A Systematic Approach To Deep Caries Removal End Points

Q U I N T E S S E N C E I N T E R N AT I O N A L
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A systematic approach to deep caries removal te
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end points: The peripheral seal concept ss en c e fo r
in adhesive dentistry
David S. Alleman, DDS1/Pascal Magne, DMD, PhD2
The objective of this article is to present evidence-based protocols for the diagnosis and
treatment of deep caries lesions in vital teeth. These protocols combine caries-detecting
EZFXJUIBOBUPNJDBMBOEIJTUPMPHJDLOPXMFEHFUPBSSJWFBUJEFBMDBSJFTSFNPWBMFOEQPJOUT
GPSBEIFTJWFSFTUPSBUJPOT%*"(/0EFOUMBTFSGMVPSFTDFODFUFDIOPMPHZDBOBMTPCFVTFEUP
confirm these end points. These ideal caries removal end points generate a peripheral seal
[POFUIBUDBOTVQQPSUMPOHUFSNCJPNJNFUJDSFTUPSBUJPOT"SFWJFXPGUIFQVCMJTIFEMJUFSBUVSF
since 1980 on caries, caries diagnosis, and caries treatments and their relationships to
BEIFTJWFCPOEJOHUFDIOJRVFTXBTDBSSJFEPVU$PNCJOJOHBOBUPNJDBMNFBTVSFNFOUTBOE
QBUIPMPHJDBOEIJTUPMPHJDLOPXMFEHFXJUIDBSJFTEFUFDUJOHEZFBOE%*"(/0EFOUMBTFS
fluorescence technologies can produce ideal caries removal end points for adhesive
EFOUJTUSZXJUIPVUFYQPTJOHWJUBMQVMQT(Quintessence Int 2012;43:197–208)
Key words: adhesive dentistry, biomimetic restorations, caries removal,

indirect pulp capping
The most common pathology clinicians treat junction (DEJ), complete removal of caries
is caries and its resulting decay.1 The treat- by the traditional visual and tactile tech-
ment of this disease involves the diagnosis nique has been successful. The minimally
and management of the patient’s biofilm invasive dental treatments for these smaller
and then the remineralization or restoration lesions using air abrasion, sonic diamond
of the damaged tooth structure.2–5 Treating tips, glass-ionomer cement, and bonded
EFDBZ XJUIPVU USFBUJOH UIF DBVTF PG EFDBZ composite resin have reduced the need for
JT B QSPCMFN UIBU UIF $".#3" $BSJFT traditional preparations that eliminate impor-
.BOBHFNFOU#Z3JTL"TTFTTNFOU
QSPHSBN tant anatomical structures.11–15 )PXFWFS GPS
is seeking to resolve. 6,7
Small lesions can lesions of medium and large depths, more
often be treated nonsurgically, according sophisticated techniques are required for
UPUIFSFWJTFE*OUFSOBUJPOBM$BSJFT%FUFDUJPO determining ideal caries removal end points
BOE "TTFTTNFOU 4ZTUFN *$%"4 **
8 After (Fig 1).
the systemic disease is treated and incipi- Using traditional visual and tactile tech-
ent lesions are remineralized9 or infiltrat- niques for these larger lesions is often
ed,10 DMJOJDJBOT BSF MFGU UP EFUFSNJOF IPX inconsistent for determining optimal caries
much of the caries should be removed removal end points that consistently preserve
CFGPSF SFTUPSBUJPO 'PS TNBMM TIBMMPX UPPUI TUSVDUVSF BOE SFNPWF JOGFDUJPO XJUIPVU
lesions limited to the enamel and super- exposing the pulp. Such ideal caries removal
ficial dentin closest to the dentinoenamel FOEQPJOUTXPVMEQSFTFSWFQVMQWJUBMJUZXJUI-
out limiting the strength and durability of the
BEIFTJWF SFDPOTUSVDUJPO 3FTFBSDIFST BOE
1
Codirector, Alleman-Deliperi Center for Biomimetic Dentistry, DMJOJDJBOT IBWF TUSVHHMFE XJUI UIF QSPCMFN
South Jordan, Utah, USA. PGUPPNVDIWTOPUFOPVHIXIFOJUDPNFTUP
2
Associate Professor, Don and Sybil Harrington Foundation the removal of decayed tissue.16–18
Chair of Esthetic Dentistry, Division of Primary Oral Health Care, This paper outlines a system for deter-
The Herman Ostrow School of Dentistry of the University of
mining more predictable caries removal
Southern California, Los Angeles, California, USA.
end points for deeper lesions in vital teeth.
Correspondence: Dr David S. Alleman, Alleman-Deliperi Center
5IJT BQQSPBDI JT CBTFE PO EFUBJMFE LOPXM-
for Biomimetic Dentistry, 10319 S. Beckstead Ln, South Jordan,
UT 84095. Email: allemancenter@gmail.com edge of three-dimensional dental anatomy,
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Fig 1 Intermediate and deep Fig 2 The concept of a periph- Fig 3 Caries removal end points for the peripheral seal
caries lesions have many visual eral seal zone is that the enamel, zone can be determined with a combination of caries-
and tactile complexities that can DEJ, and superficial dentin consti- detecting dye and DIAGNOdent technologies.
be systematically approached tute the caries-free area of a high-
with caries removal end point and ly bonded adhesive restoration.
peripheral seal zone protocols.
histology, microbiology, and adhesive seal zone, a bondability of approximately 30

