minimum intervention tooth remineralization

8/6/2019 Minimum Intervention Tooth Remineralization

1/129

Thai Dental Association June 2009Thai Dental Association June 2009

Martin J Tyas (Martin J Tyas (11))

MINIMUM INTERVENTIONMINIMUM INTERVENTION

DENTISTRYDENTISTRY ESSENTIALESSENTIALCONCEPTSCONCEPTS

Martin J TyasBDS, PhD, DDSc, GradDipHlthSc, FADM, FICD, FRACDS, FPFA, FADI

Professor and Head, Restorative Dentistry

Melbourne Dental SchoolThe University of Melbourne

Australia

Martin J TyasBDS, PhD, DDSc, GradDipHlthSc, FADM, FICD, FRACDS, FPFA, FADI

Professor and Head, Restorative Dentistry

Melbourne Dental SchoolThe University of Melbourne

Australia


2/129



SUMMARYSUMMARY

overview of Minimum Intervention (MI)

definition of MI elements of MI

dental caries

caries risk assessment prevention

remineralisation (medical)

techniques operative (surgical) techniques

management of defective restorations

overview of Minimum Intervention (MI)

definition of MI

elements of MI

dental caries

caries risk assessment prevention

remineralisation (medical)

techniques operative (surgical) techniques

management of defective restorations


3/129



DEFINITION OF MIDEFINITION OF MI

an approach to the managementof dental caries with the aim of

minimising the loss of toothstructure by disease or by

iatrogenic intervention

an approach to the managementof dental caries with the aim of

minimising the loss of toothstructure by disease or by

iatrogenic intervention


4/129



IntInt Dent J 2000;50:1Dent J 2000;50:1--1212


5/129



CONSENSUS STATEMENT (2007)

General Assembly of the World Congress of

Minimally Invasive DentistryMembers of the Western, Central, and Eastern

(US) Caries Management by Risk Assessment

(CAMBRA) CoalitionsADEA Cariology Special Interest Group

recognize the 2002 FDI Policy Statement asthe current clinical standard for caries

management

CONSENSUS STATEMENT (2007)

General Assembly of the World Congress of

Minimally Invasive DentistryMembers of the Western, Central, and Eastern

(US) Caries Management by Risk Assessment

(CAMBRA) CoalitionsADEA Cariology Special Interest Group

recognize the 2002 FDI Policy Statement asthe current clinical standard for caries

management

Tyas, Anusavice, Frencken & Mount.Tyas, Anusavice, Frencken & Mount. IntInt Dent J 2000;50:1Dent J 2000;50:1--1212


6/129



ELEMENTS OF MINIMUM INTERVENTIONELEMENTS OF MINIMUM INTERVENTION

the dentist as a physician (requires a knowledge of the

factors associated with the development of caries) individualised assessment of caries risk

appropriate preventive strategies

remineralisation/arrest of non-cavitated lesions the dentist as a surgeon (requires a knowledge of the

caries lesion)

minimum surgical intervention of cavitated lesions

appropriate maintenance of existing restorations





caries lesion)

minimum surgical intervention of cavitated lesions appropriate maintenance of existing restorations


7/129








caries lesion)





appropriate preventive strategiesappropriate preventive strategiesappropriate preventive strategies

remineralisation/arrest of nonremineralisation/arrest of nonremineralisation/arrest of non---cavitated lesionscavitated lesionscavitated lesions the dentist as a surgeon (requires a knowledge of thethe dentist as a surgeon (requires a knowledge of thethe dentist as a surgeon (requires a knowledge of the

caries lesion)caries lesion)caries lesion)

minimum surgical intervention of cavitated lesionsminimum surgical intervention of cavitated lesionsminimum surgical intervention of cavitated lesions appropriate maintenance of existing restorationsappropriate maintenance of existing restorationsappropriate maintenance of existing restorations


8/129



MULTIFACTORIAL NATURE OF CARIESMULTIFACTORIAL NATURE OF CARIES

local factors

saliva (quality; quantity) diet

carbohydrateintake

frequency ofexposure toacids

exposure to fluoride

plaque accumulationand retention

local factors

saliva (quality; quantity) diet

carbohydrateintake

frequency ofexposure toacids

exposure to fluoride

plaque accumulationand retention

modifying factors

dental history

medical history

lifestyle

socio-economic

status

compliance

modifying factors

dental history

medical history

lifestyle

socio-economic

status

compliance


9/129



TRAFFIC LIGHTTRAFFIC LIGHTRISK ASSESSMENT MODELRISK ASSESSMENT MODEL

traffic light system

colours convey levels of risk

already used in dentistry,health education, food labelling

allocates a threshold value for

each risk category for caries, 16 criteria in five

categories

traffic light system

colours convey levels of risk

already used in dentistry,health education, food labelling

allocates a threshold value for

each risk category for caries, 16 criteria in five

categories


10/129



GC (JAPAN)GC (JAPAN) TRAFFIC LIGHTTRAFFIC LIGHT SYSTEMSYSTEM

saliva five criteria

diet # of CHO

exposures/day

# of acid

exposures/day


diet # of CHO

exposures/day

# of acidexposures/day

fluoride exposure

past and current

plaque three criteria

modifying factors five criteria

fluoride exposurefluoride exposure

past and currentpast and current

plaqueplaque three criteriathree criteria

modifying factorsmodifying factors five criteriafive criteria


11/129



SALIVA ANDSALIVA AND

DENTAL CARIESDENTAL CARIES


12/129



SALIVA COMPOSITIONSALIVA COMPOSITION 99% water

bicarbonate (buffers to pH 6.7 7.4) inorganic ions (e.g, calcium, phosphate for

remineralisation)

enzymes: amylase, lipase, proteases,

nuclease

mucins (lubrication; clear bacteria) antibacterials (e.g., IgA, enzymes)

