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

Volumetric analysis after caries excavation with caries detecting dyes and chemomechanical caries removal agents using 3D scanner-a randomised clinical trial

AIM

This research aimed to use an extra-oral 3D scanner for conducting volumetric analysis after caries excavation using caries-detecting dyes and chemomechanical caries removal agents in individuals with occlusal and proximal carious lesions.

METHODS

Patients with occlusal (A1, A2, A3) and proximal carious lesions (B1, B2, B3) were treated with the conventional rotary technique, caries detecting dyes (CDD) and chemomechanical caries removal (CMCR) method on 90 teeth (n = 45 for each). Group A1, B1: Excavation was performed using diamond points. Group A2, B2: CDD (Sable Seek™ caries indicator, Ultradent) was applied and left for 10 s, and then the cavity was rinsed and dried. For caries removal, diamond points or excavators were used. Group A3 and B3: BRIX3000 papain gel was applied with a micro-brush for 20 s and was activated for 2 min, and then the carious tissue was removed with a sharp spoon excavator. Post-excavation cavity volume analysis was performed using a 3D scanner. The time required and the verbal pain score (VPS) for pain were scored during excavation. Post-restoration evaluation was performed at 1, 3, and 6 months FDI (Federation Dentaire Internationale) criteria.

RESULTS

Comparison of age, time and volume with study groups were made using Independent Sample' t' test and one-way analysis of variance (ANOVA) for two and more than two groups, respectively. Using Cohen's Kappa Statistics, evaluators 1 and 2 agreed on caries removal status aesthetic, functional and biological properties at different follow-ups. The chi-square test revealed that the rotary groups [A1(2.5 ± 0.4 min) B1(4.0 ± 0.4 min)] had significantly less (p = 0.000) mean procedural time than CDD [A2(4.5 ± 0.4 min) B2(5.7 ± 0.4 min)] and CMCR [A3(5.4 ± 0.7 min) B3(6.2 ± 0.6 min)] groups. The CMCR group showed better patient acceptance and less pain during caries excavation than the rotary and CDD groups. CMCR group showed significantly less mean caries excavated volume(p = 0.000). Evaluation of restoration after 1-, 3-, and 6-month intervals was acceptable for all the groups.

CONCLUSION

Brix3000 helps effectively remove denatured teeth with less pain or sensitivity. The time required for caries removal was lowest in the rotary method and highest in the brix3000 group, while the volume of caries removed was the lowest for brix3000 and highest for the rotary group.

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.

Systematic Review and Meta-Analysis of Randomized Clinical Trials on Chemomechanical Caries Removal

OBJECTIVES

The aim of this review was to assess the methodologies used in previously published prospective randomized clinical trials on chemomechanical caries removal and to conduct a meta-analysis to quantify the differences in the excavation time between chemomechanical and conventional caries removal methods.

METHODS

An electronic search was performed using Scopus, PubMed, EBSCO host, and Cochrane Library databases. The following categories were excluded during the assessment process: non-English studies published before 2000, animal studies, review articles, laboratory studies, case reports, and nonrandomized or retrospective clinical trials. The methodologies of the selected clinical trials were assessed. Furthermore, the reviewed clinical trials were subjected to meta-analysis for quantifying the differences in excavation time between the chemomechanical and the conventional caries removal techniques.

RESULTS

Only 19 randomized clinical trials fit the inclusion criteria of this systematic review. None of the 19 reviewed trials completely fulfilled Delphi's ideal criteria for quality assessment of randomized clinical trials. The meta-analysis results revealed that the shortest mean excavation time was recorded for rotary caries excavation (2.99±0.001 minutes), followed by the enzyme-based chemomechanical caries removal method (6.36±0.08 minutes) and the the hand excavation method (atraumatic restorative technique; 6.98±0.17 minutes). The longest caries excavation time was recorded for the sodium hypochlorite-based chemomechanical caries removal method (8.12±0.02 minutes).

