1

MINIMAL
INTERVENTION
DENTISTRY –
PART 2
2
TABLE OF CONTENTS - 1
• Introduction

• History

• Differences between Minimal intervention, Minimal invasive and

Micro dentistry.

• Background

• Rationale of MID

• Goals & objectives of MID

1. Early caries detection 3

2. Caries risk assessment.

 TABLE OF CONTENTS:
3.Classification of caries depth and progression

4.Remineralisation of demineralized enamel and dentin

5.Optimal caries preventive measures

6.Different Minimally invasive procedures

8.Repair rather than replacement.

• Conclusion
4

• References
 GOALS OF MINIMAL
INTERVENTION :

Early caries detection

Risk assessment at individual level

Classification of caries depth & progression

Remineralisation of demineralised enamel and
dentine
Optimal caries preventive measures; .

Minimally invasive operative interventions

5
Repair rather than replacement.
CLASSIFICATION OF CARIES
DEPTH & PROGRESSION

6
RADIOGRAPHIC EVALUATION OF
PROXIMAL CARIES
The radiographic changes in proximal lesions can be
assessed on the following classification given by Ben and
Dankel et al.

E1 = Radiolucency in outer 1/2 of enamel

E2 = Radiolucency in inner 1/2 of enamel
D1 = Radiolucency in outer 1/3 of dentin
D2 = Radiolucency in middle 1/3 of dentin
D3 = Radiolucency in inner 1/3 of dentin
7
 REMINERALIZATION OF
DEMINERALIZED DENTIN AND
ENAMEL
• Dental caries is a complex process of cyclical enamel de-
and re-mineralisation.

• Streptococcus mutans and Streptococcus sobrinus are

two putatively important bacteria in the initiation of
enamel demineralisation, with Lactobacillus caseii
assuming greater importance after initial progression of
the carious lesion.

• This is Loesche’s so-called ‘specific plaque hypothesis’. 8

 PATHOLOGIC FACTORS:
PROTECTIVE FACTORS :
• Acid producing bacteria
• Frequent intake of fermentable • Saliva flow and components
carbohydrates • Fluoride : remineralisation with
• Subnormal saliva flow and calcium and phosphate
function • Antibacterial : chlorhexidine, xylitol
and others

CARIES NO CARIES
Featherstone JD, Doméjean S. Minimal intervention dentistry: part 1. From 9
'compulsive' restorative dentistry to rational therapeutic strategies. Br Dent J.
2012;213(9):441‐445.
• In the noncavitated lesion, to take advantage of the
tooth’s capacity to remineralise, one must first alter the
oral environment to tip the balance in favour of
remineralisation and away from demineralization.

• This approach includes:

 Decreasing the frequency of intake of refined

carbohydrate;
 Ensuring optimum plaque control;
 Ensuring optimum salivary flow;
 Conducting patient education.
10
 MECHANISM OF ACTION OF
FLUORIDE:
Fluoride – incorporation into the crystalline structure of
carbonated hydroxyapetite.

crystal solubility , increases the precipitation of enamel mineral

Fluoride ion is
more stable than Interacts with the
hydrogen ion crystal surface, closely
and binds strongly.
11
 ROLE OF CALCIUM AND
PHOSPHATE:
• The effectiveness of fluoride to remineralise enamel and
obtain net mineral gain is limited by the bio-availability of
calcium and phosphate ions.

• If the acid challenge to the enamel is extensive, the salivary

calcium and phosphate reservoir is quickly depleted and a net
loss of enamel mineral can occur.

