Caries is the world’s most prevalent disease with carious lesions ranging from early loss of enamel mineral through non-cavitated dentine lesions to extensive loss of tooth tissue and obvious cavities. Traditional management involves the removal of all demineralised tissues and bacterially contaminated tissues and replacement with various filling materials. However, a number of alternative approaches are available including selective carious tissue removal (or selective excavation (SE)), stepwise carious tissue removal (SW), sealing carious lesions using sealant materials, sealing using preformed metal crowns (Hall Technique, HT), and non-restorative cavity control (NRCC).

The aim of this Cochrane review was to compare interventions to treat carious lesions conventionally considered to require restorations in primary or permanent teeth with vital pulps.

Methods

Searches were conducted in the Cochrane Oral Health’s Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, US National Institutes of Health Ongoing Trials Register ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry databases. Randomised controlled trials (RCTs) including split-mouth studies were considered. The primary outcome was failure, a composite measure of pulp exposure, endodontic therapy, tooth extraction, and restorative complications (including resealing of sealed lesions). Two reviewers independently selected studies, extracted data, and assessed the risk of bias with the GRADE criteria being used to assess the overall certainty of the evidence.

Results

• 27 RCTs (24 parallel, 3 split-mouth) involving 3350 patients and 4195 teeth/lesions were included.
• All the studies were considered to be at a high risk of bias.
• The studies were conducted in 11 countries and published between 1977 and 2020.
• 10 studies evaluated permanent teeth, 16 primary teeth and one both dentitions.
• 17 studies compared conventional treatment (CR) with a less invasive treatment: SE (8), SW (4), two HT (2), sealing with sealant materials (4) and NRCC (1). Other comparisons were; SE versus HT (2); SE versus SW (4); SE versus sealing with sealant materials (2); sealant materials versus no sealing (2).

Sealants versus other interventions for non-cavitated or cavitated but not deep lesions

• There was insufficient evidence of a difference between
  • Sealing with sealants and CR. OR = 5.00 (95%CI; 0.51 to 49.27).
  • Sealing versus SE. OR = 3.11 (95%CI; 0.11 to 85.52).
  • Sealing versus no treatment. OR = 0.05 (95%CI; 0.00 to 2.71).
  • All very low-certainty evidence.

HT, CR, SE, NRCC for cavitated, but not deep lesions in primary teeth

• The odds of failure may be
  • higher for CR than HT. OR = 8.35 (95%CI; 3.73 to 18.68) [low-certainty evidence] and
  • lower for HT than NRCC. OR = 0.19 (95%CI; 0.05 to 0.74) [very low-certainty evidence].
• There was insufficient evidence of a difference between
  • SE versus HT. OR = 8.94(95%CI; 0.57 to 139.67) or
  • CR versus NRCC. OR = 1.16 (95%CI; 0.50 to 2.71)
  • both very low-certainty evidence.

CR, SE, SW for deep lesions

• The odds of failure were higher for CR than SW in
  • permanent teeth, OR =2.06 (95%CI; 1.34 to 3.17) [moderate-certainty evidence],
  • but not primary teeth, OR = 2.43 (95%CI; 0.65 to 9.12) [very low-certainty evidence].
• The odds of failure may be higher for CR than SE in
  • permanent teeth, OR = 11.32(95%CI; 1.97 to 65.02) [very low-certainty evidence],
  • and primary teeth, OR = 4.43(95%CI; 1.04 to 18.77) [very low-certainty evidence].
• 2 studies compared CR versus SE in cavitated, but not deep lesions, with insufficient evidence of a difference in outcome, OR = 0.62(95%CI; 0.21 to 1.88) [very low- certainty evidence].
• The odds of failure were higher for SW than SE in
  • permanent teeth, OR = 2.25 (95%CI; 1.33 to 3.82) [moderate-certainty evidence],
  • but not primary teeth, OR = 2.05 (95%CI; 0.49 to 8.62) [ very low-certainty evidence].
• For deep lesions, a network meta-analysis showed the probability of failure to be greatest for CR compared with SE, SW and HT.

Conclusions

The authors concluded: –

Compared with conventional treatment, there were lower numbers of failures with HT and SE in the primary dentition, and with SE and SW in the permanent dentition. Most studies showed high risk of bias and limited precision of estimates due to small sample size and typically limited numbers of failures, resulting in assessments of low or very low certainty of evidence for most comparisons.

Comments

This new Cochrane review provides a broader review of treatments for cavitated or dentine carious lesions superseding an earlier more focused review by Rickett’s et al published in 2013 (Dental Elf – 11^th Apr 2013. The treatments included conventional restoration (CR) selective carious tissue removal /excavation (SE), stepwise carious tissue removal (SW), sealing carious lesions using sealant materials, sealing using preformed metal crowns (Hall Technique, HT) and non-restorative cavity control (NRCC).   All the studies included in the review were considered to be at high risk of bias was mainly due to allocation concealment and lack of blinding, with the blinding of operators and sometimes patients difficult for many of the comparisons.  The reviewers also highlighted their use of a composite measure for failure, a departure from their protocol which had planned to consider major and minor failure which may have difference impacts for patients. Most of the included studies has short follow up periods with only 4 studies presenting data for 3 years or more. While the review suggests some promise for more conservative approaches to the management of cavitated or dentine carious lesions the quality of the available evidence is only low to very low and only a small number of studies were conducted in the primary care setting. Aa the majority of caries lesion management takes place in primary care more studies should be conducted there preferably using a common outcome set and consider patient relevant outcomes as well as effectiveness and cost-effectiveness.

Links

Primary Paper

Schwendicke F, Walsh T, Lamont T, Al-yaseen W, Bjørndal L, Clarkson JE, Fontana M, Gomez Rossi J, Göstemeyer G, Levey C, Müller A, Ricketts D, Robertson M, Santamaria RM, Innes NPT. Interventions for treating cavitated or dentine carious lesions. Cochrane Database of Systematic Reviews 2021, Issue 7. Art. No.: CD013039.

DOI: 10.1002/14651858.CD013039.pub2 .

 Other references

Cochrane Oral Health Blog – Comparing treatments for advanced tooth decay

 Dental Elf – 11^th Apr 2013

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

Dental Elf – 20^th Apr 2020

FiCTION Trial: the cost effectiveness of dental caries management in primary teeth

Picture Credits

KDS4444 – This file was derived from: Blausen 0864 ToothDecay.png Own work