Good morning
MINIMAL INVASIVE
DENTISTRY
Submitted by :Shyni kunhikrishnan
Guided by :Mahmood moothedath
Aseela ahmed
INDEX
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Introduction
History
Definition
Principles
Concepts
Techniques
MID in cosmetic dentistry
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Benefits of MID
Conclusion
INTRODUCTION
• MID is focusing mostly on cariology and
restorative dentistry
• The goal is to conserve healthy tooth structure
• Focused on remineralisation and minimal dentist
intervention using scientific advances
• Uses long lasting dental materials that conserve
maximum tooth structure so need for future
repair is reduced
• One of the major tenets of MID is caries
management by risk assessment(CAMBRA)
HISTORY
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Historical development in dentistry
Extraction
Surgical approach(drilling and filling):after
G. V black
Highly formalized cavity design
‘Extension for prevention’
Based on limited knowledge about
pathology and with limited available
material
MID medical approach
“The day is surely coming, and perhaps
within the lifetime of you young men
before me, when we will be engaged in
practicing preventive, rather than reparative,
dentistry. ”
- GV Black in 1896
MINIMAL INTERVENTION
DENTISTRY
• Defined as a philosophy of professional caries
concerned with first occurrence, earliest
detection and earliest possible cure of disease on
micro levels followed by minimal invasive and
patient friendly treatment inorder to repair
irreversible damage caused by such disease
• Includes many non surgical modalities
• Key concept is that caries is treated as infectious
disease
PRINCIPLES
Principles of MID are:
• Accurate caries diagnosis
• Classification of severity of caries
• Assessment of individual caries risk
• Reduces cariogenicity of bacteria
• Uses preventive mineralisation
• Early lesion remineralisation
• Minimal surgeries on cavities
Accurate caries diagnosis
Implies whether a lesion is active, progressing
rapidly or slowly or whether is already
arrested
 - CONVENTIONAL METHOD OF CARIES DETECTION
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Visual-tactile method
Radiography
Caries detecting dyes
Fibre optic transillumination
Electronic caries monitor
Visual method
• Detection of white spot,discolouration/frank
cavitation
• Magnification loupes-head worn prism loupes
or surgical microscopes can be used
• Use of temporary elective separation
Tactile method
• Explorers
• Dental floss
Radiography
• Carious lesion are detectable radiographically
when there has enough demineralization to
allow it to differentiate from normal
• Valuable in detecting proximal caries
• Radiographic examination include:
- bitewing radiograph
- IOPA
- dental panoramic radiograph
Xeroradiography
• Similar to photocopy machine
• Consist of aluminium plate coated with selenium
which provides an uniform electrostatic charge
• Very good edge enhancement
Digital imaging
• Image formed and represented by a spatially
distributed set of descrete sensors
• Image is formed in computer
Subtraction radiography
• Structured noise is reduced in order to increase
the detectability of changes on radiograph
• Structured noise refers to the information on the
radiograph which have not diagnostic value
• Contrast can be enhanced with colour aid
Computer image analysis
• Software have been developed for automated
procedures which are able to overcome the
short coming of human eye
Dyes for caries detection
They selectively complex with carious tooth
structure which is later disclosed with help of
fluorescence
• Dyes for enamel caries
protion,calcein,zyglo ZL-22,brilliant blue
• Dyes for dentin caries
1%acid red 52 in propylene glycol complexes
specifically with denatured collagen, hence used
to differentiate infected and affected dentin
• Iodine penetration method (pot iodine) for
evaluating permeability
Fibre optic transillumination
• Different index of light transmission for decayed
and sound tooth
• Decayed tooth has decreased index and appears
dark
• The tooth is illuminated by fibre optics
• FOTI can detect caries on all types of teeth and
also detect incipient caries and recurrent caries
before their visibility on radiograph
Electric measurement for caries
• Tooth demineralization due to caries process
causes increased porosity of tooth structure,
this porosity contain fluid, containing ions.This
leads increased electrical conductivity and
decreased electrical resistance or impedance
• ECM device uses fixed frequency
(23Hz)alternatively current which measure
‘bulk resistance’ of tooth
Electric measurement for caries
Recent advances in caries detection
• Research in last two decades lead to the
development of new technologies that
assess changes in fluorescence of enamel and
dentin due to loss of mineral
• Optical methods used are:
-Quantitative light induced fluorescence - QLF
-Infrared laser fluorescence - DIAGNODENT
QLF
DIAGNODENT
Newer classification of caries
