Minimal Intervention In Operative Dentistry

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Minimum intervention dentistry is a concept based on a better understanding of the caries process and development of the carious process and the development of new diagnostic technologies and adhesives, bioactive restorative materials.

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Minimal Intervention In Operative Dentistry

  1. 1. Minimal Intervention in Operative Dentistry, Evidence Based Approach By Sahar Mohamed Aly El-marsafy BDS, Cairo university, Egypt MDSc,Cairo University, Egypt DDS Al-Azhar University, Egypt Assistant Professor, Restorative Dentistry Department, Faculty of Dentistry, Umm Al-Qura University, Makkah, Saudi Arabia 1435 (H)-2014 (G)
  2. 2. Minimum intervention dentistry is a concept based on a better understanding of the caries process and development of the carious process and the development of new diagnostic technologies and adhesives, bioactive restorative materials.
  3. 3. Minimum intervention can be defined as an approach for dentists to base their treatment plans on four key- points:  Comprehensive diagnosis of the disease.  The possibility to prevent caries and to remineralise early lesions.  Minimally invasive operative treatment including repair of previous restorations rather than their systematic replacement.  Patient education.
  4. 4.  Evidence based dentistry has been defined by the American Dental Association as : 'An approach to oral healthcare that requires the judicious integration of systematic assessments of clinically relevant scientific evidence, relating to patient's oral and medical condition and history, with the dentist's clinical expertise and the patient's treatment needs and preferences'. Abhishek M, Gurkiran K, Gupta S. Evidence based dentistry – a new paradigm. Indian J D Sc 2011; 5 (3): 24-28.
  5. 5.  In terms of where best to find answers of high quality of evidence , a clear hierarchy can be described by evidence-based clinical guidelines, Cochrane systematic reviews, systematic reviews and studies. The evidence pyramid Wilson N H F. Minimally invasive dentistry: the management of caries. 1sted. New Malden; Quintessence Publishing Co. Ltd; 2007.
  6. 6. Throughout the review, guidance on decision making in respect of best quality evidence of different aspects of minimum intervention in operative dentistry will be provided.
  7. 7.  A pan-European group of dental clinicians and clinical academics co-ordinated by GC Europe – namely the GC Europe MI Advisory Board – has developed a "Minimal Intervention Treatment Plan (MITP)".  The basis of the MITP framework is composed of four phases of patient-centered treatment interlinking with each other: MI identify; MI prevent; MI restore and MI recall.
  8. 8. Decision tree showing the treatment plan for Minimal Intervention in Cariology in four stages as proposed by the GC-MI-Advisory Board . Domejean-Orliaguet S, Banerjee A, Gaucher C, Miletic I, Basso M, Reich E et al. Minimum intervention treatment plan (MITP) – practical implementation in general dental practice. J Minim Inter Dent 2009; 2(2): 103-124.
  9. 9.  The MI Identify phase can be divided into the following practical stages; Anamnesis – the process of verbal history taking, oral examination and radiography and other methods of caries detection.  In 2005, the International Caries Detection and Assessment System (ICDAS) Foundation was set up to develop a "standardized" visual scoring system for use in dental education, research and clinical practice.
  10. 10. A modified ICDAS 5-point visual scoring system to be used in general dental practice. Green captions describe the visual appearance of occlusal / smooth surfaces and the associated black captions, the equivalent histological features of the tooth.The clinical images provide examples of each score. Domejean-Orliaguet S, Banerjee A, Gaucher C, Miletic I, Basso M, Reich E et al. Minimum intervention treatment plan (MITP) – practical implementation in general dental practice. J Minim Inter Dent 2009; 2(2): 103-124.
  11. 11.  Although, radiographs still play an important role in caries detection their ability to identify earlier or hidden caries is questionable. Wilson N H F, Roulet J-F, Fuzzi M. Advances in operative dentistry, volume2: challenges of the future. 1sted. Berlin; Quintessence Publishing Co, Inc; 2001.
  12. 12.  There are numerous other techniques developed for early caries detection like digital radiology, electrical conductance (EC), fiber optic transillumination (FOFI), digital fiber optic transillumination (DIFOTI), quantitative light fluorescence (QLF) and DIAGNOdent. DIAGNOdent device Wilson N H F, Roulet J-F, Fuzzi M. Advances in operative dentistry, volume2: challenges of the future. 1sted. Berlin; Quintessence Publishing Co, Inc; 2001.
