Carisolv® gel

Clinical Manual
®
Carisolv
Minimally-invasive, patient-friendly
removal of caries
1
Content
Minimally-invasive and patient-friendly removal of caries
3
Carisolv®
3
Dentine caries
4
Treatment of caries lesion
5
Drills
5
Lasers
5
Air abrasion
5
Atraumatic restorative treatment
5
Chemo-mechanical caries removal
5
Description of Carisolv®
6
®
Instructions for use – Carisolv gel
8
Carisolv® instruments for caries excavation
9
Cases – step-by-step treatment
10
Treating children
12
Caries at crown margins
12
Your first cases
13
Evaluating a caries-free surface
13
®
Caries removal with a drill and with Carisolv – a comparison
14
Scientific publications relating to Carisolv®
15
Questions & Answers
16
Summary of chemo-mechanical characteristics
17
Tissue preservation in caries treatment – a textbook
18
List of references
18
2
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.
3
Dentine caries
ner 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.
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 in-
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 3
Zone 2
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.
4
Treatment of carious lesions
Atraumatic restorative
treatment
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 (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
Sound
enamel
–
Sound
dentine
–
Carious
enamel
+
Carious
dentine
++
Notes
+++
+++
+++
+++
Air abrasion
+++
+++
++
+
Depends on abrasive agent used
Air turbine and slow-speed handpiece
Air polishing
+
+
+
–
Requires hard surface substance for abrasion
Ultrasonics
+
+
+
–
Retrograde root filling cavity preparation
Sono-abrasion
–
+
+
++
Carisolv®
–
–
–
+++
Lasers
+
+
+
+
Depends on wave length, intensity, pulse duration etc.
Enzymes
–
–
–
+
Further work required
Further work required
Still requires conventional access to dentine
Extracted from Banerjee et al, British Dental Journal 2000;188(9):476-4828.
5
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 Göteborg, 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.
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.
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® 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.
7
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 manufacturer’s 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.
8
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
Flat 0
Multistar
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™.
9
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.
Step-by-step treatment of root caries
lesions using Carisolv®
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.
Apply gel with the tip
called star 3.
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.
Wait 30 seconds.
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.
Remove the softened carious
dentine with flat 3 instrument.
Use rapid movements – not
force!
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 manufacturer’s recommenda
tions.
Add more gel (no need
to wait 30 seconds).
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.
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.
10
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.
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.
• 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.
11
JC Ramos, Coimbra, Portugal
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.
Sverker Toreskog
Caries in a deciduous tooth – the treatment
step by step
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”.
12
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 15–20 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
Note that, when Carisolv® has been used, the remaining surface is rougher than a drilled cavity since the
healthy tissue remains intact.
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.
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.
13
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.
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.
In scanning electron micrographs, the surface topography is assumed to follow the pattern of caries in
the lesion and resembles an alpine landscape. There
Drill
Carisolv®
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.
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.
14
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
Abstracts”at www.mediteam.com. A complete listing of all presented research can be found on
MediTeam’s website under “List of References”.
Clinical studies confirm caries free
Surface topography
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.
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
No negative effects on soft tissue (mucosa)
Several in-vitro/pre-clinical studies have shown that
Carisolv® removes dentine caries effectively.
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.
1-year results
Fure, Nevrin, Zimmerman
Clinical studies confirm caries-free
Berakdar, Burke, Chaussain, Ericson, Fure,
Haffner, Kavvadia, Kobaslija, Masouras,
Munshi, Nadanovsky, Songpaisan
No effect on healthy enamel or
dentine
Galler, Wennerberg
Selective softening confirmed in vitro
Galler, Igarashi, Tonami
Rough surface topography
Wennerberg
Caries-free confirmed in vitro
Banerjee, Braun, Dammaschke,
Ericson, Haffner, Hahn, Markovic,
Moran, Splieth
Good dentine bonding
Frankenberger, Erhardt, Haak,
Harada, Pawlowska, Russo,
Suda
No adverse pulp effects
Dammaschke, Lumbau, Young
No negative effects on soft
tissue (mucosa)
Arvidsson, Wennerberg
Effect on bacteria
Baysan, Kneist, Lager
15
Effect on bacteria
Carisolv® gel uncoloured
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.
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
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.
Is Carisolv® a minimally-invasive method?
8
®
Yes, according to Banerjee et al., Carisolv is a selective method that only removes carious dentine.
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.
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 manufacturer’s instructions regarding the etching and bonding procedure.
Can I combine air abrasion, drills or lasers
with Carisolv®?
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 go-
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®.
16
Are there any disadvantages to Carisolv®?
Should I apply rubber dam before using
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.
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.
Can I use Carisolv® in connection with
prosthetic work?
What are the greatest advantages with
Carisolv®?
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.
The components of Carisolv® gel only affect carious
dentine, so that it can be easily and completely removed, leaving the sound tissue intact.
How long will it take to remove caries with
Carisolv®?
Carisolv® reduces and in some cases eliminates the
need for local anaesthesia.
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).
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.
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.
17
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.
Mjör IA. The morphology of dentin and dentinogenesis. In Linde A (ed): Dentin and
dentinogenesis. Boca Raton. CRC Press Inc, 1984;4:351-353.
2.
Kato S, Fusayama T. Recalfication of artificially decalcified dentine in vivo.
J Dent res 1970;49:1060-1067.
3.
Miyauchi H, Iwaku M, Fusayama T.Physiological recalcification of carious dentin.
Bull Tokyo Med Dent Univ 1978;25:169-179.
4.
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.
5.
Shimizu C, Yamashita T, Ichijo T, Fusayama T. Carious change of dentine observed on
longspan ultrathin sections. J Dent Res 1981;60:1826-1831.
6.
Kuboki Y, Ohgushi K, Fusayama T. Collagen biochemistry of the two layers of carious
dentin. J Dent Res 1977;56:1233-1237.
7.
Atraumatic restorative treatment approach to control dental caries manual, WHO
collaborating centre for oral health services research. Groningen 1997.
8.
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.
9.
Strid L, Hedward C. 1989. Patent SE870483.
10.
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.
11.
Yip HK, Stevenson AG, Beeley JA. The specificity of caries detector dyes in cavity
preparation. Br Dent J 1994;176(11):417-421.
12.
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.
13.
Banerjee A, Kidd EAM, Watson TF. Scanning electron microscopic observations of
human dentine after mechanical caries excavation. J Dent 2000; 28(3):179-186.
14.
Burke FM, Lynch E. Glasspolyalkenote bond strength to dentine after chemo-mechanical
caries removal. J Dent 1994;22:283-291.
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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
19
MediTeam Dental AB (publ), Göteborgsvägen 74, SE-433 63 Sävedalen, Sweden.
Phone +46 31 336 91 00. Fax +46 31 336 82 10
www.mediteam.com
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