Pulp Management For Caries in Adults: Maintaining Pulp Vitality (Review)

Pulp management for caries in adults: maintaining pulp
vitality (Review)
Miyashita H, Worthington HV, Qualtrough A, Plasschaert A
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library
2007, Issue 2
http://www.thecochranelibrary.com
Pulp management for caries in adults: maintaining pulp vitality (Review)

Copyright 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
TABLE OF CONTENTS
HEADER . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
METHODS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
AUTHORS CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ACKNOWLEDGEMENTS
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CHARACTERISTICS OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DATA AND ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 1.1. Comparison 1 Pulp capping with Ledermix, glycerrhetinic acid, calcium hydroxide and zinc oxide eugenol,
Outcome 1 Success at 24 months. . . . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 2.1. Comparison 2 Life, Dycal and Cavitec following three modalities, Outcome 1 Clinical symptoms at 12
months following indirect pulp capping. . . . . . . . . . . . . . . . . . . . . . . . .
months following complete caries removal. . . . . . . . . . . . . . . . . . . . . . . . .
months following direct pulp capping. . . . . . . . . . . . . . . . . . . . . . . . . .
Analysis 3.1. Comparison 3 Pulp capping with potassium nitrate (KNO3), dimethyl isosorbide (DMI) and polycarboxylate
cement (PCa, Outcome 1 Absence of periapical pathology, tenderness to pressure and fistula formation at 24
months. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ADDITIONAL TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
APPENDICES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
WHATS NEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
HISTORY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
CONTRIBUTIONS OF AUTHORS . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
DECLARATIONS OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
NOTES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
INDEX TERMS
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

1
1
2
2
3
3
5
7
7
8
8
10
15
16
17
17
18
18
18
19
19
20
20
20
20
21
21
[Intervention Review]
Pulp management for caries in adults: maintaining pulp

vitality
Hiroshi Miyashita1 , Helen V Worthington2 , Alison Qualtrough3 , Alphons Plasschaert4
1 Dentistry, SPDA Japan, Minato-Ku, Tokyo, Japan. 2 Cochrane Oral Health Group, School of Dentistry, The University of Manchester,
Manchester, UK. 3 Operative Dentistry and Endodontology, School of Dentistry, The University of Manchester, Manchester, UK.
4 Department of Preventative and Curative Dentistry, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands
Contact address: Alison Qualtrough, Operative Dentistry and Endodontology, School of Dentistry, The University of Manchester,
Higher Cambridge Street, Manchester, M15 6FH, UK. alison.qualtrough@manchester.ac.uk.
Editorial group: Cochrane Oral Health Group.
Publication status and date: Edited (no change to conclusions), published in Issue 4, 2012.
Review content assessed as up-to-date: 12 February 2007.
Citation: Miyashita H, Worthington HV, Qualtrough A, Plasschaert A. Pulp management for caries in adults: maintaining pulp
vitality. Cochrane Database of Systematic Reviews 2007, Issue 2. Art. No.: CD004484. DOI: 10.1002/14651858.CD004484.pub2.
ABSTRACT
Background
There is a range of treatment options for the management of the pulp in extensively decayed teeth. These include direct and indirect
pulp capping, pulpotomy or pulpectomy. If the tooth is symptomatic or if there are periapical bone changes, then endodontic treatment
is required. However, if the tooth is asymptomatic but the caries is extensive, there is no consensus as to the best method of management.
In addition, there has been a recent move towards using alternative materials and methods such as the direct or indirect placement of
bonding agents and mineral trioxide aggregate.
Most studies have investigated the management of asymptomatic carious teeth with or without an exposed dental pulp using various
capping materials (e.g. calcium hydroxide, Ledermix, Triodent, Biorex, etc.). However, there is no long term data regarding the outcome
of management of asymptomatic, carious teeth according to different regimens.
Objectives
This study aims to assess the effectiveness of techniques used to treat asymptomatic carious teeth and maintain pulp vitality.
Search methods
Electronic searches of the following databases were undertaken: The Cochrane Oral Health Groups Trials Register (March 2006),
the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2006, Issue 1), MEDLINE (1966 to week 4,
February 2006), EMBASE (1974 to 13 March 2006), National Research Register (March 2006), Science Citation Index - SCISEARCH
(1981 to March 2006). Detailed search strategies were developed for each database. Handsearching and screening of reference lists were
undertaken. There was no restriction with regard to language of publication.
Selection criteria
Studies included were randomised controlled trials (RCTs). Asymptomatic vital permanent teeth with extensive caries were included.
Studies were those which compared techniques to maintain pulp vitality. Outcome measures included clinical success and adverse
events.
Data collection and analysis

Data were independently extracted by three review authors. Authors were contacted for details of randomisation and withdrawals and
a quality assessment was carried out. The Cochrane Collaborations statistical guidelines were followed.
Main results
Only four RCTs were identified. Interventions examined included: Ledermix, glycerrhetinic acid/antibiotic mix, zinc oxide eugenol,
calcium hydroxide, Cavitec, Life, Dycal, potassium nitrate, dimethyl isosorbide, and polycarboxylate cement. Only one study showed a
statistically significant finding; potassium nitrate/dimethyl isosorbide/polycarboxylate cement resulted in fewer clinical symptoms than
potassium nitrate/polycarboxylate cement or polycarboxylate cement alone when used as a capping material for carious pulps.
Authors conclusions
It was disappointing that there were so few studies which could be considered as being suitable for inclusion in this review. The findings
from this review do not suggest that there should be any significant change from accepted conventional practice procedures when the
pulp of the carious tooth is considered. Further well designed RCTs are needed to investigate the potential of contemporary materials
which may be suitable when used in the management of carious teeth. It is recognised that it is difficult to establish the ideal clinical
study when ethical approval for new materials must be sought and strict attention to case selection, study protocol and interpretation
of data is considered. It is also not easy to recruit sufficient numbers of patients meeting the necessary criteria.
PLAIN LANGUAGE SUMMARY

Pulp management for caries in adults: maintaining pulp vitality
The management of the pulp in extensively decayed, vital and asymptomatic teeth presents something of a clinical problem and there
is no agreement as to the most effective treatment modality. For example, there is no consensus as to whether the tooth should be
indirectly pulp capped or directly pulp capped; whether a two-stage procedure should be carried out, nor as to which material is most
effective. Recently, a variety of newer bonding materials have been introduced but the outcome regarding their use when included in
the restoration of a carious tooth with respect to symptoms and maintenance of vitality is unknown.
This review set out to address the above by examining appropriate randomised clinical trials. However, it was disappointing to find
that there were very few studies which could be included in this review (four). The findings did not indicate that there should be any
significant change from accepted conventional procedures when management of the pulp is considered.
BACKGROUND
It has been shown in many studies since the 1950s that the carious
process is initiated by oral bacteria (Orland 1955; Fitzgerald 1960;
Keyes 1960). Bacteria and their products invade dentinal tubules
when in contact with an exposed dentine surface. The tendency
for this to occur increases when the hard tissue component, such as
enamel and cementum, are absent (Brnnstrm 1965). When the
carious process is extensive, the risk of inflammation and spread of
infection towards the pulpal space increases (Bergenholtz 1990).
This may result in loss of pulp vitality (Tronstad 1991) with the
consequent need for root canal treatment to save a tooth, which
would otherwise have to be extracted.
There are several techniques available for the management of pulp

