Use of Vital Pulp Therapies in Primary Teeth 2024.

Purpose: The purpose of this study was to present an evidence-based guideline for primary teeth with deep caries or trauma requiring vital pulp therapies (VPT). Methods: A systematic review/meta-analysis on vital primary teeth resulting from trauma or caries was conducted using GRADE to assess the certainty of evidence for clinical recommendations. A decision tree was provided for choosing VPTs. Results: No articles on trauma VPT were found. For VPT in primary teeth with deep caries, indirect pulp treatment (IPT) or pulpotomy using the calcium silicate cement (mineral trioxide aggregate [MTA] or Biodentine®) show increased success over using direct pulp capping (DPC) and other pulpotomies. Different liners do not affect IPT success (high certainty) or DPC capping agents' success (very low certainty) after 24 months. It is strongly recommended, with high certainty from 24-month data, that calcium silicate cement pulpotomy is preferred over formocresol, ferric sulfate, zinc oxide eugenol pulpotomy, and other pulpotomies. Using selective caries removal and IPT for deep caries is strongly recommended with moderate certainty over complete and stepwise removal. Statistically, this results in significantly fewer pulp exposures. No caries removal and Hall technique crown may be used when indicated (moderate certainty at 24 months). For vital primary incisors with deep caries, pulpotomy was significantly better statistically than pulpectomy. Teeth diagnosed with/without reversible pulpitis pain showed comparable success after 12 months of treatment by IPT or calcium silicate cement pulpotomy. The following had little or no significant effect on MTA pulpotomy success: coronal pulp removal methods; irrigation solution; method to control hemorrhage; base over MTA; treatment in one or two visits; anterior or posterior teeth. Conclusions: Indirect pulp treatment or calcium silicate cement pulpotomy is likely to increase vital pulp therapy success over other VPTs such as direct pulp capping and other pulpotomies after 24 months (moderate certainty).

Primary Tooth Vital Pulp Treatment Interventions: Systematic Review and Meta-Analyses.

Purpose: to update the 2016 systematic review evidence for vital pulp therapy (VPT) for primary teeth affected by caries or trauma. Methods: The population, intervention, comparison, outcomes, and study (PICOS) design inclusion/exclusion was used for multiple databases. Risk of bias, meta-analyses using RevMan, and certainty of evidence was created. Results: A total of 299 studies were included; no trauma was found. Indirect pulp treatment (IPT) resulted in 97 percent success. Two calcium silicate cement (CSC) pulpotomies' success using mineral trioxide aggregate (MTA) and Biodentine® were 94 percent and 90 percent, respectively, greater than for direct pulp capping (DPC; 86 percent) and other pulpotomies (moderate certainty). The success of IPT versus pulpotomy at 24 months showed no significant difference (P=0.31). Different liners or capping agents did not affect the success of IPT (P=0.79) or DPC at 24 months (P=0.24). The two CSC pulpotomies were not significantly different based on 24-month success (P=0.34). The formocresol pulpotomy success at 24 months was significantly lower than for MTA (P=0.02). Ferric sulfate had a significant lower success at 24 months than MTA pulpotomy (69 percent versus 92 percent; P=0.03). Zinc oxide eugenol, as a singular pulpotomy, had low success (65 percent). Selective/stepwise caries removal did significantly better at avoiding pulp exposures than complete excavation (P<0.001). Complete, selective, and no caries removal (Hall technique [HT], steel crown placement with no caries removal) had no significant difference in pulp vitality success for deep caries at 24 months (P=0.29). For deep caries affecting vital incisors, pulpotomy had significantly greater success than pulpectomy (P=0.002). The following had no significant effect on MTA pulpotomy success: coronal pulp removal methods; irrigation solution; method to control hemorrhage; base over MTA; treatment in one or two visits; and anterior or posterior teeth. Conclusions: Vital pulp therapy success of indirect pulp treatment or two calcium silicate cement pulpotomies demonstrated improved success over direct pulp capping and other pulpotomies based on 24-month evidence with moderate certainty. The Hall technique did not significantly reduce pulp vitality success versus caries removal.

Use of Non-Vital Pulp Therapies in Primary Teeth.

