See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/302199941

Clinical Efficiency of Three Caries Removal Systems: Rotary Excavation,

Carisolv, and Papacarie

Article  in  Journal of dentistry for children (Chicago, Ill.) · January 2016

CITATIONS READS

12 328

4 authors, including:

Sapna Hegde Ateet ashok Kakti

39 PUBLICATIONS   419 CITATIONS   
Riyadh College of Dentistry and Pharmacy
15 PUBLICATIONS   27 CITATIONS   
SEE PROFILE
SEE PROFILE

Dinesh Rao
Pacific University India
65 PUBLICATIONS   434 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Orthodontic Management of Mentally Challenged Individuals. Is It Feasible? View project

All content following this page was uploaded by Dinesh Rao on 29 September 2022.

The user has requested enhancement of the downloaded file.

 JDC CLINICAL ARTICLE

Clinical Efficiency of Three Caries Removal Systems:

Rotary Excavation, Carisolv, and Papacarie
Sapna Hegde, BDS, MDS 1
Ateet Kakti, BDS, MDS 2
Dinesh Rao Bolar, BDS, MDS 3
Shubha Arehalli Bhaskar, BDS, MDS, PhD 4

ABSTRACT
Purpose: The removal of dentinal caries using the rotary method of excavation is
most often associated with pain and anxiety in children. Chemo-mechanical caries
removal may eliminate some of the drawbacks of the rotary technique and improve
patient comfort. The purpose of this study was to compare the efficiency of the rotary,
Carisolv, and Papacarie methods for caries removal in primary teeth, length of time
needed, influence on child behavior, pain perception, and treatment preference of
the child.
Methods: This controlled, split-mouth study with a cross-over design compared three
caries removal methods in the primary molars of 50 five- to 12-year-old children.
Results: The rotary method was the most efficient and least time-consuming
(P<0.001). Pain perception, however, was highest with this method (P<0.05). Papacarie
exhibited a higher efficiency and required fewer applications than Carisolv (P<0.01).
The Papacarie method was the most preferred, and the rotary method the least-
preferred (P<0.05).
Conclusions: Chemo-mechanical caries removal may be a promising alternative treat-
ment procedure, particularly for anxious young patients.
(J Dent Child 2016;83(1):22-8)
Received May 9, 2015; Last Revision July 21, 2015; Revision Accepted August
3, 2015.
Keywords: caries removal, chemomechanical agents, caries excavation

F
inding effective methods of caries removal has
been a major objective for dental researchers. The
fundamental inherent drawbacks of rotary exca-
vation (i.e., unpleasantness to the patient, need for local
anesthesia, and potential adverse effects to the pulp from
heat and pressure) have led to the introduction of the
chemo-mechanical approach as a non-invasive alternative
for the removal of carious dentin.1
1
Dr. Hegde is professor and head, and Drs. 3Bolar and 4Bhaskar are
professors, all in the Department of Pediatric Dentistry, Pacific Den-
tal College and Hospital, Udaipur, Rajasthan, India. 2Dr. Kakti is a
lecturer in Pediatric Dentistry, Preventive Division, Riyadh Colleges
of Dentistry, Riyadh, Kingdom of Saudi Arabia.
Correspond with Dr. Hegde at drsapnahegde@yahoo.co.in
Investigators believe that the chemo-mechanical
method satisfies most of the criteria needed for an ideal
caries removal technique, such as ease of use in the clini-
cal environment; ability to recognize and remove diseased
tissue only; pain-free preparation, thereby eliminating the
need for local anesthesia; absence of potential deleterious
effects to the dental pulp from heat and pressure; freedom
from noise; need for minimal pressure for optimal use;
ease of clinical application; safety; and conservative cavity
preparation for the placement of advanced chemically
adhesive restorative materials.1,2 Chemo-mechanical caries
removal (CMCR) techniques have been used successfully,
especially in children with dental anxiety.3 They can also
be applied where the administration of local anesthesia
is difficult as in very young or uncooperative children or

