Removal of caries using only hand instruments: a comparison of mechanical and chemo-mechanical methods

The effectiveness of Carie-Care™, chemomechanical caries removal technique in primary teeth: randomized controlled clinical trial

BACKGROUND

Chemomechanical techniques for caries removal have been introduced to overcome the shortcomings of the conventional rotatory instruments. This study aimed to clinically evaluate the effectiveness of the chemomechanical method of caries removal (Carie-Care™) over mechanical caries removal through the Atraumatic Restorative Technique in pediatric patients.

METHODS

A randomized controlled clinical trial was conducted. Fifty children fulfilling inclusion criteria were recruited from the outpatient clinic of Pediatric and Dental Public health department, Faculty of Dentistry, Alexandria University. Fifty open carious primary molars were randomly assigned into 2 equal groups according to the method of caries removal. In Group I (test group), caries was removed using the Carie-Care™ system and in Group II (control group), by using mechanical caries removal through the atraumatic restorative technique. Resin modified glass ionomer was used for teeth restoration, the two techniques were compared in each child according to time taken for caries removal, efficacy of caries removal, pain assessment, and child behavior.

RESULTS

The mean time taken for caries removal in the Carie-Care™ treatment group was (575.6 ± 114.8) seconds which was statistically significant higher as compared with the ART treatment group (346.1 ± 97.4) seconds (p < 0.001). The mean score of efficacy in caries removal was (0.6 ± 0.8) in the Carie-Care™ group, and (1.3 ± 0.7) in the ART treatment group. When compared to ART, Carie-Care™ was significantly more efficient in caries removal (p < 0.002). When pain was assessed by the SEM scale, it was observed that the Carie-Care™ caries removal technique showed statistically significantly more comfort during the procedure compared with the ART procedure (p < 0.001).Moreover, children in the Carie-Care™ group enjoyed the process and showed more cooperative behavior when assessed at the end of procedure than those in the ART group with statistically significant difference (p = 0.002).

CONCLUSIONS

Removal of carious tissue in primary teeth using Chemomechanical Carie-Care™ gel proved to be more time consuming than ART, but on the other hand it was more efficient, comfortable, and accepted by the pediatric patients.

Expert consensus on early childhood caries management

Early childhood caries (ECC) is a significant chronic disease of childhood and a rising public health burden worldwide. ECC may cause a higher risk of new caries lesions in both primary and permanent dentition, affecting lifelong oral health. The occurrence of ECC has been closely related to the core microbiome change in the oral cavity, which may be influenced by diet habits, oral health management, fluoride use, and dental manipulations. So, it is essential to improve parental oral health and awareness of health care, to establish a dental home at the early stage of childhood, and make an individualized caries management plan. Dental interventions according to the minimally invasive concept should be carried out to treat dental caries. This expert consensus mainly discusses the etiology of ECC, caries-risk assessment of children, prevention and treatment plan of ECC, aiming to achieve lifelong oral health.

Interventions for treating cavitated or dentine carious lesions

BACKGROUND

Traditionally, cavitated carious lesions and those extending into dentine have been treated by 'complete' removal of carious tissue, i.e. non-selective removal and conventional restoration (CR). Alternative strategies for managing cavitated or dentine carious lesions remove less or none of the carious tissue and include selective carious tissue removal (or selective excavation (SE)), stepwise carious tissue removal (SW), sealing carious lesions using sealant materials, sealing using preformed metal crowns (Hall Technique, HT), and non-restorative cavity control (NRCC).

OBJECTIVES

To determine the comparative effectiveness of interventions (CR, SE, SW, sealing of carious lesions using sealant materials or preformed metal crowns (HT), or NRCC) to treat carious lesions conventionally considered to require restorations (cavitated or micro-cavitated lesions, or occlusal lesions that are clinically non-cavitated but clinically/radiographically extend into dentine) in primary or permanent teeth with vital (sensitive) pulps.

SEARCH METHODS

An information specialist searched four bibliographic databases to 21 July 2020 and used additional search methods to identify published, unpublished and ongoing studies.  SELECTION CRITERIA: We included randomised clinical trials comparing different levels of carious tissue removal, as listed above, against each other, placebo, or no treatment. Participants had permanent or primary teeth (or both), and vital pulps (i.e. no irreversible pulpitis/pulp necrosis), and carious lesions conventionally considered to need a restoration (i.e. cavitated lesions, or non- or micro-cavitated lesions radiographically extending into dentine). The primary outcome was failure, a composite measure of pulp exposure, endodontic therapy, tooth extraction, and restorative complications (including resealing of sealed lesions).

DATA COLLECTION AND ANALYSIS

Pairs of review authors independently screened search results, extracted data, and assessed the risk of bias in the studies and the overall certainty of the evidence using GRADE criteria. We measured treatment effects through analysing dichotomous outcomes (presence/absence of complications) and expressing them as odds ratios (OR) with 95% confidence intervals (CI). For failure in the subgroup of deep lesions, we used network meta-analysis to assess and rank the relative effectiveness of different interventions.

MAIN RESULTS

We included 27 studies with 3350 participants and 4195 teeth/lesions, which were conducted in 11 countries and published between 1977 and 2020. Twenty-four studies used a parallel-group design and three were split-mouth. Two studies included adults only, 20 included children/adolescents only and five included both. Ten studies evaluated permanent teeth, 16 evaluated primary teeth and one evaluated both. Three studies treated non-cavitated lesions; 12 treated cavitated, deep lesions, and 12 treated cavitated but not deep lesions or lesions of varying depth.  Seventeen studies compared conventional treatment (CR) with a less invasive treatment: SE (8), SW (4), two HT (2), sealing with sealant materials (4) and NRCC (1). Other comparisons were: SE versus HT (2); SE versus SW (4); SE versus sealing  with sealant materials (2); sealant materials versus no sealing (2).  Follow-up times varied from no follow-up (pulp exposure during treatment) to 120 months, the most common being 12 to 24 months. All studies were at overall high risk of bias. Effect of interventions Sealing using sealants versus other interventions for non-cavitated or cavitated but not deep lesions There was insufficient evidence of a difference between sealing with sealants and CR (OR 5.00, 95% CI 0.51 to 49.27; 1 study, 41 teeth, permanent teeth, cavitated), sealing versus SE (OR 3.11, 95% CI 0.11 to 85.52; 2 studies, 82 primary teeth, cavitated) or sealing versus no treatment (OR 0.05, 95% CI 0.00 to 2.71; 2 studies, 103 permanent teeth, non-cavitated), but we assessed all as very low-certainty evidence. HT, CR, SE, NRCC for cavitated, but not deep lesions in primary teeth The odds of failure may be higher for CR than HT (OR 8.35, 95% CI 3.73 to 18.68; 2 studies, 249 teeth; low-certainty evidence) and lower for HT than NRCC (OR 0.19, 95% CI 0.05 to 0.74; 1 study, 84 teeth, very low-certainty evidence). There was insufficient evidence of a difference between SE versus HT (OR 8.94, 95% CI 0.57 to 139.67; 2 studies, 586 teeth) or CR versus NRCC (OR 1.16, 95% CI 0.50 to 2.71; 1 study, 102 teeth), both very low-certainty evidence. CR, SE, SW for deep lesions The odds of failure were higher for CR than SW in permanent teeth (OR 2.06, 95% CI 1.34 to 3.17; 3 studies, 398 teeth; moderate-certainty evidence), but not primary teeth (OR 2.43, 95% CI 0.65 to 9.12; 1 study, 63 teeth; very low-certainty evidence). The odds of failure may be higher for CR than SE in permanent teeth (OR 11.32, 95% CI 1.97 to 65.02; 2 studies, 179 teeth) and primary teeth (OR 4.43, 95% CI 1.04 to 18.77; 4 studies, 265 teeth), both very low-certainty evidence. Notably, two studies compared CR versus SE in cavitated, but not deep lesions, with insufficient evidence of a difference in outcome (OR 0.62, 95% CI 0.21 to 1.88; 204 teeth; very low-certainty evidence). The odds of failure were higher for SW than SE in permanent teeth (OR 2.25, 95% CI 1.33 to 3.82; 3 studies, 371 teeth; moderate-certainty evidence), but not primary teeth (OR 2.05, 95% CI 0.49 to 8.62; 2 studies, 126 teeth; very low-certainty evidence). For deep lesions, a network meta-analysis showed the probability of failure to be greatest for CR compared with SE, SW and HT.