CONCLUSIONS

It was found that none of the current reviewed trials fulfilled all the ideal requirements of clinical trials. Furthermore, the current scientific evidence shows that the sodium hypochlorite-based (Carisolv) chemomechanical caries removal method was more time consuming when compared to the enzyme-based (Papacarie) chemomechanical and the conventional caries removal methods. Further prospective randomized controlled clinical trials evaluating the long-term follow-up of papain-treated permanent teeth are needed.

Fracture resistance of root-filled teeth after cavity preparation with conventional burs, Er: YAG and Er,Cr: YSGG lasers

Purpose

The aim of the present study is to compare the fracture resistance of teeth after access cavity preparation with conventional rotary burs, Erbium-doped yttrium aluminum garnet laser (Er:YAG) and Erbium, cromium: yttrium scandium gallium garnet laser (Er,Cr:YSGG) lasers.

Materials and methods

Fifty five intact mandibular molars were divided into 3 negative groups (groups 1, 2, 3; n=5 for each), 3 study groups (groups 4, 5, 6; n=10 for each) and 1 positive control group (intact teeth; n=10). Access cavities of groups 1, 2 and 3 were prepared with conventional burs, Er:YAG laser and Er,Cr:YSGG laser respectively. After root canal obturation, their coronal portions were left non-restored. Access cavities of groups 4, 5 and 6 were prepared by using the same equipment but their coronal portions were restored with composite resinafter root canal obturation. Following thermocycling, fracture strength was evaluated with a Universal Testing Machine. Mean force at which each sample is fractured was recorded in Newton unit and statistically analyzed.

Results

Fracture resistance of group 7 (intact teeth) was significantly higher than all other groups (p<0.001). Differences among the fracture resistance values of groups 4, 5 and 6 were not significantly different but they were significantly higher than those of groups 1, 2 and 3 (p<0.001). No significant difference was found between Groups 1, 2 and 3.

Conclusion

Preparing access cavities with either laser or bur has no effect on the fracture resistance of teeth with root canal treatment.

Chemo-mechanical caries removal with Papacarie™: case series with 84 reports and 12 months of follow-up

AIM

The aim of the present study was to determine the success rate after 12 months of follow-up in a series of cases in which chemo-mechanical caries removal (CMCR) was performed with Papacarie(TM), followed by restoration with glass ionomer cement.

BACKGROUND

The development of conservative techniques for carious tissue removal and improvements in dental restoration materials have allowed better preservation of dental structures in the treatment of decayed teeth. Chemo-mechanical caries removal (CMCR) is a conservative atraumatic treatment option. Papacarie(TM) is a papain-based material developed to act only on the carious dentin, allowing its easy removal with a blunt curette.

CASE REPORT

The study involved a total of 84 deciduous posterior teeth with occlusal dentinal caries. Only teeth without risk of pulp exposure were studied. After a period of 12 months, the restorations were evaluated based on criteria employed in previous studies. The radiographic evaluation revealed resorption and calcification of the affected teeth. The data were submitted to descriptive statistical analysis with the aid of the XLSTAT program. The success rate was 88.1% and 98.8% based on the clinical and radiographic evaluations, respectively. The difference between the success and failure rates was statistically significant (p < 0.0001).

CONCLUSION

Papacarie(TM) is an effective product for CMCR on occlusal dentinal tissue in deciduous teeth, demonstrating a high clinical and radiographic success rate after 12 months of follow-up.

Microleakage of Er:YAG laser and dental bur prepared cavities in primary teeth restored with different adhesive restorative materials