Based on site and size of lesion
LOCATION
PIT/
FISSURE
1
CONTACT
AREA
2
CERVICAL
3
NO.CAVITY
MINIMAL
1
MODERATE ENLARGED
2
3
EXTENSIVE
4
1.0
1.1
1.2
1.3
1.4
2.0
2.1
2.2
2.3
2.4
3.0
3.1
3.2
3.3
3.4
Assessment of individual
caries risk
Risk factors
• Microflora
• Diet
• Tooth
Risk indicators
• Past disease experience
• Salivary flow
rate,PH,buffer
capacity,antimicrobial
effect
• Sociodemographic
factors
• Fluoride exposure
• Genetic make up
Microflora
prevalence and proportions of streptococcus mutans
in plaque are positively correlated with caries activity
 Diet
Poor oral hygiene and poor dietary habits-good
predictors of caries risk in preschool children
 Tooth
• Tooth size
• Tooth morphology and cusp and fissure pattern
Reduces cariogenicity of
bacteria
• Antimicrobial agent
Fluoride,chlorhexidine,xylitol
• Green tea extract
Rich in catechin,a class of oxidant, inhibits mutans
growth,kills oral bacteria
• Macelignan from nutmeg
• Barley tea
• Lollipop
Effective sugar free herbal lollipops are developed
to kill cavity forming bacteria
Early lesion remineralisation
• Factors promoting remineralisation
-PH>5.5
-Phosphate ion
-Calcium ion
-Fluoride
CONCEPTS IN MID
• Restoration of tooth become last treatment
decision rather than first consideration at
present
• The 3main concepts in MID are:
1. Identification
2. Prevention
3. control
Concept of identification
 Aimed at risk assessment and creating awareness
 It includes:
• Evaluation of saliva
• Evaluation of caries activity(caries activity test)
• Assessing the occlusion and tooth factor
• Understanding the patient environment such as
socioeconomic status education status etc.
• Health education
• Diet analysis and counseling
Concept of
prevention
1. Combating caries inducing microorganism
2. Modifying caries promoting ingredient of diet
and use of sugar substitutes
3. Increasing the resistance of teeth to decay
 Combating caries inducing microorganism can
be done by:
• Bisguanide antiseptic,chlorhexidine:
At high conc. act as detergent damaging
cell membrane,
Low conc. Inhibit sugar transport and glycolitic
rate
• Triclosan:non ionic agent against gram+ve
bacteria.hence used in dentifrice
• Delmophinol hydrochloride:highly surface active
substance,shown to reduce plaque formation
• Caries vaccine:Active or passive
immunisation,but it is less significant due
to involvement of bacteria and factors in
etiology of caries
• Replacement therapy:Cariogenic bacteria are replaced
by non cariogenic bacteria,practically difficult to achieve
• Blocking plaque build up:Studies are going on to produce
substance that inhibit glucosyl transferase, interfere with
adhesion and coaggregation of bacteria and an effective
antibacterial agent
 Modifying caries promoting ingredients in diet
• Addition of preservatives with enhanced antibacterial
activity
• Addition of natural demineralization inhibitors
• Increased consumption of protective food components
such as polyphenols in chocolates,oat hulls,cheese and
milk .calcium phosphate complexes of casien phoshate in
milk have anticaries activity
• Calcium phoshate can also be incorporated into
dentifrices and other fluoride containing dental products
 Increasing resistance to tooth decay
• Use of fluorides and pit and fissure sealants
• Remineralising agents like amorphous calcium phosphate
combination of tetracalcium phosphate and dicalcium
phosphate anhydrous
• Polymeric coating consisting of coating the tooth surface
with monomer and polymer
• Laser :alter the surface of enamel and increase its
resistance to acid challenge .CO2 laser is
absorbed by the tooth mineral and transformed into
heat and forms ceramic like surface highly resistant to
caries
• Augmenting host resistance:protective system in saliva
can be produced by recombinant DNA technology
Concept of control
 Aims at treatment of caries and maintanence of
restored tooth.treatment of caries is aimed at
removing only active caries and restored with an
adhesive restorative material. Continued professional
prophylaxis is important to maintain good condition
to reduce secondary caries
 Special means of caries control include:
• Ozone application:Interfere with the metabolism of
bacterial cell
• Preventive resin restoration
• Atraumatic restorative technique
TECHNIQUES IN MINIMAL
INVASIVE DENTISTRY
• Fluoride application
• Casien phosphopeptide and amorphous calcium
phosphate
• Sealants
• Antimicrobials
• Preventive restorative material
-GIC
-composite
• Repair of defective restoration
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ART(Atraumatic restorative treatment)
Carisolv
Bite splints
Inlays and onlays
Tunnel restoration slot and minibox preparation
Minimal cavity preparation technique
-Fissurotomy bur
-Air abrasion
-Laser abrasion
-Sono abrasion
-Chemomechanical method
-Smart prep
Fluoride delivery methods
• Topical fluoride
Placed directly on teeth
• Some preparation provide high concentration of
fluoride over a short period of time. Other
