Minimally invasive dentistry

Recent concepts included

1. MINImALLY INVASIVE DENTISTRY Dr. Sucheta Prabhu Second Year MDS 9/11/17 1

2. Questions asked previously 100 marker Minimally invasive dentistry Use of lasers in pediatric practice Explain in detail on traditional cavity preparation in primary teeth with a short note on MID Recent advances on chemomechanical caries prevention Changing concept in cavity preparation 2

3. Questions asked previously Short essay MID ART Changing concept in cavity preparation in class 2 cavity design 3

4. Contents Introduction Definition Principles Recent Cavity classification Tunnel,slot cavity,proximal approach Air Abrasion Sonoabrasion Smart prep burs ART and ITR Chemomechanical caries removal Use of lasers 4

5. Introduction 5

6. Recent Cavity Classification Systems Size 0-4 6

7. International caries detection and assessment system 7

8. Definition 8

9. Factors 9

10. Principles of Minimal Intervention 1. Control the disease through reduction of cryogenic flora 2. Remineralize early lesions 3. Perform minimal intervention surgical procedures, as required 4. Repair, rather than replace, defective restorations Adopted by the FDI General Assembly, 1st October 2002, Vienna, (FDI Statement, 2002 10

11. Tunnel cavity preparation 11 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

12. Slot cavity prepartion 12

13. Proximal approach 13

14. Air abrasion for cavity preparation

15. Sonic abrasion 16

16. Controlled removal of caries with a self-limiting polymer bur Polymer caries removal burs. Metal shaft +polymer blades Only diseased dentin removed KHN 50 leaving healthy dentin intact.

17. Atraumatic restorative technique 20

18. History 21

19. History 22 ART was developed by Dr. Jo Frencken DDS, MSc, PhD, a dental researcher in the Netherlands.

20. Definition 23

21. Goals 24

22. Principles of art 2 main principles are 25

23. Reasons 26

24. Indications 27

25. contraindication 28

26. advantages 29

27. Procedure 30

28. Hygiene &infection control Universal precautions In a field situation, 31

29. Instruments & materials used 32

30. 33

31. Caries removal Isolate and inspect Excavate caries Remove soft caries Remove unsupported enamel 34 Particular care taken at enamel dentin junction And floor of deep cavities

32. conditioning 35

33. Dispensing and mixing 36 Mixing time 20-30seconds Restore using Finger press technique

34. Failed/defective restorations 37

35. limitations 38

36. What not to forget? Treating dental caries using the ART approach without emphasis on preventive measures is a job only half done. Important to explain to people how they can prevent dental caries from affecting other teeth . 1. Removal of plaque 2 . Diet counselling 3 . Application of fluorides 4 . Application of antimicrobial agents 5 . Application of sealants 39

37. Community field studies with art 40 1991 71% 1993 84% Over 25 countries worldwide

38. Comparison of art to conventional treatment The survival rate in ART treated surfaces after 6 years was 68.6% compared to 74.5% in conventionally treated surfaces; this difference was not statistically significant. Single surface>multi surface 41 A systematic review by Mickenautsch et al. concludes that ART can be used in both primary and the permanent dentitions

39. Art in the public services First reported in South Africa Mexico in National oral health programme in 1998. As per data in 2002, 810 dentists trained,2 million restorations placed with 88% success rate. 42

40. South Africa (Liberian Refugee Camp, 1997-99) 43

41. Turkey ( Anatolia,Bagivar ) performed in school children, farm worker's children living in tents or children working in cotton fields. 44

42. Interim therapeutic restoration Newer terminology for ART Developed in 2001. Utilises techniques similar to ART with different therapeutic goals AAPD policy on ITR revision 2017 45

43. Goal 46

44. Uses of itr 47

45. procedure 48

46. Indian health service ( ihs ) Promotes ITR IHS Early Childhood caries collaborative plan 5 year surveillance and prevention promotion project Lessens food impaction, sensitivity and lesion growth Helps maintain teeth with large lesions until crowns can be placed Fewer pulpal exposures Performed with minimal cooperation 49

47. conclusion ART is not only a restorative but also a preventive and palliative treatment,   performed not only by dentists but also by other operating dental personnel, such as dental therapists also it can be performed by person without any dental education background if given proper training. Their purpose was to bring health care to rural areas where urban- trained doctors would not settle . This increases the chance for better oral health in underserved communities in both developed and developing countries 50

