© 2017 American Dental Association Background A lesion on an occlusal tooth surface with no cavitation and no radiographic radiolucency but in which caries is suspected owing to surface roughness, opacities, or staining can be defined as a suspicious occlusal carious lesion (SOCL). The authors' objective was to quantify the characteristics of SOCLs and their relationship to lesion depth and activity after these lesions were opened surgically. Methods Ninety-three dentists participated in the study. When a consenting patient had an SOCL, information was recorded about the tooth, lesion, treatment provided, and, if the SOCL was opened surgically, its lesion depth. The Rao-Scott cluster-adjusted χ2 test was used to evaluate associations between lesion depth and color, roughness, patient risk, and luster. Results The authors analyzed 1,593 SOCLs. Lesion color varied from yellow/light brown (40%) to dark brown/black (47%), with 13% other colors. Most (69%) of SOCLs had a rough surface when examined with an explorer. Over one-third of the SOCLs (39%) were treated surgically. Of the 585 surgically treated SOCLs, 61% had dentinal caries. There were statistically significant associations between lesion depth and color (P =.03), luster (P =.04), and roughness (P =.01). The authors classified 52% of the patients as being at elevated caries risk. The authors found no significant associations between lesion depth and patient risk (P =.07). Conclusions Although statistically significant, the clinical characteristics studied do not provide accurate guidance for making definitive treatment decisions and result in high rates of false positives. Practical Implications Given that 39% of the opened lesions did not have dentinal caries or were inactive, evidence-based preventive management is an appropriate alternative to surgical intervention.