Reduction in Bacterial Loading Using Papacarie and Carisolv As An Irrigant in Pulpectomized Primary Molars - A Preliminary Report
Reduction in Bacterial Loading Using Papacarie and Carisolv As An Irrigant in Pulpectomized Primary Molars - A Preliminary Report
Reduction in Bacterial Loading Using Papacarie and Carisolv As An Irrigant in Pulpectomized Primary Molars - A Preliminary Report
Viral P Maru*/ Dimple Padawe**/ Vandana Pandey Tripathi***/ Vilas Takate****/ Kishor Dighe*****/
Shraddha Vishwanath Dalvi ******
Objective: The aim of the present study was to evaluate the reduction in bacterial loading using Papacarie
and Carisolv as an irrigating solution in pulpectomized primary molars. Study design: A controlled,
randomized clinical trial involving 120 necrotic canals from both genders between 3 and 7 years old children
were included, 30 irrigated with Papacarie [ group I], Carisolv [ group II], 1% NaOCl gel [ group III]
and 1% Na0Cl solution [group IV ] each; in all cases, 2 microbiological samples from within the canals
were taken with sterile paper points, the first after the canal opening and before the first irrigation, and the
second after instrumentation and final irrigation, before obturation. All samples were evaluated by Agar
plate method. Results: The results were statistically analyzed by ANOVA. After analyzing samples before
and after irrigation in all the groups, a strong significant decrease in bacterial load [ p = < 0.001 ] was
found with Papacarie and Carisolv. Conclusion: Papacarie and Carisolv can be suggested as an alternative
irrigant for pulpectomy of necrotic teeth.
INTRODUCTION
T
he aim of pulpectomy procedure is to eliminate infection
and substrate from the root canal system. 1-3 Pulpectomy
procedure still proves to be complicated and has remained
controversial for a number of reasons in the pediatric population.
Mainly, the perceived difficulty of behavior management and uncer-
tainty about the effects of root canal filling material and instrumen-
tation on the succedaneous teeth, anatomic situations like the often
From the Govt Dental College and Hospital, Mumbai, India. complicated, curved and tortuous root canals and closeness of the
*Viral P Maru, MDS, MBA; Associate Professor, Department Pediatric and
advancing tooth buds, make the treatment more difficult.4
Preventive Dentistry.
** Dimple Padawe, MDS, MBA, Professor and Head, Department Pediatric Conventional root canal treatment includes mechanical instru-
and Preventive Dentistry. mentation in combination with antimicrobial and tissue solvent
***Vandana Pandey Tripathi MDS, Associate Professor, Department Pedi- irrigation to dissolve and dislodge debris, and create a clean envi-
atric and Preventive Dentistry. ronment compatible with periapical health. In the case of deciduous
****Vilas Takate, MDS ,Assistant Professor, Dept Pediatric & Preventive
teeth, extensive dentine removal is probably undesirable, placing
Dentistry, Department Pediatric and Preventive Dentistry.
*****Kishor Dighe, MDS,Assistant Professor, Department Pediatric and greater emphasis on irrigants for cleansing. Sodium hypochlorite
Preventive Dentistry. is most widely recommended endodontic irrigant because of its
******Shraddha Vishwanath Dalvi, MD,Assistant Professor, Department excellent tissue solvent and antimicrobial properties in concen-
of Microbiology, Govt. Grant Medical College and Sir JJ group of trations between 0.5 and 5.25%,5 but it is known to cause serious
Hospital.
damage when allowed to enter periradicular tissues even in small
amounts.6-7 Hence the search for an ideal irrigant for primary teeth
Send all correspondence to:
Viral P Maru still continues.