99% water

bicarbonate (buffers to pH 6.7 7.4) inorganic ions (e.g, calcium, phosphate for

remineralisation)

enzymes: amylase, lipase, proteases,

nuclease

mucins (lubrication; clear bacteria) antibacterials (e.g., IgA, enzymes)


13/129



FUNCTIONS OF SALIVAFUNCTIONS OF SALIVA

lubrication

taste (by dissolving ions) health of oral mucosa (promotes wound

healing)

assists digestion

dilutes/clears material (e.g., carbohydrate)

buffers plaque and dietary acid

reservoir for calcium and phosphate

lubrication

taste (by dissolving ions) health of oral mucosa (promotes wound

healing)

assists digestion

dilutes/clears material (e.g., carbohydrate)

buffers plaque and dietary acid

reservoir for calcium and phosphate


14/129



ASSESSMENT OF SALIVA (FIVE CRITERIA)ASSESSMENT OF SALIVA (FIVE CRITERIA)

unstimulated minor salivary gland function

viscosity

pH

stimulated

flow rate buffering capacity

GC Saliva Test kit

unstimulated minor salivary gland function

viscosity

pH

stimulated

flow rate buffering capacity

GC Saliva Test kit


15/129



MINOR SALIVARY GLAND FUNCTIONMINOR SALIVARY GLAND FUNCTION

evert lower lip

dry with gauze

measure time for droplets to appear

at minor salivary gland orifices

single ply tissue may help

evert lower lip

dry with gauze

measure time for droplets to appear

at minor salivary gland orifices single ply tissue may help

> 60 s30 60 s

< 30 s

> 60 s> 60 s3030 60 s60 s

< 30 s< 30 s


16/129



Ngo & GaffneyNgo & Gaffney


17/129



VISCOSITYVISCOSITY

open mouth; check for pooling of saliva

lift tongue to palate; check for appearanceand shiny film on floor of mouth

web test: normal = 20 50 mm

open mouth; check for pooling of saliva

lift tongue to palate; check for appearanceand shiny film on floor of mouth

web test: normal = 20 50 mm

Thick, ropy, frothy, extended web testThick, ropy, frothy, extended web test

No visible pooling; a little stickyNo visible pooling; a little sticky

Watery with pooling; shiny thin filmWatery with pooling; shiny thin film


18/129



Ngo & GaffneyNgo & Gaffney


19/129



RED OR YELLOW LIGHT!RED OR YELLOW LIGHT!

causes of defective functionsevere dehydration

medicationhormonal imbalance

salivary gland pathology

causes of defective functionsevere dehydration

medicationhormonal imbalance

salivary gland pathology


20/129



pHpH

dribble into container

insert pH paper

read after 10 s

dribble into container

insert pH paper

read after 10 s

< 5.8< 5.85.85.8 6.86.8

> 6.8> 6.8


21/129



FLOW RATEFLOW RATE chew on paraffin wax for 5 minutes

collect salivameasure volume

wide variation among individuals

mean 1.6 mL/min

chew on paraffin wax for 5 minuteschew on paraffin wax for 5 minutes

collect salivacollect saliva measure volumemeasure volume

wide variation among individualswide variation among individuals

mean 1.6 mL/minmean 1.6 mL/min

< 3.5 mL< 3.5 mLAfter 5 min: 3.5After 5 min: 3.5 5 mL5 mL

> 5 mL> 5 mL


22/129



BUFFERING CAPACITYBUFFERING CAPACITYability to neutralise acid

depends on level of bicarbonateuse saliva collected for flow rate

use test strip as directed

assess against colour standard

ability to neutralise acidability to neutralise acid

depends on level of bicarbonatedepends on level of bicarbonate use saliva collected for flow rateuse saliva collected for flow rate

use test strip as directeduse test strip as directed

assess against colour standardassess against colour standard

HighHigh

ModerateModerate

LowLow

IVOCLARIVOCLAR

1010 1212

66 99

00 55

GCGC


23/129



MR CHAIWAT SATHORN 15-FEB-2009


24/129





diet # of CHO

exposures/day


salivasalivasaliva five criteriafive criteriafive criteria

dietdiet

# of CHO# of CHO

exposures/dayexposures/day

# of acid# of acidexposures/dayexposures/day

fluoride exposure

past and current


modifying factors five criteria

fluoride exposurefluoride exposurefluoride exposure

past and currentpast and currentpast and current

plaqueplaqueplaque three criteriathree criteriathree criteria

modifying factorsmodifying factorsmodifying factors

five criteriafive criteriafive criteria


25/129



DIET: FREQUENCY OFDIET: FREQUENCY OFCARBOHYDRATE INTAKECARBOHYDRATE INTAKE

high CHO intake

immediate 2-4 point pH (depends on bacteria, plaquethickness, salivary buffering)

pH recovery; 20 min hours

high CHO intake

immediate 2-4 point pH (depends on bacteria, plaquethickness, salivary buffering)

pH recovery; 20 min hours


26/129



DIET: FREQUENCY OF EXPOSUREDIET: FREQUENCY OF EXPOSURETO ACIDSTO ACIDS

non-bacterial acid sources

intrinsic acid (e.g., gastric reflux,

bulimia)

extrinsic acid (e.g., black cola

drinks, sports drinks) caries

erosion (corrosion)

non-bacterial acid sources

intrinsic acid (e.g., gastric reflux,

bulimia)

extrinsic acid (e.g., black cola

drinks, sports drinks) caries

erosion (corrosion)


