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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 6  |  Issue : 2  |  Page : 52-58

Efficacy of new chemomechanical caries removal agent compared with conventional method in primary teeth: An in vivo study


1 Department of Pedodontics and Preventive Dentistry, College of Dental Sciences, Davangere, Karnataka, India
2 Department of Ortho and Dentofacial Orthopedics, IDEAS Dental College, Gwalior, Madhya Pradesh, India
3 Army Dental Centre (Research and Referral), New Delhi, India
4 Department of Pedodontics, Seebar Institute of Dental Sciences, Vijayawada, Andhra Pradesh, India
5 Department of Pedodontics, Hitkarni Dental College, Jabalpur, Madhya Pradesh, India

Date of Web Publication13-Feb-2017

Correspondence Address:
N B Nagaveni
Department of Pedodontics and Preventive Dentistry, College of Dental Sciences, Davangere, Karnataka
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2231-6027.199986

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  Abstract 

Background: Painless dentistry, minimal intervention and thus giving relief, comfort, and solace and thereby instilling a positive attitude toward dental treatments, are some of the factors justifying the specialty of pediatric dentistry. Aim: The purpose of this study was to evaluate clinically the effectiveness, total working time and pain reaction following treatment with a new chemomechanical caries removal gel (Carie-Care™) compared to conventional drilling method in primary teeth. Settings and Design: This study is a split-mouth clinical trial wherein two methods of caries removal were performed within the same patient. Methods: Two methods of caries removal were compared in the same patient. Sixty carious primary teeth were evaluated from thirty children and divided into two groups as test and control group. In the test group, the caries was removed using the new chemomechanical caries removal gel, and in control group, caries was removed using the dental bur. Statistical Analysis used: Unpaired t-test. Results: The mean time taken for complete caries excavation with Carie-Care™ was 3.24 ± 0.74 s. This was significantly longer compared with the conventional drilling wherein the mean time was 2.08 ± 0.24 s (P < 0.001). Patient treated with Carie-Care™ gel experienced significantly comfort (Score 1) (P < 0.001), and it was as effective as drill in caries removal. Conclusion: Carie-Care™, a new chemomechanical caries removal agent could be an effective caries removal method for the treatment of patients seeking an alternative to conventional methods.

Keywords: caries removal, dental caries, primary teeth


How to cite this article:
Nagaveni N B, Radhika N B, Satisha T S, Ashwini K S, Neni S, Gupta S. Efficacy of new chemomechanical caries removal agent compared with conventional method in primary teeth: An in vivo study. Int J Oral Health Sci 2016;6:52-8

How to cite this URL:
Nagaveni N B, Radhika N B, Satisha T S, Ashwini K S, Neni S, Gupta S. Efficacy of new chemomechanical caries removal agent compared with conventional method in primary teeth: An in vivo study. Int J Oral Health Sci [serial online] 2016 [cited 2017 Jul 22];6:52-8. Available from: http://www.ijohsjournal.org/text.asp?2016/6/2/52/199986


  Introduction Top


Painless dentistry, minimal intervention and thus giving relief, comfort, and solace and thereby instilling a positive attitude toward dental treatments, are some of the factors justifying the specialty of pediatric dentistry. It is well-known fact that traditional method of caries removal using the “dental bur” is the most common technique for caries removal in dental practice. However, this technique is always associated with many disadvantages such as (i) the perception by patients that drilling is unpleasant, (ii) frequent requirement of local anesthesia, (iii) drilling can cause deleterious thermal effects, (iv) can also cause pressure effects on the pulp, and (v) use of drill may result in excessive removal of sound tooth structure.[1] Studies [2],[3],[4] performed on dental anxiety have shown that dental drill is the most highly stressful factor in producing pain during treatment in many patients especially children. As a result, “quest” for newer materials and techniques is going on in the field of caries management. An innovative approach called “chemo-mechanical caries removal” technique which is minimally invasive and painless has been developed to overcome the shortcomings of traditional approach of caries management.[5] This method of caries removal involves chemical softening of carious dentin followed by its removal with gentle excavation.

