Graham Mount reflects on the evolution to MID

Transcription

1 minimum intervention, maximum return Issue 2 mid Breakthroughs in science and practice: Graham Mount reflects on the evolution to MID Timeline of advances in preventive dentistry No more tears or extractions: A paediatric dentist s journey to MID Fluoride-releasing glass ionomer material that truly embraces MID principles

2 Superior protection precisely when you need it: Fuji Triage from GC. Glass ionomer cement with high fluoride release for: Fissure protection Prevention and control of hypersensitivity Root surface protection Endodontic treatment Available in white and pink as capsule or powder/liquid. Part of GC s Minimum Intervention program. GC EUROPE N.V. Head Office Tel info@gceurope.com GC UNITED KINGDOM Ltd. Tel info@uk.gceurope.com

3 minimum intervention, maximum return mid Issue 2 mid Breakthroughs in science and practice: Graham Mount reflects on the evolution to MID minimum intervention, maximum return Issue 2 4. MID Worldwide Thanks to the cooperation of academia, the profession and industry leadership by GC, Minimum Intervention Dentistry principles are adopted and promoted around the world, to the ultimate benefit of the patient community. 6. Q&A Dr Andrew Brostek answers a question about his article on running a fully integrated and profitable MID practice in MID 1 8. Resources Networks, websites, books, events and journal articles relating to advances in MID 10. Practice perspectives Child-friendly, tooth-friendly dentistry Glass-ionomer Cements: Scientific analysis 18. Clinical corner The Journey to Minimum Intervention Dentistry The current status of tooth crèmes for enamel remineralization 30. Evidence FAQ on Evidence-Based Dentistry Timeline of advances in preventive dentistry No more tears or extractions: A paediatric dentist s journey to MID Fluoride-releasing glass ionomer material that truly embraces MID principles 32. MI toolkit GC Fuji Triage GC Fuji II LC Comparison of RECALDENT ToothMousse Protocol GC GC Saliva-Check Buffer mi.gceurope.com

4 MID worldwide MID Worldwide Thanks to the cooperation of academia, the profession and industry leadership by GC, Minimum Intervention Dentistry principles are adopted and promoted around the world, to the ultimate benefit of the patient community. Belgium Henri Lenn, President of GC Europe Initially, dentists were afraid when they heard about this new MID approach as they thought they would have to turn their entire practice management systems around. By gradually explaining to them the principles of identification, prevention and recall they soon discovered that most of this is in one way or the other already part of their daily practice routines. Nowadays, a growing number of dentists are beginning to realise it is a very logical approach to the management of caries and are discovering the advantages of working according the MI principles. Looking at the number of publications and events that are organised throughout Europe nowadays we can see that MI dentistry is definitely gaining popularity in Europe. We clearly see a trend that young dentists are very eager to learn more about this approach. Another positive sign is that more and more insurance companies and social health care systems are also looking for cooperation in this area. We are absolutely sure that any dentist that implements the MI principles in his daily routine will be able to run a very successful practice. MI is moving away from the standard recall systems as you create a personalized treatment protocol for every patient; some need to visit the practice regularly, low risks patients, around once a year. Today dentists still believe that they can only earn money when making restorations. We need to make them understand that implementing the steps of identification and prevention is from a business point of view probably even better. When executed properly, MI is a way to create a long term relationship with every patient. Our aim is to make dentists understand that MI is the treatment of the future. 4 mid worldwide mi.gceurope.com

5 GC Europe introduces Minimum Intervention Treatment Plan One of the most frequently asked questions by dentists when they hear about Minimum Intervention Dentistry is: How can I integrate MI in my daily practice? In order to address this, the GC Europe MI Advisory Board was established as a Pan-European group of top level academicians, researchers and general dental practitioners. Working together, they designed a Treatment Plan for the implementation of the MI philosophy into routine dental practice. Members of the MI Advisory Board are Dr Frederic Roussel (Brussels, Belgium), Dr Elmar Riech (University of Cologne, Germany). Board members include Dr Avijit Banerjee, (King s College London) Dr Matteo Basso, (University of Milan, Italy) Dr Michel Blique, (General Practitioner, Luxemburg) Dr Sophie Doméjean-Orliaguet (University of Auvergne, France) Dr Céline Gaucher, (University of Paris V, France) Dr Ivana Milètic, (University of Zagreb, Croatia) Dr Jose Zalba, (General Practitioner, Spain) and Dr Piyush Khandelwal (GC Europe, Belgium) and Dr Laetitia Lavoix (Paris, France). Minimum Intervention Treatment Plan As a result of advancements in cariology resulting in a better understanding of the carious process, GC has taken the initiative to translate these oral health philosophies into your routine dental practices. The GC approach is based on the Minimum Intervention (MI) concept and more particularly through balancing the natural biological functions of demineralization and remineralisation of the tooth structure. With the MI treatment plan GC brings solid and clear guidelines to the general practitioner for MI treatments and planning, illustrated in many clinical cases: Diagnosis, Treatments and recalls plans Patient actions and tools, Preventive and non-invasive treatments, Atraumatic and Minimally Invasive Restorative Treatments, Tentative models for the financial and practical implementations Identify The examination of a patient is not limited to the teeth, but takes the risk factors for caries into account like diet, brushing habits, the quality and buffering capacity of saliva, the amount of cariogenic bacteria (like Mutans Streptococci) in saliva and the cariogenicity of plaque. In order to diagnose and monitor caries, the diagnostic threshold has to be reduced to the first clinical signs of caries in enamel. These early forms are clinically detectable in fissures and on flat surfaces as well as on x-rays for the interproximal areas. The use of diagnostic tools like GC Saliva Check Mutans test kit, GC Plaque Indicator kit, GC Saliva Check Buffer kit not only helps you to get the most relevant information about your patient s susceptibility but also helps to motivate your patient. Prevent Preventing caries from advancing is possible, if a patient is willing to change his habits. Diet and tooth-brushing must be optimized to be effective in caries prevention. In practice active preventive treatments aims at reducing the caries risk factors and promoting remineralization. Very effective are a combination of professional mechanical tooth cleaning, a ntibacterial drugs, a healthy diet and medicaments like the GC Tooth Mousse and the MI paste Plus which help to promote remineralization and bring the oral flora back to normal. Recall In cariology standard recall schemes (see your dentist twice a year) have long been used. That approach is for a highly susceptible patient is too long and for those with very low susceptibility is perhaps too short. Hence with the MI treatment plan you can give your patients the most individualistic recall period taking into consideration their own risk factors. Restore Modern restorative System like EQUIA, the long term glass ionomer glass ionomer based restorative system and the Gradia LoFlo, the flowable composites require less removal of tooth structure as compared to the traditional materials like amalgam or gold. They adhere to the tooth structure and fulfil high aesthetic demands by the patient. Atraumatic and minimally invasive restorative treatments conserve tooth structure and promote longevity of restorations. Other products that can also be used as per the MI philosophy are the Fuji II LC (Resin modified GIC), Fuji IX (Condensable GIC) and the Gradia Composite filling materials (High strength, high aesthetic composite resin). mid worldwide 5