  13. 13.  Factors affecting the patient susceptibility to caries are general and oral.  General factors include: diet, fluoride exposure, health, medications, social factors and age.  Oral factors which influence the caries susceptibility of the patient are: oral hygiene maintenance, saliva, plaque and bacterial balance. Summitt J B, Robbins JW, HiltonT J, Schwartz R S, Santos J D. Fundamentals of operative dentistry, a contemporary approach. 3rd ed. Illinois; Quintessence Publishing Co. Inc; 2006.
  14. 14. Summary of factors to consider when assessing individual caries susceptibility
  15. 15. CRT test for Mutans Streptococci (MS) and Lactobacilli (LB) from a very high-risk patient. The Cariscreen test Three plaque pH tests from very low risk (1) low risk (2) and very high risk (3) patients. Milicich G. Caries: A clinical perspective of the oral disease we struggle to manage. J Minim Interv Dent 2008; 1(1): 26-34.
  16. 16. Tongue plaque sampling using the clinproCario Diagnisis- L-Pop (CCLP) swab and comparison of the coloration of the swab with CCLP color chart. Transcriptions of stained surfaces in Clinpro Cario Diagnosis (CCD) impressions to the tooth schema. Wilson N H F. Minimally invasive dentistry: the management of caries. 1sted. New Malden; Quintessence Publishing Co. Ltd; 2007.
  17. 17.  Recently, a number of complex risk models have been proposed.  One of these models was the Cariogram.  The Cariogram is a graphical illustration of the caries risk profile of an individual. . Wilson N H F, Roulet J-F, Fuzzi M. Advances in operative dentistry, volume2: challenges of the future. 1sted. Berlin; Quintessence Publishing Co, Inc; 2001.
  18. 18.  CAMBRA is based on performing a risk assessment on patients at risk of caries and then making individualized recommendations based on the level of risk (low, moderate, high or extreme). Finally determine the plan for caries intervention and prevention.  The approach is designed to educate and motivate patients to change their behaviors and implement changes to reach oral health and then maintain it.
  19. 19. The preventive standard care consists of: Daily oral hygiene. Dietary advice. Patient motivation.
  20. 20. The preventive active care consists of:  Preventive standard care. Professional decontamination. The professional decontamination includes:  Mechanical tooth cleaning.  Antimicrobial agents.  Management of saliva.  Replacement therapy.  Caries vaccine.
  21. 21. o Chlorhexidine (CHX) as varnish, gel and rinse. o Triclosan. o Essential oil (EO). o Recently, Ozone and Photo-Activation Disinfection (PAD) systems could be used as a disinfecting method.  Weighing its established side effects and the inconclusive evidence for benefits, the clinical usage of chlorhexidine is even being dissuaded.  However, 'inconclusive evidence does not necessarily mean not effective; therefore, the use of antimicrobial, in the current time, has been restricted to caries active individuals and to high caries risk individuals.
  22. 22. With respect to the minimal intervention treatment philosophy, the surgical excisional approach to caries should be undertaken only as a last resort in order to minimize tissue loss and patient discomfort. Non invasive restorative phase includes:  Remineralization therapies.  Therapeutic sealants.
  23. 23.  Fluorides.  Casein phosphopeptide.  Sugar substitutes.  Calcium sodium phosphosilicate.  Hydroxyapatite.  Recently, there are some techniques used for remineralization like ozone therapy and photoactivated light.  The remineralizing agents can be incorporated into different products like: • Dentifrices. • Chewing gums & lozenges. • Pastes & tooth mousse & topical cream. • Mouth rinses. • Varnishes & gels. • Dental floss. • Foods & drinks. • Also it can be added to restorative materials like; glass ionomer, compomer, giromers and fissure sealant.
  24. 24. The protective properties of saliva are maximized when saliva flow is stimulated following the consumption of fermentable carbohydrates. With increased salivary flow, the fall in plaque pH caused by acid by product is reduced and the potential for remineralization increased.
  25. 25.  The series of seven Cochrane systematic reviews, published in the Cochrane Library, assesses the effectiveness of fluoride toothpastes, gels, varnishes, and mouthrinses through comparisons against non-fluoride controls, against each other, and against different combinations. Original attached glass slow releasing fluoride device. Pessan J P, Al-ibrahim N S, Buzalaf M A R,Toumba K H. Slow release fluoride devices: a literature review. J Minim Interv Dent 2009; 2(4); 223-236.
