Included studies and documents
The initial search process yielded a total of 1098 records from multiple databases and organisations [American Academy of Paediatric Dentistry (AAPD), European Academy of Paediatric Dentistry (EAPD), Scottish Dental Clinical Effectiveness Programme (SDCEP), Qatari, Saudi, Health Ministry of Chile, Brazilian and Iraqi Dental Association] (See Appendix 3). After removing duplicates, the titles and abstracts of 417 unique records were screened for eligibility. From this initial screening, 30 papers were selected for a more detailed evaluation. Finally, 14 papers met the inclusion criteria and were included in the in-depth analysis. Figure 1 provides a visual representation of the study selection process following PRISMA-ScR guidelines (See Appendix 2) [10].
The process consists of four stages: Identification, Screening, Eligibility, and Inclusion. Identification: a total of 1098 records were identified from various databases, including PubMed/Medline (n = 120), Embase (n = 135), Scopus (n = 176), Lilacs (n = 84), Trip (n = 170), ProQuest (n = 26), and other sources (n = 387). After removing 681 duplicate records, 417 records were screened. Screening: out of the 417 records screened, 387 were excluded based on title and abstract screening, and 30 reports were sought for retrieval. Eligibility: among the 30 reports, 8 were not retrieved. The remaining 22 reports were assessed for eligibility, with 8 reports being excluded due to updated versions being available. Inclusion: ultimately, 14 studies were included in the final review.
Characteristics of included studies and documents
The included studies were primarily sourced from reputable databases, with the highest number of records obtained from the American Academy of Paediatric Dentistry (AAPD) (345), Scopus (176), Trip (170), Embase (135), and PubMed/MEDLINE (120). Additional sources, such as Lilacs (84), ProQuest (26), Scottish Dental Clinical Effectiveness Programme (SDCEP) (16), European Academy of Paediatric Dentistry (EAPD) (14), and GIN (6), also contributed to the final selection of papers. The selected papers focused on the treatment of primary teeth with deep caries lesions and provided insights into extraction, pulpectomy, pulpotomy, and variations within these treatment options.
Treatment modalities
Most CPGs discussed both Direct Pulp Capping (DPC) (n = 6) and Indirect Pulp Capping (IPC) (n = 8), pulpotomy (n = 10) and pulpectomy (n = 9) as potential treatment options for specific cases involving deep caries lesions in primary teeth. IPC and DPC techniques were outlined concerning their indications, recommended protocols, and supporting evidence. Additionally, some papers explored the concept of lesion sterilisation/tissue repair (LSTR), albeit being mentioned in only two documents. The use of LSTR for managing carious lesions reaching the pulp in primary teeth was discussed in terms of its effectiveness, limitations, and potential application.
Variations and gaps in recommendations
While the included studies and documents shared commonalities in their recommendations, some variations were observed. These variations were often influenced by contextual factors, such as the healthcare system, resources, and available treatment options in different countries or regions. Additionally, certain aspects of the management of caries lesions in primary teeth with pulp involvement lacked clear consensus or had limited evidence, indicating gaps in the existing literature.
Summary of key findings
The reviewed literature explored various treatment options for primary teeth with deep caries lesions, including extraction, pulpectomy, pulpotomy, and their subdivisions.
Indirect pulp capping
Indirect Pulp Capping was recommended as a successful treatment for vital deciduous teeth affected by deep caries, as it is a MID approach that does not interfere with the natural exfoliation process [11, 12]. This treatment is indicated when there is no pulp involvement [13] and is considered a standard treatment option [14]. To ensure successful IPC, it is crucial to achieve an excellent seal of the coronal part of the tooth [12]. The procedure involves selective removal of soft caries tissue, particularly from the dentin-enamel junction, using hand instruments [11, 15, 16]. Subsequently, materials such as zinc oxide eugenol (ZOE), hard-setting calcium hydroxide (Ca(OH)₂), or resin-modified glass ionomer cement (RMGIC) are placed and covered with a preformed crown or adhesive restoration. These procedures have received a grade B recommendation, and level III evidence, and have shown success rates of over 90% after three years [16]. Alternative approaches, including the use of slow rotary instruments and other biocompatible materials like mineral trioxide aggregate (MTA), were also mentioned (See Fig. 2). Compared to pulpotomy treatments, IPC has demonstrated higher long-term success rates [11, 15]. Meta-analyses did not find significant differences between bonding agent liners and Ca(OH)₂, with moderate and low evidence after 24–48 months [17]. In contrast, recommendations from 2005 suggested complete removal of caries and direct pulp capping (DPC) or pulpotomy in cases of iatrogenic pulp exposure due to higher symptom occurrence and uncertain outcomes. Before filling the cavity, Ca(OH)₂ is placed to promote secondary dentin formation (See Fig. 2) [18].
