INTRODUCTION:

The word “caries” is derived from the Latin word meaning “rot,” and in Greek (ker), it means “death.” According to WHO, caries is defined as a “localized post-eruptive, pathological process of external origin involving softening of hard tooth tissue and proceeding to the formation of a cavity.” History of the dental caries is as old as 5000 BC when Sumerian text describes a “tooth worm” as a cause of caries.(1)

There are a number of techniques available for removal of caries. The most primitive approach to the treatment of caries was by the hand instruments, which was a painful and ineffective method for caries removal. This led to the evolution of rotary instruments from low speed to ultrahigh speed.

Chemico Mechanical Caries Removal Method

Goldman (1970) an endodontist was the first to develop, chemicomechanical caries removal method by using sodium hypochloride (NaOCl).

Following, many studies have being attempted to improve this technique. The use of 5% sodium hypochlorite was known to be toxic and aggressive to healthy and sound tissues. Therefore, a new solution was developed by adding sodium hydroxide, sodium chloride and glycine to the 5% sodium hypochlorite solution. This modified formula was known as GK-1019 and was comprised of N-monochloroglycine. Further discoveries revealed that aminobutyric acid was more competent than glycine and the brand new product then formed was known as N- monochloroaminobutyric acid also nominated as GK- 101 E. After certain trials the first product launched into the market known as, “Caridex”.

Caridex

It was patented in the US in 1975 and a further patent taken out by the National Patent Dental Corporation, New York in 1987. It received FDA approval for use in the USA in 1984 and was marketed in the 1980’s as Caridex.

The system was granted in the form of two bottles

Solution I - contains sodium hypochlorite

Solution II - contains glycine, aminobutyric acid, sodium chloride and sodium hydroxide.

Contents of the two bottles were mixed promptly before use to give the working reagent (pH 11) which was stable for approximately one hour.

Caridex claimed to involve the chlorination and disruption of the partially degraded collagen fibres in carious dentine. The carious dentine then becomes easier to remove by excavation using the modified needle tip.

The advantage of this system includes reduced need for local anaesthesia, reduced risk of pulp exposure and also the conservation of healthy tooth structure. It is also helpful in treatment of medically compromised patients as well as pediatric patients.

The main drawback of the system is large volumes of solution were needed (200–500 ml) and the procedure was slow. Time taken for removal of the caries is also more because of these reasons caridex system was not popularized.(2,3,4,5,6,7)

Carisolv

Medi Team in Sweden continued to work on the Caridex system and resulted in the launch of a new chemico-mechanical caries removal agent known as Carisolv in January 1998. Carisolv reached the market promising to be more effective and easy to manipulate. The fundamental dissmilarity between Carisolv and caridex was the use of three amino acids – lysine, leucine and glutamic acid, instead of the amino butyric acid.

The entity is retailed in the form of two syringes:

Syringe I- contains 0.5% sodium hypochlorite solution .

Syringe II- gel consisting of three amino acids.

Carboxymethyl cellulose and erythrocin were also added to make the gel viscous and readily visible in use. The ingredients should be blended shortly before use as it will decrease it’s effectiveness after 20 minutes.

The mixed gel is applied to the carious lesion for 30 seconds and then the carious portion is gently removed using specially designed, non-traumatic hand instruments. The same procedure is consecutively repeated until removing clear gel is accomplished. The average time required for complete caries removal is about 9-12 minutes and the volume of gel utilized for this purpose is only 0.2-1.0 ml.

Carisolv was not a blockbuster chiefly because it enforced:

1. Comprehensive guidance and trained authorities are needed and

2. Customized instruments which increased the cost of the solution. (2,3,4,5,6,7)

Papacarie

In 2003, a research project in Brazil led to the development of a new formula to globalize the use of chemo-mechanical method for caries removal and promote its use in public health. The contemporary blueprint was marketed as Papacarie. Papacarie is intrinsically formed of papain gel, chloramines, toludine blue, salts, thickening agent which alltogether idiosyncranise to its antibacterial and anti-inflammatory features. Commercially available as a gel syringes that have 3 ml of solution.(2)

Papain

Papain comes from the latex of the leaves and fruits of the green adult papaya. Papain is a proteolytic enzyme and an endoprotien similar to human pepsin. Papain acts as a debridant, anti-inflammatory agent which does not damage the sound tissue and hastens the cicatricial process..

Clinical studies had proved that papain has shown excellent results in skin lesions caused by burns, areas with necrotic and purulent processes, aided cleansing of necrotic tissue and secretions and shortening the period of tissue repair.

Dawkins concluded that Carica papaya contain anti-bacterial activity that inhibits growth of gram-positive and gram-negative organisms. (S. aureus, E. coli, B. cereus, P. aeruginosa and S. flexneri). (2,3,4, 9,10,11, 12,13)

Chloramines

Chloramines are formed due to the reaction between chlorine and ammonia. They have bactericidal and disinfectant properties. Fuursted et al compared five antiseptics (chloramines T, chlorhexidine, povidone-iodine, phenoxyethanol and mandelic-lactic acid) on the basis of lag of regrowth and the antibactericial action contrary to nine bacterial pathogens. Results showed that the chloramines T and mandelic-lactic acid induced a somewhat longer lag as compared with the other agents. Chloramines are used to chemically soften the carious dentin.

Tonami’s study disclosed that chloramines resulted in the opening of dentinal tubules in the outer layer of carious dentin as compared to sodium hypochlorite application which resulted in occluded dentinal tubules.

