Caries Dentin

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Current Concepts and Techniques for Caries Excavationand Adhesion to Residual DentinAline de Almeida Nevesa/Eduardo Coutinhob/Marcio Vivan Cardosoc/Paul Lambrechtsd/Bart Van Meerbeeke

Abstract: The advent of “Adhesive Dentistry” has simplified the guidelines for cavity preparation enormously. The de-sign and extent of the current preparations are basically defined by the extent and shape of the caries lesion, poten-tially slightly extended by bevelling the cavity margins in order to meet the modern concept of minimally invasivedentistry. New caries excavation techniques have been introduced, such as the use of plastic and ceramic burs, im-proved caries-disclosing dyes, enzymatic caries-dissolving agents, caries-selective sono/air abrasion and laser abla-tion. They all aim to remove or help remove caries-infected tissue as selectively as possible, while being minimallyinvasive through maximum preservation of caries-affected tissue. Each technique entails a specific caries-removalendpoint and produces residual dentin substrates of different natures and thus different receptiveness for adhesiveprocedures. This paper reviews the newest developments in caries excavation techniques and their effect on the re-maining dentin tissue with regard to its bonding receptiveness.

Keywords: minimally invasive dentistry, dentin caries, caries excavation, bond strength of composite/dentin interfaces.

J Adhes Dent 2011; 13; 7-22. Submitted for publication: 08.07.09; accepted for publication: 24.10.09.doi: 10.3290/j.jad.a18443

The potential to bond restorative materials to tooth struc-ture has altered the general principles of cavity prepara-

tion. While new steps were added to cavity preparationprocedures, especially for bonding, others – such as cuttingretentive cavity geometries – were omitted. In light of the min-imally invasive dentistry concept,112 the macroretentive“G.V.Black” cavities15 have been replaced by cavities limitedto removal of carious dentin that are at most extended withsome additional rounding off of sharp margin edges and/orbevelling, the latter to the direct benefit of the subsequentbonding process.

However, the extent to which carious dentin should be re-moved in order to achieve a mechanically and biologicallysuccessful restoration is still a matter of debate. In particu-lar, no definite diagnostic tool is today available to clinicallydefine the caries-removal endpoint, enabling complete re-moval of infected tissue without overextending cavity prepa-ration. In addition, the different techniques presently avail-able for caries removal/cavity preparation produce residualdentin substrates of different natures and thus different re-ceptiveness for adhesion. The extent of carious dentin ex-cavation, the type of dentin substrate generated by eachcaries excavation technique, and the additional effect bond-ing agents exert on the residual dentin substrate are re-viewed in this article, along with an in-depth discussion onaspects of dental caries histopathology. The latter is of directimportance for proper understanding of the rationale behindthe different caries removal techniques.

WHY SHOULD CARIOUS DENTIN BE REMOVEDBEFORE THE ACTUAL RESTORATION IS PLACED?

At the beginning of the past century, when the first opera-tive dentistry guidelines were established, the term “cariesexcavation” was defined as a synonym for “cavity prepara-tion”, which in turn consisted of “mechanical treatment ofthe injuries to the teeth produced by dental caries, aswould best fit the remaining part of the tooth to receive afilling”.15 From this definition, it appears that caries exca-vation procedures were regarded as one of the manymandatory steps to prepare a tooth to receive the fillingmaterial. Furthermore, it has been described that the cari-ous lesion should be excavated “until a hard pulpal floor

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a PhD student, Leuven BIOMAT Research Cluster, Department of ConservativeDentistry, School of Dentistry, Oral Pathology and Maxillo-Facial Surgery,Catholic University of Leuven, Leuven, Belgium. Literatur review, wrote manu-script in partial fulfillment for PhD.

b PhD student, Leuven BIOMAT Research Cluster, Department of ConservativeDentistry, School of Dentistry, Oral Pathology and Maxillo-Facial Surgery,Catholic University of Leuven, Leuven, Belgium. Computer 3D-modeling ofcarious teeth, proofread manuscript.

c Postdoctoral Research Fellow, Leuven BIOMAT Research Cluster, Departmentof Conservative Dentistry, School of Dentistry, Oral Pathology and Maxillo-Fa-cial Surgery, Catholic University of Leuven, Leuven, Belgium. Contributed tocontent, proofread manuscript.

d Full Professor, Leuven BIOMAT Research Cluster, Department of ConservativeDentistry, School of Dentistry, Oral Pathology and Maxillo-Facial Surgery,Catholic University of Leuven, Leuven, Belgium. Neves’ PhD supervisor, con-tributed to content, proofread manuscript.

e Full Professor, Leuven BIOMAT Research Cluster, Department of ConservativeDentistry, School of Dentistry, Oral Pathology and Maxillo-Facial Surgery,Catholic University of Leuven, Leuven, Belgium. Neves’ PhD supervisor, de-fined manuscript outline, proofread manuscript.

Correspondence: B. Van Meerbeek, Leuven BIOMAT Research Cluster, Departmentof Conservative Dentistry, School of Dentistry, Oral Pathology and Maxillo-FacialSurgery, Catholic University of Leuven, Kapucijnenvoer 7, B-3000, Leuven, Belgium.Tel: +32-16-337587, Fax: +32-16-332752. e-mail: [email protected]

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was reached” and that “generally, when the cavity hasbeen cut to form, no carious dentin will remain”.15 Inshort, carious dentin should be removed until a suffi-ciently solid layer of dentin was reached to support con-densation of the restorative material (“stability form”) andto provide adequate retention for the filling material (“re-tention form”), promoting a successful and long-term sur-vival of the restoration.

It is thus clear that when nonadhesive restorations werethe only available option to directly restore decayed teeth, nodistinct separation between caries removal and cavity prepa-ration was made. In practical terms, it means that excava-tion of carious dentin was performed to remove necrotic,soft material in order to best accommodate the filling mate-rial. Perhaps it explains the general confusion still seennowadays when dealing with the term “caries excavation” inview of the minimally invasive dentistry concept.112 As al-ready mentioned, the ability to bond restorations has down-graded the rules for cavity preparation to simply and solelyremoving caries and, if needed, bevelling of the enamel cav-ity margins, while the main procedure of cavity preparation,or the excavation of caries, still lacks a more objective defi-nition.

This leads to the initial question: Does carious dentinneed to be removed prior to restoration placement? Clinicalfollow-ups of bonded restorations placed over soft cariousdentin81 provided evidence that once the cavity margins arelaid in relatively sound tissue, adequate marginal sealing isguaranteed and further progression of the carious lesioncan be arrested. Apparently, therefore, well-sealed marginsdetermine the long-term success of adhesive restorations, inparticular with respect to arresting the caries progress.81 Af-ter all, since bonding to carious dentin is generally not asgood as that to sound dentin, the somewhat unexpected an-swer to this question is that carious dentin is still removedin order to provide adequate retention for the filling materi-al (achieving better bonding), thus producing long-term suc-cessful restorations.

