CLINICAL REVIEW

F. Schwendicke*, C.E. Dörfer,

and S. Paris
Incomplete Caries Removal:
Department for Conservative Dentistry and Periodontology,
A Systematic Review and
Christian-Albrechts-University, Arnold-Heller-Str. 3, 24105
Kiel, Germany; *corresponding author, schwendicke@ Meta-analysis
konspar.uni-kiel.de

J Dent Res 92(4):306-314, 2013

Abstract Introduction
Increasing numbers of clinical trials have demon-
strated the benefits of incomplete caries removal,
in particular in the treatment of deep caries. This
F or nearly a century, dental caries has been treated by attempted eradica-
tion: Bacteria and all infected dental biomass (Fusayama et al., 1966)
were removed, and the resulting cavity was subsequently restored. As knowl-
study systematically reviewed randomized con-
edge and attitudes concerning the dental biofilm and pathogenesis of caries
trolled trials investigating one- or two-step incom-
changed, the common treatment procedure for caries lesions was questioned
plete compared with complete caries removal.
as well (Kidd, 2004). The complete removal of all carious tooth substance
Studies treating primary and permanent teeth with
from cavitated lesions is no longer seen as mandatory, and there is growing
primary caries lesions requiring a restoration were
evidence supporting incomplete removal of carious tissue before the cavity is
analyzed. The following primary and secondary
restored (Banerjee et al., 2001). Theoretically, it is argued, a completely sealed
outcomes were investigated: risk of pulpal expo-
remaining caries lesion should be arrested. Hence, therapy of cavitated lesions
sure, post-operative pulpal symptoms, overall fail-
may require less focus on complete excavation than on adequate r­ estorations
ure, and caries progression. Electronic databases
(Ricketts, 2001; Kidd, 2004).
were screened for studies from 1967 to 2012.
This re-thinking of caries treatment is based on a new understanding of the
Cross-referencing was used to identify further
disease: Caries is currently seen as the result of an ecologic shift within the
articles. Odds ratios (OR) as effect estimates were
dental biofilm to acidogenic and aciduric bacterial species, frequently created
calculated in a random-effects model. From 364
and maintained by abundant dietary fermentable carbohydrates. The patho-
screened articles, 10 studies representing 1,257
logic alteration of the pH leads to an imbalance between de- and remineraliza-
patients were included. Meta-analysis showed risk
tion, and extensively demineralized dental substance eventually cavitates,
reduction for both pulpal exposure (OR [95% CI]
thus creating clinical “decay” (Kidd, 2004; Kidd and Fejerskov, 2004; Marsh,
0.31 [0.19-0.49]) and pulpal symptoms (OR 0.58
2006). Generations of dentists have removed all infected enamel and dentin
[0.31-1.10]) for teeth treated with one- or two-step
using excavators or high- and low-speed instruments, thus risking exposure of
incomplete excavation. Risk of failure seemed to
the pulp. When one bears in mind the pathogenesis of caries, this might not
be similar for both complete and incomplete exca-
be necessary: Instead of attempting to remove all bacteria, it should be suffi-
vation, but data for this outcome were of limited
cient to re-shift the ecologic and metabolic balance within the biofilm, thus
quality and inconclusive (OR 0.97 [0.64-1.46]).
promoting remineralization, thereby arresting the caries lesions (Bjørndal and
Based on reviewed studies, incomplete caries
Kidd, 2005). Large numbers of studies investigating the sealing of fissure
removal seems advantageous compared with com-
caries have demonstrated such effects. They showed reduction of bacterial
plete excavation, especially in proximity to the
number and activity, and the clinical, microbiological, and radiological signs
pulp. However, evidence levels are currently insuf-
of caries inactivation and dentin remineralization (Handelman et al., 1976,
ficient for definitive conclusions because of high
1985; Oong et al., 2008). In contrast, a retrospective analysis found bacteria
risk of bias within studies.
in 53% of sealed caries lesions, with moist and soft dentin under clinically
intact sealants (Weerheijm et al., 1992). However, a range of treatment con-
KEY WORDS: dental caries, dental cavity prepa- cepts, like caries sealing with resins or crowns (Griffin et al., 2008; Innes
ration, partial excavation, indirect pulp treatment, et al., 2011) or caries infiltration (Paris et al., 2010), successfully use the
dental pulp exposure, dental pulp capping. described inactivation and remineralization effects.
For deeper, cavitated caries lesions, removal of carious substance followed
DOI: 10.1177/0022034513477425 by a restoration to reinstate the outline of the tooth is currently seen as clinical
standard, thus allowing for mechanical plaque control. However, there is no
Received November 22, 2012; Last revision January 14,
2013; Accepted January 14, 2013
consensus on how much carious dentin needs to be removed, partially due to
insufficient methods of easily, reproducibly, and objectively measuring caries
A supplemental appendix to this article is published elec- removal.
tronically only at http://jdr.sagepub.com/supplemental.
There are currently 2 options for performing incomplete caries removal: In
© International & American Associations for Dental Research two-step (or “stepwise”) caries treatment, carious dentin is incompletely

