Tooth decay in the milk (baby teeth) of children tends to progress rapidly, often reaching the dental nerve (or pulp, the nerves in the centre of the tooth). Dentists normally have to do one of three things:
1. pulp capping – placing a medicament over the exposed tooth pulp
2. pulpotomy – removal of some of the tooth pulp
3. pulpectomy – removal of all of the tooth pulp.
With direct pulp capping and pulpotomy, some of the nerve in the tooth is left and therefore the filling material has to be put into contact with the living pulp tissue. The most common materials used in direct pulp capping are calcium hydroxide, mineral trioxide aggregate, formocresol or an adhesive which allows a filling material to adhere to the tooth. After a pulpectomy, no nerve is left inside the treated tooth, but a filling material is put into the space created by the removal of the pulp and this must not stop the development of the permanent, adult tooth. After a pulpotomy, one of four materials is used to fill the space: ferric sulphate, formocresol, calcium hydroxide or mineral trioxide aggregate. This research investigates the success of these dental nerve treatments in milk teeth.
What was the research?
A systematic review of the evidence to find out which is the best technique for treating extensive tooth decay in milk (baby) teeth.
Who conducted the research?
The research was conducted by a team led by Violaine Smail-Faugeron, on behalf of the Cochrane Oral Health Group. Frederic Courson, Pierre Durieux, Michelle Muller-Bolla, Anne-Marie Glenny and Helen Fron Chabouis were also on the team.
What evidence was included in the review?
Data was extracted from 47 randomised controlled trials. A total of 3,910 baby teeth were included in the trials, and a total of 53 comparisons of different treatment options were made. All of the trials were small sized. 25 comparisons were between different medicaments or techniques for pulpotomy, 13 were between different medicaments for pulpectomy, 13 were between different medicaments for direct pulp capping, and 2 compared pulpotomy with pulpectomy.
What did the evidence say?
Due to the limited number of trials making each comparison, no clear treatment options were shown to be better than others for the treatment of extensive tooth decay in children’s milk teeth.
How good was the evidence?
The quality of the evidence was low due to shortcomings in the methods used within the individual trials, the small number of children included in the trials and their short-term follow up after treatment.
What are the implications for dentists and the general public?
We found no evidence to identify one superior pulpotomy medicament and technique clearly. Two medicaments may be preferable – mineral trioxide aggregate or ferric sulphate. The cost of mineral trioxide aggregate may prohibit its clinical use. However, the small number of studies in each comparison limits the evidence.
What should researchers look at in the future?
Clinical trials comparing mineral trioxide aggregate and ferric sulphate are needed to determine the cost effectiveness balance for both materials. Other modern therapies, such as laser therapy or Biodentine, need careful evaluation. Our recommendations are that future trials are larger, and follow up the children for at least one or two years.
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.