The purpose of this study was to evaluate and compare the effect of erbium:yttrium-aluminum-garnet (Er:YAG) laser irradiation and conventional dental bur cavity preparation on in vitro microleakage of class V cavities restored with different adhesive restorative materials and two types of self-etching adhesives in primary teeth. Standard class V cavities were prepared on 80 extracted primary, and the teeth were randomly divided into eight subgroups prepared either by dental bur or Er:YAG laser irradiation and then restored with self-cured glass ionomer (GI), resin-modified glass ionomer (RMGI), resin composite and Clearfil SE Bond (two-step self-etching adhesive), and resin composite and Clearfil S3 Bond (one-step self-etching adhesive). Restorations were finished and stored in distilled water at 37 °C for 24 h and then subjected to thermocycling. All the teeth were sealed with nail varnish, placed in a silver nitrate solution, and then vertically cut in a buccolingually direction. Subsequently, the specimens were evaluated for gingival and occlusal microleakage using a stereomicroscope. Data were analyzed using Kruskal-Wallis test followed by Mann-Whitney test. Wilcoxon test was used for comparing occlusal microleakage with gingival microleakage at p < 0.05. A higher degree of occlusal and gingival microleakage values for the teeth restored with GI or RMGI was obtained by both preparation methods compared with that of resin composites and the two self-etching primers. Er:YAG laser irradiation resulted in a significantly higher degree of microleakage only at the gingival margins for teeth restored with GI or RMGI, or composite and Clearfil S3 Bond compared with the bur preparation. The Er:YAG laser-prepared teeth restored with composite and Clearfil SE Bond demonstrated a better marginal seal on occlusal and gingival margins compared with that of bur-prepared cavities. The degree of microleakage in class V cavities was affected by the type of adhesive restorative materials, type of self-etching adhesive, cavity margin location, and tooth preparation method either by Er:YAG laser or dental bur.

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

OBJECTIVE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

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.

The evaluation of the vector system in removal of carious tissue

The aim of this study was to evaluate the Vector system in comparison to the conventional technique in cavity preparation. Four extracted primary teeth with no restorations and similar fissure carious lesions and four permanent teeth extracted for orthodontic reasons were used. Class I preparations were made provided that the caries depth remained within the dentin limits. Two teeth were treated with an aerator, the other two had carious tissue removed with the Vector system. Prepared cavities were evaluated with scanning electron microscopy for the surface roughness of the dentine and enamel and for the carious tissue removal efficiency. This pilot study determined that it is possible to remove carious tissue and perform cavity preparation with the Vector system. According to this preliminary evaluation of surface quality, a cavity prepared with the Vector treatment system, allows for a slicker floor, and a more regular enamel-dentine line than that prepared with an aerator. However, the Vector system requires a longer treatment time which we believe may be a negative point, especially for young patients.

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

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

Evaluation of selective caries removal in deciduous teeth by a fluorescence feedback-controlled Er:YAG laser in vivo

This study investigated the ability and efficacy of an Er:YAG laser with a fluorescence feedback system for caries removal in deciduous teeth. Seventy-nine carious lesions were excavated using a fluorescence-controlled Er:YAG laser. Endpoint of treatment was defined by emission of fluorescence from the dentine surface below the pre-selected threshold level of 7 units and the subsequent termination of Er:YAG laser radiation. Dentine samples were obtained from the cavity floor, and viable counts of both Streptococcus mutans and Lactobacilli, expressed as colony forming units (log CFU), were evaluated. Preparation time was recorded to assess efficacy of the treatment procedure. S. mutans and/or Lactobacilli were found in 25 out of 79 lesions. Regarding the counts for S. mutans and Lactobacilli, the median log CFU was 0 (min, 0; max, 5.5) and 0 (min, 0; max, 6), respectively, with 2.4% of all samples yielding more than 100 CFU S. mutans and 4.8% yielding more than 100 CFU Lactobacilli. In 8 out of 79 cases, laser excavated cavities were not judged being caries-free using the conventional tactile criterion for assessing caries tissue. Focussing on these teeth, the median log CFU was 0 (min, 0; max, 0.5) for S. mutans and 0 (min, 0; max, 1.6) for Lactobacilli. The mean time for treatment was 2.3+/-1.2 min. Of the children, 93.8% rated the laser treatment to be comfortable. The study indicates that the fluorescence feedback-controlled Er:YAG laser might be an appropriate device for caries removal in children using the suggested threshold level of 7 units.