Minimally Invasive Dentistry 101

Minimally Invasive Dentistry 101

Dentalcompare: If a patient with a not-particularly-high dental IQ asked you to explain the Minimally Invasive Dentistry philosophy, how would you answer in 100 words or less?

“The MID philosophy is to diagnose caries and gum disease and treat their infections before they cause damage.”

Graeme Milicich: A facetious, but very quick comment I sometimes use to get patient’s attention is “How would you like to stop transferring money from your retirement fund into mine?” I then explain that the minimally invasive dentistry philosophy is to diagnose if the patient has the diseases that cause cavities and gum disease and then treat their infection before it has a chance to cause damage--just like your physician identifies heart risks like high blood pressure and cholesterol and helps you manage them so you can live a longer and healthier life. If damage like cavities and gum problems have started, our next aim is to identify them as early as possible in the process and fix the damage with techniques using advanced diagnostic and treatment technologies, and materials that help maintain the strength of the teeth, to prevent expensive re-treatment that is associated with teeth fracturing later in life because they were over-prepared.

DC: Now craft a 100-word explanation for a seasoned but relatively traditional restorative dentist.

“It is preferable to treat the disease--dental caries--rather than treat the consequences, which are cavities and abscesses.”

GM: Contrary to our longstanding paradigms, the fact is we cannot simply brush and floss oral diseases away. Caries and periodontal disease are complex biofilm diseases, with caries being more complex from a bacteriological perspective, and periodontal health being complicated by varying types of genetic predisposition. The goal now is to identify individual risk factors and behaviors, and then teach patients a specific and focused management program based on their identified problems. It is preferable to treat the disease--dental caries--rather than treat the consequences, which are cavities and abscesses.

I have been having amazing clinical success with the Carifree program This unique system is based on correcting the primary caries selection pressure of low pH, which changes a healthy biofilm to a cariogenic one. The Carifree program can be tailored to a patient’s specific needs. When surgical intervention is required because irreversible damage has occurred, the goal is to identify the damage early though accurate diagnostic methods and then treat as minimally as possible incorporating remineralization and surface protection strategies using biomimetic materials like MI Paste Plus and autocure GICs like Fuji Triage and Fuji IX.

DC: Over the past several years, what have been the most significant product developments and new technologies that have promoted and advanced the practice of the minimally invasive dentistry approach?

“Lasers are minimizing the level of surgical invasion required in treating periodontal disease.”

GM: Minimally invasive dentistry really started out backwards. The initial focus was on managing the side effects of the disease we know as caries. Early detection of dental damage from the caries infection has been developed, using products like caries detection dye, digital radiography with software enhancements like Logicon, and laser fluorescence. Currently several types of products are on the market, with the KaVo DIAGNOdent being the most common. Once irreversible damage has been accurately detected, technologies like magnification using loupes and operating microscopes, air abrasion (which in my opinion is still one of the best if you have a more advanced unit with fine tips), microprep burs, and hard tissue lasers like the Waterlase MD have allowed for more precise and accurate removal of damaged tooth structure and controlled tissue contouring in perio cases, to a level we have never had before. LANAP, the new laser-assisted-new-attachment-procedure, is another example of where lasers are minimizing the level of surgical invasion required in treating periodontal disease. This type of minimal removal approach could not have occurred if adhesive restorative technology in the form of bonded resins and self-adhesive glass ionomers had not been available.

When we take one step back in the disease cycle, there has to be a change in the state of the oral biofilm from healthy to diseased before damage can occur. The ultimate goal is to identify this change in the biofilm status before it has caused any irreversible damage to either the periodontal structures or the teeth. This has been one of the primary focuses of the World Congress of Minimally Invasive Dentistry for the last 9 years.

DC: How would you characterize the general level of awareness among U.S. dental practitioners on ways to implement minimally invasive protocol?

“We have been suffering from traditional surgical approaches to treating bacterial biofilm infections, which have proven to be ineffective.”

GM: The general US dental awareness and adoption of MI philosophies and treatment protocols appears to be a bit behind many other places in the world. Interestingly, my stomping ground of New Zealand has the highest per capita utilization of air abrasion, laser fluorescence diagnosis with the DIAGNOdent, hard and soft tissue lasers and MI applications of glass ionomers.

