The University of Iowa College of Dentistry and Dental Clinics logoLink to University of Iowa home pageLink to University of Iowa home pageLink to College of Dentistry and Dental Clinics home page

college of dentistry mission graphic

Operative Dentistry - Best Practices

Caries Management: 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.


  • 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