Minimal Intervention Dentistry

Nikita Sebastian
MDS 2nd year
Department of Conservative Dentistry & Endodontics
 CONTENTS
• Introduction
 Minimally invasive operative care
• History
1. Minimally invasive excavation
• Definition techniques
• Concepts of minimal intervention dentistry 2. Sealing techniques
 Early and accurate caries diagnosis  Minimal intervention cavity designs
 Risk assessment as a factor in determining • Materials for minimally invasive
treatment operative care
 Assessment of individual caries risk  Repair v/s replacement
 Prevention of dental caries and the control • Conclusion
of disease progression
 INTRODUCTION
 G.V.Black’s concept

Removing the diseased portion of the tooth along with the extension of cavities to the areas
prone to caries

 This resulted in mechanistic/surgical approach rather than biologic/holistic/therapeutic

one

 With development in materials, instrumentation & diagnostic techniques,

Extension for
prevention Prevention of
extension
 HISTORY
1883- W.D. Miller identified bacterial involvement in the development of caries

1891- G.V. Black put forth the concept of Extension for Prevention

1917- G.V Black laid down the basic tenets for the design of cavities prescribed for restoring
carious lesion

1945- Air abrasion was 1st described by Dr. Robert Black.

1964 - 1st original research on LASER drilling of teeth by Goldman, Stern and Sognnaes

1966- Markley modification of the cavity designs laid by Black to more conservative preparation
 1977- Simonsen introduced preventive resin restoration

Mid 1980s- ART was pioneered in Zimbabwe and Tanzania

1980- Tunnel restoration was reintroduced by Hunt & Knight

1997- New classification of caries by G.J. Mount and Hume

1999 - World Congress of Minimally Invasive Dentistry

2003- Modification of cavity design by G.J. Mount and Hume

Papain Gel and Ozone therapy introduced.
 DEFINITION
“
“Philosophy of professional care concerned with first occurrence, earliest possible cure of
disease on micro (molecular) levels, followed by minimally invasive & patient friendly treatment
to repair irreversible damage caused by such disease.”

Tyas MJ Anusavice KJ, Frencken JE, Mount GJ. Minimal intervention dentistry-a review.
FDI Commission Project 1-97.
 The opportunity for The incidence
recurrent caries to of early
develop along a restoration
restoration margin failure is BENEFITS OF
reduced
is minimized
CONSERVING THE
TOOTH
Reduced incidence of
Pulp vitality STRUCTURE
is retained
tooth fracture resulting
from weakening of the
cusps
 Early and
accurate
diagnosis of
caries
Repair rather
than Assessment
replacement of individual
of defective caries risk
restorations

CONCEPTS
CONCEPTS
Restoring Decreasing the
cavitated risk of further
lesions using demineralizatio
minimal n and arresting
cavity designs The re- existing lesions
mineralization
and monitoring
of non-
cavitated
Tyas MJ Anusavice KJ, Frencken JE, Mount GJ. Minimal intervention dentistry- arrested lesion
a review. FDI Commission Project 1-97. Int Dent J 2000;50:1-12
Early and Accurate
Caries Diagnosis
 Diagnostic Tools

Traditional Methods New methods

Mirror & probe Digital fiber optic Transillumination

Elective tooth separation Fluorescence

Radiographs UV illumination

Dyes Electronic caries monitor

Ultrasonic imaging

Endoscope\ videoscope
 VISUAL & TACTILE
EXAMINATION

 VISUAL

Cavitation, surface roughness, opacification and

discoloration of clean and dried teeth under
adequate light source.

 TACTILE

Use of an explorer to detect softened tooth

structure
 DYES
• Used due to the property of the dyes to enhance the contrast by their colour.

• Stains only the demineralized dentin with collagen degradation

 Dyes for enamel caries

 ‘Procion’
 ‘Calcein’
 ‘Brilliant blue’

 Dyes for dentinal caries

 0.5% Basic Fuchsin in propylene glycol

 Methylene blue
 Acid red

DIGITAL AIDS
DIGITAL RADIOGRAPHY
Digital image is formed by
spatially distributed set of
discrete sensors and pixel.
DIGITAL SUBTRACTION
RADIOGRAPHY
- Two radiographs of the same
object can be compared by
their pixel values.
- The value of the pixels of the
first object is subtracted from
the second image.
DIGITAL FIBER OPTIC
TRANSILLUMINATION
A visible light (780 nm)
propagates via an optical fiber
through the tooth to a non-
illuminated surface (usually the
opposite surface). The data
acquired by a digital electronic
CCD camera is sent to a computer
for analysis, which produces
digital images.
 Quantitative light
induced fluoroscence

It detects carious lesion and quantifying enamel mineral loss

 Measures the percentage fluorescence change in demineralized

enamel with respect to surrounding sound enamel

 Relates it directly to the amount of mineral lost by demineralization.

