Download - Minimum Intervention Tooth Remineralization
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Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (11))
MINIMUM INTERVENTIONMINIMUM INTERVENTION
DENTISTRYDENTISTRY ESSENTIALESSENTIALCONCEPTSCONCEPTS
Martin J TyasBDS, PhD, DDSc, GradDipHlthSc, FADM, FICD, FRACDS, FPFA, FADI
Professor and Head, Restorative Dentistry
Melbourne Dental SchoolThe University of Melbourne
Australia
Martin J TyasBDS, PhD, DDSc, GradDipHlthSc, FADM, FICD, FRACDS, FPFA, FADI
Professor and Head, Restorative Dentistry
Melbourne Dental SchoolThe University of Melbourne
Australia
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SUMMARYSUMMARY
overview of Minimum Intervention (MI)
definition of MI elements of MI
dental caries
caries risk assessment prevention
remineralisation (medical)
techniques operative (surgical) techniques
management of defective restorations
overview of Minimum Intervention (MI)
definition of MI
elements of MI
dental caries
caries risk assessment prevention
remineralisation (medical)
techniques operative (surgical) techniques
management of defective restorations
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Martin J Tyas (Martin J Tyas (33))
DEFINITION OF MIDEFINITION OF MI
an approach to the managementof dental caries with the aim of
minimising the loss of toothstructure by disease or by
iatrogenic intervention
an approach to the managementof dental caries with the aim of
minimising the loss of toothstructure by disease or by
iatrogenic intervention
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Martin J Tyas (Martin J Tyas (44))
IntInt Dent J 2000;50:1Dent J 2000;50:1--1212
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CONSENSUS STATEMENT (2007)
General Assembly of the World Congress of
Minimally Invasive DentistryMembers of the Western, Central, and Eastern
(US) Caries Management by Risk Assessment
(CAMBRA) CoalitionsADEA Cariology Special Interest Group
recognize the 2002 FDI Policy Statement asthe current clinical standard for caries
management
CONSENSUS STATEMENT (2007)
General Assembly of the World Congress of
Minimally Invasive DentistryMembers of the Western, Central, and Eastern
(US) Caries Management by Risk Assessment
(CAMBRA) CoalitionsADEA Cariology Special Interest Group
recognize the 2002 FDI Policy Statement asthe current clinical standard for caries
management
Tyas, Anusavice, Frencken & Mount.Tyas, Anusavice, Frencken & Mount. IntInt Dent J 2000;50:1Dent J 2000;50:1--1212
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Martin J Tyas (Martin J Tyas (66))
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 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
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Martin J Tyas (Martin J Tyas (77))
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 risk
appropriate preventive strategiesappropriate preventive strategiesappropriate 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 thethe dentist as a surgeon (requires a knowledge of thethe 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
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Martin J Tyas (Martin J Tyas (88))
MULTIFACTORIAL NATURE OF CARIESMULTIFACTORIAL NATURE OF CARIES
local factors
saliva (quality; quantity) diet
carbohydrateintake
frequency ofexposure toacids
exposure to fluoride
plaque accumulationand retention
local factors
saliva (quality; quantity) diet
carbohydrateintake
frequency ofexposure toacids
exposure to fluoride
plaque accumulationand retention
modifying factors
dental history
medical history
lifestyle
socio-economic
status
compliance
modifying factors
dental history
medical history
lifestyle
socio-economic
status
compliance
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Martin J Tyas (Martin J Tyas (99))
TRAFFIC LIGHTTRAFFIC LIGHTRISK 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
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Martin J Tyas (Martin J Tyas (1010))
GC (JAPAN)GC (JAPAN) TRAFFIC LIGHTTRAFFIC LIGHT SYSTEMSYSTEM
saliva five criteria
diet # of CHO
exposures/day
# of acid
exposures/day
saliva five criteria
diet # of CHO
exposures/day
# of acidexposures/day
fluoride exposure
past and current
plaque three criteria
modifying factors five criteria
fluoride exposurefluoride exposure
past and currentpast and current
plaqueplaque three criteriathree criteria
modifying factorsmodifying factors five criteriafive criteria
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Martin J Tyas (Martin J Tyas (1111))
SALIVA ANDSALIVA AND
DENTAL CARIESDENTAL CARIES
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Martin J Tyas (Martin J Tyas (1212))
SALIVA COMPOSITIONSALIVA COMPOSITION 99% water
bicarbonate (buffers to pH 6.7 7.4) inorganic ions (e.g, calcium, phosphate for
remineralisation)
enzymes: amylase, lipase, proteases,
nuclease
mucins (lubrication; clear bacteria) antibacterials (e.g., IgA, enzymes)
99% water
bicarbonate (buffers to pH 6.7 7.4) inorganic ions (e.g, calcium, phosphate for
remineralisation)
enzymes: amylase, lipase, proteases,
nuclease
mucins (lubrication; clear bacteria) antibacterials (e.g., IgA, enzymes)
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Martin J Tyas (Martin J Tyas (1313))
FUNCTIONS OF SALIVAFUNCTIONS OF SALIVA
lubrication
taste (by dissolving ions) health of oral mucosa (promotes wound
healing)
assists digestion
dilutes/clears material (e.g., carbohydrate)
buffers plaque and dietary acid
reservoir for calcium and phosphate
lubrication
taste (by dissolving ions) health of oral mucosa (promotes wound
healing)
assists digestion
dilutes/clears material (e.g., carbohydrate)
buffers plaque and dietary acid
reservoir for calcium and phosphate
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Martin J Tyas (Martin J Tyas (1414))
ASSESSMENT OF SALIVA (FIVE CRITERIA)ASSESSMENT OF SALIVA (FIVE CRITERIA)
unstimulated minor salivary gland function
viscosity
pH
stimulated
flow rate buffering capacity
GC Saliva Test kit
unstimulated minor salivary gland function
viscosity
pH
stimulated
flow rate buffering capacity
GC Saliva Test kit
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Martin J Tyas (Martin J Tyas (1515))
MINOR SALIVARY GLAND FUNCTIONMINOR SALIVARY GLAND FUNCTION
evert lower lip
dry with gauze
measure time for droplets to appear
at minor salivary gland orifices
single ply tissue may help
evert lower lip
dry with gauze
measure time for droplets to appear
at minor salivary gland orifices single ply tissue may help
> 60 s30 60 s
< 30 s
> 60 s> 60 s3030 60 s60 s
< 30 s< 30 s
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Martin J Tyas (Martin J Tyas (1616))
Ngo & GaffneyNgo & Gaffney
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Martin J Tyas (Martin J Tyas (1717))
VISCOSITYVISCOSITY
open mouth; check for pooling of saliva
lift tongue to palate; check for appearanceand shiny film on floor of mouth
web test: normal = 20 50 mm
open mouth; check for pooling of saliva
lift tongue to palate; check for appearanceand shiny film on floor of mouth
web test: normal = 20 50 mm
Thick, ropy, frothy, extended web testThick, ropy, frothy, extended web test
No visible pooling; a little stickyNo visible pooling; a little sticky
Watery with pooling; shiny thin filmWatery with pooling; shiny thin film
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Martin J Tyas (Martin J Tyas (1818))
Ngo & GaffneyNgo & Gaffney
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Martin J Tyas (Martin J Tyas (1919))
RED OR YELLOW LIGHT!RED OR YELLOW LIGHT!
