JC MINIMALLY INVASIVE technique DENTISTRY.pptx

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1. MINIMAL INTERVENTION CARIES MANAGEMENT: A CASE REPORT Aditi bhajantri , Sophia thakur and rahul gupta INTERNATIONAL JOURNAL OF APPLIED DENTAL SCIENCES Presenter- S. Lipi Prakash

2. INTRODUCTION Dental caries is one of the most common chronic disease of modern times. If left untreated, caries may progress to tooth destruction and  exodontia . DEFINITION- It is an infectious, microbiologic disease of teeth that results in localized dissolution and destruction of the calcified tissues The deeper portions of carious dentin may generally exhibit two distinct areas: Infected dentin Affected dentin Sturdevant’s art and science of operative dentistry 5 th edition

3. INFECTED DENTIN MORE SUPERFICIAL LAYER OF CARIOUS DENTIN LIGHT BROWN IN COLOUR SOFT AND LEATHERY IN CONSISTENCY NOT SENSITIVE TO TOUCH COLLAGEN IS IRREVERSIBLY DENATURED HAS A HIGH CONCENTRATION OF BACTERIA NOT REMINERALIZABLE SHOULD BE REMOVED DEEPER LAYER DARK BROWN IN COLOUR HARD IN CONSISTENCY SENSITIVE TO TOUCH COLLAGEN IS REVERSIBLY DENATURED NO BACTERIA IS FOUND IN THIS ZONE CAPABLE OF REMINERALIZATION SHOULD BE RETAINED AFFECTED DENTIN Sturdevant’s art and science of operative dentistry 5 th edition

4. GREENE VARDIMAN BLACK – FATHER OF MODERN OPERATIVE DENTISTRY Extension for prevention (1891) was the hallmark of cavity design which has been revised and refined over the years Basic idea was to prevent the recurrence of dental decay by placing the margins of restorations along the lines that would be cleansed by the normal excursion of food Black's principles are still used as the basic steps in the process of designing and preparing a cavity for restoration Consists of seven principles designed mainly for amalgam and gold inlays G V BLACK CONCEPT Sturdevant’s art and science of operative dentistry 5 th edition

5. Treating deep cavities can be challenging for dentists, as it increases the risk of exposing the pulp. This makes the treatment outcome less predictable and may require additional procedures like indirect or direct pulp capping, pulpotomy , or even pulpectomy to manage the pulp's health. Minimal intervention dentistry (MID) is a dental practice that aims to preserve as much of the natural tooth structure as possible It focuses on the prevention of tooth decay and the management of carious lesions, and includes methods such as remineralization of early lesions, avoiding removal of excess tooth structure, and using strong, long-lasting materials Ramya raghu’s Clinical operative dentistry principles and practices 2 nd edition

6. In modern dentistry, preserving tooth structure and pulp health is a top priority. This approach emphasizes selective removal of decayed dentin, based on its consistency, rather than complete excavation. Outcomes of Partial and Complete Caries Excavation in Permanent Teeth: A 18 Month

7. Aditi bhajantri , Sophia thakur and rahul gupta MINIMAL INTERVENTION CARIES MANAGEMENT: A CASE REPORT

8. INTRODUCTION According to ESE (European Society of endodontology ) deep caries is defined as - Caries reaching the inner quarter of dentine, but with a zone of hard or firm dentine between the caries and the pulp, which is radiographically detectable when located on an interproximal or occlusal surface.

9. CARIES REMOVAL STRATEGY Different approaches have been used to manage tooth decay, with the main goal of halting its progression and preserving the health and function of the pulp. COMPLETE CARIES REMOVAL SELECTIVE REMOVAL OF CARIES STEPWISE CARIES REMOVAL

10. COMPLETE CARIES REMOVAL Also known as “ non selective excavation of caries ” Total excavation of caries that is contaminated with microorganisms and the demineralized tissue with the higher chances of pulpal exposure . With inadvertant pulpal exposure, alternative treatments are –Direct pulp capping - Pulpotomy Direct pulp capping - Involves placement of a medicament or material against direct pulpal exposure The success of DPC depends on- clinical techniques, the absence of microorganisms and their byproducts, and factors like bacterial contamination, size of exposure, bleeding control, and the choice of suitable pulp capping material.

11. Pulpotomy - This technique involves partial removal of the coronal portion of exposed pulp tissue in cases of carious exposures. It aims to evacuate biofilm and superficially inflamed pulp tissue, which may contain microorganisms, thereby promoting healing and repair of the pulp-dentin complex.

