Chemo-mechanical method: A valuable alternative for caries

JournalOfMinimum Intervention In Dentistry

J Minim Interv Dent 2009; 2 (4) 248

Abstract

Dental caries is considered oneof the most serious dentaldiseases that results in localizeddissolution and destruction of thecalcified tooth tissues.Neglecting the treatment of thisdisease could also endanger thetooth pulp. However, cariestreatment procedures are usuallyassociated with unpleasantpatients’ sensation. Severalapproaches for removing andtreating dental caries have beentried seeking for more comfort,but none of them seems ideal.The chemo-mechanical cariesremoval approach has beensuggested a long time ago, andthe interest regarding thismethod has recently increased.This innovative method seems tobe efficient in removing infecteddentine without altering thehealthy dental tissue or harmingthe adjacent oral mucosa. Inaddition, the bonding quality ofmost dentine adhesives and poly-alkenoate cements is notaffected by using this approachfor preparing dentine surfaces.This brief review provides simpleideas about the benefits and thedrawbacks of both classic andmodern approaches of cariesremoval. The development aswell as the clinical and labor-atory assessment of the chemo-mechanical caries removalsystems is also presented. Theavailable data has prompted theintroduction of the chemo-mechanical approach as anacceptable alternative for cariesremoval especially at the time of

treating fear expressing andpediatric patients. First publishedin Dental Update 2002; 9 (3): 16-22.

Authors:1BDS, Graduate student, Department ofConservative Dentistry, Mansoura University,Faculty of Dentistry, Egypt.2BDS, MScD, PhD, Lecturer, Department ofDental Materials, and Consultant, Elite CareDental Group, Dammam, Saudi Arabia.3BDS, MScD, PhD, Lecturer, Department ofConservative Dentistry, Mansoura University,Faculty of Dentistry, Egypt.4BDS, MScD, PhD, Assistant Professor,Department of Conservative Dentistry, SuezCanal University, Faculty of Dentistry, Egypt.

Correspondence address:Dr. Khalid M. AbdelazizDepartment of Dental Materials, MansouraUniversity, Faculty of Dentistry, El-GomhoriaSt., Mansoura, DK 35516, EgyptTel: 2 (050) 237-3897Fax: 2 (050) 226-0173Email: [email protected]

Introduction

Dental caries is currently consideredas one of the most common chronicdiseases. This disease results inlocalized dissolution and destructionof the calcified tooth tissues andsometimes causes an eventualinfection of the dental pulp1. Usuallydentine caries could be recognized astwo distinct successive layers, whichare different in their clinical features,as well as in their microscopic andchemical structures. The outer layer(infected dentine) is highly de-calcified, infected with bacteria and

Chemo-mechanical method:A valuable alternative for caries removal

Elkholany NR1, Abdelaziz KM2, Zaghloul NM3, Aboulenine N4



could be selectively stained in vivoby such caries detector dyes. In spiteof the possible discoloration, theinner layer (affected dentin) is lessdecalcified with intact collagen fibersand no bacterial invasion2. Moreover,it is more resistant to the proteolyticattack and the progression of cariouslesions3. In this instance, there is nonecessity to continue preparing thetooth until the dentin is stain-free4.but the ability to discriminate andremove only the diseased tissueremains as essential5-7. In 1893, GVBlack proposed his principle“extension for prevention” in theoperative treatment of cariouslesions. The principle proposed theremoval of sound tooth structure andthe anatomical form at sites thatmight encourage plaque stagnationto help in minimizing the caries onsetand progression. The fact is that theBlack’s principle was constrained byboth the knowledge of diseaseprocess and restorative materialspresented at that time8, but thedemand of removing sound enameland dentin has been dramaticallychanged as a result of developing theadhesive restoratives and thealternative approaches of both cariesremoval and cavity preparation 9-11.

