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Schwendicke F, Frencken J, Innes N (eds): Caries Excavation: Evolution of Treating Cavitated Carious Lesions.
Monogr Oral Sci. Basel, Karger, 2018, vol 27, pp 155–161 (DOI: 10.1159/000487842)
Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of
Health, Berlin, Germany; c Department of Oral Function and Prosthetic Dentistry, College of Dental Sciences, Radboud University
Medical Center, Nijmegen, The Netherlands
Schwendicke F, Frencken J, Innes N (eds): Caries Excavation: Evolution of Treating Cavitated Carious Lesions.
Monogr Oral Sci. Basel, Karger, 2018, vol 27, pp 155–161 (DOI: 10.1159/000487842)
deform when an instrument is pressed onto it but enamel and soft dentine until firm dentine is felt
can still be easily lifted without much force being in shallow/medium-sized lesions (or to the depth
required. There may be little difference between that will allow enough bulk of glass-ionomer to be
leathery and firm dentine, with leathery being a placed) and until soft dentine is felt in deeper le-
transition on the spectrum between soft and firm sions. The cavity is restored usually with a high-
dentine.” Soft dentine will deform when a hard viscosity glass-ionomer cement or other adhesive
instrument is “pressed onto it and can be easily material and exposed pits and fissures are sealed.
scooped up (e.g., with a sharp hand excavator) For lesions that reach the inner half of dentine
with little force being required.” The definitions (radiographically) soft carious tissue should be
of these different clinical presentations of dentine left on the pulpal wall to avoid pulp exposure. The
affected by carious lesions are taken from the decision between carrying out selective removal
original ICCC terminology document [7]. to firm dentine or to soft dentine depends on the
extent of the lesion, the resulting cavity depth,
and the possibility of pulp exposure. ART is suit-
Carious Tissue Removal Terminology able for primary and permanent teeth and has a
large evidence base around it [see the chapter by
The 3 main carious tissue removal options are de- Leal et al.; this vol., pp. 92–102].
scribed as: (1) selective removal of carious tissue
(to both soft and firm dentine), (2) stepwise re-
moval, and (3) non-selective removal to hard No Removal (No Dentinal Carious Tissue
dentine (previously known as complete removal Removal)
and no longer recommended) with “soft,” “firm,”
and “hard” as described above. However, we can There are a variety of procedures where no den-
make a comprehensive list of types of tissue re- tinal carious tissue removal is carried out. Sealing
moval by expanding this and group them under includes: (1) fissure sealants (therapeutic), (2) the
the following headings: atraumatic restorative Hall Technique, and (3) NRCC. Despite being a
treatment; no removal (which includes fissure diverse group of procedures, they have the same
sealants, the Hall Technique, and non-restorative aim – to control the carious lesion without re-
cavity control; NRCC); selective removal to soft moving any diseased dentinal tissue.
dentine; selective removal to firm dentine, and Resin or glass-ionomer sealants (usually high
stepwise removal and non-selective removal. Ta- viscosity) can be used to seal over pit and fissure
ble 1 (reproduced from the ICCC terminology enamel and dentine carious lesions. However, as
document) details their previous names and pro- described in the chapter by Fontana and Innes
vides descriptions of them and the indications for [this vol., pp. 103–112], care has to be taken in
each technique to be used where there are non- deciding when to place them and when it may be
cleansable dentine carious lesions. more appropriate to carry out a selective removal
procedure. Although there is evidence to support
placing sealants over carious lesions, there is a
Atraumatic Restorative Treatment lack of evidence around how deep a lesion can be
sealed and still be assured of success, especially
Atraumatic Restorative Treatment (ART) is a for deeper lesions. The materials have limited
specific technique for carious lesion management abilities to resist forces occlusally. They are suit-
using hand instruments only. Pulpally, excava- able for primary and permanent teeth with shal-
tion is carried out by removing demineralised low and moderate carious lesions that appear
129.125.19.61 - 6/5/2018 11:31:51 PM
Schwendicke F, Frencken J, Innes N (eds): Caries Excavation: Evolution of Treating Cavitated Carious Lesions.
