Strategies for control and treatment of carious lesions in deciduous molars: a review of the literature

http://dx.doi.org/10.1590/1981-863720160001000093057 REVISÃO | REVIEW Strategies for control and treatment of carious lesions in deciduous molars: a review of the literature Estratégias para o controle e tratamento das lesões de cárie em molares decíduos: Uma revisão de literatura Catarina Ribeiro Barros de ALENCAR1 Odailma Lima da SILVA1 Fernanda Lyrio MENDONÇA2 Francisco Juliherme Pires de ANDRADE3 ABSTRACT In recent years, a reduction has been observed in the prevalence of dental caries in the global population. However, caries is still considered a public health problem. Currently, total removal of decayed tissue has been questioned and replaced by less invasive therapeutic approaches, which offer the possibility of incomplete removal of decayed tissue in one or two clinical sessions. Other techniques aim at sealing the carious lesion or use prefabricated metal crowns on the cavitated tooth without removal of the decayed tissue, preventing direct contact of the substrates with the carious lesion. Recently, ultra-conservative treatment has gained scientific prominence, and is able to control carious lesions through the disorganization of dental biofilm via supervised brushing. Each therapeutic approach has its advantages and limitations, and it is the responsibility of dental professionals to plan their patients’ treatments according to their individual needs, allowing for better functional, aesthetic and psychological conditions for patients by preserving primary teeth until their physiological exfoliation. Indexing terms: Dental caries. Dentin. Tooth deciduous. RESUMO Nos últimos anos, foi perceptível a diminuição na prevalência da cárie dentária na população mundial. Entretanto, a doença cárie continua sendo considerada um problema de saúde pública. Atualmente, a remoção total do tecido cariado vem sendo questionada e substituída por abordagens terapêuticas menos invasivas, as quais oferecem a possibilidade de remoção incompleta do tecido cariado em uma ou duas sessões clínicas. Outras técnicas visam o selamento da lesão cariosa ou o emprego de coroas metálicas pré-fabricadas sobre o dente cavitado sem que haja remoção de tecido cariado, impedindo o contato direto dos substratos com a lesão cariosa. Recentemente, o tratamento ultraconservador tem ganhado destaque científico, o qual tem a capacidade de conduzir o controle da lesão de cárie através da desorganização do biofilme dentário pela escovação supervisionada. Cada abordagem terapêutica apresenta suas vantagens e limitações, sendo responsabilidade do profissional planejar o tratamento do seu paciente de acordo com as suas necessidades individuais, possibilitando melhores condições funcionais, estéticas e psicológicas para o paciente através da manutenção dos dentes decíduos até a sua esfoliação fisiológica. Termos de indexação: Cárie dentária. Dentina. Dentes decíduos. INTRODUCTION The conventional approach to treating carious lesions, in which all decayed tissue is removed1, has been progressively replaced by more biological and less invasive approaches2. Treatment of carious lesions based on minimally invasive techniques aims to prevent their progression and preserve pulp vitality3 via principles of prevention, remineralization and minimal intervention in the dental tissue4. Biological approaches to handling carious lesions in deciduous molars embrace several techniques, the most noteworthy being partial removal of decayed tissue with3,5 or without reopening the tooth to supplement excavation2,6, sealing the carious lesion7-8, sealing the cavitated lesion with prefabricated steel crowns, known as the Hall technique9-12 and, more recently, ultra-conservative treatment13-15. Even with growing incentives to use these ultraconservative approaches, comparative studies between Universidade Estadual da Paraíba, Faculdade de Odontologia. Campus VIII, Av. Coronel Pedro Targino, s/n., Centro, 58233-000, Araruna, PB, Brasil. Correspondência para / Correspondence to: CRB ALENCAR. E-mail: <>. 2 Faculdade de Tecnologia e Ciências, Curso de Odontologia. Salvador, BA, Brasil. 3 Universidade Estadual da Paraíba, Faculdade de Odontologia. Campina Grande, PB, Brasil. 1 RGO, Rev Gaúch Odontol, Porto Alegre, v.64, n.1, p. 62-69, jan./mar., 2016 Strategies for control and treatment of carious lesions in deciduous molars: a review of the literature techniques are limited, which leaves clinicians uncertain as to their applicability within pediatric dental care11. In light of the topic’s importance, current strategies for controlling and treating carious lesions in deciduous molars, with regard to procedures and their benefits and limitations, will be presented. Characteristics of carious lesions The carious process begins in the enamel, with demineralization caused by bacterial acids that come from dental biofilm. Usually, enamel lesions can be arrested via control of dental biofilm, dietary changes and the adequate use of fluoride16. However, if the carious lesion is not controlled, the dental-enamel junction will be affected and the lesion will progress towards the dentinal tubules, triggering progressive changes in the dentin’s hardness. As a result of these changes, the dentin may be divided into two layers, which are distinct from the morphological, biochemical, bacteriological and physiological points of view17. The external layer of carious dentin is made up of a superficial necrotic tissue, characterized by the demineralization of the intertubular dentin, with scarce, granular crystals, few collagen fibers and a lack of odontoblast processes and intertubular dentin, whose space is filled with bacteria or loosely distributed crystals of various shapes. This layer of softened tissue, irreversibly denatured and without possibility of remineralization, is called infected dentin. The underlying layer is partially demineralized and has apatite crystals together with collagen fibers that, unlike the superficial layer, exhibit a striation that is characteristic of collagen. Although the intertubular dentin is demineralized, the odontoblast processes remain in place. It is, therefore, a tissue that is harder than the infected dentin and may be remineralized, being defined as affected dentin18. Therapeutic approaches to cavitated carious lesions in deciduous molars Traditional treatment of cavitated dentin lesions advocates complete removal of the decayed structure, i.e. the infected and affected dentin layers. During this procedure, however, a significant quantity of the dental structure is removed and the pulp tissue may be exposed2,5. In light of this, the complete removal of all decayed structures from a tooth with cavitated lesions is no longer seen as mandatory, and there is growing evidence to support incomplete removal of decayed tissue prior to the restoration of the cavity19. It is argued, however, that carious lesions remaining in the cavity must be completely sealed in order to prevent their progression. T (...truncated)