DOI: 10.1111/ipd.
12228
REVIEW
Intracanal irrigants for pulpectomy in primary teeth: a
systematic review and meta-analysis
AMAURY POZOS-GUILLEN1,2, ADRIAN GARCIA-FLORES2, VICENTE ESPARZA-VILLALPANDO3
& ARTURO GARROCHO-RANGEL2
1
Basic Sciences Laboratory, Faculty of Dentistry, San Luis Potosi University, San Luis Potosi, Mexico, 2Pediatric Dentistry
Postgraduate Program, Faculty of Dentistry, San Luis Potosi University, San Luis Potosi, Mexico, and 3Clinical Research
Postgraduate Program, Faculty of Medicine, San Luis Potosi University, San Luis Potosi, Mexico
International Journal of Paediatric Dentistry 2016; 26:
412–425
Objective. To conduct a systematic review and
meta-analysis to assess the findings on the clinical
efficacy of intracanal irrigants employed during
pulpectomy of primary teeth.
Methods. A systematic search was performed in
electronic databases and peer-reviewed paediatric
dentistry journals to find relevant studies. Titles,
abstracts, and full-text papers were located,
screened, and assessed independently by two
reviewers, and a meta-analysis was performed.
Results. The search identified a total of 775
records; 46 were selected and reviewed in full
text. After screening, seven studies met the eligi-
bility criteria for inclusion. Three studies com-
pared the 2% chlorhexidine and saline solutions,
but no analysis could be performed because of the
Introduction
The success of endodontic therapy in primary
teeth strongly depends on achieving an ade-
quate level of disinfection within their root
canals. Mechanical instrumentation alone is
unlikely to be sufficient in attaining such disin-
fection, considering the root resorption process
and the complex anatomy of the root canal
system, characteristic of primary molars, and
the risk of damage to the permanent germ1.
Evidence has shown that the mechanical
instrumentation technique with files is limited
because it tends to leave significant portions of
the infected canal walls untouched; thus, an
Correspondence to:
Amaury Pozos Guillen, Faculty of Dentistry, San Luis
Potosi University, Av. Dr Manuel Nava #2, Zona
Universitaria, C.P.78290, San Luis Potos
ı, SLP, Mexico.
E-mail: apozos@uaslp.mx.
412 © 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
heterogeneity between these; two of the studies
reported non-comparative methodologies and
results when compared, and were not analysed.
Finally, two studies compared a mixture of tetra-
cycline isomer, an acid, and a detergent (MTDA)
or oxidative potential water (OPW) to sodium
hypochlorite (NaOCl), without showing significant
heterogeneity; therefore, their combined outcomes
were included. Both fixed and random mixed
models resulted in a non-significant weighted
mean difference between treatments, according to
a forest plot.
Conclusions. More studies are required with ade-
quate quality, as well as a full-result report,
including summary measurements of both
response variables and effect size, to determine
the most effective irrigant agents for use in
pulpectomies.
important number of viable pathogenic
microorganisms persist, lodged together with
dentin debris and necrotic pulp-tissue rem-
nants inside the dentin tubules, canal ramifica-
tions, and resorption craters2. Therefore, it is
necessary to significantly reduce or to eradi-
cate, to the extent possible, the microorgan-
isms and their by-products present to the pulp
canals by employing clinically effective and
biocompatible irrigants, which also aid in dis-
solving organic debris3.
Irrigation currently represents the best method
in paediatric pulpectomy for the lubrication and
flushing away of loose necrotic and contami-
nated materials during instrumentation4. In clin-
ical practice, different intracanal irrigants have
been proposed for primary teeth, such as NaOCl,
chlorhexidine gluconate, ethylenediaminete-
traacetic acid (EDTA), citric acid, MTAD, hydro-
gen peroxide, and others4, causing confusion
among professional odontologists, especially

