Ghanashyam Prasad Email: moc. This article has been cited by other articles in PMC. Abstract Objective: To compare the effectiveness of various caries removal techniques in mandibular primary molars using Smart Burs, atraumatic restorative technique ART mechanical caries removal and Carie-care chemomechanical caries removal [CMCR] among primary school children in clinical and community-based settings. Materials and Methods: A total of 80 carious primary mandibular molars were selected for the study from the dental clinic and community. They were equally assigned to four groups according to caries removal technique and also by the operating site. In Group 1, caries was removed using Carie-care in the dental clinic and in Group 2, with Smart Burs in the dental clinic.

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Metrics details Key Points Chemochemical caries removal involves the selective removal of carious dentine. The reagent is prepared by mixing solutions of amino acids and sodium hydrochlorite. Reagents for the procedure were originally marketed as a solution known as Caridex. More recently, a similar system in the form of a gel has been marketed as Carisolv. Being a gel, Carisolv has the advantage of requiring volumes of less than 1 ml. No applicator system other than specially designed instruments is required.

Because only carious dentine is removed, the painful removal of sound dentine is avoided and the need for local anaesthesia is minimised. The procedure is suitable for soft carious lesions access to which may still require conventional mechanical procedures.

Abstract Chemomechanical caries removal involves the chemical softening of carious dentine followed by its removal by gentle excavation. The reagent involved is generated by mixing amino acids with sodium hypochlorite; N-monochloroamino acids are formed which selectively degrade demineralised collagen in carious dentine. The procedure requires 5—15 minutes but avoids the painful removal of sound dentine thereby reducing the need for local anaesthesia.

It is well suited to the treatment of deciduous teeth, dental phobics and medically compromised patients. The dentine surface formed is highly irregular and well suited to bonding with composite resin or glass ionomer. When complete caries removal is achieved, the dentine remaining is sound and properly mineralised. Large volumes of solution and a special applicator system were required. A new system, Carisolv, has recently been launched on to the market. This comes as a gel, requires volumes of 0.

Modern high speed drills are the latest development of this more than a century old technique. These include air abrasion with aluminium oxide, chemomechanical caries removal, atraumatic restorative therapy ART 2 and most recently, lasers.

Restoration of cavities prepared by this technique requires materials such as composite resins or glass ionomers which bond to the dentine surface rather than materials such as amalgams which involve cutting a cavity designed to mechanically retain the restoration. The polypeptide chains are coiled into triple helices which are known as tropocollagen units; these tropocollagen units then orientate side by side to form a fibril.

Co-valent bonds between the polypeptide chains and between the tropocollagen units form cross links and give the collagen fibrils stability Fig. Possible sites of cleavage by chemomechanical caries removal reagents by degradation of glycine or hydroxyproline are indicated by red arrows. Sites of cleavage by degradation of intra-molecular cross links are shown by red arrows. Sites of cleavage by degradation of intermolecular cross links are indicated by red arrows. Modified from Dow J, Lindsay, J E, Morrison J M Biochemistry p; Wokingham:Addison-Wesley Full size image When caries occurs, acids produced by plaque bacteria by anaerobic fermentation of carbohydrate initially cause solubilisation of the mineral in enamel.

As the process progresses, dentinal tubules provide access for penetrating acids and subsequent invasion by bacteria which results in a decrease in pH and causes further acid attack and demineralisation. When the organic matrix has been demineralised, the collagen and other matrix components are then susceptible to enzymatic degradation, mainly by bacterial proteases and other hydrolases.

There is an inner layer which is partially demineralised and can be remineralised and in which the collagen fibrils are still intact, and there is an outer layer where the collagen fibrils are partially degraded and cannot be remineralised.

They were studying the effect of sodium hypochlorite, which is a non-specific proteolytic agent, on the removal of carious material from dentine. Quite fortuitously a reaction occurred which resulted in a product which was more effective in removal of carious dentine than a saline placebo. This involved the chlorination of glycine to form N-monochloroglycine NMG and the reagent subsequently became known as GK Originally it was thought that the procedure involved chlorination of the partially degraded collagen in the carious lesion and the conversion of hydroxyproline to pyrrolecarboxylic acid.

The two solutions were mixed immediately before use to give the working reagent pH approx. A delivery system was also available which consisted of a reservoir for the solution, a heater and a pump which passed the liquid warmed to body temperature through a tube to a hand piece and an applicator tip which came in various shapes and sizes.

The solution was applied to the carious lesion by means of this applicator which was used to loosen the carious dentine by a gentle scraping action; the debris together with the spent solution being removed by aspiration.

Application was continued until the dentine remaining was deemed sound by normal clinical tactile criteria. With suitable accessible soft lesions, after 5—10 minutes treatment only clinically sound dentine remained. The surface would appear to be the interface between carious and sound dentine. P, patent dentinal tubuless; O, occluded dentinal tubules; DS dentine scales.

