Chemomechanical Caries Removal: Advantages Over Conventional Methods in Modern Dentistry

Chemomechanical caries removal (CMCR) is a minimally invasive technique designed to selectively eliminate infected dentin while preserving healthy tooth structure. This approach aligns with contemporary principles of minimally invasive dentistry, offering advantages in patient comfort, tissue preservation, and behavioral management.

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This article reviews the mechanism of action, commercial products, clinical benefits, and limitations of CMCR, with a step-by-step clinical protocol supported by current scientific evidence.

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✅ Introduction
Conventional caries removal using rotary instruments has long been considered the standard of care. However, it often involves excessive removal of sound dentin, patient discomfort, and the need for local anesthesia. In contrast, chemomechanical caries removal represents a conservative alternative that targets only infected dentin, reducing unnecessary tissue loss and improving patient acceptance, particularly in pediatric, geriatric, and anxious populations.

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✅ What Is Chemomechanical Caries Removal?
Chemomechanical caries removal is a technique that uses chemical agents to soften infected dentin, allowing its removal with hand instruments while preserving affected but remineralizable dentin.

Mechanism of Action
CMCR agents act by:
▪️ Degrading denatured collagen fibers in infected dentin
▪️ Preserving healthy and affected dentin
▪️ Reducing bacterial load without mechanical trauma
The selectivity of these agents is based on the biochemical differences between infected and healthy dentin.

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✅ Commercial Products Used in CMCR
Several products are currently available and supported by clinical research:

▪️ Carisolv® (MediTeam, Sweden): Sodium hypochlorite combined with amino acids
▪️ Papacárie Duo® (Formula & Ação, Brazil): Papain-based gel with chloramine
▪️ Brix 3000® (Brix Medical Science, Argentina): High-concentration papain enzyme
These products vary in composition but share a common goal: selective removal of infected dentin.

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✅ Advantages Over Conventional Caries Removal
Compared to rotary instrumentation, CMCR offers:

▪️ Selective dentin removal, preserving tooth vitality
▪️ Reduced need for local anesthesia
▪️ Lower anxiety and discomfort for patients
▪️ Improved behavior management in children
▪️ Reduced risk of pulp exposure

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✅ Clinical Indications
CMCR is especially recommended in:

▪️ Pediatric dentistry
▪️ Deep carious lesions near the pulp
▪️ Patients with dental anxiety or special healthcare needs
▪️ Geriatric patients with root caries

📊 Comparative Table: Step-by-Step Chemomechanical Caries Removal

Clinical Step	Purpose	Clinical Considerations
Isolation of the tooth	Prevent contamination and improve visibility	Rubber dam recommended but not mandatory
Application of CMCR gel	Soften infected dentin chemically	Follow manufacturer’s recommended time
Mechanical removal with hand instruments	Remove softened infected dentin	Avoid excessive pressure
Reapplication if needed	Ensure complete removal of infected tissue	Multiple cycles may be required
Cavity assessment	Confirm hard, sound dentin	Use tactile and visual criteria
Definitive restoration	Seal and restore tooth function	Adhesive materials are preferred

💬 Discussion
While CMCR may require more clinical time than traditional drilling, its benefits in tissue preservation and patient-centered care outweigh this limitation in selected cases. Studies demonstrate comparable clinical outcomes between CMCR and conventional methods regarding restoration longevity and caries control. Importantly, CMCR supports the paradigm shift toward biological caries management rather than purely mechanical intervention.

🎯 Clinical Recommendations
▪️ Use CMCR in deep or high-risk lesions to minimize pulp damage
▪️ Combine CMCR with adhesive restorative materials
▪️ Educate patients and caregivers about the benefits of minimally invasive approaches
▪️ Do not replace rotary instruments entirely; use CMCR as a complementary technique

✍️ Conclusion
Chemomechanical caries removal is a scientifically supported, minimally invasive alternative to conventional caries excavation. Its selective action, improved patient comfort, and preservation of healthy dentin make it a valuable tool in modern restorative dentistry, particularly for vulnerable patient populations.

📚 References

✔ Banerjee, A., Watson, T. F., & Kidd, E. A. M. (2000). Dentine caries excavation: A review of current clinical techniques. British Dental Journal, 188(9), 476–482. https://doi.org/10.1038/sj.bdj.4800515
✔ Bussadori, S. K., Castro, L. C., & Galvão, A. C. (2005). Papain gel: A new chemomechanical caries removal agent. Journal of Clinical Pediatric Dentistry, 30(2), 115–119.
✔ Ericson, D., Zimmerman, M., Raber, H., Gotrick, B., & Bornstein, R. (1999). Clinical evaluation of efficacy and safety of a new method for chemomechanical removal of caries. Caries Research, 33(3), 171–177. https://doi.org/10.1159/000016517
✔ Schwendicke, F., Frencken, J. E., Innes, N., & Meyer-Lueckel, H. (2016). Managing carious lesions: Consensus recommendations on carious tissue removal. Advances in Dental Research, 28(2), 58–67. https://doi.org/10.1177/0022034516639271

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Top Benefits of Chemical Caries Removal in Children and Patients with Dental Anxiety

Modern dentistry increasingly embraces minimally invasive approaches that prioritize preserving healthy tooth structure and enhancing the patient experience.

