Journal of South Asian Association of Pediatric Dentistry
Volume 6 | Issue 3 | Year 2023

Clinical Efficacy and Pain Perception with Novel Chemomechanical Caries Removal Agent and Conventional Method in Primary Molars: A Randomized Controlled Study

Seema Bargale1https://orcid.org/0000-0003-4110-7990, Sejal Jain2https://orcid.org/0000-0002-0859-9834, Anshula N Deshpande3https://orcid.org/0000-0003-3467-2123, K S Poonacha4https://orcid.org/0000-0002-5367-3685, Saylee Deshmukh5https://orcid.org/0000-0002-6832-6942, Charmi Shah6https://orcid.org/0000-0001-9623-5290

1–6Department of Pediatric and Preventive Dentistry, KM Shah Dental College and Hospital, Sumandeep Vidyapeeth (Deemed to be University), Vadodara, Gujarat, India

Corresponding Author: Seema Bargale, Department of Pediatric and Preventive Dentistry, KM Shah Dental College and Hospital, Sumandeep Vidyapeeth (Deemed to be University), Vadodara, Gujarat, India, Phone: +91 9586115657, e-mail: drseemabargale@gmail.com

Received: 13 June 2023; Accepted: 11 July 2023; Published on: 30 December 2023


Background: Conventional means of preparing cavities include the use of high-speed handpieces and slow-rotating instruments, following the philosophy of extension for prevention. This method usually induces pain, annoying sounds, and vibration. Thus, chemomechanical caries removal (CMCR) has been developed to be an alternative. It involves the application of proteolytic substances, which softens the carious dental tissue and facilitates its removal manually. BRIX3000 is a newer agent with upgraded properties that has been used for efficient caries removal.

Aim: To evaluate and compare clinical efficacy and pain perception with a new CMCR agent (BRIX3000) and conventional caries removal method.

Materials and methods: A total of 60 children aged between 4 and 9 years were allotted to the CMCR (BRIX3000) and rotary caries removal groups. Clinical efficacy and the Wong–Baker Pain Rating Scale (WBPRS) were used as the two parameters. The obtained data analysis was done using an independent t-test and Mann–Whitney U test.

Results: Comparison of the difference in clinical efficacy showed a statistically significant difference in the CMCR (BRIX3000) group with a mean value of 2.33 ± 1.03 as compared to the rotary caries removal group with a mean value of 0.57 ± 0.68 with a p-value of <0.001. In WBPRS, the rotary caries removal group (mean: 4.6 ± 1.83) showed an increased score in comparison with the CMCR group (mean: 1.47 ± 1.17) with a p-value of <0.001.

Conclusion: Chemomechanical caries removal (CMCR) group (BRIX3000) showed increased clinical efficacy as compared to rotary caries removal group. The rotary caries removal group showed increased WBPRS scores.

Clinical significance: The use of the CMCR method in pediatric dentistry can prove to be very beneficial, especially in terms of anxiety and discomfort felt by the children.


Bargale S, Jain S, Deshpande AN, et al. Clinical Efficacy and Pain Perception with Novel Chemomechanical Caries Removal Agent and Conventional Method in Primary Molars: A Randomized Controlled Study. J South Asian Assoc Pediatr Dent 2023;6(3):124–128.

Source of support: Nil

Conflict of interest: None

Keywords: BRIX3000, Chemomechanical caries removal, Primary teeth


In spite of the substantial reduction in caries prevalence in developed countries, it continues to be widespread across the globe. Once a carious lesion starts to form, it becomes very important to use the most conservative way to prevent lesion progression and, at the same time, minimize the loss of unaffected tooth structure.1

Traditionally, caries excavation had been performed using rotary instruments, leading to overly extended cavities, unnecessary healthy tissue removal, heat and pressure on pulp, pain stimulus, and the need for using local anesthesia.2 Gradual evolution of techniques that remove caries has changed the basis of cavity preparation in numerous ways in the last two centuries.3

The principle behind minimal invasive restorative dentistry dictates the removal of carious lesions effectively, along with maximum protection of healthy tooth structure and pulp vitality.4 Chemomechanical caries removal (CMCR) is one such technique that efficaciously removes infected dentin by the use of a chemical agent. The CMCR method has a high acceptance rate, especially among children with dental anxiety.5 It selectively removes the infected tissues, avoiding harm to sound dental structure and pulp, along with negating patient discomfort.6

