journal of dentistry 40 (2012) 776782

Available online at www.sciencedirect.com

journal homepage: www.intl.elsevierhealth.com/journals/jden

Conventional caries removal and sealed caries in permanent

teeth: A microbiological evaluation

M. Maltz a,*, S.L. Henz a, E.F. de Oliveira b, J.J. Jardim a

a
Faculty of Odontology, Federal University of Rio Grande do Sul, Brazil
b
Faculty of Odontology, Federal University of Pelotas, Brazil

article info abstract

Article history: Objectives: The aim of this study was to compare microbiological infection after conven-
Received 1 December 2011 tional carious dentine removal with incomplete carious dentine removal and sealing.
Received in revised form Methods: Eighty-seven patients (1250 years of age) under treatment at the Dental Clinics of
23 May 2012 the Federal University of Rio Grande do Sul (UFRGS), Brazil, participated in the study. The
Accepted 25 May 2012 patients presented 90 posterior permanent teeth with primary caries. The lesions were
coronal, active, and reached at least the middle third of the dentine. None of the teeth
exhibited spontaneous pain, sensitivity to percussion or apical pathology (detected through
Keywords: radiographic exams). Pulp sensibility was confirmed by the cold test. The lesions were divided
Carious dentine removal into 2 experimental groups: complete caries removal (CCR) based on hardness criteria (n = 60
Stepwise excavation lesions) and incomplete caries removal (ICR) and sealing (n = 32 lesions). Microbiological
Arrested dentine lesions samples were obtained from the initial demineralized dentine, after CCR and after ICR-Seal.
Results: The number of anaerobic and aerobic bacteria, lactobacilli, and mutans streptococci
decreased at the end of treatment ( p < 0.05). Significantly less anaerobic bacteria ( p < 0.01),
aerobic bacteria ( p = 0.02), and mutans streptococci ( p < 0.01) growth was observed after
ICR-Seal compared to CCR. The difference in lactobacilli was insignificant ( p = 0.08). The
amount of bacteria detected after conventional caries removal was higher than that which
remained in sealed caries lesions.
Conclusions: The results suggest it is not necessary to remove all carious dentine before the
restoration is placed because over time, sealing of carious dentine results in lower levels of
infection than traditional dentine caries removal.
Clinical significance: The results of this study indicate that sealed carious dentine was less
infected than the remaining dentine left after conventional caries removal and sealing. Our
results support treatment of deep carious lesions in one session with incomplete removal of
carious dentine.
# 2012 Elsevier Ltd. All rights reserved.

1. Introduction
Carious dentine removal is an important step in the restora-
tion process. Microorganisms beneath the restoration are
believed to be the main cause of restoration failure.1
There is a high risk of pulp exposure if all the decayed tissue
is removed in deep carious lesions.2,3 One possible treatment
for exposed pulp is direct pulp capping; however, the success
rate for preserving tooth vitality is very low if this procedure is
performed in the presence of decayed tissue.35 An alternative

