DENTAL TRIBUNE The World’s Dental Newspaper · South Asia Edition Published in India www.dental-tribune.in 8/19 Peter Dawson “There will always be only one Peter Dawson” – Dr. Nitish Surathu Amalgam Impact Study reveals environmental impact of mercury released from dental amalgam- an unexplored topic ” Page 04 526 teeth Oral surgeons in Saveetha Dental College, Chennai extract 526 teeth from a single site in a child ” Page 05 Hydroxyapatite toothpaste Hydroxyapatite toothpaste – an alternative to fluoride toothpaste? ” Page 06 ” Page 07 “Knife-edges are back, thanks to adhesive tech & better understanding of materials“- Dr Ali Tunkiwala, as he discusses Digital and Minimal Invasive Dentistry by Rajeev Chitguppi is focused Aesthetics Dr Ali Tunkiwala (MDS, Prosthodontics) maintains a in Mumbai, dental practice on primarily Implants, and Full Mouth Rehabilitation. He is an accredited member of the American Academy of Cosmetic Dentistry, and also a Fellow and Diplomate of ICOI (International Congress of Oral Implantologists) & ISOI (Indian Society of Oral Implantologists). He a speaker for the International Team for Implantology (ITI), and also serves on the editorial board of various international journals and periodicals in dentistry. Dr Ali has several peer-reviewed publications to his credit and has authored a chapter in the book titled, “Graftless Solutions in Implant Dentistry”. He is the Director of a continuing education initiative to nurture and guide motivated clinicians towards predictable evidence-based dental practice. In this interview, he talks about three of his favourite topics: Minimally Invasive Dentistry, Esthetic Rehabilitation, and Digital Dentistry. “Impart Education”, Since when have you become a strong advocate of minimally invasive dentistry? How different was your practice when you started? It takes a while for clinicians in practice to decipher that enamel and tooth structure as such, is not a renewable resource. Once cut, it cannot be replaced at all. So, the transformation was gradual for us. In early days, 23 years, ago, when we started work, we had materials that required too much tooth structure to be taken away. Our textbooks recommended taking away close to 1.2 to 1.4 mm tooth structure on labial of anterior, for aesthetic reasons as the material of choice was PFM. That always got us into dentin, where we ended up decreasing the rigidity of the teeth and had far too many structural failures. Over the last decade, advances in ceramic materials and resins have given us the option to prepare teeth lesser and achieve better aesthetic results. Add to that, our understanding of occlusion and other aspects have led to better treatment protocols that are less invasive, and we strive to end up being within enamel at the end of the tooth preparation, as far as possible. If I look back, our practice has totally transformed from trying to make the restorations strong while weakening the teeth, to retaining the strength of teeth with optimally strong restorations. What are the The recent trends that have significantly transformed your practice of full mouth rehabilitation? understanding interaction between of the the joints, muscles and teeth have undergone a sea change. We now know that teeth can get destroyed due to parafunction that is brain mediated and may even be damaged due to the acid influx in the oral cavity that may be gastric reflux or consumed as drinks. There is so much in sleep dentistry that is affecting our diagnosis and the overall treatment plans. We understand better what lack of proper sleep and incorrect breathing during sleep can do to our occlusion. Many such aspects have helped us organise our diagnostic capabilities and also allowed us to do a thorough risk assessment to enable us to predict the outcomes of complex treatments more accurately. Furthermore, technological in material science advances and digital protocols have resulted in increased accuracy and performance. The trend in full mouth rehabilitation today is to destroy teeth as less as possible by avoiding aggressive tooth preps. Additive treatment modalities where indicated with adhesive protocols is the way forward. Even more important is that we learn how to prevent occlusal problems. If we learn to see the early signs of total dental breakdown, we can now initiate a preventive system to help our patient avoid a full mouth rehabilitation in the future. That is where our contribution to humanity will be significant. You mentioned tooth preparations have changed? What has changed and what is done differently today as compared to yesteryears? The fundamental reason for any tooth preparation is to make room for the restorative material. The amount of preparation depends on the material chosen. Each material has its minimum requirements thickness that have to be met so that the material will not fracture in function. In the earlier days, the most aesthetic material was porcelain fused to metal, and that required a horizontal finish of Dr. Ali Tunkiwala MDS (Prosthodontics) answers questions on his areas of expertise: Minimally Invasive Dentistry, Esthetic Rehabilitation, and Digital Dentistry line preparation known as a shoulder or rounded shoulder or deep chamfer. These finish lines