|Year : 2018 | Volume
| Issue : 12 | Page : 1549-1556
Conservative treatment for deep carious lesions in primary and young permanent teeth
FA Alsadat1, AA El-Housseiny2, NM Alamoudi1, AM Alnowaiser1
1 Department of Pediatric Dentistry, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia
2 Department of Pediatric Dentistry, Faculty of Dentistry, King Abdulaziz University, Jeddah, Saudi Arabia; Department of Pediatric Dentistry, Faculty of Dentistry, Alexandria University, Alexandria, Egypt
|Date of Acceptance||17-Aug-2018|
|Date of Web Publication||18-Dec-2018|
Prof. N M Alamoudi
Department of Pediatric Dentistry, Faculty of Dentistry, King Abdulaziz University, PO Box 80209, Jeddah 2158
Source of Support: None, Conflict of Interest: None
| Abstract|| |
The management of deeply carious lesion could be accomplished conservatively by two techniques: an indirect single-step and stepwise techniques. The former involves incomplete removal of carious dentin and then application of a well-sealed permanent restoration. While the latter involves incomplete removal of caries and then reentry after a period to remove the residual caries, after changing its environment. The aim of this article was to review the dental literature concerning the conservative methods available to treat deeply carious teeth. A literature search was done using electronic databases “PubMed,” “Google Scholar,” and “Cochrane Database” for articles in English. Several keywords were used: conservative treatment, deep caries, deeply carious lesion, indirect pulp capping (IPC), and stepwise excavation. This review mentions two operative methods for conservative treatment of deeply carious lesions, namely, IPC, including criteria for case selection and success and failure of the deeply carious lesion, and an account on various used materials. Both single-step and stepwise IPC techniques could be used for managing deeply carious lesions with maintaining pulp vitality; more longitudinal studies are needed to determine which technique is preferable to be used.
Keywords: Conservative treatment, deep caries, deeply carious lesion, indirect pulp capping and stepwise excavation
|How to cite this article:|
Alsadat F A, El-Housseiny A A, Alamoudi N M, Alnowaiser A M. Conservative treatment for deep carious lesions in primary and young permanent teeth. Niger J Clin Pract 2018;21:1549-56
|How to cite this URL:|
Alsadat F A, El-Housseiny A A, Alamoudi N M, Alnowaiser A M. Conservative treatment for deep carious lesions in primary and young permanent teeth. Niger J Clin Pract [serial online] 2018 [cited 2019 Jun 16];21:1549-56. Available from: http://www.njcponline.com/text.asp?2018/21/12/1549/247670
| Introduction|| |
A deep carious lesion involves a greater depth of dentin, and its complete removal could increase the risk of pulp exposure. A lesion is considered to be deep when it reaches three-quarters or more of the depth of dentin radiographically. Single-step indirect pulp capping (IPC) or stepwise excavation of caries can be performed to maintain pulp vitality and avoid pulp exposure.
According to the American Academy of Pediatric Dentistry (AAPD), indirect pulp treatment is a general term that includes both single-step and stepwise procedures. It can be performed in a primary or young permanent tooth with a diagnosis of normal or reversibly inflamed pulp that shows an ability to heal both clinically and radiographically. The final restoration should seal the affected dentin from the surrounding oral environment and tooth vitality should be preserved, that is, there should be no postoperative clinical or radiographic signs of harm to the succedaneous tooth if a primary tooth is involved and there should be continuation of development of the tooth root(s) in a permanent tooth.
