Minimal intervention dentistry

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Minimal intervention dentistry

  1. 1. Minimal Intervention Dentistry Department of Pediatric and Preventive Dentistry SUBMITTED BY: U. VIGNESH BDS – FINAL YEAR BATCH – 2009 – 2010 GUIDED BY: DR. BINITA SRIVASTAVA DR. NIDHI GUPTA DR. RASHI SINGH DR. NEETI Santosh Dental College & Hospital
  2. 2. OUTLINE Introduction Principles of Minimal Intervention dentistry Newer cavity classification systems Treatment of Carious lesions Site 1 Site 2 Site 3 References
  3. 3. INTRODUCTION  Minimum intervention dentistry (MI) can be defined as a philosophy of professional care concerned with the first occurrence, early detection, and earliest possible cure of disease on micro levels, followed by minimally invasive, patient-friendly treatment to repair irreversible damage caused by such disease.  The benefits for patients from Minimal Intervention are: 1.Better oral health through disease healing and not merely on symptom relief. 2.Assists in reducing widespread patient dental anxieties. 3. more conservative approach to caries treatment and simultaneously offer patients less invasive, health-oriented treatment options.
  4. 4.  The philosophy of minimal intervention dentistry has now arisen in an attempt to combine all the present knowledge of prevention, remineralisation, ion exchange, healing, and adhesion with the object of reducing carious damage in the simplest and least invasive manner possible.  Minimal intervention operative dentistry is dependent on the following factors: 1. The demineralization - remineralization cycle 2. Adhesion in restorative dentistry 3. Biomimetic restorative materials Ref. pg no. 450, Nikhil Marwah, 2nd edition
  5. 5. Principles of Minimal Intervention Adopted by the FDI General Assembly, 1st October 2002, Vienna, (FDI Statement, 2002) 1. Control the disease through reduction of cryogenic flora • Only in the absence of disease will restorative dentistry succeed. • This is why control of the disease is the primary focus and only when such control has been achieved will it be possible to offer long-term repair of the damage. • Correct diagnostic procedures must be carried out for any at-risk patient to determine the potential for carious activity. • Modification of the oral microflora is essential in the initial stage, and a number of oral lavages are available to modify the balance of the oral flora although chlorhexidine is probably the most effective of these. Ref. pg no. 450-451, Nikhil Marwah, 2nd edition
  6. 6. 2. Remineralize early lesions – • Remineralization should be recognized and utilized as far as possible for any tooth that has been subject to attack by caries, because there is no real substitute for natural tooth structure. • It has been known for many years that “ white-spot” lesions on the visible surfaces of teeth can be remineralized and repaired. • Successful remineralization requires intensive patient must have a full understanding of the implication of food types, the need for plaque removal, and the possible need for additional oral lavages for control of bacterial populations. Ref. pg no. 450-451, Nikhil Marwah, 2nd edition
  7. 7. 3. Perform minimal intervention surgical procedures, as required- • If the disease has progressed to cavitation on the tooth surface, it is no longer possible to completely control plaque accumulation without some degree of surgical intervention. • In view of the potential for remineralization and healing a minimal intervention approach is encouraged. • The principle of preservation of natural tooth structures should dominate decisions about both new and old lesions. Ref. pg no. 450-451, Nikhil Marwah, 2nd edition
  8. 8. 4. Repair, rather than replace, defective restorations- • The replacement of any failed restoration will also lead to further loss of tooth structure and subsequent weakening of the remaining crown. • This steady progression should be limited as far as possible; with the advent of adhesion, biomimetic materials, and minimal intervention cavity designs, it is often possible to repair, rather than replace, a restoration that has suffered a limited failure. Ref. pg no. 450-451, Nikhil Marwah, 2nd edition
  9. 9. Recent Cavity Classification Systems
  10. 10. I. BASED ON SITE AND SIZE OF LESION (Mount and Hume, 1998) Size Site No cavity Minimal 1 Moderate 2 Enlarged 3 Extensive 4 Pit/Fissure 1 1.0 1.1 1.2 1.3 1.4 Contact area 2 2.0 2.1 2.2 2.3 2.4 Cervical 3 3.0 3.1 3.2 3.3 3.4 Ref. pg no. 126, G.J. Mount and W.R. Hume, 2nd edition
  11. 11. Classification of Cavities based on site and size of lesion Ref. pg no. 126, G.J. Mount and W.R. Hume, 2nd edition
  12. 12.  Size 1, Sizes 1,2,3 and 4 – Pit and fissure caries • Cavity located on the occlusal surface of a posterior tooth or any simple enamel defect on an otherwise smooth surface of any tooth. • Black Class 1 – the smaller size 1 could not be carried out previously because suitable restorative materials were not available, so the Black classification begins with Site 1, Size 2 (#1.2) Ref. pg no. 127, G.J. Mount and W.R. Hume, 2nd edition
