This document provides an overview of minimal intervention dentistry. It defines minimal intervention dentistry as an approach focused on early detection and diagnosis of dental caries, followed by minimally invasive treatment. The key principles discussed include early caries diagnosis, classification of caries depth and progression, individual caries risk assessment, reduction of cariogenic bacteria, and remineralization of early lesions. Various methods for caries diagnosis and classification are described. The document also discusses strategies for decreasing caries risk, including remineralizing agents and antimicrobial therapies to arrest active lesions and promote remineralization. Remineralizing agents that are discussed include fluoride, bioactive glasses, CPP-ACP, TCP, ACP

1. MINIMAL
INTERVENTION
DENTISTRY
PRESENTED BY
METTINA
GUIDED BY
DR. GEETA I.B.

2. contents
 Introduction
 Definition
 Principles of minimal intervention dentistry
 Early caries diagnosis
 Classification of caries depth & progression
 Assessment of individual caries risk
 Reduction in cariogenic bacteria
 Remineralization of early lesions
 Minimal surgical intervention of carious lesions.
 Repair of defective restorations
 Periodic assessment of disease management

3. • Minimalinterventiondentistrydescribesaholistic,teamcare
approachthataimstomaintainlongtermhealth.
SirG.V.Blackadvocatedtheprincipleof “Extensionfor
prevention.
Minimuminterventiondentistryisthemodernapproachfor
managementof caries.
This approachstartswithdiagnosis&riskassessmentto
allowpropertreatmentdecision.
The currentconceptis-“Preventionofextension“rather
than“Extensionfor Prevention”.
INTRODUCTION

4. DEFINITION
 ‘’Minimum intervention dentistry is defined as the philosophy of
professional care concerned with first occurance, early detection &
earliest possible cure of the disease at micro levels followed by
minimally invasive treatment to repair irreversible damage caused
by that disease.”
- Tyas et al

5. PRINCIPLES
OF MI
 Tyas et al
1. Early caries diagnosis
2. Classification of caries depth & progression
3. Assessment of individual caries risk.
4. Reduction in cariogenic bacteria to eliminate the risk of further
demineralization.
5. Remineralization of early lesions.
6. Minimal surgical intervention of caries
7. Repair rather than replacement of defective restorations,
8. Assessing disease management outcomes at regular intervals.

6. EARLYCARIES
DIAGNOSIS

7. EARLY
DIAGNOSIS
Goal of minimal intervention dentistry is to halt the
disease first & then to restore lost structure & function.
Caries starts with imbalance between remineralization
& demineralization of tooth surface & progresses to
initial reversible lesion & later to irreversible
lesion(cavitation).
Caries activity has to be monitored over time along
with detection of carious lesion for accurate diagnosis.

8. METHODSOF
DIAGNOSIS
1. Visual tactile methods
2. Radiographic methods
3. Caries activity tests
4. Newer Methods-
 Fiber optic transillumination
 Digital imaging Fiber optic transillumination.
 Quantitative light induced fluorescence
 LASER fluorescence – DIAGNOdent
 Electronic caries monitor
 Chemical dyes
 CARIESCAN

9. Visual tactile
methods
 Visual examination is the most commonly used method for
detecting carious lesions.
 It is an easy technique routinely performed in clinical practice.
 Visual method is subjective in nature.
 The use of indices has permitted early caries signs to be detected
& recorded in a reliable way.
Ekstrand et al
Probing as
proposed by

10. VisualTactile
methods

11. Radiographic
methods
 Radiographic methods include
 Bitewing radiographs
 IOPA radiographs
 Dental panoramic tomography
 Bitewing radiograph is most commonly used to detect
interproximal lesions.
 Digital radiography is slowly replacing films.

12. Caries activity
tests
 Lactobacillus colony count test
 Saliva is collected by chewing paraffin
 Samples are evenly spread over Rogosa’s SLAgar plate
 The plate is incubated for 4 days 7 the lactobacilli are counted.

