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Management of deep caries

Alice R. Hamilton*1 and David Ricketts1

Key points
Deep caries management has Evidence, including a Cochrane International clinical guidelines Further studies are ongoing to
evolved over the past century, systematic review, supports selective and position statements, which inform on the best deep caries
following advancements in the caries removal techniques, as previously were often conflicting, management strategies and the
understanding of the disease compared to complete removal. are now aligning to support selective translation of this evidence into
process, histological zones and caries removal techniques primary care.
modern materials.

Abstract
Deep dentinal caries, despite being preventable, is an ongoing widespread global issue. This review addresses deep
carious lesions from aetiology through to management, and onto barriers in management implementation and
ongoing research. Understanding the aetiology of dentinal caries and the histopathology of both carious lesions and
the pulp-dentine complex reactions are crucial for providing the best clinical management, swinging the balance
in favour of pulpal vitality. How caries removal techniques and terminology have changed over the past 100 years
will also be explored together with current international guidelines and position statements on the management
of deep carious lesions. However, despite this published guidance in support of more minimally invasive selective
caries removal techniques, informed by decades of research, there remains a division among dental professionals
globally on which technique should be routinely carried out for deep carious lesions. This paper briefly sets out some
of the challenges associated with changing dental professionals’ behaviour to align with implementation of the best
available evidence, and how ongoing studies comparing the clinical and cost effectiveness of deep caries removal
techniques and the environment for implementation are being led to strengthen the evidence base.

Introduction The focus of this publication will be on on dental pulp health, potentially leading
permanent teeth as this is where the long- to reversible pulpitis, irreversible pulpitis,
In 2001, the second author to this publication term impact of appropriate management will necrosis and eventually apical periodontitis and
wrote an article for the British Dental Journal be seen biologically, financially, in quality of abscess formation. Although the prevalence
(BDJ) entitled ‘Management of the deep carious life and impact on society. of pulpitis is difficult to assess, especially
lesion and the vital pulp-dentine complex’.1 as many teeth may be asymptomatic, it has
Much had changed in the understanding of Global burden of disease been estimated globally that about half of the
dental caries and the pulp since the teachings of population have at least one tooth with apical
G. V. Black nearly 100 years previously.2 Since Following the widespread introduction of periodontitis.7,8 Dental caries and its sequelae
2001, interest in the management of caries, fluoridated toothpastes in the 1980s,3 the is undoubtedly the most common reason for
in particular, deep caries and maintaining a prevalence of caries was seen to dramatically carrying out endodontic treatment.9 These
healthy vital pulp through ‘vital pulp therapies’ decline in higher income countries.4 However, interrelated pathologies therefore require
has gained momentum. This paper aims to this initial optimism has not continued, interrelated joined-up strategies to address
explore the breadth and depth of knowledge with little change in caries prevalence over their management in the future.
gained through research on this topic over the subsequent decades.5 Dental caries is still a
last 20 years or so and how this translates into problem in all age groups, with patients also Dental caries aetiology and
clinical practice. living longer and retaining more teeth as they histopathology
age.4 In fact, dental caries remains one of the
1
Dundee Dental Hospital and Research School, University most common non-communicable diseases An understanding of the histopathology of
of Dundee, UK. worldwide, and the Global Burden of Disease caries and its close relationship to the pulp-
*Correspondence to: Alice R. Hamilton
Email address: AHamilton005@[Link] Study 2015 found that untreated caries in dentine complex underpins caries clinical
Refereed Paper.
permanent teeth was the most prevalent of management and vital pulp therapies.
Submitted 20 November 2024 all, impacting 2.5 billion people.6 It has been estimated that the number of
Revised 24 September 2025 While caries is an entirely preventable bacteria within the human body equates to the
Accepted 29 September 2025 disease, if left unchecked, it can develop number of human cells.10 This huge number
[Link]
into extensive lesions with a profound effect of microorganisms, or human microbiome,

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mostly exists in harmony with the human

body, providing beneficial and protective
effects. However, when this carefully balanced
relationship breaks down, disease can occur,
with caries a typical example.11

Enamel caries
Oral bacteria that colonise the tooth surface
(biofilm or dental plaque) have the potential,
given the correct environment (sugar
substrate, restricted disruption from oral
function and oral hygiene measures, reduced
salivary %ow and limited topical %uoride) to
produce sufficient acid to cause tooth tissue Fig. 1 Deep caries distally in a restored lower molar. The arrow points to a dentine bridge
demineralisation. However, this process can between the carious lesion and the pulp
be reversed by favourably controlling these
environmental factors (caries prevention),
leading to lesion arrest or remineralisation.
This delicate dynamic balance takes place in
the early stages of the disease process at a sub-
clinical level, not seen by the naked eye. But if
the environment tips this balance, favouring
acid production and demineralisation, an
enamel (white spot) lesion will eventually
become visible clinically.
While our resident oral microorganisms
are acquired from birth, dental caries is not
an infectious disease caused by external
pathogenic organisms passed from person-
to-person. Instead, it is a non-communicable
disease caused by a localised ‘ecological Fig. 2 Extremely deep caries distally in a heavily restored upper molar. No dentine bridge can
catastrophe’.11,12 be seen between the carious lesion and the pulp