had an average depth of 1.2mm to 1.4mm and usually led to preparation in dentin. Plus, procedures were undertaken to increase prepared tooth length to provide for resistance form from cohesive preparations. Today materials have changed, and adhesive technology has become very predictable. So, tooth preps have been modified to the traditional concept of knife- edged margins. In yesteryears, these were used on cementum or on amalgam and for full metal crowns. Now we have enough data to show that these types of knife-edged margin designs allow aesthetic materials like lithium disilicate and zirconia to be used with slight modification in lab protocols. In literature variations of these designs have been referred to as Vertical preparations. The advantage these offer is that the chances of being within enamel after tooth preparations are incredibly high and thus better for bonding. The disadvantage is that if the lab leaves a ledge at the margin that in the restoration, it can lead to periodontal ill-health. However, in most cases this ill-health is attributed to the violated biologic width and not so much to the type of margin geometry. (Fig 1 to Fig 5) is not finished well Occlusion is a complex topic to understand and apply in practice. In what way has
2 News 8/19 Fig 1: Horizontal margin geometry that requires preparation into dentin Fig 2: These types of preps can lead to increased flexibility of tooth structure thereby making it prone to breakage Fig 3: Knife edged margins for lithium disilicate crowns Fig 4: The presence of frosted enamel all over is a distinct advantage of these margins (Referred to as vertical preps) your practice of aesthetic work changed with respect to occlusion in recent times? If I ask you to give one simple advice to general practitioners, what would that be? and function are two sides of the same coin. is When an aesthetic work Aesthetics considered to beautify the smile, the functional aspects have to be dealt with in the background to allow the materials to survive in the long term. Hence a clinician who is going to change the anterior thereby infringe on the chewing pathway of their patients with veneers/ teeth, and restorations, must start with assessing the need to first carry out an occlusal equilibration. Deprogramming the muscles to allow an of mastication establishment of harmony between the joint and the teeth is paramount. Once the teeth fit well into each other with the joint it will seated fully in its physiologic space, remove any negative stimuli from within the dentition that can lead to stress on the anterior restorations. As a general practitioner, acquiring the skills to deprogram and diagnose the case and then instituting the most conservative Fig 5: Lithium disilicate restorations bonded and blended well with very fine preparation margins. These restorations offer tremendous benefits as far as pulpal and periodontal health is concerned methodology of treatment taking into considerations all patient factors like age, health status and habits are of utmost importance. (Fig 6 to Fig 10) Fig 6: Incisal wear evident and patient complains of slight muscle tenderness Fig 7: A Kois deprogrammer allows the muscles to relax without the teeth interferences and that helps to the condyles finding their physiologically optimal position within the joint Fig 8: Occlusal equilibration carried out to harmonize contacts on all teeth Fig 9: The most conservative treatment modality can then be chosen to restore anterior teeth keeping in mind the age, needs and habits of the patient Fig 10: The final anterior resin build-ups that now provide the aesthetic solution needed while function was taken care of How has digital dentistry transformed your practice in recent times? The digital revolution has engulfed all aspects of patient care. From Data acquisition in the form of intraoral scanners to and articulation of patients’ pre-op data; today everything can be integrated into a digital workflow and true ‘model less’ options are designing virtual becoming a reality. Integrating the patient‘s face and dental condition and then seamlessly merging that with the cone beam scan of the patient, a truly holistic pathway can be charted out for the patient‘s benefits. This not only has a direct bearing on smile design that has become digital, thereby allowing the patient to preview the treatment in totality, but also there has been a huge impact in digital planning for implants with guided surgery. The overall costs of these process have become significantly lower, and the digital protocols that were a privilege of a few big practices are now within reach of a majority of the population. Another aspect is that due to digitisation, data sharing and lab protocols have now a global reach So I can sit in my office and share the patient‘s data with a surgeon and a lab tech in different parts of the globe and garner the support I need for excellence in dentistry that I like to provide. The world has become accessible to all and thus the way we train and do dentistry has transformed for the better. Digital planning with guided implant surgery, digital planning in orthognathic surgery and orthodontics, digital today. There refinement of occlusion are all possibilities is hardly