Incomplete versus Complete Caries Removal: A Systematic Review and Meta-Analysis

Method: Based on a defined search protocol, electronic databases (CENTRAL, Pubmed, MEDLINE, EMBASE) were screened, and articles cross-referenced for randomised controlled trials investigating incomplete or stepwise compared to complete caries excavation for both primary and permanent teeth with primary caries requiring a restoration. Language was restricted to English and German. Retrieved studies were analysed qualitatively and quantitatively (Chi-square homogeneity test, Mantel-Haenszel statistics, random-effects model). Odds ratio and 95% confidence interval (OR, 95%CI) were calculated using RevManager 5.1, and risk of bias (selection, performance, detection, attrition and reporting bias) was assessed. Evidence grading was performed according to GRADE working group guidelines.

Results: From 364 screened articles, 87 were investigated full-text. Ten studies (17 articles representing 1257 patients and 1628 teeth) were included and analysed concerning pulpal exposure, pulpal symptoms and failure. Meta-analysis showed risk reduction for both pulpal exposure (OR [95% CI]: 0.31 [0.21-0.48], p<0.001) and pulpal symptoms (OR: 0.53 [0.34-0.83], p=0.006) for carious teeth treated with stepwise or incomplete compared to complete excavation. Risk of failure was similar for both complete and incomplete caries removal (OR: 1.03 [0.68-1.55], p>0.05), but data for this outcome was sparse and of limited quality. Evidence levels for risk of pulp exposure, pulp complications and overall failure were moderate, low and very low, respectively.

Conclusions: Risk of bias and limited levels of evidence permit definitive conclusions or recommendations. However, incomplete excavation seems to reduce pulp exposure and pulpal complications significantly. It is not clear if technical risks are increased after treating caries this way. Thus, further and well-designed research to increase the degree of evidence is required.