Indirect Pulp Therapy and Stepwise Excavation

Resident: Cho

Author(s): Bjorndal, Lars.

Journal: Pediatric Dentistry

Year. Volume (number). Page #’s: 2008. 30. 225-229.

Major topic: Indirect Pulp Treatment, Stepwise Excavation

Minor topic: Randomized Clinical Trial

Type of Article: Conference Paper

Main Purpose: The purpose was to provide information on the latest systematic reviews regarding indirect pulp therapy and stepwise excavation.

Overview of method of research: Systematic review

Findings:

IPT procedure involves almost complete removal of affected dentin, leaving a thin layer of demineralized dentin, and no re-entry is attempted. Stepwise excavation is similar to IPT, but it involves re-entry at varying intervals.

Very few studies on caries and pulp treatment are randomized clinical trials. Some problems arise in relation to the steps of IPT: how do you define “deep” on a carious lesion. Less than 10 studies were compared and no difference in symptoms were found at 12 months using Life, Dycal, and Cavitec formulations of calcium hydroxide for IPT.

The primary aim of the first excavation of the stepwise excavation is to change the caries environment by removing caries only up to the residual level close to the dentin-pulp interface. Microbiologic and clinical studies have shown that it is possible to decrease the number of bacteria and arrest the caries process. More detailed microbiologic data indicate that during the treatment interval the bacteria become “slow-growing.”

The final step of the stepwise excavation is to assess the tooth’s reaction and then to remove the slowly progressing lesion in the slightly infected discolored demineralized dentin before adding the final restoration.

18% of respondents would partially remove caries in a deep lesion in which one would expect that complete caries removal would lead to pulp exposure. This low percentage may be fear that leaving infected dentin may stimulate obliteration of the root canals, making future endodontic treatment more difficult. In this case, a stepwise approach may be an alternative treatment.

Clinical guidelines for stepwise excavation based on an observational study and a high-quality RCT: deep lesion evaluated by x-ray that involves ¾ or more of the dentin (no periapical pathosis, no history of spontaneous pain, mild to moderate pain on thermal stimulation is accepted), excavate the outermost necrotic and infected demineralized dentin, place a provisional material, and the final excavation should be less invasive due to dentinal changes gained, and place permanent restoration. The temporary and final restorations should provide a good seal and long-term recall should be carried out in order to have success.

Key points/Summary: More studies that are randomized clinical trials must be conducted on indirect pulp therapy and stepwise excavation to obtain a higher level of evidence. Whether the bacteria beneath a permanent restoration in a deep cavity truly remains “inactive” also needs to be further investigated. More research must be conducted whether a two-step excavation or IPT has a better clinical outcome.

Assessment of Article: This article raises a valid point that it is difficult to compare different studies involving IPT since a “deep carious lesion” is a vague term. I agree that more research needs to be conducted in this field to determine whether a one-step IPT or two-step stepwise excavation shows better clinical results.