Minimally Invasive Dentistry: Clinical Applications
MID (OR MICRODENTISTRY) IS A MINDSET
Every patient deserves to have the most recently advocated care that results in the most predictable outcome. The outcome includes the concept of longevity. When one considers that a small filling preserves strength in a tooth, it seems obvious that a small filling would be the treatment of choice where appropriate. However, this is not always the case. To do less is more, especially if one constantly has a mindset that sees every treatment plan as an opportunity to be less invasive. As an example, every root canal that saves a tooth is less invasive and more preserving than an extraction. Every implant placed between virgin teeth is more beneficial and predictable than a bridge. Every onlay preserves tooth structure compared to a crown. Every tunnel prep preserves a marginal ridge.
Each time a patient presents with a problem, whether it be a small area of decay or an edentulous ridge, an opportunity presents to perform the least invasive procedure for a good outcome. When the focus is on using technology to treat each condition, the outcome can be further enhanced. For example, detecting decay can set a basic standard of care. For more than a century, an explorer has been used along with x-rays to find caries.
However, research has shown that an explorer often does not find decay because of the nature of decay,1 especially with the new model indicating that cavitation takes place from the inside out.
Figure 1 is a photomicrograph of a non-cavitated groove that an explorer would not diagnose, yet the decay process is well underway. Further, because caries caused by streptococcus mutans and lactobacillus can be spread by inoculation from one tooth to another,2 an explorer is no longer the instrument of choice. Enter the use of laser florescence and the Diagnodent (KaVo) to find the degree of cavitation and provide confidence of measurement, leading to treating only that decay that meets a quantifiable standard. Why wait until the cavitation process has progressed further?
MANAGING THE PROBLEM
Once caries has been confirmed, CAMBRA (caries management by risk assessment), the new standard of care, needs to be implemented in every practice.
Before treating a tooth invasively, controlling the disease process that infected a tooth is paramount. By determining which habits, diets, and prevention methods a patient uses (or does not use) and by evaluating saliva flow and its bacterial count, a dentist can provide a plan for controlling the oral environment. For example, because caries is communicable, a family can rinse with Beta-iodine or Peridex (Zila) and reduce the quantity of S mutans and lactobacillus to a manageable level. Fluoride can be prescribed, and sealants can be applied. Xylitol chewing gum can cut lactic acid concentration by 22%. The total concept of prevention needs to be addressed before remedial care is rendered so the disease process will be under control.
TREATING PROBLEMS WITH TECHNOLOGY AND MID
Today, technology provides dentists with more options to provide less invasive care. Originally, microdentistry described treating small carious lesions by preparing the tooth for a composite restoration by using air abrasion. Over time, other modalities have come forth to attempt to do the same minimally invasive procedures, including ones advocating use of small “fissurotomy” burs and certain lasers. Regardless of the approach, the concept has become to prepare less, thus preserving more of the tooth. With this preservation comes the understanding that fewer teeth may break, resulting in fewer root canals, onlays, or crowns, and patients will have more predictable long-term outcomes. To dentistry’s benefit, fewer injections and less frequent drilling are predicted, thereby creating a whole generation of nonfearful adults.
The latest concept in treating periodontal disease includes the use of a peroscope of 48x magnification to see the accumulated calculus holding the bacteria that are causing the problem. With the visibility a Dental View affords, all the offending bacterial plaque can be removed. Dr. John Kwan, a periodontist and an expert with the use of perioscopy, reports that he has eliminated the majority of the surgery he used to perform. (Personal Communication with Dr. Kwan.)