Conservative Approach to Operative Dentistry PDF

11/25/2024 Dr. Nesrine Elsahn Associate professor of Operative Dentistry, Ajman university  Upon successful completion of the course, students will be able to:  2. Discuss the princi...

11/25/2024 Dr. Nesrine Elsahn Associate professor of Operative Dentistry, Ajman university  Upon successful completion of the course, students will be able to:  2. Discuss the principles of conservation of tooth structure and minimal intervention in Operative Dentistry. Dr. Nesrine Elsahn Dr. Nesrine Elsahn 1  11/25/2024 1. Discuss the reasons behind the shift from Black’s principles of extension for prevention to the concept of minimal intervention. 2. Explain the Conservative approach principles. 3. Introduce the biological model of treatment. 4. Describe caries management by risk assessment and selection of treatment according to the activity of carious lesions. 5. Introduce minimal invasive cutting tools. 6. Explain more conservative alternatives to restore initial carious lesions. 7. Describe the steps of cavity preparation from the minimal intervention prospective. Dr. Nesrine Elsahn  In 1901  The tooth has no immune areas and since the patient could not be guaranteed that decay could not attack any part of the restored surfaces of the tooth, the dentist has no right to remove sound tooth structure and to replace it with a foreign material. Dr. Nesrine Elsahn Dr. Nesrine Elsahn 2  11/25/2024 Minimal Intervention  It focuses on a minimal invasive dentistry or preservative dentistry, which allows a shift from the traditional surgical approach to a control of defects without cutting (medical biological therapeutic model) or if cutting is to be done it has to be restricted as much as possible. Dr. Nesrine Elsahn Minimal Intervention  The shift in the concept has resulted from: 1. Understanding caries process 2. Understanding the sequela of unnecessary cutting 3. Technological advances in different aspects 4. Seeing the concept of conservatism from a different perspective. Dr. Nesrine Elsahn Dr. Nesrine Elsahn 3  11/25/2024 I. Gross weakening of the remaining tooth structure. II. Structural and marginal failure of the restoration. III. Increased potential to pulpal irritation.(overextension will maximize the chemical , electrical, thermal, bacterial, osmotic and evaporative stimuli) Dr. Nesrine Elsahn V. Increased gingival and periodontal irritation.(subgingival margins, roughness and plaque accumulation) VI. Increased restorative display. VII. More time money and effort consumption. VIII. Difficult maintenance of the restorative system. Dr. Nesrine Elsahn Dr. Nesrine Elsahn 4  11/25/2024  Magnifiers and Early caries detecting devices  Minimal invasive cutting tools  Bonded and biomimetic restorative materials Dr. Nesrine Elsahn  Conservative approach principles  Control of causative factor or cariogenicity to eliminate further demineralization.  Remineralization of early lesions.  Minimal surgical intervention for cavitated lesions.  Repair rather than replacement for defective restorations. Dr. Nesrine Elsahn Dr. Nesrine Elsahn 5  11/25/2024 Benefits: 1. Preventing the development of defects or new cavities. 2. Stopping the progress of existing lesions and decay spots. 3. Stronger remaining unprepared tooth structure 4. Lower potential for damage to the pulp. 5. Preventing periodontal problems. Dr. Nesrine Elsahn Benefits: 5. Maintaining existing old restorations. 6. Restorations that have less effect on intra- arch and inter-arch relationships and esthetics. Dr. Nesrine Elsahn Dr. Nesrine Elsahn 6  11/25/2024 Therapeutic (non- Restorative (Minimal surgical) invasive surgical) Dr. Nesrine Elsahn Diet and habits modification. Salivary flow and buffering capacity adjustment. Mechanical preventive measures ( calculus and Biofilm control) to fit into a dental office preventive Program. Use of antimicrobials to fit into a home care preventive Program. Remineralization of initial lesions. Fissure sealing for susceptible sites. Close follow up to monitor the healing procedure. Perform minimal intervention and prevention for diseased tissues that can’t be remineralized and restore them conservatively.  