those who are less experienced2,4. Thus, it is
challenging for paediatric dentists to choose the
most appropriate irrigant agent when perform-
ing pulp canal treatments. Although several
in vitro, ex vivo, and in vivo approaches have been
applied in efforts to establish the effectiveness of
diverse disinfecting substances, the irrigating
solution that should be considered the ideal
agent for employment during pulpectomies in
paediatric dentistry remains an issue5–7.
Currently, no data from systematic reviews,
including meta-analyses, are available regarding
this clinic topic. Therefore, in the light of the
need for comprehensive summaries to contrast
various available pulpectomy irrigants in paedi-
atric dentistry, the purposes of this study were
to identify, assess, and summarize the existing
knowledge and to undertake a systematic
review with a meta-analysis of randomized con-
trolled trials, observational studies, and review
articles that have assessed and estimated the
clinical efficacy of different intracanal irrigants
commonly employed during pulpectomy in pri-
mary teeth. The null hypothesis was that there
were no differences in clinical effectiveness
among these agents when performing biome-
chanical disinfection of primary pulp canals.
Materials and methods
This systematic review and its meta-analysis
were prepared following PRISMA (Preferred
Reporting Items for Systematic Reviews and
Meta-Analysis) principles by Liberati et al.8, the
Cochrane Group fundamentals, and the recom-
mendations of Higgins and Green9. Initially, a
protocol was developed that specified in
advance it and documented the entire process
of the systematic review; it described and
defined the background, a focused clinical ques-
tion, the hypothesis to be tested, explicit eligi-
bility criteria for individual studies, replicable
search methodologies, and techniques for statis-
tical analysis (meta-analysis) of the pooled,
extracted data.
Selection criteria
Articles reporting clinical, radiographic, or
microbiological results with irrigant solutions
in primary pulpectomies as the primary end-
© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Intracanal irrigants for pulpectomy 413
point were considered as eligible. Included
were dental randomized controlled clinical
trials (RCTs) – parallel groups, crossover or
split-mouth designs – observational, prospec-
tive, or retrospective studies, and reviews of
the narrative literature. Studies of permanent
teeth, case reports (or case series), in vitro or
animal studies, abstracts, and unpublished
data were excluded. Intervention, and control
and outcome parameters were selected in
accordance with the following PICO criteria:
Population: Children and adolescents up to
12 years of age.
Interventions: Intracanal irrigant and chemo-
mechanical debridement in primary teeth
Control: Reference irrigant (comparison)
Outcome: Effectiveness of the interventions
(clinical, radiographic, or microbiological
results)
Literature search strategy and data extraction
The following databases were searched with-
out language or publication date restrictions:
MEDLINE (via PubMed), Cochrane Library,
EMBASE (Elsevier Science), Google Scholar,
SCOPUS Web of Science, ScienceDirect, EBS-
COhost, Wiley Online Library, OVID, Springer,
Latin Index, and SCIELO. The search algorithm
was as follows: ((‘Pulpectomy’ [Mesh] AND
‘Root Canal Irrigants’ [Mesh]) AND ‘Tooth,
Deciduous’ [Mesh]. In addition, we hand-
searched the content pages of eight, interna-
tional peer-reviewed paediatric dentistry
journals (1980 to present), including the
following: Journal of Clinical Pediatric Dentistry
(formerly known as Journal of Pedodontics);
Pediatric Dentistry; Journal of Dentistry for
Children; International Journal of Paediatric
Dentistry; International Journal of Clinical Pedi-
atric Dentistry; European Archives of Paediatric
Dentistry; Pediatric Dental Journal, and European
Journal of Paediatric Dentistry. The reference lists
of the downloaded papers were also thor-
oughly screened.
Then, the authors’ names, titles, abstracts,
keywords, design, and evaluation length of
each reference, identified according to the
selection criteria, were objectively and inde-
pendently screened by two blinded reviewers
(GFJ-A and EV-V); any difference between
414 A. Pozos-Guillen et al.

