While there is no doubt that the best way to tackle the problem of dental caries is through an effective programme of prevention, as outlined in previous chapters, it is unfortunate that many children still suffer from the disease and its consequences. Hence, there is a need to consider operative treatment to prevent the breakdown of the dentition. As discussed in earlier chapters, there are a number of different techniques and philosophies for treating dental caries. This chapter will concentrate mainly on the methods of complete caries removal (a ‘surgical’ approach). Research to support different philosophies, techniques, and materials frequently lacks evidence from randomized controlled trials, which are considered as the gold standard. Consequently, lower levels of evidence are used to support different techniques. More importantly, dentists need to be skilled in different techniques and philosophies to ensure that appropriate care is provided to each and every child. The removal of caries is not a new concept for the treatment of dental decay. Over the years the treatment of dental caries in children has been discussed and many attempts have been made to rationalize the management of the disease. Writing more than 150 years ago, Harris (1839) was one of the first to address the problem of restoring the primary dentition. Even in those days he was emphasizing the importance of prevention by good toothbrushing. Caries could be arrested by ‘plugging’, but from his description he obviously found treatment for the young patient difficult and not as successful as for adults. However, he did emphasize the importance of looking after children’s teeth: ‘If parents and guardians would pay more attention to the teeth of their children, the services of the dentist would much less frequently be required’, and ‘Many persons suppose that the teeth, in the early periods of childhood, require no attention, and thus are guilty of the most culpable neglect of the future well-being of those entrusted to their care’. Unfortunately, this statement still applies today. Caries removal can be a stressful experience for the child, the parent, and the dentist. Therefore it is important that there is a positive health gain from any treatment that is provided.