PUBLISHED IN PAKISTAN www.dental-tribune.com.pk NOVEMBER, 2018 - Issue No. 06 Vol.5 An exlusive interview with Dr Asif Niaz Arain 1st Convocation University of Health Sciences Implants should only be inserted when periodontal ... INTERVIEW Page 4 CONVOCATION Page 6 CLINICAL IMPLANTOLOGY Page 8 Mercury-free healthcare initiative DT Pakistan Report I SLAMABAD - Realising that exposure to mercury is injurious to health, the federal government is planning to embark on a c o u n t r y w i d e initiative to free health f a c i l i t i e s f r o m e q u i p m e n t a n d products made of the silvery toxic metal. Under the Mercury- F r e e H e a l t h c a r e Programme being developed by the Ministry of National H e a l t h S e r v i c e s , R e g u l a t i o n s a n d Coordination in consultation with stakeholders, all mercury-containing medical devices will be phased out by 2020 with their safe alternatives coming in. The initiative is being taken to protect people from the devastating health consequences that can arise from mercury use. the World Health Organisation identifies it as one of the top 10 chemicals, which can endanger and harm health. According to the UN agency, which c o o r d i n a t e s international health activities and helps g o v e r n m e n t s i n improving health services, mercury can h a v e s i g n i f i c a n t harmful effects on the nervous, digestive and immune system and on lungs and kidneys, a n d i t s e x c e s s exposure can even be fatal. It is known to be extremely harmful to the foetus, and even if exposed at low doses in the womb, the developing baby can experience Continued on Page 15 Currently, mercury is used in dental amalgam (fillings), thermometers, blood pressure devices, fixatives, preservatives, lab chemicals, cleaners and other medical products, though Request for increase in health budget tabled to PM I DT Pakistan Report SLAMABAD - While p l e d g i n g t r a n s f o r m a t i o n a l changes in the health sector, particularly in public sector hospitals where patients are generally denied appropriate attention, treatment and respect, Minister for Health Aamer Mehmood Kiani claimed having tabled a request to the Prime Minister for increasing the country's health budget to 2 per cent of the GDP in the next budget. Addressing a symposium o T r a n s f o r m i n g HealthCare at the Pakistan I n s t i t u t e o f M e d i c a l Sciences (PIMS), Aamer appreciated the executive director of PIMS Dr Amjad f o r b r i n g i n g a b o u t i m p r o v e m e n t s , commissioning needed equipment, and renovating dilapidated wards, but maintained that a lot still needs to be done for improved patient services and care. President Arif Alvi was INCREASE Health Budget a n d p r o f e s s i o n a l s postgraduate students. Aamer pledged to turn Islamabad into a model health city. "We want to introduce a pro-poor health system, starting from Islamabad district, as a model to revive people's confidence in the public sector's capacity to deliver quality healthcare. Concrete steps have been taken to improve the health sector," the minister stated. the chief guest. "Patients should be treated with respect. Our vision is to strengthen PIMS as a p r e m i e r t e r t i a r y c a r e institute in academics, research and innovative clinical ground-breaking procedures," Aamer stated at the symposium, which focuses on current research, technological advances, and hands-on practice through training workshops for medical, dental and nursing 100-day performance report on health sector DT Pakistan Report I SLAMABAD - Following suit from other ministries and departments, the federal health ministry presented its three-month performance report to Prime Minister Imran Khan, highlighting how it prepared an ordinance on the apex medical education regulator. According to sources in the health m i n i s t r y, t h r e e - m o n t h performance report states that the ministry worked to prepare an o r d i n a n c e a m e n d t h e P a k i s t a n i t s t o Medical and Dental Council's (PMDC) laws and that this ordinance has been sent to the federal cabinet for approval. Moreover, the report noted that the ministry had, for the first time in the history of the country, started working on a system which would help control infectious diseases at the ports of entry for all those who were either coming or leaving the country. The system has been introduced at 19 entry points to the country including international airports, seaports and land ports. The system includes installation and deployment of necessary facilities and equipping staff at all ports with the requisite equipment and training. Moreover, soon this staff will have special uniforms. Sources said that with the federal government abolishing the Capital Administration and Development Division (CADD), all health-related institutions in the federal capital were now being managed by the Continued on Page 15
4 DENTAL TRIBUNE Pakistan Edition November 2018 INTERVIEW PDA needs to be run professionally to achieve its objectives: Dr Asif Niaz Arain D r Asif Niaz Arain is a graduate of 1981. He became affiliated with Pakistan Dental Association (PDA) in 1987. From 2002 to 2005, he served as the General Secretary of PDA. In 2002, Dr Asif Arain was nominated by the PDA as National Liaison officer (NLO) to represent Pakistan in World Dental Congress, which he did for about 10 years. After a break of five years, in 2018 Dr Asif Arain was again appointed by the PDA to represent Pakistan at the FDI World Dental Congress in Buenos Aires, Argentina, where our Editor Overseas, Dr Abbas Naqvi, asked him a few exclusive questions for our readers. Currently, Dr Asif Niaz Arain is the Vice President of Asia Pacific Dental Federation (APDF). By Dr Abbas Naqvi Dental Tribune Pakistan: How will y o u d e s c r i b e P a k i s t a n ' s r o l e / p a r t i c i p a t i o n i n g l o b a l organized dentistry? Dr Asif Niaz Arain: World Dental Federation's role is policy making for different issues. Issues like amalgam usage, oral hygiene awareness etc. Alhamdulillah, Pakistan has been part and parcel of policy making in the FDI, and we have been playing our role quiet actively. Our President of Pakistan, Dr