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Carisolv
Content
Minimally-invasive and patient-friendly removal of caries Carisolv Dentine caries Treatment of caries lesion Drills Lasers Air abrasion Atraumatic restorative treatment Chemo-mechanical caries removal Description of Carisolv Instructions for use Carisolv gel Carisolv instruments for caries excavation Cases step-by-step treatment Treating children Caries at crown margins Your first cases Evaluating a caries-free surface Caries removal with a drill and with Carisolv a comparison Scientific publications relating to Carisolv Questions & Answers Summary of chemo-mechanical characteristics Tissue preservation in caries treatment a textbook List of references
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Carisolv
This compendium is about Carisolv, a method for minimally-invasive, gentle dentine caries removal based on biological principles. The system uses a gel and special instruments that preserve healthy tissue. Patient comfort is significantly enhanced. Carisolv gel is applied to the caries affected area of the dentine. It softens the diseased portion of the tooth, while healthy tissue is preserved. The softened carious dentine is removed with special Carisolv instruments. The treatment is quiet and effective. Many patients and dentists call it a silent revolution.
Dentine caries
Dentine is a vital, mineralised tissue that surrounds the pulp. The tissue is formed in a collagen network and has dentinal tubules that radiate from the pulp to the enamel. Unlike the enamel, only half the dentinal tissue volume consists of hydroxyapatite. The crystals are smaller and contain more carbonates.1 As bacterial acids come in contact with the vital dentine, the odontoblast processes in the dentinal tubules begin to deposit mineral. New dentine is also formed on the walls of the pulp.2 As the bacterial acids gradually dissolve the mineral, the collagen network is exposed and the dentine softened. The crystals become smaller during the dissolution process and porous areas are formed. Re- and demineralisation also lead to the deposition of irregular crystals in the tubules and the dentine. At this stage, the deeper (inner) carious layer is slightly demineralised, but it contains an intact organic matrix with sound collagen fibres and some apatite crystals bound to the fibres. The intact collagen framework of the inner layer has the potential to reorganise and remineralise if the acid challenge is discontinued,1, 3 whereas recalcification does not occur in the outer carious layer.2 If the disease progresses, the collagen exposed to the bacterial acids becomes less resistant to enzymatic degradation and the demineralisation is no longer reversible. As the mineral dissolves, enzymes break down the collagen4 and eventually the dentinal structure in the necrotic part of the lesion is lost. Continued progression of the disease results in the destruction of the pulp and apical periodontitis. It is therefore clear that an effective, chemo-mechanical dentine caries removal system should identify the border between remineralisable and nonremineralisable dentine and only influence the latter, in order to be a minimally-invasive treatment alternative. The surface that remains after caries removal should be hard and etchable to support a filling.
Zone 2
The dentine is not infected, it is vital and sensitive. It is soft but capable of remineralisation. The collagen network in the inner, carious dentine is reversibly denatured, i.e. it can reorganise.6 There may be discoloration.
Zone 3
In the zone near the pulp, the dentine has been affected by acid, but it is alive and can be remineralised. The hardness is somewhat reduced. This zone is usually separated from the pulp by a translucent zone. The dentine has responded to irritation by depositing mineral in the dentinal tubules.4 Unaffected dentine is encountered nearest the pulp and peripheral to the lesion. The dentine is not as hard nearest the pulp because of the larger number of dentinal tubules per unit area.
Drills
Conventional operative caries treatment is usually carried out with a high-speed handpiece to obtain access to the lesion and a low-speed handpiece to remove the caries. A water coolant is often used to reduce damage to the pulp.
Lasers
Laser technology involves the non-touch application of energy impulses. The latest instruments can also remove hard tissue with a laser beam. Impulses are passed directly to the treatment point via a flexible fibre.
Air abrasion
During air abrasion, an air-powdered stream of a substance like aluminium oxide is blasted onto the tooth. The stream is applied with incremental pressure from 40 to 150 psi. It can be used to clean crowns and bridges and to obtain access to and remove caries to some extent. The equipment comes in many shapes and price categories.
