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Chemomechanical caries removal in children
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Chemomechanical caries removal in children An operator’s and pediatric patients’ responses Marita R. Inglehart, Dr. Phil Habil; Mathilde C. Peters, DMD, PhD; Michael H. Flamenbaum, DMD, MS; Nnenna N. Eboda, DDS, MS; Robert J. Feigal, DDS, PhD
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Background. This study investigated an oper✷ ✷ ator’s and pediatric patients’ responses to chemomechanical caries removal (CMCR) versus the traN ditional method (TM) of caries removal using a C U U I handpiece and a round bur when treating dentinal- A R N G E D 1 TICLE depth occlusal lesions with minimal enamel access in primary molars. Methods. Data were collected from 50 children at baseline and before, during and after caries removal using CMCR or TM. The subjects in the CMCR group were on average younger than the subjects in the TM group and had more deep lesions. Results. The operator rated CMCR as needing more clinical and technical effort and more total effort than TM. He was less satisfied with CMCR than with TM. Subjects in the CMCR group perceived the time needed for treatment as significantly longer than did the subjects in the TM group. Fear of the dentist decreased in subjects in the TM group from before to after the operative appointment, while it increased in subjects in the CMCR group. Conclusions. The authors found no direct advantage in using CMCR over using TM. Clinical Implications. CMCR cannot be recommended as an alternative to TM when treating dentinal depth occlusal lesions with minimal access in primary molars. Key Words. Behavioral sciences; anxiety; pain; pediatric dentistry; caries. JADA 2007;138(1):47-55. I
DISCLOSURE: 3M ESPE, St. Paul, Minn., provided the restorative materials for this study. MediTeam, Göteborg, Sweden, contributed materials and instruments, as well as financial support.
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hemomechanical caries removal (CMCR) can be a useful alternative to the traditional method (TM) of caries removal using a handpiece and a bur. Instead of using a bur and sharp excavators, CMCR uses a gel (Carisolv, MediTeam, Göteborg, Sweden)1 that softens denatured dentin, which then can be removed with blunt instruments. Two comprehensive overviews of various techniques for caries removal have been published.2,3 The literature provides conflicting evidence concerning the clinical effectiveness of CMCR. CMCR does not use a slow-speed handpiece and round bur, so one might wonder if it might be a more patient-friendly technique and, thus, a preferable alternative to TM. In particular, one might argue that dental fear may be alleviated when using CMCR, because the use of the handpiece can be kept to a minimum and no local anesthetic will be needed. This outcome could be especially important when treating pediatric patients. Research findings concerning operators’ and patients’ responses to CMCR have been inconclusive.4-7 Several studies have evaluated
Dr. Inglehart is an associate professor of dentistry, Department of Periodontics and Oral Medicine, School of Dentistry, University of Michigan, Ann Arbor, and an adjunct professor of psychology, Department of Psychology, College of Literature, Science and Arts, University of Michigan, Ann Arbor. Address reprint requests to Dr. Inglehart at Department of Periodontics and Oral Medicine, School of Dentistry, University of Michigan, Ann Arbor, Mich. 48109-1078, e-mail “[email protected]”. Dr. Peters is a professor of dentistry, Department of Cariology and Restorative Dentistry, School of Dentistry, University of Michigan, Ann Arbor. Dr. Flamenbaum was a graduate student, Department of Pediatric Dentistry, University of Michigan, Ann Arbor, when this article was written. He now is in private practice in pediatric dentistry, Atlanta. Dr. Eboda was a pediatric staff dentist, Pediatric Dental Clinic, Mott Children’s Health Center, Flint, Mich., and an adjunct clinical assistant professor, Department of Pediatric Dentistry, University of Ann Arbor, when this article was written. She now is in private practice in pediatric dentistry, Flint, Mich. Dr. Feigal is a professor, Department of Developmental and Surgical Studies, University of Minnesota, Minneapolis.
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adult patients’ responses to CMCR,4,8-11 and seven studies have investigated pediatric dental patients’ responses to CMCR.7,10,12-16 While we provided an overview of the results of these seven studies concerning the efficacy and efficiency of CMCR in an earlier report,17 it is interesting to consider our findings concerning the operator’s and patients’ responses to CMCR. Attari and colleagues10 used CMCR or TM without anesthesia to treat two matched lesions in 80 first or second primary molars in 4- to 11year-old children. They recorded the time taken for caries removal and the child’s anxiety levels before and after each treatment. They found that CMCR took significantly longer than TM. They found no significant difference in anxiety levels before or after the treatment in either group. Maragakis and colleagues7 treated 32 contralateral primary molars with similar carious lesions in 16 7- to 9-year-old children. They treated each tooth with TM or CMCR, while they treated contralateral teeth with opposite treatment. They found that CMCR took more time than did TM. They administered local anesthetic for TM treatments but not for CMCR treatments. Although preoperatively 13 of the 16 children indicated that they would not mind being in the dental chair a little longer to avoid the use of the drill, postoperatively 11 of the 16 children indicated that they preferred the drill because of the shorter treatment time and the absence of a bad taste in their mouths during the treatment. The investigators concluded that the patients preferred TM to CMCR. Munshi and colleagues13 investigated the efficacy of CMCR clinically by treating 50 primary and permanent teeth with CMCR in 3- to 12-yearold children. No discomfort was reported during the removal of soft carious dentin, while mild discomfort was reported during the removal of arrested carious dentin in 11 of 20 teeth. The authors concluded that CMCR was most efficient in soft-caries removal and may have applications in pediatric dentistry. The absence of a control group, however, limited the generalizability of the study’s results. Kavvadia and colleagues14 compared CMCR and TM when treating 92 lesions in 31 children aged 28 months to 9 years. When the investigators treated 32 posterior lesions, they found that the working time with CMCR was longer. However, the children’s cooperation was similar and the prolonged time did not seem to affect their 48
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behavior negatively. The children did not report disliking the taste. Balciuniene and colleagues12 treated 30 children aged 3 to 13 years and compared CMCR and TM in primary teeth (63 percent) and permanent teeth (37 percent). The children in the CMCR group reported experiencing less pain and almost no dislike of the smell or taste of the gel, despite the fact that in 60 percent of the CMCR cases caries removal had to be completed with the bur, and that the treatment time for CMCR was longer than that for TM. Bergmann and colleagues15 studied patients’ acceptance of CMCR while treating 92 primary teeth in 46 children aged 4 to 11 years. The investigators found a high degree of patient acceptance even when the CMCR time for the treatment was more than twice as long as that needed for TM. The children and dentists reported reduced anxiety levels and lower degrees of pain with CMCR than with TM. Lozano-Chourio and colleagues16 compared CMCR with high-speed excavation in 40 children aged 7 to 9 years. They concluded that CMCR was an effective alternative clinical method for the removal of occlusal caries in cavitated primary molars; that it preserved dental tissue, resulting in smaller-sized cavities; and it appeared to be more comfortable for the patients (71 percent preferred CMCR), despite the fact that the clinical treatment time was three times longer than that required for high-speed excavation. While these studies were important steps in the assessment of pediatric patients’ responses to CMCR, they had some limitations such as a lack of a control group,13 differences between groups in treatment,7,14,16 differences in which behavioral aspects were considered12,13,15,16 and the failure to use standardized methods of assessing the child’s response in terms of dental fear and pain.7,12,14 These studies also did not assess the operators’ responses and satisfaction with the treatment. We conducted a prospective, randomized controlled clinical trial to investigate the overall effectiveness of CMCR, as well as the operator’s and pediatric patients’ responses to CMCR as compared with TM. Elsewhere, results concerning the efficacy and efficiency of CMCR as well as the need for local anesthesia with both techniques ABBREVIATION KEY. CMCR: Chemomechanical caries removal. IRB: Institutional review board. SD: Standard deviation. TM: Traditional method.