6 Q&A The question below was address to Dr Andrew Brostek about his article on running a fully integrated and profitable MID practice in MID 1 Name: Jack Stellpflug Country: USA Question: In reference to the patient case study, in the part of the remineralisation protocol in which you recommend OTC tooth past FL level as opposed to 5,000ppm, what is the reason for avoiding high FL for remineralisation? Answer Dr Andrew Brostek: Dear Jack, The rationale behind the remineralisation protocol using CPP-ACP (GC Tooth Mousse/MI Paste) with the lower concentration fluoride toothpaste (1000 ppm), is to allow remineralisation to occur in the deeper parts of the tooth first and the surface last. This does not occur if you use the 5000 ppm fluoride concurrently with the GC Tooth Mousse. As you know, the high 5000 ppm fluoride is very effective in forming fluoroapatite which creates an intact shiny surface leaving the deeper layers mineral -poor, i.e. the white scar of the white spot lesion remains. Studies and clinical experience with CPP-ACP shows that deeper remineralisation occurs more readily with the lower toothpaste fluoride concentration, allowing the white-spot lesion to almost disappear over about 6-8 weeks of topical daily CPP-ACFP patient application (I think the in-situ enamel CPP-ACFP studies show ~ 60% total remineralisation or more depending on concentration of the CPP-ACFP). Out of interest, that is why the recommended dentist clinical protocol is to acid-etch the surface of enamel for ~20 seconds to clear any protein or lipid blocking the surface pores in order to obtain the maximum possible remineralisation. In my practice I recall at monthly intervals to review and re-etch if necessary. Hope that helps! All the best Andrew Brostek Perth, Australia If you have a question for Andrew, click here. Highlights from the MI Compendium QUESTION: In patients with comparable caries risk, does GIC have a better cariostatic effect than composite? ANSWER: The analysis results of dichotomous data showed no difference in caries incidence on tooth tissue adjacent to these materials. The analysis of continuous data showed significant higher microhardness and significantly less mineral loss of tooth tissue adjacent to GIC after acid attack than tooth tissue adjacent to composite. 6 q&a mi.gceurope.com

7 Identify natural protection for teeth with Saliva-Check Buffer from GC. Chairside test to evaluate saliva s ability to protect teeth and motivate your patients When a patient presents new signs of accelerated tooth wear, abrasion, sensitivity, halitosis or any other major oral changes, the first question for the dentist should be to identify what has lead to an oral imbalance. Saliva testing is aimed to identify if changes in the salivary condition can be a contributing factor, and to motivate your patient to improve his oral heath status. Part of GC s Minimum Intervention program. GC EUROPE N.V. Head Office Tel info@gceurope.com GC UNITED KINGDOM Ltd. Tel info@uk.gceurope.com q&a 25

8 MID resources Networks, websites, books, events and journal articles relating to advances in MID Online Journal of Minimum Intervention in Dentistry Events Minimal Intervention Dentistry Compiled by Graham J Mount, Wyatt Rory Hume and Brian Monteith Compendium of Minimum Intervention in Dentistry ORCA 2010 Montpellier, France 7-10 July MI on Monday: taking your first steps to MID Issued by GC Asia at the MID Symposium in Singapore in September 2009 Click here to view pdf The ABC s of children s teeth: A 21st century guide for parents by Dr Angela Gilhespie American Dental Association Center for Evidencebased Dentistry Centre for Evidence-Based Dentistry (UK) Journal for Evidence-Based Dentistry National Maternal and Child Oral Health Resource Center Toothfriendly Foundation The Forsyth Center for Evidence-Based Dentistry html The World Congress of Minimally Invasive Dentistry 11th Annual Conference Downtown Westin San Diego San Diego, CA August 19-20, 2010 As I travel to various dental meetings and even here within the ivy-covered walls of academia where I teach, I see evidence of and hear increased talk about minimally invasive dentistry. Admittedly, I m not always comfortable with how that phrase is being used or what procedures it is being applied to describe, but at least people, dental providers and patients alike, are thinking more about preventing dental diseases in the first place, and questioning when and to what extent cutting of oral tissues is necessary. That s a good thing! Our message is being heard by more patients, dentists, hygienists, and dental industry representatives each successive day. Time is indeed on our side. Alan W. Budenz [MS, DDS, MBA] WCMID President The WCMID Annual Conference programme will feature a number of key opinion leaders covering the essential topics with Minimally Invasive Dentistry. The keynote address will be delivered by Bill Blatchford and other speakers will include Graeme Milicich, Brian Novy, John Crispin, Randy Wolcott, Beth Thompson, Robert Supple, Ray Becker, Pat Pine, Shirley Gutkowski, Bud Evans, Ryan Swain and Toni Adams. 8 resources mi.gceurope.com