 Used to assess the impact of preventive measures on the re-

mineralization and reversal of the caries process as it is capable of
monitoring and quantifying changes in the mineral content of white
spot lesions.
 DIAGNODENT
 Introduced by KaVo in 1998.
 It emits a red light (λ= 655 nm), which is absorbed
by bacterial by-products such as porphyrins.
 Principle –
Bacterial metabolites within caries produce
fluorescence that can be enhanced by a laser light

 The device captures this fluorescence and

translates it on a numerical scale from 0 to 99: the
higher the number, the deeper the carious lesions.
 Designed for the detection of caries lesions in
occlusal and smooth surfaces.
 ELECTRICAL
CARIES MONITOR
• Employs a single, fixed-frequency alternating current
which attempts to measure the ‘bulk resistance’ of tooth
tissue.

• It is generally accepted that the increase in porosity

associated with caries is responsible for the mechanism
of action for ECM.

 Interpretation of values

• -1.00 to 3.00 - sound enamel or incipient stage of caries

• 3.01 to 6.00 - caries upto the DEJ (enamel caries)
• 6.01 to 8.00 - dentinal caries
• 8.01 to 13.00 - extending half of dentine thickness
 INFRARED
THERMOGRAPHY
◆ Described by Kaneko et al. (1999)
◆ Principle - It is possible to measure changes in
thermal energy when fluid is lost from a lesion by
evaporation.

 With a constant flow of air over the surface of the

tooth, the change in temp of the lesion is compared
with that of the surrounding sound tooth structure.

Indium/antimony thermal sensors, which can

detect temp changes in the order of 0.025ºC.
 TERAHERTZ
IMAGING
◆ Makes use of waves with terahertz frequency (1012
Hz or 30 micro metre wavelength)

◆ This wave is short enough to provide reasonable

resolution and long enough to prevent serious
scattering.

◆ Terahertz images can be recorded using CCD

detector.
 Longitudinal sections through three teeth have
demonstrated increased terahertz absorption by early
occlusal caries and an apparent ability to discriminate
dental caries from idiopathic enamel Hypo-
 OPTICAL
COHERENCE
TOMOGRAPHY
◆ Developed by Otis et al.

◆ Uses broadband, near infra-red light sources with

considerable penetration into the tissues.

◆ Creates cross sectional images of structures using

differences in the reflection (scattered &
transmitted or reflected) of light emitted from the
tooth structure.

◆ Most sensitive method for detecting recurrent

 ULTRASOUND
CARIES
◆ Described by Ng et al in 1998 to find carious lesion on DETECTOR
smooth surface.

◆ Sound waves with frequency between 1.6-10MHz.

◆ Detects lesion easily because the travel time of ultrasonic

pulses differ in sound and demineralized enamel tissues.

◆ Used in detecting early enamel lesions because the

lesions confined the enamel produce no detectable or
weak echoes whereas deeper lesions produce higher
amplitudes.
 ENDOSCOPE

 This technique utilises the fluorescence of enamel that

occurs when it is illuminated with blue light in range of
wavelength of 400-500nm.

 Highly sensitive for occlusal enamel caries and high

specificity for approximal lesions.

 Advantage – 5-10 fold magnification

 Disadvantage
 Requires meticulous drying and isolation.
 Takes 5-10 minutes compared to 3-5 minutes for conventional
technique.
 VIDEOSCOPE

 The integration of the camera and endoscope is called a

videoscope.

 This is designed in such a way that the image of the

surface of enamel can be viewed directly over a
television screen.

 It has certain advantages like providing a magnified

image and being clinically feasible. However, it requires
meticulous drying and isolation of teeth and is time
consuming.
Assessment of individual caries
risk
CARIES ACTIVITY TESTS
• Caries activity is a measure of speed of progression of a carious lesion or the degree
to which the local environment challenge favors the probability of caries.

Caries activity test helps to -

• Identify high-risk groups and individuals.

