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 International Journal of Clinical Preventive Dentistry Volume 9, Number 2, June 2013

Minimally Invasive Dentistry - A Review

Kumar Raghav Gujjar and Neha Sumra
Department of Pediatric Dentistry, Seema Dental College & Hospital, Rishikesh, India

Advances in instrumentation, materials & technique have enabled the clinicians, a transition from G.V. Blacks "Extension for
prevention" to "Prevention of extension" approach in caries management. The concept of "minimally invasive dentistry"can
be defined as maximal preservation of healthy dental structure. It focuses on prevention, remineralization & minimal dentist
intervention. Dentists are currently spending most of their time replacing old restorations. This paper focuses on describing
minimally invasive dentistry from a conceptual perspective, relating to goals, objectives, principles, clinical caries diagnosis,
restorative intervention threshold and operative procedures.

Keywords: prevention, remineralization, MID, ART, PRR

Introduction pects in preparation to gain cavity access using air-abrasion, la-

Miles Markley, one of eminent leaders in preventive dentistry,
summarized the contemporary concept in the treatment of den-
tal caries: that the loss of even a part of a human tooth should
be considered a serious injury, and that dentistrys goal today
should be to preserve healthy, natural tooth structure (1).
Background
Minimally-invasive treatment in dentistry was pioneered in
the early 1970s with the application of diammine silver fluoride
(2). This was followed by the development of the preventive res-
in restoration (PRR) (3) in 1978 and the atraumatic restorative
treatment (ART) (4) in 1980s approach and chemo-mechanical
caries removal concepts (5) in the 1990s. The ultraconservative
treatment concepts in MID as shown in Figure 1 are applied with
the intention to preserve as much tooth tissue as possible and
to offer more patient-friendly care to fearful patients. Minimally-
invasive, long-term repair of tooth cavities may comprise as-
Corresponding author Kumar Raghav Gujjar
Department of Pediatric Dentistry, Seema Dental College,
Virbhadra Road, Rishikesh, [249203], India. Tel: +91-135-
2454440, Fax: +91-135-2453743, E-mail: drrags80@gmail.com
Received January, 17, 2012, Revised December, 14, 2012,
Accepted December, 14, 2012
ser treatment, or sonoabrasion (6-8) and excavation of infected
carious tooth tissue through selective caries removal or laser
treatment (6,8), as well as cavity restoration by applying ART,
PRR, or sandwich restoration treatment protocols (3,4,9,10). In
comparison to the traditional treatment modality using amal-
gam, MI restorations are usually smaller and its procedures con-
sidered being relatively painless, often without the need for lo-
cal anesthetics. However, if needed, local anesthetic can be ad-
ministered less invasively by using computer-controlled local
anesthetic delivery systems (11). Failed restorations are re-
paired rather than replaced (12).
Martin et al. (2000) have applied the term minimal inter-
vention, minimally invasive or preservative dentistry which
was earlier named as Prophylactic Odontomy. MID can be
defined as a philosophy of professional care concerned with
first occurrence, earliest possible cure of disease on micro
(molecular) levels, followed by minimally invasive & patient
friendly treatment to repair irreversible damage caused by such
disease (9). Based on MI understanding, tooth caries is consid-
ered to be a multifactor disease resulting in lesions of the tooth
hard tissues (12). The disease process has been well explained
by the Extended- Ecological Plaque Hypothesis as in Figure 2,
which shows the relation between acidogenic & aciduric shift
in composition of dental biofilm microflora & changes in min-
eral balance of dental hard tissues. Sequence of event is rever-
sible & reflected in surface features of dental hard tissues (13).

