Non - conventional caries removal methods

1. NEWER METHODS OF
CARIES REMOVAL

2. • Introduction
• Classification of techniques
• Other techniques
• Endostepper
• Smart prep burs
• Hand excavation
• Air abrasion
• Air polishing
• Ultrasonic instrumentation
• Sono abrasion
• Chemomechanical caries
removal
• LASERS
• Conclusion
CONTENTS

3. INTRODUCTION

4. CONVENTIONAL CARIES REMOVAL
• Treatment of the INFECTED DENTINE
• Defined well by the OUTCOME CRITERIA
• Lead to the Local arrestment of carious process.
• G.V.Black’s EXTENSION FOR PREVENTION 1893
• Done with handpiece and burs.

5. • Perception by patients that drilling is unpleasant
• Local anesthesia is frequently required
Drilling causes
• Deleterious thermal effect
• Combined with use of pressure for caries removal -
Causing pulpal effects
Use of hand piece
Results excessive loss of sound tooth tissue
DISADVANTAGE OF CONVENTIONAL CAVITY PREPARATION

6. The ideal cutting instrument should fulfil certain factors to satisfy both operator and patient. These factors might include:
• Comfort and ease of use in the clinical environment
• The ability to discriminate and remove diseased tissue
only
• Being painless, silent, requiring only minimal pressure
for optimal use
• Not generating vibration or heat during periods of
operation, and
• Being affordable and easy to maintain.

7. NEED FOR NEWER TECHNIQUES OF CARIES REMOVAL

8. NON CONVENTIONAL METHODS OF
CARIES REMOVAL

9. CLASSIFICATION OF OTHER CARIES REMOVAL TECHNIQUES
MECHANICAL
Non Rotary
• Air abrasion
• Air polishing
• Sono abrasion
• Ultrasonics
CHEMOMECHANICAL
• Caridex
• Carisolv
• Enzymes
• OZONE
THERAPY
• LASERS
CONTROLLED SELECTIVE ROTARY EXCAVATION
a) Endostepper -Torque controlled motors
b) Modification in Burs
- SMART prep burs
( POLYMER BURS)
c) Fluorescence aided caries excavation
BANERJEE, WATSON, KIDD 2011

10. 1. CONTROLLED SELECTIVE ROTARY
EXCAVATION

11. a) ENDOSTEPPER

12. ENDOSTEPPER
Microcontroller controlled dental handpiece
based on stepper motor
System consists of:
• Console type housing containing
electronics with LCD display and
keypad
• Foot pedal unit
• Drive unit
• Protective cover
• Contraangle

13. Principle of operationPower on
Menu text on LCD display
Select dental instrument (eg: drill)
By means of keypad
Drive unit locked
Motor started by means of foot pedal
• Stepper motor
• Develop rotational torque directly depend
on motor current
• Motor current controlled in electronics
• Deliver torque value upto defined limit value
• Friction of instrument in root canal – limit
exceeded
• Motor stops immediately
• Instrument protected
ENDOSTEPPER

14. b) SMART PREP BURS

15. b) SMART PREP BURS

16. 3 sizes - #2, #4, #6
Smaller than carbide round bur
Low speed = 500-800 rpm
Without water spray
Very light air brush type stroke

17. b) SMART PREP BURS

18. b) SMART PREP BURS

19. • In FACE, the disparity of the
reflecting nature of carious and
healthy tooth substance is used to
visualize the edge between them
and to enable a better excavation.
c) FLUORESCENCE AIDED CARIES EXCAVATION
(FACE)

20. c) FLUORESCENCE AIDED CARIES EXCAVATION
• Reliable method
• Oral microorganisms produce orange-
red fluorophores as byproducts of their
metabolism
• Good marker for the zone of bacterial
invasion in dentine
• Carious dental tissue fluorescence
more intensely in red portion of visible
spectrum (>540 nm) than sound
dentine

21. c) FLUORESCENCE AIDED CARIES EXCAVATION
35 watt xenon discharge lamp generate
violet light (370 – 420nm)
Using blue band pass filter with peak
transmission of 370nm
Fed into fibre-optic slow speed hand piece
Focused onto operating field during
excavation
Operator observe cavity through 530nm
high pass filter
Area exhibit orange-red fluorescence
indicate caries – removed by bur
Lennon et al 2002

