Summary of findings
Description of the condition
Dental caries is one of the most commonly occurring diseases worldwide and its treatment has high cost implications both in monetary and biological (dental pain/infection and tooth loss) terms. Non-operative measures (plaque and diet control, fluoride application) are considered important treatments to control caries progression. However, operative dentistry (placement of restorations) has a role to play in facilitating plaque control and in restoring tooth form and function. Cavitated lesions that cannot be cleaned are restored to allow the patient to clean effectively.
This operative treatment of dental caries traditionally has involved complete removal of the caries before placing a restoration. This tissue is heavily infected with bacteria and is removed using a slow speed bur or hand excavating instruments (Kidd 1998). Histologically and clinically, dentinal caries has been characterised as having two distinct layers: the outer zone (stains with caries detector dyes) where the dentine is highly demineralised, the collagen denatured and heavily infected with bacteria (often referred to as the infected zone), and the inner zone (does not stain with a caries detector dye) where the dentine is demineralised but the collagen intact and minimally infected (often referred to as the caries affected zone) (Fusayama 1972).
Traditionally all remnants of caries were removed during cavity preparation (Black GV 1908). However, contemporary cavity preparation clears caries from the periphery of the cavity and only removes the outer caries infected zone pulpally.This type of treatment has been accepted and practiced for generations by dentists. However, there are a number of consequences associated with such restorative intervention.
- Entry to the restorative cycle: Whilst caries removal and restoration give the short term benefit of removing the infected, soft demineralised dentine and restoring tooth form, they cannot be regarded as a definitive solution as the majority of restorations placed by dentists are replacement restorations (Elderton 1990). Individual teeth often undergo re-restoration a number of times due to restorative material failure, new caries adjacent to the restoration and tooth structure failure as a result of weakening.
- Reduction in remaining dentine thickness (RDT): When a cavity is prepared and a restoration is replaced, the cavity becomes larger and the RDT between the floor of the cavity and the dental pulp often becomes thinner. The RDT has been shown to be the most critical variable in cavity preparation which has an impact on pulpal health (Murray 2003).
- Pulpal exposure: At its most extreme, caries removal in dentine lesions can lead to exposure of vital pulp tissue. Traditionally, such exposures in symptomless teeth have been managed by placement of a direct pulp cap or with a pulpotomy. These techniques can achieve good success rates when they are used to treat pulps exposed through dental trauma (Cvek 1978). However, following carious exposures (where there is infected dentine and the pulp is more likely to be compromised) outcomes are poor (Al-Hiyasat 2006; Barthel 2000).
- Dentine is a vital tissue, and local anaesthetic (LA) is required for conventional cavity preparation, as it often involves removal of non-necrotic dentine. Studies involving children have found less reported discomfort and pain when softened demineralised dentine was removed with hand excavation without LA than when LA and burs were used (Rahimtoola 2000; van Bochove 2006).
More conservative approaches often known as minimal intervention techniques for the management of caries have been adopted and are becoming more widely accepted in efforts to address and reduce the adverse consequences of restorative treatment. The interpretation of what minimal intervention means varies, but often consists of what would be regarded as complete caries removal. It is uncertain whether the traditional approach to caries removal is necessary and this dogma has been challenged by a number of procedures and studies (Kidd 2004) where partial or no caries removal was carried out (Thompson 2008).
Description of the intervention
There is a lack of standardisation in the terminology describing the various degrees of caries removal, but those that move away from complete caries removal can be broadly grouped as follows.
- Stepwise excavation: Partial caries removal is carried out and provisionally restored, followed a few weeks later by removal of the provisional restoration and any soft caries. A definitive restoration then being placed (Bjørndal 1997).
- Partial caries removal and placement of a definitive restoration (Ribeiro 1999).
- No dentinal caries removal and use of a restorative material to seal caries into the tooth (Handelman 1991; Mertz-Fairhurst 1998). This group has a more diverse range of procedures which includes placement of traditional fissure sealants in the pits and fissures and novel techniques such as preformed metal crowns (Innes 2007) and those sealing proximal lesions using resin sealants (Martignon 2006; Paris 2007).
How the intervention might work
Sealing infected demineralised dentine into a cavity with a restoration that provides a good peripheral seal, deprives the microorganisms of substrate from the oral cavity. The bacteria reduce in numbers (Handelman 1976) and the caries process arrests. Not only do the bacteria reduce in numbers, but the microbial diversity becomes less complex. Only those microorganisms capable of breaking down pulpal tissue fluid glycoproteins are able to survive (Paddick 2005). A number of other clinical studies discussed by Fejerskov and Kidd 2008 and Thompson 2008 have investigated and provided evidence to support this theory.
The progressive reduction in the number of organisms and a change to a less cariogenic microflora within sealed carious dentine, leads to a gradual reduction in lesion activity and hence lesion progression. This allows time for the pulp-dentine complex to lay down tertiary dentine and peri-tubular dentine leading to tubular sclerosis and reduces the permeability of the remaining dentine. This reduction in pulpal exudate further depletes the nutrient source for the bacteria. In stepwise excavation the provisional restoration is removed after a period of time to allow further caries removal. The tertiary dentine which has now had time to form provides further protection of the dental pulp and reduces the risk of pulpal exposure. Avoidance of carious pulpal exposures is critical to the long term outcome of the tooth, as management of such exposures using a direct pulp capping technique is associated with a poor prognosis for maintaining a vital pulp (Al-Hiyasat 2006; Barthel 2000). Extirpation of the damaged pulp and root canal treatment would then be required.
Partial caries or no dentinal caries removal techniques also have the potential to reduce cavity size and hence preserve tooth structure. However, a consequence of such techniques is that the restoration does not have a sound foundation. The impact of this upon restoration longevity is still debated, although it may not be such an important issue in the long term for primary teeth as they exfoliate.
Why it is important to do this review
Despite the high prevalence of dental caries and the large number of restorations placed worldwide on a daily basis, clinicians remain uncertain as to which is the best operative caries management strategy: complete, partial or no dentinal caries removal. At the present time there is considerable variation in clinical practice and teaching. Therefore there is a need to systematically review the literature on stepwise, partial, no dentinal or complete caries removal prior to definitive restoration. A review of this literature was published in 2006. Since publication, further evidence has become available and there is a need to update the results.
This is an update of the Cochrane review originally entitled Complete or ultraconservative removal of decayed tissue in unfilled teeth previously published in 2006 (Ricketts 2006). It has been re-titled to encompass all studies which remove varying amounts of caries, including those that do not remove any dentinal caries.
