complete description of minimal invasive dentistry

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1
G
ood
m
orning

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3. Previous questions
• Minimal invasive dentistry Apr 2010, 2014
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4. Contents
• Introduction
• Definition
• History
• Principles of MID
• Motives for minimal invasive dentistry
• Caries diagnostic aids
• Iceberg of caries
• Potential factors 4

5. • Cavity design principles
• Minimal invasive preparation techniques
 ART
 Chemo-mechanical caries removal
 Air- abrasion
 Sono-abrasion
 Lasers
 Ozone therapy
 Polymer cutting instruments
 Silver diamine fluoride
• Conclusion
• References
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6. INTRODUCTION
• Prevention, remineralization and minimal intervention for the
placement and replacement of restorations.
• The ultimate goal of minimal intervention is to extend the life
of restored teeth with as less intervention as possible.
• When operative care is indicated, it should be aimed at
“PREVENTION OF EXTENSION” rather than “EXTENSION
FOR PREVENTION”.
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7. DEFINITION
• Minimum Invasive Dentistry (MID) 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 minimal invasive and
patient friendly treatment in order to repair irreversible damages
caused by such disease.
(FDI Commission, 2002)
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8. 8
Prevention and treatment of dental caries lesions forming in
enamel pits and fissures can be challenging because of factors
such as the "hidden caries" phenomenon, types of materials to
use, methods of bonding restorative materials, and concerns for
conserving tooth structure.

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Recent trends in
caries prevention
Recent
trends in
oral
prevention
Recent
advances
in HIV
diagnosis
Recent trends in Preventive dentistry
• Fluorides
• ART
• Caries Vaccine
• Xylitol
• Ozone
• Replacement
therapy
• Antibacterial and
antimicrobial
agents
• Caries detection
methods
• Tretinoin
Biofilm
• DNA
Vaccine
and Oral
cancer
preventi
on
• Ora
sure
• Ora
quic
k
Recent Advances
in pit and fissure
sealants
• Microscopic
identification
• Cultures
• PCR
• Genetic
analyses
• Enamel matrix
derivatives
• Bisphosphonate
s
• Photodynamic
therapy
• Local
antimicrobial
delivery systems
Recent trends in
periodontal
disease
prevention
• Fluoride releasing
sealants
• ACP-pit & fissure
sealants.
• Glass ionomers as
sealants.
• Moisture tolerant pit &
fissure sealants.
• Etch- free pit & fissure
sealants.
• Pen type handling of
sealants.
• Fissure sealants with
color change
technology.
• Nano composites as
sealants.
•Harshpriya
et al, recent
trends in
preventive
dentistry-A
review; SRM
University
dental
journal,
2011;2(3):23
2-237

10. HISTORYHISTORY
1900 - 'Extension for Prevention': G.V.Black
1912 - Hyatt introduced Prophylactic Odontomy
1951 - Dr. J. Tim Rainey introduced Air Abrasion
1954 - Bunocore introduces Acid etching
1964 - Bowen introduced Resin
1980’s – ART & Caridex
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11. • 1998 - Carisolv
• 1999 - Dr.Hugo & Mosele introduce caries excavation by
Sonoabrasion
• 2000 - Baysan & Lynch - introduced Ozone Therapy for arresting
dental caries.
• 2004 onwards - Dr Lawrence proposes genetically modified
organisms to prevent caries.
• Frietas describes the application of concept of Nanodentistry to
treat dental caries
Dentistry has moved beyond the surgical approach Now - heal a
carious lesion, at least in its early stages
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12. Principles of Minimal Intervention Dentistry
1. Modification of the oral flora / Reduction of cariogenic
bacteria
2. Patient education
3. Remineralization of non-cavitated lesions (early lesions) of
enamel and dentin
4. Minimal surgical intervention of cavitated lesions / Disease
control
5. Repair rather than replacement of defective restorations 12

