INTRODUCTION

Caries (Latin meaning ‘dry rot’) is the name given to the process of
slow disintegration that may effect any of the biological hard tissue as a
result of bacterial action. Dental caries is defined as the microbial disease
of the calcified tissues of teeth, characterized by demineralization of the
inorganic portion and destruction of organic substance of tooth (Shafer).

A surgical approach to the elimination of a carious lesion was

developed a century ago; this approach was necessary at that time, because
there was no valid alternative. The total concept of the oral environment
was not appreciated. Carious was not recognized as a bacterial disease, so
the microbiology of the oral flora was not understood. The significance of
fluoride ion was not known, so the potential for remineralization and
healing of tooth structure was not considered. This approach required
maximal intervention into the crown of tooth. Destruction of sound tooth
structure was necessary to ensure complete removal of diseased portion and
to obtain retention for the restoration. This led to loss of esthetics, a
potential alteration of the occlusal anatomy, weakening of remainder of the
crown, and further insult to the pulpal tissue that was already affected by the
disease.

Research over the last 30 years, has made it possible to modify this
approach. It is now time to encourage the profession to adopt a new overall
concept called Minimal Intervention Dentistry.

Concept of minimal intervention dentistry has evolved as a

consequence of increased understanding of the carious process and the

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development of adhesive restorative materials. It is now recognized that
demineralized but non cavitated enamel and dentin can be healed and that
surgical approach to the treatment of a carious lesion along with
“EXTENSION FOR PREVENTION” as proposed by G.V. Black is no
longer tenable.

Term minimal intervention is relatively new in dentistry and has been

introduced to suggest to the profession that it is time for changes in the
principles of operative dentistry.

Minimal intervention in relation to dental caries covers a vast area of

diagnosis, risk assessment, prevention and control (arrest and prevention of
progression).

Minimal intervention approach starts with diagnosis and risk

assessment of the disease in order to allow for proper treatment decision.

Different scenarios for management of initial carious lesion include

noninvasive management and operative care. Recent advancements in
management of caries has started a trend towards the conservation of tooth
structure and also bonding techniques which provides an alternative to
mechanical retention.

The ultimate goal of minimal intervention is to extend the life of

restored teeth with as less intervention as possible. When operative care is
indicated, it should be aimed at “PREVENTION OF EXTENSION” rather
than “EXTENSION FOR PREVENTION”.

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 Preservative dentistry is therefore based on a refined model of care
consisting of :
 Accurate caries diagnosis.
 Classification of the caries severity using radiographs ;
 Assessment of individual caries risk (high, moderate or low);
 Arresting active lesions
 Remineralising and monitoring of cavitated arrested lesions
 Placement of restorations in teeth with cavitated lesions, using minimal
cavity designs;
 Assessing disease management outcomes (that is, change in various
decayed/ missing/filled indices) at predetermined time intervals.

MINIMAL INTERVENTION RESTORATIVE DENTISTRY :

It is time to consider and discuss modifications to the control,
elimination, and restoration of caries. The surgical approach has been
proven to be inefficient and destructive, so it is obviously maximally
interventionist.

A recent policy document produced for the World Dental Federation

suggested that there are 4 basic principles that must be applied to fulfill the
description of minimal intervention dentistry :
1. Control the disease through reduction of cariogenic flora.
2. Remineralize early lesions.
3. Perform minimal intervention surgical procedures as required.
4. Repair, rather than replace, defective restorations.

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 It is suggested that these principles be followed in the modern
approach to dealing with the disease of caries.

Minimal Intervention

Evaluate Control Disease Assess need for Repair damage

Invasive treatment

Prevent Remineralize Minimal Biomimetic

Invasion material

1. Quantity and 1. Maximize 1. Only when integrity 1. Maintain integrity

quality of saliva remineralizing of tooth is of tooth, both
2. Microflora potential of oral compromised. biologic and
3. Diet environment. 2. After adequate physical.
4. Tooth morphology 2. Disrupt control of the disease 2. Use biomimetic
5. General health demineralization 3. In consultation with material
cycles. patient 3. Remineralize
3. Remineralize white affected dentin
spot lesions 4. Eliminate
4. Educate and motivate cavitation
patient. 5. Maintain seal

Essential aspects of diagnosis and treatment planning in a minimal intervention

approach to operative dentistry

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 CARIES DIAGNOSIS

The process of caries diagnosis involves both risk assessment and the
application of diagnostic criteria to determine the disease state. The
primary objective of caries diagnosis are to identify those lesions that
require surgical treatment, non-surgical treatment and persons who are at
high risk for developing carious lesions.

To diagnose carious lesions in patients, several factors must be

considered.

Some general factors are helpful in assessing a patients risk to caries.

These include ;
1) Patient history 2) General clinical examination results

ASSESSMENT TOOLS :
Patient history: Knowing certain factors pertaining to the patients history
can assist in the diagnosis of caries and identification of high risk patients.
Such factors include age, gender, fluoride exposure, smoking habits, alcohol
intake, medications, dietary habits, economic and educational status and
general health. Increased smoking, alcohol consumption, use of
medications and sucrose intake results in increased risk for caries
development.

Clinical Examination :
General information regarding inadequate salivary functioning,
plaque accumulation, inflammation of soft tissues, poor oral hygiene,

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cavitated lesions and existing restoration are potential risk to caries
development.

Nutritional Analysis :
Frequent exposure to sucrose increases the likelihood of plaque
development by the more cariogenic MS organisms. Sucrose intake and its
frequent exposure have been related to caries activity.

Salivary Analysis :
Analyzing saliva may provide important information about
appropriateness of secretion rates and buffering capacity as well as
numbers of both MS and lactobacilli, while bacterial counts may be helpful
in assessing populations, they may not be accurate for individual patient.
However knowing what constitutes high valves for the number of colony
forming units (CFU) may be helpful information in identifying high risk
patients.

Radiographic Assessment :
Dental radiographs provide useful information in diagnosing carious
lesions. Although radiographs may show caries that are not visible
clinically. The minimal depth of a detectable lesion on a radiograph is
about 500 m. Although radiographs tend to underestimate the histologic
extent of caries lesion, approximately 60% teeth with radiographic proximal
lesions in the outer half of dentin are likely to be non-cavitated. Thus many
lesions evident radiographically are not cavitated and should be
remineralised rather than restored.

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 More sensitive techniques are needed for earlier detection of incipient
carious lesions, allowing the increased usage of remineralizing techniques.

Early detection of incipient caries, limitation of caries activity before

significant tooth destruction has occurred and identification of high caries
risk patients are primary goals of an effective diagnosis and treatment
program.

Identification of Caries :
A number of methods are now available for the identification of
demineralised areas of tooth structure and presence of cavitation.
- Mirror and probe
- Radiographs
- Transillumination
- Ultraviolet illumination
- Electronic caries detector
- Dye penetration method
- DIAGNODENT
- Quantitative light induced fluorescence (QLF)
- Ultrasonography
- Digital radiography
- Endoscope / Videoscope

MIRROR AND PROBE :

This is a traditional method, but it is generally agreed that such an
examination should be carried out with care. The surface of demineralized
enamel and root surface dentin is relatively fragile and easily damaged. If a
sharp explorer is used with any vigor, the surface can be punctured; plaque

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will be retained more readily in this new defect, and thus the caries process
will continue until surface is repaired.

It is recommended that a blunt explorer (probe) be used, only if

necessary. The probe must be used very lightly, on the side rather than the
point, to test the firmness and texture of the tooth surface. The clinician can
best assess occlusal fissures by washing and drying them vigorously with
warm air and examining them visually with magnification.

Traditional occlusal caries detection methods, such as using an

explorer have been shown to be inaccurate in early caries detection.

Radiographs :
Traditional bitewing radiographs are still mandatory as a diagnostic
aid for the caries active patient. However radiographs should be
interpreted with caution, and the speed of progress of caries should be
assessed before the dentist decides to undertake restorative procedures. It
may take from 1-4 years for a proximal lesion to progress through the
enamel. Only 40% of proximal lesions that, radiographically are in outer
half of the dentin are actually cavitated on the external surface.

This suggests that identification of the degree of remineralisation in a

radiograph does not necessarily mean that a surgical approach to the
removal of lesion is justified. It may still be possible to remineralize and
heal the area. A more accurate assessment of the speed of caries progress
should be carried out overtime before a decision is made and surgical
intervention is undertaken.

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Transillumination :
This technique of transillumination has been used for many years,
without a high degree of accuracy, for the identification of caries.
Transillumination will assist in confirming the presence of a relatively large
cavity but should be used in conjunction with radiograph.

Ultraviolet Illumination :
Ultraviolet light has been used to increase the optical contrast
between the carious lesion and surrounding sound tissue. The natural
fluorescence of tooth enamel, as seen under ultraviolet light illumination is
decreased in areas of less mineral content such as in carious lesion,
artificial demineralization or developmental defects. The carious lesion
appears as a dark spot against a fluorescent background.

Electronic Caries Detector :

The concept of testing for caries through electrical impedance was
first suggested by PINCUS in 1951. Subsequently, the device called the
VANGUARD CARIES DETECTOR (Massachusetts manufacturing) was
developed. The device consists of a small electrode for the patient to hold
and a fine contact point to be placed on the tooth to explore the fissure. Any
area of demineralisation will be porous; the porosities filled are with saliva
and other electrolytes, so there will be a differential potential between these
areas and fully mineralised tooth structure. The recording dial shows
number from 0 to 10 and a picture of “FACE” that smiles upto a valve of 5
and frowns when the valve is greater than 5. This level indicate that there is
sufficient demineralisation to justify surgical intervention. However, the

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recording should not be taken entirely at face valve; sealing such an early
lesion may well bring about statis.

Dye Penetration Method :

Dyes have a widespread use in dentistry. Dyes can visualize a subject
from its routine background or if several objects have a similar appearance.
Colouring by a dye may discriminate between them and allow identification.
The observation of the colouring can be qualitative or quantitative.

In caries diagnosis qualitative examination is sufficient; observation

of coloured dye signifies presence of caries.

Dyes should fulfill the following criteria before being recommended

for clinical use :
1) Dye should be absolutely safe for intra oral use.
2) Dyes should be specific and stains only the tissues it is intended to stain.
3) Dyes should be easily removed and not lead to permanent staining.

A) Dyes for detection of carious enamel : Various dyes have been tried to
detect carious enamel, each having some advantages and disadvantages.

Procion Dyes : Stain enamel lesions but the staining becomes irreversible
because the dye reacts with nitrogen and hydroxyl groups of enamel and
acts as a fixative.

Calcein dye : Makes a complex with calcium and remains bound to lesion.
Fluorescent dye like Zyglo ZL-22 has been used in vitro as it is not suitable
invivo. The dye is made visible by U.V. illumination.

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Brilliant Blue : Has also been used to enhance the diagnostic quality of
fiberoptic transillumination.

Uses of dyes for diagnosing enamel lesions cannot be used clinically

as yet.
If possible it will allow lesions to be visualized at an early stage and
thus allow remineralisation procedure to be carried out early in the
treatment plan.

B) Dyes for Detection of Carious Dentin :

Histopathologically, carious dentin is divided into two layers – outer
layer – infected dentin and inner layer – affected dentin.
In tooth preparation, it is desirable that only infected dentin to be removed
leaving affected dentin which is then remineralised in a vital tooth following
the completion of restorative treatment.

Dyes have been tried to differentiate between these 2 zones of dentinal

caries. 0.5% basic fuchsin in propylene glycol has been proved to be
successful for the purpose.

Demineralized dentin in which the collagen has been denatured is

stained while the inner one remains unstained. This method is
recommended as a clinical guide for complete removal of carious zone in
dentin as it contains denatured collagen.

BASIC FUCHSIN dye was considered to be carcinogenic; therefore it

has been replaced by ACID RED and METHYLENE BLUE.

Methylene Blue is also slightly toxic so Acid Red is preferred.

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MODIFIED DYE PENETRATION METHOD :
IODINE penetration method for measuring enamel porosity of
incipient carious lesions was developed by BAKHOS et al. Potassium
iodide is applied for a specific period of time to a well defined area of the
enamel and thereafter the excess is removed. The iodine, which remains in
the micropores is estimated and indicates the permeability of enamel.

DIAGNODENT :
The source of light is diode laser, emits laser wave length of 655 nm.
It catches decay with more thoroughness, timeliness and accuracy. Most
minute problems are detected at a early stage, simple and comfortable to
use.

How it Works ?
Laser diode provide pulsed light of a defined wavelength from the
handpiece, which when directed onto the tooth it meets a change in tooth
structure (decay) and stimulates fluorescent light of different wavelength.
This reflected fluorescent light is taken back by the handpiece receptors and
later they convert into acoustic signals. Electronic system evaluate to give
readings between 1-100 (See Fig. in Color. Plate – 1).

Interpretation :
 10 – 20 enamel softening, potential problem requiring close monitoring.
 21 – 100 definite area of decay requiring restoration.

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Quantitative Light Induced Fluorescence (QLF) :
QLF is a dental diagnostic tool for invivo and invitro quantitative
assessment of dental caries, plaque, calculus, staining. With QLF real-time
fluorescent images are captured into the computer and stored in an image
database. Optional quantitative analysis tools enable the user to quantify
parameters like mineral loss, lesion depth, lesion size, stain size and severity
with high precision and repeatability.

QLF method is based on autofluorescence of teeth. When teeth are

illuminated with high intensity blue light they will start to emit light in the
green part of the spectrum. The fluorescence of the dental material has a
direct relation with the mineral content of the enamel (See Fig. in Color
Plate - 2).

QLF system consists : Hardware (a handpiece of control box).

Windows PC
QLF software
QLF software makes it possible to capture invivo images of the tooth
elements in the computer. The most important parameters produced by the
software are : -
 Lesion area
 Lesion depth
 Lesion volume

QLF Hardware : The hardware of intraoral system includes a measurement

probe, control unit and a computer fitter with a frame grabber. Control unit

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consists of an illumination device and imaging electronics. The light source
is a special arc lamp based on Xenon-technology.

The light from the lamp is filtered by a blue transmitting filter. A

liquid light guide transports the blue light to the teeth in the mouth. A
dental mirror provides uniform illumination of the area to be recorded. The
recording of fluorescence image is done with a yellow transmitting filter
positioned infront of a color CCD – Sensor. The blue and yellow filter
combination is optimized in such a way that the video image is completely
free of reflections. The image is digitized by the frame grabber and is
available for quantitative analysis with the QLF software.

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DIGITAL FIBEROPTIC TRANSILLUMINATION (DIFOTI) :
Digital imaging fiberoptic transillumination (DIFOTI) is a relatively
new methodology that was developed in an attempt to reduce the perceived
short comings of FOTI by combining FOTI and a digital CCD camera.

Images captured in camera are sent to a computer for analysis using

dedicated algorithms. The use of CCD allows instantaneous image to be
made and projected, and images taken during different examinations can be
compared for clinical changes between several images of same tooth over
time. DIFOTI provides clear signatures of different types of frank caries on
all types of teeth, and DIFOTI can detect incipient or recurring caries
before they are visible on radiographs.

ULTRASONIC IMAGING :
Ultrasonic imaging was introduced for detecting early carious lesions
in smooth surfaces. The demineralisation of natural enamel is assessed by
ultrasound pulse echo technique. It is observed that there is a definite
correlation between the mineral content of the body of lesion and the
relative echo amplitude changes.

Ultrasonic probe is used which sends longitudinal waves to the

surface of the tooth and also serves the function of receiving the waves.
Initial white spot lesions which extend only upto enamel, produce no or
weak surface echoes. The sites with visible cavitation produces echoes with
substantially higher amplitude.

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ENDOSCOPE / VIDEOSCOPE :
Endoscopic technique is based on observing the fluorescence that
occurs when tooth is illuminated with blue light in the wavelength range of
400-500 nm. Difference is seen in fluorescence of sound enamel and carious
enamel, when this fluoresced tooth is viewed through a specific broad band
gelatine filter, white spot lesions appears darker than enamel.

Similarly a white light source can be connected to an endoscope by a

fiberoptic cable so that the teeth can be viewed without a filter. This
technique is referred to as WHITE LIGHT ENDOSCOPY.

It has been demonstrated that this technique allows visualization of

small carious lesions in the enamel that are difficult to detect with the naked
eye or with radiograph.

Additionally a camera can be used to store the image. The

integration of the camera with the endoscope is called a VIDEOSCOPE. A
miniature color video camera is mounted in a custom made metal mirror
holder. This is designed in such a way that image of the surface of enamel
can be viewed directly over a television screen. The videotapes are viewed
by expert independent examiners who had also examined the tooth visually
and by conventional methods.

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 CONTROL THE DISEASE THROUGH REDUCTION OF
CARIOGENIC FLORA

The knowledge of the caries process gained in recent years can be

applied as the first principle in "minimal intervention dentistry".
Specifically the traditional surgical approach to early surface lesion can
now be superseded by the "biological" or "therapeutic" approach,
recognizing also that caries is an infectious disease.

There are two elements to the biological approach.

I. Alteration of the oral environment in order to minimize
demineralization.
II. Application of agents such as chlorhexidine and topical fluoride.