13. Caries activity
tests
 Snyder’s test
 This test measures the ability of salivary microorganisms to form
organic acids from a carbohydrate medium.
 Formula
 Pancreatic digest/casein
 Yeast extract
 Dextrose
 Sodium chloride
 Agar
 Bromocresol green

14. Caries activity tests

15. FOTI/ DIFOTI
 Fiber optic transillumination as
a caries detection technique is
based on the fact that carious
enamel has a lower index of light
transmission than sound enamel.
 More light is absorbed by a
demineralized structure giving it
a darkened appearance.
 DIFOTI is a digitalized version of
FOTI.

16. QUANTITATIVE
LIGHT INDUCED
FLUORESCENCE
 QLF is a tool for
detection of early carious
lesions , it is based on the
principle of auto
fluorescence of teeth.
 When the teeth are
illuminated with high
intensity blue light, the
resultant auto
fluorescence is detected
by an intraoral camera
 This camera produces a
fluorescent image.

17. LASER
FLUORESCENCE
DIAGNOdent pen – using a small LASER, the system produces an
excitation wavelength of 655 nm this produces a red light.
This is carried to one of the two intraoral tips,
The tip emits both the exciktation light & collects the fluorescent light..
DIAGNOdent displays a reading on the LED display

18. CARIES
CLASSIFICATION
BASEDONSITE
&SIZE
 Because of the importance of site & size of the carious lesions for
treatment , Mount et al gave a new classification of dental caries
by combining both site & size of the lesion.
 Basis of the classification given by Mount & Hume is that it is only
essential to make entry into the lesions & remove areas which are
infected & tooth is broken down.

19. MOUNT & HUME
CLASSIFICATION
SITE/ SIZE Minimal
1
Moderate
2
Enlarged
3
Extensive
4
PIT/FISSURE
1
1.1 1.2 1.3 1.4
CONTACT
AREA
2
2.1 2.2 2.3 2.4
CERVICAL
3
3.1 3.2 3.3 3.4
Site 1- Pits & fissures
Site 2- Contact area
Site 3- Cervical
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 atleast one cusp that is
undermined & which needs protection from occlusal
load.
Size 4- Extensive decay with atleast one lost cusp or
incisal edge.

20. GV BLACK’S
CLASSIFICATION

21. GV BLACKVs
GJ MOUNT
GV BLACK’S CLASSIFICATION MI CLASSIFICATION OF G MOUNT
Provision of specifications for pre-
conceived preparation designs for
amalgam.
Direct recommendation for
appropriate treatment according to
classification code.
Preparation designs do not take
extent of active caries into various
tooth tissues.
Considers both site as well as size of
the carious lesion.

22. CARIES
CLASSIFICATION
 Minimally invasive procedure mandates that leave the groove
intact unless there is caries on the surface, even if it is stained.
 If groove is intact, it can be sealed at the end of the procedure.
 Philosophy of minimal surgical intervention also involves anterior
aesthetic procedures.

23. ASSESSMENT
OFCARIES RISK
 Assessment of individual caries risk is one of the important tools
which helps the clinicianto make a respective treatment plan for
each individual.
 Caries risk assessment aims at identifying the children/patients
who are at a higher risk for dental caries & thus require more
dental care than those with moderate caries risk.

24. Categories of
patients based
on the risk of
developing
caries.
LOW RISK MODERATE RISK HIGH RISK
No caries in last years One carious lesion in
last years
More than 2 carious
lesions in last 3 years.
Sealed pit & fissure Deep pits & Fissures Deep pits & fissures
Good oral hygiene Fair oral hygiene No/ Little fluoride
exposure
Appropriate fluoride
use
White spots/
interproximal
radiolucencies
Poor oral hygiene
Regular dental visits Orthodontic treatment Frequent sugar intake
Inadequate saliva flow
Irregular dental visits

25. Following factors are commonly seen in patients with high risk caries
STATUS OF ORAL HYGIENE
Poor oral hygiene
Non-fluoridated toothpaste
Low frequency of tooth cleaning
Orthodontic treatment
Partial dentures
DENTAL HISTORY
History of multiple restorations
Frequent replacement of
restorations
MEDICAL FACTORS
Medications causing xerostomia
Gastric reflux
Sugar containing medication
Sjogren’s syndrome
BEHAVIOURAL FACTORS
Bottle feeding at night
Eating disorders
Frequent intake of snacks
More intake of sticky foods
SOCIOECONOMIC FACTORS
Low education status
Poverty
No fluoride supplements

26. DECREASINGTHE RISK
OF FURTHER
DEMINERALIZATION &
ARRESTINGACTIVE
LESION
 According to Minimal invasive dentistry, depending on the
patient’s risk factors, a number of suitable agents & therapies can
be applied like fluoride toothpastes, gels,varnishes, mouth rinses,
xylitol gum, diet counselling & casein derivatives to reduce the
rate of progress of tooth demineralization.

