1

INTRODUCTION:
The original approach for the treatment of caries was purely
surgical. It was thought that the only effective method of eliminating the
disease was to completely remove all of the demineralized area of the
tooth structure. Even the smallest area of demineralization required the
removal of standard amount of sound tooth structure to prevent the
progression of disease. This technique had been developed by Dr. G.V.
Black as Extension for prevention which led to specific of sound tooth
structure.
Over recent years, the dental profession has shifted towards
practicing preventive dentistry and adapting more conservative and
tooth preserving procedures.
In todays seminar, I would like to discuss about newer invasive
techniques for caries excavation.
The techniques available to excavate caries clinically can be
classified according to B.D.J. 2000 as:
Category Techniques
Mechanical, rotary
Mechanical, non-rotary

Chemo-mechanical
Photo-ablation
Hand pieces + burs
Hand excavation, air abrasion
Ultrasonics, sonoabrasion
Caridex, carisolv and enzymes
Lasers
Each of the above mentioned techniques have their own claims of
removing demineralize dentin selectively.
An ideal method should fulfill certain factors to satisfy, both the
operator as well as the patient. They are:
Comfort and ease of use in the clinical environment.
The ability to dissiminate and remove diseased tissue only.
Being painless, silent, requiring only minimal pressure for optimal use.
Not generating vibration or heating during periods of operation.
Being affordable and easy to maintain.
The handpieces and burs are in universal use with their obvious
disadvantages like:
Sensitive to vital pulp.
Pressure/heat on tooth.
Necessity of L.A.
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.
Many solutions were introduced and marketed since 1970s which
I would be discussing in detail.
Before discussing individual products I would first like to
enlighten the layers present in carious dentin. Which have importance in
our seminar regarding the chemicals.
Carious dentin consists of two layers:

2
Outer layer.
Inner layer.
1. Outer layer:
Decalcified degenerated collagen fibres.
Infected non remienralizable.
Necrotic (This layer should be removed).
2. Inner layer.
Between outer and normal dentin.
Less decalcified.
Bacteria free.
Remineralized 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. Let us now see the
different products available to us.
Chemo-mechanical approach:
The chemo-mechanical approach was initially introduced in 1972
in the form of G.K. 101 solution. In 1976, Goldman and Kronman
reported on the possibility of removing caries chemically using GK-101
(NMG), which consists of:
N-monochloroglycine (NMG).
Sodium hypochlorite.
Glycine was added to counteract the corrosive effect of NaOCl.
Also called as GK-101G.
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 NMG compounds
This NMG has the ability to convert hydroxy proline an important
factor to pyrole-2-(its glycine peptide carboxy glycine.)
Therefore the partially degraded collagen in carious dentin was
chlorinated by NMG solution and this also affected the secondary and
quaternary structure of collagen by disrupting hydrogen bond.
In this way carious material removal was facilitated.
GK-101 (NMG) was tested in bovine Achilles tendon collagen to
observe as what actually happens to the collagen fibres. SEM
evaluation showed.
Fraying fibrils i.e. essential structure was intact, but there was
separation of few peripheral fibres.
Spinaling fibrils i.e. attraction between adjacent fibres was lost and
there was shortening of individuals fibres.
Dissociating fibrils i.e. structure was totally separating, fibre
orientation was poor and hard to define.
Amorphous material i.e. there was little definitive structure and
material which was hard to define as collagen.
Advantages:

3
Absence of pain.
Absence of any deleterious effects on pulp.
Studies done by Kurosaki et al and Brannstorm et al showed that it
removed only outer carious diseased layer. They presumed that the
softening may be due to a selective attack of the solution specifically on
degenerated collagen fibres, without affecting sound fibres of the inner
layer and normal dentin underneath.
Disadvantages:
The process was very slow. Later they found that the system was
more effective if glycine was replaced by amino-butyric acid, which
evolved in the GK-101E, which was approved by FDA (food and drug
administration) in 1984 and was commercialized as CARIDEX GK-
101E, contained instead of NMG N-monochloro-DL-2-aminobutyric
acid (NMAB).
The system consists of:
reservoir.
A heater.
A pump.
A handpiece with application tip with various shapes and sizes.
In vitro studies done by Goldman et al stated that caridex
removed both the layers of caries leaving behind sound dentin.
Schertz et al reported that in histological evaluation after using
caridex exhibited 90% of caries with residual decay therefore he
concluded that caridex should be used with a spoon excavator.
Clinical studies done by:
1. Zinek et al showed 90-100% removal of decay with caridex (but it
took a very long time.)
Rompen and Chorpentier found caridex not bactericidal in 17
samples cultured from the decay.
2. Yip et al combined NMAB + 2 urea in deciduous teeth and found
it to be better.
Pioch and Stachle investigated the shear strength at the DEJ after
treatment of caridex for adhesive and bonding systems.
Caridex was found to reduce the shear strength at the DEJ 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.
3. Kurusaki et al, Walkman et al and Wedenberg and Burnstein
investigated individually the biocompatibility of caridex to pulp.
They found it to be biocompatible because of the alkalinity of caridex, it
was found to produce a hard tissue matrix formation below the necrotic
zone.
Zones:
Transient.
Dark.
Body of lesion.
Surface.

