameworks, contrasting viewpoints, and identifying knowledge gaps.

Discussion and conclusion

This is an important step before crafting a narrative review — summarize the main findings of the review and discuss their implications in the relevant field. For example — What are the practical implications for practitioners? What are the directions for future research for them?

Write a cohesive narrative review

Organize the review into coherent sections and structure your review logically, guiding the reader through the research landscape and offering valuable insights. Use clear and concise language to convey key points effectively.

Structure of Narrative Literature Review

A well-structured, narrative analysis or literature review typically includes the following components:

• Introduction: Provides an overview of the topic, objectives of the study, and rationale for the review.
• Background: Highlights relevant background information and establish the context for the review.
• Main Body: Indexes the literature into thematic sections or categories, discussing key findings, methodologies, and theoretical frameworks.
• Discussion: Analyze and synthesize the findings of the reviewed studies, stressing similarities, differences, and any gaps in the literature.
• Conclusion: Summarizes the main findings of the review, identifies implications for future research, and offers concluding remarks.

Pros and Cons of Narrative Literature Review

• Flexibility in methodology and doesn’t necessarily rely on structured methodologies
• Follows traditional approach and provides valuable and contextualized insights
• Suitable for exploring complex or interdisciplinary topics. For example — Climate change and human health, Cybersecurity and privacy in the digital age, and more
• Subjectivity in data selection and interpretation
• Potential for bias in the review process
• Lack of rigor compared to systematic reviews

Example of Well-Executed Narrative Literature Reviews

Paper title:  Examining Moral Injury in Clinical Practice: A Narrative Literature Review

Source: SciSpace

You can also chat with the papers using SciSpace ChatPDF to get a thorough understanding of the research papers.

While narrative reviews offer flexibility, academic integrity remains paramount. So, ensure proper citation of all sources and maintain a transparent and factual approach throughout your critical narrative review, itself.

2. Systematic Review

A systematic literature review is one of the comprehensive types of literature review that follows a structured approach to assembling, analyzing, and synthesizing existing research relevant to a particular topic or question. It involves clearly defined criteria for exploring and choosing studies, as well as rigorous methods for evaluating the quality of relevant studies.

It plays a prominent role in evidence-based practice and decision-making across various domains, including healthcare, social sciences, education, health sciences, and more. By systematically investigating available literature, researchers can identify gaps in knowledge, evaluate the strength of evidence, and report future research directions.

Steps to Conduct Systematic Reviews

Source:- https://www.researchgate.net/figure/Steps-of-Systematic-Literature-Review_fig1_321422320

Here are the key steps involved in conducting a systematic literature review

Formulate a clear and focused research question

Clearly define the research question or objective of the review. It helps to centralize the literature search strategy and determine inclusion criteria for relevant studies.

Develop a thorough literature search strategy

Design a comprehensive search strategy to identify relevant studies. It involves scrutinizing scientific databases and all relevant articles in journals. Plus, seek suggestions from domain experts and review reference lists of relevant review articles.

Screening and selecting studies

Employ predefined inclusion and exclusion criteria to systematically screen the identified studies. This screening process also typically involves multiple reviewers independently assessing the eligibility of each study.

Data extraction

Extract key information from selected studies using standardized forms or protocols. It includes study characteristics, methods, results, and conclusions.

Critical appraisal

Evaluate the methodological quality and potential biases of included studies. Various tools (BMC medical research methodology) and criteria can be implemented for critical evaluation depending on the study design and research quetions .

Data synthesis

Analyze and synthesize review findings from individual studies to draw encompassing conclusions or identify overarching patterns and explore heterogeneity among studies.

Interpretation and conclusion

Interpret the findings about the research question, considering the strengths and limitations of the research evidence. Draw conclusions and implications for further research.

The final step — Report writing

Craft a detailed report of the systematic literature review adhering to the established guidelines of PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses). This ensures transparency and reproducibility of the review process.

By following these steps, a systematic literature review aims to provide a comprehensive and unbiased summary of existing evidence, help make informed decisions, and advance knowledge in the respective domain or field.

Structure of a systematic literature review

A well-structured systematic literature review typically consists of the following sections:

• Introduction: Provides background information on the research topic, outlines the review objectives, and enunciates the scope of the study.
• Methodology: Describes the literature search strategy, selection criteria, data extraction process, and other methods used for data synthesis, extraction, or other data analysis..
• Results: Presents the review findings, including a summary of the incorporated studies and their key findings.
• Discussion: Interprets the findings in light of the review objectives, discusses their implications, and identifies limitations or promising areas for future research.
• Conclusion: Summarizes the main review findings and provides suggestions based on the evidence presented in depth meta analysis.

*Important (applies to all the reviews): Remember, the specific structure of your literature review may vary depending on your topic, research question, and intended audience. However, adhering to a clear and logical hierarchy ensures your review effectively analyses and synthesizes knowledge and contributes valuable insights for readers.

Pros and Cons of Systematic Literature Review

• Adopts rigorous and transparent methodology
• Minimizes bias and enhances the reliability of the study
• Provides evidence-based insights
• Time and resource-intensive
• High dependency on the quality of available literature (literature research strategy should be accurate)
• Potential for publication bias

Example of Well-Executed Systematic Literature Review

Paper title: Systematic Reviews: Understanding the Best Evidence For Clinical Decision-making in Health Care: Pros and Cons.

Read this detailed article on how to use AI tools to conduct a systematic review for your research!

3. Scoping Literature Review

A scoping literature review is a methodological review type of literature review that adopts an iterative approach to systematically map the existing literature on a particular topic or research area. It involves identifying, selecting, and synthesizing relevant papers to provide an overview of the size and scope of available evidence. Scoping reviews are broader in scope and include a diverse range of study designs and methodologies especially focused on health services research.

The main purpose of a scoping literature review is to examine the extent, range, and nature of existing studies on a topic, thereby identifying gaps in research, inconsistencies, and areas for further investigation. Additionally, scoping reviews can help researchers identify suitable methodologies and formulate clinical recommendations. They also act as the frameworks for future systematic reviews or primary research studies.

Scoping reviews are primarily focused on —

• Emerging or evolving topics — where the research landscape is still growing or budding. Example — Whole Systems Approaches to Diet and Healthy Weight: A Scoping Review of Reviews .
• Broad and complex topics : With a vast amount of existing literature.
• Scenarios where a systematic review is not feasible: Due to limited resources or time constraints.

Steps to Conduct a Scoping Literature Review

While Scoping reviews are not as rigorous as systematic reviews, however, they still follow a structured approach. Here are the steps:

Identify the research question: Define the broad topic you want to explore.

Identify Relevant Studies: Conduct a comprehensive search of relevant literature using appropriate databases, keywords, and search strategies.

Select studies to be included in the review: Based on the inclusion and exclusion criteria, determine the appropriate studies to be included in the review.

Data extraction and charting : Extract relevant information from selected studies, such as year, author, main results, study characteristics, key findings, and methodological approaches.  However, it varies depending on the research question.

Collate, summarize, and report the results: Analyze and summarize the extracted data to identify key themes and trends. Then, present the findings of the scoping review in a clear and structured manner, following established guidelines and frameworks .

Structure of a Scoping Literature Review

A scoping literature review typically follows a structured format similar to a systematic review. It includes the following sections:

• Introduction: Introduce the research topic and objectives of the review, providing the historical context, and rationale for the study.
• Methods : Describe the methods used to conduct the review, including search strategies, study selection criteria, and data extraction procedures.
• Results: Present the findings of the review, including key themes, concepts, and patterns identified in the literature review.
• Discussion: Examine the implications of the findings, including strengths, limitations, and areas for further examination.
• Conclusion: Recapitulate the main findings of the review and their implications for future research, policy, or practice.

Pros and Cons of Scoping Literature Review

• Provides a comprehensive overview of existing literature
• Helps to identify gaps and areas for further research
• Suitable for exploring broad or complex research questions
• Doesn’t provide the depth of analysis offered by systematic reviews
• Subject to researcher bias in study selection and data extraction
• Requires careful consideration of literature search strategies and inclusion criteria to ensure comprehensiveness and validity.

In short, a scoping review helps map the literature on developing or emerging topics and identifying gaps. It might be considered as a step before conducting another type of review, such as a systematic review. Basically, acts as a precursor for other literature reviews.

Example of a Well-Executed Scoping Literature Review

Paper title: Health Chatbots in Africa Literature: A Scoping Review

Check out the key differences between Systematic and Scoping reviews — Evaluating literature review: systematic vs. scoping reviews

4. Integrative Literature Review

Integrative Literature Review (ILR) is a type of literature review that proposes a distinctive way to analyze and synthesize existing literature on a specific topic, providing a thorough understanding of research and identifying potential gaps for future research.

Unlike a systematic review, which emphasizes quantitative studies and follows strict inclusion criteria, an ILR embraces a more pliable approach. It works beyond simply summarizing findings — it critically analyzes, integrates, and interprets research from various methodologies (qualitative, quantitative, mixed methods) to provide a deeper understanding of the research landscape. ILRs provide a holistic and systematic overview of existing research, integrating findings from various methodologies. ILRs are ideal for exploring intricate research issues, examining manifold perspectives, and developing new research questions.

Steps to Conduct an Integrative Literature Review

• Identify the research question: Clearly define the research question or topic of interest as formulating a clear and focused research question is critical to leading the entire review process.
• Literature search strategy: Employ systematic search techniques to locate relevant literature across various databases and sources.
• Evaluate the quality of the included studies : Critically assess the methodology, rigor, and validity of each study by applying inclusion and exclusion criteria to filter and select studies aligned with the research objectives.
• Data Extraction: Extract relevant data from selected studies using a structured approach.
• Synthesize the findings : Thoroughly analyze the selected literature, identify key themes, and synthesize findings to derive noteworthy insights.
• Critical appraisal: Critically evaluate the quality and validity of qualitative research and included studies by using BMC medical research methodology.
• Interpret and present your findings: Discuss the purpose and implications of your analysis, spotlighting key insights and limitations. Organize and present the findings coherently and systematically.

Structure of an Integrative Literature Review

• Introduction : Provide an overview of the research topic and the purpose of the integrative review.
• Methods: Describe the opted literature search strategy, selection criteria, and data extraction process.
• Results: Present the synthesized findings, including key themes, patterns, and contradictions.
• Discussion: Interpret the findings about the research question, emphasizing implications for theory, practice, and prospective research.
• Conclusion: Summarize the main findings, limitations, and contributions of the integrative review.

Pros and Cons of Integrative Literature Review

• Informs evidence-based practice and policy to the relevant stakeholders of the research.
• Contributes to theory development and methodological advancement, especially in the healthcare arena.
• Integrates diverse perspectives and findings
• Time-consuming process due to the extensive literature search and synthesis
• Requires advanced analytical and critical thinking skills
• Potential for bias in study selection and interpretation
• The quality of included studies may vary, affecting the validity of the review

Example of Integrative Literature Reviews

Paper Title: An Integrative Literature Review: The Dual Impact of Technological Tools on Health and Technostress Among Older Workers

5. Rapid Literature Review

A Rapid Literature Review (RLR) is the fastest type of literature review which makes use of a streamlined approach for synthesizing literature summaries, offering a quicker and more focused alternative to traditional systematic reviews. Despite employing identical research methods, it often simplifies or omits specific steps to expedite the process. It allows researchers to gain valuable insights into current research trends and identify key findings within a shorter timeframe, often ranging from a few days to a few weeks — unlike traditional literature reviews, which may take months or even years to complete.

When to Consider a Rapid Literature Review?

• When time impediments demand a swift summary of existing research
• For emerging topics where the latest literature requires quick evaluation
• To report pilot studies or preliminary research before embarking on a comprehensive systematic review

Steps to Conduct a Rapid Literature Review

• Define the research question or topic of interest. A well-defined question guides the search process and helps researchers focus on relevant studies.
• Determine key databases and sources of relevant literature to ensure comprehensive coverage.
• Develop literature search strategies using appropriate keywords and filters to fetch a pool of potential scientific articles.
• Screen search results based on predefined inclusion and exclusion criteria.
• Extract and summarize relevant information from the above-preferred studies.
• Synthesize findings to identify key themes, patterns, or gaps in the literature.
• Prepare a concise report or a summary of the RLR findings.

Structure of a Rapid Literature Review

An effective structure of an RLR typically includes the following sections:

• Introduction: Briefly introduce the research topic and objectives of the RLR.
• Methodology: Describe the search strategy, inclusion and exclusion criteria, and data extraction process.
• Results: Present a summary of the findings, including key themes or patterns identified.
• Discussion: Interpret the findings, discuss implications, and highlight any limitations or areas for further research
• Conclusion: Summarize the key findings and their implications for practice or future research

Pros and Cons of Rapid Literature Review

• RLRs can be completed quickly, authorizing timely decision-making
• RLRs are a cost-effective approach since they require fewer resources compared to traditional literature reviews
• Offers great accessibility as RLRs provide prompt access to synthesized evidence for stakeholders
• RLRs are flexible as they can be easily adapted for various research contexts and objectives
• RLR reports are limited and restricted, not as in-depth as systematic reviews, and do not provide comprehensive coverage of the literature compared to traditional reviews.
• Susceptible to bias because of the expedited nature of RLRs. It would increase the chance of overlooking relevant studies or biases in the selection process.
• Due to time constraints, RLR findings might not be robust enough as compared to systematic reviews.

Example of a Well-Executed Rapid Literature Review

Paper Title: What Is the Impact of ChatGPT on Education? A Rapid Review of the Literature

A Summary of Literature Review Types

Tools and Resources for Conducting Different Types of Literature Reviews

Online scientific databases.

Platforms such as SciSpace , PubMed , Scopus , Elsevier , and Web of Science provide access to a vast array of scholarly literature, facilitating the search and data retrieval process.

Reference management software

Tools like SciSpace Citation Generator , EndNote, Zotero , and Mendeley assist researchers in organizing, annotating, and citing relevant literature, streamlining the review process altogether.

Automate Literature Review with AI tools

Automate the literature review process by using tools like SciSpace literature review which helps you compare and contrast multiple papers all on one screen in an easy-to-read matrix format. You can effortlessly analyze and interpret the review findings tailored to your study. It also supports the review in 75+ languages, making it more manageable even for non-English speakers.

Goes without saying — literature review plays a pivotal role in academic research to identify the current trends and provide insights to pave the way for future research endeavors. Different types of literature review has their own strengths and limitations, making them suitable for different research designs and contexts. Whether conducting a narrative review, systematic review, scoping review, integrative review, or rapid literature review, researchers must cautiously consider the objectives, resources, and the nature of the research topic.

If you’re currently working on a literature review and still adopting a manual and traditional approach, switch to the automated AI literature review workspace and transform your traditional literature review into a rapid one by extracting all the latest and relevant data for your research!

There you go!

Frequently Asked Questions

Narrative reviews give a general overview of a topic based on the author's knowledge. They may lack clear criteria and can be biased. On the other hand, systematic reviews aim to answer specific research questions by following strict methods. They're thorough but time-consuming.

A systematic review collects and analyzes existing research to provide an overview of a topic, while a meta-analysis statistically combines data from multiple studies to draw conclusions about the overall effect of an intervention or relationship between variables.

A systematic review thoroughly analyzes existing research on a specific topic using strict methods. In contrast, a scoping review offers a broader overview of the literature without evaluating individual studies in depth.

A systematic review thoroughly examines existing research using a rigorous process, while a rapid review provides a quicker summary of evidence, often by simplifying some of the systematic review steps to meet shorter timelines.