them was resolved according to discussion
and consensus or with the involvement of a
third reviewer (PGA-J). These selected studies
were downloaded as full-text papers and were
later rescreened in detail by the same review-
ers to confirm whether they complied with
the inclusion criteria. Also, an in-depth
inquiry was performed into duplicate report
publications to avoid introducing bias due to
double counting, by means of juxtaposing
author names, treatment comparisons, sample
sizes, and results.
Data were extracted independently by the
other reviewers (PGA-J and GRJ-A) from the
selected papers, in blinded fashion, using a
developed data extraction sheet (based on the
Cochrane template)8. If the reviewers had any
data-related questions or needed additional
information, the authors of the papers were
contacted. In reports of which one of the
reviewers appeared as an author, the assess-
ment was performed by another reviewer to
prevent any potential conflicts of interest.
Quality appraisal
The methodological quality and validity of
the included studies were independently
assessed by two blinded reviewers employing
Grading of Recommendations Assessment,
Development, and Evaluation (GRADE)10 and
Table 1. Evaluated characteristics in each selected study.
Oxford Centre for Evidence-Based Medicine
(OCEBM)11 criteria; these are described later
and are both considered suitable for reducing
potential biases in RCTs12,13 (Table 1). The
reviewers scored each scale section based on
their judgment and knowledge for determin-
ing the respective section weight with regard
to the final results and conclusions of each
individual study. The maximal value was 16,
and this value was correlated with the quality
of the study, but the individual point could
be assessed for an individual value in the
study (Table 2); for type of result appraisal,
such as clinical, radiographic, and microbio-
logical (or another measurement type), out-
come success rates were also evaluated10,14,15.
If necessary, the corresponding authors were
contacted to obtain information concerning
unclear or missing data ‒ for example, numer-
ical data only presented graphically ‒ which
were considered significant by the reviewers
for the aim of performing the meta-analysis.
Meta-analysis (quantitative analysis)
Meta-analysis was performed if the studies
were homogeneous, and this was verified sta-
tistically using the inconsistency Q test. An
estimated overall-effect size of the papers
included in the analysis was obtained.
Summary measurements (means, standard-

Section Description

Sample size calculation
Randomization
Randomization (Method)
Blinding or masking
Follow-up
Response variable
Concordance of the
measurement method
Assumptions of the
statistical tests
Results
Indicates whether the calculation of sample size or a pilot study is present or not on the basis of the
type of methodological design, based on the statistical criteria16–19.
Indicates whether the process of randomization for the different experimental groups is present or not,
which can usually be determined by whether the process is performed when the baseline
characteristics of the groups are homogeneous18,20.
Indicates whether the method of randomization is described and executed properly, and again, we
recommend observing whether the groups are homogeneous20,21.
Indicates whether the method of blinding is present and whether or not it is described22,23.
Indicates whether follow-up of patients was complete or incomplete and, in this case, that lost cases
were evaluated24.
Based on the characteristics of the variable response or outcome, this variable can determine its
objectivity or subjectivity and, in keeping with this ability, the clinical implications that might have an
impact on the results and conclusions25.
In the case of the response variable being qualitative, a procedure is recommended for concordance
between the observers of the event-of-interest, as well as whether quantitative laboratory processes
are to follow recommendations for quality26,27.
Indicates whether the assumptions were evaluated for correct application of the statistical test25,28,29.
Indicates whether the results were fully reported, it being important to report the size of the resulting
effect in each analysis to be performed, with its respective error30,31.

© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 Intracanal irrigants for pulpectomy 415

ized mean difference [SMD], and standard

Total

13

12

13

11
10
9
12
deviations [SD]) were extracted from the
results and expressed as continuous data in

0 = incomplete,
1 = complete
the study groups. The weighted mean differ-
ence was chosen as the point estimate, with
Results
its corresponding 95% confidence interval

1
1
0
1
(95% CI), calculated from a restricted maxi-
categorical data,
0 = Not present,

2 = present and

mum likelihood model; a significant differ-

statistical test

1 = Not clear/
Assumptions

ence was assumed (null hypothesis rejected)

described

if the lower limit of the 95% CI surrounding

of the

the pooled estimate was >0. Further, an effect

1

1
0
0
0
size of the averaged outcomes for each indi-
0 = Not present,
Concordance of

vidual study was graphically presented in a

1 = Not clear,
2 = present/

forest plot. For all of these purposes, R soft-

measuring

laboratory
method

testing

ware version 3.2.0 and Meta and Metafor sta-

tistical software programs were used; the
2

2
2
2
2
alpha value was set at 0.05.
2 = quantitative
0 = qualitative

1 = qualitative
subjective,

objective,
Response

Results
variable

2
2
2
2

Literature findings
1 = intention to
0 = incomplete,

The electronic databases and hand-performed

methods of
treat/other
Follow-up

journal searches identified a total of 775

analysis,
2 = full

potential documents and, after adjusting for

duplicates or supplementary reports, 759
2

2
2
2
2

remained. After reviewing titles and abstracts,

inappropriate,

and described
1 = Not clear/

2 = present

713 of the citations clearly did not meet the

described,
Blinding
0 = Not

selection criteria and were discarded. The full

text of the remaining 46 records was
1

0
0
0
0

retrieved, screened in greater detail, and

0 = unsuitable/
Randomization

not described,
1 = adequate

assessed for eligibility; finally, seven relevant

(method)