for extensively decayed teeth. Dental pulp capping procedure is
the application of a protective agent to an exposed pulp (direct
capping) or the remaining thin layer of dentine over a nearly exposed pulp (indirect capping) in order to allow the pulp to recover
and maintain its normal vitality and function. When the caries
lesion is extensive and pulp is exposed, the dentist has to make a
decision whether to keep pulp vitality by applying the pulp capping materials and seal off the exposed dental pulp (pulp capping)
or to remove the part of the coronal pulp tissue (pulpotomy) or to
eliminate it completely (pulpectomy). This is a treatment dilemma
and there are many factors related to this decision making process.
For proper assessment, it is essential that at least a 5-year follow

up should be calculated. It is acknowledged that clinical studies

are insensitive to disclose pulp breakdown. For example, in one
study (Nyborg 1958) cappings of carious exposures were followed
up to 13 years. Histological assessment of a large number of pulp
specimens demonstrated that many teeth, deemed clinically successful, in fact had necrotic pulps or pulps with severe inflammatory lesions; and some of these were noted many years after the
capping procedure. Other published follow-up studies give an indication of the success rate of pulp capping procedures, ranging
from 74% to 90% in 2 to 6 years of observation (Cowan 1966;
Kalnins 1966; Weiss 1966; Jokinen 1970; Shovelton 1971). Most
of these studies treated asymptomatic teeth with at least one carious lesion and exposed dental pulp using various capping materials
(e.g. calcium hydroxide, Ledermix, Triodent, Biorex, etc.). These
studies reported good prognoses, however, careful interpretation
is required as most of these studies had short follow up with low
follow-up rates and an intention-to-treat (ITT) analysis was not
carried out in all studies. Pulpectomies, if performed correctly,
have been reported to have success rates of 93% to 96% (Molven
1988; Sjogren 1990; Friedman 1995).
A systematic review is scheduled in order to evaluate the different
pulp management procedures in terms of the effectiveness and
risks. An evaluation may also be done from the patients point of
view.
OBJECTIVES
To examine the relative effectiveness of techniques/materials which
aim to maintain pulp vitality in adults with asymptomatic extensively decayed teeth.
METHODS
Criteria for considering studies for this review
Types of interventions
For a study to be included it had to make a head to head comparison of any of the techniques used to maintain pulp vitality
(indirect pulp capping, stepwise technique, direct pulp capping
and pulpotomy).
Types of outcome measures
Clinical success (binary: yes/no).
Extraction (binary: yes/no).
Patient satisfaction (binary or continuous data).
Adverse events (pain, swelling, tooth fracture, instrument
fracture, perforation of root).
Search methods for identification of studies

For the identification of studies included or considered for this
review, detailed search strategies were developed for each database
searched. They were based on the search strategy developed for
MEDLINE but revised appropriately for each database.
The search strategy combined the subject search with phases 1
and 2 of the Cochrane Sensitive Search Strategy for Randomised
Controlled Trials (RCTs) (as published in Appendix 5b.2 in the
Cochrane Handbook for Systematic Reviews of Interventions 4.2.6
updated September 2006). The subject search used combination
of controlled vocabulary and free text terms based on the search
strategy for searching MEDLINE via OVID (Appendix 1).
Databases searched
The Cochrane Oral Health Groups Trials Register (March 2006)
The Cochrane Central Register of Controlled Trials (CENTRAL)
(The Cochrane Library 2006, Issue 1)
MEDLINE (1966 to week 4, February 2006)
EMBASE (1974 to 13 March 2006)
National Research Register (March 2006)
Science Citation Index - SCISEARCH (1981 to March 2006).
Language
The search attempted to identify all relevant studies irrespective
of language. Non-English papers were translated.
Types of studies
This review included randomised controlled trials (RCTs) or quasi
randomised controlled trials.
Types of participants
Studies of patients with permanent teeth with extensive caries,
which were asymptomatic. Traumatised teeth were excluded.
Handsearching
Details of the journals being handsearched by the Cochrane Oral
Health Groups ongoing programme are given on the website:
www.ohg.cochrane.org.
Key journals were identified for handsearching for this review.
These are as follows:
Journal of Dentistry
Caries Research

Journal of Endodontics
Dental Traumatology
Oral Surgery, Oral Medicine, and Oral Pathology
International Endodontic Journal
Operative Dentistry
Journal of Oral Rehabilitation
Journal of the American Dental Association.
Where these have not already been searched as part of the

Cochrane Journal Handsearching Programme, the journals were
handsearched by the review authors.
Searching the references

Apart from the references found by a search of the electronic
databases, reference lists from review articles were scanned, and
reference lists from endodontic textbooks were also searched.
Data collection and analysis
Study selection
The titles and abstracts (when available) of all reports identified
through the electronic searches were scanned independently by
three review authors (Hiroshi Miyashita (HM), Alison Qualtrough
(AQ), Alphons Plasschaert (AP)). For studies appearing to meet
the inclusion criteria, or for which there were insufficient data in
the title and abstract to make a clear decision, the full report was
obtained. The full reports obtained from all the electronic and
other methods of searching were assessed independently by two
review authors (HM, AQ or AP) to establish whether the studies
met the inclusion criteria or not. Any disagreements were resolved
by discussion. All studies meeting the inclusion criteria underwent
a validity assessment and data extraction. Any studies rejected at
this or subsequent stages were recorded in the Characteristics of
excluded studies table, and the reason for exclusion recorded.
Data extraction
Data were extracted by two review authors (AP, AQ) independently
using specially designed data extraction forms. The data extraction
form was piloted on several papers and modified as required before
use. Any disagreement was discussed.
For each trial the following data were recorded.
Date of the study, year of publication, country of origin and
source of study funding.
Details of the participants including demographic
characteristics, source of recruitment and criteria for inclusion.
Details on the type of intervention.
Details of the outcomes reported, including method of
assessment (where measurement scales were used it would be
recorded whether or not they had been validated), and time

