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CASE REPORT Table of Contents   
Year : 2009  |  Volume : 20  |  Issue : 1  |  Page : 117-120
Aesthetic restoration of deciduous anterior teeth after removal of carious tissue with Papacárie®


Department of Rehabilitation Sciences Post Graduation Program, Nove de Julho University (UNINOVE), SP, Brazil

Click here for correspondence address and email

Date of Submission14-May-2007
Date of Decision04-Dec-2007
Date of Acceptance11-Dec-2007
 

   Abstract 

The development of conservative techniques for the removal of carious tissue and the improvement of dental restoration materials allow better preservation of the dental structure. Chemomechanical caries removal is a conservative and atraumatic alternative. Papacárie® is a papain-based material developed to act only on the carious dentin, allowing its easy removal with a blunt curette. This study aims to present a clinical case of aesthetic restoration of both upper deciduous central incisors after the removal of carious tissue with Papacárie® .

Keywords: Caries removal, deciduous teeth, dental caries, dentin

How to cite this article:
Motta LJ, Martins MD, Porta KP, Bussadori SK. Aesthetic restoration of deciduous anterior teeth after removal of carious tissue with Papacárie®. Indian J Dent Res 2009;20:117-20

How to cite this URL:
Motta LJ, Martins MD, Porta KP, Bussadori SK. Aesthetic restoration of deciduous anterior teeth after removal of carious tissue with Papacárie®. Indian J Dent Res [serial online] 2009 [cited 2020 Oct 26];20:117-20. Available from: https://www.ijdr.in/text.asp?2009/20/1/117/49060
Dental caries is an infectious disease caused by disequilibrium in the process of demineralization and remineralization of hard dental tissues. This disequilibrium is induced by proliferation of cariogenic bacteria and consequent increase in acid production, causing the saliva pH to drop to a critical level. Dental caries is characterized by penetration of microorganisms into the dentin due to cavitation of the enamel. [1],[2]

Carious dentin can be divided into two distinct layers, the outer carious dentin and the inner carious dentin, which need to be treated differently. [3]

The outer layer, known as infected dentin, is irreversibly denatured, infected, demineralized, and dead. The inner or affected dentin is alive, sensitive, either uninfected or with low-level infection, and reversibly denatured and demineralized. In clinical procedures, the first layer must be removed and the last preserved. [2],[3],[4]

Nowadays, restorative dentistry focuses on teeth preservation and minimally invasive techniques, suggesting alternative methods for the removal of carious tissue. [5] Due to the disadvantages of using the conventional rotary techniques such as heating, pressure, vibration, and pain, restorative dentistry has observed an increased interest in the development of alternative methods for the removal of carious tissue. [1],[5]

The history of chemomechanical caries removal began in 1975, when Habib et al.[6] began to test methods for the removal of carious dentin using sodium hypochlorite. In order to overcome problems of chemical instability of sodium hypochlorite and also its adverse effects on healthy tissue, a solution was formulated where sodium hypochlorite was mixed with sodium chloride and N-chloroglycine (GK-101). As a result of studies conducted to improve the efficacy of this solution, Caridex™ was introduced to the market in 1985. It is an amino-acid-based system that is carried out at a high-alkaline pH; but the product has limitations in clinical practice such as large volume of solution required, short expiry date, the need of a bulky equipment, and preheating. [7]

Carisolv™ system was launched in the market in 1998. This system is constituted by three amino acids (glutamic acid, leucine, and lysine) and sodium hypochlorite. The action mechanism for the removal of carious tissue is based on the proteolytic action of sodium hypochlorite, which dissolves the infected dentin, and on the action of amino acids, which enhances the effect of sodium hypochlorite on denatured collagen and minimizes damage to healthy tissue, enabling the removal of infected dentin and preservation of affected dentin. [7]

In 2003, a new product for chemomechanical removal of caries was launched. The product, called Papacárie® , is constituted by papain, chloramine, and toluidine blue. Papain interacts with collagen exposed by dissolution of dentin minerals by bacterial action, softening the infected dentin, enabling its removal by blunt hand instruments, and eliminating the need for anesthesia and rotary instruments. [8]

Papain is an enzyme similar to human pepsin and acts as an anti-inflammatory and debriding agent. It does not damage healthy tissue, but accelerates the cicatricial process and has bacteriostatic and bactericidal action. Papain acts only on carious tissue, which lacks the plasmatic protease inhibitor alpha-1-antitrypsin, but its proteolytic action is inhibited on healthy tissue, which contains this substance. [9]

Papacárie® is a biocompatible gel with antibacterial properties that eliminates the need for anesthesia, removes only the compromised tissue, and preserves the healthy tissue better. The formation of a smear layer is not observed after using the gel. [10],[12]

The gel combines an atraumatic treatment with antibacterial properties without affecting healthy tissue and causing pain. [12],[13]

Presently, the demand for aesthetics neither depends on age and gender nor is limited to any age group, since aesthetic restoration is not considered a matter of vanity but the means to restore the natural appearance of the teeth.