9 Published The following articles and text books have been published in recent years relevant to a study of minimal intervention dentistry. Preservation and Restoration of tooth structure 2nd edition Mount GJ, Hume WR, Knowledge Books and Software, Brisbane, Australia Longevity in glass-ionomer restorations; Review of a successful technique GJ Mount Quintessence ; An Atlas of Glass Ionomer Cements : A Clinician s Guide. GJ Mount, 3rd Edition Martin Dunitz, London A new classification for dentistry Mount GJ, Hume RW. Quint Int. 1997, 28; Minimal intervention dentistry a new concept for operative dentistry GJ Mount, H. Ngo, Quintessence Int. 2000; 31: Minimal intervention dentistry the early lesion Mount GJ, Ngo H. Quintessence Int. 2000; 31 : Minimal intervention dentistry the advanced lesion Mount GJ, Ngo H, Quintessence International, 2000; 31: A new classification and techniques for simple restorative dentistry Mount GJ, Ann. Roy. Australian. Coll. Dent. Surg. 1998; 14:94-98 Glass-ionomers in contemporary restorative dentistry: A clinical update Hewlett ER, Mount GJ. J. Calif. Dent. Assoc. 2003; 31: The science and practice of caries prevention Featherstone JD. J Am Dent Assoc 2000;131(7): Caries Management by Risk Assessment:Consensus Statement, April 2002 Featherstone JDB. et. al. J Cal. Dent Assoc. 2003;31(3): Cariology in the new world order: moving from restoration towards prevention Featherstone JDB. J. Calif. Dental Assoc. Feb 2003 Cariology in the New World Order: Moving From Restoration Toward Prevention, Part II Featherstone JDB, Roth JR. J. Calif. Dental Assoc. Mar 2003 Fluoride-Releasing Restorative Materials and Secondary Caries Hicks J, Garcia-Godoy F, Donly K, Flaitz C. J. Calif. Dental Assoc. Mar A Review of the Efficacy of Chlorhexidine on Dental Caries and the Caries Infection Anderson MH. J. Calif. Dental Assoc. Mar New caries detection technologies and modern caries management: Merging the strategies Young DA. Gen Dent 2002;50(4): Defining, Classifying and Placing Incipient Caries Lesions in Perspective Mount GJ. Dent. Clin. of N. Am. 49 (2005) Minimal Intervention Dentistry: Rationale of Cavity Design Mount GJ Operative Dentistry, 2003, 28, Ionic Exchanges between Glass-ionomers and Demineralised Dentine Ngo HC Thesis for PhD, The University of Adelaide, 2005 Changes in operative dentistry Beyond G.V.Black Mount GJ. in Adhesive Technology for Restorative Dentistry. Eds.J-F Roulet, G Vanherle. p47-53; Chemical exchange between glass-ionomer restorations and residual carious dentine in permanent molars: an in vivo study Ngo HC, Mount GJ, McIntyre J. Tuisuva J, vondoussa J. J. Dent ; A proposal for a new classification of lesions of the exposed tooth surfaces Mount GJ, Tyas MJ, Duke ES, Lasfargues J-J, Kaleka R, Hume WR. International Dental Journal, 2006; 56: The Caries Balance: Contributing Factors and Early Detection Featherstone JDB. J. Calif. Dental Assoc. Feb resources 9

10 Child-friendly, tooth-friendly dentistry Paediatric dentist, Dr Angela Gilhespie, talks about her journey to MID and the reasons why her young patients love to come to her practice. Walking into Angela s practice you cannot help but notice that everything is child-height and positioned from a child s perspective. You are greeted by a row of photographs of happy smiling children all of Angela s patients, who see themselves this way at every appointment. Nigel the fluffy two metre crocodile grins on the floor with his sparkly white teeth, a teddy bear is seated on the panoramic x-ray seat and the dental chair is covered with a bright cover and teddy arms to wrap around you or hold on to. Parents bringing their children in for appointments are prepared for this approach because they are sent detailed information prior to the day. But many are amazed at the results of Minimum Intervention Dentistry. Angela s near-death experience in the dental chair at a young age has contributed to her commitment to create happy associations for young children visiting the dentist. Eureka moment After 25 years of running two dental practices 6 days a week, Angela has seen a sharp increase in Early Childhood Caries (ECC). She used to treat the most severe cases in the youngest children under general anaesthesia, and at one stage became accustomed to doing these up to three times a week. She had invested in a HealOzone but found it to be a very steep learning curve. I wanted to throw it out of the window I couldn t get seals and I didn t see the power of it. But one day a child came in, aged 5, the same age as when I had my near-death experience. This child was in pain; had been for the past three days and the parents were distraught. I told the parents we d have to use general anaesthesia and remove the tooth but they could not afford this and refused to leave until I helped their child. The only alternative was to try the newlyacquired HealOzone. I could barely get the cup on and I knew it wouldn t work. I administered a dose and syringed some GC Fuji Triage in and expected they would have to go to another dentist and have the tooth pulled out eventually. A year later, this same patient came in skipping into the practice. I took an x-ray and couldn t believe my eyes: a reparative band had formed on the tooth. She had no pain and had no inflammation. This was a Eureka moment for me in dentistry. I knew then that teeth could heal. For the past five years I have not used general anaesthesia once and the results I ve seen are nothing short of amazing. The right tools In her journey to practising MI dentistry, Angela identified a number of products and equipment that enable her to get the most out of this approach. Caries detection is critical, particularly in very young patients where bottle caries can easily go unnoticed without the correct diagnostic approach. You simply cannot see caries with a mirror and probe. An intraoral camera is essential and I take a panoramic x-ray of all my patients as soon as I can. It allows me to see so much more in the mouth, she explains. She also uses a Diagnodent which helps her to see the complexity of decay on the palatal aspects of fissures, for example. You can t treat what you can t see, she adds. 10 practice perspectives mi.gceurope.com