  13. 13. Site 1, Size 0 • The concept of the fissure seal, as discussed by simonsen (1989) and others is particularly sound in a newly erupted tooth. • Sealing a deep fissure before it becomes partially occluded by plaque and pellicle, and in advance of demineralization into dentin, has an acceptable clinical history. • The earliest fissure sealants were unfilled or lightly filled resins, but recent research has shown that there are some doubts about the integrity of the acid etch union between resin and enamel in these regions. It has been shown that a glass ionomer will successfully occlude such a fissure (Wilson and McLean, 1988). • This is now being termed “Fissure Protection” to differentiate it from a “Resin Seal”. Ref. pg no. 452, Nikhil Marwah, 2nd edition
  14. 14. Site 1, Size 1 • As the fissure walls become demineralized, the dentin will become involved as well. This may pose a rather dangerous situation because there is often some difficulty in diagnosing the presence of a dentin lesion. • Radiograph will not show this early lesion very clearly and laser detector and electrical impedance machines have limitations. • In the presence of strong, fluoridated enamel, the occlusal surface entry to the lesion will remain limited, and bacteria-laden plaque can be forced down into a defective fissure. Under these circumstances, dentin involvement can become advanced before symptoms are noted. • The fissure system is a complex series of pits and fissure; therefore, a carious defect will often be limited to a very restricted area, leaving the remaining fissure system sound and uninvolved. This means that only the carious defect needs to be instrumented. Ref. pg no. 452, Nikhil Marwah, 2nd edition
  15. 15. Site 1 Size 1 Fig. 1- Lesion in the occlusal fissure , Note the small #1.1 lesion in the lingual groove of the lower molar. Dentin involvement is suspected Fig. 2 - Prepared cavity- The fissure has been explored and caries removed. The conditioning liquid is present to enhance the photograph Fig. 3 – Restored lesion – The same restoration recorded 5 years after placement. Note the limited wear over time Ref. pg no. 129, G.J. Mount and W.R. Hume, 2nd edition
  16. 16. Size 1, Size 2 • In this classification, the lesion will either have progressed to some degree or it may represent replacement of a failed Class I restoration. • The same conservative principal should apply, in as much as it is only necessary to deal with the carious lesion and there is no need to open up the remaining fissures any further. • If there is any part of the fissure system that is in doubt, it can be explored very conservatively, but there is no doubt that it is sufficient to seal the fissures and any carious process below will be arrested. • However, the occlusal involvement will be more extensive and, if there is any doubt about the ability of the glass ionomer to withstand the occlusal load, it can be cut back conservatively and laminated with resin composite. Ref. pg no. 452, Nikhil Marwah, 2nd edition
  17. 17. Site 1 Size 2 A bitewing radiograph of an extensive #1.2 lesion arising from an occlusal fissure on the second molar Note the limited size of the external involvement of the fissure Prepared cavity- Restoration – the entire cavity has been restored with a glass ionomer with no sublining required. Lamination- the cement has been laminated with composite resin for occlusal support Final radiograph – shows the extent of the restoration. 1. 2. 3. 4. 5. 6. Ref. pg no. 130, G.J. Mount and W.R. Hume, 2nd edition
  18. 18. Site 1, Size 3,4 • When a restoration requires replacement, the existing cavity will be relatively large. The previous surgical approach to cavity design required the removal of all infected tooth structure and softened affected dentin on floor of the cavity and also required removal of all unsupported enamel on the occlusal surface. • Consequently, there was a potential for loss of occlusal contact with the opposing tooth. • To avoid such procedures a temporary restoration is placed over the carious structure and this helps in remineralizing the lesion and decreasing pulpal inflammation. • Glass ionomer should be used for the transitional restoration following removal of infected layer of dentin from the surface of a large cavity. Ref. pg no. 453, Nikhil Marwah, 2nd edition
  19. 19. Site 1 Size 3 Fig. 1 - Size 3 cavities - An extensive lesion on the occlusal surface of a lower molar Fig. 2 - Completed cavity Fig. 3 - Split cusp – a split at the base of the mesiolingual cusp became apparent Fig. 4 - Completed restoration with amalgam Ref. pg no. 131-132, G.J. Mount and W.R. Hume, 2nd edition
  20. 20. Site 1 Size 4 Fig. 1 – An extensive lesion in a lower second molar. It is apparent the buccal cusp is very weak Fig. 2 - Completed cavity. Retentive grooves have been placed in the floor of the cavity to retain the amalgam Ref. pg no. 132, G.J. Mount and W.R. Hume, 2nd edition