Since 1975, various chemical compositions have been introduced for chemomechanical caries removal such as sodium hypochlorite,[5] GK 101,[6] caridex,[7] and carisolv.[8] Although these chemical agents have found to be effective, each product has certain drawbacks. Recently, a new chemical gel, Papacarie developed by Bussadori et al.[9] from Brazil, has caught the interest of various clinicians in caries removal because of its advantages over other products.

With the intention of presenting a new agent that cost less than Papacarie and easy availability, a new chemomechanical caries removal system (Carie-Care™) (Uni-Biotech, Pharmaceuticals Pvt. Ltd., India) has been launched. Carie-Care a product that has been locally introduced has as its main active ingredient from papaya extract, an endoprotein, chloramines, and dye. In addition, the preparation contains specific percentages of essential oils from plant sources, which has anti-inflammatory, analgesic, and mild anesthetic effect which will reduce the pain perception during the operative procedure. The preparation also contains explicit gelling agent in accurate percentage to give exact consistency to the gel so that when applied there is no spill over. Therefore, an in vivo study was designed and carried out to investigate the efficacy of this new caries removal gel with conventional drilling method in primary teeth.


  Methods Top


The design of the present study is a split-mouth trial wherein the effectiveness of two different caries removal techniques (traditional drilling technique for one tooth and chemomechanical technique for another tooth) were evaluated within the same patient. The nature of the study was explained to the parents of each patient, and informed consent was obtained before the procedure. The protocol and consent form were approved by the Institutional Ethics Committee to perform the study.

Selection criteria

This study included total of thirty healthy pediatric individuals of both genders with age group ranging from 5 to 7 years. The presence of at least two or more in the same group of teeth (e.g. 75 and 85 or 53 and 63) in each patient involving only enamel and dentin and with sufficient opening for the application of gel and placement of hand instruments were considered for evaluation.

Inclusion criteria

  1. Presence of at least two carious lesions in primary teeth (either molars or canines) which are comparable, open and easily accessible for hand instrumentation in each child
  2. Selected teeth with only enamel, dentin involvement, and no evidence of pulpal involvement on standardized conventional periapical radiographic examination


Radiographic confirmation of inclusion criteria was performed by the main author before the clinical procedure in the same appointment.

Exclusion criteria

Teeth which exhibited a history of pain, pulp exposure, presence of sinus opening with pus discharge, and radiographic evidence of furcation or periapical pathology were excluded from this study.

Clinical protocol

A total of sixty carious primary teeth which fulfilled the selection criteria were considered for evaluation in thirty children. Sixty teeth were broadly divided into two groups as test (Group A) and control (Group B) group containing thirty teeth in each group. In group A, the caries was removed using the new chemomechanical caries removal gel (Carie-Care™) and in Group B, the caries was removed using the conventional drilling technique. A single investigator (main author) performed the complete procedure of caries removal in all sixty teeth. Moreover, the two types of evaluation methods were carried out in the same appointment in each patient.

Clinical procedures

The following steps were followed during the treatment procedure using both methods: (1) radiographic examination was performed before the treatment procedure, (2) relative isolation was maintained using cotton rolls and saliva ejector, and (3) caries removal was carried out using both techniques.

Test group (Group A): Caries removal using the chemomechanical method (Carie-Care™)

The new chemomechanical caries removal gel (Carie-Care™) was applied to the cavitated carious lesion and allowed to work for 60 s. When the gel was cloudy, the gel and softened carious dentine was removed gently by scraping with normal spoon excavator without applying pressure. Second application of the gel was performed in cases where caries was hard. The gel was then removed and the cavity was wiped with a moistened cotton pellet and rinsed with water. The cavities were examined for complete caries removal using the criteria given by Ericson et al.[8] in 1999 that is “visual inspection and tactile sensation criteria” with the help of mouth mirror and explorer. The caries was assessed as completely removed, when the explorer tip passed smoothly over the dentin surface and did not give tug back sensation [Figure 1], [Figure 2], [Figure 3].
Figure 1: Application of the Carie-Care gel in the maxillary left primary canine (test group)

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Figure 2: Caries excavation using spoon excavator after the gel application

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Figure 3: Photograph of the same tooth after complete caries removal