Different approaches of cariesremoval

The earliest attempt to removecaries involved the use of a handdrill, which was soon surpassed in1871 by James Morison’s treadleinstrument developed from themechanism of Isaac singer’s sewingmachine12. Currently, the conven-tional treatment of caries is usuallycarried out with a high-speed handpiece to access the lesion and a lowspeed hand piece to remove thecaries. This method involves quickand efficient caries removal, howeverit may result in unnecessary removalof the healthy or even the affecteddentine that shows the ability forremineralization. Caries removalutilizing the conventional techniqueis usually associated with pain and

patients’ discomfort. The bone-conducting noise and vibration andthe possibility of producing thermaland mechanical injuries to the dentalpulp are also considered between themajor shortcomings of the drillingapproach13-15. In the last fewdecades and as a result of the formerdrawbacks, a growing interest hasbeen noticed to develop alternativeminimally invasive techniques. Air-abrasion was originally developed byRobert Black in 1945 as analternative pseudo-mechanicalmethod for dental tissue removal.This technique involved bombardingthe tooth surface with high velocityaluminum oxide particles (Alumina)carried in a stream of air16. Recently,several new air-abrasive cuttinginstruments have been introduced;such systems utilize air pressure of7-11 atm with alumina powderranges 20-50 µm to cut dentaltissue17. This method of cutting isrelatively painless when comparedwith dental drills18. However, thetotal loss of tactile sensation, and theability of alumina particle to removesound tooth structure rather than thecarious substrate19 in addition to thepotential risk of inhalation problemshould also be considered at the timeof selection20, 21. Air-polishing isanother technique utilizing a mixtureof water-soluble sodium bicarbonateand tricalcium phosphate particlesthat is applied onto the tooth surfaceusing air pressure and shrouded in aconcentric water jet. The water jethelps the abrasives not to escape farfrom the operating field22, howeverthe detrimental surface attack ofsuch restoration and sound toothstructure could be the result of non-selective abrasion characteristic ofthis method23. Relative to this fact,several researchers suggested theuse of that technique only forremoving carious dentine at the endof cavity preparation24. The ultra-sonic instrumentation has also beentried. This method depends ontransferring the kinetic energy ofwater molecules to the tooth surfacevia the abrasives in presence of high-



speed oscillations of the cutting tip25.The ultrasonic procedure has theadvantage of minimizing oreliminating noise, vibration, heat andpressure26. The limited availability ofinstrument tips, slowness of actionand the inability to remove softcarious dentine were the mainlimiting factors regarding theacceptance of that technique27.Recently, sono-abrasion wasdeveloped as a modification of theoriginal ultrasonics. This techniqueutilizes high frequency, sonic, air-scalers with modified abrasive tipswhich describe an elliptical motionwith a transverse distance of 0.08-0.15 mm and a longitudinalmovement ranges from 0.055 to0.135 mm. These tips are diamond-coated on the cutting side, cooledusing water at a flow rate of 20-30ml/min and operated by 305 bar airpressure for cavity finishing. Othertips shaped length ways halvedtorpedo, small hemisphere and largehemisphere are currently available.Using the different shapes of the tipshelps in preparing predeterminedcavity outlines, and also works wellin removing softened, cariousdentine28. On the other hand, therelatively low abrasion and high hubexcursion (0.4 mm) of the tips wereknown as disadvantages of thissystem29. The limited application andthe weakening of enamel rods withthe associating cracks adjacent tothe prepared sites were alsoreported30. Another approach waspostulated with the development ofthe first ruby laser by Maiman in the1960s. However, early studies hadfound that the ruby laser producedsignificant heat that caused damageto the pulp31. In spite of thedrawbacks of that beginning, newtypes of laser are now available tocut dental hard tissues32 with thepriority of selecting Excimer Lasers(Ultraviolet emission of 337 nm) forablating carious dentine33. The non-touch application of energy impulse(Lasing) seems advantageous toregular drilling34 as it provides lesspain, noise and pressure. Moreover,

