Minimal Intervention In Operative Dentistry

Minimal Intervention in Operative
Dentistry, Evidence Based Approach
By
Sahar Mohamed Aly El-marsafy
BDS, Cairo university, Egypt
MDSc,Cairo University, Egypt
DDS Al-Azhar University, Egypt
Assistant Professor, Restorative Dentistry Department, Faculty of Dentistry,
Umm Al-Qura University, Makkah, Saudi Arabia
1435 (H)-2014 (G)

Minimum intervention dentistry is a
concept based on a better understanding of
the caries process and development of the
carious process and the development of new
diagnostic technologies and adhesives,
bioactive restorative materials.

Minimum intervention can be defined as an approach
for dentists to base their treatment plans on four key-
points:
 Comprehensive diagnosis of the disease.
 The possibility to prevent caries and to remineralise
early lesions.
 Minimally invasive operative treatment including
repair of previous restorations rather than their
systematic replacement.
 Patient education.

 Evidence based dentistry
has been defined by the
American Dental Association
as :
'An approach to oral
healthcare that requires the
judicious integration of
systematic assessments of
clinically relevant scientific
evidence, relating to patient's
oral and medical condition
and history, with the dentist's
clinical expertise and the
patient's treatment needs
and preferences'.
Abhishek M, Gurkiran K, Gupta S. Evidence based
dentistry – a new paradigm. Indian J D Sc 2011; 5 (3):
24-28.

 In terms of where best
to find answers of high
quality of evidence , a
clear hierarchy can be
described by
evidence-based
clinical guidelines,
Cochrane systematic
reviews, systematic
reviews and studies.
The evidence pyramid
Wilson N H F. Minimally invasive dentistry: the management of
caries. 1sted. New Malden; Quintessence Publishing Co. Ltd; 2007.

Throughout the review, guidance on decision
making in respect of best quality evidence of
different aspects of minimum intervention in
operative dentistry will be provided.

 A pan-European group of dental clinicians and
clinical academics co-ordinated by GC Europe –
namely the GC Europe MI Advisory Board – has
developed a "Minimal Intervention Treatment
Plan (MITP)".
 The basis of the MITP framework is composed of
four phases of patient-centered treatment
interlinking with each other: MI identify; MI
prevent; MI restore and MI recall.

Decision tree showing the treatment plan for Minimal Intervention in Cariology in four
stages as proposed by the GC-MI-Advisory Board .
Domejean-Orliaguet S, Banerjee A, Gaucher C, Miletic I, Basso M, Reich E et al. Minimum intervention treatment plan
(MITP) – practical implementation in general dental practice. J Minim Inter Dent 2009; 2(2): 103-124.

 The MI Identify phase can be divided into the
following practical stages; Anamnesis – the
process of verbal history taking, oral
examination and radiography and other
methods of caries detection.
 In 2005, the International Caries Detection and
Assessment System (ICDAS) Foundation was
set up to develop a "standardized" visual scoring
system for use in dental education, research and
clinical practice.

A modified ICDAS 5-point visual scoring system to be used in general dental practice. Green captions describe the
visual appearance of occlusal / smooth surfaces and the associated black captions, the equivalent histological
features of the tooth.The clinical images provide examples of each score.
Domejean-Orliaguet S, Banerjee A, Gaucher C, Miletic I, Basso M, Reich E et al. Minimum intervention treatment plan
(MITP) – practical implementation in general dental practice. J Minim Inter Dent 2009; 2(2): 103-124.

 Although, radiographs still play an important role in
caries detection their ability to identify earlier or
hidden caries is questionable.
Wilson N H F, Roulet J-F, Fuzzi M. Advances in operative dentistry, volume2: challenges of the future. 1sted.
Berlin; Quintessence Publishing Co, Inc; 2001.

 There are numerous other techniques developed for
early caries detection like digital radiology, electrical
conductance (EC), fiber optic transillumination
(FOFI), digital fiber optic transillumination (DIFOTI),
quantitative light fluorescence (QLF) and
DIAGNOdent.
DIAGNOdent device
Wilson N H F, Roulet J-F, Fuzzi M. Advances in operative dentistry, volume2: challenges of the
future. 1sted. Berlin; Quintessence Publishing Co, Inc; 2001.

