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Remineralization

  1. 1. MINIMAL INTERVENTION DENTISTRY MINIMUM INTERVENTION ART REMINERALISATION SMART BURS RECENT ADVANCES MAXIMUM INTERCEPTION
  2. 2. CONTENTS Introduction ART Remineralization Remineralizing agent Fluoride Newer enamel remineralizing systems Dispensing method Smart bur
  3. 3. Introduction Minimal Intervention Dentistry describes contemporary ultraconservative operative management of cavitated lesions requiring surgical intervention. It does not mean unduly early operative intervention of incipient lesions, which in most cases is unnecessary as more effective and appropriate non-invasive preventive approaches exist.
  4. 4. ATRAUMATIC RESTORATIVE TECHNIQUE(ART) ART is an innovative, largely painfree, minimal intervention approach for treating caries teeth, particularly in countries where highly trained dental personnel and the electricity needed for clinical equipment are not readily available or affordable 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. Developed in Tanzania in the mid- 1980s.ART is launched by the World Health Organization on 7th April, 1994 (world health day).
  5. 5. Principles of ART Removing carious tooth tissues using hand instruments only Restoring the cavity with a restorative material that sticks to the tooth.
  6. 6. Use of GIC in ART Properties such as fluoride release, chemical bonding to the tooth structure, biocompatibility and applicability in clinical situations, make them the most appropriate materials for the ART approach. Data suggest excellent results at a 1-year evaluation of ART restorations, where a survival rate of 93% was found for one-surface fillings. Evaluation after 2 and 3 years have been shown success rates of 89% and 85%. Med Principles Pract 2002;11(suppl 1):44–47
  7. 7. According to a study comparing the antibacterial activity of four glass ionomer cements used in ART Fuji IX demonstrate the greatest inhibitory activity for Streptococcus mutans while Ketac Molar and Fuji IX are statistically effective against Streptococcus sobrinus and Lactobacillus acidophilus. Ketac molar also has greatest inhibiting halo against Actinomyces viscosus • High strength conventional GIC Fuji IX and Ketac Molar present high P/L ratios that improve their mechanical properties for restorations in posterior teeth making these materials specially marked for ART J Mater Sci: Mater Med (2007) 18:1859– 1862
  8. 8. It was demonstrated that experimental GICs containing CHX are effective in inhibiting bacteria associated with caries, and incorporation of 1% CHX diacetate is optimal to give appropriate physical and bonding properties. RMGI exhibit better clinical performance than GIC in ART, except for marginal discoloration. RMGI can be an alternative material to the GIC. Med Princ Pract 2005;14:277–280 Dental Materials (2006) 22, 647–652
  9. 9. Composites The effective bonding of resin to enamel is a key factor in the selection of this material in MID In mechanical sense, the heavily filled resin-based composites with smaller filler particles can compete more or less with dental amalgam. Greatest features are their aesthetics and presumed ease of application.
  10. 10. 10 Main limitations are Micro-leakage, polymerization shrinkage and strength
  11. 11. • Although no ‘magic bullet’ to solve all problems related to dental caries ART is a combined preventive and curative oral care procedure which must be administered along with health promoting messages about a prudent diet , good oral hygiene, use of fluoride toothpaste and sealant application.
  12. 12. REMINERALIZATION Remineralization is defined as the process whereby calcium and phosphate ions are supplied from a source external to the tooth to promote ion deposition into crystal voids in demineralized enamel to produce net mineral gain Remineralization of dental lesions requires the presence of partially demineralized crystals that can grow to their original size when they are exposed to fluid that is supersaturated with respect to hydroxyapatite minerals. • Cochrane NJ, CaiF, Huq NL, Burrow MF, Reynolds EC. New approach to enhance remineralization of tooth enamel. J Dent Res 2010;89:1187-97.]
  13. 13. Dynamic process of demineralization and remineralization The oral cavity is a battle field of activities of demineralisation and remineralization. The ratio between two process is crucial in determining the hardness and strength of the tooth structure.
  14. 14. DEMINERALISATION
  15. 15. REMINERALISATION
  16. 16. Requirements for remineralization process….. In fact, for remineralization to proceed, six conditions or events must occur at the same time. Sufficient mineral must be present in the saliva The carbonic acid molecule must be produced in proximity to a mineral molecule, which it then dissolves into its ionic components. The carbonic acid must convert to carbon dioxide and water before any of the above circumstances change! That spot of the tooth has to be clean, so that the mineral-deficient spot is accessible. A molecule of carbonic acid must be produced This all has to occur in proximity to a demineralized spot in the hydroxyapatite latticework that requires that exact mineral ion. Int J Dent Case Reports 2011; 1(2): 73-84
  17. 17. REMINERALISING AGENTS Fluorides Calcium phosphate based Calcium Sucrose Phosphate Sugar Substitutes Hydroxyapatite
  18. 18. Requirements of an ideal remineralization material Diffuses into the subsurface or delivers calcium and phosphate into the subsurface Works at an acidic pH Does not deliver an excess of calcium Works in xerostomic patients Does not favour calculus formation Boosts the remineralizing properties of saliva. For novel materials, shows a benefit over fluoride
  19. 19. FLUORIDES The prevention of caries in children is at the forefront of public health strategies Fluoride is a major player in the slowing, arrest and even reversal of dental caries progression.