EFOUBM TDJFODF 5IJT LOPXMFEHF JT UIFO .1BXJMMCFPCUBJOFEJOUIFEFFQFSBSFBTPG
JOUFHSBUFE XJUI WJTVBM EZF TUBJOJOH -BTFS the preparation.25 5IJT XJMM CF DPOGJSNFE CZ
fluorescence technologies can also be light pink staining from caries-detecting dye.
added to guide the clinician in deep caries %*"(/0EFOU DBO BMTP IFMQ EFUFSNJOF UIF
diagnosis and removal. This combination DBSJFT SFNPWBM FOE QPJOU XJUI SFBEJOHT PG
of multiple overlapping techniques can approximately 20–24 for intermediate dentin
remedy the shortcomings of using only the and approximately 36 for deep dentin (Fig
tactile and visual method.19 3).26,27 On average, intermediate dentin is 3
The general objectives of this systematic to 4 mm from the occlusal surface and deep
approach to caries removal end point deter- dentin is 4 to 5 mm from the occlusal sur-
mination are the maintenance of pulp vitality GBDF $MJOJDJBOT DBO QSFWFOU QVMQ FYQPTVSF
after restoration by adhesive methods; the by leaving the infected outer caries inside
elimination of dentinal infections by remov- UIF QFSJQIFSBM TFBM [POF XIFO SFNPWBM
ing, deactivating, or sealing in bacteria; and XPVME SJTL QVMQ FYQPTVSF 5IJT XPVME CF
the conservation of intact tooth structure in small circumpulpal areas deeper than
for long-term biomimetic function. The spe- 5 mm from the occlusal surface. These
cific objectives of caries removal end point TNBMMJOGFDUFEBSFBTXJMMTUBJOSFEGSPNDBS-
determination are the creation of a peripher- JFTEFUFDUJOH EZF BOE IBWF %*"(/0EFOU
al seal zone and the absolute avoidance of readings higher than 36. Achieving these
QVMQBM FYQPTVSF XIJMF HFOFSBUJOH B IJHIMZ objectives should result in highly bondable
CPOEFESFTUPSBUJPOXJUIFYDFMMFOUMPOHUFSN QSFQBSBUJPOT UIBU XJMM TVQQPSU BEIFTJWF MBZ-
prognosis. First, by creating a peripheral ers and remain bonded for the long term, an
TFBM [POF UP NN XJEF DPOTJTUJOH PG essential requirement for large biomimetic
normal superficial dentin, DEJ, and enamel dental reconstructions (Fig 3).28–33
(Fig 2), a bond strength of approximately
45–55 MPa can be generated.20,21
5IJT QFSJQIFSBM TFBM [POF XJMM CF
confirmed by the total absence of car- HISTOLOGY
ies-detecting dye staining.22–24 This caries- OF CARIES LESIONS
free zone can also be confirmed by a
%*"(/0EFOU ,B7P
SFBEJOH PG BQQSPYJ- In 1980, Takao Fusayama published the
NBUFMZ $PNNFSDJBM QSPEVDUT TVDI BT research carried out by his team at Tokyo
$BSJFT %FUFDUPS ,VSBSBZ
$BSJFT 'JOEFS Medical and Dental University on the analy-
(Danville), and Seek (Ultradent) are exam- sis of caries lesions.34 Using histologic, bio-
ples of caries-detecting dye. Second, by chemical, biomechanical, microscopic, and
leaving the slightly infected and partially microbiologic techniques, the researchers
demineralized but highly bondable affected XFSFBCMFUPEJTUJOHVJTIUXPMBZFSTJODBSJFT
inner carious dentin inside the peripheral MFTJPOT UIBU XFSF WFSZ EJGGFSFOU JO OBUVSF
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5IF GJSTU MBZFS XBT OBNFE iPVUFS DBSJPVT colored solutions (one purple, one red) 38
lica
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EFOUJOw *U XBT IJHIMZ JOGFDUFE BDJEJD BOE that stained the outer and inner carious den- t
ess c e n
ot
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fo r
demineralized. The collagen fibrils in this tin layers differently. The outer carious den- en
MBZFS XFSF EFOBUVSFE IBWJOH MPTU NPTU tin stained dark red, and the inner carious
of their intermolecular cross-linkages. This dentin stained lighter (pink for the red dye
MBZFSXBTOPUTFOTJUJWFUPDPOUBDUBOEDPVME GPSNVMB
5IFJOUFSQIBTFCFUXFFOUIFPVUFS
CF SFNPWFE XJUIPVU BOFTUIFTJB CFDBVTF JU BOEJOOFSDBSJPVTEFOUJOXBTSFGFSSFEUPBT
had lost the hydrodynamic system of intact the turbid layer. This interphase is a mixture
dentinal tubules. This layer also failed to PGQBSBMMFMHSPVQTPGUVCVMFT TPNFPGXIJDI
SFNJOFSBMJ[F JO B OBUVSBM XBZ CFDBVTF UIF BSFPVUFSDBSJPVTEFOUJOBOETPNFPGXIJDI
DPMMBHFO GSBNFXPSL DPVME OPU SFUVSO UP are inner carious dentin (depending on
OPSNBM FWFO JG UIF BDJE FOWJSPONFOU XBT IPX MPOH UIF UVCVMFT IBWF CFFO JOGFDUFE
OFVUSBMJ[FE 5IF TFDPOE MBZFS XBT UFSNFE and under the influence of bacterial acids).
iJOOFS DBSJPVT EFOUJOw 5IJT MBZFS XBT QBS- Under the turbid layer, the inner carious
tially demineralized and slightly infected, dentin becomes the transparent zone. The
but the collagen fibrils retained their natural transparent zone is translucent in histologic
structure around intact dentinal tubules. FYBNJOBUJPO XJUI B MJHIU NJDSPTDPQF 5IF
#FDBVTF PG UIJT SFNBJOJOH TUSVDUVSBM JOUFH- pink staining (often referred to as a pink
SJUZ UIF JOOFS DBSJPVT EFOUJO XBT TFOTJUJWF haze) in the turbid layer becomes lighter as
UP SFNPWBM XJUIPVU BOFTUIFTJB 5IF MVNFOT it moves into the transparent zone. In this
of the dentinal tubules in this layer had no zone, the large lumens of the dentin tubules
QFSJUVCVMBS SJOHT PG IZESPYZBQBUJUF <$B10 BSF GJMMFE UP TPNF EFHSFF XJUI 8IJUMPDLJUF
(PO4)6 0)
2]. Instead, the enlarged lumens 5IFTF MBSHF DSZTUBMT TMPX CBDUFSJBM JOWB-
XFSF OPX QBSUJBMMZ PS DPNQMFUFMZ GJMMFE XJUI sion and reduce dentin permeability. This
large crystals of tribeta calcium phosphate reduced permeability decreases the out-
<$B3 (PO4)2] called Whitlockite.35 Whitlockite XBSEGMPXPGQVMQBMGMVJE XIJDIJTSFGFSSFEUP
is crystallized into the dentinal tubules as BTiUSBOTVEBUJPOw*UBMTPSFEVDFTUIFNPWF-
hydroxyapatite is dissolved from intertu- ment of pulpal fluid caused by temperature
bular dentin by bacterial acids. This inner changes. Underneath the transparent zone
MBZFS PG UIF DBSJFT MFTJPO XBT BCMF UP CF is an interphase of the transparent zone, as
SFTUPSFE UP B OPSNBM NJOFSBMJ[BUJPO XJUI B XFMM BT OPSNBM TFOTJUJWF EFOUJO DBMMFE UIF
hydroxyapatite matrix surrounding the col- iTVCUSBOTQBSFOU[POFw 'JH

