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Minimally invasive dentistry CLINICAL

Minimally invasive selective caries removal:

a clinical guide
Zi En Lim,1 Henry F. Duncan,2 Advan Moorthy3 and David McReynolds*4

Key points
The non-selective caries excavation Selective caries excavation disrupts Development of the peripheral seal Bonding protocols are very
technique, involving complete the carious biofilm ecology while zone is critical in order to create a technique-sensitive and
removal of caries-affected dentine, simultaneously minimising over- hermetic seal when methacrylate necessitate a meticulous approach
is considered overtreatment, being preparation of tooth structure and resin-based composites are used to to their execution to ensure
needlessly invasive and outdated. injury to the dentine-pulp complex. restore teeth. optimal bond strengths are
achieved.

Abstract
An evolving understanding of the carious process, along with new research in adhesive restorative materials, has led
to a more conservative, minimally invasive and biologically-based approach to managing dental carious lesions. The
growing volume of literature has also demonstrated prognostic success in the selective caries excavation technique,
subsequently preventing excessive tooth structure removal and injury to the dentine-pulp complex, which maintains
pulp vitality and improves the long-term prognosis of the tooth. However, at present, there remains a limited volume
of high-quality evidence to support selective caries removal, which subsequently could partly explain some resistance
to its use in clinical practice. This clinical technique guide aims to demonstrate the management of carious lesions of
moderate-to-deep depth in permanent teeth based on current minimally invasive dental literature.

Introduction to create cavity retention and resistance form. to selective caries removal, this clinical
We now know that the removal of so-called technique guide aims to visually document
In contemporary dental practice, a clearer caries-affected dentine is not mandated in the procedural steps and to justify its rationale
understanding of the carious process and the treatment of the carious lesion, while when restoring moderate-to-deep depth
an increased volume of clinical evidence developments in adhesive bioactive/bio- carious lesions with direct methacrylate resin
in operative dentistry has informed the interactive restorative materials and an composite restorations in clinical practice.
profession’s approach to the management awareness of the remineralisation potential
of carious lesions. The traditional G. V. of dentine has led to a decreased reliance The advantages of selective caries
Black’s cavity designs from the twentieth in Black’s cavity designs to directly restore removal
century adopted an ‘extension for prevention’ teeth.2,3 Furthermore, the Minamata Treaty
approach that involved the surgical removal of has advised the phasing-down of amalgam Minimally invasive dentistry encompasses
both demineralised carious infected dentine restorations due to environmental concerns conservative operative techniques that preserve
and any tooth structure which had been over mercury levels. 4 Thus, a paradigm hard and soft tissues when managing cavitated
affected by the carious process.1 However, shift based on a research-led approach has carious lesions.6 Decades ago, non-selective
this cavity design was traditionally intended resulted in the adoption of minimally invasive caries removal had been the recommended
for dental amalgam restorations, where dentistry in managing carious lesions. Despite treatment modality, which encompasses
further tooth structure removal is required these advances in our understanding, there removal of all carious tooth structure to sound
remains confusion, debate and resistance enamel and dentine. However, carious lesions
1
General Dental Practitioner, Dublin, Ireland; 2Professor/ to change when translating these ideas can and should be managed conservatively first
Consultant in Endodontics, Trinity College Dublin, Ireland;
into clinical practice. This is partly caused and foremost by controlling those aetiological
3
Prosthodontist, Private Practice, Ireland; 4Academic
Prosthodontist and Assistant Professor in Restorative by the lack of high-quality, definitive factors of the carious process. Such strategies
Dentistry, Dublin Dental University Hospital, Ireland. scientific evidence behind this technique, include diet modification, biofilm disruption
*Correspondence to: David McReynolds
Email address: david.mcreynolds@dental.tcd.ie particularly in the permanent dentition, and hermetically sealing cariogenic biofilm
Refereed Paper.
since most studies are obtained from trials from its nutrient supply.7,8,9 Therefore, from
Submitted 13 June 2022 on the primary dentition.5 For this reason, the an operative perspective, selectively excavating
Revised 23 October 2022 SCRiPT trial is currently being undertaken to carious tissue can be effective without having
Accepted 7 November 2022 clarify confusion around this subject.5 Using to completely eradicate the entire bacterial
https://doi.org/10.1038/s41415-023-5515-4
the currently available literature pertaining population.

