Chemo-mechanical Caries removal technology Dentistry at ease

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1 Chemo-mechanical Caries removal technology Dentistry at ease Dr.Rachna Thakur, Dr.Sandya S Patil, Dr. Anil Kush Abstract In the present day of Dental Care, Caries mount a great challenge both in terms of its frequency and technologies available for their safe removal. The conventional way of using bur/ drill creates another barrier between the Patient and Doctor often resulting in avoidance of visit to a dental doctor. The transformation from the traditional concept of extension for prevention to minimal invasive dentistry has given various rationales to manage the dental caries. Providing emphasis on preserving the tooth structure along with a Key words: Chemomechanical caries removal, dentinal caries, conventional drilling. suitable patient-dentist team-care approach to maintaining oral health, the chemomecahnical caries removal (CMCR) technology stands out among the other available options. CMCR is a minimally-invasive, gentle dentine caries removal based on biological principles. With the range of products available under CMCR, the latest added to this group is Carie Care, a natural endoprotein based formulation containing papaya extract. This paper presents the literature review, limitations of other CMCR agents with the case report on clinical application of the same. Introduction Dental caries is the most common chronic disease, being at least five times more common than asthma. It afflicts at least 90% of the world s population at some time in their lives. It is the primary cause of tooth loss in children, while between a third and two thirds of people over 50 years experience caries too1. Due to lack of awareness of oral health among the Indian population, majority of the population report the dentist with the complaint of sensitivity and pain due to dental caries which require restorative procedures. Also, that people don t go to the dentist regularly is fear. There are several clinical technologies available for cutting teeth and removing caries. The conventional method using the turbine handpiece is synonymous with anxiety for many patients whereas other treatment options are not self-selective for cariesinfected dentine and involve active discriminatory action from the operator when considering minimal invasive operative caries management strategy2. If the patients can be offered with a treatment option that is completely non-invasive, that doesn t involve a mechanical drill, then the dental surgeons can change that perceived link between dental treatment and pain. Recently developed techniques such as laser, chemomechanical excavation and air abrasion have been shown to be more or less successful in overcoming these problems yet; Chemomechanical caries removal system (CMCR) stands out among other alternative methods. Hence the recently developed CMCR system, Carie CareT- Mhas as such much amplified effect on anxious and fearful patients who are much more sensi-

2 tive to pain and trauma of drilling as such. CMCR consists of the dissolution of carious tissue by the application of a natural or synthetic agent, followed by atraumatic mechanical removal3. CMCR was first described by Habib and co-workers in 1975, using 5% sodium hypochlorite4. Subsequent studies have introduced formulas with the same purpose, such as Caridex,Carisolv, Papacarie 4 and Carie CareTM3,5,6,7. Carie Care TM, is a natural product developed by extensive research at VittalMallya 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 PvtLtd; Bangalore has launched the product with an aim to make it available to the large population at very reasonable price using efficient supply chain (Figure - 2). This product is a gel based on the papaya extract, an endo-protein in combination with essential therapeutic oils. This active ingredient 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 anti-inflammatory properties of the essential therapeutic oils8. Figure -2 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 bybacterial proteases and other hydrolases. With respect to collagen degradation, two histopathological zones can usually be distinguished within a dentinal lesion. There is an inner layer (deeper caries-affected zone), 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 the collagen fibrils are partially degraded and cannot be remineralised. A CMCR reagent must be able to cause further degradation of this partially degraded collagen, by cleavage of the polypeptide chains in the triple helix and/or hydrolysing the cross linkages. The Figure -3 polypeptide hydrolysis is brought about by endopeptidases extracted and purified to homogeneity from papaya extract (Figure -3). Figure 3: 3D structure Endopeptidases enzyme isolated from papaya extract. A) Side view show catalytic site where carbonyl carbon of peptide backbone. B) Two of the catalytic triad (Asp-175, His-159 and Cys-25) form the core of the active site is shown. In addition to the papaya extract, therapeutic oils present in the formulation exhibits natural analgesic and antiseptic action. It minimises any sensitivity and pain sensation while application thus ensuring a soothing effect and has a pleasant taste acceptable by the patient10, (Figure 4).