  20. 20. Mechanism by which fluoride increases caries resistance Increased enamel resistance , rate of maturation, surface energy Remineralization of incipient lesions Interference with microorganisms & Improved tooth morphology Int J Dent Case Reports 2011; 1(2): 73-84
  21. 21. Fluoride : Gateway to oral cavity Personal applications (eg, dentifrices, rinses) Professional applications (eg, varnishes, foams, gels, fluoride releasing restorative materials Fluoride levels of about 3 parts per million (ppm) in the enamel are required to shift the balance from net demineralization to net remineralization
  22. 22. COMMERCIALLY AVAILABLE FORMS OF FLUORIDE
  23. 23. Reasons to seek alternatives to fluorides Fluoride is highly effective on smooth-surface caries; its effect would seem to be more limited on pit and fissure caries Although fluoride presents no problems when used properly, among certain parts of the world, there has been the suggestion that fluoride exposure should be limited A high-fluoride strategy cannot be followed to avoid the potential for adverse effects (e.g., fluorosis) due to overexposure to fluoride
  24. 24. Newer Technologies for Enamel Remineralizing Systems Crystalline Calcium Phosphate Remineralizing Systems Unstabilized Amorphous Calcium Phosphate Systems Stabilized Amorphous Calcium Phosphate Systems Calcium-phosphate-based delivery systems containing high concentrations of calcium phosphate have been developed.
  25. 25. Crystalline Calcium Phosphate Remineralizing Systems Calcium phosphate can exist in one of numerous crystalline phases Problem :poor solubility of the calcium phosphate phases, such that the calcium and phosphate ions are unavailable for remineralization These crystalline calcium phosphate phases must be released from the product on contact with saliva and then dissolve in that fluid to liberate ions capable of diffusing into the enamel subsurface lesion.
  26. 26. Unstabilized Amorphous Calcium Phosphate Systems a calcium salt (e.g., calcium sulphate) and a phosphate salt (e.g. potassium phosphate) are delivered separately intra-orally or delivered in a product with a low water activity. As the salts mix with saliva, they dissolve, releasing calcium and phosphate ions. The mixing of calcium ions with phosphate ions to produce an ion activity product for amorphous calcium phosphate that exceeds its solubility product results in the immediate precipitation of ACP or, in the presence of fluoride ions, ACFP.
  27. 27. Stabilized Amorphous Calcium Phosphate Systems A biomimetic remineralization system Biological fluids containing high concentrations of calcium and phosphate ions contain inhibitory ions such as pyrophosphate and proteins to ensure stabilization. These stabilizing proteins include the caseins in milk and statherin in saliva.
  28. 28. Casein phosphopeptide amorphous calcium phosphate Technology (CPP-ACP). Uses casein phosphopeptides (CPP) to stabilise calcium and phosphate (and fluoride) ions at high concentrations as Amorphous nanocomplexes designated CPP amorphous calcium phosphate. Proposed mechanism: localisation and supply of calcium, phosphate and fluoride ions in the correct molar ratio at the tooth surface by the CPP to drive diffusion of the ions into the subsurface enamel. prevents their spontaneous transformation at the enamel surface. The increase in the concentration of the ions in the lesion fluid results in the formation of hydroxyapatite or fluorapatite via crystal growth. Caries Res 2008;42:88–97
  29. 29. 30 Recaldent - Dental chewing gum containing CPP-ACP. GC TOOTH MOUSSE - Dentifrice containing CPP-ACP.
  30. 30. EnamelonTM technology - Based on unstabilized ACP, where a calcium salt (e.g., calcium sulphate) and a phosphate salt (e.g., ammonium phosphate) are delivered separately intraorally. NovaMinTM technology - Based on Calcium Sodium Phosphosilicate Bioactive glass which is claimed to release calcium and phosphate ions intra-orally to help the self-repair process of teeth. Australian Dental Journal 2008; 53: 268–273
  31. 31. Clinpro Tooth CrèmeTM commercially available organically modified tricalcium phosphate which can coexist with fluoride in aqueous environment During brushing, this toothpaste contacts saliva and thereby calcium, phosphate and fluoride ions become readily available to tooth thus preventing demineralization International Journal of Pharm. Tech Research. 6(2), Apr-Jun 2014,487-493. ]
  32. 32. Anticay: calcium sucrose phosphate Mixture of calcium sucrose mono and diphosphate, disucrose monophosphate, Inorganic calcium phosphate (11% w/w calcium and 7.6% w/w inorganic phosphate) Products formulated with active ingredient Anticay: prevention of sensitivity; reduction in bleeding and gingivitis, whitening and erosion. enhancement of remineralization Chinese journal of dental research ,vol 17,no.1,2014
  33. 33. Hydroxyapatite Carbonate hydroxyapatite nanocrystals, having size, morphology, chemical composition, and crystallinity comparable to that of dentin Concentration of 10% nanohydroxyapatite is optimal for remineralization of early enamel caries They can effectively penetrate the dentin tubules and obturate them and can cause closure of the tubular openings of the dentin with plugs within 10 minutes as well as a regeneration of a surface mineral layer Biomed Mater. 2009;4(3):34104.
