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Paper 2

A Review of Restorative Alternatives
For Mild to Moderate Carious Lesions

October 14, 2002
Operative IV - Section 2
University of Minnesota School of Dentistry

Russell Dylla, Lucas Eichmeyer, Ben Fenger, Adam Forster
Erin Gannon, Ryan Francis, David Gilmer, Steve Graber, Jeremy Gross

Table of Contents

  1. Plan
  2. Introduction
  3. Literature Review
    1. Past, Present, and Future
    2. Dental Amalgams
    3. Resin Composite Considerations
    4. Flowable Composites and Glass-Ionomers
    5. Alternative Excavation Techniques
      1. Table 1
      2. Concluding Thoughts
      3. Position Statement/Final Thoughts
      4. Bibliography

      Plan

      The primary problem of interest is what modalities are available in a lesion specific approach to mild and moderate carious lesions. In the majority of cases, it is the standard to remove the area of decay and fill it with a variety of different restorative materials. The alternatives for treatment are numerous, as scientific researches in the area of restorative materials has expanded. Such research has currently been leading into a lesion specific approach. Based on this idea, such possibilities include composite, glass-ionomer, air abrasion, sono-abrasion, and lasers. The primary plan is to evaluate the materials and methods available to the practicing dentist for treatment of a carious lesion. The hypothetical lesion in this review will focus on a mild to moderate lesion that has been diagnosed as extending through enamel and into the dentin of the tooth. Our clinical question is: What options/alternatives are present for treatment of a mild to moderate lesions, and what are their properties that may be of interest? The hope of this review is to evaluate the different treatment options, and come to a position on the use or nonuse of each.

      Introduction

      The diagnosis and treatment of a carious lesion in an environment as harsh as the oral cavity can be a very difficult process. The operator must first identify the lesion and determine the degree of progression. Then decide if it should be treated and if so, how to treat it. Presently, there are varying trains of thought on how to treat lesions of different severity. This paper reviews the mild to moderate carious lesion; it's diagnosis, various treatments, and eventual prognosis. Our aim is to provide a detailed assessment of the role of the dentist in caring for the mild to moderate dental lesion.

      A mild carious lesion, or incipient lesion, is commonly referred to as a white spot lesion. The tooth surface is usually smooth but with a chalky white color due to the initiation of decalcification in the underlying enamel matrix. The moderate, or intermediate, lesion is a precavitated lesion that has a rough surface with slightly deeper discoloration due to repeated remineralization and demineralization cycles. Diagnosis of these precavitated lesions is very difficult and a variety of methods are often used clinically. Radiographically, these lesions usually appear as small interproximal notches, and can be nearly completely undetectable within the pits and fissures of an occlusal surface. One study in particular (Verdonschot et al. 1992) found visual identification of incipient and precavitated lesions to be only 13% specific and the use of explorers to add no accuracy to the diagnosis.

      The diagnosis of precavitated lesions is quite difficult and unreliable (Charland et al. 2002). Therefore it is often recommended to observe the lesion and implement remineralization therapy before performing any invasive procedures (Mount and Ngo 2000). If this does not resolve the lesion, a very conservative and lesion specific preparation and restoration can be implemented. Although this is the hope of dentistry to be conservative, it is not always the case. For this particular review we will be focusing on the lesion specific approach and attempt to deviate from the standard G.V. Black criterion. In order to better understand the lesion specific approach it is only necessary that we briefly discuss concepts about treatment of the lesion in question. Then the different modalities for intervention will be considered.

      Past, Present, and Future

      Dental caries is by no means a new phenomenon. As long as there have been teeth, it is only plausible to conclude that there have been cavities as well. The means by which carious lesions are treated, however, has evolved with time. In ancient times, teeth suffering from mild to moderate caries were not restored or dealt with at all. Rather, it was not until the caries reached a severe state that the teeth were "treated." Treatment usually consisted of extracting the affected tooth (Hume 1998). This was the case until 1728, when Fauchard began cleaning out the decayed area of a tooth as an alternative to extraction (Hume 1998). Metal plugs made of gold, tin, or lead were then placed in the newly excavated area. G.V. Black may have used this idea as a template for the "extension for prevention" theory of tooth restorations. According to his theory substantial amounts of healthy tooth tissue were removed to provide the correct cavity form for the placement of amalgam (Hume 1998). Not until recently composite restorative materials have allowed for restorative designs that provide for the "increased conservation of tooth structure, increased resistance to subsequent fracture, and therefore improved patient health" (Hume 1998). Thus, composites are currently one of the major areas of research in dentistry.

