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Clinical Manual

Carisolv

Minimally-invasive, patient-friendly removal of caries

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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Minimally-invasive, patient-friendly removal of caries


In every field of dentistry, an awareness of the importance of preserving tooth tissue, combined with a patient-friendly approach, is becoming self-evident. It has been shown that operative treatment often leads on an increasing scale to further operative and more invasive treatment. Wherever possible, tissue should be preserved; invasive treatment should be kept to a minimum and natural tissue should be replaced with artificial substitutes only when it is absolutely unavoidable. The best way to ensure a maximum life for the natural tooth is to respect the sound tissue and protect it from damage by using minimally-invasive techniques in restorative dentistry.

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.

How long will it take to remove caries with Carisolv?


As with any treatment, this naturally depends on the type of patient and lesion you are treating. A recent study showed that dentists who use Carisolv frequently have a treatment time close to those for drilling. This is a significant improvement compared with the very first studies back in 1998 when the caries excavation time was almost twice that for drilling. Carisolv can be used on its own or in combination with the drill, or some other method for caries excavation, depending on the clinical situation. The remaining dentine surface is suitable for etching and bonding with modern adhesive restorative materials. A quick review of dentine caries will clarify the requirements of an effective, chemo-mechanical caries removal system.

The gel is applied to the carious dentine using a Carisolv instrument.

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.

Cross-section of a carious lesion Zone 1


The outermost layer of carious dentine is necrotic. It is infected, dead and not sensitive. The collagen is irreversibly denatured. Both acids and enzymes have affected the structure of the collagen and the cross-links have been destroyed. An electron micrograph shows that the characteristic collagenous crossbands have completely disappeared.5 The dentine is soft to probing and cannot be reorganised to its original structure.

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 1 Zone 2 Zone 3

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.

Treatment of carious lesions


The current odontological era is characterised by an increasing move towards less invasive treatment and towards preventive dentistry. It is understood that preservation of original tissue enhances the prognosis of the tooth.

Atraumatic restorative treatment


Atraumatic Restorative Treatment (ART) involves both the prevention and treatment of dental caries. The ART procedure is based on excavating and removing caries with hand instruments alone. The tooth is then restored with an adhesive filling material, i. e. glass ionomers.7

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.

Chemo-mechanical caries removal


Chemo-mechanical caries removal (CMCR) is the most documented alternative to traditional drilling for dentine caries removal. To summarise, the procedure involves the application of a chemical solution to the carious dentine followed by gentle removal with hand instruments. CMCR is currently the only approach that includes a selective caries softener.

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.

Carisolv gel multimix and hand instruments

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

Carisolv gel singlemix and hand instruments

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


When the lesion has been accessed and the demineralised dentine softened, special instrument tips are used to remove the carious tissue layer by layer. Most of the Carisolv instrument tips have a sharp edge and blunt cutting angles, resulting in a large support area against the underlying surface, coupled with controlled and effective caries removal. No sound tooth substance is sacrificed or damaged unnecessarily. Drills and excavators are designed to work their way into a material in a non-precise manner due to their aggressive cutting angles and smaller support areas.

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.

Instructions for use Carisolv gel


The gel does not affect healthy dentine or soft tissue. Nor does it affect enamel. Consequently Carisolv should be used in combination with the drill or alternative techniques. Drilling can be used whenever the cavity needs to be opened up, to adjust the cavity periphery or whenever there are large amounts of caries and when the risk of affecting healthy tissue is minimal. Carisolv makes it possible to avoid drilling deep into the cavity. For treatment time see page 17.

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

each package of gel.

Carisolv instruments for caries excavation


Hand instruments
Hand instruments with permanent or interchangeable tips designed to access different types of lesion. Instruments with permanent tips The instrument tips are paired together in doubleended Carisolv instruments. Instruments with interchangeable tips A single handle can be used with a range of different interchangeable Carisolv instrument tips.

Specially-designed tips

Star 1

Star 3

Star 3 extra bend

Multistar

Flat 0

Flat 0 extra bend

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.

