Minimal intervention dentistry

Minimal Intervention
Dentistry
Department of Pediatric and Preventive Dentistry
SUBMITTED BY:
U. VIGNESH
BDS – FINAL YEAR
BATCH – 2009 – 2010
GUIDED BY:
DR. BINITA SRIVASTAVA
DR. NIDHI GUPTA
DR. RASHI SINGH
DR. NEETI
Santosh Dental College & Hospital

OUTLINE
Introduction
Principles of Minimal Intervention dentistry
Newer cavity classification systems
Treatment of Carious lesions
Site 1
Site 2
Site 3
References

INTRODUCTION
 Minimum intervention dentistry (MI) can be defined as a
philosophy of professional care concerned with the first
occurrence, early detection, and earliest possible cure of
disease on micro levels, followed by minimally invasive,
patient-friendly treatment to repair irreversible damage
caused by such disease.
 The benefits for patients from Minimal Intervention are:
1.Better oral health through disease healing and not merely
on symptom relief.
2.Assists in reducing widespread patient dental anxieties.
3. more conservative approach to caries treatment and
simultaneously offer patients less invasive, health-oriented
treatment options.

 The philosophy of minimal intervention dentistry has now
arisen in an attempt to combine all the present knowledge of
prevention, remineralisation, ion exchange, healing, and
adhesion with the object of reducing carious damage in the
simplest and least invasive manner possible.
 Minimal intervention operative dentistry is dependent on the
following factors:
1. The demineralization - remineralization cycle
2. Adhesion in restorative dentistry
3. Biomimetic restorative materials
Ref. pg no. 450, Nikhil Marwah, 2nd
edition

Principles of Minimal Intervention
Adopted by the FDI General Assembly, 1st October 2002,
Vienna, (FDI Statement, 2002)
1. Control the disease through reduction of cryogenic flora
• Only in the absence of disease will restorative dentistry succeed.
• This is why control of the disease is the primary focus and only when such
control has been achieved will it be possible to offer long-term repair of the
damage.
• Correct diagnostic procedures must be carried out for any at-risk patient to
determine the potential for carious activity.
• Modification of the oral microflora is essential in the initial stage, and a
number of oral lavages are available to modify the balance of the oral flora
although chlorhexidine is probably the most effective of these.
Ref. pg no. 450-451, Nikhil Marwah, 2nd
edition

2. Remineralize early lesions –
• Remineralization should be recognized and utilized as far as
possible for any tooth that has been subject to attack by caries,
because there is no real substitute for natural tooth structure.
• It has been known for many years that “ white-spot” lesions on the
visible surfaces of teeth can be remineralized and repaired.
• Successful remineralization requires intensive patient must have a
full understanding of the implication of food types, the need for
plaque removal, and the possible need for additional oral lavages
for control of bacterial populations.
edition

3. Perform minimal intervention surgical procedures, as
required-
• If the disease has progressed to cavitation on the tooth surface, it
is no longer possible to completely control plaque accumulation
without some degree of surgical intervention.
• In view of the potential for remineralization and healing a minimal
intervention approach is encouraged.
• The principle of preservation of natural tooth structures should
dominate decisions about both new and old lesions.
edition

4. Repair, rather than replace, defective
restorations-
• The replacement of any failed restoration will also lead to further
loss of tooth structure and subsequent weakening of the remaining
crown.
• This steady progression should be limited as far as possible; with
the advent of adhesion, biomimetic materials, and minimal
intervention cavity designs, it is often possible to repair, rather than
replace, a restoration that has suffered a limited failure.
edition

Recent Cavity
Classification Systems

I. BASED ON SITE AND SIZE OF LESION
(Mount and Hume, 1998)
Size
Site
No
cavity
Minimal
1
Moderate
2
Enlarged
3
Extensive
4
Pit/Fissure
1
1.0 1.1 1.2 1.3 1.4
Contact area
2
2.0 2.1 2.2 2.3 2.4
Cervical
3
3.0 3.1 3.2 3.3 3.4
Ref. pg no. 126, G.J. Mount and W.R. Hume, 2nd
edition