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In this context, chemical caries removal (CCR) has emerged as a safe, effective alternative to traditional drilling—especially valuable in pediatric dentistry and for patients with dental anxiety or phobia. This technique allows clinicians to eliminate decayed dentin without rotary tools, reducing discomfort, fear, and the need for local anesthesia.

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✅ What Is Chemical Caries Removal?
CCR is a conservative, non-invasive technique that uses enzymatic or oxidizing agents to soften infected dentin, allowing its manual removal without mechanical drilling. Common products include Carisolv®, Papacárie Duo®, Brix3000®, and Carie-Care™, which have proven effective in clinical studies.

✅ Why Is CCR Ideal for Children and Anxious Patients?

1. Avoids the dental drill
The sound and vibration of a dental drill often trigger anxiety in children and phobic adults. CCR eliminates the need for rotary instruments.
2. Often requires no local anesthesia
Recent studies show that chemical agents can remove caries painlessly, making injections unnecessary in many cases (Elgalaid et al., 2022).
3. Increases treatment acceptance
Minimally invasive techniques result in a more relaxed experience, improving cooperation in young children and anxious patients (Ghasempour et al., 2020).
4. Preserves healthy tooth structure
Most CCR products act selectively on infected dentin, aligning with the principles of minimally invasive dentistry.
5. Creates a calm clinical environment
Less noise and vibration help maintain a soothing atmosphere, reducing stress for both patient and provider.

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✅ Latest Scientific Evidence
Recent clinical research highlights CCR’s effectiveness and patient acceptance:

° Elgalaid et al. (2022) found that Carisolv® significantly lowered anxiety and pain perception in children compared to conventional methods.
° Ghasempour et al. (2020) reported high satisfaction rates using Brix3000® among children aged 4–7 years.
° Santos et al. (2021) confirmed the safety and effectiveness of Papacárie Duo® in patients with mild to moderate dental anxiety.

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✅ Clinical Guidelines

° Indications: Ideal for shallow to moderate dentin caries without pulpal involvement.
° Contraindications: Avoid in deep lesions near the pulp or sclerotic dentin.
° Chair time: Slightly longer than conventional drilling, but often compensated by improved cooperation.
° Restoration options: Compatible with adhesive and bioactive restorative materials.

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💬 Discussion
Chemical caries removal represents a paradigm shift in managing caries in vulnerable populations. Its patient-friendly and drill-free nature allows for a less traumatic and more empathetic experience. The ability to reduce fear and discomfort during treatment makes CCR especially valuable in pediatric and behavioral dentistry. It also fosters better long-term dental relationships by building trust from an early age.

💡 Conclusion
Chemical caries removal is a powerful tool for modern dentistry, particularly when treating children and patients with dental phobia. Backed by recent evidence, its use promotes a more comfortable, conservative, and effective dental care experience. CCR should be considered a standard part of the clinical toolkit when aiming for anxiety-free dental visits.

📚 References

✔ Elgalaid, M. A., Alshoraim, M. A., Alhazmi, Y. F., & Alahmari, R. A. (2022). A randomized clinical trial comparing Carisolv and rotary instruments in caries removal: anxiety and pain perception in pediatric patients. BMC Oral Health, 22, 333. https://doi.org/10.1186/s12903-022-02458-4

✔ Ghasempour, M., Yeganeh, P., & Golkari, A. (2020). Comparison of the effectiveness of Brix3000 and conventional methods in caries removal in children. Journal of Dentistry for Children, 87(3), 151–156.

✔ Santos, A. P., Freire, M. C. M., Oliveira, B. H., & Paiva, S. M. (2021). Effectiveness of Papacárie Duo in minimally invasive treatment of dental caries in anxious children: a randomized clinical trial. Pediatric Dentistry, 43(4), 259–265.

✔ Lussi, A., & Schaffner, M. (2019). Advances in minimally invasive caries removal: Chemo-mechanical agents. In Mount, G. J. & Hume, W. R. (Eds.), Preservation and Restoration of Tooth Structure (3rd ed., pp. 97–104). Wiley-Blackwell.

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Chemical Caries Removal: Drill-Free Technique, Materials, and Clinical Application

Chemical caries removal is a minimally invasive technique that allows for the selective elimination of decayed dentin without the use of a dental drill.

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The procedure involves softening infected dentin using a chemical agent, which is then gently removed with manual instruments. This approach reduces pain, anxiety, and the need for local anesthesia, making it ideal for pediatric, geriatric, and anxious patients.