Chemomechanical caries removal (CMCR) was introduced in 1972, and GK-101 was marketed, although because of its aggressive consequence on both carious lesion and sound structures, a search for a newer material led to the development of Caridex in 1984, which was less degrading to healthy tissues.7 In 2003, another agent derived from the papaya peel was presented (papacarie); its important component was papain, which is comparable to the human pepsin enzyme. It denatures collagen fibers, resulting in easy caries removal using an excavator instrument, and chloramine chemically softens the carious part of dentin and provides antimicrobial action.8

The newest modification in the array of papain-based CMCR gels is BRIX3000 from Argentina.9 The papain concentration in BRIX3000 is 3000 U/mg per 10%, which is bio-encapsulated using encapsulated buffer emulsion (EBE) technology. This modification maintains the ideal pH of the gel, which is needed for immobilizing enzymes, which results in more efficient collagen proteolysis, enhanced resistance to unfavorable storage environments, and better antimicrobial properties.10 Furthermore, BRIX3000 does not contain chloramines, which helps in enhanced toxicological safety.11

The CMCR and conventional caries removal methods need to be evaluated when used clinically. The methods used for evaluating the clinical efficacy are by evaluating the amount of remaining caries by scores (0–5) given by Ericson.12 Additionally, there are scales that help assess the dental pain in patients through their perception. One such scale is the Wong–Baker Faces Pain Rating Scale (WBPRS). WBPRS presents six faces that portray increasing degrees of pain. Each face is attributed a score from 0 to 10, indicated on the scale.13 This study is intended to evaluate and compare the clinical efficacy and pain perception of the new CMCR agent (BRIX3000) with a conventional airotor used for caries removal in primary molars.


This study was performed in the Department of Pediatric and Preventive Dentistry. Ethical clearance was obtained from the Institutional Ethical Committee (SVIEC/ON/DENT/RP/22005) and has been registered under the clinical trials registry India (CTRI/2022/07/043848), and the study period was from March 2022 to January 2023.

Sample Size Description

The sample size had been estimated to be 30 per group, using 1% α error, 80% power, and a clinically significant difference of 1 unit. The total sample size was decided to be 60 participants.

Inclusion Criteria

  • Children between 4 and 9 years of age.
  • Children having occlusal caries on mandibular and/or maxillary either first or second primary molars.
  • The teeth should belong to code 1.2 according to the Mount and Hume classification.
  • The child patient whose parents gave the written informed consent.

Exclusion Criteria

  • Children suffering from any illness requiring special medical care.
  • Children having teeth with pulpal exposure, mobility, spontaneous pain, swelling or fistula next to the tooth, furcation or cervical lesion, and teeth with sealants, restorations, or enamel defects.


The study design was a double-blinded, randomized control study. The written consent was obtained from the participant’s parents or caregiver after giving the participant’s parents an information sheet.

Participants were segregated into two different groups, with 30 children in each group using a computer-generated randomization program. The coinvestigator kept a record of it separately and proceeded with the treatment of the allotted group while the principal investigator performed the evaluation after every treatment. The principal investigator and the statistician were blinded in this study.

The child patient and parents were explained about the entire procedure. All the instruments were sterilized according to standardized protocols.

BRIX3000 (Group I)

BRIX3000 (Brix SRL, Argentina) (Fig. 1) was utilized. The manufacturer’s instructions were followed for the material application. BRIX3000 was placed into the carious lesion using a blunt spoon excavator for two minutes. Initially, the BRIX gel remained clear; however, later, because of its effect, it turned darker in color (turbid) (Fig. 2). The softened infected dentin was scraped away in pendulum motion without using pressure. If needed, the procedure was performed again until the gel remained clear.

Fig. 1: BRIX3000 (Brix SRL, Argentina)

Fig. 2: Application of BRIX3000 (group I)

Conventional Method (Group II)

Airotor with a round bur (BR41) was used for selected carious teeth to remove decayed dentin (Fig. 3).

Fig. 3: Conventional method (group II)

All the teeth in the study were restored with Glass Ionomer Cement (GC Gold label 9, GC Corporation Tokyo, Japan) restorative material.

