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restorative dentistry

Management of the deep carious lesion and the vital pulp dentine complex
D. Ricketts,1
This article describes the relationship between the carious process and pulp-dentine complex reactions. Where the balance between the two is in favour of the carious process and where conventional cavity preparation leads to a direct pulp exposure, the direct pulp cap technique is described. The success of the technique is addressed and more importantly an alternative technique for caries removal, namely stepwise excavation, is described which may lead to a reduced risk of carious exposure and the need for the direct pulp cap technique.
direct pulp capping technique. It will also aim to address when to place a direct pulp cap and when to undertake root canal treatment, what materials to use and the longterm prognosis of such a procedure. More importantly, an alternative technique of caries removal will be discussed which has been shown to reduce the risk of pulpal exposure.

Dental caries and the pulp dentine complex reactions

Dental caries in enamel is a subsurface demineralisation caused by acids produced by bacteria in the surface plaque. These acids diffuse into the tooth structure causing demineralisation. It is only when the relatively more mineralised surface zone breaks down that bacteria colonize the enamel lesion. At this early stage in the carious process there is some disagreement as to when the first pulp-dentine complex reactions occur. Brnnstrm and Lind (1965)5 for example, found an increase in chronic inflammatory cells beneath lesions apparently confined to enamel, whereas others report that this only occurs when caries extends into dentine.6 At the advancing front of a dentine lesion, demineralisation also precedes bacterial invasion. Considerable demineralisation of dentine occurs prior to bacterial infection7 and where occlusal lesions are concerned it is only when the caries extends into the middle third of dentine and is radiographically visible that significant infection of the dentine occurs.8 Fuzayama investigated the relationship between dentine softening, discolouration and bacterial infection and found that softening preceded discolouration which in turn preceded bacterial invasion.9 Thus bacterial acids and products, such as proteases, diffuse ahead of the bacteria towards the pulp and a number of factors influence the rate at which this occurs. These are namely the concentration of bacterial by-products, the permeability of the dentine and the pulpal fluid pressure.10 The frequency of sugar consumption and hence acid provoking attacks will affect the

rauma, rapidly progressing caries or over zealous removal of caries can result in exposure of the dental pulp. In these situations a direct pulp capping technique can be considered in an attempt to preserve the vitality of the pulp and to stimulate it to produce a calcific barrier to wall off the exposure. However, the health of the pulp and its healing capacity will depend on a number of factors, including the precipitating event leading to the exposure. Following trauma, when a previously sound, asymptomatic tooth suffers a coronal fracture involving the pulp, it is widely accepted that the direct pulp cap is the treatment of choice, providing the exposure is small and is treated within 24 hours.1,2,3 In this situation the depth of damage to the pulp tissue is small and the relatively healthy pulp tissue has considerable reparative potential, particularly in young teeth with immature apices and a good blood supply. However, the caries process can lead to marked changes within the pulp-dentine complex, which can vary considerably depending on the severity of the disease and the age of the pulp. Where deep dentine

lesions are concerned it is currently taught that the peripheral aspect of the cavity should be rendered completely caries free. This should be followed by careful excavation of caries at the base of the cavity, overlying the pulp until hard, stained dentine is reached,4 thus gradually reducing the bacterial load within the cavity. If at final excavation the pulp is exposed, the possibility of a direct pulp cap can be evaluated.

In brief
The direct pulp cap, whilst predictable for the traumatically exposed pulp, has a questionable long term prognosis where a carious exposure is concerned The activity of a deep carious lesion in dentine can be preferentially modified, by sealing in the dentine caries. This allows reparative pulpdentine complex reactions to take place When such lesions are re-entered after six months or more the risks of directly exposing the pulp are reduced

1Clinical Lecturer, Unit of Comprehensive Restorative

Care, Dundee Dental Hospital, Park Place, Dundee DD1 4HR *Correspondence to: David Ricketts email: d.n.j.ricketts@dundee.ac.uk REFEREED PAPER Received 27.02.01; Accepted 16.07.01 British Dental Journal 2001; 191: 606610

Whilst the literature is replete with studies on caries and endodontic procedures, relatively little has been published on the relationship between caries and the vital pulp-dentine complex. This article therefore aims to review the literature on pulpdentine complex reactions to caries and the

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concentration of acid produced in the dental plaque. This in turn will be moderated to some extent by saliva or whether the lesion is open (frank cavitation) or closed, but in general the more acid produced the greater the concentration gradient toward the pulp. The permeability of the dentine, which resists this inward diffusion of acid, changes with age. Newly erupted teeth are more permeable and less mineralised allowing the rapid diffusion of acids. As such they may be more susceptible to rapidly progressing caries. Pulp dentine complex reactions to this stimulus are aimed at reducing the permeability of the dentine. The most common reaction depends upon a vital odontoblast process and is the deposition of apatite and whitlockite crystals within the dentinal tubules leading to dentine tubule sclerosis. In addition to this, tertiary dentine may also be laid down by the odontoblast within the pulp chamber.10 If the carious process proceeds unchecked, degenerative changes within the odontoblasts take place before inflammatory changes within the pulp occur.11 This can lead to complete cell death and replacement by odontoprogenitor cells from the subjacent cell rich layer. Differentiation of these mesenchymal cells into odontoblastlike cells, can lead to the production of reparative dentine which, depending on the severity of the carious lesion, can be irregular with cellular inclusions or if less aggressive resemble normal tubular dentine. Thus there is a fine balance between the speed of the advancing front of the dentine lesion and the rate at which pulp-dentine defenses can be laid down. These pulp-dentine reactions require a healthy pulp, however if the carious process continues unchecked pulpal inflammation will ensue. In an attempt to evaluate the relationship between lesion depth and pulpal inflammation, Reeves and Stanley (1966) showed that if the advancing front of the lesion was about 1 mm from the pulp then no significant disturbance occurred.12 However, once within 0.5 mm of the pulp more pathological changes occur, but it was only when the reactionary dentine itself was involved that pathosis of real consequence was seen. Shovelton also showed that it was

only when the lesion was within 0.25 mm0.3 mm of the pulp that hyperaemia and pulpitis occurred.7 Thus in final excavation of soft pulpal caries, if direct perforation of the pulp occurs the relative rate of progression of the lesion has been faster than the rate of pulp-dentine reactions. At this stage the pulp is likely to be inflamed and the decision of whether to place a direct pulp cap has to be made.

The direct pulp cap.

A direct pulp cap usually involves the placement of a calcium hydroxide preparation directly in contact with an exposed pulp. For a direct pulp cap to be successful a number of factors have to be met and these are detailed in Table 1. Lin and Langland (1981) have shown that teeth with a history of pain will have an area of necrosis within the pulp chamber and for many this will extend into the root canal.13 Bacterial invasion of pulp tissue is closely related to this necrosis and as such these teeth should be endodontically treated. Teeth exposed during caries removal will inevitably have some degree of inflammation although the histological extent of this cannot be accurately predicted from a clinical examination. Table 1 provides sensible but not infallible clinical criteria for successful direct pulp capping. It was once thought that only pinpoint exposures could be pulp capped, however more recent research would suggest that the size of exposure has no bearing on clinical outcome.14,15,16 Whilst these studies pertain to traumatically exposed pulps, Mejare and Cvek (1993) have suggested that deep carious exposures be opened up so that 1 mm3 mm of exposed pulp can be

removed.17 It is important to draw attention to the fact that this study was on young posterior teeth and cannot be regarded as a true direct pulp cap, but rather a partial pulpotomy. This procedure has a number of advantages; it reduces the potential for introduction of dentine chips into the pulp tissue and it enables good contact between pulp and capping agent. It has been shown that dentine chips inadvertently pushed into the pulp tissue cause severe inflammatory reaction, which can lead to pulp necrosis.18,19 It also removes superficially contaminated pulpal tissue. It is important to emphasize that whilst the size of traumatic exposures is not so important, carious exposures should be small even if they are opened up further at operation. It is generally agreed that larger carious exposures have a poor prognosis due to a more severely inflammed pulp, risk of necrosis and bacterial contamination.20,21,22 The issue of age is also difficult, as there is no clear cut-off when a direct pulp cap should no longer be considered. The ageing process is gradual and with increased age the pulp tissue becomes more fibrous with a reduction in pulp volume as a result of physiological secondary dentine formation and reactionary dentine due to external stimuli such as trauma, caries and tooth wear. The blood supply to the dental pulp is critical to its health and regenerative capacity, and as this decreases with age so does its capacity to respond to a direct pulp cap. Hence rather than a chronological age as a cut-off, the biological age of an individual tooth should be assessed and a previous restorative history taken into consideration as well as the factors in Table 1.

