TECHNIQUES OF CARIES REMOVAL

INTRODUCTION
CLASSIFICATION OF TECHNIQUES
OTHER TECHNIQUES
HAND PIECE
ENDOSTEPPER, SMART PREP BURS, FLUORESCENCE
HAND EXCAVATION
AIR ABRASION
AIR POLISHING
ULTRASONIC INSTRUMENTATION
SONO ABRASION
CHEMOMECHANICAL CARIES REMOVAL
LASERS
CONCLUSION
TECHNIQUES OF CARIES REMOVAL
INTRODUCTION:
Caries removal or rather treatment of the infected dentine, is best defined
by outcome criteria, i.e., procedures that lead to local arrestment of the carious
process. Traditionally it includes the removal of all soft dentine, but a number of
treatment principles can be employed in order to arrest the disease locally.
The techniques used in carious dentine removal have developed since GV
Black, in 18!, initially proposed the principle of "e#tension for prevention$ in the
operative treatment of carious lesions. %e proposed that the removal of sound
tooth structure and anatomical form at sites that mi&ht other'ise encoura&e plaque
sta&nation 'ould help minimi(e caries and its pro&ression. This 'as based on the
kno'led&e of the disease process and restorative materials available at that time.
)ater, 'ith the advent of adhesive restorative materials, ne'er techniques for
removal of carious dentine have been developed in an attempt to minimi(e this
e#cessive tissue loss.
There are a number of techniques available for cuttin& tooth tissue.
* classification of these techniques accordin& to Baner+ee, ,atson and -idd.
Category Te!"#$%e
/echanical, rotary %andpiece 0 burs
/echanical, 1on2rotary %and e#cavators, air abrasion, air
polishin&, ultrasonics, sono2abrasion
Chemo2mechanical Caride#, carisolv, en(ymes
3hoto2ablation )asers
4
5ther than the techniques mentioned in the above classification, there are
other techniques also, 'hich include,
16 Controlled selective rotary e#cavation
a. Torque controlled motors
i. 7ndostepper
ii. Carisolv po'er drive
b. 3olymer burs
i. 8mart prep burs
c. 9luorescence aided caries e#cavation
Ha"&'#ee a"& B%r:
* carious lesion is usually penetrated and e#tended usin& ultra hi&h speed
rotary instruments. 3enetration throu&h the carious enamel pit and fissure is
accomplished 'ith a click 1o.1 or 1o.4 round bur. *fter e#posin& the lesion,
removal of the carious dentine pro&resses from the lateral borders of the lesion to
its center usin& round steel e#cavatin& burs in a lo' speed contra2an&led hand
piece. *s firm dentine is reached laterally, it is follo'ed to the central area by
removal of the carious dentine. * sharp round steel bur as lar&e as is suitable for
the si(e of the lesion is indicated. * positive rake an&le 'ould produce a more
acute an&le on the ed&e of the blade :ed&e an&le6. Burs 'ith positive rake an&les
may be used to cut softer, 'eaker substances, such as soft carious dentin. ;f a
blade 'ith a positive rake an&le is used to cut a hard material such as sound
enamel or dentin, it 'ould di& in leavin& an irre&ularly cut surface and the cuttin&
ed&es of the blade 'ould chip and dull rapidly.
!
The steel bur has a &reater number of flutes than does the carbide bur.
%ence, a smoother cuttin& action is achieved by usin& this bur and the operator is
provided 'ith a better tactile cue. <iscrimination bet'een carious and normal
dentin must be made and a li&ht force is applied to the bur usin& a 'ipin& motion.
,hen the removal of the carious lesion has been accomplished usin& the
tactile and visual cues, clinical +ud&ment of the caries removal can be made usin&
caries detectin& dyes. *lthou&h, this method is quite efficient for caries removal, it
is still aversive for patients, over preparation of tissues is possible and ne&ative
effects on the pulp could also result.
Co"tro((e& )e(et#*e rotary e+a*at#o":
a, Tor$%e o"tro((e& -otor):
i6 7ndostepper.
;t is that 'here the computer controlled en&ine makes possible a di&ital
attitude to the number of revolutions and torque for each individual instrument.
This system offers a patent t'istin& function = it is especially helpful 'hile usin&
files in the root canal, 'here the file can free itself by an ad+ustable left ri&ht
movements. ;t causes less vibrations, that the patient hardly feels the treatment.
., Po(y-er .%r):
8mart prep bur.
;t is a round bur made of a polymer that is only hard enou&h to remove
decayed dentin, stoppin& at the hard healthy dentin and makin& for a very
conservative preparation.
>
*s these burs are made of a material that is harder than decay yet softer
than healthy dentin, 'hen the bur contacts healthy tissue, it becomes self2limitin&.
These burs are available in ! si(es ?4, ?>, ?@, 'hich seem much smaller than their
carbide round bur counterparts. They should be used at lo' speed i.e. ABB28BB rpm
as su&&ested by the manufacturer, and 'ithout 'ater spray. They should be used
'ith very li&ht air brush type stroke.
5ld restorations, enamel or sound dentin is removed usin& burs at hi&h
speed follo'ed by smart prep burs at lo' speed to remove only the decayed
dentin. *s soon as the bur hits anythin& not as soft as decayed dentin such as
healthy dentin, affected dentin, enamel or a restoration the flutes +ust totally
smossh to&ether and render the bur completely useless.
But there have been also some false positives as 'ell 'ith this bur.
*lthou&h the bur had flaked, but upon checkin& the cavity 'ith a spoon e#cavator,
there 'as some decay left.