FRENCKEN et.al :sources

Intrinsic calciumofand phosphate
calcium is fundamental to
and phosphate:
improving the effectiveness
saliva, dissolved of theand
tooth mineral agent.
to aIncreased calcium
lesser degree,
and phosphate cangingival
be stabilised by macromolecules
crevicular fluid. inherent 12
in the saliva and plaque.
 OPTIMAL CARIES PREVENTIVE
MEASURES.
• Diet counselling and sugar substitues

• Fluoridated agents

• Chlorhexidine containing agents

• Silver diamine fluoride

• Infiltration methods
13
• Pit and fissure sealants.
Frencken JE, Peters MC, Manton DJ , Leal SC, GordanVV, Eden E. Minimal 14
intervention dentistry for managing dental caries – a review : Report of a FDI task
group.Int Dent J. 2012 oct; 62(5): 223-43.
 BASIC APPROACHES TO MINIMAL
INVASIVE DENTISTRY

MINIMAL
invasive
dentitsry

Operative Nonoperative

Conservative Modalities of
tooth caries Ozone therapy Resin infiltration
preparation excavation

15
 A. ATRAUMATIC RESTORATIVE
TREATMENT
• It is a procedure based on removing carious tissues using
hand instruments alone and restoring the cavity with
adhesive material.

HISTORY :
• In 2001, AAPD adopted the policy on ART referring it to
as “ Alternative restorative treatment ‘.
A Group in Zimbabwe and another in Thailand began
experimenting to check longevity and efficiency. .Their
• Bacterial eliminated – further ingress prevented –
results were so encouraging that the system has been
healing .
adopted by WHO and is being promoted worldwide as
a useful technique for communities that lack regular
ddental facilities. 16
Utilized :
• Routine procedure in dental clinic

• In cases of ECC

• As a restoration and an interim preventive procedure

• In uncooperative, apprehensive and nervous patients.

• Field practice in conjunction with portable dental units.

• In school and community dental health programmes.

17
Indications :
• Clinically detectable caries involving dentin
• Cavity on tooth surface accessible to hand instruments

Contraindications :
• Clinical or radiographic evidence of exposure of tooth pulp
• Presence of abscess or fistula near the carious tooth
• History of tooth pain suggesting chronic inflammation of pulp
• Obvious carious cavity but the opening is inaccessible to hand
instruments. 18
STEPS TO BE FOLLOWED.

ISOLATION

CARIES REMOVAL

PULPAL PROTECTION

CONDITIONING OF CAVITY

MIXING OF GLASS IONOMER 19

CEMENT
ADVANTAGES :
Easily available, inexpensive hand instrumentation painless
procedure.

Involves the removal of only decalcified tooth

Sound tooth structure need not be cut for retention of filling

material

A practice of straight forward and simple infection control.

Enable oral health care workers to reach people who

20
otherwise never would have received the treatment.
DISADVANTAGES :
• The average life is expected to be 2 years

• Fundamental principles of cavity preparation are not followed

• Use is limited to small and medium sized one surface cavity

only.
REASONS FOR USE OF GIC :
Chemically bonds to both enamel and dentin
• Continuous use of hand instruments lead to hand fatigue
Fluoride is released – reduces secondary caries
• A relatively unstandardized mix of gic may be produced due to
GIC – biocompatable, has thermal coefffieceint equal to tooth.
hand mixing.
21
B. PREVENTIVE RESIN RESTORATION.

• PRR – natural extension of the use of occlusal sealants.

• Integrates the preventive approach of the sealant therapy for

caries susceptible pit and fissure with therapeutic restoration
of incipient caries with composite resin that occur on the
same occlusal surface.

• Are the conservative answer for the conventional “ extension

for prevention “ philosophy of class 1 amalgam restorations.

22
 TYPES OF CARIOUS SURFACES
TREATED:
• GROUP A : DEEP PIT AND FISSURES SUSCEPTIBLE TO CARIES.

• GROUP B: MINIMAL EXPLORATORY CARIOUS LESIONS.

• GROUP 3: ISOLATED CARIOUS LESIONS.

23
TECHNIQUE OF PLACEMENT
• Placement of PRR utilizes principles of acid etch technique
similar to those of sealant placement with the exception of
caries removal from isolated pits and fissures.

