Newer techniques in caries removal /certified fixed orthodontic courses by Indian dental academy

INDIAN DENTAL ACADEMY
Leader in Continuing Dental Education
www.indiandentalacademy.com

CONTENTS

1. Introduction

2. Chemomechanical Caries Removal

3. Ozone technology

4. Air Abrasion (Kinetic)

5. Lasers (Hydrokinetic)

6. Conclusion

INTRODUCTION

 Dental caries

 G.V.Black in 1893

 Recently newer techniques


CHEMOMECHANICAL CARIES REMOVAL

 CMCR involves

 When caries occurs

 Principle - Goldman & Kronman (1970)

----- Sorensen’s Buffer (Glycine, Nacl &
NaOH) N-Monochloroglycine (NMG)- GK-1019

----- Amino butyric acid – N-Monochloro
amino butyric acid (NMAB) – GK-101E.

CARIDEX

 NMAB system - Caridex (1980)
 2 - Solutions (pH – 11)

Solution I Solution II

1% NaOCl 0.1m amino butyric acid

0.1m NaCl

0.1m NaOH

 A delivery system, reservoir, heater and a pump
 Limitation - Slow procedure

- Large volumes of

solutions (200 – 500ml)

- Delivery system

commercially not

available

CARISOLV

 Latest CMCR 1998
 Pink gel, specially designed hand instruments,
volume required less than 1mm, neither heating nor a
delivery system


 Available as 2 syringes
Syringe I Syringe II
Glutamic Acid – 2.5g/l NaOCl – 0.95%
Leucine – 2.5g/l
Lysine – 2.5g/l
NaCl – 5.8g/l
NaOH – 17.5g/l
Carmellose – 25g/l
Erythrocin (Pink dye)

Application

 Contents of 2 syringes mixed


 Gel applied to the carious lesion


 Time required 9 -12 minute, volume of gel
required 0.2 – 1.0ml, system is much easier than
caridex.

Mechanism of Action
 3 - amino acids (glutamic acid -ve, lysine +ve,
Leucine – neutral)
 On mixing the carisolv solutions
 Chlorinated aminoacids with different side
chain properties and charges.
 High pH

Advantages
 Reduced need for L.A.
 Conservation of sound tooth structure
 Reduced risk of pulp exposure
 Well suited for anxious, medically
compromised and paediatric patients.

Limitations
 Time consuming
 Rotary and hand instrument still be needed

OZONE TECHNOLOGY

 Ozone (O3) – energized form of oxygen, part
of the natural gas, surrounds earth at high altitude,
blocks UV rays, produced by lightening.
 Extensively used in medical profession, for
therapeutic purposes produced in ozone generators.
 Powerful biocide, strong oxidizer.


OZONE THERAPY IN DENTISTRY

 Dr.Edward Lynch (1980)
 Various dental treatment offered by ozone
therapy.
- Treatment and prevention of caries,
RCT, Tooth whitening, Elimination of Sensitivity,
Gum disease, Dental implant material (Pre washing
of surgical sites prior to implant placement, control
of contamination in dental units water lines

OZONE THERAPY FOR DENTAL CARIES

Principle
 Development of caries lesion by “niche
environment theory”.
 Concept of ozone therapy for dental caries
 10sec application of ozone gas at a con of
2200ppm.
 The acidic carious niche environment takes
years to establish.

Description of Oxygen Delivery Unit &
Patient kit for Ozone Therapy

 Ozone unit – Heal ozone TEC 3 (Curozone,
USA Inc.,)
 Consists of two main parts :
1. Polyurethane console
2. Handpiece


Polyurethane console
 Ozone generator
 Vacuum pump
 Desiccent
 Hydrophobic filter


HANDPIECE
 Stainless steel, contra angle handpiece
 Disposable sealing cup attaches to the head
 Handpiece attaches to the console via
detachable hose.
 Delivers ozone at a rate of 13.33ml/sec.


PATIENT KIT

 Tooth paste, oral rinse

Clinical Steps in Ozone Therapy
 Polymer cup adapted to carious lesion and air
sucked to create a vaccum.
 Ozone gas produced
delivered at a preset
concentration for 10sec into
the cup around the tooth
surface.

 Suction activated for 10 sec while cup is still

attached to carious lesion to remove residual.

 Reductant fluid is pumped for 5sec on to the

treatment site to start the demineralization process.

 Patient instructed to use home care kit

 If restoration is required place after three

months

Indications
 Primary root carious lesions
 Primary pit and fissure caries
 Early carious lesions around crown and bridges.
Advantages
 Kills more than 99% of microorganisms in carious
lesion
 Oxidizes caries and speeds up remineralization
 Helps to remove organic debris on carious lesion.
 Removed volatile sulphur compounds (Main
cause of halitosis) from root caries.

 Potentially whitens discoloured caries
 Decreased treatment time
 Treatment painless and noiseless
 Does not cause any allergic reaction
 Microorganisms do not developed resistance to

ozone.


AIR ABRASION (Kinetic)

 Air abrasive technology uses compressed air
to propel aluminium oxide particles
 Dr.Robert B Black in 1950 : first developed
and described
 Later Dr.Rainey :
improved and combined
 S.S.White in 1951:
introduced first commercially
available unit – Air-dent.

Principle
 Based on formula for kinetic energy E=½ MV2

 Cutting capability attributable to the energy of
mass in motion.
 When the rapidly moving mass strikes its
target – KINETIC CAVITY PREPARATION .


Type and Size of Abrasive Particles

 Aluminium oxide particles

 2 sizes – 27µm (more comfortable less

effective cutting).

- 50µm (more abrasive cutting but

more discomfort).

