(carisolvtm) efect antimicrob.2008

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OfMinimum Intervention In Dentistry

J Minim Interv Dent 2008; 1 (1) 59

Abstract

The chemomechanical excavationapproach fits the "adhesive cavity"design criteria by producing a roundedinternal outline of cavity walls.However, such a relatively new andconservative approach should be at

least as effective as conventional burexcavation in the removal of residualcaries. Objectives: The aim of thepresent study was to test the effect ofCarisolvTM chemomechanical excavationon caries removal and residualcariogenic bacteria as compared withconventional bur excavation usingsimple chair side methods. Methods andMaterials: A total 15 patients (mean age42.711.3), presenting with a numberof isolated class V carious lesions, were

selected for the study. The cariouslesions in each patient were randomlyassigned to one of the excavationmethods: (i) caries removal withCarisolvTM (n=22), (ii) conventionalexcavation with a bur (n=24). Thecarious lesions were measured beforeand after excavation by laserfluorescence, using DIAGNOdent, and amicrobial assay (Replica test) was usedin evaluating the presence of cariogenicbacteria. Results: Both methods yielded

similar results in DIAGNOdentreadings (9.9 and 7.9 forchemomechanical and bur excavation,respectively) and microbial assay (2.8and 2.9% for chemomechanical and burexcavation, respectively). No significantdifference was observed between thetwo excavation methods (p>0.05).Conclusions: This suggests that theefficacy of chemomechanical excavationin carious removal and cariogenicbacterial reduction equals that of

conventional bur excavation. Firstpublished in In t Dent S Afric 2007; 9: 64-72.

Address of author:Hebrew University Hadassah School of DentalMedicine, Department of Prosthodontics, P.O.B. 12272,

Jerusalem 91120, IsraelTel: 972-2-6776142

Fax: 972-2-6429683e-mail: [email protected]

Introduction

Recent developments in adhesive dentistryover the last decades have changeddramatically changed the clinical approach tocavity preparation. These changes havepaved the way for more minimalistic meansof cavity preparation in which sound toothstructure is preserved1. Traditionally, cariesmay be removed mechanically with burs,hand excavators, and air-abrasion, or

chemomechanically2

. Whereas, diamond andtungsten carbide burs simultaneously andindiscriminately remove caries-infected andcaries-affected dentine, the chemo-mechanical technique (CarisolvTM) aims topreserve tooth structure and to excavatecaries on the basis of biological principles.The existence of two layers of cariousdentine has been shown previously3,4. Thistechnique is based on the ability of sodiumhypochlorite combined with three aminoacids (Glutamic acid, Leucine, and Lysine) to

selectively remove, already denaturatedcollagen fibers in the outer layer of thecarious lesion5. The use of this techniquealso improved the process of residual cariesdiagnosis, which has traditionally beencarried out visually and relies mainly ontactile probing. Evaluating the cloudiness ofthe CarisolvTM solution, as a measure of thepresence of caries in terms of denaturatedcollagen, offered the clinician an additionaltool for caries diagnosis. Combining thisapproach with digital detection of cariesautofluorescence (DIAGNOdent) was shownto be an effective and promising method6.

Effect of chemomechanical excavation (CarisolvTM)on residual cariogenic bacteria

Sterer N, Shavit L, Lipovetsky M, Haramaty O, Ziskind D


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However, despite these improvements incaries diagnosis and treatment, the questionof residual cariogenic bacteria still remains amajor point. It has been well reported in theliterature that the presence of cariogenicbacteria around and beneath restorations isthe most important factor in restorationfailure. In a comprehensive survey ofprospective studies on the clinicalperformance of posterior resin composites itwas found, that secondary caries was one ofthe main reasons for failure7. An accurateand reliable antimicrobial approach isimportant for effective long-term treatmentsuccess.

Sodium hypochlorite is commonly

used as a disinfecting agent, owing to itsantimicrobial activities8. This antimicrobialagent has been shown to be effective againstbacteria in dental infections9 and cariogenicbacteria10. The sodium hypochloriteincorporated into the chemomechanicalexcavation gel was found to maintain theseantibacterial properties11.