Dept Pediatric & Preventive Dentistry Carisolv TM (MediTeam, Goteborg, Sweden) is a well researched
Govt Dental College & Hospital, product which is advocated for chemo mechanical removal of
Mumbai, India. infected carious dentine. A preliminary study showed that Carisolv
E-mail : viralmaru@yahoo.co.in
has the potential to clean immature canals although it was less
174 doi 10.17796/1053-4625-44.3.7 The Journal of Clinical Pediatric Dentistry Volume 44, Number 3/2020
Reduction in Bacterial Loading using Papacarie and Carisolv as an Irrigant
effective than undiluted house hold bleach.1,8 In 2003, a research added to 1% sodium hypochlorite solution to prepare the sodium
project in Brazil led to development of a new formula that was hypochlorite gel. The sodium hypochlorite solution was added drop
commercially known as Papacarie (Formula & Ac, Sao Paulo, by drop to methylcellulose powder and mixed in a mortar and pestle
Brazil) [ a word that means ‘eating caries’]. It is basically composed until uniform consistency of the gel was obtained.13 The pulpectomy
of papain, chloramines, toluidine blue salts, thickening vehicle procedure was performed in a single visit. Sample size was calcu-
which are responsible for the Papacarie’s bactericide, bacteriostatic lated on the basis of a pilot study, consisting of 20 microbiological
and anti inflammatory characteristics. Chemomechanical agents – samples taken from necrotic primary root canals [ 5 corresponding
Cariolv (MediTeam, Goteborg, Sweden) and Papacarie (Formula & to each irrigating solution ], which was not included in the statistical
Ac, Sao Paulo, Brazil) promotes the concept of conserving healthy analysis of the present study. Likewise, consistency and reliability
tooth structures and giving comfort, solace and instilling a positive tests for the diagnostic and results evaluator was carried out in an
attitude towards dental treatment, justifying its use in the specialty independent manner by means of an unweighted Kappa test, which
of public health dentistry. 9-11 resulted in a score of 0.90.14The sampling of patients was realized
However the effect of Carisolv TM (MediTeam, Goteborg, non probabilistically and the irrigant selected for each case was
Sweden) and Papacarie (Formula & Ac, Sao Paulo, Brazil) as made from a list of random numbers generated from computers.
endodontic irrigant in primary teeth needs to be investigated. Hence
the present study was conducted with the aim to evaluate and Preclinical laboratory procedures
compare the reduction in bacterial load after the use of Papacarie, Pre reduced thioglycolate tubes, supplemented with hemin
Carisolv, 1% NaOCl gel and solution as endodontic irrigant in [5mg L-1] and menadione[ 1mg L-1] [ Oxiod LTD, Basingstoke,
primary teeth. The null hypothesis was that there would be no signif- Hampshire, UK], was used as transport and growth media owing to
icant difference in these irrigants with respect to bacterial count. capacity to maintain the vitality of sampled bacteria.15
The Journal of Clinical Pediatric Dentistry Volume 44, Number 3/2020 doi 10.17796/1053-4625-44.3.7 175
Reduction in Bacterial Loading using Papacarie and Carisolv as an Irrigant
176 doi 10.17796/1053-4625-44.3.7 The Journal of Clinical Pediatric Dentistry Volume 44, Number 3/2020
Reduction in Bacterial Loading using Papacarie and Carisolv as an Irrigant
and the other containing 0.1 M amino acids, gel sub stance, sodium
chlorite, sodium hydroxide and a color indicator (erythrocin).
When these components are mixed together, the amino acids
bind with chlorine to form high pH chloramine which is a potent
disinfectant with tissue solvent activity. Carisolv also contains 0.5
% NaOCl that provides an excellent non specific proteolytic and
antimicrobial properties.21 These factors could be the probably
reason for high efficiency shown by Carisolv when used a irrigant
in pulpectomized primary molars with respect to reduced bacterial
count post irrigation.