Tips for PowerDrive


The tips to be used for caries excavation with Carisolv gel work in two directions clockwise (red) for more aggressive excavation, anti-clockwise (green) for less aggressive excavation. The cutting angles are more (red) or less (green) aggressive, although none of them cuts. The tips come in three different sizes, corresponding to Star 1, 2 and 3 of the hand instruments.

N.B. For a more detailed description of the use of PowerDrive, please see Instructions for Use PowerDrive, or the product sheet for PowerDrive.

Cases step-by-step treatment


Carisolv is a suitable approach for all situations in which minimally-invasive dentistry is desired. Some step-by-step treatment instructions for Carisolv now follow. In all situations, healthy tissue is preserved and the need for anaesthesia and/or drilling is minimised. Clinical experience also shows that post-operative problems are very uncommon after treatment with Carisolv. This is probably due to the fact that there are no movements of fluid in the dentinal tubules and no large variations in temperature caused by drilling instruments on the dentine.

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.

Step-by-step treatment of root caries lesions using Carisolv

Apply gel with the tip called star 3.

Wait 30 seconds.

Remove the softened carious dentine with flat 3 instrument. Use rapid movements not force!

Add more gel (no need to wait 30 seconds).

Check with probe. Caries-free. Clean.

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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Deep carious lesions


1. If necessary, use hand instruments or the drill to open up the cavity to obtain a good view of the lesion. 2. Use PowerDrive tip 2.0 or star 3 to apply the gel. Cover the whole lesion with mixed Carisolv gel. 3. Wait 30 seconds, then remove the bulk of the softened caries with PowerDrive tip 2.0 star with the red direction or hand instrument star 3 using a rotating/whisking movement. If the lesion is darkly stained, start with multistar. 4. Continuously add more gel, but now you do not have to wait 30 seconds before you start scraping. 5. Switch to the slower, less aggressive green direction with the PowerDrive or flat 3 when approaching the pulp. 6. Use the instrument with careful movements. Avoid force near the pulp. 7. Again use hand instruments or the drill for enamel overhangs if needed in order to carry out an accurate inspection. Keep the cavity filled with gel during the adjustment.

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.

Step-by-step treatment of a deep carious lesion using Carisolv

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.

Use flat 0 at the dentinoenamel junction.

JC Ramos, Coimbra, Portugal

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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

Caries at crown margins


One of my patients, whom I have been looking after for decades, came to me for his regular yearly checkup. When examining him I found caries just under the margin of a newly-made three-unit bridge. He told me that he had had some private problems and had taken anti-depressive medication during the last year. He had noticed that he had less saliva during this period, but it had not bothered him too much. I did not like the idea of drilling in this area since I had prepared the tooth; of course, I was also worried about the reconstruction. I tried to solve it in the most atraumatic way I could think of. By only placing a few drops of Carisolv and using the small star-shaped instrument I was able carefully to scrape away the softened carious dentine without harming the bridge or taking away too much healthy tooth substance. When the composite filling was in place, you could hardly see that there had been a problem. He was delighted with the treatment that had not caused any pain to him or to his wallet. I will naturally monitor him carefully in the future. For details in treatment performance, see Root caries.

Sverker Toreskog

Caries in a deciduous tooth the treatment step by step

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Your first cases


Select fully-visible, easily-accessible lesions, such as buccal root caries or an occlusal/approximal cavity with an opening that measures 1-2 mm or open up with the drill. Take your time! The gel needs to remain in the cavity for at least 30 seconds before scraping with the Carisolv instrument. Use PowerDrive star 2.0 or the multistar to help the gel penetrate and to remove the bulk of the caries in large cavities. New gel is then continuously applied and the treatment can proceed without any further delay or pauses. Be observant and check the dentinoenamel junction as described in the step-by-step instructions. If necessary, take away enamel overhangs to simplify cavity inspection. Remember that a learning curve is associated with the effective use of the Carisolv procedure, just as it is with any other new approach. It will take some practice (about 1520 cases) before you completely understand how and when to combine the treatment with the drill/laser/air abrasion and recognise the look of the caries-free surface after Carisolv excavation.

