Efficacy and tolerance of papain gel with conventional drilling method: a clinico-microbiological study

Comparing efficacies of various papain-based enzyme agents and 2.4% sodium hypochlorite gel in chemomechanical caries removal: a randomized controlled trial

OBJECTIVE

This study aimed to evaluate and compare the efficacies of Papacarie Duo gel, Brix 3000, Selecti-Solve gel, 2.4% sodium hypochlorite gel, and conventional rotary-mechanical method in caries removal and to evaluate the patient comfort.

METHODS

It was a single-blinded, randomized, parallel-group, active-controlled trial with five arms. It was conducted at the Department of Restorative Dentistry and Endodontics, Damascus University. Seventy-five specimens were randomly allocated into five groups: chemomechanical caries removal (CMCR) using Selecti-Solve gel (G1), BRIX3000 (G2), Papacarie DUO gel (G3), or 2.4% sodium hypochlorite gel (G4), and caries excavation using conventional rotary-mechanical method (G5) (control group). The trial considered healthy patients aged 18-40. Permanent molars with class I carious lesions extending to the middle third of dentin with no pulpal and/or periodontal pathology were included. The efficacy of caries removal was considered the primary outcome measure, and the secondary outcome measures were treatment time, volumetric measurement of the cavity, and pain assessment.

RESULTS

The majority (73.30%) of cases from BRIX3000 and conventional rotary-mechanical method groups showed complete caries removal (p = 0.982). The mean time of caries removal was the highest (17.45 ± 4.42) in the 2.4% sodium hypochlorite gel group (p < 0.05), and the lowest (6.33 ± 1.69) was in the conventional rotary-mechanical method group (p < 0.05). The mean cavity volume was the highest (18.97 ± 9.76) in the Papacarie DUO gel group, and the lowest (14.87 ± 4.76) was in the 2.4% sodium hypochlorite gel group (p = 0.506). The conventional rotary-mechanical group exhibited the highest mean score (5.40 ± 1.72) of pain (p < 0.05). However, the mean score (2.67 ± 1.11) of pain reported reduced in the BRIX3000 group.

CONCLUSIONS

CMCR agents could be a potential substitute for conventional rotary instrumentation methods, taking into account the long working time.

Antimicrobial Efficacy of Chemomechanical Carie Removal Agents-A Systematic Integrative Review

BACKGROUND

Dental caries is the most common oral disease in the world. When treatable, the drilling method continues to be used. This technique has its disadvantages because it is invasive and nonspecific. Chemomechanical carious tissue removal agents (CCRAs) such as Carisolv™ or Papacarie® are non-invasive products that allow for the specific elimination of infected dentin. On the other hand, cariogenic bacteria are largely responsible for the initiation and development of lesions.

OBJECTIVES

The aim is to analyze whether CCRAs have a relevant antimicrobial effect on cariogenic bacteria.

METHODS

A bibliographic search strategy was carried out in online databases using PRISMA 2020. The evaluation of the antibacterial efficacy of CCRAs was carried out through the analysis of the reduction in CFUs of cariogenic bacteria, and the presence of bacterial deposits, TVC, SVC and LVC by comparison with conventional drilling methods.

RESULTS

The results showed that the percentage of reduction in TVC, SVC and LVC for each agent is mostly high, but not significantly different from mechanical methods. The best results were found with CCRAs when compared to polymeric drills. The results also showed that there is a lack of methodological standardization.

CONCLUSIONS

CCRAs have been shown to have a relevant antimicrobial effect on cariogenic bacteria; however, more studies need to be carried out using standardized methodologies.

Efficacy of antiseptics and chemomechanical methods for dentin caries lesions: A systematic review with GRADE approach

Objectives

Selective caries removal aims to remove carious tissue in deep dentin lesions. However, a discussion stands on the value of antiseptics and chemomechanical adjuvant methods to reduce the bacterial load on residual caries lesions. This systematic review has addressed two main clinical questions to compare the antimicrobial efficacy of available methods using (1) antiseptic or (2) chemomechanical agents before restoring dentin carious lesions.

Methods

We included randomized and non-randomized controlled trials (RCTs/ NRCTs). We searched eight databases from inception to October 2021. Paired reviewers independently screened studies, extracted data, and assessed the risk of bias. The primary outcome was the reduction in the number of total bacterial in dentin, whereas secondary outcomes were reduction in the number of Lactobacillus and Streptococcus. We used the ratio of ratio of post-treatment to baseline means between two interventions in the logarithmic scale as a proper effect measure. Certainty of evidence was assessed with the Grading of Recommendations, Assessment, Development and Evaluation approach.

Results

We included 14 RCTs and 9 NRCTs, with nine interventions. Regardless the method, the number of bacteria at baseline was similar or exceeded that after the intervention, particularly in NRCTs. The evidence was inconclusive for most comparisons. Among antiseptic agents, chlorhexidine (CHX) resulted in an average of 1.14 times [95% confidence interval (CI): 1.08-1.21] more total bacterial than photodynamic therapy in RCTs. Among NRCTS, the natural agents resulted in five times more total bacterial than CHX (95% CI: 2-11). For chemomechanical methods, the control resulted in eight times (95% CI: 4-17) more total bacterial than Carisolv (SHAA).

