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Preserving pulp vitality: part one - strategies for managing deep caries in permanent teeth

Abstract

This is the first article in a series reviewing the current literature surrounding the management of deep caries in permanent teeth. Approaches to caries management are continuing to evolve, with more conservative management increasingly favoured. This philosophy has never been more important than in managing the deep carious lesion. Evidence is emerging that the use of selective caries removal to reduce the risk of pulp exposure, in conjunction with calcium silicate cements, can be successful in maintaining pulp vitality, delaying the restorative cycle and prolonging the lifespan of the tooth.

Key points

  • Non-selective caries removal is currently not recommended in the management of deep carious lesions.

  • Selective caries removal should be considered ahead of a stepwise approach.

  • Selective caries removal minimises the risk of pulp exposure and improves pulp survival in the short-to-medium term.

  • Calcium silicate cements show potential in the management of deep caries.

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References

  1. Black G V. Excavation of caries by classes. In A Work on Operative Dentistry: The technical procedures in filling teeth. Volume 2. pp 117-209. Chicago: Medico-Legal Publishing, 1908.

  2. Innes N P T, Stirrups D R, Evans D J P, Hall N, Leggate M. A Novel technique using preformed metal crowns for managing carious primary molars in general practice - A retrospective analysis. Br Dent J 2006; 200: 451-454.

  3. Ricketts D N, Kidd E A, Innes N, Clarkson J. Complete or ultraconservative removal of decayed tissue in unfilled teeth. Cochrane Database Syst Rev 2006; DOI: 10.1002/14651858.CD003808.pub2.

  4. Dorri M, Martinez-Zapata M J, Walsh T, Marinho V C, Sheiham A, Zaror C. Atraumatic restorative treatment versus conventional restorative treatment for managing dental caries. Cochrane Database Syst Rev 2017; DOI: 10.1002/14651858.CD008072.pub2.

  5. Holmgren C J, Roux D, Doméjean S. Minimal intervention dentistry. Atraumatic Restorative Dentistry (ART) - a minimum intervention and minimally invasive approach for the management of dental caries. Br Dent J 2013; 214: 11-18.

  6. Pitts N B, Ismail A I, Martignon S et al. ICCMS Guide for practitioners and educators. 2014. Available at https://www.iccms-web.com/uploads/asset/59284654c0a6f822230100.pdf (accessed November 2020).

  7. Alliance for a Cavity Free Future (ACFF). ICDAS ICCMS. 2019. Available online at https://www.acffglobal.org/professionals/icdasiccms/ (accessed December 2019).

  8. Public Health England. Delivering better oral health: an evidence-based toolkit for prevention. Third Edition. 2017. Available at https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/605266/Delivering_better_oral_health.pdf (accessed March 2020).

  9. Elderton R J, Nuttall N M. Variation among dentists in planning treatment. Br Dent J 1983; 154: 201-206.

  10. Bjørndal L, Darvann T, Thylstrup A. A quantative light microscopic study of the odontoblastic and subodontoblastic reactions to active and arrested enamel caries without cavitation. Caries Res 1998; 32: 59-69.

  11. Brännström M, Lind P O. Pulpal response to early caries. J Dent Res 1965; 44: 1045-1050.

  12. Farges J C, Alliot-Licht B, Renard E et al. Dental pulp defence and repair mechanisms in dental caries. Mediators Inflamm 2015; DOI: 10.1155/2015/230251.

  13. Kishen A. Mechanisms and risk factors for fracture predilection in endodontically treated teeth. Endod Topics 2006; 13: 57-83.

  14. Fusayama T, Okuse K, Hosoda H. Relationship between hardness, discoloration, and microbial invasion in carious dentin. J Dent Res 1966; 45: 1033-1046.

  15. Kato S, Fusayama T. Recalcification of artificially decalcified dentin in vivo. J Dent Res 1970; 49: 1060-1067.

  16. Miyauchi H, Iwaku M, Fusayama T. Physiological recalcification of carious dentin. Bull Tokyo Med Dent Univ 1978; 25: 169-179.

