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Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (11))
MINIMUM INTERVENTION MINIMUM INTERVENTION
DENTISTRY DENTISTRY –– ESSENTIAL ESSENTIAL
CONCEPTSCONCEPTS
Martin J TyasBDS, PhD, DDSc, GradDipHlthSc, FADM, FICD, FRACDS, FPFA, FADI
Professor and Head, Restorative Dentistry
Melbourne Dental School
The University of Melbourne
Australia
Martin J TyasBDS, PhD, DDSc, GradDipHlthSc, FADM, FICD, FRACDS, FPFA, FADI
Professor and Head, Restorative Dentistry
Melbourne Dental School
The University of Melbourne
Australia
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (22))
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
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (33))
DEFINITION OF MIDEFINITION OF MI
�an approach to the management
of dental caries with the aim of
minimising the loss of tooth
structure by disease or by
iatrogenic intervention
�an approach to the management
of dental caries with the aim of
minimising the loss of tooth
structure by disease or by
iatrogenic intervention
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (44))
IntInt Dent J 2000;50:1Dent J 2000;50:1--1212
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (55))
CONSENSUS STATEMENT (2007)
General Assembly of the World Congress of
Minimally Invasive Dentistry
Members of the Western, Central, and Eastern
(US) Caries Management by Risk Assessment
(CAMBRA) Coalitions
ADEA Cariology Special Interest Group
recognize the 2002 FDI Policy Statement 5 as
the current clinical standard for caries
management
CONSENSUS STATEMENT (2007)
General Assembly of the World Congress of
Minimally Invasive Dentistry
Members of the Western, Central, and Eastern
(US) Caries Management by Risk Assessment
(CAMBRA) Coalitions
ADEA Cariology Special Interest Group
recognize the 2002 FDI Policy Statement 5 as
the 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
Thai Dental Association June 2009Thai Dental Association June 2009
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
Thai Dental Association June 2009Thai Dental Association June 2009
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 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
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 acid
exposures/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
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (1111))
SALIVA AND SALIVA AND
DENTAL CARIESDENTAL CARIES
Thai Dental Association June 2009Thai Dental Association June 2009
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)
Thai Dental Association June 2009Thai Dental Association June 2009
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
Thai Dental Association June 2009Thai Dental Association June 2009
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
Thai Dental Association June 2009Thai Dental Association June 2009
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 s
30 – 60 s
< 30 s
> 60 s> 60 s
30 30 –– 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 appearance
and 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 appearance
and 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 function
�severe dehydration
�medication
�hormonal imbalance
�salivary gland pathology
�causes of defective function
�severe dehydration
�medication
�hormonal imbalance
�salivary gland pathology
Thai Dental Association June 2009Thai Dental Association June 2009
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< 5.8
5.8 5.8 –– 6.86.8
> 6.8> 6.8
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (2121))
FLOW RATEFLOW RATE� chew on paraffin wax for 5 minutes
� collect saliva
� measure 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 mL
After 5 min: 3.5 After 5 min: 3.5 –– 5 mL5 mL
> 5 mL> 5 mL
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (2222))
BUFFERING CAPACITYBUFFERING CAPACITY
�ability to neutralise acid
�depends on level of bicarbonate
�use 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
10 10 –– 1212
6 6 –– 99
0 0 –– 55
GCGC
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (2323))
MR CHAIWAT SATHORN 15-FEB-2009
���� �������� ����
����
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (2424))
GC (JAPAN) GC (JAPAN) ‘‘TRAFFIC LIGHTTRAFFIC LIGHT’’ SYSTEMSYSTEM
� saliva
� five criteria
� diet
� # of CHO
exposures/day
� # of acid
exposures/day
��� salivasalivasaliva
��� five criteriafive criteriafive criteria
�� dietdiet
�� # of CHO # of CHO
exposures/dayexposures/day
�� # of acid # of acid
exposures/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 OF DIET: FREQUENCY OF
CARBOHYDRATE INTAKECARBOHYDRATE INTAKE
� high CHO intake
� immediate 2-4 point pH �(depends on bacteria, plaque
thickness, salivary buffering)
� pH recovery; 20 min – hours
� high CHO intake
� immediate 2-4 point pH �(depends on bacteria, plaque
thickness, salivary buffering)
� pH recovery; 20 min – hours
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (2626))
DIET: FREQUENCY OF EXPOSURE DIET: FREQUENCY OF EXPOSURE
TO 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
