|Year : 2017 | Volume
| Issue : 1 | Page : 6-13
Comparison of efficacy of caries removal using polymer bur and chemomechanical caries removal agent: A clinical and microbiological assessment - An in vivo study
K Krishna Aswathi1, S Prathibha Rani2, Anantharaj Athimuthu2, Praveen Prasanna2, Prasannakumari Patil3, KJ Deepali4
1 Department of Pedodontics and Preventive Dentistry, KMCT Dental College, Kozhikode, Kerala, India
2 Department of Pedodontics and Preventive Dentistry, D. A. Pandu Memorial R. V. Dental College, Bengaluru, Karnataka, India
3 Department of Pedodontics and Preventive Dentistry, Maharashtra College of Dental Science and Research, Latur, Maharashtra, India
4 Consultant, Periodontist, Rajan Dental Clinic, Banglore, India
|Date of Web Publication||31-Jan-2017|
K Krishna Aswathi
Department of Pedodontics, KMCT Dental College, Manassery P.O., Mukkam, Kozhikode - 673 020, Kerala
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background and Objectives: Conservative caries removal has become an integral part of minimally invasive dentistry (MID). Polymer burs and chemomechanical caries removal are two feasible methods of MID. The objective of this study was to assess and compare the efficacy of polymer bur and chemomechanical caries removal agent clinically and microbiologically for selective removal of infected dentin. Methods: A total of fifty primary second molars with occlusal decay involving dentin were selected from 25 patients aged between 5 and 9 years. They were randomly allocated to Group A (polymer bur group) and Group B (Carie-Care group) for caries removal. Completeness of caries excavation was assessed clinically with the application of caries detector dye. Dentinal samples were collected before and after caries removal and cultured in Luria-Bertani Agar, and total viable count was assessed. All the teeth after caries excavation were restored with Type 2 glass ionomer cement. The data obtained was tabulated and statistically analyzed using paired t-test and Chi-square test. Results: There was a statistically significant reduction in the mean microbial count before and after treatment in polymer bur group and Carie-Care group. The reduction in mean microbial count was found significantly higher in polymer bur group compared to Carie-Care group. There was no significant association was observed between the two groups when efficacy was assessed clinically. Conclusions: Both polymer bur and Carie-Care were efficient caries removal agents when assessed clinically and microbiologically. Polymer bur was found to be more effective than Carie-Care when assessed microbiologically.
Keywords: Carie-Care, caries excavation, chemomechanical caries removal, minimally invasive dentistry, polymer bur
|How to cite this article:|
Aswathi K K, Rani S P, Athimuthu A, Prasanna P, Patil P, Deepali K J. Comparison of efficacy of caries removal using polymer bur and chemomechanical caries removal agent: A clinical and microbiological assessment - An in vivo study. J Indian Soc Pedod Prev Dent 2017;35:6-13
|How to cite this URL:|
Aswathi K K, Rani S P, Athimuthu A, Prasanna P, Patil P, Deepali K J. Comparison of efficacy of caries removal using polymer bur and chemomechanical caries removal agent: A clinical and microbiological assessment - An in vivo study. J Indian Soc Pedod Prev Dent [serial online] 2017 [cited 2018 May 24];35:6-13. Available from: http://www.jisppd.com/text.asp?2017/35/1/6/199232
| Introduction|| |
The management of dental caries has evolved over the last few decades with a change from “extension for prevention to prevention of extension” paradigm following extensive research in cariology and material sciences. Minimally invasive dentistry (MID) is the modern medical approach to the management of caries, utilizing caries-risk assessment, and focusing on the early prevention and interception of disease. Moving the focus away from the restoration of teeth allows the dentist to achieve maximum intervention, with minimal invasive treatments.
Chemomechanical caries removal (CMCR) is a MID technique which removes infected dentin through a chemical agent. It preserves healthy structures, avoids pulp irritation, and patient discomfort.
Polymer bur (smart bur) is a unique rotary instrument made of a specially designed polymer material, which, according to the manufacturer, selectively removes decayed dentine without cutting the healthy dentine.