11 A typical consultation with Angela Gilhespie I try to prepare myself, as well as the parent, before the first appointment. I send them to my website to download application forms. Their information is then on the system which cuts down on their first appointment time. There is a detailed questionnaire which gives me most of the information I need to categorize the child i.e. age, existing dental problems, parent s attitudes, etc. The first appointment may just be mum and child playing in the waiting room. Only when the child is comfortable would we schedule an actual appointment. If the child is cooperative, especially if I take a panoramic x-ray, I would book a 45-minute appointment. (A trained dental hygienist could carry out most of this work which frees the dentist). Parents consider their child abnormal because they enjoy going to the dentist! Recently, a mom told me she had to take her son to the doctor. His response was: couldn t he rather go to the dentist? Perhaps the best endorsement is by children s body language. I always say, if you want to know, it s in the feet! Perfect relaxation: feet at 180 Children who have their deciduous teeth extracted will always be at an disadvantage not only because the decay often infects the adult teeth but they may often require extensive orthodontic treatment later in life. She also believes in fissure sealants and has developed a specific technique to apply glass ionomer materials to semi-erupted teeth in babies where necessary. In the past, glass ionomer cements were awful to use but we knew they were the future. Now the GC range is amazing and I can use these syringable materials for one-year-olds. Angela prescribes Tooth Mousse to her high risk patients and recommends they apply it twice daily after brushing and flossing. Chewing xylitol gum after meals is another useful tool in caries prevention. Parental lack of caries knowledge ECC is a growing problem around the world and affects children from all socio-economic backgrounds. Some of the patients with the worst cases I have seen had parents who were educated, affluent and very caring yet they failed to see their children s mouths were full of abscesses, she continues. In her experience of speaking with parents, Angela has identified a number of misconceptions that parents have about their children s oral health. In today s society, it is common for both parents to work full-time. There are many lifestyle habits that negatively impact on a child s oral health. Due to a lack of time, parents feed their children processed meals and give them sweet treats and sugary drinks every day. Babies are given bottles at night so parents can get a good night s sleep. I find every child that comes in to my practice has at least one white spot lesion if not more, she says. Angela has also found that parents do not realise that chronic medication can also impact negatively on the oral health of their children. Asthma and hyperactivity medication can reduce salivary flow, she says. Another thing that some parents misunderstand is that young children with painful teeth cannot verbally express their pain, they just stop eating fibrous food, or stop eating entirely. Parents are horrified when they realise all of this. It upsets them because in other areas they look after their children very well, she explains. Every child that comes into my practice has this disease. And the parents know nothing about what causes it and how it can be avoided, she says. Thanks to skewed media emphasis, Angela believes that most parents will take their children out of school to avoid catching swine flu, but are reluctant to take them out of school to see the dentist. We have to change the whole model of how children go to the dentist. Parents only bring their children when they have a toothache, so we have to change this mindset, she continues. Seven years ago, Angela began to address these issues by writing hand-outs for parents in her waiting room. I may as well have written the stuff in hieroglyphs for the amount of understanding the moms had for children s oral health. They don t think deciduous teeth are important, don t understand that practice perspectives 11

12 acid causes the problems, not sweets and they have no concept of mother to child transmission. Some parents think the origin of tooth decay is genetic and blame is on one of the parents. Everyone thinks caries is prevented with toothbrushing, she adds. of them all with more than 600 different species of bacteria, she explains. This sparked a series of training events and educational roadshows where she presented to midwives, nurses and other childbirth educators. By educating the professionals who educate pregnant women the message of prevention will be carried through in prenatal education. I focus on connecting to small groups who have energy to propel this message forward, she explains, adding that the ultimate goal through this is to establish oral health homes for young children and mothers. Teaching pregnant women about their own oral health, and the facts about transmitting dental disease to their babies is an essential part of prenatal education. The systemic links with periodontal diseases and low birth weight, preterm birth and other adverse pregnancy outcomes have been proven in many research studies and for Angela it is important to raise awareness of that with mothers. Similarly, it has been proven that maternal Vitamin D levels during pregnancy can affect the development of teeth in unborn children. One of the tools Angela gives expectant mothers is a mouth mirror. Every new mom is instructed to clean their baby s mouth from day one. The mouth Oral health advocacy beyond dentistry Angela soon realised that it was not enough to tell people about child oral health, she would have to show and train them. Her book The ABCs of children s teeth: a 21st Century guide for parents addresses all the common misconceptions that she has found most parents to have, and also presents her Preventive Jigsaw, a 9 piece puzzle that consists of the following essential pieces: Flossing, fissure sealants, brushing, no bottle, diet, saliva, CPP-ACP, xylitol and fluoride. Angela advocates that all these pieces together create optimal oral health in babies and children. She realised this message needed to be spread to healthcare professionals who were not in dentistry. Traditionally, the day after a baby is born the nurses teach new mothers how to clean their ears, noses, nails. The one orifice they don t teach mothers to clean is the mouth, which is arguably the dirtiest Common misconceptions that the general public has about ECC Baby teeth fall out, so decay is not a problem You do not need to brush a very young child s teeth Only brushing and toothpaste can stop tooth decay Only sugar causes decay Not transmissible between a mother and baby Fruit juices and energy drinks are okay for children Medication will not affect a child s oral health 12 practice perspectives mi.gceurope.com

13 mirror is given to examine the baby s mouth she adds. Introducing good oral health habits What Angela sees on a daily basis in her practice is the day and night difference between a healthy child and a child with caries. Children who have their deciduous teeth extracted will always be at an disadvantage not only because the decay often infects the adult teeth but they may often require extensive orthodontic treatment later in life, she says. Due to the challenges involved in prescribing a complete change in diet for her young patients, Angela instead focuses on positive behaviour that can be included in a child s daily routine. Everyone knows to cut down on sweets but the parents snack on sweets themselves so it comes down to behavioural changes which are very challenging, she explains. A big breakthrough came to me with one of my patients when he was 2 years old. He constantly had plaque from ear to ear, one day he came into my practice sucking on a lollipop! And we were never able to change that behaviour. But for some reason, his mom took our advice with xylitol chewing gum and Tooth Mousse and she became absolutely religious with this. I saw him recently and nearly fell off my chair: he is now 6 and has virtually no plaque. That s the power of the combination where you ve got xylitol to break down the biofilm and prevent the adhesion of bacteria to the tooth surface and the Tooth Mousse to repair the teeth. All the lesions in his mouth started to repair, she says. With the trend of children eating more processed food means they chew less, which means they have less saliva in the mouth to rather than breakdown the formation of biofilm say neutralize plaque acids. We ve got to get these children chewing and keep them hydrated. This is the problem with fruit juice and energy drinks. If your child needs fruit let them eat whole fruit pieces instead. Other ways to stimulate saliva is to give children small pieces of cheese after a meal. These are the things parents can do to help their children, she concludes. Dr Angela Gilhespie, (BSc BDS London) is a full-time dentist in private practice in Johannesburg, South Africa. She has over 25 years experience, mainly in children s dentistry. She has recently released her book The ABC s of children s teeth. Her mission is to wipe out ECC in children. She believes this can only be achieved by firstly training health care professionals in the perinatal arena because they participate in the health of a child from the very beginning. For more information about Angela visit Queries practice perspectives 13

