Minimal Intervention Dentistry and Pain Management: Perfect Partners in Restorative Paediatric Dentistry

It was once believed that dental caries was a rapidly progressing disease that required full surgical removal of decayed tissue and restoration of the tooth. The so-called “drill and fill” approach advocated for the removal of all carious enamel and dentine (both firm and soft), taking with it healthy tooth tissue and weakening the tooth structure in the process. Further, most restorations would eventually need to be replaced, trapping the patient in a lifelong cycle of repeat restorations.

In paediatric patients, this invasive restorative treatment can be particularly distressing. There is a well-established connection between negative dental experiences – particularly during childhood – and the onset of dental anxiety, with pain the central factor in many such experiences.^1,2 Affecting up to 33% of children and adolescents, dental anxiety puts young patients at greater risk of dental avoidance and poorer oral health outcomes.^2,3 As a result, they may later require more invasive treatments that only serve to reinforce their anxiety.

Minimal intervention, minimal pain

Minimal intervention dentistry (MID), an inherently child-friendly approach, has been shown to improve oral health outcomes, patient satisfaction, and cost-effectiveness, while reducing anxiety and pain in children.^5,6

First introduced in the 1990s, MID is an holistic philosophy that aims to preserve natural tooth tissue and maintain lifelong functionality of the teeth.³ Practitioners of MID seek to achieve this with a biological approach that addresses the underlying causes of dental caries, rather than simply treating the symptomatic decay.

There is a strong emphasis on techniques that optimise the oral environment, disrupt the disease process, and restore the balance between demineralisation and remineralisation.⁵ When intervention is necessary, non-invasive or minimally invasive dentistry techniques are favoured, focussing on preserving and remineralising tissue wherever possible.^3,5

Next, we will explore various ways in which the minimal intervention approach is currently being applied in paediatric dentistry, with an emphasis on techniques that minimise pain and anxiety for young patients.

Atraumatic Restorative Treatment

One of the earliest MID techniques, Atraumatic Restorative Treatment (ART) uses only hand instruments, rather than rotary instruments. The cavity is first widened, if necessary, using a handheld opener, and the appropriate carious tissue is removed with handheld tools, such as excavators. Once cleaned, the cavity is filled and sealed with a restorative material, which is then shaped and finished with hand instruments for a good occlusal fit.

Unlike earlier approaches, ART does not advocate the removal of all demineralised dentine from the cavity. Evidence shows that this not necessary to arrest the caries disease process; in fact, doing so actually weakens the tooth structure and may compromise the adhesive bond.^3,5 In line with International Caries Consensus Collaboration (ICCC) recommendations, an ART restoration instead removes only soft, decomposed dentine, leaving behind firm dentine that is capable of remineralisation.³ In the case of deep caries, however, a layer of soft dentine can be left over the cavity floor in order to avoid pulp exposure.³

There is a substantial body of research showing that children experience reduced post-operative signs of pulpal disease after an ART restoration, and in one study they reported less discomfort than those receiving preformed metal crowns.^5,7 Further, the absence of dental drills and local anaesthesia injections means that ART is much more tolerable for children, causing less anxiety than traditional restorations.^3,5

ART and Biodentine^TM XP ^(*)

High-viscosity glass ionomer cement (HVGIC) is the most commonly chosen ART material, but newer bioactive materials like Biodentine^TM XP are proving to be excellent alternatives.^3,5 A highly biocompatible material, Biodentine^TM promotes pulp healing; has no cytotoxic, mutagenic, sensitising, or irritant effects; and limits infection and post-operative pain risk from a fundamental research point of view.^4,8

As demonstrated through experimental studies, with a high alkaline pH of approximately 12, Biodentine^TM creates an environment unfavorable for microbes that could otherwise lead to infections and pain. Across several experimental studies, it has shown effective antimicrobial activity against a number of common oral microbial strains, including S. mutans, E. faecalis, E. faecium, E. coli, C. albicans, S. aureus, and P. aeruginosa.^4,8

Further, it has proven more effective than glass ionomer cement (GIC), mineral trioxide aggregate (MTA), and a calcium-enriched mixture (CEM) cement.^9,10,11

