|Year : 2016 | Volume
| Issue : 1 | Page : 27-31
Clinical Evaluation of Caries Removal in Primary Teeth Using Carie-care and SmartPrep Burs: An In vivo Study
Pooja Ravindra Shivasharan, A Katge Farhin, Mayur Manohar Wakpanjar, Ashveeta Shetty
Department of Pedodontics and Preventive Dentistry, Terna Dental College, Navi Mumbai, Mumbai, Maharashtra, India
|Date of Web Publication||27-Jun-2016|
Pooja Ravindra Shivasharan
Department of Pedodontics and Preventive Dentistry, Terna Dental College, Sector 22, Plot No. 12, Nerul (W), Navi Mumbai - 400 706, Mumbai, Maharashtra
Source of Support: None, Conflict of Interest: None
Background: Ultra conservative caries removal now has become an integral part of Minimal Invasive Dentistry. The main objective of deep caries removal is to conserve the tooth structure as well to maintain the integrity of pulpal health. Aim: To evaluate clinically the efficiency of caries removal using Carie-Care compared to the SmartPrep burs for complete caries excavation. Materials and Methods: Split mouth study was done in 64 children where caries excavation was done using Carie-Care on one side and Smart burs on the other side. The parameters assessed were complete caries excavation, pain reaction, need for local anesthesia and mean time required. Results: The differences between complete caries excavation, pain reaction and need for local anesthesia using both the techniques were statistically insignificant. Whereas the time taken for caries removal using Carie-Care was significantly less than Smart burs (P = 0.001). Conclusion: Both the techniques can be used effectively for caries excavation in primary teeth.
Keywords: Carie-care, caries, chemomechanical agents, SmartPrep bur
|How to cite this article:|
Shivasharan PR, Farhin A K, Wakpanjar MM, Shetty A. Clinical Evaluation of Caries Removal in Primary Teeth Using Carie-care and SmartPrep Burs: An In vivo Study. Indian J Oral Health Res 2016;2:27-31
|How to cite this URL:|
Shivasharan PR, Farhin A K, Wakpanjar MM, Shetty A. Clinical Evaluation of Caries Removal in Primary Teeth Using Carie-care and SmartPrep Burs: An In vivo Study. Indian J Oral Health Res [serial online] 2016 [cited 2019 Jun 15];2:27-31. Available from: http://www.ijohr.org/text.asp?2016/2/1/27/184732
| Introduction|| |
In every field of dentistry, an awareness regarding the importance of preserving tooth tissue, combined with a patient friendly approach is becoming self-evident.  The best way to ensure maximum life for the natural tooth is to respect the sound tissue and protect it from damage by using minimally invasive techniques in restorative dentistry.  The current odontologic era is characterized by an increasing move toward less invasive treatment and toward preventive dentistry. The aim of minimally invasive restorative treatment in dentistry is selective removal of carious tissue and the preservation of the maximum amount of sound dental tissue. ,,,,
Chemomechanical caries removal involves the chemical softening of carious dentin, followed by its removal with gentle excavation. It involves the selective removal of degraded collagen fibrils in carious dentin lesion while preserving the affected demineralized dentin layer.  Since 1970s many chemical compositions have been used for chemomechanical caries removal. These include GK - 101, Caridex, Carisolv, and enzymes. 
In the present study, Carie-care (Inc., Bengaluru, Karnataka, India) was used for the noninvasive chemomechanical removal of dental caries. It is a gel-based formulation containing a purified enzyme, derived from the plant Carica papaya (papaya) which exhibits antibacterial and anti-inflammatory properties. It acts as a debris removing agent with no harmful effect on sound tissues because of the enzyme specificity along with the benefits of Clove oil which are analgesic and antiseptic. 
Another self-limiting concept in mechanical caries removal has been brought into practice by the introduction of SmartPrep bur (SS White Burs, Inc., Lakewood, NJ, USA).  The paddle-shaped bur used in this study has a unique flute design and is constructed from a medical-grade polyether-ketone-ketone, with a particular hardness and wear resistance that reportedly enables it to remove only the soft caries-infected dentin, leaving the caries-affected dentin intact. It is utilized exclusively at low speed (500-800 rpm). The bur quickly dulls and vibrates when it encounters the more highly calcified caries-affected dentin. 
