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 + Sorensons 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 0.1MAminobutyri 0.1M glutamic
c 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 10-15 mins 10-15 mins
required
Intruments Applicator tips Specially
designed
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 No micro fractures

micro fractures
Excessive destruction Less destruction of
of tooth structure tooth structure
Heat,vibrasion,bone Heatless,vibrasion
conducted noise- less, minimal sound
patient 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

NATURES 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

NATURES GIFT IS INDEED DENTISTRYS GAIN

THE CHEMISTRY OF OZONE (03 )

How is it produced and what is its safety

profile ?
OZONE

NATURALLY PRODUCED ARTIFICIALLY PRODUCED IN A

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 its 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 dont 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

!!!!
Nanotechnolog
y

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