IPC entails removal of all caries from the cavity walls except at the pulpal floor to avoid exposing the pulp. This is followed by application of a protective liner such as calcium hydroxide, which in turn should be covered by a base such as glass ionomer. The tooth is filled with a temporary restoration if it is going to be reentered to continue removal of the remaining caries or if a permanent restoration is planned; in either case, the seal needs to be excellent. The literature to date does not indicate which technique is preferable for management of deep carious lesions in the primary or permanent teeth. The aim of this review is to discuss the conservative methods available to treat deep carious primary and young permanent teeth.
| Sources and Data|| |
A literature search was done using electronic databases “PubMed,” “Google Scholar,” and “Cochrane Database,” and these were used to identify the articles in English language that cover the relevant objectives. Multiple search keywords were used, such as stepwise excavation, deep caries, deeply carious lesion, and IPC.
| Treatment of Deep Caries|| |
Management of a deep carious lesion in a primary or young permanent tooth with an underlying asymptomatic pulp is challenging for the pediatric dentist. Traditionally, the entire carious dentin was removed to halt progression of the caries and to provide a solid base of dentin for subsequent filling. Moreover, it has been demonstrated that partial caries excavation decreases the risk of pulpitis and pulp necrosis. In contrast, complete caries removal is an aggressive method that could endanger the pulp, which when exposed requires either pulp treatment or extraction of the tooth. A recent evidence-based literature review showed that conservative methods were more successful in managing deep carious lesions than less conservative techniques in terms of maintaining pulp vitality.
Nowadays, several approaches can be used to manage deep carious lesions. These include the more cautious treatment IPC, through an excavation that approaches the pulp; leaving the deeper-most carious layer untouched, followed by the application of a highly alkaline antibacterial material over one or two visits; to direct pulp capping, and pulpotomy. In addition to the more radical treatment approach, that is, pulpectomy in more severe cases. The most appropriate treatment is chosen by the dentist in consultation with the child's parent(s) or guardian(s). It was unable to favor a technique of vital pulp treatment in primary teeth over the other. Therefore, further research is needed to compare the outcomes of these techniques in primary teeth.
| Indirect Pulp Treatment Procedures: Single-Step or Stepwise|| |
A tooth with a deep carious lesion can be considered for IPC if it has a vital pulp that is symptomless or responding normally to vitality tests, reversible pulpitis with pain that does not linger after provocation thermally or mechanically, and no radiographic evidence of internal or external root resorption., IPC can be performed using either a single-step or stepwise technique.
Single-step indirect pulp capping
Single-step IPC involves almost complete removal of the infected dentin, leaves behind a fine layer of demineralized dentin, and is performed when there is no plan for reentry. Essentially, IPC is the process of removing the superficial layer of caries containing harmful bacteria and their toxins while preserving the deepest layer of dentin for remineralization [Figure 1] and [Figure 2].
|Figure 1: Clinical photographs for single-step indirect pulp capping of a permanent mandibular left first molar. A deep carious lesion (a). Caries removal with hard caries remaining in deep areas (b). Application of dycal (c). Final restoration using a stainless-steel crown (d)|
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|Figure 2: Single-step indirect pulp capping procedure (a-c). A deep lesion before treatment (a). After excavation to the residual level (b). The permanent restoration is made in the same dental visit (c)|
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When performed in the primary teeth, IPC has demonstrated higher clinical and radiographic success rates than other less conservative pulp treatments such as pulpotomy.,,, Two studies showed that IPC was a highly successful treatment for deep caries and an appropriate alternative to complete excavation, that is, pulpotomy., Another study found that less satisfactory radiographic changes, including calcific metamorphosis and periapical or furcation radiolucency, were seen in the teeth treated by formocresol pulpotomy, indicating that IPC was the better treatment option for primary molars with deep caries.
Other researchers have supported use of a single-step IPC procedure when there is no need to reenter the cavity and remove residual caries, reporting that the residual caries is sealed adequately by a high-quality restoration after the grossly carious tissue has been removed in the first stepwise excavation. Reentry to remove the residual carious dentin could damage the exposed pulp, incurring extra dental visits for the patient. However, in comparison to stepwise excavation of caries, IPC has the advantages of decreasing the risk of pulp exposure by not reentering the tooth, decreasing the amount of time spent in clinic by both the dentist and patient, and arresting progression of caries. Furthermore, an increase in radio-opacity has been reported on radiographs after 3 years of follow-up.