* Corresponding author at: Faculdade de Odontologia da UFRGS, Rua Ramiro Barcelos, 2492, Bom Fim., CEP: 90035-003, Porto Alegre, RS,
Brazil. Tel.: +55 051 3308 5247; fax: +55 051 33085439.
E-mail address: marisa.maltz@gmail.com (M. Maltz).
0300-5712/$ see front matter # 2012 Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jdent.2012.05.011
 journal of dentistry 40 (2012) 776782
to complete caries dentine removal is the stepwise excavation
technique.68 In conventional stepwise treatment, the carious
tissue is partially removed, a layer of carious dentine is left
over the pulp,9 and the tooth is temporarily sealed.2,7 This
procedure allows the pulp to react and form tertiary
dentine.10,11 Another alternative is partial caries removal in
one session, which avoids pulp exposure and preserves the
tooth structure.1216
Studies examining bacterial presence in deep caries have
demonstrated that the number of microorganisms is reduced
after incomplete carious dentine removal and tooth sealing
compared with conventional complete carious dentine re-
moval.7,14,17,18 Furthermore, the dentine underneath the
provisional restoration acquires the characteristics of an
inactive caries lesion (dry, hard, and dark).7,14 Despite these
findings, conventional treatment involves removal of all
carious dentine before restoration.1 In the stepwise treatment,
the sealed carious lesion is reopened and the remaining
carious dentine is removed. The discussion on whether or not
to leave infected dentine beneath the restoration overlooks
the well-established consensus that conventional caries
removal leaves bacteria beneath restorations. This consensus
is supported by data from the 1950s and 1960s.1921
The aim of this clinical study was to compare microbiolog-
ical infection after conventional carious dentine removal with
incomplete carious dentine removal and sealing.
2. Materials and methods
Eighty-seven patients (1250 years of age) under treatment at
the Dental Clinics of the Federal University of Rio Grande do
Sul (UFRGS), Brazil, participated in the study. The patients
presented 90 posterior permanent teeth with primary caries.
The lesions were coronal, active, and reached at least the
middle third of the dentine. None of the teeth exhibited
spontaneous pain or sensitivity to percussion. The absence of
apical pathology was established through radiographic exam-
inations, and pulp sensibility was confirmed by the cold test
(Aerojet, Rio de Janeiro, Brazil).
The lesion sample size was based on the calculations
performed by Lula et al.,32 which predicted the need for 16
restorations per treatment group. Taking into account a
potential dropout rate of 20%, the final number of restorations
required was set to a minimum of 20 restorations per group.
This study was approved by the Federal University of Rio
Grande do Sul Ethics Committee, and informed consent was
obtained from all participants.
2.1. Experimental design (Fig. 1)
Patients were treated under local anaesthesia and the teeth
were isolated by a rubber dam. When necessary, access to
dentine was obtained with a carbide bur. Standardized
dentine samples were taken for microbial analysis from the
initial carious dentine (ID) by using 2 sterile number 6 round
burs dampened with saline.7,2224 The burs were placed into a
vial containing 5 ml of reduced transport fluid (RTF), and the
samples were cultivated within 2 h.25 The lesions were then
divided into 2 experimental groups: 60 lesions were subjected
777
to conventional dentine caries removal based on the tactile
criterion of hardness to probe. A solution of 1% acid red (Sigma
Chemical Co., St. Louis, MO, USA) was applied to the cavity
with sterile cotton pellets for 10 s; the cavity was then rinsed
with saline and dried with sterile cotton pellets. Microbiolog-
ical samples were obtained in the same way from a non-
stained dentine site (complete caries removal; CCR). In the
second group 30 deep caries lesions at risk of pulp exposure if
the demineralized dentine was completely removed (lesion
deep was >2/3 dentine thickness assessed by radiographic
examination) were included. The carious tissue was complete-
ly removed from the surrounding cavity walls in accordance
with the clinical hardness criteria. However, a layer of soft
dentine was left on the pulpal wall so that the pulp was not
exposed. The cavity was washed with saline and dried with
sterile cotton pellets. Before collection of microbiological
samples (as described above), the lesions were divided into 2
halves in order to establish the donor area of initial and final
samples at the same depth9,26: for occlusal lesions in a mesio-
distal direction and for approximal lesion in a bucco-palatal or
bucco-lingual direction. The mesial or buccal dentine sample
was taken for microbiological analysis (immediately after
incomplete carious dentine removal; ICR). Calcium hydroxide-