During your first cases you should avoid:


Caries which is difficult to access Leathery and darkly-stained caries Patients with dental fear or young children Practise on more tolerant patients until you become familiar with and confident about the method.

Evaluating a caries-free surface


The most common criteria for determining that a cavity is free from caries are the colour and surface texture of the dentine and the fact that a sharp probe does not give a tug-back feeling.10 This also applies to Carisolv and it is time to check with the probe when no more dentine can be removed (the gel remains clear, does not become cloudy) and a scraping sound from the instruments indicates a hard surface. Note that, when Carisolv has been used, the remaining surface is rougher than a drilled cavity since the healthy tissue remains intact. N.B. Various types of caries indicator dye tend to stain even sound dentine to some extent,11 especially when the surface is porous, i.e. close to the pulp. This in turn may lead to over-excavation.

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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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Scientific publications relating to Carisolv


A large number of studies of various research projects including Carisolv have been presented. Links to abstracts of scientific publications available on the Internet can be found in the Book of Abstractsat www.mediteam.com. A complete listing of all presented research can be found on MediTeams website under List of References.

Clinical studies confirm caries free


To date, several studies have been conducted showing that the treatment of dentine caries with Carisolv leaves a caries-free surface. Both the chemical and the mechanical part of the treatment are important when it comes to achieving this. However, it is important to have good access to the dentine caries and to check all surfaces, especially the dentinoenamel junction for complete caries removal, before restoring the cavity.

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.

Good dentine bonding


Several studies have shown that modern dental filling materials bond just as well, or better, to the surface left after treatment with Carisolv as those left by the conventional method of drilling.

High patient acceptance


The clinical studies also include answers to questions relating to patient acceptance of the Carisolv treatment. The results show that most patients have a high acceptance of the method, i.e. are more comfortable, feel less pain and are more relaxed during treatment, compared with other treatments, such as drilling and ART.

No adverse pulp effect


The application of Carisolv to deep cavities and directly to pulp tissue does not elicit adverse effects if contact times are short. No adverse effects are reported from clinical studies.

In vitro evaluation of caries-free


Several in-vitro/pre-clinical studies have shown that Carisolv removes dentine caries effectively.

No negative effects on soft tissue (mucosa)


An experimental, clinical study shows that Carisolv gel does not affect the oral mucosa. To date, numerous patients have been treated with Carisolv, with and without the use of a rubber dam, and no negative reactions have been reported.

No effect on healthy dentine or enamel


Studies confirm that Carisolv gel only softens carious dentine. Carisolv gel does not affect the enamel, or healthy dentine.

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.

Carisolv gel uncoloured


The chemical composition of the amino acids and the sodium hypochlorite components respectively has been further optimised to produce a more effective gel compared with the original red gel. Carisolv gel uncoloured has been shown to reduce the time for caries excavation significantly. Treatment times are comparable to those found for drill excavation in other studies.

Carisolv in combination with laser


Carisolv can be used in combination with other caries excavation methods. Yamada et al. found that combined treatment with lasers produced good results.

Questions & Answers


Is Carisolv a minimally-invasive method?
Yes, according to Banerjee et al., Carisolv is a selective method that only removes carious dentine.
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How do I know when it is caries-free?


The traditional probe is still the most commonly used approach, and as usual it should not tug-back to the remaining dentine. The tactile sensation and the removal of debris during the procedure will also indicate when you are approaching a hard, caries-free surface. Always probe the surface before removing the Carisolv gel and then check again after the gel has been removed.

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.

Why should I use the special Carisolv instruments?


During the development of the gel, the need for special non-cutting, tissue-preserving instruments became clear. They are needed effectively to rub the gel into the carious lesion and to avoid cutting healthy dentine. Some of the instrument tips, such as multistar, also increase the speed of dentinal caries removal. The different working parts have different modes of action and, when combined, they make it possible to treat all types of caries. A regular excavator (see illustration, page 7) works in a cutting mode and digs into the healthy dentine, which can give the patient pain sensations.

Why is there less pain?