109
International Journal of Clinical Preventive Dentistry
Figure 1. Shows ultraconservative treatment concepts in MID.
Goals of Minimal Intervention Include
1. Prevention of caries.
2. Reduction in cariogenic bacteria.
3. Remineralization of early lesions.
4. Minimum surgical intervention of cavitated lesion.
5. Repair rather than replacement of defective restorations
Objectives Include
1. Identification
a) Evaluation of saliva.
b) Evaluation of caries activity.
c) Assessing occlusion & other tooth factors.
d) Understanding patient environment like socioeconomic
condition.
e) Health & education.
f) Diet analysis & counselling.
2. Prevention
a) Combating caries inducing microorganism.
b) Modify caries promoting ingredient & use sugar substitute
(Xylitol).
c) Increase resistance of teeth to decay.
3. Control
Identification
1. Evaluation of saliva
Normally saliva is supersaturated with calcium & phosphorus
110 Vol. 9, No. 2, June 2013
Figure 2. Shows extended ecological plaque hypothesis.
with respect to enamel surface which prevent hydroxyapatite
H
from dissolving in oral environment as long as p of environ-
ment is maintained. Various parameters used for evaluation of
saliva are illustrated in Table 1 (14).
2. Caries activity test
Caries activity is a measure of speed of progression of a carious
lesion. Various caries activity tests are used nowadays including
some traditional tests as mentioned in Table 2 (15) & some new-
er methods as mentioned in Table 3 (16-18).
3. Assessing occlusion & other tooth factors
For a number of decades, the prime area of concern has been
reducing the incidence & prevalence of caries which further de-
pends on composition, morphology & occlusion of teeth.
Depending on these factors few people are more prone to caries
in comparison to others as depicted in Figure 3.
Other factors:
- Heredity pattern
- Systemic condition like xerostomia
- Vitamin & Protein deficiency.
4. Diet analysis & counselling
All mono & disaccharides can be cariogenic under certain
circumstances. Sucrose is the arch criminal. Cariogenic poten-
tial of food containing sucrose depends on many variables like
ability to:
- Be retained by teeth
- Form acids
- Dissolve enamel
- Neutralize or buffer acids
# Factors that enhance caries development are:
 Kumar Raghav Gujjar and Neha SumraMinimally Invasive Dentistry

Table 1. Various parameters used for evaluation of saliva

S.NO. Parameter Median value Range Significance

1 Salivary flow rate 0.48 ml/min 0.10-2.0 ml/min 0.1 ml/min cause xerostomia which indicates
high caries risk
2 Salivary pH 6.7903 5.86-7.54 5.5 makes environment acidic which indicates
0.3-13.2 high caries risk
3 Bicarbonate concentration 5.7455 mmol/l Bicarbonate is important buffering system as it
diffuses into plaque & neutralizes acid so 0.3
mmol/l indicates high caries risk.
4 Viscosity Relative viscosity=1.5 If viscosity decreases then caries susceptibility
increases
5 Direct antibacterial activity: lacto- Reduction Predisposes to increased caries susceptibility
ferrin, lysozyme, lactoperoxidense
and agglutinins

Table 2. Various caries activity tests

S.NO Test Value

1 Lactobacillus count test No. of organism Degree of caries activity
0-1,000 None
10,000 Slight
1,00,000 Moderate
1,000,000 Marked
2 Dentocult lactobacilli test 10,000 C.F.U-high caries activity
1000 C.F.U-low caries activity
3 Swab test
pH Degree of caries activity
4.1 Marked caries activity
4.2-4.6 Active
4.5-4.6 Slightiy active
4.6 Caries active

4 Snyder test 24 hrs 48 hrs 72 hrs

If yellow If yellow If yellow
Marked caries susceptibility Definite caries susceptibility Limited caries susceptibility
If green If green If green
Continue to incubate & observe Continue to incubate & observe Caries inactive
at 48 hrs at 72 hrs
5 Streptococcus mutans 1,00,000/ml of s.mutans in saliva indicate high caries risk
6 Albans test Change of colour from bluish green (pH 5) to definite yellow (pH 4) indicates high risk caries
7 Salivary reductase test Colour Time (min) Score Caries activity
Blue 15 1 Non conducive
Orchid 15 2 Slight
Red 15 3 Moderate
Red Immediately 4 High
Pink/white Immediately 5 Extreme
8 Fosdick calcium dissolution test Amount of calcium dissolution is directly proportional to caries activity

Retentive starch food may be more acidogenic than high-
sugar-low-starch foods that are rapidly eliminated from the
mouth (19).
Frequent between meal snacking on sugar or processed
starch containing foods increases caries production.
Slowly sipping soft drinks & other sweetened beverages be-
tween meals increase the risk of caries (20).
The sequence in which food is taken also affects plaque lev-
els like sugared coffee consumed at the end of meal is more
cariogenic than when an unsweetened food is eaten follow-

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Table 3. Various caries activity test new methods

