Keywords
dentin physiology, dental caries, dental therapy, tooth remineralization.
How to Cite
Current therapeutic options for treating Deep Carious lesions: a review. (2019). Odontoestomatología, 19(29), 4-17. https://odon.edu.uy/ojs/index.php/ode/article/view/130
Abstract
Tis review analyzes how to treat deep carious lesions taking into consideration histophysiologic and biomolecular events of the dentin-pulp complex in permanent teeth. We focus on clinical resources to assess the degree of lesion progression and to guide the removal of carious lesions. Indirect pulp treatment, Stepwise excavation and Partial caries removal are described by presenting clinical cases, and their follow-ups, led by students of Integrated Clinic II of the School of Dentistry, Universidad de la República Uruguay. These simple and inexpensive treatments are available to all clinicians and signifcantly decrease the number of pulp exposures. The success of these therapeutic options depends on the proper selection of cases and on the integrity of the restoration within a comprehensive preventive plan.
References
1. Olmos P, Piovesan S, Musto M, Lorenzo S, Alvarez R, Massa F. Caries dental. La enfermedad más prevalente. Primer estudio poblacional en jóvenes y adultos uruguayos del interior del país. Odontoestomatología 2013; XV (nº especial): 26-34
2. Alonso Mª E, Golubchin D, Modyeievsky I. Tratamientos Conservadores Pulpares. En: Cátedra de Endodoncia de la Facultad de Odontología. UdelaR. Endodoncia Clínica. Manual de apoyo a la Enseñanza Clínica en terapias Endodónticas. Montevideo: Tradinco, 2008. P 81-105
3. Fouad AF, Levin L. Efectos de la caries y los tratamientos dentales sobre la pulpa. En: Cohen S, Hargreaves KM. Vías de la Pulpa. 10 ed. España: Elsevier, 2011. p
504-28.
4. Dommisch H, Winter J, Acil Y, Dunsche A, Tiemann M, Jepsen S. Human betadefensin (hBD-1,-2) expression in dental pulp. Oral Microbiol Inmunol 2005; 163-6
5. Gerardeli S, Li Y, Hogan MM, Tjäderhane LS, Pashley DH, Morgan TA, Zimmerman MB, Brodgen KA.Inflamatory mediators in fluid extracted from the coronal oclusal dentine of trimmed teeth. Arch Oral Biol 2012; 57: 264-70
6. Goldberg M, Smith A. Cells and extracellular matrices of dentin and pulp: a biological basis for repair and tissue engineering. Crit Rev Oral Biol Med 2004;
15(1): 13-27
7. Chaussain-Miller C, Fioretti F, Goldberg M, Menashi S. Te role of matrix metalloproteinases (MMPs) in human caries. J Dent Res 2006; 85: 22-32.
8. Bjørndal L, Mjör IA. Dental Caries: Characteristics of Lesions and Pulp Reactions. In: Mjör IA. Pulp-Dentin Biology in Restorative Dentistry. Chicago: Quintessence Publishing, 2002. p 55-75
9. Simon S, Smith AJ, Berdal A, Lumley PJ, Cooper PR. Te MAP Kinase Pathway is involved in odontoblast stimulation via p 38 Phosphorylation. J Endod 2010; 36:
256-9
10. Gomez de Ferraris MªE, Campos Muñoz A. Complejo dentino-pulpar II: dentina. En: Histología, Embriología e Ingeniería Tisular Bucodental. 3ª ed México: Panamericana, 2009. p 255-90
11. Duarte G, Sanchiz O, Martínez MªN, Ringel S, Botana A. Consideraciones acerca del “Complejo pulpo dentinario”. Montevideo: Universidad de la Repú-
blica. Facultad de Odontología; 2010. p 1-23
12. Farges JC, Carrouel F, Keller JF, Baudouin C, Msika P, Bleicher F, Staquet MJ. Cytokine production by human odontoblast-like cells upon Toll-like receptor-2 engagement. Inmunobiology 2011; 216:513-7
13. Gomez de Ferraris MªE, Campos Muñoz A. Complejo dentino-pulpar I: Pulpa dental. En: Histología, Embriología e Ingeniería Tisular Bucodental. 3ª ed. México: Panamericana, 2009. p 231-53
