Behavior management second year

Lecture 5
Minimal Invasive Dentisry
Dental Patient:
✓ Anxious. ✓ Fearful. ✓ Dental phobia.
▪ N.B negative dental experiences in childhood can lead to dental phobias in adult patients.
▪ According to the Adult Dental Health Survey (ADHS) (2009):
✓ Almost 12% of the adult population has a level of dental anxiety that is indicative of
dental phobia.
✓ Many people experience mild or moderate levels of anxiety when attending the
dentist.
✓ Dental phobia represents a significant degree of anxiety which has consequences for
the health and wellbeing of the person affected.
Problems associated with dental fear:
▪ Greater numbers of teeth with active disease (dental caries).
▪ Fewer restorations.
▪ Increased bleeding and plaque.
▪ Poorer quality of life.
Why pain?
▪ Tissue response to a damaging factor such as tissue inflammation.
▪ Local anesthesia injection.
▪ Use of the high-speed handpiece.
Dentist’s Role:
▪ Using painless procedures in caries removal.
Caries:
▪ A disease that causes a shift in the dental biofilm to acid-producing microorganisms
leads to mineral loss from hard dental tissue.
▪ As the caries lesion progresses into dentin, the dentin tissue is first attacked by acid
byproducts from microorganisms and eventually inhabited by the acid-producing
microorganisms themselves.

Non-cavitated vs Cavitated Lesions:

A non-cavitated carious lesion: early lesion. an incipient lesion. white spot lesion.
A demineralized lesion without evidence of cavitation.

▪ It is possible to arrest and reverse the loss of minerals associated with caries at an early
stage, before cavitation.
▪ Alter the oral environment: to take advantage of the tooth’s capacity to remineralize
and to tip the balance in favor of remineralization and away from demineralization.

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This includes:
Decreasing the frequency of intake of refined carbohydrates.
✓
Optimum plaque control.
✓
Optimum salivary flow.
✓
Conducting patient education.
✓
Cavitation:
▪ As caries progresses into dentin, the surface of the enamel eventually cavitates.
▪ Once cavitation begins, it becomes difficult to control plaque accumulation.
▪ In difficult access areas, plaque hinder the availability of phosphate, calcium and
fluoride ions, which may decrease the remineralization potential.
▪ Therefore, surgical treatment, caries removal and restoration are indicated for the
cavitated lesion.
CARIOUS DENTIN:
▪ Clinically, the transitions between these histological zones may be difficult to detect.
▪ Kuboki et al and Fusayama and Terachima.
▪ “Outer carious dentin: “infected dentin”.
▪ “Inner carious dentin: “affected dentin”.
▪ The two layers were differentiated by a staining dye.
Cavitated Lesions:
▪ A visible macroscopic breakdown in the tooth surface (a visible 'hole') and the area may
have softened walls or floor.
Infected Dentin:
▪ Contained irreversible destruction of collagen crosslinking.
▪ Unable to undergo remineralization.
▪ Has 1300 times greater bacterial concentrations than the nonstained affected dentin.
Affected Dentin:
▪ low permeability compared with healthy dentin which in turn protects the pulp.
▪ The odontoblasts precipitate calcium phosphate to form plugs in the dentin tubules,
creating the odontoblastic reaction zone.
▪ This will lead to caries arrest over periods of up to 10 years.
How to differentiate between infected and affected dentin:
1. Tactile sensation:
Infected Dentin Affected Dentin
✓ Lack of mineralization & collagen network. ✓ Some mineral content.
✓ Cottage cheese consistency. ✓ Collagen network intact.
✓ Soft. ✓ Leather like.
✓ Easily removed by hand excavator. ✓ Firmer.
✓ Gentle scraping. ✓ More difficult to allow instrument into it.
✓ Minimum force. ✓ Medium pressure.
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2. Caries Detecting Dyes:

▪ A propylene glycol solvent: a red or green dye.
▪ lightly stained dentin (termed “pink-haze” with the use of a red dye) represents
affected dentin.
▪ The dyes stain demineralized organic matrix, not the actual bacteria.
▪ Circumpulpal dentin and the dentin-enamel junction (DEJ): stain with these dyes
(reduced level of mineralization).
✓ will not truly differentiate affected & infected dentin.
✓ Unnecessary removal of sound or affected dentin or even expose the pulp.
3. Polymer Burs:
▪ Hardness: lower than sound dentin, but harder than carious dentin.
▪ Prevent removal of sound dentin.
▪ Leave remnant infected dentin.
Concluding how to deal with carious dentin:
✓ Affected dentin is firmer than infected dentin the presence of the collagen network
and some mineral content.
✓ Its consistency may be referred to as leatherlike.
✓ The endpoint for caries removal should be leathery, firm affected dentin on the pulpal
floor.
✓ Periphery: sound, hard dentin and enamel.
✓ A bonded restoration: effective seal that will prevent further lesion progression.
✓ Before Carie removal from deep lesion pulpal diagnosis.
✓ Selective caries removal: reduce issues with pulpal exposure.
✓ Bonded restorations: placed over carious dentin can arrest lesion progression.
✓ Balance between removing enough carious dentin to obtain a favorable bond and
effective seal for the restoration, while maintaining sufficient dentin over the pulp to
ensure pulpal health.
Conventional Dentistry:
▪ The removal of substantial tooth structures to accommodate restorations such as
dental crowns or bridges (Ericson, 2007).
▪ several drawbacks: loss of healthy tooth material, increased susceptibility to future
complications, and prolonged treatment time.
Removal of Caries:
Conventional removal of caries using burs has many drawbacks:
✓ Perception that drilling is unpleasant.
✓ Local anesthesia is needed.
✓ Drilling causes detrimental thermal effects.
✓ Drilling causes pressure effects on the pulp.
✓ Removes soft dentin not necessarily infected dentin, hence loss of important tooth
structure.

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Conventional Restorative Dentistry:

▪ The removal of a substantial portion of the tooth structure weakens the tooth, making it
more susceptible to fractures or further decay over time.
▪ The extensive tooth preparation: prolonged treatment times and increased patient
discomfort.
▪ Result in poor esthetic outcomes.
✓ Affects patient satisfaction and self-confidence.
▪ Does not prioritize the preservation of the natural tooth structure, leading to
unnecessary loss of healthy teeth.
The concept of minimum invasive dentistry:
▪ The concept bridges the traditional gap between prevention and surgical procedures,
which is just what dentistry needs today.
▪ Some MID interventions useful to treat precooperative children, anxious patients, and
individuals with SHCN or limited access to care.
Minimum invasive Dentistry
▪ Preserving a healthy tooth structure.
▪ Prioritizing the conservation of natural tooth material.
▪ Reducing the need for extensive tooth preparation.
▪ Maintain the structural integrity of the tooth.
▪ Minimize patient discomfort during treatment and promote faster recovery.
▪ By preserving more tooth structure and utilizing adhesive bonding techniques:
improved long-term stability and durability of restorations.
Rules of minimum invasive dentistry:
1. Early detection of carious lesions.
2. Control the disease through reduction of cariogenic flora.
3. Remineralise early lesions.
4. Perform minimal intervention surgical procedures.
5. Repair, rather than replace defective restorations.
Minimum Invasive Dentistry Techniques:
✓ In recent years, there has been progress in developing new less invasive painless
procedures which are effective in caries removal to replace conventional ones to minimize.
the loss of sound enamel and dentin.

These include:
1. Chemo- mechanical tecniques.
2. Ezymatic techniques.
3. Air abrasion.
4. Laser.
5. Polymer or ceramic burs.
6. Ozone

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1. Chemo-mechanical caries removal:

▪ Active ingredient would soften the pre- degraded collagen of the lesion without pain
or undesirable effects to adjacent healthy tissues.
✓ More comfortable for the patient.
✓ Better preserve the healthy tissue.
✓ Atraumatic characteristics.
✓ Bactericide and bacteriostatic action.
▪ Is a modified hand excavation procedure utilizing synthetic or natural agents to
selectively-eliminate the infected carious dentine and leave the ‘caries-affected’
dentine.
[characterized by demineralization of the intertubular dentine, minimal destruction of
the collagen matrix]
Sodium hypochlorite agents Enzyme based agents
▪ GK- 101 ▪ Papacarie
▪ CaridexTM ▪ Biosolv
▪ CarisolvTM
Sodium hypochlorite agents:
▪ The first studies on CMCR were done using a 5% NaOCl solution.
▪ But it is unstable & lacked selectivity in removing both caries-infected and caries-
affected, as well as sound dentine.
▪ This induced cutting down NaOCl concentration and addition of amino acids to
neutralize the NaOCl aggression towards the sound dentine, and immersion of
subsequent versions [GK-101, caridex, Carisolv].