  26. 26. CPP-ACP products Wilson N H F. Minimally invasive dentistry: the management of caries. 1sted. New Malden; Quintessence Publishing Co. Ltd; 2007. Basso M.Tooth restorations-non invasive techniques. J Minim Interv Dent 2011; 4(3): 165-167.
  27. 27. The remineralizing effect of CPP-ACP products on initial carious lesions has been well documented through clinical trials and systematic reviews. Further Randomized Controlled Trials are needed in order to confirm these initial results in-vivo.
  28. 28.  A nonfermentable sugar alcohol acts as a carrier or reservoir for calcium phosphates.  The abilities of xylitol and sorbitol to remineralize early enamel caries seem to be almost similar.  Adding isomalt to a demineralizing solution as soft drinks has shown to significantly reduce tooth mineral loss.
  29. 29.  The new formed hydroxycarbonate apatite (HCA) layer applied to enamel and any exposed dentine makes the tooth more resistant to acid attack. Products that contain NovaMin (dentifrices & chewing gum) Wilson N H F. Minimally invasive dentistry: the management of caries. 1sted. New Malden; Quintessence Publishing Co. Ltd; 2007.
  30. 30. Hydroxyapatite has been used in toothpaste (as filler) and pit and fissure sealant. Recent study concluded that products containing nano carbonate hydroxyapatite crystals as toothpasts revealed higher remineralization effects compared to amine fluoride toothpastes with bovine dentin and comparable trends were obtained for enamel.
  31. 31.  Ozone acts as disinfectant.  The use of O3 offers a minimally interventive approach to the management of root and fissure caries.  Further research is required to investigate the efficiency and cost benefits of this treatment modality. Application of ozone in the management of root caries Wilson N H F. Minimally invasive dentistry: the management of caries. 1sted. New Malden; Quintessence Publishing Co. Ltd; 2007.
  32. 32.  PAD is a method of disinfecting or sterilizing a site (tissue, wound and lesions of the cavity).  The low power laser energy in itself is not particularly lethal to bacteria, but is useful for photochemical activation of the dye.  The photosensitive dyes release reactive oxygen species which cause membrane and DNA damage to the microorganisms.
  33. 33.  Fissure sealant is a minimally interventive method that aims to prevent caries.  The decision to seal teeth should be based on the general and local risk, not on the patient's age alone. Wilson N H F, Roulet J-F, Fuzzi M. Advances in operative dentistry, volume2: challenges of the future. 1sted. Berlin; Quintessence Publishing Co, Inc; 2001.
  34. 34.  The principle of cavity design for amalgam restoration as established by GV Black at the end of the 19th century, have guided operative dentistry throughout most of the 20th century.  In line with the changing caries disease patterns, the advances in adhesive restorative materials, and the current focus on minimal intervention, modification and changes in cavity design are appropriate.
  35. 35. Tunnel preparation Conservative preparation Slot preparation. Summitt J B, Robbins JW, HiltonT J, Schwartz R S, Santos J D. Fundamentals of operative dentistry, a contemporary approach. 3rd ed. Illinois; Quintessence Publishing Co. Inc; 2006.
  36. 36.  systematic review of conservative intervention has revealed that conservatism per se does not guarantee increased restoration longevity.  All restorations are vulnerable to caries recurrence, material failures, and technical deficiencies.  Indeed, misguided conservatism in some cases may accelerate restoration demise due to the technical difficulties involved, the materials used, and the absence of disease control.
  37. 37. The philosophies of preservative dentistry and ART may be similar in that the greatest emphasis is placed on those individuals at highest risk for caries progression. Wilson N H F, Roulet J-F, Fuzzi M. Advances in operative dentistry, volume2: challenges of the future. 1sted. Berlin; Quintessence Publishing Co, Inc; 2001.
  38. 38. 1. Hand excavation. 2. Micro-preparation rotary instruments. 3. Non rotary cutting tools.
  39. 39. The rotary method continues to be the most widely used technique (gold standard) and is currently being adapted due to new demands, through the use of more accurate drills with smaller active components with longer and thinner necks. Examples include fissurotomy burs, self limiting burs, polymer bursand Cerabur.