  21. 21. Site 2 Lesions- Sizes1, 2, 3, 4 – Approximal lesion commencing in relation to contact areas • Approximal surface of any tooth (anterior or posterior) initiated immediately below the contact area • Black Class II – between posterior teeth only. Black classification begins with Site 2, Size 2 (#2.2) • Black class III - between anterior teeth only. Black classification begins with Site 2, Size 2 (#2.2) • Black class IV - class III lesion involving the incisal corner or incisal edge of an anterior tooth. Now classified Site 2, Size 4 (#2.4) Ref. pg no. 127, G.J. Mount and W.R. Hume, 2nd edition
  22. 22. Site 2, Size 0 • It should be noted that radiographic evidence of demineralization at the contact area does not necessarily mean that there is cavitation on the proximal surface and, in the absence of cavitation, it is often possible to heal the lesion. • In fact, proximal lesions progress very slowly because that surface is not under masticatory load and is, to a degree, protected from traumatic damage • In contrast to the occlusal fissure lesion, it may take up to four years to penetrate the full thickness of the enamel and an additional four years to progress through the dentin to the pulp. Ref. pg no. 453, Nikhil Marwah, 2nd edition
  23. 23. Site 2, Size 0 Fig. 1 - Site 2 – Proximal lesion Fig. 2 - The same lesion in the sectioned tooth Ref. pg no. 136, G.J. Mount and W.R. Hume, 2nd edition
  24. 24. Site 2, Size 1,2 • Once it has been established that there is cavitation on the proximal surface, a surgical approach to its repair becomes essential and some alternative methods are available. • First determine the position of the damage in relation to the crest of the marginal ridge. • If it is more than 2.5mm below the crest, then it may be possible to approach the lesion through the occlusal fossa and a design a “tunnel” cavity. • On the contrary, if it is less than this distance, a tunnel will only undermine the marginal ridge and weaken it still further. • Under these circumstances, it is better to design a small box or “slot” cavity beginning on the outer slope of the ridge, retaining as much of the enamel as possible. Ref. pg no. 450, Nikhil Marwah, 2nd edition
  25. 25. Site 2 Size 1 - tunnel Fig. 1. Initial approach – Enter the lesion from the occlusal fossa aiming towards the lesion. Fig. 2. Gain access – Turn the bur vertical and lean it buccally and lingually to ‘funnel’ the cavity for visibility. Fig. 3. Completed cavity – axial wall left untouched. Fig. 4. GIC Restoration done Ref. pg no. 129, G.J. Mount and W.R. Hume, 2nd edition
  26. 26. T he early proximal lesion on a posterior tooth will commence in enamel immediately below the contact area because this is where plaque will accumulate and mature. As the lesion develops, some degree of breakdown and cavitation of the enamel will eventually occur, but this will remain confined to the area below the contact until it is quite advanced. There will generally be a zone of demineralized enamel surrounding the cavitation, but as long as the surface is smooth, this remains capable of remineralization in the presence of fluoride. The contact area may remain sound and the marginal ridge may be quite strong, provided the lesion is more than 2.5 mm below the crest of the marginal ridge (Wilson and mcLean, 1988). TUNNEL PREPARATION Ref. pg no. 453-454, Nikhil Marwah, 2nd edition
  27. 27.  Access to the lesion through the occlusal surfaces should be limited to the extent required to achieve visibility and should be undertaken from an area that is not under direct occlusal load (Knight, 1984).  Fossa immediately next to medial marginal ridge is the most suitable position for entry.  Glass ionomer is best suited for such cavities as it readily flows into a small cavity and has the ability to remineralize the enamel margins and any dentin on axial wall. • Two variations are described: Closed ‘tunnel’ : Which leaves the demineralized approximal enamel intact Open ‘tunnel’ : Which is accessed from occlusal and exits through the approximal surface Ref. pg no. 453-454, Nikhil Marwah, 2nd edition
  28. 28. Indications and Contraindications •  Use of tunnel preparation can be considered when small, proximal carious lesions necessitate restoration • Preparation should be avoided: i. large carious lesion are diagnosed, where access is particularly difficult ii. Overlying marginal ridge is subjected to heavy occlusion or demonstrates a crack
  29. 29. Advantages of Tunnel Preparation • Preserves the marginal ridge - conservative approach • Less potential for a restorative overhang • Perimeter of the restoration is reduced, decreasing the potential for micro leakage. • Potential for disturbance of the adjacent tooth is reduced
