Chemomechanical caries removal: a comprehensive review of the literature

The in-vitro development of novel enzyme-based chemo-mechanical caries removal agents

OBJECTIVES

Bromelain is a potent proteolytic enzyme that has a unique functionality makes it valuable for various therapeutic purposes. This study aimed to develop three novel formulations based on bromelain to be used as chemomechanical caries removal agents.

METHODS

The novel agents were prepared using different concentrations of bromelain (10-40 wt. %), with and without 0.1-0.3 wt. % chloramine T or 0.5-1.5 wt. % chlorhexidine (CHX). Based on the enzymatic activity test, three formulations were selected; 30 % bromelain (F1), 30 % bromelain-0.1 % chloramine (F2) and 30 % bromelain-1.5 % CHX (F3). The assessments included molecular docking, Fourier-transform infrared spectroscopy (FTIR), viscosity and pH measurements. The efficiency of caries removal was assessed by DIAGNOdent pen, measuring the excavation time and number of applications, followed by a morphological evaluation of the remaining dentine using scanning electron microscopy (SEM). The results were compared to Brix 3000 as a control.

RESULTS

The chloramine and chlorhexidine were chemically compatible with bromelain without compromising the enzyme activity. All experimental formulations showed higher viscosity and pH in comparison to Brix 3000. The DIAGNOdent readings were <20 in all groups, and the lowest readings were observed in F2. The excavation time and number of applications were lowest in F2 and F1. Both F2 and F3 produced smooth dentine surfaces with less tissue debris, but more patent dentine tubules were observed in F1 and F2.

CONCLUSIONS

The bromelain-contained formulations showed a potential to be used as chemomechanical caries removal agents in vitro. Further laboratory and clinical studies are needed to validate this claim.

CLINICAL SIGNIFICANCE

The bromelain from pineapple stem has broad specificity for cleavage the peptide bonds in denatured protein to facilitate their removal. The study proved the efficiency of this enzyme to remove the dental caries chemomechanically when used alone or conjugated with chloramine and/or chlorhexidine to enhance the disinfecting and cleansing properties.

Chemomechanical Caries Removal Methods: A Literature Review

Aim

To provide dental practitioners and researchers with a comprehensive review of the historical development, chemical composition, mechanisms of action, advantages, and drawbacks of different chemomechanical caries removal (CMCR) agents.

Methods

An electronic search was performed for all articles published on CMCR agents in various databases, including the Web of Science, PubMed, Cochrane, Scopus, and Google Scholar bibliographic databases, from January 1, 1975, to July 31, 2022.

Results

Records were identified using the following search terms: Brix3000, Carie-Care, Caridex, Carisolv, chemomechanical caries removal, conventional surgical method, and Papacárie. A total of 171 articles were screened based on the titles and abstracts, of which 126 were deemed eligible for inclusion after duplicates were removed. Following a manual search of the reference list, eight articles were added. Articles were then excluded for other reasons, such as being written before 1975, being written in a language other than English, and the non-availability of the full text. Overall, 120 articles were included in the analysis (literature reviews [n = 27], systematic reviews [n = 8], research articles [n = 82], case reports [n = 3]).

Conclusion

CMCR is a potential method of caries control in the future as an alternative to the conventional surgical approach in standard dentistry applications. It is more widely accepted, less painful, and has comparable efficacy to the conventional surgical method.

Clinical significance

A continuous trend among manufacturers has been observed since 1975 to reduce the drawbacks of CMCR agents. Moreover, evidence-based minimally invasive techniques, including CMCR agents that require minimal or no aerosol-generating procedures, are preferred while measures to control the spread of coronavirus disease are in force.

Antimicrobial photodynamic therapy as an adjunctive treatment to ultrasound for the dentin caries-like lesion removal

OBJECTIVE

To evaluate in vitro the efficacy of ultrasound device to remove caries-like dentin and the curcumin-mediated antimicrobial photodynamic therapy (aPDT) to decontaminate the affected dentin.