containing base material (Dycal; Dentsply-Caulk, Rio de
Janeiro, Brazil) was applied on the pulpal wall of the cavity.
The cavity was sealed with modified zinc oxide-eugenol
cement (IRM; Dentsply-Caulk, Rio de Janeiro, Brazil). After 67
months, the temporary filling was removed under a rubber
dam to prevent contamination by saliva, and the distal or
palatal samples were collected from all teeth for microbiolog-
ical analysis (sealed carious dentine; ICR-Seal). Teeth were
then filled with a light-cure composite (Charisma; Kulzer, Sao
Paulo, Brazil).
2.2. Microbiological analysis
Samples were dispersed by sonication for 5 s in Vibra Cell
Tm# (Sonics & Material Inc., CT, USA), vortexed for 15 s,
diluted ten-fold in RTF, and 25 ml aliquots of the dilutions were
then cultivated in duplicate in 3 different culture media.
Isolation of mutans streptococci (MS; abbreviations used
in figures are shown here in parentheses) was performed in
Mitis Salivarius agar (Difco, MI, USA) supplemented with
sucrose and bacitracin at final concentrations of 20% and
0.2 units/ml (MSB), respectively.27 For isolation of lactobacilli
(LBC), Rogosa selective Lactobacillus agar (Difco, MI, USA) was
used. Counts of total colony forming units (CFU) were
obtained by culture in brain heart infusion agar (BHI; Difco,
MI, USA) supplemented with 5% sheep blood and enriched
with k-hemin vitamin.
The MSB was incubated under microaerophilic conditions
at 37 8C for 48 h. Colonies of mutans streptococci were counted
based on their morphology and confirmed with biochemical
tests.28 Rogosa SL Agar was incubated anaerobically at 37 8C
for 72 h. The pour-plate technique was used for lactobacilli
culture. The BHI was incubated anaerobically for 120 h in an
atmosphere containing 5% CO2 and 95% N2 to determine the
total anaerobic counts (AN). The BHI was also incubated
aerobically at 37 8C for 48 h to determine the total aerobic
counts (AE). The detection limit was 200 CFU per sample.
778 journal of dentistry 40 (2012) 776782
Deep caries lesion
n = 30
Sample of initial carious dentine
Incomplete caries removal
Dentine sampling
ICR
Temporary filling
for 6-7 months
Sampling
n = 30
ICR Seal
Fig. 1 Flow chart of clinical procedures and sampling.
2.3. Statistical analysis
Microorganism counts were expressed at log10 (widely
scattered data). A constant of 1 was added to the CFU counts
because many samples showed zero growth after the
experimental period. Friedmans nonparametric test was used
to compare the total CFU of microorganisms present in initial
carious dentine and in CCR dentine tissue. Friedmans
nonparametric test followed by Friedmans test for multiple
comparisons was used to compare the number of CFU for each
bacterial group in the 3 samples taken from group 2-deep
caries lesions (ID, ICR, and ICR-Seal).
The MannWhitney nonparametric test was used to
compare the different treatment groups with respect to (1)
the total microorganism CFU in the IDs and (2) the total
microorganism CFU in the CCR and ICR-Seal.
The x2 test incorporating Yates correction for continuity
was used to compare the bacterial growth in initial and final
samples of the different groups.
A level of significance of 0.05 was adopted. Analyses were
performed using the software Statistical Package for Social
Science (SPSS) version 18.0.
3. Results
The counts of anaerobic, aerobic, mutans streptococci, and
lactobacilli were significantly decreased at the end of all
treatments ( p < 0.05). Figs. 2 and 3 show the number of
anaerobic and aerobic microorganisms, mutans streptococci,
and lactobacilli in ID and in the samples from the CCR, ICR,
and ICR-Seal groups.
There was no significant difference between the growth of
aerobic and anaerobic microorganisms in ID of the deep caries
Dentine caries lesion
n = 60
ID
Conventional caries removal
Hardness criteria
Application of
1% acid red
Sampling
Unstaining sites
n = 60
CCR
lesion group ( p = 0.11). Immediately after the incomplete
carious dentine removal (ICR group), the aerobic microorgan-
ism count was 10% lower than the anaerobic count ( p = 0.009).
The same trend was observed at 67 months of treatment
(ICR-Seal group, Fig. 3).
The deep caries lesions submitted to incomplete caries
removal (group 2) showed higher numbers of aerobic micro-
organisms and lactobacilli in the initial dentine than did the
conventional carious dentine removal group (group 1,
p < 0.05), while no significant difference was observed
Fig. 2 Box plot of median counts log10 (colony forming
units {CFU}+1), 25th and 75th percentiles of anaerobic and
aerobic bacterial, mutans streptococci (MS) and lactobacilli
of the initial dentine (ID) and after complete carious
dentine removal (hardness criteria) (CCR). Different letters
show difference within each bacterial group (Friedmans
nonparametric test complemented by Friedmans multiple
comparisons test).
 journal of dentistry 40 (2012) 776782 779

