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A systematic approach to deep caries removal end points: The peripheral seal concept in adhesive dentistry

Authors:

Abstract and Figures

The objective of this article is to present evidence-based protocols for the diagnosis and treatment of deep caries lesions in vital teeth. These protocols combine caries-detecting dye with anatomical and histologic knowledge to arrive at ideal caries removal end points for adhesive restorations. DIAGNOdent laser fluorescence technology can also be used to confirm these end points. These ideal caries removal end points generate a peripheral seal zone that can support long-term biomimetic restorations. A review of the published literature since 1980 on caries, caries diagnosis, and caries treatments and their relationships to adhesive bonding techniques was carried out. Combining anatomical measurements and pathologic and histologic knowledge with caries-detecting dye and DIAGNOdent laser fluorescence technologies can produce ideal caries removal end points for adhesive dentistry without exposing vital pulps.
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VOLUME 43 t /6.#&33 t ."3$) 2012 197
QUINTESSENCE INTERNATIONAL
junction (DEJ), complete removal of caries
by the traditional visual and tactile tech-
nique has been successful. The minimally
invasive dental treatments for these smaller
lesions using air abrasion, sonic diamond
tips, glass-ionomer cement, and bonded
composite resin have reduced the need for
traditional preparations that eliminate impor-
tant anatomical structures.11–15 )PXFWFS GPS
lesions of medium and large depths, more
sophisticated techniques are required for
determining ideal caries removal end points
(Fig 1).
Using traditional visual and tactile tech-
niques for these larger lesions is often
inconsistent for determining optimal caries
removal end points that consistently preserve
UPPUITUSVDUVSFBOE SFNPWFJOGFDUJPOXJUIPVU
exposing the pulp. Such ideal caries removal
FOEQPJOUT XPVMEQSFTFSWF QVMQWJUBMJUZXJUI-
out limiting the strength and durability of the
BEIFTJWF SFDPOTUSVDUJPO 3FTFBSDIFST BOE
DMJOJDJBOT IBWF TUSVHHMFE XJUI UIF QSPCMFN
PGUPPNVDIWTOPUFOPVHIXIFO JUDPNFTUP
the removal of decayed tissue.16–18
This paper outlines a system for deter-
mining more predictable caries removal
end points for deeper lesions in vital teeth.
5IJTBQQSPBDI JTCBTFE POEFUBJMFE LOPXM-
edge of three-dimensional dental anatomy,
The most common pathology clinicians treat
is caries and its resulting decay.1 The treat-
ment of this disease involves the diagnosis
and management of the patient’s biofilm
and then the remineralization or restoration
of the damaged tooth structure.2–5 Treating
EFDBZ XJUIPVU USFBUJOH UIF DBVTF PG EFDBZ
JT B QSPCMFN UIBU UIF $".#3" $BSJFT
.BOBHFNFOU#Z3JTL"TTFTTNFOUQSPHSBN
is seeking to resolve.6,7 Small lesions can
often be treated nonsurgically, according
UPUIFSFWJTFE*OUFSOBUJPOBM$BSJFT %FUFDUJPO
BOE "TTFTTNFOU 4ZTUFN *$%"4 **8 After
the systemic disease is treated and incipi-
ent lesions are remineralized9 or infiltrat-
ed,10 DMJOJDJBOT BSF MFGU UP EFUFSNJOF IPX
much of the caries should be removed
CFGPSF SFTUPSBUJPO 'PS TNBMM TIBMMPX
lesions limited to the enamel and super-
ficial dentin closest to the dentinoenamel
1
Codirector, Alleman-Deliperi Center for Biomimetic Dentistry,
South Jordan, Utah, USA.
2
Associate Professor, Don and Sybil Harrington Foundation
Chair of Esthetic Dentistry, Division of Primary Oral Health Care,
The Herman Ostrow School of Dentistry of the University of
Southern California, Los Angeles, California, USA.
Correspondence: Dr David S. Alleman, Alleman-Deliperi Center
for Biomimetic Dentistry, 10319 S. Beckstead Ln, South Jordan,
UT 84095. Email: allemancenter@gmail.com
A systematic approach to deep caries removal
end points: The peripheral seal concept
in adhesive dentistry
David S. Alleman, DDS1/Pascal Magne, DMD, PhD2
The objective of this article is to present evidence-based protocols for the diagnosis and
treatment of deep caries lesions in vital teeth. These protocols combine caries-detecting
EZFXJUIBOBUPNJDBMBOEIJTUPMPHJDLOPXMFEHFUPBSSJWFBUJEFBMDBSJFTSFNPWBMFOEQPJOUT
GPSBEIFTJWFSFTUPSBUJPOT%*"(/0EFOUMBTFSGMVPSFTDFODFUFDIOPMPHZDBOBMTPCFVTFEUP
confirm these end points. These ideal caries removal end points generate a peripheral seal
[POFUIBUDBOTVQQPSUMPOHUFSN CJPNJNFUJDSFTUPSBUJPOT"SFWJFXPGUIF QVCMJTIFEMJUFSBUVSF
since 1980 on caries, caries diagnosis, and caries treatments and their relationships to
BEIFTJWFCPOEJOHUFDIOJRVFTXBTDBSSJFEPVU$PNCJOJOHBOBUPNJDBMNFBTVSFNFOUTBOE
QBUIPMPHJDBOEIJTUPMPHJDLOPXMFEHFXJUIDBSJFTEFUFDUJOHEZFBOE%*"(/0EFOUMBTFS
fluorescence technologies can produce ideal caries removal end points for adhesive
EFOUJTUSZXJUIPVUFYQPTJOHWJUBMQVMQT(Quintessence Int 2012;43:197–208)
Key words: adhesive dentistry, biomimetic restorations, caries removal,
indirect pulp capping
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Alleman/Magne
histology, microbiology, and adhesive
EFOUBM TDJFODF 5IJT LOPXMFEHF JT UIFO
JOUFHSBUFE XJUI WJTVBM EZF TUBJOJOH -BTFS
fluorescence technologies can also be
added to guide the clinician in deep caries
diagnosis and removal. This combination
of multiple overlapping techniques can
remedy the shortcomings of using only the
tactile and visual method.19
The general objectives of this systematic
approach to caries removal end point deter-
mination are the maintenance of pulp vitality
after restoration by adhesive methods; the
elimination of dentinal infections by remov-
ing, deactivating, or sealing in bacteria; and
the conservation of intact tooth structure
for long-term biomimetic function. The spe-
cific objectives of caries removal end point
determination are the creation of a peripher-
al seal zone and the absolute avoidance of
QVMQBM FYQPTVSF XIJMF HFOFSBUJOH B IJHIMZ
CPOEFESFTUPSBUJPOXJUIFYDFMMFOUMPOHUFSN
prognosis. First, by creating a peripheral
TFBM [POF  UP NN XJEF DPOTJTUJOH PG
normal superficial dentin, DEJ, and enamel
(Fig 2), a bond strength of approximately
45–55 MPa can be generated.20,21
5IJT QFSJQIFSBM TFBM [POF XJMM CF
confirmed by the total absence of car-
ies-detecting dye staining.22–24 This caries-
free zone can also be confirmed by a
%*"(/0EFOU ,B7P SFBEJOH PG BQQSPYJ-
NBUFMZ  $PNNFSDJBM QSPEVDUT TVDI BT
$BSJFT %FUFDUPS ,VSBSBZ $BSJFT 'JOEFS
(Danville), and Seek (Ultradent) are exam-
ples of caries-detecting dye. Second, by
leaving the slightly infected and partially
demineralized but highly bondable affected
inner carious dentin inside the peripheral
seal zone, a bondability of approximately 30
.1BXJMMCFPCUBJOFE JOUIFEFFQFSBSFBTPG
the preparation.255IJT XJMMCF DPOGJSNFECZ
light pink staining from caries-detecting dye.