This model deals with caries as a disease that should be treated prior Dr. Nesrine Elsahn to any restorative procedures Dr. Nesrine Elsahn 7  11/25/2024 Clinical examination Lesion extension Radiographic examination Lesion activity Caries risk evaluation Dr. Nesrine Elsahn Dr. Nesrine Elsahn Dr. Nesrine Elsahn 8  11/25/2024 Dr. Nesrine Elsahn Dr. Nesrine Elsahn Dr. Nesrine Elsahn 9  11/25/2024 Definition: Determining the probability of caries incidence (that is, number of new cavities or incipient lesions) in a certain period. It also involves the probability that there will be a change in the size or activity of lesions already exist in the mouth. Dr. Nesrine Elsahn Caries Risk Assessment assists in detecting if a preventive program is needed and which program to apply. Dr. Nesrine Elsahn Dr. Nesrine Elsahn 10  11/25/2024 CRA procedures 1. Identification of risk factors and Development of diagnostic tools 2. Development of a model 3. Evaluate the significance of outcomes 4. Treatment according to the model Dr. Nesrine Elsahn Destructive Factors: 1. Caries experience  Dental History(DMFT &DMFS) 2. Low Saliva flow, rate, buffering Capacity, viscous consistency  Salivary test 3. High fermentable carbohydrates diet content and high frequency  Diet Analysis (Diet questionnaire) 4. Poor Oral hygiene measures  periodontal Charting Dr. Nesrine Elsahn Dr. Nesrine Elsahn 11  11/25/2024 Destructive Factors: 5.Low Fluoride  Availability, level and form 6.High caries activity  Dental Charting  Number of lesions Appearance (dull or shiny, light or dark, definite or irregular margins)  Roughness, Plaque accumulation and adjacent gingival health 7.High cariogenic bacterial count  Bacterial counting (Clinpro cario L- pop, CRT bacteria, …etc ) Dr. Nesrine Elsahn Caries Risk Test: determination of the mutans streptococci and lactobacilli counts in saliva by means of selective agars after incubation. Dr. Nesrine Elsahn Dr. Nesrine Elsahn 12  11/25/2024 Dr. Nesrine Elsahn Dr. Nesrine Elsahn Dr. Nesrine Elsahn 13  11/25/2024 Destructive Factors: 8. Tooth anatomy 9. Non-oral factors including: → Age. Sex, medical condition and general health, social factors, and genetic role. Dr. Nesrine Elsahn 2- Development of a model  Caries risk assessment forms  Traffic light system.  Cariogram. Dr. Nesrine Elsahn Dr. Nesrine Elsahn 14  11/25/2024 Caries risk assessment forms Score 0 Low risk Score 10 High risk Score 1-10 Moderate risk Dr. Nesrine Elsahn 1. Saliva 2. Diet 3. Fluoride 4. Oral biofilm Modifying factors. past and current dental status. past and current medical status.lifestyle. socioeconomic status Dr. Nesrine Elsahn Dr. Nesrine Elsahn 15  11/25/2024 Classify the Patient as  ◦ High Risk ◦ Moderate Risk ◦ Low Risk The borderline between low, moderate or high risk is not precise Dr. Nesrine Elsahn Cariogram.  A computer program  Illustrate interactions between caries related factors.  Demonstrates the caries risk graphically and shows the risk for developing new caries in the future and also chances to avoid new caries in the near future. Dr. Nesrine Elsahn Dr. Nesrine Elsahn 16  11/25/2024 Cariogram. Susceptibility : Previous caries experience Related general diseases Diet: Diet content Diet frequency Bacteria: Amount of plaque Streptococcus mutans Circumstances: Fluoride program Saliva secretion rate Saliva buffering capacity Clinical judgment chances to avoid new caries Dr. Nesrine Elsahn 3-Evaluate significance of outcomes  It means categorization of individuals according to their liability to caries incidence, either of high, moderate, low or no risk. Dr. Nesrine Elsahn Dr. Nesrine Elsahn 17  11/25/2024  According to this caries risk assessment the patient could be either : No Care Preventive Operative Advised Care Advised Care Advised Dr. Nesrine Elsahn 5- Treatment according to the model “Caries Management By Risk Assessment”  CAMBRA is a method of assessing caries (cavity) risk and making dental treatment and restoration recommendations based on a patient’s caries risk. New directions in interorganizational collaboration in dentistry: the CAMBRA Coalition model. Young DA, Buchanan PM, Lubman RG, Badway NN. J Dent Educ. 2007. Dr. Nesrine Elsahn Dr. Nesrine Elsahn 18  11/25/2024 Dr. Nesrine Elsahn Dr. Nesrine Elsahn Dr. Nesrine Elsahn 19  11/25/2024 Dr. Nesrine Elsahn Caries Risk- Diagnostic, Restorative and