INTRODUCTION: The original approach for the treatment of caries was purely surgical.

of It was thought the that the only to

effective

method

eliminating

disease

was

completely remove all of the demineralized area of the tooth structure. Even the smallest of area of

demineralization amount of

required tooth

the

removal to

standard the been for

sound of by

structure This lac!

prevent had

progression developed prevention$ structure. %ver shifted adapting

disease. Dr. G.V. led to

technique as

"E#tension of sound

which

specific

tooth

recent

years&

the

dental

profession dentistry

has and

towards more

practicing

preventive and

conservative

tooth

preserving

procedures. In today's seminar& I would li!e to discuss about newer invasive techniques for caries e#cavation. The techniques available to e#cavate caries

clinically can be classified according to as+

.D.(. )***

Category ,. -echanical& rotary ). -echanical& rotary

Techniques 3and pieces 4 burs e#cavation& air

non. 3and

abrasion 5ltrasonics&

/. 0hemo.mechanical 1. 2hoto.ablation

sonoabrasion 0aride#& enzymes 6asers carisolv and

Each their own

of

the

above of

mentioned

techniques

have dentin

claims

removing

demineralize

selectively. 7n ideal method should fulfill certain factors to satisfy& both the operator as well as the patient. They are+ a. 0omfort and ease of use in the clinical

environment. b. The ability to dissiminate and remove diseased tissue only.

c.

eing

painless&

silent&

requiring

only

minimal

pressure for optimal use. d. 8ot generating vibration or heating during

periods of operation. e. eing affordable and easy to maintain. The handpieces and burs are in universal use with their obvious disadvantages li!e+ . . . 9ensitive to vital pulp. 2ressure:heat on tooth. 8ecessity of 6.7. It was at this point that chemo.mechanical

approach came in. It was claimed to be a non.invasive alternative for removal of caries. The technique involved applying a solution onto the decayed dentinal tissue allowing it to soften the tissue and finally scraping it off with blunt hand

instrument. -any solutions were introduced and mar!eted

since ,;<*'s which I would be discussing in detail.

efore

discussing

individual

products

would

first li!e to enlighten the layers present in carious dentin. =hich have importance in our seminar

regarding the chemicals. Carious dentin consists of two layers: ,. %uter layer. ). Inner layer. 1. Outer layer: . . . Decalcified > degenerated collagen fibres. Infected > non remienralizable. 8ecrotic ?This layer should be removed@.

2. Inner layer. . . . . . etween outer and nor mal dentin. 6ess decalcified. acteria free. Aemineralized collagen fibres present. Vital odontoblastic process present. This layer

should be left intact.

Ideally&

when

preparing

the

decayed

tooth

one

should remove the outer decayed dentin layer while retaining the inner remineralizable layer intact. The chemomechanical method claims to do so.

6et us now see the different products available to us. Chemo-mechanical approach: The chemo.mechanical approach was initially

introduced in ,;<) in the form of G.B. ,*, solution. In ,;<C& Goldman and Bronman reported on the

possibility of removing caries chemically using GB. ,*, ?8-G@& which consists of+ . . 8.monochloroglycine ?8-G@. 9odium hypochlorite. Glycine was added to counteract the corrosive

effect of 8a%0l. 7lso called as GB.,*,G. Its mode of action has been described as

chlorination of free amino groups i.e. chlorination of amino groups of peptide bonds of protein forming

8-G compounds

This

8-G

has

the

ability

to

convert

hydro#y

proline an important factor peptide carbo#y glycine.@ Therefore the partially

to pyrole.).?its glycine

degraded

collagen

in

carious dentin was chlorinated by 8-G solution and this also affected the secondary and quaternary

structure of collagen by disrupting hydrogen bond. In this way carious material removal was

facilitated. GB.,*, ?8-G@ was tested in bovine 7chilles

tendon collagen to observe as

what actually happens

to the collagen fibres. 9E- evaluation showed. ,. Draying fibrils > i.e. essential structure was

intact& but there was separation of few peripheral fibres. ). 9pinaling fibrils > i.e. attraction between shortening

adEacent fibres was lost and there was of individuals fibres.

/. Dissociating fibrils > i.e. structure was totally separating& fibre orientation was poor and hard to define.

