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ABSTRACT INTRODUCTION
Increasing numbers of clinical trials have demon-
strated the benefits of incomplete caries removal,
in particular in the treatment of deep caries. This
F or nearly a century, dental caries has been treated by attempted eradica-
tion: Bacteria and all infected dental biomass (Fusayama et al., 1966)
were removed, and the resulting cavity was subsequently restored. As knowl-
study systematically reviewed randomized con-
edge and attitudes concerning the dental biofilm and pathogenesis of caries
trolled trials investigating one- or two-step incom-
changed, the common treatment procedure for caries lesions was questioned
plete compared with complete caries removal.
as well (Kidd, 2004). The complete removal of all carious tooth substance
Studies treating primary and permanent teeth with
from cavitated lesions is no longer seen as mandatory, and there is growing
primary caries lesions requiring a restoration were
evidence supporting incomplete removal of carious tissue before the cavity is
analyzed. The following primary and secondary
restored (Banerjee et al., 2001). Theoretically, it is argued, a completely sealed
outcomes were investigated: risk of pulpal expo-
remaining caries lesion should be arrested. Hence, therapy of cavitated lesions
sure, post-operative pulpal symptoms, overall fail-
may require less focus on complete excavation than on adequate r estorations
ure, and caries progression. Electronic databases
(Ricketts, 2001; Kidd, 2004).
were screened for studies from 1967 to 2012.
This re-thinking of caries treatment is based on a new understanding of the
Cross-referencing was used to identify further
disease: Caries is currently seen as the result of an ecologic shift within the
articles. Odds ratios (OR) as effect estimates were
dental biofilm to acidogenic and aciduric bacterial species, frequently created
calculated in a random-effects model. From 364
and maintained by abundant dietary fermentable carbohydrates. The patho-
screened articles, 10 studies representing 1,257
logic alteration of the pH leads to an imbalance between de- and remineraliza-
patients were included. Meta-analysis showed risk
tion, and extensively demineralized dental substance eventually cavitates,
reduction for both pulpal exposure (OR [95% CI]
thus creating clinical “decay” (Kidd, 2004; Kidd and Fejerskov, 2004; Marsh,
0.31 [0.19-0.49]) and pulpal symptoms (OR 0.58
2006). Generations of dentists have removed all infected enamel and dentin
[0.31-1.10]) for teeth treated with one- or two-step
using excavators or high- and low-speed instruments, thus risking exposure of
incomplete excavation. Risk of failure seemed to
the pulp. When one bears in mind the pathogenesis of caries, this might not
be similar for both complete and incomplete exca-
be necessary: Instead of attempting to remove all bacteria, it should be suffi-
vation, but data for this outcome were of limited
cient to re-shift the ecologic and metabolic balance within the biofilm, thus
quality and inconclusive (OR 0.97 [0.64-1.46]).
promoting remineralization, thereby arresting the caries lesions (Bjørndal and
Based on reviewed studies, incomplete caries
Kidd, 2005). Large numbers of studies investigating the sealing of fissure
removal seems advantageous compared with com-
caries have demonstrated such effects. They showed reduction of bacterial
plete excavation, especially in proximity to the
number and activity, and the clinical, microbiological, and radiological signs
pulp. However, evidence levels are currently insuf-
of caries inactivation and dentin remineralization (Handelman et al., 1976,
ficient for definitive conclusions because of high
1985; Oong et al., 2008). In contrast, a retrospective analysis found bacteria
risk of bias within studies.
in 53% of sealed caries lesions, with moist and soft dentin under clinically
intact sealants (Weerheijm et al., 1992). However, a range of treatment con-
KEY WORDS: dental caries, dental cavity prepa- cepts, like caries sealing with resins or crowns (Griffin et al., 2008; Innes
ration, partial excavation, indirect pulp treatment, et al., 2011) or caries infiltration (Paris et al., 2010), successfully use the
dental pulp exposure, dental pulp capping. described inactivation and remineralization effects.
For deeper, cavitated caries lesions, removal of carious substance followed
DOI: 10.1177/0022034513477425 by a restoration to reinstate the outline of the tooth is currently seen as clinical
standard, thus allowing for mechanical plaque control. However, there is no
Received November 22, 2012; Last revision January 14,
2013; Accepted January 14, 2013
consensus on how much carious dentin needs to be removed, partially due to
insufficient methods of easily, reproducibly, and objectively measuring caries
A supplemental appendix to this article is published elec- removal.
tronically only at http://jdr.sagepub.com/supplemental.