Classification of Cavities based on
site and size of lesion
edition

 Size 1, Sizes 1,2,3 and 4 – Pit and fissure
caries
• Cavity located on the occlusal surface of a
posterior tooth or any simple enamel defect on
an otherwise smooth surface of any tooth.
• Black Class 1 – the smaller size 1 could not be
carried out previously because suitable
restorative materials were not available, so the
Black classification begins with Site 1, Size 2
(#1.2)
edition

Site 1, Size 0
• The concept of the fissure seal, as discussed by simonsen (1989)
and others is particularly sound in a newly erupted tooth.
• Sealing a deep fissure before it becomes partially occluded by
plaque and pellicle, and in advance of demineralization into dentin,
has an acceptable clinical history.
• The earliest fissure sealants were unfilled or lightly filled resins, but
recent research has shown that there are some doubts about the
integrity of the acid etch union between resin and enamel in these
regions. It has been shown that a glass ionomer will successfully
occlude such a fissure (Wilson and McLean, 1988).
• This is now being termed “Fissure Protection” to differentiate it from
a “Resin Seal”.
edition

Site 1, Size 1
• As the fissure walls become demineralized, the dentin will become
involved as well. This may pose a rather dangerous situation because
there is often some difficulty in diagnosing the presence of a dentin
lesion.
• Radiograph will not show this early lesion very clearly and laser
detector and electrical impedance machines have limitations.
• In the presence of strong, fluoridated enamel, the occlusal surface entry
to the lesion will remain limited, and bacteria-laden plaque can be
forced down into a defective fissure. Under these circumstances, dentin
involvement can become advanced before symptoms are noted.
• The fissure system is a complex series of pits and fissure; therefore, a
carious defect will often be limited to a very restricted area, leaving the
remaining fissure system sound and uninvolved. This means that only
the carious defect needs to be instrumented.
edition

Site 1 Size 1
Fig. 1- Lesion in the occlusal fissure , Note the small
#1.1 lesion in the lingual groove of the lower molar.
Dentin involvement is suspected
Fig. 2 - Prepared cavity- The fissure has been explored
and caries removed. The conditioning liquid is present
to enhance the photograph
Fig. 3 – Restored lesion – The same restoration recorded
5 years after placement. Note the limited wear over
time
edition

Size 1, Size 2
• In this classification, the lesion will either have progressed to some
degree or it may represent replacement of a failed Class I
restoration.
• The same conservative principal should apply, in as much as it is
only necessary to deal with the carious lesion and there is no need
to open up the remaining fissures any further.
• If there is any part of the fissure system that is in doubt, it can be
explored very conservatively, but there is no doubt that it is
sufficient to seal the fissures and any carious process below will be
arrested.
• However, the occlusal involvement will be more extensive and, if
there is any doubt about the ability of the glass ionomer to
withstand the occlusal load, it can be cut back conservatively and
laminated with resin composite.
edition

Site 1 Size 2
A bitewing
radiograph of an
extensive #1.2 lesion
arising from an occlusal
fissure on the second
molar
Note the limited
size of the external
involvement of the
fissure
Prepared cavity-
Restoration – the
entire cavity has
been restored with
a glass ionomer
with no sublining
required.
Lamination-
the cement has
been laminated
with composite
resin for
occlusal support
Final
radiograph –
shows the
extent of the
restoration.
1.
2.
3.
4.
5.
6.
edition

Site 1, Size 3,4
• When a restoration requires replacement, the existing cavity will be
relatively large. The previous surgical approach to cavity design
required the removal of all infected tooth structure and softened
affected dentin on floor of the cavity and also required removal of
all unsupported enamel on the occlusal surface.
• Consequently, there was a potential for loss of occlusal contact
with the opposing tooth.
• To avoid such procedures a temporary restoration is placed over
the carious structure and this helps in remineralizing the lesion and
decreasing pulpal inflammation.
• Glass ionomer should be used for the transitional restoration
following removal of infected layer of dentin from the surface of a
large cavity.
edition

Site 1 Size 3
Fig. 1 - Size 3 cavities - An extensive
lesion on the occlusal surface of a lower
molar
Fig. 2 - Completed cavity
Fig. 3 - Split cusp – a split at the base
of the mesiolingual cusp became
apparent
Fig. 4 - Completed restoration with
amalgam
Ref. pg no. 131-132, G.J. Mount and W.R. Hume, 2nd
edition

