***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: Concern about the survival of microorganisms in deep carious lesions may often lead to unnecessary exposure of the pulp during final excavation . There are reasons , therefore , to initiate systematic studies on the alternative procedure known as stepwise excavation . Clinical evaluation of stepwise excavation was performed on 31 deep carious lesions considered to result in pulp perforation by traditional excavation . This study examines the clinical and microbiological alterations during the final excavation performed during long intervals ( 6 - 12 months ) after the initial treatment that included peripheral dentine excavation and removal of the central cariogenic biomass and the superficial necrotic dentine . The dentine colour and consistency were assessed by means of st and ardized scales before application of a Ca(OH)2 compound and a temporary sealing for 6 - 12 months . Re assessment s were performed before the after final excavation . Microbiological dentine sample s were obtained in 19 r and omly selected lesions by a sterile bur  , transferred to and diluted in reduced transport fluid , and plated on tryptic soy agar . After anaerobic incubation at 37 degrees C for 7 days , total colony-forming units per millilitre were counted from ( 1 ) peripheral excavated and hard dentine ( control ) , ( 2 ) central demineralized dentine before and final excavation , and ( 3 ) central dentine after the final excavation . Six sample s of central demineralized dentine were without any cultivable flora increasing to 9 sample s after the final excavation . The clinical dentine changes occurring during stepwise excavation were characterized by enhanced hardness of the dentine which was associated with a marked reduction in bacterial growth after the final excavation . Despite the presence of bacteria in the excavated dentine none of the carious lesions result ed in pulp perforation , suggesting that the initial removal of the cariogenic biomass appears to be essential for control of caries progression . Stepwise excavation is not only an appropriate treatment of deep carious lesions but is also considered a suitable model for microbiological studies to determine the bacteria persisting in clinical ly excavated lesions Objective This multicenter r and omized controlled clinical trial aim ed to compare the outcomes of stepwise excavation ( SW ) and partial caries removal ( PCR ) regarding the maintenance of pulp vitality in deep caries lesions over 5 years . Methods At baseline , 299 permanent molars with deep caries lesions were r and omly assigned to control or test groups . The control group received the stepwise excavation treatment ( SW ) , while the test group received partial caries removal from the pulpal wall followed by restoration in a single session ( PCR ) . Treatments were conducted in two centers located in the cities of Porto Alegre ( South Brazil ) and Brasília ( Midwest Brazil ) . Survival analysis was performed to compare PCR and SW over time ( Weibull regression models ) . The primary outcome of this study was pulp vitality , determined by the combination of the following characteristics : positive response to cold test , negative response to percussion , absence of spontaneous pain , and absence of periapical lesion ( radiographic examination ) . Results This 5-year study includes data pertaining to 229 teeth : 121 teeth actually examined at the 5-year appointment , and 108 teeth contributed with data collected in previous follow-ups ( 18 months or 3 years ) .  Survival analysis showed success rates of 80 % in PCR group and 56 % in SW group ( p < 0.001 ) . Failure was significantly associated with treatment [ PCR , HR=0.38 ; 95%CI=0.23–0.63 ) ] and region [ South , HR=2.22 ; 95%CI=1.21–4.08 ] . Conclusion PCR significantly reduced the occurrence of pulp necrosis when compared with SW . Clinical relevance This study supports the PCR as a single-visit technique to manage deep caries lesions in permanent teeth OBJECTIVE To evaluate the clinical and radiographic outcomes ( 24 months ) of indirect pulp treatment ( IPT ) in primary teeth when a self-etching primer or a calcium hydroxide layer was used over the remaining carious dentin . STUDY DESIGN Primary molar teeth with deep carious lesions without signs and symptoms of irreversible pulpitis were divided into two groups , according to the capping material : Experimental group ( 1 ) : self-etching adhesive system ( Clearfill SE Bond ) ; and Control group ( 2 ) : calcium hydroxide liner ( Dycal ) . Both groups were followed up after application of a resin restoration ( 3 M - Z250 ) . RESULTS After 2 years of clinical and radiographic follow-up , no statistical difference was found between groups ( p = 1 ) . The overall success rate reached 87 % . CONCLUSION These results demonstrate that IPT has a high clinical and radiographic performance in primary teeth and is not dependent on the capping material used over the demineralized dentin PURPOSE The purpose of this study was to investigate dentin rehardening in the remaining carious dentin after indirect pulp treatment ( IPT ) using microhardness analysis after 37 to 71 months . METHODS Eighteen teeth su bmi tted to IPT and capped with calcium hydroxide ( CH ) or gutta-percha ( GP ) were evaluated ( treated group ) . Ten sound molars and 10 molars with deep acute carious lesions were selected to serve as positive and negative control groups , respectively . In the treated group , restorations and pulp-capping material s were removed . In the positive control group , 3- to 4-mm deep cavities were prepared . In the negative control group , the carious tissue was removed . Microhardness analysis was performed at 10- , 35- , 60- , 85- , and 110-microm depths . Data were analyzed using 1-way analysis of variance ( P<.05 ) . RESULTS Microhardness values for sound , carious , and treated groups at 10- , 35- , 60- , 85- , and 110-microm depths showed a statistically significant difference ( P < or=.01 ) among