(1)

Overseas Trained Dentists

Overseas Trained Dentists
February 2005
February 2005
MINIMUM INTERVENTION
MINIMUM INTERVENTION
DENTISTRY
DENTISTRY

OPERATIVE
OPERATIVE
PRINCIPLES
PRINCIPLES
Martin J Tyas
Martin J Tyas
Professor
Professor
School of Dental Science
School of Dental Science
University of Melbourne
University of Melbourne
(2)
Overseas Trained Dentists
Overseas Trained Dentists
February 2005
February 2005
SYNOPSIS
SYNOPSIS

to discuss some of the changes

to discuss some of the changes
which have taken place in the
which have taken place in the
restoration of carious teeth, with
restoration of carious teeth, with
particular emphasis on
particular emphasis on

minimum
minimum
intervention
intervention

(3)
Overseas Trained Dentists
Overseas Trained Dentists
February 2005
February 2005
Greene
Greene
Vardiman
Vardiman
BLACK
BLACK
(1835
(1835
-
-
1915)
1915)
(4)
Overseas Trained Dentists
Overseas Trained Dentists
February 2005
February 2005
GV BLACK
GV BLACK

extensive research on
extensive research on
amalgam (Dental Cosmos,
amalgam (Dental Cosmos,
1896)
1896)

A Work on Operative
A Work on Operative
Dentistry in Two Volumes
Dentistry in Two Volumes
(1908)
(1908)
(5)
Overseas Trained Dentists
Overseas Trained Dentists
February 2005
February 2005
BLACK
BLACK

S TEACHINGS
S TEACHINGS

highly
highly
formalised
formalised
cavity designs;
cavity designs;
precise size and geometry
precise size and geometry

weak, non
weak, non
-
-
adhesive
adhesive
materials
materials

extension for prevention

extension for prevention

(6)
Overseas Trained Dentists
Overseas Trained Dentists
February 2005
February 2005
(7)
Overseas Trained Dentists
Overseas Trained Dentists
February 2005
February 2005

SURGICAL MODEL
SURGICAL MODEL

(
(

1900
1900
-
-
1980s)
1980s)

caries can be
caries can be

cured
cured

by
by
excision of all decayed tooth
excision of all decayed tooth
structure, and replacement
structure, and replacement
with a filling material
with a filling material
(8)
Overseas Trained Dentists
Overseas Trained Dentists
February 2005
February 2005
STRUCTURALLY WEAKENED
STRUCTURALLY WEAKENED
TOOTH
TOOTH
NON
NON
-
-
ADHESIVE RESTORATIVE
ADHESIVE RESTORATIVE
MATERIAL
MATERIAL
+
+
HIGH INCIDENCE OF
HIGH INCIDENCE OF
SUBSEQUENT TOOTH FRACTURE
SUBSEQUENT TOOTH FRACTURE
(9)
Overseas Trained Dentists
Overseas Trained Dentists
February 2005
February 2005
(10)
Overseas Trained Dentists
Overseas Trained Dentists
February 2005
February 2005
WHAT
WHAT

S CHANGED?
S CHANGED?

enhanced understanding of the carious

enhanced understanding of the carious
process
process

an infectious disease
an infectious disease

demineralisation/remineralisation
demineralisation/remineralisation
cycle
cycle

recognition of the rle of fluoride

recognition of the rle of fluoride

development of adhesive materials

development of adhesive materials

glass
glass
-
-
ionomer cement
ionomer cement

resin
resin
resin
-
-
-
based materials
based materials
based materials
(11)
Overseas Trained Dentists
Overseas Trained Dentists
February 2005
February 2005

MEDICAL MODEL
MEDICAL MODEL

OF
OF

MINIMUM
MINIMUM
INTERVENTION
INTERVENTION

DENTISTRY
DENTISTRY

reduction in cariogenic bacteria

reduction in cariogenic bacteria
reduction in cariogenic bacteria

preventive measures
preventive measures
preventive measures

remineralisation of early lesions

remineralisation of early lesions

minimum surgical intervention of

minimum surgical intervention of
cavitated lesions
cavitated lesions

repair of defective restorations

repair of defective restorations
Tyas et al., Tyas et al., Int Int Dent J 2000;50:1 Dent J 2000;50:1- -12 12
(12)
Overseas Trained Dentists
Overseas Trained Dentists
February 2005
February 2005
REMINERALISATION OF EARLY
REMINERALISATION OF EARLY
ENAMEL LESIONS
ENAMEL LESIONS
casein phosphopeptide-amorphous
calcium phosphate (CPP-ACP)
releases Ca
++
, PO
4
--
sugar-free gum (Recaldent