Laboratory detection of cariogenicbacteria is fairly accurate but requires theuse of elaborate microbiological

techniques12. Dentine sampling is the mostcommonly used method for evaluating thepresence of cariogenic bacteria within thecarious dentine12,13. However, these methodsare complicated and hardly suitable as chair-side procedures. A method for imprintsampling of cariogenic bacteria from toothsurfaces was reported by Rosenberg et al.14.According to this method an imprint of thetooth surface (or cavity) can be taken usingsucrose containing impression material(chewing gum), and incubated in a selective

medium for cariogenic bacteria. In thepresent study, we implemented this simplechair side technique for the detection ofcariogenic bacteria on the tooth surfacebefore and following cavity preparation,using a conventional bur orchemomechanical excavation.

The aim of the present study was toevaluate the effect of CarisolvTMchemomechanical excavation on cariesremoval and residual cariogenic bacteria as

compared with that of conventional burexcavation.

Material and methods

Study Population

Fifteen patients (mean age 42.7+11.3)presenting with a number of isolated class Vcarious lesions were selected from theHadassah Dental Faculty patient list.Informed consent was obtained and theexperiment protocol was approved by theinstitutes Helsinki Committee. All thepatients received professional teeth cleaningand oral hygiene instructions a week beforethe experiment.

Experimental Protocol

The carious lesions (active lesions, vitalteeth) in each patient were randomlyassigned to one of the excavation methods:(i) chemomechanical excavation withCarisolvTM (Medi Team, Dentalutveckling AB,Savedalen, Sweden) (n=22), (ii)conventional excavation with a bur (n=24).Chemomechanical excavation was conductedaccording to the manufacturers instructionsusing the hand tools and gel supplied in thekit. Bur excavation was conducted using lowspeed round burs. The treatments were

performed by three experienced dentalpractitioners. Caries excavation was twofoldmonitored, before and after excavation, by asingle operator blinded to the mode ofexcavation assigned to each tooth.Measurements included DIAGNOdent(Kavo, Biberach, Germany) readings of thecarious lesion and the microbial contactassay (Replica Test; 14) for the detection ofmutans streptococci on tooth surfaces. Themeasurements are described in detail below.

Microbial Assay

The replica test, using an impression matrix,was carried out by pressing a commercialgum containing sucrose (West, bananachewing gum, ION, Greece) against thebuccal tooth and cavity surface. An imprintof the sampled teeth was obtained forfurther bacterial cultivation14. The imprintedmatrix was immersed in a liquid mutansstreptococci selective medium (composed oftryptose, proteose peptone, trypan blue,

gentian violet, potassium tellurite andbacitracin) and incubated at 37oC for 24 h.The bacterial colonies, stained dark blue,


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were clearly visible (Figure 1). After 24 hrsof incubation, the imprints werephotographed using a digital camera(Coolpix 5000, Nikon, Japan). Digital imageanalysing software (ImageJ NIH) was usedin evaluating cariogenic bacterial growth byquantifying the amount of blue colourproduced on the imprint of the sampledtooth surface/cavity.

Fluorescence caries measurement

The DIAGNOdent laser fluorescence system(Kavo, Biberach, Germany) was used tomeasure the carious lesion before and afterexcavation15. Measurements were performedby a single operator according to the

manufacturer's instructions. The probe tipfor smooth surfaces (B) was selected and thedevice was calibrated against a porcelainreference object and sound tooth surface.The device was held against the cariouslesion and the maximal reading wasrecorded.

Figure 1. Shows the results of a typical replica test. Animprint of the sampled tooth is presented followingincubation in a liquid mutans streptococci selective

medium at 37oC for 24 h. The bacterial colonies, staineddark blue are clearly visible (arrow).

Statistical Analysis

The mean results and standard deviations ofthe various parameters were compared usingANOVA. P value of 0.05 or less wasconsidered statistically significant.

Results

The results are shown in Figures 2 and 3. Nostatistical difference was observed betweenthe two excavation methods before and aftertreatment both in terms of both themicrobial assay (ANOVA, p=0.31 andp=0.71, pre- and post treatment,respectively) and the laser fluorescencereadings (ANOVA, p=0.34 and p=0.26, preand post treatment, respectively).