lagen fibrils (intertubular dentin) and around The subtransparent zone stains even
UIFUVCVMFT QFSJUVCVMBSEFOUJO
XIFOUIFQ) more lightly than the transparent zone.
XBTOFVUSBMJ[FE36 3FNPWBMPGUIFUSBOTQBSFOUBOETVCUSBOTQBS-
Since the late 1960s, the goal of remov- ent zones in an attempt to reach hard dentin
ing only outer caries and saving the inner is the cause of most pulp exposure (Fig 5).
caries for remineralization has been recog- The pink-haze staining (as differentiated
nized.375IFQSPCMFNXBTUIBUFBDIPQFSB- from the red staining) of the inner carious
tor had a different sense of hard and soft. EFOUJO XBT OFWFS EJTDVTTFE CZ 'VTBZBNB
$MJOJDBMMZ GJOEJOH UIF JOUFSQIBTF CFUXFFO JO FJUIFS PG IJT UXP CPPLT PS BOZ PG IJT
the outer and inner carious dentin layers NBOZ QVCMJTIFE BSUJDMFT )F POMZ SFGFSSFE
XBT JODPOTJTUFOU "EEJOH UP UIF EJGGJDVMUZ to stained or unstained caries. As a result,
XBT UIF BOBUPNJDBM TPGUFOJOH PG EFOUJO BT many users of caries-detecting dye solu-
it nears the pulp (reparative dentin, laid UJPOT CFDBNF DPOGVTFE BCPVU FYBDUMZ IPX
EPXOEVSJOHUIFDBSJFTQSPHSFTTJPO JTFWFO to use it. If all of the lightly stained dentin
softer than deep dentin) and the fact that XBT SFNPWFE VOEFS UIF BTTVNQUJPO UIBU JU
different instruments (hand, rotary, or ultra- contained a significant number of bacteria,
sonic) removed more or less of the lesion then an increased number of pulp expo-
during excavation. All of this subjectivity sures occurred.39–41 Other researchers in
and variability made for inconsistent car- +BQBOXIPIFMQFEXJUI'VTBZBNBTPSJHJOBM
ies removal end points. Fusayama made research came to the conclusion that the
QSPHSFTT UPXBSE B TPMVUJPO UP UIJT QSPC- MJHIUMZTUBJOFEBSFBTXFSFNPTUMZVOJOGFDUFE
MFNCZGJOEJOHUXPQSPQZMFOFHMZDPMoCBTFE XJUI JOUBDU DPMMBHFO GJCSJMT TVSSPVOEFE CZ
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Fig 4 The deep caries lesion has two parts: outer and inner cari- Fig 5 By using only visual and tactile methods
ous dentin. The inner carious dentin has three parts: the turbid for deep caries removal, the pulp is often exposed
layer, transparent zone, subtransparent zone, and normal dentin. because the tansparent zone, the subtransparent
zone, normal deep dentin, and reparative dentin are
all softer than superficial and intermediate dentin.
high levels of hydroxyapatite and Whitlockite 5IFTFGJOEJOHTXFSFSFQSPEVDFEJOBTFDPOE

