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 Table of Contents  
Year : 2022  |  Volume : 13  |  Issue : 2  |  Page : 57-60

Microleakage Evaluation of Glass Hybrid Restoration Following Usage of Papain-Based Gel and Ceramic Bur for Caries Removal: An In Vitro Study

1 Department of Pedodontics and Preventive Dentistry, College of Dentistry, University of Baghdad, Iraq
2 Assistant professor, Department of Pedodontics and Preventive Dentistry, College of Dentistry, University of Baghdad, Iraq

Date of Submission14-Apr-2022
Date of Decision02-May-2022
Date of Acceptance03-May-2022
Date of Web Publication12-Jul-2022

Correspondence Address:
Halah Abdulkareem A Alkhawaja
Department of Pedodontics and Preventive Dentistry, College of Dentistry, University of Baghdad, Najaf
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/denthyp.denthyp_48_22

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Introduction: In the field of pediatric dentistry, an urge to adopt a more comfortable, minimally invasive, and stressless technique for caries removal became a must. Coronavirus disease-2019 outbreak necessitates a paradigm change in the global health care protocols, requiring alternative, nonaerosol generating approaches. This study aimed to measure and compare the influence of two methods of caries removal, namely, Brix3000 and CeraBur, on the microleakage of glass hybrid restorative material. Materials and Methods: Thirty human primary molar teeth with accessible occluso-gingival carious cavitation were randomly allocated into CeraBur and Brix3000 groups. After selective caries excavation, samples were restored with Equia Forte HT, thermocycled, dipped in thiazine dye, washed, and sectioned through the restoration center. Then microleakage was measured using a stereomicroscope (30× magnification) at both occlusal and gingival margins. Results: No statistically significant difference was found between the two methods of caries removal (CeraBur and Brix3000) at both occlusal (P = 1.000) and gingival margins (P = 0.612). Conclusions: Brix3000 caries removing gel did not negatively affect the microleakage of Equia Forte HT compared to the CeraBur and hence can be used alternatively to the conventional drilling methods.

Keywords: Brix3000, CeraBur, ceramic bur, chemomechanical caries removal, microleakage, papain gel

How to cite this article:
Alkhawaja HA, Al Haidar AM. Microleakage Evaluation of Glass Hybrid Restoration Following Usage of Papain-Based Gel and Ceramic Bur for Caries Removal: An In Vitro Study. Dent Hypotheses 2022;13:57-60

How to cite this URL:
Alkhawaja HA, Al Haidar AM. Microleakage Evaluation of Glass Hybrid Restoration Following Usage of Papain-Based Gel and Ceramic Bur for Caries Removal: An In Vitro Study. Dent Hypotheses [serial online] 2022 [cited 2023 Jun 2];13:57-60. Available from:

  Introduction Top

The most commonly used treatment approach for dental caries is the conventional method of caries removal using rotary instruments. However, this method involves several complications and often induces fear and anxiety in patients, becoming an obstacle to achieving good treatment.[1],[2]

In light of the new era of minimally invasive dentistry, new cutting burs made of ceramic were introduced with improved tactile sensation.[3] However, their use is still linked to rotary system issues, such as pulp overheating, the necessity for local anesthetic, and vibratory discomfort.[4]

The coronavirus disease-2019 pandemic forced a shift in global health care protocols. Aerosol-generating rotary instruments result in operator/patient cross infection. Hence, an alternative, less invasive, stressless, and nonaerosol producing approach is necessary.[5],[6]

The chemomechanical caries removing (CM-CR) method seems to fulfill those requirements compared to the conventional drilling methods. CM-CR reinforces a favorable attitude toward dental procedures and has gained acceptance, especially from children and patients with dental anxiety and fear. The latest introduced CM-CR agent was BRIX3000, an enzymatic papain-based agent containing 3000 U/mg papain in 10% concentration, bioencapsulated via Encapsulating Buffer Emulsion technology, which gives the gel an ideal pH to immobilize the enzymes and release them when needed.[7],[8]

This study aimed to measure and compare the influence of two methods of caries removal: papain-based caries removal gel (Brix3000) versus the conventional rotary method (CeraBur) on the microleakage of glass hybrid restorative material (Equia Forte HT).

