Cariology/RestorativeDentistry

Dan Ericson

The Concept of Minimally Invasive

Dentistry
Abstract: This paper reviews Minimally Invasive Dentistry (MID) from a day-to-day dentistry perspective, focusing mostly on cariology
and restorative dentistry, even though it embraces many aspects of dentistry. The concept of MID supports a systematic respect for the
original tissue, including diagnosis, risk assessment, preventive treatment, and minimal tissue removal upon restoration. The motivation for
MID emerges from the fact that fillings are not permanent and that the main reasons for failure are secondary caries and filling fracture. To
address these flaws, there is a need for economical re-routing so that practices can survive on maintaining dental health and not only by
operative procedures.
Clinical Relevance: Secondary caries and fractured fillings are the main reasons for restoring teeth. The primary route to improve oral
health is to avert this by a systematic respect for the original tooth structure.
Dent Update 2007; 34: XXX-XXX

The concept prevention.

Minimally Invasive Dentistry1
(MID) is a systematic respect for the original
tissue. The concept translates:
n From a correct diagnosis of risk and
lesion assessment;
n The institution of targeted preventive
treatment to stop disease;
n Restoration of lesions with as little
removal of healthy tissue as possible;
n The use of durable materials;
n The prevention of disease recurring.
There is no such thing as a
permanent filling (yet) and this is motivation
enough to promote MID for those of us
that consider that the Hippocratic Oath
makes sense (‘First, do not harm….etc’). The
three words, Minimally Invasive Dentistry,
sound benign and therefore might have
a potential to authorize prevention in the
world of drilling and filling. The phrase can
also help to motivate proper remuneration
of diagnosis, risk assessment and
Dan Ericson, DDS, Dr Odont, Professor
and Head of Department of Cariology,
Faculty of Odontology, Malmö University,
Sweden. President of Academy of
Minimally Invasive Dentistry.
2 DentalUpdate
Minimal Intervention Dentistry,
Preservative Dentistry, and Atraumatic
Restorative Treatment (ART)1-6 are similar,
if not identical, concepts. Prevention of
disease is the ultimate goal. Microdentistry,
seems to relate more to technical
procedures.8 Obviously, all these aspects of
MID include less cutting and less removal
of healthy tooth tissue, leaving the natural
tissue as solid and as strong as possible.
MID implies systematic respect for original Figure 1. Demonstration of the amount of
tissue and prevention, as well as considerable practice time spent on repairing and replacing old
technical competence. The concept embraces restorations.11
all aspects of dentistry.9,10
This paper elaborates on the
conceptual facts and philosophy of MID in
order to give one or two new perspectives catch: There is yet little structured evidence for
on the topic. The facts may be summarized preventive treatment.
as follows:
n We spend most of our time in practice
The context
replacing and repairing previously inserted
restorations11 (Figure 1), that do not last Today we have the knowledge,
very long,12 owing to secondary caries possibility and interest to practice MID. Even
and restoration fractures13 (Figure 2). The though many of us already do, the concept
philosophical summary of MID reads: is far from established in the world.14,15 The
Demonstrate a systematic respect for the technical considerations on minimal tissue
original tissue (Figure 3) by acknowledging removal have been thoroughly described by
that caries is a multifactorial disease that is Peters and McLean,4 Burke,5 Ericson et al6.
not cured by restorations and that cavities The circumstances that have
weaken the original tooth (Figure 4). The dramatically contributed to the increased
January/February 2007

