Review article AODMR. Chemomechanical Caries Removal: Pain free technique ABSTRACT:

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1 Review article AODMR Chemomechanical Caries Removal: Pain free technique Yogesh Garg, D.J. Bhaskar, Himanshu Punia, Kamal Garg 1, Sagorika 2, Antima Saxena 3 Department of Public Health Dentistry, Teerthanker Mahaveer Dental College and Research Centre, Moradabad, Uttar Pradesh, India, 1 Department of Periodontics, Surendra Dental College, Sri Gangnagar, Rajasthan, India, 2 Department of Pedodontics and Preventive Dentistry, Teerthanker Mahaveer Dental College and Research Centre, Moradabad, Uttar Pradesh, India, 3 Department of Public Health Dentistry, Rama Dental College and Hospital, Kanpur, Uttar Pradesh, India Address for Correspondence: Dr. Yogesh Garg, Post graduate student, Department of Public Health Dentistry, Teerthanker Mahaveer Dental College and Research Centre, Moradabad, Uttar Pradesh, India. yogeshgarg1988@gmail.com ABSTRACT: Dental caries is considered as one of the most serious dental diseases that results in localized dissolution and destruction of the calcified tooth structures. Chemo mechanical caries removal systems have been introduced over the conventional techniques of caries removal as one of the possible alternative.the use of minimal invasive dentistry and attention to patient comfort is of utmost importance especially for the school children and anxious and uncooperative patients.chemo mechanical caries removal (CMCR) involvesthe chemical softening of the carious dentine, accompany by its removal with gentle excavation. Only the infected part of dental structures has been removed under this process, thus, minimizing pulpal irritation and patient discomfort. Children, dental phobic's and medically compromised patients has shown high acceptance to the Chemo mechanical caries removal system.the introduction of Carisolv focused again interest on thechemomechanical caries removal. The superiority maintainedfor the Carisolv technique are of effective & painless removal of caries lesions without affecting sound parts of the tooth and periodontal tissues. Thus CMCR is an effective alternate method for caries removal; it is more conservative and appears to be more comfortable for the patients. Keywords: Chemomechanical Caries Removal (CMCR), Carisolv, Papacarie, Infected Dentine, Dental Caries INTRODUCTION: Dental caries is considered as one of the most serious dental diseases that results in localized dissolution and destruction of the calcified tooth tissues. Caries eliminate in decayed teeth has conventionally been performed using the mechanical cutting and drilling system. However, these methods have some major limitation. First, mechanical preparation often causes pain, and local anaesthesia is used for pain management. Second, it is difficult to create how much tooth material should be removed, which often leads to overextended cavities. As possible 33

2 alternatives to conventional techniques, chemo mechanical caries removal systems have emerged. It was introduced to dentistry as an alternative method of caries removal and is mainly indicated to overcome the inconvenience of using burs and local anesthesia, hence causing less discomfort to patients and preserving healthy tooth structure, there by following the concept of the minimal invasive dentistry (MID). 1 The best way to ensure a maximum life for the natural tooth is to respect the sound tissue and protect it from damage by using minimally-invasive techniques in restorative dentistry. G.V. Black s Extension for prevention to Construction with conservation has been developed with the advancement of new dental restorative material in dentistry for management of dental caries. The tooth s potential for remineralization should be considered for a better understanding of the caries process. This idea involves the early detection of lesions, individual caries risk assessment, non-surgical interventions and modified surgical approach that involves minimaltooth preparations with altered cavity designs and adhesive dental materials and repair rather than replacement of failing restorations. The goal is to preserve the natural tooth structure. Minimally invasive dentistry adopts a philosophy that combines prevention, remineralization and minimal intervention for the placement and replacement of restorations. 2 The rotary instruments are used in the traditional caries removal, which often causes pain and is unpleasant to many patients and needs anaesthetics. In some cases, like allergy, anxiety or other diseases the usage of anaesthetics can be restricted. The usual tooth treatment can be 34 problematic in children dentistry because children are more sensitive to pain than adults. 