8
a
group, but there was no difference in the lactobacilli counts
a
( p = 0.075) (Table 2).
b b a b Table 3 shows the number of samples with bacterial growth
6
a in the treatment groups before and after carious dentine
b
removal. All groups had fewer samples with bacterial growth
CFU (Log10)

4 c
after dentine removal, irrespective of the removal technique
c
( p < 0.05). In the partial dentine removal group, there was no
growth of lactobacilli or mutans streptococci after sealing the
2 cavity for 6 months.

c c

0 4. Discussion

This study compared the number of microorganisms remain-

1 IICR

2 IICR

3 IICR
ID

IICR

1 ID

2 ID

Lacto

3 ID
Aero
A 6-7 months

1 6-7 months

MS

2 6-7 months

Anaerobic Aerobic
Fig. 3 Box plot of median counts log10 (colony forming
units {CFU} + 1), 25th and 75th percentiles of anaerobic and
aerobic bacterial, mutans streptococci (MS) and lactobacilli
of the initial dentine (ID), immediately after incomplete
carious dentine removal (ICR) and after sealing for 67
months (ICR-Seal). Different letters show difference within
each bacterial group (Friedmans nonparametric test
complemented by Friedmans multiple comparisons test).
between the number of anaerobic microorganisms and
mutans streptococci in groups 1 and 2 ( p > 0.05) (Table 1).
Significantly lower numbers of CFU of anaerobic bacteria
( p < 0.001), aerobic bacteria ( p = 0.015), and mutans strepto-
cocci ( p = 0.003) were observed in the ICR-Seal than in the CCR
3 6-7 months
ing after conventional carious dentine removal with that after
incomplete carious dentine removal and tooth sealing. Greater
numbers of microorganisms were present in the dentine after
MS Lactobacilli the incomplete caries dentine removal than after convention-
al dentine removal. However, these numbers decreased
significantly after cavity sealing. The sealed carious dentine
was less infected than the dentine remaining after conven-
tional caries removal.
One limitation of microbiologic culture method is that it
underestimates the microbiologic taxa in comparison to other
microbiologic sampling such as DNA hybridization or 16sRNA.
Although our results could underestimate the microbial load,
this technique is currently used.28,32
Sampling was performed using sterile round burs, and the
weights of dentine collected here were comparable to those
reported by Weerheijm et al.,1 who also sampled using burs. A
similar amount of soft and hard dentine sampling is obtained
using this method.7 Lager et al.29 obtained significantly more
dentine by weight from hard caries-free dentine than soft
carious dentine. While Lager et al.,29 compared soft dentine to

Table 1 Number of samples with bacterial growth according to the different groups and microorganisms.
SM N (%) Lactobacilli N (%) Anaerobic N (%) Aerobic N (%)
CCR
Initial 41 (68.3) 38 (63.3) 60 (100) 28 (82.3)
After CCR 15 (25.0) 6 (10.0) 42 (70.0) 17 (50.0)
ICR
Initial 17 (56.7) 23 (76.7) 30 (100) 24 (80.0)
After ICR 15 (50.0) 26 (86.7) 30 (100) 28 (93.3)
After 6 months 0 (0.0) 0 (0.0) 9 (30.0) 5 (16.7)

