Are different pulp treatment techniques and associated medicaments effective for the treatment of extensive decay in primary teeth?

Data sources Cochrane Oral Health's Trials Register and Central Register of Controlled Trials, Medline Ovid, Embase Ovid, Web of Science, Open Grey, US National Institutes of Health Ongoing Trials Register and World Health Organisation International Clinical Trials Registry Platform. There were no restrictions on language or publication dates.Study selection Two reviewers selected randomised clinical trials (RCTs) comparing different pulp interventions in extensively decayed primary teeth, which combined a pulp treatment technique and a medicament.Data extraction and synthesis Data were extracted independently by two reviewers recording year of publication, country of origin, inclusion/exclusion criteria, description of interventions, sample size, mean age, duration of follow-up and outcome data. Risk of bias was assessed by two reviewers. Meta-analysis was performed on RCTs comparing different medicaments for the same pulp technique or different pulp treatment techniques with each other.Results Eighty-seven RCTs were included in qualitative synthesis, yielding 59 studies for meta-analysis. The 87 RCTs involved 7,140 randomised teeth with 17 split-mouth RCTs and 70 parallel arm design. In total, 125 different comparisons were examined using clinical and radiological failure rates; 75 compared different pulpotomy agents or techniques, 25 compared different pulpectomy agents, four compared pulpotomy and pulpectomy, and 21 compared different agents for direct pulp capping. Where possible, data were compared for 6, 12 and 24 months. For pulpotomy, mineral trioxide aggregate (MTA) appears least likely to fail over those time periods. For pulpectomy, results were inconclusive comparing failure rates between various agents; however, two RCTs found a lower failure rate for zinc oxide-eugenol (ZOE) compared with Vitapex. For direct pulp capping, there was a low number of studies undertaking the same comparisons; calcium silicates (eg MTA and Biodentine) hold future promise.Conclusions Overall, evidence quality ranged from moderate to very low. For pulpotomy, MTA may be the best pulpotomy medicament in primary molars. Formocresol is effective but generally accepted as toxic. Biodentine, enamel matrix derivatives, laser application or Ankaferd Blood Stopper (a plant-based haemostatic agent used to control gastrointestinal bleeds) appear to be second choices. If all of these are unavailable, an application of sodium hypochlorite may be the safest option. For pulpectomy, evidence was inconclusive; however, ZOE paste may be more effective than Vitapex, but no further conclusions could be made. For direct pulp capping, the evidence was of low to very low quality. The best alternative may be a tricalcium silicate, especially MTA. Future RCTs may change these findings.