Journal of Dentistry 99 (2020) 103416

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Journal of Dentistry
journal homepage: www.elsevier.com/locate/jdent

Restorations after selective caries removal: 5-Year randomized trial T

a b a b
Juliana Jobim Jardim , Heliana Dantas Mestrinho , Bárbara Koppe , Lilian Marly de Paula ,
Luana Severo Alvesc,*, Paulo Márcio Yamagutib, Júlio César Franco Almeidab, Marisa Maltza
a
Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil
b
Brasilia University, Brasilia, DF, Brazil
c
Federal University of Santa Maria, Santa Maria, RS, Brazil

ARTICLE INFO ABSTRACT

Keywords: Objective: To compare the survival of restorations placed in deep caries lesions after selective caries removal to
Dental caries soft dentin (SCRSD) over a 5-year period. A secondary aim was to investigate whether the material (amalgam or
Permanent teeth resin composite) affected the survival of restorations.
Selective caries removal Methods: This study used data derived from a multicenter randomized controlled clinical trial (Clinical trials
Survival analysis
registration NCT00887952). Inclusion criteria were: patients with permanent molars presenting occlusal or
Amalgam
proximal deep caries lesions (≥1/2 of the dentin thickness on radiographic examination), positive response to a
Resin composite
cold test, absence of spontaneous pain, negative sensitivity to percussion, and absence of periapical lesions. The
teeth were randomized into SCRSD and restoration in a single visit or stepwise excavation (SW). Each of these
groups was divided according to the filling material: amalgam (AM) or resin composite (RC). Survival analyses
were performed to estimate therapy success rates over 5 years (adjusted Weibull regression model).
Results: 172 restorations were evaluated, 95 from SCRSD group and 77 from SW group, being 61 AMG and 111
RC. The 5-year survival analysis showed similar success rates for SW (76 %) and SCRSD (79 %) as well as for AM
and RC (p > 0.05).
Conclusion: This study showed that, after a 5-year follow-up period, the presence of decayed tissue beneath
restorations in deep caries lesions did not seem to affect restoration survival. Amalgam and resin composite
restorations had similar survival rates, irrespective of the caries removal technique used – SCRSD or SW.
Clinical significance: Selective caries removal to soft dentin can be used in the management of deep caries to
avoid pulp exposure and preserve tooth structure without affecting restoration longevity.

1. Introduction after incomplete excavation compared to a control group submitted to

Selective caries removal to soft dentin (SCRSD) followed by re-
storation has been proposed as a single-visit approach to manage deep
caries lesions in permanent teeth [1]. Several studies targeting pulp
vitality and dentin reactions have shown the beneficial effects of the
therapy [1–10]; however, just a few assessed the clinical performance
of restorations placed over decayed tissue. This could be a problem,
since the layer of soft tissue left on the pulpal/axial floor of the cavity
could influence some mechanical properties of restorations, such as
bond strength and marginal stress.
In vitro studies have been conducted assessing restoration perfor-
mance after SCRSD [11–13]. Hevinga et al. [11] analyzed the im-
mediate fracture strength of extracted teeth with natural deep caries
lesions receiving restorations placed over residual caries. The authors
showed a significant reduction of fracture strength of teeth restored
complete excavation. On the other hand, Schwendicke et al. [12,13]
studying extracted teeth with artificial caries lesions restored after
SCRSD found no difference between test and control groups regarding
marginal integrity, secondary caries, fracture resistance, and cuspal
deflection.
Clinical studies are also scarce on this subject. A 10-year follow-up
study showed that sealed composite restorations placed over decayed
tissue performed similarly to conventional amalgam restorations placed
after complete caries removal in shallow caries lesions [14]. Maltz et al.
[7] assessing the survival of restorations placed immediately after
SCRSD in deep caries lesions found survival rates of 82 % and 63 %
after 5 and 10 years, respectively, combining all reasons for failure
(restoration fractures and pulp necrosis). Hoefler et al. [15] conducted a
systematic review on restoration survival aiming to compare SCRSD
and stepwise excavation (SW, two-step complete caries removal);

⁎
Corresponding author at: Department of Restorative Dentistry UFSM, Roraima, 1000. Building 26 F, 97105-900, Santa Maria, RS, Brazil.
E-mail address: luanaseal@gmail.com (L.S. Alves).

