Plain language summary
Techniques for managing decay in teeth
Tooth decay (dental caries) is a common problem around the world. It can cost a lot of money to treat and causes infection, pain and the loss of teeth. Tooth decay can be controlled by what are known as 'non-operative' methods which include cleaning plaque from teeth thoroughly, advising a healthy diet and using fluoride to prevent the decay getting worse. If the decay progresses these 'non-operative' techniques may need to be combined with 'operative' management which involves filling and restoring teeth where the holes caused by decay prevent cleaning. The fillings will improve the appearance of the teeth and allow the patient to clean them.
Traditionally dentists have removed all of the decay with a dental drill or instruments before a filling is placed. However, removal of all the decay has some disadvantages, including damage to the nerve of the tooth, toothache and possibly weakening of the tooth structure. This method is known as one step complete caries removal.
Despite the large number of fillings and restorations placed worldwide on a daily basis, dentists remain uncertain as to which is the best 'operative management' strategy for tooth decay. This review has been carried out by researchers from the Cochrane Oral Health Group to assess the most effective ways of treating and managing tooth decay (dental caries) when operative methods are used in first and permanent teeth.
The most recent search of relevant studies for this review was carried out on 12th December 2012. Eight studies with 934 patients (1372 teeth) were included.
Three alternative operative caries management interventions were assessed by comparing them with the traditional treatment of removing all the decay in one go (complete caries removal). These interventions were.
- Stepwise excavation - this technique removes caries in stages over two visits some months apart, allowing the dental pulp time to repair itself and lay down dentine.
- Partial caries removal - the dentist removes part of the dentinal caries and seals what is left into the tooth permanently.
- No dentinal caries removal - no dentinal caries is removed before sealing or restoring.
It was found that when the complete caries removal technique was compared with stepwise excavation, the pulp or nerve of the tooth would have been exposed in 347 of every 1000 teeth treated with complete caries removal, whereas when the stepwise excavation technique was used, this would have occurred in only 154 teeth per 1000.
When the partial caries removal technique was used, it was found that the pulp or nerve would have been exposed in 50 teeth out of 1000 treated. However, when the complete caries removal technique was used this figure would have been 219 teeth per 1000 treated.
There was less nerve damage when part of, or all of the decay, was left behind, for both baby and adult teeth. There was no difference in the number of teeth with toothache with any of the techniques. One of the no dentinal caries removal techniques needed fewer replacement fillings, although there was no difference found when comparing any of the rest of the techniques to complete caries removal.
In the included studies, the fillings were mostly placed by specialist dentists and the teeth were followed up for a relatively short time (1 year). More studies are needed to help answer further questions. Future studies should be carried out by non-specialist dentists to check whether the results would be similar. These studies should follow the patients for a longer time, and check if there are any differences in toothache, further decay and filling replacements. They should also check which techniques patients prefer and if there is a long term difference in cost.
Techniques de prise en charge des caries dentaires
La carie dentaire est un problème répandu à l'échelle mondiale. Son traitement peut se révéler onéreux et provoquer des infections, des douleurs et la perte de dents. Une carie dentaire peut être contrôlée grâce à des méthodes dites « non opératoires » qui consistent en un détartrage minutieux des dents, des conseils pour une alimentation saine et l'utilisation de fluoride pour éviter toute aggravation de la carie. En cas de progression d'une carie, ces techniques « non opératoires » peuvent être associées à une prise en charge « opératoire » qui consiste à combler et à restaurer la dent dans laquelle les trous, dus à la carie, empêchent tout nettoyage. Les obturations vont améliorer l'apparence de la dent et permettre au patient de la nettoyer.
En général, les dentistes retirent l'intégralité d'une carie à l'aide d'une fraise ou d'instruments dentaires avant de placer une obturation. Toutefois, le retrait complet d'une carie présente certains inconvénients, notamment des lésions au niveau du nerf de la dent, des douleurs dentaires et éventuellement un affaiblissement de la structure dentaire. Cette méthode s'appelle « retrait complet d'une carie en une seule étape ».
Malgré le grand nombre d'obturations et de restaurations réalisées quotidiennement à l'échelle mondiale, les dentistes ignorent quelle est la stratégie la plus efficace de « prise en charge opératoire » d'une carie. La présente revue a été effectuée par des chercheurs du groupe Cochrane sur la santé bucco-dentaire afin d'évaluer la méthode la plus efficace de traitement et de prise en charge d'une carie lors de l'utilisation de méthodes opératoires sur des dents de lait et des dents définitives.
Les dernières recherches d'études pertinentes pour cette revue ont été réalisées le 12 décembre 2012. Huit études, composées de 934 patients (1 372 dents), ont été incluses.
