Minimum Intervention Dentistry - Essential Concepts

Thai Thai Dental Dental Association Association
June June 2009 2009
MINIMUM INTERVENTION DENTISTRY ESSENTIAL CONCEPTS

Martin Martin J J Tyas Tyas
BDS, BDS, PhD, PhD, DDSc, DDSc, GradDipHlthSc, GradDipHlthSc, FADM, FADM, FICD, FICD, FRACDS, FRACDS, FPFA, FPFA, FADI FADI
Professor Professor and and Head, Head, Restorative Restorative Dentistry Dentistry Melbourne Melbourne Dental Dental School School The The University University of of Melbourne Melbourne Australia Australia
Martin J Tyas (1 (1)
June June 2009 2009
SUMMARY
overview overview of of Minimum Minimum Intervention Intervention (MI) (MI) definition definition of of MI MI elements elements of of MI MI dental dental caries caries caries caries risk risk assessment assessment prevention prevention remineralisation remineralisation (medical) (medical) techniques techniques operative operative (surgical) (surgical) techniques techniques management management of of defective defective restorations restorations
June June 2009 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
June June 2009 2009
Int Dent J 2000;50:1-12
June June 2009 2009
CONSENSUS CONSENSUS STATEMENT STATEMENT (2007) (2007) General General Assembly Assembly of of the the World World Congress Congress of of Minimally Minimally Invasive Invasive Dentistry Dentistry Members Members of of the the Western, Western, Central, Central, and and Eastern Eastern (US) (US) Caries Caries Management Management by by Risk Risk Assessment Assessment (CAMBRA) (CAMBRA) Coalitions Coalitions ADEA ADEA Cariology Cariology Special Special Interest Interest Group Group recognize recognize the the 2002 2002 FDI FDI Policy Policy Statement Statement as as the the current current clinical clinical standard standard for for caries caries management management
Tyas, Anusavice, Frencken & Mount. Int Dent J 2000;50:1-12
June June 2009 2009
ELEMENTS OF MINIMUM INTERVENTION
the the dentist dentist as as a a physician physician (requires (requires a a knowledge knowledge of of the the factors factors associated associated with with the the development development of of caries) caries) individualised individualised assessment assessment of of caries caries risk risk appropriate appropriate preventive preventive strategies strategies remineralisation/arrest remineralisation/arrest of of non-cavitated non-cavitated lesions lesions the the dentist dentist as as a a surgeon surgeon (requires (requires a a knowledge knowledge of of the the caries caries lesion) lesion) minimum minimum surgical surgical intervention intervention of of cavitated cavitated lesions lesions appropriate appropriate maintenance maintenance of of existing existing restorations restorations
June June 2009 2009
the the dentist dentist as as a a physician physician (requires (requires a a knowledge knowledge of of the the factors factors associated associated with with the the development development of of caries) caries) individualised individualised assessment assessment of of caries caries risk risk appropriate appropriate preventive preventive strategies strategies remineralisation/arrest -cavitated lesions remineralisation/arrest of of non non-cavitated lesions the the dentist dentist as as a a surgeon surgeon (requires (requires a a knowledge knowledge of of the the caries caries lesion) lesion) minimum minimum surgical surgical intervention intervention of of cavitated cavitated lesions lesions appropriate appropriate maintenance maintenance of of existing existing restorations restorations
June June 2009 2009
MULTIFACTORIAL NATURE OF CARIES

local local factors factors saliva saliva (quality; (quality; quantity) quantity) diet diet carbohydrate carbohydrate intake intake frequency frequency of of exposure exposure to to acids acids exposure exposure to to fluoride fluoride plaque plaque accumulation accumulation and and retention retention
modifying factors dental history medical history lifestyle socio-economic status compliance
June June 2009 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
June June 2009 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)
June June 2009 2009
SALIVA AND DENTAL CARIES
June June 2009 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)
June June 2009 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
June June 2009 2009
ASSESSMENT OF SALIVA (FIVE CRITERIA)
unstimulated minor salivary gland function viscosity pH stimulated flow rate buffering capacity GC Saliva Test kit
June June 2009 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
June June 2009 2009
Ngo & Gaffney
June June 2009 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
June June 2009 2009
Ngo & Gaffney
June June 2009 2009
RED OR YELLOW LIGHT!
causes of defective function severe dehydration medication hormonal imbalance salivary gland pathology
June June 2009 2009
pH
dribble into container insert pH paper read after 10 s
< 5.8 5.8 6.8 > 6.8