306
J Dent Res 92(4) 2013 Systematic Review of Incomplete Caries Removal  307
removed at the first step and remains in proximity to the pulp
under a temporary filling. In a second visit some months later, a
re-entry procedure is performed, and complete removal of all
carious tissue and a definitive restoration are provided. Thus,
remineralization and development of tertiary dentin within the
pulp chamber between the 2 visits are facilitated (Bjørndal
et al., 1997; Bjørndal and Larsen, 2000). One-step incomplete
or partial caries removal omits the re-entry stage, since residual
caries is sealed under a definitive restoration in the first and only
visit. However, the amount of carious dentin left is variable:
Some studies removed just enamel and did not excavate at all
within dentin (Mertz-Fairhurst et al., 1998; Phonghanyudh
et al., 2012); others reported removal of affected enamel and
some dentin, leaving soft and moist carious mass on the floor
(Ribeiro et al., 1999; Lula et al., 2009). Most studies left only a
thin layer of carious substance above the pulp, thus creating a
more or less leathery surface. This technique, often combined
with the use of liners on the pulpal wall, has been called indirect
pulp capping or indirect pulp treatment (King et al., 1965;
Langeland and Langeland, 1968; Casagrande et al., 2010).
There is no consensus concerning the suitability of the
abovementioned methods for treating caries lesions before
restoring a cavity. A systematic Cochrane review published in
2006 demonstrated possible benefits of incomplete over
complete caries removal (Ricketts et al., 2006). Since then,
increasing numbers of clinical trials within this field have
been published. Another recent study systematically investi-
gated stepwise excavation, but included case series and non-
clinical studies, so no meta-analysis was possible (Hayashi
et al., 2011). Both one- and two-step incomplete excavations
seem advantageous for the treatment of deep caries, but the
inclusion of a higher number of studies would allow for the
drawing of conclusions with a stronger evidence basis. This
systematic review therefore aimed to critically summarize
and evaluate results of randomized controlled trials (RCTs)
for both deciduous and permanent teeth, comparing complete
and incomplete caries removal techniques. Subsequently,
data for certain outcomes were to be summarized in a meta-
analysis. Furthermore, excluded studies illustrating the range
of reported results for somehow-incomplete caries-removal
techniques were summarized, and clinically relevant infor-
mation was extracted as well. Thus, an “inventory” of
researched knowledge within the field should be available for
practical and scientific purposes.
Materials & Methods
Selection Criteria
Studies
We used randomized or quasi-randomized controlled trials
(RCTs) published in 1967 or later.
Participants
We included humans with primary dentin caries in deciduous or
permanent teeth requiring a restoration.
Outcomes
We recorded one or more of the following clinical outcomes:
pulpal exposure during treatment; post-operative pulpal symp-
toms (clinical or radiological pulp symptoms requiring treat-
ment, e.g., pain, irreversible pulpitis, loss of vitality), and failure
(technical or biological complications demanding intervention,
e.g., restorations lost or to be replaced, pulpitis, non-restorable
teeth).
Intervention and Control
Incomplete (one- or two-step excavation, indirect pulp treat-
ment, or capping) and complete caries removal techniques were
investigated. If re-entry was performed for cavity floor assess-
ment or microbiological sampling, but no further excavation
was attempted, this was not classified as stepwise, but as one-
step incomplete caries removal. Studies investigating non-
restorative treatment (remineralization, non-restorative cavity
treatment), non-invasive treatment (caries sealing or infiltra-
tion), or non-clinical or case studies were excluded.
Search Strategy
Identification of studies to be considered for inclusion was
based on a search strategy for each electronic database (Cochrane
Central Register of Controlled Trials, MEDLINE, PUBMED,
EMBASE) between May 16, 2012, and July 23, 2012. Screening
procedures were adjusted for higher sensitivity (with restrictive
search items omitted) if necessary. The detailed search sequence
can be found in Appendix Table 1. Cross-referencing from
found studies was used to identify further articles to be assessed.
Unpublished trials were searched electronically (www.clinical-
trials.gov). The search was limited to the English and German
languages. Neither authors nor journals were blinded to review-
ers. Gray literature was not screened systematically. Title and
abstract of identified studies were screened by 2 calibrated
reviewers (FS and SP) for eligibility. Consensus was obtained
by discussion or consultation with a third reviewer (CD).
Data Extraction
Data from eligible studies were independently extracted by two
reviewers using piloted electronic spreadsheets (Excel 10,
Microsoft, Redwood City, CA, USA). Data were recorded
according to guidelines outlined by the Cochrane Collaboration
(Higgins and Green, 2009), with additional extraction of caries
excavation depth, possible liners, and restoration type. If data
were missing or methodological issues were to be addressed, the
study author was contacted via e-mail, and, if appropriate, infor-
mation was added to the data extraction.
Risk of Bias Assessment
Selection bias (randomization, allocation concealment, unit of
randomization issues), performance and detection bias (blinding
of participants, operators, examiners), attrition bias (loss to
follow-up and missing values or participants), and reporting bias
308  Schwendicke et al. J Dent Res 92(4) 2013