Trois interventions de prise en charge opératoire alternative de caries ont été évaluées en les comparant à un traitement standard consistant à retirer l'intégralité d'une carie en une seule fois (retrait complet d'une carie). Ces interventions étaient les suivantes :
- Excavation par étapes - Cette technique permet de retirer progressivement une carie en deux visites à quelques mois d'intervalle, permettant ainsi à la pulpe dentaire de se régénérer et de laisser la dentine se reposer.
- Retrait partiel d'une carie - Le dentiste retire une partie de la carie dentaire et colmate de façon permanente ce qui reste dans la dent.
- Retrait d'aucune carie dentinaire - Aucune carie dentinaire n'est retirée avant son colmatage ou sa restauration.
Nous avons constaté que lorsque la technique de retrait complet d'une carie était comparée à une excavation par étapes, la pulpe ou le nerf de la dent était exposé(e) dans 347 dents sur 1 000 dont les caries ont été entièrement retirées, alors que si la technique d'excavation par étapes avait été utilisée, ce résultat se serait produit sur seulement 154 dents sur 1 000.
Lors de l'utilisation de la technique de retrait partiel d'une carie, nous avons constaté que la pulpe ou le nerf était exposé(e) dans 50 dents sur 1 000 ayant été traitées. Toutefois, si la technique de retrait complet d'une carie était utilisée, ce chiffre aurait été de 219 dents sur 1 000 traitées.
Il y avait moins de lésions nerveuses lorsque une partie, ou l'ensemble d'une carie, était laissée sur des dents de lait et d'adulte. Il n'y avait aucune différence concernant le nombre de douleurs dentaires avec l'une des techniques utilisées. L'une des techniques consistant à ne retirer aucune carie dentinale nécessitait moins d'obturations de remplacement, bien qu'il n'y ait aucune différence lorsque l'une des autres techniques était comparée au retrait complet d'une carie.
Dans les études incluses, les obturations étaient principalement placées par des dentistes spécialisés et les dents faisaient l'objet d'un suivi pendant une durée relativement courte (1 an). D'autres études seront nécessaires pour répondre à d'autres questions. Ces études devront être réalisées par des dentistes non spécialisés afin de vérifier si les résultats seraient similaires. Elles devront suivre les patients pendant une durée plus longue et vérifier s'il existe des différences au niveau des douleurs dentaires, de l'apparition d'autres caries et des obturations de remplacement. Elles devront également déterminer les techniques que les patients préfèrent et s'il existe une différence à long terme en termes de coûts.
Notes de traduction
Traduit par: French Cochrane Centre 22nd March, 2013
Traduction financée par: Instituts de Recherche en Sant� du Canada, Minist�re de la Sant� et des Services Sociaux du Qu�bec, Fonds de recherche du Qu�bec-Sant� et Institut National d'Excellence en Sant� et en Services Sociaux pour la France: Minist�re en charge de la Sant�
Tehnike uklanjanja zubnog karijesa
Propadanje zuba (dentalni karijes) je problem koji se viđa u cijelom svijetu. Liječenje karijesa može biti skupo te uzrokovati infekciju, bol i gubitak zuba. Propadanje zuba može se liječiti ''ne-operativnim“ metodama koje uključuju temeljito čišćenje zubnih naslaga (plaka), savjetovanje o zdravoj prehrani i uporabu fluorida kako bi se spriječilo pogoršanja kvarova zubi. U slučaju pogoršanja kvara, te ''ne-operativne'' metode mogu zahtijevati kombiniranje s ''operativnim'' metodama koje uključuju ispune i popravak zuba u kojima oštećenja zuba onemogućuju propisnu higijenu. Ispuni će popraviti izgled zuba i omogućiti pacijentu njihovo lakše čišćenje.
Do sada su liječnici dentalne medicine sva oštećenja uklanjali dentalnom bušilicom ili instrumentima prije postavljanja ispuna. No, uklanjanje zubnog karijesa ima neke nedostatke, kao što su oštećenje zubnog živca, zubobolja i moguće slabljenje zubne strukture. Ta je metoda poznata kao potpuno uklanjanje karijesa u jednom koraku.
Unatoč velikom broju ispuna i popravaka koji se svakodnevno obavljaju diljem svijeta, doktori dentalne medicine i dalje nisu sigurni koja je najbolja ''operativna'' metoda za liječenje pokvarenih zubi. Ovaj sustavni pregled proveli su istraživača iz Cochrane skupine za oralno zdravlje (engl. Cochrane Oral Health Group) kako bi procijenili najučinkovitije načine tretiranja i sanacije zubnoga kvara (zubnog karijesa) pri korištenju operativnih metoda liječenja mliječnih i trajnih zuba.