12. SELECTIVE REMOVAL OF CARIES It’s the most preferred method of caries removal which is of 2 types Selective removal to firm dentin - It is the most common preferred line of treatment in shallow to deep caries management Where the caries is extending 1/3 to ¼ of the dentine Caries excavation is done till there is a resistance to hand excavator leaving behind the leathery dentine while the peripheral dentin (cavity margins) are left hard (scratchy) after removal

13. 2.Selective removal to soft dentin It is recommended in deep cavitated lesions where caries is extending 1/3 to ¼ dentin and with the risk of pulp exposure. Soft carious tissue is left over the pulp to keep away from exposure and “stress” to the pulp, thereby promoting pulpal health, at the same time peripheral tooth and dentine are prepared to hard dentine, to achieve a fluid tight seal and placement of a long-lasting restoration. Selective removal to soft dentine reduces the chance of pulpal exposure considerably as compared with nonselective removal to hard or selective removal to firm dentin.

14. STEP WISE CARIES REMOVAL Indication for Stepwise Caries Removal: This method is recommended for teeth with reversible pulpitis , where radiographic evaluation shows that caries have not penetrated deeper than the pulpal quarter, and a zone of dentine still separates the carious lesion from the pulp chamber. Two-Step Excavation Process – First Step : Soft carious tissue is left over the pulp, while peripheral dentine is prepared to hard dentine. This allows for the formation of tertiary dentine, remineralization of demineralized dentine, and a reduction in viable bacteria. A temporary restoration is placed for 6-12 months, and the patient is recalled for evaluation.

15. Second Step- Selective removal to soft dentine is performed. This step carries a higher risk of pulpal exposure, increasing treatment costs and patient burden. Controversy and Considerations : The second step of stepwise caries removal is controversial due to its increased risk of pulpal exposure, higher treatment costs, and additional burden on the patient.

16. CASE REPORT -1 A 32 year old female patient reported to the Department of Conservative dentistry and Endodontics with a chief complaint of pain on eating on the lower right back tooth region since 15 days. On clinical examination, a class II caries lesion was seen on 46. Pulp sensibility test showed similar response to adjacent and contralateral tooth. On radiographic examination, radiolucency was seen extending upto the inner dentinal 1/4th with close proximity to the pulp. A diagnosis of reversible pulpitis was made . Treatment plan of partial caries excavation and composite restoration was made

17. Following oral prophylaxis, local anesthesia was given and rubber dam isolation was done. Caries was excavated using a slow speed bur, leaving a layer of leathery-to-soft dentin on the pulpal surface and a layer of hard dentin on the proximal walls. Cavity involvement was confirmed radiographically . A layer of RMGIC was applied on the pulpal surface as an indirect pulp capping agent . Acid etching and bonding agent application was done and the final restoration was completed by composite restoration and finishing and polishing was done.

18. 1.Challenges of Restoring Deep Carious Lesions- Restoring deep carious lesions can be challenging due to the risk of pulp exposure and the potential need for endodontic treatment, which can weaken the tooth structure and increase the likelihood of fractures. 2 . Benefits of Restoration- Prevents the progression of the carious lesion. - Facilitates plaque control. - Restores chewing function, mechanical strength, and tooth anatomy. - Prevents unwanted tooth movement. - Improves aesthetics. WAYS TO RECOVER AND OVERCOME CHALLENGES

19. 3 . Protection and Healing of the Pulp : Restorations shield the pulp, especially in deep cavities where the pulp has not yet been affected, allowing for the deposition of tertiary or reparative dentin. 4 . Importance of Restoration : Timely and appropriate restoration is crucial for maintaining tooth integrity, function, and aesthetics while protecting the pulp and preventing further complications.

20. High Risk of Pulpal Trauma : The density and organization of dentinal tubules, which are wider near the pulp, increase the risk of pulpal trauma from both the carious lesion and the application of restorative material. This risk is influenced by the remaining dentin thickness (RDT). 2. Rapid Development of Carious Lesions : Deep carious lesions, especially those lacking sclerotic dentin, can progress quickly. Bacterial metabolites in these lesions can cause subclinical inflammation. CHALLENGES IN RESTORING DEEP DENTINAL CARIES

21. 3 . Critical Considerations for Restorative Therapy : It's essential that restorative treatments do not further damage the pulp or compromise tooth structure. Careful consideration is needed to minimize additional pulpal trauma.

