Recommendations

Schwendicke F, Frencken J, Innes N (eds): Caries Excavation: Evolution of Treating Cavitated Carious Lesions.
Monogr Oral Sci. Basel, Karger, 2018, vol 27, pp 155–161 (DOI: 10.1159/000487842)

An Agreed Terminology for Carious

Tissue Removal
Nicola Innes a · Falk Schwendicke b · Jo Frencken c
a School of Dentistry, Park Place, University of Dundee, Dundee, UK; b Operative and Preventive Dentistry, Charité –

Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of
Health, Berlin, Germany; c Department of Oral Function and Prosthetic Dentistry, College of Dental Sciences, Radboud University
Medical Center, Nijmegen, The Netherlands

Abstract nology cannot be used to directly relate the visual

Understanding the carious process as a biofilm disease
rather than an infectious disease has changed lesion
management focus towards less invasive options. This
has led to new and ongoing changes in recommenda-
tions for practitioners. However, the lack of clarity over
what to do, and when, is complicated by different teach-
ing, research, and policy documents containing different
terms and definitions for carious lesions and manage-
ment strategies. Lack of clear messages and communica-
tion over recommendations hampers moving evidence
into practice. The International Caries Consensus Collab-
oration (ICCC) recommendations on terminology are one
part of improving communication for discussing the di-
agnosis and management of dental caries and dental
carious lesions. The term dental caries is the name of the
disease, its use being limited to situations involving con-
trol of the disease using preventive and noninvasive
measures at the patient level. Carious lesion manage-
ment should be used where management is directly re-
lated to disease symptoms at the tooth level. As termi-
appearance of the carious lesion to the histopathology,
the terms have been based around the clinical conse-
quences of the disease: soft, leathery, firm and hard den-
tine. The 3 main carious tissue removal options are de-
scribed as: (1) selective removal of carious tissue (to both
soft and firm dentine), (2) stepwise removal, and (3) non-
selective removal to hard dentine (previously known as
complete removal and no longer recommended). Use of
these terms across clinicians, researchers, dental educa-
tors, and even with patients, will help improve under-
standing and communication. © 2018 S. Karger AG, Basel
Background to Standardisation in
Terminology
Understanding the carious process as a biofilm
disease [1] rather than an infectious disease has
changed the focus for managing carious lesions
towards less invasive and more “sealing in” of le-
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sions. This has led to new and changing recom-
mendations for practitioners to follow when
treating patients (and carious lesions) [2]. The
recommendations have been developed, and are
supported by evidence synthesised from clinical
studies [3–5]. However, their implementation is
complicated by the use of different terms describ-
ing the lesions and the same management strate-
gies.
Making the shift from producing evidence to
actually getting it used in practice is known to be
difficult, as is discussed in detail in the chapter
by Doméjean and Grosgogeat [this vol., pp. 137–
145]. This process of translating knowledge to
action is complicated by inconsistencies in clini-
cal guidelines across dentistry, both among pro-
fessional groups and dental educationalists. The
guidelines often rely on outdated concepts, na-
tional healthcare policies, and are known to be
influenced by local remuneration systems [6]. In
addition, different terms for carious lesions,
their presentation, and management strategies
are used across teaching, research, and policy
documents. Lack of consistent, clear messages
and effective communication over recommen-
dations hampers moving evidence into practice.
The International Caries Consensus Collabo-
ration (ICCC) consensus process developed rec-
ommendations on terminology for carious tissue
removal and managing cavitated carious lesions
[7]. Standardising this terminology is one part of
improving communication within the profession
for discussing the diagnosis and management of
dental caries and dental carious lesions.
Updating the Existing Terminology
In a systematic search for terminology describing
carious tissue removal techniques, 23 different
terms were found and a further 19 unique terms
noted to being used by researchers, giving a total
of 42 unique terms to describe 4 different carious
lesion removal/management strategies (Innes
156
Schwendicke F, Frencken J, Innes N (eds): Caries Excavation: Evolution of Treating Cavitated Carious Lesions.
Monogr Oral Sci. Basel, Karger, 2018, vol 27, pp 155–161 (DOI: 10.1159/000487842)
terminology document). The ICCC group gath-
ered and, through consensus [8], came up with
definitions for dental caries/carious lesions where
there was some confusion identified in the litera-
ture, terms for the stages of carious tissue remov-
al, and terms for describing different carious
management/removal strategies [9, 10].
Dental Caries Management and Carious
Lesion Management
The term dental caries has historically been used
synonymously as the name of the disease and the
specific pathology seen at the tooth level. This