, F(%ore)e"e a#&e& ar#e) e+a*at#o":
Generally, carious re&ions can easily be overlooked and decidin& 'hether
e#cavation is complete or not is often difficult. Chan&es in tooth fluorescence have
been used to detect early tooth surface caries for some time and is found to be one
of the reliable method.
)ennon et al. in 4BB4 studied the residual caries detection usin& visible
fluorescence. *lthou&h oral microor&anisms themselves are not kno'n to
fluoresce, several oral microor&anisms 'ere reported to produce oran&e2red
fluorophores as byproducts of their metabolism. 9or this reason, oran&e2red
A
fluorescence in dental hard tissues may be a &ood marker for the (one of bacterial
invasion in dentine. The rationale for the use of visible oran&e red fluorescence for
this purpose is that carious dental tissue fluorescences more intensely in the red
portion of the visible spectrum :CA>B nm6 than the sound dentine.
;n this technique, &enerally a violet li&ht :!DB2>4B nm6 'ill be &enerated
usin& a !A 'att #enon dischar&e lamp and a blue band pass filter 'ith peak
transmission at !DB nm are used. This li&ht 'ill be fed into the fibre2optic slo'
speed hand piece so that it is focused onto the operatin& field durin& e#cavation.
The operator can observe the cavity throu&h a A!B nm = hi&h pass filter. Ender
such observation, the areas e#hibitin& oran&e2red fluorescence indicate the
presence of caries 'hich can be removed by subsequent use of an appropriate si(e
bur.
)ennon in 4BB!, conducted a study on fluorescence aided caries e#cavation
compared to conventional method and concluded that this method is more
effective than conventional caries e#cavation.
Me!a"#a( No"/rotary:
a, Ha"& e+a*ator):
/anual e#cavation of dental caries is done by usin& spoon e#cavator. They
are frequently used in con+unction 'ith rotary instruments or can also be used 'ith
other hand instruments such as enamel hatchet. The 'alls of the cavity should first
be e#tended usin& either rotary instruments or enamel hatchet so that the mar&ins
of the carious area may be seen and readily approached. The e#tent of the lesion
should determine the si(e of the spoon e#cavator to be used. The lar&est e#cavator
@
that 'ill conveniently fit the area is selected. 8harp e#cavators are effective and
'ill reduce the force required for caries removal. The sharpened ed&e of the
instrument should be carefully introduced under the most accessible mar&in of the
carious area and &ently but quickly forced under it avoidin& as far as possible
pressure in the direction o the pulp. *n effort should be made to lift out the entire
mass 'ith one stroke, follo'in& as nearly as possible the hard underlyin& dentin.
9ailin& in this, a second or third s'eep of the instrument from a different direction
should completely remove it. 9ollo'in& this, any remainin& softened matter
should be &ently scraped out 'ith the same instruments and the cavity should be
cleaned.
A&*a"tage):
1. )on& term observations have sho'n adequate tissue removal
4. 5ver e#cavation is unlikely
!. *ccepted procedure especially in pedodontics and an#ious patient
>. <oes not require any e#pensive equipment
D#)a&*a"tage):
1. %i&h pressure causes pain
Baner+ee, -idd and ,atson in 4BBB studied the efficiency :time taken6 and
effectiveness :quantity of dentine removal6 by bur, air2abrasion, sono2abrasion and
carisolv &el compared to conventional hand e#cavation. 9rom the results, it 'as
concluded that bur e#cavation 'as quickest but overprepared cavities relative to
the autofluorescence test, 'hereas carisolv e#cavation 'as slo'est but removed
adequate quantities of tissue. 8ono2abrasion tended to underprepare 'hereas air2
D
abrasion 'as more comparable to hand e#cavation in both the time and amount of
dentine removed. They concluded conventional hand e#cavation appeared to offer
the best combination of efficiency and effectiveness for carious dentine e#cavation
'ithin the parameters used in this study.
., A#r/a.ra)#o" or 0#"et# a*#ty 're'arat#o":
<r. Fobert B. Black 'as the first to study air2abrasives technolo&y in
dentistry in 1>!.
;n 1>A, he published a series of articles on the use of air2abrasive
technique for cavity preparation and oral prophyla#is.
;n 1A1, 8.8.,hite introduced the first air2abrasive system = *irdent.
*ir abrasion is not a complete replacement for the dental hand piece 'ith
burs, it is merely an ad+unct. ;ts use is limited to areas that can be easily seen and
kept free from moisture. <esired cavity details can be obtained 'hen the technique
is au&mented 'ith hand instruments.
The principle employed by the airdent unit utili(es kinetic ener&y or inertia
as a rapid and not unpleasant means of removin& tooth structure by incorporatin& a
fine abrasive material in a hi&h velocity &aseous propellent.
*ir abrasion is not a completely painless method of cavity preparationG
ho'ever it eliminate the ob+ectionable features of vibration, bone2conducted noise,
pressure and heat. The traumatic influence on tooth structure and periodontal
tissue is reduced to a minimum.
8
B%r A#r a.ra)#*e
Vibration
Bone2conducted noise
Temperature rises
3ressure = 4 pounds
1o vibration
1o bone conducted noise
Hust 1 or 49
1B = 1> &m

;n cases 'here the tooth is hypersensitive, pulpal stimulation may be
e#perienced in various de&rees. 8uch stimulation may be controlled by reducin&
the pressure of the propellant or by reducin& the amount of abrasive mi#ed 'ith
the propellant or both.
