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Cariology

Juliana Mattos
Giulia Marins Soares and Apoena de Aguiar Ribeiro

Current Status of Conservative


Treatment of Deep Carious Lesions
Abstract: Traditionally, deep carious lesions are treated by removal of all carious tissue, which may lead to pulp exposure. To minimize this
risk, conservative carious tissue removal techniques have been proposed, including partial removal and stepwise excavation. However,
there is no consensus in the literature about which is the better technique. Thus, the aim of this article is to describe and discuss the main
techniques for carious tissue removal, according to scientific evidence. It was observed that both stepwise excavation and partial carious
tissue removal presented lower pulp exposure rates and higher success rates.
Clinical Relevance: Clinicians must be aware that conservative carious tissue removal techniques, such as stepwise excavation and partial
carious tissue removal, present lower pulp exposure rates and higher success rates than traditional methods.
Dent Update 2014; 41: 452456

Dental caries lesions are a localized


pathology resulting from biofilm
accumulation and its metabolism on tooth
surfaces.1 Lesions affect a large proportion of
the population, leading to severe problems
in the stomatognathic system. In the case
of deep caries lesions, complete removal
of the carious tissue close to the pulp
frequently leads to pulp exposure.2,3 In these
cases, many dentists resort to more invasive
procedures, such as direct pulp capping,
pulpotomy or pulpectomy. However, it is
known that vital pulp tissue maintains a
capacity of defence against the advance
of carious lesions. It is the best barrier that

Juliana Mattos, Student at School


of Dentistry, Giulia Marins Soares,
Student at School of Dentistry,
Fluminense Federal University and
Apoena de Aguiar Ribeiro, Pediatric
Dentistry and Cariology, Department
of Specific Qualification, School
of Dentistry, Fluminense Federal
University, Nova Friburgo, Brazil.

452 DentalUpdate

acts against bacterial invasion,4 and this


emphasizes the importance of preserving a
layer of dentine to protect the pulp.5
In order to prevent or minimize
the potential complications of complete
excavation of carious dentine close to
the pulp, many authors have studied and
proposed alternative approaches to the
treatment of deep carious lesions. Among
these alternatives, partial carious tissue
removal3,4,68 and stepwise excavation2,5,912
are the most common. However, today
there is still no scientific evidence about
which approach should be preferred in
dental practice; that is to say, it has still
not been proved whether it is necessary
or not to re-open and re-excavate teeth
submitted to partial carious tissue removal.6
Thus, the aim of this article is to present
the treatment techniques for deep carious
lesions and discuss them in the light of
evidence-based studies.

Review and discussion


The discussion about the
quantity of carious tissue to remove in
order to halt the carious process is not new.

In 1859, Tomes wrote that it is better


to retain a layer of carious dentin to
protect the pulp than to run the risk of
sacrificing the tooth. However, in 1908,
Black disagreed, saying that it is better
to expose the pulp of a tooth than leave
it covered with softened dentin.13
Thus, complete carious
tissue removal has been considered
an essential step in the treatment of
caries lesions, assuming that the success
of restorative treatment depends on
complete elimination of the bacteria.14
Direct complete excavation consists
of complete removal of the carious
tissue in only one visit. To perform this,
dentine excavators and low speed burs
are used until hardened dentine is
reached.3,6 In this procedure, the tooth
would be ready to be restored when no
soft dentine is detected after probing
the bottom of the cavity with moderate
pressure.3
However, complete carious
tissue removal in a single session
frequently leads to pulp exposure,2,9 and,
therefore, conservative approaches have
been proposed for the management
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Cariology

