issn 2567-286X • Vol. 4 • Issue 1/2020 1/20 prevention international magazine for oral health CE article Glass ionomer fissure sealants for proactive intervention periodontal health “The link between oral disease and oxidative stress is still not that widely known” infection prevention Aseptic versus clean operating conditions in implant surgery
CALIBRATED INTERDENTAL BRUSHES
editorial | Magda Wojtkiewicz Managing Editor Dear readers, The world has become a very strange place, one in which things change by the minute. The COVID-19 pandemic has affected dental practices all around the globe. Dental practitioners in many countries are only allowed to treat emergency patients; others struggle with a lack of pro- tective masks, gloves and disinfectants. This pandemic is having an impact on the health of our loved ones, the businesses we rely upon, the condition of the global economy, the way we live our daily lives, the way we interact with other people, and the way we try to maintain good health. How we navigate through these unique and evolving challenges depends on us. Microorganisms are all around us, on our body and inside it. Some of them, like viruses and bacteria, can be dan- gerous, provoking serious disease, which can be even lethal. But many bacteria and fungi play an essential role in helping our immune system keep us healthy. A balanced diet is essential for our health and for our oral health. Why? Because the mouth is the beginning of the digestive tract and the oral microbiome is a biofilm in a complex environment in which bacteria, viruses and fungi interact at various times. Everything we eat influences the microorganisms inside our bodies, including our mouths, and can support the beneficial ones or the harmful ones. deleterious effects, as with Candida albicans, which is part of the normal microbiome of the oral cavity, but can quickly become pathogenic. Excessive consumption of simple carbohydrates can provoke the growth of patho- gens responsible for tooth decay, Streptococcus mu- tans and Streptococcus sobrinus. But that is not all; also important are interactions between different microbes. Consider S. mutans and C. albicans. In the presence of S. mutans and the availability of simple carbohydrates, C. albicans can develop a better attachment to the tooth surface. In addition, C. albicans produces a thicker biofilm when it grows together with S. mutans, which indicates that S. mutans stimulates the growth of C. albicans. This example demonstrates the complexity of relations and interactions between microorganisms and the food we eat and thus the environment we provide for microorganisms, which can influence not only oral health but the condition of the whole body as a system. Everything starts with the mouth, healthy food can help to maintain good oral health, and a healthy mouth leads to good general health, including a healthy digestive track and nervous system and a lower risk of systemic dis- eases like diabetes or cardiovascular disease. There- fore, watch what you eat, take care of yourselves and stay safe! The activity of certain microbes can modify the oral cavity environment and thus influence the growth of other mi- croorganisms, leading to an imbalance and associated Magda Wojtkiewicz Managing Editor Sincerely, prevention 1 2020 03
| content editorial Dear readers, Magda Wojtkiewicz paediatric dentistry The evolution of paediatric dentistry Dr Steven Schwartz page 10 CE article Glass ionomer ﬁssure sealants for proactive intervention Dr Fay Goldstep research Dentine hypersensitivity experience using toothpaste with added bioglass Drs Stefano Daniele & Andrea Alessandri 03 06 10 16 page 32 periodontal health “Naturally occurring substances will ﬁnd their place in oral health” 20 “The link between oral disease and oxidative stress is still not that widely known” Want to maintain good oral health? Start eating smarter healthy life and ageing page 36 “Diets rich in plant foods are increasingly associated with longevity and healthy ageing” An interview with Prof. Marcello Iriti “We aim to prepare dentists for care of the ageing population” The role of interdental cleaning for oral health, general health and quality of life education Perio Master Clinic—An EFP initiative An interview with Prof. Anton Sculean infection prevention Aseptic versus clean operating conditions in implant surgery Dr Francesca Bianchi & Prof. Tiziano Testori manufacturer news about the publisher submission guidelines imprint Cover image courtesy of miscea GmbH www.miscea.com issn 2567-286X • Vol. 4 • Issue 1/2020 1/20 prevention international magazine for oral health CE article Glass ionomer fissure sealants for proactive intervention periodontal health “The link between oral disease and oxidative stress is still not that widely known” infection prevention Aseptic versus clean operating conditions in implant surgery 04 prevention 1 2020 22 24 26 30 32 34 36 44 48 50
For adults and children aged 0+ UNIQUE* TOOTH-STRENGTHENING GEL R.O.C.S.® Medical Minerals Remineralization therapy is at present one of the most relevant techniques in modern dentistry. The number of possible situations where the teeth can lose their mineral components is extremely vast: from hormonal disorders related to imbalances in the mineral metabolism of the body to etching of enamel before a ﬁlling, the removal of dental braces, or even simple eating and drinking. In the case where the oral ﬂuid and saliva are not able to compensate these losses, the enamel reacts with the appearance of chalky spots and stripes on the teeth, and oen, an increase in sensitivity as well. R.O.C.S.® has, already for many years, been providing a product designed to take into account all clinical needs and speciﬁcs – the R.O.C.S.® Medical Minerals Remineralizing Gel. As an active base for the gel, a combination of the most essential calcium and phosphate minerals for the enamel is used – in the form of the easy-to-absorb calcium glycerophosphate. The addition of xylitol to the gel increases the remineralizing potential of the complex, as well as suppresses the activity of bacteria that cause caries and periodontal diseases. *Patent №RU 2311168 R.O.C.S.® Medical Minerals does not contain ﬂuoride, which makes it safe for babies if swallowed accidentally and indispensable and eﬀective for preventing caries at the chalky spot stage in geographical regions with a high concentration of ﬂuoride in the drinking water. It’s also vital for people whose general condition is aﬀected by metabolism imbalances, making the use of products containing ﬂuoride inadvisable for them. The use of the R.O.C.S.® Medical Minerals gel has been proven to be eﬀective and is recommended to be used in the case of : chalky spot stage caries, caries prevention, enamel hypoplasia of various origins, aer microabrasions, as a complex approach to ﬂuorosis treatment, aer clinical dental whitening procedures, as well as an alternative whitening technique that also brightens and shines the enamel, aer the removal of dental brace systems, for relieving enamel hypersensitivity, etc. Remineralization therapy is a simple, safe and very relevant technique for achieving a number of medical and aesthetic goals in modern dentistry! online.rocs.eu VISIT OUR OFFICIAL ONLINE STORE Representative Oﬀice in the EU: UNICOSMETIC OÜ, A.H. TAMMSAARE TEE 47, 11314, TALLINN, ESTONIA. Phone: (+372) 520 0227. E-Mail: firstname.lastname@example.org. Contact person: Mariya Terentyeva rocsinfo.com
| paediatric dentistry The evolution of paediatric dentistry Dr Steven Schwartz, USA Paediatric dentistry, as practised today, has evolved over a period of almost 100 years. In the early 1900s, the treatment of childhood caries consisted of extraction or just leaving carious teeth in place untreated because many dentists felt that they were going to fall out anyway. Sometime later, in the 1920s, groups of local study clubs with an interest in treating children (and in some cases limiting their practices to paedodontics—the precursor of paediatric dentistry) banded together to form the American Society of Dentistry for Children (ASDC). These den- tists dedicated themselves to re search - ing deﬁnitive methods of treating and Fig. 1 06 prevention 1 2020 Fig. 2 preventing childhood caries and to management of paediatric behaviour in the dental environment. However, no established educational qualiﬁcations, standards of practice or certifying board yet existed. Certifying paediatric dentistry To meet these needs, the ASDC established certiﬁcation requirements that led to the formation of the American Board of Pedodontics in 1940. In the late 1930s and early 1940s, dental schools instituted departments of paedodontics, followed by the establishment of postgraduate training programmes. In 1942, the American Dental Association’s Council on Dental Education formally recognised paedodontics as a distinct specialty. In 1947, a group of ASDC members met to organise the American Academy of Pedodontics (AAP) with the objectives to research and critically evaluate proce- dures used in children’s dentistry. While ASDC mem- bership was open to all dentists regardless of whether they went through a specialty training programme, AAP membership was open only to those dentists who lim- ited their practices to children or who went through a formal specialty training programme in paedodontics. It was not until 1984 that the AAP changed its name to the American Academy of Pediatric Dentistry (AAPD). Eventually in 2002, the ASDC merged with the AAPD to form a single organisation. After the establishment of certifying boards, the formal inclusion of paedodontics into dental
paediatric dentistry | may make these options unaffordable for parents without insurance reimbursement. In addition, respon- dents mentioned longer preparation time for zirconia crowns compared with stainless-steel crowns. Regarding the issue of preparation time, it should be pointed out that hands-on training programmes spon- sored by zirconia crown manufacturers help practitioners improve their technique and reduce their preparation time. The ﬁrst point cited in the poll results (lack of or minimal instruc- tion), especially, war- rants being addressed more fully and ought to be resolved by ensur- ing adequate instruc- tion during dental advanced techniques and technologies. Only in this way will their graduates be able to meet patient needs and sat- isfy parental expectations. School, hospital and programme administrators often claim funds are not available to provide such training, but it is their obligation as advocates at teach- ing institutions responsible for training the next generation of paediatric dentists to ﬁnd the means to do so. Funding one or two faculty members to attend educational forums or manufacturer-sponsored programmes will en- able them to return to their programmes with the knowledge and ability to train students. Requesting manufacturers and suppliers to provide a limited amount of free product, or in the case of technology companies (e.g. lasers, isolation products and computerised delivery systems), use of their products for a limited period, will at least expose trainees to proper techniques required in the use of these products. residency. Continuing dental education If you are a provider already in practice and no longer able to beneﬁt from training offered in a residency programme, you must take advantage of continuing education oppor- tunities to keep abreast of recent advances in paediatric dentistry. You may do so by attending formal training programmes and meeting with exhibitors at dental meetings. Or make the effort to attend specialised train- ing programmes sponsored by product manufacturers. Sales representatives should be welcome to visit your ofﬁce rather than be brushed off. As providers, we must become involved in organised dentistry to educate and encourage third-party payers to reimburse patients, at a reasonable level, for newer and more effective procedures. Advances and innovations in paediatric dentistry are coming down the pike at quantum speed. As dental health professionals, it is our obligation to keep up with them and make them available to our patients. about Dr Steven Schwartz After graduating from the New York University College of Dentistry in the US, Dr Steven Schwartz completed a postgraduate residency in paediatric dentistry at the then Jewish Hospital and Medical Center of Brooklyn in the US. He served as clinical associate professor in the Department of Pediatric Dentistry of the then University of Medicine and Dentistry of New Jersey in the US. Before retiring, he was the director of the paediatric dentistry residency programme at Staten Island University Hospital in the US. Dr Schwartz is a diplomate of the American Board of Pediatric Dentistry and writes and lectures on clinical and practice management topics. Fig. 4 Enhancing residency instruction Over a period of approximately 100 years, children’s dentistry treatment options have evolved, following these sequential, progressive steps: (1) no treatment (or tooth extraction); (2) treatment using unaesthetic materials; (3) use of aesthetic materials; (4) minimally invasive restorative treatments; and (5) more proactive preventive treatments. Behaviour management has similarly evolved from relying on physical restraint as previously practised to the non-traumatising dental experiences of today. Parents, possessing increased awareness of the newer techniques providing more aesthetic treatment outcomes and overall pleasant dental experiences for their children, are demanding that dental providers use these newer treatment options and techniques. To meet parental expectations and patient needs, dental provider training opportunities in these newer techniques and technologies must be available to those in dental undergraduate and postgraduate training programmes, as well as to those in practice. Dental schools and hospital residency programmes must provide adequate training that will enable graduates to implement the newest and most prevention 1 2020 09