14. Smith AJ, Scheven BA, Takahashi Y, Ferracane JL, Shelton RM, Cooper PR. Dentine as a biengagement bioactive extracelular matrix. Arch Oral Biol 2012;
57: 109-21
15. AAE Consensus Conference Recommended Diagnostic Terminology. J Endod 2009; 35(12): 1634
16. Universidad de la República. Facultad de Odontología. Cátedra de Anatomía Patológica, Cátedra de Endodoncia, Servicio de Urgencia, Cátedra de Quirúrgica. Alteraciones pulpares y sus complicaciones. Calibración Interdisciplinaria de diagnóstico pulpar y manejo terapéutico. Montevideo. Universidad de la República. Facultad de Odontología; 2005: 1-9
17. Fusayama T, Terashima S. Differentiation of two layers of carious dentin by staining. J Dent Res 1972; 51(3): 866
18. Banerjee A, Watson F, Kidd E. Dentin Caries: take it or leave it? Dent Update 2000; 27: 272-6
19. Turell JC. El diagnóstico clínico de la dentina cariada. Método de la fucsina básica. Odontol Urug 1963; 18(71): 8-11
20. Kuboki Y, Liu CF, Fusayama T. Mechanism of differential staining in carious dentin. J Dent Res 1983; 62(6): 713-4
21. Yip HK, Stevenson AG, Beeley JA. The specifcity of caries dyes in cavity preparation. Br Dent J 1994; 176: 417-21
22. Kidd E, Ricketts DNJ, Beighton D. Criteria for caries removal at the enamel-dentine junction: a clinical and microbiological study. Br Dent J 1996; 180(8): 287-91
23. Hosoya Y, Taguchi T, Arita S. Tay FR. Clinical evaluation of polypropylene glycol-based caries detecting dyes for primary and permanent carious dentin. Dent 2008; 36: 1041-7
24. Bjørndal L, Larsen T. Changes in the cultivable flora in deep carious lesions following a Stepwise Excavation procedure. Caries Res 2000; 34:502-8
25. Maltz M, de Oliveira E, Fontanella V, Bianchi R. A clinical, microbiologic, and radiographic study of deep caries lesions after incomplete caries removal. Quintessence Int 2002; 33: 151-9
26. Hasse PN, Conrado CA, De Oliveira MR. Proteção Pulpar Indireta. Uma revisão bibliográfca analítica e apresentação de casos clínicos. Rev Odon Ciên 2001;
16(34): 288-97
27. Bjørndal L, Kidd E. Te treatment of deep dentine caries lesions. Dent Update 2005; 32: 402-13
28. Orhan AL, Oz FT, Orhan K. Pulp exposure ocurrence and outcomes after 1 o 2 visit Indirect Pulp Terapy vs complete caries removal in primary and permanent
molars. Pediatr Dent 2010; 32(4): 347-55
29. Borba de Araújo F, Moreira C, Souza A, Massara Mª de L. Enfoque contemporáneo de la Terapia Pulpar en dientes deciduos. En: Estrela C. Ciencia Endodóntica. San Pablo: Artes Médicas, 2005. p941-67
30. Waterhouse P, Whitworth J, Camp J, Fuks A. Endodoncia pediátrica: tratamiento endodóntico en la dentición temporal y permanente joven. En: Hargreaves
KM, Cohen S. Vías de la Pulpa. 10 ed. España: Elsevier, 2011. p 821-2
31. Petrou MA, Alhamoui FA, Welk A, Altarabulsi MB. A randomized clinical trial on the use of medical Portland cement, MTA and calcium hydroxide in indirect
pulp treatment. Clin Oral Invest 2014;18: 1383-9
32. Bjørndal L. Indirect Pulp Terapy and Stepwise Excavation. J Endod 2008; 34: S29-S33
33. Castellanos L, González J, Calvo C, López FJ, Velasco E, Llamas JM, Segura JJ. Endodoncia preventiva: Protección pulpar mediante la técnica de eliminación de
la caries en etapas (Stepwise Excavation). Av Odontoestomatol 2011; 27(5): 245-52
34. Holland GR, Trowbridge HO, Rafter M. Protección de la pulpa, conservación del ápice. En: Torabinejad M, Walton RE. Endodoncia. Principios y práctica. 4ª ed.