While both Biodentine^TM and HVGIC/GIC promote the remineralisation of firm dentine, only Biodentine^TM has been shown to remineralise — and therefore preserve — soft dentine.^3,5,12,13 The dentine layer created by Biodentine^TM has been shown to be thicker and denser, offering optimal pulp protection and increased resistance to micro-leakage and infection.^8,13,14 

Thanks to its excellent biocompatibility, Biodentine^TM can even be used to restore deep cavities when the pulp is exposed. When used alongside the ART technique as a direct pulp-capping agent, Biodentine^TM demonstrated an 83.3% positive success rate in a clinical trial.¹⁶

Non-Restorative Cavity Control

Non-restorative cavity control (NRCC) is a biological method for arresting carious lesions without the removal of carious tissue and, in most cases, without the placement of a restorative material. The aim is to disrupt and remove biofilm at the surface of the tooth and lesion, achieved by opening the carious lesion to allow better access for home management of biofilm. In doing so, NRCC also prevents further demineralisation of the tooth and supports remineralisation.

In the primary dentition, NRCC is best suited to dentine cavities, root cavities and coronal smooth surface cavities.¹⁷ In the case of active lesions, or those at high risk of becoming active, it is recommended that NRCC be supported by anti-caries agents such as 38% silver diamine fluoride (SDF) or 5% sodium fluoride (NaF) varnish.^6,17

NRCC is endorsed by the Scottish Dental Clinical Effectiveness Programme (SDCEP) as a suitable restorative option for children who may find traditional invasive options difficult, e.g., pre-cooperative children or those with special needs.⁵ It eliminates the need for drilling, sedation, and anaesthesia, minimising stress and anxiety for young patients.^17,18 And because no restoration is placed, it also spares the child from the cycle of repeat restorations.

However, evidence shows that the success of NRCC depends heavily on the patient and their caregiver accepting responsibility for the home management of biofilm.⁵ They must be willing and able to fully commit to dietary modifications and meticulous oral hygiene practices. In cases where this seems unlikely, the dental professional is advised to explore other options for caries management.¹⁷

Resin Infiltration

Resin infiltration, or erosion infiltration, is a minimally invasive option for arresting and remineralising non-cavitated enamel lesions on proximal or smooth surfaces of the primary teeth.⁵ Typically completed in one or two visits, it first involves using a hydrochloric acid etch to “open up” the surface of the lesion, before infiltrating it with a low-viscosity methacrylate-based resin that penetrates the enamel.

Resin infiltration has demonstrated the ability to arrest caries and may improve the appearance of white spot lesions.⁵ In a recent randomised controlled trial, only 2.2% of non-cavitated lesions treated with resin infiltration in conjunction with oral hygiene measures had progressed after one year, compared to 20% of lesions treated with oral hygiene measures alone.¹⁹

However, while promising, these findings emphasise that oral hygiene is an essential factor in the success of resin infiltration. It must be provided alongside dietary and oral hygiene advice, and may not be suitable for patients who are unwilling or unable to adhere to such advice.

Pain management as a priority 

With our ever-growing knowledge of the drawbacks of “drilling and filling”, this approach is becoming an increasingly undesirable option for many clinicians, not to mention their young patients. And as we discover new materials and techniques to stop — and even reverse — the damage wrought by primary caries, this approach is also becoming increasingly unnecessary.

Paediatric dentistry is now trending towards preservation of the tooth tissue for the duration of its natural lifespan, with removal of tissue considered a last resort. That translates to fewer needles and drills, less pain and anxiety, and better oral health outcomes for young patients, making MID a natural choice for dental professionals who put pain management at the heart of their paediatric practice.

Regardless of the chosen treatment methods, MID should always be partnered with a comprehensive pain management approach, drawing from a range of pharmaceutical, communication and behavioural techniques for best results. For example, pre-injection topical anaesthetics in dental surgery, such as Septodont topical gel, can facilitate a safe, pain-free injection and a more tolerable experience for the patient.

You can find further information and resources for managing pain in paediatric patients in the following articles:

• Managing young patients’ pain
• Special Patient Series: Treating the Paediatric Patient
• Why topical anaesthetics go hand-in-hand with patient (and professional) satisfaction
• How to avoid the endless cycle of dentophobia?

References