Comparative Evaluation of the Efficacy of Stepwise Caries Excavation vs Indirect Pulp Capping in Preserving the Vitality of Deep Carious Lesions in Permanent Teeth of Pediatric Patients: An In Vivo Study
Aims and objectives: To comparatively evaluate the clinical efficacy of stepwise caries excavation with indirect pulp capping (IPC) in managing the young permanent teeth in pediatric patients who have deep carious lesions.
Materials and methods: Eighty-eight teeth (first/second permanent molars) were included and randomly divided into two groups: group I (stepwise caries excavation) and group II (IPC). For group I, i.e., stepwise caries excavation, in the initial visit, bulk caries removal was done from walls of the cavity, however, soft and infected dentin was left untouched on the pulpal floor. The final excavation was performed after 2 months. The dentin parameters like the color, the consistency, and the humidity of dentin were noted at the first and second visits. A final follow-up to assess the primary outcome, i.e., sustained pulp vitality, was done after 1 year.
Results: When both the groups were compared with each other using the Chi-squared test, a highly significant difference was found (p < 0.05) between them. The success rate of stepwise caries excavation (97.3%) was found to be significantly greater than IPC (82.4%). After doing statistical analysis, a significant difference between stepwise excavation at baseline and at re-entry for parameters like the color, the consistency, and the humidity (p < 0.05), where dentin was observed to be darker in color, harder in consistency, and drier to touch at re-entry was found.
Conclusion: Stepwise caries excavation was considered a safer technique than IPC for preserving the vitality of young permanent teeth. Also, the clinical changes recorded during the re-entry in the case of stepwise caries excavation technique indicated the arrest of the carious process.
Clinical significance: Pulp preservation is of utmost importance especially in the case of young permanent teeth which have open apex to aid in apexogenesis. Failure to do so in maintaining the vitality of pulp before root completion may lead to the unfavorable crown to root ratio resulting in thin dentinal walls which are prone to fracture.
Fitzgerald M, Heys RJ. A clinical histological evaluation of conservative pulpal therapy in human teeth. Oper Dent 1991;16(3):101–112.
Bjørndal L. The caries process and its effect on the pulp: the science is changing and so is our understanding. J Endod 2008;34(7 Suppl):S2–S5. DOI: 10.1016/j.joen.2008.02.037.
AAPD guideline on pulp therapy for primary and immature permanent teeth. Reference Manual V32/No.6 10/11.
Bergenholtz G, Axelsson S, Davidson T, et al. Treatment of pulps in teeth affected by deep caries – a systematic review of the literature. Singapore Dent J 2013;34(1):1–12. DOI: 10.1016/j.sdj.2013.11.001.
Kidd EA. How ‘clean’ must a cavity be before restoration? Caries Res 2004;38(3):305–313. DOI: 10.1159/000077770.
Al-Zayer MA, Straffon LH, Feigal RJ, et al. Indirect pulp treatment of primary posterior teeth: a retrospective study. Pediatr Dent 2003;25(1):29–36.
Padmaja M, Raghu R. An ultraconservative method for the treatment of deep carious lesions-step wise excavation. Adv Biolog Res 2010;4(1):42–44.
Magnusson BO, Sundell SO. Stepwise excavation of deep carious lesions in primary molars. J Int Assoc Dent Child 1977;8(2):36–40.
Bjørndal L, Larsen T, Thylstrup A. A clinical and microbiological study of deep carious lesions during stepwise excavation using long treatment intervals. Caries Res 1997;31(6):411–417. DOI: 10.1159/000262431.
Schwendicke F. Incomplete caries removal: a systematic review and meta-analysis. J Dent Res 2013;92(4):306. DOI: 10.1177/0022034513477425.
Thompson V, Craig RG, Curro FA. Treatment of deep carious lesions by complete excavation or partial removal: a critical review. J Am Dent Assoc 2008;139(6):705–712. DOI: 10.14219/jada.archive.2008.0252.
Maltz M, Garcia R, Jardim JJ, et al. Randomized trial of partial vs. stepwise caries removal: 3-year follow-up. J Dent Res 2012;91(11):1026–1031. DOI: 10.1177/0022034512460403.
Maltz M, Oliveira EF, Fontanella V, et al. Deep caries lesions after incomplete dentine caries removal: 40-month follow-up study. Caries Res 2007;41(6):493–496. DOI: 10.1159/000109349.
Suwansingha O, Rirattanapong P. Effect of fluoride varnish on caries prevention of partially erupted of permanent molar in high caries risk. Southeast Asian J Trop Med Pub Health 2012;43(3):808–813.
Bjørndal L, Reit C, Bruun G, et al. Treatment of deep caries lesions in adults: randomized clinical trials comparing stepwise vs. direct complete excavation, and direct pulp capping vs. partial pulpotomy. Eur J Oral Sci 2010;118(3):290–297. DOI: 10.1111/j.1600-0722.2010.00731.x.
Bjørndal L, Demant S, Dabelsteen S. Depth and activity of carious lesions as indicators for the regenerative potential of dental pulp after intervention. J Endod 2014;40(4 Suppl):S76–S81. DOI: 10.1016/j.joen.2014.01.016.
Orhan AI, Oz FT, Ozcelik B, et al. A clinical and microbiological comparative study of deep carious lesion treatment in deciduous and young permanent molars. Clin Oral Investig 2008;12(4):369–378. DOI: 10.1007/s00784-008-0208-6.
Leksell E, Ridell K, Cvek M, et al. Pulp exposure after stepwise versus direct complete excavation of deep carious lesions in young posterior permanent teeth. Endod Dent Traumatol 1996;12(4):192–196. DOI: 10.1111/j.1600-9657.1996.tb00513.x.
Miller WA, Massler M. Permeability and staining of active and arrested lesions in dentine. Br Dent J 1962;112:187–197.
Kleter GA, Damen JJ, Buijs MJ, et al. The Maillard reaction in demineralized dentin in vitro. Eur J Oral Sci 1997;105(3):278–284. DOI: 10.1111/j.1600-0722.1997.tb00212.x.
Bjørndal L. Dentin and pulp reactions to caries and operative treatment: biological variables affecting treatment outcome. Endodon Top 2002;2(1):10–23. DOI: 10.1034/j.1601-1546.2002.20102.x.
Paddick JS, Brailsford SR, Kidd EA, et al. Effect of the environment on genotypic diversity of actinomycesnaeslundii and Streptococcus oralis in the oral biofilm. Appl Environ Microbiol 2003;69(11):6475–6480. DOI: 10.1128/aem.69.11.6475-6480.2003.
Mertz-Fairhurst EJ, Curtis Jr JW, Ergle JW. Ultraconservative and cariostatic sealed restorations: results at year 10. JADA 1998;129(1):55–66. DOI: 10.14219/jada.archive.1998.0022.
Hevinga MA, Opdam NJ, Frecken JE, et al. Does incomplete caries removal reduce strength of restored teeth? J Dent Res 2010;89(11):1270–1275. DOI: 10.1177/0022034510377790.
Ricketts DN, Kidd EA, Innes N, et al. Complete or ultraconservative removal of decayed tissue in unfilled teeth. Cochrane Database Syst Rev 2006(3):CD003808. DOI: 10.1002/14651858.CD003808.pub2.
Bjørndal L, Simon S, Tomson PL, et al. Management of deep caries and the exposed pulp. Int Endodon J 2019;52(7):949–973. DOI: 10.1111/iej.13128.