      Another new area of current dental research is to generate synthetic tooth structure that mimics natural tissue. This synthetic structure could then be used as a treatment option for mild to moderate carious lesions. The term biomimetic means to mimic biology, and in this scientific context it deals with the study of biological structures, functions, and synthetic pathways (Slavkin 1996). This field of research has had mixed success. Many researchers have tried to employ the use of multi pluripotent stem cells to reach this goal. These human stem cells are typically harvested from dental pulp and cultured in laboratories (Krebsbach 2002). At which time they are then loaded on a synthetic scaffolding that allows for their stable transfer into the target, where they can grow to form dentin (Krebsbach 2002). This has been shown to work on immunosuppressed mice in laboratory settings, but has yet to be tried in humans. Ideally, stem cells will be harvested from the same host in which they'll be replanted to regenerate the tissue desired in the tooth. This would help to avoid a graft vs. host response or any other immune response (Krebsbach 2002). The identification of genes and gene products (enamelin, amelogenin, ameloblastin) associated with enamel formation gives hope that enamel regeneration is perhaps on the horizon (Slavkin 1996). Not only does this area of research show promise, so does that of conservation of tooth structure not seen with the placement of dental amalgams.

      In all, we have progressed from extraction (total loss of all tooth structure) to amalgams (loss of some sound tooth structure) to composites (lesion specific preparations) to potential tooth regeneration (the future).

      Dental Amalgams

      The history of dental amalgam restorations is a long one. Tin-mercury dental restorations were reportedly used in China in A.D. 600. In the 1830's, France and the western world were introduced to silver-mercury restorations. In 1896, Dr. G.V. Black published a scientific report advocating the use of amalgams for dental procedures. The dental profession eventually universally accepted amalgams, not many years after the report by G.V. Black was published (Dodes 2001).

      G.V. Black listed seven steps of cavity preparation to follow when using amalgam: outline form, resistance form, retention form, convenience form, caries removal, finish of the enamel walls, and cleansing of the cavity. Amalgam as a material requires a certain thickness to be fracture resistant; therefore, preparations are to be at least 0.5mm into tooth dentin to allow for the necessary bulk. The pulpal floor of the preparation should be flat to resist the occlusal stresses and forces from the condensation of amalgam. In class I and II amalgams, the occlusal walls at the marginal ridges are to be divergent as to not undermine or weaken the marginal ridges, while the walls around the triangular ridges are to be convergent. This ideal helps to lead to the retention of the amalgam filling by overextending beyond the outline of the lesion. In class II preparations the proximal box is to have a gingival seat that is perpendicular to the long axis of the tooth to resist occlusal stresses, and have the buccal or lingual wall under the functional cusp slightly convergent to provide retention of the amalgam against gingivoocclusal displacement. Again, this concept requires that there be extension beyond the borders of the lesion for the sole purpose of bulk and retention of the amalgam. In the class V restoration, a slot or box preparation must be created to retain the amalgam, increasing the amount to tooth structure removed. Also, line angle retention is often added into the proximal box in class II preparations to provide mechanical lock (retention) to the amalgam in a mesial or distal direction. Finally, undermined enamel must be removed in these preparations to decrease the chance of fracture at the cavosurface margin (Hill et al. 2001). All of the above requirements are based on "extension for prevention" which has been an integral part of dentistry for over 100 years (Osborne and Summitt 1998). In addition, all criterion stated above require extension of the tooth preparation beyond the lesion specific site.

      Webb presented one of the earliest references to "extension for prevention" in 1881. He stated that to prevent decay, margins of enamel should be free from contact with an adjacent tooth. In 1891 G.V. Black's idea of "extension for prevention", was to provide extension of the preparations to the facial and lingual line angles to bring about "self-cleansing" margins. Black also concluded that it was appropriate to extend preparations through fissures to allow cavosurface margins to be on non-fissured enamel. Based on this review it can be observed that a common theme runs true, extension beyond the lesion to simply facilitate the use of the dental material. By the 1950's, challenges to these ideas were made, and since that time, narrower and more conservative preparations have been made. With this change in preparation theory, preparations that extend into dentin can be confined to areas of actual dentin caries. G.V. Black's first step of cavity preparation, establishing outline form, can now be accomplished by removal of carious dentin and the overlying, unsupported enamel. This concept of decreased extension, along with treatment of active caries only when it has penetrated the dentin radiographically, is based on minimal intervention and is currently "state-of-the-art" in operative dentistry. Today's challenge to dental professionals is to maintain as much sound tooth structure as possible, rather than extending preparations into sound tooth structure. This challenge is what has caused so much controversy over the use of dental amalgams in dentistry (Osborne and Summitt 1998).

