Current update of chemomechanical caries removal methods

Current update of chemomechanical caries removalmethods

H Hamama,*† C Yiu,* M Burrow*‡

*Faculty of Dentistry, Prince Philip Dental Hospital, University of Hong Kong, Hong Kong SAR, China.†Department of Conservative Dentistry, Faculty of Dentistry, Mansoura University, Egypt.‡Melbourne Dental School, The University of Melbourne,Victoria, Australia.

ABSTRACT

Chemomechanical caries removal is an excellent method for minimally invasive caries excavation, and the removalagents are either sodium hypochlorite (NaOCl)- or enzyme-based. The NaOCl-based agents include GK-101, GK-101E(Caridex) and Carisolv, and the enzyme-based agents include Papacarie and the experimental material, Biosolv.This review outlines the changes in chemomechanical caries removal methods and focuses on recently published labora-tory and clinical studies. The historical development, mechanism of action, excavation time and biological effects onpulp and dental hard tissues are described.Based on existing evidence, the currently available chemomechanical caries removal methods are viable alternatives toconventional rotary instrument methods. Chemomechanical methods could be extremely useful in very anxious, disabledand paediatric patients. It does seem some of these agents would still benefit from quicker excavation times in order toachieve more universal acceptance. However, as a means of conserving the caries-affected dentine, chemomechanical car-ies removal is possibly much more successful than conventional rotary instrumentation.

Keywords: Biosolv, Caridex, Carisolv, chemomechanical caries removal, minimal intervention dentistry, Papacarie.

Abbreviations and acronyms: EDTA = ethylene diamine tetra-acetic acid; FDA = US Food and Drug Administration; NaOC1 = sodiumhypochlorite; VAV = Visual Analogue and Verbal scale; WBFP = Wong Baker Faces Pain scale.

(Accepted for publication 7 January 2014.)

INTRODUCTION

The philosophy of minimally invasive caries removal isone of the most important applications of the minimalintervention dentistry concept established during thelast decade.1 The use of laser ablation,2 air abrasion,3

sono-abrasion4 or chemomechanical agents5 for theremoval of infected dental tissue has greatly aidedminimal invasive caries removal techniques. The com-mon feature of these techniques is the selectiveremoval of caries-infected tissue, whilst leaving intactthe caries-affected tissue. The ‘caries-affected’ dentineis characterized by demineralization of the intertubulardentine, deposition of crystals in tubules, minimaldestruction of the collagen matrix and no bacterialpenetration.6 Conversely, the ‘caries-infected’ dentineshows distortion of the dentinal tubules microstruc-ture, irreversible denaturing of the collagen fibres andmarked bacterial invasion.6 It is the latter damaged tis-sue that should be removed during caries excavation.The principle of chemomechanical caries removal is

the use of a solution to chemically alter carious tooth

tissue to further soften it, thus facilitating its easierremoval. The softened dentine is then mechanicallyremoved using a hand instrument. Early attemptswere introduced in the 1970s using various agentssuch as ethylene diamine tetra-acetic acid (EDTA),7

collagenase8,9 and sodium dodecyl sulfate.8 Most ofthese systems proved too time consuming to be of anyuse clinically. More recently, other agents havebecome available; the best known is Carisolv (Medi-team, G€oteborg, Sweden).In the last decade, several chemomechanical caries

removal agents have been removed from the market orbeen improved. One new agent has also been introducedand a further one is currently under development. It hasbeen more than 10 years since the chemomechanicalcaries removal method5,10,11 was reported and severalchanges have occurred to improve its usefulness. Thus,it is timely to review current knowledge and outlinewhere research gaps still remain. Due to the introduc-tion of new agents, chemomechanical caries removalagents can now be classified into either sodium hypo-chlorite (NaOCl)- or enzyme-based agents (Table 1).

© 2014 Australian Dental Association 1

Australian Dental Journal 2014; 59: 1–11

doi: 10.1111/adj.12214

Australian Dental JournalThe official journal of the Australian Dental Association

Sodium hypochlorite (NaOCl)-basedchemomechanical caries removal agents

NaOCl-based chemomechanical caries removal agentsdepend on NaOCl derivatives, which chlorinate anddisrupt hydrogen bonds of partially degraded collagenin carious dentine, thus facilitating its removal.5 From1972, a 5% NaOCl solution was used as a chemome-chanical caries removal agent; however, it was unsta-ble10 and lacked selectivity and removed both caries-infected and caries-affected, as well as sound den-tine.12 To overcome this problem, amino acids wereadded to the subsequent versions.