AIR ABRASIVE S1STEM:
;t consists of a unit, foot control and hand piece. %and piece consists of a
handle, a shaft = an ad+ustable contra2an&le :ball and socket6 and a tip or no((le in
a B relationship to the shaft.
Basic principles of air2abrasive.
*ir abrasive depends for its action on a fine stream of suitable &as carryin&
a controlled quantity of small abrasive particles.
A.ra)#*e Mater#a():
*l
4
5
!
= 9or cuttin& tooth substance
Ca/&C5
!
= <olomite = oral prophyla#is
8tudies :1AB6, have sho'n a potential of inhalational problems by air2
abrasive particles.

*t present, the air2abrasive technique has E8 9<* approval for clinical use
of 4D.A alumina particles 'hich has very little health ha(ard, both to the patient
and the dentist. ;t possess a hardness of on /ohIs scale and its particles possess
sharp ed&es and pointed corners 'hen properly prepared.
5ther materials.
3olycarbonate resin
*lumina = hydro#yapetite
3ropellants.
*lthou&h compressed air may be used as a propellant, C54 'as found to
possess certain advanta&e for this purpose. ;t is,
3ractically free from moisture
1on2to#ic in lo' concentrations
Convenient and almost universally available
The pressure of the liquid C5
4
varies from DBB to 1!BB pounds per square
inch. This pressure is reduced to appro#imately 11A pounds in the line and further
reduced 'ithin the ran&e of appro#imately 8B to >A pounds at the no((le.
C!arater o2 t!e a.ra)#*e )trea-:
The abrasives escapes from the no((le in a cone2shaped stream, the 'alls of
'hich diver&e from its lon& a#is at an an&le of appro#imately ! J de&rees. The
particles of abrasive in the stream travel at speeds in e#cess of 1BBB feet per
second, 'hich is 'ell into the realm of supersonics.
1B
;n order to use the air abrasive system properly, the operator should first
understand the relation 'hich e#ists bet'een the distance at 'hich the no((le tip is
held from the tooth surface and the an&ulation of the no((le 'ith respect to the
proposed cavity.
;t is noted that 'ith a no((le tip distance of 1mm the an&ulation is (ero. *t
4 mm total an&ulation B.>A it is D. *t Amm it is 1!. *t 1B mm it is 4! and at
1Amm it is !A.
3eruchi et al. in 4BB4 evaluated the cuttin& patterns produced by air
abrasion system 'ith an 8B no((le an&le, AB abrasive particle si(e and 8B psi air
pressure. The effects of B.!8 or B.>8 mm inner tip diameter at 4 or A mm from tip
to the tooth surface and 1A or !B sec of application time on cuttin& efficiency 'ere
evaluated. 8tatistical analysis revealed that the 'idth of the cuts 'as si&nificantly
&reater 'hen the tip distance 'as increased. 8i&nificantly deeper cavities 'ere
produced by a tip 'ith a B.>8 mm inner diameter. The application time did not
influence the cuts. They concluded that precise removal of enamel is best
accomplished 'hen a tip 'ith a B.!8 mm inner diameter is used at a 4mm
distance.
C%tt#"g S'ee&:
There are certain influencin& factors 'hich affect the cuttin& speed, they
include the nature of the instrument = bur or diamond point it diameter, speed in
rpm and pressure applied.
Conversely the action of air abrasive is influenced by factors such as
propellant pressure, type and particle si(e of the abrasive used, abrasive mi#ture,
11
no((le bore and len&th, no((le distance from the enamel surface and no((le
an&ulation.
8tudies have sho'n that an ordinary no.A@1 chrome plated dental bur is
capable of removin& appro#imately @m& of enamel in !B sec at 1D4A rpm 'hen
applied 'ith the pressure of 4 pounds. ,hereas usin& aluminium o#ide 'ith a
propellant pressure of 8B pounds per square inch, a no((le of B.B18 inch inside
diameter and no((le tip distance of D to 1! mm 'ith an an&le of B, air abrasive is
capable of removin& !B m& of enamel in !B seconds.
The type and si(e of abrasive 'ill affect the coarseness of the abraded
surface. The lar&er the si(e and harder the particles, the &reater is the transferred
kinetic ener&y to the surface and thus the rou&her the final finish.
Pr#-ary o")#&erat#o") re(at#*e to t!e %)e o2 a#r/a.ra)#*e !a"& '#ee:
Ha"& '#ee Co"tro(:
The operator must develop close co2ordination bet'een the eye, hand and
foot. Because there is no tactile relation bet'een the instrument and tooth bein&
operated on, the operator must rely solely on his visual sense. Thus, &ood eye si&ht
and &ood li&htin& are imperative for this technique.
Ha"& '#ee gra)':
Enlike the rotary hand piece, an air abrasive hand piece is al'ays held
li&htly in the pen &rasp in as much as the reaction force resultin& from the abrasive
stream 'hich is only 1B to 1> &m. ;n accomplishin& the cuttin& action, the
instrument is merely pointed. 1o pushin& or pullin& is ever necessary and the !
rd
14
or >
th
fin&er is &enerally used not as a brace but as a rest for steadyin& the
instrument.
No33(e a"g%(at#o":
1o((le an&ulation must be correlated 'ith no((le tip distance. Generally
speakin&, the &reater the no((le tip distance the &reater 'ill be the an&ulation.
