|Year : 2020 | Volume
| Issue : 1 | Page : 41-45
Efficacy and efficiency of papacarie versus conventional method in caries removal in primary teeth: An SEM study
Department of Preventive Dental Sciences, College of Dentistry, Imam Abdulrahman Bin Faisal University, Dammam 31441, Saudi Arabia
|Date of Submission||02-Jul-2018|
|Date of Decision||14-Aug-2018|
|Date of Acceptance||05-Mar-2019|
|Date of Web Publication||23-Dec-2019|
Dr Jehan AlHumaid
Department of Preventive Dental Sciences, College of Dentistry, Imam Abdulrahman Bin Faisal University, P. O. Box: 1982, Dammam 31441
Background: Chemomechanical methods such as Papacarie were developed as alternate dental caries removal methods to overcome major disadvantages of the conventional drilling technique. However, few studies have demonstrated the efficacy of Papacarie for caries removal using scanning electron microscope (SEM).
Objectives: The purpose of this study was to compare the efficacy and efficiency of Papacarie and the conventional bur method in caries removal from primary teeth.
Materials and Methods: In this in vitro study, 30 freshly extracted, human primary molars with dentinal caries were obtained from the outpatient clinics at the Dental Hospital of Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia. Each tooth was sectioned mesiodistally into two halves through the center of the lesion, and each half was randomly subjected to caries removal by Papacarie (Group I) and excavation using the conventional bur method (Group II). Time taken (efficiency) for removal of caries was noted using a stopwatch. Samples were then examined under SEM for presence of bacterial colonies (efficacy). For efficiency, data were analyzed using chi-square, and for efficacy, using t-test.
Results: There was no significant difference in the presence of bacteria in both groups under SEM (Papacarie = 23.3%; conventional method = 16.7%; P = 0.52). However, significantly more time was taken for caries removal with Papacarie (mean = 351.56 s) than with the conventional bur method (mean = 158.41 s) (P < 0.0001).
Conclusion: Papacarie is as effective in removing dentinal bacteria as the conventional caries removal method but is less efficient, as the time taken for excavation was longer.
Keywords: Dental caries, Papacarie, primary teeth, scanning electron microscope
|How to cite this article:|
AlHumaid J. Efficacy and efficiency of papacarie versus conventional method in caries removal in primary teeth: An SEM study. Saudi J Med Med Sci 2020;8:41-5
|How to cite this URL:|
AlHumaid J. Efficacy and efficiency of papacarie versus conventional method in caries removal in primary teeth: An SEM study. Saudi J Med Med Sci [serial online] 2020 [cited 2021 Apr 16];8:41-5. Available from: https://www.sjmms.net/text.asp?2020/8/1/41/273809
| Introduction|| |
Caries excavation has traditionally been performed using drills and sharp-edged hand instruments. These methods, although often effective, have some major disadvantages. First, it is often difficult to establish the amount of dentine to be removed because of the possibility of unnecessary removal of sound tooth structure in addition to decayed tissue. Second, local anesthesia is needed to alleviate the pain and discomfort caused by mechanical methods. To circumvent these drawbacks, alternative dental caries removal methods were proposed.
Alternative caries removal methods such as air abrasion, sonoabrasion, ultrasonic instrumentation and laser are expensive, and hence less frequently used.,, In contrast, chemomechanical elimination of carious dentine is a promising alternative treatment procedure, particularly in pediatric dentistry and for anxious or medically compromised patients. Chemomechanical caries removal was the first such method introduced in 1975 by Habib et al. and used 5% sodium hypochlorite. This was followed by the introduction of GK-101, Caridex system and Carisolv, which consisted of sodium hypochlorite, glutamic acid, leucine and lysine.,, Of these, only Carisolv was found to be effective in removing infected carious tissue,,,, but it failed to become a practical alternative to the conventional drilling method because of its high cost, special instrument requirements and time consumption., Further, children disliked its chlorine taste and odor.
