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. 2021 Jul 19;7(7):CD013039.
doi: 10.1002/14651858.CD013039.pub2.

Interventions for treating cavitated or dentine carious lesions

Falk Schwendicke  1 , Tanya Walsh  2 , Thomas Lamont  3 , Waraf Al-Yaseen  4 , Lars Bjørndal  5 , Janet E Clarkson  6 , Margherita Fontana  7 , Jesus Gomez Rossi  1 , Gerd Göstemeyer  8 , Colin Levey  9 , Anne Müller  1 , David Ricketts  3 , Mark Robertson  3 , Ruth M Santamaria  10 , Nicola Pt Innes  4
Affiliations

Interventions for treating cavitated or dentine carious lesions

Falk Schwendicke et al. Cochrane Database Syst Rev. .

Abstract

Background: Traditionally, cavitated carious lesions and those extending into dentine have been treated by 'complete' removal of carious tissue, i.e. non-selective removal and conventional restoration (CR). Alternative strategies for managing cavitated or dentine carious lesions remove less or none of the carious tissue and include selective carious tissue removal (or selective excavation (SE)), stepwise carious tissue removal (SW), sealing carious lesions using sealant materials, sealing using preformed metal crowns (Hall Technique, HT), and non-restorative cavity control (NRCC).

Objectives: To determine the comparative effectiveness of interventions (CR, SE, SW, sealing of carious lesions using sealant materials or preformed metal crowns (HT), or NRCC) to treat carious lesions conventionally considered to require restorations (cavitated or micro-cavitated lesions, or occlusal lesions that are clinically non-cavitated but clinically/radiographically extend into dentine) in primary or permanent teeth with vital (sensitive) pulps.

Search methods: An information specialist searched four bibliographic databases to 21 July 2020 and used additional search methods to identify published, unpublished and ongoing studies. SELECTION CRITERIA: We included randomised clinical trials comparing different levels of carious tissue removal, as listed above, against each other, placebo, or no treatment. Participants had permanent or primary teeth (or both), and vital pulps (i.e. no irreversible pulpitis/pulp necrosis), and carious lesions conventionally considered to need a restoration (i.e. cavitated lesions, or non- or micro-cavitated lesions radiographically extending into dentine). The primary outcome was failure, a composite measure of pulp exposure, endodontic therapy, tooth extraction, and restorative complications (including resealing of sealed lesions).

Data collection and analysis: Pairs of review authors independently screened search results, extracted data, and assessed the risk of bias in the studies and the overall certainty of the evidence using GRADE criteria. We measured treatment effects through analysing dichotomous outcomes (presence/absence of complications) and expressing them as odds ratios (OR) with 95% confidence intervals (CI). For failure in the subgroup of deep lesions, we used network meta-analysis to assess and rank the relative effectiveness of different interventions.

