Gerodontology

Martina Hayes
Edith Allen, Cristiane da Mata, Gerald McKenna and Francis Burke

Minimal Intervention Dentistry and

Older Patients Part 2: Minimally
Invasive Operative Interventions
Abstract: As described in the first paper of this two part series, the expansion of our older population and the concomitant reduction in
levels of edentulism will result in an increase in the number of patients presenting in general practice with complex restorative challenges.
The application of the concepts of minimal intervention dentistry and minimally invasive operative techniques may offer a powerful
armamentarium to the general dentist to provide ethical and conservative treatment to older patients.
Clinical Relevance: When it is unavoidable, operative intervention should be as minimally invasive as practicable in older patients to
preserve the longevity of their natural dentition.
Dent Update 2014; 41: 500505

Minimal intervention dentistry

and minimally invasive
dentistry
Minimal (or minimum)
intervention dentistry is the complete
holistic team-care approach to patientcentred prevention of disease and
management of oral health in the long
term. It is centred on managing the

Martina Hayes, BDS, MFDS, Clinical

Research Fellow, Restorative Dentistry,
Edith Allen, BDS, MFDS, PhD, Dip Con
Sed, Lecturer in Restorative Dentistry,
Cristiane da Mata, BDS, MFD, PhD
Student, Restorative Dentistry, Gerald
McKenna, BDS, MFDS, PhD Lecturer in
Prosthodontics and Oral Rehabilitation,
Restorative Dentistry and Francis
Burke, BDentSc, MSc, PhD, FDS, FFD,
Senior Lecturer/Consultant Restorative
Dentistry, University College Cork, Cork,
Republic of Ireland.

500 DentalUpdate

dental caries process, first controlling

and curing the disease, and employing
minimally invasive techniques when
operative intervention is unavoidable. This
concept is not a new one, given that the
man frequently referred to as the father
of operative dentistry, GV Black, stated
that The day is surely comingwhen we
will be engaged in preventive rather than
reparative dentistry and there are textbooks
on the subject listed as recommended
reading for undergraduate students and
qualified dentists alike.1-3 The breakthrough
discovery of the acid-etch procedure
by Buonocore in the mid 1950s laid the
groundwork for the ability for clinical
dentistry to adapt to a more conservative,
minimally invasive approach to restorative
dentistry.4 Despite the presence of MID in
the dental literature, the application of this
concept seems slow in its integration into
general dental practice. There is no doubt
that a more restrained approach to placing
the first restoration in a tooth surface
has a long-term beneficial effect for the
longevity of the tooth.5 Unfortunately, many

dentists in NHS practice feel inadequately

reimbursed for preventive care to adults
and this may be affecting the transition
from dental surgeon to dental physician.6

Atraumatic Restorative
Technique (ART)
For a number of older people
reaching a dental surgery is extremely
difficult or simply impossible. An estimated
410,000 older people live in residential and
nursing homes across the UK.7 For these
people and those unable to leave their
homes, care may need to be provided on
a domiciliary basis. When treating older
patients with restricted mobility in the
domiciliary setting, atraumatic restorative
technique (ART) can be invaluable and
has shown comparable survival rates to
conventionally placed restorations.8-10 A
meta-analysis showed that there is no
difference in survival results between single
surface ART restorations and amalgam
restorations in the permanent dentition
over three years.11 The technique involves
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Gerodontology

the use of hand instruments only, to remove

carious dental tissue, and restoration of
the cavity with an adhesive material such
as glass ionomer cement (Figures 1 and
2). This technique can also benefit elderly
patients who have a dental phobia as it
does not require the use of anaesthesia or
rotary instruments. ART may also be aided
by chemical caries removal systems such
as Carisolv (MediTeam) (Figure 3). This
0.1% hypochlorite-based alkaline gel reacts
with carious dentine which has undergone
proteolytic breakdown of collagen, allowing
for easier removal of infected tooth tissue
with hand instruments.

