SUMMARY REVIEW/PAEDIATRIC DENTISTRY

Are different pulp treatment techniques and

associated medicaments effective for the treatment of
extensive decay in primary teeth?
Paula Waterhouse1,2

A commentary on
Practice point
Smaïl-Faugeron V, Glenny A-M, Courson F, Durieux P, Muller-
• If pulp therapy is required for primary molars, MTA is the
Bolla M, Chabouis H F. medicament of choice for pulpotomies and probably ZOE for
Pulp treatment for extensive decay in primary teeth. Cochrane pulpectomies.
Database Syst Rev 2018; DOI: 10.1002/14651858.CD003220.pub3.

Abstract as toxic. Biodentine, enamel matrix derivatives, laser application or

Data sources Cochrane Oral Health’s Trials Register and Central Ankaferd Blood Stopper (a plant-based haemostatic agent used to
Register of Controlled Trials, Medline Ovid, Embase Ovid, Web control gastrointestinal bleeds) appear to be second choices. If all
of Science, Open Grey, US National Institutes of Health Ongoing of these are unavailable, an application of sodium hypochlorite may
Trials Register and World Health Organisation International Clinical be the safest option. For pulpectomy, evidence was inconclusive;
Trials Registry Platform. There were no restrictions on language or however, ZOE paste may be more effective than Vitapex, but no
publication dates. further conclusions could be made. For direct pulp capping, the
Study selection Two reviewers selected randomised clinical trials evidence was of low to very low quality. The best alternative may be
(RCTs) comparing different pulp interventions in extensively decayed a tricalcium silicate, especially MTA. Future RCTs may change these
primary teeth, which combined a pulp treatment technique and a findings.
medicament.
Data extraction and synthesis Data were extracted independently
by two reviewers recording year of publication, country of origin, Commentary
inclusion/exclusion criteria, description of interventions, sample size, Childhood caries remains a significant challenge and remains
mean age, duration of follow-up and outcome data. Risk of bias was among the most prevalent chronic diseases globally.1 A cavity
assessed by two reviewers. Meta-analysis was performed on RCTs involving at least half the tooth surface is considered ‘extensive’.2
comparing different medicaments for the same pulp technique or Extensive caries is the commonest disease of primary teeth with
different pulp treatment techniques with each other. the sequelae of pain, infection and swelling.3
Results Eighty-seven RCTs were included in qualitative synthesis, The main aim of pulp therapy techniques in the primary
yielding 59 studies for meta-analysis. The 87 RCTs involved 7,140 dentition is to maintain the tooth until it exfoliates naturally
randomised teeth with 17 split-mouth RCTs and 70 parallel arm while maintaining the health of the tooth’s supporting structures.4
design. In total, 125 different comparisons were examined using There is a range of pulp therapy techniques which combine a
clinical and radiological failure rates; 75 compared different particular technique and medicament/agent serving to eliminate
pulpotomy agents or techniques, 25 compared different pulpectomy microbial load and protect the tooth from future microbial
agents, four compared pulpotomy and pulpectomy, and 21 compared invasion.
different agents for direct pulp capping. Where possible, data were American and British guidelines for pulp therapy indicate
compared for 6, 12 and 24 months. For pulpotomy, mineral trioxide three different approaches depending upon the severity of pulpal
aggregate (MTA) appears least likely to fail over those time periods. inflammation: direct pulp cap, pulpotomy and pulpectomy.5,6
For pulpectomy, results were inconclusive comparing failure rates In view of the safety concerns for formaldehyde-containing
between various agents; however, two RCTs found a lower failure rate formocresol solution, the most prominent medicaments appear to
for zinc oxide-eugenol (ZOE) compared with Vitapex. For direct pulp be mineral trioxide aggregate (MTA), calcium hydroxide and ferric
capping, there was a low number of studies undertaking the same sulphate.
comparisons; calcium silicates (eg MTA and Biodentine) hold future Previous Cochrane reviews in this specific area concluded there
promise. was insufficient evidence to support one type of treatment over
Conclusions Overall, evidence quality ranged from moderate to very another.7,8
low. For pulpotomy, MTA may be the best pulpotomy medicament The aim of this review was to assess the latest evidence for pulp
in primary molars. Formocresol is effective but generally accepted therapy for carious primary teeth. Both primary and secondary
outcomes were assessed. Primary outcomes were clinical and
radiographic failure. Secondary outcomes included overall failure
GRADE rating plus various clinical and radiographic signs and symptoms of