Alteration of Oral Environment is brought by :

1) Reduced frequency of refined carbohydrate intake.
2) Optimum plaque control
3) Optimum salivary flow
4) Patient education

DIAGNOSIS AND CONTROL OF ACTIVE CARIES :

When a new patient presents for consultation, it is important to
diagnose the presence or absence of caries activity. Observation and
discussion with the patient will offer some of the answers, and additional
tests are available to determine the patient's oral microflora and salivary
flow potential. If active disease is present, the patient should be counseled,
and his or her cooperation in the fight to eliminate the disease must be

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sought. The high risk patient must be clearly identified, because motivation
and education are likely to be notably more complex.

A number of positive steps can be undertaken to assist and to

encourage the patient to play his or her part in completing a sound
diagnosis and bringing about control of the disease.

Identify the Microflora :

Modification of the oral microflora is essential in the initial stages,
and relatively simple tests are available to assess the microflora in the
dental office. Simple test tube cultivation takes up to 48 hours to confirm
the presence or absence of pathologic levels of infection. This will provide
visual proof to the patient and assist motivation. Simpler, modified test
methods are being developed.

Test for Salivary Flow :

Salivary flow testing can often be carried out in conjunction with the
test for bacterial flora. Saliva plays a significant role in the health of the
oral cavity because it stabilizes the continuing ion exchange with the tooth
surface. Saliva has the capacity to buffer the pH and therefore can reduce
the potential for demineralization. However both the quantity and quality of
saliva can vary, and it is essential to note the changes.

Quantity is relatively simple to measure, and stimulated flow is

expected to be between 1.5 and 2.5 mL/min. The quantity will vary
throughout the day and will be lowest during sleep; the main concern,
however, is that flow can be seriously affected by a variety of drugs. The

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patient is often not particularly aware of a dry mouth, and the dentist may
have to draw the patient's attention to the change.

A flow less than 0.7 mL/min represents serious xerostomia, and the
caries rate is likely to rise. Xerostomia can be brought about by disease,
such as Sjogren's syndrome, or pharmaceutical routines prescribed for the
treatment of other conditions. Other health professionals responsible for a
patient's care must be consulted to determine if there can be a simple
solution to the reduced flow.

Perform a Thorough Prophylaxis :

The traditional prophylaxis is an essential part of patient motivation,
because often the patient has forgotten the feel and taste of a clean mouth.
Topical fluoride application should follow, because fluoride is most effective
in the complete absence of plaque.

Prescribe a Chlorhexidine mouthwash :

Modification and control of the balance of the oral microflora are
essential, and these can best be achieved through the use of chlorhexidine as
a mouth wash over a short period. Streptococcus mutans is very susceptible
to a twice daily rinse with 0.2% chlorhexidine. There will be a limited
uptake into the soft tissue, and the agent will remain available for several
hours, particularly overnight, and have a direct, continuing effect on the
bacterial population.

At this concentration, chlorhexidine is bactericidal and should be

used for periods limited to 3 or 4 weeks at a time. Therapy can be repeated
at 6 month intervals. However, for patients who are aged or incapacitated,

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a 0.02% concentration of chlorhexidine may be used for long periods as a
bacteriostat to maintain a relatively healthy mouth.

Prescribe a topical Fluoride Application :

The patient should be given a prescription for daily or weekly home
use. Many fluoride products are available, and the operator should choose
the most suitable for the particular patient. The frequency of application
will vary, depending on the severity of the infection, the need for
remineralization, and the patient's level of cooperation.

Place Transitional Restorations in all Open Cavitated Lesions :

It is essential to eliminate all areas that are not readily accessible to
the patient for the control of plaque. A transitional restoration is defined as
one that will last for a reasonable period of time and as long as it remains in
place, completely sealing the lesion from further infection and offer some
degree of biologic activity to help stimulate repair and healing. The
restoration should be relatively simple to place, but it will not necessarily
completely restore the coronal anatomy. Logically, it will incorporate the
use of an adhesive, biomimetic material that has acceptable physical
properties.
A complete series of final restorations should not be placed for a
patient in whom there is still active disease.

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CARIES PREVENTION :
Primary goal of caries prevention program should be to reduce the
numbers of cariogenic bacteria. Prevention should start with a
consideration of overall resistance of the patient to infection by the
cariogenic bacteria. Although the general health of patient, fluoride
exposure, history and function of immune system and salivary glands have a
significant impact on patient caries risk, the patient may have little control
over these factors.

On the other hand, patient usually is capable of controlling other

factors such as diet, oral hygiene, use of antimicrobial agents and dental
care.

Preventive treatment methods are designed to limit tooth

demineralization caused by cariogenic bacteria, there by preventing
cavitated lesions. These include ;
1) Limiting pathogen growth and metabolism.
2) Increasing the resistance of tooth surface to demineralization.

Caries control methods are operative procedures used both to stop the
advance of individual lesion and to prevent the spread of pathogenic
bacteria to the other tooth surface and in this sense, they are preventive
procedures. These operative procedures remove irreversibly damaged tooth
structure and the associated pathogenic bacteria in the site.

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General Health :
Patients general health has a significant impact on overall caries
risk. Declining health signals the need for increased preventive measures,
including more frequent recalls. Every patient has a very effective
surveillance and destruction system for foreign bacteria. The effectiveness of
patients immunologic system is highly dependent on overall health status.

Patient undergoing radiation or chemotherapy treatment have

significantly decreased immuno competence and are at the risk for increased
rate of caries.

Medically compromised patients should be examined for changes in

the following :
- Plaque index
- Salivary flow
- Oral mucosa
- Gingiva
- Teeth

Early signs of increased risk include

- Increased plaque
- Puffy bleeding gingiva
- Dry mouth with red glossy mucosa
- Demineralization of teeth

Decreased salivary flow is very common during acute and chronic

systemic illness and is responsible for dramatic increase in plaque.

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Ambulatory patients with chronic illnesses often take multiple medications,
which may significantly reduce salivary flow. Saliva should be tested for
both flow and buffering capacities when changes are detected from an oral
examination.

Medications that can reduce salivary flow :

MEDICAL CLASS EXAMPLE
Antispasmodic Belladonna alkaloids
Antidepressant Amitriptyline
Antipsychotic Chlorpromazine
Skeletal muscle relaxant Cyclobenzaprine
Parkinsonian Benztropine
Arrhythmia medications Disopyramide
Antihistamine Chlorpheniramine
Appetite depressant Chlorphentermine
Anticonvulsant Carbamazepine
Anxiolytic Alprazolam
Antihypertensive Atenolol
Diuretic Hydrochlorothiazide
Miscellaneous Isotretinoin

Fluoride exposure :
Fluoride in trace amounts increases the resistance of tooth structure
to demineralization and is therefore a particularly important consideration
for caries prevention. When fluoride is available at the time of tooth
demineralization cycle, it is a major factor in decreasing the caries activity.

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 The availability of fluoride to reduce caries risk is primarily achieved
by
- Fluoridated community water system
- Fluoride in diet
- Tooth pastes
- Mouth rinses
- Professional topical application

The optimal fluoride level for public H 2O supplies is about 1 part per
million (1 ppm).

At 0.1 ppm and below, the preventive effect is lost and caries rate is
higher for such populations lacking sufficient fluoride exposure.
Excessive fluoride exposure (10 ppm or more) results in fluorosis, a
brownish disocloration of enamel termed MOTTLED ENAMEL.

Fluoride exerts their anticaries effects by 3 different mechanisms.

1) Presence of fluoride ions greatly enhances the precipitation into tooth
structure of fluoroapatite from calcium and phosphate ions present in
saliva. This insoluble precipitate replaces the soluble salts containing
Manganese and Carbonate that were lost because of bacterial mediated
demineralization. This exchange process results in enamel becoming
more acid resistant.
2) Incipient non cavitated carious lesion are remineralised by the same
process.
3) Fluoride has antimicrobial activity in low concentration, fluoride ions
inhibits the enzymatic production of glucosyltransferase.

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 Glucosyltransferase prevents glucose from forming extracellular
polysaccharide and this reduces bacterial adhesion and slows ecological
succession. Intracellular polysaccharide formation is also inhibited,
preventing storage of carbohydrates by limiting microbial metabolism
between host meals.

In high concentrations (12,000 ppm ) used in topical fluoride

treatments, fluoride ions is directly toxic to some oral microorganisms
including streptococci mutans (MS). Suppression of growth of MS following
a single topical fluoride treatment may last several weeks.

All of the various methods for fluoride exposure are effective to some
degree Clinician’s goal is to choose the most effective combination of each
patient. The choice must be based on patient’s age, caries experience,
general health and oral hygiene.

Fluoride Treatment Modalities :

Caries
Concentrati
Route Method of Delivery Reduction
on (ppm)
(%)
Systemic Public water supply 1 50 to 60
Topical Self application
Low-dose/high frequency rinses (0.05% 225 30 to 40
sodium fluoride daily)
High-potency / low frequency rinses (0.2% 900 30 to 40
sodium fluoride weekly) after 2 years
Fluoridated dentifrices (daily) 1000 20
Professional application
Acidulated phosphate fluoride gel (1.23%) 12,300 40 to 50
annually or semiannually
Sodium fluoride solution (2%) 20,000 40 to 50
Stannous fluoride solution (8%) 80,000 40 to 50

* Caries reduction estimates for topically administered fluorides indicate their effectiveness when used
individually. When they are combined with systemic fluoride treatment, they can provide some additional
caries protection.

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 Topical application of fluoride should be done semiannually for
childrens and adults who are at high risk of caries development. Acidulated
phosphate fluoride (APF) is most effective and least objectionable topical
agent. APF is available in thixotropic gels and has a long shelf life.

Stannous fluoride (8%) an other option has a bitter taste, may burn
mucosa and have short shelf life. Tin in SnF may stain teeth. Topical
fluoride agents should be applied according to manufacturer's
recommendations.

Self administered fluoride rinses have an additive effect (about 20%

reduction) when used in conjunction with topical or systemic fluoride
treatment. Fluoride rinses are indicated in high risk patients and those
patients exhibiting a recent increase in caries activity.

Two varieties of fluoride rinses have similar effectiveness.

1) High dose (0.2% F) low frequency rinses are best used in supervised
weekly rinsing programs based in public schools.
2) Low dose (0.05% F) high frequency rinses are best used by individual
patients at home.

The high risk or caries active patients should be advised to use the
rinse daily. The optimal application time is in the evening. The rinse should
be forced between teeth many times and then expectorated, not swallowed.
Eating and drinking should be avoided after the rinse.

Various fluoride varnishes and gels are available and successful in

preventing caries. Varnishes provide a high uptake of fluoride ion into

26
enamel. Yet provides a lower dosage of fluoride than gels or rinses. They
are effectively bacteriocidal and caries preventing agents.

The general technique for fluoride varnish use is :

1) Clinician applies a thin layer of fluoride varnish directly on tooth
surface.
2) Application time is several minutes.
3) Patients are to avoid eating for several hours and then avoid brushing
until the next morning.

Because fluoride varnish sets when contacting moisture, thorough

isolation is not required. Main disadvantage of fluoride varnish is that a
temporary change in tooth color may occur.

Fluoride varnish deposits large amount of fluoride on enamel surface,

especially on a demineralized enamel surface. The high concentration of
surface fluoride also may provide a reservoir for fluoride, which promotes
remineralisation. The use of fluoride varnish as a caries preventing agent
should be expanded because it has advantages over other topical fluoride
vehicles in terms of safety, ease of application and fluoride concentration at
the enamel surface.

IMMUNIZATION :
Bacteria passing through the mouth into stomach and intestines come
in contact with specialized lymphoid tissue located in Peyer's patches along
the intestinal walls. Certain T and B cells in Peyer's patches becomes
sensitized to the new bacteria. The sensitized T and B cells migrate through
lymphatic system to blood stream and eventually settle in glandular tissues

27
including the salivary glands in the oral cavity. Therefore these sensitized
cells produce IgA class immunoglobulins that are secreted in saliva. These
IgA antibodies are capable of clumping of oral bacteria.

This prevents adherence to the teeth and other oral structures and
they are more easily cleared from mouth by swallowing. For patients with
high concentration of M.Streptococci, agglutinating IgA may have an
important anticaries effect. This immunologic occurrance promotes the
possibility of further vaccination against caries.

SALIVARY FUNCTIONING :
Saliva is very important in prevention of caries while xerostomia may
occur because of aging, it is more commonly as a result of medication. Lack
of saliva may greatly increase the incidence of caries. Saliva stimulants
(gums, paraffin waxes or saliva substitutes) also may be prescribed for
patients with impaired salivary functioning.

ANTIMICROBIAL AGENTS :
A variety of antimicrobial agents are available to help prevent caries.
In rare cases, antibiotics might be considered, but the systemic effects must
be considered.

Chlorhexidine varnish enhances remineralisation and decreases

streptococci mutans presence. Chlorhexidine is prescribed for home use at
bed time as a 30 second rinse. Used at this time when the salivary flow rate
is decreased. The agent has a better opportunity to interact with MS
organisms while tenaciously adhering to oral structures. It is used for

28
approximately 2 weeks, and results in reduction of MS counts to below
caries potential. This decrease is sustained for 12-26 weeks.

Spectrum of
Mechanism of Persistence in
antibacterial Side Effects
Action mouth
activity
Antibiotics
Vancomycin Blocks cell-wall Narrow Short Increases gram
synthesis -negative flora
Kanamycin Blocks protein Broad Short Can increase
synthesis caries activity
Actinobolin Blocks protein Streptococci Long Unknown
synthesis
Bis
Biguanides Antiseptic; Broad Long Bitter taste; stains
Alexidine prevents teeth and tongue
bacterial brown; mucosal
adherence Broad Long irritation
Chlorhexidine Antiseptic;
prevents
bacterial
adherence
Halogens
Iodine Bacteriocidal Broad Short Metallic taste
Fluoride 1 to 10 ppm Broad Long Increases enamel
reduces acid resistance to
production ; caries attack;
250 ppm fluorosis in
bacteriostatic; developing teeth
1000 ppm with chronic high
bacteriocidal doses

DIET :
Dietary sucrose has two important detrimental effects on plaque.
1) Frequent ingestion of foods containing sucrose provides a stronger
potential for colonization by MS, enhancing the caries potential of the
plaque.
2) Mature plaque exposed frequently to sucrose rapidly metabolizes into
organic acids, resulting in profound and prolonged drop in plaque pH.

29
- Caries activity is most strongly stimulated by the frequency rather than
quantity of sucrose ingested. However, for an individual patient, dietary
modification can be effective if the patient is properly motivated and
supervised. Evidence of new caries activity in adolescent and adult
patients indicates the need for dietary counseling.
- Goals of dietary counseling should be to identify the sources of sucrose
in diet and reduce frequency of sucrose ingestion.

ORAL HYGIENE :
Plaque free tooth surfaces do not decay! Daily removal of plaque by
dental flossing, tooth brushing and rinsing is the single best procedure for
preventing both caries and periodontal disease.

Xylitol Gums :
Xylitol is a five carbon sugar obtained from birch trees. It keeps the
sucrose molecule from binding with MS. Furthermore MS cannot
metabolize xylitol. Thus xylitol reduces MS by altering their metabolic path
ways and enhances remineralisation and helps arrest dentinal caries. It is
usually recommended that a patient chew a piece of xylitol gum after eating
or snacking for 5-30 minutes. Chewing any sugar free gum after meals
reduces the acidogenicity of plaque because chewing stimulates salivary
flow which improves the buffering of pH drop that occurs after eating.

PIT AND FISSURE SEALANTS :

Fluoride treatments are most effective in preventing smooth surface
caries, they are less effective in preventing pit and fissure caries. Infact the
1988 to 1991 NHANES III Survey revealed that occlusal surfaces in
children's teeth were five times more likely to be the site of caries than

30
proximal surfaces and twice as likely as facial or lingual surfaces. Thus
preventive measures for pit and fissure caries is greatly needed. Pit and
fissure sealants were specially designed for this purpose and have been
demonstrated to be effective.

Sealants have 3 important preventive effects.

1) Sealants mechanically fills pits and fissures with an acid resistant resin.
2) Pit and fissures are filled sealant deny MS and other microorganism their
preferred habitat.
3) Sealants render pit and fissures are easier to clean by tooth brushing and
mastication.

INDICATIONS FOR USE OF SEALANTS

Criteria Seal Do not seal
Tooth age Recently erupted teeth Teeth that have remained free of
caries for 4 years or longer;
staining is usually present in
pits / fissures.
Tooth type Molars Premolars, except when patient is
caries active
Occlusal Deep, retentive, narrow Well coalesced fossae and
morphology pits and fissures grooves; wide, easily cleaned
grooves
Recent caries Teeth showing signs of Teeth that have remained free of
activity softening or opacity in pit caries for 4 years or longer;
or fissure staining is usually present in
pits / fissures.
General caries Occlusal or smooth Proximal cavitated lesion on
activity surface lesions on other tooth to be sealed; cavitation of
teeth; no proximal occlusal (tooth will require
cavitated lesions on tooth restoration)
to be sealed
Availability of other Patient receiving Patient's water supply is fluoride
preventive appropriate systemic deficient; patient is not
measures and/or topical fluoride cooperating in recommended
therapy and still caries caries-preventive program
active (restoration of pits and fissures is
preferred).