This timeline summarises the evolution of IPC guidelines across various countries and regions from 2005 to 2022. It outlines the indications, recommendations, and levels of evidence in countries such as the UK, Chile, USA, New Zealand, and others. Specific recommendations range from total caries removal to selective caries removal with materials like calcium hydroxide and glass ionomer cement. Evidence levels vary from low to high across different years and regions.
Direct pulp capping (DPC)
The use of DPC as a treatment option is restricted to spot-like pulpal exposure areas due to trauma or mechanical opening during caries removal in cases of non-symptomatic and non-infectious circumstances (See Fig. 3), to facilitate dentine structure development [16, 18, 19].
The figure displays DPC guidelines across regions from 2005 to 2022, including the UK, USA, and international recommendations. Indications include traumatic pulp exposures and materials recommended include calcium hydroxide and MTA. Evidence levels range from low to not stated, reflecting the evolving clinical recommendations over the years.
For the purpose of teeth protection from microleakage, Ca(OH)₂ and mineral trioxide aggregate (MTA) have been suggested [11]. Meta-analyses show no significant difference in success between Ca(OH)₂ and MTA, formocresol (FC) and dentin bonding agents after 24 months. Due to the missing discrepancy of included studies, the quality of evidence was rated as very low [17]. Prior haemorrhage control by a piece of cotton damped with saline or water has been recommended with grade C and evidence quality level IV [16].
In general, DPC is not recommended as a regular treatment option for primary teeth [15]. This might be connected to the elevated cellular density in the pulp tissue of deciduous teeth and poor prognosis [20, 21] However, close to the physiological exfoliation time, DPC can be indicated due to less severe consequences (See Fig. 3) [16].
Pulpotomy
Pulpotomy is a recommended treatment option for primary teeth with profound carious lesions, boasting a 24-month success rate of 82.6% [22]. However, due to limited direct comparisons, no definitive evidence-supported recommendation can be made regarding the choice between pulpotomy, DPC, and IPC (See Fig. 4) [14, 22].
This figure highlights pulpotomy guidelines in the UK, Chile, Italy, and other regions from 2005 to 2022. Indications include symptoms of irreversible pulpitis, and materials recommended include formocresol (FC), MTA, and ferric sulfate. Evidence is rated from low to high depending on the year and location. The timeline also covers regional variations in managing pulpotomy procedures.
Pulpotomy is generally indicated for primary teeth with exposed vital pulp or irreversible pulpitis of the coronal pulp, if the underlying tissue is healthy or shows reversible inflammation [16, 17]. It can be performed on deciduous teeth at any developmental stage [13]. Contraindications include severe root resorption, facial cellulitis, abscess history, or specific patient conditions necessitating general anaesthesia [23]. Pulpotomy for vital pulp in primary molars is a recommended treatment, while non-vital pulpotomy, which differs in procedure and indication, is considered obsolete in most current guidelines.
Some guidelines discourage the use of Ca(OH)₂ during pulpotomy due to compromised results and lower success rates compared to ferric sulphate (FS), mineral trioxide aggregate (MTA), and formocresol [12, 16, 17, 19].
MTA (87.8%) and formocresol (85%) have shown the highest success rates among recommended treatment choices, leading to a strong recommendation for their use [17]. Other options are conditionally recommended, and the use of formocresol may raise concerns among parents [15,16,17].
MTA, despite higher initial costs, proves to be more cost-effective in the long run due to its greater success rates and reduced need for secondary treatments compared to Ca(OH)₂ [17]. MTA preserves pulp integrity, reduces inflammation, and promotes tissue formation, while Portland cement is considered a low-cost alternative [24].
Additional research is needed to determine specific recommendations for lining materials, caution is advised regarding the combination of FS and eugenol, and control of haemorrhage is essential during treatment [16, 18, 24].
Stainless steel crowns are recommended as a permanent restoration after pulpotomy, while composite resin and amalgam can be used for deciduous teeth with minor structural damage [11].
Pulpectomy
Pulpectomy is a recommended treatment for restorable primary teeth with necrosis, irreversible pulpitis, root resorption, and other pathologies [11]. It is preferred over LSTR in the absence of root resorption. Pulpectomy is generally not recommended as a first-line treatment for deep caries in vital primary molars due to the effectiveness of more conservative alternatives like indirect pulp capping or pulpotomy. However, it may be used instead of extraction when tooth loss could harm dental health and long-term occlusion, or if there is no permanent successor [12].