Table 2 Percentiles of anaerobic and aerobic bacterial, mutans streptococci (MS) and lactobacilli counts log10 (colony
forming units {CFU} + 1) of the initial dentine from teeth submitted to conventional caries removal and to incomplete
carious dentine removal and sealing.
Microorganism Initial dentine Initial dentine
Conventional caries removal Incomplete caries removal
Group 1 Group 3

Percentiles Percentiles

25th 50th 75th 25th 50th 75th

a a
Anaerobic 3.54 4.98 5.99 4.58 5.34 6.03
Aerobic 2.60 3.33 a 5.34 3.91 5.27 b 5.80
MS 0.00 2.96 a 4.35 0.00 3.80 a 4.39
Lactobacilli 0.00 2.21 a 3.81 3.63 4.32 b 4.98
Statistical differences are expressed by different letters in lines (MannWhitney nonparametric test).
780 journal of dentistry 40 (2012) 776782
Table 3 Percentiles of anaerobic and aerobic bacterial, mutans streptococci (MS) and lactobacilli counts log10 (colony
forming units {CFU}+1) after complete carious dentine removal (hardness criteria) and after incomplete carious dentine
removal and sealing for a period of 67 months.
Microorganism Complete caries removal
Group 1
Percentiles
25th 50th
Anaerobic 0.00 2.55 a
Aerobic 0.00 0.66 a
MS 0.00 0.00 a
Lactobacilli 0.00 0.00 a
Statistical differences are expressed by different letters (MannWhitney nonparametric test).
dentine of sound teeth, Bjrndal et al.7 compared soft carious
dentine with inactive dentine caries. Sound dentine showed
higher microhardness than the remaining dentine left after
carious dentine removal and sealing.30 This difference in
microhardness could explain the differences in dentine
weight observed by Lager et al.29 This standardized sampling
procedure has been previously demonstrated to have high
reproducibility.22,23
The operative caries treatment includes removal of carious
dentine (infected/disorganized dentine) prior to tooth resto-
ration.31 In general, the clinical identification of infected/
disorganized dentine is carried out by tactile procedures
(softness to probe). These procedures are operator dependent;
thus, they do not ensure that only infected tissue is removed,
as the dentine hardness correlates with the dentine depth.
Therefore, complete carious dentine removal is difficult to
achieve clinically. Microorganisms have been detected after
removal of all soft demineralized dentine.1921,24,32 In the
present study microorganisms were found after conventional
carious dentine removal. The microorganism numbers we
found in the hard tissue after caries removal were in the same
range as has been reported by others.1922 Carious dentine
removal is still considered to be essential for the durability of
restorations despite the evidence that microorganisms are
present after dentine caries removal.1,33 Moreover, the
presence of microorganisms after conventional caries remov-
al seems to be of no clinical importance.16,29
Orhan et al.24 performed a clinical trial comparing partial
caries removal in one or two visits with complete caries
removal (hardness criteria) in permanent and deciduous
teeth. The results of microbiological sampling showed that
neither treatment completely eliminated the viable micro-
organisms present in the initial excavation. Although these
investigators did observe a significant decrease in micro-
organisms after the excavations performed in the stepwise
excavation group, no statistical analysis was performed to
compare the bacterial levels after partial caries removal and
sealing for three months with the levels after complete caries
removal. The authors presented only the data comparing the
final excavation in the stepwise excavation group with the
complete caries removal. An examination of their data reveals
no difference between the numbers of microorganisms found
after partial removal and sealing for three months and the