• Determine the need for personalized preventive

measures and motivate the individual

• Ensure low level of caries activity before starting

any restoration procedure.
CARIOGRAM
• Introduced by Brathall.
• Computer program that serves to assess and graphically illustrate the caries risk for a
patient.
 AIM
 Illustrate the chance to avoid caries.
 Illustrate the interaction of caries related factors.
 Express caries risk graphically.
 Recommend targeted preventive actions.
CARIES MANAGEMENT BY RISK ASSESSMENT(CAMBRA)

Francisco et al. Caries Management by Risk Assessment : CAMBRA in Dental Practice, Updated 1 st Ed.
Prevention of dental caries and the control
of disease progression
Non-operative treatment
PLAQUE CONTROL
 MECHANICAL

• Proper brushing technique

• Brushing frequency

• Interdental cleaning

• Toothpaste type/amount
PROFESSIONAL MECHANICAL PLAQUE REMOVAL
 CHEMICAL
• Bisbiguanide – Chlorhexidine and Alexidine
• Quaternary ammonium compounds - Cetylpyridinium chloride, Benzethonium
Cationic chloride
agents • Heavy metal salts – Copper, Zinc & Tin
• Pyrimidines - Hexitindine
• Herbal extracts – Sanguinarine

Anionic
• Sodium dodecyl sulphate
agents

Non ionic • Phenol, thymol, Listerine, triclosan, 2-polyphenol & hexyl resorcinol
agents

Other • Xylitol
agents
 CHLORHEXIDINE

• Cationic bis-biguanide with both hydrophilic and

hydrophobic properties. 

• High concentration – Bactericidal

Precipitation of cell wall constituents and contents.

• Low concentration – Bacteriostatic

Interruption of membrane function

• Inhibits enzymes(glucosyltransferases) that are essential for

microbial contamination on tooth surface.
• Superior anti-plaque agent due to – Substantivity
 XYLITOL

 It is a natural 5-carbon sugar obtained from birch trees.

 Used as a sugar substitute.

 MECHANISM

• Inhibitory effect on glycolysis

• Reduces adhesiveness through impaired polysaccharide 
formation 

• Increases the salivary flow

  Remineralizing agents

 Fluorides
 CPP-ACP
 Tricalcium phosphate
New approaches  NovaMin
 Enamelon
directed towards  Dicalcium phosphate dihydrate
increasing tooth  Resin infiltration
resistance  Laser light

 New vaccine strategies

 Saliva enhancement therapies

 ROLE OF
FLUORIDES

Inhibiting bacterial
metabolism after diffusing
Inhibiting demineralization Fluoride plays a critical role in the
when fluoride is present at demineralization-remineralization cycle
into the bacteria as the
the crystal surface during
hydrogen fluoride molecule
an acid challenge
because it enhances uptake of calcium
when the plaque is acidified and phosphate ions and can appear in the
form of fluorapatite in which the fluoride
ion replaces the hydroxyl ion.
Enhancing remineralization
& thereby forming a low
solubility veneer similar to Fluorapatite begins to demineralise at a pH
the acid resistant mineral of 4.5 rather than 5.5 for hydroxyapatite
fluorapatite
 FLUORIDE
ADMINISTRATION
2% NaF (9200 ppm) 8% SnF2 (19500 ppm) 1.23% APF(12,300 ppm)
• 20g NaF + 1L distilled water
• 0.8 g SnF2 + 10 mL distilled water • 20 g of NaF in 1L of 0.1M
• Knutson and Feldman
• Muhler technique Phosphoric acid + 50%
technique (1948)
• Once per year hydrofluoric acid
• 3, 7, 11 and 13 years
 ADVANTAGES
• 2nd 3rd and 4th application are at • Brudevold technique
weekly interval.
• The rapid penetration of tin and • Semi-annual
 ADVANTAGES
fluoride within 30 sec  ADVANTAGES
• Highly insoluble tin-fluoro
• Chemically stable
phosphate complex - more • 50% more effective F uptake
• Acceptable taste because of
resistant to decay than NaF
neutral pH
 DISADVANTAGES • Solution is cheap and long shelf
• Non-irritating to the gingiva
• Does not discolour the teeth life
• Unstable in aqueous solution so
• Cheap and inexpensive
should be prepared freshly  DISADVANTAGES
 DISADVANTAGES
• Metallic taste
• May cause gingival irritation • Acidic, sour and bitter in taste
• Pt has to make four visits in a
• Discolouration
short period of time.
 Casein phosphopeptide
amorphous calcium phosphate
(CPP-ACP)
• Casein is the predominant phosphoprotein (80%) in bovine
milk.
• Under alkaline conditions, exists in an amorphous phase along
with calcium & phosphate  CPP-ACP

• CPP-ACP can be used as an adjunct preventive therapy :

 Reduce caries in high risk patients

 Reduce dental erosion in patients with gastric reflux
 To repair enamel involving white spot lesions
 Desensitizing agent
 Casein
phosphopeptide
amorphous calcium
fluoride phosphate
(CPP-ACFP)

• CPP-ACP + 0.2 w/w % NaF (900 ppm)

 CPP-ACP when combined with fluoride show

synergism in remineralizing potential.