Table 1 Criteria essential for a successful direct pulp cap.

History
No recurring or spontaneous pain. No swelling.

Preoperative assessment
Normal vitality tests. Not tender to percussion. No radiographic evidence of periradicular pathology. Young patient. Radiographically obvious pulp chamber and root canal.

Clinical findings.
Pink pulp Bleed if touched but not excessively.

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Finally the location of the exposure is important as there should be no pulp tissue coronal to the exposure. Exposure in a cervical cavity would lead to reactionary dentine formation which would restrict the blood supply to the tissue more coronal to it, leading to necrosis and failure. These teeth should therefore be root treated.23 Calcium hydroxide to date remains the material of choice for a direct pulp capping technique in general practice. Its properties and mode of action have been comprehensively reviewed previously.24 However, a relatively new material, mineral trioxide aggregate (MTA) has been investigated.25 It consists of fine hydrophilic particles, which when mixed with sterile water results in a colloidal gel of pH 12.5. This gel solidifies to a hard structure within approximately 4 hours. Once set, it has a high compressive strength comparable to IRM or Super EBA. Both laboratory and clinical studies have shown this material to be extremely biocompatable with pulp tissue and to have good sealing ability against dyes and bacteria. In a limited study, Pitt-Ford et al., showed that direct pulpal exposures treated with MTA demonstrated more predictable dentine bridge formation than calcium hydroxide.26 It would therefore appear that this material may be the material of choice for future pulp caps. However, problems associated with the materials difficult handling properties and prolonged setting time may preclude its widespread acceptance despite its superior therapeutic properties.

amount of physiological secondary and reactionary dentine would have developed which has the potential to complicate subsequent root canal treatment. In addition the root canal system may have become infected and prognosis for root treatment is less favorable than if vital pulp tissue were removed.30 These results question the success of the direct pulp cap for carious exposures. However, a further thorough audit is required, as only 123 out of a possible 401 teeth with a direct pulp cap were available for 10 year follow up.29

The indirect pulp cap.

When caries is thought to extend close to, or into the pulp, excavation of the pulpal caries can be stopped at stained but firm dentine.31 Calcium hydroxide lining is applied over the pulpal dentine prior to placement of the definitive restoration. This is classically referred to as the indirect pulp cap. The difficulty with this technique is knowing how rapid the carious process has been, how much tertiary dentine has been formed and knowing exactly when to stop excavating to avoid pulp exposure. Using a stepwise approach to caries removal these parameters can be regulated with a more predictable outcome.

Stepwise excavation.
It could be argued that in the absence of any signs and symptoms of pulpitis, and where the criteria in Table 1 are met, it is over-judicious removal of caries that leads to a pulpal exposure. In the majority of cases this can be avoided if a stepwise approach to caries removal is adopted. This approach which is not completely new,32 has recently been the subject of renewed interest. Bjrndal et al. (1997)33 investigated 31 teeth with gross caries, which from a clinical and radiographic examination were thought to have carious pulpal exposures. In these teeth caries removal was staged over two separate appointments 612 months apart. At the first appointment, access to the caries was gained and the periphery of the cavity made completely caries free. Soft, wet and pale coloured dentine was left pulpally, which has previously been shown to be heavily infected.34 The cavity was lined with cal-

What is the success rate of the pulp cap technique?

The success rate of a direct pulp cap is difficult to establish from the dental literature as studies fail to clearly identify whether exposures were due to trauma or caries27 or address those resulting from trauma only.28 Whilst the prognosis of teeth that have received direct pulp caps as a result of trauma would appear good28 those with a carious exposure fare less well.29 In a retrospective study of 123 direct pulp caps on carious exposures only 37% were clearly successful after 5 years and after 10 years 80% had failed.29 Loss of pulp vitality in these teeth poses a problem as a significant
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cium hydroxide and restored with glass ionomer and left for 612 months. After this period, cavities were re-entered and the dentine in all teeth was found to be darker in colour, harder and drier in consistency. Microbiological analysis also showed a significant reduction in cultivable microorganisms over the period in which the provisional restorations were in place. These findings would imply that by removing some of the carious biomass and sealing the remaining caries from extrinsic substrate and oral bacteria, the caries left behind after the first excavation had become less active. This allows time for pulp-dentine complex reactions to take place so that at the second excavation visit, there is less likelihood of pulpal exposure. It has also been suggested that by changing the cavity environment from an active lesion into the condition of a more slowly progressing lesion, this will be accompanied by more regular tubular tertiary dentine formation. The success of this technique has been demonstrated in a randomized controlled study comparing conventional cavity preparation of such lesions with stepwise excavation.35 Using the stepwise excavation technique significantly fewer teeth had exposed pulps (17.5%) compared with conventional caries removal (40%). These results were echoed in a similar study of deep carious lesions in primary teeth.36 In this study 55 teeth were treated with the stepwise excavation technique and 55 control teeth were prepared conventionally. The proportion of teeth where pulpal exposure occurred were 15% and 53% respectively. The technique has also been shown to be successful in a practice-based study37 where only 5.3% of pulps were exposed.

Leaving heavily infected caries, the dilemma.

The thought of leaving heavily infected carious dentine for 612 months would seem contrary to teaching in dental schools. It has been taught that when a restoration is placed, the presence and severity of pulpal inflammation is related to the level of bacterial microleakage around the restoration.3841 Thus it would be logical to think that leaving dentine caries which is heavily infected would result in similarly severe pul-

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pal inflammation. However, teeth that have been treated with the stepwise excavation technique do not show any signs or symptoms of pulpitis. The difference here may lie in the fact that in the animal studies investigating the effects of bacterial microleakage, cavities have been prepared in sound teeth. The pulp therefore has not had any opportunity to mount its protective reaction and the presence of bacteria and their by-products are in contact with dentine whose tubules are potentially patent and pulp vulnerable. To the contrary, there is now a significant amount of evidence to support the fact that there are few adverse effects, and potential benefits when caries is sealed into a tooth. These studies can be divided into those where caries has been sealed in with a simple fissure sealant and those where ultraconservative caries removal has been followed by placement of a composite restoration over active caries.

recall, 85 have been followed throughout the ten years. Various progress reports on the study sample have shown that sealing caries into the tooth arrests the progress of the lesion by effectively eliminating the oral source of substrate to the bacteria within the lesion.51-55 Only one restoration appeared to cave-in, only one succumbed to secondary caries and 3.5% showed signs of wear. All the teeth remained symptomless with no signs of pulpal inflammation or necrosis.50

tion of new dental materials, demand further research into this subject, particularly where older more compromised teeth are concerned.
1 Cox C F, Bergenholtz G, Heys D R, Syed A, Fitzgerald M, Heys J R. Pulp capping of dental pulp mechanically exposed to oral microflora: a 12 year observation of wound healing in monkey. J Oral Pathol 1985; 14: 156168. Heidi S, Kerekes K. Delayed direct pulp capping in permanent incisors of monkeys. Int Endo J 1987; 20: 6574. Pitt Ford T R, Roberts G J. Immediate and delayed direct pulp capping with the use of a new visible light-cured calcium hydroxide preparation. Oral Surg Oral Med Oral Pathol 1991; 71: 338342. Kidd E A M, Smith B G N. Pickards Manual of Operative Dentistry. 7th Edition pp 5859. Oxford: Oxford University Press; 1996. Brnnstrm M, Lind P O. Pulpal response to early dental caries. J Dent Res 1965; 44: 10451050. Massler M. Pulpal reaction to dentinal caries. Int Dent J 1967; 17: 441460. Shovelton D S. A study of deep carious dentine. Int Dent J 1968; 18: 392405. Ricketts D N J, Kidd E A M, Beighton D. Operative and microbiological validation of visual, radiographic and electronic diagnosis of occlusal caries in non-cavitated teeth judged to be in need of operative care. Br Dent J 1995; 179: 214-220. Fuzayama T, Okuse K, Hosoda H. Relationship between hardness, discoloration and microbial invasion in carious dentin. J Dent Res 1966; 45: 10331046. Kim S, Trowbridge H O. Pulpal reaction to caries and dental procedures. In Cohen S, Burns R C, Rudolph P. (eds) Pathways of the pulp. 7th Ed. pp532534. Missouri: Mosby Inc; 1998. Trowbridge H O. Pathogenesis of pulpitis resulting from dental caries. J Endod 1981; 7: 5260. Reeves R, Stanley H R. The relationship of bacterial penetration and pulpal pathosis in carious teeth. Oral Surg 1966; 22: 5965. Lin L, Langeland K. Light and electron microscopic study of teeth with carious pulp exposures. Oral Surg 1981; 51: 292316. Fuks A B, Cosack A, Klein H, Eidelman E. Partial pulpotomy as a treatment alternative for exposed pulps in crown-fractured permanent incisors. Endodont Dent Traumatol 1987; 3: 100102. Heide S, Kerekes K. Delayed partial pulpotomy in permanent incisors of monkeys. Int Endodont J 1986; 19: 7889. Klein H, Fuks A, Eidelman E, Chosack A. Partial pulpotomy following complicated crown fracture in permanent incisors: a clinical and radiographic study. J Pedodont 1985; 9: 142147.