Preventive Protocols Initial Diagnosis Caries Risk Analysis Low Risk Medium Risk High Risk Observe pits and fissures Observe stained pits, deep Initial Protocol with stain or early decay, pits, early decay in enamel. Observe stained pits. decay in enamel, very early (DD15-20) (DD < 25-30) decay in pits with halo or Restore old restorations with Restore fractured shadow, any decay in dentin. cracks and broken margins. restorations. (DD>25-30) Diet Counselling Intro Diet Counselling Intro. Fluoride- Supplements for children, Prevident 5000 for adults 3 Month Recare Caries Risk Analysis Caries Risk Re-Evaluation Re-evaluation s. mutans, lactobacillus test Salivary flow measurement Fluoride, OHI Low Risk Medium Risk High Risk Recall patient every 9 Full diet counselling with diary months, consider Recall patient every 6 months Recall patient every 3 months: increasing if remaining Topical Fluoride for children Topical Fluoride low risk. Fluoride Supplement Fluoride Varnish on prone areas No Topical Fluoride Take BW radiographs every 2 Home Fluoride Trays, No Fluoride Supplement years Chlorhexidine Rinses -Adult Take BW radiographs OHI As needed Fluoride Supplements-Child every 3 years Observe stained pits, early Xylitol Gum OHI As needed decay in enamel (DD20) dentin. (DD20) margins. restorations with poor Polish or seal old restorations Sealants/Preventve resins- all margins, and observe with fair margins, and observe. deep pits and fissures. (DD>5-20) Sealants not required Sealants are optional Fluoride-releasing sealants where possible Dr. Nesrine Elsahn Dr. Nesrine Elsahn 20  11/25/2024  Conservative approach principles  Control of causative factor or cariogenicity to eliminate further demineralization.  Remineralization of early lesions.  Minimal surgical intervention for cavitated lesions.  Repair rather than replacement for defective restorations. Dr. Nesrine Elsahn  Minimal or non-invasive cutting tools  Conservative cavity designs and restorative alternatives Dr. Nesrine Elsahn Dr. Nesrine Elsahn 21  11/25/2024  Should Be : A. Comfort. B. Ease of use. C. Discriminate and remove diseased tissue only. D. Painless. E. Silent. F. Required minimal pressure. G. No heat generation or vibration. H. Affordable. Dr. Nesrine Elsahn  Minimal or non-invasive cutting tools: 1. Air abrasion technology. 2. Laser cutting. 3. Micro-Burs and polymeric Burs 4. Ultrasonic cutting. 5. Ozone treatment. 6. Chemo-mechanical removal of carious tissues. 7. Enzymes. Dr. Nesrine Elsahn Dr. Nesrine Elsahn 22  11/25/2024 Micro-burs Low-tech way to access very small pits. ¼, 1/8 and 1/16 round burs are available for high speed handpieces. Can treat some early pits and grooves almost as well as lasers or air abrasion. Dr. Nesrine Elsahn  Air abrasive technology is the use of compressed air that carries aluminium oxide particles (20-50µm with such force as to be able to cut tooth structure, in simple terms it is a precision sandblaster. Dr. Nesrine Elsahn Dr. Nesrine Elsahn 23  11/25/2024  Advantages: Precise, quite, gentle, time saving tool. Painless as it induces no vibration, pressure or heat generation, thus reducing the need for local anesthesia and the damage to dental pulp. Dr. Nesrine Elsahn  Clinical uses:  Class I, II, III, IV, V cavity preparations  Sealants and preventive restorations  Repair of composite and Ceramic restorations especially margin of veneers  Removal of composite restorations. Dr. Nesrine Elsahn Dr. Nesrine Elsahn 24  11/25/2024  Precautions 1. Need to protect patient with glasses, rubber dam if possible. 2. Dental team needs masks and glasses. 3. Stop frequently to check the progress. 4. Start with low pressure and low power then increase as needed. 5. Hold tip 1-2 mm away from tooth at a 45 degree angle then activate. 6. Always keep tip moving. 