  17. Hosoda H, Fusayama T. A tooth substance saving restorative technique. Int Dent J 1984; 34: 1-12.

  18. Martignon S, Pitts N B, Goffin G et al. CariesCare practice guide: consensus on evidence into practice. Br Dent J 2019; 227: 353-362.

  19. Duncan H F, Galler K M, Tomson P L et al. European Society of Endodontology position statement: Management of deep caries and the exposed pulp. Int Endod J 2019; 52: 923-934.

  20. Schwendicke F, Frencken J E, Bjorndal L et al. Managing Carious Lesions: Consensus recommendations on carious tissue removal. Adv Dent Res 2016; 28: 58-67.

  21. Ricketts D, Lamont T, Innes N P T, Kidd E, Clarkson J E. Operative caries management in adults and children. Cochrane Database Syst Rev 2013; DOI: 10.1002/14651858.CD003808.pub3.

  22. Ali A H, Koller G, Foschi F et al. Self-limiting versus conventional caries removal: A randomized clinical trial. J Dent Res 2018; 97: 1207-1213.

  23. Innes N P T, Frencken J E, Bjørndal L et al. Managing carious lesions: Consensus recommendations on terminology. Adv Dent Res 2016; 28: 49-57.

  24. Bogen G, Kim J S, Bakland L K. Direct pulp capping with Mineral Trioxide Aggregate: An observational study. J Am Dent Assoc 2008; 139: 305-315.

  25. Bjørndal L, Reit C, Bruun G et al. Treatment of deep caries lesions in adults: randomised clinical trials comparing stepwise vs. direct complete excavation, and direct pulp capping vs. partial pulpotomy. Eur J Oral Sci 2010; 118: 290-297.

  26. Maltz M, De Oliveiria E F, Fontanella V, Bianchi R. A clinical, biological, and radiographic study of deep caries lesions after incomplete removal. Quintessence Int 2002; 33: 151-159.

  27. Orhan A I, Oz F T, Orhan K. Pulp exposure occurrence and outcomes after 1or 2visit indirect pulp therapy vs complete caries removal in primary and permanent molars. Pediatr Dent 2010; 32: 347-355.

  28. Ayse O I, Firdeva T O, Kaan O. Pulp exposure occurrence and outcomes after 1or 2visit indirect pulp therapy Vs complete caries removal in primary and permanent molars. Pediatr Dent 2010; 32: 347-355.

  29. Cox C F, Tarim B, Kopel H, Gürel G, Hafez A. Technique Sensitivity: Biological factors contributing to clinical success with various restorative materials. Adv Dent Res 2001; 15: 85-90.

  30. Schwendicke F, Dorfer C E, Paris S. Incomplete caries removal: a systematic review and meta-analysis. J Dent Res 2013; 92: 306-314.

  31. Bjørndal L, Fransson H, Bruun G et al. Randomized clinical trials on deep carious lesions: 5year follow-up. J Dent Res 2017; 96: 747-753.

  32. Barros M M A F, De Queiroz Rodrigues M I, Muniz F W M G, Rodrigues L K A. Selective, stepwise or nonselective removal of carious tissue: which technique offers lower risk for the treatment of dental caries in permanent teeth? A systematic review and meta-analysis. Clin Oral Investig 2019; 24: 521-534.

  33. Edwards D C, Burns L, Witton R, Tredwin C. MTA or calcium hydroxide for direct pulp capping in fully developed permanent teeth: a systematic review. 2020. Available online at https://www.researchgate.net/publication/343229994_MTA_or_Calcium_Hydroxide_for_direct_pulp_capping_in_fully_developed_permanent_teeth_A_systematic_review (accessed November 2020).

  34. Cho S-Y, Seo D-G, Lee S-J, Lee J, Lee S-J, Jung I-Y. Prognostic factors for clinical outcomes according to time after direct pulp capping. J Endod 2013; 39: 327-331.

  35. Hashem D, Mannocci F, Patel S, Manoharan A, Watson T F, Banerjee A. Evaluation of the efficacy of calcium silicate vs. glass ionomer cement indirect pulp capping and restoration assessment criteria: a randomised controlled clinical trial2year results. Clin Oral Investig 2019; 23: 1931-1939.