preparation, such as dentifrice provide continous
low concentration of fluoride to teeth
-Sodium fluoride
-Stannous fluoride
-Acidulated phosphate fluoride
-fluoride varnish
-Fluoride dentifrice
-Fluoride mouth rinse
Systemic fluoride
• Provides low concentration of
fluoride to the teeth over a long period of time
Water fluoridation
Milk fluoridation
Fluoride tablets/drops/lozenges
Salt fluoridation
 Casien phosphopeptide –Amorphous calcium phosphate
‘RECALDENT’ with technical name casien phosphopeptide –
Amorphous calcium phosphate or CPP-ACP is a milk derived
product that strengthens and remineralised teeth and helps
to prevent dental caries
• Deliver super charged calcium and phosphate ion to
enamel
• Work with fluoride tooth paste to strengthen enamel
Clinical application
Recaldent chewing gum
Tooth mousse/MI paste
CPP-ACP plus F(tooth mousse plus)
SEALANTS
• Sealant is thin plastic coat painted usually the
back tooth(premolar & molar) to prevent caries
• Plastic material binds to depression and groove
• Protect enamel from plaque and acid
• Types
1. Polyurethanes
2. Cyanoacrylates
3. Bisphenol A- glycidyl methacrylates (BIS-GMA)
PREVENTIVE RESIN RESTORATION
• Adhesive dental materials make it possible to
conserve tooth structure using minimally
invasive cavity preparations
• Several materials can be used:
- Glass ionomer cements, or GICs;
-Resin-based composite/dentin bonding agents
- Layered combination of resin-based
composites and GICs applied with a technique
called lamination.
REPAIR OF DEFECTIVE RESTORATION
• Removal of restoration result in an inevitable
increase in cavity size
• Depending on clinical judgement of dentist
,repair could be considered as an alternative to
replacement in some circumstances
• Cavity preparations Should ensure independent
retention and resistance form for the repair.
• Repair with a GIC may be preferable in cervical
areas, because of the potential for fluoride
release and GICs’ excellent adhesion.
ATRAUMATIC RESTORATIVE TREARMENT(ART)
• Indicates both prevention and treatment of
dental caries
• Two main principles of ART are:
1. Removing carious tooth tissue using hand
instruments only
2. Restoring the cavity with a restorative material
that sticks o the tooth
 Indication
• Small cavities (involving dentin)
• Caries that are accessible to hand instruments
• Public health programmes
 CONTRAINDICATION
• Swelling (abscess or fistula)near the carious tooth
• Tooth with exposed pulp
• Teeth have been painful for a long time &chronic
inflammation of pulp
• Carious cavity but opening is inaccessible to hand
instruments
 INSTRUMENTS AND MATERIALS ESSENTIAL FOR
ART
• Hand instruments used:
I. Mouth mirror
II. Explorers
III. Pair of tweezers
IV. Spoon excavators
-Hatchets
-Hoe & carvers
• Materials used:
-Cotton wool rolls&pellets
-Petroleum jelly
-Plastic strip :to shape restoration
-Wedges:to hold plastic strip
 ADVANTAGES
• Biological approach that require minimal cavity
preparation that conserves sound tooth
structure and produce less trauma
• As ART is painful the need local anesthesia is
reduced
• Simplifies infection control as hand instrument
can easily be cleaned
• No electrically driven and expensive dental
equipment needed which enables ART to practice
in remote areas
• This technique is simple enough to train nondental personnel or primary health care workers
• Coast effective
• Friendly procedure;great potential for its use
among children,fearful adults,physically
&mentally handicapped and the elderly
INLAYS & ONLAYS
• Inlay and onlay do not require to remove as
much as tooth structure
• Inlays are similar to filling except
that they are custom made to fit the
cavity in your tooth and are typically
the same colour as the tooth or gold coloured
• Onlay are used for more substantial
reconstruction
• When decay or fracture incorporate areas of a
tooth that make amalgam or composite
restorations inadequate, such as cuspal fracture
an onlay might be indicated
BITE SPLINTS
• Grinding or bruxism may cause serious damage
to teeth and may require need of crown
• Grinding often begins in teenage or early 20’s
,can be detected and corrected before damage
has been done
• Dentist can create bite splints to wear at night
or during stressful times when most teeth
grinding occurs
TUNNEL RESTORATION
• Designed with idea of preserving the marginal
ridge during posterior proximal restoration
Advantages
• Marginal ridge is maintained thereby
maintaining the strength of the tooth
• Contact area is usually not disturbed
• Risk of overhanging is minimal
Disadvantage
• Complete excavation of caries is not feasible
• Marginal adaptability of the restoration is poor
• Difficulty in insertion and finishing of the
restorative material
FISSUROTOMY BURS
Smaller burs for cavity preparation using MI
techniques. The burs are spherical,
tapered or elliptical. Examples include fissurotomy
burs and narrow diamond burs
Used with the aid of magnification, these allow very
precise preparation of teeth.