intervals.
Quality assessment
The quality assessment of the included trials was undertaken independently and in duplicate by three review authors (HM, AQ,
AP) as part of the data extraction process.
Three main quality criteria were examined:
(1) Allocation concealment, recorded as:
(A) Adequate
(B) Unclear
(C) Inadequate
(D) Not used
as described in the Cochrane Handbook for Systematic Reviews of
Interventions 4.2.6.
(2) Blind outcome assessment, recorded as:
(A) Yes
(B) No
(C) Unclear
(D) Not possible.
(3) Clear explanation of completeness of follow up by group,
recorded as:
(A) None
(B) Yes
(C) No.
Further quality assessment was carried out to assess definition of
exclusion/inclusion criteria, adequate definition of success criteria
and comparability of control and treatment groups at entry.
The quality assessment criteria was pilot tested using several articles. The agreement between the quality assessments was measured using the Kappa statistic.
Data synthesis
For dichotomous outcomes, the estimate of effect of an intervention was expressed as risk ratio together with 95% confidence intervals (CIs). For continuous outcomes, means and standard deviations were used to summarise the data for each group using mean
differences and 95% CI.
Clinical heterogeneity was assessed by examining the types of teeth
and differences in the interventions. Only if there were studies
of similar comparisons reporting the same outcome measures, a
meta-analysis was attempted. Risk ratios were to be combined for
dichotomous data, and mean differences for continuous data, using a random-effects model. The significance of any discrepancies
in the estimates of the treatment effects from the different trials
was to be assessed by means of Cochrans test for heterogeneity
and the I2 statistic.
Sensitivity analyses were undertaken to examine the effect of randomisation, allocation concealment and blind outcome assessment on the overall estimates of effect. In addition, the effect of

including unpublished literature on the reviews findings was examined.
RESULTS
Description of studies
See: Characteristics of included studies; Characteristics of excluded
studies.
Summary details are given in the Characteristics of included
studies and the Characteristics of excluded studies tables.
Thirty-four studies were identified in the initial search. Only
four of them fulfilled the criteria of the review (Shovelton 1971;
Fitzgerald 1991; Hodosh 2003; Whitworth 2005).
Participants
Shovelton 1971 recruited 275 patients (age not specified) in an
eight-centre study. Only asymptomatic teeth with vital exposures
were included.
Registered clinic patients or those presenting for emergency treatment at The University of Michigan School of Dentistry, with large
carious lesions, were recruited by Fitgerald and Heys (Fitzgerald
1991). Appropriate teeth were selected for restoration using a current set of radiographs and clinical examination. Teeth that were
periodontally compromised or had a previous history of spontaneous pain were not included in the study. A total of 151 teeth in
55 patients (29 males and 26 females) were treated. Ages ranged
from 20 to 60 years (mean 27 years +/- 5 years).
Forty-seven adults with pulpal exposures of varying sizes in vital
teeth were recruited by Hodosh 2003. Teeth were excluded if there
was pulsating pain of spontaneous toothache, purulent or serous
exudate at the exposure site, or pain created by percussion. Only
one tooth per person was included in the trial. Age and sex distribution of patients over the treatment groups was not given.
The trial conducted by Whitworth 2005 recruited a cohort of
602 healthy adults, from six general practices, requiring a new
or replacement occlusal or multi-surface restoration in a posterior
tooth with a vital pulp. Teeth were asymptomatic. Only one tooth
per person was included in the trial.
Interventions
Two materials containing anti-inflammatory agents Ledermix (a
corticosteroid/antibiotic combination) and a glycerrhetinic acid/
antibiotic mixture and two conventional materials (zinc oxide
eugenol and calcium hydroxide) were investigated by Shovelton
1971. Asymptomatic teeth with vital exposure and a control tooth
were tested by percussion and electric pulp tests and a local anaesthetic was administered. Since the patient source was derived from
eight dental schools, a number of operators were involved. In order to eliminate variations in techniques, procedures were standardised and materials were supplied from a common source. All
carious dentine was removed to investigate the presence or absence
of an exposure. Rubber dam was not utilised. Treatment was undertaken in one stage, comprising of irrigation with sterile saline,
drying of the cavity and placement of the appropriate agent. Over
this was placed a quick-setting zinc oxide eugenol base and when
fully set, an amalgam restoration was placed.
Fitzgerald and Heys (Fitzgerald 1991) randomly allocated three
different materials (Cavitec, Life and Dycal) as a base for amalgam
or composite restorations in humans following complete caries
removal. Life and Dycal were also used as direct and indirect pulp
capping agents as indicated. Teeth were initially categorised into
three groups:
a) indirect pulp capped - radiographic evidence of a deep carious
lesion in which pulpal exposure was anticipated if complete caries
removal was performed;
b) complete caries removal - radiographic evidence of a deep carious lesion in which pulp exposure was not anticipated if complete
caries removal was performed; and
c) direct pulp capped - the pulp was exposed during the course of
complete caries removal.
Following anaesthesia, the tooth was isolated with a rubber dam
and the lesion excavated to an intact dentine enamel junction.
Teeth in the indirect group had caries removed to a point at which
further excavation would result in carious exposure. A randomly
selected calcium hydroxide material (Life or Dycal) was placed as
an indirect pulp capping agent. Teeth in the complete caries removal group had caries completely removed and either Life, Dycal or an intermediary zinc oxide eugenol-containing intermediary base placed. If the pulp was exposed during treatment, caries
removal was completed, the cavity washed and dried and then either Life or Dycal placed as a direct pulp capping agent. All teeth
were restored with either amalgam for posterior teeth or composite
resin for anteriors.
Hodosh 2003 randomised patients to one of three treatment
groups. Eighteen patients received potassium nitrate/dimethyl
isosorbide and polycarboxylate cement (KNO3/DMI/PCa cement), 17 patients received KNO3/PCa and 12 patients received
PCa as capping material. The appropriate material was applied
after caries removal.
Whitworth 2005 tested the hypothesis that dentine and pulp protection by conditioning and sealing is no less effective than using a
conventional calcium hydroxide lining. Cavity preparations were
randomised to receive a calcium hydroxide lining or conditioning
and sealing with a smear removing bonding system. Choice of
bulk restorative material was at the discretion of the dentist.
Outcomes
Shovelton 1971 undertook clinical examination for haemorrhage,

pain, percussion test and electric pulp testing after 6, 12 and 24

months. Specific details about pain measurement methods were
not given.
Fitzgerald and Heys (Fitzgerald 1991) grouped clinical data to
create sensitive and non-sensitive responses. Clinical evaluations
were made at 1 week, 6 months and 1 year after treatment. Teeth
responding positively to tests of heat and cold, percussion and
other stimulus were classified as clinically symptomatic.
Hodosh 2003 examined patients after 3 months, 1 year and 2
years. The presence of periapical pathology, fistulae or sensitivity
to percussion were recorded as a failure.
In Whitworth 2005 the key outcome measure was evidence of
pulpal breakdown. Pulp status was assessed at 6, 12, 24 and 36
months and at any emergency recall appointment. Post-operative
pain scores were self recorded by patients on standard 100 mm
visual analogue scales.
Risk of bias in included studies