causes of defective functionsevere dehydration
medicationhormonal imbalance
salivary gland pathology
causes of defective functionsevere dehydration
medicationhormonal imbalance
salivary gland pathology
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Martin J Tyas (Martin J Tyas (2020))
pHpH
dribble into container
insert pH paper
read after 10 s
dribble into container
insert pH paper
read after 10 s
< 5.8< 5.85.85.8 6.86.8
> 6.8> 6.8
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Martin J Tyas (Martin J Tyas (2121))
FLOW RATEFLOW RATE chew on paraffin wax for 5 minutes
collect salivameasure volume
wide variation among individuals
mean 1.6 mL/min
chew on paraffin wax for 5 minuteschew on paraffin wax for 5 minutes
collect salivacollect saliva measure volumemeasure volume
wide variation among individualswide variation among individuals
mean 1.6 mL/minmean 1.6 mL/min
< 3.5 mL< 3.5 mLAfter 5 min: 3.5After 5 min: 3.5 5 mL5 mL
> 5 mL> 5 mL
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Martin J Tyas (Martin J Tyas (2222))
BUFFERING CAPACITYBUFFERING CAPACITYability to neutralise acid
depends on level of bicarbonateuse saliva collected for flow rate
use test strip as directed
assess against colour standard
ability to neutralise acidability to neutralise acid
depends on level of bicarbonatedepends on level of bicarbonate use saliva collected for flow rateuse saliva collected for flow rate
use test strip as directeduse test strip as directed
assess against colour standardassess against colour standard
HighHigh
ModerateModerate
LowLow
IVOCLARIVOCLAR
1010 1212
66 99
00 55
GCGC
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Martin J Tyas (Martin J Tyas (2323))
MR CHAIWAT SATHORN 15-FEB-2009
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Martin J Tyas (Martin J Tyas (2424))
GC (JAPAN)GC (JAPAN) TRAFFIC LIGHTTRAFFIC LIGHT SYSTEMSYSTEM
saliva five criteria
diet # of CHO
exposures/day
# of acidexposures/day
salivasalivasaliva five criteriafive criteriafive criteria
dietdiet
# of CHO# of CHO
exposures/dayexposures/day
# of acid# of acidexposures/dayexposures/day
fluoride exposure
past and current
plaque three criteria
modifying factors five criteria
fluoride exposurefluoride exposurefluoride exposure
past and currentpast and currentpast and current
plaqueplaqueplaque three criteriathree criteriathree criteria
modifying factorsmodifying factorsmodifying factors
five criteriafive criteriafive criteria
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Martin J Tyas (Martin J Tyas (2525))
DIET: FREQUENCY OFDIET: FREQUENCY OFCARBOHYDRATE INTAKECARBOHYDRATE INTAKE
high CHO intake
immediate 2-4 point pH (depends on bacteria, plaquethickness, salivary buffering)
pH recovery; 20 min hours
high CHO intake
immediate 2-4 point pH (depends on bacteria, plaquethickness, salivary buffering)
pH recovery; 20 min hours
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Martin J Tyas (Martin J Tyas (2626))
DIET: FREQUENCY OF EXPOSUREDIET: FREQUENCY OF EXPOSURETO ACIDSTO ACIDS
non-bacterial acid sources
intrinsic acid (e.g., gastric reflux,
bulimia)
extrinsic acid (e.g., black cola
drinks, sports drinks) caries
erosion (corrosion)
non-bacterial acid sources
intrinsic acid (e.g., gastric reflux,
bulimia)
extrinsic acid (e.g., black cola
drinks, sports drinks) caries
erosion (corrosion)
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Martin J Tyas (Martin J Tyas (2727))
ASSESSMENT OF DIETASSESSMENT OF DIET
111
> 2> 2> 2
> 3> 3> 3
# ACID EXPOSURES# ACID EXPOSURES
BETWEEN MEALSBETWEEN MEALS
NilNilNil
> 1> 1> 1
> 2> 2> 2
# CHO EXPOSURES# CHO EXPOSURES
BETWEEN MEALSBETWEEN MEALS
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Martin J Tyas (Martin J Tyas (2828))
GC (JAPAN)GC (JAPAN) TRAFFIC LIGHTTRAFFIC LIGHT SYSTEMSYSTEM
saliva five criteria
diet # of CHO
exposures/day
# of acidexposures/day
salivasalivasaliva five criteriafive criteriafive criteria
dietdietdiet
# of CHO# of CHO# of CHO
exposures/dayexposures/dayexposures/day
# of acid# of acid# of acidexposures/dayexposures/dayexposures/day
fluoride exposure
past and current
plaque three criteria
modifying factors
five criteria
fluoride exposure past and current
plaqueplaqueplaque three criteriathree criteriathree criteria
modifying factorsmodifying factorsmodifying factors
five criteriafive criteriafive criteria
Th i D t l A i ti J 2009
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CLINICAL EFFECTS OF FLUORIDECLINICAL EFFECTS OF FLUORIDE
remineralisation of incipient enamel
caries (white spot lesion)
slow down/partly remineralise carious
dentine in cavitated lesion remineralise root caries lesion
hypermineralisationmost effective for smooth-surface
caries
remineralisation of incipient enamel
caries (white spot lesion)
slow down/partly remineralise carious
dentine in cavitated lesion remineralise root caries lesion
hypermineralisationmost effective for smooth-surface
caries
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Martin J Tyas (Martin J Tyas (3030))
EXPOSURE TO FLUORIDEEXPOSURE TO FLUORIDE
Water AND toothpasteWater AND toothpasteWater AND toothpaste
Water OR toothpasteWater OR toothpasteWater OR toothpaste
NilNilNil
EXPOSURE TO
FLUORIDE
EXPOSURE TOEXPOSURE TO
FLUORIDEFLUORIDE
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Martin J Tyas (Martin J Tyas (3131))
GC (JAPAN)GC (JAPAN) TRAFFIC LIGHTTRAFFIC LIGHT SYSTEMSYSTEM
saliva five criteria
diet
# of CHO
exposures/day
# of acidexposures/day
salivasalivasaliva five criteriafive criteriafive criteria
dietdietdiet
# of CHO# of CHO# of CHO
exposures/dayexposures/dayexposures/day
# of acid# of acid# of acidexposures/dayexposures/dayexposures/day
fluoride exposure
past and current
plaque three criteria
modifying factors
five criteria
fluoride exposurefluoride exposurefluoride exposure past and currentpast and currentpast and current
plaqueplaque three criteriathree criteria
modifying factorsmodifying factorsmodifying factors
five criteriafive criteriafive criteria