Clinical perspective;
• PRR has shown to improve the long term health of the teeth.
Materials like GIC have been tried as ‘glass ionomer rest a seal’
to incorporate their various advantages, which are :
• Fluoride release benefits,
• True adhesion to enamel and dentin 24
ADVANTAGES OF PRR:
• Minimal cavity preparation is required, thus preventing
unnecessary removal of healthy tooth structure.

• Seals caries , thereby halting the destruction of tooth.

Eg: teeth with pit and fissure, dens evaginatus

• Loss of restoration and subsequent replacement

proves to be less invasive than for conventional
restoration like amalgam.

DIFFERENCE BETWEEN CONVENTIONAL AND PRR TECHNIQUE 25

C. DESIGNING FOR PROXIMAL LESIONS
• Plaque accumulates readily below the contact area
between any two teeth.

• In the absence of good plaque control and regulation of

refined carbohydrate intake, the pH interproximally will
fluctuate frequently to levels below pH 5.5 and regular
attacks of demineralization may occur.

• In the absence of cavitation there is always a chance that

the lesion can heal through remineralization.

26
 (I) TUNNEL CAVITY PREPARATION:
• First reported – 1960; for restoring distal proximal caries of a
primary second molar, accessing caries beneath the marginal
ridge & thus leaving it intact.

• 1980s – it was reintroduced with the use of GIC.

27
TYPES OF TUNNEL PREPARATIONS:

• INTERNAL TUNNEL PREPARATION : does not involve the

proximal enamel.

• PARTIAL TUNNEL PREPARATION : extends to proximal surface

into the cavitation or where enamel disintegrated during
cavity preparation, leaving some demineralized enamel
adjacent to the filling.
proximal enamel – slightly or not perforated.

• TOTAL TUNNEL : Involves the complete removal of

demineralized enamel – proximal area perforated.
28
FEATURES IN TUNNEL PREPARATION :
• 2.5mm marginal ridge has to be conserved.

• The cavity design should start 2.5mm from the buccal

marginal ridge with ovoid access extending buccolingually,
parallel to marginal ridge along the central fissure.

• Access to the lesion through the occlusal surface should be

limited to the extent required to achieve visibility and should
be undertaken from an area that is not under he occlusal load.

• Fossa immediately next to the mesial marginal ridge is the

most suitable position for entry.
29
TECHNIQUE OF PREPARATION

30
 RESTORATIVE MATERIALS FOR
TUNNEL PREPARATION
GLASS IONOMER CEMENT :
Bonds to enamel and dentin – material of choice.
Strength may not be enough to withstand the occlusal biting
force.

FACTORS AFFECTING THE CLINICAL SUCCES:

COMPOSITE RESIN :
Offers better strength
Materialinselected
comparision
for to gic.
restoration
Also bonds with enamel
Amount ofand dentin.ridge retained
marginal
Caries activity of the patient
SILVER AMALGAM : Can also be used as it offers good strength
and easy to handle/.
31
 ADVANTAGES & DISADVANTAGES:
ADVANTAGES : DISADVANTAGES:

• Preservation of • Highly technique sensitive

marginal ridge • Danger of pulpal
• Normal contact area is involvement
not normally disturbed • Uncertain – caries removal
• Less potential for • Risk of marginal ridge
microleakage fracture
• Esthetic • Chances of leakage & sec
• Risk of overhanging is caries are high 32
minimal • Marginal adaptability of
restoration is poor
(II) SLOT CAVITY/MINI BOX PREPARATION:

• It is creation of small slot on the proximal aspect of posterior

teeth.

• Indicated if there is a small lesion involving the area of or

below the marginal ridge only in deciduous teeth.

• Outline form will be dictated entirely by the extent of the

breakdown of the enamel, removing only that which is easily
friable and easily eliminated without applying undue pressure.

33
 D. HALL TECHNIQUE :
• Another minimally invasive restorative therapy introduced
especially for deciduous teeth that may be helpful in reducing
the the treatment burden of cavitated lesions in dentine.