There are currently 2 options for performing incomplete caries removal: In
© International & American Associations for Dental Research two-step (or “stepwise”) caries treatment, carious dentin is incompletely
1
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removed at the first step and remains in proximity to the pulp Outcomes
under a temporary filling. In a second visit some months later, a
re-entry procedure is performed, and complete removal of all We recorded one or more of the following clinical outcomes:
carious tissue and a definitive restoration are provided. Thus, pulpal exposure during treatment; post-operative pulpal symp-
remineralization and development of tertiary dentin within the toms (clinical or radiological pulp symptoms requiring treat-
pulp chamber between the 2 visits are facilitated (Bjørndal ment, e.g., pain, irreversible pulpitis, loss of vitality), and failure
et al., 1997; Bjørndal and Larsen, 2000). One-step incomplete (technical or biological complications demanding intervention,
or partial caries removal omits the re-entry stage, since residual e.g., restorations lost or to be replaced, pulpitis, non-restorable
caries is sealed under a definitive restoration in the first and only teeth).
visit. However, the amount of carious dentin left is variable: Intervention and Control
Some studies removed just enamel and did not excavate at all
within dentin (Mertz-Fairhurst et al., 1998; Phonghanyudh Incomplete (one- or two-step excavation, indirect pulp treat-
et al., 2012); others reported removal of affected enamel and ment, or capping) and complete caries removal techniques were
some dentin, leaving soft and moist carious mass on the floor investigated. If re-entry was performed for cavity floor assess-
(Ribeiro et al., 1999; Lula et al., 2009). Most studies left only a ment or microbiological sampling, but no further excavation
thin layer of carious substance above the pulp, thus creating a was attempted, this was not classified as stepwise, but as one-
more or less leathery surface. This technique, often combined step incomplete caries removal. Studies investigating non-
with the use of liners on the pulpal wall, has been called indirect restorative treatment (remineralization, non-restorative cavity
pulp capping or indirect pulp treatment (King et al., 1965; treatment), non-invasive treatment (caries sealing or infiltra-
Langeland and Langeland, 1968; Casagrande et al., 2010). tion), or non-clinical or case studies were excluded.
There is no consensus concerning the suitability of the
abovementioned methods for treating caries lesions before Search Strategy
restoring a cavity. A systematic Cochrane review published in
Identification of studies to be considered for inclusion was
2006 demonstrated possible benefits of incomplete over
based on a search strategy for each electronic database (Cochrane
complete caries removal (Ricketts et al., 2006). Since then,
Central Register of Controlled Trials, MEDLINE, PUBMED,
increasing numbers of clinical trials within this field have
EMBASE) between May 16, 2012, and July 23, 2012. Screening
been published. Another recent study systematically investi-
procedures were adjusted for higher sensitivity (with restrictive
gated stepwise excavation, but included case series and non-
search items omitted) if necessary. The detailed search sequence
clinical studies, so no meta-analysis was possible (Hayashi
can be found in Appendix Table 1. Cross-referencing from
et al., 2011). Both one- and two-step incomplete excavations
found studies was used to identify further articles to be assessed.
seem advantageous for the treatment of deep caries, but the
Unpublished trials were searched electronically (www.clinical-
inclusion of a higher number of studies would allow for the
trials.gov). The search was limited to the English and German
drawing of conclusions with a stronger evidence basis. This
languages. Neither authors nor journals were blinded to review-
systematic review therefore aimed to critically summarize
ers. Gray literature was not screened systematically. Title and
and evaluate results of randomized controlled trials (RCTs)
abstract of identified studies were screened by 2 calibrated
for both deciduous and permanent teeth, comparing complete
reviewers (FS and SP) for eligibility. Consensus was obtained
and incomplete caries removal techniques. Subsequently,
by discussion or consultation with a third reviewer (CD).
data for certain outcomes were to be summarized in a meta-
analysis. Furthermore, excluded studies illustrating the range
of reported results for somehow-incomplete caries-removal Data Extraction
techniques were summarized, and clinically relevant infor- Data from eligible studies were independently extracted by two
mation was extracted as well. Thus, an “inventory” of reviewers using piloted electronic spreadsheets (Excel 10,
researched knowledge within the field should be available for Microsoft, Redwood City, CA, USA). Data were recorded
practical and scientific purposes. according to guidelines outlined by the Cochrane Collaboration
(Higgins and Green, 2009), with additional extraction of caries
MATERIALS & METHODS excavation depth, possible liners, and restoration type. If data
were missing or methodological issues were to be addressed, the
Selection Criteria study author was contacted via e-mail, and, if appropriate, infor-
Studies mation was added to the data extraction.
