Very Interesting question ... but difficult to give a clear answer!

I wonder if it would be better to ask : " Should caries be left or removed?"

In this case I would definitively say that it's better to leave some in the deepest areas, clean as good as possible the cavity-margins and place a protective base over the affected dentin in order to protect the pulp-vitality and eventually stimulate the remineralisation .

Should caries be sealed ...??? This is the tricky question !!

How long will it stay sealed ? ...and after ? What type of restorative material can offer a long-lasting antibacterial protection ? Among the adhesive Resins / GIC or other modified materials commonly used ...None!

The dilemma is real, so far, in my opinion, the ZOP-base as IPC or ITR offers the best antibacterial protection, strong mechanical performances if rapidly covered by some resin to seal the cement surface and the clean margins but not the decayed dentin. Hope it helps to further debate and opening some frames in dentist's minds.

Best regards

Nicola

White spot lesions are candidate for sealing. Deep fissure caries with soften base need to be restored. Teeth not recommended for sealing are:

Coalesced pits and fissures and easily cleaned grooves. Teeth that remained caries free for 4 years or longer. Many proximal lesions.

Best wishes

there is moderate evidence that covering the caries with SSC is effective in treatment of non pulp involved primary molars, the procedure currently known as Hall tech.

Hallo,

I would like to bring a recent consensus paper to your attention, which addresses the topic of the question in full detail:

Managing Carious Lesions

Consensus Recommendations on Carious Tissue Removal

F. Schwendicke, J.E. Frencken, L. Bjørndal, ...

Volume: 28 issue: 2, page(s): 58-67

Article first published online: April 20, 2016; Issue published: May 1, 2016

https://doi.org/10.1177/0022034516639271

Maybe it is a good idea to rely more on peer-reviewed publications than on "views".

Depends upon the clinical situation, most of the infected dentin has to be removed to preserve the affected dentin

this depend on the depth and severity of the lesion

There is a new excellent Article ( DOI below) , resuming the topic and the indications guidelines in order to select an individualized care procedure.

• 10.2341/18-076-L

when the tooth is asymptomatic it can be sealed permanently , since this method change the ecology of the bacteria and reduce thier acounts by partial caries removal. and that make the infected dentine harder. this considered in deep carious lesion treatment.

the ART by using fissure sealants has similar idea by sealing the caries but carriy less longevity of restoration and also less success rate.

Caries must be removed, if it is extended beyond the superficial layer of enamel where remineralization become impossible, because sealing of caries may result in progress of caries deeply within tooth layers as cariogenic bacteria can take nutrients from underlying dentin that nourished from the pulp

Depends on carious activity. the active caries require to be deactivated, decontaminated, and a good oral hygiene. otherwise you must face a necrotic pulp and periapical abses formation after sealing a deep dentin decay. I mean the soft ones that there is no sign of tertiary dentine. So, you choose which way to deactivate a carious lesion. then you are free to seal or excavate the decay which are all benefits for a patient.

Gulsha, your reply makes sense.

Asaad Javaid Mirza thank you

The challenge is how do we keep the pulp healthy. If we excavate to far, and expose the pulp we often condemn the tooth to endodontics. If we remove the bulk of the infected decay and then covered the remaining material with something like a calcium silicate, would there not be the opportunity for the pulp to naturally heal? I think it does, especially if we seal the periphery well.

Dr Comisi

You are right but my point is removing the infected caries or not? I am of the opinion that peripheral caries should be removed leaving no traces while the rest of caries deactivated through use of chemotherapeutic agent and dietary changes and then sealing the rest of caries with GIC and subsequent definitive restoration.This way, we don't endanger the pulp even in deep lesions. What do you say?

I would agree. The walls of the preparation must be clean and free of caries and demineralized structure priohr to restoring. Otherwise, catastrophic failure will occur.

you mean cleaning of walls and whole of the demineralized structure? If so, then what is new?