studies were identified for inclusion in the

review and two in the meta-analysis (Tables 3
1

0
0
0
1

and 4), which exhibited lowest risk of bias

0 = Not present,

according to the OQS. A flow diagram (Fig. 1)

Randomization

(homogeneous
1 = Not clear,

depicts and summarizes the numbers of the

2 = Present

abstracts retrieved, and the included and

groups)

excluded papers (and the reasons why) at

2

2
2
2
2

each stage of the search process.

1 = unspecified/
Table 2. Study quality assessment.

pilot study,
2 = Present
calculation

Characteristics of included studies

Sample

The seven studies included in the present sys-

1

1
1
1
2

tematic review were all full reports on RCT

design

(six parallel trials and one crossover trial)

RTC

published in English language between 2011

P

P
P
P
P
Pruck-satham-

and 2015. The follow-up periods ranged from

Verma et al.36
Farhin et al.37
Tulsani et al.7
Ruiz-Esparza

Jolly et al.35
Louwakul &

immediate assessment (five studies) and

rongkul33

Gonz
alez
et al.32

et al.34

3 days (one study) to up to >1 month (one

Valdez
Study

study). All of the trials measured the out-

© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
416 A. Pozos-Guillen et al.
comes and results in colony-forming units
(CFU/mL), except for two trials, one of which
reporting the relative quantifying (RQ)
increase in gene expression, and the other, a
dichotomous (success/failure) result.
Qualitative synthesis
2% Chlorhexidine gluconate versus saline solu-
tion. Three studies32,33,35 assessed the efficacy
of 2% chlorhexidine gluconate compared
with saline solution. Ruiz-Esparza et al.32 and
Jolly et al.35 both reported a significant
decrease, in terms of CFU/mL, in favour of
chlorhexidine, whereas Jolly et al.35 reported
smaller values than the remaining studies
included in the present review. Thus, it was
decided not to include their study in the
quantitative synthesis. In contrast, Louwakul
and Prucksathamrongkul33 reported a statisti-
cally significant difference in favour of
chlorhexidine, employing a dichotomous
(success/failure) response variable after a 6-
month evaluation period; again, due to the
dichotomous response, it was not possible to
include this study in the quantitative synthe-
sis. In conclusion, all of the studies reporting
a difference in favour of chlorhexidine, when
compared with saline solution, exhibited
important heterogeneity with each another;
therefore, the results could not be statistically
compared among each another.
MTAD versus NaOCl. Two studies assessed the
efficacy of MTAD compared with 2.5/1%
NaOCl. Tulsani et al.7 reported no difference
between MTAD and 2.5% NaOCl against
Enterococcus faecalis in necrotic anterior pri-
mary teeth; however, both of these irrigants
were superior to saline solution. Conversely,
Farhin et al.37 reported a significant difference
in favour of MTAD in terms of CFU/mL. The
discrepancy in the results between these stud-
ies could be explained by differences in the
response variable type and methodology;
thus, the results were not comparable.
OPW and MTDA versus NaOCl. The efficacy of
NaOCl as a control irrigant was compared
with OPW34, and with MTA37, in terms of
© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
CFU/mL. Based on the homogeneity between
the studies, it was decided to combine the
results, despite their being different experi-
mental groups. Because the purpose of the
comparison was an assessment of the global
efficacy regarding NaOCl, independent of the
comparison group, a quantitative meta-analy-
sis was conducted with these two studies.
Meta-analysis
A meta-analysis was conducted with only
two studies: those of Valdez-Gonz
alez et al.34
and of Farhin et al.37, which exhibited suffi-
cient crude data, and all of the possible out-
comes were included. These combined studies
(Figs 2 and 3) did not show significant
heterogeneity (Q = 1.42; degrees of free-
dom = 1; P = 0.2326) according to the
restricted maximal likelihood model. For the
fixed effects model, the estimator of SMD was
0.1548 (95% CI = ‒0.2339, 0.5490), with a
z-statistic of 0.7697 and a P value of 0.4415.
For the random effects model, the estimator
of SMD was 0.1704 (95% CI = 0.3058,
0.6467), with a z-statistic of 0.7015 and a
P value of 0.483. No significant differences
were detected between experimental treat-
ments and NaOCl in terms of decreasing
CFU/mL amounts, from the pulp canals of
primary teeth.
Discussion
To help ensure that the therapies provided in
paediatric dentistry benefit patients more
than harming them, related uncertainties
must be identified and discussed. The publica-
tion of systematic reviews and an evidence-
based approach based on high-quality reports
are critical for assessing and interpreting the
best available relevant evidence38. In the field
of paediatric dentistry, by means of perform-
ing systematic reviews jointly with meta-ana-
lyses, it is possible to compare, combine, and
synthesize research data from multiple similar
but independent information sources, result-
ing in an increase in overall sample size and
more robust statistical power. Thus, they can
offer clinical practitioners and decision-
makers an informed overview of the knowl-
 Table 3. Individual characteristics of the studies.

