journal of dentistry 39 (2011) 95–107

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Review

Ways of enhancing pulp preservation by stepwise

excavation—A systematic review

Mikako Hayashi a,*, Morioki Fujitani b, Chinami Yamaki c, Yasuko Momoi d

a
Department of Restorative Dentistry and Endodontology, Osaka University Graduate School of Dentistry, 1-8 Yamadaoka,
Suita 565-0871, Japan
b
Department of Operative Dentistry, Aichi Gakuin University School of Dentistry, 2-11 Suemori-dori, Chikusa-ku, Nagoya 464-8651, Japan
c
Tsurumi University Library, 2-1-3 Tsurumi, Tsurumi-ku, Yokohama 230-8501, Japan
d
Department of Operative Dentistry, Tsurumi University School of Dental Medicine, 2-1-3 Tsurumi, Tsurumi-ku, Yokohama 230-8501, Japan

article info abstract

Article history: Objectives: The best possible methods and materials in stepwise excavation for deep caries
Received 26 May 2010 in permanent teeth were investigated. The review considers the questions from many
Received in revised form aspects including clinical success, effects of reducing cariogenic bacteria, possibility of
5 October 2010 hardening softened dentin, and likelihood of generating tertiary dentin.
Accepted 15 October 2010 Data: This systematic review includes the use of data from randomized controlled trials,
controlled clinical trials as well as from case series in which pulp exposure resulted
following the treatment and removal of deep caries. Only studies of caries in permanent
Keywords: teeth were considered. Those involving treatment of primary teeth were excluded.
Stepwise excavation Sources: An electronic search was conducted in the databases of MEDLINE and Igaku Chuo
Systematic review Zasshi (Japanese) from 1970 to 2008. The electronic search was supplemented by a manual
Pulp search of the references lists of all the relevant studies.
Deep caries Study selection: The electronic and manual searches of journals retrieved a total of 266
Pulp capping English and 130 Japanese papers. According to the inclusion and exclusion criteria, 10
Pulp exposure English and 3 Japanese studies were finally identified.
Calcium hydroxide Conclusion: Our research suggests that stepwise excavation is effective for pulp preservation
Cariogenic bacteria in extremely deep caries that do not show clinical symptoms of irreversible pulpitis.
Calcium hydroxide, as well as antimicrobials and polycarboxylate cement combined with
tannin-fluoride preparation, is effective in reducing bacteria and promoting remineraliza-
tion of the carious dentin that remained after stepwise excavation. Further clinical trials
with a high level of study design should be conducted to identify the best methods of
removing carious dentin using stepwise excavation.
# 2010 Elsevier Ltd. All rights reserved.

1. Introduction the caries is completely removed. In these cases, many

clinicians often immediately resort to pulpectomy for the
In everyday dental practice, clinicians often encounter exposed pulp. This is in spite of the fact that clinicians have
extremely deep caries, which can result in pulp exposure if observed that pulp inherently possesses a high ability of

* Corresponding author. Tel.: +81 6 6879 2928; fax: +81 6 6879 2928.
E-mail address: mikarin@dent.osaka-u.ac.jp (M. Hayashi).
0300-5712/$ – see front matter # 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jdent.2010.10.012
96 journal of dentistry 39 (2011) 95–107

