Minimally Invasive Dentistry - Isfahan University of ... · Isfahan Univ. of Medical Sciences Esfand1391 Dr. Zahra Saied Moallemi SPECIFIC OBJECTIVES • Dental students should be

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Dr. Zahra Saied Moallemi

Minimally Invasive Dentistry

Dr. Zahra Saied MoallemiDDS, PhD

Oral Public Health Dept.,Isfahan Univ. of Medical Sciences

Esfand 1391


SPECIFIC OBJECTIVES

• Dental students should be able to:

• 1. State definition and goals of Minimally invasive dentistry.

• 2. Understand the concept of this modern approach of care.

• 3. Describe rationale and clinical recommendations for professional caries management.

• 4. Define the iceberg of dental caries and intervention thresholds.

Dr. Zahra Saied Moallemi Markley, 1951 Dr. Zahra Saied Moallemi

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Historical Development of Dentistry

- Extraction;

- Surgical approach: Drilling and filling;

- Medical approach: Minimal Intervention.


- Extraction


- Surgical approach: drilling and filling

- Developed in the 1890s by G.V. Black;- Highly formalised cavity design;- “Extension for prevention”.


• To remove more of the tooth the decay

dictated in order to obtain

resistance form of retention.

• Still the prevailing paradigm in the profession.


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- Dental caries is an irreversible microbial disease of the calcified tissues of the teeth, characterized by de-mineralization of the hard tissue of tooth


- Dental caries is an irreversible microbial disease of the calcified tissues of the teeth, characterized by de-mineralization of the hard tissue of tooth


• Modern dentistry has made G. V. Black model

obsolete and has introduced the

New standard of care


• Modern approach to the treatment of caries management

• Dental caries progression or reversal depends upon the balance between demineralization and remineralization. The 'Caries Balance' is determined by the relative weight of the sums of pathological factors and protective factors.

Medical approach: Minimal Intervention


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Minimally Invasive Dentistry

• respecting the health, function and aesthetics of oral tissue by preventing disease from occurring or intercepting its progress with minimal tissue loss

• MID, the Leading Edge Model in Dentistry


Infectious approach of caries

• Dental caries is a preventable disease of the

mineralized tissues of the teeth with a multi-

factorial etiology related to the interactions

over time between tooth substance and

certain micro-organisms and dietary

carbohydrates producing plaque acids.


Kidd kid

Kidd and Joyston-Bechal, 1997 Dr. Zahra Saied Moallemi

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Fejerskov and Manji, 1990


• Minimally invasive dentistry aims at the least

possible removal of enamel or dentin, including

reducing pathological factors and enhancing

remineralization to avoid any removal of hard

tissues.


• Restoration of teeth will not cure the disease.Dr. Zahra Saied Moallemi

• MID is based on a medical model that controls

the disease first and then uses minimally

invasive techniques to restore the mouth to

form, function, and aesthetics.

• Caries treated as a biological infection


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• MID allows dentists to become true physicians of the mouth, rather than tooth technicians.

• MID dentists continue to treat symptoms, but also manage the underlying disease and associated risk factors.

• MID focuses on the use of highly researched, leading edge, dental materials and products to control disease and to restore hard and soft tissue to the highest standard of form, function and aesthetics.

• The MID practitioner strives to use the most bio-mimetic and biocompatible materials currently available.


Similar concepts, but not identical

• Minimal intervention dentistry• Preservative dentistry• Atraumatic restorative treatment (ART)

Required:• Microdentistry (technical procedures)• Microscope Dentistry• Caries Diagnostic Technology Development


Levels of interventions in MID• Primary prevention• Primary prevention protects individuals against disease, often

by placing barriers between the aetiological agent and the host.

• Secondary prevention• Secondary prevention aims to limit the progression and effect

of a disease at as early a stage as possible after onset. It includes further primary prevention.

• Tertiary prevention• Tertiary prevention is concerned with limiting the extent of

disability once a disease has caused some functional limitation.


• When considering dental caries, tertiary prevention is aimed not only at restoring decayed teeth but must include further primary and secondary prevention in order to prevent further carious attack.

• This means that in addition to placing a filling the causes of caries must also be addressed as part of clinically effective caries management.


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9-year-old girl

Dr. Zahra Saied Moallemi In adult

Why we should move to MID?

Worldwide, more than half and as high as 71%

of dentist’s activities are replacement and

repair of existing restorations, that do not last

very long.(Forss and Widstrom, 2004; Mjör, 2000)


How we spend our time in dental office

65%35%

Replacement and repair

New restorationsDr. Zahra Saied Moallemi Dr. Zahra Saied Moallemi

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Advantages of MID• Patients prefer the least invasive procedure.