Barcelona: Elsevier, 2010. p 28
35. Maltz M, Alves LS, Jardim JJ, Moura MS, de Oliveira EF. Incomplete caries removal in deep lesions: a 10 year prospective study. Am J Dent 2011; 24: 211-4
36. Hayashi M. Fujitani M, Yamaki Ch. Momoi Y. Ways of enhancing pulp preservation by Stepwise excavation-a systematic review. J Dent 2011; 39(2):95-107
37. Paddick JS, Brailsford SR, Kidd EA, Beighton D. Phenotypic and genotypic selection of microbiota surviving under dental restorations. Appl Environ Microbiol 2005; 71(5): 2467-72
38. Bjørndal L, Tylstrup 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
39. Leksell E, Ridell K, Cvek M, Mejare I. Pulp exposure after Stepwise versus direct complete excavation of deep carious lesions in young posterior permanent teeth. Endod Dent Traumatol 1999; 12: 192-6
40. Ricketts D. Management of deep carious lesion and the vital pulp dentine complex. Br Dent J 2001; 191(11): 606-10
41. Ricketts DN, Kidd EA, Innes N, Clarkson J. Complete or ultraconservative removal of decayed tissue in unflled teeth. Cochrane Database Syst Rev 2006; 3:
CD003808
42. Maltz M, García R, Jardim JJ, de Paula LM, Yamaguti PM, Moura MS, Garcia F, Nascimento C, Oliveira A, Mestrinho HD. Randomized trial of Partial vs Stepwise caries removal: 3 years follow-up. J Dent Res 2012: 1-6
43. Schwendicke F, Kern M, Dörfer C; Kleemann-Lüpkes J, Paris S, Blunck U. Influence of using different bonding systems and composites on the margin integrity and the mechanical properties of selectively excavated teeth in vitro. J Dent 2015; 43: 327-34
44. Atmeh AR, Chong EZ, Richard G, Festy F, Watson TF. Dentin-cement interfacial interaction: calcium silicates and polyalkenoates. J Dent Res 2012; 91(5):454-9
45. Bjørndal L, Reit C, Bruun G; Markvart M, Kjaeldgaard M, Näsman P, Tordrup M, Dige I, Nyvad B, Fransson H, Lager A, Ericson D, Petersson K, Olsson J, Santimano EM, Wennström A, Winkel P, Gluud Ch. Treatment of deep caries lesions in adults: randomized clinical trials comparing Stepwise vs direct complete
excavation, and direct pulp capping vs Partial pulpotomy Eur J Oral Sci 2010; 118: 290-7
2. Alonso Mª E, Golubchin D, Modyeievsky I. Tratamientos Conservadores Pulpares. En: Cátedra de Endodoncia de la Facultad de Odontología. UdelaR. Endodoncia Clínica. Manual de apoyo a la Enseñanza Clínica en terapias Endodónticas. Montevideo: Tradinco, 2008. P 81-105
3. Fouad AF, Levin L. Efectos de la caries y los tratamientos dentales sobre la pulpa. En: Cohen S, Hargreaves KM. Vías de la Pulpa. 10 ed. España: Elsevier, 2011. p
504-28.
4. Dommisch H, Winter J, Acil Y, Dunsche A, Tiemann M, Jepsen S. Human betadefensin (hBD-1,-2) expression in dental pulp. Oral Microbiol Inmunol 2005; 163-6
5. Gerardeli S, Li Y, Hogan MM, Tjäderhane LS, Pashley DH, Morgan TA, Zimmerman MB, Brodgen KA.Inflamatory mediators in fluid extracted from the coronal oclusal dentine of trimmed teeth. Arch Oral Biol 2012; 57: 264-70
6. Goldberg M, Smith A. Cells and extracellular matrices of dentin and pulp: a biological basis for repair and tissue engineering. Crit Rev Oral Biol Med 2004;
15(1): 13-27
7. Chaussain-Miller C, Fioretti F, Goldberg M, Menashi S. Te role of matrix metalloproteinases (MMPs) in human caries. J Dent Res 2006; 85: 22-32.
