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Year : 2020  |  Volume : 23  |  Issue : 1  |  Page : 2-9
Systematic review on alternative methods for caries removal in permanent teeth

Department of Conservative Dentistry and Endodontics, Saveetha Institute of Medical and Technical Science, Saveetha Dental College, Saveetha University, Chennai, Tamil Nadu, India

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Date of Submission19-May-2019
Date of Decision20-May-2020
Date of Acceptance07-Sep-2020
Date of Web Publication10-Oct-2020


Introduction: Dental caries is the most common chronic dental disease in the world. It is defined as a multifactorial microbial infectious disease characterized by demineralization of the inorganic and destruction of the organic substance of the tooth. The host, flora, and the substrate should be there for the formation of dental caries. There are various microorganisms responsible for caries. The treatment for caries is essential to prevent teeth from involving pulp, leading to further damage. There are various methods in removing caries such as minimally invasive technique, rotary method with different types of burs, chemomechanical caries removal, and lasers. There are no data in literature for various methods of removing caries in permanent teeth.
Materials and Methods: Research question was formulated based on the PICO strategy. A comprehensive electronic literature search was conducted, independently by two reviewers. Based on the specified inclusion and exclusion criteria's, the selected articles were subjected to quality assessment and the risk of bias was evaluated.
Objective: The objective of this study was to evaluate the efficiency of caries removal by various methods in permanent teeth.
Search Strategy: A search was performed in electronic database (i.e. PubMed and Medline) using search terms alone and in combination by means of PubMed search builder from January 1985 to January 2018.
Selection Criteria: Studies were selected if they met the following criteria: in vivo studies comparing various methods of caries removal in permanent teeth.
Results: The search identified 338 publications, out of which 328 were excluded after examination of the title and 2 were excluded after examination of the abstract. Through the hand search, three articles were included. Eight articles were retrieved for more detailed evaluation from the search. A total of 11 publications fulfilled all the criteria for inclusion.
Conclusion: With the available evidence, this review concludes that the studies included in this review have a high risk of quality evidence.

Keywords: Caries; chemomechanical; infected dentin; permanent teeth; type of burs

How to cite this article:
Senthilkumar V, Ramesh S. Systematic review on alternative methods for caries removal in permanent teeth. J Conserv Dent 2020;23:2-9

How to cite this URL:
Senthilkumar V, Ramesh S. Systematic review on alternative methods for caries removal in permanent teeth. J Conserv Dent [serial online] 2020 [cited 2023 Oct 4];23:2-9. Available from:

   Introduction Top

Dental caries is one of the most prevalent chronic diseases, which may lead to pulpal infection if left untreated. Caries may lead to infection of the dental pulp. Most of the clinicians' objective is to remove only the infected layer, leaving the unaffected dentin intact.[1] It is important to remove the infected layer to prevent the unnecessary removal of tooth structure.[1],[2]

The affected dentin is left unremoved so that remineralization may take place.[3] Previously conventional rotary method was used for tooth preparation and the cavities were designed in specific dimension for the restorative material employed. But, the current concept is to preserve as much of tooth structure as possible. Hence, the concept of minimally invasive dentistry came in.

The rotary or conventional method is not much preferred as it removes a lot of tooth structure, noise, discomfort, fear, excessive cutting of uninfected dentin, and pain. Hence, the removal of caries with minimal pain given rise to various alternative methods such as air abrasion, sono-abrasion, chemomechanical caries removal, lasers, and atraumatic restorative method fluorescence aided caries excavation.[4],[5],[6],[7],[8],[9],[10]

In the conventional method or rotary method, the high-speed handpiece is used to gain access to cavity lesion and low-speed handpiece is used to remove carious dentine.[11] Steel bur and conventional rotary methods remove a large amount of sound tissue, over preparation. It may cause pressure or heat on the pulp, noise, and pain stimulus and may need local anesthesia in many patients.[12]