Repair or replace?
Replacement of existing
restorations accounts for 5071% of all
restorations placed worldwide.12 When
treating secondary caries, it is more
conservative to repair rather than replace
a restoration unless the defect is very
large.13-15 The replacement of restorations
results in loss of tooth structure and
ultimately a reduction in the longevity of
the tooth as cavity sizes increase when
restorations are removed.16 Depending on
the reason for failure, complete removal
of the restoration may be avoided. Repair
rather than replacement slows down the
rate of the restorative cycle and prolongs
the longevity of the tooth. There is a
demographic bubble of patients now
between 30 and 65 years who have retained
much of their natural dentition but with
high levels of dental disease treated by
fillings and other restorations a so-called
heavy metal generation. The question of
repair versus replacement will become
increasingly important in the coming
decades as these people grow older and
these restorations begin to fail. The most
recent Cochrane review on the replacement
versus repair of defective amalgam
restorations in adults did not identify any
randomized controlled trials suitable for
inclusion that compared the effectiveness of
managing defective amalgam restorations
by replacing them (with amalgam)
versus repairing them (with amalgam) in
permanent molar and premolar teeth.17
The need for research in this area was
highlighted. They also identified a need
for investigators to explore qualitatively
the views of patients on repairing versus
July/August 2014

replacement of amalgam restorations and

themes around pain, distress and anxiety,
time and costs which are all relevant for
effective patient care and satisfaction.
A repair or refurbishment
procedure may be indicated in cases of
localized marginal defects or staining,
bulk fracture of a limited portion of a
restoration or secondary caries which
has not undermined the restoration
(Figures 4 and 5).18 Given the benefits of
the minimally invasive approach of repair
rather than replacement, several dental
material manufacturers have developed
products for performing chairside aesthetic
and functional composite resin repairs of
ceramic restorations (Figure 6). Studies have
demonstrated that the application of silane
significantly increases the bond strength of
the composite resin repair to the fractured
ceramic, enhancing the clinical success of
the repair procedure.19 Given that repair of
a crown or a bridge is substantially more
conservative than replacement, repair of
ceramics should be attempted in the first
instance of failure.20-22 The combined use of
different mechanisms to enhance retention,
such as sandblasting and hydrofluoric acid
etching, will increase the chance of an
effective and long-lasting repair. It has been
suggested, however, that the risk posed by
the intra-oral use of hydrofluoric acid may
outweigh the benefits due to the potential
of significant iatrogenic damage and harm
to the dentist, dental nurse and patient.19
Many older patients will present with fixed
prostheses which have served them well for
many years and may be reluctant to have
these prostheses removed, particularly if
it is likely that they will be replaced with a
removable prosthesis. It must be explained
to the patient that the lifespan of the repair
is unpredictable, but it is undoubtedly
an attractive option when compared to
complete removal of the restoration with a
high risk of damage to the remaining tooth
structure and increased financial expense.

Figure 1. Hand instruments used in the

atraumatic restorative technique (Henry Schein,
London).

Figure 2. Multiple GIC (Fuji IX, GC Dental, Europe)

Class V restorations placed using ART.

Shortened dental arch (SDA)

concept
Many older patients are
partially dentate and may seek tooth
replacement for functional or aesthetic
reasons. The number of teeth needed to
satisfy functional demands varies between
individuals.23 In 1992, the World Health

Figure 3. Carisolv (MediTeam, Finland) gel

applied to an UR2 and UR1 with root surface
caries (right) allowing conservative hand
excavation of caries infected dentine (left).