31
GENETIC MODALITIES IN CARIES PREVENTION :
The use of genetic engineering to prevent caries has led to the dawn
of new era in caries prevention. Genetic engineering as most of us know is
becoming a field of tomorrow. It may have the key to our future medical
problems.

A gene is a segment of DNA having a limited number of nucleotide

pairs in a unique sequence. Each living being in this universe contains
specific number and set of genes. These genes are coded by triplet bases
called CODON.

Earlier this triplet codon was considered as a secret blue print of that
species. Now with recent DNA recombinant technique we are in a clear
position to edit the text of our genetic code. Various approaches taken are
genetic engineering and gene therapy.

Gene : The fundamental physical and functional unit of heredity. A gene is

an ordered sequence of nucleotides located in a particular position on a
particular chromosome that encodes a specific functional product.

Genetic Code : The sequence of nucletoides coded in triplets or codons,

along the mRNA, that determines the sequence of aminoacids in protein
synthesis. The DNA sequence of a gene can be used to predict the mRNA
sequence. In turn, genetic code can be used to predict aminoacid sequence.

32
Genetically modified Organisms :
A new bug against caries.
The human mouth is home to billions of bacteria belonging to more
than 300 species, but one species is the major cause of tooth decay. The
culprit is streptococcus mutans, a spherical bacterium that thrives on the
organic film that coats tooth surface and makes an enzyme called
LACTATE DEHYDROGENASE. This enzyme converts sugars into lactic
acid, a corrosive chemical that gradually dissolves the protective enamel
coating on teeth.

Strep. Mutans

LACTATE DEHYDROGENASE

Sugar LACTIC ACID

Tooth Dissolution

Arming a new bacteria to battle with cavity promoting bacteria could

offer a new way to prevent tooth decay hence they are called genetically
modified “Good” bacteria.

In the experiments with cells and rats, scientists found that a type of
good bacteria called LACTOBACILLUS ZEAE, which could be genetically
modified to produce antibodies to attach themselves to the surface of strep.
Mutans. These antibodies grabbed free floating S.mutans in saliva and
gave them a “KISS TO DEATH”.

33
 LACTOBACILLUS laden foods and supplements – commonly
referred to as PROBIOTICS have grown increasing popularity because
they are believed to promote good gastrointestinal health.

Taking a different approach HILLMAN of florida has created a

effector strain of Strep. Mutans called BCS3-L1, that lacks the lactate
dehydrogenase gene and is incapable of producing lactic acid this effector
strain was also designed to produce elevated amounts of novel peptide
antibiotic called Mutacin 1140, that kills conventional S.mutans without
harming other bacteria, ensuring that it will dominate its disease causing
cousins.

Some evidence suggests that if a dose of engineered bacteria was

given in early childhood the bacteria could survive a lifetime in the mouth.

National Institute of Dental and Craniofacial Research Director

Dr.LAWRENCE prefers the concept of replacing S.mutans with a species
engineered to rebuild tooth surface. Some microorganism produce acids,
but other produce bases and these bases provides a milleu that favors
remineralisation.

Yet another approach is with a strains of S.mutans engineered to

increase the production of enzyme UREASE, which converts urea into NH3
to create conditions conductive to enamel remineralisation

34
GENETICALLY MODIFIED FOODS :
These are the transgenic crops that contain genes known for their
desirable qualities like high yield, disease resistance, early and uniform
maturity etc. The food thus harvested is called genetically modified foods.

“AN APPLE A DAY MAY SOON KEEP THE DENTIST AWAY”

Scientists are genetically engineering fruits to protect against tooth

decay. Eating a genetically modified apple or bowl of strawberries a day
could protect teeth from the microbes that causes decay. Scientists
developed a GM fruit to release a bacteria beating vaccine in every
mouthful. The vaccine, a protein called P1025, tricks S.mutans, the main
cause of tooth decay. A gene for a peptide protein is added to strawberries
and apples by BIOTECHNOLOGISTS. The antagonist peptide work
against the specific enzyme system glycosyltransferase of S.mutans. It
stops the microbes from binding to the tooth, preventing caries for upto 80
days at a time without using antibiotics.

35
 NEW CAVITY CLASSIFICATION
The three sites of carious lesions.
Carious lesions occur in 3 sites on the crown or root of a tooth; that
is, those areas subject to accumulation of plaque.
Site 1 : Pits, fissures and enamel defects on occlusal surfaces of posterior
teeth or other smooth surfaces.
Site 2 : The contact areas between any two teeth, anteriors or posteriors.
Site 3 : Cervical one third of the crown or following gingival recession, the
exposed root.
It is regarded as logical to classify lesions by these sites and then to grade
them by size according to extent of progress. The classification applies
equally to both anterior and posterior teeth.

Four Sizes of Carious Lesion :

Taking into account the progress of the carious lesion described
above. It is possible to consider restoration in four sizes, regardless of the
site of origin of the lesion.
Size 1 : Minimal involvement of dentine just beyond treatment by
remineralisation alone.
Size 2 : Moderate involvement of dentine following cavity preparation
remaining enamel is sound, well supported by dentine and not likely to fail
under normal occlusal load. The tooth is sufficiently strong to support
restoration.
Size 3 : Cavity is enlarged beyond moderate involvement. Remaining tooth
structure is weakened that cusps or incisal edges are split or likely to fail if
exposed to occlusal load. The cavity needs to be further enlarged so that the

36
restoration can be designed to provide support to the remaining tooth
structure.
Size 4 : Extensive caries and bulk loss of tooth structure has already
occurred.

Size Minimal Moderate Enlarged Extensive

Site 1 2 3 4
Pit / Fissure
1.1 1.2 1.3 1.4
1
Contact area
2.1 2.2 2.3 2.4
2
Cervical
3.1 3.2 3.3 3.4
3

37
MINIMAL INTERVENTION Operative Dentistry is dependent on
following factors :
1) The demineralization - remineralization cycle.
2) Adhesion in restorative dentistry
3) Biomimetic restorative material

DEMINERALIZATION - REMINERALIZATION CYCLE :

Over the last 30 years, there has been considerable increase in the
knowledge and understanding of progress of caries through tooth structure.
It is now clear that in a normal healthy mouth there is a continuous cycle of
demineralisation and remineralisation of the surface of tooth (See Fig. in
Color Plate 3). If the acidity on the surface of tooth falls below pH 5.5 there
will be release of calcium and phosphate ions and these will be taken up into
the surrounding saliva, leaving behind the demineralised collagen frame
work.

Because the saliva is already a supersaturated solution of these ions

there is constant potential for their return to the tooth structure. Thus once
the ambient pH rises above pH 5.5 any early lesion caries or erosion will
begin to remineralise and heal. However, if the acidity remains high for
prolonged periods of time surface integrity may be lost to the extent of
cavitation. Thereafter it will be difficult or impossible for the patient to keep
the area free from further plaque accumulation.

Fluorides play an important role in demineralization -

remineralization cycle. If demineralization takes place in presence of free

38
fluoride ions, the remineralisation stage will be facilitated to the extent that
fluorapatite rather than hydroxyapatite will be laid down within the surface
of lesion which has several advantages.

First, the critical pH of fluorapatite 4.5 which means that it is notably

more resistant to further demineralisation than the original hydroxyapatite.
That is, addition of fluoride to tooth surface will increase resistance to
further caries attack.

Second advantage, is that fluoride is bacteriostatic so that species

such as streptococcus mutans fail to thrive in its presence. It also modifies
the surface energy of the enamel to the extent that plaque will not be so
firmly attached to it.

Finally fluoride helps to buffer the pH of plaque on surface of tooth

or any restorative material that can release it.

This cycle is significant and remineralisation is available through all

stages of development of cavity. In early stages, when only the enamel is
involved, attaining remineralisation is simply a matter of plaque removal
through normal oral hygiene methods in conjunction with the introduction of
free fluoride ions by either topical or systemic methods. Demineralised
enamel is relatively fragile and the lesions subject to masticatory stresses
such as occlusal lesion may breakdown readily. However in a proximal
lesion that is not subject to so much damage the enamel may not be
cavitated even when dentin is involved in demineralization process. Such a
lesion can also be reversed and healed. Once the lesion has advanced to

39
surface cavitation and dentin is involved the content of the cavity can be
divided roughly into 2 layers :
1) Infected layer - on the outer surface of cavity, tooth structure in this layer
is completely denatured and laden with microorganisms.
2) Affected layer - Relatively sterile, softened demineralised inner layer to
some degree depending on the speed and the aggression of the disease
process, but it will still contain the original collagen framework that is
capable of remineralization.
Full control of caries requires elimination of both infected layer and
the cavitation that is allowing bacterial plaque to be retained.

In the absence of bacterial plaque the demineralization cannot

progress in this context it is important to note that affected layer at the base
of cavity is relatively sterile. In the past the surgical approach to control of
caries dictated the removal of all tooth structure that appeared to be
involved in disease. This principle included the removal of affected layer, on
the assumption that it was part of the problem. It is now been demonstrated
that this layer can be remineralised as well provided that it is sealed under a
biomimetic restorative material. Therefore it is suggested that
demineralised layer in affected dentine be regarded as precarious rather
than actively caries. This layer should be retained and remineralised under
most circumstances thereby reducing the iatrogenic loss of tooth structure.

40
ADHESION IN RESTORATIVE DENTISTRY :
There has been considerably research into restorative materials with
the object of replacing gold, amalgam and silicate cement. Although these
materials have served well over the last century, the first 2 are not esthetic
and silicate although it released fluoride in limited quantities did not
perform well in the oral environment. Both gold and amalgam still have
place in restorative dentistry particularly for restorations that are extensive
and need to withstand heavy occlusal load. However, if all new lesions are
approached conservatively and natural tooth structure is preserved as far as
possible, the need for the more extensive restoration will be reduced.

Several major advances have evolved through recent research. All of

the new materials are now esthetic and natural tooth structure can be
imitated with biomimetic potential including release of fluoride, calcium and
phosphate ions that can be value in enhancing the remineralisation potential
of a carious lesion. In addition, it is now possible to develop true adhesion
between tooth structure and restorative material and thus prevent
microleakage that is ingress of bacteria between cavity walls and
restoration.
Two forms of adhesion are available :
i. First is - micromechanical union between tooth surface and
restorative material.
ii. Second - chemical adhesion

Micromechanical attachment between enamel and restorative

material can be developed by bevelling the enamel cavity margin and then
etching with phosphoric acid.

41
 Second type of adhesion is chemical union that is result of an ion
exchange between glass ionomer cement and tooth structure both enamel
and dentine. When freshly mixed GIC material is placed on clean tooth
structure the surface of tooth will be dissolved by the free polyalkenoic acid
still available in the cement. Calcium and phosphate ions will be available
from enamel or dentin to mix with calcium, phosphate, aluminium and
fluoride ions that are free within the cement matrix. As the acid base setting
reaction is buffered and progresses at the interface, the ion exchange layer
will also set and unite the two materials. The acid-base setting reaction
takes place relatively slow, so any shrinkage will be slow and controlled,
thus minimizing the stress on the adhesion. The result is absence of
microleakage at the interface.

BIOMIMETIC RESTORATIVE MATERIALS :

The concept of a biomimetic material is very important in restorative
dentistry. The term biomimetic suggests "imitation of nature". In other
words, the material should in some way reproduce one or more natural
phenomena within a biologic situation. It also implies that the material will
be biocompatible to and not rejected by adjacent vital tissues. Glass
ionomer cement has shown to fulfill these requirements not only in the oral
environment but also in relation to osteoid tissues elsewhere in the body.

When a tooth has been restored there are two surfaces that are
important to the survival of both the restoration and the tooth. The external
surface of restoration has to withstand all the problem posed by the
relatively hostile environment of the oral cavity, restoration must be strong
enough to withstand occlusal load as well as have a wear factor that is very

42
similar to that of tooth structure, finally it would be desirable for the
material to have some antibacterial properties to discourage plaque
accumulation as well as to release fluoride ions to encourage
remineralisation in the adjacent tooth structure.
The internal surface of restoration which is in contact with dentin on
the floor and walls of cavity is equally important. It has been shown that it
is sufficient to remove bacteria laden affected layer from the surface of
carious lesion and then seal the tooth, this procedure will allow the pulpal
inflammation to subside and in absence of further bacterial invasion the
pulp will heal.

It has also been shown recently that it is safe to leave the softened,
demineralised affected but sterile dentine on floor of cavity. IF the cavity is
then sealed with a biomimetic restoration that releases calcium, phosphate
and fluoride ions in a wet environment the results will be remineralisation
and healing of underlying dentine.

MATERIALS USED ARE :

- Glass Ionomer
- RMGIC
- Polyacid modified resin composite
- Composites

IONOMER RESIN CONTINUUM :

GIC Composite
Cermet RM GI Compomer Resin

HV GI Flowables

43
 It is helpful to think of the glass ionomer and composite resin
materials as being at opposite ends of formulation spectrum. Blends or
hybrid materials (RMGIC and Compomer) can be placed in middle of
continuum. The development of materials along the ionomer - resin
continues in the direction of bioactive materials.

Characteristics of Bioactive materials for Minimal Intervention Cavities :

- Sealing ability - Adhesive materials
- Caries inhibiting - Fluoride release, antimicrobial
- Advance healing - Remineralization

Fluoride releasing resin have been introduced. Improvements in

mechanical (polymerisation shrinkage, wear resistance), biological
(biocompatibility) and cariostatic properties (Sustained fluoride release,
sealing ability) have led to materials with optimized characteristics. New
materials with antimicrobial characteristics are in development. As of
today, no one material on the continuum has all the characteristics desired
for a perfect restorative material. Although each of the materials has
desirable properties, it is the specific characteristics of each material that
should be considered to determine its usefulness in a given clinical situation.

GLASS IONOMER :
Conventional GIC :
Glass ionomers enjoy the same favourable characteristics of silicate
cements. They release fluoride into the surrounding tooth structure,
anticariogenic properties, a favourable LCTE. GIC uses polyacrylic acid
which renders the final restorative material less soluble.

44
 Conventional GIC are relatively technique sensitive regarding mixing
and insertion procedures.
1) They are good materials for restoration of root surface caries because of
their inherent potential anticariogenic quality and adhesion to dentin.
2) Indicated for anterior restorations in patient exhibiting high caries
activity.
3) Widely advocated for permanent crown cementations.
4) Because of low wear resistance and low strength when compared to
amalgam, composite GIC are not recommended in occlusal areas of
posterior teeth.

RESIN MODIFIED GLASS IONOMER (RMGIC) :

To improve the physical properties and esthetic qualities of
conventional GIC - RMGIC materials have been developed.
RMGIC  Glass ionomer to which resin has been added.
- An acid base reaction is present, similar to GIC. This is the primary
feature that distinguishes these materials from compomer. Additional the
resin component affords the potential for light curing, autocuring or
both.
- RMGIC are easier to use and possess better strength, wear resistance
and esthetics than conventional GIC.
- Their physical properties are generally inferior to those of composites
and their indications for clinical use are limited.
Advantage of sustained fluoride release they may be best indicated for
i) Class V restorations in adults who are at high risk of caries and
ii) Class I and II restorations in primary teeth that will not require long
term service.

45
METAL-MODIFIED GLASS IONOMER CEMENT :
GIC lack toughness and hence they cannot withstand high stress
concentrations. GICs have been modified by inclusion of metal filler
particles in an attempt to improve the strength, fracture toughness and
resistance to wear.

Two methods of modification have been employed. First approach is

that of mixing spherical amalgam alloy powder with the type II glass
ionomer powder. This cement is referred to as silver alloy admix.

Second approach involves fusing glass powder to silver particles

through high temperature sintering of a mixture of the two powders. This
cement is commonly referred to as a CERMET.

The cermet material is far more resistant to sliding wear than Type II
GIC. The improvement in wear resistance is attributed to the metal filler.

With increased wear resistance and the anticariogenic potential these

metal modified cements have been suggested for limited use as an
alternative to amalgam or composites for posterior restorations. However,
these materials must still be classified as brittle materials, for this reason
their use should be restricted to conservative preparations. These cements
harden rapidly so they can be finished in a relatively short time.

Coupled with their potential for adhesion and caries resistance these
characteristics have prompted their use.
Fluoride release - fluoride leaches out from both metal modified
systems.

46
 However, less fluoride is released from cermet cement than Type II,
because a portion of original glass particles that contains the fluoride is
metal coated.

Admix cement releases more fluoride than Type II initially. However

magnitude of release decreases overtime. The explanation for this effect
may be that the metal filler particles are not bonded to the cement matrix,
thus the filler cement interfaces becomes pathways for fluid exchange. This
greatly increases the surface area available for leaching of fluoride.

Composites : In an effort to improve the physical characteristics of unfilled

acrylic resin, Bowen developed a polymeric restorative material reinforced
with silica particles.

Basically composite restorative materials consists of continuous resin

matrix in which an inorganic filler is dispersed. The inorganic filler phase
significantly enhances the physical properties of the composite by increasing
the strength of restorative material and reducing the linear coefficient of
thermal expansion.

For a composite to have good mechanical properties a strong bond

must exist between the organic resin matrix and inorganic filler. This bond
is achieved by coating the filler particles with a silane coupling agent,
which not only increases the strength of composite but also reduces its
solubility and water absorption.