%*"(/0EFOU DBO BMTP IFMQ EFUFSNJOF UIF
DBSJFT SFNPWBM FOE QPJOU XJUI SFBEJOHT PG
approximately 20–24 for intermediate dentin
and approximately 36 for deep dentin (Fig
3).26,27 On average, intermediate dentin is 3
to 4 mm from the occlusal surface and deep
dentin is 4 to 5 mm from the occlusal sur-
GBDF$MJOJDJBOT DBO QSFWFOUQVMQ FYQPTVSF
by leaving the infected outer caries inside
UIF QFSJQIFSBM TFBM [POF XIFO SFNPWBM
XPVME SJTL QVMQ FYQPTVSF 5IJT XPVME CF
in small circumpulpal areas deeper than
5 mm from the occlusal surface. These
TNBMMJOGFDUFE BSFBTXJMM TUBJOSFE GSPNDBS-
JFTEFUFDUJOH EZF BOE IBWF %*"(/0EFOU
readings higher than 36. Achieving these
objectives should result in highly bondable
QSFQBSBUJPOTUIBU XJMM TVQQPSUBEIFTJWF MBZ-
ers and remain bonded for the long term, an
essential requirement for large biomimetic
dental reconstructions (Fig 3).28–33
HISTOLOGY
OF CARIES LESIONS
In 1980, Takao Fusayama published the
research carried out by his team at Tokyo
Medical and Dental University on the analy-
sis of caries lesions.34 Using histologic, bio-
chemical, biomechanical, microscopic, and
microbiologic techniques, the researchers
XFSFBCMFUPEJTUJOHVJTIUXPMBZFSTJODBSJFT
MFTJPOT UIBU XFSF WFSZ EJGGFSFOU JO OBUVSF
Fig 1 Intermediate and deep
caries lesions have many visual
and tactile complexities that can
be systematically approached
with caries removal end point and
peripheral seal zone protocols.
Fig 2 The concept of a periph-
eral seal zone is that the enamel,
DEJ, and supercial dentin consti-
tute the caries-free area of a high-
ly bonded adhesive restoration.
Fig 3 Caries removal end points for the peripheral seal
zone can be determined with a combination of caries-
detecting dye and DIAGNOdent technologies.
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5IF GJSTU MBZFS XBT OBNFE iPVUFS DBSJPVT
EFOUJOw *U XBT IJHIMZ JOGFDUFE BDJEJD BOE
demineralized. The collagen fibrils in this
MBZFS XFSF EFOBUVSFE IBWJOH MPTU NPTU
of their intermolecular cross-linkages. This
MBZFSXBTOPUTFOTJUJWFUPDPOUBDUBOEDPVME
CFSFNPWFEXJUIPVU BOFTUIFTJB CFDBVTFJU
had lost the hydrodynamic system of intact
dentinal tubules. This layer also failed to
SFNJOFSBMJ[F JO B OBUVSBM XBZ CFDBVTF UIF
DPMMBHFO GSBNFXPSL DPVME OPU SFUVSO UP
OPSNBM FWFO JG UIF BDJE FOWJSPONFOU XBT
OFVUSBMJ[FE 5IF TFDPOE MBZFS XBT UFSNFE
iJOOFS DBSJPVT EFOUJOw 5IJT MBZFS XBT QBS-
tially demineralized and slightly infected,
but the collagen fibrils retained their natural
structure around intact dentinal tubules.
#FDBVTF PG UIJT SFNBJOJOH TUSVDUVSBM JOUFH-
SJUZ UIF JOOFS DBSJPVT EFOUJO XBT TFOTJUJWF
UPSFNPWBMXJUIPVU BOFTUIFTJB5IF MVNFOT
of the dentinal tubules in this layer had no
QFSJUVCVMBS SJOHT PG IZESPYZBQBUJUF <$B10
(PO4)6 0)2]. Instead, the enlarged lumens
XFSFOPXQBSUJBMMZ PSDPNQMFUFMZGJMMFE XJUI
large crystals of tribeta calcium phosphate
<$B3 (PO4)2] called Whitlockite.35 Whitlockite
is crystallized into the dentinal tubules as
hydroxyapatite is dissolved from intertu-
bular dentin by bacterial acids. This inner
MBZFS PG UIF DBSJFT MFTJPO XBT BCMF UP CF
SFTUPSFE UP B OPSNBM NJOFSBMJ[BUJPO XJUI B
hydroxyapatite matrix surrounding the col-
lagen fibrils (intertubular dentin) and around
UIFUVCVMFTQFSJUVCVMBSEFOUJOXIFOUIFQ)
XBTOFVUSBMJ[FE36
Since the late 1960s, the goal of remov-
ing only outer caries and saving the inner
caries for remineralization has been recog-
nized.375IF QSPCMFNXBT UIBUFBDIPQFSB-
tor had a different sense of hard and soft.