In consequence of such disadvantages, Papacarie (Fórmula and Ação, São Paulo, Brazil) was developed by Bussadori et al. for removal of caries. It contains 10% papain, 0.5% chloramine, toluidine blue, salts and a thickening vehicle. Papain is responsible for its bactericidal, bacteriostatic and anti-inflammatory properties. Ease of application and no special device requirements are added advantages.
Cytotoxic studies of Papacarie have suggested that it is safe for use in pediatric patients. A number of studies have compared the efficacy of chemomechanical methods with the conventional bur method and highlighted the merits of the former with respect to reduced pain and need of anesthesia as well as patient acceptance.,,,, A few studies have used scanning electron microscope (SEM) to demonstrate the efficacy of Carisolv in removing infected primary, and permanent dentine.,,, However, to the best of the author's understanding, only Kotb et al. have used SEM for demonstrating the efficacy of Papacarie in removing infected primary dentine. Therefore, this study was conducted to evaluate and compare the efficacy of Papacarie and the conventional method (bur) for caries removal in primary molars using SEM.
The null hypotheses tested for this study were that there was no difference in (1) efficacy of caries removal and (2) time required for caries removal, following the two caries excavation techniques.
| Materials and Methods|| |
The present study was approved by the Institutional Review Board (IRB-2019-02-122) of Imam Abdulrahman Bin Faisal University (IAU), Dammam, Saudi Arabia. All tooth samples were collected from outpatient clinics at the Dental Hospital of IAU.
In thisin vitro study, the method of carious dentine removal is the independent variable, and time (in seconds) required to remove dentine (efficiency) and the detection of bacteria after carious removal (efficacy) are the response or dependent variables.
Thirty freshly extracted, human primary molars with occlusal caries extending into the dentine, with cavity opening diameter ≥2 mm and with accessibility to hand instruments were collected over a period of 3 months from the Pediatric Dentistry clinics at the Dental Hospital. The sample size was determined using the Dinam 1.0 program, and calculations were performed considering time and colony-forming bacteria.
These teeth were extracted due to exfoliative mobility and/or orthodontic reasons. A written consent was taken from the patient's parent/guardian before the extraction procedure. The primary molars with occlusal caries extending into dentine were confirmed through intraoral periapical radiograph, whereas teeth involving pulpal and/or periapical pathology, multisurface carious lesions and teeth with developmental anomalies were excluded. The teeth were stored in phosphate-buffered saline containing 0.2% (w/v) sodium azide at 4°C.
All soft tissue and extrinsic deposits were removed from the teeth using hand scalars, and the debris was cleaned with a slurry of pumice and water followed by rinsing in distilled water and drying with compressed air for 5 s. Each tooth was sectioned through the center of the lesion into two halves mesiodistally using a diamond circular disc on a slow-speed handpiece with water spray. The cut surface of both pieces of each tooth was visually examined to see the extent of carious lesion. Only teeth in which carious lesion extended up to the dentine were included in the study. The two halves of each tooth were randomly assigned to Group I (caries removal by Papacarie) and Group 2 (conventional bur method) for evaluation of ultrastructure of residual dentine.
Group I consisted of 30 samples; carious tissue was removed for each sample using the Papacarie gel (Fórmula and Ação, Laboratório Farmacêutico Ltda Me, Sao Paulo, Brazil). Dental caries was excavated using hand instruments after initial gel application for 30–60 s. The technique was continued until the lesion surfaces felt hard. The cavity was dabbed with a cotton pellet and washed with water spray.
Group II consisted of 30 samples; carious tissue was removed for each sample by conventional method, using a high-speed handpiece under water spray with a number 330 carbide bur, followed by a Hu-Friedy spoon excavator for any remaining infected dentine. The cavity was rinsed with water and wiped with a sterile cotton pellet.
Efficacy of caries removal
The completeness of caries removal was judged by visual (absence of any discoloration) and tactile (smooth passage of the explorer and absence of a catch or a tug-back sensation) methods in both groups by a pediatric dentist who was blinded to the group status.
Time required for caries removal
The time for each caries removal technique was noted using a stopwatch. For Group I, time was calculated from the start of gel application until it was no longer cloudy. For Group II, time was calculated from the beginning of caries removal with a bur until it was free from caries.