CE article | Fig. 2a Fig. 2b Fig. 2c Fig. 2d Fig. 2e Fig. 2f Fig. 2g Fig. 2h Fig. 2i Fig. 2j Figs. 2a–j: An erupting mandibular ﬁrst molar is sealed with GC Fuji TRIAGE (GC America; white). Erupting mandibular ﬁrst molar prior to treatment (a). Prophy- laxis with pumice is performed to prepare for treatment, and the tooth is then rinsed thoroughly (b). Etching is performed with 37 % phosphoric acid left on for ﬁve seconds (Alternatively, CAVITY CONDITIONER, GC America, can be applied and left on for ten seconds.) (c). The tooth is thoroughly rinsed. Excess mois- ture is removed. The tooth is kept moist, not desiccated (d). The capsule of the glass ionomer material is tapped on a hard surface to loosen the contents (e). The plunger is pushed into the capsule to activate it (f). The capsule is put into the applicator, which is then clicked once for further activation (g). The capsule is placed into the triturator and mixed for ten seconds (h). The capsule is loaded into the applicator, the trigger clicked until the paste extrudes, and the extruded paste dispensed on to the prepared tooth (i). Once the material has lost its gloss, one drop of GC Fuji COAT (GC America) is applied and polymerised. The completed restoration is inspected (j). prevention 1 2020 11
| CE article Fig. 3a Fig. 3b Fig. 3c Fig. 3d Fig. 3e Fig. 3f Fig. 3g Figs. 3a–g: An erupting maxillary ﬁrst molar is sealed with Riva Protect (SDI Australia; pink). Erupting maxillary ﬁrst molar prior to treatment (a). After pro- phylaxis with pumice and thorough rinsing, Riva Conditioner (SDI Australia) is applied with a micro-brush, left on for ten seconds and then thoroughly rinsed. (Alternatively, etching can be done with 37 % phosphoric acid left on for ﬁve seconds.) Excess moisture is removed. The tooth is kept moist, not desiccated (b). The capsule of glass ionomer is tapped on a hard surface to loosen the contents (c). The plunger is pushed into the capsule to activate it. There is no need to put the capsule into an applicator for further activation when using the Riva Protect system (d). After the capsule has been mixed in the triturator for ten seconds, it is loaded into the applicator, the trigger clicked until the paste extrudes, and the extruded paste dispensed on to the prepared tooth (e). A micro-brush is used to ensure that the material gets into all the pits and ﬁssures (f). Once the material has lost its gloss, one drop of Riva Coat is applied and polymerised. The completed restoration is inspected (g). barrier to the bacteria and promotes remineralisation through the release of ﬂuoride.10, 11 the sealant retention rate is a valid predictor of clinical outcomes.12 Hence, it should not be used to measure sealant success in preventing caries. Most studies have used retention of the sealant as the end point for ﬁssure sealant effectiveness. In addition, many studies have assumed that only a totally intact sealant (as opposed to a lost or partially retained sealant) is the criterion for effective caries prevention and clinical success,12 but systematic reviews have not found that Two systematic reviews found that neither resin sealants nor GI sealants were superior in the prevention of dental caries in children.10, 11 Therefore, the choice of which material to use may have more to do with ease of use, moisture control and patient compliance.13 12 prevention 1 2020
CE article | Hydrophobic resin sealants do not provide the best solu- tion for sealing permanent ﬁrst molars, since they are only partially erupted for a prolonged period and adequate isolation is not attainable.5 Moreover, it has been shown that improperly placed resin sealants can leak and allow caries to develop unnoticed under the leaking sealant.14 This is a reason why many dentists have stopped using resin ﬁssure sealants: too many surprises when opening up carious lesions under failed resin sealants and ﬁnding very extensive decay that has been left undisturbed for a prolonged period. Furthermore, resin sealants cover the immature under- mineralised tooth surface, preventing ﬂuoride, calcium, phosphate and other minerals from the saliva con- tacting the tooth surface and mineralising it.5 Enamel requires almost three years to reach full mature minera- lisation. During this time, the enamel is incompletely formed and more susceptible to demineralisation under low pH.15 Advantages of GI ﬁssure sealants GI ﬁssure sealants offer several major advantages over resin sealants, especially in partially erupted teeth:5 1. GI sealants are hydrophilic; they can chemically bond to tooth structure in a moist environment. This is es- pecially advantageous when placing sealants in young children, where isolation can be challenging owing to location and/or behaviour. Resin sealants only bond mechanically to tooth substance, so they require a completely dry, isolated environment. 2. GI sealants release and recharge ﬂuoride. Resin seal- ants only provide a barrier to bacterial inﬁltration, while GIs provide a barrier to bacteria and release and recharge ﬂuoride. GIs adhere to enamel and dentine via ionic and polar bonding.16 This creates intimate contact and the ﬂuoride is exchanged with the hydroxyl ions in the adjacent enamel hydroxyapatite, forming ﬂuorapatite, which is a stronger, more acid-resistant structure (Fig. 1). 3. GI sealants allow for the easy diffusion of calcium and phosphate ions (in addition to the ﬂuoride ions) from the saliva into the tooth. This helps to achieve faster, more complete mineralisation and maturation of the enamel surface. Resin sealants consist of a solid mate- rial that seals the tooth and does not allow for the ionic exchange of minerals. GIs are porous and have large spaces to allow the diffusion of calcium, phosphate, ﬂuoride, etc. and this assists enamel in the maturation AD PRINT EVENTS EDUCATION DIGITAL SERVICES Dental Tribune International The World's Dental Marketplace www.dental-tribune.com
| CE article process.5 Newly erupting enamel is immature, as it is composed of carbonate apatite, which is easily dis- solved. GI sealants can be applied as a thin ﬁlm over the exposed enamel as well as under the operculum of a partially erupted tooth. The GI sealant forms a semi- permeable membrane that allows calcium and phos- phate from saliva to diffuse through it, into the enamel, and react with the released ﬂuoride to form mineralised ﬂuorapatite enamel. This mature mineralised enamel is more caries-resistant (Fig. 1). 4. A study has shown that GI sealants penetrate more deeply into enamel ﬁssures and occlusal convolu- tions than resins do.17 As a result, sometimes the GI is not visible on clinical examination. However, when the teeth were sectioned for this study, the GI sealant was present deep in the ﬁssure, providing maximum protection where it is most needed. Clinical application A young patient presented at his six-month re-care appointment with erupting ﬁrst permanent molars in all quadrants. In view of the child’s history of decay and deep pits and ﬁssures on the occlusal surfaces, all the erupting teeth were sealed with auto-polymerising GI ﬁssure sealants. GC Fuji TRIAGE (GC America; white shade) was applied to the mandibular molars and Riva Protect (SDI Austra- lia; pink shade) was applied to the maxillary molars. Dif ferent materials were used in this case to illustrate the technique for this article and for further educational purposes. Both materials come in white and pink shades. Procedure (Figs. 2a–3g) – To prepare the newly emerged molars for treatment, prophylaxis is performed using pumice and the teeth are thoroughly rinsed. – Cotton rolls and a triangular shield are placed to retract the cheek and tongue and to control excess moisture. – Either 20 % polyacrylic acid cavity conditioner (for ten seconds) or 37 % phosphoric acid (for 5 seconds) is applied and thoroughly rinsed. This optimises adhe- sion of the GI to the tooth structure. Excess moisture is removed. The tooth should have a moist, shiny surface. – The capsule of the GI material is tapped on a hard sur- face to loosen the contents. The plunger is pushed into the capsule to activate it. (The GC Fuji TRIAGE capsule must be further activated by one click once in the applicator). – The capsule is placed into the triturator and mixed for ten seconds. – The capsule is removed and loaded into the applicator and the trigger clicked until paste extrudes. – The GI ﬁssure sealant paste is dispensed on to the prepared tooth. A micro-brush can be used to ensure the material gets into all the pits and ﬁssures. – Once the material has lost its gloss, one drop of the coating (GC Fuji COAT, GC America; or Riva Coat, SDI Australia) is dispensed and applied to the treated area and polymerised. – The sealant is inspected for complete coverage and absence of voids. Conclusion Fissure sealant application is an excellent proactive dental treatment. It is an under-used treatment because of the difﬁculties of isolation with resin sealants and the unwelcome surprise of advanced decay that is some- times found under failed resin sealants. GI sealants offer the advantages of easier isolation and the ionic exchange of ﬂuoride and other minerals to help in the minerali - sation of the immature tooth surface. It is time to bring ﬁssure sealants back as proactive intervention treatments for our young patients, this time with patient-friendly GI materials. Editorial note: A list of references is available from the publisher. CE credit This article qualiﬁes for CE credit. To take the CE quiz, log on to www.dtstudyclub.com. Click on ‘CE articles’ and search for this edition of the magazine. If you are not registered with the site, you will be asked to do so before taking the quiz. about Dr Fay Goldstep, DDS, is a clinician, author and educator. She has lectured nationally and internationally on proactive/minimal intervention dentistry, soft-tissue lasers, electronic caries detection, healing dentistry and innovations in hygiene. Dr Goldstep has served on the teaching faculties of the postgraduate programmes in aesthetic dentistry at the State University of New York at Buffalo, the universities of Florida and Minnesota, and the University of Missouri–Kansas City in the US. She sits on several editorial boards, has contributed to four textbooks and published more than 100 articles. She is a fellow of the American College of Dentists, International Academy for Dental-Facial Esthetics and Academy of Dentistry International. Dr Goldstep is a consultant to a number of dental companies and practises in Toronto, Canada. 14 prevention 1 2020
REGISTER FOR FREE! DT Study Club – e-learning platform Join the largest educational network in dentistry! www.DTStudyClub.com Tribune Group GmbH is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Tribune Group GmbH designates this activity for one continuing education credit.
