Chapter 11

Patient Management Through Non-invasive Treatment

Aim

The aim of this chapter is to describe non-invasive operative procedures that can be used as an alternative to conventional techniques such as local anaesthetic injection and the dental drill.

Outcome

After reading this chapter you should be aware of the techniques that are available as an alternative to current conventional invasive restorative techniques and understand when they are useful.

Introduction

Rotary instruments and hand excavators are routinely used to remove caries during operative treatment of cavitated carious lesions in dentine. Unfortunately, these conventional techniques have several drawbacks including bone-conducted vibrations, high-pitched noise of the air-turbine, sensitivity of vital dentine, development of high temperatures at the cutting surface leading to thermal stimulation as well as possible over-preparation of the cavity. Combined, they are responsible for causing discomfort and pain to the patient. Even if the operator tries to minimise these disagreeable aspects of cavity preparation by keeping the bur speed and pressure constant they are not completely eradicated and local anaesthesia is required. Local anaesthetic injections and the use of dental handpieces and burs are well-documented triggers of dental anxiety.

Anxiety is a well-recognised barrier to the receipt of dental care that can lead to avoidance behaviours and, thus, can have a detrimental effect on oral health. Consequently, people with severe dental anxiety are often in pain and require complex treatment by the time they present to the dentist. In some instances anxiety is such that treatment under sedation or general anaesthesia is required (see Chapter 12), but in others the use of non-invasive treatment can be helpful in building trust, rapport and communication. Coping with conventional techniques can also be difficult for other groups of people to deal with and may be part of the reason why people with learning disabilities have more missing than restored teeth compared with the general population. Whilst it is accepted that the preferred dental management of people requiring Special Care Dentistry is the prevention of dental disease (thus removing the need for invasive dental treatment), in reality, this is not always an achievable goal. In circumstances where dental disease already exists and its treatment is required, the goal must be to make the treatment experience as acceptable as possible. This can be achieved with the use of dental techniques that are as non-invasive and as atraumatic as possible.

Alternative Operative Techniques

Techniques that can help overcome the common triggers of dental anxiety include:

1. Atraumatic Restorative Technique (ART)

ART is based on excavating carious cavities using hand instruments only and using adhesive filling material, such as a glass-ionomer cement, for subsequent restoration. This technique was originally developed to bridge the gap in provision of dental treatment in Tanzania, and aimed at treating people living in rural areas in developing countries where installation of appropriate treatment facilities is difficult, as it does not require the use of drills, running water or electricity. In 1994, the regulation and promotion of this technique were fostered by the World Health Organization. The technique has been widely used since then and evaluation of restorations placed using ART shows satisfactory results at six months, one year, and three years. It is a simple, quick and inexpensive technique requiring no special equipment.

Its minimal intervention approach provides an excellent alternative for:

• children who are being introduced to dental treatment

• patients who experience extreme fear or anxiety about dental procedures

• people who require domiciliary care

• people who are unable to tolerate more conventional restorative treatment, such as patients with a learning disability, dementia, etc.

• people who have movement disorders that can make the use of some dental equipment hazardous, such as athetoid cerebral palsy.

2. Air Abrasion

Air abrasion, developed by Robert Black in 1945, was designed to supplement the conventional high-speed air turbine to avoid its unwanted effects of vibrations, pressure, heat production and pulpal reactions. It is a pseudo-mechanical, non-rotary method that uses kinetic energy to cut dental hard tissues and composite or porcelain restorations. Recent advances in dental technology and adhesive materials permitting minimal cavity preparation, improved isolation using the rubber dam technique and high-volume suction apparatus have led to a renewed interest in the air abrasion technique. Air abrasion can abrade carious enamel and sound dentine painlessly by blasting the tooth with high-velocity alumina particles at a pressure between 60 and 120 p.s.i., depending on the diameter of the nozzle tip. The energy is transferred to the tooth surface on impact and, acting as an end cutting instrument, produces a small diameter access c/>

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