22. 2. MECHANICAL NON – ROTARY
METHODS

23. a) AIR-ABRASION
• RB Black in 1945
• 1951 S.S.White - Airdent
• Bombarding tooth surface with high-
velocity particles carried in a stream of air
• Painless method of cavity preparation
• No Vibration
• No bone conducted noise
Al2 O3 particle size:
-27µm : more comfortable ,less effective cutting
- 50 µm : less comfort. more Abrasive cutting

24. AIR-ABRASION- Other particles used

25. Abrasive escapes from nozzle in cone shaped stream
Diverge from long axis at an angle of 3½ degrees
Travel at speed in excess of 1000 feet per second
Propellant pressure of 80 pounds per square inch
Nozzle of 0.018 inch inside diameter
Nozzle tip distance of 7 to 13 mm with an angle of 90ᵒ
30mg of enamel in 30 seconds
AIR-ABRASION

26. AIR-ABRASION

27. LIMITATIONS
 The nozzle of the air abrasive instrument
does not come into actual contact with
the tooth, providing no tactile guidance
 In case of secondary caries, it is difficult
to remove existing restoration
 High cost
 Abrasive particles strikes surface of
mirror become frosted
 Might damage cavosurface sound tooth
enamel
AIR-ABRASION

28. AIR-ABRASION

29. b) AIR-POLISHING
Sodium bicarbonate & tricalcium phosphate
Water soluble
Continuous mechanical abrasive action
Removal of carious dentin at the end of cavity
preparation
AIR POLISHING UNITS
Air Flow (Electo Medical Systems, London) ,CaviJet (DENTSPLY, York, Penn) , Air Max (Satellec,
Merignac, France) ,Prophyflex II (KaVo, Biberach, Germany)

30. • Air Flow and Cavi–Jet units produced increased
powder emissions with all increases in power
settings.
The Air Max unit produced comparable powder
emissions at low and medium settings but 5 to 12
times greater powder emissions at the high setting.
• The Prophyflex II unit powder setting had no
significant effect on powder emission .
Efficacy of air polishing depends on the amount
of powder present in the powder chamber .
• Refill the powder chamber before
each treatment session
AIR-POLISHING

31. C) SONICS AND ULTRASONICS

32. • A sound is a wave produced by the
mechanical vibration of a carrier fluid or
solid, and propagated through the elasticity
of the surrounding medium.
• Depending on the frequency of the wave,
the sounds are classified into different
categories:
Infrasound = 1–20 Hz
Sound = 20–20,000 Hz
Ultrasound = 20–1,000 KHz
Megasound = 1–100 MHz
Hypersound = >100 MHz
Pierre and Marie Curie in 1880
Alternating current amplified by a
generator
Led through ceramic pellets
React by changing shape (elongation
and contraction) in handpiece
Alternation amplifies the vibration
Transmitted to the tip
Working capacity
C) SONICS AND ULTRASONICS

33. • Nielsen et al
• Magnetostrictive instrument
with a 25 kHz
• oscillating frequency
• Conjunction with a thick
aluminium oxide and water
slurry
• Created the cutting action
ULTRASONICS

34. Mechanism
Kinetic energy of water molecules
Transferred to the tooth surface Via abrasive
Through high speed oscillations of cutting tip
• Soft, carious dentine could not be removed
• Harder, leathery, deeper layer was more susceptible
• Harder the tissue, the easier it was to cut
ULTRASONICS

35. The Sonicsys micro unit, designed by Drs Hugo, Unterbrink and Mösele was based upon the
Sonicflex 2000L and 2000N air-scaler handpieces that oscillate in the sonic region (< 6.5 kHz)
SONO ABRASION
SONIC ABRASION - High-frequency, sonic, air-scalers with modified abrasive tips.
KaVo Sonicflex 2000L air-scaler handpiece with diamond-coated tip

36. Tips- Elliptical motion
Transverse distance of between 0.08 – 0.15 mm
and Longitudinal movement of between 0.055 –
0.135 mm
Diamond coated on one side using 40 μm grit
Cooled using water irrigant at a flow rate of
between 20–30 mL /min
Operational air pressure for cavity finishing should
be around 305 bar (ie the nominal pressure at the
coupling)
SONO ABRASION