GK-101

The next development was a chemomechanical cariesremoval solution introduced by Goldman and Kron-man in 1976 and marketed as ‘GK-101’.13 In thesame year, GK-101 was approved by the United StatesFood and Drug Administration (FDA).13 GK-101 con-sisted of 0.05% N-monochloroglycine (NMG) andNaOCl, and was prepared by mixing two solutions.Solution A consisted of 25 mL each of 2M NaCl, 2MNaOH and 2M glycine, and solution B consisted of10 mL of 4–6% NaOCl.13 GK-101 required a specialdelivery system consisting of a reservoir (for warmingthe freshly prepared solution to 41 °C) and a pump(similar in shape to a straight handpiece) attached toa 20-gauge needle delivery tip. The delivery tip wasapplied to the carious lesion with minimal pressurevia a paintbrush-like motion,13 since it was reportedthat excessive pressure led to an increase in thepatient’s pain response and blocked solution flowthrough the needle tip.13 GK-101 disrupted theorganic structure of dentine by conversion ofhydroxyproline (an essential factor for the stability ofcollagen) to pyrrole-2-carboxyglycine.5 Few studiesevaluated the GK-101 solution; however, Goldmanand Kronman13 reported that the mean caries excava-tion time for GK-101 was 8.5 minutes and using bursremained an essential subsequent step in order toachieve ideal finishing of the excavated sites. Labora-tory findings showed GK-101 had no adverse effectson red or white blood cells or the platelet count.13

Kurosaki et al.14 reported that GK-101 had noadverse effect on the pulpal tissue of dogs; however,they concluded GK-101 was not efficient in removingthe entire carious lesion. These findings led toimprovements in the formula of GK-101 to GK-101E.

GK-101E (Caridex)

GK-101E is the ethyl derivative [N-monochloro-DL-2 amino butyrate (NMAB)] of GK-101 (NMG). Itwas claimed this formula increased the specificity of

the solution towards denatured protein of caries-infected dentine.15 The mechanism of action ofNMAB on denatured collagen fibrils was similar tothat of NMG, which involved the chlorination ofthe partially degraded collagen in the carious lesionand the conversion of hydroxylproline to pyrrole-2-carboxylic acid.11 In addition to the chlorinationreaction, cleavage of the denatured collagen fibrilsmight have occurred as a result of the oxidation ofglycine residues.11,16 Furthermore, Schutzbanket al.15 reported that the improved formula seemedto be effective in shortening the caries excavationtime. They attributed this time difference to the ‘lag’period (time between the application of the solutionand true active caries removal).15 The NMG solu-tion exhibited a lag period of 30 to 90 seconds.Conversely, NMAB solution showed no lag period.15

Most other studies were in disagreement with theclaims of Schutzbank et al.,15 and it was reportedthat Caridex chemomechanical caries removal wastime consuming in comparison with conventionalcaries removal methods.17–19

GK-101E was marketed as ‘CaridexTM’ (NationalPatent Dental Products, Inc., New Brunswick, NJ,USA) and received FDA approval in 1984.10 The Car-idex system was critically evaluated, demonstrating itscaries removal efficiency,15 biocompatibility13 andpulpal safety.20–22 Many studies reported that usingCaridex did not enhance the caries removal processcompared to irrigation of the carious lesions withcopious volumes of isotonic saline solution.23,24 Fur-thermore, one of the most important drawbacks ofthe Caridex system was its complex delivery equip-ment (Fig. 1).5,10 Yip et al.24 reported that the addi-tion of urea to Caridex enhanced the efficiency ofcaries excavation in deciduous teeth. The clinicalusage and acceptance of both GK-101 and GK-101Esolutions was very limited because neither showed asignificant improvement in caries excavation com-pared with the conventional caries removal methods.