| research Dentine hypersensitivity experience using toothpaste with added bioglass: A clinical trial Drs Stefano Daniele & Andrea Alessandri, Italy Fig. 1 Fig. 2 Fig. 1: Small areas of cervical loss of enamel, resulting in exposure of dentine to evocative stimuli, in particular cold and air, and thus dentine hypersensitivity pain. Fig. 2: Large areas of cervical loss of enamel due to powerful phenomena of abrasion and erosion of enamel and high dentine hypersensitivity pain. In our clinical practices, dentine hypersensitivity (DH) has always been a challenge. Our best approach was to sug- gest at-home solutions such as sensitivity toothpaste or mouthrinse, but often there was no significant relief experi- enced by our patients. Last year, we met Richard Whatley, CEO of BioMin Technologies, who gave us some samples of BioMin F toothpaste for provision of relief from DH, and he explained the technology behind the effectiveness of this novel bioactive glass-based toothpaste. The bioglass parti- cles contained in BioMin F toothpaste adhere to dental hard tissue and then slowly dissolve in saliva to release calcium, phosphate and ﬂuoride ions, which precipitate on nucleation sites as ﬂuorapatite crystals to occlude open dentinal tubules. According to Brännström’s hydrodynamic theory, ﬂuid movement inside the dentinal tubules in response to evocative stimuli such as cold—first of all—but also hot and sweet food and beverages, stimulating the odonto- blast fibres and nerves fibers and thereby creating a brief and acute pain, like an electric shock. This is what patients refer to as pain from DH. A special polymer in BioMin F toothpaste is able to chem- ically bond the calcium from the bioglass to the hydroxy- apatite of enamel. This adhesion is similar to that of glass ionomer cement to tooth surfaces. Saliva slowly dissolves these bioglass particles. This enables the release of ions from bioglass particles over eight to twelve hours after brushing to create new crystals of ﬂuorapatite, which form on nucleation sites like peritubular dentine and the internal surfaces of dentinal tubules. The formation and develop- ment of these ﬂuorapatite crystals closes exposed dentinal tubules and provides relief from the pain of DH. It is important to note that the ﬂuoride concentration in BioMin F toothpaste is much lower than that of other DH or caries prevention toothpastes, which often utilise several thousand parts per million of ﬂuoride (from 1,000 to almost 5,000 ppm in some countries). BioMin F has a ﬂuoride concentration of only 530 ppm, and this concentration is sufficient to promote the formation of ﬂuorapatite crystals on the tooth surfaces. Soluble-ﬂuoride toothpastes (typically including sodium ﬂuoride or sodium monoﬂuorophosphate) require a high concentration of ﬂuoride because most of the available ﬂuoride is washed away by the salivary ﬂow however at high concentrations, it forms amorphous crystalline calcium ﬂuoride on dental hard tissue and not ﬂuorapatite mineral. It is very important to start remineralisation on initial cari- ous lesions such Codes 1 and 2 on the International Car- ies Detection and Assessment System.1 A scientific paper on caries research published in 2013 by Hill et al. shows that only a salivary ﬂuoride concentration of below 45 ppm is effective in promoting remineralisation when combined with calcium and phosphate to form ﬂuorapatite crystals.2 16 prevention 1 2020
research | Fig. 3 Fig. 4 Fig. 3: Percentage of patients included in the clinical trial who reported dentine hypersensitivity pain to the dentist on consuming hot, cold or acidic foodstuffs or brushing their teeth. Fig. 4: Of the patients in the trial, 48.27 per cent reported prior use of sensitivity toothpaste. It is in its crystalline phase that it is able to exchange ions in the oral environment (equilibrium between remineralisation and demineralisation). Clinical trial with BioMin F for dentine hypersensitivity The crystalline phase of ﬂuorapatite developed by bioglass has enhanced acid-resistant features too.3 Most concentrated- ﬂuoride dental products, such as toothpaste and varnishes, might be able to form an amorphous crystalline phase on enamel, but that is not remineralisation, as mentioned, but calcium ﬂuoride. Calcium ﬂuoride is not acid-resistant like ﬂuorapatite crystals, but resistance to acid is a very important feature for overcoming the DH challenge. In fact, an amorphous and not acid-resistant layer is prone to dissolving in con- tact with erosive beverages or foodstuffs, thereby restarting DH pain owing to the re-exposure of dentinal tubules. We started the trial in November 2018 and included only patients with pronounced DH of a grade of moderate to severe. In July 2019, we collected the last recall from this trial. For the trial, every participant was given a sample of BioMin F and instructed to use the toothpaste twice a day for two weeks before recall. At recall, the evaluation sheet given to the participants con- tained some general questions, covering their experience of the ﬂavour of the toothpaste, its texture and its foaming capabilities, for example, as well as some speciﬁc ques- tions, such as concerning their prior use of other tooth- Fig. 5 Fig. 6 Fig. 5: Of the patients treated with BioMin F, 27.58 per cent had no further dentine hypersensitivity pain and 52.72 per cent reported a reduction. Fig. 6: Of the patients in the trial, 73.07 per cent reported that BioMin F toothpaste is more effective than other sensitivity toothpastes in reducing dentine hypersensitivity pain. prevention 1 2020 17
| research Fig. 7 Fig. 8 Fig. 9 Fig. 10 Fig. 7: Patient’s evaluation questionnaire in which she reported vomiting bouts during BioMin F treatment, but a complete absence of dentine hypersensitivity (score of 9) despite this severe acidic challenge. Fig. 8: Open tubules on the dentine surface (research at Queen Mary University of London). Fig. 9: Tubules occluded after brushing with BioMin F (research at Queen Mary University of London). Fig. 10: Tubules remained occluded after acid challenge (research at Queen Mary University of London). pastes for DH. In particular, the questionnaire asked the patients to grade the scale of relief from DH using BioMin F on a scale of 0 to 10. We considered that an average score of 9 or 10 meant that the DH has been completely resolved using BioMin F toothpaste for only two weeks. The clinical photographs in Figures 1 and 2 are of patients who reported diffused DH in the cervical areas of the teeth and this was treated with BioMin F for two weeks. This ap- proach substantially reduced or eliminated their pain from DH. Figure 3 shows the percentage of patients included in the clinical study who reported pain after consuming cold, hot or acidic food and after brushing their teeth with cold water. Most patients included in the trial had diffuse (58.62 per cent) or occasional (37.93 per cent) DH, and only 3.44 per cent did not report any DH. Of the 29 patients included in the clinical trial, the major- ity (48.27 per cent) reported that they were already using a toothpaste to speciﬁcally address DH (Fig. 4). cent of patients treated with BioMin F for two weeks reported an elimination of hypersensitivity, while in 52.72 per cent, the pain had been signiﬁcantly reduced. Just 20.68 per cent reported no obvious change after using BioMin F for two weeks. Importantly, no patients reported an increase in DH pain. One of the last questions asked of patients was whether they felt that there was a greater beneﬁt to using BioMin F, rather than their previous toothpaste, to tackle DH, and a large number (73.07 per cent) reported a positive response as shown in Figure 6. We would now like to describe in detail one particular clinical case from the trial which demonstrates the acid- resistant features of ﬂuorapatite crystals produced by the bioglass in BioMin F. The 44-year-old female patient with high DH started the BioMin F trial according to our instruc- tions (twice a day), and after just a few days, she reported greater relief from DH and she was very satisﬁed. In the following days, the patient had repetitive bouts of vomiting with gastric acid reﬂux with a very low pH (a pH of around 1) capable of removing any mineral pellicle or aggregate covering tubule oriﬁces and which would likely cause DH pain to reoccur. Naturally, the patient feared that this would happen. At the conclusion of these episodes, she checked her hypersensitivity pain by rinsing her teeth with cold water after brushing in the cold air of winter, and she told us that the beneﬁt of using BioMin F remained unchanged (Fig. 7). This suggests, as evident in microscopy studies under- taken at Queen Mary University of London, that the bio- glass contained in the toothpaste does not produce an amorphous mineral layer on the tubule oriﬁces, but produces a true mineralisation process through which ﬂuorapatite crystals form that appear to be acid-resistant. This is shown in Figures 8 to 10. Editorial note: A list of references is available from the publisher. about Dr Stefano Daniele is an academic tutor for restorative dentistry in the Department of Biomedical, Surgical and Dental Sciences at the Faculty of Medicine and Dentistry of University of Milan, San Paolo hospital in Milan, Italy. He has been visiting professor at Amedeo Avogadro University in Novara, Italy, for teaching Restorative Dentistry and Dental Materials and has a private clinical practice in Milan. It is interesting to note, as shown in Figure 5, how many pa- tients using BioMin toothpaste twice a day for two weeks experienced a reduction in DH pain. Most of the patients found it relieved their pain from DH. In particular, 27.58 per Dr Andrea Alessandri is a post graduate student in the European University of Valencia in Spain and works in private practice in Novara in Italy. 18 prevention 1 2020