Initial Evaluation
Study Age (range) Methods Characteristic of patients sample Irrigant agent Final sample period

Ruiz-Esparza (3–9) Randomized, • 40 patients of both genders 20 Saline solution 20 Pre-irrigation

et al.32 parallel • Patients in good general health 20 20 Post-irrigation
clinical trial • Primary teeth with necrotic pulp, 20 2% Chlorhexidine 20 Pre-irrigation
abscess, or fistula 20 gluconate 20 Post-irrigation
• Presence of radiolucent area(s) in
the furcal or periapical region
• At least two-thirds of the root
remaining
• Carious lesion(s) without direct
exposure to the oral environment
• Sufficient isolation and sterility
control of the operative field
Louwakul&Pruck- (3–9) Randomized, • 42 healthy patients (17 girls and 32 Saline solution 30 6 months
satham-rongkul33 triple-blind, 25 boys) 30 12 months
parallel • 64 mandibular primary teeth 30 18 months
clinical trial • Presence of a deep carious lesion 32 2% Chlorhexidine 31 6 months
with pulp exposure
gluconate 31 12 months
• History or presence of spontaneous
pain 31 18 months
• Presence of abscess or fistula
Valdez-Gonz
alez, (3–8) Randomized, • 40 patients of both genders 20 NaOCl 1% 20 Pre-irrigation
et al.34 triple- blind, • Primary teeth containing at least 20 20 Post-irrigation
crossover one necrotic pulp canal, abscess, or 20 Oxidative Potential 20 Pre-irrigation
clinical trial sinus tract 20 Water (OPW) 20 Post-irrigation

© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
• Presence of a radiolucent area in
the furcal or periapical regions
• Carious lesion without direct expo
sure to the oral environment
• Sufficient isolation and sterility
control in the operative field to demon
strate no bacterial growth
Jolly et al.35 (6–12) Randomized, • 60 children with pulpally involved 15 Saline solution 15 Pre-irrigation
parallel primary maxillary molars Post-irrigation
clinical trial • Children with an acute apical 15 Chlorhexidine 15 Pre-irrigation
abscess of the maxillary primary molars gluconate 2% Post-irrigation
• Children not receiving systemic
15 Calcium 15 Pre-irrigation
antibiotics within the past 3–6 months
hydroxide 4% Post-irrigation
15 Propolis 4% 15 Pre-irrigation
Post-irrigation
Intracanal irrigants for pulpectomy

(Continued)
417
 418

Table 3 (Contd.)

Initial Evaluation
A. Pozos-Guillen et al.

