Thai Dental Association June 2009 Thai Dental Association June 2009 Martin J Tyas ( Martin J Tyas ( 1 1 ) ) MINIMUM INTERVENTION MINIMUM INTERVENTION DENTISTRY DENTISTRY – – ESSENTIAL ESSENTIAL CONCEPTS CONCEPTS Martin J Tyas BDS, PhD, DDSc, GradDipHlthSc, FADM, FICD, FRACDS, FPFA, FADI Professor and Head, Restorative Dentistry Melbourne Dental School The University of Melbourne Australia Martin J Tyas BDS, PhD, DDSc, GradDipHlthSc, FADM, FICD, FRACDS, FPFA, FADI Professor and Head, Restorative Dentistry Melbourne Dental School The University of Melbourne Australia
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MINIMUM INTERVENTION DENTISTRY –ESSENTIAL · PDF filelifestyle socio-economic status compliance modifying factors medical history lifestyle ... health of oral mucosa (promotes wound
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Thai Dental Association June 2009Thai Dental Association June 2009
��� remineralisation/arrest of nonremineralisation/arrest of nonremineralisation/arrest of non---cavitated lesionscavitated lesionscavitated lesions
��� the dentist as a surgeon (requires a knowledge of the the dentist as a surgeon (requires a knowledge of the the dentist as a surgeon (requires a knowledge of the
caries lesion)caries lesion)caries lesion)
��� minimum surgical intervention of cavitated lesionsminimum surgical intervention of cavitated lesionsminimum surgical intervention of cavitated lesions
��� appropriate maintenance of existing restorationsappropriate maintenance of existing restorationsappropriate maintenance of existing restorations
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (88))
MULTIFACTORIAL NATURE OF CARIESMULTIFACTORIAL NATURE OF CARIES
� local factors
� saliva (quality; quantity)
� diet
� carbohydrate intake
� frequency of exposure to acids
� exposure to fluoride
� plaque accumulation and retention
� local factors
� saliva (quality; quantity)
� diet
� carbohydrate intake
� frequency of exposure to acids
� exposure to fluoride
� plaque accumulation and retention
� modifying factors
� dental history
� medical history
� lifestyle
� socio-economic
status
� compliance
� modifying factors
� dental history
� medical history
� lifestyle
� socio-economic
status
� compliance
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (99))
‘‘TRAFFIC LIGHTTRAFFIC LIGHT’’
RISK ASSESSMENT MODELRISK ASSESSMENT MODEL
� ‘traffic light’ system
� colours convey levels of risk
� already used in dentistry, health education, food labelling
� allocates a threshold value for each risk category
� for caries, 16 criteria in five categories
� ‘traffic light’ system
� colours convey levels of risk
� already used in dentistry, health education, food labelling
� allocates a threshold value for each risk category
� for caries, 16 criteria in five categories
Thai Dental Association June 2009Thai Dental Association June 2009
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (3636))
MODIFYING FACTORS (5)MODIFYING FACTORS (5)
1. dental history
● active caries lesions
● restorations (past or current risk?)
2. medical history
● numerous medications � xerostomia, e.g.,
antidepressants; hypotensives;
anticholinergics; antipsychotics; diuretics;
anti-Parkinson
3. lifestyle
● caffeine, alcohol (diuretics)
● smoking (effect on saliva)
1. dental history
● active caries lesions
● restorations (past or current risk?)
2. medical history
● numerous medications � xerostomia, e.g.,
antidepressants; hypotensives;
anticholinergics; antipsychotics; diuretics;
anti-Parkinson
3. lifestyle
● caffeine, alcohol (diuretics)
● smoking (effect on saliva)
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (3737))
4. socio-economic status (SES)
● low SES may indicate low educational
level, thus low level of understanding
● financial issues
� cost of treatment
� cost of accessing treatment
5. compliance; depends on
● patient attitude
● practicality/appropriateness of treatment
plan
4. socio-economic status (SES)
● low SES may indicate low educational
level, thus low level of understanding
● financial issues
� cost of treatment
� cost of accessing treatment
5. compliance; depends on
● patient attitude
● practicality/appropriateness of treatment
plan
MODIFYING FACTORS (5)MODIFYING FACTORS (5)
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (3838))
ASSESSMENT OF MODIFYING FACTORSASSESSMENT OF MODIFYING FACTORS
� any drugs (OTC/Rx/recreational) which
reduce salivary flow?