27. DECREASINGTHE
RISKOF
DEMINERALIZATION
REMINERALIZATIONANTIMICROBIAL
AGENTS
SALIVA
REMINERALIZING
AGENTS
HEALTHY DIET
DEMINERALIZATIONPOOR DIETARY
HABITS
SALIVARY
DYSFUNCTION
TOOTH DEFECTS
BACTERIA

28. DECREASINGTHE
RISKOF
DEMINERALIZATION

29. DECREASINGTHE
RISKOF
DEMINERALIZATION
 ROLE OF DIET
Fluoride
supplements
Calcium
supplements
Reduced
Sugar intake

30. DECREASINGTHE
RISKOF
DEMINERALIZATION
When the mouth has a healthy balance, saliva
crushes starches, and keeps calcium and phosphates
flowing around so teeth can re-mineralize.

31. REMINERALIZATION
OF INITIAL LESIONS &
REDUCTION IN
CARIOGENIC
BACTERIA
 Dental caries passes through the series of demineralization &
remineralization cycles depending on the micro environment.
 When the Ph is less than 5.5 , Demineralization occurs.
 In a neutral environment , hydroxyapatite of enamel is in
equilibrium with saliva which is saturated with calcium &
phosphate ions.
 At or below Ph of 5.5, H+ ions produced by bacterial metabolites,
react preferentially with the phosphate group of the enamel
crystals.
 This converts, PO 4 2- to HPO4 2- ions which once formed can no
more form the crystal lattice..
 This leads to enamel dissolution.

32. REMINERALIZATION
OF INITIAL LESIONS
Re-mineralization
Demineralization

33. REMINERALIZATION
OF INITIAL LESIONS
Hydroxyapatite- (Ca)10 (PO4)6 (OH)2

34. INDICATIONS
As an adjunct preventive therapy to reduce caries in high risk
patients.
To repair enamel in cases involving white spot lesions.
Reduce decalcification in orthodontic patients 7 after tooth
whitening.
Reduce dental erosion in patients with gastric reflux.
To desensitize sensitive teeth.

35. IDEAL
REQUIREMENTS
It should diffuse into the subsurface or deliver calcium &
phosphate into the subsurface.
It should be able to work at an acidic pH.
It should be effective in patients with xerostomia.
Should not favour calculus formation.
Should boost the remineralizing properties of saliva.

36. DIFFERENT
REMINERALIZING
AGENTS

37. FLUORIDE
 Arnold in 1957 was the first to
mention posteruptive effects of
fluorides in drinking water & topical
fluoride in caries prevention.
 There are four mechanisms by which
Fluoride acts-
 When fluoride is present in biofilms,
Hydroxyapatite is dissolved &
fluorapatite is formed.
Increased enamel
resistance
Increased rate of
maturation
Remineralization
of incipient
lesions
Imroved tooth
morphology
Interference with
microorganisms

38. FLUORIDE
 The discovery of fluorides as an agent for caries remineralization-
landmark.
 The dramatic decline in caries prevalence rates of developed
countries from the latter half of the 20th century has been largely
attributed to the widespread use of oral care products containing
fluoride [Fejerskov, 2004].
 Fluoride remains the gold standard for arresting caries lesions

39. NEED FOR NON FLUORIDATED REMINERALIZING
AGENTS
 While fluoride is highly effective on smooth surface caries,its effect is limited
on pit & fissure caries.
 Toxicity of fluorides increases with inadequate nutrition.
 If used in limits fluoride shows no problem , while exposure is strictly regulated
in some parts of the world.
 Many countries do not have fluoridated products.