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 CLINICAL Minimally invasive dentistry

Fig. 1 a, b, c, d) The pre-operative presentation of the 26 illustrates an ICDAS II code 06 carious lesion, with an ICDAS/ICCMS radiographic code
RB4. This carious lesion can be described as a moderately deep cavitated carious lesion. This type of presentation is a very common occurrence
in routine general dental practice

In the short-term, the non-selective caries with which one can consequently achieve The radiographic findings of the carious lesion
excavation approach involves unnecessary over- high bond strengths and a hermetic seal when were consistent with the clinical diagnosis. The
preparation of tooth structure with resultant methacrylate resin-based adhesives are used.12 radiolucency attributed to the carious lesion
damage to the dentine-pulp complex.8 In the extends to the middle third of the dentine
long-term, the unnecessary excessive removal Clinical technique (Figures 1b and 1c) giving it an International
of healthy tooth structure tends to compromise Caries Classification and Management System
the mechanical integrity of the tooth, making it The patient was a 37-year-old man in [ICCMS]/ICDAS radiographic score of RB4.14
more prone to potentially catastrophic ‘cracks’, good health. The patient presented with Therefore, the carious lesion can be described
fractures and their associated sequalae.10,11 an asymptomatic cavity, which he noticed as a moderately deep cavitated carious lesion.2
Particularly in the deeper cavity, excessive developed spontaneously when chewing
removal of tooth structure would tend to food, days before presentation. The patient Initial treatment
increase the risk of a pulpal exposure, resulting in was most likely asymptomatic due to the
irreversible damage to the odontoblastic palisade dynamic reparative response of the dentine- The patient also presented with Stage III
and death of primary odontoblasts.8,9 Selective pulp complex, thus blocking the early stage Grade C periodontal disease which was
caries removal, on the other hand, arrests carious of bacterial invasion through the dentinal exacerbated by root shortening (Fig. 1d). As
lesion activity while simultaneously reducing tubules towards the pulp. Intraoral examination such, the patient has concurrently undergone
the risk of pulpal exposure and preserving the revealed a partially dentate patient who was four quadrants of non-surgical root surface
odontoblastic palisade; a crucial area that induces missing all first permanent pre-molars, most debridement in the context of interdisciplinary
the more ordered deposition of reactionary likely due to a history of orthodontic treatment. care with a periodontist.
rather than reparative tertiary dentinogenesis.8,9,10 An extensive, distinct cavity with visible dentine Selective caries excavation would be
It also reduces risk of bacterial ingress into the was noted clinically on the mesial and occlusal conducted on the 26 in order to halt the
pulp, thereby maintaining pulp vitality. This surfaces of the 26 (Fig. 1a) and it did not appear carious process and prevent potential carious
maximises the prognosis of the tooth and should to be previously restored (International Caries progression towards the pulpal tissues. A
reduce long-term management costs and burden Detection and Assessment System [ICDAS] II direct methacrylate resin-based composite
associated with teeth.2,10,11 code 06).13 The dentine appeared glossy and felt restoration was the restorative material
Although dentine bonding to so-called caries- soft on gentle probing, which is suggestive of of choice. However, in the long-term, an
infected or caries-affected dentine is weaker, active carious progression. The tooth displayed assessment for cuspal coverage restoration
this is thought to be clinically insignificant physiological mobility, was not tender to for the 26 may be considered, providing
as the appropriately prepared cavity should percussion and had a non-lingering response periodontal and carious process stabilisation
be surrounded by sound enamel and dentine to cold and electrical pulpal sensibility testing. has been achieved.