As caries excavation is still an important step towardsachieving good-quality bonded restorations, the next ques-tion arises: What is the current definition of the caries re-moval endpoint? Even now, there is still no better clinical cri-terion to define the caries excavation limit than the “normal”hardness feeling of sound dentin when probed by hand in-struments.94 Although this so-called “cris dentinaire” is verysubjective and dependent on the operator’s clinical back-ground, it is still the gold-standard method to check residualcaries. It was strongly corroborated after research showedthat cariogenic bacteria were never found beyond the soft-ening front of dentin.40 Further identification of a superficialinfected dentin layer and a subjacent affected dentin layer41

has laid the foundation for a more rational approach forcaries removal. Elimination of the heavily infected dentinand preservation of the residual affected dentin were thusdefined as prerequisites for effectively arresting the cariousprocess without harming the long-term survival of the pulpand the restoration.62 This has currently raised some dis-cussion about moving toward more objective and hopefullymore conservative approaches to selectively remove cariousdentin.10,121

HISTOPATHOLOGY OF DENTIN CARIES

Dentin is a mineralized tissue permeated by cellular exten-sions from odontoblasts, which are located at the periph-eral zone of the pulp adjacent to the pre-dentin.110 For thisreason, dentin, as a vital tissue, is perfectly able to re-spond to any stimuli, even when invoked at the enamelsurface, such as an acid challenge produced by an orga-nized, acid-producing biofilm.106

The first detectable change in dentin in response to a car-iogenic biofilm at the outer enamel surface is an area of scle-rotic dentin subjacent to the demineralized enamel site (Figs1A and 1B). The predominant feature of this reactive dentinis its increased translucency, which can be ascribed to in-tratubular mineral deposition.6 The translucent dentinaltubules will be those localized precisely beneath the dem-ineralized enamel surface, and appear even before theenamel demineralization has reached the dentin-enameljunction (DEJ). Only when the caries lesion has progressedto a considerable length along the DEJ will the subjacentdentin be demineralized14 and become recognizable by ayellow to dark-brown discoloration (Figs 1C and 1D). At thispoint, bearing in mind that the dentin response to dentalplaque is directly related to its metabolic activity77 and thatdifferent maturation stages can coexist in a fully-formeddental plaque depending on the self-cleaning ability of thesurface, different phases of caries progression will co-existwithin one lesion14 (Figs 2A and 2B).

It is also well known that dentin caries will not spread lat-erally along the DEJ before dentin is cavitated and colonizedby cariogenic bacteria.34 From this moment, the demineral-ized and thus unprotected organic dentin matrix (collagen)will be directly degraded through bacterial and host-mediat-ed enzymes.65,107 Especially at peripheral parts of the cavi-ty where the cariogenic biofilm is sheltered by the surround-ing (undermined) enamel, the lesion may spread rapidlyalong the DEJ (“hidden” caries lesion) (Figs 2B and 2C).

CARIES-EXCAVATION PROCEDURES

Conventional Excavation with BursCarbon-steel or tungsten-carbide bursTungsten-carbide burs replaced carbon-steel burs oncethe process of hardening steel with tungsten carbide wasintroduced to the dental bur industry. Microscopic tung-sten-carbide particles are held together in a matrix ofcobalt or nickel at the head (working end) of the bur.120

The head has typical spiral-like cutting edges with or with-out additional cross cuts to improve cutting efficiency. Carbon-steel burs possess the same caries-removing pro-perties as tungsten-carbide burs and are less expensive,but they are much more prone to corrosion and dulling.12

For caries removal, a round bur is recommended with di-ameters corresponding to the size of the carious lesion.Water irrigation is optional because generally low-speed(700 to 800 rpm) counter-angle handpieces are employed.It is generally advised to start carious dentin excavationfrom the periphery towards the center of the lesion inorder to minimize the risk of infection in case of accidental

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8 The Journal of Adhesive Dentistry

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pulp exposure. Larger burs are recommended for this rea-son as well.

Tungsten-carbide or carbon-steel burs in low-speedcounter-angle handpieces are the most efficient method to ex-cavate carious lesions in terms of time,24 and are thereforestill the most widely used caries-excavation method. Howev-er, in terms of minimal invasiveness, bur-prepared cavities,combined with the use of a dental explorer to check for thecaries removal endpoint, tend to overexcavate. This was

found, for instance, when auto-fluorescence induced by bac-terial metabolites was used to detect carious tissue.8 Whenstudied by scanning electron microscopy (SEM), this methodleaves a homogeneous smear layer with more or less uniformroughness, and dentinal tubules visibly obstructed with smearplugs.116 With regard to bonding receptiveness, the smear-covered surface does not interfere with etch-and-rinse adhe-sives, but has been shown to potentially reduce the bondingeffectiveness of self-etching adhesives.91.

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Fig 1A Proximal surface of a molar showing anon-cavitated lesion (black arrow) beneaththe contact point (white arrow). The dottedline indicates the location of the mesiodistalsection in Fig 1B.Fig 1B Mesiodistal section reveals an area ofhypermineralized dentin (black arrow) be-neath the area of enamel demineralization(white arrow).Fig 1C Occlusal surface of the same toothshowing a non-cavitated lesion on the centralfossa (black arrow) and a cavitated lesion inthe occluso-palatal groove (white arrow). Thedotted line indicates the location of themesiodistal section in Fig 1D.Fig 1D Mesiodistal section showing a yellow-brown discoloration under the demineralizedenamel (black arrow). The white arrow depictsresidual demineralized dentin originatingfrom the occluso-palatal lesion (C: whitearrow).

Fig 2A Volume-rendered slices based on x-ray micro-CT data of a molar showing a cavi-tated lesion in the central fossa. The numbersalong the black lines in Fig 2B refer to eachcorresponding volume rendering based on x-ray micro-CT data of the tooth. From 1 to 6, in-creasing progression stages can be observedfrom the periphery to the center of the lesion.Fig 2B Occlusal surface of the same tooth el-ement. The dotted red line indicates the loca-tion of the mesiodistal section in Fig 2C. Theblack lines indicate the location of the vol-ume-rendered slices in Fig 2A.Fig 2C Mesiodistal section showing the lat-eral spread of the dentin lesion (white arrows)beyond the limit of the enamel cavitation (dot-ted lines).

