Contemporary concepts in carious tissue removal: A review.

OBJECTIVES: Based on a changed understanding of the disease caries and its pathogenesis, strategies for carious tissue removal have changed, too. This review aims to summarize these changes and to provide clinical recommendations. OVERVIEW: Removing all carious dentin from a cavity is not needed any longer to manage caries or the carious lesion. Instead, the carious lesion should be treated in a way allowing to arrest its activity, while preserving sound tooth tissue and pulp vitality. For teeth with vital pulps, a number of removal strategies have been developed: (1) Nonselective (complete) removal, which is not recommended any longer, (2) Selective removal to firm dentin, where firm dentin is left centrally and hard dentin peripherally, allowing the placement of a long-lasting restoration while avoiding the removal of remineralizable tissue; this is recommended for shallow or moderately deep lesions; (3) Selective removal to soft dentin, where soft or leathery dentin is left in proximity to the pulp and sealed beneath a restoration; this is recommended for deep lesions; (4) Stepwise removal; which combines different strategies and is also suitable for deep lesions, at least in adult patients. Alternatives include not removing but sealing the lesions using resins (for shallow, noncavitated lesions) or stainless steel crowns (the Hall Technique, for cavitated lesions in primary molars), or opening up the lesion and regularly cleaning it (nonrestorative cavity control, currently not supported by sufficient evidence). CLINICAL SIGNIFICANCE: Dentists should tailor their carious tissue removal strategy according to tooth type and, more importantly, lesion depth.