Pulp exposure after stepwise versus direct complete excavation of deep carious lesions in young posterior permanent teeth

Abstract

The aim was to assess the prevalence of pulp exposure after stepwise versus direct complete excavation of permanent posterior teeth with deep carious lesions. The material, representing 116 patients aged 6-16 yrs (mean = 10.2 yrs), consisted of 127 teeth with radiographs revealing carious lesions to such a depth that pulp exposure could be expected if direct complete excavation was performed. Teeth with clinical symptoms, other than transient pain shortly before treatment, were not accepted. The teeth were randomly selected for either treatment procedure. Stepwise excavation implied removal of the bulk of carious tissue and application of calcium hydroxide, followed by sealing of the cavity with zinc-oxide eugenol cement. After a period of 8-24 weeks the rest of the carious dentin was removed and the cavity sealed with calcium hydroxide, zinc-oxide-eugenol (ZOE) and a restorative material. Direct complete excavation entailed removal of all carious dentin followed by sealing as mentioned above. In case of pulp exposure, pulp treatment was performed. The pulp was exposed in 40 of the teeth treated by direct complete excavation. The corresponding figure for those treated by stepwise excavation was 17.5%. The difference was statistically significant. The teeth with no pulp exposure after direct or stepwise excavation showed normal clinical and radiographic conditions at the last check-up (mean = 43 months).

Estimation of remaining dentine thickness below deep lesions of caries

“…In conventional treatment of deep lesions of caries, 40% of treated teeth had pulpal exposures compared to 17.5% with the stepwise approach. 4 A number of methods have been explored to assess the remaining dentine thickness…”

Acciones Terapéuticas Actuales en Caries Profunda. Revisión

“…Those who advocate for a longer waiting period (six months or longer) believe that this induces more tertiary dentin and thus reduces the risk of pulp exposure 38 . In their clinical study, Leksel et al 39 found no differences in exposure frequency between a group of lesions reopened after two months and another reopened after six months. The success of Stepwise excavation technique depends on the sealing: follow-up is essential.…”

Remoção parcial do tecido cariado em dentes permanentes: uma revisão integrativa da literatura

“…5 Contudo, a grande desvantagem desta técnica é o risco de exposição pulpar durante o tratamento em cavidades profundas. 3 Devido ao risco elevado de exposição pulpar durante a RTTC 3 , houve a busca por tratamentos mais conservadores, sendo atualmente discutida a RPTC, com intuito de diminuir e prevenir a exposição pulpar, [6][7][8][9] suportados pelo conhecimento de que a RTTC não é necessariamente um indicador para o sucesso do tratamento das lesões cariosas. 4 Com o advento da Odontologia conservadora, propõe-se a preservação de uma camada da dentina desmineralizada sobre a polpa e a aplicação de um material forrador para induzir a formação de dentina terciária, selando a cavidade temporariamente, antes de realizar a restauração definitiva no dente.…”

“…7 O selamento da cavidade com materiais restauradores sobre a dentina cariada é capaz de estacionar a progressão da cárie por pelo menos 10 anos, indicando a não necessidade da remoção completa para a obtenção de sucesso clínico. 1 Além disso, o correto selamento da dentina cariada diminui significativamente a microbiota sobrevivente, 9 aumenta a dureza e reorganização da dentina, independente do material forrador utilizado. 7 Duas linhas têm sido bastante investigadas: a RPTC em dois passos ou stepwise excavation e a RPTC em sessão única, considerada conservadora.…”