PUBLISHED IN DUBAI www.dental-tribune.me May-June | No. 3, Vol. 9 Plaque bacteria prove no match for guided bioﬁlm therapy By Faye Donald, UK Presented here is a guided bioﬁlm therapy case with the aim of achiev- ing improved periodontal health in a nervous patient. Treatment was carried out over a period of several months between April and Novem- ber 2018. Background This 45-year-old female patient had never smoked, was a healthy weight and presented with no relevant medical history. However, she was diagnosed with generalised chronic periodontal disease, which needed to be addressed. The patient joined the practice after moving to the area and was referred to the dental hygienist following a routine examination with the den- tist which revealed BPE codes 3 and 4 and radiographic examination con- ﬁrmed moderate to advanced peri- odontal disease. tivity and improving prognosis was stressed. Clinically, the patient presented with plaque accumulation on all surfaces, heavy supraand sub-gingival calcu- lus deposits, ﬂorid gingivitis, moder- ate to severe pocketing and bleeding on probing in all sextants, with spon- taneous bleeding in the lower anteri- or sextant. Signiﬁcant fetor oris was also noted at the initial consultation. The patient had avoided the dentist for many years after a bad experi- ence had left her fearful and anxious but had decided it was time to face her fears after becoming conscious of how “ugly” her gums had started to look. The patient was very anxious but equally keen to improve her situa- tion. The aetiology of her periodon- tal disease was explained carefully to her and her role in eliminating ac- Treatment options The patient was given the choice of three treatment options: 1. Do nothing. The condition was unlikely to improve without profes- sional intervention and it was more than likely that symptoms would gradually worsen, and the condition would deteriorate to a point where teeth were lost prematurely; 2. A course of non-surgical therapy (NST) with the dental hygienist us- ing the guided bioﬁlm therapy (GBT) protocol. If successful and the pa- tient co-operated with home care, it was expected that a good resolution could be achieved; 3. Referral to a specialist. This would not be possible via the NHS pathway until a course of NST had been com- pleted, so private referral was her only option. The patient was advised AD Fig. 1: Upper – Initial presentation. Lower – 8 Weeks later Be a part of something extraordinary. 4–8 September 2019 Moscone Convention Center 3 DAYS OF EXHIBITION SCIENTIFIC PROGRAMME 5–7 SEPTEMBER 2 HALF DAYS (4, 8 SEPT) & 3 FULL DAYS (5-7 SEPT) MORE THAN 1,300 STANDS 200 WORLDWIDE SPEAKERS 40,000 M2 OF EXHIBITION SPACE MORE THAN 30,000 PARTICIPANTS Abstract submission deadline 1 April 2019 Early-bird registration deadline 30 April 2019 www.world-dental-congress.org that at this stage there appeared to be no reason why she could not be managed in general prac- tice with NST. However, she was advised that a referral might be necessary at a later date, if she proved to be a non-responder. NST and GBT for anxious patients The patient decided to go ahead with NST. GBT can be applied to all types of patients and it lends itself well to very anxious patients since: – Hands-on treatment inside the mouth is quick, freeing up time for crucial oral hygiene instruction – It is gentle – anaesthetic is rarely required, there is no tissue trauma from invasive hand in- struments and the warm water and PIEZON NO PAIN is a relationship builder – It is minimally invasive, so tissues are pre- served, and post-operative sensitivity and reces- sion are kept to a minimum. Treatment Appointment 1 In line with the GBT protocol, disclosing solu- tion was applied and initial assessments, which included plaque and bleeding indices, were car- ried out; both were recorded at 100%. Intensive oral hygiene instruction followed, which included an explanation of the nature of disease and its progression. Oral hygiene aids were demonstrated, including an electric tooth- brush with an oscillating/rotating head, inter- dental brushes and a slimline interspace brush for sub-gingival cleaning. Bioﬁlm was then disrupted using AIRFLOW and PLUS powder containing erythritol, which has been shown to be not only effective in disrupt- ing bioﬁlms but also in the suppression of peri- odontal pathogens. A gross scale using the PIE- ZON NO PAIN module was used to remove large calculus deposits that, if left, would have pre- vented adequate access for interdental cleaning aids. A review appointment was arranged for three weeks later. Appointment 2 (3 weeks later) Once again, the patient was disclosed, and plaque and bleeding scores were taken. Plaque was recorded at <10% and bleeding had dropped to 40%. A review of the patient’s oral hygiene regimen took place and adjustments to tech- niques and interdental aid sizing were made as