$MJOJDBMMZ GJOEJOH UIF JOUFSQIBTF CFUXFFO
the outer and inner carious dentin layers
XBT JODPOTJTUFOU "EEJOH UP UIF EJGGJDVMUZ
XBT UIF BOBUPNJDBM TPGUFOJOH PG EFOUJO BT
it nears the pulp (reparative dentin, laid
EPXOEVSJOHUIFDBSJFTQSPHSFTTJPOJTFWFO
softer than deep dentin) and the fact that
different instruments (hand, rotary, or ultra-
sonic) removed more or less of the lesion
during excavation. All of this subjectivity
and variability made for inconsistent car-
ies removal end points. Fusayama made
QSPHSFTT UPXBSE B TPMVUJPO UP UIJT QSPC-
MFNCZGJOEJOHUXPQSPQZMFOFHMZDPMoCBTFE
colored solutions (one purple, one red)38
that stained the outer and inner carious den-
tin layers differently. The outer carious den-
tin stained dark red, and the inner carious
dentin stained lighter (pink for the red dye
GPSNVMB5IFJOUFSQIBTF CFUXFFOUIFPVUFS
BOEJOOFSDBSJPVT EFOUJOXBTSFGFSSFEUPBT
the turbid layer. This interphase is a mixture
PGQBSBMMFMHSPVQTPGUVCVMFTTPNFPGXIJDI
BSFPVUFSDBSJPVTEFOUJOBOETPNF PGXIJDI
are inner carious dentin (depending on
IPX MPOH UIF UVCVMFT IBWF CFFO JOGFDUFE
and under the influence of bacterial acids).
Under the turbid layer, the inner carious
dentin becomes the transparent zone. The
transparent zone is translucent in histologic
FYBNJOBUJPO XJUI B MJHIU NJDSPTDPQF 5IF
pink staining (often referred to as a pink
haze) in the turbid layer becomes lighter as
it moves into the transparent zone. In this
zone, the large lumens of the dentin tubules
BSF GJMMFE UP TPNF EFHSFF XJUI 8IJUMPDLJUF
5IFTF MBSHF DSZTUBMT TMPX CBDUFSJBM JOWB-
sion and reduce dentin permeability. This
reduced permeability decreases the out-
XBSEGMPXPGQVMQBMGMVJEXIJDIJTSFGFSSFEUP
BTiUSBOTVEBUJPOw*UBMTPSFEVDFTUIFNPWF-
ment of pulpal fluid caused by temperature
changes. Underneath the transparent zone
is an interphase of the transparent zone, as
XFMM BT OPSNBM TFOTJUJWF EFOUJO DBMMFE UIF
iTVCUSBOTQBSFOU[POFw'JH
The subtransparent zone stains even
more lightly than the transparent zone.
3FNPWBMPGUIFUSBOTQBSFOUBOETVCUSBOTQBS-
ent zones in an attempt to reach hard dentin
is the cause of most pulp exposure (Fig 5).
The pink-haze staining (as differentiated
from the red staining) of the inner carious
EFOUJO XBT OFWFS EJTDVTTFE CZ 'VTBZBNB
JO FJUIFS PG IJT UXP CPPLT PS BOZ PG IJT
NBOZ QVCMJTIFE BSUJDMFT )F POMZ SFGFSSFE
to stained or unstained caries. As a result,
many users of caries-detecting dye solu-
UJPOTCFDBNFDPOGVTFE BCPVU FYBDUMZIPX
to use it. If all of the lightly stained dentin
XBTSFNPWFE VOEFSUIF BTTVNQUJPOUIBU JU
contained a significant number of bacteria,
then an increased number of pulp expo-
sures occurred.39–41 Other researchers in
+BQBOXIPIFMQFEXJUI'VTBZBNBTPSJHJOBM
research came to the conclusion that the
MJHIUMZTUBJOFEBSFBTXFSFNPTUMZVOJOGFDUFE
XJUI JOUBDU DPMMBHFO GJCSJMT TVSSPVOEFE CZ
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high levels of hydroxyapatite and Whitlockite
and should therefore be preserved for
remineralization.42–45 Further research in
"NFSJDB DMBSJGJFE UIF SFMBUJPOTIJQ CFUXFFO
TUBJOJOHBOECBDUFSJBMMFWFMT)JTUPMPHJDBOE
NJDSPCJPMPHJDBOBMZTJTTIPXFEUIBUUIFDPS-
relation is high in the darkly stained outer
DBSJFTCVUOPUXJUIJOUIFJOOFSDBSJFTXIJDI
stained lightly.46There appeared to be a
need for a clinical technology that could
assess the amount of bacteria in the lightly
stained inner caries.
*O UIF MBUF T B OFX MBTFSGMVPSFT-
DFODFUFDIOPMPHZ%*"(/0EFOUXBTJOUSP-
EVDFE BT B XBZ UP EJBHOPTF JOJUJBM DBSJFT
lesions (Fig 6). Teams of investigators in
(FSNBOZBOE4XJU[FSMBOEGPVOEUIBUCBDUF-
rial metabolic products called porphyrins
XPVME GMVPSFTDF XIFO JSSBEJBUFE XJUI B
655-nm red laser. This fluorescence could
be read and given a numeric value that cor-
responded approximately to the amount of
bacteria present.47,48
%*"(/0EFOU QSPWFE JUT FGGJDJFODZ GPS
the nondestructive diagnosis of pit and fis-
sure caries.49,50 In vivo investigations using
%*"(/0EFOU TIPXFE UIBU JU NJHIU BMTP CF
used to establish a caries removal end point
UIBU DPSSFMBUFE XJUI USBEJUJPOBM FYDBWBUJPO
UFDIOJRVFT %*"(/0EFOU SFBEJOHT GPS UIF
TVQFSGJDJBMEFOUJOFOE QPJOUXFSF 
= (< 12). The end points for intermediate to
EFFQ EFOUJO XFSF      
5IFTFGJOEJOHTXFSF SFQSPEVDFEJOBTFDPOE
TUVEZBUUIF6OJWFSTJUZPG #FSO26,51 The differ-
ent readings in deeper lesions correspond
approximately to the proportional differences
in pulpal fluid/mm2 at the DEJ vs circumpulpal
areas. This is because dentinal tubules are
three times more concentrated near the pulp
than they are near the DEJ.15,52 Depending
POUIFQFSNFBCJMJUZ PGUIFJOOFSDBSJFTXIJDI
is related to the amount of Whitlockite in the
EFOUJOBM UVCVMFT UIFSF XJMM CF B HSFBUFS PS
lesser diffusion of the porphyrins (hence, the
IJHIWBSJBODFJOUIF%*"(/0EFOUSFBEJOHTJO
intermediate and deep inner carious dentin).