meant that the patient would be described as suf-
fering from dental caries and the tooth would also
be described as having dental caries. However, the
ICCC recommended that use of the term dental
caries is limited to situations involving control of
the disease using preventive and noninvasive
measures at the patient level. The more accurate
term, carious lesion, should be used where the
management is directly related to the disease
manifestation/symptoms at the tooth level, i.e.,
this should be referred to as managing the carious
lesion.
Terminology for Descriptions of States of
Carious Dentine
As terminology cannot be used to directly relate
the visual appearance of the carious lesion to the
histopathology, the terms have been based around
the clinical consequences of the disease. Hard
dentine requires a pushing force “with a hard in-
strument to engage the dentine, and only a sharp
cutting edge or a burr will lift it. A scratchy sound
or ‘cri dentinaire’ can be heard when a straight
probe is taken across the dentine.” Firm dentine
is physically resistant to hand excavation, and
“some pressure needs to be exerted through an
instrument to lift it.” Leathery dentine “does not
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deform when an instrument is pressed onto it but
can still be easily lifted without much force being
required. There may be little difference between
leathery and firm dentine, with leathery being a
transition on the spectrum between soft and firm
dentine.” Soft dentine will deform when a hard
instrument is “pressed onto it and can be easily
scooped up (e.g., with a sharp hand excavator)
with little force being required.” The definitions
of these different clinical presentations of dentine
affected by carious lesions are taken from the
original ICCC terminology document [7].
Carious Tissue Removal Terminology
The 3 main carious tissue removal options are de-
scribed as: (1) selective removal of carious tissue
(to both soft and firm dentine), (2) stepwise re-
moval, and (3) non-selective removal to hard
dentine (previously known as complete removal
and no longer recommended) with “soft,” “firm,”
and “hard” as described above. However, we can
make a comprehensive list of types of tissue re-
moval by expanding this and group them under
the following headings: atraumatic restorative
treatment; no removal (which includes fissure
sealants, the Hall Technique, and non-restorative
cavity control; NRCC); selective removal to soft
dentine; selective removal to firm dentine, and
stepwise removal and non-selective removal. Ta-
ble  1 (reproduced from the ICCC terminology
document) details their previous names and pro-
vides descriptions of them and the indications for
each technique to be used where there are non-
cleansable dentine carious lesions.
Atraumatic Restorative Treatment
Atraumatic Restorative Treatment (ART) is a
specific technique for carious lesion management
using hand instruments only. Pulpally, excava-
tion is carried out by removing demineralised
Terminology for Removing Carious Tissue
Schwendicke F, Frencken J, Innes N (eds): Caries Excavation: Evolution of Treating Cavitated Carious Lesions.
Monogr Oral Sci. Basel, Karger, 2018, vol 27, pp 155–161 (DOI: 10.1159/000487842)
enamel and soft dentine until firm dentine is felt
in shallow/medium-sized lesions (or to the depth
that will allow enough bulk of glass-ionomer to be
placed) and until soft dentine is felt in deeper le-
sions. The cavity is restored usually with a high-
viscosity glass-ionomer cement or other adhesive
material and exposed pits and fissures are sealed.
For lesions that reach the inner half of dentine
(radiographically) soft carious tissue should be
left on the pulpal wall to avoid pulp exposure. The
decision between carrying out selective removal
to firm dentine or to soft dentine depends on the
extent of the lesion, the resulting cavity depth,
and the possibility of pulp exposure. ART is suit-
able for primary and permanent teeth and has a
large evidence base around it [see the chapter by
Leal et al.; this vol., pp. 92–102].
No Removal (No Dentinal Carious Tissue
Removal)
There are a variety of procedures where no den-
tinal carious tissue removal is carried out. Sealing
includes: (1) fissure sealants (therapeutic), (2) the
Hall Technique, and (3) NRCC. Despite being a
diverse group of procedures, they have the same
aim – to control the carious lesion without re-
moving any diseased dentinal tissue.
Resin or glass-ionomer sealants (usually high
viscosity) can be used to seal over pit and fissure
enamel and dentine carious lesions. However, as
described in the chapter by Fontana and Innes
[this vol., pp. 103–112], care has to be taken in
deciding when to place them and when it may be
more appropriate to carry out a selective removal
procedure. Although there is evidence to support
placing sealants over carious lesions, there is a
lack of evidence around how deep a lesion can be
sealed and still be assured of success, especially
for deeper lesions. The materials have limited
abilities to resist forces occlusally. They are suit-
able for primary and permanent teeth with shal-
low and moderate carious lesions that appear
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Table 1. Overview of carious tissue removal terminology and groupings (reproduced from the ADR Terminology
Group) [7]