Criteria of success and failure in single-step indirect pulp capping
The criteria for success of IPC are absence of symptoms such as pain or swelling and absence of any abnormal features on the follow-up radiograph of the treated tooth [Figure 3]. Determinants of the success of IPC include the original pretreatment pulpal diagnosis, the amount of caries removed, and whether the overlying restoration prevents leakage or not.
|Figure 3: Radiographs for single-step indirect pulp capping of a permanent mandibular left first molar. Periapical radiograph showing a deep carious lesion (a). Final restoration using a stainless-steel crown (b). Pretreatment radiograph showing a deep carious lesion with no apical pathology (c). After 6 months, the radiograph shows a successful treatment outcome with no apical pathology (d)|
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Several studies have evaluated primary teeth treated with calcium hydroxide clinically or microbiologically after incomplete caries removal. It was found that the dentin hardened and became dry after 4–7 months and that there was a significant reduction in levels of aerobic and anaerobic bacteria. Moreover, the dentin became darker in color and harder in consistency after 3 months. Furthermore, it has been shown that bacterial counts are significantly lower in dry and harder lesions than in more soft and wet lesions.
Stepwise excavation of caries
Stepwise excavation of caries is considered a safe procedure [Figure 4] that can be used in both the primary and young permanent teeth. The technique of stepwise excavation involves two visits. At the first visit, the entire carious lesion is removed from the walls but only the soft carious bulk (infected dentin) is removed from the pulpal floor and axial wall., The residual carious dentin, defined as the caries that would lead to exposure of the pulp if any pressure was applied by an excavator, is left behind to alter the environment of the caries; this is followed by application of calcium hydroxide, a cement-based covering, sealing from the oral environment, and a provisional restoration. At the second visit about 3–6 months later, the tooth is reentered to remove the residual caries.
|Figure 4: Stepwise technique (a-f). A deep carious lesion before and after excavation (a and b), followed by a calcium-hydroxide-containing base material and a provisional restoration (c). During the treatment interval, the retained demineralized dentin indicates slow progression of the lesion, evidenced by a darker demineralized dentin (d). After final excavation (e), the permanent restoration is made (f)|
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In one study, 94 permanent teeth with deeply caries treated by stepwise excavation were followed up for a period of 1 year. Five teeth had pulp exposure during the final excavation step. After 1 year, only one case failed because of loss of its aluminum cap after the final excavation and required endodontic treatment. It was concluded that stepwise excavation was a highly successful procedure for treatment of teeth with deep caries. This technique has some disadvantages, that is, an increased risk of pulp exposure at the time of the reentry step and the extra cost required for the second visit, as well as the possibility of loss of the temporary restoration or its presence being forgotten by the patient., While it has several advantages over IPC, including preservation of pulp by avoiding its unnecessary exposure during excavation, making the environment of the cavity more favorable, and encouraging deposition of tertiary dentin and repairing the pulp. The second step of complete caries removal plays a role in strengthening the tooth-restoration interface.
Time interval between two stepwise visits
The interval between two stepwise visits is that between the first visit for removal of caries and the second visit made for final restoration. Historically, there was wide variation in this time interval, ranging from 2 to 3 weeks, 6 months, to 1 year, so it has been difficult to compare the early studies. More recently, it was found that when teeth were treated by stepwise excavation, there was no significant difference between teeth treated with calcium hydroxide for 8–10 weeks and those treated for longer. Furthermore, the reported time interval between the two visits in the more recent studies has ranged from 6 to 12 months, 2 to 19 (median 6) months, 4 to 6 months, 6 to 7 months, and 6 to 8 months. According to the AAPD guidelines, a period of 3–6 months is considered adequate for formation of a tertiary dentin layer above the pulp.
