CHEMOMECHANICAL CARIES REMOVAL

• Use a solution to chemically alter

carious tooth to further soften it.
PRINCIPLE • Softened dentin removed using hand
instruments.

• 1970’s

HISTORY • EDTA, collagenase, sodium dodecyl

sulfate.

1
 An alternative to the conventional mechanical removal of caries is chemo
mechanical method.

 The need for local anesthesia is reduced or eliminated as there is little

pain during the procedure.

 It is an effective alternative for caries removal because it brings together

atraumatic characteristics and bactericide / bacteriostatic action.

 The chemicals used can be in the form of liquid (caridex) or gel (carisolv).

2
 Agents

Sodium
Enzyme
Hypochlorite
based
Based

GK-101E
GK-101 Carisolv Papacarie Carie care Brix 3000
(Caridex)

3
 GK-101
 Introduced in 1976

 Solution A- 0.05% Nmonochloroglycerine

Solution B-4-6% NaOCl

 Mechanism of Action: Chlorination of

denatured collagen by conversion of
hydroxyproline to pyrrole-2-
carboxyglycine •

 Limitation: Need special equipment for

delivery. 4
 GK-101E (CARIDEX)
 Introduced in 1984, CM Habib • Solution A- 0.05% N-
monochloro-DL-2amino butyrate(NMAB) • Solution B-4-6%
NaOCl

 The system involved the intermittent application of preheated

N- monochloro-DL-2-aminobutyric acid (GK-101E) to the
carious lesion.

 The solution was claimed to cause disruption of collagen in

the carious dentine, thus facilitating its removal.
5
 The mechanism of softening involved chlorination of remaining partially
degraded dentinal collagen and the conversion of hydroxyproline to pyrrole-2-
carboxylic acid, which initiated disruption of the altered collagen fibers in the
caries.

 Disadvantages:

1. Expensive

2. Large quantity required

3. Solution had to be heated

4. Short shelf-life
6
5. Hand instruments were not optimum
 CARISOLV
 During the 1980s studies at the universities by Malmo, Huddinge at
Chalmers Technical university in Goteborg was directed toward a more
efficient and effective chemomechanical caries removal system than
caridex.

 Carisolv key difference to other products already in the market was the use
of three amino acids – Lysine, leucine, and glutamic acid – instead of the
aminobutyric acid.
7
 These aminoacids counteracted the sodium hypochlorite aggressive
behavior at the oral healthy tissues.

 Despite its effectiveness, carisolv was not a blockbuster mainly because it

required-

1. Extensive training and registration of professionals

2. Customized instruments which increased the cost of the solution

8
 CONSTITUENTS OF CARISOLV
1. Syringe one: sodium hypochlorite (0.5%)
2. Syringe two: three amino acids (glutamic
acid, leucine, lysine)
3. Gel substance: carboxymethlcellulose
4. Sodium chloride / sodium hydroxide
5. Saline solution coloring indicator (red)
6. Available as single mix or multi mix
syringes.

9
 Original gel :
 Before 2004

 Syringe A : Carboxymethyl cellulose based gel ,

coloring agent, amino acids(glutamine,leucine,lysine)

 Syringe B: 0.25% NaOCl

 Action is similar to caridex but amino acids react with

different moieties of carious lesion.

 Higher viscosity, easier handling.

 Caries excavation time: 10.4-12.2 minutes 10

 Modified gel:
 After 2004

 Multimix syringe

 Amino acid concentration halved

 NaOCl increased by 0.475%

 Caries excavation time:9.0-11.4minutes

 Comes with a set of hand instruments

11
12
 NEW CARISOLV SYSTEM
 2013

 Incorporation of minimally invasive

burs(Cerabur,polymer bur)

 Special detector dye

 Shortened caries excavation time

 Caries excavation time:7.6+/-

4.2minutes 13
 INDICATIONS OF CARISOLV
1. Where the preservation of tooth structure is important. The removal of root /
cervical caries.
2. The management of coronal caries with cavitation.
3. The removal of caries at the margins of crowns and bridge abutments.
4. The completion of tunnel preparations. Where local anesthesia is
contraindicated.
5. The care of caries in dentally anxious patients, notably needle phobic's.
6. Management of primary carious lesions in deciduous teeth. Atraumatic
restorative technique procedures.
7. Caries management in patients with special needs.
14
 PROCEDURE
1. Mix the two components of carisolv (NaOCl and amino
acid solution) thoroughly according to the instructions
included with the package. Put the required amount of gel
into a suitable container.