Type of carious Previous names/ Short description Indications for non-cleansable

tissue removal further details dentinal carious lesions

Atraumatic A specific technique Carious tissue removal using Primary and permanent teeth
restorative for carious lesion hand instruments only Shallow and moderate1 dentine
treatment (ART) management using Pulpally: excavate to firm dentine carious lesions to allow
hand instruments only in shallow lesions and to adequate depth for a
soft dentine durable restoration
in deep lesions
Restore cavity and seal available
pits and fissures with adhesive
dental material, usually
a high-viscosity
glass-ionomer cement

No removal No dentine carious tissue removal

Fissure sealant Fissure sealants: place sealants Primary and permanent teeth
including “ART (resins) or glass-ionomer cement Shallow and moderate1
sealants” (therapeutic) over clinically intact enamel or carious lesions that appear
enamel with signs of early non-cavitated clinically,
breakdown; this can also be radiographically they
suitable where there might extend into dentine
is a microcavitation
but the material is considered
to have adequate mechanical
properties to bridge any
enamel breaches

Hall Technique Preformed (stainless-steel) Primary teeth

crown is cemented over the
primary molar tooth to seal
dentinal carious lesions
Moderate1 and deep2
non-cavitated and cavitated
aproximal carious lesions
Permanent teeth
Not indicated

Non-restorative Non-restorative Cavitated dentinal carious Primary and permanent teeth

cavity control (NRCC) caries treatment, non-operative
caries treatment and
prevention, slicing technique
lesions are transformed to
cleansable forms that can
be cleaned by the patient
or parent/carer with
a toothbrush
May or may not be supported
by regular fluoride varnish
application or placement
of glass-ionomer-based material
Cavitated dentine carious
lesions that can be made
cleansable; might not be
restorable (for permanent teeth,
might also be suitable for
root surface carious lesions)

Selective removal Partial, incomplete, minimally Pulpally: remove carious Primary and permanent teeth
to soft dentine invasive, or ultraconservative tissue until soft Deep carious lesions2
caries removal dentine is reached
Enough tissue is removed
to place a durable
restoration
avoiding pulp exposure
Periphery of cavity: clean to
hard dentine
(similar to sound dentine)

Selective removal Partial caries removal, minimally Pulpally: remove carious Primary and permanent teeth
to firm dentine invasive or incomplete caries tissue until leathery or Shallow and moderate
removal firm dentine dentinal carious lesions1 to
(resistant to allow adequate depth for
hand excavator) a durable restoration
is reached
Periphery of cavity:
clean to hard dentine
(similar to sound dentine)
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Schwendicke F, Frencken J, Innes N (eds): Caries Excavation: Evolution of Treating Cavitated Carious Lesions.
Monogr Oral Sci. Basel, Karger, 2018, vol 27, pp 155–161 (DOI: 10.1159/000487842)
Table 1. Continued

Type of carious Previous names/ Short description Indications for non-cleansable

tissue removal further details dentinal carious lesions

Stepwise removal
Stepwise caries removal,
stepwise excavation,
2-step caries removal
Pulpally: selective removal Primary teeth
to soft dentine during 1st Not indicated – use
step – remove carious tissue selective removal to
until soft dentine is reached soft dentine
Enough tissue is removed Permanent teeth
to place a durable restoration Deep carious lesions2
avoiding pulp exposure
Periphery of cavity: clean
until hard dentine is reached
(similar to sound dentine)
Subsequently (6–12 months)
Pulpally: selective removal to
firm dentine and place a
long-term restoration

Non-selective to Complete Pulpally and cavity periphery: carious Primary and

hard dentine caries removal tissue removal aims to remove permanent teeth
(not advocated) all demineralised dentine to Not advocated
reach hard dentine, leaving
no softened dentine
Considered overtreatment

1
Shallow and moderate lesions involving the outer pulpal two thirds or three quarters of dentine radiographically, or where there is no risk of pulp
exposure.
2
Deep lesions are those defined as radiographically involving the inner pulpal third or quarter of dentine, or with clinically assessed risk of pulpal
exposure.

non-cavitated clinically, and radiographically are
not too extensive in dentine either in depth or
volume of lesion.
The Hall Technique [as described in the chap-
ter by Santamaria and Innes, this vol., pp 113–
122] is a specific procedure suitable only for pri-
mary molars, where a preformed metal (stainless-
steel) crown is used to seal dentinal carious lesions
by cementing the crown using glass-ionomer ce-
ment onto the tooth with no tooth preparation or
carious lesion removal. The crown is used to seal
the dentinal carious lesion and slow down or pre-
vent its progression to the dental pulp. This al-
lows a carious primary molar to exfoliate without
pain or infection. The Hall Technique is usually
indicated for approximal lesions where there is
still a radiographically visible band of dentine be-
tween the carious lesion and the dental pulp.
NRCC used to be known as non-operative caries
treatment and prevention (NOCTP), non-restor-
ative caries treatment (NRCT), and slicing prepara-
tions. These make up a group of techniques that aim
to arrest carious lesions using a package of care in-
volving caries management at the level of the pa-
tient. By creating a cleanable cavity (sometimes this
involves altering the shape of the cavity through op-
erative although not restorative intervention) and
putting a successful preventive regimen in place,
they aim to prevent further loss of tooth tissue
through carious lesion progression. The regimen
includes plaque removal through toothbrushing
with a fluoridated toothpaste and/or application of
fluoride varnish. NRCC is most commonly used for
primary teeth but also has a role in the management
of root surface carious lesions.
Selective Removal
Selective removal of carious dentine used to be
known as partial, incomplete, minimally inva-
sive, or ultraconservative carious tissue remov-
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Terminology for Removing Carious Tissue 159