complete caries removal, suggesting there was no need for the
final excavation. In our study, the bacterial levels observed
after carious dentine removal and sealing were lower than
Sealed carious dentine
Group 2
Percentiles
75th 25th 50th 75th
3.87 0.00 0.00 b 2.48
2.30 0.00 0.00 b 0.00
0.66 0.00 0.00 b 0.00
0.00 0.00 0.00 a 0.00
after conventional caries removal. These findings strongly
suggest that (1) the methods traditionally recommended do
not eliminate microorganisms, and (2) it is not necessary to
remove all soft contaminated dentine before placing a
restoration. In this context, one may question whether it is
reasonable to establish objectives that are neither attainable
nor necessary.
It is has been suggested that bacteria present under the
restoration may impair the health of the pulp. For this reason
the current operative paradigm is to remove the infected
dentine. However, the pulp is capable of defending itself by
biological mechanisms. Massler34 studied the pulp reactions
to dental caries and concluded: in all cases, except when the
pulp is actually invaded by instrumentation or microorgan-
isms, the response of the pulp is productive and not
degenerative. Sclerosis of the underlying dentine and repara-
tive dentine is the rule not exception.
The aim of removing the superficial necrotic dentine and
sealing the teeth is to promote physiological reactions in the
pulp-dentine organ35 with deposition of tertiary dentine. This
dentine acts as a barrier to bacteriological products and thus
allows the pulp to heal.36
Our results support the incomplete removal of carious
dentine and placement of a restoration rather than the
stepwise treatment (re-entry to remove the carious dentine
left). Treatment of deep carious lesions in one session may
reduce the risk of pulp exposure during the re-entry procedure
and decrease treatment costs. Jardim37 performed a clinical
trial comparing stepwise excavation with partial removal of
carious dentine in one session in deep caries lesions. Using a
cost-effectiveness analysis, the author showed that the partial
caries removal procedure reduced the cost of the treatment by
45.24%.
The rationale behind removal of carious dentine is based
on rather blunt clinical criteria.29 It is not clear if bacteria left
beneath restoration represent any danger for the durability of
the restoration.38 Two recent clinical studies3,24 compared
stepwise excavation and partial caries removal in one session
with complete caries removal, and the authors found that
leaving bacteria beneath restorations had no effect on the
restoration survival at one year follow-up. The results are not
yet available from long-term studies that evaluate restorations
placed in deep caries lesions with different caries removal
techniques.
Several studies have been developed in order to test
less invasive methods to perform caries removal, such as
 journal of dentistry 40 (2012) 776782
chemo-mechanical excavation and air-abrasion.3942 Those
methods aimed to remove the caries affected dentine in a
minimally invasive way, showing favourable results com-
pared to conventional caries removal (burs and hand
excavators).3942 These results include a lack of difference in
the values of microtensile strength of adhesive systems
between chemo-mechanical caries removal and conventional
methods.41,42 Therefore, the maintenance of a higher amount
of caries affected dentine does not seem to influence some
mechanical aspects of the restoration technique.
The results of this study indicate that sealed carious
dentine was less infected than the remaining dentine left after
conventional caries removal and sealing. We conclude that it
is not necessary to remove all soft carious dentine before the
placement of the restoration because the sealing procedure