Criteria for success or failure of stepwise excavation
An essential requirement for the success of stepwise excavation is the complete removal of caries from the lateral walls of the cavity followed by insertion of a provisional and permanent restoration of excellent quality with good sealing ability.,, Frequent recalls are needed to check tooth vitality because it is possible that the pulp could become irreversibly damaged without any symptoms., The criteria for successful pulp treatment by stepwise excavation are as follows: absence of symptoms such as sensitivity, pain, or swelling; a tooth that remains sensitive to pulp testing; a periapical area with a normal radiographic appearance; and continued development of immature teeth. The criteria for treatment failure include presence of symptoms, that is, pain and tenderness, and clinical (such as fistula) or radiographic signs of pulp necrosis.,,
Case selection for stepwise excavation
Stepwise excavation is recommended in patients with deep dentinal caries that would expose the pulp if completely removed at a single visit. Such cases could be selected radiographically, that is, when the caries extends to three-quarters of the total thickness of the dentin with no pathology in the periapical area. Diagnostic selection criteria are a positive response to pulp tests and an absence of unprovoked or stimulated pain, although reasonable pain on thermal stimuli is considered acceptable. However, appropriate diagnosis is not always easy in children, hence pediatric dentists need to rely on their clinical judgment with regard to thickness of the remaining carious dentin and radiographic extent of the lesion.
Microbiology of deep carious lesions using stepwise excavation
The bacteria present in deep carious lesions may differ from one individual to another. The cariogenic bacteria present are either facultative-anaerobic, that is, streptococci and lactobacilli, or obligate anaerobic Gram-negative rods. However, Streptococcus mutans is rarely found in deep carious lesions. Bacteria tend to die or become inactive in deeper parts of the dentin after a well-sealed restoration, and this is attributed to the reduced supply of nutrients from the diet and in saliva, leading to selection of less cariogenic bacteria that can survive on serum proteins obtained from the pulp through the dentinal tubules. In a recent study, both Enterococcus faecalis and Aggregatibacter actinomycetemcomitans decreased substantially after removal of temporary restoration after IPC, while Porphyromonas gingivalis has been eliminated from samples after 60 days.
There has been a study in which the investigators evaluated 31 teeth with deep caries treated with stepwise excavation. Microbial samples were taken before and after the two steps, which were separated by an interval of 6–12 months. After the first excavation, there were high cultivable bacteria counts (median 1.0 × 104) that were markedly lower before the final excavation step (median 1.5 × 102) and decreased even further after the procedure (median 1.0 × 101). In that study, 6 of the 31 teeth had no cultivable flora before the final excavation; this number increased to 9 after the final excavation. The authors concluded that stepwise excavation was an appropriate treatment approach for deep carious lesions and a good model for studying the microbiota in excavated lesions. In another study, incomplete excavation of carious dentin was done in 32 teeth with deep caries and applied a layer of calcium hydroxide at the time of the provisional restoration. Microbiologic samples were taken from all teeth before and after removing the provisional restoration 6–7 months later. It was found at that time that both aerobic and anaerobic bacteria counts have decreased in number, indicating probable bacterial cell death or inactivation.
A further study examined the types of viable microflora present in nine permanent teeth before and after both steps of stepwise excavation, which were separated by an interval of 4–6 months. The median cultivable bacteria count was 1.6 × 104 at the time of the first excavation, and most (70%) of the total colony-forming units in carious dentin were Gram-positive rods, predominantly lactobacillus and Actinomyces naeslundii. S. mutans were the least abundant bacteria. Gram-negative rods were found in 20% of all the colony-forming units. After the final excavation, the median cultivable bacteria count was 4.3 × 102. Several streptococcal species and A. naeslundii were identified, but Gram-negative rods were no longer found. It was concluded that the species of bacteria present after the final excavation were not those usually associated with deep caries and were likely to be representative of those found in an arrested carious lesion.