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Polymeric bursIn an attempt to develop a selective caries-removal rotat-ing instrument, a “plastic” bur was made of a polyamide/imide (PAI) polymer, possessing slightly lower mechanicalproperties than sound dentin. However, soon it becameclear that if the bur touches sound or caries-affecteddentin, it quickly becomes dull and produces undesirablevibration, making further cutting impossible. The blade de-sign was developed to remove dentin by locally depressingthe carious tissue and pushing it forward along the sur-face until it ruptures and is carried out of the cavity. With aprototype, single-use instrument, complete removal of cari-ous tissue could be accomplished from extracted teethwhen a 1% acid-red-propylene glycol solution was used ascaries detector.17

The commercial version of these burs (SmartPrep, SS-White Burs; Lakewood, NJ, USA) consisted of a polymer(PEKK – polyether-ketone-ketone) with a particular hardnessof 50 KHN, which was higher than the hardness attributedto carious dentin (0 to 30 KHN), but lower than that of sounddentin (70 to 90 KHN).103 As opposed to conventional car-bide burs, their cutting edges were not spiralled but straight.One disadvantage was that by keeping to the recommenda-tion to excavate caries from the center to the periphery in or-der to avoid contact with sound tooth tissue, the bur wouldbe prematurely and irreversibly damaged.28 Local anaes-thesia was said not to be needed, based on the claim thatthese plastic burs would remove only the insensitive, soft,and necrotic carious dentin (caries-infected dentin), leavingthe demineralized, noninfected sensitive layer (caries-af-fected dentin). Nevertheless, while the need for local anaes-thesia during cavity preparation was in fact reduced, somepatients still reported one or more episodes of pain sensa-tion during treatment.3

The efficacy of the SmartPrep burs for caries removal wasquestioned in a histological study when excavated tooth sec-tions were stained with Mallory-Azan.28 More residual carieswas found in cavities excavated with SmartPrep burs than in

cavities prepared with conventional tungsten-carbide burs.In addition, not only the microtensile bond strength to cari-ous dentin excavated with SmartPrep burs was lower forboth etch-and-rinse and self-etching adhesives,103 trans-mission electron microscopy (TEM) of the bonded interfacesdisclosed remnants of carious tissue at the excavateddentin/composite interface. It was then suggested that theefficiency of the polymer burs could be enhanced if the hard-ness of the polymeric material could be increased.

An improved version of the polymeric burs was more re-cently marketed (SmartBurs, SSWhite Burs; Lakewood, NJ,USA) and resulted, in primary teeth, in the highest coinci-dence between the caries removal endpoint obtained by au-to-fluorescence of carious dentin and the actual degree ofcaries removal. A great amount of residual caries was nev-ertheless still found, especially in inactive caries-arrested le-sions. This can probably be explained by the still rather lowsurface hardness of the SmartBurs (26.6 KHN) as com-pared to the hardness of arrested carious dentin (39.2KHN).24

Ceramic bursA new line of slow-speed rotary cutting instruments madeof ceramic materials is now commercially available for re-moval of carious dentin. The CeraBurs (Komet-Brasseler;Lemgo, Germany) are all-ceramic round burs made of alu-mina-yttria stabilized zirconia and are available in differentdiameter sizes (Fig 3). The manufacturer claims that be-sides its high cutting efficiency in infected, soft dentin, theuse of this instrument for caries removal replaces both theexplorer and the excavation spoon (commonly needed toevaluate the degree of decay removal) by simultaneouslyproviding tactile sensation, self-evidently reducing prepara-tion time.

However, an in vitro investigation of the caries-removal ef-ficiency (time consumption for excavation) and efficacy (abil-ity to remove all carious material from the cavity) did notshow any significant difference between the ceramic andconventional tungsten-carbide burs.27 Nevertheless, one im-portant aspect to be emphasized – and which applies to allkinds of bur instruments – is its nonspecificity. Especially ifno tactile instrument is used to check the cavity for its hard-ness, areas of underprepared dentin are likely to be left,59

as can be observed in the 3D volumetric reconstruction of acarious tooth when caries was excavated using ceramic burs(Fig 4). Further in vivo studies testing the effectiveness ofthese new burs are unfortunately still lacking.

Caries-disclosing DyesEarly TEM and biochemical characterization of cariousdentin revealed that the most superficial carious layer isnecrotic, highly decalcified, and contains irregularly scat-tered granular crystals and irreversibly denatured collagenfibrils. Underneath this “caries-infected” dentin, thedeeper “caries-affected” dentin layer exhibits decreasedcollagen crosslinks, but comprises needle-like apatite crys-tals, regularly attached to collagen fibrils with no signs ofbacterial invasion.68,90 Based on this knowledge, the idealcaries-disclosing dye should stain solely the caries-in-fected, but not the caries-affected dentin.

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Fig 3 CeraBurs with different diameters. From left to right: 10-,14-, 18-, and 23-mm diameter.

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0.5% Basic fuchsin in a propylene glycol baseOne of the first caries-disclosing dyes was based on a so-lution of 0.5% basic fuchsin in propylene glycol and wasclaimed to stain exclusively the top, irreversibly destroyedcarious layer, enabling differentiation from what could beleft in the cavity.42 The mechanism of this differentialstaining was initially ascribed to the irreversible collagendenaturation of caries-infected dentin, caused by break-down of the intermolecular crosslinks through bacteriallactic acid.69 Later, the differential stainability was attrib-uted rather to differences in the degree of mineralizationin the carious lesion than being specific for denatured col-lagen fibrils.119 The exact mechanism for the differentialstaining is however still unknown.

The first combined clinical/laboratory study on the relia-bility of this caries-disclosing dye has pointed out that the ex-tent of dentin excavated by the fuchsin-guided method waslarger than the extent of demineralized dentin, as shown byconventional dental radiographs taken before histologicalsections were made.100 Later, others also showed that whencaries was removed using conventional tactile probing to de-termine the caries removal endpoint, both in primary andpermanent teeth, the cavity walls and floors were stillfuchsin-stainable.119 Some concerns were also raised re-garding possible carcinogenic effects of fuchsin for intra-oral

use,119 and for this reason, alternative caries-disclosingdyes are sought.

1% Acid-red in propylene glycol base Although a 1% acid-red solution (Caries Detector, Kuraray;Tokyo, Japan) was launched as an alternative to fuchsinfor intra-oral use,69 clinical inconsistencies have been re-ported when assessing the presence of stained tissue atthe DEJ by means of the usual tactile probing method. Twostudies have shown that more than half of the teethjudged clinically as having no caries at the DEJ could bestained with acid red.60,61 Microbiological assessment ofthe caries-stained and stain-free dentin at the DEJ failed todisclose differences in level of infection.61

Moreover, it has been demonstrated that a 1% acid-redsolution can lead to staining of dentin clinically judged as“sound”, with a 30% false positive diagnosis of residualcaries.18 At the pulpal floor, also more than half of the teethdiagnosed as having “hard” and “sound” pulpal floors stilltook up some stain.60 In fact, it has been reported thatsound circumpulpal dentin takes up stain more easily, be-cause of its lower degree of mineralization18,119 (Fig 5). Forall these reasons, the use of caries-staining agents is stillmuch criticized.

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Fig 4A Occlusal surface of a tooth presentingdentin caries.Fig 4B Occlusal view after minimally invasivepreparation and carious dentin excavationwith Ceraburs. The dotted line depicts the lo-cation of the volume-rendered slice in Fig 4C.Fig 4C Volume-rendered slice based on x-raymicro-CT data of the section depicted by dot-ted line in Fig 4B. The arrow denotes an areaof residual caries according to the mineral-density calibration shown at the left side. Thecaries-removal endpoint was determined bythe self-limiting property of the bur.

