Title: Success of endodontic management of compromised first permanent molars in children: a

Accepted Article
systematic review

Short Title: Endodontic management of FPM in children

Authors: Mr Greig D Taylor1, Dr. Christopher R Vernazza1, Dr B Abdulmohsen1

1. Centre for Oral Health Research, School of Dental Sciences, Institute of Health and
Society, Newcastle University, Newcastle upon Tyne, NE2 4AZ

GDT contributions to the study are: overall design of the study; developing search strategy;
undertaking the search; analysing the search results; assessing quality and bias of included studies;
compiling the report and manuscript.

CRV contributions to the study are: overall design of the study; analysing the search results;
assessing quality and bias of included studies; compiling the report and manuscript.

BA contributions to the study are: overall design of the study; developing search strategy;
analysing the search results; assessing quality and bias of included studies; compiling the report
and manuscript.

Conflict of Interests

This research did not receive any project specific grant from funding agencies in the public,
commercial, or not-for-profit sectors. However, GT is funded by an NIHR Academic Clinical
Fellow award and CRV by an NIHR Clinician Scientist award. The views expressed are those of
the authors and not necessarily those of the NHS, the NIHR or the Department of Health and
Social Care.

Word Count: 3933 (including references & excluding tables)

This article has been accepted for publication and undergone full peer review but has not been through the
copyediting, typesetting, pagination and proofreading process, which may lead to differences between this
version and the Version of Record. Please cite this article as doi: 10.1111/IPD.12599

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Accepted Article
MR. GREIG D TAYLOR (Orcid ID : 0000-0001-9369-917X)

Article type : Original Article

Corresponding Author Email ID: greig.taylor@newcastle.ac.uk

Title: Success of endodontic management of compromised first permanent molars in
children: a systematic review

Summary:

Background

Endodontic therapies may be required in the management of first permanent molar teeth,
however, their success in children is unknown.

Aim

To determine the success of endodontic therapies used on first permanent molar teeth in
children aged sixteen and under.

Design

MEDLINE, Embase, Cochrane library, CENTRAL, Clinicaltrials.gov and the ISRCTN

registry as well as relevant paediatric, endodontic, and traumatology journal were searched
using a detailed search strategy. References of included studies were hand-searched.

A PICOS question was formulated: (P): Children aged sixteen and under; (I): Endodontic
therapies (not pulp-capping) on a first permanent molar tooth; (C): No treatment; (O):
Success of endodontic therapy; (S): All study types included.

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 Bias was assessed using the Cochrane and Robins-I risk of bias tools. Quality of evidence
Accepted Article
was assessed using the GRADE approach. Significant heterogeneity precluded meta-
analysis.

Results

4172 studies were retrieved with eleven included (three RCTs, five prospective and one
retrospective cohort, one case series and one case report). Partial and coronal pulpotomies
have high success rates in the short- and long-term. Limited evidence is available for
conventional pulpectomy or regenerative techniques.

Conclusions

Partial and coronal pulpotomies are successful endodontic therapies for use in a compromised
child’s first permanent molar.

Keywords: endodontics; pulp biology; restorative dentistry/dental materials

Introduction
Compromised first permanent molars (cFPM) affect 25% of UK children1 with the impact of
these teeth being detrimental to the general health and social well-being of these children.2-4
Dental caries and molar incisor hypomineralisation (MIH) are viewed as the most common
aetiological factors that render a first permanent molar to be of compromised prognosis.1, 5
The most recent UK child dental health survey in 2013 has shown that caries prevalence, in
the first permanent molar tooth, increases with age as prevalence rises from 5% in 8 year olds
to 25% by the time the child reaches age 15.1 The mean number of molar teeth affected teeth
per child diagnosed with MIH is reported as 1.6 to 3.16 (out of 4).6

The management of compromised first permanent molars in young children is under-

researched. The key clinical question is whether restore the cFPM, which enters the tooth
into the ‘restorative cycle’ at an early stage or to extract the cFPM and allow for spontaneous
tooth closure by the second permanent molar.7 Which approach to adopt is complicated and
confusing for the dental profession with a recent UK study showing that general dental
practitioners prefer to restore whilst specialists in paediatric dentistry prefer to extract cFPM.8

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 Deciding which option to choose is complicated and will be influenced by several factors
Accepted Article
such as: patient and parental attitudes; diagnosis of cFPM; tooth restorability; pulpal and peri-
radicular diagnoses; level of patient compliance; general dental health (including ability to
maintain any advanced restorative work); current/future orthodontic need.

