Operative Dentistry - Best Practices

Caries Management: Step-wise Caries Removal

(last modified September 1, 2016)

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