Toluidine Blue

Originally, the malachite green was used as colouring agent. After a few studies toluidine blue was found highly effective against Streptococcus mutans. Toludine blue is a photosensitive pigment that fixes into the bacterial membrane.

Mechanism of Action

The mixed gel is applied to the carious lesion for 30- 40 seconds and then the carious portion can be gently removed using specially designed, non-traumatic hand instruments.

1. Degrades and eliminates the fibrin "mantle" formed by carious process

2. Breaks the partially degraded collagen molecules

3. By digesting the dead cell, causes breakdown of the collagen molecules

4. Degraded collagen is chlorinated by chloramines

5. Disturb the hydrogen bond and affects the secondary and quaternary structure

6. Chemically soften the carious dentin and facilitating removal of caries tissue.

Papacaries Gel

Papacaries gel is a novel dental material and composed ofa mixture of polyphenol from mangosteen extracts and papin in a gel preparation.

Mangosteen pericarp extract, which contains alpha mangostinwas active against S. mutans strain ATCC25175. In vitro study depicted that 1mg/ml of mangosteen extract can reduce S. mutans by 50% within approximately 5 seconds, after this the bacterial count drops to 0 after 60 seconds. Combination of mangosteen extract and papain gel created a larger zone of inhibition as compared to using mangosteen and papain gel separately.Papain activity can hydrolyse the proteins in the outer portion of gram–negative bacteria and as a result, perturbs the membrane permeability.

Papacarie gel is a biocompatible material and also has antibacterial characters. The mixed gel is applied to the carious lesion for 40 seconds and then the carious portion can be gently removed using hand instruments. It removes only the compromised tissueand preserves the healthy tissue and also there is no need of local anesthesia. It is less painful, noise and vibration free and also provides serenity to the patients.(3,12)

Carie Care

Carie care has an active ingredient from papaya extract - an endoprotein, chloramines and dye. 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 the gel so that when applied there is no spill over.

The present gel preparation does not contain sodium hypochlorite or any other strong chlorinating agent instead has most of the ingredients from natural sources. Other chemico-mechanical caries removal agents including Papacarie contain essential oils which are incorporated in the gel and which act as anti-inflammatory agent. Carie Care not only softens infected dentine but gives additional advantage of anti-inflammatory activity and aroma.

Carie Care is applied directly onto the tooth having caries by means of a disposable applicator tip; soon gel changes the color in the affected area. After 1 minute the gel along with dissolved caries is removed by means of a Sharp Spoon Excavator. Carie Care is in the form of single preparation, which can be stored at 4^oC for more than 6 months.(4,5,6,7)

CONCLUSION:

Chemico-mechanical method is extremely comfortable method and is successful in achieving patient co-operation.(7) Fear and anxiety is mainly because of the injection site and the noise caused by the cavity cutting. These drawbacks can be easily eliminated using chemico-mechanical caries removal methods. In the past Caisolv and Papacarie is used effectively in treating dental caries and currently Carie Care is gaining popularity with the same. It also helps in instillation of positive attitude towards the dental treatments in patients mind and in creating a healthy smile.(8)

REFERENCES:

1. Formyl, Judit. The beginnings of dental caries and its treatments. J Dent Clin Res 2009;5(2):187-192.

2. Mhatre S, Kumar SVK, Sinha S, Ahmed BMN, Thanawala EA. Chemo-Mechanical Method Of Caries Removal: A Brief Review. Int J Clin Dent Sci 2011;2(2):52-57.

3. Ganesh M and Dhaval Parikh. Chemomechanical caries removal (CMCR) agents: Review and clinical application in primary teeth. J Dent Oral Hyg 2011;3(3):34-45.

4. Elkholany NR, Abdelaziz KM, Zaghloul NM, Aboulenine N. Chemo-Mechanical Method: A Valuable Alternative for Caries Removal. Dent News 2004;9(3):16-22.

5. Beeley JA, Yip HK, Stevenson AG. Chemochemical caries removal: a review of the techniques and latest developments. Brit Dent J 2000;188(8):427-430.

6. Elkholany NR, Abdelaziz KM, Zaghloul NM, Aboulenine N. Chemo-mechanical method: A valuable alternative for caries removal. J Minim Interv Dent 2009;2(4):248-259.

7. Chemomechanical Caries Removal: A Review & Study of an Indigen-ously Developed Agent (Carie Care ^TM Gel) In Children.

8. Clinical Manual Carisolv® Minimally-invasive, patient-friendly removal of caries. MediTeam Dental AB, 2002

9. Bussadori SK, Castro LC, Galvão AC. Papain Gel: A New Chemo-Mechanical Caries Removal Agent. J Clin Pediatr Dent 2005;30(20):115–120.

10. Guzman AY, Guzman MGS. The enzymatic debridement of suppurations, necrotic lesions and burns with papain. J Int Coil Surg 1953; 20:695-702.

11. Udok VM, Storojuk VT. Use of papain in trating suppurative postoperative soft tissue complications and daises. Khirurgiia 1981;19: 99-101.

12. Velasco MVR. Desenvolvimento e padronização do gel contend papaína para uso tópico. [Dissertação de Mestrado]. São Paulo: faculdade de Ciências Farmacêuticas da USP; 1993.

13. Bhardwaj A, Bhardwaj SV. Papacarie® containing papain: A Natural Chemomechanical Caries Removal Agent. Research J Pharmaceu, Biolog Chem Sci 2012;3(2):660-666.

Received on 06.05.2016 Modified on 24.05.2016

Research J. Pharm. and Tech 2016; 9(10):1765-1767.

DOI: 10.5958/0974-360X.2016.00355.3