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| Year : 2012 | Volume
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| Issue : 5 | Page : 697 |
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| A comparative study of the clinical efficiency of chemomechanical caries removal using Carisolv® and Papacarie® - A papain gel |
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J Kumar, M Nayak, KL Prasad, N Gupta
Department of Conservative Dentistry and Endodontics, KVG Dental College and Hospital, Kurunjibagh Sullia (Karnataka), India
Click here for correspondence address and email
| Date of Submission | 26-Mar-2011 |
| Date of Decision | 10-Dec-2011 |
| Date of Acceptance | 08-Feb-2012 |
| Date of Web Publication | 19-Feb-2013 |
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 Abstract | | |
Objectives: The purpose of this study was to compare the clinical efficiency of chemomechanical caries removal using Carisolv® and Papacarie® - a papain gel.
Materials and Methods: The Carisolv® system for caries removal, consisting of a solvent gel and a specially designed hand instrument, was compared to Papacarie - a papain gel. The outcome variables were: time taken for complete caries removal and volume of carious tissue excavated. Forty patients in the age-group of 20-40 years, having Black's class I dentinal caries with cavity entrance size of ≥3 mm in the molars, were enrolled for the study. The time taken for the complete removal of caries was measured using a stopwatch. Pre- and post-excavation single-step putty/wash elastomeric impression was recorded using addition silicone impression material. Subsequently, casts were poured and measured under a traveling microscope. The total volume of caries excavated was computed using the formula π (d/2)2 h. The difference between the two groups in clinical efficiency and volume excavated was statistically analyzed using the Student's unpaired 't' test.
Results: The time for caries removal with Carisolv® and Papacarie® were, respectively, 11.67 ± 3.25 minutes and 10.48 ± 2.96 minutes (P>.05). The mean volume of carious tissue removed with Papacarie® (135.99 ± 66.43 mm 3 ) was higher than that with Carisolv® (126.33 ± 53.56 mm 3 ); however, the difference was not significant.
Conclusion: Carisolv® and Papacarie® have similar clinically efficiency as chemomechanical agents for dentinal caries removal. Keywords: Carisolv®, chemomechanical caries removal, clinical efficiency, Papacarie® - a papain gel, traveling microscope
How to cite this article:
Kumar J, Nayak M, Prasad K L, Gupta N. A comparative study of the clinical efficiency of chemomechanical caries removal using Carisolv® and Papacarie® - A papain gel. Indian J Dent Res 2012;23:697 |
How to cite this URL:
Kumar J, Nayak M, Prasad K L, Gupta N. A comparative study of the clinical efficiency of chemomechanical caries removal using Carisolv® and Papacarie® - A papain gel. Indian J Dent Res [serial online] 2012 [cited 2023 Jun 9];23:697. Available from: https://www.ijdr.in/text.asp?2012/23/5/697/107429 |
The word 'caries' is derived from the Latin word for 'rot' and the Greek ker, which means 'death'. Dental caries has been known since times immemorial. According to the World Health Organization (WHO) definition, caries is a 'localized posterupted pathological process of external origin, involving softening of hard tooth tissue and proceeding to the formation of a cavity.' It is one of the most prevalent oral diseases and is of great public health concern. Caries affects 50%-60% of the Indian population.
Carious dentine consists of two distinct layers having different ultramicroscopic and chemical structures. The outer layer of carious dentine (infected dentine) is irreversibly denatured, infected by bacteria, not remineralizable, and must be removed. The inner layer of carious dentine (affected dentine) is reversibly denatured, not infected, remineralizable, and should be preserved. [1] Thus, the objective when treating the carious lesion is to remove the infected layer, while retaining the affected dentin.
Caries excavation has traditionally been performed using rotary and sharp-edged hand instruments. These have some major disadvantages; for example, there is difficulty in establishing the amount of dentin to be removed due to lack of objective clinical markers; mechanical preparation often induces pain and discomfort; and there is generation of heat, vibration, and noise. To overcome these drawbacks, alternative methods have been proposed, including chemomechanical techniques, air abrasion, sono-abrasion, ultrasonic instrumentation, and lasers. [2]
The chemomechanical caries removal method selectively removes carious dentine but avoids the painful and unnecessary removal of sound dentine. It facilitates delivery of atraumatic, bactericidal and bacteriostatic activity, while removing the least amount of tooth structure and not leaving behind any infected and untreatable dentin. [3]
Carisolv ® gel (MediTeam, Sweden) was launched in 1998. Its effectiveness is based on the proteolytic action of sodium hypochlorite, which dissolves the infected dentin, and on the action of amino acids, which enhance the effect of sodium hypochlorite on denatured collagen and minimize damage to healthy tissue. [4] In 2003, Papacarie ® gel (Fórmula and Açäo, Brazil) was introduced as a biocompatible gel with conservative, antibacterial, and atraumatic properties, which could reduce the risk of pulp exposure and not damage healthy tissue, making it an excellent option for caries removal. [4]
Clinical efficiency or the time factor may be crucial for acceptance of a treatment by some patients, especially children and medically compromised patients. The volume of tissue removed offers evidence of the minimal intervention effect of the chemomechanical method of removing carious tissue.