Carisolv

At the time of writing, Carisolv is the only commer-cially available NaOCl-based chemomechanical cariesremoval agent. In 1998, Carisolv (Medi Team Denta-lutveckling AB, G€oteborg, Sweden) was introduced asthe latest variation of the NaOCl-based chemome-chanical agents.25 Although Carisolv has a similarchemical structure to Caridex, it has the advantagethat it requires neither heating nor, because of its gelform, a special delivery system.25 The original Cari-solv was red in colour, consisted of two syringes; onecontaining carboxy-methylcellulose-based gels andamino acids (glutamic, leucine and lysine); the othercontaining 0.25% NaOCl (Fig. 2a).

2 © 2014 Australian Dental Association

H Hamama et al.

Table1.

Asummaryof

thech

emical

form

ula,

mod

eof

action

andman

ufac

turerreco

mmen

dation

sof

thedifferen

tch

emom

echa

nica

lca

ries

remov

alag

ents

CMCR

agent

Chem

ical

form

ula

Modeofaction

Yearof

introduction

Man

ufacturer

Commercial

availability

Special

instrumentation

NaOCl-basedCMCR

GK-101

•So

lutionA:0.05%

N-m

onochloroglycine

Chlorinationofthe

denaturedcollagen

by

conversionof

hyd

roxyp

roline(essential

factorofthestab

ilityof

collagen)to

pyrrole-2-

carboxyglycine

1976

--

Needspecial

delivery

equipment

•So

lutionB:4-6%

NaO

Cl.

GK-101E(C

aridex)

•So

lutionA:

N-m

onochloro-D

L-2

amino

butyrate

(NMAB)

Sameas

GK-101

(chlorination

mechan

ism)+

cleavage

ofthedenatured

collagen

fibrilsas

aresult

oftheoxidationof

glycineresidues

1984

National

Patent

DentalProducts,

Inc.,New

Brunsw

ick,NJ,

USA

Commercialized

under

thenam

eofCaridex,

however,

currently

disap

peared

from

market

Needspecial

delivery

equipment

(Fig.1)

•So

lutionB:4-6%

NaO

Cl.

Carisolv

•Original

gel(before

2004):(Fig.2a)

Syringe

A:carboxy-

methylcellulose-based

gels,colouringagentan

dam

inoacids(glutamic,

leucinean

dlysine)

inone

Syringe

B:0.25%

NaO

Cl

intheother

Similar

toCaridex,except,

thereplacementof

monoam

inobutyricacid

bythreedifferentcharged

aminoacids.

Theseacids

wereshownto

reactwith

differentmoieties

of

cariouslesion.

1998,then

modified

at2004byFure

and

Lingstrom,24

andin

2013the

New

Carisolv

System

©was

introduced

MediTeam

Dentalutveckling

AB,now

Rubicon

LifeScience

AB,

G€ oteborg,Sw

eden

Availab

leNon-cuttingtip

Carisolv

han

dinstruments

(Fig.3)

New

Carisolv

System

TM:Cera-

andPolymer

Burs

(Komet,UK)

(Fig.2c)

•Modified

gel(after

2004)

Multim

ixsyringe

(Fig.2b)

theredcolouringagent

was

removed,theam

ino

acid

concentrationwas

reducedbyhalfan

dthe

NaO

Clconcentrationwas

increasedto

0.475%

•New

Carisolv

System

TM

(2013)(Fig.2c)

Incorporationofminim

ally

invasive

burs

andspecial

Carisolv

caries

detector

dye

tothemodified

Carisolv

gelto

shorten

thecaries

excavationtime

(continued)


Chemomechanical caries removal methods

Tab

le1.continued

CMCR

agent

Chem

ical

form

ula

Modeofaction

Yearof

introduction

Man

ufacturer

Commercial

availability

Special

instrumentation

Enzyme-basedCMCR

Pap

acarie

Pap

ainenzyme,

chloramine,

toluidine

blue,

salts,preservatives,

athickener,stab

ilizers

anddeionized

water

(Fig.5)

•Theprecise

mechan

ism

ofactionoftheenzyme-

based

chem

omechan

ical

caries

removalagents

remainsunclear.

2003

(Form

ula

&Acao,

Brazil).

Availab

leMan

ufacturer

recommends

usingbackof

bluntspoon

excavator

•Bussad

uriet

al.53

reported

that

the

enzymatic

caries

removal

methodwas

based

on

the

fact

that

infected

carious

tissues

lost

the

antiproteasea-1-anti-

tryp

sin.