Kilani et al ascertained that Carisolv is more effective than
physiologic saline in removing debris from the non instrumented
walls of root canals. Carisolv cleaned canals more effectively than
phosphate buffer saline but never reached the consistent high levels
Graph 1 : Comparison (log)Colony forming units x 106 in four of cleanliness achieved with strong sodium hypochlorite, even after
groups studied long incubation times and ultrasonic agitation.1 Parul and associates
reported that 1% NaOCl solution, 1% NaOCl gel, and Carisolv
had comparable activity at coronal third and middle third of root
DISCUSSION canals of primary teeth. At the apical third, NaOCl solution cleaned
One of the fundamental steps in a pulpectomy treatment in canals better than NaOCl gel and Carisolv. Carisolv cleaned debris
primary teeth is the reduction of the pathogenic bacterial load to better than NaOCl gel at the apical third.22Shabnam and associates
the minimum level within the root canals.19 Hence the clinician concluded that Carisolv and Papacarie both are equally efficient as
must pay particular attention to the biochemical preparation of an antibacterial gel against S mutans and Lactobacillus present on
the complex pulp canal system characteristic of primary teeth carious primary dentin.23 Lager et al reported that the composition
to reduce the bacteria and their byproducts to a minimum, thus of Carisolv (contains NaOCl as the main ingredient) is responsible
increasing the chances of a successful pulpectomy. In the present for its antibacterial activity. In accordance with our data, this has
study a strong statistical significant difference was found between been proved by Silva et al 24-26 Korb,27 Motta et al 28The studies of
Papacarie, Carisolv and NaOCl with respect to reduction in bacte- Motta29 and Matsumoto30 inferred Papacarie as an excellent option
rial count post irrigation. for achieving significant reduction in total bacteria and Strepto-
The present study is the first to evaluate Papacarie Formula & coccus mutans.
Ac, Sao Paulo, Brazil) as an endodontic irrigant in pulpectomized Pre reduced thioglycolate had been used in the present study
primary molars. Papacarie Formula & Ac, Sao Paulo, Brazil) to transfer microbiological samples from infected root canals to
consists of papain, chloramines, toluidine blue salts, thickening the laboratory, as suggested by Carlsson15. This medium reduces
vehicle which are responsible for the Papacarie’s bactericide, oxygen, preventing the accumulation of superoxide radicals that
bacteriostatic and anti inflammatory characteristics.11 Papain is a would kill anaerobic bacteria; also, it contains small amounts of
proteolytic enzyme. Similarly to the human pepsin, papain acts as agar that prevent diffusion of oxygen into the medium. An essential
a debridant anti – inflammatory agent which does no damage the step in endodontic microbiology studies is the design and imple-
healthy tissue and accelerates the cicatricial process. Papain comes mentation of a preoperative disinfection protocol of the field, so
from the latex of the leaves and fruits of the green adult papaya. that the taking of microbiological samples is carried out in the most
Carica papaya, for instance, is cultivated in tropical regions such aseptic possible conditions, avoiding the contamination that might
as Brazil, India, South Africa and Hawaii, and is largely used in confuse the results.16 The disinfection protocol used in this study
food, beverage and drug industries. It acts only on carious tissue was a modification of the one described by Ng .17
which lacks the plasmatic protease inhibitor alpha -1 – antitrypsin, 1% NaOCl gel was used in the present study since Papacarie and
but its proteolytic action is inhibited on healthy tissue, which Carisolv both exists in gel form.1% NaOCl was used since studies
contains this substance. showed negligible differences in antibacterial activity among
Chloramine is a compound composed of chlorine and ammonia 5.25%, 2.5% and 1 % NaOCl in infected root canals.24,25 Even 0.5%
having bactericidal and disinfectant properties. Widely used as an NaOCl, when used in larger volumes and with longer irrigation
irrigating solution for radicular canals in order to chemically soften times, possesses good bactericidal activity.26 Sodium hypochlorite at
the root carious dentin. These factors could be the probably reasons all concentrations was effective in eliminating resistant endodonti-
for high efficiency shown by Papacarie when used as irrigant with cally relevant microbes including Candida albicans, Pseudomonas
respect to reduction in bacterial count post irrigation in the present aeruginosa, E faecalis, Bacillus subtilis, Streptococcus mutans and
study. The degraded portion of the carious dentin collagen is Staphylococcus aureus.27-29 From a cleansing perspective, lower
chlorinated by the chloramines and is easily removed with exca- concentrations of NaOCl still retained substantial tissue dissolution
vator.20Toluidine blue is a photosensitive pigment that fixes into capacity and are effective in cleaning root canals. Baumgartner and
bacterial membrane. Cuenin30 showed that all NaOCl concentrations were equally effec-
CarisolvTM (MediTeam, Goteborg, Sweden was introduced by tive in flushing out loose debris and completely removing pulpal
Ericson and available in two syringes, one containing 0.5% NaOCl remnants and predentin from non instrumented canal walls.
