Minimally invasive dentistry

Sept. 1, 2004
Dr. Joe Whitehouse, president of the World Congress on Minimally Invasive Dentistry (WCMID), speaks with Dr. John H. Jameson about how minimally invasive dentistry causes a paradigm shift in treatment.

by John Jameson

Dr. Joe Whitehouse, president of the World Congress on Minimally Invasive Dentistry (WCMID), speaks with Dr. John H. Jameson about how minimally invasive dentistry causes a paradigm shift in treatment.

Dr. Jameson: As we look at this type of dentistry being provided for patients, what would be a good layman's definition for us to use when educating our patients about minimally invasive dentistry?

Dr. Whitehouse: The real crux of that is often best seen by the patient with an intraoral camera so that the tooth or situation first of all can be identified. When they see, for instance, a broken cusp that may, in the past, have been diagnosed for needing a crown—especially if they already have a crown—we can explain by pointing to the monitor how we're going to replace that missing cusp with an onlay, whether done in gold or ceramic. The point is still that the patient can experience more tooth structure being preserved. If it has to do with finding decay and the need for a filling where they've got a lot of old silver fillings already, we can show them how minimally invasive and how tiny the new filling may end up being. This causes a shift in the paradigm of extension for prevention which G.V. Black advocated, which we now no longer actually endorse.

The other thing would be the use of technology, specifically lasers, which are extremely kind to tissues. The healing is much quicker than, for instance, an electrosurgery. We can help the patient understand the value of what the technology—the laser in this case—can do. It's really what the patient is looking for! When we present them minimally invasive dentistry, they are all for it. It can be the difference between, for them, reducing two virgin teeth for a bridge versus an implant.They can see the value of that.

We could go on and on about these various areas but, essentially, patients want definition and explanation centered around exactly what this can do for them and what it means to save tooth structure or being kinder to the tissue.

Dr. Jameson: So, video dentistry and lasers are two forms of technology that help promote and accelerate the use of minimally invasive dentistry. What other technological advancements might allow us to do that? For example, I'd think digital radiography and its diagnostic/patient education capabilities would be another tremendous help in advancing this aspect of one's practice.

Dr. Whitehouse: There's no question that when the patient is informed that digital radiography allows them approximately 1/10 of the exposure they'd have from normal X-rays, they immediately realize the high regard for safety that digital radiography would render for them.

I'd also bring up the Diagnodent. Practically every member in the WCMID owns a Diagnodent. Our ability to quantify the decay that's present and know where we actually treat the tooth is a great help. According to Rella Christiansen, we want to have a reading of a minimum of 10—or many of us use 15—on the Diagnodent as a factor that helps us know when there are caries that really need treatment versus the possibility of remineralization with fluoride.

The technology advancements also come into focus with minimally invasive dentistry when we talk about an electric handpiece where the noise factor is greatly reduced. So many patients have expressed their dread of hearing the noise. The electric handpiece is accurate, so that's helpful. But it's also much less invasive in the whole office for everybody. I find this to be an extraordinary instrument by itself.

Dr. Jameson: To introduce these kinds of technologies into our practice, we have to trust that there will be a real positive effect on the mindset of the patient who grows to trust that it's not going to be a grotesque procedure but a conservative procedure. This, in turn, would then increase one's referral rate for patients looking for that kind of dentist, and so forth. So, in looking at the economics of the practice, we'd need to see a positive return of the initial investments of going into this type of technology-driven, minimally-invasive practice. From those of you in the WCMID, have you been able to see or quantify any type of financial opportunity or growth in the practices that have made this transition?

Dr. Whitehouse: I think the technology part is actually the most apparent to the patient, besides the paradigm shift toward minimally invasive dentistry which they certainly embrace. WCMID is really about the technology that goes with the science to help reward the patient with less invasive care. So you must realize that, without the technology, we really can't do the job.

For example, when air abrasion really became useful and very well developed, minimally invasive preps were not only without anesthesia but were very, very small. So the structure of the tooth, obviously, was retained much better than if a central groove and a proximal box were removed. With the technology of the Waterlase now, I do a lot of tunnel preps when there is a proximal surface that is decayed. Maintaining that marginal ridge really preserves tooth strength with the use of technology and materials. We need not forget that the materials we have now—the adhesive materials—have made a huge stride in our ability to actually perform minimally invasive dentistry. The complete prep design has changed from what you and I learned and now allows us to actually just remove whatever it is we want to remove and bond it rather than use extensions for prevention—the kind of retention that amalgams used to require. A product like Fuji IX is a fantastic material. It is a resin-glass ionomer that's very strong in nature, and can be injected into a tunnel prep on the proximal. The seal that we get is extremely good. We therefore are able to predictably fill the prep, whereas if we try the light cure in a tunnel prep, we have some difficulty. But Fuji IX works incredibly well. So, I think we're embracing both technology with science and materials, along with the application of this to the patient's benefit. If we don't explain it to them, we do really lose our opportunity for conversion toward that feeling of "Gosh, my dentist is a minimally invasive dentist. He really tries to save everything he can for my benefit."