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 Minimally invasive dentistry CLINICAL

Selective caries removal

When placing a direct methacrylate resin-based

composite restoration, moisture control and a
strict asepsis protocol is essential, particularly
as blood, saliva and gingival crevicular fluid will
affect the adhesion of the restorative material,
thereby increasing the chance of microleakage.11
After buccal and palatal infiltration with 2%
lidocaine 1:80,000 adrenaline, rubber dam
isolation was used in order to separate the
operative field from the oral fluids, and to Fig. 2 Note shadowing of underlying carious lesion occlusally around the fissure. Rubber
improve visual and mechanical access (Fig. 2). dam isolation is an essential aspect of treatment, which becomes particularly salient when
restoring teeth with moisture-sensitive restorative materials such as methacrylate resin-based
The 27, 26 and 25 were isolated with a W14
composites. A strict asepsis protocol optimises treatment outcomes in vital pulp therapy, even
clamp (Ivory, Kulzer, Helsingborg, Sweden)
when the pulp is not directly exposed
secured on tooth 27.
The 2019 European Society of Endodontics
(ESE) position statement defines two selective
caries excavation endpoints: selective caries to
soft dentine or to firm dentine.15 The decision
of an appropriate caries excavation endpoint is
determined by the depth of the carious lesion.
In moderately deep carious lesions, selective
removal of carious tissue to firm dentine is
recommended.2 This means that the dentine
situated on the pulpal wall should be leathery,
while cavity margins and peripheral dentine
should be caries-free and prepared to sound
Fig. 3 Access form is developed through the removal of carious enamel using a diamond fissure
hard dentine.2 Leathery dentine is described
bur in a turbine handpiece under copious water coolant
clinically as dentine that doesn’t deform when
an instrument is pressed onto it and has a slight
‘tackiness’.2,12 With hard dentine, a pushing force recalls evaluating outcomes of the stepwise Enamel undermined and demineralised
needs to be used to engage the dentine and a technique. 15 The inability to adequately by the carious process was removed using a
scratchy sound, known as ‘cri dentinaire’, can compare success outcomes between the two diamond fissure bur (Kerr, Bioggio, Switzerland)
be heard.2,12,16 techniques has therefore incited controversy in a turbine dental handpiece (W&H, Bürmoos,
There are also two available selective within the dental profession. In this case Austria) under copious water coolant to develop
caries excavation methods which have been example, the one-step caries excavation access form, thereby revealing the extent
recommended by the ESE: the one-stage or technique was employed, thereby avoiding of the underlying carious dentine (Fig.  3).
two-stage stepwise technique.15 The one-stage the need of a later appointment for re-entry Subsequently, clearing of the peripheral
approach to caries excavation appears to have into the tooth and subsequent risk of further amelodentinal junction was conducted using a
a more favourable long-term success compared iatrogenic tooth structure loss upon removal large steel rosehead bur (Prima Dental Group,
with the two-step method.17 However, there is of a temporary restoration, which would have Gloucester, England) at slow speed under
currently insufficient evidence to definitively otherwise been necessitated with the step-wise copious water coolant (Figures 4a, 4b and 4c).
advocate its superiority due to the lack of technique. The periphery of the carious lesion should be

Fig. 4 a, b, c) Initial clearing of the amelodentinal junction using the largest steel rosehead bur that can fit within the carious cavity. The
preparation is carried out using a conventional handpiece under copious water coolant. Note that at this stage, the carious tooth structure is
cleared from its periphery whilst the pulpal wall remains unprepared

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 CLINICAL Minimally invasive dentistry

