Brazilian Dental Journal Braz. Dent. J. vol.17 no.

1 Ribeiro Preto 2006

Effectiveness and efficiency chemomechanical carious dentin removal

of

Cludia Silami de Ma al!e"# $ll%"on &o ueira Moreira# 'a ner Rei" da Co"ta Cam(o"# )ernanda Ma al!e" Ro""i# *uil!erme $u u"to $l+araz Ca"til!o# Ra,uel Con+ei-o )erreira

Abstract

.!e aim" o/ t!i" in vitro "tud% 0ere bot! to determine t!e time ne+e""ar% /or removal o/ +ariou" dentin 1e//i+ien+%2 and t!e 3noo( 4ardne"" &umber 134&2 o/ t!e remainin dentin 1e//e+tivene""25 u"in a +!emome+!ani+al met!od 1Cari"olv2 or !and e6+avation. .!irt% !uman molar" 0ere bi"e+ted t!rou ! o++lu"al +ariou" le"ion" into t0o e,ual !alve". 7a+! !al/ 0a" randoml% e6+avated b% !and in +ir+ular movement" 0it! a "(oon e6+avator or u"in Cari"olv el a++ordin to t!e manu/a+turer8" in"tru+tion". .!e duration o/ +ariou" dentin removal 0a" re+orded. .oot! "e+tion" 0ere re"in9embedded5 round /lat and (oli"!ed. Dentin 34& 0a" determined at di"tan+e" o/ 1005 2005 :005 ;00 and <00 mm /rom t!e +avit% /loor. Data 0ere anal%zed b% 'il+o6on8" te"t 1a=0.0125 $&>?$ and Student8" t te"t 1a= 0.0<2. .!e median o/ t!e time ne+e""ar% /or +!emome+!ani+al e6+avation 0a" "i ni/i+antl% reater t!an /or !and e6+avation. 34& mean" 1@ SD2 at 1005 2005 :005 ;005 <00 Am /or +!emome+!ani+al met!od 0ere5 re"(e+tivel%B 1<.6 1@;.C625 1D.0 1@6.2225 21.: 1@C.:025 2;.: 1@C.2<25 2D.< 1@11.D02# and /or !and e6+avation 0ereB 21.2 1@10.2625 2:.; 1@C.;C25 2D.2 1@11.6225 :1.0 1@12.1725 :;.: 1@11.C<2. Et ma% be +on+luded t!at !and e6+avation (re"ented !i !er e//i+ien+% and e//e+tivene"" t!an +!emome+!ani+al e6+avation.

Introduction
Et i" enerall% a reed b% +lini+ian" t!at t!e obFe+tive in treatin +ariou" le"ion" i" to remove t!e in/e+ted la%er5 0!ile leavin t!e a//e+ted dentin. .!e outer +ariou" dentin i" irrever"ibl% denatured5 in/e+ted5 non9remineralizable and mu"t be removed.

The inner carious dentin is reversibly denatured, not infected, remineralizable and must be preserved . .!e di//erentiation bet0een t!e"e la%er" i" +lini+all% relevant in order to
avoid t!e (ain/ul and unne+e""ar% removal o/ "ound toot! "tru+ture. Carie" e6+avation !a" traditionall% been (er/ormed a++ordin to me+!ani+al (rin+i(le" u"in drill" and "!ar(9ed ed !and in"trument". .!e"e met!od"5 alt!ou ! o/ten e//e+tive5 !ave "ome maFor di"advanta e". )ir"t5 it i" o/ten di//i+ult to e"tabli"! e6a+tl% !o0 mu+! dentin "!ould be removed be+au"e t!ere i" an a((arent la+G o/ obFe+tive +lini+al marGer". Se+ondl%5 me+!ani+al (re(aration o/ten indu+e" (ain and di"+om/ort5 t!ere/ore lo+al ane"t!e"ia i" needed. .o (revent t!e"e dra0ba+G"5 alternative dentin +arie" removal met!od" !ave been (ro(o"ed5 in+ludin +!emome+!ani+al te+!ni,ue" 5 air abra"ion 0it! aluminum o6ide or la"" (arti+le"5 "ono9abra"ion 5 ultra"oni+ in"trumentation and la"er". C!emome+!ani+al +arie" removal i" an attra+tive alternative to +onventional me+!ani+al +arie" removal (ro+edure". En t!e 1C70"5 t!e (o""ibilit% o/ removin +ariou" ti""ue +!emi+all% u"in &9 mono+!loro l%+ine 0a" re(orted and t!e Caride6 "%"tem 0a" introdu+ed 1&ational Patent Medi+al Produ+t"5 &e0 Brun"0i+G5 &J5 HS$2. More re+entl%5 a +!emome+!ani+al +arie" removal "%"tem +alled Cari"olv 1Medi .eam5 Savedalen5 S0eden2 0a" introdu+ed to t!e 7uro(ean dental marGet. Cari"olv +on"i"t" o/ a red el5 +ontainin lutami+ a+id5 leu+in5 l%"ine5