47
CONVENTIONAL COMPOSITE :
Generally contain approximately 75% - 80% inorganic filler by
weight average particle size is 8 m, because of the relatively large size and
extreme hardness of filler particles, these composites exhibit a rough surface
texture.

Resin matrix wears at a faster rate than a filler particles, further

roughening surface. This type of surface texture causes the restoration to be
more susceptible to discoloration from extrinsic staining.

MICROFILL (OR) POLISHABLE COMPOSITE :

These materials were designed to replace the rough surface
characteristic of conventional composites with a smooth, lustrous surface
similar to tooth enamel.

Microfill composites contain colloidal silica particles whose average

diameter is ranging from 0.01 to 0.04 m.

Inorganic filler content 35% - 60% by weight. This small particle size
results in a smooth polished surface in the finished restoration.

Because these materials contain considerably less filler than do

conventional or hybrid composite some of their physical and chemical
properties are somewhat inferior.

Their low modulus of elasticity may allow microfill composite

restoration to flex during tooth flexure thus better protecting the bonding

48
interface. Microfill composites, an appropriate choice for restoring Class V
cervical lesions or defects where cervical flexure can be significant.

HYBRID COMPOSITES :
Combination of favourable physical and mechanical properties
characteristic of conventional composite with the smooth surface typical of
the microfill composites, the hybrid composites were developed.

Inorganic filler content 75% - 85% by weight, filler size is 0.4 to1 m.
Because of high content of inorganic fillers, the physical and
mechanical characteristics are generally superior to those of conventional
composites also the presence of submicrometersized microfiller particles
interspersed among the larger particles provides a smooth"PATINA-LIKE"
surface texture in the finished restoration.

HYBRID composites currently are predominant direct esthetic

restorative material used.

FLOWABLE COMPOSITES :
Were introduced in 1996.
Flowable composites have low filler content and consequently
inferior physical properties such as a lower wear resistance and strength.
Filler content is generally less than 50% by volume so polymerization
shrinkage will be greater than for heavily filled materials.
- Low modulus of elasticity.
- Flowable composites cannot be used in high stress areas.

49
Uses :
- Can be used as filling material in low stress application but not in class I
and II premolars and molars.
- Resurfacing composite or glass ionomer restoration rebuilding worn
composite contact areas.
- Linear or base in Class II proximal box.
- Restoration of air abrasion preparation, Class V preparation, porcelain
repair, enamel defects, incisal edge repair in anteriors, Class III lesion.
- Flowable composites may be useful in preventing voids at the line angles
when old amalgam restorations are replaced and filled with resin-based
composites.

PACKABLE COMPOSITE : CONDENSABLE COMPOSITE

They are based on newly introduced concept called PRIMM (Polymer
Rigid Inorganic Matrix Material)
This system consists of a resin and a ceramic component.
The filler / inorganic phase instead of being incorporating into
composites as ground particles is present as a continuous network / scaffold
of ceramic fibers. The fibers are composed of Alumina (Al 2O3) and Silicon
dioxide (SiO2).
Consistency of PRIMM based composites is similar to that of freshly
triturated mass of silver amalgam, which makes the handling and
manipulation much easier.

The composite is inserted into prepared cavity by carrying and

ejecting from a carrier whose nozzle is preferably made from coated with
wear resistant Teflon polymer. Use of conventional amalgam carrier is not

50
indicated as hard alumina fibers can scratch / damage the nozzle easily.
Each increment is then condensed similar to silver amalgam restoration.

IMPROVED PROPERTIES OF PACKABLE COMPOSITES :

1) Increased flexural modulus : Greater the level of incorporation of
ceramic fibers into the composite resin, greater the flexural modulus.
2) Increased wear resistance : Higher the amount of ceramic fibers in
composite material, greater is the wear resistance.
3) Higher depth cure : Higher depth of cure because of light conducting
properties of individual ceramic fibers.
4) Decreased polymerization shrinkage : Greater the incorporation of
ceramic fibers, lesser the polymerisation shrinkage.
5) Non-stickiness :

INDICATIONS : Used in stress bearing areas.

COMPOMERS (Polyacid-Modified Resin Composite) :

Compomer is a polyacid modified resin composite with constituents
derived from composite and glass ionomer components. The etchable glass
fillers which provide fluoride release.

Wear resistance and mechanical properties of compomers are less

than composite resin but the fluoride release and uptake are greater.

They gained popularity because of their superb handling properties.

Compomers such as Dyract AP (LD Caulk), Compoglass (Ivoclar),

F-2000 (3M), Hytac (ESPE) are composed of BISGMA, modified monomer,
fluoride releasing fillers.

51
 These single component, light cured materials contain no water.
Water is absorbed into the compomer after they contact saliva and produces
the small acid base reaction.

Compomers are clearily differentiated from RMGIC with respect to

water, which place a role in the acid base reaction and release of fluoride
ions.

SMART COMPOSITES :
This class of composite was introduced as the product ARISTON in
1998.
ARISTON is an ion releasing composite material. It releases
functional ions like fluoride, hydroxyl and calcium ions as the pH drops in
the area immediately adjacent to the restorative material as a result of
active plaque.

The paste contain Barium, Aluminium, Fluoride, Silicate glass fillers,

1m with Ytterbium trifluoride, SiO2 , alkaline glass (1.6 m) in
dimethacrylate monomer. Fluoride released is less than GIC but more than
compomer.

TOOTH COLORED MATERIALS

Composite
Glass Ionomer Resin modified GIC Compomer
High fluoride release Low fluoride release
Low strength High strength
Poor esthetics Excellent esthetics
Low wear resistance High wear resistance

52
 TREATMENT OF OCCLUSAL FISSURES
– SITE 1, SIZES 1 AND 2
Many teeth, particularly molars, erupt with a rather deep and
convoluted system of fissures in the enamel of the occlusal surface. Defects
can run the entire length of a fissure or be confined to small clefts in limited
areas. Because these surfaces are constantly subjected to the stresses of
occlusion and mastication plaque and food debris are easily forced into the
fissures; they will therefore be more vulnerable to caries attack than other
areas of the coronal surface. Once the dentin is involved, an occlusal lesion
may progress much faster than a proximal lesion, which is not under
occlusal pressure. Greater care will be required when the dentist monitors
occlusal lesions over time.

It would be wise, therefore, to carefully examine the occlusal fissures

of all newly erupted posterior teeth. The dentist should dry them thoroughly
and, under magnification, determine the presence of defects in the surface
enamel. If defects are present, the entire fissure system on that tooth should
be protected with a glass ionomer protective restoration or a resin sealant.
This is a simple exercise and does not require the removal of any tooth
structure. The tooth should be carefully isolated, preferably under rubber
dam. The occlusal surface should be dried and either conditioned or
etched, depending on the material to be used. The glass ionomer or resin
material can then be placed with the expectation of considerable longevity
(See Fig. in Color Plate – 4).

If the fissure has not been protected, one or more sections of the
fissure system may become demineralized down the walls. During

53
mastication, bacterial plaque will be impacted readily into the defect, and
caries may progress rapidly to the dentin beneath. It is important to identify
such a lesion before it has advanced too far. This is a situation in which
either the electronic or laser caries detector may be of value.

In the past, it was necessary to remove the entire fissure system

because the usual restorative materials, amalgam or gold foil, could not
provide a complete seal part way along a fissure. Now, with the existence of
adhesive materials such as glass ionomer cement and resin composite, it is
possible to intervene minimally.

Alternatively, it is possible to open only those sections of the fissure

under which the dentin is involved and remove the infected surface dentin.
The cavity can then be restored and, at the same time, the remaining fissures
can be sealed. Minimal surgical intervention will be required and maximum
strength will be maintained in the remainder of the tooth crown.

Surgical intervention can be undertaken with either a traditional

rotating instrument or with air abrasion. If a traditional bur is chosen, it
should be a diamond bur with a very fine, tapered point rotating at
intermediate high speed under air water spray.

Until the lesion is moderately advanced, it can be restored with a

glass ionomer cement, a resin composite, or a combination of the two (See
Fig. in Color Plate – 5). Glass ionomer cement has the advantage of being
bioactive and has, therefore, the ability to assist in the remineralization of
any remaining demineralized dentin. Lamination with a resin composite
may be indicated if the occlusal load is heavy.

54
 TREATMENT OF PROXIMAL LESIONS
– SITE 2, SIZES 1 AND 2
The problems involved in identifying and determining the extent of
proximal lesion are similar to those involved in an occlusal lesion, but there
are other factors to be considered as well. Techniques such as electronic
and laser devices are of no value for identifying the interproximal lesion.
Bitewing radiographs are the traditional method, but they must be
considered unreliable for determining either the depth of penetration or the
speed of progress of the lesion.

It has been shown that, in the presence of good preventive procedures,

it can take more than 2 years for a proximal enamel lesion in a primary
tooth to progress to dentin. In an adult population, it can take as long as 6
years for a significant degree of progress to occur. A number of factors
control the rate of progress, including the patient’s age, salivary flow and
willingness to undertake disease control procedures, but the inference is
clear: under normal circumstances progress is slow, and it is generally
unnecessary to immediately undertake a surgical form of maximal
intervention to control the lesion.

Even if the lesion appears to be halfway through the dentin, there may
still be no actual cavitation on the proximal surface where the lesion began.
As suggested previously, the main object of surgical intervention should be
to eliminate cavitation so that the patient is able to completely control
plaque accumulation and thus control progression of the disease in that
particular area. In the absence of cavitation, there is always the possibility

55
of remineralization, particularly in the presence of free fluoride ions.
Additional calcium and phosphate ions are always available from the saliva,
and, in the presence of fluoride, the tooth can heal. There is a further
advantage to healing the lesion, because enamel that is remineralized in the
presence of fluoride will contain fluoroapatite, and the critical pH for
fluoroapatite is pH 4.5. This means it is more resistant to further
demineralization and therefore more stable.

In some patients, particularly young people with a high caries rate,

careful examination of the proximal surface of a tooth should be carried out
to determine the presence or absence of cavitation before surgical
intervention is performed. The routine is simple. A rubber spacing ring,
such as one used in orthodontics, is placed interproximally and left in place
for 24 to 48 hours. The ring is removed, and a small, limited impression of
the space is taken with a low viscosity rubber based impression material.
This will record the 2 approximating surfaces with sufficient accuracy to
determine the presence or absence of cavitation (See Color Plate – 6, Figs.
A, B, C, D, E).

56
 In the absence of cavitation, 2 options are available. The surface can
be subjected to intensive fluoride treatment with a fluoride gel or varnish
several times daily over a reasonable period. This treatment would be
expected to promote remineralization.

The alternative treatment would be to etch the proximal surface,

following the prescribed fluoride treatment, and seal it with a light curing ,
low viscosity, unfilled resin. This would seal the surface against further
demineralization for some time, particularly because it is a surface free of
occlusal load and wear. However, placement of the sealant will eliminate
the opportunity to further remineralize and heal the lesion. Immediately
prior to sealing, a further test can be carried out. While the teeth are
isolated, the approximating surfaces are dried with a stream of cool air. If
this action elicit pain, there is likely to be cavitation through the enamel,
because the dentin has been dehydrated and has pulled away from the
enamel. Minimal surgical intervention is probably now justified.

In the presence of cavitation on the proximal surface, surgical

intervention is necessary, but only to the extent that the surface can be made
smooth again to minimize plaque accumulation. It is certainly undesirable
and unnecessary to remove the entire proximal tooth surface, as
recommended in the traditional surgical approach of placing the restoration
margins on a so called caries free area. Today, 3 possible approaches are
available for minimal surgical intervention, depending on the position of the
lesion on the proximal surface and its accessibility.

57
INTERNAL OCCLUSAL FOSSA (TUNNEL)
First Approach :
If the lesion is located more than 2.5 mm below the crest of the
proximal marginal ridge, the recommended technique is the “occlusal
fossa” or “tunnel” approach. The lesion is opened very conservatively,
through a limited access from the occlusal fossa just medial to the marginal
ridge. Under careful observation using magnification, the clinician makes
access with a small, cylindrical diamond bur, used at intermediate high
speed under air water spray, until the lesion is identified. The access cavity
is then carefully enlarged to a triangular form, particularly buccally and
lingually, to improve visibility.
In the absence of cavitation through the enamel of the proximal
surface, the surface can be left intact and will subsequently be supported by
the restoration. In the presence of cavitation, a short strip of a metal matrix
band should be placed interproximally and wedged in place, to protect the
adjacent tooth and to serve as a matrix during restoration. The area of
enamel breakdown can now be carefully debrided until demineralized but
firm enamel is left surrounding the cavitation. At this point, any infected
surface dentin will have been removed, and the remaining affected dentin on
the axial wall can be left in place in the expectation that it will remineralize
in the presence of a biologically active restorative material. There is no
need to place a sublining, such as calcium hydroxide, on the axial wall. In
fact, this would more likely interfere with the desired ion exchange adhesion.
The material of choice for restoration of such a limited cavity is glass
ionomer cement because of its biomimetic potential. Also, resin composite
will only adhere to sound, well mineralized beveled enamel, and it is not
possible to develop such a margin around the proximal lesion under these

58
circumstances. It is important that the selected glass ionomer cement be the
strongest available. It must have high physical properties, early resistance
to water uptake, and a viscosity suitable for syringing into place. It can be
light activated or autocured.
The restoration should be placed incrementally because it is
important for the material to be fully adapted to the cavity surface as well as
slightly extruded out through any lateral cavitation present. The first
increment should be lightly tamped into place with a small, dry instrument
to ensure adaptation. Then a second increment should be placed over the
first one. If the occlusion is too heavy for the material used, 2 mm of glass
ionomer cement can be removed from the surface after it has set, and a resin
composite can be bonded to both the enamel and the cement.

2nd Approach (Slot Cavity) :

If the lesion is closer to the marginal ridge, it may be wise to modify
the approach and enter the lesion directly from the occlusal aspect through
the outer slope of the marginal ridge, thus forming a small “slot or boxlike
cavity” (See Color Plate – 7, Figs. A & B). The same principles regarding
preservation of natural tooth structure apply. A short piece of a metal
matrix strip should be placed and wedged lightly in place if there is any risk
to the adjacent proximal surface. This strip can also serve as a matrix for
the final restoration.
Only completely degraded enamel need be removed. Demineralized
affected dentin on the axial wall can be left in place. The occlusal fissure is
not included unless it is frankly carious. The fissure can, however, be
sealed, if necessary, with the final restoration.

59
 Placement of a sublining is of no value if a glass-ionomer material
will be placed as the final restoration. Again, the strongest available glass
ionomer cement should be used and syringed into place incrementally.
Adaptation to the cavity floor is important if remineralizatiton is to be fully
effective. If the occlusal contact is expected to be too heavy for the glass
ionomer material, the cement can be cut back after it is set and laminated
with a resin composite.

3rd Approach (Proximal) :

A third version of a minimal cavity design for the restoration of a
proximal lesion is possible only when a larger lesion in the adjacent tooth is
being restored. After cavity preparation for the larger lesion is completed,
the proximal surface will be available for closer examination. A suspected
lesion may have been detected on a radiograph, or cavitation will be
identified through direct examination.
Provided that the lesion can be accessed without too much difficulty, a
very conservative design can be undertaken (See Color Plate – 7, Figs. C &
D). The marginal ridge can be maintained, and only those areas of the
enamel that are completely degraded should be removed. The infected
dentin can be debrided with a small, round bur, possibly with a long shank.
It is not necessary to place a sublining, but it is essential that a radiopaque
glass ionomer restoration be placed because it will not be possible to see
this restoration again after the larger, adjacent restoration is placed.
Because the cement will not be subjected to occlusal loading, there is no
need to laminate it with resin composite.
For Site 2, Size 2 (# 2.2) (See Figs. in Color Plate – 8).

60
 RESTORATION OF OCCLUSAL LESIONS
- SITE 1, SIZE 3 AND 4
When a restoration requires replacement, the existing cavity will be
relatively large. The previous surgical approach to cavity design required
the removal of all infected tooth structure and softened affected dentin on
the floor of the cavity. Irreversible pulp damage, with the need for
endodontic procedures, was relatively frequent. It also required removal of
all unsupported enamel on the occlusal surface. Consequently, there was a
potential for loss of occlusal contact with the opposing tooth. This led to
possible changes in occlusal relationships.

It is suggested that such over preparation is both unnecessary and

undesirable. It has been shown that it is possible to remineralize the
affected dentin on the floor of a cavity, thus retaining and healing tooth
structure while minimizing the risk to the pulp. An effective technique for
control of large cavities was suggested by Massler nearly 40 years ago. He
used zinc oxide eugenol as a provisional restoration because it was
antibacterial and isolated the lesion from further bacterial invasion, thus
giving the pulp an opportunity to recover from inflammation. However, it
did not actually lead to remineralization of the affected dentin and if the
provisional restoration was removed 3 weeks later, often there would be
some softened dentin remaining on the floor of the cavity. At the same time,
pulpal inflammation would subside, and many times, there would be some
degree of secondary dentin formed on the roof of the pulp chamber.