13. MOTIVES FOR MID
• Early diagnosis of lesions and accurate risk assessments are
available.
• The extensive knowledge on caries progression rates .
• Adhesive restorative materials and techniques promote less
removal of healthy tissues .
• High risk for Iatrogenic effects.
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14. CARIES DIAGNOSTIC AIDS
1. Visual Method
2. Visual – Tactile method
3. Elective Temporary Tooth Separation
4. Magnification
5. Radiographic method
6. Laser fluorescence method
7. Fiber-optic transillumination method (FOTI)
8. Electrical conductive method
9. Ultra Violet illumination method
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15. 10.Endoscope / Videoscope
11.Dye penetration method
12.Iodide Penetration
13.Multi-Photon Imaging
14.Infrared Thermography
15.Infrared Fluorescence
16.Ultra sonic imaging
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16. VISUAL METHOD
• Cavitation,opacification and discolorations.
• Secondary lesions with cavitations.
• Root caries.
• But limited detection of posterior proximal and occlusal
lesions.
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17. VISUAL - TACTILE METHOD
• Determining roughness or softness of the tooth surface with a sharp
explorer.
• May transmit cariogenic bacteria from one site to another
• May produce irreversible traumatic defects in potentially
remineralisable non-cavitated lesions of enamel and dentin.
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18. Mechanical binding of on explorer tip in a fissure may not be
because of caries but due to other causes like.
a. Shape of the fissure
b. Sharpness of explorer: A sharp explorer has a diameter of
200microns
c. Force of application
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19. ELECTIVE TEMPORARY
TOOTH SEPARATION
• Elastomeric separating modules (separators)
(Rimmer and Pits 1990)
• Diagnosis of caries in proximal smooth surface
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20. Magnification
• Essential aid to diagnose small cavities & initial lesions
• High reproducibility of results
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21. RADIOGRAPHIC METHOD
21atomic composition, density and thickness of the tissues.

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Advantages:
1.The depth of a lesion
2.Relation between the lesion and the pulp of the tooth.
3.Aproximal lesions.
4.Non-invasive method while probing may cause a break of the enamel
covering a subsurface lesion.
5.Lasting documentation.

24. LIMITATIONS:
1. Two dimensional image of three-dimensional object.
2. Under estimations or over estimations due to projection errors.
3. Radiolucency cannot be judged whether this is due to caries or
resorption or any other defect.
4. Proximal secondary caries on the more apical part of a
restoration may not be detected.
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25. Laser fluorescence method
Quantitative Light Induced fluorescence (QLF)
method
• Diagnostic tool for in vivo and in vitro quantitative
assessment of dental caries, plaque, calculus, staining.
• images are captured into the computer and stored in an
image database.
• Optional quantitative analysis tools enable the user to
quantify parameters like mineral loss, lesion depth, lesion
size, stain size and severity with high precision and
repeatability.
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26. • It relies on the fluorescence signal observed when teeth are
exposed to light
(wavelength – 488-514 nm).
• This causes sound tooth structure to fluoresce.
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27. • It is a two step method
- The first step involves image acquisition with CCD camera.
- The second step involves image analysis, using the software.
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28. DIAGNODENT
• It is the chair side, battery powered quantitative diode laser
fluorescence device.
• It measures the fluorescence of bacterial products within
carious lesions
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29. It consists of a control unit
and a hand held probe.
The probe comes with 2
attachments, one with a
small tip for examining
fissure caries and the other
with a larger, broader tip
for examining smooth
surfaces.
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30. FIBER OPTIC TRANS
ILLUMINATION (FOTI)
• It works under the principle that since a carious lesion has a
lowered index of light transmission, an area of caries appears as a
darkened shadow that follows the spread of decay through the
dentine.
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31. 31
ADVANTAGES
No hazards of radiation
Simple and comfortable for the patients
Lesions which cannot be diagnosed radiographically can be
diagnosed by this method
Less time consuming
DISADVANTAGES
Permanent records are difficult to maintain as in
radiographs
Difficult to locate probe in certain areas