Site 1 Size 4
Fig. 1 – An extensive lesion in a
lower second molar. It is
apparent the buccal cusp is very
weak
Fig. 2 - Completed cavity.
Retentive grooves have been
placed in the floor of the cavity
to retain the amalgam
edition

Site 2 Lesions- Sizes1, 2, 3, 4 –
Approximal lesion commencing in relation to contact
areas
• Approximal surface of any tooth (anterior or posterior)
initiated immediately below the contact area
• Black Class II – between posterior teeth only. Black
classification begins with Site 2, Size 2 (#2.2)
• Black class III - between anterior teeth only. Black
classification begins with Site 2, Size 2 (#2.2)
• Black class IV - class III lesion involving the incisal
corner or incisal edge of an anterior tooth. Now
classified Site 2, Size 4 (#2.4)
edition

Site 2, Size 0
• It should be noted that radiographic evidence of demineralization
at the contact area does not necessarily mean that there is
cavitation on the proximal surface and, in the absence of
cavitation, it is often possible to heal the lesion.
• In fact, proximal lesions progress very slowly because that surface
is not under masticatory load and is, to a degree, protected from
traumatic damage
• In contrast to the occlusal fissure lesion, it may take up to four
years to penetrate the full thickness of the enamel and an
additional four years to progress through the dentin to the pulp.
edition

Site 2, Size 0
Fig. 1 - Site 2 – Proximal lesion Fig. 2 - The same lesion in the
sectioned tooth
edition

Site 2, Size 1,2
• Once it has been established that there is cavitation on the proximal
surface, a surgical approach to its repair becomes essential and some
alternative methods are available.
• First determine the position of the damage in relation to the crest of the
marginal ridge.
• If it is more than 2.5mm below the crest, then it may be possible to
approach the lesion through the occlusal fossa and a design a “tunnel”
cavity.
• On the contrary, if it is less than this distance, a tunnel will only undermine
the marginal ridge and weaken it still further.
• Under these circumstances, it is better to design a small box or “slot” cavity
beginning on the outer slope of the ridge, retaining as much of the enamel
as possible.
edition

Site 2 Size 1 - tunnel
Fig. 1. Initial approach – Enter the
lesion from the occlusal fossa aiming
towards the lesion.
Fig. 2. Gain access – Turn the bur
vertical and lean it buccally and
lingually to ‘funnel’ the cavity for
visibility.
Fig. 3. Completed cavity – axial wall
left untouched.
Fig. 4. GIC Restoration done
edition

T he early proximal lesion on a posterior tooth will commence in
enamel immediately below the contact area because this is where
plaque will accumulate and mature.
As the lesion develops, some degree of breakdown and cavitation
of the enamel will eventually occur, but this will remain confined to
the area below the contact until it is quite advanced.
There will generally be a zone of demineralized enamel
surrounding the cavitation, but as long as the surface is smooth, this
remains capable of remineralization in the presence of fluoride.
The contact area may remain sound and the marginal ridge may be
quite strong, provided the lesion is more than 2.5 mm below the crest
of the marginal ridge (Wilson and mcLean, 1988).
TUNNEL PREPARATION
edition

 Access to the lesion through the occlusal surfaces should be limited
to the extent required to achieve visibility and should be undertaken
from an area that is not under direct occlusal load (Knight, 1984).
 Fossa immediately next to medial marginal ridge is the most
suitable position for entry.
 Glass ionomer is best suited for such cavities as it readily flows into
a small cavity and has the ability to remineralize the enamel margins
and any dentin on axial wall.
• Two variations are described:
Closed ‘tunnel’ : Which leaves the demineralized approximal enamel
intact
Open ‘tunnel’ : Which is accessed from occlusal and exits through
the approximal surface
edition

Indications and Contraindications
• Use of tunnel preparation can be considered
when small, proximal carious lesions necessitate
restoration
• Preparation should be avoided:
i. large carious lesion are diagnosed, where access is
particularly difficult
ii. Overlying marginal ridge is subjected to heavy
occlusion or demonstrates a crack