| periodontal health “Naturally occurring substances will ﬁ nd their place in oral health” An Interview with Dr Alex Solderer, University of Zurich, Switzerland. By Kasper Mussche, DTI I do not see any indication that the patient should con- tinue to rinse with chlorhexidine. Chlorhexidine is good at reducing bioﬁlm, plaque and inﬂammation, but your paper says it has no ef- fect on periodontal pocket depth. Only mechanical therapy, such as scaling, root planing and periodontal surgery, can reduce pockets, as these procedures include the removal of the aetiological fac- tors for periodontal pockets: bioﬁlm and bioﬁlm reten- tion structures, such as calculus. Oral antiseptics should always be seen only as an adjunctive therapy. Chlorhexidine has a number of side effects, such as tooth discoloration and taste disturbances. It also tastes unpleasant. Have you had any problems be- cause of this when treating patients? Patients who come to me for treatment normally have se- vere periodontal issues and are aware of them. After inform- ing patients thoroughly on their oral health and disease, the beneﬁts of chlorhexidine therapy and its temporary side ef- fects, they generally do not complain about taste and dis- coloration. Patients do not like the side effects, but owing to their temporary character, they normally accept them. However, in a few cases, patients suffer from mouth burn- ing, and then we have to stop the rinsing therapy. I never prescribe a chlorhexidine rinse for longer than two weeks, as side effects begin to increase after this period. After ter- mination of the prescribed rinsing time, I always schedule an appointment for removal of the discoloration. What is the importance of compliance during peri- odontal treatment? Patient compliance—especially correct oral hygiene at home—is crucial. In my opinion, it makes no sense to start periodontal treatment before adequate oral hygiene has been established. In a university department, this might work more easily than in a private practice. We work with plaque-disclosing methods to reveal bioﬁlm and that helps patients to visualise their problem areas and to know where brushing is particularly important. In other words, the key factor is to educate patients. This also includes instructing the patient how long, how often and in what manner the rinse should be used. After sur- Dr Alex Solderer A graduate of the specialisation programme in periodontics at the University of Zurich in Switzerland, Dr Alex Solderer mostly treats severe cases of periodon- titis in his daily routine. In addition, he conducts research on periodontal and dental implant topics. In his latest research paper, Dr Solderer conducted a systematic review of the efﬁcacy of chlorhexidine rinsing after peri- odontal or implant surgery. Chlorhexidine is considered the gold standard for oral antiseptics. In your experience, would you agree with this? Yes, I would. Just with regard to the literature alone, a search for chlorhexidine on PubMed yields 10,000 results. It is clearly the best-documented oral antiseptic you can ﬁnd. Every new antibacterial rinse is and has to be compared with chlorhexidine. After writing your review, what is your conclusion about chlorhexidine’s efﬁcacy after surgery? Well, after surgery, patients should not brush the teeth in the operation area until the stitches have been re- moved. Until then, chlorhexidine works like a “chemical toothbrush” in this area. Formation of plaque and gingival inﬂammation can be successfully suppressed. From the point at which normal oral hygiene can be re-established, 20 prevention 1 2020
| periodontal health “The link between oral disease and oxidative stress is still not that widely known” An interview with Dr Lenka Banasova, Pearl Dental, Slovakia. By Kasper Mussche, DTI results in the clinical research and proved our hypotheses, I got more and more into it. I am currently finishing a mas- ter’s degree in oral implantology in Italy and I am writing my thesis on peri-implantitis and oxidative stress markers, so I am still continuing with the topic. Could you explain to our readers what oxidative stress is? What happens in our bodies when this takes place? Oxidative stress is an imbalance of free radicals and anti- oxidants in the body, which can lead to cell and tissue damage. On the one hand, this occurs naturally and plays a role in the ageing process; on the other hand, a large body of scientific evidence suggests that long-term oxidative stress contributes to the development of a range of chronic conditions. Such conditions include cancer, dia- betes, heart disease, atherosclerosis, Parkinson’s disease, periodontitis and many other diseases. What role does it play in inflammation? What is the link between oxidative stress and periodontal disease? The body’s natural immune response can trigger oxidative stress temporarily. This type of oxidative stress causes mild inflammation that goes away after the immune system fights off an infection or repairs an injury. Uncontrolled oxidative stress can accelerate the ageing process and may contribute to the development of a num- ber of conditions which I mentioned earlier. Oxidative stress is involved in the pathogenesis of periodontitis as well. Could patients identify risk factors or find ways to avoid or reduce oxidative stress? Several risk factors contribute to oxidative stress and excess free radical production. These can include diet, lack of exercise, smoking, alcohol consumption, certain conditions, such as obesity, medications, and environmen- tal factors, such as pollution and radiation. Dr Lenka Banasova Dr Lenka Banasova runs her own dental centre, Pearl Dental, in the Slovakian capital of Bratislava, where she has a passionate staff of dentists, dental assistants and den- tal hygienists. In recent years, her focus has increasingly shifted from conservative dentistry and prosthodontics towards periodontics. Most importantly, however, she is one of the few dentists to touch on the largely neglected topic of oxidative stress. In this interview, she explains how natural antioxidants can improve periodontal therapy. Dr Banasova, how did you become interested in dentistry and what led you to researching oxidative stress? My mum is also a dentist and I spent lots of time with her in her office as a child. Actually, she was the one person who did not want me to study dentistry, and now I under- stand why. She understood that dentistry is not an easy profession. Nonetheless, I can say today that watching her doing her job with passion was what motivated me to study dentistry. The topic of my PhD thesis was periodontitis and oxidative stress markers. I must say that it was quite difficult in the beginning, because there were not enough studies in this field at the time, but as my colleagues and I achieved good While you can’t completely avoid exposure to free radicals, you can make lifestyle choices regarding your diet, exercise, environment and so on to help keep your body in balance and prevent damage and disease. And this includes your 22 prevention 1 2020
| healthy life and ageing Morbidity and mortality due to cardiovascular disease are low in Mediterranean countries. Epidemiological data indicates that the Mediterranean diet and polyphenol intake are cardioprotective factors. Remarkably, melatonin is a powerful antioxidant and anti- inﬂammatory agent promoting bone metabolism in the oral cavity. Therefore, a certain degree of synergy between melatonin and polyphenols has been hypo- thesised. However, the melatonin and polyphenols we get from our diet are far from effective in the oral cavity, because they should be administered as topical formu- lations to reach pharmacologically active concentrations in saliva and oral tissue and also bypass the Phase I and Phase II metabolic transformation by our digestive system. Low oral bioavailability represents the major drawback of dietary phytochemicals. Nonetheless, morbidity and mortality due to cardio- vascular disease are low in Mediterranean countries, and epidemiological data indicates that adherence to a Mediterranean diet and polyphenol intake are cardio- protective factors. As vaso-dilating, anti-thrombotic and antioxidant agents, polyphenols can mitigate endothelial dysfunction, reduce low-density lipoprotein oxidation and prevent atherosclerosis. Regular low to moderate red 28 prevention 1 2020 “Dietary patterns involving plenty of fruit, vegetables and legumes have been associated with reduced risk and incidence of chronic degenerative diseases.” wine consumption at main meals has shown to be cardioprotective. Are there examples of organic plant compounds that have already become commonplace in the treatment of disease? A plethora of dietary supplements based on botanicals and nutraceuticals have been developed. However, these products are not drugs and care should be taken not to try to cure major diseases with dietary supplements. With regard to oral health, aloe vera gel and Melaleuca alternifolia (tea-tree) essential oil have proven to be effective as antimicrobial and wound-healing agents. Antibiotic resistance is becoming an increasingly common problem. Do you think a transition towards more organically sourced polyphenols in oral care products could offer a solution here? This is a very relevant topic. Antibiotic resistance is one of the biggest threats to global health, as is anti-cancer drug resistance. In this scenario, polyphenols could be promising natural antibiotics. Indeed, plant extracts rich in polyphenols can be active on different bacterial and fungal targets, thus reducing the risk of selecting resis- tant microbial populations. In addition, polyphenols can reverse chemoresistance by targeting some microbial resistance mechanisms. In this regard, polyphenols could be used as adjuvants in combination with con- ventional antibiotics with the goal of slowing down the occurrence of resistance. Lastly, has your research changed the way you eat and live? Yes, of course, even though I was already “ Mediterranean” before becoming a researcher. I am Italian and come from a southern region where traditional Mediterranean dishes are part of everyday life. The Mediterranean diet is one piece of the puzzle, but the Mediterranean lifestyle also includes sociocultural aspects relevant in terms of well-being, such as low- to moderate-intensity physical activity and of course conviviality.
