Post on 07-May-2015
description
Minimally Intervention Dentistry
Dr. Hakan Çolak
DDs, Phd
Ishık University School of Dentistry
Erbil city
INTRODUCTION
The “extension for prevention” approach to dental disease management, with GV Black’s tooth preparation
Buonocore described etching of enamel surfaces to make it retentive for a restoration.
In 1962, Bowen introduced Bis-GMA
INTRODUCTION
• Minimum (or minimal) intervention dentistry (MI) 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 minimally invasive and patient-friendly treatment to repair
irreversible damage caused by such disease
Introduction
Caries
Caries is an infectious microbial disease
INTRODUCTION
MinumumIntervention
Concept of MID
Concepts of minimally intervention dentistry (Tyas et al)
• Early caries diagnosis.
• Classification of caries depth and progression
• Assessment of individual caries risk (high, moderate,low)
• Reduction in cariogenic bacteria to eliminate the risk of further demineralization and cavitation and arresting of active lesions
• Remineralization of early lesions
• Minimal surgical intervention of caries lesions
• Repair rather than the replacement of defective restorations
• Assessing disease management outcomes at intervals.
EARLY DIAGNOSIS
• The goal of minimally intervention dentistry is to halt the disease first and then to restore lost structure and function. • an accurate diagnosis of the disease is mandatory.
• It is important to note that caries activity cannot be determined at one stage only, it has to be monitored over the time by taking radiographs and clinical checkups.
NEW CAVITY CLASSIFICATION BASED ONSITE AND SIZE OF LESION
Difference between caries classification given by GV black and G mount
GV Black classification MI classification of G Mount (1997)
Provision of specifications for preconceived preparation designs for amalgam.
Direct recommendation for appropriate treatment according to classification code
Preparation designs do not take extent of active caries nto various tooth tisssues
Considers both site as well as size of the carious lesion
NEW CAVITY CLASSIFICATION
• Firstly, lesions are classified according to their location:• Site 1: Pits and fissures • Site 2: Contact area between two teeth• Site 3: Cervical area in contact with gingival tissues
NEW CAVITY CLASSIFICATION
• Secondly, the classification identifies carious lesions according to various sizes:• 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 at least one cusp which is
undermined and which needs protection from occlusal load.• Size 4: Extensive decay with atleast one lost cusp or incisal edge
NEW CAVITY CLASSIFICATION
SiteMinimal Moderate Enlarged Extensive
Pit and Fissure1
1.1 1.2 1.3 1.4
Contact area2
2.1 2.1 2.2 2.3
Cervival3
3.1 3.2 3.3 3.4
Size
ASSESSMENT OF INDIVIDUAL CARIES RISK (HIGH, MODERATE,LOW)
Poor oral hygiene
Nonfluoridated toothpaste
Low frequency of tooth cleaning
Orthodontic treatment
Partial denture
History of multiple
restorationsFrequent
replacement of restorations
Medications causing
xerostomiaGastric reflux
Sugar containing medicationSjögren’s syndrome
Bottle feeding at nightEating
disorders Frequent intake of snacks
More intake of �sticky foods
Status of oral hygien
Low education status
PovertyNo fluoride supplement
Status of oral hygiene
Dental history Medical factors Behavioral factors
Socioeconomic factors
DECREASING THE RISK OF FURTHER DEMINERALIZATION AND ARRESTING ACTIVE LESION
REMINERALIZATION OF INITIAL LESIONS AND REDUCTION IN CARIOGENIC BACTERIA
REMINERALIZATION OF INITIAL LESIONS AND REDUCTION IN CARIOGENIC BACTERIA
Protective factorsSaliva and sealantsAntibacterialsFluorideEffective diet
Pathological factorsBacterial infectionAbsence of salivaFluorideDieatary habits
REMINERALIZATION OF INITIAL LESIONS AND REDUCTION IN CARIOGENIC BACTERIA
REMINERALIZATION OF INITIAL LESIONS AND REDUCTION IN CARIOGENIC BACTERIA
In the noncavitated lesion, one should always try to remineralize the tooth by
Decreasing the frequency of intake of refined carbohydratesFollowing plaque control measures Ensuring optimum salivary flow Patient educationApplication of chlorhexidine as an antimicrobial which acts by reducing the number of cariogenic bacteriaApplication of topical fluorides
REMINERALIZATION OF INITIAL LESIONS AND REDUCTION IN CARIOGENIC BACTERIA
REMINERALIZATION OF INITIAL LESIONS AND REDUCTION IN CARIOGENIC BACTERIA
• Commonly used agent for remineralization of teeth is fluorides, though some new materials have also been introduced in dentistry in an attempt to remineralize the teeth. These are:• Bioactive glasses—NovaMin• Recaldent (CPP-ACP).
