Glutaraldehyde preparations and pulpotomy in primary molars

Pulp treatment for extensive decay in primary teeth

BACKGROUND

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.

OBJECTIVES

To assess the effects of different pulp treatment techniques and associated medicaments for the treatment of extensive decay in primary teeth.

SEARCH METHODS

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.

SELECTION CRITERIA

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.

DATA COLLECTION AND ANALYSIS

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.

MAIN RESULTS

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.

AUTHORS' CONCLUSIONS

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.

Clinical and radiographic comparison of various medicaments used for pulpotomy in primary molars: A randomized clinical trial

Objective:

To evaluate and compare the efficacy of ferric sulfate, glutaraldehyde, and mineral trioxide aggregate (MTA) as pulpotomy medicaments in primary molars.

Materials and Methods:

This was a perspective randomized clinical trial. A total of 90 molars from 42 children aged 4–8 years were selected for pulpotomy procedure. Teeth were randomly divided into three equal groups of 30 teeth each. Teeth in Group I were intended to be treated with ferric sulfate, Group II were intended to be treated with buffered glutaraldehyde and Group III with MTA. All the molars were evaluated clinically at 24 h and both clinically and radio graphically at 1, 3, and 6 months. The observations were statistically analyzed using Chi-square test and Fisher's exact test.

Results:

After 1 month, there was no clinical finding observed in all the three groups. At 3 months postoperative evaluation, 13.3% of teeth in Group I and 12.5% of teeth in Group II had mobility. At 6 months interval, pain and sinus formation each was noted in 9.1% of primary teeth in Group I while periodontal ligament widening was reported in 66.7% of teeth in Group I and 85.7% of teeth in Group II.

Conclusion:

MTA exhibited overall best results as pulpotomy agent for primary molars followed by 15.5% ferric sulfate, whereas 2% buffered glutaraldehyde was found to be least effective as a pulpotomy agent.

Pulpotomy Medicaments used in Deciduous Dentition: An Update

The aim of this paper was to review the history and the scientific literature published on pulpotomy medicaments and to present the findings of these studies. The review showed that pulpotomy of primary teeth has been treated with many different techniques and medicaments, that some of these approaches are controversial and that their results have presented variables of success rates in term of clinical, radiographic and histologic observation. It is important that all clinicians, particularly for pediatric dentists, be up to date with the recent trends in this area of dental treatment for children.

Pulp treatment for extensive decay in primary teeth

BACKGROUND

In children, dental caries 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.This is an update of a Cochrane review first published in 2003. The previous review found insufficient evidence regarding the relative efficacy of these interventions, combining one pulp treatment technique and one medicament.

OBJECTIVES

To assess the effects of different pulp treatment techniques and associated medicaments for the treatment of extensive decay in primary teeth.

SEARCH METHODS

We searched the Cochrane Oral Health Group's Trials Register (to 25 October 2013), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2013, Issue 9), MEDLINE via OVID (1946 to 25 October 2013), EMBASE via OVID (1980 to 25 October 2013) and the Web of Science (1945 to 25 October 2013). We searched OpenGrey for grey literature and the US National Institutes of Health Trials Register and the World Health Organization (WHO) Clinical Trials Registry Platform for ongoing trials. We placed no restrictions on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

Eligible studies were randomised controlled trials comparing different pulp interventions combining a pulp treatment technique and a medicament in children with extensive decay involving dental pulp in primary teeth.

DATA COLLECTION AND ANALYSIS

Two review authors independently carried out data extraction and risk of bias assessment in duplicate. We contacted authors of randomised controlled trials for additional information if 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 pairwise meta-analyses using fixed-effect models. We assessed statistical heterogeneity using by I(2) coefficients.

MAIN RESULTS

We included 47 trials (3910 randomised teeth) compared to three trials in the previous version of the review published in 2003. All trials were single centre and small sized (median number of randomised teeth 68). Overall, the risk of bias was low in only one trial with all other trials being at unclear or high risk of bias. The overall quality of the evidence was low. The 47 trials examined 53 different comparisons: 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. Regarding 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) (two trials) for all outcomes measured, but the differences were not statistically significant (with the exception of radiological failure at 12 months). When comparing MTA with ferric sulphate (FS) (three trials), 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. The 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.

AUTHORS' CONCLUSIONS

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.

A Comparative Evaluation of Hydroxyapatite Crystals and Glutaraldehyde as Agents for Pulpotomy in Deciduous Molars

Purpose: To evaluate and compare clinically and radiographically use of hydroxyapatite crystals and 2% glutaraldehyde as a pulpotomy agent.