https://doi.org/10.1016/j.jdent.2020.103416
Received 28 April 2020; Received in revised form 17 June 2020; Accepted 20 June 2020
0300-5712/ © 2020 Elsevier Ltd. All rights reserved.
J.J. Jardim, et al.
however, no randomized clinical trial has compared both techniques.
More recently, a pilot study comparing SCRSD and SW for the treatment
of deep caries lesions in permanent teeth included pulp vitality and
restoration integrity as part of the outcome definition [16]; however, as
no restorative failure was detected in this 1-year follow-up study, no
conclusion on restoration survival could be drawn. As discussed by the
authors, for restorative complications and to discern possible re-
storative advantages of SW over SCRSD, longer-term data are required.
There is no long-term study assessing the survival of restorations
placed over decayed tissue in permanent teeth using a proper control
group. Therefore, the aim of this study was to compare the survival of
restorations placed in deep caries lesions after SCRSD over a 5-year
period using data derived from a multicenter randomized controlled
clinical trial. A secondary aim was to investigate whether the material
(amalgam or resin composite) affected the survival of restorations.
2. Materials and methods
2.1. Study design
This study used data derived from a multicenter randomized con-
trolled clinical trial conducted to compare SCRSD and SW for the
treatment of deep caries lesions in permanent molars (Registration
number at www.clinicaltrials.gov NCT00887952). The 5-year outcomes
regarding pulp vitality are published elsewhere [1]. Briefly, treatments
were performed by 22 dentists during two years (2005–2007), invol-
ving centers located at two Brazilian cities: Brasília (Midwest region)
and Porto Alegre (South region). The clinical procedures were per-
formed at Public Health Centers and Brazilian Public Universities. Main
researchers (MM and LMP) updated and trained the operators before
the beginning of the study. The materials used to perform the treat-
ments as well as the clinical files were supplied by the South center to
all treatment centers, ensuring standardization.
The study protocol was approved by the Federal University of Rio
Grande do Sul Ethics Committee (protocol 18/05), the Porto Alegre
Municipal Ethics Committee (protocol 27/06 and registration number
001000837067), the Conceição Hospital Ethics Committee (protocol
070/05), and the Brasilia University Hospital Ethics Committee (pro-
tocol 045/2005). The research was conducted ethically in accordance
with the World Medical Association Declaration of Helsinki. All parti-
cipants or their legal guardians signed a written informed consent.
Patients had their dental needs provided by the researchers during the
whole study period, except prosthetic rehabilitation and orthodontic
treatment. No financial incentive was paid for the participants.
2.2. Sample
Subjects regularly attending the public services, community pro-
grams, and local schools were enrolled in the study. The inclusion cri-
teria were: patients with permanent molars presenting primary occlusal
or proximal deep caries lesion (lesion affecting ≥1/2 of the dentin
thickness on radiographic examination); positive response to the cold
test (refrigerated gas); absence of spontaneous pain; negative sensitivity
to percussion and absence of periapical lesion (radiographic examina-
tion). Teeth presenting cuspal loss or caries beneath the gingival margin
were excluded from the study.
Sample size calculation was performed based on the survival of
restorations placed after SCRSD (66 %) and complete caries removal
(86 %) described by Franzon et al. [17], at α = 5 %, with a power of 80
%. The number of required treatments per group was 71. Considering a
dropout rate of 56 %, the final number of treatments needed per group
was set on 111.
2.3. Study groups, randomization procedures and blinding
The subjects were randomly assigned into test or control groups:
2
Journal of Dentistry 99 (2020) 103416
Test - SCRSD plus restoration in one session; or Control - SW. Each of
these groups was divided according to the filling material: amalgam or
resin composite.
The unit of randomization was the tooth. The randomization pro-
cedure was performed by raffle. The treatment group was printed on a
paper, numerated and kept on a dark flask. A different person from the
operator selected a paper from the dark flask at the appropriate mo-
ment (see clinical procedures). The filling material was determined on a
weekly basis, alternating in each center between amalgam and resin.
Blinding of the patients was not possible because a different number
of appointments was required for each treatment. The operator was
blinded until randomization to avoid biases with regard to the removal
of decayed dentin. The clinical assessment of the restorations was
performed blindly as well as the statistical analysis. Data were recorded
in the clinical files and then transferred to a digital system (http://
odonto.cityzoom.net).