The relative ability of the various excavation techniques to remove tooth tissue
Method Hand excavators Rotary burrs Air abrasion Air polishing Ultrasonics Sono-abrasion Carisolv Lasers Enzymes Sound enamel +++ +++ + + + Sound dentine +++ +++ + + + + Carious enamel + +++ ++ + + + + Carious dentine ++ +++ + ++ +++ + + Notes
Air turbine and slow-speed handpiece Depends on abrasive agent used Requires hard surface substance for abrasion Retrograde root filling cavity preparation Further work required Still requires conventional access to dentine Depends on wave length, intensity, pulse duration etc. Further work required
Extracted from Banerjee et al, British Dental Journal 2000;188(9):476-4828.
Description of Carisolv
Carisolv is a minimally-invasive method for chemo-mechanical dentine caries removal, developed in close collaboration between universities, scientists and industry in Sweden. Carisolv is a patented product system, comprising two parts: a gel and specially-designed hand or power-operated instruments.
Carisolv gel
Carisolv gel is a two-component mixture. Equal parts of the two are mixed to form the active gel substance. One of the components primarily contains three amino acids (glutamic acid, leucine and lysine) and sodium hydroxide. The other fluid contains the reactive hypochlorite component (NaOCl). Carisolv gel is available in two different packages; Carisolv gel multimix and Carisolv gel singlemix. The first marketed version of Carisolv gel was red. In recent years, the gel has been further developed at the University of Gteborg, Sweden. To improve its efficacy, an increase of the amount of free chloramines was needed, which in turn required a higher concentration of NaOCl. One effect of the higher concentration of NaOCl is that the colour agent has been removed, i.e. the gel is uncoloured. Basic research has been performed on this revised gel composition and no differences in terms of surface topography, pulp effects or soft tissue effects have been noted. The mode of action is the same for both versions of the gel. So the published research is still applicable.
Mode of action
When the Carisolv gel is mixed, the amino acids bind chlorine and form chloramines at a high pH. The softening effect on the carious tissue is the result of several reactions that act in concert to disrupt the fibre structure of collagen. The three amino acids (all of which are found among the twenty that are used naturally as building blocks in proteins) are differently charged, which allows for an electrostatic attraction to different areas of the proteins in the carious dentine. The peptide chains of all proteins, including collagen, are made up of hydrophilic (positively or negatively charged) and hydrophobic (noncharged) patches. So each of the three chloro-amino acids in Carisolv electrostatically attracts one of these patches, effectively bringing reactive power to the full length of the target, the collagen fibre, while minimising unwanted side-reactions from hypochlorite.9 The formation of chloramines reduces the reactivity of the chlorine without altering its chemical function. Moreover, chlorinated amino acids are probably able to disrupt the several types of electrostatic bond that hold the fibrous structure together. The chemical result of these processes is a breakdown of degraded collagen characteristically found in the demineralised portion of a carious lesion. The gel only softens the carious dentine, while healthy tissue is unaffected. The degraded collagen has an 6
open structure and is therefore more susceptible to further breakdown by chloramines. The porous nature of demineralised dentine allows Carisolv to penetrate. The unaffected collagen is more resistant to degradation, but the framework of degraded collagen in the porous mineral is broken down and can easily be scraped off sound and carious dentine become easily separable clinically: the carious dentine is easier to dislodge than the sound dentine.
Carisolv instrument tips have sharp edges but a blunt angle. They thus provide excellent depth control when the dentist scrapes away the carious dentine that has been softened by the Carisolv gel.
Instruments with sharper cutting angles are designed to work themselves down into dental tissue and make it difficult to control the depth.
Worn out burrs or excavators with rounded cutting angles slide over the surface and the scraping effect is therefore poor.