and should therefore be preserved for TUVEZBUUIF6OJWFSTJUZPG#FSO26,51 The differ-
remineralization. 42–45
Further research in ent readings in deeper lesions correspond
"NFSJDB DMBSJGJFE UIF SFMBUJPOTIJQ CFUXFFO approximately to the proportional differences
TUBJOJOHBOECBDUFSJBMMFWFMT)JTUPMPHJDBOE in pulpal fluid/mm2 at the DEJ vs circumpulpal
NJDSPCJPMPHJDBOBMZTJTTIPXFEUIBUUIFDPS- areas. This is because dentinal tubules are
relation is high in the darkly stained outer three times more concentrated near the pulp
DBSJFT CVUOPUXJUIJOUIFJOOFSDBSJFT XIJDI than they are near the DEJ.15,52 Depending
stained lightly.46There appeared to be a POUIFQFSNFBCJMJUZPGUIFJOOFSDBSJFT XIJDI
need for a clinical technology that could is related to the amount of Whitlockite in the
assess the amount of bacteria in the lightly EFOUJOBM UVCVMFT
UIFSF XJMM CF B HSFBUFS PS
stained inner caries. lesser diffusion of the porphyrins (hence, the
*O UIF MBUF T B OFX MBTFSGMVPSFT- IJHIWBSJBODFJOUIF%*"(/0EFOUSFBEJOHTJO
DFODFUFDIOPMPHZ %*"(/0EFOU
XBTJOUSP- intermediate and deep inner carious dentin).
EVDFE BT B XBZ UP EJBHOPTF JOJUJBM DBSJFT An increase of demineralized dentin in inner
lesions (Fig 6). Teams of investigators in DBSJPVT EFOUJO BOE EFOBUVSFE DPMMBHFO XJUI
(FSNBOZBOE4XJU[FSMBOEGPVOEUIBUCBDUF- high demineralization in the outer carious den-
rial metabolic products called porphyrins UJO XJMM JODSFBTF UIF WPMVNF PG QVMQBM GMVJE JO
XPVME GMVPSFTDF XIFO JSSBEJBUFE XJUI B the outer and inner carious dentin. In turn, this
655-nm red laser. This fluorescence could XJMM BMMPX UIF QPSQIZSJO EJGGVTJPO UP JODSFBTF
be read and given a numeric value that cor- XIJDI XJMM DBVTF IJHIFS %*"(/0EFOU SFBE-
responded approximately to the amount of ings in the outer carious dentin and deep
bacteria present.47,48 JOOFS DBSJPVT EFOUJO #PTUPO BOE 4BVCMF22
%*"(/0EFOU QSPWFE JUT FGGJDJFODZ GPS DPOGJSNFE UIF (FSNBO BOE 4XJTT FYQFSJ-
the nondestructive diagnosis of pit and fis- NFOUTBOEDPSSFMBUFEUIFNXJUIUIF+BQBOFTF
sure caries.49,50 In vivo investigations using SFTFBSDI VTJOH DBSJFTEFUFDUJOH EZF #PTUPO
%*"(/0EFOU TIPXFE UIBU JU NJHIU BMTP CF and Liao also investigated the light pink stain-
used to establish a caries removal end point ing of circumpulpal dentin and concluded
UIBU DPSSFMBUFE XJUI USBEJUJPOBM FYDBWBUJPO UIBU JU XBT EVF UP UIF IJHIFS QFSDFOUBHF PG
UFDIOJRVFT %*"(/0EFOU SFBEJOHT GPS UIF collagen not completely surrounded by the
TVQFSGJDJBMEFOUJOFOEQPJOUXFSF hydroxyapatite matrix and not from denatured
= (< 12). The end points for intermediate to collagen (as in outer carious dentin) or from
EFFQ EFOUJO XFSF
acidic demineralization (as in inner carious
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Fig 6 DIAGNOdent reads bacterial products called
lica
tio
porphyrins and is used to assess the relative amount te otn
n
of bacteria present in a caries lesion. ss e n c e
fo r
dentin).18,53,54 Staining and remineralization achieved predictably inside the peripheral