June June 2009 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
June June 2009 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
05 69 10 12
Low Moderate High

June June 2009 2009
MR CHAIWAT SATHORN
15-FEB-2009
June June 2009 2009
GC (JAPAN) TRAFFIC LIGHT SYSTEM saliva saliva five five criteria criteria diet # of CHO exposures/day # of acid exposures/day fluoride exposure past and current plaque three criteria modifying factors five criteria
June June 2009 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
June June 2009 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)
June June 2009 2009
ASSESSMENT OF DIET
# CHO EXPOSURES # ACID EXPOSURES BETWEEN MEALS BETWEEN MEALS
>2 >1 Nil
>3 >2 1
June June 2009 2009
GC (JAPAN) TRAFFIC LIGHT SYSTEM saliva saliva five five criteria criteria diet diet # # of of CHO CHO exposures/day exposures/day # # of of acid acid exposures/day exposures/day fluoride exposure past and current plaque three criteria modifying factors five criteria
June June 2009 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
June June 2009 2009
EXPOSURE TO FLUORIDE
EXPOSURE TO FLUORIDE Nil Water OR toothpaste Water AND toothpaste
June June 2009 2009
GC (JAPAN) TRAFFIC LIGHT SYSTEM saliva saliva five five criteria criteria diet diet # # of of CHO CHO exposures/day exposures/day # # of of acid acid exposures/day exposures/day fluoride exposure past and current plaque three criteria modifying factors five criteria
June June 2009 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

DR HIEN NGO
June June 2009 2009
GC Corporation
June June 2009 2009
Ivoclar Vivadent
June June 2009 2009
CRT Buffer, CRT Bacteria (Ivoclar Vivadent)
June June 2009 2009
MODIFYING FACTORS (5)

1. 1.
2. 2.
3. 3.
dental dental history history active active caries caries lesions lesions restorations restorations (past (past or or current current risk?) risk?) medical medical history history xerostomia, numerous numerous medications medications xerostomia, e.g., e.g., antidepressants; antidepressants; hypotensives; hypotensives; anticholinergics; anticholinergics; antipsychotics; antipsychotics; diuretics; diuretics; anti-Parkinson anti-Parkinson lifestyle lifestyle caffeine, caffeine, alcohol alcohol (diuretics) (diuretics) smoking smoking (effect (effect on on saliva) saliva)
June June 2009 2009
MODIFYING FACTORS (5)

socio-economic socio-economic status status (SES) (SES) low low SES SES may may indicate indicate low low educational educational level, level, thus thus low low level level of of understanding understanding financial financial issues issues cost cost of of treatment treatment cost cost of of accessing accessing treatment treatment 5. 5. compliance; compliance; depends depends on on patient patient attitude attitude practicality/appropriateness practicality/appropriateness of of treatment treatment plan plan
4. 4.
June June 2009 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
June June 2009 2009
DAVID AGED 24
lives lives in in unfluoridated unfluoridated town town labourer labourer on on building building site site not not well well educated educated works works outdoors outdoors in in hot hot climate climate potential potential dehydration dehydration drinks drinks low low pH pH black black cola cola drinks drinks (Coca (Coca Cola) Cola) frequent frequent refined refined CHO CHO intake intake poor poor oral oral hygiene hygiene poor poor attitude attitude (parents (parents F/F) F/F)
June June 2009 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
June June 2009 2009
DAVID AGED 24
Saliva Plaque Diet Fluoride Modifying factors
Thai Thai Dental Dental Association Association Dr Douglas Bratthall
June June 2009 2009
CARIOGRAM SCORE CARD
FREQUENCY OF INTAKE OF FERMENTABLE CARBOHYDRATE
June June 2009 2009
2 1
www.db.od.mah.se/car/cariogram/cariograminfo.html
June June 2009 2009
AGED CARE FACILITY
Dr Jane Chalmers
Dr Jane Chalmers
Dr Jane Chalmers
June June 2009 2009
Dr MA Stacey, University of Melbourne
SJOGRENS SYNDROME

