Written by Joseph Whitehouse, MS, DDS Tuesday, 31 May 2005 19:00
Imagine, if you will, that a woman calls the dental office for appointments for a family of 4. She also mentions she is pregnant. As the receptionist listens, the prospective patient announces that she is looking for a minimally invasive dentist. Your receptionist, trying to entice the family to enter your practice, says, “Why yes, doctor practices minimally invasive dentistry (MID).” (The receptionist isn’t really sure what MID is, but she knows the office tries to be on the cutting edge.) And so, the family is appointed.
When the family arrives, the wife-mother (call her Helene) wants to be sure that the practice of MID is, in fact, what the family will receive. The receptionist leaves her desk to speak to you and to pass along this request about MID. You have read something about MID but wonder what the woman has read or heard that makes her so focused on this philosophy of practice.
Helene requests that she be seen first, so she is shown the office and is seated in an operatory. You enter and learn from your assistant that Helene has read a great deal about MID on the Internet and would like that approach for her family. After learning some personal information to build rapport, you pick up the conversation by asking her to share how she would like your office to provide care in a way that meets her goals.
Perhaps at this juncture you wished you had not asked the question, because Helene shows that she is extremely informed about something called CAMBRA (caries management by risk assessment). As a pregnant mother, she shows a concern about passing bacteria to her unborn child and wants to know what method of decay diagnosis you perform, what materials are used to restore teeth, whether you have air abrasion, a treatment laser and a laser for diagnosis, whether you do implants, if you have a perioscope, if you use magnification, and if you have digital x-rays. After you recover, she asks if you can do onlays in one visit.
A REVIEW OF MID AS A PHILOSOPHY
What is happening here may be repeated often in many dental offices, as the lay population is reading about MID. Enter minimally invasive dentistry into the Google search engine and you will get 173,000 hits. Sites such as the one sponsored by the World Congress of Minimally Invasive Dentistry (middentist.com) provide the public with a definition of what MID is and what technology can provide those procedures. The philosophy is being shared with family and friends who have received MID treatment. Are you prepared to deliver MID to all your patients?
Dentistry had been relatively stuck with decades-old procedures until the bonding of composites arrived in the 1980s. Placement of amalgam had been necessary, as it worked reasonably well and no alternatives were available, but it required excessive tooth structure removal for retention. The general dentist was not trained to think minimally invasively. However, with the advent of bonding composite, the need for excessive tooth structure removal became archaic. Even Dr. G.V. Black envisioned that his “extension for prevention” was a temporary concept.1
As the concept of bonding was proving that a minimal amount of tooth structure need be removed, other areas of restorative and surgical dentistry began to be examined for the possibility of a more minimally invasive approach. Technol-ogy, materials, procedures, and thinking evolved, which today provide patients with the comfort of knowing a philosophy that will aid them in keeping more tooth structure, having less gum surgery, fighting tooth decay and periodontal disease, having an onlay prepared (instead of a crown) and seated in one appointment, experiencing less invasive tooth preparations with air abrasion or lasers, having treatment with no anesthesia or single-tooth anesthesia, and encountering a communication style that is more supportive. Patients truly appreciate an MID philosophy.
SPECIFIC CHANGES USED TO DELIVER MID TO A FAMILY
There is no definitive starting point in a practice that defines itself as MID. Since this is a philosophy that developed over time as attitudes changed, new materials came along, and technologies were developed, one can embrace MID with even older materials and, to some extent, his or her present technology. For example, small, precisely located occlusial amalgams can be placed that save tooth structure. Tunnel preps using end-cutting carbide burs can allow amalgam to be placed to save a marginal ridge. Although I am not advocating the use of amalgam, the point is that there is no limit to thinking minimally invasively.
However, when considering a new patient, the 2 most likely technologies to provide an MID approach are digital x-rays and a DIAGNOdent (KaVo). A digital x-ray impresses patients with a 90% reduction in radiation. Beyond that, images can be shown to the patient that provide a much better explanation of a problem. Images can be enhanced and magnified.
Because decay is no longer found accurately with an explorer and can actually spread Streptococcus mutans to other fissures,2 and because fluoride has made occlusal grooves the focus of the “new” caries, a DIAGNOdent is a must for documenting the caries present in the grooves. It can also be used to find decay around crown margins. Patients prefer not having an explorer poking them, anyway.3
|Figure 1. An example of air abrasion.||Figure 2. Preparation with a mosquito diamond.|
Once decay has been documented, the alternatives to drilling large extension-for- prevention preparations are now the standard of care.1 Several methods of tooth surface removal can be implemented, such as air abrasion (Figure 1), fissurotomy burs, mosquito diamonds (Figure 2), or an Er,Cr:YSGG laser (Waterlase/Biolase). The less-is-more attitude permeates the thought process of a minimally invasive dentist, so that the teeth prepared for restoration may not experience the fracturing that is so common with the former extension-for-prevention approach. Drs. Graeme Milicich and Tim Rainey describe the marginal ridge as the backbone of integrity for holding the cusps together.4 For that reason, slot preps from the occlusal down toward an interproximal area or tunnel preps from the facial aspect make a lot of sense. The material of choice for these preparations is a resin-modified glass ionomer, and if needed, it can be covered with a composite.