  30. 30. Disadvantages of Tunnel Preparation  Highly technique sensitive, demanding careful control of the preparation by the operator  Angulations of preparation often passes close pulp  Visibility is decreased and caries removal is more uncertain - caries detecting solution  Fragile marginal ridge - at least 2.5 mm apical to crest of the marginal ridge (Mount 1997)
  31. 31. Site 2 Size 1 – Minibox / Slot Fig. 1. Small carious lesion on the proximal surface of the first bicuspid Fig. 2. Slot cavity preparation Fig. 3. Finished slot cavity Fig . 4 Resin modified GIC Restoration done Ref. pg no. 137, G.J. Mount and W.R. Hume, 2nd edition
  32. 32. “SLOT CAVITY PREPARATIONS”  It could be used when the lesion is less 2.5 mm below the crest of the marginal ridge.  The basic principles of cavity design remain the same, with the objective of removing only that tooth structure that has broken beyond the possibility of remineralisation.  If this is allowed to dictate the extent of the cavity, there will many occasions with this design where there is sound contact with the adjacent tooth in one or more areas. It is desirable to retain this to ease the problems of maintaining a good, firm contact area.  The outline form will be dictated entirely by the extent of the breakdown of the enamel, removing only that which is friable and easily eliminated without applying undue pressure . Ref. pg no. 454, Nikhil Marwah, 2nd edition
  33. 33.  Retention will be through adhesion, so it is only necessary to clean the walls around the full circumference of the lesion, leaving the axial wall because it will be affected by dentin only.  For such a lesion, resin composite may be a useful material because on many occasions there will be a useful material because on many occasions there will be an enamel margin around the full circumference.  However, glass ionomer is still a sound option because the occlusal load will not be great and the ion exchange will remain valuable both for adhesion and remineralization. Ref. pg no. 454, Nikhil Marwah, 2nd edition
  34. 34. Site 2 Size 1 – Proximal Approach Fig. 1. Proximal approach. A small proximal lesion becomes accessible through a traditional cavity prepared in the adjacent tooth Fig. 2. Restoration. The cavity has been restored with GIC before placing the other restoration Ref. pg no. 138, G.J. Mount and W.R. Hume, 2nd edition
  35. 35. PROXIMAL CAVITY PREPARATION  This is a very conservative approach used when the proximal surface of a tooth becomes accessible at the time of cavity preparation in an adjacent tooth.  The lesion may have been revealed through radiographs or it may be noted only during cavity preparation.  The larger cavity in the adjacent tooth will normally need to be of reasonably generous proportions to allow room to maneuver, but when such an approach is possible, it leads to considerable conservation of natural tooth structure.  It is only necessary to remove enamel that is broken down beyond remineralisation. Ref. pg no. 454, Nikhil Marwah, 2nd edition
  36. 36.  There will often be a residual area of demineralized enamel around the circumference of the lesion and this should be retained because it is quite capable of being remineralized.  As this entire restoration will be hidden by adjacent tooth, it is essential to use a radiopaque material.  Glass ionomer is preferred because the limited access will make it difficult to assure full polymerization of the resin through light activation. Ref. pg no. 454, Nikhil Marwah, 2nd edition
  37. 37. Site 2 Size 2 Fig. 1. Moderate lesion. A 2.2 lesion, distal of second bicuspid, to be prepared for adhesive restoration Fig. 2. Finished cavity. Note minimal involvement of occlusal fissure Ref. pg no. 137, G.J. Mount and W.R. Hume, 2nd edition
  38. 38. Site 2, size 3,4 • The principles for the restoration of an extensive proximal lesion are essentially the same as those for the occlusal lesion. • In gaining access to the affected demineralized dentin, there is no need to remove enamel just because it appears to be unsupported according to the old surgical principles. • However, the walls of the cavity should be cleaned of all infected dentin to allow development of the full ion-exchange adhesion with the glass ionomer. • Demineralized dentin can remain on both the axial and pulpal walls on the assumption that it will remineralize under the influence of the glass ionomer. Ref. pg no. 455, Nikhil Marwah, 2nd edition
  39. 39. Site 2 Size 3 Fig. 1. Anterior #2.3 lesion. Old amalgam restoration, distal of canine, to be replaced Fig. 2. Cavity design. Completed cavity. Note retention of labial enamel to be supported by adhesive restoration Fig. 3. Glass- ionomer cement restoration Fig. 4. Completed restoration Ref. pg no. 141-142, G.J. Mount and W.R. Hume, 2nd edition
  40. 40. Site 2 Size 4 Fig. 1. Lost buccal cusp Fig. 2. Placement of a base Fig. 3. Shaping the base Fig. 4. Begin composite Rebuild Fig. 5. Incremental build-up Fig. 6. Completed restoration Ref. pg no. 137, G.J. Mount and W.R. Hume, 2nd edition