AUTHORS' CONCLUSIONS

Compared with CR, there were lower numbers of failures with HT and SE in the primary dentition, and with SE and SW in the permanent dentition. Most studies showed high risk of bias and limited precision of estimates due to small sample size and typically limited numbers of failures, resulting in assessments of low or very low certainty of evidence for most comparisons.

Comparison of two minimally invasive restorative techniques in improving the oral health-related quality of life of pregnant women: a six months randomized controlled trial

BACKGROUND

Women tend to delay dental treatment due to misconceptions regarding the safety of dental procedures during pregnancy which may negatively affect their quality of life. Minimally invasive restorative techniques offer alternatives for caries treatment and can improve their oral health-related quality of life (OHRQoL) during this stage.

METHODS

A randomized controlled clinical trial was conducted in 2019 and included 162 pregnant women visiting public family health centers in Alexandria, Egypt, with mild to moderate dental pain due to caries. Participants were randomly assigned into Papacarie-Duo group (n = 82) and ART group (n = 80). The outcome variable was percent change in OHRQoL (oral health impact profile, OHIP-14) after 6 months. T test/Mann Whitney U test were used to compare groups and a multivariable linear regression analysis was conducted to evaluate the factors affecting the outcome variable.

RESULTS

A significant reduction (P < 0.002) was noted in OHIP-14 between baseline and 6 months indicating improvement in OHRQoL in the Papacarie-Duo and ART groups (16.26% and 18.91%, P = 0.120 in bivariate analysis). Multiple linear regression revealed significantly greater reduction in OHIP-14 scores in the Papacarie-Duo than the ART group (regression coefficient = 4.03, 95% confidence interval: 0.652, 7.409, P = 0.020).

CONCLUSION

Minimally invasive restorative techniques, such as ART and chemo-mechanical caries removal using Papacarie- Duo can improve the OHRQoL of pregnant women suffering from mild to moderate pain due to dental caries. Significantly more improvement was noted in the Papacarie-Duo group after adjusting all other variables. Trial registration ID NCT04619264 ( https://clinicaltrials.gov/ ); November 6 2020, retrospective registration. ( https://clinicaltrials.gov/ct2/show/NCT04619264?term=NCT04619264&draw=2&rank=1 ).

Vibration Exposure and Transmissibility on Dentist's Anatomy: A Study of Micro Motors and Air-Turbines

The use of dental hand pieces endanger dentists to vibration exposure as they are subjected to very high amplitude and vibration frequency. This paper has envisaged a comparative analysis of vibration amplitudes and transmissibility during idling and drilling with micro motor (MM) and air-turbine (AT) hand pieces. The study aims to identify the mean difference in vibration amplitudes during idling, explore different grasp forces while drilling with irrigant injection by the dentist, and various vibration transmission of these hand pieces. The study utilized 22 separate frequency resonances on two new and eight used MMs and two new and eight used ATs of different brands by observing the investigator at 16 different dentist clinics. The study adopted a descriptive research design with non–probability sampling techniques for selecting dentists and hand pieces. Statistical methods like Levene Test of Homogeneity, Welch ANOVA, independent t-test, and Games–Howell test were utilized with SPSS version 22 and MS-Excel. The results reveal that vibration amplitudes and vibration transmissibility when measured at position 2 are higher than in another position 1. Vibrations during idling for used MMs are more than AT hand pieces, and the used MM (MUD) and used AT (AUA) hand pieces differ due to their obsolescence and over-usage. Vibration amplitudes increase every time with the tightening of grasping of the hand piece. Vibration amplitudes for each grasping style of MM hand piece differ from all other grasping styles of AT hand pieces. Routine exposure to consistent vibrations has ill physical, mental, and psychological effects on dentists. The used hand pieces more hazardous as compared to newer ones. The study suggests that these hand pieces must be replaced periodically, sufficient to break between two operations, especially after every hand piece usage. Hence, the present research work can be further extended by creating some control groups among dentists and then studying the vibration amplitude exposure of various dental hand pieces and subsequent transmissibility to their body parts.

The impact of minimally invasive restorative techniques on perception of dental pain among pregnant women: a randomized controlled clinical trial

BACKGROUND

The public dental care sector is striving to fulfill the preventive and restorative needs of Egyptians, including pregnant women, who may not receive timely care due to misconceptions about dental treatment during pregnancy. Because of this, they are likely to suffer dental pain, with higher risk of infection affecting their offsprings.

AIM OF THE STUDY

To compare the effectiveness of chemo-mechanical caries removal using Papacarie-Duo and Atraumatic Restorative Treatment (ART) in reducing dental pain among pregnant women.

MATERIALS AND METHODS

A randomized controlled clinical trial was conducted, in 2019, and included 162 pregnant women visiting family health centers in Alexandria, Egypt, with dental pain due to dental caries not extending to pulp. Patients were randomly assigned to Papacarie-Duo group (n = 82) and ART group (n = 80) after stratification by number of treated surfaces. The outcome variables were reduction in pain assessed using Visual Analogue Scale (VAS), satisfaction with treatment, and time taken for dental caries removal. T test/ Mann Whitney U test were used to compare groups and Freidman test was used to compare change across time.

RESULTS

Pain reduction was significantly greater in the Papacarie-Duo than the ART group (81.55% and 69.43%, P = 0.001). Patients in the Papacarie-Duo group were significantly more satisfied with treatment than those in the ART, immediately after treatment (mean = 9.60 and 8.00, P =  < 0.01) and after 6 months (mean = 9.63 and 8.16, P =  < 0.01). Significantly less excavation time was recorded in the Papacarie-Duo group than in the ART group (mean = 10.38 and 11.56 min, P =  < 0.01).

CONCLUSION

Chemo-mechanical caries removal using Papacarie-Duo is more effective in reducing dental pain, in pregnant women, and is associated with more satisfaction and less excavation time than ART.

TRIAL REGISTRATION

ID NCT04573608 ( https://clinicaltrials.gov/ ); 5/10/2020, retrospective registration.

Development of artificial neural network model for prediction of post-streptococcus mutans in dental caries

BACKGROUND AND OBJECTIVE

Streptococcus mutans is the primary initiator and most common organism associated with dental caries. Prediction of post-Streptococcus mutans favours in the selection of appropriate caries excavation method which eventually results in meliorate caries-free cavity preparation for restoration. The objective of this study is to predict the post-Streptococcus mutans prior to dental caries excavation based on pre- Streptococcus mutans using iOS App developed on Artificial Neural Network (ANN) model.

METHODS

For the current research work, children with occlusal dentinal caries lesion were chosen, 45 primary molar teeth cases were studied. Caries excavation was done with carbide bur, polymer bur and spoon excavator. The colony forming units for pre and post-Streptococcus mutans were recorded, data emanating from clinical trials was employed to develop the ANN models. ANN models were trained, validated and tested with the registered clinical data using different ANN architectures.

RESULTS

Feedforward backpropagation ANN model with an architecture of 4-5-1, predicts post-Streptococcus mutans with an efficiency of 0.99033, mean squared error and mean absolute percentage error for testing cases were 0.2341 and 4.967 respectively.

CONCLUSIONS

Caries excavation methods and pre-Streptococcus mutans are feed as inputs, while post-Streptococcus mutans as targets to develop ANN model. Based on the developed ANN model, an ingenious iOS App was developed, the global clinician may utilize the App to meticulously predict post-Streptococcus mutans on iPhone based on pre-Streptococcus mutans, which in turn aids in decision making for the selection of caries excavation method. This study manifests the potential application of iOS App with built-in ANN model in efficiently predicting the post-Streptococcus mutans. Also, the study extends scope for applications of iOS App with built-in ANN models in clinical medicine.