3eruchi et al. in 4BB1 evaluated the effect of no((le an&le and the tip
diameter on the cuttin& efficiency of an air abrasion system. They 'orked 'ith
prep star microabrasion machine usin& a hand piece 'ith either 8B or >B no((le
an&les 'ith B.!8 or B.>8 mm tip inner diameter. The parameters 'hich 'ere held
constant 'ere abrasive particle si(e = 4D , air pressure = 8B psi, distance = 4mm
and duration = 1A sec. 8tatistical analysis revealed that the 'idth of the cuts 'as
si&nificantly &reater 'hen the cavities 'ere prepared usin& the >A no((le an&le.
8i&nificantly deeper cavities 'ere produced 'ith the 8B no((le an&le. The no((le
diameter influenced the cuttin& efficiency in softer substrates, dentin and
cementum. They concluded that precise removal of hard tissue is best
accomplished usin& the 8B an&le no((le tips for all types of surfaces, enamel,
dentin and cementum.
Ba)# ty'e) o2 %t):
Fe&ardless of the type, si(e or location of the cavity bein& prepared, the
principles involved for the establishment of cavity 'alls and floor do not vary.
There are t'o basic types of cuts usin& air abrasive hand piece.
1. 8trai&ht line cut
1!
4. *n&le cut
1>
1. 8trai&ht line cut.
;t is employed 'here hi&h de&ree of definition is desired. This type of cut
utili(es close no((le distances and is precise and narro'.
4. *n&le cut.
The an&le cut employs the use of &reater no((le distance, to&ether 'ith the
required no((le an&ulation. *s the no((le distance from the substance bein& cut
increases, the an&le of the 'alls increases proportionately.
The advanta&es afforded by the employment of the an&le cut are = a6
&reater cuttin& speed and b6 less visual interference.
*lthou&h there are advanta&es of usin& air2abrasion system, there are
certain limitations.
1. The no((le of the air2abrasive instrument does not come into actual contact
'ith the tooth, providin& no tactile &uidance.
4. ;n case of secondary caries, it is difficult to remove the e#istin& restoration.
!. %i&h cost
>. ,hen the abrasive particles strikes the surface of the mirror, it becomes
frosted.
A. /i&ht dama&e the cavosurface sound tooth enamel.
Goto and Khan& in 1@, conducted a study to establish a protective
method for cavo surface sound tooth enamel durin& air abrasive cavity preparation
usin& protective varnish. Varnish 'as applied to the tooth surface in sin&le, double
and triple coats. Class V cavities 'ere then prepared on the border area of varnish
coated and intact tooth surface. The varnish 'as then 'ashed off and the enamel
1A
mar&ins 'ere observed throu&h 87/. They found that tooth surface enamel 'hich
'as coated 'ith varnish appeared intact and the cavo2surface mar&in remained at a
ri&ht an&le, 'hereas, the tooth surface enamel 'ithout varnish coatin& appeared
rou&h and the cavo2surface mar&in e#hibited a round shape.
,averen and *ndersen in 4BBB studied the quantification of surface enamel
loss and a comparison of shear bone stren&th. 7namel loss 'as determined for 4
enamel conditionin& methods. acid etchin& 'ith !DL phosphoric acid and sand
blastin& 'ith AB aluminium o#ide. The results sho'ed that the enamel loss
associated 'ith sand blastin& is equal to or smaller than that resultin& from acid
etchin&. The results also sho'ed that the bond stren&th of the sandblasted &roups
'as si&nificantly lo'er than that of the etchin& &roups. This indicates that
sandblastin& is not an alternative for the acid2etchin& technique currently used.
*r(u and 5sman in 4BB>, studied the effect of air2borne particle abrasion
on the shear bond stren&th of four restorative materials to enamel and dentin. The
control &roup specimens 'ere treated 'ith silicon carbide paper. Festorative
materials tested 'ere composite, compomer, G;C :)6 and G;C. They concluded
that the use of air2borne particle abrasion increased the shear bond stren&th of
restorative materials tested to enamel and dentin.
, A#r/'o(#)!#"g:
;t is the process by 'hich 'ater2soluble particles of sodium bicarbonate and
tricalcium phosphate :B.B8L by 'ei&ht6 = to improve the flo' characteristics are
applied onto the tooth surface usin& air pressure, shrouded in a concentric 'ater
+et. This is the important difference bet'een this technique and that of air2
1@
abrasion. *s the abrasive is 'ater soluble it does not escape too far from the
operatin& field. The bombardment of the hard tooth surfaces by these particles
results in a continuous mechanical abrasive action 'hich removes surface
deposits.
Fa(oo& and -oka in 1>, noted that increasin& the air2pressure beyond B
psi actually reduced the abrasiveness of the microprophy system. This 'as due to
a phenomenon found in one2dimensional, t'o phase fluid dynamics = choked
flo'. ;n this phenomenon, as the air pressure e#ceeds the critical pressure, the
mass flo' of particles 'ill reduce thus limitin& the systemIs abrasiveness.
The commercially recommended use of this technique is to remove surface
enamel stains, plaque and calculus 'ell a'ay from the &in&ival mar&ins of healthy
teeth. %o'ever, over(ealous use could easily remove a considerable amount of
healthy tooth structure especially at the cervical mar&in. ;t has also been su&&ested
that air2polishin& could be used for the removal of carious dentine at the end of
cavity preparation.
Bester et al. in 1A studied the effect of air polishin& on the dentin smear
layer and dentin. The purpose of this study 'as to determine the most effective
period by 'hich the smear layer can be removed by air2abrasive polishin& 'ithout
totally e#posin& the dentinal tubules and the effect air polishin& has on dentin at
different e#perimental application periods 'ith re&ard to the appearance of the
dentinal tubules :open or obliterated6 and the amount of tissue loss from the
dentinal surface. 87/ observation sho'ed smear layer removal as an immediate
effect of air polishin&. *pplication times of lon&er than A sec sho'ed obstruction
of dentinal tubule openin&, possibly a result of abrasive po'der residue.