the groups for microhardness . No difference was observed between CH- and GP-treated groups for microhardness . CONCLUSION The results showed a hardness increase in treated teeth when compared to carious teeth in all dentin depths investigated , suggesting mineral gain after treatment PURPOSE The purpose of this study was to evaluate the effect of the material s used for indirect pulp treatment ( IPT ) on the long-term outcome of primary molar teeth . METHODS Forty-eight teeth with deep carious lesions , but without signs and symptoms of irreversible pulpitis , were r and omly divided into 2 groups , according to the material placed on the demineralized dentin remain : ( 1 ) experimental group , adhesive system ( Scotchbond Multi purpose ) ; and ( 2 ) control group , calcium hydroxide liner ( Dycal ) . Both groups were followed by a resin restoration application . RESULTS After 4 to 5 years , the clinical and radiographic success rates between groups were similar ( group 1=14 of 15 ; group 2=8 of 10 ; P=0.350 ) . Subsequent to exfoliation , scanning electron microscopy revealed the presence of a hybrid layer at the resin-dentin interface and a microtensile bond strength of 9.63 MPa ( group 1 ) . Histological analysis showed that the pulp health status was similar in both groups . CONCLUSIONS Indirect pulp treatment has a high clinical and radiographic long-term success rate in primary teeth and is not material -dependent 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 With the purpose of checking , in vivo , the effect of atraumatic restorative treatment ( ART ) on the remaining demineralized dentin , 12 primary molars with deep occlusal lesions from children with ages ranging from 3 to 7 were evaluated . After lesion excavation , and before glass ionomer cement placement , dentin sample s were collected from the pulpal wall of the cavity . After 3 months , the restorations were removed and new sample s were collected . Six micro areas of each sample were analyzed by X-ray energy dispersion spectrometer . Sample s obtained before treatment were infected and intertubular dentin had a loosely organized collagen matrix , with well-defined collagen fibers . Following treatment , in addition to a drastic reduction of the amount of bacteria , the intertubular dentin was denser , with more compact and closely packed collagen fibers . An increased calcium concentration was observed in dentin collected after treatment ( p < 0.001 ) , suggesting tissue remineralization , but fluoride was not detected . We conclude that ART allows a one-session approach , with the purpose of creating more favorable conditions for the healing process PURPOSE To evaluate the clinical and radiographic changes in primary teeth su bmi tted to indirect pulp treatment ( IPT )  over a 36-month period . METHODS Thirty-nine primary molars with deep caries , but without preoperative signs and symptoms of irreversible pulpits , received IPT .  The teeth were r and omly divided into two groups , according to the material used for protection of the dentin-pulp complex : ( 1 ) a calcium hydroxide liner ( Hydro C ) and ( 2 ) a gutta-percha sheet . Both groups were restored with Z250 resin-based composite . RESULTS After 36 months , Group 1 showed a success rate of 73.3 % and Group 2 , 85.7 % . The overall success rate was 79.3 % , with no statistically significant difference between the groups ( P = 0.36 ) The aim of this r and omized , controlled , single-blind and prospect i ve study was to evaluate the clinical and radiographic success rates of three different bonding protocol s vs calcium hydroxide liner for protection of the dentin – pulp complex of primary molars with different remaining dentin thicknesses . Two hundred forty primary molar teeth with moderate to deep occlusal caries were restored in 97 children who met inclusion criteria . After cavity preparation , the teeth were r and omly assigned into four groups ( n = 60/group ) with respect to the material used for protection of the dentin – pulp complex : ( 1 ) total-etching with 36 % phosphoric acid followed by an acetone-based adhesive ( Prime&Bond NT ) , ( 2 ) a self-etch adhesive system ( Xeno III ) , ( 3 ) an acetone-based adhesive ( Prime&Bond NT ) without prior acid conditioning , and ( 4 ) control : calcium hydroxide cement ( Dycal ) . Teeth in groups 1–3 were restored with a polyacid-modified resin-based composite ( Dyract AP ) and those in group 4 with amalgam . The remaining dentin thickness was calculated using image analysis software ( ImageJ ) . The teeth were evaluated clinical ly and radiographically for 24 months . The distribution of restored teeth with minimal remaining dentin thickness ( ≤0.5 mm ) was 3.3 , 8.3 , 8.3 , and 10 % for groups 1 , 2 , 3 , and 4 , respectively . Despite the absence of pulpal protection in groups 1–3 , none of those teeth exhibited any significant clinical or radiographic symptom during the study period . After 2 years , the clinical and radiographic success rate of restorative treatments was 100 % . Protection of the dentin – pulp complex with the tested bonding protocol s result ed in similar outcomes in mainly shallow and medium deep cavities as compared to calcium hydroxide amalgam in more deep cavities , when indirect pulp treatment was performed in class I compomer restorations This r and omized , multicenter clinical trial evaluated the effectiveness of 2 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 . Inclusion criteria were as follows : patients with permanent molars presenting deep caries lesions ( lesion affecting ≥ 1/2 of the dentin on radiographic examination ) , positive response to 
    Output:
    
The overall risk difference for CH versus adhesive system  in primary teeth was 0.06 [ 95 % CI -0.01 to 0.13 ] , and the overall risk difference for  CH  versus  GIC  was 0.10 [ 95 % CI -0.01 to 0.22 ] , with no significant differences between material s. CH liner did not influence the clinical success of treatment for deep caries lesions of primary or permanent teeth .