  22 Hegde et al. Rotary vs. chemomechanical caries removal Journal of Dentistry for Children-83:1, 2016
 contraindicated, as in rare cases of allergy to local anes-
thesia.4,5 However, drawbacks may include prolonged
operating time and the possible need for rotary methods
in order to gain access to the carious dentin so that the
gel can function.2
CMCR systems gained popularity in the late 1990s,
with the advent of Carisolv (Medi Team Dental AB,
Savedalen, Sweden). This system involves the application
of a gel containing an amino acid solution and hypo-
chlorite, which leads to dissolution of collagen fibers
degraded by the dental caries process, facilitating their
removal by manual instruments. 5 In 2003, Papacarie
(Fórmula e Ação, São Paulo, São Paulo, Brazil) was in-
troduced, which contains a proteolytic gel that combines
the collagen degradation effect of papain, a natural prote-
ase, and the bactericide effect of chloramines.6 A system
that reduces/eliminates the need for painful, invasive
dental procedures and maximizes patient comfort during
the dental visit could change the entire face of pediatric
operative dentistry.
The purpose of this study was to compare the effi-
ciency of the rotary, Carisolv, and Papacarie methods for
caries removal, length of time needed, influence on
child behavior, pain perception of and preference of
treatment method by children, in order to obtain insight
into their application and scope in pediatric dentistry.
METHODS
Study approval was obtained from the Ethical Commit-
tee, Pacific Dental College and Hospital, Udaipur, Ra-
jasthan, India. This study was designed as a controlled
split-mouth trial with a crossover design in which three
caries removal methods were compared in five- to 12-
year-old children screened in the Department of Pediatric
Dentistry, Pacific Dental College and Hospital.
Occlusal carious lesions were examined by an experi-
enced clinician visually and via periapical radiographs to
assess the depth of the lesions and rule out any pathol-
ogy. Dental examinations were carried out in a dental chair
under standardized conditions after an oral prophylaxis.
Only children exhibiting definitely positive or posi-
tive behavior according to Frankl’s behavior rating scale7
were included so they could provide appropriate re-
sponses to the operator’s queries. Each child had at least
three primary molars with similar occlusal carious lesions
that were clinically and radiographically judged to extend
at least two mm into the dentin (measured by a World
Health Organization periodontal probe placed into
the cavity depth without pressure), but not involve the
pulp, and have a minimum cavity opening diameter of
1.5 mm for easy access to the lesion (estimated using
digital vernier calipers).
Children with molars showing more than one third
of root resorption were excluded from the study, since
teeth nearing exfoliation respond very differently to cavity
preparation procedures, with little or no pain response.
  Journal of Dentistry for Children-83:1, 2016 Rotary vs. chemomechanical caries removal
Also excluded were children with a history of sponta-
neous pain, any painful sensitivity to cold, or any
clinical or radiographic evidence of periapical/inter-
radicular pathology.
The teeth were randomly allocated to one of three
groups using a random numbers table. After random-
ization, the sample was allocated as follows: Group A
(rotary excavation), Group B (Carisolv), and Group C
(Papacarie) The order of treatment in every child was
also randomized. All clinical interventions were per-
formed by a trained operator, who underwent theoretical
and practical training with a co-investigator, on 15 chil-
dren during a pilot study carried out under the same
conditions as the present study. These children were
eventually included in the study. The criteria for what
would constitute complete caries removal were dis-
cussed exhaustively. At the end of training, the degree
of inter-observer variability between the operator and
the co-investigator was assessed using the kappa statistic.
A kappa coefficient of 0.86 was obtained.
After parental consent, the children were told that
their teeth would be cleaned of germs and their cavities
would be filled with cement. No references were made
to the smells, sounds, or feel of the methods in order to
avoid creating a bias against any method. The children
were not told that a particular method would involve
the sound of the drill or the taste of the material etc.
The patient was asked to sit in a quiet waiting room for
10 minutes before every intervention to avoid/reduce
the effects on behavior between interventions. Caries re-
moval was done under cotton roll isolation with suction,
by the same trained operator. All three interventions
were performed in the same session to allow a more ac-
curate comparison between methods. Child behavior
was assessed using the Frankl behavior rating scale7 at
three points of time: (1) just before the start of the pro-
cedure, once the patient was seated on the dental chair;
(2) during caries excavation; and (3) immediately upon
completion of the procedure. Only the most negative
behavior was noted for study purposes.