3 Painless dentistry and minimal intervention providing support, relaxation, act of consoling and instillation of positive attitude towards dental treatments are some of the factors justifying the specialty of pediatric dentistry. Especially in children, with dental anxiety, caries removal by means of conventional instruments is considered an unpleasant step of the restorative process mainly because of pain, drilling and noise. Furthermore, drilling results in rapid and excessive removal of tooth structure and may cause harmful thermal and pressure effects to the pulp. These disadvantages of conventional method had led to a more gentle, pleasantand conservative caries excavation method aimed at providing minimal thermal changes of the pulp, minimal vibration and minimal pain, and elimination of infected dentine only. 4 A new method based on chemicals to remove carious lesion has been launched, Chemo-mechanical Caries Removal method (CMCR). This procedure has gained importance due to the selective removal of carious dentine and avoidance of painful and unnecessary removal of sound dentine. Restoration of cavities prepared by such technique requires materials that bond to the dentine surface such as composite resins or glass ionomer, rather than materials which requires the preparation of cavity designed to mechanically retain the restoration such as amalgam. 5 Chemomechanical caries removal (CMCR) method is a non-invasive technique which eliminates infected dental tissues, preserving healthy structures,

3 avoiding pulp irritation and patient discomfort. 6 In 1998, Mediteam in Sweden introduced carisolv TM which removes caries selectively by reacting with denatured collagen thereby making carious dentin soft. In Brazil, in 2003Papacarie, another chemomechnical caries removal (CMCR) reagent (Formula e Aeao, Sao Paulo, Brazil) was introduced. 7 Caridex was later developed from a formula made of N-monochloroglycine and amino butyric acid. Caridex disrupted the carious dentin collagen making it easier to remove. Despite its effectiveness, Caridex had certain clinical limitations, among them, (i) it was costly, (ii) a large reservoir was required with pump, (iii) large quantities of solution was also required, (iv) it presented various troubles during heating, and (v) it had a short shelf life. In 2003, a research project in Brazil led to the development of a new formula to universalize the use of chemo-mechanical method for caries removal and promote its use in community health. The new formula was comprised of papain, chloramines, toluidine blue, salts, thickening vehicle, which together are responsible for the Papacarie s bacteriostatic, bactericide and anti-inflammatory characteristics and they commercially known as Papacarie. 8 In chemomechanical caries removal system, the latest product available is Carisolv (MediTeam Dental AB, Gothenburg, Sweden). It comprises of three natural amino acids (leucine, lysine, and glutamic acid) and sodium hypochlorite (NaOCl). When amino acids are added to NaOCl, its proteolytic action is aimed more specifically at denatured proteins carious dentine so that sound and carious dentine become readily separable. 35 During treatment, various reactions occurs in concert to disrupt the fiber structure of collagen and have a softening effect on the carious tissue. Due to the attack of the solution solely on denatured collagen fibers, the chemomechanical method affects neither sound dentine nor healthy or carious enamel. Specific hand instruments are designed to remove softened carious dentine without damaging the healthy dentine. 9 Minimally invasive dentistry is based on the principle of prevention, remineralisation and minimal intervention for the placement and replacement of the restoration.the superiority of minimally invasive dentistry are less patient discomfort especially in paediatric, anxious and medically compromised patients, non-invasive reduces the use of conventional drilling and local anaesthesia, preservation of healthy dental structure. Various minimally invasive dentistry procedures are Air Abrasion, Atraumatic Restorative Technique, Sono Abrasion, LASER and Chemo Mechanical Caries Removal(CMCR). 10 Carie Care TM, is a natural product developed by extensive research at Vittal Mallya Scientific Research Foundation, a Ministry of Science and Technology, Govt of India approved Research Centre. The research involving biotechnology, natural products chemistry and cell biology was followed by lots of scientific and clinical validation for its efficacy and safety by various in house and external accredited agencies including multiple dental colleges. Eco works India Pvt Ltd; Bangalore has launched the product with an aim to make it available to the large population at very reasonable price using efficient supply chain. This product is a gel based on the papaya extract, a mixture of

