Integrated Mini Reviews

Evidenced-Based Review of Clinical Studies on Direct Pulp Capping
The delivery of vital pulp therapy is a field replete with controversies regarding clinical outcomes, risk factors (eg, primary vs permanent teeth), and optimal treatments. This is an ideal topic for summary analyses of the evidence-based literature that focus on study quality, advantages, and limitations. In this year’s inaugural special issue on evidence-based endodontics, we provide an analysis of two recent clinical trials on direct pulp capping in primary teeth. white mineral trioxide aggregate (MTA) with the symmetric pair being covered with calcium hydroxide. The material used for the first capping was randomized. Resin-bonded zinc oxide–eugenol cement (Kalzinol, Dentsply Middle East & Africa) was placed over the experimental materials followed by an amalgam restoration. If one pulp of the symmetric pair was not exposed, the tooth was restored and the patient was excluded from the study. Initially, 50 pairs of primary molar teeth in 25 patients were evaluated clinically and radiographically at 1, 3, 6, 9, 12, 18, and 24 months. Two calibrated investigators blindly evaluate the teeth. A 24-month follow-up was performed on 22 patients (22 teeth with MTA and 20 teeth with calcium hydroxide). Patient variability was minimized by using a split-mouth model.

Analysis of Article #1
Clinical Long-Term Evaluation of MTA as a Direct Pulp Capping Material in Primary Teeth ¨ Tuna D, Okmez A–Int Endod J 2008;41:273–8

Study Overview
Level of Evidence: Level 2 Purpose / Question: The purpose of this review was to evaluate the long-term effectiveness of mineral trioxide aggregate (MTA) compared with calcium hydroxide when used as a pulp-capping material in primary teeth. Source of Funding: Scientific Research Foundation of Gazi University, Ankara, Turkey (grant no. 03/2003-15) Type of Study / Design: Randomized controlled clinical trial–low level Title: Mineral Trioxide Aggregate Successful as Calcium Hydroxide When Used as a Pulp Capping Agent in Primary Molar Teeth Author Affiliation / contact: Department of Pediatric Dentistry, School of Dentistry, Gazi University, Ankara, Turkey, e-mail:

Main Outcome Measure The main outcomes measures for the determination of successful outcomes were (1) no spontaneous pain; (2) no tenderness to percussion; (3) no swelling, sinus tract, or pathological mobility; and (4) no furcation radiolucency, PDL space widening, or internal or external resorption. Data were subjected to statistical analysis. Main Results During the evaluation period, no teeth exhibited clinical and radiographic failure; hence, no statistical analyses were performed regarding the success of treatment. Conclusions Based on this long-term clinical and radiographic study, MTA was found to be as successful as the control calcium hydroxide when used as a direct pulp-capping material in primary teeth. Statistical Analysis and Commentary Patients were randomly assigned to receive MTA or calcium hydroxide as a direct pulp-capping agent. Clinical evaluators were calibrated and blinded when evaluating clinical signs of failure during follow-up visits. Because there were no failures, a statistical analysis was not performed. Re-evaluation of cases of pulp treatment in primary molars for a 2-year timeframe would appear to be sufficient to identify the outcomes of treatment. The use of these two materials for direct pulp capping in primary teeth is a movement toward tissue repair/regeneration during the time of tooth retention as opposed to one of pulp ‘‘fixation or mummification,’’ as was the historical approach with primary molars. When using the latter approach, the success rate for direct pulp capping has not been particularly high, and, therefore, this treatment modality has limited application and investigation. Furthermore, the dentin bridge that may form in primary molars was thought to be porous and a potential avenue for bacterial penetration. The CONSORT guidelines appear to have been followed in this study. This is one of the few studies that has studied pulp capping in primary molars and has used a material like MTA. In doing so, a split-mouth design was used to minimize patient-to-patient variability.

Subjects Fifty primary teeth with deep occlusal caries in 25 patients (13 females/12 males) were randomized according to Consolidated Standards of Reporting Trials (CONSORT) guidelines. Clinical exclusion criteria were (1) spontaneous pain, (2) sensitivity to percussion/palpation, (3) swelling in the buccal vestibule or presence of a sinus tract, and (4) pathological mobility. Radiographic exclusion criteria were (1) Periodontal Ligament (PDL) space widening, (2) loss of lamina dura, (3) furcation radiolucency, and (4) internal or external resorption. Informed consent was signed by parent or guardian. Procedures Under local anesthesia and dental dam coverage, carious enamel lesions were removed with high-speed handpieces and diamond burs. Dentin was excavated with low-speed handpieces and tungsten carbide burs. When a pulp exposure occurred, the hemorrhage was controlled with light pressure, and one of the exposed pulps was covered with