Prior to treatment, a periapical radiograph is taken for diagnosis, and anaesthesia is administered [4]. Root canal shaping can be done with rotary or hand files, followed by irrigation using sodium hypochlorite or alternative solutions [11, 15]. Canals are dried before using zinc oxide eugenol (ZOE) cement or calcium hydroxide (Ca(OH)₂) with iodoform paste for obturation [11, 15].
Different approaches exist for pulpectomy depending on the condition, such as two-stage or one-stage procedures [18]. The Italian Ministry of Health recommends pulpectomy for non-vital primary teeth in specific developmental stages and with clinical signs like abscesses, fistula, and pain [2]. The use of Ca(OH)₂ combined with iodoform paste is advantageous, although ZOE is also suggested [2]. Irrigation should be performed using hypochlorite, saline, or chlorhexidine [16].
The Federal University of Rio de Janeiro (UFRJ) recommends specific irrigation techniques and materials for obturation, such as ZOE, glass ionomer cement (GIC), or heated gutta-percha. The heated gutta-percha is used specifically to seal the canal orifice, not to fill the canals [25]. Preformed crowns are suggested for excellent coronal seal [16]. Pulpectomy success rates range from 59% to 69% for teeth with root resorption and 84% to 90% for those without [25]. Extraction may be necessary if fistula or abscess persists after Ca(OH)₂ [25]. The Dubai Health Authority limits pulpectomy to primary teeth with less than one-third root resorption and without facial cellulitis or abscess [23]. Considerations for pulpectomy include long-term retention of second deciduous molars and stable occlusion, with conservative treatments preferred for profound carious lesions (See Fig. 5).
The pulpectomy timeline from 2005 to 2022 illustrates recommendations from the UK, Chile, USA, and other countries. It covers the management of irreversible pulpitis and related pathology, with recommendations including the use of zinc oxideeugenol, MTA, and root canal instrumentation. Evidence levels range from low to moderate across different regions.
Lesion sterilisation/tissue repair (LSTR)
LSTR is a possible treatment option for primary teeth experiencing clinical symptoms of irreversible pulpitis, fistula formation, and other pathologies (see Fig. 6) [11, 15]. It is considered preferable over pulpectomy in cases of root resorption and teeth expected to exfoliate within one year. The treatment involves establishing access to the pulp chamber and augmenting the orifices. Phosphoric acid is used to cleanse the chamber, followed by rinsing and drying. Subsequently, a paste containing ciprofloxacin, metronidazole, and clindamycin, along with macrogol and polyethylene, is placed in the affected areas. It is important to avoid the incorporation of tetracycline into the antibiotic mix. Finally, glass ionomer cement (GIC) and a stainless-steel crown are placed [11, 15].
This figure outlines LSTR treatment guidelines between 2005 and 2022 in regions like the USA and international contexts. The timeline reflects recommendations for disinfecting root canals using antibiotics like ciprofloxacin and metronidazole for cases of irreversible pulpitis and root resorption. Evidence is generally not stated.
Extractions
Extraction is indicated for primary teeth in the following situations: teeth approaching exfoliation, teeth that are non-restorable due to extensive caries or uncontrolled pulp haemorrhage [16, 18, 20, 26]. In addition, pulpectomy with repeated medication application without symptom relief or continuous exudation is also a reason for extraction [25]. (See Fig. 7).
From 2005 to 2022, this figure tracks extraction guidelines in the UK, Chile, USA, and other regions. Indications include nonrestorable teeth with extensive decay or advanced root resorption. Recommendations include balanced extractions and use of chlorhexidine (CHX) irrigation. Evidence levels vary from low to not stated.
Balanced bilateral extractions may be considered for primary canines, and in cases where there is absence of the contralateral tooth, extraction may be indicated for the first deciduous molars, provided that the jaw space is not excessively crowded [16, 18]. However, primary incisors are less frequently subjected to extraction [18]. It is important to consider the need for space maintainers when the development of permanent root formation does not exceed one-third of its completion [25].
In addition to clinical factors, such as tooth condition and stage of eruption, other factors including patient cooperation, social factors, and medical conditions should be considered when deciding on extraction [20]. Furthermore, the attitude of the patient and parents, as well as the number and complexity of required treatments, should be also considered [16, 18]. It is generally recommended to avoid extractions during initial dental visits [13, 20]. Whenever possible, extraction should be avoided in cases of crowding, absence of underlying permanent teeth, and situations that may cause increased stress for the patient [18].