61
 It is now suggested that glass ionomer should be used for the
transitional restoration following removal of the infected layer of dentin
from the surface a large cavity. It will adhere to both enamel and dentin
through an ion exchange mechanism, thus eliminating microleakage. It will
also adhere to the collagen of demineralized dentin on the cavity floor
through either hydrogen bonding or metallic ion bridging. In the absence of
bacterial activity, the pulpal inflammation will subside. In the presence of
water from the positive dentinal fluid flow that follows, there will be
calcium, phosphate, and fluoride ions exchanged between the glass ionomer
and the demineralized dentin. Further ions will be available from the pulpal
fluid, and the dentin will remineralize.

There may be a problem in deciding how much demineralized dentin

to remove and in being confident that the cavity is clean enough. The use of
a caries disclosing solution is possible, but it should be handled with
caution. Following the first application, heavily stained dentin should be
removed with caution until clean dentin can be identified. A second
application of the dye may show light stains, but removal of this layer may
not be needed. This means that only a single application is the preferred
technique. On the other hand, it is necessary to take into account the
resistance form of the proposed transitional restoration. A glass ionomer
has a relatively low fracture resistance; therefore, it is important to provide
for a layer of atleast 3 mm if there is soft demineralized dentin remaining on
the floor of the cavity. Care should be taken to condition the cavity walls to
ensure proper development of the ion exchange adhesion and elimination of
microleakage. If there is doubt about the amount of affected dentin left
behind at the time of provisional restoration placement, the entire glass

62
ionomer can be removed after 3 months, and the cavity can be inspected and
modified as required. If there is no doubt about the integrity of the cavity,
then there is a choice between leaving the glass ionomer as the final
restoration or laminating it with another material, as discussed previously.

RESTORATION OF PROXIMAL LESIONS (Site 2, Sizes 3 and 4) :

The principles for the restoration of an extensive proximal lesion are
essentially the same as those for an occlusal lesion. In gaining access to the
affected demineralized dentin, there is no need to remove enamel just
because it appears to be unsupported according to the old surgical
principles. However, the walls of the cavity should be cleaned of all infected
dentin to allow development of the full ion exchange adhesion with the glass
ionomer. Demineralized dentin can remain on both the axial and pulpal
walls on the assumption that it will remineralize under the influence of the
glass ionomer. Placement of an additional subliner, such as calcium
hydroxide, is contra indicated because it will interfere with the development
of the ion-exchange adhesion, and glass ionomer will not irritate the pulp.

It is essential that the glass ionomer be carefully and completely

adapted to all the walls of the cavity without the inclusion of voids and air
bubbles. The strongest material available should be used and syringed very
carefully into place in increments. The first increment should be placed and
tamped over the entire floor of the cavity using a small, dry plastic sponge.
A further increment must be applied and, if the size of the cavity requires it,
this one should be tamped in as well to adapt it properly to the walls. The
cavity must be overfilled, the glass ionomer allowed to set, and lastly, the
occlusion adjusted.

63
 With active caries, this restoration may be regarded as a long term
transitional restoration, destined to be replaced after 3 months or more, by
which time the caries should be controlled. On the other hand, if the glass
ionomer is intended to complete the restoration at the same appointment, it
should be allowed to set before trimming it back and re preparing the cavity
for resin composite to be laminated over it. If a resin modified glass
ionomer is used for the base, it can be trimmed immediately after light
activation. It is only necessary to make room for a reasonably substantial
layer of 2 to 3 mm of resin composite, sufficient to compensate for its
relative flexibility. All enamel margins should be exposed and beveled to
ensure a good adhesion between the resin composite and the enamel. The
resin composite can then be built up incrementally.

In a very extensive cavity, where some degree of protection is required

for the remaining cuspal inclines, it will be necessary to decide which
material is the best to provide substantial protection for the long term.
While modern hybrid resin composites have an acceptable wear factor, the
adhesion to the long axis of enamel rods is less than ideal. It may be
necessary to remove a considerable amount of tooth structure to obtain a
good margin at the tip of a cusp. It is possible that amalgam may be a
better choice if a large part of the occlusal surface is involved in the cavity
design. Glass ionomer is also an acceptable base for these alternate
materials.

Modifications to a Site 2, Size 3 cavity in which there is a need to

protect remaining cusps form undue occlusal load. The standard proximal
box is normally dovetailed in outline. However, under these circumstances,

64
the walls are made to diverge, rather than converge, toward the occlusal,
and the cusp height is reduced to a very limited degree to allow for coverage
and protection by the amalgam. The buccolingual width of the gingival
margin should be extended no further than what is essential. The intention
is to retain as much of the original cusp as possible but at the same time
maintain the bulk and reduce the lateral stress on the cusps to prevent the
tooth from splitting at the base. The design makes it relatively simple to
restore the occlusal surface at the original height and, at the same time, the
retained enamel helps to hide the unaesthetic restorative material. Non
working cusps require less than 0.5 mm of amalgam cover to provide
protection, but working cusps should be covered by atleast 1.5 mm.
Rebuilding to this height requires placement of a good matrix and some skill
in carving the amalgam. However, the problem is not as complex as the old
cusp capping designs. The retentive elements should always be developed in
the gingival one third of the tooth crown and must be designed to encompass
the central core of dentin containing the pulp chamber. Ditches and grooves
are preferred to pins, which have a limited life expectancy, often lead to
microcracks, and may pose a risk to the pulp.

These designs have shown acceptable longevity and are a satisfactory

compromise for the extensive restoration with which preservation of
remaining tooth structure is a problem. They make a very satisfactory base
or core for a full or three quarter crown and, if the retentive elements of the
amalgam have been properly developed, they will remain in place despite
further removal of tooth structure for a more elaborate restoration.

65
 RESTORATIONS OF SITE 3 LESIONS

The current adhesive materials shows great promise for durable

cervical restorations. Increased reliability of dentin bonding (composite
resin and compomer) and adhesion through ion exchange (glass ionomer
reaction) reduces the cavity preparations to a minimum. Caries removal
only determines the shape of the cavity (See Figs. in Color Plate – 9).

66
 MINIMALLY INVASIVE PREPARATION TECHNIQUES

Today the adhesive restorative materials in conjunction with

increased knowledge on the pathology of caries and effective preventive
methods allow for minimally invasive techniques.

MECHANICAL :
ATRAUMATIC RESTORATIVE TREATMENT ART
ROTARY High / Low speed bur
SONIC OSCILLATION SONICSYS micro
CHEMOMECHANICAL CARISOLV, ENZYMES
KINETIC AIR ABRASION
HYDROKINETIC LASER (CO2, Er : YAG ;
Nd : YAG etc)
OZONE TECHNOLOGY O3

MECHANICAL TECHNIQUES :
ATRAUMATIC RESTORATIVE TECHNIQUES (ART) :
The treatment approach that can provide curative care to
disadvantaged populations is called atraumatic restorative treatment (ART).

This approach was pioneered in Tanzania in the mid 1980's as a part

of community based primary oral health program by the University of Dares
Salaam.

ART consists of an elementary technique of caries removal using hand

instruments only, combined with the use of modern restorative material with
adhesive characteristics.

67
 Currently GIC that leach fluorides and minimize the onset of
secondary caries are used. The often cited disadvantages of GIC namely
low wear resistance and strength are minimized because the cavity
preparations of ART technique usually result in relatively small restorations.
Furthermore, new GIC with improved wear resistance and strength are
being developed specifically for ART technique

INSTRUMENTS AND MATERIALS USED :

Essential instruments for ART are :
- Mouth mirror - Glass slab
- Explorer - Spatula
- Pair of tweezers - Carver
- Dental hatchet - Applier
- Small and medium spoon
excavator
- To improve working visibility, a special light source fixed to a pair of
spectacle frame that is powered by a rechargable battery source
(Voroscope) is used.

Essential materials :
- Gloves - Petroleum jelly
- Cotton wool rolls and pellets - Wedges
(Size 4) - Plastic strips
- GIC (powder / liquid) - Clean water
- Dentin conditioner

68
ART is based on combined technique material effect :
Applying Massler's theory to arrest caries progression while using
the healing potential of GIC to remineralise affected dentin. (See Color
Plate 10).

DESCRIPTION OF ART TECHNIQUE :

ART requires a proper patient to operator position. A number of
devices have been developed and one that is very useful is a light weight,
cushioned headrest attached to short end of the table combined with a
foldable cushion for the comfort of the person receiving the treatment.

Unlike many other restorative procedures, usually there is no need to

give local anesthesia when using ART technique because temperature
induced pain from using a drill is avoided, because the technique mainly
involves the removal of decalcified tooth tissue, pain can be minimized and
often does not require at all. Thus, fear of dental procedures is reduced.

Principle Steps of ART :

1) Isolate the tooth with cotton wool rolls. Rationale - It is easier to work in
a dry environment than in wet one.
2) Clean the tooth surface to be treated with wet cotton wool pellet. Have a
small cup of water. Separate the cotton wool pellets from each other.
Then dry the surface with a dry pellet.
Rationale : Wet cotton wool pellet removes debris and plaque from the
surface thus improving visibility.
3) Widen the entrance of the lesion : This step is necessary only if the
entrance is small. Place the working tip of dental hatchet in the

69
 entrance and rotate it backwards and forwards for opening very small
cavities, the corner of working tip is placed in cavity first and rotated.
Rationale : Hatchet replaces the bur by rotating the instrument tip,
unsupported enamel will break off creating an opening large enough
for the small excavator to enter.
4) Remove caries : Depending on size of cavity use either the small or
medium sized excavator. Remove caries at DEJ before removing caries
from floor of cavity. If working without an assistant, deposit the soft,
excavated caries on the cotton wool roll placed next to the tooth. Thin
unsupported enamel can be broken away carefully by placing the
hatchet on the enamel and pressing gently downwards. Wash the cavity
with lukewarm water on a small cotton wool pellet.
Rationale : All soft caries should be removed. Thin, often decalcified,
unsupported enamel is relatively easy to break off. The enamel and DEJ
need to thoroughly cleaned to prevent caries progression and to obtain
a good seal of coronal part of restoration.
5) Provide pulpal protection if necessary: This step is used only for very
deep cavities and is achieved by applying a setting Ca(OH) 2 paste to
the deeper parts of floor of the cavity. The cavity floor does not need to
be covered completely because it will reduce area available for
adhesion of filling material.
Rationale : Ca(OH)2 stimulates repair of dentin and GICs are
biocompatible.
6) Clean the occlusal surface : All pits and fissures should be clear of
plaque and debris as much as possible. Use a probe and a wet pellet
for cleaning.

70
 Rationale : Remaining pits and fissure will be sealed with same
material used for filling the cavity.
7) Condition the cavity and occlusal surfaces. Use a drop of dentin
conditioner on a cotton wool pellet and rub both the cavity and
occlusal surface for 10-15 seconds. Conditioned surfaces should be
washed several times with wet cotton wool pellets. The surfaces are
then dried with dry pellets.
Rationale : Conditioning increases bond strength of GIC.
8) Mix glass ionomer according to manufacturers instructions - Do not
alter P/L ratio.
9) Insert mixed GIC into cavity and overfill slightly : Mixed material is
inserted using the flat end of the applier and plugged into the corners
of the cavity with smooth side of an excavator or with a ball burnisher.
Avoid the inclusion of airbubbles. The material is also placed over pits
and fissures in small amounts.
10) Press coated gloved finger on the top of entire occlusal surface and
apply slight pressure. Petroleum jelly is used to coat the gloved finger
to prevent the GIC from sticking to the glove. Place the finger on top of
the mixture. Apply slight pressure for a few seconds and remove finger.
Rationale : Finger pressure should push the GIC into the deeper parts
of pits and fissures. Any excess material will overflow the occlusal
surface and can be easily removed. A smooth restoration surface will
result and reduce the need for carving.
11)Check the bite : Place articulating paper over the filling / sealant and
ask the patient to close. Petroleum jelly left on the surface will prevent
saliva contact with the filling while the bite is checked.
12) Remove excess material with the carver.

71
13) Recheck the bite and adjust the height of restoration until comfortable.
14) Cover filling / sealant with petroleum jelly once again or apply varnish.
15) Instruct the patient not to eat for atleast one hour.

For restoring approximal cavities a plastic strip and wedges are used
to produce a correct contour to the filling.

Advantages and Limitations of ART :

1) The use of easily available and relatively inexpensive hand instruments
rather than expensive electrically driven dental equipment.
2) A biologically friendly approach involving the removal of only
decalcified tooth tissues which results in relatively small cavities and
conserves sound tooth tissue.
3) Limitation of pain, thereby minimizing the need of local anesthesia.
4) Straight forward and simple infection control practice without the need
to use sequentially autoclaved handpieces.
5) Chemical adhesion of glass ionomers that reduces the need to cut sound
tooth tissue for retention of restorative material.
6) Leaching of fluoride from GIC, which prevents secondary caries
development and probably remineralises carious dentin.
7) Combination of preventive and curative treatment in one procedure.
8) Ease of repairing defects in restoration
9) Low cost

ART Technique is
- Non-threatening oral procedure
- Fear inducing situations caused by threatening dental equipment are not
involved and there is no noise from a drill.

72
- Greatest advantage of ART is that it makes possible to reach people who
otherwise never would have received any oral care.
- Technique allows oral care workers to leave the clinic and visit people in
their own living environment. Eg. Senior citizen homes, institutions for
the handicapped, villages in rural and suburban areas in economically
less developed countries.

LIMITATIONS OF ART :
1) Long term survival rates of GIC ART restorations and sealants are not
yet available, long study reported so far is of 3 years duration.
2) At the moment its use is limited to small and medium sized one surface
lesions because of low wear resistance and strength of existing GIC
results.
3) Possibility exists for hand fatigue from the use of hand instruments over
long periods.
4) Hand mixing might produce a relatively unstandardized mix of GIC,
varying among operators and different geographical / climatic
situations.
5) Misapprehension that ART can be performed easily - this is not the ease
and each step must be carried out to perfection.
6) A misconception by the public that the new GIC "White fillings are only
temporary dressings.

Disadvantages of GIC, such as low wear resistance and reduced

strength are being addressed. When improved materials become available,
larger one surface and small to medium sized multisurface lesions might
also be managed with ART technique.

73
ROTARY - HIGH SPEED / LOW :
Though the rotary bur is in universal use, there are still problems that
need to be overcome.
Five factors are potentially responsible for discomfort and pain
associated with cavity preparation.
1) The sensitivity of vital dentine
2) Pressure on the tooth (i.e. Mechanical stimulation)
3) Bone conducted noise
4) High pitched noise of air turbine handpiece and
5) Development of high temperature at cutting surface (i.e. thermal
stimulation).

Several studies have showed that temperatures at the cutting surface

of burs and could easily rise above the pain threshold and even with water
spray lubrication, some damage to the underlying pulp might still occur.

The rotating bur easily cuts through carious dentin to eventually open
up healthy tubules deeper in tissue and in conjunction with water
stimulation of odontoblastic processes that will result in pain associated
with cavity preparation using this technique.

Even if the operator maintains continuous bur movement over a large

surface area and keeps bur speed and pressure constant throughout use, the
type and size of bur used can all help to reduce these detrimental factors to
some degree, however they are not completely eradicated and thus still pose
a significant problem.

74
 In current practice, having gained access to the carious dentine using
high speed air turbine handpiece and burs, the slow speed bur or hand
excavation can be used for carious dentin excavation. As the hand
excavator will remove softened tissue with more sensitive tactile feed back
than bur, this method is more self-limiting of two.

75
SONIC OSCILLATION (SONO-ABRASION) :
A recent development from the original ultrasonics is the use of high
frequency, sonic air-scalers with modified abrasive tips a technique known
as SONO-ABRASION. The Sonicsys Micro unit designed by Drs Hugo,
Unterbrink and Mosele in a venture between Ivoclar Vivadent and Kavo, is
based upon the SONICFLEX 2000L and 2000N air scaler handpieces that
oscillate in a sonic region <6.5 KHZ (See Color Plate - 11).

The tips describe an elliptical motion with a transverse distance of

between 0.08 to 0.15 mm and a longitudinal movement of between 0.055 -
0.135 mm. They are diamond coated on one side using 40 m grit diamond
and are cooled using water irrigant at a flow rate between 20-30 mL/min.
The operational air pressure for cavity finishing should be around 3.5 bar.

There are currently 3 different instrument tips :

1) A lengthways halved torpedo shape - 9.5 mm long, 1.3 mm wide.
2) A small hemisphere 1.5 mm diameter
3) A large hemisphere 2.2 mm diameter.
The torque applied to the instrument tip should be in the region of 2N.
If the applied pressure is too great, the cutting efficiency is reduced due to
damping of the oscillations. This technique was initially developed using
different shaped tips, to help prepare predetermined cavity outlines
(SONICSYS APPROX) but also works well in removing hard tissues when
finishing cavity preparation.

Favourable results from laboratory studies using SONO-ABRASION

to remove softened carious dentine have indicated another possible use for
this technique in future.

76
CHEMOMECHANICAL CARIES REMOVAL (CMCR) :
Chemomechanical caries removal involves the chemical softening of
carious dentin followed by its removal by gentle excavation. The reagent
generated by mixing aminoacids with NaOCl, N-Monochloroaminoacids are
formed which selectively degrade the demineralised collagen in carious
dentine. The procedure requires 5-15 minutes but avoids the painful removal
of sound dentine thereby reducing the need for local anaesthesia. It is well
suited to the treatment of deciduous teeth, dental phobics and medically
compromised patients. The dentine surface formed is highly irregular and
well suited to bonding with composite resin or GIC.