REASONS WHY YOU NEED THE MISCEA CLASSIC SYSTEM NOW Achieve optimal hand hygiene. Reduce the risk of cross contamination with state of the art sensor technology. Work comfortably. Ergonomic sensor faucets with integrated dispensers for perfect hand hygiene. Live beautifully. Style that works in harmony with modern interiors. Built to last. Enjoy world class quality. Designed for professionals. The professional choice for hand hygiene. www.miscea.com / email@example.com LIKE & FOLLOW SCAN TO LEARN MORE
JOIN OUR COMMUNITY D A established the Nakao Foundation right after my 70th birthday and final retirement from the board of direc- tors of GC Corp. Which problems are associated with an ageing population? What can we, or the Nakao Foundation, do to be prepared? While an ageing population is a long-term and global development, it is important to note that the impact and quality of this ageing can vary greatly. A healthy person will age differently than a sick person in terms of physical strength, quality of life, and cost of and possibility of requiring medical care. That is why the Nakao Foundation is seeking to promote oral disease prevention and healthy ageing through identification, prevention, disease man- agement and education. How can the experience and knowledge gained at GC aid the Nakao Foundation? What is the synergy between the two? The mission of GC is to develop and supply the products and information that practitioners need. Therefore, we be- lieve that we are in a great position: being able to respond appropriately to requests and developments from our foundation’s research support programme and being able to promote the mission of the Nakao Foundation through GC. “We want to support academic research, not for proﬁt but because we believe this will make a signiﬁcant and sustainable impact on people’s oral health.” The foundation is about to launch its first activities. What can we expect? Yes, we are now at kick-off stage and just closed two board meetings, one with the foundation’s board and another with the management board, in which six world-renowned experts finalised a detailed procedure as well as the criteria for applying for funding. We will be starting the application process soon and encourage researchers to visit our website (www.foundation- nakao.com) on regular basis. The call for applications will also be forwarded to all International Association for Dental Research members. We want to support aca- demic research, not for profit but because we believe this will make a significant and sustainable impact on people’s oral health. Thank you very much.
| healthy life and ageing The role of interdental cleaning for oral health, general health and quality of life By Dr Anna Nilvéus Olofsson, Sweden Recent research shows that oral health is an essen- tial prerequisite for people’s well-being and quality of life. In order to reach the global goals for oral health, the dental profession has a great responsibility to work with a preventive and health-promoting approach. Oral health is multifaceted and includes the ability to speak, smile, smell, taste, touch, chew, swallow and con- vey a range of emotions through facial expressions with confidence and without pain, discomfort or disease of the craniofacial complex, according to the definition of FDI World Dental Federation.1 With this definition in mind, oral health is an undeniable part of general health and well-being. The broad consequences of oral disease Periodontal disease is common worldwide. It affects approximately 50 per cent of the adult population, and severe periodontitis prevalence varies from 10 to 15 per cent; prevalence figures are positively associated with increasing age.2–4 Given the massive effects of the dis- ease, it becomes clear that it should be a matter of global concern. First, there is growing scientific support for a link between periodontal disease and several general diseases, including cardiovascular disease, diabetes and obesity. Thus, oral diseases are no longer considered local problems affect- ing the oral cavity but rather diseases with consequences for overall health.5 Research has also shown a significant association be- tween periodontal disease and oral health-related qual- ity of life, independent of factors such as age, sex and other dental problems.6 The disease can contribute to anxiety, low self-esteem, and feelings of shame and vulnerability.7 Oral disease has a vast impact from a financial per- spective too. In 2015, the total global cost of oral dis- ease was shown to be US$544.41 billion. The direct cost, measured as dental expenditure, accounted for US$356.80 billion, and the indirect cost, measured as productivity loss, was US$187.61 billion. Among oral diseases, periodontitis was the second greatest contributor to global productivity loss.8 Severe peri- odontitis accounts for US$54 billion yearly in indirect costs.9
Causes and prevention Dental professionals have a central role in preventing dis- ease through a health-promoting approach based on sci- ence and proven clinical experience. Evaluating individual needs and conditions and weighing them together with scientiﬁc support should form the basis for instructions and recommendations, thus creating the best possible foundation for patient compliance and long-lasting oral health. There are several risk factors for the development of peri- odontitis. Most important is the accumulation of plaque along and below the gingival margin. Control and removal of this bioﬁlm are of utmost importance to maintain oral health. The signiﬁcance of good oral hygiene in order to prevent oral disease is, therefore, indisputable. Toothbrushing and interdental cleaning are cornerstones of high-quality oral hygiene. Interdental cleaning is asso- ciated with lower levels of periodontal disease, and peri- odontal health increases with a higher frequency of use of interdental cleaning devices.10 The recommendation of an interdental cleaning device needs to be tailored, but for the majority of the adult population, an interdental brush is preferred. A meta-review concluded that there is consistent ev- idence for interdental brushes being the most effec- tive devices for interdental plaque removal.11 This is also stated in the report of the 11th European Workshop on Periodontology on primary prevention of periodontitis.2 According to the working group, interdental brushes are the preferred choice for interdental cleaning, while ﬂoss is an alternative only when sites are too narrow for an in- terdental brush and show gingival and periodontal health. These results were conﬁrmed in a network meta-analy- sis in which interdental brushes achieved the best result regarding gingival inﬂammation, plaque reduction and pocket reduction.12 From the presented articles, it appears that interden- tal brushes, when compared with other manual clean- ing devices, have the highest efﬁcacy in terms of plaque removal and periodontal parameters. Every recommen- dation regarding interdental cleaning devices must be tailored; the sizes and shapes of the interdental spaces must be considered. In addition, an individual who is rec- ommended to use interdental brushes needs to be in- structed regarding the appropriate size or sizes and on an appropriate technique.13 Conclusion Current research emphasises the importance of good oral hygiene in maintaining oral health and its conse- quences for general health and quality of life. Because the most common oral diseases are predominantly in- terdental diseases, preventive efforts must include inter- dental cleaning as an adjunct to toothbrushing in daily home care. In achieving optimal plaque control, the inter- dental brush is the preferred device for most of the adult population globally. A preventive approach is well in line with FDI’s 2020 global goals for oral health, one of the targets of which is to increase the population of people of all ages with a healthy periodontium.14 FDI also has a vision for 2020 of ensuring that oral health is recognised and accepted as a core element of general health and well-being.1 In light of ﬁnancial reports, a preventive approach will most likely be beneﬁcial also from an economic perspective, since it will limit the need for other dental treatments. Editorial note: A list of references is available from the publisher. about Dr Anna Nilvéus Olofsson is manager of odontology and scientiﬁc affairs at TePe. prevention 1 2020 33
education | How does the Perio Master Clinic differ from EuroPerio? Well, both events attract eminent speakers and act as global references in periodontics and implant dentistry. The priority of the Perio Master Clinic is to provide the best possible training to clinicians on a well-deﬁned topic. It has a practical, hands-on approach and is about improving technique. The Perio Master Clinic 2020, spe- ciﬁcally, will focus on current and future challenges of hard- and soft-tissue aesthetic reconstructions around teeth and dental implants. As the world’s leading congress in periodontics and implant dentistry, EuroPerio, by deﬁnition, has a global audience and a longer scientiﬁc programme, and is not focused on one speciﬁc theme. The congress attracts thousands of gingival health-related professionals from around the world. Details regarding EuroPerio10, which will take place in Copenhagen in June 2021, and its scien- tiﬁc programme, will be announced in the coming months. In scientiﬁc terms, what are your expectations for the 2020 Perio Master Clinic? I expect that the Perio Master Clinic 2020 will set the standard for all future meetings designed for clinicians interested in the science of periodontal and peri- implant tissue regeneration. Together with congress chair, Dr Declan Corcoran, we want this meeting to provide an unforgettable experience from a scientiﬁc, clinical and social point of view for every attendee, speaker and moderator—and for the EFP and the Irish Society of Periodontology. Why is regeneration of periodontium lost owing to periodontitis or trauma so important? The global population’s life expectancy has increased substantially in the past few decades. As a consequence, patients now need to maintain their masticatory function and aesthetics for a much longer period. Thus, tooth maintenance has become extremely important to ensure function and aesthetics but also to minimise the costs related to extensive reconstructions, which may be nec- essary in the event of tooth loss and loss of associated hard and soft tissue. Owing to advances in clinical research, we now have the possibility of saving teeth that only a few years ago would have been deemed non-salvageable. Today, we have the biological understanding, surgical techniques and biomaterials needed for predictable restitutio in inte- grum, or restoration to their original condition, as