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Comparing acid red to basic fuchsin, both in propyleneglycol bases, acid-red produces a less intense and lessbound stain with a more intense staining of the outer thanthe inner layer of carious dentin.119 Further in vitro studieshave shown that the light pink staining from acid red, typi-cally seen at the inner layer of carious dentin, was related toa low degree or absence of bacterial infection55 as well asto a low level of peritubular dentin dissolution and increasedhardness.96,125 For these reasons, the lightly stained tissueshould not be removed.

Another concern is that the propylene glycol base of bothstaining agents can easily penetrate into normal dentin dueits low molecular weight (76 MW), which could thus also ex-plain the overstaining frequently reported for commercialproducts, such as Caries Detector.48 This finding has re-cently led to the introduction of a 1% acid-red dye in apolypropylene glycol base (Caries Check, Nippon ShikaYahuhin; Japan). The higher molecular weight of polypropy-lene glycol (300 MW) makes it more caries specific than apropylene-glycol-based dye. The fluorescence readings ofresidual dentin using DIAGNOdent (Kavo Dental; Jena, Ger-many) after caries removal guided by acid red in polypropy-lene-glycol-based dye were higher than those when carieswas removed using a propylene-glycol-based dye, indicatingthat less dentin was removed with the former caries-dis-closing dye.48,64

Clinically, both formulations of Caries Check (1% acid redor a 1% brilliant blue FCF in a polypropylene glycol base) al-so produced significantly lower DIAGNOdent readings aftercaries removal than an 1% acid red in propylene glycol.49

The blue version of the dye was introduced to facilitate iden-tification of caries in heavily stained cavities, where the redcolor is more difficult to differentiate.

Chemo-mechanical ExcavationSodium hypochlorite-based agentsThe first attempt to develop of a chemical solubilizer thatwould selectively act on carious dentin resulted in asodium hypochlorite solution buffered with an amino-acid-containing mixture of amino butyric acid, sodium chlorideand sodium hydroxide.43 Even though sodium hypochloriteis a nonspecific deproteinizing agent, the capability to selectively remove carious dentin was attributed to thebuffering effect of the amino acid mixture, originally in-tended to reduce the aggressiveness of sodium hypochlo-rite on sound dentin and to enhance the disrupting effecton degenerated collagen within carious dentin.108 Afterchlorination and cleavage of the partially degraded colla-gen fibrils in the carious lesion, the resultant friable colla-gen fibrils could be more easily removed with a spoonexcavator.13

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Fig 5A Mesiodistal section of a tooth pre-senting occlusal dentin caries (black arrow)and an approximal lesion (white arrow). DD =demineralized dentin; HD= hypermineralizeddentin. Fig 5B Higher magnification of the dottedarea in Fig 5A after staining with a 1% acid-red-in-propylene-glycol solution. Note stainingof circumpulpal dentin (black arrow) andareas of hypermineralized dentin (whitearrow).

Fig 6A Volume rendering based on x-raymicro-CT data (occlusal view) from a tooth pre-senting dentin caries (insert: stereomicro-scopic view). Fig 6B Volume rendering based on x-raymicro-CT data of the same tooth after excava-tion with the aid of a pepsin-based gel and aspecially designed plastic instrument (SFC-VIII, 3M ESPE) (insert: stereomicroscopicview).Fig 6C Volume rendering based on x-ray mi-cro-CT data of one slice (corresponding to thedotted line in Fig 6A before excavation, show-ing the extent of the lesion into dentin (blue =carious lesion; green = sound dentin).Fig 6D Volume rendering based on x-raymicro-CT data of one slice (corresponding tothe dotted line in Fig 6B after excavation,showing the extent of the excavated dentin(blue = carious lesion; green = sound dentin).

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However, this new caries-removing system, first commer-cialized as Caridex (National Patent Medical Products; NewBrunswick, NJ, USA), was not fully successful in clinical prac-tice. Not only its efficacy in caries removal was contested,but technical problems – such as the need of a specific ap-paratus to deliver the solution into the cavity, short shelf-life,longer treatment time, and higher treatment cost – were ad-vanced as reasons why it was not adopted extensively bydental practitioners.11

Renewed interest in chemomechanical caries removingagents was associated with the emerging concept of mini-mally invasive dentistry. A new caries removing system, alsobased on sodium hypochlorite, was introduced in the formof a gel (Carisolv, MediTeam Dental; Sävedalem, Sweden)which contained 0.5% w/v sodium hypochlorite, 0.1M of anamino acid mixture (glutamic acid, leucine and lysine), andwater. The gel is applied in the cavity, after which the cariousdentin is scraped off using specially designed noncuttinghand instruments. The method has been shown to effec-tively remove caries and was readily accepted by patients.However, compared with conventional drilling, a substan-tially longer treatment time was reported.38 In fact, the op-erative steps in chemomechanical caries excavation in-clude: (1) application of the solution, (2) scrapping off thecarious dentin with possible change of instrument size, (3)rinsing, and (4) repetition of the procedures until all cariesis removed.38,73 However, if the use of local anaesthesia canbe omitted, the total treatment time can be shortened.97.

Carisolv has proven its efficacy in establishing the end-point of caries excavation by removing carious dentin to thesame extent as the auto-fluorescence signature of carioustissue when measured using confocal microscopy.8 Howev-er, histological evaluation using toluidine blue as a stainingagent still revealed a higher percentage of teeth presentingbacteria invading the dentinal tubules. A great amount ofresidual bacteria was also detected at the DEJ, where directaccess of the gel and the hand instruments is difficult.117

The presence of bacteria at the bottom of the cavity was ex-plained by the relative absence of smear layer formationwhen Carisolv was used,9,98 and presumably resulted from“pushing” bacteria into the dental tubules.117 On the otherhand, the viability of such residual bacteria should be verylow, because Carisolv has some bactericidal activity due toformation of chloramine compounds. In fact, Carisolv hasproven to be somewhat superior in reducing the counts of vi-able bacteria in residual dentin, as compared to conven-tional bur excavation.70

The chemical composition and microstructure of dentinafter excavation with Carisolv does not seem to be signifi-cantly altered. The calcium and phosphorus content remainsimilar after excavation, while the hardness values of resid-ual dentin left at the cavity bottom approximate those ob-tained for sound dentin.51,99 Actually, the chloride presentin the gel does not seem able to interact with the collagenfibrils of sound dentin, since they are protected by mineralcrystals.104

Although the etch pattern of dentin in Carisolv-excavatedlesions is deeper than that in dentin from which caries wasremoved with a conventional bur guided by a caries-stainingdye,117 the bonding effectiveness of adhesives to Carisolv-

treated dentin did not appear to be affected.20,36,47 Carisolv-excavated dentin has good bonding receptiveness, meaningthat it is not covered by a smear layer, exhibits patent denti-nal tubules46 and an irregular surface topography47 with im-proved wetting potential.35 Acceptable bond strengths havebeen reported after caries was excavated with Carisolv anda self-etching adhesive was employed.105 In other studies,bond strengths obtained with both etch-and-rinse and self-etching adhesives to dentin from which caries was excavat-ed with Carisolv were even found to be similar to that ofsound dentin.20,104

Pepsin-based caries excavationA new experimental gel consisting of pepsin in a phos-phoric acid/sodium biphosphate buffer is being consid-ered as an alternative chemomechanical caries excavationagent (SFC-VIII, 3M ESPE; Seefeld, Germany). The main ad-vantage of this new enzyme-based solution is that it canbe more specific by digesting only denatured collagen(after the triple-helix integrity is lost) than the sodiumhypochlorite-based agents.1 According to the manufac-turer, the phosphoric acid dissolves the inorganic compo-nent of carious dentin, while it at the same time givespepsin access to the organic part of the carious biomassto selectively dissolve the denatured collagen. To avoidoverexcavation, the SFC-VIII gel should be used in combi-nation with a prototype plastic instrument having hardnessbetween that of sound and infected dentin. Heavily pig-mented, arrested dentin caries is known to be more resis-tant to pepsin digestion,109 but this does not seem topresent a major drawback to the method.

