Potential use of chemo-mechanical caries removal as an

innovation for caries treatment in remote areas:

literature review
Citra Camalin1,* Cahyani2
1
Faculty of Dentistry, Universitas Muhammadiyah Surakarta, Indonesia
2
Faculty of Dentistry, Universitas Muhammadiyah Surakarta, Indonesia
Email: [email protected]

ABSTRACT
Caries prevalence in Indonesia reached 88.8% and predominantly occurred in a remote areas. Dental caries is a
chronic infection of hard tooth tissue that demineralized due to organic acids produced by bacteria. Caries in the
dentin layer will cause collagen and other matrices form two zones, infected-dentin and affected-dentin. Infected
dentin is essentially removed in the restoration procedure due to its bacterial infiltration mechanically using a bur with
a handpiece. Chemo-mechanical Caries Removal (CMCR) itself or incorporated with rotary instruments is an
alternative therapy to remove carious tissue and is consistent with the principle of minimal invasion dentistry. This
literature aimed to find the potential use of CMCR as an innovative caries treatment in remote areas. The results of
this literature are through a scientific literature review from 2011-2021. Based on the previous literature, we can
conclude the effectiveness of CMCR in removing carious tissue to prevent the progression of caries severity. CMCR
can be brought to bear in adult and pediatric carious tissue removal procedures. CMCR reduces pain and anxiety in
children, so it certainly increases the prevalence of children taking caries treatment at the dentist. The utilization of
CMCR is potential caries treatment in the region with low socioeconomic levels because of its relatively cheap.
CMCR has the potential to succeed in the 2030 Caries Free Indonesia program because of the effectiveness of CMCR
in caries tissue removal and the treatment of childhood caries. This literature concludes that CMCR has a lot of
applicable potentials to solve caries cases in remote areas and potentially support the success of the 2030 Caries Free
Indonesia government program.
Keywords: Caries, Carisolv, Papacarie, Chemomechanical Caries Removal

1. INTRODUCTION treatment is to remove carious tissue and fill the cavity

Dental caries is a chronic infection when the with restorative materials to restore the function and
acid products of bacteria dissolve the hard tissue 1. aesthetics of the teeth 4. Chemo-mechanical Caries
Based on WHO data in 2017, caries was the highest Removal (CMCR) is a caries removal method by
case of oral health disease. The highest prevalence applying a material to the tooth surface, resulting in a
occurs in developing countries with low-medium chemical reaction that can dissolved infected dentin and
percapita income. Caries prevalence in Indonesia is retain affected dentin. Furthermore, the infected dentin
90.5% higher than in other developing countries 2. carious that dissolved is removed mechanically by hand
According to Riskesdas (Baseline health research) data instrument. CMCR is potentially used in areas with
in 2018, caries prevalence in Indonesia is 88.8%. FDI minimal healthcare facilities because the procedure does
World Dental Federation explained that some causes of not use electric tools and is plausibly cheap.
caries prevalence are excessive sugar consumption, lack
of dental health care, and difficulty accessing standard 1.1. Caries
dental health care facilities. Healthcare facilities carry
out promotive, preventive, curative, and rehabilitative The etiologies of caries are microbiota, include
treatment held by the local government. Remote areas acid products by cariogenic bacteria on the tooth
are hard to reach due to geographical conditions surface, and host factors include the condition of teeth
(islands, mountains, land, forests, and swamps), and saliva and dietary factors 5. These three factors must
transportation, and social and economic conditions 3. influence each other to be able to cause caries. The main
Based on Iin Nurlinawati (2020), tooth bacteria are Streptococcus mutans, Lactobacillus, and
extraction is a treatment often chosen in an area with Actinomycetes which have acidogenic and aciduric
minimal access to healthcare facilities, increasing the properties. Acidogenic is a bacteria that can produce
number of tooth loss suffered. The principle of caries acid, while aciduric is a bacteria that can survive in
acidic environment 6. Saliva acts as a natural increase plaque pH and instruct patients to improve
antibacterial by maintaining the pH of the oral cavity. habits in maintaining dental and oral hygiene 8. The
The reduced amount of saliva causes an acidic treatment option for a cavity is a restorative procedure
atmosphere which potentially increase caries occurence. when hard tissue can not be remineralized. The
Consuming carbohydrate can increase the occurrence of treatment is accomplished after removing demineralized
caries because the fermentation products of caries and following minimally invasive dental
carbohydrates will be converted by bacteria into organic treatment, which focuses on removing infected dentin
acids, thereby increasing the attachment of caries and preserving as much of the affected dentin as
bacteria colonization 2. possible. Conventional method accomplished by filling
Enamel is the outermost layer of the tooth, the cavity with restorative materials after removing
composed of 92-95% inorganic material in the form of caries using highspeed bur 9.