Monogr Oral Sci. Basel, Karger, 2018, vol 27, pp 155–161 (DOI: 10.1159/000487842)
Table 1. Overview of carious tissue removal terminology and groupings (reproduced from the ADR Terminology
Group) [7]
Atraumatic A specific technique Carious tissue removal using Primary and permanent teeth
restorative for carious lesion hand instruments only Shallow and moderate1 dentine
treatment (ART) management using Pulpally: excavate to firm dentine carious lesions to allow
hand instruments only in shallow lesions and to adequate depth for a
soft dentine durable restoration
in deep lesions
Restore cavity and seal available
pits and fissures with adhesive
dental material, usually
a high-viscosity
glass-ionomer cement
Selective removal Partial, incomplete, minimally Pulpally: remove carious Primary and permanent teeth
to soft dentine invasive, or ultraconservative tissue until soft Deep carious lesions2
caries removal dentine is reached
Enough tissue is removed
to place a durable
restoration
avoiding pulp exposure
Periphery of cavity: clean to
hard dentine
(similar to sound dentine)
Selective removal Partial caries removal, minimally Pulpally: remove carious Primary and permanent teeth
to firm dentine invasive or incomplete caries tissue until leathery or Shallow and moderate
removal firm dentine dentinal carious lesions1 to
(resistant to allow adequate depth for
hand excavator) a durable restoration
is reached
Periphery of cavity:
clean to hard dentine
(similar to sound dentine)
129.125.19.61 - 6/5/2018 11:31:51 PM
Schwendicke F, Frencken J, Innes N (eds): Caries Excavation: Evolution of Treating Cavitated Carious Lesions.
Monogr Oral Sci. Basel, Karger, 2018, vol 27, pp 155–161 (DOI: 10.1159/000487842)
Table 1. Continued
Stepwise removal Stepwise caries removal, Pulpally: selective removal Primary teeth
stepwise excavation, to soft dentine during 1st Not indicated – use
2-step caries removal step – remove carious tissue selective removal to
until soft dentine is reached soft dentine
Enough tissue is removed Permanent teeth
to place a durable restoration Deep carious lesions2
avoiding pulp exposure
Periphery of cavity: clean
until hard dentine is reached
(similar to sound dentine)
Subsequently (6–12 months)
Pulpally: selective removal to
firm dentine and place a
long-term restoration
1
Shallow and moderate lesions involving the outer pulpal two thirds or three quarters of dentine radiographically, or where there is no risk of pulp
exposure.
2
Deep lesions are those defined as radiographically involving the inner pulpal third or quarter of dentine, or with clinically assessed risk of pulpal
exposure.
non-cavitated clinically, and radiographically are tions. These make up a group of techniques that aim
not too extensive in dentine either in depth or to arrest carious lesions using a package of care in-
volume of lesion. volving caries management at the level of the pa-
The Hall Technique [as described in the chap- tient. By creating a cleanable cavity (sometimes this
ter by Santamaria and Innes, this vol., pp 113– involves altering the shape of the cavity through op-
122] is a specific procedure suitable only for pri- erative although not restorative intervention) and
mary molars, where a preformed metal (stainless- putting a successful preventive regimen in place,
steel) crown is used to seal dentinal carious lesions they aim to prevent further loss of tooth tissue
by cementing the crown using glass-ionomer ce- through carious lesion progression. The regimen
ment onto the tooth with no tooth preparation or includes plaque removal through toothbrushing
carious lesion removal. The crown is used to seal with a fluoridated toothpaste and/or application of
the dentinal carious lesion and slow down or pre- fluoride varnish. NRCC is most commonly used for
vent its progression to the dental pulp. This al- primary teeth but also has a role in the management
lows a carious primary molar to exfoliate without of root surface carious lesions.
pain or infection. The Hall Technique is usually
indicated for approximal lesions where there is
still a radiographically visible band of dentine be- Selective Removal
tween the carious lesion and the dental pulp.
