Thai Dental Association Thai Dental Association

June 2009 June 2009

MINIMUM INTERVENTION DENTISTRY – ESSENTIAL CONCEPTS
Martin J Tyas Martin J Tyas
BDS, PhD, DDSc, GradDipHlthSc, FADM, FICD, FRACDS, FPFA, FADI BDS, PhD, DDSc, GradDipHlthSc, FADM, FICD, FRACDS, FPFA, FADI

Professor and Head, Restorative Dentistry Professor and Head, Restorative Dentistry Melbourne Dental School Melbourne Dental School The University of Melbourne The University of Melbourne Australia Australia
Martin J Tyas (1) (1

Thai Dental Association Thai Dental Association

June 2009 June 2009

SUMMARY
overview of Minimum Intervention (MI) overview of Minimum Intervention (MI) definition of MI definition of MI elements of MI elements of MI dental caries dental caries caries risk assessment caries risk assessment prevention prevention remineralisation (medical) remineralisation (medical) techniques techniques operative (surgical) techniques operative (surgical) techniques management of defective restorations management of defective restorations
Martin J Tyas (2) (2

Thai Dental Association Thai Dental Association

June 2009 June 2009

DEFINITION OF MI

an approach to the management of dental caries with the aim of minimising the loss of tooth structure by disease or by iatrogenic intervention
Martin J Tyas (3) (3

Thai Dental Association Thai Dental Association

June 2009 June 2009

Int Dent J 2000;50:1-12

Martin J Tyas (4) (4

Thai Dental Association Thai Dental Association

June 2009 June 2009

CONSENSUS STATEMENT (2007) CONSENSUS STATEMENT (2007) General Assembly of the World Congress of General Assembly of the World Congress of Minimally Invasive Dentistry Minimally Invasive Dentistry Members of the Western, Central, and Eastern Members of the Western, Central, and Eastern (US) Caries Management by Risk Assessment (US) Caries Management by Risk Assessment (CAMBRA) Coalitions (CAMBRA) Coalitions ADEA Cariology Special Interest Group ADEA Cariology Special Interest Group recognize the 2002 FDI Policy Statement recognize the 2002 FDI Policy Statement as as the current clinical standard for caries the current clinical standard for caries management management
Tyas, Anusavice, Frencken & Mount. Int Dent J 2000;50:1-12
Martin J Tyas (5) (5

Thai Dental Association Thai Dental Association

June 2009 June 2009

ELEMENTS OF MINIMUM INTERVENTION

the dentist as a physician (requires a knowledge of the the dentist as a physician (requires a knowledge of the factors associated with the development of caries) factors associated with the development of caries) individualised assessment of caries risk individualised assessment of caries risk appropriate preventive strategies appropriate preventive strategies remineralisation/arrest of non-cavitated lesions remineralisation/arrest of non-cavitated lesions the dentist as a surgeon (requires a knowledge of the the dentist as a surgeon (requires a knowledge of the caries lesion) caries lesion) minimum surgical intervention of cavitated lesions minimum surgical intervention of cavitated lesions appropriate maintenance of existing restorations appropriate maintenance of existing restorations
Martin J Tyas (6) (6

Thai Dental Association Thai Dental Association

June 2009 June 2009

ELEMENTS OF MINIMUM INTERVENTION

the dentist as a physician (requires a knowledge of the the dentist as a physician (requires a knowledge of the factors associated with the development of caries) factors associated with the development of caries) individualised assessment of caries risk individualised assessment of caries risk appropriate preventive strategies appropriate preventive strategies remineralisation/arrest of non-cavitated lesions remineralisation/arrest of non-cavitated lesions the dentist as a surgeon (requires a knowledge of the the dentist as a surgeon (requires a knowledge of the caries lesion) caries lesion) minimum surgical intervention of cavitated lesions minimum surgical intervention of cavitated lesions appropriate maintenance of existing restorations appropriate maintenance of existing restorations
Martin J Tyas (7) (7

Thai Dental Association Thai Dental Association

June 2009 June 2009

MULTIFACTORIAL NATURE OF CARIES
local factors local factors saliva (quality; quantity) saliva (quality; quantity) diet diet carbohydrate carbohydrate intake intake frequency of frequency of exposure to exposure to acids acids exposure to fluoride exposure to fluoride plaque accumulation plaque accumulation and retention and retention

modifying factors dental history medical history lifestyle socio-economic status compliance

Martin J Tyas (8) (8

Thai Dental Association Thai Dental Association

June 2009 June 2009

‘TRAFFIC LIGHT’ RISK 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
Martin J Tyas (9) (9

Thai Dental Association Thai Dental Association

June 2009 June 2009

GC (JAPAN) ‘TRAFFIC LIGHT’ SYSTEM saliva five criteria diet # of CHO exposures/day # of acid exposures/day fluoride exposure past and current plaque three criteria modifying factors five criteria
Martin J Tyas (10) (10)

Thai Dental Association Thai Dental Association

June 2009 June 2009

SALIVA AND DENTAL CARIES

Martin J Tyas (11) (11)

Thai Dental Association Thai Dental Association

June 2009 June 2009

SALIVA 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)
Martin J Tyas (12) (12)

