***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Three intermediary base material s , a zinc oxide-eugenol ( Cavitec ) and two calcium hydroxide liners ( Life and Dycal ) , were selected at r and om for use as a base beneath  amalgam or composite restorations on humans following complete caries removal .  Life and Dycal , selected at r and om , were also used as direct and indirect pulp capping agents as clinical ly indicated . Clinical evaluations of signs and symptoms were made before treatment and at one-week , six-month , and one-year intervals following treatment . Histological evaluations were performed on three complete caries removal teeth and 18 direct pulp capping teeth six months following treatment . No significant differences in clinical symptomatology result ed between the material s in the complete caries removal group or the indirect and direct pulp capping groups Objectives Root canal therapy ( RCT ) and tooth extraction have been conventional treatment options for management of human mature teeth with irreversible pulpitis . Excellent short-term treatment outcomes of vital pulp therapy with calcium-enriched mixture cement ( VPT/CEM ) , as a new treatment option , on postoperative pain relief was demonstrated ; if intermediate- and long-term treatment outcomes of the new treatment are also non-inferior compared to RCT , then VPT/CEM may become a viable treatment option for management of mature teeth with irreversible pulpitis . Material s and methods In 23 healthcare centers , 407 9- to 65-year-old patients were r and omly allocated into two study arms including one-visit RCT ( reference treatment ; n = 202 ) and VPT/CEM ( alternative treatment ; n = 205 ) . Six- and twelve-month clinical and radiographic successes were assessed . Results Mean follow-up times at 6- and 12-month follow-ups were “ 6.70 ± 0.68 and 6.72 ± 0.71 months ” and “ 12.96 ± 0.67 and 12.90 ± 0.66 months ” in the available cases of RCT and VPT/CEM arms , respectively . Favorable clinical success rates in the two study arms did not show statistical difference ; however , the radiographic success rate in the VPT/CEM was significantly greater than RCT arm at the two follow-ups ( P < 0.001 ) . The patients ’ age had no effect on the treatment outcomes ( P = 0.231 ) . Conclusions Treatment outcomes of VPT/CEM may be superior to RCT in mature molars with irreversible pulpitis . The performance of bio material s such CEM cement may assist in the shift towards more biologic treatments . Clinical relevance VPT/CEM may be a realistic alternative treatment for human mature molar teeth with symptoms of irreversible pulpitis ; the use of VPT/CEM is highly beneficial for patients as well as general dentists In the GRADE approach , r and omized trials start as high- quality evidence and observational studies as low- quality evidence , but both can be rated down if most of the relevant evidence comes from studies that suffer from a high risk of bias . Well-established limitations of r and omized trials include failure to conceal allocation , failure to blind , loss to follow-up , and failure to appropriately consider the intention-to-treat principle . More recently recognized limitations include stopping early for apparent benefit and selective reporting of outcomes according to the results . Key limitations of observational studies include use of inappropriate controls and failure to adequately adjust for prognostic imbalance . Risk of bias may vary across outcomes ( e.g. , loss to follow-up may be far less for all-cause mortality than for quality of life ) , a consideration that many systematic review s ignore . In deciding whether to rate down for risk of bias -- whether for r and omized trials or observational studies -- authors should not take an approach that averages across studies . Rather , for any individual outcome , when there are some studies with a high risk , and some with a low risk of bias , they should consider including only the studies with a lower risk of bias Aim : This r and omized , multicenter clinical trial by Maltz et al. [ 1 ] evaluated the effectiveness of two treatments for deep caries lesions — partial caries removal ( PCR ) and stepwise excavation (SW)—with respect to the primary outcome of pulp vitality for a 3-year follow-up period . Material and methods : Inclusion criteria were as follows : patients with permanent molars presenting deep caries lesions ( lesion affecting ≥1/2 of the dentin on radiographic examina tion ) , positive response to a cold test , absence of spontaneous pain , negative sensitivity to percussion , and absence of periapical lesions ( radiographic examination ) . Teeth r and omly assigned to PCR ( test ) received incomplete caries removal and filling in a single session . Outcome success was evaluated by assessment of pulp vitality , determined by pulp sensitivity to a cold test and the absence of periapical lesions . Data were analyzed by a Weibull regression model with shared frailty term ( survival analysis ) . Results : At baseline , 299 treatments were executed : PCR 152 and SW 147 . By the end of the 3-year follow-up period , 213 teeth had been  evaluated . Adjusted survival rates were 91 % for PCR and 69 % for SW ( p=0.004 ) . Conclusion : These results suggest that there is no need to reopen a cavity and perform a second excavation for pulp vitality to be preserved ( Clinical trials registration NCT00887952 ) . Conflict of interest The corresponding author states that there are no conflicts of interest . Ziel : Diese r and omisierte , multizentrische klinische Studie untersuchte die Effektivitat von zwei Therapieansatzen zur Beh and lung tiefer karioser Lasionen : partielle Kariesentfernung ( PCR ) und mehrstufige Exkavation ( SW ) . Die primar zu untersuchende Auswirkung war die Vitalitat uber 3 Jahre . Material und Method e : Einschlusskriterien waren : Patienten deren permanente Molaren tiefe kariose Lasionen aufweisen ( rontgenologische Lasionen ≥½ des Dentins ) , positive Reak tion auf Kalte , Ausbleiben von Spontanschmerzen , negative Sensitivitat auf Perkussion , radiologisch keine apikalen Lasionen . Bei Zahnen , die in die PCR-Gruppe ( Test ) r and omisiert wurden , erfolgten eine unvollst and ige Kariesentfernung und die Fullung in einer Sitzung . I m Anschluss wurden die Vitalitat , das Ansprechen auf einen Kaltetest und das Ausbleiben von periapikalen Lasionen ermittelt . Die Auswertung erfolgte uber ein Weibull Regressionsmodell mit einem " shared frailty term " ( Lebensdaueranalyse ) Less invasive excavation methods have been suggested for deep caries lesions . We tested the effects of stepwise vs. direct complete excavation , 1 yr after the procedure had been carried out , in 314 adults ( from six centres ) who had received treatment of a tooth with deep caries . The teeth had caries lesions involving 75 % or more of the dentin and were central ly r and omized to stepwise or direct complete excavation . Stepwise excavation result ed in fewer pulp exposures compared with direct complete excavation [ difference : 11.4 % , 95 % confidence interval ( CI ) ( 1.2 ; 21.3 ) ] . At 1 yr of follow-up , there was a statistically significantly higher success rate with stepwise excavation , with success being defined as an unexposed pulp with sustained pulp vitality without apical radiolucency [ difference : 11.7 % , 95 % CI ( 0.5 ; 22.5 ) ] . In a subsequent nested trial , 58 patients with exposed pulps were r and omized to direct capping or partial pulpotomy . We found no significant difference in pulp vitality without apical radiolucency between the two capping procedures after more than 1 yr [ 31.8 % and 34.5 % ; difference : 2.7 % , 95 % CI ( -22.7 ; 26.6 ) ] . In conclusion , stepwise excavation decreases the risk of pulp exposure compared with direct complete excavation . In view of the poor prognosis of vital pulp treatment , a stepwise excavation approach for managing deep caries lesions is recommended OBJECTIVE The purpose of this project was to evaluate the performance of a dentin adhesive system on carious and noncarious primary dentin in vivo . METHOD AND MATERIAL S Forty-eight primary molars with carious lesions were r and omly assigned to 2 different treatments : group 1 ( control , n = 24)--All identifiable , irreversibly infected dentin was removed prior to the application of the bonding agent and restorative material ; group 2 ( experimental , n = 24)--Irreversibly infected dentin was partially removed prior to the application of the bonding agent and restorative material . The control and experimental teeth were clinical ly monitored every 3 months and evaluated 12 months after restoration . The teeth were extracted around the time of exfoliation and processed for scanning electron microscopy . RESULTS Retention rate , marginal integrity , and pulpal symptoms were identical in both groups . Radiographically , the radiolucent area associated with the experimental restorations did not increase with time in 75 % of the cases . For the control group , the adhesive system formed a hybrid layer . In the experimental group , there was morphologic evidence of the formation of an acid-resistant " altered hybrid layer . " An acid-resistant tissue , result ing from the interdiffusion of