40. BIOACTIVE
GLASSES
 NovaMin bioactive glass was invented by Dr. Larry Hench in 1960s
 It containsCalcium sodium Phosphosilicate.
 Mechanism of action-
NovaMin reacts with
saliva allowing exchange
of ions between sodium 7
hydrogen, elevating pH
At this elevated Ph
Calcium & phosphate
precipitate as Calcium
Phosphate.
Calcium phosphate
crystallizes to build a new
hydroxyapatite like layer
over exposed dentin.

41. CPP-ACP
CPPACPisanacronymfora
complexofcasein
phosphopeptides&Amorphous
calciumphosphate.
Caseinisapartofgroupof
peptidesthatnaturally occurin
milk.
Innormalstate,Calcium
phosphateformscrystalline
structure7becomesinsoluble
CPPkeepscalcium7phosphorus
inionicformwhichpromotes
remineralization.
LocalizesACP
in dental
plaque
This buffers
free Ca & P
Supersaturation
promotes
remineralization

42. TRI-CALCIUM
PHOSPHATE
• Tricalcium Phosphate is a new hybrid
material that fuses Beta- tricalcium
phosphate & Sodium Lauryl sulphate.
• Resulting in functionalized calcium & a free
phosphate thus increasing efficiency of
fluoride remineralization.
When used in toothpaste formulations it forms a
protective barrier around calcium enabling it to co-
exist with the fluoride ions.
WhenTCP comes in contact with saliva, the
protective barrier breaks down makingCa, P & F
ions available for remineralization.

43. ACP
TECHNOLOGY
• ACP technology contains,
Calcium sulfate &
Dipotassium phosphate.
• When these two salts are
mixed they rapidly form ACP
that can precipitate.
• This precipitatedACP can
readily dissolve into saliva &
help in remineralization.

44. SUGAR
SUBSTITUTES
-XYLITOL
 Xylitol is a naturally occurring sweetener in the same category as
sorbitol & Mannitol.
 It acts by inhibiting growth & metabolism of S. Mutans & reduces
dental plaque.
Xylitol
Ca+
PO4 2-
No acid
Saliva stimulationpH increase
Remineralization

45. NATURAL
REMINERALIZING
AGENTS
Gum Arabic
Grape seed extract

46. NANOHYDROXY
APATITE
 Carbonated hydroxyapatite nanocrystals are synthesized with
biomimetic characteristics for composition, structure, size &
morphology.
 These Nano HAP particles penetrate below the surface & replace
calcium & phosphate ions to areas from which the minerals have
dissolved.

47. CALCIUM
CARBONATE
CARRIER-
SensiStat
 SensiStat technology was developed by Dr. Israel Kleinberg of NewYork.
 ContainsArginine Bicarbonate & Calcium Bicarbonate, the latter holds
the Calcium carbonate onto the tooth surface thus providing a reservoir
for Calcium Ions.
Figure. Scanning electron micrographs of dentin slices
with open tubules before (bottom) and after (top) exposure
to SensiStat containing prophy paste (ProClude) and
subsequent rinsing six times with distilled water.
Magnification 4,000X.

48. OZONE
Ozone is a chemical compound containing three oxygen atoms .
Ozone therapy has shown to be effective in remineralization.

49. Does Ozone Enhance the Remineralizing Potential of Nanohydroxyapatite on Artificially Demineralized
Enamel? A Laser Induced Fluorescence Study Samuel Raj S et al
Abstract
The present era of minimal invasive dentistry emphasizes the early detection and remineralization of
initial enamel caries. Ozone has been shown to reverse the initial demineralization before the integrity of
the enamel surface is lost. Nano-hydroxyapatite is a proven remineralizing agent for early enamel caries.
In the present study, the effect of ozone in enhancing the remineralizing potential of nano-
hydroxyapatite on artificially demineralized enamel was investigated using laser induced fluorescence.
Thirty five sound human premolars were collected from healthy subjects undergoing orthodontic
treatment. Fluorescence was recorded by exciting the mesial surfaces using 325 nm He-Cd laser with 2
mW power.Tooth specimens were subjected to demineralization to create initial enamel caries.
Following which the specimens were divided into three groups, i.e ozone (ozonated water for 2 min),
without ozone and artificial saliva. Remineralization regimen was followed for 3 weeks.The fluorescence
spectra of the specimens were recorded from all the three experimental groups at baseline, after
demineralization and remineralization.The average spectrum for each experimental group was used for
statistical analysis. Fluorescence intensities of Ozone treated specimens following remineralization were
higher than that of artificial saliva, and this difference was found to be statistically significant (P<0.0001).
In a nutshell, ozone enhanced the remineralizing potential of nanohydroxyapatite, and laser induced
fluorescence was found to be effective in assessing the surface mineral changes in enamel. Ozone can be
considered an effective agent in reversing the initial enamel caries there by preventing the tooth from
entering into the repetitive restorative cycle.