also makes for higher variability and less pre- seal zone by further excavation of the red
dictability of any technology. For superficial PVUFSDBSJPVTEFOUJO)PXFWFS XIFOFYDB-
EFOUJO UIF%*"(/0EFOUSFBEJOHTPGPS vation is near the pulp (> 5 mm from the
corresponded to a nonstaining and bacteria- occlusal surface or > 3 mm from the DEJ)
free caries-removal end point.12 A group at and the caries-detecting dye still stains red,
4IPXB6OJWFSTJUZJO5PLZPEFWFMPQFEBQPMZ- FYDBWBUJPO TIPVME TUPQ 5IJT QSPUPDPM XJMM
QSPQZMFOF HMZDPMoCBTFE $BSJFT$IFDL EZF eliminate most pulp exposures (Figs 7 to 9).
/JTIJLB
UIBU TUBJOFE POMZ UIF PVUFS DBSJPVT Avoiding direct pulp caps has been
dentin and not the inner carious dentin. This TIPXO UP SFEVDF UIF OFFE GPS TVCTFRVFOU
type of caries-detecting dye gave the same endodontic treatment.58–60$POTFSWJOHNPSF
SFTVMUT JO TVQFSGJDJBM EFOUJO %*"(/0EFOU dentin in tooth preparations has also been
XJUI OP TUBJOJOH
BT 'VTBZBNBT QSPQZM- TIPXO UP SFEVDF UIF JODJEFODF PG JSSFWFST-
ene glycol–based caries-detecting dye.55#VU ible pulpitis.61#ZFMJNJOBUJOHPSSFEVDJOHUIF
CFDBVTFUIJTIJHIFSNPMFDVMBSXFJHIUDBSJFT surface area and thickness of the nonelastic
detecting dye formula does not lightly stain and deformable outer carious dentin, the
the turbid layer, transparent zone, and sub- performance of a bonded composite under
transparent zone, it is not as useful to find the GVODUJPOBMMPBETXJMMBMTPJNQSPWF62
caries removal end point that is ideal for the The final goal of ideal caries removal
highest dentin bond strength in the peripheral end points and peripheral seal zones is
seal zone.56 This is because clinicians are not UP DSFBUF BO BEIFTJWF CPOE UIBU XJMM CF
able to detect inner carious dentin that should preserved for as long as possible. Such a
be removed for the highest bond strength in bond to dentin should mimic the strength
UIFQFSJQIFSBMTFBM[POF)PXFWFS "NFSJDBO of a natural tooth. The tensile strength of
and Japanese researchers did not test the the DEJ has been measured at 51.5 MPa.63
deeper lesions like the Europeans did. Only bonding to sound dentin can achieve
$PNCJOJOH DBSJFTEFUFDUJOH EZF BOE and even exceed this tensile bond strength.
%*"(/0EFOU DBO HJWF DMJOJDJBOT BOPUI- 6TJOHUIFiHPMETUBOEBSETwUISFFTUFQUPUBM
FS XBZ UP EFUFSNJOF XIFO UIF FYDBWBUFE FUDI PS UXPTUFQ NJMEMZ BDJEJD TFMGFUDIJOH
MFTJPO JT FTTFOUJBMMZ CBDUFSJBGSFF XIJMF BU dentinal bonding systems are the most
the same time not removing affected inner consistent bonding strategies to obtain
carious dentin inside the peripheral seal these high bond strengths.20,64 Adhesive
zone. 57
The anatomical depth of the lesion bonding to normal and carious dentin has
needs to be monitored to make the cor- been studied for the past 15 years at the
SFDU EFUFSNJOBUJPO PO XIFUIFS UP QSPDFFE .FEJDBM$PMMFHFPG(FPSHJBVOEFSUIFEJSFD-
XJUI UIF SFNPWBM PG PVUFS DBSJPVT EFOUJO tion of David Pashley.25,65 These studies
inside the peripheral seal zone. Measuring have been continued at many Japanese
GSPN JOUBDU UPPUI TUSVDUVSF XJUI POF PS UXP universities. This research has established
periodontal probes (see Fig 4) is a useful the bond strengths of normal and carious
UFDIOJRVF UP EFUFSNJOF XIFO UIF FYDBWB- dentin. Inner carious dentin loses 25% to
tion is into circumpulpal areas (5 to 6 mm 33% of its bondability.25,65 Outer carious
from the occlusal surface). If the excavation dentin has a reduction of bondability of over
is into intermediate dentin (3 to 4 mm from 66%.21,66 This reduction in bondability cor-
the occlusal surface), the caries removal responds to the amount of demineralization
FOE QPJOUT XJUI MJHIU QJOL TUBJOJOH DBO CF in the outer and inner carious dentin.67 The
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Fig 7 Deep caries lesion showing the outer carious Fig 8 Caries removal end points for a deep lesion.
dentin staining red and extending to the circum- The peripheral seal zone has been created without
pulpal dentin ( > 5 mm from the occlusal surface). exposing the pulp. A small amount of outer carious
dentin is left on top of the inner carious dentin inside
the peripheral seal zone.
Fig 9 Clinical case illustrating Fig 8. The ideal caries