required. Again, bioﬁlm was disrupted both su- pra- and sub-gingivally ﬁrst, followed this time with a thorough ultrasonic debridement to re- move remaining calculus. No hand instrumentation was used. Appointment 3 (8 weeks later) The patient was again disclosed, and plaque and bleeding scores were taken. Both scores were re- corded as <10% and a dramatic difference in ap- pearance was noted. At this stage, a full-mouth periodontal chart was recorded. Anterior sex- tants showed no pockets >4mm and posterior sextants showed some shallow residual pock- eting interdentally of between 4mm and 5mm with 3 sites measuring 6mm, one of which had bleeding on probing. Oral hygiene was again reviewed andadjusted as necessary. Full-mouth bioﬁlm disruption took place supra- and subgingivally up to 4mm. Sites measuring >4mm were treated with PERI- OFLOW and erythritol powder. PIEZON NO PAIN was used only at sites with obvious remaining calculus and in the 6mm site, which had bleed- ing on probing. Post-appointment monitoring As the patient had displayed a good grasp of home care, motivation was excellent and early tissue resolution was extremely promising, a hands-off approach was applied to allow natu- ral healing to continue. The patient was moni- tored closely at 12-week intervals for 1 year, dur- ing which her pocket chart revealed further resolution, with no site measuring >4mm and bleeding on probing remaining at <10%. About the Author Faye Donald is an award-winning dental hygienist and Swiss Dental Academy trainer lecturing nationally and internationally on guided bioﬁlm therapy. Email: firstname.lastname@example.org
Dental Tribune Middle East & Africa Edition | 3/2019 ◊Page E4 HYGIENE TRIBUNE option results in bruxism, but also symptoms such as hypertension, ir- ritable bowel syndrome, fatigue and an increase in the muscle tone in the head, neck and back. The place where this tension will express itself differs from person to person. What is the best way for bruxism sufferers to alleviate stress? It is difﬁcult to give an exact answer to this question. For me personally, a good way to reduce stress is to take some time, listen to myself and ob- serve myself, and do those things that make me feel good. Relieving stress depends on one’s own tastes and personality. Is bruxism always caused by stress? How about temporoman- dibular joint disorders? No, during the day, a patient can also show hypertonicity of the jaw even during a moment of relaxation. He might just not be aware of this bad habit, because he is not aware of this tension. At night, other factors in- tervene, such as gastrointestinal re- ﬂux, respiration or others. Some are stress-related, others are anatomical and genetic. Temporomandibular disorders are a vast subject because they depend on many factors, such as occlusion, trauma and the adapta- bility of the individual. For example, bruxism causes chronic micro-trau- mas in musculoskeletal structures and can lead to orthopaedic instabil- ity, and sometimes pain associated with temporomandibular disorders can reinforce bruxism. Is there a possible link between bruxism and tongue position? That is a very good question. The ﬁrst step of the self-management approach is sensorimotor aware- ness. The patient becomes aware of the hypertonia of the jaw muscles that the tongue is part of. The hyper- tonia we are talking about is related to stress and—depending on the patient—when these forces are pro- longed, symptoms could appear in the temporomandibular system. The correct resting position of the jaw is a neutral position in which muscle tension is minimal—just enough to counteract gravity. Thus, the lips are closed, there is no vis- ible mimicry and the muscles are relaxed. A small space separates the teeth. The tongue can have differ- ent resting positions in adulthood: at the bottom or in the middle of the mouth or gently touching the pal- ate—the tongue is and is not tense. It is a mistake to advise patients to actively push the tongue against the palate, because they will have to make an effort, which in turn leads to increased tension for the entire musculature. So, the correct advice would be that the tongue should be completely relaxed and soft, and it may touch the palate if it moves there naturally. Some dentists think bruxism does not cause abfractions and that ab- fractions are only caused by brush- ing teeth too hard. What is your opinion on this? I think abfractions have multifac- torial origins, including erosion AD =C4A=0C8>=0;4=C0;G7818C8>=5A820 4TH INTERNATIONAL TRADE SHOW FOR THE DENTAL SECTOR IN AFRICA HYATT REGENCY HOTEL IN COOPERATION WITH MORROCAN ASSOCIATION OF ORO-DENTAL PREVENTION www.idea-africa.com E5 (chemical wear), abrasion (brushing and chewing) and attrition (brux- ism). These three components will be found to varying degrees in a person. This corresponds to the situations I’ve found in patients. The enamel at the