50. NEWER NON-
FLUORIDE
REMINERALIZING
AGENTS
Non-fluoride Enamel remineralizing technologies
 Technology Commercial product
 1 Dentin phosphoprotein 8DSS peptides Not available
 2 P11-4 peptides Curodont Repair/Curodont
Protect
 3 Leucine-rich amelogenin peptides Not available
 4 Poly(amido amine) dendrimers Not available
 5 Electrically accelerated and enhanced
 Remineralization Not available
 6 Nanohydroxyapatite Apagard toothpaste/Desensin
oral rinse

51. MINIMAL
INTERVENTION
OFCAVITATED
LESIONS
RATIONALE OF MINIMALTOOTH
PREPARATION
Early diagnosis of caries by newer
diagnostic methods.
Understanding of gradation of mineral loss
from center of the lesion to peripheral part.
Understanding of ion migration which takes place
both in & out of the tooth structure.(
Remineralization reverses non-cavitated lesion)
Evolution of adhesive dentistry allows minimal
tooth preparation, reduces microleakage at
tooth- restoration interface.
Development & evolution of restorative material
which is capable of ion exchange can remineralize
tooth structure.

52. FISSUROTOMY
 It is the ultraconservative tooth
preparationusing fissurotomy bur of head
length- 2.5mm & diameter of 0.6mm,
0.7mm & 1.1mm.
 Width of the prepared cavity becomes 1/8th
to 1/10th the intercuspal distance.
 It can be later restored with flowable
composite.

53. CHEMOMECHANICAL
CARIESREMOVAL
 Chemomechanical caries removal involves the selective removal
of carious dentin..
 Reagents commonly available in the market are Caridex &
carisolv.
 Caridex consists of two solutions-
Solution 1- contains sodium hypochlorite
Solution 2- contains glycine, aminobutyric acid, sodium
chloride & sodium hydroxide.
 Carisolv consists of a mixture of amino acids & 5% sodium
bicarbonate.
 Mechanism-The resulting high pH reacts with denatured
collagen in carious dentin & removes softened dentin.

54. PIT & FISSURE
SEALANTS/
PREVENTIVE
RESIN
RESTORATIONS
 A pit & fissure sealant is a material which is placed in
deep pits & fissures of newly erupted teeth so as to
prevent development of caries.
 Materials used- Composite Resins, Compomers &
Fluoride releasing sealants.
 Preventive resin restorations are placed in teeth with
the rationale that the carious lesion would be
isolated from the surface biofilm.
 Use of preventive resin restorations should be
limited to fissures where lesion is confined to enamel
only.

55. TUNNEL
PREPARATION
 Tunnel preparation is the removal of proximal caries via access in
occlusal surface.
 It is called as internal oblique preparation.
 Indicated if carious lesion is more than 2.5 mm from the marginal
ridge.
 In tunnel preparation, marginal ridge is preserved & normal
contact is not disturbed.

56. BOX &SLOT
PREPARATION
 Box & slot preparations are
conservative preparations which
involve marginal ridge, contact is
maintained undisturbed.

57. AIRABRASION
 In this method, kinetic energy is used to remove carious lesion.
 Powerful , fine stream of aluminium oxide particles is directed
against the target tooth surface, this results in tooth structure
removal.
 Size- 27- 50 micrometres, air pressure- 40-160 psi, at a distance of
0.5- 2 mm from target area.
 Indications-
 Superficial enamel defects, surface preparation of abrasion lesions.
 Contraindications –
 Dust allergy,COPD, open wounds, advanced periodontal disease,
fresh extractions, recent placement of orthodontic appliances.

