ADA restorative caries guideline (2023): selective removal over complete excavation, and 12 material recommendations by surface and dentition

What it says#

An expert panel convened by the ADA Council on Scientific Affairs together with the ADA Science and Research Institute's program for Clinical and Translational Research searched for systematic reviews comparing carious tissue removal approaches and for randomized trials comparing direct restorative materials, graded everything with GRADE, and produced 16 recommendations and good practice statements: four on carious tissue removal by lesion depth, and 12 on direct restorative materials by tooth location and the surfaces involved. Every recommendation is conditional. The certainty of the evidence is very low for all of them except the one on restoring root caries in permanent teeth, which is low.

The guideline defines its own vocabulary. A moderate caries lesion is ICDAS codes 3 and 4; an advanced lesion is ICDAS 5 and 6, the same stages as the ADA Caries Classification System. Selective carious tissue removal means carious tissue is removed until soft or firm dentin is reached, also known as partial or incomplete caries removal. Non-selective removal means removal until hard dentin is reached, also known as complete caries removal. Stepwise removal means removing to soft dentin, placing a temporary restoration, and returning months later to remove to firm dentin and place the permanent restoration. No carious tissue removal means sealing the lesion with a preformed crown.

On removal, the direction is consistently conservative. For moderate lesions in permanent teeth the panel suggests prioritizing selective removal over non-selective removal; for advanced lesions in permanent teeth, prioritizing selective removal over stepwise or non-selective removal. In primary teeth, for moderate lesions the panel suggests selective removal, non-selective removal, or no removal (sealing the lesion with a preformed crown) without prioritizing any of them; for advanced lesions it suggests prioritizing selective removal or no removal over non-selective or stepwise removal. The chairside guide adds the conditions for choosing the no-removal route: clinicians should consider the number of involved surfaces, caries risk and activity, moisture control, patient behavior, patient and caregiver preferences, and anticipated time to exfoliation when deciding whether to place a preformed metal crown using the Hall technique.

On materials, the pattern is that most classes accept several options and a few are ranked. In permanent teeth: an anterior Class I in the lingual pit takes conventional glass ionomer cement, hybrid resin composite or resin-modified glass ionomer, with no prioritization; an anterior Class III takes nanocomposite or hybrid resin composite; Class V in either arch takes conventional GIC, hybrid resin composite or resin-modified GIC; a posterior Class I prioritizes conventional GIC, dental amalgam, resin composite or resin-modified GIC over compomer; a posterior Class II prioritizes dental amalgam, resin composite or resin-modified GIC over conventional GIC; and root caries takes either resin-modified GIC or conventional GIC, the only recommendation at low rather than very low certainty. In primary teeth: an anterior Class III takes nanocomposite or hybrid resin composite; a posterior Class I prioritizes resin-modified GIC, resin composites, conventional GIC or preformed crowns over compomer or dental amalgam; a posterior Class II prioritizes resin-modified GIC, resin composites or preformed crowns over compomer, conventional GIC or dental amalgam; and Class V takes conventional GIC, hybrid resin composite or resin-modified GIC. The primary-teeth guide gives no recommendation for an anterior Class I or for root caries.

Three practical notes travel with the material lists. Conventional and resin-modified glass ionomer may be preferable when tooth isolation cannot be achieved, in patients with special health care needs, or in patients lacking predictable access to care. Conventional GIC may be preferable when light-curing is not feasible. And the good practice statement repeats the FDA's recommendation not to use dental amalgam, wherever possible, in children especially those younger than six, people with pre-existing neurological disease, people with impaired kidney function, and people with known heightened sensitivity to mercury or its other components.

Who it applies to#

Any vital, non-endodontically treated primary or permanent tooth with a moderate or advanced cavitated lesion that requires a restoration, with no pulp therapy planned. That is the boundary the panel drew, and it is written into the first clause of every recommendation.

Outside it: teeth needing pulp therapy or already treated endodontically, noncavitated and initial lesions (which belong to the 2018 nonrestorative guideline), and indirect restorations. The guideline also does not tell you whether a lesion needs a restoration at all; that judgment comes from staging the lesion and from the arrest options in the 2018 document, including silver diamine fluoride.

What changed#

This is the first edition of an ADA guideline on restorative treatment of caries lesions, and it completes the pair the ADA started in 2018. The change it makes to common practice is on the removal side: the traditional instruction to excavate to hard dentin is the option the panel ranks below selective removal in permanent teeth, for both moderate and advanced lesions, and its stated reason is that more conservative approaches may decrease the risk of adverse effects. The other change is the standing of preformed crowns and the Hall technique in primary teeth, which appear as a prioritized option for advanced lesions rather than as a fallback.

What did not change is the level of confidence. The panel rated the evidence very low for nearly everything and made no strong recommendation. Read it as a ranking of reasonable options, not as a rule.

Where the source is#

The link under the title is the ADA's page for the guideline. Both chairside guides, permanent and primary teeth, were downloaded and read in full for this entry: they carry all 16 recommendations verbatim, the certainty and strength of each, the definitions of the four carious tissue removal approaches, the ICDAS mapping for moderate and advanced lesions, the material notes, the two algorithm pages and the FDA good practice statement. The full JADA article (2023;154(7):551-566) is behind JADA access, so the systematic review methods and the counts reported here are cross-checked against the published PubMed abstract rather than the article body. The permanent teeth guide is copyright 2024 and the primary teeth guide copyright 2023; both may be used, copied and distributed for noncommercial purposes without prior ADA approval.