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14th June 2013

Minimally Invasive Dentistry

For those of you reading this, imagine a relationship with patients in which we are really saving teeth and not just repairing damage.  Imagine a style of dentistry where we avoid doing fillings at all if possible and when restoration is required, we negotiate a means of repair which keeps drilling to a minimum and quite often doesn`t require an injection.  Futuristic?

Well not so, Minimally Invasive Dentistry, or MID, has been around for some time but is becoming more mainstream now.  MID is not a prescriptive term and means different things to different people.  However, the principles are concerned with prevention, remineralisation and conserving tooth structure.  It has been described variously as “a systematic respect for the original tissue” and less formally as “the dentistry dentists would want for their families”!  What is certain is that once patients understand the concept they are very interested in the idea and it can be a big practice-builder.  Doing less repairs doesn`t mean earning less either, this state-of-the-art dentistry can reduce the number of minutes needed to earn UDAs in NHS practice, it can also become an added source of income in Independent practice.  Further, it`s a tool for patient retention across the board.

In it`s purest sense, MID is concerned with Prevention of Caries through risk assessment and targeting of advice.  Indices such as saliva buffering (pH of saliva) and host levels of Strep Mutans bacteria, combined with analysis of dietary and other habits, give a good indication of caries risk.  Susceptible people can then be targeted with useful preventative advice and coached in good care, without using valuable time working with patients at low risk.  Discussion of the indices and risk factors raises patients` awareness of all those bad things and can `join up the dots` in preventative practice.

Where you might not want to go to those lengths, but still in good MID practice, Xrays, transillumination and visual acuity are used to identify early carious lesions. There are also devices which can identify early caries, before any more conventional methods.  These devices use Laser-Induced Phosphorescence to indicate tooth surfaces which are affected by early, and quite often invisible, de-mineralisation.  These are relatively affordable tools to add to the kit we normally have handy.  The idea is to catch caries before cavitation has started and reverse the process, so saving the downhill spiral of fillings through life on the same tooth.  Re-mineralisation can be achieved with a variety of products, including simple fluoride.

Once a cavity has been identified, though, it is important to keep damage to the minimum.  Air abrasion techniques can remove early caries without the need for anaesthetic and is so much better tolerated as a technique because there is no sound either.  The only downside is the fine white powder, not something to do in a black uniform!  The advent of adhesive materials has meant that drilling can be kept to simple access, if at all, and many early spots treated with simple sealants.  It is so satisfying to see a patient`s smiley face when they say “Is that it?”

On a more macroscopic level, MID principles drive the choice of conventional restoration.  There is a movement towards full mouth rehabilitation with multiple crown and veneer preparations.  Much of this is quite destructive to tooth hard tissue.  For instance, a crown preparation can destroy 75% of a visible tooth.  Using MID principles, restoration choice favours adhesive composite techniques to alter tooth shape and colour, so avoiding preparation if possible.  For simple gaps, damage from erosion and unsightly large anterior restorations, adhesive dentistry can give someone their smile back in one visit.  Even in more complex cases (using a combination of orthodontics, bleaching and adhesive restorations), multiple crowns and veneers can be avoided.  If anyone has been to a talk by Restorative Consultant, Martin Kelleher, they will have a good idea of these principles as Martin does not `mince words`.  If you haven`t yet, his lectures are both informative and entertaining!

Finally, there is a more unexpected area of clinical dentistry for which there is a place for Minimally Invasive Dentistry -  in Endodontics.  Protecting the vitality of the canal tissue if at all possible is paramount, so MID practices include pulpectomies, pulp capping and the `stepwise` technique for avoiding carious exposure of a potentially vital tooth.

We are being advised that informed consent in dental practice is an important principle too.  If patients are not informed of the choices of treatments (and the risks of each one) in a given situation, it is agreed that full and proper consent cannot be given.  Evaluation of Risk concerning caries is more than just a valid consideration at an examination, it is essential. Patients need to be informed of preventative choices and techniques as much as restorative procedures.  Where restoration is the only choice, the pros and cons of crowns versus adhesive composite restorations need to be spelt out.  Once informed, it is the patient`s responsibility to make a decision, but that decision is only as good as the information you have provided.  However, without all the talk,  consent is not valid and this can come back and haunt you later as the result of a complaint about something completely different.

Minimally Invasive Dentistry is potentially a `practice builder` as well as a tool for patient retention.  It is relatively easy to market this approach, through your existing database of patients and through external means.  I know a lot of dentists who have fun in getting out of the surgery and giving talks to local groups and speaking on local radio about different aspects of their practices.  Invest in some time outside the practice and become a `local expert` on Minimally Invasive Dentistry.  Use a Practice Newsletter to inform and invite patients to ask you about it.

In conclusion, think `conservatively`, which choice is going to give the best result for least tissue destruction.  There is lots of evidence base out there too, just use the Google reference library!

Dr John Shapter

Topics: Dentists

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