Early dentine caries

Continuation of this ‘ecological catastrophe’ where operative intervention is required. zone of unaffected dentine separating the
and imbalance in the biofilm on the surface The microorganisms now colonise en masse lesion from the pulp (Fig. 2).
of the tooth leads to demineralisation of the within the cavity, protected from disruption.
enamel in both density and depth. Eventually Further demineralisation and breakdown of Visualising the extent or depth of a carious
if the carious process is left unchecked, dentine collagen from bacterially produced lesion from clinical examination alone
demineralisation reaches the enamel dentine proteolytic enzymes can now spread more is difficult and needs supplemented with
junction (EDJ) and demineralisation of the rapidly through the less mineralised dentine, radiographic examination. This paper focuses
dentine begins driven by acid produced by the leading to extensive dentine involvement or on the management of deep caries, but it is
biofilm microorganisms on the tooth surface deep caries. important to emphasise that interpretation
diffusing into the tooth tissue. However, at this of radiographic images can be subjective
early dentine caries stage, modification of the What is deep caries? and is not a precise science due to the two-
oral environment through altered diet, oral dimensional representation of a complex
hygiene and %uoride is still all that is needed Deep caries is defined as radiographically three-dimensional structure.
to control the disease process. extending into the inner third or inner quarter
of dentine with a risk of pulpal exposure.14 Zones of dentine caries – histology and
Moderate/deep dentine lesions However, more recently Bjørndal et al. (2019)15 clinical significance
It is not until demineralisation extends well subdivided deep lesions further: It has long been accepted that deeper caries
into the outer half of dentine that the over-lying • Deep caries – extending radiographically is comprised histologically of two distinct
enamel loses so much mineral that the surface into the pulpal quarter of dentine, but a zones; the outer zone (infected zone) and the
breaks down and cavitation takes place.13 clear zone of unaffected dentine separates inner zone (caries-affected zone).16,17,18,19,20
Frank cavitation of the tooth surface the lesion from the pulp (Fig. 1) The infected (outer) zone is closest to the EDJ,
therefore occurs relatively late in the carious • Extremely deep caries – penetrating the and within this zone the dentine is severely
process, reflecting a position of no return entire thickness of the dentine with no clear demineralised, heavily infected with the oral

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micro%ora, and the collagen is broken down.

Table 1 New terminology used to describe various degrees of caries removal, the
This zone is not capable of remineralisation. previously used terms and when to adopt each approach14
Acids and by-products from microorganisms
within the infected outer zone diffuse towards New terminology Old terminology equivalent When to adopt

the pulp, leading to dentine demineralisation No longer recommended for

Non-selective caries removal Complete caries removal
lesions of any depth
ahead of this infected zone. This is the caries
affected zone, where the dentine is not as Selective caries removal to firm Partial caries removal/indirect pulp
Most carious lesions that are not
dentine* cap, near complete, incomplete, or
severely demineralised and the collagen thought to be deep
*includes firm or leathery dentine minimally invasive caries removal
remains intact. Partial caries removal, minimally
If the carious process is controlled by Selective caries removal to soft Deep carious lesions as defined
invasive, incomplete, or
dentine by Bjørndal et al. (2019)15
removing the infected (outer) zone, then ultraconservative caries removal
the caries affected (inner) zone is minimally Stepwise caries removal, stepwise Deep carious lesions as defined
Stepwise removal
excavation, two step caries removal by Bjørndal et al. (2019)15
infected, capable of remineralisation and
does not need removed. This caries affected
inner zone is often stained and discoloured However, the significance of their presence in are not mutually exclusive to a specific lesion;
clinically; 21 therefore, firm discoloured relation to caries progression is questionable reactionary dentine may dominate beneath the
carious dentine pulpally is not a good guide as they may be in insufficient numbers to wider extremes of the lesion and reparative
for completing caries removal. support lesion progression alone. The pulp- dentine in relation to the deepest aspect.15 The
Unfortunately, the divide between these dentine complex also has an amazing ability ability of the pulp-dentine complex to mount
two histologically determined zones are to respond to dental caries and has been shown and maintain these protective responses
not well-defined clinically. Early research to respond to even these early stages of the depends upon the level of pulpal in%ammation
suggested the use of various caries detector disease process.27,28 and continued pulpal health. However,
dyes to differentiate the zones, advising only Pulp-dentine complex reactions take place evaluation of the actual pulp health is difficult
the outer infected zone being stained with due to the released bacterial by-products from a patient history, especially as symptoms
dye. However, more recent research has shown including acids, together with bioactive may be absent until the lesion is extremely
that the dyes are not as specific as originally molecules released from the demineralised and deep, if presenting at all. Research showed that
thought, because they can also pick up the denatured dentine, diffusing toward the pulp, significant pathology of the pulp, including
naturally less mineralised non-carious dentine stimulating pulpal in%ammatory and immune micro-abscess formation, did not occur until
toward the pulp and at the EDJ.22 Therefore, responses.29 The responses are complex but bacterial penetration of the carious dentine
the use of these dyes cannot be recommended fundamentally depend on the severity of the extended to within 1 mm of the pulp and only
for general use to guide cavity preparation, stimulus; caries. when reactionary dentine itself was invaded by
as they can lead to over-preparation and A low-grade stimulus, resulting from a bacteria that ‘pathosis of real consequence and
greater risk to the pulp. Instead, the use of a slowly progressing lesion causes mild pulpal of an irreversible nature was found’.30
spoon excavator pulpally has been shown in in%ammation in the sub-odontoblast layer A fine balance therefore exists between the
auto%uorescent studies (the infected dentine and the odontoblasts are upregulated to carious process in deep lesions and pulp health,
marked through its auto%uorescent signal) produce reactionary dentine similar to normal with the ultimate aim of operative dentistry to
to be the most effective and efficient way of physiological dentine’s tubular structure. More tip that balance in favour of the pulp.
judiciously removing the outer infected zone peritubular dentine may also be laid down
and leaving the caries affected zone.23 within the dentinal tubules leading to tubular History of deep caries management
sclerosis. These responses aim to reduce strategies
The vital pulp-dentine complex the diffusion of injurious products toward
Structurally, dentine and pulp are inextricably the pulp. Non-selective caries removal/complete
linked by the odontoblasts found within With more severe stimulus, for example caries removal
the pulpal periphery with their processes deeper and more rapidly progressing It has historically been taught, and is still in
extending into the dentinal tubules, thus carious lesions, the in%ammatory response some countries, that all traces of caries should
referred to as the pulp-dentine complex. progressively increases. The reactionary be removed (including stained, caries-affected
Dentine itself is therefore regarded as a vital dentine may not be so ordered, with fewer dentine) before restoration placement. It was
structure and the management of deep dentine dentinal tubules and cellular inclusions. At thought that exposing the pulp and dealing
caries should constitute the first line strategy its most severe, death of the odontoblast with its consequences was better than the
in vital pulp treatments aimed at maintaining layer will take place. Removal of the stimulus risk of leaving soft and infected caries.2 This
pulp vitality.24,25 following appropriate caries management may has most often been referred to in the past as
Despite early enamel lesions re%ecting a lead to differentiation of pulpal stem cells into complete caries removal (updated terminology
disease process taking place in the biofilm on odontoblast-like cells and the formation of now ‘non-selective caries removal’ [NSCR], see
the tooth surface, some studies have shown reparative dentine or calcific bridge. Table 1).
that the presence of microorganisms within Dentinogenesis of reactionary and However, concerns soon grew over this
these early non-cavitated lesions may even reparative dentine have collectively been approach, and it was suggested that the
extend through to the EDJ or outer dentine.26,27 referred to as tertiary dentine formation and exposed pulp was a doomed organ.25