Short ultrasonic debridement with adjunctive low-concentrated hypochlorite/amino acid gel during periodontal maintenance: randomized clinical trial of 12 months

OBJECTIVES

The objective of this study was to evaluate the benefit of repeated subgingival cleaning with a low-concentrated hypochlorite/amino acid gel in subjects in maintenance care with residual pockets ≥ 5 mm.

MATERIAL AND METHODS

Examiner masked, randomized two-arm parallel design. Thirty-two adult periodontal patients in maintenance phase, > 3 months after periodontal therapy, with at least one residual periodontal pocket ≥ 5 mm, were randomly assigned to treatment by subgingival ultrasonic debridement with the gel or ultrasonic debridement only. At months 0, 4, and 8, all sites presenting with a probing depth (PD) ≥ 5 mm were treated. Six sites were monitored on each tooth. The primary end point was the presence or absence of PD ≥ 5 mm after 12 months. Secondary clinical outcomes were oral tissue safety; patient acceptance; changes in PD; bleeding on probing; recession after 4, 8, and 12 months; and the presence or absence of six target microorganisms in treated pockets at baseline, after 7 days and 4 months.

RESULTS

A total of 365 sites in 32 patients with PD ≥ 5 mm were treated at baseline. At the final evaluation at month 12, 47% of these sites in the test and 49% in the control group were still in this PD category. The difference between baseline and month 12 was significant in both groups (p < 0.01), whereas the difference between groups was not. Repeated short ultrasonic instrumentation with adjunctive administration of the test product resulted in a clinical attachment level (CAL) gain of 1.02 mm (p < 0.01) and led to - 0.97 mm of pocket reduction (p < 0.01) without inducing further recession. However, repeated short ultrasonic debridement without the gel led to a similar clinical outcome (p < 0.01). No adverse events were recorded.

CONCLUSIONS

Short ultrasonic instrumentation of residual pockets with PD ≥ 5 mm during maintenance visits resulted in a clinically relevant CAL gain and PD reduction in the order of 1 mm in 1 year, without inducing further recession.

CLINICAL RELEVANCE

This study corroborates the benefit of regular maintenance care after periodontal therapy, including short debridement of the residual pockets.

Atraumatic Restorative Treatment and Interim Therapeutic Restoration: A Review of the Literature

This review discusses the techniques and uses of atraumatic restorative treatment (ART) and interim therapeutic restoration (ITR) and states the differences between these two approaches. ART and ITR are similar approaches and are performed using the same material, but they differ in the purpose of their use. ART is used in cases when there are obstacles to reaching dental care units and has been proven to have high success rates in primary and permanent dentitions. ITR is used as a temporary restoration that will be replaced with a more definitive one. ITR is used in cases when the ideal dental treatment cannot be performed. Conventional glass polyalkenoate (ionomer) restorative cement (GIC) is the material of choice that has been used for ART and ITR. This is because of its fluoride release properties, including its ability to bond to enamel and dentine, its pulpal biocompatibility, and its ease of manipulation. High-viscosity glass ionomer performed better than low and medium-viscosity glass ionomer in ART. Combining GIC with conditioner, as well as the use of a chemo-mechanical approach, improved the success rate of ART. Both ATR and ITR are acceptable strategies, with success rates comparable to the traditional treatment methods.

New treatment method for pain and reduction of local anesthesia use in deep caries

Chemo-mechanical caries removal methods are known to be more effective compared with conventional methods in pain reduction. Carie-care™, a chemo-mechanical caries removal agent, was introduced in 2010 but a systematic review of its efficacy has not yet been performed. The purpose of this study was to investigate the effectiveness of Carie-care™ on the outcomes of treatment of caries in children and adolescents. The primary outcome was pain while the secondary outcomes included complete caries removal (CCR), time, need for local anesthesia and behavioral response changes.

A Comprehensive literature search was performed in PubMed, EMBASE, and the Cochrane Library up to 30 September 2018. The following keywords were used in the search: ‘chemo-mechanical caries removal agent’, ‘dental caries’, ‘Carie-care’, ‘chemo-mechanical caries removal’, ‘chemo-mechanical caries excavation’, other related keywords, and their combinations. From 942 studies identified, 16 were analyzed. Finally, 4 studies met the eligibility criteria and 260 teeth in 120 children and adolescents were included in this review.

This review showed that Carie-care™ reduces pain during caries treatment but requires a longer time for effective treatment than conventional methods. Local anesthesia was not required in the Chemo-mechanical caries removal (CMCR) group. In addition, dental anxiety decreased compared to the control group, and co-operation was more positive. Therefore, it may be a useful alternative to conventional methods in children and adolescents, but further verification through additional studies is needed.

Microhardness and shear bond-strength of carious dentin after fluorescence-aided or conventionally excavation: (An in-vitro comparison)

Background

To compare the fluorescence-aided and conventionally excavated dentin with microhardness and shear bond strength(SBS) tests.

Material and Methods

Twenty-four teeth with dentin caries were bisected through the center of the lesion into two halves. Forty-eight dentin specimens were embedded and mounted in an acrylic resin. All carious tissue was removed and classified as caries free using conventional visual tactile criteria. Then half of the specimens(n=24) were reinspected with fluorescence-aided caries excavation light(FACE) (FaceLight, W&H Dentalwerk, Bürmoos GmbH, Austria). Specimens were subjected to microhardness and shear bond strength testings. The fracture mode analysis was also performed. The data were compared with Student's t test and Chi-square test.

Results

Residual caries was observed in 2 out of 24 conventionally excavated specimens with FACE inspection(p>0.05). Mean Vickers hardness of the dentin was 61.5±5 in the FACE group and 70.3±3 kg/mm2 in the conventionally excavated group(p>0.05). The mean SBS value of FACE group was 11.42±1.63 MPa and 18.27±1.43 MPa in conventionally excavated group. There was no statistically significant difference between conventional and FACE groups for microhardness and SBS tests(p>0.05). There were also no significant differences on the fracture mode distributions of the groups(p>0.05).

Conclusions

FACE method could be considered as a promising technique for removing infected dentin. Key words:FACE, conventional excavation, residual caries detection, shear bond strength, microhardness.

Effect of Papacarie and Alternative Restorative Treatment on Pain Reaction during Caries Removal among Children: A Randomized Controlled Clinical Trial

OBJECTIVE

To compare the effect of Papacarie and Atraumatic Restorative Treatment (ART) on pain and discomfort during caries removal among children.

STUDY DESIGN

Fifty healthy, 4-8 year-old children were equally and randomly allocated to Papacarie and ART to remove caries from decayed primary teeth. A randomized, controlled, blinded, two parallel-arms clinical trial was conducted in the clinic of the Pediatric Dentistry and Dental Public Health Department, Alexandria University, Egypt in March 2014. Pain and discomfort were assessed blindly by two independent investigators watching videotaped treatment sessions using the Sound, Eye and Motor scale (SEM). Their reliability was assessed using Kappa statistics. The effect of caries removal methods, time spent to remove caries and other confounders on SEM score was assessed using regression analysis.

RESULTS

Mean time to remove caries using Papacarie and ART was 5.8 and 4.8 minutes, P= 0.005. Median Paparie and ART scores for the S, E and M components were 1, 1, 1 and 3, 2, 3. Adjusted mean SEM score= 3.6 and 7.8, P <0.0001. Method of caries removal was the only factor significantly affecting pain and discomfort.

CONCLUSION

Papacarie is associated with minimal pain during caries removal from primary teeth compared to ART, although it has longer working time.

Comparison of two different methods of detecting residual caries

Objectives

The aim of this study was to investigate the ability of the fluorescence-aided caries excavation (FACE) device to detect residual caries by comparing conventional methods in vivo.