Dr. Jameson: As we begin to have that kind of a philosophy in a practice, we must recognize that, in any practice, dentists—even WCMID members—have not reached the limit of where they feel like this can go. Thus, a term, CAMBRA, has been coined. Give us what your feeling is about this acronym's definition and its meaning in the minimally invasive practice today.

Dr. Whitehouse: This may be the most important development to come out of the WCMID, specifically through the efforts of two members—Drs. Doug Young and John Featherstone—who are really focused on Caries Management By Risk Assessment or CAMBRA. Caries Management By Risk Assessment means we need to understand the disease process in the mouth we're restoring. No longer is it appropriate for us to simply put a filling in and let the patient go. We have to put the filling in because of the decay caused by lactobacillus and/or strep mutans. Those particular caries, unless controlled, simply have a field day in a mouth that is already decay prone. So, not controlling that disease process really says that we're not doing minimally invasive dentistry. In California, one of our major plaintiff attorneys, Dr. Ed Zinman, has written that the standard of care now embraces CAMBRA and minimally invasive dentistry. So, we're looking forward to preventing anyone from ever having a lawsuit related to the issue of invasion in a particular situation for a patient's mouth. CAMBRA is, in fact, a philosophy using the science of culturing any bacteria in the saliva of an individual with the Ivoclar culturing unit. The level of bacteria and saliva flow calculated leads to being able to manage the risk. So, for somebody that's at high risk, we certainly want to get into a program of reducing and controlling that bacteria. That way we are not back in the game of drilling and filling.

Dr. Jameson: What concepts or procedures lend themselves best for this evolutionary process to become a minimally invasive dentist?

Dr. Whitehouse: Every dentist can decide just by, say, reading this article or attending the World Congress Meeting, Aug. 11-14, in San Francisco (visit wcmid.com for details) that this is a priority. The issue of how to get started is really a decision about your attitude and philosophy toward diagnosis and case presentation. It means that if I do have to break a marginal ridge to place a proximal filling, I'm going to try and do that with my handpiece or laser and the right materials. If a person needs a bridge, I, as the dentist, am going to recommend they consider having an implant. If they have broken an anterior tooth off at the gumline, instead of extracting that tooth and putting in a bridge or an implant, I'm going to see about super-erupting that tooth and preserving the root so that I have at least a three-millimeter ferrel effect. I'm going to place a crown on that tooth rather than having the patient lose their own root. It goes on and on. It comes down to a decision and a way of practicing that results in "I try to propose what I can do that will be the least invasive way to get a good outcome." That does not mean that we're not aggressive in treating issues that need to be addressed. It means that we're looking at every opportunity from every filling to every periodontal condition to try to manage them effectively, possibly without surgery. That's where something like a perioscope comes in; where we can actually see at 48 power all the calculus that's below the gumline causing the disease, and then just remove that. Some people are having phenomenal success with that. Dr. John Kwan who spoke at the August WCMID meeting is a periodontist doing less surgery. He is using the perioscope and a super minimally invasive technique.

Again, it comes down to introducing that technology and science and asking ourselves, "How can we be minimally invasive?" I'd encourage every dentist to look at all the possibilities of how to treat patients with the technology we have. Then, as we embrace new technology, like CEREC or lasers, learning how they are less invasiveUthen we're on the way. A CEREC is less invasive. By simply replacing a restoration in one appointment, we don't have to be concerned that the patient is always at risk for losing the temporary, of having more invasion into that preparation, etc. Patients think it's tremendously less invasive to have it all done in one appointment.

Dr. Jameson: Observation, total patient care, preservation. Those seem to be the key terms in what you've been describing in minimally invasive dentistry.

Dr. Whitehouse: That's exactly right. You said it well.

Dr. Whitehouse graduated from the University of Iowa in 1970 and practices in Castro Valley, Calif. He is president of the World Congress of Minimally Invasive Dentistry. He is a Diplomate of the World Congress of Minimally Invasive Dentistry and a Fellow of the International Congress of Oral Implantology. He is one of a few dentists with a master's degree in counseling. He is available for speaking engagements on communication skills, tooth surface loss, and cosmetic dentistry. He spoke and conducted the 5th Annual World Congress of Minimally Invasive Dentistry meetings held Aug. 11-14, in San Francisco. To learn more about attending the 6th World Congress meeting in San Diego, visit www.wcmid.com.

Dr. John Jameson is chairman of the Board for Jameson Management, Inc., an international dental consulting firm. Representing JMI, he writes for numerous dental publications and provides research for manufacturers and marketing companies, as well as lectures worldwide on the integration of technology into the dental practice, and leadership. He also manages the technology phase of the consulting program carried out by JMI consultants in the United States, Canada, and Europe. He may be reached at (877) 369-5558 or by visiting www.jamesonmanagement.com.

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