  41. 41. Site 3 Lesions - Sizes 1, 2, 3 and 4 • Gingival 1/3rd of the clinical crown or exposed root surface following recession • Black class V - this classification does not differentiate lesions on the gingival one-third of the approximal surface (particularly root surface caries) from class II lesions. Ref. pg. no.128, G.J Mount and W.R. Hume, 2nd edition
  42. 42. Site 3 Size 0 Fig.1. Site 3. Erosion lesion seen on Labio-cervical area of upper canine Fig. 2. Site 3. Erosion lesion seen on the Bucco-cervical area of lower first molar Ref. pg no. 150-151, G.J. Mount and W.R. Hume, 2nd edition
  43. 43. Site 3 Size 1 Fig. 1 erosion lesion, #3.1. erosion lesions at the gingival of the central, lateral and canine were restored with GIC Fig. 2. Root surface caries at the gingival of the lateral incisor requires repair Fig. 3. Restoration done for the fig.2. tooth involved carious lesion Ref. pg no. 149, G.J. Mount and W.R. Hume, 2nd edition
  44. 44. Site 3 Size 2 Fig. 1. Carious lesion present on cervical area of lower second bicuspid Fig. 2. Placement of Resin modified GIC Fig. 3. Restoration done with GIC Ref. pg no. 150-151, G.J. Mount and W.R. Hume, 2nd edition
  45. 45. Site 3 Size 3 Fig. 1. Root surface carious, #3.3 lesion on the cervical area of Upper Anterior Teeth Fig. 2. Final cavity design, refine the cavity with small round burs, cleaning the margins only and leaving the axial wall alone Fig. 3. Place the restoration, a modified glass – ionomer was placed and light activated from both labial and lingual Ref. pg no. 137, G.J. Mount and W.R. Hume, 2nd edition
  46. 46. Site 3 Size 4 Fig. 1 #3.4, an old composite restoration is failing and requires replacement Fig. 2. Lingual view showing general failure around to the lingual Fig. 3. final cavity From labial view Fig. 4. Final cavity – labial view Fig. 5. Finished restoration Ref. pg no. 152-153, G.J. Mount and W.R. Hume, 2nd edition
  47. 47. ATRAUMATIC RESTORATIVE TREATMENT (ART) • The Atraumatic restorative treatment is a procedure based on removing carious tooth tissues using hand instruments alone and restoring the cavity with an adhesive restorative material. • It is also known as “Alternative Restorative treatment”. • ART is launched by the World Health Organization on 7th April, 1994 (world health day). • Goals of ART are: i. Preserving the tooth structure ii. Reducing infection iii. Avoiding discomfort Ref. pg no. 443, Nikhil Marwah, 2nd edition Ref. pg no. 320, S.G. Damle, 3rd edition
  48. 48. • The essential instrument used for ART are: 1. Mouth mirror 2. Explorer 3. Pair of tweezers 4. Dental hatchet 5. Small, medium sized spoon excavators 6. Glass slab 7. Spatula 8. Carver • The materials used are: 1. Gloves 2. Cotton rolls and pellets 3. Glass ionomer restorative material 4. Dentin conditioner 5. Petroleum jelly 6. Wedges 7. Plastic strips and water Ref. pg no. 320, S.G. Damle, 3rd edition
  49. 49. Procedure for ART: The tooth is isolated with cotton rolls The tooth surface to be treated is cleaned with a wet cotton pellet The entrance of the lesion is slightly widened by hand instrument to remove gross overhanging unsupported enamel rods The dental caries is removed by using either the small or medium size spoon shaped excavator If necessary provide pulpal protection by calcium hydroxide paste The cavity surface along with occlusal margins are cleaned The cavity is acid - etched Ref. pg no. 447, Nikhil Marwah, 2nd edition
  50. 50. According to manufacturer’s instructions the glass ionomer cement is mixed The mixed glass ionomer is inserted into the cavity and slightly overfield A gloved finger, which is smeared with petroleum jelly, is pressed on top the entire occlusal surface and slight pressure is applied The bite is checked Excess material is removed with a sharp carver The bite is rechecked and all high points are removed The filling is covered with petroleum jelly once again or the varnish may be applied The patient is instructed not to bite with the tooth for at least half an hour
  51. 51. fig 1. preoperative fig 2. excavation of caries fig 3. cavity after caries removal fig 4. cavity conditioning Procedure for ART S T E P 1 S T E P 2 S T E P 3 S T E P 4 Ref. pg no. 443, Nikhil Marwah, 2nd edition
  52. 52. fig. 5- Dispensing of GIC fig. 6- Mixing of GIC fig. 7- Insertion of GIC fig. 8- Restored cavity S T E P 5 S T E P 6 S T E P 7 S T E P 8
  53. 53. Advantages of ART 1. Easily available inexpensive hand instruments are used rather than the expensive electrically driven dental equipment. 2. As it is almost a painless procedure the need for local anesthesia is eliminated or minimized. 3. ART involves the removal of only decalcified tooth tissues, which results in relatively small cavities and conserves sound tooth tissues as much as possible. 4. Sound tooth tissue need not be cut for retention of filling material. 5. The leaching of fluoride from glass ionomer probably remineralizes sterile demineralized dentin and prevents development of secondary caries. Ref. pg no. 443, Nikhil Marwah, 2nd edition
