Mid

MINIMALLY INVASIVE DENTISTR Y 1

CONTENTS • Definition • Concepts • Recent Cavity classification • Tunnel,slot cavity,proximal approach • Air Abrasion • Sonoabrasion • Smart prep burs • ART and ITR • Chemomechanical caries removal • Use of lasers

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DEFINITION A philosophy of professional care concerned with the first occurrence, early detection, and earliest possible cure of disease on micro levels, followed by minimally invasive, patient-friendly treatment to repair irreversible damage caused by such disease.

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CONCEPTS •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 4

FACTORS 1. The demineralization remineralization cycle

3. Biomimetic

2. Adhesion in

restorative

restorative

materials

dentistry

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RECENT CAVITY CLASSIFICATION SYSTEMS Site 1: Pits and fissures • Site 2: Contact area between two teeth • Site 3: Cervical area in contact with gingival tissues. 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. 6

INTERNATIONAL CARIES DETECTION AND ASSESSMENT SYSTEM

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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

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TUNNEL CAVITY PREPARATION 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

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SLOT CAVITY PREPARTION

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PROXIMAL APPROACH

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AIR ABRASION FOR CAVITY PREPARATION Introduced in 1945 by Robert Black

Only cuts hard tissue and decalcified enamel

Use of microabrasion eliminates the noise,odor, vibration, and negative psychologic connotation

Factors that influence the speed of cutting with air abrasion are the air pressure, powder flow, particle size of abrasive powder, nozzle diameter, and nozzle angle .

Major disadvantage of air abrasion technology is the debris created during the cavity preparation.

Particle size 20-30 micron.

60-120 lbs pressure

Set on pulsed mode with a 0.014-inch diameter nozzle.

Aluminum oxide air abrasion device was used to prepare the occlusal surfaces.

SONIC ABRASION High frequency airscalers with modified abrasive tips

Tips describe elliptical motion

Tips are diamond coated on the cutting side, cooled using water at a flow rate of 20-30 ml/min and operated by 305 bar air pressure..

Advantages- minimising noise, vibration, heat and pressure. Iatrogenic bur damage interproximally avoided.

Disadvantages- relatively low abrasion, cracks adjacent to the prepared sites. 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.

SMARTBUR (SS White Burs, Lakewood, New Jersey)

Smart burs in no. 2, no. 4, and no. 6, with an innovative flute design

The cutting surface of the instrument is made from a medical grade polymer that has a hardness less than that of healthy enamel and dentin but harder than that of carious dentin.

selectively removes carious tooth structure without removing or damaging healthy tooth structure.

Used at slow rotation rotary speeds of 500 to 800 rpm

light touch with a slow-speed handpiece and a latch contra-angle attachment.

ATRAUMATIC RESTORATIVE TECHNIQUE • Oral care in economically backward regions

WHO

Developed • Tanzania

• Minimal intervention • Maximal prevention

• 1980’s

Basi s

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HISTORY 2002: ART was adopted as one of examples of minimal 7th April 1994 : Official

invasive dentistry, by FDI at

adoption of ART by WHO

the annual meeting in

on “World Health Day”.

Vienna

1996: ART was being used in 25 countries

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

DEFINITION American Academy of Pediatric Dentistry “a dental caries treatment procedure involving the removal of soft, demineralized tooth tissue using hand instrument alone, followed by restoration of the tooth with an adhesive restorative material, routinely glass ionomer”

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GOALS Preservin g

the

tooth structure

Reducin g infection Avoiding discomfort.

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PRINCIPLES OF ART • 2 main principles are Restoring the Removing the

cavity with a

carious

restorative

lesions using

material that

hand

sticks to the

instruments.

tooth

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REASONS Hand intruments

GIC • Adhesive property

• Acessible to all patient groups.