  Materials and Methods Top

Simple randomization was adopted in this study by an independent person to randomly divide samples into two main groups according to the method of caries removal: CeraBur (control) and Brix3000 group using the “Random sequence Generator” tool (


The Ethics Committee of Baghdad University/college of dentistry approved the study protocol.

Sample preparation

This study included 30 human primary molar teeth with accessible class II carious cavitation. Teeth were extracted as a part of an orthodontic treatment plan (serial extraction), over retention, and normal exfoliation. Samples were stored after proper debridement and cleaning in 0.1 thymol solution (M Dent, Bangkok, Thailand) until use.[9] During the collection process, teeth that exhibited cracks or malformation were excluded when examined with a dental loupe and transillumination.[10]

A selective caries excavation was conducted in this study, with caries-affected dentine being set as an excavation end point. Before carious dentin excavation, a fine enamel diamond bur (VERDENT, Lodz, Poland) was used to remove undermined and carious enamel.[11] In the CeraBur group, a conventional technique using a rotary slow speed handpiece (NSK, Saitama, Japan) with ceramic bur (CeraBur, Komet, Lemgo, Germany) was utilized to remove carious infected dentine selectively [supplementary figure 1],[12] whereas in the other group an enzymatic papain-based caries removing gel (Brix3000, Brix S.R.L., Carcarañá, Argentina) was employed, followed by hand excavation [supplementary figure 2].[13]

According to the manufacturers’ instructions, Brix3000 was applied three consecutive times to the carious lesion, and each time lasted for 2 minutes to soften the carious infected dentin. Then a blunt spoon excavator was used to remove the softened mass in a pendulum movement.

Excavation end point

The completeness of caries removal was evaluated by visual and tactile criteria (hardness of dentine)[14] along with the ability of CeraBur to tactilely distinguish between the healthy and infected dentine[3] and the self-limiting property of Brix3000.[8] A single well-trained operator performed all the procedures.

Restoration procedures

Cavities were washed, dried, and conditioned by applying a 20% polyacrylic acid (Cavity conditioner, GC, Tokyo, Japan) for 10 seconds and then washed and moisture dried gently by air without desiccation. A glass hybrid restorative material (Equia Forte HT, GC, Tokyo, Japan) was dispensed in an automatic mixer for 10 seconds and injected into the cavity through a capsule applicator (SDI Limited, Bayswater, Australia). Then the restoration was adequately adapted, finished, and polished.

Microleakage determination

The samples were stored in distilled water at 37°C for 24 hours.[15] They were subjected to a thermocycling process for 500 cycles between cold and hot water baths 5°C to 55°C, respectively, with 30-second dwell time at each temperature.[9]

Then, the teeth were dipped in 2% thiazine dye, methylene blue (Zuhair lab, Baghdad, Iraq) for 24 hours at 37°C. Before dipping, the specimens were completely coated in two coats of nail varnish (MARKT MEKYACH®, China), except for the filled cavity and 1 mm beyond the edges.[16] The root apices and furcation area were sealed with flowable composite (Ivoclar Vivadent AG, Schaan, Liechtenstein) to avoid dye solution penetration.[17] Then samples were washed thoroughly and dried. Each tooth was sectioned longitudinally at the restoration center by slow-speed sectioning saw (XP Precision Sectioning Saw, Ted Pella, California, USA) from mesial to distal surface into two halves to prepare it for microscopic evaluation.[18]

After saw sectioning, microleakage represented by dye penetration was measured in millimeters (mm) by Optika Vision lite 2.1 software (OPTIKA, Ponteranica, Italy) using a stereomicroscope (KRÜSS, Hamburg, Germany) under (30×) magnification. Two trained examiners assessed the sections. The image was taken for each tooth section by a camera (OPTIKA, Ponteranica, Italy) mounted on the stereomicroscope. Then each tooth received four readings, two for each half/section at two sites, one at the occlusal margin (OM) and the other at the gingival margin (GM). The highest recorded value was used to represent the tooth at each site.[19]

Intra- and inter-examiner agreements were 99% (P = 0.99), determined by the intraclass correlation coefficient (ρ). The two examiners who performed data measurements and the statistician were blinded to the method of caries removal. The groups were only revealed at the end of the measuring and data analysis process.