Fig. 5 a, b, c) Definitive clearing of the amelodentinal junction to sound high-quality enamel and dentine margins. The pulpal wall remains
unprepared at this stage. Note, evidence of an underlying crack within the tooth, running from mesial to distal, begins to become apparent. This
is a typical finding in long-standing carious lesions, secondary to a loss of structural integrity

cleared to sound dentine using a sequence of

sterile rosehead burs from largest to smallest.
The largest rosehead bur that can fit within a
cavity is recommended initially to clear soft
dentine, as this drill sequence prevents gouging
into the dentine and resultant iatrogenic tooth
structure removal. To permit the insertion of a
matrix band, the mesial proximal contact was
broken (Figures 5a, 5b and 5c). Unsupported
enamel was also removed as it is prone to fracture
under functional loading once restored.11 The
function of creating a periphery of sound hard
dentine, amelodentinal junction and sound Fig. 6 In the final steps of tooth preparation, caries that lies over the pulpal wall is excavated
by hand, with the final endpoint of caries excavation being determined by tactile sensation
enamel is to create a peripheral seal when the
rather than by the colour of the so-called caries-affected dentine
adhesive restoration is placed. The creation of
the peripheral seal zone enables the adhesive
bond to be preserved for the long-term.18 In excavation, a ‘crack’ running from mesial to a fifth-generation bonding system was used: a
such circumstances, dentine bonding should distal on the 26 was noted at the base of the cavity two-step etch-and-rinse system.
be similar to that carried out in the healthy (Figures 5b, 5c, 6 and 8b). The implications of An anatomical V-ring sectional matrix system
tooth. Thus, if the tensile strength of a resin this will be discussed under the heading ‘Long- (Palodent V3, Dentsply Sirona, North Carolina,
bond to the amelodentine junction is 51.5 MPa, term prognosis’. USA) was placed on the tooth and a wedge was
bonding to dentine should mimic this value.18 Although it is recommended to place a placed in between the 25 and 26 to ensure its tight
Bonding to the peripheral seal zone generates a hydraulic calcium silicate or a conventional glass adaptation to the 26 (Figures 7a and 7b). The
bond strength of 45–55 MPa according to the ionomer cement on the dentine barrier before pre-curved V-ring sectional matrices have been
literature.18 Enamel bevelling was not conducted placing a definitive restoration, no underlying shown to be advantageous over circumferential
in this clinical technique. Enamel bevelling is layer of pulp protection materials were matrix systems in providing properly contoured
generally not recommended in posterior teeth placed in this case example as it still remains proximal contacts, which will thereby render the
since bevelled margins are more difficult to elusive whether the presence of an underlying marginal ridge less susceptible to chipping and
detect and the resin composite layer is more substrate will compromise the strength and fracture.4,23 Moreover, it will recreate embrasure
prone to marginal staining and paramarginal longevity of the overlying methacrylate resin- anatomy and ‘tight’ contacts that will facilitate
fractures under long-term occlusal loading.19,20 based composite restoration.15,21 The literature biofilm removal proximally and reduce food
Hand excavation was conducted to remove also provides no evidence supporting any impaction respectively.11
carious tissue on the pulpal walls (Fig.  6). auxiliary clinical benefit in placing indirect
The final endpoint of excavation of carious pulp protection to avoid post-operative Bonding protocol
tissue should be determined by the texture of sensitivity.2,4,22 In this case, since the carious
the lesion, rather than the colour.11 Removing lesion was moderate to deep and not deep or Enamel was etched with 37% orthophosphoric
carious tissue using hand excavation enables extremely deep, a decision was made that a liner acid for 30 seconds first, followed by etching
the operator to have tactile sensation. Using was not essential, as the probability of a micro- of dentine for 15  seconds. The surface of
rotary instruments considerably reduces tactile exposure was low. unetched enamel is smooth and has little
feedback during selective excavation and can One of the ‘golden triangles’ of minimally potential for bonding by micro-mechanical
risk iatrogenic removal of excessive tooth invasive dentistry is the understanding of retention. Acid etching enamel modifies
structure at this key site. In this particular the chemistry and handling of adhesive the surface of enamel by demineralisation
case, following completion of selective caries materials used to restore a cavity.6 In this case, of the hydroxyapatite crystal, creating