Conclusions

The certainty of the evidence was very low for all comparisons showing uncertainty whether one treatment could be more effective than another for dentin disinfection. So far, exclusively removing soft carious dentin would be enough to reduce the bacterial count.

Adjunctive therapies for in vitro carious lesions: Antimicrobial activity, activation of dentin metalloproteinases and effects on dental pulp cells

BACKGROUND

Adjunctive therapies used before dental restorative procedures may encourage carious tissue removal. Beyond promising antimicrobial properties, treatments could positively modulate the dentin-pulp complex while not interfering with restoration survival. Herein, we evaluated a set of substances and their effects on carious lesions and the underlying dentin or pulp cells.

METHODS

Artificial caries lesions were developed in bovine teeth cavities immersed in Streptococcus mutans and Lactobacillus casei co-cultures. The cavities were treated according to the following groups: Phosphate Buffer Saline (PBS), Chlorhexidine (CHX), Papacárie® (Papain gel), Ozone (O₃), and antimicrobial Photodynamic Therapy (aPDT). After treatments, samples were cultivated to count isolated microbial colonies. The zymography assay evaluated the activity of dentin metalloproteinases (MMP-2 and MMP-9). Cell viability was indirectly assessed on human dental pulp cells after 24, 72, or 120 h, whereas the odontodifferentiation potential was evaluated after ten days of cell culture.

RESULTS

CHX and aPDT led to around 1 log bacterial load reduction. PBS, CHX, and aPDT showed the eventual expression of MMP-2 and MMP-9. Cell viability was reduced (< 30%) after 120 h for all groups compared to the control. CHX, O3, and aPDT induced greater odontodifferentiation (≈ 20% higher) than PBS and papain gel.

CONCLUSION

Adjunctive therapies presented little or no biological significance in reducing bacterial load in artificial carious lesions. Although the activation of endogenous metalloproteinases may represent a possible concern for adhesive restorations, some of these treatments may have a positive role in dental pulp tissue repair.

A Bibliometric Analysis (2010-2020) of the Dental Scientific Literature on Chemo-Mechanical Methods of Caries Removal Using Carisolv and BRIX3000

Reports in the literature have proposed and analyzed several minimally invasive techniques for caries removal in recent decades. In light of recent events surrounding the ongoing epidemiological context, concerns have been raised regarding the generation of aerosols during dental procedures. The aim of our research was to provide an overview of the scientific literature on the topic of chemo-mechanical caries removal (CMCR) methods, focusing on two products (Carisolv, BRIX3000), commercially available in Europe. A bibliometric analysis was used to investigate the scientific articles included in Web of Science (WoS) Core Collection database, published from January 2010 to December 2020. We analyzed the co-occurrence of all keywords (Author Keywords and the KeyWords Plus section), co-authorship and co-citation, using the free software VOSviewer. Our bibliometric analysis revealed a worldwide interest in the subject of chemo-mechanical methods of caries removal, which has transcended the area of pediatric dentistry. The analyzed studies have been conducted mainly in high-income countries that have developed sanitary policies regarding prevention and early treatment of carious lesions as a health priority.

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.

BRIX3000® Papain Gel for Cavity Treatment in the Adult Patient

Tooth decay is a multifactorial disease. Fermentable sugar, host factors, and cariogenic microbial flora are several agents that influence dental structure. In literature, alternative protocols for treating cavities are always of interest in terms of reducing pain and preserving tissue. In this case report, the use of a new gel-based on papain, which has a chemical effect on bacteria and allows the consistency of the altered tissue to be modified, leads to a less traumatic removal of the infected tissue. In this case report, BRIX3000, a gel with papain as its main ingredient, was used to treat an interproximal cavity on an upper premolar of a 35-year-old man frightened of the turbine. After a clinical check of all the systematic conditions and a first view of the oral cavity, the protocol was explained to the patient, and informed consent was obtained. The protocol involved applying the papain gel directly to the cavity, and after 2.5–3 minutes, it was removed. The complete removal of the infected tissue was achieved in three steps. The patient reported no discomfort, and the cavity was completely treated and ready to be restored. In conclusion, BRIX3000 seems to be a good alternative to the turbine in cavity treatment, particularly in patients who have discomfort during traditional treatments and are frightened of the turbine.

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.