Thai Dental Association Thai Dental Association

June 2009 June 2009

FUNCTIONS 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
Martin J Tyas (13) (13)

Thai Dental Association Thai Dental Association

June 2009 June 2009

ASSESSMENT OF SALIVA (FIVE CRITERIA)

unstimulated minor salivary gland function viscosity pH stimulated flow rate buffering capacity GC Saliva Test kit
Martin J Tyas (14) (14)

Thai Dental Association Thai Dental Association

June 2009 June 2009

MINOR 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
> 60 s 30 – 60 s < 30 s
Martin J Tyas (15) (15)

Thai Dental Association Thai Dental Association

June 2009 June 2009

Ngo & Gaffney

Martin J Tyas (16) (16)

Thai Dental Association Thai Dental Association

June 2009 June 2009

VISCOSITY
open mouth; check for pooling of saliva lift tongue to palate; check for appearance and shiny film on floor of mouth web test: normal = 20 – 50 mm
Thick, ropy, frothy, extended web test No visible pooling; a little sticky Watery with pooling; shiny thin film

Martin J Tyas (17) (17)

Thai Dental Association Thai Dental Association

June 2009 June 2009

Ngo & Gaffney

Martin J Tyas (18) (18)

Thai Dental Association Thai Dental Association

June 2009 June 2009

RED OR YELLOW LIGHT!

causes of defective function severe dehydration medication hormonal imbalance salivary gland pathology
Martin J Tyas (19) (19)

Thai Dental Association Thai Dental Association

June 2009 June 2009

pH
dribble into container insert pH paper read after 10 s

< 5.8 5.8 – 6.8 > 6.8
Martin J Tyas (20) (20)

Thai Dental Association Thai Dental Association

June 2009 June 2009

FLOW RATE
chew on paraffin wax for 5 minutes collect saliva measure volume wide variation among individuals mean 1.6 mL/min

< 3.5 mL After 5 min: 3.5 – 5 mL > 5 mL

Martin J Tyas (21) (21)

Thai Dental Association Thai Dental Association

June 2009 June 2009

BUFFERING CAPACITY
ability to neutralise acid depends on level of bicarbonate use saliva collected for flow rate use test strip as directed assess against colour standard
GC IVOCLAR

0–5 6–9 10 – 12

Low Moderate High
Martin J Tyas (22) (22)

Thai Dental Association Thai Dental Association

June 2009 June 2009

MR CHAIWAT SATHORN

15-FEB-2009

Martin J Tyas (23) (23)

Thai Dental Association Thai Dental Association

June 2009 June 2009

GC (JAPAN) ‘TRAFFIC LIGHT’ SYSTEM saliva saliva five criteria five criteria diet # of CHO exposures/day # of acid exposures/day fluoride exposure past and current plaque three criteria modifying factors five criteria
Martin J Tyas (24) (24)

Thai Dental Association Thai Dental Association

June 2009 June 2009

DIET: FREQUENCY OF CARBOHYDRATE INTAKE
high CHO intake immediate 2-4 point pH (depends on bacteria, plaque thickness, salivary buffering) pH recovery; 20 min – hours
Martin J Tyas (25) (25)

Thai Dental Association Thai Dental Association

June 2009 June 2009

DIET: FREQUENCY OF EXPOSURE TO ACIDS
non-bacterial acid sources intrinsic acid (e.g., gastric reflux, bulimia) extrinsic acid (e.g., black cola drinks, ‘sports’ drinks) caries ‘erosion’ (corrosion)
Martin J Tyas (26) (26)

Thai Dental Association Thai Dental Association

June 2009 June 2009

ASSESSMENT OF DIET
# CHO EXPOSURES # ACID EXPOSURES BETWEEN MEALS BETWEEN MEALS

>2 >1 Nil

>3 >2 1

Martin J Tyas (27) (27)

Thai Dental Association Thai Dental Association

June 2009 June 2009

GC (JAPAN) ‘TRAFFIC LIGHT’ SYSTEM saliva saliva five criteria five criteria diet diet # of CHO # of CHO exposures/day exposures/day # of acid # of acid exposures/day exposures/day fluoride exposure past and current plaque three criteria modifying factors five criteria
Martin J Tyas (28) (28)

Thai Dental Association Thai Dental Association

June 2009 June 2009

CLINICAL EFFECTS OF FLUORIDE

remineralisation of incipient enamel caries (‘white spot’ lesion) slow down/partly remineralise carious dentine in cavitated lesion remineralise root caries lesion hypermineralisation most effective for smooth-surface caries
Martin J Tyas (29) (29)

Thai Dental Association Thai Dental Association

June 2009 June 2009

EXPOSURE TO FLUORIDE
EXPOSURE TO FLUORIDE Nil Water OR toothpaste Water AND toothpaste

Martin J Tyas (30) (30)

Thai Dental Association Thai Dental Association

June 2009 June 2009

GC (JAPAN) ‘TRAFFIC LIGHT’ SYSTEM saliva saliva five criteria five criteria diet diet # of CHO # of CHO exposures/day exposures/day # of acid # of acid exposures/day exposures/day fluoride exposure past and current plaque three criteria modifying factors five criteria
Martin J Tyas (31) (31)