limit between crown and root is very thin, so with little force of ﬂexion it can chip easily. I ﬁnd ab- fractions very often in patients with recessions. Does a mouthguard protect against tooth wear and receding gingivae? One of the only proven effects of mouthguards is protection and consequently the slowing down of tooth wear. They can also reduce the occlusal forces. The more open your mouth is, the less force you have to bite down. This is the same princi- ple as a crocodile’s bite: with a small piece of wood in its mouth, it cannot bite down. For the periodontium, mouthguards allow better distribu- tion of the occlusal forces, especially in cases of missing teeth or untreat- ed malpositions, thus, better balanc- ing the constraints related to reces- sions. Bruxism is an aggravating factor of periodontal problems, and a mouthguard can prevent signiﬁcant damage in some people at risk and extend the life of loose teeth. How- ever, one must be vigilant in cases of difﬁculty of breathing and sleep ap- noea. In these cases, a mouthguard causing mandibular loosening may increase the number of obstructive episodes. In these cases—and they are very common—it is essential to do a more complete analysis of sleep. I’ve heard people say that biofeed- back is the only thing that helped them. Could you tell me more about this? Yes, biofeedback is the principle that I mentioned before that allows aware- ness throughout the day. There are various feedback possibilities. It can either be a reminder on your phone or a visual cue, such as sticky notes, to remind you of the correct jaw po- sition. However, being aware at night is, of course, an entirely different mat- ter. Luckily, there are functional devices, such as labial interceptors, that stimulate a suction reﬂex. This reﬂex stimulates nasal breathing and causes muscle relaxation. Other functional devices, such as Bionator appliances, have remarkable effects in children when the dental struc- tures are still in development. I am currently looking into the possible beneﬁts they could have for adults too. Lastly, I am experimenting with bilaterally stimulating certain points on the cranium to help calm down the limbic system and am looking forward to the results it may have. Finally, do you know of cases of bruxism where it was healed or simply disappeared? And, how? Yes, a multidisciplinary team that approaches bruxism from multiple perspectives and allows patients to be active participants in their own health can reduce bruxism to a nor- mal, non-iatrogenic degree. In the case of sleep bruxism associated with respiratory disorders, surgery or mandibular advancement or- thoses give good results while im- proving the patient’s quality of life. Editorial note: A list of references can be obtained from the publisher. This article was originally published in prevention international maga- zine for oral health, Issue 1/2019
E6 HYGIENE TRIBUNE Dental Tribune Middle East & Africa Edition | 3/2019 EMS opens its regional ofﬁ ce for Middle East, Africa and India in Amman By E.M.S. On the 29th of April, at the W hotel in Amman and with the presence of 24 delegates from some of the leading dental companies in the world, EMS opened its new ofﬁ ce in the Middle East. There was the active participa- tion from EMS’s top management who came from Nyon to join the inauguration with Mr. Paolo Zanetti, the General Manager. The morning session displayed EMS’s drive and determination to continue to provide evidence-based and clinically-proven solutions. An example of this was the Guided Bio- ﬁ lm Therapy (GBT), a true revolution in terms of how we manage bioﬁ lm today. What makes the GBT protocol unique is these 3 crucial concepts: – We disclose bioﬁ lm – We start with the AIRFLOW and PLUS powder ﬁ rst – We decrease the use of hand instru- mentation & ultrasonic power on the tooth All this combines to provide a higher standard of preventive care, more patient comfort and less tooth abra- sion as manual instrumentation can be damaging to the crystal prisms of the enamel and the surfaces of the dentine. At the same time, EMS revealed its plan to invest more in the area in an effort to better support its partners, dentists and dental hygienists. EMS will also be expanding the number of GBT & SDA courses in the area and collaborating more closely with uni- versities. The IMEA team will be opening an accredited afﬁ liate for the Swiss Den- tal Academy in Amman, where EMS will be hosting a number of profes- sional training courses. The inauguration represents an im- portant step forward for EMS in the Middle East. Under the leadership of Mr. Al Assali, EMS will establish a new vision for customer care, im- prove quality of courses and above all, share the EMS “I FEEL GOOD” culture. Tooth whitening products may harm dentin tissue By DTI ORLANDO, Fla., U.S.: In three new studies, researchers have recently found that hydrogen