Materials and Methods

A total of 301 females and 202 males with carious teeth participated in this study. The cavity preparations were done by grade 4 (Group 1, 154 teeth), grade 5 (Group 2, 176 teeth), and postgraduate (Group 3, 173 teeth) students. After caries excavation using a handpiece and hand instruments, the presence of residual caries was evaluated by 2 investigators who were previously calibrated for visual-tactile assessment with and without magnifying glasses and trained in the use of a FACE device. The tooth number, cavity type, and presence or absence of residual caries were recorded. The data were analyzed using the Chi-square test, the Fisher's Exact test, or the McNemar test as appropriate. Kappa statistics was used for calibration. In all tests, the level of significance was set at p = 0.05.

Results

Almost half of the cavities prepared were Class II (Class I, 20.9%; Class II, 48.9%; Class III, 20.1%; Class IV, 3.4%; Class V, 6.8%). Higher numbers of cavities left with caries were observed in Groups 1 and 2 than in Group 3 for all examination methods. Significant differences were found between visual inspection with or without magnifying glasses and inspection with a FACE device for all groups (p < 0.001). More residual caries were detected through inspection with a FACE device (46.5%) than through either visual inspection (31.8%) or inspection with a magnifying glass (37.6%).

Conclusions

Within the limitations of this study, the FACE device may be an effective method for the detection of residual caries.

Evaluation of Microhardness of Residual Dentin in Primary Molars Following Caries Removal with Conventional and Chemomechanical Techniques: An In vitro Study

Background:

Many patients consider removal of caries to be a very unpleasant experience. Removal of caries with conventional drill is considered traumatic mainly due to fear and anxiety of children and their parents. Minimally invasive dentistry adopts a philosophy that integrates prevention, remineralization, and minimal intervention for the placement and replacement of restorations, thus reaching the treatment objective using the least invasive surgical approach, with the removal of the minimal amount of healthy tissues. Chemomechanical caries removal (CMCR) is a method for minimally invasive, gentle dentin caries removal based on biological principles which is an effective alternative to the traditional method. The present study was done to compare the microhardness of sound dentin before and after carious removal using a chemomechanical method and a conventional method.

Materials and Methods:

The present in vitro study was done on 28 proximal surfaces of fourteen extracted primary molars (with active caries on one proximal surface and sound side as control). The study was done to assess the Knoop microhardness of remaining dentinal surface after caries removal using a slow speed conventional bur and a chemomechanical method (Carie-Care^™). Results and

Conclusion:

The rotary instrument group showed a consistent microhardness value with not much difference according to depth. The chemomechanical group showed a lesser microhardness value closer to the cavity floor than away from it. The microhardness values at all depths were significantly different for each treatment group with an increased value seen in the rotary group. The mean microhardness values of residual dentin in treated side were found to be insignificant when compared among each interval in each group. The microhardness of sound dentin had high significant difference from that of residual dentin in both the rotary group and the chemomechanical group.

Effects of air polishing and an amino acid buffered hypochlorite solution to dentin surfaces and periodontal ligament cell survival, attachment, and spreading

OBJECTIVES

The aim of this study is to examine morphological changes of dentin surfaces following air polishing or amino acid buffered hypochlorite solution application and to assess their influence on periodontal ligament (PDL) cell survival, attachment, and spreading to dentin discs in vitro.

MATERIALS AND METHODS

Bovine dentin discs were treated with either (i) Classic, (ii) Plus, or (iii) Perio powder (EMS). Furthermore, Perisolv® a hypochlorite solution buffered with various amino acids was investigated. Untreated dentin discs served as controls. Morphological changes to dentin discs were assessed using scanning electron microscopy (SEM). Human PDL cells were seeded onto the respectively treated discs, and samples were then investigated for PDL cell survival, attachment, and spreading using a live/dead assay, adhesion assay, and SEM imaging, respectively.

RESULTS

Both control and Perisolv®-rinsed dentin discs demonstrated smooth surfaces at low and high magnifications. The Classic powders demonstrated the thickest coating followed by the Powder Plus. The Perio powder demonstrated marked alterations of dentin discs by revealing the potential to open dentinal tubules even before rinsing. Seeding of PDL cells demonstrated an almost 100 % survival rate on all samples demonstrating very high biocompatibility for all materials. Significantly higher PDL cell numbers were observed on samples treated with the Perio powder and the Perisolv® solution (approximately 40 % more cells; p < 0.05). SEM imaging revealed the potential for PDL cells to attach and spread on all surfaces.

CONCLUSION

The results from the present study demonstrate that cell survival and spreading of PDL cells on root surfaces is possible following either air polishing or application with Perisolv®. Future in vitro and animal testing is necessary to further characterize the beneficial effects of either system in a clinical setting.

CLINICAL RELEVANCE

The use of air polishing or application with Perisolv amino acid buffered hypochlorite solution was effective in treating root surfaces and allowed for near 100 % PDL cell survival, attachment, and spreading onto all root surfaces.

Managing Carious Lesions

The International Caries Consensus Collaboration undertook a consensus process and here presents clinical recommendations for carious tissue removal and managing cavitated carious lesions, including restoration, based on texture of demineralized dentine. Dentists should manage the disease dental caries and control activity of existing cavitated lesions to preserve hard tissues and retain teeth long-term. Entering the restorative cycle should be avoided as far as possible. Controlling the disease in cavitated carious lesions should be attempted using methods which are aimed at biofilm removal or control first. Only when cavitated carious lesions either are noncleansable or can no longer be sealed are restorative interventions indicated. When a restoration is indicated, the priorities are as follows: preserving healthy and remineralizable tissue, achieving a restorative seal, maintaining pulpal health, and maximizing restoration success. Carious tissue is removed purely to create conditions for long-lasting restorations. Bacterially contaminated or demineralized tissues close to the pulp do not need to be removed. In deeper lesions in teeth with sensible (vital) pulps, preserving pulpal health should be prioritized, while in shallow or moderately deep lesions, restoration longevity becomes more important. For teeth with shallow or moderately deep cavitated lesions, carious tissue removal is performed according to selective removal to firm dentine. In deep cavitated lesions in primary or permanent teeth, selective removal to soft dentine should be performed, although in permanent teeth, stepwise removal is an option. The evidence and, therefore, these recommendations support less invasive carious lesion management, delaying entry to, and slowing down, the restorative cycle by preserving tooth tissue and retaining teeth long-term.

Caries Removal by Chemomechanical (Carisolv™) vs. Rotary Drill: A Systematic Review

Background:

Chemomechanical caries removal is an effective alternative to the traditional rotary drilling method. The advantages of chemomechanical techniques in terms of the need for anesthesia, pain perception and patient preference are systematically reviewed and a meta-analysis of the time required for caries removal is reported.

Method:

Randomized controlled studies of comparison of chemomechanical techniques with conventional rotary drill were selected from a systematic search of standard biomedical databases, including the PubMed and Cochrane clinical trials. Non-repeated search results were screened for relevance and risk of bias assessment, followed by methodology assessment. Statistical models were applied to the outcome parameters - time required, pain perception, need of anesthesia and patient preference - extracted from the studies.

Results:

Out of the 111 non-repeated search results, 26 studies receiving a low bias score were selected for the review, and 16 randomized clinical trials of rotary and Carisolv techniques were considered for meta-analysis. Meta-analysis by fixed effect as well as random effect models indicate that Carisolv takes more time (3.65 ± 0.05 and 4.09 ± 0.29 min) than rotary drill (8.65 ± 0.09 and 8.97 ± 0.66 min) method. Advantages of reduced pain (14.67 for Carisolv vs. 6.76 for rotary drill), need for anesthesia (1.59% vs. 10.52%) outweigh the longer time requirement and make it the preferred (18.68% vs. 4.69%) method.

Conclusion:

Chemomechanical techniques stand out as a minimally invasive and preferred method based on the meta-analyses. Evaluation of pain experienced using robust methods is needed to strengthen the evidence for their use.

A comparative clinical study of various methods of caries removal in children

AIM

The aim of the study was to compare the efficacy of caries removal, time taken and to evaluate the pain threshold experienced by children during various caries removal methods.