8. Bjørndal L, Mjör IA. Dental Caries: Characteristics of Lesions and Pulp Reactions. In: Mjör IA. Pulp-Dentin Biology in Restorative Dentistry. Chicago: Quintessence Publishing, 2002. p 55-75
9. Simon S, Smith AJ, Berdal A, Lumley PJ, Cooper PR. Te MAP Kinase Pathway is involved in odontoblast stimulation via p 38 Phosphorylation. J Endod 2010; 36:
256-9
10. Gomez de Ferraris MªE, Campos Muñoz A. Complejo dentino-pulpar II: dentina. En: Histología, Embriología e Ingeniería Tisular Bucodental. 3ª ed México: Panamericana, 2009. p 255-90
11. Duarte G, Sanchiz O, Martínez MªN, Ringel S, Botana A. Consideraciones acerca del “Complejo pulpo dentinario”. Montevideo: Universidad de la Repú-
blica. Facultad de Odontología; 2010. p 1-23
12. Farges JC, Carrouel F, Keller JF, Baudouin C, Msika P, Bleicher F, Staquet MJ. Cytokine production by human odontoblast-like cells upon Toll-like receptor-2 engagement. Inmunobiology 2011; 216:513-7
13. Gomez de Ferraris MªE, Campos Muñoz A. Complejo dentino-pulpar I: Pulpa dental. En: Histología, Embriología e Ingeniería Tisular Bucodental. 3ª ed. México: Panamericana, 2009. p 231-53
14. Smith AJ, Scheven BA, Takahashi Y, Ferracane JL, Shelton RM, Cooper PR. Dentine as a biengagement bioactive extracelular matrix. Arch Oral Biol 2012;
57: 109-21
15. AAE Consensus Conference Recommended Diagnostic Terminology. J Endod 2009; 35(12): 1634
16. Universidad de la República. Facultad de Odontología. Cátedra de Anatomía Patológica, Cátedra de Endodoncia, Servicio de Urgencia, Cátedra de Quirúrgica. Alteraciones pulpares y sus complicaciones. Calibración Interdisciplinaria de diagnóstico pulpar y manejo terapéutico. Montevideo. Universidad de la República. Facultad de Odontología; 2005: 1-9
17. Fusayama T, Terashima S. Differentiation of two layers of carious dentin by staining. J Dent Res 1972; 51(3): 866
18. Banerjee A, Watson F, Kidd E. Dentin Caries: take it or leave it? Dent Update 2000; 27: 272-6
19. Turell JC. El diagnóstico clínico de la dentina cariada. Método de la fucsina básica. Odontol Urug 1963; 18(71): 8-11
20. Kuboki Y, Liu CF, Fusayama T. Mechanism of differential staining in carious dentin. J Dent Res 1983; 62(6): 713-4
21. Yip HK, Stevenson AG, Beeley JA. The specifcity of caries dyes in cavity preparation. Br Dent J 1994; 176: 417-21
22. Kidd E, Ricketts DNJ, Beighton D. Criteria for caries removal at the enamel-dentine junction: a clinical and microbiological study. Br Dent J 1996; 180(8): 287-91
23. Hosoya Y, Taguchi T, Arita S. Tay FR. Clinical evaluation of polypropylene glycol-based caries detecting dyes for primary and permanent carious dentin. Dent 2008; 36: 1041-7
24. Bjørndal L, Larsen T. Changes in the cultivable flora in deep carious lesions following a Stepwise Excavation procedure. Caries Res 2000; 34:502-8
25. Maltz M, de Oliveira E, Fontanella V, Bianchi R. A clinical, microbiologic, and radiographic study of deep caries lesions after incomplete caries removal. Quintessence Int 2002; 33: 151-9
26. Hasse PN, Conrado CA, De Oliveira MR. Proteção Pulpar Indireta. Uma revisão bibliográfca analítica e apresentação de casos clínicos. Rev Odon Ciên 2001;
16(34): 288-97
27. Bjørndal L, Kidd E. Te treatment of deep dentine caries lesions. Dent Update 2005; 32: 402-13
28. Orhan AL, Oz FT, Orhan K. Pulp exposure ocurrence and outcomes after 1 o 2 visit Indirect Pulp Terapy vs complete caries removal in primary and permanent
