Operative caries management in adults and children

Dundee Dental School, University of Dundee, Park Place, Dundee, Tayside, UK, DD1 4HN.
Cochrane database of systematic reviews (Online) (Impact Factor: 5.94). 01/2013; 3(3):CD003808. DOI: 10.1002/14651858.CD003808.pub3
Source: PubMed

ABSTRACT The management of dental caries has traditionally involved removal of all soft demineralised dentine before a filling is placed. However, the benefits of complete caries removal have been questioned because of concerns about the possible adverse effects of removing all soft dentine from the tooth. Three groups of studies have also challenged the doctrine of complete caries removal by sealing caries into teeth using three different techniques. The first technique removes caries in stages over two visits some months apart, allowing the dental pulp time to lay down reparative dentine (the stepwise excavation technique). The second removes part of the dentinal caries and seals the residual caries into the tooth permanently (partial caries removal) and the third technique removes no dentinal caries prior to sealing or restoring (no dentinal caries removal). This is an update of a Cochrane review first short term follow-up in most of the included studies and the high risk of bias, further high quality, long term clinical trials are still required to assess the most effective intervention. However, it should be noted that in studies of this nature, complete elimination of risk of bias may not necessarily be possible. Future research should also investigate patient centred outcomes.

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Available from: Nicola P Innes, Dec 22, 2013
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    • "It seemed that, in particular, pulpal exposure has significant long-term influence on both effectiveness and costs, since follow-up treatments like direct capping or rootcanal treatment either have relatively poor success rates (see Appendix Table 7) or are rather invasive and costly, thereby accelerating the " death spiral " of the tooth (Qvist, 2008). Thus, our study translates current evidence regarding pulpal exposure after one-step incomplete excavation, as outlined in the recent Cochrane review as well (Ricketts et al., 2013), to long-term cost-effectiveness. "
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    ABSTRACT: The treatment of deep caries lesions carries significant risks for the integrity of the pulp and often initiates a cascade of re-interventions. Incomplete caries removal may reduce these risks and avoid or delay re-treatment. The present study analyzed the cost-effectiveness of one- and two-step incomplete as well as complete excavations. We used Markov models to simulate treatment of a molar tooth with a deep caries lesion in a 15-year-old patient. Retention of the tooth and its vitality as effectiveness measures as well as accruing costs were analyzed over the patient's lifetime. The model adopted a public-private-payer perspective within German health care. Transition probabilities were calculated based on literature reviews. Monte-Carlo microsimulations were performed with 6-month cycles. One-step incomplete excavation resulted in lower long-term costs and in longer-retained teeth and their vitality (means: 53.5 and 41.0 yrs) compared with two-step incomplete (52.5 and 37.5 yrs) and complete excavations (49.5 and 31.0 yrs), and dominated the other strategies in 70% to 100% of simulations. Regardless of the assumed willingness-to-pay ceiling value, one-step incomplete excavation had the highest probability of being cost-effective. Despite limited evidence levels of input data, we expect one-step incomplete excavation to reduce costs while retaining deeply carious teeth and their vitality for longer.
    Journal of dental research 08/2013; 92(10). DOI:10.1177/0022034513500792 · 4.14 Impact Factor
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    ABSTRACT: OBJECTIVES: When treating deep caries, one- and two-step incomplete caries removal reduce the risk of pulpal exposure. However, it is currently unclear if incompletely excavated teeth fail due to pulpal or rather non-pulpal complications. The present study systematically analysed how incompletely excavated teeth fail, and if certain tooth- or treatment-related factors may influence risk of failure. Data: Clinical studies investigating clinical or radiologic failure after incomplete excavation of deep caries (depth >1/2 dentin thickness) were evaluated. Weighted annual failure rates (AFRs) were used to analyse frequency and mode of failures. Sub-analyses compared risk of failure in different groups of possible influencing factors. Sources: Electronic databases were screened and studies cross-referenced. Language was restricted to English and German. Grey literature was not evaluated. RESULTS: 19 studies with a median (Q25/75) follow-up of 24 (12/48) months were included. AFR was 3.8 (1.4/4.4)%. Eleven studies reported pulpal complications being the major reason for failure, and only 2 studies found more non-pulpal than pulpal failures. Sub-analyses found significantly lower risk of failure for teeth after one- compared with two-step excavation (Odds ratio [95% CI] = 0.21 [0.08, 0.55]) and teeth with single- compared with multi-surface cavities (0.33 [0.16, 0.67]). Risk of bias differed widely between studies, and evidence levels were graded as very low. CONCLUSIONS: After incomplete removal of deep caries, pulpal failure was more common. One- compared with two-step excavation reduces risk of failure, and factors like number of restored surfaces seem to but influence failure, but limited evidence permits drawing definitive conclusions. Clinical Significance: Growing evidence indicates that one-step incomplete excavation seems suitable to treat deep caries lesions, and might have advantages compared to two-step incomplete or complete caries removal. However, it is too early to recommend certain clinical strategies.