A Cochrane review supported partial rather than complete caries removal to decrease the risk of pulp exposure in asymptomatic primary or permanent teeth. This should be accompanied by a well-sealed restoration to remove the nutrient supply to the bacteria remaining in the infected dentin. This Cochrane review was subsequently updated; it demonstrated that both stepwise and partial excavation decreased the risk of pulp exposure in vital asymptomatic carious primary or permanent teeth.
A systematic review investigated whether incomplete or complete caries removal was more successful. Ten of 332 studies reported between 1967 and 2012 were eligible for inclusion in this review. It was found that incomplete removal of deep caries adjacent to the pulp was more able to avoid unnecessary pulp exposure and decrease the risk of symptoms that may be experienced afterwards. However, this review was assessed as having a limited level of evidence because of the substantial risk of bias in the studies included. It was suggested that further additional research was needed to detect complications of incompletely excavated caries. More studies comparing the relative benefits of incomplete and complete caries removal are needed.
Another systematic review evaluated the effect of the different techniques used for treatment of the pulp in teeth with deep caries to determine whether the pulp should be preserved or removed but could not reach a conclusion. About 24 of the 161 studies included in that review were performed between 1950 and 2010 and showed a moderate to low strength of evidence. Again, further studies are needed to compare the outcomes of the different methods of management of pulp in teeth with deep caries.
Two studies supported partial removal of caries. The first included 299 patients 6 years of age or older and aimed to determine whether IPC was an effective treatment for deep carious lesions in the permanent teeth. The patients were divided into an IPC group and a stepwise excavation group (with the final excavation undertaken after 60 days) and followed up after 2 years. They found that IPC was significantly more successful than stepwise excavation for treatment of deep caries, with success rates of 95.45% and 80.85%, respectively (P = 0.001). The second study compared 152 permanent teeth treated by IPC with 147 teeth treated by stepwise excavation to determine which procedure had a better outcome in terms of pulp vitality. Pulp vitality was confirmed clinically by cold sensitivity and radiographically by the tooth being free of periapical lesions. The success rate for IPC was significantly higher than that for stepwise excavation (91% and 69%, respectively; P = 0.004). Furthermore, the authors suggested that when the plan is to preserve pulp vitality, there is no need to reopen the cavity for a second excavation of caries. A more recent systematic review favored single-step IPC over stepwise excavation in permanent teeth in terms of both a decreased risk of restorative failures (loss of interim restoration) and loss of pulp vitality. However, this conclusion was based on limited evidence, and therefore more longitudinal studies are necessary.
Therefore, the evidence available to date is inconclusive, and a “risk-to-benefit ratio” is recommended on a case-by-case basis for deep caries, that is, whether to use glass ionomer or another material as a provisional material as part of a stepwise technique or whether to apply a definitive restoration directly (IPC) to prevent a delay in treatment that requires additional compliance and incurs further cost to the patient. Furthermore, it is still unclear which conservative technique is preferable, that is, stepwise excavation or IPC. Therefore, more longitudinal studies are again needed.
| Materials Used in Indirect Pulp Treatment|| |
Different types of materials have been used as liners for IPC, including calcium hydroxide (Dycal),, zinc oxide and eugenol cement, glass ionomer cement, resin-modified glass ionomer, mineral trioxide aggregate,, medical Portland cement (White Portland Cement CEM I-52.5N; Medcem GmbH, Schezeiz), self-etching primer (Clearfil SE Bond),, different adhesive systems (Prime & Bond NT, DeTrey/Dentsply, Xeni III, DeTrey/Dentsply), bioactive molecules such as enamel matrix protein (Emdogain) or bone morphogenic protein, and adhesive resin system. Calcium hydroxide has the advantages of promoting remineralization of carious dentin with or without formation of a dentinal bridge overlying the pulp and irritating the pulpal cells, causing them to release growth factors that stimulate repair of the pulp. According to the latest guidelines and a recent systematic review, the success of primary teeth treated with IPC was irrelevant to the lining material used, indicating that the clinical practitioner is the one who decides which material is to be used for each clinical scenario; the quality of the evidence was moderate at 24 months and low at 48 months.,
Another study has compared the long-term outcome of protection using calcium hydroxide with that of an adhesive resin system when applied as a pulp liner for IPC in 48 primary molars with deep caries. After 2 years, both materials were clinically and radiographically effective as class I restorations. Casagrande et al. evaluated the clinical and radiographic outcomes in 32 primary teeth from 15 patients treated by IPC using two different capping materials, that is, self-etching adhesive (Clearfil SE Bond) and calcium hydroxide (Dycal), after which the teeth were filled with composite resin and followed up for 60 months. The overall success rate for IPC was 78%, and there was no statistically significant difference in outcome between the two treatment groups.