Healthy dentine is not removed by the instruments. There are no vibrations from drilling. There are no large temperature variations. The dentine is covered with isotonic gel of body temperature. The high pH value. Psychology; the method is quiet and pleasant. In many cases, the dentine between the carious lesion and the pulp, is sclerotic. A slight anaesthetic effect from the gel has also been observed (Braun et al.).

Must I use a special bonding system?


No. For a summary of tested bond strength, please refer to page 15. Our recommendation is to make sure that you have completely cleaned the cavity from gel and then to follow the manufacturers instructions regarding the etching and bonding procedure.

How is pain minimised during treatment?


Patient perception is influenced by factors such as the force applied to the instruments and flushing with cold water. It is important that the carious lesion is thoroughly covered with gel during the entire procedure. Do not work with a half-filled/half-dry cavity. Use the PowerDrive and Carisolv hand instruments with speed and light pressure rather than excessive force. Initially, probe for a caries-free lesion by go16

Can I combine air abrasion, drills or lasers with Carisolv?


Yes, use air abrasion, drills or laser to obtain access to the carious lesion and maybe remove the bulk of the caries. Then continue with Carisolv according to the instructions (see step-by-step procedures). Always remove the deepest part of the caries with Carisolv.

Should I apply rubber dam before using Carisolv?


It depends on the clinical situation and the kind of restorative material you plan to use. However, a rubber dam is recommended when the patient has a dry mouth.

Are there any disadvantages to Carisolv?


If preconceived expectations of Carisolv are unrealistic, professionals and patients will be disappointed. It is important to remember that modern drills are high-precision tools that are excellent in many situations, when cutting enamel/dentine to obtain access to the carious lesion or during preparation for inlays or crowns, for example.

Can I use Carisolv in connection with prosthetic work?


Carisolv is ideal for removing caries at crown margins as it minimises the risk of fracturing the crown/ bridge. Carisolv can also be used to clean the dentine after using a temporary crown.

What are the greatest advantages with Carisolv?


The components of Carisolv gel only affect carious dentine, so that it can be easily and completely removed, leaving the sound tissue intact. Carisolv reduces and in some cases eliminates the need for local anaesthesia. Whether used alone or in combination with drills, Carisolv is always a gentle, safe, precise and nontraumatic alternative that enhances tissue preservation and increases patient comfort a minimallyinvasive method for caries removal.

How long will it take to remove caries with Carisolv?


As with any treatment, this naturally depends on the type of patient and lesion you are treating. In the early studies of Carisolv, the mean treatment time was ten minutes for coronal caries and six minutes for root surface lesions. The mean time for drilling was four to five minutes in these cases. A more recent study showed that dentists who use Carisolv frequently have a mean treatment time of six minutes with the uncoloured gel (2/3 coronal caries, more than 80% medium to deep caries).

Summary of chemo-mechanical characteristics


Only demineralised dentine containing denatured collagen is affected. The three amino acids react with the NaOCl to form chloramines. This modifies the chlorine reactivity, i.e. neutralises its aggressive behaviour on healthy tissue. The gel is applied at room temperature, which reduces the risk of pain sometimes associated with the cool liquids that are used with other caries removal procedures. The gel consistency simplifies control of the application and reduces the risk of spillage. The mechanical removal of the softened caries is performed with the poweroperated PowerDrive or special hand instruments. The hand instruments are available with permanent or interchangeable tips that have different sizes and shapes. The unique designs of both PowerDrive and Carisolv hand instrument tips enable effective caries removal and access in hard-to-reach areas. The noncutting characteristics of the instruments assure ultimate tissue preservation.

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If you want to read more about Carisolv, please look for:


Tissue Preservation in Caries Treatment a book from Quintessence Publishing.
The book Tissue Preservation in Caries Treatment, edited by T Albrektsson, D Bratthall, P-O Glantz and J Lindhe, is an international book with contributions from more than 30 authors from Europe, Asia, North and South America and Australia. The theme is tissue preservation with special emphasis on treating carious lesions. This new book has something for everyone undergraduate and graduate students, general practitioners and specialised dentists.

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.

5. 6. 7. 8. 9. 10. 11. 12. 13. 14.

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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

50008 GB-0 02.08

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