  54. 54.  The combined preventing and curative treatment can be done in one appointment.  Repairing of defects in the restoration can be easily done  It is less expensive and less time consuming.  It enables to oral health workers to reach people who otherwise never would have received any oral health service. Ref. pg no. 443, Nikhil Marwah, 2nd edition
  55. 55. Disadvantages of ART  ART restorations are not long lasting. The average life is two years depending upon the rate of caries activity of the individual oral cavity.  Because of the low wear resistance and low strength of the existing glass ionomer materials their use is limited.  A relatively unstandardized mix of glass ionomer may be produced due to hand mixing.  The continuous use of hand instruments over long period of time may result in hand fatigue.  As fundamental principles of cavity preparation are not followed all oral health workers may not accept it. Ref. pg no. 443, Nikhil Marwah, 2nd edition
  56. 56. Air abrasion (Micro-Abrasion and Kinetic Cavity Preparation) • It is a method of tooth structure removal that is considered to be an effective alternative to the standard dental drill. • In 1943 Dr. Robert Black of Corpus Christi Texas began his pioneering work in this field. • In 1945 he published a series of articles on the use of air abrasive technique for cavity preparation and prophylaxis. • Air abrasive technology is the use of compressed air to propel aluminium oxide particles with such force as to be able to cut tooth structure in simple terms it is a precision sandblaster. • An air abrasive unit called AIRDENT was introduced in 1951. Ref. pg. no. 440, Nikhil Marwah, 2nd edition Fig. AIR ABRASIVE SYSTEM -Ref pg 348, Sturdevant’s Art and Science of Operative Dentistry, 5th edition
  57. 57. Advantages  It is painless  Local anesthesia is rarely needed  It works quickly and the tooth with a small lesion is ready to restore in seconds  It work quietly without the whine of the all too familiar dental handpiece  There is no vibration or pressure to cause microfractures that weaken tooth  There is no production of heat to damage the dental pulp and lesser sound tooth structure is removed. Ref. pg. no. 440, Nikhil Marwah, 2nd edition
  58. 58. Principles of Air abrasion 1.Accurate diagnosis of unsound tooth structure and decay. 2.Accurate removal of unsound tooth structure with minimal destruction of sound tooth structure. 3.Restorative treatment planning based on the probability of longevity of the restorative material. Ref. pg. no. 440, Nikhil Marwah, 2nd edition
  59. 59. Procedure of Air Abrasion Take preoperative radiograph to determine if interproximal caries is present Isolate preferably with rubber dam Use caries detecting dye to know the carious lesions Using air abrasive unit with high volume evacuation placed in the proximity of the tooth prepare cavity After a few seconds of initial preparation examine the preparation for decay Re-apply caries detecting dye Complete the preparation using the caries detecting dye until all caries is removed Ref. pg. no. 440, Nikhil Marwah, 2nd edition
  60. 60. Apply the etchant for 20 seconds rinse with water spray Disinfect the cavity preparation with chlorhexidine or other materials Within 10 seconds apply the dentin-bonding agent Immediately place the correct shade of composite and photo-polymerize the material for 40 seconds Use a carbide bur for initial shaping A flexible polishing cup point or disc will provide the final polish for the restoration Remove the rubber dam and check occlusion Ref. pg. no. 440-441, Nikhil Marwah, 2nd edition
  61. 61. Precautions 1. Need to protect patient with glasses, rubber dam if possible. 2. Dental team needs masks and glasses. 3. Stop frequently to check the progress. 4. Start with low pressure and low power then increase as needed. 5. Hold tip 1-2 mm away from tooth at a 45 degree angle then activate. 6. Always keep tip moving. 7. Requires external suction and air evacuation for the room. 8. Use disposable mirrors. 9. Like any air stream air abrasion can cause subcutaneous emphysema. Ref. pg. no. 441, Nikhil Marwah, 2nd edition
  62. 62. Clinical uses: • Class I, II, III, IV, V cavity preparations • Sealants and preventive restorations • Repair of composite and porcelain especially margin of veneers • Removal of composite and amalgam. Ref. pg. no. 441, Nikhil Marwah, 2nd edition
  63. 63. Chemico-mechanical removal of caries • An alternative to the conventional mechanical removal of caries is chemo mechanical method. • The need for local anesthesia is reduced or eliminated as there is little pain during the procedure. • It is an effective alternative for caries removal because it brings together Atraumatic characteristics and bactericide / bacteriostatic action. • The chemicals used can be in the form of liquid (caridex) or gel (carisolv). Ref. pg. no. 491-492, S.G. Damle, 3rd edition Ref. pg. no. 387, Nikhil Marwah, 2nd edition