1D
Therefore, they concluded that air polishin& removes the smear layer and the
amount of dentine removed corresponded to the time of application.
&, U(tra)o"# #")tr%-e"tat#o":
1ielson et al. in 1ABs, indicated the possibility of usin& an ultrasonic
instrument to cut tooth tissue. %e desi&ned a /a&netostrictive instrument 'ith a
4A k%( oscillatin& frequency. This is used in con+unction 'ith a thick aluminium
o#ide and 'ater slurry, created by the cuttin& action, the mechanism of 'hich 'as
the kinetic ener&y of 'ater molecules bein& transferred to the tooth surface via the
abrasive throu&h the hi&h speed oscillations of the cuttin& tip.
;t 'as found that the harder the tissue, the easier it 'as to cut. 8oft, carious
dentine apparently could not be removed, but the harder, deeper layer 'as more
susceptible.
There are many parameters that could potentially be ad+usted to alter the
cuttin& characteristics and 1ielsen attempted to analyse the results from alterin&
the pressure applied, the len&th of use of the instrument, the po'der 'ater ratio in
the slurry, the nature of the material cut and the type of abrasive used. %o'ever,
due to the erratic and unpredictable performance of this instrument, his results
'ere inconclusive. 7ven thou&h this method 'as developed only to a preliminary
sta&e, it 'as used on forty patients in a clinical trial 'here they found the
technique to be favorable in terms of the reduced vibration and sound &enerated
'hen compared 'ith the dental drill.
18
e, So"o/a.ra)#o":
9urther development from the ori&inal ultrasonics is the hi&h frequency,
sonic, air scalers 'ith modified abrasive tips = a technique kno'n as 8ono2
abrasion. The 8onicys micro unit desi&ned by <rs %u&o is based upon the sonic
fle# 4BBB ) and 4BBB 1 air2scaler hand pieces that oscillate in the sonic re&ion
:M@.A k%(6. The tip describe an elliptical motion 'ith a transverse distance of
bet'een B.B8 B B.1A mm and a lon&itudinal movement of bet'een B.AA =
B.1!Amm. These tips are diamond coated on one side usin& >B &rit diamond and
are cooled usin& 'ater irri&ant at a flo' rate of bet'een 4B2!B mlNmin. The
operational air pressure for cavity finishin& should be around !.A bar. There are
currently three different instrument tips. a len&th'ays halved torpedo shape :.A
mm lon&, 1.! mm 'ide6, a small hemisphere :1.A mm diameter6 and a lar&e
hemisphere :4.4 mm diameter6. The torque applied to the instrument tips should be
in the re&ion of 41. ;f the applied pressure is too &reat, the cuttin& efficiency is
reduced due to dampin& of the oscillations. This technique 'as initially developed,
usin& different shaped tips, to help prepare pre2determined cavity outlines
:8onicys6 but also 'orks 'ell in removin& hard tissue 'hen finishin& cavity
preparation.
Oo(ici et al. in 4BB4 conducted an 87/ study on different caries removal
techniques on human dentine. The carious tissue 'as removed by hand
e#cavation, bur e#cavation, air2abrasion, )aser ablation, chemomechanical
removal and sono2abrasion. 8urfaces treated by hand e#cavation, bur e#cavation
and air abrasion 'ere covered 'ith a residual smear layer. 8ono2abrasion 'ith
1
patent dentinal tubule completely removed the smear layer. * fe' patent orifices
of dentinal tubules 'ere observed in dentin sub+ected to laser ablation and
chemomechanical caries removal.
*dvanta&e of this caries removal technique is less over preparation than
'ith rotary instruments and smaller access cavity is possible. ,hereas the
disadvanta&e bein& unclear completeness of e#cavation.
2, C!e-o-e!a"#a( Car#e) Re-o*a(:
<entine consists of /ineral :DBL 't6, 'ater :1BL 't6, or&anic matri#
:4BL 't6. 5f this or&anic matri#, 18L colla&en and 4L non2colla&enous
substances includin& chondroitin sulphate, other proteo&lycans and
phosphophoryns. Colla&en is an unusual protein 'hich contains lar&e amounts of
proline and one third of the amino acid content is &lycine. The polypeptide chains
are coiled into triple helices 'hich are kno'n as tropocolla&en unitsG these
tropocolla&en units then orient side by side to form a fibril. Covalent bonds
bet'een the polypeptide chains and bet'een the tropocolla&en units from cross
links and &ive the colla&en fibrils stability, in dentine the fibrils are in the form of
a dense mesh 'ork 'hich becomes minerali(ed.
,hen caries occurs, acids produced by plaque bacteria by anaerobic
fermentation of carbohydrate initially cause solubili(ation of mineral in enamel.
*s the process pro&resses, dentinal tubules provide access for penetratin& acids
and subsequent invasion by bacteria 'hich results in a decrease in p% and causes
further acid attack and deminerali(ation. ,hen the or&anic matri# has been
demineralised, the colla&en and other matri# components are then susceptible to
4B
en(ymatic de&radation, mainly by bacterial proteases and other hydrolyases 'ith
respect to colla&en de&radation, t'o (ones can usually be distin&uished 'ithin a
lesion. There is an inner layer 'hich is partially demineralised and can be
remineralised and in 'hich the colla&en fibrils are still intact, and there is an outer
layer 'here the colla&en fibrils are partially de&raded and cannot be remineralised.