METHODS

Bovine dentin specimens (n = 173) of 4 × 4 × 2 mm were first submitted to Knoop surface microhardness to standardize the specimens (29 ± 3 KHN). Artificial caries lesion was induced by Streptococcus mutans strain by biological model for 7 days. Infected dentin was removed (1 min) with the following techniques: dentin excavator, bur at low-speed rotation and ultrasound device. After that, aPDT application was performed using blue LED under 460 nm. Polarized light microscopy (PLM), removal rate (n = 10), cross-sectional microhardness (n = 10), colony forming units per milliliter (CFU) (n = 9) and confocal laser microscopy (CM) (n = 2) were performed. ANOVA with Welch correction, post-hoc Games-Howell and two-way ANOVA followed by Tukey's post-hoc tests were used.

RESULTS

PLM confirmed the caries lesion formation with a depth of ∼147.9 µm. Groups treated with ultrasound showed lower removal rate (p = 0.001). Regardless of the treatment, the microhardness values increased as function of depth (p ≤ 0.05). Carbide bur showed the highest microhardness value, followed by ultrasound and excavator. CFU and CM showed a significant reduction in S. mutans after aPDT application.

CONCLUSION

Ultrasound was efficient, since it removed infected dentin, preserving the affected dentin and aPDT can be used as a complementary therapy to decontaminate the affected dentin.

CLINICAL SIGNIFICANCE

Ultrasound device may help the clinician to remove dentin caries-like lesions since it is a conservative technique and provided the removal of infected dentin, preserving the affected dentin. aPDT application may be used as a complimentary technique to promote antibacterial effect and possibly minimize the risk of secondary caries.

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.

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.

Model for Taking Care of Patients with Early Childhood Caries during the SARS-Cov-2 Pandemic

Pending the availability of vaccines to contain the SARS-CoV-2 pandemic, the current solution is "social distancing" with a reduction of dental treatments to those assessed as urgent and emergency cases. These treatments also involve Early Childhood Caries (ECC) due to the fact that this disease affects preschool children (a vulnerable population) and, in addition, shows a propensity to evolve into more serious complications (dental pain, infections). A narrative review was carried out to support a protocol for treating ECC with efficacious and safe (in terms of SARS-CoV-2 transmission) procedures. Protocol involves criteria for patients' selection remotely (telemedicine), and well-detailed criteria/equipment and hygiene procedures to combat against SARS-CoV-2 transmission. Moreover, the protocol proposes innovative caries treatments, named Minimally Invasive Treatments (MITs), well known in pedodontics for their high level of children's acceptance during dental care. MITs allow for caries removal (particularly in primary teeth) without any high-speed rotating instrument cooled with nebulized air-water spray (with high risk of virus environmental diffusion), usually adopted during traditional treatments. For evaluating MITs effectiveness in caries management, only Systematic Review and Randomized Controlled Trials (RCTs) were included in our study, without any risk of bias assessment. The indications proposed in this protocol could support clinicians for the temporary management of ECC until the SARS-CoV-2 pandemic ends.

Comparing the efficacies of two chemo-mechanical caries removal agents (2.25% sodium hypochlorite gel and brix 3000), in caries removal and patient cooperation: A randomized controlled clinical trial

INTRODUCTION

This study compared and evaluated the effectiveness of Brix 3000 and 2.25 % sodium hypochlorite (NaOCl) gel with conventional rotary instrumentation method in caries excavation of primary molars. The null hypothesis: no difference between the two tested chemo-mechanical caries removal (CMCR) agents used in this trial.

MATERIALS AND METHODS

a randomized controlled clinical trial conducted with 32 children suffering from proximal caries of primary maxillary molars, age ranging between 6 and 9 years old. Subjects were randomly assigned into three groups: Brix 3000, NaOCl gel, and conventional with 10, 12, and 10 teeth in each group, respectively. After isolation of selected teeth, either CMCR agent were applied for two minutes. The application was repeated as needed until a caries-free surface was obtained. The conventional group used low-speed burs to excavate all carious lesions. The time required to obtain a caries-free result for each testing method was recorded. Wong-Baker FACES pain rating scale was used to assess the acceptance of the technique used by the child.

RESULTS

Conventional treatment required significantly less time for caries removal compared to Brix 3000 (P = .002) and NaOCl gel (P = .000). No significant difference observed between Brix 3000 and NaOCl gel (P = .679). Statistically higher pain scores were observed with conventional treatment compared to both Brix 3000 (P = .000) and NaOCl gel (P = .005). Pain scores were lower with Brix 3000, and NaOCl gel with no significant difference observed between the CMCR agents (p = .690).

CONCLUSIONS

CMCR agents that are effective in removing the carious dentine of primary teeth without negatively affecting the cooperation of children.

