INTERNATIONAL ASSOCIATION OF DENTAL STUDENTS No. 3, 2020

IADS Experience Written by: Silvi Domnori Proofread by: Shukri M. Jama Design by: Živa Antolin ONLINE TRAINING SESSIONS When ‘travelling’ puts the ‘T’ in TNT but the lockdown makes OTS your new MVP “What would you do if the thing you’ve been working on (for months) is suddenly made totally and com- pletely impractical? Living in times of COVID-19 has meant life in limbo with no end in sight. No end to travel bans, at least. And for an international organization like IADS that relies on air travel to bring us together, not being able to meet in person meant we either needed to improvise (and fast) or give in to a standstill for the rest of the term. As we say in the Training Committee, improvisation is key. So, improvise we did. Queue our first OTS meeting on April 12th where we debated training topics, session timings, vid- eo conferencing platforms, and even the term ‘OTS’ itself. Somewhere between the many trial sessions, a laughable number of “Can you hear me’s” and “Do you guys see my screen’s”, and the meetings that went on late after midnight (sorry GMT+4:30), we ended up with 4 training topics, 1 set of guidelines, and a whole lot of determination to make our ideas work. We customized our standard TNT topics to the world’s current ordeal: stress management and a lack of motivation, time management, productivity, communi- cation and keeping in touch despite the many barriers this pandemic has put in our way, and team build- ing online. These issues trouble most of us nowadays so we knew participants would be intrigued too. Hours and hours of organization later, including sifting through nearly 300 applications, we held our first Online Training Session and the following 11 went on to make the first edition of IADS’ OTSs. Screens were shared, tips and tricks on how to be our best selves during these trying times were offered, and quite a few friendships were made. Not to mention the numerous mishaps and awkward moments we faced as calls dropped or robotic audio/video had to be dealt with. As a trainer in my last year with IADS, this adventure fit right in with the countless memorable events I’ve proudly been a part of and was one that I had a blast organizing. Hats off to my team for making the best of a mad situation, and I hope all our participants had as great a time as we did during our time with them.” -Arghavan Navadeh 12 Regional Training Officer – Middle East

Opening this article with the trainer’s perspective in true chronological fashion, we hope to have given you a glimpse of how the situation has shifted on the inside to then understand better how it is reflected on the outside. In a time when dental students are already having their classes at home, it can be diﬃcult to mould ‘real life’ programs created to cater to their social needs as well as academic ones, into a virtual ‘clone experience’; all while trying not to lose its essence. The odds didn’t seem to be in our favor, hence the reach of these Online Training Sessions was truly overwhelming. Held on 12th – 17th of May, these sessions have proved to be fruitful not only for the trainers’ versatility but the participants’ soft skills as well. Topics like “Productivity and Time Management”, “Motivation and Empowerment” and “Online Communication and Team Building” came at a time when the first two were at an all-time-low and the latter was skyrocket-high – and brought this back into proportion for numerous young students and young dentists worldwide. Then again, nothing better than first hand experiences to convey the spirit of the event: “As a person who took the 3 courses, I say they all were so beneficial and worth taking. I felt that I got the chance to share my ideas and thoughts with other dental students from all over the world. The trainers were so cooperative and motivating to answer any questions running in our heads, especially the Motivation and Empowerment course. It was so encourag- ing that it has extremely refilled our batteries with positive energy in these hard quarantine times. In general, the concept itself and gathering dental students from many cultures were so serviceable and interesting I would be so happy to re-participate in such experience, again.” -Samar H. Abu Al-Ees “I participated it was in the Motivation and Empowerment course and also my first time joining the group. This course helped me a lot in such a diﬃcult time. I understood that when there is communication and group discussion, development comes along. I finally had the motivation to or- ganize my day better; I got to know amazing students from around the world and the organizers took care that we felt comfortable in every mo - ment. Definitely want to be part of this experience again.” -E l i sa Ce sa j We would like to thank the training committee coming through with the amazing content and organization and all the participants for their interest. Who knows, maybe this program could be a new regular! 13 Al-Azhar University – Palestine (PADS)UMK Faculty of Dentistry – Albania (Brainstorm Organization)

IADS Experience N E E R G Y R T S I T N E D 0 2 0 2 In the last 20 years the amount of trash produced by dental clinics has strongly increased, due to required aseptic and/or sterile work conditions; which are the easiest to ensure by the use of disposable instruments and materials. Heavy metals and biomedi- cal waste also present a potential challenge to the envi- ronment. The idea of Green Dentistry was born to promote a more eco-friendly and environmentally sustainable dental practice in the future; since this problem is not talked about as much. What is Green Dentistry? GreenDentistry is a joint project between the Interna- tional Association of Dental Students (IADS) and Freier Verband Deutscher Zahnärzte (FVDZ) Student Chamber with the goal to: • raise awareness within dental practitioners; • teach them how to change their daily routine towards a profitable and eco-friendly workflow in order to have an eco-friendly dental practice in the future. Green Dentistry Competition This year, the project was launched for the first time. To encourage our mem- bers to spread awareness among the dental community, we organized a Green Dentistry Competition. The competition was open from the 25th of April (an- nouncement of the project) to the 22nd of June (deadline to submit the final report). The most important date was the 22nd of May, when we celebrated the Green Dentistry Day. The participating member associations were encouraged to organize a campaign that should include at least one of the following: • lecture/panel discussion on “Green Dentistry”; • awareness station/booth at their University or Campus; online campaign. 14