The purpose of this study was to compare the clinical efficiency of chemomechanical caries removal using two agents: Carisolv ® and Papacarie ® .
| Materials and Methods | |  |
Forty patients with Black's class I occlusal dentinal caries in permanent molars, with dimensions of ≥3 mm (maximum entrance size), brownish-gray discoloration, and soft consistency, were selected for the study [Figure 1] and [Figure 2]. Preoperative intraoral periapical radiograph was taken with a Confident dental x-ray unit set at 70 kV and 7 mA, using Kodak E-speed x-ray film and the bisecting angle technique so as to exclude any pulpal involvement and periapical lesion associated with an asymptomatic chronic carious lesion. | Figure 1: Photograph showing Black's class I cavity in relation to 36 for group 1
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 | Figure 2: Photograph showing Black's class I cavity in relation to 37 for group 2.
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The scientific committee approved the study, clearance was obtained from the ethical committee, and written informed consent was obtained from all participants. The 40 patients were randomly divided into two groups (group I and group II) of 20 patients each. Group I patients were treated with Carisolv ® gel and group II patients were treated with Papacarie ® .
Initial impression making
The stock plastic sectional tray was selected and a polyvinyl siloxane tray adhesive (Dentsply) was applied in a thin and even layer over the intaglio surface of the tray. All materials were mixed manually in the standard proportions according to the manufacturer's recommendations. Impression making was done with the putty/wash single-step impression technique, using elastomeric addition silicone (Dentsply) [Figure 3] and [Figure 4]. The cast was poured on the obtained impression using type IV die stone (Pearl stone, Asian Chemicals, India) to measure maximum entrance size (≥3 mm) and initial volume of the cavity using a traveling microscope.
Procedure for caries excavation
Group I - Carisolv® gel
The target carious tooth was isolated with rubber dam. Solution I and solution II of Carisolv ® gel were mixed and applied into the cavity. Timing of the procedure started at initial application of gel and was recorded using a stopwatch. After 30 seconds, the cavity was gently scraped using a Multistar ® excavator (Mediteam, Sweden) to remove the softened carious tissue. Only light pressure was used on the instrument, without causing any pain to the patient. [5]
At application, the fresh gel was clear but it became opaque/cloudy with admixture of debris removed from the lesion. When the gel was heavily contaminated with debris it was removed with gentle suction or with a cotton roll/pellet, and fresh gel was applied. [5]
The completeness of dentinal caries removal was judged on the basis of clinical criteria, i.e., the explorer does not stick in the dentin or give a 'tug-back' sensation and the cavity is stain free [Figure 5] and [Figure 6]. If carious dentin remained, then the procedure was repeated until the whole caries was removed. Finally the cavity was rinsed with water, dried, and examined; if found to be caries free, the timing of the procedure was stopped. [6]
Group II - Papacarie®- papain gel
The same procedure was followed as in group I, except that the motion of the instrument which was pendulum like. As with Carisolv ® gel, the freshly applied Papacarie ® gel was clear. Immediately after degradation, oxygen was freed, bubbles appeared on the surface, and there was blurring of the gel. [4]
Evaluation of time taken for complete caries removal
The stopwatch was started when the application of Carisolv ® or Papacarie ® gel was begun and stopped only when the cavity was confirmed to be stain free, without any 'tug-back' sensation or binding of the explorer.
Final impression making
The final impression was made after the completion of caries excavation in a similar manner as was done for initial impression making [Figure 7] and [Figure 8]. Immediately cast was poured to study under traveling microscope.
Measurement of the volume of carious tissue removed
The difference between final and initial sizes of the cavity was measured using a traveling microscope. The linear measurement of the cavity entrance size was measured to the nearest 0.5 mm and the average value for the cavity size was estimated. The final cavity size (in cubic millimeters) was computed using the formula π (d/2) 2 h. [7]
The differences between the groups in clinical efficiency and volume excavated was compared and statistically analyzed using Student's unpaired 't' test. Correlation between volume excavated and time taken in each group was analyzed by calculating the coefficient of correlation.
| Results | | |
The patients in this study were aged 20-40 years, with a mean of 27.3 years in group I and 27.5 in group II. Twenty-three patients (57.5%) were males and 17 (42.5%) were females. Twenty-one (52.5%) teeth were in the lower arch and 19 (47.5%) in the upper arch [Table 1].