METHODS

One hundred and twenty patients aged between 4 and 14 years requiring dental restorations were selected. Caries removal was completed using an air-rotor, hand instruments, Carisolv and polymer burs. The efficacy, time taken and pain thresholds were evaluated during caries removal by Ericsson et al. scale, visual analogue scale and verbal pain scale, respectively.

STATISTICAL ANALYSIS

Data was collected and statistically analysed using one-way analysis of variance followed by Post Hoc comparison by Bonferroni method. The skewed data was analysed amongst groups by applying Kruskal-Wallis test followed by probability adjustment by Mann-Whitney test.

RESULT

These results indicated that the efficacy of caries removal was highest with air-rotor and was least by the hand instrument, whilst Carisolv® was least painful and the most time-consuming method.

CONCLUSIONS

Caries removal with polymer burs and Carisolv were found to be as effective in caries removal and could be considered as alternatives to painful procedures as air-rotor in management of caries especially in children.

Current update of chemomechanical caries removal methods

Chemomechanical caries removal is an excellent method for minimally invasive caries excavation, and the removal agents are either sodium hypochlorite (NaOCl)- or enzyme-based. The NaOCl-based agents include GK-101, GK-101E (Caridex) and Carisolv, and the enzyme-based agents include Papacarie and the experimental material, Biosolv. This review outlines the changes in chemomechanical caries removal methods and focuses on recently published laboratory and clinical studies. The historical development, mechanism of action, excavation time and biological effects on pulp and dental hard tissues are described. Based on existing evidence, the currently available chemomechanical caries removal methods are viable alternatives to conventional rotary instrument methods. Chemomechanical methods could be extremely useful in very anxious, disabled and paediatric patients. It does seem some of these agents would still benefit from quicker excavation times in order to achieve more universal acceptance. However, as a means of conserving the caries-affected dentine, chemomechanical caries removal is possibly much more successful than conventional rotary instrumentation.

Efficacy of chemomechanical caries removal in reducing cariogenic microbiota: a randomized clinical trial

The aim of this study was to compare the efficacy of chemochemical methods (Carisolv™ and Papacárie®) versus the manual method (excavators) in reducing the cariogenic microbiota in dentine caries of primary teeth. Forty-six healthy children (5 to 9 years old) having at least one primary tooth with a cavitated dentine carious lesion were included in the study. The teeth presented no clinical or radiographic signs of pulpal involvement. The sample of 74 teeth was randomly divided into three different groups: Papacárie® (n = 25), Carisolv™ (n = 27) and Manual (n = 22). Samples of carious and sound dentine were collected with sterile excavators before and after caries removal in the three groups. The dentine samples were transferred to glass tubes containing a 1mL thioglycollate medium used as a carrier and enriched for microbiological detection of mutans streptococci and Lactobacillus spp, after incubation for 6h at room temperature. The minimum detection value for colony forming units (CFU) was 3.3 x 102 CFU/ml, and the results were converted into scores from 0 to 4. A significant difference was observed in relation to the microbiological scores before and after caries removal for all methods (Wilcoxon test; p < 0.001). The use of chemomechanical methods for caries removal did not improve the reduction of cariogenic microorganisms in dentine caries lesions, in comparison with manual excavation.

Evaluation of the Efficiency and Effectiveness of Three Minimally Invasive Methods of Caries Removal: An in vitro Study

BACKGROUND

Many chemomechanical caries removal (CMCR) agents have been introduced and marketed since 1970s, with each new one being better and effective than the previously introduced. Papacarie and Carisolv are new systems in the field of CMCR techniques. These are reportedly minimally invasive methods of removing carious dentin while preserving sound dentin.

AIM

To compare the Efficiency (time taken for caries removal) and effectiveness (Knoop hardness number of the remaining dentin) of caries removal by three minimally invasive methods, i.e. hand excavation and chemomechanical caries removal using Carisolv and Papacarie.

MATERIALS AND METHODS

Thirty recently extracted human permanent molars with occlusal carious lesions were divided randomly in three equal groups and bisected through the middle of the lesion mesiodistally and excavated by two methods on each tooth.

RESULTS

Statistically significant difference was present among three methods with respect to time and knoop hardness values (KHN) of the remaining dentin.

CONCLUSION

The Efficiency of Hand method is better compared to CMCR techniques and effectiveness of CMCR techniques is better than Hand method in terms of dentin preservation so the chances of maintaining vitality of the pulp will be enhanced. How to cite this article: Boob AR, Manjula M, Reddy ER, Srilaxmi N, Rani T. Evaluation of the Efficiency and Effectiveness of Three Minimally Invasive Methods of Caries Removal: An in vitro Study. Int J Clin Pediatr Dent 2014;7(1):11-18.

Minimal intervention dentistry for managing dental caries - a review: report of a FDI task group

This publication describes the history of minimal intervention dentistry (MID) for managing dental caries and presents evidence for various carious lesion detection devices, for preventive measures, for restorative and non-restorative therapies as well as for repairing rather than replacing defective restorations. It is a follow-up to the FDI World Dental Federation publication on MID, of 2000. The dental profession currently is faced with an enormous task of how to manage the high burden of consequences of the caries process amongst the world population. If it is to manage carious lesion development and its progression, it should move away from the 'surgical' care approach and fully embrace the MID approach. The chance for MID to be successful is thought to be increased tremendously if dental caries is not considered an infectious but instead a behavioural disease with a bacterial component. Controlling the two main carious lesion development related behaviours, i.e. intake and frequency of fermentable sugars, to not more than five times daily and removing/disturbing dental plaque from all tooth surfaces using an effective fluoridated toothpaste twice daily, are the ingredients for reducing the burden of dental caries in many communities in the world. FDI's policy of reducing the need for restorative therapy by placing an even greater emphasis on caries prevention than is currently done, is therefore, worth pursuing.

Antimicrobial efficacy of an indigenously prepared caries removing gel

Objective:

The aim of this study was to assess the anti-microbial efficacy of an indigenously prepared caries removing gel, in primary molars.

Materials and Methods:

Twenty teeth with broad occlusal cavitated lesions that fulfilled the clinical and radiographic criteria formed the study group. These teeth were subjected to chemomechanical method of caries removal, using an indigenously prepared caries removing gel. Prior to and following caries removal, the dentin samples were analyzed for total viable count and lactobacilli count.

Results:

The percentage of reduction in the total viable count was 92.4% and in the lactobacilli count it was 94.1%, which was statistically highly significant.

Conclusion:

Removal of carious tissue with a caries removing gel, a natural plant extract, proved to be efficient, easy to perform, and comfortable for the patient.

Clinical evaluation of a chemomechanical method for caries removal in children and adolescents

OBJECTIVE

The purpose of this study was to make a clinical comparison of the chemomechanical method for caries removal and the conventional rotary instruments technique when used in children and adolescents.

MATERIAL AND METHODS

The study comprised 120 patients aged 3-17 years randomized into two groups: caries were removed chemomechanically in 60 patients and 60 patients received conventional treatment with rotary instruments. The outcome variables were: clinically complete caries removal, pain during caries removal, need for local anesthesia, treatment time, preferences of patients, and clinical success of the restorations during the 12-month evaluation period.

RESULTS

Complete caries removal was achieved in 92% of chemomechanically treated teeth and in all teeth treated with rotary instruments (p>0.05). The chemomechanical method significantly reduced the need for local anesthesia (p<0.001). Eighty-five percent of patients treated with Carisolv and 47% treated with rotary instruments were satisfied with the treatment (p<0.05). The mean time for chemomechanical caries removal was 11.2 ± 3.3 min and 5.2 ± 2.8 min for caries removal with rotary instruments (p<0.001). At the end of the 12-month evaluation period, there was no observed influence of the caries removal method on the survival of the restorations.

CONCLUSIONS

The chemomechanical caries removal technique is an adequate alternative to the conventional rotary instruments method and is advantageous in pediatric dentistry.