any aspect of patient care that cannot be done digitally. In these times, clinicians have to be cautious and not get carried away with digitisation on autopilot mode; for the human brain and its contribution treatment planning is still of great value today and will always be. (Fig 11 to Fig 17) to Fig 11: Pre-operative intraoral scans of patient with severe Fig 12: Same patient with digital impressions done for all the Fig 13: The final lithium disilicate restorations bonded in a case mutilation of teeth tooth preps in the process of a full mouth rehabilitation that has been done with a full digital protocol Fig 14: Merging the patients’ pre-operative scanned data with Fig 15: Digital Planning for implant surgery Fig 16: Surgical guide used to place implants the CBCT data for implant planning
3 News 8/19 Genome-wide analysis finds genetic link between oral health and cardiovascular- metabolic factors by Dental Tribune International UMEÅ, Sweden: Researchers from the Institute of Odontology at Umeå University in Sweden collaborated with the Bristol Dental School in the UK, in the largest study of its kind, in order to improve our understanding on the role our genes in oral health. The team collected meta-data from thousands of patients and was able to identify 47 new genes with connections to tooth decay. Also, they used Mendelian randomisation to find a genetic link between oral health and cardiovascular- metabolic factors According to the 2016 Global Burden of Diseases, Injuries and Risk Factors Study, dental caries in permanent teeth and periodontitis were the leading and 11th most prevalent causes of disease worldwide in 2016. Another study in 2015 estimated the global cost of dental diseases to be more than 540 billion US dollars. Even after knowing that the genetic contribution to oral health outcomes and the heritability of dental caries and periodontitis happens to be as high as 50%, the nature of this contribution remains poorly characterised. We know that an increased understanding of genetic factors can improve our knowledge of the aetiology and clinical management of oral diseases, yet the role of genes in oral health remains understudied. One of the reasons for this is that the complex nature of tooth decay and periodontitis requires extensive studies to draw firm conclusions. Researchers, in order to fulfil the large data requirement, took the data from nine international clinical studies with 62,000 participants and merged it with the data on self-reported dental health from the UK Biobank, involving 461,000 participants. Ingegerd Senior Professor at the Institute of Odontology, the lead researcher at Umeå University, said, “The study makes it clear that teeth are part of the body. Among other things, we can see that there seems to be a causal link between risk factors for cardiovascular disease and tooth decay.” Johansson, The data analysis could identify 47 new genetic loci with connections to tooth decay. The research also confirmed a previously known immune- related gene to be linked to periodontitis. The genes linked For the first time, researchers have been able to pinpoint genes that can have an effect on oral health. (Image: Arek Socha/ Pixabay) to tooth decay included those that help form teeth and the jawbone, those with protective functions in saliva and those which affect the bacteria found on the teeth. The researchers used a technique called Mendelian randomisation, to find a genetic link between oral health and cardiovascular- metabolic risk factors such as smoking, obesity, education and personality. They stated that there might be a causal link between decay and some cardiovascular-metabolic risk factors. AIIMS to carry out the largest nationwide dental survey for national oral health policy and Research, Education Chandigarh, and Maulana Azad Institute of Dental Sciences, New Delhi, strategies The data collected in this survey would act as a baseline for planning preventive and treatment in oral healthcare in India. There is no India specific policy on oral and dental health, and there is an urgent need to create one. The data collected in this survey will be a part of the oral and dental health policy that will bring all aspects related to oral and dental health under a single umbrella. Dr O P Kharbanda, Chief, Centre for Dental Education and Research, AIIMS. „Multiple surveys have been conducted in the past, some at the institutional level and some regional. The last national- level survey was conducted in 2002 and this exercise in 2019, seventeen years later, is vital and will bring out glaring facts about the need for oral health interventions and the changing paradigm of dental diseases,“ said Dr OP Kharbanda, Chief, Centre for Dental Education and Research, AIIMS. Centre for Dental Education and Research (CDER), AIIMS will undertake the largest nationwide oral health survey this year to identify gaps in dental education, human resources and treatment. (Photo: Wikipedia) by Dental Tribune South Asia New Delhi, India: A series of workshops conducted at AIIMS, Delhi have drafted the survey guidelines as a part of the process to create an all-encompassing policy related to oral health. The data collected in this survey would act as a baseline for planning