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of adequate thickness leaving frankly

Table 2 The clinical presentation of carious dentine and definition14
soft caries. Cavity lined (optional) and
Clinical presentation restored with an adhesive (glass ionomer
Definition
of dentine
or composite resin) provisional restoration
‘Will deform when a hard instrument is pressed onto it and can be easily scooped up and left for 6–12 months. Second visit:
Soft
(e.g., with a sharp hand excavator) with little force being required’
provisional restoration removed, residual
‘Although the dentine does not deform when an instrument is pressed onto it,
Leathery caries excavated and definitive restoration
leathery dentine can still be easily lifted without much force being required’
placed45
‘Firm dentine is physically resistant to hand excavation, and some pressure needs to
Firm • Partial caries removal (updated terminology
be exerted through an instrument to lift it’
‘A pushing force needs to be used with a hard instrument to engage the dentine, and now ‘selective caries removal’ [SCR] see
Hard only a sharp cutting edge or a bur will lift it. A scratchy sound or ‘cridentinaire’ can be Table 1). Essentially, this is the first stage
heard when a straight probe is taken across the dentine’ of SW excavation and the placement of a
definitive restoration sealing the residual
Direct pulp cap of caries and leaving the inner stained zone dentine caries over the pulp without
Even careful caries removal in deep lesions, (as described in the following section), there re-entering.46,47
particularly in young patients with large pulps appears to be little difference if any. As such
and pulp horns still has a significant risk of perhaps the term ‘indirect pulp cap’ for the Re-evaluating terminology and
pulpal exposure.31 When the pulp tissue appears management of deep caries is now a redundant clinical management – International
healthy and arrest of haemorrhoage readily term and should be relegated to the history Caries Consensus Collaboration
achieved, the first line vital pulp therapy for books?
many would be a direct pulp cap, due to its With increasing clinical and research interest
relative ease of application, minimal invasiveness Minimally invasive deep caries in the ‘management of deep caries’ since
and reduced cost compared to endodontic management the 2001 BDJ publication, there has been a
treatment. Retrospective studies carried out in Historically, the driving force behind the concomitant rise in the number of publications
dental schools observing the long-term success complete removal of caries had been the need and terms used in relation to caries removal.
rate of direct pulp caps after carious exposure to remove all infected carious dentine, to ensure This has been the source of some confusion
showed that after 3–5 years only about one- the carious process could not continue beneath with different terms being used to describe
third (33–37%)32,33 were successful, and after five the restoration, and remove demineralised the same technique.14,48 In addition, a carious
years only 13% were successful.33 Improvements softened dentine so that the restoration could lesion is continuous and progressive through
in techniques and dental materials has seen a be packed against a sound tooth surface. dentine with no definitive boundaries to
dramatic improvement in success rates with However, there is now a wealth of evidence delineate between hard, firm, leathery or soft
a systematic review showing 84–86% success from numerous types of study which support dentine. This terminology for dentine hardness
after 2–3 years using hydraulic calcium silicate that not all soft and infected carious dentine has been used widely in the literature; however,
cements as the capping agent.34 However, the needs to be removed. In permanent teeth, there are no convenient aids to assist in
included studies often had small sample sizes researchers have investigated the following. differentiating between these clinically. There
and the authors concluded that the studies were is little surprise that assessment of carious
of fair to poor quality with a high risk of bias. For occlusal dentine lesions dentine’s hardness is very subjective from one
With such conflicting and inconclusive • Placing resin fissure sealants to seal in practitioner to another. One dentist’s hard, may
evidence, avoidance of carious exposure would dentine lesions that are radiographically be another’s leathery or even soft. This adds
be the ideal goal and various caries removal visible. Such lesions have been shown confusion to the %avours of caries removal
strategies have been described to achieve this. to extend through to the middle third techniques outlined in the previous sections.
of dentine and likely to be heavily To address some of these issues and reach a
Indirect pulp cap infected36,37,38,39,40,41,42,43 consensus, the International Caries Consensus
As a result, the indirect pulp cap was proposed • Ultraconservative caries removal, where Collaboration (ICCC) was formed and
and is still advocated today as part of the vital the enamel caries at the entrance to the produced recommendations on terminology14
pulp therapy armamentarium. The indirect fissure is removed, but without any dentine and operative management of carious tissue
pulp cap has been described for deep lesions caries being removed, and restored with a removal.48 Table 1 summarises the updated
as ‘almost completely’ removing ‘demineralised composite restoration.44 international consensus on terminology for
and discoloured dentine leaving a thin layer of operative procedures, including when to adopt
residual caries’ over the pulp which ‘if removed For occlusal and approximal extensive them, and Table 2 shows the definitions for the
with an excavator will certainly expose the pulp’.35 coronal lesions clinical presentation of dentine.
This traditionally was lined with setting calcium • Stepwise excavation (updated terminology While various terms have been used to
hydroxide but has been superseded with the now ‘stepwise removal’ [SW], see Table 1). describe operative procedures during cavity
superior hydraulic tricalcium silicate cements. Two-stage caries removal. First visit: access preparation, ‘caries removal’ was preferred
Reflecting on the indirect pulp capping to caries and periphery of cavity rendered to avoid confusion with other caries removal
technique and the now widely accepted totally caries/stain free, with pulpal caries techniques such as excavation (e.g., with a
selective caries removal of only the outer zone removed sufficiently to place a restoration spoon excavator).