Thus, the aim of this study was to evaluate clinically the efficiency of caries removal using a new chemomechanical agent (Carie-care) compared to the SmartPrep burs for complete caries excavation including the need for local anesthesia, duration of the treatment, and the pain reaction.
| Materials and methods|| |
Ethical clearance was obtained by institutional review board. Informed consent was obtained from parents or guardians to conduct the study. The study was conducted in the Department of Pedodontics and Preventive Dentistry, Terna Dental College, Nerul, Navi Mumbai. This study was a clinical controlled study (split-mouth) where two methods of caries removal were compared in the same patient. The sample size was selected empirically and not based on any assumptions and statistical calculations. The study included a total of 32 healthy children aged 5-10 years. Each child had two contralateral primary teeth showing comparable open carious lesions. A total of 64 primary teeth were included in this study.
Teeth were divided into two groups according to the method of caries removal. Each group consisted of 32 teeth.
- Bilateral open carious lesion with dentin involvement
- Opening should be large enough to allow penetration of a small excavator
- No proximal caries as evidenced by bitewing radiographs
- Teeth without clinical or radiographic evidence of pulp, furcation, or periapical pathosis.
Group I: Caries was removed using the Carie-Care (Ecoworks Inc., Bengaluru, Karnataka, India).
Group II: Caries was removed using the SmartPrep burs (SS White Burs, Inc., Lakewood, NJ, USA).
Treatment was carried out according to the following steps:
Group I: Using the chemomechanical method
- No local anesthesia was given, unless required
- Isolation was done using cotton rolls and saliva ejector 
- Caries removal was performed using either of the two methods.
Carie-Care (Ecoworks Inc., Bengaluru, Karnataka, India) was applied on the carious lesion according to the manufacturer's instruction for 1 min [Figure 1]. The caries was gently excavated using blunt spoon excavator. Caries detecting dye was applied on the cavity for 10 s. Dye was water washed using three-way syringe.
|Figure 1: Application of Carie-care in the maxillary left primary canine|
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Group II: Using SmartPrep burs
This group consisted of 32 samples. The carious portion of these samples was excavated with the help of SmartPrep bur (SS White Burs, Inc., Lakewood, NJ, USA) at slow speed [Figure 2]. During the excavation procedure, there was no limitation to number of burs used, but the main aim was to remove all the carious portion of dentin.  Caries-detector dye "Seek®" (Ultradent product Inc., USA) was applied on the cavity for 10 s and the dye was water washed using three-way syringe [Figure 3] .
For each patient, the following was recorded by the same investigator: Pain reaction using sound, eye and motor scale (SEM) according to Wright et al.  [Table 1].
It is an objective method for pain assessment where measurement of comfort was taken according to three types of observations; SEM. The level of response for each observation was given a numerical value (score), and these values were averaged to obtain the comfort level [Table 1].
The need for local anesthesia which was given if the patient scored more than two in any of the SEM. 
The total working time, taken for caries removal and cavity preparation with either method, was recorded in minutes using a stopwatch. When anesthesia was given, time was recorded twice:
- The total working time of caries removal including time of anesthesia administration
- Only the operative time of caries removal excluding time of anesthesia administration.
All data were entered into a Microsoft Office Excel (version 2013) in a spreadsheet and checked for errors and discrepancies. Data analysis was done using Windows-based "MedCalc Statistical Software" version 13.3.1 (MedCalc Software bvba, Ostend, Belgium; http://www.medcalc.org; 2014).
- The proportion of complete caries excavation was compared between the Carie-care and SmartPrep burs using Fischer's exact test
- The comfort/pain levels using SEM was compared between the two groups (Carie-care and SmartPrep burs) using Chi-square test
- Mean working time was compared between the groups using unpaired t-test.
| Results|| |
Of 64 teeth, complete caries excavation was observed in 28 (43.75%) and 25 (39.07%) teeth with Carie-care and SmartPrep burs, respectively. The comparison between both groups based on caries excavation was statistically insignificant [Table 2].