of deep lesions, considering that the


curative potential of the dentinopulp
complex is much greater than was
supposed in the past. Therefore, acute
caries treatment has been directed
towards deterring its progression and
promoting cure by dentinal sclerosis
and repair.15
One of the conservative
approaches for the treatment of deep
caries lesions has been stepwise
excavation. This technique is indicated
for teeth that present high risk of pulp
exposure if submitted to direct complete
excavation. To be suitable for stepwise
excavation, the tooth should not present
spontaneous or provoked pain; although
moderate pain on thermal stimulation is
accepted. In addition, the tooth should
respond positively to pulp sensitivity
tests and previous radiographic
evaluation should not show signs of
periapical pathology.10
Stepwise excavation
involves the removal of carious tissue in
stages.16 Therefore, in the first session,
the peripheral demineralized dentine
is completely removed as well as only
the superficial parts of the necrotic and
demineralized central dentine, thus
leaving the softened and wet tissue on
the pulp wall.12 After this, the base of
the cavity may be lined with calcium
hydroxide-based medication (although
this is not essential) and the tooth
is sealed with temporary restorative
material.16,17 After a treatment interval
of 22,5 to 12 months,12 the temporary
restoration and remaining carious tissue
are removed,3,5,12 so that the final cavity
is as hard as one where there was an
indirect complete excavation technique
used.2 The base of the cavity is once again
lined with calcium hydroxide (although
this is not essential) and the tooth is
restored with permanent material.3,11
Figure 1 shows a clinical case of stepwise
excavation.
The purpose of the first stepwise
excavation session is to halt the progression
of the lesion, by changing the cariogenic
environment, rather than removing the
carious dentine close to the pulp.18 After the
treatment interval, it is easier to distinguish
between hardened and softened dentine.
This facilitates final excavation and reduces
the risks of pulp exposure.2
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Figure 1. Clinical case of a second primary molar, treated with stepwise excavation technique. First
session: (a) Initial aspect of the dentine lesion. (b) The peripheral demineralized dentine was completely
removed as well as only the superficial parts of the necrotic and demineralized central dentine, thus
leaving the softened and wet tissue on the pulp wall. (c) The tooth was sealed with temporary restorative
material (glass ionomer cement). Second session: (d) After a treatment interval of 4 months, the clinical
aspect of the demineralized dentine, immediately after temporary filling removal. (e) The remaining
carious tissue was removed. (f) The tooth was restored with permanent material (composite).

One of the advantages of


stepwise excavation is the possibility
of clinically monitoring the alterations
that occur in the dentine during the
treatment interval. Various studies have
demonstrated that, after the treatment
interval, the dentine becomes dried,
hardened and darker, indicating that the
carious lesion has been arrested.3,11,12,16
Moreover, the results of microbiologic
analysis between the stages of stepwise
excavation have demonstrated that
the total colony forming unit (CFU)
counts of S. mutans and Lactobacillus
were gradually reduced during
the treatment.3,11,12 It has also been
demonstrated that the distribution of

the species found in the dentine after the


treatment interval did not characterize the
typical microbiota of deep lesions, which
confirms the clinical findings that lesions
had been arrested.11
An even more controversial
technique for the treatment of deep
caries lesions is the conservative or
ultraconservative removal of carious
tissue, sometimes called partial carious
tissue removal. This technique is based
on the concept that the carious process
is guided by caries activity in the biofilm,
therefore, this process could be halted
simply by sealing the cavity.13
The partial removal protocol
recommends that, after total elimination
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Cariology

of the superficial parts of necrotic dentine,


excavation continues until a partial
removal of demineralized central dentine
(similar to the first stage of stepwise
excavation) and then leaving a thick layer
of softened dentine on the pulp wall.3,6,16,17
After this, the carious tissue must be
completely removed only from the cavity
walls, in order to obtain adequate sealing
of the restoration. After partial excavation,
the base of the cavity may be lined with
calcium hydroxide (although this is not
essential) and the cavity is filled with a
permanent restorative material, with no
re-entry in the cavity.7,16,17
Some studies have made
longitudinal evaluations of teeth with
deep caries lesions treated with partial
carious tissue removal. Maltz et al,7 after
3645 months of follow-up, observed a
success rate (that is to say, maintenance
of pulp vitality and absence of symptoms)
of 88% of the permanent teeth treated.
Similarly, in the study of Gruythuysen et
al,4 a success rate was observed (that is to
say, absence of symptoms and clinical and
radiographic signs of pathology) in 96%
of primary and 93% of permanent molars,
after 3 years.
Considering that there is no
consensus about the best treatment technique
for deep carious lesions, it is important to carry
out clinical trials. Table 1 presents the studies
that compared direct complete excavation and
stepwise excavation.

Those who defend the partial


removal technique allege that re-opening
the cavity during stepwise excavation may
lead to pulp exposure and result in future
damage to the pulp. This hypothesis
may be verified in the study of Orhan et
al,6 in which it was demonstrated that
pulp exposures in the group treated with
stepwise excavation always occurred
during cavity re-opening. Another point
questioned in stepwise excavation is the
use of temporary restoration between
sessions, which may become lost or
are forgotten by patients, which would
increase the chances of failure of the
technique.6
Stepwise excavation has
advantages. Final excavation helps the
dentist to control the reaction of the tooth,
and allows the removal of dentine with
slow progression of demineralization, but
nevertheless infected, before performing
the permanent restoration.6,10,17,18,20

Conclusion
Based on the studies cited in
this review, the authors suggest that the
conservative techniques for the treatment
of deep carious lesions, namely stepwise
excavation and partial removal, are
preferable to direct complete excavation,
since they present less risk of pulp
exposure and higher success rates. There
is no consensus about which technique

is better partial removal or stepwise


excavation.

