Recent vs Conventional Methods of Caries Removal: A Comparative in vivo Study in Pediatric Patients

Comparative evaluation of the clinical effectiveness of chemomechanical (Papacarie) and conventional mechanical caries removal methods in treatment of carious primary molars: a randomized controlled clinical study

BACKGROUND

Traditionally, treating dental caries involves using rotary instruments, which can create noise that may frighten and cause discomfort in children. Recent research into caries management has introduced minimal invasive techniques like the Papacarie, which is a chemomechanical caries removal agent.

OBJECTIVES

To determine and compare the average time taken for caries removal and pain perception during caries removal by Papacarie as a chemomechanical caries removal method with the use of mechanical method using rotary instrument on carious primary molars.

METHODOLOGY

This randomized controlled clinical study carried out at the dental clinic in Lagos university teaching hospital. A split-mouth design was used and it involved 50 primary molars in 25 healthy children aged 5-9 years, each child having at least two primary molar teeth with occlusal dentine caries. Each tooth was allocated to the intervention using simple balloting method and treated with either Papacarie or conventional method for caries removal. Outcome measured were caries removal time, pain during caries removal and preference. Pain assessment was blinded. The statistical package for social sciences (SPSS) version 25.0 IBM was used for data analysis. The significance level was set at p ≤ 0.05 for all statistical tests at 95% confidence interval.

RESULT

Twenty-five children (with 50 primary molars) met the inclusion criteria and were recruited for the study. The children were between ages 5-9 years. Twenty-five primary molars were treated using Papacarie caries removal method while 25 primary molars were treated using conventional rotary method. There was no statistically significant difference in the time of caries removal between the two groups. Pain perception was lower with the Papacarie method compared to the conventional method, which was statistically significant. More participants preferred the Papacarie method. Twenty-five children (with 50 primary molars) met the inclusion criteria and were recruited for the study. The children were between ages 5-9 years. Twenty-five primary molars were treated using Papacarie caries removal method while 25 primary molars were treated using conventional rotary method. There was no statistically significant difference in the time of caries removal between the two groups. Pain perception was lower with the Papacarie method compared to the conventional method, which was statistically significant. More participants preferred the Papacarie method.

CONCLUSION

The findings from this study indicates that the Papacarie demonstrated a comparable caries removal time, lesser pain perception and better acceptability compared to the conventional method of caries removal.

TRIAL REGISTRATION

Pan African Clinical Trial Registry (PACTR) Trial number PACTR202111738486539. Registered 18th November 2021.

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.

Assessment of Smear Layer Formation After Caries Removal Using Erbium Laser and Papain-Based Chemo-Mechanical Caries Removal Agent: An In Vitro Scanning Electron Microscopy Study

Introduction With the advancement in the field of adhesive dentistry, there has been a significant and groundbreaking shift toward the adoption of minimally invasive caries removal techniques where substrate modification is known to enhance adhesive bonding. The smear layer has always been controversial, as its modification helps in bonding, but if contaminated with bacteria, it compromises the formation of a satisfactory marginal seal. Thus, the recognition of the role played by the smear layer highlights the importance of the type of caries removal method employed. Hence, the aim of the present study was to assess and compare smear layer formation after caries removal using an erbium laser and chemo-mechanical caries removal agent by scanning electron microscopy. Methods The study involved the evaluation of 30 extracted human molars with occlusal caries. Based on the method of caries excavation, the samples were allocated into two separate groups: group 1 - caries removed using erbium laser (Waterlase, Biolase, Lake Forest, CA); group 2 - caries removed using papain-based chemo-mechanical caries removal agent (Carie Fix, Dengen Dental, Bahadurgarh, India). To assess the smear layer, the samples underwent examination using a scanning electron microscope at 1500x and 3000x magnification after removal of caries. Statistical analysis was done using SPSS version 22 software (IBM Corp., Armonk, NY). Mann-Whitney test was used to compare the mean smear layer (nonparametric) between both groups. Results Group 1 (Er:YAG laser) showed significantly greater removal of the smear layer than group 2 (papain-based chemo-mechanical caries removal agent) on the excavated caries surfaces (p < 0.001). In group 1, the dentinal tubules exhibited greater patency when compared to the partial patency observed in group 2. Conclusion Both techniques for caries removal were effective; however, the Er:YAG laser method was determined to be more efficient in comparison to the chemo-mechanical agent. These caries removal methods can be considered the future of minimally invasive dentistry.

