MINIMAL INTERVENTION

TECHNIQUES FOR DENTAL

CARIES TREATMENT
CONTENTS
• Introduction
• Definition
• Principles of Minimal Intervention Dentistry
• Minimal Intervention Techniques
• ART
• Rotary Burs
• Sonic Oscillations
• Chemo-mechanical caries removal (CMCR)
• Enzymes
• Air Abrasion
• Lasers
• Ozone Therapy
• Future Modality
• Conclusion
• References
Minimal Invasive Dentistry
“A systematic respect for the original tissue.”

An artifact is of less biological value than the

original healthy tissue

Tissue preservation by preventing disease from

occurring and intercepting disease
progression as well as removing and
replacing diseased tissue with as little tissue
loss as possible
PRINCIPLES
• Control the disease through reduction
of cariogenic flora
• Remineralize early lesions
• Perform minimal intervention surgical
procedures as required
• Repair, rather than replace ,defective
restorations
Minimal Intervention Techniques

1. ATRAUMATIC 1. ART
RESTORATIVE
TREATMENT
2. ROTARY 2.HIGH / LOW SPEED BUR
3. SONIC OCILLATION 3.SONICSYS MICRO
4. CHEMOMECHANICAL 4.CARISOLV,ENZYMES
5. KINETIC 5.AIR ABRASION
6. HYDROKINETIC 6.LASER
7. OZONE TECHNOLOGY 7.O3
ATRAUMATIC RESTORATIVE
TREATMENT
DEFINITION

• Elementary technique of caries removal

using hand instruments only ,combined
with the use of modern restorative
material with adhesive characteristics

Pioneers
Frencken JoE, Makoni F. in Tanzania 1980
Principle

Arrest the disease process

•Removal of cariogenic
biomass
•Seal & protect tooth
•Place an adhesive
restorative material
ADVANTAGES OF ART
• Easy Caries Removal
• Conserve tooth structure
• Hand Instruments
• Limitation of Pain, Non threatening
• Restore with an adhesive material
• No local anesthesia
• No high/low handpiece
• No suction
• No water
• Simple infection control
• Prevent secondary caries(Fluoride)
• Ease of repair
• Low cost
ART Indications

• Limited access to traditional care

• Pediatric & Geriatric care
• High caries risk management
• Extreme dental fear/anxiety
management
Armamentarium

• Instruments

– Mouth mirror
– Cotton Forceps
– Explorer

– Small spoon excavator

– Medium spoon excavator
– Dental hatchet
Armamentarium
• Instruments
– Glass slab
– Spatula
– Carver
– Applicator
– Light Source
Armamentarium
• Materials
– Dentinal
Conditioner
– Petroleum jelly
– Wedges
– Plastic matrix
– Clean Water
– Gloves
– Cotton
rolls/pellets
Armamentarium
• Materials
– High-viscosity,
auto-cure glass
ionomer
– Examples
• Fuji IX (GC
America)
• Ketac Molar
(3M ESPE)
Procedure
• Isolate
• Access
• Excavate
• Condition
• Insert
• Press
• Remove excess
Procedure
Procedure….Isolate
Procedure….Clean Surface
Procedure….Widen Entrance
Procedure….Remove Caries
Procedure….Pulp Protection
Procedure….Clean Preparation
Procedure….Condition
Procedure….Mix Restorative Material
Procedure….Place Glass Ionomer
Procedure….Place coated gloved finger
on occlusal surface and apply
light pressure
Procedure….Check Occlusion
Procedure….Remove Excess Material
Procedure….Recheck Occlusion
Procedure….Cover restoration with
varnish, unfilled resin, petroleum
jelly
Procedure….Instruct patient not to
eat for at least an hour
Keys to a Successful Mission
• Know your mission before you go

• Be prepared

• Have a good attitude

Limitations
• Short term survival rates
• Limited to restoration of small and
medium sized one surface lesions
• Hand fatigue
• Unstandardized mix
• Misapprehension that ART can be
performed easily
• Misconception by the public that “White
fillings are temporary restorations”
Studies
• Dr.Jo Frencken 1988 Tanzania
• Yupin S. et al 1991 Thailand
• IADR 1995 Singapore symposium.ART part of
WHO goal
• Evert.V.A.1993 Pakisthan
• Christopher H.1998 China
• Frencken et al 1996,98,99,Mjor et al
1999,2000,Smales et al 2000,Weerheijm et al
2002,03.
• Farhan.K.S.& R.K.Tiwari 2003
ROTARY BURS