34
 E. SANDWICH TECHNIQUE:
• It was developed by McClean et.al – 1985.

• Replacemnt dentine technique/ bilayered technique /

Laminate restoration technique.

GIC : COMPOSITE:
Anticariogenicity, Enamel bonding ,
chemical adhesion good surface
,fluoride release, finish
reduced durability &
microleakage, esthetic
remineralisation superiority. 35
 MODALITIES OF CARIES EXCAVATION FOR
MANAGING CAVITATED DENTINE CARIOUS
LESIONS:
MECHANICAL BURS
HAND INSTRUMENTS

CHEMO MECHANICAL Sodium hypochlorite based agents

Pepsin based caries excavation

SONIC Sono abrasion

KINETIC Air abrasion

HYDROKINETIC Laser 36
 EXCAVATION BY BURS:
1.SMART BURS:
• Goal of MID : Remove caries infected & preserve caries
affected.

37
 • Instead of metal body and cutting blades, these burs
have a metal shaft and polymer blades.
Knoops Hardness
Number(KHN)
Disease dentin 0-30
Healthy dentin 70-90
Enamel 360-430
Polymer blades 50

Therefore only diseased dentin will be removed, leaving a healthy

tooth structure that will effectively resist the action of a polymer
cutting instrument.

38
Dr. Luxmi Chopra, Dr. Seema Thakur, Dr. Parul Singhal, 2018. “Minimal intervention
dentistry for children with latest advancements”, International Journal of
Development Research, 8, (06) .
INDICATIONS : Excavation of soft carious lesions in symptom free
primary and permanent teeth.

LIMITATIONS :

Polymer bur can leave some amount of decayed tissue.

The burs disintegrate when it comes in contact with sound

dentin so sometimes a large bur is required for adequate
removal of carious dentin.

39
2. MICRODIAMOND PREP SYSTEM :

For conservative cavity preparations, Microprep diamond burs

have ben introduced recently.

They are designed with small abrasive heads to facilitate

conservative tooth preparation and longer necks to enhance
vision and control.

These are ideal for minimally invasive and microscope assisted

dentistry.

40
41
3. FISSUROTOMY BURS:

These burs are scientifically developed for the treatment of

hidden caries.

Increase use of fluoride sometimes result in hidden caries

which is difficult to detect clinically.

Fissurotomy burs with the help of magnifying loops allows

precise tooth preparation.

42
Conventional vs Fissuorotmy bur.
43
 CHEMOMECHANICAL CARIES
REMOVAL
• Is a non-invasive technique of caries removal by dissolution.

• Developed to overcome the barriers

Applicationof
of conventional
chemical agent
technique on carious dentin

Removal of soft
carious tissue

Restoration with
adhesve
materials. 44
CLASSIFICATION OF CHEMOMECHANICAL
AGENTS:
S ED
BA
ED E
A S ZyM
B
CL Depend on NAOCL EN
O ER
NA derivatives H
OT
chlorinate and disrupt
hydrogen bonds of partially
PAPIECARE
degraded collagen in carious
dentine
BIOSOLV
GK101
GK101E ( CARIDEX )
CARIOSOLV

45

Hamama H, Yiu C, Burrow M. Current update of chemomechanical caries

removal methods. Aust Dent J. 2014;59(4):446‐525.
1.GK101: GK-101 consisted of
0.05% N-
• 1976 – GOLDMANN & KROMANN monochloroglycine
(NMG) and NaOCl, and
was prepared by mixing
GK-101 required a special delivery system: two solutions.

1. A reservoir (for warming the freshly prepared solution

25 mLto 41 °C)
each
of 2M NaCl,
10 mL of 4–
2M NaOH GK101
6% NaOCl
2.andA2Mpump
(similar in shape to a straight handpiece)
glycine
attached to a 20-gauge needle delivery tip.

