Effectiveness of stepwise or selective in comparison to non-selective caries removal in managing deep caries in vital permanent teeth: A systematic review with trial sequential, pairwise and network meta-analyses.

The aim of this systematic review was to assess the available evidence related to the effectiveness of stepwise (SW) or selective excavation (SE) when compared to non-selective caries excavation (NSE) for the management of permanent teeth with deep carious lesions without signs of irreversible pulpitis. This systematic review was conducted according to Cochrane guidelines. Literature search was performed using several databases including English language only. Pairwise and network meta-analysis (NMA) was conducted. 19 out of 819 studies were included. The outcomes assessed were dental pulp exposure and the measure 'success' defined as tooth not having complications after a follow-up (i.e., without dental pulp exposure following treatment, no dental pulp complications after treatment, no periapical lesion, no severe/unbearable pain, no restoration failure or tooth extraction). The Risk of Bias analysis revealed that more than 50% of the studies had high risk of bias. In addition, the GRADE assessment for the outcomes showed that most of the evidence was low and very low quality. Based on the results of the NMA, SW had the highest success rate (RR: 1.11, 95% CI: 1.00-1.23, with NSE as the reference), followed by SE (RR: 1.06, 95% CI: 0.97-1.16, with NSE as the reference). However, the difference was not statistically significant. In most cases, SE was the treatment of choice in relation to carious lesion depths with the threshold of >2/3 of the dentine thickness and SW was advocated only in cooperative patients due to the two-step procedures. However, within the limitations of this review, the effect of remaining carious dentine could not be assessed with respect to the success rate for each intervention. Therefore, long-term well organized multi-centre randomized controlled trials (RCTs) are still required to provide concrete evidence.