Dental caries is one of the commonest diseases of children worldwide. Once the pulp has become involved a range of interventions involving a treatment technique and a medicament are available; pulp capping; pulpotomy and pulpectomy.

The aim of this review was to assess the effects of different pulp treatment techniques and associated medicaments for the treatment of extensive decay in primary teeth.

Methods

Searches were conducted with no language or date restriction in the Cochrane Oral Health Group’s Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, the Web of Science, OpenGrey, the US National Institutes of Health Trials Register and the World Health Organization (WHO) Clinical Trials Registry Platform.

Randomised controlled trials comparing different pulp interventions combining a pulp treatment technique and a medicament in primary teeth were considered.

Study selection, data abstraction and risk of bias assessment was carried out independently by two reviewers. The primary outcomes were clinical failure and radiological failure, as defined in trials, at six, 12 and 24 months. Pairwise meta-analyses using fixed-effect models was conducted with statistical heterogeneity being assessed using I2 coefficients.

Results

• 47 trials (3910 teeth) were included.
• The overall level of evidence was low with only 1 trial having a low risk of bias , 20 a high risk and 26 unclear risk of bias.
• 53 different comparisons were examined; 25 comparisons between different medicaments/techniques for pulpotomy, 13 comparisons between different medicaments for pulpectomy, 13 comparisons between different medicaments for direct pulp capping and two comparisons between pulpotomy and pulpectomy.

• For pulpotomy,
• 14 trials compared mineral trioxide aggregate (MTA) with formocresol (FC).
  • MTA reduced both clinical and radiological failures at six, 12 and 24 months, although the difference was not statistically significant.
  • MTA also showed favourable results for all secondary outcomes measured, although again, differences between MTA and FC were not statistically significant (with the exception of pathological root resorption at 24 months and dentine bridge formation at six months).
  • MTA showed favourable results compared with calcium hydroxide (CH) (2 trials) for all outcomes measured, but the differences were not statistically significant (with the exception of radiological failure at 12 months).
  • 3 trails compares MTA with ferric sulphate (FS), MTA had statistically significantly fewer clinical, radiological and overall failures at 24 months. This difference was not shown at six or 12 months.
  • FC was compared with CH in seven trials and with FS in seven trials. There was a statistically significant difference in favour of FC for clinical failure at six and 12 months, and radiological failure at six, 12 and 24 months.
  • FC also showed favourable results for all secondary outcomes measured, although differences between FC and CH were not consistently statistically significant across time points.
  • Comparisons between FC and FS showed no statistically significantly difference between the two medicaments for any outcome at any time point.
• For all other comparisons of medicaments used during pulpotomies, pulpectomies or direct pulp capping, the small numbers of studies and the inconsistency in results limits any interpretation.

Conclusions

The authors concluded

We found no evidence to identify one superior pulpotomy medicament and technique clearly. Two medicaments may be preferable: MTA or FS. The cost of MTA may preclude its clinical use and therefore FS could be used in such situations. Regarding other comparisons for pulpectomies or direct pulp capping, the small numbers of studies undertaking the same comparison limits any interpretation.

Commentary

This publication updates the earlier Cochrane review first published in 2003; that review only included 3 studies so the increase in available publications that address this topic is welcome. However, as the authors note there are a number of shortcomings in the primary studies.

One of those highlighted is the wide range of outcome measures reported which makes meta-analysis difficult if not impossible. The other is the size of the included studies the majority of which are small.

In their discussion the authors also suggest that a network meta-analysis of this area may be helpful to unravel the efficacy hierarchy. One was published earlier this year by Lin et al (Dental Elf – 27^th Feb 2014) which included 37 studies with 22 contributing to the network meta-analysis.  That suggests that MTA had the best clinical and radiographic outcomes at 9-12 months.

Links

Smaïl-Faugeron V, Courson F, Durieux P, Muller-Bolla M, Glenny AM, Fron Chabouis H. Pulp treatment for extensive decay in primary teeth. Cochrane Database of Systematic Reviews 2014, Issue 8. Art. No.: CD003220. DOI: 10.1002/14651858.CD003220.pub2.

Dental Elf – 27^th Feb 2014 – Review suggests that mineral trioxide aggregate had best clinical and radiographic outcomes at 9-12 months for primary molar pulpotomy