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中华口腔医学研究杂志(电子版)

中华口腔医学研究杂志(电子版) ›› 2024, Vol. 18 ›› Issue (04) : 243 -249. doi: 10.3877/cma.j.issn.1674-1366.2024.04.005

论著

选择性与完全去龋技术治疗恒牙深龋近髓的临床疗效比较
李午丽1, 赵春晖1, 孙成1, 郑桂婷1, 孟丹婕2, 李颂1,†()   
  1. 1. 安徽医科大学口腔医学院，安徽医科大学附属口腔医院牙体牙髓科，安徽省口腔疾病研究重点实验室，合肥　230032
    2. 合肥市口腔医院综合科，合肥　230001
  • 收稿日期:2024-04-01 出版日期:2024-08-01
  • 通信作者: 李颂

A clinical comparison of selective and complete caries removal techniques in the management of deep carious lesions proximal to the pulp in permanent teeth

Wuli Li1, Chunhui Zhao1, Cheng Sun1, Guiting Zheng1, Danjie Meng2, Song Li1,†()   

  1. 1. Department of Endodontics, College & Hospital of Stomatology, Anhui Medical University, Key Lab. of Oral Diseases Research of Anhui Province, Hefei 230032, China
    2. Department of General Dentistry, Hefei Stomatological Hospital, Hefei 230001, China
  • Received:2024-04-01 Published:2024-08-01
  • Corresponding author: Song Li
  • Supported by:
    Scientifc Research Funding of Anhui Province Health Commission(AHWJ2023A20112); Disciplinary Construction Project in School of Dentistry, Anhui Medical University(2022xkfyts05)
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引用本文：

李午丽, 赵春晖, 孙成, 郑桂婷, 孟丹婕, 李颂. 选择性与完全去龋技术治疗恒牙深龋近髓的临床疗效比较[J]. 中华口腔医学研究杂志(电子版), 2024, 18(04): 243-249.

Wuli Li, Chunhui Zhao, Cheng Sun, Guiting Zheng, Danjie Meng, Song Li. A clinical comparison of selective and complete caries removal techniques in the management of deep carious lesions proximal to the pulp in permanent teeth[J]. Chinese Journal of Stomatological Research(Electronic Edition), 2024, 18(04): 243-249.

目的

比较选择性与完全去龋技术治疗恒牙深龋近髓的临床疗效。

方法

选取2021年10月至2023年10月于安徽医科大学附属口腔医院牙体牙髓科就诊的恒牙深龋患者52例（患牙52颗），采用随机数字表法将患者分为观察组（选择性去龋组）和对照组（完全去龋组）各26例（患牙26颗），分别在口腔手术显微镜下以对应方法去龋。根据去龋完成后是否露髓，采用iRoot BP Plus直接盖髓或TheraCal LC间接盖髓，流体树脂封闭牙本质层，3M复合树脂分层充填窝洞。采用卡方检验比较两组术中露髓率；采用独立样本t检验比较两组术后1周的疼痛程度；采用Fisher精确检验比较两组术后随访6个月的并发症；采用符合方案分析和意向治疗分析比较两组术后6个月的成功率。

结果

选择性去龋组的术中露髓率（0%）明显低于完全去龋组（30.77%），差异有统计学意义（P = 0.004）；选择性去龋组术后24 h的疼痛视觉模拟评分（VAS）值为（2.9 ± 0.7）分，明显低于完全去龋组（3.3 ± 0.6）分，差异有统计学意义（t = 2.120，P = 0.039）；选择性去龋组的术后并发症（2例牙髓炎）与完全去龋组（1例根尖炎和2例牙髓炎）相比较，差异无统计学意义（P = 0.369）；符合方案分析结果显示，选择性去龋组术后半年的成功率（91.30%）和完全去龋组的成功率（87.50%）均较高，差异无统计学意义（RR 失访不计入 = 0.696，95% CI 失访不计入：0.128 ~ 3.790，P失访不计入 = 0.675）。意向治疗分析结果显示，选择性去龋组术后半年的成功率分别为80.77%和92.31%，完全去龋组的成功率分别为80.77%和88.46%，差异均无统计学意义（RR失访全部失败 = 1.000，95% CI失访全部失败：0.328 ~ 3.047，P失访全部失败 = 1.000；RR失访全部成功 = 0.667，95% CI失访全部成功：0.121 ~ 3.666，P失访全部成功 = 0.641）。

结论

与传统完全去腐技术相比较，选择性去龋技术牙髓暴露风险低、微创、术后并发症少、成功率高，建议在恒牙深龋近髓患者中推广应用。

关键词: 牙列，恒, 龋齿, 牙髓覆盖术, 去龋技术
Objective

This study aimed to assess the clinical efficacy of selective caries removal and complete caries removal for the management of deep carious lesions proximal to the pulp in permanent teeth.