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have been reported.17 This report discusses the findings concerning the operator’s and pediatric patients’ responses to CMCR. The operator’s responses were concerned with the clinical effort needed, the effort required for managing the behavior of the pediatric patient, the operator’s satisfaction with the treatment, the degree of acceptance of both methods by the child and the perceived pain the patient experienced. We collected data from the pediatric patients concerning their happiness and fear before and after the appointment, their perception of the time needed and the pain they experienced. METHODS
The Institutional Review Board (IRB) for the Health Sciences at the University of Michigan, Ann Arbor, and the Institutional Review Board of Mott Children’s Health Center, Flint, Mich., approved our randomized controlled study. We obtained written assent from the pediatric patients and written consent from the parents or legal guardians before we enrolled the subjects in the study. We recruited 50 healthy subjects (27 male, 23 female) aged between 6 and 11 years (average age: 8.1 years) at regularly scheduled appointments at the pediatric dentistry department of Mott Children’s Health Center. The study inclusion criteria were the patient’s age (6-12 years) and the presence of at least one primary molar with occlusal caries penetrating into dentin. To reduce operator variability affecting the outcomes, one trained operator (M.H.F.), who had experience using CMCR, treated all of the subjects. After enrollment, the subjects responded to a baseline child survey that measured happiness, oral health–related quality of life,18,19 dental fear (measured with the Dental Subscale of the Children’s Fear Survey Schedule developed by Cuthbert and Melamed)20 and memory of previous dental experiences. A dental assistant read the survey to the subjects while they followed along with a corresponding survey aid. A dental assistant collected all other data when the subjects returned for the operative appointment. Pretreatment. A trained staff member administered the preoperative child survey immediately before the restorative treatment, while the subjects’ caregivers waited outside the room. This survey consisted of only three questions concerning the subject’s level of happiness and the subject’s knowledge about the forthcoming opera-
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tive treatment; the staff member asked the second question first as a closed-ended question and then as an open-ended question that allowed the child to explain the answer. Treatment session. Before the treatment appointment, the operator randomly assigned each tooth to either the CMCR or TM (control) group. (We did not include a group of subjects who received both treatments owing to the length of time that would have been needed to recruit sufficient numbers of patients with two eligible carious lesions.) He then isolated the study tooth with cotton rolls, dry angles or both, and he instructed the subjects to raise their left hands if they felt any discomfort (“a hurt on your tooth”). After achieving an adequate opening and access of the carious lesion, the operator used the randomly assigned method of caries removal. For CMCR, he repeated the procedure for a maximum of 15 minutes. In 42.3 percent of the CMCR cases, complete caries removal was not achieved at the 15-minute mark, and the operator used TM to complete caries removal. He assessed complete caries removal using visual-tactile clinical criteria (experiencing a no “tug-back” sensation with explorer inspection), and an independent evaluator confirmed complete caries removal. If both dentists (the operator and the evaluator) still noted active caries, they examined the area in question and reached a consensus. After the operator removed residual active caries using the assigned method, he restored the teeth using a standard adhesive resin-based composite system according to the manufacturer’s instructions. Local anesthesia. We initiated all treatment without local anesthesia. In the event that the child raised his or her left hand, the operator ruled out external sources of discomfort (that is, cotton rolls, sound of the drill, water spray, etc.) unrelated to caries removal. If the caries removal procedure was the cause of the child’s discomfort, the operator asked the child, “Can I try that again and count to 5?” or “Should I help the tooth take a nap first with some sleepy juice?” If the subject requested local anesthesia, the operator noted at which phase (access phase, caries removal phase, etc.) the request was made and administered the local anesthetic. If the subject declined local anesthesia, the operator administered anesthetic later if the subject appeared to have continued discomfort and if he judged that the subject would benefit from it.
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TABLE 1
Pretreatment overview of subjects’ characteristics and experiences, by treatment group. SUBJECTS’ CHARACTERISTICS AND EXPERIENCES
TREATMENT GROUP
Characteristics (Means or Frequencies)
CMCR* (n = 26)
Age (years)
TM † (n = 24)
P Value
7.65
8.67
.006
15/11
12/12
NS‡
Oral health–related quality of life§
1.67
1.50
NS
Baseline happiness¶
3.50
3.38
NS
Baseline dental fear¶
1.76
1.83
NS
Caries prevalence (dmft# score)
6.04
5.17
NS
No. of prior operative appointments
4.15
3.50
NS
No. of prior operative appointments with local anesthesia
2.73
1.92
NS
No. of operative appointments with local anesthesia in the last year
1.65
1.29
NS
3.04
3.38
.089
Sex (male/female)
Experiences (Means)
Past operative * † ‡ § ¶ # ** ††
behavior**
(Frankl Behavior Rating
Scale††)
CMCR: Chemomechanical caries removal. TM: The traditional caries removal method using a round bur. NS: No statistically significant difference. Scale in which 0 = highest and 8 = lowest. Five-point scale in which 1 = least and 5 = most. dmft: Decayed, missing, filled primary teeth. Four-point scale in which 1 = definitely negative and 4 = definitely positive. Source: Frankl and colleagues.21
Postoperative surveys. Immediately after completing the restorative treatment, the operator completed a provider survey, which consisted of a Frankl Behavior Rating Scale21 and nine questions evaluating aspects of the appointment. At the same time, a dental assistant assessing the child’s emotional response, dental fear,20 and perception of the treatment administered a postoperative child survey. RESULTS
Table 1 provides an overview of the subjects’ characteristics and experiences before their appointments. While the proportion of boys and girls in the CMCR and TM groups did not differ significantly, the subjects in the CMCR group were on average about one year younger than the subjects in the TM group (7.65 years versus 8.67 years, respectively; P = .006). The subjects in two groups did not differ significantly in their baseline assessments of their oral health–related quality of life, their happiness and their dental fears. The subjects in the two groups also did not differ in their decayed-missing-filled primary teeth scores, the number of prior operative appointments, the 50
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number of prior operative appointments with local anesthesia or the number of operative appointments with local anesthesia in the past year. There was, however, a tendency for the subjects in the CMCR group to be less well-behaved than the subjects in the TM group during the baseline appointment. The operator used the Frankl Behavior Rating Scale21 to assess the subjects’ behavior. The score for the subjects in the CMCR group was 3.04, while the score for the subjects in the TM group was 3.38 (P = .089) on a scale ranging from 1 = “definitely negative” to 4 = “definitely positive.” When assessing the subjects’ responses to the CMCR treatment versus the TM treatment, it is important to understand whether the treatment characteristics in the groups were comparable. Despite the random assignment, there was a significant difference in preoperative cavity depth, with CMCR subjects having a mean of 26.9 percent superficial lesions and 73.1 percent deep lesions and TM subjects having a mean of 62.5 percent superficial lesions and 37.5 percent deep lesions (P = .012) (Table 2). We found no significant difference between the groups in the per-
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TABLE 2
Overview of treatment characteristics, efficiency and efficacy, by treatment group. VARIABLE
TREATMENT GROUP CMCR* (n = 26)
P Value
TM † (n = 24)
Treatment Characteristics (Means or Frequencies) Actual cavity depth (%)
Superficial (26.9) Deep (73.1)
Superficial (62.5) Deep (37.5)
.012
Local anesthesia (%)
23.1
16.7
NS‡
Phase of local anesthetic administration (%)
High-speed access (0.0) Hand instrument (15.4) Removal with a slow-speed handpiece and round bur (7.7)
High-speed access (4.2) Removal with a slowspeed handpiece and round bur (12.5)
NS
Dry field maintained (%)
Problematic (42.3) Yes (57.7)
Problematic (8.3) Yes (91.7)
Caries removal: all CMCR lesions including > 15 minutes and bur completion (n = 26)
604.19 ± 227.54
80.71 ± 83.99
Caries removal: only CMCR (n = 15)
484.00 ± 187.96
NA§
NA
57.7
100.0
.000
.007
Efficiency (Average Time ± SD in Seconds) .001
Efficacy (Frequencies) Complete caries removal within 15 minutes (%) * † ‡ §
CMCR: Chemomechanical caries removal. TM: The traditional caries removal method using a round bur. NS: No statistically significant difference. NA: Not applicable.