Advantages of Tunnel Preparation
• Preserves the marginal ridge - conservative approach
• Less potential for a restorative overhang
• Perimeter of the restoration is reduced, decreasing the
potential for micro leakage.
• Potential for disturbance of the adjacent tooth is
reduced

Disadvantages of Tunnel Preparation
 Highly technique sensitive, demanding careful control of
the preparation by the operator
 Angulations of preparation often passes close pulp
 Visibility is decreased and caries removal is more uncertain
- caries detecting solution
 Fragile marginal ridge - at least 2.5 mm apical to crest of the
marginal ridge (Mount 1997)

Site 2 Size 1 – Minibox / Slot
Fig. 1. Small carious lesion on
the proximal surface of the
first bicuspid
Fig. 2. Slot cavity preparation
Fig. 3. Finished slot cavity Fig . 4 Resin modified GIC
Restoration done
edition

“SLOT CAVITY PREPARATIONS”
 It could be used when the lesion is less 2.5 mm below the crest of the
marginal ridge.
 The basic principles of cavity design remain the same, with the
objective of removing only that tooth structure that has broken beyond
the possibility of remineralisation.
 If this is allowed to dictate the extent of the cavity, there will many
occasions with this design where there is sound contact with the
adjacent tooth in one or more areas. It is desirable to retain this to
ease the problems of maintaining a good, firm contact area.
 The outline form will be dictated entirely by the extent of the
breakdown of the enamel, removing only that which is friable and
easily eliminated without applying undue pressure .
edition

 Retention will be through adhesion, so it is only necessary to
clean the walls around the full circumference of the lesion, leaving
the axial wall because it will be affected by dentin only.
 For such a lesion, resin composite may be a useful material
because on many occasions there will be a useful material
because on many occasions there will be an enamel margin
around the full circumference.
 However, glass ionomer is still a sound option because the
occlusal load will not be great and the ion exchange will remain
valuable both for adhesion and remineralization.
edition

Site 2 Size 1 – Proximal Approach
Fig. 1. Proximal approach. A
small proximal lesion becomes
accessible through a
traditional cavity prepared in
the adjacent tooth
Fig. 2. Restoration. The
cavity has been restored
with GIC before placing the
other restoration
edition

PROXIMAL CAVITY PREPARATION
 This is a very conservative approach used when the proximal
surface of a tooth becomes accessible at the time of cavity
preparation in an adjacent tooth.
 The lesion may have been revealed through radiographs or it
may be noted only during cavity preparation.
 The larger cavity in the adjacent tooth will normally need to be of
reasonably generous proportions to allow room to maneuver, but
when such an approach is possible, it leads to considerable
conservation of natural tooth structure.
 It is only necessary to remove enamel that is broken down
beyond remineralisation.
edition

 There will often be a residual area of demineralized enamel around
the circumference of the lesion and this should be retained
because it is quite capable of being remineralized.
 As this entire restoration will be hidden by adjacent tooth, it is
essential to use a radiopaque material.
 Glass ionomer is preferred because the limited access will make it
difficult to assure full polymerization of the resin through light
activation.
edition

Site 2 Size 2
Fig. 1. Moderate lesion. A 2.2
lesion, distal of second
bicuspid, to be prepared for
adhesive restoration
Fig. 2. Finished cavity. Note
minimal involvement of
occlusal fissure
edition

Site 2, size 3,4
• The principles for the restoration of an extensive proximal lesion
are essentially the same as those for the occlusal lesion.
• In gaining access to the affected demineralized dentin, there is no
need to remove enamel just because it appears to be unsupported
according to the old surgical principles.
• However, the walls of the cavity should be cleaned of all infected
dentin to allow development of the full ion-exchange adhesion with
the glass ionomer.
• Demineralized dentin can remain on both the axial and pulpal walls
on the assumption that it will remineralize under the influence of
the glass ionomer.
edition

Site 2 Size 3
Fig. 1. Anterior #2.3 lesion. Old
amalgam restoration, distal of
canine, to be replaced
Fig. 2. Cavity design. Completed
cavity. Note retention of labial
enamel to be supported by
adhesive restoration
Fig. 3. Glass- ionomer cement
restoration
Fig. 4. Completed restoration
edition