Records identified through Additional records identified

synthesis. Data were analyzed with
database screening through cross-referencing Review Manager 5.1 (Cochrane IMS,
(n = 332) (n = 32) Copenhagen, Denmark).
Evidence for each outcome effect
Total records screened
estimate was graded according to the
Records excluded (n = 277)
(n = 364) GRADE working group of evidence
with Grade Profiler 3.6 (Grade Working
Full-text articles excluded (n = 70)
group). Publication bias was assessed by
Interventions: Funnel plots. Data synthesis and hetero-
- caries sealing: 23
- 1-step incomplete excavation: 33
geneity assessment were omitted if the
Full-text articles
assessed for eligibility
- 2-step (stepwise) excavation: 6 number of trials was insufficient.
- ART: 8
(n = 87)
Study types:
- RCTs: 18 Results
- CCTs: 20
- case studies: 19
- in situ study: 1
Results of the Search
Articles included in We found 332 studies to be possibly
qualitative synthesis eligible. Two additional trials were on-
(n = 17) Repeated reports (n = 7)
going according to clinicaltrials.gov
(trial identifier NCT00887952 and
NCT00973089), with no published
Studies included in qualitative synthesis results. Thirty-two further studies were
(n = 10) retrieved by cross-referencing and
screened for eligibility. In total, 87
studies were investigated full-text.
Studies included in quantitative synthesis (meta-analysis)
Three authors of 4 studies were con-
(n = 10)
tacted, and two of these authors
Figure 1. Flow-chart of study selection for qualitative and quantitative syntheses. Details of
replied. Eventually, 10 studies reported
studies excluded at full-text stage can be found in the Appendix. in 17 articles were found eligible for
this review (Fig. 1). All studies
excluded at the full-text stage can be
(unclear withdrawals or reported outcomes) were recorded, found in Appendix Table 2, including reported data and rea-
assessed, and classified according to Cochrane guidelines sons for exclusion.
(Higgins and Green, 2009). If n­ecessary, possible effects of
cluster-randomization on treatment outcomes were evaluated.
Included Studies
The 10 included studies (Table 1) represented 1,257 patients and
Data Synthesis and Grading
1,628 teeth and had been conducted in Scandinavia (Magnusson
Treatment effects were measured based on reported outcomes. and Sundell, 1977; Leksell et al., 1996; Bjørndal et al., 2010),
Pulpal exposure, pulpal symptoms, and failure were measured Scotland (Foley et al., 2004), Turkey (Orhan et al., 2010), the
dichotomously. Teeth with exposed pulps were not included in U.S. (Mertz-Fairhurst et al., 1998), Germany (Heinrich et al.,
calculations of other risks (post-operative symptoms, failure), 1991), Brazil (Ribeiro et al., 1999; Lula et al., 2009), and
since they were not always followed up and usually received Thailand (Phonghanyudh et al., 2012). All but one study were
further treatment (direct capping, root canal treatment), which published in English. Some studies were reported in multiple
could influence treatment outcomes. As secondary outcome, articles (Mertz-Fairhurst et al., 1998; Orhan et al., 2010). Trials
caries progression was assessed and reported as either relative were reported between 1977 and 2012, with a follow-up range
or absolute progression. Calculations were based on the number up to 10 yrs. Drop-out rate was 0 to 47% in total, or 0 to 12%/
of teeth, not patients. Data synthesis was performed according yr. Most patients were children, with 2 studies also investigating
to measured outcomes for subgroups of treatments (e.g., one- or adult patients (Mertz-Fairhurst et al., 1998; Bjørndal et al.,
two-step incomplete excavation). To overcome unit-of-analysis 2010). Thus, both primary and permanent teeth were treated.
errors for pooled data from multi-arm studies, we combined Dentitions were not analyzed separately, since teeth from both
suitable groups to create a single pairwise comparison. dentitions were mixed within 1 study and only 2 other studies
We used a random-effects model to calculate weighted and reported data for permanent teeth. The amount of carious tissue
summary odds ratios (OR) with 95% confidence interval (95% removed varied considerably. Furthermore, a range of materials
CI) and Forest plots. Heterogeneity was assessed quantitatively had been used (liners, cements, restorative materials). A more
by Chi-square and I2-statistics (Higgins and Thompson, 2002). detailed summary of included studies can be found in Appendix
If p > 0.2 or I² < 70%, subgroups were also pooled for data Table 3.
J Dent Res 92(4) 2013 Systematic Review of Incomplete Caries Removal  309

Table 1.  Details of and Findings from Included Studies (in order retrieved)

No. of Participants Pulp Exposure (PE)

(age, yrs); Intervention = Pulp Symptoms (PS)
Nos. and Types of Incomplete Control = Complete Failure (F)
Teeth; Excavation (No. of Excavation (No. of Caries Progression
Study Study Method Caries Extension teeth) teeth) Follow-up, Drop-out (CP)