regeneration, which can lead to the reversal of pulp were not found, so case series would also be considered.
inflammation relatively quickly.1–4 Additionally, in recent Studies of caries in permanent teeth were considered, but
years, the importance of preserving pulp has been highlighted, those involving treatment of primary teeth were excluded.
because critical complexities such as tooth fracture often Case reports and laboratory studies were also excluded.
occur in pulpless teeth.5 With this increased understanding of
the important role that pulp plays in preserving the healthy 2.2. Search strategy
status of teeth, increasingly clinicians seek to preserve pulp
even after it has been exposed during caries removal.6–9 The journal search, consisting of both electronic and manual
Direct pulp capping is typically applied for preserving searching, was undertaken to identify all relevant studies
exposed pulp. However, prognoses of direct pulp capping for written in English and Japanese.
exposed pulp due to caries removal have not been promising
in some clinical studies,6–9 with the success rates reported to 2.2.1. Electronic databases
vary widely from unsatisfactory lows of 33.39 to 50%8 and up to An electronic search was conducted by a librarian (CY), who is
a potentially satisfactory 81.8% in one paper.6 Conversely, one of the authors, and included the following databases from
favourable results of stepwise excavation for extremely deep 1970 to 2008: MEDLINE and Igaku Chuo Zasshi (Japanese). The
caries with an aim of preserving pulp have been reported.10,11 subject search used a combination of controlled vocabulary
In a Cochrane systematic review published in 2006,12 stepwise and free text based on the search strategy for MEDLINE, which
excavation was effective in avoiding pulp exposure when is shown as follows:
treating extremely deep caries. In addition, in a randomized
clinical trial,13 it was reported that the pulpal reactions in #1 DENTAL(W)CARIES$/DE
those teeth that had been treated by stepwise excavation were #2 (TEETH + TOOTH + DENTAL$) AND (CARIES + CAR-
similar to those that underwent complete removal of the IOUS + DECAY$ + LESIONS$)
caries, where stepwise excavation was able to be completed #3 (DEEP + EXTENSIVE + ASYMPTOMATIC$) AND (CARIE$ + -
without pulpal exposure. CARIOUS + DECAY$ + LESIONS$)
However, there are many clinical questions that need to be #4 #1 + #2 + #3
considered when clinicians apply the stepwise excavation #5 DENTAL(W)PULP
technique to permanent teeth with deep caries. For example, #6 ((DENTAL + TOOTH + TEETH) AND PULP$)(3W)EXPOSE$
what is the best way to remove softened dentin to promote #7 DENTAL(W)PULP(W)CAVITY
remineralization of the remaining dentin? Which lining #8 DENTAL(W)PULP(W)DISEASE$/DE
material is the most effective to protect pulp from cariogenic #9 (CARIOUS(W)PULP) OR (CARIE$(W)PULP)
bacteria and to accelerate remineralization? How long should #10 #5 + #6 + #7 + #8 + #9
the sealed cavities be left before they can safely be re-entered? #11 PULP$(W)DEVITALIZATION$
How often and how quickly is tertiary dentin generated after #12 PULP(W)PROTECTION$
stepwise excavation? #13 PULP$(W)MANAGEMENT$
In this systematic review, we discuss the best possible #14 PULP$(W)(TREAT$ + THERAP$ + EXTIRPATE$ + REMO-
methods and materials for stepwise excavation of deep caries VE$ + EXPOSE$ + EXTRACT$ + CAP$)
in permanent teeth, including criteria such as clinical success, #15 STEPWISE(1W)EXCAVATION$
reduction of cariogenic bacteria, prospects and the length of #16 #11 + #12 + #13 + #17 + #18
time it takes for hardening of softened dentin, and likelihood #17 (#4 OR #10) AND #16
of generating tertiary dentin. #18 #17/HUMAN
#19 DT = (CLINICAL TRIAL$ + RANDOMIZED CONTROLLED
TRIAL$) + (STUD$ + TRIAL$ + RANDOMIZED()CONTROL-
2. Materials and methods LED()TRIAL$)/DE
#20 #18 AND #19
The Cochrane Collaboration guidelines are primarily intended #21 #20 AND PY > 1970
for conducting systematic reviews of the effectiveness of an
intervention.14 In this review, we attempted to adopt The literature search in Japanese was also conducted using
Cochrane’s general principles to evaluate the clinical effec- the same search strategy.
tiveness of stepwise excavation for dealing with extremely
deep caries in permanent teeth. 2.2.2. Manual searching
The reference lists of all the relevant studies, existing reviews
2.1. Selection criteria and personal reprint collections of authors were screened for
additional relevant publications.
Inclusion and exclusion criteria for the selection of papers for
review were established prior to the literature search. The 2.3. Selection of relevant publications
inclusion criteria consisted of written clinical studies: ran-
domized controlled trials (RCTs) and controlled clinical trials Each publication was initially assessed for relevance by two of
(CCTs), where treatment of deep caries that potentially result the authors (MH and MF) using the information presented in
in pulp exposure if the caries are completely removed were the abstract. When an abstract was not available or failed to
performed. In the event sufficient numbers of RCTs and CCTs provide sufficient information, a reprint of the full paper was
 journal of dentistry 39 (2011) 95–107
obtained. When papers or abstracts reported different stages
of clinical trials, only the longer-term study was included in
the review.
2.4. Evaluation of clinical effectiveness
2.4.1. Study selection
To evaluate the clinical effectiveness of stepwise excavation,
RCTs and CCTs, in which complete caries removal was used as