Attiguppe P, Malik N, et al. CPP–ACP and Fluoride: A Synergism to Combat Caries. Int J Clin
Pediatr Dent 2019;12(2):120–125.
TRICALCIUM PHOSPHATE
• A substantial increase in Ca & P
concentration in plaque and saliva after
using TCP chewing gums
• This increases pH which further
increases tooth mineral saturation during
an acidic challenge and thus decreasing
demineralization
ENAMELON
• Consists of unstabilized Ca & P salts
with sodium fluoride
• Enamelon toothpastes shown to be
beneficial in reduction of white spot
lesions and remineralization of tooth
enamel by acidic beverages

NOVAMIN
• It is a bioactive glass ceramic (calcium sodium
phosphosilicate) material that when exposed to
aqueous medium provides calcium and
phosphate ions that form hydroxyl-carbonate
apatite (HCA) with time.
• Able to fill in small surface defects in tooth
enamel and thereby help stop erosion from
acidic foods and helps in remineralization.
DICALCIUM PHOSPHATE
DIHYDRATE
• Its slurries were shown to be
effective in preventing plaque pH
drop and allowing higher degree
of saturation for an extended
period of time
 RESIN
INFILTRATION
 Represents an approach to the treatment of non-cavitated lesions on proximal and smooth surfaces
of primary and permanent teeth.

 PRINCIPLE

To perfuse porous enamel with resin by capillary action, thereby

stopping the process of demineralisation and stabilising the carious
lesion

 Resin infiltrates the lesion, make the bacteria inactive and prevents
caries progression compared to the sealant which only work as
mechanical barrier between the tooth structure and the oral
environment .
• ICON® works on the principle of the light-scattering
phenomenon.
• The sound enamel has a refractive index of 1.62. The porosities
of a white spot carious lesion are usually filled with either a
watery medium or air, which have refractive indices of 1.33
and 1, respectively.
• The whitish appearance of the lesion is because of the difference in the refractive
index between the enamel crystals and the medium within causing scattering of the
light.
• The microporosities on lesion body are infiltrated with the resin material which has a
refractive index of 1.46, thus making the differences between the enamel and porosities
negligible, so that the lesion appears similar to the surrounding enamel.
 COMPOSITION – 15% hydrochloric acid, ethanol & resin material

Meligy OAESE, Ibrahim STE, Alamoudi NM (2018) Resin Infiltration of Non-Cavitated Proximal Caries Lesions: A Literature
Review. J Oral Hyg Health 6: 235.
• In addition to masking enamel white spot lesions, resin infiltration is able to envelop
residual enamel crystallites forming an enamel hybrid layer.

• This hybridization makes resin-embedded enamel more resistant to acid attack than
sound enamel.

Perdigão J. Resin infiltration of enamel white spot lesions: An ultramorphological analysis. J

Esthet Restor Dent. 2020 Apr;32(3):317-324.
 LASER LIGHT
• Low energy CO2 laser treatment of dental enamel can inhibit caries-progression in
laboratory studies by up to 85%

This decomposes the carbonate,

The carbonated hydroxyapatite in the leaving behind a hydroxyapatite-like
surface and immediate subsurface of mineral that is much less soluble than
the enamel is heated upto temp the original mineral; thus reducing
>400⁰C during the laser irradiation. the caries progression

Featherstone et al. Dent Clin N Am 2000;44:955-69

 CARIES VACCINE
Active immunization
- Use of synthetic s.mutans peptide
Coupling s.mutans antigen to cholera
toxin subunits
Fusing s.mutans gene with avirulent  Objective
salmonellla
Liposome delivery systems
To stimulate the oral mucosal
immune system and induce
Passive immunization potent secretary IgA
- Monoclonal antibodies applied
topically
Immune bovine milk
Egg yolk antibody
Transgenic plant antibody
 Saliva
enhancement
Local or topical therapies
sialagogues
Systemic sialagogues
◆ Local stimulation of salivary
gland  fiber-rich, well- ◆ Pilocarpine - 5-10mg ,4 times daily
flavoured aromatic food ◆ Cevimeline HCl - 30mg thrice daily
◆ Use of fluoridated chewing ◆ Yohimbine
gums, mouthwash and gel
◆ Interferon alpha – IU 3 (improved salivary acini H/P
◆ Artificial saliva containing
by 6 months)
sodium fluoride
Minimally invasive
Operative Care
 Minimally invasive
excavation techniques
MANUAL EXCAVATION
◆ It is based on the mechanical removal of softened,
completely denatured dentin using a sharp hand
excavator; and is an accepted procedure especially in
anxious patients and pediatric patients.