Clinical evaluation of caries removal in primary teeth using conventional, chemomechanical and laser technique: an in vivo study

AIM

To evaluate four different techniques of caries excavation in primary teeth in terms of efficacy, efficiency and pain experienced during the procedure.

MATERIALS AND METHODS

Sample of 120 teeth from children aged 5 to 9 years were equally divided into 4 groups - Air rotor (group A), Carisolv (group B), Papacarie (group C) and Er:YAG laser (group D). Visual and tactile criteria along with DIAGNOdent pen value was used to evaluate efficacy. Time was recorded to determine efficiency and FLACC scale was used to assess the pain experienced.

RESULTS

Air rotor and laser were more effective and efficient method whereas laser and CMCR methods were more comfortable methods.

CONCLUSION

Laser irradiation and CMCR methods are comparable to conventional methods in terms of effectiveness and are less painful methods.

CLINICAL SIGNIFICANCE

Newer techniques of CMCR and laser irradiation of dentinal caries are minimally invasive methods and are less painful and thus should be more frequently employed in pediatric dentistry.

The correct use of the ART approach

Confusion exists amongst dentists and scientists about the correct use of the caries management approach termed atraumatic restorative treatment (ART). Inconsistent use of the original definition of ART and suggested modifications (mART) have led to misunderstanding, misconception and miscommunication in the dental literature over the last decade. The aim of this paper is to contribute to a uniform understanding and use of the term ART. Adherence to its original description is suggested and two major aspects were addressed: the use of hand instruments only and the use of adhesive materials and systems.

Two years survival rate of class II composite resin restorations prepared by ART with and without a chemomechanical caries removal gel in primary molars

The aim was to test the null hypotheses that there is no difference: (1) in carious lesion development at the restoration margin between class II composite resin restorations in primary molars produced through the atraumatic restorative treatment (ART) with and without a chemomechanical caries removal gel and (2) in the survival rate of class II composite resin restorations between two treatment groups after 2 years. Three hundred twenty-seven children with 568 class II cavitated lesions were included in a parallel mouth study design. Four operators placed resin composite (Filtek Z 250) restorations bonded with a self-etch adhesive (Adper prompt L pop). Two independent examiners evaluated the restorations after 0.5, 1, and 2 years using the modified Ryge criteria. The Kaplan-Meier survival method was applied to estimate survival percentages. A high proportion of restorations were lost during the study period. Therefore, the first hypothesis could not be tested. No statistically significant difference was observed between the cumulative survival percentages of restorations produced by the two treatment approaches over the 2-year period (ART, 54.1 +/- 3.4%; ART with Carisolv, 46.0 +/- 3.4%). This hypothesis was accepted. ART with chemomechanical gel might not provide an added benefit increasing the survival percentages of ART class II composite resin restorations in primary teeth.

Comparison of two minimally invasive methods on the longevity of glass ionomer cement restorations: short-term results of a pilot study

The purpose of this study was to evaluate the clinical performance of glass ionomer cement (GIC) restorations comparing two minimally invasive methods in permanent teeth after 12 months. Fifty pregnant women (second trimester of pregnancy), mean age 22 +/- 5.30 years, were treated by two previously trained operators. The treatment approaches tested were: chemomechanical method (Carisolv; MediTeam) and atraumatic restorative treatment (ART). A split-mouth study design was used in which the two treatments were randomly placed in 50 matched pairs of permanent teeth. The chemomechanical method (CM) was the test group and the ART was the control group. The treatments were performed in Public Health Centers. The tested restorative material was a high-strength GIC (Ketac Molar; 3M/ESPE). The restorations were placed according to the ART guidelines. Two calibrated independent examiners evaluated the restorations in accordance with ART criteria. The inter-examiner kappa was 0.97. Data were analyzed using 95% confidence interval on the binomial distribution and Fisher's exact test at 5% significance level. In a 12-month follow-up, 86% of the restorations were evaluated. In the test group (CM), 100% (CI=93.3-100%) of the restorations were considered successful. In the control group (ART) 97.6% (CI=87.4-99.9%) of the restorations were considered successful and 2.4% unsuccessful (marginal defect >0.5 mm). There was no statistically significant difference between the 12-month success rate for both groups (Fisher's exact test: P=0.49) and between the two operators (Fisher's exact test: P=1.00). Both minimally invasive methods, chemomechanical method and ART, showed a similar clinical performance after 12 months of follow up.

The ART approach: clinical aspects reviewed

The success of ART as a caries management approach is supported by more than 20 years of scientific evidence. ART follows the contemporary concepts of modern cariology and restorative dentistry. It challenges treatment concepts such as step-wise excavation and the need for complete removal of affected dentine. The ART approach so far has mainly used high-viscosity glass-ionomer as the sealant and restorative material. Cariostatic and remineralization properties have been ascribed to this material which requires further research to establish its clinical relevance. The adhesion of high-viscosity glass-ionomer to enamel in pits and fissures is apparently strong, as its remnants, blocking the pits and fissures, have been considered a possible reason for the low prevalence of carious lesion development after the glass-ionomer has clinically disappeared from it. Encapsulated high-viscosity glass-ionomers may lead to higher restoration survival results than those of the hand-mixed version and should, therefore, not be neglected when using ART. Similarly, the use of resin-modified glass-ionomer with ART should be researched. The effectiveness of ART when compared to conventional caries management approaches has been shown in numerous studies. Proper case selection is an important factor for long-lasting ART restoration survival. This is based on the caries risk situation of the individual, the size of the cavity opening, the strategic position of the cavitated tooth and the presence of adequate caries control measures. As the operator is one of the main causes for failure of ART restorations, attending a well-conducted ART training course is mandatory for successful implementation of ART.

Chemical versus conventional caries removal techniques in primary teeth: a microhardness study

The aim of this in vitro study was to assess the remaining dentinal surface after carious tooth tissue removal with a low speed conventional bur and two chemomechanical methods, (Papacárie and Carisolv), using the microhardness test. It was concluded that the hardness of the remaining dentin after carious tissue removal was lower than that obtained on healthy dentin, without significance between the different means of carious tissue removal (p<0.05).

Chemomechanical caries removal in children: an operator's and pediatric patients' responses

BACKGROUND

This study investigated an operator's and pediatric patients' responses to chemo-mechanical caries removal (CMCR) versus the traditional method (TM) of caries removal using a handpiece and a round bur when treating dentinal-depth occlusal lesions with minimal enamel access in primary molars.

METHODS

Data were collected from 50 children at baseline and before, during and after caries removal using CMCR or TM. The subjects in the CMCR group were on average younger than the subjects in the TM group and had more deep lesions.

RESULTS

The operator rated CMCR as needing more clinical and technical effort and more total effort than TM. He was less satisfied with CMCR than with TM. Subjects in the CMCR group perceived the time needed for treatment as significantly longer than did the subjects in the TM group. Fear of the dentist decreased in subjects in the TM group from before to after the operative appointment, while it increased in subjects in the CMCR group.

CONCLUSIONS

The authors found no direct advantage in using CMCR over using TM.

CLINICAL IMPLICATIONS

CMCR cannot be recommended as an alternative to TM when treating dentinal depth occlusal lesions with minimal access in primary molars.

Antibacterial effect of chlorhexidine- containing glass ionomer cement in vivo: a pilot study

This in vivo pilot study was carried out to test the antibacterial effect of glass ionomer containing chlorhexidine (test group) in comparison to conventional glass ionomer (control group). Fifty 6- to 11-year-old children with one occlusal lesion in a molar were randomly allocated to test and control groups in a parallel-group design. The cavity walls and one half of the floor were cleaned and restored with one of the materials without dentine conditioning. The restorations were removed after 7 days. Dentine samples were taken from the cleaned (affected dentine) and noncleaned area (infected dentine) at baseline and at day 7. Samples were anaerobically and aerobically cultivated for mutans streptococci, lactobacilli and total viable bacterial count (TVC) following common laboratory procedures. ANCOVA was used to test for treatment effects. Seven days after treatment, a significant decrease in anaerobic and aerobic bacterial counts (p = 0.0001) was shown. Lower numbers of anaerobic lactobacilli (p = 0.02), TVC (p = 0.008) and aerobic lactobacilli and TVC (p = 0.03), but not of mutans streptococci, were indicated in the test group compared to the control group. A significant reduction in aerobic lactobacilli from infected dentine treated with the glass ionomer containing chlorhexidine (p = 0.05) was observed whereas in affected dentine, anaerobic mutans streptococci, lactobacilli and TVC and aerobic TVC and mutans streptococci were significantly lower in the test group 7 days after treatment (p = 0.01). We conclude that the present pilot study revealed lower microorganism counts in chlorhexidine-containing glass ionomers than in conventional glass ionomers for both affected and infected dentine over a 7-day period.