3 Figure 4 : Mechanism of action of Carie Care Indications / Case selection:caries-infected dentine is necrotic, wet, sticky and soft to a sharp dental explorer whereas caries-affected dentine is a little more tacky ( scratchy and sticky ) in nature and blends to the hard, scratchy con sistency of deeper sound dentine. The success of the procedure depends on the question How much dentine caries should be excavated? the answer to this question depends on the following criterias: a) Pulp status:the vitality (sensibility) of the pulp must be assessed from the clinical signs and symptoms and suitable investigations like sensitivity tests. b) Lesion depth:lesion-pulp proximity affects the level of protection afforded to the vital pulp. Indirect pulp protection (capping) con serves caries-affected dentine close to the pulp, minimising the risk of unnecessary pulp exposure c) Extent of viable tooth structure The functional and aesthetic restorability of the tooth must be assessed. A minimal invasive technique conserves more tooth structure that can help retain and support the definitive sealed restoration2. Thus considering all the key points, the ideal indication for the usage of Carie care is any carious lesion extending into the dentine. The cases may vary from the pin point or bottle neck caries into the dentine to the grossly carious lesion in the dentine. It is an established approach for the anxious patients and young paediatric patients. Limitations of other CMCR agents: The challenges the Indian dental doctors faced with respect to imported CMCR products like Carisolv and Papacarie are their astronomical cost, non availability at ease, short shelf life, difficulty in using, special instruments/gadgets and skill set required compounded by often the unpleasant smell of the product8. These challenges seem to be addressed by innovative Carie Care whose availability in all the pockets of India still waited. The initial feedback both from doctors and patients have shown over 90% as satisfying experience both for the product efficacy and patientdoctor acceptability (Table 1) Table 1: Comparison of the three leading products in terms of pain perception, requirement of local anaesthesia as efficiency of removal of caries from. Carisolv Papacarie Carie-care Pain perception Requirement of LA Yes No No Efficiency of caries removal Good Good Good

4 Case Report with the management: A 14 years old male patient with the deep dentinal caries in relation to 36 without any clinical symptom of pain and sensitivity was selected (Figure - 5A). The radiographic evaluation was done to confirm the extent of caries into the dentine with no pulpal involvement. The tooth was isolated using the proper isolation method (Figure - 5B) The caries excavation was done according to manufacturer s instructions. The carious lesion was covered with the gel and left undisturbed for seconds (Figure - 5C). The gel was removed by gently scrapping with the spoon excavator without applying pressure. Removal of the caries was continued until the hard and affected dentine appeared on the tooth. Then gel proper isolation method (Figure - 5B) The caries excavation was done according to manufacturer s instructions. The carious lesion was covered with the gel and left undisturbed for seconds (Figure - 5C). The gel was removed by gently scrapping with the spoon excavator without applying pressure. Removal of the caries was continued until the hard and affected dentine appeared on the tooth. Then gel was removed and the cavity was wiped with the moistened cotton pellet and rinsed (Figure - 5D). Figure 6: Carie Care brings in smile bondage between the patient and Doctor. The fear and trauma of drilling and invasion is eliminated. Inset: Patients with multiple infectious caries; early detection and removal of caries using carie care Dental caries in children continues to affect a significant portion of the world population, especially in developing countries. There are many techniques used for dental caries treatment. The conventional method is to remove caries and prepare the cavity using dental burs. Disadvantages of this method; however, include the patients repulsion of drilling, and possible thermal changes on tooth surface that may have an effect on the dental pulp tissues. In addition, the drilling technique frequently requires local anaesthesia injections and sometimes results in the removal of sound tooth tissues. To overcome these problems and preserve the healthy dental tissues, the chemo-mechanical caries removal method was developed. The advantage by chemomechanical was removed and the cavity was wiped with the moistened cotton pellet and rinsed (Figure - 5D). Case Report with the management: A 14 years old male patient with the deep dentinal caries in relation to 36 without any clinical symptom of pain and sensitivity was selected (Figure - 5A). The radiographic evaluation was done to confirm the extent of caries into the dentine with no pulpal involvement. The tooth was isolated using the of vital for comprehensive dental health. The problem ported by the operator in using CMCR technology is the time consumed for caries excavation. However with time and development of expertise the reverse took place with CMCR being less time consuming than conventional method as reported previously. This is attributed to lack of any specialized equipment and ease of procedure using CMCR products14. caries removal include less traumatic, less need local anaesthesia, reduced chance of dental pulp exposure. And also it could be benefit to medical compromised patients.rotary instruments may still be required however for some cavitiesbut preliminary reports indicate that patient acceptance is very good 15, 16. In a recent clinical trial in India, a total of 64 teeth of 32children with class 1 open carious lesion

