Cariology and Endodontics, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
Paris Diderot University, Paris, France.
Int Endod J. 2019 Jul;52(7):949-973. doi: 10.1111/iej.13128. Epub 2019 May 13.
Caries prevalence remains high throughout the world, with the burden of disease increasingly affecting older and socially disadvantaged groups in Western cultures. If left untreated, caries will advance through dentine stimulating pulpitis and eventually pulp infection and necrosis; however, if conservatively managed, pulpal recovery occurs even in deep carious lesions. Traditionally, deep caries management was destructive with nonselective (complete) removal of all carious dentine; however, the promotion of minimally invasive biologically based treatment strategies has been advocated for selective (partial) caries removal and a reduced risk of pulp exposure. Selective caries removal strategies can be one-visit as indirect pulp treatment or two-visit using a stepwise approach. Management strategies for the treatment of the cariously exposed pulp are also shifting with avoidance of pulpectomy and the re-emergence of vital pulp treatment (VPT) techniques such as partial and complete pulpotomy. These changes stem from an improved understanding of the pulp-dentine complex's defensive and reparative response to irritation, with harnessing the release of bioactive dentine matrix components and careful handling of the damaged tissue considered critical. Notably, the development of new pulp capping materials such as mineral trioxide aggregate, which although not an ideal material, has resulted in more predictable treatments from both a histological and a clinical perspective. Unfortunately, the changes in management are only supported by relatively weak evidence with case series, cohort studies and preliminary studies containing low patient numbers forming the bulk of the evidence. As a result, critical questions related to the superiority of one caries removal technique over another, the best pulp capping biomaterial or whether pulp exposure is a negative prognostic factor remain unanswered. There is an urgent need to promote minimally invasive treatment strategies in Operative Dentistry and Endodontology; however, the development of accurate diagnostic tools, evidence-based management strategies and education in management of the exposed pulp are critical in the future.
龋齿患病率在全球范围内仍然很高，疾病负担日益影响到西方文化中老年人和社会弱势群体。如果不进行治疗，龋齿将通过刺激牙髓的牙本质进展，最终导致牙髓感染和坏死；然而，如果进行保守治疗，即使在深龋病变中也会发生牙髓恢复。传统上，深龋的管理是具有破坏性的，需要非选择性（完全）去除所有龋坏的牙本质；然而，提倡微创、基于生物学的治疗策略，以实现选择性（部分）龋坏去除，并降低牙髓暴露的风险。选择性龋坏去除策略可以是一次就诊的间接牙髓治疗，也可以是两步就诊的逐步治疗。暴露龋坏的牙髓治疗的管理策略也在发生变化，避免牙髓切除术，并重新采用活髓治疗（VPT）技术，如部分和完全活髓切断术。这些变化源于对牙髓-牙本质复合体对刺激的防御和修复反应的理解的提高，利用生物活性牙本质基质成分的释放和对受损组织的小心处理被认为是关键。值得注意的是，新的牙髓盖髓材料的发展，如三氧化矿物聚合体，尽管不是理想的材料，但从组织学和临床角度来看，治疗效果更具可预测性。不幸的是，管理上的变化仅得到相对较弱的证据支持，病例系列、队列研究和初步研究包含大量低患者数量的证据。因此，关于一种龋坏去除技术优于另一种技术、最佳牙髓盖髓生物材料、或牙髓暴露是否为负预后因素等关键问题仍未得到解答。在口腔修复学和牙髓病学中迫切需要推广微创治疗策略；然而，在未来，开发准确的诊断工具、基于证据的管理策略以及对暴露牙髓的管理教育至关重要。