  64. 64. Caridex • Caridex was developed by CM Habib from a formula made of N- mono -chloroglycine and amino butyric acid and was called as GK 101 E. • It gained FDA approval in 1984. • It was initially introduced on the US market in 1985. • The system involved the intermittent application of preheated N- monochloro-DL-2-aminobutyric acid (GK-101E) to the carious lesion. • The solution was claimed to cause disruption of collagen in the carious dentine, thus facilitating its removal. • The mechanism of softening involved chlorination of remaining partially degraded dentinal collagen and the conversion of hydroxyproline to pyrrole-2-carboxylic acid, which initiated disruption of the altered collagen fibers in the caries. Ref. pg. no. 387, Nikhil Marwah, 2nd edition
  65. 65.  Disadvantages- 1. Expensive 2. Large quantity required 3. Solution had to be heated 4. Short shelf-life 5. Hand instruments were not optimum Ref. pg. no. 387-388, Nikhil Marwah, 2nd edition
  66. 66. Carisolv • During the 1980s studies at the universities by Malmo, Huddinge at Chalmers Technical university in Goteborg was directed toward a more efficient and effective chemomechanical caries removal system than caridex. • Carisolv key difference to other products already in the market was the use of three amino acids – Lysine, leucine, and glutamic acid – instead of the aminobutyric acid. • These aminoacids counteracted the sodium hypochlorite aggressive behavior at the oral healthy tissues. • Despite its effectiveness, carisolv was not a blockbuster mainly because it required- 1. Extensive training and registration of professionals 2. Customized instruments which increased the cost of the solution. Ref. pg. no. 388, Nikhil Marwah, 2nd edition
  67. 67.  Constituents of carisolv • Syringe one: sodium hypochlorite (0.5%) • Syringe two: three amino acids (glutamic acid, leucine, lysine) • Gel substance: carboxymethlcellulose • Sodium chloride / sodium hydroxide • Saline solution coloring indicator (red) • Available as single mix or multi mix syringes. • New gel formulation Ref. pg. no. 388, Nikhil Marwah, 2nd edition
  68. 68. Indications of Carisolv • Where the preservation of tooth structure is important. • The removal of root / cervical caries. • The management of coronal caries with cavitation. • The removal of caries et the margins of crowns and bridge abutments. • The completion of tunnel preparations. • Where local anesthesia is contraindicated. • The care of caries in dentally anxious patients, notably needle phobic's. • Management of primary carious lesions in deciduous teeth. • Atraumatic restorative technique procedures. • Caries management in patients with special needs. Ref. pg. no. 38, Nikhil Marwah, 2nd edition
  69. 69. Cavity preparation using Carisolv Mix the two components of carisolv (NaOCl and amino acid solution) thoroughly according to the instructions included with the package. Put the required amount of gel into a suitable container. Use a carisolv instrument to pick up the gel and apply it to the carious dentine Soak the caries generously Wait for at least 30 seconds, for the chemical process to soften the caries Scraped off the superficial softened carious dentine. The hand instrument with the multistar tip may facilitate the early penetration of the gel. Work carefully using scraping or rotating movements Select a power drive tip or a Carisolv hand instrument to match the size, position and accessibility of the cavity
  70. 70. Keep the lesion soaked with the gel and continue scraping. 30 seconds of waiting time is needed Repeat until the gel no longer turns cloudy and the surface feels hard using the instrument Check extra carefully for caries at the dentinoenamel junction. If you are using a drill to adjust the periphery before filling, this can be done while the gel is still in the cavity When the cavity feels free from caries, remove the gel and wipe the cavity with a moistened cotton pellet or rinse it with lukewarm water, inspect and check it with a sharp probe If the cavity is not free from caries, apply new gel and continue scrapping If necessary the periphery of the cavity should be adjusted using hand instruments or the drill Restore the tooth with a suitable filling material according to the manufacturer’s instructions for use Remove the softened carious dentine with the instrument. Avoid flushing or drying the cavity
  71. 71. Advantages of Carisolv • Three amino acids are incorporated instead of one, and the different charges have improved the interaction with the degraded collagen within the lesion, thus increasing the efficacy. • Carisolv has a higher viscosity, which allows for the application of higher concentrations of amino acids and sodium hypochlorite without increasing the total amount of fluid used, therefore reducing the total volume required. • The solution does not need to be heated, or applied through a pump mechanism. • The increased viscosity of carisolv enhances precision placement. • The overall stability is increased, giving an improved shelf life.