CLINICAL SIGNIFICANCE

The use of a 2.25 % sodium hypochlorite gel can be an effective and well-tolerated method of removing decay from primary teeth and reduce the trauma associated with conventional rotary caries removal.

Erbium Laser Technology vs Traditional Drilling for Caries Removal: A Systematic Review with Meta-Analysis

OBJECTIVE

The study aimed to assess the efficacy of erbium laser technology compared with traditional drilling for caries removal.

METHODS

A systematic search was conducted through Medline via PubMed, Embase, Cochrane databases, CNKI till December 2016. Randomised controlled trials, quasi-randomized controlled trials, or controlled clinical trials with data comparing the efficacy of erbium laser technology versus traditional drilling for caries removal were included.

RESULTS

Fourteen studies were selected in our meta-analysis. Erbium laser technology showed an increased time when removing caries compared with drilling (mean difference: 3.48, 95% confidence interval: 1.90-5.06, P < .0001). However, erbium laser technology reduced the requirement for local anesthesia (risk ratio: 0.28, 95% confidence interval: 0.13-0.62, P = .002). Erbium laser technology was also not significantly different to traditional drilling with regard to restoration loss, pulpal vitality, and postoperative sensitivity.

CONCLUSIONS

Erbium laser technology showed an increased time for cavity preparation compared with traditional drilling. However, erbium laser technology reduced the requirement for local anesthesia. There was no significant difference between erbium laser technology and traditional drilling regarding restoration loss, pulpal vitality, and postoperative sensitivity.

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.

Effect of chemomechanical caries removal on bonding of resin-modified glass ionomer cement adhesives to caries-affected dentine

BACKGROUND

This study evaluated the effect of: (1) chemomechanical caries removal (CMCR); (2) dentine surface treatments and (3) dentine substrates on adhesion of resin-modified glass ionomer cement (RMGIC) adhesives.

METHODS

One hundred and twenty permanent molars exhibiting moderate cavitation on the occlusal surface into dentine were used. Seventy-five carious molars were used for bond strength testing; the remaining 45 for micromorphological evaluation of the bonded interface. Caries was excavated with NaOCl-based CMCR (Carisolv), enzyme-based CMCR (Papacarie), or conventional rotary caries removal methods. Dentine surface treatment was performed using 37% phosphoric acid, 25-30% PAA or 20% PAA + 3% AlCl3 .

RESULTS

Three-way ANOVA revealed that all three factors 'caries removal methods', 'dentine surface treatments' and 'dentine substrates' did not significantly affect bond strength (p > 0.05). Scanning electron microscopy micrographs showed that the acid-base resistant layer was thicker in caries-affected dentine compared to sound dentine.

CONCLUSIONS

NaOCl- and enzyme-based CMCR methods have no adverse effect on adhesion of RMGIC adhesives to sound and caries-affected dentine. Dentine surface treatment with 37% phosphoric acid for 5 s has no negative effect on bonding of RMGIC adhesives to dentine compared with using polyacrylic acid for 10 s. RMGIC adhesives bonded well to both sound and caries-affected dentine.

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.

The Antibacterial Effects of Apacaries Gel on Streptococcus mutans: An in vitro Study

Background: New approaches for chemomechanical caries removal require effective materials with antibacterial properties for removal of infected dentin. Apacaries gel is a newly developed material comprised polyphenol from mangosteen extracts and papain mixed in gel preparation.

Aim: This study evaluated the antibacterial effects of Apacaries gel on Streptococcus mutans in vitro.

Materials and methods: Mangosteen pericarp powder was extracted. The amount of phenolic compounds was determined using the Folin-Ciocalteu method. The time-kill kinetics were investigated. Mangosteen extract and papain were mixed with gel base to develop Apacaries gel. The inhibition zone of the Apacaries gel was determined using agar well diffusion methods.

Results: The mangosteen pericarp extract, which contains α-mangostin, was active against S. mutans strain ATCC25175. The time-kill kinetics curve showed that applying 1 mg/ml of mangosteen extract can reduce S. mutans by 50% within approximately 5 seconds; after this reduction, the bacterial count rapidly dropped to 0 within 60 seconds. Using mangosteen extract and papain mixture gel preparation resulted in a larger inhibition zone than using the mangosteen extract gel or papain gel separately.