The Journal of Clinical Pediatric Dentistry Volume 44, Number 3/2020 doi 10.17796/1053-4625-44.3.7 177
Reduction in Bacterial Loading using Papacarie and Carisolv as an Irrigant
CONCLUSION x
Cynthia K.Y. Yiu
More controlled clinical trials are required to support the
Search for articles by this author
effectiveness of 3.8% SDF as an irrigant solution, the results Affiliations
reported by this study are highly encouraging in terms of being a Paediatric Dentistry and Orthodontics, Faculty of Dentistry, The University of
suitable and potent alternative for irrigation of endodontic canals Hong Kong, Hong Kong, China
of primary teeth. x
Nigel M. King
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REFERENCES Affiliations
1. Al-Kilani MG, Whitworth JM, Dummer PM. Preliminary in vitro evaluation
Paediatric Dentistry and Orthodontics, Faculty of Dentistry, The University of
of Carisolv as a root canal irrigant. Int Endod J;36:433-40. 2003.
Hong Kong, Hong Kong, China
2 . Nair PN, Sjogren U, Krey G, Kahberg K, Sundqvist G. Intraradicular bacteria
x
and fungi in root filled, asymptomatic human teeth with therapy resistant
Franklin R. Tay
periapical lesion: A long term light and electron microscopic follow up
Search for articles by this author
study. J Endod;16:580-8. 1990.
Affiliations
3. Sjogren U, Figdor D, Persson S, Sundqvist G. Influence of infection at the
Department of Endodontics, School of Dentistry, Medical College of Georgia,
time of root filling on the outcome of endodontic treatment of teeth with
Augusta, GA
apical periodontitis. Int Endod J;30:297-306. 1997.
4. Holan G, Fuks AB. A comparison of pulpectomies using ZOE and KRI paste
in primary molars: A retrospective study. Pediatr Dent;15:403-7. 1993.
5 Zehnder M, Kosicki D, Luder H, Sener B, Waltimo T. Tissue dissolving
capacity and antimicrobial effect of buffered and unbuffered hypochlorite
solutions. Oral Surg Oral Med Oral Pathol Oral Radiol Endod;94:756-62.
2002.
Citations
6 Hulsmann M, Hahn W. Complications during root canal irrigation: Literature
Citation Indexes: 20
review and case reports. Int Endod J;33:186-93. 2000.
Captures
7 Gernhardt CR, Eppendorf K, Kozlowski A, Brandt M. Toxicity of concen-
Exports-Saves: 8
trated sodium hypochlorite used as an endodontic irrigant. Int Endod
Readers: 11
J;37:272-80. 2004.
see details
8 Priyanka S, Prateek J, Banu PS. A comparative study of the clinical efficiency
Manzur A, Gonzalez AM, Pozos A, Silva Herzog D, Friedman S. Bacteria
of chemomechanical caries using Carie – Care gel for permanent teeth of
quantification in teeth with apical periodontitis related to instrumenta-
children of age group of 12-15 years with that of conventional drilling
tion and different intracanal medications: a randomized clinical trial. J
method: A randomized controlled trial. Dent Res J;16[1]:42-46. 2019.
Endod;33:114-18. 2007.
9. Harsha SN, Gauri SL, Hrishikesh SW. Comparative evaluation of efficacy
17.Siqueira JF Jr, Rocas IN: Catonella morbid and Granulicatella adiancodens:
chemomechanical and conventional methods of caries excavation in young
new species in endodontic infections. Oral Surg Oral Med Oral Pathol Oral
permanent molar teeth: In vivo study. J Dent Res Rev;6:13-18. 2019.
Radiol Endod;102:259-64. 2006.
10 Afnan MS, Azza AEL, Najlaa MA. Atraumatic Restorative Treatment and
18.Elizabeth M, Mangala AN & Nicholas A. Jacques Neil Hunter. Quantitative
interim therapeutic restoration : A review of the literature. Dent J;28:1-10.
microbiological study of human carious dentin by culture and real-time
2019.
