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Indirect Pulp Capping Versus Pulpotomy for Treating Deep Carious

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Indirect Pulp Capping Versus Pulpotomy for Treating Deep Carious V. Smaïl-Faugeron*,**,***, A. Porot**, practice showed an overall increase in the teaching M. Muller-Bolla***,****, F. Courson**,*** and practice of indirect pulp capping in primary teeth. The non-randomised study found a statistically significant difference in favour of indirect pulp capping *Institut National de la Santé et de la Recherche Médicale, for clinical and radiological success at 3 years but with U1138, Equipe 22, Centre de Recherche des Cordeliers, Paris, high overall risk of bias. France Conclusions Despite the success rate of indirect pulp **Assistance Publique-Hôpitaux de Paris, Hôpital Bretonneau, capping for treating deep carious lesions approaching Service d'Odontologie, Paris, France the pulp in primary teeth, practitioners still hesitate ***Université Paris Descartes - Sorbonne Paris Cité, Faculté to practice this technique because of lack of evidence de Chirurgie Dentaire, Unité de Recherches Biomatériaux and studies on this topic. Thus, for strong evidence, Innovants et Interface EA4462, Montrouge, France investigators are encouraged to conduct randomised ****Université de Nice-Sophia Antipolis, Service d’Odontologie, trials comparing the efficacy of indirect pulp capping Faculté de Chirurgie Dentaire, Nice, France and pulpotomy for treating deep carious lesions approaching the pulp in primary teeth. e-mail: [email protected] Keywords Carious lesions; Indirect pulp capping; Indirect pulp capping Primary teeth; Pulpotomy. versus pulpotomy for treating deep carious Introduction lesions approaching In children, deep carious lesions represent the most In children, deep carious lesions represent the most common the pulp in primary disease of primary teeth; 42% of children aged 2 to 11 have dental carious lesions in their primary teeth, with an teeth: a systematic average of 1.6 decayed teeth per child [NHANES, 1999- 2004]. A recent review described the management of review deep carious lesions in permanent and primary teeth. Pulpotomy is the pulp treatment most commonly used for primary teeth with a deep carious lesion approaching the pulp. Complete caries removal often leads to pulpotomy ABSTRACT of primary teeth. Partial caries removal is another option that has been recently suggested [Blanchard and Boynton, Aim To assess dental practice regarding the use of 2010; Ricketts et al., 2013]. The guidelines of the American indirect pulp capping or pulpotomy in children with Academy of Pediatric Dentistry highlight two pulp deep carious lesions approaching the pulp in primary treatment techniques available for managing deep carious teeth and to compare the efficacy of the two pulp lesions approaching the pulp in primary teeth: pulpotomy treatments. and indirect pulp capping [American Academy of Pediatric Methods Study design: Systematic review. We Dentistry, 2014-2015]. The primary aim of both is to searched the Cochrane Library, PubMed via MEDLINE, preserve the vitality of pulp without clinical or radiological and EMBASE as well as the reference lists of included signs of failure (e.g., pain, pathologic mobility, pathologic reports and ClinicalTrials.gov (for ongoing trials). radiolucency or pathologic root resorption) [Camp, 2008]. Eligible studies were surveys of dental practice sent With pulpotomy, a portion of the pulp is removed: the to dentists regarding the use of indirect pulp capping coronal pulp is removed and the radicular pulp is preserved. and pulpotomy in children with deep carious lesions After treatment, the cavity is filled with a medicament approaching the pulp in primary teeth and any type followed by a final restoration. A recent systematic of clinical study. Two review authors independently review found no evidence to clearly identify one superior extracted data and assessed risk of bias in duplicate. pulpotomy medicament, although two medicaments Results Of the 481 potentially eligible articles, 11 seem to be preferable: mineral trioxide aggregate or ferric were included in the review: 8 described surveys of sulfate [Smail-Faugeron et al., 2014]. dental practice, 1 a non-randomised study, and 2 With indirect pulp capping, the deepest layer of ongoing randomised trials. The surveys of dental decayed dentin closest to the pulp is left in place to avoid pulp exposure. Then, it is covered with a medicament EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY VOL. 17/2-2016 107 SMAÏL-FAUGERON V. ET AL. (dentin bonding agent, calcium hydroxide, zinc oxide- Risk of Bias tool, which includes the following items: eugenol, or glass-ionomer cement), followed by a final selection of participants, blinding of participants and restoration [American Academy of Pediatric Dentistry, personnel, blinding