• Fluoride release

• Use of a biological approach

• Biocompatible to oral tissues

• Low cost • Limited pain • Psychological benifit • Simplified infection control

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INDICATIONS Only in the small and shallow cavities (involving the dentine ) that are accessible to hand instruments. Very young children For patients with extreme fear/anxiety For the home-bound elderly and those living in nursing homes. For mentally and/or physically handicapped patients. In high-risk caries cases, as an intermediate treatment, to stabilize conditions

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CONTRAINDICATION

Presence of swelling (abscess) or

Pulp exposed

fistula

Chronic

Inaccessible to

inflammation of

hand

the pulp.

instruments

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ADVANTAGES Conservation of tooth structure.

Reduced discomfort

Simplified infection control.

Fluoride release property.

Low cost .

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PROCEDURE Arrange a good working environment

Outside the mouth

Operators position and posture

Assistant or working alone

Inside the mouth

Patient’s position

Operating light

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HYGIENE &INFECTION CONTROL • Universal precautions • In a field situation,

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INSTRUMENTS & MATERIALS USED

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CARIES REMOVAL • Isolate and inspect • Excavate caries • Remove soft caries • Remove unsupported enamel

Particular care taken at enamel dentin junction And floor of deep cavities

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CONDITIONING

10% solution of polyacrylic acid One drop on slab Dip tweezer , squeeze excess Clean cavity for 10-15 seconds

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DISPENSING AND MIXING Mixing time 2030seconds

Restore using Finger press technique 33

FAILED/DEFECTIVE RESTORATIONS Restoration is completely missing

Part of restoration broken chipped

or

away or

fractured

Restoration worn away

Caries developed in adjacent fissures or surface

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LIMITATIONS Long-term survival rates for glass-ionomer ART restorations and sealants are not available. Hand mixing might produce an improper mix .

Each step must be carried out to perfection.

Possibility exists for hand fatigue

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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

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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

A systematic review by Mickenautsch et al. concludes that ART can be used in both primary and the permanent dentitions 37

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.

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• South Africa (Liberian Refugee Camp, 1997-99)

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

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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

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GOAL

Controlling decay when other options are not feasible or until they become feasible.

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USES OF ITR Restore, arrest or prevent progress of caries in young patients, uncooperative patients, or patients with special health care needs. Can be used for stepwise caries excavation in children with multiple open lesions prior to definite restoration.

Reduces oral bacterial count for upto 6 months

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PROCEDURE Scoop out caries

Apply glass ionomer into cavitation

Seal all other grooves with glass ionomer

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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

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CHEMOMECHANICAL CARIES REMOVAL Principle

• Use a solution to chemically alter carious tooth to further soften it. • Softened dentin removed using hand instruments.

History

• 1970’s • EDTA, collagenase, sodium dodecyl sulfate.

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CLASSIFIED AS Agents

Sodium

Enzyme based

hypochloride based

GK-101E GK-101

Carisolv (Caridex)

Papacari e

Biosolv

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GK-101 • Introduced in 1976 • Solution A- 0.05% Nmonochloroglycerine • Solution B-4-6% NaOCl • Mechanism of Action: Chlorination of denatured collagen by conversion of hydroxyproline to pyrrole-2carboxyglycine • Limitation: Need special equipment for delivery. 48

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.

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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

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CARISOLV • Modified gel • 2004 • Multimix syringe • Amino acid concentration halved • NaOCl increased by 0.475% • Caries excavation time:9.0-11.4minutes

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NEW CARISOLV SYSTEM • 2013 • Incorporation of minimally invasive burs(Cerabur,polymer bur) • Special detector dye • Shortened caries excavation time • Caries excavation time:7.6+/4.2minutes

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CARISOLV • 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

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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

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LASERS

Er:YAG (λ 2940 nm)

Er-Cr:YSGG (λ

CO2

2780 nm)

(λ 10,600 nm)

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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.

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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.

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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. 59

REFERENCES • .Marwah N. Textbook of pediatric dentistry.3rd edn. • Tandon S. Textbook of Pedodontics. 2nd edn. Paras medical publishers 2009 • Peter S. Essentials of Community Dentistry . 4th 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.

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THANK YOU

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