      Today, the use of amalgams is often questioned for many reasons. First, the esthetics of amalgams is far from superior when compared with other restorative materials. Most patients do not prefer silver colored fillings in their anterior teeth or even in their pre-molars. Second, amalgam restorations contain mercury, which leaches into the oral cavity over time. Many studies have been done to determine if detrimental health effects occur due to the leached mercury. No health problems can be directly linked to amalgam restoration, but many consumers are still skeptical (Dodes 2001). Third, amalgam does not adhere to tooth structure. Therefore it must rely on cavity design for retention, and this leads to larger preparations. Furthermore, amalgams cannot increase the fracture resistance of prepared teeth unless complete cuspal coverage is provided or an amalgam pin technique is used. Even today amalgam pin use is questioned. Hence, teeth that have been restored with class I or II amalgams have an increased chance of cuspal fracture. Current advancements in amalgams, such as the use of adhesive bonding agents with amalgam, may help to provide support to weakened cusps and improve resistance to fracture. Despite amalgams several disadvantages, their longevity is similar or slightly superior to composite resin restorations. Composites, while considered more "lesion-specific" than amalgams, show problems such as increased wear, polymerization shrinkage, long-term microleakage, and greater technique sensitivity than amalgams. These disadvantages of composites are what may keep amalgam restorations from disappearing in dental offices (Santos and Meiers 1994). Before a sound conclusion can be made a review of resin composite restorations must be made.

      Resin Composite Considerations

      Mild to moderate dental lesion can pose several issues for the dental practitioner. The ability of the tooth to render itself vital by way of inhibiting the lesion from entering the pulp chamber is the primary goal when treating this type of lesion. In order to accomplish this the clinician must remove all decay and restore the tooth to an optimal condition that not only stops the lesion from entering the pulp, but also inhibits the process and progression of secondary caries. It is agreed upon that the clinical diagnosis of secondary caries is the most common reason for replacement of restorations in general practice (Gordan et al 2002). Of course, this is highly dependent upon the type of restorable material used. The scope of this section concentrates on the use of composites, primarily packable, and its use for restoring the mild to moderate dental lesion.

      Despite excellent esthetics and vast improvements in the bonding processes; polymerization shrinkage, different coefficients of thermal expansion, and wear resistance of resin-bonded composites prevent these materials from becoming lifelong restorations (Gordan et al 2002). The aforementioned factors in conjunction with cavity depth can greatly affect the success of an extensive composite restoration.

      When one considers a mild to moderate dental lesion, it is generally considered the lesion extends well into the dentin. The depth of the lesion can have great impact on the success of a composite restoration. Yoshikawa et al agree that it is difficult to obtain high bond strengths to deep dentin (1999). Although our scope doesn't focus on adhesion, this is a crucial process in determining the ultimate outcome of a composite restoration. Due to the vast number and larger size of the dentinal tubules a high content of water is present, decreasing the potential for high bond strength. The lack of a secure bond can increase the opportunity for secondary caries to progress and jeopardize the success of treatment.

      Another issue involved with resin composites is polymerization. The greater the volume of composite to be polymerized is proportional to a greater amount of shrinkage (Yap 2000). As a general rule, polymerization should be performed in increments of 2.0mm. This recommendation is especially true for cavity preparations with four or five walls. Yap and other researchers have noted that at depths greater than 2.0mm poor polymerization resulted. Therefore, larger lesions deep into dentin require more polymerization and produce larger stresses on the adhesive bonding agents. Consequently, this may result in secondary caries due to potential for bacterial ingress along the margin of the restoration and the remaining tooth structure.