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Control group (Group B): Caries removal using the conventional drilling method

In this group, caries was removed using a high-speed handpiece under water spray with carbide bur without giving local anesthesia. For assessment of complete caries removal and pain reaction, the same criteria used for the test group was followed [Figure 4].
Figure 4: Removal of caries using dental bur (control group)

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Assessment parameters

The total time taken for complete caries removal using both techniques was recorded in minutes using a stopwatch. For assessment of pain reaction in each patient during caries removal using both methods, a sound (S), eye (E), and motor (M) scale given by Wright et al.[10] in 1991 was employed [Table 1]. SEM scale is an objective method of pain assessment (patient's comfort level) where measurement of comfort is recorded based on three types of observations exhibited by a patient like sound, eye and motor. The type of response obtained for each observation was given a numerical value (score) like Score 1 (comfort), Score 2 (mild discomfort), Score 3 (moderately painful), and Score 4 (painful) as given in [Table 1]. The data obtained was tabulated and subjected to statistical analysis.
Table 1: Sound Eye Motor (SEM) scale scores proposed by Wright et al. (1999)

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  Results Top


The present study included children with age ranging from 5 to 7 years. Of total 60 patients, there were 32 boys (53%) and 28 girls (47%).

When total time taken for complete caries removal was estimated between the two study groups, the mean time taken for caries removal in Group A was 3.24 ± 0.74 s (range = 0.53–4.40) and in Group B, it was 2.08 ± 0.24 s (range = 1.55–2.56) which found statistically significant when analyzed using the unpaired t-test (P < 0.001) [Table 2] and [Figure 5].
Table 2: Mean time taken for complete caries removal between test and control group

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Figure 5: Graphical representation of total working time between two groups

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Assessment of pain level (comfort of patient) using SEM scale between two study groups showed that in test group, 83.3% of cases demonstrated comfort (Score 1), 16.7% of cases demonstrated mild discomfort (Score 2), and none of the cases showed either moderately painful (Score 3) or painful (Score 4) observation during caries excavation procedure. Whereas in control group, only 3.3% of cases demonstrated comfort level (Score 1), 56.7% of cases showed mild discomfort (Score 2), while 30% of cases exhibited moderately painful (Score 3) observation and remaining 10% of cases complained of painful sensation (Score 4). This finding was also found to be statistically highly significant when analyzed using unpaired t-test (P < 0.001) [Table 3] and [Figure 6].
Table 3: SEM score (pain assessment) between two groups

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Figure 6: Pain assessment scores between two methods of caries removal

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  Discussion Top


In the current scenario, different treatment modalities have been introduced for the removal of carious tissue while maintaining the maximal preservation of the healthy dental structure. The development of caries removal techniques in pediatric dentistry is aiming toward a more biological and conservative direction.[2] The chemical-mechanical method of caries removal became a new arena in dental research field due its concept of tissue preservation. As only infected dentin is removed, the painful removal of sound dentin is avoided. Hence, a painless technique is one of the keys to avoid dentally fearful and uncooperative children, and a skill every pediatric dentist should strive to master.[1],[2]

The recent production of chemomechanical caries removal gel “Carie-Care™” has been developed recently in India to overcome the clinical limitations of other chemomechanical caries removal agents.[11] Therefore, this present study was undertaken to evaluate the effectiveness of this new agent in removing caries from carious primary teeth with only dentin involvement.

The product Carie-Care™ is a gel, based on papaya extract which is rich in papain, a proteolytic cysteine enzyme which presents antibacterial and anti-inflammatory properties. Papain in papaya extract acts as a debris-removing agent, with no harmful effect on sound dental tissues because of the enzyme specificity.[11] It acts only on affected tissues, which lack the alpha 1 antitrypsin plasmatic anti-protease that inhibits proteolysis in healthy tissues. In addition to papain, the chloramines present in the product have the potential of dissolving carious dentin by means of chlorination of the partially degraded collagen. Thus, chloramine helps to soften the carious dentin, thus facilitating its removal. This mechanism affects the collagen structure, dissolving hydrogen bonds and thus facilitating tissue removal.[11] In addition, the preparation contains specific percentage of clove oil, which has anti-inflammatory, analgesic and mild anesthetic effect. Carie-Care™ also contains explicit gelling agent in accurate percentage to give exact consistency to the gel so that during application there is no spill over.[11] It was also noticed that the color and taste of the gel was well appreciated by the patients during the study. It does not contain sodium hypochlorite, so there is no chance of irritation even if the gel comes in contact with the adjacent soft tissues. Hence, this agent can be used for caries removal in proximal lesions also. In addition to these, it is more cost-effective, as compared to other agents, and does not require any specialized equipment or special training during application.[11]