* C/CF rea&ent must be able to cause further de&radation of this partially
de&raded colla&en, by cleava&e of the polypeptide chains in the triple heli# or
hydroly(in& the cross linka&es.
;t involves the application of a solution that selectively softens the carious
dentine, thus facilitatin& its removal. This limits the removal of sound tooth
structure, the cuttin& of open dentinal tubules, pulpal irritation and pain compared
'ith conventional mechanical methods.
The principal of chemomechanical caries removal is based on the studies
done by Goldman and -ronman in 1DBs. They studied the effect of 1a5Cl :non2
specific proteolytic a&ent6 on the removal of carious material from <entine. They
found that 1a5Cl 'as too corrosive for use on healthy tissues, therefore
incorporated it into 8orensenIs buffer :'hich contains &lycine 1aCl and 1a5%.
)ater it 'as found that chlorination of &lycine to form 12/onochloro&lycine 'as
more effective in caries removal and 'as available as G-21B1. ;n subsequent
studies, they found that the system 'as more effective if &lycine 'as replaced by
amino butyric acid, 'hich 'as 12monochloro <)24 aminobutyric acid = available
as G-21B17.
The mechanism of action of these substances on colla&en 'as unclear.
5ri&inally, it 'as thou&ht that the procedure involved chlorination of the partially
41
de&raded colla&en in the carious lesion and the coversion of hydro#yproline to
3yrrole242carbo#ylic acid. 9urther studies su&&est that cleava&e by o#idation of
&lycine residues could be involved. This causes disruption of the colla&en fibrils
'hich become more friable and can then be removed.
This system :G-21B176 'as patented in the E8 in 1DA and received 9<*
approval for use in E8* in 18A and 'as then marketed as caride#.
;t consisted of t'o solutions.2
8olution ; = 1L 1a 5Cl
8olution ;; = Glycine, *minobutyric acid, 1aCl and 1a5%
The p% of this solution 'as 11.
* delivery system 'as also available 'ith this 'hich consisted of a
reservoir for the solution, a heater and a pump 'hich passed the liquid, 'armed to
body temperature throu&h a tube to a hand piece and an applicator tips of various
si(es and shapes.
The solution 'as applied to the carious lesion by means of an applicator,
'hich 'as then used to loosen the carious dentine by a &entle scrappin& actionG the
debris to&ether 'ith the spent solution bein& removed by aspiration. *pplication
'as continued until the dentine remainin& 'as deemed sound by normal clinical
tactile criteria.
;t 'as found that 'ith suitable accessible soft lesions, after A21B min
treatment only clinically sound dentine remained.
*fter the removal of carious dentine, the surface 'ould appear to be the
interface bet'een carious and sound dentine, such surface has sho'n to have
44
better adhesion 'ith materials such as G;C, than 'ith the conventional smear
layer.
This system avoids the painful removal of sound dentine but is ineffective
in the removal of hard eburnated parts of the lesion :may not be necessary6.
Fotary or hand instruments may sometimes be needed for the removal of
tissue or material other than de&raded dentin colla&en2access to small or
interpro#imal carious lesion, removal of enamel overlyin& the caries, removal of
e#istin& restorations as 'ell as for cavity desi&n 'hen non2adhesive restorative
materials are used. This system requires lar&e volumes of solution = 4BB2ABBml.
Because of the time required for chemomechanical caries removal, lar&e
volumes of solution needed and the fact that the delivery system 'as no lon&er
commercially available, use of chemomechanical caries removal, despite its
potential, became minimal.
9urther research 'as carried out on chemomechanical caries removal and a
ne' product 'as introduced by /edi Team in 8'eden in 18, 'hich they
marketed as carisolv. ;t is in the form of a pink &el 'hich can be applied to the
carious lesion 'ith specially desi&ned hand instruments or the recently introduced
carisolv po'er drive.
Carisolv &el is available in t'o different packa&es.2
a6 Carisolv &el = /ultimi#
b6 Carisolv &el = 8in&le mi#
The first marketed version of carisolv is a multimi# system. 4 syrin&es =
8yrin&e ;. B.AL 1a5Cl
4!
8yrin&e ;;. *mino acids = )ysine, )eucine and &lucamic acid
Carbo#ymethyl cellulose
7rythrocin
1aCl and 1a5%
*fter the components of both the syrin&es are mi#ed, it is active for only 4B min.
;n recent years, the &el has been further developed at 8'eden. To improve
its efficacy, an increase of the amount of free chloramines 'as needed, 'hich in
turn required a hi&her concentration of 1a5Cl. 5ne effect of the hi&her
concentration of 1a5Cl is that the colour a&ent has been removed i.e., the &el is
uncoloured. The mode of action is the same for both versions of the &el.
S#"g(e M#+:
5ne syrin&e contains material sufficient for 1B21A cases. This dispenses the
e#act amount required throu&h a disposable mi#in& tip and it can be active for up
to 1 month if stored in a refri&erator even after openin&.
The &el is applied to the carious lesion 'ith one of the hand instruments
and after !B sec, carious dentine can be &ently scraped. /ore &el is then applied
and the procedure is repeated until no more carious dentin remains, a &uide to this
bein&, 'hen the &el is removed from the tooth it is clear. Time required for caries
removal usin& carisolv is = 14 min :A21A min6 and the volume required is B.4 =
1.B ml.
A&*a"tage) o2 Car#)o(* o*er Car#&e+:
1. Gel2consistency, there is better contact 'ith the carious lesion and the quantity
required is very less, enhances precision placement.