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Martin J Tyas (Martin J Tyas (3232))
ASSESSMENT OF BIOFILM (PLAQUE)ASSESSMENT OF BIOFILM (PLAQUE)
Plaque Check (GC Corporation) thickness/maturity
2-colour disclosing gelpink = thin, new plaque
blue = thick, mature plaque
sucrose challenge and resultant pH
Plaque Check (GC Corporation) thickness/maturity
2-colour disclosing gel
pink = thin, new plaquepink = thin, new plaque
blue = thick, mature plaqueblue = thick, mature plaque
sucrose challenge and resultant pH
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Martin J Tyas (Martin J Tyas (3333))
GC CorporationGC Corporation
DR HIEN NGODR HIEN NGO
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Martin J Tyas (Martin J Tyas (3434))
Ivoclar VivadentIvoclar Vivadent
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Martin J Tyas (Martin J Tyas (3535))CRT BufferCRT Buffer,, CRT BacteriaCRT Bacteria (Ivoclar Vivadent)(Ivoclar Vivadent)
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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-Parkinson3. 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)
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Martin J Tyas (Martin J Tyas (3737))
4. socio-economic status (SES)
low SES may indicate low educationallevel, 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 educationallevel, 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)
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Thai Dental Association June 2009a e a ssoc a o Ju e 009
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
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Martin J Tyas (Martin J Tyas (3939))
DAVIDDAVID 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)
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a e ta ssoc at o Ju e 009
Martin J Tyas (Martin J Tyas (4040))
DAVIDDAVID 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
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Martin J Tyas (Martin J Tyas (4141))
Modifying factorsModifying factors
FluorideFluoride
DietDiet
PlaquePlaque
SalivaSaliva
DAVIDDAVID AGED 24AGED 24
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Martin J Tyas (Martin J Tyas (4242))
Dr Douglas Bratthall
CARIOGRAM SCORE CARD
FREQUENCY OF INTAKEFREQUENCY OF INTAKE
OF FERMENTABLEOF FERMENTABLE
CARBOHYDRATECARBOHYDRATE
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Martin J Tyas (Martin J Tyas (4343))www.db.od.mah.se/car/cariogram/cariograminfo.html
1
2
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Martin J Tyas (Martin J Tyas (4444))
AGED CARE FACILITYAGED CARE FACILITY
Dr Jane ChalmersDr Jane ChalmersDr Jane ChalmersDr Jane Chalmers
Dr Jane ChalmersDr Jane Chalmers
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Martin J Tyas (Martin J Tyas (4545))
SJOGRENSJOGRENS SYNDROMES SYNDROME
Dr MA Stacey, University of MelbourneDr MA Stacey, University of Melbourne
Dr MA Stacey, University of MelbourneDr MA Stacey, University of Melbourne
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Martin J Tyas (Martin J Tyas (4646))
RADIATION CARIESRADIATION CARIES
Dr MA Stacey, University of MelbourneDr MA Stacey, University of Melbourne
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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 thethe dentist as a surgeon (requires a knowledge of thethe 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
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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
appropriate preventive strategiesappropriate preventive strategiesappropriate preventive strategies
remineralisation/arrest of non-cavitated lesions the dentist as a surgeon (requires a knowledge of thethe dentist as a surgeon (requires a knowledge of thethe 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
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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 pHCritical pH
of HAof HACritical pHCritical pH
of FAof FA
DEMINERALISATIONDEMINERALISATION
HA dissolves; FAHA dissolves; FA
forms if Fforms if F-- presentpresent
REMINERALISATIONREMINERALISATION
FA reformsFA reforms
FA and HAFA and HA
dissolvedissolve
If H+ neutralised,If H+ neutralised,
and Ca++ andand Ca++ andPOPO44---- presentpresentFA and HA reformFA and HA reform
HH++ reacts with POreacts with PO44----
in saliva and plaquein saliva and plaque
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Martin J Tyas (Martin J Tyas (5050))
FACTORS PROMOTINGFACTORS PROMOTING REMINREMIN
pH > 5.5phosphate ions
calcium ions
fluoride ions
pH > 5.5phosphate ions
calcium ions
fluoride ions
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Martin J Tyas (Martin J Tyas (5151))
Clinical use of calcium phosphates forremineralization not successful
Clinical use of calcium phosphates forClinical use of calcium phosphates for
remineralization not successfulremineralization not successful
insoluble calcium phosphates low solubility (particularly with F) not easily applied nor effectively
localized at tooth surface require acid for solubility to produce
remineralizing ions soluble calcium phosphates
can only be used at low concentrations do not effectively localize at tooth
surface
insoluble calcium phosphates
low solubility (particularly with F) not easily applied nor effectively
localized at tooth surface
require acid for solubility to produceremineralizing ions
soluble calcium phosphates
can only be used at low concentrations do not effectively localize at tooth
surface
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Martin J Tyas (Martin J Tyas (5252))
CALCIUM PHOSPHOPEPTIDE-AMORPHOUS CALCIUMPHOSPHATECALCIUM PHOSPHOPEPTIDECALCIUM PHOSPHOPEPTIDE--AMORPHOUS CALCIUMAMORPHOUS CALCIUMPHOSPHATEPHOSPHATE
casein phosphopeptide-amorphouscalcium phosphate (CPP-ACP)
25+ years research by Reynolds et
al. (Melbourne Dental School,University of Melbourne)
based on milk protein Recaldent (Cadbury Schweppes)
casein phosphopeptide-amorphouscalcium phosphate (CPP-ACP)
25+ years research by Reynolds et
