REVIEW ANALYSIS & EVALUATION

ARTICLE TITLE AND

BIBLIOGRAPHIC
INFORMATION
Primary molar pulpotomy: a
systematic review and network
meta-analysis.
Lin PY, Chen H-S, Wang Y-H, Tu Y-K.
J Dent 2014;42(9):106077

MTA, Formocresol, and Ferric Sulfate Have

Significantly Better Clinical and
Radiographic Outcomes Than Calcium
Hydroxide and Laser Therapies in Primary
Molar Pulpotomies After 1824 Months
SUMMARY

REVIEWER

Selection Criteria

Samah Omar, BDS, DDS, MSD

The literature search included MEDLINE (via PubMed), Science-Direct,

Web of Science, Cochrane, and Clinical Key databases up to December
2012. Original prospective clinical trials comparing two or more pulpotomy agents were identified. The three authors did the search and started
screening titles and abstracts for potential relevant articles, then performed a quality assessment of the included articles. Any disagreements
were resolved by discussion among them. A total of 2083 potential relevant
titles, abstracts, and articles were identified in addition to reference lists of
reviews and related articles, with 171 articles screened for further evaluation. Finally, 37 trials met all the inclusion criteria, and 22 were considered
for network and pair-wise meta-analyses. Of all 37 studies, 22 were parallel
trials and the others were split-mouth trials. Follow-up periods were diverse,
ranging from 5.2 to between 48 and 60 months. Twenty-two studies were
chosen for meta-analyses for 912 months, and 12 were chosen for metaanalyses for 1824 months. The majority of the studies were randomized
controlled trials (RCTs).

PURPOSE/QUESTION
The aim of this study is to undertake
a systematic review and network
meta-analysis, comparing the
clinical and radiographic outcomes
in primary molar pulpotomy among
different dressing materials.

SOURCE OF FUNDING
This project was partly supported by
a grant from the National Science
Council in Taiwan (grant number:
NSC 101-2314-B-002-197-MY2).

TYPE OF STUDY/DESIGN
Systematic review with
meta-analysis of data.

LEVEL OF EVIDENCE
Level 2: Limited-quality,
patient-oriented evidence

Key Study Factor

The review included human clinical trials comparing two or more pulpotomy agents to treat vital primary molars with carious pulp exposure. Only
studies with follow-up periods of 6 months or more were considered.
Studies were required to have clear reporting of clinical or radiographic
success and failure rates to be included in the systematic review. The final
network meta-analysis included five commonly used medicaments for primary molar pulpotomies: formocresol, ferric sulfate, calcium hydroxide,
mineral trioxide aggregate (MTA), and laser therapies.

Main Outcome Measure

STRENGTH OF
RECOMMENDATION GRADE

Clinical and radiographic outcome among different pulpotomy treatments

for primary molars after follow-up periods of 912 months and
1824 months.

Grade B: Inconsistent, limitedquality patient-oriented evidence

Main Results

J Evid Base Dent Pract 2015;15:58-60

1532-3382/$36.00
2015 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.jebdp.2015.03.007

Thirty studies out of the identified 37 were described as randomized, 11 of

which clearly described the randomization methods. There were no trials
that employed double blinding, and only 2 trials performed patient blinding. Four of the included trials reported sample size and statistical power
calculations. The results of network meta-analysis of clinical and radiographic outcome for primary molar pulpotomy after 912 month followup (Table 3 in the article) indicated that formocresol had significantly
better clinical outcomes than calcium hydroxide. MTA had significantly

JOURNAL OF EVIDENCE-BASED DENTAL PRACTICE

better clinical outcomes than formocresol and calcium

hydroxide, and better radiographic outcome than formocresol, ferric sulfate, and calcium hydroxide. Calcium
hydroxide had more clinical and radiographic failures
than formocresol and ferric sulfate after 912 months.
The authors reported that after 1824 months, formocresol, ferric sulfate, and MTA had significantly better clinical outcomes than calcium hydroxide and laser
therapies (Table 4 in the article). Calcium hydroxide
and laser treatments had two and three times more failures than formocresol, ferric sulfate, and MTA, respectively. Results of the pair-wise meta-analysis were similar
to those from the network meta-analysis. Trials with
100% success rates of both treatments were excluded
from the pair-wise meta-analysis.

Conclusions
MTA had significantly better clinical and radiographic
outcomes than formocresol and calcium hydroxide,
and calcium hydroxide had more failures than formocresol and ferric sulfate after 912 months. After 18
24 months, formocresol, ferric sulfate, and MTA had
significantly better clinical and radiographic outcomes
than calcium hydroxide and laser therapies in primary
molar pulpotomies.