Methods Principle Uses

Antigen-Specific assays - Utilize highly specific monoclonal anti-bodies, giving
absolute specificity for bacteria of choice
GC-Saliva check SMTM - Uses a combination of 3 highly specific anti-S.mutans
monoclonal antibodies (SWLA-1,2,&3) (17,18) to inc-
rease binding & reduce
- Includes immunoflorescence, flow cytometry, latex
agglutination, immunoblots & solid phase immunoa-
ssays
- Used particularly in tracking transfer of MS from mother
to infant, to detect risk of early childhood caries

Figure 3. Shows role of composi-

tion, morphology & occlusion of
teeth in caries.

ing intake of sugared coffee (21). Increasing resistance of teeth to decay

Children who obtain higher percentage of their calories
from sugar intake are more prone for proximal caries (22).
# Factors that decrease caries rate are: - Protein, fat, phospho-
rus & calcium (23).
Protective effect of cheese is due to its texture, which stim-
ulate salivary flow & its protein, calcium & phosphate con-
tent which neutralizes plaque acids.
If peanuts are eaten before / after sugar containing food the
plaque pH is less depressed (24).
The presence of minerals in a food (fluoride intake declines
caries rate) (25).
Fats accelerate oral clearance of food particles.
Calcium & phosphorus neutralize plaque acids.
Prevention
Prevention is better than cure. Increasingly, the attention of
dental profession has been directed towards prevention of den-
tal caries by taking various measures which includes:
Tussling caries inducing microorganisms
Modifying diet
All of these have been discussed in details in Table 4 (26).
Principles of Minimal Intervention Are
Based on (9)
1. Disease risk assessment & early caries diagnosis;
2. The classification of caries depth and progression using
Radiographs;
3. The reduction of cariogenic bacteria, to decrease the risk of
further demineralization and cavitation;
4. The arresting of active lesions;
5. The remineralization and monitoring of noncavitated ar-
rested lesions;
6. The placement of restorations in teeth with cavitated lesions,
using minimal cavity designs;
7. The repair rather than replacement of defective restorations;
8. Assessing disease management outcomes at pre established
intervals.
1. DIsease risk assessment & early caries diagnosis
The goal of MI is to stop disease first and then to restore lost

112 Vol. 9, No. 2, June 2013

 Kumar Raghav Gujjar and Neha SumraMinimally Invasive Dentistry

Table 4. Dental caries prevention

Tussling caries inducing microorganisms
- Bisguanides-chlorhexidine
- Triclosan
- Delmophinol hydrochloride
- Replacement therapy: cariogenic ba-
cteria replaced by non cariogenic
bacteria.
- Blocking plaque build
Up: develop substance that inhibit
glycosyl transferase, interfere with
adhesion & coaggregation of bacteria
& an effective antibacterial agent.
Modifying diet Increasing resistance of teeth to decay
- Addition of preservative with enhanced antibacterial activity - Fluoride & pit & fissure sealant
e.g. essential oil components like thymol, cinnamic acid, - Reminerilizing agent-amorphous
carvacrol. calciumphosphate.
- Addition of natural demineralization inhibitors e.g. fluorides - Polymeric coating
in drinking water. - LASER.
- Increase consumption of protective food component like - Augmenting host resistance by
Polyphenols in oat, hulls, cheese & milk. recombinant DNA technology.
- Calcium phosphate complex of casein phosphopeptides in
milk
Sugar substitutes:
Sugar substitutes are tooth friendly, as they are not fermented
by the microflora of the dental plaque. An example is
xylitol. Xylitol, either with chlorhexidine for elimination of
cariogenic bacteria or as a stand-alone therapy, has proven
to be an effective adjunct to an antimicrobial approach to
caries reduction & both should be part of the remineraliza-
tion protocol (26). Gastrointestinal side-effects (risk of osmo-
tic diarrhoea) were recorded daily throughout the xylitol
consumption period of 55 days
In the United States, according to FDA six intensely-sweet sugar
substitutes have been approved for use. They are Stevia,
Aspartame, Sucralose, Neotame, Sucralose, Neotame,
Acesulfame potassium & Saccharin.