      Yet another interesting study included using cavity depth as a variable versus the amount of enamel loss at the cavosurface margin upon removal of composite restorations. Gordan et al (2002) found that the deeper the cavity, the greater the loss of tooth structure at the cavosurface margin. A possible explanation could be due to the higher bonding strength adhesives have with enamel versus dentin.

      Resin bonded composites are highly superior to other direct restorable materials in regards to the cavity design. Studies have indicated that cavity configuration is of minor importance when using composites due to the bond strength to tooth structure. Therefore more attention may be laid on removing the carious tooth structure, rather than exact preparation designs dictated by materials. Although, depth may compromise bond strength as found by Yoshikawa et al (1999), the design is secondary to depth and conservative preparations can lead to greater conservation of healthy tooth structure. Despite the various disadvantages of restoring larger lesions with composite, this benefit of composite restorations is what attracts many clinicians to the use of composite as a direct restorative material. Another variant of composite is a flowable composite and glass-ionomer.

      Flowable Composites and Glass-Ionomers

      In dentistry today, the common patient demands both functional use and esthetic satisfaction of their dental restorations. "The increasing attractiveness of tooth-colored restorations has promoted research in this particular area of operative dentistry during the last few years" (Frankenberger, et al. 2002). Flowable composites and glass-ionomers are on the cutting-edge of dentistry right now and it is the hope of many dentists that such materials can be proven competent and strong. Currently, flowable composites and glass-ionomers are being used to restore mild to moderate carious lesions. The PRR (preventative resin restoration) is an example of a mild restoration that both of these materials are being used for. The questions that many dentists have are: how good is the bond to enamel and dentin of these materials and how durable are these materials?

      A significant advantage of virtually all adhesion dental procedures is conservation of tooth structure. Flowable composites are commonly used to penetrate small pits and fissures in teeth, avoiding the need to remove additional tooth structure to accommodate other filling materials. Containing fluoride, these agents are ideally suited as decay prevention sealants, especially for children. Other uses for this material include shallow occlusal restorations, sealants, class I restorations on primary teeth, mild class II restorations on primary teeth, temporary restoring of fractured cusps, some smaller class IV restorations and class III and V restorations when the restoration is isolatable. Studies have shown that flowable composites have yet to prove their ability to adhere to enamel or dentin on their own. Bonding agents still must be utilized to achieve this adhesion. Flowable composites or low viscosity composites show different properties compared with hybrid or packable composites and are indicated for the restoration of minimally invasive cavity preparations. Also, they are indicated as a stress-breaking base material under packable composites because of their lower elastic modulus. Until newer flowable composites can be developed, packable composites are preferred as the universal solution for restorative needs in the majority of cases.

      Glass-ionomers have been around for over 20 years in dentistry. "Glass-ionomers have certain advantageous properties, such as sustained fluoride release, chemical bonding to tooth substance, and pulpal biocompatibility, but they are not considered to possess the adequate mechanical properties that qualify them for general use as permanent restoration materials in stress-bearing posterior areas" (Manhart et al. 2002). Many of these restorations fail because of their low mechanical strength. In a literature review study conducted on papers written from 1988 to 2000, it was discovered that the annual failure rates of posterior glass-ionomer restorations range within 1.9% to 14.4%. It has been also reported that most glass-ionomer restorations have only a median longevity of three years, including all cavity classes placed by general practitioners. Glass-ionomers have several uses including "luting cement; restorative cements: restorative aesthetic-auto cure, restorative aesthetic-resin modified, restorative reinforced; and lining and base cements" (Mount 1998). Each type has its own respective advantages. Luting cements have an ultimate fine thickness, which is the most appealing characteristic. Some restorative cements have esthetic advantages, while others have high physical properties (losing their esthetic advantages). Lining and base cements obviously line and base the tooth preparation. The problems now found with glass-ionomers are the actual release of fluoride and the decrease in fluoride release over time. Products tested in 2001(Glass-ionomer Ketac-Fil, Fuji II, and Ketac Silver) showed "a strong initial rate of release which decreased over time until, it reached a relatively steady state rate after two weeks" (Hattab, et al. 2001). This same study showed that fluoride release was significantly less in artificial saliva than in ionized water. Many of the products do not release the amount of fluoride that they claim to release.

