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radiographic recognition of enlargement of lesions over time.7,12,13 The benefits of restorative therapy include: removing cavitations or defects to eliminate areas that are susceptible to caries; stopping the progression of tooth demineralization; restoring the integrity of tooth structure; preventing the spread of infection into the dental pulp; and preventing the shifting of teeth due to loss of tooth structure. The risks of restorative therapy include reducing the longevity of teeth by making them more susceptible to fracture, recurrent lesions, restoration failure, pulp exposure during caries excavation, future pulpal complications, and iatrogenic damage to adjacent teeth.14,15 Primary teeth may be more susceptible to restoration failures ABBREVIATIONS AAPD: American Academy of Pediatric Dentistry. ART: Alternative restorative technique. BPA: Bisphenol A. FDA: Food and Drug Administration. GIC: Glass ionomer cement. HT: Hall technique. ITR: Interim therapeutic restoration. RCTs: Randomized controlled trials. RMGIC: Resin modified glass ionomer cements. SSC: Stainless steel crowns. UK: United Kingdom. Latest Revision 2019 Pediatric Restorative Dentistry BEST PRACTICES: RESTORATIVE DENTISTRY THE REFERENCE MANUAL OF PEDIATRIC DENTISTRY 341 than permanent teeth.16 Additionally, before restoration of primary teeth, one needs to consider the length of time remaining prior to tooth exfoliation. Recommendations: 1. Management of dental caries includes identification of an individual’s risk for caries progression, understanding of the disease process for that individual, and active surveillance to assess disease progression and manage with appropriate preventive services, supplemented by restorative therapy when indicated. 2. Decisions for when to restore carious lesions should include at least clinical criteria of visual detection of enamel cavitation, visual identification of shadowing of the enamel, and/or radiographic recognition of progression of lesions. Deep caries excavation and restoration Among the objectives of restorative treatment are to repair or limit the damage from caries, protect and preserve the tooth structure, and maintain pulp vitality whenever possible. The AAPD's Guideline on Use of Vital Pulp Therapies in Primary Teeth with Deep Caries Lesions17 and Best Practices for Pulp Therapy for Primary and Immature Permanent Teeth18 state the treatment objective for a tooth affected by caries is to maintain pulpal vitality, especially in immature permanent teeth for continued apexogenesis.19 With regard to the treatment of deep caries, three methods of caries removal have been compared to complete excavation, where all carious dentin is removed. Stepwise excavation is a two-step caries removal process in which carious dentin is partially removed at the first appointment, leaving caries over the pulp, with placement of a temporary filling. At the second appointment, all remaining carious dentin is removed and a final restoration placed.19 Partial, or one-step, caries excavation removes part of the carious dentin, but leaves caries over the pulp, and subsequently places a base and final restoration.20,21 No removal of caries before restoration of primary molars in children aged three to 10 years also has been reported.22 Evidence from RCTs and a systematic review shows that pulp exposures in primary and permanent teeth are significantly reduced using incomplete caries excavation compared to complete excavation in teeth with a normal pulp or reversible pulpitis. Two trials and a Cochrane review found that partial excavation resulted in significantly fewer pulp exposures compared to complete excavation.23-25 Two trials of step-wise excavation showed that pulp exposure occurred more frequently from complete excavation compared to stepwise excavation.19,24 There also is evidence of a decrease in pulpal complications and post-operative pain after incomplete caries excavation compared to complete excavation in clinical trials, summarized in a meta-analysis.28 Additionally, a meta-analysis found the risk for permanent restoration failure was similar for incompletely and completely excavated teeth.28 With regard to the need to