1. 7morphous

material

>

i.e.

there

was

little

definitive structure and material which was hard to define as collagen. !"antages: ,. 7bsence of pain. ). 7bsence of any deleterious effects on pulp. /. 9tudies done by Burosa!i et al and al showed that it removed only rannstorm et outer carious

diseased layer. They presumed that the softening may be due to a selective attac! of the solution specifically on degenerated collagen fibres&

without affecting sound fibres of the inner layer and normal dentin underneath. Disa!"antages: The process was very slow. 6ater they found that the system was more effective if glycine was replaced by amino.butyric acid& which evolved in the GB.,*,E& which was approved in ,;F1 by and DD7 was ?food and drug as

administration@

commercialized

"07AIDEG$ GB.,*,E& contained instead of 8-G > "8.monochloro.D6.).aminobutyric acid$ ?8-7 @.

The system consists of: . . . . reservoir. 7 heater. 7 pump. 7 handpiece with application tip with various

shapes and sizes. In vitro studies done by > Goldman et al stated that caride# removed both the layers of caries leaving behind sound dentin. 9chertz et al reported that in histological

evaluation after using caride# e#hibited ;*H of caries with residual decay therefore he concluded that

caride# should be used with a spoon e#cavator. Clinical studies done by: ,. Iine! et al showed ;*.,**H removal of decay with caride# ?but it too! a very long time.@ Aompen and 0horpentier found caride# not

bactericidal in ,< samples cultured from the decay.

). Jip et al combined 8-7

4 ) urea in deciduous

teeth and found it to be better. 2ioch and 9tachle investigated the shear strength at the DE( after treatment of caride# for adhesive and bonding systems. 0aride# was found to reduce the shear strength at the DE( in bovine teeth. This was attributed because of the denaturation of the collagen. This disadvantage to be related to fracture of tooth still needs further clinical studies and investigations. /. Burusa!i et al& =al!man et al and =edenberg and urnstein investigated individually the

biocompatibility of caride# to pulp. They found it to be biocompatible because of the al!alinity of caride#& it was found to produce a hard tissue matri# formation below the necrotic zone. Zones: ,. Transient. ). Dar!. /. ody of lesion.

1. 9urface.

Jip

et

al

investigated

the

mineralization

of

dentinal surface remaining after caride# usage in a small sample. They used "bac! scattered electron

imaging$ ?

9I@ and "electron probe micro.analysis$

?E2-7@ which measured the surface level of 0a 44 and 2.. The authors concluded that the amount of 0a and 2 was )+, which matched with the sound dentin because it is better. K. %ther studies have reported that often usage of caride#& the dentinal surface produced. . . . . . 3igh degree of roughness. 5ndercuts. Dentin scales. Dentin tubules were partially patent. 9mear free surface. They postulated that it was better for adhesive restorative etching. C. Iinc! et al also evaluated patient acceptance and found out ;/H acceptance level. material without the necessity of acid

10

7lthough caride# had many advantages it was . . . . Very e#pensive. Time consuming. 3ad bul!y delivery system. 8eeded additional mechanical means decay. . 6arge volumes of solutions were required from ?)**.K**ml.@ . Dollowing introduced this& in a gel based with system medi was team to remove

collaboration

?Dental attracting+ Gotiberg 7 carisolv ?Dental update )***@.

@ in ,;;F called

0arisolv was initially approved for clinical use in dental practice by the 9wedish counter part to 59. DD7.

11

Composition: The formulation is isotonic in nature and consists of ) syringes. I. II. 9yringes > *.KH 8a%0l 9yringe / amino acids 6ucine. 6ysine. Gel substance > carbo#y methyl cellulose 9odium chloride. 9odium hydro#ide Erythrosine > to ma!e the gel visible. 9aline solution ?i.e. colonizing indicator@. #o!e o$ action: 0arisolv is al!aline in nature with a p3 of around ,,. 5pon mi#ing& the positively and negatively charged groups of aminoacids of 8a%0l become 8a%0l chlorinated due to glutanic

presence

and

constituents.

