Minimally Intervention Dentistry

Minimally Intervention Dentistry

Dr. Hakan Çolak

DDs, Phd

Ishık University School of Dentistry

Erbil city

INTRODUCTION

The “extension for prevention” approach to dental disease management, with GV Black’s tooth preparation

Buonocore described etching of enamel surfaces to make it retentive for a restoration.

In 1962, Bowen introduced Bis-GMA

INTRODUCTION

• Minimum (or minimal) intervention dentistry (MI) can be defined as a philosophy of professional care concerned with the first occurrence, earliest detection, and earliest possible

cure of disease on micro (molecular) levels, followed by minimally invasive and patient-friendly treatment to repair

irreversible damage caused by such disease

Introduction

Caries

Caries is an infectious microbial disease

INTRODUCTION

MinumumIntervention

Concept of MID

Concepts of minimally intervention dentistry (Tyas et al)

• Early caries diagnosis.

• Classification of caries depth and progression

• Assessment of individual caries risk (high, moderate,low)

• Reduction in cariogenic bacteria to eliminate the risk of further demineralization and cavitation and arresting of active lesions

• Remineralization of early lesions

• Minimal surgical intervention of caries lesions

• Repair rather than the replacement of defective restorations

• Assessing disease management outcomes at intervals.

EARLY DIAGNOSIS

• The goal of minimally intervention dentistry is to halt the disease first and then to restore lost structure and function. • an accurate diagnosis of the disease is mandatory.

• It is important to note that caries activity cannot be determined at one stage only, it has to be monitored over the time by taking radiographs and clinical checkups.

NEW CAVITY CLASSIFICATION BASED ONSITE AND SIZE OF LESION

Difference between caries classification given by GV black and G mount

GV Black classification MI classification of G Mount (1997)

Provision of specifications for preconceived preparation designs for amalgam.

Direct recommendation for appropriate treatment according to classification code

Preparation designs do not take extent of active caries nto various tooth tisssues

Considers both site as well as size of the carious lesion

NEW CAVITY CLASSIFICATION

• Firstly, lesions are classified according to their location:• Site 1: Pits and fissures • Site 2: Contact area between two teeth• Site 3: Cervical area in contact with gingival tissues


• Secondly, the classification identifies carious lesions according to various sizes:• Size 0: Carious lesion without cavitation, can be remineralized.• Size 1: Small cavitation, just beyond healing through

remineralization.• Size 2: Moderate cavitation not extended to cusps.• Size 3: Enlarged cavitation with at least one cusp which is

undermined and which needs protection from occlusal load.• Size 4: Extensive decay with atleast one lost cusp or incisal edge


SiteMinimal Moderate Enlarged Extensive

Pit and Fissure1

1.1 1.2 1.3 1.4

Contact area2

2.1 2.1 2.2 2.3

Cervival3

3.1 3.2 3.3 3.4

Size

ASSESSMENT OF INDIVIDUAL CARIES RISK (HIGH, MODERATE,LOW)

Poor oral hygiene

Nonfluoridated toothpaste

Low frequency of tooth cleaning

Orthodontic treatment

Partial denture

History of multiple

restorationsFrequent

replacement of restorations

Medications causing

xerostomiaGastric reflux

Sugar containing medicationSjögren’s syndrome

Bottle feeding at nightEating

disorders Frequent intake of snacks

More intake of �sticky foods

Status of oral hygien

Low education status

PovertyNo fluoride supplement

Status of oral hygiene

Dental history Medical factors Behavioral factors

Socioeconomic factors

DECREASING THE RISK OF FURTHER DEMINERALIZATION AND ARRESTING ACTIVE LESION

REMINERALIZATION OF INITIAL LESIONS AND REDUCTION IN CARIOGENIC BACTERIA


Protective factorsSaliva and sealantsAntibacterialsFluorideEffective diet

Pathological factorsBacterial infectionAbsence of salivaFluorideDieatary habits



In the noncavitated lesion, one should always try to remineralize the tooth by

Decreasing the frequency of intake of refined carbohydratesFollowing plaque control measures Ensuring optimum salivary flow Patient educationApplication of chlorhexidine as an antimicrobial which acts by reducing the number of cariogenic bacteriaApplication of topical fluorides



• Commonly used agent for remineralization of teeth is fluorides, though some new materials have also been introduced in dentistry in an attempt to remineralize the teeth. These are:• Bioactive glasses—NovaMin• Recaldent (CPP-ACP).