Leksell et al., 1996 Multi-centered 116 (6-16); Two-step (64) CR (70) (“hard”) 24 wks, 4.3% yearly PE: 18% two-step,
parallel-group 134 primary molars; (“remaining 40% CR
RCT; university and caries with “risk of innermost layer PS: Non-exposed
clinics; Sweden pulp exposure” of carious dentin” teeth remained
left); re-entry after asymptomatic
8-24 wks F: 0% two-step, 0%
CR
Mertz-Fairhurst et al., Split-mouth RCT; 123 (8-52); One-step (156) CR, sealed AM (77) 10 yrs, 4.5% yearly F: Restoration failure
1998 university; USA 312 permanent with only enamel or AM (79) in 14% sealed, 2%
teeth; caries < 1/2 margins beveled, sealed AM, 17%
dentin no dentin caries AM
removal, resin CP: Caries in 1%
sealant sealed, 2% sealed
AM, 17% AM
Bjørndal et al., 2010 Multi-centered 314 (> 18); Two-step (156) CR (158) 12 mos, 7.1% yearly PE: 17% two-step,
parallel-group 314 permanent (leaving “soft, wet 29% CR
RCT; universities; molars; and discolored PS: 10% two-step,
Sweden and caries > 3/4 of dentin” at first 12% CR
Denmark dentin step); re-entry after F: 10% two-step,
8-12 wks 12% CR
Foley et al., 2004 Split-mouth RCT; 44 (3-9); One-step (36) CR (41) 24 mos, 11% yearly PS: More abscesses
university; 120 primary molars; restored with BCC in BCC group
Scotland dentin caries and GIC; one-step F: 23% GIC, 33%
(43) restored with BCC, 22% CR
just GIC CP: Caries increase
highest in CR
Ribeiro et al., 1999 Parallel-group RCT; 38 (7-11); One-step (24) CR (24) (dye) 12 mos, 0% yearly PS: 0% one-step,
university; Brazil 48 primary molars; (“partially 4% CR
dentin caries without removed, soft and F: 0% one-step,
risk of pulp moist dentin left”) 4% CR
exposure CP: 25% one-step
Orhan et al., 2010 Parallel-group RCT; 123 (4-15); One-step (50) (“thin CR (55) 12 mos, 0% yearly PE: 6% one-step, 8%
university; Turkey 154 (94 deciduous layer of soft tissue two-step, 22% CR
and 60 left”); two-step PS: 0% one-step, 2%
permanent) (49); re-entry after two-step, 5% CR
molars; 3 mos F: 0%/2% one/two-
caries > 3/4 dentin step, 5% CR-
Magnusson and Parallel-group quasi- 62 (5-10); Two-step (55) (“soft CR (55) (“until hard”) No follow-up PE: 11% two-step,
Sundell, 1977 RCT; university; 110 primary molars; layer of dentin 53% CR
Sweden caries “considered over the pulp”); PS: 5% two-step, CR
for stepwise re-entry after 4-6 not followed up
excavation” wks
Heinrich et al., 1991 Parallel-group 125 (6-7); Two-step (52) CR (52) (“hard with 16 mos,12% yearly PE: 15% two-step,
RCT; university; 125 primary molars; (“slightly soft”); explorer”) 31% CR
Germany deep caries re-entry after 6-8 PS: 8% two-step,
wks 18% CR
F: 8% two-step, 18%
CR
Lula et al., 2009 Parallel-group RCT; 30 (5-8); One-step (18) (“only CR (18) (dye) 6 mos, 5.7% yearly PE: 0% one-step,
university; Brazil 36 primary molars; superficial necrotic 22% CR
caries > 1/2 dentin dentin removed PS: 0% one-step,
from the pulpal 7% CR
and axial walls”) F: 0% one-step, 14%
CR
Phonghanyudh et al., Bi-centered parallel- 276 (6-11); One-step (92) (“soft CR (92) 12 mos, 2.5% yearly PE: 0% one-step,
2012 group RCT; dental 276 primary molars; carious tissues at 2% CR
hospitals; Thailand caries ≥ 1/3 EDJ completely PS: 1% one-step,
removed, without 2% CR
further removal of F: 18% one-
carious dentin”) step, 14% CR
restoration failure
CP: No caries
progression in any
group
Abbreviations: AM, Amalgam; BCC, black copper cement; CR, complete caries removal; GIC, glass-ionomer cement; mos, months; RCT, random-
ized controlled trial; wks, weeks; yr/yrs, years(s).
310  Schwendicke et al. J Dent Res 92(4) 2013

Table 2. Meta-analysis for Primary Outcomes: Odds Ratios (OR) and Absolute Risk Reduction with 95% Confidence Interval (95% CI), and
Evidence-grading According to GRADE

Absolute Effect
Relative Effect Fewer or More/ 1,000 No. of Participants Quality of the Evidence
Outcome Treatment (95% CI) (95% CI) (studies) (GRADE)

Pulpal exposure Two-step incomplete OR 0.35 fewer 182 729 ⊕⊕⊕

caries removal (0.22 - 0.56) (114 - 232) (5 studies) moderate1,2,3
Follow-up: up to 16 mos
One-step incomplete OR 0.20 fewer 85 322 ⊕⊕
caries removal (0.06 - 0.61) (40 - 102) (3 studies) low 1,4,5
Follow-up: up to 12 mos
One- and two-step OR 0.31 fewer 167 996 ⊕⊕⊕
incomplete caries (0.19 - 0.49) (117 - 205) (7 studies) moderate1,2,3
removal
Follow-up: up to 16 mos
Post-operative pulpal One- and two-step OR 0.58 fewer 33 680 ⊕⊕
symptoms incomplete caries (0.31 - 1.10) (55 fewer - 7 more) (6 studies) low1,5
removal
Follow-up: up to 16 mos
Failure One- and two-step OR 0.97 fewer 3 1,017 ⊕
incomplete caries (0.64 - 1.46) (37 fewer - 41 more) (9 studies) very low1,6,7
removal
Follow-up: up to 10 yrs

1
See risk of bias assessment.
2
Effect magnitude consistent and large, OR < 0.5.
3
GRADE – Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change
the estimate.
4
Imprecision due to small numbers of studies and events.
5
GRADE – Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change
the estimate.
6
Publication bias assumed based on Funnel plot.
7
GRADE - Very low quality: We are very uncertain about the estimate.