preventive treatment strategies in oral healthcare in India. Once the policy is notified, the health ministry of India will work on a national strategic implementation and framework with implementation points. detailed the Centre for Dental Education and Research (CDER), AIIMS will undertake largest nationwide oral health survey this year to identify gaps in dental education, human resources and treatment. The study will take place in collaboration with the Ministry of Health, which has identified CDER as the National Centre for Excellence for oral and dental health. Also, it will be supervised by a committee of representatives from AIIMS, Post Graduate Institute of Medical The survey will create a new baseline by recording specific, representative data on the most prevalent dental diseases in the country like dental decay, gum diseases, dentofacial deformities, cancerous dental fluorosis and dental trauma etc. It will also bring out glaring facts about the need for oral health interventions. lesions, sampling The survey is designed by an expert committee of dentists representing various oral health specialities and health ministry officials, who have formulated the strategies, planning and timelines of the survey. Scientifically validated guidelines will be utilised for sampling, and recording of data by experts. The survey logistics, necessary resources infrastructure and have also been thoroughly discussed. examination „It is an all-encompassing policy related to oral health,” said Dr Kharbanda. „The plan is to ensure trained, and calibrated oral health workforce examines the teeth following protocols in coherence with global guidelines to bring out an authentic data bank that acts as a baseline to Dr O P Kharbanda, Chief, Centre for Dental Education and Research, AIIMS. plan preventive and treatment strategies,“ he added. The survey will collect oral health data of the children in early years of life, examine the geriatric groups to assess their prosthetic treatment needs considering the increasing life expectancy, the impact of traditional oral hygiene practices, and the effects of high sugar diet on oral health, and much more.\ Once the policy is notified, the health ministry of India will work on a national strategic implementation framework with detailed implementation points.
4 News 8/19 “There will always be only one Peter Dawson” – Dr. Nitish Surathu in 1979, that has trained over 40,000 dental professionals globally on TMJ and occlusal principles developed by Dr Dawson. His work earned him the ADA Distinguished Service Award, the highest honour given by the American Dental Association’s Board of Trustees. It‘s a great privilege to have Dr Nitish Surathu as the guest editor on Dental Tribune (South Asia) and pay his tribute to Dr Peter Dawson. in Periodontics Dr Nitish Surathu completed his MDS in 1994. He is, by examination, an accredited Associate Fellow of the American Academy of Implant Dentistry. He is also a Fellow and Diplomate of the International Congress of Oral Implantologists. In 2009, he completed the New Zealand Dental Registration Examination process and now maintains a private practice in Gisborne, New Zealand. A stellar clinician and a great speaker, Dr Nitish has lectured around the world on periodontics and dental implants. He has also travelled all around the world and interacted with most of internationally acclaimed the clinicians educators, including Dr. Peter Dawson. and Guest Editorial: It is my absolute privilege to be invited to be the Guest Editor for this issue of Dental Tribune South Asia and write a tribute to Dr Peter Dawson. symposium I first had the privilege of meeting Dr Dawson in October 2011 when I attended his very well-known on Functional Occlusion – From TMJ to Smile Design in St Petersburg in Florida. It was my first introduction to this great man and the Academy he had helped to found, based on his many years of hard work and research. I remember being surprised when I finally met him. Somehow, I had unconsciously expected to meet a stereotype in my mind of a charismatic and dynamic man! And while Dr Dawson is certainly both of those in his own way, the quality that first struck me when I met him was his humble and down to earth nature. He was always a gentleman first, a kind man who had time for everybody who came up to him and soft- spoken words of encouragement for anyone who cared to listen to his words of wisdom. There was never any sense of coercion or persuasion to ‘believe’ in his philosophy of care, only a humble sharing of Dr Peter Dawson A pioneer in the field of TMJ and dental occlusion passed away at the age of 89. (Image courtesy: The Dawson Academy) by Rajeev Chitguppi, Dental Tribune South Asia clinicians Dr Peter E. Dawson, D.D.S., (1930- 2019) - a dental industry pioneer, who was globally acclaimed as one of the most influential and teachers in dentistry, passed away on 27th July 2019 at the age of 89. He will be remembered for his great contributions to the fields of TMJ, occlusion and restorative dentistry. In his illustrious career of over 60 years, Dr Dawson wrote and published five books, including the highly acclaimed “Functional Occlusion: From TMJ to Smile Design.” He founded the Dawson Academy what God