Conclusion: Apacaries gel can effectively inhibit S. mutans strain ATCC25175. Apacaries is capable of S. mutans inhibition better than both mangosteen extract or papain separately.

How to cite this article: Juntavee A, Peerapattana J, Ratanathongkam A, Nualkaew N, Chatchiwiwattana S, Treesuwan P.

The Antibacterial Effects of Apacaries Gel on Streptococcus mutans: An in vitro Study. Int J Clin Pediatr Dent 2014;7(2):77-81.

Effect of rotatory instrument speed on its capacity to remove demineralized and sound dentin

Objectives:

The aim of this study was to evaluate the capacity of two rotatory instruments (controlled speed electric motor [CSEM] – 300 rpm; conventional slow handpiece [CSHP] – 18,000 rpm) to remove sound and demineralized dentin, by examining prepared cavity walls using the scanning electron microscopy (SEM) and assessing loss of mass.

Materials and Methods:

A total of 40 blocks of human occlusal dentin, measuring 5 mm × 5 mm × 4 mm (L × W × H), were divided into two groups according to the substrate type in which the cavity preparation was performed: D - demineralized dentin; and S - sound dentin (control group). The groups were subdivided according to the rotatory instrument used for cavity preparation (n = 10): CSEM (300 rpm); and CSHP (18,000 rpm). In half of the dentin blocks, caries lesion induction was performed for 6 weeks. The preparation of the cavities was performed on a standardizing machine, using a cylindrical tungsten carbide burr. Before and after the preparation, specimens were dehydrated in an incubator at 60°C for 30 min. The initial and final mass (in mg) of each dentin block was measured 3 times using the digital precision balance to obtain the mean weight Following cavity preparation, all specimens were hemisected and SEM was used to blindly assess each half so that the lateral walls of the prepared cavity were measured in μm, accepting the average of two measurements as the total depth of the preparation. Non-parametric Mann-Whitney analysis was performed with a 5% of significance level.

Results:

Regarding the weight difference (mg), no significance was detected between the groups. Regarding depth (μm), a significant difference was found between the groups, so that the CSRM showed lower cavity depth when compared with CSHP, both in sound and demineralized dentin.

Conclusions:

Controlled speed rotatory instruments were found to be more conservative in removing both sound and demineralized dentin, in terms of preparation and depth.

Micro-computerized tomography assessment of fluorescence aided caries excavation (FACE) technology: comparison with three other caries removal techniques

BACKGROUND

The aim of this study was to determine the caries removal effectiveness (CRE) and minimal invasiveness potential (MIP) of four dentine caries removal methods.

METHODS

After carious molars were scanned using micro-computerized tomography (micro-CT), dentine caries were removed by fluorescence aided caries excavation (FACE) technology, laser induced fluorescence (LIF), chemomechanical excavation (CME), and conventional excavation (CE). Micro-CT was then repeated. CRE was determined based on the volume of residual caries/initial caries (RC/IC) and the mean mineral density (MD) at the cavity floor. MIP was determined by measuring the volume of the prepared cavity/initial cavity (PC/IC).

RESULTS

Among the four groups, the LIF group had the smallest RC/IC (0.08), the highest mean MD at the cavity floor (1.32 g/cm(3) ) and the highest MIP (4.47). The CME group had the highest RC/IC (0.24), the lowest mean MD (1.01 g/cm(3) ) and the lowest MIP (2.23). The CE group exhibited a more acceptable CRE (RC/IC = 0.13, mean MD = 1.21 g/cm(3) ) but had a higher MIP (3.95). Both the CRE and MIP parameters of FACE technology were the second most acceptable (RC/IC = 0.12, mean MD = 1.13 g/cm(3) , MIP = 3.20) and did not differ significantly from the most acceptable.

CONCLUSIONS

FACE is an effective caries removal technology for removing infected dentine without significantly increasing cavity size.

Comparative evaluation of the antimicrobial activity of natural extracts of Morinda citrifolia, papain and aloe vera (all in gel formulation), 2% chlorhexidine gel and calcium hydroxide, against Enterococcus faecalis: An in vitro study

Aim:

A comparative evaluation of the antimicrobial activity of natural extracts of Morinda citrifolia, papain, and aloe vera (all in gel formulations), 2% chlorhexidine gel and calcium hydroxide, against Enterococcus faecalis—an in vitro study.