      Preventative resin restorations are restorations that are used to prevent and destroy incipient lesions in the enamel or rarely to the DEJ (dentin-enamel junction). When extended into the dentin the restoration is no longer considered a PRR. A PRR can be placed anywhere on a tooth, including: pits, fissures, abnormal anatomic structures, or any other bacteria collecting area on a tooth. The idea of these restorations is to prevent mild to moderate cavitation of the bacteria prone or infected tooth. Both flowable composites and glass-ionomers are now being noted as viable materials for patients with small approximal lesions and intact marginal ridges without cracks or opacities, otherwise known as class I or II tunnel restorations. The tunnel preparation technique is a more conservative approach for the treatment of approximal lesions than that of G.V. Black's classic principles. The longevity of these dental restorations is dependent on many different factors, including those related to materials, the dentist, and the individual patient. It is to be expected that the use of improved direct restorative materials will provide excellent longevity even in stress bearing situations. Now with the understanding of the sedative fillings it is necessary that the mechanisms for removal of carious dentin and enamel be considered.

      Alternative Excavation Techniques

      Dental air abrasion is a process similar to sandblasting. The instrument uses pressurized air and an abrasive dust (usually aluminum oxide) (Banerjee 2000). The stream of dust and air is aimed at the tooth to remove tooth structure. The application of air abrasion, for dental use was first studied in 1940 by Dr. Robert Black. The first dental air abrasion unit was introduced by The S.S. White company in 1951. Using air abrasion was a welcomed alternative to the loud belt driven handpieces of the 1940's. The procedure also increased patient comfort because it produced less heat and vibration than the handpieces (White 2000).

      The procedure quickly fell out of favor for several reasons. The first reason is that the preparations made with the air abrasion unit are smooth and flowing, which does not lend itself to material specific preparations. The second reason is that suction was not very good in the 1940s so the machine made a mess in the clinic operatory. Third, dentists were able to do preparations faster with the new air turbines of the 1950s (White 2000).

      Air abrasion has made a comeback. In 2000 18% of general practitioners used air abrasion. The resurgence of the air abrasion procedure can be attributed to the availability of lesion specific composites and the attempt to conserve tooth structure. Air abrasion is indicated as a method for removal of caries and restoration preparation. There are several positive aspects of air abrasion usage for mild to moderate caries. One reason is that the majority of preparations done with air abrasion can be done without anesthesia. White found that 85-90% of patients surveyed did not request anesthesia for air abrasion procedures in the dentin (White 2000). Air abrasion produces cavity margins that are almost imperceptible (Setien 2001). Also, air abrasion is good for anxious patients because it is much quieter than air turbine drills (White 2000).

      As with many novel dental procedures, there are disadvantages to using air abrasion. One disadvantage is that air abrasion with aluminum oxide does not effectively remove carious dentin. This is because the kinetic energy of aluminum oxide tends to be absorbed by soft leathery carious dentin. However, air abrasion does remove sound enamel and dentin, which can lead to over preparation. Another negative factor is the lack of tactile ability with the air abrasion. This is because the nozzle does not touch the tooth during the procedure (Banerjee 2000). Additionally, air abrasion should not be used near amalgam fillings because it releases 4 times the OSHA limit of mercury vapor when used for one minute on amalgam (White 2000). In light of these negative factors, air abrasion is not the method of choice for excavation of mild to moderate carious tooth structure. Soft decay is best removed with a slow speed and a large round bur or a spoon excavator (Banerjee 2000).

      Sono-abrasion is essentially a modified cavitron with a diamond-coated tip. This device is called Sonicsys and was recently developed by KaVo (Banerjee 2000). Setien (2001) found that the Sonicsys weakened enamel rods causing cracks in the enamel adjacent to a preparation in 11 out of 18 trials.

      Er:YAG (erbium: yttrium-aluminum-garnet) lasers have been investigated for removal of hard tissue. At the present date there are many problems with this technique. One problem is that the laser tends to heat up the pulp causing irritation or permanent damage (Banerjee 2000). An additional problem with the laser rapidly heating the tooth is that it causes microexplosions in the dentinal tubules. These microexplosions cause cracks and fractures in the dentin. In addition to these problems the lasers are very expensive (Setien 2001).