al. (Melbourne Dental School,University of Melbourne)
based on milk protein Recaldent (Cadbury Schweppes)
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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.)
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Martin J Tyas (Martin J Tyas (5454))
Thai Dental Association June 2009Thai Dental Association June 2009
Cli i l t d f l d d
Cli i l t d f l dClinical study of enamel de dand re
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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, fluoridatedwater
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, fluoridatedwater
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
Morganet al.
(2006)J Dent Res
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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 controlsugar-free gum in school children
in an optimally fluoridated cityand using fluoride-containing toothpaste
Recaldent in sugar-free gum
significantly slowed progression
promoted regression (remineralization)
of dental caries relative to a controlsugar-free gum in school children
in an optimally fluoridated cityand 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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OBEFORE TREATMENT
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Martin J Tyas (Martin J Tyas (5858))
BEFORE TREATMENTBEFORE TREATMENT
AFTER RECALDENTAFTER RECALDENT
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Prof L J Walsh U of Q
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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
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Martin J Tyas (Martin J Tyas (6161))
RESIN INFILTRATIONRESIN INFILTRATION
infiltration of non-cavitated lesions bylow viscosity polymerisable resin
Icon; DMG Co, Hamburg several published laboratory studies
clinical studies in progress
infiltration of non-cavitated lesions bylow viscosity polymerisable resin
Icon; DMG Co, Hamburg several published laboratory studies
clinical studies in progress
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Martin J Tyas (Martin J Tyas (6262))
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Martin J Tyas (Martin J Tyas (6363))
Courtesy of DMG GmbHCourtesy of DMG GmbHCourtesy of DMG GmbH
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ELEMENTS OF MINIMUM INTERVENTIONELEMENTS OF MINIMUM INTERVENTION
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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 thethe dentist as a physician (requires a knowledge of thethe 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
appropriate preventive strategiesappropriate preventive strategiesappropriate 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
caries lesion)
minimum surgical intervention of cavitated lesions
appropriate maintenance of existing restorationsappropriate maintenance of existing restorationsappropriate maintenance of existing restorations
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Martin J Tyas (Martin J Tyas (6565))
GV BLACKGV BLACK
GreeneGreene VardimanVardiman
BLACK (1835BLACK (1835--1915)1915)
extensive research
on amalgam (DentalCosmos, 1896)
A Work onOperative Dentistry
in Two Volumes
(1908)
extensive research
on amalgam (DentalCosmos, 1896)
A Work on
Operative Dentistry
in Two Volumes
(1908)
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Martin J Tyas (Martin J Tyas (6666))
BLACKBLACKS TEACHINGSS TEACHINGS
highly formalised cavity designs;
precise size and geometry
weak, non-adhesive materials
extension for prevention
highly formalised cavity designs;
precise size and geometry
weak, non-adhesive materials
extension for prevention
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Martin J Tyas (Martin J Tyas (6767))
A Work on Operative DentistryA Work on Operative Dentistry
in Two Volumes (5in Two Volumes (5thth Ed, 1922)Ed, 1922)
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Martin J Tyas (Martin J Tyas (6868))
SURGICAL MODELSURGICAL MODEL (( 19001900 -- 1980s)1980s)
caries can be cured byexcision of all decayed tooth
structure, and replacement
with a filling material
now known to be incorrect
caries can be cured byexcision of all decayed tooth
structure, and replacementwith a filling material
now known to be incorrect
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Martin J Tyas (Martin J Tyas (6969))
STRUCTURALLY WEAKENED TOOTHSTRUCTURALLY WEAKENED TOOTH
NONNON--ADHESIVE RESTORATIVEADHESIVE RESTORATIVE
MATERIALMATERIAL
++
HIGH INCIDENCE OF SUBSEQUENTHIGH INCIDENCE OF SUBSEQUENT
TOOTH FRACTURETOOTH FRACTURE
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Martin J Tyas (Martin J Tyas (7070))
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Martin J Tyas (Martin J Tyas (7171))
WHATWHATS CHANGED?S CHANGED? enhanced understanding of the carious
process an infectious disease
demineralisation/remineralisation cycle
recognition of the rle of fluoride inhibiting demineralisation
enhancing remineralisation
development of adhesive materials glass-ionomer cement
resin-based materials
enhanced understanding of the cariousprocess
an infectious disease
demineralisation/remineralisation cycle
recognition of the rle of fluoride inhibiting demineralisation
enhancing remineralisation
development of adhesive materials glass-ionomer cement
resin-based materials
Thai Dental Association June 2009Thai Dental Association June 2009
MINIMUM INTERVENTION IN OPERATIVE
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Martin J Tyas (Martin J Tyas (7272))
MINIMUM INTERVENTION IN OPERATIVEMINIMUM INTERVENTION IN OPERATIVE
DENTISTRY (1990s ONWARDS)DENTISTRY (1990s ONWARDS)
remineralisation of non-cavitated lesions
arrest of active lesions
restoration (surgical treatment) only if
required for plaque control or aesthetics removal of caries only (infected
dentine)
restoration with adhesive materials
repair of defective restorations
remineralisation of non-cavitated lesions
arrest of active lesions
