Quality Resource Guide l Caries Risk Assessment and Management for Adults 2nd Edition 8 www.metdental.com Selective Caries Excavation (SCR): The SCR protocol is a professionally recognized and accepted tooth-level caries control treatment. 7,103-109 It can be used on any restorable tooth with an advanced (deep) caries lesion and having a healthy pulpal and periapical tissues. SCR consists of complete caries removal peripherally to a sound, caries-free DEJ. Caries is removed axially and pulpally to within approximately 1 mm of the pulp (within soft dentin). A glass ionomer (Fuji IX, GC America, Alsip, or IL) temporary restoration or a definitive restoration, is then placed. Growing evidence suggests that temporization followed by re-entry does not contribute to improved clinical outcomes, therefore current research supports the placement of a definitive restoration. 7,103,104 Selective caries removal allows a restoration to be placed while avoiding pulpal exposure. 7,104 Avoiding a pulpal exposure has a great impact on the lifetime prognosis of the tooth and long-term treatment costs. Although the residual dentin thickness cannot be accurately assessed clinically, its preservation is a significant factor in avoiding pulpal distress. Historically, removal of the bacterial infection has been seen as an essential part of all restorative dental procedures. However even removal of dentin up to hard dentin in deep, advanced caries lesions does not assure that “sterile” dentin remains. Bacteria have been found to be present in all dentinal layers in deep caries lesions. Even when bacteria are present, increasing evidence indicates that when a good seal can be achieved with restorative materials, the lesion will arrest. 103,110,111 (see Figure 9) Therefore, it is not necessary to remove all of the dentin that has been compromised by the caries process. Complete removal of all stained tooth structure in the preparation ultimately leads to significantly larger preparations than the visual-tactile method of evaluating for caries removal, so that approach is no longer recommended. There are some critical aspects that must be considered when using a SCR protocol: 112 1. The tooth should not be symptomatic or have signs of irreversible pulpitis 2. A caries free DEJ must be achieved during restoration, as a well-sealed restoration is critical for a successful outcome 3. The patient should be clearly informed that some leathery and soft dentin may remain under the restoration with a radiographic presentation that may suggest secondary or residual caries 4. The patient must be cognizant of the risk and benefits of this procedure, including the higher risk for endodontic complications. If the patient is not willing to accept the risks, then alternative treatment such as complete caries removal with vital pulp therapy, endodontic therapy or tooth extraction should be considered. Part of management is establishing a follow-up or recall interval that is appropriate for the patient’s risk. A patient at low risk for caries and having no other concerns (such as periodontal disease or oral cancer risk) can be placed on a 1-year recall interval. A patient at moderate to high-risk interval should be placed at shorter intervals ranging from 2-6 months. A shorter interval allows for more frequent monitoring of lesions that are being treated non-surgically, and re-enforcement of preventive interventions as needed. Summary Dental caries is a process that must be managed throughout life. Caries risk assessment should be an ongoing practice facilitating personalization of disease management to the patients’ current risk factors and disease status. Although there are a variety of new treatment modalities, fluoride remains the standard of care and other strategies should be used as a supplement to fluoride. Outcomes of care can be improved by selection of the least invasive procedure (fluoride, sealants, infiltration) or selective caries removal aiming to preserve tooth structure and restoring the patient to health.