3. The delivery tip was applied to the carious lesion with

46
minimal pressure via a paintbrush-like motion.
 GK101
HYDROXYPROLOINE PYRROLE - 2 - CARBOXYGLYCERINE

Goldman and Kronman reported that the mean caries excavation time for GK-
101 was 8.5 minutes and using burs remained an essential subsequent step in
order to achieve ideal finishing of the excavated sites.

Laboratory findings showed GK-101 had no adverse effects on red or white

blood cells or the platelet count.

Kurosaki etal. reported that GK-101 had no adverse effect on the pulpal tissue of
dogs; however, they concluded GK-101 was not efficient in removing the entire
carious lesion.

These findings led to improvements in the formula of GK-101 to GK-101E. 47

2.CARIDEX:
• GK-101E is the ethyl derivative [N-monochloro-DL- 2 amino
butyrate (NMAB)] of GK-101 (NMG). GK-101E was marketed as
‘CaridexTM’ and received FDA approval in 1984.

48
 HABIB Et.al - 1975
MECHANISM OF ACTION :

GK101
HYDROXYPROLOINE PYRROLE - 2 - CARBOXYGLYCERINE

CHLORINATION REACTION

Cleavage of the denatured collagen fibrils might have occurred as a result

of the oxidation of glycine residues. This causes disruption of the collagen
fibrils which become more friable and can then be removed.

49
YIP et.al - 1989
 Schutzbank et al
The improved formula seemed to be effective in shortening
the caries excavation time. They attributed this time
difference to the ‘lag’ period

NMG – 30 – 90 SEC.

NMAB – NO LAG PERIOD.

Zinc et.al; Mccune et.al

Caridex chemomechanical caries removal was time
consuming in comparison with conventional caries removal
50
methods.
 LIMITATIONS OF CARIDEX SYSTEM :

(1) Rotary and/or hand instruments may still be needed for the removal
of tissue or material other than degraded dentine collagen

(2) Large volumes of solution were needed (200 to 500 ml) and the
procedure was slow and also costly.

(3) Only certain cavities were suitable for treatment by the technique and
because of the time involved (10 to 15 min) and limited use, its
popularity waned.

(4) Although there were studies on the efficacy of caries removal by the
procedure, studies on the long term success of cavities restored after
CMCR treatment were lacking.
51
3. CARISOLV:
• The original Carisolv was red in colour.

Carboxy-
methylecllulose
1ST SYRINGE:

2ND SYRINGE
0.25% Sodium
Aminoacids : hypochlorite
Glutamic , leucine
& lysine.

52
 Cariosolv gel is applied for 30 sec

Aminoacids bind and form chloramines at higher pH

3 aminoacids are differently charged which allows for an

electrostatic attraction to different areas in the carious dentine.

Destroys the bonds which hold the fibrous structure together

Breakdown of the degraded collagen fibres

The gel only softens the carious dentin, while healthy tissue is
unaffected.

53
Kathuria V, Ankola AV, Hebbal M, Mocherla M. Carisolv – an innovative
method of caries removal. J Clin Diagn Res. 2013; 7(12) : 3111-3115.
54
PAPACARIE:
 Papacarie - ‘caries eater’.

 Introduced in 2003 Sao Paulo.

 It consists of papain enzyme, chloramine, toluidine blue,

salts, preservatives, a thickener, stabilizers and deionized
water

55
MODE OF ACTION :

56
 SONICFLEX SYSTEM:

• The sonic oscillating, SONIC flex system ( KaVo Dental ) was

developed to cut and finish small proximal cavities.

• The use of safe sided, diamond coated, round ended

preparation tips can minimize the damage to neighbouring
teeth during proximal preparation and finishng.

• Different tips are available each in a mesial and distal form.

57
 The frequency of sonic waves is 6.0 kHz and the pressure is
0.1N.

 During finishing , the frequency & operating pressure are

reduced.

 Bevel tips are suitable for cutting and finishing of cavities.

 The angled instruments may be used in situations in which

access is especially difficult.

