Chemo-mechanical Caries Removal in dentistry, Minimal invasive caries removal, Non Invasive caries removal. newer methods in caries removal

1. CHEMO-MECHANICAL CARIES REMOVAL

2. CONTENTS
 INTRODUCTION
 MATERIALS
 ADVANTAGES
 DISADVANTAGES
 LIMITATIONS
 STUDIES
 REFERENCES

3. INTRODUCTION
 Dentinal caries – two zones-
 In ancient times – hand instruments- painful which surpasssed
in 1871 by James Morrisons instrument from Issac Singer’s
sewing machine – ineffective- Evolution- rotary instruments-
low- high speed- extension for prevention.
thermal, pressure effects, annoying sounds, vibration, use of
anesthesia, pain, fear, anxiety in children, dentin dessication
(WHO-2005)- CARIES- as a localized post- operative, pathological
process of external origin, involving softening of hard tooth
tissue and proceeding to the formation of a cavity.

4.  Alternative techniques- air abrasion, sono abrasion, ART,
Lasers, ultrasonic instrumentation, CMCR .
 Banerjee et al (2000) in a review, conlcuded that except for the
rotary burs and chemomechanical systems, none of the
techniques were effective in removal of dentinal caries.
 1975- Habib et al – 5% - sodium hypochlorite- toxic and
aggressive to adjacent healthy tissues.
 Newer solution- NaCL, NaOH, and glycine to 5% NaOCL
 GK- 101- N- monocloroglycine- more effective- very slow
 Caridex- GK 101E

5.  CARIDEX
 N- monochloroglycine and amino butyric acid- GK 101E.
 Krogman and Goldman (1975)published this material and FDA
approval -1984
 Intermittent application of preheated- N- mono-DL-2-aminobutyric
acid.
 Chlorination of remaining partially degraded dentinal collagen –
hydroxy proline – pyrrole -2 – carboxilic acid- disruption of altered
collagen fibres in the caries.
 Expense, additional clinical time, bulky caridex delivery system,
which consisted of reservoir, a heater, a pump and a hand piece with
applicator tip, large quantity required, solution t5o be heated, short
shelf life, hand instruments were not optimum.

6. CARISOLV
 1998- Chriser Hedwards with Lars Strid of Mediteam
collaborated with Dan Ericson and Rolf Bornstein –sweden.
 Lysine, luecine, glutamic acid- instead of amino butyric acid.
 The improved version of carisolv 1, introduced- 1997, by
Mediteam dental AB (Sweden)
 Now been improved and marketed as carisolv -2004 – consists
of two syringes.
 Syringe one- NaOCL,
 syringe two- 3 amino acids, gel substance- carboxy methyl
cellulose, NaCL, NaOH, saline solution coloring indicator( red)

7.  Removal of caries – 5.2 min- as fast as
 When carisolv is mixed- the aminoacids bind chlorine and form
chloramines at high pH.
 3 amino acids are differently charged- electrostatic attraction
to different areas of proteins – hydrophilic and hydrophobic
patches.
 These three choloramine acids gets attracted to one of these
patches, bringing reactive power- breakdown of degraded
collagen- characteristically seen in demineralized portion of
carious lesion- softens only carious dentin leaving healthy
tissue intact.
 The porous nature of demineralized dentin allows carisolv to
penetrate.

8. INDICATIONS
 Where preservation of tooth structure is important
 Removal of root/ cervical caries
 Coronal caries with cavitation
 Removal of caries at crown margins and bridge abutments
 Completion of tunnel preparations
 Local anesthesia is contraindicated
 In dentally anxious patients, needle phobics
 Primary carious lessions in deciduous teeth
 ART procedures
 In patients with special needs

9. Hand instruments
 Specially designed instruments and tips
 Atraumatic, help to preserve the tissue, speed up the
treatment- with different shapes and sizes.
 Classified-
 Type of tips- permanent tips ( double ended), interchangeable
tips( single handle- diff tips)

10.  Standard insrument classification:
 Carisolv hand instrument 1- extra bend- crown margins and
areas difficult to access
 2- multistar- apply gel and start removing caries- promotes
penetration of gel- scraping in all directions with its four
pronged design
 3- remove caries in smaller cavities- root caries or deciduous
teeth
 4- close to the pulp and to remove softened carious dentin
from the cavity
 5- remove caries at DEJ.