27/129



ASSESSMENT OF DIETASSESSMENT OF DIET

111

> 2> 2> 2

> 3> 3> 3

# ACID EXPOSURES# ACID EXPOSURES

BETWEEN MEALSBETWEEN MEALS

NilNilNil

> 1> 1> 1

> 2> 2> 2

# CHO EXPOSURES# CHO EXPOSURES

BETWEEN MEALSBETWEEN MEALS


28/129





diet # of CHO

exposures/day



dietdietdiet

# of CHO# of CHO# of CHO

exposures/dayexposures/dayexposures/day

# of acid# of acid# of acidexposures/dayexposures/dayexposures/day

fluoride exposure

past and current


modifying factors

five criteria

fluoride exposure past and current

plaqueplaqueplaque three criteriathree criteriathree criteria



Th i D t l A i ti J 2009


29/129



CLINICAL EFFECTS OF FLUORIDECLINICAL EFFECTS OF FLUORIDE

remineralisation of incipient enamel

caries (white spot lesion)

slow down/partly remineralise carious

dentine in cavitated lesion remineralise root caries lesion

hypermineralisationmost effective for smooth-surface

caries

remineralisation of incipient enamel

caries (white spot lesion)

slow down/partly remineralise carious

dentine in cavitated lesion remineralise root caries lesion

hypermineralisationmost effective for smooth-surface

caries

Th i D t l A i ti J 2009


30/129



EXPOSURE TO FLUORIDEEXPOSURE TO FLUORIDE

Water AND toothpasteWater AND toothpasteWater AND toothpaste

Water OR toothpasteWater OR toothpasteWater OR toothpaste

NilNilNil

EXPOSURE TO

FLUORIDE

EXPOSURE TOEXPOSURE TO

FLUORIDEFLUORIDE

Th i D t l A i ti J 2009Thai Dental Association June 2009


31/129





diet

# of CHO

exposures/day



dietdietdiet

# of CHO# of CHO# of CHO

exposures/dayexposures/dayexposures/day

# of acid# of acid# of acidexposures/dayexposures/dayexposures/day

fluoride exposure

past and current


modifying factors

five criteria

fluoride exposurefluoride exposurefluoride exposure past and currentpast and currentpast and current

plaqueplaque three criteriathree criteria



Th i D t l A i ti J 2009Thai Dental Association June 2009


32/129



ASSESSMENT OF BIOFILM (PLAQUE)ASSESSMENT OF BIOFILM (PLAQUE)

Plaque Check (GC Corporation) thickness/maturity

2-colour disclosing gelpink = thin, new plaque

blue = thick, mature plaque

sucrose challenge and resultant pH

Plaque Check (GC Corporation) thickness/maturity

2-colour disclosing gel

pink = thin, new plaquepink = thin, new plaque

blue = thick, mature plaqueblue = thick, mature plaque

sucrose challenge and resultant pH

Thai Dental Association J ne 2009Thai Dental Association June 2009


33/129



GC CorporationGC Corporation

DR HIEN NGODR HIEN NGO



34/129



Ivoclar VivadentIvoclar Vivadent



35/129


Martin J Tyas (Martin J Tyas (3535))CRT BufferCRT Buffer,, CRT BacteriaCRT Bacteria (Ivoclar Vivadent)(Ivoclar Vivadent)



36/129



MODIFYING FACTORS (5)MODIFYING FACTORS (5)1. dental history

active caries lesions

restorations (past or current risk?)

2. medical history

numerous medications xerostomia, e.g.,antidepressants; hypotensives;anticholinergics; antipsychotics; diuretics;

anti-Parkinson3. lifestyle

caffeine, alcohol (diuretics)

smoking (effect on saliva)

1. dental history

active caries lesions

restorations (past or current risk?)

2. medical history

numerous medications xerostomia, e.g.,antidepressants; hypotensives;anticholinergics; antipsychotics; diuretics;

anti-Parkinson

3. lifestyle

caffeine, alcohol (diuretics)

smoking (effect on saliva)



37/129



4. socio-economic status (SES)

low SES may indicate low educationallevel, thus low level of understanding

financial issues

cost of treatment

cost of accessing treatment

5. compliance; depends on

patient attitude

practicality/appropriateness of treatment

plan

4. socio-economic status (SES)

low SES may indicate low educationallevel, thus low level of understanding

financial issues

cost of treatment cost of accessing treatment

5. compliance; depends on

patient attitude

practicality/appropriateness of treatment

plan

MODIFYING FACTORS (5)MODIFYING FACTORS (5)



38/129

Thai Dental Association June 2009a e a ssoc a o Ju e 009


ASSESSMENT OF MODIFYING FACTORSASSESSMENT OF MODIFYING FACTORS

any drugs (OTC/Rx/recreational) which

reduce salivary flow? any diseases which result in dry mouth?

fixed/removable appliances?

recent active caries?

poor compliance?

any drugs (OTC/Rx/recreational) which

reduce salivary flow? any diseases which result in dry mouth?

fixed/removable appliances?

recent active caries?

poor compliance?

NO to all above

YES to any ONE above



39/129

Thai Dental Association June 2009


DAVIDDAVID AGED 24AGED 24 lives in unfluoridated town

labourer on building site not well educated

works outdoors in hot climate

potential dehydration

drinks low pH black cola drinks (Coca Cola)

frequent refined CHO intake

poor oral hygiene

poor attitude (parents F/F)

lives in unfluoridated town

labourer on building site not well educated

works outdoors in hot climate

potential dehydration drinks low pH black cola drinks (Coca Cola)

frequent refined CHO intake

poor oral hygiene

poor attitude (parents F/F)



40/129

a e ta ssoc at o Ju e 009


DAVIDDAVID AGED 24AGED 24

diet (high acid; high CHO) -

fluoride exposure (nil) - plaque (thick) -

dental history (poor attender) - SES (low) -

attitude and compliance (poor) - challenges

risk factors: red green

diet (high acid; high CHO) -

fluoride exposure (nil) - plaque (thick) -

dental history (poor attender) - SES (low) -

attitude and compliance (poor) - challenges

risk factors: red green



41/129


Modifying factorsModifying factors

FluorideFluoride

DietDiet

PlaquePlaque

SalivaSaliva

DAVIDDAVID AGED 24AGED 24



42/129


Dr Douglas Bratthall

CARIOGRAM SCORE CARD

FREQUENCY OF INTAKEFREQUENCY OF INTAKE

OF FERMENTABLEOF FERMENTABLE

CARBOHYDRATECARBOHYDRATE



43/129

Martin J Tyas (Martin J Tyas (4343))www.db.od.mah.se/car/cariogram/cariograminfo.html