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (2828))
GC (JAPAN) GC (JAPAN) ‘‘TRAFFIC LIGHTTRAFFIC LIGHT’’ SYSTEMSYSTEM
� saliva
� five criteria
� diet
� # of CHO
exposures/day
� # of acid
exposures/day
��� salivasalivasaliva
��� five criteriafive criteriafive criteria
��� dietdietdiet
��� # of CHO # of CHO # of CHO
exposures/dayexposures/dayexposures/day
��� # of acid # of acid # of acid
exposures/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
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (2929))
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
�� hypermineralisation
� most 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
�� hypermineralisation
� most effective for smooth-surface
caries
Thai Dental Association June 2009Thai Dental Association June 2009
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 TO EXPOSURE TO
FLUORIDEFLUORIDE
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (3131))
GC (JAPAN) GC (JAPAN) ‘‘TRAFFIC LIGHTTRAFFIC LIGHT’’ SYSTEMSYSTEM
� saliva
� five criteria
� diet
� # of CHO
exposures/day
� # of acid
exposures/day
��� salivasalivasaliva
��� five criteriafive criteriafive criteria
��� dietdietdiet
��� # of CHO # of CHO # of CHO
exposures/dayexposures/dayexposures/day
��� # of acid # of acid # of acid
exposures/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
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (3232))
ASSESSMENT OF BIOFILM (PLAQUE)ASSESSMENT OF BIOFILM (PLAQUE)
� Plaque Check (GC Corporation)
� thickness/maturity
� 2-colour disclosing gel
�pink = 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
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (3333))
GC CorporationGC Corporation
DR HIEN NGODR HIEN NGO
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (3434))
Ivoclar VivadentIvoclar Vivadent
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (3535))‘‘CRT BufferCRT Buffer’’, , ‘‘CRT BacteriaCRT Bacteria’’ (Ivoclar Vivadent)(Ivoclar Vivadent)
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
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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
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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 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
��� appropriate preventive strategiesappropriate preventive strategiesappropriate preventive strategies
� 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
Martin J Tyas (Martin J Tyas (5050))
FACTORS PROMOTING FACTORS PROMOTING ‘‘REMINREMIN’’
�pH > 5.5
�phosphate ions
�calcium ions
�fluoride ions
�pH > 5.5
�phosphate ions
�calcium ions
�fluoride ions
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (5151))
Clinical use of calcium phosphates for
remineralization not successful
Clinical use of calcium phosphates for Clinical 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 produce
remineralizing ions� soluble calcium phosphates
� can only be used at low concentrations� do not effectively localize at tooth
surface
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (5252))
CALCIUM PHOSPHOPEPTIDE-AMORPHOUS CALCIUM
PHOSPHATE
CALCIUM PHOSPHOPEPTIDECALCIUM PHOSPHOPEPTIDE--AMORPHOUS CALCIUM AMORPHOUS CALCIUM
PHOSPHATEPHOSPHATE
� casein phosphopeptide-amorphous calcium 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-amorphous calcium phosphate (CPP-ACP)
� 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
Thai Dental Association June 2009Thai Dental Association June 2009
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
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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
��� 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
Greene Greene VardimanVardiman
BLACK (1835BLACK (1835--1915)1915)
� extensive research
on amalgam (Dental
Cosmos, 1896)
� A Work on
Operative Dentistry
in Two Volumes
(1908)
� extensive research
on amalgam (Dental
Cosmos, 1896)
� A Work on
Operative Dentistry
in Two Volumes
(1908)
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (6666))
BLACKBLACK’’S 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’
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (6767))
A Work on Operative Dentistry A 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’’ ((≈≈≈≈≈≈≈≈ 1900 1900 -- 1980s)1980s)
�caries can be ‘cured’ by
excision of all decayed tooth
structure, and replacement
with a filling material
�now known to be incorrect
�caries can be ‘cured’ by
excision of all decayed tooth
structure, and replacement
with a filling material
�now known to be incorrect
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (6969))
STRUCTURALLY WEAKENED TOOTHSTRUCTURALLY WEAKENED TOOTH
NONNON--ADHESIVE RESTORATIVE ADHESIVE RESTORATIVE
MATERIALMATERIAL
++
HIGH INCIDENCE OF SUBSEQUENT HIGH INCIDENCE OF SUBSEQUENT
TOOTH FRACTURETOOTH FRACTURE
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Martin J Tyas (Martin J Tyas (7070))
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (7171))
WHATWHAT’’S CHANGED?S CHANGED?