Zadnje pretraživanje studija za ovaj sustavni pregled provedeno je 12. prosinca 2012. U sustavni pregled uključeno je 8 studija s 934 pacijenta (1.372 zuba).
Analizirane su tri različite intervencije za operativno uklanjanje karijesa i napravljena je usporedba s tradicionalnim tretmanom uklanjanja cjelokupnog kvara u jednom potezu (potpuno uklanjanje karijesa). Analizirani su sljedeći zahvati.
-Postupna ekskavacija – ta tehnika uklanja karijes postupno, u fazama tijekom dva posjeta u razmaku od nekoliko mjeseci, čime se daje mekom tkivu u unutrašnjosti zuba (zubnoj pulpi) vrijeme za oporavak i stvaranje novog sloja tkiva dentina.
-Djelomično uklanjanje karijesa prilikom kojeg doktor dentalne medicine uklanja dio zubnoga karijesa i trajno pečati ono što je ostalo u zubu.
-Nedentinsko uklanjanje karijesa – nedentinski karijes se uklanja prije pečaćenja ili obnove zuba.
Utvrđeno je da bi tehnikom potpunog uklanjanja karijesa s postupnom ekskavacijom pulpa ili zubni živac bili izloženi u 347 od svakih 1000 zuba, dok bi se korištenjem tehnike postupne ekskavacije to dogodilo u samo 154 zuba od 1000.
Kada je korištena tehnika djelomičnog uklanjanja karijesa, utvrđeno je da bi pulpa ili živac bili izloženi u 50 od 1000 tretiranih zuba. Međutim, kada je korištena tehnika potpunog uklanjanja karijesa ta brojka bi bila 219 od 1000 tretiranih zuba.
Manje oštećenja živaca uočeno je kad je ostavljen dio ili cijeli karijes i kod djece i odraslih Nije bilo razlike u broju zuba sa zuboboljom ni kod jedne tehnike. Jedna od tehnika nedentinskog uklanjanja karijesa je bila povezana s manjim brojem zamjene ispuna (plombi), iako nije pronađena razlika u usporedbi bilo koje od ostalih tehnika s potpunim uklanjanjem karijesa.
U uključenim studijama, ispune su uglavnom postavljali specijalisti dentalne medicine te je stanje zuba praćeno razmjerno kratko vrijeme (1 godina). Potrebno je više studija da bi se dobio odgovor na daljnja pitanja. Buduća istraživanja bi trebala ispitati i postupke koje ne provode liječnici specijalisti dentalne medicine da bi se provjerilo dobivaju li se slični rezultati. Ta istraživanja bi trebala pratiti pacijente kroz dulje vrijeme te provjeriti postoje li ikakve razlike u zubobolji, daljnjem oštećenju zuba i učestalosti zamjene ispuna Također bi trebali provjeriti koje tehnike pacijenti bolje prihvaćaju i postoji li dugoročno razlika u cijeni.
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Teknik untuk mengendali kerosakan gigi
Kerosakan gigi (karies gigi) adalah masalah yang lazim di seluruh dunia. Ia melibatkan kos untuk dirawat dan boleh menyebabkan jangkitan, sakit dan kehilangan gigi. Kerosakan gigi boleh dikawal dengan kaedah 'bukan-operatif' yang melibatkan pembersihan plak gigi dengan teliti, nasihat diet yang sihat dan penggunaan fluorida untuk mencegah kerosakan lebih teruk. Jika proses kerosakan berlarutan teknik 'bukan operatif' ini mungkin perlu digabung dengan pengendalian 'operatif' yang melibatkan tampalan dan restorasi gigi yang berlubang akibat kerosakan yang menghalang daripada dicuci. Tampalan akan memperbaiki rupa bentuk gigi dan membolehkan pesakit membersihkannya.
Secara tradisi, doktor gigi akan membersihkan kerosakan dengan alat gerudi pergigian sebelum bahan tampalan diletakkan. Walau bagaimanapun, pembuangan bahagian gigi yang rosak mempunyai beberapa keburukan termasuk kerosakan saraf gigi, sakit gigi dan mungkin juga melemahkan struktur gigi. Kaedah ini dipanggil pembuangan karies sempurna dalam satu langkah.
Walaupun banyak tampalan dan restorasi dibuat di seluruh dunia setiap hari, doktor gigi masih tidak pasti strategi 'pengendalian operatif' terbaik untuk kerosakan gigi. Ulasan yang dibuat oleh penyelidik-penyelidik Kumpulan Kesihatan Oral Cochrane ini bertujuan menilai cara yang paling berkesan untuk merawat dan mengendali kerosakan gigi (karies gigi) apabila kaedah operatif diguna dalam gigi susu dan gigi kekal.