a control group or in which the effects of different pulp
capping agents were compared, were selected by two
independent reviewers. Because small numbers of RCTs and
CCTs were found, we included case series that described
longitudinal clinical prognoses of permanent teeth with
stepwise excavation. The study design of each of the selected
papers was assessed by the two reviewers independently in
the review process. If a trial was excluded from evaluation, the
reasons for exclusion were described.
2.4.2. Data extraction and synthesis
The following information was extracted from the papers
selected for evaluation of the clinical effectiveness of
stepwise excavation for extremely deep caries in permanent
teeth: date of the study, year of publication, setting and
funding source of the trials, sample size, age and gender of the
patients, types of teeth and cavities restored, methods of
removing caries, materials for lining, time to re-entry and
duration of study. Information on adverse events or effects
was also recorded.
The outcomes were evaluated in terms of pulp exposure,
pulp breakdown, postoperative pain or discomfort, amounts
of cariogenic bacteria in a cavity, colour and hardness of
carious dentin, remineralization of softened dentin, regener-
ation of tertiary dentin, and retention of sealing material.
Teeth with stepwise excavation were considered to have failed
when postoperative pain or discomfort continued or pulp
breakdown occurred. On the other hand, the clinical success of
stepwise excavation was that pulp kept its vitality without any
adverse symptoms after treatment.
Data were extracted by two reviewers independently using
specially designed data extraction forms. These forms were
piloted on several papers and modified as required before use.
Data that could be presented in graphs and figures were
extracted whenever possible. Such data were only included,
however, if both reviewers independently extracted the same
result. Any disagreement was discussed, and a third reviewer
was consulted as necessary.
2.4.3. Statistical analysis
The statistical guideline in The Cochrane Handbook14 was
followed for evaluating the clinical effectiveness of stepwise
excavation.
3. Results
3.1. Results of the literature search
Electronic and manual searches of journals retrieved a total
of 266 English and 130 Japanese papers. These studies were
97
selected according to the inclusion and exclusion criteria as
described previously. Ten English and three Japanese
studies, which are full papers, were finally identified.13,15–
26
The summary of these clinical studies is presented in
Table 1. In terms of study designs, two RCTs13,15 and five
CCTs16–20 were found, and the remaining six consisted of
case series, which are longitudinal clinical trials without
control groups.21–26
3.2. Clinical methods of stepwise excavation
The expressions of removing carious dentin with stepwise
excavation were different amongst the studies identified. The
types of carious dentin removed were variously described as
‘‘central biomass’’,15 ‘‘bulk caries tissue’’,13 ‘‘surface car-
ies’’,16,17 ‘‘gross infected dentin’’,18 ‘‘necrotic and fragmented
tissue’’21 and ‘‘cariogenic biomass’’.22–24 In all of these studies,
the authors did not clearly state either how much carious
dentin was removed or how much infected dentin remained in
the cavities. It was clear, however, that in all the studies
clinicians intended to avoid visible pulp exposure.
Amongst the 13 studies identified, setting calcium hydrox-
ide (Dycal1, improved Dycal1, Porcal1, Hydrex1, Pulpdent1)
was used as a lining material in 11 studies.13,17–26 In the
remaining two studies, antimicrobials such as chlorhexidine
and thymol containing varnish (Cervitec1), as well as
demeclocycline hydrocortisone containing ointment (Leder-
mix1)15 or polycarboxylate cement combined with tannin-
fluoride preparation (HY-Bond Temporary Cement Soft1)16,
were used.
The time to re-entry varied from 4 weeks to 12 months. The
most common times to re-entry were three and six months.
3.3. Clinical findings
Clinical success rates were reported between 94 and 100% in
eight studies13,16–18,21–26 (Table 2). There were no significant
differences in the success rates amongst the cases using
different lining materials. When caries were removed by
stepwise excavation without pulp exposure, pulp in most of
the cases was symptomless.
The conditions of dentin upon re-entry were reported in
five studies,21–25 and all of these studies stated that the
remaining softened dentin in the cavities became darker,
harder and drier after 2–12 months following stepwise
excavation.
3.4. Radiographic findings
Radiographic examinations were reported in four stud-
ies16,17,21,25 (Table 2) and all reported increasing radio density
or radiopacity, suggesting an encouraging process of reminer-
alization of the remaining carious dentin after stepwise
excavation. However, it was difficult to identify exactly when
the remineralization started or when the remineralization
became sufficient for re-entry, since the observational periods
were different in each of the studies. One study reported the
generation of tertiary dentin, but it was observed in only two
cases (7.1%) of the 28 cases, six months following the stepwise
excavation.25
 98
Table 1 – Clinical studies on stepwise excavation for deep cavities in permanent teeth. Arranged by study designs with chronological order (1970–).
Study [reference Study Patients Tooth type; lesion Intervention Control Time to Outcome Setting
number] design depth re-entry measured