centage of subjects in need of local anesthesia or in the phase of treatment in which local anesthetic was administered. Maintaining a dry field, however, was more problematic in the CMCR group (42.3 percent) than in the TM group (8.3 percent) (P = .007). A subject’s response to dental treatment also may be affected by the length of time needed to complete a treatment. Table 2 provides information about the efficiency of the two treatments. The average time for the caries removal phase in the CMCR group was significantly higher (604.19 ± 227.54 standard deviation [SD] seconds) than the time needed in the TM group (80.71 ± 83.99 SD seconds; P < .001). When we considered lesions successfully treated with only CMCR, the caries removal time for the CMCR group dropped to 484.00 ± 187.96 SD seconds on average. This time still was about six times higher than the average time needed for TM. These data show conclusively that on average subjects in the CMCR group had to spend more time in the dental chair than did subjects in the TM group. In addition to spending more time in the dental chair, 42.3 percent of subjects in the CMCR group
needed to have caries removal completed with a slow-speed handpiece and round bur (Table 2). The operator’s and subjects’ responses to CMCR and TM are summarized in Table 3. The operator perceived that CMCR demanded more clinical or technical effort than did TM (on a fivepoint scale in which 1 = least and 5 = most: 2.77 versus 1.50, respectively; P < .001), as well as more total effort (2.62 versus 1.46, respectively; P < .001). In addition, the operator was significantly less satisfied with the treatment in the CMCR group compared with the TM group (2.62 versus 4.00, respectively; P < .001). When the operator was asked to rate the pediatric patients’ satisfaction with the treatment on a four-point scale in which 1 = definitely negative and 4 = definitely positive, the satisfaction ratings for the subjects in the CMCR group tended to be lower (less satisfied) than the ratings for the subjects in the TM group (2.96 versus 3.46, respectively; P = .095). In addition, the operator indicated that the subjects in the CMCR group tended to be less well-behaved during caries removal than were the subjects in the TM group (2.88 versus 3.38, respectively; P = .07), and that they were signifi-
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TABLE 3
Overview of operator’s and subjects’ responses, by treatment group. TREATMENT GROUP
RESPONSES
CMCR * (n = 26)
TM † (n = 24)
P Value
Clinical or technical effort (5-point‡)
2.77
1.50
.001
Total effort including behavior management (5-point)
2.62
1.46
.001
Operator satisfaction with treatment (5-point)
2.62
4.00
.001
Perceived patient satisfaction (5-point)
2.96
3.46
.095
Frankl Behavior Rating Scale§ score during caries removal (4-point¶)
2.88
3.38
.07
Frankl Behavior Rating Scale score during composite placement (4-point)
3.09
3.57
.05
2.77
2.42
NS#
13/26 (50)
9/24 (37.5)
NS
Perceived treatment time (3-point**)
1.77
1.33
.033
Posttreatment happiness (5-point)
4.15
4.50
NS
Satisfaction with the treatment (4-point)
3.46
3.96
NS
Experienced intraoperative pain (Cont††)
69.71
61.12
NS
Change in overall dental fear, baseline to posttreatment (4-point)
Pretreatment: 1.76 Posttreatment: 1.77
Pretreatment: 1.84 Posttreatment: 1.83
NS
Change in fear of the doctor, baseline to posttreatment (4-point)
Pretreatment: 1.34 Posttreatment: 1.84
Pretreatment: 1.30 Posttreatment: 1.17
.040
Operator Variables (Scale) (Means or Frequencies)
Perceived patient pain (4-point) No. (%) of patients displaying behavioral cues indicative of pain Subject Variables (Scale) (Means)
Change in fear of the sound of the drill, combined treatment groups (4-point)
Pretreatment: 2.04 Posttreatment: 1.53
.038
Change in fear of a dental cleaning, combined treatment groups (4-point)
Pretreatment: 1.46 Posttreatment: 1.16
.064
* † ‡ § ¶ # ** ††
CMCR: Chemomechanical caries removal. TM: The traditional caries removal method using a round bur. 5-point scale in which 1 = least and 5 = most. Source: Frankl and colleagues.21 4-point scale in which 1 = definitely negative and 4 = definitely positive. NS: No statistically significant difference. 3-point scale in which 1 = short time and 3 = very long time. Cont: Continuous 100-millimeter scale in which 0 = worst hurt and 100 = no pain.
cantly less well-behaved during resin-based composite restoration placement compared with subjects in the TM group (3.09 versus 3.57, respectively; P = .05). Concerning the pediatric patients’ responses to the treatments, we found that subjects in the CMCR group perceived the time spent in the chair as being significantly longer than did the subjects in the TM group (on a three-point scale in which 1 = short time and 3 = very long time: 1.77 versus 1.33, respectively; P = .033). However, the subjects in the two groups did not differ 52
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in their posttreatment happiness, their satisfaction with the treatment, their experienced intraoperative pain and their overall fear scores.20 An interaction effect was found for the item “fear of the doctor.” While the subjects in the CMCR and TM groups did not differ before their treatment in their responses (on a four-point scale: 1.34 versus 1.30, respectively), the subjects in the CMCR group increased in their fear responses on average to 1.84, while the subjects in the TM group decreased in their fear response on average to 1.17 (P = .040). However, the subjects
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in both groups reduced their fear response to the sound of the drill, as well as their fear of a “dental cleaning” from before to after the appointment. DISCUSSION
We investigated the benefits of using CMCR for dentinal-depth occlusal lesions with limited enamel access as compared with TM in pediatric patients in a controlled clinical setting. We previously reported on how these two techniques differed in objective treatment indicators such as efficacy and efficiency.17 The data we present in this article complement those findings by providing information concerning the operator’s and pediatric patients’ responses to the two techniques. Overall, both the results concerning the efficacy and efficiency of CMCR, as well as the results concerning the operator’s and pediatric patients’ responses were less favorable for CMCR than for TM. The operator evaluated the effort needed for CMCR as higher and his satisfaction with CMCR as lower compared with TM. Pediatric patients were aware of the fact that CMCR took longer than did TM. These results, however, should be considered with four issues in mind. First, this study required complete caries removal in the CMCR group. The results concerning the operator’s and the pediatric patients’ responses might have been more positive for CMCR if the study had used modified caries removal criteria consistent with the minimally invasive philosophy.22-24 Second, this study focused on occlusal lesions with minimal cavitation instead of focusing on primarily open and easily accessible lesions, which are the more common indication for CMCR. Third, the depth of the lesions in the two groups differed; there were a larger number of deep lesions in the CMCR group than in the TM group. Finally, the subjects in the CMCR group were on average about one year younger than the subjects in the TM group. This age difference might explain why there was a tendency for the subjects in the CMCR group to show poorer behavior during the baseline treatment compared with the subjects in the TM group. This age difference might explain some of the operator-perceived differences in the subjects and might have affected the pediatric patients’ responses in the two groups. However, even when we considered these four potentially moderating factors, the differences in the responses was powerful and supports
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the conclusion that using CMCR to treat occlusal lesions with minimal access in pediatric patients demands more effort from the operator and leads to lower operator satisfaction than does TM. The subjects reported a prolonged average treatment time for CMCR, and this might have contributed to the less positive behavior during caries removal and resin-based composite restoration placement in the subjects in the CMCR group compared with the subjects in the TM group. Even more importantly, for four out of 10 subjects, caries removal with a slow-speed handpiece and round bur was necessary, as not all caries had been removed during the 15 minutes of repeated CMCR applications with proper instrumentation. In addition, 23.1 percent of the CMCR-treated teeth required local anesthesia. These findings imply that a substantial number of subjects in the CMCR group had experienced the aspects of TM that are fear-evoking, namely an injection of local anesthetic and the sounds and sensations caused by the “drill.”25 Operator-related outcomes. Compared with other studies,7,10,12-16 our study is the first that included an analysis of the operator’s responses to both types of treatment. One advantage—and at the same time a limitation—of our study is that only one operator treated all patients. This ensured that outcomes were not due to operator variability. The significant differences in the operator’s satisfaction with the two techniques and in his evaluations of the effort needed for CMCR versus TM were, therefore, not due to interoperator effects. The operator perceived that using CMCR required more clinical and technical effort and more total effort including patient behavior management than did using TM. It was interesting to find that the operator not only indicated that the pediatric patients in the CMCR group showed more negative behavior during caries removal compared with subjects the TM group, but that the behavior of the subjects in the two groups differed in the same way during resin-based composite restoration placement. This finding could be due to the fact that the subjects’ patience had run low in the CMCR group by the time the resin-based composite restoration was being placed because of the longer time needed to remove the caries. Overall, the data showed that the operator did not perceive any psychosocial or behavioral advantage when using CMCR compared with using TM. While productivity was not an issue in our study, it would be of significance