An increase of demineralized dentin in inner
DBSJPVT EFOUJO BOE EFOBUVSFE DPMMBHFO XJUI
high demineralization in the outer carious den-
UJO XJMM JODSFBTF UIF WPMVNF PG QVMQBM GMVJE JO
the outer and inner carious dentin. In turn, this
XJMMBMMPXUIF QPSQIZSJO EJGGVTJPOUP JODSFBTF
XIJDI XJMM DBVTF IJHIFS %*"(/0EFOU SFBE-
ings in the outer carious dentin and deep
JOOFS DBSJPVT EFOUJO #PTUPO BOE 4BVCMF22
DPOGJSNFE UIF (FSNBO BOE 4XJTT FYQFSJ-
NFOUTBOEDPSSFMBUFEUIFNXJUIUIF+BQBOFTF
SFTFBSDI VTJOH DBSJFTEFUFDUJOH EZF #PTUPO
and Liao also investigated the light pink stain-
ing of circumpulpal dentin and concluded
UIBU JU XBT EVF UP UIF IJHIFS QFSDFOUBHF PG
collagen not completely surrounded by the
hydroxyapatite matrix and not from denatured
collagen (as in outer carious dentin) or from
acidic demineralization (as in inner carious
Fig 4 The deep caries lesion has two parts: outer and inner cari-
ous dentin. The inner carious dentin has three parts: the turbid
layer, transparent zone, subtransparent zone, and normal dentin.
Fig 5 By using only visual and tactile methods
for deep caries removal, the pulp is often exposed
because the tansparent zone, the subtransparent
zone, normal deep dentin, and reparative dentin are
all softer than supercial and intermediate dentin.
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dentin).18,53,54 Staining and remineralization
also makes for higher variability and less pre-
dictability of any technology. For superficial
EFOUJOUIF%*"(/0EFOUSFBEJOHTPGPS
corresponded to a nonstaining and bacteria-
free caries-removal end point.12 A group at
4IPXB6OJWFSTJUZJO 5PLZPEFWFMPQFEBQPMZ-
QSPQZMFOF HMZDPMoCBTFE $BSJFT$IFDL EZF
/JTIJLB UIBU TUBJOFE POMZ UIF PVUFS DBSJPVT
dentin and not the inner carious dentin. This
type of caries-detecting dye gave the same
SFTVMUT JO TVQFSGJDJBM EFOUJO %*"(/0EFOU 
 XJUI OP TUBJOJOH BT 'VTBZBNBT QSPQZM-
ene glycol–based caries-detecting dye.55#VU
CFDBVTFUIJTIJHIFSNPMFDVMBSXFJHIU DBSJFT
detecting dye formula does not lightly stain
the turbid layer, transparent zone, and sub-
transparent zone, it is not as useful to find the
caries removal end point that is ideal for the
highest dentin bond strength in the peripheral
seal zone.56 This is because clinicians are not
able to detect inner carious dentin that should
be removed for the highest bond strength in
UIFQFSJQIFSBMTFBM [POF)PXFWFS"NFSJDBO
and Japanese researchers did not test the
deeper lesions like the Europeans did.
$PNCJOJOH DBSJFTEFUFDUJOH EZF BOE
%*"(/0EFOU DBO HJWF DMJOJDJBOT BOPUI-
FS XBZ UP EFUFSNJOF XIFO UIF FYDBWBUFE
MFTJPO JT FTTFOUJBMMZ CBDUFSJBGSFF XIJMF BU
the same time not removing affected inner
carious dentin inside the peripheral seal
zone.57 The anatomical depth of the lesion
needs to be monitored to make the cor-
SFDU EFUFSNJOBUJPO PO XIFUIFS UP QSPDFFE
XJUI UIF SFNPWBM PG PVUFS DBSJPVT EFOUJO
inside the peripheral seal zone. Measuring
GSPN JOUBDU UPPUI TUSVDUVSF XJUI POF PS UXP
periodontal probes (see Fig 4) is a useful
UFDIOJRVF UP EFUFSNJOF XIFO UIF FYDBWB-
tion is into circumpulpal areas (5 to 6 mm
from the occlusal surface). If the excavation
is into intermediate dentin (3 to 4 mm from
the occlusal surface), the caries removal
FOE QPJOUT XJUI MJHIU QJOL TUBJOJOH DBO CF
achieved predictably inside the peripheral
seal zone by further excavation of the red
PVUFSDBSJPVT EFOUJO)PXFWFS XIFOFYDB-
vation is near the pulp (> 5 mm from the
occlusal surface or > 3 mm from the DEJ)
and the caries-detecting dye still stains red,
FYDBWBUJPO TIPVME TUPQ 5IJT QSPUPDPM XJMM
eliminate most pulp exposures (Figs 7 to 9).
Avoiding direct pulp caps has been
TIPXO UP SFEVDF UIF OFFE GPS TVCTFRVFOU
endodontic treatment.58–60$POTFSWJOHNPSF
dentin in tooth preparations has also been
TIPXOUPSFEVDF UIFJODJEFODF PG JSSFWFST-
ible pulpitis.61#ZFMJNJOBUJOHPSSFEVDJOHUIF
surface area and thickness of the nonelastic
and deformable outer carious dentin, the
performance of a bonded composite under
GVODUJPOBMMPBETXJMMBMTPJNQSPWF62
The final goal of ideal caries removal
end points and peripheral seal zones is
UP DSFBUF BO BEIFTJWF CPOE UIBU XJMM CF
preserved for as long as possible. Such a
bond to dentin should mimic the strength
of a natural tooth. The tensile strength of
the DEJ has been measured at 51.5 MPa.63
Only bonding to sound dentin can achieve
and even exceed this tensile bond strength.
6TJOHUIFiHPMETUBOEBSETwUISFFTUFQUPUBM
FUDI PS UXPTUFQ NJMEMZ BDJEJD TFMGFUDIJOH
dentinal bonding systems are the most
consistent bonding strategies to obtain
these high bond strengths.20,64 Adhesive
bonding to normal and carious dentin has
been studied for the past 15 years at the
.FEJDBM$PMMFHFPG(FPSHJBVOEFSUIFEJSFD-
tion of David Pashley.25,65 These studies
have been continued at many Japanese
universities. This research has established
the bond strengths of normal and carious
dentin. Inner carious dentin loses 25% to
33% of its bondability.25,65 Outer carious
dentin has a reduction of bondability of over
66%.21,66 This reduction in bondability cor-
responds to the amount of demineralization
in the outer and inner carious dentin.67 The
Fig 6 DIAGNOdent reads bacterial products called
porphyrins and is used to assess the relative amount
of bacteria present in a caries lesion.
