Primary Tooth Vital Pulp Therapy: A Systematic Review and Meta-analysis

Abstract

Purpose: This systematic review and meta-analysis assessed outcomes in primary teeth for the vital pulp therapy (VPT) options of indirect pulp therapy (IPT), direct pulp capping (DPC), and pulpotomy after a minimum of 12 months to determine whether one VPT was superior.

Methods: The following databases were searched from 1960 to September 2016: MEDLINE, EMBASE, CENTRAL, EBSCO, ICTRP, Dissertation abstracts, and grey literature for parallel and split-mouth randomized controlled trials of at least 12 months duration comparing the success of IPT, DPC, and pulpotomy in children with deep caries in primary teeth. Our primary outcome measure was overall success (combined clinical and radiographic). Three authors determined the included RCTs, performed data extraction, and assessed the risk of bias (ROB). Meta-analysis and assignment of quality of evidence by Grading of Recommendations Assessment, Development and Evaluation approach were done.

Results: Forty-one articles qualified for meta-analysis (six IPT, four DPC, and 31 pulpotomy) from 322 screened articles. The 24-month success rates were: IPT=94.4 percent, and the liner material (calcium hydroxide [CH]/bonding agents) had no effect on success (P=0.88), based on a moderate quality of evidence; DP =88.8 percent, and the capping agent (CH/alternate agent) did not affect success (P=0.56), based on a low quality of evidence. The combined success rate for all pulpotomies was 82.6 percent based on 1,022 teeth. Mineral trioxide aggregate (MTA) (89.6 percent) and formocresol (FC) (85.0 percent) success rates were the highest of all pulpotomy types and were not significantly different (P=0.15), with a high quality of evidence. MTA's success rate (92.2 percent) was higher than ferric sulfate (FS) (79.3 percent) and approached significance (P=0.06), while FS's success rate (84.8 percent) was not significantly different from FC (87.1 percent), both with a moderate quality of evidence. MTA and FC success rates were significantly better than CH (P=0.0001), with a moderate quality of evidence. At 18 months, sodium hypochlorite (NaOCl) success rate was significantly less than FC (P=0.01) with a low quality of evidence.

Conclusions: The highest level of success and quality of evidence supported IPT and the pulpotomy techniques of MTA and FC for the treatment of deep caries in primary teeth after 24-months. DPC showed similar success rates to IPT and MTA or FC pulpotomy, but the quality of the evidence was lower. Systematic Review Registration Number: PROSPERO 2015: CRD42015006942.