Figure 2. The reasons for filling replacement are demonstrated in this graph after Mjör and co-workers
2000,13 the main reasons being secondary caries and restoration fracture. (Mean annual failure rates of
stress bearing restorations 3.0% for amalgam and 2.2% for direct composite restorations12).
Figure 3. This symbol of a rose-bur with a
disarming knot might give a vision of prevention
and minimally invasive dentistry.
focus on the topic are among others: the
vast technical possibilities to make tissue-
preserving restorations using adhesive
materials5,6 and that restoration thresholds
have changed in many countries.16,17
Further, the limited survival of traditional
restorations in an increasingly older
population has made us aware that dental
January/February 2007
Figure 4. Traditional preparation technique often
renders removal of a smaller amount of caries as
compared to healthy dentine.
health is beyond restorative artefacts.18
The option to adopt the MID concept
depends also on the recall convention.17 In
some countries, every individual is raised
and aged within a dental recall system. In
others, the tradition is to visit the dentist
when symptoms arise or there are too
few dentists.19 To assess and monitor risk
Cariology/RestorativeDentistry
and early symptoms, individualized recall
systems are pertinent. Such recall systems
are also necessary to be able to delegate
health behaviour to the patient and assist
in his/her success. Within some European
countries, the dentist is not allowed to
arrange a recall appointment, as the
patient must have a free choice to select a
dentist on each occasion. If such a dentist
is not sure that the patient will return, it
might be likely that the dentist makes a
restoration rather than monitor a lesion’s
progress to institute prevention and to
select the optimal timing for a filling. Yet,
in Scandinavian countries, it is becoming
more common to use individualized recall
intervals, and to monitor caries lesions for
longer periods. Even though all aspects of
MID cannot be implemented at all times,
the minimal removal of healthy tooth
substance in operative dentistry can be
achieved.
However, the procedures
included in the minimally invasive
philosophy are not in line with
reimbursement systems in many (if any)
countries. Preventive measures and tissue-
preserving operative procedures may take
longer than do traditional fillings. The fee
for fillings always ends up being higher per
time unit. It is essential to level the payment
systems so the prevention and tissue-
preserving approach can be rewarding, not
only for the patient, but also for the dentist,
as ‘fillings are not curative’, stated already by
Black in 1908.20
The consequences
It is quite clear that the
mere process of restoring teeth with
different materials will not cure the
disease that caused the cavity in the
first place. Therefore, it is imperative that
each restorative procedure also includes
treatment directed against the disease
process, as the evidence base demonstrates
that filling survival is not impressive.12
Fillings are only second to prevention.
But, on the other hand, small fillings
survive better than large ones.21 So, once a
decision to restore is made, it is important
to maintain a maximum amount of the
original structure.
The introduction of adhesive
restorative materials and the deeper
knowledge of the caries lesion in enamel
DentalUpdate 3
 Cariology/RestorativeDentistry
Figure 5. A screenshot of the Cariogram model. Can be downloaded free. http://www.db.od.mah.
se/car/cariogram/cariograminfo.html
and dentine are main achievements in
clinical dentistry that have allowed the
further application of a tissue-preserving
attitude in restoring teeth.2 Many
techniques have been reviewed.5,6 But
before arriving at an operative or preventive
treatment decision, we need to consider:
n What happens if I restore? What is the
survival rate of fillings?
n If I don’t? What is the ‘survival’ of small
and large caries lesions (before they
progress beyond prevention)?
Drives for MID in cariology
It is essential to sharpen the
motives for MID in relation to how far the
techniques have come and where the
traditional alternatives lead. Some motives
are not new at all as ‘fillings are not curative’
and this is of course still true. Beyond that,
the current most important motives are
(condensed after Ericson9):
n The limited survival of restorations;
n Early diagnosis of lesions and accurate
risk assessment are available;
n The extensive knowledge on caries
progression rates;
n Adhesive restorative materials and
4 DentalUpdate
techniques promote less removal of healthy
tissue;
n The high risk for iatrogenic effects.
The limited survival of restorations
A huge evidence-base clearly
establishes that secondary caries and
fracture of fillings are the main reasons
for restoration replacement in general
dental practices.12,13,22,23 The survival times
of restorations are increasing, at least from
the days of GV Black24 when a filling should
protect the tooth ‘for two or three years.’ But
there is still no such thing as a ‘permanent’
filling. It is also evident that 65% of the
time in practice is spent for re-restoration
or repair of previous restorations, again the
main reason being secondary caries.11. The
mean annual failure rates of stress-bearing
restorations have been reported to be 3.0%
for amalgam and 2.2% for direct composite
restorations.12
Secondary caries
It might be wise to recognize
that ‘secondary caries is no different from
primary caries except that it occurs next
to a filling.’25 The difficulties in diagnosing
secondary caries were recently reviewed by
Mjör.26 It is well known that the explorer will
catch in any crevice whether it is carious or
not and that staining is not a predictor for
secondary caries. The diagnosis should be
supported by other findings (radiographic,
presence of soft dentine, etc). The rationale
suggested by Mjör26 is to consider it a
localized disease, and that restoration
should start with a limited exploratory
preparation, and that the reparation should
not extend more than the actual caries
lesion. The outcome could often be repair
instead of replacement.
Fractures
Large fillings and teeth with
large restorations are more prone to
failure.21,27 In replacing a restoration, there
is a considerable waste of healthy tooth
substance and increase of cavity size.28,29
This is particularly true when replacing
tooth-coloured resin composites, when it
is difficult to identify the border between
filling and tooth. The result of resin
replacement is a faster increase in cavity
size. The fact that large fillings survive for
a shorter time than small ones, increases
the motives for repair and refurbishing
procedures.
Even though fillings are not
permanent, they are still needed to fill
the defect after excision of necrotic (and
healthy) tissue. It is also obvious that
disease preventing efforts and the timing
of the restoration placement is crucial to
maximize longevity.
Early diagnosis of lesions and accurate risk
assessment
Caries diagnosis has been
described as a mental resting place on the
way to a treatment decision.30 Diagnosis
(from Greek, through knowledge) implies
that it is not merely the recognition of
lesions using more and more sophisticated
tools,31 but rather the conceptual triad:
n Identify the caries lesion;
n Establish whether it will progress or not;
n Assess if more lesions will occur.
Tools for early detection of caries lesions
A number of tools, apart
from the eye, explorer and traditional
radiograph, have been developed. Examples
January/February 2007

