Operative Dentistry

Clinical guide for removing caries nsing a caries-detecting solution

Tiikao Fusayama. DDS, DMSc*

Introduction

The Caries Detector (Kuraray Co) is a solution which

permits differentiation between infected, irreversibly
deteriorated outer canous detitin and uninfected but
reversibly detiatured inner carious dentin.'"' Its devel-
opment has allowed minimal tooth structure to be
removed and has furthered "painless dentistry" inso-
far as it requires removal of only the peripheral, non-
vital carious dentin. The system utilizes chemically
adhesive composite resins. (At least three currently
available adhesive composite resins have been shown
to be reliably adhesive to both enamel and dentin.^)
This paper describes improved application tech- Fig 1 The Caries Detector, as marketed.
niques developed upon ten years' clinical experience
with the Caries Detector.

Formuiation BASIC FUCHSIN tH,

(magent a)
The Canes Detector is widely distributed. However, \
'• / \

because it is still unavailable in some countries, and CîoHiD MaCl

Mol.w, - 33
because complete removal of the canous denlin with-
out overreduction is essential for successful adhesive
composite resin restorations, the contents of the Caries 0 . 5 % BASIC FUCHSIN SOLUTION IÍJ PROPYLEME GLYCOL

Detector are presented here for noncommercial prep- detection i s

The dos e pos si b l y swdllowed on caries
aration.
1/17,000,000
Initially the Caries Detector included a 0.5% basic
fuchsm solution in propylene glycol.' - When the prod- the dos ssary to produce eiperim Fntal cancers.
uct was placed on the market, however, the fuchsin
was replaced with a substitute dye because fuchsin is Fig 2 Chemicai structure of basic fuchsin.
beheved to be carcinogenic. 1.0% Acid Red 52 solution
in the same solvent was then found to function simi-
larly and wa5 marketed as the Caries Detector
(Fig Î).
Basic fuchsin produeed lymph gland eancers in an
animal experiment.* The dose that could possibly be
swallowed by a patient during application of the
CariesDetectoris, however, only'/Í7 x 10^ of the dose
Emeritus Professor, Tokyo Medical and Denial University; Guest that produced the experimental tumor (Fig 2) and
ProfesEoi, Showa University Denial Hospital. Address all corre-
spondence (o: Dr T. Fusayama, 4-16-23 Kamiigusa, Suginamiku,
appears to pose no risk when prepared as described.
Tokyo 167, Japan. Fuchsin penetrates the outer carious dentin somewhat

Quintessence International Voiume t9, Number 6/1988 397

Operative Dentistry
ACID
(Food Red 106)
C27H 2907N2S2fJa
Mol w, = 50a,fi7
1
(Aci d Rhodamine B)
V 0,5* Basic Fuchsin
1.0 ¿ ACID RED SOLUTION IN PROPYLENE GLYCOL
no tl-carcinogenic
Fig 3 Chemicai structure ot Acid Red 52.
more easily than Acid Red 52 because of its smaller
molecular size (Fig 3). Thus, repetition of detection
procedures and reduction of tooth structure can be
minimized. The noncomtnercially prepared sololion
can be applied with an endodontic syringe (Fig 4),
DiffereDtial-stainiiig mechanism
The differential staining is not the result of a chemical
bond: tbis is obvious because tbe basic and acidic dyes
stain (differentiate) in a similar manner and the stain
fades away with time. Further, the differentiation has
no relation to either the degree to which deminerali-
zation has occurred or the hardness of the tooth strnc-
ture. Neither is the staining dependent on penetrability
of the dentinal tubules, because it differentiates be-
tween carious and noncarious structure even in pulp-
less or desiccated extracted teetb having open dentinal
tubules with broken odontoblast processes.
The outer carious dentin stainable by the solution
has collagen fibers loosened by irreversible breakdown
of the intermolecular crosslinks, whereas the inner car-
ious dentin and normal dentin, which are unstainable,
have solid collagen fibers with undisturbed molecular
structure.' ' Only the loosened collagen fibers of the
outer carious dentin seem to permit penetration of the
solvent (p ropy le ne glycol).
Uses
Vitai teeth
With conventional tactile methods of caries diagnosis,
acute caries is likely to result in overreduction because
398
1.0Ï Acitî Red 52
in propylene glycol
Fig 4 The noncommercialiy prepared solution in a sy-
ringe.
carious dentin is softened by demineraüzation, which
far precedes actual bacterial invasion.* Tissue affected
by chronic caries, on the other hand, is apt to be
underreduced, resuhing in incomplete removal of in-
fected tissue. This occurs because the carious tissue is
only slightly softened and bacteria will penetrate eveti
up to fairly hard tissue.
The use of the Caries Detector allows greater ac-
curacy in removing only the tissue that is infected and
irreversibly deteriorated. Unstained (uninfected) inner
carious dentin, though softened, is left intact, while
stained (infected), hard tissue is removed (Fig 5). Fur-
ther, because only tbe stained outer carious dentin is
removed, and because the adhesive composite resin
restoration to be placed does not require mechanical
retention, reduction is usually a painless procedure.
The use of the Caries Detector in vital teeth has
other advantages. Undermined free enamel is dis-
closed by the stained outer carious dentin beneath it,
thus facilitating cavity preparation. Additionally, the
detector is especially useful in the treatment of acute
caries in a young looth, often experienced with a pri-
mary tooth or a newly erupted third moiar. In such
cases, even sound dentin is very soft in the deep layer,
and natural carious discoloration is very light. If an
attempt is made to remove the softened dentin com-
pletely, the pulp can easily be exposed. The detector
minimizes Ihe chances of such an occurrence by mak-
ing the infected tissue more easily visttahzed, ever
when the infected outer carious dentin is very close to
the pulp horn. Better visualization of such infected
tissue also facilitates diagno,sis of the pulp. If the stain-
ing extends completely to the pulp, the pulp will be
exposed when the stained tissue is removed and must
Quintessence internationai Volume 19, Number 6/1983
 operative Dentistry