"odium +!loride5 er%t!ro"ine5 +arbo6%met!%l+ellulo"e5 0ater and "odium !%dro6ide5 and a tran"(arent /luid +ontainin 0.<I "odium !%(o+!lorite. .!e +!emi+al a+tion o/ Cari"olv i" "imilar to t!at o/ Caride6 in "o/tenin t!e +ariou" dentin but leavin t!e !ealt!% dentin una//e+ted. )urt!ermore5 t!i" "%"tem i" "u((lied /or in"trument" de"i ned to "+ra(e in t0o or in "everal dire+tion"5 0!i+! redu+e t!e /ri+tion durin +arie" e6+avation. $lt!ou ! t!i" met!od !a" been "!o0n to be more time9+on"umin t!an traditional e6+avation5 it ma% !ave a !i !er de ree o/ a++e(tan+e amon (ediatri+ (atient" and (atient" 0!o /eel an6iet% and /ear5 a" it o//er" entle e6+avation +lo"e t!e (ul( and e6+avation o/ root +arie". .!u"5 t!e 0orGin !%(ot!e"i" i" t!at5 alt!ou ! t!e time re,uired /or +!emome+!ani+al +arie" removal i" lon er t!an !and e6+avation5 it i" a more "ele+tive met!od and leave" a "o/ter dentin at t!e /loor o/ +avitie". .!e aim o/ t!i" "tud% 0a" to evaluate t!e e//i+ien+% 1time taGen2 and t!e e//e+tivene"" 13noo( mi+ro!ardne"" of remanescent dentin2 o/ +!emome+!ani+al +ariou" dentin removal u"in Cari"olv5 a" +om(ared to +onventional !and e6+avation.

Material and Methods

Experimental Design. .!e inde(endent variable" inve"ti ated in t!i" e6(eriment 0ere t!e met!od" o/ +ariou" dentin removal on t0o level" 1!and e6+avation and +!emome+!ani+al e6+avation2 and t!e di"tan+e /rom t!e +avit% /loor on /ive level" 11005 2005 :005 ;00 and <00 mi+rometer"2. .!e re"(on"e or de(endent variable" 0ere t!e time re,uired to remove dentin mea"ured in "e+ond" 1e//i+ien+%2 and t!e 3noo( mi+ro!ardne"" o/ t!e remainin dentin mea"ured b% a mi+ro!ardne"" te"ter 1e//e+tivene""2. .!e e6(erimental unit" 0ere :0 re+entl% e6tra+ted !uman molar" 0it! o++lu"al +ariou" le"ion"5 bi"e+ted t!rou ! t!e middle o/ t!e le"ion and arran ed in a "(lit9toot! de"i n. Sam(le Sele+tion. Jo+al et!i+al +ommittee a((roval 0a" obtained /or t!i" "tud% 1C>7PKH)M* Pro+e"" number 07;K022. Re"ult" o/ a (ilot "tud% 0ere u"ed to e"timate a rea"onabl% "ized "am(le5 +om(arin t!e mean" o/ t0o rou(". .!irt% !uman molar" 0it! o++lu"al +arie" le"ion" 0ere +olle+ted at t!e Sur er% Clini+ o/ t!e )a+ult% o/ Denti"tr% o/ t!e )ederal Hniver"it% o/ Mina" *erai" and "tored /or no more t!an :0 da%" in 0.0< M (!o"(!ate bu//ered "aline 1(4=7.22. En an attem(t to "tandardize t!e le"ion de(t!"5 t!e in+lu"ion +riteria 0ere molar" 0it! o++lu"al +arie" le"ion" e6tendin to0ard" t!e middle t!ird o/ dentin. Dentin Carious Removal. .!e +ro0n" 0ere "e(arated /rom t!e root" and me"iodi"tall% "e+tioned t!rou ! t!e o++lu"al +ariou" le"ion" into t0o e,ual !alve"5 u"in diamond di"G" 13* Soren"en End. e Com. Barueri5 SP5 Bra"il2 mounted in a !and(ie+e. >ne !al/ o/ ea+! toot! 0a" randoml% e6+avated b% !and and t!e ot!er !al/ 0a" e6+avated u"in Cari"olv el. $ (reviou"l% +alibrated o(erator (er/ormed all (ro+edure".