 Factors affecting the patient
susceptibility to caries are
general and oral.
 General factors include: diet,
fluoride exposure, health,
medications, social factors
and age.
 Oral factors which influence
the caries susceptibility of
the patient are: oral hygiene
maintenance, saliva, plaque
and bacterial balance.
Summitt J B, Robbins JW, HiltonT J, Schwartz R S, Santos J D.
Fundamentals of operative dentistry, a contemporary approach.
3rd ed. Illinois; Quintessence Publishing Co. Inc; 2006.

Summary of factors to consider when assessing individual caries susceptibility

CRT test for Mutans Streptococci (MS) and
Lactobacilli (LB) from a very high-risk patient.
The Cariscreen test
Three plaque pH tests from very low
risk (1) low risk (2) and very high risk
(3) patients.
Milicich G. Caries: A clinical perspective of the oral disease we
struggle to manage. J Minim Interv Dent 2008; 1(1): 26-34.

Tongue plaque sampling using the clinproCario Diagnisis-
L-Pop (CCLP) swab and comparison of the coloration of
the swab with CCLP color chart.
Transcriptions of stained surfaces in Clinpro
Cario Diagnosis (CCD) impressions to the
tooth schema.
Wilson N H F. Minimally invasive dentistry: the management of caries. 1sted. New Malden; Quintessence Publishing Co. Ltd;
2007.

 Recently, a number
of complex risk
models have been
proposed.
 One of these
models was the
Cariogram.
 The Cariogram is a
graphical illustration
of the caries risk
profile of an
individual.
.
Wilson N H F, Roulet J-F, Fuzzi M. Advances in operative
dentistry, volume2: challenges of the future. 1sted. Berlin;
Quintessence Publishing Co, Inc; 2001.

 CAMBRA is based on performing a risk
assessment on patients at risk of caries and then
making individualized recommendations based
on the level of risk (low, moderate, high or
extreme). Finally determine the plan for caries
intervention and prevention.
 The approach is designed to educate and
motivate patients to change their behaviors and
implement changes to reach oral health and
then maintain it.

The preventive standard care consists of:
Daily oral hygiene.
Dietary advice.
Patient motivation.

The preventive active care consists of:
 Preventive standard care.
Professional decontamination.
The professional decontamination includes:
 Mechanical tooth cleaning.
 Antimicrobial agents.
 Management of saliva.
 Replacement therapy.
 Caries vaccine.

o Chlorhexidine (CHX) as varnish, gel and rinse.
o Triclosan.
o Essential oil (EO).
o Recently, Ozone and Photo-Activation Disinfection
(PAD) systems could be used as a disinfecting method.
 Weighing its established side effects and the inconclusive
evidence for benefits, the clinical usage of chlorhexidine is
even being dissuaded.
 However, 'inconclusive evidence does not necessarily
mean not effective; therefore, the use of antimicrobial, in
the current time, has been restricted to caries active
individuals and to high caries risk individuals.

With respect to the minimal intervention
treatment philosophy, the surgical excisional
approach to caries should be undertaken only
as a last resort in order to minimize tissue loss
and patient discomfort.
Non invasive restorative phase includes:
 Remineralization therapies.
 Therapeutic sealants.

 Fluorides.
 Casein phosphopeptide.
 Sugar substitutes.
 Calcium sodium phosphosilicate.
 Hydroxyapatite.
 Recently, there are some techniques used for remineralization like ozone
therapy and photoactivated light.
 The remineralizing agents can be incorporated into different products
like:
• Dentifrices.
• Chewing gums & lozenges.
• Pastes & tooth mousse & topical cream.
• Mouth rinses.
• Varnishes & gels.
• Dental floss.
• Foods & drinks.
• Also it can be added to restorative materials like; glass ionomer,
compomer, giromers and fissure sealant.

The protective properties of saliva are
maximized when saliva flow is stimulated
following the consumption of fermentable
carbohydrates.
With increased salivary flow, the fall in plaque
pH caused by acid by product is reduced and
the potential for remineralization increased.

 The series of seven Cochrane systematic reviews,
published in the Cochrane Library, assesses the
effectiveness of fluoride toothpastes, gels,
varnishes, and mouthrinses through comparisons
against non-fluoride controls, against each other,
and against different combinations.
Original attached glass slow releasing fluoride device.
Pessan J P, Al-ibrahim N S, Buzalaf M A R,Toumba K H. Slow release fluoride devices: a literature review. J
Minim Interv Dent 2009; 2(4); 223-236.