Chemomechanical caries removal in children: efficacy and efficiency

BACKGROUND

The authors investigated the effectiveness of chemomechanical caries removal (CMCR) compared with the traditional method (TM) of caries removal using a round bur when treating dentinal-depth occlusal lesions with minimal enamel access in primary molars. The authors also compare CMCR with TM to determine if it had a higher efficacy and could be used more frequently without the subject's having to undergo local anesthesia.

METHODS

The authors collected data from 50 children during operative appointments at which caries was removed using one of the two methods.

RESULTS

Complete caries removal within 15 minutes was achieved in only 57.7 percent of the CMCR-treated teeth. In 42.3 percent of these teeth, residual caries was removed using TM. CMCR was almost eight times more time-consuming than was TM when used to excavate dentinal-depth occlusal lesions with minimal cavitation. There was no significant difference between CMCR and TM in the number of subjects who needed to undergo local anesthesia.

CONCLUSIONS

The authors found no direct clinical advantage in using CMCR over using TM for treating occlusal dentinal lesions with minimal cavitation in pediatric patients.

Pain perception in children during caries removal with the Vector system: a pilot study

AIM

A pilot study to compare pain perception during caries treatment in children by means of: the Vector system versus a mechanical method.

STUDY DESIGN AND METHODS

A population of 31 children, aged 7-11 years, with a positive attitude towards dental treatment was recruited. Every child had two permanent molar teeth treated, one using the Vector system (piezo-driven ultrasonic device) and the other using conventional method (dental bur). Corah, Hochman and the visual scale (Facial Expression Scale) were applied to evaluate anxiety and pain perception.

RESULTS

Treatment with the Vector system required significantly longer time 31.1 versus 4.7 mins for the conventional method. With the Vector system 54.8% of children and with conventional method 29.0% felt no pain. Girls admitted to feeling more pain than boys (verbal scale p < 0.018, visual scale p < 0.072). A high statistical correlation between verbal and visual scales was confirmed (r = 0.821; p < 0.001 and a greater level of pain was found using conventional method.

CONCLUSIONS

The Vector system is useful in treating caries in children, because it minimizes the negative attitudes to pain but takes significantly longer to use.

Evaluation of the methodologies used in clinical trials and effectiveness of chemo-mechanical caries removal with CarisolvTM

This investigation aims to discuss the methodologies applied in clinical trials published about CarisolvTM, in order to assess the best scientific evidence concerning chemo-mechanical caries removal. Papers concerning the use of CarisolvTM were sought using a search strategy. The titles and abstracts of all the reports identified through the search were analyzed by a single reviewer. The inclusion criterion involved: clinical trials having CarisolvTM in one of the study groups. Then, those that fulfilled the inclusion criterion underwent methodology assessment and data extraction. Only 12 papers met the inclusion criterion. It was observed that none of these studies complied with all the evaluated research methodological principles required in order to have power of evidence generation. CarisolvTM proved to be effective in caries removal. Appointment mean time was greater, but the perceived time was shorter than that using conventional techniques due to patients' perception of more comfort and a reduction of anesthesia needs. There were no adverse effect in long-term assessments. In studies with microbiological evaluation of the remaining dentine, it was observed that both the conventional and chemo-mechanical methods produced statistically significant reduction on counts of viable microorganisms.

Clinical evaluation of chemomechanical and mechanical caries removal: status of the restorations at 3, 6, 9 and 12 months

In this study, the clinical efficacy of Carisolvtrade mark system and the hand excavation method in the removal of occlusal dentine caries of primary molar teeth was evaluated. Both Carisolv system and hand excavation method were applied for the removal of caries on different teeth of the same children. After the removal of the caries, Dyract AP materials were used to restore the teeth. The clinical follow-up was made every 3 months within a year. The clinical evaluations of restorations were carried out in accordance with US Public Health Service (USPHS) criteria. To determine whether there was any statistical difference between the groups, chi-square analysis was used. During both excavation methods, pain occurrence and the need for anesthesia and the time spent were all recorded. The time spent for the removal of caries in Carisolv system and in hand excavation method was 9.03+/-4.14 min (mean+/-SD) and 7.34+/-3.41 min (mean+/-SD), respectively (P>0.05). At the end of 1 year, differences between Carisolv and hand excavation groups in terms of marginal adaptation and secondary caries were found to be statistically insignificant (P>0.05). During the removal of caries, certain children complained about pain both in Carisolv system and hand excavation method (7.1 and 35.7%, respectively). As a result, it can be argued that Carisolv system is effective in the removal of caries and causes minimum level pain occurrence. Compared to hand excavation, Carisolv system seems to be a promising restorative approach to remove occlusal caries in primary molar teeth. Studies of longer duration are needed to confirm these findings.

Clinical randomized controlled trial of chemomechanical caries removal (Carisolv)

OBJECTIVES

The purpose of this study was to compare the chemomechanical caries-removal system (Carisolv) with high-speed excavation in cavitated occlusal caries of primary molars. Design and setting. The study was a randomized controlled, clinical trial in which the two techniques were compared in each subject. Participants were chosen from public schools, in Maracaibo County, Zulia State, Venezuela.

SAMPLE AND METHODS

The sample consisted of 80 primary molars selected from 40 children (mean age 7.7+/-0.7 years). Each patient had at least two contralateral primary molars with cavitated occlusal caries and approximately equal-size access to lesions. The outcome variables were: clinically complete caries removal, size of the opening of the cavity, volume of carious tissue removed, pain during caries removal, anaesthesia requested by the patient, caries-removal time, and behaviour and preference of patients.

RESULTS

All treated molars were clinically caries free whichever caries-removal procedure was used. When Carisolv' was used the final cavity entrance sizes were smaller (P<0.001) and the estimated volume of tissue removed was less (P<0.001). The time taken for caries removal was three times longer (7.51+/-1.83 min, P<0.001). Some pain was reported by seven (17.5%) participants when Carisolv was used, compared with 16 (40%) when high-speed excavation was used (P<0.05). Using the Carisolv method there was a higher proportion of patients with positive behaviour (P<0.01), and 71.0% (P<0.05) preferred this treatment.

CONCLUSION

Carisolv is an effective clinical alternative treatment for the removal of occlusal dentinal caries in cavitated primary molars; it is more conservative of dental tissue and appeared to be more comfortable for most patients, although the clinical time spent is longer than when using high-speed excavation.

Removing carious dentin using a polymer instrument without anesthesia versus a carbide bur with anesthesia

BACKGROUND

The authors describe a new rotary polymer instrument that selectively removes infected dentin. This instrument has the potential to prepare selected cavities without the need for local anesthesia (LA). Patient acceptance has not been investigated in a clinical trial.

METHODS

In this open-label clinical study, the authors enrolled 20 subjects with two Class I carious lesions and randomly assigned them to receive one restoration with the polymer instrument and no LA and the second restoration with a carbide bur and LA. Both procedures were completed in one appointment. Subjects completed dental history, dental anxiety and situational pain questionnaires. At specific points during the procedure, subjects rated their perception of the intensity of cold, heat, pain, pressure, vibration, fear and anxiety. On completion of the restorative procedures and at 48-hour and one-week telephone contacts, subjects indicated which procedure they preferred.

