Pediatric dentistry
MINIMALLY INVASIVE TREATMENT IN DECIDUOUS TEETH DECAY
Ana PETCU1, Carmen SAVIN2, Vasilica TOMA3, Adriana BĂLAN4
1
Lecturer, Dept. Surgery, Faculty of Dental Medicine „Gr. T. Popa” University of Medicine and Pharmacy Iași, Romania
2
Lecturer, Dept. Surgery, Faculty of Dental Medicine, „Gr. T. Popa” University of Medicine and Pharmacy Iași, Romania
3
Associated Professor, Dept. Surgery, Faculty of Dental Medicine, „Gr. T. Popa” University of Medicine and Pharmacy Iași,
Romania
4
Professor, Dept. Surgery, Faculty of Dental Medicine, „Gr. T. Popa” University of Medicine and Pharmacy Iași
Corresponding author: Carmen Savin; email: savin.carmen@gmail.com
Abstract
Dental caries is one of the most common disorders of
childhood. Although preventable, it is found in large
sectors of the pediatric population. In recent decades, focus
was laid on the methods for its prevention, by controlling
bacterial plaque, food diet and various methods of local or
general fluoridation. On the other hand, developing of
methods for early diagnosis of dental caries led to detection
of the disease in its incipient stages. In the same time, there
was a big breakthrough in the development of restorative
materials, whose properties do not require removal of
large amounts of substance to achieve retentive dental
cavities. Thus, modern dentistry has proposed a more
reasonable theory, called minimally invasive treatment.
Keywords: air abrasion, air polishing, ART, sono-abrasion.
The minimally invasive treatment refers to the
preservation of tooth structure as much as
possible, being a branch of conservative dentistry.
In literature, terms such as minimally invasive
dentistry and microdentistry are used.
Tyas et al. were of the opinion that minimally
invasive dentistry is concentrated on how to
approach tooth decay, including early diagnosis,
prevention and treatment, focusing on changing
treatments - from dental operational interventions
to the biological methods of preventing the
development of dental caries and preservation
of as much sound tooth tissue as possible [1].
Peters et al. considered that minimally invasive
dentistry focuses on preserving healthy tooth
tissue by removing only the carious lesion, rather
than the “preventive extension” developed by
G.V. Black [2,3].
Regarding the study of the dental tissue,
combined with caries etiology, especially the
remineralization process, the revolution of
diagnostic measures and the new perspective of
prevention enabled the development of dental
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materials which set the basis for minimally
invasive dentistry.
Tyas et al. proposed four basic principles for
minimally invasive dentistry: control of the
lesion, remineralization of early tooth decay,
minimum surgical trauma and restoration, but
not replacement of dental caries lesions.
The minimally invasive techniques involve:
1. rotatory mechanical techniques - involving
burs
2. non-rotatory mechanical techniques - air
abrasion, air polishing, ART, ultrasonic and
sono-abrasion
3. chemo-mechanical techniques - cariosolv,
caridex, enzymes
4. photoablation with laser [4].
In the following, the non-rotating techniques
for minimally invasive treatment are enumerated.
These techniques are used in the early stages of
dental caries in people susceptible to tooth decay
and caries prevention in the areas.
Air abrasion
Air abrasion is a pseudo-mechanical, non-
rotating technique, used to remove decayed
tissues. The air abrasion principle is to apply,
under a high pressure, non-toxic particles, such
as ions of aluminum oxide, to remove accurately
the enamel, dentin caries tissue and old fillings.
To adjust the action to the characteristics of the
instrument, a number of parameters can be
modified: type and size of the abrasive particles,
particle speed, air pressure, distance between the
instrument and the tooth surface, time of use [5].
Air abrasion is quieter and more efficient in
terms of time and energy consumption, it requires
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 MINIMALLY INVASIVE TREATMENT IN DECIDUOUS TEETH DECAY
no anesthesia, and does not produce vibrations
and heat. It is easily accepted by the patient and
maximizes the preservation of tooth structure.
The interior of the prepared cavity is fine, making
it easier to fill. It also reduces the stress between
filling and tooth structure, possible
microfracturing, thus prolonging the life of
fillings.
The air abrasion system uses abrasive particles
projected mainly for the affected area of ​​the
cavity. If the blackened area is a simple stain, it
can be removed easily. If decay is accompanied
by affected tissue, a strong jet of abrasive particles
can remove both stain and the affected tissue. If
dentin is wet, thick and elastic, the particles bind
to the surface, making the device unable to exert
its effects. Therefore, soft dentin should be
removed manually. Another disadvantage of
this method is that, because of an easier removal
of dentin, comparatively with the enamel, the
latter one should be removed by burs. Another
disadvantage would be the total lack of tactile
sensation, because the tool head does not touch
the surface of the tooth. Therefore, the physician
should be able to foresee the cavity limits before
cutting, to reduce the high risk of its over
preparation [6].