Additional Table 1.
Allocation concealment
Allocation concealment was coded as adequate in three trials (
Shovelton 1971; Hodosh 2003; Whitworth 2005). Two trials used
sequentially numbered envelopes (Shovelton 1971; Hodosh 2003)
and the third used a sequential list supplied by a third party (
Whitworth 2005). Allocation concealment was not stated in the
trial by Fitzgerald and Heys (Fitzgerald 1991).
Blind outcome assessment
Double-blindness in the Shovelton 1971 study was not possible
due to the nature of the materials.
In the trial by Fitzgerald and Heys (Fitzgerald 1991) there appears
to be no details regarding the number of operators and the independence between operator and evaluator. This could not be a
blinded study due to the different treatment groups, the allocation
to which depended on the extent of caries.
The Hodosh 2003 trial was double-blind with the dentist being
unaware which pulp-capping agent was being used due to all three
liquid bottles being identical.
In the Whitworth 2005 trial only the patients were blind to the
cavity treatment they received.
Clear explanation of completeness of follow up by
group
In the Shovelton 1971 trial, of the 275 initially included, 235 were
followed up at 6 months, 160 at 12 months and 85 at 24 months.
Eleven of 151 teeth recruited by Fitzgerald and Heys (Fitzgerald
1991) were lost from the study at the 6-month recall (one extracted
at week 1, 11 from patient attrition). A further 43 teeth were lost

by the 1-year recall (19 planned extraction and 24 from attrition).
Whitworth 2005 evaluated a total of 390 teeth (64.8%) at 6
months, 307 teeth (51%) at 12 months, 363 teeth (60.3%) at 2
years and 279 teeth (46.3%) at 3 years.
All patients recruited by Hodosh 2003 were included in the analysis.
Effects of interventions
The only significant findings were those given in Hodosh 2003,
in which potassium nitrate/dimethyl isosorbide/polycarboxylate
cement was significantly better, or rather resulted in fewer clinical symptoms than potassium nitrate/polycarboxylate cement or
polycarboxylate cement alone when used as a capping material for
carious pulps.
Ledermix versus glycerrhetinic acid/antibiotic
mixture versus zinc oxide eugenol versus calcium
hydroxide (Comparison 1)
The 275 teeth were followed up for 2 years (Shovelton 1971).
Of the 275 initially included, 235 were followed up at 6 months,
160 at 12 months and 85 at 24 months. Success rates between
50% and 80% were achieved. At all periods, Ledermix cement
and calcium hydroxide had the highest success rates, followed by
glycerrhetinic acid cement and then zinc oxide eugenol paste. The
differences in success rate were, however, not significant at the 5%
level. There was no statistically significant difference between the
materials, however it was noted that there was an overall fall in
success rate between 12 and 24 months.
Cavitec versus Life versus Dycal (Comparison 2)
Clinical evaluations were made up to 1 year after treatment
(Fitzgerald 1991). Eleven teeth were lost from the study at 6month recall, an additional 43 after 1 year, representing a 7.3%
and 23.1% attrition rate respectively. One tooth was extracted at
1 week due to severe sensitivity. Otherwise, there were no cases
of prolonged sensitivity to heat, cold or percussion in any of the
teeth either before or after treatment. There were no statistically
significant differences in symptomatology between materials and
between procedures. However comparison between different treatment times indicated significant increases in sensitivity in calcium
hydroxide treated teeth from pre-treatment to 1 week post-treatment for the direct pulp cap. There were significant decreases
in symptomatology from pre-treatment to 6 months and from 6
months to 1 year after treatment in indirect pulp capped and from
1 week to 6 months post-treatment in direct pulp capped teeth.
However, it should be noted that analysis did not take clustering
into account, with analysis undertaken at the tooth level rather
than patient level.

KNO3/DMI/PCa cement versus KNO3/PCa versus

PCa (Comparison 3)
In this study (Hodosh 2003) a total of 47 adult male and female
patients with pulpal exposures were randomly selected. Eighteen
patients received KNO3/DMI/PCa cement, 17 patients received
KNO3/PCa and 12 patients received PCa as capping material.
The appropriate material was applied after caries removal. Patients
were examined after 3 months, 1 year and 2 years. The presence
of periapical pathology, fistulae or sensitivity to percussion were
recorded as a failure. All patients receiving KNO3/DMI/PCa responded favourably. Nine out of 17 patients in the KNO3/PCa
group and 10 out of 12 in the PCa group developed clinical symptoms. These teeth required either endodontic therapy or extraction. The results in groups two and three were statistically significant.
Conditioning and sealing versus conventional calcium

hydroxide lining
A total of 602 teeth were recruited to this trial (Whitworth 2005).
Randomisation produced similar numbers of lined and conditioned and sealed cavities, while amalgam was the commonest
bulk restorative material. Thirty-nine emergency recalls involving
trial teeth were recorded in the 36 months after restoration placement. Pulp breakdown was associated with 16 teeth. Of these,
nine restorations had been placed in deep carious cavities. Two
had been lined with calcium hydroxide and two had been restored
with amalgam. Bearing the other factors in mind, it was concluded
that
a) dentists should be confident that pulps will be equally well protected from post-operative breakdown up to 30 months by calcium hydroxide lining and conditioning and sealing with adhesive
resins;
b) residual dentine thickness appears to be a key factor in determining pulpal responses after restorative treatment;
c) in deep cavities in posterior teeth, composites were associated
with more pulpal breakdowns than amalgam.
indication as to the most effective method of pulp treatment of

carious teeth. In fact, the range of materials used in this review,
the variety of clinical settings, variations in trial length, numbers
of patients, review procedures, outcome measurements, etc., contribute to the lack of a definitive conclusion. In addition, the wide
range of research protocols in this review made direct comparisons
between materials and treatment modalities impossible. Although
the paper by Whitworth et al (Whitworth 2005) primarily compared lining with a Ca(OH)2-containing cement versus no lining
under resin composites, and indeed, not all teeth had very deep
carious lesions, a finding worth noting is that calcium hydroxide
and conditioning and sealing were found to be equally as effective
in maintaining pulp vitality for non-exposed pulps.
This is not to say that this review is not positive in that it highlights
an outstanding need for further well controlled, randomised clinical trials according to internationally accepted standards/protocols to investigate the management of symptom free carious teeth
with the aim of maintaining pulp vitality. Such a study would be
realistic and would also provide the opportunity for meaningful
evaluation of materials such as directly bonded restorations and
mineral trioxide aggregate and Emdogain, data related to which
are missing from contemporary literature.
AUTHORS CONCLUSIONS
Implications for practice
It was disappointing that there were so few studies which could
be considered as being suitable for inclusion in this review. The
findings from this review do not suggest that there should be any
significant change from accepted conventional practice procedures
when management of the pulp of the carious tooth is considered.
Practitioners are often confronted with new materials/techniques
despite the lack of clinical evidence regarding the efficacy of their
use and it is essential that the use of such materials is justified,
particularly when the longevity of the tooth may be at stake.
Implications for research

DISCUSSION
This review intended to define the best form of treatment of large
carious cavities in adult teeth. It was not easy to determine inclusion criteria as so many variables must be considered including indirect pulp capping, stepwise technique, direct pulp capping and
pulpotomy. In the clinical situation, a decision must be made as to
whether all carious tooth tissue should be removed, and as such,
warrants a clinical trial in itself. Another category of clinical trial
could relate to the management of the exposed pulp. With the
above in mind but using those search criteria considered to be of
significance the limited number of studies resulted in no definitive
As indicated above, further well designed, randomly controlled

clinical trials are needed to investigate the potential of contemporary materials which may be suitable when used in the management of carious teeth. It is recognised that it is difficult to establish
the ideal clinical study when ethical approval for new materials
must be sought and strict attention to case selection, study protocol and interpretation of data is considered. It is also not easy to
recruit sufficient numbers of patients meeting the necessary criteria. The outcome criteria in studies such as these (tooth sensitivity
and tooth vitality) are hard to validate in an accurate, quantitative
way. More research is needed in this respect.