In the present study, local anesthesia was required for only one tooth using Carie-care and three teeth using SmartPrep burs. Score 1 was observed in 48.44% with Carie-care and 45.31% with SmartPrep burs. Score 3 was observed only in 1.56% and 4.69% using Carie-care and SmartPrep burs, respectively. Both scores showed statistically insignificant result [Table 3], [Graph 1].
|Table 3: Comparison between Carie-care and SmartPrep bur groups as regards sound, eyes and motor scale for pain assessment |
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The mean time required for the procedure was longer for SmartPrep burs (7.77 min) as compared to Carie-care (4.53 min). On comparison of mean times between both the groups, the results showed statistically significant difference (P < 0.001) [Table 4].
| Discussion|| |
The development of caries removal techniques in restorative dentistry is progressing toward a more biological and conservative direction. The chemomechanical caries removal technique became an area of interest in dental researches due to its concept of tissue preservation. As only carious dentin is removed, the painful removal of sound dentin is avoided and hence, the need for local anesthesia is minimized. 
In the chemomechanical method, partially degraded collagen in carious dentine will be chlorinated by chemomechanical caries removal solutions. This chlorination affected the secondary and/or quaternary structure of collagen by disrupting hydrogen bonding. Carious material removal was thus facilitated. The main advantage of this method is that it does not require complete patient cooperation.
Papacarie® (Formula and Acao, Sao Paulo - Brazil) is a chemomechanical caries removal product composed of papain, chloramine, toluidine blue, salts, and a thickening vehicle.  It obtains a synergistic action from each of its components that facilitates the removal of the decay with highly antimicrobial properties.
Kotb et al. clinically evaluated the efficiency of caries removal using Papacarie compared to the conventional drilling. The results showed that the Papacarie was as efficient as the drill in caries removal from open carious lesions with no significant difference in the operating time. 
Another study by Motta et al. concluded that chemomechanical caries removal with Papacarie provided a lesser degree of pain in comparison to conventional caries removal and did not require the use of local anesthesia. 
Carie-care is a product that has been locally introduced and is used in the present study. It has its main active ingredient from papaya extract - an endoprotein, chloramines, and dye which is similar to the composition of Papacarie. In addition, the preparation contains specific percentages of essential oils from plant sources, which has anti-inflammatory and mild anesthetic effect. The preparation also contains explicit gelling agent in accurate percentage to give exact consistency to gel so that when applied there is no spill over. Carie-care has most of the ingredients from natural resources. It contains essential oils which act as anti-inflammatory agent. It not only softens infected dentin but gives additional advantage of anti-inflammatory activity and aroma. Carie-care is in the form of single preparation, which can be stored at 4° for more than 6 months. 
Dentinal caries removal is normally accomplished using rotary carbide burs and hand excavators. Carbide burs are superior at a higher speed but mostly are associated with noise, pain, overheating, vibration, and discomfort.  Therefore, special burs made of polymer material were used in Group II, and the hardness of this bur is less than that of healthy dentin but more than infected dentin. 
The hardness of sound dentin ranges from 54 to 65 KHN and carious dentin having a hardness of 20 KHN or less. The hardness of SmartPrep bur is 50 KHN, thus it removes only carious part of the dentin and gets worn off when comes in the contact with healthy dentin. 
Isik et al. compared the caries removal efficiency of polymer burs (Smartburs) and conventional carbide burs microbiologically and found polymer burs to be as effective as the conventional carbide burs in caries removal.  Prabhakar and Kiran in another study proved that carbon steel round burs removed caries lesions more efficiently than polymer burs, but they contributed to the over-preparation of the cavity.  In a study done by Shakya et al., the time required for complete excavation procedure was significantly higher in SmartPrep bur group when compared to Diamond points and Carbide bur group. 
Caries-detector dye "Seek®" (Ultradent product Inc., USA) was used to detect remaining caries in samples of this study. "Seek" is a glycol based dye, which stains outer carious dentin and spares affected dentin. It has been shown that dyes that were dispensed in higher molecular weight carriers exhibited reduced diffusion properties in porous tissues. Thus, caries detecting dyes prepared with higher molecular weight polypropylene glycols may prevent over-staining and excessive removal of caries-affected or sound dentin.
Gaddam et al. concluded that the mean time taken by stainless steel bur excavation was found to be less and caused more amount of dentinal tubule destruction when compared to Polymer Bur, Carisolv, and Papacarie.  Hegde et al. evaluated caries removal using Carie-care system compared to conventional method among school children. Carie-care showed a marginal increase in time compared to the conventional technique. Whereas, in the present study, the time required was less with Carie-care when compared to SmarPrep burs. 