June June 2009 2009
RADIATION CARIES
June June 2009 2009
June June 2009 2009
the the dentist dentist as as a a physician physician (requires (requires a a knowledge knowledge of of the the factors factors associated associated with with the the development development of of caries) caries) individualised individualised assessment assessment of of caries caries risk risk appropriate appropriate preventive preventive strategies strategies remineralisation/arrest remineralisation/arrest of of non-cavitated non-cavitated lesions lesions the the dentist dentist as as a a surgeon surgeon (requires (requires a a knowledge knowledge of of the the caries caries lesion) lesion) minimum minimum surgical surgical intervention intervention of of cavitated cavitated lesions lesions appropriate appropriate maintenance maintenance of of existing existing restorations restorations
June June 2009 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
June June 2009 2009
FACTORS PROMOTING REMIN
pH > 5.5 phosphate ions calcium ions fluoride ions

June June 2009 2009
Clinical use of calcium phosphates for remineralization not successful
insoluble insoluble calcium calcium phosphates phosphates low low solubility solubility (particularly (particularly with with F) F) not not easily easily applied applied nor nor effectively effectively localized localized at at tooth tooth surface surface require require acid acid for for solubility solubility to to produce produce remineralizing remineralizing ions ions soluble soluble calcium calcium phosphates phosphates can can only only be be used used at at low low concentrations concentrations do do not not effectively effectively localize localize at at tooth tooth surface surface
June June 2009 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)
June June 2009 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.)
June June 2009 2009
June June 2009 2009
Clinical study of enamel de - and re deremineralization by chewing gum

2720 2720 subjects subjects ( ( 12.5 12.5 y y old) old) Normal Normal use use of of fluoride fluoride toothpaste, toothpaste, fluoridated fluoridated water water Sugar-free Sugar-free gum gum containing containing CPP-ACP; CPP-ACP; control control gum gum randomly randomly assigned, assigned, double double blinded blinded Gum Gum chewed chewed 3 3x x daily daily for for 2 2 years years Standardized Standardized digital digital radiographs radiographs at at baseline baseline and and 24 24 months months Caries Caries progression/regression progression/regression analyzed analyzed using using a a transition transition matrix matrix
Morgan et al. (2006) J Dent Res
June June 2009 2009
Clinical study of enamel de - and re deremineralization 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
June June 2009 2009
MI PASTE
Thai Thai Dental Dental Association Association BEFORE BEFORE TREATMENT TREATMENT
June June 2009 2009
AFTER AFTER RECALDENT RECALDENT


Prof L J Walsh, U of Q
June June 2009 2009
Prof L J Walsh, U of Q
June June 2009 2009
CONCLUSION
TM (CPP-ACP) Recaldent RecaldentTM (CPP-ACP) technology technology remineralizes remineralizes enamel enamel subsurface subsurface lesions lesions in in situ situ slows slows the the progression progression of of coronal coronal caries caries promotes promotes regression regression of of caries caries
CPP-ACP CPP-ACP plus plus F F (Tooth (Tooth Mousse Mousse Plus) Plus) is is a a superior superior form form of of fluoride fluoride should should be be clinicians clinicians first first choice choice for for the the prevention prevention of of caries caries and and erosion erosion for for the the treatment treatment of of dentinal dentinal hypersensitivity hypersensitivity for for the the repair repair of of white white spot spot lesions lesions
June June 2009 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
June June 2009 2009
June June 2009 2009

Courtesy Courtesy of of DMG DMG GmbH GmbH
June June 2009 2009
June June 2009 2009
GV BLACK
extensive research on amalgam (Dental Cosmos, 1896) A Work on Operative Dentistry in Two Volumes (1908)
Greene Vardiman BLACK (1835-1915)
June June 2009 2009
BLACKS TEACHINGS
highly formalised cavity designs; precise size and geometry weak, non-adhesive materials extension for prevention
June June 2009 2009
A Work on Operative Dentistry in Two Volumes (5th Ed, 1922)
June June 2009 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
June June 2009 2009
STRUCTURALLY WEAKENED TOOTH + NON-ADHESIVE RESTORATIVE MATERIAL
HIGH INCIDENCE OF SUBSEQUENT TOOTH FRACTURE

