Abstract
ObjectivesFor well-defined deep (> 2/3 dentin extension) carious lesions, selective (SE) or stepwise (SW) carious tissue removals have been recommended, while there is limited comparative evidence for both. We compared SE and SW over 24 months in a randomized controlled trial.MethodsA two-arm superiority trial was conducted comparing SW/SE in primary molars without pulpal symptoms but well-defined deep lesions. Seventy-four children (1 molar/child) aged 3–9 years were recruited. In a first step, peripheral carious tissue was removed until hard dentin remained, while in proximity to the pulp, leathery dentin was left. An adhesive compomer restoration was placed and restorations re-examined after 6 months. In SW, re-entry and removal to firm dentin was conducted pulpo-proximally, followed by re-restoration. Molars were re-evaluated for a total of 24 months. Our primary outcome was success (absence of restorative/endodontic complications or pulp exposures). Secondary outcomes included total treatment and opportunity costs and restoration quality, assessed using modified USPHS criteria.ResultsAfter 24 months, 63 molars (31 SE, 32 SW) were re-assessed. Four failures occurred (2 exposures in SW; 2 pulpal complications in SE, 1 of them leading to extraction, p > 0.05). Restoration integrity was satisfying in both groups (USPHS A/B/C in 21/8/0 SE and 23/7/0 SW, p > 0.05). Treatment and opportunity costs were significantly higher in SW than SE (mean 171 ± 51 vs. 106 ± 90; p < 0.001).ConclusionsAfter 2 years, SE and SW showed similar efficacy for managing deep carious lesions in primary molars. The higher costs for SW should be considered during decision-making.Clinical significanceIn primary molars with well-defined deep carious lesions SE was less costly and similarly efficacious like SW. From a cost and applicability perspective, SW may need to be indicated restrictively, e.g., for very deep (> 3/4 dentin extension) lesions only.Trial registrationClinicalTrials.gov Identifier: NCT02232828
Highlights
When managing deep carious lesions, especially in primary teeth, the risk of pulp exposure and complications is high, and managing these complications usually involves endodontic, surgical, or orthodontic follow-up treatments [1,2,3]
In the present analysis of this trial after 24 months, we report on success, survival and costs, as well as the restoration quality according to modified USPHS criteria
When managing deep carious lesions in primary molars, dentists conventionally relied on non-selective carious tissue removal, which was found to be associated with high risks of pulp exposure and complications like pulpitis [18]
Summary
When managing deep carious lesions, especially in primary teeth, the risk of pulp exposure and complications is high, and managing these complications usually involves endodontic, surgical, or orthodontic follow-up treatments [1,2,3]. When initiating the present study, only one three-arm study involving 63 primary teeth had compared both therapies for managing deep carious lesions, i.e., those involving the inner third of the dentin [4] This study found both strategies to show similar risks of pulp exposures and complications, but did not at all assess restorative complications or compared the costs of both treatments, which will be very different initially given the second step being required for SW, but may be long term in case SE shows more restorative complications than SW, for example, [5, 6]. In a 1-year interim analysis [7], we showed that success, survival, patients’, parents’, and dentists’ subjective evaluation did not significantly differ Both the initial and long-term cost were significantly higher in SW than SE. In the present analysis of this trial after 24 months, we report on success, survival and costs, as well as the restoration quality according to modified USPHS criteria
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