Clinical efficiency/time taken
The mean time for complete caries removal in group I (Carisolv ® ) was 11.67 ± 3.25 minutes, whereas the mean time in group II (Papacarie ® ) was 10.48 ± 2.96 minutes. The difference was statistically nonsignificant [P>.05; [Table 2]].
| Volume of Caries Excavated | | |
The mean and standard deviation of the estimated volume of carious tissue removed from the cavities in each technique is shown in [Table 3]. The volume of carious tissue removed was less in group I (Carisolv ® ) (126.33 ± 53.56 mm 3 ). However, the difference was not statistically significant (P>.05) as shown in [Graph 1]. [Additional file 1]
| Correlation Between Volume of Caries Excavated and Time Taken | | |
A strong correlation was observed between the volume of caries excavated and the time taken for both group II (PapacarieÒ ) (r = 0.766) and group I (Carisolv ® ) (r =0.683) [Table 4]. In both the treatment groups, the greater the volume of caries removed, the more the time taken [Graph 2]. [Additional file 2]
| Discussion | | |
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. With respect to collagen degradation, two zones can usually be distinguished within a lesion, as demonstrated by Ogushi and Fusayama in 1975: an inner layer in which collagen is intact (affected dentin) and a second zone where the collagen fibrils are partially degraded and cannot be remineralized (the infected dentin). [8]
In vitro studies have shown chemomechanically treated dentin to have more surface energy, greater affinity for adhesive material, and better bonding than conventionally treated dentin. Moreover, morphological studies have shown Carisolv ® treatment to consistently remove the carious lesion and open the dentinal tubules along with more irregular and rougher surface with modified smear layer. [9]
Ansari et al.[3] advocated the chemomechanical caries removal method over the conventional method due to the advantages offered by the former, which include less traumatic caries removal, less need for local anesthesia, high patient preference, reduced chance of exposure in deep carious cavities, great usefulness in immunocompromised patients and patients with bleeding disorders, absence of a smear layer, and better bonding to restorative materials.
The initial size of the carious lesion was selected as ≥3 mm in this study because lesions with dimensions ≤2 mm would not have provided sufficient access for the CMCR instrument to reach the dentinal caries. [10] In vivo studies have shown the Carisolv ® instrument to be less painful than the traditional rotary instruments or excavators. [11] Although the Papacarie ® manufacturer recommends the use of old, blunt curettes, we opted to use the instrument supplied with the Carisolv ® kit in order to obtain standardization.
Margakis et al.[6] estimated the dimensions of removed carious tissue with the aid of a calibrated dental probe, assuming that all carious material was rectangular in shape. They acquired an estimate of the total volume removed by multiplying the linear dimensions of the occlusogingival, mesiodistal, and faciolingual lengths. Lennon et al.[12] used silicone impression material for calculation of volume. The impression was weighed and cavity volume was calculated according to the density of the impression material. Lozano-Chourio et al.[7] in 2006 used metallic structured calipers to measure cavity entrance size before and after removal of caries and estimated volume of tissue removed by using the formula π (d/2)2 h. In this study, the volume of caries excavated was calculated by first making a single-step putty/wash impression, followed by analysis of the cast under a traveling microscope and calculation of volume using the formula π (d/2)2 h. This method has several advantages: the greater accuracy of the single-step putty wash impression material, the availability of study casts as a records, and the accuracy of the traveling microscope (accurate up to 1/100 th of a millimeter).
In present study, it was noticed that the actual dimensions of the cavity was larger than was apparent clinically on the occlusal surface. Hence, to record all the details of the cavity, including undercuts, addition silicone impression material was used. Johnson and Craig [13] showed addition silicone to demonstrate the best recovery from undercuts, extremely high accuracy, superior tear resistance, less polymerization shrinkage, increased dimensional stability, and neutral odor and taste; besides, it permits multiple accurate casts. Polyvinyl siloxane material shows 96.86% overall accuracy. [14]
Hung et al. reported that the putty/wash one-step impression technique did not differ substantially in dimensional accuracy from the putty/wash two-step impression technique when addition silicones were used. [15] Similarly, Abuasi and Wassell [16] concluded that the most convenient and reliable way of recording a putty-wash impression is to use the one-stage technique with addition silicone putty. The present study employed the single-step putty/wash impression technique using addition silicone impression material to record the cavity dimensions prior to and after chemomechanical caries excavation.
In the present study, dyes were not used because dyes are not specific for infected dentin; they are nonspecific protein dyes that stain the organic matrix of less mineralized dentin, including normal circumpulpal dentin and sound dentin in the area of the amelodentinal junction. The lack of specificity of caries-detector dyes was confirmed in 1994 by Yip and others. [17] The caries excavation in the present study was judged to be complete by using clinical criteria, i.e., tactile and visual examination. However, this method is subjective and has shortcomings.