1

2



44/129


AGED CARE FACILITYAGED CARE FACILITY

Dr Jane ChalmersDr Jane ChalmersDr Jane ChalmersDr Jane Chalmers

Dr Jane ChalmersDr Jane Chalmers



45/129


SJOGRENSJOGRENS SYNDROMES SYNDROME

Dr MA Stacey, University of MelbourneDr MA Stacey, University of Melbourne




46/129


RADIATION CARIESRADIATION CARIES




47/129




factors associated with the development of caries)

individualised assessment of caries risk



caries lesion)




individualised assessment of caries riskindividualised assessment of caries riskindividualised assessment of caries risk


remineralisation/arrest of nonremineralisation/arrest of nonremineralisation/arrest of non---cavitated lesionscavitated lesionscavitated lesions the dentist as a surgeon (requires a knowledge of thethe dentist as a surgeon (requires a knowledge of thethe dentist as a surgeon (requires a knowledge of the





48/129








caries lesion)






remineralisation/arrest of non-cavitated lesions the dentist as a surgeon (requires a knowledge of thethe dentist as a surgeon (requires a knowledge of thethe dentist as a surgeon (requires a knowledge of the





49/129


DEMINDEMIN

--REMINREMIN

CYCLECYCLE

pHpH 6.06.0 5.55.5 5.05.0 4.54.5 4.04.0

pHpH 6.06.0 5.55.5 5.05.0 4.54.5 4.04.0

Critical pHCritical pH

of HAof HACritical pHCritical pH

of FAof FA

DEMINERALISATIONDEMINERALISATION

HA dissolves; FAHA dissolves; FA

forms if Fforms if F-- presentpresent

REMINERALISATIONREMINERALISATION

FA reformsFA reforms

FA and HAFA and HA

dissolvedissolve

If H+ neutralised,If H+ neutralised,

and Ca++ andand Ca++ andPOPO44---- presentpresentFA and HA reformFA and HA reform

HH++ reacts with POreacts with PO44----

in saliva and plaquein saliva and plaque



50/129


FACTORS PROMOTINGFACTORS PROMOTING REMINREMIN

pH > 5.5phosphate ions

calcium ions

fluoride ions

pH > 5.5phosphate ions

calcium ions

fluoride ions



51/129


Clinical use of calcium phosphates forremineralization not successful

Clinical use of calcium phosphates forClinical use of calcium phosphates for

remineralization not successfulremineralization not successful

insoluble calcium phosphates low solubility (particularly with F) not easily applied nor effectively

localized at tooth surface require acid for solubility to produce

remineralizing ions soluble calcium phosphates

can only be used at low concentrations do not effectively localize at tooth

surface

insoluble calcium phosphates

low solubility (particularly with F) not easily applied nor effectively

localized at tooth surface

require acid for solubility to produceremineralizing ions

soluble calcium phosphates

can only be used at low concentrations do not effectively localize at tooth

surface



52/129


CALCIUM PHOSPHOPEPTIDE-AMORPHOUS CALCIUMPHOSPHATECALCIUM PHOSPHOPEPTIDECALCIUM PHOSPHOPEPTIDE--AMORPHOUS CALCIUMAMORPHOUS CALCIUMPHOSPHATEPHOSPHATE

casein phosphopeptide-amorphouscalcium phosphate (CPP-ACP)

25+ years research by Reynolds et

al. (Melbourne Dental School,University of Melbourne)

based on milk protein Recaldent (Cadbury Schweppes)

casein phosphopeptide-amorphouscalcium phosphate (CPP-ACP)

25+ years research by Reynolds et

al. (Melbourne Dental School,University of Melbourne)

based on milk protein Recaldent (Cadbury Schweppes)



53/129


CLINICAL APPLICATIONS OF CPPCLINICAL APPLICATIONS OF CPP--ACPACP

CPP-ACP products

Recaldent chewing gum Tooth Mousse/ MI Paste (GC,

Japan)

addition to glass-ionomer cement(Mazzaoui, Tyas et al.)

compressive strength bond strength to dentine current work: addition to other

GICs (Burrow et al.)

CPP-ACP products

Recaldent chewing gum Tooth Mousse/ MI Paste (GC,

Japan)

addition to glass-ionomer cement(Mazzaoui, Tyas et al.)

compressive strength bond strength to dentine current work: addition to other

GICs (Burrow et al.)



54/129



Cli i l t d f l d d

Cli i l t d f l dClinical study of enamel de dand re


55/129


Clinical study of enamel de- and re-

mineralization by chewing gum

Clinical study of enamel deClinical study of enamel de-- and reand re--

mineralization by chewing gummineralization by chewing gum 2720 subjects ( 12.5 y old)

Normal use of fluoride toothpaste, fluoridatedwater

Sugar-free gum containing CPP-ACP; control gum

randomly assigned, double blinded Gum chewed 3 x daily for 2 years

Standardized digital radiographs at baseline and

24 months Caries progression/regression analyzed using a

transition matrix

2720 subjects ( 12.5 y old)

Normal use of fluoride toothpaste, fluoridatedwater

Sugar-free gum containing CPP-ACP; control gum

randomly assigned, double blinded Gum chewed 3 x daily for 2 years

Standardized digital radiographs at baseline and

24 months Caries progression/regression analyzed using a

transition matrix

Morganet al.

