A Comparative Evaluation of the Efficacy of Different Caries Excavation Techniques in reducing the Cariogenic Flora: An in vivo Study

Comparative Meta-Analysis of Minimally Invasive and Conventional Approaches for Caries Removal in Permanent Dentition

Background and Objectives: Addressing deep carious lesions poses significant challenges in daily dental practice due to the inherent complexity of their treatment. Traditionally, complete removal of carious tissues has been the norm, potentially leading to pulp tissue exposure and subsequent pulpitis. In contemporary dentistry, there is a growing preference for minimally invasive techniques, such as selective removal, offering a more conservative approach with enhanced predictability and success rates. Materials and Methods: Our study commenced with a comprehensive systematic review. After that, we performed a meta-analysis focused exclusively on randomized controlled trials involving permanent dentition. Our investigation incorporated seven selected articles, which scrutinized success rates and the incidence of pulp exposure in minimally invasive techniques (MIT) versus conventional techniques (CT). Statistical analysis employed U Mann-Whitney and Wilcoxon tests to interpret the results. Results: Although the difference did not reach statistical significance, MIT demonstrated marginally superior success rates compared to CT. Furthermore, MIT exhibited a lower percentage of pulp exposure when contrasted with CT. However, due to the limited sample size, statistical significance for this difference could not be established. Conclusions: Minimally invasive techniques for caries removal emerge as a conservative and promising approach to safeguard pulp tissues in comparison to conventional techniques. The need for additional randomized controlled trials is emphasized to unequivocally establish the superior success rates of these procedures over their conventional counterparts.

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.

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.

Polyacrylic Acid with Methylene Blue Dye as a Sensitizing Agent for Photodynamic Therapy to Reduce Streptococcus mutans in Dentinal Caries

Objective: To evaluate 11.5% polyacrylic acid (PA) containing 0.3% methylene blue (MB) dye as a photosensitizer for photodynamic therapy (PDT) of carious dentin. Methods: One hundred twenty molars were selected and the dentin was exposed for cariogenic challenge, where the molars were placed in brain heart infusion medium containing a standard strain of Streptococcus mutans (ATCC). Samples were randomly divided into eight groups (n = 15): S: saline, PA, MB: MB 0.3%, PA+MB: PA containing 0.3% MB + LLL: irradiation with low-level laser, PDT (MB): MB 0.3% + laser, PDT (PA): PA + laser, and PDT (PA+MB): PA containing 0.3% MB + laser. Carious dentin was collected before and after exposure to S. mutans. All samples of carious dentin were homogenized, diluted, and seeded in mitis salivarius bacitracin medium, and the cultures were incubated at 37°C for 15 days in anaerobic jars. The Wilcoxon test was used for analysis. Results: The percent microbial reduction achieved with each treatment was as follows: PDT (MB), 53.62%; PDT (PA+MB), 50.47%; PDT (PA), 46.73%; PA, 38.51%; MB, 19.75%; PA+MB, 17.18%; LLL, 12.83%; S, 5.99%. The greatest reductions in S. mutans growth occurred with PDT (MB), PDT (PA+MB), and PDT (PA) when compared to the S group (p = 0.0002, 0.0023, and 0.0232, respectively). Conclusions: PA containing 0.3% MB can be used as a photosensitizer for PDT to reduce S. mutans burden in carious dentin.

Histological determination of cariously altered collagen after dentin caries excavation with the polymer bur PolyBur P1 in comparison to a conventional bud bur

BACKGROUND

To compare the polymer bur PolyBur P1 (P1) with tungsten carbide bud bur H1 SE (H1) in removing cariously altered collagen during dentin caries excavation.

METHODS

Fifty extracted teeth were split in the center of a carious lesion. The 100 specimens were randomly divided into 5 groups. Five dentists were asked to excavate 10 teeth each: one half with P1 and the corresponding half with H1. The time needed for caries excavation was measured. Subsequently, histological specimens were produced and analyzed by light-microscope after Mallory-Azan-staining. The thickness of remaining cariously altered collagen was measured (< 1 mm or > 1 mm). The results were statistically evaluated.

RESULTS

The average time to excavate a cavity with P1 was 254 (± 148) sec and 202 (± 129) sec with H1. The difference in times was not statistically significant (p > 0.05). In the group P1 in 66.1% of the sections cariously altered collagen remained, whereas 33.9% showed sound collagen. In the group H1 45.7% sections had remaining cariously altered collagen and 54.3% showed sound collagen. The difference between P1 and H1 was statistically significant (p = 0.004). In the group P1 the layer of cariously altered collagen was significantly more often thicker than 1 mm than in the group H1 (p < 0.05). The variable "type of bur" had a statistically significant influence for the presence of cariously altered collagen (p = 0.003).

CONCLUSIONS

Conventional H1 bud burs were significantly more effective in removing cariously altered collagen during dentin caries excavation than the polymer bur P1.