In the year 2003, Boston developed new polymer prototype burs as an alternative to conventional burs. It is the self-limiting polymer bur, which is the new version of SmartPrep, now called SmartBurs. It can be used with slow speed handpiece. It removes only infected dentin, and it does not remove healthy dentin. It is claimed to be disposable once the cutting portion of the bur wears off. Hence, these cannot be used repeatedly for tooth preparations.[13],[14]

The chemomechanical system was developed 30 years back. But it was gained into attention only in the late 1990s by the introduction of Carisolv in the market.[15],[16] It can able to dissolve collagen fibers, so that caries is easy to remove with hand instruments.[15],[16] Chemomechanical caries removal (CMCR) method is a noninvasive technique, avoids pulp irritation and patient discomfort, eliminates infected tissues, and preserves healthy structures. It has antibacterial, anti-inflammatory effects. Chemomechanical method is a minimally invasive method.

In Brazil 2003, it was the first time they introduced papain gel commercially known as Papacarie for CMCR agent.[17],[18],[19] Papain is a proteolytic enzyme. It has bactericide, anti-inflammatory, and bacteriostatic characteristics.[20] It is extracted from the latex of leaves and fruits of adult green papaya. It acts only in infected tissue because infected tissue lacks a plasmatic antiprotease called antitrypsin.[20]

Structured question

Does efficiency of removing caries in permanent teeth with conventional method and other alternative methods have any difference?

PICO analysis

  • Population – Caries in permanent teeth
  • Intervention – Alternative methods for caries removal
  • Comparison – Conventional method
  • Outcome – Efficiency of caries removal.

Null hypothesis

There is no significant difference in removing caries by alternative methods when compared to conventional method in permanent teeth.

Alternate hypothesis

There is a significant difference in removing caries by alternative method when compared to conventional method in permanent teeth.

   Materials and Methods Top

Sources used

For identification of studies included or considered for this review, detailed search strategies were developed for the database searched. The Medline search used the combination of controlled vocabulary and free text terms [Table 1].
Table 1: Search methodology

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Searched databases

  • PubMed
  • PubMed advanced search
  • Cochrane database of systematic review
  • Science direct.


There were no language restrictions.

Hand search

The following journals were hand searched:

  • International Endodontic Journal
  • Journal of Endodontics
  • Journal of International Oral Health
  • Dental Research Journal
  • Journal of the American Dental Association
  • Journal of Dentistry
  • Operative Dentistry.

Inclusion criteria

Criteria for considering studies for this review

Types of studies

  1. Randomized controlled trials, clinical trials, retrospective clinical trials, or observational studies
  2. In vivo studies assessing the efficiency of caries removal in permanent teeth.

Types of participants

  • Studies having patients with permanent teeth
  • Teeth with caries.

Types of interventions

Studies in which caries removal is done by alternative methods other than conventional method.

Types of interventions

Studies in which caries removal is done by conventional method.

Types of outcome measure

Efficiency of caries removal.

Exclusion criteria

The following studies were excluded:

  • Case reports or series
  • Animal studies
  • In vitro studies
  • Studies not meeting inclusion criteria.

   Results Top

Description of studies

The search identified 338 publications, out of which 330 publications were excluded after removing the duplicates, reviewing the title or abstract, and for the reason of being retracted by the journal. Three articles were obtained after hand searching specified journals. A total of 11 publications fulfilled all criteria for inclusion [Flow Chart 1].

   Discussion Top

The purpose of this review was to determine the efficacy of alternative methods of caries removal in permanent teeth. Elevenin vivo studies fulfilled the criteria for being included in this review (A. H. Ali et al., 2018; AR Yazici et al., 2010; Prabhakar et al., 2009; Hosein and Hasan, 2008; Henrik Dommisch et al., 2008; S. Rafique et al., 2003; Hadley et al., 2000; S. Fure et al., 2000; Keller et al., 1998; J. H. Zinck et al., 1988; and K. J. Anusavice and J. E. Kincheloe, 1987) [Table 2]. The sample size distribution of included studies is presented in [Figure 1].
Table 2: General information - results

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Figure 1: Overall sample size distribution

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Interpretation of the results

Of these 11 studies, all were clinical trials (A. H. Ali et al., 2018; AR Yazici et al., 2010; Prabhakar et al., 2009; Hosein and Hasan, 2008; Henrik Dommisch et al., 2008; S. Rafique et al., 2003; Hadley et al., 2000; S. Fure et al., 2000; Keller et al., 1998; J. H. Zinck et al., 1988; and K. J. Anusavice and J. E. Kincheloe, 1987), and they evaluated the alternative method of caries removal in permanent teeth.