Wicht et al., 2004, RCT 6 weeks University

Germany15 18–67 years Permanent molar Removal of central biomass Removal of central bio- Micro-organisms (operative
(mean = 38.4), (n = 23) and and application of one of two mass. No pulp capping before sealing dentistry and
n = 30 premolar (n = 7), antimicrobials; CE group: 1% agent was applied but and on re-entry periodontology)
Primary deep chlorhexidine- and 1% thymol- cavies were sealed with
caries penetrated containing varnish (Cervitec1, compomer. (n = 10)
more than 25% n = 10), LE group: 3%
into dentin, no demeclocycline
pulpitis hyd r oc ortisone -c on tainin g
ointment; (Ledermix1, n = 10).
All cavities were sealed with
compomer.

journal of dentistry 39 (2011) 95–107

Leksell, 1996, RCT 8–24 weeks University
Sweden13 6–16 years Permanent teeth, Stepwise excavation: bulk car- Complete caries 1. Incidence of (paediatric
(mean = 10.2) deep lesions*, ious tissue was excavated fol- removal: all softened pulp exposure at dentistry)
n = 127 no pulpitis lowed by applying Ca(OH)2 and dentin were removed. If removal of caries.
ZOE. At re-entry, all soft dentin no exposure, Ca(OH) 2 2. Clinical
removed, and cavities were and ZOE were applied. observation
covered by Ca(OH)2 and ZOE. Then, the teeth were including
Then, the teeth were restored restored with GIC, CR or examining pulp
with GIC, CR or Am. (n = 57) Am. (n = 70) vitality for 80
teeth without
pulp exposure.
Nagamine, 1993, CCT 3 months University
Japan16 17–46 years, Permanent molar Removal of surface caries Removal of surface 1. Clinical (restorative
n = 23 teeth and premolar dentin. Then, application of caries dentin. Then, observation and dentistry)
in 20 patients teeth deep caries polycarboxylate cement application of hydraulic radiographic
no pulpitis combined with tannin-fluoride temporary sealing examination.
preparation (HAY-Bond material (Lexicon1) 2. Micro-
Temporary Cement Soft1) followed by sealing with organisms before
followed by sealing with GIC. (n = 5) sealing and on
GIC. (n = 18) re-entry
Gotoh, 1985, CCT 12 weeks University
Japan17 19–33 years, Permanent molar Removal of surface caries Removal of surface (7196 days) 1. Clinical (paediatric
n = 10 (n = 9) and dentin. Then, application of caries dentin. Then, observation. dentistry)
premolar (n = 1) Ca(OH)2 (Dycal1) followed by application of ZOE 2. H i stolog ic al
deep caries* no sealing with Am. (n = 6) (Neodyne1) followed by evaluation
pulpitis sealing with Am. (n = 4)
Sawusch, 1982, CCT 6 months University
US18 14 years or Permanent teeth Removal of gross infected Removal of gross Clinical (pedodontic
younger, with deep caries, dentin and applied Ca(OH)2; infected dentin and observation clinic) and a local
n = 48 no pulpitis Experimental Dycal1 (n = 36). applied Ca(OH)2; pedodontist
Sealed with zinc phosphate or Improved Dycal1
ZOE. (Experimental Dycal1 was (n = 12). Sealed with zinc
improved its compressive phosphate or ZOE.
strength more than 2 times (Improved Dycal1 was
compared with the original.) improved in its both
compressive strength
and shear strength 1.5
times compared with
the original one.)
Leung, 1980, US19 CCT 4 weeks Unknown
n = 40 Permanent teeth, Half of the caries dentin in Half of the caries dentin Micro-organisms
deep caries* no lesions removed and the in lesions removed and before sealing
pulpal symptom remaining half caries was lined the remaining half and on re-entry

journal of dentistry 39 (2011) 95–107

with Ca(OH)2 (Dycal1). Cavities caries was covered by
were sealed with IRM1. (n = 20) wax; no pulp capping
agent. Cavities were
sealed with IRM1.
(n = 20)
Fairbourn, 1980, CCT 5 months Unknown
US20 n = 40 Permanent teeth, Half of the caries dentin in Half of the caries dentin Micro-organisms
deep caries* no lesions removed and the in lesions removed and before sealing
pulpal symptom remaining half caries was lined the cavities were sealed and on re-entry
with Ca(OH)2 (Improved with IRM1. (n = 20)
Dycal1). Cavities were sealed
with IRM1. (n = 20)
Maltz, 2002, Case series 6–7 months Unknown
Brazil21 12–23 years, Permanent teeth, Removal of necrotic and – 1. Clinical and
n = 32 deep lesions*, fragmented tissue, followed by radiographic
no pulpitis complete excavation of examination.
surrounding cavity wall. 2. Clinical
Application of Ca(OH)2 observation
(Dycal1). Cavities were sealed of dentin on
with IRM1. re-entry.
3. Micro-
organisms before
sealing and
on re-entry
Bjørndal, 2000, Case series 4–6 months Unknown
Denmark22 n=9 Permanent teeth, Removal of carcinogenic bio- – 1. Clinical
deep lesions mass and superficial deminer- observation of
(deeper than 2/3 alized dentin, followed by dentin on
of dentin), no complete peripheral excava- re-entry.
pulpitis tion. Application of Ca(OH)2 2. Micro-
and temporary restoration. organisms before
sealing and on

99
re-entry
 100
Table 1 (Continued )
Study [reference Study Patients Tooth type; lesion Intervention Control Time to Outcome Setting
number] design depth re-entry measured