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$BSJTPMW DIFNPNFDIBOJDBM UFDIOJRVF PG
caries removal leaves a thin layer of residu-
al outer carious dentin that may reduce the
NJDSPUFOTJMFCPOETUSFOHUIN5#468,69 This
technique can be clinically successful in
TIBMMPXSFTUPSBUJPOTCVUJTOPUJEFBMJOMBSHFS
load-bearing situations.16,70
4JNQMJGJFE UXPTUFQ UPUBMFUDI EFOUJOBM
CPOEJOHTZTUFNT MPTF UP PGN5#4
XIFO CPOEFE UP JOOFS DBSJPVT EFOUJO71 The
TBNFEFDSFBTFJO CPOETUSFOHUIXJMMPDDVS JG
acid etching is performed on dentin that is to
CFCPOEFE XJUIB NJMEUXPTUFQ TFMGFUDIJOH
dentinal bonding system.72,73 Dual-cure den-
tinal bonding systems can have the same
negative effect.74 The acid from caries lesions
also activates endogenous collagenase
enzymes called matrix metalloproteinases. In
the presence of matrix metalloproteinases, a
 UP  SFEVDUJPO JO CPOE TUSFOHUI XJMM
be observed after (approximately in the first
12 months) restoration placement. A 0.2% to
 DIMPSIFYJEJOF TPMVUJPO XJMM EFBDUJWBUF
the matrix metalloproteinases and preserve
the maximum bond strength.75–77 Mild self-
etching dentinal bonding systems produce an
acid/base resistant zone of a 1 to 1.5 micron
UIJDLOFTT SFGFSSFE UP BT iTVQFS EFOUJOw
CFDBVTF PG JUT BCJMJUZ UP XJUITUBOE IJHI BOE
MPX Q) BUUBDLT 4& 1SPUFDU ,VSBSBZ XJUI
the unique proprietary methacryloyloxydo-
decylpyridinium bromide monomer contain-
ing pyridinium bromide produces this super
dentin and also deactivates matrix metal-
loproteinases. Other mild self-etching dential
bonding systems also produce the acid/base
resisitant zones but need additional matrix
metalloproteinase-deactivating chemicals
Fig 7 Deep caries lesion showing the outer carious
dentin staining red and extending to the circum-
pulpal dentin ( > 5 mm from the occlusal surface).
Fig 8 Caries removal end points for a deep lesion.
The peripheral seal zone has been created without
exposing the pulp. A small amount of outer carious
dentin is left on top of the inner carious dentin inside
the peripheral seal zone.
Fig 9 Clinical case illustrating Fig 8. The ideal caries
removal end points for highly bonded restorations
without pulpal exposure.
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TVDIBTDIMPSIFYJEJOF$POTFQTJT6MUSBEFOU
PS CFO[BMLPOJVN DIMPSJEF .JDSP1SJNF #
%BOWJMMFPS&UDI#JTDP78–80
The anatomical location of the peripher-
al seal zone dentin must also be considered
UPQSFEJDU QPUFOUJBMCPOETUSFOHUI $FSWJDBM
root dentin loses approximately 20% of its
CPOEBCJMJUZ DPNQBSFE XJUI DPSPOBM TVQFS-
ficial dentin. If the cervical root dentin has
inner carious dentin present, the bond
strength is only 50% of sound coronal den-
tin.81 Deep dentin vs superficial dentin bond
strengths are also dependant on the type of
dentinal bonding system used. Three-step
UPUBMFUDI BOE UXPTUFQ NJME TFMGFUDIJOH
EFOUJOBMCPOEJOHTZTUFNTCPOEFRVBMMZXFMM
UPEFFQEFOUJOCVUTJNQMJGJFEUXPTUFQUPUBM
etch and one-step highly acidic self-etching
systems can lose up to 50% of their bond
strength in deep dentin.73,82
During placement of the restorative
material, the ratio of bonded to unbonded
surface areas of each layer or increment of
composite (the configuration factor or c-fac-
tor)83XJMM BGGFDU UIFTUSFTT PGQPMZNFSJ[BUJPO
shrinkage that is applied to the maturing
CPOE UP EFOUJO )JHIFS DGBDUPST BMXBZT
JODSFBTFTUSFTTPOUIFCPOEUPEFOUJOXIJDI
EFDSFBTFTJUTN5#484VOMFTTJUJTBGMPXBCMF
DPNQPTJUF XJUI B MPX NPEVMVT PG FMBTUJD-
ity compared to dentin85). Therefore, high
DGBDUPSMBZFSJOHXJUIIJHINPEVMVTDPNQPT-
ites (thicker than 0.5 mm) should be avoided
XIJMF UIF CPOE UP EFOUJO JT NBUVSJOH 5IJT
can best be accomplished by using an indi-
rect or semidirect restorative technique.86 If
direct restoration is necessary for socioeco-
nomic reasons, compensatory measures
are required to prevent excessive stresses
to the bond and remaining hard tissue. This
can best be accomplished by multiple thin
IPSJ[POUBM MBZFST XIJDI UBLF NPSF UJNF UP
BQQMZ PO B UIJO MBZFS PG GMPXBCMF DPNQPT-
ite.20,87 " UIJO NJDSPO NJDSPGJMMFE GMPX-
able composite or a thick dentinal bonding
system adhesive layer (50 to 80 microns)
can secure the dentin bond and create a
GBJMTBGFMBZFS4VDIBSFTJODPBUJOHXJMMTUBZ
CPOEFE FWFO XIFO PWFSMBZJOH MBZFST GBJM
under high stress.88,89*OTIBMMPXQSFQBSBUJPOT
in superficial dentin, the detrimental effect of
resin shrinkage is not as great because the
c-factor is reduced.90,91 Polyethylene fiber
nets used to line high c-factor prepara-
UJPOT IBWF BMTP CFFO TIPXO UP SFEVDF UIF
effects of polymerization stress and cervical
microleakage.92,93 If c-factor stresses are not
reduced, the bond strength is decreased by
30% to 50% during the first 24 hours and
by another 10% during functional loading
in the first years of service.94$BSFGVMPQFSB-
UPST XIP UBLF BMM PG UIFTF DPOTJEFSBUJPOT
into account during caries excavation and
bonding procedures can decrease the array
of differences in regional bond strengths in
their restorations.95
TREATMENT GOALS
FOR DEEP CARIES LESIONS
1. $SFBUFBQFSJQIFSBMTFBM[POFPGFOBNFM
DEJ, and normal superficial dentin near
the DEJ (this should bond at 55 MPa)
(Figs 10 and 11).
2. Leave the inner carious dentin inside
of the peripheral seal zone (this should
bond at 30 MPa) (compare Figs 2 and 3
XJUI'JHTBOE
3. 3FNPWF IJHIMZ JOGFDUFE PVUFS DBSJPVT
dentin inside of the peripheral seal zone
XJUIPVU FYQPTJOH UIF QVMQ 4NBMM BSFBT
of circumpulpal outer carious dentin are
left to prevent exposure (see Figs 7 to 9).
4. Seal in and deactivate any remaining
bacteria left inside the peripheral seal
zone.
5. Use adhesive restorative techniques
UIBU XJMM NBYJNJ[F UIF CPOE TUSFOHUI
of the peripheral seal zone and the
inner carious affected dentin inside the
peripheral seal zone.