12 © EBD 2021:22.1

© The Author(s), under exclusive licence to British Dental Association 2021
 SUMMARY REVIEW/PAEDIATRIC DENTISTRY

failure together with dental anxiety, physiological exfoliation and served by concentrating upon finding the optimum technique and
dentine bridge formation. Wherever possible, these outcomes were medicaments/obtundants.
assessed at 6, 12 and 24 months. There were few trials comparing direct pulp-capping agents;
An extensive database search was undertaken with no however, the data favoured the calcium silicates such as MTA and
restrictions on either publication date or language, optimising Biodentine. Careful consideration should be given as to when
identification of relevant global randomised clinical trials. A risk direct pulp capping is used in the primary dentition and it is
of bias assessment was undertaken by two authors independently generally accepted that it should be reserved for traumatic non-
using the Cochrane tool. carious exposure of pulp tissue.5,6 As such, future research should
A vast number of comparisons were made for each of the three perhaps concentrate on the optimum technique/medicament for
broad pulp treatment areas. For pulpotomy, 53 trials compared non-carious pulp exposures.
different agents/techniques in 75 comparisons. Four trials The review supports the abandonment of the use of formocresol
compared pulpotomy to pulpectomy in four comparisons and in pulpotomy in favour of the calcium silicates and suggests that
seven trials involving pulp capping resulted in 21 comparisons. the way forward would be a large long-term clinical trial of MTA,
Follow-up post-pulp therapy is important, and the review included Biodentine and enamel matrix derivatives, although the latter, if
data assessed at 6 months (70 trials), 12 months (59 trials) and of porcine origin, would not be appropriate for clinical use in all
24 months (24 trials). From a perspective of techniques used, patients.
data relating to a range of variables were recorded; for example,
rubber dam usage, technique for pulp access, haemostasis, type of Author affiliations
medicament/agent, and intermediate and definitive restorations. 1
Clinical Senior Lecturer in Child Dental Health and Honorary
The random sequence generation and associated risk of selection Consultant in Paediatric Dentistry, The School of Dental
bias was reported to be low in 37 trials. One trial was judged to be Sciences, Faculty of Medical Sciences, Newcastle University,
at high risk of bias, but there was insufficient evidence to judge Newcastle upon Tyne, UK; 2Department of Paediatric Dentistry,
risk of bias in 49 trials. In 91% of trials, allocation concealment Newcastle Dental Hospital, Newcastle upon Tyne Hospital NHS
was unclear. Foundation Trust, Newcastle upon Tyne, UK.
From the review of pulpotomy outcomes, the relatively costly Correspondence to: Paula Waterhouse
MTA was superior to formocresol and ferric sulphate, and all
three were superior to calcium hydroxide. Evidence for other References
medicaments/agents was weak due to the small numbers of 1. World Health Organisation. WHO Expert Consultation on Public Health Intervention
against Early Childhood Caries: Report of a Meeting. Switzerland: World Health
studies included. Buckley’s formocresol (48.5% formaldehyde, Organisation, 2017.
2. International Caries Detection and Assessment System Coordinating Committee.
48.5% cresol, 3% glycerine) is no longer widely used in paediatric
Rationale and Evidence for the International Caries Detection and Assessment
dentistry due to the carcinogenicity of formaldehyde and toxicity System (ICDAS II). 2012. Available at https://www.iccms-web.com/uploads/
asset/592848be55d87564970232.pdf (accessed May 2020).
of cresols.9 The authors recommend that MTA should become the 3. Selwitz R H, Ismail A I, Pitts N B. Dental caries. Lancet 2007; 369: 51–59.
‘gold standard’ against which other pulpotomy medicaments/ 4. Waterhouse P J. “New Age” pulp therapy: personal thoughts on a hot debate.
Pediatr Dent 2008; 30: 247–252.
agents should be tested and that formocresol should have no place 5. Rodd H D, Waterhouse P J, Fuks A B, Fayle S A, Moffat M A, British Society of
in research trials. Paediatric Dentistry. Pulp therapy for primary molars. Int J Paediatr Dent 2006; 16
Suppl 1: 15–23.
For pulpectomy, the optimum agent to use as a resorbable root 6. Anonymous. Guideline on pulp therapy for primary and immature permanent teeth.
Pediatr Dent 2016; 38: 280–288.
canal obtundant was zinc oxide-eugenol (ZOE), although there 7. Nadin G, Goel B R, Yeung C A, Glenny A M. Pulp treatment for extensive decay in
were only a small number of studies with often incomparable primary teeth. Cochrane Database Syst Rev 2003; DOI: 10.1002/14651858.CD003220.
8. Smaïl-Faugeron V, Courson F, Durieux P, Muller-Bolla M, Glenny A M, Chabouis H
results. The two different techniques of pulpectomy and F. Pulp treatment for extensive decay in primary teeth. Cochrane Database Syst Rev
pulpotomy were compared, yielding limited evidence. This is 2014; DOI: 10.1002/14651858.CD003220.pub3.
9. World Health Organisation. IARC Monographs on the Evaluation of Carcinogenic
unsurprising because each treatment approach is used for different Risks to Humans. 2006. Available at https://monographs.iarc.who.int/wp-content/
uploads/2018/06/mono86.pdf (accessed May 2020).
reasons; one may use pulpotomy for a reversibly inflamed pulp,
but an irreversibly inflamed or infected pulp would require Evidence-Based Dentistry (2021) 22, 12-13.
pulpectomy. Future research relating to pulpectomy may be best https://doi.org/ 10.1038/s41432-021-0162-6

© EBD 2021:22.1 13
© The Author(s), under exclusive licence to British Dental Association 2021