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Schwendicke F, Frencken J, Innes N (eds): Caries Excavation: Evolution of Treating Cavitated Carious Lesions.
Monogr Oral Sci. Basel, Karger, 2018, vol 27, pp 155–161 (DOI: 10.1159/000487842)
al. However, these terms all focus on the end
result of the carious tissue removal process. The
new terms, selective removal to soft, leathery,
or firm dentine, shift the focus to what is being
carried out rather than the aim of the proce-
dure. Selective removal uses different excava-
tion criteria for the cavity walls (periphery of
the cavity) where the aim is to have “sound”
enamel to allow the best adhesive seal, using an
adhesive material, to be achieved. The periph-
eral dentine should also be hard and should
give the feel of hard dentine – a scratching
noise if a sharp hand excavator is dragged
across it. For deep lesions (extending beyond
the inner, pulpal, third or quarter of the dentine
radiographically), carious tissue removal should
be selective removal to soft dentine (the main
aim is to avoid exposure and irritation of the
dental pulp), provided that there are no clinical
symptoms of pulp inflammation present. Soft
dentine will deform when an instrument is
pressed onto it and little force would be re-
quired to lift it.
For less deep lesions, selective removal should
take place to leathery or firm dentine pulpally
(physically resistant to a hand excavator) in the
pulpal aspect of the cavity. This is likely to be nec-
essary to allow adequate depth for the restorative
material bulk.
Although somewhat subjective, the tactile
sense of dentine softness and hardness is proba-
bly the best guide that can be given as there is a
lack of easily available or reliable diagnostic tools
for this purpose.
Stepwise Removal (Stepwise Carious Lesion
Removal)
Stepwise removal, or stepwise carious lesion re-
moval, was agreed by the ICCC group to be a
well-known and accepted term with less variabil-
ity in its definition and understanding. As such, it
was considered better to accept this as standard
160
Schwendicke F, Frencken J, Innes N (eds): Caries Excavation: Evolution of Treating Cavitated Carious Lesions.
Monogr Oral Sci. Basel, Karger, 2018, vol 27, pp 155–161 (DOI: 10.1159/000487842)
with just a clear and unambiguous explanation of
the definition behind it. Stepwise removal in-
volves “selective removal to soft dentine” at stage
1, followed 6–12 months later by “selective re-
moval to firm dentine” for stage 2. This technique
was previously also known as “2-step excavation.”
It is no longer recommended for primary teeth as
selective removal to soft dentine would normally
be carried out and a permanent restoration
placed. The teeth have a limited lifespan and there
is no demonstrable advantage to using a stepwise
approach. Stepwise removal is indicated for deep
carious lesions.
Non-Selective Removal
Non-selective removal to hard dentine was previ-
ously known as “complete excavation” or “com-
plete removal.” It is the approach to carious tissue
removal that was accepted in the past and is now
considered overtreatment. It is no longer recom-
mended and is only mentioned here for com-
pleteness. The aim was to remove soft carious tis-
sue to reach hard dentine resembling healthy
dentine in all parts of the cavity, including pulp-
ally.
Conclusion
It is difficult to change custom and habit as
terms around dentistry, dental caries, and man-
aging carious lesions have been in place for
many decades and even a century in some cas-
es. However, by standardising the use of these
terms across the profession, clinicians, re-
searchers, and dental educators will help im-
prove understanding and communication. This,
in turn, should help reduce some of the barriers
we face in improving the standard of
care  for  our  patients by putting new evi-
dence  and effective practices into day-to-day
clinical use.
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E-Mail n.p.innes@dundee.ac.uk
Terminology for Removing Carious Tissue
Schwendicke F, Frencken J, Innes N (eds): Caries Excavation: Evolution of Treating Cavitated Carious Lesions.
Monogr Oral Sci. Basel, Karger, 2018, vol 27, pp 155–161 (DOI: 10.1159/000487842)
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