Stepwise and partial-caries-removal –reduces longer term pulpal complications?

occlusal caries, molar teeth

The traditional approach to carried management involved the removal of all softened dentine. This approach can lead to pulpal exposure an increased loss of pulp vitality.  Two alternative approaches are increasingly being used, stepwise excavation  which aims to removes all caries in two appointments, reducing exposure risk and partial caries removal (PCR), also known as incomplete caries removal.

The main aim of this review was to determine if permanent teeth with deep dentine caries treated with PCR differed in loss of pulp vitality and/or restorative failures compared to similar teeth treated with stepwise excavation.


Searches were conducted in the PubMed, Web of Science, Dentistry and Oral Sciences Source, and Cochrane Library databases.  English language randomised controlled trials (RCTs), controlled clinical trials (CCTs), cohort studies, observational and case-series of permanent teeth with carious lesions that radiographically penetrates >50% dentine thickness beyond the amelodentinal junction published between 1980 and 2016 and followed up for a minimum of 2 years was considered.

2 reviewers independently selected studies, abstracted data and assessed study quality The Cochrane risk of bias tool was used for RCTs and the Newcastle- Ottawa scale (NOS) for observational studies.


  • 5 studies (2RCTs, 2 case-series, 1 retrospective) reported in 9 articles were included.
  • A total of 426 permanent teeth were treated with PCR or stepwise excavation and observed over periods of 2–10 years.
  • Both RCTs were considered to be at high risk of bias and the observational studies were of low quality.
  • Regarding restorative failures, >88% success at two years for both techniques was reported.
  • For loss of pulp vitality, observational studies reported >96% vitality at two years for each technique, while one RCT reported significantly higher vitality (p<0.05) at three years for PCR (96%) compared to SWT (83%).


The authors concluded

There is limited evidence that there are fewer pulpal complications over a three-year period when permanent teeth with deep dentine caries are treated with PCR rather than stepwise excavation. Any claim of a therapeutic advantage when treating permanent teeth with deep dentine caries using PCR rather than stepwise excavation. is supported by low numbers of studies consisting of limited- quality patient-oriented evidence. Successful vitality and restorative outcomes have been demonstrated for two years and beyond in permanent teeth with deep dentine caries treated with both techniques. Larger, long-term clinical studies that carefully follow diverse populations of participants are needed.


This review covers a similar topic to a Cochrane review by Ricketts et al published in 2013 (Dental Elf – 11th Apr 2013). Their review was restricted to RCTs and while they concluded

‘Stepwise and partial excavation reduced the incidence of pulp exposure in symptomless, vital, carious primary as well as permanent teeth. Therefore these techniques show clinical advantage over complete caries removal in the management of dentinal caries.

The included studies had a short follow up period. In comparison this review has looked at only those studies with a longer follow up period. This means that fewer studies of a lower quality are available and while the finding suggest  that there are fewer pulpal complications after 3 years this should be interpreted cautiously until further higher quality evidence is available.


Primary paper

Hoefler V, Nagaoka H, Miller CS. Long-term survival and vitality outcomes of permanent teeth following deep caries treatment with step-wise and partial-caries-removal: A Systematic Review. J Dent. 2016 Nov;54:25-32. doi: 10.1016/j.jdent.2016.09.009. Review. PubMed PMID: 27664467.

Other references

Dental Elf – 19th Sep 2013

Partial removal of caries as effective as stepwise removal in deep cavities


Dental Elf – 11th Apr 2013

Stepwise and partial excavation reduces the incidence of pulp exposure in carious primary and permanent teeth





Share on Facebook Tweet this on Twitter Share on LinkedIn Share on Google+
Mark as read
Create a personal elf note about this blog
Profile photo of Derek Richards

Derek Richards

Derek Richards is a specialist in dental public health, Director of the Centre for Evidence-Based Dentistry and Specialist Advisor to the Scottish Dental Clinical Effectiveness Programme (SDCEP) Development Team. A former editor of the Evidence-Based Dentistry Journal and chief blogger for the Dental Elf website until December 2023. Derek has been involved with a wide range of evidence-based initiatives both nationally and internationally since 1994. Derek retired from the NHS in 2019 remaining as a part-time senior lecturer at Dundee Dental School until the end of 2023.

More posts - Website

Follow me here –