The Modern State of Minimal Dentistry

The concept of minimally invasive dentistry (MID) means different things to different clinicians, and it’s far from a new idea.

Some 3 decades ago when cosmetic dentistry first took off, many people wanted a Hollywood smile and were not concerned about how much tooth structure was removed to achieve those extreme makeovers. Veneers—some procedures of which today would seem plenty invasive—were popular in the 1990s. Also, everyone seemed to be pushing tooth whitening lights and materials, some of which worked better than others and some of which caused patients to experience sensitivity issues.

Fast forward to today and many things have changed, but the concept and the importance of providing MID is more important than ever. Patients expect to keep their teeth longer while they live longer. They expect procedures and treatments to prevent caries, reduce the need for surgeries, and to provide care with as little pain as possible.

Thanks to advances in materials, techniques, and technology, all these expectations can and should be met today. Improved early diagnostic methods can better fend off caries and tackle periodontal issues, and technological advances in terms of imaging, lasers, and even rotary instrumentation have had positive impacts as well. The awareness that minor tooth movements can prevent the need for major treatments later, coupled with clear aligner therapy advances in software, technique, and materials, means more general practitioners (GPs) can deliver more efficient orthodontic care to their patients.

In addition to all the new developments, lessons learned years ago by organizations such as the World Congress of Minimally Invasive Dentistry (WCMID)—which used to meet annually to showcase topics such as how materials and research on caries risk assessment can help prevent them and how lasers can play a role—planted seeds that have an impact today.

Now, many material companies offer products designed to remineralize tooth structure and others offer prescription-formula toothpaste and rinses geared toward preventing caries for at-risk patients who need a little extra tooth protection.

Chris Walinski, DDS, a longtime consultant and educator in laser dentistry, was the WCMID president many years ago. Back then, air abrasion was more common than it is today, but early caries detection systems were just taking hold, and dental materials geared specifically for MID protocols also were in their early stages.

“Twenty years ago, I was president of the [WCMID],” he says. “The hot topics were wet vs dry air abrasion, ozone therapy, early caries detection systems, and biomimetic restorations. If I had to boil it down, the emphasis was [on treating] our patients using a medical model to treat disease rather than the surgical model we still employ today. In other words, treat bacterial infections including dental caries so that we could stop excavating or amputating portions of our patients’ teeth.”

While some clinicians may argue that not enough of today’s dentists implement adequate minimally invasive methods in their everyday care, great strides in awareness, expectations, and follow -through have made for better results and happier patients.

“Many of the philosophies and techniques we implemented back then are now staples in our treatment regimens,” adds Dr Walinski, now the dental director for a dental service organization. “An example would be caries management by risk assessment (CAMBRA), which is taught in every dental school in the country. I am proud of how instrumental the WCMID was in bringing [MID] into the mainstream.”

CAMBRA protocol consists of analyzing the dental patient’s profile by assessing their risk and protective factors and assigning a risk level to the patient to develop an individualized treatment plan. This protocol combines restorative treatments with preventive chemical therapy.¹

Like Dr Walinski, V. Kim Kutsch, DMD, was a fixture at WCMID conferences years ago and a pioneer in the CAMBRA protocol. The longtime dentist, who was frustrated about the lack of effective options for cavity-prone patients, worked with researchers and world-renowned experts to find a solution. He launched CariFree products in 2004 and his company, Oral BioTech, has a line of products geared toward cavity prevention with a blueprint that includes antibacterial and acidity reduction, proprietary pH+ technology, fluoride for remineralization, and nano-hydroxyapatite.

The CariFree products are just some of many dental solutions available today designed to help prevent cavities, remineralize tooth structure, limit the removal of as much healthy tooth structure as possible, and provide the least invasive, longest-lasting optimal care for patients.

“In regard to the biomimetic movement, I feel personally that this was originally referred to as minimally invasive dentistry almost a decade or so ago,” says Gregor Connell, VOCO Canada/America Inc, North American Director of Clinical Education. “To speak to this movement, I published an article in the southern hemisphere journal, Australasian Dentist, back in 2023. The article introduced the reader to the 6 key material tests that composites undergo that really matter once the material is placed in the mouth.”

These tests were termed key clinical performance indicators (KCPI), and if a material could achieve tooth-like values the material could have a very positive impact on long-term marginal integrity and success of direct restorations, he adds.

“Minimally invasive dentistry is only one half of the equation—if you are placing a non-tooth-like material into the MIP [maximum intercuspal position], you cannot expect an optimal outcome. VOCO created a family of restorative materials over the past decade that focus on having ‘tooth-like’ properties, offering a more synergistic restorative medium to promote longevity and function,” Connell adds.

VOCO’s product line includes GrandioSO, GrandioSO Xtra, and GrandioSO Heavy Flow materials formulated to deliver function and long-lasting results.