A systematic review carefully examines many studies on a single topic using specific guidelines. Conversely, an integrative review blends various types of research to provide a more comprehensive understanding of the topic.

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Strengths and Weaknesses of Systematic Reviews

Automate every stage of your literature review to produce evidence-based research faster and more accurately.

Systematic reviews are considered credible sources since they are comprehensive, reproducible, and precise in stating the outcomes. The type of review system used and the approach taken depend on the goals and objectives of the research. To choose the best-suited review system, researchers must be aware of the strengths and weaknesses of each one.

Let us now look at the strengths and limitations of systematic reviews.

Strengths Of Systematic Reviews

Systematic reviews have become increasingly popular owing to their transparency, accuracy, replicability, and reduced risk of bias. Some of the main benefits of systematic reviews are;

Specificity

Researchers can answer specific research questions of high importance. For example, the efficacy of a particular drug in the treatment of an illness.

Explicit Methodology

A systematic review requires rigorous planning. Each stage of the review is predefined to the last detail. The research question is formulated using the PICO (population, intervention, comparison, and outcome) approach. A strict eligibility criteria is then established for inclusion and exclusion criteria for selecting the primary studies for the review. Every stage of the systematic review methodology is pre-specified to the last detail and made publicly available, even before starting the review process. This makes all the stages in the methodology transparent and reproducible.

Reliable And Accurate Results

The results of a systematic review are either analyzed qualitatively and presented as a textual narrative or quantitatively using statistical methods such as meta-analyses and numeric effect estimates. The quality of evidence or the confidence in effect estimates is calculated using the standardized GRADE approach.

Comprehensive And Exhaustive

A systematic review involves a thorough search of all the available data on a certain topic. It is exhaustive and considers every bit of evidence in synthesizing the outcome. Primary sources for the review are collected from databases and multiple sources, such as blogs from pharmaceutical companies, unpublished research directly from researchers, government reports, and conference proceedings. These are referred to as grey literature. The search criteria and keywords used in sourcing are specific and predefined.

Reproducible

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Weaknesses Of Systematic Reviews

Although systematic reviews are robust tools in scientific research they are not immune to errors. They can be misleading, or even harmful if the data is inappropriately handled or if they are biased. Some of the limitations of systematic reviews include:

Mass Production

Due to the popularity systematic reviews have gained, they tend to be used more than required. The growth rate of systematic reviews has outpaced the growth rate of studies overall. This results in redundancy. For example, a survey published in the BMJ[1], included 73 randomly selected meta-analyses published in 2010 found that for two-thirds of these studies, there was at least one, and sometimes as many as 13, additional meta-analyses published on the same topic by early 2013.

Risk of Bias

Although systematic reviews have many advantages, they are also more susceptible to certain types of biases. A bias is a systematic or methodological error that causes misrepresentation of the study outcomes. As bias can appear at any stage, authors should be aware of the specific risks at each stage of the review process. Most of the known errors in systematic reviews arise in the selection and publication stages. The eligibility criterion in a systematic review helps to avoid selection bias. Poor study design and execution can also result in a biased outcome. It’s important to learn about the types of bias in systematic reviews .

Expressing Strong Opinions by Stealth

Selective outcome reporting is a major threat to a systematic review. The author or reviewer may decide to only report a selection of the statistically significant outcomes that suit his interest. The possibility of unfair or misleading interpretation of evidence outcomes in a systematic review can have serious implications.

Like any review system, systematic reviews have their advantages and disadvantages. Understanding them is essential to making a choice of which review system to use.

Overlapping meta-analyses on the same topic: survey of published studies. BMJ 2013; 347:f4501

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Neal Haddaway

October 19th, 2020, 8 common problems with literature reviews and how to fix them.

3 comments | 320 shares

Estimated reading time: 5 minutes

Literature reviews are an integral part of the process and communication of scientific research. Whilst systematic reviews have become regarded as the highest standard of evidence synthesis, many literature reviews fall short of these standards and may end up presenting biased or incorrect conclusions. In this post, Neal Haddaway highlights 8 common problems with literature review methods, provides examples for each and provides practical solutions for ways to mitigate them.

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Researchers regularly review the literature – it’s an integral part of day-to-day research: finding relevant research, reading and digesting the main findings, summarising across papers, and making conclusions about the evidence base as a whole. However, there is a fundamental difference between brief, narrative approaches to summarising a selection of studies and attempting to reliably and comprehensively summarise an evidence base to support decision-making in policy and practice.

So-called ‘evidence-informed decision-making’ (EIDM) relies on rigorous systematic approaches to synthesising the evidence. Systematic review has become the highest standard of evidence synthesis and is well established in the pipeline from research to practice in the field of health . Systematic reviews must include a suite of specifically designed methods for the conduct and reporting of all synthesis activities (planning, searching, screening, appraising, extracting data, qualitative/quantitative/mixed methods synthesis, writing; e.g. see the Cochrane Handbook ). The method has been widely adapted into other fields, including environment (the Collaboration for Environmental Evidence ) and social policy (the Campbell Collaboration ).

Despite the growing interest in systematic reviews, traditional approaches to reviewing the literature continue to persist in contemporary publications across disciplines. These reviews, some of which are incorrectly referred to as ‘systematic’ reviews, may be susceptible to bias and as a result, may end up providing incorrect conclusions. This is of particular concern when reviews address key policy- and practice- relevant questions, such as the ongoing COVID-19 pandemic or climate change.

These limitations with traditional literature review approaches could be improved relatively easily with a few key procedures; some of them not prohibitively costly in terms of skill, time or resources.

In our recent paper in Nature Ecology and Evolution , we highlight 8 common problems with traditional literature review methods, provide examples for each from the field of environmental management and ecology, and provide practical solutions for ways to mitigate them.

There is a lack of awareness and appreciation of the methods needed to ensure systematic reviews are as free from bias and as reliable as possible: demonstrated by recent, flawed, high-profile reviews. We call on review authors to conduct more rigorous reviews, on editors and peer-reviewers to gate-keep more strictly, and the community of methodologists to better support the broader research community. Only by working together can we build and maintain a strong system of rigorous, evidence-informed decision-making in conservation and environmental management.

Note: This article gives the views of the authors, and not the position of the LSE Impact Blog, nor of the London School of Economics. Please review our  comments policy  if you have any concerns on posting a comment below

Image credit:  Jaeyoung Geoffrey Kang  via unsplash

About the author

Neal Haddaway is a Senior Research Fellow at the Stockholm Environment Institute, a Humboldt Research Fellow at the Mercator Research Institute on Global Commons and Climate Change, and a Research Associate at the Africa Centre for Evidence. He researches evidence synthesis methodology and conducts systematic reviews and maps in the field of sustainability and environmental science. His main research interests focus on improving the transparency, efficiency and reliability of evidence synthesis as a methodology and supporting evidence synthesis in resource constrained contexts. He co-founded and coordinates the Evidence Synthesis Hackathon (www.eshackathon.org) and is the leader of the Collaboration for Environmental Evidence centre at SEI. @nealhaddaway

Why is mission creep a problem and not a legitimate response to an unexpected finding in the literature? Surely the crucial points are that the review’s scope is stated clearly and implemented rigorously, not when the scope was finalised.

• Pingback: Quick, but not dirty – Can rapid evidence reviews reliably inform policy? | Impact of Social Sciences

#9. Most of them are terribly boring. Which is why I teach students how to make them engaging…and useful.

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Systematic reviews: the good, the bad, and the ugly

Affiliation.

• 1 Division of Gastroenterology, Department of Medicine, McMaster University Health Science Centre, Hamilton, Ontario, Canada.
• PMID: 19417748
• DOI: 10.1038/ajg.2009.118

Systematic reviews systematically evaluate and summarize current knowledge and have many advantages over narrative reviews. Meta-analyses provide a more reliable and enhanced precision of effect estimate than do individual studies. Systematic reviews are invaluable for defining the methods used in subsequent studies, but, as retrospective research projects, they are subject to bias. Rigorous research methods are essential, and the quality depends on the extent to which scientific review methods are used. Systematic reviews can be misleading, unhelpful, or even harmful when data are inappropriately handled; meta-analyses can be misused when the difference between a patient seen in the clinic and those included in the meta-analysis is not considered. Furthermore, systematic reviews cannot answer all clinically relevant questions, and their conclusions may be difficult to incorporate into practice. They should be reviewed on an ongoing basis. As clinicians, we need proper methodological training to perform good systematic reviews and must ask the appropriate questions before we can properly interpret such a review and apply its conclusions to our patients. This paper aims to assist in the reading of a systematic review.

PubMed Disclaimer

• Was it really an "ugly" meta-analysis? Fuccio L, Eusebi LH, Bazzoli F. Fuccio L, et al. Am J Gastroenterol. 2009 Nov;104(11):2853; author reply 2853-4. doi: 10.1038/ajg.2009.458. Am J Gastroenterol. 2009. PMID: 19888243 No abstract available.

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JSmol Viewer

Silver nanoparticles: a comprehensive review of synthesis methods and chemical and physical properties.

1. Introduction

2. properties of silver nanoparticles.

Click here to enlarge figure

2.3. Surface Charge

2.4. electrical conductivity and melting point, 2.5. thermal conductivity, 2.6. optical properties, 2.7. antibacterial activity.

2.7.1. Effect of Size on Antibacterial Activity

2.7.2. effect of shape on antibacterial activity, 2.7.3. effect of surface charge on antibacterial activity, 2.7.4. effect of surface functionalization on antibacterial activity, 2.8. antifungal activity.

2.9. Antiviral Activity

2.10. Anticancer Activity

2.11. Anti-Inflammatory Activity

3. Synthesis of Silver Nanoparticles

3.1. physical methods, 3.1.1. ball milling method, 3.1.2. laser ablation method, 3.1.3. vapor condensation method, 3.1.4. electrical arc-discharge method, 3.2. chemical methods, 3.2.1. chemical reduction, 3.2.2. electrochemical synthetic method, 3.2.3. microwave-assisted synthesis, 3.2.4. photoinduced reduction, 3.2.5. microemulsion techniques, 3.3. bio-based (green-synthesized) methods, 3.3.1. plants, 3.3.2. algae, 3.3.3. fungi, 3.3.4. bacteria.

3.4. Factors Affecting Silver NP Synthesis and Their Stability

3.4.1. factors affecting silver np synthesis, 3.4.2. factors affecting silver np stability, 4. toxicity, 5. conclusions and future trends, author contributions, conflicts of interest.

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Duman, H.; Eker, F.; Akdaşçi, E.; Witkowska, A.M.; Bechelany, M.; Karav, S. Silver Nanoparticles: A Comprehensive Review of Synthesis Methods and Chemical and Physical Properties. Nanomaterials 2024 , 14 , 1527. https://doi.org/10.3390/nano14181527

Duman H, Eker F, Akdaşçi E, Witkowska AM, Bechelany M, Karav S. Silver Nanoparticles: A Comprehensive Review of Synthesis Methods and Chemical and Physical Properties. Nanomaterials . 2024; 14(18):1527. https://doi.org/10.3390/nano14181527

Duman, Hatice, Furkan Eker, Emir Akdaşçi, Anna Maria Witkowska, Mikhael Bechelany, and Sercan Karav. 2024. "Silver Nanoparticles: A Comprehensive Review of Synthesis Methods and Chemical and Physical Properties" Nanomaterials 14, no. 18: 1527. https://doi.org/10.3390/nano14181527

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• Published: 18 September 2024

Comprehensive review of composition, properties, clinical applications, and future perspectives of calcium-enriched mixture (CEM) cement: a systematic analysis

• Saeed Asgary 1 ,
• Mahtab Aram 2 &
• Mahta Fazlyab 3  

BioMedical Engineering OnLine volume  23 , Article number:  96 ( 2024 ) Cite this article

24 Accesses

Metrics details

This review aims to comprehensively explore calcium-enriched mixture (CEM) cement as a crucial biomaterial in dentistry/endodontics. With its growing clinical relevance, there is a need to evaluate its composition, chemical/physical/biological properties, clinical applications, and future perspectives to provide clinicians/researchers with a detailed understanding of its potential in endodontic procedures. Through systematic analysis of available evidence, we assess the advantages/limitations of CEM cement, offering valuable insights for informed decision-making in dental/endodontic practice. Our findings highlight the commendable chemical/physical properties of CEM cement, including handling characteristics, alkalinity, color stability, bioactivity, biocompatibility, sealing ability, and antimicrobial properties. Importantly, CEM cement has shown the potential in promoting regenerative processes, such as dentinogenesis and cementogenesis. It has demonstrated successful outcomes in various clinical applications, including vital pulp therapy techniques, endodontic surgery, open apices management, root resorption/perforation repair, and as an orifice/root canal obturation material. The efficacy and reliability of CEM cement in diverse clinical scenarios underscore its effectiveness in endodontic practice. However, we emphasize the need for well-designed clinical trials with long-term follow-up to further substantiate the full potential of CEM cement. This review serves as a robust reference for researchers/practitioners, offering an in-depth exploration of CEM cement and its multifaceted roles in contemporary dentistry/endodontics.

The success of endodontic therapy relies on various factors, including effective root canal instrumentation and obturation techniques. Throughout the years, numerous materials and techniques have been developed to optimize treatment outcomes in endodontics. One promising endodontic biomaterial that has gained significant attention is calcium-enriched mixture (CEM) cement [ 1 ]. Similar to mineral trioxide aggregate (MTA), CEM cement is a type of calcium-silicate cement (CSC) that contains calcium compounds [ 2 ], which give it distinctive properties like biocompatibility, alkalinity, and bioactivity. As a result, CEM cement has gained significant attention in vital pulp therapy (VPT) within the field of endodontics [ 3 ]. Recognizing its potential advantages in various endodontic procedures, including sealing ability, biocompatibility, and release of bioactive ions promoting successful healing and treatment outcomes [ 4 ], CEM cement has emerged as a cornerstone in contemporary endodontics.

The composition, properties, and clinical efficacy of CEM cement form the crux of understanding and optimizing its application in endodontic treatments [ 5 ]. Responding to the growing interest and the emergence of newer CSCs in endodontics [ 6 ], this article aims to provide a more nuanced perspective by addressing the research gap and highlighting the novelty of CEM cement. Through a rigorous assessment of available evidence and analysis of relevant studies, this review delves deeper into the multifaceted aspects of CEM cement. By enabling clinicians/researchers to make informed decisions and advancements, the comprehensive review paves the way for the next phase of endodontic research. This comprehensive overview aims to summarize published studies on CEM cement. However, it is important to acknowledge certain limitations in our search strategy. As detailed in the Methods section (Sect. " Methods of searching existing literature "), we conducted comprehensive searches across multiple electronic databases and reviewed reference lists from relevant articles. Despite these efforts, our search was confined to published studies available in English, and we did not include a specific search for grey literature. Consequently, this may have led to the exclusion of some relevant studies, particularly those found in the grey literature, which could impact the comprehensiveness of our review.

Methods of searching existing literature

Objectives of the review.

To discuss the composition and physical/chemical/biological properties of CEM cement.

To provide an understanding of the clinical applications of CEM cement in endodontics.

To examine the available evidence and level of research supporting the use of CEM cement in clinical endodontics.

To evaluate the limitations and potential challenges associated with the use of CEM cement in endodontics.

To propose future perspectives and potential advancements of CEM cement applications in clinical endodontics.

Search methodology

A comprehensive search strategy was implemented to identify relevant studies for this review. Electronic databases, including MEDLINE (via PubMed), Embase, and Scopus, were searched to retrieve articles published from the inception of the databases to June 2023. The search terms used were "CEM cement" and "calcium-enriched mixture cement".