2 3

Why re-enter?
The success of this technique is dependent upon the integrity of the restoration and its seal. Regular recall would be essential. In the Mertz-Fairhurst et al. study (1998) the regular recall would identify any lost restoration at an early stage. However, over the ten year period between 18% and 45% of patients failed to attend for annual recall.50 In the unlikely event that the restoration should fail and not be detected, the potentially reactivated lesion would already be in an advance stage. Following sealing caries into the tooth, the carious dentine becomes dry, harder and darker in colour.33 As a result there is shrinkage of the tissue leaving a void beneath the restoration. These two factors support the second stage of the stepwise excavation. However, the work by MertzFairhurst et al. (1998)50 would suggest that the interval between first and second excavation is not critical and could be left for considerably longer than 612 months. Thus use of a more conservative technique for removing caries in a young patient with very deep lesions could eliminate the need for the conventional direct pulp cap technique. In those rare instances when this is still required, adoption of the stepwise excavation technique should result in a minimally inflamed pulp, superior tertiary dentine formation, less bacterial load and a more predictable pulp cap. Where this is required the use of calcium hydroxide, whilst acceptable at present, may become superceded by a mineral trioxide aggregate material.

4 5 6 7 8

Fissure sealant studies.

When occlusal caries is visible radiographically, the lesion extends into the middle third of dentine42 and is heavily infected.8 Studies have shown that when a fissure sealant is placed over such lesions there is a significant reduction in the number of cultivable microorganisms.4348 Such lesions appear to arrest and no increase in lesion size has been found radiographically over a period of two years.49 In addition no study has reported symptoms of pulpitis or loss of vitality.

10

Ultraconservative caries removal.

Perhaps some of the most compelling evidence is provided by Mertz-Fairhurst et al., who in 1998 presented ten year data on 156 ultraconservative, cariostatic sealed restorations.50 In this study, teeth with clinical and radiographic evidence of occlusal caries were minimally prepared by placing a 45 60 bevel in the enamel, surrounding a frankly cavitated lesion. The bevel was at least 1 mm wide and placed in sound enamel. No attempt was made to remove any carious dentine and the resultant cavities were restored with acid etched composites and covered with fissure sealant. Although a number of these teeth have been lost from the study due to patients failing to return for

11 12 13 14

15 16

Conclusion
These are exciting times when the conventional wisdom of caries removal is being challenged.56 This together with the evolu-

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17 Mejare I, Cvek M. Partial pulpotomy in young permanent teeth with deep carious lesions. Endodont Dent Traumatol 1993; 9: 238242. 18 Kalins V, Frisbie H E. Effect of dentine fragments on the healing of the exposed pulp. Arch Oral Biol 1960; 2: 96 103. 19 Mjr I A, Dahl E, Cox C F. Healing of pulp exposures: an ultrastructural study. J Oral Pathol Med 1991; 20: 496501. 20 Dannenberg J L. Pedodontic-endodontics. Dent Clin North Am 1974; 18: 367377. 21 McDonald R E, Avery D R. Treatment of deep caries, vital pulp exposure, and pulpless teeth in children. In McDonald R E, Avery D R, (eds). Dentistry for the child and adolescent. 3rd ed. St Louis: Mosby, 1978. 22 Seltzer S, Bender I B. Pulp capping and pulpotomy. In Seltzer S, Bender I B (eds). The dental pulp, biologic considerations in dental procedures. 2nd ed. Philadelphia: Jb Lippincott, 1975. 23 Stanley H R, Lundy T. Dycal therapy for pulp exposure. Oral Surg Oral Med Oral Pathol. 1972; 34: 818827. 24 Forman P C, Barnes I E. A review of calcium hydroxide. Int Endod J 1990; 23: 283297. 25 Torabinejad M, Chivian N. Clinical applications of mineral trioxide aggregate. J Endodon 1999; 25: 197205. 26 Pitt Ford T R, Torabinejad M, Abedi H R, Bakland L K, Kariyawasam S P. Using mineral trioxide aggregate as a pulp-capping material. J Am Dent Assoc 1996; 127: 14911494. 27 Armstrong W P, Hoffman S. Pulp cap study. Oral Surg Oral Med Oral Pathol. 1965; 15: 15051509. 28 Cvek M. A clinical report on partial pulpotomy and capping with calcium hydroxide in permanent incisors with complicated crown fracture. J Endodon 1978; 4: 232-242. 29 Barthel C R, Rosenkranz B, Leuenberg A, Roulet J-F. Pulp capping of carious exposures: treatment outcome after 5 and 10 years: a retrospective study. J Endodon 2000; 26: 525528. 30 Sjgren U, Hagglund B, Sundqvist G, Wing K. Factors affecting long term results of endodontic treatment. J Endodon 1990; 16: 498504. 31 Kidd E A M, Smith B G N. Pickards Manual of Operative Dentistry. 7th Edition p 59. Oxford: Oxford University Press; 1996.

32 King J B, Crawford J J, Lindahl R L. Indirect pulp capping: a bacteriologic study of deep carious dentine in human teeth. Oral Surg Oral Med Oral Pathol 1965; 20: 663671. 33 Bjrndal L, Larsen T, Thylstrup A. A clinical and microbiological study of deep carious lesions during stepwise excavation using long treatment intervals. Caries Res 1997; 31: 411417. 34 Kidd E A M, Ricketts D N J, Beighton D. Criteria for caries removal at the enamel dentine junction: a clinical and microbiological study. Br Dent J 1996; 180: 287291. 35 Leksell E, Ridell K, Cvek M, Mejare I. Pulp exposure after stepwise versus direct complete excavation of deep carious lesions in young posterior permanent teeth. Endod Dent Traumatol 1996; 12: 192196. 36 Magnusson B O, Sundell S O. Stepwise excavation of deep carious lesions in primary molars. J Int Ass Dent Child 1977; 8: 3640. 37 Bjrndal L, Thylstrup A. A practice-based study on stepwise excavation of deep carious lesions in permanent teeth: a 1 year follow-up study. Community Dent Oral Epidemiol. 1998; 26: 122128. 38 Bergenholtz G, Cox C F, Loesche W J, Syed S A. Bacterial leakage around dental restorations: its effect on the dental pulp. J Oral Pathol 1982; 11: 439450. 39 Cox C F, Keall C L, Keall H J, Ostro E, Bergenholtz G. Biocompatibility of surfacesealed dental materials against exposed pulps. J Pros Dent 1987; 57: 18. 40 Cox C F, Sbay R K, Suzuki S, Suzuki S H, Ostro E. Biocompatability of various dental materials: pulp healing with a surface seal. Int J Periodont Rest Dent 1996; 16: 241251. 41 Grieve A R, Alani A, Saunders W P. The effects on the dental pulp of a composite resin and two dentine bonding agents and associated bacterial microleakage. Int Endod J 1991; 24: 108118. 42 Ricketts D N J, Kidd E A M, Smith B G N, Wilson R F. Clinical and radiographic diagnosis of occlusal caries: a study in vitro. J Oral Rehabil 1995; 22: 1520. 43 Handelman S L, Buonocore M G, Heseck D J. A preliminary report on the effect of fissure sealant on bacteria in dental caries. J Prosthet Dent 1972; 27: 390392. 44 Handelman S L, Buonocore M G, Schoute P C.