  34. 34. Dispensing methods Commonly used vehicles are dentifrices, pit- and-fissure sealants, chewing gums, rinses and restorative materials
  35. 35. Dentifrices One of the most practical methods for delivering remineralizing agents. Burwell and Muscle found that CPP- ACP provided sustained condition for remineralization when used in a dentifrice J Contemp Dent Pract. 2007;8(7):1-10.] Dentrifices
  36. 36. Pit and fissure sealant Available sealants are either resin-based or glass-ionomer-based. Since resin-based sealants do not provide fluoride release, glass- ionomer sealants are more effective for caries prevention. The addition of fluorides and CCP- ACP can further enhance remineralization Inside Dentistry.2009;5(4):78-80
  37. 37. Pastes Rinses and Dental Floss  . Pastes used for remineralization contain calcium- and phosphate realeasing components (eg, CCP-ACP) with or without fluoride. Commercial pastes containing CPP are designed for professional application as well as professionally supervised home application. They can be applied via prophy cup, custom tray, toothbrush, or fingertip. J Dent Hyg. 2008;82(2):19].
  38. 38. Chewing gums Numerous studies have demonstrated the caries-preventing qualities of frequent use of chewing gum sweetened by dietary sugar alcohols such as xylitol and sorbitol. Chewing gum, particularly sugar-free gum, may offer a valuable adjunct to a caries prevention and remineralization program. Chewing gums
  39. 39. In a trial, Manton et al showed that a sugar-free gum containing xylitol produces superior remineralization. [Int J Paediatr Dent. 2008;18(4):284-290.] Sorbitol is another sugar substitute that is used as an artificial sweetener. Isomalt is a noncariogenic sweetener that is widely used as a sugar substitute. Adding isomalt to a demineralizing solution has shown to significantly reduce tooth mineral loss. [Clin Oral Investig. 2008;12(2):173-177.]
  40. 40. Restorative materials Glass Ionomers Compomers Giomers
  41. 41. Glass ionomers Glass ionomer cement is a water based material that hardens following an acid base reaction between basic fluoroaluminosilicate glass and an aqueous solution of polyacids. Salivary fluoride concentration is found to remain elevated for up to 1 year after placement of GIC restorations (0.3 ppm after placement and 0.04 ppm 1 year later)
  42. 42. Certain studies reported a “burst” of fluoride release, with high early release for 1 to 2 days, followed by a rapid decline The fluoride release must be maintained to about 2 to 3 μg/mL/day for effective remineralization, and this can be achieved by fluoride recharge Am J. Dent, 13,2000, 201-204
  43. 43. Compomers Compomers contain polyacid- modified monomers with fluoride-releasing silicate glasses and are formulated without water. Used for restorations in low stress-bearing areas and for patients at medium risk of developing caries, or when using the sandwich technique Release fluoride by a mechanism similar to that of glass and hybrid ionomers but the amount of fluoride release and its duration are less than those of glass and hybrid ionomers. J Can Dent Assoc. 1999;65(9):500-504.
  44. 44. Giomers Anhydrous resin-based restoratives that utilizes prereacted glass ionomer technology (PRG).Incorporate fillers that are produced from the complete or partial reaction of ion-leachable glasses with polyalkenoic acid E.g. Beautifil (Shofu); Reactmer paste (Shofu). • J Am Dent Assoc. 2007;138(5):621-627. While giomer released fluoride, it did not have an initial “burst” type of release like glass ionomers. Their long term release of fluoride is lower than that of the other materials.
  45. 45. POLYMER BUR ( SMART BUR) One innovative approach for answering the lingering questions about precision caries removal is a new bur system (SS White SmartPrep™ Instrument). Smartprep instrument in a range of sizes (equivalent to round burs nos. 2, 4 and 6)
  46. 46. The Smartprep Instrument is used in a slow speed handpiece (500-800 rpm) to complete caries removal. Are single-patient-use rotary instruments. Carious tissue is removed with circular movements starting from the center to the periphery
  47. 47. DISADVANTAGES of POLYMER BUR or SMART BUR Polymer bur left large amount of decayed tissue unexcavated (underprepation) Technique sensitive (the Smart Prep can be readily defeated by the dumb operator). The burs disintegrate when they touch enamel or even sound dentin Potentially expensive.
  48. 48. With the progress in understanding the caries process, the MI Concept has evolved as a proposal for dentistry in the 21st century. .

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