A base material of reinforced zinc oxide and eugenol or resin-modified glass ionomer can be applied over the liner for single-step IPC. Another study reviewed the records of 132 patients with a total of 187 primary posterior teeth treated by IPC and followed up for 2 weeks to 73 months. The authors reported a significantly increased success rate for IPC when any of the above bases was used over the calcium hydroxide liner, attributing this finding to the additional seal, thermal insulation, and hardness that the base provides.
Several materials could be used in the temporary restoration after stepwise excavation, including amalgam, composite resin, or glass ionomer. In addition, several materials could be used in the final restoration. The optimum definitive restoration should be selected based on the clinical experience of the dental practitioner, that is, amalgam, a composite or glass ionomer, a resin-modified glass ionomer for cavities involving only the occlusal surface, or a stainless-steel crown for cavities that involve more than one surface. When stainless steel crowns were used as final restorations in primary teeth, IPC was significantly more successful than when amalgam fillings were used.
Single-step IPC is less time-consuming than the more conservative method of treating deeply carious lesions, that is, stepwise excavation. As already mentioned, both these procedures have an evidence base to support their use,,,,,,,, and choice of the best method would depend on whether time or pulp vitality was the more crucial factor in a specific patient.
| Conclusion|| |
Both single-step IPC and stepwise excavation procedures aim to preserve pulp vitality and are useful options for the management of teeth with deep caries. However, more long-term clinical trials are needed to determine which technique is more successful.
The authors would like to thank Editage (www.editage.com) for English language editing.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Fitzgerald M, Heys RJ. A clinical and histological evaluation of conservative pulpal therapy in human teeth. Oper Dent 1991;16:101-12.
Bjørndal L. Indirect pulp therapy and stepwise excavation. J Endod 2008;34:S29-33.
AAPD. Pulp therapy for primary and immature permanent teeth: Reference manual 2017/18. Pediatr Dent2017;39:325-33.
Thompson V, Craig RG, Curro FA, Green WS, Ship JA. Treatment of deep carious lesions by complete excavation or partial removal: A critical review. J Am Dent Assoc 2008;139:705-12.
Ricketts D. Management of the deep carious lesion and the vital pulp dentine complex. Br Dent J 2001;191:606-10.
Ritter AV, Browning WD, Swift EJ Jr. Critical appraisal. Partial caries excavation. J Esthet Restor Dent 2012;24:148-52.
Mattos J, Soares GM, Ribeiro Ade A. Current status of conservative treatment of deep carious lesions. Dent Update 2014;41:452-4, 456.
Ricketts DN, Kidd EA, Innes N, Clarkson J. Complete or ultraconservative removal of decayed tissue in unfilled teeth. Cochrane Database Syst Rev 2006;(3):CD003808.
Fuks AB, Guelmann M, Kupietzky A. Current developments in pulp therapy for primary teeth. Endod Topics2012;23:50-72.
AAPD. Use of vital pulp therapies in primary teeth with deep carious lesions: Reference manual 2017/18. Pediatr Dent 2017;39:173-86.