restoration (surgical treatment) only if
required for plaque control or aesthetics removal of caries only (infected
dentine)
restoration with adhesive materials
repair of defective restorations
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Martin J Tyas (Martin J Tyas (7373))
INDICATIONS FOR RESTORATIONINDICATIONS FOR RESTORATION((SURGICAL APPROACHSURGICAL APPROACH))
cavitation rendering
plaque control
unachievable
aesthetics
unsatisfactory function
compromised
cavitation rendering
plaque control
unachievable
aesthetics
unsatisfactory function
compromised
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Martin J Tyas (Martin J Tyas (7474))
ADHESIVEADHESIVE PREPARATIONSPREPARATIONS conservative cavity
macromechanical retention notrequired
reduction in microleakage
reduced incidence of secondary caries reduced marginal staining
reduced pulp damage
restoration of tooth strength
conservative cavity
macromechanical retention notrequired
reduction in microleakage
reduced incidence of secondary caries reduced marginal staining
reduced pulp damage
restoration of tooth strength
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Martin J Tyas (Martin J Tyas (7575))
DENTINE CARIES (DENTINE CARIES (FusayamaFusayama;; MasslerMassler))
infected (outer carious) dentine (A)
moist, soft, pale yellow heavy bacterial load
collagen degraded
non-remineralisable affected (inner carious) dentine (B)
dry, hard, brown/black
few or no bacteria
collagen cross-links intact
remineralisable
infected (outer carious) dentine (A)
moist, soft, pale yellow heavy bacterial load
collagen degraded
non-remineralisable affected (inner carious) dentine (B)
dry, hard, brown/black
few or no bacteria
collagen cross-links intact
remineralisable
AA
BB
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TREATMENT OF CARIOUS DENTINTREATMENT OF CARIOUS DENTIN
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Martin J Tyas (Martin J Tyas (7676))
ExperimentalExperimentalLaser photoLaser photo--ablationablationExperimentalExperimentalEnzymatic digestionEnzymatic digestion
Limited applicationsLimited applicationsChemoChemo--mechanical excavationmechanical excavation
ExperimentalExperimentalAir abrasionAir abrasionExperimentalExperimentalSonoSono--abrasionabrasion
ExperimentalExperimental
UnconvincingUnconvincing
Controlled selective rotary excavationControlled selective rotary excavation
torque control handpiecetorque control handpiece
polymer burspolymer burs
Gold standardGold standard but should bebut should be
modifiedmodifiedRotary excavationRotary excavation
Accepted procedureAccepted procedureManual excavationManual excavationEXCAVATION TECHNIQUESEXCAVATION TECHNIQUES
NoackNoack et al., Oral Health & Prev Dent 2004;2 (Supp 1):301et al., Oral Health & Prev Dent 2004;2 (Supp 1):301--306306
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TREATMENT OF CARIOUS DENTINTREATMENT OF CARIOUS DENTIN
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Martin J Tyas (Martin J Tyas (7777))
DISINFECTION TECHNIQUESDISINFECTION TECHNIQUES
Adjunctive to other methodsAdjunctive to other methodsAntibacterial therapyAntibacterial therapy
PromisingPromisingPhotodynamic therapyPhotodynamic therapy
Primary root cariesPrimary root caries
More research for other applicationsMore research for other applicationsOzoneOzone
SEALING TECHNIQUESSEALING TECHNIQUES
NoackNoack et al., Oral Health & Prev Dent 2004;2 (Supp 1):301et al., Oral Health & Prev Dent 2004;2 (Supp 1):301--306306
PromisingPromisingAntibacterial materialsAntibacterial materials
PromisingPromisingDentin adhesivesDentin adhesives
Limited acceptanceLimited acceptanceFluorideFluoride--releasingreleasing
materialsmaterials
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Martin J Tyas (Martin J Tyas (7878))
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Martin J Tyas (Martin J Tyas (7979))
EXCAVATE WITH FIRM PRESSURE UNTILEXCAVATE WITH FIRM PRESSURE UNTIL
HARD, DRY, DARK COLOURHARD, DRY, DARK COLOUR
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Martin J Tyas (Martin J Tyas (8080))
PRINCIPLES OF MINIMUM INTERVENTIONPRINCIPLES OF MINIMUM INTERVENTIONRESTORATIONSRESTORATIONS
remove only degraded enamel andinfected dentine
leave affected dentine
support undermined enamel by theadhesive restorative material
the cavity shape is dictated by the caries
and is unique Blacks formal cavity designs are obsolete
remove only degraded enamel and
infected dentine leave affected dentine
support undermined enamel by theadhesive restorative material
the cavity shape is dictated by the cariesand is unique
Blacks formal cavity designs are obsolete
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MANAGEMENT OF CARIOUS DENTINEMANAGEMENT OF CARIOUS DENTINE
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Martin J Tyas (Martin J Tyas (8181))
John Tomes (1859)
it is better that a layer ofdiscoloured dentine should be
allowed to remain for theprotection of the pulp rather
than run the risk of sacrificingthe tooth
John Tomes (1859)
it is better that a layer ofdiscoloured dentine should be
allowed to remain for theprotection of the pulp rather
than run the risk of sacrificingthe tooth
Thai Dental Association June 2009Thai Dental Association June 2009
When removing caries make the enamelWhen removing caries make the enamel--dentine junctiondentine junction
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Martin J Tyas (Martin J Tyas (8282))
When removing caries make the enamel-dentine junctionhard
Excavate demineralized dentine over the pulpal surface to
the level of firm dentine provided there is no likelihood of
pulpal exposureDeep lesions, in symptomless vital teeth, should be gently
excavated. Soft demineralized dentine may remain where its
removal might expose the pulp
Where it is not possible to remove soft, infected dentine(perhaps the patient is anxious or not cooperative), seal in
the infected dentine. A permanent restoration is placed. Do
not re-enter
In a symptomless, vital tooth, this should have a highsuccess rate.