Caries in Group A was excavated using a tungsten-
carbide bur at low speed. Local anesthetic was admin-
istered whenever needed/requested by the child; however,
those children requiring local anesthetic were excluded
from the study. In India, it is not customary to anesthe-
tize for enamel/dentinal caries. The children were given
the choice of being treated under a local anesthetic at
the beginning of the study. Those who decided against
the anesthetic were given the option of requesting it at
any point during the procedure.
In Group B, Carisolv gel was mixed using the multi-
mix syringe dispenser according to the manufacturer’s
instructions, dispensed into a dappen dish, and applied
onto the dentinal carious lesions with a plastic filling
instrument. The lesions were completely covered by the
gel for 60 seconds, following which the softened dentin
Hegde et al. 23
was gently excavated using the spoon excavator provided
with the Carisolv kit. During excavation, the clear gel
became opaque or cloudy due to contamination with
debris. The contaminated gel and debris were removed
using a small cotton pelet and fresh gel was applied. This
procedure was repeated until the gel was no longer
cloudy with debris and the cavity surface felt hard on
excavation.
In Group C, caries excavation was carried out using
Papacarie, per the manufacturer’s instructions. The sy-
ringe containing Papacarie was removed from the refrig-
erator half an hour before treatment. The carious
cavities were filled with Papacarie gel, using an appli-
cator tip, and allowed to act for 40 to 60 seconds. The
gel appeared darker in color during the process of de-
composition of the decayed tissue. The decayed dentin,
thus softened, was scraped away with the non-cutting
edge of a sharp spoon excavator in a pendulum motion
without applying pressure. The gel was reapplied until
its light color remained unchanged, without washing or
rinsing the cavity between gel applications. A dark color
indicated that the decomposition of the decayed tissues
was still in progress.
Once the cavities were judged free of caries, the gel
was removed with a cotton pellet soaked in saline. Caries
removal status was evaluated and rated, according to the
scoring criteria of Munshi et al.,8 by an independent co-
investigator who was blinded to the method of caries
removal. Rating was done after the completion of the
procedure for the rotary method and following excava-
tion after the first application of the agent for the chemo-
mechanical methods (Table 1). Caries removal was
considered to be complete when the dentin showed
slight resistance to excavation and the tip of a blunt
dental explorer (moved across the dentinal wall) did not
stick in the dentin or provide a tug-back sensation. If
the dentin was reasonably firm, caries removal was stop-
ped. Discolored/stained dentin was not considered to
be indicative of infection.9-12 The time taken for each
method of intervention was recorded in seconds, using
a stopwatch, from the start of caries removal until the
cavity was confirmed to be free of caries.
Following complete caries removal in each tooth, the
Faces Pain Scale – Revised was used to evaluate the degree
of pain experienced by the child during the procedure.
Children were instructed to select the face that best de-
picted their level of pain. Scores ranging from 0 (no
pain) to 10 (severe pain) were allotted. 13 All cavities
were restored using glass ionomer cement. After comple-
tion of all three procedures, the children were asked to
list the methods of treatment in order of their prefer-
ence. The number of children expressing the highest
preference for each treatment method was calculated.
Data were analyzed using the SPSS 17.0 software for
Windows (SPSS Inc., Chicago, Ill., USA). Results were
expressed as mean with standard deviation. A compari-
son of study parameters between groups was carried out
using analysis of variance and paired t tests. For all
tests, a P-value of 0.05 or less was considered to be
statistically significant.
RESULTS
Eighteen hundred and twenty-eight five- to 12-year-old
patients were screened; 357 presented at least three
teeth with dentinal caries accessible (cavitated) for exca-
vation in the occlusal surfaces but 223 did not meet the
clinical inclusion criteria and 31 were uncooperative.
Parental consent was not obtained for 42 children.
Hence, 61 children (43 boys and 18 girls), with 183
primary teeth, participated in the study. After random-
ization, the sample was allocated as follows: 61 teeth to
Group A (rotary excavation), 61 to Group B (Carisolv),
and 61 to Group C (Papacarie). The order of treatment
in every child was also randomized. During the course
of the study, five patients were lost due to pulp expo-
sure, four due to the need for local anesthetic and two
for uncooperative behavior. Therefore, the final sample
consisted of 50 children (36 boys and 14 girls) and
150 teeth with occlusal carious lesions.
Table 2 presents the distribution of tooth types in
each intervention group. The mean values with standard
deviations of time taken, caries removal efficiency, pa-
tients’ pain perception, and number of applications of