The search strategy adhered to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Keywords and MeSH terms were selected based on initial exploratory searches and expert consultation. The detailed search strategy for PubMed is tabulated to facilitate replication by other researchers (Table  1 ).

The screening process involved the review of titles/abstracts to assess the relevance of articles to the review topic. Full-text articles that met the inclusion criteria were further evaluated for data extraction/analysis. Additionally, the references of selected articles were examined to identify any additional relevant studies that may have been missed during the initial search. The final search results were exported into EndNote, and duplicates were removed.

Inclusion criteria

Studies that investigate CEM cement and provide information on the composition, properties, clinical applications, and future perspectives.

Clinical/laboratory studies, systematic reviews, and meta-analyses.

Exclusion criteria

Studies not relevant to the topic of CEM cement.

Conference abstracts and letters to the editor.

PRISMA flowchart

A PRISMA flowchart (Fig.  1 ) is included in the revised manuscript to illustrate the selection process, showing the number of records identified, screened, and included in the review.

PRISMA flow diagram

Risk-of-bias assessment

Although risk-of-bias assessments are crucial in systematic reviews, our study’s primary goal is to provide a broad synthesis of the evidence related to CEM cement rather than performing a meta-analysis of specific outcomes. Due to the variability in study designs, outcomes, and reporting standards among the included studies, conducting a formal risk-of-bias assessment was deemed less relevant. Instead, we have concentrated on summarizing the overall trends and common findings identified in the literature.

Article structure and details

For a detailed overview of the article structure and specifics, please refer to Appendix 1 , which outlines the comprehensive organization and content of the review.

Composition and properties of CEM cement

Chemical composition.

CEM cement is a member of calcium-silicate cements (CSC) characterized by its specific chemical composition, which plays a crucial role in its performance and clinical applications. Scanning electron microscopy (SEM) and electron probe microanalysis (EPMA) have revealed that CEM cement predominantly consists of calcium oxide (CaO; wt% = 51.81), sulfur trioxide (SO 3 ; wt% = 9.48), phosphorous pentoxide (P 2 O 5 ; wt% = 8.52), and silicon dioxide (SiO 2 ; wt% = 6.28). Trace amounts of other elements, including aluminum oxide (Al 2 O 3 ; wt% = 0.95), sodium oxide (Na 2 O; wt% = 0.35), magnesium oxide (MgO; wt% = 0.23), and chlorine (Cl; wt% = 0.18), are also present [ 7 ]. The X-ray diffraction (XRD) results further elucidate the mineralogical content of CEM cement, revealing reflections corresponding to tricalcium silicate (Ca3SiO5), dicalcium silicate (Ca2SiO4), silicon oxide (SiO2), and zirconium oxide (ZrO2), providing insights into the crystalline phases present in the material (unpublished data).

EPMA has shown similar distribution patterns of calcium, phosphorus, and oxygen between CEM cement and the surrounding dentin, indicating its compatibility with dental tissues. However, significant elemental variations have been observed in other CSCs, emphasizing the distinctive composition of CEM cement [ 8 ].

The notable concentrations of calcium, phosphorus, and silicon in CEM cement significantly influence its physical/chemical reactions, as well as its interactions with dental tissues. Calcium enhances bioactivity by promoting hydroxyapatite formation, which improves the cement’s bonding and mineralization capabilities. Phosphorus aids in this process by facilitating the formation of a mineralized layer that integrates with dental tissues and maintains a favorable pH balance. Silicon, present as silica, reacts with calcium to form calcium-silicate hydrate, which contributes to the cement’s strength, durability, and resistance to dissolution. Optimal levels of these elements contribute to the bioactivity, biocompatibility, and mechanical properties of CEM cement, making it suitable for a wide range of endodontic procedures [ 2 ].

The liquid used for mixing, phosphate-buffered saline (PBS) solution, is a critical component influencing the performance of CEM cement, particularly in its water-reactive characteristics.

Physical properties

Handling characteristics.

Handling characteristics of CEM cement are crucial for its successful clinical application and ease of use during endodontic procedures. These properties determine its workability, manipulability, and ability to achieve optimal placement [ 9 ]. When the powder and liquid components of CEM cement are mixed, it results in a homogeneous white mixture with a smooth and creamy consistency.

One important aspect of handling characteristics is the working and setting time of CEM cement. According to ISO 6876-2001, the working time of CEM cement is almost similar to that of ProRoot MTA (average of 4.5 ± 0.77 min and 5 ± 0.79 min for CEM and ProRoot MTA, respectively). However, CEM cement has a shorter setting time, typically around 50 ± 7.5 min, as opposed to 70 ± 8.5 min for ProRoot MTA [ 7 ].

The flowability of CEM cement is significantly higher than that of ProRoot MTA, with a measurement of approximately 14 ± 1 mm compared to 10 ± 0.79 mm for ProRoot MTA [ 7 ]. This improved flowability allows CEM cement to easily penetrate the cavity, reach difficult-to-access areas, and effectively fill and seal irregularities. It plays a crucial role in preventing microleakage and ensuring a more reliable seal.

Furthermore, the film thickness of CEM cement is significantly thinner than that of ProRoot MTA, with an average thickness of approximately 174 ± 25 µm (452 ± 63 µm for ProRoot MTA) [ 7 ]. This allows for better adaptation and closer contact of the cement to the root canal walls, improving the quality of the seal and reducing the potential for microleakage. Additionally, CEM cement exhibits minimal dimensional changes compared to ProRoot MTA, with an average of 0.075 ± 0.032 mm, further contributing to its handling characteristics [ 7 ].

In summary, the smooth and creamy consistency of CEM ensures ease of use and precise placement. Properties comparable to/better than ProRoot MTA, including similar working time, shorter setting time, higher flowability, thinner film thickness, and minimal dimensional changes, make it a suitable choice for endodontic procedures.

Setting reaction

CEM cement undergoes complex chemical reactions during setting. The setting reaction of CEM cement is a critical process during which transformation from a flowable and creamy consistency to a solid and stable state occurs.

The setting process of CEM cement, similar to other CSCs, involves the reactions of tricalcium silicate and dicalcium silicate during hydration, resulting in the formation of calcium-silicate hydrate gel and calcium hydroxide [Ca(OH) 2 ; CH] [ 10 ]. This gel-like substance provides initial cohesion and strength to the mixed cement. Additionally, the reaction between calcium and phosphorus ions contributes to the formation of hydroxyapatite [ 11 ], which is essential for the regeneration and remineralization of hard tissues. The alkaline pH of CEM cement is a result of the release of CH during the setting reaction [ 12 ]. This alkalinity provides the material with antimicrobial properties and supports the stimulation of hard-tissue formation.

Mixing and placing methods

The mixing and placing methods employed during the handling of CEM cement can have a significant impact on its properties and performance in endodontic procedures. Several studies have investigated the influence of different mixing techniques on various aspects of CEM cement, such as compressive strength, pH, solubility, and push-out bond strength [ 13 , 14 , 15 , 16 , 17 ]. Based on the ISO 6876:2012 standard, it has been demonstrated that an increased water-to-powder ratio leads to a reduction in compressive strength, an elevation in solubility, and a decrease in the microhardness of CEM cement [ 18 , 19 ].

Furthermore, a systematic review conducted in 2019 assessed the impact of different mixing methods on various properties of CEM cement, including bacterial microleakage, push-out bond strength, flow rate, compressive strength, solubility, pH, film thickness, dimensional changes, working time, setting time, and the quality of the apical plug [ 20 ]. While no single mixing method was found to enhance all properties simultaneously, mechanical and manual methods generally showed better effectiveness compared to the ultrasonic method in improving specific properties of CEM cement [ 20 ].

These findings highlight the importance of proper mixing and placing techniques for CEM cement to achieve desired outcomes in endodontic procedures. Clinicians should consider the specific properties they aim to optimize and choose an appropriate mixing method accordingly. Mechanical and manual methods are generally recommended for better overall effectiveness.

Release of ions and pH

CEM cement is recognized for its capacity to release calcium (Ca 2 + ) and phosphate (PO 4 3− ) ions from indigenous sources over time, which facilitates the formation of mineralized tissues such as dentin and cementum [ 11 ]. Notably, studies have demonstrated that CEM cement exhibits a significantly higher release of phosphate ions during the first hour after mixing compared to other materials [ 12 ]. Furthermore, the setting reaction of CEM cement generates hydroxyl ions (OH − ), leading to an elevated pH level [ 12 ]. This alkaline pH environment offers various advantages, including antimicrobial properties and favorable interactions with dental tissues.

Effect of environment

The effect of different environmental conditions on the behavior of CEM cement has been investigated in several studies, encompassing storage solutions, blood contamination, solvents, and variations in pH [ 11 , 21 , 22 , 23 , 24 , 25 , 26 ].

One study demonstrated that the choice of storage solution affects the surface topography of root-end fillings, with CEM cement showing greater hydroxyapatite formation in phosphate buffer solution compared to normal saline solution [ 11 ]. Another study evaluated the impact of blood contamination on CEM cement, revealing that while it does not affect compressive strength, the incorporation of blood renders the cement more brittle [ 21 ]. Additionally, the response of CEM cement to different solvents was assessed, with solvents found to be more effective in reducing the microhardness of Angelus MTA compared to CEM cement [ 22 ].

The effect of blood exposure on push-out bond strength was examined, showing an influence on various CSCs, including CEM cement. After exposure to blood, the push-out bond strength of all materials increased over time [ 23 ]. The application of different bleaching agents on the microstructure of set CEM cement was also investigated, revealing variations in the mean elemental distribution of completely set CEM cement when exposed to sodium perborate, carbamide peroxide, and hydrogen peroxide [ 24 ]. Furthermore, surface microstructure analysis of CEM cement and other bioceramic materials under different pH conditions provided insights into their behavior [ 25 ]. Studies exploring the microstructure and chemical analysis of various CSCs, including CEM cement, under different environmental conditions, have highlighted the impairment of CH formation in the presence of blood and acid exposures in ProRoot MTA and CEM cement [ 26 ]. The influence of pH on the physical properties of CEM cement and ProRoot MTA was examined in another study. The surface microhardness and setting time of the cements were evaluated when exposed to acidic, neutral, and alkaline solutions. The results revealed that CEM cement exhibited a faster setting time compared to ProRoot MTA. However, both cements were negatively affected by acidic pH. Furthermore, the surface topography and elemental composition of the cements were altered in different pH environments [ 27 ].

Overall, these studies provide valuable insights into the behavior of CEM cement under different environmental conditions, helping to optimize its clinical application.

Compressive strength

Two studies have explored the factors influencing the compressive strength of CEM cement. In one study, the effect of acid etching procedures on the compressive strength of four CSCs, including CEM cement, was evaluated. The results demonstrated that acid etching harmed mechanical properties and compressive strength of all tested CSCs [ 28 ]. Another study indicated that the addition of propylene glycol to Angelus MTA and CEM cement affected the compressive strength of both biomaterials [ 29 ].

Flexural strength

The flexural strength of CEM cement has been the subject of investigation in several studies, which have compared it with other materials such as MTA, BioAggregate, and CH. In one study, the flexural strength of Angelus MTA, CEM cement, and BioAggregate was compared according to the ISO 4049 standard, revealing significant differences among the three materials [ 30 ]. Another study evaluated the short-term effect of CH, ProRoot MTA, and CEM cement on the strength of bovine root dentin, showing that both MTA and CEM cement caused a decrease in the flexural strength of bovine root dentin, similar to CH [ 31 ].

Furthermore, a study examined the long-term impact of CEM cement, Angelus MTA, and CH on the flexural strength of bovine dentin. The findings indicated that after 1 year, the flexural strength of dentin decreased in CH and Angelus MTA groups, while the samples exposed to CEM cement maintained their initial strength [ 32 ].

Push-out strength

The push-out bond strength of CEM cement has been extensively investigated in various research studies. One study compared the bond strength of CEM cement and ProRoot MTA in root-end cavities prepared using either ultrasonic or Er,Cr:YSGG laser, demonstrating comparable bond strength of CEM and ProRoot MTA which was higher in ultrasonically prepared cavities [ 33 ]. Another study emphasized the importance of smear layer removal for achieving higher push-out bond strength in CEM cement [ 34 ]. Comparative evaluations of different MTA formulations and CEM cement have provided valuable insights into their push-out bond strength [ 35 ].

The effect of an alkaline environment on the push-out bond strength of CEM cement has been investigated, contributing to our understanding of its mechanical properties [ 36 ]. Placement of CH before CEM cement in simulated furcation perforations has been shown to improve the bond strength [ 37 ]. Furthermore, the impact of calcium chloride on the push-out bond strength of CEM cement and Angelus MTA was explored, revealing an increase in bond strength over time for CEM cement, while the addition of calcium chloride decreased the strength of Angelus MTA [ 38 ].

Comparative evaluations of various endodontic irrigants on the push-out bond strength of CEM cement and ProRoot MTA have demonstrated higher bond strength for CEM cement, with an increase over time [ 15 ]. Dentin conditioning using a diode and Er:YAG laser has enhanced the bond strength of CEM cement and other CSCs [ 39 ]. Studies have shown no adverse effects of intracanal medicaments on the push-out bond strength of CEM cement [ 40 , 41 ]. Laser-assisted retrograde cavity preparation has also been found to impact the push-out bond strength of CEM cement and Angelus MTA [ 42 ].

Comparative evaluations of retrograde root-end filling materials, including CEM cement and Biodentine, have provided insights into their push-out bond strength [ 43 ]. Additionally, comparisons between Root MTA and CEM cement have further contributed to understanding their bonding characteristics [ 44 ]. The push-out bond strength of two CSCs used for the repair of artificial furcal perforations has been influenced by different power outputs of Nd:YAG laser [ 45 ]. These studies collectively enhance our understanding of the push-out bond strength of CEM cement and its performance in various clinical scenarios.

Bond strength

Bond strength directly influences the durability and effectiveness of restorative procedures and a strong bond is essential for the long-term stability and success of dental restorations [ 46 ]. Understanding the bond strength properties of dental materials is crucial for optimizing bonding techniques, selecting appropriate materials, and achieving successful clinical outcomes [ 47 ]. Several factors contribute to bond strength, including the material used, surface preparation techniques, adhesive systems employed, and the characteristics of the tooth structure being bonded.

Research has demonstrated comparable shear bond strength of CEM cement and ProRoot MTA to composite resin, with surface etching having minimal impact on their bond strength [ 46 ]. Resin-modified glass ionomer (RMGI) cement exhibits higher shear bond strength to pulp capping agents compared to composite resin, while the bond strength of composite resin to ProRoot MTA is weaker than that of CEM cement [ 48 ]. RMGI cement demonstrates superior bond strength to composite resin compared to ProRoot MTA or CEM cement, regardless of the adhesive system used [ 49 ]. ProRoot MTA and CEM cement exhibit higher shear bond strength than Biodentine, making them more suitable for use with flowable composites [ 50 ]. The bond strength of self-adhering flowable composite resin to Root MTA and CEM cement is higher than RMGI, and additional adhesive application further enhances the bond strength [ 51 ]. The shear bond strength of silorane and nanohybrid composite resins to CEM cement has been evaluated over different time periods [ 52 ]. The type of pulp capping material and bonding system have minimal impact on the bond strengths of composite resin to ProRoot MTA and CEM cement [ 53 ].