)or !and e6+avation5 a L2: !at+!et 1Du/le65 SS '!ite5 Rio de Janeiro5 RJ5 Bra"il2 0a" u"ed to ain a++e"" to t!e dentin t!rou ! t!e enamel. Dentin e6+avation 0a" a++om(li"!ed in +ir+ular "+rat+!in movement" /rom t!e dentinoenamel Fun+tion to t!e +avit% /loor5 u"in L< or L1D "(oon e6+avator" 1Du/le65 SS '!ite5 Rio de Janeiro5 RJ5 Bra"il2 a++ordin to t!e le"ion "ize. 76+avation 0a" +om(leted 0!en dentin at t!e +avit% /loor 0a" re"i"tant to (robin 5 /ollo0in t!e +lini+al +riteria o/ !ard te6ture. Cari"olv "%"tem 0a" u"ed /or +!emome+!ani+al removal5 a++ordin to t!e manu/a+turer8" in"tru+tion"5 u"in Cari"olv !and in"trument". Hn"u((orted enamel 0a" removed u"in t!e L< in"trument to ain a++e"" to t!e +avit% t!at 0a" t!en +overed 0it! Cari"olv el. $/ter 0aitin /or at lea"t :0 " /or t!e el to a+t5 t!e "o/tened dentin 0a" e6+avated 0it! L25 L:5 and L; in"trument". '!en t!e el be+ame +loud% it 0a" removed 0it! moi"tened +otton to et!er 0it! t!e di""olved +ariou" dentin. )re"! el 0a" t!en a((lied and t!e +avit% /loor 0a" re(eatedl% "+ra(ed until t!e el be+ame +lear. Carie" e6+avation o/ t!e 0a" Fud ed +om(lete b% ta+tile +riterion5 0!en t!e +avit% /loor /elt !ard on (robin . Efficiency. .!e time u"ed /or +ariou" dentin e6+avation u"in !and and +!emome+!ani+al met!od" 0a" re+orded5 in "e+ond"5 to determine t!e e//i+ien+%. 7//e+tivene"". $/ter e6+avation5 toot! !alve" 0ere embedded in <061 & (ol%e"ter re"in 1Cra% ?alle% Jtda5 .aboo da Serra5 SP5 Brazil25 (laned in a 0ater9+ooled me+!ani+al rinder5 u"in ;0095 6009 and 12009 rit $l2>: abra"ive (a(er 1Carborundum $bra"ivo"5 Re+i/e5 P75 Brazil2 and (oli"!ed 0it! +lot!" u"in 0.6 to ;.< mm $l2>: "olution 1)arma+Muti+a Carlo" 7rba5 Divi"o NuOmi+a5 So Paulo5 SP5 Brazil2. .!e 3noo( 4ardne"" &umber 134&2 0a" obtained in a mi+ro!ardne"" te"ter 1Durimet# 7rn"t Jeitz *MB4 D96::0 'etzlar5 4annover5 *erman%2 0it! a 2<9 "tati+9load a((lied /or 1< ". )ive indentation" 0ere made at t!e di"tan+e" o/ 100 mm5 200 mm5 :00 mm5 ;00 mm and <00 mm re"(e+tivel%5 /rom t!e dee(e"t (oint o/ t!e +avit% /loor to t!e (ul( +!amber roo/. .!e 34& value" are derived u"in t!e e,uation 34& = 1;22C.3KJ25 0!ere 3 i" t!e a((lied load in ram"5 and J i" t!e indentation len t!5 in mi+rometer". Statistical Analysis. .!e median" o/ t!e time needed to remove +ariou" dentin b% !and and +!emome+!ani+al e6+avation 0ere +al+ulated5 +on"iderin :0 time re+ordin " /or ea+! met!od. 'il+o6on te"t 1a = 0.012 0a" u"ed to +om(are t!e median" and determine t!e e//i+ien+% o/ ea+! met!od. Stati"ti+al anal%"i" +on"idered t!e mean" o/ :0 indentation" 134&2 /or ea+! met!od o/ +arie" removal5 at ea+! di"tan+e /rom t!e +avit% /loor. $nal%"i" o/ ?arian+e 1$&>?$2 1a = 0.0<2 0a" u"ed to +om(are t!e e6(erimental +ondition". .!e intera+tion amon t!e /a+tor" 0a" anal%zed 1e6+avation met!od" and di"tan+e" /rom t!e +avit% /loor2. Student8" t te"t 1a = 0.0<2 0a" u"ed to +om(are t!e level" o/ /a+tor" under "tud% and to determine t!e e//i+a+% o/ t!e +arie" removal met!od".