STEP-BY-STEP
TECHNIQUE
1. 5FTU GPSQVMQBM WJUBMJUZ XJUIJDF PS BFSP-
TPM SFGSJHFSBOU &OEP*DF $PMUÒOF
Whaledent). If the test is positive,
QSPDFFE XJUI DBSJFT EJBHOPTJT BOE
treatment. If the test is ambiguous or
negative, inform the patient of the pos-
sible need for endodontic treatment.
2. Anesthetize the tooth. Isolate it using rub-
ber dam or other isolation techniques.
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3. Access the lesion after removal of any
failed restorations. Stain the caries
MFTJPO XJUI SFE DBSJFTEFUFDUJOH EZF
Wait 10 seconds and rinse (see Fig 12).
4. Starting near the DEJ, use a 1-mm round
diamond bur of fine to medium grit (30
to 100 microns) to create a peripheral
seal zone area free of red-stained outer
caries and pink-stained inner caries.
5IJT TVQFSGJDJBM OPSNBM EFOUJO XJMM CF
UPNN XJEFEFQFOEJOHPOXIFUIFS
it is on the buccal or the occlusal areas
of a molar (1.5 to 2 mm) or on the mesial
or distal root dentin (1 mm). Premolars
are smaller, and the superficial dentin is
OBSSPXFSJOBMMBSFBT'JHTBOE
5. Staining and removing outer and inner
carious dentin is repeated until the
caries removal end point in the periph-
eral seal zone is stain free. This can be
DPOGJSNFECZ %*"(/0EFOUSFBEJOHTPG
approximately 12 (see Fig 3) and the
total absence of caries-detecting dye.
(This indicates virtually bacteria-free
superficial dentin.)
6. 3FNPWF UIF SFETUBJOFE PVUFS DBSJPVT
dentin from the area inside the periph-
eral seal zone (being careful to avoid
the pulp horn areas). Measure from
the occlusal surface to determine if the
excavation is in superficial (outer third),
intermediate (middle third), or deep
(pulpal third) dentin (see Fig 4).
7. After removing the red and leaving the
QJOL CFUXFFO UIF QVMQ IPSOT UIF QJOL
inner carious dentin areas in these
intermediate dentin areas can be evalu-
BUFE XJUI %*"(/0EFOU 5IF OVNCFST
should read approximately 24 (accept-
able range, 12 to 36). Those readings
indicate a virtually bacteria-free area in
the intermediate to deep dentin inside
the peripheral seal zone (see Figs 10
and 11).
8. Move to the deep pulp horn areas last.
$BSFGVMMZSFNPWFSFETUBJOFEPVUFSDBSJ-
ous dentin until deep dentin is reached
(5 mm from occlusal surface). If the
tissue continues to stain red and mea-
TVSFNFOUT XJUI UIF QFSJPEPOUBM QSPCF
indicate that you are deeper than 5 mm
from the occlusal surface (> 3 mm from
the DEJ), stop excavation to avoid pulp
exposure (compare Figs 4 to 9).
9. Optional step: Treat the peripheral seal
zone, inner carious dentin, and outer
DBSJPVT EFOUJO XJUI  UP  DIMPS
hexidine for 30 seconds to inactivate both
the matrix matalloproteinases and any
remaining bacteria; 0.1% to 1.5% benzal-
konium chloride solution in the acid-etch
or methacryloyloxydodecylpyridinium
Fig 10 Ideal caries removal end points and peripheral seal zone devel-
oped in an intermediate-depth lesion using combined technologies.
Fig 11 The peripheral seal zone is free of outer and
inner carious dentin. Inside the peripheral seal zone,
the lightly stained inner carious dentin is retained
and will remineralize in vital teeth.
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bromide monomer in the dentinal bond-
JOHTZTUFNXJMMBMTPBDIJFWFUIFTFHPBMT80
If using a three-step total-etch dentinal
bonding system, this step is performed
after acid etching and rinsing. If using
BUXPTUFQTFMGFUDIJOH EFOUJOBM CPOEJOH
system, after applying chlorhexidine or
benzalkonium chloride, dry the prepara-
tion for 10 seconds before applying the
self-etching primer.96
10. 0QUJPOBM TUFQ JG VTJOH B NJME UXPTUFQ
self-etching dentinal bonding system:
Use air abrasion on the preparation to
NBYJNJ[FUIFN5#497
11. 4UBSU EFOUJO CPOEJOH XJUI B UISFFTUFQ
UPUBMFUDI PS B NJME UXPTUFQ TFMGFUDI-
ing dentinal bonding system.
These techniques for caries removal
end point determination and peripheral seal
zone development are the foundation of
conservative dentistry. Such minimally inva-
sive procedures are best performed under
magnification. This type of microdentistry is
greatly aided by using high-magnification
prismatic loupes of 6.5× to 8.0×PSXJUIBO
PQFSBUPSZ NJDSPTDPQF XJUI TJNJMBS NBHOJGJ-
cation (Fig 13).
The peripheral seal zone in superficial
EFOUJOXJMMBMMPXCJPNJNFUJDCPOETUSFOHUIT
of approximately 45–55 MPa to be created.
The intermediate and deeper areas of light
QJOLoTUBJOFEJOOFSDBSJPVT EFOUJOXJMM MJLFMZ
generate a dentin bond of 30 MPa. If any
outer caries is left in deep circumpulpal
areas to prevent pulp from being exposed,
UIF N5#4 JO UIPTF TNBMM BSFBT XJMM CF
approximately 15 MPa. To maximize all of
these bond strengths, the dentinal bonding
TZTUFNDBOCF BMMPXFEUPNBUVSFGPSBDFS-
tain length of time (3 minutes to 24 hours)
before being bonded to another layer of
polymerizing resin cement or composite
resin.98,99 5IJT JT XIZ JU JT JNQPSUBOU UP VTF
the immediate dentin sealing technique
XIFOFWFSQPTTJCMF86,89,100,101
CONCLUSION
#Z DPNCJOJOH EFUBJMFE BOBUPNJDBM BOE
QBUIPIJTUPMPHJD LOPXMFEHF XJUI UIF UFDI-
nologies of caries-detecting dyes and laser
fluorescence, an ideal caries removal end
QPJOU DBO CF BDIJFWFE GPS WJUBM UFFUI XJUI
deep caries lesions. These ideal end points
XJMM QSFTFSWF NPSF WJUBM QVMQT DPOTFSWF
more dental hard tissue, and create a highly
CPOEBCMFQFSJQIFSBMTFBMUIBUXJMMNJNJDUIF
OBUVSBMUPPUI XIFOSFTUPSFE XJUIMPX TUSFTT
adhesive techniques.