Evaluation Criteria

The evaluation of CMCR and conventional caries removal method was performed by assessing clinical efficacy and using the WBPRS for pain perception.

Clinical Efficacy

The extent of remaining caries after the procedure was checked and marked by the following scores given by Ericson.12 Score 0: caries have been removed completely; score 1: caries still present in the base of the cavity; score 2: caries still present in base and/or wall; score 3: caries still present in base and/or two walls; score 4: caries still present in base and/or >2 walls; score 5: caries present in base, walls, and margins of the cavity.

Pain Perception

Wong–Baker Pain Rating Scale (WBPRS) was utilized. Children chose the face that they could relate to describe their own pain. Face 0, depicted that it does not hurt at all; face 2, depicted that it hurts just a little bit; face 4, depicted that it hurts a little more; face 6: depicted that it hurts even more; face 8: depicted that it hurts a whole lot, and face 10, depicted that it hurts as much as you can imagine.

Statistical Analysis

It was analyzed through IBM Statistical Package for the Social Sciences (SPSS) software (SPSS version 20.0; SPSS Inc., Chicago, Illinois, United States of America). Intergroup comparison was done using the independent t-test and Mann–Whitney U test.


A comparison of age between both groups showed that the mean age is higher in group I (BRIX3000) (6.23 ± 1.46) as compared to group II (conventional method) (6 ± 1.34).

In Figure 4, the mean clinical efficacy values in both groups were obtained, and it was found that the clinical efficacy was higher in group I (BRIX3000) with a mean value of 2.33 ± 1.03 than in group II (conventional method) (0.57 ± 0.68).

Fig. 1: Clinical efficacy scores in the BRIX3000 (group I) and conventional method (group II)

In Figure 5, the mean values of the scores from the WBPRS, which portrayed the pain perception, were obtained, and the WBPRS score for group II (conventional method) was higher with a mean value of 4.6 ± 1.83 when compared to group I (BRIX3000) (1.47 ± 1.17).

Fig. 5: Wong–Baker faces pain scale scores in BRIX3000 (group I) and conventional method (group II)


One of the common pathologies that affect people of all ages is dental caries. There are several different restoration techniques that can be implemented to cure carious lesions. Ranging from very invasive airotor drilling to minimally invasive chemomechanical techniques.

Conventional airotor is the most regularly used device in carious structure removal; however, it generates discomfort and pain along with instilling anxiety and fear in child patients.14 The importance of caries management has shifted toward a more biological as well as less invasive approach.

The CMCR technique is desirable since it offers a minimally invasive method. This system also eradicates anesthesia usage and painful symptoms, along with needless removal of healthy tooth structure, as only infected dentin is scooped.15

The most recent upgrade observed in the papain-gel category is the BRIX3000. It has a superior enzymatic activity when compared to other CMCR agents. Papain, being a crucial component, aids in faster and more efficient degradation of collagen without the use of any special armamentarium.16

In this study, pain perception was evaluated in 4–9-year-olds because a child undergoes the concrete development stage in cognitive behavior, and self-assessment of pain is common among this age group. Hence, the reliability of the study’s intervention was properly assessed using WBFPS.17 A study by Gupta18 observed that BRIX 3000® acted efficiently in removing caries and showed to be a promising and effective treatment option for child patients, which is in accordance with our study.

According to a study by Oommen,19 CMCR methods can be subjected as an alternative for caries removal when it comes to dental fear among patients associated with the noise of drilling and associated discomfort. The results showed that little pain response was observed while using a chemomechanical gel, which might be because of papain present in BRIX3000 gel, which works exclusively on dead infected cells, leaving behind unharmed healthy tissue. Papain has a debriding anti-inflammatory impact in contrast to the airotor caries removal group, where the operator uses the airotor against the hard dentin, hence harming more dentinal tubules that cause discomfort.12,20 Abdul21 stated that CMCR encompasses less pain compared to atraumatic restorative treatment (ART).

Pascareli-Carlos,22 in his study, agreed with a similar finding that participants who underwent CMCR showed lower pulse rate compared to ART. However, both techniques portrayed minimal perceived pain. On the contrary, Adham23 obtained results where patients complained of increased discomfort upon using the CMCR method compared to ART.