Jeff Rohde, DDS, and Katrina Sanders, RDH, are each passionate about providing the best, minimally invasive care to their patients. Dr Rohde lectures on a variety of topics, including clear aligner therapy and dental lasers, while Sanders too is an international speaker and a co-host of the Floss & Flip-Flops podcast that is produced monthly by Dental Products Report and Modern Hygienist, in partnership with The Sanders sisters.

What Is MID?
Dr Rohde is all in on using his Solea all-tissue laser from Convergent Dental, maintaining as much healthy tooth structure as possible, and keeping his patients happy and comfortable.

Technology has a major impact here, as lasers can mean less painful injections, and same-day digital dentistry can mean fewer visits to the office for patients getting a crown milled chairside. Many patients will tell you an intraoral scan is less invasive than placing trays with impression material in their mouths, so there again technology is a plus.

But one thing Dr Rohde is adamant about is using orthodontics to move teeth and eliminate the need for more extensive surgeries.

“There are 2 ways where you can say minimally invasive,” explains Dr Rohde, who has lectured on behalf of Dentsply Sirona and its SureSmile aligner therapy. “One is, if you are going to do work, you’re aligning the teeth first. Any esthetic case where you can get the roots in the right position first means more conservative preparations, right?”

A veneer prep when teeth are not properly aligned can be the opposite of minimally invasive because the first thing you must do in that situation is “cut everything off that’s not in the right spot,” he says. “So, you’re amputating all this tooth structure unnecessarily, when if you just move it into position now, you can do your ultraconservative treatment, right?”

Another aspect with MID in mind is to avoid certain procedures in the first place. Correcting a patient’s bite with aligner therapy can improve the periodontal health of the patient and prevent incorrect wear on the teeth.

“Rather than waiting for the destruction, gradually having the slow decline of teeth and incorrect wear and periodontal disease, the minimally invasive part is, why wait until the problem has just gotten worse? You’re going to fix it on the front end. When someone’s teeth and bite are all in the correct position, then your need for maintenance goes way down. You’re fixing the potential [problems] that way,” Dr Rohde adds.

Many lessons have been learned since the cosmetic explosion decades ago. One, says Dr Rohde, is that veneers should not be placed as a temporary cosmetic fix that leaves long-term problems in the mouth.

“If someone has good teeth [but] they’re just in the wrong spot, why are you doing veneers?” he asks. “If there is no restorative need, there’s no size discrepancy, no unsightly old restorations, there’s no previous fracture traumas…they just maybe have teeth in the wrong position. No one should be prepping those for veneers anymore. That’s ortho[dontics]. You may do something conservative; you align, do some whitening, and you’re done. Then maybe a little bit of bonding, so I guess the third way [to practice MID] is that you may not need any restoration on the front end when you’re doing it for a cosmetic case like that.”

The materials, software, and number of options available for clear aligner therapy have exploded over the past decade. While many GPs may not have been interested or confident in straightening their patients’ teeth in the past, today they are doing themselves and their patients a disservice if they don’t offer some type of clear aligner therapy. Clinicians must understand the idea of a multidisciplinary mindset.

“Not every patient who comes in your door needs orthodontics. Let’s be clear,” Dr Rohde says. “But orthodontics should be part of your treatment planning, at least when considering something like occlusion. If you can look at a patient and go, here’s what’s going on, and you have a mindset that includes perio[dontal], restorative, ortho…if someone comes in with destructive occlusion because the teeth are not in the right position and you’re like, ‘Well, I guess I’ll just do a filling here and not consider ortho, or not treat that, or not make a recommendation,’ [then] yes, you’re failing that patient.”

The Whole Picture
Dental lasers have not eliminated the need fordentists to reach for their handy handpiece. In fact, some manufacturers were discredited a bit years ago by overpromising how they could end the need for anesthetic injections. No-drill dentistry had a nice ring to it, but the technology early on couldn’t deliver on all the hype.

Things have changed for the better and all-tissue lasers such as the Solea, the PerioLase MVP-7 from Millennium Dental Technologies, and the BIOLASE Waterlase iPlus Premier Edition are just a few of the available options that can indeed handle more procedures and usually do so with less trauma and faster healing.

“No one should be doing extension for prevention anymore,” Dr Rohde says, referring to the early dental practice of removing a large amount of tooth structure to allow for amalgam restorations. “You should be treating just the decay. And, worst case, any given tooth could have part filling, part preventive resin restoration, or part sealant all on the same molar. You’re just treating what needs to be treated and sealing it back up. I’d be so bold as to say no one should be doing extension for prevention anymore—no one should be cutting teeth unnecessarily.

“Now add the laser to it. The laser allows you to conservatively treat. It essentially removes decay and stops at that healthy enamel. It kills bacteria and removes all biomatter from the grooves for more adequate sealing. It’s also minimally invasive if you use a hard tissue laser such as Solea because you’re not injecting the patient. So again, minimally invasive doesn’t mean just the tooth. It means, what experience does the patient have?”

