Highlighted review: Pulp treatment for extensive decay in primary teeth

Violaine Smaïl-Faugeron, Anne-Marie Glenny, Frédéric Courson, Pierre Durieux, Michele Muller-Bolla, Helene Fron Chabouis

Plain language summary: Pulp treatment for extensive decay in primary teeth

Review question
How effective are different options for treating extensive tooth decay in children's primary (milk) teeth to resolve the child's symptoms (typically pain, swelling, abnormal movement) and tooth signs (as shown on an x-ray)?

In children, tooth decay is among the most common diseases. Tooth decay in the primary teeth tends to progress rapidly, often reaching the pulp - the nerves, tiny blood vessels and connective tissue that make up the centre of a tooth. Dentists often have to perform one of three pulp treatment techniques: direct pulp capping (where a healing agent is placed directly over the exposed pulp), pulpotomy (removal of a portion of the pulp) or pulpectomy (removal of all of the pulp in the pulp chamber and root canal of a tooth).

The most common materials used for direct pulp capping are calcium hydroxide, the more recent but more expensive mineral trioxide aggregate, formocresol or an adhesive resin (placed directly over the tooth's nerve).

After a pulpotomy, one of four materials is generally used: ferric sulphate, formocresol, calcium hydroxide or mineral trioxide aggregate. After a pulpectomy, a material is put into the space created by pulp removal. This material should not prevent the resorption of the primary tooth's root, to let the permanent tooth to grow in.

Study characteristics
Review authors working with Cochrane Oral Health carried out this review of randomised controlled trials. The evidence is current up to August 2017.

We included 87 trials that investigated the success of pulp treatment of milk teeth. The trials were published between 1989 and 2017 and provided 125 comparisons of different treatment options.

Key results
Pulp treatment for extensive decay in primary teeth is generally successful. The proportion of treatment failures was low, with many of the included trials having no failures with either of the treatments being compared.

After a pulpotomy, mineral trioxide aggregate (MTA) seems to be the best material (in terms of biocompatibility and efficacy) to put into contact with the remaining root dental nerve. The evidence showed it to be less likely to fail than either calcium hydroxide or formocresol.

After pulpectomy, it is not clear whether any medicament is superior to another. ZOE paste may give better results than Vitapex (calcium hydroxide/iodoform) paste, but more studies are needed to confirm this and to explore other treatment options.

Regarding direct pulp capping, the small number of studies undertaking the same comparison limits any interpretation. Formocresol may be superior to calcium hydroxide in terms of clinical and radiological failure, but because of toxic effects associated with formocresol, safer alternatives should be evaluated.

Quality of the evidence
We judged the quality of the evidence suggesting the superiority of MTA over calcium hydroxide or formocresol after pulpotomy to be moderate. For other comparisons, the quality of the evidence is low or very low, which means we cannot be certain about the findings. The low quality is due to shortcomings in the methods used within the individual trials, the small number of children included in the trials and the short-term follow-up after treatment.

Future trials to evaluate which healing agents are best for the three pulp treatments would require a very large sample size and should follow up the participants of a minimum of one year.

Read the full review

Citation: Smaïl-Faugeron V, Glenny AM, Courson F, Durieux P, Muller-Bolla M, Fron Chabouis H. Pulp treatment for extensive decay in primary teeth. Cochrane Database of Systematic Reviews 2018, Issue 5. Art. No.: CD003220. DOI: 10.1002/14651858.CD003220.pub3.