Rajakumar3 conducted a study that evaluated and compared the efficacy of the CMCR method using carie care with hand and rotary excavation by evaluating the time taken, pain response, and residual caries left. Their results portrayed that more time was taken in the caries care group than the airotor group and hand excavation group, efficacy was more with airotor, followed by carie-care, and least for manual excavation, the pain experienced was more with airotor followed by manual excavation and least of all is caries care. In the present study, the clinical efficacy of BRIX3000 was better in removing carious tooth structure owing to its EBE technology.

According to a study by Balachandran et al.,24 CMCR with BRIX3000 has emerged as a comfortable, less pain-inducing, effective, minimally invasive technique compared with traditional caries excavation. Although BRIX3000 takes more working time, it selectively eradicates only carious dentine while still conserving sound dentine, helping in remineralization. Moreover, it eliminates any need for local anesthesia, thus improving patient compliance.

Inamdar et al.25 performed an in vivo study where they compared BRIX3000, caries care, and smart burs in caries excavation and checked for bacterial count reduction. BRIX3000 had shown the highest reduction in bacterial count, followed by smart burs and carie care. Further studies are required on a larger sample to justify the implementation of newer CMCR agents as a part of minimally invasive procedures in pediatric dentistry. The limitations of the study included a lack of standardization of the number of times the chemomechanical agent was used for each tooth.


Clinical Significance

The CMCR used as an alternative for caries removal in pediatric dentistry can prove to be very beneficial, especially in terms of anxiety and discomfort felt by the children.


Seema Bargale https://orcid.org/0000-0003-4110-7990

Sejal Jain https://orcid.org/0000-0002-0859-9834

Anshula N Deshpande https://orcid.org/0000-0003-3467-2123

K S Poonacha https://orcid.org/0000-0002-5367-3685

Saylee Deshmukh https://orcid.org/0000-0002-6832-6942

Charmi Shah https://orcid.org/0000-0001-9623-5290


1. Reddy MV, Shankar AJ, Pentakota VG, et al. Efficacy of antimicrobial property of two commercially available chemomechanical caries removal agents (Carisolv and Papacarie): an ex vivo study. J Int Soc Prev Community Dent 2015;5(3):183–189. DOI: 10.4103/2231-0762.159955

2. Anusavice KJ, Kincheloe JE. Comparison of pain associated with mechanical and chemomechanical removal of caries. J Dent Res 1987;66(11):1680–1683. DOI: 10.1177/00220345870660111501

3. Rajakumar S, Mungara J, Joseph E, et al. Evaluation of three different caries removal techniques in children: a comparative clinical study. J Clin Pediatr Dent 2013;38(1):23–26. DOI: 10.17796/jcpd.38.1.p3324121m66n1737

4. Roberson M, Heymann O. Sturdevant’s Art and Science of Operative Dentistry, 5th edition. St Louis: Mosby; 2006. pp. 308–311.

5. Burke FJ, Crisp RJ, Hall AF. Patient’s perception of treatment with Carisolv in general dental practice. J Dent Res 33:171–177.

6. Bussadori SK, Guedes CC, Hermida Bruno ML, et al. Chemo-mechanical removal of caries in an adolescent patient using a papain gel: case report. J Clin Pediatr Dent 2008;32(3):177–180. DOI: 10.17796/jcpd.32.3.1168770338617085

7. Subramaniam P, Gilhotra K. Antimicrobial efficacy of an indigenously prepared caries removing gel. Contemp Clin Dent 2011;2(1):13–16. DOI: 10.4103/0976-237X.79294

8. Bussadori SK, Guedes CC, Bachiega JC, et al. Clinical and radiographic study of chemical-mechanical removal of caries using Papacarie: 24-month follow up. J Clin Pediatr Dent 2011;35(3):251–254. DOI: 10.17796/jcpd.35.3.75803m02524625h5

9. Ismail MM, Haidar AH. Impact of Brix 3000 and conventional restorative treatment on pain reaction during caries removal among group of children in Baghdad city. J Baghdad Coll Dent 2019;31(2):7–13. DOI: 10.26477/jbcd.v31i2.2617

10. Torresi F, Besereni L. Effectiveness method of chemomechanical removal of dental caries as papain in adults. J Rev Assoc Paul Cir Dent 2017;71(3):266–269.