Table 1. Numerical Scoring Criteria For Table 2. Distribution Of Tooth Types By

Caries Removal Status Intervention Groups
Score Scoring criteria Method Primary Primary Total
maxillary teeth mandibular teeth
0 Caries removed completely
1st 2nd 1st 2nd
1 Caries present in the base of the cavity molar molar molar molar
2 Caries present in the base and/or one wall Rotary 5 10 10 25 50
3 Caries present in the base and/or two walls Carisolv 6 12 12 20 50
Caries present in the base and/or more than two Papacarie 8 11 13 18 50
4
walls
Caries present in the base, walls, and margins 19 33 35 63
5 Total 150
of the cavity 52 98

24 Hegde et al. Rotary vs. chemomechanical caries removal Journal of Dentistry for Children-83:1, 2016
 Table 3. Intra-Method Comparison Of Clinical Parameters
Groups Time taken Clinical efficacy scores Pain perception No. of applications of
(seconds) (Munshi caries scores (Faces Pain chemo-mechanical caries
removal criteria) Scale - Revised) removal agent
Mean±(SD) P-value* Mean±(SD) P-value* Mean±(SD) P-value* Mean±(SD) P-value*
Rotary 61.34±30.43 <0.001 0.04±0.19 <0.001 2.58±0.90 0.018 - -
versus
Carisolv 341.21±110.93 1.78±1.07 2.22±0.54

Rotary 61.34±30.43 <0.001 0.04±0.19 <0.001 2.58±0.90 0.006 - -

versus
322.49±91.24 1.20±0.97 2.14±0.64
Papacarie

Carisolv 341.21±110.93 0.347 1.78±1.07 0.006 2.22±0.54 0.502 1.82±0.72 0.007

versus
322.49±91.24 1.20±0.97 2.14±0.64 1.48±0.51
Papacarie

* Analysis of variance; P<0.05=significant.