  40. 40. Fissurotomy burs (SSWhite) Summitt J B, Robbins JW, HiltonT J, Schwartz R S, Santos J D. Fundamentals of operative dentistry, a contemporary approach. 3rd ed. Illinois; Quintessence Publishing Co. Inc; 2006. (left) Smart burs removing carious dentine (a).The polymer instrument remains largely intact (b). (right) When the polymer instrument hits sound dentine (a) it is visibly worn away (b). Wilson N H F. Minimally invasive dentistry: the management of caries. 1sted. New Malden; Quintessence Publishing Co. Ltd; 2007.
  41. 41.  Following minimal intervension approach, various non rotary cutting techniques were introduced.  These techniques include:  Ultrasonic.  Air abrasion.  Chemomechanical.  Laser.  Most of them still in the experimental stage and did not have strong evidence.
  42. 42. Wilson N H F, Roulet J-F, Fuzzi M. Advances in operative dentistry, volume2: challenges of the future. 1sted. Berlin; Quintessence Publishing Co, Inc; 2001.
  43. 43. Some of the situations where the air abrasion has particularly proved a boon include:  Removal of superficial enamel defects.  Detection of pit and fissure caries.  Removal of pit and fissure surface stain.  Preparation of conservative cavities.  Surface preparation of abfractions and abrasions.  Removal of existing restorations.  The use of local anesthesia while working in dentin may be avoided because of their cooling action through high pressure air.
  44. 44. Air abrasion used to remove pit & fissure caries using 27 micron-sized powder particles. HegdeV S, Khatavkar R A.A new dimension to conservative dentistry: air abrasion. J Conserv Dent 2010; 13(1): 4-8.
  45. 45.  Bioglass is a novel ceramic materials that can be manufactured with different hardness, which could therefore allow tailoring of their properties for cutting hard substances such as enamel and exposed sound dentine, or soft ones such as carious dentins. (a) Occlusal enamel fissure following bioactive glass air-abrasion. (b) SEM replica of prepared tooth showing fissure opening has been increased by the use bioactive glass powder, the powder preferentially removed weakened enamel in the carious fissure X25 Wilson N H F. Minimally invasive dentistry: the management of caries. 1sted. New Malden; Quintessence Publishing Co. Ltd; 2007.
  46. 46.  Given the limitations of the existing Cariosolv system, the application of this approach tend to be limited to the treatment of anxious patients, root caries and deep lesions of caries. Wilson N H F. Minimally invasive dentistry: the management of caries. 1sted. New Malden; Quintessence Publishing Co. Ltd; 2007.
  47. 47.  It would seem at this time that laser is most useful for smaller occlusal and cervical lesions where access is simple.  Preparation of larger cavities can be tedious and time consuming with little gain from the patient point of view.
  48. 48. .  By GV Black, in 1908, that is preferable to expose the pulp of a tooth than to leave it covered only with softened dentine. Present day discussion is how much caries can be left, rather than how much should be removed.  In the late 1970s, Fusayma suggested that only the outer layer of irreversible demineralized, non sensitive, caries-infected dentine should be removed, leaving the inner layer of remineralizable, sensitive, caries-affected dentine.
  49. 49. Well controlled study at 10 years on a series of occlusal restorations where soft demineralized dentine was not removed gives long term clinical evidence that, soft, infected demineralized dentine may be safely left, provided it is sealed from the oral environment as carious dentine left under a properly seal restoration will not progress.
  50. 50.  Restorative intervention in the MI philosophy is based on the principle of maximal preservation of natural tooth structure and on the use of biomimetic materials.  Currently there are several restorative materials that are compatible with a minimal interventive philosophy. These include the following: resin composites, giomers, ormocers, compomers, resin-modified and traditional glass-ionomer cements.  Some adhesives and resin-based composite have antimicrobial properties.  Amalgam despite its proven longevity is not compatible with a minimal interventive philosophy.
  51. 51. Biomimetics (amelogenins, hydroxyapatite, enamel replication and repair) and Genetic Engineering technology are a new technology mimicking processes that occur in nature such as the formation of dental enamel.
  52. 52.  Glass ionomer has been shown to fulfill some requirements of biomimetic materials although physical properties of the material fall short of ideal at this time.  Biomimetic or Bioactive composites introduced nanoparticles of amorphous calcium phosphate component in resin composites, with a smart release of calcium and phosphate ions at a cariogenic pH 4 to inhibit caries.
  53. 53.  Options for management of failed restoration started with recontour and/or polish, fissure seal margins, repair local defect and finally replace the restoration.  Additional measures include preventive procedures to limit the risk of secondary caries formation, and detailed oral hygiene instructions.  For small sized cavities suitably restored with composite, fracture, pulpal complications and post-operative sensitivity are unlikely.