Acute or Moderate Carles

Outer Carious Dentin Inner Carious Demin Dark Discoloration

intected unintected masking
rrot remineraliiable remineralizable the detector's
nonvitaf vital-sensrtive stairirng
stainable by detector rot stainable by detector (to be removed)
(to be oved 1 (tobepr ed)

Fig 5 Detector-guided canes re-

moval of acute and chronic caries.

•ashing

Fig 6 Application ot ttie detector.

be regarded as infected; otherwise the pulp can be tissue will eventually damage the seal of endodontic
diagnosed with certainty as being healthy. material. Complete removal of the stained tissue guar-
antees aseptic endodontic treatment.

Nonvital teeth Other uses

In the restoration of a pulpless tooth, it is necessary
to provide a solid base for restoration by completely
removing the nonremineralizable carious dentin,
which can allow leakage and further carious invasion.
Complete reduction of the stained tissue and the
heavy, natural carious discoloration assures complete
removal of the infected tissue.
In endodontic therapy, it is essential that tissue be
removed if it is infected and softened because stich
The Caries Detector can be used as a guide in the
removal of carious enamel. However, application of
the solution to enamel sometimes fails to stain de-
mineralized tissue when that tissue is covered by thin,
superficial, dense enamel or a surface deposition of
calcitim salt from sahva. Nevertheless, even in such
cases, the demineralized tissue can be stained in the
prepared wall of a cavity.
Finally, the Caries Detector ean be used to disclose