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 Minimally invasive dentistry CLINICAL

micro-porosities that enable adhesive resins

to flow by capillary action forces into them,
allowing for micro-mechanical retention of
the methacylate resin-based composite. Acid
etching of dentine causes demineralisation
of intertubular and peritubular dentine.24
Etching enamel for a longer duration than
dentine enables sufficient surface roughness
to be created in order to yield increased bond
strength when the resin adhesive is applied
Fig. 7 a, b) The use of and correct positioning of an anatomical matrix system offers many
on the surface.8,25,26 The frosted appearance
benefits for contemporary adhesive restorative materials. The superior contouring of proximal
of enamel after etching allows the clinician contacts that can be achieved with such systems creates more structural integrity in the
to visualise the extent and efficacy of the etch resultant restoration and also prevents food impaction
(Figures 8a and 8b).27 The total etch technique
on dentine removes the smear layer, thereby
exposing the dentinal tubules.8,24 Bonding to
dentine similarly utilises a micromechanical
bond. This mechanical bond originates
from the network of interlocking monomers
with the collagen fibrils and the formation
of resin tags from the adhesive diffusing
into the demineralised enamel and dentine
structure.8,24 The combination of primer and
adhesive essentially creates a critical ‘hybrid
Fig. 8 a, b) The total-etch technique recognises that enamel and dentine are fundamentally
layer’ on the collagen matrix which forms the
two different substrates which benefit from a nuanced approach to their bonding. The
foundation to a successful adhesive bonding inclusion of air bubbles demonstrates that the etch has been agitated on the tooth surface
of overlying composite resin. Over-etching
dentine longer than the recommended time
will result in decreased longevity of dentine
bond strength, as the adhesive may not be able
to infiltrate the demineralised collagen matrix
in order to create this hybrid layer.28,29
After application of the acid etch and thorough
rinsing with water, the next step consists of
applying the primer and adhesive. In fifth-
generation dentine bonding systems, these two
immiscible liquids are both contained within
one bottle. It is important that the bottle is well-
shaken before use to ensure adequate primer
and adhesive dispersion. The bonding agent Fig. 9 Methacrylate resin-based composite is incrementally cured in three layers of maximum 2 mm
thickness. Such a placement strategy ensures complete light polymerisation of the restorative
should not be applied to desiccated dentine as
material whilst controlling for stresses which develop at the resin-tooth structure interface
some moisture maintains the spaces between the
collagen fibrils, thereby preventing the collapse
of the collagen fibril network and encouraging into the moist dentine collagen matrix, it is lead to inadequate adaptation of composite to
hydrophilic resin primer infiltration into the important to evaporate the solvent (acetone) the cavity, microcrack propagation and loss of
dentinal tubules.24,30 A doubled-layer application with dry, uncontaminated compressed air before marginal seal, with associated post-operative
of the bonding agent on dentine was used, as this light curing.24 This essential step facilitates the sensitivity and microleakage.33 Therefore,
technique has been shown to provide a higher polymerisation reaction of the resin adhesive and consideration of the C-factor is important when
bond strength and durability.31 The first layer prevents a porous structure of the cured adhesive restoring a cavity. C-factor is the ratio between
will not have the right ratio applied on the cavity within the adhesive-dentine interface.32 Primer a bonded and unbonded surface.33 Higher
preparation but will improve ‘wettability’ for the and adhesive was light cured for 40 seconds, with C-factor leads to an increased risk of debonding
subsequent layer of resin adhesive. the light curing unit placed as close to the resin at the resin-dentine interface, with resultant
Evaporation of the solvent in the bonding composite as possible. microleakage.33,34,35 This cavity was filled with
agent is a necessary step before curing. When methacrylate resin-based composite three horizontal increments in order to reduce
Although the solvent is an important carrying is cured, polymerisation shrinkage occurs and the C-factor and achieve adequate bond to the
medium incorporated in the formulation of imparts residual stresses on the tooth. According cavity floor (Fig. 9).35 The final restoration was
the bonding agent to allow infiltration of resin to the literature, residual shrinkage stresses can polished using intensive finishing diamond burs

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 CLINICAL Minimally invasive dentistry