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(unclear withdrawals or reported out- Records identified through Additional records identified
comes) were recorded, assessed, and database screening through cross-referencing
classified according to Cochrane guide- (n = 332) (n = 32)
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Table 1. Details of and Findings from Included Studies (in order retrieved)
Leksell et al., 1996 Multi-centered 116 (6-16); Two-step (64) CR (70) (“hard”) 24 wks, 4.3% yearly PE: 18% two-step,
parallel-group 134 primary molars; (“remaining 40% CR
RCT; university and caries with “risk of innermost layer PS: Non-exposed
clinics; Sweden pulp exposure” of carious dentin” teeth remained
left); re-entry after asymptomatic
8-24 wks F: 0% two-step, 0%
CR
Mertz-Fairhurst et al., Split-mouth RCT; 123 (8-52); One-step (156) CR, sealed AM (77) 10 yrs, 4.5% yearly F: Restoration failure
1998 university; USA 312 permanent with only enamel or AM (79) in 14% sealed, 2%
teeth; caries < 1/2 margins beveled, sealed AM, 17%
dentin no dentin caries AM
removal, resin CP: Caries in 1%
sealant sealed, 2% sealed
AM, 17% AM
Bjørndal et al., 2010 Multi-centered 314 (> 18); Two-step (156) CR (158) 12 mos, 7.1% yearly PE: 17% two-step,
parallel-group 314 permanent (leaving “soft, wet 29% CR
RCT; universities; molars; and discolored PS: 10% two-step,
Sweden and caries > 3/4 of dentin” at first 12% CR
Denmark dentin step); re-entry after F: 10% two-step,
8-12 wks 12% CR
Foley et al., 2004 Split-mouth RCT; 44 (3-9); One-step (36) CR (41) 24 mos, 11% yearly PS: More abscesses
university; 120 primary molars; restored with BCC in BCC group
Scotland dentin caries and GIC; one-step F: 23% GIC, 33%
(43) restored with BCC, 22% CR
just GIC CP: Caries increase
highest in CR
Ribeiro et al., 1999 Parallel-group RCT; 38 (7-11); One-step (24) CR (24) (dye) 12 mos, 0% yearly PS: 0% one-step,
university; Brazil 48 primary molars; (“partially 4% CR
dentin caries without removed, soft and F: 0% one-step,
risk of pulp moist dentin left”) 4% CR
exposure CP: 25% one-step
Orhan et al., 2010 Parallel-group RCT; 123 (4-15); One-step (50) (“thin CR (55) 12 mos, 0% yearly PE: 6% one-step, 8%
university; Turkey 154 (94 deciduous layer of soft tissue two-step, 22% CR
and 60 left”); two-step PS: 0% one-step, 2%
permanent) (49); re-entry after two-step, 5% CR
molars; 3 mos F: 0%/2% one/two-
caries > 3/4 dentin step, 5% CR-
Magnusson and Parallel-group quasi- 62 (5-10); Two-step (55) (“soft CR (55) (“until hard”) No follow-up PE: 11% two-step,
Sundell, 1977 RCT; university; 110 primary molars; layer of dentin 53% CR
Sweden caries “considered over the pulp”); PS: 5% two-step, CR
for stepwise re-entry after 4-6 not followed up
excavation” wks
Heinrich et al., 1991 Parallel-group 125 (6-7); Two-step (52) CR (52) (“hard with 16 mos,12% yearly PE: 15% two-step,
RCT; university; 125 primary molars; (“slightly soft”); explorer”) 31% CR
Germany deep caries re-entry after 6-8 PS: 8% two-step,
wks 18% CR
F: 8% two-step, 18%
CR
Lula et al., 2009 Parallel-group RCT; 30 (5-8); One-step (18) (“only CR (18) (dye) 6 mos, 5.7% yearly PE: 0% one-step,
university; Brazil 36 primary molars; superficial necrotic 22% CR
caries > 1/2 dentin dentin removed PS: 0% one-step,
from the pulpal 7% CR
and axial walls”) F: 0% one-step, 14%
CR
Phonghanyudh et al., Bi-centered parallel- 276 (6-11); One-step (92) (“soft CR (92) 12 mos, 2.5% yearly PE: 0% one-step,
2012 group RCT; dental 276 primary molars; carious tissues at 2% CR
hospitals; Thailand caries ≥ 1/3 EDJ completely PS: 1% one-step,
removed, without 2% CR
further removal of F: 18% one-
carious dentin”) step, 14% CR
restoration failure
CP: No caries
progression in any
group
Abbreviations: AM, Amalgam; BCC, black copper cement; CR, complete caries removal; GIC, glass-ionomer cement; mos, months; RCT, random-
ized controlled trial; wks, weeks; yr/yrs, years(s).