Methods

Fifty-two patients presenting with deep caries in permanent teeth (affecting a total of 52 teeth) were recruited from the Department of Endodontics at the Affiliated Stomatological Hospital of Anhui Medical University between October 2021 and October 2023. A random number table method was utilised to divide each of the 26 cases (26 affected teeth) into an observation group (selective caries removal group) and a control group (complete caries removal group). Dental surgical microscopy was employed for precise tooth removal in both groups. Depending on pulp exposure following caries removal, either iRoot BP Plus or TheraCal LC was utilized for direct or indirect pulp capping. Flow resin was applied for dentin layer sealing, followed by cavity filling with 3M composite resin. A Chi-squared test was employed to ascertain whether there was a significant difference in the rate of intraoperative pulp exposure of the affected teeth between the two groups. An independent samples t-test was used to compare the pain levels of the patients in the two groups at one week postoperatively. A comparison of the postoperative complications of the patients in the two groups at the 6-month postoperative follow-up was conducted using Fisher′s exact test. Per-protocol and intention-to-treat analysis were conducted to evaluate the success rate of the affected teeth in both groups at the 6-month postoperative interval.

Results

The intraoperative pulp exposure rate in the selective caries removal group (0%) was significantly lower than that in the complete caries removal group (30.77%), and the difference was statistically significant (P = 0.004). The visual analogue score (VAS) of pain in the selective caries removal group at 24 hours postoperatively was (2.9±0.7), which was significantly lower than that in the complete caries removal group (3.3 ± 0.6). The difference was statistically significant (t = 2.120, P = 0.039). The postoperative complications in the selective caries removal group (two cases of pulpitis) were statistically comparable with those in the complete caries removal group (one case of apical periodontitis and two cases of pulpitis) (P = 0.369). The per-protocol analysis revealed that the success rates were high for both the selective caries removal group (91.30%) and the complete caries removal group (87.50%), with no statistically significant difference (RRexcluding lost follow-up = 0.696, 95% CIexcluding lost follow-up: 0.128 to 3.790, Pexcluding lost follow-up = 0.675). The intention-to-treat analysis showed that the success rates for the selective caries removal group were 80.77% and 92.31%, and for the complete caries removal group, they were 80.77% and 88.46%, respectively. The differences were not statistically significant (RRall lost follow-up considered as failure = 1.000, 95% CIall lost follow-up considered as failure: 0.328 to 3.047, Pall lost follow-up considered as failure = 1.000; RRall lost follow-up considered as success = 0.667, 95% CIall lost follow-up considered as success: 0.121 to 3.666, Pall lost follow-up considered as success = 0.641) .

Conclusions

Selective caries removal presented a lower risk of pulp exposure, entailed minimal invasiveness, resulted in fewer postoperative complications, and yielded higher success rates compared to traditional complete caries removal technique. Therefore, its promotion and application were recommended for treating permanent teeth with deep caries proximal to the pulp.