    Journal of Dentistry 05/2013; DOI:10.1016/j.jdent.2013.05.004 · 2.84 Impact Factor
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    ABSTRACT: BACKGROUND: There is a lack of evidence for effective management of dental caries (decay) in children's primary (baby) teeth and an apparent failure of conventional dental restorations (fillings) to prevent dental pain and infection for UK children in Primary Care. UK dental schools' teaching has been based on British Society of Paediatric Dentistry guidance which recommends that caries in primary teeth should be removed and a restoration placed. However, the evidence base for this is limited in volume and quality, and comes from studies conducted in either secondary care or specialist practices. Restorations provided in specialist environments can be effective but the generalisability of this evidence to Primary Care has been questioned.The FiCTION trial addresses the Health Technology Assessment (HTA) Programme's commissioning brief and research question "What is the clinical and cost effectiveness of restoration caries in primary teeth, compared to no treatment?" It compares conventional restorations with an intermediate treatment strategy based on the biological (sealing-in) management of caries and with no restorations.Methods/design: This is a Primary Care-based multi-centre, three-arm, parallel group, patient-randomised controlled trial. Practitioners are recruiting 1461 children, (3--7 years) with at least one primary molar tooth where caries extends into dentine. Children are randomized and treated according to one of three treatment approaches; conventional caries management with best practice prevention, biological management of caries with best practice prevention or best practice prevention alone.Baseline measures and outcome data (at review/treatment during three year follow-up) are assessed through direct reporting, clinical examination including blinded radiograph assessment, and child/parent questionnaires.The primary outcome measure is the incidence of either pain or infection related to dental caries.Secondary outcomes are; incidence of caries in primary and permanent teeth, patient quality of life, cost-effectiveness, acceptability of treatment strategies to patients and parents and their experiences, and dentists' preferences.Discussion/ Summary: FiCTION will provide evidence for the most clinically-effective and cost-effective approach to managing caries in children's primary teeth in Primary Care. This will support general dental practitioners in treatment decision making for child patients to minimize pain and infection in primary teeth. The trial is currently recruiting patients.Trial registration: Protocol ID: NCTU: ISRCTN77044005,
    BMC Oral Health 06/2013; 13(1):25. DOI:10.1186/1472-6831-13-25 · 1.15 Impact Factor
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Questions & Answers about this publication

  • Nicola P Innes added an answer in Enamel:
    Can anybody send me details about tooth "Filling without Drilling"

    Caries has conventionally been treated with drlling and fillling keeping GV Black's rule of extension for prevention in mind. Contemporarily, caries is recommended to be treated with minimal intervention (MID) keeping prevention of extension in mind.In near future, caries will be treated without drill or any other method which involves loss of tooth structure as protien has been synthesized which replaces enamel. I will appreciate if someone elaborate on it in this forum.

    Nicola P Innes · University of Dundee

     Hi there,

    you should try (for dentistry in Children) the Scottish Dental Clinical Effectiveness Programmes manual (although it is currently being updated, it is still contemporaneous). This document has been adopted for use in several other countries and is meant to be international in its scope although produced by a Scottish Group. It is very much about 'how to' do minimal intervention dentistry.

    There is VERY little evidence for lasers and ozone both of which are expensive and, from the research would seem to be unnecessary.  I would urge caution in adopting these when simpler, proven, effective methods are available.

    Again, if it is primary teeth you are interested in, you could look at

    Also, please find a link to the Cochrane review on minimal caries removal techniques and the evidence for them.

    If you wish, I'd be happy to send you more literature or point to more information.

    Kind regards,