An x-ray micro-CT evaluation of carious teeth excavatedwith SFC-V revealed that the new enzymatic caries-removinggel was able to remove equivalent volumes of carious dentinas Carisolv.25 Figure 6 shows volume-rendering slices basedon micro-CT data of a carious tooth before and after cariesexcavation with SFC-VIII aided by the prototype plastic in-strument. SFC-VIII selectively removed carious dentin, leav-ing residual dentin with an acceptably high mineral density(1.18 to 1.44g/cm3). Figure 7 shows the prototype plastic in-strument (Star v 1.8, 3M ESPE) before and after caries ex-cavation.

Others have found partially demineralized intertubularcollagen fibrils and some tubule occlusion upon treatmentof artificially-formed dentin caries with a pepsin-basedcaries-excavation agent.1 However, further laboratory stud-ies and clinical trials are still lacking.

Excavation by sono-abrasionCaries excavation by “sono-abrasion” is based on the useof cutting tips coupled to high-frequency, sonic, air-scalerhandpieces under water cooling. The handpiece oscillatesin the sonic region (< 6.5 kHz), while the tips perform anelliptical motion. A maximum 2-N torque force should beapplied, otherwise the cutting efficiency is reduced due todamping of the oscillations.10

Sono-abrasion excavation with diamond-coated tips ap-peared as efficient (time required for excavation) as con-ventional hand excavation using dental spoons, but still tak-ing more time than the carbide-bur excavation method.8 Re-

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garding caries removal, the effectiveness of sono-abrasionbased on its auto-fluorescence signature has shown a ten-dency to underprepare carious cavities. Some authors spec-ulated that the oscillation of the diamond-coated tip is trans-ferred to only a slight vibration at the dentin surface, im-pairing effective tissue cutting and resulting only in a com-pacting effect on the carious dentin substrate.8 No chemi-cal or structural changes were observed in sono-abradeddentin, the surface characteristics of which resembled thoseof conventionally bur-cut dentin.113 The surface topographyof dentin after sono-abrasion excavation with diamond-coat-ed tips revealed relatively little9 or even no evidence ofsmear layer formation.116 According to another study, anysmear layer produced tends to be thinner than the one yield-ed by diamond/carbide burs,95 which may be advantageousfor the bonding effectiveness of so-called mild self-etchingadhesives in particular.39

More recently, the Cariex system (Kavo Dental; Biberach,Germany) was launched, including two sets of cutting tips:two diamond-coated tips with different diameters for enam-el preparation and two tungsten-carbide tips with differentdiameters for dentin excavation (Fig 8). The effectivenessand efficacy of these new tungsten carbide tips in removingcarious dentin have, however, not yet been explored.

Air-abrasion ExcavationAir-abrasion systems for cavity preparation use the kineticenergy of abrasive particles to cut tooth structure in a lessinvasive way, while rounding off internal and cavosurfaceangles to the direct benefit of the subsequent adhesiverestoration. Pure aluminium oxide particles (alumina) havebeen most frequently used as the abrading agent, thanks

to their high cutting effectiveness, chemical stability, lowcost, low affinity for water, and neutral color.16

Air-abrasion systems using 27-μm diameter alumina par-ticles are currently available to remove tooth staining or toprepare shallow cavities. Aside from the type and size of theabrasive particles, other variables which also directly influ-ence the cutting effectiveness of air-abrasion systems arethe particle speed and the angle of surface approach, andnaturally the properties of the substrate itself. The majordrawback of air-abrasion excavation of carious dentin is thatsound dentin is more efficiently removed than cariousdentin.92 Although 27-μm alumina particles have proven toremove more carious dentin than particles with larger di-mensions (50- and 125-μm diameter), cavities produced insound dentin were still considerably deeper than in cariousdentin.82 As carious dentin has a softer consistency, the en-ergy of the particles is absorbed during the impact, reducingthe cutting ability.

Other types of particles were tested in order to improvethe effectiveness of caries removal with air-abrasion sys-tems. Spherical glass beads with different diameters im-proved removal of artificially softened dentin, but althoughat lower rates, sound enamel and dentin were still removed.Polycarbonate resin-crushed powder removed artificiallysoftened dentin more selectively without cutting sounddentin or enamel,45 but further clinical investigations withthese particles are still lacking. A mixture of alumina and hy-droxyapatite in a volume ratio of 3:1, with particle sizes rang-ing from 3 to 60 μm, was shown to be as efficient as con-ventional hand excavation with dental spoons, and was pos-itively rated when related to the auto-fluorescence signatureof the lesion.8 An air-abrasion system that makes use of a

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Fig 7A Plastic single-use instrument in-tended to be used with the enzymatic pepsin-based gel (SFC-VIII, 3M ESPE).Fig 7B The same instrument after use in thetooth depicted in Fig 6, showing completedulling after the excavation procedure.

Fig 8A Cariex diamond-coated tips forenamel preparation. Fig 8B Cariex tungsten carbide tips fordentin excavation.

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bioactive glass powder (Bioglass, Novamin Technology;Alachua, USA) with a particle diameter between 25 and 32μm was also explored. Although still removing sound dentin,the risk of unnecessary sound dentin removal was reducedbecause of the difference in cutting rate between sound andcarious dentin.93 The authors suggested that other bioactiveglasses with different hardness should be evaluated for theircaries-removal selectivity.

The topography of residual dentin caries after removalwith 50-μm alumina particles exhibits a porous, sponge-likeappearance caused by the impact of the particles undercompressed air. Remnants of alumina powder were alsoidentified and tubules were fully occluded with surface de-bris.116 Although air abrasion produces a more irregular, im-bricate surface pattern and a thinner smear layer when com-pared to bur-cut dentin, it does not seem to affect bondingperformance of adhesives to dentin on the condition that itis still acid-etched if etch-and-rinse adhesives are em-ployed.113

Fluorescence-aided Caries Excavation (“FACE”)This technique was developed as a direct method to clini-cally differentiate between infected and affected cariousdentin. Based on the fact that several oral microorganismsproduce orange-red fluorophores as by-products of theirmetabolism (porphyrins), infected carious tissue will fluo-resce especially in the red fraction of the visible spectrum2

due to the presence of proto- and meso-porphyrins.76 Inthis way, continuous visual detection of orange-red fluores-cence during caries excavation was thought to be conve-nient for clinicians.