Bjørndal, 1998, Case series 2–9 months General practices

Denmark23 11–65 years, Permanent teeth, Removal of carcinogenic bio- – 1. Clinical and
(mean 24 deep lesions*, no mass and superficial deminer- radiographic
years) n = 94 pulpitis alized dentin, followed by e x a mi n at i o n 1
complete peripheral excava- year after final
tion. Application of Ca(OH)2 restoration.
and temporary restoration. 2. Clinical
observation of

journal of dentistry 39 (2011) 95–107

dentin on
re-entry
Bjørndal, 1997, Case series 6–9 months Unknown
Denmark24 n = 31 Permanent teeth, Removal of carcinogenic bio- – (n = 20), 9–12 1. Clinical
deep lesions*, no mass and superficial deminer- months observation of
pulpitis alized dentin, followed by (n = 11) dentin on
complete peripheral excava- re-entry.
tion. Application of Ca(OH)2 2. Micro-
and temporary restoration. organisms before
sealing and on
re-entry
Ogawa, 1984, Case series 2–6 months University
Japan25 6–13 years, Permanent teeth, partially excavation, Ca(OH)2 – 1. Clinical (paediatric
n = 28 deep lesions*, no (Porcal1) application and tem- observation and dentistry)
pulpitis porary sealing radiographic
examination.
2 Clinical
observation of
dentin on
re-entry
Jordan, 1971, Case series 10–12 weeks Unknown
Canada26 8–37 years, Permanent teeth, Superficially excavation of car- – Clinical
n = 243 teeth deep lesions*, no ies lesions followed by applica- observation and
in 97 patients pulpitis tion of 1)Ca(OH) 2 (Dycal 1 , radiographic
Hydrex1, Pulpdent1), examination
2)Ca(OH) 2 +crestatin, 3)ZOE,
and temporary sealing with re-
inforced ZOE and Am.
RCT: randomized controlled trial, CCT: controlled clinical trial.
Ca(OH)2: calcium hydroxide, ZOE: zinc oxide and eugenol cement, GIC: glass ionomer cement.
Deep lesions*: The conventional complete removal of caries dentin would cause pulp exposure.
Table 2 – Clinical and radiographic findings of stepwise excavation for deep cavities in permanent teeth. Clinical studies arranged by levels of study designs with
chronological order (1970–).
Study [reference number]Study design Patients Intervention Time to re-entry Clinical Radiographic
observation examination and
histological
evaluation

Leksell, 1996, RCT 6–16 years

Sweden13 (mean = 10.2) Stepwise excavation 8–24 weeks All 80 teeth without pulp exposure –
n = 127 with Ca(OH)2 (n = 57) vs showed normal clinical and radio-
complete caries removal graphic conditions at the last check-
(n = 70) up (x = 43 months). No difference in
their progress in the two treatment
groups when no pulp exposure.
Nagamine, 1993, CCT 17–46 years,
Japan16 n = 23 teeth Stepwise excavation 3 month All pulp were vital after 3 months. In Radio density:

journal of dentistry 39 (2011) 95–107

in 20 patients with polycarboxylate ce- intervention group, 1 amongst 18 Intervention group:
ment combined with cases showed sensitivity to cold; in increase in 14 cases
tannin-fluoride prepara- control group, 3 amongst 5 showed the amongst 16. Control group:
tion sensitivity. no changes in all 4 cases.
(HY-Bond
Temporary Cement
Soft1) (n = 18) vs
hydraulic temporary
sealing material (
Lumicon1) (n = 5)
Gotoh, 1985, Japan17 CCT 19–33 years,
n = 10 Stepwise excavation 12 weeks (71–96 days) Clinical observation: Histological
with Ca(OH)2 all cases showed evaluation: all cases
(Dycal1) (n = 6) vs. ZOE good prognoses after demonstrated
(Neodyne1) (n = 4) 12 weeks. 2 cases applied Ca(OH)2 acceptable, although slight
showed inflammation was observed
postoperative sensitivity, but in 2
it disappeared cases applied
within 4 days Ca(OH)2. Reparative
dentin was found in
2 cases amongst 6 in
Ca(OH)2 group, and 1
amongst 4 in ZOE
group.
Sawusch, 1982, CCT 14 years or
US18 younger, n = 48 Stepwise excavation 6 months No clinical failure in the both groups. –
with Ca(OH) 2 ; Experi-
mental Dycal1 (n = 36)
vs Improved Dycal 1
(n = 12).

101
 102
Table 2 (Continued )
Study [reference number]Study design Patients Intervention Time to re-entry Clinical Radiographic
observation examination and
histological
evaluation