Bioactive Glasses—NovaMin

• Introduced in 1969 by Hench.

• Contains calcium sodium phosphosilicate.

• Contact with water, NovaMin releases active calcium and phosphorus ions resulting in remineralization.

• Sodium present in NovaMin • increases the pH of oral cavity• enhances remineralization (precipitation of

crystals occur on teeth at pH ≥ 7)

• A minimum of 40 to 50 minutes of exposure time is required for remineralization to occur, so the person using NovaMin dentifrice should be refrained from rinsing, drinking or eating after tooth brushing

MINIMAL INTERVENTION OF CAVITATED LESIONS

Dental Materials Used for Minimally Invasive Treatment

Amalgam

Adhesive dental materials

Small cavities

Introduction of adhesive materials have played a major role in minimally intervention dentistry because they do not require the incorporation of mechanical retention features.

Dentistry

Glass Ionomer Cement

• Glass ionomer cement has various advantages like • chemical adhesion to tooth structure, • esthetics• anticariogenicity• rechargeable

Glass Ionomer Cement

Fluoride balance between glass ionomer and tooth.

A, Fluoride ions from a glass ionomer leach into the tooth.B, Fluoride in the restoration and tooth reach equilibrium. C, Saliva draws fluoride from the tooth and restoration. D, Bothtooth and restoration are depleted of fluoride. E, A topical application of fluoride recharges the cement.

Composites Resins

Effective bonding to enamel and dentin

micromechanical retention

Minimal cavities

Minimally Invasive Treatment Options for Cavitated Lesions

• Atraumatic restorative technique.

• Sandwich technique.

• Chemomechanical caries removal (CMCR).

• Pit and fissure sealants and preventive resin restorations.

• Tunnel, box and slot preparation.

• Tooth preparation using air abrasion.

• Tooth preparation using lasers.

Atraumatic Restorative Technique

• Atraumatic restorative technique (ART) was pioneered in mid-1980s in Zimbabwe and Tanzania in the need for basic treatment of carious teeth in communities with limited resources.

• In this excavation of caries is done using hand instruments and then tooth is restored using glass ionomer cement, an adhesive material

Sandwich Technique

• Given by McLean in 1985.

• Takes the advantage of the physical properties of both GIC and composite

• especially useful in situations when strength and pleasing esthetics are essential

Sandwich Technique

first the tooth is restored with GIC

because of its chemical adhesion to dentin and fluoride

release

Over it, composite resin is placed so as to have

better occlusal wear and esthetics

Chemomechanical Caries Removal

• Carisolv®• Well documented• Minimally-invasive, selective and precise• Minimises the need for the drill and

anaestheticsand enhances patient comfort

• Makes it possible to avoid drilling close to the pulp

• Carisolv® instruments with sharp yet blunt cutting angles help to protect healthy tissue

Chemomechanical Caries RemovalCarisolv® – the clinical procedure

1. The gel does not affect healthy dentine or softtissue. Nor does it affect enamel. Consequently Carisolv™ should be used in combination with thedrill or alternative techniques.

2. Drilling could preferably be used whenever thecavity needs to be opened up, for adjustment ofcavity periphery or whenever there are largeamounts of caries and when the risk to affecthealthy tissue is minimal.

3. Cover the cavity with gel and wait for 30 seconds until the carious dentine has been softened.

4. Softened caries can then be scraped away usingthe PowerDrive™ and/or the Carisolv® handinstruments.

5. Repeat steps three and four without waiting 30seconds, until the cavity is free from caries.

6. Inspect and fill as usual.

Pit and Fissure Sealants and Preventive Resin Restorations

• PRR utilizes the invasive and non invasive treatment of borderline or questionable caries.