2.4. Clinical and evaluation procedures
Patients were submitted to the following procedures: anesthesia and
rubber dam isolation of the area to be treated; access to the lesion using
rotating diamond burs on rotator instruments, if necessary; complete
removal of carious dentin on the surrounding cavity walls according to
the hardness criteria (low-speed metal burs and/or hand excavators);
SCRSD (only disorganized dentin was removed) on the pulpal/axial
wall using hand instruments (Bjorndal and Thylstrup, 1998); washing
of the cavity with distilled water; drying with sterile filter paper; group
randomization. Teeth allocated to the SCRSD group received: partial
filling of the cavity with glass-ionomer cement (Vitro Fil, DFL, Rio de
Janeiro, RJ, Brazil); restoration using amalgam capsule system (GS-80,
SDI, Bayswater WA, Australia; Ultramat 2, SDI, Bayswater WA,
Australia) or resin composite (Tetric EvoCeram + Excite + Total Etch,
Ivoclar/Vivadent, Liechtenstein). Teeth allocated to the SW group re-
ceived: indirect pulp capping with calcium hydroxide cement (Dycal,
Caulk/Dentsply, Rio de Janeiro, RJ, Brazil) and temporary filling with a
modified zinc oxide-eugenol cement (IRM, Caulk/Dentsply, Rio de
Janeiro, RJ, Brazil); cavity reopening after a median time of 90 days
(P25-P75=60-150; mean ± standard deviation[sd] = 120 ± 120), fol-
lowed by the removal of the remaining decayed dentin and filling ac-
cording to the same procedures described to SCRSD group. In the resin
composite restorations, the incremental technique was used according
to the following procedures: etching with 37 % phosphoric acid for 30 s
in enamel and 15 s in dentin (phosphoric acid, Total Etch – Ivoclar/
Vivadent, Liechtenstein); washing for 20 s; application of Excite ad-
hesive system (Ivoclar/Vivadent, Liechtenstein) with micro brush in
enamel and dentin walls and rubbing for 20 s; gentle air-drying for
approximately 5 s for solvent evaporation; light curing for 20 s
(Bluephase, Ivoclar/Vivadent, Liechtenstein); application of a nanohy-
brid composite resin (Tetric EvoCeram, Ivoclar/Vivadent,
Liechtenstein) using the incremental technique; light curing for 20 s of
each 2 mm increment (Bluephase, Ivoclar/Vivadent, Liechtenstein);
removal of the rubber dam isolation; occlusal adjust, finishing and
polishing with diamond burs (nº1190 F, KG Sorensen, Cotia – SP,
Brazil) and Astropol and Astrobrush (Bluephase, Ivoclar/Vivadent,
Liechtenstein).
Clinical evaluation of the restorations was carried out by trained
dentists right after the treatment and then annually. Restorations were
classified according to marginal integrity, anatomical shape and ad-
jacent carious lesion using the modified USPHS criteria [18]. If the
restoration received a Charlie or Delta score on at least one of these
characteristics, it was considered a failure for the purpose of this study.
Subjects’ sex, age, region (Midwest or South), number of restored
surfaces, and DMFT were recorded as baseline characteristics.
J.J. Jardim, et al.
2.5. Statistical analysis
The primary outcome of the study was restoration failure.
Intervention groups were compared according to baseline character-
istics (sex, age, region, filling material, caries removal technique, and
number of restored surfaces) using the chi-square test. Followed pa-
tients and those lost to follow-up were also compared using the chi-
square test.
Parametric survival models with individual level frailty were used
with the caries removal technique (SCRSD versus SW) as the main
predictor variable. Estimates were adjusted for potential predictors of
treatment failure, such as sex (male versus female), age (≤17 years
versus >17 years), region (Midwest versus South), filling material
(amalgam versus resin composite), number of restored surfaces (one
versus two or more), type of molar (first versus second/third), and
dental arch (upper versus lower). Because the carious responses are
clustered within a subject, statistical methods must account for the
correlation between teeth within a subject. The goodness of fit test with
the likelihood statistic was used to compare nested models and the
Weibull regression model was used for adjusting the data. Censored
observation (missing data) was stipulated for all patients lost to follow-
up. All patients evaluated at least once contributed to survival rate. The
time to the event was counted and analyzed in days. The significance
level was set in 5% and the unit of analysis was the restoration.
Analyses were performed using STATA software, version 12.0.
A secondary analysis stratifying the sample by caries removal
technique was performed to investigate a possible confounding effect of
treatment group on the association between filling material and re-
storation failure.