ACKNOWLEDGEMENTS
The staff from the Cochrane Oral Health Group, particularly,
Anne-Marie Glenny, Luisa Fernandez Mauleffinch for their support, help and invaluable assistance and Sylvia Bickley for her help
with searching the databases is gratefully acknowledged.
REFERENCES
References to studies included in this review

Fitzgerald 1991 {published data only}
Fitzgerald M, Heys RJ. A clinical and histological evaluation
of conservative pulpal therapy in human teeth. Operative
Dentistry 1991;16(3):10112.
Hodosh 2003 {published data only}
Hodosh M, Hodosh SH, Hodosh AJ. Capping carious
exposed pulps with potassium nitrate, dimethyl isosorbide,
polycarboxylate cement. Dentistry Today 2003;22(1):4651.
Shovelton 1971 {published data only}
Shovelton DS, Friend LA, Kirk EE, Rowe AH. The efficacy
of pulp capping materials. A comparative trial. British
Dental Journal 1971;130(9):38591.
Whitworth 2005 {published data only}
Whitworth JM, Myers PM, Smith J, Walls AW, McCabe
JF. Endodontic complications after plastic restorations in
general practice. International Endodontic Journal 2005;38
(6):40916.
References to studies excluded from this review
fracture and pulp injury following glass-ionomer cement or

composite resin applied as a base filling in teeth restored
with amalgam. Journal of Oral Rehabilitation 2001;28(7):
6349.
Falster 2002 {published data only}
Falster CA, Araujo FB, Straffon LH, Nor JE. Indirect pulp
treatment: in vivo outcomes of an adhesive resin system
vs calcium hydroxide for protection of the dentin-pulp
complex. Pediatric Dentistry 2002;24(3):2418.
Gallien 1985 {published data only}
Gallien GS Jr, Schuman NJ. Local versus general
anaesthesia: a study response in the treatment of cariously
exposed teeth. Journal of the American Dental Association
1985;111(4):599601.
Hasselgren 1989 {published data only}
Hasselgren G, Reit C. Emergency pulpotomy: pain relieving
effect with and without the use of sedative dressings. Journal
of Endodontics 1989;15(6):2546.
About 2001 {published data only}

About I, Murray PE, Franquin JC, Remusat M, Smith AJ.
Pulpal inflammatory responses following non-carious Class
V restorations. Operative Dentistry 2001;26(4):33642.
Heinrich 1988 {published data only}

Heinrich R, Kneist S. [Microbiological-histological
controlled treatment study for evaluation of efficacy of
one step and stepwise excavation of deep carious lesions].
Stomatologie der DDR 1988;38(10):6938.
Bjorndal 1997 {published data only}

Bjorndal L, Larsen T, Thylstrup A. A clinical and
microbiological study of deep carious lesions during
stepwise excavation using long treatment intervals. Caries
Research 1997;31(6):4117.
Kerkhove 1967 {published data only}

Kerkhove BC Jr, Herman SC, Klein AI, McDonald RE.
A clinical and television densitometric evaluation of the
indirect pulp capping technique. Journal of Dentistry for
Children 1967;34(3):192201.
Brannstrom 1979 {published data only}

Brannstrom M, Nyborg H, Stromberg T. Experiments
with pulp capping. Oral Surgery, Oral Medicine, and Oral
Pathology 1979;48(4):34752.
Collins 1998 {published data only}
Collins CJ, Bryant RW, Hodge KL. A clinical evaluation
of posterior composite resin restorations: 8-year findings.
Journal of Dentistry 1998;26(4):3117.
Cowan 1966 {published data only}
Cowan A. Treatment of exposed vital pulps with a
corticosteroid antibiotic agent. British Dental Journal 1966;
120(11):52132.
De 2001 {published data only}
De C Luz MA, Ciaramicoli-Rodrigues MT, Garone
Netto N, De Lima AC. Long-term clinical evaluation of
King 1965 {published data only}

King JB Jr, Crawford JJ, Lindahl RL. Indirect pulp capping:
a bacteriologic study of deep carious dentine in human
teeth. Oral Surgery, Oral Medicine, and Oral Pathology 1965;
20(5):6639.
Leksell 1996 {published data only}
Leksell E, Ridell K, Cvek M, Mejare I. Pulp exposure after
stepwise versus direct complete excavation of deep carious
lesions in young posterior permanent teeth. Endodontics &
Dental Traumatology 1996;12(4):1926.
Leung 1980 {published data only}
Leung RL, Loesche WJ, Charbeneau GT. Effect of Dycal
on bacteria in deep carious lesions. Journal of the American
Dental Association 1980;100(2):1937.

Litowski 1995 {published data only}

Litowski LJ, Niehaus Rohde C. Inflammatory response of
Bioglas and Ca(OH)2 in direct pulp caps in human teeth.
Journal of Dental Research 1995;74(SI):84.
Matsuo 1996 {published data only}
Matsuo T, Nakanishi T, Shimizu H, Ebisu S. A clinical
study of direct pulp capping applied to carious-exposed
pulps. Journal of Endodontics 1996;22(10):5516.
Moritz 1998 {published data only}
Moritz A, Schoop U, Goharkhay K, Sperr W. The CO2
laser as an aid in direct pulp capping. Journal of Endodontics
1998;24(4):24851.
Nieuwenhuysen 2003 {published data only}
Van Nieuwenhuysen JP, DHoore W, Carvalho J, Qvist V.
Long-term evaluation of extensive restorations in permanent
teeth. Journal of Dentistry 2003;31(6):395405.
Nirschl 1983 {published data only}
Nirschl RF, Avery DR. Evaluation of a new pulp capping
agent in indirect pulp therapy. ASDC Journal of Dentistry
for Children 1983;50(1):2530.
Nordstrom 1974 {published data only}
Nordstrom DO, Wei SH, Johnson R. Use of stannous
fluoride for indirect pulp capping. Journal of the American
Dental Association 1974;88(5):9971003.
References to studies awaiting assessment

Iakovleva 1983 {published data only}
Iakovleva VI, Denisov LA, Diachenko IuV. [Paste for
treating dental caries]. Stomatologiia 1983;62(3):402.
Additional references
Bergenholtz 1990
Bergenholtz G. Etiologic factors for pulpal disease. Journal
of Endodontics 1990;16:98101.
Brnnstrm 1965
Brnnstrm M, Lind PO. Pulpal response to early dental
caries. Journal of Dental Research 1965;44(5):104550.
Fitzgerald 1960
Fitzgerald RJ, Keyes PH. Demonstration of the etiologic
role of streptococci in experimental caries in the hamster.
Journal of the American Dental Association 1960;61:919.
Friedman 1995
Friedman S, Lost C, Zarrabian M, Trope M. Evaluation of
success and failure after endodontic therapy using a glass
ionomer cement sealer. Journal of Endodontics 1995;21(7):
38490.
Jokinen 1970
Jokinen MA, Korte I. Pulp capping with corticoidchemotherapeutic plus calciumhydroxide. Suomen
Hammaslaakariseuran Toimituksia 1970;66(1):710.
Nosrat 1998 {published data only}