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for practitioners who consider CMCR as a treatment alternative. The length of time and the effort to manage patient behavior needed when using CMCR should be considered in this context. Pediatric patient-related outcomes. An interpretation of the results concerning the patient-related outcomes should factor in the large range in ages of the subjects (6 to 12 years) and the fact that no children younger than 6 years were included in the study. In addition, while the subjects were randomly assigned to the two treatment groups, the subjects in the CMCR group were on average one year younger and showed a tendency toward poorer behavior during the initial visit than the subjects in the TM group. However, subjects in the CMCR group perceived the time needed for the treatment as significantly longer than did the subjects in the TM group, which was consistent with the objective time spent. Concerning differences in dental anxiety between the two groups, we expected that the subjects in the CMCR group would be less likely to be fearful of dental treatment after the appointment than the subjects in the TM group. This assumption was not supported by the data. The results showed that the subjects in the subjects in the two groups did not differ in their overall fear before compared with after treatment. In addition, subjects in both groups had less fear of the sound of the drill and of prophylaxis after the treatment compared with before the treatment. This finding may be due to the excellent provider communication and behavior management skills and might be less related to the type of treatment provided. The subjects’ fear of the dentist increased in the CMCR group, while it slightly decreased in the TM group. This may have been the result of the longer treatment time required for CMCR. While the subjects in the CMCR group were on average younger and had on average deeper lesions than the subjects in the TM group, it still seems justified to conclude that if CMCR has any behavioral advantages, they were not sufficient to overcome the disadvantages of these differences between the groups. We therefore conclude that the subjects’ responses to the two treatment modalities did not show the expected positive effect when using CMCR versus TM. When we compared these findings to results from other studies,7,10,12-16 we found that the other studies did not use standardized scales (such as the Dental Subscale of the Children’s Fear 54
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Survey Schedule developed by Cuthbert and Melamed20) that we used when considering the pediatric patients’ responses, and only one other study included a standardized scale when asking the operators to assess the children’s behavior.16 Two studies,7,12 however, included questions concerning the taste experiences in the CMCR group. It would have been worthwhile to consider this aspect of the pediatric patients’ responses in our study. Clinical relevance. When using CMCR in children, local anesthesia still should be considered and provided, as a substantial percentage of the subjects in our study reported pain. From a behavioral standpoint, our study has contributed to a better understanding of dental fear in pediatric patients. Given the longer time needed with CMCR, it seems important to consider strategies to prevent pediatric patients from becoming restless and negative toward the treatment experience. Letting children watch a favorite videotape or digital video disc or listen to a recorded story on tape or compact disc are examples of ways to cope with the additional time demanded and should help young patients have more patience. These interventional strategies might decrease the development of dental fear, and, thus, prevent avoidance of dental health care services later in life. Further research into enhanced, rapid-effect gels and alternative self-limiting caries removal techniques may show increased potential for more patient-friendly, minimally invasive management strategies.26 CONCLUSIONS
The operator perceived that using CMCR required more clinical and technical effort and more overall effort than using TM. The operator’s satisfaction with using CMCR was, therefore, lower than his satisfaction with using TM. In addition, he perceived more challenging patient behavior during caries removal, as well as during the placement of the resin-based composite restoration in subjects in the CMCR group compared with subjects in the TM group. While proponents of the CMCR might expect a positive effect of CMCR on pediatric patients’ affective responses to caries removal, the findings of this study did not support this assumption. Subjects in the CMCR group were aware that the CMCR method took a longer time than did TM. ■
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This article is based on a thesis submitted by Dr. Michael H. Flamenbaum in partial fulfillment of the requirements for the Master of Science degree in pediatric dentistry at the University of Michigan, Ann Arbor. He presented a preliminary report at the 32nd Annual Meeting and Exhibition of the American Association for Dental Research in San Antonio, March 14, 2003. The authors gratefully acknowledge Mott’s Children’s Health Center, Flint, Mich., and the University of Michigan School of Dentistry, Ann Arbor, for providing facilities and faculty and staff support. 1. Ericson D. The efficacy of a new gel for chemo-mechanical caries removal (abstract 360). J Dent Res 1998;77(5):1252. 2. Banerjee A, Watson TF, Kidd EA. Dentine caries excavation: a review of current clinical techniques. Br Dent J 2000;188(9):476-82. 3. Noack MJ, Wicht MJ, Haak R. Lesion orientated caries treatment: a classification of carious dentin treatment procedures. Oral Health Prev Dent 2004;2(supplement 1):301-6. 4. Ericson D, Zimmerman M, Raber H, Gotrick B, Bornstein R, Thorell J. Clinical evaluation of efficacy and safety of a new method for chemo-mechanical removal of caries: a multi-centre study. Caries Res 1999;33(3):171-7. 5. Kakaboura A, Masouras C, Staikou O, Vougiouklakis G. A comparative clinical study on the Carisolv caries removal method. Quintessence Int 2003;34(4):269-71. 6. Rafique S, Fiske J, Banerjee A. Clinical trial of an airabrasion/chemomechanical operative procedure for the restorative treatment of dental patients. Caries Res 2003;37(5):360-4. 7. Maragakis GM, Hahn P, Hellwig E. Clinical evaluation of chemomechanical caries removal in primary molars and its acceptance by patients. Caries Res 2001;35(3):205-10. 8. Fure S, Lingstrom P, Birkhed D. Evaluation of Carisolv for the chemo-mechanical removal of primary root caries in vivo. Caries Res 2000;34(3):275-80. 9. Nadanovsky P, Cohen Carneiro F, Sousa de Mello F. Removal of caries using only hand instruments: a comparison of mechanical and chemo-mechanical methods. Caries Res 2001;35(5):384-9. 10. Attari N, Roberts GJ, Ashley P. Children’s anxiety during caries removal: Carisolv compared with dental drill (abstract 1178). J Dent Res 2001;80:674. 11. Chaussain-Miller C, Decup F, Domejean-Orliaquet S. Clinical evaluation of the Carisolv chemomechanical caries removal technique according to the site/stage concept, a revised caries classification system. Clin Oral Investig 2003;7(1):32-7. 12. Balciuniene I, Sabalaite R, Juskiene I. Chemomechanical caries
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removal for children. Stomatologija 2005;7(2):40-4. 13. Munshi AK, Hegde AM, Shetty PK. Clinical evaluation of Carisolv in the chemico-mechanical removal of carious dentin. J Clin Pediatr Dent 2001;26(1):49-54. 14. Kavvadia K, Karagianni V, Polychronopoulou A, Papagiannouli L. Primary teeth caries removal using the Carisolv chemomechanical method: a clinical trial. Pediatr Dent 2004;26(1):23-8. 15. Bergmann J, Leitao J, Kultje C, Bergmann D, Clode MJ. Removing dentine caries in deciduous teeth with Carisolv: a randomised, controlled, prospective study with six-month follow-up, comparing chemomechanical treatment with drilling. Oral Health Prev Dent 2005;3(2):105-11. 16. Lozano-Chourio MA, Zambrano O, Gonzalez H, Quero M. Clinical randomized controlled clinical trial of chemomechanical caries removal (Carisolv). Int J Paediatr Dent 2006;16(3):161-7. 17. Peters MC, Flamenbaum MH, Eboda NN, Feigal RJ, Inglehart MR. Chemomechanical caries removal in children: efficacy and efficiency. JADA 2006;137(12):1658-66. 18. Inglehart MR, Filstrup SL, Wandera A. Oral health and quality of life in children. In: Inglehart MR, Bagramian RA, eds. Oral healthrelated quality of life. Carol Stream, Ill.: Quintessence; 2002:79-88. 19. Filstrup SL, Briskey D, da Fonseca M, Lawrence L, Wandera A, Inglehart MR. Early childhood caries and quality of life: child and parent perspectives. Pediatr Dent 2003;25(5):431-40. 20. Cuthbert MI, Melamed BG. A screening device: children at risk for dental fears and management problems. ASDC J Dent Child 1982;49(6):432-6. 21. Frankl SN, Shiere FR, Fogels HR. Should the parent remain with the child in the dental operatory? J Dent Child 1962;29:150-63. 22. Kidd EA, Banerjee A. What is absence of caries? In: Albrektsson TO, ed. Tissue preservation in caries treatment. Chicago: Quintessence; 2001:69-79. 23. Peters MC, McLean ME. Minimally invasive operative care, I: minimal intervention and concepts for minimally invasive cavities. J Adhes Dent 2001;3(1):7-16. 24. Maltz M, de Oliveira EF, Fontanella V, Bianchi R. A clinical, microbiologic, and radiographic study of deep caries lesions after incomplete caries removal. Quintessence Int 2002;33(2):151-9. 25. Inglehart MR, George S, Feigal RJ. Dental fear in pediatric patients: challenges and opportunities for dental care providers. J Pract Hyg 2003;12(3):11-5. 26. Ericson D, Kidd E, McComb D, Mjör I, Noack MJ. Minimally invasive dentistry: concepts and techniques in cariology. Oral Health Prev Dent 2003;1(1):59-72.