– Need sufficient explanation

• Less invasive procedure provide greater degree of predictability:– Marginal ridges provide up to 50% support for

cusps (Milicich and Rainey, 2000).

– small fillings survive better than large ones (Lucarottiet al., 2005).

• Longevity of teeth for patientsDr. Zahra Saied Moallemi Dr. Zahra Saied Moallemi

Advantages of MID• For dentists:

– Trust and understanding by patients:• Patients left the previous dentist due to dental fear and

bad experiences: 14 concerns of dental fear refer back to dentist (Rankin and Harris, 1985).

– Fewer injection,– Less frequent drilling,

(Whitehouse, 2009)

– Less stressDr. Zahra Saied Moallemi

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What patients imagine by a Dental Drill


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Figure 1. The “iceberg of dental caries”—diagnostic thresholds in clinical trials and practice.

Pitts N J DENT RES 2004;83:C43-C47

Copyright © by International & American Associations for Dental ResearchDr. Zahra Saied Moallemi

Figure 2. The “iceberg of dental caries” and contemporary treatment need/advice.

Pitts N J DENT RES 2004;83:C43-C47

Copyright © by International & American Associations for Dental ResearchDr. Zahra Saied Moallemi

A 10-year-old girl


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• For every treatment, the concept of MID can be applied.

• In all parts of dentistry:– RCT is more preserving than extraction.– Implant better than bridge.– Onlay preserves tooth structure more than the

crown.– Tunnel prep preserves marginal ridge.


Dr. Zahra Saied Moallemi Dr. Zahra Saied Moallemi

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MID Technologies• Digital Radiography• Laser and Non-Invasive Decay Detection• Magnification• Intra-Oral Camera• Caries Screening and Management• Oral Cancer Detection Systems• Soft Tissue Lasers• Hard Tissue Lasers• Air Abrasion• CAD/CAM Restoration Fabrication• Implants


MID Technologies

• In orthodontics:– Invisalign

• The latest in periodontal treatment:– Perioscope of 48x magnification to see calculus


• Are we ready to move from Operative to Non-

Operative / Preventive treatment of Dental

Caries in clinical practice?

Prof. NB Pitts


• What happen if I restore? What is the

survival rate of fillings?

• If I don’t? what is the survival of small

and large caries lesion (before they

progress beyond prevention)?


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Annual dentine caries progression rates in different agesDr. Zahra Saied Moallemi Dr. Zahra Saied Moallemi

• Minimal Intervention dentistry is the futurefuture:

– Advocated by FDI;– Cost effective;– Less trauma for the patient.

• A biological approach, not a mechanical one.• Makes significant demands on materials.

Prof. John W. NicholsonUniversity of GreenwichProfessor of Biomaterials Chemistry

• Additional slides:


Details of the MI approach

- (1) Reduces cariogenic bacteria;

- (2) Uses preventive measures;

- (3) Early lesions remineralised;

- (4) Minimal surgery on cavities;

- (5) Repair of defective restorations.


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(1) Cariogenic bacteria

• Caries is a bacterial disease;• Depends on dietary sucrose;• Driven by frequency of eating;• Modified by saliva.

Dr. Zahra Saied Moallemi Dr. Zahra Saied Moallemi

(2) Preventive measures

• Topical fluoride;• Fissure sealants;• Patient education on oral hygiene


(3) Remineralisation

• Requires management by non-intervention;• Enhanced by fluoride ion in saliva.


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(4) Minimal surgery

• Requires adhesive materials (glass-ionomers, adhesive composite systems);

• Innovative, bespoke cavity design:– Possibly without drilling (ART technique).


(5) Repair of materials

• To prevent cavity extension;• Not “botch job”, but appropriate.


The challenge for materials

• Adhesion– Occurs naturally for glass-ionomers; problematic for

composites.

• Fluoride-release;• Release of other mineralising ions (PO4, Ca2+);• Repairable.


References• The concept of minimally invasive dentistry.

Ericson D. DentalUpdate 2007;9-18.• Minimally Invasive Dentistry – Clinical

Applications. Whitehouse JA. J Minim IntervDent 2009;2:16-23.

• Are we ready to move from Operative to Non-Operative/Preventive treatment of Dental Caries in clinical practice? Pitts NB. Caries Res 2004;38:294-304.

• http://www.wcmidentistry.com/Dr. Zahra Saied Moallemi

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Minimally Invasive Dentistry - Isfahan University of ... · Isfahan Univ. of Medical Sciences Esfand1391 Dr. Zahra Saied Moallemi SPECIFIC OBJECTIVES • Dental students should be