removal end points for highly bonded restorations
without pulpal exposure.
$BSJTPMW DIFNPNFDIBOJDBM UFDIOJRVF PG UP SFEVDUJPO JO CPOE TUSFOHUI XJMM
caries removal leaves a thin layer of residu- be observed after (approximately in the first
al outer carious dentin that may reduce the 12 months) restoration placement. A 0.2% to
NJDSPUFOTJMFCPOETUSFOHUI N5#4
68,69 This DIMPSIFYJEJOF TPMVUJPO XJMM EFBDUJWBUF
technique can be clinically successful in the matrix metalloproteinases and preserve
TIBMMPXSFTUPSBUJPOTCVUJTOPUJEFBMJOMBSHFS the maximum bond strength.75–77 Mild self-
load-bearing situations. 16,70 etching dentinal bonding systems produce an
4JNQMJGJFE UXPTUFQ UPUBMFUDI EFOUJOBM acid/base resistant zone of a 1 to 1.5 micron
CPOEJOHTZTUFNTMPTFUPPGN5#4 UIJDLOFTT SFGFSSFE UP BT iTVQFS EFOUJOw
XIFO CPOEFE UP JOOFS DBSJPVT EFOUJO71 The CFDBVTF PG JUT BCJMJUZ UP XJUITUBOE IJHI BOE
TBNFEFDSFBTFJOCPOETUSFOHUIXJMMPDDVSJG MPX Q) BUUBDLT 4& 1SPUFDU ,VSBSBZ
XJUI
acid etching is performed on dentin that is to the unique proprietary methacryloyloxydo-
CFCPOEFEXJUIBNJMEUXPTUFQTFMGFUDIJOH decylpyridinium bromide monomer contain-
dentinal bonding system.72,73 Dual-cure den- ing pyridinium bromide produces this super
tinal bonding systems can have the same dentin and also deactivates matrix metal-
negative effect.74 The acid from caries lesions loproteinases. Other mild self-etching dential
also activates endogenous collagenase bonding systems also produce the acid/base
enzymes called matrix metalloproteinases. In resisitant zones but need additional matrix
the presence of matrix metalloproteinases, a metalloproteinase-deactivating chemicals
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TVDIBTDIMPSIFYJEJOF $POTFQTJT 6MUSBEFOU
UJPOT IBWF BMTP CFFO TIPXO UP SFEVDF UIF
lica
tio
PS CFO[BMLPOJVN DIMPSJEF .JDSP1SJNF # effects of polymerization stress and cervical t
ess c e n
ot
n
fo r
%BOWJMMFPS&UDI #JTDP
78–80 microleakage. 92,93
If c-factor stresses are not en
The anatomical location of the peripher- reduced, the bond strength is decreased by
al seal zone dentin must also be considered 30% to 50% during the first 24 hours and
UPQSFEJDUQPUFOUJBMCPOETUSFOHUI$FSWJDBM by another 10% during functional loading
root dentin loses approximately 20% of its in the first years of service.94$BSFGVMPQFSB-
CPOEBCJMJUZ DPNQBSFE XJUI DPSPOBM TVQFS- UPST XIP UBLF BMM PG UIFTF DPOTJEFSBUJPOT
ficial dentin. If the cervical root dentin has into account during caries excavation and
inner carious dentin present, the bond bonding procedures can decrease the array
strength is only 50% of sound coronal den- of differences in regional bond strengths in
tin.81 Deep dentin vs superficial dentin bond their restorations.95
strengths are also dependant on the type of
dentinal bonding system used. Three-step
UPUBMFUDI BOE UXPTUFQ NJME TFMGFUDIJOH
EFOUJOBMCPOEJOHTZTUFNTCPOEFRVBMMZXFMM TREATMENT GOALS
UPEFFQEFOUJO CVUTJNQMJGJFEUXPTUFQUPUBM FOR DEEP CARIES LESIONS
etch and one-step highly acidic self-etching
systems can lose up to 50% of their bond 1. $SFBUFBQFSJQIFSBMTFBM[POFPGFOBNFM
strength in deep dentin.73,82 DEJ, and normal superficial dentin near
During placement of the restorative the DEJ (this should bond at 55 MPa)
material, the ratio of bonded to unbonded (Figs 10 and 11).
surface areas of each layer or increment of 2. Leave the inner carious dentin inside
composite (the configuration factor or c-fac- of the peripheral seal zone (this should
tor)83 XJMM BGGFDU UIF TUSFTT PG QPMZNFSJ[BUJPO bond at 30 MPa) (compare Figs 2 and 3
shrinkage that is applied to the maturing XJUI'JHTBOE