Key words: Dentition, permanent, Dental caries, Dental pulp capping, Caries removal techniques
图1 深龋恒牙经选择性去龋和完全去龋技术治疗的临床流程　A：36选择性去龋的术前照片；B：36选择性去龋后牙髓未暴露；C：使用TheraCal LC行36间接盖髓术；D：使用流动树脂行36窝洞垫底；E：使用膏体树脂完成36窝洞充填；F：36完全去龋的术前照片；G：36完全去龋后牙髓未暴露；H：使用TheraCal LC行36间接盖髓术；I：使用流动树脂行36窝洞垫底；J：使用膏体树脂完成36窝洞充填；K：47完全去龋的术前照片；L：47完全去龋后牙髓暴露；M：使用iRoot BP Plus行47直接盖髓术；N：使用流动树脂行47窝洞垫底；O：使用膏体树脂完成47窝洞充填。
表1 纳入病例的基本资料
组别 例数 年龄（岁， ± s） 性别例数（男/女） 牙位（例）
前磨牙 磨牙
选择性去龋组 26 28 ± 9 10/16 2 24
完全去龋组 26 25 ± 9 14/12 6 20
检验值   t = 1.273 χ2=1.238 χ2=1.330
P值   0.209 0.266 0.249
表2 深龋恒牙经选择性去龋和完全去龋技术治疗后1周内的疼痛评分比较（ ± s）
组别 例数 治疗后时间
24 h 48 h 72 h 7 d
选择性去龋组 26 2.9 ± 0.7 1.9 ± 0.7 1.5 ± 0.7 0.2 ± 0.4
完全去龋组 26 3.3 ± 0.6 2.2 ± 0.8 1.6 ± 0.8 0.3 ± 0.5
t值   2.120 1.518 0.791 0.615
P值   0.039a 0.135 0.433 0.541
图2 深龋恒牙经选择性去龋和完全去龋技术治疗的影像学资料　A：26选择性去龋术前X线片；B：26选择性去龋后行间接盖髓术的术后即刻X线片；C：26选择性去龋术后半年复查X线片；D：46完全去龋的术前X线片；E：46完全去龋后行间接盖髓术的术后即刻X线片；F：46完全去龋术后半年复查X线片；G：27完全去龋的术前X线片；H：27完全去龋后行直接盖髓术的术后即刻X线片；I：27完全去龋术后半年复查X线片。
表3 深龋恒牙经选择性去龋和完全去龋治疗术后半年的临床疗效比较[例（%）]
临床疗效 PP分析（失访不计入） ITT分析（失访全部失败） ITT分析（失访全部成功）
选择性去龋组（n = 23） 完全去龋组（n = 24） 选择性去龋组（n = 26） 完全去龋组（n = 26） 选择性去龋组（n = 26） 完全去龋组（n = 26）
成功 21（91.30） 21（87.50） 21（80.77） 21（80.77） 24（92.31） 23（88.46）
失败 2（9.70） 3（12.50） 5（19.23） 5（19.23） 2（7.69） 3（11.54）
RR 0.696 1.000 0.667
95% CI 0.128 ~ 3.790 0.328 ~ 3.047 0.121 ~ 3.666
P值 0.675 1.000 0.641
[1]
Schwendicke F，Frencken JE，Bjørndal L，et al. Managing carious lesions：Consensus recommendations on carious tissue removal[J]. Adv Dent Res，2016，28（2）：58-67. DOI：10.1177/0022034516639271.
[2]
张露，陈智.深龋的治疗策略[J].中华口腔医学杂志，2024，59（1）：23-29. DOI：10.3760/cma.j.cn112144-20231018-00203.
[3]
陈智，卢展民，Schwendicke F，等.龋损管理：龋坏组织去除的专家共识[J].中华口腔医学杂志，2016，51（12）：712-716. DOI：10.3760/cma.j.issn.1002-0098.2016.12.003.
[4]
R R，Wani W，Sharma S，et al. Selective removal to soft dentine versus full pulpotomy for management of proximal deep carious lesions：A randomized controlled non-inferiority trial[J]. Caries Res，2023，57（4）：536-545. DOI：10.1159/000530895.
[5]
Jardim JJ，Mestrinho HD，Koppe B，et al. Restorations after selective caries removal：5-Year randomized trial[J]. J Dent，2020，99：103416. DOI：10.1016/j.jdent.2020.103416.
[6]
Gözetici-Çil B，Erdem-Hepçenoğlu Y，Tekin A，et al. Selective removal to soft dentine or selective removal to firm dentine for deep caries lesions in permanent posterior teeth：A randomized controlled clinical trial up to 2 years[J]. Clin Oral Investig，2023，27（5）：2125-2137. DOI：10.1007/s00784-022-04815-0.
[7]
Pedrotti D，Cavalheiro CP，Casagrande L，et al. Does selective carious tissue removal of soft dentin increase the restorative failure risk in primary teeth？：Systematic review and meta-analysis[J]. J Am Dent Assoc，2019，150（7）：582-590.e1. DOI：10.1016/j.adaj.2019.02.018.
[8]
Rossoni NB，Cavalheiro CP，Casagrande L，et al. Influence of the chemomechanical and mechanical carious tissue removal on the risk of restorative failure：A systematic review and meta-analysis[J]. Clin Oral Investig，2022，26（11）：6457-6467. DOI：10.1007/s00784-022-04695-4.
[9]
Weimann D，Morgenthal A，Schwendicke F，et al. Substantial regional differences in the biomechanical behavior of molar treated with selective caries tissue removal technique：A finite element study[J]. Dent Mater，2021，37（3）：e162-e175. DOI：10.1016/j.dental.2020.11.008.
[10]
宋雪，崔岳，刘晓燕等.三种手术方案治疗儿童乳磨牙深龋的随机对照临床研究[J].临床口腔医学杂志，2023，39（9）：558-562. DOI：10.3969/j.issn.1003-1634.2023.09.011.
[11]
