Chemo-mechanical Caries Removal

Chemo-mechanical Caries Removal in dentistry, Minimal invasive caries removal, Non Invasive caries removal. newer methods in caries removal

1. CHEMO-MECHANICAL CARIES REMOVAL

2. CONTENTS INTRODUCTION MATERIALS ADVANTAGES DISADVANTAGES LIMITATIONS STUDIES REFERENCES

3. I NTRODUCTION Dentinal caries – two zones- In ancient times – hand instruments- painful which surpasssed in 1871 by James Morrisons instrument from Issac Singer’s sewing machine – ineffective- Evolution- rotary instruments- low- high speed- extension for prevention. thermal, pressure effects, annoying sounds, vibration, use of anesthesia, pain, fear, anxiety in children, dentin dessication (WHO-2005)- CARIES- as a localized post- operative, pathological process of external origin, involving softening of hard tooth tissue and proceeding to the formation of a cavity.

4. Alternative techniques- air abrasion, sono abrasion, ART, Lasers, ultrasonic instrumentation, CMCR . Banerjee et al (2000) in a review, conlcuded that except for the rotary burs and chemomechanical systems, none of the techniques were effective in removal of dentinal caries. 1975- Habib et al – 5% - sodium hypochlorite- toxic and aggressive to adjacent healthy tissues. Newer solution- NaCL , NaOH , and glycine to 5% NaOCL GK- 101- N- monocloroglycine - more effective- very slow Caridex - GK 101E

5. CARIDEX N- monochloroglycine and amino butyric acid- GK 101E. Krogman and Goldman (1975)published this material and FDA approval -1984 Intermittent application of preheated- N- mono-DL-2-aminobutyric acid. Chlorination of remaining partially degraded dentinal collagen – hydroxy proline – pyrrole -2 – carboxilic acid- disruption of altered collagen fibres in the caries. Expense, additional clinical time, bulky caridex delivery system, which consisted of reservoir, a heater, a pump and a hand piece with applicator tip, large quantity required, solution t5o be heated, short shelf life, hand instruments were not optimum.

6. CARISOLV 1998- Chriser Hedwards with Lars Strid of Mediteam collaborated with Dan Ericson and Rolf Bornstein – sweden . Lysine, luecine , glutamic acid- instead of amino butyric acid. The improved version of carisolv 1, introduced- 1997, by Mediteam dental AB (Sweden) Now been improved and marketed as carisolv -2004 – consists of two syringes. Syringe one- NaOCL , syringe two- 3 amino acids, gel substance- carboxy methyl cellulose, NaCL , NaOH , saline solution coloring indicator( red)

7. Removal of caries – 5.2 min- as fast as When carisolv is mixed- the aminoacids bind chlorine and form chloramines at high pH. 3 amino acids are differently charged- electrostatic attraction to different areas of proteins – hydrophilic and hydrophobic patches. These three choloramine acids gets attracted to one of these patches, bringing reactive power- breakdown of degraded collagen- characteristically seen in demineralized portion of carious lesion- softens only carious dentin leaving healthy tissue intact. The porous nature of demineralized dentin allows carisolv to penetrate.

8. INDICATIONS Where preservation of tooth structure is important Removal of root/ cervical caries Coronal caries with cavitation Removal of caries at crown margins and bridge abutments Completion of tunnel preparations Local anesthesia is contraindicated In dentally anxious patients, needle phobics Primary carious lessions in deciduous teeth ART procedures In patients with special needs

9. Hand instruments Specially designed instruments and tips Atraumatic , help to preserve the tissue, speed up the treatment- with different shapes and sizes. Classified- Type of tips- permanent tips ( double ended), interchangeable tips( single handle- diff tips)

10. Standard insrument classification : Carisolv hand instrument 1- extra bend- crown margins and areas difficult to access 2- multistar - apply gel and start removing caries- promotes penetration of gel- scraping in all directions with its four pronged design 3- remove caries in smaller cavities- root caries or deciduous teeth 4- close to the pulp and to remove softened carious dentin from the cavity 5- remove caries at DEJ.