Thai Dental Association Thai Dental Association

June 2009 June 2009

ASSESSMENT OF BIOFILM (PLAQUE)

Plaque Check (GC Corporation) thickness/maturity 2-colour disclosing gel pink = thin, new plaque blue = thick, mature plaque sucrose challenge and resultant pH
Martin J Tyas (32) (32)

Thai Dental Association Thai Dental Association
DR HIEN NGO

June 2009 June 2009

GC Corporation

Martin J Tyas (33) (33)

Thai Dental Association Thai Dental Association

June 2009 June 2009

Ivoclar Vivadent

Martin J Tyas (34) (34)

Thai Dental Association Thai Dental Association

June 2009 June 2009

‘CRT Buffer’, ‘CRT Bacteria’ (Ivoclar Vivadent)

Martin J Tyas (35) (35)

Thai Dental Association Thai Dental Association

June 2009 June 2009

MODIFYING FACTORS (5)
1. 1.

2. 2.

3. 3.

dental history dental history ● active caries lesions ● active caries lesions ● restorations (past or current risk?) ● restorations (past or current risk?) medical history medical history ● numerous medications xerostomia, e.g., ● numerous medications xerostomia, e.g., antidepressants; hypotensives; antidepressants; hypotensives; anticholinergics; antipsychotics; diuretics; anticholinergics; antipsychotics; diuretics; anti-Parkinson anti-Parkinson lifestyle lifestyle ● caffeine, alcohol (diuretics) ● caffeine, alcohol (diuretics) ● smoking (effect on saliva) ● smoking (effect on saliva)

Martin J Tyas (36) (36)

Thai Dental Association Thai Dental Association

June 2009 June 2009

MODIFYING FACTORS (5)
socio-economic status (SES) socio-economic status (SES) ● low SES may indicate low educational ● low SES may indicate low educational level, thus low level of understanding level, thus low level of understanding ● financial issues ● financial issues cost of treatment cost of treatment cost of accessing treatment cost of accessing treatment 5. compliance; depends on 5. compliance; depends on ● patient attitude ● patient attitude ● practicality/appropriateness of treatment ● practicality/appropriateness of treatment plan plan
4. 4.

Martin J Tyas (37) (37)

Thai Dental Association Thai Dental Association

June 2009 June 2009

ASSESSMENT 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?
YES to any ONE above NO to all above
Martin J Tyas (38) (38)

Thai Dental Association Thai Dental Association

June 2009 June 2009

DAVID – AGED 24
lives in unfluoridated town lives in unfluoridated town labourer on building site labourer on building site not well educated not well educated works outdoors in hot climate works outdoors in hot climate potential dehydration potential dehydration drinks low pH black cola drinks (‘Coca Cola’) drinks low pH black cola drinks (‘Coca Cola’) frequent refined CHO intake frequent refined CHO intake poor oral hygiene poor oral hygiene poor attitude (parents F/F) poor attitude (parents F/F)
Martin J Tyas (39) (39)

Thai Dental Association Thai Dental Association

June 2009 June 2009

DAVID – AGED 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
Martin J Tyas (40) (40)

Thai Dental Association Thai Dental Association

June 2009 June 2009

DAVID – AGED 24
Saliva Plaque Diet Fluoride Modifying factors

Martin J Tyas (41) (41)

Thai Dental Association Thai Dental Association Dr Douglas Bratthall

June 2009 June 2009

CARIOGRAM SCORE CARD

FREQUENCY OF INTAKE OF FERMENTABLE CARBOHYDRATE

Martin J Tyas (42) (42)

Thai Dental Association Thai Dental Association

June 2009 June 2009

2 1
www.db.od.mah.se/car/cariogram/cariograminfo.html
Martin J Tyas (43) (43)

Thai Dental Association Thai Dental Association

June 2009 June 2009

AGED CARE FACILITY

Dr Jane Chalmers

Dr Jane Chalmers

Dr Jane Chalmers

Martin J Tyas (44) (44)

Thai Dental Association Thai Dental Association

June 2009 June 2009

Dr MA Stacey, University of Melbourne

SJOGREN’S SYNDROME

Dr MA Stacey, University of Melbourne
Martin J Tyas (45) (45)

Thai Dental Association Thai Dental Association

June 2009 June 2009

‘RADIATION CARIES’

Dr MA Stacey, University of Melbourne

Martin J Tyas (46) (46)

Thai Dental Association Thai Dental Association

June 2009 June 2009

ELEMENTS OF MINIMUM INTERVENTION

the dentist as a physician (requires a knowledge of the the dentist as a physician (requires a knowledge of the factors associated with the development of caries) factors associated with the development of caries) individualised assessment of caries risk individualised assessment of caries risk appropriate preventive strategies appropriate preventive strategies remineralisation/arrest of non-cavitated lesions remineralisation/arrest of non-cavitated lesions the dentist as a surgeon (requires a knowledge of the the dentist as a surgeon (requires a knowledge of the caries lesion) caries lesion) minimum surgical intervention of cavitated lesions minimum surgical intervention of cavitated lesions appropriate maintenance of existing restorations appropriate maintenance of existing restorations
Martin J Tyas (47) (47)