CPP-ACP products
Wilson N H F. Minimally invasive dentistry: the management of caries. 1sted.
New Malden; Quintessence Publishing Co. Ltd; 2007.
Basso M.Tooth restorations-non invasive techniques. J Minim Interv Dent
2011; 4(3): 165-167.

The remineralizing effect of CPP-ACP
products on initial carious lesions has been
well documented through clinical trials and
systematic reviews.
Further Randomized Controlled Trials are
needed in order to confirm these initial
results in-vivo.

 A nonfermentable sugar alcohol acts as a
carrier or reservoir for calcium phosphates.
 The abilities of xylitol and sorbitol to
remineralize early enamel caries seem to be
almost similar.
 Adding isomalt to a demineralizing solution as
soft drinks has shown to significantly reduce
tooth mineral loss.

 The new formed hydroxycarbonate
apatite (HCA) layer applied to
enamel and any exposed dentine
makes the tooth more resistant to
acid attack.
Products that contain NovaMin
(dentifrices & chewing gum)
Wilson N H F. Minimally invasive dentistry: the management of caries. 1sted. New Malden; Quintessence
Publishing Co. Ltd; 2007.

Hydroxyapatite has been used in toothpaste
(as filler) and pit and fissure sealant.
Recent study concluded that products
containing nano carbonate hydroxyapatite
crystals as toothpasts revealed higher
remineralization effects compared to amine
fluoride toothpastes with bovine dentin and
comparable trends were obtained for enamel.

 Ozone acts as disinfectant.
 The use of O3 offers a minimally interventive approach to
the management of root and fissure caries.
 Further research is required to investigate the efficiency and
cost benefits of this treatment modality.
Application of ozone in the management of root caries

 PAD is a method of disinfecting or sterilizing a
site (tissue, wound and lesions of the cavity).
 The low power laser energy in itself is not
particularly lethal to bacteria, but is useful for
photochemical activation of the dye.
 The photosensitive dyes release reactive oxygen
species which cause membrane and DNA
damage to the microorganisms.

 Fissure sealant is a
minimally interventive
method that aims to
prevent caries.
 The decision to seal
teeth should be based
on the general and
local risk, not on the
patient's age alone.
Wilson N H F, Roulet J-F, Fuzzi M. Advances in
operative dentistry, volume2: challenges of the
future. 1sted. Berlin; Quintessence Publishing
Co, Inc; 2001.

 The principle of cavity design for amalgam
restoration as established by GV Black at the end
of the 19th century, have guided operative
dentistry throughout most of the 20th century.
 In line with the changing caries disease patterns,
the advances in adhesive restorative materials,
and the current focus on minimal intervention,
modification and changes in cavity design are
appropriate.

Tunnel preparation
Conservative preparation
Slot preparation.
Summitt J B, Robbins JW, HiltonT J, Schwartz R S, Santos J D. Fundamentals of operative dentistry, a contemporary approach.
3rd ed. Illinois; Quintessence Publishing Co. Inc; 2006.

 systematic review of conservative intervention
has revealed that conservatism per se does not
guarantee increased restoration longevity.
 All restorations are vulnerable to caries
recurrence, material failures, and technical
deficiencies.
 Indeed, misguided conservatism in some cases
may accelerate restoration demise due to the
technical difficulties involved, the materials
used, and the absence of disease control.

The philosophies of preservative dentistry
and ART may be similar in that the greatest
emphasis is placed on those individuals at
highest risk for caries progression.
Wilson N H F, Roulet J-F, Fuzzi M. Advances in operative dentistry, volume2: challenges of the future.
1sted. Berlin; Quintessence Publishing Co, Inc; 2001.

1. Hand excavation.
2. Micro-preparation rotary instruments.
3. Non rotary cutting tools.

The rotary method continues to be the most
widely used technique (gold standard) and is
currently being adapted due to new
demands, through the use of more accurate
drills with smaller active components with
longer and thinner necks.
Examples include fissurotomy burs, self
limiting burs, polymer bursand Cerabur.