June June 2009 2009
June June 2009 2009
WHATS CHANGED?
enhanced enhanced understanding understanding of of the the carious carious process process an an infectious infectious disease disease demineralisation/remineralisation demineralisation/remineralisation cycle cycle recognition recognition of of the the rle rle of of fluoride fluoride inhibiting inhibiting demineralisation demineralisation enhancing enhancing remineralisation remineralisation development development of of adhesive adhesive materials materials glass-ionomer glass-ionomer cement cement resin-based resin-based materials materials
June June 2009 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
June June 2009 2009
INDICATIONS FOR RESTORATION (SURGICAL APPROACH)
cavitation rendering plaque control unachievable aesthetics unsatisfactory function compromised
June June 2009 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
June June 2009 2009
DENTINE CARIES (Fusayama; Massler)

infected infected (outer (outer carious) carious) dentine dentine (A) (A) moist, moist, soft, soft, pale pale yellow yellow heavy heavy bacterial bacterial load load collagen collagen degraded degraded non-remineralisable non-remineralisable affected affected (inner (inner carious) carious) dentine dentine (B) (B) dry, dry, hard, hard, brown/black brown/black few few or or no no bacteria bacteria collagen collagen cross-links cross-links intact intact remineralisable remineralisable
A B
June June 2009 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
June June 2009 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
June June 2009 2009
June June 2009 2009
EXCAVATE WITH FIRM PRESSURE UNTIL HARD, DRY, DARK COLOUR
June June 2009 2009
PRINCIPLES OF MINIMUM INTERVENTION RESTORATIONS
remove remove only only degraded degraded enamel enamel and and infected infected dentine leave leave affected affected dentine dentine support support undermined undermined enamel enamel by by the the adhesive adhesive restorative restorative material material the the cavity cavity shape shape is is dictated dictated by by the the caries caries and and is is unique unique Blacks Blacks formal formal cavity cavity designs designs are are obsolete obsolete
June June 2009 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
June June 2009 2009
When -dentine junction Whenremoving removingcaries cariesmake makethe theenamel enamel-dentine junction hard hard Excavate Excavatedemineralized demineralizeddentine dentineover overthe thepulpal pulpalsurface surfaceto to the thelevel levelof offirm firmdentine dentineprovided providedthere thereis isno nolikelihood likelihoodof of pulpal pulpalexposure exposure Deep Deeplesions, lesions,in insymptomless symptomlessvital vitalteeth, teeth,should shouldbe begently gently excavated. excavated. Soft Softdemineralized demineralizeddentine dentinemay mayremain remainwhere whereits its removal removalmight mightexpose exposethe thepulp pulp Where Whereit itis isnot notpossible possibleto toremove removesoft, soft,infected infecteddentine dentine (perhaps (perhapsthe thepatient patientis isanxious anxiousor ornot notcooperative), cooperative),seal sealin in the theinfected infecteddentine. dentine.A Apermanent permanentrestoration restorationis isplaced. placed.Do Do not -enter notre re-enter In , this Inaasymptomless, symptomless,vital vitaltooth tooth, thisshould shouldhave haveaahigh high success successrate. rate.
Kidd EAM, Essentials of Dental Caries, 3rd Ed
June June 2009 2009
June June 2009 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
June June 2009 2009
GLASS-IONOMER CEMENTS
significant properties in minimum intervention dentistry achieves reliable adhesion may prevent secondary caries may remineralise affected dentine
June June 2009 2009
Ngo, in Mount 2002
June June 2009 2009
MINIMAL INTERVENTION APPROACHES
occlusal surfaces fissure sealant preventive resin restoration posterior approximal surfaces tunnel and internal preparations slot preparations
June June 2009 2009
PREVENTIVE RESIN RESTORATION
Dr Hien Ngo Adelaide

June June 2009 2009
FISSUROTOMY BURS
June June 2009 2009
June June 2009 2009
GIC
June June 2009 2009
June June 2009 2009
THE APPROXIMAL CAVITY

E1 OUTER HALF OF ENAMEL
June June 2009 2009
E2 INNER HALF OF ENAMEL
APPLY APPLY TOPICAL TOPICAL FLUORIDE FLUORIDE AND AND MONITOR MONITOR
D1 JUST INTO DENTINE
D2 OUTER 1/3 OF DENTINE
DO DO NOT NOT RESTORE RESTORE WITHOUT WITHOUT FURTHER FURTHER CONSIDERATION CONSIDERATION
D3 INNER 2/3 OF DENTINE
RESTORE RESTORE NOW NOW