14 14 practice perspectives Glass-ionomer Cements: Scientific analysis By Prof.Dr.Karl-Heinz Friedl, Germany In modern operative dentistry the focus is on minimal removal of tooth tissues and on the application of adhesive restorative materials that possibly perform therapeutic actions on demineralized dentin. Those requirements are perfectly matched by glass-ionomer cements (GICs). Highly viscous GICs achieve superior physical properties compared to traditional GIC by optimizing polyacid and particle size distribution and resulting in a high cross-linkage in the GIC matrix 1. However, one has to know that highly viscous GIC perform worse in a number of standardized in vitro testing aspects compared to most hybrid composite resins, and they are, therefore, still considered a semi-permanent restoration material by a number of universities 2-5, although they are widely used as a permanent restoration material in private practices. However, not only mechanical properties, but a series of practical aspects have to be taken into account for assessing the benefits of GICs (much better performance with a coating protective layer) for the patient and the dentist. Facts on highly viscous GIC GIC interact with tooth substrate and there mayeven be an in situ transformation of glassionomer into an enamel-like material 6-9. GIC contract during setting like composite resins, but they show significant differences in the development of viscosity and stiffness in the early stage of setting. This is of clinical importance, since during the early setting stage GIC are better capable of reducing the contraction stresses than resin composites, thus increasing the likelihood that the bond with the cavity walls will form and survive during setting. Shortly spoken, materials with a shrinking characteristic like composites need higher bond strength to achieve the same sealing ability like GIC Bond strength of GIC is not as susceptible to moisture like most adhesive systems and bond strength improves with the maturation of the material Physical and mechanical properties might be a slightly inferior or sometimes equal to hybrid composite resins, but they increase during maturation whereas composite properties mi.gceurope.com

15 decrease. However research works indicate that, when placed in a cavity the resistance to fracture of occlusal enamel supported by either a composite resin (Filtek Z250) or Fuji IX was not different GIC release fluoride, show antibacterial activity and may have a caries protective potential. Literature: Performance and longevity of restorations If we try to summarize clinical outcomes of amalgam, composite or glass ionomer trials, we have to face the fact that clinical results are very difficult to interpret and to compare for different reasons. There are not only differences in the validity among the trial designs (e.g. randomized controlled prospective, retrospective, cohort, case control, etc.), furthermore, the studies partly suffer from high drop-out rates 37;38. Important details, like cavity size etc. are often missing and in a number of clinical investigations cavity-type-specific survival rates cannot be clarified 39;40. Furthermore, the clinical success of dental restorations does not only involve the restorative material per se but also different operative techniques. Technique-sensitive materials like adhesive systems may behave completely different when used by differently experienced operators in different clinical environments. One investigation on the preparation quality of 610 cavities showed big differences among the 8 participating dentists 41, which supports other findings on a significant effect of the operator on the longevity of the restoration 5;42. Differences in performance mainly become obvious, if different types of materials are evaluated within one study 43. A composite resin may show good longevity data when applied in conventional cavities but not in modified operative approaches. Completely different restoration techniques hamper an judgement on composite longevity 44 because different restorative procedures like chemically cured bulk technique, a light-cured bulk technique, and different light-cured layering techniques may have small, but significant effects on stress development 45. Polymerization shrinkage during curing of an adhesive restoration and mismatch in mechanical properties can lead to the initiation and development of interfacial defects. Those defects, which could have a detrimental effect on the longevity of the restored tooth, are often dependent from filler content and shape 46. Promising prospective longitudinal data of highly viscous GIC were shown in the ART approach, e.g. in a prospective longitudinal study a total of 1117 Class I and Class II GIC (Fuji IX and Ketac Molar) and amalgam restorations were placed in permanent teeth of 370 and 311 children, respectively, by eight dentists. The cumulative survival rates after 6.3 years were 66.1% for GIC and 57.0% for amalgam. Differences between the GICs were not significant 47;48. However, it has to be considered that the relation between class I and class II restorations was around 10:1. Studies not performed under ART conditions in Class I and II cavities are scarce, but also promising. In a study on 169 Class I (n=67) and Class II (n=102) GIC restorations (Fuji IX) in 116 patients placed by 3 dentists the survival rate was 98% after 2 years. The reason for replacement was fracture of the filling 49. In a 6-year retrospective clinical study 116 Class II GIC restorations (Fuji IX GP) in 72 patients placed by 2 dentists in a private practice were examined. Until 1.5y no failures were observed. From y survival dropped to 93%. After 3.5y failure rate increased and at 6y survival was 60% 50. The Equia Restorative System (Fuji IX GP Extra + G- Coat Plus) The new concept of EQUIA to combine a highly viscous GIC (Fuji IX GP Extra) with a nano filled, light curing varnish (G-Coat Plus) is unique and shall combine the main advantages of the highly viscous GIC (self-adhesion, bulk application, improved mechanical properties) with a protection in the early maturation phase and an improved surface hardness. However, if EQUIA is to be used as an alternative restorative material to amalgam or composite resins, a few questions need to be addressed: 1. Are the mechanical properties strong enough? 2. What about the clinical success? 3. What are the economical aspects Properties of the material Summarizing the mechanical properties of highly viscous GICs in comparison to composite resins, GIC may compete with composites, if the maturation characteristics can be further improved and/or the GIC is effectively protected during the maturation phase (SEM-pictures). The benefits of G-Coat Plus have been shown before 51. Parameters like fluoride release and the possible effect of caries protection are even advantageous compared to Amalgams and composite resins. Clinical success It is a fact that that there is a discrepancy between existing results from ongoing pro- and retrospective studies with EQUIA in Europe, and the positive experiences of EQUIA users all over Europe, which are only empiric. These are the positive experiences with highly viscous GIC as outlined before and the in vitro proven and clinically expected positive effect of the coat, which, by the way, also has an impressive aesthetic effect. On the other hand, there are numerous studies ongoing in various Universities to indicate the longevity of the EQUIA restorative system. Economical aspects The economical aspect is very important in public practice perspectives 15