4 endo-protein with required therapeutic oils. This active ingre dient has proteolytic action that would soften the pre degraded collagen of the lesion without pain or undesirable effects to adjacent healthy tissues with the antiseptic and antiinflammatory properties of the essential therapeutic oils. 11 HISTORY The earliest attempts to remove caries involved the use of a hand drill which was soon surpassed in 1871 by James Morrison s treadle instrument, developed from the mechanism of Isaac Singer s sewing machine. Moder hand pieces with high speed are the latest development of this more than a century old technique. Conventional caries removal and cavity preparation entail the use of the burs. Limitations of this system involve: (1) The experience of patient is unpleasant. (2) Local anesthesia is considered. (3) The use of pressure for caries removal causes destructive thermal effect to the Pulp during cutting of tooth. (4) The use of a hand piece may result in eliminate of softened, but affected dentine, resulting in an uncontrolled loss of sound tooth tissue. Dentine contains of mineral (70%), water (10%) and an organic matrix (20%). In this organic matrix, 18% are collagen while 2% are non-collagenous compounds including chondroitin sulphate, phosphophoryns and other proteoglycans. Collagen is an unusual protein which contains large amounts of proline and one third of the amino acid content is glycine. The polypeptide chains are coiled into triple helices which are known as tropocollagen units. Side by side orientation of tropocollagen units to form a 36 fibril. Covalent bonds between the polypeptide chains and the tropocollagen units form cross links and give the collagen fibrils stability. In dentine, the fibrils are in the form of a dense meshwork which becomes mineralized. When caries occurs, acids produced by plaque bacteria; by anaerobic fermentation of carbohydrate initially cause solubilisation of the mineral in enamel. As this proceeds, 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 demineralization. The collagen and other matrix components are susceptible to enzymatic deterioration, commonly by bacterial proteases and other hydrolases, when the organic matrix has been demineralized Therefore, collagen degradation, two zones can usually be distinguished within a lesion. There is an inner layer which is slightly demineralized and can be re-mineralized and in which the collagen fibrils are still intact, known as affected dentine, and there is an outer layer where the collagen fibrils are partially degraded and cannot be remineralized, known as infected dentine. 2 DEVELOPMENT OF CMCR AGENTS The first used chemo mechanical caries removalagent was Sodium hypochlorite, which is a non-specific proteolytic agent, which effectively eliminatesorganic components at room temperature. Habib CM, J Goldman and M Kronman studied the effects of sodium hypochlorite as a chemo mechanical caries removal agent by keeping a carious tooth in 5% sodium hypochlorite with the result that all carious tissue was eliminated. However, it proved to be irregular and aggressive on healthy tissue. It was used with the solution of

5 Sorensen s buffer, which consists of sodium hydroxide, sodium chloride and Glycine in an attempt to minimize the problem. This first formula, called GK101 consisted of N-MONOCHLORO GLYCINE (NMG), which proved to be more effective than sodium hypo chlorite alone.gk 101 turned out to act slowly and additional efforts to speed up the procedure resulted in evolution of GK101E. Glycine wasreplaced by amino butyric acid in this system and the product was named as N-monochloroaminobutyric acid (NMAB),designated as GK101E. 12 EVOLUTION OF CARIDEX The NMAB system was patented in the US in 1975, and further patented by National Patent Dental Corporation, New York in It accepted FDA approval for use in USA in 1984, and was promoted in 1980 s as Caridex. GK 101 turned out to act slowly and additional efforts to speed up the procedure resulted in GK 101E. In 1984, a caries removal system called Caridex gained FDA approvalwhich was based on GK 101E. Research was carried out documenting clinical efficacy and safety. It consists of two solutions which were mixed instantly before use, and was stable for only one hour. A delivery system contained a reservoir for the solution, a heater and a pump which passed the liquid warmed to body temperature through a tube to a handpiece and an applicator tip available in various shapes and sizes. Both the solutions in Caridex required instant mixing followed by warming in the heater to the body temperature and pump used to pass to the hand piece. 