Key messages

• Selective caries removal may decrease the need for root canal treatment and the risk of pulp exposure in teeth with deep caries (low certainty of evidence)

• We are uncertain whether selective caries removal decreases the risk of signs and symptoms of pulp disease and the risk of failure of restorations, as the certainty of the evidence has been assessed as very low.

What is the evidence

See evidence matrix in Epistemonikos later

We found seven systematic reviews[4],[7],[8],[9],[10],[11],[12] which included seven primary studies overall, reported in nine references[13],[14],[15],[16],[17],[18],[19],[20],[21], all of which correspond to randomized trials.

What types of patients were included*

Of the seven trials, five included only children (3 to 11 years old)[13],[14],[15],[18],[20] and two included children and adolescents (4 to 17 years old) [17],[19]. Four included only temporary teeth[13],[14],[17],[19], one trial included only permanent teeth[19], and two both dentitions[13],[17].

Regarding the extent of caries, all trials included only deep tooth decay, excluding those lesions circumscribed only to enamel. Five trials included occlusal and proximal caries[13],[14],[17],[18],[20], while two included only occlusal caries[15],[19].

Finally, all trials excluded patients with irreversible pulp symptoms and/or apical lesion prior to inclusion[13],[14],[15],[17],[18],[19],[20].

What types of interventions were included*

All trials compared the selective removal of deep dental caries against conventional treatment (complete removal).

Selective removal was described in various ways by the different trials, but in general it was defined as the excavation of the remaining dentin from the floor of the cavity near the pulp, soft to the touch, of sticky consistency and soft to the probing procedure[8].
Complete removal was described as the excavation of the remaining dentin from the floor of the cavity near the pulp, until a hard touch consistency was reached[8].

None of the reviews included information on the instruments used or the depth of excavation.

What types of outcomes were measured

The trials measured multiple outcomes, which were pooled by the systematic reviews as follows:

• Need for root treatment
• Pulp exposure
• Signs or symptoms of pulp disease
• Failure of restoration 

The follow-up ranged between 6[15],[17],[18],[20] and 24 months[13],[14],[19].

Follow the link to access the interactive version of this table (Interactive Summary of Findings – iSoF)

To whom this evidence does and does not apply 

• The results of this summary are widely applicable to people with deep tooth decay in temporary and/or permanent teeth.

• Even though the participants in the trials did not include adults or adolescents over 17 years, there are no compelling clinical reasons for not applying the evidence to these groups.

About the outcomes included in this summary 

• The outcomes selected are those considered critical for decision-making according to the opinion of the authors of this summary, which coincide in general with those presented in the systematic reviews identified.

• The “pulp exposure” outcome was included in the summary of findings table because it is a relevant outcome for clinical experts, even when it is an intermediate outcome for the need of root canal treatment.

• The "need of root canal treatment" outcome is critical for health decision-making as it involves performing a more complex and expensive additional procedure for the patient.

• It is necessary to establish main outcomes (core set outcomes) for clinical trials on caries management, including long-term effectiveness measures (survival of restoration) and patient values and preferences.

Balance between benefits and risks, and certainty of the evidence 

• The evidence presented in this summary shows a possible benefit in the need of root canal treatment and the risk of pulp exposure outcomes. However, there is uncertainty about the possible risk of selective removal in relation to the occurrence of signs and symptoms of pulp disease and restoration failure.

• On the other hand, the duration of the follow-up of the included studies (6 to 24 months) makes it difficult to measure the long-term adverse effects of both interventions.

• It is not possible to determine the balance between benefits and risks between selective and complete removal because the certainty of evidence was low or very low for reported outcomes.

Resource considerations 

• None of the systematic reviews considered an economic analysis for each intervention. However, selective caries removal could reduce operating costs and the total cost of dental treatment as it prevents adverse events that will require new and more expensive interventions[4].

What would patients and their doctors think about this intervention

• Most patients would prefer complete caries removal over selective removal. This preference is marked by the quality of the treatment, the sociodemographic characteristics, the personality of the patient, and previous dental experiences[22].

• There is evidence that almost half of dentists prefer the use of conventional techniques such as non-selective removal, in the management of deep tooth decay. However, in recent years this preference tends to decrease, raising the preference for conservative removal techniques[4].

• Taking into account the results of this summary, patients and dentists are expected to be in favor of selective caries removal, due to the importance of the expected benefits of this technique in relation to its possible harms.

Differences between this summary and others sources

• The conclusions of this summary coincide with those of the seven systematic reviews identified[4],[6],[7],[8],[9],[10],[11],[12], which consider that selective removal decreases the risk of pulp exposure. In addition, they declare that there is uncertainty about the outcome of restoration failure and signs of pulp disease.

• The results of this summary also coincide with the recommendations of the guideline for clinical practice on restorative dentistry of the American Academy of Pediatric Dentistry[23]. 

Could this evidence change in the future?

• It is very likely that future research will modify the conclusion of this summary, due to the low certainty of the available evidence.

• We identified one ongoing randomized trial[24] in the International Clinical Trials Registry Platform of the World Health Organization that could yield relevant data for the outcome of pulp signs and symptoms.

• We did not identify any ongoing systematic review in the International prospective register of systematic reviews (PROSPERO) of the National Institute for Health Research.