Purpose: To present an evidence-based guideline for non-vital pulp therapies due to deep caries or trauma in primary teeth. Methods: The authors, working with the American Academy of Pediatric Dentistry, conducted a systematic review/meta-analysis for studies on non-vital primary teeth resulting from trauma or caries and used the GRADE approach to assess level of certainty of evidence for clinical recommendations. Results: GRADE was assessed from high to very low. Comparing teeth with/without root resorption, pulpectomy success was better (P<0.001) in those without preoperative root resorption. Zinc oxide plus iodoform plus calcium hydroxide ([ZO/iodoform/CH]; Endoflas TM ) and zinc oxide and eugenol (ZOE) pulpectomy success did not differ from iodoform (iodoform plus calcium hydroxide; VitapexTM, MetapexTM) (P=0.55) after 18-months; however, ZO/iodoform/CH and ZOE success rates remained near 90 percent while iodoform was 71 percent or less. Network analysis ratings showed ZO/iodoform/CH and ZOE better than iodoform. Lesion sterilization tissue repair (LSTR) was better (P<0.001) than pulpectomy in teeth with preoperative root resorption, but pulpectomy results were better (P=0.09) if roots were intact. Rotary instrumentation of root canals was significantly faster (P<0.001) than manual, but the quality of fill did not differ (P=0.09) and both had comparable success. Network analysis ranked ZO/iodoform/CH the best, ZOE second, and iodoform lowest at 18 months. Success rates were not impacted by method of obturation or root length determination, type of tooth, number of visits, irrigants, smear layer removal, or timing/type of final restoration. Conclusions: Pulpectomy 18-month success rates supported ZO/iodoform/CH and ZOE pulpectomy over iodoform. LSTR had limited indication for teeth with resorbed roots and requires close monitoring.

A Systematic Review and Meta-Analysis of Nonvital Pulp Therapy for Primary Teeth.

Purpose: The purpose of this systematic review and meta-analysis was to assess success rates for nonvital treatment in primary teeth for caries/trauma. Methods: Databases were searched between 1960 and 2020 for randomized controlled trials, cohorts, case series, and in vitro studies. The primary outcome was overall success (clinical and radiographic) for pulpectomy and lesion sterilization tissue repair (LSTR). Included articles were independently determined, agreed upon, data extraction assessed, risk of bias, meta-analyses, and assignment of quality of evidence (GRADE). Results: Comparing teeth with and without root resorption, pulpectomy success was better (P<0.001) in teeth without preoperative root resorption. Success with pulpectomies performed with zinc oxide eugenol [ZOE] and with Endoflas (ZOE plus iodoform plus calcium hydroxide) did not differ from that observed using Vitapex or Metapex (iodoform plus calcium hydroxide; P≥0.50) after 18 months; however, Endoflas and ZOE success rates remained near 90 percent versus 71 percent or less for iodoform. Network analysis ratings showed Endoflas and ZOE performed better than iodoform alone. Also, LSTR performed better (P<0.001) than pulpectomies in teeth with preoperative root resorption, but pulpectomy results were superior (P=0.09) if roots were intact. Rotary instrumentation of root canals was significantly faster (P<0.001) than manual instrumentation. Success rates were not impacted by method of obturation or root length determination, type of tooth, number of visits, irrigants, smear layer removal, or timing/type of final restoration. Conclusions: Eighteen-month success rates support Endloflas and zinc oxide eugenol pulpectomies over iodoform pulpectomies. Lesion sterilization tissue repair had limited indication for teeth with resorbed roots.

Identifying Public Policy and Advocacy Practices Among Millennial Pediatric Dental Residents.

Purpose: This study's purpose was to identify public policy and advocacy practices among millennial pediatric dental residents in order to provide recommendations for engagement to the American Academy of Pediatric Dentistry (AAPD) leadership and pediatric dental residency program directors. Methods: A total of 138 residents from the 2016 Public Policy Advocacy Conference (PPAC) participated in a 13-item survey addressing demographics, advocacy education experience, student debt and financial contributions, resident training interests, the impact of the PPAC, and technology utilization. Sixty responses (45 percent response) were analyzed using SPSS software. Results: Residents believed that the PPAC was more beneficial than advocacy didactic education (P=0.008). The impact of the PPAC versus clinical experience was not significant (P=0.61). Pediatric dental residents were more likely to contribute financial donations to the AAPD's advocacy efforts following attendance of a program like the PPAC (P=0.051). Conclusion: Pediatric dental residents who participated in the PPAC or a local clinically oriented experience, perceived these two types of activities to provide greater value in their advocacy education than that of a didactic lecture in this subject area. Study results can be used to guide program directors in developing millennial-specific, resident-driven advocacy education experiences to fulfill Commission on Dental Accreditation advocacy curricula requirements.