When it comes to restoring lost cusps, onlays preserve a lot more tooth structure than does a crown. I have personally witnessed diagnoses for crowns by other dentists where much sound tooth structure would have been needlessly destroyed. With the advent of bonding, porcelain onlays can be bonded that nearly restore a tooth to its original integrity.
BACK TO THE FAMILY
Let’s return to the hypothetical family of 4 (soon to be 5) and work up a treatment plan that meets the goal of the requested MID approach to care. See the Table for each patient’s diagnosis. How can each problem be approached to meet Helene’s expectations?
Let’s make the assumption that your office has a minimally invasive philosophy, and you can deliver what the mother wants. Would your diagnosis include using a goal-focused interview, digital x-rays, a DIAGNOdent, and a CAMBRA interview along with CRT testing? When it came to the treatment plan, would you incorporate the use of whitening, veneers, orthodontics, sealants, interceptive orthodontics, an implant, an inlay-supported bridge, air abrasion, a laser, an apex locator, an intraoral camera, a perioscope, magnification, Invisalign, and caries indicator dye?
The first thing that comes to attention when looking at the Table is that all members of the family have decay. Therefore, CAMBRA needs to be performed to manage the disease process. (For more information about CAMBRA, visit cdafoundation.org/journal/index.htm and cdafoundation.org/journal/jour0303/consensus. The second site affords the opportunity to download CAMBRA forms [at end of article] to start managing your patients’ risks.) It makes no sense to restore these mouths without the support the family needs to manage its future health. Since Helene knew of CAMBRA, she is very open to filling out the form that documents the habits of the family members and having the saliva test for counts of S mutans and lactobacillus (CRT Test/Ivoclar Vivadent). Once the baseline is established for each family member, therapy begins and goes on for 2 months, at which time another CRT test can confirm changes in the bacterial counts. If the counts are down to an appropriate level, each patient continues with Prevident 5000 (Colgate Oral Pharmaceuticals) and xylitol gum or mints (Welldent) to maintain health.
The saliva tests confirmed the presence of high concentrations of S mutans and lactobacillus in each family member. At the consultation appointment, the CAMBRA portion of the treatment plan was shared first. Each family member would rinse for a minute with beta iodine to make the initial effort to knock down the bacteria counts. A family packet of toothbrushes, Peridex (Zila Pharmaceuticals), Prevident 5000, and xylitol gum was provided. Instructions were given for implementing the regimen.
If each family member’s needed treatment is provided with an MID approach, Helene will appreciate that her family will receive the care she had desired. Taking each family member’s diagnosis and marrying it with MID techniques, we can see how to apply these procedures. All family members were prepared to have a dental hygiene visit for prophylaxis and home care instruction.
|Figure 3. Waterlase preparation of tunnel preps.||Figure 4. Injection of GI in tunnel preps.|
|Figure 5. Use of a perioscope and laser in hygiene.||Figure 6. Bleaching results.|
The father’s decay on the proximal surfaces could be restored with tunnel preps prepared with a Waterlase (Figure 3), using resin-modified glass ionomer (Figure 4, Fuji II or Fuji IX, GC America). No anesthesia was necessary. The 7-mm pockets would have a soft-tissue management application using micro-ultrasonics, a perioscope (Dental View), and a diode laser (LaserSmile, Biolase, Figure 5) application for 3 appointments to prevent epithelium from reentering the pockets.5 Arestin (OraPharma) would be placed where appropriate. The patient had already been provided Peridex for caries control, and it will now help control the periodontal disease. A root canal would be provided for tooth No. 29 using an apex locator for accuracy. However, a crown would not be placed, as the peripheral rim is intact. For the most MID approach, a glass post (Snowlight/Danville Engi-neering) was placed with a composite occlusal restoration. The dark teeth were addressed with what is perhaps the least invasive procedure in dentistry: whitening (Figure 6).
|Figure 7. Fractured incisors.||Figure 8. Forced eruption ready for preparation.|
|Figure 9. Conservative inlay-supported bridge.||Figure 10. Deteriorating amalgams.|
|Figure 11. CEREC inlays and onlay.|
Helene’s issues were addressed using MID in the following ways. The broken tooth No. 8 was erupted (Figures 7 and 8) instead of extracted. A crown was then placed using a shade-taking device to provide accuracy (Vita Easyshade/Vident). Tooth No. 19 required extraction. An implant was offered, but the patient chose an inlay-supported bridge that was prepared because teeth Nos. 18 and 20 were virgin teeth (Figure 9). Using an interosseous injection (Stabi-dent), each area was anesthetized to avoid a numb lip. The teeth were prepared, the tooth extracted, a cotton pellet placed in the socket, an impression with polyether taken, and a bone graft using Bioplant (Kerr) was placed. The patient expressed the desire for replacement of the amalgams with a longer-lasting and stabilizing material. Figures 10 and 11 show the one-appointment CAD/CAM (CEREC/Sirona) milled onlay for tooth No. 30 and inlays for teeth Nos. 28 and 29. The benefit to the patient was one anesthetic experience, no temporaries, and restoration of the teeth with a long-lasting material. A Ligajet (Miltex) was used to anesthetize individual teeth, eliminating a numb lip and tongue.