Arif Alvi, whom we are very proud of, was member of the FDI council for about 4 years. His son Dr Awab Alvi has represented Pakistan in the World Dental Federation as well. So, they have been part and parcel of making policies. DTP: Who are the people apart from yourself and Dr Alvi, who have been actively representing Pakistan on these platforms in the past decade or so? ANA: There are a couple of people actually, namely Dr Mahmood Shah and Dr Anwar Saeed. They have been participating very regularly. I, myself, have been attending World Dental Congress since 1994. Very rarely do I miss them. So, every time there is a flag ceremony at such events, we have been there to raise the Pakistani flag and to represent Pakistan; and we have been there to discuss and offer opinions on several issues; and have contributed in policy making. DTP: When you look back, how effective have we been? ANA: We have been quite effective with making policies. As I said, Dr Arif Alvi has been very actively involved in policy making. After a policy is made and FDI has officiated it, the FDI, unfortunately, cannot do much about its execution; they can only guide the dental associations to carry on with its implementation. programmes, and Dr Ayyaz Ali Khan conducted them in Punjab. The funds are very limited, because FDI does not receive a lot of funding. Certain manufacturers at times release funds for awareness activities and we use Pakistan has been part and parcel of policy making in the FDI, and we have been playing our role quiet actively. Awareness about issues like oral health problems, maintenance of oral hygiene and especially training children for it, is important. Media, such as social platforms are used for this reason. DTP: How has the PDA kept up with transferring the policies that we contribute to, to benefit the people of Pakistan? ANA: Policies can only be translated simply through various media. I don't know how the PDA does it, I'm not the part and parcel of PDA anymore, but I think they try through newsletters or dental publications. One or two times we had the chance to get some funds for awareness programmes. Back in 2007 or 2008, we got a budget for oral health them for that purpose. Whenever, we get a chance, we did it very well. Pakistan has been playing its role very responsibly. DTP: How do you see Pakistan's future in global organized dentistry? A N A : We h a v e b e e n w e l l - represented in FDI and Asia Pacific Dental Federation, which the regional organization of FDI. We have been officers in APDC since last 12 years. The top benefit of being part of such large-scale associations is that you get to organize educational programs in your country. In 2006, the Asia Pacific Dental Congress was held in Karachi. Unfortunately, due to security concerns we lost our chances in 2015 and 2017. We were allotted APDC for the two years but were unable to execute it since due to our circumstances, our security problems people were not willing to come to Pakistan. Insha'Allah, when the security problems will be solved in Pakistan, foreign people will be happy to come. We will again conduct some dental congresses for the betterment of dental education. DTP: In the last 15 years, we have only seen 5 Pakistani dentists attaining international stature. Why is that? Is there no replacement of these 5 people? ANA: People have to take initiative. Very few people want to spend money from their own pockets, since you don't get any support from our association. Whenever we travel for representation we do so by our own expenditures. Government doesn't take any interest in sending their people to attend these congresses. So unfortunately, not many people are interested in sparing the time to go to attend these conference. D T P : H o w i s i t w i t h o t h e r organizations in other countries? Should it be the PDA's responsibility t o f i n a n c e i t s c o u n t r y ' s representation? ANA: Let's take Indian Dental Association for example. They have a budget of many, many millions of rupees, and they fund 8 to 10 people to attend these congresses, but unfortunately, in the case of Pakistan Dental Association, they don't have funds enough to even finance one participation in these congresses. Continued on page 06
6 DENTAL TRIBUNE Pakistan Edition November 2018 CONVOCATION 1ST CONVOCATION UNIVERSITY OF HEALTH SCIENCES IADSR raises bar of CPD standards DT Pakistan Report L AHORE - Institute of Advance Dental Sciences & Research i t s F i r s t ( I A D S R ) h e l d Convocation at the University of Health Sciences, Lahore on December 9th. Professor Javed Akram, Vice Chancellor UHS, was the Chief Guest, and Professor Paul Tipton from U.K. was the Guest of Honor for the occasion. Professor Paul Tipton kept a 250 plus audience glued to their seat during his marathon three-hour session on Occlusion. Starting from the very basics he took his enthralled audience along to finer details of occlusion management. Prof. Tipton is rated as one of the most influential speakers in dentistry globally; this proactive and participatory session witnessed his command on the subject. Prof. Tipton conferred the Professional Diploma in Advance General Dentistry to the successful participants, while Prof. Javed Akram honored the faculty of the course with Certificates of Appreciation. At the end Professor Ayyaz Ali Khan, National Coordinator, IADSR presented plaques to the worthy guests. An exclusive interview with Dr Asif Niaz Arain ... Continued from page 4 DTP: From your experience of local organized dentistry, why do you think the PDA does not have funds? ANA: What is PDA? PDA is a collection of dental surgeons of Pakistan. Unfortunately, we expect that PDA should spend from its pocket. This is unfortunate. There are so many of us yet no one is really ready to pay even a decent amount of money as membership fee to Pakistan Dental Association. DTP: Associations generate funds from sponsorships, which realize when sponsors see value. Is it not fair to say that PDA has failed to create value for sponsors? ANA: No, I don't think PDA has failed. It is just that we are not very well organized. You can say that we have not channelized the things well, b e c a u s e u s