hydroxyapatite crystals. Beneath the layer of the enamel
is dentin. Dentin has a lower inorganic matrix than 1.2. Chemomechanical Caries Removal
enamel, which is 70% hydroxyapatite. The highest
number of organic substances in dentin is type 1 Chemomechanical caries removal (CMCR) is a
collagen. The pulp chamber under the dentin is a space treatment by dissolving carious tissue using chemical
with blood vessels and nerves extending to the root agents and removing mechanically. Minimal invasive
canal. The root canal is surrounded by dentin and dentistry in the CMCR method achieved when the
cementum with 50% hydroxyapatite and a collagen materials can selectively dissolve infected dentin
matrix. Teeth will undergo a continuous process of without affecting affected dentin7,9. CMCR is divided
remineralization and demineralization. The atmosphere into two types, that are sodium hypochlorite (NaOCl)-
in oral affect the process of demineralization and based and enzyme-based. Sodium hypochlorite–based
remineralization processes 5. are GK-101, Caridex, and Carisolv. The enzyme-based
Caries progression undergoes two stages, there CMCR agents are Papacarie and Biosolv10. GK 101,
are reversible caries and irreversible caries. Reversible discovered by Goldman and Kron in 1976 composed of
occurs when the remineralization process is higher than 0.05% N-monochloroglycine (NMG) and NaOCl.
demineralization. Irreversible occurs when Several literature evaluated GK-101 and concluded that
demineralization is higher than remineralization and GK-101 was inefficient in removing caries, so the
cavities are found in the teeth. Early caries phase occurs formula developed from GK-101 to GK-101E
when the acid product of the bacteria dissolves the (Caridex). GK-101E consists of an ethyl derivative, N-
mineral substance in the enamel. The initial monochrome-DL2 amino butyrate (NMAB). However,
demineralization of the enamel layer forms an opaque some literature states that removing carious tissue with
surface known as a 'white spot .' In this phase, the GK-101E is too time-consuming compared to
enamel layer can remineralize because hydroxyapatite conventional methods. After being evaluated, GK-101
crystals are not completely demineralized. When and GK101E were found to have no significant effect on
hydroxyapatite crystals demineralize completely, caries removal compared to conventional methods. In
remineralization will not occur. When caries reach the 1998, Carisolv was the newest version of the NaOCl-
dentin, the dentinal tubules will provide access for acid based CMCR agent, which is currently one of the most
attachment, causing demineralization of the dentin 5. widely marketed CMCR agents. The enzyme-based
The organic matrix in the dentin will be demineralized, CMCR agent is Papacarie. The main components of
collagen and other matrices will degrade enzymes so it Papacarie are papain, chloramine, and toluidine blue.
forms two zones on the dentin, namely the infected- Biosolv is one of the enzyme-based CMCR agents and
dentin and affected-dentin areas. Histologically, dentinal is still in the testing phase and has not been marketed in
caries divides into some layers, including normal, general yet. Based on product information, this
subtransparent, turbid and infected. The base layer is ingredient contains the enzyme pepsin in phosphoric
healthy dentin. The layer above the base layer is acid/sodium biphosphate buffer. Previous research
subtransparent or transparent. In this layer, there is stated that the CMCR materials that are often used are
minimal demineralization where there is still collagen Carisolv and Papacarie 11,7. CMCR was applied to the
and no bacterial penetration. This layer is also known as cavity using an applicator and stand for 40 seconds, and
affected-dentin caries. The turbid and infected-dentin a blunt excavator was used to remove and clean the
layers are characterized by damage to the dentinal dissolved dentin. The remaining gel is cleaned with a
tubules, collagen decomposition, and bacterial cotton pellet. When the gel's color remains consistent, it
infiltration. Layers with bacterial infiltration of the implies that the cavity is caries-free 12.
dentin are called infected-dentin caries 7.