structure and function. To be able to stop tooth caries as early
as possible, present caries risk and caries activity should be
established. Caries risk may be assessed from CRAT Table 5
(27) as given by AAPD (American Academy of Paediatric
Dentistry).
1) Risk category
- High Risk- The presence of a single risk indicator in any area
of the high risk category is sufficient to classify a child as be-
ing at high-risk.
- Moderate Risk- The presence of at least 1 moderate risk
indicator & no high risk indicator results in moderate risk
classification.
- Low Risk- The child does not have moderate risk or high
risk indicators.
2) ICDAS caries classification (28)
- It offers double coded system for each surface observed.
*First number indicates whether surface has restoration & if
it does, the type of material used.
*Second code indicates the carious state of surface examined
as:
0- Sound tooth surface
1- First visual change in enamel
# visible only after prolonged drying for 5 seconds or
# confined to the pit & fissure area
2- Distinct visual changes in enamel on wet surface
3- Localized enamel breakdown with no visible dentin
4- Underlying dark shadow from dentin visible through the en-
amel
5- Distinct cavity with visible dentin
6- Extensive cavity with exposed dentin
Example
01-0indicates sound surface with no restoration
1indicates first visual change in enamel
15-1indicates surface with partial sealant
5indicates distinct cavity with visible dentin
3) Caries diagnosis
Earliest caries detection, traditionally by use of mirror and
light, as well as bitewing radiographs, can now be aided by new
developments in dental magnification and imaging, laser fluo-
rescence or quantitative light-induced fluorescence (29-32).
Use of diagnostic aids based on ICDAS classification of caries
as described by Topping GV, Pitts NB is shown in Table 6 (33).
One of the latest method used nowadays is OCT (Optical
Coherence Tomography) -it is an optical ultrasound that emits
no radiation & provide detailed information to operator.

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Table 5. Disease risk assessment & early caries diagnosis

Caries-risk
Low risk
indicators
Clinical conditions # No carious teeth in past 24 mos.
# No enamel demineralization
# No visible plaque, no gingivitis
Environmental # Optimal systemic & topical fluoride
characteristics exposure
# Consumption of simple sugars or foods
strongly associated with caries initia- # Occasional (i.e. 1-2) between
tion primarily at meal times.
# High caregiver socioeconomic status
# Regular use of dental care in an establi-
shed dental home
General health conditions
Moderate risk
# Carious teeth in past 24 mos.
# 1 area of enamel demineraliza-
tion
# Gingivitis
# Suboptimal systemic fluoride ex- # Suboptimal topical fluoride ex-
posure with optimal topical ex-
posure.
meal exposures to simple sugars
or foods strongly associated with
caries
# Midlevel caregiver socioecono-
mic status
# Irregular use of dental services # Active caries present in mother
High risk
# Carious teeth in past 12 mos.
# More than 1 area enamel demi-
neralization (enamel caries)
white spot lesion
# Visible plaque on anterior (front)
teeth.
# Radiographic enamel caries
# High titres of mutans
streptococci
# Wearing dental or orthodontic
appliances.
# Enamel hypoplasia
posure
# Frequent (i.e. 3 or more) between
meal exposures to simple sugars
or foods strongly associated with
caries
# Low level caregiver socioecono-
mic status
# No usual source of dental care
# Children with special health care
needs
# Conditions impairing saliva
composition/flow

4) Indication to tip the balance in favour of remineralisation and away from

In morphologic tissue imaging at high resolution (better than
10 m)
USES-
*To image hard & soft dental tissue (34),
*Detect enamel demineralization & remineralization (35,36)
*Early caries diagnosis (37).
2. Remineralization of early lesion and reduction
in cariogenic bacteria
Enamel and dentin demineralization is not a continuous, irre-
versible process .Through a series of demineralization and re-
mineralisation cycles, the tooth alternately loses and gains cal-
cium and phosphate ions, depending on the microenvironment.
When the pH is less than 5.5, subsurface enamel or dentin will
demineralize. Fluoride enhances the uptake of calcium and
phosphate ions and can form fluoroapatite. Fluorapatite de-
mineralises at a pH less than 4.5, making it more resistant to de-
mineralization from an acid challenge than hydroxyapatite. In
the noncavitated lesion, to take advantage of the tooths ca-
pacity to remineralise, one must first alter the oral environment,
demineralization.
This approach includes:
- Decreasing the frequency of intake of refined carbohydrates;
- Ensuring optimum plaque control;
- Ensuring optimum salivary flow;
- Conducting patient education.
Agents such as chlorhexidine and topical fluorides than can
be applied to encourage remineralisation. Chlorhexidine acts
by reducing the number of cariogenic bacteria. Topical fluo-
rides increase the availability of fluoride ion for remineralisa-
tion and the formation of fluoroapatite, with its increased resist-
ance to demineralization (9), is especially true in patients ex-
posed to fluoride.
Various methods used for reduction of cariogenic bacteria are
enlisted in Table 7 (38).
3. Placement of restoration in cavitated lesion with
minimal cavity design
- Once the lesion has advanced to surface cavitation and the
dentin is involved, the contents of the cavity can be roughly div-