Systematic Review and Meta-Analysis of Passive Lower Lingual Arch for Resolving Mandibular Incisor Crowding and Effects on Arch Dimension.

Purpose: This systematic review and meta-analysis assessed whether passive lower lingual arch (LLA) resolves mandibular incisor crowding and affects mandibular arch dimension. Methods: We searched PubMed, Web of Science, and Cochrane Database of Systemic Reviews for both randomized controlled trials and nonrandomized studies from 1940 to March 2018. Inclusion criteria were healthy children in mixed dentition with mandibular incisor crowding treated with LLA. Our primary outcome was the amount of mandibular incisor crowding resolved after LLA, and secondary outcomes were effects of LLA mandibular arch dimension changes versus untreated controls (UTCs). Results: From 559 screened articles, seven qualified for systematic review and meta-analyses. The average resolution of mandibular incisor crowding after LLA was 5.10 mm (P=.001) with the evidence assessed as very low quality. Arch perimeter and arch length changes were not significantly different between LLA and UTCs (P=0.20 and P=0.87, respectively). There were significant small increases of 0.79 mm in intercanine width (P<.001) and 0.69 mm in intermolar width (P=.003) with a low and a very low quality of evidence, respectively. Conclusions: Lower lingual arch was effective in resolving mandibular incisor crowding without any significant arch perimeter or arch length changes of greater than one mm.

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

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.

Effects of glass ionomer temporary restorations on pulpal diagnosis and treatment outcomes in primary molars.

PURPOSE: To evaluate 1) if glass ionomer interim temporary restorations (ITR) placed for 1-3 months prior to vital pulp therapy (VPT) improved accuracy of diagnosing the pulp's clinical status and subsequent VPT success, and 2) the effect of the location of the carious lesion on VPT. METHODS: Primary molars (N=117) receiving pulp therapy with or without ITR were evaluated retrospectively. All teeth had caries extending >50 percent into dentin; caries lesion location was identified (proximal or non-proximal). Two examiners rated pulp status assessment, caries location, and pulp treatment, and correlated treatment outcomes after a mean of 34.7 months to these factors. RESULTS: VPT failed more often in first primary molars (P<.001) than in second primary molars. Using ITR improved diagnosis of the pulp status, clinical success of VPT, (P=.013) and first molar VPT success (P=.02). First primary molars had more proximal lesions than second molars (P<.001). Failure of VPT was greater for teeth with proximal lesions (P=.03). Use of ITR significantly improved VPT in teeth with proximal lesions (P=.007) but not non-proximal lesions (P=.38). CONCLUSIONS: ITR placed prior to VPT improved pulpal diagnosis and VPT outcomes. Vital pulp therapy was less successful in primary molars with proximal lesions, and ITR significantly improved the success.

Vital pulp therapy for the primary dentition.

The goal of primary tooth pulp therapy is the preservation of the primary teeth until their normal time of exfoliation. Teeth with carious involvement approaching the pulp can be treated with a variety of approaches, including three pulpotomy techniques--diluted formocresol, ferric sulfate, and mineral trioxide aggregate--and an indirect pulp therapy technique. Accurate diagnosis of the vitality status of the pulp is critical to the success of each treatment and involves careful radiographic and clinical assessment of the teeth to make sure that they are either healthy or reversibly inflamed.

Indirect pulp capping and primary teeth: is the primary tooth pulpotomy out of date?

Formocresol pulpotomy (FP) in the United States is most frequently used to treat asymptomatic caries near the pulp in primary teeth. Indirect pulp therapy (IPT) is also indicated and has a significantly higher long-term success. Pulpotomy is thought to be indicated for primary teeth with carious pulp exposures, but research shows the majority of such teeth are nonvital or questionable for treatment with vital pulp therapy. IPT has a significantly higher success in treating all primary first molars, but especially those with reversible pulpitis compared with FP. The purpose of this article was to review the dental literature and new research in vital pulp therapy to determine the following: (1) Is a pulpotomy indicated for a true carious pulp exposure? (2) Is there a diagnostic method to reliably identify teeth that are candidates for vital pulp therapy? (3) Is primary tooth pulpotomy out of date, and should indirect pulp therapy replace pulpotomy?