Sample size

It was determined based on a pilot study conducted prior to the research using G power software ( with 1.21 effect size, 80% power of the study, two-tailed test at 5% alpha error of probability. With two groups, a minimum of 13 samples for each group was rounded to 15 to account for dropout.

Statistical analysis

Data analyses were performed by independent t test, Mann–Whitney U test, and Wilcoxon test using R 4.2.0 (R Foundation for Statistical Computing, Vienna, Austria). Shapiro–Wilk test was used for the assessment of normality.

  Results Top

Mann–Whitney U test showed a nonsignificant difference for OM microleakage between groups Brix3000 and CeraBur (P = 1.000) [Figure 1]. Also, the independent t test revealed a nonsignificant difference for GM microleakage between groups Brix3000 and CeraBur (P = 0.612) [Figure 1] (supplementary tables 1 and 2).[20],[21] Wilcoxon test showed significant differences between microleakage of GM and OM for groups Brix3000 (P < 0.01) and CeraBur (P < 0.01) [Figure 1] (supplementary table 3 and Figure 3).[22],[23]
Figure 1 Box and whisker plots showed results of the microleakage in millimeters

Click here to view

  Discussion Top

The conventional drilling method for removing caries unnecessarily removes healthy or potentially mineralizable caries-affected dentin.[24]

CM-CR method selectively removes carious infected dentine, avoids unnecessary removal of sound dentine, minimizes inconvenience associated with local anesthetic administration, and is noise-free. These factors can help emphasize a child’s positive behavior, which results in improved cooperation.[7],[25]

As the success of a restoration is highly reliant on a good marginal seal, microleakage evaluation is regarded as a valid tool for assessing different methods for caries removal.[26]

In 2019, the newest Equia Forte HT material (GC, Tokyo, Japan) was launched into the market, composed of a hybrid glass-ionomer system with a greater viscosity than the earlier generation Equia Forte Fil. Glass hybrid materials based on GIC technology had been developed by adding glass particles of varying sizes to the usual filler, such as highly reactive tiny particles. This characteristic boosts reactivity and greatly improves the material’s mechanical capabilities, making it appropriate for long-lasting fillings.[27]

In this study, both caries removing methods showed some microleakage values in Equia Forte HT restoration at both the OM and GM; however, no statistically significant differences were found between them at the OM and GM. This might be owing to the proximity of the excavation end point of CeraBur and Brix3000 (both being at the affected dentin). These data agreed with those of Kwak et al.,[28] regarding the Brix3000 group, and Fathy et al.,[26] regarding the Cerabur group. In contrast, they were inconsistent with the findings of Ludeña and Bravo,[29] regarding the Brix3000 group, this may be related to the fact that carbide burs were not as conservative as the CeraBur and did not provide tactile confirmation. Also, the study used composite restoration rather than glass-based restoration.

According to manufacturers (Komet, 2015), the CeraBur permits controlled and tactile excavation in a way that when it leaves the soft, carious dentin, the operator can feel it. This property provides high excavation capabilities on softened carious dentin while preserving as much sound tooth structure as possible.[30]

Brix3000 has a self-limiting property. When the gel reaches the healthy dentin, two mechanisms neutralize its activity: physiologically and microphysiologically by the activity of the α1-antitrypsin antiprotease enzyme and the unrestrained collagen fibers. So its mechanism ceases once it reaches the healthy dentine,[8] which might explain the result of this study.

When it comes to margin site location, this study showed a high statistically significant difference existed in the microleakage values when comparing the OM and GM within the CeraBur group (P < 0.01) and the Brix3000 group (P < 0.01), with more microleakage values associated with the GM tooth-restoration interface than in the occlusal interface in each group.

Thus, the results of this study suggested that neither method (Brix 3000 and CeraBur) adversely affected the microleakage of Equia Forte HT restoration. Although further clinical studies should back up the current laboratory study result, it might provide some information for clinicians who elect to incorporate these agents into clinical work.

  Limitation Top

More studies using other restorative materials and comparing other caries removing agents and methods are required to establish the effect of the papain Brix 3000 gel on marginal sealing (microleakage). Also, in vivo confirmation of the result is required due to different variables related to the oral environment.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

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