To assess the effects of stepwise, partial or no dentinal caries removal compared to complete caries removal in both primary and permanent teeth.
Specifically, the primary outcomes were: exposure of the dental pulp during caries removal, signs or symptoms of pulpal disease, progression of caries, and restoration failure. The secondary outcomes were: health economic measures, oral health related quality of life, patient/carer and dentist perceptions of treatment, and patient discomfort during treatment.
To investigate factors such as depth of lesion, surface(s) affected, extent of caries removal, method of caries removal, restorative material used and effect of primary or secondary teeth.
Criteria for considering studies for this review
Types of studies
Parallel group and split-mouth randomised controlled trials (RCTs), including quasi-randomised trials, that compared stepwise, partial or no dentinal caries removal with complete caries removal, prior to restoration.
Types of participants
Participants with caries, affecting any tooth surface(s), in unrestored primary and permanent teeth.
Types of interventions
Stepwise, partial or no dentinal caries removal prior to restoration. The control groups involved complete caries removal. To avoid including dental pulps compromised by previous treatment only teeth with no previous restorations were considered.
Types of outcome measures
- Exposure of the dental pulp during caries removal.
- Signs or symptoms of pulpal disease.
- Progression of caries.
- Restoration failure.
- Health economic measures.
- Oral health related quality of life.
- Patient/carer and dentist perceptions of treatment.
- Patient discomfort during treatment.
Search methods for identification of studies
For the identification of studies included or considered for this review, we developed detailed search strategies for each database searched. These were based on the search strategy developed for MEDLINE (OVID) but revised appropriately for each database. The search strategy used a combination of controlled vocabulary and free text terms and was linked with the Cochrane Highly Sensitive Search Strategy (CHSSS) for identifying randomised trials (RCTs) in MEDLINE: sensitivity maximising version (2008 revision) as referenced in Chapter 18.104.22.168 and detailed in box 6.4.c of the Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 (updated March 2011) (Higgins 2011).
We searched the following electronic databases:
- The Cochrane Oral Health Group's Trials Register (to 12 December 2012) (Appendix 1)
- The Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 11) (Appendix 2)
- MEDLINE via OVID (1948 to 12 December 2012) (Appendix 3)
- EMBASE (1980 to 12 December 2012) (Appendix 4).
Searching other resources
Handsearching for this review was done as part of the Cochrane worldwide handsearching programme (Cochrane Masterlist contains details of journals searched to date). All relevant trials found by this handsearching were retrieved by the search of the Cochrane Oral Health Group's Trials Register.
The search was not limited by language and any non-English published trials considered to be relevant were translated.
First authors of included studies were contacted where possible for unpublished data. Reference lists of included studies were screened for further trials.
Data collection and analysis
Selection of studies
The titles and abstracts of all reports identified through the electronic searches were scanned independently by three review authors (David Ricketts (DR), Nicola Innes (NI) and Thomas Lamont (TL)) for eligibility. For studies appearing to meet the inclusion criteria, or for which there were insufficient data in the title and abstract to make a clear decision, the full report was obtained. These full reports were assessed independently by the same three authors to establish whether the studies met the inclusion criteria or not. Agreements were reached through discussion and where resolution was not possible a fourth review author (Janet Clarkson (JC)) was consulted. Studies rejected at this or subsequent stages were recorded in the Characteristics of excluded studies table and the reason for exclusion recorded.
Data extraction and management
All studies meeting the inclusion criteria underwent a risk of bias assessment and data extraction was carried out using a specially designed data extraction form. Review authors were not masked to the journal title or authors. Data were extracted by three authors (DR, NI and TL) independently and in triplicate. One of the included studies was conducted by an author of this review (NI). For this study the other two review authors extracted the data (DR and TL) in duplicate.
For each trial the following data were recorded:
- the year of publication, country of origin and source of study funding;
- details of the participants including demographic characteristics, criteria for inclusion and exclusion and withdrawals;
- details of the type of intervention, timing and duration; and
- details of the outcomes reported including methods of assessment.
The primary outcome measures were: exposure of the dental pulp during caries removal, signs or symptoms of pulpal disease, progression of caries and restoration failure. Other reported outcomes were recorded for descriptive purposes.
The number of studies eligible for inclusion were recorded (Characteristics of included studies). Data were analysed using Review Manager (RevMan) software (RevMan 2011) and reported according to Cochrane Collaboration criteria.
Assessment of risk of bias in included studies
Assessment of risk of bias in included studies was conducted by three review authors (DR, NI and TL) using the Cochrane risk of bias assessment tool (Higgins 2011). Any disagreements were resolved by discussion. One of the included studies was conducted by an author of this review (NI). For this study the other two review authors (DR and TL) assessed the risk of bias. Seven domains were assessed for each included study: sequence generation, allocation concealment, masking of participants and personnel, masking of outcome assessment, incomplete outcome data, selective outcome reporting and 'other bias'. Within each domain, a description of what happened, as reported in the study, was recorded along with a judgement of either 'low', 'high' or 'unclear' risk of bias. An overall risk of bias assessment was also made.
After taking into account any additional information provided by the authors of the trials, studies were grouped into the following categories.
- Low risk of bias (plausible bias unlikely to seriously alter the results).
- Unclear risk of bias where one or more of the domains was assessed as unclear.
- High risk of bias (plausible bias that weakens confidence in the results) where one or more domains was assessed as at high risk of bias.
Measures of treatment effect
For dichotomous outcomes, the estimate of effect of an intervention was expressed as risk ratios (RR) together with 95% confidence intervals (CIs). For any possible continuous outcomes, mean differences and standard deviations were used to summarise the data for each group using mean differences and 95% CIs.
Unit of analysis issues
The units of randomisation and analysis in the included trials would ideally all have been at the level of the individual. When split-mouth studies were included and each individual trial participant had one tooth randomised to intervention and another randomised to control, analyses took into account the paired nature of the data. In trials where the unit of randomisation was the tooth and the number of teeth included in the trial was not more than twice the number of participants, the data were treated as if the unit of randomisation was the individual. It was recognised that the resulting 95% confidence intervals produced would appear narrower (i.e. the estimate will seem to be more precise) than they should be, and would therefore be interpreted accordingly.
Dealing with missing data
Attempts were made to retrieve missing data from authors of trials. Although there were no continuous data for this version of the review, methods for estimating missing standard deviations in section 7.7.3 of the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011) will be used in future updates of this review.The techniques described by Follmann (Follmann 1992) were to be used to estimate the standard error of the difference for split-mouth studies, where the appropriate data were not presented and could not be obtained.