had taught him in his life. It endeared him to many and made him the influential figure he was in dentistry. And yet he never exploited that influence for any reason, commercial or otherwise. Over the years I met him a few times, most memorably when he unexpectedly came in for an afternoon on a Comprehensive Examination and Records course at the Academy in 2012. By then he had slowed down with his speaking commitments as he was taking care of his wife. I remember sitting and discussing the Piper classification with him and his lucid soft-spoken explanation that sorted several lacunae in my understanding. It was this kind of interaction that will always cause me to remember him as the human being he was first, before I think of him as a gifted dentist, author or speaker. He modelled his faith and beliefs in every way and am sure he would rather be remembered for that, more than anything else. As I write this editorial, am sitting with my good prosthodontist friend Dr Ali Tunkiwala in New Zealand and we both cannot help thinking Dr. Nitish Surathu of the influence he has been on our professional lives as well. Dr Dawson laid the foundation for much of what has come to be known as the field of Occlusion and Oral rehabilitation. There isn’t a prosthodontist in the world who will not acknowledge that, regardless of whatever philosophy of care they subscribe to. In that sense, he was probably one of the single greatest influences on dentistry in this generation and there are so many who will proudly carry the torch of his legacy for many more that follow. There will always be only one Dr Peter Dawson. We have lost a giant of a man but to paraphrase Newton, we will always see further because we stood and will continue to stand on his broad shoulders.‘ Ad Relax your patients and make them feel more comfortable during dental procedures Matrx Nitrous Oxide and Oxygen Conscious Sedation Systems There are many good reasons to use nitrous oxide sedation in your dental practice: • Safe - N2O/O2 has been used globally for over 100 years • Relieves patient anxiety and discomfort • Patients remain awake, yet more relaxed, making it an excellent patient management tool • Improves patient experience, resulting in return visits Matrx is made in the USA 210 Udyog Mandir 1 7-C Bhagoji Keer Road Mahim West, Mumbai 400016 India Phone: +91 22 61 46 47 48 Email: email@example.com www.lifecare.in
6 News 8/19 Oral surgeons in Saveetha Dental College, Chennai extract 526 teeth from a single site in a child A surgery performed on a 7-year-old boy with a swelling in his lower jaw revealed 526 teeth. (Photograph: Павел Сороки/pexels) Ad by Dental Tribune South Asia CHENNAI, India: In a 2-hour long surgery, performed at the Saveetha Dental College and Hospital, the Oral and Maxillofacial Surgeons have successfully removed 526 teeth from a single site in a 7-year- old boy‘s mouth. The operating surgeon a well- defined bag like mass in its entirety, instead of exploring it on the operating table (akin to opening a bag of worms) which could have extended the duration of general anaesthesia unnecessarily. removed A 7-year-old boy was brought to Saveetha Dental College and Hospital by his parents for a swelling he had developed in his lower jaw. Earlier, he had been taken to another hospital in Chennai after his parents noticed a small swelling for the first time, but he had refused to co-operate for any investigations as he was just 3 years old then. Thus the swelling had remained undiagnosed for 4 years. As the size of the swelling gradually increased, his parents brought him to Saveetha Dental College. the jaw. in His parents were very assuming apprehensive that it could be a cancerous swelling Initial investigations revealed a large lesion in the right side of the jaw, which contained lower multiple hard structures at a site. Radiographic investigations revealed multiple tiny radiopaque structures. The single surgery was performed revealing a well-defined bag like mass, weighing about 200gms, which was removed in its entirety. tooth-like H i s t o p a t h o l o g i c a l investigation of the bag like mass by the oral pathologists revealed structures, 526 about which they said: “it was reminiscent of pearls in an oyster.” It took 5 hours of laborious work to separate and remove all the minute teeth from the specimen. Each one of them resembled a tooth with a crown covered by enamel and a root- like structure. The tooth sizes varied from 1mm to 3mm. The postgraduate students said “This pandora box of miniature teeth is a jewel on our crown.” Such lesions, where so many minute teeth were found in a single individual, single- site - are termed as “compound odontoma”, a benign tumour. Dr Pratibha Ramani, head of the hospital’s Department of Oral and Maxillofacial Pathology commented that, surprisingly, in any the boy was barely discomfort. “The only thing which was bothering him was that the tooth on that side had not erupted, it was empty, and [he had] occasional pain, and there was slight swelling that was increasing in size,” she added. Earlier, in another similar case reported in 2014, ear, nose and throat surgeons at the JJ hospital‘s dental department in Mumbai had removed 232 teeth from the mouth of a 17-year-old boy.