Indirect pulp capping and primary teeth: is the primary tooth pulpotomy out of date?

Formocresol pulpotomy (FP) in the United States is most frequently used to treat asymptomatic caries near the pulp in primary teeth. Indirect pulp therapy (IPT) is also indicated and has a significantly higher long-term success. Pulpotomy is thought to be indicated for primary teeth with carious pulp exposures, but research shows the majority of such teeth are nonvital or questionable for treatment with vital pulp therapy. IPT has a significantly higher success in treating all primary first molars, but especially those with reversible pulpitis compared with FP. The purpose of this article was to review the dental literature and new research in vital pulp therapy to determine the following: (1) Is a pulpotomy indicated for a true carious pulp exposure? (2) Is there a diagnostic method to reliably identify teeth that are candidates for vital pulp therapy? (3) Is primary tooth pulpotomy out of date, and should indirect pulp therapy replace pulpotomy? )

A survey of primary tooth pulp therapy as taught in US dental schools and practiced by diplomates of the American Board Of Pediatric Dentistry.

PURPOSE: The purpose of this study was to repeat a 1997 survey of current pulp therapy practice. METHODS: The directors of dental school predoctoral pediatric dentistry programs (N=56) and board certified pediatric dentists (N=1200) were surveyed in 2005. RESULTS: More dental schools (83%) taught indirect pulp therapy (IPT) compared to 1997. Significantly more used glass ionomer for IPT with most dental schools and diplomates not re-entering a tooth after IPT. Over 30% of schools and diplomates do direct pulp cops using glass ionomer. For pulpotomy, diluted formocresol usage decreased in dental schools (54%) while ferric sulfate significantly increased (24%) and full strength remained at 22%. Shorter placement of pulpotomy medication was noted and ZOE alone the preferred base. Pulpectomy was advocated by 85% of 2005 schools and diplomates with ZOE filler use decreasing while iodoform/calcium hydroxide filler use increasing. CONCLUSIONS: More pediatric dentists are using glass ionomer for IPT and direct pulp capping, and there was a trend away from the use of 1:5 diluted formocresol with more using ferric sulfate for pulpotomy. For pulpectomy, most use ZOE but iodoform pastes and calcium hydroxide have increased in usage since 1997 Disagreements continue concerning when to use certain pulp therapies and some directors and diplomates did not follow the AAPD guidelines.

Caries control and other variables associated with success of primary molar vital pulp therapy.

PURPOSE: This research evaluated initial treatment of deep dental caries with caries control (CC) procedure and the effect of other factors on the success of indirect pulp therapy (IPT) and formocresol pulpotomy (FP). METHODS: Retrospective chart audits were performed on 226 primary molars with deep caries approaching the pulp that were treated using IPT and FP. Mean follow-up was 3.4 years. CC with glass ionomer cement (GIC) was performed on 50 of the 226 teeth 1 to 3 months before pulp therapy. RESULTS: IPT therapy was successful 94% of the time, whereas FP was successful 70% of the time. The initial use of CC increased the IPT/FP success rate to 92% vs a 79% success rate in teeth without CC. Primary molar FP success on primary first molars was 61% vs 83% in second molars. IPT therapy was successful 92% of the time for first molars vs 98% of the time for second molars. Thirty-six percent of the FP-treated teeth exfoliated early vs 2% of the IPT-treated teeth. Primary first molars with reversible pulpitis had a higher success with IPT (85%) vs FP (53%). The type of final restoration did not affect IPT or FP success, except that FPs restored with an immediate IRM (Dentsply/Caulk, Milford, Del) restoration decreased success to 39%. CONCLUSIONS: IPT for the treatment of deep dental caries lesions produced greater long-term success than FP. FP success in primary first molars was lower compared to IPT success, especially in teeth with reversible pulpitis. Also FP-treated teeth showed significantly earlier exfoliation patterns. The prior treatment of deep dental caries lesions with CC procedures improved the subsequent IPT or FP success.