Nosrat IV, Nosrat CA. Reparative hard tissue formation
following calcium hydroxide application after partial
pulpotomy in cariously exposed pulps of permanent teeth.
International Endodontic Journal 1998;31(3):2216.
Kalnins 1966
Kalnins V. Healing of pulps under pressure dressing in
permanent teeth. Oral Surgery, Oral Medicine, and Oral
Pathology 1966;22(1):10013.
Pereira 2000 {published data only}

Pereira JC, Segala AD, Costa CA. Human pulpal response
to direct pulp capping with an adhesive system. American
Journal of Dentistry 2000;13(3):13947.
Keyes 1960
Keyes PH. The infectious and transmissible nature of
experimental dental caries. Findings and implications.
Archives of Oral Biology 1960;1:30420.
Santini 1985 {published data only}

Santini AH. Intraoral comparison of calcium hydroxide
(Calnex) alone and in combination with Ledermix in first
permanent mandibular molars using two direct inspection
criteria. Journal of Dentistry 1985;13(1):529.
Molven 1988
Molven O, Halse A. Success rates for gutta-percha and
Kloroperka N-0 root fillings made by undergraduate
students: radiographic findings after 10-17 years.
International Journal of Endodontics 1988;21(4):24350.
Sepetcioglu 1998 {published data only}

Sepetcioglu F, Ataman BA. Long-term monitoring of
microleakage of cavity varnish and adhesive resin with
amalgam. Journal of Prosthetic Dentistry 1998;79(2):1369.
Nyborg 1958
Nyborg H. Capping of the pulp. The processes involved
and their outcome. A report of the follow-ups of a clinical
series. Odontologisk Tidskrift 1958;46:296364.
Shiflett 1997 {published data only}

Shiflett K, White SN. Microleakage of cements for stainless
steel crowns. Pediatric Dentistry 1997;19(4):2626.
Orland 1955
Orland FJ, Blayney JR, Harrison RW, Reynier JA, Trexler
PC, Ervin RF, et al.Experimental caries in germfree rats
inoculated with enterococci. Journal of the American Dental
Association 1955;50(3):25972.
Torstenson 1995 {published data only}

Torstenson B. Pulpal reaction to a dental adhesive in deep
human cavities. Endodontics & Dental Traumatology 1995;
11(4):1726.
Unemori 2001 {published data only}
Unemori M, Matsuya Y, Akashi A, Goto Y, Akamine A.
Composite resin restoration and postoperative sensitivity:
clinical follow-up in an undergraduate program. Journal of
Dentistry 2001;29(1):713.
Sjogren 1990
Sjogren U, Hagglund B, Sundqvist G, Wing K. Factors
affecting the long-term results of endodontic treatment.
Journal of Endodontics 1990;16(10):498504.
Tronstad 1991
Tronstad L. The endodontium. Textbook clinical endodontics.
New York: Thieme, 1991:131.

Weiss 1966
Weiss M. Pulp capping in older patients. The New York
State Dental Journal 1966;32(10):4517.
Indicates the major publication for the study

10
CHARACTERISTICS OF STUDIES
Characteristics of included studies [ordered by study ID]

Fitzgerald 1991
Methods
3 test materials randomly assigned to 151 teeth with deep carious lesions or pulp exposure.
Clinical symptoms were evaluated at 3 follow-up visits up to 1 year
Participants
55 patients ages ranged from 20-60 years.
Interventions
Three different base materials:

Cavitec
Life
Dycal.
Teeth initially categorised as requiring indirect pulp capping, complete caries removal,
direct pulp capping
Outcomes
Electrical pulp test measurements and histological evaluation
Notes
Risk of bias
Bias
Authors judgement
Support for judgement
Allocation concealment (selection bias)
Unclear risk
B - Unclear
Hodosh 2003
Methods
Patients randomly assigned to 3 different capping cements. Double blind evaluation after
1 and 2 years
Participants
47 adult male and female patients with pulp exposures in vital teeth
Interventions
KNO3/DMI/PCa cement.
KNO3/PCa cement.
PCa cement.
Outcomes
Periapical pathology on radiographs, fistulous tracts, or sensitivity to percussion
Notes
Risk of bias
Bias
Authors judgement
Low risk
A - Adequate

11
Shovelton 1971
Methods
In trial A 4 medicaments were tested in teeth with actual exposures of the pulp after carious
excavation. Patients were followed up to 2 years
Participants
275 patients with exposed pulps were randomly assigned to 4 groups. Age is not specified
Interventions
Four pulp capping materials:

Ledermix
Glycerrhetinic cement
Calcium hydroxide cement
Zinc oxide and eugenol cement
Outcomes
Clinical examination for haemorrhage, pain, percussion test and electric pulp testing after
6, 12 and 24 months
Notes
Risk of bias
Bias
Authors judgement
Low risk
A - Adequate
Whitworth 2005
Methods
Either calcium hydroxide or a conditioning and sealing agent randomly allocated as pulp
protective materials in 602 teeth in 6 general practices. Follow up for 3 years
Participants
Healthy adult patients requiring a new or replacement occlusal or multi-surface restoration

in a posterior tooth with an asymptomatic vital pulp. 602 teeth in 602 patients
Interventions
Random allocation for lining or conditioning and sealing. Choice of bulk material (amalgam
or composite) at the discretion of the dentist
Outcomes
Routine recalls at 6, 12, 24 and 36 months. Pain score measurements on standard 10 mm

visual analogue. Radiographs at 12, 24 and 36 months
Notes
Risk of bias
Bias
Authors judgement
Low risk
A - Adequate

12
Characteristics of excluded studies [ordered by study ID]
Study
Reason for exclusion
About 2001
No RCT; carious teeth not included; only permanent teeth in children.