If a restorative approach is to be adopted, endodontic management could be required if a

pulpal exposure is noted after tissue removal or if the patient presents with clinical and/or
radiographic features of pulpal involvement. Perceived (yet not evidence-based factors) such
as limited compliance, immature root development and lack of clinical benefit in retention are
raised when considering endodontic treatment in children.9 The American Academy of
Pediatric Dentistry (AAPD) guideline on pulp therapy for primary and young permanent teeth
suggests several endodontic techniques (pulpotomy (partial & coronal), pulpectomy,
axpefication and regenerative techniques) are available.10 Despite these guidelines, their use
for cFPM in amongst dental care professionals appears to remain limited.8 Partial and
coronal pulpotomies are endodontic techniques that have shown to be successful in immature
anterior teeth in children and adults.11 Coronal pulpotomies have good success rates in
permanent posterior teeth with closed apices in adults.12 Similarly, convectional
pulpectomies, apexification and regenerative techniques have all been shown to be successful
techniques in adults.13, 14 However, there appears to be limited evidence for the use of these
techniques specifically for cFPM in children. Therefore, the aim of this systematic review is
to answer the following focused question: What is the clinical success of endodontic
therapies used on first permanent molar teeth in a child aged 16 and under?

Materials and Methods

Protocol and registration
The study protocol was registered at the Prospective Register of Systematic Reviews
(PROSPERO - CRD42018089145), and it followed the recommendations of the Preferred
Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement for the
report of this review.15
Search Strategy
The Medical Subject Headings (MeSH) terms and free keywords in the search strategy were
defined based on the following PICOS question:

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  Population (P): Children, aged 16 and under, undergoing endodontic therapies (not
Accepted Article including pulp capping) on a first permanent molar tooth
 Intervention (I): Endodontic therapies on a first permanent molar tooth
 Comparison (C): No treatment
 Outcome (O): Success of endodontic therapies
 Study Design (S): All studies included

Clinical success, defined as the tooth being in-situ at the end of the study, was used as the
outcome measure in this review. Given the variation in outcome measures this was a
pragmatic broad measure likely to allow comparison across studies but this did involve an
assumption that for the tooth to remain in-situ it was symptom free and showed no signs of
new or progressive infection. Anticipating a scarcity of studies, it was agreed to avoid
excluding potentially valid studies that reported clinical success but not radiographic success.
Similarly, the expected paucity of data provided the rationale for including all study designs,
including case reports and case series.

To identify articles to be included in this review, an electronic search was developed for the
following databases: MEDLINE via PubMed and Embase. The search strategies were defined
appropriately for each database and are shown in Table 1. A search was run on 6th
November 2019, and all studies up to this date were included in this review. A minimum
follow-up of 6 months was required for evaluation. A hand search was performed, using
keywords ‘children’ and ‘molar’, in the Cochrane library, the Cochrane Central Register of
Controlled Trials (CENTRAL), Clinicaltrials.gov and the ISRCTN registry as well relevant
journals: Journal of Endodontics, Australian Dental Journal, Australian Endodontic Journal,
Dental Traumatology, International Endodontic Journal, and International Journal of
Paediatric Dentistry. The reference lists of included articles were examined to verify whether
there were additional relevant studies that were not found during the database searches.

Eligibility Criteria
In this review, any study that assessed the overall success of endodontic therapies (partial
pulpotomy/coronal pulpotomy, pulpectomy, apexification, regenerative techniques) in a first
permanent molar of a child under the age of sixteen were included. Any studies (including

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 editorial letters and in-vitro studies) that had a follow-up period of less than 6 months and
Accepted Article
were not written in English were excluded.

Study Selection and Data Extraction

The search strategies were executed by one reviewer (GT), to identify eligible studies.
Duplicates were removed, and two reviewers (GT and BA) screened the titles and abstracts to
identify eligible studies. Full-text versions of all eligible studies were obtained and two
reviewers (GT & BA) extracted the data and carried out an assessment of bias. Any
disagreements between reviewers during study selection and bias assessment were discussed
until an agreement was met. If necessary, any unresolved differences were resolved by a
third reviewer (CRV).

A data-extraction spreadsheet was designed and two reviewers (GT, BA) collected data
independently. The quality of the evidence was assessed using the GRADE approach. For
each selected article, the following information was collected: author; year; type of study;
operator; number of children in study; age range of children; pre-operative clinical and
radiographic diagnosis; number of teeth; maturity of apex; type of endodontic therapy used;
rubber dam use; material used; follow up period; comparator treatment; overall success of
treatment (tooth still in-situ after the follow-up period). Where there was a lack of data in the
articles, the authors were contacted to request the missing information.

