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Operative Dentistry - Best Practices

Caries Management: Deep caries removal

(last modified August 10, 2017)

Deep (Advanced/Extensive) caries lesion management options include:

(1) Selective removal to soft dentin

Selective removal to soft dentine is recommended in deep cavitated lesions (i.e., extending into the pulpal third or quarter of the dentine). Soft carious tissue is left over the pulp to avoid exposure and “stress” to the pulp, thereby promoting pulpal health, while peripheral enamel and dentine are prepared to hard dentine, to allow a tight seal and placement of a durable restoration. Selective removal to soft dentine reduces the risk of pulpal exposure significantly as compared with nonselective removal to hard or selective removal to firm dentine (Schwendicke et al ADR 2016;28:58-67). A sharp hand excavator can be used to check the hardness/softness of the remaining dentine; remember that soft dentine will deform when an instrument is pressed onto it and little force would be required to lift it (Innes et al ADR 28:49-57).

 

(2) Stepwise removal (see below)

Stepwise excavation is a method of managing deep/extensive/advanced 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 in permanent teeth 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
  • Rapidly progressing lesions in a closed cavity environment

1st STAGE: Selective removal to soft dentine:

  • Stepwise procedure is planned and discussed with patient before beginning any irreversible treatment
  • Use rubber dam isolation
  • Stage 1 has the same caries removal aims as selective removal to soft dentin
    • Periphery of the cavity should be hard with a clean DEJ resulting in a 1-1.5mm wide zone of sound/hard dentin
    • Centrally (pulpal/axial) perform selective removal to soft dentin, but there should be enough removal of carious tooth tissue to place a durable provisional restoration while still avoiding pulp exposure.
  • 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: Selective removal to firm dentin 6 to 12 months later:

  • New periapical radiograph to evaluate for periradicular pathosis
  • Evaluate for symptoms or signs of a possible pulp pathosis, sensibility/vitality test MUST be confirmed
  • Remove provisional restoration taking caution to not exposure the pulp
  • Perform selective removal to firm dentin centrally (complete removal of pink Fuji Triage may not be required to achieve this objective)
  • Place final restoration as indicated with appropriate material specific modifications to the preparation
  • Follow up every 6 months with vitality testing and obtain periapical radiographs as indicated

 

decision making for noncleansable carious lesions