Maltz, 2002, Case series 12–23 years,

Brazil21 n = 32 Stepwise excavation 6–7 months 30 amongst 32 were successful, whilst Radiopacity was signifi-
with Ca(OH)2 (Dycal1). two failed due to pulp necrosis and cantly increased during the
pulp exposure during removing provi- observation period.
sional seal. Dentin became harder and
darker on re-entry.
Bjørndal, 2000, Case series n=9
Denmark22 Stepwise excavation 4–6 months dentin became harder and darker on –

journal of dentistry 39 (2011) 95–107

with Ca(OH)2. re-entry
Bjørndal, 1998, Case series 11–65 years,
Denmark23 (mean 24 years) Stepwise excavation 2–9 months A total of 88 cases without pulp –
n = 94 with Ca(OH)2. exposure were symptomless at 1 year
except 1 case, which lost temporary
seal and needed endodontic treat-
ment. Dentin got harder and darker
on re-entry.
Bjørndal, 1997, Case series n = 31
Denmark24 Stepwise excavation 6–9 months (n = 20), 9–12 No pulpal exposures at final excava-
with Ca(OH)2. months (n = 11) tion. At re-entry, dentin got darker,
harder, dryer.
Ogawa, 1984, Case series 6–13 years,
Japan25 n = 28 Stepwise excavation 2–6 months Hypersensitivity observed in two cases Radio opacity increased in 2
with Ca(OH)2 (Porcal1). disappeared within a week. Other cases (7.1%) at 3 months
cases were symptomless. Dentin be- and 12 cases (42.9%) at 6
came darker, dryer at 3 months and months. Tertiary dentin
harder at 6 months was observed in only 2
cases (7.1%).
Jordan, 1971, Case series 8–37 years,
Canada26 n = 243 teeth Stepwise excavation 10–12 weeks Clinical success rate was 98% (236/ Remineralization was ob-
in 97 patients with Ca(OH)2 (Dycal1, 243), and 7 teeth needed endodontic served after 10 to 16 weeks
Hydrex1, Pulpdent1), treatment. (mean 12 weeks).
Ca(OH)2 + crestatin,
or ZOE.
RCT: randomized controlled trial, CCT: controlled clinical trial.
Ca(OH)2: calcium hydroxide, ZOE: zinc oxide and eugenol cement, GIC: glass ionomer cement.
Deep lesions*: The conventional complete removal of caries dentin would cause pulp exposure.
 journal of dentistry 39 (2011) 95–107
3.5. Changes in cariogenic bacteria
The findings of cariogenic bacteria were reported in seven
studies15,16,19–22,24 (Table 3). The decrease of cariogenic
bacteria after stepwise excavation was confirmed at re-entry
in all of the selected studies. Some studies evaluated the
changes in specific bacteria, such as Streptococci mutans and
lactobaccilli,15,22 and some evaluated changes in aerobic and
anaerobic bacteria separately.16,21 Calcium hydroxide was
used in five studies,19–22,24 and antimicrobials14 and poly-
carboxylate cement combined with tannin-fluoride prepara-
tion16 were used in the remaining two studies. Notably,
cariogenic bacteria were not detected in 21 cases out of 3021
and in 6 out of 1924 from cavities that were applied with
calcium hydroxide at the time of re-entry after six to seven
months and 6 to 12 months, respectively. Neither aerobic nor
anaerobic bacteria were detected in 13 cases out of 18 from the
cavities that were applied with polycarboxylate cement
combined with tannin-fluoride preparation after three
months.16
We did not combine the data in the aforementioned studies
to produce statistical analyses which would compare the
effectiveness of various lining materials in reducing the
bacteria. This was because the units showing the amount of
bacteria were different in the studies, reflecting the different
methods of collecting bacteria. Additionally, since the various
authors were not specific in defining how much carious dentin
remained in cavities, we felt it was not safe to draw
generalized statistical conclusions from different data sets.
4. Discussion
Results of the electronic and manual searches showed that
there were small numbers of RCTs13,15 and CCTs16–20 that
fulfilled the inclusion criteria in this research field. Thus, we
decided to include case series21–26 in order to get a better
understanding of the clinical results of stepwise excavation.
Because limited numbers of RCTs and CCTs that used the
same clinical methods and materials were available, we could
not undertake data synthesis followed by the selected
statistical analyses. Instead, we summarized the outcome of
the stepwise excavations pertaining to the clinical and
radiographic findings and to the individual changes in bacteria
(Tables 2 and 3). This approach seemed appropriate to