u a l l y t h e d e n t a l manufacturers or suppliers are the ones that fund the PDA activities in Pakistan. Now there is a separate association for them and so sometimes we don't get enough funds. If we become better organized if we will have some power and influence like in other countries. National Dental Association (NDA) has a very powerful role in the certification of the dentists. DTP: Please tell us about the next position you are vouching for and what's your manifesto? ANA: I have been nominated by Pakistan Dental Association to run in the elections for a post in Dental Practice Committee. First point from the agenda that I have in mind is that young dentists in our country don't have proper guidance in regards to setting up their clinics, designing their clinics or their practices. There should be certain plans in place to guide these young dentists. DTP: What is your message for the profession? A N A : We h a v e S o c i e t y o f Maxillofacial Surgeon, we have Society of Prosthodontics, we have Society of Orthodontists in Pakistan, but when you are not organized, you can do nothing on the larger scale. Yes, you can do better for your own self but you cannot do anything better on the larger scale. It has to be a triangle. At the tip of the triangle there s h o u l d b e P a k i s t a n D e n t a l Association. Every person should be the part and parcel of that. You will f i n d m a n y g r o u p s f o r m i n g themselves. What is the problem? Why can't they all get together, sit together and solve the problem, if there is some personal problem. Only one organization can be effective. When you form a triangle, a pyramid, then only can you be more influential, and then you can make policies and go to the government. So my advice to the young dentists is that they should respect the Pakistan Dental Association. If they have any issue, they should come up and talk about it but by remaining within the framework of one association, not splitting up into different groups. Unity is the only survival. If you don't have unity, you can't do anything. That is my message to the youngsters. We have played our part, now there must come some youngsters who should take over. If there is some restriction for them in taking over, please come up. Use media for your problems. If they have some issue with the central council they should come up, so that it could be solved, but should remain in one house. Like parents and children, they should respect the seniors and the seniors should respect the juniors. It should go both ways. DTP: Are the seniors willing to delegate? ANA: Yeah, why not? Who can live forever, nobody can live forever. In Asia, we have a new central council. There are so many young people. Apart from Dr Mahmood Shah and Dr Anwar Saeed, the rest of the council is of young people. So, why can't the young people come up? If there are some issues, they should be solved. Adam and Eve had many advantages, but the principal one was, that they escaped teething. ~Mark Twain
8 DENTAL TRIBUNE Pakistan Edition November 2018 CLINICAL IMPLANTOLOGY Implants should only be inserted when periodontal conditions are stable By Dr. Jan H. Koch B iofilm is the most significant cause of inflammatory bone loss around teeth and implants. D i a g n o s t i c s , b i o f i l m management and, where necessary, treatment help in patients with this problem. The W&H No Implantology without Periodontology workflow should provide s t a b l e t o i m p l a n t a t i o n t h r o u g h prevention, and implant success in the long term through aftercare-something that is advantageous to both the patient and the treatment team. t i s s u e p r i o r Implant treatment can significantly improve quality of life after tooth loss. The l o n g - t e r m p r o g n o s i s i s generally good, but biological complications are common. Peri-implantitis and its preliminary stage, mucositis, o c c u r i n a s u b s t a n t i a l proportion of patients. As is the case for periodontitis and gingivitis, oral biofilm is the main cause. This microbial b i o c o e n o s i s c a n a l s o encourage the development of severe systemic disease in the event of pathological changes, such as endocarditis and inflammatory bowel disease. The only difference in the microbial flora in periodontitis and peri-implantitis is in the detail.8 Compared with healthy conditions, the quantity and aggressiveness of the pathogenic microorganisms change in both diseases. Bone loss around implants is generally more rapid and leads to more extensive defects than when it occurs around teeth. Accordingly, preventative care is advised even before implant treatment. Determining risks and p r o v i d i n g p e r i o d o n t a l treatment Periodontitis is a key risk f a c t o r f o r p e r i - i m p l a n t inflammation. This means untreated periodontitis patients have an increased risk of peri- implant inflammation through to implant loss. The risk is also higher when patients who are initially treated are not included in a supportive periodontitis treatment/recall programme. L e a d i n g p e r i o d o n t i s t s therefore recommend carrying out a screening procedure before implant treatment using, for example, the periodontal screening index or periodontal screening and recording. Bleeding on probing and pocket depths are determined at selected positions. An extensive check of the periodontal status should be carried out if the results are abnormal. Taking a careful medical history, including previous systemic exposure, is also important. This provides important information about increased risk of inflammation, for example in patients with diabetes that is not being o p t i m a l l y m a n a g e d . Furthermore, patients should be informed of the risks relating to implants. Where necessary, initial periodontal treatment is carried out. First, professional tooth cleaning establishes healthy gingival conditions. In this procedure, calculus (Fig. 1) and biofilm (Fig. 2) are removed as far as the gingival sulcus. In combination with careful instruction on oral hygiene, this gives the patient the basis for long-term freedom from inflammation. Removal of subgingival coatings (debridement) is carried out using