results, over time, in lower dentine infection than traditional
dentine caries removal.
Acknowledgements
We acknowledge support from the Brazilian Ministry of
Science and Technology through its agency National Council
of Research (CNPq), Rio Grande do Sul Research Foundation
(FAPERGS) and Kulzer (Sao Paulo Brazil).
references
1. Weerheijm KL, Kreulen CM, de Soet JJ, Groen HJ, van
Amerongen WE. Bacterial counts in carious dentine under
restorations: 2-year in vivo effects. Caries Research
1999;33:1304.
2. Leksell E, Ridell K, Cvek ME, Me`jare I. Pulp exposure after
stepwise versus direct complete excavation of deep carious
lesions in young posterior permanent teeth. Endodontics and
Dental Traumatology 1996;12:1926.
3. Bjrndal L, Reit C, Bruun G, Markvart M, Kjaeldgaard M,
Nasman P, et al. Treatment of deep caries lesions in adults:
randomized clinical trials comparing stepwise vs. Direct
complete excavation, and direct pulp capping vs. Partial
pulpotomy. European Journal of Oral Sciences 2010;118:2907.
4. Barthel CR, Rosenkranz B, Leuenberg A, Roulet JF. Pulp capping
of carious exposures: treatment outcome after 5 and 10 years: a
retrospective study. Journal of Endodontics 2000;26:5258.
5. Al-Hiyasat AS, Barrieshi-Nusair KM, Al-Omari MA. The
radiographic outcomes of direct pulp-capping procedures
performed by dental students: a retrospective study. Journal
of the American Dental Association 2006;137:1699705.
6. Magnusson BO, Sundell SO. Stepwise excavation of deep
carious lesions in primary molars. Journal of the International
Association of Dentistry for Children 1977;8:3640.
7. Bjrndal L, Larsen T, Thylstrup A. A clinical and
microbiological study of deep carious lesions during
stepwise excavation using long treatment intervals. Caries
Research 1997;31:4117.
8. Bjrndal L, Thylstrup A. A practice-based study on stepwise
excavation of deep carious lesions in permanent teeth: a 1-
year follow-up study. Community Dentistry and Oral
Epidemiology 1998;26:1228.
9. Eidelman E, Finn S, Koulourides T. Remineralization of
carious dentin treated with calcium hydroxide. Journal of
Dentistry for Children 1965;32:21825.
781
10. King JB, Crawford JJ, Lindall RL, Hill C. Indirect pulp capping:
a bacteriologic study of deep carious dentin in human teeth.
Oral Surgery Oral Medicine Oral Pathology 1965;20:66371.
11. Massler M. Treatment of profound caries to prevent pulpal
damage. Journal of Pedodontics 1978;2:99105.
12. Alves LS, Fontanella V, Damo AC, Ferreira de Oliveira E,
Maltz M. Qualitative and quantitative radiographic
assessment of sealed carious dentin: a 10-year prospective
study. Oral Surgery Oral Medicine Oral Pathology Oral Radiology
Endodontics 2010;109:13541.
13. Falster CA, Araujo FB, Straffon LH, Nor JE. Indirect pulp
treatment: In vivo outcomes of an adhesive resin system vs
calcium hydroxide for protection of the dentinpulp
complex. Pediatric Dentistry 2002;24:2418.
14. Maltz M, Oliveira EF, Fontanella V, Bianchi R. A clinical,
microbiologic, and radiographic study of deep caries lesions
after incomplete caries removal. Quintessence International
2002;33:1519.
15. Maltz M, Oliveira EF, Fontanella V, Carminatti G. Deep caries
lesions after incomplete dentine caries removal: 40-month
follow-up study. Caries Research 2007;41:4936.
16. Oliveira EF, Carminatti G, Fontanella V, Maltz M. The
monitoring of deep caries lesion after incomplete dentine
carious removal. results after fourteeneighteen months.
Clinical and Oral Investigations 2006;10:1349.
17. Besic FC. The fate of bacteria sealed in dental cavities.
Journal of Dental Research 1943;22:34954.
18. Pinto AS, de Araujo FB, Franzon R, Figueiredo MC, Henz S,
Garca-Godoy F, et al. Clinical and microbiological effect of
calcium hydroxide protection in indirect pulp capping in
primary teeth. American Journal of Dentistry 2006;19:3826.