Dentine consists of mineral : 70% weight

H2O : 10% weight
Organic matrix : 20% weight (18% collagen and 2% non collagenous
compounds including proteoglycans, phosphophoryns, chondroitin
sulphate).

Collagen is an unusual protein which contains large amount of

proline and one third of aminoacid content is glycine. The polypeptide
chains are coiled into triple helices which is known as tropocollagen units.
These tropocollagen units then orientate side by side to form a fibril.

Covalent bonds between the polypeptide chains and between

tropocollagen units forms cross links and gives the collagen fibrils stability,
in dentine the fibrils are in the form of a dense meshwork which becomes
mineralized.

77
 When caries occurs, acids produced by plaque bacteria by anaerobic
fermentation of carbohydrate initially cause solubilisation of mineral in
enamel. As the process progresses, dentinal tubules provide access for
penetrating acids and subsequent invasion by bacteria which results in a
decrease in pH and causes further acid attack and demineralization.

When organic matrix has been demineralised the collagen and other
matrix components are then susceptible to enzymatic degradation mainly by
bacterial proteases and other hydrolases. With respect to collagen
degradation two zones can usually be distinguished within a lesion. There
is a inner layer which is partially demineralised and can be remineralised
and in which the collagen fibrils are still intact and there is an outer layer
where the collagen fibrils are partially degraded and cannot be
remineralised. CMCR reagent must be able to cause further degradation of
this partially degraded collagen by cleavage of the polypeptide chain in the
triple helix.

Principle on which CMCR is based arises from studies by Goldman

and Kronman. They were studying the effect of NaOCl which is a
nonspecific proteolytic agent, on removal of caries material from dentine.
NaOCl itself however was too corrosive for use on healthy tissue and so
they decided to incorporate into sorenson's buffer (which contains glycine,
NaOH, NaCl) in an attempt to minimise problem.

Quite fortuitously a reaction occurred with in a product which was

more effective in removal of carious dentine. This involved chlorination of
glycine to form N-monochloroglycine (NMG) and the reagent became
known as GK-1019. They found that system was more effective, if glycine

78
was replaced by aminobutyric acid, the product then being N-
Monochloroamino butyric acid (NMAB) designated as GK 101E.

Mechanism of Action :
Originally it was thought that procedure involved chlorination of
partially degraded collagen in the carious lesion and the conversion of
hydroxyproline to pyrrole-2-carboxylic acid.

Recent work suggests that clevage by oxidation of glycine residues

could also be involved. This causes disruption of collagen fibrils which
becomes more friable and then can be removed.

NMAB (Caridex) it consisted of 2 solutions

Solution - I containing NaOCl
Solution - II - Glycine, aminobutyric acid, NaCl and NaOH.
The two solutions were mixed immediately before use to give the
working reagent (pH approximately 11) which is stable for one hour. A
delivery system was also available which consists of reservoir for the
solution, a heater and a pump which passed the liquid warmed to body
temperature through a tube to a handpiece and an applicator tip which
came in various shapes and sizes. The solution was applied to the carious
lesion by means of this applicator which was used to loosen the carious
dentine by a gentle scraping action; the debris together with the spent
solution being removed by aspiration. Application was continued until the
dentine remaining was deemed sound by normal clinical tactile criteria with
suitable accessible soft lesions, after 5-10 minutes treatment only clinically
sound dentine remained.

79
 The reagent selectively removes carious dentine leaving a surface
with many overhangs and undercuts dentine scales were a frequent feature
of the surfaces formed and dentinal tubules were both patent and occluded.
This surface should be well suited to restoration with modern adhesive
materials such as GIC.

The procedure avoids the painful removal of sound dentin but is

ineffective in the removal of hard eburnated parts of the lesion ; removal of
eburnated caries however may not be necessary. Recently it has been shown
that discoloration in carious dentin results from the Maillard reaction
which modifies aminoacids in collagen thereby making them more resistant
to proteolytic attack and inhibiting lesion progression in discolored dentine.

Although cardex system initially proved to be quite popular, large

volumes of solution were needed 200-500 ml and the procedure was slow
(time involved 10-15 minutes).

Studies have been carried out on the nature of dentine surface

remaining after complete caries removal by CMCR. Electron probe micro-
analysis showed that dentine is sound and properly mineralized and that
surface formed is highly irregular.

Histological studies have confirmed the irregular nature of dentine

surface and also shown that some dentinal tubules contain bacteria but the
level of these is no higher than in mechanically prepared cavities.

Because of time required for CMCR treatment, the large volume of

solution needed and the fact that the delivery system was no longer

80
commercially available. Use of CMCR, despite its potential became
minimal.

During this time however, Mediteam in Sweden continued to work on

the system and the latest CMCR Reagent known as CARISOLV hit the
headlines in January 1998 (See Color Plate – 12).

Although this is similar to the caridex and NMAB systems it is in the

form of Pink gel which can be applied to the carious lesion with specially
designed hand instruments. Because it is gel, the volume required is less
than one millilitre and it requires neither heating nor a delivery system. It is
marketed in 2 syringes, one containing NaOCl and the other a pink viscous
gel which contains 3 aminoacids lysine, leucine, glutamic acid together with
CMC (Carboxymethyl cellulose) to make it viscous and erythrocin to make it
readily visible in use. The contents of the 2 syringes are mixed by a simple
system which involves joining the two together immediately before use as its
effectiveness begins to deteriorate after 20 minutes.

The gel is applied to the carious dentine with one of hand instrument
and after 30 seconds, carious dentine can be gently removed. More gel is
then applied and the procedure repeated until no more carious dentine
remains, a guide to this being when the gel removed from the tooth is clear.
The time required for this procedure is 10-15 minutes and the volume of gel
is only 0.2 - 1.0 ml.

Rotary instruments may still be required however for some cavities

but preliminary reports indicate the patient acceptance is very good.

81
 The system is much easier to use than Caridex and because it involves
gel rather than liquid there is better contact with the carious lesion. When
complete caries removal is achieved by this technique the cavity surface has
been shown to be as sound as that remaining after conventional drilling.

COMPARISON OF CARIDEX AND CARISOLV :

CARIDEX CARISOLV
Solution - I 1% NaOCl 0.5% NaOCl
Solution - II 0.1 M aminobutyric acid glycine 0.1 M glutamic acid / leucine /
0.1 M NaCl lysine
0.1 M NaOH NaCl
NaOH
Dye - Erythrocin
pH 11 11
Physical properties Liquid Gel
Volume needed 100-500 ml 0.2 - 1.0 ml
Time required 10-15 min 10-15 minutes
Equipment required Applicator unit None
Instruments Applicator tips Specially designed
Preparation remains active 1 hour 20 minutes
after mixing

Advantages :
1) Reduced need for local anaesthesia
2) Conservation of sound tooth structure
3) Reduced risk of pulpal exposure
4) Well suited for anxious and medically compromised patients as well as to
pediatric and domiciallary dentistry.

Limitations :

82
1) Rotary and hand instruments may still be needed for removal of tissue or
material other than degraded dentine collagen. This includes access to
small or interproximal carious lesions, removal of enamel overlying the
caries, removal of existing restorations etc as well as for cavity design
when non adhesive restorative materials are used.

83
ENZYMES :
Studies have examined the possibility that carious dentine might be
able to be removed by using certain enzymes. In 1989, Goldsberg and Keil
successfully removed soft carious dentin using bacterial Achromobacter
collagenase, which did not affect the sound dentin layer beneath the lesion.

A more recent study has used the enzyme pronase, an non-specific

proteolytic enzyme originating from Streptomyces griseus to help remove
carious dentine.

This might have significant clinical implications but further

laboratory research is required for validation of this technique.

84
 AIR ABRASION – MICRODENTISTRY

Air abrasion utilizes kinetic energy from alumina particles entrained

in high velocity stream of air to remove tooth structure. Air abrasive
methods are suited for restorations with current bonded resin materials and
well into a philosophy of tooth conservation and improves the longevity of
restoration.

The father of concept of air-abrasive microdentistry is an American

Dentist, Dr.J.Tim Rainey, from Refugio, Texas, USA. He was a student and
friend of late Dr.Robert Black, who actually invented and unsuccessfully
introduced the first air abrasive machine in the 1950's. Dr. Rainey was able
to improve and combine this technology with the use of modern adhesive
restorative material.

Development of Air Abrasive Technology :

The instrument was first developed in the 1940's by Dr.Robert Black.
In 1951- S.S. White Technology introduced Air-Dent the first
commercially available unit for preparing cavities in teeth air abrasion.

New Technology for the 1990's - Air abrasion resurfaced as an

exciting "new technology" that acts in synergy with rapid evolution of
adhesive dentistry, which has changed tooth preparation requirements and
eliminated the need for mechanical retention.
AIR-ABRASION SYSTEMS AND FEATURES :
Air abrasion devices include cart, table top and handheld models.
Hand held devices are generally not suitable for restoration preparation but
used to prepare tooth, metal, composite or porcelain surfaces for bonding.
Some models have built in features and accessories, such as
additional compressor, evacuation system and high intensity curing light.
Operator controls are either mechanical or digital.
Some systems (eg. AIR-FLOW Prep K1) capture the Al2O3 powder
stream in H2O spray to reduce the pollution which increase comfort of
operation.

Principle behind air abrasion is Based on the formula for KINETIC

ENERGY
E = ½ mv2
M = mass
V = Velocity

Essentially this equation underscores the fact that the cutting

capability of air abrasive is attributable to the energy of mass in motion
unlike conventional mechanical methods that depend on friction.

When that rapidly moving mass strikes its target, most of its energy is
transferred to that material, if that material is hard the results is removal of
small amount of material. If, on the other hand the material is soft, the
energy is mostly absorbed by the material and then the mass rebounds.
When these highly energized abrasive particles are directed at healthy
enamel, dentin the kinetic energy is absorbed by the substrate and cuts or
abrades rapidly. That is why the modality is sometimes referred to as
KINETIC CAVITY PREPARATION (KCP).

ABRASIVE PARTICLES :
Abrasives normally employed for cutting tooth structure is Aluminium
oxide, which is sharp, irregular particles, the hardness required and
relatively low cost.

Alumina particles - Alpha alumina, Pure, Bio-compatible long used in

medicine and food. Infact it is prime ingredient in several popular tooth
whitening pastes.

Depending on the nature of abrasive used this technique has ability to

effectively abrade both sound enamel and dentin, but to date, these
applications using commercially available alumina abrasive donot include
the efficient removal of softened carious dentin. Further investigation, into
the use of alternative abrasive mixture has indicated that softer particles.
(eg. Polycarbonate resin alumina-hydroxyapatite mixtures) might be more
selective in removal of carious dentin, because they are only capable of
removing tissue of equivalent hardness leaving healthier, sound tissue
virtually unscathed.

Air Abrasion Variables :

Air abrasive units allow the clinician to focus a stream of aluminium
oxide particles on a specific area of the tooth. The restorative capabilities
of this techniques are wide ranging and dependent on how the operator
controls the following variables.
1) Pressure
2) Tip size
3) Tip angle
4) Tip distance
5) Dwell time
6) Particle size

Pressure : Most available units operate between 40-140 psi (pounds per
square inch). The lowest effective pressure should be used to achieve the
desired tooth preparation. For fissure cleaning prior to sealant application,
a brief exposure of 40 psi is sufficient. While more extensive decay removal
may require a nozzle pressures of 80 psi or more.

Tip Size : Tip aperture ranges from 0.015" to 0.027" in diameter, large tips
allow more particles to pass through and are well suited for more
substantial preparations, while smaller tips are used for discrete
applications such as preventive resin restorations.

Tip Angle : Tip angle can range from 40o to 120o allowing access to both
straight occlusal surfaces and the distolingual grooves of upper molars.

Tip Distance : By keeping the tip less than 2 mm from target surface, the
clinician maximizes the focus of abrasive stream.

Dwell Time : Longer the exposure, the further the preparation will advance.

Particle Size : 27 m aluminium oxide powder is normal for intra oral

procedure, 50 m powder for extraoral endeavours due to its excessive
cutting and the difficulty in controlling over spray.
Scanning electron micrographic effects of KCP preparation on human
enamel and dentine :
Cavity preparations of the high speed burs had sharply defined
cavosurface margins. Higher magnification revealed that the cavosurface
margins showed areas of cracking and micro chipping.

KCP preparations demonstrated.

i. Rounded cavosurface margins and internal line angles.
ii. Microscopic roughness of treated enamel and dentin
iii. A halo of abraded enamel surrounding the cavity's outline.
iv. Apparent closure of dentinal tubules.

Rounding of margins is caused by 'fanning' of abrasive particles as

they exit the orifice. However, abrasion provided by the peripheral portion
of stream is less efficient because of lower velocity and concentration of
alumina particles. This phenomenon causes all internal line angles to be
rounded (See Color Plate – 13, Fig. A & B).

The effect is minimized when tip is placed less than 1.0 mm from the
tooth, where fanning is negligible. Therefore for preparation that require a
bevelled cavosurface margin (i.e. acid etched retained resin restoration) the
instrument tip should be placed approximately 2.0 mm from the tooth
surface. For restorations requiring a butt joint, the orifice should be placed
approximately 0.5 mm from the tooth.
NEW ANATOMICAL STRUCTURES IN TEETH :
Due to newly discovered anatomical structures, we are beginning to
understand why over cutting teeth according to G.V.Black’s principles,
greatly reduces tooth strength.

In lower first molars, a sub-occlusal transvere ridge of enamel called

"Rainey's Ridge", connects to other blocks of enamel to contribute to tooth
strength (See Color Plate – 13, Fig. C).

In upper molars, there is similar structure of enamel called "Rainey's

Web". Microdentistry cavity design attempts to retain these structures and
only remove the damaged carious enamel and dentin. The importance of
conserving these anatomical structures, is to retain the strength of natural
tooth and to avoid the long term implications of over cutting.

RAINEY RIDGE : It is inter connection of distolingual cusp and

mesiobuccal cusp (DCNA 46 (2002) 185-209).

Applications and Limitations of Air - Abrasion :

1) Cavity preparations - Class I, V, VI
2) Internal cleaning of tunnel preparations
3) Removal of temporary cement from inside a crown
4) Microairabrasion of white spot enamel hypoplasia
5) Stain removal
6) Preparation of metal surfaces inside a crown for better bonding.
7) Aid in repair of acrylic, composite and porcelain : the narrow cutting
path and lack of vibration and heat make air abrasion technology an
alternate method for these repairs.

Situations in which air abrasion is not an effective procedure include :

1) Crown preparation
2) Large carious defects - Air abrasion is not effective for removal of gross
caries because it does not effectively cut substances that are soft or
resilient.
3) Amalgam removal - Air abrasion is not an efficient means of removing
large amalgams especially and there is concern for the levels of mercury
released when amalgam is abraded.
4) Class - II Cavity preparation - Soft materials such as carious dentin or
moist and resilient decayed dentin cannot be abraded effectively with air
abrasive unit. The particles tend to bounce and they do not cut
effectively. Hand or rotary instruments should be use in these cases.

Advantages of Air-Abrasion :
1) Non - traumatic treatment
2) Biocompatibility
3) No chipping
4) No microfracturing
5) Decreased thermal build up
6) Microsmooth margins
7) Less invasive procedure that preserves more natural tooth structure than
conventional instrumentation.
8) Greater strength and longevity because of lesser preparation.
9) No anesthesia
10) Less discomfort during preparation

Disadvantages :
1) Ability to accomplish only some aspects of dentistry.
2) Lack of tactile sensation when using the air abrasion handpiece, because
the nozzle of air abrasion instrument does not come in actual contact
with the tooth.
3) Non contact based modality, leading to significant risk of cavity over
preparation and inadequate carious dentin removal.
4) Mess and spread of aluminium oxide around the dental operatory.
5) Danger of air embolism and emphysema.
6) Impaired indirect view because abrasive particles collect on mirror
rapidly blocking the viewing surfaces.
7) Damage to dental mirrors, optical devices like magnifying lopes,
intraoral camera lenses or photographic equipment.

Contraindications to Airabrasive Treatment :

1) Asthma patients
2) Severe dust allergy
3) Chronic pulmonary disease
4) Recent extraction
5) Any open wounds in oral cavity
6) Subgingival caries removal
MESS AND SAFETY ISSUES :
1) To reduce respiratory exposure, the clinical staff should always use
surgical face masks and use dry vacuum systems to reduce patient
exposure.
2) Use rubber dam, protective eye glass and dead soft metal matrix to
protect adjacent tooth structure.
3) Use disposable mouth mirrors.
4) Rinsing instead of rubbing the optical surfaces helps prevent scratches.
5) High speed suction and an external vacuum system are necessary to
capture the powder that escapes into the air and to enhance practitioner
vision and patient comfort.

