What should we consider when treatment planning caries removal in a tooth?

Recently we came across an interesting article, Contemporary concepts in carious tissue removal: A review, by Dr. F. Schwendicke in the Journal of Esthetics and Restorative Dentistry. Caries removal is an important and fundamental element of the practice of dentistry. This article nicely highlights the most important factors that should be taken into consideration when treating caries as well as the rationale for the treatment that should be rendered for each individual tooth and circumstance.

Key Message

Caries removal should be based on the individual tooth being treated and, most importantly, the depth of the lesion.

The removal of all carious tissue from a cavity is no longer required to manage a carious lesion and can be considered overtreatment. Instead, caries management should focus on the prevention of lesion development and progression. As such treatment modalities are aimed at arresting caries activity, preserving sound tooth structures and maintaining pulp vitality.

Strategies to address carious lesions in teeth with vital pulps:

Non-selective caries removal

• Not recommended

Selective caries removal

• Indicated for shallow to moderately deep lesions
• Caries is removed until firm dentin is reached both centrally and peripherally
• Avoid removing remineralizable tissue
• Enables placement of a long-lasting restoration

Selective caries removal to soft dentin

• Indicated for deep lesions
• Carious tooth structure is removed, but softer dentin remains close to the pulp
• Restoration is placed that effectively seals the pulp and inhibits progression of caries

Stepwise caries removal

• Indicated for all lesions, including deep lesions in adults
• Two step process where carious tissue is removed to soft dentin with hard dentin on the periphery and a temporary restoration is placed. The patient returns to have a permanent restoration placed after 6-12 months
• May increase patient cost and time

Not removing caries

• No carious tissue is removed
• The lesion is sealed with a resin material if it is shallow and non-cavitated
• The lesion is capped with a stainless steel crown if the primary molar is cavitated
• Alternatively, the lesion is opened and cleaned regularly, but evidence does not support this method

Reference: Schwendicke F. Contemporary concepts in carious tissue removal: A review. J Esthet Restor Dent. 2017;29:403–408.