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Chemomechanical caries removal in children An operator’s and pediatric patients’ responses Marita R. Inglehart, Dr. Phil Habil; Mathilde C. Peters, DMD, PhD; Michael H. Flamenbaum, DMD, MS; Nnenna N. Eboda, DDS, MS; Robert J. Feigal, DDS, PhD
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Background. This study investigated an oper✷ ✷ ator’s and pediatric patients’ responses to chemomechanical caries removal (CMCR) versus the traN ditional method (TM) of caries removal using a C U U I handpiece and a round bur when treating dentinal- A R N G E D 1 TICLE depth occlusal lesions with minimal enamel access in primary molars. Methods. Data were collected from 50 children at baseline and before, during and after caries removal using CMCR or TM. The subjects in the CMCR group were on average younger than the subjects in the TM group and had more deep lesions. Results. The operator rated CMCR as needing more clinical and technical effort and more total effort than TM. He was less satisfied with CMCR than with TM. Subjects in the CMCR group perceived the time needed for treatment as significantly longer than did the subjects in the TM group. Fear of the dentist decreased in subjects in the TM group from before to after the operative appointment, while it increased in subjects in the CMCR group. Conclusions. The authors found no direct advantage in using CMCR over using TM. Clinical Implications. CMCR cannot be recommended as an alternative to TM when treating dentinal depth occlusal lesions with minimal access in primary molars. Key Words. Behavioral sciences; anxiety; pain; pediatric dentistry; caries. JADA 2007;138(1):47-55. I
DISCLOSURE: 3M ESPE, St. Paul, Minn., provided the restorative materials for this study. MediTeam, Göteborg, Sweden, contributed materials and instruments, as well as financial support.
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hemomechanical caries removal (CMCR) can be a useful alternative to the traditional method (TM) of caries removal using a handpiece and a bur. Instead of using a bur and sharp excavators, CMCR uses a gel (Carisolv, MediTeam, Göteborg, Sweden)1 that softens denatured dentin, which then can be removed with blunt instruments. Two comprehensive overviews of various techniques for caries removal have been published.2,3 The literature provides conflicting evidence concerning the clinical effectiveness of CMCR. CMCR does not use a slow-speed handpiece and round bur, so one might wonder if it might be a more patient-friendly technique and, thus, a preferable alternative to TM. In particular, one might argue that dental fear may be alleviated when using CMCR, because the use of the handpiece can be kept to a minimum and no local anesthetic will be needed. This outcome could be especially important when treating pediatric patients. Research findings concerning operators’ and patients’ responses to CMCR have been inconclusive.4-7 Several studies have evaluated
Dr. Inglehart is an associate professor of dentistry, Department of Periodontics and Oral Medicine, School of Dentistry, University of Michigan, Ann Arbor, and an adjunct professor of psychology, Department of Psychology, College of Literature, Science and Arts, University of Michigan, Ann Arbor. Address reprint requests to Dr. Inglehart at Department of Periodontics and Oral Medicine, School of Dentistry, University of Michigan, Ann Arbor, Mich. 48109-1078, e-mail “[email protected]”. Dr. Peters is a professor of dentistry, Department of Cariology and Restorative Dentistry, School of Dentistry, University of Michigan, Ann Arbor. Dr. Flamenbaum was a graduate student, Department of Pediatric Dentistry, University of Michigan, Ann Arbor, when this article was written. He now is in private practice in pediatric dentistry, Atlanta. Dr. Eboda was a pediatric staff dentist, Pediatric Dental Clinic, Mott Children’s Health Center, Flint, Mich., and an adjunct clinical assistant professor, Department of Pediatric Dentistry, University of Ann Arbor, when this article was written. She now is in private practice in pediatric dentistry, Flint, Mich. Dr. Feigal is a professor, Department of Developmental and Surgical Studies, University of Minnesota, Minneapolis.
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adult patients’ responses to CMCR,4,8-11 and seven studies have investigated pediatric dental patients’ responses to CMCR.7,10,12-16 While we provided an overview of the results of these seven studies concerning the efficacy and efficiency of CMCR in an earlier report,17 it is interesting to consider our findings concerning the operator’s and patients’ responses to CMCR. Attari and colleagues10 used CMCR or TM without anesthesia to treat two matched lesions in 80 first or second primary molars in 4- to 11year-old children. They recorded the time taken for caries removal and the child’s anxiety levels before and after each treatment. They found that CMCR took significantly longer than TM. They found no significant difference in anxiety levels before or after the treatment in either group. Maragakis and colleagues7 treated 32 contralateral primary molars with similar carious lesions in 16 7- to 9-year-old children. They treated each tooth with TM or CMCR, while they treated contralateral teeth with opposite treatment. They found that CMCR took more time than did TM. They administered local anesthetic for TM treatments but not for CMCR treatments. Although preoperatively 13 of the 16 children indicated that they would not mind being in the dental chair a little longer to avoid the use of the drill, postoperatively 11 of the 16 children indicated that they preferred the drill because of the shorter treatment time and the absence of a bad taste in their mouths during the treatment. The investigators concluded that the patients preferred TM to CMCR. Munshi and colleagues13 investigated the efficacy of CMCR clinically by treating 50 primary and permanent teeth with CMCR in 3- to 12-yearold children. No discomfort was reported during the removal of soft carious dentin, while mild discomfort was reported during the removal of arrested carious dentin in 11 of 20 teeth. The authors concluded that CMCR was most efficient in soft-caries removal and may have applications in pediatric dentistry. The absence of a control group, however, limited the generalizability of the study’s results. Kavvadia and colleagues14 compared CMCR and TM when treating 92 lesions in 31 children aged 28 months to 9 years. When the investigators treated 32 posterior lesions, they found that the working time with CMCR was longer. However, the children’s cooperation was similar and the prolonged time did not seem to affect their 48
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behavior negatively. The children did not report disliking the taste. Balciuniene and colleagues12 treated 30 children aged 3 to 13 years and compared CMCR and TM in primary teeth (63 percent) and permanent teeth (37 percent). The children in the CMCR group reported experiencing less pain and almost no dislike of the smell or taste of the gel, despite the fact that in 60 percent of the CMCR cases caries removal had to be completed with the bur, and that the treatment time for CMCR was longer than that for TM. Bergmann and colleagues15 studied patients’ acceptance of CMCR while treating 92 primary teeth in 46 children aged 4 to 11 years. The investigators found a high degree of patient acceptance even when the CMCR time for the treatment was more than twice as long as that needed for TM. The children and dentists reported reduced anxiety levels and lower degrees of pain with CMCR than with TM. Lozano-Chourio and colleagues16 compared CMCR with high-speed excavation in 40 children aged 7 to 9 years. They concluded that CMCR was an effective alternative clinical method for the removal of occlusal caries in cavitated primary molars; that it preserved dental tissue, resulting in smaller-sized cavities; and it appeared to be more comfortable for the patients (71 percent preferred CMCR), despite the fact that the clinical treatment time was three times longer than that required for high-speed excavation. While these studies were important steps in the assessment of pediatric patients’ responses to CMCR, they had some limitations such as a lack of a control group,13 differences between groups in treatment,7,14,16 differences in which behavioral aspects were considered12,13,15,16 and the failure to use standardized methods of assessing the child’s response in terms of dental fear and pain.7,12,14 These studies also did not assess the operators’ responses and satisfaction with the treatment. We conducted a prospective, randomized controlled clinical trial to investigate the overall effectiveness of CMCR, as well as the operator’s and pediatric patients’ responses to CMCR as compared with TM. Elsewhere, results concerning the efficacy and efficiency of CMCR as well as the need for local anesthesia with both techniques ABBREVIATION KEY. CMCR: Chemomechanical caries removal. IRB: Institutional review board. SD: Standard deviation. TM: Traditional method.
