CHEMOMECHANICAL CARIES REMOVAL (CMCR)

SHARATH CHANDRA
THIRD B.D.S

CARIES
DEF:
It is defined as microbiological disease of calcified tissues of teeth that leads demineralization of the inorganic components and the subsequent breakdown of the organic moieties of enamel and dentin.

TOPICS
INTRODUCTION

ADVANTAGES & DISADVANTAGES OF CMCR OVER TRADIATIONAL METHOD HISTORY VARIOUS METHODS OF CMCR : 1.CARIDEX 2.CARISOLV 3.PAPAIN GEL

INTRODUCTION
Caries still continues to affect significant portion of world population and treatment of decay in most patients is associated with pain.

Conventional caries removal technique has various disadvantages like : frequent use of local anesthesia. perception by patients that drilling is unpleasant. drilling can cause deleterious thermal effects. use of hand piece may result in removal of softened but unaffected dentin.

So the chemo-mechanical method for caries removal was developed to overcome these shortcomings.it is not only more comfortable but also preserve the healthy tissue.

ADVANTAGES & DISADVANTAGES OF CMCR OVER TRADIATIONAL METHOD

ADVANTAGES
No need for local anesthesia. Suited for treatment of anxious & pediatric patients. Indicated in medically compromised patients. Conservation of sound tooth structure. Reduced risk of pulp exposure.

DISADVANTAGES
Increased operation time. Unpleasant taste . It is ineffective in removal of hard eburnated parts of lesion.

HISTORY
According to Banerjee et al, the chemo mechanical method is an effective alternative for caries removal because it brings together atraumatic characteristics and bactericide /bacteriostatic action.

In 1975, habib et al introduced a method using 5% sodium hypochlorite to Remove carious tissue.

But the sole use of 5% sodium hypochlorite was known to be toxic and aggressive to adjacent healthy tissues.

Therefore a new solution was developed by adding: 1.sodium hydroxide 2.sodium chloride 3.glycine 4.5%sodium hypochlorite & also amino butyric acid.

GK-101

Slow in carious tissue removal

More effective than hypochlorite alone

CARIDEX
History :
It was developed by CM Habib and was called as GK101E.

COMPSITION: 2 solutions

SOLUTION 1
Sodium hypochlorite

SOLUTION 2
Glycine Amino butyric acid Sodium hydroxide Sodium chloride

SOLUTIONS ARE MIXED BEFOREUSE

APPLICATION
Intermittent application of preheated N-Monochloro-DL-2-Amino butyric acid (GK101E) to carious lesion.

MECHANISM OF ACTION
To understand the mechanism of action completely we have to know about : composition of dentin. Structure of dentin. Affect of caries on collagen fibers of dentin.

COMPOSITION OF DENTIN

70% MINERAL

DENTIN

10% WATER
18% COLLGEN 20% ORGANIC MATRIX 2% NON COLLAGENOUS

STRUCTURE OF DENTIN
D E N T I N

Proline and other amino acids.

Polypeptide Chains.

Coiled in triple helices called tropocollagen units(tcu).

Tcu arranged side by side to form a fibril.

Fibrils are in form of dense meshwork which become mineralized.

CARIES

Acid produced by bacteria.

Demineralization of enamel & dentin.

Organic matrix becomes susceptible to enzymes produced by bacteria.

When the dentin is demineralized the collagen undergoes degradation and two layers are formed:

Outer layer

Collagen fibrils partially degraded & cannot be remineralizd.

Partially demineralized & can be remneralized. Collagen fibrils intact.

Inner layer

MECHANISM OF ACTION
The mechanism of action involved chlorination of partially degraded collagen & conversion of:

Hydroxy proline

Pyrrole-2carboxylic acid

Disruption of altered collagen fibers

INDICATIONS
Deciduous teeth. Dental phobics. Medically compromised patients.

ADVANTAGES
No need for local anesthesia. Conservation of sound tooth structure. Decrease risk of pulp exposure.

DISADVANTAGES
Expensive. Large quantity required. Solution had to be heated. Short shelf life. Hand instruments were not optimum. Unpleasant taste. Procedure is slow.