Study Age (range) Methods Characteristic of patients sample Irrigant agent Final sample period

Tulsani et al.7 (4–8) Randomized, • 40 primary anterior teeth 10 Isotonic saline solution 0.9% 10 Post-irrigation
parallel • Referrals for dental treatment 15 2.5% NaOCl 15
clinical trial • Patients without systemic 15 MTAD (Biopure) 15
conditions
• Teeth primary with necrotic pulp,
asymptomatic, through clinical and
radiographic assessment
• Without surgical interventions
• Without periodontal lesions
Verma et al.36 (4–7) Randomized, • 70 primary teeth 35 Isotonic saline solution 0.9% 35 Pre-irrigation
parallel • Children with good general health, Post-irrigation
clinical trial without histories of antibiotic coverage 35 Water-soluble propolis 25% 35 Pre-irrigation
and radiographic evidence of carious Post-irrigation
pulp exposure
Farhin et al.37 (3–7) Randomized, • Patients in good health 30 NaOCl 1% 30 Pre-irrigation
parallel • 60 primary molar teeth that con 30 30 Post-irrigation
clinical trial tain at least one root canal with necro 30 MTAD 30 Pre-irrigation
sis pulp, abscess, or fistula 30 30 Post-irrigation
• Injury to decay without direct pul
pal exposure to the oral environment
• Presence of a radiolucent area in
the furca or periapical region
• Sufficient tooth structure to place
a rubber dam

© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 Table 4. Individual results of individual studies.

Initial Final Evaluation Success of Failure of Response

Study sample Irrigant agent sample period treatment treatment Mean SD variable Results Conclusion

Ruiz-Esparza 20 Saline solution 20 Pre-irrigation ND ND 1.689109 4.79107 Colony- Statistically Chlorhexidine

et al.32 20 20 Post-irrigation 1.069109 4.69107 forming significant gluconate
20 2% 20 Pre-irrigation 1.59109 5.29107 units difference showed
20 Chlorhexidine 20 Post-irrigation 1.59106 4.69106 (CFU/mL) was observed greater
gluconate in favour of the reduction of
experimental intracanal
group bacterial
loading
Louwakul&Pruck- 32 Saline solution 30 6 months 25 5 ND ND Success At 6 months Chlorhexidine
satha-mrongkul33 30 12 months 28 2 and failure, in favour of 2% could
30 18 months 29 1 radiographic experimental improve the
32 2% 31 6 months 31 0 and clinical group and no results
Chlorhexidine 31 12 months 30 1 criteria difference at 6 months
gluconate 31 18 months 28 2 12 or 18 months after
intervention

© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Valdez- 20 NaOCl 1% 20 Pre-irrigation ND ND 1.569109 3.369108 CFU/mL Significant OPW was as
Gonz
alez, 20 20 Post-irrigation 0 0 difference in effective as
et al.34 20 OPW 20 Pre-irrigation 1.639109 4.189108 favour of the NaOCl
20 20 Post-irrigation 59107 1.539108 experimental
group when
evaluated
pre- and
post-irrigation

(Continued)
Intracanal irrigants for pulpectomy
419
 420

Table 4 (Contd.)

Initial Final Evaluation Success of Failure of Response

Study sample Irrigant agent sample period treatment treatment Mean SD variable Results Conclusion

Jolly et al.35 15 Saline solution 15 Pre-irrigation ND ND Aerobes (7.13) 1.19 CFU/mL In all groups, Chlorhexidine
Post-irrigation Anaerobes (7.4) 1.24 a significant proved to
Aerobes (3.8) 1.08 decrease in be a superior
Anaerobes 0.91 mean aerobic antimicrobial
(6.40) CFU was agent
15 Chlorhexidine 15 Pre-irrigation Aerobes (7.13) 1.19 observed; against both
A. Pozos-Guillen et al.

gluconate 2% Post-irrigation Anaerobes (7.2) 1.26 maximal endodontic

Aerobes (3.8) 1.08 change in aerobes and
Anaerobes 0.88 anaerobic CFU anaerobes
(3.73) count was
15 Calcium 15 Pre-irrigation Aerobes (7.13) 1.19 observed
hydroxide 4% Post-irrigation Anaerobes 1.19 with 2%
(7.13) chlorhexidine
Aerobes 1.49
(5.73) 1.16
Anaerobes
(5.27)
15 Propolis 15 Pre-irrigation Aerobes 1.58
extract 4% Post-irrigation (6.93) 1.28
Anaerobes
(7.27)
Aerobes 1.19
(3.87) 1.12
Anaerobes
(4.40)
Tulsani et al.7 10 Isotonic saline 10 Post-irrigation ND ND 2.09 1.54 Relative Statistically Both irrigants
solution 0.9% Quantifying significant (NaOCl and
15 2.5% NaOCl 15 0.23 0.34 (RQ) difference MTAD) were
15 MTAD 15 0.19 0.40 increase in between effective
(Bio-pure) gene NaOCl and against
expression MTAD against E. faecalis
control was
found, but no
difference was
found between
the experimental
groups

(Continued)

© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
 Table 4 (Contd.)