Carian terkini untuk kajian-kajian yang relevan bagi ulasan ini dibuat pada 12hb Disember 2012. Lapan kajian dengan 934 pesakit (1372 gigi) dimasukkan.
Tiga intervensi pengendalian karies alternatif dinilai dengan membandingkan rawatan tradisional membuang semua kerosakan gigi dalam satu langkah (pembuangan karies sempurna) Intervensi tersebut adalah
- Ekskavasi berperingkat - teknik membuang karies berperingkat dalam dua lawatan selang beberapa bulan, membolehkan pulpa gigi sembuh dan membentuk lapisan dentin.
- Pembuangan karies separa - doktor gigi membuang sebahagian dentin berkaries dan memengap dengan kekal selebihnya dentin berkaries dalam gigi.
- Tiada pembuangan dentin berkaries - tiada dentin berkaries dibuang sebelum memengap atau merestorasi.
Apabila teknik pembuangan karies sempurna dibanding dengan ekskavasi berperingkat, 347 dari setiap 1000 pulpa atau saraf gigi mungkin terdedah dengan teknik pembuangan karies sempurna sedangkan bagi penggunaan teknik ekskavasi berperingkat, pendedahan hanya berlaku kepada 154 dari 1000 gigi.
Apabila teknik pembuangan karies separa diguna, didapati 50 daripada 1000 pulpa atau saraf gigi mungkin terdedah. Walau bagaimanapun, apabila teknik pembuangan karies sempurna diguna, angka ini mungkin berubah menjadi 219 setiap 1000 gigi yang dirawat.
Terdapat kurang kerosakan apabila sebahagian atau semua kerosakan ditinggalkan bagi gigi susu dan gigi kekal. Tiada perbezaan bilangan gigi yang sakit dengan sebarang teknik-teknik tersebut. Salah satu teknik tanpa pembuangan karies memerlukan kurang penggantian tampalan, walaupun tiada sebarang perbezaan didapati apabila membandingkan teknik-teknik lain untuk melengkapkan pembuangan karies
Dalam kajian-kajian tersebut, kebanyakan tampalan diletakkan oleh doktor pakar pergigian dan gigi-gigi tersebut dipantau dengan singkat (1 tahun) Lebih banyak mkajian diperlukan untuk membantu menjawab soalan lanjutan. Sebilangan kecil kajian mungkin boleh dibuat oleh doktor gigi yang bukan pakar untuk menentukan sama ada keputusan adalah sama. Kajian-kajian ini sepatutnya menyusul pesakit untuk jangkamasa lebih lama untuk menentukan jika ada sebarang perbezaan sakit gigi, kerosakan lanjutan dan penggantian tampalan. Ia juga patut menentukan teknik yang dipilih oleh pesakit dan jika ada perbezaan kos dalam jangkamasa panjang.
Diterjemahkan oleh Noorliza Mastura Ismail (Kolej Perubatan Melaka-Manipal). Disunting oleh Mohd. Shaharudin Shah Che Hamzah (Universiti Sains Malaysia). Untuk sebarang pertanyaan berkaitan terjemahan ini sila hubungi firstname.lastname@example.org
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.
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, I2 = 0%). This is a large effect based on moderate quality evidence (Summary of findings for the main comparison).
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, I2 = 0%). This large effect is also based on moderate quality evidence (Summary of findings 2).
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, I2 = 0%). The small sample size was reflected in the wide confidence intervals, with Lula 2009 reporting one case of pulpal necrosis in the complete removal group (Summary of findings 2).
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
This systematic review which has only randomised controlled trials has found similar encouraging results to two review papers (Hayashi 2011; Thompson 2008) that have also included clinical trials.
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$))
18. 16 and 17
19. 4 or 5 or 6
20. 7 or 8 or 9 or 10 or 18
21. 3 and 19 and 20
The above subject search was linked to the Cochrane Highly Sensitive Search Strategy (CHSSS) for identifying randomised trials in MEDLINE: sensitivity maximising version (2008 revision) as referenced in Chapter 126.96.36.199 and detailed in box 6.4.c of the Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 (updated March 2011) (Higgins 2011).
1. randomized controlled trial.pt.
2. controlled clinical trial.pt.
5. drug therapy.fs.
10. exp animals/ not humans.sh.
11. 9 not 10
Appendix 4. EMBASE (OVID) search strategy
1. exp DENTAL CARIES/
2. ((tooth or tooth or dental$) 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
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.