Each sample was washed with distilled water and placed in 2.5% glutaraldehyde in 0.1 M phosphate buffer (pH 7.4) for 24 h, then washed and dehydrated in a series of graded alcohol solutions for 10 min each. The specimens were then mounted on aluminum stubs for gold sputter coating. Surfaces of the remaining dentine were examined under SEM (Hitachi S3000N, Tokyo, Japan) at 20 KV, and images were taken to analyze the presence or absence of bacterial deposits or smear layer in primary dentine after caries excavation in both groups. All SEM observations were performed by a single examiner blinded to the grouping of the teeth.
The presence/absence of bacteria was compared between the two groups using chi-square test, and the time (in seconds) taken for caries removal was compared using t-test. The analysis was done using SPSS version 17.0 software (SPSS Inc., Chicago, IL, USA). Significance level was set at the 5% level.
| Results|| |
The SEM analysis showed that the presence of bacterial colonies after caries removal with Papacarie (n = 7; 23.3%) was slightly higher than that with the conventional method (n = 5; 16.7%) (P = 0.52) [Table 1] and [Figure 1], [Figure 2]. Further, significantly more time was taken for caries removal with Papacarie (mean = 351.56 s) than that with the conventional bur method (mean = 158.41 s) (P < 0.0001) [Table 2].
|Figure 1: Scanning electron micrograph high magnification (×5000) of dentin surface in Group I showing open dentinal tubules (arrows pointing) with no bacterial colonies after caries removal with Papacarie gel|
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|Figure 2: Scanning electron micrograph high magnification (×6000) of dentin surface in Group I showing amorphic layer indicative of smear layer (arrows pointing) at dentino-enamel junction (DEJ) after caries removal with Papacarie gel|
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|Table 2: Comparison between two groups for time taken to excavate caries|
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| Discussion|| |
Removal of dental caries using rotary instruments is frequently associated with thermal and pressure effects on the pulp, which produces pain. Moreover, drilling may also involve the removal of sound tooth tissue adjacent to the affected caries area.,, Due to the shortcoming of the drill, alternative techniques such as chemomechanical caries removal were developed.
The chemomechanical agents of caries removal have a disintegrating effect on caries tissue, while leaving healthy dentine largely intact. The affected tissue consists of mostly demineralized, partly disrupted collagen fibers together with other components of the dentine extracellular organic matrix. Papacarie acts by breaking the partially degraded collagen molecules. It breaks the polypeptide chains and hydrolyses the crosslinks of collagen fibrils. The appearance of bubbles on the surface and blearing of the gel during the clinical procedure indicate that the degradation is occurring, and oxygen is being released, and thus demonstrate that the removal process has begun.
In this study, only caries-infected dentine was removed, and visual and tactile criteria were used to evaluate the efficacy of caries removal, as proven in previous studies evaluating the efficacy of chemomechanical methods.,,,, The difference in the efficacy between Papacarie and drilling was found to be statistically insignificant (23.3% vs. 16.7%; P = 0.52). These results support those of previous studies., Hence, the fir
st hypothesis of this study was accepted: there is no significant difference in the efficacy of caries removal between the two caries excavation techniques.
In the present study, the mean time for caries removal in primary teeth using Papacarie was significantly higher than that using carbide bur (351.56 s vs. 158.41; P < 0.0001). These results corroborate the results of Singh et al., who reported that the time taken for caries removal with Papacarie was three times more than the conventional method. Requirement of multiple gel applications to complete caries removal could also account for the longer time. Thus, the second hypothesis was rejected, as there was a significant difference in the time required for caries removal between the two caries excavation techniques.
The slightly higher presence of bacterial colonies in the smear layer after the caries removal with Papacarie may have been because of the conservative preparation in this method compared to the conventional drilling with 330 carbide bur. This chemomechanical method preserves the sound tooth structure where the remaining bacteria can be found in the dentinal tubules. These findings are in contrast with the results of Kotb et al., who reported the absence of bacteria and open tubules due to the proteolytic effect of Papacarie, which enhances the disrupting effect of chloramines on degenerated collagen of carious dentin, thereby facilitating its removal. Our study results corroborate with those of Thakur et al., who found that use of Papacarie gel resulted in a minimal smear layer with the patent dentinal tubules.