(2006)J Dent Res



56/129


Clinical study of enamel de- and re-

mineralization by chewing gum

Clinical study of enamel deClinical study of enamel de-- and reand re--

mineralization by chewing gummineralization by chewing gum

Recaldent in sugar-free gum significantly slowed progression

promoted regression (remineralization)

of dental caries relative to a controlsugar-free gum in school children

in an optimally fluoridated cityand using fluoride-containing toothpaste

Recaldent in sugar-free gum

significantly slowed progression

promoted regression (remineralization)

of dental caries relative to a controlsugar-free gum in school children

in an optimally fluoridated cityand using fluoride-containing toothpaste

Morgan et al. (2006) J Dent Res



57/129


MI PASTEMI PASTE


OBEFORE TREATMENT


58/129


BEFORE TREATMENTBEFORE TREATMENT

AFTER RECALDENTAFTER RECALDENT


Prof L J Walsh U of Q


59/129


Prof L J Walsh, U of Q

Prof L J Walsh, U of Q



60/129


CONCLUSIONCONCLUSIONCONCLUSION

RecaldentTM (CPP-ACP) technology

remineralizes enamel subsurface lesions in situ

slows the progression of coronal caries

promotes regression of caries

CPP-ACP plus F (Tooth Mousse Plus)

is a superior form of fluoride

should be clinicians first choice for the prevention of caries and erosion

for the treatment of dentinal hypersensitivity

for the repair of white spot lesions

RecaldentTM (CPP-ACP) technology

remineralizes enamel subsurface lesions in situ

slows the progression of coronal caries promotes regression of caries

CPP-ACP plus F (Tooth Mousse Plus)

is a superior form of fluoride

should be clinicians first choice

for the prevention of caries and erosion

for the treatment of dentinal hypersensitivity

for the repair of white spot lesions



61/129


RESIN INFILTRATIONRESIN INFILTRATION

infiltration of non-cavitated lesions bylow viscosity polymerisable resin

Icon; DMG Co, Hamburg several published laboratory studies

clinical studies in progress

infiltration of non-cavitated lesions bylow viscosity polymerisable resin

Icon; DMG Co, Hamburg several published laboratory studies

clinical studies in progress



62/129




63/129


Courtesy of DMG GmbHCourtesy of DMG GmbHCourtesy of DMG GmbH




64/129







remineralisation/arrest of non-cavitated lesions

the dentist as a surgeon (requires a knowledge of the

caries lesion)


the dentist as a physician (requires a knowledge of thethe dentist as a physician (requires a knowledge of thethe dentist as a physician (requires a knowledge of the

factors associated with the development of caries)factors associated with the development of caries)factors associated with the development of caries)



remineralisation/arrest of nonremineralisation/arrest of nonremineralisation/arrest of non---cavitated lesionscavitated lesionscavitated lesions


caries lesion)


appropriate maintenance of existing restorationsappropriate maintenance of existing restorationsappropriate maintenance of existing restorations



65/129


GV BLACKGV BLACK

GreeneGreene VardimanVardiman

BLACK (1835BLACK (1835--1915)1915)

extensive research

on amalgam (DentalCosmos, 1896)

A Work onOperative Dentistry

in Two Volumes

(1908)

extensive research

on amalgam (DentalCosmos, 1896)

A Work on

Operative Dentistry

in Two Volumes

(1908)



66/129


BLACKBLACKS TEACHINGSS TEACHINGS

highly formalised cavity designs;

precise size and geometry

weak, non-adhesive materials

extension for prevention

highly formalised cavity designs;

precise size and geometry

weak, non-adhesive materials

extension for prevention



67/129


A Work on Operative DentistryA Work on Operative Dentistry

in Two Volumes (5in Two Volumes (5thth Ed, 1922)Ed, 1922)



68/129


SURGICAL MODELSURGICAL MODEL (( 19001900 -- 1980s)1980s)

caries can be cured byexcision of all decayed tooth

structure, and replacement

with a filling material

now known to be incorrect

caries can be cured byexcision of all decayed tooth

structure, and replacementwith a filling material

now known to be incorrect



69/129


STRUCTURALLY WEAKENED TOOTHSTRUCTURALLY WEAKENED TOOTH

NONNON--ADHESIVE RESTORATIVEADHESIVE RESTORATIVE

MATERIALMATERIAL

++

HIGH INCIDENCE OF SUBSEQUENTHIGH INCIDENCE OF SUBSEQUENT

TOOTH FRACTURETOOTH FRACTURE



70/129




71/129


WHATWHATS CHANGED?S CHANGED? enhanced understanding of the carious

process an infectious disease

demineralisation/remineralisation cycle

recognition of the rle of fluoride inhibiting demineralisation

enhancing remineralisation

development of adhesive materials glass-ionomer cement

resin-based materials

enhanced understanding of the cariousprocess

an infectious disease

demineralisation/remineralisation cycle

recognition of the rle of fluoride inhibiting demineralisation

enhancing remineralisation

development of adhesive materials glass-ionomer cement

resin-based materials


MINIMUM INTERVENTION IN OPERATIVE


72/129


MINIMUM INTERVENTION IN OPERATIVEMINIMUM INTERVENTION IN OPERATIVE

DENTISTRY (1990s ONWARDS)DENTISTRY (1990s ONWARDS)

remineralisation of non-cavitated lesions

arrest of active lesions

restoration (surgical treatment) only if

required for plaque control or aesthetics removal of caries only (infected

dentine)

restoration with adhesive materials

repair of defective restorations

remineralisation of non-cavitated lesions

arrest of active lesions

restoration (surgical treatment) only if

required for plaque control or aesthetics removal of caries only (infected

dentine)

restoration with adhesive materials

repair of defective restorations



73/129


INDICATIONS FOR RESTORATIONINDICATIONS FOR RESTORATION((SURGICAL APPROACHSURGICAL APPROACH))