HIGH OR LOW
SPEED ?
• Gain access to carious dentin through
high speed bur later use low speed bur
or hand excavation for carious dentin
excavation.
• Low speed bur More tactile sensitive
Why not use high speed bur
for caries excavation ?
Discomfort and pain due to ……..

• Sensitivity of vital dentin

• Pressure on the tooth
• Bone conducted noise
• Development of high temperature at
cutting surface
Smart Polymer Burs !!!

Dream or Reality ?
Studies
• Banargee et al 2000 .Rotary excavation
-low speed burs, Round carbon steel
burs-removal of softened dentin.
• Freedman et al 2003
• Kidd et al 1993 Controlled selective
rotary excavation
SONIC OSCILLATION
(SONOABRASION)
SONO ABRASION

• Removal of carious dentin using high

frequency ,sonic air scaler with modified
abrasive tips
First Design
•Sonic micro unit deigned by Dr.Hugo
Unterbrink and Mosele
•Venture between Ivoclar Vivadent and Kavo
•Based on Soniflex 2000L and 2000N Air
scaler Hand piece
•Oscillations - < 6.5 KHZ
Mechanics

Elliptical motion Transverse 0.08 - 0.15mm

Longitudinal - 0.055 -0.135mm

Diamond Coated – 40 micro meter grit diamond

Water irrigant 20-30ml/min
Air pressure 3.5 bar
 Currently 3 tips

A lengthways A large
halved torpedo hemisphere 2.2mm
shape diameter
9.5mm
long,1.3mm wide
A small hemisphere
1.5 mm diameter
 • Torque Applied – 2N
• More pressure - dampens oscillations

Indications

•Carious dentin removal

•Finishing cavity preparations

More studies needed to prove its efficiency

Studies
• Hugo et al 1999-Air scaler handpiece –
Unclear completeness of excavation
• Hugo et al 2000 Diamond coated tip
and brushes – Cavo surface bevels
CHEMOMECHANICAL CARIES
REMOVAL (CMCR)
• Chemo mechanical caries removal
involves the chemical softening of
carious dentin followed by its removal
by gentle excavation

Reagent
(NaOCl + Amino Acids )

N-Monochloro Amino Acids

Selectively degrade demineralized collagen

Indications

• Dental phobics
• Deciduous teeth
• Medically compromised patients
Mechanism of action
Dentin

Inorganic – 70% Organic matrix - 20 % H2O – 10 %

18 % Collagen 2 % Non Collagen

Proline + Glycine - Polypeptides – Tropocollagen - Fibril

 Caries

Collagen Degradation

2 zones

Inner layer Outer Layer

Partially Demineralized Partially Degraded
Collagen fibrils are intact Cannot be remineralized

CMCR Agent

Further degradation of partially degraded collagen

 CMCR First Used by Goldman and Kronman

Na0Cl + Sorenson’s Buffer N Mono Chloro

(Glycine ,NaOH,NaCl) Glycine (GK1019)

Glycine replaced by N-Mono Chloroamino butyric acid

Amino Butyric acid (NMAB) –GK101E

Mechanism of Action

• Chlorination of Partially Degraded Collagen (Conversion

of Hydroxyproline to Pyrrole-2-carboxylic acid)
• Oxidation of glycine residues – Disruption of collagen –
more friable collagen
CARISOLV
• Developed by Mediteam in Sweden January 1998

2 Syringes

NaOCl Pink Viscous gel ( Lyciene,

Leucine, Glutamic Acid
+Carboxymethyl cellulose +
Erythrosine )