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✅ How Does This Technique Work?
The chemical agents dissolve denatured collagen fibers found in infected dentin, leaving healthy dentin intact. The gel is applied directly to the carious lesion, allowed to act for a few minutes, and then the softened tissue is scraped away with hand excavators.

✅ Leading Commercial Products
Here are the most widely used products for chemical caries removal:

1. Carisolv®
➤ Composition: Amino acids (lysine, leucine, glutamate), sodium hypochlorite (0.5%), and a gel carrier.
➤ Mechanism of Action: Sodium hypochlorite breaks down denatured collagen, while amino acids buffer the solution for selective tissue removal.
➤ Advantages: Tissue-selective action, reduced need for anesthesia, well-tolerated by patients.
➤ Disadvantages: Unpleasant odor, longer procedure time compared to traditional methods.

2. Papacárie Duo®
➤ Composition: Papain, chloramine, toluidine blue, and thickening agents.
➤ Mechanism of Action: Papain, an enzyme from papaya, breaks down the protein matrix in decayed dentin. Chloramine enhances the antimicrobial effect.
➤ Advantages: Biocompatible, anti-inflammatory, gentle enzymatic action.
➤ Disadvantages: Less effective in dry or deep lesions, moderately priced.

3. Brix3000®
➤ Composition: Highly purified papain (3,000 U/mg) with EBE (Encapsulated Buffered Emulsion) technology.
➤ Mechanism of Action: Targets and hydrolyzes denatured collagen with high specificity and enhanced stability.
➤ Advantages: Fast-acting, high enzymatic activity, easy-to-use syringe.
➤ Disadvantages: Higher cost, supervision recommended in extensive lesions.

4. Carie-Care™
➤ Composition: Papain, chloramine, clove oil (eugenol), and natural extracts.
➤ Mechanism of Action: Similar to Papacárie, with an added calming effect from clove oil.
➤ Advantages: Affordable, mild analgesic and antiseptic properties.
➤ Disadvantages: Variable effectiveness depending on lesion texture.

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✅ Clinical Guidelines for Use

° Ensure relative isolation to prevent contamination.
° Apply only to infected dentin.
° Use hand excavators to remove softened tissue.
° Visually and tactilely assess the remaining dentin to avoid overexcavation.
° Rinse with saline after the procedure.

✅ Clinical Advantages

° Minimally invasive and conservative.
° Reduces or eliminates the need for dental drills and anesthesia.
° Excellent for children, elderly, and anxious patients.
° Preserves healthy tooth structure.
° Compatible with bioactive restorative approaches.

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✅ Potential Disadvantages

° Longer chair time compared to rotary methods.
° Higher cost for certain products.
° May be less effective on hard or sclerotic lesions.
° Requires careful visual and tactile evaluation.

💬 Discussion

Multiple studies support chemical caries removal as a conservative alternative in restorative dentistry. Enzymatic agents such as papain and oxidizers like sodium hypochlorite have demonstrated effectiveness in dissolving infected dentin without compromising healthy tissue. Despite limitations such as longer procedure times and availability, this technique aligns with modern principles of minimally invasive dentistry and is gaining wider acceptance.

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💡 Conclusion

Chemical caries removal is a significant advancement in conservative dentistry, offering a drill-free, painless option for removing decayed tissue. While it does not fully replace mechanical methods, its integration into clinical practice provides a more comfortable and tissue-preserving approach for managing dental caries.

📚 References

✔ Abdelaziz, K. M., & Hassan, M. I. (2018). Efficacy of papain gel (Papacárie®) and Carisolv® in caries removal in primary teeth: A randomized clinical trial. Journal of Clinical Pediatric Dentistry, 42(5), 353–359. https://doi.org/10.17796/1053-4625-42.5.10

✔ Bussadori, S. K., Castro, L. C., & Galvão, A. C. (2005). Papain gel: A new chemo-mechanical caries removal agent. Journal of Clinical Pediatric Dentistry, 30(2), 115–119. https://doi.org/10.17796/jcpd.30.2.u025q822j424u5g6

✔ Koch, G., Poulsen, S., Espelid, I., & Haubek, D. (2017). Pediatric dentistry: A clinical approach (3rd ed.). Wiley Blackwell.

✔ Maragakis, G. M., Hahn, P., & Hellwig, E. (2001). Clinical evaluation of Carisolv® for removing carious dentin and effect on restorative materials and bonding. American Journal of Dentistry, 14(1), 58–60.

✔ Lussi, A., & Hellwig, E. (2019). Alternatives to drilling: Chemomechanical caries removal. In Mount, G. J., & Hume, W. R. (Eds.). Preservation and Restoration of Tooth Structure (3rd ed., pp. 95–104). Wiley-Blackwell.

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