Opal S, Garg S, Dhindsa A, Taluja T. Minimally invasive clinical approach in indirect pulp therapy and healing of deep carious lesions. J Clin Pediatr Dent 2014;38:185-92.
Roberts JD. Indirect Pulp Treatment Versus Formocresol Pulpotomy in Human Primary Molars: A Randomized Controlled Trial. MSc Thesis in Oral Biology, Texas A & M University College of Dentistry, Dallas, Texas; 2009.
Falster CA, Araujo FB, Straffon LH, Nör JE. Indirect pulp treatment:In vivo
outcomes of an adhesive resin system vs. calcium hydroxide for protection of the dentin-pulp complex. Pediatr Dent 2002;24:241-8.
Al-Zayer MA, Straffon LH, Feigal RJ, Welch KB. Indirect pulp treatment of primary posterior teeth: A retrospective study. Pediatr Dent 2003;25:29-36.
Orhan AI, Oz FT, Orhan K. Pulp exposure occurrence and outcomes after 1- or 2-visit indirect pulp therapy vs. complete caries removal in primary and permanent molars. Pediatr Dent 2010;32:347-55.
Kidd EA. How ‘clean’ must a cavity be before restoration? Caries Res 2004;38:305-13.
Oliveira EF, Carminatti G, Fontanella V, Maltz M. The monitoring of deep caries lesions after incomplete dentine caries removal: Results after 14-18 months. Clin Oral Investig 2006;10:134-9.
Simone GI, Steiner-Oliveira C, Braga MM, Imparato JC. Indirect pulp treatment without re-entry in a permanent tooth: 36 months of follow-up. Rev Caucha Odontol2014;62:71-5.
Gruythuysen RJ, van Strijp AJ, Wu MK. Long-term survival of indirect pulp treatment performed in primary and permanent teeth with clinically diagnosed deep carious lesions. J Endod 2010;36:1490-3.
Akhlaghi N, Khademi A. Outcomes of vital pulp therapy in permanent teeth with different medicaments based on review of the literature. Dent Res J (Isfahan) 2015;12:406-17.
Pinto AS, de Araújo FB, Franzon R, Figueiredo MC, Henz S, García-Godoy F, et al.
Clinical and microbiological effect of calcium hydroxide protection in indirect pulp capping in primary teeth. Am J Dent 2006;19:382-6.
Bressani AE, Mariath AA, Haas AN, Garcia-Godoy F, de Araujo FB. Incomplete caries removal and indirect pulp capping in primary molars: A randomized controlled trial. Am J Dent 2013;26:196-200.
Orhan AI, Oz FT, Ozcelik B, Orhan K. A clinical and microbiological comparative study of deep carious lesion treatment in deciduous and young permanent molars. Clin Oral Investig 2008;12:369-78.
Leksell E, Ridell K, Cvek M, Mejàre I. Pulp exposure after stepwise versus direct complete excavation of deep carious lesions in young posterior permanent teeth. Endod Dent Traumatol 1996;12:192-6.
Kerkhove BC Jr., Herman SC, Klein AI, McDonald RE. A clinical and television densitometric evaluation of the indirect pulp capping technique. J Dent Child 1967;34:192-201.
Bjørndal L, Larsen T, Thylstrup A. A clinical and microbiological study of deep carious lesions during stepwise excavation using long treatment intervals. Caries Res 1997;31:411-7.
Bjørndal L, Thylstrup A. A practice-based study on stepwise excavation of deep carious lesions in permanent teeth: A 1-year follow-up study. Community Dent Oral Epidemiol 1998;26:122-8.
Maltz M, de Oliveira EF, Fontanella V, Bianchi R. A clinical, microbiologic, and radiographic study of deep caries lesions after incomplete caries removal. Quintessence Int 2002;33:151-9.
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. J Dent 2016;54:25-32.
Monari V, Lima-Arsati YB, Rodrigues JA. Avoiding pulp exposure in deep caries lesions: stepwise excavation. Rev Caucha Odontol2011;59:633-8.