FACTS :
1) Scientific tests showed that patient who have to undergo about 28 typical
20-30 seconds KCP preparations in older to inhale enough alpha
alumina is equal to the weight of one grain of table salt.
2) Amount inhaled in a single procedure is about 1000 times less than the
limit established by the occupational safety and health administration.
3) Particles inhaled are more than 10 m in size and cannot enter the
alveoli; they are readily swept away by the normal ciliary action.
4) Generally 10 grams of aluminium oxide is used to remove pit and fissure
caries for one preparation.
5) Most preparation procedures can be easily accomplished with
approximately 40-60 psi and 2.5 gr/minute powder flow.
6) Stream intensity or particle flow rate is variable from 0-8 g/min. A good
standard is approximately 2 gr/min.
Comparison between high speed drills and air abrasion :
High Speed Drills Air Abrasion
1) Rotary burs known to cause 1) No microfractures
microfractures

2) Excessive destruction of tooth 2) Less destruction of tooth structure.

structure

3) Heat, vibration, bone conducted 3) Heatless, vibration less, minimal

noise all contribute to patient sound.
discomfort.
4) Requires anesthesia 4) No anaesthesia

Available Air abrasive Equipment

Kavo Rondoflex (Kavo, India).
KCP 100
Prepstart
 LASERS
LASERS are devices that produce beams of Coherent and very high
intensity light. A large number of current and potential uses of lasers in
dentistry have been identified that involve the treatment of soft tissues and
modification of hard tooth structures. The word laser is an acronym for
light amplification by stimulated emission of radiation. A crystal or gas is
excited to emit light photons of a characteristic wavelength that are
amplified and filtered to make a coherent light beam.

Since the development of the first ruby laser by Maiman in 1960,

researchers postulated that it could be applied to cutting both hard and soft
tissues in the mouth. However, early studies found that the ruby laser
produced significant heat that caused damage to pulp. Since these early
beginnings, the field of lasers has developed considerably and many types of
lasers are available to cut dental hard tissues. The efficacy of the lasers will
depend on numerous factors including the wave length characteristics, pulse
energy, repetition rate and the optical properties of the incident tissue.

Lasers that are currently being investigated for more selective hard
tissue ablation include :
 Er:YAG (erbium : Yttrium-aluminium-garnet) and Nd:YAG
(Neodymium : YAG) – Mid IR to IR emission.
 CO2 laser – IR emission
 Excimer lasers [ArF (argon : Freon) and XeCl (Xenon : Chlorine)] –
U.V. emission.
 Holmium lasers
 Dye enhanced laser ablation – exogenous dye, indocyanine green in
conjunction with a diode laser.

In terms of carious dentine removal, the UV emission of excimer

lasers (377 nm) has the potential to be more selective in the ablation of
carious dentin and there may be a possible use of dye enhanced laser
ablation to develop this selectively further. In addition to caries removal,
studies have shown that, in the presence of suitable photosensitizer, low
power laser light has ability to destroy S.mutans.

Laser irradiation facilitates sealing of fissures (melting and

recrystallizing of enamel by CO2 lasing) and is able to cut dental hard
tissues (Er:YAG, Nd:YAG lasers and others).

Laser technology is used as adjunct treatment in caries prophylaxis

on occlusal fissures, based on the lasers capacity to reduce the number of
microorganisms in fissures (due to its action on dental plaque) and
selectively volatize the carious tissues, which contains a relatively large
amount of water.

Laser treatment may also modify the structures of dentin and enamel
through physical action on hydroxyapatite crystals, making them more
resistant to the demineralizing actions of acids.

Using laser ablation techniques, the effect of mechanical vibrations,

pressure and unfavourable temperatures changes associated with use of
rotational cutting instruments is eliminated. Laser irradiation has proved to
be a safe and efficacious treatment modality for caries removal and cavity
preparation, and the reduced need for anesthesia is considered an
advantage (See Color Plate – 14).

The factors coupled with the expense and size of equipment have
meant their use in general practice as a hard tissue cutting tool has been
effectively limited to date.

On going research and development will further enhance application

of laser irradiation in general practice.
 OZONE TECHNOLOGY IN CARIES REMOVAL
WHAT IS OZONE?
Ozone is part of natural gas mix that surrounds the earth at high
altitude and protect worlds population from excessive UV radiation's. The
fresh wonderful smell on mountains after the thunderstorms is ozone.
This ozone is oxidizing agent, used to purify water.

How it is Produced ?
Ozone is produced naturally during thunder stroms and it can be
produced in a controlled manner using electrical corona discharge units.

Mechanism of Action :
O3 is effective in reducing the amount of bacteria and virus present in
the H2O and air.

O2 Ozoniser
O3
 acts
Live bacteria, virus and fungi

Dead bacteria, virus & fungi
+ H2O + CO2

Treatment with O3 is based on niche environment theory :

Niche Environment Theory States :

Caries process begins with initial colonization of bacteria on tooth
surface. As the bacterial count increases on tooth surface they produce
acid, which leads to loss of mineral content and demineralization start. This
demineralization can be reversed by improved oral care and use of mineral
mouth washes, dentifrice.

Now there is balance between the mineral loss and mineral

reabsorption by the tooth surface the net effect leads to remineralisation.

O3 technology developed by Prof. Dr.Edward Lynch. This technique

utilizes O3 gas which is applied to the tooth surface in a controlled manner
with the use of heal ozone delivery handpiece. This O 3 gas eliminate
bacteria, those cause decay, thus halting decay process. Once the bacteria
are eliminated the treated surface can be restored or left to re-mineralize.

Heal Ozone Unit :

Heal ozone is a portable apparatus (See Color Plate–15, Fig. A & B).
This comprises of O3 generator that deliver O3 at a concentration of 2,200
ppm, vaccum pump pulls air through the generator at 615 cc/minute to
supply O3 to the lesion and immediately after treatment the unreacted O 3 is
taken by back by the unit. In the unit there is an O 3 destructor or the
catalyst (i.e. Manganese ions) that convert O3 to O2

Disposable silicon removable cup ranging from diameter (3 to 10

mm) are attached to handpiece. These cups seals the selected area on tooth
to prevent O3 escape.

This unit delivers a 10 second burst of O3 gas at a preset

concentration through the handpiece into a polymer cup that is placed
around the lesion on tooth surface. The cup seals the selected area on tooth
to prevent O3 escape, without this seal heal ozone unit will not produce O 3
gas.

At the end of 10 second, the unit sucks back unreacted O 3 back into
unit. In the unit O3 converts into O2. This takes only 10 seconds.

To complete the treatment heal ozone unit pumps reductant

fluid/mineral wash onto the treatment site to further neutralize any residual
O3 and facilitate the remineralisation process this takes only 5 seconds.

So in just 25 seconds we can eliminate the decay and start

remineralisation process.

Once O3 treatment is completed the patient is sent away with an home

care kit. This consist of dentifrice and mouth washes (See Color Plate –15,
Fig. C).

Once the bacteria are eliminated the treated surface can be restored
or left to re-mineralize.

One important factor that needs to be remembered is that during the

initial stages, the treated area of decay will be relatively soft and will not
support any restoration.

Therefore if a restoration is planned after O 3 treatment. It should be

planned at review appointment by which time the remineralization process
will be advanced and the tissue becomes hard enough to support restoration.
Follow up :
Follow up is critical to success of this technology.
Patient is recalled at 3 and 6 months interval to remeasure the treated
lesion and compare with old records.

Advantages :
1) No injections
2) No drilling
3) No discomfort
4) Conservative preparation
5) Less time consuming

Adverse Effects :
1) In increased concentration it can cause respiratory distress.

Applications :
1) Used to purify water
2) Used to eliminate pollution in air supplies in hospitals
3) Used to decontaminate dental unit water lines.
4) Cleaning of root canals
5) Tooth whitening procedures
6) Treatment of periodontal disease
7) Prewashing of surgical sites prior to implant placement.
 CAVITY DESIGNS FOR MINIMAL INTERVENTION
Cavity design principles :
1) Gaining access to the body of the lesion without being destructive.
2) Removal of tooth structure that is infected and incapable of regeneration.
3) Avoiding the exposure of dentine unaffected by the caries process.
4) Retaining and reinforcing sound but undermined enamel.
5) Reducing perimeter of the restoration.
6) Keeping the margins of the restoration away from the gingiva.
7) Reducing occlusal stress on the final restoration.

RATIONAL CAVITY PREPARATIONS :

Specific designs for approximal lesions.
I. Tunnel preparation
II. Microchip cavity preparation
III. Minibox cavity preparation
IV. Full box cavity preparation

INTERNAL APPROXIMAL CAVITY PREPARATION :

The cavity preparation is started with an occlusal approach to the
lesion from just inside the marginal ridge.

Proximal and occlusal views of Class II “Internal” cavity preparation

 The carious lesion of dentin is identified and hollowed out. The full
extent of the dentine lesion is explored before any decisions about enamel
extension are made, although some extension of the enamel access may be
required for full removal of the dentinal caries. Invariably, the dentinal
lesion is larger than might be imagined. It is critical to the technique that
all the infected carious unremineralizable dentine be removed, which is why
the preparation is best described as “INTERNAL” rather than ‘TUNNEL’.
The final extent of the carious removal may be determined by staining.

Once the dentine preparation has been completed, it is necessary to

examine the residual approximal enamel wall. In some cases, the enamel
may not be penetrated, but may simply have a small region of porosity
sufficient to allow bacterial percolation through to the dentine. In other
cases, the enamel wall is penetrated and the penetration defect is
surrounded by a region of porous enamel. Even if the enamel is penetrated,
the lesion may be surprisingly small in comparison to the size of the dentine
lesion. While some reports have criticized internal procedures in that they
allow some porosity in the enamel to remain and that there is some difficulty
in filling the region adequately, it should be always be understood that this
region is deliberately left in this way in order to preserve contour, to allow
remineralisation and to avoid placing a restoration with a larger perimeter.

The question becomes how best to handle the enamel penetration region.
There are several concepts :
The first is to remove the deficiency by drilling or by punching it out
with a hand instrument. Obviously, access and visibility are such that it can
be difficult to ensure all of the porous enamel is removed. Besides, there is a
chance that the marginal ridge may be either fractured out at the time of the
procedure or that it may fail in a short time. Hasslerot and Nordbro et al
have reported that there is a much higher incidence of marginal ridge
fracture when manipulation or tunneling through of the enamel porosity has
been performed.

The alternative is merely to smooth the inner portion of the deficient

enamel. The idea is to encourage reinforcement and remineralisation of the
deficient enamel. In these cases the restorative material will come to the
outer surface. Several reports indicates that the most conservative
treatment gives the greatest long term success. When removal of the
porosity is necessary, then the intentional preparation of a “MICRO CHIP”
or “MINI BOX’ as described below, is better to perform than to make any
attempt to punch out the porous enamel.

TUNNEL PREPARATION :
An alternative to the traditional approach to accessing interproximal
caries have been termed the tunnel preparation.

It was first suggested by Jinks in 1963 as a method for placing a

silver alloy mixed with sodium silicofluoride in the distal aspect of primary
second molars to “inoculate” permanent first molars with fluoride as they
erupted.

Hunt and Knight later modified this procedure to be utilized as a

conservative technique for restoring small interproximal carious lesions.
 Two variations are described.
1) Closed tunnel : Which leaves the demineralized approximal enamel
intact.
2) Open tunnel : Which is accessed from occlusal and exits through the
approximal surface.

Advantages :
 It preserves the marginal ridge, it is considered to be as conservative
approach.
 Outer surface of the interproximal enamel is removed only if cavitated by
caries, so there is less potential for a restorative overhang. Overhangs
have been shown to occur 25% to 76% of the time with traditional Class
II restorations, resulting in bleeding, gingivitis, bone loss.
 Two surface cavity preparation has been shown to reduce tooth stiffness
by 46%; only a 20% reduction occurs with an occlusal preparation.
 Perimeter of the restoration is reduced, decreasing the potential for
microleakage.
 Minimal preparation is required interproximally, the potential for
disturbance of the adjacent tooth is reduced.

Disadvantages :
 It is highly technique sensitive, demanding careful control of the
preparation by the operator.
 Angulation of preparation often passes close to pulp.
 Because of conservative nature of the preparation, visibility is decreased
and caries removal is more uncertain. For this reason, caries detecting
solution should be used to examine remaining caries.
 In addition the procedure can leave a fragile marginal ridge. To avoid
weak ridges, Mount G.J advices employing a tunnel preparation if the
lesion is atleast 2.5 mm apical to crest of the marginal ridge.

Indications and Contraindications :

 Use of tunnel preparation can be considered when small, proximal
carious lesions necessitate restoration and esthetics demands are high.
 Preparation should be avoided when large carious lesions are
diagnosed, where access is particularly difficult, or when the overlying
marginal ridge is subjected to heavy occlusion or demonstrates a crack.

Preparation :
Access may be gained through the occlusal surface with No.2 bur
used in a high speed handpiece and directed towards the carious lesion.
The preparation should be started about 2.0 mm from the marginal ridge.
Because of the limited access, caries disclosing solution is needed to
improve visibility for caries removal. After the dentinal caries is removed,
the proximal enamel lesion is evaluated. If it is weak or porous, the enamel
is punched or drilled through; if it is intact, it is left alone and allowed to
remineralise. If enamel is to be removed, a matrix band is placed to protect
the adjacent tooth. If the clinician determines that the marginal ridge has
been undermined the tunnel preparation can be converted to a traditional
Class II preparation at this time.

Restoration :
Glass ionomer has been the suggested restorative material of choice.
Cermet glass ionomers were originally used because of their radiopacity
and fluoride release. In addition, mutans streptococci levels in plaque
adjacent to interproximal glass ionomer restorations are lower than levels
adjacent to either composite or amalgam restorations.

Resin modified glass ionomer cements are the current materials of

choice for this restoration. They are radiopaque and have been shown to
prevent microleakage. The glass ionomer should be placed in accordance
with manufacturer’s recommendations, to approximately the level of DEJ.

The occlusal 1.5 to 2.0 mm of the preparation should be restored with

composite. Composites are more wear resistance than glass ionomer
cement.

MICRO CHIP APPROXIMAL CAVITY PREPARATION:

This is a variant of the internal procedure, called for when removal of
the porous enamel is required. It is also used when fractures in the enamel
wall are found to extend down from the marginal ridge to the porous region.
Whatever the need, the cavity preparation is carried out as described above
for an internal preparation. The enamel deficiency is noted. The cavity is
also filled with glass ionomer. When this is set and the excess is being
removed form the occlusal access region. An extension of the occlusal
access is made over to and including the fractured portion of the marginal
ridge. This ridge deficiency is little more than groove extended down
gingivally to remove the porosity and deficiencies in the enamel lesion (See
Fig. below). The glass ionomer and enamel are then etched, and posterior
composite is placed to restore the deficiency.

This same solution is used for those cases where late fracture of the
marginal ridge over an internal restoration has occured. In almost every
case, the fracture is limited to that portion directly above the porosity, the
deficiency can be repaired by the microchip approach.

Proximal and Occlusal Views of Class II “Micro Chip” cavity preparation

“MINIBOX” APPROXIMAL CAVITY PREPARATIONS :

In this preparation, the excavation of the dentine lesion is just as for
the previous preparations. Where the design differs is in the handling of the
enamel. Essentially, the integrity of enamel wall needs to be ensured by
extending the margin back to where it can be considered stable and durable.
This does not mean that a full box needs to be developed.

Laterally, the enamel should be opened out until it can be considered

stable. Opening the enamel right out to sound dentine, as advocated
conventionally, removes much sound enamel. It is preferable to retain and
reinforce this enamel even if it is unsupported by dentine by placing glass
ionomer cement base.

Much the same principles applies at the gingival aspect of the lesion.
Classically, the enamel walls is removed down to the level of the bottom of
the dentine lesion, giving a flat cavity floor. This may take the box
subgingivally and leave the cavity margin on root surface. These days all
that seems necessary is to remove the remnants of porous enamel and to take
the enamel wall higher than the dentine wall but the deficiency in the
dentine can easily be restored with glass ionomer base.

In this way, considerable enamel can be maintained at the gingival

and lateral aspects of the box. Even though the dentine lesion may be quite
large, there is no need to have a comparably sized enamel box. This
facilitates the use of modern adhesive restorative materials, makes gingival
contamination less likely, aids contouring of the restoration and reduces the
perimeter of the restoration.

Proximal and occlusal view of Class II “Mini Box” Cavity Preparation

In preparing a cavity for a fresh proximal lesion, there is rarely a

need for a conventional lock, because the shape of the boxes in the designs
described above is such that restoration is inherently retentive.

If necessary, additional retention can be provided by the use of

adhesive restorative materials. The only additional preparation that may be
required is a modest extension at the occlusal portion of box to gain enamel
for an acid etch bond. This is achieved by opening out the enamel
preparation at the occlusal aspect of the box by 1 to 2 millimeters. Care
should be taken to give this extension sufficient bulk and a heavy enough,
cavosurface margin to ensure the durability of restorative material.
“FULL BOX” APPROXIMAL CAVITY PREPARATION:
Full box restoration is still a very common procedure, mainly because
there are so many conventional restorations requiring replacement. In these
situations or where the enamel is in hopelessly poor condition, it will need
refining after eradicating the dentine lesion.

Much of the final refinement will depend on the type of restoration

that is to be placed. For example, the preparation design for an amalgam or
composite restoration differs from the design for a porcelain or gold inlay.

Proximal and occlusal views of generic Class II “Full Box” cavity

preparation. Design variations would be made accordingly to whether the
cavity will be restored directly or indirectly.

Key ways may be required where there is no inherent retention of the

restoration. They will be required where Class I lesion or restoration is
present or when an existing restoration is being replaced.