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New terms were derived to avoid terms in permanent teeth and 69% in primary But what do dentists do globally?
such as ‘complete’, ‘partial’ or ‘incomplete’ teeth, while SCR leaving softened dentine
caries removal, which brought with them over the pulp in a one-stage technique can Since the 2001 BDJ publication1 and 2016
negative connotations, implying that the result in a 77% reduction in risk of pulp ICCC recommendations14,48 many studies have
latter was in some way sub-standard. exposure in primary and permanent teeth shown that there is still little agreement among
Partial caries removal covered a spectrum combined dentists internationally on how to best manage
of caries removal endpoints and was • The three studies 46,58,59 on permanent deep carious lesions.
therefore redefined as SCR, and further teeth included in the 2021 Cochrane Edwards et al. showed this divide in the UK,
split into two separate definitions to reflect systematic review50 provided evidence with a survey conducted in 2021, where equal
different intended operational endpoints that SCR leaving softened dentine over numbers of primary care dental professionals
(either to soft or firm dentine over the the pulp reduces failure compared to reported using NSCR and SCR, with 41.4%
pulp). Historically, many studies did not SW over a 12–60-month follow-up. This each.62 However, more recent unpublished
make this distinction, but going forward, it is may be due to the risk with SW that, on survey data have suggested a further shift
important to define the intended endpoints, re-entering, there is additional trauma to towards conservative techniques, with only 28%
as leaving only firm-stained dentine may the pulp-dentine complex of UK dentists reporting NSCR as their typical
carry an entirely different risk to the pulp • Stressed pulp syndrome has long been technique in 2023.63 A similar trend was shown
than leaving soft dentine. recognised, in which the pulp-dentine in the USA, with reported implementation of
complex repairs following operative SCR by only around 22% and 34% of dentists
Evidence for minimally invasive trauma but has a diminished ability in 2006 and 2010, respectively.64,65 However,
techniques to repair following repeated trauma. 60 in 2022, this increased to 62.4% of dentists
Therefore, re-entering with SW carries reporting to use SCR more than 50% of the
The numerous studies published looking with it the risk of further trauma to the time for asymptomatic deep carious teeth,
at more minimally invasive caries removal pulp-dentine complex and, albeit much decreasing to 49.3% for the management of
techniques have the same underlying theme reduced, the risk of pulpal exposure. symptomatic teeth.66 Alternatively, dentists in
of sealing soft, infected carious dentine into Norway and Germany report SW as their most
permanent teeth and the highest quality However, although the ever-growing used deep caries removal technique, with 84%
available evidence has been evaluated in evidence base supports more minimally and 48%, respectively, compared to dentists in
three consecutively updated Cochrane interventive techniques, studies often have France where the majority favoured NSCR.67
systematic reviews, with the latest published small sample sizes, leading to a high risk of Dentists in Spain were one of the most polarised
in 2021.31,49,50 Salient research findings can be bias. Clinical trials are also often carried out groups with only 8% of dentists reporting they
summarised as: in a secondary care setting and do not always would carry out SCR for a tooth with reversible
• Sealed dentine caries with a resin measure the ‘real-life’ application of the pulpitis and 88% choosing NSCR in one or two
restoration through ultraconservative techniques in the wider primary care setting. stages.68 The question arises as to why there is
caries removal, has been associated with Further high-quality studies are required to such divided behaviour in regards to deep caries
no evidence of lesion progression over strengthen this evidence base. removal bearing in mind the aforementioned
time, no significant loss or deterioration One ongoing clinical trial – the Selective evidence supporting minimally invasive
of restorations, no reports of signs or Caries Removal in Permanent Teeth techniques over NSCR.
symptoms of pulp pathology with one (SCRiPT) study – is a multi-centre, pragmatic, Studies have shown that dentistry has many
study having ten-year follow-up44 randomised control trial currently being complexities which may in%uence behaviour
• Sealing dentine caries leads to changes carried out in primary care dental practices such as individual clinicians’ knowledge, beliefs
in colour and consistency of the dentine across Scotland and England.61 The National or fear of failure with change, social in%uencers
consistent with an arrested lesion45,51,52,53,54,55 Institute for Health and Care Research Health (including fear of litigation or judgement from
• Once sealed, a reduction of viable Technology Assessment (HTA) programme peers), varying undergraduate curriculums,
organisms occurs over time, due to has commissioned and funded a collaborative access to resources and remuneration.69,70,71,72
restriction of sugar substrate from the diet/ team from universities across the UK to carry Understanding this landscape is essential for
oral cavity51,52,54,55,56,57 out this study (trial number: HTA 17/127/07/ navigating implementation of the best quality
• Once sealed, a reduction in the diversity ISRCTN76503940), which compares the of evidence into clinical practice. However,
of organisms contributing to the microbial clinical and cost effectiveness of SCR (with changing behaviour is known to be extremely
load.57 Only bacteria capable of breaking the intention of leaving soft dentine over the challenging and it is not as simple as publishing
down glycoproteins from pulpal tissue pulp), compared to complete (NSCR) or near research or clinical guidelines and expecting
%uids survive, and these are not associated complete caries removal (SCR to firm/leathery them to be applied into practice. To tackle
with active lesions dentine). The SCRiPT study is due to be this, robust evidence-based theory-grounded
• Meta-analysis in one Cochrane systematic completed in 2026 with an average follow-up of behaviour change approaches must be used.
reviews showed a significant reduction three years and results are expected to have an Further research by the lead author is
in risk of pulpal exposure with less impact on the provision of treatment for deep being undertaken into the barriers and
invasive techniques.31 SW can lead to a carious lesions globally by adding strength to facilitators to changing behaviours regarding
49% reduction in risk of pulpal exposure the evidence base. the implementation of the highest quality