Thai Dental Association Thai Dental Association

June 2009 June 2009

ELEMENTS OF MINIMUM INTERVENTION

the dentist as a physician (requires a knowledge of the the dentist as a physician (requires a knowledge of the factors associated with the development of caries) factors associated with the development of caries) individualised assessment of caries risk individualised assessment of caries risk appropriate preventive strategies appropriate preventive strategies remineralisation/arrest of non-cavitated lesions remineralisation/arrest of non-cavitated lesions the dentist as a surgeon (requires a knowledge of the the dentist as a surgeon (requires a knowledge of the caries lesion) caries lesion) minimum surgical intervention of cavitated lesions minimum surgical intervention of cavitated lesions appropriate maintenance of existing restorations appropriate maintenance of existing restorations
Martin J Tyas (48) (48)

Thai Dental Association Thai Dental Association

June 2009 June 2009

‘DEMIN-REMIN’ CYCLE
Critical pH of HA Critical pH of FA

pH

6.0

5.5

5.0
HA dissolves; FA forms if F- present

4.5

4.0
FA and HA dissolve

H+ reacts with PO4-in saliva and plaque

DEMINERALISATION

FA and HA reform

FA reforms

REMINERALISATION

If H+ neutralised, and Ca++ and PO4-- present

pH

6.0

5.5

5.0

4.5

4.0
Martin J Tyas (49) (49)

Thai Dental Association Thai Dental Association

June 2009 June 2009

FACTORS PROMOTING ‘REMIN’

pH > 5.5 phosphate ions calcium ions fluoride ions
Martin J Tyas (50) (50)

Thai Dental Association Thai Dental Association

June 2009 June 2009

Clinical use of calcium phosphates for remineralization not successful

‘insoluble’ calcium phosphates ‘insoluble’ calcium phosphates low solubility (particularly with F) low solubility (particularly with F) not easily applied nor effectively not easily applied nor effectively localized at tooth surface localized at tooth surface require acid for solubility to produce require acid for solubility to produce remineralizing ions remineralizing ions soluble calcium phosphates soluble calcium phosphates can only be used at low concentrations can only be used at low concentrations do not effectively localize at tooth do not effectively localize at tooth surface surface
Martin J Tyas (51) (51)

Thai Dental Association Thai Dental Association

June 2009 June 2009

CALCIUM PHOSPHOPEPTIDE-AMORPHOUS CALCIUM PHOSPHOPEPTIDE-AMORPHOUS PHOSPHATE

casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) 25+ years research by Reynolds et al. (Melbourne Dental School, University of Melbourne) based on milk protein ‘Recaldent’™ (Cadbury Schweppes)
Martin J Tyas (52) (52)

Thai Dental Association Thai Dental Association

June 2009 June 2009

CLINICAL APPLICATIONS OF CPP-ACP
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.)

Martin J Tyas (53) (53)

Thai Dental Association Thai Dental Association

June 2009 June 2009

Martin J Tyas (54) (54)

Thai Dental Association Thai Dental Association

June 2009 June 2009

Clinical study of enamel de- and rederemineralization by chewing gum
2720 subjects (≈ 12.5 y old) 2720 subjects (≈ 12.5 y old) Normal use of fluoride toothpaste, fluoridated Normal use of fluoride toothpaste, fluoridated water water Sugar-free gum containing CPP-ACP; control gum Sugar-free gum containing CPP-ACP; control gum randomly assigned, double blinded randomly assigned, double blinded Gum chewed 3 x daily for 2 years Gum chewed 3 x daily for 2 years Standardized digital radiographs at baseline and Standardized digital radiographs at baseline and 24 months 24 months Caries progression/regression analyzed using a Caries progression/regression analyzed using a transition matrix transition matrix
Morgan et al. (2006) J Dent Res
Martin J Tyas (55) (55)

Thai Dental Association Thai Dental Association

June 2009 June 2009

Clinical study of enamel de- and rederemineralization by chewing gum Recaldent in sugar-free gum significantly slowed progression promoted regression (remineralization) of dental caries relative to a control sugar-free gum in school children in an optimally fluoridated city and using fluoride-containing toothpaste
Morgan et al. (2006) J Dent Res
Martin J Tyas (56) (56)

Thai Dental Association Thai Dental Association

June 2009 June 2009

MI PASTE

Martin J Tyas (57) (57)

Thai Dental Association Thai Dental Association BEFORE TREATMENT BEFORE TREATMENT

June 2009 June 2009

AFTER RECALDENT AFTER RECALDENT
Martin J Tyas (58) (58)

Thai Dental Association Thai Dental Association
Prof L J Walsh, U of Q

June 2009 June 2009

Prof L J Walsh, U of Q

Martin J Tyas (59) (59)

Thai Dental Association Thai Dental Association

June 2009 June 2009

CONCLUSION
RecaldentTM (CPP-ACP) technology RecaldentTM (CPP-ACP) technology remineralizes enamel subsurface lesions in situ remineralizes enamel subsurface lesions in situ slows the progression of coronal caries slows the progression of coronal caries promotes regression of caries promotes regression of caries CPP-ACP plus F (Tooth Mousse Plus) CPP-ACP plus F (Tooth Mousse Plus) is a superior form of fluoride is a superior form of fluoride should be clinicians’ first choice should be clinicians’ first choice for the prevention of caries and erosion for the prevention of caries and erosion for the treatment of dentinal hypersensitivity for the treatment of dentinal hypersensitivity for the repair of ‘white spot’ lesions for the repair of ‘white spot’ lesions

