Effectiveness of selective, non-selective, and stepwise caries removal techniques in permanent teeth: An umbrella...

To synthesize evidence from systematic reviews/meta-analyses of clinical trials comparing selective removal (SR), non-selective removal (NSR), and stepwise removal (SW) for caries management in permanent teeth, reporting outcomes of pulp health preservation, pulp exposure risk, post-operative pain, restorative success, dentin deposition/remineralization, and microbial load.

This umbrella review was conducted in accordance with PRIOR guidelines and registered in PROSPERO. Five electronic databases were searched for eligible systematic reviews/meta-analyses. Methodological quality was assessed using AMSTAR-2, and certainty of evidence was evaluated using GRADE. Overlap of primary studies across reviews was also assessed.

Seven systematic reviews and/or meta-analyses were included. No single caries removal technique was superior across all outcomes. SR was generally favored when pulp exposure risk was high; however, avoiding exposure did not fully ensure pulp health or eliminate pulpal complications. Post-operative pain was slightly lower with NSR compared to SW. NSR and SW may be associated with higher restorative success compared with SR. No significant differences were observed among techniques in dentin deposition/remineralization and microbial load reduction. Overall certainty of evidence ranged from low to very low, and methodological quality was moderate in only two systematic reviews and critically low in the remaining. Therefore, the findings should be interpreted with caution.

Current evidence remains insufficient to recommend a gold-standard caries removal technique. Technique selection should be guided by an accurate pulpal diagnosis, the radiographic depth of the lesion, an understanding of patient-related factors, and the limitations of adhesive bonding to carious and caries-affected dentin. Further high-quality primary studies with longer follow-up are required to clarify clinical indications and the impact of removal techniques on the restorative cycle.

This umbrella review highlights that preserving pulp vitality in deep carious lesions requires more than simply avoiding pulp exposure. While selective caries removal may offer a safer biological approach by reducing exposure risk, the available evidence does not demonstrate consistent superiority relative to pulp health, restorative success, microbial reduction, or dentin remineralization outcomes. Clinicians should therefore adopt a patient-centered and diagnosis-driven approach, balancing the benefits of minimally invasive excavation with the restorative challenges of bonding to caries-affected dentin.