11. Power drive Is a combined electronic instrument for power operated, minimally invasive caries removal with carisolv and fro endodontic treatment. Selective and precise Fast, simple, efficient High tissue control, low sound level Patients can operate the control unit themselves In dental phobic patients

12. Clinical procedure Quickly and easily mastered careful selection – fully visible and easily accesssible lesions – buccal root caries/ occlusal caries Instruments- four different handles- eight interchangeable tips- 0.3-0.2mm- like spoon excavators- rapid whisking or cutting fashion- removal of carious tissue only Tactile sensation- differentiation carious and non carious lesions

13. Effectiveness will decrease- 20-30 min after mixing, gel is mixed directly before use and used for a single treatment only – refrigerated- allowed to come to room temperature before use. Unmixed gel – two syringe- like tubes- before use two tubes are secured together using male and female connecting parts- plungers then depressed to activate the gel- uniform color- dispensed into the container- 30 sec in place to degrade – rapid light pressure is applied with the instruments to facilitate removal of caries, the gel must be continously applied until cavity preparation is complete.

14. Cavity assessment : surface color, structure and hardness – gel no longer becomes cloudy once caries removal is complete, tactile sensation- instrument should easily pass over sound tooth structure- sound dentin once washed and dried has frost and irregular appliance- restored in a conventional manner. Treatment of children using carisolv - Do not rush, be sure to give the geo 30 sec to react Keep the patient well informed during treatment If the patient experience pain- check the cavity is easilt filled with gel Very important not to work with too much force – use speed and not pressure.

15. advantages 3 amino acids- incorporated- and different charges – have improved interaction with degraded collagen within lesion. Higher concentration, higher viscosity, doesnot need to be heated, or applied through a pump mechanism, improved shelf life. Positive acceptance , less pain, discomfort, pleasant experience, without need of LA, psychologically – less traumatic experience

16. Disadvantages Short life High corrosiveness Requirement of specialized instruments high cost Prolonged time extensive training , registration of professionals

17. PAPACARIE 2003- Brazil- Papacarie - papain , chloramines, toluidine blue, salts, thickening vehicle- antibacterial, anti-inflammatory characteristics. From latex of leaves and fruits – carica papaya Papain accelerates- cicatricial process – Chemical debridement Granulation and epithelialization , -phases of cicatrization Stimulation of the tensile strength of scars

18. Anti- trypsin - inhibits- protien digestion- but infected tissues donot show anti- trypsin - can digest only dead cells, degraded collagen, excavator (opposite side) is used like a pendulum movement without cutting- without promoting any kind of stimulus / pressure. Guzman and Guzman (1953) – skin lesions- burns- enz action – papain - necrotic and purulent processes. Dawkins (2003)- has bactericidal and bacteriostatic properties .

19. Advantages: Naturally available,antimicrobial , affecting only infected dentin efficient ,easy application Comfortable, less destructive to dentinal tissues Inexpensive solution Does not need special instruments Very apprehensive patients

20. Carie – care system (India)-2010- Unitech pharamcueticals - papaya extract( papain ) 100mg, clove oil 2 mg, colored gel (blue), chloramines, NaCL , sodium methyl paraben - a gel based on papain and chloramines containing similar to papacarie , is less costly than carisolv and has similar use The newer version of the product- Papacarie Duo was released in 2011 and has same eficacy with number of additional properties - such as longer shelf life, no need of refrigerated storage, also has greater viscosity, allowing more precise placement and less waste during procedure, and offers of minimally invasive method, that is easy to apply, and dispenses of dental equipment beyond the need for blunt scraping instruments, isolation of the operating field and water.

21. Indigenously Prepared Caries Removing Gel ( papEdent - a painless gel -2011) Consists of an enzyme- papin , an anti-oxidant ( D-∞ tocopherol acetate, humectant – glycerin,emulsifier - amylopectin , thickener – carbopol , preservative- propyl –p- hydroxybenzoate ), coloring agent – green apple and distilled water as a vehicle. Refrigerated, within 1 hour Natural product Bactericidal, anti-inflammatory, whitening properties Acts only on damaged tissues No allergies, no special instrument easy, economical

22. ADVANTAGES Minimal invasive technique Increase patient’s compliance, left the healthy dentin intact Eliminates use of anesthesia, pain, sound tooth structure removal Selectively removes softened dentin - tooth structure – iatrogenic pulp exposure. Painless procedure Biocompatible, bactericidal, bacteriostatic , atraumatic Also aids in bonding adhesive restorations Special child, medically compromised patients Dental camps , school dental camps, community dental camps.

23. LIMITATIONS Difficult clinical handling Large volume of solution needed Short life of opened packages Time required Hand instruments are not appropriate for cutting enamel, and now a days, most cavities are not large enough to allow proper access to carious dentin.