Bioactive Glasses—NovaMin
• Introduced in 1969 by Hench.
• Contains calcium sodium phosphosilicate.
• Contact with water, NovaMin releases active calcium and phosphorus ions resulting in remineralization.
• Sodium present in NovaMin • increases the pH of oral cavity• enhances remineralization (precipitation of
crystals occur on teeth at pH ≥ 7)
• A minimum of 40 to 50 minutes of exposure time is required for remineralization to occur, so the person using NovaMin dentifrice should be refrained from rinsing, drinking or eating after tooth brushing
MINIMAL INTERVENTION OF CAVITATED LESIONS
Dental Materials Used for Minimally Invasive Treatment
Amalgam
Adhesive dental materials
Small cavities
Introduction of adhesive materials have played a major role in minimally intervention dentistry because they do not require the incorporation of mechanical retention features.
Glass Ionomer Cement
• Glass ionomer cement has various advantages like • chemical adhesion to tooth structure, • esthetics• anticariogenicity• rechargeable
Glass Ionomer Cement
Fluoride balance between glass ionomer and tooth.
A, Fluoride ions from a glass ionomer leach into the tooth.B, Fluoride in the restoration and tooth reach equilibrium. C, Saliva draws fluoride from the tooth and restoration. D, Bothtooth and restoration are depleted of fluoride. E, A topical application of fluoride recharges the cement.
Composites Resins
Effective bonding to enamel and dentin
micromechanical retention
Minimal cavities
Minimally Invasive Treatment Options for Cavitated Lesions
• Atraumatic restorative technique.
• Sandwich technique.
• Chemomechanical caries removal (CMCR).
• Pit and fissure sealants and preventive resin restorations.
• Tunnel, box and slot preparation.
• Tooth preparation using air abrasion.
• Tooth preparation using lasers.
Atraumatic Restorative Technique
• Atraumatic restorative technique (ART) was pioneered in mid-1980s in Zimbabwe and Tanzania in the need for basic treatment of carious teeth in communities with limited resources.
• In this excavation of caries is done using hand instruments and then tooth is restored using glass ionomer cement, an adhesive material
Sandwich Technique
• Given by McLean in 1985.
• Takes the advantage of the physical properties of both GIC and composite
• especially useful in situations when strength and pleasing esthetics are essential
Sandwich Technique
first the tooth is restored with GIC
because of its chemical adhesion to dentin and fluoride
release
Over it, composite resin is placed so as to have
better occlusal wear and esthetics
Chemomechanical Caries Removal
• Carisolv®• Well documented• Minimally-invasive, selective and precise• Minimises the need for the drill and
anaestheticsand enhances patient comfort
• Makes it possible to avoid drilling close to the pulp
• Carisolv® instruments with sharp yet blunt cutting angles help to protect healthy tissue
Chemomechanical Caries RemovalCarisolv® – the clinical procedure
1. The gel does not affect healthy dentine or softtissue. Nor does it affect enamel. Consequently Carisolv™ should be used in combination with thedrill or alternative techniques.
2. Drilling could preferably be used whenever thecavity needs to be opened up, for adjustment ofcavity periphery or whenever there are largeamounts of caries and when the risk to affecthealthy tissue is minimal.
3. Cover the cavity with gel and wait for 30 seconds until the carious dentine has been softened.
4. Softened caries can then be scraped away usingthe PowerDrive™ and/or the Carisolv® handinstruments.
5. Repeat steps three and four without waiting 30seconds, until the cavity is free from caries.
6. Inspect and fill as usual.
Pit and Fissure Sealants and Preventive Resin Restorations
• PRR utilizes the invasive and non invasive treatment of borderline or questionable caries.