We can leave the infected dentine if we can isolate it from oral environment and starve the microorganisms by good seal and efficient filling material

Zainab

What do you think about sealing the caries with glass ionomer? I think it seals very efficiently.

In my experience I found that it depends on the patient hygiene and care

@Asaad Javaid

It has a good seal if it is covered by SSC

Yes, Steel crown gives perfect protection but I think intracoronal restoration with composite or amalgam may also wok efficiently

So am I

First of all I would like to draw your attention to the following review article. It is one of many that have appeared recently. But it is very well-balanced and formulated with practical relevance.

https://www.springer.com/cda/content/document/cda_downloaddocument/9783319613697-c1.pdf?SGWID=0-0-45-1628825-p180926246

In addition I would like to add:

In connection with caries excavation, one must not only consider how much tooth substance should be removed (infected tissue, demineralized tissue, selective caries excavation, etc.), but also how the cavity is subsequently treated.

The preparation recommendations of Black (excavation to healthy dentin) apply above all if no bacteria-proof filling is available. The preparation recommendations for selective caries excavation only apply if bacteria-proof fillings can be fabricated. Composite fillings that are fabricated with modern dentin adhesives and with correct processing in mind are considered "bacteria-proof".

The dependence on the restoration can easily be explained by the primary factors of caries ethiology: Substrate, microorganisms, tooth and time.

With amalgam fillings, the substrate cannot be kept away from the microorganisms, since amalgam does not adhere adhesively to the tooth and therefore there is always a percolation gap. In this case, the primary factor "microorganisms" must be largely removed. However, it is not possible to remove all bacteria by excavation, as they can be detected in the dentin tubuli far into healthy dentin.

With composite fillings, the primary factor "substrate" can be kept away from microorganisms, since the bond to the tooth is considered to be bacteria-proof. For this reason, however, it is also required that the cavity margins must be localized in healthy dentin and enamel during selective caries removal. Mertz-Fairhurst has impressively demonstrated in her studies that this principle works in the sense of a proof-of-concept.

(Translated at least in part with www.DeepL.com/Translator)

Sincerely

Karl-Heinz Kunzelmann

I wonder if we can rely on modern dentin adhesives .... with ( but often without..!!) correct processing ?! I believe that are ultimately not to be considered "bacteria-proof".

Moreover composite showed to be an appreciated substrate for biofilms growth...!!

Amalgam does not adhere adhesively to the tooth, right ... but is antibacterial and showed to perform better against secondary caries !!

So I agree about : " selective caries excavation only apply if bacteria-proof fillings can be fabricated.

Thus some kind of antibacterial long-term effective barrier should be considered !

Regards

Nicola

We were one of the first German universities to use dentin adhesives in our student courses as early as 1992, which means that beginners were already using adhesives in their first restoration.

In addition, we have accompanied the development of dentin adhesives with our own research.

I can say (eminence-based): We would have had many problems if the dentin adhesives had not already worked well enough in 1992. We used Syntac then (now Syntac Classic) and still use it for indirect restorations.

For more than 30 years I have been following the adhesive restorations of my own patients.

Over the last three decades, dentin adhesives have greatly improved.

We have observed that

- the early Syntac, Optibond FL and and even Clearfil SE dentin adhesives were already clinically very successful

- the current dentin adhesives are now even better.

Our own in vitro data on marginal quality, which were tested under harsh conditions, show that more than 95% (usually more than 98%) of the filling margin of a restoration is free of defects after fatigue loading and thermocycling.

My own oldest clinical restorations, which were carried out according to the concept of selective caries excavations, are now more than 20 years old and are still in use with vital pulps.

I therefore draw the following conclusions:

Considering the prerequisites for selective caries removal, symptom-free teeth and margins in healthy dentin/enamel, there is no risk for our patients if we follow the principles of selective restoration. In my opinion, this way we get much more pulps vital than with any conventional approach.

My current most popular approach to selective caries removal is using a polymer drill: Pulybur/Brasseler or Smartbur II/SS White Burs. But there are other, even more conservative approaches. All in all, we can rely on dentin adhesives today!