By feeding a slow-speed handpiece with a fiber-optic vio-let light source (370 to 420 nm) and allowing the operatorto use a 530-nm yellow glass filter, areas exhibiting orange-red fluorescence can be selectively identified and removedwith the bur. Compared to Caries Detector or the visual-tac-tile method for establishing the caries removal endpoint, theFACE method showed the highest sensitivity, specificity, per-centage correct score, and predictive values for residualcaries detection, as evaluated using confocal microscopy.71

Histological examination after staining with ethidium bro-mide revealed fewer samples presenting bacteria in dentinwhen the FACE method was used than was the case withconventional bur excavation.72 Others failed to find differ-ences in the number of infected samples between FACE andconventional bur excavation, but observed a significant re-duction in the number of samples presenting residual bac-teria after excavation with FACE, when compared to Carisolvor bur excavation guided by Caries Detector.73

The FACE method also proved to be very efficient, withless time needed to excavate caries and without a need tochange instruments, apply chemical agents, orto test thecavity with an explorer.73 Another important aspect is thatthe increased caries-removal efficacy of FACE was appar-ently not associated with an increased cavity size or overex-cavation.74

Excavation Aided by Laser-induced FluorescenceBased on the above-mentioned fact that caries-inducedchanges lead to increased fluorescence of dentin at the

655-nm (red) wavelength,2 a laser-fluorescence devicethat irradiates at this particular wavelength has been de-veloped to diagnose “hidden” occlusal carious lesions (DIAGNOdent, Kavo Dental; Biberach, Germany). A photo-diode attached to the tip of the handpiece measures thefeedback of fluorescence after initial irradiation, where theintensity of fluorescence at the occlusal surface is directlyrelated to the degree of caries progression into dentin.76

Based on a diagnostic scale correlating the readings of flu-orescence with the histological presence of caries, valuesabove 30 should be considered a stage of caries progres-sion demanding operative intervention.75

Beyond using laser-induced fluorescence for occlusalcaries diagnosis, these readings are currently being investi-gated as a possible end-point guide to caries excavation.Based on a comparison with histological examination in theconfocal microscope after staining with ethidium bromide,a DIAGNOdent reading of 15 was seen to best predict thepresence of residual caries at the bottom of the cavity.71 Lat-er, this value was correlated to the absence of detectablebacteria, and thus set as the endpoint for complete cariesremoval.54 It is interesting to note that when Caries Detec-tor was used as caries removal endpoint, a threshold of 11was found,19 corroborating previous findings that the stain-ing method invariably leads to overexcavation. When com-bined with caries removal using an erbium laser, a DIAG-NOdent threshold between 11 and 20 was shown to bestpredict removal of infected carious dentin.121 Others whoused a threshold value of 30 for dentin caries have found ac-ceptable sensitivity values (ability to correctly diagnosecaries) for DIAGNOdent when used to determine the cariesremoval endpoint.118 One should, however, realize that theDIAGNOdent readings increase with the proximity to the pulpas well as with stained, sclerotic dentin,66 which thus couldlead to a false-positive threshold for caries removal.

Laser ExcavationThe word “laser” is an acronym for “Light Amplification byStimulated Emission of Radiation”, which means thatlaser devices produce beams of coherent and high-inten-sity light. The indications for the use of lasers in dentistryare nowadays broad, varying from caries diagnosis, disin-fection of periodontal pockets or root canals, photody-namic therapy of oral tumors, soft-tissue surgery, cariesremoval, and cavity preparation.114 Especially in the fieldof operative dentistry, erbium lasers have been pointedout as most promising due to their specificity in ablatingenamel and dentin without side effects to the pulp andsurrounding tissues when the approprate parameters areemployed.114

The erbium-loaded yttrium-aluminum-garnet (Er:YAG) andthe erbium,chromium: yttrium-scandium-gallium-garnet(Er,Cr:YSGG) lasers are the two types of erbium-based de-vices currently available on the market. Both devices presentvery similar wavelengths (2.78 μm for Er,Cr:YSGG and 2.94μm for Er:YAG), although the Er,Cr:YSGG laser is discretelymore absorbed by hydroxyapatite than Er:YAG.114 Despitethis difference, both wavelengths are very close to the ab-sorption peak of water in the infrared spectrum, whichmakes their interaction with dental hard tissues very similar.

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Fundamentally, the mechanism by which enamel anddentin are removed during Er:YAG irradiation consists of ex-plosive subsurface expansion of water interstitially trappedin the dental hard tissues. During irradiation, the water mol-ecules absorb the incident radiation, causing sudden heat-ing and water evaporation. As a result, a high-stream pres-sure is formed, inducing a violent, yet controlled expansionand ejection of dental hard tissue components.50 In con-trast, the Er,Cr:YSGG laser system, usually known as a “laser-powered hydrokinetic system”, delivers photons straight in-to an air-water spray directed to the target tissue. This phe-nomenon induces micro-explosive forces into water droplets,which is said to contribute significantly to the mechanism ofhard-tissue removal.44 Unfortunately, no systematic studiescomparing these two types of erbium lasers have been per-formed so far, especially considering their particular effectson cavity morphology and on the characteristics of the resid-ual dentin after caries removal.

Several advantages have been related to the use of laserirradiation in operative dentistry, such as a more conserva-tive cavity design, an alleged antibacterial activity,111 and asignificant decrease of enamel solubility, therefore also pos-sibly playing a role in the prevention of recurrent caries.23

Moreover, laser ablation apparently provides more comfortto the patient due to the absence of vibration57 and a lowerpain sensation. In fact, the need for local anaesthesia is re-ported to be lower when compared to the use of conven-tional rotary instruments.58 On the other hand, the majordrawback related to their use in operative dentistry is the rel-atively long time needed for cavity preparation. The time re-quired for a complete excavation is, in general, twice thatwith rotary instruments,4,12,58 Recently, one study succeed-ed in reducing the overall cavity preparation time by usingconsiderably high energies (700 mJ).80 However, it shouldbe noted that such high energies can also induce irreversiblechemical and structural alteration to the dental hard tis-sues7 and even damage the pulp.114

Irrespective of the parameters used during laser irradia-tion, the effectiveness of carious dentin removal with erbiumlasers has been questioned. SEM has shown that the laserproduces an undefined and random excavation pattern indentin, with deep overprepared and wide underpreparedzones present in the same cavity. For optimal irradiation, anoncontact beam emission mode is usually recommended,thus rendering caries excavation more difficult to control dueto the lack of tactile sensation.12 Moreover, the irregulardentin surface left after laser ablation hampers an accuratetactile feedback when an ordinary probe is used for detect-ing the status of excavation.12,116 Despite this, some stud-ies have relied upon visual/tactile methods44,57 or stainingwith 1% acid-red solution to evaluate the thoroughness ofcaries removal,4 obtaining residual dentin hardness valuessimilar to sound dentin. Histological observations have alsodisclosed the same degree of bacterial removal by an Er:YAGlaser and conventional bur excavation.4 Additionally, betterDIAGNOdent scores of residual dentin were obtained afterexcavation with an Er,Cr:YSGG laser than with Carisolv.63