According to A. H. Ali et al., at the end of month 12, periapical radiograph showed 92% (rotary burs) and 98.6% (Carisolv) showed as healthy, and bacterial tissue reduction after excavation of caries is about 96.5% in total.

According to AR Yazici et al., both diamond bur and erbium, chromium-doped yttrium, scandium, gallium, and garnet (Er: Cr: YSGG) laser performed equally in all the parameters such as marginal discoloration and marginal adaptation.

According to Prabhakar et al., polymer group showed complete caries removal in 76% of the cases analyzed and partial removal in 24%. Among these 30% of the patients reported no discomfort and 70% of them showed mild discomfort. Whereas, carbon steel round bur group showed complete caries removal in 46.6% of cases and partial removal in 53.4%. Among these 47.5% of the patients reported no discomfort and 52.5% of them showed mild discomfort.

According to Hosein and Hasan, the mean time for caries removal with Carisolv was 12.19 min in 27 cases. The mean time for caries removal was 7.4 min with steel bur group.

According to Henrik Dommisch et al., colony-forming unit (CFU) for lactobacilli after laser treatment was 0.00–2.11 and after bur treatment was 0.00–1.68. CFU for Streptococcus mutans was around 0.00-0.70 after laser treatment and ranged from 0.00-1.52, when the rotary bur was used for preparation.

According to S. Rafique et al., 86% of participants showed some level of anxiety, 59% are moderately anxious during Local Anesthesia (LA) or drill. Time taken for cavity preparation with tungsten carbide bur was 6.3 min and 5.4 min for air-abrasion and Carisolv groups, respectivel y.

According to Hadley et al., both conventional bur and Er: Cr: YSGG laser groups remained vital at the evaluation at the 6th month of restoration. There was no discomfort in 87.9% in conventional bur group and 98.5% in Er, Cr: YSGG laser group during day 1 of procedure.

According to S. Fure et al., at 1 year follow up, among the 29 intact restorations reported in Carisolv group, two were lost during follow up. Conventional reported 21 intact restorations, among them 2 teeth were lost due to extraction and one teeth showed secondary caries on follow up visits. Thirty-one teeth in Carisolv group were sensitive and 24 were found to be sensitive in the conventional drill group. Anesthesia was not preferred by patients in the Carisolv group, and 12 out of 20 preferred anesthesia in the conventional group.

According to Keller et al., the mean preparation time by laser was 7.3 min. The mean preparation time by mechanical means was 3 min.

According to J. H. Zinck et al., 21% of patients requested for LA during Caridex treatment and 37% during conventional treatment.

According to K. J. Anusavice and J. E. Kincheloe, 85.3% of patients responded that they did not require LA for CRS procedure in the future. 29.4% would allow the conventional treatment without anesthetic.

   Conclusion Top

With the available evidences, this review concludes that alternative methods for caries removal are not as effective as other commercially available conventional burs.