� enhanced understanding of the carious process
� an infectious disease
� demineralisation/remineralisation cycle
� recognition of the rôle of fluoride
� inhibiting demineralisation
� enhancing remineralisation
� development of adhesive materials
� glass-ionomer cement
� resin-based materials
� enhanced understanding of the carious process
� an infectious disease
� demineralisation/remineralisation cycle
� recognition of the rôle 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
Martin J Tyas (Martin J Tyas (7272))
MINIMUM INTERVENTION IN OPERATIVE MINIMUM 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
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (7373))
INDICATIONS FOR RESTORATION INDICATIONS FOR RESTORATION
((‘‘SURGICAL APPROACHSURGICAL APPROACH’’))
� cavitation rendering
plaque control
unachievable
� aesthetics
unsatisfactory
� function
compromised
� cavitation rendering
plaque control
unachievable
� aesthetics
unsatisfactory
� function
compromised
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (7474))
‘‘ADHESIVEADHESIVE’’ PREPARATIONSPREPARATIONS
� conservative cavity
� macromechanical retention not required
� reduction in microleakage
� reduced incidence of secondary caries
� reduced marginal staining
� reduced pulp damage
� restoration of tooth strength
� conservative cavity
� macromechanical retention not required
� reduction in microleakage
� reduced incidence of secondary caries
� reduced marginal staining
� reduced pulp damage
� restoration of tooth strength
Thai Dental Association June 2009Thai Dental Association June 2009
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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Martin J Tyas (Martin J Tyas (7676))
TREATMENT OF CARIOUS DENTINTREATMENT OF CARIOUS DENTIN
ExperimentalExperimentalLaser photoLaser photo--ablationablation
ExperimentalExperimentalEnzymatic digestionEnzymatic digestion
Limited applicationsLimited applicationsChemoChemo--mechanical excavationmechanical excavation
ExperimentalExperimentalAir abrasionAir abrasion
ExperimentalExperimentalSonoSono--abrasionabrasion
ExperimentalExperimental
UnconvincingUnconvincing
Controlled selective rotary excavationControlled selective rotary excavation
torque control handpiecetorque control handpiece
polymer burspolymer burs
‘‘Gold standardGold standard’’ –– but should be but should be
modifiedmodifiedRotary excavationRotary excavation
Accepted procedureAccepted procedureManual excavationManual excavation
EXCAVATION 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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Martin J Tyas (Martin J Tyas (7777))
TREATMENT OF CARIOUS DENTINTREATMENT OF CARIOUS DENTINDISINFECTION 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--releasing releasing
materialsmaterials
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Martin J Tyas (Martin J Tyas (7878))
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (7979))
EXCAVATE WITH FIRM PRESSURE UNTIL EXCAVATE WITH FIRM PRESSURE UNTIL
HARD, DRY, DARK COLOURHARD, DRY, DARK COLOUR
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (8080))
PRINCIPLES OF MINIMUM INTERVENTION PRINCIPLES OF MINIMUM INTERVENTION
RESTORATIONSRESTORATIONS
� remove only degraded enamel and ‘infected’ dentine
� leave ‘affected’ dentine
� support undermined enamel by the adhesive restorative material
� the cavity shape is dictated by the caries and is unique
� Black’s ‘formal’ cavity designs are obsolete
� remove only degraded enamel and ‘infected’ dentine
� leave ‘affected’ dentine
� support undermined enamel by the adhesive restorative material
� the cavity shape is dictated by the caries and is unique
� Black’s ‘formal’ cavity designs are obsolete
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (8181))
MANAGEMENT OF CARIOUS DENTINEMANAGEMENT OF CARIOUS DENTINE
�John Tomes (1859)
� ‘it is better that a layer of
discoloured dentine should be
allowed to remain for the
protection of the pulp rather
than run the risk of sacrificing
the tooth’
�John Tomes (1859)
� ‘it is better that a layer of
discoloured dentine should be
allowed to remain for the
protection of the pulp rather
than run the risk of sacrificing
the tooth’
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (8282))
When removing caries make the enamel-dentine junction
hard
Excavate demineralized dentine over the pulpal surface to
the level of firm dentine provided there is no likelihood of
pulpal exposure
Deep 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 high
success rate.