The mean time taken for complete caries removal in the present study with group I (Carisolv ® ) was 11.67 ±3.25 minutes, whereas in group II (Papacarie ® ) it was 10.48 ± 2.96 minutes. Our results were in accordance with that of two separate studies conducted by Hosein and Hasan [18] and Ansari et al.[3] who recorded 12.5 minutes and 10- 12 minutes, respectively, for caries removal using Carisolv ® . Balciuniene and Ericson also recorded 10.5 minutes and 10.4 minutes for chemomechanical caries removal using Carisolv ® in comparison to high-speed excavation. Faster excavation using chemomechanical method were observed by Habib et al., Fure et al., and Maragakis et al .[6] , who recorded 6-8 minutes, 5.9 ± 1 minutes, and 6.0 minutes, respectively. [11] Motta et al. [4] found that the time required for the treatment using Papacarie ® was about 6 minutes. Pandit et al.[19] recorded 4-5 minutes for the traditional method and 8 minutes with Carisolv ® . The reason for the increased time in group I (Carisolv ® ) in the present study may be because we used multiple applications of Carisolv ® gel to achieve complete caries removal.
In this study, all cavities were found to be clinically caries free after being treated with Carisolv ® (group I) and Papacarie ® (group II), which is concordant with the results reported by Ericson et al., Banerjee, Kidd and Watson, and Fure et al. who showed that Carisolv ® was as effective as rotary bur in removing infected carious dentin. [5] However, Hosoya et al.[9] reported incomplete caries removal in 63.6% of their cases, and Maragakis et al.[6] reported residual caries in 37.5% of their cases after treatment. Balciuniene et al.[11] reported the need of the bur in 60% of their cases for achieving complete removal of caries. Munshi et al.[20] described the CMCR method as 'very efficient' in soft caries removal, but reported that it was not very effective in 90% of cases with hard, arrested dentinal caries.
The results of the present investigation show that Carisolv ® and Papacarie ® are both clinically efficient as chemomechanical agents for caries removal. However, Papacarie ® gel was marginally better in the parameters used to measure clinical efficiency.
The active ingredient in Carisolv ® , sodium hypochlorite, combines with amino acids to generate chloramines. This results in chlorination of partially degraded collagen and the conversion of hydroxyproline to pyrrole-2-carboxylic acid, which initiates the disruption of collagen fibers and softening of the outer layer of carious dentin. Beeley et al. [21] suggested that cleavage by oxidation of glycine residue could also be involved. This causes disruption of collagen fibrils, which become friable and are then easily removable.
Papacarie ® is constituted of papain, chloramines, and toluidine blue. Papain is an enzyme similar to human pepsin, with anti-inflammatory and debriding actions. It does not damage healthy tissue, but accelerates the cicatricial process and has bacteriostatic and bactericidal action. Papain acts only on carious tissue, which lacks the plasma protease inhibitor alpha-1 antitrypsin; its proteolytic action in inhibited in healthy tissue, which contains alpha-1 antitrypsin. [4]
In the present study, strong correlation was observed between time required for complete removal of caries and volume of caries excavated. Time taken was directly proportional to volume of caries excavated. This has a clinical significance because the larger the cavity size the more the time required for complete caries excavation.
It was interesting to note that all patients in both groups experienced no pain at all even though they did not receive any anesthetic. This may be due to fact that Carisolv ® instruments are specially designed for a safe scraping action, having a 90° edge and not a sharp cutting profile. This design allows the operator to work in two or more directions and reduces breaking off of dentin and the opening up of a large number of dentin tubules. [11]
An important limitation of the technique evaluated in this study is that hand instruments are not appropriate for cutting enamel and, nowadays, most cavities are not large enough to allow proper access to carious dentin. This limitation might make the public feel misled and might raise doubts as to whether this is really a satisfactory solution for the very unpleasant conventional treatment of dental decay.
Further research with large sample size and longer follow-up is required to substantiate the findings of this study. Also, color and hardness were used as clinical criteria to indicate endpoint of excavation, but these may not always be reliable.
| Conclusion | | |
Within the limitations of this study comparing the clinical efficiency of chemomechanical caries removal using Carisolv ® and Papacarie ® , the following conclusions could be drawn:
- Carisolv ® and Papacarie ® were both clinically efficient for carious dentin removal.
- Papacarie ® was marginally better in the tested clinical parameters, i.e., time taken and volume of carious tissue excavated.
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Correspondence Address:
J Kumar
Department of Conservative Dentistry and Endodontics, KVG Dental College and Hospital, Kurunjibagh Sullia (Karnataka)
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0970-9290.107429
[Table 1], [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8]
[Table 2], [Table 3], [Table 4] |
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