A limitation of this study is that the visual and tactile measures used to evaluate the completion of caries removal are subjective. In addition, a single trained operator in a laboratory conducted this study, and this may result in variation when these techniques are used with multiple operators. Therefore, the author suggests validating this study's results with multiple operators in clinical studies in the future.
| Conclusion|| |
This study found that there was insignificant difference in the presence of bacterial colonies after caries removal with Papacarie and the conventional drilling techniques. This indicates that Papacarie can be used as a possible alternative to conventional methods for caries removal, particularly in highly active or anxious children. However, the longer excavation time with Papacarie gel should be considered during the selection of this caries removal method.
This study was approved by the Institutional Review Board (IRB-2019-02-122) of IAU, Dammam, Saudi Arabia. Parents/guardians of all patients provided a written consent for use of the extracted teeth in this study. This study was also conducted in accordance with the ethical standards in the Declaration of Helsinki, as revised in 2013.
This article was peer-reviewed by two independent and anonymous reviewers.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Hamama H, Yiu C, Burrow M. Current update of chemomechanical caries removal methods. Aust Dent J 2014;59:446-56.
Peskersoy C, Turkun M, Onal B. Comparative clinical evaluation of the efficacy of a new method for caries diagnosis and excavation. J Conserv Dent 2015;18:364-8.
] [Full text]
Hegde S, Kakti A, Bolar DR, Bhaskar SA. Clinical efficiency of three caries removal systems: Rotary excavation, Carisolv, and Papacarie. J Dent Child (Chic) 2016;83:22-8.
Lai G, Lara Capi C, Cocco F, Cagetti MG, Lingström P, Almhöjd U, et al.
Comparison of Carisolv system vs. traditional rotating instruments for caries removal in the primary dentition: A systematic review and meta-analysis. Acta Odontol Scand 2015;73:569-80.
Soni HK, Sharma A, Sood PB. A comparative clinical study of various methods of caries removal in children. Eur Arch Paediatr Dent 2015;16:19-26.
Reddy MV, Shankar AJ, Pentakota VG, Kolli H, Ganta H, Katari PK, et al.
Efficacy of antimicrobial property of two commercially available chemomechanical caries removal agents (Carisolv and Papacarie): An ex vivo
study. J Int Soc Prev Community Dent 2015;5:183-9.
Habib CM, Kronman J, Goldman M. A chemical evaluation of collagen and hydroxyproline after treatment with GK-101 (N-Chloroglycine). Pharmacol Ther Dent. 1975;2(3-4):209-15.
AlHumaid J, Al-Harbi F, El Tantawi M, Elembaby A. X-ray microtomography assessment of Carisolv and Papacarie effect on dentin mineral density and amount of removed tissue. Acta Odontol Scand 2018;76:236-40.
Corrêa FN, Rodrigues Filho LE, Rodrigues CR. Evaluation of residual dentin after conventional and chemomechanical caries removal using SEM. J Clin Pediatr Dent 2008;32:115-20.
Schwendicke F, Paris S, Tu YK. Effects of using different criteria for caries removal: A systematic review and network meta-analysis. J Dent 2015;43:1-5.
Subramaniam P, Babu KL, Neeraja G. Comparison of the antimicrobial efficacy of chemomechanical caries removal (Carisolv) with that of conventional drilling in reducing cariogenic flora. J Clin Pediatr Dent 2008;32:215-9.
Gulzar S, Arora R, Shah AH, Bhardwaj B, Abusalim G, Khalil HS, et al.
Antibacterial activity of two chemomechanical caries removal gels on carious dentin of primary teeth: Anin vitro
study. J Contemp Dent Pract 2016;17:1027-32.
Hamama HH, Yiu CK, Burrow MF. Viability of intratubular bacteria after chemomechanical caries removal. J Endod 2014;40:1972-6.