Carisolv gel
1. Mix the two components of Carisolv (NaOCl and amino acid solution) thoroughly according to the instructions included with the package. Put the required amount of gel into a suitable container. 2. Use a Carisolv instrument to pick up the gel and apply it to the carious dentine. Soak the caries generously. 3. Wait for at least 30 seconds, for the chemical process to soften the caries. 4. Select a PowerDrive tip or a Carisolv hand instrument to match the size, position and accessibility of the cavity. Scrape off the superficial softened carious dentine. The hand instrument with the multistar tip may facilitate the early penetration of the gel. Work carefully using scraping or rotating movements. Remove the softened carious dentine with the instrument. Avoid flushing or drying the cavity. 5. Keep the lesion soaked with gel and continue scraping. No 30 seconds of waiting time is needed. Repeat until the gel no longer turns cloudy and the surface feels hard using the instrument. Check extra carefully for caries at the dentinoenamel junction. If you are using a drill to adjust the periphery before filling, this can be done while the gel is still in the cavity. 6. When the cavity feels free from caries, remove the gel and wipe the cavity with a moistened cotton pellet or rinse it with lukewarm water, inspect and check it with a sharp probe. If the cavity is not free from caries, apply new gel and continue scraping. Note: when the cavity is dried with air, the treated surface looks frosted and not shiny, as it does after excavation using a drill. 7. If necessary the periphery of the cavity should be adjusted using hand instruments or the drill. Restore the tooth with a suitable filling material according to the manufacturers instructions for use. Note Once the gel has been mixed, its caries softening ability will begin to decline after about 30 minutes. Any gel that is left over should be destroyed in accordance with local regulations.
For detailed information, refer to the Instructions for Use enclosed in
Specially-designed tips
Star 1
Star 3
Multistar
Flat 0
Flat 3
Point
The tips of the instruments have been designed to provide optimal access to different types of lesion. For further information about the instruments, see the separate product sheet.
PowerDrive
PowerDrive is a combined electronic instrument for power-operated, minimally-invasive caries removal with Carisolv and for endodontic treatment. PowerDrive for caries removal with Carisolv Selective and precise removes only carious dentine Fast, simple and efficient removal of caries PowerDrive operates with high tissue control and at a low sound level Patients can operate the control unit themselves. Useful for patients with dental phobia.
N.B. For a more detailed description of the use of PowerDrive, please see Instructions for Use PowerDrive, or the product sheet for PowerDrive.
Root caries
1. Use PowerDrive or star 3/star 2 to apply the gel depending on the size of the lesion. 2. Cover the whole lesion with mixed Carisolv gel. 3. Wait 30 seconds then start to work with PowerDrive or rotate/whisk the multistar or star-shaped tip (unless the lesion is shallow then use a back-and-forth movement with a flat tip). 4. When using hand instruments, use quick movements rather than force. 5. Continuously add more gel but now you do not have to wait 30 seconds before scraping. 6. When the gel is cloudy, scope/remove it with the PowerDrive or appropriate Carisolv instruments depending on the size and accessibility of the lesion. 7. Root caries lesions often become caries-free quickly. Check with the probe before rinsing. 8. If caries is still present, add more gel after removing excess debris. 9. When the probe does not give a tug-back feeling, thoroughly clean the area with a cotton pellet soaked in warm water. 10. If necessary, use hand instruments or a drill to adjust the enamel margins. 11. Etch, apply priming/bonding systems and restore according to the manufacturers recommenda tions. If the patient has multiple root caries lesions, you will be more efficient if you work with several cavities at the same time. Apply the gel to two or more lesions and proceed according to the instructions above.
Wait 30 seconds.
Remove the softened carious dentine with flat 3 instrument. Use rapid movements not force!
Restore as usual.
Dan Ericson
N.B. The images illustrate the red Carisolv gel. The follow-up is uncoloured, but the clinical procedure is the same.
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8. When the gel is very cloudy, continue to scope/ remove it with the PowerDrive or flat 3. Add more gel and continue to rub it into the caries. 9. Use the special instrument flat 0 at the dentinoenamel junction, under the cusps and in other areas that are difficult to reach. 10. Treat the surface near the pulp as you would after drilling. 11. Perform the remaining treatment as described in Step by step treatment of root caries lesions. N.B. It is important to keep the cavity filled with gel to the greatest extent possible during the entire caries removal procedure. This will minimise pain and in most cases the patient will perceive the treatment as painless. Remember that it is always possible to use a stepwise approach (i.e. indirect pulp capping). Ensure that the lesion is fully covered in gel during the whole caries removal procedure. Do not spray with water or blast with air during caries and gel removal.