Site 2 Size 4
Fig. 1. Lost buccal cusp Fig. 2. Placement of a base Fig. 3. Shaping the base
Fig. 4. Begin composite
Rebuild
Fig. 5. Incremental build-up Fig. 6. Completed restoration
edition

Site 3 Lesions - Sizes 1, 2, 3 and 4
• Gingival 1/3rd
of the clinical crown or exposed root
surface following recession
• Black class V - this classification does not differentiate
lesions on the gingival one-third of the approximal
surface (particularly root surface caries) from class II
lesions.
Ref. pg. no.128, G.J Mount and W.R. Hume, 2nd
edition

Site 3 Size 0
Fig.1. Site 3. Erosion lesion seen on
Labio-cervical area of upper canine
Fig. 2. Site 3. Erosion lesion seen
on the Bucco-cervical area of lower
first molar
edition

Site 3 Size 1
Fig. 1 erosion lesion, #3.1. erosion lesions at the
gingival of the central, lateral and canine were
restored with GIC
Fig. 2. Root surface caries at the gingival of the
lateral incisor requires repair
Fig. 3. Restoration done for the fig.2. tooth
involved carious lesion
edition

Site 3 Size 2
Fig. 1. Carious lesion present on cervical area of
lower second bicuspid
Fig. 2. Placement of Resin modified GIC
Fig. 3. Restoration done with GIC
edition

Site 3 Size 3
Fig. 1. Root surface carious, #3.3 lesion on the
cervical area of Upper Anterior Teeth
Fig. 2. Final cavity design, refine the cavity with
small round burs, cleaning the margins only
and leaving the axial wall alone
Fig. 3. Place the restoration, a modified glass –
ionomer was placed and light activated from
both labial and lingual
edition

Site 3 Size 4
Fig. 1 #3.4, an old composite
restoration is failing and
requires replacement
Fig. 2. Lingual view
showing general failure
around to the lingual
Fig. 3. final cavity From
labial view
Fig. 4. Final cavity – labial
view
Fig. 5. Finished restoration
edition

ATRAUMATIC RESTORATIVE TREATMENT
(ART)
• The Atraumatic restorative treatment is a procedure based on
removing carious tooth tissues using hand instruments alone
and restoring the cavity with an adhesive restorative material.
• It is also known as “Alternative Restorative treatment”.
• ART is launched by the World Health Organization on 7th
April,
1994 (world health day).
• Goals of ART are:
i. Preserving the tooth structure
ii. Reducing infection
iii. Avoiding discomfort
edition
Ref. pg no. 320, S.G. Damle, 3rd
edition

• The essential instrument used for
ART are:
1. Mouth mirror
2. Explorer
3. Pair of tweezers
4. Dental hatchet
5. Small, medium sized spoon excavators
6. Glass slab
7. Spatula
8. Carver
• The materials used are:
1. Gloves
2. Cotton rolls and pellets
3. Glass ionomer restorative material
4. Dentin conditioner
5. Petroleum jelly
6. Wedges
7. Plastic strips and water Ref. pg no. 320, S.G. Damle, 3rd
edition

Procedure for ART:
The tooth is isolated with cotton rolls
The tooth surface to be treated is cleaned with a wet cotton pellet
The entrance of the lesion is slightly widened by hand instrument to remove
gross overhanging unsupported enamel rods
The dental caries is removed by using either the small or medium size spoon
shaped excavator
If necessary provide pulpal protection by calcium hydroxide paste
The cavity surface along with occlusal margins are cleaned
The cavity is acid - etched
edition

According to manufacturer’s instructions the glass ionomer cement is mixed
The mixed glass ionomer is inserted into the cavity and slightly overfield
A gloved finger, which is smeared with petroleum jelly, is pressed on top the
entire occlusal surface and slight pressure is applied
The bite is checked
Excess material is removed with a sharp carver
The bite is rechecked and all high points are removed
The filling is covered with petroleum jelly once again or the varnish may be
applied
The patient is instructed not to bite with the tooth for at least half an hour

fig 1. preoperative
fig 2. excavation of caries
fig 3. cavity after caries removal
fig 4. cavity conditioning
Procedure for ART
S
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1
S
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2
S
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3
S
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4
edition

fig. 5- Dispensing of GIC
fig. 6- Mixing of GIC
fig. 7- Insertion of GIC
fig. 8- Restored cavity
S
T
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5
S
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6
S
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7
S
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8