• The resin placed in the carious areas and adjacent caries susceptible areas, seals them from the oral environment and provides a valuable treatment alternative to conventional restorations like amalgam
Pit and Fissure Sealants and Preventive Resin Restorations
That particular caries is restored and remaining pits and fissures are protected with sealants
PREVENTIVE RESIN RESTORATION
Tunnel, Box and Slot Preparation
• Tunnel preparations • if the lesion is more than 2.5 mm from the marginal ridge, a tunnel
preparation is indicated.• we preserve the marginal ridge and the proximal surface enamel
Tunnel, Box and Slot Preparation
• slot preparation • indicated for lesions which are less than 2.5 mm from the marginal
ridge• there is removal of the marginal ridge, but the preparation does not
include the occlusal pits and fissures if caries removal in these areas is not required
Tooth Preparations Using Air Abrasion
• Kinetic energy is used to remove carious lesion.
• Here powerful fine stream of moving aluminum oxide particles is directed against the surface to be removed.
• The abrasive particles hit the tooth with high velocity and a small amount of tooth structure is removed.
• Commonly used particle sizes are either 27 or 50 micrometers in diameter.
Tooth Preparations Using Air Abrasion
• The speed of the abrasive particles when they hit the target depends upon air pressure, size of particles, powder flow, nozzle diameter, the angle of the tip and the distance of tip from the tooth.
• Usually the distance from the tooth ranges from 0.5 to 2 millimeters. As the distance increases, the cutting efficiency decrease
• An added advantage is that tooth preparations achieved using air abrasion show rounded internal contours when compared with those prepared with a handpiece and straight burs.
Tooth Preparation Using Lasers
• Commonly used lasers for tooth preparation are • erbium: yttrium-aluminum-garnet lasers • erbium, chromium: yttrium-scandium-gallium-garnet lasers.
• These lasers can remove soft caries as well as hard tissue.
• Lasers have shown to remove caries selectively while leaving the sound enamel and dentin.
Tooth Preparation Using Lasers
• Advantages• can be used without application of
local anesthetics• no vibration,• little noise, • no smell • tooth preparation almost similar to
that prepared by using air abrasion technique
Management of caries using LASER
REPAIR INSTEAD OF REPLACEMENT OF THE RESTORATION
• When treating an old restoration, one should consider the following options before performing their replacement• Recontour and/or polish• Seal margins• Repair local defect• Replace restoration.
REPAIR INSTEAD OF REPLACEMENT OF THE RESTORATION
• Restoration is indicated for replacement when any of following occurs• Secondary caries which cannot be removed during repair procedure• Need for esthetics• Presence of pulpal pathology
The decision to repair rather than replace a restoration should be based on the patient’s risk of developing caries, the professional’s judgment of
advantages vs. risks and conservative principles of tooth preparation.
DISEASE CONTROL
• We know that dental caries is an infectious disease.
• Different efforts which must be made in order to decrease the incidence of caries include identification and monitoring of bacterias, diet analysis and modification, use of topical fluorides and antimicrobial agents.
• For caries control, caries vaccines and bacterial replacement therapy have also come up in the show
CONCLUSION
• Minimally intervention dentistry (MID) is the natural evolution of dentistry. As new materials and techniques are developed, dentistry is changed to make use of most conservative techniques.
CONCLUSION
• In general, the minimally intervention dentistry should fulfil following objectives of dental care which involve:• Categorizing the patients for risk of developing dental caries
depending upon existing oral health conditions. • Applying aggressive caries preventive measures like
implementation of fluoride therapy, antimicrobial therapy, diet modification and calcium supplementation to reduce the caries risk.
• Conservative use of intervention procedures.
Further reading
• Garg Nisha, Garg Amit, Textbook of Operative Dentistry, Jaypee Publishing
• James B. Summitt, Fundamentals of Operative Dentistry: A Contemporary Approach, Quintessence Pub