Winners of Green Dentistry 2020 We had seven participating associ- ations and many individual partici- pants, who all did an amazing job mostly based on online campaigns, due to the pandemic situation. In the end, the Green Dentistry team picked three winners after anony- mously evaluating all the activities according to an evaluation form. These are the final results: 2 nd PLACE Pakistan Association of Dental Students (PADS) 1 st PLACE Palestinian Association of Dental Students (PADS) 3 rd PLACE Persatuan Senat Mahasiswa Kedokteran Gigi Indonesia (PSMKGI) Other associations that participated in the competition are Iraqi Dental Students Association (IDSA), Jordan Association Of Dental Students (JADS), Turkish Dental Students International Committee (Turk-Dentsic) and UM6SS Smile Creators Asso- ciation. What did we do at IADS? Besides offering support to the participating associations, the IADS Prophylaxis Committee also orga- nized an online campaign in collabo- ration with the Editorial Board. Through the month of May, we prepared a series of short videos that introduced the problem of envi- ronmental pollution in dentistry. We asked our members, workforce, delegates and leadership to submit their photos as a sign of their sup- port to more eco-friendly dental practice in the future. The response was overwhelming and on the 22nd of May, we shared a mosaic photo of our students who support Green Dentistry. We have also added the Green Dentistry section to our web- site that you can still check out under the Prophylaxis section. team “Finally, in the name of the Green Dentistry I would like to thank all participating associations and state that we really appreciated their efforts - the competition was tight between them. Congratu- lations the winning associations and good luck next year for the other to participants!” -Julien ISSA, IADS Prophylaxis Committee Chairman 2019/20 Written by: Julien Issa, Živa Antolin Proofread by: Silvi Domnori Design by: Živa Antolin 15

IADS RESEARCH BENEFITS OF COENZYME Q10 SUPPLEMENT SUPPLEMENT TO CONVENTIONAL THERAPY OF CHRONIC PERIODONTITIS Inflammation and the accompanying oxidative stress play major roles in the pathogenesis of periodontitis. Coenzyme Q10 serves as an antioxidant that effectively ensures a balance between reactive oxygen species generation and antioxidant defence, suppresses advanced inflammation and limits tissue damage.1 However, its eﬃciency as adjunctive therapy for the periodontal disease remains uncertain. INTRODUCTION: CoQ10 is a well-studied antioxi- dant and during the last several years it attracted considerable attention in the medical litera- ture. However, the question of whether is eﬃcient as adjunctive therapy for peri- odontal disease treatment remains uncertain and requires additional research. Although non-surgical treatment, such subgingival as scaling supragingival polishing, is the cornerstone of periodontal therapy, better results can be achieved by inhibiting inﬂammation and accompanying oxidative stress (picture 1). supra- and it and Supragingival calculus removal with ultrasonic instruments Subgingival scaling Removal of local factors (margins and surfaces polishing) Re-evaluation Patient education about oral hygiene and plaque control Improving antioxidant defense Picture 1 Antioxidants are substances, that can reduce some of the damage caused by reactive oxygen species (ROS) by neutralising them.2 In these circumstances, the potential usefulness of CoQ10 as a complementary to dental practitioners. This approach is very promising since, as well as improved oral hygiene, this can help patients contribute to their treatment, get more involved in the process, and feel like they have control over their condition. With the following research, we want to focus on additional treatment methods of periodontitis. therapy with mechanical debridement may be of interest 32