Fissurotomy burs (SSWhite)
Summitt J B, Robbins JW, HiltonT J, Schwartz R S, Santos J D. Fundamentals of operative dentistry, a contemporary
approach. 3rd ed. Illinois; Quintessence Publishing Co. Inc; 2006.
(left) Smart burs removing carious dentine (a).The polymer instrument remains largely intact (b). (right)
When the polymer instrument hits sound dentine (a) it is visibly worn away (b).
Wilson N H F. Minimally invasive dentistry: the management of caries. 1sted. New Malden; Quintessence Publishing
Co. Ltd; 2007.

 Following minimal intervension approach,
various non rotary cutting techniques were
introduced.
 These techniques include:
 Ultrasonic.
 Air abrasion.
 Chemomechanical.
 Laser.
 Most of them still in the experimental stage and
did not have strong evidence.

Wilson N H F, Roulet J-F, Fuzzi M. Advances in operative dentistry, volume2: challenges of the
future. 1sted. Berlin; Quintessence Publishing Co, Inc; 2001.

Some of the situations where the air abrasion has
particularly proved a boon include:
 Removal of superficial enamel defects.
 Detection of pit and fissure caries.
 Removal of pit and fissure surface stain.
 Preparation of conservative cavities.
 Surface preparation of abfractions and abrasions.
 Removal of existing restorations.
 The use of local anesthesia while working in dentin
may be avoided because of their cooling action
through high pressure air.

Air abrasion used to remove pit & fissure caries using 27 micron-sized powder particles.
HegdeV S, Khatavkar R A.A new dimension to conservative dentistry: air abrasion. J
Conserv Dent 2010; 13(1): 4-8.

 Bioglass is a novel ceramic materials that can be
manufactured with different hardness, which could
therefore allow tailoring of their properties for
cutting hard substances such as enamel and exposed
sound dentine, or soft ones such as carious dentins.
(a) Occlusal enamel fissure following bioactive glass air-abrasion. (b) SEM replica of prepared tooth
showing fissure opening has been increased by the use bioactive glass powder, the powder preferentially
removed weakened enamel in the carious fissure X25

 Given the limitations of the existing Cariosolv system, the
application of this approach tend to be limited to the
treatment of anxious patients, root caries and deep lesions
of caries.
Wilson N H F. Minimally invasive dentistry: the management of caries. 1sted. New Malden; Quintessence Publishing Co. Ltd; 2007.

 It would seem at this time that laser is most
useful for smaller occlusal and cervical lesions
where access is simple.
 Preparation of larger cavities can be tedious
and time consuming with little gain from the
patient point of view.

.
 By GV Black, in 1908, that is preferable to expose
the pulp of a tooth than to leave it covered only
with softened dentine. Present day discussion is
how much caries can be left, rather than how
much should be removed.
 In the late 1970s, Fusayma suggested that only
the outer layer of irreversible demineralized, non
sensitive, caries-infected dentine should be
removed, leaving the inner layer of
remineralizable, sensitive, caries-affected
dentine.

Well controlled study at 10 years on a series
of occlusal restorations where soft
demineralized dentine was not removed
gives long term clinical evidence that, soft,
infected demineralized dentine may be safely
left, provided it is sealed from the oral
environment as carious dentine left under a
properly seal restoration will not progress.

 Restorative intervention in the MI philosophy is based on
the principle of maximal preservation of natural tooth
structure and on the use of biomimetic materials.
 Currently there are several restorative materials that are
compatible with a minimal interventive philosophy. These
include the following: resin composites, giomers,
ormocers, compomers, resin-modified and traditional
glass-ionomer cements.
 Some adhesives and resin-based composite have
antimicrobial properties.
 Amalgam despite its proven longevity is not compatible
with a minimal interventive philosophy.

Biomimetics (amelogenins, hydroxyapatite,
enamel replication and repair) and Genetic
Engineering technology are a new
technology mimicking processes that occur in
nature such as the formation of dental
enamel.

 Glass ionomer has been shown to fulfill some
requirements of biomimetic materials although
physical properties of the material fall short of
ideal at this time.
 Biomimetic or Bioactive composites introduced
nanoparticles of amorphous calcium phosphate
component in resin composites, with a smart
release of calcium and phosphate ions at a
cariogenic pH 4 to inhibit caries.

 Options for management of failed restoration
started with recontour and/or polish, fissure seal
margins, repair local defect and finally replace
the restoration.
 Additional measures include preventive
procedures to limit the risk of secondary caries
formation, and detailed oral hygiene
instructions.
 For small sized cavities suitably restored with
composite, fracture, pulpal complications and
post-operative sensitivity are unlikely.