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of evidence in relation to caries removal Current clinical guidelines and The aim of clinical guidelines and position
techniques.63 Translational studies are also position statements statements are to provide clear and concise
required to measure the impact and efficacy recommendations and expert consensus
of any applied interventions to reduce resource Despite this worldwide con%ict of opinions on from the best available evidence. However,
and research wastage, in addition to improving the best management for deep carious lesions it is not as simple as publishing a guideline
health outcomes, patient quality of life, among dental professionals, there are a number and expecting clinicians to implement it
and improved sustainability with a reduced of guidelines and position statements published into their clinical practice. Many dentists
restorative cycle. internationally, as summarised in Table 3.73,74,75 are balancing a busy work life and may

Table 3 The main guidelines and position statements currently available for the management of deep carious lesions in permanent teeth

Guideline/position Summary of main recommendations for deep

Scope Further comments
statement caries management in permanent teeth
International Caries Consensus Consensus for the Recommendations for deep carious lesions into One of the most detailed consensus
Collaboration (ICCC): management of carious lesions the pulpal third or quarter with vital pulps: statements relating to caries removal
Recommendations on Carious in primary and permanent • SCR leaving soft dentine over the pulp strategies as they advise on the consistency
Tissue Removal (2016)14 teeth. Developed by a group (strongly recommended). of dentine to be left over the pulp with SCR
of 21 clinical experts from 12 – often left to the reader’s discretion in other
countries, with expertise in • SW considered a possible alternative. guidance/position statements.
cariology, operative dentistry, This guidance advises NSCR is no longer
biomaterials science, clinical Advise against: recommended as for cavitated lesions
trials, systematic reviews and • Cavity disinfection due to a lack of evidence of (considered over-treatment)
guideline development benefit
• Use of caries detector dyes as these may lead to
over-treatment.

Cavity linings:
Not recommended for improving cavity seal
but may be considered to prevent monomer
penetration during composite placement
or thermal injury to the pulp with amalgam
restorations

Scottish Dental Clinical Clinical practice guidance for Recommendations for vital posterior permanent This guidance has a dedicated website
Effectiveness Programme prevention and management teeth with deep carious lesions: containing useful clinical resources, including:
(SDCEP): Prevention and of caries in children, covering • SCR leaving soft dentine over the pulp if a • Flowchart and table to aid clinical
Management of Dental Caries primary and permanent teeth dentine bridge is visible between the carious decision making – located in the ‘Caries
in Children Guidance (2025)73 lesion and the pulp radiographically management for permanent teeth’ section
(Third edition) • Consider SCR or pulpotomy for extremely deep • Step-by-step clinical guides for SCR and
*National Institute for Health lesions where no dentine bridge is visible pulpotomy techniques in permanent teeth –
and Care Excellence (NICE) between the carious lesion and the pulp located in the ‘Dental techniques’ section
accredited radiographically
European Society of Consensus from an expert For asymptomatic permanent teeth with deep This position statement divides deep caries
Endodontology (ESE) position committee setting out caries or showing signs of reversible pulpitis: into the accepted ‘deep’ and ‘extremely deep’
statement: Management of guidance on diagnosis, SCR or SW is recommended, ideally with: categories described earlier in this paper.15
Deep Caries and the Exposed classification of deep caries The remaining dentine recommended to
Pulp (2019)74 and pulpal disease, and their • Rubber dam
be left over the pulp in SCR is not discussed
management • Magnification (whether firm, leathery or soft following cavity
• Hydraulic calcium silicate cement or glass preparation)
ionomer cement over the deep dentine.

Where a carious pulpal exposure occurs: Isolation

with rubber dam, sterile instruments used, and
the tooth disinfected before vital pulp therapy
with either:
• Pulp cap or partial pulpotomy using a hydraulic
calcium silicate cement.

Progressing to:
• Full pulpotomy – if partial irreversible pulpitis
• Pulpectomy – if more fully irreversibly inflamed
American Dental Association Clinical practice guidelines Recommendation for pulpal dentine for the These guidelines presented a dynamic
(ADA): Evidence-based developed for USA with management of deep carious lesions in permanent shift to align more with European guidance
Clinical Practice Guideline on recommendations for the teeth and international consensus, with a higher
Restorative Treatments for management of caries in • SCR to firm or soft, preferable over NSCR emphasis on more minimally invasive caries
Caries Lesions (2023)75 primary and permanent teeth and SW techniques (recommended with low removal techniques and away from its more
certainty and advised further research) traditional preference for NSCR

NSCR, non-selective caries removal; SCR, selective caries removal; SW, stepwise removal