cavitation rendering

plaque control

unachievable

aesthetics

unsatisfactory function

compromised

cavitation rendering

plaque control

unachievable

aesthetics

unsatisfactory function

compromised



74/129


ADHESIVEADHESIVE PREPARATIONSPREPARATIONS conservative cavity

macromechanical retention notrequired

reduction in microleakage

reduced incidence of secondary caries reduced marginal staining

reduced pulp damage

restoration of tooth strength

conservative cavity

macromechanical retention notrequired

reduction in microleakage

reduced incidence of secondary caries reduced marginal staining

reduced pulp damage

restoration of tooth strength



75/129


DENTINE CARIES (DENTINE CARIES (FusayamaFusayama;; MasslerMassler))

infected (outer carious) dentine (A)

moist, soft, pale yellow heavy bacterial load

collagen degraded

non-remineralisable affected (inner carious) dentine (B)

dry, hard, brown/black

few or no bacteria

collagen cross-links intact

remineralisable

infected (outer carious) dentine (A)

moist, soft, pale yellow heavy bacterial load

collagen degraded

non-remineralisable affected (inner carious) dentine (B)

dry, hard, brown/black

few or no bacteria

collagen cross-links intact

remineralisable

AA

BB


TREATMENT OF CARIOUS DENTINTREATMENT OF CARIOUS DENTIN


76/129


ExperimentalExperimentalLaser photoLaser photo--ablationablationExperimentalExperimentalEnzymatic digestionEnzymatic digestion

Limited applicationsLimited applicationsChemoChemo--mechanical excavationmechanical excavation

ExperimentalExperimentalAir abrasionAir abrasionExperimentalExperimentalSonoSono--abrasionabrasion

ExperimentalExperimental

UnconvincingUnconvincing

Controlled selective rotary excavationControlled selective rotary excavation

torque control handpiecetorque control handpiece

polymer burspolymer burs

Gold standardGold standard but should bebut should be

modifiedmodifiedRotary excavationRotary excavation

Accepted procedureAccepted procedureManual excavationManual excavationEXCAVATION TECHNIQUESEXCAVATION TECHNIQUES

NoackNoack et al., Oral Health & Prev Dent 2004;2 (Supp 1):301et al., Oral Health & Prev Dent 2004;2 (Supp 1):301--306306


TREATMENT OF CARIOUS DENTINTREATMENT OF CARIOUS DENTIN


77/129


DISINFECTION TECHNIQUESDISINFECTION TECHNIQUES

Adjunctive to other methodsAdjunctive to other methodsAntibacterial therapyAntibacterial therapy

PromisingPromisingPhotodynamic therapyPhotodynamic therapy

Primary root cariesPrimary root caries

More research for other applicationsMore research for other applicationsOzoneOzone

SEALING TECHNIQUESSEALING TECHNIQUES

NoackNoack et al., Oral Health & Prev Dent 2004;2 (Supp 1):301et al., Oral Health & Prev Dent 2004;2 (Supp 1):301--306306

PromisingPromisingAntibacterial materialsAntibacterial materials

PromisingPromisingDentin adhesivesDentin adhesives

Limited acceptanceLimited acceptanceFluorideFluoride--releasingreleasing

materialsmaterials



78/129




79/129


EXCAVATE WITH FIRM PRESSURE UNTILEXCAVATE WITH FIRM PRESSURE UNTIL

HARD, DRY, DARK COLOURHARD, DRY, DARK COLOUR



80/129


PRINCIPLES OF MINIMUM INTERVENTIONPRINCIPLES OF MINIMUM INTERVENTIONRESTORATIONSRESTORATIONS

remove only degraded enamel andinfected dentine

leave affected dentine

support undermined enamel by theadhesive restorative material

the cavity shape is dictated by the caries

and is unique Blacks formal cavity designs are obsolete

remove only degraded enamel and

infected dentine leave affected dentine

support undermined enamel by theadhesive restorative material

the cavity shape is dictated by the cariesand is unique

Blacks formal cavity designs are obsolete


MANAGEMENT OF CARIOUS DENTINEMANAGEMENT OF CARIOUS DENTINE


81/129


John Tomes (1859)

it is better that a layer ofdiscoloured dentine should be

allowed to remain for theprotection of the pulp rather

than run the risk of sacrificingthe tooth

John Tomes (1859)

it is better that a layer ofdiscoloured dentine should be

allowed to remain for theprotection of the pulp rather

than run the risk of sacrificingthe tooth


When removing caries make the enamelWhen removing caries make the enamel--dentine junctiondentine junction


82/129


When removing caries make the enamel-dentine junctionhard

Excavate demineralized dentine over the pulpal surface to

the level of firm dentine provided there is no likelihood of

pulpal exposureDeep lesions, in symptomless vital teeth, should be gently

excavated. Soft demineralized dentine may remain where its

removal might expose the pulp

Where it is not possible to remove soft, infected dentine(perhaps the patient is anxious or not cooperative), seal in

the infected dentine. A permanent restoration is placed. Do

not re-enter

In a symptomless, vital tooth, this should have a highsuccess rate.

gg jj

hardhard

Excavate demineralized dentine over the pulpal surface toExcavate demineralized dentine over the pulpal surface to

the level of firm dentine provided there is no likelihood ofthe level of firm dentine provided there is no likelihood of

pulpal exposurepulpal exposure

Deep lesions, in symptomless vital teeth, should be gentlyDeep lesions, in symptomless vital teeth, should be gently

excavated. Soft demineralized dentine may remain where itsexcavated. Soft demineralized dentine may remain where its

removal might expose the pulpremoval might expose the pulp

Where it is not possible to remove soft, infected dentineWhere it is not possible to remove soft, infected dentine

(perhaps the patient is anxious or not cooperative),(perhaps the patient is anxious or not cooperative), sealseal inin

the infected dentine. A permanent restoration is placed. Dothe infected dentine. A permanent restoration is placed. Do

not renot re--enterenter

In aIn a symptomless, vital toothsymptomless, vital tooth, this should have a high, this should have a high

success rate.success rate.