Time Required – 10 – 15 mins

Max Volume of Gel – 0.2 – 1 ml

Procedure
 CARIDEX CARISOLV
SOL I 1% NaOCl 0.5 % NaOCl
SOL II 0.1MAminobutyric 0.1M glutamic
acid glyciene acid / leucine /
0.1M NaCl,0.1 M lysine,NaCl, NaOH
NaOH
Dye - Erythrocyin
pH 11 11
Physical.N Liquid gel
Volume 100-500ml 0.2 – 1ml
Time required 10-15 mins 10-15 mins
Intruments Applicator tips Specially designed
Active time 1 Hr 20 mins
ADVANTAGES
• Painless
• No need of local anesthesia
• Conservation of sound tooth structure
• Reduced risk of pulp exposure
• Well suited for anxious and medically
compromised patients
Limitation
•Rotary and hand instruments
may still be needed
Studies
• Burke et al 1995
• Ericon et al 1999
• Fure et al 2000
Enzymes for removal of caries !!!!!!
In 1989 Goldsberg and Keil
Achromobacter collagenase

Enzyme Pronase –non specific proteolytic

enzyme –Streptomyces griseus
Studies
• Beltz et al 1999
• Noack et al 2003 – promising invitro
results
AIR ABRASION MICRODENTISTRY

(Kinetic Cavity Preparation)

Air abrasion utilizes kinetic energy from alumina
particles entrained in high velocity stream of air
to remove tooth structure

• Father of air abrasive micro dentistry-

Dr.J.Tim Rainey ,Texas, USA.Student of
Dr.Robert Black
• 1951 - White Technology –Airdent –First
commercially available unit
 Components

Compressor Operator control

Mechanical / Digital

Accessories Evacuation System

Principle

E=1/2 MV2 Air abrasion = Kinetic energy

M=Mass Conventional = Frictional energy

V=Velocity
Abrasive particles

• Aluminum oxide
• Alumina particles – Alpha alumina, pure,
biocompatible, used in food and medicine,
prime ingredient in tooth paste
• Polycarbonate resin alumina-hydroxyapetite
mixtures-selective in removal of caries
Capable of removing tissue of equal
hardness
Abrasion variables
• Pressure – 40 -140psi
• Tip Size – 0.015II – 0.027II
• Tip Angle – 40 -120 degrees
• Tip Distance – 2mm from target
• Dwell time
• Particle size – 27micro meter aluminium
oxide powder
Applications of Air Abrasion
• Cavity preparations
• Internal cleaning of tunnel preparations
• Removal temporary cement
• Micro abrasion of white spot enamel
hyperplasia
• Stain removal
• Repair of acrylic ,composite, porcelain
Air abrasion cannot be used for …

• Crown preparation
• Large carious defects
• Amalgam removal
• Class II Cavity preparations
Advantages
• Non traumatic treatment
• Biocompatibility
• No Chipping
• No micro fracturing
• Decreased thermal build up
• smooth margins
• Less invasive procedure
• No anesthesia
• Less discomfort
Disadvantages
• Lack of tactile sensation
• Non contact based modality
• Messy –Spread of aluminium oxide
• Danger of air embolism and
emphysema
• Impaired indirect view
• Damage to dental operatory
Contraindications
• Asthma patients
• Severe dust allergy
• Chronic pulmonary disease
• Recent extraction
• Open wound in oral cavity
• Sub gingival caries removal
Safety Issues

• Masks
• Rubber dam
• Dry vaccum systems
• Eye glasses
• Disposable mouth mirror
• High speed suction
Comparison between Drill and Air Abrasion

High Speed Drills Air Abrasion

Rotary bur cause micro No micro fractures

fractures
Excessive destruction of Less destruction of tooth
tooth structure structure
Heat,vibrasion,bone Heatless,vibrasion less,
conducted noise-patient minimal sound
discomfort
Patient Anxiety Patient friendly
KCP 100

Kavo Rondo Flex Kavo India)

Prep Start
Studies
• Baneerge et al 2000
• Yazici et al 2002
Lasers
Laser Therapy
 Lasers are devices that produce beams
of coherent high intensity light

Laser Is an acronym for Light Amplification

by Stimulated Emission of Radiation

A crystal or a gas is excited to emit light

photons of a characteristic wavelength that
are amplified and filtered to make a
coherent light beam

