Dr Len D’Cruz considers what additional risks arise for clinicians adopting a minimally invasive approach to dentistry
Read this article to:
- Understand what minimal intervention dentistry is
- Discover the risks associated with this approach
Whilst a minimally invasive (MI) approach to dentistry is not entirely new, its evidence base and popularity amongst forward-thinking practitioners is gaining momentum in a number of countries across the world, including South Africa.
What is minimal intervention (MI) dentistry?
Based on all the factors that affect the onset and progression of disease, minimal intervention dentistry integrates the concepts of prevention, control and treatment. The field of MI dentistry is wide, and includes the early detection of lesions, the identification of risk factors (risk assessment) and the implementation of preventive strategies and health education for the patient.
When the effects of disease are present, in the form of a carious lesion, other therapeutic strategies may be required, but MI dentistry looks to the least invasive solutions, for example remineralisation, therapeutic sealants and restorative care aimed at conserving the maximum amount of sound tissue.
Stop destroying tissue
Ever since the concept of ‘extension for prevention’ was discredited in the 1980s as a method of managing fissure caries, the drive to a more minimally invasive approach to caries has been ever-faster: utilising technology; leading edge diagnostic tests; modern materials and practice-based research.
Why does this conservative way of thinking warrant an article in a risk management publication? The first and most obvious reason is that it is new. When something is new it has its innovators and early adopters, before the majority come on board sometime later. It is at this time that the concept presents the greatest challenge and risk for the innovators and early adopters.
For example, a non-interventive approach, to the untrained eye and in the absence of good clear records, could well appear to be supervised neglect, unless the clinical records indicate otherwise.
There have also been a number of publications and conferences on this issue, such that it is becoming increasingly mainstream.
Consent
Where the patient is young, such as in this case, it is important that the patient and their parents agree to the approach being taken based upon an understanding of the purpose, nature and likely effects and risks of the treatment, including the likelihood of its success, and also discuss any alternative to the MI approach.
The obvious alternative to a preventive approach is an interventive one, and the risks of that should be made clear. When a non-operative approach to caries is taken, there needs to be significant understanding and cooperation from the patient in order to manage their personal diet, as well as committing to a daily preventive regime, which could well be time-consuming. The patient might choose not to do this and instead would prefer to have their cavities restored conventionally; it is their right to choose.
There is a large body of evidence to support these MI principles and the concept now forms part of the curriculum at undergraduate level.
There have also been a number of publications and conferences on this issue, such that it is becoming increasingly mainstream. The HPCSA would expect all dental healthcare professionals to provide good-quality care based on current evidence and authoritative guidance. It further advises that if you deviate from established practice and guidance, you should record the reasons why and be able to justify your decision.
Records
It is not unusual for a risk management article to exhort the readers to make good clinical notes. It is standard advice for the delivery of all clinical care, but it assumes greater significance when patient compliance is the actual treatment delivered to the patient. These clinical records will include the written notes, radiographs, intra-oral photographs, diet sheets and advice (both written and oral).
A minimally invasive approach helps to preserve pulpal health when there are deep cavities. By isolating a lesion and incarcerating the bacteria under a restoration, the clinician will be judged by some to have adopted an effective approach, but to the uninitiated, it may appear to resemble recurrent caries or a failure to remove all the caries.
When communicating this philosophy to the patient, they should understand their ongoing commitment and duty to inform future dentists that a non-interventive approach has been adopted. Without this information, the philosophy is squandered through ignorance.
Risk transfer
The MI approach to caries has the need for patient compliance in common with the management of periodontal disease. But unlike periodontal disease, where the patient can see an improvement in gum health and reduction in measured pockets, the signs of improvement in caries stabilisation are not so obvious. These developments help to reinforce behaviour change and compliance, but for the patient whose early lesions are being actively monitored, there is no such feedback. This may have an impact on a patient’s devotion to the daily routine of prevention and to re-attendance.
The dentist undertaking this approach could effectively be transferring the risk back to themselves. They are taking a gamble that the patient is sufficiently motivated to act on the preventive advice and attend for regular reviews. If they get it wrong, the patient’s condition may worsen.
This is not analogous to periodontal disease management since there is no alternative to the non-surgical management of periodontal disease and plaque control; either they do it or they don’t. In MI dentistry the alternative to them not doing the prevention is for the dentist to intervene. Patient selection is therefore important and understanding their motivation may very well become increasingly important.
If their lifestyle and commitment militate against the MI approach, this should be taken into consideration. It should also be explained, and recorded in the notes. If the patient is willing to try the concept, in order to save enamel, this should be a shared decision. Legal and ethical standards for consent have made the communication of the risks to the specific patient in your chair very relevant.
MI dentistry offers a new way of providing high-quality care to patients that is biologically sound and in the patient’s best interests. There remains some risk to both patients and dental professionals in providing this, but careful and thoughtful communication with the patient will mean that these risks will be largely ameliorated.