Figure 6. Annual dentine caries progression rates in a prospective study by Mejare and co-workers
2004.42 The progression of early dentine lesions (left side of tooth) to deep dentine lesion (right side) is
less frequent in the older age groups.
of objective tools are digital radiographic
techniques, DIFOTI32 (digital imaging optic
trans-illumination), electric conductivity
methods and laser and light fluorescence
techniques.33 However, little clinical data are
available to validate the technologies.31,34
The laser fluorescence methods have been
debated lately,35-37 and visual criteria for
detection of early occlusal caries are still
applicable, provided the surfaces are clean
and dry. Probing can cause iatrogenic
damages. Combining radiographs and
visual criteria-based diagnoses increases
diagnostic accuracy.37 The spotting of an
active incipient caries lesion is a clinical
symptom to be acted upon, as this proves
beyond any reasonable doubt that the
patient is highly susceptible to caries.
Caries risk assessment involves
the process of analysing and weighing up
risk factors and then coming up with a
value of the risk to develop caries lesions
or not. The result will be used for selection
of appropriate prevention strategies.
Assessing caries risk is a complex task, and
the theme of risk assessment prompts
extensive elaboration beyond the focus of
this chapter. Among those risk-prediction
January/February 2007
models that have been validated, the
Cariogram may be of value38,39 (Figure
5). Such tools can help the clinician to
structure the information on caries risk and
also institute measures directed towards the
specific risk situation. It can be downloaded
for free (http://www.db.od.mah.se/car/
cariogram/cariograminfo.html).
Caries progression rates
The actual progression of caries
have been studied in various populations.40-42
Mean values in such studies demonstrate
that early enamel lesions progress rather
slowly and, for early dentine lesions, the
annual progression rate to deep dentinal
lesions is approximately 20% of all dentinal
lesions. One could also say that 80% do not
progress significantly during one year.40
Also, average progression times for dentine
caries progression vary with patient’s
age42 (Figure 6). Early dentine lesion in
12−15 year-olds show annual progression
in 32.5% (one out of three progresses). If
the restorative decision is based on the
radiographs only (caries in the dentine),
one would end up with unnecessary
restorations in two out of three cases, given
Cariology/RestorativeDentistry
the circumstances that patients are recalled
annually. Such studies show that restorative
intervention thresholds should be based
on an individual risk assessment and not
only on what is seen on the radiograph. The
progression is faster in primary teeth.43
Restoration thresholds
In many European countries,
restoration thresholds have become
more and more ‘into the dentine’16. As an
example, for occlusal cavities (on a second
molar in a 20-year-old), the threshold for
operative treatment is a moderately-sized
open cavity and/or radiolucency into the
dentine for approximately 70% of dentists
in Scandinavia.44 Similar data can be found
for proximal caries lesions.45
In the light of caries progression
rates and restoration survival data, operative
intervention should be postponed until all
other methods of controlling the disease
have been exhausted. This also means that
early lesions have to be monitored more
or less throughout life, preferably in an
individual recall system.17
As a consequence of the
evidence of caries diagnosis accuracy,
progression and restoration survival data,
every filling should be carefully considered
and a lesion restored when:
n We are certain of progression and cannot
stop it;
n There are symptoms;
n There are aesthetic considerations;
n The surface is needed for oral function.
Adhesive restorative materials and techniques
promote less removal of healthy tissue
One of the most important
prerequisites for MID within cariology is
the development of adhesive restorative
materials,2 useful for a number of
procedures from preventive restorations
as fissure sealants, to large fillings and
even crown-replacements.46 These
adhesive materials have revolutionized
dentistry by opening the alternatives in
cavity preparation. Smaller cavities can be
prepared, aiming at removing diseased
dental tissue only.6,37 The fluoride releasing
materials may contribute slightly to less
secondary caries.47
Several new preparation