  36. Asgary S, Hassanizadeh R, Torabzadeh H, Eghbal M J. Treatment outcomes of 4 vital pulp therapies in mature molars. J Endod 2018; 44: 529-535.

  37. Maltz M, Garcia R, Jardim J J et al. Randomized trial of partial vs. stepwise caries removal: 3year follow up. J Dent Res 2012; 91: 1026-1031.

  38. Maltz M, Koppe B, Jardim J J et al. Partial caries removal in deep caries lesions: a 5year multicentre randomized controlled trial. Clin Oral Investig 2018; 22: 1337-1343.

  39. Al-Hiyasat A S, Barrieshi-Nusair K M, Al-Omari M A. The radiographic outcomes of direct pulp-capping procedures performed by dental students: a retrospective study. J Am Dent Assoc 2006; 137: 1699-1705.

  40. Marques M S, Wesselink P R, Shemesh H. Outcome of direct pulp capping with mineral trioxide aggregate: A prospective study. J Endod 2015; 41: 1026-1031.

  41. Bailey O, O'Connor C. Papilla management in sub-gingival, interproximal, direct composite restoration: A key concept to success. Br Dent J 2019; 226: 933-937.

  42. Hood J A. Biomechanics of the intact, prepared and restored tooth: some clinical implications. Int Dent J 1991; 41: 25-32.

  43. American Association of Endodontists. Endodontics: Colleagues for Excellence - endodontic diagnosis. 2013. Available at https://www.aae.org/specialty/wp-content/uploads/sites/2/2017/07/endodonticdiagnosisfall2013.pdf (accessed March 2020).

  44. 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.

  45. Riccucci D, Loghin S, Siqueira Jr J. Correlation between clinical and histologic pulp diagnoses. J Endod 2014; 40: 1932-1939.

  46. Mejàre I A, Axelsson S, Davidson T et al. Diagnosis of the condition of the dental pulp: a systematic review. Int Endod J 2012; 45: 597-613.

  47. Michaelson P L, Holland G R. Is pulpitis painful? Int Endod J 2002;35: 829-832.

  48. Iwamoto C E, Adachi E, Pameijer C H, Barnes D, Romberg E E, Jefferies S. Clinical and histological evaluation of white ProRoot MTA in direct pulp capping. Am J Dent 2006; 19: 85-90.

  49. Iqbal M, Kim S, Yoon F. An investigation into differential diagnosis of pulp and periapical pain: a PennEndo database study. J Endod 2007; 33: 548-551.

  50. Seltzer S, Bender I B, Ziontz M. The dynamics of pulpal inflammation: correllations between diagnostic data and actual histologic findings in the pulp. Oral Surg Oral Med Oral Pathol 1963; 16: 871-876.

  51. Garfunkel A, Sela J, Ulmansky M. Dental Pulp pathosis: Clinicopathologic correlations based on 109 cases. Oral Surg Oral Med Oral Pathol 1973; 35: 110-117.

  52. Johnson R H, Dachi S F, Haley J V. Pulpal hyperaemia - A correlation of clinical and histologic data from 706 teeth. J Am Dent Assoc 1970; 81: 108-117.

  53. Dummer P M H, Hicks R, Huws D. Clinical signs and symptoms in pulp disease. Int Endod J 1980; 13: 27-35.

  54. Villa-Chávez C E, Patiño-Marín N, Loyola-Rodríguez J P, Zavala-Alonso N V, Martínez-Castañón G A, Medina-Solís C E. Predictive values of thermal and electrical dental pulp tests: a clinical study. J Endod 2013; 39: 365-369.

  55. Jespersen J J, Hellstein J, Williamson A, Johnson W T, Qian F. Evaluation of dental pulp sensibility tests in a clinical setting. J Endod 2014; 40: 351-354.

  56. Weisleder R, Yamauchi S, Caplan D J, Trope M, Teixeira F B. The validity of pulp testing: A clinical study. J Am Dent Assoc 2009; 140: 1013-1017.