32. Electrical conductive method
(Pincus, 1951)
• Electrical conductivity is directly proportional to the amount of
demineralization.
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33. ADVANTAGES:
•Very effective in detecting early pit and fissure caries
•It can monitor the progress of caries during caries control
programme.
DISADVANTAGES:
•It can only recognize demineralization and not caries specifically.
•Presence of enamel cracks may lead to false positive diagnosis
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34. The observation of the colouring can be qualitative
or quantitative.
Qualitative assessment is observation for colour
difference and quantitative assessment is
determination of the intensity of colour.
Both fluorescent and non fluorescent dyes have
been used for staining the porous carious lesion.
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CARIES DETECTOR DYES

35. • “Procion” and “Calcein” dyes stain enamel lesions.
• Basic fuchsine red stain was developed to differentiate
between 2 layers of carious dentin. .
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36. Iceberg of caries
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37. 37

38. POTENTIAL FACTORS
1. Deminerlization – Remineralization cycle
2. Adhesion in restorative dentistry
3. Biomimetic restorative material
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40. (Image Courtesy of Dr. Steve Steinberg)(Image Courtesy of Dr. Steve Steinberg)
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41. (Image Courtesy of Dr. Steve Steinberg)(Image Courtesy of Dr. Steve Steinberg)
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42. Adhesion in restorative dentistry
Two forms of adhesion are available;
i. Micromechanical
union between tooth surface and restorative material - beveling
the enamel cavity margin and then etching with phosphoric acid.
ii. Chemical adhesion - result of an ion exchange between glass
ionomer cement and tooth structure both enamel and dentine
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43. Biomimetic Restorative Materials
“Imitation of nature” :- should in some way reproduce one or
more natural phenomena within a biologic situation, the material
will be biocompatible and not be rejected by adjacent vital tissues
Glass ionomer cement
Other materials -
Resin – based composite.
A layered combination of resin – based composites and GICs
applied with a technique called lamination.
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44. CAVITY DESIGN PRINCIPLES
1. Gaining access to the body of the lesion without being
destructive.
2. Removal of tooth structure that is infected and incapable of
regeneration.
3. Avoiding the exposure of dentine unaffected by the caries
process.
4. Reducing perimeter of the restoration.
5. Keeping the margins of the restoration away from the gingiva.
6. Reducing occlusal stress on the final restoration.
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45. DESIGNS FOR CAVITY
PREPARATION
• Specific designs for approximal lesions:
I. Tunnel preparation
II. Microchip cavity preparation
.
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45

46. DESIGNS FOR CAVITY
PREPARATION
III. Minibox cavity preparation
IV. Full box cavity preparation.
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47. MINIMALLY INVASIVE
PREPARATION
TECHNIQUES
• Atraumatic restorative treatment (ART)
• High / Low speed bur
• Chemomechanical Caries removal
• Air abrasion
• Laser
• Ozone Technology
• Polymer Cutting Instruments
• Silver Diamine Fluoride (AG (NH3)2F)
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48. ATRAUMATIC RESTORATIVE
TREATMENT (ART)
Tanzania in the mid 1980’s as a part of community based
primary oral health program.
Technique of caries removal using hand instruments only.
Currently glass-ionomer cement that leach fluorides and
minimize the onset of secondary caries are used.
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51. ADVANTAGES
• Easily available and relatively inexpensive hand instruments.
• A biologically friendly approach
• Conservation of sound tooth tissue
• Limitation of pain, by minimizing the need of local anesthesia.
• Straightforward and simple infection control practice without the
need to use sequentially autoclaved handpieces.
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52. • Chemical adhesion of GIC.
• Leaching of fluoride from GIC.
• Ease of repairing defects in restoration
• Low cost
• Non-threatening oral procedure.
• No noise from a drill.
• Greatest advantage of ART is that it makes possible to reach
people who otherwise never would have received any oral care.
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53. LIMITATIONS
• Its use is limited to small and medium sized one surface lesions
because of low wear resistance and strength of GIC.
• Hand fatigue from the use of hand instruments over long periods
• Hand mixing might produce a relatively unstandardized mix of
GIC
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54. CHEMOMECHANICAL CARIES
REMOVAL
Caridex:
It consists of 2 solutions.
Solution – I containing Sodium hypochloride
Solution – II- Glycine, Aminobutyric acid, Sodium chloride and
Sodium hydroxide.
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55. ADVANTAGES
Reduced need for local anaesthesia
Conservation of sound tooth structure
Reduced risk of pulpal exposure
Well suited for anxious and medically compromised patients as
well as for the child patients.
LIMITATIONS:
Large volumes of solution were needed and the procedure was
slow (10-15 minutes)
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56. CARISOLV
• It is in the form of Pink gel which can be applied to the carious
lesion with specially designated hand instruments.
• It is marketed in 2 syringes,
• 1.Sodium hypochloride
• 2.pink viscous gel which contains
aminoacids lysine, leucine, glutamic acid togetherwith CMC
(Carboxymethyl cellulose) to make it viscous and is readily visible
in use.
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Mediteam in Sweden , January, 1998