3. Results
A total of 299 treatments were performed in 233 patients, 152
SCRSD and 147 SW, randomized to receive 122 amalgam restorations
and 177 resin composite restorations. The median (P25-P75) number of
restorations per subject was 1 (1-1), with a mean (±sd) of 1.2 (±0.6).
Participants were mainly adolescents, with a mean (±sd) age of 17.2
(±10.9) years (median 14 years, minimum 6, maximum 53 years).
Most participants were public schools attendees (72 %). The mean
(±sd) DMFT was 7.9 (±5.7). No difference was observed between
intervention groups regarding baseline characteristics (p > 0.05).
Since 70 teeth were lost to follow-up, this 5-year study included
data pertaining to 229 teeth. At the 5-year recall, 57 restorations could
not be evaluated: 28 teeth have not undergone the complete ex-
amination; 20 teeth allocated in the SW group have not received the
restoration with amalgam or resin composite (patients failed to attend
the second appointment of the SW protocol); and 9 restorations had
been replaced by another dentist for unknown reasons or the tooth had
been extracted. Therefore, 172 restorations had been evaluated, 77
from the SW group and 95 from the SCRSD group. Regarding the filling
material, 61 were amalgam restorations and 111 were resin composite
restorations. Fig. 1 presents the flowchart of the study. When evaluated
and non-evaluated patients were compared, the only difference was
observed in regard to region. A higher proportion of patients lost to
follow-up was observed in the Midwest region than in the South region
(p < 0.001).
Regarding the caries removal technique, the 5-year survival analysis
showed similar success rates for SW (76 %) and SCRSD (79 %), with no
difference between groups (p = 0.63). Regarding the filling material,
amalgam and resin composite restorations showed similar 5-year sur-
vival rates (83 % and 75 %, respectively, p = 0.66). Fig. 2 presents the
survival curves comparing the caries removal technique (Fig. 2A) and
the filling material (Fig. 2B).
Table 1 shows the adjusted Weibull regression model assessing the
association between predictor variables and restoration failure. None of
the studied variables was significantly associated with the outcome.
3
Journal of Dentistry 99 (2020) 103416
The stratified analysis by caries removal technique showed no effect of
the filling material on restoration survival (p > 0.05).
Out of 29 restoration failures observed over the study period
(SCRSD = 16, SW = 13), the vast majority (n = 28) were restoration
fracture. There was only one case of failure due to secondary caries.
4. Discussion
This study compared the survival of amalgam and resin composite
restorations placed in permanent molars with deep caries lesions placed
on two different subtracts, soft carious dentin (SCRSD group) and firm
dentin (SW group). The 5-year follow-up results showed that neither
the caries removal technique nor the filling material affected the
longevity of restorations. To the best of our knowledge, this is the first
long-term randomized clinical trial assessing this issue in permanent
teeth.
The beneficial effect of SCRSD on pulp vitality outcomes has been
already shown in this same sample [1]. Survival analysis showed suc-
cess rates of 80 % for SCRSD and 56 % for SW (p < 0.001), with teeth
receiving SCRSD being 62 % less likely to present pulp necrosis than
teeth receiving SW (adjusted Hazard Ratio = 0.38; 95
%CI = 0.23−0.63; p < 0.001) [1]. In that study, restorative failures
were not computed since the focus was the biological events taking
place after the sealing of decayed dentin, being the survival of re-
storations placed over carious tissue still unclear. In the present study,
focusing in the restorative outcomes, the survival rate of restorations
placed after SCRSD was similar to that of conventional restorations
placed after complete caries removal (SW group); thereby suggesting
that leaving decayed tissue (soft dentin) at the cavity floor does not
seem to compromise the clinical performance of restorations over a 5-
year period. This finding contradicts the results by Hevinga et al. [11]
suggesting that incomplete caries removal reduced tooth strength when
compared with complete excavation. In fact, the study design adopted
in their in vitro study disregards the increase in hardness that occurs in a
vital tooth after the sealing of carious dentin, widely documented in the
literature using different outcomes, such as clinical hardness [4],
radiographic density [4,8], and microhardness [19, 20]. The present
clinical study showed a similar proportion of fractures over 5 years
irrespective of the caries removal technique adopted.
The annual failure rate of resin composite restorations observed in
the present study was about 5%, which is somewhat higher than the
annual failure rate of 3.17 % for conventional resin restorations placed
after complete caries removal found in the meta-analysis by Moraschini
et al. [21]. As previously shown in the literature, several factors other
than the material may influence restoration longevity, such as clinical
aspects and characteristics related to patients and to operators [22].