In conclusion, bond strength is a critical aspect of restorative dentistry, and studies have investigated the bond strengths of CEM cement and various MTAs to different substrates.

Fracture resistance

Fracture resistance is a critical parameter in assessing the success and longevity of restorative procedures in dentistry. In an ex vivo study, evaluating the reinforcement of immature teeth by ProRoot MTA and CEM cement after a 6-month period, both biomaterials demonstrated significant improvements in fracture strength [ 54 ]. Another study involving simulated immature teeth filled with Angelus MTA, CEM cement, and Biodentine found that all three materials contributed to increased fracture resistance compared to the control group with no statistically significant differences among Angelus MTA, CEM cement, and Biodentine [ 55 ]. In another study, no significant differences in fracture strength of teeth restored with a fiber post and Angelus MTA or CEM cement apical plug were observed [ 56 ].

These studies emphasize the positive impact of preferred CSCs, including CEM cement, on fracture resistance of restored teeth.

Microhardness

According to several studies comparing the microhardness properties, MTAs generally exhibit higher microhardness values compared to other (bio)materials [ 27 , 57 , 58 ]. Factors such as exposure to acids or PBS can influence the microhardness of these biomaterials, with PBS exposure leading to increased microhardness [ 57 ]. On the other hand, humidity conditions and indentation thickness may not have a significant impact on the microhardness of Angelus MTA and CEM cement plugs [ 58 ]. It is worth noting that the pH of the environment can affect the microhardness and setting time of these materials, meaning that acidic solutions negatively affect their properties [ 27 ].

The microhardness of ProRoot MTA decreases in the presence of bone graft powder, while CEM cement is not significantly affected [ 59 ]. Additionally, the immediate placement of coronal restorations can influence the setting reaction of CEM cement. Proper moist curing and hydration before restoration placement are crucial to ensure optimal properties [ 60 ].

In a study investigating the microhardness of CEM cement and glass ionomers at different periods, an increase in surface microhardness was observed in both materials over time from 1 to 7 days. This suggests that using glass ionomers adjacent to CEM cement in single-visit restorative treatments could be advantageous [ 61 ].

Particle size

In a comparative study, although there were no significant differences in the mean particle size of CEM cement and ProRoot MTA, differences were observed in the particle distribution within the size range of ≤ 30 μm. CEM cement exhibited a narrower range of particle sizes in this range compared to ProRoot MTA. Notably, CEM cement contained a higher percentage of small particles [ 62 ].

The presence of a high percentage of small particles in CEM cement contributes to its desirable properties and performance in clinical applications. These small particles facilitate effective sealing, as they can penetrate into microgaps and irregularities, ensuring a more thorough seal. The optimal setting time of CEM cement is also influenced by its particle-size distribution, with the presence of small particles allowing for a more efficient setting reaction. The appropriate film thickness of CEM cement is achieved in part due to the presence of small particles, which contribute to a more compact and closely packed material. Additionally, the flow and adaptability of CEM cement are enhanced by the presence of small particles, allowing for easier manipulation and placement in various clinical scenarios.

Overall, the particle-size distribution of CEM cement, particularly the presence of a high percentage of small particles, contributes to its desirable properties and ensures its effective performance as an endodontic biomaterial.

Radiopacity

While CEM cement exhibits a higher radiopacity at least twice to that of dentin (2.227 mmAl), it is essential to consider that it may not meet the ISO standard (ISO 6877, 2006) [ 63 ]. The radiopacity of CEM cement allows for the identification and differentiation of the material from surrounding tooth structures on radiographs, which is beneficial for its clinical use and assessment.

Another study investigated the radiopacity of CEM cement using various scanners. The study found that the Hounsfield unit (HU) and grayscale value (GSV) measurements of dental materials, including CEM cement, varied depending on the scanner used [ 64 ].

Elevated radiopacity of CEM compared to dentine provides clinical advantages in terms of material identification and assessment on radiographs. Clinicians must be aware of the potential variations in radiopacity measurements due to different imaging devices and to follow standardized protocols to ensure accurate radiographic evaluation of CEM cement and other dental materials.

Color stability

While no clinical evidence specifically addresses the tooth discoloration potential of CEM cement, studies have investigated CEM cement and various MTAs, comparing them to other dental materials and evaluating their potential for tooth discoloration [ 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 , 73 , 74 , 75 ]. The findings consistently indicate that both MTA and CEM cement have the potential to cause tooth discoloration, although the degree of discoloration varies between the two biomaterials. ProRoot and Angelus MTAs generally exhibit greater discoloration compared to CEM cement [ 65 , 68 ]. Comparative studies suggest that CEM cement exhibits a lower color-changing potential compared to Angelus MTA [ 66 , 67 ]. Furthermore, CEM cement has been found to induce similar levels of discoloration as CH, indicating its suitability for use in esthetically sensitive areas [ 67 ].

Factors such as the light curing duration of the restorative material and exposure to different media significantly influence the color stability of ProRoot MTA and CEM cement. Longer light curing durations have been shown to result in decreased lightness (ΔL) and increased overall color change (ΔE) values in both biomaterials [ 65 ]. This highlights the importance of proper light curing techniques and durations to minimize the risk of discoloration. Additionally, the interaction of MTA and CEM cement with irrigation solutions, such as chlorhexidine and sodium hypochlorite, has been found to affect their color stability, with severe discoloration observed in some cases [ 69 ].

In summary, when performing VPT in esthetic zones, it is crucial to consider the color stability of endodontic biomaterials, particularly MTA and CEM cement. Clinicians should be aware of factors such as light curing duration, exposure to different media, and interactions with irrigation solutions that can influence color stability. By taking these factors into account and selecting appropriate materials, the risk of tooth discoloration can be minimized, leading to better clinical outcomes and patient satisfaction.

Role of additives

The role of additives in modifying the properties of CEM cement has been the subject of several studies. For example, the addition of calcium chloride (CaCl 2 ) was found to significantly decrease the initial setting time of CEM cement [ 76 ]. Another study revealed that the addition of propylene glycol (PG) to CEM cement did not affect the flowability of the cement and increased its microhardness over the long term. Moreover, calcium ion release was increased [ 77 ].

Incorporating titanium dioxide nanoparticles into various cement types, including CEM cement, was explored in another study, although specific findings and conclusions were not provided [ 78 ]. Additionally, the bond strength of CEM cement in the presence of certain concentrations of propylene glycol was decreased [ 79 ]. Chemical modification of Angelus MTA and CEM cement by adding alkaline salts led to a decrease in setting time, an increase in pH and calcium ion release, and the deposition of hydroxyapatite on the surface of the samples [ 80 ]. These studies highlight the potential of additives to influence various properties of CEM cement, such as setting time, flowability, microhardness, bond strength, pH, and ion release. However, further research is needed to fully understand the effects of different additives on the overall performance and clinical applications of CEM cement.

Sealing ability

Root-end filling.

Numerous studies have demonstrated that in comparison to MTA-like biomaterials, CEM cement exhibits comparable or superior sealing properties [ 81 , 82 ]. CEM cement has shown excellent sealing ability in PBS and has demonstrated similar or better sealing ability than intermediate restorative material (IRM) and amalgam [ 83 , 84 , 85 , 86 ]. Moreover, CEM cement has exhibited similar levels of microleakage compared to commonly used root-end filling materials [ 87 ]. The presence of a smear layer enhances the sealing ability of both ProRoot MTA and CEM cement in root-end fillings [ 88 ].

Several factors have an impact on the sealing ability of CSCs. Saliva contamination has been shown to affect the sealing ability, with CEM cement being less affected [ 89 ]. While root resection procedures did not significantly affect the sealing ability of Angelus MTA, they increased microleakage in CEM cement [ 90 ]. Studies have indicated that a 3-mm thickness of CEM cement is sufficient for effective root-end sealing [ 91 ].

Comparative evaluations of different techniques and mixing methods have not revealed significant differences in sealing ability [ 92 , 93 , 94 ]. These findings collectively support the sealing effectiveness of CEM cement as a viable alternative to other CSCs, highlighting its potential for use in various endodontic applications.

Perforation repair

Multiple studies have examined the microleakage and sealing ability of CEM cement in the repair of furcation perforations. In comparison to ProRoot MTA, CEM cement has consistently shown significantly less microleakage using the fluid filtration method [ 95 ]. In primary molar teeth, studies have reported no significant difference in microleakage between ProRoot MTA and CEM cement [ 96 , 97 ]. Additionally, the bacterial leakage potential of ProRoot MTA, CEM cement, and Biodentine has been found to be similar [ 98 ]. Selecting the appropriate biomaterial is essential for achieving successful furcal perforation repair in dental procedures.

Apical plug

CEM cement has been extensively studied as a biomaterial for use as an apical barrier in endodontic procedures [ 99 , 100 , 101 , 102 , 103 , 104 , 105 , 106 , 107 ]. CEM cement exhibits superior sealing performance compared to Angelus MTA, particularly in dry and saliva-contaminated conditions [ 99 ]. The diameter of the canal and the thickness of the apical plug have been identified as important factors influencing the sealing ability of CEM cement [ 100 ]. Various studies have investigated different mixing and placement methods of CEM cement, with manual placement in association with the indirect ultrasonic technique showing promising results in reducing the number of voids [ 101 ]. The powder-to-liquid ratio of CEM cement has also been shown to impact its sealing ability, with higher ratios resulting in better sealing outcomes [ 102 ]. CH premedication does not have any adverse effect on short- or long-term sealing properties of CEM apical plugs [ 107 ]. The influence of alkaline pH and the addition of propylene glycol did not have adverse effects on the sealing ability of Angelus MTA and CEM cement [ 103 , 104 ]. Microleakage studies have consistently shown that CEM cement exhibits comparable results to other biomaterials, such as Biodentine, and has better sealing ability compared to Angelus MTA [ 99 , 105 ].

Various factors, including canal diameter, apical plug thickness, mixing and placement techniques, pH conditions, and powder-to-liquid ratios, can influence the sealing performance of these materials.

Coronal barrier

Both CEM cement and ProRoot MTA have been shown to be more effective than amalgam and composite resin in terms of coronal sealing [ 108 ]. The thickness of the CEM cement has also been investigated, with no statistically significant difference in coronal microleakage observed between 2 and 3 mm thicknesses [ 109 ]. Furthermore, CEM cement, Angelus MTA, and glass ionomer cement have been identified as suitable intra-orifice barriers to provide a coronal seal during nonvital bleaching procedures [ 110 ]. Microleakage assessments comparing Angelus MTA, CEM cement, and Biodentine as intra-orifice barriers demonstrated that CEM cement exhibited the least microleakage, although the differences were not statistically significant [ 111 ]. Additionally, CEM cement has shown sealing properties comparable to Angelus MTA when used as a cervical barrier during intra-coronal bleaching procedures [ 112 ]. In a comparative study, Angelus MTA, CEM cement, and Biodentine showed equally promising results as coronal plugs during internal bleaching procedures [ 113 ].

In summary, studies have indicated the effectiveness of CEM cement and MTAs as coronal barriers in endodontically treated teeth. The thickness of the material and its application technique should be considered, and further research is needed to optimize their clinical performance.

Root canal filling

Studies investigating the sealing ability of CEM cement have demonstrated favorable coronal and apical seals when using the simple single-cone technique [ 114 ]. It has been concluded that single-cone obturation with both ProRoot MTA and CEM cement is a suitable technique [ 114 , 115 ]. In an in vitro study comparing orthograde ProRoot MTA and CEM cement, no significant differences were observed in bacterial leakage between the two biomaterials [ 92 ]. Additionally, an investigation on apical microleakage in root canals with broken rotary instruments revealed that CEM cement exhibited the lowest microleakage, whereas injected gutta-percha showed the highest microleakage. Importantly, no significant difference in microleakage was found between CEM and OrthoMTA [ 116 ].

Marginal adaptation

Studies have investigated the marginal adaptation of CEM cement in various scenarios and compared it to other materials. The findings indicate that CEM cement demonstrates favorable marginal adaptation in different conditions. CH premedication did not negatively affect the marginal adaptation of the CEM cement apical plug [ 107 ]. The addition of calcium chloride as an accelerator substance also did not significantly influence the marginal adaptation of CEM cement [ 117 ]. Blood contamination did not have an impact on the marginal adaptation of CEM cement, Angelus MTA, Biodentine, or BioAggregate [ 73 ]. Additionally, when comparing Angelus MTA and CEM cement in root canal treatment (RCT), a similar prevalence of cracks was observed in the apical plug, suggesting that both materials can be used with potential future surgical access [ 118 ].

Antimicrobial attributes

Antibacterial.

Studies have consistently shown that CEM cement possesses potent antibacterial activity similar to CH [ 119 , 120 , 121 ]. The addition of chlorhexidine enhanced the antibacterial activity of both ProRoot MTA and CEM cement [ 122 , 123 ]. Incorporating dentin powder into the suspension of CEM cement or ProRoot MTA has also resulted in more rapid elimination of bacteria [ 124 ]. Moreover, the inclusion of silver nanoparticles in ProRoot MTA and CEM cement has demonstrated increased antimicrobial activity [ 125 ]. Comparative studies have highlighted the comparable or even superior antibacterial effects of CEM cement compared to other root canal filling materials. When compared to Biodentine, CEM cement has displayed higher antibacterial activity against Enterococcus (E) faecalis [ 126 , 127 ]. Similarly, CEM cement has exhibited stronger antimicrobial effects against both E. faecalis and Candida albicans compared to Angelus MTA [ 127 ].

These findings underscore the potential for modifying the antibacterial properties of CEM cement and other biomaterials to enhance their performance in combating microbial infections during endodontic procedures.

One study demonstrated that different power/liquid ratios in CEM cement effectively inhibited the growth of Candida albicans , except the early hours, indicating its anti-fungal property which was unaffected by the power/liquid ratio [ 128 ]. In another study comparing the anti-fungal effects of CEM cement and ProRoot MTA against Candida albicans , both biomaterials exhibited complete fungicidal activity after 24 and 48 h, even at a concentration of 50 mg/mL [ 129 ].

Bioactivity

One study examined the impact of various storage solutions, such as normal saline and phosphate buffer solutions, on the surface characteristics of CEM cement and ProRoot MTA root-end fillings. The findings indicated that both biomaterials experienced crystal formation and precipitation on their surfaces, except for ProRoot MTA stored in normal saline. The composition and structure of the precipitated crystals resembled hydroxyapatite, suggesting a bioactive response. This bioactivity is believed to contribute to the biocompatibility and sealing ability of ProRoot MTA and CEM cement, leading to the formation of an additional biological seal (Bioseal) at the interface between the biomaterial and dentine [ 11 ].

Another study investigated the bioactivity of CEM cement, MTA, hydroxyapatite, and nano-hydroxyapatite-chitosan cements. These cements were immersed in a simulated body fluid solution, and parameters, such as pH, surface morphology, calcium–phosphorus ratio, and apatite deposition, were assessed. All tested cements demonstrated bioactivity, with CEM cement and nano-hydroxyapatite-chitosan cements exhibiting superior bioactive characteristics in terms of pH values [ 130 ]. A study has demonstrated the bioactivity of CEM cement and ProRoot MTA on dental pulp stem cells (DPSCs) through dentin. These biomaterials have shown the ability to stimulate cell proliferation, promote cell attachment, and induce the formation of calcified structures resembling hydroxyapatite [ 131 ].

