Beruflich Dokumente
Kultur Dokumente
Key Words
Caries removal Clinical trial Dentine caries Permanent
teeth Restorations Restorative materials
Abstract
Aim: The aim of this study was to evaluate the effectiveness
of partial removal of carious dentine and restoration in a single session (PDR) and stepwise excavation (SW), both of
which are treatments for deep carious lesions, in Public
Health Services in Brazil. Methods: Inclusion criteria: patients
66 years old, permanent molars with deep caries lesions
(having a radiolucency halfway or more into dentine) and
pulp vitality but absence of spontaneous pain, positive percussion test, and periapical alterations. The subjects received
either PDR (test group) or SW (control group). The radiological and clinical exams were performed after a mean time of
18 months. Outcomes: success was defined as pulp sensitivity to cold test and absence of periapical alterations. Results:
Of the 299 treatments performed, 146 were SW and 153 were
PDR; 122 were amalgam restorations and 168 resin-composite restorations. There were no differences between the
groups regarding the baseline characteristics (i.e. age, gender and family income). After 18 months, 212 evaluations
The management of deep caries lesions has been discussed extensively in the literature [Magnusson and Sundell, 1977; Leksell et al., 1996; Bjrndal et al., 1997;
Bjrndal and Thylstrup, 1998; Weerheijm et al., 1999;
Maltz et al., 2002; Massara et al., 2002; Paddick et al.,
2005; Pinto et al., 2006; Ricketts et al., 2006]. These papers cover different topics, including the appropriate instruments for removing carious tissues, the amount of
decayed tissue that needs to be removed [Bjrndal and
Thylstrup, 1998], and the interaction between pulp and
dentine [Massara et al., 2002; McLachlan et al., 2003; Lee
et al., 2006].
Marisa Maltz
Faculdade de Odontologia UFRGS, Departamento de Odontologia Preventiva e Social
Ramiro Barcelos, 2492, Bom Fim
CEP 90035-003 Porto Alegre (Brazil)
E-Mail marisa.maltz@gmail.com
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In order to preserve dental structures as much as possible and avoid irreversible damage to the pulp, some conservative techniques concerning carious dentine removal
have been proposed [Magnusson and Sundell, 1977;
Bjrndal et al., 1997; Bjrndal and Thylstrup, 1998; Maltz
et al., 2002; Pinto et al., 2006]. Among them is the stepwise excavation technique (SW), which involves the partial removal of the decayed tissue leaving some caries at
the bottom of the cavity, temporary sealing for 16
months, subsequently reopening the cavity, and fully removing the carious tissue followed by restoration [Magnusson and Sundell, 1977; Bjrndal et al., 1997; Bjrndal
and Thylstrup, 1998]. During the temporary sealing, the
remaining carious dentine becomes harder and drier,
both characteristics of inactive lesions, and exhibit a low
level of bacterial infection [Bjrndal et al., 1997]. The aim
of this procedure is to allow the occurrence of physiological reactions in the pulp-dentine complex, including
dentine sclerosis and tertiary dentine formation [King et
al., 1965; Massler, 1978]; this ensures the protection of
pulp tissue during the reentry by avoiding pulp exposure.
Many studies have shown that this treatment can achieve
a high level of success [Magnusson and Sundell, 1977;
Leksell et al., 1996; Bjrndal and Thylstrup, 1998]. A recent study using SW in the permanent dentition has reported a success rate of 74.1% after 1 year of follow-up
[Bjrndal et al., 2010]. The disadvantages of SW are mainly the risk of pulp exposure during the reentering of the
cavity [Magnusson and Sundell, 1977; Leksell et al., 1996;
Bjrndal and Thylstrup, 1998; Bjrndal et al., 2010], failure of the temporary filling, and increased cost (2 sessions are needed to complete the treatment). In addition,
some patients may never return for the second appointment once their pain problem has been solved.
Furthermore, if all decayed tissue is removed in a deep
carious lesion and the pulp is exposed, a very common
treatment used is direct pulp capping. A retrospective
study evaluated the treatment outcomes of pulp-capped
teeth after 5 and 10 years and showed that 79.7% of the
teeth exhibited necrosis and required postoperative root
canal treatment or an extraction after 10 years [Barthel et
al., 2000]. Bjrndal et al. [2010] evaluated direct pulp capping performed on permanent teeth with deep carious
lesions and reported a success rate of only 31.8% after
1 year of treatment. Similar results were obtained if the
teeth were treated with partial pulpotomy (34.5% success
rate).
In order to avoid these problems, it is proposed that the
definitive restoration should be placed during the same
session in which the partial caries removal is performed
Selection
Analysis
Outcome Follow-up
Randomization
Excluded
There was no exclusion after
clinical and radiographic
selection
Randomized
(n = 299)
Test (PDR)
(n = 153)
Control (SW)
(n = 146)
Outcome
Pulp sensitivity
Outcome
Pulp sensitivity
Analyzed PDR
(n = 112)
Analyzed SW
(n = 101)
Sample
The sample size calculation was based on a difference in the
percentage of success of SW and partial removal of caries after
a 5-year follow-up period of 60.9% [Parolo et al., 2007] versus
82% [Maltz et al., 2007] at = 5% with a power of 90%. This in-
Exclusion Criteria
Subjects with general diseases affecting their caries experience
Cusp loss
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Study Design
This is a multicenter randomized controlled clinical trial (registration No. NCT00887952. www.clinicaltrials.gov). Details of
the study design can be seen in figure 1.