When removing caries make the enamelWhen removing caries make the enamel--dentine junction dentine junction
hardhard
Excavate demineralized dentine over the pulpal surface to Excavate demineralized dentine over the pulpal surface to
the level of firm dentine provided there is no likelihood of the level of firm dentine provided there is no likelihood of
pulpal exposurepulpal exposure
Deep lesions, in symptomless vital teeth, should be gently Deep lesions, in symptomless vital teeth, should be gently
excavated. Soft demineralized dentine may remain where its excavated. 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 dentine Where 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 in in
the infected dentine. A permanent restoration is placed. Do the infected dentine. A permanent restoration is placed. Do
not renot re--enterenter
In a In 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
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (8585))
GLASSGLASS--IONOMER CEMENTSIONOMER CEMENTS
� significant properties in minimum intervention dentistry
� achieves reliable adhesion
� may prevent secondary caries
� may remineralise affected dentine
�� significant properties in significant properties in minimum intervention dentistryminimum intervention dentistry
�� achieves reliable adhesionachieves reliable adhesion
�� may prevent secondary may prevent secondary cariescaries
�� may remineralise affected may remineralise affected dentinedentine
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Martin J Tyas (Martin J Tyas (8686))
Ngo, Ngo, inin Mount 2002Mount 2002
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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
Martin J Tyas (Martin J Tyas (8888))
Dr Hien Ngo
Adelaide
PREVENTIVE RESIN RESTORATIONPREVENTIVE RESIN RESTORATION
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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))
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (9191))
GICGIC
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Martin J Tyas (Martin J Tyas (9292))
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Martin J Tyas (Martin J Tyas (9393))
THE APPROXIMAL CAVITYTHE APPROXIMAL CAVITY
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (9494))
E1
OUTER HALF OF ENAMEL
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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Martin J Tyas (Martin J Tyas (9595))
EVOLUTION OF THE APPROXIMAL CAVITYEVOLUTION OF THE APPROXIMAL CAVITY
Soderholm,Soderholm,
Tyas & Jokstad.Tyas & Jokstad.
Crit Rev Oral Crit Rev Oral BiolBiol
MedMed
1998;9:4641998;9:464--7979
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Martin J Tyas (Martin J Tyas (9696))
‘TUNNEL’ AND ‘INTERNAL’
PREPARATIONS
‘‘TUNNELTUNNEL’’ AND AND ‘‘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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Martin J Tyas (Martin J Tyas (9898))
TUNNEL AND INTERNAL TUNNEL AND INTERNAL
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
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (9999))
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (100100))
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (101101))
INTERNALINTERNAL
PREPARATIONPREPARATION
INTERNAL
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Martin J Tyas (Martin J Tyas (102102))
INTERNALINTERNAL
PREPARATIONPREPARATION
≥ 1.5 mm
INTERNAL
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Martin J Tyas (Martin J Tyas (103103))
CONDITION (PAA)CONDITION (PAA)
INTERNALINTERNAL
PREPARATIONPREPARATION
WASH; DRY; PLACE WASH; DRY; PLACE S/C S/C GICGIC
INTERNAL
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Martin J Tyas (Martin J Tyas (104104))
ETCH (PHOSPHORIC ACID); WASH; DRYETCH (PHOSPHORIC ACID); WASH; DRY
APPLY BOND; BLOW THIN; CURE;APPLY BOND; BLOW THIN; CURE;
PLACE COMPOSITE; (PLACE SEALANT); CURE; APPLY PLACE COMPOSITE; (PLACE SEALANT); CURE; APPLY
NEUTRAL FLUORIDENEUTRAL FLUORIDE
INTERNALINTERNAL
PREPARATIONPREPARATION
INTERNAL