well as the healing of soft and hard tissue around natural teeth and dental implants. Not so long ago, obtaining such promising results was unimaginable. Is it actually possible to regenerate the tissue around teeth and implants that has been lost owing to peri- odontitis or peri-implantitis? The simple answer is yes. We now have surgical tech- niques and biomaterials that make this goal of every patient and dentist a reality. Of course, a thorough diagnosis, treatment planning and the necessary surgical skills are mandatory for obtaining the desired outcomes. Is it possible to evolve from simply arresting peri- odontitis to actually reversing it? We have the knowledge and skills to predictably treat periodontitis and arrest its progression. However, a re- versal is only possible in certain well-deﬁned situations. Thus, for the clinician, it is crucial to understand for which cases it is a real possibility and how this regenerative surgery can be performed successfully. “Owing to advances in clinical research, we now have the possibility of saving teeth that only a few years ago would have been deemed non-salvageable.” In your opinion, why did the Perio Master Clinic 2020 sell out three months in advance? It’s deﬁnitely a result of the success of previous edi- tions of the Perio Master Clinic. Clinicians know that they can expect to see the best periodontal experts and the most challenging approaches. For this edition, at least 37 world-renowned specialists from 14 countries will be sharing their knowledge and experiences in this ﬁeld of dentistry. Furthermore, the Perio Master Clinic is an EFP initiative, so attendees can be conﬁdent that they will receive a solid evidence-based approach with high-quality ser- vice and an engaging atmosphere. Of course, the topic is really attractive—regeneration is an emerging and very promising ﬁeld. And Dublin is a charming city, interesting and well connected, promising an excellent experience for all attendees. In your experience, are patients increasingly expecting aesthetic reconstructions? Deﬁnitely. Today, patients expect not only an optimal func- tional result but also an aesthetically appealing outcome, even in demanding clinical situations. Thus, clinicians are facing challenges in accomplishing, in a predictable manner, excellent functional and aesthetic outcomes that will satisfy these expectations. prevention 1 2020 35
| infection prevention Aseptic versus clean operating conditions in implant surgery Dr Francesca Bianchi & Prof. Tiziano Testori, Italy Introduction Infection prevention is a cornerstone of modern health- care. When the Brånemark implant system was intro- duced, the surgical procedures were to be carried out in a hospital environment under strict, sterile conditions.1–4 Over the years, implant surgeons started to move away from the original sterile conditions and began operating in dental surgeries. Hence, the original protocols have Fig. 1a Fig. 1b Figs. 1a & b: Preparation of the operating room begins with cleansing and scrubbing of the surfaces using dedicated products. 36 prevention 1 2020 been simpliﬁed and adapted to clinical practice, leading to a clean preparation protocol as opposed to the asep- tic preparation protocol. Implant surgery is classiﬁed as a Class II or contami- nated clean surgical procedure; this deﬁnition refers to surgical procedures where injury is caused by surgery within the respiratory tract, alimentary canal, or urinary or genital system, which is incised by the surgeon under controlled conditions and no contamination is expected. Implant surgery is included in this category; it is however necessary to remember that, when sterile conditions are mentioned in dentistry, the term “sterile” refers to surgi- cal tools, surgeons and assistants, and covering of sur- faces and patients with sterile cloth. A sterile environment cannot be achieved within the oral cavity even after careful removal of plaque and bacteria both mechanically and chemically.5, 6 For these reasons, the term “aseptic”, instead of “sterile”, is often used. The goal is to protect the patient by preventing or mi- nimising infection after procedures in order to prevent the introduction of microbial contamination to sterile ﬁelds, sterile equipment and the operative site. Currently two preparation protocols can be described for the pa- tient, staff and operating room: a preparation protocol to achieve aseptic operating conditions and a preparation protocol to achieve clean operating conditions. Aseptic preparation protocol The operating team carrying out implant surgery under aseptic conditions involves more people than standard dentistry does. The operating team consists of ﬁrst and second surgeons, a scrubbed assistant and a circulating assistant. Scrubbing and preparation of operating per- sonnel and the patient take place outside the operat- ing room to avoid contaminating the operating room. After all the surfaces inside the operating room have been scrubbed clean using dedicated products (Figs. 1a & b), the circulating assistant dons shoe covers, a hair cover, protective eyewear and a surgical mask and, after wash- ing hands with soap, dons a clean disposable coat and gloves. The circulating assistant then unwraps dispos- able materials for the preparation of the operating team
Fig. 2a Fig. 2b Fig. 2c Fig. 3a Fig. 3b Fig. 3c Fig. 4a Fig. 4b Fig. 4c Fig. 4d Figs. 2a–c: Disposable personalised kits containing disposable sterile materials necessary for the operation simplify the preparation of the operating room (a). The circulating assistant opens the disposable kit while the scrubbed members proceed to surgical handwashing and scrubbing (b & c). Figs. 3a–c: Surgical handwashing and scrubbing with a soap solution. Washing begins from the tips of ﬁngers toward the palms (a). Particular care must be taken to wash and scrub between the ﬁngers (b). When rinsing, water must run from the hands toward the elbows, distancing the soapy water from the more to less sterile area (c). Figs. 4a–d: Surgical handwashing and scrubbing begin from under the nails using an appropriate brush (a & b). Next, hands and between the ﬁngers are washed and scrubbed (c). Washing and scrubbing must include the forearms up to the elbows (d). and the operating room; packs containing sterile materi- als are opened along the sealing liner without tearing the wrapping (Figs. 2a–c). The scrubbed assistant entering the operating theatre anteroom ﬁrst of all scrubs hands with soap, after removing any rings, bracelets or watches or any other object which may hinder proper cleansing of hands and wrists. Shoe covers, a hair cover, protective eyewear and a surgical mask must be worn before any surgical hand scrubbing starts. Surgical hand scrubbing is done with an approved scrub solution, taking care to apply it to wet hands and forearms (Figs. 3a–c). The appli- cation of the scrub must be timed according to the man- ufacturer’s instructions in order to allow adequate product contact with skin. The palm and back of the hand, be- tween the ﬁngers, the wrists and the forearms up to the elbows are scrubbed (Figs. 4a–d).7, 8 A dedicated brush soaked in povidone-iodine is used and care is taken to scrub under the nails, hands and forearms, starting from the ﬁngertips and proceeding up to the elbows on all four sides without ever returning to the scrubbed parts.7, 8 The hands must be rinsed under running water in one direction from the ﬁngertips to the elbows, keeping hands and forearms above the elbows in order to drain water away from the scrubbed areas. Once the scrubbing has terminated, the scrubbed assistant enters the operating room to dry hands with sterile towels; drying must fol- low the same pattern as scrubbing and washing, from prevention 1 2020 37
Fig. 5a Fig. 5b Fig. 5c Fig. 6a Fig. 6b Fig. 7a Fig. 7b Fig. 7c Fig. 7d Figs. 5a–c: The scrubbed assistant dries hands using disposable sterile towels. Drying, like washing, must proceed from the ﬁngers toward the elbow without backtracking toward areas already dried. Figs. 6a & b: The scrubbed assistant puts on a sterile gown, touching only the inner surface, and the circulating assistant helps. Figs. 7a–d: Sterile gloves are donned, touching the inner surface with the ungloved hand and the external, folded-back surface with the gloved hand. the tips of the fingers toward the elbows without back- tracking (Figs. 5a–c). The scrubbed assistant then dons a sterile surgical gown, touching only the inner surface and holding the inside surface of the gown just at the arm- holes with both hands and letting the gown unfold after stepping back from the table into an unobstructed area. At this stage, he or she is helped by the circulating assis- tant to complete the donning of the gown (Figs. 6a & b). After the gown, sterile gloves are donned. Different from clean disposable gloves, the sterile gloves are folded so that only the non-sterile part can be touched by the un- gloved hand in order not to compromise the sterile condi- tion of the gown or the gloves (Figs. 7a–d). The scrubbed assistant picks up the cuff of the right glove, sliding the hand into the cuff, then slides the right fingertips into the folded cuff of the left glove. The assistant then unfolds the cuff down over the gown sleeves. line, the shoulders, under the arms and the back are considered unsterile. Once the gloves have been donned, the gown can be fastened. The scrubbed assistant grasps the strap and protector, removing one strap from the protector and handing the protector to the circulating assistant: the scrubbed assistant turns and pulls the strap out of the protector held by the circulating assistant, then ties it to secure the gown (Figs. 8a–c). At this stage, the scrubbed assistant can go ahead with the preparation of operating instruments, assisted by the circulating assistant, who will open the drapes to lay the surgical stands on, followed by adhesive sheaths or covers to insulate all the surfaces that may be touched by sterile operating staff during the operation (Figs. 10a & b). Although totally sterile, it is worth remembering that gowns are only considered sterile in the front; the neck- Once the operating tables and carts on which electromed- ical equipment is placed have been prepared (Fig. 11), 38 prevention 1 2020
