Remoção seletiva do tecido cariado: um enfoque da odontologia da mínima intervenção

Abstract

Contemporary dentistry is based on scientific evidence and advocates minimal intervention dentistry, which points to less invasive therapies and preventive procedures. This philosophy seeks the maintenance of pulp vitality and less mutilating cavities preparations, with the selective removal of carious tissue as one of the proposed therapies for carious lesions. Aspects of this removal technique were sought originating this literature review. Publications were searched on Pubmed and Periódico Capes platforms, using the following keywords as descriptors: selective removal of carious tissue, carious lesion, cariology and minimal intervention dentistry. The 23 publications discovered were added to 13 classic publications on the topic used for a historical understanding of the technique. It was found that carious dentin tissue can be divided into two main areas, currently referred to clinically as soft and firm carious dentin and previously known as infected and affected carious dentin respectively. Firm dentin is capable of remineralization with the interruption of carious aggression, as long as there is an effective marginal sealing during restorative treatment. Selective removal of carious tissue is limited to the bottom walls of the cavity, while the surrounding walls must undergo complete removal of carious tissue. Selective removal of carious tissue should only be performed on elements without symptoms of irreversible pulpitis and can be differentiated according to the number of sessions in stepwise removal (two sessions) and selective removal in a single session. In selective removal of carious tissue in two sessions, known as stepwise removal and used in deep and very deep treatments, partial selected removal of the soft dentin from the back walls is carried out in the first session and the total removal of the remaining soft dentin in the reopening session, with the cavity being provisionally restored between sessions by a period from 45 days to 12 months. Selective removal in a single session involves a definitive restoration at the end of the single session that may or may not remove all the soft dentin from the back walls, depending on the depth of the deep cavity. In deep or very deep cavities, due to the risk of pulp exposure, partial removal of the soft dentin from the carious dentin on the bottom walls is preferred. In this current paradigm of dentistry, total/traditional, until the classic “dentinaire cry sound”, removal of decayed tissue in the bottom walls of deep cavities is not recommended, and is considered restorative overtreatment. However, there are still a large number of professionals who opt for the traditional technique, regardless of the depth of the cavity. Several clinical studies have evaluated the effectiveness of selective removal of decayed tissue, as long as there is marginal sealing by the restoration. Some studies have discussed that selected removal in a single session is better than in two sessions (stepwise removal), although this statement is not conclusive. The selective removal of carious tissue on the bottom walls of the cavity reduces the risk of pulp exposure and leads to greater maintenance of tooth structure. Regarding what was said, at the current dentistry paradigm based on scientific evidence the selective removal of carious dentin in the bottom walls of the cavity conformation is recommended, especially in deep and very deep cavities.