Effects of Interventions
Outcome: Pulpal Exposure
Two and five studies with one- and two-step incomplete caries
removal reported pulpal exposures, with 1 study reporting
results for both methods (Orhan et al., 2010). Data were ana-
lyzed within subgroups (one- and two-step incomplete excava-
tion) as well as pooled for both subgroups (Table 2 and Fig. 2).
There was a significant overall risk reduction for pulpal expo-
sure (OR [95% CI] 0.31 [0.19-0.49]) for incomplete excavation
compared with complete caries removal. Data for one-step
incomplete caries removal indicated an even lower risk for this
technique (OR 0.20 [0.06-0.61]). For stepwise excavation, only
2 studies reported the visit during which the pulps were exposed.
Pulpal exposure was more common during the second excava-
tion step, with 87% (Bjørndal et al., 2010) and 100% (Magnusson
and Sundell, 1977) of exposures at this stage.
Outcome: Pulpal Symptoms
Six studies reported post-operative pulpal symptoms. One study
reported pulp affection within the intervention group (Magnusson
and Sundell, 1977), but it remained unclear if the control group
was followed up (pulps were presumably found necrotic when
exposed during excavation, thus being unrelated to treatment).
The study was therefore excluded for this outcome analysis. For
another study, teeth with unclear vitality diagnosis were excluded
(Heinrich et al., 1991). Since only 3 studies investigated one-step
incomplete excavation, data for one- and two-step treatments
were pooled (Table 2 and Fig. 2). There was a significant overall
risk reduction of pulpal complications after incomplete compared
with complete excavation (OR 0.58 [0.31-1.10]).
Outcome: Failure
Five studies investigated the integrity of the restoration and
technical complications, with reduced (Lula et al., 2009),
increased (Mertz-Fairhurst et al., 1998; Phonghanyudh et al.,
2012), or similar (Foley et al., 2004; Orhan et al., 2010) failure
rates for incomplete vs. complete excavation. For one study
(Foley et al., 2004), teeth restored with black copper cement
were excluded for further analysis, since black copper cement is
not the standard of treatment for incomplete caries removal.
Four other studies reported pulpal complications. All nine stud-
ies were eventually pooled for failure analysis (Table 2 and
Fig. 2). Risk of failure was similar for incompletely and com-
pletely excavated teeth (OR 0.97 [0.64-1.46]).
Secondary Outcome: Caries Progression
Caries was found to progress marginally or under the restoration
within the incomplete removal group in 25% (6/24) (Ribeiro
et al., 1999) or 0.6% (1/156) (Mertz-Fairhurst et al., 1998) of
J Dent Res 92(4) 2013 Systematic Review of Incomplete Caries Removal  311

Figure 2.  Meta-analysis for primary outcomes after one- or two-step incomplete caries removal compared with complete (CR) caries removal. Study
data, weighted odds ratios (OR), and 95% confidence Intervals (95%CI), heterogeneity I2, and overall effect statistics as well as Forest plots are
shown. Studies are shown in chronological order. Failure included biological (e.g., pulpal) and technical (e.g., restoration) failures after exclusion
of teeth with exposed pulps.