CPOE UP EFOUJO )JHIFS DGBDUPST BMXBZT 3. 3FNPWF IJHIMZ JOGFDUFE PVUFS DBSJPVT
JODSFBTFTUSFTTPOUIFCPOEUPEFOUJO XIJDI dentin inside of the peripheral seal zone
EFDSFBTFTJUTN5#484 VOMFTTJUJTBGMPXBCMF XJUIPVU FYQPTJOH UIF QVMQ 4NBMM BSFBT
DPNQPTJUF XJUI B MPX NPEVMVT PG FMBTUJD- of circumpulpal outer carious dentin are
ity compared to dentin85). Therefore, high left to prevent exposure (see Figs 7 to 9).
DGBDUPSMBZFSJOHXJUIIJHINPEVMVTDPNQPT- 4. Seal in and deactivate any remaining
ites (thicker than 0.5 mm) should be avoided bacteria left inside the peripheral seal
XIJMF UIF CPOE UP EFOUJO JT NBUVSJOH 5IJT zone.
can best be accomplished by using an indi- 5. Use adhesive restorative techniques
rect or semidirect restorative technique.86 If UIBU XJMM NBYJNJ[F UIF CPOE TUSFOHUI
direct restoration is necessary for socioeco- of the peripheral seal zone and the
nomic reasons, compensatory measures inner carious affected dentin inside the
are required to prevent excessive stresses peripheral seal zone.
to the bond and remaining hard tissue. This
can best be accomplished by multiple thin
IPSJ[POUBM MBZFST XIJDI UBLF NPSF UJNF UP
BQQMZ
PO B UIJO MBZFS PG GMPXBCMF DPNQPT- STEP-BY-STEP
ite.20,87 " UIJO NJDSPO
NJDSPGJMMFE GMPX- TECHNIQUE
able composite or a thick dentinal bonding
system adhesive layer (50 to 80 microns) 1. 5FTU GPS QVMQBM WJUBMJUZ XJUI JDF PS BFSP-
can secure the dentin bond and create a TPM SFGSJHFSBOU &OEP*DF $PMUÒOF
GBJMTBGFMBZFS4VDIBSFTJODPBUJOHXJMMTUBZ Whaledent). If the test is positive,
CPOEFE FWFO XIFO PWFSMBZJOH MBZFST GBJM QSPDFFE XJUI DBSJFT EJBHOPTJT BOE
under high stress.88,89*OTIBMMPXQSFQBSBUJPOT treatment. If the test is ambiguous or
in superficial dentin, the detrimental effect of negative, inform the patient of the pos-
resin shrinkage is not as great because the sible need for endodontic treatment.
c-factor is reduced.90,91 Polyethylene fiber 2. Anesthetize the tooth. Isolate it using rub-
nets used to line high c-factor prepara- ber dam or other isolation techniques.
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ot
n
ss e n c e
fo r
Fig 10 Ideal caries removal end points and peripheral seal zone devel- Fig 11 The peripheral seal zone is free of outer and
oped in an intermediate-depth lesion using combined technologies. inner carious dentin. Inside the peripheral seal zone,
the lightly stained inner carious dentin is retained
and will remineralize in vital teeth.
3. Access the lesion after removal of any intermediate (middle third), or deep
failed restorations. Stain the caries (pulpal third) dentin (see Fig 4).
MFTJPO XJUI SFE DBSJFTEFUFDUJOH EZF 7. After removing the red and leaving the
Wait 10 seconds and rinse (see Fig 12). QJOL CFUXFFO UIF QVMQ IPSOT UIF QJOL
4. Starting near the DEJ, use a 1-mm round inner carious dentin areas in these
diamond bur of fine to medium grit (30 intermediate dentin areas can be evalu-
to 100 microns) to create a peripheral BUFE XJUI %*"(/0EFOU 5IF OVNCFST
seal zone area free of red-stained outer should read approximately 24 (accept-
caries and pink-stained inner caries. able range, 12 to 36). Those readings
5IJT TVQFSGJDJBM OPSNBM EFOUJO XJMM CF indicate a virtually bacteria-free area in
UPNNXJEFEFQFOEJOHPOXIFUIFS the intermediate to deep dentin inside
it is on the buccal or the occlusal areas the peripheral seal zone (see Figs 10
of a molar (1.5 to 2 mm) or on the mesial and 11).
or distal root dentin (1 mm). Premolars 8. Move to the deep pulp horn areas last.
are smaller, and the superficial dentin is $BSFGVMMZSFNPWFSFETUBJOFEPVUFSDBSJ-
OBSSPXFSJOBMMBSFBT 'JHTBOE
ous dentin until deep dentin is reached
5. Staining and removing outer and inner (5 mm from occlusal surface). If the
carious dentin is repeated until the tissue continues to stain red and mea-
caries removal end point in the periph- TVSFNFOUT XJUI UIF QFSJPEPOUBM QSPCF
eral seal zone is stain free. This can be indicate that you are deeper than 5 mm
DPOGJSNFECZ%*"(/0EFOUSFBEJOHTPG from the occlusal surface (> 3 mm from
approximately 12 (see Fig 3) and the the DEJ), stop excavation to avoid pulp
total absence of caries-detecting dye. exposure (compare Figs 4 to 9).
(This indicates virtually bacteria-free 9. Optional step: Treat the peripheral seal
superficial dentin.) zone, inner carious dentin, and outer
6. 3FNPWF UIF SFETUBJOFE PVUFS DBSJPVT DBSJPVT EFOUJO XJUI UP DIMPS
dentin from the area inside the periph- hexidine for 30 seconds to inactivate both
eral seal zone (being careful to avoid the matrix matalloproteinases and any
the pulp horn areas). Measure from remaining bacteria; 0.1% to 1.5% benzal-
the occlusal surface to determine if the konium chloride solution in the acid-etch
excavation is in superficial (outer third), or methacryloyloxydodecylpyridinium
204 VOLUME 43 t /6.#&33 t ."3$) 2012