Advantages of ART
1. Easily available inexpensive hand instruments are used rather than the
expensive electrically driven dental equipment.
2. As it is almost a painless procedure the need for local anesthesia is
eliminated or minimized.
3. ART involves the removal of only decalcified tooth tissues, which results
in relatively small cavities and conserves sound tooth tissues as much
as possible.
4. Sound tooth tissue need not be cut for retention of filling material.
5. The leaching of fluoride from glass ionomer probably remineralizes
sterile demineralized dentin and prevents development of secondary
caries.
edition

 The combined preventing and curative treatment can be done in
one appointment.
 Repairing of defects in the restoration can be easily done
 It is less expensive and less time consuming.
 It enables to oral health workers to reach people who otherwise
never would have received any oral health service.
edition

Disadvantages of ART
 ART restorations are not long lasting. The average life is two years
depending upon the rate of caries activity of the individual oral
cavity.
 Because of the low wear resistance and low strength of the
existing glass ionomer materials their use is limited.
 A relatively unstandardized mix of glass ionomer may be produced
due to hand mixing.
 The continuous use of hand instruments over long period of time
may result in hand fatigue.
 As fundamental principles of cavity preparation are not followed all
oral health workers may not accept it.
edition

Air abrasion
(Micro-Abrasion and Kinetic Cavity Preparation)
• It is a method of tooth structure removal that is
considered to be an effective alternative to the
standard dental drill.
• In 1943 Dr. Robert Black of Corpus Christi Texas
began his pioneering work in this field.
• In 1945 he published a series of articles on the
use of air abrasive technique for cavity
preparation and prophylaxis.
• Air abrasive technology is the use of
compressed air to propel aluminium oxide
particles with such force as to be able to cut
tooth structure in simple terms it is a precision
sandblaster.
• An air abrasive unit called AIRDENT was
introduced in 1951.
Ref. pg. no. 440, Nikhil Marwah, 2nd
edition
Fig. AIR ABRASIVE SYSTEM
-Ref pg 348, Sturdevant’s Art
and Science of Operative
Dentistry, 5th
edition

Advantages
 It is painless
 Local anesthesia is rarely needed
 It works quickly and the tooth with a
small lesion is ready to restore in
seconds
 It work quietly without the whine of
the all too familiar dental handpiece
 There is no vibration or pressure to
cause microfractures that weaken
tooth
 There is no production of heat to
damage the dental pulp and lesser
sound tooth structure is removed.
edition

Principles of Air abrasion
1.Accurate diagnosis of unsound tooth structure
and decay.
2.Accurate removal of unsound tooth structure
with minimal destruction of sound tooth
structure.
3.Restorative treatment planning based on the
probability of longevity of the restorative
material.
edition

Procedure of Air Abrasion
Take preoperative radiograph to determine if interproximal caries is present
Isolate preferably with rubber dam
Use caries detecting dye to know the carious lesions
Using air abrasive unit with high volume evacuation placed in the proximity of
the tooth prepare cavity
After a few seconds of initial preparation examine the preparation for decay
Re-apply caries detecting dye
Complete the preparation using the caries detecting dye until all caries is
removed
edition

Apply the etchant for 20 seconds rinse with water spray
Disinfect the cavity preparation with chlorhexidine or other materials
Within 10 seconds apply the dentin-bonding agent
Immediately place the correct shade of composite and photo-polymerize the
material for 40 seconds
Use a carbide bur for initial shaping
A flexible polishing cup point or disc will provide the final polish for the
restoration
Remove the rubber dam and check occlusion
Ref. pg. no. 440-441, Nikhil Marwah, 2nd
edition

Precautions
1. Need to protect patient with glasses, rubber dam if possible.
2. Dental team needs masks and glasses.
3. Stop frequently to check the progress.
4. Start with low pressure and low power then increase as
needed.
5. Hold tip 1-2 mm away from tooth at a 45 degree angle then
activate.
6. Always keep tip moving.
7. Requires external suction and air evacuation for the room.
8. Use disposable mirrors.
9. Like any air stream air abrasion can cause subcutaneous
emphysema.
edition