it is believed to have minimalvibration and the ability to produce asterile cut surface35. In spite of thesebenefits, still there is a risk of heatgeneration with its subsequent effecton the tooth structure(carbonization, melting and cracking)and dental pulp (inflammation andnecrosis). Moreover, the high priceand the disability to use laser in thepresence of intraoral metalrestorations are additional limitingfactors36. During the last few years,reversal of caries using Ozone hasalso been suggested based on thefact that the remineralized toothtissues are known to be moreresistant to decay than sound toothstructure37. The technique uses laserdetection of caries38 and Ozonetreatment for less than 2 minutes39.Ozone readily penetrates throughdecayed tissue, eliminating theecological niche of cariogenicmicroorganisms as well as primingthe carious tissue forremineralization40. The remineral-ization process will then take placewith the aid of a topically appliedremineralizing solution and therecommended patient’s maintenancekit39. This simple fast novel approachavoids the need for local anesthesia,drilling and filling, however itsapplication is restricted to treat thesuperficial enamel and root caries41,and the use of conventional drillingand filling are still recommended totreat deep carious lesions42. It isobvious that most of the proceedingtrials are trying to achieve aconservative approach for removingdental caries. This issue stimulatedthe development of the currentlyknown atraumatic restorativetreatment (ART) approach. Thismethod includes excavation andremoving of the caries with handinstruments only and subsequentlyrestoring the cavities with suchadhesive restorative material43.However, a potential risk of leavinginfected carious dentine stillexist44,45. On the other hand,Goldberg and Keil in 1989 havediscovered the efficacy of the



collagenase enzyme, released fromAchromobacter bacterial species, inremoving soft carious dentine 2-5hours after its application. A residualsound layer of dentine will result withno bacteria seen within the exposedcollagen of the dentinal floor.Another enzyme named Pronase hasalso been discovered for the sameapplication. In spite of the potentialeffectiveness, the slow action of thisapproach for caries removal limits itsclinical application46,47. Combiningthe last two approaches resulted indeveloping what is known these daysby the chemo-mechanical caries re-moval. The details regarding thedevelopment and the assessment ofthis innovative method are coveredin the following section.

The chemo-mechanical Cariesremoval method (CMCR)

The idea of chemo-mechanical cariesremoval has been developed in1970s by Goldman who wasprimarily an endodontist, while usingsodium hypochlorite (NaOCl) inremoving organic materials in theroot canals. This chemical got theability to dissolve carious dentineand since that time, the idea ofremoving caries chemically wasborne. However, NaOCl itself was toocorrosive to be used on healthytissues because of its high reactivityand its ability to decompose non-necrotic tissue, subsequently NaOClwas diluted and buffered with sodiumhydroxide, sodium chloride andglycine producing a solution of0.05% N-monochloroglycine (NMG)having a pH of 11.4. This solution iscommercially known as GK10148.Goldman et al. in 197649 documentedthe effectiveness of the GK101 inremoving carious tooth material,while its mechanism of action waslater on described by Kurosak etal.50. The GK101 material is normallygoing to soften only the infectedlayer of carious dentine by selectiveattack on the degenerated collagenfibers. The attack causes cleavage ofthe polypeptide chains and

hydrolyzes the cross-links of collagenfibrils. The surprise is that thischemical agent has no ability toaffect the sound collagen fibers inthe inner affected and normaldentine, causing no or slight effecton the teeth pulps. GK101 systemwas found to be more effective if theglycine is replaced by aminobutyricacid51, the product then being N-monochloro-D-2 aminobutyrate(NMAB) and named as GK101E andmarketed in the United States in1984 as “Caridex”. The Caridex waspresented as a two-bottle system;the first contains sodiumhypochlorite and the second containsglycine, aminobutyric acid, sodiumchloride and sodium hydroxide. Bothsolutions are mixed immediatelybefore use to give the warningreagent with a pH approximatelyequal to 11 that becomes stable forone hour. The delivery system ofCaridex consisted of a reservoir forthe solution, heater and pump whichpassed the liquid warmed to thebody temperature through a tube toa hand piece and applicator tip (20gauge hypodermic needle, the tip ofwhich had been modified into spoonshape)52. Caridex system wasclaimed to involve the chlorinationand disruption of the partiallydegraded collagen fibers in cariousdentine with NMAB. The cariousdentine then becomes easier toremove by excavation using themodified needle tip53. An additionalattempt was carried out to improveNMAB reagent incorporating urea inits formula. The action of thismodification involves the two aminogroups of urea being chlorinated bysodium hypochlorite to form mono ordichloro derivatives. These inter-mediate compounds along withNMAB then attack and break downthe partially degraded collagen incarious dentine54. Scanning electronmicroscope (SEM) examination ofdentine after caries removal revealedthat NMAB reagent selectivelyremoves carious dentine leaving asurface with many overhangs andundercuts.



