New review highlights growing global shift towards selective caries removal
For generations, dentists were taught a simple rule when treating caries: remove all decayed tooth structure before placing a restoration. However, a comprehensive new review suggests that this long-standing approach may no longer represent the best strategy for managing deep carious lesions.
The review, published in the British Dental Journal, examines more than two decades of evidence on deep caries management and concludes that selective caries removal techniques are increasingly supported by scientific evidence, international guidelines and contemporary understanding of pulp biology.
Historically, complete caries removal was considered the gold standard. The rationale was straightforward: any remaining infected dentine could allow disease progression beneath a restoration. However, complete excavation often comes at a cost—an increased risk of pulp exposure, especially in teeth with deep lesions.
Researchers note that our understanding of dentine caries has evolved significantly. Deep carious lesions contain two distinct zones: an outer infected layer that is heavily contaminated and irreversibly damaged, and an inner affected layer that contains intact collagen and retains the potential for remineralisation.
This distinction has changed the philosophy of treatment.
Rather than removing all softened dentine, selective caries removal aims to eliminate heavily infected tissue while preserving affected dentine close to the pulp, thereby reducing operative trauma and maintaining pulp vitality.
Evidence increasingly favours selective removal
The review highlights findings from multiple clinical studies and Cochrane systematic reviews demonstrating that less invasive approaches significantly reduce the risk of accidental pulp exposure.
According to the evidence cited, selective caries removal can reduce pulp exposure risk by as much as 77% compared with complete excavation techniques.
Furthermore, studies have shown that when residual carious dentine is effectively sealed beneath a restoration, bacterial activity decreases, lesion progression arrests and pulpal health can be maintained.
Researchers also point out that reopening cavities during stepwise excavation may subject the pulp to additional trauma, potentially compromising long-term outcomes.
International guidelines are beginning to align
One of the most notable developments identified in the review is the growing consensus among major international organisations.
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