Assessment of heterogeneity
The significance of any discrepancies in the estimates of the treatment effects from the different trials was assessed by means of Cochran's test for heterogeneity and heterogeneity would have been considered significant if P < 0.1.
Meta-analyses were carried out only where there were studies of similar comparisons reporting the same outcome measures. Risk ratios were combined for dichotomous data, and mean differences would have been used for continuous data, using random-effects models provided there were more than three studies in the meta-analysis. Data from split-mouth studies were combined with data from parallel group trials using the method outlined by Elbourne (Elbourne 2002), using the generic inverse variance method in RevMan.
Subgroup analysis and investigation of heterogeneity
Clinical heterogeneity was assessed by examining the types of participants and interventions for all outcomes in each study. It was decided not to formulate any hypotheses to be investigated for subgroup analyses since no significant meta-analysis was expected. However, this may be carried out in future updates of this review.
It was planned to undertake sensitivity analyses to examine the effect of the risk of bias for each study on the overall estimates of effect. If there were insufficient trials to undertake this, the effect of including unpublished literature on the review's findings would also have been examined.
Description of studies
Results of the search
The electronic searches identified 690 titles and abstracts, four additional studies were identified through searching the reference lists from published reviews and from this, we obtained 30 full reports. The titles and abstracts were screened by three review authors (David Ricketts (DR), Nicola Innes (NI) and Thomas Lamont (TL)) to assess whether the inclusion criteria were met. Full reports of papers that appeared to meet the inclusion criteria were obtained and from these, eight trials were included (Bjørndal 2010; Innes 2007; Leksell 1996; Lula 2009; Magnusson 1977; Mertz-Fairhurst 1987; Orhan 2010; Ribeiro 1999). All of these studies were randomised controlled trials.
The eight trials included in the review involved 934 participants with 1372 teeth treated and outcome data for 1191 teeth were available for analysis.
Characteristics of the trial, setting and investigators
One study was carried out in America (Mertz-Fairhurst 1987), two in Brazil (Lula 2009; Ribeiro 1999), two in Sweden (Leksell 1996; Magnusson 1977), one in Scotland (Innes 2007), one in Turkey (Orhan 2010) and one multicentre trial in Sweden and Denmark (Bjørndal 2010). The trials were published in eight reports between 1977 and 2010. Funding for these studies was varied and included government and pharmaceutical sources, although for some the funding remained unclear.
Three studies reported no drop-outs and the remaining five studies reported 3% to 19% of teeth lost to follow-up at 1 year.
Two of the studies were of split-mouth design (Innes 2007; Mertz-Fairhurst 1987) and six were parallel group studies (Bjørndal 2010; Leksell 1996; Lula 2009; Magnusson 1977; Orhan 2010; Ribeiro 1999). Most studies compared two different treatments but one study (Orhan 2010) compared three different treatments.
The unit of randomisation varied within the parallel group studies from patient level (Magnusson 1977) to tooth level (Bjørndal 2010; Leksell 1996; Lula 2009; Orhan 2010; Ribeiro 1999). In studies where more than one tooth per participant was included, no cluster analyses were performed.
Three secondary care based studies (Leksell 1996; Magnusson 1977; Orhan 2010) reported the number of operators (n = 1-6) and treatment centres (n = 1-6). Innes 2007 reported 17 operators (general dental practitioners) in 10 primary care dental practices. In Bjørndal 2010 there were six treatment centres and in Mertz-Fairhurst 1987 and Lula 2009 one treatment centre, but none reported the number of operators although all three implied that more than one operator was involved. No information was provided on operator or number of treatment centres for the remaining study (Ribeiro 1999).
Characteristics of the participants
Four of the trials included only primary teeth (Innes 2007; Lula 2009; Magnusson 1977; Ribeiro 1999) where participants' ages ranged from 3 to 11 years. Three trials were carried out on permanent teeth (Bjørndal 2010; Leksell 1996; Mertz-Fairhurst 1987) and the ages of the subjects ranged from 6 to 89 years. One study included both primary and permanent teeth (Orhan 2010) and the patients ranged from age 4 to 15 years.
Characteristics of carious lesions
Information on the depth of lesions included in the studies varied from no information (Ribeiro 1999 (lesion width given only as "at least 2 mm wide (faciolingually)") to lesions extending radiographically up to the outer half of dentine (Mertz-Fairhurst 1987), lesions extending radiographically into the pulpal half of dentine (Innes 2007; Lula 2009) or the pulpal quarter of dentine (Bjørndal 2010; Leksell 1996 (pulpal exposure expected); Magnusson 1977; Orhan 2010). The different methods of reporting caries lesion depth estimation, reflects the current lack of an accepted standardised measure.
Whilst the study by Mertz-Fairhurst 1987 only investigated occlusal (Class I) lesions, Innes 2007; Lula 2009; Orhan 2010 and Ribeiro 1999 looked at both occlusal and occlusal-approximal (Class II) lesions, and Bjørndal 2010 looked predominantly (96%) at occlusal-approximal (Class II) lesions. The illustrations, examples and descriptions presented by Magnusson 1977 and Leksell 1996 would suggest that only occlusal lesions were investigated, however, this cannot be confirmed from the text.
Characteristics of the intervention
For all studies, the intervention was compared with complete caries removal as the control. Three studies investigated stepwise excavation (Bjørndal 2010; Leksell 1996; Magnusson 1977). One study (Orhan 2010) reported both stepwise excavation and partial caries removal compared to complete caries removal. In the stepwise excavation studies, the time interval between first stage excavation and second stage varied between 4 and 24 weeks. Two further studies compared partial caries removal and all three of these trials (Lula 2009; Orhan 2010; Ribeiro 1999) sealed the caries into the tooth definitively.
What authors termed partial caries removal at the first stage of the stepwise excavation technique varied between studies. Magnusson 1977 and Orhan 2010 removed caries until the operator determined that there was a significant risk of pulpal exposure with further excavation, whereas Bjørndal 2010 appears to be more conservative and described only "removal of the superficial necrotic and demineralized dentin with complete excavation of the peripheral demineralized dentin, avoiding excavation close to the pulp". In both of the studies investigating partial caries removal, with no re-entry (Lula 2009; Ribeiro 1999), only the enamel-dentine junction was cleared of caries, and superficial necrotic dentine was removed from the pulpal and axial walls of the cavity. In the two studies that did not make any attempt to remove dentinal caries, one was in permanent teeth and involved bevelling the enamel at the entrance of pits and fissures prior to restoration with composite resin (Mertz-Fairhurst 1987). The second study investigated primary teeth and restoration was with a preformed metal crown using the Hall Technique (Innes 2007).