Air Abrasive Variable

 Pressure – 40 – 140pounds per sq.inch.
 Tip size - ranges from 0.015 – 0.027 diameter
Small lesions – 0.015
Large lesions and existing
restorations - 0.018.


Tip Angle – 40 – 125°

Tip distance - less than 2mm from the lesion
Dwell time – longer the exposure, further the
preparation will advance (start always with 3sec
burst).

Decay Detection Air Abrasion Preparation

Application of Air Abrasion

 Cavity Preparation
 Internal cleaning of tunnel preparation
 Removal of temporary cement from inside the
crown
 Microabrasion of white spot enamel
hypoplasia
 Stain removal
 Repair of acrylic, composite and porcelain

Situation in which air abrasion not effective
 Crown preparation
 Large caries defect
 Amalgam removal
Advantages of Air abrasion
 Non-traumatic
 No micro chipping or microfracturing
 Less discomfort
 No anaesthesia
 Decreased thermal buildup
 Less invasive

Disadvantages of Air abrasion
 Lack of tactile sensation
 Risk of cavity over preparation and inadequate
caries dentin removal
 Spread of aluminium oxide around the dental
operatory.
 Danger of air embolism and emphysema
 Impaired indirect view
 Damaged to dental mirrors, optical devices
like magnifying lopes.

Contraindication to Air abrasion treatment
 Asthma patients
 Severe dust allergy
 Any open wounds in the oral cavity
 subgingival caries removal
Safety Issues
 To reduce respiratory exposure – surgical
mask, dry vacuum systems.
 Use rubber dam, protective eyeglass and
metal matrix to protect adjacent tooth structure.
 Use disposable mouth mirrors.

LASERS (Hydrokinetic)

 Devices that produce beams of coherent and
very high intensity light.
 Large number of uses of lasers in dentistry
 Maiman in 1960 developed the first Ruby laser.
 Since these early beginnings, field of lasers has
developed considerably.
 Efficiency of Lasers – wavelength characteristics,
pulse energy and the optical properties of the incident
tissue. www.indiandentalacademy.com

FDA HUMAN CLINICAL TRIALS
 Clinical studies of more than 1,700 teeth with hard
tissue laser treatment showed that
1. Pulp vitality not compromised
2. Tooth structure equivalent between laser
treated and control group
3. Can remove caries effectively
4. Can perform cavity preparation effectively
5. Quality of cavity preparation equivalent to
that with the handpiece

MECHANISM OF ACTION OF LASERS ON
HARD TISSUE ABLATION

 Lasers have photomechanical effects, laser
light is highly energetic and when exposed causes
fast heating of dental tissues in small area.
 Fast shockwave created when energy
dissipates explosively as a volumetric expansion of
water in hard tissue occurs.

 Water molecules in the target tooth are
superheated, explode and inturn ablate tooth
structure and caries.
 Mechanical shock waves occur due to
photovapourization of water within the tooth. This
change creates high pressure, removing and
destroying selective areas of adjacent tooth.
 Pulpal temperature rise is less than 2°C at
2sec exposure time with water cooling.

LASER CURRENTLY BEING INVESTIGATED FOR

MORE SELECTIVE HARD TISSUE ABLATION

 Er : YAG (2,940nm) and Nd:YAG

(1,064)

 Co2 Laser (10,600nm) Co 2 Laser

 Excimer lasers (Arf – 193nm) and

(Xecl – 308nm)

www.indiandentalacademy.com Er: YAG Laser

 Of all the available lasers Er:YAG laser can ablate

dental hard tissue with minimal damage to the pulp and

approved by the FDA for the following,

- Removal of caries, Enamel, Dentin,

Cementum, composite, GIC.

- Can be used for enamel etching
 Limitation of Er:YAG – do not ablate amalgam,

gold and porcelain.

LASER CAVITY PREPARATION TECHNIQUE

 Different laser techniques required for ablation of

enamel, dentin and caries because of difference in

water content in increasing order for enamel, dentin and

caries.
 Recommended setting for Er:YAG laser

Caries : 100 – 200mj, Dentin : 150-200mj, Enamel

– 200 – 250mj, Etching : 30-50mj.

PROCEDURE

 Gently touch target tissue with tip end
 Direct water stream to the target tissue
 Always keep operation area wet
 Keep tip moving to provoke effective ablation and
better cooling.
 For deep cut move the tip constantly up and down
(pumping action)

ADVANTAGES

 Lasers capable of ablating and preparing cavity in
an irregular fashion ideal for composite and GIC
restorations.
 Conservation of tooth structure
 Reduced need for L.A.
 More comfortable


CONCLUSION

With the advent of adhesive dentistry, and
currently available caries removal techniques, greater
conservation of tooth structure is possible with less
discomfort to the patient. When operative care is
indicated, it should be aimed at prevention of extension
rather than extension for prevention.


REFERENCES
1. Beeley. J.A. et al, Chemomechanical caries removal a
review of the techniques and latest developments. BDJ, 2000,
188, 8, 427- 430.
2. Dr.Poonam Bogra, Ozone therapy for dental caries – A
revolutionary treatment for the future. JIDA, 2003, 74, 41-45.
3. Banarjee et al, Dentin caries excavation : a review of
current clinical techniques. BDJ, 2000, 188, 9, 476-482.
4. E.Goldstein et al, Air-Abrasive technology : New role in
restorative dentistry. JADA, 1994, 125, 551 – 557.

5. Robert Reyto, Lasers and Air-abrasion new modalities for
tooth preparation, Dental clinics of North America, 2001, 45, 1,
189-213.
6. J.Tim Rainey, Air-Abrasion : an emerging standard of care
in conservative operative dentistry, Dental clinics of North
America, 2002, 46, 185 – 209.
7. Hans J. Koort and Methias Frentzen, Laser effects on
Dental hard tissues, Lasers in Dentistry.


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