A macroscopic and histological analysis of radiographically well‐defined deep and extremely deep carious lesions: carious lesion characteristics as indicators of the level of bacterial penetration and pulp response

AIM: To investigate the relationship between radiographically and macroscopically well-defined carious lesions and the dentine-pulp complex with regard to: (i) level of bacterial penetration; (ii) inflammatory status including the presence of hyperplastic pulp stroma; and (iii) formation of hard and/or ectopic connective tissue. METHODOLOGY: The material comprised 68 untreated cavitated permanent teeth divided into well-defined radiographic categories based on the lesion penetration depth: (i) deep lesions ( ≥3/4 of the dentine thickness with a radio-dense zone separating the lesion from the pulp) and (ii) extremely deep lesions (the carious lesion penetrated the entire thickness of the dentine, without a radio-dense zone). After extraction, the teeth were processed for histology. The material was scored with regard to coronal breakdown, macroscopic variables describing caries activity and histological variables describing the dentine-pulp complex (bacteria, inflammatory infiltrate, partial pulp necrosis, hyperplastic changes and hard tissue/ectopic presence of connective tissue). Interrater agreement was assessed using Cohen's kappa. Associations between variables were assessed using Pearson's chi-squared or Fisher's exact test. The effect size was reported by odds ratio (OR) and associated 95% confidence interval (CI). Level of significance was set to 5%. RESULTS: There were significant associations between a closed environment (1-2 surfaces involved) and the presence of biofilm, retrograde demineralization and light-coloured demineralized dentine. Whereas radiographically defined deep lesions tended to have bacteria only in the primary dentine (P < 0.001, OR = 20.55, 95% CI 4.44, 107.89), extremely deep carious lesions tended to have bacteria in contact with the pulpal tissue (P = 0.007, OR = 6.84, 95% CI 2.00, 62.83), presence of an inflammatory infiltrate (Fisher's exact; P < 0.001) and partial pulp necrosis. Hyperplastic pulps were seen only in extremely deep lesions. CONCLUSIONS: Unlike deep lesions, extremely deep carious lesions were often associated with severe pulp inflammation and infection. A radiographic threshold between deep and extremely deep lesions is suggested as indicator of the bacterial penetration level and the severity of the pulpal response prior to intervention.