57. ADVANTAGES:
The system is much easier to use than Caridex
As it involves gel rather than liquid there is better contact with
the carious lesion.
When complete caries removal is achieved by this technique the
cavity surface has been shown to be as sound as that remaining
after conventional drilling.
LIMITATIONS:
Rotary and hand instruments may still be needed for removal of
tissue or material other than degraded dentine collagen.
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58. ENZYMES
• (Goldsberg and Keil, 1989) successfully removed soft carious
dentine using bacterial Achromobacter Collagenase, which did
not affect the sound dentin layer beneath the lesion.
• Enzyme pronase, a non-specific proteolytic enzyme originating
from Streptomyces griseus to help remove carious dentine.
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59. SILVER DIAMINE FLUORIDE
Ag+ (Silver ions) plus Protein (Bacterial proteins and proteins
from infected carious dentine) leading to instant coagulation
and form Silver protein
Bacterial enzymes (Trypsin, Collagenase), consisting of
proteins, are inhibited, thus further denaturation of dentine
collagen is prevented
Stops degeneration of affected into infected dentine
Fluoride assists in the remineralisation of affected dentine
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60. AIR ABRASION
• Dr.Robert Black , 1950’s introduced
• Dr. J. Tim Rainey was able to improve and combine this
technology with the use of modern adhesive restorative material.
• Air abrasion devices include cart, table top and handheld models.
• Operator controls are either mechanical or digital.
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61. • Some systems (e.g. AIR – FLOW Prep K1) capture the Al2O3
powder stream in H2O spray to reduce the pollution which
increases comfort of operation.
• When highly energized abrasive particles are directed at healthy
enamel and dentin the kinetic energy is absorbed by the substrate
and cuts or abrades rapidly.
• kinetic cavity preparation.
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62. ADVANTAGES OF AIR – ABRASION
Non – traumatic treatment
No chipping and micro fracturing
Decreased thermal build up
Less invasive procedure that preserves more natural tooth
structure.
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63. DISADVANTAGES
Non-contact based modality, leading to significant risk of cavity
over preparation and inadequate carious dentin removal.
Spread of aluminum oxide powder particles around the dental
operatory.
Impaired indirect view because abrasive particles collect on
mirror rapidly blocking the viewing surfaces.
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64. SONO ABRASION
Recent advances have demonstrated the use of high speed
ultrasonic's with abrasive tips for the purpose of cavity preparation
High frequency sonic air scaler, modified abrasive tips
Oscillate in sonic region of 6.5 kHz
Air cooled with water: 20-30 mL/min
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65. LASERS
Maiman in 1960.
• Lasers are devices that produce beams of Coherent
and very high intensity light. Lasers are used in the
treatment of soft tissues and modification of hard
tooth structures.
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66. Lasers that are currently being investigated for more selective hard
tissue ablation include
• Er : YAG and Nd : YAG.
• CO2 lasers.
• Excimer lasers with U.V. emission.
• Holmium lasers
• Dye enhanced laser ablation.
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67. ADVANTAGES
• Laser radiation has proved to be a safe and effective treatment
modality for caries removal and cavity preparation, and the
reduced need for anesthesia is considered an advantage.
LIMITATIONS
• Expensive
• Huge size of the equipment
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68. OZONE TECHNOLOGY
• Ozone (O3) is an energized form of oxygen.
• It is now a proven fact that 10 seconds application of ozone gas
at a concentration of 2200ppm could eliminate 99% of the
carious micro flora.
• For the therapeutic purposes, ozone can be produced in a
controlled manner using electrical units.
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69. 69