11. Power drive
 Is a combined electronic instrument for power
operated, minimally invasive caries removal with
carisolv and fro endodontic treatment.
 Selective and precise
 Fast, simple, efficient
 High tissue control, low sound level
 Patients can operate the control unit themselves
 In dental phobic patients

12. Clinical procedure
 Quickly and easily mastered
 careful selection – fully visible and easily accesssible
lesions – buccal root caries/ occlusal caries
 Instruments- four different handles- eight
interchangeable tips- 0.3-0.2mm- like spoon
excavators- rapid whisking or cutting fashion- removal
of carious tissue only
 Tactile sensation- differentiation carious and non
carious lesions

13.  Effectiveness will decrease- 20-30 min after mixing, gel is mixed
directly before use and used for a single treatment only –
refrigerated- allowed to come to room temperature before use.
 Unmixed gel – two syringe- like tubes- before use two tubes are
secured together using male and female connecting parts-
plungers then depressed to activate the gel- uniform color-
dispensed into the container- 30 sec in place to degrade – rapid
light pressure is applied with the instruments to facilitate
removal of caries, the gel must be continously applied until
cavity preparation is complete.

14.  Cavity assessment: surface color, structure and hardness – gel
no longer becomes cloudy once caries removal is complete,
tactile sensation- instrument should easily pass over sound
tooth structure- sound dentin once washed and dried has
frost and irregular appliance- restored in a conventional
manner.
 Treatment of children using carisolv-
 Do not rush, be sure to give the geo 30 sec to react
 Keep the patient well informed during treatment
 If the patient experience pain- check the cavity is easilt filled
with gel
 Very important not to work with too much force – use speed
and not pressure.

15. advantages
 3 amino acids- incorporated- and different charges – have
improved interaction with degraded collagen within lesion.
 Higher concentration, higher viscosity, doesnot need to be
heated, or applied through a pump mechanism, improved
shelf life.
 Positive acceptance , less pain, discomfort, pleasant
experience, without need of LA, psychologically – less
traumatic experience

16. Disadvantages
 Short life
 High corrosiveness
 Requirement of specialized instruments
 high cost
 Prolonged time
 extensive training ,
 registration of professionals

17. PAPACARIE
 2003- Brazil- Papacarie- papain, chloramines, toluidine blue,
salts, thickening vehicle- antibacterial, anti-inflammatory
characteristics.
 From latex of leaves and fruits – carica papaya
Papain accelerates- cicatricial process –
i. Chemical debridement
ii. Granulation and epithelialization, -phases of cicatrization
iii. Stimulation of the tensile strength of scars

18.  Anti- trypsin- inhibits- protien digestion- but infected tissues
donot show anti- trypsin- can digest only dead cells, degraded
collagen, excavator (opposite side) is used like a pendulum
movement without cutting- without promoting any kind of
stimulus / pressure.
 Guzman and Guzman (1953) – skin lesions- burns- enz
action –papain- necrotic and purulent processes.
 Dawkins (2003)- has bactericidal and bacteriostatic
properties .

19. Advantages:
 Naturally available,antimicrobial, affecting only infected dentin
 efficient ,easy application
 Comfortable, less destructive to dentinal tissues
 Inexpensive solution
 Does not need special instruments
 Very apprehensive patients

20.  Carie – care system (India)-2010- Unitech pharamcueticals-
papaya extract( papain) 100mg, clove oil 2 mg, colored gel
(blue), chloramines, NaCL, sodium methyl paraben
 - a gel based on papain and chloramines containing similar to
papacarie, is less costly than carisolv and has similar use
 The newer version of the product- Papacarie Duo was released
in 2011 and has same eficacy with number of additional
properties -
such as longer shelf life, no need of refrigerated storage, also
has greater viscosity, allowing more precise placement and
less waste during procedure, and offers of minimally invasive
method, that is easy to apply, and dispenses of dental
equipment beyond the need for blunt scraping instruments,
isolation of the operating field and water.

21. Indigenously Prepared Caries Removing Gel ( papEdent- a
painless gel -2011)
 Consists of an enzyme- papin, an anti-oxidant ( D-∞
tocopherol acetate, humectant – glycerin,emulsifier-
amylopectin, thickener – carbopol, preservative- propyl –p-
hydroxybenzoate), coloring agent – green apple and distilled
water as a vehicle.
 Refrigerated, within 1 hour
 Natural product
 Bactericidal, anti-inflammatory, whitening properties
 Acts only on damaged tissues
 No allergies, no special instrument
 easy, economical

22. ADVANTAGES
 Minimal invasive technique
 Increase patient’s compliance, left the healthy dentin intact
 Eliminates use of anesthesia, pain, sound tooth structure
removal
 Selectively removes softened dentin - tooth structure –
iatrogenic pulp exposure.
 Painless procedure
 Biocompatible, bactericidal, bacteriostatic, atraumatic
 Also aids in bonding adhesive restorations
 Special child, medically compromised patients
 Dental camps , school dental camps, community dental camps.

