Current Thinking on Caries Removal
Restorative recommendations for carious lesions are an evolving science and integral to managing caries (tooth decay). As research improves our understanding of the pathogenesis of carious lesions, more conservative treatment protocols have evolved. Also, advances in restorative materials impacts treatment recommendations. Recently, the American Dental Association (ADA) Council on Scientific Affairs and the ADA Science and Research Institute’s program for Clinical and Translational Research conducted a systematic review and developed recommendations for the treatment of moderate and advanced cavitated carious lesions in patients with vital, non-endodontically treated primary and permanent teeth.
Traditionally, most dental schools teach complete caries removal until sound dentin is achieved to stop the propagation of the carious lesion. This can result in significant tooth structure loss. There has been a move toward more conservative (incomplete) caries removal to preserve natural tooth structure. There are four considerations: non-selective caries removal (complete caries removal to sound dentin), selective caries removal (carious tissue being removed until soft or firm dentin is reached, aka incomplete caries removal), two-step caries removal (carious tissue being first removed until soft dentin is reached, temporarization, then the remaining carious tissue is removed until firm dentin is reached, and finally no carious tissue removal for lesions in which a preformed metal crown is indicated. All were shown to have indications.
In most clinical scenarios, the evidence did not show important differences between carious tissue removal (CTR) approaches and direct restorative materials to suggest if one treatment option is superior to another. One key finding for advanced lesions was that more conservative CTR approaches were associated with fewer clinical failures. The panel urges clinicians to use more conservative CTR approaches that align with restorative dentistry’s two main aims: preserving healthy tooth structure and protecting the pulp-dentin complex.
This trend in conservative management is facilitated by advances in restorative materials. For conservative restorations, amalgam, resin composite, compomer, conventional glass ionomer cement, resin-modified glass ionomer cement and preformed metal crowns are used to restore moderate to advanced carious lesions. A systematic review by the ADA Science & Research Institute found a lack of clinically important differences among direct restorative materials. It was noted that the studies reviewed were of small sample size and all recommendations were considered very low certainty and conditional. The need for larger studies was acknowledged.
It was interesting to note that the authors supported the use of factors other than the science when managing carious lesions. Costs, patients' values and preferences, and patient acceptability should be considered. The decisions involved in restoring teeth are complex and based on the balance of many factors. The latest evidence-based guidelines by the ADA supports the trends towards more conservative management of carious lesions.