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 However, a comprehensive new review suggests that this long-standing approach may no longer represent the best strategy for managing deep carious lesions.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.
Recommendations from the International Caries Consensus Collaboration, the European Society of Endodontology, the Scottish Dental Clinical Effectiveness Programme and the American Dental Association now increasingly support selective caries removal for deep lesions in vital teeth.
This represents a substantial shift from traditional teaching and reflects a broader movement towards minimally invasive dentistry.
Why are dentists still divided?
Despite mounting evidence, adoption remains inconsistent worldwide.
Surveys from several countries reveal significant variation in how clinicians manage deep carious lesions. While some practitioners routinely use selective techniques, others continue to favour complete caries removal.
The authors suggest that factors such as undergraduate training, fear of treatment failure, medico-legal concerns, peer influence and limited awareness of current guidelines may contribute to this variation.
What does this mean for everyday practice?
For practising dentists, the message is clear: preserving pulp vitality should be a primary treatment objective when managing deep carious lesions.
The review emphasises that successful outcomes depend not only on the amount of dentine removed, but also on achieving a durable peripheral seal that prevents bacterial ingress and allows pulpal healing to occur.
As additional evidence emerges—including results from the ongoing Selective Caries Removal in Permanent Teeth (SCRiPT) trial—the debate surrounding deep caries management may finally move closer to resolution.
For now, the question facing clinicians is no longer whether all carious dentine can be removed, but whether it should be.
Clinical Takeaway
• Deep caries management is shifting towards pulp preservation rather than complete excavation.
• Selective caries removal significantly reduces the risk of accidental pulp exposure.
• International guidelines increasingly support minimally invasive approaches.
• A well-sealed restoration remains critical to treatment success.
• Preserving pulp vitality may ultimately be more important than removing every trace of discoloured dentine.