• Biocompatibility

Cytotoxicity

In a study examining the cytotoxicity of CEM cement and ProRoot MTA on L929 cell culture, similar cytotoxic effects were observed between the two materials. However, the viability of cells was better in the presence of set materials compared to fresh ones, indicating improved cell compatibility over time [ 132 ]. Another comparative study assessed the cytotoxicity of CEM cement, ProRoot MTA, and IRM, and found that CEM cement exhibited lower cytotoxicity than IRM, suggesting its potential as a less harmful alternative material [ 133 ].

Further investigations have evaluated the cytotoxic effects of CEM cement on specific cell types. In vitro cytotoxicity tests on human monocytes compared the effects of four CSCs, including CEM cement and ProRoot MTA, and revealed that CEM cement demonstrated lower cytotoxicity than ProRoot MTA after 48 h of incubation [ 134 ]. Similarly, a study on stem cells of human apical papilla (SCAP) demonstrated acceptable biocompatibility of CEM cement and less cytotoxicity compared to ProRoot MTA over time, indicating its suitability for regenerative endodontic procedures [ 135 ].

Comparative studies involving various biomaterials have shown comparable cytotoxicity profiles among different CSCs used as root-end filling materials [ 136 ]. Another study comparing the cytotoxicity of ProRoot MTA, CEM cement, Biodentine, and octacalcium phosphate against human gingival fibroblasts (HGF) found no significant difference in cytotoxicity among the tested materials, suggesting their overall biocompatibility [ 137 ].

Moreover, studies investigating the cytotoxicity of CEM cement on specific cell types have demonstrated favorable biocompatibility. A study examining the effect of three different biomaterials, including CEM cement, on the proliferation and viability of human dental pulp stem cells (DPSCs), showed that all tested biomaterials supported the proliferation of DPSCs, with CEM cement exhibiting the least cytotoxicity over time [ 138 ]. Another study evaluated the cytotoxicity of Angelus and nanohybrid MTAs with CEM on human gingival fibroblasts (HGF) and found that both set CEM cement and set MTAs had similar and favorable effects on cell viability [ 139 ]. Furthermore, the combination of CEM cement and Emdogain-coated biomaterials demonstrated high cell viability in DPSCs, indicating their potential for regenerative procedures [ 140 ]. Additionally, studies on the antimicrobial and cytotoxic properties of CEM cement found that the cement exhibited high viability of dental pulp stem cells in comparison with Iranian propolis and propolis with herbal extracts [ 141 ]. Application of low-level laser therapy (LLLT) with dental capping agents, including ProRoot MTA, EMD, and CEM cement, increased the cell viability percentage of SCAPs, suggesting the synergistic effect of LLLT and CEM cement in promoting cell viability [ 142 ].

SEM cytotoxicity evaluations of CEM cement in different experimental setups demonstrated normal cell morphology and favorable cell adhesion of HGFs exposed to CEM cement, with no statistically significant differences observed compared to ProRoot MTA [ 143 ]. Another study evaluating the attachment of gingival fibroblasts to root surfaces restored with various dental materials, including CEM cement, demonstrated acceptable biocompatibility of CEM cement and other tested materials after 24 h and up to 5 days of incubation [ 144 ]. Overall, these studies collectively indicate that CEM cement exhibits favorable biocompatibility and lower cytotoxicity compared to certain other biomaterials.

Mutagenicity

The Ames test was employed to evaluating the mutagenicity of commonly used pulpotomy agents. While ferric sulfate exhibited mutagenic effects at certain concentrations and formocresol displayed significant toxicity, CEM cement did not induce significant reverse mutations and was classified as a non-mutagenic and less toxic agent [ 145 ]. These results suggest that CEM cement may present a safer alternative in terms of mutagenicity compared to other pulpotomy agents.

Genotoxicity

In a study investigating the genotoxicity of CEM cement and ProRoot MTA, L929 mouse fibroblast cells were exposed to different concentrations of these biomaterials. At low concentrations, CEM cement exhibited more noticeable genotoxic effects. However, at higher concentrations, CEM cement demonstrated lower genotoxicity compared to ProRoot MTA. Both biomaterials displayed increased genotoxicity in a concentration-dependent manner. The study concluded that CEM cement is biocompatible in terms of cyto- and genotoxicity and suggested that it could serve as a favorable alternative to ProRoot MTA, offering several advantages [ 146 ]. These findings provide valuable insights into the genotoxicity profile of CEM cement, indicating its potential for safe use in various dental applications.

Gene expression

In a study investigating the odontogenic differentiation of dental pulp stem cells (DPSCs) induced by CEM cement and ProRoot MTA, the gene expression and cytokine release were examined [ 147 ]. The results showed that both CEM cement and ProRoot MTA supported the adherence, proliferation, and spreading of DPSCs. Gene expressions of dentin matrix protein 1 (DMP 1 ) and dentin sialophosphoprotein (DSPP) were similar in CEM cement, ProRoot MTA, and dentin matrix (DM) groups, and significantly higher compared to the negative control. The gene expressions of fibroblast growth factor 4 (FGF 4 ) and bone morphogenetic protein 2 (BMP 2 ) through protein concentration analysis were significantly higher in the CEM cement group. The study concluded that both ProRoot MTA and CEM cement can induce osteo-/odontogenic differentiation of DPSCs, albeit with different gene expressions and growth factor release. In another study comparing the effects of ProRoot MTA, Biodentine, and CEM cement on DPSCs, it was found that the CEM cement group showed minimal expression of dentin sialophosphoprotein (DSPP) and DMP1 [ 148 ].

Furthermore, in a study investigating the effect of ProRoot MTA and CEM cement on mineralization-associated gene expression in SCAP, the 2-week expression of various mineralization genes was significantly upregulated compared to the control group [ 149 ]. Alizarin red staining confirmed the formation of mineralized nodules in all groups, with larger nodules observed in the ProRoot MTA group at 3 weeks. The study concluded that both ProRoot MTA and CEM cement upregulated mineralization-associated gene expression, with ProRoot MTA showing a greater effect after 3 weeks compared to CEM cement.

These studies provide insights into the gene expression profiles and osteo-/odontogenic differentiation potential of CEM cement and ProRoot MTA, indicating their ability to promote the expression of key genes involved in mineralization and dentin formation.

Cytokine release

The release of cytokines by endodontic biomaterials can influence the behavior of DPSCs, including their proliferation, migration, and differentiation capabilities [ 150 , 151 ]. CEM cement has shown the capacity to stimulate the release of specific cytokines, which play essential roles in cellular communication and tissue healing [ 152 , 153 ]. In terms of cytokine release, both CEM cement and ProRoot MTA have demonstrated comparable abilities to induce cytokine production. Studies have revealed that these biomaterials can promote the release of transforming growth factor-beta 1 (TGF-β1) and bone morphogenetic protein-2 (BMP-2), which are involved in crucial cellular processes such as cell proliferation, differentiation, and tissue formation [ 152 , 154 ].

Cell differentiation

Differentiation of DPSCs into odontogenic/osteogenic lineages is a critical process in regenerative dentistry. Studies have shown that CEM cement, ProRoot MTA, and nano-hydroxyapatite have potential applications in pulp capping and regenerative therapies and can promote odontogenic differentiation of DPSCs [ 152 ]. Comparing the effects of CEM cement and ProRoot MTA on the survival and mineralization potential of human mesenchymal stem cells (hMSCs) indicated similar cell viability and CEM cement enhanced osteocalcin gene expression [ 155 ]. Another study focused on the effect of CEM cement on the mineralization ability of stem cells of human exfoliated deciduous teeth (SHEDs) using alizarin red staining and reported more mineralized nodules in CEM cement samples [ 156 ]. This suggests that CEM cement can stimulate mineral deposit formation and enhance osteoblastic differentiation. Comparative studies have also evaluated the differentiation potential of various biomaterials on stem cells from the apical papilla (SCAPs) [ 157 , 158 ]. It was found that ProRoot MTA had a greater potential for inducing odontoblastic differentiation of SCAPs, while osteocalcin phosphate cement (OCP) had a higher potential for inducing osteoblastic differentiation [ 157 ]. Additionally, a comparative study showed that the CEM/Emdogain combination was highly effective in promoting the differentiation of SCAPs, gene expression related to odontogenesis, and alkaline phosphatase (ALP) activity [ 158 ].

These findings demonstrate the potential of CEM cement in promoting the differentiation of dental stem cells toward odontogenic and osteogenic lineages. This supports its use in regenerative dentistry and provides opportunities for developing novel treatment approaches. Further research is needed to explore the underlying mechanisms and optimize the differentiation potential of CEM cement for clinical applications.

Electrophysiological effects

The effects of CEM cement and ProRoot MTA on the firing behavior and action potential (AP) of neuronal cells were examined in a study. Both biomaterials had a significant reduction in neuronal activity which is mediated by the enhancement of outward potassium ion currents. These findings indicate that CEM cement and ProRoot MTA can modulate neuronal activity and may have potential applications in regenerative endodontics [ 159 ].

It is important to note that further research is necessary to fully understand the electrophysiological effects of CEM cement and ProRoot MTA on neuronal cells and their implications in clinical settings. The findings suggest the potential for these biomaterials to interact with neuronal cells and provide a basis for exploring their use in neuroregenerative approaches.

Subcutaneous reaction

In a comparative study evaluating subcutaneous tissue responses, CEM cement demonstrated favorable outcomes compared to white and grey ProRoot MTAs [ 160 ]. At the 1-week mark, CEM cement did not exhibit any signs of necrosis, while both ProRoot MTAs showed necrotic tissue. At the 60-day mark, CEM cement displayed significantly less inflammation than the other biomaterials. Overall, all biomaterials, including CEM cement, were well tolerated by the subcutaneous tissues, with the presence of dystrophic calcifications near the biomaterials, indicating their osteoinductive properties [ 160 ].

These findings suggest that CEM cement has a favorable biocompatibility profile in subcutaneous tissues and can induce osteoinductive responses. However, it is important to note that the study focused on subcutaneous tissue reactions, and further research is needed to evaluate the tissue responses and biocompatibility of CEM cement in other clinical applications.

Intraosseous implantation

In a comparative study evaluating the osseous reaction to the implantation of CEM cement and ProRoot MTA, after 1, 4, and 8 weeks of implantation, the number of inflammatory cells decreased similarly in both CEM cement and ProRoot MTA groups. Additionally, new bone formation increased in both ProRoot MTA and CEM groups, again without statistically significant differences [ 161 ]. These findings suggest that CEM cement exhibits a comparable level of osteoconductivity to ProRoot MTA when used for intraosseous implantation.

It is important to note that this study focused on the osseous reaction and biocompatibility of CEM cement and ProRoot MTA in an intraosseous implantation model. Further research is needed to assess the long-term effects, mechanical properties, and clinical outcomes of CEM cement in intraosseous applications to fully evaluate its efficacy as a biomaterial in this context.

In a histological study assessing skin test reactivity in rabbits, the ProRoot MTA group exhibited a statistically higher level of inflammation, followed by CEM cement and control groups [ 162 ]. Another study found significant differences in erythematous surface areas at 1, 24, and 48 h after removing the implanted materials from rabbits. However, there was no significant difference at 72 h. The average erythematous surface areas were wider in Root MTA compared to CEM cement [ 163 ]. These findings suggest that CEM cement exhibits higher biocompatibility than MTAs in terms of skin reaction. Further research is necessary to evaluate the skin reactivity and biocompatibility of CEM cement in human subjects and to assess its clinical implications in dermatological applications.

Induction of dentinogenesis

Animal studies.

In an SEM evaluation of dog pulp reactions to CEM cement, ProRoot MTA, and CH, all test pulp capping agents could stimulate calcified tissue formation in the underlying pulp [ 164 ]. Furthermore, a comparative histologic study showed that both ProRoot MTA and CEM cement exhibited similar responses and did not induce pulpal inflammation with a complete dentinal bridge formed in 75% of cases. In contrast, CH exhibited inflammation and incomplete dentinal bridge formation in all cases [ 165 ]. This suggests that both CEM cement and ProRoot MTA have the potential to promote dentinal bridge formation and preserve pulp vitality, surpassing the performance of CH.

Moreover, a preliminary study investigated the histopathologic response of dental pulp to pulp capping using Angelus MTA or CEM cement in diabetic rats. The results indicated that while both materials induced dentin bridge formation in diabetic and healthy controls, CEM cement-treated diabetic rats exhibited a significantly higher inflammatory response compared to healthy controls [ 166 ].

Additionally, another comparative histologic study demonstrated significantly higher dentinal bridge formation, preserved pulp vitality, and absence of inflammation in teeth treated with CEM cement and ProRoot MTA compared to CH [ 167 ]. These findings underscore the superior biological responses of CEM cement and ProRoot MTA in pulp capping procedures, indicating their potential applications in preserving pulp vitality and promoting dentin formation.

These animal studies collectively provide evidence that CEM cement and ProRoot MTA can induce dentinogenesis and promote the formation of dentinal bridges in pulp capping procedures. They demonstrate superior biological responses compared to CH, which is a traditional pulp capping material. The results suggest that both CEM cement and ProRoot MTA have potential applications in preserving pulp vitality and promoting dentin formation, contributing to the overall success of endodontic treatments. However, further research and clinical studies are needed to validate these findings and assess their applicability in human subjects.

Human studies on permanent teeth

In a clinical study evaluating the histologic assessment of human pulp response to capping with CEM cement and ProRoot MTA, both biomaterials showed significantly improved pulp response after 8 weeks compared to 2 weeks. They exhibited a thicker and more tubular dentinal bridge pattern, reduced pulp inflammation, and a palisade pattern of odontoblast cells. Although there was no significant difference between ProRoot MTA and CEM cement at both time intervals in each measure, CEM cement induced a thicker dentinal bridge with less pulp inflammation compared to ProRoot MTA [ 168 ]. Another immunohistochemical study investigating fibronectin (FN) and tenascin (TN) expression in human tooth pulp capped with ProRoot MTA and CEM cement revealed staining for FN and TN in the dentinal bridge matrix after 2 weeks. However, the expression of both markers decreased significantly after 8 weeks, with staining observed only in the unmineralized parts of the dentinal bridge. The staining pattern of TN in the CEM cement group was slightly higher than in the ProRoot MTA group, although the difference was not significant. The study concluded that both materials are suitable for direct pulp capping (DPC) and contribute to the formation of a reparative dentinal bridge [ 169 ]. A comparative study evaluating the histological evaluation of human pulp response to DPC with CEM cement, Angelus MTA, and Biodentine found that although dentin bridge formation and thickness were higher in the Biodentine group, the pulp exhibited greater inflammation compared to CEM cement and Angelus MTA. The study suggested that CEM cement and Angelus MTA performed better as DPC materials [ 170 ]. In a preliminary report on the histological outcome of pulpotomy with CEM cement and MTA compared to CH, it was found that CEM cement and ProRoot MTA were reliable biomaterials for full pulpotomy treatment, while the human dental pulp response to CH was unpredictable [ 171 ].

Human studies on primary teeth

In a case report examining the histological and CBCT evaluation of a pulpotomized primary molar using CEM cement, thick and complete calcific bridges with tubular dentin were observed at the amputation sites. The underlying dental pulp exhibited a normal structure and was free from inflammation [ 172 ]. The findings suggest that CEM cement can elicit a favorable biological response in the dental pulps of primary teeth. In a randomized clinical trial comparing nano-hydroxyapatite (NHA) and CEM cement for DPC in sound primary teeth, CEM cement demonstrated superior outcomes in terms of calcific bridge formation and pulp inflammation scores compared to NHA [ 173 ]. A histopathological evaluation of primary teeth after DPC with CEM cement and bioactive glass found that both materials were suitable for DPC, exhibiting calcific bridge formation and low pulp inflammation scores [ 174 ]. A study comparing the effects of CEM cement, propolis, and MTA as DPC agents found that their impact on pulpal tissue was comparable [ 175 ].