Treatment for caries can be preventive and 1.2.1. Carisolv
restorative. In the early stage of caries, preventive
procedures are conceivably considered when cavity has Carisolv consists of a set of instruments and
not formed yet. The preventive procedure by giving materials. The instrument is a non-cutting tip to increase
certain materials to increase the remineralization of efficiency in removing infected dentin and retaining
dental hard tissue, reduce the growth of bacteria, affected dentin. The instrument has right angles to make
removing caries easier than conventional excavators. 2. METHOD
The movement when applying this instrument is a
scooping motion 13. Carisolv materials consist of gel and This article uses a literature review to summarize
liquid. Before being put in, the gel and liquid were previous literature correlated with a particular topic
manipulated until homogeneous. Subsequently, the from secondary data. The data was obtained through the
material is placed on the hand instrument and applied to search for scientific articles in 2011-2021 through
dental caries, waiting for 30 seconds and then gently Researchgate, Pubmed, NCBI, IJCPD, MPDI,
remove the carious tissue. Carisolv needed several times Australian Dental Journal, IOSR-JDMS, BMC Health,
repetitions until there was no caries-infected dentin JPDA, and European Journal Dentistry. The keywords
tissue on the teeth. The total time needed is generally 5- used are carisolv, papacarie, and chemomechanical
15 minutes. Carisolv's mechanism in dissolving carious caries removal. The articles used in this study are from
undergoes several stages of destroying fiber tissue in international journals relevant to the topic.
collagen-infected dentin. Carisolv has three amino acids
with different charges that allow electrostatic bonding to 3. RESULT AND DISCUSSION
the carious dentinal protein. All peptide bonds in
protein, collagen are formed by hydrophilic (has Caries is the highest case of oral disease
positive/negative charges) and hydrophobic (does not in Indonesia, with a higher incidence in areas with
have electric charges). Each amino acid in Carisolv will limited healthcare facilities and accessibility. The
bind electrostatically to the protein and produces a prevalence of crown caries is higher than root caries.
chemical process without affecting affected-dentin 14.. CMCR material selectively removes carious-infected
dentin tissue both on the crown and roots. The
1.2.2. Papacarie prevalence of caries in children and adults reaches more
than 75%, with the prevalence of going to the dentist
Papacarie is patented, registered, and approved higher in adults than in children. CMCR material is
by ANVISA (Brazilian Health Regulatory Agency) effectively used in the treatment of childhood caries, so
Brazil and available in gel. Papacarie's main it can potentially increase the number of children going
composition consists of papain, chloramine, and to the dentist. This literature was obtained from research
toluidine blue 9. Papain is an enzyme extracted from the that conducted by previous researchers regarding
leaves and fruits of ripe green papaya and papaya CMCR in the range of 2011-2021 as seen in Table 1.
Carica. Papain is a bactericidal, bacteriostatic, and anti- The prevalence of caries in Indonesia is 88.8%,
inflammatory and will not affect healthy tissue. In with the incidence of crown caries is higher than root
caries, papain works by cleaving collagen molecules caries. Crown caries occur in the enamel or dentin layer,
damaged by caries and can eliminate caries-coated while root caries are in the cementum or dentin layer 13.
fibrin. Chloramine is a compound of chlorine and CMCR method has proven effetive removing both
ammonia, which has bactericidal and disinfectant crown or root infected caries than the conventional
properties. This material is commonly used as an method. Literature by Vartikha et al. state that Carisolv
irrigation solution in root canals and can dissolve removes carious tissue in roots effectively 15. Research
dentinal caries. Toluidine blue was originally a coloring conducted by Hamdi H. Hamama stated that the
agent but proved effective as an antibacterial against removal of caries tissue was more effective in Papacarie
Streptococcus mutans. The mechanism of Papacarie than in Carisolv, referring to the remaining bacteria in
occurs 30-60 seconds after being applied. In the necrotic the crown dentinal tubules after Papacarie was applied
zone of carious tissue, the proteolytic agent papain gel less than Carisolv. Literature by Dr. Sivakumar Pydi
will degrade and eliminate the caries-coated fibrin. compared the efficacy of carious tissue removal with
Furthermore, papain agents will digest necrotic cells. Carisolv and the conventional method based on the time
The degraded collagen will be chlorinated by of work and the size of the carious tissue removed.