);
toothpaste; mouthwash

casein phosphopeptide
casein phosphopeptide
-
-
amorphous
amorphous
calcium phosphate (CPP
calcium phosphate (CPP
-
-
ACP)
ACP)

releases Ca
releases Ca
++ ++
, PO
, PO
4 4
-- --

sugar
sugar
-
-
free gum (
free gum (
Recaldent
Recaldent

);
);
toothpaste; mouthwash
toothpaste; mouthwash
Reynolds (1998). J Spec Care Dent 18:8 Reynolds (1998). J Spec Care Dent 18:8- -16 16

fluoride + CPP
fluoride + CPP
-
-
ACP
ACP
(CPP
(CPP
-
-
ACFP)
ACFP)

additive effect of F
additive effect of F
- -
Prof L J Walsh, U of Q
Prof L J Walsh, U of Q
(13)
Overseas Trained Dentists
Overseas Trained Dentists
February 2005
February 2005
INDICATIONS FOR RESTORATION
INDICATIONS FOR RESTORATION
(
(

SURGICAL APPROACH
SURGICAL APPROACH

)
)

cavitation rendering
cavitation rendering
plaque control
plaque control
unachievable
unachievable

aesthetics
aesthetics
unsatisfactory
unsatisfactory

function
function
compromised
compromised
(14)
Overseas Trained Dentists
Overseas Trained Dentists
February 2005
February 2005
(15)
Overseas Trained Dentists
Overseas Trained Dentists
February 2005
February 2005

ADHESIVE
ADHESIVE

PREPARATIONS
PREPARATIONS

conservative cavity
conservative cavity

macromechanical retention not

macromechanical retention not
required
required

reduction in microleakage
reduction in microleakage

reduced incidence of secondary caries

reduced incidence of secondary caries

reduced marginal staining

reduced marginal staining

reduced pulp damage

reduced pulp damage

restoration of tooth strength

restoration of tooth strength
(16)
Overseas Trained Dentists
Overseas Trained Dentists
February 2005
February 2005
DENTINE CARIES
DENTINE CARIES

infected
infected

(outer carious) dentine (A)

(outer carious) dentine (A)

soft, moist, pale yellow/brown
soft, moist, pale yellow/brown

heavy bacterial load
heavy bacterial load

collagen degraded
collagen degraded

non
non
-
-
remineralisable
remineralisable

affected
affected

(inner carious) dentine (B)

(inner carious) dentine (B)

hard, dry, dark brown/black
hard, dry, dark brown/black

few or no bacteria
few or no bacteria

collagen cross
collagen cross
-
-
links intact
links intact

remineralisable
remineralisable
A A
B B
(17)
Overseas Trained Dentists
Overseas Trained Dentists
February 2005
February 2005
PRINCIPLES OF MINIMUM
PRINCIPLES OF MINIMUM
INTERVENTION RESTORATIONS
INTERVENTION RESTORATIONS

only degraded enamel and
only degraded enamel and

infected
infected

dentine should be removed;

dentine should be removed;

affected
affected

dentine can be left

dentine can be left

undermined enamel can be supported by
undermined enamel can be supported by
the adhesive restorative material
the adhesive restorative material

the cavity shape is dictated by the caries
the cavity shape is dictated by the caries
and is unique
and is unique

Black
Black

s
s

formal
formal

cavity designs are obsolete

cavity designs are obsolete
(18)
Overseas Trained Dentists
Overseas Trained Dentists
February 2005
February 2005
(19)
Overseas Trained Dentists
Overseas Trained Dentists
February 2005
February 2005
GLASS
GLASS
-
-
IONOMER CEMENTS
IONOMER CEMENTS

powder (basic)
powder (basic)

fluoroaluminosilicate glass
fluoroaluminosilicate glass

liquid (acidic)
liquid (acidic)

aqueous polyalkenoic acid

aqueous polyalkenoic acid

setting reaction
setting reaction

acid:base
acid:base

(resin polymerisation)
(resin polymerisation)
(20)
Overseas Trained Dentists
Overseas Trained Dentists
February 2005
February 2005
GLASS IONOMER CEMENTS
GLASS IONOMER CEMENTS

tooth
tooth
-
-
coloured
coloured

moisture
moisture
-
-
tolerant
tolerant

adhesive to tooth structure

adhesive to tooth structure

release fluoride
release fluoride

prevent secondary caries?

prevent secondary caries?

promotes remineralisation of
promotes remineralisation of

affected
affected

dentine?
dentine?