evaluate the clinical effectiveness of the stepwise excavation.
In this systematic review, as previously reported,12 step-
wise excavation was considered effective for the preservation
of pulp that might be exposed during removal of extremely
deep caries in permanent teeth when there were no clinical
symptoms showing irreversible pulpitis. The collective results
indicate that cariogenic bacteria are effectively reduced, and
remaining softened dentin becomes harder as a consequence
of remineralization. Paddick et al.27 reported details of
changes in cariogenic bacteria upon stepwise excavation.
During the interval between sealing a cavity after stepwise
excavation and re-entry, the available nutrient, primarily
serum proteins, or the relative simplicity and homogeneity of
the nutrient supply significantly affected the surviving
bacteria. The surviving bacteria were less complex, based
103
on compositional, phenotypic, and genotypic analyses, than
those isolated from carious lesions which were also exposed to
salivary secretions and pH perturbations. In addition, not only
calcium hydroxide but also other materials such as anti-
microbials15 and polycarboxylate cement combined with
tannin-fluoride preparation16 are suitable as lining materials,
since all these materials were found to reduce cariogenic
bacteria and to promote remineralization as effectively as
calcium hydroxide.
The methods and extent of removing carious dentin during
stepwise excavation were not sufficiently clear when compar-
ing the expressions in the various selected papers (Table 1).
Recently, promising clinical results have been reported when
carious dentin was left in deep cavities and the cavities were
restored without re-entry.28–30 However, the amount or extent
of dentin that can be left in the cavities has again not been
discussed in those studies. The consensus on this issue is to
remove peripheral caries dentin completely, to remove as
much of the caries adjacent to the pulp as possible, and to
avoid pulp exposure with maximum caution. As described
previously, avoiding pulp exposure is important since the
prognosis of direct pulp capping is reportedly unpredictable.6–
9
Additionally, when considering the bonding ability of carious
dentin, it has been reported that dentin affected and infected
with caries shows inferior adhesion with dentin bonding
systems as compared to sound dentin.31–33 Therefore, remov-
ing peripheral carious dentin and achieving firm marginal
adhesion is a minimum mandatory requirement for protecting
vital pulp from the invasion of bacteria and any other
potentially invasive stimuli. For long-lasting restorations,
after removing deep caries, marginal sound dentin is critically
important since it can produce more reliable adhesion to
restorative materials.
Examination of dentin upon re-entry21–25 and of radio-
graphic findings16,21,25,26 showed evidence of remineralization
in carious dentin left after stepwise excavation. However, we
could not confirm when remineralization became sufficient
for re-entry or how quickly it occurred. Again, the onset and
speed of remineralization may be affected by the quality and
quantity of the remaining carious dentin in the cavities
following stepwise excavation. To our knowledge, there has
not been a clinical study in which the speed and amount of
remineralization have been investigated longitudinally. Lack
of such information limits the determination of an ideal time
for re-entry.
Only one study with a small sample size reported the
generation of tertiary dentin found upon radiographic
examination, meaning that it was observed in only 7.1% of
the cases.25 It should be noted that evaluating the generation
of tertiary dentin is not easy, since only precisely standardized
longitudinal radiographic or histological examinations make
such an assessment possible. Generation of tertiary dentin has
usually been considered to relate to lesion activity. When a
lesion progresses rapidly, there is either atubular dentin
formation or no tertiary dentin; whereas in slowly progressing
lesions, the tertiary dentin contains tubules and resembles
normal dentin.34 From the results of this systematic review,
the likelihood of tertiary dentin generation is not so frequent.
This finding suggests that removal of carious dentin at re-
entry must be carried out cautiously to avoid pulp exposure,