Fig 12 Application of caries-detecting dyes guides
the creation of the peripheral seal zone using
DIAGNOdent and 3D measurements to make end
point decisions in the intermediate and deep dentin
areas.
Fig 13 Magnication of 6.5× to 8.0× is ideal for
implementing minimally invasive caries removal.
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... The difficulty in distinguishing between these two caries layers led Fusayama to search for a caries dye solution. 8,9 He found that a 0.5% basic fuchsin-propylene glycol solution would specifically and distinctly stain the superficial layer of carious dentin without any staining of the deep layer. 9 An expert working group subsequently agreed, by consensus, that removal of carious dentin was effectively indicated by the color after staining using a dye consisting of 1% acid red-propylene glycol. ...
... The final goal of achieving ideal caries removal endpoints and peripheral seal zones is to create an adhesive bond that will be preserved for as long as possible. 8 An excellent understanding of the adhesive systems is required for successful implementation of the minimally invasive strategy. The clinician must enhance the physico-chemical interaction of the dental substrate left at the cavity surface with the adhesive material to achieve successful long-term performance. ...
Article
Deciding on what treatment (repair or replacement) to provide for a failed indirect restoration can be challenging. Notably, the strength of the residual tooth structure could be improved after replacing the failed indirect restoration using a minimally invasive strategy. Objective: To describe the use of a minimally invasive strategy for the successful clinical replacement of two failed indirect metal restorations with direct composite restorations and the attainment of bonded restoration. Case Report: Case 1. A 52-year-old male patient came to the dental hospital complaining of discomfort when drinking cold beverages and food impaction on the proximal area of the upper left first molar. Case 2. A 45-year-old female patient complained about her debonded metal onlay and secondary caries in the upper right second molar. Both of these indirect restoration failures were treated with direct resin composite restoration. Both patients were highly satisfied with the results. Conclusion: This report presents the benefits of adopting a minimally invasive strategy approach for replacing failed indirect restorations (inlays and onlays) with direct-bonded composite restorations. Minimally invasive direct restorations are designed to maximize the preservation of tooth structure, thereby ensuring a long-term bonded restoration and leaving future options open when a failure occurs.
... Ceramic or polymer burs could help to selectively remove the carious tissue to hard dentine (on border, 2 mm width) and preserve the gingival enamel margin. In particular, polymer burs are offering a compromise between the caries removal effectiveness (CRE) and minimal invasiveness potential (MIP) to remove the soft carious tissue [34][35][36]. ...
... Intrinsic fluorescence signals from carious dentine can guide tissue removal; necrotic, caries-infected dentine appears dark green, while the leathery, caries-affected dentine is grey green with red shadows. This approach is conducted to optimize the restoration peripherical sealing and therefore avoid bacterial infiltration, in addition to promoting dentine healing using an IRB [31,32,35]. For teeth with shallow or moderately deep lesions, selective removal to firm dentine excavation protocols should be followed. ...
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The contemporary approach for operative caries management emphasizes personalized interventions for each patient, dependent upon the individual’s caries susceptibility/risk, the stage of the carious lesion and its activity. The clinician’s challenge is to optimize the extent of cavity preparation and the choice of dental restorative biomaterials, appreciating the benefits offered by ion-releasing restorative materials. There is a growing application of bioactive/bio-interactive materials in minimally invasive operative dentistry, as they may help with tissue recovery by ion release. In case of moderate or extensive occlusal cavitation, the clinical criteria include the individual caries susceptibility and carious lesion activity. In high caries risk cases, ion-releasing biomaterials (IRB) can be used, as well as for active carious lesions. In proximal lesions, the clinical criteria include the individual caries susceptibility, the lesion activity and presence of cavities with little or no enamel at the gingival margin. This article aims to discuss the restorative ion-releasing options, according to different clinical situations, and the caries susceptibility to manage cavitated carious lesions in permanent adult teeth.
... The dentinal substrate remaining after caries excavation is very important to maintain pulp vitality, for the adhesion of restorative material and to achieve bio-mimetic restoration. [8,13,14] The remaining dentinal substrate is a hydrated biological complex. It shows variations with different physiological processes, age changes and diseases. ...
... Partial caries removal or incomplete caries removal is more demanding based on scientific evidence [36][37][38]. For those situations, using the stepwise removal and selective removal technique, GIC is recommended as it has similar bond strength to both normal and caries-affected dentin [39,40]. ...
Article
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Objective The purpose of this study was to determine the bond stability and the change in interfacial ultra-structure of a conventional glass-ionomer cement bonded to dentin, with and without pre-treatment using a polyalkenoic acid conditioner. Methods The occlusal dentin surfaces of six teeth were ground flat. Glass-ionomer cement was bonded to the surfaces either with or without polyalkenoic acid conditioning. The teeth were sectioned into 1-mm² stick-shaped specimens. The specimens obtained were randomly assigned to two groups with different periods of storage in water: 1 week and 1 year. The micro-tensile bond strength (μTBS) was determined for each storage time. Additional specimens were prepared for Transmission Electron Microscopy (TEM); they were produced with or without prior polyalkenoic acid conditioning in the same way as in the μTBS test. Results There was no significant difference in μTBS to conditioned dentin and non-conditioned dentin (p > 0.05). The failures appeared to be of a mixed nature, although aging caused more areas of cohesive than adhesive failure in both groups. The TEM observation showed an intermediate layer, a matrix-rich layer and a partially demineralized layer in the polyalkenoic acid conditioned group. Significance Aging did not reduce the bond strength of the conventional glass-ionomer cement to dentin with or without the use of a polyalkenoic acid conditioner.
... The periphery of a cavity usually is key because it acts as a barrier to microleakage which if it occurs, it compromises the adhesion not because the material fails but because the tooth structure fails due to structural changes that affect the material/tooth interface. It is known that bacteria can still be detected in caries bonded dentine but it is not known whether they remain abeyant whilst embedded in the restoration (Alleman and Magne, 2012). Therefore, it makes sense to aim to achieve a peripheral seal in order not to allow new bacteria to recolonize the tooth tissues or reactivate the already embedded bacteria. ...