Too many variables involved in an uncontrolled way.
Bjorndal 1997
No RCT; type of teeth (primary, permanent) not specified; no interventions tested; only dentine consistency,
dentine colour and cfus evaluated
Brannstrom 1979
No RCT; a controlled clinical study; no carious teeth included
Collins 1998
No RCT; unclear if teeth were symptomless at start; no pulp management tested
Cowan 1966
No RCT; symptomatic teeth included; too many uncontrolled variables; operator is also evaluator
De 2001
Not really focused on pulp management. No details given regarding clinical testing
Falster 2002
Only primary teeth in 3-5 year old children studied.
Gallien 1985
Not RCT.
Hasselgren 1989
Symptomatic teeth included. Short term reviews. However, this was mainly an RCT to evaluate the effect
of different treatment modalities on pain relief
Heinrich 1988
No information regarding randomisation.
Kerkhove 1967
Not randomised. Only short term (3 months) reviews. Mixed deciduous and permanent teeth (19 first
primary molars, 37 second primary molars, 20 first permanent molars)
King 1965
A CCT and not an RCT. A study of deciduous teeth.
Leksell 1996
An RCT of permanent teeth in children (6-16 years).
Leung 1980
Not an RCT. Only mean colony forming units measured. No information regarding clinical symptoms
Litowski 1995
Not an RCT but a controlled, short term clinical study to compare the difference between Dycal and Bioglass
as direct pulp capping agents
Matsuo 1996
Not an RCT but a CCT in which symptomatic teeth were included
Moritz 1998
An RCT in which pulps were accidentally exposed during mechanical removal of healthy dentine
Nieuwenhuysen 2003
Not RCT. Pulp management was not the subject of investigation
Nirschl 1983
Not all permanent teeth. 14 primary first molars, 16 primary second molars, 6 permanent first molars and
2 permanent second molars

13
(Continued)
Nordstrom 1974
Mixture of deciduous (25) and permanent (39) teeth.
Nosrat 1998
Not an RCT. Limited numbers.
Pereira 2000
Not RCT.
Santini 1985
Symptomatic teeth included. Otherwise, an interesting study.
Sepetcioglu 1998
An in vitro study.
Shiflett 1997
An in vitro microleakage study.
Torstenson 1995
Short term response to placement of adhesive restorations studied. No information related to the proximity
to the pulp/presence of caries, etc.
Unemori 2001
Not RCT. Short term reviews only. Outcome measures not specified
CCT = controlled clinical trial

RCT = randomised controlled trial

14
DATA AND ANALYSES
Comparison 1. Pulp capping with Ledermix, glycerrhetinic acid, calcium hydroxide and zinc oxide eugenol
Outcome or subgroup title

1 Success at 24 months
1.1 Ledermix versus
glycerrhetinic acid
1.2 Glycerrhetinic acid and
calcium hydroxide
1.3 Ledermix and calcium
hydroxide
1.4 Glycerrhetinic acid and
zinc oxide eugenol
1.5 Ledermix and zinc oxide
eugenol
1.6 Calcium hydroxide and
zinc oxide eugenol
No. of
studies
No. of
participants
Statistical method
Effect size
1
1
Risk Ratio (M-H, Random, 95% CI)

Totals not selected

0.0 [0.0, 0.0]
0.0 [0.0, 0.0]
0.0 [0.0, 0.0]
0.0 [0.0, 0.0]
0.0 [0.0, 0.0]
0.0 [0.0, 0.0]
Comparison 2. Life, Dycal and Cavitec following three modalities

1 Clinical symptoms at 12 months
following indirect pulp capping
following complete caries
removal
2.1 Life/Dycal
2.2 Life/Cavitec
2.3 Dycal/Cavitec
following direct pulp capping
No. of
studies
No. of
participants
Statistical method
Effect size
Totals not selected
Totals not selected
1
1
1
1

0.0 [0.0, 0.0]

0.0 [0.0, 0.0]
0.0 [0.0, 0.0]
Totals not selected

15
Comparison 3. Pulp capping with potassium nitrate (KNO3), dimethyl isosorbide (DMI) and polycarboxylate
cement (PCa
No. of
studies

1 Absence of periapical pathology,
tenderness to pressure and
fistula formation at 24 months
1.1 KNO3/DMI/PCa versus
KNO3/PCa
1.2 KNO3/PCa versus PCa
1.3 KNO3/DMI/PCa versus
PCa
No. of
participants
Statistical method
Effect size
Totals not selected
0.0 [0.0, 0.0]
1
1

0.0 [0.0, 0.0]

0.0 [0.0, 0.0]
Analysis 1.1. Comparison 1 Pulp capping with Ledermix, glycerrhetinic acid, calcium hydroxide and zinc
oxide eugenol, Outcome 1 Success at 24 months.
Review:
Comparison: 1 Pulp capping with Ledermix, glycerrhetinic acid, calcium hydroxide and zinc oxide eugenol
Outcome: 1 Success at 24 months
Study or subgroup
Group 1
Group 2
Risk Ratio
MH,Random,95%
CI
Risk Ratio
MH,Random,95%
CI
n/N
n/N
28/36
28/38
1.06 [ 0.82, 1.37 ]
28/38
32/41
0.94 [ 0.74, 1.21 ]
28/36
32/41
1.00 [ 0.79, 1.26 ]
28/38
27/39
1.06 [ 0.80, 1.41 ]
28/36
27/39
1.12 [ 0.86, 1.48 ]
27/39
1.13 [ 0.87, 1.47 ]
1 Ledermix versus glycerrhetinic acid

Shovelton 1971
2 Glycerrhetinic acid and calcium hydroxide

Shovelton 1971
3 Ledermix and calcium hydroxide
Shovelton 1971
4 Glycerrhetinic acid and zinc oxide eugenol

Shovelton 1971
5 Ledermix and zinc oxide eugenol
Shovelton 1971
6 Calcium hydroxide and zinc oxide eugenol

Shovelton 1971
32/41
0.1 0.2
0.5
Favours group 2

10
Favours group 1
16
Analysis 2.1. Comparison 2 Life, Dycal and Cavitec following three modalities, Outcome 1 Clinical
symptoms at 12 months following indirect pulp capping.
Review:
Comparison: 2 Life, Dycal and Cavitec following three modalities

Outcome: 1 Clinical symptoms at 12 months following indirect pulp capping
Study or subgroup
Life
Dycal
n/N
n/N
Fitzgerald 1991
4/22
3/24
Risk Ratio
MH,Random,95%
CI
Risk Ratio
MH,Random,95%
CI
1.45 [ 0.37, 5.79 ]
0.1 0.2
0.5
Favours Life
10
Favours Dycal
symptoms at 12 months following complete caries removal.
Review:

Outcome: 2 Clinical symptoms at 12 months following complete caries removal
Study or subgroup
Group 1
Group 2
Risk Ratio
MH,Random,95%
CI
Risk Ratio
MH,Random,95%
CI
n/N
n/N
1/14
3/18
0.43 [ 0.05, 3.69 ]
1/14
0/14
3.00 [ 0.13, 67.91 ]
3/18
0/14
5.53 [ 0.31, 98.92 ]
1 Life/Dycal
Fitzgerald 1991
2 Life/Cavitec
Fitzgerald 1991
3 Dycal/Cavitec
Fitzgerald 1991
0.1 0.2
0.5
Favours group 1

