Minimally Intervention Dentistry

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Minimal intervention dentistry is a modern dental practice designed around the principal aim of preservation of as much of the natural tooth structure as possible. It uses a disease-centric philosophy that directs attention to first control and management of the disease that causes tooth decay—dental caries—and then to relief of the residual symptoms it has left behind—the decayed teeth. The approach uses similar principles for prevention of future caries, and is intended to be a complete management solution for tooth decay.

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Minimally Intervention Dentistry

  1. 1. Minimally Intervention Dentistry Dr. Hakan Çolak DDs, Phd Ishık University School of Dentistry Erbil city
  2. 2. 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
  3. 3. 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
  4. 4. Introduction Caries Cariogenic bacteria Host Time Diet Caries is an infectious microbial disease
  5. 5. INTRODUCTION Minumum Intervention Identify Treatment and control Prevention Concept of MID
  6. 6. 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.
  7. 7. 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.
  8. 8. NEW CAVITY CLASSIFICATION BASED ON SITE 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
  9. 9. 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
  10. 10. NEW CAVITY CLASSIFICATION • 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
  11. 11. NEW CAVITY CLASSIFICATION Site Minimal Moderate Enlarged Extensive Pit and Fissure 1 1.1 1.2 1.3 1.4 Contact area 2 2.1 2.1 2.2 2.3 Cervival 3 3.1 3.2 3.3 3.4 Size
  12. 12. 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 restorations Frequent replacement of restorations Medications causing xerostomia Gastric reflux Sugar containing medication Sjögren’s syndrome Bottle feeding at night Eating disorders Frequent intake of snacks •More intake of sticky foods Status of oral hygien Low education status Poverty No fluoride supplement Status of oral hygiene Dental history Medical factors Behavioral factors Socioeconomic factors
  13. 13. DECREASING THE RISK OF FURTHER DEMINERALIZATION AND ARRESTING ACTIVE LESION
  14. 14. REMINERALIZATION OF INITIAL LESIONS AND REDUCTION IN CARIOGENIC BACTERIA
  15. 15. REMINERALIZATION OF INITIAL LESIONS AND REDUCTION IN CARIOGENIC BACTERIA Protective factors Saliva and sealants Antibacterials Fluoride Effective diet Pathological factors Bacterial infection Absence of saliva Fluoride Dieatary habits
  16. 16. REMINERALIZATION OF INITIAL LESIONS AND REDUCTION IN CARIOGENIC BACTERIA
  17. 17. REMINERALIZATION OF INITIAL LESIONS AND REDUCTION IN CARIOGENIC BACTERIA In the noncavitated lesion, one should always try to remineralize the tooth by Decreasing the frequency of intake of refined carbohydrates Following plaque control measures Ensuring optimum salivary flow Patient education Application of chlorhexidine as an antimicrobial which acts by reducing the number of cariogenic bacteria Application of topical fluorides
  18. 18. REMINERALIZATION OF INITIAL LESIONS AND REDUCTION IN CARIOGENIC BACTERIA
  19. 19. REMINERALIZATION OF INITIAL LESIONS AND REDUCTION IN CARIOGENIC BACTERIA • 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).
  20. 20. 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
  21. 21. MINIMAL INTERVENTION OF CAVITATED LESIONS
  22. 22. Dental Materials Used for Minimally Invasive Treatment Introduction of adhesive materials have played a major role in minimally intervention dentistry because they do not require the incorporation of mechanical retention features.
  23. 23. Glass Ionomer Cement • Glass ionomer cement has various advantages like • chemical adhesion to tooth structure, • esthetics • anticariogenicity • rechargeable
  24. 24. 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, Both tooth and restoration are depleted of fluoride. E, A topical application of fluoride recharges the cement.
  25. 25. Composites Resins Effective bonding to enamel and dentin micromechanical retention Minimal cavities
  26. 26. 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.
  27. 27. 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
  28. 28. 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
  29. 29. 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
  30. 30. 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
  31. 31. Chemomechanical Caries Removal Carisolv® – 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.
  32. 32. 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
  33. 33. Pit and Fissure Sealants and Preventive Resin Restorations If caries present in one area or part of the pits or fissures That particular caries is restored and remaining pits and fissures are protected with sealants PREVENTIVE RESIN RESTORATION
  34. 34. 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
  35. 35. 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
  36. 36. 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.
  37. 37. 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.
  38. 38. 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.
  39. 39. 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
  40. 40. 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.
  41. 41. 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.
  42. 42. 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
  43. 43. 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.
  44. 44. 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.
  45. 45. Further reading • Garg Nisha, Garg Amit, Textbook of Operative Dentistry, Jaypee Publishing • James B. Summitt, Fundamentals of Operative Dentistry: A Contemporary Approach, Quintessence Pub

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