� any diseases which result in dry mouth?
� fixed/removable appliances?
� recent active caries?
� poor compliance?
� any drugs (OTC/Rx/recreational) which
reduce salivary flow?
� any diseases which result in dry mouth?
� fixed/removable appliances?
� recent active caries?
� poor compliance?
NO to all above
YES to any ONE above
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (3939))
DAVID DAVID –– AGED 24AGED 24
� lives in unfluoridated town
� labourer on building site
� not well educated
� works outdoors in hot climate
� potential dehydration
� drinks low pH black cola drinks (‘Coca Cola’)
� frequent refined CHO intake
� poor oral hygiene
� poor attitude (parents F/F)
� lives in unfluoridated town
� labourer on building site
� not well educated
� works outdoors in hot climate
� potential dehydration
� drinks low pH black cola drinks (‘Coca Cola’)
� frequent refined CHO intake
� poor oral hygiene
� poor attitude (parents F/F)
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (4040))
DAVID DAVID –– AGED 24AGED 24
� diet (high acid; high CHO) - �
� fluoride exposure (nil) - �
� plaque (thick) - �
� dental history (poor attender) - �
� SES (low) - �
� attitude and compliance (poor) - �
� challenges
� risk factors: red � green
� diet (high acid; high CHO) - �
� fluoride exposure (nil) - �
� plaque (thick) - �
� dental history (poor attender) - �
� SES (low) - �
� attitude and compliance (poor) - �
� challenges
� risk factors: red � green
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (4141))
Modifying factorsModifying factors
FluorideFluoride
DietDiet
PlaquePlaque
SalivaSaliva
DAVID DAVID –– AGED 24AGED 24
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (4242))
Dr Douglas Bratthall
CARIOGRAM SCORE CARD
FREQUENCY OF INTAKE FREQUENCY OF INTAKE
OF FERMENTABLE OF FERMENTABLE
CARBOHYDRATECARBOHYDRATE
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (4343))www.db.od.mah.se/car/cariogram/cariograminfo.html
1
2
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (4444))
AGED CARE FACILITY AGED CARE FACILITY
Dr Jane ChalmersDr Jane ChalmersDr Jane ChalmersDr Jane Chalmers
Dr Jane ChalmersDr Jane Chalmers
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (4545))
SJOGRENSJOGREN’’S SYNDROMES SYNDROME
Dr MA Stacey, University of MelbourneDr MA Stacey, University of Melbourne
Dr MA Stacey, University of MelbourneDr MA Stacey, University of Melbourne
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (4646))
‘‘RADIATION CARIESRADIATION CARIES’’
Dr MA Stacey, University of MelbourneDr MA Stacey, University of Melbourne
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (4747))
ELEMENTS OF MINIMUM INTERVENTIONELEMENTS OF MINIMUM INTERVENTION
� the dentist as a physician (requires a knowledge of the
factors associated with the development of caries)
� individualised assessment of caries risk
� appropriate preventive strategies
� remineralisation/arrest of non-cavitated lesions
� the dentist as a surgeon (requires a knowledge of the
caries lesion)
� minimum surgical intervention of cavitated lesions
� appropriate maintenance of existing restorations
� the dentist as a physician (requires a knowledge of the
factors associated with the development of caries)
��� individualised assessment of caries riskindividualised assessment of caries riskindividualised assessment of caries risk
� appropriate preventive strategies