  57. Wolters W J, Duncan H F, Tomson, P L et al. Minimally invasive endodontics: a new diagnostic system for assessing pulpitis and subsequent treatment needs. Int Endod J 2017; 50: 825-829.

  58. Petrou M A, Alhamoui F A, Welk A, Altarabulsi M B, Alkilzy M, Splieth C H. A randomized clinical trial on the use of medical portland cement, MTA and calcium hydroxide in indirect pulp treatment. Clin Oral Investig 2014; 18: 1383-1389.

  59. Opdam N J M, van de Sande F H, Bronkhorst E et al. Longevity of posterior composite restorations: A systematic review and meta-analysis. J Dent Res 2014; 93: 943-949.

  60. Kaup M, Dammann C H, Schafer E, Dammaschke T. Shear bond strength of Biodentine, ProRoot MTA, glass ionomer cement and composite resin on human dentine ex vivo. Head Face Med 2015; 11: 14.

  61. Raju V G, Venumbaka N R, Mungara J, Vijayakumar P, Rajendran S, Elangovan A. Comparative evaluation of shear bond strength and microleakage of tricalcium silicate-based restorative material and radiopaque posterior glass ionomer restorative cement in primary and permanent teeth: an in vitro study. J Indian Soc Pedod Prev Dent 2014; 32: 304-310.

  62. Grech L, Mallia B, Camilleri J. Investigation of the physical properties of tricalcium silicate cement-based root-end filling materials. Dent Mater 2013; 29: 20-28.

  63. Singh S, Podar R, Dadu S, Kulkarni G, Purba R. Solubility of a new calcium silicate-based root-end filling material. J Conserv Dent 2015; 18: 149-153.

  64. Singh S, Mittal S, Tewari S. Effect of different liners on pulpal outcome after partial caries removal: A preliminary 12-months randomised controlled trial. Caries Res 2019; 53: 547-554.

  65. Modena K C D, CasasApayco L C, Atta M T et al. Cytotoxicity and Biocompatability of direct and indirect pulp capping materials. J Appl Oral Sci 2009; 17: 544-554.

  66. Tjäderhane L. Dentin bonding: Can we make it last? Oper Dent 2015; 40: 4-18.

  67. Schenkel A B, Veitz-Keenan A. Dental cavity liners for class I and class II resin-based composite restorations. Cochrane Database Syst Rev 2019; DOI: 10.1002/14651858.CD010526.pub2.

  68. Blum I R, Wilson N H F. An end to linings under posterior composites? J Am Dent Assoc 2018; 149: 209-213.

  69. FGDP (UK). Selection criteria for dental radiography standards. 2018. Available online at https://www.fgdp.org.uk/selection-criteria-dental-radiography (accessed January 2020).

  70. Hilton T J, Ferracane J L, Mancl L, Northwest Practice-based Research Collaborative in Evidence-based Dentistry (NWP). Comparison of CaOH with MTA for direct pulp capping: a PBRN randomized clinical trial. J Dent Res 2013; 92(7 Suppl): 16S-22S.

  71. Kundzina R, Stangvaltaite L, Eriksen H M, Kerosuo E. Capping carious exposures in adults: a randomized controlled trial investigating mineral trioxide aggregate versus calcium hydroxide. Int Endod J 2017; 50: 924-932.

  72. Dammaschke T, Leidinger J, Schafer E. Long-term evaluation of direct pulp capping-treatment outcomes over an average period of 6.1 years. Clin Oral Investig 2010; 14: 559-567.

  73. Willershausen B, Willershausen I, Ross A, Velikonja S, Kasaj A, Blettner M. Retrospective study on direct pulp capping with calcium hydroxide. Quintessence Int 2011; 42: 165-171.

  74. Barthel C R, Rosenkranz B, Leuenberg A, Roulet J F. Pulp capping of carious exposures: treatment outcome after 5 and 10 years: a retrospective study. J Endod 2000; 26: 525-528.

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Edwards, D., Stone, S., Bailey, O. et al. Preserving pulp vitality: part one - strategies for managing deep caries in permanent teeth. Br Dent J 230, 77–82 (2021). https://doi.org/10.1038/s41415-020-2590-7

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