NRCC used to be known as non-operative caries Selective removal of carious dentine used to be
treatment and prevention (NOCTP), non-restor- known as partial, incomplete, minimally inva-
ative caries treatment (NRCT), and slicing prepara- sive, or ultraconservative carious tissue remov-
129.125.19.61 - 6/5/2018 11:31:51 PM
Schwendicke F, Frencken J, Innes N (eds): Caries Excavation: Evolution of Treating Cavitated Carious Lesions.
Monogr Oral Sci. Basel, Karger, 2018, vol 27, pp 155–161 (DOI: 10.1159/000487842)
al. However, these terms all focus on the end with just a clear and unambiguous explanation of
result of the carious tissue removal process. The the definition behind it. Stepwise removal in-
new terms, selective removal to soft, leathery, volves “selective removal to soft dentine” at stage
or firm dentine, shift the focus to what is being 1, followed 6–12 months later by “selective re-
carried out rather than the aim of the proce- moval to firm dentine” for stage 2. This technique
dure. Selective removal uses different excava- was previously also known as “2-step excavation.”
tion criteria for the cavity walls (periphery of It is no longer recommended for primary teeth as
the cavity) where the aim is to have “sound” selective removal to soft dentine would normally
enamel to allow the best adhesive seal, using an be carried out and a permanent restoration
adhesive material, to be achieved. The periph- placed. The teeth have a limited lifespan and there
eral dentine should also be hard and should is no demonstrable advantage to using a stepwise
give the feel of hard dentine – a scratching approach. Stepwise removal is indicated for deep
noise if a sharp hand excavator is dragged carious lesions.
across it. For deep lesions (extending beyond
the inner, pulpal, third or quarter of the dentine
radiographically), carious tissue removal should Non-Selective Removal
be selective removal to soft dentine (the main
aim is to avoid exposure and irritation of the Non-selective removal to hard dentine was previ-
dental pulp), provided that there are no clinical ously known as “complete excavation” or “com-
symptoms of pulp inflammation present. Soft plete removal.” It is the approach to carious tissue
dentine will deform when an instrument is removal that was accepted in the past and is now
pressed onto it and little force would be re- considered overtreatment. It is no longer recom-
quired to lift it. mended and is only mentioned here for com-
For less deep lesions, selective removal should pleteness. The aim was to remove soft carious tis-
take place to leathery or firm dentine pulpally sue to reach hard dentine resembling healthy
(physically resistant to a hand excavator) in the dentine in all parts of the cavity, including pulp-
pulpal aspect of the cavity. This is likely to be nec- ally.
essary to allow adequate depth for the restorative
material bulk.
Although somewhat subjective, the tactile Conclusion
sense of dentine softness and hardness is proba-
bly the best guide that can be given as there is a It is difficult to change custom and habit as
lack of easily available or reliable diagnostic tools terms around dentistry, dental caries, and man-
for this purpose. aging carious lesions have been in place for
many decades and even a century in some cas-
es. However, by standardising the use of these
Stepwise Removal (Stepwise Carious Lesion terms across the profession, clinicians, re-
Removal) searchers, and dental educators will help im-
prove understanding and communication. This,
Stepwise removal, or stepwise carious lesion re- in turn, should help reduce some of the barriers
moval, was agreed by the ICCC group to be a we face in improving the standard of
well-known and accepted term with less variabil- care for our patients by putting new evi-
ity in its definition and understanding. As such, it dence and effective practices into day-to-day
was considered better to accept this as standard clinical use.
129.125.19.61 - 6/5/2018 11:31:51 PM
Schwendicke F, Frencken J, Innes N (eds): Caries Excavation: Evolution of Treating Cavitated Carious Lesions.
Monogr Oral Sci. Basel, Karger, 2018, vol 27, pp 155–161 (DOI: 10.1159/000487842)
References
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Nicola Innes
School of Dentistry, University of Dundee
2 Park Place
Dundee DD1 4HR (UK)
E-Mail n.p.innes@dundee.ac.uk
129.125.19.61 - 6/5/2018 11:31:51 PM
Schwendicke F, Frencken J, Innes N (eds): Caries Excavation: Evolution of Treating Cavitated Carious Lesions.
Monogr Oral Sci. Basel, Karger, 2018, vol 27, pp 155–161 (DOI: 10.1159/000487842)