In the control group of the Innes study, dentists were asked to carry out their routine management of carious lesions; 76% reported complete caries removal and 24% partial caries removal. The data presented in this review were for the complete caries removal control group and were obtained from personal communication with the first author.
The restorative materials varied throughout the included studies: the provisional restorative materials used in the stepwise excavation technique were zinc oxide-eugenol (Leksell 1996; Magnusson 1977; Orhan 2010) and glass ionomer (Bjørndal 2010), whereas the definitive restorations provided for the other techniques were composite (Lula 2009; Mertz-Fairhurst 1987; Ribeiro 1999) and preformed metal crowns (Innes 2007).
Characteristics of the outcome measures
The primary outcomes were: exposure of the dental pulp during caries removal, signs or symptoms of pulpal disease, progression of caries and restoration failure. Five studies measured exposure of the dental pulp during caries removal (Bjørndal 2010; Leksell 1996; Lula 2009; Magnusson 1977; Orhan 2010). Seven studies reported signs or symptoms of pulpal disease at 1 year follow-up (Bjørndal 2010; Innes 2007; Lula 2009; Magnusson 1977; Mertz-Fairhurst 1987; Orhan 2010; Ribeiro 1999). None of the studies reported upon progression of caries. Restoration failure was presented in six studies (Innes 2007; Leksell 1996; Lula 2009; Mertz-Fairhurst 1987; Orhan 2010; Ribeiro 1999) with this being the major focus for two of the studies (Mertz-Fairhurst 1987; Ribeiro 1999). The study by Innes reported outcome data at 2 years (Innes 2007) and 5-year data are available (Innes 2007). To improve consistency with the other studies, the author provided 1 year follow-up data, including results of the exposure of dental pulp during caries removal.
For the secondary outcomes of health economic measures, oral health related quality of life, patient/carer and dentist perceptions of treatment, and patient discomfort during treatment, only one study (Innes 2007) reported on perceptions of treatment and patient discomfort.
Fifteen trials were excluded for the following reasons: no control, the atraumatic restorative treatment (ART) technique was compared to conventional caries removal where the ART technique was judged to constitute complete caries removal.
Risk of bias in included studies
A summary of the risk of bias is presented in Figure 1.
|Figure 1. Risk of bias summary: review authors' judgements about each risk of bias item for each included study.|
Reporting on sequence generation varied between the studies. Two studies provided no information on the method of sequence generation and were assessed at unclear risk of selection bias (Leksell 1996; Ribeiro 1999). Allocation was based on date of birth in Magnusson 1977, so this quasi-randomised study was assessed at high risk of bias. Four studies were assessed at low risk of selection bias based on the reported method of sequence generation: paper based "randomised treatment assignment sheet" (Mertz-Fairhurst 1987) to computerised sequence generation (Bjørndal 2010; Innes 2007; Lula 2009).
In Orhan 2010, teeth were allocated to treatment by the investigator drawing lots. However, in this study randomisation was carried out in one stage for both the control and intervention groups. At this stage the intervention group was divided into two subgroups, stepwise and partial caries removal. This meant that when the operator was partially removing caries, it was known whether there would be a subsequent appointment to remove further caries (the stepwise group). The authors commented that this may have introduced bias because the operator knew there was to be a second caries removal stage, and this might have affected the extent of caries excavation they were carrying out. The authors point out there should have been a second randomisation, following the initial caries removal to divide the group into two, and decide which teeth would be allocated to stepwise or partial caries removal. Orhan 2010 was therefore assessed as having a high risk of selection bias.
The concealment of allocation was unclear for four studies (Leksell 1996; Mertz-Fairhurst 1987; Orhan 2010; Ribeiro 1999). Bjørndal 2010; Innes 2007 and Lula 2009 allocated at the time of treatment via a central randomisation sequence, which was concealed from the operators. Magnusson 1977 allocated on the basis of date of birth which was not concealed from the operators and this trial was therefore judged to have a high risk of selection bias.
Masking of participants and personnel (performance bias)
Steps were taken in three studies to mask participants to which procedures they had received, or which tooth had received which treatment (Bjørndal 2010; Lula 2009; Ribeiro 1999) by using the same dental material for both the intervention and control groups, and standardising the number of surgical stages for each procedure from the patient perspective. These studies were assessed as having a low risk of bias for masking of participants due to the steps taken in the study design and management which reduced the potential risk of bias.
In the remaining five included studies, masking of participants was not reported and these were assessed as at high risk of performance bias. For two studies, patients could not be masked as different materials were used for the intervention and control groups (Innes 2007; Mertz-Fairhurst 1987). In the remaining three studies, patients had to attend one or two appointments depending on whether they had received the control or intervention (Leksell 1996; Magnusson 1977; Orhan 2010).
As with most dental restorative intervention studies, masking of the operator was not possible in any of the studies included in this review; the intervention and control procedures involved different treatment protocols. All the included studies were therefore assessed as being at high risk of performance bias with regards to masking of personnel providing the trial interventions.
Masking of outcome assessment (detection bias)
For the five studies which investigated the primary outcome of pulp exposure (Bjørndal 2010; Leksell 1996; Lula 2009; Magnusson 1977;Orhan 2010), this outcome was assessed at the time of caries removal by the operator, who knew which treatment they were carrying out. These studies were therefore assessed as having a high risk of detection bias.
Innes 2007 and Mertz-Fairhurst 1987 were also assessed as having a high risk of bias for outcome assessment, as they used different restorative materials and therefore the outcome assessor could not be masked. Ribeiro 1999 was assessed as having a low risk of bias as the same restorative materials and review protocol were used for both intervention and control groups and adequate masking was therefore likely to have been in place.
Where radiographs and microbiology were used to assess outcome measures, the outcome assessors were masked to the intervention. However, where partial caries removal was compared to complete caries removal, the radiologists may have been able to determine which intervention group the tooth was in, which may have introduced an element of bias.
Incomplete outcome data
Leksell 1996 and Mertz-Fairhurst 1987 reported 40% and 19% drop-outs at 1 year respectively; neither provided adequate explanation for their drop-outs and were therefore assessed as having a high risk of attrition bias. Whilst Bjørndal 2010 also failed to provide adequate explanations of the drop-outs from this study, it was considered unlikely to introduce a risk of attrition bias due to the small numbers involved (7%), and therefore risk of attrition bias is assessed as low.