These clinical studies demonstrate that CEM cement is effective in promoting dentin bridge formation and reducing pulp inflammation in both permanent and primary teeth. It shows favorable biocompatibility and holds promise as a biomaterial for pulp capping and pulpotomy procedures.

Induction of cementogenesis

In studies investigating the induction of cementogenesis, CEM cement has shown promising results:

Periradicular regeneration: A study evaluating periradicular regeneration after endodontic surgery using CEM cement and ProRoot MTA observed the deposition of cementum adjacent to the biomaterials in the majority of samples. Both CEM cement and ProRoot MTA demonstrated similar periradicular tissue responses, with no significant differences [ 176 ]. This suggests that CEM cement has the potential to induce cementum formation in the periradicular region similar to MTA.

Repair of furcal perforation: Another study focused on the repair of furcal perforation using CEM cement and compared it to ProRoot MTA. Both biomaterials resulted in the formation of hard tissue, indicating successful repair. The inflammatory response observed in the experimental groups was mild, and there were no significant differences between CEM cement and ProRoot MTA [ 177 ]. These findings indicate that CEM cement is effective in inducing cementogenesis and promoting the repair of furcal perforations, comparable to ProRoot MTA.

Overall, these studies highlight the ability of CEM cement to promote the deposition of cementum and facilitate the repair of perforations, suggesting its potential for inducing cementogenesis in endodontic procedures.

Clinical applications and treatment outcomes

Endodontic literature has revealed various clinical applications for CEM cement (Fig.  2 ). In this part, the name of the author(s) as well as the first work/time of utilizing a treatment using CEM cement is mentioned. In addition, the success rates and level of evidence until now will be provided.

Various clinical applications of CEM cement in endodontics

• Vital pulp therapy

VPT is a conservative approach that aims to preserve the vitality and functionality of the dental pulp in cases of pulp exposure even with irreversible pulpitis (IP) [ 178 ]. CEM cement has emerged as a promising biomaterial for VPT, offering favorable biocompatibility and dentinogenic potential. Several reviews and meta-analyses have explored the clinical applications and effectiveness of CEM cement in VPT procedures in primary and permanent teeth with/without IP or apical periodontitis (AP) [ 4 , 179 , 180 , 181 , 182 ].

Indirect pulp capping

Permanent teeth: Indirect pulp capping (IDPC) utilizing CEM cement was first introduced by Torabzadeh and Asgary in 2013 with Level V evidence supporting its efficacy [ 183 ]. In their case report, IDPC with CEM cement was performed on a mature molar with symptomatic IP and AP. After a 1-year follow-up period, the tooth exhibited pulp vitality, normal clinical function, and the absence of pain, tenderness to percussion/palpation, and cold sensitivity. Radiographic examination revealed healing of the periradicular lesion with the formation of new bone, indicating successful treatment outcomes. This case report highlights the effectiveness of IDPC with CEM cement in preserving pulp vitality and promoting periradicular healing.

Moreover, a Level I evidence study conducted in 2018 further supports the effectiveness of IDPC and reported a 100% success rate at 1-year recall [ 184 ].

Direct pulp capping

Permanent teeth: The use of CEM cement for direct pulp capping (DPC) was first reported in a case report by Asgary et al . in 2012, providing Level V evidence [ 185 ]. In this case report, CEM cement was used for the DPC of a mature molar with symptomatic IP and symptomatic AP. The treatment resulted in successful periapical healing, with the tooth exhibiting normal function, absence of pain, and a normal response to cold testing during follow-ups of up to 15 months. Additionally, a Level I evidence study conducted in 2018 further supports the effectiveness of DPC with CEM cement and reported a 94.7% success rate at 1-year recall [ 184 ].

Primary teeth: In a randomized clinical trial conducted by Fallahinejad Ghajari et al . in 2010 (Level I evidence), the outcomes of DPC using CEM cement and ProRoot MTA in primary molar teeth were compared [ 186 ]. The trial, using a split-mouth design, demonstrated a high success rate of 94.8% for CEM cement and 100% for ProRoot MTA, with no failures observed on radiographic evaluations at the 6-month follow-up. Subsequent evaluations after 20 months revealed a final success rate of 89% in the CEM cement group and 95% in the ProRoot MTA group, with no statistically significant difference [ 187 ]. These results indicate that both CEM cement and ProRoot MTA are effective options for DPC in primary molars. Furthermore, a recent systematic review has provided additional support for the effectiveness of both biomaterials in DPC procedures [ 188 ].

Miniature pulpotomy

The concept of miniature pulpotomy (MP) was introduced in a hypothesis article by Asgary and Ahmadyar in 2012, proposing that performing an MP could improve the outcomes of VPT for cariously exposed pulp [ 189 ]. The hypothesis was based on biological principles, including creating a clean surgical wound in the pulp, removing infected dentin chips and damaged pulp tissue, controlling bleeding, enhancing the interaction of pulp capping biomaterial with stem cells, and achieving a better seal.

Permanent teeth: The use of CEM cement in the management of complicated crown fractures with MP was described by Asgary and Fazlyab in 2014, providing Level V evidence [ 190 ]. At the 1-year follow-up, the treated tooth showed vitality, and radiographic examination revealed the presence of a thick dentinal bridge beneath the CEM cement layer, indicating successful treatment. Other case studies have also reported successful utilization of CEM cement for MP in symptomatic mature permanent teeth, both in immediate and delayed scenarios following pulp exposure [ 191 , 192 ]. Furthermore, a Level I evidence study conducted in 2018 further supports the effectiveness of MP with CEM cement and reported a 91.4% success rate at 1-year recall [ 184 ].

Partial pulpotomy

Permanent teeth: The first reported utilization of partial pulpotomy (PP) treatment with CEM cement was described in a case report by Tavassoli-Hojjati et al . in 2013, providing Level V evidence [ 193 ]. The case report presented the management of an exposed pulp in an 8-year-old boy with incomplete root formation in a central incisor. PP was performed using CEM cement, and at the 1-year follow-up, the tooth exhibited a normal response to cold and electric pulp tests, with radiographic examination showing normal closure of the root apex.

A recent clinical trial conducted in 2021 compared the effectiveness of PP using various biomaterials, including CEM cement, in cases of symptomatic IP, providing Level II evidence [ 194 ]. The study found no statistically significant differences in the frequencies of clinical and radiographic outcomes among the different biomaterials at various periods up to 1 year. This indicates that CEM cement is a viable option for PP treatment in cases of symptomatic IP.

Coronal pulpotomy

Permanent teeth: The use of coronal pulpotomy (CP) with CEM cement in permanent teeth with IP has been extensively studied. In 2009, Asgary and Ehsani published the first case series on FP with CEM cement, providing Level IV evidence [ 11 ]. Positive clinical and radiographic outcomes were reported, with all treated teeth showing normal function and the absence of signs and symptoms during the follow-up period. Histological examination confirmed the formation of complete dentin bridges and the presence of a healthy pulp. Subsequent studies have further supported the effectiveness of CP with CEM cement in managing IP and AP with condensing osteitis, as well as serving as an alternative to tooth extraction in molars with hyperplastic IP [ 195 , 196 ].

Long-term assessments using micro-computed tomography (Micro CT) have demonstrated complete dentinal bridge formation without negative consequences on the dental pulp, such as pulp canal obliteration or calcification [ 197 ]. CP with CEM cement has also shown success in managing pink spots due to internal/external cervical root resorption, restoring aesthetics, and preventing further resorption [ 198 ]. Case studies have demonstrated the stability of pulpotomy-treated molars despite recurrent decay, with the formation of complete calcified bridges at the canal orifices [ 199 ].

Two multi-center randomized-controlled trials have compared the pain relief effect of CP in mature teeth with clinical signs and symptoms of IP. In one trial, CP using CEM cement was compared to RCT [ 200 ]. The results showed a significant difference in the change in mean pain intensity between the two groups, with the CEM group experiencing faster pain relief (18 h) compared to the RCT group (36 h). Additionally, patients in the CEM group had lower pain intensity scores and less pain in response to percussion tests. Another randomized-controlled trial compared post-endodontic pain following CP or RCT in mature teeth with carious pulp exposure [ 201 ]. The study found comparable mean pain intensity scores and trends of pain relief among the different treatment groups. Furthermore, the incidences of preoperative moderate–severe pain significantly decreased after 24 h in all groups.

Randomized-controlled trials have evaluated the treatment outcomes of CP in mature permanent molars with IP using CEM cement or ProRoot MTA. Both ProRoot MTA and CEM groups showed high clinical success rates (98% and 97%) and radiographic success rates (95% and 92%) at the 12-month follow-up [ 202 ]. Long-term follow-up studies demonstrated clinical success rates > 98% and radiographic success rates of 84% for ProRoot MTA and 78% for CEM at the 5-year mark [ 203 ].

In a serial multicenter randomized clinical trial comparing RCT with CP using CEM cement, both treatment groups showed comparable clinical success rates of ≥ 97%. However, the radiographic success rate was significantly higher in the CEM group at the 1-year follow-up (92% vs. 81%) [ 204 ]. At the 2-year follow-up, both groups had equal clinical success rates (98%), but the radiographic success rates were 79% for RCT and 86% for CEM, with no statistical difference [ 205 ]. Long-term follow-up studies of 5 years also demonstrated the non-inferiority and long-term success of CP using CEM compared to RCT in mature permanent molars, with success rates of 78% and 75% for CEM and RCT groups, respectively [ 206 ]. Furthermore, in a randomized clinical trial, CEM and ProRoot MTA full pulpotomy were compared in young permanent molars with IP [ 207 ]. The study found no significant difference between the two groups in terms of clinical and radiographic outcomes over 12 months. Both treatments showed excellent success rates.

In a recent randomized-controlled trial comparing RCT or CP using ProRoot MTA or CEM cement, no significant differences in the success rates were found between the treatment groups [ 208 ]. The 2-year radiographic success rates were 98% for RCT, 100% for ProRoot MTA, and 98% for CEM full pulpotomy, without statistically significant differences.

These studies collectively provide Level I evidence for the effectiveness of CP with CEM cement in managing IP in permanent teeth, with comparable outcomes to the traditional RCT.

Primary teeth: In primary molars, the effectiveness of CP with CEM cement has been extensively studied. A randomized clinical trial by Malekafzali et al . in 2011 provided Level I evidence comparing CP outcomes using CEM cement and ProRoot MTA [ 209 ]. The study found similar clinical and radiographic outcomes between the two biomaterials, indicating that CEM cement is an effective pulp dressing material for CP in primary molars. Several other randomized clinical trials with Level I evidence have compared CP using CEM cement with other techniques and materials, including ProRoot MTA, formocresol, sodium hypochlorite, ferric sulfate, and low-level laser therapy, and have consistently reported high radiographic success rates ranging from 95 to 100% [ 209 , 210 , 211 , 212 , 213 ].

In cases of IP in primary molars, the use of CEM cement for CP has shown promising results. A clinical trial investigating CP using CEM cement reported a high success rate and significant pain relief in the majority of children after treatment, with a radiographic success rate of 90.4% observed at the 1-year recall [ 214 ]. Additionally, tampon-based CP using CEM cement has demonstrated reliability in the treatment of vital primary molars with IP, leading to successful outcomes in multiple cases [ 215 , 216 ].

These studies provide strong evidence for the effectiveness of CP with CEM cement in managing primary molars with IP, with comparable outcomes to other techniques and materials. CEM cement serves as a reliable and successful treatment option for preserving the vitality and functionality of primary molars.

Partial pulpectomy

In partial pulpectomy (PPC), the procedure involves the removal of dental pulp from the coronal third of the roots, followed by the placement of capping material to protect the remaining pulp. CEM cement has shown promising results. The first published work utilizing CEM cement in PPC was a case report by Asgary and Çalışkan in 2015 (Level V evidence) [ 217 ]. The case report described the successful treatment of a mature mandibular first molar with hyperplastic pulpitis, internal root resorption, and periradicular periodontitis. After 6 months, a radiographic examination revealed complete healing, and the tooth remained functional without any signs or symptoms of infection or inflammation.

Although more research is needed to establish the effectiveness of CEM cement in PPC, this case report demonstrates its potential as a viable option for managing cases requiring partial removal of pulp. CEM cement offers biocompatibility and dentinogenic properties that contribute to successful healing and preservation of tooth functionality. Further studies and clinical trials are warranted to explore the efficacy of CEM cement in PPC and compare its outcomes with other treatment approaches.

Comparing VPTs

Comparative studies play a crucial role in evaluating and comparing the effectiveness of different VPT techniques. Two studies have provided insights into the comparison of various VPT techniques using CEM cement. In a comprehensive case series, the treatment outcomes of 94 permanent teeth with IP were evaluated using different VPT techniques, including IDPC, DPC, MP, and CP with CEM cement (Level IV evidence) [ 218 ]. The study reported a high success rate across all techniques, with 93 teeth demonstrating both radiographic and clinical success. Only one radiographic failure was observed in the DPC group. This case series highlights the favorable treatment outcomes of different VPT techniques utilizing CEM cement in managing IP in permanent teeth.

A randomized clinical trial with Level I evidence compared the treatment outcomes of four VPT techniques (IDPC, DPC, MP, and CP) in mature molars [ 184 ]. The study evaluated the success rates at 3 and 12 months and found that all four techniques had comparable success rates of over 91%, with no significant differences observed. The study concluded that these VPT techniques using CEM cement were associated with favorable and comparable clinical and radiographic outcomes. Factors such as pulpal and periapical status, as well as the type and location of pulpal exposure, did not significantly impact the treatment outcomes.

These studies provide valuable evidence supporting the effectiveness of different VPT techniques utilizing CEM cement. However, further research, including larger clinical trials and longer term follow-ups, is necessary to strengthen the evidence and determine the optimal VPT approach for different clinical scenarios.

Health technology assessment

Yazdani et al . conducted a health technology assessment (HTA) to evaluate the use of VPT with CEM cement compared to RCT in permanent molars with IP [ 219 ]. The study aimed to assess various factors including patient-related factors, safety, and organizational considerations, as well as the impact on reducing the burden of disease.

Patient-related factors were evaluated based on short- and long-term clinical success. The study found that VPT with CEM cement was more successful in treating IP compared to RCT. Safety factors were assessed by a specialist committee and discussion board, which concluded that VPT with CEM cement was a safe and reliable treatment option.

The organizational evaluation included cost, availability, accessibility, and acceptability. VPT with CEM cement was found to be more accessible, affordable, and available compared to RCT. Additionally, it was deemed acceptable by patients and healthcare providers.

The study also investigated the impact of VPT with CEM cement on reducing the burden of disease. It highlighted the potential benefits of VPT in preserving natural teeth, avoiding unnecessary extractions, and improving oral health-related quality of life.

Overall, the HTA concluded that VPT with CEM cement was a feasible and effective alternative to RCT in mature permanent molars with IP. It emphasized the potential advantages of VPT/CEM in terms of improved clinical outcomes, patient satisfaction, cost-effectiveness, and the overall burden of disease.

This HTA provides valuable insights into the advantages of VPT with CEM cement and supports its consideration as a preferred treatment modality for IP in permanent molars. However, it is important to note that further research and evidence are necessary to validate and expand upon these findings.

Management of open apices

Apexogenesis.

