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.

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.

Protocol for a Systematic Review and Meta-analysis of Vital Pulp Therapy for Children with Deep Caries in the Primary Dentition.

PURPOSE: The purpose of this protocol for a systematic review of randomized controlled trials of primary tooth vital pulp therapy is to describe the reasoning and need for the review, the objectives of the review, and the methodology that will be used to analyse data from the included studies. Publication of a systematic review protocol also helps establish and maintain transparency of the process and accountability for the stated methods and outcomes sought. METHODS: This protocol adheres to PRISMA-P standards for protocol reporting. A variety of relevant databases and resources will be searched. Trials selection, data extraction, and risk of bias assessment will be performed by two independent investigators. Primary outcome measures include clinical and radiographic success. Evidence tables will be generated for included study characteristics. The Cochrane risk of bias assessment tool will be applied to the selected studies. For meta-analysis, results will be pooled to provide estimates of appropriate effect size and heterogeneity of trials. The quality of evidence for outcomes will be determined using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach. RESULTS: The proposed systematic review will provide findings useful for pediatric and general dentists, researchers, guideline developers, policymakers, and public and private insurers and can be the basis for an evidence-based guideline on pulp treatment of vital primary teeth with deep caries approximating the pulp.

Cross sectional: use of coolant for high-speed tooth preparation: a survey of pediatric dentist members of the American Academy of Pediatric Dentistry.

PURPOSE: To report the findings of a survey to determine the educational experiences, opinions and clinical practices relative to the use of coolant during cavity preparation of pediatric dentist members of the American Academy of Pediatric Dentistry (AAPD) and to determine whether teaching policies influenced the type of coolant used in private practice. METHODS: Four thousand fifty surveys were emailed to AAPD members and included questions regarding demographics and predoctoral, graduate, and current practice policies for the use of dry cutting. RESULTS: Returned survey numbered 1730 for a response rate of 43%. Fifteen percent were taught the concept of dry cutting in their predoctoral programs and 34% in their specialty, programs. Sixty percent never or rarely prepare teeth without water coolant. Slightly more than 40% prepared teeth with air coolant alone. Patient behavior (25%) and sedation (21%) were reported as determining factors for cutting dry. Thirty-one percent of private practice clinicians and 34% of part time academics use dry cutting, while only 15% of full time academicians use the technique (P<0.0001). CONCLUSIONS: Respondents tend to use the technique they were taught during their residency. Use of dry cutting was more likely to be utilized during sedations or general anesthesia to avoid airway compromise.

Parental cooperation scale in the pediatric dentistry setting: reliability and criteria.

OBJECTIVE: The purpose of this study was to provide reliability and criteria data on a newly defined parental cooperation scale (PCS) and in addition correlate between parent scores and their child's behavior in the dental setting. STUDY DESIGN: 244 parents accompanying their child to a dental visit were evaluated by two independent pediatric dentist evaluators. 150 parents were designated to be revaluated at least two weeks following the initial evaluation by the same examiner. Children's dental behavior was previously evaluated using the Frankl rating scale. RESULTS: A majority of the parents were found to be highly positive and positive (40% of the parents were evaluated as being PCS rating 4, 26% were rated 3). 35% of the parents were rated as being negative or extremely negative (27%, 8% respectively). 139 parents were re-evaluated at least two weeks following their initial assessment. 64% were rated as highly cooperative and cooperative; 36% were negative or extremely negative. 244 children participated in the study (mean age +/- SD, 6.8 years +/- 2.86). 67% were rated as Frankl scale extremely cooperative and cooperative (31%, 35.5% respectively). 33% were negative or extremely negative (26.1%, 7.3% respectively). When comparing the Frankl behavior of each child to their parent's PCS a significant association was found (McNemar test value 17.668, p = 0.007). CONCLUSION: The PCS was evaluated and found to be a reliable tool to evaluate parental dental behavior. Parents with negative behavior were more likely to present with children who also exhibit negative dental behavior and vice versa.

Use of restraint and management style as parameters for defining sedation success: a survey of pediatric dentists.