Initial Final Evaluation Success of Failure of Response

Study sample Irrigant agent sample period treatment treatment Mean SD variable Results Conclusion

Verma et al.36 35 Isotonic saline 35 Pre-irrigation ND ND ND ND CFU/mL Greater The

solution 0.9% Post-irrigation reduction in water–soluble
35 Water- soluble 35 bacterial colony propolis
propolis 25% counts isolated extract 25%
in the Propolis can be used
group compared as an irrigant
with the control
group
Farhin et al.37 30 NaOCl 1% 30 Pre-irrigation ND ND 111301.7 10.809103 CFU/mL Group (NaOCl) The results
30 30 Post-irrigation 354.25 18.739103 showed presented
30 MTAD 30 Pre-irrigation 105873.5 11.829103 significant in this study
30 30 Post-irrigation 183.09 59.149103 decrease in are very
bacterial load; promising
the same in the in terms of

© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
MTAD group; being
when both a viable
groups were alternative
compared in
post-irrigation,
MTAD was
superior
Intracanal irrigants for pulpectomy
421
422 A. Pozos-Guillen et al.

Identification

Records identified through Google Records identified through other Records identified through other
Scholar databases sources and manual searching
667 104 4
Screening

After duplicates removed

759
Excluded after
screening title and
abstract
713
Eligibility

Full-text papers screened for eligibility

46

Excluded for not

eligibility
39

Included in the qualitative synthesis

7
Included

Included in quantitative analysis

2
Fig. 1. Search strategy flowchart.

Experimental Control Standardised mean difference

Study Total Mean SD Total Mean SD SMD 95% -CI W(fixed) W(random)

Valdez_G_2012 OPW NaOCl 20 50000000 153000000 20 0.00000001 0.00001 0.45 [–0.18; 1.08] 39.3% 42.5%
Farhin_K_2015 MTA NaOCl 30 183 5910 30 354.00000000 1870.00000 –0.04 [–0.54; 0.47] 60.7% 57.5%

Fixed effect model 50 50 0.15 [–0.24; 0.55] 100% --

Random effects model 0.17 [–0.31; 0.65] -- 100%
Heterogeneity: I-squared=29.8%, tau-squared=0.036, p=0.2326

–1 –0.5 0 0.5 1

Fig. 2. Forest plot for NaOCl.

Contrast to sodium hypoclorite Random effects model SMD 95% -CI

MTA –0.04 [–0.17; 0.09]

NaOCl 0.00
OPW 0.45 [ 0.25; 0.65]

–1.5 –1 –0.5 0 0.5 1

CFU/mL difference

Fig. 3. Forest plot in contrast with NaOCl.

edge gaps in strategic clinical areas and prac- involved in irreversibly inflamed/infected or
tice-relevant research activities39. non-vital primary teeth; this absence of con-
The preservation of primary teeth is one the sensus is probably due to the lack of research-
most important aims of paediatric dentistry. based evidence to support the use of any ‘best’
The aim is to maintain the harmonious agent2. In their narrative review of intracanal
growth and development of arch length and irrigants for primary teeth, Kaur et al.4 pro-
occlusal balance, with optimal function for posed six requirements that the ideal irrigant
swallowing, chewing, speech, and aesthetics4. must possess: (1) broad antimicrobial spec-
Therefore, pulp therapies should be performed trum, (2) high efficacy against anaerobic and
with high levels of quality to ensure a maxi- facultative microorganisms organized in bio-
mally successful clinical result. Currently, films, (3) ability to dissolve necrotic pulp-tis-
there is no agreement among paediatric den- sue remnants, (4) ability to inactivate
tists concerning the best intracanal irrigant endotoxin, (5) ability to prevent the formation
solution for use against pulp pathogens of or to dissolve the smear layer during instru-

© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd

mentation, and (6) a non-toxic (to periodontal
tissues), non-caustic nature that does not
cause an allergic reaction. In this same narra-
tive review, the authors concluded that, dur-
ing instrumentation, canals should be
irrigated utilizing copious amounts of NaOCl,
and once the shaping procedure is completed,
EDTA or citric acid should be employed; these
authors also mentioned that chlorhexidine or
MTDA are strongly recommended as best final
irrigant agent prior to canal drying and filling.
Although a comprehensive search was per-
formed, and a substantial number of articles
were reviewed for the purposes of the present
systematic review, it is possible that some
papers were missed due to the limitations
inherent in the process; however, we are
confident that the majority of potentially suf-
ficient published papers with quality method-
ologies were retrieved.
After critically evaluating the included stud-
ies, some variations in restrictions among jour-
nals were found, and search strategies for
relevant information or data in the text of the
papers were not always feasible. Regarding this
limitation, the majority searches might have
had constraints; these included small sample
sizes, limited time or financial resources, inac-
cessible or inadequately indexed reports and
databases, or questions posed for which perti-
nent evidence is not easy to find8.
This systematic review revealed a certain
homogeneity with regard to evidence quality
among the studies finally included, mainly
with regard to clear descriptions and the
reporting of methodological issues, such as sta-
tistical methods (e.g., ‘intention to treat analy-
sis’), sample-size calculation procedures,
differences in outcome definitions, dropout
impacts, follow-up screening, randomization
and allocation and the concealment methods
thereof, reports of adverse events, and cost-
saving analyses; thus, it is more difficult to
analyse and combine their findings. Also, addi-
tional uncontrolled, confounding factors,
which can reduce comparability among study
outcomes, must be considered for purposes of
analysis testing. According to Al-Namankany
et al.40 and Rajasekharan et al.41, the reporting
quality of RTC in paediatric dentistry journals
© 2016 BSPD, IAPD and John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Intracanal irrigants for pulpectomy 423
is, in general, poor, and inadequate for ensur-
ing that the results can be considered reliable
and reproducible; this issue has been associ-
ated with an increased tendency to overesti-
mate the experimental intervention efficacy
reported, which occurs in approximately 35%
of meta-analyses published in Medicine, as
determined by the Consolidated Standards in
Reporting Trials (CONSORT) Group42.
Therefore, and according to this collected
information, authors are encouraged to com-
ply carefully with the accepted quality
methodologies (e.g., the CONSORT state-
ment) in order to perform and publish more
transparent and better designed RTCs, system-
atic reviews, and meta-analyses10. Although
the quality of paediatric- dentistry RTC
reports might constitute the major limiting
factor in determining and reporting all valid
and important outcomes with regard to esti-
mates of treatment effects, the value of meta-
analyses ‒ that is, the highest quality evidence
design of published clinical literature ‒ is quite
important. This type of study guarantees that
the pooling of relevant results from primary
studies is as valid and bias free as possible43.
Conclusions
More comparative/controlled studies are
required with sufficient quality and adequate
full-result report, including both summary
measurements of the response variable and
the observed size effect, to determine the most
efficient intracanal irrigant agents for use in
the pulpectomy treatment of primary teeth.
Why this paper is important to paediatric dentists
• The success of pulpectomy therapy in primary teeth
depends on achieving an adequate level of disinfection
within the root canals. It is challenging for paediatric
dentists to choose the most appropriate irrigant agent
when performing pulpectomy treatments.
• In the present study, the evidence was inconclusive
from the combined findings of the selected and anal-
ysed controlled clinical trials, in which the most effec-
tive intracanal irrigants were considered.
• More high-quality clinical studies are definitely
needed, with proper monitoring, and following the
appropriate parameters of a clinical trial, such as those
suggested by the CONSORT guidelines.
424 A. Pozos-Guillen et al.
Conflict of interest
The authors declare no conflict of interest.
Acknowledgements
This work was supported partially by PROFO-
CIE 2014 Grant. Adri
an Garc
ıa was a CONA-
CYT fellow. The reviewing of the manuscript
by Maggie Brunner has been particularly
appreciated.
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