��� remineralisation/arrest of nonremineralisation/arrest of nonremineralisation/arrest of non---cavitated lesionscavitated lesionscavitated lesions
��� the dentist as a surgeon (requires a knowledge of the the dentist as a surgeon (requires a knowledge of the the dentist as a surgeon (requires a knowledge of the
caries lesion)caries lesion)caries lesion)
��� minimum surgical intervention of cavitated lesionsminimum surgical intervention of cavitated lesionsminimum surgical intervention of cavitated lesions
��� appropriate maintenance of existing restorationsappropriate maintenance of existing restorationsappropriate maintenance of existing restorations
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (4848))
ELEMENTS OF MINIMUM INTERVENTIONELEMENTS OF MINIMUM INTERVENTION
� the dentist as a physician (requires a knowledge of the
factors associated with the development of caries)
� individualised assessment of caries risk
� appropriate preventive strategies
� remineralisation/arrest of non-cavitated lesions
� the dentist as a surgeon (requires a knowledge of the
caries lesion)
� minimum surgical intervention of cavitated lesions
� appropriate maintenance of existing restorations
� the dentist as a physician (requires a knowledge of the
factors associated with the development of caries)
��� individualised assessment of caries riskindividualised assessment of caries riskindividualised assessment of caries risk
� remineralisation/arrest of non-cavitated lesions
��� the dentist as a surgeon (requires a knowledge of the the dentist as a surgeon (requires a knowledge of the the dentist as a surgeon (requires a knowledge of the
caries lesion)caries lesion)caries lesion)
��� minimum surgical intervention of cavitated lesionsminimum surgical intervention of cavitated lesionsminimum surgical intervention of cavitated lesions
��� appropriate maintenance of existing restorationsappropriate maintenance of existing restorationsappropriate maintenance of existing restorations
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (4949))
‘‘DEMINDEMIN--REMINREMIN’’ CYCLECYCLE
pHpH 6.06.0 5.55.5 5.05.0 4.54.5 4.04.0
pHpH 6.06.0 5.55.5 5.05.0 4.54.5 4.04.0
Critical pH Critical pH
of HAof HACritical pH Critical pH
of FAof FA
DEMINERALISATIONDEMINERALISATION
HA dissolves; FA HA dissolves; FA
forms if Fforms if F-- presentpresent
REMINERALISATIONREMINERALISATION
FA reformsFA reforms
FA and HA FA and HA
dissolvedissolve
If H+ neutralised, If H+ neutralised,
and Ca++ and and Ca++ and
POPO44---- presentpresent
FA and HA reformFA and HA reform
HH++ reacts with POreacts with PO44----
in saliva and plaque in saliva and plaque
Thai Dental Association June 2009Thai Dental Association June 2009
� 25+ years research by Reynolds et al. (Melbourne Dental School, University of Melbourne)
� based on milk protein
� ‘Recaldent’™ (Cadbury Schweppes)
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (5353))
CLINICAL APPLICATIONS OF CPPCLINICAL APPLICATIONS OF CPP--ACPACP
� CPP-ACP products
� ‘Recaldent’ chewing gum
� ‘Tooth Mousse’/ ‘MI Paste’ (GC, Japan)
� addition to glass-ionomer cement (Mazzaoui, Tyas et al.)
� � compressive strength
� � bond strength to dentine
� current work: addition to other GICs (Burrow et al.)
� CPP-ACP products
� ‘Recaldent’ chewing gum
� ‘Tooth Mousse’/ ‘MI Paste’ (GC, Japan)
� addition to glass-ionomer cement (Mazzaoui, Tyas et al.)
� � compressive strength
� � bond strength to dentine
� current work: addition to other GICs (Burrow et al.)