PURPOSE: The purpose of this study was to identify factors that may influence current American Academy of Pediatric Dentistry (AAPD) members' definitions of a successful oral sedation. METHODS: Surveys were electronically mailed to all AAPD members with registered e-mail addresses, and printed surveys were sent via postal mail to all other members. The survey included: (1) items on demographic variables; and (2) questions on sedation methods and definition of success. RESULTS: The following response rates were recorded: (1) electronic survey = 26%; (2) printed = 45%; and (3) diplomate = 53%. The majority of members (55%) characterized their patient management style as being authoritarian. Sixty-seven percent agreed that the need to employ restraints when using sedation does not necessarily indicate that sedation is inadequate or unacceptable. When asked if such a sedation outcome could be defined as being successful, however, the agreement dropped to 47%. When defined as optimal, the respondents' agreement was further reduced to 36%. CONCLUSIONS: The practitioner's management style and use of restraint significantly influence how a dentist defines a successful sedation.

Recall rates and caries experience of patients undergoing general anesthesia for dental treatment.

PURPOSE: The purpose of this study was to evaluate the recall rate and caries experience of children seen under general anesthesia (GA) at The University of Iowa Hospitals and Clinics. METHODS: After a retrospective chart review, information from 217ASA (American Society of Anesthesiologists) 1 patients undergoing GA between 1998 and 2002 was gleaned regarding: (1) date of GA; (2) age at time of GA; (3) follow-up (recall) visits; (4) referral status; (5) new caries experience; and (6) treatment of new/recurrent lesions. A 19-question survey was also mailed to parents/legal guardians for satisfaction. RESULTS: Survey data were not reported in this study due to the poor (25%) return rate after several attempts: 41% of the patients were referrals; 54% returned for a 2 week postoperative visit, but only 13% returned for a 6-month recall, with subsequent recoils being even lower; 72% were insured by Medicaid; and 25% had recurrent or new lesions at follow-up appointments. CONCLUSION: Recall rates after general anesthesia for dental treatment at a university hospital are very low, and new or recurrent caries experience is high.

Preliminary evaluation of sodium hypochlorite for pulpotomies in primary molars.

PURPOSE: The purpose of this study was to compare the effectiveness of 5% sodium hypochlorite (NaOCl) to that of ferric sulfate (FeSO4) as a pulpotomy medicament in decayed primary molars. METHODS: Healthy subjects between 4 and 9 years with at least 2 primary molars needing pulpotomy consented to receive either NaOCl or FeSO4 and restoration with IRM base/stainless steel crown in a prospective, randomized design. Clinical and radiographic signs/symptoms were recorded at 0, 6, and 12 months. RESULTS: Twenty-three subjects were recruited. Six-month results are based on the first 32 teeth in the NaOCl group and 28 teeth in the FeSO4 group. Twelve-month results are based on 13 teeth in the FeSO4 group and 14 in the NaOCl group. Results show 100% restoration retention in both groups and no signs/symptoms of pain at 6 and 12 months. At 6 months, 100% clinical success was found with both FeSO4 and NaOCl. Radiographic success for FeSO4 was 68%, with internal resorption being the most common finding. The NaOCl group showed 91% radiographic success, P = .050. At 12 months, FeSO4 had 85% clinical success and 62% radiographic success. NaOCl had 100% clinical success and 79% radiographic success. CONCLUSION: Preliminary evidence shows that NaOCl can be used successfully as a pulpotomy medicament.

Comparison of chloral hydrate, meperidine, and hydroxyzine to midazolam regimens for oral sedation of pediatric dental patients.

PURPOSE: The purpose of this retrospective study was to compare the effects of oral administration of a combination of chloral hydrate (CH) 25 mg/kg, hydroxyzine (H) 1 mg/kg, and meperidine (M) 1 mg/kg to midazolam 0.65 mg/kg using 50% nitrous oxide (N2O) on behavioral and physiological parameters of young children sedated for dental procedures. Factors associated with sedation effectiveness were identified, including age, preoperative behavior, and type of procedure. METHODS: Records of 116 sedation sessions of 66 healthy, uncooperative children ages 24 to 60 months at The University of Iowa Centers for Disabilities and Development were reviewed. Patients received 1 of the 2 regimens. Intraoperative behavior was rated using a dichotomous scale. Physiological variables including heart rate and oxygen saturation were recorded at baseline and at 10-minute intervals of the session. Data were analyzed using SPSS Version 9. RESULTS: Overall, 81 % of sessions were rated successful. Sedation sessions using CH+H+M combination had significantly higher success rate (P<.01, odds ratio=3.38, 95% confidence interval= 1.06 to 7.15) compared to sessions with midazolam. Sedation success was not associated with age, preoperative behavior, or type of dental procedure performed. Physiological variables were within the normal range for both regimens, although midazolam regimen recorded higher heart rates. CONCLUSIONS: CH+H+M combination using 25 mg/kg CH resulted in significantly more effective sedation sessions compared to midazolam. Both regimens used 50% N2O and were found to be safe.

