Minimally invasive dentistry (Endodontics) Minimally invasive dentistry (MID) is the application of “a systematic respect for the original tissue.” This implies that the dental profession recognizes that an artifact is of less biological value than the original healthy tissue. MID is a concept that can embrace all aspects of the profession. The common delineator is tissue preservation, preferably by preventing disease from occurring and intercepting its progress, but also removing and replacing with as little tissue loss as possible. It does not suggest that we make small fillings to restore incipient lesions or surgically remove impacted third molars without symptoms as routine procedures (Ericson 2004). Some authors have defined MID as maximal preservation of healthy dental structures. For example, within cardiology, this concept includes the use of all available information and techniques ranging from accurate diagnosis of caries, caries risk assessment and prevention, to technical procedures in repairing restorations (Ericson et al. 2003; Ericson 2007). [2,3] Others have defined it with even greater clarity, such as White and Eakle (2000) and Murdoch-Kinch and McLean (2003) with the objective of MID encompassing a range of clinical procedures that include assessment of caries risk to reinforce patient self-help, early detection of the disease before lesion cavitation to fortify the oral environment, restoration of fissure caries with maximum retention of sound tooth structure and sealant placement in unaffected areas. This conservative approach minimizes the restoration/re-restoration cycle; thus, benefiting the patient over a lifetime. The world congress of MID defines minimally invasive dentistry as those techniques, which respect health, function and esthetics of oral tissue by preventing disease from occurring, or intercepting its progress with minimal tissue loss (Nový and Fuller 2008). With regards to endodontic procedures, it can range anywhere from diagnosis to making a decision not to treat, to a minimally but purposefully crafted access openings based on anatomical challenges, to minimal removal of dentin during access opening, enlarging and shaping of the root canal to retain as much sound dentin as possible, to retention of tooth structure during disassembly and retreatment or considering apical surgical intervention, to performing a crown lengthening procedure to establish sound tooth margins for core/crown restorations as opposed to tooth extraction and implant or bridge placement. To be more specific with regards to endodontics and root canal procedures the following bulleted items are put forth to capture the essence of what is needed to be achieved within the scope of minimally invasive endodontics (MIE) if this is to be the future of dental practice. • Diagnostic testing to determine the actual status of the dental pulp often finishing up as guess work for the
clinician and more often than not treatment of some type is chosen because of “a hunch;” or the position of “let’s do something that might work;” or is driven by economic pressures within the framework of today’s dental practices. Efforts must be made to enhance diagnostic testing and standardize the concepts within the dental profession. MIE could also include the provision of a pulpotomy as a definitive procedure, but only if the status of the dental pulp can be determined much better than we do today. There are many patients who could be helped in this way, especially if there are financial constraints to having a root canal procedure. Knowledge of anatomical structures and their variations is essential so that from caries removal to root canal enlargement sound tooth structure should be preserved. Cervical root structure is at risk with excessive enlargement that is proposed with some techniques and results with the use of certain instruments. Development of techniques that minimize tooth structure removal for crown placement as the excessive use of porcelain-fused to metal crowns or for that matter, porcelain-only type crowns requires the removal of too much tooth structure that results in adverse pulpal responses. Considerations for crown lengthening procedures (and possible orthodontic extrusion) must be a priority before wholesale tooth extraction in cases of deep carious tooth margins, fractured tooth margins or margins violated by resorptive or perforative defects. Access openings must be crafted to preserve sound tooth structure; especially important is the prevention of gouging cervically, laterally or into the floor of the pulp chamber. However, access that is too restricted will impact greatly on what we do in certain situations. While judicious orifice location and careful canal penetration are essential, efforts should be made to minimize the excess removal of cervical tooth structure in the canal orifice through the use of Peeso reamers, Gates Glidden drills and orifice opening instruments. The literature indicates that loss of tooth structure cervically weakens the tooth and makes it susceptible to fracture. The use of Peeso reamers and Gates Glidden drills deep into the root canal should be abandoned in favor of minimally tapered rotary instruments (no larger than .06). The former instruments tend to straighten the canal, weaken the root walls and predisposing them to cracks and in some cases leads to irreparable defects, like root wall stripping defects. While the concept of larger apical sizes has received
Journal of Conservative Dentistry | Jul-Aug 2013 | Vol 16 | Issue 4
Gutmann: Minimally invasive dentistry
some literature credibility with regards to bacterial reduction, maintaining smaller sizes when possible (>20 ≤ 40) would seem desirable for preservation of radicular dentin in the majority of cases. It would then seem reasonable to develop better methods of canal cleaning and disinfection that can be used in the presence of retained, sound tooth structure. • Techniques that favor ease of deliver of obturation materials thoroughly within the root canal with minimal application forces would tend to avert the possibility of root fractures and the placement of material beyond the confines of the canal orifice. • The use of strong, well-placed, bonded core materials and a post (only when absolutely necessary) prior to crown placement would help to tie the components of the tooth together to resist both functional forces and occlusal leakage. • Excellence in occlusal adjustments to prevent adverse functional forces is essential for all dental practitioners, including endodontists. Caution must be exercised when espousing the concepts of MIE in that there are proponents that would have you believe that MIE exists solely with the framework of preserving a few millimeters or less of cervical tooth structure while their empirical claims lack documented and meaningful studies (Clark and Khademi 2010 and Clark et al., 2013a, b).[7-9] Prevention/management of pulpal and periapical disease, along with tooth retention, are prime goals within MIE. Within this framework is the need for preservation of tooth structure and supporting tissues, especially as it relates to the preservation of sound coronal and radicular dentin. The concept and application of minimally invasive approaches to what dental professionals do bridges the
traditional gap between prevention/retention and surgical/ removal type procedures, which is just what dentistry and endodontics need today and research must focus on the validity of these dictates.
James L Gutmann Department of Restorative Sciences, Texas A&M University Baylor College of Dentistry, Dallas, Texas, USA E-mail: [email protected]
REFERENCES 1. 2. 3. 4. 5. 6. 7. 8. 9.
Ericson D. What is minimally invasive dentistry? Oral Health Prev Dent 2004;2(Suppl 1):287-92. Ericson D, Kidd E, McComb D, Mjör I, Noack MJ. Minimally invasive dentistry – Concepts and techniques in cariology. Oral Health Prev Dent 2003;1:59-72. Ericson D. The concept of minimally invasive dentistry. Dent Update 2007;34:9-10, 12. White JM, Eakle WS. Rationale and treatment approach in minimally invasive dentistry. J Am Dent Assoc 2000;131(Suppl):13S-9. Murdoch-Kinch CA, McLean ME. Minimally invasive dentistry. J Am Dent Assoc 2003;134:87-95. Nový BB, Fuller CE. The material science of minimally invasive esthetic restorations. Compend Contin Educ Dent 2008;29:338-46. Clark D, Khademi J. Modern molar endodontic access and directed dentin conservation. Dent Clin North Am 2010;54:249-73. Clark D, Khademi J, Herbranson E. Fracture resistant endodontic and restorative preparations. Dent Today 2013;32:118, 120-3. Clark D, Khademi J, Herbranson E. The new science of strong endo teeth. Dent Today 2013;32:112, 114, 116-7.
How to cite this Article: Gutmann JL. Minimally invasive dentistry (Endodontics). J Conserv Dent 2013;16:282-3. Access this article online Quick Response Code: Website: www.jcd.org.in
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