Continue with star 3 or PowerDrive 2.0, red direction, when removing the bulk of the softened caries.
Apply the gel using the tip called star 3 or PowerDrive 2.0, red direction. To minimise pain, cover the cavity with gel before drilling in the enamel to open up the cavity.
Add more gel. Use rapid movement rather than force to rub /massage the gel into the lesion (no need to wait 30 seconds).
Carefully inspect and check with probe. Caries-free! Clean with a wet cotton pellet soaked in warm water. Restore as usual.
Wait 30 seconds. When approaching the pulp, switch to flat 3 or the green direction of PowerDrive. Carefully scrape out the softened carious dentine. Do not use force close to the pulp.
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Treating children
Maria is eight years old and her experience of dental care has so far been limited to regular check-ups and preventive dentistry. She has now developed a deep carious lesion on a deciduous molar, which has to be restored. Maria is accompanied by her father who is rather nervous. His earlier experiences of drilling and local anaesthesia have not been positive. The child senses his anxiety and also becomes nervous and tense. They are both relieved when the dentist explains how Carisolv may enable Maria to be treated without local anaesthesia or drilling. In this case, it is important not to rush. Be sure to give the gel 30 seconds to react. Keep the patient well informed during the treatment. If the patient experiences any pain, check that the cavity is completely covered with gel and consider the potential benefit of local anaesthesia. It is very important not to work with too much force use speed and not pressure in your movement of the Carisolv instruments. Rub/massage the gel into the carious lesion. For complete instructions, see Deep carious lesions
Sverker Toreskog
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Caries removal with a drill and with Carisolv results in different dentinal surfaces
It takes time to become familiar with the fact that, after Carisolv treatment, the dentinal surface is different from a mechanically-prepared surface, which is usually flat, shiny and smooth. After Carisolv treatment, the surface is dull and has a frosty appearance when dried. The surface is uneven because the depth of action of the gel is restricted to the caries in the lesion. In scanning electron micrographs, the surface topography is assumed to follow the pattern of caries in the lesion and resembles an alpine landscape. There is no obvious smear layer and the surface appears clean.12, 13 The surface excavated with a regular drill has a compact smear layer. It is important to note that, when the dentine has been conditioned with phosphoric acid or polyacrylic acid before the insertion of a restorative material, the outer layer of the surface treated by chemo-mechanical caries removal and the smear layer on the mechanically-prepared surface have been removed,14 so that the appearance of the two surfaces are the same after etching.
Drill
Carious lesion prepared with a drill. The cavity is fairly symmetrical and follows the contours made by the drill as it removes tissue. The structure of the dentine shows that even sound tissue has been removed and furthermore the pulp has been exposed.
Carisolv
Carious lesion prepared with Carisolv. The cavity is uneven and follows the spread of the lesion. The dentine has a different structure and no sound dentine has been removed.
Carious lesion prepared with a drill, seen at a magnification of 75. The surface is smooth. Some sound dentine has been removed.
Carious lesion after Carisolv treatment, seen at a magnification of 75. The surface is uneven. Only carious tissue has been removed.
A detail (1500) of the mechanically-prepared surface. The surface is smooth and covered with a smear layer.
A detail (1500) of the surface treated with Carisolv. The uneven topography increases the area available for retention of the restorative material.
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Surface topography
The surface topography of the healthy dentine remaining after complete caries removal with Carisolv is rougher than that after conventional caries removal with the burr. No typical smear layer is left on the surface. The surface remaining after caries removal with Carisolv may contain thin patches of smear, but they are much less prominent than after drilling.