techniques have emerged as a consequence
of the knowledge of caries progression
DentalUpdate 5
 Cariology/RestorativeDentistry
Figure 7. Interproximal preparation protection device, based on a steel band attached to a wedge. This
makes application simpler and the wedge retains the device even after the interproximal contact is lost
during preparation (FenderWedge Directa AB, www.trycare.co.uk).
rates, survival of fillings and new adhesive
materials. A lesion orientation in preparation
procedures is promoted,48,49 which means
first to access the dentine caries to remove
or modify the infected dentine, leaving
the affected dentine, then to modify the
cavity as little as possible to receive the
filling material, as pertinently described by
Ericson et al.6 Several reviews on operative
techniques have also been described
elsewhere.5,50 This is conceptually different
from ‘fitting the filling in the tooth’ −
an approach using classical amalgam
preparation rules. The lesion orientation is
also applied in repair or refurbishing of a
restoration.26,29
High risk for iatrogenic effects
It has been demonstrated
that, in 60−70% of proximal preparations,
the adjacent tooth is damaged and will
thus develop caries more frequently as
compared to an undamaged surface.51
This fact is very seldom considered when
discussing longevity of restoration, and one
should certainly add the aspect of longevity
of the unrestored adjacent surface (Figure
7). The drift in restorative thresholds leads to
less iatrogenic effects and might also have
influenced the caries decline.52 The increase
in cavity size by waste of healthy tissue
at each re-restoration is also iatrogenic.
Repair or refurbishing of a restoration may
6 DentalUpdate
decrease iatrogenic damages.26,29
A truly MID procedure,
minimizing iatrogenic effects, is the
step-wise excavation approach.53 The
procedure is based on considerations of
caries pathology; to change the cariogenic
environment, and not to remove carious
dentine close to the pulp because this risks
an iatrogenic pulp exposure. After a sealing
period, lesions arrest and the vital dentine
responds by remineralization and formation
of pulpal dentine. At re-entry, the excavation
is continued as far as hard dentine, reducing
the risk for unnecessary exposure, root-
canal treatment and weakening of the
tooth.
The conflict
We have the means, motives
and opportunities for MID, but there
may be a lack of economical incentives.
Habitually, patients and third parties
are convinced that the only things that
count are operative procedures, that is,
it is alright to pay for a filling but not for
diagnostics, risk assessment or procedures
that can help avoid having a restoration.
This is the bottom line and many
reimbursement systems do not recognize
non-operative procedures to the extent
that the care provider can survive. There
is a reimbursement threshold to every
enterprise as well as a restorative threshold
to caries lesions. It would be convenient if
reimbursement could go hand in hand with
MID and the maintenance of health.
The conclusion
The main reasons for restoration
replacement are secondary caries and
restoration fractures. Secondary caries is
the same disease as primary caries, but
located in the tooth structure adjacent to
the restoration. To increase the survival rate
of restorations, the main focus should be to
address the conditions that caused caries
in the first place, and the second to make
fillings less prone to fracture.
Within cariology, MID has lately
evolved faster since we now understand
the disease better and the evidence-
base on the short survival of restorations
prompts action. We can intercept disease
development and have the technical
possibilities to remove a minimal amount of
healthy tooth substance and make smaller
adhesive fillings. There has been a change
from ‘caries lesions are treated operatively’
towards ‘caries lesions are treated by
addressing their causes’, as well as using
a more tissue-preserving approach when
restoring teeth.
Even though we do not have
sufficient evidence that prevention is always
effective,54 we have an enormous evidence-
base indicating, without doubt, that fillings
are futile to treat the disease. Such therapy
is directed towards the symptoms − the
cavities and, at its best, it buys some time,
as stated by Black in 1908. When it comes
to MID philosophy, addressing ‘caries as a
whole’ – I dare say ‘Black to the future’.
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