45

46

47

48

49

50

51

52

53 54

55

56

Progress report on the effect of a fissure sealant in dental caries. J Am Dent Assoc 1973; 87: 11891191. Handelman S L, Wasburn F, Wopperer P. Two-year report of sealant effect on bacteria in dental caries. J Am Dent Assoc 1976; 93: 967970. Going R E, Loesche W J, Grainger D A, Syed S A. The viability of micro-organisms in carious lesions five years after covering with a fissure sealant. J Am Dent Assoc 1978; 97: 455462. Jensen O E, Handelman S L. Effect of an autopolymerising sealant on viability of microflora in occlusal dental caries. Scand J Dent Res 1980; 88: 382388. Mertz-Fairhurst E J, Schuster G S, Fairhurst C W. Arresting caries by sealants: results of a clinical study. J Am Dent Assoc 1986; 112: 194197. Handelman S L, Leverett D H, Espeland M A, Curzon J A. Clinical radiographic evaluation of sealed carious and sound tooth surfaces. J Am Dent Assoc 1986; 113: 751754. Mertz-Fairhurst E J, Curtis J W, Ergle J W, Rueggeberg F A, Adair S M. Ultraconservative and cariostatic sealed restorations: results at year 10. J Am Dent Assoc 1998; 129: 5566. Mertz-Fairhurst E J, Call-Smith K M, Schuster G S, et al. Clinical performance of sealed composite restorations placed over caries compared with sealed and unsealed amalgam restorations. J Am Dent Assoc 1987; 115: 689694. Mertz-Fairhurst E J, Williams J E, Schustre G S, et al. Ultraconservative sealed restorations: three-year results. J Public Health Dent 1991; 51: 23950. Mertz-Fairhurst E J, Williams J E, Pierce K L, et al. Sealed restorations: 5 year results. Am J Dent 1992; 5: 510. Mertz-Fairhurst E J, Smith C D, Williams J E, et al. Cariostatic and ultraconservative sealed restorations: six year results. Quintessence Int 1992; 23: 827838. Mertz-Fairhurst E J, Adair S M, Sams D R, et al. Cariostatic and ultraconservative sealed restorations: nine-year results among children and adults. ASDC J Dent Child 1995; 62: 97106. Kidd E. Caries removal and the pulpo-dentinal complex. Dent Update 2000; 27; 476482.

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Treatment of deep carious lesions by complete excavation or partial removal: A critical review Van Thompson, Ronald G. Craig, Fredrick A. Curro, William S. Green and Jonathan A. Ship J Am Dent Assoc 2008;139;705-712

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CLINICAL PRACTICE

CRITICAL REVIEW

Treatment of deep carious lesions by complete excavation or partial removal

A critical review
Van Thompson, DDS, PhD; Ronald G. Craig, DMD, PhD; Fredrick A. Curro, DMD, PhD; William S. Green, AB; Jonathan A. Ship, DMD

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he treatment of deep carious lesions approaching a healthy pulp presents a significant challenge to the practitioner. The traditional management of carious lesions of any kind dictates the removal of all infected and affected dentin to prevent further cariogenic activity and provide a wellmineralized base of dentin for restoration. When the procedure risks exposing or even breaching the pulp, however, the course of treatment becomes less predictable and may require such measures as indirect pulp capping (typically using a protective material such as a calcium hydroxidebased preparation), pulpotomy or, in the most extreme cases, pulpectomy. Choosing among these options can be daunting for the dentistas well as for the patient, who is advised of the risks and asked to share in the decision. To preclude or at least minimize the potential complications of com-

ABSTRACT
Background. The classical approach to treatment of deep carious lesions approaching the pulp mandates removing all infected and affected dentin. Several studies call this approach into question. Types of Studies Reviewed. A search of five electronic databases using selected key words to identify studies relating to partial versus complete removal of carious lesions yielded 1,059 reports, of which the authors judged 23 to be relevant. Three articles reported the results of randomized controlled trials. Results. The results of three randomized controlled trials, one of which followed up patients for 10 years, provide strong evidence for the advisability of leaving behind infected dentin, the removal of which would put the pulp at risk of exposure. Several additional studies have demonstrated that cariogenic bacteria, once isolated from their source of nutrition by a restoration of sufficient integrity, either die or remain dormant and thus pose no risk to the health of the dentition. Clinical Implications. There is substantial evidence that removing all vestiges of infected dentin from lesions approaching the pulp is not required for caries management. Key Words. Deep caries; deep carious lesions; partial caries removal; indirect pulp capping; pulpal exposure; stepwise excavation; alternative restorative treatment. JADA 2008;139(6):705-712.

Dr. Thompson is a professor and the chair, Department of Biomaterials and Biomimetics, and the director, Protocol Development and Training Core, Practitioners Engaged In Applied Research and Learning (PEARL) Network, New York University College of Dentistry, New York City. Dr. Craig is an associate professor, Department of Basic Sciences and Craniofacial Biology and Department of Periodontology and Implant Dentistry, and the director, Information Dissemination Core, PEARL Network, New York University College of Dentistry. Address reprint requests to Dr. Craig at New York University College of Dentistry, 345 E. 24th Street/1001S, New York, N.Y. 10010-4086, e-mail rgc1@nyu.edu. Dr. Curro is a clinical professor, Department of Oral and Maxillofacial Pathology, Radiology, and Medicine; the director of pharmacotherapeutic research, Bluestone Center for Clinical Research; and the director, Recruitment, Retention, and Operations Core, PEARL Network, New York University College of Dentistry, New York City. Mr. Green is a scientific writer, PEARL Network, New York University College of Dentistry, New York City. The late Dr. Ship was a professor, Department of Oral and Maxillofacial Pathology, Radiology and Medicine, New York University College of Dentistry; a professor of medicine, New York University School of Medicine; and the director, PEARL Network, New York University College of Dentistry, New York City.

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plete excavation of carious dentin close to the pulp, several authors have investigated and proposed alternative approaches. One such method, stepwise (or two-step) excavation, involves the staged removal of carious tissue. At the patients initial visit, once the clinician has established that the pulp still is vital, he or she partially removes necrotic infected dentin, often characterized as soft and removed easily by using hand instruments. The clinician then seals the lesion with a medicament such as calcium hydroxide and places a temporary restoration. At the second visittypically some months after the first and, in some cases, up to two years laterthe clinician removes all or most of the remaining infected tissue. The rationale for this approach is that by this point any remaining bacteria will have died, residual infected dentin as well as affected dentin will have remineralized, and reparative dentin will have been generated, making it easier for the dentist to remove any remaining carious tissue. An even more controversial approach is conservative or ultraconservative removal of carious tissue, often referred to as partial caries removal. In this method, the practitioner removes most but not all of the infected dentin, seals the cavity (with or without indirect pulp treatment) and proceeds with the restoration. The tradeoff for avoiding pulpal exposureleaving behind a layer of infected dentinis defended by citing the substantial evidence (discussed below) that cariogenic bacteria isolated from their source of nutrition by a restoration of sufficient integrity either die or remain quiescent and thus, given a vital pulp, pose no risk to the health of the dentition. Studies comparing either partial caries removal or stepwise excavation with complete removal of infected tissue from deep carious lesions were the subject of a 2006 Cochrane Review.1 The Cochrane article, while extremely valuable, is limited in scope by virtue of being a meta-analysis focused solely on the results of randomized controlled trials. In preparing this review, we sought to cast a wider net by performing a traditional review, taking into account observational studies and ancillary investigations that also might be of interest to the practitioner.
METHODS

Reviews, Cochrane Central Register of Controlled Trials and OVIDs Database of Abstracts of Reviews of Effects) using the following key words: deep caries; deep carious lesions; partial caries removal; indirect pulp capping; pulpal exposure; stepwise excavation; alternative restorative treatment (ART). We limited the search to reports written in English describing studies using human subjects and published from 1950 through the first week of November 2007. The literature search yielded 1,059 articles, of which 23 including articles relating to restoration longevity, cariogenic activity and pulp vitality, as well as those directly addressing partial versus complete removal of deep carious lesions reported results we deemed directly relevant.
RESULTS