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Gerodontology

Organization stated that the retention,

throughout life, of a functional, aesthetic,
natural dentition of not less than 20 teeth
and not requiring recourse to prostheses
should be the treatment goal for oral
health.24 Kyser proposed the shortened
dental arch (SDA) concept in 1981 as
a means of limiting treatment goals to
provide a functional rather than a complete
dentition.25 The benefits of accepting a
shortened dental arch are considerable if
patients are satisfied with the appearance
and function of their dentition. Studies have
shown that removable partial dentures
increase the risk of dental disease and
are not popular with patients.26-29 Many
patients, however, will not have the
required number of occluding contacts
to fulfil the SDA criteria and may need
restoration to a functional dentition.
Functionally-oriented treatment options
include fixed bridgework, resin-bonded
bridgework and implants (Figures 7 and 8).
Unfortunately, many elderly patients have
a negative attitude toward dental implants
as they fear pain or medical complications.
A focus group of elderly patients from
Montreal and Newcastle reported that
elderly people believe that information
about implants is based on data from
younger, healthier patients and hence
cannot give them an accurate indication
of what to expect.30 Even when elderly
patients are exempt from charges, up to
one third will refuse implant treatment.31
When the occlusion is
favourable, resin-bonded bridgework is
more conservative of tooth tissue than
conventional bridgework. In addition,
restoration to a SDA using resin-bonded
bridgework has a positive impact on
the oral health quality of life of older
patients.32 A recent randomized clinical
trial demonstrated that the provision of
resin-bonded bridgework to a functionally
oriented treatment group involved
significantly lower costs than provision
of removable partial dentures to a similar
group of elderly patients.33 Patients also
required fewer clinical visits which may be
of benefit to patients who have difficulty
accessing transport.

Resin infiltration techniques

Where operative intervention
of a carious lesion is required, adhesive

502 DentalUpdate

Figure 4. LR6 with caries in the disto-occlusal

surface and a large amalgam filling on the mesioocclusal surface.

Figure 7. Functionally oriented treatment

planning. This patient was restored to a
shortened dental arch using minimal preparation
resin-bonded bridgework.

Figure 8. Another example of a patient restored

functionally and aesthetically using minimal
preparation resin-bonded bridgework.

Figure 5. After caries removal, the missing tooth

tissue has been restored with composite resin
and the old restoration has been conserved.

Figure 6. Secondary caries around the margins

of this UR3 has been excavated and a composite
restoration allows the crown to continue to
function.

materials should be employed to enable

minimally invasive cavity preparation with
maximum preservation of dental tissues.
Ultraconservative approaches, such as
sealing over frank, cavitated lesions or
resin-infiltration of early lesions, may be
sufficient to arrest caries progress.34-37 DMG
America, an American dental technology
company (DMG America, Englewood, NJ,

Figure 9. Icon being applied to the distal

surface of UL5 using rubber dam isolation (photo
provided by Paul Willmer, DMG America).

USA) markets a resin infiltration system

under the name of Icon (Figure 9). This
concept was first developed in Germany,
at the Charit University Hospital in Berlin,
from in vitro studies on the penetration of
resin into caries.38 Resin infiltration differs
from surface sealing techniques as the resin
infuses the porous demineralized enamel
by capillary action, thereby stabilizing the
lesion. The technique involves application
of 15% hydrochloric acid gel to the tooth
surface for two minutes, followed by a
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Gerodontology

low viscosity TEGDMA (tri-ethylene

glycol dimethacrylate) resin with a high
penetration coefficient (at least 200 cm/
sec). Before the development of resin
infiltration techniques, the prevailing
advice was to take a watch-and-wait
attitude to lesions of this type. This
required multiple appointments in the
dental surgery and strict long-term
follow-up, which may be difficult for
older adults who cannot easily access
transport or leave their homes. The
benefits of resin infiltration to a patient
in this situation are clear. However,
the clinical experience of dental
practitioners using this technique is
limited. The application of this system
is quite different from that of applying
a fissure sealant and the treatment
of a single lesion by an experienced
practitioner takes approximately 20
minutes. The system is highly technique
sensitive, requiring complete isolation
from moisture contamination and the
radiolucent resin does not allow the
finished result to be seen on radiograph.
The treatment also does not currently
have a code for NHS remuneration, which
is likely to limit its incorporation into
general practices.

4.

5.

6.

7.

8.

9.

Conclusion
The age of a patient should
not be a determining factor when
planning restorative treatment, however,
as with any age group, it is important
to consider the physical, social and
financial impacts of any treatment we
provide to our older patients. Minimally
invasive operative techniques offer the
opportunity to improve the long-term
prognosis of the older dentition and to
provide older patients with a functional
aesthetic dentition for life.

10.

11.

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Flexible working patterns

suits my lifestyle

Zahraa Al-Shamary - Dentist, Exeter Practices

35.

of prevention to adults in NHS

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