Postgraduate student, Unit of Oral Health, Dentistry and Society, School of Clinical Dentistry, University of Sheffield, Clarement Crescent, Sheffield, S10 2TA, UK.
Dean, Professor/Honorary Consultant in Paediatric Dentistry, School of Clinical Dentistry, University of Sheffield, Claremont Crescent, Sheffield, S10 2TA, UK.
Evid Based Dent. 2021 Jan;22(1):20-21. doi: 10.1038/s41432-021-0150-x.
Aim This systematic review and meta-analysis of randomised controlled trials (RCTs) aimed to compare the efficacy of different caries removal techniques: complete caries removal (CCR), selective caries removal (SCR) and stepwise caries removal (SWR) for deep carious lesions in vital primary teeth.Data sources The design of this review followed the PRISMA guidance ( http://www.prisma-statement.org/ ). Relevant studies were identified using electronic databases (PubMed [Medline], Cochrane Library, EMBASE) and finally reference lists were screened. The US National Institutes of Health Trials Register (NIHTR; http://clinicaltrials.gov ) and World Health Organisation International Clinical Trials Registry Platform (WHO ICTRP; http://apps.who.int/trialsearch ) were used to help assess publication bias, as it was not possible to test funnel plot asymmetry. Duplicates were located and eliminated using EndNote X7 programme.Study selection To be included, studies had to be published RCTs comparing SCR or SWR with CCR as caries removal strategies for deep carious lesions in vital primary teeth. The outcomes were pulp exposure, pulpo-periodontal complications (clinical and radiological failures) and/or restorative failures. RCTs applying these caries removal techniques were excluded if one of the other trial arms did not involve caries removal (that is, Hall Technique, therapeutic sealing of cavity lesions). Initially, 1,374 potentially eligible articles were identified, out of which 15 (English or French language only) were selected for full-text screening, which included ten relevant references corresponding to eight studies.Data extraction and synthesis Two authors independently extracted data using a piloted data extraction sheet, with a third reviewer resolving any disagreements. The authors performed conventional intention-to-treat and per-protocol meta-analyses, and calculated odds ratios (ORs) as effect estimates in the random-effects model, using Revman5.Results The eight included RCTs were conducted between 1977 and 2018. They include 669 patients and 824 teeth, with follow-up ranging from four weeks to 24 months. Collective results showed reduced risk of pulp exposure after SCR (OR: 0.10, 95% CI [0.04, 0.25]) or SWR (OR: 0.20, 95% CI [0.09, 0.44]), compared with CCR. There was a higher risk of composite restorative failure (OR: 2.61, 95% CI [1.05, 6.49]) using United States Public Health Service (USPHS) criteria, after SCR was compared with CCR only in intention-to-treat analysis. However, when comparing the risk of clinical or radiographic failure of pulpo-periodontal complications, no difference was found between SCR, CCR or SWR.Conclusion The conclusions of the paper are that there is a significant decrease in pulp exposure risk with SCR and SWR in comparison with CCR. However, there is a need for further studies with less risk of bias powered to report on the long-term outcomes of pulpo-periodontal health and restoration longevity.
本系统评价和荟萃分析旨在比较不同龋病去除技术的疗效：全龋去除（CCR）、选择性龋去除（SCR）和逐步龋去除（SWR）在活髓恒牙深龋中的应用。
本综述的设计遵循 PRISMA 指南（http://www.prisma-statement.org/）。使用电子数据库（PubMed [Medline]、Cochrane 图书馆、EMBASE）和最终的参考文献列表来识别相关研究。美国国立卫生研究院试验登记处（NIHTR；http://clinicaltrials.gov）和世界卫生组织国际临床试验注册平台（WHO ICTRP；http://apps.who.int/trialsearch）用于帮助评估发表偏倚，因为无法检验漏斗图的不对称性。使用 EndNote X7 程序定位并消除重复项。
纳入研究必须为比较 SCR 或 SWR 与 CCR 作为活髓恒牙深龋治疗策略的随机对照试验。结局为牙髓暴露、牙髓牙周并发症（临床和影像学失败）和/或修复失败。如果其中一个试验臂不涉及龋病去除（即 Hall 技术、腔病变的治疗性密封），则排除应用这些龋病去除技术的 RCT。最初，确定了 1374 篇潜在合格的文章，其中 15 篇（仅为英文或法文）被选入全文筛选，其中包括与 8 项研究相对应的 10 篇相关参考文献。
两位作者使用预试验数据提取表独立提取数据，由第三位评审员解决任何分歧。作者进行了常规意向治疗和方案治疗荟萃分析，并使用 Revman5 在随机效应模型中计算了比值比（OR）作为效应估计。
纳入的 8 项 RCT 于 1977 年至 2018 年进行。共纳入 669 例患者和 824 颗牙齿，随访时间从 4 周到 24 个月不等。综合结果显示，与 CCR 相比，SCR（OR：0.10，95%CI [0.04，0.25]）或 SWR（OR：0.20，95%CI [0.09，0.44]）可降低牙髓暴露的风险。仅在意向治疗分析中，与 CCR 相比，SCR 后使用美国公共卫生服务（USPHS）标准时，复合修复体失败的风险更高（OR：2.61，95%CI [1.05，6.49]）。然而，当比较牙髓牙周并发症的临床或影像学失败风险时，SCR、CCR 或 SWR 之间没有差异。
本研究的结论是，与 CCR 相比，SCR 和 SWR 可显著降低牙髓暴露的风险。然而，需要进一步开展风险偏倚较小的研究，以报告牙髓牙周健康和修复体耐久性的长期结局。