In 2010, Nosrat and Asgary published a case report describing successful apexogenesis using CEM cement in a traumatized tooth with long-lasting pulpal exposure (Level V evidence) [ 220 ]. The tooth, treated with a complete pulpotomy technique using CEM cement, showed functional status, complete root development, and the formation of a calcified bridge at the apex during follow-up examinations.

Several case studies have also investigated the use of CEM cement in complete pulpotomy techniques for teeth with open apices, reporting successful outcomes, such as continued root development, resolution of symptoms, and radiographic evidence of healing [ 221 , 222 , 223 , 224 ]. Although these studies have Level V evidence, they collectively support the efficacy of CEM cement in apexogenesis procedures.

In a randomized clinical trial (Level I evidence), the outcomes of pulpotomy using CEM cement and ProRoot MTA were compared in immature caries-exposed permanent molars [ 207 ]. The study found no significant difference in pulp survival and signs of ongoing root development between the two materials. Both CEM cement and ProRoot MTA demonstrated comparable radiographic outcomes, with apexogenesis observed in 76.8% and 73.8% of radiographically evaluated roots in the CEM cement and ProRoot MTA groups, respectively.

Systematic reviews have also evaluated various endodontic medicaments, including CEM cement, for CP in immature permanent teeth. The evidence suggests similar success rates among these biomaterials, as well as other agents such as CH and platelet-rich fibrin [ 225 , 226 ].

Collectively, these studies and systematic reviews provide valuable evidence supporting the use of CEM cement in apexogenesis procedures for teeth with open apices. However, further research with higher level evidence is necessary to establish standardized protocols and confirm the long-term success of apexogenesis using CEM cement.

Apexification (apical plug)

The effectiveness of CEM cement as an artificial apical plug in teeth with open apices and necrotic pulps was investigated in a study by Nosrat et al . (Level IV evidence) [ 227 ]. Thirteen single-rooted teeth were treated with CEM cement as an apical plug, either in the first or second appointment. The teeth were restored, and patients were followed up until radiographic evidence of periradicular healing was observed, with an average follow-up period of 14.5 months. The study demonstrated complete periradicular healing in all cases, indicating the efficacy of CEM cement as an apical plug.

Case reports have also showcased successful outcomes with the use of CEM cement in apexification procedures. In one case report, CEM cement was utilized for the apexification of a traumatized anterior tooth, resulting in positive outcomes during a 1-year follow-up [ 228 ]. Another case report described the conservative management of an unset MTA root-end filling using CEM cement, with successful outcomes observed during a 27-month follow-up [ 229 ]. Additionally, CEM cement was used as an apical plug in a mandibular premolar with dens invaginatus, leading to positive outcomes during a 36-month follow-up [ 230 ]. These case reports further demonstrate the versatility and efficacy of CEM cement in various endodontic treatments. Overall, the studies and case reports provide evidence supporting the effectiveness of CEM cement as an artificial apical plug-in teeth with open apices and necrotic pulps. However, further research with higher level evidence is needed to confirm these findings and establish standardized protocols for apexification procedures using CEM cement.

Revascularization (revitalization)

A study conducted by Nosrat et al . presented the cases of regenerative endodontic treatment (RET), also known as revitalization, in necrotic immature permanent molars (Level V evidence) [ 231 ]. The treatment approach involved irrigation with sodium hypochlorite (NaOCl), a triple antibiotic paste dressing, induction of bleeding, and placement of a CEM cement coronal plug. The treated teeth showed complete healing of periapical radiolucencies, continued root development, and remained asymptomatic and functional.

Another case study compared RET with apical plug in necrotic immature maxillary central incisors, demonstrating complete radiographic healing without tooth discoloration [ 232 ]. Furthermore, a study on modified revascularization using a treated dentin matrix showed successful outcomes and continued root development [ 233 ]. Similarly, a case report of RET and apical plugs in an immature molar resulted in symptom relief and successful management using CEM cement [ 234 ].

RET using CEM cement achieved the resolution of periapical radiolucency, apical closure, and positive responses to cold tests in a case of necrotic immature permanent anterior tooth [ 235 ]. Finally, a recent case report highlighted the resolution of endodontic lesions, dentinal bridge formation, and continuous root maturation in an infected immature tooth with a talon cusp following RET [ 236 ].

Endodontic surgery

Root-end surgery.

The use of CEM cement in root-end surgery was first reported in a study by Asgary and Ehsani, where successful treatment outcomes were achieved in 13 out of 14 teeth with persistent apical periodontitis (Level IV evidence) [ 237 ]. This study provided the initial evidence of the effectiveness of CEM cement in root-end surgery. Subsequent case reports further demonstrated the successful use of CEM cement in various clinical scenarios.

One case report described the surgical management of a vertically fractured maxillary incisor, where the fracture line and retrograde cavity were treated with CEM cement [ 238 ]. Another case report highlighted the use of CEM cement as a root-end filling material in an infected immature incisor with severe root resorption and a large periradicular lesion [ 239 ]. Additionally, CEM cement was used to manage a failed overfilled MTA apical plug in a symptomatic open apex upper central incisor [ 240 ]. The limitations of CBCT in detecting a labial fiber post-perforation were demonstrated, leading to the importance of exploratory surgery using CEM [ 241 ]. These cases demonstrated the versatility of CEM cement in different surgical endodontic scenarios.

Further case reports emphasized the importance of accurate diagnosis and treatment planning in surgical endodontics [ 242 ]. Successful outcomes were reported in cases involving the management of large periapical cysts, progressive actinomycosis, symptomatic horizontal mid-root fractures, and therapy-resistant periapical actinomycosis using CEM cement [ 243 , 244 , 245 ]. Additionally, a case of partial necrosis resulting from the spread of infection from adjacent apical periodontitis was treated with surgical retreatment using CEM cement, leading to complete recovery [ 246 ].

These case reports collectively demonstrate the effectiveness of CEM cement in surgical endodontic treatments, highlighting its positive impact on healing, symptom relief, and restoration of tooth functionality [ 198 ]. The use of CEM cement in root-end surgery offers a viable treatment option for managing various endodontic challenges and improving patient outcomes. However, further research with higher level evidence, such as randomized-controlled trials, is needed to further evaluate the efficacy and long-term success of CEM cement in surgical endodontics.

Intentional replantation

The first reported utilization of intentional replantation (IR) with CEM cement was described in a case study by Asgary in 2011, demonstrating successful management of a mandibular molar with chronic AP and previous RCT (Level V evidence) [ 247 ]. Follow-up examinations showed no signs of infection or inflammation and complete periradicular healing. This case report provided initial evidence of the effectiveness of CEM cement in IR procedures.

A subsequent case series in 2014 further investigated the indications and case selection for IR in endodontics, involving 20 cases treated with IR using CEM cement for root-end filling (Level IV evidence) [ 248 ]. The success rate of IR with CEM cement was reported as 90% over a mean follow-up period of 15.5 months. This study demonstrated the favorable outcomes of IR with CEM cement in a larger cohort of patients.

Various case reports have since been published, highlighting the effectiveness of IR with CEM cement in managing specific endodontic complications. These cases include the successful treatment of external root resorption after orthodontic treatment [ 249 ], necrotic calcified teeth [ 250 ], maxillary molars [ 251 ], avulsed immature permanent teeth [ 252 ], apical actinomycosis [ 253 ], and teeth with multiple endodontic complications [ 254 ]. Additionally, CEM cement has been found to decelerate replacement resorption in replanted teeth [ 255 ].

These case reports collectively demonstrate the effectiveness of IR with CEM cement in managing a range of endodontic challenges and complications. The use of CEM cement in IR procedures offers a viable treatment option for selected cases where conventional endodontic therapy may not be feasible or successful. However, further research with higher level evidence, such as randomized-controlled trials, is needed to further evaluate the efficacy and long-term success of IR with CEM cement.

Autotransplantation

The first reported use of autogenous tooth transplantation (AT) with CEM cement was described in a case study by Asgary, in 2009, demonstrating successful transplantation of a fully developed mandibular third molar to replace a vertically root-fractured second molar (Level V evidence) [ 256 ]. The transplanted tooth was treated with CEM cement as a root-end filling, and clinical follow-up over 2 years showed no complications and normal functionality. This case report provided initial evidence of the effectiveness of CEM cement in AT procedures.

In another case report, AT using a maxillary third molar with closed roots was performed to replace a tooth with a perio-endo lesion [ 256 ]. CEM cement was used to fill the roots before transplantation, and the patient had no symptoms during the follow-up period, with radiographic evidence of bone regeneration and a healthy periodontal ligament.

These case reports demonstrate the successful utilization of AT with CEM cement in replacing damaged or compromised teeth. The use of CEM cement in AT procedures offers a promising approach to promote healing, root-end sealing, and long-term stability of transplanted teeth. However, further research, including larger clinical studies, is needed to evaluate the success rates and long-term outcomes of AT with CEM cement compared to other materials or techniques in autotransplantation procedures.

Other surgical applications

The study by Ghanbari et al . aimed to compare the efficacy of CEM cement and ProRoot MTA in the treatment of Class II furcation defects in human mandibular molars (Level IV evidence) [ 257 ]. In this study, 40 furcation defects in 16 patients with chronic periodontitis were treated using either CEM cement or ProRoot MTA. Various clinical parameters, including probing depth (PD), vertical and horizontal clinical attachment levels (VCAL and HCAL), open vertical and horizontal furcation depths (OVFD and OHFD), and gingival margin level (GML), were measured at baseline and 3- and 6-month follow-ups. The results of the study showed that both ProRoot MTA and CEM cement significantly reduced PD, VCAL, HCAL, OVFD, and OHFD at the re-entry surgery. This indicates that both materials were effective in improving the clinical parameters and reducing the furcation defects. Importantly, there were no statistically significant differences between the two treatment options in terms of soft- and hard-tissue parameters. This suggests that CEM cement can be a viable alternative to ProRoot MTA in the treatment of Class II furcation defects.

It is worth noting that more research is needed to further evaluate the long-term outcomes and comparative effectiveness of CEM cement and ProRoot MTA in various surgical applications beyond the specific study mentioned above.

Management of root resorptions/perforations

Root perforation repair.

In a case report by Eghbal et al . , the repair of a strip perforation using CEM cement was successful (Level V evidence) [ 258 ]. The patient had a mandibular molar with a history of RCT and experienced a procedural mishap resulting in a perforation. After 1 week of treatment with CEM cement, the patient's symptoms improved, and radiographic evaluation at the 1-year follow-up showed complete healing of the lesion with bone replacement.

Another case report demonstrated the non-surgical repair of an old perforation with pocket formation and oral communication [ 259 ]. Despite negative prognostic factors, such as perforations in the coronal third of the tooth and the presence of a radiolucent lesion, the tooth exhibited normal functionality, and probing depths remained within the normal range after 18 months of treatment.

Additionally, a case report discussed the surgical management of a failed internal root resorption (IRR) treatment and highlighted the use of retrograde CEM cement filling following the initial failed treatment with orthograde MTA [ 260 ]. This report provided insights into the treatment approach and demonstrated successful outcomes.

Furthermore, another recent case report described the successful management of an unrepairable root perforation resulting from IRR using CEM cement as the root perforation repair material [ 236 ]. This case report showcased the potential of CEM cement in addressing challenging root perforation cases.

These case reports collectively demonstrate the effectiveness of CEM cement in repairing root perforations and highlight its role as a valuable material in the management of various types of root perforations, including strip perforations, old perforations with pocket formation, and cases of failed IRR treatment.

Furcal perforation repair

In a case report by Asgary, the repair of a furcal perforation using CEM cement was described (Level V evidence) [ 261 ]. The case involved a mandibular first molar with a furcal perforation and accompanying furcal lesion. The treatment approach included RCT to address the infected pulp and the repair of the perforation using CEM cement. At the 24-month recall, the patient showed no evidence of periodontal breakdown, no symptoms, and complete healing of the furcal lesion.

Another case study reported the successful repair of an extensive furcation perforation in a mandibular molar using CEM cement [ 262 ]. The patient remained asymptomatic during the 1-year follow-up, indicating a favorable treatment outcome.

In a separate case report, the management and healing of a large furcal lesion were achieved using a novel combination of triple antibiotic paste and CEM cement [ 263 ]. This case report highlighted the potential of CEM cement in conjunction with antibiotics for the successful treatment of furcation perforations.

Furthermore, a recent systematic review and meta-analysis compared various materials used for iatrogenic perforation repair in primary molars and found that premixed bioceramics, Atelocollagen, and CEM cement demonstrated superior clinical success rates compared to MTA [ 264 ]. This suggests that CEM cement is a viable option for furcal perforation repair in primary molars.

These findings collectively demonstrate the effectiveness of CEM cement in repairing furcal perforations and highlight its potential as a reliable material for the management of such cases.

External root resorption

In the study by Asgary et al . , the management of external root resorption (ERR) using CEM cement was investigated (Level V evidence) [ 265 ]. The case involved a patient with mobility of a replanted maxillary left central incisor and pain while chewing on the left central/lateral incisors. Radiographic examination revealed progressive inflammatory ERR in the left central incisor, as well as inadequate RCT. Both teeth were immature and had periapical radiolucencies. The treatment approach consisted of thorough irrigation of both teeth, followed by obturation with CEM cement. In the case of the central incisor, initial treatment with CH for 6 weeks was performed before the CEM cement obturation. Follow-up examinations were conducted for up to 40 months. The results demonstrated that the treated teeth remained functional with normal mobility, and the progression of the inflammatory ERR ceased. The resorptive lacunae were filled with newly formed bone, and complete healing of the periapical radiolucencies was observed.

Other case reports have also highlighted the successful management of external root resorption using antibiotics followed by root canal filling with CEM cement [ 266 , 267 ]. These reports further support the efficacy of CEM cement in the treatment of external root resorption.

Overall, these findings suggest that CEM cement can be an effective treatment option for managing external root resorption, promoting healing, and preserving the functionality of the affected teeth.

Internal root resorption

The case report by Ramazani et al . presented a management approach for internal root resorption (IRR) (Level V evidence) [ 268 ]. The treatment plan involved a two-visit non-surgical approach, where CEM cement was utilized during the root canal treatment to address the internal root resorption. Follow-up evaluations conducted for 1 year demonstrated the complete resolution of the patient's signs and symptoms, along with radiographic evidence of complete healing.

In cases of internal root resorption in primary molars of endodontic origin, the traditional treatment approach involves tooth extraction and placement of a space maintainer. However, a study by Tavassoli-Hojjati et al . investigated a different method using CEM cement as a treatment option for three primary molars with extensive internal root resorption and associated furcal lesions (Level V evidence) [ 269 ]. The procedure involved accessing the pulp chambers, irrigating with sodium hypochlorite, and filling the cavities with CEM cement. Stainless steel crowns were placed to restore the teeth. Follow-up examinations were performed for up to 17 months. The study showed successful outcomes, as all treated teeth indicated complete bone healing in the affected areas, radiographically. These findings suggest that using CEM cement in the treatment of primary molars with extensive internal root resorption, even in the presence of furcal lesions, may provide a viable alternative to tooth extraction and space maintainer placement.

Overall, these studies demonstrate the efficacy of CEM cement in managing internal root resorption, highlighting its potential for successful resolution of the condition and preservation of affected teeth.

