Pulp management for caries in adults: maintaining pulp vitality
Editorial Group: Cochrane Oral Health Group
Published Online: 18 APR 2007
Assessed as up-to-date: 12 FEB 2007
Copyright © 2012 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
How to Cite
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.
- Publication Status: Edited (no change to conclusions)
- Published Online: 18 APR 2007
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.
This study aims to assess the effectiveness of techniques used to treat asymptomatic carious teeth and maintain pulp vitality.
Electronic searches of the following databases were undertaken: The Cochrane Oral Health Group's 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.
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 Collaboration's statistical guidelines were followed.
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.
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.
對於齲齒廣泛牙齒的牙髓處置有許多的方式。 包括直接、間接覆髓、活髓切斷術或牙髓摘除術等。 若牙齒是有症狀的或是有牙根尖骨頭病變，則根管治療是必須的。 但是，如果牙齒是沒有症狀的，但卻有廣泛性齲齒，目前並沒有何種治療方式才是最好的共識。 除此以外，最近有使用不同的材料與方法，如直接或間接放置黏著劑(bonding agents)和mineral trioxide aggregate。 大部分的研究在於探討對於沒有症狀的齲齒，在有或無牙髓暴露的情況下使用各式不同的覆髓材料，(如calcium hydroxide、Ledermix、 Triodent、Biorex等等)。 但是對於利用不同治療處置無症狀齲齒並沒有長期資料提供結果。
電子搜尋以下的資料庫: The Cochrane Oral Health Group's 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)。 對於各個資料庫有發展出詳細搜尋的策略。 也使用人工搜尋及篩選參考文獻清單。 對於發表文獻的語言並沒有限制。
包含的研究是屬於隨機對照試驗(RCTs)。 納入無症狀仍有活性牙髓的廣泛齲齒至本研究。 研究對象是比較為保持牙髓活性的不同技術。度量結果的方式包括臨床成效及副作用。
資料是由三位回顧作者獨立分析。作者們會對於隨機抽樣，退出研究及品質評估的細節做必要的聯絡。本研究遵循The Cochrane Oral Health Group 的統計準則。
只有4個RCTs符合此研究。 所測試的處置包括: Ledermix、glycerrhetinic acid/antibiotic mix、zinc oxide eugenol、 calcium hydroxide、Cavitec、Life、Dycal、potassium nitrate、dimethyl isosorbide、以及 polycarboxylate 接合劑(cement)。 只有1個研究顯示出統計學上顯著意義; potassium nitrate/dimethyl isosorbide/ polycarboxylate 接合劑比potassium nitrate/單獨使用 polycarboxylate 接合劑 或 polycarboxylate 接合劑用於作為齲齒牙髓的覆髓材料有較少的臨床症狀。
可惜的是在本篇回顧中只有非常少的研究被認為符合收納入此研究的條件。 此回顧發現， 以齲齒牙髓作為考量時，並沒有與傳統上被接受的臨床處置考量有明顯的差距。 我們仍然需要有設計更完美的RCTs，來探討這些當代材料對於處置齲齒時的潛力。我們發覺到在尋求新材料倫理上批准，嚴格注意病例選擇，研究流程和分析資料這些都要考慮下，要建立理想的臨床研究是非常困難的。 要召集到足夠數量符合必要條件的病患也不是一件容易的事。
此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。
牙髓處置在破壞齲齒，有活性且無症狀的牙齒是臨床會面臨到的問題，且至今並無大家都同意是最有效果的治療。 舉例而言，對於何種牙齒適合作間接或直接覆髓，是否要進行兩階段式的步驟或何種材料最有效果都沒有共識。最近，種種的新型黏著材料(bonding materials)被引進，但對於這類材料使用在填補一個齲齒上，對於症狀及維持活性的結果上仍是未知的。 這個回顧利用檢驗適當的隨機臨床試驗來解釋上述的問題。 但是，令人遺憾的是只找到了相當少數的研究(4個)可以被包含在此回顧研究中。 這些發現也不支持在維持牙髓這個考量下，已被接受的這些傳統處置間有明顯的差異。