Martin J Tyas (60) (60)

Thai Dental Association Thai Dental Association

June 2009 June 2009

RESIN INFILTRATION infiltration of non-cavitated lesions by low viscosity polymerisable resin ‘Icon’; DMG Co, Hamburg several published laboratory studies clinical studies in progress
Martin J Tyas (61) (61)

Thai Dental Association Thai Dental Association

June 2009 June 2009

Martin J Tyas (62) (62)

Thai Dental Association Thai Dental Association

June 2009 June 2009
Courtesy of DMG GmbH Courtesy of DMG GmbH

Martin J Tyas (63) (63)

Thai Dental Association Thai Dental Association

June 2009 June 2009

ELEMENTS OF MINIMUM INTERVENTION

the dentist as a physician (requires a knowledge of the the dentist as a physician (requires a knowledge of the factors associated with the development of caries) factors associated with the development of caries) individualised assessment of caries risk individualised assessment of caries risk appropriate preventive strategies appropriate preventive strategies remineralisation/arrest of non-cavitated lesions remineralisation/arrest of non-cavitated lesions the dentist as a surgeon (requires a knowledge of the the dentist as a surgeon (requires a knowledge of the caries lesion) caries lesion) minimum surgical intervention of cavitated lesions minimum surgical intervention of cavitated lesions appropriate maintenance of existing restorations appropriate maintenance of existing restorations
Martin J Tyas (64) (64)

Thai Dental Association Thai Dental Association

June 2009 June 2009

GV BLACK
extensive research on amalgam (Dental Cosmos, 1896) A Work on Operative Dentistry in Two Volumes (1908)

Greene Vardiman BLACK (1835-1915)

Martin J Tyas (65) (65)

Thai Dental Association Thai Dental Association

June 2009 June 2009

BLACK’S TEACHINGS

highly formalised cavity designs; precise size and geometry weak, non-adhesive materials ‘extension for prevention’

Martin J Tyas (66) (66)

Thai Dental Association Thai Dental Association

June 2009 June 2009

A Work on Operative Dentistry in Two Volumes (5th Ed, 1922)

Martin J Tyas (67) (67)

Thai Dental Association Thai Dental Association

June 2009 June 2009

‘SURGICAL MODEL’ (≈ 1900 - 1980s)

caries can be ‘cured’ by excision of all decayed tooth structure, and replacement with a filling material now known to be incorrect
Martin J Tyas (68) (68)

Thai Dental Association Thai Dental Association

June 2009 June 2009

STRUCTURALLY WEAKENED TOOTH + NON-ADHESIVE RESTORATIVE MATERIAL

HIGH INCIDENCE OF SUBSEQUENT TOOTH FRACTURE
Martin J Tyas (69) (69)

Thai Dental Association Thai Dental Association

June 2009 June 2009

Martin J Tyas (70) (70)

Thai Dental Association Thai Dental Association

June 2009 June 2009

WHAT’S CHANGED?
enhanced understanding of the carious enhanced understanding of the carious process process an infectious disease an infectious disease demineralisation/remineralisation cycle demineralisation/remineralisation cycle recognition of the rôle of fluoride recognition of the rôle of fluoride inhibiting demineralisation inhibiting demineralisation enhancing remineralisation enhancing remineralisation development of adhesive materials development of adhesive materials glass-ionomer cement glass-ionomer cement resin-based materials resin-based materials
Martin J Tyas (71) (71)

Thai Dental Association Thai Dental Association

June 2009 June 2009

MINIMUM INTERVENTION IN OPERATIVE 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
Martin J Tyas (72) (72)

Thai Dental Association Thai Dental Association

June 2009 June 2009

INDICATIONS FOR RESTORATION (‘SURGICAL APPROACH’)

cavitation rendering plaque control unachievable aesthetics unsatisfactory function compromised

Martin J Tyas (73) (73)

Thai Dental Association Thai Dental Association

June 2009 June 2009

‘ADHESIVE’ PREPARATIONS
conservative cavity macromechanical retention not required reduction in microleakage reduced incidence of secondary caries reduced marginal staining reduced pulp damage restoration of tooth strength
Martin J Tyas (74) (74)

Thai Dental Association Thai Dental Association

June 2009 June 2009

DENTINE CARIES (Fusayama; Massler)
‘infected’ (outer carious) dentine (A) ‘infected’ (outer carious) dentine (A) moist, soft, pale yellow moist, soft, pale yellow heavy bacterial load heavy bacterial load collagen degraded collagen degraded non-remineralisable non-remineralisable ‘affected’ (inner carious) dentine (B) ‘affected’ (inner carious) dentine (B) dry, hard, brown/black dry, hard, brown/black few or no bacteria few or no bacteria collagen cross-links intact collagen cross-links intact remineralisable remineralisable

A B

Martin J Tyas (75) (75)