Combined external/internal root resorption

In the study by Asgary and Ahmadyar, the management of combined external and internal root resorptions (ERR/IRR) using CEM cement was investigated (Level V evidence) [ 270 ]. Radiographic examination revealed inadequate obturation of the root canals along with severe external and internal root resorptions and a large periradicular lesion. Nonsurgical endodontic retreatment was performed, involving the conventional chemomechanical debridement of the root canals. In the same session, the entire distal root canal was obturated using CEM cement, while the mesial canals were obturated with gutta-percha and sealer. The clinical findings and follow-up radiographs after 12 months showed favorable treatment outcomes, indicating the successful management of the combined external and internal root resorptions using CEM cement.

Another case report presented the management of merged external and internal root resorptions using CEM cement, further demonstrating the effectiveness of CEM cement in treating this challenging condition [ 271 ].

These findings suggest that CEM cement can be a suitable material for the management of combined external and internal root resorptions, providing favorable treatment outcomes and potential for successful resolution of these complex cases.

Invasive cervical root resorption

In the study by Asgary and Fazlyab, the management of invasive cervical root resorption (ICRR) in a mandibular canine using CEM cement was investigated (Level V evidence) [ 272 ]. The treatment approach involved the placement of CEM cement in the cavity after performing a full mucoperiosteal flap. One week later, CEM cement was polished and covered with composite resin. The 1-year follow-up showed a healthy pulp and a reduction in gingival probing depth, indicating improved attachment.

Another report discussed the conservative management of Class 4 ICRR using CEM cement, further emphasizing the effectiveness of the biomaterial in treating ICRR [ 273 ]. This case report demonstrated successful outcomes in managing ICRR with CEM cement.

Additionally, another case report described the intracanal management of a post-traumatic perforative ICRR using CEM cement [ 274 ]. The case showcased the successful use of CEM cement in managing the perforation and preserving the tooth structure in ICRR.

Furthermore, a case series by Asgary et al . presented the management of ICRR using VPT with CEM cement (Level IV evidence) [ 275 ]. The study included six teeth diagnosed with ICRR and having normal pulpal and periodontal status. Various VPT techniques, such as direct pulp capping (DPC), partial pulpotomy (PP), and partial pulpectomy, were selected based on the accessibility of the resorptive lacunae. The teeth were then restored, and follow-up evaluations were conducted. The results showed that all treated teeth remained functional and asymptomatic, with a healthy periodontium, during an average follow-up period of 19.6 months. No progression of the resorption or development of new resorption was observed.

These studies collectively demonstrate the effectiveness of CEM cement in the management of invasive cervical root resorption, offering promising outcomes and potential for preserving tooth structure and function.

Root canal/orifice obturation

In the study by Asgary and Eghbal, the use of CEM cement for root canal obturation in a mandibular molar with internal root resorption and an open apex was investigated (Level V evidence) [ 276 ]. The case report described a non-surgical retreatment procedure in which the root canal was cleaned, shaped, and obturated using CEM cement in combination with gutta-percha and sealer. After a follow-up period of 3 years, the tooth remained asymptomatic, and both clinical and radiographic assessments showed complete healing.

Other case reports have also highlighted the successful use of CEM cement in various clinical scenarios for root canal obturation. One case report focused on the management of infected primary molars using CEM cement, demonstrating positive treatment outcomes [ 277 ]. Another case report discussed the successful treatment of non-obturated canals using CEM cement, emphasizing its efficacy in such cases [ 278 ].

These reports collectively demonstrate the effectiveness of CEM cement as a root canal obturation material, showcasing its potential for achieving successful endodontic outcomes in different clinical situations.

As a sealer

This section explores the practical application of CEM cement, focusing on its innovative premixed bio-sealer variant, HealApex. While CEM cement is not recommended for use as a sealer, HealApex, derived from CEM powder, is specifically designed to function as an endodontic sealer, providing a unique perspective compared to the established AH-26 [ 279 ]. The investigation meticulously assessed crucial parameters such as setting time, working time, film thickness, flow, and radiopacity, adhering to ISO 6876 standards. Biocompatibility evaluations, conducted under ISO 10993-5 and utilizing L929 fibroblasts, yielded positive insights into the cytotoxicity profile of HealApex. Furthermore, the study scrutinized the favorable sealing ability of HealApex through a fluid filtration method spanning one month, revealing its performance in both short-term and long-term scenarios. These findings contribute to a deeper understanding of the practical implications of CEM-based bio-sealers, offering valuable information for optimizing endodontic treatments.

Merits and limitations of CEM cement

Setting time: CEM cement has a relatively shorter setting time compared to ProRoot MTA, allowing for efficient and timely completion of endodontic procedures [ 7 ].

Handling characteristics: CEM cement has a high percentage of small particles that enable easy manipulation and placement within the root canal system [ 62 ]. It adapts well to cavity walls, facilitating precise/effective application.

Slight material expansion: CEM cement has been reported to undergo a very slight expansion during the setting process, which can contribute to its excellent sealing ability [ 7 ].

Moisture resistance: CEM cement is hydrophilic, meaning that it can set and function effectively in the presence of moisture [ 12 , 89 ]. This characteristic is advantageous in endodontic procedures where moisture control can be challenging, ensuring reliable performance in clinical situations.

Sealing ability: CEM cement exhibits superior sealing properties, effectively preventing the microleakage of bacteria/toxins from the root canal system [ 87 ]. Its ability to form a tight seal with dentinal walls reduces the risk of reinfection.

Alkalinity and calcium ion release: CEM cement's alkaline pH and sustained release of calcium ions offer several advantages [ 12 ]. Its alkaline environment inhibits bacterial growth and promotes antibacterial effects. The release of calcium ions facilitates remineralization, aiding in the formation of mineralized tissues and enhancing the overall healing process.

Antibacterial properties: CEM cement demonstrates antibacterial effects against various microorganisms commonly associated with intracanal infections [ 120 ], enhancing the success rate of endodontic therapy.

Reinforcement of tooth structure: CEM cement has been shown to reinforce weakened tooth structure, providing added strength and support to treated teeth [ 32 ]. This reinforcement can help prevent fractures and improve the long-term prognosis of the treated tooth.

Bioactivity: CEM cement possesses bioactive properties, allowing it to interact with surrounding tissues and promote regeneration/repair of dental structures [ 11 ]. It stimulates the formation of new dentin, contributing to the healing process within the root canal system.

Biocompatibility: CEM cement demonstrates excellent biocompatibility, making it well tolerated by tissues [ 143 ]. Its compatibility with the surrounding biological environment reduces the risk of adverse reactions or inflammation, promoting favorable healing outcomes.

Dentinogenesis: CEM cement has the unique ability to stimulate dentin formation [ 164 ]. It supports the regeneration/healing of damaged dental tissues, promoting the structural integrity and functionality of the tooth.

Versatile applications: CEM cement has versatile applications in endodontics, making it suitable for various procedures, such as root/furcal perforation repair [ 236 ], management of root resorptions [ 198 ], and obturation of root canals with open apices [ 232 ]. Its versatility simplifies treatment protocols and expands the range of clinical challenges it can effectively address.

Long-term stability: CEM cement has demonstrated long-term stability in clinical studies, indicating its ability to maintain its sealing and biocompatible properties over time [ 280 ]. This long-term stability contributes to the durability and success of endodontic treatments.

Cost: The cost of CEM cement is generally lower compared to other commonly used endodontic biomaterials, i.e., ProRoot MTA. This cost advantage makes CEM cement more accessible to a wider range of patients and facilitates its adoption in clinical practice, offering a cost-effective solution for endodontic treatments [ 219 ].

It is important to note that the advantages of CEM cement listed here are based on the available knowledge and understanding of the biomaterial up to the current date. Ongoing research and advancements may uncover additional benefits or further support the existing advantages of it.

Limitations and challenges

Radiopacity: CEM cement exhibits a higher radiopacity at least twice that of dentin, but it has lower radiopacity compared to related ISO standards.

Influence of environmental factors: The setting and properties of CEM cement may be affected by environmental factors such as severe blood contamination, which can impact its performance and clinical outcomes.

Learning curve: Familiarity and experience with working with CEM cement are necessary to achieve consistent and predictable results. The learning curve associated with mastering the handling and placement techniques of CEM cement may initially pose a challenge for some practitioners.

Limited long-term clinical data: Although CEM cement has shown promising results in various clinical trials and case reports, there is still a relatively limited amount of long-term clinical data available. Further long-term studies are needed to evaluate its performance and success rates over extended periods.

By addressing these challenges and limitations, and with ongoing research and advancements, the full potential of CEM cement as a valuable biomaterial in endodontics can be realized.

Future perspectives and research directions

Advances in cem cement technology.

Ongoing research is focused on enhancing the properties of CEM cement. Efforts are being made to improve its radiopacity, optimize handling characteristics, and refine the setting time. Additionally, researchers are exploring the incorporation of bioactive additives or nanoparticles to enhance their antibacterial properties and regenerative potential. These advancements in CEM cement technology will contribute to its overall performance and expand its applications in various endodontic procedures. Further investigations are crucial to unravel the underlying mechanisms causing discoloration in CEM cement, providing valuable insights that can guide future improvements in its formulation.

Clinical studies and outcomes

Further well-designed and long-term clinical studies are needed to strengthen the evidence base for CEM cement. Large-scale studies with extended follow-up periods will provide valuable insights into the long-term success and durability of CEM cement in different clinical scenarios. Comparative studies comparing CEM cement with other endodontic materials will help evaluate its performance and advantages in specific treatment modalities. Assessing patient-reported outcomes, such as pain, functionality, and satisfaction, will provide a comprehensive understanding of the patient-centered benefits of CEM cement.

Novel applications and modifications

As our understanding of CEM cement expands, there is potential for novel applications and modifications. Researchers are exploring innovative uses of CEM cement beyond the conventional endodontic procedures, such as VPT, regenerative endodontics, and periodontal applications. Modifying CEM cement formulations, such as incorporating growth factors or bioactive molecules, is being investigated to enhance its regenerative potential and expand its therapeutic applications. Exploring these novel applications and modifications will further optimize the clinical outcomes and expand the utility of CEM cement in diverse clinical scenarios.

Biocompatibility and safety studies

While CEM cement has demonstrated excellent biocompatibility, further research is needed to explore its long-term effects on periapical tissues and systemic health. Comprehensive studies evaluating cytotoxicity, immunogenicity, and potential adverse reactions associated with CEM cement are necessary. Additionally, investigations into its biodegradation and biocompatibility in various clinical scenarios, such as re-treatments, will provide insights into its long-term safety and performance.

Conclusions

Summary of key findings.

CEM cement demonstrates excellent biocompatibility, promoting tissue healing.

It exhibits bioactivity and sustained release of calcium/phosphate ions, contributing to hydroxyapatite formation and mineralized tissue regeneration.

CEM cement demonstrates favorable sealing ability, contributing to the formation of an effective bioseal and preventing bacterial microleakage, thereby reducing the risk of reinfection.

It possesses antibacterial and anti-fungal properties, aiding in infections control.

CEM cement stimulates dentinogenesis/cementogenesis, promoting the formation of dentin bridges and cementum.

It has good handling characteristics, making it easy to manipulate/place in clinical settings.

CEM cement is versatile and can be used in various endodontic procedures.

It has shown successful outcomes in VPTs and preserving pulpal vitality.

CEM cement is cost-effective, providing an affordable option for endodontic treatment.

It is compatible with other dental materials, allowing for successful integration with restorative/prosthetic treatments.

Implications for clinical practice

The use of CEM cement in endodontics has important implications for clinical practice. Clinicians can benefit from its excellent sealing ability, biocompatibility, and antibacterial properties, which contribute to the success of endodontic treatments. CEM cement's regenerative potential makes it particularly suitable for cases involving large periapical lesions, apexification, and root-end filling. Its versatility allows for simplified treatment protocols and effective management of various clinical situations. Clinicians should ensure proper operator experience and training with CEM cement's handling characteristics to achieve optimal results in clinical practice.

Availability of data and materials

No datasets were generated or analysed during the current study.

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Asgary S, Ehsani S. Periradicular surgery of human permanent teeth with calcium-enriched mixture cement. Iran Endod J. 2013;8(3):140.

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Asgary S, Mirmohammadi H, Parhizkar A. Management of symptomatic horizontal mid-root fractures after unsuccessful orthograde endodontic retreatments. Cureus. 2019;11(8):e5473.

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Asgary S, Nosrat A. Concurrent intentional replantation of maxillary molars using a novel root-end filling. Gen Dent. 2014;62(3):30–3.

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Eghbal MJ, Fazlyab M, Asgary S. Repair of an extensive furcation perforation with CEM cement: a case study. Iran Endod J. 2014;9(1):79.

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Asgary S, Ahmadyar M. One-visit endodontic retreatment of combined external/internal root resorption using a calcium-enriched mixture. Gen Dent. 2012;60(4):e244–8.

Mirmohammadi H, Asgary S. Management of merged external/internal root resorption using cem cement: a case report. J Oral Res. 2018;7(8):318–22.

Asgary S, Fazlyab M. Surgical repair of invasive cervical root resorption with calcium-enriched mixture cement: a case report. Gen Dent. 2015;63(1):37–40.

Asgary S, Nosrat A. Conservative management of class 4 invasive cervical root resorption using calcium-enriched mixture cement. J Endod. 2016;42(8):1291–4.

Asgary S, Nosrat A, Fazlyab M. Intracanal management of a post-traumatic perforative invasive cervical root resorption using calcium enriched matrix cement. Saudi Endod J. 2013;3(3):139–43.

Asgary S, Nourzadeh M, Verma P, Hicks ML, Nosrat A. Vital pulp therapy as a conservative approach for management of invasive cervical root resorption: a case series. J Endod. 2019;45(9):1161–7.

Asgary S, Eghbal MJ. Root canal obturation of an open apex root with calcium enriched mixture. J Int J Case Rep Imaging. 2012;3:50–2.

Asgary S, Fazlyab M. Endodontic management of an infected primary molar in a child with agenesis of the permanent premolar. Iran Endod J. 2017;12(1):119–22.

Asgary S, Fazlyab M. A successful endodontic outcome with non-obturated canals. Iran Endod J. 2015;10(3):208–10.

Shourgashti Z, Keshvari H, Torabzadeh H, Rostami M, Bonakdar S, Asgary S. Physical properties, cytocompatibility and sealability of HealApex (a novel premixed biosealer). Iran Endod J. 2018;13(3):299–304.

Asgary S, Eghbal MJ, Fazlyab M, Baghban AA, Ghoddusi J. Five-year results of vital pulp therapy in permanent molars with irreversible pulpitis: a non-inferiority multi-center randomized clinical trial. Clin Oral Invest. 2015;19(2):335–41.

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Iranian Centre for Endodontic Research, Research Institute of Dental Sciences, School of Dentistry, Shahid Beheshti University of Medical Sciences, Tehran, Iran

Saeed Asgary

Sharif University of Technology, Tehran, Iran

Mahtab Aram

Department of Endodontics, Faculty of Dentistry, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran

Mahta Fazlyab

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SA conceptualized the study, performed data analyses, and prepared the manuscript. MA and MF supported the conceptualization of the study and assisted in manuscript preparation and revision.

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Correspondence to Saeed Asgary .

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SA is the inventor of CEM cement (Endodontic Filling Material; USA, 7,942,961, 2011 May 17).

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Asgary, S., Aram, M. & Fazlyab, M. Comprehensive review of composition, properties, clinical applications, and future perspectives of calcium-enriched mixture (CEM) cement: a systematic analysis. BioMed Eng OnLine 23 , 96 (2024). https://doi.org/10.1186/s12938-024-01290-4

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Received : 07 February 2024

Accepted : 07 September 2024

Published : 18 September 2024

DOI : https://doi.org/10.1186/s12938-024-01290-4

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