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 Table of Contents  
ORIGINAL RESEARCH
Year : 2020  |  Volume : 12  |  Issue : 3  |  Page : 253-259

Comparative evaluation of the efficiency of caries removal using various minimally invasive techniques with conventional rotary instruments using cone beam computed tomography: An in vitro study


1 Department of Conservative Dentistry and Endodontics, Manipal Academy of Higher Education, Melaka, Malaysia
2 Department of Oral Medicine and Radiology, Melaka-Manipal Medical College, Manipal Academy of Higher Education, Melaka, Malaysia
3 Department of Conservative Dentistry and Endodontics, SRM Kattankulathur Dental College and Hospital, Kattankulathur, India
4 Department of Prosthodontics, Sathyabama Institute of Science and Technology Dental College and Hospital, Chennai, Tamil Nadu, India

Date of Submission27-Sep-2019
Date of Decision13-Dec-2019
Date of Acceptance15-Dec-2019
Date of Web Publication02-Jun-2020

Correspondence Address:
Dr. Anchu R Thomas
Lancor Lumina Apartments, G Block 313, Vishnupriya Avenue, Kancheepuram, Tamil Nadu.
Malaysia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JIOH.JIOH_256_19

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  Abstract 

Aim: The aim of this in vitro investigation was to assess the most efficient minimally invasive technique (MIT) by comparing the change in volume after caries removal using cone beam computed tomography (CBCT) and the time taken for each technique. Materials and Methods: Forty human extracted molars, stored in 0.1% thymol solution, with carious lesions extending into the dentin were used in the study. The caries status of dentin was judged initially by visual inspection and probing and confirmed by caries detector dye. A pre-scan CBCT was performed before assessing the volume of the carious lesion. Teeth were assigned into four groups (n = 10): Group 1 = Carisolv gel, Group 2 = Carie Care, Group 3 = ultrasonic tips, and Group 4 = slow-speed rotary instruments. The caries removal was performed according to the manufacturer’s instructions. Time taken was recorded for each method. A postoperative scan was conducted, and volumetric analysis was carried out. The amount of removal of sound tooth structure was assessed to determine the most MIT. Descriptive and inferential statistics were used to analyze the data. The intergroup volume change of caries was carried out using the Kruskal–Wallis test, whereas comparison within the group was carried out using Wilcoxon signed-rank test. The assessment of time taken during each procedure was analyzed with one-way analysis of variance and Tukey honest significant difference test. The results were tabulated accordingly. Significance was set at P value ≤ 0.05. Results: The chemomechanical agents (Carisolv and Carie Care) showed minimal change in volume when compared to conventional diamond points. The time taken with conventional diamond point was minimum, and it was maximum for ultrasonic tips. Conclusion: Chemomechanical caries removal is the most minimalistic approach when compared to the other techniques.

Keywords: Carie Care, Carisolv, Cone Beam Computed Tomography, Minimal Invasive Technique, Ultrasonic Tips


How to cite this article:
Thomas AR, Nagraj SK, Mani R, Haribabu R. Comparative evaluation of the efficiency of caries removal using various minimally invasive techniques with conventional rotary instruments using cone beam computed tomography: An in vitro study. J Int Oral Health 2020;12:253-9

How to cite this URL:
Thomas AR, Nagraj SK, Mani R, Haribabu R. Comparative evaluation of the efficiency of caries removal using various minimally invasive techniques with conventional rotary instruments using cone beam computed tomography: An in vitro study. J Int Oral Health [serial online] 2020 [cited 2020 Aug 10];12:253-9. Available from: http://www.jioh.org/text.asp?2020/12/3/253/285572




  Introduction Top


The “minimally invasive” approach incorporates the science of detection, diagnosis, interception, and treatment of dental caries at a microscopic level.[1],[2] The use of high-speed rotary instruments for the operative treatment of carious lesions has often resulted in considerable removal of tooth structure. Advancements in technology and material science have led to a paradigm shift from the traditional surgical model (drill and fill) to the modern medical model of care, involving caries risk assessment, alteration of cariogenic environment, potential tissue remineralization, and minimal tooth preparation.[3],[4]

Minimally invasive dentistry (MID) focuses on tissue preservation, preferably by preventing disease from occurring and intercepting its progress, but also removing and replacing with as little tissue loss as possible.[5] Dentinal caries has an outer layer, referred to as infected dentin, and an inner layer called the affected dentin. The infected dentin has the presence of bacteria, the collagen is irreversibly denatured, and remineralization is not possible; hence, it must be removed. The affected dentin has no bacteria, is reversibly denatured, remineralizable, and should be preserved. Preserving this layer of dentin would be a conservative approach.[5],[6] To achieve this, various minimally invasive techniques (MITs) have been suggested such as air abrasion, ultrasonics, sono-abrasion, lasers, and chemomechanical caries removal technique.