•Recentstudy5

6reported

noevidence

a-1-anti-

tryp

sincould

be

identified

indentine.

Reported

the

actionofPap

acarie

was

resultofdegradationof

proteoglycan

sof

dentinal

matrix,suggestingthat

theactionofpap

ain

mightbenon-specific.56

Biosolv

(SFC-V

andSF

C-V

III)

Pepsinenzymein

aphosphoricacid/sodium

biophosphatebuffer

Phosphoricacid

dissolves

theinorgan

iccomponents

ofcaries-infected

dentine;

whilepermittingthe

pepsinenzymeto

selectivelydisruptthe

denaturedcollagen

fibres

2006,then

developed

in2010

3M-ESP

EAG,

Seefeld,German

yNotavailable

(experim

ental

gel)

•Initially

man

ufacturer

recommends

usingspecial

plastic

instruments

(STAR

V1.3).

•Recently,

recommended

touse

inconjunction

withmetallic

instruments


H Hamama et al.

Mechanism of actionEricson et al.25 reported that the chemical structureand the mechanism of action of Carisolv was similarto Caridex, except that the monoaminobutyric acidwas replaced by three different amino acids (listedabove). The amino acids were shown to react withdifferent moieties of carious lesions.25 Furthermore,the addition of carboxy-methylcellulose created ahigher viscosity of the Carisolv gel, which enhancedits handling properties compared to the Caridex solu-tion.26 In 2004, Carisolv was modified by removingthe red colouring agent, decreasing the amino acidconcentration by half and almost doubling the NaOClconcentration from 0.25% to 0.475% (Fig. 2b).27

Carisolv instrumentsThe manufacturer of Carisolv introduced a set ofnon-cutting tip instruments in order to increase car-ies removal efficiency and provide maximumconservation of the residual caries-affected dental

(a) (b) (c)

Fig. 2 Carisolv gel (Medi Team Dentalutveckling AB, Sweden). (a) Original Carisolv gel. (b) Modified gel (multimix syringe). (c) New CarisolvSystemTM. Finger pointer shows Cera-bur (Komet), the arrow head pointed to the polymer bur (Komet), and the hand pointer shows the Carisolv caries

detector dye.

(a) (b)

Fig. 1 (a) Caridex delivery equipment. (b) Caridex delivery tip (needle). (Published with permission by the Academy of General Dentistry. © Copyright1986 by the Academy of General Dentistry. All rights reserved.)

Fig. 3 Double-ended Carisolv hand instrument tips.



tissue (Fig. 3).25,26 The non-cutting tip has a 90° edgethat allows a simple scraping movement for cariesexcavation which cannot be achieved with conven-tional spoon excavators that cut the dentine in onedirection using a scooping motion.26 There was anattempt by Meller et al.28 to use soft microbrushesmounted on a low-speed handpiece for speeding upthe caries excavation process. However, they foundthis method was not effective and took a longer timecompared to the manufacturer’s recommended instru-ments. Recently, the Carisolv manufacturer has intro-duced a preset Carisolv treatment programme into anelectronic endodontic motor PowerDrive (Medi TeamDentalutveckling AB). This uses a specially designedhandpiece with non-cutting tip ‘burs’ operated in asimilar manner to a conventional slow-speed hand-piece. The manufacturer claims that this method has amuch greater control of tissue removal at very lowsound and vibration levels.26 However, until now nostudy has been published that supports the manufac-turer’s claims regarding efficacy of the caries excava-tion with such rotary tips. Recently, a cooperativearrangement took place between the bur manufac-turer, Komet (Komet, Dental-Gbr Brasseler GmbH &Co, Lemgo, Germany) and the Carisolv manufacturerto establish the ‘New Carisolv’ systemTM (Fig. 2c). Thenew system contains two types of slow-speed bur, aceramic (Cera-bur) and polymer (Polymer-bur),designed for removing the softened Carisolv-treatedcarious dentine. The aim is to significantly reduce thecaries excavation time, while ensuring that over-excavation is avoided. It is too early to know whethersuch claims can be substantiated; however, it mayenhance the effectiveness of caries removal.