Various studies have been conducted to compare the efficacy of polymer bur and chemomechanical caries removal agents with that of conventional caries removing methods. However, there is a paucity of studies comparing these two minimal invasive techniques. Thus, the objective of this study is to assess and compare the efficacy of indigenously developed chemomechanical caries removal agent; Carie-Care and polymer burs in selective removal of infected carious dentin.
| Methods|| |
A total of fifty primary molars with Class I occlusal caries were selected from 5- to 9-year-old patients for the study using the inclusion and exclusion criteria. The inclusion criteria were patients aged 5–9 years with Class 1 (occlusal) active caries involving dentine in primary molars as confirmed using intraoral periapical radiographs. The exclusion criteria were uncooperative children, medically compromised children and children with special care needs, primary teeth with deep dentinal caries which are symptomatic, patient on systemic/topical antibiotics or antiseptics, proximal caries, patients with developmental defects of teeth, and tooth which have already been restored or fractured.
Approval for the study was obtained from an Institutional Ethical Committee, and informed parental consent was obtained before including the children in the study. A detailed dental assessment was done including clinical and radiographic examination as required.
The selected teeth were randomly allocated to either of the two groups:
- Group A - Polymer bur group - Teeth to be treated by polymer bur for caries removal (n = 25)
- Group B - Carie-Care group - Teeth to be treated by Carie-Care for caries removal (n = 25).
Caries excavation was done by a single operator for all the fifty selected teeth. In both group, the tooth to be restored was anesthetized and isolated with rubber dam. The outline form of the cavity was established using airotor hand piece and burs to increase accessibility and visibility and also to remove unsupported enamel margins. An initial baseline sample of the carious dentin was removed superficially from the lesion using a sterile spoon excavator. The dentin sample was immediately transferred into a sterile vial containing saline for microbial culture and assessment of total viable count.
For the teeth allocated to Group A polymer bur group, removal of carious dentin was performed with polymer bur (SmartBurs II) size RA4, RA6, and RA8 according to the size of carious lesion, running at slow speed without a water coolant [Figure 1] and [Figure 2]. Caries was excavated with circular movements starting from the center of the lesion to the periphery as recommended by the manufacturer. The excavation was stopped when the instrument became macroscopically abraded and blunted and was no longer able to remove tissue [Figure 3] and [Figure 4].
For the teeth allocated to Group B Carie-Care group, the indigenous CMCR gel was applied directly to the carious tooth, and left undisturbed for 30–60 s, and then, the caries was removed gently with the spoon excavator [Figure 5] and [Figure 6].
The above procedure was repeated until no more soft dentin was detected, using tactile method. A sample of dentin was then taken from the cavity floor in both groups using sterile spoon excavator and transferred to sterile screw cap vial. Care was taken to obtain adequate amount of dentine particles for microbial culture and evaluation.
The efficacy of caries removal in both groups was evaluated clinically by visual examination after application of caries detector dye and rated as complete or incomplete. The caries detector dye was dropped onto a sterile cotton pellet, and then, the pellet was placed into the cavity and removed after 10 s [Figure 7]. The solution was rinsed off with sterile saline [Figure 8]. All the teeth were then restored by Type 2 glass ionomer cement.
The dentin samples collected in screw cap vials were immediately transferred to the laboratory for microbial culture and evaluation. The samples collected were diluted with saline and then plated on Luria-Bertani agar plates. The Luria-Bertani agar plates were incubated aerobically for 2 days at 32°C. Then, the number of colonies was determined and expressed as CFU (colony forming units) per sample [Figure 9] and [Figure 10].
| Results|| |
The present in vivo study, a total of 50 primary molars with occlusal decay involving dentin were selected from 25 patients and were randomly allocated either to polymer bur group (n = 25) or to Carie-Care group (n = 25).
Among the selected 25 patients, 10 were male and 15 were female. Age group of the sample was in the range of 5–9 years. The mean age of the sample in the polymer bur group was 7.04 years while in the Carie-Care group, it was 6.52 years [Table 1] and [Graph 1].
The selected teeth for this study included 8 maxillary second primary molars, 4 mandibular first primary molars, and 13 mandibular second primary molars in polymer bur group, and 3 maxillary first primary molars, 5 maxillary second primary molars, one mandibular first primary molar, and 16 mandibular second primary molars in Carie-Care group [Table 2] and [Graph 2].
After caries excavation in both groups, the efficacy of caries removal was assessed clinically and microbiologically. The data obtained was tabulated and subjected to statistical analysis using paired t-test and Chi-square test. The results were summarized as follows.