• The resin placed in the carious areas and adjacent caries susceptible areas, seals them from the oral environment and provides a valuable treatment alternative to conventional restorations like amalgam

Pit and Fissure Sealants and Preventive Resin Restorations

That particular caries is restored and remaining pits and fissures are protected with sealants

PREVENTIVE RESIN RESTORATION

Tunnel, Box and Slot Preparation

• Tunnel preparations • if the lesion is more than 2.5 mm from the marginal ridge, a tunnel

preparation is indicated.• we preserve the marginal ridge and the proximal surface enamel

Tunnel, Box and Slot Preparation

• slot preparation • indicated for lesions which are less than 2.5 mm from the marginal

ridge• there is removal of the marginal ridge, but the preparation does not

include the occlusal pits and fissures if caries removal in these areas is not required

Tooth Preparations Using Air Abrasion

• Kinetic energy is used to remove carious lesion.

• Here powerful fine stream of moving aluminum oxide particles is directed against the surface to be removed.

• The abrasive particles hit the tooth with high velocity and a small amount of tooth structure is removed.

• Commonly used particle sizes are either 27 or 50 micrometers in diameter.

Tooth Preparations Using Air Abrasion

• The speed of the abrasive particles when they hit the target depends upon air pressure, size of particles, powder flow, nozzle diameter, the angle of the tip and the distance of tip from the tooth.

• Usually the distance from the tooth ranges from 0.5 to 2 millimeters. As the distance increases, the cutting efficiency decrease

• An added advantage is that tooth preparations achieved using air abrasion show rounded internal contours when compared with those prepared with a handpiece and straight burs.

Tooth Preparation Using Lasers

• Commonly used lasers for tooth preparation are • erbium: yttrium-aluminum-garnet lasers • erbium, chromium: yttrium-scandium-gallium-garnet lasers.

• These lasers can remove soft caries as well as hard tissue.

• Lasers have shown to remove caries selectively while leaving the sound enamel and dentin.

Tooth Preparation Using Lasers

• Advantages• can be used without application of

local anesthetics• no vibration,• little noise, • no smell • tooth preparation almost similar to

that prepared by using air abrasion technique

Management of caries using LASER

REPAIR INSTEAD OF REPLACEMENT OF THE RESTORATION

• When treating an old restoration, one should consider the following options before performing their replacement• Recontour and/or polish• Seal margins• Repair local defect• Replace restoration.

REPAIR INSTEAD OF REPLACEMENT OF THE RESTORATION

• Restoration is indicated for replacement when any of following occurs• Secondary caries which cannot be removed during repair procedure• Need for esthetics• Presence of pulpal pathology

The decision to repair rather than replace a restoration should be based on the patient’s risk of developing caries, the professional’s judgment of

advantages vs. risks and conservative principles of tooth preparation.

DISEASE CONTROL

• We know that dental caries is an infectious disease.

• Different efforts which must be made in order to decrease the incidence of caries include identification and monitoring of bacterias, diet analysis and modification, use of topical fluorides and antimicrobial agents.

• For caries control, caries vaccines and bacterial replacement therapy have also come up in the show

CONCLUSION

• Minimally intervention dentistry (MID) is the natural evolution of dentistry. As new materials and techniques are developed, dentistry is changed to make use of most conservative techniques.

CONCLUSION

• In general, the minimally intervention dentistry should fulfil following objectives of dental care which involve:• Categorizing the patients for risk of developing dental caries

depending upon existing oral health conditions. • Applying aggressive caries preventive measures like

implementation of fluoride therapy, antimicrobial therapy, diet modification and calcium supplementation to reduce the caries risk.

• Conservative use of intervention procedures.

Further reading

• Garg Nisha, Garg Amit, Textbook of Operative Dentistry, Jaypee Publishing

• James B. Summitt, Fundamentals of Operative Dentistry: A Contemporary Approach, Quintessence Pub

Education

Minimally Intervention Dentistry