 The high pressure exerted during excavation may cause

pain
 The sharp cutting profile may increase the risk of
removing intact dentin
SMART PREP BURS
• Manufactured from a special polymer material. The
cutting edges are shovel-like straight.
• Knoop Hardness Number

Carious dentin < Smart burs < Healthy dentin

Selective removal of carious dentin

• Excavation is carried out from the center to the

periphery
The polymer burs were found to be as effective as the conventional burs in terms of
microbial presence after caries removal but are more time-consuming than
conventional burs.

Somani R, Chaudhary R, Jaidka S, Singh DJ. Comparative Microbiological Evaluation after Caries
Removal by Various Burs. Int J Clin Pediatr Dent. 2019 Nov-Dec;12(6):524-527.
 AIR ABRASION

 Originally developed by R.B.Black (1945).

 1st commercially available unit for preparing

cavities in teeth – AIRDENT (1951)

 Involves bombarding the tooth surface with high

velocity particles (aluminium oxide) carried in a
stream of compressed air or bottled carbon
dioxide or nitrogen gas.

Dent Clinics of North Amer.2005


Air abrasion variables
 Pressure – 40 – 140 psi.
 Tip Size – Tip aperture ranges from
0.015”-0.027” in diameter.
 Tip Angle – 400 – 1200
 Tip Distance – Tip should be < 2mm
from the target surface.
APPLICATIONS
• As an adjunct to dental drill for
caries removal
• Cutting and etching tooth
structure for resins and ceramics
• Removal of superficial enamel
defects
• Cleaning pits/fissures for
sealants
• Minimally opens pits and
fissures to allow visualization
and access to occlusal caries
 • Non traumatic treatment.
• Biocompatibility.
• No chipping. • Lack of tactile sensation
• No micro fractures. • Inefficient removal of
• Decreased thermal build up. softened carious dentin
• Micro smooth margins. • Messy work as Al oxide dust
• No LA. impairs vision
• Less discomfort due to less
pressure.
 AIR POLISHING

Water soluble particles of sodium bicarbonate are

added to tricalcium phosphate

Applied onto the tooth surface using air pressure

in a concentric water jet

INDICATIONS
 Remove enamel surface stains , plaque and
calculus away from gingival margins.
 VECTOR METHOD

◆ The Vector preparation combines both, ultrasonic effects & microabrasive action of
fine silicon carbide particles of size 50µm suspended in water.

◆ By using light to moderate pressure of the activated instrument against the surfaces to
be prepared, these particles are accelerated within the operating gap between the
instrument and the preparation surface.

◆ A cavity is produced using lengthwise sinking of the instrument as well as by its

horizontal translation through the silicon carbide particles.
AIROTOR VECTOR SYSTEM
SONO ABRASION

◆ It uses an air driven handpiece that oscillates in the

sonic region (< 6.5 kHz) and partially coated
working tips
◆ Tips are diamond coated with 40 µm grit diamond
and cooled using water irrigant (20-30mL/min)
◆ Initially developed for cutting and finishing of
proximal mini-cavities
◆ Can be used for beveling the cavity margins,
thereby improving the marginal adaptation of a
composite filling
CHEMOMECHANICAL CARIES REMOVAL
◆ Involves the chemical softening of carious dentine followed by its removal by gentle
excavation.

• INDICATIONS
1. Exposed buccal lesions
2. Cervical or root caries
3. Very deep carious lesions
4. Treatment of uncooperative pediatric patient

• CONTRAINDICATIONS
1. Sessions that necessitate short treatment time
2. Less retentive pit and fissure caries
 Cleavage by degradation of
Glycine /Hydroxyproline

Triple helix of collagen-

degradation of intramolecular
cross links

Tropocollagen units- cleavage by

Degradation of intermolecular
cross links
 APPLICATION

DISSOLUTION
EXCAVATION

Mix the two components

thoroughly, according to
Carry the Carisolv gel to
the instructions
the carious tooth
Wait for at least 30 seconds
for the chemical process to
soften caries till the gel
appears cloudy.
Scrape off the softened carious
dentine.
When the cavity is free from caries,
remove the gel and wipe the cavity
with a moistened cotton pellet or
rinse with luke warm water.
 PAPAIN
 It is a proteolytic enzyme
 It has bactericidal, bacteriostatic and anti-inflammatory
properties.

 Developed in Brazil (2003)

 Commercially known as Papain gel or papacarie

 COMPOSITION

 Papain
 Chloramines
 Toludine blue
 Salts
 Thickening vehicle.
 PAPAIN GEL

 The instrument should scrape the carious tissue

without promoting any kind of stimulus or
Acts by breaking pressure.
the partially  The main characteristic of the complete removal of
degraded collagen the infected dentinal tissue is the vitreous aspect of
molecules
the cavity which appears after using Papacarie.