Materials and Methods:

The antimicrobial efficacy was assessed in vitro using dentin shavings collected at 2 depths of 200 and 400 μm. The total colony forming units at the end of 1, 3, and 5 days were assessed.

Results:

The overall percentage inhibition of bacterial growth (200 and 400 μm depth) was 100% with chlorhexidine gel. This was followed by M. citrifolia gel (86.02%), which showed better antimicrobial efficacy as compared with aloe vera gel (78.9%), papain gel (67.3%), and calcium hydroxide (64.3%). There was no statistical difference between data at 200 and 400 μm depth.

Conclusion:

Chlorhexidine gel showed the maximum antimicrobial activity against E. faecalis, whereas calcium hydroxide showed the least. Among the natural intracanal medicaments, M. citrifolia gel consistently exhibited good inhibition up to the 5^th day followed by aloe vera gel and papain gel.

The influence of resin infiltration system on enamel microhardness and surface roughness: An in vitro study

OBJECTIVE

To investigate the effect of a resin infiltrant on the surface microhardness and roughness of healthy enamel and, as a subsidiary aim, to compare it with a fissure sealant.

MATERIALS AND METHODS

Twenty freshly extracted premolars were used. Sound enamel surfaces were treated with a resin infiltrant (Icon) or fissure sealant (Seal-Rite). The average roughness (R a, μm) of the specimens was measured with a profilometer (Surtronic 10 Tylor Hobson). Surface hardness was determined by utilizing Vicker's surface hardness (VHN) with a Micromet II Microhardness tester. Each specimen acted as its own control. Data were analyzed with 2-way analysis of variance (ANOVA), and mean values were compared with independent t-test. All analyses were performed with the SPSS program version 16 (USA). Differences with a P-value of ⩽0.05 were considered statistically significant.

RESULTS

Comparison of enamel surfaces before and after application of resin infiltrant revealed no significant differences in surface hardness; however, enamel surfaces treated by infiltrant showed significantly higher VHN (244.0 ± 79.8) values than those treated with fissure sealant (37.5 ± 14.2). Surface roughness did not differ before and after application of either material to sound enamel. Enamel surfaces treated with fissure sealant (5.3 ± 1.4) were significantly smoother than those treated with infiltrant (6.9 ± 2.0).

CONCLUSION

Within the limitations of the study, the results showed that enamels treated with the resin infiltrant showed approximately the same microhardness and surface roughness as sound enamel, indicating that this material might be suitable for the treatment of enamel subsurface lesions.

Permeability evaluation after decay removal in primary teeth with current caries-excavation techniques

AIM

The goal of the study was to evaluate the effect of caries removal by three various methods on the permeability of class II composite resin restorations in primary molar teeth.

MATERIALS AND METHODS

Forty-five recently extracted primary molars were randomly assigned to three groups for three different methods of caries removal; group 1-mechanical, group 2-caries detector dye, and group 3-Carisolv (n = 15). After that, class II cavities in all groups were restored with the adhesive (Opti Bond Solo Plus) that was applied according to the manufacturer's instruction and a posterior composite (Herculite XRV), which was used incrementally. After 24 hours the samples were thermocycled in water for 500 cycles between 5 and 55°C with a dwell time of 30 sec. Permeability was assessed by the fluid filtration method. The data were analyzed using the ANOVA test while study groups were compared with Tukey test for statistically significant differences at a 5% significance level.

RESULTS

The evaluation of tested groups indicated that the highest (0.80) and least (0.37) mean of permeability was observed in group 2 and 3 respectively. Significant difference was revealed among the tested groups (p = 0.045). The comparison of Carisolv and caries detector dye groups indicated a statistically significant difference (p = 0.037). There was not any significant difference between Carisolv or caries dye in the conventional group.

CONCLUSION

Using the chemomechanical and staining methods for caries removal had no more detrimental effect on permeability than the conventional technique. However, caries detection dye for caries removal could be more harmful than chemomechanical method.

CLINICAL SIGNIFICANCE

None of the current caries-excavation techniques could eliminate permeability in class II composite resin restorations. Furthermore, staining methods do not have an adverse effect on sealing ability in comparison to the conventional technique.