      Table 1

      The relative ability of various excavation techniques to remove tooth tissue (Banerjee 2000)
      Method Sound Enamel Sound Dentin Carious Enamel Carious Dentin
      Hand Excavators - - + ++
      Rotary Burs +++ +++ +++ +++
      Air-Abrasion +++ +++ ++ +
      Sono-Abrasion - + + ++
      Lasers + + + +

      Several novel techniques for caries excavation/preparation have been discussed. As table 1 indicates, rotary burs are the most effective for removing all types of tooth structure. After reviewing several papers on these instruments, it is this author's opinion that rotary burs and spoon excavators should be considered the gold standard for caries excavation/preparation. Air abrasion may have a role in dentistry for anxious patients. Without further development Sono-Abrasion and lasers have no part in dentistry for caries excavation/preparation.

      Concluding Thoughts

      Restoration of carious lesions in the future is progressing to improve upon the materials and methods that dentists currently use. For example, it has recently been shown that amalgam restorations designed with rounded internal line angles resulted in less tooth and cusp fractures (Hume 1998). This idea is contradictory to past and current teachings that sharp internal line angles are the ideal. As amalgam becomes phased out of many dental practices, the general shift in dentistry is toward restoring mild to moderate carious lesions with composite tooth bonding materials. Being in the active stage of development, composite materials and techniques for application are subject to change and improvement. Strides for improvement should be made to reduce moisture sensitivity of these materials in the future. This would help limit the amount of operator error involved in placement. Future adhesive restorative materials may "incorporate biomimetic intermediate-strength domains that can undergo stepwise reversible unfolding in response to varying functional stress levels before ultimate catastrophic failure of the adhesive joint occurs. These domains may also re-establish folded configurations on stress relaxation, making the adhesive both strong and tough" (Tay 2002). Another area in which dental adhesives could advance is with the addition of fluorescent biosensors to sense changes in the pH around leaking restorations (Tay 2002). In other words, adhesives of the future will be smarter and be better able to adapt to the stresses of their surroundings. This should result in restorations that last longer and hold up better in the oral cavity.

      Restorative dentistry could head in any one of many directions in the future, but a few things are certain and a few definite trends exist. Treatment has been heading towards more and more conservative means of dealing with carious lesions. Prevention of caries is being stressed through better education and more widespread fluoridation tactics. Fortunately, less unnecessary tooth destruction is occurring. So where do we go from here? Is it possible to progress even further and restore carious lesions without having to remove tooth structure at all? Undoubtedly, research has shown that the restorative materials used on a daily basis will continue to get better. It seems very likely that in the near future we will have a method of tooth regeneration that will forever change the face of dentistry. In addition, the methods and instruments to remove dental caries are changing. With all of the options available today it is imperative that there be adequate research and knowledge available to the practitioner so that treatment decisions can be made based on sound evidence. These certainly are exciting and evolving times in the world of restorative dentistry!

      Position Statement/Final Thoughts

      Each material discussed in this review has a place in dentistry, but the degree is still in question. Based on our current knowledge and understanding of each material and technique we formulated some final thoughts. These were expressed in each respective section, but here is a brief summary. First, resin composites are currently the superior material for the future, and there use will dictate the majority of our practice today and in private practice. In spite of the risk for shrinkage we feel as though proper technique and placement will provide for a successful restoration because of the bonding strength. As for flowable composites, we think that they would serve as an excellent restoration in children (pediatric cases) because of the easy of placement. Therefore we support their use, despite the increased wearability of their surfaces. The use of flowables for PRR is still suggested, based upon their easy of placement with proper technique. The third material to mention is Glass-ionomers. We feel that these materials will place a significant role in cervical lesions that occur on the root surface, in situations were emergency placement of a restorative material is needed for a temporary amount of time, and in locations were remineralization is key to the success of treatment. Our reasoning behind this thought goes back to glass-ionomers ability to release fluoride, and their brittle nature that would not warrant their use in Class I or II restorations on a regular basis. When considering the use of air abrasion, sono-abrasion, and lasers we feel as though there is some need for further improvement on their weaknesses. One reason is the lack of lesion specificity to remove the carious dentin with air abrasion. As far as amalgams are concerned, there use still has a place in dentistry for those patients that lack serious esthetic concerns. After all, they have the longest track record of all materials presented. However, bonding with amalgam in a cavity preparation seems to be a better restoration than an amalgam without. Finally, we feel as though the traditional use of Rotary Burs for carious excavation is still the gold standard because of its ability to be specific and accurate in the hands of a trained practitioner. Whether or not we will use the other modalities of carious excavation is still to be determined.

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