About 1 in 4 first permanent molar in UK children are compromised. Caries and molar incisor hypomineralisation (MIH) being the commonest factors. Views on the management of these compromised first permanent molars differ with some preferring extraction to allow for spontaneous tooth closure by the second permanent molar while other prefer to restore. Restoration may require endodontic management with a range of techniques available, pulpotomy (partial and coronal), pulpectomy, apexification, and regenerative techniques. However, the use of these techniques is limited.
The aim of this review was to assess the clinical success rates of endodontic therapies used on compromised first permanent molar teeth in a child aged 16 and under.
Methods
Searches were conducted in the Medline/PubMed, Embase, Cochrane Library, Cochrane Central Register of Controlled Trials (CENTRAL), Clinicaltrials.gov, and the ISRCTN registry databases. This was supplemented by searches in the journals; Journal of Endodontics, Australian Dental Journal, Australian Endodontic Journal, Dental Traumatology, International Endodontic Journal, and International Journal of Paediatric Dentistry. Any study assessing the overall success of endodontic therapy (partial pulpotomy/coronal pulpotomy, pulpectomy, apexification, and regenerative techniques) in a first permanent molar of a child under the age of sixteen was considered. Studies published in English and with less than 6 months follow up were excluded.
Two reviewers screened and selected studies and extracted data. Study bias was also assessed independently by two reviewers using the Cochrane tool for randomised trials and the ROBINS-I tool for non-randomised clinical trials. Quality of the evidence was assessed using the GRADE (Grading of Recommendations Assessment, Development, and Evaluation) approach. A narrative summary was provided as meta-analysis was not carried out because of study heterogeneity.
Results
- 11 studies (3 RCTs; 5 prospective cohorts, 1 retrospective cohort, 1 case series, 1 case report) were included.
- All 3 RCTs were considered to be at high risk of bias and all 6 non-randomised studies classified at having serious biases.
- 5 studies performed partial pulpotomy,4 studies coronal pulpotomy, 1 study a conventional pulpotomy and 1 study a regenerative technique.
- 6 studies reported on rubber dam use with a possible 10.9% improvement in success with its use.
- 4 studies used mineral trioxide aggregate (MTA)alone, 2 studies used calcium hydroxide (Ca (OH)2) alone, 3 studies compared MTA and Ca (OH)2 and 1 a triple antibiotic paste.
| Technique | Indicative success rates |
| Pulpotomies overall | 91.1% (range 70%-100%) |
| Partial pulpotomies | 91.3% (range 78.5%-100%) |
| Coronal pulpotomies | 90.5% (range 70%-100%) |
| Pulpectomies | 36% |
Conclusions
The authors concluded: –
Despite small numbers, coronal and partial pulpotomies have shown to be successful options for managing immature and mature compromised first permanent molar teeth in children. These options should be given due consideration, irrespective of the pre-operative clinical state as this did not appear to influence the success rates of these modalities. We cannot however draw definite conclusions regarding conventional pulpectomy, apexification, and regenerative techniques, in first permanent molars in children, due to the paucity of available evidence. This is not say that these techniques cannot be used. Further well-designed studies, with larger sample sizes, should be undertaken with the range of techniques available to provide a more definitive answer.
Comments
The authors have searched a good range of databases and relevant journals for this review although limiting the inclusions to English language publication may have excluded some relevant studies. While the inclusion of a broad range of study designs has the potential to make use of all the available literature in an area where there is a perceived scarcity of evidence this needs to be carefully considered when interpreting the findings.
The findings suggest a good success rate for pulpotomy however the included studies had small sample sizes and none of them were at low risk of bias. While in theory a high quality of evidence is provided by the 3 RCTs all three were considered to be at high risk of bias with concerns about the randomisation process, attrition and selective reporting making a ‘high GRADE’ assessment generous. As the authors indicated well conducted and reported studies with larger sample sizes using a variety of available techniques are needed to provide better evidence on this question.
Links
Primary Paper
Taylor GD, Vernazza CR, Abdulmohsen B. Success of endodontic management of compromised first permanent molars in children: A systematic review. Int J Paediatr Dent. 2019 Nov 28. doi: 10.1111/ipd.12599. [Epub ahead of print] PubMed PMID: 31778237.
Other references
Dental Elf – 22nd Jan 2016
Dental Elf – Pulpotomy blogs