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (105105))
TUNNEL PREPARATIONTUNNEL PREPARATION
GICGICGIC
AFFECTED DENTINEAFFECTED DENTINEAFFECTED DENTINE
COMPOSITECOMPOSITECOMPOSITE
≥ 3 mm
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Martin J Tyas (Martin J Tyas (106106))
TUNNELTUNNEL
PREPARATIONPREPARATION
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Martin J Tyas (Martin J Tyas (107107))
CLINICAL REVIEW OF ‘TUNNEL’ AND ‘INTERNAL’
RESTORATIONS
CLINICAL REVIEW OF CLINICAL REVIEW OF ‘‘TUNNELTUNNEL’’ AND AND ‘‘INTERNALINTERNAL’’
RESTORATIONSRESTORATIONS
� 15 clinical trials in permanent teeth reviewed
� 57 – 90% success up to 3 years
� main reasons for failure
� caries
� marginal ridge fracture
� placement of resin composite over GIC does not
increase fracture resistance of marginal ridge
� failure in one study
� 3 y – 10%; 5 y – 65%
� 15 clinical trials in permanent teeth reviewed
� 57 – 90% success up to 3 years
� main reasons for failure
� caries
� marginal ridge fracture
� placement of resin composite over GIC does not
increase 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
Martin J Tyas (Martin J Tyas (108108))WiegandWiegand & & AttinAttin, Dent Mater 2007;23:1461, Dent Mater 2007;23:1461--14671467
� median survival times
� 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%
� median survival times
� 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%
CLINICAL REVIEW OF ‘TUNNEL’ AND ‘INTERNAL’
RESTORATIONS
CLINICAL REVIEW OF CLINICAL REVIEW OF ‘‘TUNNELTUNNEL’’ AND AND ‘‘INTERNALINTERNAL’’
RESTORATIONSRESTORATIONS
Thai Dental Association June 2009Thai Dental Association June 2009
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
CLINICAL REVIEW OF ‘TUNNEL’ AND ‘INTERNAL’
RESTORATIONS
CLINICAL REVIEW OF CLINICAL REVIEW OF ‘‘TUNNELTUNNEL’’ AND AND ‘‘INTERNALINTERNAL’’
RESTORATIONSRESTORATIONS
Thai Dental Association June 2009Thai Dental Association June 2009
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 GIC
restorations (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 GIC
restorations (no resin composite over
GIC) in high caries active patients
CLINICAL REVIEW OF ‘TUNNEL’ AND ‘INTERNAL’
RESTORATIONS
CLINICAL REVIEW OF CLINICAL REVIEW OF ‘‘TUNNELTUNNEL’’ AND AND ‘‘INTERNALINTERNAL’’
RESTORATIONSRESTORATIONS
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Martin J Tyas (Martin J Tyas (111111))
OVERALL CONCLUSIONOVERALL CONCLUSIONOVERALL CONCLUSION
� clinical success may be related to
� mechanical strength of cavity
� characteristics of restorative material
� operator skill
� patient caries activity
� demanding procedure requiring practice
� rubber dam; lighting; magnification
� clinical success may be related to
� mechanical strength of cavity
� characteristics of restorative material
� operator skill
� patient caries activity
� demanding procedure requiring practice
� rubber dam; lighting; magnification
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
��� 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 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
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Martin J Tyas (Martin J Tyas (114114))
MANAGEMENT OF DEFECTIVE MANAGEMENT OF DEFECTIVE
RESTORATIONSRESTORATIONS
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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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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)
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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))
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (122122))
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (123123))
Thai Dental Association June 2009Thai Dental Association June 2009
Martin J Tyas (Martin J Tyas (124124))
Thai Dental Association June 2009Thai Dental Association June 2009
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
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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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