material (Papacarie and Carisolv) required are presented
in Table 3.
The rotary method exhibited a higher caries-removing
ability than the chemo-mechanical methods (P<0.001).
Papacarie was more efficient than Carisolv (P<0.05).
The rotary method required significantly less time for
complete caries removal than both the chemo-
mechanical methods, which, on average, took over five
times as long as the rotary method (P<0.001). Between
the chemo-mechanical methods, however, there was
no significant difference in length of time needed. On
average, significantly fewer applications of Papacarie
were required for complete caries removal compared to
Carisolv (P<0.01). A significantly higher number of
children reported increased pain perception with the
rotary method compared to the Carisolv (P<0.05) and
Papacarie methods (P<0.01), but not with the chemo-
mechanical methods (P>0.05; Table 3).
In a significant majority of children, the behavior
deteriorated during and after caries removal using the
rotary method (P<0.01). Although behavior improved
slightly on completion of caries removal, there was still
evidence of negative behavior. With the chemo-
mechanical methods, no change was observed in be-
havior toward the negative from before to after the
treatment (Table 4). A significant majority of children
in the study group (48 percent) expressed a preference
for the Papacarie method of caries removal, while 26
percent preferred the Carisolv method and 24 percent
preferred the rotary method (P<0.05).
Table 5 presents the comparison between groups of
mean behavior ratings before, during, and after the in-
terventions. Significant differences were observed in the
children’s behavior during and after treatment with the
rotary and chemo-mechanical methods.
DISCUSSION
CMCR has been reported to be potentially useful and
more effective in treating children.1-3 The rotary method
was the most efficient at caries removal in the present
study, as has been observed in other studies. 1,14-16 Be-
tween Carisolv and Papacarie, the latter was signifi-
cantly more efficient following a single application, an

Table 4. Intra-Method Comparison Of Mean Behavior Rating Of Children

Before, During, And After Procedure
Rotary Carisolv Papacarie
Mean±(SD) P-value* Mean±(SD) P-value* Mean±(SD) P-value*
Before versus 3.18±0.60 <0.001 3.14±0.61 0.659 3.16±0.61 0.444
during
2.44±0.89 3.10±0.30 3.10±0.41
During versus 2.44±0.89 <0.341 3.10±0.30 0.743 3.10±0.41 0.322
after 2.54±0.90 3.12±0.44 3.14±0.41
Before versus 3.18±0.60 <0.001 3.14±0.61 0.821 3.16±0.61 0.785
after 2.54±0.90 3.14±0.61 3.14±0.41

* Paired t test; P<0.05=significant.

