How ‘Clean’ Must a Cavity Be before Restoration?

Abstract

The metabolic activity in dental plaque, the biofilm at the tooth surface, is the driving force behind any loss of mineral from the tooth or cavity surface. The symptoms of the process (the lesion) reflect this activity and can be modified by altering the biofilm, most conveniently by disturbing it by brushing with a fluoride-containing toothpaste. The role of operative dentistry in caries management is to restore the integrity of the tooth surface so that the patient can clean. Thus, the question, ‘how clean must a cavity be before restoration?’ may be irrelevant. There is little evidence that infected dentine must be removed prior to sealing the tooth. Leaving infected dentine does not seem to result in caries progression, pulpitis or pulp death. However, some of the bacteria survive. What is their fate and if they are not damaging, why is this?

Efficacy of chemomechanical caries removal in reducing cariogenic microbiota: a randomized clinical trial

“…Actually, it is not even possible to remove all the infected dentine. 21 The relevant bacterial reduction observed in the present study, regardless of the method used to remove caries, indicates that the necrotic and highly infected dentine was removed by excavation. Although the clinical criteria of dental firmness are subjective, it seemed to be enough to guide the operator to decide when to stop removing the caries.…”

“…1,4,6,12,21 In pediatric dentistry, chemomechanical methods (Carisolv ™ and Papacárie ® ) and ART aim to remove only softened and infected dentine, avoiding over-preparation of the cavity, eliminating pain and discomfort, and reducing both the need for anesthesia and the level of dental anxiety. Satisfactory results with chemomechanical methods have been observed in clinical studies, in regard to preserving tooth structure and promoting patient acceptability.…”

“…However, the dentin is invaded by microorganisms very early during the caries process and even a so-called complete caries removal does not guarantee complete elimination of the bacteria 21 . After partial caries removal, some bacteria still remain within the affected dentine tissue, but this bacteriological content is compatible with health.…”

Aviation dentistry: current concepts and practice

“…Nevertheless, as Sognnaes suggested, 17 it seems that such lesions carry dangers in a pressure-changed environment and should be removed. Moreover, although there is supportive evidence for treating deep carious lesions by the indirect pulp capping technique (in which leathery/softened and wet pulpal dentine is not removed, but sealed) in the general population, 44 it is not recommended for aircrews, who are daily exposed to barometric pressure changes. After carious tissue is removed, the clinician has to carefully examine the cavity fl oor and rule out penetration to the pulp chamber.…”

Estimation of remaining dentine thickness below deep lesions of caries

“…The need to remove dentine in deep lesions to the point of being hard and stain-free while risking pulpal exposure if the tooth has been symptom-free is no longer necessary. 1 Alternative techniques, such as atraumatic restorative treatment 2 and stepwise excavation, 3 appear to be very successful in maintaining pulpal health and vitality. In conventional treatment of deep lesions of caries, 40% of treated teeth had pulpal exposures compared to 17.5% with the stepwise approach.…”