16 health systems with a kind of basic and economic approach. Economical calculations have shown that EQUIA may be a valuable solution for the dentist in cases, where the patient is not able to or willing to pay additional costs for composite resin restorations and does not want to opt for an Amalgam filling for its bad aesthetics. Article originally published in Romanian Journal of Dentistry Medicine, vol XII, no 6/2009. Reprinted with permission. References (1) Guggenberger R, May R, Stefan KP: New trends in glass-ionomer chemistry. Biomaterials 1998; 19(6): (2) Hickel R, Manhart J, Garcia-Godoy F: Clinical results and new developments of direct posterior restorations. Am J Dent 2000; 13(Spec No):41D-54D. (3) Hickel R, Manhart J: Longevity of restorations in posterior teeth and reasons for failure. J Adhes Dent 2001; 3(1): (4) Manhart J, Chen H, Hamm G, Hickel R: Buonocore Memorial Lecture. Review of the clinical survival of direct and indirect restorations in posterior teeth of the permanent dentition. Oper Dent 2004; 29(5): (5) Manhart J, Garcia-Godoy F, Hickel R: Direct posterior restorations: clinical results and new developments. Dent Clin North Am 2002; 46(2): (6) van Duinen RN, Davidson CL, de Gee AJ, Feilzer AJ: In situ transformation of glass-ionomer into an enamel-like material. Am J Dent 2004; 17(4): (7) Knight GM, McIntyre JM, Craig GG, Mulyani: Electron probe microanalysis of ion exchange of selected elements between dentine and adhesive restorative materials. Aust Dent J 2007; 52(2): (8) Czarnecka B, Limanowska SH, Nicholson JW: Microscopic evaluation of the interface between glassionomer cements and tooth structures prepared using conventional instruments and the atraumatic restorative treatment (ART) technique. Quintessence Int 2006; 37(7): (9) Ferrari M, Davidson CL: Interdiffusion of a traditional glass ionomer cement into conditioned dentin. Am J Dent 1997; 10(6): (10) Dauvillier BS, Feilzer AJ, de Gee AJ, Davidson CL: Visco-elastic parameters of dental restorative materials during setting. J Dent Res 2000; 79(3): (11) Bryant RW, Mahler DB: Volumetric contraction in some tooth-coloured restorative materials. Aust Dent J 2007; 52(2): (12) Feilzer AJ, Kakaboura AI, de Gee AJ, Davidson CL: The influence of water sorption on the development of setting shrinkage stress in traditional and resin-modified glass ionomer cements. Dent Mater 1995; 11(3): (13) Castro A, Feigal RE: Microleakage of a new improved glass ionomer restorative material in primary and permanent teeth. Pediatr Dent 2002; 24(1): (14) Lott JR, Fitchie JG, Creasy MO, Puckett AD, Jr.: Microleakage of three conventional glass ionomers using 45Ca and methylene blue. Gen Dent 2007; 55(1): (15) Banomyong D, Palamara JE, Burrow MF, Messer HH: Effect of dentin conditioning on dentin permeability and micro-shear bond strength. Eur J Oral Sci 2007; 115(6): (16) Czarnecka B, regowska-nosowicz P, Limanowska-Shaw H, Nicholson JW: Shear bond strengths of glassionomer cements to sound and to prepared carious dentine. J Mater Sci Mater Med 2007; 18(5): (17) Lucas ME, Arita K, Nishino M: Toughness, bonding and fluoride-release properties of hydroxyapatiteadded glass ionomer cement. Biomaterials 2003; 24(21): (18) Algera TJ, Kleverlaan CJ, Prahl-Andersen B, Feilzer AJ: The influence of environmental conditions on the material properties of setting glass-ionomer cements. Dent Mater 2006; 22(9): (19) Peez R, Frank S: The physical-mechanical performance of the new Ketac Molar Easymix compared to commercially available glass ionomer restoratives. J Dent 2006; 34(8): (20) Mitra SB, Wu D, Holmes BN: An application of nanotechnology in advanced dental materials. J Am Dent Assoc 2003; 134(10): (21) Grisanti LP, Troendle KB, Summitt JB: Support of occlusal enamel provided by bonded restorations. Oper Dent 2004; 29(1): (22) Wang XY, Yap AU, Ngo HC, Chung SM: Environmental degradation of glass-ionomer cements: a depthsensing microindentation study. J Biomed Mater Res B Appl Biomater 2007; 82(1):1-6. (23) Ellakuria J, Triana R, Minguez N, Soler I, Ibaseta G, Maza J, Garcia-Godoy F: Effect of one-year water storage on the surface microhardness of resin-modified versus conventional glass-ionomer cements. Dent Mater 2003; 19(4): (24) Yap AU, Cheang PH, Chay PL: Mechanical properties of two restorative reinforced glass-ionomer cements. J Oral Rehabil 2002; 29(7): (25) van Duinen RN, Kleverlaan CJ, de Gee AJ, Werner A, Feilzer AJ: Early and long-term wear of fast-set conventional glass-ionomer cements. Dent Mater 2005; 21(8): (26) Yap AU, Teo JC, Teoh SH: Comparative wear resistance of reinforced glass ionomer restorative materials. Oper Dent 2001; 26(4): (27) Wiegand A, Buchalla W, Attin T: Review on fluoride-releasing restorative materials--fluoride release and uptake characteristics, antibacterial activity and influence on caries formation. Dent Mater 2007; 23(3): (28) Kantovitz KR, Pascon FM, Correr GM, Borges AF, Uchoa MN, Puppin-Rontani RM: Inhibition of mineral loss at the enamel/sealant interface of fissures sealed with fluoride- and non-fluoride containing dental materials in vitro. Acta Odontol Scand 2006; 64(6): (29) Amaral MT, Guedes-Pinto AC, Chevitarese O: Effects of a glass-ionomer cement on the remineralization of occlusal caries--an in situ study. Braz Oral Res 2006; 20(2): (30) Burke FM, Ray NJ, McConnell RJ: Fluoride-containing restorative materials. Int Dent J 2006; 56(1): (31) Beiruti N, Frencken JE, van t Hof MA, Taifour D, van Palenstein Helderman WH: Caries-preventive effect of a one-time application of composite resin and glass ionomer sealants after 5 years. Caries Res 2006; 40(1): (32) Kotsanos N: An intraoral study of caries induced on enamel in contact with fluoride-releasing restorative materials. Caries Res 2001; 35(3): (33) Shimada Y, Kawashima M, Higashi T, Foxton RM, Tagami J: Histologic evaluation of adhesive restorations on dentin caries in rat molar teeth. Quintessence Int 2004; 35(3): (34) Boeckh C, Schumacher E, Podbielski A, Haller B: Antibacterial activity of restorative dental biomaterials in vitro. Caries Res 2002; 36(2): (35) Brambilla E, Cagetti MG, Gagliani M, Fadini L, Garcia-Godoy F, Strohmenger L: Influence of different adhesive restorative materials on mutans streptococci colonization. Am J Dent 2005; 18(3): (36) Davidovich E, Weiss E, Fuks AB, Beyth N: Surface antibacterial properties of glass ionomer cements used in atraumatic restorative treatment. J Am Dent Assoc 2007; 138(10): (37) Scheibenbogen-Fuchsbrunner A, Manhart J, Kremers L, Kunzelmann KH, Hickel R: Two-year clinical evaluation of direct and indirect composite restorations in posterior teeth. J Prosthet Dent 1999; 82(4): (38) Lund RG, Sehn FP, Piva E, Detoni D, Moura FR, Cardoso PE, Demarco FF: Clinical performance and wear resistance of two compomers in posterior occlusal restorations of permanent teeth: six-year follow-up. Oper Dent 2007; 32(2): (39) Nikaido T, Takada T, Kitasako Y, Ogata M, Shimada Y, Yoshikawa T, Nakajima M, Otsuki M, Tagami J, Burrow MF: Retrospective study of five-year clinical performance of direct composite restorations using a self-etching primer adhesive system. Dent Mater J 2006; 25(3): (40) Nikaido T, Takada T, Kitasako Y, Ogata M, Shimada Y, Yoshikawa T, Nakajima M, Otsuki M, Tagami J, Burrow MF: Retrospective study of the 10-year clinical performance of direct resin composite restorations placed with the acid-etch technique. Quintessence Int 2007; 38(5):e240-e246. (41) Jokstad A, Mjor IA: The quality of routine class II cavity preparations for amalgam. Acta Odontol Scand 1989; 47(1): (42) Smales RJ: Longevity of low- and high-copper amalgams analyzed by preparation class, tooth site, patient age, and operator. Oper Dent 1991; 16(5): (43) Bernardo M, Luis H, Martin MD, Leroux BG, Rue T, Leitao J, DeRouen TA: Survival and reasons for failure of amalgam versus composite posterior restorations placed in a randomized clinical trial. J Am Dent Assoc 2007; 138(6): (44) Lindberg A, van Dijken JW, Lindberg M: Nine-year evaluation of a polyacid-modified resin composite/ resin composite open sandwich technique in Class II cavities. J Dent 2007; 35(2): (45) Kuijs RH, Fennis WM, Kreulen CM, Barink M, Verdonschot N: Does layering minimize shrinkage stresses in composite restorations? J Dent Res 2003; 82(12): (46) Kahler B, Kotousov A, Swain MV: On the design of dental resin-based composites: a micromechanical approach. Acta Biomater 2008; 4(1): (47) Frencken JE, Taifour D, van t Hof MA: Survival of ART and amalgam restorations in permanent teeth of children after 6.3 years. J Dent Res 2006; 85(7): (48) Taifour D, Frencken JE, Beiruti N, van t Hof MA, Truin GJ, van Palenstein Helderman WH: Comparison between restorations in the permanent dentition produced by hand and rotary instrumentation--survival after 3 years. Community Dent Oral Epidemiol 2003; 31(2): (49) Burke FJ, Siddons C, Cripps S, Bardha J, Crisp RJ, Dopheide B: Clinical performance of reinforced glass ionomer restorations placed in UK dental practices. Br Dent J 2007; 203(1):E2-1. (50) Scholtanus JD, Huysmans MC: Clinical failure of class-ii restorations of a highly viscous glass-ionomer material over a 6-year period: a retrospective study. J Dent 2007; 35(2): (51) Kato K, Yarimizu H, Nakaseko H, Sakuma T. Influence of coating materials on conventional glassionomer cement Ref Type: Electronic Citation Professor Karl-Heinz Friedl obtained a DDS Degree from the University of Erlangen-Nuremberg, Germany in His career has included various teaching positions both at the Department of Operative Dentistry and Periodontology in Regensburg, Germany and the University of Texas, Houston Health Science Center, Houston, TX, USA. In 2000 he achieved a PhD degree and since then has had a private practice in Regensburg, Germany. He has extensively published articles in leading dental journals and presented at leading conferences throughout his career. Queries Highlights from the MI Compendium QUESTION: In deep cavities of comparable size, is RMGIC as a liner less biocompatible to pulp tissue than calcium hydroxide? ANSWER: The evidence suggests that RMGIC are as biocompatible as calcium hydroxide. However, the internal validity of the available evidence is limited and needs to be validated by future randomized control trials practice perspectives mi.gceurope.com