PCR: Association of anaerobes with histopathological changes in chronic
11.Bussadori S, L. Castro and A.Galvao. Papain gel : A new chemomechanical
pulpitis. Clin. Microbiol; 40 [5]:1698-1704. 2002.
caries removal agent. J Clin Pediatr Dent;30[2]:115-20. 2005.
19. Ruiz Esparza CL, Garrocho Rangel A, Gonzalez Amaro AM, Flores REeyes
12.Frais S, Ng Yl, Gulabivala K. Some factors affecting the concentration
H, Pozos Guillen AJ. Reduction in bacterial loading using 2% chlorhexi-
of available chlorine in commercial sources of sodium hypochlorite. Int
dine gluconate as an irrigant in pulpectomized primary teeth : A prelimi-
Endod J;34:206-15. 2001.
nary report. J Clin Pediatr Dent; 35[3]:265-70. 2011.
13 Ganesh C, Gopikrishna V, Prakash V, Kandaswamy D, Parameswaram A.
.20 Osato J.A, Santiago L.A, Remo GM, Cuadra M.S & Mori A. Antibacterial
Evaluation of nanolekage following deprotienization of dentine using
and antioxidant activities of unripe papaya. Life Sci;53[17]:1383-1387.
varying concentrations and application times of sodium hypochlorite
1999.
solution and gel- an in vitro conofocal laser scanning microscope study. J
21. Ericson D, Zimmerman M, Raber H, Gotrick B, Bornstein R & Thorell J.
Conserv Dent;8:27-36. 2005.
Clinical evaluation of efficacy and safety of a new method for chemome-
14 Landis JR, Koch G. The measurement of observer agreement for categorical
chanical removal of caries. Caries Res;33:171-177. 1999.
data. Biometrics;33:159-74. 1977.
22. Parul S, Usha M D, Deepak V, Anita S. Carisolv as an endodontic irrigant in
15.Carlsson J, Sundqvist G. Evaluation of methods of transport and cultivation
deciduous teeth : An SEM study. Indian J Dent Res;23:120-1. 2012.
of bacterial specimens from infected dental root canals. Oral Surg Oral Med
23. Shabnam G, Ruchi A, Altaf S, Bhupendra B, Ghadah A, Hesham K et
Oral Pathol;49:451- 54.1980.Search for articles by this authorAffiliation-
al. Antibacterial activity Of two chemomechanical caries removal gels
sCariology and Operative Dentistry, Department of Restorative Science,
on carious dentin of primary teeth: An in vitro Study. J Contempt Dent
Graduate School, Tokyo Medical and Dental University, Tokyo, Japan
Pract;17[12]:1-6. 2016.
16.Search for articles by this author Affiliations Cariology and Operative
24 Silva LR, Murillo JH, Santos EM, Guedes-Pinto AC, Bussadori SK. Utilizing
Dentistry, Department of Restorative Science, Graduate School, Tokyo
papaya gel for removal of caries: Report of case with 1-year follow-up.
Medical and Dental University, Tokyo, Japan
Acra Odontol Venez.;43:155–8. 2005.
Paediatric Dentistry and Orthodontics, Faculty of Dentistry, The University of
25 Yip HK, Stevenson AG, Beeley JA. An improved reagent for chemomechan-
Hong Kong, Hong Kong, China
ical caries removal in permanent and deciduous teeth: an in vitro study. J
Correspondence
Dent;23:197–204. 1995.
Address requests for reprints to Dr Noriko Hiraishi, Graduate School, Tokyo
26 Korb RM. Alexandria, Egypt: Alexandria University; 2008. Evaluation of
Medical and Dental University, Cariology and Operative Dentistry,
a New Agent for Chemomechanical Caries Removal in Primary Teeth
Department of Restorative Science, 1-5-45 Yushima, Bunkyo-ku, Tokyo
(Master’s Thesis) .
113-8549, Japan.