37 EVENTUALLY SHORTCOMING WITH CARIDEX BECAME APPARENT: 1. Efficacy and speed of caries removal needed improvement. 2. It was expensive. 3. Large quantities were required for intermittent use during excavation. 4. The solution had to be heated. 5. A large reservoir with pump was needed for application and the product was delivered in large containers. 6. The shelf-life of an opened container was short. 7. The hand instruments were not optimal. 8. The product was launched in an era when new dentine bonding agents were not considered reliable, instead mechanical undercuts created by drilling were needed for retention. 5 CHEMOMECHANICAL CARIES REMOVAL TECHNIQUE Chemomechanical caries removal is a technique of eliminating infected dentin via a chemical agent. This method of treatment has high acceptance especially among children and patients with dental anxiety. The elimination of local anesthesia and bur, less perception of pain, no pulpal irritation and more comfort for patient are the advantages offered by the chemo-mechanical method, hence, lowers the anxiety and eliminates only infected layer of dentin and leads to the conservation of the sound tissue which is useful in patients with infectious diseases like Tuberculosis, Herpes. It is advisable in very deep carious lesions (potential pulp exposure may be decreased), Cervical, buccal or root caries. But it is contraindicated in pit and fissure caries that are not deep where rotary preparation is needed suffice to remove caries. Several

6 chemo mechanical methods for dental caries removal have been developed, beginning with the use of 5% Sodium hypochlorite (NaOCl), which was shown to be an easily way to remove carious lesions. The solution was called GK-101 or n-monochloroglycine composed of: sodium hydroxide (NaOH), sodium chloride (NaCl), glycine, and 0.05% of NaOCl was efficient at removing carious lesions and further modified by the addition of an ethyl group renamed GK- 101E or N-monochloro-D,L-2- aminobutyrate, which was shown to be more efficient. By using the same technique used for GK-101 brand name Caridex was given. In 2003, a research project in Brazil by Sandra Kalil Bassadori et al led to the development of Papacarie (a word that means eating caries ).The gel is applied to the contaminated dentin and its proteolytic, chlorinating, and oxidating properties act on the affected collagen, without acting on the sound dentin. 10 MECHANISM OF ACTION OF CMCR AGENTS AND CARIE CARE ON THE AFFECTED TISSUE When the organic matrix of the enamel and dentine has been demineralised, the collagen and other matrix components are then susceptible to enzymatic degradation, mainly by bacterial proteases and other hydrolases. Therefore, deterioration of collagen, two histopathological zones can be distinguished within a dentinal lesion. 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 (peripheral caries-infected zone (close to the enamel-dentine junction [EDJ]) where 38 the collagen fibrils are partially degraded and cannot be remineralised. A CMCR reagent must be able to cause further degradation of this partially deteriorated collagen, by cleavage of the polypeptide chains in the triple helix and/or hydrolysing the cross linkages. The polypeptide hydrolysis is brought about by endopeptidases extracted and purified to homogeneity from papaya extract. In addition to the papaya extract, therapeutic oils present in the formulation exhibits natural analgesic and antiseptic action. It decreases sensitivity and pain sensation while application thus ensuring a soothing effect and has a pleasant taste acceptable by the patient. 11 IMPORTANCE OF CHEMO- MECHANICAL CARIES REMOVAL AGENTS IN PEDIATRIC DENTISTRY Fear and anxiety are known barriers to the receptivity of dental treatment and in detriment to oral health. Especially among children, the conventional drilling techniques are associated with discomfort. Usually, the triggering factors are local anesthesia, low and high speed rotary instruments, and previous dental treatment. In children, it is tough to change between fear and anxiety-originated behaviour problems. The most anxiety-provoking procedure for children, however, is the local anesthetic injection. Thus, changes in dentistry routines such as the chemomechanical caries removal, nitrous oxide sedation, and general anesthesia are required. The chemomechanical caries removal technique was developed specifically to overcome these barriers and to preserve the healthy dentine tissue. This method is characterized by the use of a material that acts on the pre-degraded