All that needs to be said here is the smaller the lesion, the simpler is
to restore and the less subject the final restoration is to breakdown.

Semidirect or indirect systems are still useful for larger restorations

and allow the use of more durable materials.
 REPAIR, RATHER THAN REPLACE, DEFECTIVE
RESTORATIONS
The replacement of any failed restoration will also lead to further loss
of tooth structure and subsequent weakening of the remaining crown. This
steady progression should be limited as far as possible; with the advent of
adhesion, biomimetic materials and minimal intervention cavity designs, the
MI philosophy advocates selective repair as a treatment modality over total
restoration replacement with its unnecessary loss of sound tooth tissue and
acceleration of the restoration cycle.
The repair of restorations placed by another clinician must be based
on the premise that all carious tissue was removed originally, and that
secondary caries has not developed.

Resin composite restoration whose gingival margins are located

along root surfaces, good bonding is more difficult to achieve. Thus, repairs
in these areas are more critically dependent on patients caries risk, since
plaque accumulation and leakage at the gingival margin region for a high
risk patient is associated with an increased probability of secondary caries.
Repair with glass ionomer cement may be preferable in the cervical area
because of the advantages of reliable adhesion and release of fluoride.
Long term success of the repair may depend on the patient being moved to a
low risk status.

In contemporary clinical practice, management of recurrent caries

involves extension, repair or resurfacing of failing restorations rather than
total restoration replacement. A preventive / reparative approach should be
adopted as a part of ongoing care of the patient.
 REVIEW OF LITERATURE

Joshua Friedman, Morton I.Marcus (1970) stated that fiber optics

applied to transillumination of teeth and other oral structures is a useful
technique for detection of caries, calculus and soft tissue lesions. It permits
a cold, high intensity light source to be used anywhere in the oral cavity
with ease and flexibility. It often shows the degree of undermined carious
tooth structure more accurately than the usual bitewing radiograph, and
may aid in diagnosis of periapical and periodontal abscesses before bone
destruction has occurred or swelling is apparent.

Frank Brantley C., James D. Bader, Daniel A.Shugars et al (1995).

The common practice of rerestoring teeth has been termed the "cycle of
rerestoration”. Some researchers and clinicians have speculated that this
cycle results in teeth receiving progressively larger restorations In this
study involving 1,337 decisions to replace existing restorations in posterior
teeth, they noted that 70% of all recommendations resulted in an increased
number of restored surfaces. This observed increase in restoration size
raises questions about the effects of the rerestoration cycle on the health of a
tooth and suggests that practitioners should attempt to avoid rerestoration
since it could hasten the cycle.

Kim A. Laurell, John A.Hess (1995) Recent developments in

technology and restorative materials have renewed interest in air abrasion
as a means of tooth preparation. The technique, also called kinetic cavity
preparation, uses kinetic energy to remove tooth structure. The cavities
prepared with No.34 carbide bur used at 4,00,000 rpm showed sharp line
angles, chipping of cavosurface margin and striated internal surfaces.
Cavities prepared with air abrasion showed rounded cavosurface margins
and internal line angles. The surfaces were microscopically rough and the
dentinal tubules were occluded.

J. Tim Rainey (1996) Identified a previously unreported structure of

mandibular molars, known as a subocclusal oblique transverse ridge. A
predominant feature of this ridge as it underlies the anatomical landmark
commonly referred to as the central fossae, is its interconnection of
distolingual cusp and the mesiolingual cusp. This ridge and other web
structures found in enamel are important considerations when preparing
teeth using ultra conservative dentistry.

A.Schneiderman et al (1997) Introduced DIFOTI as a new method

for the reliable detection of dental caries. Images of teeth obtained through
visible light, fiber optic transillumination are acquired with digital CCD
camera and sent to a computer for analysis with dedicated logarithms. The
logarithms were developed to facilitate the location and diagnosis of the
carious lesion by the operator in real time and provide quantitative
characterization for monitoring of the lesions. The results suggested the
superior sensitivity of DIFOTI for detection of approximal, occlusal and
smooth-surface caries.

Graham J. Mount (2000) minimal intervention techniques are

generally considered in relation to initial carious lesions. However, it
appears logical to apply the same principles to extensive cavities as well as
to the replacement of failed existing restorations. As the cavity becomes
larger, there is an increasing need to consider protection of remaining cusps
because they become seriously weakened. However, it is possible to develop
a protective cavity design without undue sacrifice of remaining tooth
structure, at the same time the maintenance of occlusal anatomy and correct
contact with the opposing arch are ensured. For larger cavities, special
consideration needs to be given to the strength of restorative material.
Glass ionomer is relatively brittle and should not be exposed to undue
occlusal load. Resin composites cannot be regarded as universal in their
physical properties, and placement is time consuming. A lamination
technique is often useful, combining the advantages of both glass ionomer
and resin composite. Amalgam should not be entirely discarded as an
option because it has greater strength than glass ionomer and resin
composite and is still useful for restoration of extensive cavities and for
protection of and retention of weakened cusps. Minimal intervention
principles designed to limit the loss of tooth structure, should be applied to
all restorative dentistry. None of the available restorative materials are
entirely satisfactory in the long term.

Graham J. Mount (2000) The term minimal intervention is relatively

new in dentistry and has been introduced to suggest to the profession that it
is time for change in the principles of operative dentistry. The disease
should be treated first; the surgical approach should be undertaken as a last
resort and then with the removal of as little natural tooth structure as
possible. The advances in techniques and materials that have led to change
and attempts to put them into perspective. Treatment should begin with
identification and elimination of the disease. There will then be a need for
limited restoration of actual cavitation arising from demineralization of
tooth crown. Restorations, per se, will not prevent or eliminate disease.
Caries is a bacterial infection and, until microflora is controlled, all
restorations are at risk of further demineralisation in remaining tooth
structure. This leads to the continuum of replacement dentistry that keeps
the profession occupied for much of its productive time. If this cycle is to be
broken, the profession must first acknowledge the primacy of prevention.

Graham J. Mount (2000) The use of modified cavity designs for the
treatment of initial carious lesions can be justified on the grounds that,
because no restorative material can adequately replace natural tooth
structure for the long term, preservation of natural tooth structure is
important. It is apparent that it is possible to remineralise and heal
demineralised tooth structure to some degree. Therefore, neither enamel
nor dentin should be removed simply because it has calcium and phosphate
ions as a result of acid attack. The older surgical approach to cavity design
was adopted in the absence of adhesive techniques and on the basis of
Black’s principle of “Extension for prevention”, but this theory is no longer
tenable. The current availability of adhesive bioactive restorative materials
makes it possible to maintain areas of tooth structure even though they
appear to be undermined and weakened. Thus, the concept of geometric
designs for prescribed cavities is no longer valid. The modified cavity
designs for small initial lesions; preservation of natural tooth structure is
the principle objective of these designs.

J.A. Beeley, H.K. Yip, A.G. Stevenson (2000) Chemomechanical

caries removal involves the chemical softening of carious dentine followed
by its removal by gentle excavation. The reagent involved is generated by
mixing aminoacids with NaOCl; N-Monochloroamino acids are formed
which selectively degrade demineralised collagen in carious dentin. The
procedure requires 5-15 minutes but avoids painful removal of sound
dentine thereby reducing the need for local anaesthesia. It is well suited to
the treatment of deciduous teeth, dental phobics and medically compromised
patients. The dentine surface formed is highly irregular and well suited to
bonding with composite resin or glass ionomer. When complete caries
removal is achieved, the dentine remaining is sound and properly
mineralized. The system was originally marked in USA in the 1980’s as
Caridex. Larger volumes of solution and a special applicator system were
required. A new system, Carisolv, has been launched. This comes as a gel,
requires volumes of 0.2 – 1.0 ml and is accompanied by specially designed
instruments.

Martin J. Tyas, Kenneth J.Anusavice, Jo E. Frencken, Graham J.

Mount (2000) The concept of minimal intervention dentistry has evolved as
a consequence of increased understanding of the caries process and the
development of adhesive restorative materials. It is now recognized that
demineralised but non cavitated enamel and dentin can be healed, and that
the surgical approach to the treatment of the carious lesion along with
“extension for prevention” as proposed by G.V.Black is no longer teneable.

J.D.Hillman (2001) in this approach, a harmless effector strain is

permanently implanted in the host’s microflora. Once established, the
presence of the effector strain prevents the colonization or out growth of a
particular pathogen. In the case of dental caries, replacement therapy has
involved construction of an effector strain called BCS3-L1, which was
derived from a clinical streptococcus mutans isolate. Recombinant DNA
technology was used to delete the gene encoding lactate dehydrogenase in
BCS3-L1, making it entirely deficient in lactic acid production. This effector
strain was also designed to produce strong elevated amounts of novel
peptide antibiotic called Mutacin 1140, which gives it a strong selective
advantage over most other strains of S.mutans. Thus BCS3-L1, replacement
therapy for the prevention of dental caries is an example of biofilm
engineering that offers the potential for a highly efficient, cost effective
augmentation of conventional prevention strategies.

Mathilde C. Peters, Mary Ellen McLean (2001) restorative dentistry

has experienced a shift from the mainly reparative dentistry of the 20th
century towards a minimal intervention approach. Contemporary operative
treatment incorporates the minimal intervention philosophy in cavity
designs. When operative intervention is the designated treatment of initial
caries, currently available operative techniques and contemporary materials
warrant a minimally invasive approach. Minimal intervention applied to
the operative field keeps the options open for long term preservation of the
restored tooth.

Mathilde C.Peters, Mary Ellen McLean (2001) From the mainly

reparative dentistry of the 20th century, contemporary dentistry shifts
towards a minimal intervention approach encompassing up-to-date caries
diagnosis and risk assessment before arriving at a treatment decision. The
ultimate goal of minimal intervention is to extend the life time of restored
teeth with as little intervention as possible. When operative care indicated,
it should be aimed at “prevention of extension”. Black’s principles for
cavity design are considered and put in the perspective of minimally
invasive operative care. Contemporary operative care should be based on a
minimally invasive approach. Minimal intervention is not just a technique,
it is a philosophy!

Vasundhara Shivanna, K. Ramakrishna Raju (2002) Restorative

dentistry has experienced a shift from the mainly reparative dentistry of the
20th century towards a minimal intervention (MI) approach encompassing
up-to-date caries diagnosis and risk assessment before arriving at a
treatment decision. In the past, dental caries has been treated by surgical
excision. Sound tooth structure has to be sacrified to make up for the short
comings of the available operative techniques and restorative materials with
more insight into the caries progress, the advent of adhesive dentistry and
currently available techniques, prevention of caries and greater
conservation of tooth structure is possible. A shift in philosophy from the
traditional surgical model of excision to a more modern medical model of
treating caries is occurring so, when operative care is indicated, it should be
aimed at “prevention of extension” rather than Black’s concept of
“extension for prevention”.

Lennon A.M. et al (2002) Studied the ability of new fluorescence

method to detect residual caries. The new method, visible fluorescence had
the greatest sensitivity, specificity, percent correct score and predictive
values of any of the methods tested. The new method had significantly
higher percent correct score than any of the other methods and significantly
higher specificity than visual tactile and caries detector. Concluded that
visible fluorescence is an improvement on the currently available aids for
residual caries detection.
 Ashutosh Sharma, Vijay P. Mathur (2003) A fundamental
requirement for any good diagnostic tool is to have the ability to diagnose a
disease at its onset. With the introduction of fluorides in various forms there
has been a significant change in appearance and clinical behaviour of
carious lesions, fewer lesions now progress onto the stage of frank
cavitation, thus making dental caries diagnosis more challenging. To take
on this challenge, myriad of approaches are being developed, amongst
these, laser based caries detection methods shows the greatest promise,
laser based detection besides being able to diagnose a lesion at its onset can
also quantify mineral loss.

Farhan K.Shan, R.K Tiwari (2003) With the growing need to bring
more people under the cover of the dental treatment who earlier had no
access to any sort of dental restorative techniques, the alternative
restorative treatment came into being. Removal of dental caries and
restoration of teeth can often present unique challenges to the practitioners.
Not all dental diseases can be treated by traditional restorative techniques.
Young, unco-operative patient, patient with special needs and situations
where traditional cavity preparation and placement of traditional dental
restorations is not possible, may require the use of an alternative restoration
treatment. ART is a technique used to restore defective or carious teeth with
minimal cavity preparations followed by placement of a fluoride releasing
material such as glass ionomer. This technique is promoted and endorsed
by WHO with the goal of preserving tooth structure, reducing infections and
avoiding discomfort. ART will be a great success in our country side where
millions of people are rendered no restorative treatment, the only option
being extraction!.

Lennon (2003) A new FACE (Fluorescence Aided Caries Excavation)

caries excavation method that uses a fluorescence diagnostic procedure
during excavation allows the operator to identify and remove bacterially
infected dentin more successfully than with the conventional method that
uses visual tactile criteria for identification of caries.

Poonam Bogra, Vineeta Nikhil, Vijay Singh, Sumeet Sharma et al

(2003) Currently the most widely used treatment method for dental caries
requires a dentist to drill the infected tooth, remove the decay and then
restore the tooth with a restorative material. This therapy is relatively
invasive and time intensive. Generation of heat and desiccation, sometimes
inadvertently damage pulp. Offering an alternative to conventional
treatment, a new approach based on ozone, a powerful biocide, rapidly
penetrates the bacteria and kills them. This painless ozone gas treatment
for tooth decay has been proven to halt primary root caries, primary pit and
fissure caries and even clinically reverse the lesions. Ozone alters
metabolic products of bacteria that inhibit remineralization. This therapy
involves a 10 seconds application of ozone gas to eliminate microorganisms
in caries lesion. Significantly reducing treatment time and cost, this therapy
is less invasive than previous methods and conserves more of tooth’s natural
structure.

Shlomo Matalon, Osnat Feuerstein, Isreal Kaffe, Tel Aviv et al

(2003) examined the validity, sensitivity and specificity of bitewing
radiographs and a high frequency sound wave device. The ultrasound caries
detector used to detect caries on contacting approximal surfaces. They
concluded that ultrasound diagnostic device had a higher sensitivity and
specificity in terms of the detection of approximal carious lesion, than
bitewing radiographs.

Poonam Bogra, Vineetanikhil, Vijay Singh, Summet Sharma et al

(2003) Microorganisms play a vital role in causation of dental caries.
Among these streptococcus mutans play the lead role. Establishment of the
fact that organisms play a lead role paved the way for antibiotics in the
global fight against dental caries but it totally disturbed the oral ecology.
So, some scientists tried to control caries at the genetic level. The genes for
lactic dehydrogenase were decoded and the strains of streptococcus mutans
were developed which lacked the capability to produce lactic acid
responsible for caries. Fight against caries became easy with genetically
modified S.mutans. Various genetically modified fruits and vegetables are
being developed by incorporating antagonist peptides to work against
glucosyltransferase. Genetically modified bacteria may also produces
antibodies against caries causing organisms.
 CONCLUSION
It is apparent that it is time for a change in operative dentistry. It is
not possible to really imitate natural tooth structure on a long term basis, so
it is best that it be retained as far as possible.

Now that the profession has a better understanding of prevention of

dental disease and use of fluoride, with the advent of adhesive and bioactive
restorative materials, dentists should adopt to more conservative attitude to
the treatment of the cavitation caused by demineralisation of the tooth
structure.

Dentist should eliminate the disease first and then eliminate existing
lesions as much as possible through remineralisation procedure. When all
else fails, the surgical repair of lesions should be the last resort and carried
out with minimal intervention into the crown of the tooth.

The age old principles that we have used for preparing teeth
increasingly seem to be some what anachronisitc, rigid and irrelevant.
Instead of a mechanical or engineering approach to the subject of the tooth
preparation, what is needed now is a more rational, biologically oriented
approach.
Surgical approach for the restoration of diseased tooth structure leads
to loss of both esthetics and strength. It is also a self propagating process
where in one restoration often leads to another, because the relatively large
cavity design weaken the tooth structure.

It is important that the profession embrace modern science and move

into the new century. The profession has a responsibility to move away from
the maximally interventionist approach, which was necessary prior to
advent of fluoride, adhesions, and biomimetic restorative materials.

Only minimal intervention is required to stabilize and heal an initial

carious lesion; this approach will lead to optimum retention of natural tooth
structure, maintaining both strength and esthetics.

All efforts should be made to preserve a maximum amount of sound

tooth structure. At the turn of the century, we now have arrived at what
G.V.Black visionarily described when he noted that in the future, dentists
would be mostly involved with prevention instead of repair and became
reality within the present decade.

Minimal intervention is not just a technique, it is a philosophy !

Dr. Greene Vardiman Black was a innovative and insightful teacher,
researcher and great clinician who undoubtedly understood how to bring
about quality in restorative dentistry. We still continue to honor his
tremendous accomplishments. He was well ahead of his time and had he
been alive today he would been leading us in the development and usage of
advanced therapies and techniques.
What lies ahead in the new century?
Anderson offered a brief view of what lies ahead in the near term, as
we start a new century: “Completion of decoding the human genome will
also solve the coding for the major pathogens associated with the two
primary diseases in dentistry. Armed with this knowledge, researchers will
be able to synthesize new and robust strategies for diagnosing and treating
caries and periodontal diseases with significant reductions in surgical
therapies”.
 BIBLIOGRAPHY
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