In children, dental caries (tooth decay) is among the most prevalent chronic diseases
worldwide. Pulp interventions are indicated for extensive tooth decay. Depending on
the severity of the disease, three pulp treatment techniques are available: direct
pulp capping, pulpotomy and pulpectomy. After treatment, the cavity is filled with
a medicament. Materials commonly used include mineral trioxide aggregate (MTA), calcium
hydroxide, formocresol or ferric sulphate. This is an update of a Cochrane Review
published in 2014 when insufficient evidence was found to clearly identify one superior
pulpotomy medicament and technique. To assess the effects of different pulp treatment
techniques and associated medicaments for the treatment of extensive decay in primary
teeth. Cochrane Oral Health's Information Specialist searched the Cochrane Oral Health
Group's Trials Register (to 10 August 2017), the Cochrane Central Register of Controlled
Trials (CENTRAL) ( The Cochrane Library 2017, Issue 7), MEDLINE Ovid (1946 to 10
August 2017), Embase Ovid (1980 to 10 August 2017) and the Web of Science (1945 to
10 August 2017). OpenGrey was searched for grey literature. The US National Institutes
of Health Trials Registry ( ClinicalTrials.gov ) and the World Health Organization
International Clinical Trials Registry Platform were searched for ongoing trials.
No restrictions were placed on the language or date of publication when searching
the electronic databases. We included randomised controlled trials (RCTs) comparing
interventions that combined a pulp treatment technique with a medicament or device
in children with extensive decay in the dental pulp of their primary teeth. Two review
authors independently extracted data and assessed 'Risk of bias'. We contacted authors
of RCTs for additional information when necessary. The primary outcomes were clinical
failure and radiological failure, as defined in trials, at six, 12 and 24 months.
We performed data synthesis with pair‐wise meta‐analyses using fixed‐effect models.
We assessed statistical heterogeneity by using I² coefficients. We included 40 new
trials bringing the total to 87 included trials (7140 randomised teeth) for this update.
All were small, single‐centre trials (median number of randomised teeth = 68). All
trials were assessed at unclear or high risk of bias. The 87 trials examined 125 different
comparisons: 75 comparisons of different medicaments or techniques for pulpotomy;
25 comparisons of different medicaments for pulpectomy; four comparisons of pulpotomy
and pulpectomy; and 21 comparisons of different medicaments for direct pulp capping.
The proportion of clinical failures and radiological failures was low in all trials.
In many trials, there were either no clinical failures or no radiographic failures
in either study arm. For pulpotomy, we assessed three comparisons as providing moderate‐quality
evidence. Compared with formocresol, MTA reduced both clinical and radiological failures,
with a statistically significant difference at 12 months for clinical failure and
at six, 12 and 24 months for radiological failure (12 trials, 740 participants). Compared
with calcium hydroxide, MTA reduced both clinical and radiological failures, with
statistically significant differences for clinical failure at 12 and 24 months. MTA
also appeared to reduce radiological failure at six, 12 and 24 months (four trials,
150 participants) (low‐quality evidence). When comparing calcium hydroxide with formocresol,
there was a statistically significant difference in favour of formocresol for clinical
failure at six and 12 months and radiological failure at six, 12 and 24 months (six
trials (one with no failures), 332 participants). Regarding pulpectomy, we found moderate‐quality
evidence for two comparisons. The comparison between Metapex and zinc oxide and eugenol
(ZOE) paste was inconclusive, with no clear evidence of a difference between the interventions
for failure at 6 or 12 months (two trials, 62 participants). Similarly inconclusive,
there was no clear evidence of a difference in failure between Endoflas and ZOE (outcomes
measured at 6 months; two trials, 80 participants). There was low‐quality evidence
of a difference in failure at 12 months that suggested ZOE paste may be better than
Vitapex (calcium hydroxide/iodoform) paste (two trials, 161 participants). Regarding
direct pulp capping, the small number of studies undertaking the same comparison limits
any interpretation. We assessed the quality of the evidence as low or very low for
all comparisons. One trial appeared to favour formocresol over calcium hydroxide;
however, there are safety concerns about formocresol. Pulp treatment for extensive
decay in primary teeth is generally successful. Many included trials had no clinical
or radiological failures in either trial arm, and the overall proportion of failures
was low. Any future trials in this area would require a very large sample size and
follow up of a minimum of one year. The evidence suggests MTA may be the most efficacious
medicament to heal the root pulp after pulpotomy of a deciduous tooth. As MTA is relatively
expensive, future research could be undertaken to confirm if Biodentine, enamel matrix
derivative, laser treatment or Ankaferd Blood Stopper are acceptable second choices,
and whether, where none of these treatments can be used, application of sodium hypochlorite
is the safest option. Formocresol, though effective, has known concerns about toxicity.
Regarding pulpectomy, there is no conclusive evidence that one medicament or technique
is superior to another, and so the choice of medicament remains at the clinician's
discretion. Research could be undertaken to confirm if ZOE paste is more effective
than Vitapex and to evaluate other alternatives. Regarding direct pulp capping, the
small number of studies and low quality of the evidence limited interpretation. Formocresol
may be more successful than calcium hydroxide; however, given its toxicity, any future
research should focus on alternatives. 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)? Background 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.