CARISOLV
HISTORY
Chriser hedwards with Lars strid of mediteam collaborated with Dan Ericson & Rolf Bornstein in Sweden led to development of a new Patented system called carisolv.

It was initially approved for clinical use in dental practice by the Swedish counterpart to the fda. Carisolv was introduced to the European market as a successor to the caridex system.

CONSTITUNTS
SOLUTION 1

: 2 solutions

Sodium hypochlorite 0.5%

SOLUTION 2
Amino acids- glutamic acid, leucine, lysine. Gel subs- carboxy methyl cellular to increase viscosity. Sodium chloride. Sodium hypochlorite. Saline solution. Erythrosine(red)- coloring indicator.

MECHANISM OF ACTION
When the carisolv gel is mixed, the amino acids bind chlorine and form

C H L O R A M I N E S

The formation of chloramines decrease the reactivity of chlorine without altering its chemical properties.

Are able to disrupt to disrupt the several types of electrostatic bonds that holds the fibers together.

The 3 aa are differently charged, which allows for an electrostatic attraction to different areas of proteins in the carious dentin.

The peptide chains of all proteins, including collagen, are made of hydrophilic (+veor-ve) and hydrophobic( no charge)so each of these c-aa attracts to one of these patches.

Effectively bringing reactive power to full Length of

target.

The chemical result of these is breakdown of degraded collagen.

EASY REMOVAL

HAND INSRUMENTS
To ensure the most effective removal when the carisolv gel has softened the carious dentine , specially designed instruments and tips have been developed. The tips have different shapes and sizes to suit cavities of all kind.hand Instruments can be classified as:

1.BASED ON TYPES OF TIPS

CARISOLV HAND INSTRUMENTS.

2.STANDARD INSTRUMENT CLASSIFICATION

1.BASED ON TYPES OF TIPS

A.WITH PERMANENT TIPSInstruments are paired-double ended carisolv instruments

B.WITH INTERCHANGABLE TIPSSingle handle can be used with a range interchangeable carisolv instruments

INSTRUMENTS WITH PERMANENT TIPS

2.STANDARD INSTRUMENT CLASSIFICATION

A.CARSOLV HAND INSTRUMENT 1 : Extra bend; Star3, Flat0 Uses: Primarily used for crown margins and areas that are difficult to access.

B.CARISOLV HAND INSTRUMENT 2 :

Multistar, Star3. Uses:

Basic instrument to apply gel and start removing caries. Multistar tip promotes penetration of gel. Star shaped tip helps scraping in all directions with its four pronged design.

CARISOLV HAND INSTRUMENT 3: Star2, Star1

Uses To remove caries in smaller cavities for e.g.; root caries or decidious teeth.

CARISOLV HAND INSTRUMENT 4: Flat3, Flat2

Uses caries present close to the pulp. To remove softened carious dentin from the cavity

CARISOLV HAND INSTRUMENT 5: Flat1, Flat0

Uses:

To remove caries at the DEJ.

POWER DRIVE
It is a combined electronic instrument for power operated, Minimally invasive caries removal with carisolv .

The advantages of this instrument are: Selective and precise removal of only carious dentin. Fast, simple and efficient removal of caries. It operates with high tissue control at low sound levels. Patient can operate unit themselves. Useful for patients with dental phobia.

POWER DRIVE

PROCESS OF APPLICATION AND REMOVING OF CARIOUS LESION BY CMCR

Miix the two components of carisolv thoroughly according to instructions. put the required amount of gel in suitable container .

Use a carisolv instrument tip to pick up the gel and apply to the carious dentin.

Soak the caries generously.

Wait for at least 30 seconds , for the chemical process to soften caries.

Select a power drive tip or a carisolv hand instrument to the size, position and accessibility of the cavity.
Scrape of the superficial softened carious dentin. The hand instrument with multistar tipmay facilitate the early penetration of the gel. Work carefully using scraping or rotating movements.

Remove the softend carious dentin with the instrument. Avoid flushing or drying the cavity.

Keep the lesion soaked with gel and continue scraping . 30 seconds of waiting time is needed.

Repeat until the gel no longer turns cloudy and the surface feels hard using the instrument.