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (5454))
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (5555))
Clinical study of enamel de- and re-mineralization by chewing gum
Clinical study of enamel deClinical study of enamel de-- and reand re--mineralization by chewing gummineralization by chewing gum
� 2720 subjects (≈ 12.5 y old)
� Normal use of fluoride toothpaste, fluoridated water
� Sugar-free gum containing CPP-ACP; control gum
� randomly assigned, double blinded
� Gum chewed 3 x daily for 2 years
� Standardized digital radiographs at baseline and 24 months
� Caries progression/regression analyzed using a transition matrix
� 2720 subjects (≈ 12.5 y old)
� Normal use of fluoride toothpaste, fluoridated water
� Sugar-free gum containing CPP-ACP; control gum
� randomly assigned, double blinded
� Gum chewed 3 x daily for 2 years
� Standardized digital radiographs at baseline and 24 months
� Caries progression/regression analyzed using a transition matrix
Morgan et al. (2006) J Dent Res
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (5656))
Clinical study of enamel de- and re-
mineralization by chewing gum
Clinical study of enamel deClinical study of enamel de-- and reand re--
mineralization by chewing gummineralization by chewing gum
Recaldent in sugar-free gum
� significantly slowed progression
� promoted regression (remineralization)
�of dental caries relative to a control
sugar-free gum in school children
�in an optimally fluoridated city
�and using fluoride-containing toothpaste
Recaldent in sugar-free gum
� significantly slowed progression
� promoted regression (remineralization)
�of dental caries relative to a control
sugar-free gum in school children
�in an optimally fluoridated city
�and using fluoride-containing toothpaste
Morgan et al. (2006) J Dent Res
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Martin J Tyas (Martin J Tyas (5757))
MI PASTEMI PASTE
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Martin J Tyas (Martin J Tyas (5858))
BEFORE TREATMENTBEFORE TREATMENT
AFTER RECALDENTAFTER RECALDENT
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Martin J Tyas (Martin J Tyas (5959))
Prof L J Walsh, U of Q
Prof L J Walsh, U of Q
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Martin J Tyas (Martin J Tyas (6060))
CONCLUSIONCONCLUSIONCONCLUSION
RecaldentTM (CPP-ACP) technology
� remineralizes enamel subsurface lesions in situ
� slows the progression of coronal caries
� promotes regression of caries
CPP-ACP plus F (Tooth Mousse Plus)
� is a superior form of fluoride
� should be clinicians’ first choice
� for the prevention of caries and erosion
� for the treatment of dentinal hypersensitivity
� for the repair of ‘white spot’ lesions
RecaldentTM (CPP-ACP) technology
� remineralizes enamel subsurface lesions in situ
� slows the progression of coronal caries
� promotes regression of caries
CPP-ACP plus F (Tooth Mousse Plus)
� is a superior form of fluoride
� should be clinicians’ first choice
� for the prevention of caries and erosion
� for the treatment of dentinal hypersensitivity
� for the repair of ‘white spot’ lesions
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (6161))
RESIN INFILTRATIONRESIN INFILTRATION
� infiltration of non-cavitated lesions by
low viscosity polymerisable resin
� ‘Icon’; DMG Co, Hamburg
� several published laboratory studies
� clinical studies in progress
� infiltration of non-cavitated lesions by
low viscosity polymerisable resin
� ‘Icon’; DMG Co, Hamburg
� several published laboratory studies
� clinical studies in progress
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (6262))
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (6363))
Courtesy of DMG GmbHCourtesy of DMG GmbHCourtesy of DMG GmbH
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (6464))
ELEMENTS OF MINIMUM INTERVENTIONELEMENTS OF MINIMUM INTERVENTION
� the dentist as a physician (requires a knowledge of the
factors associated with the development of caries)
� individualised assessment of caries risk
� appropriate preventive strategies
� remineralisation/arrest of non-cavitated lesions
� the dentist as a surgeon (requires a knowledge of the
caries lesion)
� minimum surgical intervention of cavitated lesions
� appropriate maintenance of existing restorations
��� the dentist as a physician (requires a knowledge of the the dentist as a physician (requires a knowledge of the the dentist as a physician (requires a knowledge of the
factors associated with the development of caries)factors associated with the development of caries)factors associated with the development of caries)
��� individualised assessment of caries riskindividualised assessment of caries riskindividualised assessment of caries risk
WiegandWiegand & & AttinAttin, Dent Mater 2007;23:1461, Dent Mater 2007;23:1461--14671467
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (112112))
Lasfargues et al.Lasfargues et al.