RESULTS

During treatment with the polymer instrument, subjects indicated that they experienced slightly more pain, pressure, vibration and anxiety, but not more heat, cold or fear. Immediately after the procedure, 14 (70 percent) of 20 respondents (binomial test; P = .11) said that they would prefer having no LA and use of the polymer instrument for future dental work. The number of subjects indicating this preference increased to 15 (P < .05) at both the 48-hour and one-week contacts. One subject requested rescue LA during the polymer instrument treatment.

CONCLUSIONS

A significant number of subjects preferred the rotary polymer instrumentation with no LA to the carbide bur instrumentation with LA. They held this preference despite experiencing slightly, but reliably, more pain and pressure when treated with the polymer instrument.

CLINICAL IMPLICATIONS

A polymer (bur-like) rotary instrument with cutting ability limited to infected dentin can be used in Class I cavity preparations without the need for LA.

CarisolvTM: an alternative to NaOCl in immature root canals?

AIM

To test the null hypothesis that Carisolv is no more effective than 1% sodium hypochlorite in cleaning uninstrumented, immature root canals.

METHODOLOGY

A total of 240 uniform, immature ovine incisors were decoronated at the CEJ level and randomly divided into four groups of 60. After gross pulp extirpation, canals were flooded with normal saline (negative control), 1% NaOCl, Carisolv or 5% NaOCl (positive control) and incubated for 10 min (group 1), 20 min (group 2), 30 min (group 3) or 30 min, refreshing irrigant at 10 and 20 min (group 4). SEM photomicrographs of canal wall debris in the apical, middle and coronal thirds were scored against a 5-point scale. Internal consistency was assessed by kappa statistics. Debris scores for different irrigant regimes at different canal levels were analysed by non-parametric tests (P < 0.05).

RESULTS

Canals were consistently cleaner in the coronal and middle than apical thirds. NaOCl (5%) was consistently most effective. Carisolv and NaOCl (1%) were no more effective than normal saline in group 1 (P > 0.05), but significantly more effective than normal saline in groups 2 (middle and apical 1/3), 3 and 4 (P < 0.05). Carisolv and NaOCl (1%) had comparable activity in groups 1, 2 (middle and apical thirds) and 3, but NaOCl (1%) was significantly more effective than Carisolv in group 4 (coronal and middle thirds).

CONCLUSIONS

1. The ovine incisor model presents opportunities to investigate irrigation regimes under controlled ex-vivo conditions. 2.NaOCl (5%) remains the most effective irrigant for rapid debris removal in immature root canals. 3. Carisolv cleans pulp debris from the walls of immature root canals as effectively as NaOCl (1%) during static, unrefreshed wall contact for between 20 and 30 min. 4. Refreshment of NaOCl (1%) enhances its cleaning ability above that of Carisolv.

Influence of Carisolv on resin adhesion for two different adhesive systems to sound human primary dentin and young permanent dentin

OBJECTIVE

This study evaluated the influence of Carisolv (Medi Team) for resin adhesion to sound human primary and young permanent dentin.

METHODS

The buccal surfaces of 28 primary molars and 64 premolars were used. Two adhesive systems and resin composites were used; SE: Clearfil SE (Kuraray) and Clearfil APX (Kuraray), and SB: Single Bond (3M) and Z250 (3M). Six groups were prepared. Groups 1-2 were primary dentin and Groups 3-6 were permanent dentin. Groups 1 and 3: SE was used. Groups 2 and 4: treated with Carisolv and then primed, SE was used. Group 5: SB was used. Group 6: treated with Carisolv and then etched, SB was used. The microstructural effects of primer or etchant, and Carisolv plus primer or etchant applied to dentin were evaluated by SEM. In addition, the microstructure of the resin-dentin interfaces of each group was studied using SEM. Shear bond strengths (SBS) were tested, and the failed surfaces were observed using SEM. Data was statistically analyzed using ANOVA with subsequent application of Fisher's PLSD at p<0.05.

RESULTS

The mean SBS (unit: MPa) of Groups 1-6 were: 27.8, 19.2, 21.3, 21.7, 6.7 and 7.6. The SBS of Group 2 was significantly lower than that of Group 1. There was no significant difference of the SBS among Groups 1 and 4, 2, 3 and 4, and 5 and 6. In SE groups, the hybrid layer for primary dentin was thicker than that for permanent dentin.

CONCLUSIONS

Carisolv treatment before priming significantly decreased the SBS to primary dentin in SE groups, but did not influence the SBS to permanent dentin in both SE and SB groups.

In vitro comparison of the efficacy of CarisolvTM and conventional rotary instrument in caries removal

The purpose of this in vitro study was to compare the efficacy of a new chemomechanical caries removal agent, Carisolv (MediTeam AB, Sävedalen, Sweden), with conventional slow-speed rotary instrument (bur). Fourteen extracted human molar teeth with deep dentine caries and no enamel coverage were selected for the study. Their laser fluorescence values were over 30 (DIAGNOdent; KaVo, Biberach, Germany). After the teeth were sectioned through the centre of the carious lesion, one half was removed with conventional drilling (bur); the other half was removed with Carisolv gel. Removal of carious dentine was continued until the lesion was deemed caries-free by visual and tactile criteria. The preparation time for each caries removal technique was also noted. The two halves of each tooth were fixed in 10% buffered-formaldehyde for 1 week. They were then decalcified, dehydrated and embedded in paraffin blocks for histological studies. After taking serial sections of 5 microm thickness, sections were mounted on glass slides, deparaffinized, dehydrated and stained with toluidine blue for observation under a light microscope. Each section was examined for the presence of bacteria. Complete removal of caries was achieved in 13 (93%) of 14 conventionally prepared teeth, and 5 (36%) of 14 chemomechanically prepared teeth (P < 0.05). Mean (+/-SD) time for caries removal was 272 s (+/-53.3) with Carisolv, and 116 s (+/-49.4) with drilling. The results of this study suggest that conventional rotary instrument (bur) was more effective than Carisolv in removal of carious tissue and also takes shorter time.

Preliminary in vitro evaluation of Carisolv as a root canal irrigant

AIM

To test the null hypothesis that Carisolv is no better than PBS in removing organic debris from uninstrumented root canals.

METHODOLOGY

The pulps of two uniform groups of 36 immature, sheep mandibular incisors were grossly removed with barbed broaches immediately prior to the study. Roots in group 1 were irrigated with phosphate buffered saline (PBS), strong sodium hypochlorite (4.5%) or Carisolv without ultrasonic agitation, whilst in group 2 the same irrigants were activated with ultrasound. Canal walls were exposed to irrigants for 10, 20 or 30 min at 37 degree C. In group 2, ultrasound was applied for 30 s at 2, 5 and 7 min within each 10 min incubation period. After washing irrigants free and immersion in fixative, all teeth were split longitudinally, critical point dried and sputter coated for SEM analysis. SEM photomicrographs were recorded of representative areas in the coronal, middle and apical canal thirds and debris scored by a single assessor against a five-point scale. Intraobserver reliability was assessed by Cohens kappa scores and debris scores analysed by the non-parametric Kruskal-Wallis test at P < 0.05.

RESULTS

Sodium hypochlorite was significantly better than Carisolv and PBS in cleaning root canals (P < 0.0001), whether or not ultrasound was applied. Carisolv was shown to clean canals better than PBS, again whether or not ultrasound was applied (P = 0.01). Both incubation time and ultrasound enhanced the action of Carisolv (P < 0.001) whilst the activity of PBS was not significantly improved by exposure time or the application of ultrasound. Kappa scores of 0.90-0.95 indicated excellent consistency in debris scoring.

CONCLUSIONS

Within the limitations of this preliminary study (i). Carisolv cleaned root canals better than PBS and shows promise as an adjunct to root canal preparation; (ii). the action of Carisolv was enhanced by incubation times beyond 20 min whether or not ultrasound was applied; (iii). sodium hypochlorite solution remains the gold standard endodontic irrigant, provided that it is used with care and is contained in the canal system.