Complete or ultraconservative removal of decayed tissue in unfilled teeth

 

Abstract

Background

The treatment of deep dental decay has traditionally involved removal of all the soft demineralised dentine before a filling is placed. However this has been challenged in three groups of studies which involve sealing soft caries into the tooth. The three main groups either remove no caries and seal the decay into the tooth, remove minimal (ultraconservative) caries at the entrance to a cavity and seal the remaining caries in, or remove caries in stages over two visits some months apart to allow the pulp time to lay down reparative dentine (the stepwise excavation technique).

Objectives

To test the null hypothesis of no difference in the incidence of damage or disease of the nerve of the tooth (pulp), progression of decay and longevity of restorations irrespective of whether the removal of decay had been minimal (ultraconservative) or complete.

Search methods

The Cochrane Oral Health Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PubMed and EMBASE databases were searched. The reference lists in relevant papers were checked.

Selection criteria

Randomised controlled trials and controlled clinical trials comparing minimal (ultraconservative) caries removal with complete caries removal in unrestored permanent and deciduous teeth.

Data collection and analysis

Outcome measures recorded were exposure of the nerve of the tooth (pulp) during caries removal, patient experience of symptoms of pulpal inflammation or necrosis, progression of caries under the filling, time until the filling was lost or replaced. Due to the heterogeneity of the included studies the overall estimate of effect was calculated using a random-effects model.

Main results

Four studies met the inclusion criteria; two stepwise excavation studies and two ultraconservative caries removal studies. Partial caries removal in symptomless, primary or permanent teeth reduces the risk of pulp exposure. We found no detriment to the patient in terms of pulpal symptoms in this procedure and no reported premature loss or deterioration of the restoration.

Authors' conclusions

The results of this systematic review reject the null hypothesis of no difference in the incidence of damage or disease of the nerve of the tooth (pulp) irrespective of whether the removal of decay had been minimal (ultraconservative) or complete and accepts the null hypothesis of no difference in the progression of decay and longevity of restorations. However, the number of included studies is small and differ considerably.

Partial caries removal is therefore preferable to complete caries removal in the deep lesion, in order to reduce the risk of carious exposure. However, there is insufficient evidence to know whether it is necessary to re-enter and excavate further but studies that have not re-entered do not report adverse consequences.

 

Plain language summary

Complete or ultraconservative removal of decayed tissue in unfilled teeth

A systematic review of the literature revealed four studies comparing complete and minimal (ultraconservative) caries removal. It was found that partial caries removal in symptomless, primary or permanent teeth reduces the risk of pulp exposure. We found no detriment to the patient in terms of pulpal symptoms in this procedure. Therefore, partial caries removal is preferable to complete caries removal in the deep lesion, in order to reduce the risk of carious exposure. However, there is insufficient evidence to know whether it is necessary to re-enter and excavate further but studies that have not re-entered do not report adverse consequences.

 

摘要

背景

在未填補的牙齒完全或極保守移除齲齒組織

傳統治療深部齲齒為在放置填補物前移去所有弱化去礦化的牙本質。 然而，這個說法在三組把弱化齲齒密封在牙齒內的研究中被挑戰。這三組或許不移除全部的齲齒，在窩洞的入口移除最少(極保守)齲齒並密封剩餘的齲齒組織在內；或在兩次距離數月的看診時，把齲齒分階段移除，讓牙髓組織有時間可以形成修復性牙本質 (逐步移除技術)。

目標

實驗測試完全去除齲齒、或去除最少(極保守)齲齒，對牙齒牙髓神經、齲齒進程、以及填補物的壽命，並無影響的虛無假設。

搜尋策略

搜索 Cochrane Oral Health Group Trials Register，Cochrane Central Register of Controlled Trials (CENTRAL)， MEDLINE， PubMed和EBASE等資料庫。並檢查了相關文章的參考文獻清單。

選擇標準

在齲齒未填補的乳牙和恆牙中，進行隨機對照試驗和對照的臨床試驗，以比較最少(極保守)去除齲齒和完全去除齲齒。

資料收集與分析

結果測量紀錄包括在齲齒移除過程中暴露的牙髓神經、病人對牙髓發炎或壞死的症狀、填補物底下的齲齒進行、填補物喪失或是必須重複填補的時間長短。由於此實驗之異質性，使用隨機效用模式計算總體估計的影響。

主要結論

四項研究滿足了列入的標準；兩個逐步移除技術的研究和兩個完全去除齲齒研究。沒有症狀的乳牙或恆牙部分移除齲齒減低了牙髓暴露的危險。我們發現在此過程中並無損害病人的牙髓症狀，也沒有填補物過早喪失或變質的報告。

作者結論

這系列的系統性文獻回顧否決了最少(極保守)移除法或完全移除齲齒法對危害牙髓神經並無差別的虛無假設；但接受了無論哪種方法對齲齒進程和填補物壽命沒有影響的虛無假設。然而，涵括研究的數量少，並且差異大。因此，在較深的病灶，部份取除齲齒比完全去除齲齒好，以避免因齲齒而造成牙髓暴露的風險。然而，並無足夠的證據明白未來是否須重新進入或移除齲齒，但還沒有重新進入的不良後果。

翻譯人

本摘要由臺灣大學附設醫院曾琬瑜翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

此系統性文獻回顧揭露比較齲齒完全移除法和最少(極保守)齲齒移除法的四項研究。結果發現，齲齒部分去除並無症狀，且對乳牙或恆牙而言，降低了牙髓暴露的風險。我們發現在此過程中，對病人並無造成牙髓傷害。因此，在較深的齲齒，移除部分齲齒比完全移除齲齒好，以減少因齲齒而牙髓暴露的風險。然而，並無足夠的證據顯示未來是否重新進入或再度移除齲齒的必要性，也沒有重新進入造成不良後果的報告。