  72. 72.  Procedure for using carisolv gel: 1. The gel is applied to the carious lesion with a hand instrument. 2. After 30 seconds, carious dentin is removed gently by scraping with a hand instrument. 3. More gel is then applied and the procedure repeated until no more carious dentin remains, a guide to this being, when the gel removed from the tooth is clear. Ref. pg. no. 492, S.G. Damle, 3rd edition
  73. 73. CARIDEX CARISOLV Chemical Composition Dye PH Physical properties Volume Needed Time Required 1% NaOCl 0.1 M aminobutyric acid Glycine NaCl and NaOH ---- 11 Liquid 100-500 ml 5-15 mins 0.5% NaOCl 0.1 M glutamic acid / luecine NaCl and NaOH Erythrocin (pink) 11 Gel 0.2-1.0 ml 5-15 mins Comparison of two systems for chemicomechanical removal of caries Ref. pg. no. 491-492, S.G. Damle, 3rd edition
  74. 74. Papain Gel • In 2003, a research project in Brazil led to the development of a new formula to universalize the use of chemo-mechanical method for caries removal and promote its use in public health. • The new formula was commercially known as papacarie. • It is basically composed of Papain, chloramines, toluidine blue, salts, thickening vehicle, which together are responsible for the papacarie’s bactericide, bacteriostatic and anti-inflammatory characteristics. • Papain comes from the latex of the leaves and fruits of the green adult papaya. Ref. pg. no. 394, Nikhil Marwah, 2nd edition PAPAIN GEL
  75. 75. • Carica papaya, is cultivated in tropical regions such as Brazil, India, South Africa, and Hawaii, and is largely used in the food, beverages, and drug industries. • Papain promotes: I. Chemical debridement II. Granulation and epithelialization, which hastens the phases of cicatrization III.Stimulation of the tensile strength of the scars. Ref. pg. no. 394, Nikhil Marwah, 2nd edition
  76. 76. Mechanism of action • Antitrypsin inhibits protein digestion but infected tissues do not usually show antitrypsin. • Since Papain can digest only dead cells, it acts breaking the partially degraded collagen molecules, contributing to the degradation and elimination of the fibrin “mantle” formed by the carious process. • Right after the degradation, oxygen is freed, bubbles appear on the surface, and a blearing of the gel is thus noted. • These signs demonstrate that the removal process can be started. Ref. pg. no. 394, Nikhil Marwah, 2nd edition
  77. 77. • For removal, we recommended the use of the opposite side of an excavator, like a pendulum movement and without cutting. • The instrument should scrap the carious tissue without promoting any kind of stimulus or pressure. • The main characteristics of the complete removal of the infected dentinal tissue is the vitreous aspect of the cavity which appears after using Papacarie. Ref. pg. no. 394, Nikhil Marwah, 2nd edition
  78. 78. Clinical procedure of Papain Gel Radiograph of the target tooth Prophylaxis of the region using rubber cup and slurry of pumice Rinsing with air/water spray or cotton pellet with water Isolation of target tooth Application of Papacarie, allowing the chemistry to work for 30 to 40 seconds Removal of the softened carious dentin using the opposite side of the excavator and promoting a pendulum movement; the softened tissue must be scraped, not cut Application of gel, if necessary Ref. pg. no. 394-395, Nikhil Marwah, 2nd edition
  79. 79. Rinsing 0.12%, 1% or 2% chlorhexidine or waterspray Drying with moisture-free and oil-free air Restoration with a suitable filling material according to manufacturer’s instructions The vitrous aspect of the cavity appears when the cavity feels free from caries Ref. pg. no. 394-395, Nikhil Marwah, 2nd edition
  80. 80. 1. Arrow indicating proximocclusal carious lesion 2. Isolation and application of Papain Gel 3. Caries had been removed 4. Arrow showing filled cavity with composite Clinical procedure of Papain Gel
  81. 81. Advantages of chemico-mechanical method • Its proven effectiveness • Method’s safety • Elimination of local anesthesia • Lower anxiety built in patients • Conservation of the sound tissue • Only demineralised dentine containing collagen is affected. • Gel consistency simplifies control of the application and reduces the risk of spillage. Ref. pg. no. 395, Nikhil Marwah, 2nd edition
  82. 82. References • TEXTBOOK OF PEDIATRIC DENTISTRY- 2nd EDITION - NIKHIL MARWAH • TEXTBOOK OF PEDODONTICS – 2nd EDITION - SHOBHA TANDON • TEXTBOOK OF PEDIATRIC DENTISTRY – 3rd EDITION – S.G. DAMLE • PRESERVATION AND RESTORATION OF TOOTH STRUCTURE – 2nd EDITION – GRAHAM J. MOUNT, W.R. HUME
  83. 83. THANKYOU

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