7 collagen of the lesion, promotes its softening, doesn t affect the adjacent healthy tissues, and avoids pain stimuli (chemical action). This technique is recognized by removing the softened carious tissue via gentle excavation, which makes this technique an effective alternative method to treat carious lesions since it allies no traumatic characteristics with bactericide and bacteriostatic action. 2 TECHNIQUE OF USING CARISOLV 1 The syringes are held with their orifice upwards. Separate the caps, keep the syringes upright and screw them together. Mix the liquid till the liquid become homogenous and apply it to the cavity. 2. Drilling, when the cavity needs to be cut for adjustment of cavity margins and when there are large amounts of caries and the risk to affect healthy tissue is minimal. 3. A drop of the gel is removed with an instrument and applied to the carious dentine. 4. Let the chemistry work for at least 30 seconds. 5. Scrape the superficial softened carious dentine with hand instrument. Then continue to scraping or rotating movements. The gel should not intendedin direct contact with the pulp tissues. 6. Remove the softened carious dentine with the instrument and avoid drying of the cavity. 7. Gradually add new gel and continue scraping. Repeat the procedure till the gel is no longer cloudy and the surface feels hard. 8. If the cavity feels free from caries, eliminate the gel and clean the cavity with the moistened cotton pellet and check it with a sharp probe. 9. If the caries are not fully removed from the cavity, then, apply new gel and continue the process. 10. Adjust the periphery of the cavity with a hand instrument or a drill. Restore the tooth with a suitable filling material. 11. Once the gel is mixed, its effect will begin to decline after about 30 minutes. Any gel that is left over should be destroyed. 13 ADVANTAGES OF CARISOLV Atraumatic technique. Non-invasive caries removal. No need for local analgesia in 80% of cases. No need for cutting in 80% of cases; when the lesion is accessible. Resin bonding at least the same as after drilling. Reduced postoperative pain. 14 LIMITATIONS OF CARIDEX SYSTEM (1) Rotary and/or hand instruments may still be needed for the removal of tissue or material other than degraded dentinal collagen. This involves approach to small or interproximal carious lesions, removal of existing restorations, elimination of enamel overlying the caries and cavity design when non-adhesives restorative materials are used. (2) Large volumes of solution were needed (200 to 500 ml) and the procedure was slow and also costly. (3) Only cavity preparations were ideal for treatment by the technique and because of the time involved (10 to 15 min) and limited use, its popularity waned. (4) Although there were studies on the efficacy of caries removal by the method, studies on the long term success of cavities 39

8 restored after CMCR treatment were lacking. 2 HAND INSTRUMENTS FOR CARIES REMOVAL Special hand instruments are available for use with carisolv gel. These instruments are available with permanent or interchangeable tips designed to access different types of lesions. Most of these instruments have a sharp edge and blunt cutting angles, followed in a large area of support opposing the underlying surface coupled with controlled and effective cutting depth. Other drills may favour to cut less precisely due to their aggressive cutting angle and smaller support area. 12 PAPACARIE Though carisolv is the most successful agent, it has its own share of disadvantage which includes extensive training and customized instrument which increases the cost of the solution. Due to this, there was a limited use. To control these limitations of carisolv system, a new reagent was developed in Brazil. In Brazil 2003, papain gel as papacarie for chemomechanical caries removal agent, Formula eacao by Sao Paulo, was introduced. Papacarie is a national product; patented, registered and approved by ANVISA in Brazil. Its main ingredients are papain, chloramine and toluidine blue. PAPAIN (1) Papain is an enzyme obtained from the latex of leaves and fruits of the adult green papaya, Carica papaya. (2) It is an endoprotein alike as human pepsin which has a bacteriocidal, bacteriostatic