Full size image The procedure avoids the painful removal of sound dentine but is ineffective in the removal of hard eburnated parts of the lesion; removal of eburnated caries however may not be necessary. Although a few patients find the taste unpleasant, generally this is not a problem and patient acceptance is high. Its advantages include reduced need for local anaesthesia, conservation of sound tooth structure and reduced risk of pulp exposure.

It is well suited to the treatment of anxious or medically compromised patients as well as to paediatric and domiciallary dentistry. There are however some limitations with the use of this system. This includes access to small or interproximal carious lesions, removal of enamel overlying the caries, removal of existing restorations, etc.

Although the Caridex system initially proved to be quite popular, large volumes of solution were needed — ml and the procedure was slow. Only certain cavities were suitable for treatment by the technique and because of the time involved 10—15 mins and limited use, popularity in the US waned. Although there were studies on the efficacy of caries removal by the procedure, studies on the long term success of cavities restored after CMCR treatment were lacking.

Interest in the UK began in the late s in Glasgow and London. Bartholomews and Royal London Hospital School of Medicine and Dentistry 13 carried out some more clinical studies together with studies on bonding to adhesives 14 the group in Glasgow attempted to modify the formulation and develop an improved CMCR reagent. In vitro studies were carried out on permanent and deciduous teeth using an NMAB solution similar in composition to Caridex.

They found that CMCR was more effective on deciduous teeth than on permanent ones. An attempt was made to improve the reagent by the addition of urea, which normally denatures proteins by breaking down hydrogen bonding thereby making them more soluble.

Indeed, NMAB was only statistically significantly more effective than a saline control when it contained urea, 20 a finding which has been confirmed in a subsequent more carefully controlled study. Electron probe micro-analysis showed that the dentine is sound and properly mineralised and that the surface formed is highly irregular.

These have included all classes of coronal lesions, cervical lesions and root caries and involved both deciduous and permanent teeth. A 3-year follow-up study is currently taking place in Glasgow comparing laser and CMCR removal of carious dentine with conventional treatment carried out under local and general anaesthesia. Because of the time required for CMCR treatment, the large volumes of solution needed and the fact that the delivery system was no longer commercially available, use of CMCR, despite its potential, became minimal.

Although this is similar to the Caridex and NMAB systems, it is in the form of a pink gel which can be applied to the carious lesion with specially designed hand instruments which have recently been modified. It is marketed in two syringes, one containing the sodium hypochlorite solution and the other a pink viscous gel which contains three amino acids, lysine, leucine and glutamic acid, together with carboxymethylcellulose to make it viscous and erythrocin to make it readily visible in use.

The contents of the two syringes are mixed by a simple system which involves joining the two together immediately before use as its effectiveness begins to deteriorate after 20 minutes.

More recently a new twin syringe mixing system containing sufficient material for 10—15 treatments has been introduced. This dispenses the exact amount required through a disposable mixing tip, and it can be active for up to one month if stored in a refrigerator after opening.

The gel is applied to the carious lesion with one of the hand instruments and after 30 seconds, carious dentine can be gently removed Fig 3. More gel is then applied and the procedure repeated until no more carious dentine remains, a guide to this being when the gel removed from the tooth is clear.

The time required for the procedure is about 9—12 minutes range about 5—15 minutes and the volume of gel is only 0. The system is much easier to use than Caridex and, because it involves a gel rather than a liquid, there is better contact with the carious lesion. When complete caries removal is achieved by this technique, the cavity surface has been shown to be as sound as that remaining after conventional drilling.

Hopefully statistical analysis of the findings will show it to be more effective than Caridex. Caridex and Carisolv are compared in Table 1. Figure 3.


Chemochemical caries removal: a review of the techniques and latest developments

Metrics details Key Points Chemochemical caries removal involves the selective removal of carious dentine. The reagent is prepared by mixing solutions of amino acids and sodium hydrochlorite. Reagents for the procedure were originally marketed as a solution known as Caridex. More recently, a similar system in the form of a gel has been marketed as Carisolv. Being a gel, Carisolv has the advantage of requiring volumes of less than 1 ml. No applicator system other than specially designed instruments is required.


As possible alternatives to conventional techniques of caries removal, chemomechanical caries removal systems have emerged. This study aims to clinically observe the advantages of chemomechanical method of caries removal over conventional technique. Materials and Methods: Inthis randomized controlled trial a total of 60 children with Class 1 open carious lesions were selected for the study. They were divided into two equal groups according to a method of caries removal 30 chemomechanical and 30 conventional on permanent molars. In Group A, caries was removed using the Carie-Care system and in Group B with the conventional drill and were restored equally with glass ionomer cement. The visual analogy face scale was used to determine the level of anxiety in children at baseline, during treatment and after treatment.





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