COMMENTARY AND ANALYSIS

In recent years, the diversity of techniques and medicaments used for primary tooth pulpotomy has raised the
need for a search of the available evidence to formulate
the best practice clinical guidelines. Practical guidelines
for choosing one treatment modality over the other
depend on the evidence behind different medicaments
used, their actions and success rates, and the different
clinical presentations of the treated teeth. Many RCTs
and systematic reviews have been conducted recently to
identify the best technique or medicament. The American Academy of Pediatric Dentistry (AAPD) encourages
additional research for consistently successful and predictable techniques using biologically compatible medicaments for vital and non-vital primary and immature
permanent teeth.1 A 2003 Cochrane review found that
there is no reliable evidence supporting the superiority
of one type of treatment for pulpally involved primary
molars and that high-quality RCTs, with appropriate units
of randomization and analysis, are needed.2
This systematic review attempted to identify the evidence that will support using one pulpotomy medicament over the others. The review included 37 studies
and compiled data about 5 different pulpotomy techniques. The results of the meta-analysis should be interpreted carefully because considering the drop-off and
premature loss of teeth as failures might have affected
them, as mentioned by the authors. Only a limited number of the trials were considered for meta-analysis; 22
Volume 15, Number 2

trials for 912 months follow-up and only 12 for

1824 months. The authors of this review concluded
that MTA was superior clinically and radiographically after 912 months and that it is comparable to formocresol,
and ferric sulfate after 1824 months. These results are in
agreement with most of the published reviews and studies
of these materials for the same follow-up periods.37
The results of a more recent Cochrane review were published in 2014; the review included 47 RCTs and 25 comparisons among different medicaments/techniques, of
which 14 compared MTA and formocresol.8 The authors
only judged 1 trial to be at low risk of bias and reported
that the overall quality of the evidence was low and there
is no evidence to identify one superior pulpotomy medicament. They also stated that two medicaments may be
preferable: MTA or ferric sulfate, with the cost of MTA being a limiting factor.8
Most published meta-analyses and systematic reviews
target well-controlled RCTs to be able to extract the highest level of evidence with the lowest bias; this was not the
case in this review. The inclusion criteria were not strict
and were set up in a way to include as many studies as
possible. The disadvantage of this is that the included trials displayed high heterogeneity, making direct comparisons difficult. For example, blinding, randomization,
follow-up periods, or clinical procedure were not considered when selecting these studies. Although the majority
of the included studies were described as being randomized, the randomization methods were not specified and
the blinding was not mentioned in all of them. Only 4 of
the included trials reported sample size and statistical power calculations. Approximately 12 of those studies
mentioned using amalgam or glass ionomer as a final
restoration, while the rest of them used stainless steel
crowns. On the other hand, strict inclusion criteria might
be a limiting factor in some studies, as this may lead to
exclusion of some well-designed trials with valuable information. Having fewer restrictions in the inclusion criteria
of this review resulted in the inclusion of a considerable
number of trials that studied different pulpotomy medicaments. The only drawback is that it might have affected
the strength of the evidence. It is recommended for
future systematic reviews to use a risk-of-bias assessment
tool to evaluate the included studies; this will help in validating the extracted data and assessing the quality of the
evidence provided from these studies.9
As mentioned before, the data of this review are consistent with the recently published trials. Despite the heterogeneity of the data, this meta-analysis provides valuable
information for clinicians. Its worth mentioning that
the authors did perform network meta-regression analysis
to investigate the impact of the restoration type and it was
found to be not significant. New concepts in the preservation of the healthy pulp tissue in deciduous teeth and the
induction of the reparative dentin formation with new
biomaterials instead of devitalization are experimented
59

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and discussed in the current literature.10 It is necessary

for practitioners to continue conducting high-quality
clinical trials and for investigators to perform systematic
reviews until we reach the best practical guidelines with
the highest level of evidence.

REFERENCES
1. American Academy of Pediatric Dentistry, Clinical Affairs Committee, Pulp Therapy Subcommittee. Guideline on pulp therapy for primary and immature permanent teeth. In: American Academy of
Pediatric Dentistry, editor. Reference Manual, 36(6); 2014. p. 242-50.
2. Nadin G, Goel BR, Yeung CA, Glenny AM. Pulp treatment for extensive decay in primary teeth. Cochrane Database Syst Rev
2003;(1):CD003220.
3. Marghalani A, Omar S, Chen JW. Clinical and radiographic success
rate of MTA compared with FC as pulpotomy treatment in primary
molars: a (systematic) review and meta analysis. J Am Dent Assoc
2014;145(7):714-21.
4. Asgary S, Shirvani A, Fazlyab M. MTA and ferric sulfate in pulpotomy
outcomes of primary molars: a systematic review and meta-analysis. J
Clin Pediatr Dent 2014;39(1):1-8.
5. Peng L, Ye L, Tan H, Zhou X. Evaluation of the formocresol
versus mineral trioxide aggregate primary molar pulpotomy: a

60

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meta-analysis. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;102(6):e40-4.
Shirvani A, Hassanizadeh R, Asgary S. Mineral trioxide aggregate vs.
calcium hydroxide in primary molar pulpotomy: a systematic review.
Iran Endod J 2014;9(2):83-8.
De Coster P, Rajasekharan S, Martens L. Laser-assisted pulpotomy in
primary teeth: a systematic review. Int J Paediatr Dent 2013;23(6):
389-99.
Smal-Faugeron V, Courson F, Durieux P, Muller-Bolla M,
Glenny AM, Fron Chabouis H. Pulp treatment for extensive decay
in primary teeth. Cochrane Database Syst Rev 2014;(8):CD003220.
Higgins J, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions. The Cochrane Collaboration, www.cochranehandbook.org; 2011.
Parisay I, Ghoddusi J, Forghani M. A review on vital pulp therapy in
primary teeth. Iran Endod J 2015;10(1):6-15.

REVIEWER
Samah Omar
Diplomat, American Board of Pediatric Dentistry, Assistant
Professor and Full Time Faculty, Advanced Specialty Education
Program in Pediatric Dentistry, Loma Linda University, Loma
Linda, CA, USA, Tel.: 1 909 558 4690
somar@llu.edu

June 2015