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 Kumar Raghav Gujjar and Neha SumraMinimally Invasive Dentistry

Table 6. Use of diagnostic aids based on ICDAS classification of caries

Sound Subclinical caries 1-clinical sign (initial) Established (moderate) Severe (extensive)
ICDAS codes 0 0 1+2 3+4 5+6
Light induced fluorescence Some false + Detectable Detectable Detectable Not useful
Infrared fluorescence - Non detectable May detect on occlusal & Detectable Detectable
smooth surface
Infrared fluorescence+ - Non detectable Detectable Detectable Detectable
photothermal radiometry
Transillumination - Non detectable Detectable on approximal Detectable Detectable
surface & in some lesion
occlusal surface
AC impedence - Non detectable Detectable Detectable Detectable
Spectroscopy

Table 7. Various methods used for reduction of cariogenic bacteria

Patient example
Low caries risk & gingivitis
Low caries risk & hypersen-
sitivity
Low caries risk & hypersen-
sitivity due to home blea-
ching treatment
High caries risk, high carbo- 1,000 ppm two times daily
hydrate & beverage freq-
uency, Gastro-esophageal
reflux disease, poor oral
hygiene as consequence of
drug abuse, prevention of
demineralization before,
during & after head & neck
radiotherapy, chemothe-
rapy, & treatment of sali-
vary dysfunction.
Toothpaste
1,000 ppm two times daily
1,000 ppm two times daily
1,000 ppm two times daily
(morning & night)
TM Fluoride varnish
Recaldent product CHX (0.12% mouthrinse)
(22,600 ppm)
Not needed Once daily after lunch for 0-1 times annually
four weeks & then review
Use MI paste plus &/or gum Not needed 0-1 times annually
several times daily after
brushing &/or tray at night
for hypersensitivity
Use MI paste plus for two Not needed 0-1 times annually
weeks before & after
bleaching, & use MI paste
plus one to two times daily
on days when bleaching.
Use MI paste plus &/or gum Once daily after lunch for Monthly initially,
several times daily (inclu- four weeks & then review then reduce to
ding after brushing &/or oral bacteria & reduce several times
trays); multiple times daily frequency annually
for saliva dysfunction &
caries.

ided into two layers-infected layer (completely demineralized)
& affected layer (can be remineralized).
Use of Caries detector dyes-Various dyes used in detection of
Enamel caries-Calcein, Zyglo ZL-22 & Dentin caries-Fuschin,
Acid-red system, 9-aminoacridine
- Full control of caries requires elimination of the infected layer
and also the cavitation that is allowing bacterial plaque to be
retained.
- Conservative preparation designs such as facial and lingual
slots, occlusal boxes and tunnel preparations should be the prep-
arations of choice. The tunnel preparation is performed by ac-
cessing the carious dentin from the occlusal surface, while pre-
serving the marginal ridge.
Internal preparations preserve the marginal ridge & proximal
surface enamel (9,39,40).
1) Methods for restorative dental treatments (Banerjee A et
al: BDJ 2000)
Minimally invasive dentistry reaches the treatment objective
using the least invasive surgical approach, with the removal of
the minimal amount of healthy tissues. It includes different

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Table 8. Methods for restorative dental treatments

Method Sound enamel Sound dentin Carious enamel Carious dentin

Hand excavator - - + ++
Air abrasion +++ +++ ++ +
Carisolv - - - +++
LASER + + + +