Clinical uses:
• Class I, II, III, IV, V cavity
preparations
• Sealants and preventive
restorations
• Repair of composite and
porcelain especially margin
of veneers
• Removal of composite and
amalgam.
edition

Chemico-mechanical removal of caries
• An alternative to the conventional
mechanical removal of caries is
chemo mechanical method.
• The need for local anesthesia is
reduced or eliminated as there is
little pain during the procedure.
• It is an effective alternative for caries
removal because it brings together
Atraumatic characteristics and
bactericide / bacteriostatic action.
• The chemicals used can be in the
form of liquid (caridex) or gel
(carisolv).
Ref. pg. no. 491-492, S.G. Damle, 3rd
edition
edition

Caridex
• Caridex was developed by CM Habib from a formula made of N-
mono -chloroglycine and amino butyric acid and was called as GK
101 E.
• It gained FDA approval in 1984.
• It was initially introduced on the US market in 1985.
• The system involved the intermittent application of preheated N-
monochloro-DL-2-aminobutyric acid (GK-101E) to the carious lesion.
• The solution was claimed to cause disruption of collagen in the
carious dentine, thus facilitating its removal.
• The mechanism of softening involved chlorination of remaining
partially degraded dentinal collagen and the conversion of
hydroxyproline to pyrrole-2-carboxylic acid, which initiated disruption
of the altered collagen fibers in the caries.
edition

 Disadvantages-
1. Expensive
2. Large quantity required
3. Solution had to be heated
4. Short shelf-life
5. Hand instruments were not optimum
edition

Carisolv
• During the 1980s studies at the universities by Malmo,
Huddinge at Chalmers Technical university in Goteborg was
directed toward a more efficient and effective
chemomechanical caries removal system than caridex.
• Carisolv key difference to other products already in the
market was the use of three amino acids – Lysine, leucine,
and glutamic acid – instead of the aminobutyric acid.
• These aminoacids counteracted the sodium hypochlorite
aggressive behavior at the oral healthy tissues.
• Despite its effectiveness, carisolv was not a blockbuster
mainly because it required-
1. Extensive training and registration of professionals
2. Customized instruments which increased the cost of the solution.
edition

 Constituents of carisolv
• Syringe one: sodium hypochlorite
(0.5%)
• Syringe two: three amino acids
(glutamic acid, leucine, lysine)
• Gel substance:
carboxymethlcellulose
• Sodium chloride / sodium hydroxide
• Saline solution coloring indicator
(red)
• Available as single mix or multi mix
syringes.
• New gel formulation
edition

Indications of Carisolv
• Where the preservation of tooth structure is important.
• The removal of root / cervical caries.
• The management of coronal caries with cavitation.
• The removal of caries et the margins of crowns and bridge
abutments.
• The completion of tunnel preparations.
• Where local anesthesia is contraindicated.
• The care of caries in dentally anxious patients, notably
needle phobic's.
• Management of primary carious lesions in deciduous teeth.
• Atraumatic restorative technique procedures.
• Caries management in patients with special needs.
edition

Cavity preparation using Carisolv
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.
Use a carisolv instrument to pick up the gel and apply it to the carious dentine
Soak the caries generously
Wait for at least 30 seconds, for the chemical process to soften the caries
Scraped 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
Select a power drive tip or a Carisolv hand instrument to match the size, position and accessibility
of the cavity

Keep the lesion soaked with the gel and continue scraping. 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
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 scrapping
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 manufacturer’s instructions for
use
Remove the softened carious dentine with the instrument. Avoid flushing or drying the cavity

Advantages of Carisolv
• Three amino acids are incorporated instead of one, and the
different charges have improved the interaction with the
degraded collagen within the lesion, thus increasing the
efficacy.
• Carisolv has a higher viscosity, which allows for the
application of higher concentrations of amino acids and
sodium hypochlorite without increasing the total amount of
fluid used, therefore reducing the total volume required.
• The solution does not need to be heated, or applied through
a pump mechanism.
• The increased viscosity of carisolv enhances precision
placement.
• The overall stability is increased, giving an improved shelf
life.

