Published on September 16, 2016
1. Hayat Al-Ghutaimel
2. Background Finding effective methods of caries removal has been a major objective for dental researchers. The fundamental inherent drawbacks of rotary excavation have led to the introduction of the chemo-mechanical.
3. Background Investigators believe that the chemo-mechanical method satisfies most of the criteria needed for an ideal caries removal technique, such as: ease of use ability to recognize and remove diseased tissue only pain-free preparation, thereby eliminating the need for local anaesthesia absence of potential deleterious effects to the dental pulp from heat and pressure freedom from noise
4. Background Two CMCR systems are available: Carisolv (Medi Team Dental AB,Savedalen, Sweden) 1990: Gel containing an amino acid solution and hypochlorite, which leads to dissolution of collagen fibers degraded by the dental caries process, facilitating their removal by manual instruments.
5. Background Two CMCR systems are available: Papacarie (Fórmula e Ação, São Paulo, Brazil) 2003: proteolytic gel that combines the collagen degradation effect of papain, a natural protease, and the bactericide effect of chloramines
6. OBJECTIVE To compare the efficiency of the rotary, Carisolv, and Papacarie methods for caries removal, length of time needed, influence on child behaviour, pain perception and preference of treatment method by children.
7. Method Study approval was obtained from the Ethical Committee, Pacific Dental College and Hospital, India. Study 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
8. Method Occlusal carious lesions were examined by an experienced clinician visually and via periapical radiographs to assess the depth of the lesions and rule out any pathology. Dental examinations were carried out in a dental chair under standardized conditions after an oral prophylaxis.
9. Method Only children exhibiting (++) or (+) according to Frankl’s behaviour rating scale were included so they could provide appropriate responses to the operator’s queries.
10. Method Each child should had at least 3 primary molars with similar occlusal carious lesions that were: Clinically and radiographically judged to extend at least 2mm into the dentin (measured by a WHO periodontal probe), but not involve the pulp, Have a minimum cavity opening diameter of 1.5 mm for easy access to the lesion (estimated using digital vernier calipers).
11. Method Children with molars showing more than one third of root resorption were excluded from the study. Children with a history of spontaneous pain, any painful sensitivity to cold, or any clinical or radiographic evidence of periapical/interradicular pathology were also excluded.
12. Method The teeth were randomly allocated to one of three groups using a random numbers table. After randomization, 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.
13. Method All clinical interventions were performed by a trained operator, who underwent theoretical and practical training with a co-investigator, on 15 children during a pilot study carried out under the same conditions as the present study.
14. Method The criteria for what would constitute complete caries removal were discussed 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.
15. Method 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.
16. Method The patient was asked to sit in a quiet waiting room for 10 minutes before every intervention to avoid/reduce the effects on behaviour between interventions. Caries removal was done under cotton roll isolation with suction, by the same trained operator.
17. Method All three interventions were performed in the same session to allow a more accurate comparison between methods. Child behaviour was assessed using the Frankl behaviour rating scale at three points of time: (1) just before; (2) during caries excavation; and (3) immediately upon completion of the procedure.
18. Method Caries in Group A was excavated using a tungsten carbide bur at low speed. Local anaesthetic was administered whenever needed/requested by the child; however, those children requiring local anaesthetic were excluded from the study.
19. Method In Group B, Carisolv gel was mixed using the multimix syringe dispenser, 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 was gently excavated using the spoon excavator provided with the Carisolv kit.
20. Method 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 pellet 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.
21. Method In Group C, caries excavation was carried out using Papacarie. The syringe containing Papacarie was removed from the refrigerator half an hour before treatment. The carious cavities were filled with Papacarie gel, using an applicator tip, and allowed to act for 40 to 60 seconds.
22. Method The gel appeared darker in colour during the process of decomposition of the decayed tissue. The decayed dentin, thus softened, was scraped away with the non-cutting edge of a sharp spoon excavator. The gel was reapplied until its light colour remained unchanged.
23. Method 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. Discoloured/stained firm dentin was not considered to be indicative of infection.
24. Method Caries removal status was evaluated and rated, according to the scoring criteria of Munshi et al., by an independent co-investigator who was blinded to the method of caries removal.
25. Method 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.
26. Method 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. Scores ranging from 0 (no pain) to 10 (severe pain) were allotted.
27. Method All cavities were restored using GIC. After completion of all three procedures, the children were asked to list the methods of treatment in order of their preference. The number of children expressing the highest preference for each treatment method was calculated.
28. Method Data were analysed using the SPSS 17.0 software Results were expressed as mean with standard deviation. A comparison 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.
29. Results 61 children (43 boys and 18 girls, age 5-12), with 183 primary teeth, participated in the study. After randomization, the sample was allocated as follows: 61 teeth to Group A (rotary excavation), 61 to Group B (Carisolv), and 61 to Group C (Papacarie). During the course of the study, 5 patients were lost due to pulp exposure, 4 due to the need for LA and 2 for uncooperative behaviour.
30. Results Final sample consisted of 50 children (36 boys and 14 girls) and 150 teeth with occlusal carious lesions.
31. Results The mean values with standard deviations of time taken, caries removal efficiency, patients’ pain perception, and number of applications of material.
33. Results 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 CMCR methods, which, on average, took over five times as long as the rotary method (P<0.001).
34. Results 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).
35. Results In a significant majority of children, the behaviour deteriorated during and after caries removal using the rotary method (P<0.01). With the CMCR methods, no change was observed in behaviour toward the negative from before to after the treatment (Table 4). A significant majority of children
37. Results A significant majority of children in the study group (48 %) expressed a preference for the Papacarie method of caries removal, while 26% preferred the Carisolv method 24% preferred the rotary method (P<0.05).
38. Conclusion The rotary method was the most efficient in caries removal and required the least amount of time. Both chemo-mechanical caries removal agents took five times longer than rotary excavation for caries removal. The rotary method more often led to deterioration in behaviour compared to the CMCR methods but the children were not anesthetized. Children reported less pain with the CMCR methods. The Papacarie method was the most preferred method by the children.
39. Time For Discussion
40. Critical appraisal The aim is clear and focused. Exclusion & inclusion criteria are clear. The assignment of subjects to treatment groups is randomised. Groups are not similar at the start of the trial (age, gender). All relevant outcomes are measured in a standard, valid and reliable way. results are comparable. the overall effect is due to the study intervention.
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