chloramine, and O2 will be released and cause a Carisolv proved effective in removing carious tissue
bubbling effect. Hydrogen bonds will be disrupted and compared to the conventional method because in
affect the secondary and quaternary structures. conventional method healthy tissue was removed. In
Afterward the caries  will be chemically dissolved and line with that, the literature by Ahmed H. Ali states that
removed with an excavator on the opposite side 9. Carisolv removal maintains more healthy
Table 1. potential use of CMCR in previous literature
No Title Author Year Publisher Language Method Aim
1. Evaluation of the (Boob, 2014 IJCPD English An in vitro To compare the
Efficiency and Manjula, Study efficiency (time
Effectiveness of Three Reddy, taken for caries
Minimally Invasive Srilaxmi, & removal) and
Methods of Caries Rani) effectiveness
Removal (Knoop hardness
number of the
remaining dentin)
of caries removal
 by three minimally
invasive methods,
i.e. Hand
excavation and
chemomechanical
caries removal
using Carisolv and
Papacarie.
2. Atraumatic (Saber, El- 2019 MPDI English Literature This review
Restorative Treatment Housseiny, review discusses the
and Interim & Alamoud) techniques and
Therapeutic uses of atraumatic
Restoration restorative
treatment (ART)
and interim
therapeutic
restoration (ITR)
and states the
differences
between these two
approaches.
3. Evaluation of the (Divya et 2015 Journal of English An Invitro To evaluate the
Efficacy of Caries al.,) Clinical and Comparative efficacy and
Removal Using Diagnostic efficiency of
Polymer Bur, Research Caries removal
Stainless Steel Bur, Using Polymer
Carisolv, Papacarie Bur, Stainless
Steel Bur, Carisolv
and Papacarie.
4. A short review: (Yamada) 2018 J Clin English Literature To understand
Effectiveness Dentistry Oral review caries treatment
combination with Health effectivity by
glass ionomer cements combining
and chemo- chemomechanical
mechanical caries caries removal and
removal glass ionomer
cement
5. Current update of (H. 2014 Australian English Literature To understand the
chemomechanical Hamama, dental journal review development of
caries removal Yiu, & chemomechanical
methods Burrow) caries removal
materials
6. Effect of (H. H. H. 2015 Australian English Case study This study
chemomechanical Hamama, dental journal and field evaluated the
caries removal on Yiu, & research effect of:
bonding of resin- Burrow) chemomechanical
modified glass caries removal
ionomer cement (CMCR); dentine
adhesives to caries- surface treatments
affected dentine and dentine
substrates on
adhesion of resin-
modified glass
ionomer cement
(RMGIC)
adhesives.
7. Does (Stolic) 2015 Malmö English Systematic This systematic
chemomechanical University review review aimed to
caries removal affect Faculty of summarize
restoration survival? Odontology randomized
controlled trials
(rcts) that evaluate
the survival rates
of restorations,
comparing the
Carisolv system to
hand excavation
 and/or the
conventional
drilling method.
The aim was also
to collect all data
in one place to be
used for further
research
8. Caries Removal by (Pydi & 2015 Journal of English Comparative To compare the
Chemomechanical RaoV) Dental and In-Vitro caries removal
(carisolvtm) and Medical Study efficacy between
Conventional Sciences chemomechanical
(Airotor) Methods (IOSR-JDMS) method
(carisolvtm) and
conventional
method (airotor) in
freshly extracted
molars.
9. Comparative (Avula 2016 Journal of English An in vitro To compare the
Evaluation of Samatha et Contemporary Study microleakage of
Microleakage in al.,) Dentistry primary molars
Restored Primary restored with
Molars using conventional
Conventional and glassionomer
Chemomechanical cement (GIC) and
Removal of Carious Giomer after caries
Tissue removal using
conventional
cavity preparation
(CCP) and chemo-
mechanical caries
removal (CMCR)
techniques.