This

12

leads

to

interaction

with of

dentin

which

involves than and and

proteolytic

degradation of

collagen this

rather

demineralization removal of the

collagen& carious

softening dentin

altered

preserving the sound dentin. The gel consistency allows the active molecules

access to the dentin for a longer period than the equivalent This gel irrigating also helps solution by in caride# system. hand

lubricating

the

instrument specifically designed for carisolv. The instrument consists of 1 different handle with F interchangable tips ranging from *./mm.)mm. These instruments resemble e#cavators& but they are designed to be used in rapid whis!ing or curetting fashion& thereby limiting only to diseased tissue. The configuration of instrument allows access to all areas of lesion. 3elps to give a tactile sensation. 3elps in differentiating between carious and non. carious. 3elps to apply the gel.

13

Ca"ity preparation: The two syringes should be mi#ed Eust prior to use& as its efficiency decreases after )*./*mts. The two gels are mi#ed till a uniform colour is

obtained in a dapen dish. The mi#ed gel is then applied to carious lesion and left in place for /* seconds to allow it to degrade the diseased dentin before instrumentation. Aapid& light pressure is applied with instrument to facilitate caries removal. 7s the caries removal& the gel becomes cloudy with debris indicating cleaning with water. Gel is applied again for further removal. ssessment %i.e. &hen to stop': ,. =hen the gel no longer becomes cloudy. ). Tactile sensation on the carious dentin will present with "a catch$ whereas in a sound dentin the

instrument will pass easily.

14

/. 7fter completion& the cavity appears frosted and irregular appearance as compared to smooth

preparation of conventional bur and hand piece. The reason for their visual difference is that in a conventional preparation the presence of smear layer& which is over the underlying dentin& gives a smooth& glossy appearance. In contrast& in chemo.mechanically treated dentin lac!s smear layer and also forms

irregular dentin layer giving a matt finish. Patients acceptance: ,. 9horter time. ). 8o pain and discomfort. 7 number of theories have been postulated as to why there is reduce pain. They are+ a. b. c. d. e. 6ac! of cutting into caries.free dentin. Aelatively few dentinal tubes are e#posed. There are no vibrations from drilling. 8o temperature variations. Dentin is always covered with a isotonic gel at body temperature.

15

f.

2sychologically e#perience.

quiet

and

less

traumatic

In!ications: ,. =here preservation of tooth structure is

important. ). /. 1. Aemoval of root : cervical caries. -anagement of coronal caries without cavitation. Aemoval of caries at the margins bridge abutments. K. C. <. F. ;. 0ompletion of tunnel preparation. =here 6.7. is contraindicated. In an#ious patients. In deciduous dentition. 7 traumatic restorative technique ?7AT@. of crown and

!"antages o"er Cari!e(: ,. Three amino groups are incorporated instead of

one because interaction and degradation efficiency is increased.

16

).

0arisolv

has

higher

viscosity&

which

allows

for

application of higher concentration of aminoacids and 8a%0l without increasing the total volume or amount ?only *.).,.*ml carisolv required as

compared to caride# i.e. )K*.K**ml@. /. Increased placement. 1. The gel does not need to be heated or supplied through a pump. K. Improved shelf life. viscosity also helps in precision

In "itro stu!ies: (epsen et al analyzed collagen structure of residual dentin after usage of carisolv. They found that it differed from sound dentin and had characteristic denatured collagen. In clinical studies: Drom the abstracts published in 9toc!holm

different authors concluded individually that although carisolv removed ;;H of decay& it was slower as

compared to conventional techniques.

17

Enzymes: 9tudies have e#amined that caries could be

removed by enzymes+ . ,;F;& Goldberg and Beil successfully removed

soft carious dentin using bacterial achromobacter collagenase which did not effect sound dentin. . Enzyme enzyme pronase& originating a non from specific proteolytic griseus

streptomyces

also helps in removing caries. . 9till e#periments are going on for the validity of such enzyme. CONC)U*ION: 7s with of all new procedures& new there are the new

uncertainty

learning

techniques&

using

techniques& clinical time& cost etc& which need to be considered on an individual level. %ver the decades& dentistry has changed dramatically and practitioners follow the new trends and master new less techniques. sound tooth

0hemo.mechanical

means

removes

structure and reduced pulpal irritation. This technique can help to supplement and complement other methods of caries removal& further research and clinically

based e#periments are required for acceptance of such new techniques.

18

R+,+R+NC+*: ,. 0hemo.mechanical method of caries removal >

Dental 5pdate& )***L )<L /;F.1*,. ).

19