The reason for increased time consumption with SmartPrep burs in complete caries excavation may be because of changing the burs that abrade when in contact with hard dentin and attachment of another bur to the handpiece. The number of burs used for complete caries excavation in every case of SmartPrep bur group was more than one.
| Conclusion|| |
Following conclusions can be derived from the present study:
- Both the techniques: Carie-care and SmartPrep burs can be used effectively for caries excavation in primary teeth.
- The comfort level and need for local anesthesia using Carie-care were comparable to SmartPrep burs.
- The working time for caries excavation using SmartPrep burs was more than Carie-care which was statistically significant.
- Carie-care was cost effective as compared to SmartPrep burs.
| References|| |
Sabalaite BR, Juskiene J. Chemomechanical caries removal for children. Stomatologija 2005;7:40-4.
Bertassoni LE, Marshall GW. Papain-gel degrades intact nonmineralized type I collagen fibrils. Scanning 2009;31:253-8.
Bussadori SK, Castro LC, Galvão AC. Papain gel: A new chemo-mechanical caries removal agent. J Clin Pediatr Dent 2005;30:115-9.
Kumar J, Nayak M, Prasad KL, Gupta N. A comparative study of the clinical efficiency of chemomechanical caries removal using Carisolv and Papacarie - A papain gel. Indian J Dent Res 2012;23:697.
Mickenautsch S, Yengopal V, Banerjee A. Atraumatic restorative treatment versus amalgam restoration longevity: A systematic review. Clin Oral Investig 2010;14:233-40.
Beeley JA, Yip HK, Stevenson AG. Chemochemical caries removal: A review of the techniques and latest developments. Br Dent J 2000;188:427-30.
Hegde AM, Preethi VC, Shetty A, Shetty S. Clinical evaluation of chemo-mechanical caries removal using Carie-care system among school children. Nitte Univ J Health Sci 2014;4:80-4.
Kochhar GK, Srivastava N, Pandit IK, Gugnani N, Gupta M. An evaluation of different caries removal techniques in primary teeth: A comparitive clinical study. J Clin Pediatr Dent 2011;36:5-9.
Daniel W, Boston DM. New device for selective dentin caries removal. Quintessence Int 2004;3:40-7.
Shakya VK, Chandra A, Tikku AP, Verma P, Yadav RK. A comparative evaluation of dentin caries removal with polymer bur and conventional burs - An in vitro
study. Open J Stomatol 2012;2:12-5.
Wright GZ, Weinberger SJ, Marti R, Plotzke O. The effectiveness of infiltration anesthesia in the mandibular primary molar region. Pediatr Dent 1991;6:238-42.
Kotb RM, Abdella AA, El Kateb MA, Ahmed AM. Clinical evaluation of Papacarie in primary teeth. J Clin Pediatr Dent 2009;34:117-23.
Motta LJ, Bussadori SK, Campanelli AP, da Silva AL, Alfaya TA, de Godoy CH, et al.
Pain during removal of carious lesions in children: A randomized controlled clinical trial. Int J Dent 2013;2013:896381.
Venkataraghavan K, Kush A, Lakshminarayana C, Diwakar L, Ravikumar P, Patil S, et al.
Chemomechanical caries removal: A review and study of an indigen-ously developed agent (Carie Care (TM) Gel) in children. J Int Oral Health 2013;5:84-90.
Banerjee A, Watson TF, Kidd EA. Dentine caries excavation: A review of current clinical techniques. Br Dent J 2000;188:476-82.
Celiberti P, Francescut P, Lussi A. Performance of four dentine excavation methods in deciduous teeth. Caries Res 2006;40:117-23.
Isik EE, Olmez A, Akca G, Sultan N. A microbiological assessment of polymer and conventional carbide burs in caries removal. Pediatr Dent 2010;32:316-23.
Prabhakar A, Kiran NK. Clinical evaluation of polyamide polymer burs for selective carious dentin removal. J Contemp Dent Pract 2009;10:26-34.
Gaddam D, Ghanashyam M, Vasa AA, Vasanthi D, Ramanarayana B, Mynampati P. Evaluation of the efficacy of caries removal using polymer bur, stainless steel bur, Carisolv, Papacarie - An in vitro
comparative study J Clin Diagn Res 2015;7:42-6.
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]