The remaining five studies were also assessed as having a low risk of attrition bias: three reported no drop-outs (Magnusson 1977; Orhan 2010; Ribeiro 1999) and the remaining two had few drop-outs and provided adequate information on those lost to follow-up (Innes 2007; Lula 2009).
All of the included studies reported in full the outcomes listed in the methods sections. There was no suggestion of selective outcome reporting and therefore all studies were assessed as being at low risk of reporting bias.
Other potential sources of bias
Bjørndal 2010, Leksell 1996 and Orhan 2010 excluded teeth from further outcome assessment once exposure of the dental pulp had occurred. Excluding these teeth from further outcome assessment is a potential source of bias, resulting in potential under-reporting of the other outcomes. This may have a bearing on the complete caries removal groups where there was a higher incidence of pulpal exposure. These trials were therefore assessed as having a high risk of other bias.
There was no evidence of other sources of bias in the remaining studies.
Overall risk of bias
Although the authors of this review acknowledge that the included studies would be classified at high risk of bias based on the assessments above, this has to be taken in the context of the pragmatic nature of dental clinical trials. To design and conduct a study free of all biases would however be impossible for the primary outcome of exposure of the dental pulp, as the outcome assessor would know the allocated caries removal technique after cavity preparation was completed, by virtue of the status of the remaining dentine. Whilst the overall risk of bias of the included studies may be regarded as high, the four new studies included in this update (Bjørndal 2010; Innes 2007; Lula 2009; Orhan 2010) have demonstrated improved methodologies in an attempt to address these shortcomings.
Effects of interventions
See: Summary of findings for the main comparison Stepwise excavation versus complete one stage caries removal prior to restoration of carious teeth; Summary of findings 2 Partial caries removal compared to complete caries removal for patients with carious teeth; Summary of findings 3 No dentinal caries removal versus complete caries removal prior to restoration
Most of the included studies compared complete caries removal prior to restoration with either stepwise, partial or no removal of dentinal caries. Therefore data for stepwise excavation, partial caries removal and no dentinal caries removal were analysed as separate groups. The studies reported outcome data for the primary outcomes of exposure of the dental pulp during caries removal, signs or symptoms of pulpal disease and restoration failure. No studies reported on the primary outcome of progression of caries.
Comparison 1: Stepwise excavation versus complete caries removal
There were four trials comparing stepwise excavation with complete caries removal (Bjørndal 2010; Leksell 1996; Magnusson 1977; Orhan 2010). Orhan 2010 included both primary and permanent teeth in their investigation, Bjørndal 2010 and Leksell 1996 permanent teeth only and Magnusson 1977 primary teeth only.
Exposure of the dental pulp during caries removal (Analysis 1.1)
All four studies reported outcome data for dental pulp exposure. Exposures of the dental pulp at any stage of caries removal (either initial or in the case of stepwise, on re-entry) have been included in the meta-analysis. Data were provided for both primary and permanent teeth. Stepwise excavation was associated with a reduced risk of pulp exposure risk ratio (RR) 0.44 (95% confidence interval (CI) 0.33 to 0.60, P < 0.00001, I
For primary teeth, the risk ratio for pulpal exposure during stepwise excavation was RR 0.31 (95% CI 0.17 to 0.57, P = 0.0002, I
A breakdown of when these exposures occurred is shown in the table below.
Signs or symptoms of pulpal disease (Analysis 1.2)
Signs or symptoms of pulpal disease were reported by Bjørndal 2010; Leksell 1996 and Orhan 2010. Two trials have been included in the meta-analysis, one included primary teeth and permanent teeth (Orhan 2010) and the other (Bjørndal 2010) included permanent teeth only. From the meta-analysis, there is no evidence of a difference in the development of signs or symptoms of pulpal disease (RR 0.78 (95% CI 0.39 to 1.58, P = 0.50, I
In the Magnusson 1977 study, pulp necrosis was reported as occurring in three teeth in the complete caries removal arm and one in the stepwise excavation arm. However, it is not clear from the publication whether this was a finding at excavation or on review, and therefore these data were not included in the analyses on signs and symptoms of pulpal pathology.
Comparison 2: Partial caries removal versus complete caries removal
Three trials compared partial caries removal with complete caries removal (Lula 2009; Orhan 2010 and Ribeiro 1999). Orhan 2010 included both primary and permanent teeth in their investigation, whilst Lula 2009 and Ribeiro 1999 only included primary teeth.
Exposure of the dental pulp during caries removal (Analysis 2.1)
Two studies provided data for meta-analysis (Lula 2009; Orhan 2010) for this outcome. For primary teeth, there was a reduction in risk favouring partial caries removal (RR 0.24 (95% CI 0.06 to 0.90; P = 0.03, I
Overall there was a reduction in risk of exposure of dental pulp favouring partial caries removal (RR 0.23 (95% CI 0.08 to 0.69, P = 0.009, I
Signs or symptoms of pulpal disease (Analysis 2.2)
All three trials provided data for the outcome of signs or symptoms of pulpal disease. There was no difference in pulpal disease between partial and complete caries removal (RR 0.27, 95% CI 0.05 to 1.60, P = 0.15, I
Failure of restorations (Analysis 2.3)
Lula 2009 and Ribeiro 1999 also reported the outcome of restoration failure. There was only one failure of restoration recorded, which occurred in the complete caries removal group in Lula 2009, and no restoration failures were reported in either group in the study by Ribeiro 1999. These small studies with a combined total of 80 participants provide insufficient evidence to determine whether or not there is a difference in restoration failure between partial and complete caries removal ( Summary of findings 2).
Comparison 3: No dentinal caries removal versus complete caries removal
Two trials compared no dentinal caries removal with complete caries removal (Innes 2007 and Mertz-Fairhurst 1987). They were both split-mouth designs, one with primary teeth where preformed metal crowns were used to seal the occlusal and approximal caries (Innes 2007), and one with permanent teeth which used composite materials to seal occlusal caries (Mertz-Fairhurst 1987). Both studies reported the outcomes of signs or symptoms of pulpal disease and restoration failure.
Exposure of the dental pulp during caries removal could not occur in the intervention groups where no dentinal caries removal was carried out. It was therefore inappropriate to report this outcome in these studies, but we note that no exposure of the dental pulp occurred in either complete caries removal group in either study.