Table 3 – Changes in micro-organisms in deep cavities of permanent teeth after stepwise excavation. Clinical studies arranged by study designs with chronological order
(1970–).
Study [reference number] Study Patients Intervention
design
Wicht et al., 2004, RCT 18–67 years (mean = 38.4),
Germany15 n = 30 Removal of central biomass
and application of one of
two antimi crobials; CE
group: 1%
chlorhexidine-and 1% thy-
mol-
containing varnish
(Cervitec1, n = 10), LE group:
3% demeclocycline hydro-
cortisone-containing oint-
ment; (Ledermix1, n = 10).
All cavities were sealed
with
compomer.
Nagamine, 1993, CCT 17–46 years, n = 23 teeth in 20
Japan16 patients Removal of surface caries
dentin. Then, application of
polycarboxylate cement
combined with tannin-
fluoride preparation (HY-
Bond Temporary Cement
Soft1) followed by
sealing with GIC. (n = 18)
Leung, 1980, US19 CCT n = 40
Half of the caries dentin in
lesions removed and the
remaining half caries was
lined with Ca(OH)2 (Dycal1).
Cavities were sealed with
IRM1. (n = 20)
104
Control Time to re-entry Changes in
micro-organisms
Removal of central bio- 6 weeks cChanges in total viable counts of
mass. No pulp capping micro-organisms on re-entry (log10
agent was applied but CFU): LE group from 5.03 to 2.93
cavies were sealed with ( p < 0.001); CE group from 5.06 to
compomer. (n = 10) 3.51 ( p = 0.057); CO group from 5.39
to 4.88 ( p = 0.271). LE significantly
reduced the total micro-organisms
compared with CO, but not CE.
Changes in latibacilli countson re-
entry (log10 CFU): LE group from
journal of dentistry 39 (2011) 95–107
3.67 to 1.88 ( p < 0.001): CE group
from 4.21 to 2.81 ( p = 0.002); CO
group from 3.08 to 2.54 ( p = 0.230).
Both antimicrobials significantly
reduced the total micro-organisms
compared with CO. None of the
both antimicrobials completely
eliminated the viable micro-organ-
isms, but LE was more effective
than CE.
Removal of surface car- 3 months Intervention group: micro-organ-
ies dentin. Then, appli- isms reduced from log10 4–5 CFU/
cation of hydraulic mg dentin to log 10 0–3 CFU/mg
temporary sealing mate- dentin; control group: no change
rial (Lumicon1) followed in all cases.
by sealing with GIC.
(n = 5)
Half of the caries dentin 4 weeks Numbers of bacteria on re-entry
in lesions removed and compared to the one before seal-
the remaining half car- ing: Ca(OH)2 group: decreased from
ies was covered by wax; log10 4.36 to log10 2.80 ( p < 0.01);
no pulp capping agent. control group: increased from log10
Cavities were sealed 4.56 to log10 5.05 ( p < 0.05). (unit:
with IRM1. (n = 20) CFU/mg carious dentin)
Fairbourn, 1980, US20 CCT n = 40
Half of the caries dentin in
lesions removed and the
remaining half caries was
lined with Ca(OH) 2 (Im-
proved Dycal 1 ). Cavities
were sealed with IRM 1 .
(n = 20)
Maltz, 2002, Case series 12–23 years, n = 32
Brazil21 Removal of necrotic and
fragmented tissue, followed
by complete excavation of
surrounding cavity wall.
Application of Ca(OH)2 (Dy-
cal1). Cavities were sealed
with IRM1.
Bjørndal, 2000, Case series n=9
Denmark22 Removal of cariogenic bio-
mass and superficial demi-
neralized dentin, followed
by complete peripheral ex-
cavation. Application of
Ca(OH)2 and temporary re-
storation.
Bjørndal, 1997, Case series n = 31
Denmark23 Removal of cariogenic bio-
mass and superficial demi-
neralized dentin, followed
by complete peripheral ex-
cavation. Application of
Ca(OH)2 and temporary re-
storation.
RCT: randomized controlled trial, CCT: controlled clinical trial, CFU: colony forming units.
Ca(OH)2: calcium hydroxide, ZOE: zinc oxide and eugenol cement, GIC: glass ionomer cement.
Deep lesions*: The conventional complete removal of caries dentin would cause pulp exposure.
Half of the caries dentin 5 months
in lesions removed and
the cavities were sealed
with IRM1. (n = 20)
– 6–7 months
– 4–6 months
– 6–9 months
(n = 20), 9–12
months (n = 11)
Numbers of bacteria on re-entry
compared to the one before seal-
ing: improved Dycal1 group: de-
creased from log10 4.83 to log10 2.78
( p < 0.001); IRM1 group: decreased
from log 1 0 5.02 to log 1 0 3.22
( p < 0.001). (unit: CFU/mg carious
dentin)
Numbers of bacteria on re-entry
compared to the one before sealing
were decreased from 2.6–5.6 to 0–
journal of dentistry 39 (2011) 95–107
3.3 in anaerobic bacteria, and 0.0–
6.5 to 0 to 3.2 in aerobic bacteria
(unit: log10 (CFU + 1)).
Numbers of bacteria on re-entry
compared to the one before sealing
were decreased from 2.9  10 4 –
4.4  106 to 0–3.9  103 (unit: CFU/
ml carious dentin). Proportion of
lactobacilli was substantially re-
duced; gram-negative rods was
declined; flora dominated by Acti-
nomyces naeslundii and various
streptcocci
Numbers of bacteria on re-entry
compared to the one before sealing
were decreased from 1.2  10 3 –
9.5  105 to 0–5.3  103 (unit: CFU/
ml carious dentin). Substantial re-
duction in colony forming units –
not time dependent.
105
106 journal of dentistry 39 (2011) 95–107
since the thickness of the remaining dentin may be un-
changed after stepwise excavation even though remaining
carious dentin may have become harder.
Further clinical trials with high levels of study design in this
research field are needed to clarify the best possible methods
and materials for stepwise excavation. Specifically, clinical
studies must devise recommendations for how much and how
far to remove carious dentin during stepwise excavation. In
addition, there is a lacuna in studies where the clinical
outcomes using different lining materials are compared.
Conducting such studies and subsequently more clearly
understanding the changes in carious dentin after stepwise
excavation will facilitate the elucidation of the best possible
clinical methods that can enhance the preservation of pulp in
deep cavities.
5. Conclusions
From this review, stepwise excavation can be concluded as
effective for pulp preservation in extremely deep caries where
there are no clinical symptoms of irreversible pulpitis.
Calcium hydroxide and other materials, such as antimicro-
bials and polycarboxylate cement combined with tannin-
fluoride preparation, have been shown to be effective in
reducing bacteria after stepwise excavation. Further clinical
trials with high levels of study design in this research field are
needed to identify the best possible methods for removing
carious dentin during stepwise excavation.
Acknowledgments
This work was a part of developing the ‘‘Evidence-based
clinical guidelines for restoring caries in permanent teeth with
a minimal intervention policy’’ and was supported by the
Japanese Society of Conservative Dentistry.
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