gg jj
hardhard
Excavate demineralized dentine over the pulpal surface toExcavate demineralized dentine over the pulpal surface to
the level of firm dentine provided there is no likelihood ofthe level of firm dentine provided there is no likelihood of
pulpal exposurepulpal exposure
Deep lesions, in symptomless vital teeth, should be gentlyDeep lesions, in symptomless vital teeth, should be gently
excavated. Soft demineralized dentine may remain where itsexcavated. Soft demineralized dentine may remain where its
removal might expose the pulpremoval might expose the pulp
Where it is not possible to remove soft, infected dentineWhere it is not possible to remove soft, infected dentine
(perhaps the patient is anxious or not cooperative),(perhaps the patient is anxious or not cooperative), sealseal inin
the infected dentine. A permanent restoration is placed. Dothe infected dentine. A permanent restoration is placed. Do
not renot re--enterenter
In aIn a symptomless, vital toothsymptomless, vital tooth, this should have a high, this should have a high
success rate.success rate.
Kidd EAM, Essentials of Dental Caries, 3Kidd EAM, Essentials of Dental Caries, 3rdrd EdEd
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Martin J Tyas (Martin J Tyas (8383))
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Martin J Tyas (Martin J Tyas (8484))
ADHESIVE MATERIALSADHESIVE MATERIALS
resin composite
highly effective to enamel questionable to dentine
excellent mechanical properties
glass-ionomer
highly effective to enamel
highly effective to dentine brittle
resin composite
highly effective to enamel questionable to dentine
excellent mechanical properties
glass-ionomer
highly effective to enamel
highly effective to dentine brittle
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Martin J Tyas (Martin J Tyas (8585))
GLASSGLASS--IONOMER CEMENTSIONOMER CEMENTS
significant properties in
minimum intervention dentistry achieves reliable adhesion
may prevent secondarycaries
may remineralise affecteddentine
significant properties insignificant properties in
minimum intervention dentistryminimum intervention dentistry achieves reliable adhesionachieves reliable adhesion
may prevent secondarymay prevent secondarycariescaries
may remineralise affectedmay remineralise affecteddentinedentine
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Martin J Tyas (Martin J Tyas (8686))
Ngo,Ngo, inin Mount 2002Mount 2002
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MINIMAL INTERVENTION APPROACHESMINIMAL INTERVENTION APPROACHES
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Martin J Tyas (Martin J Tyas (
8787
))
MINIMAL INTERVENTION APPROACHESMINIMAL INTERVENTION APPROACHES
occlusal surfaces fissure sealant
preventive resin restoration
posterior approximal surfaces
tunnel and internal
preparations
slot preparations
occlusal surfaces
fissure sealant
preventive resin restoration
posterior approximal surfaces
tunnel and internal
preparations
slot preparations
Thai Dental Association June 2009Thai Dental Association June 2009
PREVENTIVE RESIN RESTORATIONPREVENTIVE RESIN RESTORATION
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Martin J Tyas (Martin J Tyas (8888))
Dr Hien Ngo
Adelaide
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FISSUROTOMY BURSFISSUROTOMY BURS
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Martin J Tyas (Martin J Tyas (8989))
FISSUROTOMY BURSFISSUROTOMY BURS
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Martin J Tyas (Martin J Tyas (9090))
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Martin J Tyas (Martin J Tyas (9191))
GICGIC
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Martin J Tyas (Martin J Tyas (9292))
Thai Dental Association June 2009Thai Dental Association June 2009
THE APPROXIMAL CAVITYTHE APPROXIMAL CAVITY
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Martin J Tyas (Martin J Tyas (9393))
THE APPROXIMAL CAVITYTHE APPROXIMAL CAVITY
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E1
OUTER HALF OF ENAMEL
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Martin J Tyas (Martin J Tyas (9494))
E2
INNER HALF OF ENAMEL
D1
JUST INTO DENTINE
APPLY TOPICAL FLUORIDE
AND MONITOR
APPLY TOPICAL FLUORIDE
AND MONITOR
D2
OUTER 1/3 OF DENTINE
DO NOT RESTORE
WITHOUT FURTHER
CONSIDERATION
DO NOT RESTORE
WITHOUT FURTHER
CONSIDERATION
D3
INNER 2/3 OF DENTINE RESTORE NOWRESTORE NOW
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EVOLUTION OF THE APPROXIMAL CAVITYEVOLUTION OF THE APPROXIMAL CAVITY
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Martin J Tyas (Martin J Tyas (9595))
Soderholm,Soderholm,
Tyas & Jokstad.Tyas & Jokstad.