Radiographic success of ferric sulfate and formocresol pulpotomies in relation to early exfoliation.

PURPOSE: The purpose of this retrospective study was to evaluate the radiographic findings with formocresol and ferric sulfate pulpotomies in relation to early tooth loss. METHODS: Vital pulpotomies with either ferric sulfate or formocresol, performed by faculty members between 1992 and 2002 at The University of Iowa, were evaluated retrospectively. Radiographic criteria were established to assess success or failure of the treated tooth. This was then correlated with time of tooth loss and space management. RESULTS: Eighty-five molars, followed between 6 to 61 months, met the inclusion criteria. Of these, 15 (43%) teeth treated with ferric sulfate, 23 (56%) treated with formocresol, and 5 (55%) treated with a combination of ferric sulfate and formocresol remained free of any radiographic pathology. Overall, 13% of the pulpotomized teeth were prematurely lost due to abscess formation and in need of space management. Regardless of the treatment type, internal root resorption was the most common cause of premature exfoliation. CONCLUSIONS: Both ferric sulfate and formocresol pulpotomies can lead to premature exfoliation of primary teeth, with the subsequent need for orthodontic space maintenance. Therefore, radiographic criteria should be taken into consideration when evaluating pulpotomized teeth at recall visits.

Oral midazolam with and without meperidine for management of the difficult young pediatric dental patient: a retrospective study.

PURPOSE: The purpose of this retrospective study was to examine different dosages of midazolam used alone or in combination with different dosages of meperidine for managing difficult young pediatric dental patients. METHODS: Patient records and sedation logs of 120 moderately to severely apprehensive/ uncooperative subjects, ages 24-48 mos, sedated in private practice setting, were reviewed. Subjects, divided into six groups of 20, received midazolam in doses of 0.7 or 1.0 mg/kg with and without meperidine in doses of 1.0 or 1.5 mg/kg. Ratings of the effectiveness of sedation, duration of action, need for restraint to accomplish treatment, and recovery times were made. Nitrous oxide was not used. RESULTS: When used alone, use of 0.7 mg/kg midazolam produced the most agitation, required restraint most frequently, and produced the shortest working time (P<0.001). Subjects receiving 1.0 mg/kg midazolam and meperidine were the most effective, completing 20/20 visits with no need for restraint, no loss of consciousness throughout appointments, and no adverse reactions (P<0.001). Use of lower dose midazolam and higher dose meperidine was reliable, permitting treatment to be completed without restraint in 18/20 patients. Combined higher doses of both agents demonstrated somnolence and oversedation. The addition of meperidine increased working time (P<0.05). CONCLUSIONS: The addition of meperidine appears to enhance the effectiveness and duration of action of midazolam for managing difficult young pediatric patients.

Carriage frequency, intensity of carriage, and strains of oral yeast species vary in the progression to oral candidiasis in human immunodeficiency virus-positive individuals.

Candida samples were taken over a period of 2 years from 54 human immunodeficiency virus (HIV)-positive asymptomatic subjects to evaluate changes in yeast carriage, intensity of carriage, and genotype over time. Overall, we found that HIV-positive patients with CD4(+)-cell counts of between 200 and 400/microl had significantly more yeast colonization than healthy control subjects. Of the 54 patients, 11 developed thrush. We found that intensity of carriage in these 11 patients increased significantly in the progression from asymptomatic yeast carrier to an episode of oral thrush. Also, the most common yeast species isolated was Candida albicans; however, we did see a number of patients harboring multiple species at the same time. Using the C. albicans-specific probe Ca3, we found that 54% (n = 6) of the 11 patients who developed thrush maintained genetically similar strains throughout the study period, with minor genetic variations in all patients except one. Forty-six percent of these patients had either multiple strains throughout the study period (n = 2), strain replacement (n = 1), or species replacement (n = 2). Of the patients who had multiple strains, one (I4) was infected by two different strains of Candida dubliniensis distinguished by a recently developed species-specific probe. These results suggest that commensal strains colonizing HIV-positive individuals can undergo alterations prior to producing an episode of thrush.