Fig. 10 a, b, c) Prior to removal of the rubber dam, the restoration is shaped and polished with intensive finishing diamonds and interproximal
finishing strips. The restoration must conform to the existing occlusal scheme, which should be confirmed with articulating paper following
removal of the rubber dam

(Meisinger, Neuss, Germany) and proximal areas

were polished with interproximal strips (3M,
Minnesota, USA) to remove resin flash (Fig. 10).
Optimum occlusal relationship was confirmed
using articulating paper.
With advances in resin composite
technology, bulk-fill flowable composites have
become readily available which has thereby
led to alternative incremental restorative
techniques. The rationale behind the bulk-
fill incremental technique aims to restore
the majority of the cavity with a less-viscous
methacrylate resin-based composite of 4 mm
in thickness, followed by a 2  mm capping
of high-viscosity methacrylate resin-based
composite. This technique aims to reduce resin
composite placement time, making it more
time-efficient compared with the conventional
oblique incremental technique. Moreover, the
4 mm bulk-fill technique with flowable resin Fig. 11 a, b, c, d) At 12-month post-operative review, the restorative margins should be
composite has been demonstrated to have examined and be clinically intact. Pulpal sensibility should be confirmed with electrical and
cold testing whilst percussive sensitivity should be excluded. An updated intraoral periapical
comparable polymerisation shrinkage stress
radiograph or bitewing radiograph may be made to permit future restorative planning for the
and clinical effectiveness compared to the tooth or teeth in question
conventional layering technique.36,37,38 However,
the polymerisation shrinkage of bulk-fill resin
composites is dependent on several factors, incidence of secondary caries of glass ionomers Selectively excavating caries and leaving some
such as filler content, polymerisation kinetics remain questionable.42,43 Glass ionomers have carious tissue behind beneath a restoration
and degree of conversion.36 In addition to the also yet to be advocated for posterior dentitions poses a potential dento-legal concern. The
insufficient clinical data available regarding due to their inferior tensile strength in load- rationale behind the technique should
the shrinkage behaviour of these composite bearing sites.42,44 Despite attempts to reinforce therefore be communicated to the patient
types, their behaviour and formulation the glass ionomer matrix with the addition with an emphasis on recall to confirm pulpal
characteristics will differ among the various of filler types, these strategies are still unable health of the tooth over time.15 In this case,
product manufacturers.36,39,40 to produce mechanical properties similar to the 26 tooth was re-assessed at 12  months
Glass ionomer cements were first resin-based composites.45 (Fig.  11). Assessment involves visual and
developed in the 1960s but continue to be tactile clinical examination, percussion
used as restorative materials to this day. Their Long-term prognosis testing, cold and electrical pulpal sensibility
adhesion to tooth structure coupled with testing and intraoral radiography. Pulpal
their supposedly cariostatic properties due When managing deep carious lesions, vitality and apical health was maintained in
to fluoride release continues to make glass review of the final restoration is part of this case example.
ionomer cements relevant in clinical practice, holistic patient care to eliminate the failure As highlighted previously, in this particular
particularly when restoring primary teeth of the tooth-restorative complex. Clinicians case example, a mesial-distal ‘crack’ was
via the atraumatic restorative technique.41 should examine surface irregularities and the detected clinically at the base of the 26 cavity
However, the evidence behind the fluoride marginal integrity of the restoration, ensuring preparation. This is likely due to a reduction in
releasing capabilities and ability to reduce the it does not become a plaque stagnation area.8,46 structural integrity of this tooth, subsequent

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 Minimally invasive dentistry CLINICAL

to the loss of its mesial and oblique marginal Acknowledgements in adhesive dentistry. Quintessence Int 2012; 43:
197–208.
ridges caused by the unchecked progression The authors thank specialist periodontist, Dr Peter 19. Frankenberger R, Dudek M-C, Krämer N, Winter J,
of the proximal carious lesion, resulting in an Harrison of Dublin Dental University Hospital, for Roggendorf M J. The 10 most popular mistakes in
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Seemann R. One-year clinical results of restorations
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