Kidd EAM, Essentials of Dental Caries, 3Kidd EAM, Essentials of Dental Caries, 3rdrd EdEd



83/129




84/129


ADHESIVE MATERIALSADHESIVE MATERIALS

resin composite

highly effective to enamel questionable to dentine

excellent mechanical properties

glass-ionomer

highly effective to enamel

highly effective to dentine brittle

resin composite

highly effective to enamel questionable to dentine

excellent mechanical properties

glass-ionomer

highly effective to enamel

highly effective to dentine brittle



85/129


GLASSGLASS--IONOMER CEMENTSIONOMER CEMENTS

significant properties in

minimum intervention dentistry achieves reliable adhesion

may prevent secondarycaries

may remineralise affecteddentine

significant properties insignificant properties in

minimum intervention dentistryminimum intervention dentistry achieves reliable adhesionachieves reliable adhesion

may prevent secondarymay prevent secondarycariescaries

may remineralise affectedmay remineralise affecteddentinedentine



86/129


Ngo,Ngo, inin Mount 2002Mount 2002


MINIMAL INTERVENTION APPROACHESMINIMAL INTERVENTION APPROACHES


87/129

Martin J Tyas (Martin J Tyas (

8787

))

MINIMAL INTERVENTION APPROACHESMINIMAL INTERVENTION APPROACHES

occlusal surfaces fissure sealant

preventive resin restoration

posterior approximal surfaces

tunnel and internal

preparations

slot preparations

occlusal surfaces

fissure sealant

preventive resin restoration

posterior approximal surfaces

tunnel and internal

preparations

slot preparations


PREVENTIVE RESIN RESTORATIONPREVENTIVE RESIN RESTORATION


88/129


Dr Hien Ngo

Adelaide


FISSUROTOMY BURSFISSUROTOMY BURS


89/129


FISSUROTOMY BURSFISSUROTOMY BURS



90/129




91/129


GICGIC



92/129



THE APPROXIMAL CAVITYTHE APPROXIMAL CAVITY


93/129


THE APPROXIMAL CAVITYTHE APPROXIMAL CAVITY


E1

OUTER HALF OF ENAMEL


94/129


E2

INNER HALF OF ENAMEL

D1

JUST INTO DENTINE

APPLY TOPICAL FLUORIDE

AND MONITOR

APPLY TOPICAL FLUORIDE

AND MONITOR

D2

OUTER 1/3 OF DENTINE

DO NOT RESTORE

WITHOUT FURTHER

CONSIDERATION

DO NOT RESTORE

WITHOUT FURTHER

CONSIDERATION

D3

INNER 2/3 OF DENTINE RESTORE NOWRESTORE NOW


EVOLUTION OF THE APPROXIMAL CAVITYEVOLUTION OF THE APPROXIMAL CAVITY


95/129


Soderholm,Soderholm,

Tyas & Jokstad.Tyas & Jokstad.

Crit Rev OralCrit Rev Oral BiolBiolMedMed

1998;9:4641998;9:464--7979



96/129


TUNNEL AND INTERNAL

PREPARATIONS

TUNNELTUNNEL ANDAND INTERNALINTERNAL

PREPARATIONSPREPARATIONS



97/129


Jinks GM, J Dent Child 1963;30:87Jinks GM, J Dent Child 1963;30:87--9292


TUNNEL AND INTERNALTUNNEL AND INTERNAL



98/129



access through marginal fossa to

approximal caries

maintains marginal ridge

tunnel preparation cavity exits into approximal space

internal preparation

demineralised approximal enamel

retained

access through marginal fossa to

approximal caries

maintains marginal ridge

tunnel preparation cavity exits into approximal space


demineralised approximal enamel

retained



99/129




100/129



INTERNALINTERNALPREPARATIONPREPARATION


101/129


PREPARATIONPREPARATION

INTERNAL


INTERNALINTERNALPREPARATIONPREPARATION


102/129


PREPARATION

1.5 mm

INTERNAL


CONDITION (PAA)CONDITION (PAA)

INTERNALINTERNAL



103/129


CONDITION (PAA)CONDITION (PAA)

WASH; DRY; PLACEWASH; DRY; PLACE S/CS/C GICGIC

INTERNAL


ETCH (PHOSPHORIC ACID); WASH; DRYETCH (PHOSPHORIC ACID); WASH; DRY

INTERNALINTERNAL



104/129


APPLY BOND; BLOW THIN; CURE;APPLY BOND; BLOW THIN; CURE;

PLACE COMPOSITE; (PLACE SEALANT); CURE; APPLYPLACE COMPOSITE; (PLACE SEALANT); CURE; APPLY

NEUTRAL FLUORIDENEUTRAL FLUORIDE

INTERNAL


TUNNEL PREPARATIONTUNNEL PREPARATION


105/129


GICGICGIC

AFFECTED DENTINEAFFECTED DENTINEAFFECTED DENTINE

COMPOSITECOMPOSITECOMPOSITE

3 mm


TUNNELTUNNEL



106/129



CLINICAL REVIEW OF TUNNEL AND INTERNAL

RESTORATIONS

CLINICAL REVIEW OFCLINICAL REVIEW OF TUNNELTUNNEL ANDAND INTERNALINTERNAL

RESTORATIONSRESTORATIONS

15 clinical trials in permanent teeth reviewed 15 clinical trials in permanent teeth reviewed