Risk of bias assessment

The quality assessment was conducted according to Cochrane Collaboration for randomised
clinical trials for bias16 and ROBINS-I tool for non-randomised clinical trials17,
independently by two reviewers (GT and BA), with any disagreements being resolved by
discussion or seeking the opinion of a third reviewer (CRV).
The Cochrane collaboration’s risk of bias for randomised control trial included assessment of
the random sequence generation, allocation concealment, blinding of participants and
personnel, blinding of outcome assessment, incomplete outcome data and selective
reporting.16 Studies were considered to be at ‘low risk’ of bias if all the key domains were
judged as adequate.16 A study was considered as ‘high risk’ if one or more of the domains
were deemed inadequate.16 In all studies assessed using this method, some domains were of
‘unclear’ bias, however, authors were not contacted for more information as each had at least
one domain judged as ‘high risk’ of bias, so overall these were judged as ‘high risk’.

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Accepted Article
For non-randomised control trials, the following domains were evaluated for bias using the
ROBINS-I tool17: confounding; selection of participants into the study; classification of
interventions; deviations from intended interventions; missing data; measurement of
outcomes; selection of the reported results. Each domain was recorded as low, moderate,
serious, critical, or no information available for risk of bias. An overall risk of bias judgement
was determined through combining the levels bias in each domain
Case reports and case-series were not assessed for risk of bias.

Quality of evidence
The quality of evidence was assessed using a GRADE (Grading of Recommendations
Assessment, Development and Evaluation) approach.16 A level of quality (‘High’,
‘Moderate’, ‘Low’, or ‘Very Low’) was assigned to each study by assessing the follow
domains: within-study risk of bias; directness of evidence; heterogeneity; precision of effect
estimates and risk of publication bias.16

Results
The search resulted in 4177 articles and after the removal of duplicates, 3786 articles were
identified for title and abstract screening. Fifty-four papers were included for review of the
full text. Hand searching and reference linkage did not result in any additional papers. Forty-
three were excluded because they did not meet the inclusion criteria. Eleven articles were
included for further analysis to inform this review. A summary of article selection is
presented as a flowchart, based on PRISMA guidelines (Figure 1). The characteristics of the
eleven included studies are shown in Table 2, which has been separated into four sections
reflecting the clinical status of patients at the beginning of the study. Three studies were of
high quality, six of low quality and two of very low quality.

Risk of Bias
The risk of bias of the included studies has been tabulated (Figure 2 and 3). The risk of bias
was high in all randomised control trials for blinding of participants and personnel because
these details were not mentioned. Similarly, the six non-randomised control studies were all
classified to be of ‘critical’ bias as no information was provided on measurement of
outcomes. Two studies, a case-series and a case report were not assessed for bias. The
overall risk of bias was considered high.

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 There was significant heterogeneity in the methodological variables, and hence, a quantitative
Accepted Article
synthesis could not be performed. A qualitative synthesis of the eleven papers was
performed.

Endodontic Therapies used

Five studies undertook a partial pulpotomy18-22, four studies a coronal pulpotomy23-26, one a
conventional pulpectomy27 and one a regenerative technique.28

Success of endodontic therapies

Pulpotomies have an overall success rate of 91.1% (range 70% to 100%), with partial and
coronal pulpotomies having overall success rates reported at 91.3% (range 78.5% to 100%)
and 90.5% (range 70% to 100%) respectively. For both pulpotomy treatments alone, rubber
dam use, material of choice (MTA vs Ca(OH)2) and pre-operative apical status (mature vs
immature) did not influence the success rates of either techniques. Pulpectomies had a
success rate of 36%, with success deemed as the tooth having clinical or radiographic
pathological features of endodontic failure, although it is unknown whether the presence of
known radiographic pathology influenced the success rate. There was only one case report,
covering regenerative techniques, which reported success in one tooth 28.

Rubber Dam Use

Six studies provided information on rubber dam use during the endodontic technique.18, 23-26,
28
In these studies, which included the range of endodontic techniques being reviewed,
rubber dam was found to have a mean influence on success rates of 10.9%.