This surface is believed to be theinterface between carious and sounddentine. The appearance of dentinescales is also a frequent featurewhile dentinal tubules seem to bepatent and occluded55. In 1994 Yip etal.56 used both the back-scatteredelectron (BSE) imaging and electronprobe microanalysis (EPMA) tocompare the calcium and phosphoruslevels of normal dentine with thoseof dentine remaining after chemo-mechanical caries removal usingNMAB. The results indicated noremnants of the demineralizeddentine were detected aftertreatment and the remaining dentinewas chemically and clinically sound.The clinical trials57 showed highacceptance and preference ofCaridex caries removing system thatshowed this system could be avaluable alternative for dentinalcaries removal, with the advantageof reducing the use of conventionaldrilling and the need for localanesthesia. These findingsnominated that system for treatinganxious, medically compromised andpediatric dental patients. On theother hand, the biocompatibilitystudies58,59 indicated no adverseeffect of NMAB on dental pulp.However, the unpleasant tasteindicated by few patients and thelengthy procedure (10-15min), inaddition to the large volumes ofsolution needed (200-500ml) and tothe fact that the delivery system wasno longer commercially available,limit the use of NMAB chemo-mechanical caries removal system60.Recently, the Carisolv system hasbeen developed by the Swedish MediTeam. This system works throughthe same mode of action as Caridex,however it utilizes three naturallyoccurring amino acids (glutamic acid,leucin and lycine) with differentcharges. All of these charges helpthe electrostatic attraction of eitherthe hydrophilic (positively ornegatively charged) or hydrophobic(noncharged) patches that normallyform the peptide chains of allproteins including collagen61. The

new system is marketed in twosyringes, one containing 0.5%sodium hypochlorite solution and theother containing pink gel of the threeamino acids. Carboxymethyl celluloseand erythrocin are also added tomake the gel viscous and readilyvisible in use. The contents of thetwo syringes should be mixedimmediately before use as itseffectiveness begins to deteriorateafter 20 minutes. The mixed gel isapplied to the carious lesion for 30seconds and then the carious dentinecan be gently removed, usingCarisolv specially designed, non-traumatic hand instruments. Thesame procedure is continuouslyrepeated until removing clear gel isachieved. The average time requiredfor complete caries removal is about9-12 minutes and the volume of gelutilized for this purpose is only 0.2-1.0 ml60. The clinical efficiency andsafety of Carisolv system wasdocumented by Ericson et al.62 in1999. These findings were thenconfirmed through different in vivoand in vitro studies63-67, whichshowed a wide range of patients’acceptance and comfort. The Carisolvsystem also seemed very successfulin selective removal of cariousdentine with no pain demonstratedand no need for local anesthesia,however its slowness was the onlyapparent drawback. Laboratoryassessment of cavities treated withCarisolv using light microscopeindicated sound, caries-free dentinehaving the same chemistry of thatdentine left after conventionaldrilling68. Another study69 showed nopenetration to the residual dentineand accordingly pulp damage wouldnot be expected with this system.Young et al.70 confirmed this findingin 2001 through histological andimmuno-histochemical examination.Other studies71-73 utilizing fancymicroscope technology revealed noharmful threat either on healthy oraffected dentine. The bactericidaleffect of the Carisolv system wasalso observed as well as itsstimulating ability for reactive



dentine formation74. On the otherhand, no harm was noticed clinicallywhen the oral mucous tissues wassubjected to 3 minutes contact withthe Carisolv solution75. The formerobservation has gained a histologicalsupport when no significant increasein the number of inflammatory cellshas been detected after exposing thegingival tissue to the same chemicalagent75. The effect on certainrestorative material was alsoevaluated. Minor influence wasdemonstrated on the surfacetopography of ceramic restorationsafter 20 minutes contact withCarisolv gel76, however this effectcould not be noticeable in case ofaccidental contact.