Crit Rev OralCrit Rev Oral BiolBiolMedMed
1998;9:4641998;9:464--7979
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Martin J Tyas (Martin J Tyas (9696))
TUNNEL AND INTERNAL
PREPARATIONS
TUNNELTUNNEL ANDAND INTERNALINTERNAL
PREPARATIONSPREPARATIONS
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Martin J Tyas (Martin J Tyas (9797))
Jinks GM, J Dent Child 1963;30:87Jinks GM, J Dent Child 1963;30:87--9292
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TUNNEL AND INTERNALTUNNEL AND INTERNAL
PREPARATIONSPREPARATIONS
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Martin J Tyas (Martin J Tyas (9898))
PREPARATIONSPREPARATIONS
access through marginal fossa to
approximal caries
maintains marginal ridge
tunnel preparation cavity exits into approximal space
internal preparation
demineralised approximal enamel
retained
access through marginal fossa to
approximal caries
maintains marginal ridge
tunnel preparation cavity exits into approximal space
internal preparation
demineralised approximal enamel
retained
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Martin J Tyas (Martin J Tyas (9999))
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Martin J Tyas (Martin J Tyas (100100))
Thai Dental Association June 2009Thai Dental Association June 2009
INTERNALINTERNALPREPARATIONPREPARATION
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PREPARATIONPREPARATION
INTERNAL
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INTERNALINTERNALPREPARATIONPREPARATION
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Martin J Tyas (Martin J Tyas (102102))
PREPARATION
1.5 mm
INTERNAL
Thai Dental Association June 2009Thai Dental Association June 2009
CONDITION (PAA)CONDITION (PAA)
INTERNALINTERNAL
PREPARATIONPREPARATION
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Martin J Tyas (Martin J Tyas (103103))
CONDITION (PAA)CONDITION (PAA)
WASH; DRY; PLACEWASH; DRY; PLACE S/CS/C GICGIC
INTERNAL
Thai Dental Association June 2009Thai Dental Association June 2009
ETCH (PHOSPHORIC ACID); WASH; DRYETCH (PHOSPHORIC ACID); WASH; DRY
INTERNALINTERNAL
PREPARATIONPREPARATION
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Martin J Tyas (Martin J Tyas (104104))
APPLY BOND; BLOW THIN; CURE;APPLY BOND; BLOW THIN; CURE;
PLACE COMPOSITE; (PLACE SEALANT); CURE; APPLYPLACE COMPOSITE; (PLACE SEALANT); CURE; APPLY
NEUTRAL FLUORIDENEUTRAL FLUORIDE
INTERNAL
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TUNNEL PREPARATIONTUNNEL PREPARATION
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Martin J Tyas (Martin J Tyas (105105))
GICGICGIC
AFFECTED DENTINEAFFECTED DENTINEAFFECTED DENTINE
COMPOSITECOMPOSITECOMPOSITE
3 mm
Thai Dental Association June 2009Thai Dental Association June 2009
TUNNELTUNNEL
PREPARATIONPREPARATION
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Martin J Tyas (Martin J Tyas (106106))
Thai Dental Association June 2009Thai Dental Association June 2009
CLINICAL REVIEW OF TUNNEL AND INTERNAL
RESTORATIONS
CLINICAL REVIEW OFCLINICAL REVIEW OF TUNNELTUNNEL ANDAND INTERNALINTERNAL
RESTORATIONSRESTORATIONS
15 clinical trials in permanent teeth reviewed 15 clinical trials in permanent teeth reviewed
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Martin J Tyas (Martin J Tyas (107107))
p
57 90% success up to 3 years
main reasons for failure caries
marginal ridge fracture
placement of resin composite over GIC does notincrease fracture resistance of marginal ridge
failure in one study
3 y 10%; 5 y 65%
p
57 90% success up to 3 years
main reasons for failure caries
marginal ridge fracture
placement of resin composite over GIC does notincrease fracture resistance of marginal ridge
failure in one study
3 y 10%; 5 y 65%
WiegandWiegand && AttinAttin, Dent Mater 2007;23:1461, Dent Mater 2007;23:1461--14671467
Thai Dental Association June 2009Thai Dental Association June 2009
median survival times median survival times
CLINICAL REVIEW OF TUNNEL AND INTERNAL
RESTORATIONS
CLINICAL REVIEW OFCLINICAL REVIEW OF TUNNELTUNNEL ANDAND INTERNALINTERNAL
RESTORATIONSRESTORATIONS
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Martin J Tyas (Martin J Tyas (108108))WiegandWiegand && AttinAttin, Dent Mater 2007;23:1461, Dent Mater 2007;23:1461--14671467
GIC tunnel 6 y
resin composite approximal up to 9 y amalgam approximal up to 13 y
annual failure rate
GIC tunnel 7-10%
GIC approximal 7-10%
resin composite approximal 2.3%
amalgam approximal 3.3%
GIC tunnel 6 y
resin composite approximal up to 9 y amalgam approximal up to 13 y
annual failure rate
GIC tunnel 7-10%
GIC approximal 7-10%
resin composite approximal 2.3%
amalgam approximal 3.3%
Thai Dental Association June 2009Thai Dental Association June 2009
f t ff ti factors affecting success
CLINICAL REVIEW OF TUNNEL AND INTERNAL
RESTORATIONS
CLINICAL REVIEW OFCLINICAL REVIEW OF TUNNELTUNNEL ANDAND INTERNALINTERNAL
RESTORATIONSRESTORATIONS
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Martin J Tyas (Martin J Tyas (109109))WiegandWiegand && AttinAttin, Dent Mater 2007;23:1461, Dent Mater 2007;23:1461--14671467
factors affecting success
tooth type, lesion size, tunnel or internal: equivocal
data on influence on performance preservation of approximal enamel in internal
preparation may support ridge, BUT
complete caries removal more difficult to assess in
internal preparation
strong operator influence
9 50% failure among 12 dentists
median survival 40 65 mo among 5 dentists
factors affecting success
tooth type, lesion size, tunnel or internal: equivocal
data on influence on performance preservation of approximal enamel in internal
preparation may support ridge, BUT
complete caries removal more difficult to assess in
internal preparation
strong operator influence
9 50% failure among 12 dentists
median survival 40 65 mo among 5 dentists
Thai Dental Association June 2009Thai Dental Association June 2009
CLINICAL REVIEW OF TUNNEL AND INTERNAL
RESTORATIONS
CLINICAL REVIEW OFCLINICAL REVIEW OF TUNNELTUNNEL ANDAND INTERNALINTERNAL
RESTORATIONSRESTORATIONS
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Martin J Tyas (Martin J Tyas (110110))WiegandWiegand && AttinAttin, Dent Mater 2007;23:1461, Dent Mater 2007;23:1461--14671467
influence of caries activity
conflicting data on success v caries
activity
one trial: higher failure of GICrestorations (no resin composite over
GIC) in high caries active patients
influence of caries activity
conflicting data on success v caries
activity
one trial: higher failure of GICrestorations (no resin composite over
GIC) in high caries active patients
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Thai Dental Association June 2009Thai Dental Association June 2009
SLOT PREPARATIONSLOT PREPARATION
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Martin J Tyas (Martin J Tyas (112112))
Lasfargues et al.Lasfargues et al.