10. The impact (Adham, El 2021 BMC oral English A randomized To compare the
of minimally invasive Kashlan, health controlled efectiveness of
restorative techniques Abdelaziz, & clinical trial chemo-mechanical
on perception Rashad) caries removal
of dental pain using
among pregnant
women
11. The Assessment of a (Ali, Thani, 2020 King College English In Vivo and To determine the
Minimally Invasive Foschi, London In Vitro effectiveness of a
Procedure in the Banerjee, & Journal Studies minimally invasive
Treatment of Deep Mannocci) indirect clinical
Carious Lesions pulp protection
technique in
preserving pulp
vitality in
symptomatic teeth
in vivo
12. Microtensile bond (Varun, 2018 J. Evolution English An in vitro To evaluate the
strength of gic and Chamarthi, Med. Dent. study influence of
rmgic restored to & Sci. Carisolv and
carious teeth treated Annamalai) Papacarie on the
with carisolv and microtensile bond
papacarie strength (µtbs) of
conventional glass
ionomer cement
(GIC) and resin
modified glass
ionomer cement
(RMGIC) restored
to caries-affected
dentin.
13. Shear bond strength of (Shamim, 2011 JPDA English A randomized To determine the
conventional glass Ullah, & Ali) controlled effect of a chemo
ionomer cement to clinical trial mechanical caries
 mechanically treated in vivo removal (CMCR)
versus gel Carisolv™ on
chemomechanically shear bond
treated dentin strength (SBS) of
conventional glass
ionomer cement
bonded to human
permanent dentin
14. Comparative (Hegde & 2016 Journal of English An In Vivo To compare the
Evaluation of Chaudhari) International Study efficacy of caries
Mechanical and Oral Health removal, time
Chemo-mechanical taken, pain
Methods of Caries threshold
Excavation: experienced by the
patient and anxiety
experienced during
various caries
removal methods.
15. Chemomechanical (Mithra 2018 JP publisher English Literature To compare
Caries Removal: A Hedge et reviewe papacarie
Conservative and al.,) affectiveness as
Pain-Free Approach chemomechanical
caries removal
than with
atraumatic
restorative
removal
16. Randomized (Motta et 2014 J Appl Oral English Randomized Compare the
controlled clinical trial al.,) Sci. controlled effectiveness of
of longterm chemo- clinical trial papacarietm gel
mechanical caries for the chemo-
removal using mechanical
papacarietm gel removal of carious
lesions on primary
teeth to
conventional
caries removal
with a low-speed
bur with regard to
execution time,
clinical aspects
and radiographic
finding
17. No Drill Dentistry: A (Pradnya 2018 Journal of English Literature To reviews the
Review of Advances Bansode) medical review newest
in Non-Rotary science and developments in
Methods of Caries clinical non-rotary caries
Removal research excavation
techniques and
their mechanism of
action
18. Chemomechanical (Kumar et 2020 European English A To compare the
caries removal method al) journal comparative effectiveness of
versus mechanical dentistry in vivo study various caries
caries removal removal
methods in clinical techniques in
and community-based mandibular
setting primary molars
using Smart Burs,
atraumatic
restorative
technique (ART)
(mechanical caries
removal) and
Carie-care
(chemomechanical
caries removal
 [CMCR]) among
primary school
children in clinical
and community-
based settings.
19. Chemomechanical (Krishnan, 2020 Drug English Literature To understand
caries removal Ganapathy, invention review cmcr development
& Ranjan) today journal depends on
eficacy, time,
materials and
instruments
20. Costs and benefts of (Bottega et 2018 Nature of English A randomized To analyzed the
Papacarie in pediatric al.,) scientific clinical trial cost, per
dentistry report journal procedure, of
Papacarie gel
compared to the
traditional method
(drilling), and
performed a
comparison
between these
methods of carious
tissue removal
21. Evaluation of (Viral Maru, 2016 International English In vivo study To evaluate and
Marginal Leakage and Shakuntala, Scholarly compare the
Shear Bond Strength & Research marginal leakage
of Bonded Nagarathna) Notices and shear bond
Restorations in strength between
Primary Teeth after conventional and
Caries Removal by Papacarie
Conventional and techniques of
Chemomechanical caries removal in
Techniques primary molars
22. Endodontic (Navin et 2020 Journal of English Literature To understand
implications and al.,) dental review endodontic
innovative preventive problems and inovation
strategies during novel solutions treatment in Covid
COVID-19 pandemic era
requiring emergency
endodontic treatment
23. Chemomechanical (Ganesh & 2011 J. Dent. Oral English Literature To understand
caries removal Parikh) Hyg. review effectiveness of
(CMCR) agents: carisolv and
Review and clinical papacarie in
application in primary decreasing pain
teeth during treatment
24. Carisolv- An (Kathuria, 2013 Journal of English Literature To understand
Innovative Method of Ankola, critical and review effectiveness
Caries Removal Hebbal, & diganostic CMCR as an
Mocherla) research alternative
procedure in
removing caries
treatment

tissue than caries removal using a bur, so there is principle because healthy tissue is preserved to the
enough affected-dentin left to maximize the function of greatest extent 9,12 .