Bonding to dentine after CMCR

Enhancing the dentine-adhesivebond seems desirable to achievelongevity of restorations and tominimize the postoperative compli-cations77. However, the quality ofbonding to dentine could be affectedto a great extent by the mode ofcaries removal78. The chemo-mechanical caries removal showedmore irregular and rougher surfaceswith modified smear layer whencompared with the conventionalrotary preparation79. Moreover, acidetching of the chemo-mechanicallytreated dentine exposed a clearperitubular and intertubular collagennetwork. This finding for sure couldaffect the quality of the formedhybrid layer and therefore thelongevity of the adhesiverestorations80-83. Some re-searchers84,85 registered a com-parable adhesion of glass ionomercements either to the chemo-mechanically or conventionallytreated dentine surfaces. At thesame time, bonding quality ofmodern adhesive systems to dentineseems not to be affected in presenceof chemo-mechanical caries re-moving agents86,87. However, certainreports88-90. indicated higher bondstrength values with the chemo-mechanically prepared dentine than

those exhibited with conventionallyprepared dentine. In addition nodifference in microleakage para-meters was observed when eitherCMCR system or conventional burcaries removal technique is used toprepare a cavity for composite resinrestoration91.

Summary

Patient acceptance and comfort areimportant at the time of cariestreatment. This could be achieved byusing the chemo-mechanical methodfor removing dental caries. Utilizingthis approach, especially with usingthe Carisolv system, providesefficient removal of dental caries withno harm expected either on thehealthy dentine or the pulp tissues.Considering the other advantagesregarding the adhesive bonding, andthe compatibility with both softtissues and restorative materials, thelengthy procedure is probably theonly apparent drawback of thechemo-mechanical caries removalmethod. Consequently, the chemo-mechanical approach seems to be avaluable alternative for cariesremoval especially in feardemonstrating and pediatric patients.

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DentalUpdate 2002; 9 (3): 16-22

Resumen

La caries dental es consideradauna de las enfermedadesdentales más serias que resultaen la disolución y destrucciónlocalizada de tejidos dentalescalcificados. Descuidar eltratamiento de esta enfermedadpodría también poner en peligrola pulpa dental. Sin embargo, losprocedimientos de tratamientode caries son usualmenteasociados a sensacionesdesagradables para lospacientes. Se han tratado variosmétodos para remoción y trata-miento de la caries dentalbuscando mayor comodidad parael paciente, pero ninguno deellos parece ser idóneo. Se hasugerido por mucho tiempo elmétodo quimiomecánico deremoción de caries y recient-emente ha aumentado el interésen el mismo. Este métodoinnovador parece ser eficaz en laremoción de dentina infectadasin alterar el tejido dentalsaludable o dañar la mucosa oraladyacente. Además, la cualidadde fijación de la mayoría de losadhesivos dentinales y cementospolialquenoatos no es afectadacuando se usa este método parapreparar superficies dentinales.Este breve estudio proporcionaideas simples sobre losbeneficios y desventajas de losmétodos clásico y moderno pararemoción de caries. Asimismo,presenta el desarrollo y eval-uación de laboratorio de lossistemas quimiomecánicos deremoción de caries. La infor-mación disponible ha impulsadola introducción del métodoquimiomecánico como unaalternativa aceptable para

remoción de caries, especial-mente al tratar pacientes queexpresan temor y pacientespediátricos. Publicado primeroen Dental Update 2002; 9 (3):16-22

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Chemo-mechanical method: A valuable alternative for caries