sonic or ultrasonic devices and special periodontal tips as initial periodontal treatment (Fig. 3). Manual instruments can also be used. Further surgical and/or regenerative measures may be necessary, depending on the situation. Periodontal aftercare for long- term success In the periodontal aftercare subsequent to implantation, soft (biofilm) and hard c o a t i n g s a r e r e g u l a r l y p r o f e s s i o n a l l y a n d mechanically removed. In the subgingival and supragingival areas, ultrasonic devices are generally used for this (Fig. 4), in combination with manual instruments where necessary. Alternatively, subgingival air polishing can be used in combination with periodontal attachments and powders. Checking for individual risk factors, such as smoking and diabetes, and working towards a healthy lifestyle are also recommended for a good long- t e r m p r o g n o s i s a f t e r periodontitis treatment. If the patient had severe periodontitis before the initial treatment, the recall frequency will be increased accordingly, partially to prevent peri-implant inflammation. Proactive implant treatment If the patient has received good preventative treatment and where necessary has received preliminary periodontal treatment, implant treatment can be planned. A suboptimal implant-supported prosthesis increases the likelihood of biofilm forming. In order to avoid this, the correct implant position, sufficient distances from adjacent teeth and an ideal axial alignment should be considered during the planning phase. A sufficiently sized bone site and soft tissue that is well supplied with blood are needed for successful implant healing and a good long-term prognosis. Prior or simultaneous augmentation may be needed to achieve this. In contrast to this, the time at which the implant is inserted and the treatment is provided plays a less significant role. t o s u p p o r t predictable and stable implant treatment, it is also necessary to prepare the implant bed using suitable methods and equipment. This can be a c h i e v e d u s i n g h i g h - performance implantology motors in combination with s u r g i c a l c o n t r a - a n g l e handpieces. Using a low speed and an ample supply of sterile cooling fluid is essential during preparation. Otherwise, the bone can overheat and affect the healing process. Alternatively, the implant bed can be prepared with piezo- surgical systems, for which special sets of instruments are available. Bone can be worked on in a gentle yet highly effective manner using other special instruments. Indications include alveolar ridge splitting, surgical tooth removal, and the preparation of bone blocks or lateral windows for augmentation. Continued on page 12 I n o r d e r Fig. 1: Calculus removal using an ultrasound (W&H Tigon (+) with a 3U tip) is a key part of professional tooth cleaning. (Photograph: W&H) Fig. 2: Rotary cleaning with prophylaxis polishing cups and brushes (W&H Proxeo prophylaxis contra-angle handpiece) ensures smooth surfaces on teeth. It enables patients to check biofilm effectively at home. (Photograph: W&H)(Photograph: W&H) Fig. 3: If marginal periodontitis is diagnosed, the initial debridement can be carried out very efficiently with an air scaler (sonar technology, W&H Proxeo with 1AP tip). (Photograph: W&H) Fig. 4: Ultrasound devices are particularly suitable for UPT, for example in combination with periodontal tips (W&H Tigon (+) with 1P tip). (Photograph: W&H) Fig. 5: Implants and suprastructures are routinely cleaned, for example using ultrasound devices and special plastic instruments (W&H Tigon (+) with 1I tip). (Photograph: W&H)
10 DENTAL TRIBUNE Pakistan Edition November 2018 NEWS IDS 2019 to present latest digital strategies in orthodontics C equipment are just a few examples of the tools and procedures that visitors to the exhibition will be able to experience. l a t e s t d e v e l o p m e n t s OLOGNE, GERMANY - Digital technologies are changing the tools and solutions available in orthodontics. O rg a n i s e r s o f t h e u p c o m i n g International Dental Show (IDS), taking place from 12 to 16 March 2019 in Cologne, say visitors will have the opportunity to experience t h e i n orthodontics regarding diagnostics, therapy planning, therapy and aftercare. In the areas of diagnostics and therapy planning, owners of established practices have a number of options r e g a r d i n g u p g r a d e s t o n e w technologies, while founders of new practices are now relying almost exclusively on digitalised tools and workflows. According to the IDS organisers, 3-D radiographic units, intra-oral scanners, and the virtual set-up and design of orthodontic Many of the changes that digital technologies have effected in orthodontics are irrefutable and their benefits are clear, such as in aligner therapy, where digital technologies now dominate preparatory measures for aesthetic dentistry. Regarding some of the emerging digital tools, however, such as support through artificial intelligence (AI), their scale of influence remains to be seen. At IDS, visitors will have the opportunity to inspect a number of different products related to aligner therapy treatment, such as software and virtual reality options for the subclassification of complex tooth movements, and to learn about the trend towards the use of AI support to warn of extreme tooth movements. According to the show Digital technologies are driving orthodontics forward. (Photograph: Koelnmesse/IDS Cologne) organisers, AI-aided support of this nature is becoming more conceivable a s t h e d a t a b a s e s t h a t w o u l d substantiate these tools continue to grow. The forthcoming instalment of the biennial trade fair will help practice owners learn about the developments that are driving orthodontics forward. "IDS 2019 will help visitors advance forward in all these points," commented Mark Stephen Pace, Chairman of the Association of the German Dental Industry (VDDI), in a press release. "This is important because carrying out a consistent orthodontic treatment at an early point in time enables the avoidance of complications in later years from the very beginning. The world's biggest showcase for dental medicine and dental