SLOT PREPARATIONSLOT PREPARATION
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Martin J Tyas (Martin J Tyas (113113))
ELEMENTS OF MINIMUM INTERVENTIONELEMENTS OF MINIMUM INTERVENTION
� the dentist as a physician (requires a knowledge of the
factors associated with the development of caries)
� individualised assessment of caries risk
� appropriate preventive strategies
� remineralisation/arrest of non-cavitated lesions
� the dentist as a surgeon (requires a knowledge of the
caries lesion)
� minimum surgical intervention of cavitated lesions
� appropriate maintenance of existing restorations
��� the dentist as a physician (requires a knowledge of the the dentist as a physician (requires a knowledge of the the dentist as a physician (requires a knowledge of the
factors associated with the development of caries)factors associated with the development of caries)factors associated with the development of caries)
��� individualised assessment of caries riskindividualised assessment of caries riskindividualised assessment of caries risk
��� remineralisation/arrest of nonremineralisation/arrest of nonremineralisation/arrest of non---cavitated lesionscavitated lesionscavitated lesions
��� the dentist as a surgeon (requires a knowledge of the the dentist as a surgeon (requires a knowledge of the the dentist as a surgeon (requires a knowledge of the
caries lesion)caries lesion)caries lesion)
��� minimum surgical intervention of cavitated lesionsminimum surgical intervention of cavitated lesionsminimum surgical intervention of cavitated lesions
� appropriate maintenance of existing restorations
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (114114))
MANAGEMENT OF DEFECTIVE MANAGEMENT OF DEFECTIVE
RESTORATIONSRESTORATIONS
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (115115))
RESTORATION REPLACEMENTRESTORATION REPLACEMENT
� about 60% of a general practitioner’s time is spent replacing restorations
� most frequent reason is secondary caries
� replacement results in
� larger cavity
� damage to adjacent teeth
� increased risk of more complex restorations
� new defects introduced
� about 60% of a general practitioner’s time is spent replacing restorations
� most frequent reason is secondary caries
� replacement results in
� larger cavity
� damage to adjacent teeth
� increased risk of more complex restorations
� new defects introduced
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Martin J Tyas (Martin J Tyas (116116))
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (117117))
DIAGNOSIS OF SECONDARY CARIESDIAGNOSIS OF SECONDARY CARIES
� ‘ditched’ margins correlate poorly with secondary caries (Pimenta et al., JPD 1995;74:219, Rudolphy et al., Caries Res 1995;29:371
� only amalgam restorations with marginal defects > 0.4 mm wide should be replaced (Kidd et al., J Dent Res 1995;74:1206)
� ‘ditched’ margins correlate poorly with secondary caries (Pimenta et al., JPD 1995;74:219, Rudolphy et al., Caries Res 1995;29:371
� only amalgam restorations with marginal defects > 0.4 mm wide should be replaced (Kidd et al., J Dent Res 1995;74:1206)
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (118118))
OPTIONS FOR MANAGEMENTOPTIONS FOR MANAGEMENT
� recontour and/or polish
� fissure seal margins
� repair local defect
� replace restoration
� recontour and/or polish
� fissure seal margins
� repair local defect
� replace restoration
INCREASINGLYINCREASINGLY
INVASIVEINVASIVE
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Martin J Tyas (Martin J Tyas (120120))
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Martin J Tyas (Martin J Tyas (121121))
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Martin J Tyas (Martin J Tyas (124124))
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Martin J Tyas (Martin J Tyas (125125))
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Martin J Tyas (Martin J Tyas (126126))
SOME INDICATIONS FOR SOME INDICATIONS FOR
RESTORATION REPLACEMENTRESTORATION REPLACEMENT
�extensive secondary caries
�cannot be removed in a repair procedure
�aesthetic need
�pulpal pathology
� fixed prosthodontic procedure
�extensive secondary caries
�cannot be removed in a repair procedure
�aesthetic need
�pulpal pathology
� fixed prosthodontic procedure
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (127127))
TWENTIETH CENTURY (GV BLACK)TWENTIETH CENTURY (GV BLACK)
‘‘Extension for preventionExtension for prevention’’
TWENTYTWENTY--FIRST CENTURYFIRST CENTURY
‘‘Prevention of extensionPrevention of extension’’
OPERATIVE DENTISTRYOPERATIVE DENTISTRY
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Martin J Tyas (Martin J Tyas (128128))
Graham MountGraham Mount
Hien NgoHien Ngo
LawrieLawrie WalshWalsh
Sue GaffneySue Gaffney
John McIntyreJohn McIntyre
Eric ReynoldsEric Reynolds
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