Method: Thirty deciduous molars were treated with pulpotomy using hydroxyapatite crystals and 2% glutaraldehyde.

Results: Clinical and radiographic findings were observed at three months and six months. The success rate was found to be 100% clinically and 80.33% radiographically in the hydroxyapatite crystals group and 100% clinically and radiographically in the glutaraldehyde group.

Clinical significance: The results of this study revealed that hydroxyapatite crystals is a potential pulpotomy agent for deciduous molars.

Pulp treatment for extensive decay in primary teeth

BACKGROUND

Dental decay in primary teeth remains a considerable health problem. Where decay extends to involve the dental pulp, pulp treatment techniques are often used to manage both symptomatic and symptom free teeth.

OBJECTIVES

To assess the relative effectiveness of: various pulp treatment techniques in retaining primary molar teeth with decay involving the pulp for at least 12 months; pulp treatment techniques and extractions in avoiding long term sequelae.

SEARCH STRATEGY

We searched the Cochrane Oral Health Group's Trials Register (August 2002); the Cochrane Central Register of Controlled Trials (The Cochrane Library Issue 3, 2002); MEDLINE (January 1966 to August 2002); EMBASE (1980 to August 2002); Science Citation Index Expanded (1981 to August 2002); Social Science Citation Index (1981 to August 2002); Index to Scientific and Technical Proceedings (1982 to August 2002); System for Information on Grey Literature in Europe (August 2002). Key journals were handsearched. There was no restriction on language of publication.

SELECTION CRITERIA

Randomised or quasi-randomised controlled trials (RCTs) comparing different pulp treatment techniques (with each other, with extraction or with no treatment) for extensive decay in primary molar teeth. Primary outcomes were extractions following pulp treatment and long term effects.

DATA COLLECTION AND ANALYSIS

Data extraction and quality assessment were carried out independently and in duplicate. Authors were contacted for additional information where necessary.

MAIN RESULTS

Eighty-two studies were identified but only three were suitable for inclusion. Nine studies meeting the inclusion criteria but with inappropriate study design or analysis are also described. Included trials investigated formocresol pulpotomy, ferric sulphate pulpotomy, electrosurgical pulpotomy or zinc oxide eugenol pulpectomy in symptom free, cariously exposed teeth. Data were unavailable on long term effects. Data on extraction following pulp treatment was available in all three studies and in two studies there was no statistically significant difference between the treatments. The difference seen in the other study, where more teeth treated by ferric sulphate pulpotomy were extracted compared to zinc oxide eugenol pulpectomy, must be viewed with caution.

REVIEWER'S CONCLUSIONS

Based on the available RCTs, there is no reliable evidence supporting the superiority of one type of treatment for pulpally involved primary molars. No conclusions can be made as to the optimum treatment or techniques for pulpally involved primary molar teeth due to the scarcity of reliable scientific research. High quality RCTs, with appropriate unit of randomisation and analysis are needed.

Clinical evaluation of glutaraldehyde with calcium hydroxide and glutaraldehyde with zinc oxide eugenol in pulpotomy of primary molars

The objectives of this study were to clinically evaluate the effectiveness of 2% buffered glutaraldehyde in pulpotomies of human primary molars and to compare the success rate of glutaraldehyde with calcium hydroxide and glutaraldehyde with zinc oxide eugenol as dressing material on the radicular pulp. Pulpotomies were completed on 61 primary molars in 19 children. The teeth were divided into two groups by random allocation. One group had a dressing of zinc oxide-eugenol base (IRM) incorporated with one drop of 2% buffered glutaraldehyde while the other group had a dressing of calcium hydroxide base incorporated with one drop of 2% buffered glutaraldehyde after the initial placement of 2% buffered glutaraldehyde on cotton pellet for 3 min. All teeth had light-curing compomer (Dyract) placed over the dressing material followed by a stainless steel crown restoration within 1 or 2 weeks after the pulpotomy. Blind clinical and radiographic evaluations of 57 teeth available after 12 months showed a success rate of 92.9% and 73.6% respectively. The clinical and radiographic success rates for glutaraldehyde/zinc oxide eugenol pulpotomies were 96.5% and 75.8% respectively while those for glutaraldehyde-calcium hydroxide were 89.2% and 71.4%. There was no statistically significant difference between the two groups either clinically or radiographically. The overall clinical success rate suggested that 2% buffered glutaraldehyde was an effective agent in the pulpotomy of human primary molars.

Formocresol and alternative primary molar pulpotomy medicaments: a review

This paper reviews the history, clinical success and concerns regarding the safety of formocresol as a primary molar pulpotomy medicament. The alternatives to formocresol are discussed and their advantages and disadvantages evaluated.