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We identified 10 articles2-11 accounting for six studies (four of these articles reported follow-up results) that directly address the issue of partial removal of carious tissue from deep lesions (Table). Three investigations stood out by virtue of being randomized controlled trials: the 1987 study by Mertz-Fairhurst and colleagues,2 the 1999 study by Ribeiro and colleagues5 and the 2004 study by Foley and colleagues.6 Mertz-Fairhurst and colleagues2 used a randomized split-mouth, four-celled design to compare sealed composite restorations in teeth treated via partial caries removal with both sealed and unsealed amalgam restorations in teeth from which all carious tissue had been removed. The study population consisted of 123 patients aged 8 to 52 years who had at least one pair of frank Class I lesions that, according to the investigators radiographic evaluation, extended as far as halfway from the dentinoenamel junction (DEJ) to the pulp. A total of 156 pairs (312 teeth) were included in the study. The investigators evaluated restorations radiographically as well as clinically (using a modification of the Ryge/Snyder criteria12) at six months, one year and two years after treatment. They detected no significant differences among the three treatmentssealed conservative, sealed amalgam, unsealed amalgamat any period. MertzABBREVIATION KEY. ART: Alternative restorative treatment. CFU: Colony-forming unit. DEJ: Dentinoenamel junction. GIC: Glass ionomer cement. PEARL: Practitioners Engaged in Applied Research and Learning.

We conducted a systematic search of five databases (MEDLINE, Evidence-Based Medicine Reviews, the Cochrane Database of Systematic
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TABLE

Summary of studies examining partial caries removal.

STUDY STUDY DESIGN FOLLOW-UP PERIOD RESULTS Randomized Controlled Trials Mertz-Fairhurst and colleagues2-4 Split-mouth randomized trial of 156 pairs of teeth, in subjects aged 8 through 52 years, comparing sealed resin-based composites after partial caries removal versus sealed and unsealed amalgams after complete caries removal Randomized controlled trial of 48 primary molars, in subjects aged 7 through 11 years, restored with a resin-bonded composite, comparing partial versus complete caries removal Split-mouth randomized controlled trial of 88 teeth in 44 subjects aged 3.7 through 9.5 years; teeth divided into four groups: complete or partial caries removal restored with copper phosphate cement with or without glass ionomer cement or amalgam Clinical and radiographic follow-up at six months and at one, two, five and 10 years No differences noted among groups at any time of follow-up

Ribeiro and colleagues5

Extracted near time of exfoliation and examined radiographically and via electron microscopy

No differences noted between groups

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Foley and colleagues6

Restorations assessed clinically at six-month intervals for 24 months and radiographically at 12 and 24 months

Use of copper phosphate cement plus glass ionomer cement resulted in more abscess or sinus formation; use of glass ionomer cement alone resulted in no differences between groups

Observational Studies Fairbourn and colleagues10 Observational study of the effect on cultivatable flora after partial caries removal followed by zinc oxide eugenol with or without calcium hydroxide base in 40 permanent teeth Observational study of partial caries removal in 32 subjects aged 12 through 23 years At reentry after five months, the remaining infected dentin was removed and cultivated for microbiological analysis Clinical, radiographic and microbiological data collected at reentry at six to seven, 14 to 18, and 36 to 45 months after treatment Examined at four years for clinical or radiographic evidence of pulp pathology Nine of 20 teeth treated with calcium hydroxide and five of 20 teeth treated with zinc oxideeugenol were sterile

Maltz and colleagues7,9, Oliveira and colleagues8

Remineralization occurred and caries was arrested at each of the three times of follow-up

Marchi and colleagues11

Observational study of the effect of calcium hydroxide and resin-modified glass ionomer liners on indirect pulp caps of 27 primary molars in subjects aged 4 through 9 years

88 percent success for calcium hydroxide and 93 percent success for resinmodified glass ionomer

Fairhursts group followed up these patients across the next decade,3,4 finally observing that the bonded and sealed composite restorations placed over the frank cavitated lesions [had] arrested the clinical progress of these lesions for 10 years.4 The randomized controlled trial conducted by Ribeiro and colleagues,5 in which they evaluated the performance of a dentin adhesive system, also served to test the relative performance of com-

plete and partial caries removal. After etching, the investigators applied a bonding agent to both carious and noncarious dentin in 48 primary molars of 38 children aged 7 to 11 years. In one group, the clinicians removed carious dentin completely from the DEJ but only superficially from the remainder of the cavity; they treated a second group by completely excavating caries. The investigators extracted 40 teeth (20 from each group) at about the time of exfoliation (approximately
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one year after treatment) and subjected the teeth to radiographic and scanning electron microscopic analysis. These results, as well as evaluations of retention rates, marginal integrity and pulpal symptoms, indicated no significant differences between the two groups. A more recent study by Foley and colleagues6 compared the cariostatic effectiveness of alternative restorative materials in both partial and complete removal of carious tissue. The authors used a split-mouth design in 44 patients aged 3.7 to 9.5 years who had at least one pair of previously unrestored primary molars that had no pulpal involvement. They treated one tooth of each pair by complete caries removal and the other by incomplete caries removal followed by restoration using copper phosphate cement, glass ionomer cement (GIC) or both, or a material of the operators choice (such as amalgam). At 24 months after treatment, teeth that had undergone partial caries removal followed by restoration with copper phosphate cement and GIC exhibited greater abscess or sinus formation than did teeth that had undergone other treatments. Restorations placed in teeth treated with GIC alone after partial caries removal, however, exhibited a durability and effectiveness comparable with those placed in teeth that had undergone complete caries removal. In an observational study, Maltz and colleagues7 investigated the effects of partial caries removal in 32 teeth with deep carious lesions. On the basis of clinical, radiographic and microbiologic evidence at reentry six to seven months after treatment (after which they placed a permanent restoration), the authors concluded that remineralization had taken place and that caries had been arrested. In follow-up studies of the same patients, the authors reported similar results 14 to 18 months after treatment8 and 36 to 45 months after treatment.9 Fairbourn and colleagues10 reported the effect of indirect pulp capping, after partial caries removal, on cultivable aerobic and anaerobic bacteria. These investigators restored 40 permanent asymptomatic teeth that had carious occlusal or interproximal lesions approaching the pulp after partial excavation of infected dentin in which zinc oxideeugenol (Caulk IRM Intermediate Restorative Material, Dentsply Caulk, Milford, Del.) with or without a calcium hydroxide base (Dycal, Dentsply Caulk) was used. After five months, they isolated the teeth, excavated the remaining
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infected dentin and cultivated it to identify bacterial species. Both groups showed a dramatic decrease in colony-forming units (CFUs); nine of 20 teeth treated with the calcium hydroxide liner and five of 20 teeth treated with zinc oxide eugenol had become operationally sterile (< 300 CFUs per milligram of dentin). The authors concluded that reentry to remove residual infected dentin with either restorative material may be unnecessary, provided that the restoration maintains an effective seal. Marchi and colleagues11 studied the effectiveness of two protective liners, calcium hydroxide and resin-modified glass ionomer, in the indirect pulp treatment of 27 primary molars. At four years after treatment, the success rate using the former was 88.8 percent and using the latter was 93 percent. The investigators defined success essentially as the absence of any clinical radiographic signs or symptoms of irreversible pulp pathologies or necrosis. The authors concluded that indirect pulp capping in primary teeth arrests the progression of the underlying caries, regardless of the material used as a liner.11 Several studies that did not focus on partial caries removal nevertheless are relevant to the treatment of deep carious lesions. There has been evidence for several decades, for example, that caries development is arrested in sealed lesions. Handelman and colleagues13-17 have published extensively on this subject. Perhaps most frequently cited is their 1976 study,13 in which they placed sealants on 60 teeth with carious lesions extending into the dentin; 29 unsealed teeth served as control specimens. They sampled teeth for bacterial culture at periods ranging from one week to two years; at the latter point, they found a substantial decrease in the number of cultivable microorganisms in sealed lesions when compared with the unsealed control teeth. Interestingly, they found the greatest amount of bacterial reduction within two weeks after treatment. In a subsequent study, Handelmans group,14 describing a radiographic analysis of teeth treated similarly to those in the 1976 study, reported a significant decrease in caries penetration in teeth in which the sealant remained intact. Bjorndal and colleagues,18 performing stepwise excavation, cultured bacteria from the dentin of 19 teeth after the initial procedure and after intervals of six to 12 months; at the latter point, they observed that CFUs had been reduced substantially.

