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Introduction: Pulpotomy is a common therapeutic procedure to treat reversible pulpitis in primary molars by using various materials and techniques. Pulpotomy method via formocresol has raised concern about the toxicity and potential carcinogenicity and alternative materials have been proposed to maintain the partial pulp vitality, however to date no material have been accepted as an ideal pulpotomy agent. This evidence-based study of the literature assessed the relative efficacy of non-aldehyde medicaments as opposed to formocresol in vital pulpotomy to treat primary teeth with extensive carious lesions involving the pulp.

Objective: This study is to undertaken a systemic review and meta-analysis to compare the clinical and radiographic outcomes of various medicaments and techniques like calcium hydroxide, ferric sulfate, electrosurgery, laser, and MTA that can act as an alternative to formocresol pulpotomy in primary molars.

Materials and Method: Electronic literature search of scientific papers from 2000 to 2010 was carried out on the PubMed, EMBASE, Science Citation Index (SCI), Google Scholar, the Springer, John Wiley & Sons, Elsevier, and Scopus databases using specific key words. Medications for pulpotomy including ferric sulfate, calcium hydroxide, mineral trioxide aggregate (MTA),electrosurgery and laser pulpotomy are compared with formocresol in the meta-analyses. The outcome is the odds ratio for clinical and radiographic failure including premature tooth loss at 6 months to 74 months after treatments amongst different treatment procedures.  The search yielded 448 papers, out of which 100 were identified as conforming to the applied criteria from which 41 full text were used for this study by a series of validity criteria. Jadad’s score was done and it came to be 3/5. Mantel-Haenszel method1 was used to calculate odd pool ratio assuming a fixed-effects model, and the DerSimonian-Laird method that assumes a random-effects model2. Cochran Q test was used to evaluate whether the results were homogenous.3 All tests were two tailed and p <0.05 was considered significant. Stata 10 (Stata Corp, College Station, TX, USA) software was used for analysis.

Result: After 6-74 months, in terms of treatment failure, the odds ratio for calcium hydroxide vs. formocresol clinically was 4.08 [95% credible interval (CI): 2.69, 6.20] and radiographic 4.9 [95% credible interval (CI): 2.82, 8.85]  ; clinically 3.1 (95% CI: 0.3, 30.7) and  radiographic 2.24 (95% CI 0.72, 7.00) for electrosurgery vs. formocresol; clinically 1.01 (95% CI: 0.62, 1.66) and  radiographic 1.14 (95% CI 0.76, 1.70) for ferric sulfate vs. formocresol; clinically 0.66 (95% CI: 0.35, 1.26) and radiographic 0.47 (95% CI 0.23, 0.93) for lasers vs. formocresol; and clinically 0.7 (95% CI: 0.46, 1.05)  and radiographic 1.06 (95% CI 0.62, 1.80) for MTA vs. formocresol.

Conclusion: This study showed that Laser, MTA and ferric sulfate showed significantly better clinical and radiographic outcomes than calcium hydroxide and electrosurgery therapies in primary molar pulpotomies. Laser can be the first choice for primary molar pulpotomies. However, due to treatment cost as an issue, since treated primary molars are going to be replaced by permanent teeth, MTA and ferric sulfate may be the choice. However, there is insufficient long term, clinical evidence to make a strong recommendation regarding an alternative material and techniques to formocresol as a medicament for pulpotomy in primary teeth.

Calcium hydroxide; electrosurgery; ferric sulphate; formocresol; lasers; mineral trioxide aggregate; primary teeth, pulpotomy.