Efficacy and Patient's Acceptance of Alternative Methods for Caries Removal-a Systematic Review

Dental caries is a disease of dental hard tissues, considered the most common non-communicable disease worldwide. Conventional treatments for caries removal are often associated with pain and fear, so different therapeutic approaches have been developed towards more conservative and pleasant treatments. This systematic review aimed to assess the efficacy and patient's acceptance of alternative methods for caries removal compared to conventional methods. The Cochrane Library, Embase, Medline/Pubmed, Web of Science, and Clinical Trials databases were searched. Clinical trials of primary dental caries treated with alternative methods were included. The last search was performed on 5 August 2020. The Population, Intervention, Comparison, and Outcome (PICO) strategy was followed. Thirty-seven clinical trials were included, reporting caries removal using alternative (chemomechanical-Brix 3000, Carie-care, Carisolv and Papacarie, laser-Er:YAG (Erbium-doped Yttrium Aluminium Garnet) and Er,Cr:YSGG (Erbium, Chromium-doped Yttrium, Scandium, Gallium and Garnet), and a system combining air and sono-abrasion-Vector^® System) and conventional methods. Alternative methods tended to prolong treatment time and lessen anesthesia need. All treatments were effective in reducing cariogenic flora, and the restoration's performance did not differ significantly. Chemomechanical solutions seemed to be the best option towards minimally invasive treatments, with good control during application and action and good treatment experiences for patients. Papacarie was demonstrated to be an effective method for caries removal with less pain, and superior acceptance by patients when compared to conventional treatments.

Effects of Papain-Based Gel Used For Caries Removal on Macrophages and Dental Pulp Cells

Papain-based gel is used for chemical-mechanical caries removal and present antimicrobial and anti-inflammatory activities. However, its effects on dental pulp cells and on macrophages remains largely unknown. Therefore, the aim of this study was to investigate whether the papain-based gel Papacárie Duo® acts as an immunomodulator in lipopolysaccharide (LPS)-activated macrophages and its effects on dental pulp cells . J774.1 macrophage and OD-21 dental pulp cells were stimulated with 0.5% and 5% of Papacárie Duo®, following pre-treatment or not with LPS. After 24 h, a lactate dehydrogenase assay was used to measure cytotoxicity, a tetrazolium-based colorimetric assay (MTT) was used to measure cell viability, and qRT-PCR was used to analyze relative gene expression of Ptgs2, Il10, Tnf, Mmp9, Runx2, Ibsp and Spp1. Papacárie Duo® was cytotoxic and reduced cell viability at 5% but not at 0.5% in both cultures. In macrophages, Papacárie Duo® increased the expression Il10 and LPS-induced Ptgs2, but it did not affect Tnf or Mmp9. In OD-21 cells, Papacárie Duo® inhibited Runx2 and Ibsp expression, but stimulated Spp1 expression. Papain-based gel presented a concentration dependent cytotoxicity, without affecting cell viability, for dental pulp cells and macrophages. Interestingly, the gel presented an inhibitory effect on pulp cell differentiation but modulated the activation of macrophages stimulated with LPS. We speculate that in dental pulp tissue, Papacárie Duo® would impair reparative dentinogenesis but could activate macrophages to perform their role in defense and inflammation.

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.

Effects of Papacarie on children with dental caries in primary teeth: a systematic review and meta-analysis

BACKGROUND

Caries in primary teeth hinder the child to bite and chew and influence their development. Papacarie has the characteristics of selective removal of decayed tissue and can preserve healthy dentine to the maximum, but its efficiency has not been critically evaluated compared to conventional method.

AIM

This review is aiming at comparing the Papacarie and traditional method in caries removal in primary dental caries with children.

DESIGN

Comprehensive literature searching at PubMed, Embase, Cochrane Central Register of Controlled Trials, and Web of Science to January 2018.

RESULTS

Six randomized controlled trials (RCTs) and four prospective controlled clinical trials (CCTs) were included. The microbiota in caries dentine was significantly reduced using the Papacarie treatment (MD = 0.57, 95% CI 0.04 to 1.09, P = 0.03), and the anxiety feeling declined more in the Papacarie group (MD = -1.01, 95% CI -1.72 to -0.30, P < 0.005). There was a greater 200.79 (MD = 200.79, 95%CI 152.50 to 249.09, P < 0.00001) increase in time taken for the Papacarie treatment compared with the conventional method.

CONCLUSION

Papacarie exerts a positive effect in reducing the bacteria and decreases the pain during caries removal in primary teeth although it costed a longer treatment time compared with the conventional method.

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.

Dentin Topographic Features following Chemomechanical Caries Removal in Primary Teeth

AIM

Study the topographic features of dentin after caries removal with a chemomechanical agent (Papacarie) compared with the conventional drilling method.

STUDY DESIGN

The sample included 7 exfoliated and extracted primary teeth with carious dentin lesions, not reaching the pulp. Each tooth was sectioned longitudinally through the center of the carious lesions into two halves. The teeth were then divided into two groups according to the method of caries removal. Following caries removal, dentin topography and the cut section were examined using the scanning electron microscope.

RESULTS

Papacarie produced an irregular, porous, rough and globular dentin appearance. The dentin surfaces were generally free of smear layer, visible bacteria and the dentinal tubules were opened. The dentin cut surfaces showed patent dentinal tubules with open orifices. The drilling method created a smooth and amorphous surface with a continuous smear layer occluding the dentinal tubules. Numerous bacteria were also observed. The cut dentin surfaces showed patent dentinal tubules with their orifices plugged with smear layer.

CONCLUSIONS

Papacarie produced a rough and porous surface with partial or complete removal of the smear layer and opened dentinal tubules, while the drill produced a smooth surface with uniform smear layer occluding the dentinal tubules.