Introduction
When a radiograph shows a lesion in the inner dentine of a molar, and the patient reports cold sensitivity that fades within seconds; for a long time, the expected sequence was to excavate until hard dentine remained everywhere, accept an exposure if one occurred, and often proceed to root canal treatment.
That sequence has been formally revised. In 2016 the International Caries Consensus Collaboration agreed the terminology in use today and stated that carious tissue is removed to create the conditions for a long-lasting restoration, and that bacterially contaminated or demineralised tissue close to the pulp need not be removed [1,2]. In 2026 the European Federation of Conservative Dentistry, the European Society of Endodontology and the Organisation for Caries Research, with the German Society of Conservative Dentistry, published an S3-level guideline for deep and extremely deep caries in vital permanent teeth, built on four systematic reviews and a structured consensus [3].
A guideline speaks to populations; a decision is made for one tooth, with the equipment in one surgery. This article turns the guideline and its evidence into a chairside sequence, and states the uncertainties plainly.
How this guide was assembled
The S3 guideline [3] is cross-checked here against the consensus papers [1,2], the European Society of Endodontology position statement [4], the 2021 Cochrane review [5], the 2025 systematic review behind the guideline [6] and the underlying trials, plus studies published after the guideline's searches closed in early 2025. All sources were checked on PubMed. This is a narrative synthesis, not a systematic review.
Step 1: Diagnose the pulp before you measure the lesion
Every caries-removal recommendation in the guideline applies to teeth with no symptoms or with symptoms of reversible pulpitis [3]. Lingering, nocturnal or spontaneous pain points to a different conversation.
History, cold testing, percussion, palpation and a well-angled radiograph are imperfect but useful. In 95 teeth examined histologically, a clinical diagnosis of normal pulp or reversible pulpitis matched the histology in 57 of 59 (96.6%), and a clinical diagnosis of irreversible pulpitis matched in 27 of 32 (84.4%) [7].
If the pulp is judged irreversibly inflamed, the question becomes whether a pulpotomy can replace pulpectomy (Step 4). Necrotic pulps and apical periodontitis are outside this guide.
Step 2: Read the depth, and respect the limits of the radiograph
The European Society of Endodontology defines deep caries as reaching the inner quarter of the dentine while leaving a radiographically visible zone of hard or firm dentine over the pulp, and extremely deep caries as penetrating the full thickness of the dentine with no visible barrier, so that exposure is highly likely [3,4].
The guideline warns that whether that radiopaque band can be seen depends on the projection and is unlikely to be reliable [3]. Histology adds a caution. In 31 extracted teeth classified radiographically as deep or extremely deep, bacteria had reached the pulp in 26 (83.9%), with no association between radiographic category and bacterial penetration [8]. Extracted teeth are not typical of lesions treated conservatively, but the authors' point stands: avoiding an exposure does not establish that the pulp is free of infection [8].
Step 3: Decide how much carious dentine to remove
The consensus definitions [1]:
Selective removal to firm dentine: leathery dentine that resists hand excavation is left over the pulp.
Selective removal to soft dentine: soft carious dentine is left over the pulp.
Stepwise removal: soft dentine is left initially, and the cavity is re-entered 6 to 12 months later to remove carious tissue to firm dentine.
Non-selective removal to hard dentine: formerly called complete caries removal, and no longer recommended.
In every selective approach the periphery of the cavity is taken to hard dentine so that the restoration can seal [2,3]. In shallow and moderately deep lesions, restoration longevity comes to the fore and selective removal to firm dentine is recommended; in deep lesions, pulpal health takes priority and selective removal to soft dentine is recommended, with stepwise removal an option in permanent teeth [2].
What the trials show. For deep lesions in permanent teeth, the Cochrane review found higher odds of failure with non-selective than with stepwise removal (odds ratio 2.06; 3 trials, 398 teeth; moderate certainty), probably higher odds than with selective removal (odds ratio 11.32; very low certainty), and higher odds with stepwise than with selective removal (odds ratio 2.25; 3 trials, 371 teeth; moderate certainty) [5]. In the 2025 network meta-analysis, stepwise removal (risk ratio 1.11) and selective removal (1.06) showed gains in success over non-selective removal that were not statistically significant, and more than half of the studies were at high risk of bias [6].
In a Danish and Swedish multicentre trial of 314 adults with lesions reaching at least 75% of the dentine [9], stepwise removal led to fewer exposures at five years (21.2% versus 35.5%) and, counting exposures as failures, to more successful outcomes (60.2% versus 46.3%) [10]. In a Brazilian multicentre trial of 299 molars, one-visit selective removal to soft dentine maintained pulp vitality in 80% of teeth at five years, against 56% with stepwise removal [11], and restorations placed over the retained dentine survived similarly, whether amalgam or composite (79% versus 76%) [12]. In an 18-month trial on mature mandibular molars from Rohtak, India, all 13 exposures occurred with complete excavation, and success among the teeth reviewed did not differ significantly (98.2% versus 92.5%); the authors add that caries-detector dye is not caries-specific and can lead to removal of sound dentine [13].
What the guideline concludes. The guideline therefore suggests selective or stepwise rather than non-selective removal for deep lesions without symptoms of irreversible pulpitis, with strong consensus but very low to low certainty [3]. Between the two, selective removal may be preferred for lesions in the inner third but not the inner quarter of the dentine, while stepwise removal may also be used in the inner quarter; re-entry carries its own risk of exposure, and some patients do not return for the second visit [3].
Extremely deep lesions. An exploratory randomised trial from Singapore, published after the guideline's searches, allocated 120 vital mature teeth with lesions reaching at least 75% of the dentine, more than two-thirds of them extremely deep, to selective removal or full pulpotomy [14]. At three years, 29.5% of the reviewed teeth in the selective-removal group needed root canal treatment or extraction, against 10.8% after pulpotomy; the difference lay in the extremely deep lesions, and the small deep-lesion subgroup showed no significant difference [14]. Exploratory, single-setting and with substantial loss to follow-up, it does not overturn the guideline, but it supports treating an extremely deep lesion as a separate decision, discussed with the patient beforehand, in which a planned pulpotomy is worth raising when it can be delivered under the protocol in Step 4.
Step 4: Be ready for an exposure
The guideline asks clinicians to prepare for a possible exposure before starting, particularly in extremely deep lesions [3]. If the pulp is exposed in a tooth without symptoms of irreversible pulpitis, it suggests direct pulp capping or a partial or full pulpotomy after removal of the remaining carious tissue; with signs of irreversible pulpitis, a partial or full pulpotomy as an alternative to pulpectomy, guided by intraoperative findings such as haemostasis [3].
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