Perceived dental anxiety among schoolchildren treated through three caries removal approaches

Objectives:

The aim of the investigation was to test the differences in the perceived level of dental anxiety among children treated restoratively using the Atraumatic Restorative Treatment (ART) approach, the traditional restorative (TRA) approach and ART aided with a chemomechanical caries removal gel (ART plus).

Methods:

The study subjects were 6-7-year-old children. TRA was compared to ART in a clinical setting after children had seen a dentist twice (Group A), ART was compared to 'ART plus' in a clinical setting after children had seen a dentist once (Group B) and ART was applied outside the clinic on school premises (Group C). The treatments were carried out in Class II cavitated dentine lesion in primary molars. Dental anxiety was measured using the Venham Picture Test (VPT). Three-way analysis of variances and interaction was applied to test for treatment approach, gender and operator effects on the mean VPT scores.

Results:

There was no statistically significant difference (p=0.80) observed between the mean VPT scores for the traditional approach and those for the ART approach and between ART with and without a chemomechanical caries removal gel (p=0.07). Children in Group A had lower mean VPT scores than children in Group B (p=0.02) and Group C (p<0.00001) when treated using the ART approach by the same two operators.

Conclusions:

The level of dental anxiety was low. There was no difference in level of dental anxiety observed in children treated with ART in comparison to the traditional restorative approach, and between children treated with ART with and without a chemomechanical caries removal gel. The treatment environment and prepatory visits may be factors determining the level of dental anxiety in children treated through the ART approach only.

Papain-based gel for biochemical caries removal: influence on microtensile bond strength to dentin

This study investigated the influence of a papain-based gel (Papacárie) for chemo-mechanical caries removal on bond strength to dentin. Human molars were assigned to the following groups: Group 1: sound teeth were flattened to expose dentin; Group 2: after flattening of surfaces, the papain-based gel was applied on the sound dentin; Group 3: overlying enamel from carious teeth was removed and mechanical excavation of dentin was conducted; Group 4: chemo-mechanical excavation of carious dentin was conducted using the papain-based gel. The Prime&Bond NT or Clearfil SE Bond adhesive systems were used for restorative procedures. A microtensile bond strength test was performed, and the modes of failure were determined under SEM. The data were submitted to two-way ANOVA and Tukey's test (p < or = 0.05). No significant differences were observed between the sound dentin groups. For both excavation methods, Clearfil presented a significantly higher bond strength than Prime&Bond NT. Also, for Clearfil, the mechanically excavated samples disclosed a significantly higher bond strength than the chemo-mechanically ones. For Prime&Bond NT, no significant differences were detected between the excavation methods. Predominance of mixed failures for the sound substrate and of adhesive failures for the carious dentin one was detected. The bond strength to carious dentin of the self-etching system was negatively affected by chemo-mechanical excavation using the papain-based gel.

Papain gel: a new chemo-mechanical caries removal agent

The chemo-mechanical caries removal method has been a solution for treatment of patients seeking alternatives to conventional methods. Among different kinds of chemo-mechanical caries removal systems, Papacarie--a papain gel--was found to be easy to manipulate, simple and cheap, as well as effective in removing infected tissues.

The role of Carisolv™ and different auxiliary chemical substances in the removal of bovine root canal smear layer

To evaluate the effectiveness of Carisolv and different auxiliary chemical substances in root canal smear layer (SL) removal. SL was produced in the centre of 40 hemi-disks of bovine root dentine. The samples were divided into four irrigation groups (G): GI (control) - 0.9% NaCl; GII - 1% NaOCl + 0.9% NaCl; GIII - Carisolv + 0.9% NaCl; GIV - 1% NaOCl + 10% citric acid solution + 0.9% NaCl. The photomicrographs (SEM analysis) were coded (0 - absence of SL; 1 - moderate SL; 2 - dense SL with visible tubules; 3 - dense SL with no visible tubules). GIV was more effective in SL removal (P < 0.01). It should be noted that GI and GIII obtained score 3 in 100% of the samples (P > 0.01).

CONCLUSION

NaOHCl, citric acid and NaCl solutions, when used together, presented a better performance in the removal of SL when compared to the other solutions.

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.

Dentistry for those requiring special care

Individuals with special needs, namely those whose dental care is complicated by a physical, mental or social disability, often have a higher level of unmet dental need and poorer oral hygiene than the general population, and offer unique challenges to the dental practitioner. This paper outlines the dental management of the three most common groups of individuals with special needs.