Release of oxygen
Visible as bubbles
 Chemomechanical caries removal was as efficacious as drilling in term of completeness of
caries removal but required longer excavation times and resulted in lower microhardness of
residual dentin as well as more microleakage after restorations with GI.

Kitsahawong K, Seminario AL, Pungchanchaikul P, Rattanacharoenthum A, Pitiphat W. Chemomechanical

versus drilling methods for caries removal: an in vitro study. Braz Oral Res. 2015;29:1-8.
LASERS

 A laser is a device that delivers coherent,

monochromatic and collimated light as a form
of energy.

• Most of the dental lasers emit light in infra red

area of the electromagnetic spectrum.

• Hard tissue lasers – developed in 1990s.

Er:YAG – Cavity preparation

 MECHANISM OF ACTION

1. Photothermal effect

 Laser light absorbed by water and

hydroxyapaptite ; vaporizes the water &
causes micro-explosion within the tissue.

2. Photomechanical effect

 Rapid shock wave causes expansion of

volume of disrupted tissues resulting in
destruction of the surrounding mineral
matrix that explodes and is removed from
the irradiated surface, thus removing the
tooth structure.
HARD TISSUE LASERS
Highly absorbed by pigmented
tissues
The pigmented surface carious
lesions can be vaporized without
Er:Cr:YSG removing the healthy
Nd:YAG surrounding sound tooth
G
(1064 nm) structure
(2780 nm)
Erbium family
Choice of laser for
deep enamel & dentin
caries removal
Er:YAG CO2
Sealing of the fissures
(2940 nm) (10,600 nm)
• The difference in the absorption coefficients leads to a difference in the penetration
depths of the two erbium laser wavelengths in dental tissues.
 WATERLASE

• New Revolutionary Dental LASER Device that uses

“Hydrokinetic Technology” 

Waterlase – Water + Laser Energy

• Performs cutting or ablation using water.

• Waterlase uses an Ultra white shadow free illumination
from the new hydro beam t-handpiece based on cutting
edge , bulb free LED light technology.
• This new feature significantly enhances visibility in the
surgical field.
 Ozone therapy

DISINFECTION
TECHNIQUES Antibacterial Photodynamic
therapy therapy
 ANTIBACTERIAL
THERAPY
◆ Principle

Stepwise excavation for the management of deep dentinal lesions in order to induce
‘self-repair’ and arrest the carious process; thus to maintain pulp vitality

 Sate et al (1993) reported that a combination of metronidazole, ciprofloxacin and

cefaclor when applied onto the samples taken from carious dentin killed all
microorganisms in vitro.

 Wicht et al (2004) reported 1% chlorhexidine/ 1% thymol varnish or demeclocyine/

triamcinalone paste onto the cavity floor significantly reduced the lactobacillus count
after 6 weeks of a stepwise excavation procedure.
 OZONE THERAPY
• Developed by Dr. Edward Lyach.

• PRINCIPLE

Based on the niche environmental theory

 HEAL OZONE

 Heal ozone is a device that delivers ozone in a

controlled manner for dental procedures.

 Heal ozone converts oxygen into ozone.

 Components of Heal Ozone
• O3 Generator – delivers O2 at concentration of 2,200 ppm

• Vacuum pump – Pulls air through the generator at 615 cc/

min to supply 03 to the lesion. Immediately after the

treatment, the unreacted O3 is taken back.

• O3 Destructor (or the catalyst) – Manganese ions that

convert O3 to O2.

• Handpiece with disposable silicon cups (3 – 10mm in

diameter). These cups seals the selected area on the tooth to
prevent the escape of O3.
 Mechanism of action
• Ozone dissipates in water and kills the micro organism
via a mechanism involving the rupture of their
membrane .
• Strong oxidizer to cell wall and cytoplasmic membrane
of the bacteria.
• Causes oxidative decarboxylation of plaque pyruvate
generating acetate and carbon dioxide as by product.
 PHOTODYNAMIC
THERAPY

Light source + Release of Irreversibly damages

cellular components
Photosensitizer singlet oxygen & modifies Cell death
+ O2 & free radicals metabolic activities

• Burns et al (1994)
Low power GaAlAs diode laser with a power output of 11 mV could effectively kill
species like S.mutans, S.sobriuns, L.casei & A.viscosus in the presence of a
photosensitising agent
SEALING TECHNIQUES
 PIT & FISSURE
SEALANTS

• Recognized as a primary caries prevention

measure.