Note that in the Innes 2007 study only the control teeth that actually underwent complete caries removal were included in the analysis throughout the review. These data were provided following communication with the author (Additional Table 1).
Signs or symptoms of pulpal disease (Analysis 3.1)
After 1 year of follow-up, there was no difference in signs or symptoms of pulpal disease in the primary teeth in the study by Innes 2007 ( Analysis 3.1; Additional Table 1) (data supplied by author Additional Table 1).
In the study by Mertz-Fairhurst 1987, there were no signs or symptoms of pulpal disease reported for either group.
Failure of restorations (Analysis 3.2)
The Mertz-Fairhurst 1987 study with permanent teeth showed no difference between the groups in restoration failure.
It was not considered appropriate to combine these studies in any analysis because of their clinical heterogeneity (i.e. primary/permanent teeth, settings of studies, different surfaces of initial caries, different restoration types).
Innes 2007 was the only study that reported on secondary outcomes of patient, carer and dentist perception of treatment and patient discomfort during treatment. In this study 77% of the children, 83% of the carers and 81% of the dentists preferred the no dentinal caries removal and restoration with preformed metal crowns compared to complete caries removal and conventional restoration. In relation to pain as assessed by the dentist, 89% of children were assessed as experiencing "no pain, discomfort" to "mild, not significant" during the intervention, compared to 78% in the control group.
Summary of main results
This review compares different caries removal techniques with complete caries removal. Eight trials met the inclusion criteria, 934 patients with 1372 teeth were recruited into the trials and outcome data for 1191 teeth were available for analysis. The trials were divided into three different comparisons, according to the extent of caries removal. Three primary outcomes were reported, with none of the trials providing data for the progression of caries at 1 year.
Comparison 1: Stepwise excavation versus complete caries removal
Four trials reported stepwise excavation versus complete caries removal. The analyses show that there was a 56% reduction in risk of exposure of the dental pulp during stepwise excavation when compared with complete caries removal risk ratio (RR) 0.44 (95% confidence interval (CI) 0.33 to 0.60, P < 0.00001, I
There was no evidence of a difference in signs or symptoms of pulpal disease when comparing stepwise excavation to complete caries removal. However, in the three studies included (Bjørndal 2010; Leksell 1996; Orhan 2010), once exposure had occurred, the teeth were excluded from the study. As these teeth were not evaluated at follow-up, the effect estimate may be biased towards the control which had a greater incidence of exposure of the dental pulp. This may have resulted in an underestimation of the potential benefit of the intervention.
The studies in this review demonstrate that partial caries removal and sealing into the tooth (first stage stepwise) leads to the systematic and progressive arrest of the carious lesion. This allows time for pulp dentine complex reactions, reducing the risk of pulpal exposure when cavities are re-entered at the second visit of stepwise to remove the remaining demineralised tissue. Indeed, with increasing evidence from studies presenting microbiological data and the randomised controlled trials in this systematic review, some clinicians and researchers question whether re-entry is required in the stepwise excavation procedure. With this in mind, when the first stage of stepwise excavation caries removal was carried out there was only four (1.3%) exposures of the dental pulp compared to 43 (14.3%) exposures at second stage of stepwise.
Comparison 2: Partial caries removal versus complete caries removal
Comparison 2 included three trials (Lula 2009; Orhan 2010 and Ribeiro 1999) which compared partial caries removal to complete caries removal. Partial caries removal resulted in a 77% reduction in the risk of exposure of the dental pulp during caries removal when compared with complete caries removal (RR 0.23, 95% CI 0.08 to 0.69, P = 0.009, I
All three trials reported signs and symptoms of pulpal disease, and two provided data for meta-analysis, which showed no evidence of a difference (RR 0.27, 95% CI 0.05 to 1.60; P = 0.15, I
There was insufficient evidence to determine whether there was a difference with regards to restoration failure. In Lula 2009 there was one restoration failure in the complete caries removal group and there were no restoration failures in either group in the study by Ribeiro 1999 ( Summary of findings 2).
Comparison 3: No dentinal caries removal versus complete caries removal
Comparison 3 included two studies (Innes 2007; Mertz-Fairhurst 1987) which compared no dentinal caries removal with complete caries removal. Exposure of the dental pulp during caries removal was not possible in the intervention groups where no dentinal caries removal was carried out. However, it is interesting to note that no exposures of the dental pulp occurred in the control groups of these studies either. This result might be expected in the Mertz-Fairhurst 1987 study as the included teeth had caries radiographically confined to the outer half of dentine. However in the Innes 2007 study, almost half (42%) of the included teeth demonstrated caries radiographically into the inner half of dentine and some exposures would therefore have been expected in the control group. There are at least two possible explanations for this lack of pulp exposures during caries removal. Firstly, the participating dentists may have modified their management due to their very involvement in a clinical trial, the so called 'Hawthorne effect' (Fernald 2012). Secondly, although these dentists were assumed to be representative of general practitioners, they volunteered to take part in this trial of a highly conservative approach to caries removal and may have had a general tendency to avoid radical caries removal where there was a risk of exposing the dental pulp.
Innes 2007 reported 3% restoration failure rate in the intervention group, whereas the control group reached 37%. However, the restorations placed in the control group in this study of primary teeth were mainly multi-surface glass ionomer restorations, which have been shown to have poor survival clinically (Chadwick 2007). This failure rate in the control arm was much higher than has been reported from secondary care/specialist practice studies of complete caries removal and restoration. This pragmatic trial presents results achieved in a primary care setting where the majority of dental care is usually provided. Innes 2007 was the only trial that reported on any of the secondary outcomes, namely patient, carer and dentists perceptions of treatment and patient discomfort (assessed by the dentist). In this study the intervention group was preferred by the patient, carer and dentist, and resulted in less discomfort during treatment ( Summary of findings 3).
This review only considers the 1-year follow-up data, however, the 5-year data of this trial, have recently been published (Innes 2007) and also show low restoration failure rates in the intervention group (Hall crowns) ( Summary of findings 3).
Overall completeness and applicability of evidence
Although eight studies have been included in this review, there are only a small number available for each intervention group. There were no data available for the primary outcome of progression of caries, and only one study (Innes 2007) reported upon any of the secondary outcomes.
Seven of the studies were carried out in a secondary care environment by specialist dentists, even though the majority of dental treatment is provided in primary care. This poses two questions: are the patients treated in primary care similar to those seen in secondary care, and is the care provided and outcomes achieved in both settings comparable. Some issues related to these questions may include aspects of cost, time allocation, appointments required, funding source (e.g. dental insurance company). Therefore, clinicians will need to assess whether the findings are applicable to the patients in their clinical setting.