Translated with www.DeepL.com/Translator

Dear Karl-Heinz Kunzelmann , congratulations for the great results you observed in your cases, nevertheless it seems that some concerns about dentin-bonding still remains .... As pointed out from this recent review article :

Modifying Adhesive Materials to Improve the Longevity of Resinous Restorations

February 2019 International Journal of Molecular Sciences 20(3):723

DOI: 10.3390/ijms20030723

stating : "However, multiple factors, such as microleakage and recurrent caries, impair the durability of resinous restorations" ...!

Further there is a detailed list of all the different factors possibly implicated impairing dentinal adhesion.

I agree that selective excavation is a good option and that adhesive restorations may works very well if enough sound enamel is remaining and also if the defect's volume to restore is not to large, deep or includes missing cusps .

Regards

Nicola

Hello Nicola,

I do not want to spend a lot of time with this article.

I just want to comment on the second sentence:

"However, longevity of resinous restorations is not satisfactory. The failure rate ranges from 15% to 50% according to previous survival investigations [3,4]."

Now let's look into the very few cited references: 3 and 4

4 is from 2006. The observation time is 17 years. The restorations were made in 1987 and 1988 (in a private practice!). "Dentine walls were covered with glass ionomer cement,..." - nice adhesion by the way.

You can further read in 4 "The main failure cause was repair–fracture of restoration (42.9%), and this failure occurred in most of restorations at the occusal surface."

So: adhesion does not seem to be a major issue, even with dentin isolation from adhesion with glassionomer and the earliest available materials for posterior use.

A quick view into reference 3 reveals the following conclusion of the authors:

"In the high-risk group, composite and amalgam restorations showed comparable performance, with amalgam performing better on smaller restorations. For the combined risk groups and the low-risk group, composite restorations showed better survival at 12 yrs."

What else do you want?

Shall I continue to analyse the article sentence by sentence? Or can draw your own conclusions about the care with which the data for the article have been researched?

Sincerely

Karl-Heinz

Dear Karl-Heinz , it is not much about the care with which the data for the article have been researched that may deserves our focus , nor statistical numbers that are too often far away from delivering sound evidence...

If there would be no issue about bonding to dentine, How can you explain the extensive research targetting the topic...?

Moreover mainly dedicated to improve adhesive performances and dentinal interface stability ... ?

Even in the more recent articles of opinion leaders the question remain of great concern:

Dentin Bonding: Can We Make it Last? L Tjäderhane

"Clinical RelevanceBond strength to dentin decreases with time because of the hydrolytic degradation of the hybrid layer components dentin collagen and adhesive resin. Inhibition of enzymes responsible for the collagen degradation may improve the bond strength durability."

or Current aspects on bonding effectiveness and stability in adhesive dentistry

MV Cardoso,* A de Almeida Neves,* A Mine,* E Coutinho,* K Van Landuyt,* J De Munck,*B Van Meerbeek* >> stating :

" Although these restorations tend to fulfil the main requirements of a more conservative and aesthetic treatment, their clinical longevity is still a topical issue, mainly due to the degradation of the adhesive interface over time."

Finally I do have my own opinion, as you have yours and both may be contributing to give some kind of an answer to the difficult question .

Regards

Nicola

Sealing caries can often be an acceptable solution depending on caries extension

Riad,

Thnx for your input. How much extended a carious lesion should be when it can be acceptably sealed?

I prefer to excavate soft caries as much as possible and the following restoration or pulp capping depending upon the extent and depth. If the teeth are symptomatic post this then follows the endodontic procedures.

thanks

Amina

Amina

Thank you for your response. But how can you differentiate between "soft" and "hard" dentin. Something which is soft for a male, may be hard for a female as these are relative terms. Isn't it?

There has been many iatrogenic (traumatic) pulp exposures due to the complete caries removal and reaching a hard dentin (depending on tactile and visual aids).

But some of the soft dentin is well organized and can be left without later problems.