The clinical treatments were carried out by 22 dentists and
supervised by the main researchers (M.M., L.M.P., H.D.M., and
J.J.J.) over 2 years. The centers involved were located in Brasilia
(Federal District, FD) in the eastern-central part of Brazil and
Porto Alegre (Rio Grande do Sul, RS) in the south. The RS center
was mainly responsible for the research. In the FD center, both
sample selection and treatments were performed by 10 dentists
from the Brasilia University Hospital. In the RS center, the sample
selection and treatments were performed by 5 dentists from the
Federal Health Service, 4 dentists from the Municipal Health Service, and 3 dentists (2 postgraduate students and 1 clinician) from
the Federal University of Rio Grande do Sul. All dentists were updated and trained before the beginning of the clinical procedures
by 2 main researchers (M.M. and L.M.P.).
The materials used to perform the treatments as well as the
clinical files were supplied by the RS center to all treatment centers, ensuring standardization.
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Results
Study Groups
The subjects were randomly assigned to test or control groups,
which received PDR or SW, respectively. Each of these groups was
further divided according to the filling material: amalgam or resin composite.
ments
Treatments
Time, min
SW (n = 146)
PDR (n = 153)
78.3821.3
47.8815.4
146
16.687.5
56
90
PDR
153
16.387.2
54
99
600.00
(380.00, 800.00)
600.00
(380.00, 960.00)
PDR
SW
Total
Success
Failure
Total
Lost to
follow-up
111 (99)
87 (86)
194 (91)
1 (1)
14 (14)
19 (9)
112
101
213
41
45
86
p value
0.016*
Treatment (PDR-SW)
Filling material (AM-RC)
Age
Gender
Number of surfaces
Size of cavity
Family income
0.000
0.423
0.589
0.887
0.092
0.120
0.991
95% CI
lower
upper
0.010
0.503
0.900
0.294
0.833
0.116
1.000
0.268
5.142
1.062
2.887
11.480
1.280
1.000
group, there were 14 failures: 8 pulpitis; 1 osteitis; 4 necrosis; 1 endodontic treatment. No differences were observed between followed and nonfollowed cases regarding age, number of surfaces included in the restoration,
treatment and income (p 1 0.05). The main reason for the
loss to follow-up was loss of contact.
During the treatment of SW cases, 4 cases of pulp exposure were observed. One pulp exposure occurred at
the first appointment of the SW and the other 3 occurred
at the second appointment. Three cases were treated
with direct pulp capping and 1 case received endodontic
treatment right after the pulp exposure. After 18 months,
of the 4 patients who presented pulp exposure, 2 presented irreversible pulpitis and 1 patient maintained pulp
sensitivity. No pulp exposure was observed in the PDR
group.
In the final logistic regression analysis, none of the
variables exhibited a significant causal influence on the
success rate besides the type of treatment (table3).
The time taken to perform the treatments was different between the groups. The PDR group had a faster overall treatment time since treatments took 39% less time
than the SW group (table4).
Discussion
In the present study, 2 treatments for deep carious lesions, namely, SW performed in 2 (or 3) sessions, and
PDR performed in a single session, were tested. After 18
months of follow-up, the results show that PDR was more
effective than SW in preserving pulp vitality. Moreover,
age, gender, family income, filling material, and number
of surfaces of the restoration were not correlated with
treatment success (table3).
SW was chosen to be the control treatment because of
the possibility of avoiding pulp exposure and its established high rate of success in several studies dealing with
deep caries lesions [Magnusson and Sundell, 1977; Leksell et al., 1996; Bjrndal and Thylstrup, 1998]. The alterCaries Res 2013;47:103109
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SW
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is also reported in longitudinal direct pulp capping studies [Al-Hiyasat et al., 2006; Dammaschke et al., 2010].
Bjrndal and Thylstrup [1998] report a 93.4% success
rate of SW after 1 year of follow-up (including pulp exposures at the final excavation), which is a better result than
that found in the present study (86.14% success after 18
months). However, in another study involving 1 year of
follow-up, Bjrndal et al. [2010] reported a lower success
rate of SW compared to the present study. In the present
study, most of the failures in the SW group occurred in
patients who did not return at the appropriate time to receive the second step of the treatment, leading to temporary filling failure followed by pulp injury. In the present
study, if the remaining carious dentine still exhibited active characteristics when the tooth was reopened and offered a risk of pulp exposure during the final excavation,
a new temporary filling was placed. After a 30-day period, the tooth was reopened and the final excavation was
performed. This may explain the difference between the
pulp exposure rates from the study of Bjrndal et al.
[2010] (17.5%) and the present study (2.7%).
The 95% success rate after PDR found in the present
study is concordant with the results of Oliveira et al.
[2006] who reported a success rate of 97% after 18 months
of follow-up after partial dentine removal in deep carious
lesions.
Conclusion
The retention of carious dentine does not adversely affect pulp vitality. Data from this 18-month study suggest
that the procedure of reopening the cavity to remove the
residual infected dentine is not necessary.
Acknowledgments
We thank the National Coordination of Postgraduate Education (CAPES), Brazilian Ministry of Science and Technology
through its agency, the National Council of Research (CNPq, process No. 40.3420/04-0), the Research Support Fund of Rio Grande
do Sul (FAPERGS, process No. 04/1531-8), and DFL (Rio de
Janeiro, Brazil), Ivoclar Vivadent (Schaan, Liechtenstein), SDI
(Bayswater, W.A., Australia) and Hu-Friedy (Chicago, Ill., USA).
Disclosure Statement
All authors declare that there are no conflicts of interest.
References
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