Conference Paper
Dental composites were a revelation when they were introduced into the market. Even though they have kept evolving by becoming mechanically stronger, less technique sensitive and aesthetically appealing, they are still not easy to place and fail due to bacterial microleakage which leads to recurrent caries. Therefore, they have not been the staple material of choice for paediatric patients since they are not as reliable as preformed metal crowns long-term. AIMS AND OBJECTIVES: The aim of this project was to develop novel SMART composites which will target the paediatric patient. They have antibacterial polylysine and remineralising MCPM incorporated in them which could potentially address the bacterial microleakage problem of existing materials. They are self-etching and can be used as a bulk filling after soft caries removal. Good monomer conversion at depth and dimensional stability are essential for bulk filling and prevention of microleakage respectively and therefore the focus of this work. METHODS: An FTIR machine was used to measure the monomer conversion at 2 different sample depths (1mm, 2mm) with three different curing times (10s, 20s, 40s) in order to determine the effect of low versus high MCPM and PLS. In addition, mass and volume change was measured and shrinkage was calculated in order to determine the volumetric stability of the SMART composites. To assess microleakage, a dye test was performed in natural primary teeth drilled and directly filled with the SMART composite. This had the highest MCPM and PLS content. Three commercial materials which included Activa (following tooth etching) and two glass ionomer cements were used as comparators. RESULTS: Antibacterial polylysine and remineralising MCPM had negligible effect on monomer conversion. Volume change (2%) upon water sorption could help balanced polymerization shrinkage (3%). Microleakage of the SMART composite was equivalent to Activa but less than the glass ionomer cements. CONCLUSION: SMART composites good monomer conversion, volumetric stability, microleakage resistance and ease of placement should enable a more viable and predictable composite restorative paediatric option in the future.
... Those two methods were not fully reliable, so a more confirmatory method using caries detection dye was used in this study, in which dye stains the outer surface that contained caries infected dentin and facilitate its removal by excavation. Many reports have proven that specifically Seek Caries Indicator had no effect on adhesive bond strength, this was why it was selected to be used in the current study [6,12,13] . ...
... Takao Fusayama in 1979 distinguished two layers in caries lesions. The first layer "outer carious dentine" is highly infected, acidic, demineralized, not sensitive to contact, can be removed without anesthesia and fail to remineralize in a natural way and the second layer "inner carious dentine " is partially demineralized and slightly infected, but the collagen fibrils retained their natural structure around intact dentinal tubules (2) . ...
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Advancement in restorative material science and better understanding of bonding have influenced the treatment approach for restoring dentition. Thus evolved the concept of biomimetics in the field of restorative dentistry. Biomimetic dentistry helps to recreate the form, function and aesthetics of the dentition in a natural way. This narrative review intends to give an overview of biomimetics in restorative dentistry.
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Objective: This study evaluated the ability of benzalkonium chloride (BAC) to bind to dentine and to inhibit soluble recombinant MMPs and bound dentine matrix metalloproteinases (MMPs). Methods: Dentine powder was prepared from extracted human molars. Half was left mineralized; the other half was completely demineralized. The binding of BAC to dentine powder was followed by measuring changes in the supernatant concentration using UV spectrometry. The inhibitory effects of BAC on rhMMP-2,-8 and-9 were followed using a commercially available in vitro proteolytic assay. Matrix-bound endogenous MMP-activity was evaluated in completely demineralized beams. Each beam was either dipped into BAC and then dropped into 1 mL of a complete medium (CM) or they were placed in 1 mL of CM containing BAC for 30 days. After 30 days, changes in the dry mass of the beams or in the hydroxyproline (HYP) content of hydrolysates of the media were quantitated as indirect measures of matrix collagen hydrolysis by MMPs. Results: Demineralized dentine powder took up 10-times more BAC than did mineralized powder. Water rinsing removed about 50% of the bound BAC, whilst rinsing with 0.5 M NaCl removed more than 90% of the bound BAC. BAC concentrations 0.5 wt% produced 100% inhibition of soluble recombinant MMP-2,-8 or-9, and inhibited matrix-bound MMPs between 55 and 66% when measured as mass loss or 76-81% when measured as solubilization of collagen peptide fragments. Conclusions: BAC is effective at inhibiting both soluble recombinant MMPs and matrix-bound dentine MMPs in the absence of resins.
Conference Paper
Objectives: The purpose of this study was to investigate the physical characteristics of the dentin cavity wall after removing the caries dentin by CarisolvTM. Materials and Methods: Twenty extracted human teeth with moderate dentin caries were used. The teeth were sectioned longitudinally through the canter of caries defect and the section surface was polished on linen mediated with alumina slurry. The Micro Vickers Hardness of dentin was measured on the section surface from the pulp chamber wall to the caries defect every 200μm. Then the caries dentin was removed using the CarisolvTM system according to the manufacturer's instruction. After removing the caries dentin, the Micro Vickers Hardness was determined by observing the indentation adjacent to the cavity wall and the DIAGNOdent values was measured. In addition, a commercially available caries detecting agent (Caries Check, Nishika, Japan) was applied in the cavity to observe the staining ability of the cavity wall. In the control group, the caries dentin was removed by using the round shaped steel bur mounted on the low-speed dental cutting machine with the guide of the Caries Check staining. Results: The Micro Vickers Hardness of the dentin cavity wall of the CarisolvTM specimens (26.656.67) were significantly lower than that of the control group (35.6110.93) (Student t-test, p<0.05). In addition, the DIAGNODent of the CarisolvTM group (17.785.97) was significantly higher than that of the control group (13.201.60). The cavity wall after removing the caries dentin by CarisolvTM was stained by the Caries Check in all of the specimens. Conclusion: The dentin cavity wall of the CarisolvTM system was diagnosed as the caries dentin that should be still removed. More improvement should be required for the CarisolvTM system to be practiced in clinic.
Article
summary The purpose of this in vitro study was to compare the efficacy of a new chemomechanical caries removal agent, CarisolvTM (MediTeam AB, Sävedalen, Sweden), with conventional slow-speed rotary instrument (bur). Fourteen extracted human molar teeth with deep dentine caries and no enamel coverage were selected for the study. Their laser fluorescence values were over 30 (DIAGNOdent®; KaVo, Biberach, Germany). After the teeth were sectioned through the centre of the carious lesion, one half was removed with conventional drilling (bur); the other half was removed with Carisolv gel. Removal of carious dentine was continued until the lesion was deemed caries-free by visual and tactile criteria. The preparation time for each caries removal technique was also noted. The two halves of each tooth were fixed in 10% buffered-formaldehyde for 1 week. They were then decalcified, dehydrated and embedded in paraffin blocks for histological studies. After taking serial sections of 5 μm thickness, sections were mounted on glass slides, deparaffinized, dehydrated and stained with toluidine blue for observation under a light microscope. Each section was examined for the presence of bacteria. Complete removal of caries was achieved in 13 (93%) of 14 conventionally prepared teeth, and 5 (36%) of 14 chemomechanically prepared teeth (P < 0·05). Mean (±SD) time for caries removal was 272 s (±53·3) with Carisolv, and 116 s (±49·4) with drilling. The results of this study suggest that conventional rotary instrument (bur) was more effective than Carisolv in removal of carious tissue and also takes shorter time.