Fig. 8a Fig. 8b Fig. 8c Fig. 9 Figs. 8a–c: Once the sterile gloves have been donned, the gown is fastened. The scrubbed assistant removes the fastening laces of the belt (strap) from their hold, making sure that the part marked “sterile” is handled, and passes the “non-sterile” end to the circulating assistant, who, walking around the sterile member, gives him or her the lace to complete the fastening of the gown. Fig. 9: The ﬁrst member preparing clean operating conditions: a disposable gown is put on and then sterile gloves are donned. the circulating assistant begins opening the operating instruments by peeling back the two ends of the sterile packaging with- out ripping or tearing. The cables of the op- erating units not sterilised in an autoclave will have to be covered with sterile sheaths (Figs. 12a–d); the use of suction tubing with dedicated surgical tips is recommended, as the sheathing of suction tubing of a dentist’s chair is a difficult operation and unprotected areas may be touched, breaking the proto- col for sterile conditions. Once the preparation of the operating room has been completed, the patient can be prepared while the first and sec- ond team members are scrubbing hands, creating sterile conditions described above for the instrument nurse. The patient is accompanied to the anteroom and read- ied by the circulating assistant at the en- trance to the operating room by asking the patient to wear a head cover, shoe covers and a disposable gown after instructing the patient to remove all metal and other ob- jects which may be uncomfortable to wear during the operation (Fig. 13). The patient rinses with a 0.2 % chlorohex- idine solution for 1 minute to reduce bac- terial concentration5, 6 and is taken to the operating room (Fig. 14). An intravenous catheter is then inserted to attach a drip and for possible emergency drug admin- istration, and then monitoring devices are positioned to monitor vital parameters during the operation. Fig. 10a Fig. 10b Fig. 11 Figs. 10a & b: Preparation of a Mayo stand. The instrument nurse lays the Mayo stand cover drape and disposable barriers over surfaces that are likely to be touched during the operation. Fig. 11: During preparation of clean operating conditions, fewer instruments and equipment are necessary, and hence it is sufﬁcient to prepare only one stand for the purpose. prevention 1 2020 39
| infection prevention The scrubbed assistant takes care of the perioral skin asepsis by wiping the area with antiseptic povidone-io- dine solution, starting from the lips and moving up to the nose and under the chin, with circular movements (Fig. 15a).9, 10 After disinfection of the skin has been car- ried out, sterile adhesive drapes are positioned to mark the previously cleaned area (Fig. 16a). Preparation protocol to achieve clean operating conditions The preparation protocol to achieve clean operating con- ditions is no different from the procedures used in pre- paring the medical staff and patient to work under sterile conditions, but fewer sterile towels are used and it can be done more easily with a team of three members: two sterile ones and a non-sterile member. The second member begins the surgical scrubbing after donning protective eyewear, a hair cover and a surgi- cal mask; the non-sterile assistant who has seen to the cleansing of surfaces in the operating room opens the sterile gloves for the second team member, who will don them after the procedure already described. The ﬁrst and second team members will not wear sterile gowns in this case,11 but will take care not to touch their gowns with sterile gloves, as this will lead to loss of sterile conditions and will necessitate a new pair of sterile gloves (Fig. 9). The preparation of the operating room continues with the positioning of sterile drapes over the surgical stands. Operations carried out under clean conditions usually re- quire fewer instruments, and only one cart covered with Fig. 12a Fig. 12b Fig. 12c Fig. 12d Fig. 13 Fig. 14 Fig. 15a Fig. 15b Figs. 12a–d: All non-sterile tubing must be covered with disposable sheaths regardless of the type of preparation protocol. Fig. 13: The patient is prepared in the anteroom; a head cover, shoe covers and a disposable gown are worn. Fig. 14: One-minute mouth rinsing with 0.2% chlorohexidine is an effective way to reduce intra-oral bacteria. Figs. 15a & b: Perioral skin is wiped with circular movements using a povidone-iodine solution, starting from the lips. It is necessary to protect the eyes with gauze or a mask (a). In preparing clean conditions, it is recommended to wear a mask, as an adhesive sterile drape is not positioned; gauzes would be insufﬁcient to protect the area (b). 40 prevention 1 2020
Fig. 16a Fig. 16b Figs. 16a & b: Completed sterile conditions: the U-shaped and rectangular drapes leave only the cleansed area exposed (a). Completed clean conditions: only the U-shaped drape is positioned, and the upper limit of the cleansed area is marked only by the mask (b). Study Type of operating conditions Number of implants Successes Failures Statistically signiﬁcant Scharf and Tarnow Sterile Clean Cardemil et al. Sterile Clean 273 113 2,414 1,586 270 111 2,332 1,241 3 2 82 45 Yes No Yes No Table 1: Analysis of literature data on implant survival rates under sterile versus clean operating conditions. The studies analysed concern speciﬁc cases that did not use biomaterials or regenerative procedures.11, 13 sterile drapes on to which to lay the operating instruments and another to carry electromedical equipment may be sufﬁcient (Fig. 11). Operating instruments are therefore opened by the non-sterile member as described and put in order by the second member. Once the operating room has been prepared, the patient is brought in and will proceed with rinsing with a 0.2 % chlorohexidine solution, and wear a hair cover and shoe covers in the anteroom. After putting on a mask to pro- tect the eyes (Fig. 15b), the perioral area is cleansed. This procedure varies from the sterile preparation protocol, as no sterile adhesive drape to cover the eyes is used. An adhesive U-shaped drape is positioned to mark the sur- gery site (Fig. 16b). conditions used in dental surgeries. It must be considered that some types of surgery are more vulnerable to infec- tion. Although the literature does not establish operating under aseptic conditions as superior to clean conditions in terms of comparative success rate in implant surgery, it must be pointed out that reports take into consideration minor interventions that do not make use of biomaterials (Table 1). There are no comparative studies in the litera- ture regarding the two preparation protocols in extensive surgery, bone regeneration or maxillary sinus elevation. A reduced preparation protocol in cases in which biomateri- als are used is not recommended. When a graft is placed, it is appropriate to carry out the procedure under asep- tic conditions, as the graft lacking vascular supply will not beneﬁt from antibiotic treatment. Equally, in extensive Discussion A controversy still exists regarding aseptic versus clean conditions for implant surgery. The protocols for the preparation of the patient, the medical staff and the op- erating ﬁeld aim to avoid contamination of the surgery site by bacteria normally not found in the oral ﬂora, especially by bacteria on the skin of the patient and medical staff. Antibiotics administered before the operation and chemi- cal control of plaque are not enough to guarantee a sterile operation site, but they do signiﬁcantly reduce the ﬂora.5, 6 The two types of preparation, for clean and sterile con- ditions, have much in common; the creation of clean conditions is but a simpliﬁcation of the protocol for sterile Material Sterile preparation protocol Clean preparation protocol Sterile drape for instrument cart Mayo cover for surfaces Sterile equipment cover Sterile sheaths Yes Yes Yes Yes Yes No Yes Yes Table 2: Materials used in the two different preparation protocols. The clean preparation protocol requires fewer towels and gowns and hence is easier to realise within a dental surgery. prevention 1 2020 41
Sterile preparation protocol Clean preparation protocol Preparation of ﬁrst operating team member Head cover Mask Dedicated footwear Hand scrubbing Sterile gown Disposable gown Sterile gloves Preparation of patient Head cover Shoe covers Disposable gown Rinsing with 0.2 % chlorhexidine for 1 min Skin cleansing with iodine solution Sterile U-shaped drape Eye protection (e.g. mask) Sterile drape to cover head Preparation of operating room Sterile drapes for instrument cart Mayo stand cover drape Sterile equipment covers Sterile sheaths Surgical suction x x x x x Clinical recommendations: Preparation of sterile vs clean operating conditions x x x Limited traditional implant operations without the use of regenerative techniques Stage 2 surgery Bone reconstruction surgery Bone grafting Maxillary sinus operation x Table 3: Conclusions and clinical recommendations. 42 prevention 1 2020 operations, the prolonged surgery time may lead to in- creased risk of contamination (Table 2).12 Conclusion The superiority of aseptic operating conditions over clean conditions in terms of success rate in implant surgery is still controversial. Operating under clean conditions may be viable in traditional implantology to treat limited edentulism when the use of biomaterials is not required. Aseptic oper- ating conditions are recommended in complex surgery or implant placement using regenerative techniques. Editorial note: A list of references is available from the publisher. about Dr Francesca Bianchi, obtained Degree in Dental Science (DDS) with top grades at University of Milan (Italy), 1995. Visiting lecturer at Milan University of Milan lecturing on Dental Hygiene (2001–2002). Lecturer at University of Milan—Den- tistry Department (Chairman: Prof. R. L. Weinstein; scientiﬁc chief Dr T. Testori), I.R.C.C.S. Galeazzi Orthopaedic Institute, (2005–2007) on Improvements in Oral Implantology. Holds refresher courses at ANDI, the society of Italian dentists, on the latest developments in oral implantology. Is the author of several papers on topics relating to implant dentistry. Prof. Tiziano Testori is Head of the Section of Implant Den- tistry and Oral Rehabilitation, I.R.C.C.S., Galeazzi Institute, Milan, Italy. He is Assistant Clinical Professor, Depart- ment of Biomedical, Surgical and Dental Science (Chairman: Prof. L. Francetti), University of Milan, Milan, Italy and he is Adjunct Clinical Associate Professor, Department of Periodon- tics and Oral Medicine, The University of Michigan, School of Dentistry, Ann Arbor, MI, USA. Received his MD degree (1981), DDS degree (1984). Speciality in Orthodontics (1986) from University of Milan, Italy. Fellowship at the Department of Oral Maxillo-Facial Surgery (Head: Philip J. Boyne, DMD, MS, DSc), School of Dentistry, Loma Linda University, Loma Linda, CA, USA (1991). Fellow- ship at the Division of Oral Maxillo-Facial Surgery (Head: Robert E. Marx, DDS), School of Medicine, University of Miami, Miami FL, USA (2000). Currently Head of the Section of Implant Dentistry and Oral Rehabilitation Department of Biomedical, Surgical and Dental Science (Chairman: Prof. L. Francetti), I.R.C.C.S., Galeazzi Institute, University of Milan, Milan, Italy.