22. 1. Effective Sealing- The restoration must seal the lesion completely. For an adequate seal, cavity borders should terminate in sound dentin and enamel, as effective adhesion is only possible on a healthy tooth surface. 2. Durability and Longevity : The restoration should be as long-lasting as possible to prevent early failure and the need for replacements. Factors influencing longevity include the mechanical strength of the restorative material, the residual tooth structure, and restorative variables like sealing ability, surface smoothness, and buffering capacity. MAIN REQUIREMENTS FOR AN ADEQUATE RESTORATION

23. CRITICAL APPRAISAL ADVANTAGES Highlights modern approach to caries management, emphasizing tooth structure conservation and pulpal vitality Provides different techniques in the minimal intervention of deep caries management. Restoration protects the pulp, especially in deep cavities hence halting the progression of caries to pulp, allowing for preserving the vitality of the pulp by deposition of tertiary and reparative dentin

24. LIMITATIONS The title of the topic is misleading as the article is mainly focusing on minimal intervention of deep caries management The findings are based on single patient’s treatment, limiting generalizability No extensive follow-up data to assess the long term success of the intervention As a case report, it lacks the information to provide in materials being used and the techniques. It lacks the statistical analysis found in larger studies or RCTs No clear indication on the status of pulp Does not compare outcomes with traditional caries management approach Inspite of article being published in 2021 there is no mention regarding the usage of bioceramic materials.

25. CONCLUSION In conclusion, restoring deep carious lesions presents significant challenges due to the risk of pulpal exposure and rapid lesion progression. Suggesting selective caries excavation as an elective treatment option in management of deep carious lesions in everyday practice helps to maintain pulp vitality.

26. Randomized Trial of Partial vs. Stepwise Caries Removal: 3-year Follow-up Federal University of Rio Grande do Sul, Porto Alegre, RS, Brazil; and 2 Brasilia University, Brasilia, DF, Brazil SUPPORTING ARTICLE 1

27. This randomized, multicenter clinical trial evaluated the effectiveness of 2 treatments for deep caries lesions — partial caries removal (PCR) and stepwise excavation (SW) — with respect to the primary outcome of pulp vitality for a 3-year follow-up period. Inclusion criteria were as follows: Patients with permanent molars presenting deep caries lesions (lesion affecting ≥ 1/2 of the dentin on radiographic examination Positive response to a cold test Absence of spontaneous pain Negative sensitivity to percussion, and absence of periapical lesions (radiographic examination).

28. METHODOLOGY- Anesthesia and Isolation - Local anesthesia was administered. A rubber dam was used for isolation. 2. Lesion Access and Excavation Lesion accessed with a diamond bur. Complete excavation from cavity walls using dentin excavators or low-speed burs based on hardness-tactile sensation 3. Partial Carious Dentin Removal Disorganized dentin on the pulp wall removed using manual instruments 4. Cavity Cleaning and Drying Cavity washed with distilled water. Dried with sterile filter paper. 5. Randomization and Group Allocation Teeth randomized into test (PCR) and control (SW) groups.

29. Test Group (PCR) Treatment Reconstruction of surrounding walls and pulp lining with glass- ionomer cement (Vitro Fil ). Teeth filled with either composite resin ( Tetric EvoCeram ) or amalgam (GS-80).7. Control Group (SW) Treatment: Indirect pulp capping with calcium hydroxide cement ( Dycal ). Temporary filling with modified zinc oxide- eugenol cement (IRM).8. Follow-up Treatment Cavity re-opened after a median of 90 days (range: 60 to 150 days; mean: 120 ± 120 days). Remaining decayed dentin removed. Teeth restored permanently. Outcome success was evaluated by assessment of Pulp vitality, determined by PULP SENSITIVITY to a cold test and the ABSENCE OF PERIAPICAL LESION

30. DISCUSSION SW has been considered the most conservative treatment for asymptomatic teeth presenting deep caries lesions. In comparison with complete caries removal, SW leads to less pulp exposure and provides better outcomes with regard to preserving pulp sensitivity. The success rates for SW were 93% and 69% after 1- and 3-year follow-up, respectively. The completion of SW necessitates 2 sessions, adding costs and patient discomfort. Furthermore, patients may not return to complete the treatment, as observed in this study. Restorations in patients with uncompleted SW showed a very low survival rate

31. These results suggest that there is no need to re-open a cavity and perform a second excavation for pulp vitality to be preserved The survival rates of PCR in this study after 1 and 3 yrs were 98% and 91%, respectively In this study, a comparison between SW and PCR treatments showed statistically significant differences after 3 yrs. This difference could be explained by the high number of uncompleted SW treatments. Completed SW presented survival rates similar to those of PCR.

32. Outcomes of Partial and Complete Caries Excavation in Permanent Teeth: A 18 Month Clinical Study Monika Khokhar , Sanjay Tewari Department of Conservative Dentistry and Endodontics , Post Graduate Institute of Dental Sciences, Rohtak , Haryana, India SUPPORTING ARTICLE 2

33. AIM- The aim of this study was to compare the clinical and radiographic outcomes of partial and complete caries removal (CCR) in permanent teeth with deep carious lesions.