Materials used
Mineral trioxide aggregate (MTA) was used alone in four studies 20, 24-26, calcium hydroxide
(Ca(OH)2) alone in two studies18, 29, and a comparison of both MTA and Ca(OH)2 was
undertaken in three studies.21-23 One study used a recognised regime of triple antibiotic paste
(containing ciprofloxacin (250 mg), metronidazole (500 mg), and minocycline (50 mg)) &
MTA, for regenerative techniques.28 One study did not provide any details.27

Assessor/Operator identification

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 Only seven of the studies provided the number of operators who carried out the chosen
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therapy.18, 20, 21, 23, 25, 26, 28 Five studies provided specific details on who examined the patients
at the clinical and radiographic reviews.20-23, 28

Discussion
This review aimed to ascertain the success of endodontic therapies on a first permanent molar
tooth in a child under the age of 16. In summary, there appears to be very limited evidence to
support conventional and regenerative endodontics techniques for managing first permanent
molar teeth in children, however, there is some evidence to suggest that partial and coronal
pulpotomies can be useful techniques. Although some studies were of high quality, the
sample size and high and critical level of bias amongst several of the studies suggest the
findings must be interpreted with some degree of caution.

The 90.5% (range 70% to 100%) success rate over a mean follow-up of 28.4 months (range 6
months to 73.6 months) shown for coronal pulpotomies in this review is consistent with those
studies carried out in the adult population. A review by Alqaderi et al12 suggested that
coronal pulpotomies carried out in closed-apex adult permanent teeth have a 94% (95%
confidence interval (CI): [90,99]) and 92% (CI: [84,100]) over one and two years
respectively.12

A similar success rate of 91.3% (range 78.5% to 100%) is observed for a partial pulpotomy
review over a mean review period of 34.4 months (range 12 months to 140 months). This is
slightly less when compared to previous literature in adults which has suggested a 97.6% rate
>2–3 years.30 This suggests that pulpotomies are attractive techniques for use in all ages of
children given they are less technique-sensitive and time consuming when compared to
conventional pulpectomies and regenerative techniques. They may provide an alternative to
an elective extraction. Furthermore, equivocal success is noted in this review for immature
and mature first permanent molars, providing the operator with a higher degree confidence
when using these techniques. A recent prospective study31 reported 100% clinical success
(n=20) and 95% radiographic success (n=19) at 12 months which twenty cariously affected
permanent molars, in fourteen children aged 9-17 years, where managed a biodentine coronal
pulpotomy.31 As they included children both within and out with the age range pre-
determined for this review it could not be included. Unfortunately, baseline characteristics of

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 study participants did not identify the ages of individual children to identify success for
Accepted Article
children under 16 alone, but where the teeth managed had immature roots (n=3), they all
showed signs of continued root development.31

It appears from this review that conventional pulpectomies appear to be rarely employed by
practitioners in children as only one study was included. The success rate of 36% (although in
a small number of cases (n=10)) noted from this review contrasts markedly with a pooled
survival rate of 87% (95% CI: 82%, 92%) noted at 10 years for a conventional pulpectomies
in permanent teeth in adults 32. This is unsurprising, as molar teeth are often harder to treat in
children with cooperation often being a limiting factor. In these cases, extraction is likely to
be favoured by practitioners and the findings of this review would support this approach until
further evidence is available.
In terms of case-selection, it appears that for partial and coronal pulpotomies, pre-operative
clinical diagnoses did not influence the overall success of either of these techniques. This
suggests that using these techniques should be based on the clinical assessment of the pulpal
tissues solely rather than being led by pre-operative clinical signs or symptoms. A number of
studies included in this review undertook either a partial pulpotomy18, 21, 22 or a coronal
pulpotomy25 for children who were diagnosed with a reversible pulpitis. It could be argued
that for these teeth, adopting minimally invasive approaches33 or placing an indirect pulp cap
may be more appropriate than electively removing pulpal tissues.34

In contrast, for conventional pulpectomies, the extent of the pathology will influence overall
success and so this should be carefully considered. In some situations, such as for patients
with congenital absence of teeth, when only one molar is compromised or retention is
required to prevent worsening a class II malocclusion, retention of molars is desirable and as
such, endodontic techniques are more likely to be carried out. However, which technique to
undertake will be determined by the pre-operative clinical and radiographic signs and
symptoms of the tooth, which are essential prognostic variables for overall success.

There were no studies included in this review that reported on apexification in first permanent
molar teeth in children. This could suggest that it is a technique that is not used, due to being
technically demanding, or the evidence base is yet to establish for its’ use in these teeth.
Further research is clearly required before a conclusion about this technique for these teeth
can be reached.

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