  Journal of Dentistry for Children-83:1, 2016 Rotary vs. chemomechanical caries removal Hegde et al. 25
 Table 5. Inter-method Comparison of Mean
Behavior Ratings Before, During, and
After Intervention
Rotary Carisolv Papacarie P-value*
mean±(SD) mean±(SD) mean±(SD)
Before 3.18±0.60 3.14±0.61 3.16±0.61 0.947
During 2.44±0.89 3.10±0.30 3.10±0.41 <0.001
After 2.54±0.90 3.12±0.44 3.14±0.41 <0.001
* One-way analysis of variance; P<0.05=significant.
observation attributable to the proven dental and med-
ical therapeutic effects of papain.1,6,17
In the present study, visual and tactile methods were
used to determine caries removal, which was considered
to be complete based on resistance and dentin hard-
ness but not dentin color. A systematic review of the
literature has demonstrated that, although visual and
visual/tactile methods give low sensitivity, they provide
the highest and least variable diagnostic specificity. 10
Moreover, regardless of the method used to excavate
caries, there is little evidence to support the concept of
complete caries removal. In fact, it is impossible to re-
move all the infected dentin.12 Although the clinical
criterion of dental firmness is subjective, it appears to be
adequate to establish when to stop caries removal. Addi-
tionally, it has been demonstrated that, if the cavity is
properly sealed with an appropriate restorative material,
the residual bacteria at the bottom of the cavity are not
harmful to the dentin-pulp complex and do not lead to
further lesion progression or pulpal damage.18
Caries removal was accomplished in all teeth using
both rotary and chemo-mechanical methods. This find-
ing was in accordance with the results of some studies
comparing the Carisolv and rotary methods.14,15 Other
studies have reported varying degrees of caries removal
with Carisolv, as compared with rotary excavation.5,19,20
Both chemo-mechanical agents took five times lon-
ger than rotary excavation for caries removal, which is
consistent with studies that compared rotary excavation
with Carisolv1,2,5,8,19,20 and Papacarie.21,22 This increased
time has been attributed to the need for multiple appli-
cations of the CMCR gels for complete caries removal19
and to differences in type and size of cavities, type of
teeth, and age of the patient.16 This can be disadvanta-
geous in young children, who are often unable to main-
tain cooperation over prolonged treatment sessions.
Kotb et al.,23 however, observed no difference in time re-
quired by the rotary and Papacarie methods. In the
present study, fewer applications and, consequently, less
time was required for caries removal with Papacarie than
with Carisolv.
26 Hegde et al. Rotary vs. chemomechanical caries removal
A significant number of children in the present study
exhibited deterioration in behavior during treatment
with the rotary method, with improvement observed
after completion of treatment. Some children reported
experiencing an unpleasant feeling caused by the noise
and vibration of the drill. No change was observed in
a majority of children during or after treatment with
Carisolv and Papacarie; in some, however, behavior im-
proved. This is in accordance with the results of several
studies, which have reported reduced anxiety levels with
the use of the CMCR method.3,15,24 Contradictory results
have been reported by Inglehart et al.,25 who found that
the subjects’ fear of the dentist increased in the CMCR
group and decreased slightly in the traditional rotary
method group. They have attributed this finding to the
longer treatment time required for the CMCR method.
It is recommended that intervention strategies (such as
allowing children to watch a favourite videotape or
listen to a recorded story or music) be employed to
enable young children to cope with the additional time
demanded. Anegundi et al.22 did not observe any be-
havior change in children subjected to either the rotary
or Papacarie methods.
In the present study, patients reported significantly less
pain with the CMCR methods when compared to the
rotary method Similar observations have been made by
other investigators comparing the rotary with the
Carisolv3,24 and Papacarie26,27 methods. Inglehart et al.,25
however, observed that a substantial percentage of sub-
jects in their study reported pain with the Carisolv meth-
od. The difference in results may be due to the subjective
nature of pain as well as variability of the pain threshold
among individuals.15 The difference in pain scores be-