AIR ABRASION
• Used instead of traditional drill and may not
require anesthesis.Resembles microscopic sand
blasting and uses steam of air combined with
superfine abrasive powder
• It is a parallel stream of focused
narrow beam of 27 micron size of
aluminium oxide.
• When directed towards toothsurface it abrade
with out heat, vibration,and noise.
• Air abrasion conserve the tooth structure and
maintains the structural integrity of the tooth.
• Contraindicated in asthma ,dust allergy,and
periodontal disease
SONO ABRASION
• A recent development from the original
ultrasonics ,is the use of
high-frequency, sonic, air-scalers with modified
abrasive tips – a technique known as ‘sonoabrasion’
• This technique is based on the removal of tooth
material by an air-driven hand piece equipped
with a diamond-coated working tip that removes
tooth material by ultrasonic kinetic energy.
DIAMOND COATED HEMISPHERICAL CUTTING TIP
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LASER CAVITY PREPARATION
• Erbium: yttrium aluminum garnet lasers and
erbium,chromium:yttrium-scandiumgallium-garnet lasers are being used to cut
dental hard tissues.
• These lasers can remove soft caries,
as well as hard tissue
• Remove caries selectively while
maintaining healthy dentin and enamel.
• Used without anesthetic most of the time.
CHEMOMECHANICAL METHOD
• Involves the application of a chemical solution to
the infected carious dentine,selectively softening
the carious dentine by proteolysis, facilitating its
removal with mechanical hand instruments, and
without affecting sound non-carious dentine.
• The most efficient system available is Carisolv™
CARISOLV
• Method of gentle treatment of cavities
• Gel softens the caries & saves sound tooth
• Reduce or eliminates the need for drill & local
anesthetics
Procedure :
• Cover cavity with carisolv gel
• Wait for 30 seconds for carious dentin to soften
• Carefully scrape away softened caries
• Carisolv gel may be applied again and gentle
scrapping is repeated until the cavity is caries free
• Inspect and fill it like any cavity
Recommended in:
-cavities on root surface
-Deep cavities
-Children
-Patient with anxiety
-Whenever local anesthesia is not an option
SMARTPREP(SMARTBUR)
INSTRUMENT
• The SMARTPREP Instrument is a medical grade
polymer that safely and effectively remove decayed
dentin, leaving healthy dentin intact.
• The hardness of instrument is less than that of healthy
dentin and enamel but harder than carious dentin
• SELFLIMITING
The polymer instrument is self-limiting and will not cut
sound dentin unless applied with great force, and then it
will only wear away, rather than cut, the healthy dentin
• They are single-patient-use rotary instruments
• Used for deep caries removal in anticipation of an
indirect pulp capping procedure
MID IN COSMETIC
DENTISTRY
• Cosmetic procedure require extensive tooth
preparation can leave a patient with severly
compromised dentition with little room to
manoeuver if the desired outcome is not
achieved
• MI direct replacement technique require only
minimal tooth preparation
BENEFITS OF MID
• Better oral health through disease healing and
not merely symptom relief
• Further more minimal intervention may assist
in reducing widespread patient dental
anxieties
CONCLUSION
• Allows dentist to perform least amount of dentistry needed while
never remove more of tooth structure than is required to restore
the teeth to normal condition
• It use long lasting dental materials that conserve maximum tooth
structure
• MID gives better oral health through disease healing not merely
symptom relief
• It assist in reducing dental anxieties
• Cost effective compared to other treatment mode
• Cause less trauma to patient
• Although further research is needed it can so far concluded that
minimal invasive dentistry has the potential for dentist to apply a
more conservative approach to caries treatment and
simultaneously offer patient more friendly health oriented
treatment option
REFERENCE
• STURDEVANT’S ARTS AND SCIENCE OF
OPERATIVE DENTISTRY
• TEXT BOOK OF OPERATIVE DENTISTRY -VIMAL
SIKRI
• PRINCIPLES AND PRACTICE OF PEDODONTICS
–ARATHI RAO
• ESSENTIALS OF PREVENTIVE AND
COMMUNITY DENTISTRY-SOBEN PETER
• KENNEDY’S PAEDIATRIC OPERATIVE DENTISTRY