Chemomechanical caries removal technique is a minimally invasive hand excavation method with the aid of a chemical gel. Carisolv is a chemomechanical agent, marketed in two solutions. Solution 1 contains amino acids (leucine, lysine, and glutamic acid) and sodium hydroxide, and solution 2 contains 0.5% sodium hypochlorite.[7] The two solutions are mixed before application onto the tooth surface. The mode of action of chemomechanical caries removal systems is by chlorination of the partially degraded collagen and cleavage by oxidation of glycine residue, which results in collagen fibril disruption making the collagen fibrils more friable and easier to remove. The hard, unaffected dentin is not removed.[7],[8]

Another chemomechanical caries removal agent Carie Care (Biosynergics, Bangalore, India), a gel, comprises papain, which is a proteolytic enzyme showing antibacterial and anti-inflammatory properties. Papain works as a debris-removing agent, with no harmful effect on sound tissues because of the enzyme’s specificity. It acts only on infected dentin, which lacks the α1-antitripsine plasmatic antiprotease that inhibits proteolysis in healthy tissues. In addition to papain, the chloramines present in the product have the potential of dissolving carious dentin by means of chlorination of the partially degraded collagen. This mechanism affects the collagen structure by disrupting hydrogen bonds and thus facilitating tissue removal.[9]

Ultrasonic tips use the ultrasonic vibrational energy rather than rotation. With the aid of diamond-coated ultrasonic tips, small preparations can be carried out without significant removal of additional tooth structure. The design features and the smaller tip dimensions allow direct access to the lesion without damaging the adjacent tooth or the adjacent healthy tissue.[10]

The purpose of this study was to compare the caries removal efficiency of Carisolv, Carie Care, and ultrasonic tip with conventional rotary instruments by assessing the change in volume after preparation, using cone beam computed tomography (CBCT) volumetric analysis, and to evaluate the time taken by each technique.


  Materials and Methods Top


Study design

An in vitro comparative study was performed at Department of Conservative Dentistry and Endodontics, SRM Kattankulathur Dental College, Kattankulathur, Tamil Nadu, India, and permission was obtained (Ref. no. SRMKD/2019/23). An inclusion criterion was permanent teeth with caries extending into the dentin. Exclusion criteria were caries extending into the pulp chamber, enamel caries, teeth extracted for more than 2 months, fractured teeth, and heavily restored teeth.

Sample preparation and handling

A total of 120 human permanent molars extracted for reasons other than for this study were collected from private clinics of which 40 human permanent molars with carious lesions extending into the dentin, extracted within 2 months, stored in 0.1% thymol solution (KM Chemicals, Uttar Pradesh, India), were selected for the study.[11] The teeth were then mounted on resin blocks. The carious status of dentin was judged according to the clinical criteria (visual inspection and probing). A preoperative CBCT scan (Planmeca ProMax, Helsinki, Finland) [Figure 1] was carried out, and the volume and extent of the carious lesion were analyzed using the Planmeca Romexis software, version 3.0.1.R, Asentajankatu 6, Helsinki, Finland. They were assigned into the following four groups (n = 10), depending on the method used for caries removal:
Figure 1: Cone beam computed tomography volume analysis using Planmeca Romexis software (version 3.0.1.R) region growing method

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  • Group 1: Carisolv (Medi Team, Goteborg, Sweden)


  • Group 2: Carie Care (Biosynergics Ltd, Bangalore, India)


  • Group 3: Ultrasonic tips for caries removal (Woodpecker, International, Guilin, China)


  • Group 4 (control group): Conventional slow-speed rotary instruments (Mani Medical India Private Limited, Delhi, India)


If it was necessary, the undermined enamel covering the carious lesion was removed to gain access to the carious dentin with a slow-speed round diamond points of sizes 0.012 or 0.014 (Mani), before the preoperative CBCT scan, to make sure no discrepancies arise during the volume assessment. All the procedures were carried out by a single operator.

Study method

For the teeth belonging to:

Group 1: Carisolv (Medi Team) was applied according to the manufacturer’s instructions, on the carious dentin. After waiting for 60s, when the gel turns cloudy, the carious lesion was gently excavated using spoon excavator. The procedure was continued till the caries was completely removed. The preparation was then rinsed thoroughly with water and dried.

Group 2: Carie Care (Biosynergics) application was also carried out according to the manufacturer’s instructions. The gel was placed directly onto the carious dentin with the aid of an applicator tip. Following 60s, as the gel gradually changed color in the affected regions, the gel along with dissolved caries was removed by means of a sharp spoon excavator.