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Two randomized controlled trials comparing stepwise and complete excavation, while only tangentially relevant to the partial caries removal technique, nevertheless are important for results relevant to the risk of pulpal complications after complete removal of deep caries. Magnusson and Sundell19 reported postprocedural pulpal complications in eight (15 percent) of 55 teeth treated by stepwise excavation and in 29 (53 percent) of 55 teeth treated by direct excavation. Leksell and colleagues20 similarly reported pulpal exposure in 10 (17.5 percent) of 57 teeth treated in stepwise fashion compared with 28 (40.0 percent) of 70 teeth treated by direct excavation. A 2002 study comparing the efficacy of two materials used in conjunction with indirect pulp capping in 48 primary molars reported a success rate, as measured by absence of irreversible pulp pathology, of 96 percent for teeth treated with a proprietary adhesive resin system at two years after treatment.21 Al-Zayer and colleagues22 retrospectively analyzed 187 primary posterior teeth (132 patients) treated with indirect pulp capping in which sufficient carious dentin was left to preclude pulpal exposure. The authors then followed up patients clinically and radiographically for periods ranging from two weeks to 73 months after treatment. Of the 187 teeth in the study, nine (4.8 percent) experienced complications, amounting to a 95 percent success rate. Kreulen and colleagues,23 using a split-mouth model, sampled carious dentin from molars before restoring the teeth using either a biologically active (that is, antimicrobial) resin-modified glass ionomer preparation or amalgam. They processed samples for viable bacteria and evaluated them for color and consistency. Dentin from the same sites similarly sampled and evaluated at six months after treatment in 39 patients from both groups exhibited a significant decrease in the mean number of bacteria and a significant overall treatment effect for color and consistency. In a microbiological study of dentin samples taken from 40 carious lesions before and after undergoing ART, Bonecker and colleagues24 found significant reductions in the frequency and proportions of total viable cells as well as of mutans streptococci (but not lactobacilli) in restorations sealed with a GIC. Vij and colleagues25 conducted a retrospective analysis of two approaches to treating carious lesions approaching the pulp in 226 primary

molars (141 patients), including 133 teeth from a previous study26 that used similar criteria for the same treatments. The investigators treated all teeth in two stages (not to be confused with stepwise excavation). First, they removed superficial carious tissue and temporarily filled the cavity with either zinc oxideeugenol or GIC. Then, at a second appointment one to three months later, they either removed the remaining carious tissue completely and performed a pulpotomy followed by treatment with formocreosol or removed all but the deepest layer of remaining carious dentin and performed indirect pulp capping by using one of two GIC preparations. At three years after treatment, the success rateas measured by the absence of swelling, abnormal mobility, pain and radiographic signs of pathologywas 94 percent for teeth treated by means of partial caries removal and indirect pulp capping and 70 percent for the group treated by means of formocreosol pulpotomy. While this study cannot serve to measure the relative merits of partial caries and complete caries removal per se, it demonstrates the relative superiority of partial caries removal to a technique (formocreosol pulpotomy) that some consider a viable alternative.
DISCUSSION

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Is it necessary to remove all carious tissue from lesions approaching the pulp? Although there is substantial evidence to the contrary, most practitioners continue to follow the basic principle guiding any surgeon: that one must eradicate any and all affected tissue from the site of an infection. It is not clear, however, whether this principle is, or ought to be, followed at all times. In conventional endodontic therapy, for example, which has a high rate of clinical success, it is likely that viable bacteria and necrotic host tissue typically remain in the root canal system after instrumentation and obturation.27 The conventional treatment paradigm has a long history. G.V. Black, in his classic 1908 text, asserted that it is better to expose the pulp of a tooth than to leave it covered only with softened dentine.28 More recently, the majority of respondents to a survey on this subject indicated that they would remove all carious tissue even if the procedure, in their judgment, would risk pulpal exposure; only about one in five respondents said they would choose to proceed with partial caries removal, and a slightly higher proportion indicated that they would initiate or refer the patient
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for endodontic treatment.29 In another recent survey, conducted in 2006, the majority of respondents opted for pulpotomy as the treatment of choice in a similar scenario. 30 Ironically, G.V. Black also stated that it is imperative that dentists understand the pathology of the caries process lest they be reduced to the role of mechanics.31 It is interesting to speculate, given our ability to create a restoration with well-sealed margins and associated grooves and fissures, what Black would say about the subject of partial caries removal today. Several of the studies cited above (such as those by Handelman and colleagues,13 Kreulen and colleagues,23 Maltz and colleagues7-9 and Bonecker and colleagues24) have demonstrated that bacterial counts under sealed restorations become drastically reduced. In their 2002 study, Maltz and colleagues,7 citing significant decreases in counts of both aerobic and anaerobic viable bacteria and radiographic evidence of a mineral gain in affected areas, concluded that complete dentinal caries lesion removal is not essential to the control of caries lesionsa conclusion that was repeated in two follow-up studies.8,9 Kidd,32 who cited most of these same sources and several others, including studies of stepwise excavation and partial caries removal, concluded that there is no clear evidence that it is deleterious to leave infected dentine. Some of the best evidence for the rationale underlying partial caries removal can be found in studies of a related technique, the stepwise excavation approach. The literature regarding stepwise excavation18-20,33,34 has reported consistently that residual carious dentin recedes and hardens under temporary restorations in the interim between the initial excavation and reentry. But as Kidd32 stated, Why re-enter? In other words, if the goal is to avoid pulpal exposure and residual carious dentin poses no threat to the dentition, why subject the patient to a second excavation? Assuming it is preferable to leave caries in deep restorations, must the practitioner alter his or her restorative technique? The previously cited survey of dentists conducted by the Practitioners Engaged in Applied Research and Learning (PEARL), a practice-based research network at the New York University College of Dentistry sponsored by the National Institutes of Health,29 may hold an answer to that. The surveys respondents, who represented a wide range of
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approaches to restoration, stated that they expected that roughly the same percentage of their patients would require endodontic treatment three to five years after treatment regardless of whether the respondent favored complete or partial caries removal in deep lesions and regardless of the respondents restoration technique. Evidence from the literature also suggests that a change of approach is unnecessary. Even before the advent of dentin bonding, the efficacy of bonding to enamel alone was demonstrated in a 17-year recall study of a large-particle ultraviolet lightcured resin-based composite in Class I and Class II restorations.35 Moreover, Mertz-Fairhurst and colleagues4 demonstrated that bonding to enamel alone (with carious dentin remaining) was sufficient at 10 years. Dentin bonding adds to our ability to seal restorations, but its long-term efficacy is still in question.36 Partial removal of caries from deep lesions usually involves complete removal of carious tissue from cavity walls but limited removal from the pulpal floor and axial wall, which are sites of reduced bond strength. Resin-based composite restoration polymerization shrinkage can result in retraction of the bonding agent from the pulpal floor or axial wall of sound dentin.37,38 The resulting gap can fill with fluid, and with tooth deformation, the fluid is forced down open dentinal tubules, causing postoperative occlusal loading sensitivity. While clinicians may find pulpal floor gaps more often when deep caries remains because of composites inability to bond completely to caries-infected and caries-affected dentin,39-42 the chance of postoperative hypersensitivity might be reduced because the pulp is protected from fluid flow in the tubules by the lowpermeability zone in deep infected dentin.43,44 On the basis of these findings, one might suggest that infected dentin be removed completely from preparation walls but selectively from the pulpal floor or axial wall. Finally, it is worthwhile to consider the recent meta-analysis1 that pooled the results of four of the randomized controlled trials discussed earlier: those by the Mertz-Fairhurst,2 Ribeiro,5 Magnusson19 and Leksell20 research groups. The review is entitled Complete or Ultraconservative Removal of Decayed Tissue in Unfilled Teeth, and while one can argue that ultraconservative does not apply to the focus of the studies by Magnusson and colleagues19 and Leksell and colleagues20 (stepwise excavation), the authors nev-