Table 9. Newer generation of materials

GIC RMGIC CAR Lamination

Advantages - Fluoride - Command Conservative approach - The GIC is placed first because of
Release Set - Hybrid layer has improved its adhesion to dentin and fluo-
- Adhesion to tooth by ion - Improved esthetics the quality of the bond ride release. Resin-based compo-
exchange site then is laminated over the
GIC for the purpose of improved
occlusal wear or esthetics (9,40,
41).
- Reduce the amount of shrinkage
stress between the direct resin
restoration and the cavity pre-
paration walls by approximately
20% to 50%.
Disadvantages - Technique sensitive - Polymerization shrinkage Polymerization shrinkage &
- Poor strength - Low wear resistance (42) marginal leakage when
margins are in dentin (43)

techniques: Hand excavator, Air abrasion, Chemomechanical 4. Compomers

method, LASER as discussed in Table 8 (41).
Restoration
-Technique of removing infected dentin only and sealing the
cavity with GIC is just valid in general practice where normal
instrumentation is available and a further review of the restora-
tion can be undertaken relatively simply.
-Now a days, with adhesive dentistry, composite resins & resin
modified GIC are a better option with conservative approach.
2) Materials used
Newer generation of materials known as SMART materials
are used now a days as depicted in Table 9 (9,40-43). The new
composite resins are showing great success because they visu-
ally reflect, refract, & absorb light in similar manner as natural
dentition. When esthetic materials (eg, composite resin, RMGI,
etc) are able to mimic the physical properties of the human denti-
tion, biomimetic results can ultimately be attained (44,45).
They are classified as:
A) Passive smart materials
1. Glass ionomer cement
2. Resin modified GIC
3. Composite adhesive resin (CAR)
B) Active smart materials
1. Ariston pHc alkaline glass restorative
2. ACP (amorphous calcium phosphate) composite
EQUIA restorative system
- It includes a high viscosity GIC (EQUIA Fil or Fuji IX GP
Extra) with a highly-filled, light curing varnish (EQUIA Coat
or G-Coat Plus)
- It has advantages of high-viscosity GIC (self-adhesion, bulk
application, improved mechanical properties) & protective res-
in coating which increases its fracture toughness (46) & reduces
microleakage (47).
- Indication-Cost effective, Mercury free & Aesthetic tooth
restoration.
3) Comparision of various mid techniques
In the process of treating caries, the first step is not only to iden-
tify risk factors & the presence of demineralised areas, but also
to identify the best way of treating cavitated or non-cavitated
lesions. Cavitated lesion must be dealt with invasive approach
while the non-cavitated lesions are treated by non-invasive
methods. All such techniques have been elaborated in Table 10
(48-55).

116 Vol. 9, No. 2, June 2013

 Kumar Raghav Gujjar and Neha SumraMinimally Invasive Dentistry

Table 10. Comparision of various mid techniques

Techniques Method Indications Contraindications

Air abrasion - Use stream of air combine with superfine
abrasive powder (Aluminium oxide) to
remove tooth structure by brittle micro-
fracture (49-52)
- Particle size: 27-50 m in diameter
- Pressure: 40-160 pound per sq inch
- Operating distance from tooth range-
0.5-2 mm
Lasers - Erbium, yttrium-aluminium garnet LASER
& erbium, chromium: yttrium-scandium-
gallium Garnet LASER-to cut dental hard
tissue
Chemomechanical agent - Caridex, Carisolv, papacarie are various
agents used
- Uses a chemical agentassisted by an
atraumatic mechanical force to remove
soft carious structure
Pit & fissure sealants - Made of plastic resin-fits into grooves &
depressions of teeth & act as barrier,
protecting against acid & plaque
Reminerization - By fluoride application (ACP) in form of Caries active children
2% NaF, 1.23% APF
ART (alternative restorative - ART is used either to seal pits and fissures - Caries prone pits & fissures
treatment) or to restore tooth cavities, hand instru- - In incipient caries
ments are used in conjunction with
adhesive materials or systems (54,55)
- Pit & fissure caries
- Small class I & V preparation
- Based on wavelengths some are
used to cut hard tissue & others
cut soft tissue (53) without tou-
ching the healthy tissue
- Can be used in anxious uncoo-
perative & medically compro-
mised patient
- Used in infectious disease like
tuberculosis
- Newly erupted primary molars &
permanent bicuspids & molars
- Teeth in question erupted less
than 4 yrs ago
- Stained pits & fissure with mini-
mum decalcification
- Shortly after tooth eruption
- Patients with reduced salivary
flow rate due to medication
- Disabled child
- Not used in allergic, asthmatic &
medically compromised patient
- Not used when there is risk of
pulp exposure as amount of heat
may damage pulp tissue
- Caridex is time taking & costly so
not indicated in poor people
- Individual with no previous caries
experience
- Wide & self-cleansable pit &
fissure
- Pits & fissures that are caries free
for 4 yrs or longer
- Partially erupted teeth
- When carious lesion has progre-
ssed to dentin
- When carious lesion has progre-
ssed to dentin