adhesive resin within the area of carious dentin , was observed adjacent to and under the altered hybrid layer . CONCLUSION Application of an adhesive restorative system to irreversibly infected dentin did not affect the clinical performance of the restoration PURPOSE The purpose of this prospect i ve and r and omized in vivo study was to compare the clinical and radiographic outcomes of an adhesive resin system vs a calcium hydroxide liner for protection of the dentin-pulp complex of primary molars treated with indirect pulp treatment . METHODS Forty-eight primary molars with deep occlusal caries , but without preoperative signs and symptoms of irreversible pulpitis , received indirect pulp treatment and were restored with a composite resin ( Z100 ) . The teeth were r and omly divided into 2 groups according to the material used for protection of the dentin-pulp complex : ( 1 ) adhesive resin system ( Scotchbond Multi Purpose ) ; and ( 2 ) calcium hydroxide liner ( Dycal ) . These teeth were evaluated clinical ly and radiographicaly for 2 years . RESULTS After 2 years , 83 % ( 19/23 ) of the teeth treated with calcium hydroxide and 96 % ( 24/25 ) of teeth treated with only the adhesive resin system presented a successful outcome , as determined by clinical and radiographic examination . Interradicular and /or periapical lesions were the most predominant signs of treatment failure , since 3 out of 23 teeth treated with calcium hydroxide and 1 out of 25 teeth treated with only adhesive resin presented this outcome . One tooth treated with the calcium hydroxide liner was diagnosed with internal root resorption at the 18-month examination . Of the 5 teeth diagnosed from radiographs as a failure of the indirect pulp treatment , none presented clinical signs/symptoms of pulpitis or necrosis such as the presence of fistula , enhanced tooth mobility , or pain . CONCLUSIONS This study demonstrates that protection of the dentin-pulp complex of primary molars with an adhesive resin system results in similar clinical and radiographic 2-year outcomes as compared to calcium hydroxide when indirect pulp treatment is performed in Class I composite restorations Aim : To prospect ively compare the clinical success rate of partial pulpotomy treatment in permanent molars using calcium hydroxide ( CH ) and mineral trioxide aggregates ( MTA ) as pulp dressing agents . Methods : Restorable permanent first molars ( 64 ) with carious pulp exposures were r and omly assigned to two groups ; CH and MTA . A st and ardized operative procedure was followed in both groups . Following isolation and caries removal , the exposed superficial pulp tissue layers were removed with a sterile flame shape diamond bur to a depth of 2–4 mm . Bleeding was controlled and pulp dressed with either a paste of non- setting Ca(OH)2 followed by a setting layer of Ca(OH)2 , or with grey MTA . The dressing material s in both groups were then covered with a layer of light cured glass ionomer cement . The teeth were either restored using amalgam , or where grossly carious with preformed metal crowns . Patients were scheduled for follow-up at 3 , 6 , 12 months and annually thereafter . Results : There were 34 patients ( 17 males and 17 females ) with 51 teeth available for evaluation . The age of patients at the time of restoration ranged between 6.8 to 13.3 years ( mean of 10.3 ±1.8 years ) . The follow-up period ranged from 25.4 to 45.6 months with an average of 34.8 ± 4.4 months . There was no statistically significant difference in the success rate of teeth treated with CH ( 91 % ) in comparison to teeth treated with MTA ( 93 % ) . Radiographically , a hard tissue barrier under CH was noticed in 12 ( 55 % ) teeth compared with 18 ( 64 % ) teeth under MTA ( p=0.4 ) . Conclusions : MTA has clinical success rate comparable to CH as a pulp dressing material for partial pulpotomy in permanent molars with carious The aim was to assess the prevalence of pulp exposure after stepwise versus direct complete excavation of permanent posterior teeth with deep carious lesions . The material , representing 116 patients aged 6 - 16 yrs ( mean = 10.2 yrs ) , consisted of 1 
    Output:
    
The overall evidence was insufficient to assess which of  indirect pulp capping , stepwise excavation , direct excavation and pulp capping/partial pulpotomy , pulpotomy or pulpectomy  is the most effective treatment approach for teeth with deep caries .
CONCLUSIONS Because of the lack of good studies it is not possible to determine whether an injured pulp by deep caries can be maintained or whether it should be removed and replaced with a root canal filling .