A material applied onto the occlusal surfaces of pits

and fissures of teeth to obliterate pits & fissures &
to remove the sheltered environment in which
caries can thrive.
- Gordon
CLASSIFICATION

Based on the materials used Based on the generation

• Polyurethanes • 1st generation – UV light polymerized

• Cyanoacrylates resin
• Bis-GMA • 2nd generation – Chemical
• Glass ionomer cements polymerization
• 3rd generation – Visible light cured
polymerization
Based on the method of curing • 4th generation – Fluoride containing
sealants
• Self curing
• Light cured Based on the colour

Based on the filler content • Clear

• Opaque
• Filled • Tinted
• Unfilled • Colour changing
 • Resin-based sealants applied on occlusal surfaces of permanent molars are effective for
preventing caries in children and adolescents.

• This review found moderate-quality evidence that resin-based sealants reduced caries by
between 11% and 51% compared to no sealant, when measured at 24 months. 

Ahovuo-Saloranta A, Forss H, Walsh T, Nordblad A, Mäkelä M, Worthington HV. Pit and fissure sealants for
preventing dental decay in permanent teeth. Cochrane Database Syst Rev. 2017 Jul 31;7(7)
 INDICATIONS
• Newly erupted posterior
teeth with deep pits and
fissures
• Presence of deep lingual
pits and fissures
• Early incipient lesions in
pits & fissures
• Patients with xerostomia
• Children in non fluoridated
areas
CONTRAINDICATIONS
• Pits & fissures that have
remained caries free for 4
years or more
• Difficulty in isolation
• Teeth with radiographic
evidence of caries
• Pit & fissure caries involving
dentin
• Well coalesced, self
cleansing pits and fissures
 PREVENTIVE
RESIN
RESTORATIONS
• Concept put forward by Simonsen (1977)

Composite restoration + sealant

• Also called as Conservative Adhesive resin

Restoration (CAR).

• Here, only the demineralized tissue is removed from

the cavitated isolated part of the pits and fissure &
repaired by placing a composite restoration, after
which the remaining unaffected pits and fissure is
covered and protected by a sealant.
 ATRAUMATIC
RESTORATIVE
 CONCEPT : Minimal intervention
TREATMENT
 AIM

 To prevent the development of carious lesions and to stop

their progression into dentin.
 To restore dentin carious lesions in a minimally invasive
way.

 INDICATIONS
 Multiple carious lesions
 Nervous patients
 Patients with medical or physical disability.
 TECHNIQUE

1. Cleaning & Isolation

2. Caries excavation
 Enamel hatchet
 Spoon excavator

3. Restoration with high viscosity GIC

 Cavity conditioning
 Cavity is slightly overfilled
(finger press method)

4. Checking of occlusion

5. Surface protection with petroleum jelly

 ENAMELOPLASTY

• Enameloplasty is the careful removal of sharp and irregular

enamel margins of the enamel surface by ‘rounding’ or
‘saucering’ it and converting it into a smooth groove,
making it self-cleansable, finishable & allowing
conservative placement of margins.

• Done by either hand instruments or slow speed burs

• The tooth is later restored with GIC.

 FISSUROTOMY

• It is ultraconservative tooth preparation which includes

removal of hidden fissure caries by using fissurotomy
burs

• Fissurotomy burs of head length 2.5mm and diameter

0.6, 0.7, 1.1, mm is used

• Tooth is later restored with GIC or flowable composites.

 Fissurotomy original
1.1mm wide, 2.5mm long
 Fissurotomy Micro NTF
0.7mm wide, 2.5mm long
 Fissurotomy Micro STF
0.6mm wide, 1.5mm long

 MATERIAL : Carbide burs

 Do not abrade as easily as the diamond points

 WHO
MINIMAL scoring for
shape and
INTERVENTION depth of
carious
CAVITY lesion Based on lesion
size and site (By
DESIGNS Mount and Hume
1997)
 ◆ E0- No carious lesion
◆ E1- Radiolucency in the outer half of enamel
Based on ◆ E2- Radiolucency in the inner half of enamel
radiographic ◆ D1- Radiolucency in the outer third of dentin
◆ D2- Radiolucency in the middle third of dentin
changes ◆ D3- Radiolucency in the inner third of dentin

In preventive dentistry, restorations are not indicated until the lesion has extended to
D2 region
Martin J.Tyas IDJ(2000)50
 ◆ D1- Clinically detectable enamel lesion
with intact non-cavitated surfaces
◆ D2- Clinically detectable cavities
WHO scoring for shape limited to enamel
and depth of carious ◆ D3- Clinically detectable lesion in
lesion dentin (with and without cavitation)
◆ D4- Lesions into the pulp
Based on lesion size
and site
(Mount and Hume
1997)
 ”