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Table 2. Meta-analysis for Primary Outcomes: Odds Ratios (OR) and Absolute Risk Reduction with 95% Confidence Interval (95% CI), and
Evidence-grading According to GRADE
Absolute Effect
Relative Effect Fewer or More/ 1,000 No. of Participants Quality of the Evidence
Outcome Treatment (95% CI) (95% CI) (studies) (GRADE)
1
See risk of bias assessment.
2
Effect magnitude consistent and large, OR < 0.5.
3
GRADE – Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change
the estimate.
4
Imprecision due to small numbers of studies and events.
5
GRADE – Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change
the estimate.
6
Publication bias assumed based on Funnel plot.
7
GRADE - Very low quality: We are very uncertain about the estimate.
EFFECTS OF INTERVENTIONS another study, teeth with unclear vitality diagnosis were excluded
(Heinrich et al., 1991). Since only 3 studies investigated one-step
Outcome: Pulpal Exposure incomplete excavation, data for one- and two-step treatments
Two and five studies with one- and two-step incomplete caries were pooled (Table 2 and Fig. 2). There was a significant overall
removal reported pulpal exposures, with 1 study reporting risk reduction of pulpal complications after incomplete compared
results for both methods (Orhan et al., 2010). Data were ana- with complete excavation (OR 0.58 [0.31-1.10]).
lyzed within subgroups (one- and two-step incomplete excava- Outcome: Failure
tion) as well as pooled for both subgroups (Table 2 and Fig. 2).
There was a significant overall risk reduction for pulpal expo- Five studies investigated the integrity of the restoration and
sure (OR [95% CI] 0.31 [0.19-0.49]) for incomplete excavation technical complications, with reduced (Lula et al., 2009),
compared with complete caries removal. Data for one-step increased (Mertz-Fairhurst et al., 1998; Phonghanyudh et al.,
incomplete caries removal indicated an even lower risk for this 2012), or similar (Foley et al., 2004; Orhan et al., 2010) failure
technique (OR 0.20 [0.06-0.61]). For stepwise excavation, only rates for incomplete vs. complete excavation. For one study
2 studies reported the visit during which the pulps were exposed. (Foley et al., 2004), teeth restored with black copper cement
Pulpal exposure was more common during the second excava- were excluded for further analysis, since black copper cement is
tion step, with 87% (Bjørndal et al., 2010) and 100% (Magnusson not the standard of treatment for incomplete caries removal.
and Sundell, 1977) of exposures at this stage. Four other studies reported pulpal complications. All nine stud-
ies were eventually pooled for failure analysis (Table 2 and
Outcome: Pulpal Symptoms Fig. 2). Risk of failure was similar for incompletely and com-
Six studies reported post-operative pulpal symptoms. One study pletely excavated teeth (OR 0.97 [0.64-1.46]).
reported pulp affection within the intervention group (Magnusson
Secondary Outcome: Caries Progression
and Sundell, 1977), but it remained unclear if the control group
was followed up (pulps were presumably found necrotic when Caries was found to progress marginally or under the restoration
exposed during excavation, thus being unrelated to treatment). within the incomplete removal group in 25% (6/24) (Ribeiro
The study was therefore excluded for this outcome analysis. For et al., 1999) or 0.6% (1/156) (Mertz-Fairhurst et al., 1998) of
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Figure 2. Meta-analysis for primary outcomes after one- or two-step incomplete caries removal compared with complete (CR) caries removal. Study
data, weighted odds ratios (OR), and 95% confidence Intervals (95%CI), heterogeneity I2, and overall effect statistics as well as Forest plots are
shown. Studies are shown in chronological order. Failure included biological (e.g., pulpal) and technical (e.g., restoration) failures after exclusion
of teeth with exposed pulps.