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18 Probably the most important contribution now can be made by individuals and groups in general practice who have adopted MI Dentistry principles. The Journey to Minimum Intervention Dentistry Graham Mount reflects on his work in MID, dentistry s advances in the field over the last few decades and what elements are needed to make this approach more widespread and established in order for more patients to benefit. What inspires you to continue your work in MID? Graham Mount: As an undergraduate in the early 1940s I was trained in the GV Black principles of restorative dentistry. These were a rather rigid set of rules based upon the requirements of the trade of carpentry wherein a cavity designed to repair a caries lesion had to fulfil precise factors of design almost regardless of the extent of the lesion. First, all softened or discoloured tooth structure had to be removed and all the walls had to extend out to caries free areas. Retention elements were also part of the design. These basic requirements led to the removal of considerable amounts of sound tooth structure thus weakening the remaining crown to some degree. Over the following years of clinical practice I adhered strictly to these rules and developed pride in my ability to cut a precise cavity with flat floors and sharp line angles. However, it also became apparent over time that I had to protect, replace or repair a large number of cusps of teeth that had been weakened by these design principals. In fact, much of my practice in later years became involved in the design and construction of extra-coronal crowns and inlays that were required to support and protect these weakened cusps. It became apparent that the restorative materials we used were there to simply fill in the hole and in many ways were very intrusive and made no contribution to the health and strength of the remaining tooth crown. It seemed to me that the ideal restorative would provide some level of positive adhesion within the crown thus strengthening it. One of the oldest restorative materials was silicate cement and this became known for the release of fluoride ions into adjacent tooth structure thus limiting the recurrence of caries. We had great faith in fluoride at that time on the grounds that it may be a preventive for caries so any material related to its release was regarded as desirable. Micro-leakage into the interface between a restorative material and tooth structure was regarded as a major risk factor in relation to the recurrence of caries. There was therefore a need for a material which would chemically seal this interface. In 1976 the glass-ionomer cements became available and it seemed that they had the potential to accommodate all the above requirements at the same time. They released fluoride ions, they adhered to tooth structure (both enamel and dentine) they sealed the interface thus preventing micro-leakage and they were tooth coloured. They represented a major break though in the area of restorative materials and therefore deserved some level of further research. It is interesting to note that in this same period, from the 1970s onwards, there was concurrent research in to the disease of caries itself. This showed clearly that it is caused primarily by bacteria which flourish and do their damage when the condition of the oral environment is condusive to a lowering of the ph within the adhesive biofilm which always covers the tooth crown. Research proved that if the oral flora can be controlled then the ph can be A quadrant of GV Black amalgam restorations showing the typical over-extension of the cavity designs leading to weakening of the cusps. The cusps are so exposed to occlusal load that loss of one or more in predictable. 18 clinical corner mi.gceurope.com