Microbial Assay

0

2

4

6

8

Pre-treatment Post-treatment%S

tainedArea/To

talArea

CME

BE

Figure 2. Meanresult and standard deviation of the%of cariogenic bacteria CFU stained area as measuredusing the replica test before and after caries removal by

chemomechanical (CME) or bur (BE) excavation.

Laser Fluorescence

0

10

20

30

40

50

60

Pre-treatment Post-treatment

ReadingsfromL

F

CME

BE

Figure 3. Mean result and standard deviation of thelaser fluorescence readings as measured using theDIAGNOdent before and after caries removal by

chemomechanical (CME) or bur (BE) excavation.

Both excavation methods showed a similarefficacy in reducing cariogenic bacterialconcentration, resulting in mean bacterialconcentration (expressed as percentage ofstained area within the total cavity area) ofless than 3% (2.82.9 and 2.92.3% forchemomechanical and bur excavation,

respectively) for both methods. Laserfluorescence readings as measured by the


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DIAGNOdent were significantly reduced byboth methods to mean readings of less than10 (9.96.3 and 7.95.2 forchemomechanical and bur excavation,respectively) levels defined by themanufacture as no caries.

Discussion

Traditional bur excavation and thechemomechanical excavation used in thisstudy both showed a similar efficacy in cariesremoval, as measured using DIAGNOdent ,and in reduction of the amount of cariogenicbacteria, as measured using the replica test.These results are in agreement with those ofother investigators12,16-18, who used differentbacteriological methods, mainly culture ofdentine samples.

Dentine sampling is traditionallycarried out by sampling the deepest dentinewithin the carious lesion or cavitypreparation, using a sterile low speed roundbur. These samples are later processed andevaluated for their bacterial content. Themicrobial assay used in this study (i.e.replica test) is a simple chair-side methodthat does not require extensive

microbiological expertise. In contrast to thedentine sampling techniques commonly usedin this type of investigation, the replica testdoes not require sampling dentine forlaboratory analysis, thus eliminating theneed for healthy tissue removal once thecavity preparation has been completed.Furthermore, this method helps to overcomea problematic aspect of dentine sampling,i.e. variations in sample volume. Thesevariations were attributed to diverse factors,such as the differences in dentine

consistency, sampling procedures and dryingtime12.

However, despite its manyadvantages, the replica test used in thisstudy still requires incubation and growth ofthe bacteria and suffers from the samedrawbacks as the traditional cultivationmethods in comparison with molecularmethods (i.e. PCR), especially inunderestimating the number of bacteria.The criteria for complete caries removal are

subjective and open to interpretation by theclinician. In the present study we supported

these criteria using objective laserfluorescence (DIAGNOdent) readings.According to the DIAGNOdent criteria allthe cavities were considered caries freefollowing excavation with both excavationmethods.

Various studies have shown thatclinically caries-free dentine still containsresidual cariogenic bacteria and it has beensuggested that the small number ofpersisting cariogenic bacteria is of no clinicalsignificance13,19. However, the location of theresidual cariogenic bacteria may also be ofsignificance. For instance, bacteria located inthe vicinity of the dentine-enamel junctionare of more clinical significance with regard

to secondary caries formation than thosesituated in other parts of the cavity20. Use ofthe replica test provides an imprint sampleof the entire cavity surface, enablingadditional information to be obtainedregarding the topographical distribution ofthe residual cariogenic bacteria within thevarious parts of the cavity surface.

Other studies have shown thatalthough chemomechanical excavation ismore time consuming then traditional bur

excavation21 and can take up to three timeslonger22, the estimated quantity of tissueremoved is significantly lower22. Theapproach now gaining acceptance worldwideof treating caries as a disease rather than alesion21 places great emphasis on thereduction of the cariogenic bacterial load aspart of this treatment. The results of ourstudy indicate that the antimicrobial abilityof the chemomechanical excavation enablesit to achieve the same reduction in thecariogenic bacterial load as the bur

excavation, while using a more minimalisticapproach.