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ertheless came to the conclusiontempered by their observation that the number of these trials is smallthat partial caries removal is preferable to complete caries removal in the deep lesion, in order to reduce the risk of carious exposure [of the pulp].1 Apparently, dentists need more evidence before they will accept this determinationdespite the fact that (to our knowledge) no study has been initiated to prove the desirability of removing all infected dentin. An observational study under way within the PEARL practice-based research network will attempt to fill in some of the gaps in our understanding of deep caries treatment and may provide the basis for a clinical trial.
CONCLUSION

On the basis of the studies cited in this review, one can state that there is substantial evidence that the removal of all infected dentin in deep carious lesions is not required for successful caries treatmentprovided that the restoration can seal the lesion from the oral environment effectively. However, before this concept is accepted generally by the dental profession, additional clinical trials may be needed.
Disclosures. None of the authors reported any disclosures. The authors acknowledge the support of the National Institute of Dental and Craniofacial Research, National Institutes of Health, through grant U-01-DE016755-01 awarded to the New York University College of Dentistry, New York City. 1. Ricketts DN, Kidd EA, Innes N, Clarkson J. Complete or ultraconservative removal of decayed tissue in unfilled teeth. Cochrane Database Syst Rev 2006;3:CD003808. 2. Mertz-Fairhurst EJ, Call-Smith KM, Shuster GS, et al. Clinical performance of sealed composite restorations placed over caries compared with sealed and unsealed amagam restorations. JADA 1987;115(5):689-694. 3. Mertz-Fairhurst EJ, Richards EE, Williams JE, Smith CD, Mackert JR Jr, Schuster GS, et al. Sealed restorations: 5-year results. Am J Dent 1992;5(1):5-10. 4. Mertz-Fairhurst EJ, Curtis JW Jr, Ergle JW, Rueggeberg FA, Adair SM. Ultraconservative and cariostatic sealed restorations: results at year 10. JADA 1998;129(1):55-66. 5. Ribeiro CC, Baratieri LN, Perdigao J, Baratieri NM, Ritter AV. A clinical, radiographic, and scanning electron microscopic evaluation of adhesive restorations on carious dentin in primary teeth. Quintessence Int 1999;30(9):591-599. 6. Foley J, Evans D, Blackwell A. Partial caries removal and cariostatic materials in carious primary molar teeth: a randomised controlled clinical trial. Br Dent J 2004;197(11):697-701; discussion 689. 7. Maltz M, de Oliveira EF, Fontanella V, Bianchi R. A clinical, microbiologic, and radiographic study of deep caries lesions after incomplete caries removal. Quintessence Int 2002;33(2):151-159. 8. Oliveira EF, Carminatti G, Fontanella V, Maltz M. The monitoring of deep caries lesions after incomplete dentine caries removal: results after 14-18 months. Clin Oral Investig 2006;10(2):134-139. 9. Maltz M, Oliveira EF, Fontanella V, Carminatti G. Deep caries lesions after incomplete dentine caries removal: 40-month follow-up study. Caries Res 2007;41(6):493-496. 10. Fairbourn DR, Charbeneau GT, Loesche WJ. Effect of improved Dycal and IRM on bacteria in deep carious lesions. JADA 1980;100(4):547-552.

11. Marchi JJ, de Araujo FB, Froner AM, Straffon LH, Nor JE. Indirect pulp capping in the primary dentition: a 4 year follow-up study. J Clin Pediatr Dent 2006;31(2):68-71. 12. Ryge G, Snyder M. Evaluating the clinical quality of restorations. JADA 1973;87(2):369-377. 13. Handelman SL, Washburn F, Wopperer P. Two-year report of sealant effect on bacteria in dental caries. JADA 1976;93(5):967-970. 14. Handelman SL, Leverett DH, Solomon ES, Brenner CM. Use of adhesive sealants over occlusal carious lesions: radiographic evaluation. Community Dent Oral Epidemiol 1981;9(6):256-259. 15. Leverett DH, Handelman SL, Brenner CM, Iker HP. Use of sealants in the prevention and early treatment of carious lesions: cost analysis. JADA 1983;106(1):39-42. 16. Handelman SL, Leverett DH, Espeland M, Curzon J. Retention of sealants over carious and sound tooth surfaces. Community Dent Oral Epidemiol 1987;15(1):1-5. 17. Handelman S. Therapeutic use of sealants for incipient or early carious lesions in children and young adults. Proc Finn Dent Soc 1991;87(4):463-475. 18. Bjorndal L, Larsen T, Thylstrup A. A clinical and microbiological study of deep carious lesions during stepwise excavation using long treatment intervals. Caries Res 1997;31(6):411-417. 19. Magnusson BO, Sundell SO. Stepwise excavation of deep carious lesions in primary molars. J Int Assoc Dent Child 1977;8(2):36-40. 20. Leksell E, Ridell K, Cvek M, Mejare I. Pulp exposure after stepwise versus direct complete excavation of deep carious lesions in young posterior permanent teeth. Endod Dent Traumatol 1996;12(4):192-196. 21. Falster CA, Araujo FB, Straffon LH, Nor JE. Indirect pulp treatment: in vivo outcomes of an adhesive resin system vs. calcium hydroxide for protection of the dentin-pulp complex. Pediatr Dent 2002;24(3):241-248. 22. Al-Zayer MA, Straffon LH, Feigal RJ, Welch KB. Indirect pulp treatment of primary posterior teeth: a retrospective study. Pediatr Dent 2003;25(1):29-36. 23. Kreulen CM, de Soet JJ, Weerheijm KL, van Amerongen WE. In vivo cariostatic effect of resin modified glass ionomer cement and amalgam on dentine. Caries Res 1997;31(5):384-389. 24. Bonecker M, Toi C, Cleaton-Jones P. Mutans streptococci and lactobacilli in carious dentine before and after Atraumatic Restorative Treatment. J Dent 2003;31(6):423-428. 25. Vij R, Coll JA, Shelton P, Farooq NS. Caries control and other variables associated with success of primary molar vital pulp therapy. Pediatr Dent 2004;26(3):214-220. 26. Farooq NS, Coll JA, Kuwabara A, Shelton P. Success rates of formocresol pulpotomy and indirect pulp therapy in the treatment of deep dentinal caries in primary teeth. Pediatr Dent 2000;22(4):278-286. 27. Oguntebi BR. Dentine tubule infection and endodontic therapy implications. Int Endod J 1994;27(4):218-222. 28. Black GV. A Work on Operative Dentistry. Volume 2: The Technical Procedures in Filling Teeth. Chicago: Medico-Dental Publishing Company; 1908. 29. Oen KT, Thompson VP, Vena D, Caufield PW, Curro F, Dasanayake A, et al. Attitudes and expectations of treating deep caries: a PEARL Network survey. Gen Dent 2007;55(3):197-203. 30. Qudeimat MA, Al-Saiegh FA, Al-Omari Q, Omar R. Restorative treatment decisions for deep proximal carious lesions in primary molars. Eur Arch Paediatr Dent 2007;8(1):37-42. 31. Black GV. A Work on Operative Dentistry. Volume 1: The Pathology of the Hard Tissues of the Teeth. Chicago: Medico-Dental Publishing Company; 1908. 32. Kidd EA. How clean must a cavity be before restoration? Caries Res 2004;38(3):305-313. 33. Bjorndal L, Thylstrup A. A practice-based study on stepwise excavation of deep carious lesions in permanent teeth: a 1-year follow-up study. Community Dent Oral Epidemiol 1998;26(2):122-128. 34. Bjorndal L, Larsen T. Changes in the cultivable flora in deep carious lesions following a stepwise excavation procedure. Caries Res 2000;34(6):502-508. 35. Wilder AD Jr, May KN Jr, Bayne SC, Taylor DF, Leinfelder KF. Seventeen-year clinical study of ultraviolet-cured posterior composite Class I and II restorations. J Esthet Dent 1999;11(3):135-142. 36. De Munck J, Van Landuyt K, Peumans M, et al. A critical review of the durability of adhesion to tooth tissue: methods and results. J Dent Res 2005;84(2):118-132. 37. Cho BH, Dickens SH, Bae JH, Chang CG, Son HH, Um CM. Effect of interfacial bond quality on the direction of polymerization shrinkage flow in resin composite restorations. Oper Dent 2002;27(3):297-304. 38. Lopes GC, Baratieri LN, Monteiro S Jr, Vieira LC. Effect of pos-