37. The working action of sono-
abrasive tips is based on four
different effects:
Vibration
Abrasion
Thermal effect
Cavitation
SONO ABRASION
Three different instrument tips:
Lengthways halved torpedo shape
(9.5mm long, 1.3 mm wide)
Small hemisphere(1.5 mm diameter) and
Large hemisphere(2.2 mm)

38. • Torque applied to instrument tips of 2 N
• Pressure is too great, the cutting efficiency
is reduced due to damping of the
oscillations
• Using different shaped tips, to help
prepare predetermined cavity outlines
• Removing hard tissue when finishing
cavity preparation
• Remove softened, carious dentine
SONO ABRASION

39. CHEMOMECHANICAL CARIES
REMOVAL -CMCR

40. • Chemomechanical caries removal is a noninvasive
technique eliminating infected dentine via a
chemical agent
• It also preserves healthy dental structure, avoiding
pulp irritation and patient discomfort
• Method of caries removal based on dissolution
• Chemical agent assisted by an atraumatic
mechanical force to remove soft carious structure.
CHEMOMECHANICAL CARIES REMOVAL -CMCR

41. Dentin Collagen is an unusual protein
Contains proline and one third of the
amino acid content glycine
The polypeptide chains are coiled into
triple helices are known as tropocollagen
units
These tropocollagen units orientate side
by side to form a fibril
Covalent bonds between the polypeptide
chains and tropocollagen units form cross
links
Give collagen fibrils stability
Fibrils are in the form of a dense
meshwork which becomes mineralized
MECHANISM OF CMCR
CHLORINATION OF
PARTIALLY DEGRADED
COLLAGEN
Conversion of
Hydroxyproline to Pyrrole
2- carboxylic acid

42. Advantages
• Less perception of pain and more comfortable
for patient.
• Less fear and anxiety to method, leads to less
• discomfort to patients especially in children.
• Removes only infected layer and leads to more
tissue preservation.
• No pulpal irritation.
• Well suited to the treatment of
deciduous teeth, dental phobic’s and
medically compromised patients.
• Better removal of caries in
uncooperative patients.
• Useful in physically handicapped
patients.
• Useful in patients with T.B like
infectious diseases (prevent droplet
infection).
CHEMOMECHANICAL CARIES REMOVAL -CMCR

43. EVOLUTION OF CMCR
• 1970 Habib et al
• Effect of sodium hypochlorite
• Nonspecific proteolytic agent on removal of carious
dentine

44. • GK-101E received FDA approval for use in
the USA in 1984 and was marketed as
caridex
• It consisted of two solutions;
• Solution 1 containing sodium hypochlorite
• Solution 2 containing glycine,aminobutyric
acid, sodium chloride and sodium
hydroxide
• Mixed immediately before use to give the
working reagent pH 12 (Gulcin et al., 2004)
which was stable for 1 h
Delivery system
Reservoir for the solution, a heater and a
pump which passed the liquid
Warmed to body temperature through a
tube to a hand piece and an applicator tip
Applied to the carious lesion
Loosen carious dentine by a gentle
scraping action
Removed by aspiration
Application continued until remaining
carious dentin
After 15 to 20 min treatment, only clinically
sound dentine remained
CARIDEX- EVOLUTION OF CMCR

45. Limitations of caridex system
• Rotary and/or hand instruments still
needed for removal of tissue other than
degraded dentine collagen
• Large volumes of solution were needed
(200 to 500 ml) and the procedure was
slow and also costly
• Only certain cavities were suitable for
treatment by the technique and because
of the time involved (10 to 15 min) and
limited use, its popularity waned
• Studies on the long term success of
cavities restored after CMCR treatment
were lacking
Early 1990’s caridex ceased to be
marketed and manufacturer’s patent
lapsed
During this time
Mediteam in Sweden
Continued to work on a system and
Latest CMCR reagent known as carisolv
In January, 1998