 The main objective of the MI recall visit are to
control the oral balance, to prevent oral disease
and possibly to detect and treat it at an early
stage.
 A recent systematic review on the subject
published by the Cochrane Collaboration
pointed out that there is still an ongoing
international debate in relation to the clinical
effectiveness and recall intervals for specific
types of care.

1. Having decided that caries is essentially a
disease of bacterial origin then it is
mandatory that we think in terms of early
recognition of its presence in the mouth,
followed by elimination of the active disease,
prior to undertaking moves to repair the
damaged that it has caused.

2. Although of more sensitive techniques and
various systems have been developed,
bitewing radiography associated with a
visual examination is still the gold
standard for detecting and following up the
initial carious lesions, because it is reliable,
reproducible and quick and easy to use.

3. Caries risk must be assessed periodically as
by using a Cariogram model and lesion
severity must be monitored to track the
activity status of the disease and to adjust
the treatment including the program of
prevention, all of these should be explained
to the patient.

4. Until such time as the alternative therapies
are proven to be safe and effective for
humans, conventional caries prevention
methods primarily based on applications of
fluoride and effective plaque removal must
be used.

5. Remineralization through the stimulation
of saliva, preferably in the presence of
fluoride is well established. The recent
development of novel remineralization
agents like CPP-ACP, bioactive glass and
Ozone therapy may herald the introduction
of new approaches to the minimally, if not
non-interventive management of caries.

6. Operative intervention is indicated to treat
caries, conservation of sound tooth tissue is
possible using of the modern techniques like
ultrasonic, air abrasion and laser. The rotary
method continues to be the most widely
used tooth cutting technique (gold
standard) and is currently being adapted due
to new demands.

7. To move toward less interventive restorative
procedures coupled with patient pressure has
rightly fuelled the greater use of direct
adhesive tooth-colored restorative materials.
8. New evidence is now available supporting the
use of Atraumaric Restorative Treatment as
viable alternative for tooth restoration.

9. Although conservatism per se does not
guarantee increased restoration longevity, the
long term performance of minimally
interventive restorations appears to be good.
10. Despite the limitations of repair and
modifications to existing restoration, such
procedures are considered to be an integral
element of modern minimally interventive
dentistry.

11. There are different international consensus
guidelines for implementation of minimal
intervention dentistry in clinical practice.
Minimum Intervention Treatment Plan
(MITP) which developed by GC Europe MI
Advisory Board present easy evidence
based protocol to follow, step-by-step
flowchart to be used in daily practice.

1. Whatever your individual difficulties and
challenges may be, your professional
responsibilities to your patients require that,
together with the other members of your
dental team, you make the shift to evidence
based, minimally invasive approaches to
oral healthcare provision.

2. Further minimum intervention applications
are currently under development or already
pioneered. As the clinical implementation
of minimum intervention is still new, there
is a need for the best available evidence
and its continuous update in order to show
its efficacy in daily dental practice.

• Mickenautsch S. An introduction to minimum intervention dentistry. Singapore Dent J 2005; 27: 1-6.
• Wilson N H F. Minimally invasive dentistry: the management of caries. 1sted. New Malden;
Quintessence Publishing Co. Ltd; 2007.
• Tays M J, Anusaavice K, Frencken J E, Mount G J. Minimal intervention dentistry- a review. FDI
Commission Project 1-97. Int Dent J 2000; 50: 1-12.
• Roulet J F. Proceedings of the 1st European conference on preventive and minimally invasive
dentistry. Oral Hlth Press Dent 2004; Suppl 1.
• Mickenautsch S. Adopting minimum intervention in dentistry: diffusion, bias and the role of scientific
evidence. International Dentistry S A 2009; 11(1): 16-26.
• Domejean-Orliaguet S, Banerjee A, Gaucher C, Miletic I, Basso M, Reich E et al. Minimum intervention
treatment plan (MITP) – practical implementation in general dental practice. J Minim Inter Dent 2009;
2(2): 103-124.
• Mount G J. Minimal intervention: a new concept for operative dentistry. Quint Int 2000; 31: 527-533.
• Jensen L, BudenzAW, Featherstone F D B. Clinical protocol for caries management by risk
assessment. J Calif Dent Assoc 2009; 35: 714-723.

Minimal Intervention In Operative Dentistry

Minimal Intervention In Operative Dentistry

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