brittle
brittle
(21)
Overseas Trained Dentists
Overseas Trained Dentists
February 2005
February 2005
Ngo, Ngo, in in Mount 2002 Mount 2002
(22)
Overseas Trained Dentists
Overseas Trained Dentists
February 2005
February 2005
MINIMAL INTERVENTION APPROACHES
MINIMAL INTERVENTION APPROACHES

occlusal surfaces
occlusal surfaces

fissure sealant
fissure sealant

preventive resin restoration

preventive resin restoration

posterior approximal surfaces

posterior approximal surfaces

tunnel
tunnel

and
and

internal
internal

preparations
preparations

slot
slot

preparations
preparations
(23)
Overseas Trained Dentists
Overseas Trained Dentists
February 2005
February 2005
FISSURE SEALANT
FISSURE SEALANT
(24)
Overseas Trained Dentists
Overseas Trained Dentists
February 2005
February 2005
Dr Hien Ngo
Adelaide
PREVENTIVE RESIN RESTORATION
PREVENTIVE RESIN RESTORATION
(25)
Overseas Trained Dentists
Overseas Trained Dentists
February 2005
February 2005
(26)
Overseas Trained Dentists
Overseas Trained Dentists
February 2005
February 2005
GIC
GIC
(27)
Overseas Trained Dentists
Overseas Trained Dentists
February 2005
February 2005
(28)
Overseas Trained Dentists
Overseas Trained Dentists
February 2005
February 2005
THE APPROXIMAL CAVITY
THE APPROXIMAL CAVITY
(29)
Overseas Trained Dentists
Overseas Trained Dentists
February 2005
February 2005
EVOLUTION OF THE APPROXIMAL CAVITY
EVOLUTION OF THE APPROXIMAL CAVITY
Soderholm,
Soderholm,
Tyas & J okstad.
Tyas & J okstad.
Crit Rev Oral
Crit Rev Oral
Biol
Biol
Med
Med
1998;9:464
1998;9:464
-
-
79
79
(30)
Overseas Trained Dentists
Overseas Trained Dentists
February 2005
February 2005
Hunt, 1984 Hunt, 1984
Knight, 1984 Knight, 1984
TUNNEL PREPARATION
TUNNEL PREPARATION
GIC
GIC
(31)
Overseas Trained Dentists
Overseas Trained Dentists
February 2005
February 2005
(32)
Overseas Trained Dentists
Overseas Trained Dentists
February 2005
February 2005
Lasfargues et al. Lasfargues et al.
SLOT PREPARATION
SLOT PREPARATION
(33)
Overseas Trained Dentists
Overseas Trained Dentists
February 2005
February 2005
MANAGEMENT OF DEFECTIVE
MANAGEMENT OF DEFECTIVE
RESTORATIONS
RESTORATIONS
(34)
Overseas Trained Dentists
Overseas Trained Dentists
February 2005
February 2005
RESTORATION REPLACEMENT
RESTORATION REPLACEMENT

60
60
% of a general practitioner
% of a general practitioner

s time is
s time is
spent replacing restorations
spent replacing restorations

most frequent reason is secondary caries
most frequent reason is secondary caries

replacement results in
replacement results in

larger cavity
larger cavity

damage to adjacent teeth
damage to adjacent teeth

increased risk of more complex
increased risk of more complex
restorations
restorations

new defects introduced
new defects introduced
(35)
Overseas Trained Dentists
Overseas Trained Dentists
February 2005
February 2005
(36)
Overseas Trained Dentists
Overseas Trained Dentists
February 2005
February 2005
OPTIONS FOR MANAGEMENT
OPTIONS FOR MANAGEMENT

recontour
recontour
and/or polish
and/or polish

fissure seal margins

fissure seal margins

repair local defect

repair local defect

replace restoration
replace restoration
INCREASINGLY
INCREASINGLY
INVASIVE
INVASIVE
(37)
Overseas Trained Dentists
Overseas Trained Dentists
February 2005
February 2005
(38)
Overseas Trained Dentists
Overseas Trained Dentists
February 2005
February 2005
(39)
Overseas Trained Dentists
Overseas Trained Dentists
February 2005
February 2005
(40)
Overseas Trained Dentists
Overseas Trained Dentists
February 2005
February 2005
(41)
Overseas Trained Dentists
Overseas Trained Dentists
February 2005
February 2005
(42)
Overseas Trained Dentists
Overseas Trained Dentists
February 2005
February 2005
(43)
Overseas Trained Dentists
Overseas Trained Dentists
February 2005
February 2005
SOME INDICATIONS FOR
SOME INDICATIONS FOR
RESTORATION REPLACEMENT
RESTORATION REPLACEMENT

extensive secondary caries

extensive secondary caries

cannot be removed in a repair

cannot be removed in a repair
procedure
procedure

aesthetic need
aesthetic need

pulpal pathology
pulpal pathology
(44)
Overseas Trained Dentists
Overseas Trained Dentists
February 2005
February 2005

The professional man has no

The professional man has no
right to be other than a continuous
right to be other than a continuous
student
student

GV BLACK:
GV BLACK:
(45)
Overseas Trained Dentists
Overseas Trained Dentists
February 2005
February 2005
TWENTIETH CENTURY (GV BLACK)
TWENTIETH CENTURY (GV BLACK)

Extension for prevention

Extension for prevention

TWENTY
TWENTY
-
-
FIRST CENTURY
FIRST CENTURY

Prevention of extension
Prevention of extension

OPERATIVE DENTISTRY
OPERATIVE DENTISTRY
(46)
Overseas Trained Dentists
Overseas Trained Dentists
February 2005
February 2005