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have been reported.17 This report discusses the findings concerning the operator’s and pediatric patients’ responses to CMCR. The operator’s responses were concerned with the clinical effort needed, the effort required for managing the behavior of the pediatric patient, the operator’s satisfaction with the treatment, the degree of acceptance of both methods by the child and the perceived pain the patient experienced. We collected data from the pediatric patients concerning their happiness and fear before and after the appointment, their perception of the time needed and the pain they experienced. METHODS
The Institutional Review Board (IRB) for the Health Sciences at the University of Michigan, Ann Arbor, and the Institutional Review Board of Mott Children’s Health Center, Flint, Mich., approved our randomized controlled study. We obtained written assent from the pediatric patients and written consent from the parents or legal guardians before we enrolled the subjects in the study. We recruited 50 healthy subjects (27 male, 23 female) aged between 6 and 11 years (average age: 8.1 years) at regularly scheduled appointments at the pediatric dentistry department of Mott Children’s Health Center. The study inclusion criteria were the patient’s age (6-12 years) and the presence of at least one primary molar with occlusal caries penetrating into dentin. To reduce operator variability affecting the outcomes, one trained operator (M.H.F.), who had experience using CMCR, treated all of the subjects. After enrollment, the subjects responded to a baseline child survey that measured happiness, oral health–related quality of life,18,19 dental fear (measured with the Dental Subscale of the Children’s Fear Survey Schedule developed by Cuthbert and Melamed)20 and memory of previous dental experiences. A dental assistant read the survey to the subjects while they followed along with a corresponding survey aid. A dental assistant collected all other data when the subjects returned for the operative appointment. Pretreatment. A trained staff member administered the preoperative child survey immediately before the restorative treatment, while the subjects’ caregivers waited outside the room. This survey consisted of only three questions concerning the subject’s level of happiness and the subject’s knowledge about the forthcoming opera-
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tive treatment; the staff member asked the second question first as a closed-ended question and then as an open-ended question that allowed the child to explain the answer. Treatment session. Before the treatment appointment, the operator randomly assigned each tooth to either the CMCR or TM (control) group. (We did not include a group of subjects who received both treatments owing to the length of time that would have been needed to recruit sufficient numbers of patients with two eligible carious lesions.) He then isolated the study tooth with cotton rolls, dry angles or both, and he instructed the subjects to raise their left hands if they felt any discomfort (“a hurt on your tooth”). After achieving an adequate opening and access of the carious lesion, the operator used the randomly assigned method of caries removal. For CMCR, he repeated the procedure for a maximum of 15 minutes. In 42.3 percent of the CMCR cases, complete caries removal was not achieved at the 15-minute mark, and the operator used TM to complete caries removal. He assessed complete caries removal using visual-tactile clinical criteria (experiencing a no “tug-back” sensation with explorer inspection), and an independent evaluator confirmed complete caries removal. If both dentists (the operator and the evaluator) still noted active caries, they examined the area in question and reached a consensus. After the operator removed residual active caries using the assigned method, he restored the teeth using a standard adhesive resin-based composite system according to the manufacturer’s instructions. Local anesthesia. We initiated all treatment without local anesthesia. In the event that the child raised his or her left hand, the operator ruled out external sources of discomfort (that is, cotton rolls, sound of the drill, water spray, etc.) unrelated to caries removal. If the caries removal procedure was the cause of the child’s discomfort, the operator asked the child, “Can I try that again and count to 5?” or “Should I help the tooth take a nap first with some sleepy juice?” If the subject requested local anesthesia, the operator noted at which phase (access phase, caries removal phase, etc.) the request was made and administered the local anesthetic. If the subject declined local anesthesia, the operator administered anesthetic later if the subject appeared to have continued discomfort and if he judged that the subject would benefit from it.
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TABLE 1
Pretreatment overview of subjects’ characteristics and experiences, by treatment group. SUBJECTS’ CHARACTERISTICS AND EXPERIENCES
TREATMENT GROUP
Characteristics (Means or Frequencies)
CMCR* (n = 26)
Age (years)
TM † (n = 24)
P Value
7.65
8.67
.006
15/11
12/12
NS‡
Oral health–related quality of life§
1.67
1.50
NS
Baseline happiness¶
3.50
3.38
NS
Baseline dental fear¶
1.76
1.83
NS
Caries prevalence (dmft# score)
6.04
5.17
NS
No. of prior operative appointments
4.15
3.50
NS
No. of prior operative appointments with local anesthesia
2.73
1.92
NS
No. of operative appointments with local anesthesia in the last year
1.65
1.29
NS
3.04
3.38
.089
Sex (male/female)
Experiences (Means)
Past operative * † ‡ § ¶ # ** ††
behavior**
(Frankl Behavior Rating
Scale††)
CMCR: Chemomechanical caries removal. TM: The traditional caries removal method using a round bur. NS: No statistically significant difference. Scale in which 0 = highest and 8 = lowest. Five-point scale in which 1 = least and 5 = most. dmft: Decayed, missing, filled primary teeth. Four-point scale in which 1 = definitely negative and 4 = definitely positive. Source: Frankl and colleagues.21
Postoperative surveys. Immediately after completing the restorative treatment, the operator completed a provider survey, which consisted of a Frankl Behavior Rating Scale21 and nine questions evaluating aspects of the appointment. At the same time, a dental assistant assessing the child’s emotional response, dental fear,20 and perception of the treatment administered a postoperative child survey. RESULTS
Table 1 provides an overview of the subjects’ characteristics and experiences before their appointments. While the proportion of boys and girls in the CMCR and TM groups did not differ significantly, the subjects in the CMCR group were on average about one year younger than the subjects in the TM group (7.65 years versus 8.67 years, respectively; P = .006). The subjects in two groups did not differ significantly in their baseline assessments of their oral health–related quality of life, their happiness and their dental fears. The subjects in the two groups also did not differ in their decayed-missing-filled primary teeth scores, the number of prior operative appointments, the 50
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number of prior operative appointments with local anesthesia or the number of operative appointments with local anesthesia in the past year. There was, however, a tendency for the subjects in the CMCR group to be less well-behaved than the subjects in the TM group during the baseline appointment. The operator used the Frankl Behavior Rating Scale21 to assess the subjects’ behavior. The score for the subjects in the CMCR group was 3.04, while the score for the subjects in the TM group was 3.38 (P = .089) on a scale ranging from 1 = “definitely negative” to 4 = “definitely positive.” When assessing the subjects’ responses to the CMCR treatment versus the TM treatment, it is important to understand whether the treatment characteristics in the groups were comparable. Despite the random assignment, there was a significant difference in preoperative cavity depth, with CMCR subjects having a mean of 26.9 percent superficial lesions and 73.1 percent deep lesions and TM subjects having a mean of 62.5 percent superficial lesions and 37.5 percent deep lesions (P = .012) (Table 2). We found no significant difference between the groups in the per-
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TABLE 2
Overview of treatment characteristics, efficiency and efficacy, by treatment group. VARIABLE
TREATMENT GROUP CMCR* (n = 26)
P Value
TM † (n = 24)
Treatment Characteristics (Means or Frequencies) Actual cavity depth (%)
Superficial (26.9) Deep (73.1)
Superficial (62.5) Deep (37.5)
.012
Local anesthesia (%)
23.1
16.7
NS‡
Phase of local anesthetic administration (%)
High-speed access (0.0) Hand instrument (15.4) Removal with a slow-speed handpiece and round bur (7.7)
High-speed access (4.2) Removal with a slowspeed handpiece and round bur (12.5)
NS
Dry field maintained (%)
Problematic (42.3) Yes (57.7)
Problematic (8.3) Yes (91.7)
Caries removal: all CMCR lesions including > 15 minutes and bur completion (n = 26)
604.19 ± 227.54
80.71 ± 83.99
Caries removal: only CMCR (n = 15)
484.00 ± 187.96
NA§
NA
57.7
100.0
.000
.007
Efficiency (Average Time ± SD in Seconds) .001
Efficacy (Frequencies) Complete caries removal within 15 minutes (%) * † ‡ §
CMCR: Chemomechanical caries removal. TM: The traditional caries removal method using a round bur. NS: No statistically significant difference. NA: Not applicable.