JOE — Volume 35, Number 8, August 2009

Title: Direct Pulp Capping Procedures With NaOCl Hemostasis Can Be Performed With Calcium Hydroxide Or Total. thereafter. Analysis of Article #2 Clinical and Radiographic Evaluation of Adhesive Pulp Capping in Primary Molars Following Hemostasis With 1. Group 2: Placement of an acetone-based single-bottle adhesive and light cured.25% NaOCl using sterile cotton pellets soaked in the solution. The integrity of the restorative margins was also checked based on a modified United States Public Health Service clinical rating system (1). and. tooth-resin margins were etched as in group and sealed with an unfilled light-cured resin. the teeth in groups 1 and 2 were considered the most successful because of the absence of any clinical and radiographic signs of failure. and (3) no internal or pathologic external resorption not compatible with the normal exfoliative process. Source of Funding: None indicated Type of Study / Design: Randomized prospective controlled clinical trial—low level. Group 4: Total-etch technique was used without pulpal contact. (2) no swelling.0 mm).35) were treated with direct pulp-capping procedures and evaluated over a 24-month period. Cehreli ZC–Am J Dent 2007. Ankara. if there was no sign of an exposure. 9. restored as in group 2.20:182–8 ¸ Study Overview Level of Evidence: Level 2 Purpose / Question: The purpose of this study was to evaluate the clinical and radiologic response of primary molars pulp capped with different adhesive systems after hemorrhage control with 1. Data were subjected to statistical analysis. and if there was an exposure it was greater than 1. male:female ratio = 0. and informed consent was signed by the parent or guardian. restoration with a polyacid-modified resin-based composite. Main Results After 24 months. restored as in group 2. Group 1: Calcium hydroxide (Dycal.Integrated Mini Reviews However. Procedures Under local anesthesia and dental dam coverage. The Kruskal-Wallis is a nonparametric one-way analysis of variance test for ranked data. Comparisons within each group system with respect to evaluation criteria and recall periods were evaluated statistically using Wilcoxon signed ranks test. and 30 days. and 24 months with radiographs taken at the 3. One operator performed all the clinical procedures and took all the radiographs of the teeth (including the immediate postoperative films). JOE — Volume 35. The majority of failures were determined between the 12. PA) was placed followed by a non-gamma II type amalgam. Two calibrated operators blinded to the treatment preformed all postoperative examinations.25% Sodium Hypochlorite: 2-Year Results Demir T. which was used as the criteria to move directly to a pulpotomy. Standardized exclusion criteria were used. and (3) cavity outline was limited to the occlusal surface. The Wilcoxon signed rank test is a nonparametric statistical hypothesis test for the case of two related samples or repeated measurements on a single sample. Statistical Analysis and Commentary Comparisons between the test groups were evaluated statistically using Kruskal-Wallis and Friedman tests. Failure rates in groups 3 and 4 were Evidenced-Based Review of Clinical Studies on Direct Pulp Capping Summary Subjects Primary molars from 5. e-mail: not available Main Outcome Measure The main outcomes measures for the determination of successful outcomes were (1) no spontaneous pain and/or sensitivity to pressure/ percussion.0 mm. York. direct pulp-capping procedures with NaOCl hemostasis can be performed with calcium hydroxide or 24-month re-examinations. August 2009 1153 . 6. restored as in group 2. Group 5: Application of a self-etch adhesive system and light cured. The total-etch adhesive must not be used in conjunction with a total-etch technique or nonrinse conditioner. Failure was recorded if one or more of the signs/symptoms were present.25% sodium hypochlorite (NaOCl). 7. There was a significant tendency toward treatment failure in groups 3 and 4. It is used to detect differences in treatments across multiple test attempts. Failures were more frequently observed in mandibular primary second molars. Inclusion criteria were (1) one active occlusal carious lesion in middle or deep dentin. at 3. Number 9-year-old children (67 total. which is a parametric test. Turkey. The Friedman test is a nonparametric statistical test that is similar to the parametric repeated-measures analysis of variance. 18. carious enamel lesions were removed with high-speed handpieces and diamond burs. or pathological mobility. a limitation of this in vivo study was to collect a satisfactory number of eligible patients with occlusal caries of similar depth in symmetric primary molars within a reasonable timeframe. It is similar in function to the paired Student t test. the hemorrhage was controlled with 1.And Self-Etching Adhesives on Primary Molars That Are Expected to Exfoliate Within Two Years Author Affiliation / Contact: Department of Pediatric Dentistry. (3) no furcation or periapical radiolucency. For teeth with small exposures (<1. sinus tract. 12. Dycal-Dentsply. the overall success rate of direct pulp capping was approximately 93%. When all groups were pooled and evaluated. Procedures for each group were as follows:. Group 3: Placement of a nonrinse conditioner in the entire cavity. No failures were observed in the maxillary arch. tooth/amalgam margins were etched and sealed with a light-cured fissure sealant.and self-etching adhesives. 14. squeezed to remove the excess.and 24-month re-examination periods. Hacettepe University. Teeth were assigned randomly to one of five groups with respect to the material/technique used for capping. and placed on the exposure for 60 seconds without pressure. Teeth were examined at baseline. (2) extension of the cavity preparation would risk exposure based on clinical and radiographic assessments. Teeth were excluded if the caries-affected dentin was removed. Conclusions For primary molars with Class I occlusal cavities that are expected to exfoliate within 2 years. Dentin was excavated with low-speed handpieces and carbide burs.

Pediatr Dent 2004. Guidelines on pulp therapy for primary and young permanent teeth. and 5. There was no significant difference in failure rates between groups 1. 7:115–6. American Academy of Pediatric Dentistry Reference Manual 2004-2005. August 2009 . 1154 JOE — Volume 35. 2.Integrated Mini Reviews significantly higher than groups 1. There was no statistically significant relationship between marginal integrity and failure rates. and it could be less through time because of restoration failure or exfoliation. Number 8. the sample size in each group was only 20. Reference 1. In this study. 2. the operator was not blinded to treatment materials and adherence to CONSORT guidelines was not evident. Because there were so many test groups. and 5.

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