of outcome assessors, incomplete 2014-2015; Franzon et al., 2007]. Indirect pulp capping is outcome data, and selective outcome reporting [Higgins more conservative than pulpotomy because the vitality of et al., 2011]. For non-randomised studies, we considered coronal and radicular pulp is preserved [Fuks, 2008]. the risk of selection bias as high and also assessed the Aim of this study was to assess by a systematic review risk of bias related to confounding factors. For each study, of the literature current dental practice regarding the use each domain was rated as low, high, or unclear risk of of indirect pulp capping and pulpotomy for treating deep bias. Then, each study was assigned an overall risk of bias carious lesions in primary teeth. The second objective was score: low risk (low for all key domains), high risk (high for to compare the efficacy of the two pulp treatments. one key or more domains), or unclear risk (unclear for one key or more domains). The two review authors compared evaluations and resolved any disagreements by discussion. Material and methods Analysis A systematic review of the literature was performed. We did not perform any meta-analysis, but we described the study characteristics and results qualitatively with Criteria for considering studies for this review number, percentage or mean (min-max). Eligible studies were results of surveys of dental practice sent to dentists regarding the use of indirect pulp capping and pulpotomy in children with deep carious Results lesions approaching the pulp in primary molars and any type of clinical study comparing indirect pulp capping The search yielded 481 potentially eligible articles. We and pulpotomy (case report or case series, cohort study, included 11 relevant articles in the review: 8 described comparative non-randomised study or randomised trial). surveys of dental practice [Bergoli et al., 2010; Bowen et al., 2012; Dunston and Coll, 2008; Hincapie et al., 2015; Search methods for identifying studies Ni Chaollai et al., 2009; Primosch et al., 1997; Seale and We searched the databases Cochrane Library, MEDLINE, Glickman, 2008; Spedding, 1968] and 1 a retrospective and EMBASE for articles, with no restriction on date or language. Search equations for each database combined free text words and controlled vocabulary pertaining to the condition and interventions (see Supporting Information, 481 references identified through 2 additional Text S1). The last search was conducted in February 2015. database searching references identified 236 Pubmed through We checked the references of all eligible articles for relevant 205 Embase ClinicalTrials.gov studies and scanned reference lists from identified review 40 Cochrane library articles for further studies. We searched ClinicalTrials. gov for the protocols of included studies and to identify ongoing trials [Chan and Altman, 2005]. 6 duplicates eliminated Data collection Two authors independently and in duplicate screened 475 references the titles and abstracts of records retrieved by the search, 407 references eliminated then the selected full-text reports. Finally, we included by selection on title studies after checking for multiple publications of a given and abstract study. 68 references For each survey of dental practice, we collected data on publication year and country, sender, target population, 59 references eliminated mode of administration, description of the survey, number by selection on full text of surveys sent, and number of responses. 11 For each clinical study, two authors independently and relevant reports 8 in duplicate recorded the year of publication and country survey of dental practice 1 of origin, inclusion/exclusion criteria specified, number non-randomized study 2 of arms in the trial, treatments compared, detailed protocols of ongoing randomized trials description of interventions, number of patients enrolled, number of treated teeth, mean age of participants, duration of follow-up and outcome data. We assessed the risk of bias for each trial by the Cochrane Collaboration FIG. 1 Flow of studies in the systematic review. 108 EUROPEAN JOURNAL OF PAEDIATRIC DENTISTRY VOL. 17/2-2016 PULP THERAPY FOR PRIMARY AND YOUNG PERMANENT TEETH First author, publication year Spedding Primosch Dunston Seale Ni Chaollai Bergoli Bowen Hinciapie 1968 1997 2007 2008 2009 2010 2012 2015 Target Dental schools-PD × × × × × × population Dental schools-GP × ABPD diplomates × × × AAE diplomates × Private GP × Mode of Posted letter × × × administration E-mail × × × × × Description of Open-ended × the survey questionnaire Multiple-choice questions × × × × × × 5-point Likert-type scale × No. of Dental schools-PD 58/58 53/53 48/56 14/18 83/191 48/? responses / (100) (100) (86) (78) (43) number of surveys sent Dental schools-GP 11/? (%) ABPD diplomates 690/1200 252/? 953/3691 (57)
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