Acknowledgements

This research was performed in the RolandE. Goldstein Center for Esthetic Dentistryand Dental Materials Research, HebrewUniversity. The research was funded by thedepartmental research budget.


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CarisolvTM

15 42.7+11.3 V

i CarisolvTM n=22 ii n=24

DIAGNOdent

DIAGNOdent

9.9 7.9 2.8% 2.9% p>0.05

I nt Dent S Afric 2007; 9: 64-72

Resumen

El enfoque de excavacin quimo-mecnica cabe los criterios del conceptocavidad adhesiva por producir unperfil redondeado interno de paredes decavidad. Sin embargo, un tal enfoquerelativamente nuevo y conservativodebera ser al menos tan efectivo queuna excavacin convencional de broca

en la eliminacin de caries residual.Objetivos: La metal del estudio presenteera probar el efecto de la excavacinquimo-mecnica CarisolvTM sobreeliminacin de caries y bacteriascariognicas residuales en comparacincon excavacin convencional con brocausando mtodos simples de lado desilla. Mtodos y materiales:Seleccionados para el estudio fue untotal de 15 pacientes (edad media 42.7+ 11.3), presentando con un nmero de

lesiones con caries aisladas de Clase V.Las lesiones con caries en cada paciente

fueran a designadas al atar a uno de losmtodos de excavacin: (i) eliminacinde caries con CarisolvTM (n=22), (ii)excavacin convencional con una broca(n=24). Las lesiones con caries fueranmedidas antes y despus de excavacinpor fluorescencia de lser, empleandoDIAGNOdent, y la presencia debacterias cariognicas fue evaluada enutilizar un juicio microbiolgico (pruebade Replica). Resultados: Ambos losmtodos han producido resultadossemejantes en las lecturas deDIAGOdent (9.9 y 7.9 para excavacinquimo-mecnica y de broca,respectivamente). No fue observadaninguna diferencia significativa entre

los dos mtodos de excavacin(p>0.05). Conclusiones: Este sugiereque la eficacia de excavacin quimo-mecnica en eliminacin de caries yreduccin de bacterias cariognicas esigual a esa de la excavacinconvencional por broca. Publicadoprimero en I nt Dent S Afric 1007; 9: 64-

72.

Resumo

O enfoque quimomecnico excavaose adapta aos critrios ao projeto decavidade adesiva por produzindo umcontorno interno arrendondado de lasparedes de uma cavidade. No entanto,um tal enfoque relativamente novo econservador deve ser pelo menos toeficaz como a excavao convencionalpela broca na extrao de crie.Objectivos: A meta da presenteinvestigao era pr prova o efeito da

excavao quimomecnica CarisolvTMsobre a extrao de crie e as bactriascariognicas residuais em comparaocom a excavao com brocaconvencional fazendo uso dos mtodossimples na cadeira a lado. Metodos eMaterial: Um total de 15 pacientes(idade mdia 42.7 + 11.3),apresentandos-se com vrias lesescariadas isoladas de classe V, estiveramseleccionados para o estudo. As lesescariadas em cada paciente estiveram

designadas aleatoriamente a um dosmtodos de excavao: (i) extrao de


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crie com CarisolvTM (n=22), (ii)excavao convencional com uma broca(n=24). As leses cariadas estiveramantes e depois da excavao pelafluorescncia de laser, fazendo uso deDIAGNOdent(R), e a presena dasbactrias cariognicas foi avaliadafazendo uso duma anlise microbial (2.8e 2.9% para excavaes quimomecnicae de broca, respectivamente). No foiobservada ninguna diferenasignificativo entre os dois mtodos deexcavao (p>0.05). Concluses: Istosugere que a eficcia da excavaoquimomecnica nas extrao cariada ereduo bacteriana cariognica igual aessa da excavao convencional de

broca. Publicado primeiro em I nt Dent SAfr ic 2007; 9: 64-72.

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16. Azrak B, Callaway A, Grundheber A,Stender E, Willershausen B.Comparison of the efficacy ofchemomechanical caries removal(Carisolv) with that of conventionalexcavation in reducing the cariogenicflora. Int J Paediatr Dent 2004; 14:182-91.

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(carisolvtm) efect antimicrob.2008

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