ReviewFailure of incompletely excavated teeth—A systematic review
Introduction
There has been an increasing interest into conservative techniques of caries removal in recent years, mirrored in the development of more selective excavation aids or methods like fluorescence-aided excavation, polymer burs or chemo-mechanical caries removal.1 This interest is triggered by a growing number of clinical trials demonstrating the benefits of minimal invasive compared with attempted complete caries removal, especially for deeper dentine lesions approaching the pulp.2, 3 Such techniques include incomplete excavation, atraumatic restorative technique or non-invasive restorations, for example using stainless steel crowns. Incomplete caries removal can be performed during one step only, intentionally leaving remaining caries under a sealing restoration. Alternatively, remaining carious substance is removed during a second excavation step after some months. A sufficient seal deprives remaining bacteria from nutrition, thereby reducing their number and activity, with subsequent caries arrest and remineralisation of carious dentine.2, 4, 5, 6, 7 Both one- and two-step partial excavation significantly reduce the risk of pulpal exposure, and may lead to fewer post-operative pulpal complications compared with complete excavation.8, 9 The risk of overall failure, however, was shown to be similar after incomplete and complete excavation,8 but it is important to bear in mind that this risk was calculated for only those teeth without previous pulpal exposures (since exposed pulps were treated separately and thus not followed-up within studies). It is therefore likely that incomplete excavation reduces overall risk of failures, since pulpal exposure frequently leads to failure of the initial treatment,10 but due to described limitations current evidence is unable to support this hypothesis.
In contrast, concerns have been raised that incompletely excavated teeth might show higher risk of fracture or micro-leakage11, 12 compared with completely excavated teeth, possibly associated with reduced bond strengths to carious dentine depending on the used adhesive system.13, 14 Such higher risk of non-pulpal complications may compensate for the possibly lower risk of pulpal complications. Since recent reviews were not able to describe the type of failure in detail,8, 9 it is of high relevance to investigate how exactly incompletely excavated teeth fail (pulpal or non-pulpal failure mode). In addition, it is currently unclear if certain tooth- or treatment-associated factors (like kind of dentition, cavity size or excavation strategy) have an influence on risk of failure of partially excavated teeth.
The present review therefore systematically assessed failure of incompletely excavated teeth and evaluated, if incompletely excavated teeth fail due to pulpal or rather non-pulpal reasons. In addition, effects of certain influencing factors on risk of failure of partially excavated teeth were sub-analysed.
Section snippets
Review design
The present review aimed at systematically retrieving and analysing studies investigating failure of incompletely excavated teeth to assess failure mode and possible influencing factors on risk of failure. A literature search was performed using a search strategy and study inclusion followed pre-defined criteria. Extracted data was analysed in three steps: Firstly, failure frequency and failure mode distribution (pulpal versus non-pulpal failures) were assessed. Secondly, failure in different
Results
335 articles were identified by screening electronic databases, 32 further articles were identified by cross-referencing. A total of 88 articles was screened full-text, 59 articles (44 studies) were excluded (Fig. 1, Tab. S1). Eventually, 29 articles reporting 19 trials were included, representing 2405 teeth from over 1547 patients (the total numbers of patients is unknown, as one study did not report this). A total of 1637 teeth was analysed after a median (25th/75th percentiles) follow-up
Discussion
The present study investigated annual failure rate and failure mode of incompletely excavated teeth, and sub-analysed possible influencing factors on the risk of failure after partial caries removal. Total AFRs for incompletely excavated teeth (median 3.8%) were similar to reported failure rates for teeth after conventional excavation, or even indicated a possible superiority of incomplete compared with complete excavation: a meta-analysis of studies investigating extensive composite and
Conclusions
After incomplete excavation of deep caries the majority of failures were found to be of pulpal origin. Based on sub-analyses of influencing factors, teeth with single-surface restorations and one-step incompletely excavated teeth showed reduced risk of failure compared to teeth with multi-surface restorations or two-step excavated teeth. Doubts remain regarding a suitable treatment of deep cavities with liners or restorative materials. Our estimates, however, have very low evidence; it is
Conflicts of interest
The authors declare no interest conflict. The study was funded by the authors and their institutions.
Acknowledgements
We are grateful to Dipl.-Inf. Jürgen Hedderich, Institute for Medical Informatics and Statistics, Christian-Albrechts-University, Kiel, for statistical advice. Many thanks to Dharshani Anandanesan-Midgley (BDS, PGDp [Bris]) for proof-reading the manuscript.
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