Minimal intervention dentistry

A ppt on minimal intervention dentistry.

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. Minimal intervention dentistry describes a holistic, team care approach that aims to maintain long term health. Sir G.V. Black advocated the principle of “ Extension for prevention. Minimum intervention dentistry is the modern approach for management of caries. This approach starts with diagnosis & risk assessment to allow proper treatment decision. The current concept is- “ Prevention of extension “ rather than “Extension for 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 Early caries diagnosis Classification of caries depth & progression Assessment of individual caries risk. Reduction in cariogenic bacteria to eliminate the risk of further demineralization. Remineralization of early lesions. Minimal surgical intervention of caries Repair rather than replacement of defective restorations, Assessing disease management outcomes at regular intervals.

6. EARLY CARIES DIAGNOSIS

7. EARLY DIAGNOSIS

8. METHODS OF DIAGNOSIS Visual tactile methods Radiographic methods Caries activity tests 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. Visual Tactile 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 SL Agar 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 BASED ON SITE & 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. G V BLACK’S CLASSIFICATION

21. GV BLACK Vs GJ MOUNT G V 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 OF CARIES 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

26. DECREASING THE RISK OF FURTHER DEMINERALIZATION & ARRESTING ACTIVE 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. DECREASING THE RISK OF DEMINERALIZATION REMINERALIZATION ANTIMICROBIAL AGENTS SALIVA REMINERALIZING AGENTS HEALTHY DIET DEMINERALIZATION POOR DIETARY HABITS SALIVARY DYSFUNCTION TOOTH DEFECTS BACTERIA

28. DECREASING THE RISK OF DEMINERALIZATION

29. DECREASING THE RISK OF DEMINERALIZATION ROLE OF DIET

30. DECREASING THE RISK OF 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

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

34. INDICATIONS

35. IDEAL REQUIREMENTS

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.

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 contains Calcium sodium Phosphosilicate . Mechanism of action-

41. CPP-ACP CPP ACP is an acronym for a complex of casein phosphopeptides & Amorphous calcium phosphate. Casein is a part of group of peptides that naturally occur in milk. In normal state , Calcium phosphate forms crystalline structure 7 becomes insoluble CPP keeps calcium 7 phosphorus in ionic form which 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. When TCP comes in contact with saliva, the protective barrier breaks down making Ca, 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 precipitated ACP 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.

45. NATURAL REMINERALIZING AGENTS Gum Arabic Grape seed extract

46. NANOHYDROXYAPATITE 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 New York. Contains Arginine 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 OF CAVITATED LESIONS

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 1/8 th to 1/10 th the intercuspal distance. It can be later restored with flowable composite.

53. CHEMOMECHANICAL CARIES REMOVAL 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. AIR ABRASION 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. LASER TOOTH PREPARATION

59. TOOTH PREPARATION BY OZONE 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 INSTEAD OF 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.

61. DISEASE CONTROL Dental caries is an infectious disease & efforts should be made in order to decrease the incidence of disease.

62. DISEASE CONTROL VITAL PULP THERAPY For minimal intervention of cavitated lesions, Vital pulp therapy is indicated. It involves stepwise remineralization using biocompatible dental materials. VITAL PULP THERAPY 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 Mineral Trioxide 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 (SO 3 ), phosphorous pentoxide (P 2 O 5 ), and silicon dioxide (SiO 2 ). 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 in Tanzania. 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 Nisha Garg Pubmed.NCBI.NLM British Dental journal Nikhil Marwah textbook of pediatric dentistry.

67. THANK YOU !