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not have time or opportunity to seek out, Conclusion 7. Duncan H F, Kirkevang L L, Peters O A et al. Treatment
of pulpal and apical disease: the European society
navigate, and digest available published of endodontology (ESE) S3–level clinical practice
guidance. Unpublished research from a Over the past century, there have been guideline. Int Endod J 2023; DOI: 10.1111/iej.13974
8. Tiburcio-Machado C S, Michelon C, Zanatta F B, Gomes
questionnaire assessing UK primary care advances in the understanding of deep
M S, Marin J A, Bier C A. The global prevalence of apical
dentists’ management of deep carious carious lesions and the pulp at an aetiological, periodontitis: a systematic review and meta-analysis.
lesions in permanent teeth confirmed histopathological, and clinical level, which Int Endod J 2021; 54: 712–735.
9. Bjørndal L, Laustsen M H, Reit C. Root canal treatment
that many practitioners are not aware has in turn been driven by improvements in in Denmark is most often carried out in carious vital
of guidelines, with only 15% of the 410 materials and techniques. The development molar teeth and retreatments are rare. Int Endod J 2006;
39: 785–790.
surveyed dentists able to provide knowledge of more minimally invasive selective caries 10. Sender R, Fuchs S, Milo R. Revised estimates for the
of a guideline on caries management with removal techniques, such as SCR, manages the number of human and bacteria cells in the body. PLoS
Biol 2016; DOI: 10.1371/[Link].1002533.
the most known guidance being published carious process from a biological perspective, 11. Pitts N B, Twetman S, Fisher J, Marsh P D.
by the Scottish Dental Clinical Effectiveness with a good peripheral seal on sound dentine Understanding dental caries as a non-communicable
disease. Br Dent J 2021; 231: 749–753.
Programme, closely followed by the crucial for success. This leads to a reduction 12. Marsh P D. Are dental diseases examples of ecological
European Society of Endodontology 2019 in the number and diversity of viable catastrophes?. Microbiology (Reading) 2003; DOI:
10.1099/mic.0.26082-0.
position statement.63 microorganisms within the sealed caries and 13. Ricketts D N J. How much caries do we have to remove?.
Further challenges in implementing prevention of further bacterial ingress. Balance In Meyer-Lueckel H, Paris S, Ekstrand KR (ed) Caries
Management – Science and Clinical Practice. pp 260–268.
evidence-based caries removal techniques is tipped in favour of the pulp by arrest of the Stuttgart: Theime, 2013.
have arisen due to previously published carious process to allow resolution of pulpal 14. Innes N P, Frencken J E, Bjørndal L et al. Managing
carious lesions: consensus recommendations on
international guidelines often having in%ammation and promote tubular sclerosis
terminology. Adv Dent Res 2016; 28: 49–57.
conflicting recommendations, with some and tertiary dentine formation. The strength 15. Bjørndal L, Simon S, Tomson P L, Duncan H F.
promoting NSCR, while others promoting of evidence in support of these techniques is Management of deep caries and the exposed pulp. Int
Endod J 2019; 52: 949–973.
SCR or SW. However, this has recently being further strengthened by ongoing studies, 16. Kato S, Fusayama T. Recalcification of artificially
changed, as throughout almost all of the which will help to inform future development decalcified dentin in vivo. J Dent Res 1970; 49:
1060–1067.
currently published key guidelines and of guidelines, undergraduate and postgraduate 17. Fusayama T, Terachima S. Differentiation of two layers
position statements internationally, there is education and other theory-grounded of carious dentin by staining. J Dent Res 1972; 51: 866.
18. Ogushi K, Fusayama T. Electron microscopic structure
now alignment with a strong global theme behavioural change interventions to unite and of the two layers of carious dentin. J Dent Res 1975; 54:
promoting more minimally invasive caries empower dental professionals to apply the best 1019–1026.
19. Sato Y, Fusayama T. Removal of dentin by fuchsin
removal techniques (Table 3). The American evidence-based practices regarding deep caries staining. J Dent Res 1976; 55: 678–683.
Association of Endodontists Position management. 20. Kuboki Y, Ohgushi K, Fusayama T. Collagen
biochemistry of the two layers of carious dentin. J Dent
Statement on Vital Pulp Therapy (2021) may Res 1977; 56: 1233–1237.
be considered an outlier, advocating for a Ethics declaration 21. Fusayama T, Okuse K, Hosoda H. Relationship between
hardness, discoloration, and microbial invasion in
less conservative approach, stating ‘complete The authors declare no conflicts of interest.
carious dentin. J Dent Res 1966; 45: 1033–1046.
caries removal is essential to eliminate 22. McComb D. Caries-detector dyes – how accurate and
infected tissues and visualise pulp tissue Author contributions useful are they?.J Can Dent Assoc 2000; 66: 195–198.
23. Banerjee A, Kidd E A, Watson T F. In vitro evaluation of
conditions under magnification when pulpal Both authors contributed equally to the design of five alternative methods of carious dentine excavation.
exposures occur’.76 However, this statement the narrative, review of the literature, and writing of Caries Res 2000; 34: 144–150.
24. Duncan H F, Galler K M, Tomson P L et al. European
may add further to the confusion, as it is the original manuscript draft. AH edited the second society of endodontology position statement:
not clear whether it advocates NSCR for the draft following the reviewers’ comments. DR reviewed Management of deep caries and the exposed pulp.
European Society of Endodontology 2019; 52: 923–934.
management of all deep lesions, or only those and confirmed the final version for submission. All 25. Duncan H F. Present status and future directions-vital
with pulpal exposure. A further challenge authors approved the final manuscript. pulp treatment and pulp preservation strategies. Int
Endod J 2022; DOI: 10.1111/iej.13688
in primary care is that magnification may 26. Parolo C C, Maltz M. Microbial contamination of
not be routinely available to the clinician, References noncavitated caries lesions: a scanning electron
microscopic study. Caries Res 2006; 40: 536–541.
and the statement also promotes the use of 1. Ricketts D. Management of the deep carious lesion and the
27. Ricucci D, Siqueira J F [Link] status of non-
vital pulp dentine complex. Br Dent J 2001; 191: 606–610.
caries detector dyes, which as mentioned 2. Black G V. Operative Dentistry. Pathology of Hard Tissues
cavitated proximal enamel caries lesions. A histologic
and histobacteriologic study. J Dent 2020; 100: 103422.
previously, may lead to overpreparation and of the Teeth: Oral Diagnosis. Chicago: Medico-Dental Pub.
28. Bjørndal L, Darvann T, Thylstrup A. A quantitative
Co., 1936.
removal of healthy tooth tissue.22 3. Walsh T, Worthington H V, Glenny A M, Marinho V C, light microscopic study of the odontoblast and
Throughout all the guidelines and position Jeroncic A. Fluoride toothpastes of different concentrations subodontoblastic reactions to active and arrested enamel
for preventing dental caries. Cochrane Database Syst Rev caries without cavitation. Caries Res 1998; 32: 59–69.
statements, it is agreed that it is essential, 2019; DOI: 10.1002/14651858.CD007868.pub3. 29. Farges J C, Alliot-Licht B, Renard E et al. Dental pulp
irrespective of which caries removal 4. Frencken J E, Sharma P, Stenhouse L, Green D, Laverty D, defence and repair mechanisms in dental caries.
Dietrich T. Global epidemiology of dental caries and severe Mediators Inflamm 2015; DOI: 10.1155/2015/230251
approach is used pulpally, that the dentine periodontitis - a comprehensive review. J Clin Periodontol 30. Reeves R, Stanley H R. The relationship of bacterial
at the periphery of the cavity (the EDJ or 2017; DOI: 10.1111/jcpe.12677. penetration and pulpal pathosis in carious teeth. Oral
5. Watt R G, Daly B, Allison P et al. Ending the neglect of Surg Oral Med Oral Path 1966; 22: 59–65.
outer 2 mm of dentine if extending onto the global oral health: time for radical action. Lancet 2019; 31. Ricketts D, Lamont T, Innes N P, Kidd E, Clarkson
root) should be hard with similar tactile 394: 261–272. J E. Operative caries management in adults and
6. Kassebaum N J, Smith A G C, Bernabé E et al. Global, children. Cochrane Database Syst Rev 2013; DOI:
characteristics to sound dentine. This allows regional, and national prevalence, incidence, and 10.1002/14651858.CD003808.pub3.
good adaptation and bond of the restorative disability-adjusted life years for oral conditions for 195 32. Al-Hiyasat A S, Barrieshi-Nusair K M, Al-Omari M A. The
countries, 1990–2015: a systematic analysis for the global radiographic outcomes of direct pulp-capping procedures
material to cavity, crucially creating a good burden of diseases, Injuries, and risk factors. J Dent Res performed by dental students: a retrospective study. J Am
peripheral seal. 2017; 96: 380–387. Dent Assoc 2006; 137: 1699–1705.