34. Materials and Methods: 143 patients of age group 14–54 years with mature permanent molars having deep carious lesions were divided into two groups: partial caries removal (PCR) and CCR. A layer of soft, wet carious dentin was left adjacent to pulpal wall in PCR group, Whereas in CCR group, complete infected caries was removed with the help of caries‑detector dye. Teeth were restored with composite resin ( Tetric N‑Ceram ; Ivoclar Vivadent ), with base of resin‑modified glass ionomer cement (RMGIC) and patients were recalled at 1, 3, 6, 12, and 18 months. Success was defined as absence of signs and symptoms of irreversible pulpitis (spontaneous pain, fistula, and swelling) and absence of periapical alterations ( radiolucency at furcal or periapical region).

35. DISCUSSION The findings of this study showed statistically significant difference in pulp exposure between partial and CCR with low proportion of exposure in PCR. The high clinical and radiographic success rate in PCR after 18 months suggests that PCR may be as effective as CCR in permanent teeth with additional advantage of reduction of pulp exposures. The higher success rate in PCR could be attributed to proper sealing, reduction of exogenous nutrient supply, and stabilization of remaining carious dentine by adhesive resin restoration. The protocol followed in this study was complete removal of carious tissue from cavity walls but limited removal from the pulpal floor and axial wall.

36. RMGIC was used as base due to less moisture sensitivity, higher shear bond strength to composites than conventional GIC. Randomization, less attrition of follow‑up, single operator, standardized treatment protocol, and histological evaluation of failured cases were the strengths of this study attributed to high level of evidence in this study. Major limitations of this study were that randomization was performed before caries excavation that may cause bias in the study. Results: Success rate in CCR group (98.21%) and the PCR group (92.53%) did not differ significantly Conclusion: PCR could be as an elective treatment option for the mature permanent teeth with deep carious lesions

37. SUPPORTING ARTICLE 3 Comparison of Partial and Complete Caries Excavation in Permanent Teeth: 24 Months Follow-up MOHAMMAD RAUF AHMED1 , SAIRA AASLAM2 , JAFFAR HUSSAIN BUKHARI3 1Assistant Professor of Operative Dentistry, Nishtar Institute of Dentistry Multan. 2Assistant Professor of Operative Dentistry, Nishtar Institute of Dentistry Multan. 3Assistant Professor of Dental Materials, Nishtar Institute of Dentistry Multan .

38. Objective: To compare performance and survival of composite restorations using partial caries removal (PCR) versus complete caries removal (CCR). Methodology: In this study, 70 permanent molars having deep caries lesions were selected and divided equally into CCR and PCR groups. In CCR group, complete dentin removal was done and confirmed by applying dentin detector dye for 10 seconds. In PCR group, visual & tactile criteria were followed for dentin removal. After dentin removal all cavities were filled using RMGIC cement resin. Follow-up was done at 06, 12 18 and 24 months

39. Results: At 24 months’ follow-up, success rate was 100% in CCR group and 93.3% in PCR group (p=0.49). Pulp exposure occurred in 23.3% procedures in CCR group and none in PCR group. Conclusion: Partial caries removal has nearly similar success rates as that of complete caries removal and is associated with significantly less pulp exposure rate as compared to CCR

40. CONCLUSION Dental procedures, now a days, are done more frequently using minimal invasive dentistry techniques, as these are associated with lower adverse complications than the invasive ones. There is also a shift in complete caries removal (CCR) to partial caries removal (PCR). PCR is associated with reduced pulp exposure and less interference with pulp vitality. It’s hypothesized that preservation of pulp vitality enhances local defenses, proprioception and reduce tooth sensitivity.

41. REFERENCES Randomized Trial of Partial vs. Stepwise Caries Removal: 3-year Follow-up M. Maltz , R. Garcia, J.J. Jardim , L.M. de Paula, P.M. Yamaguti , M.S. Moura , F. Garcia, C. Nascimento , A. Oliveira Outcomes of Partial and Complete Caries Excavation in Permanent Teeth: A 18 Month Clinical Study Monika Khokhar , Sanjay Tewari Department of Conservative Dentistry and Endodontics , Post Graduate Institute of Dental Sciences, Rohtak , Haryana, India Comparison of Partial and Complete Caries Excavation in Permanent Teeth: An 24 Months Follow-up MOHAMMAD RAUF AHMED1 , SAIRA AASLAM2 , JAFFAR HUSSAIN BUKHARI Sturdevant’s art and science of operative dentistry 5 th edition Ramya raghu’s Clinical operative dentistry principles and practices 2 nd edition Minimal intervention caries managemnt : a case report

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