Elhennawy K，Finke C，Paris S，et al. Selective vs stepwise removal of deep carious lesions in primary molars：12-Months results of a randomized controlled pilot trial[J]. J Dent，2018，77：72-77. DOI：10.1016/j.jdent.2018.07.011.
[12]
张青，区跃坚，张玲.部分去龋法治疗恒磨牙深龋的疗效观察[J].上海口腔医学，2017，26（3）：321-323. DOI：10.19439/j.sjos.2017.03.020.
[13]
孟丹婕，杨英泽，周一闻，等. iRoot BP Plus用于恒牙深龋选择性去龋后间接牙髓治疗的临床疗效评估[J].临床口腔医学杂志，2023，39（10）：617-620. DOI：10.3969/j.issn.1003-1634.2023.10.009.
[14]
吕胜慎，马兰，印晶晶，等.不完全去龋法治疗深龋临床效果的Meta分析[J].中国实用口腔科杂志，2021，14（2）：207-215. DOI：10.19538/j.kq.2021.02.017.
[15]
Lim ZE，Duncan HF，Moorthy A，et al. Minimally invasive selective caries removal：A clinical guide[J]. Br Dent J，2023，234（4）：233-240. DOI：10.1038/s41415-023-5515-4.
[16]
Duncan HF，Galler KM，Tomson PL，et al. European Society of Endodontology position statement：Management of deep caries and the exposed pulp[J]. Int Endod J，2019，52（7）：923-934. DOI：10.1111/iej.13080.
[17]
Elhennawy K，Finke C，Paris S，et al. Selective vs stepwise removal of deep carious lesions in primary molars：24 Months follow-up from a randomized controlled trial[J]. Clin Oral Investig，2021，25（2）：645-652. DOI：10.1007/s00784-020-03536-6.
[18]
Pereira JT，Knorst JK，Ardenghi TM，et al. Pulp vitality and longevity of adhesive restorations are not affected by selective carious removal：A multicenter clinical trial[J]. Caries Res，2021，55（1）：55-62. DOI：10.1159/000510698.
[19]
Barros MMAF，de Queiroz Rodrigues MI，Muniz FWMG，et al. Selective，stepwise，or nonselective removal of carious tissue：Which technique offers lower risk for the treatment of dental caries in permanent teeth？A systematic review and meta-analysis[J]. Clin Oral Investig，2020，24（2）：521-532. DOI：10.1007/s00784-019-03114-5.
[20]
Franzon R，Guimarães LF，Magalhães CE，et al. Outcomes of one-step incomplete and complete excavation in primary teeth：A 24-month randomized controlled trial[J]. Caries Res，2014，48（5）：376-383. DOI：10.1159/000357628.
[21]
Khokhar M，Tewari S. Outcomes of partial and complete caries excavation in permanent teeth：A 18 month clinical study[J]. Contemp Clin Dent，2018，9（3）：468-473. DOI：10.4103/ccd.ccd_344_18.
[22]
范博文，于飞.硅酸钙类盖髓剂用于深龋恒牙直接盖髓的临床疗效观察[J].临床口腔医学杂志，2021，37（8）：480-482. DOI：10.3969/j.issn.1003-1634.2021.08.009.
[23]
Hassanpour S，Aminabadi NA，Rahbar M，et al. Comparison between the radiographic and clinical rates of success for TheraCal and MTA in primary tooth pulpotomy within a 12-month follow-up：A split-mouth clinical trial[J]. Biomed Res Int，2023，2023：8735145. DOI：10.1155/2023/8735145.
[24]
陈敏，张颖，仇晨光，等. iRoot BP Plus和TheraCal LC用于恒牙直接盖髓的临床效果比较[J].临床口腔医学杂志，2021，37（12）：727-729. DOI：10.3969/j.issn.1003-1634.2021.12.007.
[25]
刘思毅，宫玮玉，刘木清，等.成熟恒牙因龋露髓行生物陶瓷材料直接盖髓术的临床疗效观察[J].中华口腔医学杂志，2020，55（12）：945-951. DOI：10.3760/cma.j.cn112144-20200327-00173.
[26]
Miotti LL，Vissotto C，de Nardin L，et al. Does the liner material influence pulpal vitality in deep carious cavities submitted to selective caries removal？A network meta-analysis review[J]. Clin Oral Investig，2023，27（12）：7143-7156. DOI：10.1007/s00784-023-05372-w.
[27]
Singh S，Mittal S，Tewari S. Effect of different liners on pulpal outcome after partial caries removal：A preliminary 12 months randomised controlled trial[J]. Caries Res，2019，53（5）：547-554. DOI：10.1159/000499131.
[28]
刘奕雯，蒋宏伟.活髓保存治疗中的微创理念[J/OL].中华口腔医学研究杂志（电子版），2019，13（4）：193-199. DOI：10.3877/cma.j.issn.1674-1366.2019.04.001.
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