19 controlled and demineralisation of tooth structure is far less likely to occur. It was the combination of the above research that inspired me to look more deeply in to the control of the disease and more limited restoration of the tooth crown from the damage that will result from caries. When they were first released I conducted research into the glass-ionomers to determine the best methods of obtaining optimum results in their clinical application. This lead to investigating modifications of cavity designs with the object of making the most of the caries resistance and the adhesion potential of the GICs. It then became apparent that there was a degree of remineralisation available using these cements and further investigation was warranted. All of these investigations have been conducted concurrently and have succeeded to the extent that it is now apparent that the profession has opened a new paradigm in operative dentistry wherein natural tooth structure can be saved, retained, remineralised and aesthetically reinstated to the extent that GV Black s techniques are almost completely out of date. It is this concept that has helped to maintain my enthusiasm for change. What are the most important developments in Minimum Intervention Dentistry today? And what do they mean for the future of dentistry as a whole? Graham Mount: The one most important development that has lead to the evolution of MI Dentistry is the recognition of the fact that caries is Timeline of MID developments GV Black and carpentry dentistry = all softened or discoloured tooth structure was removed and all the walls had to extend out to caries free areas. GV Black identifies the fact that the presence of bacteria was a necessary factor in caries and suggested that the profession had an obligation to continue to research this problem Dr Frederick McKay (Colorado, USA) corresponded with GV Black about a brown stain which he found to be common in school children in his area of practice Recognition that excess fluoride in the water supply was the cause of brown stains and a notable reduction in the caries rate in those affected. 1940s Restorative materials: silicate cement with fluoride releasing ions 1950s Kingston/Evanston experiment in the USA showed conclusively that there was benefit to be gained by offering children, to the age of 12 years, controlled levels of the fluoride ion. 1960s Dental profession and most of the public finally agreed that all age groups benefit from the continuous presence of low levels of the fluoride ion in the oral environment. 1970s Research reveals that decay is caused primarily by bacteria which flourish and do their damage when the condition of the oral environment is condusive to a lowering of the ph within the adhesive biofilm which always covers the tooth crown. Research proved that if the oral flora can be controlled then the ph can be controlled and demineralisation of tooth structure is far less likely to occur Glass ionomer cements are developed which are: Tooth coloured, release fluoride ions, adhere to tooth structure (both enamel and dentine), seal the interface preventing micro-leakage. They The same patient presented again three years later showing the represented a major break though in the area of loss of two of the buccal cusps. restorative materials and therefore deserved some level of further research. The profession opens a new paradigm in operative dentistry wherein natural tooth structure can be treatment plan 25

20 A patient showed a sudden increase in the caries rate with several new proximal lesions. A very conservative approach was adopted to cavity design. Removal of a large occlusal amalgam in the molar gave access to the proximal lesion and the three lesions on the proximal surfaces of the bicuspids were prepared as tunnels in order to preserve the marginal ridges. a bacterial disease. It is interesting to note that GV Black himself identified the fact that the presence of bacteria was a necessary factor in caries and he suggested that the profession had an obligation to continue to research this problem. He did not have the facilities available himself and it was only a couple of years before he died that he became involved in the recognition of fluoride and its role in caries control. He understood the complexity of the oral environment and knew that bacteria play a significant role but he was not able to get it all fully in to perspective. Research over the last three decades has shown clearly that bacteria play the primary role in the disease. It has been shown that if the oral environment remains in fine balance then all factors can live together. The tooth surface is constantly undergoing some degree of de- and re-mineralisation as the ph of the environment fluctuates but variations in the intra-oral balance can allow certain bacteria to become dominant. As some bacteria (notably streptococcus mutans) are both aciduric and acidogenic, there is likely to be a higher level of demineralisation occurring in their presence on the tooth surface leading to an accumulated loss of ions with insufficient compensatory uptake and replacement. The other factors making up the balance of the oral environment include such things as the ph of the saliva and its capacity to buffer lowered levels of ph, saliva flow at rest and during function, presence of refined carbohydrates to provide nutrition for the bacterial flora, intake of low ph fluids and, most importantly, level of oral hygiene. It is apparent that the oral flora are very diverse and possibly no single strain is wholely responsible for caries. However, it is also apparent that if the population of acidogenic The ultimate restorations using glass-ionomer cements in all three teeth with an amalgam laminate in the molar. The two bicuspids could also be reinforced with composite resin laminates if the occlusal load is considered to be too great. bacteria is low then the biofilm on the tooth surface will remain capable of maintaining control over the flow of ions in to and out from the tooth surface. This means in total that, if the bacterial flora can be controlled, then the ph of the biofilm can be controlled. In the absence of high levels of acid the tooth surface will remain free of permanent damage and the exchange of ions will be balanced. Thus caries can be regarded as a disease which is primarily of bacterial origin. The GV Black system of simply removing tooth structure to prevent the disease was fraught with risk simply because further removal reduced the strength of remaining tooth structure and this is a very negative concept. Further, such surgery did not eliminate the disease. The second most important development is the discovery that it is possible to remineralise and heal an initial enamel caries lesion as long as the tooth surface remains smooth. Once there is permanent loss of surface contour it is no longer possible to eliminate bacterial activity entirely because plaque will accumulate in surface defects. However, over recent years several researchers have shown that, if the open lesion can be sealed and the bacteria deprived of further nutrition, there can be some degree of remineralisation of the underlying lesion. This first became apparent when it was realised that the enamel margins around an occlusal lesion could be etched and sealed with a resin material. The results were even better when glass-ionomer was used as the sealant because it is capable of developing a seal with both enamel and dentine. Also, being a water-based material, there can be migration of calcium, strontium and phosphate ions between the restoration and the underlying tooth structure thus allowing a high level of remineralisation of even carious dentine. 20 clinical corner mi.gceurope.com