Main results: We included 27 studies with 3350 participants and 4195 teeth/lesions, which were conducted in 11 countries and published between 1977 and 2020. Twenty-four studies used a parallel-group design and three were split-mouth. Two studies included adults only, 20 included children/adolescents only and five included both. Ten studies evaluated permanent teeth, 16 evaluated primary teeth and one evaluated both. Three studies treated non-cavitated lesions; 12 treated cavitated, deep lesions, and 12 treated cavitated but not deep lesions or lesions of varying depth. Seventeen studies compared conventional treatment (CR) with a less invasive treatment: SE (8), SW (4), two HT (2), sealing with sealant materials (4) and NRCC (1). Other comparisons were: SE versus HT (2); SE versus SW (4); SE versus sealing with sealant materials (2); sealant materials versus no sealing (2). Follow-up times varied from no follow-up (pulp exposure during treatment) to 120 months, the most common being 12 to 24 months. All studies were at overall high risk of bias. Effect of interventions Sealing using sealants versus other interventions for non-cavitated or cavitated but not deep lesions There was insufficient evidence of a difference between sealing with sealants and CR (OR 5.00, 95% CI 0.51 to 49.27; 1 study, 41 teeth, permanent teeth, cavitated), sealing versus SE (OR 3.11, 95% CI 0.11 to 85.52; 2 studies, 82 primary teeth, cavitated) or sealing versus no treatment (OR 0.05, 95% CI 0.00 to 2.71; 2 studies, 103 permanent teeth, non-cavitated), but we assessed all as very low-certainty evidence. HT, CR, SE, NRCC for cavitated, but not deep lesions in primary teeth The odds of failure may be higher for CR than HT (OR 8.35, 95% CI 3.73 to 18.68; 2 studies, 249 teeth; low-certainty evidence) and lower for HT than NRCC (OR 0.19, 95% CI 0.05 to 0.74; 1 study, 84 teeth, very low-certainty evidence). There was insufficient evidence of a difference between SE versus HT (OR 8.94, 95% CI 0.57 to 139.67; 2 studies, 586 teeth) or CR versus NRCC (OR 1.16, 95% CI 0.50 to 2.71; 1 study, 102 teeth), both very low-certainty evidence. CR, SE, SW for deep lesions The odds of failure were higher for CR than SW in permanent teeth (OR 2.06, 95% CI 1.34 to 3.17; 3 studies, 398 teeth; moderate-certainty evidence), but not primary teeth (OR 2.43, 95% CI 0.65 to 9.12; 1 study, 63 teeth; very low-certainty evidence). The odds of failure may be higher for CR than SE in permanent teeth (OR 11.32, 95% CI 1.97 to 65.02; 2 studies, 179 teeth) and primary teeth (OR 4.43, 95% CI 1.04 to 18.77; 4 studies, 265 teeth), both very low-certainty evidence. Notably, two studies compared CR versus SE in cavitated, but not deep lesions, with insufficient evidence of a difference in outcome (OR 0.62, 95% CI 0.21 to 1.88; 204 teeth; very low-certainty evidence). The odds of failure were higher for SW than SE in permanent teeth (OR 2.25, 95% CI 1.33 to 3.82; 3 studies, 371 teeth; moderate-certainty evidence), but not primary teeth (OR 2.05, 95% CI 0.49 to 8.62; 2 studies, 126 teeth; very low-certainty evidence). For deep lesions, a network meta-analysis showed the probability of failure to be greatest for CR compared with SE, SW and HT.

Authors' conclusions: Compared with CR, there were lower numbers of failures with HT and SE in the primary dentition, and with SE and SW in the permanent dentition. Most studies showed high risk of bias and limited precision of estimates due to small sample size and typically limited numbers of failures, resulting in assessments of low or very low certainty of evidence for most comparisons.

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Conflict of interest statement

FS: none.

TW: none. I am Statistical Editor with Cochrane Oral Health.

TL: none. I am an Editor with Cochrane Oral Health.

WA: none.

LB: none.

JEC: none. I am a Co‐ordinating Editor with Cochrane Oral Health.

MF: in the last 36 months, I have received grant support from the National Institutes for Health (NIH), the Delta Dental Foundation, DentaQUest, Colgate; have served as a grant reviewer for NIH; have consulted for 3M, DentaQuest; served as part of the National Scientific Advisory Committee for Delta Dental Foundation; and been a member of the Council for Scientific Affairs of the American Dental Association.

JGR: none.

GG: none.

CL: none.

AM: none.

DR: none.

MR: none.

RMS: none.

NPI: none.