Thai Dental Association Thai Dental Association

June 2009 June 2009

TREATMENT OF CARIOUS DENTIN EXCAVATION TECHNIQUES
Manual excavation Rotary excavation Controlled selective rotary excavation torque control handpiece polymer burs Sono-abrasion Air abrasion Chemo-mechanical excavation Enzymatic digestion Laser photo-ablation Accepted procedure ‘Gold standard’ – but should be modified Experimental Unconvincing Experimental Experimental Limited applications Experimental Experimental

Noack et al., Oral Health & Prev Dent 2004;2 (Supp 1):301-306
Martin J Tyas (76) (76)

Thai Dental Association Thai Dental Association

June 2009 June 2009

TREATMENT OF CARIOUS DENTIN DISINFECTION TECHNIQUES
Ozone Photodynamic therapy Antibacterial therapy Primary root caries More research for other applications Promising Adjunctive to other methods

SEALING TECHNIQUES
Fluoride-releasing materials Dentin adhesives Limited acceptance Promising

Antibacterial materials Promising
Noack et al., Oral Health & Prev Dent 2004;2 (Supp 1):301-306
Martin J Tyas (77) (77)

Thai Dental Association Thai Dental Association

June 2009 June 2009

Martin J Tyas (78) (78)

Thai Dental Association Thai Dental Association

June 2009 June 2009

EXCAVATE WITH FIRM PRESSURE UNTIL HARD, DRY, DARK COLOUR

Martin J Tyas (79) (79)

Thai Dental Association Thai Dental Association

June 2009 June 2009

PRINCIPLES OF MINIMUM INTERVENTION RESTORATIONS

remove only degraded enamel and remove only degraded enamel and ‘infected’ dentine ‘infected’ leave ‘affected’ dentine leave ‘affected’ dentine support undermined enamel by the support undermined enamel by the adhesive restorative material adhesive restorative material the cavity shape is dictated by the caries the cavity shape is dictated by the caries and is unique and is unique Black’s ‘formal’ cavity designs are obsolete Black’s ‘formal’ cavity designs are obsolete
Martin J Tyas (80) (80)

Thai Dental Association Thai Dental Association

June 2009 June 2009

MANAGEMENT OF CARIOUS DENTINE

John Tomes (1859) ‘it is better that a layer of discoloured dentine should be allowed to remain for the protection of the pulp rather than run the risk of sacrificing the tooth’
Martin J Tyas (81) (81)

Thai Dental Association Thai Dental Association

June 2009 June 2009

When removing caries make the enamel-dentine junction When removing caries make the enamel-dentine junction hard hard Excavate demineralized dentine over the pulpal surface to Excavate demineralized dentine over the pulpal surface to the level of firm dentine provided there is no likelihood of the level of firm dentine provided there is no likelihood of pulpal exposure pulpal exposure Deep lesions, in symptomless vital teeth, should be gently Deep lesions, in symptomless vital teeth, should be gently excavated. Soft demineralized dentine may remain where its excavated. Soft demineralized dentine may remain where its removal might expose the pulp removal might expose the pulp Where it is not possible to remove soft, infected dentine Where it is not possible to remove soft, infected dentine (perhaps the patient is anxious or not cooperative), seal in (perhaps the patient is anxious or not cooperative), seal in the infected dentine. A permanent restoration is placed. Do the infected dentine. A permanent restoration is placed. Do not re-enter not re-enter In aasymptomless, vital tooth, this should have aahigh In symptomless, vital tooth, this should have high success rate. success rate.
Kidd EAM, Essentials of Dental Caries, 3rd Ed

Martin J Tyas (82) (82)

Thai Dental Association Thai Dental Association

June 2009 June 2009

Martin J Tyas (83) (83)

Thai Dental Association Thai Dental Association

June 2009 June 2009

ADHESIVE MATERIALS
resin composite highly effective to enamel questionable to dentine excellent mechanical properties glass-ionomer highly effective to enamel highly effective to dentine brittle
Martin J Tyas (84) (84)

Thai Dental Association Thai Dental Association

June 2009 June 2009

GLASS-IONOMER CEMENTS

significant properties in minimum intervention dentistry achieves reliable adhesion may prevent secondary caries may remineralise affected dentine
Martin J Tyas (85) (85)

Thai Dental Association Thai Dental Association

June 2009 June 2009

Ngo, in Mount 2002

Martin J Tyas (86) (86)

Thai Dental Association Thai Dental Association

June 2009 June 2009

MINIMAL INTERVENTION APPROACHES

occlusal surfaces fissure sealant ‘preventive resin restoration’ posterior approximal surfaces ‘tunnel’ and ‘internal’ preparations ‘slot’ preparations
Martin J Tyas (87) (87)

Thai Dental Association Thai Dental Association

June 2009 June 2009

PREVENTIVE RESIN RESTORATION

Dr Hien Ngo Adelaide
Martin J Tyas (88) (88)

Thai Dental Association Thai Dental Association

June 2009 June 2009

FISSUROTOMY BURS

Martin J Tyas (89) (89)

Thai Dental Association Thai Dental Association

June 2009 June 2009

Martin J Tyas (90) (90)

Thai Dental Association Thai Dental Association

June 2009 June 2009

GIC

Martin J Tyas (91) (91)

Thai Dental Association Thai Dental Association

June 2009 June 2009

Martin J Tyas (92) (92)