48. Chemomechanical caries removal 51

49. Classified as 52

50. Gk-101 Introduced in 1976 Solution A- 0.05% N- monochloroglycerine Solution B-4-6% NaOCl Mechanism of Action: Chlorination of denatured collagen by conversion of hydroxyproline to pyrrole-2-carboxyglycine Limitation: Need special equipment for delivery. 53

51. GK-101e ( caridex ) Introduced in 1984, CM Habib Solution A- 0.05% N-monochloro-DL-2amino butyrate(NMAB) Solution B-4-6% NaOCl Mechanism of Action: Chlorination of denatured collagen+cleavage of denatured collagen fibres . Limitation: Need special equipment for delivery. 54

52. carisolv Original gel Before 2004 Syringe A : Carboxymethyl cellulose based gel , coloring agent, amino acids( glutamine,leucine,lysine ) Syringe B: 0.25% NaOCl Action is similar to caridex but amino acids react with different moieties of carious lesion. Higher viscosity, easier handling. Caries excavation time: 10.4-12.2 minutes 55

53. carisolv 56 Modified gel 2004 Multimix syringe Amino acid concentration halved NaOCl increased by 0.475% Caries excavation time:9.0-11.4minutes

54. New carisolv system 2013 Incorporation of minimally invasive burs( Cera-bur,polymer bur) Special detector dye Shortened caries excavation time Caries excavation time:7.6+/-4.2minutes 57

55. carisolv 58 Biologically no adverse effects Similar action to calcium hydroxide Promotes repair of pulp No adverse effect on dentin,preserves Ca:P ratio Special instruments to apply

56. 59

57. Enzyme based: Papacarie Portuguese word ”caries eater” 2003 Papain enzyme extracted from papaya leaf “ Carica papaya” Mechanism of action is unclear Exhibits shorter excavation time than carisolv 60

58. lasers 61

59. Caries prevention Reduces the carbonate to phosphorous ratio and leads to the formation of more stable and less acid soluble compounds, reducing susceptibility to acid attack and caries. . pH from 5.5 to 4.8 and the hard tooth structure is four times more resistance to acid dissolution. Flaitz CM et al., that the application of acidulated phosphate fluoride (1.23% gel for 4min) before or after argon laser exposure resulted in a significant reduction in lesion depth when compared with argon laser alone or other methods. Zezell DM et al., showing that treatment with APF solution after irradiation with a Nd:YAG laser caused a remarkable increase in acid resistance of the enamel. 62

60. Caries Removal Carious material contains a higher water content compared with surrounding healthy dental hard tissues. Consequently , the ablation efficiency of caries is greater than for healthy tissues. In an in-vitro study conducted by Bader C and Krejci investigating the effectiveness of caries removal by Er : YAG laser, it was found that the laser ablated carious dentin effectively with minimal thermal damage to the surrounding intact dentin. 63

61. Cavity Preparation Utilisation of the Er:YAG laser has been considered an effective instrument for cavity preparation and is able to cut as high-speed turbines, stimulate the secondary dentin and have an antibacterial effect. The radiation with Er:YAG laser may modify the dentin structure removes the smear layer of the dentin and exposes the dentinal tubules, which theoretically makes the surface more favorable to adhesion with the adhesive systems and consequently improving sealing of the restorations. According to Vissuri et al., and Groth et al ., it is able to provide acceptable microretention for adhesive materials, roughening the dentin as the acid-etching. 64

62. references . Marwah N. Textbook of pediatric dentistry.3 rd edn . Tandon S. Textbook of Pedodontics . 2 nd edn . Paras medical publishers 2009 Peter S. Essentials of Community Dentistry . 4 th edn . Studervant CM, Roberson TM, Heymann HO, Studervant JR. The Art and science of operative dentistry. 3rd ed. Mosby Co: 1995.p. 62-3 Freedman G, Pakroo JS. Polymer preparation persuades patients. Dental Town Magazine 2003;May:22–5 Strassler HE.Aunique approach for the treatment of caries using self-limiting caries removal instruments. Contemp Esthet Rest Pract 2003;7(3):66–8. 65

63. Thank you 66