4>
4. ! amino acids are incorporated instead of one and the different char&es have
improved the interaction 'ith the de&raded colla&en 'ithin the lesion, thus
increasin& the efficiency.
Ca)e Se(et#o":
9or the first fe' cases, it is advisable to select fully visible and easily
accessible lesions such as buccal or occlusal caries, 'ith 124 mm of openin&, thus
allo'in& the procedure to be observed.
I")tr%-e"t):
8pecially desi&ned instruments are available 'hich consists of > different
handles 'ith 8 interchan&eable tips ran&in& in diameter from B.! to 4mm. They
may have a feel or look of e#cavators, but they are desi&ned to be used in a rapid
'hiskin& or curettin& fashion, thereby limitin& the removal of tooth structure to
carious tissue only. The instrument also help to &uide the operator around the
cavity, tactile sensation helps differentiation bet'een carious and non2carious
dentine.
16 /ultistar, star ! = Basic instrument to apply &el and start removin& caries.
The multistar tip promotes penetration of the &el. ,hen &ettin& close to
healthy dentine, use the star2shaped tip, scrapin& in all directions 'ith its >
pron&ed desi&n.
46 8tar 4, star 1, point = To remove caries in smaller cavities for e#ample root
caries or deciduous teeth.
!6 9lat 1, flat B = Esed to remove caries at the <7H.
>6 9lat !, 9lat 4 = To be used for e#ample, close to the pulp and to remove the
softened carious dentine from the cavity.
4A
A6 7#tra bend star !, flat B e#tra bend = 3rimarily used for cro'n mar&ins and
areas that are difficult to access.
Carisolv power drive is a faster and easier 'ay of 'orkin& 'ith carisolv.
*dvanta&es.2
1. ;t has unique torque limitations and this helps to protect the healthy dentine.
4. ;t 'orks at very lo' speed, thereby minimi(in& noise and pain.
!. ;t has the ability to po'er drive to s'itch very smoothly bet'een more
po'erful and more cautious caries removal.
3o'er drive is used 'ith special star bur = 1.B, 1.A, 4.B. These burs 'ork
'ith po'er drive or a lo' speed handpiece of ma#imum !BB rpm.
/i#in& = 9or a sin&le mi# system, it can be applied directly. ;f it is a
multimi# system, then it should be mi#ed immediately before use, as the
effectiveness of this 'ill decrease in 4B2!B min. The unmi#ed &el should be stored
in the refri&erator, but allo'ed to come to room temperature before use.
The lids of both the syrin&es are removed and the syrin&es are secured
to&ether usin& the male and female connectin& parts. The plun&ers are then
pressed alternately to mi# and activate the &el. 5nce the &el has uniform colour, it
maybe dispensed directly into a container such as a dapen dish. ;t is then placed in
the carious lesion for !B sec, then rapid li&ht pressure is applied 'ith the
instruments to facilitate removal of caries, the &el must be continuously applied
until cavity preparation is complete. *s the caries is removed, the &el becomes
clouded 'ith debris and it may be useful to flush the cavity intermittently for
inspection. ;t is advised to use 'arm 'ater, but cold 'ater dispensed from the !
'ay syrin&e does not appear to cause any si&nificant discomfort to the patients.
4@
Ca*#ty A))e))-e"t:
8urface colour, structure and hardness
Caries indicators can also be used.
The &el no lon&er becomes cloudy once caries removal is complete. The
sound dentine after caries removal has a sli&htly frosted and irre&ular appearance
compared 'ith the smooth shiny appearance achieved follo'in& conventional
preparation.
Feason = follo'in& conventional cavity preparation, the smooth &lossy
appearance is that of the smear layer 'hich is spread out across the underlyin&
dentine. By contrast the chemomechanically treated surface lacks a smear layer,
leavin& the underlyin& dentine relatively rou&h surface of the dentine e#posed,
'hich has a characteristic matt finish.
A&*a"tage):
1. 5nly demineralised dentine containin& denatured colla&en is affected.
4. The &el is applied at room temperature, 'hich reduces the risk of pain
sometimes associated 'ith the cool liquids that are used 'ith other caries
removal procedures.
!. The characteristics of the instruments assure ultimate tissue preservation.
E"3y-e):
8tudies have e#amined the possibility that carious dentine mi&ht be able to
be removed by usin& certain en(ymes.
4D
;n 18, Goldber& and -eil successfully removed soft carious dentine usin&
bacterial *chromobacter colla&enase, 'hich did not affect the sound layers of
dentine beneath the lesion. ;n 1@ 1orbo, Bro'n and Han had used the en(yme
3ronase, a non2specific proteolytic en(yme ori&inatin& from 8treptomyces &riseus,
to help remove carious dentine.
This mi&ht have si&nificant clinical implications but further laboratory
research is required for validation of this technique.
La)er:
)asers are devices that produce beams of coherent hi&h intensity li&ht. ;t is
an acronym for li&ht amplification by stimulated emission of radiation. ;n 1@B,
Theodore /aiman developed the first 'orkin& laser device 'hich emitted a deep
red2coloured beam from a ruby crystal and 'as postulated that it could be applied
to cuttin& both hard and soft tissues in the mouth. %o'ever, further research found
that the ruby laser produced si&nificant heat that caused dama&e to the dental pulp.
)aser devices use different physical media and sources to &enerate a variety
of 'avelen&ths that interact 'ith specific molecular components in thermal
tissues. 7ach of these 'avelen&ths tar&ets specific tissue components such as
melanin, hemosiderin or haemo&lobin, e#trinsic tattoo materials, 'ater and other
materials. )asers have been sho'n to effectively cut and ablate hard and soft
tissues 'hen the appropriate 'avelen&th is selected.