technology in Cologne from 12 to 16 March 2019 contributes greatly to this," he said. IDS takes place at the Koelnmesse fairground in Cologne every two years and is organised by the Gesellschaft zur Förderung der Dental-Industrie, the commercial enterprise of the V D D I , i n c o l l a b o r a t i o n w i t h Koelnmesse. - Dental Tribune International COP2 focuses on dental amalgam By Anita Vazquez Tibau G E N E V A , SWITZERLAND - The second meeting of the Conference of the P a r t i e s ( C O P 2 ) t o t h e Minamata Convention on Mercury was held at the International Conference Centre Geneva from 19 to 23 November. It was determined in this session that all future COP meetings will be held in Geneva. The Minamata treaty, which came into force on 16 August 2017, now has 128 signatories, and 101 countries have ratified it. As at the first COP meeting, dental amalgam continued to be a major focal point at COP2. Say No To Mercury, an Australian non-governmental organisation, joined forces w i t h t h e I n t e r n a t i o n a l Academy of Oral Medicine and Toxicology (IAOMT), whose representatives span the globe, including Brazil, Chile, Italy, the Philippines, Slovenia and South Africa. They submitted a joint paper titled Dental AmalgamA Major Topic at COP2, which identified the following pathways: dental office wastewater, dental waste going into landfills, air discharge f r o m d e n t a l o f f i c e s , incineration of dental waste, cremation, burial, human waste, mercury vapour from breathing, and illegally sold dental mercury for artisanal and small-scale gold mining. Harmonised custom codes were also addressed to include not only bulk mercury for d e n t a l u s e , b u t a l s o encapsulated dental amalgam. In addition, all parties and non- parties to the convention were a s k e d c o n s i d e r implementing steps to reduce or eliminate the environmental pathways created by the use of mercury from dental a m a l g a m , i n c l u d i n g mandatory mercury amalgam separators. This was in accordance with the Minamata Conventions nine measures to phase down the use of dental amalgam, namely promoting the use of best environmental practices in dental facilities to reduce releases of mercury and mercury compounds to water and land. t o Claudia Marin Diez, Anita Tibau, Lisa Matriste, Lillian Ebuen, Maria Theologides and Damir Skripec Larisseger (from left) got together for a group photo at COP2 in Switzerland. Throughout the week, Say No To Mercury and IAOMT members met with delegates to discuss strategies for implementation of these nine measures to phase down dental amalgam use. A luncheon meeting was held with Mohammed Khashashneh (Jordan), vice president of the group of Asian and Pacific country members of COP, along with industrial engineer Ali Sabra of Lebanon, who wish to arrange a regional meeting with both parties and non-parties in cooperation with all relevant stakeholders; including ministries of health, IGOs, dental associations, and NGOs of the convention on (Photograph: Anita Tibau) m e r c u r y - f r e e d e n t i s t r y, incorporating how to properly manage dental mercury waste. Say No To Mercury and IAOMT also held discussions w i t h B r a z i l , i n w h i c h environmental analyst Camila Boechat and environmental health officer Luisa Gregorio of the Ministry of Health in Brazil shared perspectives on mercury-free dentistry. They were pleased that the first conference on mercury and human health to be held under the Fiocruz ministry of health would follow COP2, in Rio de Janeiro in Brazil on 29 and 30 November. There, Dr S a n d r a H a c o n w i l l b e presenting on the Minamata Convention, and President of the IAOMT Brazilian Chapter Dr Martha Faissol will be discussing safe removal of dental amalgam. The Africa group was extremely vocal in its concerns on dental amalgam, and the urgency to stop its use in order to protect the health of women and children. Many of the participants were in support of following the European U n i o n s b a n o f d e n t a l amalgam for children under 1 5 a n d p r e g n a n t o r breastfeeding women that came into effect on 1 July 2018. The Latin America and Continued on page 15
12 DENTAL TRIBUNE Pakistan Edition November 2018 CLINICAL IMPLANTOLOGY Implant-supported fixed full-arch rehabilitation without bone grafting By Dr. Aizcorbe Vicente Objective: The objective of this article is t o a s s e s s t h e c l i n i c a l , radiographic and patient- related outcomes of patients with severe atrophy of the maxilla (Cawood and Howell Class V) rehabilitated with fixed full-arch prostheses on dental implants placed in anatomical buttresses and remnant bone. Materials and methods A n o b s e r v a t i o n a l retrospective clinical study was performed with a minimum follow-up period of 10 years. An analysis of the following parameters was performed: (a) periimplant parameters (plaque index, modified gingival index, probing pocket depth and keratinized mucosa width); (b) marginal bone loss; (c) implant survival rate; and (d) patient satisfaction based on a visual analog scale (VAS). Results Ten patients and 71 dental implants were studied, with a mean follow-up period of 126 months (range: 120144). The mean plaque index was 1.0 ± 0.5, with a mean probing pocket depth of 2.3 mm (range: 1.04.0 mm). Sixty-one percent and 39% of the implants presented a modified gingival index of 1 and 2, respectively, and the mean keratinized mucosa width was 5.8 mm (range: 4.010.0 mm). The mean marginal bone loss of the implants was 0.7 ± 0.4 mm (range: 0.05.0 mm). The implant survival rate was 97.2%, and the overall mean patient satisfaction score was 90 (range: 0100). Prosthesis Control panoramic radiograph showing correct prosthetic fit. cleaning ease scored lowest on the VAS. Conclusion In our limited sample of patients with severe maxillary atrophy (Cawood and Howell Class V), the placement of dental implants in anatomical buttresses and remnant bone, associated with rehabilitation with fixed full-arch prostheses, was found to be an adequate treatment option in the long term regarding implant survival, marginal bone loss, periimplant clinical parameters and patient satisfaction. Editorial note: The full article was published in the 4/2018 issue of the Journal of Oral Science and Rehabilitation. It can be accessed free of charge a t w w w. d t s c i e n c e . c o m . - Dental Tribune International Implants should only be ... Continued from page 8 Highly advanced piezo-surgical devices are also minimally invasive in soft tissue. Stability measurement and bone surgery Once the implant has been screwed into its final position, the primary stability can be safely and precisely determined using resonance frequency analysis. The technology is available either separately or as an optional module in an implantology motor. If the ISQ (Implant Stability Quotient) value measured is 66 or higher, early intervention is possible, and if it is over 70, treatment must be provided immediately. An exposure protocol based on the ISQ value improves the prognosis of treatment. Simply measuring the torque resistance, however, does not provide the same level of clinical safety. If reduced ISQ values are measured after the implant has been inserted, a two- phase protocol is generally chosen. After exposure, a new measurement can then be used to determine whether osseointegration has been successful (secondary stability) and loading will be predictable at this point. H y g i e n e - f r i e n d l y p r o s t h e s e s The emergence region should be designed to ensure that it is atraumatic to the tissue for long-lasting implant restorations. The implant-abutment connection, material, surface and e m e r g e n c e p r o f i l e m u s t b e biocompatible and mechanically resilient over the long term. The transgingival components should also be accessible for individual and professional cleaning and for probing. Definitively integrating abutments or other components at implant level immediately ("one abutment, one time") has also proved to be effective. In combination with good hygiene and correspondingly healthy tissue, this concept can probably be used to achieve a more stable attachment of the implant to the oral cavity than if the components have to be replaced several times - a requirement for peri-implant health. Whether it is with crowns, bridges, partial or complete prostheses, the implant-supported superstructure should be designed so that the patient can maintain it without any difficulty. Additionally, a distance of at least 2 mm between the bone and the mucosal edge of the prosthesis appears to be advised to prevent infection and subsequent bone loss. Peri-implant aftercare Experts recommend treatment immediately after the initial occurrence of symptoms of inflammation to avoid peri-implant bone loss from the start. Mucositis affects almost half of all implants, and since patients often have several implants, it occurs in a high percentage of patients. The prophylactic or periodontal recall programme established after the implant has been inserted should therefore be continued. At-home oral hygiene should be carefully tailored to the new prosthesis and the patient accordingly instructed on this. In combination with professional biofilm management, good preventative efficacy can be achieved in this way. The risk of peri-implantitis decreases from 43.9 per cent (no recall) to 18.0 per cent if a patient receives a recall appointment carried out carefully each year, in other words by more than half.36 Ultrasonic systems with special instruments that do not affect the materials are suitable for this, such as those made of PEEK (Fig. 5), or appropriate manual instruments. Mechanically preventing mucositis As for periodontitis patients, peri- implant recall includes regular screening with a clinical check of both periodontal and peri-implant tissue for symptoms of inflammation, probing and, where necessary, radiographic diagnosis. A frequency of two to four times a year has proved to be effective. Deep probing values and bleeding occur more commonly in patients with peri- implantitis than in those with mucositis; pus secretion only occurs in patients with peri-implantitis. If a patient has mucositis, professional supragingival and subgingival biofilm removal reduce the risk of the inflammation advancing to peri- implantitis. Local and systemic antibiotics used as supportive measures or air polishing, however, show no additional benefit. Treating peri-implantitis Peri-implant bone loss can develop even if good preventative care is provided, for example if the patient's oral hygiene is not sufficient. Most minimal defects should be treated in a non-surgical manner using peri-implant debridement. Mechanical removal of coatings using suitable ultrasonic systems, supported by Er:YAG lasers, antibacterial photodynamic treatment, air polishing, or treatment with local or systemic antibiotics, where appropriate, has shown promising results. If closed treatment is no longer possible, the defect must be surgically exposed and carefully decontaminated. This is carried out after flap preparation by removing inflamed tissue and cleaning the surface of the implant using, for example, ultrasonic or piezo- surgical systems. Measures designed to regenerate the bone carried out after this procedure have been successful.40 Special piezosurgical instruments are available for the surgical treatment of periodontal defects. After treatment, the patient is once again intensively instructed on oral hygiene and made aware of the need for continual recall. If necessary, the frequency can be selected to be higher than previously in line with periodontal aftercare. If biofilm management is carried out consistently, the implantological results can remain stable for several years even after the periodontitis, mucositis or peri- implantitis has healed. N o Periodontology I m p l a n t o l o g y w i t h o u t Successful implant treatment requires consistent, long-term preventative thinking. In each phase, this includes regular periodontal and peri-implant screening in combination with individually tailored risk management, oral hygiene training and professional biofilm management where possible for every patient. Ideally, this preventative workflow should start well before each restorative measure, before periodontitis can develop. It is essential if implant prosthetic treatment is planned or has already been integrated. Patients will be pleased with the long-term success of the treatment and will be pleased to return to a practice or clinic they trust. Editorial note: A list of references and information is available from the publisher. - Dental Tribune International