Thai Dental Association Thai Dental Association

June 2009 June 2009

THE APPROXIMAL CAVITY

Martin J Tyas (93) (93)

Thai Dental Association Thai Dental Association
E1 OUTER HALF OF ENAMEL

June 2009 June 2009

E2 INNER HALF OF ENAMEL

APPLY TOPICAL FLUORIDE APPLY TOPICAL FLUORIDE AND MONITOR AND MONITOR

D1 JUST INTO DENTINE

D2 OUTER 1/3 OF DENTINE

DO NOT RESTORE DO NOT RESTORE WITHOUT FURTHER WITHOUT FURTHER CONSIDERATION CONSIDERATION

D3 INNER 2/3 OF DENTINE

RESTORE NOW RESTORE NOW
Martin J Tyas (94) (94)

Thai Dental Association Thai Dental Association

June 2009 June 2009

EVOLUTION OF THE APPROXIMAL CAVITY

Soderholm, Tyas & Jokstad. Crit Rev Oral Biol Med 1998;9:464-79

Martin J Tyas (95) (95)

Thai Dental Association Thai Dental Association

June 2009 June 2009

‘‘TUNNEL’ AND ‘‘INTERNAL’ TUNNEL’ AND INTERNAL’ PREPARATIONS PREPARATIONS

Martin J Tyas (96) (96)

Thai Dental Association Thai Dental Association

June 2009 June 2009

Jinks GM, J Dent Child 1963;30:87-92
Martin J Tyas (97) (97)

Thai Dental Association Thai Dental Association

June 2009 June 2009

TUNNEL AND INTERNAL PREPARATIONS
access through marginal fossa to access through marginal fossa to approximal caries approximal caries maintains marginal ridge maintains marginal ridge tunnel preparation tunnel preparation cavity ‘exits’ into approximal space cavity ‘exits’ into approximal space internal preparation internal preparation demineralised approximal enamel demineralised approximal enamel retained retained
Martin J Tyas (98) (98)

Thai Dental Association Thai Dental Association

June 2009 June 2009

Martin J Tyas (99) (99)

Thai Dental Association Thai Dental Association

June 2009 June 2009

Martin J Tyas (100) (100)

Thai Dental Association Thai Dental Association

June 2009 June 2009

INTERNAL PREPARATION

INTERNAL

Martin J Tyas (101) (101)

Thai Dental Association Thai Dental Association

June 2009 June 2009

INTERNAL PREPARATION

≥ 1.5 mm

INTERNAL

Martin J Tyas (102) (102)

Thai Dental Association Thai Dental Association

June 2009 June 2009
INTERNAL PREPARATION CONDITION (PAA)

WASH; DRY; PLACE S/C GIC

INTERNAL
Martin J Tyas (103) (103)

Thai Dental Association Thai Dental Association

June 2009 June 2009
INTERNAL PREPARATION

ETCH (PHOSPHORIC ACID); WASH; DRY

APPLY BOND; BLOW THIN; CURE; PLACE COMPOSITE; (PLACE SEALANT); CURE; APPLY NEUTRAL FLUORIDE

INTERNAL

Martin J Tyas (104) (104)

Thai Dental Association Thai Dental Association

June 2009 June 2009

TUNNEL PREPARATION

AFFECTED DENTINE AFFECTED DENTINE

GIC
≥ 3 mm

COMPOSITE COMPOSITE

Martin J Tyas (105) (105)

Thai Dental Association Thai Dental Association

June 2009 June 2009
TUNNEL PREPARATION

Martin J Tyas (106) (106)

Thai Dental Association Thai Dental Association

June 2009 June 2009

CLINICAL REVIEW OF ‘‘TUNNEL’ AND ‘‘INTERNAL’ CLINICAL REVIEW OF TUNNEL’ AND INTERNAL’ RESTORATIONS RESTORATIONS

15 clinical trials in permanent teeth reviewed 57 – 90% success up to 3 years main reasons for failure caries marginal ridge fracture placement of resin composite over GIC does not increase fracture resistance of marginal ridge failure in one study 3 y – 10%; 5 y – 65%
Wiegand & Attin, Dent Mater 2007;23:1461-1467
Martin J Tyas (107) (107)

Thai Dental Association Thai Dental Association

June 2009 June 2009

CLINICAL REVIEW OF ‘‘TUNNEL’ AND ‘‘INTERNAL’ CLINICAL REVIEW OF TUNNEL’ AND INTERNAL’ RESTORATIONS RESTORATIONS

median survival times 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%
Wiegand & Attin, Dent Mater 2007;23:1461-1467
Martin J Tyas (108) (108)

Thai Dental Association Thai Dental Association

June 2009 June 2009

CLINICAL REVIEW OF ‘‘TUNNEL’ AND ‘‘INTERNAL’ CLINICAL REVIEW OF TUNNEL’ AND INTERNAL’ RESTORATIONS RESTORATIONS

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 internal preparation strong operator influence 9 – 50% failure among 12 dentists median survival 40 – 65 mo among 5 dentists
Wiegand & Attin, Dent Mater 2007;23:1461-1467

Martin J Tyas (109) (109)