Thai Dental Association June 2009Thai Dental Association June 2009
ELEMENTS OF MINIMUM INTERVENTIONELEMENTS OF MINIMUM INTERVENTION
th d ti t h i i ( i k l d f th the dentist as a physician (requires a knowledge of thethe dentist as a physician (requires a knowledge of thethe dentist as a physician (requires a knowledge of the
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Martin J Tyas (Martin J Tyas (113113))
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 thethe dentist as a physician (requires a knowledge of thethe 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 appropriate preventive strategiesappropriate preventive strategiesappropriate 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 thethe dentist as a surgeon (requires a knowledge of thethe 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
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Martin J Tyas (Martin J Tyas (114114))
MANAGEMENT OF DEFECTIVEMANAGEMENT OF DEFECTIVE
RESTORATIONSRESTORATIONS
Thai Dental Association June 2009Thai Dental Association June 2009
RESTORATION REPLACEMENTRESTORATION REPLACEMENT
b t 60% f l titi ti
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Martin J Tyas (Martin J Tyas (115115))
about 60% of a general practitioners timeis 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 practitioners timeis 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
Thai Dental Association June 2009Thai Dental Association June 2009
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Martin J Tyas (Martin J Tyas (116116))
Thai Dental Association June 2009Thai Dental Association June 2009
DIAGNOSIS OF SECONDARY CARIESDIAGNOSIS OF SECONDARY CARIES
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Martin J Tyas (Martin J Tyas (117117))
ditched margins correlate poorly with
secondary caries (Pimenta et al., JPD1995;74:219, Rudolphy et al., Caries Res1995;29:371
only amalgam restorations withmarginal defects > 0.4 mm wide shouldbe replaced (Kidd et al., J Dent Res1995;74:1206)
ditched margins correlate poorly with
secondary caries (Pimenta et al., JPD1995;74:219, Rudolphy et al., Caries Res1995;29:371
only amalgam restorations withmarginal defects > 0.4 mm wide shouldbe replaced (Kidd et al., J Dent Res1995;74:1206)
Thai Dental Association June 2009Thai Dental Association June 2009
OPTIONS FOR MANAGEMENTOPTIONS FOR MANAGEMENT
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Martin J Tyas (Martin J Tyas (118118))
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
Thai Dental Association June 2009Thai Dental Association June 2009
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Martin J Tyas (Martin J Tyas (119119))
Thai Dental Association June 2009Thai Dental Association June 2009
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Martin J Tyas (Martin J Tyas (120120))
Thai Dental Association June 2009Thai Dental Association June 2009
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121/129
Martin J Tyas (Martin J Tyas (121121))
Thai Dental Association June 2009Thai Dental Association June 2009
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122/129
Martin J Tyas (Martin J Tyas (122122))
Thai Dental Association June 2009Thai Dental Association June 2009
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Martin J Tyas (Martin J Tyas (123123))
Thai Dental Association June 2009Thai Dental Association June 2009
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124/129
Martin J Tyas (Martin J Tyas (124124))
Thai Dental Association June 2009Thai Dental Association June 2009
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Martin J Tyas (Martin J Tyas (125125))
Thai Dental Association June 2009Thai Dental Association June 2009
SOME INDICATIONS FORSOME INDICATIONS FOR
RESTORATION REPLACEMENTRESTORATION REPLACEMENT
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Martin J Tyas (Martin J Tyas (126126))
extensive secondary cariescannot be removed in a
repair procedure
aesthetic need
pulpal pathology
fixed prosthodontic procedure
extensive secondary caries
cannot be removed in arepair procedure
aesthetic need
pulpal pathology
fixed prosthodontic procedure
Thai Dental Association June 2009Thai Dental Association June 2009
OPERATIVE DENTISTRYOPERATIVE DENTISTRY
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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
Thai Dental Association June 2009Thai Dental Association June 2009
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Martin J Tyas (Martin J Tyas (128128))
Graham MountGraham MountHien NgoHien Ngo
LawrieLawrie WalshWalsh
Sue GaffneySue GaffneyJohn McIntyreJohn McIntyre
Eric ReynoldsEric Reynolds
Thai Dental Association June 2009Thai Dental Association June 2009
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Martin J Tyas (Martin J Tyas (129129))