Check extra carefully for caries at the dentinoenamel junction.if you are using a drill to adjust the periphery before filling, this can be done while the gel is still in the cavity.

When the cavity feels free from caries , remove the gel and wipe the cavity with a moistened cotton pellet or rinse it with Luke warm water, inspect and check it with a sharp probe.

If the cavity is not free from caries , apply new gel and continue scrapping .

If necessary the periphery of the cavity should be adjusted using hand instruments or drill.

Restore the tooth with suitable filling material according to the manufacturer's instructions for use.

EXCAVATION OF CARIES AFTER CARISOLV APPLICATION

TREATMENT OF CHILDREN USING CARISOLV

The clinical procedure is same but there are few behavioral modifications they are:

Do not rush Be sure to give 30 seconds to react. Keep the patient well informed during treatment. If the patient experience any pain, check that the cavity is completely covered with gel. It is very important not to work with too much force- use speed not pressure in your movements.

INDICATIONS
Where the preservation of tooth structure is important. The removal of root/cervical caries.

The management of coronal caries with cavitation.

The removal of caries at the margins of crowns and bridge abutments. The completion of tunnel preparations. Where local anesthesia is contraindicated. The care of caries in dentally anxious patients, notably needle phobics. Management of primary carious lesion in decidious teeth. Atraumatic restorative technique procedures.

Caries management in patients with special needs.

ADVANTAGES
Three aa are incorporated instead of one, and the different charges have improved the interaction with degraded collagen within the lesion thus increasing efficiency.

Carisolv has a higher viscosity, which allows for the application of higher concentration of aa and sodium hypochlorite without increasing the total amount of fluid used, therefore reducing total volume required.
The solution does not need to be heated, or applied through pump mechanism. The overall stability is increased, giving an improved shelf life.

DISADVANTAGES
Extensive training and registration of professionals. Customized instruments which increased the cost of solution.

PAPAIN GEL
In 2003, a research project in brazil to the development of a new formula to universalize the use of CMCR and promote its use in health.
The new formula was commercially known as papacaire. Papain comes from the latex of leaves and fruits of the green adult papaya. Dawkins showed that carica papaya has bactericide and bacteriostatic properties which inhibits growth of gram+ve & gram-ve organisms. Pereira et al used samples of infected dentin cultivated in BHI broth in petri dish to asses the Papacarie antimicrobial activity. The results showed the largest papacarie activity was in case of streptococcus and lactobacillus.

COMPOSITION
PAPAIN CHLORAMINES TOLUIDINE BLUE SALTS THICKENING VEHICLE

MECHANISM OF ACTION
Papain acts only on the dead cells , it acts by breaking the partially degraded collagen molecules, contributing to the degradation & elimination of fibrous mantle formed by carious lesion.

Right after degradation , oxygen is freed, bubbles appear on the surface and a blearing of the gel is thus noted. These signs demonstrate that removal process can be started.
For removal of caries opposite side of an excavator can be used like a pendulum movement and carefully without cutting. The instrument should scrap the tissue without promoting any kind of stimulus or pressure. The main characteristic of the complete removal of the infected dentinal tissue is the vitreous aspect of the cavity.

CLINICAL PROCEDURE
Radiograph of the target tooth. Prophylaxis of the region using rubber cup and slurry of pumice. Rinsing with air/water spray or cotton pellet with water

Isolation of target tooth

Application of papacaire
Allow the chemistry to work for 30-40 seconds

Removal of the softened carious dentin using the opp. side of Excavator and using a pendulum movements; the softened Carious tissue must be scraped, not cut.
Application of gel , if necessary

The vitreous aspect of the cavity appears when the cavity feels free from caries

Rinsing 0.12%, 1% chlorhexidine or water spray

Drying with moisture-free and oil-free air

Restoration with a suitable filling material according to manufacturers instructions

REFERENCES
TEXTBOOK OF PEDIATRIC DENTISTRY Nikhil Marwah

FUNDEMANTALS OF OPERATIVE DENTISTRYBalwant rai Jasdeep kaur ESSENTIALS OF OPERATIVE DENTISTRYI Anand Sherwood
TEXTBOOK OF OPERATIVE DENTISTRY Nisha Garg Amit Garg INTERNET