Biological effects of Carisolv on the pulp and dentalhard tissueMany studies have evaluated the effect of the directapplication of Carisolv gel on exposed pulpal tissue,mostly using a rat model.30–33 All have reported thatCarisolv gel has no adverse effects on the dentalpulp and interestingly, some mentioned that Carisolvhas a similar action as Ca(OH)2 pulp capping mate-rials.30,33 Moreover, it was reported that Carisolvhas bactericidal and haemostatic effects on exposedpulp tissue, which is attributed to the alkaline pH ofCarisolv of 11.30,33 Furthermore, histological findingsshowed Carisolv caused minimal superficial necrosisat pulp exposure sites, an effect which could pro-mote the repair function of the injured pulp.30,31

Only Bulut et al.33 used human pulp tissue; the teethused were maxillary and mandibular premolarsplanned to be extracted for orthodontic purposes.The rationale of using human dental pulp tissue wasbecause the repair capacity of rat pulp tissue, due toits continuous growth, is higher than that of human

pulp tissue.33,34 However, the results of Bulut et al.33

were in total agreement with the previous animalstudies.Many studies have reported that Carisolv gel has no

adverse effect on the mineral content of dentine.35–37

Sakoolnamarka et al.38 and Hamama et al.39 reportedthat the Ca:P ratio of residual dentine following Cari-solv removal of carious dentine did not significantlydiffer from the Ca:P ratio of sound dentine. This mayimply that Carisolv is an effective method of removingcaries-infected dentine.25,36,40,41 Scanning electronmicroscope observations of the dentine surface follow-ing Carisolv treatment showed that the excavated sur-face has an irregular surface topography and was alsopartially covered with a smear layer.39,41–45 Themajority of studies have reported that the hardness ofresidual dentine following Carisolv treatment waslower than the hardness of residual dentine followingconventional caries removal methods.39,41,46 Further-more, it was found that the hardness of the residualdentine gradually decreased towards the caries exca-vation edge.38,39 Based on these findings, Magalhaeset al.46 concluded that ‘Carisolv chemomechanicalcaries removal method seemed to be less effective incaries removal than conventional rotary methods’.However, Sakoolnamarka et al.,38 correlating hard-ness values to the Ca:P ratio, concluded that Carisolvseemed to be an effective method in preserving caries-affected dentine, but usually showed lower hardnessvalues.39,47,48 Thus, the Carisolv method is consideredmore conservative of tooth tissue.

Caries excavation timeTwo studies demonstrated the original Carisolv gelexhibited prolonged caries excavation times;10.4 ! 6.1 min (control: rotary 4.4 ! 2.2 min)25 and12.2 ! 4.1 min (control: rotary 6.8 ! 2.8 min).49 In2004, the new Carisolv gel was introduced after sev-eral attempts to improve the efficiency of the gel andreduce the excavation time.27 Fure and Lingstr€om27

compared the caries excavation time of the originaland new Carisolv gels and reported there was no sig-nificant difference in moderately-sized carious lesions;(new gel 6.7 ! 4.1 min vs original gel: 7.6 !4.2 min; p > 0.05). Conversely, in deep lesions, thenew gel exhibited a shorter mean excavation timecompared with the original gel; (new gel:9.0 ! 7.0 min vs original gel 11.6 ! 4.4 min;p < 0.05). However, Fure and Lingstr€om did not pro-vide a logical explanation for these findings.27 Subse-quent studies, including the Fure and Lingstr€omstudy,27 reported that Carisolv chemomechanical car-ies removal is considered as a time-consuming methodcompared with conventional rotary methods. A recentstudy39 showed that the relatively longer excavationtime using Carisolv may be attributed to the number


H Hamama et al.

of times the gel has to be applied; usually in the orderof six, to remove the carious lesion. The end-point iswhen the gel no longer becomes turbid (Fig. 4).

Other uses of CarisolvCarisolv gel can be used for other purposes notrelated to caries excavation, e.g. treatment of oralulcers,50 periodontal therapy,51,52 cleaning of organicdebris prior to application of pit and fissure seal-ants,53 plaque removal54 and root canal irrigation.55

Enzyme-based chemomechanical caries removalagents

At the time of writing, there are two products repre-senting enzyme-based chemomechanical caries removalagents. However, at present, only one is commerciallyavailable, which is PapacarieTM (papain-based gel, For-mula & Acao, Sao Paulo, Brazil) while the otheragent, BiosolvTM (SFC-V gel, 3M-ESPE AG, Seefeld,Germany), remains an experimental material.46,56

