For vital permanent teeth requiring restoration, the ADA guide favours selective carious tissue removal over more aggressive approaches in most moderate and advanced lesions. But what does that actually mean when the bur is in your hand?
For years, one of the most familiar principles in restorative dentistry was simple: remove the decay until you reach hard dentine.
The problem is that deep carious lesions do not always give the clinician much room for error. The closer the lesion gets to the pulp, the greater the price of aggressive excavation can become.
The American Dental Association’s chairside guide on restorative treatment of caries lesions takes a more conservative approach. For vital, non-endodontically treated permanent teeth requiring restoration, the guideline prioritises selective carious tissue removal for both moderate and advanced lesions.
The important part is understanding what the guideline means by “selective.”
Selective does not mean leaving caries everywhere.
The ADA defines selective carious tissue removal as removing carious tissue until soft or firm dentine is reached, rather than continuing until hard dentine is encountered everywhere. Non-selective removal, by comparison, means removing carious tissue until hard dentine is reached.
That distinction becomes particularly relevant in deeper lesions.
For moderate caries lesions, defined in the guide as ICDAS 3 and 4, selective removal is prioritised over non-selective removal when a restoration is required.
For advanced lesions, ICDAS 5 and 6, the recommendation goes further: selective removal is prioritised over both stepwise caries removal and non-selective removal.
In other words, the recommendation is not simply “remove less.”
It is remove carious tissue selectively, preserve tooth structure and avoid unnecessary excavation—while still creating a restoration that can be successfully placed and maintained.
What about stepwise excavation?
This is an important distinction at the chairside.
Stepwise carious tissue removal involves removing caries to soft dentine initially, placing a temporary restoration, and then returning months later to remove the remaining carious tissue to firm dentine before placing the definitive restoration.
The ADA guide does not prioritise this approach over selective removal for advanced lesions.
Instead, selective removal is ranked ahead of stepwise and non-selective removal.
That is a clinically important shift for dentists who still routinely plan a second excavation simply because deep caries was left over the pulpal aspect.
The peripheral seal still matters
Selective removal should not be interpreted as “leave infected dentine wherever you want.”
The purpose is to preserve dentine where further excavation risks unnecessary pulpal exposure, while creating the conditions necessary for a durable restoration.
The guide specifically defines the endpoint of selective removal according to dentine consistency rather than insisting on hard dentine throughout the cavity.
And what should we restore it with?
The ADA guide does not identify one universal restorative material as the winner.
For posterior Class I lesions, the recommendations include conventional GIC, amalgam, resin composite or resin-modified GIC, with these options prioritised over compomer.
For posterior Class II lesions, amalgam, resin composite and resin-modified GIC are prioritised over conventional GIC.
For posterior Class V lesions, conventional GIC, hybrid resin composite and resin-modified GIC are suggested.
For root caries, the guide suggests either resin-modified GIC or conventional GIC, with a low certainty of evidence.
The recommendations are similarly site-specific for anterior restorations. For example, nanocomposite or hybrid resin composite is suggested for Class III lesions, while conventional GIC, hybrid composite or resin-modified GIC are options for Class I and Class V lesions.
When might GIC make more sense?
Conventional or resin-modified GIC may be preferable when isolation cannot be achieved, in patients with special healthcare needs, or when predictable access to care is a concern. Conventional GIC may also be preferable when light curing is not feasible.
The approach is particularly relevant in deep lesions, where unnecessary excavation can turn a tooth that could have been restored into one requiring pulp intervention.
These are conditional recommendations. The guide is intended to support clinical decision-making and should be used in consultation with the patient.