Operative Dentistry - Best Practices

Caries Management: Caries Removal - shallow to moderate lesions

(last modified May 10, 2016)

Caries lesion management goals:  based upon symptoms, detection, diagnosis, risk assessment and treatment planning

  • Prevent lesions rather than heal
  • Heal lesions rather than surgically repair
  • Minimally invasive surgical treatment of lesions

Minimally Invasive Surgical Approach    

  • Defect specific lesion access and management
  • Final selection of restorative material after removal of defect
  • Material-specific cavity preparation modifications are then accomplished
    • Repair rather than replace restorations with lesions adjacent to margins whenever possible
    • Restorations are of last resort and do not make patients “caries free”

Caries lesion removal:

(Please see Schwendicke et al. ADR 2016;28:58-67. Managing carious lesions: Consensus recommendations on carious tissue removal.)

  • Convenience form access to the caries defect is made just large enough to sufficiently visualize and adequately instrument the carious tooth structure
  • The caries lesion is removed first peripherally by excavating peripheral 1 to 1.5 mm tooth structure to sound, hard dentin including a visually stain-free DEJ and healthy enamel. Histological “sound” dentin will have similar hardness and texture to sound unaffected dentin when applying a spoon excavator or slowly rotating round bur.
  • Moving inward or centrally from  this hard peripheral region it is acceptable to leave discolored caries affected/reparative dentin that is firm to a hand excavator.
    • Discolored and stained dentin, in itself, does not warrant continued tooth structure removal. Reparative dentin will have a lower hardness and rougher texture as compared to sound unaffected dentin when applying a spoon excavator or slowly rotating round bur.
    • The goal of central (axial and pulpal) caries lesion management is to remove infected dentin only and preserve the pulp; however, with currently existing technologies, clinically removing only infected dentin remains a highly subjective procedure. Therefore selective removal of central dentin should stop when firm dentin is reached.

decision making for noncleansable carious lesions

Note:

  • This best practices document does not address alternative caries removal/management strategies, such as, ultraconservative caries removal, indirect pulp capping, stepwise caries removal, etc.
  • Sound dentin has a Knoop hardness of 50 or higher with affected/reparative dentin roughly 25 to 50. This cannot be measured currently in the clinic.