Concerning clinical aspects, in this study, a base with glass-ionomer
cement was applied, which has already been shown to significantly
affect the longevity of restorations due to the possible increased risk of
fatigue in the long-term [22]. In addition, we included only deep caries
lesions, which may have influenced the survival estimates, in contrast
to studies including caries lesions of different depths. It is possible to
speculate that the greater volume of restorative material and the re-
duced tooth remnant may have played a role in the study findings. The
effect of lesion depth on restoration survival, already shown for class II
restorations [23], was possibly observed in the present study. Re-
garding the characteristics related to patients, the caries risk is probably
the most relevant aspect [21, 24]. Opdam et al. [24] in a systematic
review with meta-analysis investigating the longevity of posterior
composite restorations showed annual failure rates of 4.6 %, 4.1 %, and
1.6 % for patients classified as high, medium, and low caries risk, re-
spectively. Given the mean DMFT of 7.9 and the mean age of 17.2 years
observed in our sample, it is possible to consider that the subjects in-
cluded in the present study were mainly high caries risk patients.
Notwithstanding, we do not believe this had a major impact on the
study findings because secondary caries was not the main reason for
J.J. Jardim, et al.
Fig. 1. Flowchat of the study.
failure. Lastly, some effect of the great number of operators on survival
rates cannot be disregarded in the present investigation.
There was no difference between the survival rates of amalgam and
resin composite restorations in this 5-year study, corroborating the
previous literature [21, 25]. Moraschini et al. [21] showed an overall
survival rate higher for amalgam than for resin composite restorations;
however, when the reason for failure was taken into account, this su-
periority was detected only for secondary caries, with no difference
between the two restorative materials in relation to fractures. No such
difference could be detected in our patients since only one case of
failure occurred due to secondary caries. We could speculate that fur-
ther reassessments of our patients could improve the study power and a
statistical difference between restorative materials could be reached,
since amalgam were found to be numerically superior to resin compo-
site in this 5-year follow-up. Opdam et al. [25] also found that resin and
amalgam restorations, placed after conventional carious dentine re-
moval, presented a comparable performance at 5 years, which is in
agreement with our results; however, after 12 years, a difference be-
tween these two materials were found.
Within the strengths of this study, we emphasize its high external
validity considering that treatments were performed by 22 dentists in
centers located in two different regions from Brazil and that it included
patients with a wide age range. In addition, this 5-year follow-up study
provides the first evidence on the longevity of restorations placed over
carious tissue in deep caries lesions in permanent teeth with a proper
control group. The lost to follow-up of 70 teeth and the lack of data on
57 restorations could be seen as a possible limitation of our study. We
Fig. 2. Survival curves comparing the caries removal technique (Fig. 2A) and the filling material (Fig. 2B).
4
Journal of Dentistry 99 (2020) 103416
acknowledge that attrition bias is a concern on long-term studies and
that it could compromise the reliability of clinical studies. For this
reason, a high dropout rate was anticipated in the sample size calcu-
lation and followed cases were compared with those lost to follow-up. A
possible effect of the variable “region” on the study results was ad-
dressed by the inclusion of this and other predictor variables in the
adjusted model.
5. Conclusions
This study showed that, after a 5-year follow-up period, the pre-
sence of decayed tissue beneath restorations in deep caries lesions did
not seem to affect restoration survival. Amalgam and resin composite
restorations had similar survival rates irrespective of the caries removal
technique used – SCRSD or SW. SCRSD can be used in the management
of deep caries to avoid pulp exposure and preserve tooth structure
without affecting restoration longevity.
Declaration of Competing Interest
The authors declare that they have no known competing financial
interests or personal relationships that could have appeared to influ-
ence the work reported in this paper.
CRediT authorship contribution statement
Juliana Jobim Jardim: Data curation, Formal analysis, Writing -
J.J. Jardim, et al. Journal of Dentistry 99 (2020) 103416

Table 1 [2] L. Bjørndal, T. Larsen, A. Thylstrup, A clinical and microbiological study of deep
Association between predictor variables and restoration failure (adjusted carious lesions during stepwise excavation using long treatment intervals, Caries
Weibull regression model). n = 172. Res. 31 (6) (1997) 411–417.