centage of subjects in need of local anesthesia or in the phase of treatment in which local anesthetic was administered. Maintaining a dry field, however, was more problematic in the CMCR group (42.3 percent) than in the TM group (8.3 percent) (P = .007). A subject’s response to dental treatment also may be affected by the length of time needed to complete a treatment. Table 2 provides information about the efficiency of the two treatments. The average time for the caries removal phase in the CMCR group was significantly higher (604.19 ± 227.54 standard deviation [SD] seconds) than the time needed in the TM group (80.71 ± 83.99 SD seconds; P < .001). When we considered lesions successfully treated with only CMCR, the caries removal time for the CMCR group dropped to 484.00 ± 187.96 SD seconds on average. This time still was about six times higher than the average time needed for TM. These data show conclusively that on average subjects in the CMCR group had to spend more time in the dental chair than did subjects in the TM group. In addition to spending more time in the dental chair, 42.3 percent of subjects in the CMCR group
needed to have caries removal completed with a slow-speed handpiece and round bur (Table 2). The operator’s and subjects’ responses to CMCR and TM are summarized in Table 3. The operator perceived that CMCR demanded more clinical or technical effort than did TM (on a fivepoint scale in which 1 = least and 5 = most: 2.77 versus 1.50, respectively; P < .001), as well as more total effort (2.62 versus 1.46, respectively; P < .001). In addition, the operator was significantly less satisfied with the treatment in the CMCR group compared with the TM group (2.62 versus 4.00, respectively; P < .001). When the operator was asked to rate the pediatric patients’ satisfaction with the treatment on a four-point scale in which 1 = definitely negative and 4 = definitely positive, the satisfaction ratings for the subjects in the CMCR group tended to be lower (less satisfied) than the ratings for the subjects in the TM group (2.96 versus 3.46, respectively; P = .095). In addition, the operator indicated that the subjects in the CMCR group tended to be less well-behaved during caries removal than were the subjects in the TM group (2.88 versus 3.38, respectively; P = .07), and that they were signifi-
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TABLE 3
Overview of operator’s and subjects’ responses, by treatment group. TREATMENT GROUP
RESPONSES
CMCR * (n = 26)
TM † (n = 24)
P Value
Clinical or technical effort (5-point‡)
2.77
1.50
.001
Total effort including behavior management (5-point)
2.62
1.46
.001
Operator satisfaction with treatment (5-point)
2.62
4.00
.001
Perceived patient satisfaction (5-point)
2.96
3.46
.095
Frankl Behavior Rating Scale§ score during caries removal (4-point¶)
2.88
3.38
.07
Frankl Behavior Rating Scale score during composite placement (4-point)
3.09
3.57
.05
2.77
2.42
NS#
13/26 (50)
9/24 (37.5)
NS
Perceived treatment time (3-point**)
1.77
1.33
.033
Posttreatment happiness (5-point)
4.15
4.50
NS
Satisfaction with the treatment (4-point)
3.46
3.96
NS
Experienced intraoperative pain (Cont††)
69.71
61.12
NS
Change in overall dental fear, baseline to posttreatment (4-point)
Pretreatment: 1.76 Posttreatment: 1.77
Pretreatment: 1.84 Posttreatment: 1.83
NS
Change in fear of the doctor, baseline to posttreatment (4-point)
Pretreatment: 1.34 Posttreatment: 1.84
Pretreatment: 1.30 Posttreatment: 1.17
.040
Operator Variables (Scale) (Means or Frequencies)
Perceived patient pain (4-point) No. (%) of patients displaying behavioral cues indicative of pain Subject Variables (Scale) (Means)
Change in fear of the sound of the drill, combined treatment groups (4-point)
Pretreatment: 2.04 Posttreatment: 1.53
.038
Change in fear of a dental cleaning, combined treatment groups (4-point)
Pretreatment: 1.46 Posttreatment: 1.16
.064
* † ‡ § ¶ # ** ††
CMCR: Chemomechanical caries removal. TM: The traditional caries removal method using a round bur. 5-point scale in which 1 = least and 5 = most. Source: Frankl and colleagues.21 4-point scale in which 1 = definitely negative and 4 = definitely positive. NS: No statistically significant difference. 3-point scale in which 1 = short time and 3 = very long time. Cont: Continuous 100-millimeter scale in which 0 = worst hurt and 100 = no pain.
cantly less well-behaved during resin-based composite restoration placement compared with subjects in the TM group (3.09 versus 3.57, respectively; P = .05). Concerning the pediatric patients’ responses to the treatments, we found that subjects in the CMCR group perceived the time spent in the chair as being significantly longer than did the subjects in the TM group (on a three-point scale in which 1 = short time and 3 = very long time: 1.77 versus 1.33, respectively; P = .033). However, the subjects in the two groups did not differ 52
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in their posttreatment happiness, their satisfaction with the treatment, their experienced intraoperative pain and their overall fear scores.20 An interaction effect was found for the item “fear of the doctor.” While the subjects in the CMCR and TM groups did not differ before their treatment in their responses (on a four-point scale: 1.34 versus 1.30, respectively), the subjects in the CMCR group increased in their fear responses on average to 1.84, while the subjects in the TM group decreased in their fear response on average to 1.17 (P = .040). However, the subjects
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in both groups reduced their fear response to the sound of the drill, as well as their fear of a “dental cleaning” from before to after the appointment. DISCUSSION
We investigated the benefits of using CMCR for dentinal-depth occlusal lesions with limited enamel access as compared with TM in pediatric patients in a controlled clinical setting. We previously reported on how these two techniques differed in objective treatment indicators such as efficacy and efficiency.17 The data we present in this article complement those findings by providing information concerning the operator’s and pediatric patients’ responses to the two techniques. Overall, both the results concerning the efficacy and efficiency of CMCR, as well as the results concerning the operator’s and pediatric patients’ responses were less favorable for CMCR than for TM. The operator evaluated the effort needed for CMCR as higher and his satisfaction with CMCR as lower compared with TM. Pediatric patients were aware of the fact that CMCR took longer than did TM. These results, however, should be considered with four issues in mind. First, this study required complete caries removal in the CMCR group. The results concerning the operator’s and the pediatric patients’ responses might have been more positive for CMCR if the study had used modified caries removal criteria consistent with the minimally invasive philosophy.22-24 Second, this study focused on occlusal lesions with minimal cavitation instead of focusing on primarily open and easily accessible lesions, which are the more common indication for CMCR. Third, the depth of the lesions in the two groups differed; there were a larger number of deep lesions in the CMCR group than in the TM group. Finally, the subjects in the CMCR group were on average about one year younger than the subjects in the TM group. This age difference might explain why there was a tendency for the subjects in the CMCR group to show poorer behavior during the baseline treatment compared with the subjects in the TM group. This age difference might explain some of the operator-perceived differences in the subjects and might have affected the pediatric patients’ responses in the two groups. However, even when we considered these four potentially moderating factors, the differences in the responses was powerful and supports
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the conclusion that using CMCR to treat occlusal lesions with minimal access in pediatric patients demands more effort from the operator and leads to lower operator satisfaction than does TM. The subjects reported a prolonged average treatment time for CMCR, and this might have contributed to the less positive behavior during caries removal and resin-based composite restoration placement in the subjects in the CMCR group compared with the subjects in the TM group. Even more importantly, for four out of 10 subjects, caries removal with a slow-speed handpiece and round bur was necessary, as not all caries had been removed during the 15 minutes of repeated CMCR applications with proper instrumentation. In addition, 23.1 percent of the CMCR-treated teeth required local anesthesia. These findings imply that a substantial number of subjects in the CMCR group had experienced the aspects of TM that are fear-evoking, namely an injection of local anesthetic and the sounds and sensations caused by the “drill.”25 Operator-related outcomes. Compared with other studies,7,10,12-16 our study is the first that included an analysis of the operator’s responses to both types of treatment. One advantage—and at the same time a limitation—of our study is that only one operator treated all patients. This ensured that outcomes were not due to operator variability. The significant differences in the operator’s satisfaction with the two techniques and in his evaluations of the effort needed for CMCR versus TM were, therefore, not due to interoperator effects. The operator perceived that using CMCR required more clinical and technical effort and more total effort including patient behavior management than did using TM. It was interesting to find that the operator not only indicated that the pediatric patients in the CMCR group showed more negative behavior during caries removal compared with subjects the TM group, but that the behavior of the subjects in the two groups differed in the same way during resin-based composite restoration placement. This finding could be due to the fact that the subjects’ patience had run low in the CMCR group by the time the resin-based composite restoration was being placed because of the longer time needed to remove the caries. Overall, the data showed that the operator did not perceive any psychosocial or behavioral advantage when using CMCR compared with using TM. While productivity was not an issue in our study, it would be of significance