14 DENTAL TRIBUNE Pakistan Edition November 2018 Women with edentulism more likely to develop hypertension B NEWS Straumann partners with Z-SYSTEMS to offer widest range of ceramic implants U F FA L O , N . Y. , U S A - D e s p i t e m u l t i p l e c r o s s - sectional, epidemiologic s t u d i e s s u g g e s t i n g a n a s s o c i a t i o n b e t w e e n periodontal disease and e d e n t u l i s m , a n d hypertension, the exact relationship between them remains unclear. In a new study, researchers from the University at Buffalo have found that postmenopausal w o m e n w h o h a v e experienced tooth loss have a higher risk of developing high blood pressure. In the Women's Health Initiative-Observational Study, researchers looked at d a t a f r o m 3 6 , 6 9 2 postmenopausal women in the U.S., who were followed a n n u a l l y - f r o m i n i t i a l periodontal assessment in 1998 through to 2015-for n e w l y d i a g n o s e d hypertension. t o A c c o r d i n g t h e researchers, an association was found between tooth loss and hypertension risk among postmenopausal women, who had an approximately 20 per cent higher chance of developing hypertension. The association was also stronger among younger A new study has revealed that postmenopausal women who have experienced tooth loss may be at a higher risk of developing hypertension. (Photograph: ivandan/Shutterstock) women and those with a larger body mass index. However, there was no association found between periodontal disease and hypertension. The researchers suggested that a possible explanation for the results is that when people lose teeth, they may c h a n g e t h e i r d i e t s t o incorporate softer and more processed foods. These changes in their dietary patterns could then be a contributing factor towards t h e i r d e v e l o p i n g hypertension. Researchers t h e r e f o r e b e l i e v e t h a t improved dental hygiene among those at risk for tooth loss, as well as preventive measures, such as closer blood pressure monitoring, d i e t a r y m o d i f i c a t i o n s , physical activity and weight loss may reduce risks of developing blood pressure problems. The study, titled "Association of periodontal disease and edentulism with hypertension risk in postmenopausal women" was published on 4 December in the A m e r i c a n J o u r n a l o f Hypertension. - Dental Tr i b u n e I n t e r n a t i o n a l Z-SYSTEM's new two-piece ceramic implant features a ceramic connection screw, making it the first two-piece, screw-retained dental implant to be completely metal- and plastic-free. (Image: Z-SYSTEMS) B ASEL, SWITZERLAND - Straumann, global leader in tooth replacement and orthodontic solutions, has entered a strategic partnership with Swiss-based international leader in ceramic dental implant systems, Z- SYSTEMS. The two companies have signed an agreement that provides Straumann with a 34 per cent stake in Z- SYSTEMS, and in return, Z-SYSTEMS will receive a capital injection to expand its production capabilities and develop its pipeline. Straumann has obtained exclusive distribution rights in most major markets for Z-SYSTEMs next generation implant line, which complements their current PURE Ceramic Implant system. The new implant has a bone-level, two- piece design for prosthetic flexibility and convenient handling. Unlike other implants, it features a ceramic connection screw, making it the first two-piece, screw- retained dental implant to be completely metal- and plastic- free. Straumann plans to launch the new line in 2019. We are convinced that ceramic implants offer substantial growth opportunities and will continue to gain popularity, Continued on page 15 Combination of breast milk and babies saliva shapes healthy oral microbiome, study suggests R I S B A N E , A U S T R A L I A - There is much debate of the pros and cons of breast- and bottle-feeding. A research team from the Queensland University of Technology (QUT), in collaboration with the University of Queensland, both in Australia, has found that breastfeeding, at least in terms of oral health of the baby, is beneficial. According to lead author Dr Emma Sweeney, from the Institute of Health and Biomedical Innovation at QUT, the team's earlier studies h a d f o u n d s i g n i f i c a n t differences in the prevalence of key bacteria in the mouths of breastfed and formula-fed babies and that breastmilk and saliva interactions boost innate immunity by acting in synergy t o r e g u l a t e t h e o r a l microbiome of newborn babies. For the recent study, a variety of microorganisms were exposed to breastmilk and saliva mixtures. The results showed that inhibited growth of the microorganisms t o o k p l a c e immediately and for u p t o o n e d a y r e g a r d l e s s o f w h e t h e r t h e microorganisms were considered pathogenic or commensal in an infant's mouth. "Our findings suggest that breastmilk is more than a simple source of nutrition for babies because it plays an important role in shaping a healthy oral microbiome," said Sweeney. "Our previous research found that the interaction of neonatal saliva and breast milk releases a n t i b a c t e r i a l c o m p o u n d s , including hydrogen peroxide. The release o f t h i s c h e m i c a l a l s o activates the lactoperoxidase system, which produces c o m p o u n d additional compounds that also have antibacterial activity, and these compounds are capable of regulating the growth of microorganisms," she added. According to the research team, the composition of a baby's mouth microbiota has an important role in its health and well-being and also has an impact on infections and diseases in babies' early lives. The study, titled "The effect of b r e a s t m i l k a n d s a l i v a combinations on the in vitro growth of oral pathogenic and commensal microorganisms", was published online in Scientific Reports on 11 October 2018. - Dental Tribune International.