Results

.!e 'il+o6on te"t 1a= 0.01# P = ;.;:2 demon"trated t!at t!e median o/ t!e +on"umed time /or +!emome+!ani+al e6+avation 1:1C "2 0a" "i ni/i+antl% reater t!an /or !and e6+avation 117: "2 1.able 12.

.!e re"ult" o/ $&>?$ /or ea+! /a+tor 1+arie" removal met!od and di"tan+e /rom +avit% /loor2 anal%zed "e(aratel% 0a" "i ni/i+ant 1(=0.00025 0!ile t!e intera+tion bet0een t!em 0a" not "i ni/i+ant 1(=0.CD12. .!e"e re"ult" allo0ed an inde(endent +om(ari"on o/ t!e level" o/ t!e /a+tor"5 de"(ite t!eir intera+tion. .!e Student8" t te"t 1a = 0.0<2 demon"trated t!at5 at all di"tan+e"5 t!e dentin remainin a/ter !and e6+avation (re"ented 3noo( mi+ro!ardne"" "i ni/i+antl% !i !er t!an +!emome+!ani+al e6+avation 1.able 22.

Discussion
.!i" in vitro "tud% evaluated t!e e//i+ien+% and t!e e//e+tivene"" o/ +!emome+!ani+al +ariou" dentin e6+avation u"in t!e Cari"olv "%"tem in +om(ari"on to +onventional !and e6+avation. Be+au"e natural le"ion" 0ere u"ed5 it 0a" not (o""ible to "tandardize all variable" o/ t!e "am(le5 e. .5 a e5 "!a(e and a+tivit% "tatu" o/ t!e le"ion". .!ere/ore5 a "(lit9toot! met!odolo % 0a" u"ed to minimize t!e"e variable" a" t!e "our+e o/ +ariou" dentin5 allo0in in t!i" 0a% /or +om(ari"on" to be made bet0een di//erent5 (aired e6+avation met!od" . 4and e6+avation 0a" more e//i+ient t!an Cari"olv a""i"ted9!and e6+avation o/ +ariou" dentin5 a" indi+ated b% t!eir +orre"(ondin +on"umed time. >t!er aut!or" !ave al"o "!o0n t!at +!emome+!ani+al e6+avation u"in Cari"olv el 0a" t!e "lo0e"t te+!ni,ue. $n in vitro5 "(lit9 toot! "tud% "!o0ed t!at Cari"olv9a""i"ted e6+avation time" 0ere around t0i+e a" lon a" +onventional !and e6+avation. $not!er in vitro "tud% /ound t!at e6+avation 0it! Cari"olv tooG 1;.2 1@;.02 min on avera e. .!i" lon er time 0a" Fu"ti/ied a" t!e manu/a+turer doe" not "(e+i/% t!e minimum a((li+ation time5 but rat!er "tate" t!at t!e +avitie" "!ould be treated until t!e el be+ome" +lear to be +on"idered caries free. $lt!ou ! Cari"olv a""i"ted9!and e6+avation +ould be le"" (ain/ul /or t!e (atient"5 a multi+entre (ro"(e+tive "tud% "tated t!at