58. LASERTOOTH
PREPARATION
Commonly used LASERS for tooth preparation are Er:YAG
LASER, Er:Cr:YSGG LASERS.
LASERS have shown to remove caries effectively while
leaving the sound enamel & Dentin intact.
Advantages- No vibration, pain free, sound free, increased
patient compatibility.
Disadvantages- time consuming

59. TOOTH PREPARATION
BYOZONE
 It is mainly indicated to treat primary root
carious lesions, pis & fissures, & early
carious lesions around crowns & bridges.
 Commercially available dental ozone units
like HealOzone & DentOzone deliver ozone
gas at preset concentrations.
 After 30-60 secs of ozone exposure, a
mineral wash is placed to initiate the
remineralization.

60. REPAIR
INSTEADOF
REPLACEMENT
OF THE
RESTORATION
 Repair of defective restorations ather than replacement has an advantage
of saving tooth structure, patient-chair time & places minimal trauma on
pulp,
 The decision to repair rather than replace a defective restoration should
be based on the patient’s risk of developing caries.
Following options should
be considered before
performing replacement
of old restorations-
• Recontour/polish
• Seal the margins
• Repair local defect
• Replace restoration
When any of the
following occurs, old
restoration is considered
for replacement rather
than repair
• Secondary caries
• Need for aesthetics
• Presence of pulpal pathology
• Fractured restoration.

61. DISEASE
CONTROL
Identification &
monitoring of
bacteria,
Diet analysis &
modification
Use of topical
fluoride &
antimicrobial
agents.
Caries vaccines
Probiotics
Dental caries is an infectious disease & efforts should be made in order
to decrease the incidence of disease.

62. DISEASE
CONTROL
 VITAL PULPTHERAPY
 For minimal intervention of cavitated lesions,Vital pulp therapy is
indicated.
 It involves stepwise remineralization using biocompatible dental
materials.
VITAL PULPTHERAPY
Direct pulp
capping
Indirect pulp
capping
Indirect pulp capping (IPC) is
defined as a procedure in
which carious dentin closest
to the pulp, is preserved to
avoid pulp exposure and is
covered with a
biocompatible material
Direct pulp capping (DPC) is defined as the
treatment of a mechanical or traumatic vital
pulp exposure by sealing the pulpal wound with
a biomaterial placed directly on exposed pulp
to facilitate formation of reparative dentin and
maintenance of the vital pulp (American
Association of Endodontists guideline, 2003)

63. PULP
CAPPING
AGENTS
 Calcium hydroxide
 Resin modified GIC
 Self- etching adhesive resins
 MineralTrioxide Aggregate
 Bioceramics- ERMM, Bioaggregate, Biodentin
 Calcium enriched mixture ( CEM)
 Enamel matrix Derivative
 Propolis
Calcium enriched mixture (CEM) cement (Yektazist Dandan,Tehran, Iran)
was introduced to dentistry as an endodontic filling biomaterial (USPTO
number: 7,942,961).The major components of the cement powder are
calcium oxide (CaO), sulfur trioxide (SO3), phosphorous pentoxide (P2O5),
and silicon dioxide (SiO2).The physical properties of this biomaterial,
such as flow, film thickness, and primary setting time are favorable [62],
and its clinical applications are similar to those of MTA, Its properties are
superior to those of Calcium Hydroxide. Harandi et al

64. ATRAUMATIC
RESTORATIVE
TREATMENT
 ART was first introduced in South Africa by Frencken in 1996.
 Originally practiced inTanzania.
 Allows restorative treatments in places with no electricity &
without the aid of sophisticated dental equipment.

65. CONCLUSION
 Minimal intervention dentistry is the natural evolution of dentistry.
 As new materials & techniques are developed, dentistry is changed to make the
use of most conservative techniques.
 MID should fulfill the following objectives of dental care,ategorizing the patients
for risk of developing dental caries based on existing oral health conditions.
 Applying aggressive caries preventive measures like supplementation of fluoride
therapy,antimicrobial therapy , diet modification & calcium supplementation.
 Conservative use of intervention procedures.

66. REFERENCES
Sturdevant’s- Art & science of operative dentistry
Textbook of operative dentistry by NishaGarg
Pubmed.NCBI.NLM
British Dental journal
Nikhil Marwah textbook of pediatric dentistry.

67. THANK YOU !