19. MacGregor A, Marsland EA, Batty I. Experimental studies of
dental caries. British Dental Journal 1956;2:2305.
20. Whitehead FIH, MacGregor AB, Marsland EA. Experimental
studies of dental caries. II. The relation of bacterial invasion
to softening of the dentin in permanent and deciduous
teeth. British Dental Journal 1960;108:2615.
21. Shovelton DS. A Study of deep carious dentine. International
Dental Journal 1968;18:392405.
22. Kidd EAM, Joyston-Bechal S, Beighton D. Microbiological
validation of assessments of caries activity during cavity
preparation. Caries Research 1993;27:4028.
23. Paddick JS, Brailsford SR, Kidd EA, Beighton D. Phenotypic
and genotypic selection of microbiota surviving under
dental restorations. Applied Environmental Microbiology
2005;71:246772.
24. Orhan AI, Oz FT, Ozcelik B, Orhan K. A clinical and
microbiological comparative study of deep carious lesion
treatment in deciduous and young permanent molars.
Clinical and Oral Investigations 2008;12:36978.
25. Loesche WJ, Hockett RN, Syed SA. The predominant
cultivable flora of tooth surface plaque removed from
institutionalized subjects. Archives of Oral Biology
1972;17:131126.
26. Leung RL, Loesche WJ, Charbeneau GT. Effect of Dycal on
bacteria in deep carious lesions. Journal of the American Dental
Association 1980;100:1937.
27. Gold OG, Jordan HV, Van Hout JA. A selective medium for
Streptococcus mutans. Archives of Oral Biology 1973;18:135764.
28. Shklair IL, Keene HJ. A biochemical scheme for the
separation of the five varieties of Streptococcus mutans.
Archives of Oral Biology 1974;19:107981.
29. Lager A, Thornqvist E, Ericson D. Cultivatable bacteria in
dentine after caries excavation using rose-bur or Carisolv.
Caries Research 2003;37:20611.
30. Franzon R, Gomes M, Pitoni CM, Bergmann CP, Araujo FB.
Dentin rehardening after indirect pulp treatment in primary
teeth. Journal of Dentistry for Children 2009;76:2238.
782 journal of dentistry 40 (2012) 776782
31. Gilmore HW, Lund MR, Bales DJ, Vernetti JP. Operative
dentistry. St. Louis: C V Mosby Co.; 1982.
32. Lula EC, Monteiro-Neto V, Alves CM, Ribeiro CC.
Microbiological analysis after complete or partial removal of
carious dentin in primary teeth:a randomized clinical trial.
Caries Research 2009;43:3548.
33. Kreulen CM, de Soet JJ, Weerheijm KL, van Amerongen WE.
In vivo cariostatic effect of resin modified glass ionomer
cement and amalgam on dentine. Caries Research
1997;31:3849.
34. Massler M. Pulpal reactions to dental caries. International
Dental Journal 1967;17:44160.
35. Bjrndal L. Dentin caries: progression and clinical
management. Operative Dentistry 2002;27:2117.
36. Tziafas D, Smith AJ, Lesot H. Designing new treatment
strategies in vital pulp therapy. Journal of Dentistry
2000;28:7792.
37. Jardim JJ. Partial caries removal in permanent teeth. PhD
Thesis; 2010.
38. Kidd EA. How clean must a cavity be before restoration?
Caries Research 2004;38:30513.
39. Neves AdeA, Coutinho E, De Munck J, Van Meerbeek B.
Caries-removal effectiveness and minimal-invasiveness
potential of caries-excavation techniques: a micro-CT
investigation. Journal of Dentistry 2011;39:15462.
40. Banerjee A, Thompson ID, Watson TF. Minimally invasive
caries removal using bio-active glass air-abrasion. Journal of
Dentistry 2011;39:27.
41. Banerjee A, Kellow S, Mannocci F, Cook RJ, Watson TF. An
in vitro evaluation of microtensile bond strengths of two
adhesive bonding agents to residual dentine after caries
removal using three excavation techniques. Journal of
Dentistry 2010;38:4809.
42. Li H, Wang W-M, Yu S-L, Wen Q. Morphological and
microtensile bond strength evaluation of three adhesive
systems to caries-affected human dentine with
chemomechanical caries removal. Journal of Dentistry
2011;39:3329.