7 News 8/19 Hydroxyapatite toothpaste – an alternative to fluoride toothpaste? by Dental Tribune International WÜRZBURG, Germany: The use of hydroxyapatite has been investigated and discussed for years as an artificial tooth enamel to prevent loss of tooth structure by erosion and also to contribute to the regeneration of natural tooth enamel. However, we scientific evidence to prove its benefits. A recent German study has now shown that hydroxyapatite can be as effective as fluoride for prophylaxis. need more contribute to Recent in vitro studies have suggested that microcrystalline hydroxyapatite (HAP) particles might the prevention of demineralisation and of remineralisation on enamel and dentine surfaces. The present clinical study assessed the caries- inhibiting effect of a fluoride-free HAP dentifrice with regular use stimulation the by a group of patients with high caries risk. appliance Researchers selected a group of individuals with a relatively high caries risk – 133 patients aged 11–25 years scheduled to undergo fixed orthodontic treatment. They assigned them to two randomised groups - a test group comprising individuals using a 10% hydroxyapatite toothpaste was compared with a control group that brushed with a 350 ppm and 1050 ppm fluoride toothpaste. The researchers performed an oral examination before the start of fixed appliance orthodontic therapy and repeated it every four weeks after that for half a year. They used the International Caries Detection and Assessment System to assess the vestibular enamel surfaces, along with two indices - the plaque index and the gingival index. Results showed a significant increase in enamel caries during A recent study has found that fluoride and hydroxyapatite in toothpastes perform equally well. (Photograph: by dejavu/Shutterstock) the observation period. However, fluoride and hydroxyapatite did not differ significantly from each other. The test group with hydroxyapatite use showed 54.7% of patients having a carious lesion after six months, whereas the control group with fluoride use showed 60.9% of patients with a lesion. The plaque and gingival indices also increased slightly, without any significant difference. The results of this study show that hydroxyapatite toothpaste can serve as an alternative to fluoride toothpaste. Ad Ad THE FIRST AND UNIQUE DENTAL IMPLANT IN THE WORLD MANUFACTURED THROUGH DIRECT LASER METAL FORMING TECHNIQUE BY MICROFUSION OF TITANIUM PARTICLES SURFACE l SPONGY l TRIDIMENSIONAL l ISOELASTIC CAVITIES l INTERCONNECTED l 2-200 µm Cleared! ACTIVE POROUS SURFACE l THICKNESS TO 250 µm l DESIGNED TO PROMOTE BONE GROWTH MORE THAN 15 YEARS OF EXPERIENCE BY DOCTORS ALL AROUND THE WORLD OVER 250.000 UNITS SOLD WORLDWIDE References available upon request ONE STEP BEYOND LifeCare Devices Private Limited 210 Udyog Mandir 1, 2nd Floor, 7-C Bhagoji Keer Marg, Mahim West, Mumbai - 400 016 Phone: +91 22 6146 4725 / 27 E-mail: firstname.lastname@example.org
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