tween the chemo-mechanical and rotary methods could
be attributed to the inadvertent removal of sound den-
tin with the latter method.28 The chemo-mechanical gel
itself may have a thermal insulating function because it
covers the cavity during the procedure. The method
also expects not to open so many dentinal tubules as in
drilling.29 Furthermore, pain experience is extremely sug-
gestive, and the introduction of a new method and all
circumstances surrounding a clinical trial may have in-
fluenced the children.30
A few patients experienced pain during rotary excava-
tion of caries and required local anesthesia. This affected
the pain perception recordings, and the patient’s behavior
during the treatment led to increased working time and
an unpleasant feeling for the patient. This, in turn, affected
the choice of or preference for caries removal method.
Hence, these children were excluded from the study
sample. With the CMCR agents, the need for the use of
local anesthetic did not arise, which may indicate a clear
advantage of these agents over the rotary method.
The Papacarie method was most preferred by the
children in the present study, followed by the Carisolv
and rotary methods. This could be explained by the fact
Journal of Dentistry for Children-83:1, 2016
 that, in addition to eliminating/reducing the pain and an-
xiety associated with drilling, Papacarie also takes shorter
time than Carisolv. Other studies3,15 have also reported a
higher preference by children for the chemo-mechanical
method over the rotary. Contrasting results were reported
by Maragakis et al.,1 who found that patients preferred
the air rotor method because it was quicker, tasted better,
and allowed them to finish sooner, which was the case
for some children in the present study. Thus, time may
be a crucial factor that influences the acceptance of
treatment by pediatric patients.
Further studies with larger sample sizes are recom-
mended with an additional group, in whom manual
excavation of caries can be done using hand instruments
only, that can be compared with the three methods al-
ready tested. It is also suggested that an assessment of
clinical efficiency be made based on tooth type.
The CMCR technique, together with the adhesive re-
storative technique, may reduce patient discomfort, avoid
the unnecessary removal of sound dental tissue and pre-
vent accidental exposure of the pulp. However, the chief
disadvantage of the chemo-mechanical technique, i.e.,
the longer time required for caries removal, needs to be
addressed and less time-consuming agents need to be
developed. Moreover, the cost of CMCR agents and
their limited shelf life may make their use less economical
and limit their routine use in clinical practice. Hence,
the importance of conventional rotary techniques cannot
be negated and, until a substitute for the same is dis-
covered, chemo-mechanical methods may be used without
any other mechanical aid only in cases with free access
to the carious lesion. This study is limited in the lack
of inclusion of a group in whom caries excavation was
done under local anesthesia, which may have resulted in
better acceptance of the rotary technique.
CONCLUSIONS
Based on the results of this study, the following conclu-
sions can be made:
1. The rotary method was the most efficient in caries
removal and required the least amount of time.
2. Both chemo-mechanical caries removal agents took
five times longer than rotary excavation for caries
removal.
3. The rotary method more often led to deterioration
in behavior compared to the CMCR methods but
the children were not anesthetized.
4. Children reported less pain with the CMCR
methods.
5. The Papacarie method was the most preferred
method by the children.
  Journal of Dentistry for Children-83:1, 2016 Rotary vs. chemomechanical caries removal
REFERENCES
1. M aragakis GM, Hahn P, Hellwig E. Chemome-
chanical caries removal: a comprehensive review of
the literature. Int Dent J 2001;51(4):291-9.
2. Banerjee A, Watson TF, Kidd EAM. Dentin caries
excavation: a review of current clinical techniques.
Br Dent J 2000;188(9):476-82.
3. Ansari G, Beeley JA, Fung DE. Chemomechanical
caries removal in primary teeth in a group of an-
xious children. J Oral Rehabil 2003;30(8):773-9.
4. Yip HK, Stevenson AG, Beeley JA. Chemomechanical
removal of dental caries in deciduous teeth: further
studies in vitro. Br Dent J 1999;186(4 Spec No.):
179-82.
5. E ricson D, Zimmerman M, Raber H, Götrick
B, Bornstein R, Thorell J. Clinical evaluation of