Figures

1
1
Study flow diagram.
2
2
Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies.
3
3
Risk of bias summary: review authors' judgements about each risk of bias item for each included study.
4
4
1.1. Failure ‐ sealing vs  CR
5
5
2.1 Failure ‐ sealing vs SE
6
6
3.1 Failure ‐ sealing vs no treatment
7
7
4.1 Failure ‐ CR vs HT
8
8
5.1 Failure ‐ SE vs HT
9
9
6.1 Failure ‐ CR vs NRCC
10
10
7.1 Failure ‐ HT vs NRCC
11
11
8.1 Failure ‐ CR vs SW
12
12
9.1 Failure ‐ CR vs SE
13
13
10.1 Failure ‐ SW vs SE
14
14
Network plot for different interventions for managing deep lesions. (a) Base‐case analysis, (b) sensitivity analysis excluding the single study using a modified Hall Technique (HT). Nodes (orange circles) and connections (grey lines) are used to display actual pairwise comparisons. The size of the node indicates the number of studies testing this strategy; thickness of the lines indicates the number of studies in which exact comparison was made. CR: complete removal; SE: selective removal; SW: stepwise removal.
15
15
Network meta‐analysis relative effects of different interventions for treating deep lesions. (a) Base‐case analysis, (b) sensitivity analysis excluding the single study which used a modified Hall Technique (HT). Odds ratio and 95% credible intervals are shown. The odds of failure with each intervention in each row is compared against the ones in each column (e.g. in (a), CR had a 12.83 (1.05–252) times increased odds of failure compared with HT). CR: complete removal; SE: selective removal; SW: stepwise removal.
1.1
1.1. Analysis
Comparison 1: Sealing versus conventional restoration (CR) (cavitated, permanent dentition), Outcome 1: Failure: sealing vs CR
2.1
2.1. Analysis
Comparison 2: Sealing versus selective excavation (SE) (cavitated, primary dentition), Outcome 1: Failure: sealing vs SE
3.1
3.1. Analysis
Comparison 3: Sealing versus no treatment (non‐cavitated, permanent), Outcome 1: Failure: sealing vs no treatment
4.1
4.1. Analysis
Comparison 4: Conventional restoration (CR) versus Hall Technique (HT) (cavitated, primary), Outcome 1: Failure: CR vs HT
5.1
5.1. Analysis
Comparison 5: Selective excavation (SE) versus Hall Technique (HT) (primary, cavitated; primary, deep), Outcome 1: Failure: SE vs HT
6.1
6.1. Analysis
Comparison 6: Conventional restoration (CR) versus non‐restorative cavity control (NRCC) (cavitated, primary), Outcome 1: Failure: CR vs NRCC
7.1
7.1. Analysis
Comparison 7: Hall Technique (HT) versus non‐restorative cavity control (NRCC) (cavitated, primary), Outcome 1: Failure: HT vs NRCC
8.1
8.1. Analysis
Comparison 8: Conventional restoration (CR) versus stepwise (SW) (deep, primary; deep, permanent), Outcome 1: Failure: CR vs SW
9.1
9.1. Analysis
Comparison 9: Conventional restoration (CR) versus selective excavation (SE) (deep, permanent; deep, primary; cavitated, primary), Outcome 1: Failure: CR vs SE
10.1
10.1. Analysis
Comparison 10: Stepwise (SW) versus selective excavation (SE) (deep, primary; deep, permanent), Outcome 1: Failure: SW vs SE
See this image and copyright information in PMC

Update of

  • doi: 10.1002/14651858.CD013039

References

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Labib 2019 {published data only}
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Leksell 1996 {published data only}
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Lula 2009 {published data only}
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Phonghanyudh 2012 {published data only}
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Qvist 2017 {published data only}
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References to studies excluded from this review