107/129


p

57 90% success up to 3 years

main reasons for failure caries

marginal ridge fracture

placement of resin composite over GIC does notincrease fracture resistance of marginal ridge

failure in one study

3 y 10%; 5 y 65%

p

57 90% success up to 3 years

main reasons for failure caries

marginal ridge fracture

placement of resin composite over GIC does notincrease fracture resistance of marginal ridge

failure in one study

3 y 10%; 5 y 65%

WiegandWiegand && AttinAttin, Dent Mater 2007;23:1461, Dent Mater 2007;23:1461--14671467


median survival times median survival times


RESTORATIONS




108/129

Martin J Tyas (Martin J Tyas (108108))WiegandWiegand && AttinAttin, Dent Mater 2007;23:1461, Dent Mater 2007;23:1461--14671467

GIC tunnel 6 y

resin composite approximal up to 9 y amalgam approximal up to 13 y

annual failure rate

GIC tunnel 7-10%

GIC approximal 7-10%

resin composite approximal 2.3%

amalgam approximal 3.3%

GIC tunnel 6 y

resin composite approximal up to 9 y amalgam approximal up to 13 y

annual failure rate

GIC tunnel 7-10%

GIC approximal 7-10%

resin composite approximal 2.3%

amalgam approximal 3.3%


f t ff ti factors affecting success


RESTORATIONS




109/129


factors affecting success

tooth type, lesion size, tunnel or internal: equivocal

data on influence on performance preservation of approximal enamel in internal

preparation may support ridge, BUT

complete caries removal more difficult to assess in


strong operator influence

9 50% failure among 12 dentists

median survival 40 65 mo among 5 dentists

factors affecting success

tooth type, lesion size, tunnel or internal: equivocal

data on influence on performance preservation of approximal enamel in internal

preparation may support ridge, BUT

complete caries removal more difficult to assess in


strong operator influence

9 50% failure among 12 dentists

median survival 40 65 mo among 5 dentists



RESTORATIONS




110/129


influence of caries activity

conflicting data on success v caries

activity

one trial: higher failure of GICrestorations (no resin composite over

GIC) in high caries active patients

influence of caries activity

conflicting data on success v caries

activity

one trial: higher failure of GICrestorations (no resin composite over

GIC) in high caries active patients


111/129


SLOT PREPARATIONSLOT PREPARATION


112/129


Lasfargues et al.Lasfargues et al.



th d ti t h i i ( i k l d f th the dentist as a physician (requires a knowledge of thethe dentist as a physician (requires a knowledge of thethe dentist as a physician (requires a knowledge of the


113/129






remineralisation/arrest of non-cavitated lesions


caries lesion)



the dentist as a physician (requires a knowledge of thethe dentist as a physician (requires a knowledge of thethe dentist as a physician (requires a knowledge of the

factors associated with the development of caries)factors associated with the development of caries)factors associated with the development of caries)

individualised assessment of caries riskindividualised assessment of caries riskindividualised assessment of caries risk appropriate preventive strategiesappropriate preventive strategiesappropriate preventive strategies

remineralisation/arrest of nonremineralisation/arrest of nonremineralisation/arrest of non---cavitated lesionscavitated lesionscavitated lesions

the dentist as a surgeon (requires a knowledge of thethe dentist as a surgeon (requires a knowledge of thethe dentist as a surgeon (requires a knowledge of the


minimum surgical intervention of cavitated lesionsminimum surgical intervention of cavitated lesionsminimum surgical intervention of cavitated lesions




114/129


MANAGEMENT OF DEFECTIVEMANAGEMENT OF DEFECTIVE



RESTORATION REPLACEMENTRESTORATION REPLACEMENT

b t 60% f l titi ti


115/129


about 60% of a general practitioners timeis spent replacing restorations

most frequent reason is secondary caries

replacement results in

larger cavity damage to adjacent teeth

increased risk of more complex

restorations new defects introduced

about 60% of a general practitioners timeis spent replacing restorations

most frequent reason is secondary caries

replacement results in

larger cavity damage to adjacent teeth

increased risk of more complex

restorations new defects introduced



116/129



DIAGNOSIS OF SECONDARY CARIESDIAGNOSIS OF SECONDARY CARIES


117/129


ditched margins correlate poorly with

secondary caries (Pimenta et al., JPD1995;74:219, Rudolphy et al., Caries Res1995;29:371

only amalgam restorations withmarginal defects > 0.4 mm wide shouldbe replaced (Kidd et al., J Dent Res1995;74:1206)

ditched margins correlate poorly with

secondary caries (Pimenta et al., JPD1995;74:219, Rudolphy et al., Caries Res1995;29:371

only amalgam restorations withmarginal defects > 0.4 mm wide shouldbe replaced (Kidd et al., J Dent Res1995;74:1206)


OPTIONS FOR MANAGEMENTOPTIONS FOR MANAGEMENT


118/129


recontour and/or polish

fissure seal margins

repair local defect

replace restoration

recontour and/or polish

fissure seal margins

repair local defect

replace restoration

INCREASINGLYINCREASINGLY

INVASIVEINVASIVE



119/129




120/129




121/129




122/129




123/129




124/129




125/129



SOME INDICATIONS FORSOME INDICATIONS FOR

RESTORATION REPLACEMENTRESTORATION REPLACEMENT


126/129


extensive secondary cariescannot be removed in a

repair procedure

aesthetic need

pulpal pathology

fixed prosthodontic procedure

extensive secondary caries

cannot be removed in arepair procedure

aesthetic need

pulpal pathology

fixed prosthodontic procedure


OPERATIVE DENTISTRYOPERATIVE DENTISTRY


127/129


TWENTIETH CENTURY (GV BLACK)TWENTIETH CENTURY (GV BLACK)

Extension for preventionExtension for prevention

TWENTYTWENTY--FIRST CENTURYFIRST CENTURY

Prevention of extensionPrevention of extension



128/129


Graham MountGraham MountHien NgoHien Ngo

LawrieLawrie WalshWalsh

Sue GaffneySue GaffneyJohn McIntyreJohn McIntyre

Eric ReynoldsEric Reynolds



129/129


minimum intervention tooth remineralization

Documents