10
Favours group 2
17
symptoms at 12 months following direct pulp capping.
Review:

Outcome: 3 Clinical symptoms at 12 months following direct pulp capping
Study or subgroup
Fitzgerald 1991
Life
Dycal
n/N
n/N
2/4
0/4
Risk Ratio
MH,Random,95%
CI
Risk Ratio
MH,Random,95%
CI
5.00 [ 0.31, 79.94 ]
0.1 0.2
0.5
Favours Life
10
Favours Dycal
Analysis 3.1. Comparison 3 Pulp capping with potassium nitrate (KNO3), dimethyl isosorbide (DMI) and
polycarboxylate cement (PCa, Outcome 1 Absence of periapical pathology, tenderness to pressure and fistula
formation at 24 months.
Review:
Comparison: 3 Pulp capping with potassium nitrate (KNO3), dimethyl isosorbide (DMI) and polycarboxylate cement (PCa
Outcome: 1 Absence of periapical pathology, tenderness to pressure and fistula formation at 24 months
Study or subgroup
Group 1
Group 2
Risk Ratio
MH,Random,95%
CI
Risk Ratio
MH,Random,95%
CI
n/N
n/N
18/18
8/17
2.06 [ 1.26, 3.38 ]
8/17
2/12
2.82 [ 0.72, 11.02 ]
18/18
2/12
5.06 [ 1.66, 15.46 ]
1 KNO3/DMI/PCa versus KNO3/PCa

Hodosh 2003
2 KNO3/PCa versus PCa
Hodosh 2003
3 KNO3/DMI/PCa versus PCa
Hodosh 2003
0.1 0.2
0.5
Favours group 2

10
Favours group 1
18
ADDITIONAL TABLES
Table 1. Quality assessment
Study
Allocation conceal- Blinding

ment
Withdrawals
Sample size
Duration F-U
Fitzgerald 1991
Not stated
No
Yes
55 patients/151 teeth
1 year
Hodosh 2003
Adequate
Yes - double
No
47 patients/47 teeth
2 years
Shovelton 1971
Adequate
No
Yes
275 patients/ 275 teeth
2 years
Whitworth 2005
Adequate
Yes - single
Yes
602 patients/ 602 teeth
3 years
APPENDICES
Appendix 1. MEDLINE (OVID) search strategy
(MeSH terms are presented in uppercase, and free text terms in lowercase text.)
1. Explode DENTAL CARIES
2. ((dental OR tooth OR teeth OR root OR enamel) ADJ (caries OR carious OR
decay$ OR lesion$))
3. OR/1-2
4. DENTAL PULP
5. ((dental OR tooth OR teeth) AND pulp$) expose$ adj3 pulp$
6. DENTAL-PULP-CAVITY
7. (Explode) DENTAL-PULP-DISEASES
8. DENTAL PULP DEVITALIZATION
9. DENTAL PULP CAPPING
10. PULPOTOMY
11. PULPECTOMY:
12. Pulp$ adj (treatment OR treated OR therapy OR therapies OR extirpate$ OR remove$ OR expose$ OR extract$ OR cap$)
13. Pulp AND stepwise technique
14. Pulpotomy$ OR Pulpectomy$
15. OR/4-14
16. 3 AND 15

19
WHATS NEW
Last assessed as up-to-date: 12 February 2007.
Date
Event
Description
6 March 2012
Amended
Additional table linked to text.
HISTORY
Protocol first published: Issue 4, 2003
Review first published: Issue 2, 2007
Date
Event
Description
6 August 2008
Amended
Converted to new review format.
CONTRIBUTIONS OF AUTHORS
Conceiving, designing and co-ordinating the review (Alison Qualtrough (AQ), Hiroshi Miyashita (HM)). Developing search strategy
and undertaking searches (AQ, HM). Screening search results and retrieved papers against inclusion criteria (AQ, HM, Alphons
Plasschaert (AP)). Appraising quality and extracting data from papers (AQ, HM, AP). Writing to authors for additional information
(AQ). Data management for the review and entering data into RevMan (Anne-Marie Glenny (A-MG)). Analysis and interpretation of
data (Helen Worthington (HW), A-MG). Writing the review (AQ, AP). Providing general advice on the review (HW, A-MG).
DECLARATIONS OF INTEREST
None known.
SOURCES OF SUPPORT
Internal sources
School of Dentistry, The University of Manchester, UK.

20
External sources
Tokio Dental School, Japan.
University Medical Centre Nijmegen, Netherlands.
NOTES
Title changed to Pulp management for caries in adults: maintaining pulp vitality in October 2004.
INDEX TERMS
Medical Subject Headings (MeSH)
Dental
Pulp; Dental Caries [ therapy]; Dental Pulp Diseases [ therapy]; Randomized Controlled Trials as Topic
MeSH check words

Adult; Humans

21

Pulp Management For Caries in Adults: Maintaining Pulp Vitality (Review)

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Pulp management for caries in adults: maintaining pulp

Pulp management for caries in adults: maintaining pulp vitality (Review)

Pulp management for caries in adults: maintaining pulp vitality (Review)

Pulp management for caries in adults: maintaining pulp

Data collection and analysis

PLAIN LANGUAGE SUMMARY

There are several techniques available for the management of pulp

Pulp management for caries in adults: maintaining pulp vitality (Review)

up should be calculated. It is acknowledged that clinical studies

Criteria for considering studies for this review

Search methods for identification of studies

Pulp management for caries in adults: maintaining pulp vitality (Review)

Where these have not already been searched as part of the

Searching the references

Data collection and analysis

recorded whether or not they had been validated), and time

Pulp management for caries in adults: maintaining pulp vitality (Review)

including unpublished literature on the reviews findings was examined.

Pulp management for caries in adults: maintaining pulp vitality (Review)

pain, percussion test and electric pulp testing after 6, 12 and 24

Risk of bias in included studies

at week 1, 11 from patient attrition). A further 43 teeth were lost

Pulp management for caries in adults: maintaining pulp vitality (Review)

KNO3/DMI/PCa cement versus KNO3/PCa versus

Conditioning and sealing versus conventional calcium

indication as to the most effective method of pulp treatment of

Implications for research

As indicated above, further well designed, randomly controlled

Pulp management for caries in adults: maintaining pulp vitality (Review)

References to studies included in this review

References to studies excluded from this review

fracture and pulp injury following glass-ionomer cement or

About 2001 {published data only}

Heinrich 1988 {published data only}

Bjorndal 1997 {published data only}

Kerkhove 1967 {published data only}

Brannstrom 1979 {published data only}

King 1965 {published data only}

Pulp management for caries in adults: maintaining pulp vitality (Review)

Litowski 1995 {published data only}

References to studies awaiting assessment

Nosrat 1998 {published data only}

Pereira 2000 {published data only}

Santini 1985 {published data only}

Sepetcioglu 1998 {published data only}

Shiflett 1997 {published data only}

Torstenson 1995 {published data only}

Pulp management for caries in adults: maintaining pulp vitality (Review)

Indicates the major publication for the study

Pulp management for caries in adults: maintaining pulp vitality (Review)

Characteristics of included studies [ordered by study ID]

55 patients ages ranged from 20-60 years.

Three different base materials:

Electrical pulp test measurements and histological evaluation

Support for judgement

Allocation concealment (selection bias)

Periapical pathology on radiographs, fistulous tracts, or sensitivity to percussion

Support for judgement

Allocation concealment (selection bias)

Pulp management for caries in adults: maintaining pulp vitality (Review)

Four pulp capping materials:

Support for judgement

Allocation concealment (selection bias)