Most of the included studies investigated teeth in children and adolescents. Therefore the applicability to patients of all ages has to be considered. Only two of the included studies involved older patients (Bjørndal 2010; Mertz-Fairhurst 1987).
Early work in this field concentrated on occlusal caries where a good seal could readily be obtained to sound enamel, but there was skepticism as to whether the techniques could be applied to approximal lesions. More recent research has included approximal lesions in addition to occlusal lesions (Innes 2007; Lula 2009; Orhan 2010; Ribeiro 1999) and one study has looked almost exclusively at approximal lesions (Bjørndal 2010). Unfortunately, subgroup analyses based on surface could not be carried out as the studies did not always report the outcomes separately.
Quality of the evidence
The quality of evidence provided from a number of the studies included in this review is poor due to their high risk of bias. Ideally in a clinical trial the patient, the operator and the assessor should all be masked as to any treatment/intervention. However, this conventional masking was not always possible in these studies. The operator knew whether caries removal was partial or complete and certainly knew whether an exposure was present. The operator was often the assessor and it must be assumed that this also precluded conventional masking. However, a primary outcome was symptoms of pulpitis or pulp necrosis and it seems unlikely that this would have been affected by a lack of assessor masking. In the Mertz-Fairhurst 1987 and Innes 2007 studies, different restorative materials were used in the intervention and control groups, therefore masking was not possible.
The more recent studies have improved methodologies, with respect to sequence generation, allocation concealment and attempts to mask patients to the treatment received. Using the same restorative materials and re-entering the teeth where complete caries removal had taken place, Bjørndal 2010 may have ensured patients did not know which treatment arm was being carried out. As re-entry took place in Lula 2009, in order to take a microbiological sample, the patients may also have been unaware of which treatment was being carried out.
Although eight studies have been included, they have explored three alternative strategies resulting in a small number of studies in individual analyses. In addition to this, a number of the studies had small sample sizes resulting in wide confidence intervals and lower level of certitude.
One of the sources of heterogeneity within the studies was the depth of the lesions. Variation in lesion depth may have an impact on whether the pulp is exposed during caries removal. The depth of the lesions in the studies varied in radiographic extent, from Mertz-Fairhurst 1987 where all lesions were confined to the outer half of dentine to Bjørndal 2010 and Orhan 2010 where all lesions were over 75% of the way through dentine. Only Bjørndal 2010 included teeth with pre-treatment pain and there were no radiographic signs of periapical or periradicular pathology in any of the studies. The medicaments and materials used in the studies varied widely from zinc oxide-eugenol through standard restorative materials to preformed metal crowns. There were insufficient data to draw conclusions about the respective benefits of the various materials used in the intervention groups.
Potential biases in the review process
A potential source of bias in this review process was that one of the review authors (Nicola Innes) carried out one of the included studies. To decrease the risk of bias in the review process, this author was not involved in the assessment of risk of bias, data extraction, data analysis and interpretation for this study.
Agreements and disagreements with other studies or reviews
Implications for practice
The results from the included studies should be interpreted in light of the fact that a number of the studies suffer from a high risk of bias and had a short follow-up period. Whilst bearing this in mind the current evidence demonstrates that in symptomless, vital, carious primary or permanent teeth, stepwise and partial excavation reduced the risk of pulp exposure. Therefore these techniques show clinical advantage over complete caries removal in the management of dentinal caries. Whilst there is insufficient evidence to determine whether it is necessary to re-enter and excavate further in the stepwise excavation technique, the studies that did not re-enter, reported no adverse consequences (Innes 2007; Lula 2009; Mertz-Fairhurst 1987; Ribeiro 1999). In primary teeth, the use of Hall Technique crowns would make re-entry difficult and the study by Innes 2007 demonstrated that this may not be necessary: the restoration having adequate inherent retention in the longer term.
Implications for research
This review found no evidence that incomplete caries removal is harmful. In fact, the reverse is true as complete caries removal is more likely to result in carious exposure of the pulp. The need to re-enter the cavity and excavate further in the stepwise excavation technique must continue to be questioned and should be a priority in future research. This could be investigated by high quality, well conducted randomised controlled trials involving long term follow-up of symptoms of pulpitis and pulp necrosis, radiographic evidence of caries progression, microbiological evidence of caries progression or arrest and longevity of restorations. This review only included trials investigating stepwise, partial or no dentinal caries removal versus complete caries removal; future reviews should consider trials which compare these different techniques.
It should be noted that the only long term clinical trial in permanent teeth (Mertz-Fairhurst 1987) involved occlusal caries where caries had only extended to half way through dentine. There is a need to apply the methodology to deeper lesions, lesions affecting multiple tooth surfaces, lesions in compromised teeth that have had a history of restoration and re-restoration and to permanent as well as primary teeth. A major difficulty in this work will be finding stable populations and it will be essential that such studies include multiple practitioners from primary care.
There is also scope for investigation of bonding of materials to soft, wet and infected dentine.
Future research should also investigate patient centred outcomes including oral health related quality of life and patient perception of treatment. Health economic measures should be used to determine the cost of treatment and patient willingness to pay.
We wish to thank Sue Furness for her valued contribution and methodological advice and Anne Littlewood (Cochrane Oral Health Group) for her assistance with literature searching. We also wish to thank the referees and Cochrane editors for their valuable comments.