t!e onl% +au"e o/ inve"ti ator8" di""ati"/a+tion 0it! Cari"olv 0a" t!e (rolon ed treatment time5 0!i+! in+rea"ed 0it! t!e "ta e o/ (ro re""ion o/ t!e +ariou" le"ion. 4ardne"" !a" been a""o+iated 0it! t!e relative in/e+tivene"" o/ +ariou" dentin5 !el(in t!e denti"t di"tin ui"!in bet0een eit!er !eavil% in/e+ted 1"o/t2 and minimall% in/e+ted 1!ard2 dentin. En t!i" "tud%5 t!e u"e o/ a mi+ro!ardne"" te"ter 0it! a 3noo( diamond indentor allo0ed mea"urin t!e !ardne"" o/ t!e remainin dentin5 a" an indi+ator o/ treatment e//e+tivene"". Dentin !ardne"" !a" been "tudied b% a number o/ re"ear+!er" and t!e 3noo( met!od i" t!e mo"t (o(ular . 34& /or !ealt!% dentin ,uoted in t!e literature ran e /rom <0 to 70 34&. 4o0ever5 t!e mi+ro!ardne"" o/ dentin remainin a/ter me+!ani+al +ariou" removal di//er" /rom t!at o/ t!e inta+t dentin. The dentinal floors of cavities after caries removal u"in !and in"trument" (re"ented a lo0er mi+ro!ardne""5 "u e"tin t!at it i" le"" mineralized t!an t!e underl%in "ound dentin. &evert!ele""5 dentin 0it! lo0er mi+ro!ardne"" 0ould not ne+e""aril% need to be removed /or biolo i+al rea"on". .!e inta+t +olla en in t!e demineralized inner dentin la%er o/ a +ariou" le"ion +an be remineralized and !ardened . En t!i" "tud%5 t!e mean o/ dentin mi+ro!ardne"" at 100 Am /rom +avit% /loor a/ter !and e6+avation 0a" 21.2 34& 1@10.2625 0!i+! i" in a reement to )u"a%ama and 3uro"aGi 5 0!o de"+ribed t!e !ardne"" o/ t!e remainin dentin a/ter removal o/ "o/t dentin 0it! "(oon e6+avator 0a" 22.D 34& 1@ C.6;2. 4o0ever5 0!en Cari"olv 0a" u"ed5 t!e 34& value" 0ere "i ni/i+antl% lo0er5 at t!e di"tan+e interval" evaluated 11005 2005 :005 ;005 <00 mm2. .!e (o""ible e6(lanation /or t!i" re"ult i" t!at a more demineralized dentin ma% be le/t on t!e +avit% /loor a/ter Cari"olv el9a""i"ted e6+avation5 "o t!i" treatment +ould be +on"idered more "ele+tive be+au"e it (re"erved remineralizable ti""ue.

BanerFee5 3idd and 'at"on /ound t!at !and e6+avation and Cari"olv el9a""i"ted e6+avation removed "imilar ,uantitie" o/ ti""ue and a((eared to be more "ele+tive t!an burs