BRITISH DENTAL JOURNAL | VOLUME 240 NO. 5 | MarCH 13 2026 363

© The author(s) 2026.
 GENEraL

33. Barthel C R, Rosenkranz B, Leuenberg A, Roulet J F. Pulp 49. Ricketts D N, Kidd E A, Innes N, Clarkson J. Complete 63. Hamilton A R, Clarkson J E, Goulao B, Marshman Z,
capping of carious exposures: treatment outcome after or ultraconservative removal of decayed tissue in Ricketts D. Dental practitioners’ perspectives, behaviour
5 and 10 years: a retrospective study. J Endod 2000; 26: unfilled teeth. Cochrane Database Syst Rev 2006; DOI: and understanding of caries removal techniques in deep
525–528. 10.1002/14651858.CD003808.pub2. carious lesions. 2024 [Unpublished].
34. Cushley S, Duncan H F, Lappin M J et al. Efficacy of direct 50. Schwendicke F, Walsh T, Lamont T et al. Interventions for 64. Jurasic M M, Gillespie S, Sorbara P et al. Deep caries
pulp capping for management of cariously exposed treating cavitated or dentine carious lesions. Cochrane removal strategies: findings from the national dental
pulps in permanent teeth: a systematic review and Database Syst Rev 2021; DOI: 10.1002/14651858. practice-based research network. J Am Dent Assoc 2022;
meta-analysis. Int Endod J 2021; 54: 556–571. CD013039.pub2. 153: 1078–1088.
35. Bjørndal L, Kidd E A. The treatment of deep dentine 51. Kreulen C M, de Soet J J, Weerheijm K L, van Amerongen 65. Oen K T, Thompson V P, Vena D et al. Attitudes and
caries lesions. Dent Update 2005; DOI: 10.12968/ W E. In vivo cariostatic effect of resin modified glass expectations of treating deep caries: a PEARL network
denu.2005.32.7.402. ionomer cement and amalgam on dentine. Caries Res survey. Gen Dent 2007; 55: 197–203.
36. Going R E, Loesche W J, Grainger D A, Syed S A. The 1997; 31: 384–389. 66. McBride R, Leroux B, Lindblad A et al. Measuring the
viability of microorganisms in carious lesions five years 52. Bjørndal L, Larsen T, Thylstrup A. A clinical and impact of practice-based research networks on member
after covering with a fissure sealant. J Am Dent Assoc microbiological study of deep carious lesions during dentists in the collaboration on networked dental, oral
1978; 97: 455–462. stepwise excavation using long treatment intervals. health research, CONDOR. J Dent 2013; 41: 393–403.
37. Jeronimus D J, Till M J Jr, Sveen O B. Reduced viability Caries Res 1997; 31: 411–417. 67. Schwendicke F, Stangvaltaite L, Holmgren C et al.
of microorganisms under dental sealants. ASDC J Dent 53. Bjørndal L, Thylstrup A. A practice-based study Dentists’ attitudes and behaviour regarding deep
Child 1975; 42: 275–280. on stepwise excavation of deep carious lesions in carious lesion management: a multi-national survey.
38. Handelman S L, Washburn F, Wopperer P. Two-year permanent teeth: a 1 year follow-up study. Community Clinical Oral Investig 2017; 21: 191–198.
report of sealant effect on bacteria in dental caries. J Am Dent Oral Epidemiol 1998; 26: 122–128. 68. Crespo-Gallardo I, Martin-Gonzalez J, Jimenez-Sanchez
Dent Assoc 1976; 93: 967–970. 54. Bjørndal L, Larsen T. Changes in the cultivable flora in M, Cabanillas-Balsera D, Sanchez-Dominguez B,
39. Mertz-Fairhurst E J, Schuster G S, Williams J E, Fairhurst deep carious lesions following a stepwise excavation Segura-Egea J. Dentist´s knowledge, attitudes and
C W Clinical progress of sealed, unsealed caries, Part procedure. Caries Res 2000; 34: 502–508. determining factors of the conservative approach in
I. Depth changes and bacterial counts. J Prosthet Dent 55. Maltz M, de Oliveira E F, Fontanella V, Bianchi R. A teeth with reversible pulpitis and deep caries lesions. J
1979; 42: 521–526. clinical and radiographic study of deep caries lesions Clin Exp Dent 2018; DOI: 10.4317/jced.55395.
40. Jensen O E, Handelman S L. Effect of an autopolymerising after incomplete caries removal. Quintessence Int 2002; 69. Jeggle L M, Baker S R, Schwendicke F. Changing
sealant on viability of microflora in occlusal dental caries. 33: 151–159. dentists’ carious tissue removal behavior: Qualitative
