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Operative Dentistry - Best Practices

Step-wise Caries Removal

(last modified August 8, 2014)

Stepwise excavation is a method of managing deep dentinal caries lesions to reduce the risk of pulpal exposures and pulpal pathosis by removing the caries lesion in separate appointments with ≥ 6 month intervals.

Indications:

  • Deep dentinal lesions likely to result in pulp exposure during single excavation
  • Clear evidence of pulp vitality and no evidence of irreversible pulpitis
  • No history of spontaneous or prolonged pain
  • Positive pulp vitality test (electric, thermal, mechanical)
  • Negative to percussion/palpation
  • Radiographically: >75% through dentin and no periradicular pathosis
  • Reliable patient – controls and follow up in place

1st STAGE: initial excavation:

  • Stepwise procedure is planned and discussed with patient before beginning any irreversible treatment
  • Use rubber dam isolation
  • Remove peripheral superficial layers of caries lesion (cleaning DEJ and cavosurface margins), resulting in at least 1-1.5mm wide zone of sound dentin
  • Leave discolored, leathery dentin (identified with scrapping spoon, not poking with the explorer) once the cavity floor is reasonably firm to avoid the risk of pulp exposure.
  • Leathery wet dentin on the pulpal and axial floors
  • Undermined enamel can remain at this stage for retention of glass ionomer
  • Good sealing with materials that enhance the dentin’s potential to remineralize are recommended. Providing a good seal is critical for arresting caries progression. (FDI Policy statement, October 2001)
  • Material of choice: Glass Ionomer (Conventional or RMGI). We use glass ionomer PINK Fuji VII (Triage) as the initial layer directly over and only over the remaining leathery wet dentin as a visual identifier and then Fuji IX or Fuji II LC is placed on top for functional and esthetic purposes
  • Check occlusion
  • CLEAR and complete information should be recorded in the EHR
  • Re-evaluation/ re-entry after ≥6 months

2nd STAGE: Re-evaluation/ re-entry:

  • New periapical radiograph to evaluate for periradicular pathosis
  • Evaluate for symptoms or signs of a possible pulp pathosis, vitality test MUST be confirmed
  • Remove provisional restoration taking caution to not exposure the pulp
  • Completely remove remaining carious tissue (complete removal of pink Fuji Triage may not be required to achieve this objective)
  • Place final restoration as indicated
  • Follow up every 6 months with vitality testing and obtain periapical radiographs as indicated