In this study, we showed that the chemical-mechanical method (Papacarie) has a lower cost per procedure compared to the traditional method (drill). Papacarie provided a cost savings of 42% compared to the traditional method. Using local anesthesia, the cost savings increased to 58%. In a similar restorative procedure using drill + Papacarie, the cost savings remained at 33%. Heart rate, consultation duration, and number of restorations were not significantly different between the methods of caries removal. The clinical results, assessed by the blind evaluator, indicate that both restorations were successful, with only one failure in the Papacarie group, and with no pain symptoms.
Dental caries are the most common chronic disease in children, and they are of interest to public health care because of their prevalence and treatment costs2. Prevention is an important tool because it avoids unnecessary spending on major clinical complications from the caries process. This problem can be avoided by using chemical-mechanical agents, such as Papacarie gel15.
Several studies6,9,11,16,17 have investigated the effectiveness of this gel compared with the traditional method (drilling) and have reported satisfactory results in the time required for the procedure, clinical monitoring, pain complaints, patient acceptance, and cytotoxicity, which demonstrates its safe use in pediatric patients. Papacarie has proved to be an effective technique in primary and permanent teeth, with a significant reduction of the need for local anesthesia and drill use6.
The anxiety in dental treatment has shown that anesthesia and drilling are highly stressful factors. Thus, a non-traumatic method is crucial to avoid fearful and uncooperative patients in dental procedures11. Moreover, the knowledge of parents, family environment, and socioeconomic conditions are associated with the collaboration of patients during the treatment18. The increased incidence of caries and poor oral hygiene of children are also being attributed to the misinformation of parents19. The method of chemical-mechanical removal of caries was developed to overcome these disadvantages by offering more comfort and reducing the stress of the child, therefore resulting in lower clinical complications and adults with no fear of dental care14.
Regarding clinical intervention results, there were no significant differences in consultation duration or values of heart rate. Recent literature20,21 has shown that Papacarie is associated with longer procedure time; however, our study shows no significant difference. Despite the literature recognizing significant progress in dental treatment, patients bring with them a high level of anxiety4. Fear is a natural reaction, which strongly influences patients’ behavior and their cooperation during the procedures. This is a problem especially in pediatric patients who often become a challenge for the professional to treat22. Literature6,7,10 shows that chemical-mechanical methods act efficiently and have high patient acceptance. Despite a longer time for removal of caries, chemical-mechanical methods can be considered as a feasible alternative especially in pediatric patients.
One month after the dental intervention, both groups had an appointment with the blind evaluator who analyzed the effectiveness of the treatment. It was found that both groups were successful, even though one restoration in the Papacarie group showed a fracture of the restorative material. A previous study23 evaluated the success rate after 12 months of follow-up in a series of 84 cases in which chemo-mechanical caries removal was performed with Papacarie and found a failure rate of 12%. Some research14,18 reported that the degree of fractures or marginal leakage were related to the properties and clinical limitations of the restorative material, being extremely sensitive to handling and humidity, regardless of the approach. However, this is still the material of choice for non-traumatic restorations due to its ease of use, good adhesiveness, and gradual release of fluoride.
Heart rate may be one of the signs which most expresses anxiety during dental treatment because of the stress common in this situation which stimulates the sympathetic nervous system and consequently releases adrenaline and increases the heart rate24. In this study, it can be observed that during the dental care of children, regardless of the treatment group, there were no significant changes in heart rate. The biggest changes, although not significant, occurred at 5 minutes into the intervention and from a clinical point of view, this behavior did not change until the end of the consultation. Anxiety and fear are symptoms usually present in children during dental treatment. The cardiovascular system actively adapts to stress. Cardiovascular responses result mainly in an increase in contractility, cardiac output, and blood pressure24. Projective techniques, questionnaires, and physiological signs have been used to assess anxiety in dentistry19.
The material cost of a restorative procedure with a chemical-mechanical method with Papacarie gel had greater cost savings when compared with the traditional method with drills. In clinical situations in which local anesthesia would be necessary, or both methods would be needed (drill + Papacarie) in the same procedure, the cost savings would remained. This result was also observed in other studies9,10,12,13, although they did not describe the values or cost calculations because neither was the main objective of their studies. The chemical-mechanical agents prevent unnecessary removal of healthy tooth structure, decrease or eliminate the use of local anesthesia, and are more economical compared to all other methods8.
Our study has a few potential limitations. First, the resistance of the guardians in taking the children to the dental consultation resulted in a large number of children excluded from this study due to non-attendance at the pre-scheduled appointments. Second, only the total consultation duration was recorded, and not the carious tissue removal duration; therefore, interferences due to non-collaborative patient’s behavior may have influenced the data related to the consultation duration. Third, the lack of consideration of the human resource cost, because only the cost of materials for the dental restorative procedure for both methods of removing carious tissue was recorded.