June June 2009 2009
EVOLUTION OF THE APPROXIMAL CAVITY
Soderholm, Tyas & Jokstad. Crit Rev Oral Biol Med 1998;9:464-79
June June 2009 2009
TUNNEL TUNNEL AND INTERNAL AND INTERNAL PREPARATIONS PREPARATIONS
June June 2009 2009
Jinks GM, J Dent Child 1963;30:87-92

June June 2009 2009
TUNNEL AND INTERNAL PREPARATIONS

access access through through marginal marginal fossa fossa to to approximal approximal caries caries maintains maintains marginal marginal ridge ridge tunnel tunnel preparation preparation cavity cavity exits exits into into approximal approximal space space internal internal preparation preparation demineralised demineralised approximal approximal enamel enamel retained retained
June June 2009 2009
June June 2009 2009
June June 2009 2009
INTERNAL PREPARATION
INTERNAL
June June 2009 2009
1.5 mm
INTERNAL
June June 2009 2009

INTERNAL PREPARATION CONDITION (PAA)
WASH; DRY; PLACE S/C GIC
INTERNAL
June June 2009 2009

ETCH (PHOSPHORIC ACID); WASH; DRY
APPLY BOND; BLOW THIN; CURE; PLACE COMPOSITE; (PLACE SEALANT); CURE; APPLY NEUTRAL FLUORIDE
INTERNAL
June June 2009 2009
TUNNEL PREPARATION
AFFECTED AFFECTED DENTINE DENTINE
GIC
3 mm
COMPOSITE COMPOSITE
June June 2009 2009

TUNNEL PREPARATION
June June 2009 2009
CLINICAL TUNNEL AND INTERNAL CLINICAL REVIEW REVIEW OF 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
June June 2009 2009
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%
June June 2009 2009
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
June June 2009 2009
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
June June 2009 2009
OVERALL OVERALL CONCLUSION CONCLUSION clinical clinical success success may may be be related related to to mechanical mechanical strength strength of of cavity cavity characteristics characteristics of of restorative restorative material material operator operator skill skill patient patient caries caries activity activity demanding demanding procedure procedure requiring requiring practice practice rubber rubber dam; dam; lighting; lighting; magnification magnification
June June 2009 2009
SLOT PREPARATION
Lasfargues et al.
June June 2009 2009
June June 2009 2009
MANAGEMENT OF DEFECTIVE RESTORATIONS
June June 2009 2009
RESTORATION REPLACEMENT
about about 60% 60% of of a a general general practitioners practitioners time time is is spent spent replacing replacing restorations restorations most most frequent frequent reason reason is is secondary secondary caries caries replacement replacement results results in in larger larger cavity cavity damage damage to to adjacent adjacent teeth teeth increased increased risk risk of of more more complex complex restorations restorations new new defects defects introduced introduced
June June 2009 2009
June June 2009 2009
DIAGNOSIS OF SECONDARY CARIES ditched margins correlate poorly with secondary caries (Pimenta (Pimenta et et al., al., JPD JPD
1995;74:219, 1995;74:219, Rudolphy Rudolphy et et al., al., Caries Caries Res Res 1995;29:371 1995;29:371
only amalgam restorations with marginal defects > 0.4 mm wide should be replaced (Kidd (Kidd et et al., al., J J Dent Dent Res Res
1995;74:1206) 1995;74:1206)
June June 2009 2009
OPTIONS FOR MANAGEMENT
recontour and/or polish fissure seal margins INCREASINGLY INVASIVE repair local defect replace restoration
June June 2009 2009
June June 2009 2009
June June 2009 2009
June June 2009 2009
June June 2009 2009
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June June 2009 2009
June June 2009 2009
SOME INDICATIONS FOR RESTORATION REPLACEMENT
extensive secondary caries cannot be removed in a repair procedure aesthetic need pulpal pathology fixed prosthodontic procedure
June June 2009 2009
OPERATIVE DENTISTRY
TWENTIETH CENTURY (GV BLACK) Extension for prevention TWENTY-FIRST CENTURY Prevention of extension
June June 2009 2009
Graham Mount Hien Ngo Lawrie Walsh Sue Gaffney John McIntyre Eric Reynolds
June June 2009 2009

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Thai Thai Dental Dental Association Association

June June 2009 2009