Eg : Cutting & finishing of proximal section of a tunnel

preparation.
58
In the direct access approach to management of proximal caries.
AIR ABRASION EXCAVATION ( KINETIC SYSTEM )
• Air abrasion also referred to as advanced particle beam/ Micro
abrasive technology.

• Kinectic cavity preparation (KCP) is a technique, which uses

fine particles of powder fired at high speed in a controlled
manner.

Quantity of tooth removal & depth of penetration :

 Air pressure
 Particle size
 Nozzle diameter of the handpiece
 Distance placed 59
 Exposure of the object.
  Removal of superficial enamel defects
INDICATIONS
 Box preparation for class 2 cavities

 Removal of fractured amalgam restorations

 Repair of composites, glass ionomers and porcelain

restorations.

INDICATIONS
 History of asthma, dust allergy, chronic pulmonary

CONTRA
disease.

 Recent extraction, any open wound in oral cavity &

subgingival caries removal 60
 ADVANTAGES : DISADVANTAGES :

 No vibrations &
pulsations  Lack of tactile sensation

 Allows operator to  Danger of air embolism &

perform quadrant emphysema
dentistry in dental
phobic patients  Spread of aluminium oxide
particles around operatory
impairs view as particles
collect on mirror. 61
 OZONE THERAPY:
• Ozone therapy causes re-mineralization of incipient pit
and fissure caries as well as incipient root caries

• Ozone readily penetrates through decayed tissue,

eliminating the ecological niche of cariogenic micro-
organism’s as well as priming the carious tissue for re-
mineralization.
Ozone has the effect, through its powerful oxidizing properties, of
not only removing the protein protection the biomolecules that
• The
allowre-
themineralization process
niche to survive and will
expand. then
The take
lesion will place
become with
populated
the aid ofwith normal mouth
a topically commensals
applied which do solution
re-mineralizing not produce
and
acid, after ozone therapy.
the recommended patient’s maintenance kit
62
 REPAIR RATHER THAN REPLACEMENT OF
DEFECTIVE RESTORATION

Replacement dentistry’ leads to:

Weakening of tooth structure by increasing the surface area

of the cavity

The increased surface area tends to make more complex form

of restoration

Larger restorations which usually have a shorter life span than

their predecessors
63
Possible damage to adjacent teeth.
CONCLUSION

64
REFERENCES :
• McDonald’s and Avery’s Dentistry for the child and
adolescent , 2nd South Asian Edition , Elsevier
publications , 2019.

• Pedatric Dentistry Infancy through Adolescence –

Casamassimo – 5th Ed, Elsevier publication , 2013.

• Featherstone JD, Doméjean S. Minimal intervention

dentistry: part 1. From 'compulsive' restorative dentistry
to rational therapeutic strategies. Br Dent J.
2012;213(9):441‐445. 65
• Frencken JE, Peters MC, Manton DJ , Leal SC, GordanVV, Eden
E. Minimal intervention dentistry for managing dental caries –
a review : Report of a FDI task group. Int Dent J. 2012 oct;
62(5): 223-43.

• Hamama H, Yiu C, Burrow M. Current update of

chemomechanical caries removal methods. Aust Dent J.
2014;59(4):446‐525.

• Kathuria V, Ankola AV, Hebbal M, Mocherla M. Carisolv – an

innovative method of caries removal. J Clin Diagn Res. 2013;
7(12) : 3111-3115.

• Gujjar RK, Surma N. Minimally Invasive Dentistry - A Review.

Int Pediatr Dent.2013; 9(2):109-20.
66
• Dr. Luxmi Chopra, Dr. Seema Thakur, Dr. Parul Singhal,
2018. “Minimal intervention dentistry for children with
latest advancements”, International Journal of
Development Research, 8, (06)

• Bhatiya P, Thosar N. Minimal invasive dentistry – An

emerging trend in pediatric dentistry: A review. Int J
Contemp Dent Med Rev. 2015; 1-6.

67
68