References

1. Thylstrup A, Bruun C, Holmen L. In


vivo caries models mechanisms for
caries initiation and arrestment.
Adv Dent Res 1994; 8: 144157.
2. Leksell E, Ridell K, Cvek M, Mejre I.
Pulp exposure after stepwise versus
direct complete excavation of deep
carious lesions in young posterior
permanent teeth. Endod Dent
Traumatol 1996; 12: 192196.
3. Orhan AI, Oz FT, Ozcelik B, Orhan
K. A clinical and microbiological
comparative study of deep carious
lesion treatment in deciduous and
young permanent molars. Clin Oral
Investig 2008; 12: 369378.
4. Gruythuysen RJM, van Strijp AJP, Wu
M-K. Long-term survival of indirect
pulp treatment performed in primary
and permanent teeth with clinically
diagnosed deep carious lesions.
J Endod 2010; 36: 14901493.
5. Bjrndal L, Reit C, Bruun G, Markvart
M, Kjaeldgaard M, Nsman P et al.
Treatment of deep caries lesions
in adults: randomized clinical trials
comparing stepwise vs direct
complete excavation, and direct pulp
capping vs. partial pulpotomy.
Eur J Oral Sci 2010; 118: 290297.

Reference
Dentition

Percentage of pulp exposure Percentage of pulp exposure


in direct complete excavation in stepwise excavation

Magnusson & Sundell, 19779 Primary

53%

Leksell et al, 19962

Permanent 40%

15%
17.5%

Bjrndal et al, 20105 Permanent 28.9%

17.5%

Orhan et al, 20106

8%

Primary and permanent

22%

Reference
Dentition

Comparison of bacteriological counts between direct complete


excavation and stepwise excavation

Orhan et al, 20083


Primary and permanent

No statistically significant difference in the total CFU counts of


S. mutans and Lactobacillus sp.

Lula et al, 200919

No statistically significant difference in the total CFU counts.

Primary

Table 1. Comparison between direct complete excavation and stepwise excavation, in relation to pulp exposure and microbiological analysis.

454 DentalUpdate

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Cariology

6. Orhan AI, Oz FT, Orhan K. Pulp


exposure occurrence and outcomes
after 1 or 2visit indirect pulp
therapy vs complete caries removal
in primary and permanent molars.
Pediatr Dent 2010; 32: 347355.
7. 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: 493496.
8. 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.
9. Magnusson BO, Sundell SO. Stepwise
excavation of deep carious lesions in
primary molars. J Int Assoc Dent Child
1977; 8: 3640.
10. Bjrndal L. Indirect pulp therapy and
stepwise excavation. J Endod 2008;
34: S29S33.
11. Bjrndal L, Larsen T. Changes in the
cultivable flora in deep carious lesions

12.

13.

14.

15.

16.

following a stepwise excavation


procedure. Caries Res 2000; 34:
502508.
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.
Kidd EAM. How clean must a cavity
be before restoration? Caries Res
2004; 38: 305313.
Weerheijm KL, Kreulen CM, de Soet
JJ, Groen HJ, van Amerongen WE.
Bacterial counts in carious dentine
under restorations: 2-year in vivo
effects. Caries Res 1999; 33: 130134.
Fejerskov O, Kidd E. Dental Caries: The
Disease and Its Clinical Management
2nd edn. Oxford: Wiley-Blackwell,
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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.
17. Ricketts D, Lamont T, Innes NP, Kidd
E, Clarkson JE. Operative caries
management in adults and children.
Cochrane Database Syst Rev 2013; 3:
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and clinical management. Oper Dent
2002; 27: 211217.
19. Lula ECO, Monteiro-Neto V, Alves
CMC, Ribeiro CCC. Microbiological
analysis after complete or partial
removal of carious dentin in primary
teeth: a randomized clinical trial.
Caries Res 2009; 43: 354358.
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Acknowledgements

We would like to
acknowledge Fundao Carlos Chagas
Filho de Amparo Pesquisa do Estado
do Rio de Janeiro (FAPERJ), Brasil, for
financial support.

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