2. Use a carisolv instrument to pick up the gel and apply it to

the carious dentine

3. Soak the caries generously

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

soften the caries
15
5. Select a power drive tip or a Carisolv hand instrument to
match the size, position and accessibility of the cavity

6. Scraped off the superficial softened carious dentine. The hand

instrument with the multistar tip may facilitate the early
penetration of the gel. Work carefully using scraping or rotating
movements

7. Remove the softened carious dentine with the instrument.

Avoid flushing or drying the cavity

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

9. Repeat until the gel no longer turns cloudy and the surface feels
16

hard using the instrument

10. 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

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

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

13. If necessary the periphery of the cavity should be adjusted

using hand instruments or the drill

14. Restore the tooth with a suitable filling material according

to the manufacturer’s instructions for use 17
 ADVANTAGES OF CARISOLV
1. Three amino acids are incorporated instead of one, and the different charges have
improved the interaction with the degraded collagen within the lesion, thus increasing the
efficacy.

2. Carisolv has a higher viscosity, which allows for the application of higher concentrations
of amino acids and sodium hypochlorite without increasing the total amount of fluid
used, therefore reducing the total volume required.

3. The solution does not need to be heated, or applied through a pump mechanism.

4. The increased viscosity of carisolv enhances precision placement.

5. The overall stability is increased, giving an improved shelf life.

18
 CARIDEX
CARISOLV

Chemical 1% NaOCl 0.5% NaOCl

Composition 0.1 M aminobutyric acid 0.1 M glutamic acid /
Glycine luecine
NaCl and NaOH NaCl and NaOH

Dye ---- Erythrocin (pink)

PH 11 11

Physical properties Liquid Gel

Volume Needed 100-500 ml 0.2-1.0 ml

Time 5-15 mins 5-15 mins

Required 19

Ref. pg. no. 491-492, S.G. Damle, 3rd edition

 PAPAIN GEL
 In 2003, a research project in Brazil led to the
development of a new formula to universalize the use
of chemo-mechanical method for caries removal and
promote its use in public health.

 The new formula was commercially known as

papacarie.

20
 It is basically composed of Papain,
chloramines, toluidine blue, salts,
thickening vehicle, which together are
responsible for the papacarie’s bactericide,
bacteriostatic and anti-inflammatory
characteristics.

 Papain comes from the latex of the leaves

and fruits of the green adult papaya

21
 Chemical
debridement

Papain
gel
Granulation and
Stimulation of the epithelialization,
tensile strength of which hastens the
the scars. phases of
cicatrization

22
 MECHANISM OF ACTION
1. Antitrypsin inhibits protein digestion but infected tissues do not usually show
antitrypsin.

2. Since Papain can digest only dead cells, it acts breaking the partially degraded
collagen molecules, contributing to the degradation and elimination of the fibrin
“mantle” formed by the carious process.

3. Right after the degradation, oxygen is freed, bubbles appear on the surface, and a
blearing of the gel is thus noted.

4. These signs demonstrate that the removal process can be started.

23
5. For removal, we recommended the use of the opposite side of an excavator, like a
pendulum movement and without cutting.

6. The instrument should scrap the carious tissue without promoting any kind of
stimulus or pressure.

7. The main characteristics of the complete removal of the infected dentinal tissue is
the vitreous aspect of the cavity which appears after using Papacarie.

24
 PROCEDURE FOR PAPAIN GEL

 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 Papacarie, allowing the chemistry to work for 30 to

40 seconds

25
 Removal of the softened carious dentin The vitrous aspect of the cavity
appears when the cavity feels free from caries

 Rinsing 0.12%, 1% or 2% chlorhexidine or waterspray

 Drying with moisture-free and oil-free air

 Restoration with a suitable filling material according to manufacturer’s

instructions

26
1. Arrow indicating proximocclusal carious lesion
2. Isolation and application of Papain Gel
3. Caries had been removed
4. Arrow showing filled cavity with composite 27
 CARIE CARE
 Carie care gel, an innovation of Indian origin,
contains papaya extract as its key ingredient together
with chloramines, dye, and clove oil.

 It acts as a debris removing agent with no harmful

effect on sound tissues because of the enzyme
specificity with additional benefits of clove oil
inducing mild analgesic, antiseptic, and anti-
inflammatory effect

28
 BRIX 3000
 BRIX3000 is an innocuous papain-based gel
formulation, introduced in 2012 by Brix Medical
science, Argentina.

 The unique features of this product include the

high concentration of papain (3000 U/mg) and
bioencapsulation (EBE) technology, which
provides the gel with the optimum pH to
immobilize the enzyme at the moment of exerting
proteolysis in collagen hence, increasing its activity
29
ADVANTAGES OF CHEMICO-MECHANICAL
METHOD

1. Its proven effectiveness Method’s safety

2. Elimination of local anesthesia Lower anxiety built in patients

Conservation of the sound tissue

3. Only demineralised dentine containing collagen is affected.

4. Gel consistency simplifies control of the application and reduces the

risk of spillage. 30