Quintessence Internationai Vglurne 19, Number 6/1988 399

Operative Dentistry
Fig 7 A small, round bur is used for a narrow, deep path
ol caries invasion.
carious, demineralized root surfaces, as well as de-
posits of dental plaque.
Technique
Before the detector is apphed, the carious lesion is
cleansed with water and dried thoroughly with an air
syringe. Any contaminant, including water, will inhibit
staining.
One drop of the solution is applied to the lesion,
where it is allowed to penetrate _/<»• a full ten seconds
(Fig 6). A vacuum ejector is held close to the lesion,
and the lesion is rinsed with water. The solution is
rinsed off carefully, so that it does not splash otit of
the mouth. When the red color is no longer visible, it
is spray-washed with water/air jet and then air-dried.
The detector will probably not penetrate through all
carious tissue in one application. Therefore, applica-
tion/reduction must be repeated until application of
the detector produces no further staining. For a small,
acute carious lesion, three repetitions may be neces-
sary for complete removal; harder, chronically carious
dentin, which the detector will penetrate more slowly,
will require more.
Ensuring "painless" reduction
As discussed, use of the Caries Detector should allow
restoration to proceed painlessly. Although a patient
will occasionally experience some sensation or even
slight pain because the tissue immediately adjacent to
the sensitive inner carious dentin is reduced, it is usu-
ally not severe enough to warrant anesthesia.
Several precautions should be taken to ensure pain-
400
le.ss treatment. As enamel is being reduced, water
should be tised in conjunction with the high-speed air
turbine to prevent pain caused by friction heat.
Carious dentin must be reduced at low-speed with a
round steel bur. The use of a high-speed turbine is apt
to induce pain, either by accidental cutting into sen-
sitive tissue or even by friction heat against deminer-
alized tissue.
Occasionally the carious area of dentin is in the
shape of a deep, narrow cone. In such cases, a small
round bur must be used to remove the infected tissue
without impinging upon the surrounding sensitive
dentin (Fig 7).
Carious dentin must be reduced in a dry state. If it
is cut while wet, visualization of the stained tissue will
become difflcult, wet debris will become packed into
the bur, and friction heat will cause pain.
Finally, reduction should not extend into unstained
dentin: this has no benefit and in fact is injurious. The
so-called pioneer bacteria layer' is certainly removed
with the retnoval of all stainable tissue.
Cases in which painless caries removal is impossible
There are, of course, instances when painless reduc-
tion is not possible. These include the following:
1. Preparation of teeth to receive restorative materials
other than the ehemically adhesive composite resiti.
Anesthesia is required when reduction must extend
into sensitive, vital dentin to accommodate the pre-
ventive and retentive requirements of various res-
torative materials,
2, Selective reduction of stainabie tissue located in an
area that is difflcult to reach or difftcuh to visu-
alize. In such cases, anesthesia is sometimes re-
quired even for an adhesive resin restoration.
3, Treatment of a wedge-shaped cervical erosion.
Although the dentin is reduced only slightly, an
especially sensitive tooth will require anesthesia.
4. Treatment of proximal caries in a posterior tooth.
The use of anesthesia may be required if vital den-
tin must be cut because an occlusal approach is
made rather than an approach through the inter-
dental space.
Although the need for anesthesia in .such cases is
sometimes inescapable, its use is nevertheless better
avoided as much as possible. Reduction with anes-
thesia can result in over reduction: pain serves as a
warning in preventing overreduction and contributes
Quintessence International Volume 19, hJumber 6/19SB

to the maximal preservation of the strength atid vi-
tality ofa tooth.
Preparation using the Caries Detector
When there is acute caries, the detector can be used
throughout the procedure because it will stam carious
enamel, undermined enamel, and the outer carious
dentin. Caries removal can procede quickly, with the
simultaneous opening of the cavity and removal of
carious tissue.
For a cavity of small aperture, such as an initial
occlusal fissure caries or a small proximal carious le-
sion, the detector is applied after the cavity has been
opened because the stained dentin cannut he visual-
ized otherwise.
With a cervical lesion, wedge-shaped erosion, or
other defect long-exposed to the oral environment,
some calcium salt deposition is to be expected. Be-
cause such a surface cover is difficult to stain, the area
should be reduced slightly to facilitate subsequent
staining.
Finally, when there is chronic caries, with a thick,
heavily discolored layer of hard carious dentin, gross
reduction should be made prior to application of the
detector. Because the depth of detector penetration per
application is limited in hard carious dentin, use of
the detector from the beginning of the procedure
would only necessitate lengthy repetition of staining
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Ouintessence International Volume 19, Number 6/1968
operative Dentistry
and reduction. In such cases, the detector is better
used for staining residual infected dentin once reduc-
tion more closely approaches sensitive tissue.
Summary
The Caries Detector has been an asset to the under-
standing of and techniques for caries removal. This
report has described the principals, applications, and
methods of caries removal using the detector.
References
1, hiisayama T, Ttrashima S: Differentiation of tivo layers of car-
ious dentin by staining. Bull Tokyo Med Dent Univ 1972; 19:83,
2, Fusayama T: Two layers of carious dentin: diagnosis and treat-
ment, Oper Dent 1979; 4:63.
3, Fusayama T: Netv Concepts in Operative Denlislrv. Chicago,
Quintessence Pub Co, Inc, 1980; pp IS 46, 49 S3, 84-94.
4, Fusayama T. Nakamura tvl, Kurosaki N, et al: Non-pressure
adhesion of a new adhesii'e restorative resin, J Dem Res 1979:
58:t364.
5, Nakajinia A: Bond strength of tbe adhesive composite resins.
Part 1 (Japanese), J Jpn Soc Dem Mater Devices 1983; 2;623,
6, .Survey of eompounds which have been tested for carcinogenic ac-
liviiy. National Cancer Institute, Public Health Service pnblica-
tion No, 149, suppl 2. 1954-196Ü,
7, Kuboki T, Ohgushi K, Fusayama T; Collagen biocbemistry of
the two layers of carious dentin, J Dent Res 1977; 56;1233,
8, Fusayama T, Okuse K.: Microbial invasion in carious dentin,
J Dent Res 1966; 45;1033. D
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