dentin as pulp protection. Removing carious tissue with In the restoration procedure, after the carious
the help of Carisolv and Papacarie can minimize the tissue is removed, the next step is to prepare the cavity
damage of dentinal tubules compared to Stainless Steel and filled with an adhesive material to restore its
bur so that more healthy tooth tissue remains higher 18. function, shape, and aesthetics and to maintain the
The mechanism of CMCR that selectively dissolves remaining healthy tissue. Treatment with extraction is
infected tissue is a line with the minimally invasive more common in remote areas than with restoration.
The percentage of tooth extraction is 29.6%, and the exposed, which will cause pain and pressure, so local
restoration treatment reached 2.6% 4. In children aged 5- anesthetic injection is often required. Injection of local
9 years, tooth extraction treatment reached 33.2%, and anesthetic in pediatric patients often causes fear and
restoration treatment 3%. In adults aged 55-64, tooth discomfited and is not easy to do because of the low
extraction treatment reached 29%, and restoration level of cooperation in children 36. Referring to the
treatment only 5%3. ART is a caries treatment procedure basic principles of pediatric dentistry, which is painless
used in areas with limited facilities and accessibility. treatment and minimal intervention, CMCR with
The most effective restorative material in ART papacarie method have lower perceptions of pain and
procedures is high-viscosity glass ionomer cement. anxiety than conventional methods 37. That is in line
Some advantages of GIC are fluoride release that will with research conducted by Motta LJ that caries tissue
increase the potential of remineralization, bind well to removal with CMCR causes a lower degree of pain than
enamel and dentin, does not irritate the pulp, and easy to conventional methods and does not require local
manipulate 34. The use of CMCR did not affect the anesthesia. Taking carious tissue with CMCR material
bonding of the GIC to the affected dentin. The literature preserved more healthy tissue to be maintained. The
by Yoshihide Yamada states that CMCR with GIC is literature by Cardoso et al. conducted a study based on
effective in areas with limited instruments and materials previous research and found that from 6 studies, the
because there is no need to use a bur. CMCR procedure final cavity produced by conventional methods was
filled with GIC shows a slighter incidence of relatively more comprehensive than the Carisolv, and
microleakage rather than the conventional method. Papacarie. This resulted in a relatively more minor
Literature by Ravi Prasaanthini Varun, comparing the caries-free cavity. Carisolv was statistically more
strenght bond of CMCR and GIC, found that GIC binds efficient than an excavator, ten previous studies stated
better to Carisolv than to Papacarie. The specifics that patients who were approached with CMCR
instrument used in the Carisolv and Carisolv's ability to materials for carious lesions had a significantly better
dissolve the carious tissue can minimize trauma to the treatment experience.
dentin and make the remaining tissue surface suitable Based on Riskesdas data in 2018, the
for the restorative materials attachment.. The research of prevalence of caries incidence in rural areas is higher
Ali Shamim Atta Ullah was alined, where the results of than in urban areas, with visits to the dentist higher in
the GIC bond were better when caries tissue was cities than in rural areas. In 2018, 96% of Indonesians
removed with Carisolv compared to without using did not visit the dentist. In addition to the lack of
Carisolv. availability of health facilities, according to Cornelia et
Literature by Santoso in 2020 stated that al., low economic status affects an individual's ability to
treatment to the dentist is higher in adults than children visit the dentist. Based on the literature by Santosh
35
. Riskesdas data state that more than 95% of children Kumar et al., the ART method with the addition of
aged 3-14 years do not go to dental treatment. Pediatric CMCR is effective in areas with low incomes because
dental care causes pain and anxiety in children during of its lower price and minimal use of instruments
the procedure. During conventional methods, removal compared to other atraumatic restorative methods such
using a bur is often painful in children. The sound as atraumatic resin restoration, air abrasion, and laser. In
produced by the device and the vibrations generated will line with this, literature by Preethi Krishnan states that
trigger anxiety and affect the level of cooperativeness of apart from being effective in removing carious tissue,
pediatric patients 36. Literature by Rahul J Hegde states the addition of CMCR material to ART procedures has
that CMCR can reduce pain and anxiety during other advantages, such as this method proven to be easy,
treatment for children because it does not cause thermal more convenient, and cheaper. Research conducted in
or vibration effects compared with bur. The specific Mecca, an area with limited facilities and resources,
hand instrument used in the Carisolv design is without a Papacarie is more effective than Carisolv because it is
sharp surface, so the caries tissue removal procedure cheaper and takes less time to remove caries tissue 12.