efficacy and safety of a new method for chemo-
mechanical removal of caries: a multicentre study.
Caries Res 1999;33(3):171-7.
6. Bussadori SK, Castro LC, Galvão AC. Papain gel:
a new chemomechanical caries removal agent.
J Clin Pediatr Dent 2005;30(2):115-9.
7. Frankl SN, Shiere FR, Fogels HR. Should the parent
remain with the child in the dental operatory?
ASDC J Dent Child 1962;29(2):150-63.
8. Munshi AK, Hegde AM, Shetty PK. Clinical evalu-
ation of Carisolv in the chemico-mechanical rem-
oval of carious dentin. J Clin Pediatr Dent 2001;
26(1):49-54.
9. Bader JD, Shugars DA, Bonito AJ. A systematic
review of the performance of methods for identi-
fying carious lesions. J Public Health Dent 2002;
62(4):201-13.
10. NIH consensus development conference on diagn-
osis and management of dental caries throughout
life. Bethesda, Md., USA, March 26-28, 2001. Con-
ference Papers. J Dent Educ 2001;65:935-1179.
11. Dennison JB, Hamilton JC. Treatment decisions
and conservation of tooth structure. Dent Clin
North Am 2005;49(4):825-45.
12. Kidd EAM, Joyston-Bechal S, Beighton D. The
use of a caries detector dye during cavity prepara-
tion: a microbiological assessment. Br Dent J 1993;
174(7):245-8.
13. Hicks CL, von Baeyer CL, Spafford PA, van Korlaar
I,  Goodenough B. The Faces Pain Scale-Revised:
toward a common metric in pediatric pain mea-
surement. Pain 2001;93(2):173-83.
14. Fure S, Lingström P, Birkhed D. Evaluation of
Carisolv for chemomechanical removal of primary
root caries in vivo. Caries Res 2000;34(3):275-80.
15. Lozano-Chourio MA, Zambrano O, González H,
Quero M. Clinical randomized controlled trial of
chemomechanical carious dentin removal (Carisolv).
Int J Paediatr Dent 2006;16(3):161-7.
Hegde et al. 27
16. Bussadori SK, Martins MD, Fernandes KPS, et al.
Evaluation of the in-vitro biocompability of a new
material for the chemical and mechanical removal
of caries Papacarie. Pesq Bras Odontoped Clin
Integr 2005;5(3):253-9.
17. Kimmel JR, Smith EL. The properties of Papain. Adv
Enzymol Relat Subj Biochem 1957;19:267-334.
18. Nyvad B, Crielaard W, Mira A, Takahashi N,
Beighton D. Dental caries from a molecular mi-
crobiological perspective. Caries Res 2013;47(2):
89-102.
19. Kakaboura A, Masouras C, Staikou O, Vougiouklakis
G. A comparative clinical study on the Carisolv car-
ies removal method. Quintessence Int 2003;34(4):
269-71.
20. Balciuniene I, Sabalaite R, Juskiene I. Chemome-
chanical caries removal for children. Stomatologija
2005;7(2):40-4.
21. Ferrari JCL, Motisuki C, Bortoletto CC, Santos-
Pinto L. Efficiency of Papacarie in. the  chemo
-mechanical carious dentine removal. Rev Bras
Odontol 2005;62(2):209-11.
22. Anegundi RT, Patil SB, Tegginmani V, Shetty SD.
A comparative microbiological study to assess car-
ies excavation by conventional rotary method and
a chemo-mechanical method. Contemp Clin Dent
2012;3(4):388-92.
23. Kotb RM, Abdella AA, El Kateb MA, Ahmed AM.
Clinical evaluation of Papacarie in primary teeth. J
Clin Pediatr Dent 2009;34(2):117-23.
28 Hegde et al. Rotary vs. chemomechanical caries removal
View publication stats
24. Bergmann J, Leitão J, Kultje C, Bergmann D, Clode
MJ. Removing dentin caries in deciduous teeth
with Carisolv: a randomized, controlled, prospective
study with six-month follow-up, comparing che-
momechanical treatment with drilling. Oral Health
Prev Dent 2005;3(2):105-11.
25. Inglehart MR, Peters MC, Flamenbaum MH, Eboda
NN, Feigal RJ. Chemomechanical caries removal
in children: an operator’s and paediatric patients’
responses. J Am Dent Assoc 2007;138(1):47-55.
26. Silva LR, Motta LJ, Reda SH, Facanha RAA, Bus-
sadori SK. Papacarie: new system for chemical and
mechanical removal of carious tissue—case report.
Rev Paul Odontol 2004;26(6):4-8.
27. Maru VP, Kumar A, Badiyani BK, Sharma AR,
Sharma J., Dobariya CV. Behavioral changes in pre-
schoolers treated with or without rotary instruments.
J Int Soc Prev Community Dent 2014;4(2):77-81
28. Pandit IK, Srivastava N, Gugnani N, Gupta M, Verma
L. Various methods of caries removal in children:
a comparative clinical study. J Indian Soc Pedod
Prev Dent 2007;25(2):93-6.
29. Lopes MC, Mascarini RC, da Silva BMC, Florio FM,
Basting RT. Effect of papain-based gel for chemo-
mechanical caries removal on dentin shear bond
strength. J Dent Child 2007;74(2):93-7.
30. Zinck JH, McInnes-Ledoux P, Capdeboscq C,
Weinberg R. Chemomechanical caries removal:
a clinical evaluation. J Oral Rehabil 1988;15(1):
23-33.
Journal of Dentistry for Children-83:1, 2016