The estimation of total working time taken for completion of caries removal using Carie-Care™ system showed longer as compared to conventional method of caries excavation. This may be because use of Carie-Care™ was performed in carious lesions which were soft, medium, and hard consistency.[5],[9] Hard carious lesions required more than one or two application of gel to decompose the infected dentin. The color of the gel is an indicator of complete caries removal. The darkish color of the gel indicates that the decomposition of the decayed tissue is still in process.[1] As a result reapplication of the gel is required until the gel appears clear and reaches an unchanged light color indicating that the infected carious dentin was completely removed.[9] Therefore, the results indicated that hard carious lesions took additional time and significantly increased the total working time needed for the complete caries removal using the Carie-Care™ gel to 3.24 ± 0.74 s. This finding appeared similar to the results of Jawa et al.[12] and Venkataraghavan et al.,[11] but opposite to the observations of Kotb et al.[1] who used Papacarie for evaluation with the traditional method. However, the increased total working time in test group did not influence the patient behavior during the study.

As compared to adults, it is difficult to assess and measure pain in young children. Therefore, SEM scale which is an objective method of pain assessment was used to measure sound, eye and motor aspects of the child's response to pain stimulation. The children who treated with Carie-Care™ gel experienced significantly more comfort, and no patient showed either moderately painful or painful observation during the study compared to the patient in which the carious lesions were removed using the dental drill. This observation might be due to the absence of sound, vibrations, and pain associated with the drilling procedure and cavity preparation. The same assumption is suggested by the findings of Locker et al.,[4] Bedi et al.[3] Venkataraghavan et al.[11] and Kotb et al.[1] who stated that the dental drill is the stressful factor in inducing pain not only in children but also in adolescents and elderly patients.

Based on the results of this study, it was found that Carie-Care™ gel was efficient in removing caries completely from open cavitated lesions. This finding is in accordance with results of Silva et al.,[13],[14] Kotb et al.,[1] Bussadori et al.[9] and Culquicondor [15] who used Papacarie in their study and to the study carried out by Venkataraghavan et al.[11] who used the Carie-Care gel. Kotb et al.[1] also assessed the need for local anesthesia in comparing the Papacarie with conventional method of caries removal and reported that Papacarie system significantly reduced the need of local anesthesia.

Assessment of complete caries removal using both techniques was evaluated using the most widely used visual and tactile sensation criteria given by Ericson et al.[8] in 1999. The explorer passed smoothly over the remaining sound dentin surface, and there was the absence of catch and tug-back sensation in all treated teeth. The color of the chemomechanical caries removal gel is another clinical indicator of caries removal assessment, as the absence of turbidity indicates presence of sound dentin or complete caries removal.[1],[9]

Compared to conventional method of caries removal using burs, a number of scientific studies have documented that carious dentin removal with Papacarie caused no painful sensitivity in most cases. The present study as well as Venkataraghavan et al.,[11] study found the similar result using the Carie-Care™, a new chemomechanical caries removal gel introduced recently in India when used on primary teeth with carious lesions in the dentin. During the treatment, no high-speed rotary devices were employed except to finish the enamel margins in some cases but not to remove the carious lesion. None of the patients required the use of local anesthesia or reported discomfort during caries removal using Carie-Care™. Carie-Care™ has conservative properties thereby reduce the risk of pulp exposure which is highly important in primary teeth as pulpal treatment necessitates use of local anesthesia and dental drill which in turn induces anxiety in children.[8] Therefore, the chemical-mechanical method of caries removal using Carie-Care™ significantly minimized patient anxiety and discomfort, thereby showing promising satisfactory acceptance in pediatric practice.