7. Requires external suction and air evacuation for the room. 8. Use disposable mirrors. Dr. Nesrine Elsahn Air abrasion Limitations: Large cavities with definite walls and floor couldn’t be cut. Limited to cavities prepared for bonded restorations. cannot remove amalgam restorations Dr. Nesrine Elsahn Dr. Nesrine Elsahn 25  11/25/2024 Dr. Nesrine Elsahn  Are an acronym for light amplification by stimulated emission of radiation Dr. Nesrine Elsahn Dr. Nesrine Elsahn 26  11/25/2024  Diagnosis of dental caries  Cavity preparation  Prevention of dental caries  Whitening of teeth  Modification of different surfaces Photo-polymerization of resin composite Dr. Nesrine Elsahn Dr. Nesrine Elsahn Dr. Nesrine Elsahn 27  11/25/2024. Decay in enamel and early dentin decay (DD 5-30) can be treated with hard tissue ERBIUM LASER , almost always without local anaesthetic. There is no powder spray mess. Laser leaves smear layer free surface. Like Air Abrasion, you cannot remove amalgams or easily treat larger lesions. These units cost 20-50X more than air abrasion units, and are much larger. Dr. Nesrine Elsahn Preset programs  Cavity prep Enamel  Cavity Prep Dentin  Cavity prep deep or Carious Dentin  Pulp Capping Mode  Surface Modification Mode Dr. Nesrine Elsahn Dr. Nesrine Elsahn 28  11/25/2024  Hard tissue Laser (Er:YAG) used for caries removal with a laser-induced fluorescence feed back system.  fluorescence emitted by the bacterial metabolites present in the carious tissue is continuously measured during the caries- removal process.  if a pre-selected threshold is exceeded, the hard tissue laser device is activated and the carious tissue is ablated. Dr. Nesrine Elsahn  Minimal damage to surrounding tissues  Reduced operating time  Reduction of post operative inflammation & edema  Little post-operative scarring  Reduction in post operative sensation due to nerve end blockage  Haemostatic effects by sealing blood vessels  Dressing & suturing is not required  sterilization of wound  Excellent wound healing Dr. Nesrine Elsahn Dr. Nesrine Elsahn 29  11/25/2024 PolyMer burs ( sMart burs) Hard enough to remove Carious dentin Stop at hard healthy dentin Dr. Nesrine Elsahn  Ozone (O3) is a gas  Ozone treatment is excellent as a preventative measure against future decay as it removes the biofilms and the related microorganisms.  Rapidly penetrate and Kills 99% of bacteria in cavities (20 seconds).  It also alters metabolic products of bacteria that inhibit re-mineralization thus allowing clinical reversal of the lesion. Dr. Nesrine Elsahn Dr. Nesrine Elsahn 30  11/25/2024 Proposed steps in Healozone Treatment 1. Cleaning 3. Treatment 2. Measurement 4. Reductant Fluid Promotes the immediate re- mineralization of the tooth. Dr. Nesrine Elsahn Eliminate the use of drills & fillings ( non cutting). Reduces inflammation and pain sensation Eliminates the use of anasthesia Excellent for nervous or anxious patients Dr. Nesrine Elsahn Dr. Nesrine Elsahn 31  11/25/2024 A cocktail of three amino acids and a weak solution of sodium hypochlorite. The sodium hypochlorite dissolves the decay which can be removed easily by light pressure excavation, while the amino acids act as a buffering solution preventing damage to the healthy surrounding tissues. Dr. Nesrine Elsahn Dr. Nesrine Elsahn Dr. Nesrine Elsahn 32  11/25/2024  In 2003, a research project in Brazil led to the development of a new formula.  It has an antibacterial and anti-inflammatory properties.  Dissolves hydrogen bonds in partially degraded collagen fibers thus facilitate carious tissue removal. PAPAIN GEL Dr. Nesrine Elsahn Clinical procedure of Papain Gel 1. Arrow indicating proximocclusal carious lesion 2. Isolation and application of Papain Gel 3. Caries had been removed 4. Arrow showing filled cavity with composite Dr. Nesrine Elsahn Dr. Nesrine Elsahn 33  11/25/2024  Its proven effectiveness  Method’s safety  Elimination of local anesthesia  Lower anxiety built in patients  Conservation of the sound tissue  Only demineralized dentine containing collagen is affected.  Gel consistency simplifies control of the application and reduces the risk of spillage. Dr. Nesrine Elsahn  Pronase enzyme successfully disintegrate decayed dentin as it solubilize more than90% of the nitrogen present in carious dentin.  It has no effect on sound dentin, sound or carious enamel. Dr. Nesrine Elsahn Dr. Nesrine Elsahn 34  11/25/2024  1- Sturdevants Art & Science of Operative Dentistry 7th Ed. Andre V. Ritter et al, 2017. 70-80.  2-Operative Dentistry, A Practical Guide to Recent Innovations. Devlin, Hugh 2006. 1-13.  3- A Practical Approach to Operative Dentistry 1st Ed. Gordon B. Gray; Alaa H. Daud, 2020. chapter 4. Dr.Nesrine Elsahn Dr. Nesrine Elsahn Dr. Nesrine Elsahn 35