With the development of new composite resins, it is possible to replace the lost tissue with a material having optical, physical, and mechanical properties very similar to the natural teeth.

This paper aims to present a clinical case of aesthetic restoration after conservative removal of carious tissue with Papacárie® .


   Case Report Top


A female patient aged four years was brought to the Children's Clinic, Nove de Julho University College of Dentistry, with caries lesions on the vestibular face of both upper deciduous central incisors. After the informed consent form was signed by the parent or legal guardian, the procedures for the removal of carious tissue using Papacárie® and restoration with composite resin Filtek™ Supreme XT (3M ESPE) were carried out.

The removal of carious dentin followed the protocol for the use of Papacárie® gel as described below:

  1. Radiographic assessment;
  2. General field isolation of the operative site with a rubber dam, since the patient did not receive local anesthesia [Figure 1];
  3. Dental prophylaxis with pumice and water;
  4. Papacárie® gel application to the carious tissue located on the vestibular face of the 51 and 61 teeth for 40 sec [Figure 2];
  5. Removal of infected dentin by scraping with blunt hand excavators (Levy System). and
  6. Reapplication of the gel and scraping of infected tissue until no signs of softened tissue remain or dentin shavings come out.


After complete removal of the infected tissue and a glossy dentin surface was obtained [Figure 3], the cavity was cleaned with 1% chlorhexidine digluconate and subsequent restorative procedures were performed.

The composite resin Filtek™ Supreme XT (3M ESPE) was the restorative material of choice. The steps taken were as follows:

  1. Acid conditioning for 15 seconds;
  2. Application of adhesive (Adper™ Single Bond 2-3M ESPE) and light curing for 20 sec;
  3. Insertion of the first increment of restorative material in shade A1B (Filtek™ Supreme XT) into the cavity;
  4. Application of the last increment in white enamel (WE) shade (Filtek™ Supreme XT); and
  5. Finishing and polishing with Sof-Lex system (3M ESPE) [Figure 4].



   Discussion Top


To date, the restorative principles include the promotion of oral health, preservation of sound tooth structure, maintenance of pulp vitality, fracture and wear resistance, and aesthetics.

Changes in the restorative principles are based on three factors: the promotion of oral health, preservation of sound tooth structure, and use of adhesive materials. The main factor in determining a real solution for the dental caries is the inclusion of this aspect of personal health in a global health promotion effort. In this way, the dental treatment may be defined as a link between restorative and noninvasive procedures with a common purpose in promoting health. The advances made in the field of adhesive dentistry were possible due to the development of restorative techniques and materials that mark the beginning of significant changes in the adhesive restorative techniques.

The inconveniences caused by the use of high- and low-speed dental drills such as noise, overheating, possible deleterious effect on pulpal tissue, and patient's high level of anxiety and distress have stimulated the development of alternative and conservative methods for caries removal. [1],[5]

The chemomechanical method for caries removal stands out among other alternative methods. The objective of chemomechanical caries removal is to eliminate the outer layer or infected dentin, leaving the affected layer or partly demineralized dentin, which can be remineralized and repaired. [3]

This paper presents a clinical case of aesthetic rehabilitation of deciduous anterior teeth after removal of carious tissue with Papacárie® .

In accordance to Fusayama, [3] the restorative treatment was carried out without local anesthesia in order to maximize the preservation of healthy tooth structure. The patient did not report pain or discomfort during removal of carious tissue.

Papacárie® is a papain-based gel product for selective removal of carious dentin. Papain acts only on the infected dentin that lacks alpha-1-antitrypsin, a substance that inhibits its proteolytic action on healthy tissue. [8] The infected dentin is irreversibly denatured, infected, demineralized and dead, [2],[4],[5],[6],[7] and therefore, susceptible to the proteolytic action of papain. Papacárie® softens the infected dentin allowing its easy removal.

Using scanning electron microscopy, the presence of a residual smear layer was detected on the dentinal surfaces of permanent teeth treated with conventional techniques. In comparison, when permanent teeth were treated by techniques using Papacárie® or Carisolv™, the smear layer was not present and the dentinal structures were preserved better. [12]

Mechanical preparation using rotary or hand instruments results in a smear layer covering the preparation surface. This layer has low bond strength and may reduce the strength of the bond between the restorative material and dentin. In the chemomechanical method, after the removal of carious tissue, the smear layer was not observed and many dentinal tubules remained open. [12] These results justify the combination of caries removal with Papacαrie® and aesthetic restoration using composite resin.