teeth. For the complete excavation group, one study (Mertz- One study used quasi-randomization based on patients’ date of
Fairhurst et al., 1998) reported that 9% (7/79) of teeth restored birth (Magnusson and Sundell, 1977). Four studies gave informa-
with amalgam showed marginal or occlusal caries. Another tion concerning concealment of allocation procedures. Drop-out
study reported significantly more lesions progressing in the rates were reported for all trials, but some studies did exclude
complete excavation group (Foley et al., 2004). One study certain teeth or patients for various reasons (Heinrich et al., 1991;
found no caries progression in either completely or incom- Mertz-Fairhurst et al., 1998; Foley et al., 2004). Neither operator
pletely excavated teeth (Phonghanyudh et al., 2012). Because of nor examiner was blinded except for 2 studies (Bjørndal et al.,
these sparse and contradictive data, meta-analysis was not 2010; Phonghanyudh et al., 2012). For meta-analysis, risk of bias
attempted. was therefore graded as “very strong”. For one outcome (pulp
exposure), the magnitude of reported effects was consistent and
large. This was included within the grading. For one outcome
Risk of Bias and Evidence-grading
(failure), we assumed publication bias based on Funnel plot
Because of their methodology, most studies were found to have analysis. Overall, only pulp exposure effect estimates were
considerable risk of bias (Appendix Tables 4 and 5). Randomization graded as “moderate”. All other outcomes were graded as “low”
was reported for most studies, often without detailed explanation. or “very low” evidence (Table 2).
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generalizability, thus giving better guidance to clinicians. In the Foley J, Evans D, Blackwell A (2004). Partial caries removal and cariostatic
light of results from studies investigating the attitudes and materials in carious primary molar teeth: a randomised controlled
clinical trial. Br Dent J 197:697-701.
behavior of dentists concerning the treatment options reviewed, Fusayama T, Okuse K, Hosoda H (1966). Relationship between hardness,
this seems to be of the utmost importance (Sundberg et al., discoloration, and microbial invasion in carious dentin. J Dent Res
2000; Oen et al., 2007; Qudeimat et al., 2007; Weber et al., 45:1033-1046.
2011; Bowen et al., 2012). Griffin SO, Oong E, Kohn W, Vidakovic B, Gooch BF, Bader J, et al.
(2008). The effectiveness of sealants in managing caries lesions. J Dent
Res 87:169-174.
CONCLUSIONS Handelman SL, Washburn F, Wopperer P (1976). Two-year report of sealant
effect on bacteria in dental caries. J Am Dent Assoc 93:967-970.
Incomplete caries removal seems advantageous, particularly in Handelman SL, Leverett DH, Iker HP (1985). Longitudinal radiographic
the treatment of caries in proximity to the pulp, since it signifi- evaluation of the progress of caries under sealants. J Pedod 9:119-126.
Hayashi M, Fujitani M, Yamaki C, Momoi Y (2011). Ways of enhancing
cantly reduces the risks of pulpal exposure and post-operative
pulp preservation by stepwise excavation—a systematic review. J Dent
pulpal symptoms compared with complete excavation. There is 39:95-107.
currently no evidence that incompletely excavated teeth are Heinrich R, Kneist S, Künzel W (1991). Klinisch kontrollierte Untersuchung
more prone to complications. However, because of high risk of zur Caries-profunda-Therapie am Milchmolaren. Dtsch Zahnärztl Z
bias within studies, evidence levels are limited, and further 46:581-584.
Hevinga MA, Opdam NJ, Frencken JE, Truin GJ, Huysmans MC (2010).
research is required before definitive conclusions can be drawn.
Does incomplete caries removal reduce strength of restored teeth?
J Dent Res 89:1270-1275.
Higgins JP, Green S (2009). Cochrane handbook for systematic reviews of
ACKNOWLEDGMENTS interventions. Chichester, UK: John Wiley & Sons.
We are grateful to Dipl.-Inf. Jürgen Hedderich, Institute for Higgins JP, Thompson SG (2002). Quantifying heterogeneity in a meta-
analysis. Stat Med 21:1539-1558.
Medical Informatics and Statistics, Christian-Albrechts- Huang X, Li L, Huang C, Du X (2011). Effect of ethanol-wet bonding with
University, Kiel, for statistical advice. This study was funded by hydrophobic adhesive on caries-affected dentine. Eur J Oral Sci
the authors and their institutions. The authors declare no poten- 119:310-315.
tial conflicts of interest with respect to the authorship and/or Innes NP, Evans DJ, Stirrups DR (2011). Sealing caries in primary molars:
publication of this article. randomized control trial, 5-year results. J Dent Res 90:1405-1410.
Jordan RE, Suzuki M, Skinner DH (1978). Indirect pulp-capping of carious
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