NEWS E TOY, Switzerland: T h e r o l e d e n t a l hygienists play within the dental industry can sometimes be overlooked, with some curtail work often taking place before a dentist has even seen the patient. Presented by the SUNSTAR Foundation and supported by the International Symposium on Dental Hygiene (ISDH), the World Dental Hygienist Awards recognise dental hygienists who have made a significant contribution to dental hygiene science, patients and the broader community. Presented every two years at ISDH, entries for this years awards close on 14 January 2019. The 2019 ISDH will take place in August in Brisbane, Australia. As per previous years, the winners of the Dental Hygienist Awards are chosen by an independent selection committee. These awards are an excellent opportunity to give visibility to a crucial profession in the 2018 Pakistan Edition DENTAL TRIBUNE 15 November Last call for entries for the World Dental Hygienist Awards Presented every two years at the International Symposium on Dental Hygiene, the World Dental Hygienist Awards recognises dental hygienists who have made a significant contribution to their field. (Photograph: Anna Jurkovska/Shutterstock) o r a l h e a l t h f i e l d . Unfortunately, the dental hygienists role is often underrated, although it is key to show patients how to maintain a proper oral care routine, and to detect some oral problems at earlier s t a g e s , s a i d J o A n n Gurenlian, President of the American Dental Hygienists Association. The awards are divided into two categories: research and activity or project, with professionals and students competing separately. The research entries may include b o t h q u a n t i t a t i v e a n d qualitative analyses that provide important new insights that contribute to the body of knowledge in the oral hygiene field. The total prize money for the professional and student category is US$5,000 (4,407) and U S $ 2 , 0 0 0 ( 1 , 7 6 3 ) , respectively. In the activity or project category, entrants are required to provide details of the activities that have made a key contribution to patients, the community or the general public. The positive impact of the activities on the health of a significant number of i n d i v i d u a l s s h o u l d b e empirically demonstrated, with measurable outcomes that demonstrate improved health. The award is open to individuals as well as groups, with the total prize money for the professional and student entry totalling US$3,000 (2,644) and US$2,000, respectively. - Dental Tribune International Mercury-free healthcare ... Continued from front page intellectual delays and problems during childhood. Under the health ministry's initiative, policy guidelines will be developed for stakeholders on how to phase out mercury-based products, while a complete ban will be slapped on the use of mercury-containing amalgam for restorative dental care. Also, the medical and dental colleges' curriculum will be changed accordingly; strict regulations and legislation will be introduced on the use of mercury in cosmetics and fairness creams, and a nationwide campaign will be begun to raise public awareness of the hazards of mercury-based products and equipment. National Health Services and Regulations Minister Aamir Mehmood Kiani is understood to have directed the relevant officers lately to turn the programme, his brainchild, into a reality without delay saying this will help further the cause of healthcare in the country as promised by the ruling PTI. Experts welcome the ministry's plans saying their successful execution will go a long way in protecting the people f r o m t h e d e v a s t a t i n g h e a l t h consequences of mercury use. Dr Wasim Khwaja of the Pakistan Institute of Medical Sciences said that the mercury dispersed into the ecosystem, remained in the ecosystem for generations, causing severe health and intellectual impairment to the exposed populations. "The mercury discarded and spilled by healthcare settings makes its way into the environment, where it methylises and bio-accumulates in the food supply, negatively impacting human and environmental health," he said. The gastroenterologist said the removal of mercury-containing devices and products from hospitals and clinics would prevent doctors, health workers and patients from the potentially highly toxic levels of elemental mercury. Noted dental surgeon Dr Pakiza Hyder hailed the proposed ban on mercury dental fillings saying it would protect patients from poisoning, exhaustion, emotional disturbance and high blood pressure. "Mercury is used in fillings commonly known as silver fillings. It is mixed with silver and copper to form a durable mixture to lock in the quicksilver. However, it is seen that toxic mercury vapours leak and travel throughout the body, and are deposited in the vital organs causing multiple health problems," she said. Regretting the rampant use of mercury fillings by hospitals and clinics, the dental surgeon strongly felt that better public awareness was the best way to turn Pakistan into a mercury hazard-free country. 100-day performance ... Continued from front page health ministry. Hence, the ministry had embarked on a process to upgrade all basic healthcare facilities in the federal capital. To consolidate all the healthcare facilities of the city under one ministry, they were in the process of making new appointments. Moreover, plans to build four more hospitals in Islamabad, especially with help from Saudi Arabia, were underway. In this regard, work on building a hospital in Tarlai is expected to start soon. To regulate all public and private healthcare facilities in the capital, including clinics, hospices and even health care professionals, a registration process is being initiated. For this purpose, a healthcare commission and healthcare regulatory authority are in the process of being created. The second phase of the Prime Minister's Health Programme has also begun for which the bid collection process has been completed. The ministry hopes that by the middle of January next year, more than two million people will get health coverage. Additionally, this phase will also see the funds provided for medical treatment become more than double from Rs3.5 million to Rs7.2 million. The health ministry has also worked on revamping the apex drug regulator of the country, the Drug Regulatory Authority of Pakistan (DRAP). In this regard, the aspects of medicine making process, checking laboratories according to international standards has been emphasised and that soon level three qualification will be achieved. Sources, quoting the report, further said it lists the measures which were taken on family planning - as recommended by a high-powered board formed on controlling the country's population. Moreover, the government has decided to impose a 'Sin' tax on cigarette and other tobacco products which will amount to two per cent tax on these products, which will be contributed in the development and progress of health sector. COP2 focuses on dental ... Continued from page 10 Caribbean group also supported this ban. The environmental project coordinator for Honduras, Pablo Rodríguez, shared his countrys pilot project on eliminating products and processes that use mercury in the health care sector in the four largest hospitals in the country. They have eradicated the use of medical devices that use mercury and the use of dental amalgam in these hospitals. He said that this project was started in 2014 and is gaining momentum and has now become the model for his countrys transition out of mercury use in the health care sector. Representing VOCO dental materials, Peter Hoffmann shared with participants solutions for non-mercury dental restorations. It is extremely important, in particular for developing countries and countries in transition, to learn to use the atraumatic restorative treatment (ART) technique. ART was developed in Tanzania, more than 30 years ago as an alternative to conventional dental treatments. A concerted commitment to end the use of dental amalgam was evident during COP2. Delegates throughout the week agreed that this use of mercury m u s t e n d . - D e n t a l Tr i b u n e International Straumann partners with ... Continued from page 14 driven by increasing clinical experience and the improved flexibility provided by two-piece solutions, said Marco Gadola, CEO of Straumann. Together with Z-SYSTEMS, we offer the widest range of ceramic implant options supported by digital workflows and biomaterial solutions. The combination of our expertise, research capabilities, sales power and global reach position us as a leading force in the global ceramic implant market. We are very proud to partner with the world leader in implant dentistry, stated Ernst Thomke, member of the board of directors of Z-SYSTEMS. - Dental Tribune International