teeth. For the complete excavation group, one study (Mertz-
Fairhurst et al., 1998) reported that 9% (7/79) of teeth restored
with amalgam showed marginal or occlusal caries. Another
study reported significantly more lesions progressing in the
complete excavation group (Foley et al., 2004). One study
found no caries progression in either completely or incom-
pletely excavated teeth (Phonghanyudh et al., 2012). Because of
these sparse and contradictive data, meta-analysis was not
attempted.
Risk of Bias and Evidence-grading
Because of their methodology, most studies were found to have
considerable risk of bias (Appendix Tables 4 and 5). Randomization
was reported for most studies, often without detailed explanation.
One study used quasi-randomization based on patients’ date of
birth (Magnusson and Sundell, 1977). Four studies gave informa-
tion concerning concealment of allocation procedures. Drop-out
rates were reported for all trials, but some studies did exclude
certain teeth or patients for various reasons (Heinrich et al., 1991;
Mertz-Fairhurst et al., 1998; Foley et al., 2004). Neither operator
nor examiner was blinded except for 2 studies (Bjørndal et al.,
2010; Phonghanyudh et al., 2012). For meta-analysis, risk of bias
was therefore graded as “very strong”. For one outcome (pulp
exposure), the magnitude of reported effects was consistent and
large. This was included within the grading. For one outcome
(failure), we assumed publication bias based on Funnel plot
analysis. Overall, only pulp exposure effect estimates were
graded as “moderate”. All other outcomes were graded as “low”
or “very low” evidence (Table 2).
312  Schwendicke et al. J Dent Res 92(4) 2013
Discussion
Since there has been growing clinical evidence supporting the
suitability of one- and two-step incomplete caries removal tech-
niques, an updated systematic review and meta-analysis were
required. Effect estimates showed considerable reduction of
pulp exposure and post-operative pulpal complications for
incomplete excavation compared with complete caries removal.
Risk of total failure, after exclusion of teeth with exposed pulps,
was similar for incompletely and completely excavated teeth.
A major problem for all studies investigating partial caries
removal (and most likely complete excavation as well) is mea-
suring the degree of excavation, i.e., the amount of carious tis-
sue left or removed. Attempted complete caries removal may
not always be complete and vice versa for partial excavation.
Furthermore, it remains unclear whether leaving more carious
dentin may be beneficial (fewer pulp exposures and symptoms)
or detrimental (higher risk of failure and caries progression).
The majority of included studies showed a high risk of bias.
Randomization procedures were not always explained, and with
few exceptions allocation concealment remained unclear. In
addition, randomization and allocation were always performed
before caries excavation. Thus, the operator was aware of the
allocation and subsequently may have removed different
amounts of caries. One study tried to reduce this risk by calibrat-
ing the operators (Bjørndal et al., 2010). Blinding the examiner
might be easier, but the use of different restorative materials
limited this option, since dental professionals are usually able to
distinguish between different restorative materials based on
characteristic surface behavior or color.
Follow-up times varied considerably, which did not seem
problematic for reports of pulp exposure, but pulpal symptoms
and restoration failures may decrease or increase differently
over time. However, we did not attempt to calculate yearly fail-
ure rates or Kaplan statistics, since failures did not occur lin-
early over time and complete censoring data were not available
for most studies. It would be of clinical relevance to evaluate
long-term survival, since the risk of secondary or progressing
residual caries is presumably increasing with the lifetime of
restorations (Brunthaler et al., 2003).
We did not address the problem of treating several teeth in
one patient, since the risk of clustering seemed limited: Most
studies investigated an average of 1.4 or fewer teeth per patient.
The studies by Magnusson et al. and Mertz-Fairhurst et al.
investigated an average of 1.8 and 2.5 teeth per patient, but were
included only once in the meta-analysis, with weights of 15%
and 19%, respectively. Hence, the statistical effect of data clus-
tering was assumed to be limited.
The results showed congruence with previous reviews. A
Cochrane Review (Ricketts et al., 2006) evaluated 4 studies,
which are included in the present review as well, and calculated
similar outcome effects on pulp exposure (RR [95% CI] 0.35
[0.22/0.56] compared with RR 0.42 [0.30/0.59] for the present
study) and pulp symptoms (RR [95% CI] 0.81 [0.20/3.25]) com-
pared with 0.62 [0.35/1.11]) for incomplete vs. complete exca-
vation. The inclusion of 6 additional studies in the present
review considerably strengthened the evidence concerning
pulpal exposure and post-operative complications. Other review
articles for one-step (Thompson et al., 2008) or two-step
(Hayashi et al., 2011) incomplete caries removal also showed
reduced risks of pulpal exposure and complications compared
with complete excavation. All trials included in these reviews
were either included within the present review (5 studies), not
tracked because of language restrictions (3 Japanese studies
investigating the use of liners for two-step excavation), or did
not meet other inclusion criteria (as shown in Appendix Table
2). Most of these excluded studies reported similarly reduced
risk of pulpal exposure (Fitzgerald and Heys, 1991) or failure
(Sawusch, 1982) for incomplete compared with complete exca-
vation, and more than 25 studies confirmed the numeric reduc-
tion or inactivation of residual bacteria after caries sealing or
one- and two-step incomplete excavation.
The advantage of one- compared with two-step caries
removal in terms of pulpal exposure was also confirmed by a
recent randomized trial (Maltz et al., 2012, 2013). These studies
reported significantly higher success rates of one-step incom-
plete compared with stepwise excavation (99% and 91% com-
pared with 88% and 61% after 18 and 36 mos, respectively). It