Papacarie

Papacarie is a Portuguese word meaning ‘carieseater’. Papacarie gel was introduced in 2003 by Bus-sadori et al.,56 and consists of papain enzyme, chlor-amine, toluidine blue, salts, preservatives, athickener, stabilizers and deionized water (Fig. 5).53

Although Papacarie contains a small amount ofchloramine, the main action depends on the presenceof the papain enzyme. The chloramine was addedto enhance removal of denatured tissues.56,57

Papain is a proteolytic enzyme with bactericidal and

anti-inflammatory actions.6 It is extracted from thelatex of leaves and fruits of the green adult Caricapapaya tree, which is cultivated in tropical regionssuch as Brazil, India, South Africa and Hawaii.58

The manufacturer recommends using the back of ablunt spoon excavator during caries excavation;however, good results have been reported whenusing the No. 4 Carisolv hand instrument39 (Fig. 3).Further studies are needed to compare the efficiencyof both instruments in conjunction with the Papaca-rie caries removal method.

Mechanism of actionThe precise mechanism of action of the enzyme-based caries removal agents remains unclear, thusfurther investigations are needed. Bussadori et al.56

reported that the enzymatic method was based onthe fact that infected carious tissues have lost the an-tiprotease, a-1-anti-trypsin. However, a recent studyby Bertassoni and Marshall59 reported that, untilnow, there is no evidence that a-1-anti-trypsin couldbe identified in dentine. Also, it was reported thatthe papain enzyme could partially degrade intactnon-mineralized type I collagen fibrils from rat tailtendon.59 Furthermore, papain has been shown toreduce the mechanical properties of intact mineral-ized dentine as a result of degradation of proteogly-cans of the matrix, suggesting that the action ofpapain might be non-specific.59

Biological effects of Papacarie on the pulp and dentalhard tissueAt present, there is only one study that has evaluatedthe effect of Papacarie gel, which was on cultured

(a)

(d)

(b)

(e)

(c)

(f)

Fig. 4 Chemomechanical caries removal procedures using Carisolv gel (Medi Team Dentalutveckling AB, Sweden). (a) Dentinal caries lesion. (b) Thecarious lesion was treated with Carisolv gel and left for 30 seconds prior to excavating the dentine. (c) Excavation of the caries using Carisolv non-cutting

instruments (Medi Team Dentalutveckling AB, Sweden) until the gel becomes cloudy and then rinsed-off with distilled water for 20 seconds. (d) Thesame process was repeated until successive application of the gel failed to become cloudy. (e), (f) Post-excavation view of the lesion site.



fibroblasts and subcutaneous tissue.60 Although thisstudy has not been conducted on dental pulp tissue, itused the Carisolv gel as a positive control.60 Theauthors reported that Papacarie was biocompatibleand exhibited similar in vitro cytotoxicity and animalimplantation assays as Carisolv gel.60 Although theresults of this study showed no adverse effects, furtheranimal studies are needed to evaluate the effect of Pa-pacarie on dental pulp tissue. Furthermore, only twostudies have evaluated the effect of Papacarie gel onthe mineral content of deciduous37 and permanent39

residual dentine using atomic absorption spectropho-tometry and energy dispersive X-rays respectively.The results of both studies revealed that Papacarie gelhas no adverse effect on the mineral content of theresidual dentine.37,39

Caries excavation timeFew clinical trials61–63 and laboratory studies39,64,65

have evaluated Papacarie caries excavation time andmost studies compared the results with rotary andCarisolv caries excavation methods. All of these stud-ies reported that there was no significant difference incaries excavation time between Papacarie and rotarycaries excavation methods. Moreover, Papacarieexhibited significantly shorter excavation times thanCarisolv.39,63,65

Biosolv

Biosolv (SFC-V and SFC-VIII, 3M-ESPE AG, Seefeld,Germany) is a new experimental enzymatic chemome-chanical caries removal agent. The information aboutBiosolv remains very limited and is based mainly onthe manufacturer’s claims. In 2006, Clementino-Luedemann et al.66 evaluated SFC-V solution andcomparing the results with Carisolv, reported that theSFC-V solution was not as effective as Carisolv. Since2010, Banerjee et al.45 and Neves et al.67,68 evaluatedthe efficiency of caries excavation of two improvedversions of SFC-V and SFC-VIII gels. However, nodetails about the difference were provided.67,68