5 were selected for the study. They were divided into two equal groups according to method of caries removal (32 chemo-mechanical using CarieCare and 32 conventional drilling from both primary and permanent teeth respectively. After the cavity preparation by either of the two methods, the teeth were restored andwere later followed up after 1 week, 1 month, 6 months and 1 year respectively for its clinical success17. The results showed that the two techniques were comparable in caries removal efficiency and removal of caries by Carie care was pain less, noninvasive, safe and more patient friendly The above study does underlines and supports the previous extensive studies which also showed better efficiency of a new product Carie Care in various patients tested17, 18, 19, 20. Conclusion: Development of a clinically effective CMCR, which is harmless to healthy tissue and bio-compatible has given a conservative clinical approach to the management of the extensive caries. The new system offers considerable attractions for the clinician to opt it as a routine practice for the painless and non-invasive approach thus ensuring a positive patient dentist relationship. Carie Care provides a unique opportunity of pain-less bondage between the patients and dental doctors as such- which could serve as a unique step in dental health in country like India. Dr. Rachna Thakur MDS (Pediatric Dentistry) Private Consultant, B- 605, RNS ShanthiNivas, Next to TajVivanta, Tumkur Road, Yeshwanthpur, Bangalore, India, Dr. Sandya S Patil Scientist and Chief Executive Officer, Vittal Mallya Scientific Research Foundation, BTM II Stage, Bangalore, India Dr. Anil Kush Prof and HOD, Department of Pedodontics and Preventive Dentistry, K.L.E Society s Institute of Dental Sciences, No. 22, Yeshwanthpur suburb, Tumkur Road, Bangalore. References 1. Benjamin RM. Oral Health: The Silent Epidemic. Public Health Reports. 2010;125(2): Banerjee A. Minimal intervention Dentistry: Part 7. Minimallly invasive operative caries management:rationales and techniques. British Dental Journal 2013;214(3): Matsumoto SFB, Motta LJ, Alfaya TA, Guedes CC, Fernandes KPS, Bussadori SK, Assessment of chemomechanical removal of carious lesions using Papacarie Duo : Randomized longitudinal clinical trial. Indian Journal of Dental Research, 24(4), 2013: Habib CM, Kronman J, Goldman M. A chemical evaluation of collagen and hydroxyproline after treatment with GK-101 (N-chloroglycine). PharmacolTher Dent. 1975; 2: Robbins A. Efficacy of GK101E solution (Caridex 100) for caries removal. Gen Dent 1987;35: Ericson D, Zimmerman M, Raber H, Gotrick B, Bornstein R, Thorell J. Clinical evaluation of efficacy and safety of a new method for chemomechanical removal of caries. A multi-centre study. Caries Res1999;33: Venkataraghavan K1, Kush A, Lakshminarayana C, Diwakar L, Ravikumar P, Patil S, KarthikS.Chemomechanical Caries Removal: A Review & Study of an Indigen-ously Developed Agent (Carie Care (TM) Gel) In Children.JInt Oral Health.2013 : Bussadori SK, Castro LC, Galvão AC. Papain gel: a new chemo-mechanical caries removal agent. J ClinPediatr Dent. 2005;30: Beeley JA, Yip HK, and Stevenson AJ.Chemochemical caries removal: a review of the techniques and latest developments British Dental Journal 2000;188(8) : Hosseini M, Kamkar M Asl, Raklshandeh H. Analgesic effect of clove essential oil in mice. Avicenna Journal of Phytomedicine 2011;1(1): Flindt M. Health and safety aspects of working with enzymes. Process Biochem 1979; 13(8): Dawkins G, HewittH,Wint Y, ObiefunaPC,WintB. Antibacterialeffects of Carica Papaya fruit on common wound organisms. West Indian Med J 2003; 52(4): Balciuniene I, Sabalaite R, Juskiene I. Chemo-mechanical caries removal for children. Stomatologija, Baltic Dental and Maxillofacial Journal 2005;7: Konde S, Urs P, Raj S. Efficacy of Papacarie for caries removal: An in vivo study. World Journal of Dentistry 2011;2(3): Corrêa FN, Rocha RO, Rodrigues LE, Filho, Muench A, Rodrigues CR. Chemical versus conventional caries removal techniques in primary teeth: a microhardness study. J ClinPediatr Dent. 2007;31: Ericson D, Kidd E, McComb D, Mjör I, Noack MJ. Minimally Invasive Dentistry - concepts and techniques in cariology. Oral Health Prev Dent. 2003;1: Hedge AM, Preeti VC, Shetty A and Shetty S. Clinical evaluation of Chemo-mechanical caries removal using CarieCaresystem in school children. NUJHS 2014;4(3): Kochhar GK, Srivastava N, Pandit IK, Gugnani N, Gupta M. An evaluation of different caries removal techniques in primary teeth: a comparative clinical study. J ClinPediatr Dent. 2011;3: Mathre S, Kumar S, Sinha S, Ahmed BM, Thanawala EA. Chemo-mechanical method of caries removal: a brief review. IJCDS. 2011;2: Bohari MR, Chunawalla YK, Ahmed BM. Clinical evaluation of caries removal in primary teeth using conventional, chemo-mechanical and laser technique: an in vivo study. J Contemp Dent Pract. 2012;13:40 47.