remains unclear if longer intervals between first and second
visits could reduce the risks of pulpal exposure and complica-
tions, or if certain liners or restorative materials are advanta-
geous to maintain pulp vitality (Miyashita et al., 2007; Yengopal
et al., 2009; Mickenautsch et al., 2010).
Bearing in mind findings from laboratory studies reporting
reduced fracture stability of incompletely excavated teeth and
lower bonding strengths of resins to carious dentin (Doi et al.,
2004; Hevinga et al., 2010), we were surprised to find a similar
combined risk of biological and mechanical failure for completely
and incompletely excavated teeth (evidence level was graded as
very low, however). It needs to be emphasized that teeth with
exposed pulps were excluded for this outcome parameter to be
calculated. Most of these exposed pulps would presumably be
treated by direct capping (Oen et al., 2007; Weber et al., 2011).
Based on reported low success rates of direct capping of cariously
exposed pulps (Barthel et al., 2000; Al-Zayer et al., 2003), the
inclusion of these teeth would have led to a dramatic shift of risk
of failure. It is therefore of great relevance that, even after this
exclusion, incomplete excavation does not seem to have any dis-
advantages compared with complete caries removal.
Several questions remain: How much caries can be left, and
how could we measure this? How does residual caries affect
physical properties of restored teeth, and could current limita-
tions of bonding to carious substrate be overcome by the use of
other materials or techniques (Doi et al., 2004; Yoshiyama et al.,
2004; Wei et al., 2008; Huang et al., 2011)? Analysis of the real
benefits of currently widely used liners will have great clinical
relevance. The development of reliable methods for the correct
assessment of pulp status would be helpful, since pulp diagnosis
has been shown to be important for the prediction of treatment
outcomes (Jordan et al., 1978; Ricketts, 2001; Wambier et al.,
2007; Bjørndal et al., 2010).
To answer such questions, we will need more calibrated,
multi-centered randomized studies. Long-term trials with
lower heterogeneity and less risk of bias will allow for better
J Dent Res 92(4) 2013 Systematic Review of Incomplete Caries Removal  313
generalizability, thus giving better guidance to clinicians. In the
light of results from studies investigating the attitudes and
behavior of dentists concerning the treatment options reviewed,
this seems to be of the utmost importance (Sundberg et al.,
2000; Oen et al., 2007; Qudeimat et al., 2007; Weber et al.,
2011; Bowen et al., 2012).
Conclusions
Incomplete caries removal seems advantageous, particularly in
the treatment of caries in proximity to the pulp, since it signifi-
cantly reduces the risks of pulpal exposure and post-operative
pulpal symptoms compared with complete excavation. There is
currently no evidence that incompletely excavated teeth are
more prone to complications. However, because of high risk of
bias within studies, evidence levels are limited, and further
research is required before definitive conclusions can be drawn.
Acknowledgments
We are grateful to Dipl.-Inf. Jürgen Hedderich, Institute for
Medical Informatics and Statistics, Christian-Albrechts-
University, Kiel, for statistical advice. This study was funded by
the authors and their institutions. The authors declare no poten-
tial conflicts of interest with respect to the authorship and/or
publication of this article.
References
Al-Zayer MA, Straffon LH, Feigal RJ, Welch KB (2003). Indirect pulp treat-
ment of primary posterior teeth: a retrospective study. Pediatr Dent
25:29-36.
Banerjee A, Watson TF, Kidd EA (2001). Dentine caries: take it or leave it?
S Afr Dent J 56:189-192.
Barthel CR, Rosenkranz B, Leuenberg A, Roulet JF (2000). Pulp capping of
carious exposures: treatment outcome after 5 and 10 years: a retrospec-
tive study. J Endod 26:525-528.
Bjørndal L, Kidd E (2005). The treatment of deep dentine caries lesions.
Dent Update 32:402-404, 407-410, 413.
Bjørndal L, Larsen T (2000). Changes in the cultivable flora in deep carious
lesions following a stepwise excavation procedure. Caries Res 34:502-508.
Bjørndal L, Larsen T, Thylstrup A (1997). A clinical and microbiological
study of deep carious lesions during stepwise excavation using long
treatment intervals. Caries Res 31:411-417.
Bjørndal L, Reit C, Bruun G, Markvart M, Kjældgaard M, Näsman P, et al.
(2010). 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 118:290-297.
Bowen JL, Mathu-Muju KR, Nash DA, Chance KB, Bush HM, Li HF
(2012). Pediatric and general dentists’ attitudes toward pulp therapy for
primary teeth. Pediatr Dent 34:210-215.
Brunthaler A, König F, Lucas T, Sperr W, Schedle A (2003). Longevity of
direct resin composite restorations in posterior teeth: a review. Clin
Oral Investig 7:63-70.
Casagrande L, Bento LW, Dalpian DM, García-Godoy F, de Araujo FB
(2010). Indirect pulp treatment in primary teeth: 4-year results. Am J
Dent 21:34-38.
Doi J, Itota T, Torii Y, Nakabo S, Yoshiyama M (2004). Micro-tensile bond
strength of self-etching primer adhesive systems to human coronal
carious dentin. J Oral Rehabil 31:1023-1028.
Fitzgerald M, Heys RJ (1991). A clinical and histological evaluation of
conservative pulpal therapy in human teeth. Oper Dent 16:101-112.
Foley J, Evans D, Blackwell A (2004). Partial caries removal and cariostatic
materials in carious primary molar teeth: a randomised controlled
clinical trial. Br Dent J 197:697-701.
Fusayama T, Okuse K, Hosoda H (1966). Relationship between hardness,
discoloration, and microbial invasion in carious dentin. J Dent Res
45:1033-1046.
Griffin SO, Oong E, Kohn W, Vidakovic B, Gooch BF, Bader J, et al.
(2008). The effectiveness of sealants in managing caries lesions. J Dent
Res 87:169-174.
Handelman SL, Washburn F, Wopperer P (1976). Two-year report of sealant
effect on bacteria in dental caries. J Am Dent Assoc 93:967-970.
Handelman SL, Leverett DH, Iker HP (1985). Longitudinal radiographic
evaluation of the progress of caries under sealants. J Pedod 9:119-126.
Hayashi M, Fujitani M, Yamaki C, Momoi Y (2011). Ways of enhancing
pulp preservation by stepwise excavation—a systematic review. J Dent
39:95-107.
