Pain in children’s milk teeth caused by extensive decay: we examine the best ways to treat the dental pulp

Tooth decay is one of the most common diseases in children. Tooth decay in the primary or milk teeth tends to progress rapidly, and it often reaches the pulp. Dental pulp consists of nerves, tiny blood vessels and connective tissue that make up the centre of a tooth. Symptoms of this extensive tooth decay include pain, swelling and abnormal tooth movement.

Dentists often have to perform one of three pulp treatment techniques to resolve the problem:

  1. Direct pulp capping: where a healing agent is placed directly over the exposed pulp. The most common materials used for direct pulp capping are calcium hydroxide, mineral trioxide aggregate, formocresol or an adhesive resin, placed directly over the tooth’s nerve.
  2. Pulpotomy: removal of a portion of the pulp. After a pulpotomy, one of four materials is generally used to fill the cavity: ferric sulphate, formocresol, calcium hydroxide or mineral trioxide aggregate.
  3. Pulpectomy: removal of all of the pulp in the pulp chamber and root canal of a tooth. After a pulpectomy, a material is put into the space created by pulp removal.

This review looks at the three techniques, and the effectiveness of different materials (known as medicaments) for pulp capping, pulpotomy and pulpectomy.

What was the research?

A systematic review to examine the effectiveness of different options for treating extensive tooth decay in children’s primary (milk) teeth

Who conducted the research?

The research was conducted by a team led by Violaine Smaïl-Faugeron of Université Paris Descartes on behalf of Cochrane Oral Health. Anne-Marie Glenny, Frédéric Courson, Pierre Durieux, Michele Muller-Bolla and Helene Fron Chabouis were also on the team.

What evidence was included in the review?

We included 87 randomised controlled trials, that investigated the success of pulp treatment of milk teeth.

What did the evidence say?

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 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.

How good was 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.

What are the implications for dentists and the general public?

Mineral trioxide aggregate (MTA) may be the best medicament to apply on the pulp stumps after pulpotomy of a milk tooth. Formocresol is effective, but there are known concerns about toxicity. Where MTA is not accessible, Biodentine, enamel matrix derivatives (EMD), laser treatment or maybe Ankaferd Blood Stopper seem to be the second choices. Where none of these treatments can be used, application of sodium hypochlorite (NaOCl) could be the safest option.

What should researchers look at in the future?

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.


Smaïl-Faugeron VGlenny AMCourson FDurieux PMuller-Bolla MFron Chabouis HPulp treatment for extensive decay in primary teethCochrane Database of Systematic Reviews 2018, Issue 5. Art. No.: CD003220. DOI: 10.1002/14651858.CD003220.pub3.

This post is an extended version of the review’s plain language summary, compiled by Anne Littlewood at the Cochrane Oral Health Editorial Base.

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  1. Pingback: Pulp treatments in primary teeth - National Elf Service

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