Ali 2018 {published data only}
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Arrow 2015 {published data only}
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Aswathi 2017 {published data only}
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Azrak 2004 {published data only}
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Bakhshandeh 2015 {published data only}
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Barata 2008 {published data only}
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Bergmann 2005 {published data only}
    1. Bergmann J, Leitão J, Kultje C, Bergmann D, Clode MJ. Removing dentine caries in deciduous teeth with Carisolv: a randomised, controlled, prospective study with six-month follow-up, comparing chemomechanical treatment with drilling. Oral Health Preventive Dentistry 2005;3(2):105-11. - PubMed
Bianchi 1989 {published data only}
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Bohari 2012 {published data only}
    1. Bohari MR, Chunawalla YK, Ahmed BM. Clinical evaluation of caries removal in primary teeth using conventional chemomechanical and laser technique: an in vivo study. Journal of Contemporary Dental Practice 2012;13(1):40-7. [DOI: 10.5005/jp-journals-10024-1093] - DOI - PubMed
Braga 2009 {published data only}
    1. Braga MM, Mendes FM, De Benedetto MS, Imparato JC. Effect of silver diamine fluoride on incipient caries lesions in erupting permanent first molars: a pilot study. Journal of Dentistry for Children (Chicago, Ill.) 2009;76(1):28-33. - PubMed
Bressani 2013 {published data only}
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Chomyszyn‐Gajewska 2006 {published data only}
    1. Chomyszyn-Gajewska M, Kwapinska H, Zarzecka J. Pain perception in children during caries removal with the Vector system: a pilot study. European Archives of Paediatric Dentistry 2006;7(1):38-41. [DOI: 10.1007/BF03320813 Full-text links] - PubMed
de Almeida 2013 {published data only}
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Dülgergil 2005 {published data only}
    1. Dülgergil CT, Ercan E, Yildirim I. A combined application of ART-fluoride varnish for immigrant junior field-workers: 12-months follow-up field trial in rural Anatolia. Oral Health and Preventive Dentistry 2005;3(2):97-104. - PubMed
Ekstrand 2010 {published data only}
    1. Ekstrand KR, Bakhshandeh A, Martignon S. Treatment of proximal superficial caries lesions on primary molar teeth with resin infiltration and fluoride varnish versus fluoride varnish only: efficacy after 1 year. Caries Research 2010;44(1):41-6. [DOI: 10.1159/000275573] - DOI - PubMed
El‐Tekeya 2012 {published data only}
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Flório 2001 {published data only}
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Giza 2007 {published data only}
    1. Giza S. Comparative studies of carious defects filling using the classical method and dental drill, and using the Carisolv chemomechanical method and the YAG: Er CTL-1601 laser [Badanie Porównawcze Opracowywania Ubytków Próchnicowych Metodą Klasyczną Przy Użyciu Wiertarki Stomatologicznej, Metodą Chemo-Mechaniczną Preparatem Carisolv Oraz Laserem Yag:Er Ctl-1601]. Annales Academiae Medicae Stetinensis 2007;53(3):88-99. - PubMed
Goyal 2015 {published data only}
    1. Goyal PA, Kumari R, Kannan VP, Madhu S. Efficacy and tolerance of papain gel with conventional drilling method: a clinico-microbiological study. Journal Clinical Paediatric Dentistry 2015;39(2):109-12. [DOI: 10.17796/jcpd.39.2.n25754863557k727] - DOI - PubMed
Hamilton 2001 {published data only}
    1. Hamilton JC, Dennison JB, Stoffers KW, Gregory WA, Welch KB. Early treatment of incipient carious lesions: a two-year clinical evaluation. Journal of the American Dental Association 2002;133(12):1643-51. [DOI: 10.14219/jada.archive.2002.0114] - DOI - PubMed
    1. Hamilton JC, Dennison JB, Stoffers KW, Welch KB. A clinical evaluation of air-abrasion treatment of questionable carious lesions: a 12-month report. Journal of the American Dental Association 2001;132(6):762-9. [DOI: 10.14219/jada.archive.2001.0273] - DOI - PubMed
Handelman 1976 {published data only}
    1. Handelman SL, Leverett DH, Espeland M, Curzon J. Retention of sealants over carious and sound tooth surfaces. Community Dentistry Oral Epidemiology 1987;15(1):1-5. [DOI: 10.1111/j.1600-0528.1987.tb00470.x] - DOI - PubMed
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Hassan 2016 {published data only}
    1. Hassan AF, Yadav G, Tripathi AM, Mehrotra M, Saha S, Garg N. A comparative evaluation of the efficacy of different caries excavation techniques in reducing the cariogenic flora: an in vivo study. International Journal Clinical Paediatric Dentistry 2016;9(3):214. [DOI: 10.5005/jp-journals-10005-1366] - DOI - PMC - PubMed
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Hoefler 2016 {published data only}
    1. Hoefler V, Nagaoka H, Miller CS. Long-term survival and vitality outcomes of permanent teeth following deep caries treatment with step-wise and partial-caries-removal: a systematic review. Journal of Dentistry 2016;54:25-32. [DOI: 10.1016/j.jdent.2016.09.009] - DOI - PubMed
Hosein 2008 {published data only}
    1. Hosein T, Hasan A. Efficacy of chemo-mechanical caries removal with Carisolv. Journal of College of Physicians and Surgeons Pakistan 2008;18(4):222-5. - PubMed
Kakaboura 2003 {published data only}