First Ruby Laser – Maiman- 1960

Efficacy of laser depends on
•Wavelength characteristics
•Pulse energy
•Optical properties of incident tissue

Applications
•Selective Hard Tissue Ablation
•Selective Carious Dentin Removal
•Destroy S.Mutans
•Sealing of Fissures
•Cut Dental Hard Tissue
•Adjunctive treatment in caries prophylaxis
•Modify structures of dentin and enamel
 Lasers used for selective hard tissue ablation
•Er:YAG :Yttrium –Aluminium-Garnet and Nd:YAG –
Neodymium-YAG-IR Emission
•C02 Laser – IR Emission
•Excimer Lasers (ArF- Argon: Freon and XeCl – Xenon :
Chlorine – U.V.Emission
•Holomium lasers
•Dye enhanced laser ablation – Indocyanine Green &
Diode Laser

Carious Dentin Removal – UV Excimer (377nm)

Destroy S.Mutans – Excimer with Dye

Sealing of fissures – CO2

Advantages

• Effect of vibrasions,pressure and unfavorable

temperatures associated with rotational cutting
instruments –avoided
• Safe and efficacious modality of caries removal
and cavity preparation

Limitations
•Expensive
•Size of the instrument
Photo Activated Disinfection
(Photo Dynamic Therapy)

A gift for the future !!!!!

Studies
– Yamada et al 2000,2001,
– Yazici et al 2002
– Yip and Samaranayake 1998
 OZONE THERAPY

BIDDING A FINAL FAREWELL TO

OUR DRILL, FILL AND BILL
PHILOSOPHY !!!!
 “THE MOST BEAUTIFUL THINGS ON EARTH
ARE ALSO THE MOST SIMPLEST AND MOST
NATURAL !!!!!

OZONE

PROTECTION UTRA MODERN STATE OF

FROM U.V.RAYS ART ,PAINLESS,DRILL LESS
DENTISTRY !!
 OZONE AND DENTISTRY
OZONE

NATURE’S MOST POWERFUL OXIDANT

EFFECTIVE TOOL AGAINT THE CARIES SCOURGE AS IT

IS PRIMARILY A BACTERIAL DISEASE

CARIOUS LESIONS NOT ONLY BECOME STERILE AFTER

EXPOSURE TO OZONE BUT ALSO TEND TO RE-
MINERALIZE AFTER SOMETIME

NATURE’S GIFT IS INDEED DENTISTRY’S GAIN

THE CHEMISTRY OF OZONE (03 )

How is it produced and what is it’s safety

profile ?
OZONE

NATURALLY ARTIFICIALLY PRODUCED IN A

PRODUCED DURING CONTROLLED MANNER
THUNDERSTROMS •ELECTRICAL CORONA
DISCHARGE UNITS
•OZONE GENERATORS
•OZONIZERS
How Safe Is Ozone?

• Ozone Is often found in the ambient air

• Ozone decomposes to a harm-less, non-
toxic and environmentally safe material
(oxygen!!)
• Humans are continually exposed to ozone
during their daily life
• (Arc welds, photo copies, laser printers)
• Confirms to FDA regulations
Principles Of Ozone Therapy

“The Niche Environment Theory" of caries

development
Key Factors

•Initial Colonization
•Development of Acidophilic organisms in a
specialized Niche environment
•Acid production and demineralization
•Re-De -Mineralization
How does ozone come to our rescue ?
• Ozone completely eliminates
acidophilic bacteria ,fungi and viruses
to create a sterile environment
• Sterile environment not only reverses
decay but also helps in re-
mineralization
• 10 secs of 2200 ppm ozone eliminates
99 % of the carious micro flora
• Niche is very unlikely to re-develop
after re- mineralization
Ozone: The ‘kiss’ of death for Mutans and
Lactos !!!
Ozone A powerful biocide
• Quickly dissipates in water and kills microbes via a
mechanism involving the rupture of their membranes
• It is a strong oxidizer to cell walls and cytoplamic
membrane of bacteria
• Ozone treatment leads to oxidative decarboxylation of
plaque pyruate.
• It oxidizes volatile sulfur compounds precursor
methionine to it’s corresponding sulphoxide and thus
prevents malodour associated with caries.
• It also oxidizes poly-unsaturated fatty acids
 The Ozone Delivery Unit And Patient Kit For
Ozone Therapy
The Ozone Armamentarium Heal ozone Tec3,Curosone,USA)