Statistical comparison of caries excavation in polymer bur group and Carie-Care group clinically
In polymer bur group, 92% of lesions showed complete removal of caries after the application of caries detector dye while 8% showed incomplete removal of caries. In Carie-Care group, all the lesions that are 100% showed complete removal of caries. The difference between the scores was not statistically significant (P > 0.05%) [Table 3] and [Graph 3].
|Table 3: Comparison of caries excavation in polymer bur group and Carie-Care group clinically (Chi-squared test)|
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Statistical evaluation of reduction in mean microbial count within polymer bur group
In polymer bur group, the mean difference between the total viable bacterial count before and after caries excavation was 29098.600. The reduction in total viable count was statistically significant when analyzed using paired t-test (P < 0.001) [Table 4] and [Graph 4].
|Table 4: Evaluation of reduction in mean microbial count within polymer bur group: Paired t-test|
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Statistical evaluation of reduction in mean microbial count within Carie-Care group
In Carie-Care group, the mean difference between the total viable bacterial count before and after caries excavation was 25660.960. The reduction in total viable count was statistically significant when analyzed using paired t-test (P < 0.001) [Table 5] and [Graph 5].
|Table 5: Evaluation of reduction in mean microbial count within Carie-Care group: Paired t-test|
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Statistical comparison of reduction in mean microbial count after caries excavation using polymer bur and Carie-Care
The reduction in mean total viable count of bacteria was found to be higher in polymer bur group (29098.600) compared to that of Carie-Care group (25660.960). The mean difference between the groups was 3437.640, and it was statistically significant when analyzed with paired t-test (P < 0.001) [Table 6] and [Graph 6].
|Table 6: Comparison of reduction in mean microbial count after caries excavation using polymer bur and Carie-Care: Paired t-test|
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| Discussion|| |
Conventional burs are designed to efficiently remove decalcified enamel and dentine; however, they do not readily differentiate between carious and normal dentine, and the use of conventional bur is considered unsatisfactory because of its less conservative approach. CMCR and polymer burs are two minimally invasive techniques which selectively remove infected dentin. This in vivo study evaluated and compared the efficacy of these two minimally invasive techniques clinically and microbiologically.
CMCR agent; Carie-Care, an indigenously prepared CMCR agent was used in this study. It was developed by Vittal Mallya Scientific Research Foundation, India. It has papain, an endoprotein as main active ingredient. It is also composed of therapeutic essential oils, chloramine and sodium chloride, coloring agent, preservative sodium methyl paraben and sodium propyl paraben, and sterile water. The gel allows maximum preservation of healthy tooth structure, advantage being easy application which does not need special instruments.
Polymer bur is a unique rotary instrument which is constructed from a medical-grade polyether-ketone-ketone, and it selectively removes decayed dentine without cutting the healthy dentine. This property is based on the hardness of the instrument being lower than the hardness of the healthy dentine. In addition, this minimally invasive excavation has the advantage of fewer dentin tubules being cut and thereby, less pain sensations being triggered compared to using conventional burs.
In the present study, caries excavation in polymer bur group and Carie-Care group was performed according to the manufacturer's instructions and techniques described in the previous studies.,,,,,
Visual and tactile examination is the most widely used clinical criterion to evaluate the completeness of caries removal. The difficulty in accurately and reliably detecting infected dentine by tactile and visual examination alone is well established and also it depends on the operators judgment and experience., Removal of carious dentine can be guided by staining it with caries detector dyes. Hence, the cavity preparations in this study were verified for completeness of caries removal using caries detector dye; caries marker. After the excavation of carious lesion, the coinvestigator assessed the completeness of the infected dentin removal.
In the present study, two cases in polymer bur group showed incomplete caries removal when assessed clinically after the application of caries detector dye though statistically not significant when compared to the Carie-Care group [Table 3] and [Graph 3].
Studies have demonstrated that the absence of stain after using caries detector dye does not ensure elimination of bacteria,, and it is now clearly established that these dyes do not stain bacteria but instead stain the organic matrix of less mineralized dentin.