Biosolv instrumentsClementino-Luedemann et al.66 mentioned that theBiosolv developer recommends the use of special plas-tic instruments (Star V1.3) with their system. The

hardness of these instruments is purportedly betweenthe hardness of sound and infected dentine.66 More-over, they reported that Star V1.3 instruments werenot efficient in caries excavation with Carisolv gel,but they did not clearly state its effectiveness withBiosolv gel. In recent studies of Biosolv, caries excava-tion was performed with a metal spoon excava-tor.45,67,68 Neves et al.67 reported that the best cariesexcavation results were obtained using metallic instru-ments in conjunction with the Biosolv system.

Mechanism of actionThe Biosolv gel is not commercially available however,based on the manufacturer information, it consists ofpepsin enzyme in a phosphoric acid/sodium biophos-phate buffer.66,67 It is claimed that the phosphoricacid can dissolve the inorganic components ofcaries-infected dentine, while permitting the pepsin toselectively disrupt the dentured collagen fibres. Mean-while, this softened mass can then be easily removedby the specially designed plastics instruments withoutaffecting sound tissue.

Effectiveness of Biosolv in caries excavationThe limited published data about the effectiveness ofBiosolv gel are confusing and tend to be contradictory.Banerjee et al.45 reported that Biosolv gel cariesremoval tends to leave more caries-infected dentinecompared to Carisolv and hand excavation methods.They attributed this action to the rapid bufferingaction of dentine on the Biosolv gel, which interfereswith the selective function of pepsin on denturatedcollagen fibres. Conversely, Neves et al.68 reportedthat Biosolv is the most aggressive chemomechanicalcaries removal gel due to its acidity, which can affectboth sound and caries-infected dentine. They alsoreported that the manufacturer attributed this non-selective function to an artefact in the preparation ofthe thickening agent of the experimental SFC-V gel.This artefact increases the flowability of the gel, andconsequently increases the penetration into the sounddentine.67,68 It is still too early for this experimentalproduct to be applied clinically. Further studies areneeded for a better understanding of its mode ofaction and effectiveness in caries excavation.

Clinical aspects of chemomechanical caries removalIn general, the majority of clinical studies conducted onCaridex (GK-101E), Carisolv and Papacarie showed apositive attitude of patients toward this type of treat-ment. Patient satisfaction rates for the Caridex systemwere 78–93%,17,19,69,70 and it was reported that Cari-dex significantly reduced the need for local anaesthesiacompared with conventional caries removal meth-ods.10,17,18,21 The patient satisfaction rates of Carisolvuse ranged between 70% to 90%,25,71–73 and also

Fig. 5 Papacarie gel (Formula & Acao, Brazil).


H Hamama et al.

showed marked reduction for the need for local anaes-thesia.74 However, some studies have reported negativefeedback with regard to the unpleasant taste and odourof Carisolv.27,49,75 Several studies have evaluated thepain response and patient satisfaction rate after Pa-pacarie treatment.62,63,76,77 Kochhar et al.59 reported,using a Visual Analogue and Verbal (VAV) scale, thatthe least pain was associated with the Papacarie cariesexcavation method, followed by Carisolv, while thehighest pain response was observed in both hand androtary caries excavation methods. Moreover, Singhet al.63 reported that Papacarie exhibited a high patientcomfort level compared to a rotary caries excavationmethod using the Wong Baker Faces Pain (WBFP)scale. They attributed this to the selective action of Pa-pacarie on caries-infected dentine without affecting thesound dental tissue. Much more clinical work is neededto determine whether these methods influence restora-tion survival rates.

CONCLUSIONS

Based on existing evidence, it can be concluded thatthe currently available chemomechanical cariesremoval methods can be considered as a viable alter-native to conventional rotary caries removal methods.These methods could be extremely useful in very anx-ious, disabled and paediatric patients. The concern ofthe long excavation time of Carisolv gel should beconsidered during the selection of this caries removalmethod.

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Address for correspondence:Professor Michael BurrowMelbourne Dental School

Faculty of Medicine, Dentistry and Health SciencesThe University of Melbourne

Melbourne VIC 3010Email: [email protected]



Current update of chemomechanical caries removal methods

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