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for practitioners who consider CMCR as a treatment alternative. The length of time and the effort to manage patient behavior needed when using CMCR should be considered in this context. Pediatric patient-related outcomes. An interpretation of the results concerning the patient-related outcomes should factor in the large range in ages of the subjects (6 to 12 years) and the fact that no children younger than 6 years were included in the study. In addition, while the subjects were randomly assigned to the two treatment groups, the subjects in the CMCR group were on average one year younger and showed a tendency toward poorer behavior during the initial visit than the subjects in the TM group. However, subjects in the CMCR group perceived the time needed for the treatment as significantly longer than did the subjects in the TM group, which was consistent with the objective time spent. Concerning differences in dental anxiety between the two groups, we expected that the subjects in the CMCR group would be less likely to be fearful of dental treatment after the appointment than the subjects in the TM group. This assumption was not supported by the data. The results showed that the subjects in the subjects in the two groups did not differ in their overall fear before compared with after treatment. In addition, subjects in both groups had less fear of the sound of the drill and of prophylaxis after the treatment compared with before the treatment. This finding may be due to the excellent provider communication and behavior management skills and might be less related to the type of treatment provided. The subjects’ fear of the dentist increased in the CMCR group, while it slightly decreased in the TM group. This may have been the result of the longer treatment time required for CMCR. While the subjects in the CMCR group were on average younger and had on average deeper lesions than the subjects in the TM group, it still seems justified to conclude that if CMCR has any behavioral advantages, they were not sufficient to overcome the disadvantages of these differences between the groups. We therefore conclude that the subjects’ responses to the two treatment modalities did not show the expected positive effect when using CMCR versus TM. When we compared these findings to results from other studies,7,10,12-16 we found that the other studies did not use standardized scales (such as the Dental Subscale of the Children’s Fear 54
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Survey Schedule developed by Cuthbert and Melamed20) that we used when considering the pediatric patients’ responses, and only one other study included a standardized scale when asking the operators to assess the children’s behavior.16 Two studies,7,12 however, included questions concerning the taste experiences in the CMCR group. It would have been worthwhile to consider this aspect of the pediatric patients’ responses in our study. Clinical relevance. When using CMCR in children, local anesthesia still should be considered and provided, as a substantial percentage of the subjects in our study reported pain. From a behavioral standpoint, our study has contributed to a better understanding of dental fear in pediatric patients. Given the longer time needed with CMCR, it seems important to consider strategies to prevent pediatric patients from becoming restless and negative toward the treatment experience. Letting children watch a favorite videotape or digital video disc or listen to a recorded story on tape or compact disc are examples of ways to cope with the additional time demanded and should help young patients have more patience. These interventional strategies might decrease the development of dental fear, and, thus, prevent avoidance of dental health care services later in life. Further research into enhanced, rapid-effect gels and alternative self-limiting caries removal techniques may show increased potential for more patient-friendly, minimally invasive management strategies.26 CONCLUSIONS
The operator perceived that using CMCR required more clinical and technical effort and more overall effort than using TM. The operator’s satisfaction with using CMCR was, therefore, lower than his satisfaction with using TM. In addition, he perceived more challenging patient behavior during caries removal, as well as during the placement of the resin-based composite restoration in subjects in the CMCR group compared with subjects in the TM group. While proponents of the CMCR might expect a positive effect of CMCR on pediatric patients’ affective responses to caries removal, the findings of this study did not support this assumption. Subjects in the CMCR group were aware that the CMCR method took a longer time than did TM. ■
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This article is based on a thesis submitted by Dr. Michael H. Flamenbaum in partial fulfillment of the requirements for the Master of Science degree in pediatric dentistry at the University of Michigan, Ann Arbor. He presented a preliminary report at the 32nd Annual Meeting and Exhibition of the American Association for Dental Research in San Antonio, March 14, 2003. The authors gratefully acknowledge Mott’s Children’s Health Center, Flint, Mich., and the University of Michigan School of Dentistry, Ann Arbor, for providing facilities and faculty and staff support. 1. Ericson D. The efficacy of a new gel for chemo-mechanical caries removal (abstract 360). J Dent Res 1998;77(5):1252. 2. Banerjee A, Watson TF, Kidd EA. Dentine caries excavation: a review of current clinical techniques. Br Dent J 2000;188(9):476-82. 3. Noack MJ, Wicht MJ, Haak R. Lesion orientated caries treatment: a classification of carious dentin treatment procedures. Oral Health Prev Dent 2004;2(supplement 1):301-6. 4. Ericson D, Zimmerman M, Raber H, Gotrick B, Bornstein R, Thorell J. Clinical evaluation of efficacy and safety of a new method for chemo-mechanical removal of caries: a multi-centre study. Caries Res 1999;33(3):171-7. 5. Kakaboura A, Masouras C, Staikou O, Vougiouklakis G. A comparative clinical study on the Carisolv caries removal method. Quintessence Int 2003;34(4):269-71. 6. Rafique S, Fiske J, Banerjee A. Clinical trial of an airabrasion/chemomechanical operative procedure for the restorative treatment of dental patients. Caries Res 2003;37(5):360-4. 7. Maragakis GM, Hahn P, Hellwig E. Clinical evaluation of chemomechanical caries removal in primary molars and its acceptance by patients. Caries Res 2001;35(3):205-10. 8. Fure S, Lingstrom P, Birkhed D. Evaluation of Carisolv for the chemo-mechanical removal of primary root caries in vivo. Caries Res 2000;34(3):275-80. 9. Nadanovsky P, Cohen Carneiro F, Sousa de Mello F. Removal of caries using only hand instruments: a comparison of mechanical and chemo-mechanical methods. Caries Res 2001;35(5):384-9. 10. Attari N, Roberts GJ, Ashley P. Children’s anxiety during caries removal: Carisolv compared with dental drill (abstract 1178). J Dent Res 2001;80:674. 11. Chaussain-Miller C, Decup F, Domejean-Orliaquet S. Clinical evaluation of the Carisolv chemomechanical caries removal technique according to the site/stage concept, a revised caries classification system. Clin Oral Investig 2003;7(1):32-7. 12. Balciuniene I, Sabalaite R, Juskiene I. Chemomechanical caries
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removal for children. Stomatologija 2005;7(2):40-4. 13. Munshi AK, Hegde AM, Shetty PK. Clinical evaluation of Carisolv in the chemico-mechanical removal of carious dentin. J Clin Pediatr Dent 2001;26(1):49-54. 14. Kavvadia K, Karagianni V, Polychronopoulou A, Papagiannouli L. Primary teeth caries removal using the Carisolv chemomechanical method: a clinical trial. Pediatr Dent 2004;26(1):23-8. 15. Bergmann J, Leitao J, Kultje C, Bergmann D, Clode MJ. Removing dentine caries in deciduous teeth with Carisolv: a randomised, controlled, prospective study with six-month follow-up, comparing chemomechanical treatment with drilling. Oral Health Prev Dent 2005;3(2):105-11. 16. Lozano-Chourio MA, Zambrano O, Gonzalez H, Quero M. Clinical randomized controlled clinical trial of chemomechanical caries removal (Carisolv). Int J Paediatr Dent 2006;16(3):161-7. 17. Peters MC, Flamenbaum MH, Eboda NN, Feigal RJ, Inglehart MR. Chemomechanical caries removal in children: efficacy and efficiency. JADA 2006;137(12):1658-66. 18. Inglehart MR, Filstrup SL, Wandera A. Oral health and quality of life in children. In: Inglehart MR, Bagramian RA, eds. Oral healthrelated quality of life. Carol Stream, Ill.: Quintessence; 2002:79-88. 19. Filstrup SL, Briskey D, da Fonseca M, Lawrence L, Wandera A, Inglehart MR. Early childhood caries and quality of life: child and parent perspectives. Pediatr Dent 2003;25(5):431-40. 20. Cuthbert MI, Melamed BG. A screening device: children at risk for dental fears and management problems. ASDC J Dent Child 1982;49(6):432-6. 21. Frankl SN, Shiere FR, Fogels HR. Should the parent remain with the child in the dental operatory? J Dent Child 1962;29:150-63. 22. Kidd EA, Banerjee A. What is absence of caries? In: Albrektsson TO, ed. Tissue preservation in caries treatment. Chicago: Quintessence; 2001:69-79. 23. Peters MC, McLean ME. Minimally invasive operative care, I: minimal intervention and concepts for minimally invasive cavities. J Adhes Dent 2001;3(1):7-16. 24. Maltz M, de Oliveira EF, Fontanella V, Bianchi R. A clinical, microbiologic, and radiographic study of deep caries lesions after incomplete caries removal. Quintessence Int 2002;33(2):151-9. 25. Inglehart MR, George S, Feigal RJ. Dental fear in pediatric patients: challenges and opportunities for dental care providers. J Pract Hyg 2003;12(3):11-5. 26. Ericson D, Kidd E, McComb D, Mjör I, Noack MJ. Minimally invasive dentistry: concepts and techniques in cariology. Oral Health Prev Dent 2003;1(1):59-72.
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