Data and analyses
- Top of page
- Summary of findings [Explanations]
- Authors' conclusions
- Data and analyses
- What's new
- Contributions of authors
- Declarations of interest
- Sources of support
- Differences between protocol and review
- Index terms
Appendix 1. Cochrane Oral Health Group's Trials Register search strategy
((caries or carious or decay*) and (restor* or fill*) and (ultraconservative or "stepwise excavation*" or "atraumatic resto*" or ART or "atraumatic therap*" or "atraumatic technique*" or "atraumatic treat*" or "minima* invas*" or "fissure seal*" or "dental seal*" or "resin cement*" or "resin seal*" or "glass ionomer*"))
Appendix 2. Cochrane Central Register of Controlled Trials (CENTRAL) search strategy
#1 Explode DENTAL CARIES
#2 ((teeth or tooth or dental*) and (caries or carious or decay* or lesion*))
#3 DENTAL RESTORATION PERMANENT
#4 DENTAL RESTORATION TEMPORARY
#5 (restor* or fill*)
#6 (ultraconservative or stepwise excavation* or (atraumatic* near restor*) or (atraumatic* near technique*) or (atraumatic near therapy) or (atraumatic* near treat*) or (minimal next invasion) or (minimum next invasion) or (minim* next invasive))
#9 PIT AND FISSURE SEALANTS
#10 ((fissure near seal*) or (dental near seal*))
#11 Explode GLASS IONOMER CEMENTS
#12 RESIN CEMENTS
#13 (resin near cement*)
#14 (resin near seal*)
#15 ((glass next ionomer*) or cermet*)
#16 (#1 or #2)
#17 (#3 or #4 or #5)
#18 (#11 or #12 or #13 or #14 or #15)
#19 ((dental near seal*) or (fissure near seal*) or (teeth near seal*) or (tooth near seal*))
#20 (#18 and #19)
#21 (#6 or #7 or #8 or #9 or #10 or #20)
#22 (#16 and #17 and #21)
Appendix 3. MEDLINE (OVID) search strategy
1.exp DENTAL CARIES/
2. ((tooth or tooth or dental$) and (caries or carious or decay$ or lesion$))
4. DENTAL RESTORATION PERMANENT/
5. DENTAL RESTORATION TEMPORARY/
6. (restor$ or fill$)
7. (ultraconservative or stepwise excavation$ or (atraumatic$ adj6 restor$) or (atraumatic$ adj6 technique$) or (atraumatic$ adj6 therapy) or (atraumatic$ adj6 treat$) or minimal invasion or minimum invasion or minim$ invasive)
9. "PIT AND FISSURE SEALANTS"/
10. ((fissure adj6 seal$) or (dental adj6 seal$))
11. exp GLASS IONOMER CEMENTS/
12. RESIN CEMENTS/
13. (resin adj6 cement$)
14. (resin adj6 seal$)
15. (glass ionomer$ or cemet$)
17. ((dental adj6 seal$) or (fissure$ adj6 seal$) or (teeth adj6 seal$) or (tooth adj6 seal$))
18. 16 and 17
19. 4 or 5 or 6
20. 7 or 8 or 9 or 10 or 18
21. 3 and 19 and 20
The above subject search was linked to the Cochrane Highly Sensitive Search Strategy (CHSSS) for identifying randomised trials in MEDLINE: sensitivity maximising version (2008 revision) as referenced in Chapter 22.214.171.124 and detailed in box 6.4.c of the Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 (updated March 2011) (Higgins 2011).
1. randomized controlled trial.pt.
2. controlled clinical trial.pt.
5. drug therapy.fs.
10. exp animals/ not humans.sh.
11. 9 not 10
Appendix 4. EMBASE (OVID) search strategy
1. exp DENTAL CARIES/
2. ((tooth or tooth or dental$) and (caries or carious or decay$ or lesion$)).mp.
4. TOOTH FILLING/
5. (restor$ or fill$)
6. (ultraconservative or stepwise excavation$ or (atraumatic$ adj6 restor$) or (atraumatic$ adj6 technique$) or (atraumatic$ adj6 therapy) or (atraumatic$ adj6 treat$) or minimal invasion or minimum invasion or minim$ invasive).mp.
8. FISSURE SEALANT/
9. ((fissure adj6 seal$) or (dental adj6 seal$))
10. GLASS IONOMER CEMENT/
11. RESIN CEMENT/
12. (resin adj6 cement$)
13. (resin adj6 seal$)
14. (glass ionomer$ or cemet$)
15. ((dental adj6 seal$) or (fissure$ adj6 seal$) or (teeth adj6 seal$) or (tooth adj6 seal$))
16. (10 or 11 or 12 or 13 or 14) and 15
17. 4 or 5
18. 6 or 7 or 8 or 9 or 16
19. 3 and 17 and 18
The above subject search was linked to the Cochrane Oral Health Group filter for EMBASE via OVID:
3. (crossover$ or cross over$ or cross-over$).ti,ab.
5. (doubl$ adj blind$).ti,ab.
6. (singl$ adj blind$).ti,ab.
10. CROSSOVER PROCEDURE.sh.
11. DOUBLE-BLIND PROCEDURE.sh.
12. RANDOMIZED CONTROLLED TRIAL.sh.
13. SINGLE BLIND PROCEDURE.sh.
15. ANIMAL/ or NONHUMAN/ or ANIMAL EXPERIMENT/
17. 16 and 15
18. 15 not 17
19. 14 not 18
Last assessed as up-to-date: 12 December 2012.
Contributions of authors
Development of protocol: David Ricketts (DR), Edwina Kidd (EK), Nicola Innes (NI) and Jan Clarkson (JC).
Identification of studies: Thomas Lamont (TL), DR, NI, EK.
Data extraction: TL, DR, NI.
Appraising risk of bias: TL, DR, NI.
Writing to authors of papers for additional information: TL.
Entering data into RevMan: TL.
Analysis and interpretation of data: DR, TL, NI, EK and JC.
Writing the review: DR, NI, TL, EK, JC.
Methodological support: JC.
Declarations of interest
The author of one of the included studies was also an author of this review. To avoid any conflict of interest this author did not take part in any of the data extraction, risk of bias assessment or analyses relating to this study.
Sources of support
- University of Dundee Dental School, UK.
- Guy's, King's and St Thomas Dental School, UK.
- Cochrane Oral Health Group Global Alliance, UK.All reviews in the Cochrane Oral Health Group are supported by Global Alliance member organisations (British Orthodontic Society, UK; British Society of Paediatric Dentistry, UK; National Center for Dental Hygiene Research & Practice, USA and New York University College of Dentistry, USA) providing funding for the editorial process (http://ohg.cochrane.org).
- National Institute for Health Research (NIHR), UK.All reviews in the Cochrane Oral Health Group are supported by NIHR Systematic Reviews Programme infrastructure funding.
Differences between protocol and review
Change of title from Complete or ultraconservative removal of decayed tissue in unfilled teeth to Operative caries management in adults and children to encompass all studies which remove varying amounts of caries, including those that do not remove any dentinal caries.
Medical Subject Headings (MeSH)
*Dental Pulp; *Dentin [surgery]; Cariostatic Agents [*therapeutic use]; Dental Caries [*therapy]; Dental Enamel [surgery]; Pit and Fissure Sealants [*therapeutic use]; Randomized Controlled Trials as Topic
MeSH check words
Adult; Child; Humans
* Indicates the major publication for the study