Bacteria are the most common cause of dental caries, and for this reason, it is important to eliminate the largest possible numbers of bacteria during the removal of carious tissue. Papacαrie® exerts an inhibitory action on cariogenic bacteria. [8],[9],[10],[11],[12],[13]

Inglenhart et al.[14] investigated an operator´s and children´s responses to chemomechanical caries removal using Carisolv™ versus the traditional method of caries removal using a handpiece and round bur. The operator perceived that using Carisolv™ required more clinical and technical effort and the time needed for the treatment as significantly longer than traditional method. The study was evaluated by only one operator, a limitation to conclude. [14]

The time needed for the treatment using Papacαrie® was about 6 min. In accordance with the study conducted by Pandit et al. [15] who evaluated various methods of caries removal, the time needed for caries removal using traditional method was about 4-5 min and using Carisolv™ was about 8 min. The authors conclude that all the methods removed caries effectively, the time taken to remove caries by Carisolv™ method was observed to be maximum, followed by hand-instrument method, and least by traditional method. The pain experienced by the patients during caries removal was found to be maximum with traditional method, followed by hand excavation and the least by Carisolv™ method.

Papacárie® combines atraumatic, conservative, and selective properties for the removal of carious dentin, has antibacterial properties that reduce the number of cariogenic bacteria, and does not cause dentinal mud on the surface of a prepared cavity, thus facilitating the bonding of the restorative material. The gel reduces the risk of pulp exposure and does not damage healthy tissue, making it an excellent option for caries removal. [8]


   Conclusion Top


The use of Papacárie® for the removal of carious tissue represents an alternative for dental cavity preparation. It promotes better preservation of healthy tissue and reduces the disadvantages of conventional methods using dental drills and excavators that induce discomfort and pain. This technique combined with restorative composite resins Filtek™ Supreme XT (3M ESPE) is an appropriate procedure for aesthetic solutions in pediatric dentistry.

 
   References Top

1.Beeley JA, Yip HK, Stevenson AG. Chemomechanical caries removal: A review of the techniques and latest developments. Br Dent J 2000;188:427-30.  Back to cited text no. 1  [PUBMED]  
2.Massler M. Pulpal reactions to dental caries. Int Dent J 1967;17:441-60.  Back to cited text no. 2  [PUBMED]  
3.Fusayama T. Two layers of carious dentin: Diagnosis and treatment. Oper Dent 1979;4:63-70.  Back to cited text no. 3    
4.Kidd EA, Joyston-Bechal S, Beighton D. Microbiological validation of assessments of caries activity during cavity preparation. Caries Res 1993;27:402-8.  Back to cited text no. 4  [PUBMED]  
5.Horowitz AM. Introduction to the symposium on minimal intervention techniques for caries. J Public Health Dent 1996;56:133-4.  Back to cited text no. 5  [PUBMED]  
6.Ericson D, Zimmernan M, Raber H, Gotrick 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. 6    
7.Bussadori SK, Guedes CC, Martins MD, Fernandes KP, Santos EM. Gel a base de papaνna: Uma nueva alternativa para la remoción quνmica y mecβnica de lγs caries. Actas Oodntológicas 2006;3:35-9.  Back to cited text no. 7    
8.Reda SH, Motta LJ, Guedes CC, Canηado MF, Bussadori SK. El uso de um gel a base de papaνna em odontopediatria: Um caso clinico. Boletin de la Asociacion Argentina de Odontologia para niρos 2005;34:19-22.  Back to cited text no. 8    
9.Bussadori SK, Guedes CC, Fernandes KP, Martins MD, Massuda MS. Utilizaηγo do gel à base de papaνna para remoηγo quνmica e mecβnica do tecido cariado. Rev Assoc Paul Cir Dent 2006;60:450-3.  Back to cited text no. 9    
10.Bussadori SK. Remoηγo quνmica e mecβnica da cαrie. Clin Inter J Braz Dent 2006;2:82-4.  Back to cited text no. 10    
11.Bussadori SK, Castro LC, Galvγo AC. Papain gel: A new chemo-mechanical caries removal agent. J Clin Pediatr Dent 2005;30:115-9.  Back to cited text no. 11    
12.Bussadori SK, Santos EM, Abrahγo IJ, Ozaki J, Masuda MS. Avaliaηγo da biocompatibilidade in vitro em subcutβneos de ratos, potencial microbiológico e MEV do gel de papaνna [resumo]. Braz Oral Res 2004;18:178.  Back to cited text no. 12    
13.Pereira AS, Silva LR, Piccinini DP, Santos EM, Bussadori, SK. Comparaηγo in vitro do potencial antimicrobiano de dois materiais para remoηγo quνmico-mecβnica da cαrie [resumo]. Braz Oral Res 2004;18:78.  Back to cited text no. 13    
14.Inglehart MR, Peters MC, Flamenbaum MH, Eboda MN, Feigal RJ. Chemomechanical caries removal in children: An operator's and pediatric patients' responses. J Am Dent Assoc 2007;138:47-55.  Back to cited text no. 14    
15.Pandit IK, Srivastava N, Gugnani N, Gupta M, Verma L. Various methods of caries removal in children: A comparative clinical study. J Indian Soc Pedod Prev Dent 2007;25:93-6.  Back to cited text no. 15  [PUBMED]  Medknow Journal

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Correspondence Address:
Lara J Motta
Department of Rehabilitation Sciences Post Graduation Program, Nove de Julho University (UNINOVE), SP
Brazil
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0970-9290.49060

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