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Kalf‐Scholte 2003 {published data only}
    1. Kalf-Scholte SM, Amerongen WE, Smith AJ, Haastrecht HJ. Atraumatic restorative treatment (ART): a three-year clinical study in Malawi – comparison of conventional amalgam and ART restorations. Journal Public Health Dentistry 2003;63(2):99-103. [DOI: 10.1111/j.1752-7325.2003.tb03482.x] - DOI - PubMed
Kavvadia 2004 {published data only}
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Kirzioglu 2007 {published data only}
    1. Kirzioglu Z, Gurbuz T, Yilmaz Y. Clinical evaluation of chemomechanical and mechanical caries removal: status of the restorations at 3, 6, 9 and 12 months. Clinical Oral Investigation 2007;11(1):69. [DOI: 10.1007/s00784-006-0072-1] - DOI - PubMed
Kochhar 2011 {published data only}
    1. Kochhar GK, Srivastava N, Pandit IK, Gugnani N, Gupta M. An evaluation of different caries removal techniques in primary teeth: a comparative clinical study. Journal of Clinical Paediatric Dentistry 2011;36(1):5-9. [DOI: 10.17796/jcpd.36.1.u2421l4j68847215] - DOI - PubMed
Kotb 2009 {published data only}
    1. Kotb RM, Abdella AA, El Kateb MA, Ahmed AM. Clinical evaluation of Papacarie in primary teeth. Journal of Clinical Paediatric Dentistry 2009;34(2):117-23. [DOI: 10.17796/jcpd.34.2.f312p36g18463716] - DOI - PubMed
Lager 2003 {published data only}
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Lakshmi 2018 {published data only}
    1. Lakshmi MS, Srilatha KT, Nandlal B, Deshmukh S. Clinical evaluation of preventive effect of fissure sealants on initial carious lesion of permanent mandibular molars pretreated with and without fluoride varnish by fluorescence camera. International Journal of Clinical Paediatric Dentistry 2018;11(2):89-93. [DOI: 10.5005/jp-journals-10005-1491] - DOI - PMC - PubMed
Lozano‐Chourio 2006 {published data only}
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Maguire 2020 {published data only}
    1. Maguire A, Clarkson JE, Douglas GV, Ryan V, Homer T, Marshman Z, et al. Best-practice prevention alone or with conventional or biological caries management for 3- to 7-year-olds: the FiCTION three-arm RCT. Health Technology Assessment 2020;24(1):1-174. [DOI: 10.3310/hta24010] - DOI - PMC - PubMed
Malmström 2003 {published data only}
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Maltz 2012 {published data only}
    1. Maltz M, Henz SL, Oliveira EF, Jardim JJ. Conventional caries removal and sealed caries in permanent teeth: a microbiological evaluation. Journal of Dentistry 2012;40(9):776-82. [DOI: 10.1016/j.jdent.2012.05.011] - DOI - PubMed
Mandari 2001 {published data only}
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Maragakis 2001 {published data only}
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Martignon 2012 {published data only}
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Matsumoto 2013 {published data only}
    1. Matsumoto SF, Motta LJ, Alfaya TA, Guedes CC, Fernandes KP, Bussadori SK. Assessment of chemomechanical removal of carious lesions using Papacarie Duo™: randomized longitudinal clinical trial. Indian Journal of Dental Research 2013;24(4):488-92. [DOI: 10.4103/0970-9290.118393] - DOI - PubMed
Moreira 2017 {published data only}
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Motta 2013 {published data only}
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Muñoz‐Sandoval  2019 {published data only}
    1. Muñoz-Sandoval C, Gambetta-Tessini K, Giacaman RA. Microcavitated (ICDAS 3) carious lesion arrest with resin or glass ionomer sealants in first permanent molars: a randomized controlled trial. Journal of Dentistry 2019;88:103163. [DOI: 10.1016/j.jdent.2019.07.001] - DOI - PubMed
Nadanovsky 2001 {published data only}
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Pandit 2007 {published data only}
    1. Pandit IK, Srivastava N, Gugnani N, Gupta M, Verma L. Various methods of caries removal in children: a comparative clinical study. Indian Society of Pedodontic and Preventive Dentistry 2007;25(2):93. [DOI: 10.4103/0970-4388.33456] - DOI - PubMed
Peric 2009 {published data only}
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Peters 2006 {published data only}
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Rios Caro 2012 {published data only}
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Ruff 2018 {published data only}
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Santamaria 2014 {published data only}
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Sarmadi 2018 {published data only}
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Straffon 1988a {published data only}
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Valério 2016 {published data only}
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Wang 2007 {published data only}
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Zakirulla 2012 {published data only}
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References to ongoing studies

Vicioni‐Marques 2018 {published data only}
    1. Vicioni-Marques F, Carvalho FK. Comparison of three restorative protocols in teeth with molar-incisor hipomineralization (MIH): a randomized controlled clinical study, University of Sao Paulo. clinicaltrials.gov/ct2/show/NCT03760497 (first received 30 November 2018). [CLINICALTRIALS.GOV IDENTIFIER (NCT NUMBER): NCT03760497]

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