Although Er:YAG laser ablation is not selective for cariousdentin, it has been described that the popping sound emit-ted by these lasers when operating in dental hard tissues

changes according to the presence or absence of caries.This change in sound could assist the user in determiningwhen caries removal is complete.114 This approach is, how-ever, not very objective or practical, and is susceptible tomisinterpretation. An improvement in the caries-removalability of erbium lasers is to combine it with laser-fluores-cence technology for caries detection. In one unit (Key III, Ka-vo Dental), Er:YAG laser irradiation is controlled by the feed-back response provided by the red-infrared diagnostic diodelaser, resulting in a self-limiting laser ablation. Actually, thelaser ablation is activated only if the fluorescence emittedfrom the dental tissue exceeds a pre-determined thresh-old.32 An initial threshold value of 7 for the laser fluores-cence detection system removed all bacteria at the bottomof the cavity, as was detected histologically.32 This thresholdvalue was corroborated by clinical studies in permanent31

and primary teeth,67 in which only clinically insignificantamounts of bacteria could be detected at the bottom of theexcavated cavities. Beyond appropriate removal of infecteddentin, this laser also precluded less sound dentin removal,resulting in smaller cavities compared to conventional burexcavation.33

Absence of smear layer is very often mentioned as an ad-vantage of laser irradiation of tooth surfaces, in particular forbonding procedures.5,56,63 However, while relatively highbond strengths have been reported with either an etch-and-rinse or a self-etching adhesive after caries removal with anEr:YAG laser,101 other authors found lower bond strengths tolaser-irradiated dentin when compared to a conventionallybur-cut substrate.21,105,113 Such disappointing results havebeen related to the presence of subsurface microcracks pro-duced in dentin during laser ablation, rendering it moreprone to cohesive failures.21 Moreover, laser-irradiateddentin has also been reported to change the compositionand conformation of the organic matrix of dentin,7 whichmay impair adhesive penetration and facilitate collagendegradation.

ADHESION TO CARIOUS DENTIN

Sound human dentin is most convenient to test the perfor-mance of dental adhesives by means of standard bond-strength protocols. This “model” dentin is, however, farfrom the clinically more relevant substrate remaining aftercaries removal, which exhibits “mixed” chemical and me-chanical characteristics and includes caries-infected,caries-affected, sclerotic, eroded, and sound dentin.79

In general, the presence of carious dentin results in thick-er hybrid layers and lower bond strengths.83,84,123,124 Thebond strength of adhesives to carious dentin has been re-ported to be inversely proportional to the degree of cariesprogression, with caries-infected dentin presenting the low-est bond strength.30 The thickness of the hybrid layer is in-directly correlated to the degree of caries progression, withcaries-infected dentin presenting thicker hybrid layers, fol-lowed by caries-affected and sound dentin.52,123,124 Like insound dentin, hybrid layers in caries-affected dentin arethicker using etch-and-rinse than self-etching adhe-sives.52,123 For caries-infected dentin, however, the thick-

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ness of the hybrid layer tends to be similar, irrespective ofthe adhesive approach.52 Thicker hybrid layers in caries-af-fected dentin are explained by the increased porosity of in-tertubular dentin, which promotes diffusion of resinmonomers.53,83

The lower bonding effectiveness to caries-infected dentinis related to its extremely low cohesive strength, due to itslow degree of mineralization and the collagen-matrix disor-ganization.83 Although resulting in thicker hybrid layers, thistype of dentin allows only superficial monomer penetration,keeping many dentin tubules completely free from tag for-mation.52,123,124 Considering the poor interaction with thesubstrate, bonding to caries-infected dentin is seldom indi-cated, except when aiming to prevent further caries pro-gression in uncooperative patients while implementing be-havior control.

The lower bonding effectiveness to caries-affected dentinthan to sound dentin is related to the alterations that occurin this substrate as a consequence of caries progression.First, the reduction in mineral content and loss of crys-tallinity of the remaining mineral phase, coupled to thechanges in the secondary structure of collagen,115 result ina dentin substrate with a lower hardness89 and modulus ofelasticity than those of sound dentin,78 performing poorer inmechanical tests. Secondly, the deposition of mineral casts,namely of β-tricalcium phosphates (whitlockites),26,115 inthe dentin tubules during caries progression also alters theetch pattern and thus the penetration capacity of resinmonomers into the tubules. When bonding using the moistbonding technique with etch-and-rinse adhesives, somestudies were able to achieve similar bond strengths to resid-ual dentin after caries excavation (guided by Caries Detec-tor) as to sound dentin.83,85,86 While one of these studies83

with sound dentin achieved a relatively “low” bond strength(20 to 30 MPa) compared to what is achieved nowadays withmodern adhesives (40 to 50 MPa),29 the others may haveachieved these favorable results by using a rather aggres-sive threshold to establish the endpoint of caries removal,that is, by having produced a substrate that is more recep-tive for bonding than that obtained in other studies. It wasalso demonstrated that acetone-based etch-and-rinse ad-hesives bonded better to caries-affected dentin than didethanol-based adhesives, although both were able to pro-duce acceptable bond strengths to non-stained (with CariesDetector) dentin left after excavation.86

Although other studies were not able to produce similarresults in bond strength to sound as to caries-affecteddentin for many materials tested,22,88,102,122 it becameclear that the chemical composition of the adhesive couldstrongly influence the bond strength to caries-affecteddentin. Apparently, the immediate bond strength of etch-and-rinse adhesives to caries-affected dentin is higher thanthat of self-etching adhesives.22,37,122 However, no differ-ences in bond strength of etch-and-rinse and self-etching ad-hesives to carious dentin was observed after the specimenswere stored for 6 months in water.37

In summary, although the bond strength at caries-affect-ed dentin interfaces is lower than that at sound dentin in-terfaces, they are both continually improving and have nowreached relatively high values. Table 1 offers an overview of

bond-strength values in relation to different caries removalendpoints employed, different methods used to produce thecarious substrate, and different types of adhesives used.Figure 9 summarizes the bond strength values depicted inTable 1, when the caries removal endpoint was obtainedwith two different thresholds for staining (no staining vs light-pink staining) and after the carious dentin substrate wasproduced with a standardized surface-preparation methodusing 600-grit SiC paper. Figure 10 depicts the bondstrength results for the studies presented in Table 1 thatused a conventional bur and Carisolv to excavate caries. Inboth cases, essentially no differences in bond strength be-tween etch-and-rinse and self-etching approach were found.

Altogether, irrespective of the caries excavation methodchosen, it remains clinically recommended to finish the cav-ity margins in clean/sound tooth tissue in order to achievethe best performance of adhesives, while being at the sametime least invasive with regard to caries excavation and mostconservative with regard to sound-tissue preservation.