  Conclusion Top


Carie-Care™, a new chemomechanical caries removal gel could be an effective caries removal method for the treatment of patients seeking an alternative to conventional methods. Removal of carious tissue in primary teeth using this gel proved to be comfortable, inexpensive and showed promising results. However, further studies are highly recommended to obtain more clinical evidence for regular use of this material in clinical practice.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Kotb RM, Abdella AA, El Kateb MA, Ahmed AM. Clinical evaluation of Papacarie in primary teeth. J Clin Pediatr Dent 2009;34:117-23.  Back to cited text no. 1
    
2.
Ten Berge M, Veerkamp JS, Hoogstraten J, Prins PJ. Behavioural and emotional problems in children referred to a centre for special dental care. Community Dent Oral Epidemiol 1999;27:181-6.  Back to cited text no. 2
    
3.
Bedi R, Sutcliffe P, Donnan PT, McConnachie J. The prevalence of dental anxiety in a group of 13- and 14-year-old Scottish children. Int J Paediatr Dent 1992;2:17-24.  Back to cited text no. 3
    
4.
Locker D, Shapiro D, Liddell A. Negative dental experiences and their relationship to dental anxiety. Community Dent Health 1996;13:86-92.  Back to cited text no. 4
    
5.
Habib CM, Kronman J, Goldman M. A chemical evaluation of collagen and hydroxyproline after treatment with GK-101 (N-Chloroglycine). Pharmacol Ther Dent 1975;2:209-15.  Back to cited text no. 5
    
6.
Schutzbank SG, Galaini J, Kronman JH, Goldman M, Clark RE. A comparative in vitro study of GK-101 and GK-101E in caries removal. J Dent Res 1978;57:861-4.  Back to cited text no. 6
    
7.
Beeley JA, Yip HK, Stevenson AG. Chemochemical caries removal: a review of the techniques and latest developments. Br Dent J 2000;188:427-30.  Back to cited text no. 7
    
8.
Ericson D, Zimmerman M, Raber H, Götrick B, Bornstein R, Thorell J. Clinical evaluation of efficacy and safety of a new method for chemo-mechanical removal of caries. A multi-centre study. Caries Res 1999;33:171-7.  Back to cited text no. 8
    
9.
Bussadori SK, Castro LC, Galvão AC. Papain gel: a new chemo-mechanical caries removal agent. J Clin Pediatr Dent 2005;30:115-9.  Back to cited text no. 9
    
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Wright GZ, Weinberger SJ, Marti R, Plotzke O. The effectiveness of infiltration anesthesia in the mandibular primary molar region. Pediatr Dent 1991;13:278-83.  Back to cited text no. 10
    
11.
Venkataraghavan K, Kush A, Lakshminarayana C, Diwakar L, Ravikumar P, Patil S, et al. Chemomechanical caries removal: A review & study of an indigen-ously developed agent (Carie Care Gel) in children. J Int Oral Health 2013;5:84-90.  Back to cited text no. 11
    
12.
Jawa D, Singh S, Somani R, Jaidka S, Sirkar K, Jaidka R. Comparative evaluation of the efficacy of chemomechanical caries removal agent (Papacarie) and conventional method of caries removal: an in vitro study. J Indian Soc Pedod Prev Dent 2010;28:73-7.  Back to cited text no. 12
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Silva LR, Murillo JH, Santos EM, Guedes-Pinto AC, Bussadori SK. Utilizacion del gel de la papaya para la remocion de la caries – Reporte de un caso con seguimiento clinic de un ano. Acta Odontol Venez 2005;43:155-8.  Back to cited text no. 13
    
14.
Silva LR, Motta LJ, Red SH, Facanha RA, Bussadori SK. Papacarie – A new system for de chemo-mechanical caries removal. Case report. Rev Paul Odontol 2004;26:4-8.  Back to cited text no. 14
    
15.
Culquicondor EA. Tratamiento ultraconservador y minimamente invasive de la caries dental; 2006. Available from: http://www.ecuaodontologos.com/revistaaorybg/vol4num3/tratamiento.htm1. [Last accessed on 2011 Dec 02].  Back to cited text no. 15
    


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