The Polyurethane Console Heal ozone Hand piece Patient Kit

•Ozone Generator •Stainless steel Meant to achieve

•Vacuums pump to suction hand piece remineralization
air at pre-set rate) •Disposable Consists of
•Flow sensors to turn the sealing cup •Re-Mineralizing
generator on •Push button tooth paste
•Peristaltic pump to deliver starter to deliver •Oral rinse
reducing agent ozone at a rate •Travel spray to
•Desiccant to dry the air of 13.3ml/sec allow convenient
•Ozone destructor with a
application of re-
hydrophobic filter
mineralization oral
•Back-lit LCD Display
rinse
OZONE THERAPY
 Clinical steps in Ozone Therapy
Polymer Cup is Adapted to carious lesion and air is sucked to create a
vacuum

Ozone gas is delivered at a If the seal is defective the unit

preset conc. ,for 10 secs if switches off
the seal is good

Suction activated for 10 secs to remove debris from the surface

Suction system passes gas through Granular activated

carbon filter to remove all traces of ozone

Reductant fluid is pumped for 5 secs onto treatment site to

start the remineralization process

Patient is instructed to use ‘home care kit’ and recalled after 3

months for check up ,when a cosmetic restoration can be placed if
needed
Indications for Ozone Therapy

• Primary root carious lesions

• Early carious lesions
• Pit and Fissure caries
• Caries around crowns and bridges
Ozonic Advantages Re-Visited !!!

• Kills 99%micro organisms

• Oxidizes caries and speeds up re-mineralization
• Removes organic debris on carious lesions
• Removes volatile sulphur which cause halitosis
• Potentially whiten discolored caries
• Decrease treatment time
• Microbes don’t become resistant
• Non –allergic, noiseless, painless and Phobic
friendly and pedo friendly
Studies
• Baysan & Lynch 2000,2001
• Baysan et al 1999,2000
• Holmes 2003
 Future

of

Minimal Intervention Techniques !!!!

Nanotechnology

Richard.P.Feynman
Conclusion
Think twice before you pick
up that hand piece …….
….Because the cutting edge is
not a dental bur anymore !!!
References
• Mathilde.C.P.& Mclean. Concept Mathilde.C.P.&
McLean. Concept of Minimally invasive cavity
preparations.J.Adheive.Dentistry.2001:3:7-16

• Mathilde.C.P.& Mclean. Minimally invasive operative

care. Contemporary techniques.
J.Adheive.Dentistry.2001:3:17-31

• Michael.J.N.,Wicht.M.J. & Rainer. Lesion oriented

caries treatment-A classification of carious dentin
treatment procedures. Oral Health Prev
Dent :2004:2;301-306

• Banargee.A.T.,Waton & Kidd.E.A.M. Dental caries

excavation A Review of current clinical
techniques.BDJ:2000:188:9:476-482
References Cont….
• Taco Pilot.Introducton :ART from a global perspective
CDOE:1999:27:421-422

• Smales.R.J.,Yip.H.K. The ART approach for management

of dental caries.Quintessence Int :2002:33:427-432

• Goldstein. E. and Parkins.M. Air Abrasive Technology.

JADA:1994:125:551 – 557

• J.Tim.Rainey. Air Abrasion: An emerging care in

conservative operative dentistry.Dental Clinics of North
America:2002:185-209
• A.Bysan & E.Lynch. Effect of ozone on oral microbiota
and clinical severity of primary root caries.American.Jol
Dent:2004:17:56-60

• Poonam .B.et al .Ozone therapy for dental caries.JIDA

2003:74:41-45

• R.E.Beltz,Herman.E.C. & Nordh.H. Pronase digestion of

carious dentin. Caries Res.1999:33:468-72

• Robert.A.F. Nanodentistry. JADA 2000:131:1559-1565

• Sahil.N.,Raghunath.P.Dupriya.N. & Gangadhar. Promise

of molecular nanotechnology. KSDJ 2004:28:2:48-52