The clinical impact of bacterial persistence in caries-free dentine is not clear, but some authors agree that elevated bacterial counts remaining after a caries removal procedure can be considered clinically significant because they cause further disease progression, and the efficacy of caries excavation methods can be assessed based on the reduction in microbial flora from the tooth cavity. Hence, the reduction in microbial flora was used to assess the efficacy of polymer bur and Carie-Care after the caries excavation.
The microbial populations involved in dental caries are known to be highly complex and variable and have not yet been fully identified although key organisms are generally recognized to be associated with disease progression. Hence, the study aimed to measure the amount of all viable bacteria that is total viable count regarding cariogenicity of dentin samples.
In this study, polymer bur group showed a mean total viable count of 2.9 × 104 CFU before caries excavation and 2.1 × 101 CFU after caries excavation [Table 4] and [Graph 4]. In Carie-Care group, a mean total viable count of 2.5 × 104 CFU was observed before caries excavation and 1.9 × 101 CFU after caries excavation [Table 5] and [Graph 5].
Several investigations have shown that often a lower number of residual microorganisms (101–102 CFU) remain behind in clinically sound dentin, in spite of a significant reduction in bacterial count after caries excavation. This lower number of bacteria, however, is considered to be clinically acceptable by several authors. The relevant bacterial reduction observed in the present study, regardless of the method used to remove caries, indicates that the necrotic and highly infected dentine was removed by excavation.
The residual bacteria do not lead to further lesion progression or pulp reactions, if the cavity is appropriately sealed with a restorative material. Moreover, caries recurrence cannot be attributed exclusively to the residual bacterial counts in dentine since other factors may represent a more relevant influence on the recurrence of secondary caries, such as marginal failure and presence of gap on remaining restored/sealed carious dentin, leading to leakage and infiltration of bacteria and carbohydrates. Hence, hermetic seal after caries excavation is essential, and glass ionomer cement was used to restore cavity in this study. Glass ionomer cement showed acceptable, marginal adaptation and durability when used to restore deciduous teeth in the previous studies.
Compared to the baseline microbial count, the total viable counts after the caries excavation in the groups, that is, the polymer bur and Carie-Care showed a statistically significant reduction [Table 4] and [Table 5]. This is in agreement with other studies.,,
In this study, reduction in total viable count of bacteria in the polymer bur group was compared with Carie-Care group, and it showed a statistically significant difference between the groups with a greater reduction in total viable bacterial counts in the polymer bur group than Carie-Care group [Table 6] and [Graph 6].
The probable reason for significant reduction in microbial count in polymer bur group compared to that of Carie-Care group may be attributed to the nature of polymer bur in losing its cutting efficiency on reaching the affected dentin,, whereas in the Carie-Care group, extent of caries excavation is dependent on the operator's decision.
The advantages of polymer bur reported in the previous studies were its self-limiting ability, less heat generation, minimal discomfort during caries excavation, and reduced chances of pulpal exposure during deep caries excavation. Advantages observed with Carie-Care were selective removal of carious dentine, applicability to child care, and produced less anxiety in children.
Limitations of these techniques noticed in the previous studies were both were consuming more time compared to conventional technique ,, and required preparation of enamel with high-speed airotor and burs whenever there is no direct access to the carious dentine., In small cavities, the polymer bur easily touched the enamel and the bur went blunt, and during excavation of large cavities, more than one bur was required.
The present in vivo study showed that polymer bur and Carie-Care could be the feasible alternative methods in pediatric dentistry owing to their efficacy and being minimally invasive techniques of effective caries removal. However, further studies need to be conducted, comparing the species-specific reduction after caries excavation, and also long-term follow-up studies to assess the longevity of the restoration placed after caries excavation with these recently introduced materials.
| Conclusions|| |
Within the limitations of the study, the following conclusions were drawn:
- Both polymer bur (smart bur) and CMCR using indigenous papain containing gel (Carie-Care) were effective in removing carious dentine when assessed clinically
- Both polymer bur (smart bur) and CMCR using indigenous papain containing gel (Carie-Care) showed a significant reduction in total viable count after caries excavation
- Polymer bur showed statistically significant difference in reducing the total viable count from baseline compared to the chemomechanical method of caries removal using Carie-Care.
Materials for the study (Carie-Care) and equipment for microbiological assessment were sponsored by Vittal Mallya Scientific Research Foundation, Bengaluru, Karnataka, India.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10]
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]