I don’t know what to do. I feel like an idiot for admitting that after practicing dentistry for over 20 years. My 12-year-old patient has a large carious lesion on the occlusal of tooth 46. Should I remove all the caries and risk pulp exposure? Is it okay if I leave some caries behind? What material should I restore it with?
This constant battle in my mind finally got resolved with the American Dental Association’s (ADA) “Evidence-based Clinical Practice Guideline on Restorative Treatments for Caries Lesion.”1 Instead of being wracked with angst with every big cavity, I now refer to the Practice Guideline to help me provide the best care for my patients.
The guideline was created in 2023 by a panel of experts put together by the ADA Council of Scientific Affairs. It focuses on the best method of caries removal in moderate and advanced lesions (Table 1,2,3) as well as the most appropriate materials to directly restore these lesions on vital non-endodontically treated primary and permanent teeth (Table 4,5).
Moderate carious lesions are classified as International Caries and Detection and Assessment System (ICDAS) Codes 3 and 4. Advanced carious lesions are classified as ICDAS codes 5 and 6.2
Table 1: Approaches to Caries Removal
| Nonselective Caries Removal | This is completely removing caries until hard dentin Is reached. |
| Selective Caries Removal | This is partially removing caries until soft or firm dentin is reached. |
| Stepwise Caries Removal | This is partially removing caries until soft dentin is reached. A temporary restoration is placed and then removed months later along with caries until firm dentin is reached. |
| No Caries Removal | A final restoration is placed without removing caries. This is the Hall Crown technique for primary molars.3 |
Table 2: Caries Removal Recommendations in Primary Teeth (Vital. Requiring a Restoration. No Pulp Therapy)
| Moderate Carious Lesion | • Non-Selective Caries Removal • Selective Caries Removal • No Caries Removal (Hall Crown Technique) |
| Advanced Carious Lesion | • Selective Caries Removal • No Caries Removal (Hall Crown Technique) |
Table 3: Caries Removal Recommendations in Permanent Teeth (Vital. Requiring a Restoration. No Pulp Therapy)
| Moderate Carious Lesion | Selective Caries Removal |
| Advanced Carious Lesion | Selective Caries Removal |
Table 4: Direct Restorative Material Recommendations for Primary Teeth (Vital. Requiring a Restoration. No Pulp Therapy Moderate and Advanced Lesions)
Table 4a: Anterior Primary Teeth
| Class III | • Nanocomposite • Hybrid Resin Composite |
| Class V | • Hybrid Resin Composite • Resin-Modified Glass Lonomer Cement • Glass Ionomer Cement |
Table 4b: Posterior Primary Teeth
| Class I | • Resin Composite • Resin-Modified Glass Ionomer Cement • Glass Ionomer Cement • Preformed Crowns |
| Class II | • Resin Composite • Resin-Modified Glass Ionomer Cement • Performed Crowns |
| Class V | • Hybrid Composite Resin • Resin-Modified Glass Ionomer Cement • Glass Ionomer Cement |
Table 5: Direct Restorative Material Recommendations for Permanent Teeth
(Vital. Requiring a Restoration. No Pulp Therapy Moderate and Advanced Lesions)
Table 5a: Permanent Anterior Teeth
| Class I (lingual pit and fissure) | • Hybrid Composite Resin • Resin-Modified Glass Ionomer Cement • Glass Ionomer Cement |
| Class III | • Nanocomposite • Hybrid Resin Composite |
| Class V | • Hybrid Resin Composite • Resin-Modified Glass Ionomer Cement • Glass Ionomer Cement |
| Root Caries | • Resin-Modified Glass Ionomer Cement • Glass Ionomer Cement |
Table 5b: Permanent Posterior Teeth
| Class I | • Resin Composite • Resin-Modified Glass Ionomer Cement • Glass Ionomer Cement • Amalgam |
| Class II | • Resin Composite • Resin-Modified Glass Ionomer Cement • Amalgam |
| Class V | • Hybrid Composite Resin • Resin-Modified Glass Ionomer Cement • Glass Ionomer Cement |
| Root Caries | • Resin-Modified Glass Ionomer Cement • Glass Ionomer Cement |
Summary
I learned from the ADA report that conservative caries removal is the best option.
The expert panel found that single-appointment conservative caries removal in advanced lesions provided the best outcomes. The evidence did not show a superior way to remove caries or directly restore teeth.
All the guidelines are conditional recommendations with low or very low certainty of evidence. Conditional recommendation means that most patients would want it and that treatment should be individualized. Treatment options should be discussed with patients and include factors such as patient preference, patient factors, clinical situation, resources, and cost.
Conclusion
Remember that 12-year-old patient with large caries on the occlusal of tooth 46? After reading the report and discussing treatment options with the child and parent, I performed selective caries removal and placed a composite resin. This report did not discuss liners, silver diamine fluoride, pulp therapy and indirect restorations. I applied a glass ionomer liner before placing the composite resin for its fluoride-releasing benefits. I am confident that the best treatment was provided, and I no longer say, “I don’t know what to do!”
This article showed recommendations for removing caries and the various direct restorative options. Caries can also be treated without restorations. To learn more about that, check out the report from the ADA on Evidence-Based Clinical Practice Guidelines on Non-Restorative Treatments for Carious Lesions.
Oral Health welcomes this original article.
References
- Dhar, V., Pilcher, L., Fontana, M., Gonzalez-Cabezas, C., Keels, M. A., Mascarenhas, A. K., Nascimento, M., Platt, J., Sabino, G., Slayton, R., Tinanoff, N., Young, D., Zero, D., Pahlke, S., Urquhart, O., O’Brien, K., & Carrasco-Labra, A. (2023). Restorative treatments for caries lesions clinical practice guideline (2023). Evidence-Based Clinical Practice Guideline on Restorative Treatments for Caries Lesions | American Dental Association. https://www.ada.org/resources/research/science-and-research-institute/evidence-based-dental-research/caries-management-clinical-practice-guidelines/evidence-based-clinical-practice-guideline-on-restorative-treatments-for-caries-lesions
- Gugnani, N., Pandit, I. K., Srivastava, N., Gupta, M., & Sharma, M. (2010, April 15). International caries detection and assessment system (ICDAS): A new concept. International journal of clinical pediatric dentistry. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5030492/
- Altoukhi, D. H., & El-Housseiny, A. A. (2020, January 17). Hall technique for carious primary molars: A review of the literature. Dentistry journal. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7148518/
- Slayton, R., Urquhart, O., Araujo, M., Pilcher, L., Banfield, L., & Carrasco-Labra, A. (2018, October). Evidence-based clinical practice guideline on nonrestorative treatments … American Dental Association – Caries Management Clinical Practice Guidelines. https://jada.ada.org/article/S0002-8177(18)30469-0/fulltext
About the Author
Dr. Sanjukta Mohanta is a general dentist who graduated from the University of Toronto in 1999. She practices in Brampton, Ontario. She can be reached by email: sanjuktamohanta@hotmail.com