A.)or't#o" C!arater#)t#):
;n 18!, 1a&asa'aIs li&ht transmission data from dental hard substances
has sho'n that selective ablation of caries based on natural absorption differences
48
'ould not be possible 'ith lasers emittin& in the infrared spectrum. Esin& a li&ht
source emittin& 'avelen&ths bet'een 1 and 14.A, he demonstrated that
absorption in healthy dentine is hi&her than absorption in carious dentine. Because
that findin& is the opposite of the authorIs &oal, a measurement of the absorption
of carious and healthy enamel and dentin by the EV and visible li&ht spectrum
'as undertaken. The optical density of healthy and carious dentine and enamel
'as measured 'hich had sho'n that in the 'avelen&th ran&e of 4>B to DDB nm,
carious lesion demonstrates a stron&er absorption than healthy dentin and enamel.
;t 'as then sho'n that in the spectral ran&e of !4B to A4B nm, the optical density
and absorption of carious dentine is four times hi&her than for healthy dentine.
A.(at#o":
The ablation thresholds for carious and healthy dentine 'ere determined
usin& lasers emittin& in the blue spectral ran&e 'here the absorption differences
bet'een carious and healthy 'ere the hi&hest and it 'as found that selective
ablation of caries is possible 'hen applied ener&ies are at least B.>HNcm
4
but belo'
1.8HNcm
4
. Esin& that ener&y, caries should be removed and sound dentine is
unaffected. The laser ener&y must be delivered uniformly to the lesion surface.
/urray et al. stated that the remainin& dentine thickness should be at least B.A mm
to avoid evidence of pulp in+ury.
)aser interaction 'ith biocalcified tissues has been studied and it 'as found
that C5
4
lasers and 1d. O*G lasers produce surface chan&es in enamel such as
rou&hness, creatin&, crackin&, fissurin&, meltin& and recrystallisation. ;n addition,
some studies have demonstrated that these lasers can &enerate markedly elevated
4
surface and pulpal temperature. The profound thermal effects and inability to
precisely cut biocalcified tissues have eliminated the initial C54 and 1d. O*G
laser systems from consideration as modalities for dental sur&ery.
The *r9 e#cimer lasers have been reported to remove dental cariesG the
ability to effectively cut sound enamel and dentine, ho'ever has not proven to be
efficacious. -rypton 9 e#cimer laser has been sho'n to cut dentinG ho'ever
enamel is resistant to effective ablation.
;n vitro studies have sho'n that C5
4
laser irradiation inhibits the
pro&ression of caries like lesion up to 8AL. 8ubsequent studies have sho'n
similar effects for 7r . O*G and 7r, Cr . O8GG 'ith a >BL and @BL caries
reduction respectively.
7r . O*G lasers, 7F . O8GG and 7r, Cr . O8GG lasers operate at
'avelen&ths of 4>B, 4DB and 4D8B nm. These 'avelen&ths correspond to the
peak absorption ran&e of 'ater in the infra red spectrum. 8ince all three lasers rely
on 'ater2based absorption for cuttin& enamel and dentine, the efficiency of
ablation is &reatest for the 7r . O*G laser.
These laser systems can be used for effective caries removal and cavity
preparation 'ithout si&nificant thermal effects, collateral dama&e to tooth structure
or patient discomfort. * characteristic feature of 7r2based laser systems is a
poppin& sound 'hen the laser is operatin& on dental hard tissues 'hich varies
accordin& to the presence or absence of caries. ;n contrast to the poppin& sound
durin& caries removal, one current &eneration 7r, Cr . O8GG laser system creates
a loud snappin& sound even 'hen not in contact 'ith any structure in the mouth.
!B
* laser po'ered hydrokinetic system 'hich has been said to 'ork on the
mechanism of 7r, Cr . O8GG 'hich delivers photons into an air2'ater spray
matri# 'ith resultant microe#plosive forces on 'ater droplets. This process is
hypothesi(ed to contribute si&nificantly to the mechanism of hard tissue cuttin&.
The laser po'ered hydrokinetic system 'ith its accompanyin& air 'ater spray has
been sho'n to cut enamel, dentine, cementum and bone efficiently and clearly
'ithout any deleterious thermal effects on dental pulp.
A.ra)#o":
*n important theoretical e#tension to the principal of 'ater2based laser
ablation of tooth structure is recently described effect of laser abrasion in 'hich
7F . O*G laser ener&y is used to accelerate the movement of particles of 8apphire
!B2AB in diameter in aqueous suspension. *s in air2abrasion, these particles
causes brittle splittin&, resultin& in the substance removal. ;n the laser abrasion2
method, speed photo&raphy has documented particle velocity in the ran&e of AB2
1BB mtsNsec 'hich enables a rate of enamel removal hi&her than that of hi&h air
turbines 'ith a very lo' volume of abrasive particles. This technique could be
employed 'ith current &eneration lasers once a suitable system 'ith the
suspension of particles has been developed.
!1
CONCLUSION:
Various techniques for caries removal are available but the main problem at
present is the apparent lack of the self2limitin& nature of the individual methods.
*ll the techniques 'ill remove carious dentine 'ith differin& levels of efficiency
but more importantly, it is still kno'n if these techniques 'ill discriminate
bet'een the soft, outer, necrotic, hi&hly infected (one that needs to be e#cavated
and the inner reversibly dama&ed, less infected (one 'hich could be retained.
Compared to most sin&le technique, a combination of techniques 'ould
ensure better caries removal.
!4