GK-101:
A- 0.05% N monochloroglycerine.
b- 4-6% NaOCl.
✓ Chlorination of denatured collagen by conversion of hydroxyproline to pyrrole-2-
carboxyglycine.
✓ Limitation: need special equipment.

Caridex TM:
▪ N-monochloroglycine + amino butyric acid.
▪ Disrupted the carious dentin collagen making it easier to remove.
Clinical limitations:
✓ Expensive.
✓ Requireed a large reservoir with pump
✓ Required large quantities of solution
✓ Presented several problems during heating.
✓ Had a short shelf life.

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Carisolv TM:
▪ Lysine, leucine, and glutamic acid – instead of the amino butyric acid.
▪ These amino acids counteracted the sodium hypochlorite aggressive behavior at the
oral healthy tissues.
▪ Chlorination reaction and breaking down the hydrogen bond between denatured
collagen so making them more soluble for excavation.
▪ More selective in action and better in handling compared to Caridex.
▪ Old version: long excavation time.
▪ It was modified in 2004 by reducing the amino acid to half concentration, and doubling
that of sodium hypochlorite to 0.475%.
▪ This led to removal of the red coloring agent and became in the form of multi-mix
syringe that contains all ingredients.
▪ Non-cutting tip instruments:
✓ increase caries removal efficiency
✓ provide maximum conservation of the residual caries- affected dentine.

Enzyme based agents:

Papacarie:
▪ In 2003, new formula was created known as Papacarie®.
▪ Papacarie® comprised of papain, chloramines, toluidine blue, salts, thickening vehicle,
which together are responsible for the Papacarie’s bactericide, bacteriostatic and anti-
inflammatory characteristics.
✓ Fast action. ✓ Ideal consistency.
✓ Effectiveness. ✓ No sensitivity.
✓ No bubbling during the oxygen liberation

Biosolv:
▪ A new experimental enzymatic chemomechanical caries removal agent.
▪ The best caries excavation results: using metallic instruments with the Biosolv system.

ADVANCED METHODS FOR CAVITY PREPARATIONS:

2. Air Abrasion:
▪ Uses a stream of purified aluminium oxide particles that are forced under pressure.
▪ Best used with adhesive restorations requiring minimal tooth preparation.
▪ No need for anesthesia.
▪ Lack of tactile sensation.
▪ Alumina particles may remove sound tooth structure.
▪ Used towards the end of the cavity preparation to remove carious dentin.

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Contraindications:
✓ Severe allergies to pollen or dust.
✓ Chronic obstructive pulmonary disease.
✓ Asthma.
✓ Recent surgery.
✓ Open wounds.
Some of the situations where the air abrasion has particularly proved a boon include:
A. Removal of superficial enamel defects.
B. Detection of pit and fissure caries.

3. Lasers:
▪ Target the decay without affecting the healthy portion of the tooth
▪ More precise process than is the case with traditional fillings.

▪ The end of the 1990s lasers in dentistry, but three wavelengths are now accessible for
clinical application in the treatment of hard tooth tissue.
These included:
1. Erbium: yttrium-aluminum-garnet Er: YAG (λ =2.94μm)
2. Erbium- chromium: yttrium- scandium- gadolinium- garnet Er, Cr: YSGG, (λ =78μm)
3. Er: YSGG (λ =2.79μm).
Uses:
✓ Preparation of cavities.
✓ Elimination of dental caries.
✓ Removal of restorative materials.
✓ Etching of the dentin.
✓ Prevention of dental caries.
✓ Bleaching.

4. Smart burs:
▪ softer polyamide polymer material different than the traditional carbide bur.
▪ Fewer dentinal tubules being cut.
▪ Less pain sensations being triggered compared to using conventional burs.
▪ look like conventional burs, but they are not manufactured from metal, manufactured
from a special polymer material.
▪ The cutting edges are not spiral-like but shovel-like straight.
▪ Wear down in contact with harder materials, such as healthy dentin & will go blunt.

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5. Ozone therapy
▪ (O3) is an energized form of oxygen.
▪ Ozone therapy used in the medical professions for more than a century.
▪ Ozone is one of nature’s most powerful oxidant, which accounts for its ability to kill
bacteria, spores and viruses.
▪ The primary carious lesions when exposed to ozone become sterile and re-mineralize
after some time.

Conclusion:
▪ Natural enamel and dentin are still the best “dental materials” in existence.
▪ Ultraconservative dentistry represents a significant step forward for the dentist, the
profession, and especially the patient.
▪ A changing understanding of the disease of dental caries has initiated a paradigm shift
in the management of carious lesions.

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