46. Carisolv gel was a 2-component mixture
Single mix system
Three differently charged amino acids mixed
with sodium hypochlorite prior to treatment
Available as 5 transparent syringes containing
an uncoloured gel and 5 white syringes
containing transparent liquid
The uncoloured gel contains: amino acids
(glutamic acid, leucine, lysine), sodium
chloride, purified water and sodium
hydroxide, pH 11
The transparent liquid contains: sodium
hypochlorite solution 0.95%
Hold the syringes with their openings upwards
Remove the corks, keep the syringes upright and
screw them together
Mix the liquids by pressing alternately on the
ends of the syringes until the liquids are
homogeneous
Press all the liquid into one of the syringes
Pour the mixed liquid into a suitable container or
keep it in the transparent syringe and apply it to
the cavity using a cannula with a Luerlock
Drops of the gel removed from the container with
a Carisolv instrument and applied to the carious
dentine
Make sure that the carious lesion is thoroughly
soaked by the gel

50. Advantages of carisolv over caridex:
Gel – consistency
Better contact with carious lesion
Quantity required is very less
Enhances precision placement
3 amino acids incorporated instead of one
Different charges improved interaction with
degraded collagen within lesion
Increasing efficiency

52. • 1996 Norbo, Brown & Jan
• PRONASE, non specific proteolytic
enzyme
• Orginating from streptomyces griseus
• Helps to remove carious dentin
• 1989 – Goldberg & Keil
• BACTERIAL ACHROMOBACTER
COLLAGENASE
• Not affect sound layer of dentin beneath
lesion
ENZYMES IN CMCR

53. OZONE THERAPY

54. THERE ARE THREE DIFFERENT SYSTEMS FOR
GENERATING OZONE GAS:
• Ultraviolet system:
produces low concentrations of ozone. It is
used in esthetics and for air purification.
• Corona Discharge system:
Produces high concentrations of ozone. It is the
most common system used in the medical /
dental field. It is easy to handle and it has a
controlled ozone production rate.
• Cold plasma system:
used in air and water purification.
OZONE THERAPY

55. MODE OF OZONE
ADMINISTRATION
Three fundamental form of application of
ozone to oral tissue are:
• Ozonated water
• Ozonated olive oil
• Ozone gas
Ozonated water
Used in Root canal therapy
Hemostatic effect
Disinfectant & sterlization effect
Accelerated wound healing
Ozonated olive oil
• Pure plant extracts through which ozone are passed
• Final product contain ozides - harmless
• Used in treatment of dry socket, periapical sinus, lip
herpes, denture sore mouth, mouth & tongue ulcers
Ozone gas
• Ozone generating equipment converts oxygen to
ozone
• Used to treat dental caries and aphthous ulcer
OZONE THERAPY

56. OZONE THERAPY

57. • Application of ozone on pit and fissure
caries, noncavitated occlusal carious
lesions and primary root caries
• application of ozone gas for a period of
10 seconds was capable of killing bacteria
present in carious lession
• Painlessly and without anaesthesia
• In incipient caries, ozone kill bacteria in
demineralized part & then remineralized
using remineralizing kit containing
calcium, fluorine, phosphorus, sodium in
ionic forms
Advantages:
• Minimal intervention technique
• Friendly ecologic environment
• Oxidizing effect in infected tissue
Disadvantages:
OZONE THERAPY

58. LASER THERAPY

63. Development of the first ruby laser by Maiman
in 1960, applied to cutting both hard and soft
tissues in the mouth
Lasers that are currently being investigated for
more selective hard tissue ablation include:
Er:YAG (erbium: yttrium-aluminiumgarnet)
and Nd:YAG (neodymium: YAG) —mid-IR to IR
emission
Carbon dioxide lasers (CO2) — IR emission
Excimer lasers (ArF (argon:freon) and XeCl
(xenon:chlorine) — UV emission
Holmium lasers
Dye-enhanced laser ablation –— exogenous
dye, indocyanine green in conjunction with a
diode laser
In 1964, Dr. Leon Goldman used laser on his
brother Bernard teeth to cut hard tissues
CO₂ cause cracking with flaking of the enamel
surface
Nd:YAG laser at 10J/cm² inhibit incipient carious
lesions but it causes irreversible pulpal damage
Er:YAG at wavelength of 2.94µm, ability to cut
or ablate dental hard tissues effectively and
efficiently
Temperature less than 3ᵒC with water coolant
Pulpal response – minimal & reversible

64. UV emission of excimer lasers (377 nm)
More selective in the ablation of carious
dentine