  54. 54.  The main objective of the MI recall visit are to control the oral balance, to prevent oral disease and possibly to detect and treat it at an early stage.  A recent systematic review on the subject published by the Cochrane Collaboration pointed out that there is still an ongoing international debate in relation to the clinical effectiveness and recall intervals for specific types of care.
  55. 55. 1. Having decided that caries is essentially a disease of bacterial origin then it is mandatory that we think in terms of early recognition of its presence in the mouth, followed by elimination of the active disease, prior to undertaking moves to repair the damaged that it has caused.
  56. 56. 2. Although of more sensitive techniques and various systems have been developed, bitewing radiography associated with a visual examination is still the gold standard for detecting and following up the initial carious lesions, because it is reliable, reproducible and quick and easy to use.
  57. 57. 3. Caries risk must be assessed periodically as by using a Cariogram model and lesion severity must be monitored to track the activity status of the disease and to adjust the treatment including the program of prevention, all of these should be explained to the patient.
  58. 58. 4. Until such time as the alternative therapies are proven to be safe and effective for humans, conventional caries prevention methods primarily based on applications of fluoride and effective plaque removal must be used.
  59. 59. 5. Remineralization through the stimulation of saliva, preferably in the presence of fluoride is well established. The recent development of novel remineralization agents like CPP-ACP, bioactive glass and Ozone therapy may herald the introduction of new approaches to the minimally, if not non-interventive management of caries.
  60. 60. 6. Operative intervention is indicated to treat caries, conservation of sound tooth tissue is possible using of the modern techniques like ultrasonic, air abrasion and laser. The rotary method continues to be the most widely used tooth cutting technique (gold standard) and is currently being adapted due to new demands.
  61. 61. 7. To move toward less interventive restorative procedures coupled with patient pressure has rightly fuelled the greater use of direct adhesive tooth-colored restorative materials. 8. New evidence is now available supporting the use of Atraumaric Restorative Treatment as viable alternative for tooth restoration.
  62. 62. 9. Although conservatism per se does not guarantee increased restoration longevity, the long term performance of minimally interventive restorations appears to be good. 10. Despite the limitations of repair and modifications to existing restoration, such procedures are considered to be an integral element of modern minimally interventive dentistry.
  63. 63. 11. There are different international consensus guidelines for implementation of minimal intervention dentistry in clinical practice. Minimum Intervention Treatment Plan (MITP) which developed by GC Europe MI Advisory Board present easy evidence based protocol to follow, step-by-step flowchart to be used in daily practice.
  64. 64. 1. Whatever your individual difficulties and challenges may be, your professional responsibilities to your patients require that, together with the other members of your dental team, you make the shift to evidence based, minimally invasive approaches to oral healthcare provision.
  65. 65. 2. Further minimum intervention applications are currently under development or already pioneered. As the clinical implementation of minimum intervention is still new, there is a need for the best available evidence and its continuous update in order to show its efficacy in daily dental practice.
  66. 66. • Mickenautsch S. An introduction to minimum intervention dentistry. Singapore Dent J 2005; 27: 1-6. • Wilson N H F. Minimally invasive dentistry: the management of caries. 1sted. New Malden; Quintessence Publishing Co. Ltd; 2007. • Tays M J, Anusaavice K, Frencken J E, Mount G J. Minimal intervention dentistry- a review. FDI Commission Project 1-97. Int Dent J 2000; 50: 1-12. • Roulet J F. Proceedings of the 1st European conference on preventive and minimally invasive dentistry. Oral Hlth Press Dent 2004; Suppl 1. • Mickenautsch S. Adopting minimum intervention in dentistry: diffusion, bias and the role of scientific evidence. International Dentistry S A 2009; 11(1): 16-26. • Domejean-Orliaguet S, Banerjee A, Gaucher C, Miletic I, Basso M, Reich E et al. Minimum intervention treatment plan (MITP) – practical implementation in general dental practice. J Minim Inter Dent 2009; 2(2): 103-124. • Mount G J. Minimal intervention: a new concept for operative dentistry. Quint Int 2000; 31: 527-533. • Jensen L, BudenzAW, Featherstone F D B. Clinical protocol for caries management by risk assessment. J Calif Dent Assoc 2009; 35: 714-723.

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