Clinical studies confirm caries-free Berakdar, Burke, Chaussain, Ericson, Fure, Haffner, Kavvadia, Kobaslija, Masouras, Munshi, Nadanovsky, Songpaisan
1-year results Fure, Nevrin, Zimmerman No effect on healthy enamel or dentine Galler, Wennerberg Rough surface topography Wennerberg Good dentine bonding Frankenberger, Erhardt, Haak, Harada, Pawlowska, Russo, Suda No negative effects on soft tissue (mucosa) Arvidsson, Wennerberg Effect on bacteria Baysan, Kneist, Lager
Selective softening confirmed in vitro Galler, Igarashi, Tonami Caries-free confirmed in vitro Banerjee, Braun, Dammaschke, Ericson, Haffner, Hahn, Markovic, Moran, Splieth No adverse pulp effects Dammaschke, Lumbau, Young
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Effect on bacteria
Bacteria in dentine after caries removal has been an issue that has been discussed over the years. It is perfectly clear that conventional methods using roseburrs for caries removal do not leave the dentine sterile, but bacteria can be found in small numbers. Caries removal using Carisolv does not dramatically differ in this respect. A few studies have demonstrated a slight antibacterial effect by Carisolv and dentine caries removal using the Carisolv system appears to produce somewhat fewer bacteria in the cavity floor.
ing through the gel. If the probe does not give a tugback feeling, clean out with a Carisolv instrument tip and then use a wet cotton pellet. Avoid spraying with water or blasting with air. Another important factor is that the patient is well informed.
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List of references
The following articles have been referred to in the text. 1. 2. 3. 4. Mjr IA. The morphology of dentin and dentinogenesis. In Linde A (ed): Dentin and dentinogenesis. Boca Raton. CRC Press Inc, 1984;4:351-353. Kato S, Fusayama T. Recalfication of artificially decalcified dentine in vivo. J Dent res 1970;49:1060-1067. Miyauchi H, Iwaku M, Fusayama T.Physiological recalcification of carious dentin. Bull Tokyo Med Dent Univ 1978;25:169-179. Thylstrup A, Fejerskov O. Clinical and pathological features of dental caries. In: Thylstrup A, Fejerskov O (eds): Textbook of clinical cariology, 1994 (2nd ed), Munksgaard, Copenhagen. Shimizu C, Yamashita T, Ichijo T, Fusayama T. Carious change of dentine observed on longspan ultrathin sections. J Dent Res 1981;60:1826-1831. Kuboki Y, Ohgushi K, Fusayama T. Collagen biochemistry of the two layers of carious dentin. J Dent Res 1977;56:1233-1237. Atraumatic restorative treatment approach to control dental caries manual, WHO collaborating centre for oral health services research. Groningen 1997. Banerjee A, Watson T F, Kidd E A M. Dentine caries excavation: a review of current clinical techniques. Br Dent J 2000;188(9): 476-482. Strid L, Hedward C. 1989. Patent SE870483. Kidd EA, Joyston-Bechal S, Beighton D. The use of a carious detector dye during cavity preparation: a microbiological assessment. Br Dent J 1993;174(7):245-248. Yip HK, Stevenson AG, Beeley JA. The specificity of caries detector dyes in cavity preparation. Br Dent J 1994;176(11):417-421. Wennerberg A, Sawase T, Kultje C. The influence of Carisolv on enamel and dentin surface topography. Eur J Oral Sci 1999;107(4):297-306. Banerjee A, Kidd EAM, Watson TF. Scanning electron microscopic observations of human dentine after mechanical caries excavation. J Dent 2000; 28(3):179-186. Burke FM, Lynch E. Glasspolyalkenote bond strength to dentine after chemo-mechanical caries removal. J Dent 1994;22:283-291.
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MediTeam Dental AB is a Swedish research-oriented dental company that markets new methods worldwide based on odontological research. For more information, please visit www.mediteam.com The Carisolv system is patented. PowerDrive and Carisolv are trademarks owned by MediTeam Dental AB. MediTeam Dental AB, 2002
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MediTeam Dental AB (publ), Gteborgsvgen 74, SE-433 63 Svedalen, Sweden. Phone +46 31 336 91 00. Fax +46 31 336 82 10
www.mediteam.com