Minimal Intervention Dentistry: Biocompatibility and Mechanism of Action of Products for Chemical-Mechanical Removal of Carious Tissue

Conventional method for removal of carious tissue using low speed drills usually induce noise and vibration, in addition to thermal and pressure effects that can be harmful to the pulp tissue and cause fear in children. Therefore, several alternative methods are being developed to try to minimize the unpleasant perception of the patient during caries removal. Chemical-mechanical removal of carious tissue goal is to selectively remove the carious lesion, which reduces the amount of bacteria inside the cavity without removing the tissue susceptible to remineralization. This method is also able to minimize the tactile perception by the patient during the manipulation of the lesion compared to the conventional method, and, therefore, it has been widely accepted among phobic patients, children and special needs patients. Due to the close relationship between dentin and pulp tissue, all injuries imposed on this dentin may have repercussions on the underlying pulp connective tissue. The morphological aspects of remaining dentin favor the diffusion of chemical components of dental materials, which can be toxic to the pulp tissue or even negatively interfere in the reparative process. Thus, considering the proximity between the applied material and the underlying pulp tissue, especially in deep cavities, there is a need to assess the biological behavior of dental materials against pulp cells, since aggressions to the pulp tissue can be caused not only by metabolites from microorganisms involved in dental caries but also by components that are released from these products. This subject was explored in this narrative literature review.

Worldwide research trends on the use of chemical-mechanical caries removal products over the years: a critical review

BACKGROUND

Chemical-mechanical caries removal (CMCR) products are in constant evolution and were recommended during the COVID-19 pandemic as substitutes for conventional caries removal.

AIM

Characterize the worldwide scientific literature about CMCR products, over the years, by means of a critical review.

DESIGN

Electronic search was performed on Medline/PubMed, Scopus, Web of Science, Cochrane Library, Lilacs, and Embase up to November 2020. Year, journal, country of authors, and type of study were the data extracted from the retrieved studies. Additional data of the clinical studies and systematic reviews were investigated.

RESULTS

2221 records were identified, 397 selected. 2011-2020 period concentrates higher number of publications (n = 169), in the Journal of Dental Research (n = 51), developed in Brazil (n = 45) and India (n = 44). Most studies were in vitro (n = 211) and clinical trials (n = 101). Carisolv™ (n = 48) and Papacarie Duo Gel™ (n = 33) were the most used products, prescript in isolated usage (n = 101), and compared with drills (n = 77). CMCR were more studied in primary teeth (n = 78), receiving glass ionomer cement (GIC) (n = 51) as restorative material. The most evaluated outcomes were time spent (n = 48) and pain (n = 41). Clinical application of CMCR takes more time than other techniques, but can also reduce patient anxiety, pain, and need for anesthesia.

CONCLUSION

In vitro and clinical studies with CMCR products have been increasing, mostly carried out in developing countries, evaluating Carisolv™ and Papacarie Duo Gel™. Clinical studies tend to evaluate the time spent and pain compared to drills for removing caries in primary teeth, posteriorly restored with GIC. CMCR clinical application reduces anxiety, pain, and need for anesthesia, despite increase treatments' time.

Clinical and Microbiological Assessment of Carisolv and Polymer Bur for Selective Caries Removal in Primary Molars

Aim and objective

To assess the efficacy of the new Carisolv system and Polymer bur (SmartbursII®) for selective caries removal in primary molars clinically and microbiologically, compared with the conventional mechanical method.

Materials and methods

Sixty children with class I active carious lesions were selected. The children were randomly allocated to three groups (n = 20) according to the caries removal method. Under rubber dam isolation, dentin samples were taken before and after caries removal for microbial culture. Time spent in each technique was recorded. The clinical efficacy of caries removal was verified using caries detector dye. Patient satisfaction toward the treatment was evaluated using a facial image scale.

Results

The median of caries detector dye scores was significantly lower in the conventional group compared to others (p value < 0.05). The mean time for caries removal was the longest with Carisolv (p value < 0.05). The median of facial image scale scores was significantly higher in the conventional group compared with others (p value < 0.05). The mean total viable bacterial count after caries removal was significantly higher in polymer bur group compared with others (p value < 0.05). While, there was no significant difference between Carisolv and conventional groups (p value > 0.05).

Conclusion

The clinical efficacy of caries removal was highest with the mechanical method. Carisolv took the longest time for caries removal. Patient satisfaction was higher with Carisolv and polymer bur than the mechanical method. The antimicrobial efficacy of Carisolv and the mechanical method was higher than the polymer bur.

Clinical significance

Carisolv is a viable alternative to the mechanical method in the management of dental caries, especially in children. Further studies are needed to assess the efficacy of caries removal by SmartbursII®.

How to cite this article

Asal MA, Abdellatif AM, Hammouda HE. Clinical and Microbiological Assessment of Carisolv and Polymer Bur for Selective Caries Removal in Primary Molars. Int J Clin Pediatr Dent 2021;14(3):357–363.

