There has been a lot of interest in how to best manage deep carious lesions to maintain pulp vitality. Different approaches have included the partial removal of caries only, stepwise removal and full removal. In the stepwise approach, caries is partially removed and the remainder sealed in for a period of 1-6 months. The lesion is supposed to become inactive in this time and tertiary dentine laid down allowing removal of the remaining caries in due course.

This multi-centre randomised controlled trial sought to compare the effectiveness of this approach with simple partial caries removal and permanent restoration (i.e. there would be no re-entry). Patients were eligible for the trial if:

• they were older than 6 years
• had molar with a carious lesion >1/2 into dentine and that, in the judgement of the treating dentist, could result in pulpal exposure if completely removed.

Initial caries removal was the same for each group and randomisation to partial or stepwise groups was made once this was completed. The partial caries group had GIC placed before amalgam or composite. The stepwise group received a calcium hydroxide liner before a modified zinc-oxide eugenol restoration was placed. This was removed at a median of 90 days later, all soft caries removed and then restored as per the partial caries removal group.

• 146 stepwise and 153 partial removal treatments were completed in 233 patients.
• Of the approximately 70% of teeth evaluated at 18 months 99% of the partial and 86% of the stepwise treatments were successful (p = 0.016).
• The time taken to complete the treatments was significantly different with stepwise taking 78 minutes on average and partial removal 48 minutes.

The authors concluded:

The retention of carious dentine does not adversely affect pulp vitality.

Comment

This appears to be a well conducted pragmatic trial. The recent Cochrane review by Ricketts et al on deep caries management found moderate quality (GRADE criteria) evidence to suggest that partial caries removal had a relative risk of pulpal exposure of 0.23 compared to full caries removal but low or very low quality evidence regarding signs and symptoms of pulpal disease 1 year later and difference in the failure of the restoration. The review did not report on any studies comparing partial to stepwise caries removal.

Links

Maltz M, Jardim JJ, Mestrinho HD, Yamaguti PM, Podesta K, Moura MS, et al. Partial removal of carious dentine: a multicenter randomized controlled trial and 18-month follow-up results. Caries Res. 2013;47(2):103-9. PubMed PMID: 23207420.

Ricketts D, Lamont T, Innes NP, Kidd E, Clarkson JE. Operative caries management in adults and children. Cochrane Database Syst Rev. 2013;3:CD003808. PubMed PMID: 23543523.