and antinflammatory activity, and debriding agent. (3) It does not damage healthy tissue, but accelerates the cicatricial process and has bacteriostatic and bactericidal action. (4) Acts by cleaving collagen molecules slightly destroyed by the action of caries, and is able to digest dead cells and eliminating the fibrin coat formed by the caries process. (5) Acts only on carious tissue which lacks the plasmatic protease inhibitor alpha-1- antitrypsin, but its proteolytic action is inhibited on healthy tissue, which contains this substance. CHLORAMINE (1) A compound comprised by chlorine and ammonia has bactericidal and disinfectant properties. (2) It is used as a canal irrigant of radicular canals for softening the carious dentine chemically. (3) The decayed portion of the carious dentine collagen is chlorated by the chloramine and is easily removed with excavator. TOLUIDINE BLUE (1) Originally, the malachite green was used as colouring agent, however, after a few studies toluidine blue was found highly effective against Streptococcus mutans. (2) It is a photosensitive pigment that gets fixed into the bacterial membrane. ADVANTAGES OF PAPAIN GEL (1) Papacarie is a biocompatible gel with antibacterial properties that eliminates the need for anesthesia, removes only the compromised tissue, and preserves the healthy tissue better. (2) The formation of a smear layer is not noticed after using the gel. 40

9 (3) The gel combines an atraumatic treatment with antibacterial properties without affecting healthy tissue and causing pain. 2 CONCLUSION Wherever possible, tissue should be preserved; invasive treatment should be kept to a minimum and natural tissue should be replaced with artificial substitutes only when it is mandatory. The best way to ensure maximum life for the natural tooth is to respect the sound tissue and protect it from damage by using minimally invasive techniques in restorative dentistry. Chemo-mechanical caries removal agent has been proved to be an efficient method of caries removal. It can be successfully employed to treat medically compromised, bed-ridden patients and in school dental camps. The new system provide significant feature for the clinician to opt it as a routine practice for the painless and non-invasive ap proach thus ensuring a positive patient dentist relationship. REFERENCES 1. Hegde AM, Preethi VC, Shetty A, Shetty S. Clinical evaluation of chemomechanical caries Removal using cariecare system among school Children. NUJHS 2014;4(3): Ganesh M and Parikh D. Chemomechanical caries removal (CMCR) agents: Review and clinical application in primary teeth. Journal of Dentistry and Oral Hygiene. 2011;3(3): Balčiunienė I, Sabalaitė R, Juškienė I. Chemomechanical Caries Removal for Children. Stomatologija, Baltic Dental and Maxillofacial Journal 2005;7(2): Singh S, Singh DJ, Jaidka S, Somani R. Comparative clinical evaluation of 41 chemomechanical caries removal agent Papacarie with conventional method among rural population in India - in vivo study. Braz J Oral Sci 2011;10(3): Kathuria V, Ankola AV, Hebbal M, Mocherla M. Carisolv- An Innovative Method of Caries Removal. Journal of Clinical and Diagnostic Research. 2013;7(12): Anegundi RT, Patil SB, Tegginmani V, Shetty SD. A Comparative Microbiologic Study to assess the caries excavation by conventional rotary method and chemomechanical method. Contemporary Clinical Dentistry. 2012;3(4): Bohari MR, Chunawalla YK, Ahmed BMN. Clinical Evaluation of Caries Removal in Primary Teeth using Conventional,Chemomechanical and Laser Technique: An in Vivo Study. The Journal of Contemporary Dental Practice. 2012; 13(1): Bussadori SK, Castro LC, Galvão AC. Papain Gel: A New Chemo-Mechanical Caries Removal Agent. The Journal of Clinical Pediatric Dentistry 2005;30(2): Peric T, Markovic D, Petrovic B. Clinical evaluation of a chemomechanical method for caries removal in children and adolescents. Acta Odontologica Scandinavica 2009;67: Kumar RP. A Natural Chemomechanical Caries Removal Agent- Papacarie. Int J Pharm Bio Sci 2014;5(4): Thakur R, Patil SS, Kush A. Chemo- Mechanical Caries Removal Technology Dentistry at Ease. 12. Pratap Kumar M, Nandakumar K, Sambashivarao P, Sandhya PS. Chemo Mechanical Caries Removal - A New Horizon. Indian J Dent Adv 2011;3(4):

10 13. Madan N, Gandhi A. Conservative Approach to Caries Excavation - A Chemo Mechanical Method. 14. Qasem A. Chemomechanical Caries Removal. Dental News 2004;11(4): How to cite this article: Garg Y, Bhaskar DJ, Punia H, Garg K, Sagorika, Saxena A. Chemomechanical Caries Removal: Pain free technique. Arch of Dent and Med Res 2015;1(2):