[3] L. Bjørndal, H. Fransson, G. Bruun, M. Markvart, M. Kjældgaard, P. Näsman,
Variables Adjusted Weibull Regression A. Hedenbjörk-Lager, I. Dige, M. Thordrup, Randomized clinical trials on deep
carious lesions: 5-year follow-up, J. Dent. Res. 96 (7) (2017) 747–753.
N (%) HR 95 % CI p [4] M. Maltz, E.F. de Oliveira, V. Fontanella, R. Bianchi, A clinical, microbiologic, and
radiographic study of deep caries lesions after incomplete caries removal,
Sex Quintessence Int. (Berl) 33 (2) (2002) 151–159.
[5] E.F. Oliveira, G. Carminatti, V. Fontanella, M. Maltz, The monitoring of deep caries
Male 66 (38) 1.00
lesions after incomplete dentine caries removal: results after 14-18 months, Clin.
Female 106 (62) 0.94 0.41−2.20 0.90
Oral Investig. 10 (2) (2006) 134–139.
Age [6] M. Maltz, E.F. de Oliveira, V. Fontanella, G. Carminatti, Deep caries lesions after
≤ 17 years 113 (66) 1.00 incomplete dentine caries removal: 40-month follow-up study, Caries Res. 41 (6)
> 17 years 59 (34) 0.78 0.31−1.93 0.59 (2002) 493–496.
Region [7] M. Maltz, L.S. Alves, J.J. Jardim, M.S. Moura, E.F. de Oliveira, Incomplete caries
Midwest 93 (54) 1.00 removal in deep lesions: a 10-year prospective study, Am. J. Dent. 24 (4) (2011)
South 79 (46) 1.86 0.77−4.46 0.17 211–214.
Caries removal technique [8] L.S. Alves, V. Fontanella, A.C. Damo, E.F. de Oliveira, M. Maltz, Qualitative and
SW 77 (45) 1.00 quantitative radiographic assessment of sealed carious dentin: a 10-year prospective
SCRSD 95 (55) 0.83 0.41−1.69 0.61 study, Oral Surg. Oral Med. Oral Pathol. Oral Radiol. Endod. 109 (1) (2010)
Filling material 135–141.
Amalgam 61 (35) 1.00 [9] M. Maltz, J.J. Jardim, H.D. Mestrinho, P.M. Yamaguti, K. Podestá, M.S. Moura,
L.M. de Paula, Partial removal of carious dentine: a multicenter randomized con-
Resin composite 111 (65) 1.50 0.55−4.12 0.43
trolled trial and 18-month follow-up results, Caries Res. 47 (2) (2013) 103–109.
Number of restored surfaces
[10] M. Maltz, R. Garcia, J.J. Jardim, L.M. de Paula, P.M. Yamaguti, M.S. Moura,
One 150 (87) 1.00
F. Garcia, C. Nascimento, A. Oliveira, H.D. Mestrinho, Randomized trial of partial
Two or more 22 (13) 0.46 0.11−1.94 0.29 vs. stepwise caries removal: 3-year follow-up, J. Dent. Res. 91 (11) (2012)
Type of molar 1026–1031.
First 105 (61) 1.00 [11] M.A. Hevinga, N.J. Opdam, J.E. Frencken, G.J. Truin, M.C. Huysmans, Does in-
Second/third 67 (39) 1.16 0.52−2.59 0.71 complete caries removal reduce strength of restored teeth? J. Dent. Res. 89 (11)
Dental arch (2010) 1270–1275.
Upper 77 (45) 1.00 [12] F. Schwendicke, M. Kern, H. Meyer-Lueckel, A. Boels, C. Doerfer, S. Paris, Fracture
Lower 95 (55) 0.74 0.33−1.67 0.47 resistance and cuspal deflection of incompletely excavated teeth, J. Dent. 42 (2)
(2014) 107–113.
SW = Stepwise excavation; SCRSD = Selective caries removal to soft dentin. [13] F. Schwendicke, M. Kern, U. Blunck, C. Dörfer, J. Drenck, S. Paris, Marginal in-
tegrity and secondary caries of selectively excavated teeth in vitro, J. Dent. 42 (10)
HR = Hazard ratio; CI = Confidence interval. (2014) 1261–1268.
[14] E.J. Mertz-Fairhurst, J.W. Curtis Jr, J.W. Ergle, F.A. Rueggeberg, S.M. Adair,
original draft, Writing - review & editing. Heliana Dantas Mestrinho: Ultraconservative and cariostatic sealed restorations: results at year 10, J. Am.