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Fig 12 Application of caries-detecting dyes guides Fig 13 Magnification of 6.5× to 8.0× is ideal for
the creation of the peripheral seal zone using implementing minimally invasive caries removal.
DIAGNOdent and 3D measurements to make end
point decisions in the intermediate and deep dentin
areas.
bromide monomer in the dentinal bond- The intermediate and deeper areas of light
JOHTZTUFNXJMMBMTPBDIJFWFUIFTFHPBMT80 QJOLoTUBJOFE JOOFS DBSJPVT EFOUJO XJMM MJLFMZ
If using a three-step total-etch dentinal generate a dentin bond of 30 MPa. If any
bonding system, this step is performed outer caries is left in deep circumpulpal
after acid etching and rinsing. If using areas to prevent pulp from being exposed,
B UXPTUFQ TFMGFUDIJOH EFOUJOBM CPOEJOH UIF N5#4 JO UIPTF TNBMM BSFBT XJMM CF
system, after applying chlorhexidine or approximately 15 MPa. To maximize all of
benzalkonium chloride, dry the prepara- these bond strengths, the dentinal bonding
tion for 10 seconds before applying the TZTUFNDBOCFBMMPXFEUPNBUVSFGPSBDFS-
self-etching primer.96 tain length of time (3 minutes to 24 hours)
10. 0QUJPOBM TUFQ JG VTJOH B NJME UXPTUFQ before being bonded to another layer of
self-etching dentinal bonding system: polymerizing resin cement or composite
Use air abrasion on the preparation to resin.98,99 5IJT JT XIZ JU JT JNQPSUBOU UP VTF
NBYJNJ[FUIFN5#497 the immediate dentin sealing technique
11. 4UBSU EFOUJO CPOEJOH XJUI B UISFFTUFQ XIFOFWFSQPTTJCMF86,89,100,101
UPUBMFUDI PS B NJME UXPTUFQ TFMGFUDI-
ing dentinal bonding system.
These techniques for caries removal CONCLUSION

end point determination and peripheral seal
zone development are the foundation of #Z DPNCJOJOH EFUBJMFE BOBUPNJDBM BOE
conservative dentistry. Such minimally inva- QBUIPIJTUPMPHJD LOPXMFEHF XJUI UIF UFDI-
sive procedures are best performed under nologies of caries-detecting dyes and laser
magnification. This type of microdentistry is fluorescence, an ideal caries removal end
greatly aided by using high-magnification QPJOU DBO CF BDIJFWFE GPS WJUBM UFFUI XJUI
prismatic loupes of 6.5× to 8.0×PSXJUIBO deep caries lesions. These ideal end points
PQFSBUPSZ NJDSPTDPQF XJUI TJNJMBS NBHOJGJ- XJMM QSFTFSWF NPSF WJUBM QVMQT DPOTFSWF
cation (Fig 13). more dental hard tissue, and create a highly
The peripheral seal zone in superficial CPOEBCMFQFSJQIFSBMTFBMUIBUXJMMNJNJDUIF
EFOUJOXJMMBMMPXCJPNJNFUJDCPOETUSFOHUIT OBUVSBM UPPUI XIFO SFTUPSFE XJUI MPX TUSFTT
of approximately 45–55 MPa to be created. adhesive techniques.
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A Systematic Approach To Deep Caries Removal End Points

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Key words: adhesive dentistry, biomimetic restorations, caries removal,

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histology, microbiology, and adhesive seal zone, a bondability of approximately 30

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high levels of hydroxyapatite and Whitlockite 5IFTFGJOEJOHTXFSFSFQSPEVDFEJOBTFDPOE

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dentin).18,53,54 Staining and remineralization achieved predictably inside the peripheral

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Fig 9 Clinical case illustrating Fig 8. The ideal caries

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These techniques for caries removal CONCLUSION

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