does not cause pain. Based on some literature, anxiety in This follows Preethi Krishnan's research which states
children is lower in the CMCR treatment than in the bur that Papacarie is cheaper than Caridex and Carisolv.
treatment. Another study also stated that carious tissue Papacarie also proved to be 42% cheaper than the
removal with CMCR can reduce apprehension and fear conventional method with a bur. In conventional
in children compared to hand instruments without treatments that require anesthesia, the use of Papacarie
CMCR. Literature by Mithra N Hegde and Abhishek is 58% cheaper because the procedure does not require
MA stated that pain perceptions during treatment in anesthesia. In line with this, the literature by Viral P
children and medically compromised patients could be Maru in 2013 states, caries removal with Carisolv takes
suppressed using CMCR due to not using bur in the longer than conventional methods, the advantages of
procedure, which possibly increasing pain perception. Carisolv are it does not cause pain and does not require
Carie-care with an enzyme-based mechanism is proven anesthesia.
more effective in children than Papacarie and Carisolv The 2030 Caries-Free Indonesia Program
26
. Conventional caries removal using a bur has the targets children aged 12 years to be caries-free by 2030,
potential to widen and affect the healthy dentin even to with the DMFT index reaching 1. One of the efforts
a deeper layer so that the dentinal tubules will be more made is to provide preventive and curative caries care.
The ART method is one of the caries treatment launched 6. P SM, Mallya S. Microbiology and Clinical
by the government in the 2030 Caries Free Indonesia Implications of Dental Caries – A Review. J
program 38. CMCR has the potential to succeed in the Evol Med Dent Sci. 2020;9(48):3670-3675.
2030 Caries Free Indonesia program based on the doi:10.14260/jemds/2020/805
effectiveness of CMCR as a caries removal method with
7. Hamama HHH, Yiu CKY, Burrow MF. Effect
ART principles and the effectiveness of CMCR in the
of chemomechanical caries removal on bonding
treatment of childhood caries.
of resin-modified glass ionomer cement
In cases with deep or proximal caries, it is
adhesives to caries-affected dentine. Aust Dent
necessary to open the cavity using a bur. CMCR can be
J. 2015;60(2):190-199. doi:10.1111/adj.12318
combined with a bur in caries removal procedures.
Recent research has developed a tool in the form of 8. Slayton RL, Fontana M, Young D, et al. Dental
Cera-bur and Polybur on Carisolv with a low-speed Caries Management in Children and Adults.
handpiece to reduce the work time of caries removal and NAM Perspect. 2016;6(9).
increase the ability to remove caries tissue 7. Another doi:10.31478/201609d
advantage of CMCR is that it can be used as a treatment
9. Ganesh M, Parikh D. Chemomechanical caries
option during a pandemic because the procedure uses a
removal ( CMCR ) agents : Review and clinical
hand instrument to reduce the potential for aerosols, and
application in primary teeth. J Dent Oral Hyg.
Carisolv has a high pH, and after being applied to dental
2011;3(March):34-45.
hard tissue, Carisolv can remineralize after two weeks
33
. Some of the disadvantages of CMCR are that the 10. MA A. Chemomechanical Caries Removal: A
Carisolv excavation time is longer than conventional, Conservative and Pain-Free Approach. Adv Res
because the procedure requires to be applied several Gastroenterol Hepatol. 2017;5(4):69-71.
times. CMCR cannot be used on enamel caries because doi:10.19080/argh.2017.05.555666
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