 Procedure for using carisolv gel:
1. The gel is applied to the carious lesion with a hand
instrument.
2. After 30 seconds, carious dentin is removed gently by
scraping with a hand instrument.
3. More gel is then applied and the procedure repeated until no
more carious dentin remains, a guide to this being, when the
gel removed from the tooth is clear.
Ref. pg. no. 492, S.G. Damle, 3rd
edition

CARIDEX CARISOLV
Chemical
Composition
Dye
PH
Physical properties
Volume Needed
Time Required
1% NaOCl
0.1 M aminobutyric acid
Glycine
NaCl and NaOH
----
11
Liquid
100-500 ml
5-15 mins
0.5% NaOCl
0.1 M glutamic acid /
luecine
NaCl and NaOH
Erythrocin (pink)
11
Gel
0.2-1.0 ml
5-15 mins
Comparison of two systems for chemicomechanical removal of caries
Ref. pg. no. 491-492, S.G. Damle, 3rd
edition

Papain Gel
• In 2003, a research project in Brazil led to the
development of a new formula to universalize
the use of chemo-mechanical method for
caries removal and promote its use in public
health.
• The new formula was commercially known as
papacarie.
• It is basically composed of Papain,
chloramines, toluidine blue, salts, thickening
vehicle, which together are responsible for
the papacarie’s bactericide, bacteriostatic and
anti-inflammatory characteristics.
• Papain comes from the latex of the leaves
and fruits of the green adult papaya.
edition
PAPAIN GEL

• Carica papaya, is cultivated in tropical regions such as
Brazil, India, South Africa, and Hawaii, and is largely used in
the food, beverages, and drug industries.
• Papain promotes:
I. Chemical debridement
II. Granulation and epithelialization, which hastens the phases
of cicatrization
III.Stimulation of the tensile strength of the scars.
edition

Mechanism of action
• Antitrypsin inhibits protein digestion but
infected tissues do not usually show
antitrypsin.
• Since Papain can digest only dead cells,
it acts breaking the partially degraded
collagen molecules, contributing to the
degradation and elimination of the fibrin
“mantle” formed by the carious process.
• Right after the degradation, oxygen is
freed, bubbles appear on the surface,
and a blearing of the gel is thus noted.
• These signs demonstrate that the
removal process can be started.
edition

• For removal, we recommended the use of the opposite
side of an excavator, like a pendulum movement and
without cutting.
• The instrument should scrap the carious tissue without
promoting any kind of stimulus or pressure.
• The main characteristics of the complete removal of the
infected dentinal tissue is the vitreous aspect of the
cavity which appears after using Papacarie.
edition

Clinical procedure of Papain Gel
Radiograph of the target tooth
Prophylaxis of the region using rubber cup and slurry of pumice
Rinsing with air/water spray or cotton pellet with water
Isolation of target tooth
Application of Papacarie, allowing the chemistry to work for 30 to 40 seconds
Removal of the softened carious dentin using the opposite side of the excavator and promoting a
pendulum movement; the softened tissue must be scraped, not cut
Application of gel, if necessary
edition

Rinsing 0.12%, 1% or 2% chlorhexidine or waterspray
Drying with moisture-free and oil-free air
Restoration with a suitable filling material according to manufacturer’s instructions
The vitrous aspect of the cavity appears when the cavity feels free from caries
edition

1. Arrow indicating proximocclusal carious lesion
2. Isolation and application of Papain Gel
3. Caries had been removed
4. Arrow showing filled cavity with composite
Clinical procedure of Papain Gel

Advantages of chemico-mechanical method
• Its proven effectiveness
• Method’s safety
• Elimination of local anesthesia
• Lower anxiety built in patients
• Conservation of the sound tissue
• Only demineralised dentine containing collagen is
affected.
• Gel consistency simplifies control of the application
and reduces the risk of spillage.
edition

References
• TEXTBOOK OF PEDIATRIC DENTISTRY- 2nd
EDITION - NIKHIL MARWAH
• TEXTBOOK OF PEDODONTICS – 2nd
EDITION -
SHOBHA TANDON
• TEXTBOOK OF PEDIATRIC DENTISTRY – 3rd
EDITION – S.G. DAMLE
• PRESERVATION AND RESTORATION OF TOOTH
STRUCTURE – 2nd
EDITION – GRAHAM J. MOUNT,
W.R. HUME

Minimal intervention dentistry

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