Group 3: In the ultrasonic group, ultrasonic tips SBD1, SBD2, and SBD3 (Woodpecker International, Guilin, China) were used at a frequency of 30kHz to remove the carious lesion.

Group 4: In the control group, caries removal was carried out using conventional slow-speed handpiece (NSK, Tochigi, Japan) (600–25,000rpm) and slow-speed diamond points, until the cavity was found to be caries free.

The caries removal was initially verified by visual and tactile examination and finally by caries detector dye (Snoop, SS White, Lakewood, New Jersey, Germany), to confirm the complete removal of the carious lesion in all the groups. The time taken by each procedure was recorded.

Outcomes: primary and secondary outcome assessment

Primary outcome

The primary outcome was to assess the most efficient MIT by comparing the change in volume after caries removal using CBCT [Figure 1].

Secondary outcome

The secondary outcome was to evaluate the time taken by each technique.

After caries removal, the teeth were subjected to a postoperative CBCT scan to measure the volume of remaining tooth structure. The percentage of difference in volume between preoperative and postoperative scan was calculated based on the following formula:



where b = postoperative CBCT scan volume and a = preoperative CBCT scan volume.

Statistical analysis

The data collected were compiled using MS Office Excel and were subjected to statistical analysis using the Statistical Package for the Social Sciences (SPSS) software for Windows, version 20.0 (IBM, Armonk, New York). Descriptive and inferential statistics were used to analyze the data. Normality of the data was assessed. The intergroup volume change of caries was carried out using the Kruskal–Wallis test [Table 1], whereas comparison within the group was performed using Wilcoxon signed-rank test [Table 2] and [Table 3]. The assessment of time taken during each procedure was analyzed with one-way analysis of variance and Tukey honest significant difference test [Table 4] and [Table 5]. The results were tabulated accordingly. Significance was set at P value ≤ 0.05.
Table 1: Comparison of volume of caries between pre- and post-scan using Kruskal–Wallis test

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,
Table 2: Mean and standard deviation of volume of caries in each group before and after scan. Percentage reduction after caries removal

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,
Table 3: Descriptive statistics of time taken to remove the caries using each method

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,
Table 4: Comparison of time taken between groups

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,
Table 5: Multiple comparison: Tukey post hoc test

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  Results Top


The study was conducted with 40 teeth of the 120 teeth collected based on the inclusion or the exclusion criteria. [Table 2] shows the mean and standard deviation of volume of caries in each group before and after scan and the mean difference. According to the statistical analysis for calculating the percentage of volume change, Group 1 and Group 2 showed significant statistical difference when compared to the control group. The maximum volume change was observed in the control group. Groups 1 and 2 showed minimum change in volume when compared to Group 3 but the values were not statistically significant. Among Groups 1 and 2, no significant difference was observed. Group 3 and the control group also did not show any statistical significance [Graph 1]. [Table 3] shows the descriptive statistics of time taken to remove the caries using each method. Time taken was in the order of Group 3 (4.4 min) > Groups 1 and 2 (3.4 and 3.2 min) > Group 4 (2.13 min) [Graph 2]. The ultrasonic tips took more time when compared to the other groups, and conventional diamond points took the least time for caries removal. No statistically significant difference was observed between Groups 1 and 2. Statistically significant difference was observed between Group 3 and Groups 1 and 2 and between the control group and Groups 1 and 2 [Tables 2]–[5]. Comparison of volume of caries between groups in pre- and post-scan was carried out using Kruskal–Wallis test. As the P value was more than 0.05, it proved that there was no statistically significant difference between groups during pre-scan (P = 0.99, df = 3, 95% confidence interval [CI]) and post-scan (P = 0.71, df = 3, 95% CI). The sample size for future research was calculated with the Cochran’s formula, and it was found to be 384 samples per group at 95% CI, ±5% precision.
Graph 1: The percentage of change in volume of tooth structure with each technique; x-axis: Group 1, Carisolv, Group 2, Carie Care, Group 3, ultrasonic tips, and Group 4, slow-speed rotary instruments; y-axis: percentage of volume change in each group (%)

Click here to view
,
Graph 2: Comparison of time taken by each technique; x-axis: Group 1, Carisolv, Group 2, Carie Care, Group 3, ultrasonic tips, and Group 4, slow-speed rotary instruments; y-axis: time taken by each group in minutes

Click here to view



  Discussion Top


In collation to the past, caries removal has become more efficient; however, inherent fundamental drawbacks of the drilling approach have remained.[12] Conventional rotary instruments have been found to remove excessive tooth structure.[13]

Earlier studies were conducted to compare the efficiency of chemomechanical agents with diamond points; two studies analyzed the surface chemistry of the dentin using Raman spectroscopy and the penetration of resin into the dentinal tubules using the scanning electron microscope,[3],[14] few other studies assessed the microhardness of the dentin surface after the use of chemomechanical agents using hardness tests.[15] The use of chemomechanical agents was to find the most conservative technique compared to diamond points; so far no studies comparing the volume of the tooth structure removed using different techniques are available.

