1. Búsqueda de información
Profesor Pablo Milla
Alumna Francisca Lavandero
Integral del adulto
Marzo 2012

2. Desarrollo: Documento de trabajo y
estrategia de búsqueda
P: Pacientes mayores de 18 con caries dentinaria
profunda (asintomática sin lesión periapical)
T
E I: Stepwise
R
A C: Remoción completa de caries en una sesión
P
O: Éxito de la restauración (ausencia de pulpitis y de
I perforación)
A
T: Reviews y RTC

3. Pregunta
Pregunta:
Tipo de pregunta: Tratamiento.
En pacientes mayores de 18 años con caries dentinaria profunda
(asintomáticas y sin lesión periapicales)
¿es mejor realizar la técnica Stepwise que remover completamente la
caries en una sesión, para tener éxito en la restauración (ausencia de
pulpitis y menor tasa de perforación)?

4. Tipo de estudio para búsqueda
Documentos
de búsqueda
Revisión
Metanálisis RCT
sistemática

5. Los principales temas y términos
alternativos de su pregunta “PICOT”
que pueda ser usado para su
búsqueda:
Dental caries AND Therapy AND Adult
AND
Dental Caries/therapy*

6. Límites
•Meta-Analysis
Type of Article •Randomized Controlled Trial
•Review
Languages •English
•Spanish
Age •All adults +19
Dates •Five years
• Bases de datos:

7. Papers seleccionados
• Eur J Oral Sci. 2010 Jun;118(3):290-7.
• Treatment of deep caries lesions in adults: randomized clinical trials comparing stepwise vs.direct complete exca
vation, and direct pulp capping vs. partial pulpotomy.
• Bjørndal L, Reit C, Bruun G, Markvart M, Kjaeldgaard M, Näsman P, Thordrup M, Dige I, Nyvad B, Fransson H, Lager
A, Ericson D, Petersson K, Olsson J,Santimano EM, Wennström A, Winkel P, Gluud C.
• Source
• Dental School, University of Copenhagen, Copenhagen, Denmark. labj@sund.ku.dk
• Abstract
• Less invasive excavation methods have been suggested for deep caries lesions. We tested the effects
of stepwise vs. direct complete excavation, 1 yr after the procedure had been carried out, in 314 adults (from six
centres) who had received treatment of a tooth with deep caries. The teeth hadcaries lesions involving 75% or
more of the dentin and were
centrally randomized to stepwise or direct complete excavation. Stepwise excavationresulted in
fewer pulp exposures compared with direct complete excavation [difference: 11.4%, 95% confidence interval (CI)
(1.2; 21.3)]. At 1 yr of follow-up, there was a statistically significantly higher success rate with stepwise excavation,
with success being defined as an unexposed pulp with sustained pulp vitality without apical radiolucency
[difference: 11.7%, 95% CI (0.5; 22.5)]. In a subsequent nested trial, 58 patients with exposed pulps
were randomized to direct capping or partial pulpotomy. We found no significant difference in pulp vitality
without apical radiolucency between the two capping procedures after more than 1 yr [31.8% and 34.5%;
difference: 2.7%, 95% CI (-22.7; 26.6)]. In conclusion, stepwise excavationdecreases the risk of pulp exposure
compared with direct complete excavation. In view of the poor prognosis of vital pulp treatment,
a stepwiseexcavation approach for managing deep caries lesions is recommended.
• PMID: 20572864 [PubMed - indexed for MEDLINE]
• Publication Types, MeSH Terms, Substances

8. Papers seleccionados
• J Dent. 2011 Feb;39(2):95-107. Epub 2010 Dec 3.
• Ways of enhancing pulp preservation by stepwise excavation--a systematic review.
• Hayashi M, Fujitani M, Yamaki C, Momoi Y.
• Source
• Department of Restorative Dentistry and Endodontology, Osaka University Graduate School of Dentistry, 1-8 Yamadaoka, Suita 565-0871, Japan.
mikarin@dent.osaka-u.ac.jp
• Abstract
• OBJECTIVES:
• The best possible methods and materials in stepwise excavation for deep caries in permanent teeth were investigated. The reviewconsiders the
questions from many aspects including clinical success, effects of reducing cariogenic bacteria, possibility of hardening softened dentin, and
likelihood of generating tertiary dentin.
• DATA:
• This systematic review includes the use of data from randomized controlled trials, controlled clinical trials as well as from case series in
whichpulp exposure resulted following the treatment and removal of deep caries. Only studies of caries in permanent teeth were considered. Those
involving treatment of primary teeth were excluded.
• SOURCES:
• An electronic search was conducted in the databases of MEDLINE and Igaku Chuo Zasshi (Japanese) from 1970 to 2008. The electronic search was
supplemented by a manual search of the references lists of all the relevant studies.
• STUDY SELECTION:
• The electronic and manual searches of journals retrieved a total of 266 English and 130 Japanese papers. According to the inclusion and exclusion
criteria, 10 English and 3 Japanese studies were finally identified.
• CONCLUSION:
• Our research suggests that stepwise excavation is effective for pulp preservation 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 remineralization 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.
• Copyright © 2010 Elsevier Ltd. All rights reserved.
• Comment in
• Evid Based Dent. 2011;12(3):68.
• J Evid Based Dent Pract. 2011 Dec;11(4):175-7.
• PMID: 20971154 [PubMed - indexed for MEDLINE]