However, a good number of clinical trials are needed to establish their potency as an effective caries removal agent.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

   References Top

Fusayama T, Kurosaki N. Structure and removal of carious dentin. Int Dent J 1972;22:401-11.  Back to cited text no. 1
Beeley JA, Yip HK, Stevenson AG. Chemochemical caries removal: A review of the techniques and latest developments. Br Dent J 2000;188:427-30.  Back to cited text no. 2
Pai VS, Nadig RR, Jagadeesh T, Usha G, Karthik J, Sridhara K. Chemical analysis of dentin surfaces after Carisolv treatment. J Conserv Dent 2009;12:118-22.  Back to cited text no. 3
[PUBMED]  [Full text]  
Banerjee A, Kidd EA, Watson TF. Scanning electron microscopic observations of human dentine after mechanical caries excavation. J Dent 2000;28:179-86.  Back to cited text no. 4
Goldstein RE, Parkins FM. Air-abrasive technology: Its new role in restorative dentistry. J Am Dent Assoc 1994;125:551-7.  Back to cited text no. 5
Frencken JE, Pilot T, Songpaisan Y, Phantumvanit P. Atraumatic restorative treatment (ART): Rationale, technique, and development. J Public Health Dent 1996;56:135-40.  Back to cited text no. 6
Keller U, Hibst R, Geurtsen W, Schilke R, Heidemann D, Klaiber B, et al. Erbium: YAG laser application in caries therapy. Evaluation of patient perception and acceptance. J Dent 1998;26:649-56.  Back to cited text no. 7
Goldman M, Kronman JH. A preliminary report on a chemomechanical means of removing caries. J Am Dent Assoc 1939 1976;93:1149-53.  Back to cited text no. 9
Zhang X, Tu R, Yin W, Zhou X, Li X, Hu D. Micro-computerized tomography assessment of fluorescence aided caries excavation (FACE) technology: Comparison with three other caries removal techniques. Aust Dent J 2013;58:461-7.  Back to cited text no. 10
Elkholany NR, Abdelaziz KM, Zaghloul NM, Aboulenine N. Chemo-mechanical method: A valuable alternative for caries removal. Journal Of Minimum Intervention In Dentistry 2009;2:248-60.  Back to cited text no. 11
Celiberti P, Francescut P, Lussi A. Performance of four dentine excavation methods in deciduous teeth. Caries Res 2006;40:117-23.  Back to cited text no. 12
Corrêa FN, Rocha RO, Filho LE, Muench A, Rodrigues CR. Chemical versus conventional caries removal techniques in primary teeth: A microhardness study. J Clin Pediatr Dent 2007;31:187-92.  Back to cited text no. 13
Meller C, Welk A, Zeligowski T, Splieth C. Comparison of dentin caries excavation with polymer and conventional tungsten carbide burs. Quintessence Int Berl Ger 1985 2007;38:565-9.  Back to cited text no. 14
Ericson D, Zimmerman M, Raber H, Götrick B, Bornstein R, Thorell J. Clinical evaluation of efficacy and safety of a new method for chemo-mechanical removal of caries. A multi-centre study. Caries Res 1999;33:171-7.  Back to cited text no. 15
Fure S, Lingström P. Evaluation of the chemomechanical removal of dentine cariesin vivo with a new modified Carisolv gel. Clin Oral Investig 2004;8:139-44.  Back to cited text no. 16
Lopes MC, Mascarini RC, da Silva BM, Flório FM, Basting RT. Effect of a papain-based gel for chemomechanical caries removal on dentin shear bond strength. J Dent Child (Chic) 2007;74:93-7.  Back to cited text no. 17
Piva E, Ogliari FA, Moraes RR, Corá F, Henn S, Correr-Sobrinho L. Papain-based gel for biochemical caries removal: Influence on microtensile bond strength to dentin. Braz Oral Res 2008;22:364-70.  Back to cited text no. 18
Bussadori SK, Castro LC, Galvão AC. Papain gel: A new chemo-mechanical caries removal agent. J Clin Pediatr Dent 2005;30:115-9.  Back to cited text no. 19
Papacarie: A Chemomechanical Caries Removal Agent. Available from: d9cbabe66943828b c79af9397f6. [Last accessed on 2018 Jan 13].  Back to cited text no. 20

Correspondence Address:
Prof. Sindhu Ramesh
Department of Conservative Dentistry and Endodontics, Saveetha Institute of Medical and Technical Science, Saveetha Dental College, Saveetha University, 162, Poonamallee High Road, Chennai - 600 077, Tamil Nadu, India
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JCD.JCD_263_19

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