Scand J Dent Res 1980; 88: 382–388. 56. Weerheijm K L, Kreulen C M, de Soet J J, Groen H J, van study and behavioral change simulation experiment. J
41. Handelman S L, Leverett D H, Espeland M A, Curzon Amerongen W E. Bacterial counts in carious dentine Dent 2019; 81: 43–51.
J A. Clinical radiographic evaluation of sealed carious under restorations: 2-year in vivo effects. Caries Res 70. Schwendicke F, Doméjean S, Ricketts D, Peters M.
and sound tooth surfaces. J Am Dent Assoc 1986; 113: 1999; 33: 130–134. Managing caries: the need to close the gap between
751–754. 57. Paddick J S, Brailsford S R, Kidd E A, Beighton D. the evidence base and current practice. Br Dent J 2015;
42. Mertz-Fairhurst E J, Schuster G S, Fairhurst C W. Phenotypic and genotypic selection of microbiota 219: 433–438.
Arresting caries by sealants: results of a clinical study. J surviving under dental restorations. Appl Environ 71. Campbell F, Rogers H, Goldsmith R, Rowles K, Raggio
Am Dent Assoc 1986; 112: 194–197. Microbiol 2005; 71: 2467–2472. D P, Innes N. A scoping review of guidelines on caries
43. Bakhshandeh A, Qvist V, Ekstrand K R. Sealing 58. Labib M E, Hassanein O E, Moussa M, Yassen management for children and young people to inform
occlusal caries lesions in adults referred for restorative A, Schwendicke F. Selective versus stepwise UK undergraduate core curriculum development. BMC
treatment: 2–3 years of follow-up. Clin Oral Investig removal of deep carious lesions in permanent Oral Health 2024; DOI: 10.1186/s12903-024-04278-7.
2012; 16: 521–529. teeth: a randomised controlled trial from Egypt-an 72. Kettle J, Marshman Z, Hamilton A R et al. Dentists’
44. Mertz-Fairhurst E J, Curtis J W, Jr Ergle J W, Rueggeberg interim analysis. BMJ Open 2019; DOI: 10.1136/ perspectives on selective caries removal for the
F A, Adair S M. Ultraconservative and cariostatic sealed bmjopen-2019-030957. management of deep carious lesions in permanent
restorations: results at year 10. J Am Dent Assoc 1998; 59. Maltz M, Koppe B, Jardim J J et al. Partial caries removal teeth. BMC Oral Health 2025; 25: 362.
129: 55–66. in deep caries lesions: a 5-year multicenter randomized 73. Scottish Dental Clinical Effectiveness Programme.
45. Bjørndal L. Caries excavation: evolution of treating controlled trial. Clin Oral Investig 2018; 22: 1337–1343. Prevention and management of dental caries in
cavitated carious lesions. Monogr Oral Sci 2018; 27: 60. Abou-Rass M. The stressed pulp condition: an children: Dental Clinical Guidance (3rd edition). 2025.
68–81. endodontic-restorative diagnostic concept. J Prosthet Available at [Link]
46. Orhan A I, Oz F T, Orhan K. Pulp exposure occurrence Dent 1982; 48: 264–267. (accessed 19 September 2025).
and outcomes after 1- or 2-visit indirect pulp therapy 61. Clarkson J E, Ramsay C R, Ricketts D et al. Selective 74. Duncan H F, Galler K M, Tomson P L et al. European
vs complete caries removal in primary and permanent caries removal in permanent teeth (SCRiPT) for the Society of endodontology position statement:
molars. Pediatr Dent 2010; 32: 347–355. treatment of deep carious lesions: a randomised management of deep caries and the exposed pulp. Int
47. Khokhar_M, Tewari_S. Outcomes of partial and complete controlled clinical trial in primary care. BMC Oral Health Endod J 2019; 52: 923–923.
caries excavation in permanent teeth: a 18 month clinical 2021; DOI: 10.1186/s12903-021-01637-6. 75. Dhar V, Pilcher L, Fontana M et al. Evidence-based
study. Contemp Clin Dent 2018; 9: 468–473. 62. Edwards D, Bailey O, Stone S, Duncan H. The clinical practice guideline on restorative treatments for
48. Schwendicke F, Frencken J E, Bjørndal L et al. Managing management of deep caries in UK primary care: A caries lesions. J Am Dent Assoc 2023; 154: 551–566.
carious lesions: consensus recommendations on carious nationwide questionnaire-based study. Int Endod J 76. Anonymous. AAE Position Statement on Vital Pulp
tissue removal. Adv Dent Res 2016; 28: 58–67. 2021; 54: 1804–1818. Therapy. J Endod 2021; 47: 1340–1344.

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