molars. Pediatr Dent 2010; 32(4): 347-55
29. Borba de Araújo F, Moreira C, Souza A, Massara Mª de L. Enfoque contemporáneo de la Terapia Pulpar en dientes deciduos. En: Estrela C. Ciencia Endodóntica. San Pablo: Artes Médicas, 2005. p941-67
30. Waterhouse P, Whitworth J, Camp J, Fuks A. Endodoncia pediátrica: tratamiento endodóntico en la dentición temporal y permanente joven. En: Hargreaves
KM, Cohen S. Vías de la Pulpa. 10 ed. España: Elsevier, 2011. p 821-2
31. Petrou MA, Alhamoui FA, Welk A, Altarabulsi MB. A randomized clinical trial on the use of medical Portland cement, MTA and calcium hydroxide in indirect
pulp treatment. Clin Oral Invest 2014;18: 1383-9
32. Bjørndal L. Indirect Pulp Terapy and Stepwise Excavation. J Endod 2008; 34: S29-S33
33. Castellanos L, González J, Calvo C, López FJ, Velasco E, Llamas JM, Segura JJ. Endodoncia preventiva: Protección pulpar mediante la técnica de eliminación de
la caries en etapas (Stepwise Excavation). Av Odontoestomatol 2011; 27(5): 245-52
34. Holland GR, Trowbridge HO, Rafter M. Protección de la pulpa, conservación del ápice. En: Torabinejad M, Walton RE. Endodoncia. Principios y práctica. 4ª ed.
Barcelona: Elsevier, 2010. p 28
35. Maltz M, Alves LS, Jardim JJ, Moura MS, de Oliveira EF. Incomplete caries removal in deep lesions: a 10 year prospective study. Am J Dent 2011; 24: 211-4
36. Hayashi M. Fujitani M, Yamaki Ch. Momoi Y. Ways of enhancing pulp preservation by Stepwise excavation-a systematic review. J Dent 2011; 39(2):95-107
37. Paddick JS, Brailsford SR, Kidd EA, Beighton D. Phenotypic and genotypic selection of microbiota surviving under dental restorations. Appl Environ Microbiol 2005; 71(5): 2467-72
38. Bjørndal L, Tylstrup 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
39. Leksell E, Ridell K, Cvek M, Mejare I. Pulp exposure after Stepwise versus direct complete excavation of deep carious lesions in young posterior permanent teeth. Endod Dent Traumatol 1999; 12: 192-6
40. Ricketts D. Management of deep carious lesion and the vital pulp dentine complex. Br Dent J 2001; 191(11): 606-10
41. Ricketts DN, Kidd EA, Innes N, Clarkson J. Complete or ultraconservative removal of decayed tissue in unflled teeth. Cochrane Database Syst Rev 2006; 3:
CD003808
42. Maltz M, García R, Jardim JJ, de Paula LM, Yamaguti PM, Moura MS, Garcia F, Nascimento C, Oliveira A, Mestrinho HD. Randomized trial of Partial vs Stepwise caries removal: 3 years follow-up. J Dent Res 2012: 1-6
43. Schwendicke F, Kern M, Dörfer C; Kleemann-Lüpkes J, Paris S, Blunck U. Influence of using different bonding systems and composites on the margin integrity and the mechanical properties of selectively excavated teeth in vitro. J Dent 2015; 43: 327-34
44. Atmeh AR, Chong EZ, Richard G, Festy F, Watson TF. Dentin-cement interfacial interaction: calcium silicates and polyalkenoates. J Dent Res 2012; 91(5):454-9
45. Bjørndal L, Reit C, Bruun G; Markvart M, Kjaeldgaard M, Näsman P, Tordrup M, Dige I, Nyvad B, Fransson H, Lager A, Ericson D, Petersson K, Olsson J, Santimano EM, Wennström A, Winkel P, Gluud Ch. Treatment of deep caries lesions in adults: randomized clinical trials comparing Stepwise vs direct complete
excavation, and direct pulp capping vs Partial pulpotomy Eur J Oral Sci 2010; 118: 290-7