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terior resin composite placement technique on the resin-dentin interface formed in vivo. Quintessence Int 2004;35(2):156-161. 39. Doi J, Itota T, Yoshiyama M, Tay FR, Pashley DH. Bonding to root caries by a self-etching adhesive system containing MDPB. Am J Dent 2004;17(2):89-93. 40. Palma-Dibb RG, de Castro CG, Ramos RP, Chimello DT, Chinelatti MA. Bond strength of glass-ionomer cements to cariesaffected dentin. J Adhes Dent 2003;5(1):57-62. 41. Yoshiyama M, Tay FR, Doi J, et al. Bonding of self-etch and total-

etch adhesives to carious dentin. J Dent Res 2002;81(8):556-560. 42. Yoshiyama M, Tay FR, Torii Y, et al. Resin adhesion to carious dentin. Am J Dent 2003;16(1):47-52. 43. Allen KL, Salgado TL, Janal MN, Thompson VP. Removing carious dentin using a polymer instrument without anesthesia versus a carbide bur with anesthesia. JADA 2005;136(5):643-651. 44. Pashley EL, Talman R, Horner JA, Pashley DH. Permeability of normal versus carious dentin. Endod Dent Traumatol 1991; 7(5):207-211.

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SUMMARY REVIEW/RESTORATIVE DENTISTRY

3A| 2C| 2B| 2A| 1B| 1A|

Deep or partial caries removal: which is best?

In deep carious lesions, should all infected and affected dentine be removed prior to restoration?

Thompson V, Craig RG, Curro FA, Green WS, Ship JA. Treatment of deep carious lesions by complete excavation or partial removal. A critical review. J Am Dent Assoc 2008; 139:705712 Data sources Searches for studies were made using the databases: Medline, Evidence-based Medicine Reviews, Cochrane Database of Systematic Reviews, Cochrane Central Register of Controlled Trials and OVIDs Database of Abstracts of Reviews of Effects. Study selection Only studies reported in English with human participants were included. Randomised controlled trials (RCT) and relevant observational studies were included. No other inclusion or exclusion criteria are described. Data extraction and synthesis A formal data extraction process is not described and a qualitative description of the included studies is provided. Results Ten articles reporting six studies were included. The results of three RCT, one with a followup period of 10 years, provide evidence supporting the practice of leaving behind infected dentine, the removal of which would risk pulp exposure. A number of other studies show that cariogenic bacteria, once isolated from their source of nutrition by a restoration of sufficient integrity, either remain dormant or die and thus pose no risk to the health of the dentition. Conclusions There is substantial evidence that, for caries management, it is not necessary to remove all vestiges of infected dentin from lesions approaching the pulp.

Address for correspondence: Dr R Craig, Department of Basic Sciences and Craniofacial Biology, New York University College of Dentistry, 345 East 24th Street/ 1001S, New York NY 10010-4086, USA. E-mail: rgc1@nyu.edu

Commentary Since the days of GV Black, complete caries removal has been regarded as the gold standard in cavity preparation and, despite the lack of evidence to support this approach, it remains common practice today. In deep cavities, the carious process itself and the trauma of such radical caries removal can cause detrimental inflammatory changes within the pulp. If such caries removal leads to exposure of a vital pulp, a direct pulp cap, commonly using calcium hydroxide, is considered. Although most research on the direct pulp cap has focussed on the favourable outcome for traumatically exposed pulps which are healthy prior to the injurious incident, the prognosis following a carious exposure is not good: 5- and 10-year success rates of 37% and 13% respectively have been reported.1 This critical review is therefore appropriate, with its systematic search of the literature for evidence that might elucidate whether complete caries removal and its concomitant complications is necessary. Carefully designed prospective RCT provide the strongest evidence for any intervention. Such trials were the focus of our 2006 Cochrane review2 comparing complete or ultraconservative caries removal. The authors of this paper are correct, however, to draw attention to the fact that studies of a different design can also add to our understanding and can often provide compelling evidence for an intervention. Not including such studies may be regarded by some as throwing the baby out with the bathwater. The aim here was therefore to extend the search and look for additional studies comparing complete or partial caries removal. In addition to two RCT included in the Cochrane review, four further studies were found, specifically three observational studies and one more RCT. The main aim of the additional RCT was to investigate the cariostatic effect of black copper cement when partial caries removal was carried out in primary teeth. In the partial caries removal group, the durability of glass ionomer restorations lined with black copper cement was poor, but glass ionomer restorations alone performed as well following partial caries removal as they did following complete caries removal. Of the three observational studies included here, two were stepwise excavation in all but name.3,4 Although other similar clinical studies on stepwise excavation were not included in the main results of this paper, they were mentioned in the text (those cited in the Cochrane review1 and the review by Bjrndal and Larsen, 2005). Three of these studies showed that caries that is left and sealed into the tooth after partial caries removal appears to arrest, so that when the cavities are re-entered the number of viable organisms within the lesions is significantly reduced.35 The final study included looked at the success of indirect pulp caps in primary molar teeth using either a calcium hydroxide lining material or resin-modified glass ionomer. The success rates presented at 4 years were 89% and 93%, respectively.

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Although partial caries removal may sit uncomfortably with some dentists, the authors of this paper also describe a series of studies in which occlusal caries is arrested by simply fissure-sealing the lesions with no caries removal at all. Other studies are described that add further weight to the partial caries removal argument. These all show that by depriving the organisms within lesions of the intra-oral substrate they require to survive, both the number and diversity of organisms decline, with only those able to metabolise pulpal serum proteins surviving.6 These organisms are not associated with active carious lesions, and even pulpal nutrients will decline with time because of pulp-dentine complex reactions of tubular sclerosis and reactionary dentine formation. Unfortunately, it is not clear from this review, or the original papers, what constitutes deep caries or partial caries removal. Some authors have described lesions reaching up to halfway to the pulp, determined on a radiograph, whereas others have given little specific information other than saying the lesion is deep, or adding that the extent means pulpal exposure is likely if caries is completely removed. Similarly, partial caries removal varies from simply bevelling enamel at the entrance to the fissure to carrying out only peripheral caries removal and leaving soft infected carious dentine pulpally; to removal of caries until firm, stained dentine is reached and then placement of an indirect pulp cap. The studies cited are therefore heterogeneous, but the evidence stemming from them all is that removal of all carious tissue is not necessary. In light of the substantial evidence cited to support partial caries removal, the authors of this paper point out that there

have, as yet been no studies to prove the desirability of removing all infected dentine. They conclude that, before this concept (of partial removal) is generally accepted by the profession additional clinical trials may be needed. This, I am sure, is true. These trials should be carried out in primary care with detailed, specific information on lesion extent and what constitutes partial caries removal. The success of such interventions also needs to be assessed along with research into techniques for monitoring sealed caries. David Ricketts Department of Restorative Dental Care and Clinical Dental Sciences, University of Dundee Dental School, Dundee, Scotland, UK
1. Barthel CR, Rosenkranz B, Leuenberg A, Roulet JF. Pulp capping of carious exposures: treatment outcome after 5 and 10 years: a retrospective study. J Endod 2000; 26:525528. 2. Ricketts DN, Kidd EA, Innes N, Clarkson J. Complete or ultraconservative removal of decayed tissue in unfilled teeth. Cochrane Database Syst Rev 2006; issue 3. 3. Maltz M, de Oliveira EF, Fontanella V, Bianchi R. A clinical, microbiologic, and radiographic study of deep caries lesions after incomplete caries removal. Quintessence Int 2002; 33:151159. 4. Fairbourn DR, Charbeneau GT, Loesche WJ. Effect of improved Dycal and IRM on bacteria in deep carious lesions. J Am Dent Assoc 1980; 100:547552. 5. Bjrndal L, Larsen T. Changes in the cultivable flora in deep carious lesions following a stepwise excavation procedure. Caries Res 2000; 34:502508. 6. Paddick JS, Brailsford SR, Kidd EA, Beighton D. Phenotypic and genotypic selection of microbiota surviving under dental restorations. Appl Environ Microbiol 2005; 71:24672472.

Evidence-Based Dentistry (2008) 9, 71-72. doi:10.1038/sj.ebd.6400592

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