C E O N M T R P S U A L I N M B S C E C E N T T A R I B O F E R Y R M DATE 18 19 SEPTEMBER 2020 OLYMPIA CENTRAL LONDON UK VENUE S C BOOK YOUR TICKETS TODAY LONDON’S INTERNATIONAL DENTAL SHOW EXPERIENCE 70+ ENGAGING LECTURES OVER TWO DAYS WORLDCLASS SPEAKERS A COMPREHENSIVE RANGE OF CLINICAL AND BUSINESS TOPICS 350+ PREMIER BRANDS EXHIBITING SAVE THOUSANDS ON YOUR PURCHASES EXCLUSIVE SHOW OFFERS FROM HUNDREDS OF EXHIBITORS EIGHT LECTURE THEATRES COMPLIMENTARY BEER & BUBBLES SPONSORED BY DÜRR DENTAL UNLIMITED TEA & COFFEE ON BOTH DAYS LONDON’S BIGGEST DENTAL SHOW OF 2020 LECTURE ZONES AESTHETIC THEATRE IDDA DIGITAL DENTISTRY THEATRE IN PARTNERSHIP WITH CLINICAL EXCELLENCE THEATRE RISK MANAGEMENT HUB SPONSORED BY COMPLIANCE HUB BUSINESS THEATRE ENHANCED CPD THEATRE BUSINESS UPDATE THEATRE WITH THANKS TO OUR PARTNERS DIAMOND SPONSOR CORPORATE PARTNER GOLD SPONSORS OVER 350 PREMIER BRANDS EXHIBITING ORGANISED BY DIGITAL PARTNERS TWO DAY PASS $199 USD MEDIA PARTNER EDUCATION PARTNER Book your place at www.londondentistryshow.co.uk today T +44 (0) 1923 851 777 E firstname.lastname@example.org W www.fmc.co.uk
| manufacturer news Sanitise your hands ergonomically with miscea The core business of the company is the development of innovative and effective hand hygiene solutions through beautifully designed, reliable and qual- ity products. The unique combination of be- ing able to comfortably get soap, water and disinfectant, as well as change the water temperature, completely con- tact-free from one faucet has made miscea the brand of choice for hand hygiene by healthcare profession- als. With several patents for this unique technology, miscea is the only company offering this excep- tional solution and markets its prod- ucts through a network of trusted partners in more than 40 countries worldwide. The idea of creating a completely sensor-operated faucet that could dispense not only water but also multi- ple liquids, such as soap and disinfectant, was concep- tualised in a small garage in 1999 by a German engineer and his Dutch partner. Their vision was to help healthcare facilities improve hand hygiene compliance by develop- ing a hygienic, ergonomic, all-in-one faucet that could be operated without touching the faucet or a dispens- ing device. After many failed attempts, prototypes, and years of research and development, the very ﬁrst working model became commercially available, under the name alfa-innovations, and miscea as a company was ofﬁcially founded in 2003. Today, miscea is a privately held company with head- quarters and a production facility near Berlin in Germany. As the market leader in hygienic sensor faucet systems with integrated dispensers for professionals in the health- care and medical industry in Europe, miscea has revo- lutionised the way these professionals wash and sani- tise their hands through an ergonomic, functional and award-winning hand hygiene system. The company’s range of sensor faucet systems is the ideal choice for those seeking a higher standard of hygiene while still desiring modern aesthetics. Through the harmonious balance of innovative technology, func- tionality and detail in design, the miscea CLASSIC model is the world’s ﬁrst sensor-controlled faucet system of its kind. One of the major beneﬁts of using the miscea sen- sor faucet is that it reduces the risk of cross-contamina- tion, facilitating a more hygienic and bacteria-free envi- ronment. By combining the functions of a water faucet with two dispensers, the system has made handwashing more comfortable, convenient and efﬁcient. This system is especially suitable for hygiene-sensitive applications, such as in medical environments, dental practices, hos- pital surgery preparation areas and laboratories. contact miscea GmbH Hauptstraße 2, 14979 Großbeeren, Germany www.miscea.com 44 prevention 1 2020
| manufacturer news Kitten Planet wins German Design Award 2020 for Brush Monster access via the free and simple to use download application, available for both Apple and Android devices. Parents struggle to get their child to brush his or her teeth. In addressing this issue in a fun and dynamic way using Monster Brush, preventative oral health- care in this manner at young age culti- vates consistency, independence and self-assurance. Parents are also re- assured through monitoring and obtaining veriﬁable information. When a child brushes his or her teeth while using the smartphone as a mirror, the screen displays a reﬂection of the child's face. By analysing the locations of the user's teeth and AR technology, Brush Monster shows the child how to properly brush his or her teeth. It not only encourages children, through game-like ele- ments, to think brushing their teeth is fun but also in- forms the child which teeth were brushed well and which ones require more work. The mobile application is freely download from Android and Apple App stores and par- ents can use it their kids’ brushing education effectively Choi Jongho, Kitten Planet CEO, said, “Given that AR is still not widely applied in an everyday setting, we are honoured that Brush Monster’s innovative AR-based user experience has received such a prestigious award. We will be engaging in more business endeavours in the dental care sector that apply a variety of digital technol- ogies, including AR, AI and IoT.” Founded in 2017, Kitten Planet is a digital dental care start-up in South Korea who aims to solve preventive oral health problems using digital contents and solution. Since its launch in April 2018, Brush Monster, Kitten Planet’s oral health management service, has ranked ﬁrst in tooth brushing applications in many countries. In December 2018, Kitten Planet collaborated with a Korean insurance company to release a children’s dental insur- ance package to promote oral health. www.brushmon.com/english.html Smart brushing education application, “Brush Mon- ster” acknowledged for its innovative design and as AR content that can help build healthy oral care habits for kids. In February at this year’s German Design Awards (GDA), Kitten Planet, with just 2 years ago in the dental mar- ket was decreed the 2020 winner. Kitten Planet was hon- oured in the “Excellent Product Design—Baby and Child Care” category for its Brush Monster, a smart brushing education application for kids. The GDA was founded in 1969 by the German Design Council and is one of the world’s most prestigious design awards. With a tradition over 50 years long, only products/works invited by the hosting institution are considered, in addition to the requirement for entrants to have prior award. Such stringent regulations have re- sulted in the GDA gaining a reputation as the “champion- ship” level of international design awards competitions. Kitten Planet’s most representative product is Brush Monster, an educational AR (augmented reality) brush- ing education service imparting accurate brushing tech- niques in children aged three to ten years. Service is 46 prevention 1 2020
SUBSCRIBE NOW! DTI—international magazine subscriptions I would like to subscribe to: CAD/CAM dental labs 2 issues per year ceramic implants 2 issues per year cosmetic dentistry 1 issue per year digital dentistry 4 issues per year implants 4 issues per year e-paper €5.50 per issue e-paper €5.50 per issue e-paper €5.50 per issue e-paper €5.50 per issue e-paper €5.50 per issue e-paper €10 annual subscription e-paper €10 annual subscription print €15 e-paper €20 annual subscription e-paper €20 annual subscription print €30 annual subscription print €30 annual subscription print €46 annual subscription laser 4 issues per year ortho 2 issues per year prevention 2 issues per year roots 4 issues per year e-paper €5.50 per issue e-paper €5.50 per issue e-paper €5.50 per issue e-paper €5.50 per issue e-paper €20 annual subscription e-paper €10 annual subscription e-paper €10 annual subscription e-paper €20 annual subscription print €46 annual subscription print €30 annual subscription print €30 annual subscription print €46 annual subscription www.dental-tribune.com/shop/ Full Name ZIP | City | Country E-mail Address Credit Card Number | Expiration Date | Security Code Date | Signature Dental Tribune International GmbH Holbeinstr. 29 | 04229 Leipzig | Germany Tel.: +49 341 48 474 302 Fax: +49 341 48 474 173 www.dental-tribune.com email@example.com Terms & conditions: Subscriptions will be renewed automatically every year until a written cancellation is sent to Dental Tribune International GmbH, Holbeinstr. 04229 Leipzig, Germany, six weeks prior to the renewal date. All prices include VAT, shipping and handling.
Welcome to MasterClass.Dental Online classes taught by the world’s best doctors directly from their practice OBSERVE DISCUSS YOUR CASE ON DEMAND ALL DEVICES GUARANTEED www.MasterClass.Dental Tribune Group GmbH is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Tribune Group GmbH designates this activity for 1 continuing education credits. This continuing education activity has been planned and implemented in accordance with the standards of the ADA Continuing Education Recognition Program (ADA CERP) through joint efforts between Tribune Group GmbH and Dental Tribune Int. GmbH.