24. STUDIES Pandit IK et al (2007) compared – airotor , carisolv , hand instruments- caries removal, time, pain experience. Pai S V et al (2009)- depth of penetration of bonding resin was significantly more in carisolv group compared to bur group. Singhal P, Das UM, Vishwanathan D, Singhal A (2012)- Carisolv was slightly better than NaoCl 1% gel at apical third because of formation of high pH chloramines, which is a potent disinfectant with tissue solvent properties.

25. Anegudi RT, Patil SB, Tagginmani V, Shetty SD (2012)- carried to compare reduction of cariogenic flora, duration of caries removal, the amount of tooth loss, child’s behavioral assessment before, during, after procedure, pain perception.

26. Maragakis et al (2001) who claimed that children prefr conventional method as it was quicker, it tasted better and finished earlier. Yazici et al(2003) – presence of bacteria, absence of smear layer- pushing of bacteria into the dentinal tubules Ingle et al (2007) found that subjects fear of the dentists increased in the CMCR method, while slightly decreased in the conventional method.

27. RFERENCES Pandit IK, Srivastava N, Gugnani N, Gupta M, Verma L. Various Methods of Caries Removal in Children: A Comparative Clinical Study. J Indian Soc Pedod Prev Dent 2007 Pai VS , Nadig RR, Jagadeesh TG, Usha G, Karthik J, Sridhara KS. Chemical Analysis Of Dentin Surfaces After Carisolv Treatment. J Conserv Dent 2009;2(3): 118-22 Jawa D, Singh S, Somani R, Jaida S, Srikar K, Jaidka R. Comparative evaluation of the efficacy of chemomechanical caries removal agent ( Papacarie ) and conventional method of caries removal: An invitro study. J Indian Soc Pedod Prev Dent 2010;2(28):73-77

28. Subramaniam P, Gilhotra K. Antimicrobial efficacy of an indigenously prepared caries removing gel. Contemp Clinic Dent 2011;2(1):13-16 Singhal P, Das UM, Vishwanathan D, Singhal A. Carisolv as an endodontic irrigant in decidous teeth: An SEM study. Indian Journal of Dental Research 2012;23(1) J Kumar, M Nayak , KL Prasad, N Gupta. A comparative study of the clinical efficiency of chemomechanical caries removal using Carisolv ® and Papacarie ® – A papain gel. Indian Journal of Dental Research 2012;23(5) Anegundi RT, Patil SB, Tegginmani V, Shetty SD. A comparative microbiological study to assess caries excavation by conventional rotary method and a chemo-mechanical method. Contemp Clinic Dent 2012;3(4):388-392.

29. Avinash A, Grover SD, Koul M, Nayak MT,Singhvi A, Singh RK. Comparison of mechanical and chemomechanical methods of caries removal in deciduous and permanent teeth: A SEM study. J Indian Soc Pedod Prev Dent 2012;2(30):115-121. Ramamoorthi S, Nivedhitha MS, Vanajassun PP. Effect of two different chemomechanical caries removal agents on dentin microhardness : An in vitro study. J Conserv Dent 2013;16(5):429-433. Matsumoto SFB, Motta LJ, Alfaya TA, Guedes CC, Fernandes KPS, Bussadori SK. Assessment of chemomechanical removal of carious lesions using Papacarie Duo ™: Randomized longitudinal clinical trial. Indian Journal of Dental Research 2013;24(4):488-492 .

30. Dean A J, Mc Donald R E, Avery D R. Dentistry for the Child and Adolescent, 9 th edition, Missouri, Mosby,2011 Marwah N. Text Book of Pediatric Dentistry. 2 nd edition. New Delhi: Jaypee medical publishers; 2009. Tandon S. Text Book of Pedodontics . 2 nd edition. Hyderabad: Paras medical publishers; 2008. Damle HG. Text Book of Pediatric Dentistry. 3 rd edition. New Delhi : Arya publishers;2009. Pinkham JR, Casamassimo PS, Mc Tigue DJ, Fields HW, Nowak AJ. Text Book of Pediatric Dentistry. 4 th edition. St.Louis,Missouri : Saunders publishers;2005. Meera R, Muthu MS, Phanibabu M, Rathnaprabhu V. First dental visit of a child. J Indian Soc Pedod Prevent Dent. 2008( Suppl );S68-S71.