178 doi 10.17796/1053-4625-44.3.7 The Journal of Clinical Pediatric Dentistry Volume 44, Number 3/2020
Reduction in Bacterial Loading using Papacarie and Carisolv as an Irrigant
27 Bussadori SK, Guedes GC, Martins MD, Fernandes KP, Des Santos EM. x
Papain-based gel: A new alternative to chemical and mechanical decay Franklin R. Tay
removal. Actas Odontologicas. ;3:35–9. 2006. Search for articles by this author
28 Motta LJ, Bussadori SK, Campanelli AP, Silva AL, Alfaya TA, Godoy CH, Affiliations
et al. Efficacy of papacarie® in reduction of residual bacteria in deciduous Department of Endodontics, School of Dentistry, Medical College of Georgia,
teeth: A randomized, controlled clinical trial. Clinics (Sao Paulo);69:319– Augusta, GA
22. 2014.
29 Matsumoto SF, Motta LJ, Alfaya TA, Guedes CC, Fernandes KP, Bussa-
dori SK. Assesment of chemomechanical removal of carious lesions using
Papacarie Duo™: Randomized longitudinal clinical trial. Indian J Dent
Res. 24:488–92. 2013
30 Siqueira JF Jr, Rocas IN, Favieri A, Lima KC. Chemomechanical reduction
of the bacterial population in the root canal after instrumentation and irri- Citations
gation with 1%, 2.5% and 5.25% sodium hypochlorite. J Endod;26:331-4. Citation Indexes: 20
2000. Captures
31Siqueira JF Jr, Rocas IN, Santos SR, Lima KC, Magalhaes FA, de Uzeda M. Exports-Saves: 8
Efficacy of instrumentation techniques and irrigation regimes I reducing Readers: 11
the bacterial population within root canals. J Endod; 28:181-4. 2002. see details
32 Estrela CR, Estrela C, Reis C, Bammann LL, Pecora JD. Control of micro-
organisms in vitro by endodontic irrigants. Braz Dent J;14:187-92. 2003.
33 Camara AC, de Albuquerque MM, Aguiar CM, de Barros Correia AC. In
vitro antimicrobial activity of 0.5%, 1% and 2.5% sodium hypochlorite in
root canals instrumented with the Protaper Universal system. Oral Surg
Oral Med Oral Pathol Oral Radiol Endod 2009;108:e55-61.
34 Arcangelo C, Varvara G, de Fazio P. An evaluation of the action of different
root canal irrigants on facultative aerobicanareobic, obligate anaerobic and
microaerophilic bacteria. J Endod;25:351-3. 1999.
35 Naenni N, Thoma K, Zehnder M. Soft tissue dissolution capacity of currently
used and potential endodontic irrigants. J Endod;30:785-7. 2004.
36 Baumgartner JC, Cuenin PR. Efficacy of several concentrations of sodium
hypochlorite for root canal irrigation. J Endod;18:605-12. 1992.
Noriko Hiraishi
Paediatric Dentistry and Orthodontics, Faculty of Dentistry, The University of
Hong Kong, Hong Kong, China
Correspondence
Address requests for reprints to Dr Noriko Hiraishi, Graduate School, Tokyo
Medical and Dental University, Cariology and Operative Dentistry,
Department of Restorative Science, 1-5-45 Yushima, Bunkyo-ku, Tokyo
113-8549, Japan.
x
Noriko Hiraishi
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Affiliations
Cariology and Operative Dentistry, Department of Restorative Science, Grad-
uate School, Tokyo Medical and Dental University, Tokyo, Japan
Paediatric Dentistry and Orthodontics, Faculty of Dentistry, The University of
Hong Kong, Hong Kong, China
Correspondence
Address requests for reprints to Dr Noriko Hiraishi, Graduate School, Tokyo
Medical and Dental University, Cariology and Operative Dentistry,
Department of Restorative Science, 1-5-45 Yushima, Bunkyo-ku, Tokyo
113-8549, Japan.
x
Cynthia K.Y. Yiu
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Affiliations
Paediatric Dentistry and Orthodontics, Faculty of Dentistry, The University of
Hong Kong, Hong Kong, China
x
Nigel M. King
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Affiliations
Paediatric Dentistry and Orthodontics, Faculty of Dentistry, The University of
Hong Kong, Hong Kong, China
The Journal of Clinical Pediatric Dentistry Volume 44, Number 3/2020 doi 10.17796/1053-4625-44.3.7 179