Heinrich R, Kneist S, Künzel W (1991). Klinisch kontrollierte Untersuchung
zur Caries-profunda-Therapie am Milchmolaren. Dtsch Zahnärztl Z
46:581-584.
Hevinga MA, Opdam NJ, Frencken JE, Truin GJ, Huysmans MC (2010).
Does incomplete caries removal reduce strength of restored teeth?
J Dent Res 89:1270-1275.
Higgins JP, Green S (2009). Cochrane handbook for systematic reviews of
interventions. Chichester, UK: John Wiley & Sons.
Higgins JP, Thompson SG (2002). Quantifying heterogeneity in a meta-
analysis. Stat Med 21:1539-1558.
Huang X, Li L, Huang C, Du X (2011). Effect of ethanol-wet bonding with
hydrophobic adhesive on caries-affected dentine. Eur J Oral Sci
119:310-315.
Innes NP, Evans DJ, Stirrups DR (2011). Sealing caries in primary molars:
randomized control trial, 5-year results. J Dent Res 90:1405-1410.
Jordan RE, Suzuki M, Skinner DH (1978). Indirect pulp-capping of carious
teeth with periapical lesions. J Am Dent Assoc 97:37-43.
Kidd EA (2004). How ‘clean’ must a cavity be before restoration? Caries
Res 38:305-313.
Kidd EA, Fejerskov O (2004). What constitutes dental caries? Histopathology
of carious enamel and dentin related to the action of cariogenic bio-
films. J Dent Res 83(Spec No.C):C35-C38.
King JB, Crawford JJ, Lindahl RL (1965). Indirect pulp capping: a bacterio-
logic study of deep carious dentine in human teeth. Oral Surg Oral Med
Oral Pathol 20:663-669.
Langeland K, Langeland LK (1968). Indirect capping and the treatment of
deep carious lesions. Int Dent J 18:362-380.
Leksell E, Ridell K, Cvek M, Mejàre I (1996). Pulp exposure after stepwise
versus direct complete excavation of deep carious lesions in young
posterior permanent teeth. Endod Dent Traumatol 12:192-196.
Lula EC, Monteiro-Neto V, Alves CM, Ribeiro CC (2009). Microbiological
analysis after complete or partial removal of carious dentin in primary
teeth: a randomized clinical trial. Caries Res 43:354-358.
Magnusson BO, Sundell SO (1977). Stepwise excavation of deep carious
lesions in primary molars. J Int Assoc Dent Child 8:36-40.
Maltz M, Garcia R, Jardim JJ, de Paula LM, Yamaguti PM, Moura MS,
et al. (2012). Randomized trial of partial vs. stepwise caries removal.
J Dent Res 91:1026-1031.
Maltz M, Jardim JJ, Mestrinho HD, Yamaguti PM, Podestá K, Moura MS, et al.
(2013). Partial removal of carious dentine: a multicenter randomized con-
trolled trial and 18-month follow-up results. Caries Res 47:103-109.
Marsh PD (2006). Dental plaque as a biofilm and a microbial community —
implications for health and disease. BMC Oral Health 6(Suppl 1):14.
Mertz-Fairhurst EJ, Curtis JW, Ergle JW, Rueggeberg FA, Adair SM (1998).
Ultraconservative and cariostatic sealed restorations: results at year 10.
J Am Dent Assoc 129:55-66.
Mickenautsch S, Yengopal V, Banerjee A (2010). Pulp response to resin-
modified glass ionomer and calcium hydroxide cements in deep cavi-
ties: a quantitative systematic review. Dent Mater 26:761-770.
Miyashita H, Worthington H, Qualtrough A, Plasschaert A (2007). Pulp
management for caries in adults: maintaining pulp vitality. Cochrane
Database Syst Rev 2:CD004484.
314  Schwendicke et al. J Dent Res 92(4) 2013
Oen KT, Thompson VP, Vena D, Caufield PW, Curro F, Dasanayake A, et al.
(2007). Attitudes and expectations of treating deep caries: a PEARL
Network survey. Gen Dent 55:197-203.
Oong EM, Griffin SO, Kohn WG, Gooch BF, Caufield PW (2008). The
effect of dental sealants on bacteria levels in caries lesions. J Am Dent
Assoc 139:271-278.
Orhan AI, Oz FT, Orhan K (2010). Pulp exposure occurrence and outcomes
after 1- or 2-visit indirect pulp therapy vs complete caries removal in
primary and permanent molars. Pediatr Dent 32:347-355.
Paris S, Hopfenmuller W, Meyer-Lueckel H (2010). Resin infiltration of
caries lesions. J Dent Res 89:823-826.
Phonghanyudh A, Phantumvanit P, Songpaisan Y, Petersen PE (2012).
Clinical evaluation of three caries removal approaches in primary teeth:
a randomised controlled trial. Community Dent Health 29:173-178.
Qudeimat MA, Al-Saiegh FA, Al-Omari Q, Omar R (2007). Restorative
treatment decisions for deep proximal carious lesions in primary
molars. Eur Arch Paediatr Dent 8:37-42.
Ribeiro CC, Baratieri LN, Perdigão J, Baratieri NM, Ritter AV (1999). A
clinical, radiographic, and scanning electron microscopic evaluation of
adhesive restorations on carious dentin in primary teeth. Quintessence
Int 30:591-599.
Ricketts D (2001). Restorative dentistry: management of the deep
carious lesion and the vital pulp dentine complex. Br Dent J 191:606-
610.
Ricketts D, Kidd E, Innes N, Clarkson JE (2006). Complete or ultraconser-
vative removal of decayed tissue in unfilled teeth. Cochrane Database
Syst Rev 3:CD003808.
Sawusch RH (1982). Direct and indirect pulp capping with two new prod-
ucts. J Am Dent Assoc 104:459-462.
Sundberg H, Mejàre I, Espelid I, Tveit AB (2000). Swedish dentists’ deci-
sions on preparation techniques and restorative materials. Acta Odontol
Scand 58:135-141.
Thompson V, Craig RG, Curro FA, Green WS, Ship JA (2008). Treatment of
deep carious lesions by complete excavation or partial removal. J Am
Dent Assoc 139:705-712.
Wambier DS, dos Santos FA, Guedes-Pinto AC, Jaeger RG, Simionato MR
(2007). Ultrastructural and microbiological analysis of the dentin layers
affected by caries lesions in primary molars treated by minimal inter-
vention. Pediatr Dent 29:228-234.
Weber CM, Alves LS, Maltz M (2011). Treatment decisions for deep carious
lesions in the Public Health Service in Southern Brazil. J Public Health
Dent 71:265-270.
Weerheijm KL, de Soet JJ, van Amerongen WE, de Graaff J (1992). Sealing
of occlusal hidden caries lesions: an alternative for curative treatment?
ASDC J Dent Child 59:263-268.
Wei S, Sadr A, Shimada Y, Tagami J (2008). Effect of caries-affected dentin
hardness on the shear bond strength of current adhesives. J Adhes Dent
10:431-440.
Yengopal V, Harneker SY, Patel N, Siegfried N (2009). Dental fillings for
the treatment of caries in the primary dentition. Cochrane Database
Syst Rev 12:CD004483.
Yoshiyama M, Doi J, Nishitani Y, Itota T, Tay FR, Carvalho RM, et al.
(2004). Bonding ability of adhesive resins to caries-affected and caries-
infected dentin. J Appl Oral Sci 12:171-176.
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