Primary pulpotomies - what should we be using?

Introduction A systematic review and meta-analysis of the effectiveness of Biodentine compared to formocresol for pulpotomies in the deciduous dentition.Data sources and study selection Four electronic data bases were searched (Medline, Embase, Cochrane Central Register of Controlled Trials and Web of Science). Randomised controlled trials (RCTs) which compared the use of Biodentine with formocresol were included in the screening. Two reviewers screened the titles and abstracts of the RCTs independently for inclusion in the review and a third reviewer was consulted in the case of any disagreements. Thirteen articles were used for full-text reading and nine were included in the review. Two investigators assessed risk of bias (RoB) by allocating a score of either high, low or unclear, in line with the Cochrane handbook for systematic reviews of interventions. Failure to blind practitioners paired with a lack of standardised application protocol results in high RoB.Data extraction and synthesis Data was extracted from the included studies using customised forms, including: sample size, patient ages, treatment and clinical and radiographic follow-up and results. Meta-analysis of the results was completed using ReviewManager version 5.4.0.Results In total, 626 children were assessed in the RCTs. All teeth were restored with a preformed metal crown placed directly after the procedure, except for two studies, which placed them 24 and 48 hours later. The primary outcomes of clinical failure were defined as pain, tenderness to percussion, swelling, abscess, fistula and pathological tooth mobility at 12 months. These showed that Biodentine had significantly lower failure rates (RR 0.16; 95% CI 0.003-0.87; N = 394). Radiographic failure rates defined as either internal or pathological external root resorption, furcation radiolucencies or a widened periodontal ligament showed significantly lower failure rates (RR 0.19; 95% CI 0.08-0.49; N = 393). However, the results showed no significant difference for secondary outcomes which assessed the teeth both clinically and radiographically at intervals up to 48 months. Outcomes were assessed using GRADE; this showed all results to be of low certainty due to the high RoB.Conclusions Biodentine may be the superior material to formocresol for pulpotomy in the deciduous dentition. However, the results for both primary and secondary outcomes have a very low to low GRADE rating due to high RoB; therefore, robust future studies should be completed to further substantiate these findings.