Site 1 Size 0

• Concept of fissure protection

 Introduced by Simonsen & Stallard

in 1978
 Site 1, size 1
Pit/fissure
• Fissures explored using small tapered
diamond point.
• It is unnecessary to remove the affected,
demineralized dentin on the floor of the
cavity, but its essential that the
. walls are
completely clean and free of caries
• Cavity is conditioned
• High strength, fast set, auto cure/resin
modified GIC syringed into cavity and pushed
into place
 ◆ This may be a new cavity or will arise as a need to
replace an existing restoration
◆ No.140TC is used to remove the old restoration, taking
Site 1, size 2 care not to extend the cavity any further than necessary
Pit/fissure
◆ Lamination technique
Moderate
- GIC – to reinforce the undermined enamel
- Composite resin – to withstand the occlusal load
If lesion is >2.5mm If lesion < 2.5mm
below the crest of from the crest of If proximal surface
marginal ridge marginal ridge accessible
“Tunnel” cavity “Slot” cavity Proximal
design design
approach”

Site 2, size 1 - Proximal Minimal

 TUNNEL CAVITY
PREPARATION

The preparation joins an occlusal lesion with a proximal lesion by

means of a prepared tunnel under the involved marginal ridge.

• Closed Tunnel – which leaves the demineralized proximal

enamel intact.

• Open Tunnel – which is accessed from occlusal & exits

through the proximal surface.
• Internal tunnel- proximal enamel is
retained because there is no
macroscopically observable cavitation
and the cavity preparation is just
touching the lesion.

• Partial tunnel-extends to the proximal

surface into the cavitation or where
enamel disintegrated during cavity
preparation, leaving some demineralized
enamel adjacent to the filling.

 Total tunnel- all demineralized enamel is

removed .
 Advantages DISADVANTAGES
• Preserves the marginal ridge. • Highly technique sensitive.

• Outer surface of the interproximal • Angulation of the preparation often

enamel is removed only if cavitated by passes close to the pulp.
caries, so there is less potential for a
• Visibility is reduced & caries removal
restorative overhang.
is uncertain.
• Decreasing the potential for micro-
• The procedure can leave a fragile
leakage.
marginal ridge.
 SLOT CAVITY/MINI BOX
PREPARATION
◆ These involve the removal of the marginal ridge, but
do not include the pits and fissures if caries removal in
these areas is not necessary.
◆ The lesion can be approached occlusally through the
outer slope of the marginal ridge (vertical slot) or
facially/lingually (horizontal slot) using a very fine
tapered diamond at intermediate speed.
◆ These cavities may have either a box or a saucer shape
and may be restored with resin-based composite or
amalgam.
 PROXIMAL APPROACH

 In conditions where the proximal

surface is accessible
 GIC is preferred over composite resin
because the limited access will make it
difficult to assure full polymerization
of resin through light activation.
 Site 3
Size 0 – Erosion lesions appearing on the labio/bucco cervical
region of the teeth
Size 1 – Erosion lesions at the gingival region/ root surface caries
at the gingival region
Size 2 – Carious lesions on the cervical region
GIC – material of choice
Size 3 – Multiple root surface caries at the cervical region of tooth
Size 4 – An old restoration failure at the cervical region and
requires retreatment
Materials for minimally
invasive operative care
 GIC
Chemical adhesion by ion exchange
Chemical union even with
demineralized exposed collagen fibrils
Remineralization of demineralized
dentin
Anticariogenic – Fl
RMGIC
More apt as better handling
properties,strength, easy to
place,light cured and improved
esthetics

Composites Bonded Amalgam

Micromechanical bonding –
thus no need for retentive
features
Conservation of tooth
structure
Compomer Chemically active, resin based
Esthetics luting material along cavity
Strength comparable to wall and base
composites Preparations lacking proper
depth for amalgam
 Might necessitate the removal of some of
the occlusal part of the amalgam to allow
condensation
Sealing the ditches using a resin based
sealant

REPAIR Cavity margin should be left intact in

v/s order to preserve the fluoride
impregnated enamel of the cavity walls
REPLACEMENT

Accessible areas - Roughen with stone,

re etch, bond and restore
Inaccessible – Modify tooth preparation
to expose the defective area
 CONCLUSION

◆ With the development of new dental restorative

materials and advances in adhesive dentistry, a better
understanding of the carious process and the tooth’s
potential for remineralization and changes in caries
prevalence and progression, efforts have been made to
preserve maximum amount of sound tooth structure.

◆ Although further research is needed, it can so far be

concluded that minimum intervention has the potential
to apply a more conservative approach to caries
treatment and health orientated treatment option.
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