Sowden JR. A preliminary report on the recalcification of carious dentin. J Dent Child 1956;23:187-8.
Law DB, Lewis TM. The effect of calcium hydroxide on deep carious lesions. Oral Surg Oral Med Oral Pathol 1961;14:1130-7.
Eidelman E, Finn SB, Koulourides T. Remineralization of carious dentin treated with calcium hydroxide. J Dent Child 1965;32:218-25.
Bjørndal L, Larsen T. Changes in the cultivable flora in deep carious lesions following a stepwise excavation procedure. Caries Res 2000;34:502-8.
Bjorndal L. Dentin and pulp reactions to caries and operative treatment: Biological variables affecting treatment outcome. Endod Topics2002;2:10-23.
Bergenholtz G, Axelsson S, Davidson T, Frisk F, Hakeberg M, Kvist T, et al.
Treatment of pulps in teeth affected by deep caries – A systematic review of the literature. Singapore Dent J 2013;34:1-2.
Marchi JJ, de Araujo FB, Fröner AM, Straffon LH, Nör JE. Indirect pulp capping in the primary dentition: A 4 year follow-up study. J Clin Pediatr Dent 2006;31:68-71.
Love RM, Jenkinson HF. Invasion of dentinal tubules by oral bacteria. Crit Rev Oral Biol Med 2002;13:171-83.
Paddick JS, Brailsford SR, Kidd EA, Beighton D. Phenotypic and genotypic selection of microbiota surviving under dental restorations. Appl Environ Microbiol 2005;71:2467-72.
Kuzmanović Radman I, Djeri A, Arbutina A, Milašin J. Microbiological findings in deep caries lesions. Serbian Dent J2016;63:7-14.
Ricketts D, Lamont T, Innes NP, Kidd E, Clarkson JE. Operative caries management in adults and children. Cochrane Database Syst Rev 2013;(3):CD003808.
Schwendicke F, Dörfer CE, Paris S. Incomplete caries removal: A systematic review and meta-analysis. J Dent Res 2013;92:306-14.
Maltz M, Moura MdS, Jardim JJ, Marques C, De Paula LM, Mestrinho HD. Partial caries removal in deep lesions: 19-30 months follow-up study. J Dent Sch Porto Alegre2010;51:20-3.
Maltz M, Garcia R, Jardim JJ, de Paula LM, Yamaguti PM, Moura MS, et al.
Randomized trial of partial vs. stepwise caries removal: 3-year follow-up. J Dent Res 2012;91:1026-31.
Petrou MA, Alhamoui FA, Welk A, Altarabulsi MB, Alkilzy M, H Splieth C, et al.
Arandomized clinical trial on the use of medical portland cement, MTA and calcium hydroxide in indirect pulp treatment. Clin Oral Investig 2014;18:1383-9.
Casagrande L, Bento LW, Dalpian DM, García-Godoy F, de Araujo FB. Indirect pulp treatment in primary teeth: 4-year results. Am J Dent 2010;23:34-8.
Casagrande L, Bento LW, Rerin SO, Lucas Ede R, Dalpian DM, de Araujo FB, et al. In vivo
outcomes of indirect pulp treatment using a self-etching primer versus calcium hydroxide over the demineralized dentin in primary molars. J Clin Pediatr Dent 2008;33:131-5.
Büyükgüral B, Cehreli ZC. Effect of different adhesive protocols vs calcium hydroxide on primary tooth pulp with different remaining dentin thicknesses: 24-month results. Clin Oral Investig 2008;12:91-6.
Tziafas D, Smith AJ, Lesot H. Designing new treatment strategies in vital pulp therapy. J Dent 2000;28:77-92.
Coll JA, Seale NS, Vargas K, Marghalani AA, Al Shamali S, Graham L, et al.
Primary tooth vital pulp therapy: A systematic review and meta-analysis. Pediatr Dent 2017;39:16-23.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]