11. Felizardo KR, de Alvarenga Barradas NP, Guedes GF, et al. Use of BRIX-3000 enzymatic gel in mechanical chemical removal of caries: clinical case report. J Health Sci 2018;20(2):87–93. DOI: 10.17921/2447-8938.2018v20n2p87-93

12. Ericson D, Zimmerman M, Raber H, et al. Clinical evaluation of efficacy and safety of a new method for chemo-mechanical removal of caries. A multi-centre study. Caries Res 1999;33(3):171–177. DOI: 10.1159/000016513

13. Kumar KVKS, Prasad MG, Sandeep RV, et al. Chemomechanical caries removal method versus mechanical caries removal methods in clinical and community-based setting: a comparative in vivo study. Eur J Dent 2016;10(3):386–391. DOI: 10.4103/1305-7456.184151

14. Nadanovsky P, Cohen Carneiro F, Souza de Mello F. Removal of caries using only hand instruments: a comparison of mechanical and chemo-mechanical methods. Caries Res 2001;35(5):384–389. DOI: 10.1159/000047478

15. Lager A, Thornqvist E, Ericson D. Cultivatable bacteria in dentine after caries excavation using rose-bur or carisolv. Caries Res 2003;37(3):206–211. DOI: 10.1159/000070446

16. Mahdi M, Haidar AH. Evaluation of the efficacy of caries removal using papain gel (BRIX 3000) and smart preparation bur (in vivo comparative study). J Pharm Sci Res 2019;11(2):444–449.

17. Nalawade HS, Lele GS, Walimbe HS. Comparative evaluation of efficacy of chemomechanical and conventional methods of caries excavation in young permanent molar teeth: in vivo study. J Dent Res 2019;6(1):13–18. DOI: 10.4103/jdrr.jdrr_71_18

18. Gupta N, Chowdhary N, Reddy VR, et al. Evaluation of caries removal efficacy using BRIX 3000 and atraumatic restorative treatment in primary molars: a clinical comparative study. J Contemp Dent Pract 2022;23(4):419–424.

19. Oommen SR, George L, Mathew J, et al. Assessment of pain response during caries removal using conventional tungsten carbide bur and a chemomechanical caries removal agent (Brix Gel): an in vivo study. JIDA 2021;15:21–27.

20. Innes NP, Frencken JE, Bjørndal L, et al. Managing carious lesions: consensus recommendations on terminology. Adv Dent Res 2016;28(2):49–57. DOI: 10.1177/0022034516639276

21. Abdul Khalek A, Elkateb MA, Abdel Aziz WE, et al. Effect of papacarie and alternative restorative treatment on pain reaction during caries removal among children: a randomized controlled clinical trial. J Clin Pediatr Dent 2017;41(3):219–224. DOI: 10.17796/1053-4628-41.3.219

22. Pascareli-Carlos AM, Martins LF, Silva Gonçalves MD, et al. Pain perception of children after restorative treatments: atraumatic restorative treatment versus chemomechanical removal–a noninferiority randomized clinical trial. J Indian Soc Pedod Prevent Dent 2021;39(2):202–207. DOI: 10.4103/jisppd.jisppd_426_20

23. Adham MM, El Kashlan MK, Abdelaziz WE, et al. The impact of minimally invasive restorative techniques on perception of dental pain among pregnant women: a randomized controlled clinical trial. BMC Oral Health 2021;21(1):1–9. DOI: 10.1186/s12903-021-01432-3

24. Balachandran J, Raees T, Rao M, et al. Evaluation of efficacy of chemomechanical method of caries removal using BRIX- 3000 compared to conventional excavation with burs- a randomized controlled trial – original research. JIDA 2020;14;12–18. DOI: 10.33882/jida.14.25900

25. Inamdar MS, Chole DG, Bakle SS, et al. Comparative evaluation of BRIX3000, CARIE CARE, and SMART BURS in caries excavation: an in vivo study. J Conserv Dent 2020;23(2):163–168. DOI: 10.4103/JCD.JCD_269_20

© The Author(s). 2023 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (https://creativecommons.org/licenses/by-nc/4.0/), which permits unrestricted use, distribution, and non-commercial reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.