4
Yip et al investigated the mineralization of dentinal surface remaining
after caridex usage in a small sample. They used back scattered
electron imaging (BSI) and electron probe micro-analysis (EPMA)
which measured the surface level of Ca
++
and P
-
. The authors concluded
that the amount of Ca and P was 2:1 which matched with the sound
dentin because it is better.
Other studies have reported that often usage of caridex, the dentinal
surface produced.
High degree of roughness.
Undercuts.
Dentin scales.
Dentin tubules were partially patent.
Smear free surface.
They postulated that it was better for adhesive restorative material
without the necessity of acid etching.
Zinck et al also evaluated patient acceptance and found out 93%
acceptance level.
Although caridex had many advantages it was
- Very expensive.
Time consuming.
Had bulky delivery system.
Needed additional mechanical means to remove decay.
Large volumes of solutions were required from (200-500ml.)
Following this, a gel based system was introduced in collaboration with
medi team (Dental attracting: Gotiberg AB) in 1998 called carisolv
(Dental update 2000).
Carisolv was initially approved for clinical use in dental practice
by the Swedish counter part to US. FDA.

5
Composition:
The formulation is isotonic in nature and consists of 2 syringes.
Syringes 0.5% NaOCl
Syringe 3 amino acids glutanic
Lucine.
Lysine.
Gel substance carboxy methyl cellulose
Sodium chloride.
Sodium hydroxide
Erythrosine to make the gel visible.
Saline solution (i.e. colonizing indicator).
Mode of action:
Carisolv is alkaline in nature with a pH of around 11.
Upon mixing, the positively and negatively charged groups of
aminoacids become chlorinated due to presence of NaOCl and NaOCl
constituents. This leads to interaction with dentin which involves
proteolytic degradation of collagen rather than demineralization of
collagen, this softening and removal of the carious altered dentin and
preserving the sound dentin.
The gel consistency allows the active molecules access to the dentin for
a longer period than the equivalent irrigating solution in caridex system.
This gel also helps by lubricating the hand instrument specifically
designed for carisolv.
The instrument consists of 4 different handle with 8 interchangable tips
ranging from 0.3mm-2mm.
These instruments resemble excavators, but they are designed to be used
in rapid whisking or curetting fashion, thereby limiting only to diseased
tissue.
The configuration of instrument allows access to all areas of lesion.
Helps to give a tactile sensation.
Helps in differentiating between carious and non-carious.
Helps to apply the gel.
Cavity preparation:
The two syringes should be mixed just prior to use, as its efficiency
decreases after 20-30mts.
The two gels are mixed till a uniform colour is obtained in a dapen dish.
The mixed gel is then applied to carious lesion and left in place for 30
seconds to allow it to degrade the diseased dentin before
instrumentation.
Rapid, light pressure is applied with instrument to facilitate caries
removal.
As the caries removal, the gel becomes cloudy with debris indicating
cleaning with water.
Gel is applied again for further removal.
Assessment (i.e. when to stop):
1. When the gel no longer becomes cloudy.

6
2. Tactile sensation on the carious dentin will present with a catch
whereas in a sound dentin the instrument will pass easily.
3. After 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 lacks smear layer and also forms irregular
dentin layer giving a matt finish.
Patients acceptance:
Shorter time.
No pain and discomfort.
A number of theories have been postulated as to why there is reduce
pain. They are:
a. Lack of cutting into caries-free dentin.
b. Relatively few dentinal tubes are exposed.
c. There are no vibrations from drilling.
d. No temperature variations.
e. Dentin is always covered with a isotonic gel at body temperature.
f. Psychologically quiet and less traumatic experience.
Indications:
1. Where preservation of tooth structure is important.
2. Removal of root / cervical caries.
3. Management of coronal caries without cavitation.
4. Removal of caries at the margins of crown and bridge abutments.
5. Completion of tunnel preparation.
6. Where L.A. is contraindicated.
7. In anxious patients.
8. In deciduous dentition.
9. A traumatic restorative technique (ART).
Advantages over Caridex:
1. Three amino groups are incorporated instead of one because
interaction and degradation efficiency is increased.
2. Carisolv has higher viscosity, which allows for application of
higher concentration of aminoacids and NaOCl without increasing the
total volume or amount (only 0.2-1.0ml carisolv required as compared to
caridex i.e. 250-500ml).
3. Increased viscosity also helps in precision placement.
4. The gel does not need to be heated or supplied through a pump.
5. Improved shelf life.
In vitro studies:
Jepsen 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:

7
From the abstracts published in Stockholm different authors concluded
individually that although carisolv removed 99% of decay, it was slower as compared
to conventional techniques.
Enzymes:
Studies have examined that caries could be removed by enzymes:
1989, Goldberg and Keil successfully removed soft carious dentin using
bacterial achromobacter collagenase which did not effect sound dentin.
Enzyme pronase, a non specific proteolytic enzyme originating from
streptomyces griseus also helps in removing caries.
Still experiments are going on for the validity of such enzyme.
CONCLUSION:
As with all new procedures, there are the uncertainty of learning
new techniques, using new techniques, clinical time, cost etc, which
need to be considered on an individual level. Over the decades, dentistry
has changed dramatically and practitioners follow the new trends and
master new techniques. Chemo-mechanical means removes less sound
tooth structure and reduced pulpal irritation. This technique can help to
supplement and complement other methods of caries removal, further
research and clinically based experiments are required for acceptance of
such new techniques.
REFERENCES:
1. Chemo-mechanical method of caries removal Dental Update,
2000; 27; 398-401.
2.