Kumar KV, Prasad MG, Sandeep RV, Reddy SP, Divya D, Pratyusha K, et al.
Chemomechanical caries removal method versus mechanical caries removal methods in clinical and community-based setting: A comparativein vivo
study. Eur J Dent 2016;10:386-91.
] [Full text]
Bussadori SK, Godoy CH, Alfaya TA, Fernandes KP, Mesquita-Ferrari RA, Motta LJ, et al.
Chemo-mechanical caries removal with Papacarie™: Case series with 84 reports and 12 months of follow-up. J Contemp Dent Pract 2014;15:250-3.
Martins MD, Fernandes KP, Motta LJ, Santos EM, Pavesi VC, Bussadori SK. Biocompatibility analysis of chemomechanical caries removal material Papacárie on cultured fibroblasts and subcutaneous tissue. J Dent Child (Chic) 2009;76:123-9.
Kotb RM, Abdella AA, El Kateb MA, Ahmed AM. Clinical evaluation of Papacarie in primary teeth. J Clin Pediatr Dent 2009;34:117-23.
Bussadori SK, Guedes CC, Bachiega JC, Santis TO, Motta LJ. Clinical and radiographic study of chemical-mechanical removal of caries using Papacárie: 24-month follow up. J Clin Pediatr Dent 2011;35:251-4.
Singh S, Jawa D, Jaidka S, Somani R. Comparative clinical evaluation of chemomechanical caries removal agent Papacarie® with conventional method among rural population in India –In vivo
study. Braz J Oral Sci 2011;10:193-98.
Bittencourt ST, Pereira JR, Rosa AW, Oliveira KS, Ghizoni JS, Oliveira MT. Mineral content removal after Papacarie application in primary teeth: A quantitative analysis. J Clin Pediatr Dent 2010;34:229-31.
Banerjee A, Kidd EA, Watson TF. Scanning electron microscopic observations of human dentine after mechanical caries excavation. J Dent 2000;28:179-86.
Avinash A, Grover SD, Koul M, Nayak MT, Singhvi A, Singh RK. Comparison of mechanical and chemomechanical methods of caries removal in deciduous and permanent teeth: A SEM study. J Indian Soc Pedod Prev Dent 2012;30:115-21. [Full text]
Sakoolnamarka R, Burrow MF, Kubo S, Tyas MJ. Morphological study of demineralized dentine after caries removal using two different methods. Aust Dent J 2002;47:116-22.
Splieth C, Rosin M, Gellissen B. Determination of residual dentine caries after conventional mechanical and chemomechanical caries removal with Carisolv. Clin Oral Investig 2001;5:250-3.
Yamada Y, Kimura Y, Hossain M, Kinoshita JI, Shimizu Y, Matsumoto K. Caries removal with Carisolv system: Criteria evaluation and microleakage test. J Clin Pediatr Dent 2005;30:121-6.
Kotb RM, Elkateb MA, Ahmed AM, Kawana KY, El Meligy OA. Dentin topographic features following chemomechanical caries removal in primary teeth. J Clin Pediatr Dent 2016;40:472-9.
Albrektsson Tomas O, Douglas B, Glantz PJ, Lindhe Jan T. Tissue Preservation in Caries Treatment. Great Britain: Quintessence Books; 2001.
Divya G, Prasad MG, Vasa AA, Vasanthi D, Ramanarayana B, Mynampati P. Evaluation of the efficacy of caries removal using polymer bur, stainless steel bur, Carisolv, Papacarie – Anin vitro
comparative study. J Clin Diagn Res 2015;9:ZC42-6.
Kitsahawong K, Seminario AL, Pungchanchaikul P, Rattanacharoenthum A, Pitiphat W. Chemomechanical versus drilling methods for caries removal: Anin vitro
study. Braz Oral Res 2015;29:1-8.
Thakur R, Patil SD, Kush A, Madhu K. SEM analysis of residual dentin surface in primary teeth using different chemomechanical caries removal agents. J Clin Pediatr Dent 2017;41:289-93.
[Figure 1], [Figure 2]
[Table 1], [Table 2]