23. LIMITATIONS
 Difficult clinical handling
 Large volume of solution needed
 Short life of opened packages
 Time required
 Hand instruments are not appropriate for cutting enamel, and
now a days, most cavities are not large enough to allow proper
access to carious dentin.

24. STUDIES
 Pandit IK et al (2007) compared – airotor, carisolv, hand
instruments- caries removal, time, pain experience.
 Pai S V et al (2009)- depth of penetration of bonding resin was
significantly more in carisolv group compared to bur group.
 Singhal P, Das UM, Vishwanathan D, Singhal A (2012)- Carisolv
was slightly better than NaoCl 1% gel at apical third because of
formation of high pH chloramines, which is a potent
disinfectant with tissue solvent properties.

25.  Anegudi RT, Patil SB, Tagginmani V, Shetty SD (2012)- carried to
compare reduction of cariogenic flora, duration of caries
removal, the amount of tooth loss, child’s behavioral
assessment before, during, after procedure, pain perception.

26.  Maragakis et al (2001) who claimed that children prefr
conventional method as it was quicker, it tasted better and
finished earlier.
 Yazici et al(2003) – presence of bacteria, absence of smear
layer- pushing of bacteria into the dentinal tubules
 Ingle et al (2007)found that subjects fear of the dentists
increased in the CMCR method, while slightly decreased in the
conventional method.

27. RFERENCES
 Pandit IK, Srivastava N, Gugnani N, Gupta M, Verma L. Various
Methods of Caries Removal in Children: A Comparative Clinical Study.
J Indian Soc Pedod Prev Dent 2007
 Pai VS , Nadig RR, Jagadeesh TG, Usha G, Karthik J, Sridhara KS.
Chemical Analysis Of Dentin Surfaces After Carisolv Treatment. J
Conserv Dent 2009;2(3): 118-22
 Jawa D, Singh S, Somani R, Jaida S, Srikar K, Jaidka R. Comparative
evaluation of the efficacy of chemomechanical caries removal agent
( Papacarie) and conventional method of caries removal: An invitro
study. J Indian Soc Pedod Prev Dent 2010;2(28):73-77

28.  Subramaniam P, Gilhotra K. Antimicrobial efficacy of an
indigenously prepared caries removing gel. Contemp Clinic
Dent 2011;2(1):13-16
 Singhal P, Das UM, Vishwanathan D, Singhal A. Carisolv as an
endodontic irrigant in decidous teeth: An SEM study. Indian
Journal of Dental Research 2012;23(1)
 J Kumar, M Nayak, KL Prasad, N Gupta. A comparative study of
the clinical efficiency of chemomechanical caries removal
using Carisolv® and Papacarie® – A papain gel. Indian Journal
of Dental Research 2012;23(5)
 Anegundi RT, Patil SB, Tegginmani V, Shetty SD. A
comparative microbiological study to assess caries excavation
by conventional rotary method and a chemo-mechanical
method. Contemp Clinic Dent 2012;3(4):388-392.

29.  Avinash A, Grover SD, Koul M, Nayak MT,Singhvi A, Singh RK.
Comparison of mechanical and chemomechanical methods of caries
removal in deciduous and permanent teeth: A SEM study. J Indian
Soc Pedod Prev Dent 2012;2(30):115-121.
 Ramamoorthi S, Nivedhitha MS, Vanajassun PP. Effect of two
different chemomechanical caries removal agents on dentin
microhardness: An in vitro study. J Conserv Dent 2013;16(5):429-
433.
 Matsumoto SFB, Motta LJ, Alfaya TA, Guedes CC, Fernandes KPS,
Bussadori SK. Assessment of chemomechanical removal of carious
lesions using Papacarie Duo ™: Randomized longitudinal clinical trial.
Indian Journal of Dental Research 2013;24(4):488-492.

30.  Dean A J, Mc Donald R E, Avery D R. Dentistry for the
Child and Adolescent, 9th edition, Missouri, Mosby,2011
 Marwah N. Text Book of Pediatric Dentistry. 2nd edition.
New Delhi: Jaypee medical publishers; 2009.
 Tandon S. Text Book of Pedodontics. 2nd edition.
Hyderabad: Paras medical publishers; 2008.
 Damle HG. Text Book of Pediatric Dentistry. 3rd edition.
New Delhi :Arya publishers;2009.
 Pinkham JR, Casamassimo PS, Mc Tigue DJ, Fields HW,
Nowak AJ. Text Book of Pediatric Dentistry. 4th edition.
St.Louis,Missouri: Saunders publishers;2005.
 Meera R, Muthu MS, Phanibabu M, Rathnaprabhu V. First
dental visit of a child. J Indian Soc Pedod Prevent Dent.
2008(Suppl);S68-S71.