for

carious dentin removal. $n in vitro "tud% !a" "!o0n t!at t!e Cari"olv "%"tem le/t u( to <0 mm more +ariou" dentin on avera e5 a" +om(ared to t!e u"e o/ a round bur. .!e"e
/indin " are +on"i"tent 0it! t!o"e o/ a bio+!emi+al "tud% t!at /ound t!at t!e +olla en +ontent o/ dentin remainin a/ter treatment 0it! Cari"olv el !a" an in+rea"ed (ortion o/ denatured +olla en in +om(ari"on to "ound dentin. .!e lo0er 34& o/ dentin le/t a/ter Cari"olv a""i"ted9!and e6+avation +ould be a""o+iated 0it! a (o""ible e//e+t o/ t!e el on it" inor ani+ +ontent. 4o0ever5 no "i ni/i+ant di//eren+e" 0ere /ound bet0een t!e ,uantitie" o/ +al+ium and (!o"(!oru" or CaKP ratio o/ Cari"olv9treated +avitie" 0it! t!at o/ t!e adFa+ent "ound dentin. )urt!ermore5 no di//eren+e" 0ere ob"erved in 34& o/ Cari"olv +avit% /loor 160.:0 @ ;.162 and t!e re/eren+e +ontrol 162.<0 @ <.0<2. .!e /indin " o/ t!e (re"ent "tud% do not a ree 0it! t!e"e re"ult"5 but an% +om(ari"on i" ,uite di//i+ult due to t!e reat variation bet0een met!od" u"ed to "ele+t rou(" o/ teet!5 toot! "ur/a+e"5 t!e e6tent o/ +ariou" le"ion" and t!e 0a% o/ de/inin a +arie"9/ree "ur/a+e. En t!e a/ore9mentioned "tud% 5 t!e aut!or" "ele+ted onl% +ariou" le"ion" 0it! a bro0n9to9bla+G +olor and medium +on"i"ten+% on t!e (ro6imal "ur/a+e. *ro"" +arie" removal 0a" veri/ied a++ordin to t!e +olor and !ardne"" o/ t!e le"ion 0it! a sharper explorer. Sub"e,uentl%5 t!e treated +avit% 0a" a""e""ed b% mean" o/ a (ul"ed 6<<9nm la"er beam. $lt!ou ! t!e u"e/ulne"" o/ t!i" devi+e /or t!e a""e""ment o/ +ariou" dentin removal !a" (reviou"l% been re(orted5 /urt!er re"ear+! on it" abilit% to dete+t dental +arie" "!ould be (er/ormed . .!e e//e+tivene"" mea"ured a" 3noo( mi+ro!ardne"" o/ remainin dentin indi+ate" !and e6+avation a" t!e more e//e+tive met!od be+au"e o/ t!e harder dentin produced. 4o0ever5 due to biolo i+al variation5 t!ere i" no ab"olute 34&5 0!i+! +ould be u"ed a" +riterion to di"tin ui"! +ariou" dentin re,uirin removal. Et "!ould be +lear t!at alt!ou ! t!e manu/a+turer8" in"tru+tion" indi+ate "to((in Cari"olv e6+avation 0!en t!e el a((ear" +lear5 t!e met!od o/ determinin 0!en to end e6+avation 1b% u"in a dental (robe2 0a" t!e "ame /or bot! treatment". Et i" "till unGno0n i/ t!e +lini+al marGer u"ed 1!ardne""Kte6ture2 i" reliable and 0ill di"+riminate bet0een t!e outer5 ne+roti+5 !i !l% in/e+ted zone t!at need" to be e6+avated and t!e inner5 rever"ibl% dama ed5 le"" in/e+ted zone t!at +ould be maintained. 4ardne"" a" a""e""ed b% ta+tile mean" 0it! !and in"trument" i" ver% in+on"i"tent5 "!o0in a 0ide variation bet0een di//erent inve"ti ator" and al"o /or a "ame individual on di//erent o++a"ion" . $lt!ou ! ot!er +arie" (arameter"5 "u+! a" d%e"5 ele+tri+ monitor 17CM25 auto/luore"+en+e and la"er beam" !ave (reviou"l% been "tudied5 at (re"ent t!ere are no +lear5 obFe+tive +lini+al marGer" available to delineate 0!i+! dentin (ortion "!ould be removed . Et i"5 t!ere/ore5 im(ortant to determine a +lini+all% reliable uide to +ontrol t!e ,ualit% and ,uantit% o/ ti""ue removed b% individual o(erator".

Ac no!led"ements

.!e aut!or" 0ould liGe to e6(re"" t!eir ratitude to Mr. .aniu" Rodri ue" Man"ur5 C!ie/ o/ t!e Stru+tural Ente rit% Servi+e 7C 25 Center o/ &u+lear .e+!nolo % Develo(ment 1CD.&KC&7&2 /or t!e /a+ilitie". .!e aut!or" are al"o rate/ul to Medi.eam Dental /or (rovidin Cari"olv el u"ed in t!i" "tud%. Su((orted b% C&P, 1Pro+e"" number ;7.;011K2001912.

References
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