In this study, the percentage of change in the volume of the tooth structure removed was evaluated using the Planmeca Romexis software (version 3.0.1.R) region growing method. It was a determining factor in the selection of teeth for the study. The samples with carious lesions extending into the pulp chamber, as observed in the pre-scan, were not used in the study. In this study, the change in volume of tooth structure removed was more when the diamond points were used, whereas it was least with the chemomechanical agents.

Chemomechanical caries removal involves the chemical softening of carious dentin followed by its removal by gentle excavation; it selectively removes softened carious dentin and conserves the sound tooth structure. The dentin surface formed is well suited to bonding with composite resin.[8]

The Carisolv gel set also comprises a set of non‐cutting tip instruments with a 90° edge that allows simple scraping movement for caries excavation, which cannot be performed with the conventional spoon excavators that cut the dentin in one single direction using a scooping motion.[16] On complete removal of caries, the dentin remaining is sound and properly mineralized.[17] Previous studies stated that Carisolv had similar effect as calcium hydroxide (CaOH2) and it was also observed that it had bactericidal and hemostatic effects on the exposed pulp tissue, which could be due to its alkaline pH.[16],[18] Histological findings have further shown that Carisolv promoted superficial necrosis at pulpal exposure sites, initiating repair of the injured pulp.[18],[19] There is also a reduced need for local anesthesia, which is very important while treating patients with anxiety and children. However, drawbacks may include the prolonged operating time (when compared with rotary instrumentation) and the simple fact that more conventional rotary methods are still necessary to gain access to the carious dentin to allow the gel to function.[4]

The Carie Care also has similar properties as Carisolv. It is an enzyme-based gel formulation developed in 2010. The endoprotein, which is an important component of the gel, works as an antibacterial agent and a disinfectant. It has been observed that the presence of papain gel (natural anti-inflammatory property) and clove oil (analgesic and anesthetic action) compounds have significant advantage over Carisolv or Papacarie.[20],[21] Previous researchers have observed that dental phobia and patient cooperation was better with Carie Care treatment.[9] In this study, both the chemomechanical methods performed well compared to the ultrasonic tips and the conventional rotary instruments in terms of caries removal efficiency.

Studies by Nielsen (1955) indicated the possibility of using an ultrasonic instrument to cut tooth tissue.[22],[23],[24] He designed a magnetostrictive instrument with a 25kHz oscillating frequency. This ultrasonic instrument, when used in conjunction with thick aluminium oxide and water slurry, created the cutting action, wherein the kinetic energy of the water molecules was transferred to the tooth surface via the abrasive through high-speed oscillations of the cutting tip.[10],[23],[25] Soft, carious dentin apparently could not be removed, but the harder layers were more susceptible. However, in the light of current knowledge regarding the structure of the carious lesion in dentin, it is a debatable point as to whether this harder layer should be removed as it probably represents the dentin that can be remineralized.[9]

In this study, on assessing the time taken for each procedure, ultrasonic tip was found to take more time compared to the other three groups, which could be due to the inefficiency in removing soft dentin decay. It necessitated the use of spoon excavator for removing the soft dentinal decay. But it has been observed that they present better minimally invasive approach than the rotary handpieces as the removal of carious tissues is selective and well controlled and they have special tip designs, which aid in approaching the lesion.[26],[27],[28] The operator expertise and skill was a confounding factor in this research, as the procedures were carried out by a single operator.

Though it has been observed that there is a paradigm shift in the knowledge of MID, doubts persist if they are being practiced effectively. Many studies conducted on the awareness of MID techniques have concluded that most of the practitioners are aware but do not choose to practice it.[24],[29],[30] Therefore, this study also aimed to highlight the advantages of adopting MID techniques: chemomechanical caries removal technique and ultrasonic tips, in our clinical practice.

The results showed that the chemomechanical agents (Carisolv and Carie Care) showed minimal change in volume when compared to conventional diamond points. The time taken for the procedure was maximum in the case of ultrasonic tips. This study was a preliminary attempt to find the most conservative technique, by assessing the percentage of volume change after preparation using CBCT Romexis software. Further studies with larger sample size must be conducted to obtain a clear picture.

Data availability statement

The data set used in the study is available with the corresponding author and will be available till november 2026

Acknowledgement

We would like to thank Dr. Bijivin Raj for his contributions toward this research.

Financial support and sponsorship

This study was self-funded.

Conflicts of interest

There are no conflicts of interest



 
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    Figures

  [Figure 1], [Graph 1], [Graph 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5]



 

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