Thai Dental Association Thai Dental Association

June 2009 June 2009

CLINICAL REVIEW OF ‘‘TUNNEL’ AND ‘‘INTERNAL’ CLINICAL REVIEW OF TUNNEL’ AND INTERNAL’ RESTORATIONS RESTORATIONS

influence of caries activity conflicting data on success v caries activity one trial: higher failure of GIC restorations (no resin composite over GIC) in high caries active patients

Wiegand & Attin, Dent Mater 2007;23:1461-1467

Martin J Tyas (110) (110)

Thai Dental Association Thai Dental Association

June 2009 June 2009

OVERALL CONCLUSION OVERALL CONCLUSION clinical success may be related to clinical success may be related to mechanical strength of cavity mechanical strength of cavity characteristics of restorative material characteristics of restorative material operator skill operator skill patient caries activity patient caries activity demanding procedure requiring practice demanding procedure requiring practice rubber dam; lighting; magnification rubber dam; lighting; magnification
Wiegand & Attin, Dent Mater 2007;23:1461-1467
Martin J Tyas (111) (111)

Thai Dental Association Thai Dental Association

June 2009 June 2009

SLOT PREPARATION

Lasfargues et al.
Martin J Tyas (112) (112)

Thai Dental Association Thai Dental Association

June 2009 June 2009

ELEMENTS OF MINIMUM INTERVENTION

the dentist as a physician (requires a knowledge of the the dentist as a physician (requires a knowledge of the factors associated with the development of caries) factors associated with the development of caries) individualised assessment of caries risk individualised assessment of caries risk appropriate preventive strategies appropriate preventive strategies remineralisation/arrest of non-cavitated lesions remineralisation/arrest of non-cavitated lesions the dentist as a surgeon (requires a knowledge of the the dentist as a surgeon (requires a knowledge of the caries lesion) caries lesion) minimum surgical intervention of cavitated lesions minimum surgical intervention of cavitated lesions appropriate maintenance of existing restorations appropriate maintenance of existing restorations
Martin J Tyas (113) (113)

Thai Dental Association Thai Dental Association

June 2009 June 2009

MANAGEMENT OF DEFECTIVE RESTORATIONS

Martin J Tyas (114) (114)

Thai Dental Association Thai Dental Association

June 2009 June 2009

RESTORATION REPLACEMENT
about 60% of a general practitioner’s time about 60% of a general practitioner’s time is spent replacing restorations is spent replacing restorations most frequent reason is secondary caries most frequent reason is secondary caries replacement results in replacement results in larger cavity larger cavity damage to adjacent teeth damage to adjacent teeth increased risk of more complex increased risk of more complex restorations restorations new defects introduced new defects introduced
Martin J Tyas (115) (115)

Thai Dental Association Thai Dental Association

June 2009 June 2009

Martin J Tyas (116) (116)

Thai Dental Association Thai Dental Association

June 2009 June 2009

DIAGNOSIS OF SECONDARY CARIES ‘ditched’ margins correlate poorly with secondary caries (Pimenta et al., JPD (Pimenta et al., JPD
1995;74:219, Rudolphy et al., Caries Res 1995;74:219, Rudolphy et al., Caries Res 1995;29:371 1995;29:371

only amalgam restorations with marginal defects > 0.4 mm wide should be replaced (Kidd et al., J Dent Res (Kidd et al., J Dent Res
1995;74:1206) 1995;74:1206)

Martin J Tyas (117) (117)

Thai Dental Association Thai Dental Association

June 2009 June 2009

OPTIONS FOR MANAGEMENT

recontour and/or polish fissure seal margins INCREASINGLY INVASIVE repair local defect replace restoration
Martin J Tyas (118) (118)

Thai Dental Association Thai Dental Association

June 2009 June 2009

Martin J Tyas (119) (119)

Thai Dental Association Thai Dental Association

June 2009 June 2009

Martin J Tyas (120) (120)

Thai Dental Association Thai Dental Association

June 2009 June 2009

Martin J Tyas (121) (121)

Thai Dental Association Thai Dental Association

June 2009 June 2009

Martin J Tyas (122) (122)

Thai Dental Association Thai Dental Association

June 2009 June 2009

Martin J Tyas (123) (123)

Thai Dental Association Thai Dental Association

June 2009 June 2009

Martin J Tyas (124) (124)

Thai Dental Association Thai Dental Association

June 2009 June 2009

Martin J Tyas (125) (125)

Thai Dental Association Thai Dental Association

June 2009 June 2009

SOME INDICATIONS FOR RESTORATION REPLACEMENT

extensive secondary caries cannot be removed in a repair procedure aesthetic need pulpal pathology fixed prosthodontic procedure
Martin J Tyas (126) (126)

Thai Dental Association Thai Dental Association

June 2009 June 2009

OPERATIVE DENTISTRY
TWENTIETH CENTURY (GV BLACK) ‘Extension for prevention’ TWENTY-FIRST CENTURY ‘Prevention of extension’
Martin J Tyas (127) (127)

Thai Dental Association Thai Dental Association

June 2009 June 2009

Graham Mount Hien Ngo Lawrie Walsh Sue Gaffney John McIntyre Eric Reynolds

Martin J Tyas (128) (128)

Thai Dental Association Thai Dental Association

June 2009 June 2009

Martin J Tyas (129) (129)