gresses slowly in populations, repairing defective restorations

4. Repair rather than replacement of defective re-
storations
It is estimated that worldwide, the replacement of existing re-
storations accounts for 50 to 71 percent of each general dentists
activities (9). The replacement of amalgam and resin restora-
tions leads to larger restorations with successively shorter life
spans than their predecessors. Reasons for replacing restora-
tions rather than repairing them include several concerns about
bond strength to previously placed materials, about residual ca-
ries left behind, and about recurrent caries around the margin
of a restoration implying an increased risk of developing caries
in other sites, including under existing restorations.
Considering all of these points, plus the fact that caries under
well-sealed restorations fails to progress and that caries pro-
rather than replacing them is a valid and more conservative op-
tion for treatment. Cavity preparations should ensure in-
dependent retention and resistance form for the repair (9,55).
Repair with a GIC may be preferable in cervical areas, because
of the potential for fluoride release and GICs excellent
adhesion. The decision to repair rather than replace a restoration
always must be based on the patients risk of developing caries,
the professionals judgment of benefits vs. risks and con-
servative principles of cavity preparation (9).
5. Disease control
Any intervention, whether primary or secondary, i.e. restora-
tion-replacement, needs to first heal the caries lesion and con-
trol the disease. Without disease control, any replacement will

IJCPD 117
International Journal of Clinical Preventive Dentistry
fail because of continued disease activity. MI treatment on mi-
cro or molecular levels starts, e.g. with fighting the bacterial ac-
tivities and healing reversible carious lesions. Bacterial activ-
ities may be controlled using a wide range of treatment methods,
which may involve the use of chlorhexidine, diammine silver
fluoride, triclosan, or cavity seal by chemical material adhesion
(56-60). After disease control, the loss of minerals from tooth
hard tissues needs to be addressed and the oral balance between
de- and remineralization processes on the tooth surface
regained. This may be done through external remineraliza-
tion (on the tooth surface) and in cavity walls through internal
remineralization (61). In general, remineralization depends on
the presence of water, a pH higher than 6.5, and the availability
of minerals such as calcium and phosphate. Remineralization
of the tooth surface relies on an increase in saliva flow, which
can be aided by an increase in fluid intake and the use of sug-
ar-free chewing gum. Efficient oral hygiene and diet adjust-
ments help to reduce acidic conditions and adjust the pH to neu-
tral levels by reducing the substrate availability for bacterial
metabolism. Mineral availability can be supported by the use
of dentifrice containing casein phosphopeptide-amorphous
calcium phosphate (CPP-ACP) and fluoride (12,62). Remine-
ralization within cavity walls relies mainly on the use of a ther-
apeutic biomimetic filling material like glass ionomer cement
(GIC). GICs are hydrophilic and provide a good seal (by chem-
ical adhesion) and a constant mineral and fluoride release
(12,63). During this period of caries treatment, repeated patient
118 Vol. 9, No. 2, June 2013
Figure 4. Shows treatment plan of
MID.
recalls for diagnostic measurements, monitoring, and patient
motivation may be required. Treatment should continue until
the bacterial infection is controlled and reversible carious le-
sions are healed. Once absence of disease is achieved, the irre-
versible loss of structure and function can be addressed using
minimally-invasive, patient-friendly treatment options.
Treatment planning in MID essentially includes 3steps:-
Prevention, Restoration & Recall as depicted in Figure 4 (64).
Benefits of MI
The benefit for patients from MI lies in better oral health
through disease healing, not merely symptom relief. Further-
more, MI may assist in reducing widespread patient dental anxi-
eties, which are usually caused by conventional, highly in-
vasive dental procedures (65-70).
Conclusion
An astute dentist should apply the concepts of MID for the con-
servative management of dental caries and simultaneously of-
fer patients a friendlier and health orientated treatment option
for the victorious management.
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