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.

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.

Costs and benefits of Papacarie in pediatric dentistry: a randomized clinical trial

Papacarie gel is an agent that eliminates the need for local anesthesia and reduces the need for using a drill. However, there is no information regarding the cost per procedure. Therefore we analyzed the cost, per procedure, of Papacarie gel compared to the traditional method (drilling), and performed a comparison between these methods of carious tissue removal. A randomized clinical trial was performed with 24 children with an average age of 5.9 years old. Of these children, 12 were boys and 12 were girls, which resulted in a total of 46 restorations. Patients were separated into: Papacarie group (caries removal with the chemical-mechanical method - Papacarie gel) and Drill group (caries removal with the traditional method - drilling). Values of the materials used in the procedures, heart rate (before, 5 minutes during, and after dental treatment), and the total consultation duration were recorded. A level of significance of 5% was adopted. Papacarie had a lower cost per procedure ($ 0.91) when compared to the traditional method ($ 1.58). Papacarie provided a cost reduction of 42% compared to the traditional method. Using local anesthesia ($ 2.17), the cost reduction increased to 58%. In the procedure using drill + Papacarie ($ 1.37), the cost reduction was 33%. Heart rate, consultation duration, and number of restorations were not statistically different. Papacarie shows an excellent cost benefit for minimally invasive removal of carious tissue and is a feasible alternative for public health care.

Efficacy of Caries Removal by Carie-Care and Erbium-doped Yttrium Aluminum Garnet Laser in Primary Molars: A Scanning Electron Microscope Study

Aim

To compare and evaluate morphological changes and bacterial deposits in primary carious molars after caries excavation with Carie-Care, erbium-doped yttrium aluminum garnet (Er:YAG) laser, and round tungsten carbide bur.

Materials and methods

Thirty human carious primary molars extracted for therapeutic reasons were sectioned mesiodistally. These sectioned samples were allocated into three groups (20 samples each): group I: Carie Care, group II: Er:YAG laser, and group III: round tungsten carbide bur. After caries excavation, all samples were processed and examined under conventional light microscope to examine for bacterial deposits. Representative samples from each group were processed and analyzed to examine the morphology of caries-excavated tissue by scanning electron microscope (SEM). Statistical analysis was done using Fisher’s exact test, Kruskal–Wallis test, and Mann-Whitney U test.

Results

The Er:YAG laser showed best results with no smear layer followed by chemomechanically excavated surfaces with Carie-Care. Amount of bacterial deposits was observed to be more in group I while least in group II (p-value < 0.001). Mann-Whitney U test and Fisher’s exact test revealed that there was statistically significant difference among all the three groups.

Conclusion

Among the three different methods of caries excavation, Er:YAG laser was found to be more effective compared with Carie-Care and round tungsten carbide bur.

Clinical significance

Laser-induced caries excavation by Er:YAG laser and chemomechanical method of caries removal by Carie-Care can be considered as future of noninvasive pediatric and preventive dentistry.

How to cite this article: Prabhakar A, Lokeshwari M, Naik SV, Yavagal C. Efficacy of Caries Removal by Carie-Care and Erbium-doped Yttrium Aluminum Garnet Laser in Primary Molars: A Scanning Electron Microscope Study. Int J Clin Pediatr Dent 2018;11(4):323-329.

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.

Effectiveness of chemomechanical caries removal agents Papacarie(®) and Carie-Care™ in primary molars: An in vitro study

Aims and Objectives:

The chemomechanical caries removal system is made presently available containing a natural proteolytic enzyme for ease in the excavation of infected dentin. The aim of the study was to evaluate the efficacy and efficiency of caries removal using Papacarie^® and Carie-Care™.

Materials and Methods:

A total of 30 extracted deciduous molars with proximal caries were collected, and each tooth was sectioned mesiodistally in the center of the carious lesion so that the two halves (buccal and lingual or palatal) have similar carious lesions, thus 30 teeth yielded 60 specimens. The specimens from each tooth were divided alternatively into two groups for caries excavation either using Papacarie^® or Carie-Care™ so as to avoid selection bias. Paired t-test was used to compare mean time taken for caries removal and Fischer's exact test was done for comparing bacterial remnants after caries excavation.

Results:

Mean time taken for caries removal was significantly higher for Carie-Care™ (427.13 s) when compared to Papacarie^® (385.8 s). Papacarie^® was found to be significantly more efficient in caries removal with marked reduction in the bacterial remnants following excavation. However, both gels were found to be conservative as dentinal tubule destruction was not evident in either of them.

Conclusion:

Both Papacarie^® and Carie-Care™ were found to be conservative in caries removal. Papacarie^® was more efficient in removing bacteria in lesser time from the infected carious lesion.