peroxide, even at the concentration used in over- the-counter whitening strips, can damage protein-rich dentin tissue, and collagen and noncollagen pro- teins in particular. The research team is currently planning to further char- acterize the protein fragments re- leased when collagen is treated with hydrogen peroxide and determine whether hydrogen peroxide has the same impact on other proteins in the teeth. While most studies of whitening strips focused on tooth enamel, which contains very little protein, the current studies focused on den- tin, which contains high levels of protein, most of which is collagen. Previous work has shown that hy- drogen peroxide can penetrate the enamel and dentin, and that col- lagen in the dentin layer decreased when teeth were treated with whit- ening strips. “We sought to further characterize what the hydrogen per- oxide was doing to collagen,” said Dr. Kelly A. Keenan, Associate Professor of Chemistry and of Biochemistry/ Molecular Biology at Stockton Uni- versity School of Natural Sciences and Mathematics. “We used entire teeth for the studies and focused on the impact hydrogen peroxide has on the proteins.” AD In the new study, the researchers demonstrated that the major pro- tein in the dentin is converted to smaller fragments when treated with hydrogen peroxide. In addi- tional experiments, they treated pure collagen with hydrogen perox- ide and then analyzed the protein using a gel electrophoresis labora- tory method that allows the protein to be visualized. “Our results showed that treatment with hydrogen peroxide concentra- tions similar to those found in whit- ening strips is enough to make the original collagen protein disappear, which is presumably due to the for- mation of many smaller fragments,” Keenan added. The researchers speciﬁ ed that their experiments did not address wheth- er collagen and other proteins in the teeth can be regenerated. Therefore, it is unclear whether the tooth dam- age is permanent. The study abstracts (abstracts one, two & three) were presented at the American Society for Biochemis- try and Molecular Biology’s annual meeting, which took place on April 6–9 in Orlando. New oral appliance could help manage sleep apnoea save the date 08 NOVEMBER 2019 InterContinental Hotel Dubai Festival City DUBAI, UAE Part of 11th Dental Facial Cosmetic Conference & Exhibition Contact Us Mobile: +971502793711 Telephone: +971 4 347 6747 E-mail: email@example.com www.cappmea.com/aesthetic-dentistry www.facebook.com/CAPPDHS ORGANISED BY By DTI HIROSHIMA, Japan: Researchers have recently developed a novel treatment to improve the quality of sleep for patients who suffer from mild to moderate obstructive sleep apnoea (OSA). Using 3-D imaging of the airways with the patients supine to simulate sleeping condi- tions, the study conﬁ rmed that the treatment is effective at opening the airways and warrants further collaboration between dentists and doctors in the treatment of sleep apnoea. The treatment was developed by researchers from the Department of Orthodontics at Hiroshima Uni- versity Hospital. The participants included eight men and ﬁ ve wom- en who were diagnosed with mild to moderate OSA and underwent mandibular advancement appli- ance (MAA) therapy. The research- ers used multi-slice computed to- mography in order to measure the regional effects of the appliance on the upper airway. “This is like when you have to use glasses. You have to wear them every time you want to see prop- erly so [patients] have to wear this appliance every time [they] want to sleep better,” said study co-author Dr Hiroshi Ueda, an associate pro- fessor in the Graduate School of Biomedical and Health Sciences at Hiroshima University. Previous research typically meas- ured patients standing up, a tech- nique that does not simulate sleep- ing conditions. The current study measured the change in airway space of patients lying ﬂ at. It dem- onstrated that the proportional size of the soft-tissue volume, that is, the soft palate and tongue in the oro-hypopharyngeal region, signiﬁ cantly decreased when the patient was wearing an MAA. This forward displacement of the soft tissue thereby increased the retro- glossal airway space, except the nasopharynx, three-dimensionally and therefore allowed for easier breathing. According to the researchers, fur- ther investigations that focus on 3-D airway enlargement analysis of various sites affected by MAA therapy are required in a larger number of patients with OSA. This would help scientists understand the pathogenesis of OSA and the clinical applicability of MAA fully. The study, titled “Multislice com- puted tomography assessment of airway patency changes associated with mandibular advancement ap- pliance therapy in supine patients with obstructive sleep apnea”, was published online on 3 March 2019 in Sleep Disorders.
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