Over time, the advent of better bonding systems means clinicians can predictably bond, add to teeth, and maintain them in ways that produce long-lasting results. Improvements in materials science have led to better and stronger materials that don’t have to be as thick. Add in topical anesthetics and other new products that hygienists can give patients to keep them comfortable, including during minimum scaling and root planing. This can help patients avoid getting injections, yet another plus delivered by MID concepts.²

A Periodontal Perspective
Previously, periodontal issues were heavily treated through integrating cutting edges, scraping teeth, and curetting diseased cellular epithelium, says Sanders, who added that those methods were a big focus for a long time.

“To me, minimally invasive periodontics started to see pivots when we integrated things such as growth factors like PRP [platelet-rich plasma] or PRF [platelet-rich fibrin], where now we’re leveraging the patient’s own body to help us with this,” she says. “There is an intervention, but that intervention is really leveraging the use of the host response, right? How is the body going to take its own cells and utilize that as scaffolding, etc? Which I love.

“That’s one piece to the puzzle. I think that really paved the way for periodontics to expand beyond scraping teeth. Patients don’t want flap surgeries anymore where they’re getting flipped open and then sewn shut. They don’t want gingival grafts with giant slices from the palate getting sewn into places. They want minimally invasive, and that terminology indicates to the patient that it’s likely going to be less painful. And minimally invasive also means that we’re going to be leveraging the patient’s own body in a lot of ways.”

Many products are helping deliver this form of care to patients, and Sanders has a few she believes dentists and hygienists should consider implementing.

Designs for Vision’s REVEAL utilizes a blue excitation headlight with specially filtered eyewear to provide hands-free vibrant fluorescence visualization in real time. This wearable fluorescence guide dentistry solution allows clinicians to visualize the byproducts of bacteria associated with caries, calculus, and peri-implantitis without the use of any pharmaceutical, chemical, or dye. Designs for Vision adds that REVEAL allows users to control and conform the complete removal of mature biofilm during prophylaxis.

Sanders says this technology has been used in the medical space for a long time with strong results during brain surgeries, foot surgeries for diabetics, and in other treatments where it’s important to remove unhealthy tissues while leaving behind as much healthy tissue as possible.

“If you’re removing healthy tissue, that is just far more work the body of a diabetic patient who may have delayed wound healing or immunocompromised status is going to have to do, right?” she explains. “So, then we take this technology and let’s go ahead and plop it into dentistry. What we’re doing in dentistry is we’re utilizing this technology to see infected tissue. We’re also using this technology to see calculus. Now the areas where the clinician is scaling are only those sites where we see calculus, but we’re leaving behind healthy tooth structures.”

This technology prevents hygienists from intentionally removing cementum, which is important to preserve so that you can get gum attachment for healing. “That REVEAL technology is really an interesting bridging of the gap between our health care colleagues and the dental colleagues in saying, ‘Hey, we’re going to take this minimally invasive case, and it’s going to allow us to target or be precise,’” Sanders says.

Another product that fits this mold is the Perio Protect noninvasive Perio Tray therapy that holds medication deep below the patient’s gums.

“This tray, when loaded with an appropriate medicament and seated in the patient’s mouth, pushes that medicament underneath the gum line area, and it pushes it such that now the gum tissue is in an interaction with that medicament,” adds Sanders, who says the product does wonders with wound healing and has led to several cases where bleeding scores have been reduced.

There’s More
Probiotics is another area in which breakthroughs have shown promise in helping to maintain healthy flora in both the oral microbiome and the gut. StellaLife, with itsPre+Post+Probiotics Kit, and BioGaia are just 2 of many brands offering products designed to promote healthy gums and deliver a minimally invasive, preventive approach to both oral and overall health.

With so many technologies and techniques now available, clinicians can and should take a minimally invasive approach whenever possible. Researchers, manufacturers, and organizations such as the WCMID laid the groundwork decades ago, and today’s patients are seeing and feeling the benefits.

When these patients get more involved with their health and know more about what their dentist’s office is doing for them by delivering the best, most comfortable care, everyone wins. They’re more inclined to floss and brush better, maybe wear their Perio Protect trays or aligner trays more frequently, and certainly not be as afraid to see a dentist or hygienist who they know is taking steps to be minimally invasive with their care.

“Not only are the patients now kind of taking charge and being in control, but they’re also more comfortable,” Sanders says. “You remember [the dentist scene in] Little Shop of Horrors? We don’t want to do that. We don’t want to be that. We don’t want patients to sit down and say, ‘I hate going to the dentist.’ This is a huge opportunity [to change those perceptions].”

References

1. Coelho A, Amaro I, Iunes T, et al. CAMBRA protocol efficacy: a systematic review and critical appraisal. Dent J (Basel). 2022;10(6):97. doi:10.3390/dj10060097

2. Elsenpeter R. Do patients less harm. Dental Products Report. 2021;55(4):24. https://www.dentalproductsreport.com/view/do-patients-less-harm