Management of deep dentine caries

16 September 2019

The FDI World Dental Federation’s recent adoption (September 2018) of a new Policy Statement, Dentine Caries and Restorative Care, may be of particular interest to dentists and dental professionals involved in the area of teaching.

The Policy Statement emphasises the need to update contemporary thinking on the treatment of carious dentine, in particular, conventions on tooth preservation, to align with the current evidence base. A summary of the key points of the Policy Statement follows below and it is also recommended that interested dental professionals review the policy in full on the FDI website www.fdiworlddental.org.

In 1859, John Tomes stated that "…it is better that a layer of discoloured dentine should be allowed to remain for the protection of the pulp rather than run the risk of sacrificing the tooth" (1) However, this view did not prevail, and 50 years later GV Black2 took an opposite stance: "…it is better to expose the pulp of a tooth than to leave it covered only with softened dentine." For much of the last century it has been standard practice to follow Black’s teachings and remove all carious dentine to the level of sound dentine, even if a pulp exposure resulted.

Over the last 20 or so years, evidence has emerged to support Tomes’ writings, and on 7 September 2018, the General Assembly of the FDI adopted a Policy Statement titled (Deep) Dentine caries and restorative care, subsequently published in the International Dental Journal. (3) The policy statement noted that "…complete removal of demineralised and discoloured dentine…is still taught at a large number of dental schools and practiced by a very large number of dentists…". The Policy Statement continues "…recent scientific evidence on caries excavation and cavity preparation is not well translated into undergraduate dental education and clinical practice, resulting in unnecessary removal of tooth substance".

The scope of the Policy Statement is to support the evidence-based recommendations and international consensus with the aim of maintaining pulp vitality in 'deep' cavities and thus increasing tooth longevity. The principles behind the Policy Statement are that the least invasive approach should be followed in order to halt disease progression and empower the patient to improve and maintain oral health.

The essentials of the Policy Statement are that in vital and symptomless teeth:

- non-demineralised and remineralisable dentine should be preserved;

- a seal should be obtained by placing a restorative material on peripheral sound dentine/enamel, thus controlling the lesion and inactivating remaining bacteria;

- if required, soft, affected dentine in proximity to the pulp should be left and sealed in; and

- enough soft dentine should be removed in order to accommodate a restoration of sufficient strength and seal.

Regarding clinical practice and education, the FDI Policy Statement recommends that clinicians should:

- apply evidence-based research results in their practices,

- be discouraged from using invasive methods which completely remove carious tissue close to the pulp, and

- adopt less invasive techniques of caries removal as recommended by the International Caries Consensus Cooperation:4 selective removal of carious tissue; step-wise excavation; the Hall Technique; the Atraumatic Restorative Treatment (ART) technique; nonrestorative caries control methods, e.g. silver diamine fluoride.

References supplied are available on request by emailing [email protected]

(article by Martin Tyas, Dental Instruments, Materials and Equipment Committee. First appearance in News Bulletin (September 2019) - you can access original article via News Bulletin online.)