REFERENCES

1. Ahmed AA, Garcia-Godoy F, Kunzelmann KH. Self-limiting caries therapywith proteolytic agents. Am J Dent 2008;21:303-312.

2. Alfano RR, Yao SS. Human teeth with and without dental caries studied byvisible luminescent spectroscopy. J Dent Res 1981;60:120-122.

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Fig 9 Pooled data from Table 1 (Nakajima et al;84-86 Yoshiyamaet al;122-124 Tachibana et al105) regarding carious dentin surfacesthat were prepared with 600-grit SiC-paper and when Caries De-tector was used as caries removal endpoint following two differ-ent thresholds: non-stained vs lightly pink-stained dentin. Themore “aggressive” threshold (non-stained) shows only slightlyhigher bond strength values than the more conservative thresh-old (light pink). The 3-step etch-and-rinse adhesives achieved thehighest values, followed by the 2-step etch-and-rinse and the 2-step self-etching adhesives. Horizontal lines represent the meanvalues and bars represent the upper and lower standard devia-tions.

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Table 1 Bond strength related to the different caries removal endpoints, type of caries-affected substrate, and adhesive material used

Method of caries Type of caries-affected Type of adhesive (brand name) μTBS Referenceexcavation endpoint substrate

Staining with 0.5% fuchsin 220-grit SiC paper 2-step etch-and-rinse 41.3±10.7 Ceballos et al22

(Prime & Bond NT, Dentsply)2-step etch-and-rinse 36.3±12.2(Scotchbond 1, 3M ESPE)2-step self-etch 21.5±5.5(Clearfil SE Bond, Kuraray)1-step self-etch 13.4±1.9(Prompt L-Pop, 3M ESPE)

Non-stained dentin 600-grit SiC paper 3-step etch-and-rinse 48.2±3.9 Nakajima et al85

remaining after using (Scotchbond MP, 3M ESPE)Caries Detector 3-step etch-and-rinse 30.2±13.4 Nakajima et al84

(ART Bond, VITA)2-step etch-and-rinse 45±7.2 Nakajima et al86

(One-Step, Bisco)2-step etch-and-rinse 40.2±11.1(Single Bond, 3M ESPE)2-step etch-and-rinse 28.8±6.3 Yoshiyama et al123

(Single Bond, 3M ESPE)2-step etch-and-rinse 27.1±6.5 Yoshiyama et al122

(Single Bond, 3M ESPE)2-step self-etch 30.3±11.9 Tachibana et al105

(Clearfil SE Bond, Kuraray)2-step self-etch 30±10 Yoshiyama et al124

(Clearfil Liner Bond 2, Kuraray)2-step self-etch 29.7±10.3 Nakajima et al84

(Clearfil Liner Bond 2, Kuraray)2-step self-etch 29.4±7.5 Nakajima et al87

(Clearfil Protect Bond, Kuraray)2-step self-etch 25.3±5 Yoshiyama et al123

(Tenure ABS System, Denmat)2-step self-etch 17.5±2.1 Yoshiyama et al122

(FluoroBond, Shofu)320-grit SiC paper 3-step etch-and-rinse 18.49±4.04 Nakajima et al83

(Scotchbond MP, 3M ESPE)3-step etch-and-rinse 13.01±3.64(All Bond 2, Bisco)2-step self-etch 13.97±4.3(Clearfil Liner Bond 2, Kuraray)

Conventional bur 2-step self-etch 29±10.3 Tachibana et al105

(Clearfil SE Bond, Kuraray)Er,Cr:YSGG Laser 2-step self-etch 18.4±11

(Clearfil SE Bond, Kuraray)Carisolv 2-step self-etch 21.5±10

(Clearfil SE Bond, Kuraray)Light-pink staining 600-grit SiC paper 2-step etch-and-rinse 34.5±6.8 Erhardt et al37

remaining after using (Scotchbond 1, 3M ESPE)Caries Detector 2-step etch-and-rinse 29.2±4.3 Say et al102

(Optibond Solo Plus, Kerr)2-step self-etch 28.7±5 Erhardt et al37

(Clearfil Protect Bond, Kuraray)2-step self-etch 24.2±7(AdheSE, Ivoclar Vivadent)2-step self-etch 21.5±5.3 Doi et al30

(Clearfil SE Bond, Kuraray)2-step self-etch 20.2±5.8(Mac-Bond II, Tokuyama)2-step self-etch 19.6±6(UniFil Bond, GC)

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Table 1 Bond strength related to the different caries removal endpoints, type of caries-affected substrate, and adhesive material used (continued)

Method of caries Type of caries-affected Type of adhesive (brand name) μTBS Referenceexcavation endpoint substrate

Diagnodent value = 20 600-grit SiC paper 2-step etch-and-rinse 25.7±5.9 Sattabanasuk et al101

(Optibond Solo Plus, Kerr)2-step self-etch 35.4±9.7(Clearfil Protect Bond, Kuraray)

Conventional bur 2-step etch-and-rinse 21.3±7.5(Optibond Solo Plus, Kerr)2-step self-etch 12.2±3.1(Clearfil Protect Bond, Kuraray)

Er:YAG laser 2-step etch-and-rinse 26.6±9.4(Optibond Solo Plus, Kerr)2-step self-etch 32.5±7.1(Clearfil Protect Bond, Kuraray)

Visual-tactile method Hand excavation 2-step etch-and-rinse 25.06±10.16 Sonoda et al104

(Prime & Bond NT, Dentsply)2-step self-etch 22.33±6.9(Tenure ABS System, Denmat)

Conventional bur 2-step etch-and-rinse 24.8±15.9 Silva et al103

(Single Bond, 3M ESPE)2-step self-etch 31.4±12.7(Clearfil SE Bond, Kuraray)

Carisolv 2-step etch-and-rinse 26.99±11.69 Sonoda et al104

(Prime & Bond NT, Dentsply)2-step self-etch 28.7±6.9 Burrow et al20

(Clearfil SE Bond, Kuraray)2-step self-etch 27.4±6.4(One Coat Bond, Coltene)2-step self-etch 31.1±9.21 Sonoda et al104

(Tenure ABS System, Denmat)Smart Prep bur 2-step etch-and-rinse 13.9±7.1 Silva et al103

(Single Bond, 3M ESPE)2-step self-etch 10.5±6.6(Clearfil SE Bond, Kuraray)

Fig 10 Pooled data from Table 1 (Burrow et al;20 Sattabanasuket al;101 Silva et al;103 Tachibana et al105) comparing the bondstrength results when caries was excavated with a conventionalbur (left) or Carisolv (right). Similar mean bond strength valueswere recorded for etch-and-rinse and self-etching adhesives inboth cases. Horizontal line represents the mean values and barsrepresent the upper and lower standard deviations.

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Clinical relevance: The bonding performance to cari-ous dentin is directly related to the caries-excavationmethod and to the caries removal endpoint. Despitethis, the bond strength achieved today to carious dentinusing modern adhesives has shown major improve-ment.

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