The final diagnosed problem was a frenum pull on tooth No. 24. Attached gingiva remained, so a diode laser (LaserSmile) was used to remove the frenum, using topical anesthetic (Emla) to numb the area.
The 10-year-old patient with deep decay of tooth No. K, who disliked “shots,” could have the tooth anesthetized with a Er,Cr:YSGG laser6 (Waterlase/Biolase). It could be prepared even into the pulp, restored with Fuji Triage (GC America) over the pulpal area, and covered by a strong resin-modified glass ionomer (Fuji IX). The laser bactericidal effect on an exposed pulp and control of any bleeding provides good potential for a successful pulpotomy. The stained grooves of the molars were investigated by cleaning them with air abrasion and using a DIAGNOdent to detect any caries. Since all of them were showing very low (7 to 10) DIAGNOdent readings, each was sealed with Fuji IX, which provides fluoride release. The bruxism was discovered using a 28-power intraoral camera. The parents were shown examples of severely worn teeth of other patients, and a night guard was prescribed.
Because all the primary molars are filled in the 6-year-old patient, it is obvious that the patient is decay-prone, as is the rest of the family. The patient has first molars erupting with no decay, but these teeth could have Fuji Triage sealants to provide high fluor-ide content (6 x greater than Fuji IX) for prevention. The crowded anterior lower incisors indicate that this child could be treated with an MID approach of arch expansion. Early interceptive orthodontics can often alleviate major orthodontics in the future.7,8
Finally, and perhaps most importantly, the family will be undertaking home care that will include Peridex rinse once a day for one week, followed by a 5,000 ppm toothpaste (Prevident 5000) for 3 weeks, and chewing xylitol gum or mints 3 to 5 times a day to reduce S mutans.9 For Helene, this will also decrease the risk of passing the disease to her unborn child.10
A FAMILY SPREADS THE WORD
Now that you have successfully treated the family using an MID approach, the mother is excited and pleased. She can’t understand how her former family dentists did not use such an attitude in treating her family. She is, however, going to make sure her friends know that you treat patients with an MID philosophy.
It could be said that dentistry changes slowly. The schools are not teaching MID, and the boards are not testing for it. However, that is not true on the West Coast. Each of the 7 dental schools sends a representative to the World Congress of Minimally Invasive Dentistry each year to report on how the schools are progressing in teaching MID, especially CAMBRA.
Embracing a minimally invasive philosophy can begin with your next patient. Consider each procedure to be performed and observe what you might do less invasively than you did before. Speak to the patient about your approach and see if he or she is appreciative. As you continue to think MID, you will become a “preservation” dentist.
Finally, join those who are contributing the science and technology to make MID the standard of care. Attend the sixth World Congress of Minimally Invasive Dentistry. Go to wcmid.com for information.
1. Spaeth D. Not your father’s dentistry. Dental Practice Report. Jul 2003:27-34.
2. Loesche WJ, Svanberg ML, Pape HR. Intraoral transmission of Streptococcus mutans by a dental explorer. J Dent Res. 1979;58:1765-1770.
3. Roth S. Communication with style. Part 3: never assume. J Cosmet Dent. 2004;20:82-84.
4. Milicich G, Rainey JT. Clinical presentations of stress distribution in teeth and the significance in operative dentistry. Pract Periodontics Aesthet Dent. 2000;12:695-700.
5. Rossmann JA, Israel M. Laser de-epithelialization for enhanced guided tissue regeneration. A paradigm shift? Dent Clin North Am. 2000;44:793-809.
6. Parkins F. Lasers in pediatric and adolescent dentistry. Dent Clin North Am. 2000;44:821-830.
7. Dugoni SA. Comprehensive mixed dentition treatment. Am J Orthod Dentofacial Orthop. 1998;113:75-84.
8. Wong ML, Che Fatimah Awang, Ng LK, et al. Role of interceptive orthodontics in early mixed dentition. Singapore Dent J. 2004;26:10-14.
9. Lynch H, Milgrom P. Xylitol and dental caries: an overview for clinicians. J Calif Dent Assoc. 2003;31:205-209.
10. Featherstone JD, Adair SM, Anderson MH, et al. Caries management by risk assessment: consensus statement, April 2002. J Calif Dent Assoc. 2003;31:257-269.
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