Recent studies proposed alternative abrasive
particles, showing that software particles, such
as polycarbonate resin or alumina hydroxyapatite
mixtures can be more selective in removing
carious dentin, because they are capable of
removing only tissue of equivalent hardness, the
healthier tissue remaining unaffected [7].
Air polishing
Air polishing produces a high pressure jet
which contains sodium bicarbonate; it is projected
on the surface of teeth, producing a cutting/
grinding effect. This technique was originally
designed for removing stains. Air polishing is
not very selective when grinding tooth structure
and it can affect the health of dentin and
cementum. It is used especially in the final
preparation of the tooth to remove the remaining
altered dentin. Air polishing is accomplished by
the propulsion of abrasive particles through a
mixture of compressed air and water, with a
handpiece, thus removing stain and/or dental
plaque [8].
International Journal of Medical Dentistry
The abrasion rate is influenced by speed,
pressure, time of abrasion, shape and hardness
of the particles used [9]. However, hardness and
size of particles used are those that determine
decisively pigmentation removal. Commercial
preparations are divided into fine, medium or
coarse. The doctor has the mission to determine
what type of powder is best suited for natural
areas and restorative materials.
There follows a set of information about air
polishing supported by scientific evidence when
using an air polishing powder with a Mohs
hardness number of 3 or less:
• Air polishing removes the stain and dental
plaque in half the time it would take using
traditional polishing, while stain can be
removed 3.15 times faster than with a curette
[10].
• Air polishing is not painful if the air / water
/ powder stream is not directed on the soft
tissues [11].
• Air polishing can be safely used on titanium
implants, being the method of choice for
orthodontic banded and teeth bracketed,
preparation for sealant placement and
bacterial removal from root surfaces [12].
• Air polishing can produce uniform smooth
root surfaces and remove 100% of bacteria and
/ or bacterial endotoxins from cementum.
ART
A traumatic restorative treatment (ART) is an
alternative treatment for tooth decay. It was
originally developed for use in underdeveloped
countries, in rural areas, because it requires no
anesthesia or electricity. Recently, the increased
interest in this technique was manifested in
developed countries, because of its “atraumatic”
approach in relation to the stress and pain
experienced by patients [13].
The ART principles are:
1. Removal of carious tooth tissue using only
hand tools
2. Restauration of the cavity with a high-viscosity
glass-ionomer, along with concurrent sealing
of the adjacent pits and fissures [14].
ART includes the absence of noise and
vibration and reduces the need to administer
anesthesia. Studies have shown that ART
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Ana PETCU, Carmen SAVIN, Vasilica TOMA, Adriana BĂLAN
restorations on one surface of temporary teeth
have the same survival rates as those with
amalgam. ART restorations on more surfaces of
temporary molars have a shorter survival
compared to those on a single surface [15].
ART technique indications:
- Very young children who have never been to
the dentist
- Patients with anxiety / strong fear
- Patients with physical and / or mental
disability
- High-risk caries clinics, as an intermediate
treatment, to assure stabilization conditions
[16].
The ART approach is very cost effective since
it is a friendly procedure. It makes restorative
care more accessible for all population groups
[17].
Ultrasonics and sono-abrasion
The high frequency ultrasonic vibrations have
been recommended since the 1950s to remove
proximal carious lesions in both posterior and
anterior teeth, with the aim of achieving a more
conservative cavity preparation. This technique
does not physically excise the dentin, yet it
abrades it using a diamond-coated tip oscillating
at a frequency of about 6.5 kHz, up to a maximum
frequency of 20-40 kHz [18].
Recently, sono-abrasion has been developed
as a modification of the original ultrasonic
method. Sono-abrasion is a technique for the
selective preparation of enamel and dentin,
offering excellent efficacy, quality and safety
[19]. It utilizes high frequency, sonic, airscalers
with modified abrasive tips which describe an
elliptical motion with a transverse distance of
0.08- 0.15 mm and a longitudinal movement
ranging from 0.055 to 0.135 mm. These tips are
diamond coated on the cutting side, cooled using
water at a flow rate of 20-30 ml/min and operated
by 305 bar air pressure for finishing cavity. Using
different shapes of tips helps in preparing
predetermined cavity contours, while also
working well in removing the softened, carious
dentin [20].
Advantages - The ultrasonic procedure has
the advantage of minimizing or eliminating
noise, vibration, heat and pressure. The use of
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the ultrasonic technique can modify the proximal
preparation procedure in order to protect
adjacent teeth against iatrogenic damage caused
by the use of dental burs. The disadvantages of
this system are the relatively low abrasion and
high hub excursion (0.4 mm) of the tips, and
weakening of the enamel rods with the associating
cracks adjacent to the prepared sites [21,22].
With the development of modern restorative
procedures, dentistry engages in a new era.
Dentists have a responsibility to upgrade the
praxis from maximal to minimal interventions.
The minimally invasive treatment of dental
caries offers the potential for a more conservative
approach and also provides a patient-friendly
treatment option.
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