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

shutterstock_34500700 - caries sign

The traditional management of caries by the removal of all softened demineralised dentine before a filling is placed is being increasingly challenged. This updated Cochrane review aims to assess the effects of stepwise, partial or no dentinal caries removal compared with complete caries removal for the management of dentinal caries in previously unrestored primary and permanent teeth. The original review was published in 2006 under the title, Complete or ultraconservative removal of decayed tissue in unfilled teeth.’

The review followed standard Cochrane protocols with searches of the Cochrane Oral Health Group’s Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) Medline and Embase databases with no restrictions. Parallel group and split-mouth randomised and quasi-randomised controlled trials that compared stepwise, partial or no dentinal caries removal with complete caries removal in primary or permanent teeth were included.

  • 8 trials involving 934 participants and 1372 teeth were included
  • All of the trials were assessed at high risk of bias, although the new trials showed evidence of attempts to minimise bias.
  • 4 trials compared stepwise caries removal to complete one stage caries removal
    • Stepwise caries removal resulted in a 56% reduction in incidence of pulp exposure (risk ratio (RR) 0.44, 95% confidence interval (CI) 0.33 to 0.60, P < 0.00001, I2 = 0%) compared to complete caries removal based on moderate quality evidence.
    • The mean incidence of pulp exposure was 34.7% in the complete caries removal group and 15.4% in the stepwise groups.
    • There was also moderate quality evidence of no difference in the outcome of signs and symptoms of pulp disease (RR 0.78, 95% CI 0.39 to 1.58, P = 0.50, I2 = 0%).
  • 3 trials compared partial caries removal compared to complete removal
    • Partial caries removal reduced incidence of pulp exposure by 77% compared to complete caries removal (RR 0.23, 95% CI 0.08 to 0.69, P = 0.009, I2 = 0%), also based on moderate quality evidence
    • The mean incidence of pulp exposure was 21.9% in the complete caries removal groups and 5% in the partial caries removal groups.
    • There was insufficient evidence to determine whether or not there was a difference in signs and symptoms of pulp disease,or restoration failure.
  • 2 trials compared no dentinal caries removal compared to complete caries removal
    • This was compared in two very different studies. There was some moderate evidence of no difference between these techniques for the outcome of signs and symptoms of pulp disease and reduced risk of restoration failure favouring no dentinal caries removal, from one study, and no instances of pulp disease or restoration failure in either group from a second quasi-randomised study. Meta-analysis of these two studies was not performed due to substantial clinical differences between the studies
  • 1 trial compared complete caries removal to both stepwise and partial caries removal
  • 4 studies investigated primary teeth, 3 permanent teeth and 1 included both.

The authors 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. There was no evidence of a difference in signs or symptoms of pulpal disease between stepwise excavation, and complete caries removal, and insufficient evidence to determine whether or not there was a difference in signs and symptoms of pulp disease between partial caries removal and complete caries removal. When partial caries removal was carried out there was also insufficient evidence to determine whether or not there is a difference in risk of restoration failure. The no dentinal caries removal studies investigating permanent teeth had a similar result with no difference in restoration failure. The other no dentinal caries removal study, which investigated primary teeth, showed a statistically significant difference in restoration failure favouring the intervention.

Due to the short-term follow-up in most of the included studies and the high risk of bias, further high quality, long-term clinical trials are still required to assess the most effective intervention. However, it should be noted that in studies of this nature, complete elimination of risk of bias may not necessarily be possible. Future research should also investigate patient centred outcomes.

Links

Ricketts D, Lamont T, Innes NPT, Kidd E, Clarkson JE. Operative caries management in adults and children. Cochrane Database of Systematic Reviews 2013, Issue 3. Art. No.: CD003808. DOI: 10.1002/14651858.CD003808.pub3.

Ricketts DN, Kidd EA, Innes N, Clarkson J. Complete or ultraconservative removal of decayed tissue in unfilled teeth. Cochrane Database Syst Rev. 2006 Jul 19;(3):CD003808. Review. PubMed PMID: 16856019.

 

 

 

 

 

 

 

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Derek Richards

Derek Richards is the Director of the Centre for Evidence-based Dentistry, Editor of the Evidence-based Dentistry Journal, Consultant in Dental Public Health with Forth Valley Health Board and Honorary Senior Lecturer at Dundee & Glasgow Dental Schools. He helped to establish both the Centre for Evidence-based Dentistry and the Evidence-based Dentistry Journal. He has been involved with teaching EBD and a wide range of evidence-based initiatives both nationally and internationally since 1994.

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