Dent. Assoc. 129 (1) (1998) 55–66.
Conceptualization, Supervision, Project administration, Writing - re-
[15] V. Hoefler, H. Nagaoka, C.S. Miller, Long-term survival and vitality outcomes of
view & editing. Bárbara Koppe: Data curation, Writing - review & permanent teeth following deep caries treatment with step-wise and partial-caries-
editing. Lilian Marly de Paula: Conceptualization, Supervision, Project removal: a Systematic Review, J. Dent. 54 (2016) 25–32.
[16] M.E. Labib, O.E. Hassanein, M. Moussa, A. Yassen, F. Schwendicke, Selective versus
administration, Writing - review & editing. Luana Severo Alves:
stepwise removal of deep carious lesions in permanent teeth: a randomised con-
Formal analysis, Writing - original draft, Writing - review & editing. trolled trial from Egypt-an interim analysis, BMJ Open 9 (9) (2019) e030957.
Paulo Márcio Yamaguti: Data curation, Writing - review & editing. [17] R. Franzon, N.J. Opdam, L.F. Guimarães, F.F. Demarco, L. Casagrande, A.N. Haas,
Júlio César Franco Almeida: Data curation, Writing - review & F.B. Araujo, Randomized controlled clinical trial of the 24-months survival of
composite resin restorations after one-step incomplete and complete excavation on
editing. Marisa Maltz: Conceptualization, Funding acquisition, primary teeth, J. Dent. 43 (10) (2015) 1235–1241.
Supervision, Project administration, Writing - original draft, Writing - [18] J.G. Cvar, G. Ryge, Reprint of criteria for the clinical evaluation of dental re-
review & editing. storative materials, Clin. Oral. Invest. 9 (2005) 215–232.
[19] J.J. Marchi, A.M. Froner, H.L. Alves, C.P. Bergmann, F.B. Araújo, Analysis of pri-
mary tooth dentin after indirect pulp capping, J. Dent. Child. (Chic) 75 (3) (2008)
Acknowledgments 295–300.
[20] R. Franzon, M. Gomes, C.M. Pitoni, C.P. Bergmann, F.B. Araújo, Dentin rehardening
after indirect pulp treatment in primary teeth, J. Dent. Child. (Chic) 76 (3) (2009)
We acknowledge the support of CAPES (finance code 001), CNPq 223–228.
(40.3420/04-0), FAPERGS (04/1531-8), and the industries DFL (Rio de [21] V. Moraschini, C.K. Fai, R.M. Alto, G.O. Dos Santos, Amalgam and resin composite
Janeiro, Brazil), Ivoclar/Vivadent (Schaan, Liechtenstein), SDI longevity of posterior restorations: a systematic review and meta-analysis, J. Dent.
43 (9) (2015) 1043–1050.
(Bayswater WA, Australia), and Hu-Friedy (Chicago IL, USA). The au-
[22] F.F. Demarco, M.B. Corrêa, M.S. Cenci, R.R. Moraes, N.J. Opdam, Longevity of
thors certify that there is no conflict of interest with any financial or- posterior composite restorations: not only a matter of materials, Dent. Mater. 28 (1)
ganization. (2012) 87–101.
[23] S.E. Kopperud, A.B. Tveit, T. Gaarden, L. Sandvik, I. Espelid, Longevity of posterior
dental restorations and reasons for failure, Eur. J. Oral Sci. 120 (6) (2012) 539–548.
References [24] N.J. Opdam, F.H. van de Sande, E. Bronkhorst, M.S. Cenci, P. Bottenberg,
U. Pallesen, P. Gaengler, A. Lindberg, M.C. Huysmans, J.W. van Dijken, Longevity
[1] M. Maltz, B. Koppe, J.J. Jardim, L.S. Alves, L.M. de Paula, P.M. Yamaguti, of posterior composite restorations: a systematic review and meta-analysis, J. Dent.
J.C.F. Almeida, M.S. Moura, H.D. Mestrinho, Partial caries removal in deep caries Res. 93 (10) (2014) 943–949.
lesions: a 5-year multicenter randomized controlled trial, Clin. Oral Investig. 22 (3) [25] N.J. Opdam, E.M. Bronkhorst, B.A. Loomans, M.C. Huysmans, 12-year survival of
(2018) 1337–1343. composite vs. Amalgam restorations, J. Dent. Res. 89 (10) (2010) 1063–1067.