Regarding dental caries, there are two phases to MI implementation by the dental profession. The first is focused on disease diagnosis and risk factor management, and the second is the treatment of early non-cavitated, and early cavitated lesions. It appears the second phase is more advanced and has been adopted better in the US than the first phase, which is a reflection of where the profession in general has advanced from. Overall, as a profession, we have been suffering from traditional surgical approaches to treating bacterial biofilm infections, which have proven to be ineffective over the last 100 years.

DC: Are dental schools adapting curriculum to a minimally invasive philosophy?

GM: Many already have, and most all of them are trying to figure out how to incorporate the principles. In the area of caries risk assessment, this has been adopted by most dental schools and is being practiced on the clinic floor as standard of care on every patient. This last year the Western Regional Board exam also included caries risk assessment for every patient being treated during the exam. This year there will be probably close to 40 dental schools represented at the CAMBRA Coalition meeting held in conjunction with theWCMID meeting in Chicago. Many schools are now also members of the WCMID as they see this organization being at the forefront in the evolution of minimally invasive dentistry in the profession.

DC: Are there any third party coverage challenges for doctors who opt for minimally invasive treatment?

GM: While this has been an issue in the past, the new CDT VII includes many new procedure codes for minimally invasive diagnostic, and therapeutic procedures. These include: D0145: Oral Evaluation for children less than 3 years of age, and counseling with the primary caregiver. D0415: Bacteriology Studies.
D0421 Genetic test for susceptibility to oral diseases. D0425 Caries Susceptibility Test. D1206 Topical Fluoride Varnish: therapeutic application for moderate to high-risk caries patients. D1310: Nutritional counseling for control of dental disease. Many contracts have these procedures included and as a result many patients have coverage for this level of care. I expect to see the number of diagnostic and preventive services continue to grow, as the public and profession realize the benefit from this kind of care.

DC: What research and development in the MID field are you aware of coming down the pipeline?

“Ozone is another area of great interest. It is a very powerful broad spectrum antibacterial, antifungal gas.”

GM: There are several areas in MID that are beginning to gain serious traction. Probably the most significant is in the area of caries risk assessment and the treatment of caries from a medical model. The emerging scientific evidence is based on the continuing advances in the understanding of how biofilms behave and how we can successfully modify them to help them return to a healthy state from a current diseased state. My personal experience has been in adopting the CAMBRA model developed by John Featherstone et al, modifying it to fit a private practice environment, and incorporating the new Carifree system into my practice. This is the first system I have found that has been able to offer real time chairside screening of a dental surface biofilm within 15 seconds that assess the levels of all cariogenic bacteria in a biofilm. The clinical results from the Carifree biofilm treatment program have been outstanding. GC also have a monoclonal antibody test that will assess salivary planktonic Mutans Streptococci CFU’s in about five minutes.

The Carifree system recognizes that the selection pressure that causes a biofilm to change from healthy to cariogenic is low pH, not sugar availability. The system combines a cycle of mouth rinses of elevated pH with elevated pH oral gel, and a between-meals elevated pH oral spray, and buffering capable xylitol gum, combined with patient specific advice that is collated from an initial clinical assessment of the patient.

If biofilm assessment is not being done, the first clinical evidence of biofilm disease (caries) is demineralization in the form of white spots and contact point radiolucencies on radiographs. GC’s MI Plus paste has been engineered to provides significant pool of calcium phosphate and fluoride ions in the correct ratios, to aid in remineralization. However, this will not occur unless the local environment is conducive to remineralization. Therefore, the biofilm disease has to be dealt with concurrently for a positive outcome is to occur.

Ozone is another area of great interest. It is a very powerful broad spectrum antibacterial, antifungal gas. Ozone is very effective in dealing with biofilms. Current applications under investigation include not only local surface applications as with the KaVo Healozone unit (Editor’s note: This unit is awaiting 510k market clearance from the U.S. FDA), but also total arch ozonation using custom fabricated tray systems. I believe this type of application will have merit, and will have to be combined with identification of patient specific risk factors and behaviors and the counseling this will need if long-term success is to be achieved.

Research is also occurring using target specific immunologically based “smart bombs” that are being designed to selectively destroy target bacterial species. Developments in this area will be interesting when we consider there are at least 29 species of bacteria and Candida albicans, amongst an existing total oral species population of 700 types of bacteria, that have been implicated in the caries process. There are probably many more to come as the dental biofilm continues to be investigated.

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