70. Indications
• Primary pit and fissure caries
• To treat primary root carious lesions
• Early carious lesions around crowns and bridges
Advantages
• Ozone therapy kills more than 99% of microorganisms in caries.
• It oxidizes caries and speeds up remineralization
• Ozone does not cause allergic reaction.
• Microorganisms do not develop resistance to ozone.
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71. POLYMER CUTTING
INSTRUMENTS
• Metal and diamond burs cut decayed and healthy
dentin indiscriminately. Innovative polymer
instruments have been designed to differentiate
between these two structures, they are able to
remove softened dentin, but cannot cut hard, healthy
dentin.
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72. CONCLUSION
• The 21st
century of dentistry surely belongs to the 'preventive'
paradigm. Minimal intervention approach accompanies up-to-date
caries diagnosis and risk assessment before arriving at a treatment
decision.
• The minimal intervention philosophy could be fruitfully
incorporated into contemporary preventive and public health
dentistry.
• we should be engaged in treating 'CARIES' and not the 'CAVITY'
anymore.
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73. REFERENCES
Norman o harris. preventive dentistry 2009
Joel M. White, M.S, W. Stephan Eakle. Rationale and treatment
approach in minimally invasive dentistry. JADA, Vol. 131, June
2000. Pg: 13S-19S.
FDI Policy Statement. Minimal Intervention in the Management
of Dental Caries. Adopted by the FDI General Assembly: 1
October 2002 – Vienna, Austria
Mount GJ. Minimal Intervention: A new concept for operative
dentistry. Quintessence Int 2000:31:527-533
Bennett T. Amaechi. Emerging technologies for diagnosis of
dental caries: The road so far. JOURNAL OF APPLIED
PHYSICS 105, 102047 ; 2009.
73

74. M. Ganesh and Dhaval Parikh. Chemomechanical caries
removal (CMCR) agents: Review and clinical application
in primary teeth. Journal of Dentistry and Oral Hygiene
2011; 3(3);34-45.
Pitts NB. Diagnostic methods for caries: what is
appropriate when? J Dent 1991 Dec; 19(6):377-82.
Vivek S Hegde, Roheet A Khatavkar. A new dimension
to conservative dentistry. Air Abrasion. J Conserv Dent
2010: 13(1); 4-8.
Sumita Bhagwat, Deepil Mehta Bur ….no more. Non
rotary methods of cavity preparation. Scientific Journal
Vol. II – 2008
Iain A. Pretty. Review Caries detection and diagnosis:
Novel technologies. Journal of dentistry 34 (2006) 727 –
739.
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75. • LJ Walsh. The current status of laser applications in dentistry.
Australian Dental Journal 2003; 48 :( 3):146-155.
• www.midentistry .com
• Banerjee A, Watson TF, Kidd EA. Dentine caries excavation: a
review of current clinical techniques. Br Dent J 2000 May 13;
188(9):476-82.
• Beeley JA, Yip HK. Stevenson AG. Chemochemical caries
removal: a review of the techniques and latest developments. Br
Dent J. 2000 Apr 22; 188(8):427-30.
• Harshpriya et al, recent trends in preventive dentistry-A review;
SRM University dental journal, 2011;2(3):232-237
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76. THANK YOU
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