SUPPLEMENT PERIODONTITIS AND OXIDATIVE STRESS: SUPPLEMENT Periodontitis is an inﬂammatory disease with a multifactorial etiology and complex pathogenesis.3 Periodontitis is a term used to describe an inﬂammatory process, initiated by the plaque bioﬁlm, which leads to loss of periodontal attachment to the root surface and adjacent alveolar bone and ultimately results in tooth loss.1 Reactive oxygen species overproduction and following oxidative stress are thought to play an important role in the pathogenesis of a variety of inﬂammatory disorders. Chronic periodontitis, as any other persistent inﬂammation, aﬀects general health, exhausts the host’s antioxidant response, which results in oxidative stress due to an imbalance between reactive oxygen species generation and antioxidant defense.4 (Picture 2). Although periodontal pathogens in the bioﬁlm are obligatory for the develop- ment of a periodontal disease, it alone is not enough for the disease to occur. A susceptible host is also necessary because most of the damage done to periodontal tissues and supporting bone structure is due to the host immune-in- ﬂammatory response.5 Plaque bacteria and host inﬂammatory response are the main causes of periodontitis and their complex interaction leads to the clinical signs and determines the progression of the disease (picture 3). IMBALACE Bacteria + responsive organism Antioxidant defense Production of reactive oxygen species { -Protein degeneration -Lipid peroxidation -DNA damage -Collagen degeneration -Bone loss Clinical symptoms of periodontitis Picture 2 Host inflammatory response and the immune systerm Antigen LPS Virulence Factors Plaque biofilm and periodontal pathogens IMMUNE CELLS Polymorphonuclear leukocytes neutrophils macrophage Cytokins Prostaglandin Metalloproteinases Damaged periodontal tissue (bone loss and collagen degeneration Bacteria colonizes more apically increased in probing depth Picture 3 33

COENZYME Q10 The potential beneﬁts of CoQ10 in adjunctive periodontitis treatment can be explained by its antioxidant and energy carrier functions.6 Even though CoQ10 can be synthesized in the body, it is possible that the body’s synthetic capacity could become insuﬃcient to meet CoQ10 requirements.2 Periodontal cells, being metabolically active, have the highest requirements for CoQ10 and hence are particularly susceptible to CoQ10 deﬁciency.2 The situation can occur when our endogenous antioxidant system requires additional CoQ10 supplementation to ﬁght oxidative stress. AIM: The purpose of this research was to evaluate the effect of Coenzyme Q10 supplementa- tion as adjunctive therapy to conventional non-surgical periodontal treatment. MATERIALS AND METHODS: consent The study was conducted in the Institute of Dentistry, University of Tartu, Estonia. The research protocol was approved by the Research Ethics Committee of the University of Tartu. Written informed was obtained from all subjects. A total of 30 subjects aged between 35 and 80 with a diagnosis of chronic periodon- titis and probing pocket depth ≥ 4mm, but ≤ 6mm were enrolled in the study during a dental appointment at Tartu University Hospital's Clinic of Dentistry. { In the same week After 1 month After 3 month 1 - Anammesis - Extra- and intraoral examination - Measurment and recording of periodontal indices - Mechanical debridement with hand- and ultrasonic instruments Mechanical tooth depuratiom I reassesment: re-evaluation of periodontial indices II reassesment: re-evaluation of periodontial indices 2 3 4 Clinical parameters: PD BOP VP RC OHI } 4 visits in total Figure1 The diagnosis was established according to the new Classiﬁcation of Periodontal and Peri-Implant Diseases and Conditions. Exclusion criteria for the patient enrolled in the study were: the presence of any systemic disease, smoking, pregnancy, and lactation. All the subjects were randomly grouped into two categories (test- and control-group), each group comprising 15 subjects. During the ﬁrst visit was performed peri- odontal examination and were recorded following clinical parameters: probing pocket depth (PPD), bleed- ing on probing (BOP), visible plaque index (VP), calculus index (CI), the simpliﬁed oral hygiene index (OHI, Greene-vermillion). Also at the ﬁrst visit, all the subjects underwent non-surgical therapy (supra- and subgingival instrumentation) and received oral hygiene instructions. 34

Test-group subjects were instructed to take oral CoQ10 (90 capsules) supplements once a day for 3 months. One capsule contained 100mg of CoQ10 (Ubiquinone). The same clinical parameters were mea- sured repeatedly during reassessments at one month and three months after the ﬁrst visit (Figure 1). RESULTS: In this study we found that non-surgical treatment outcome both with and without Q10 supplement adjunctive therapy was successful: both groups showed improvement in all the clinical parameters, which conﬁrmed the major role of conventional mechanical instrumentation in periodontal therapy. Although the statistically signiﬁcant diﬀerence in the reduction of clinical parameters between the test and control groups at one month and three months was not observed, test-group changes improvements in periodontal indices are more pronounced and show noticeably better dynamics, considering relatively the small amount of research subjects. The results of the study also show a positive change in oral hygiene in both groups. This proved that patients' education and motivation about oral hygiene were successful and hence highly important. An interesting observation was done concerning the connection between hygiene index and bleeding on probing: improvement in one parameter leads to improvement in others. (Figure 2. Comparison of baseline parameters between groups), (Figure 3. Comparison of clinical parameters between groups on 90th day) 1st day 90th day control group Test group 6 5 4 3 2 1 0 control group Test group 2.5 2.0 1.5 1.0 0.5 0.0 Bleeding on probing Probing depth Plaque index Calcu- lus index Oral hygiene index Bleeding on probing Probing depth Plaque index Calcu- lus index Oral hygiene index Figure 2: Comparison of baseline parameters between groups Figure 3: Comparison of clinical parameters between groups on 90th day 35

CONCLUSION: Coenzyme Q10 supplementation should be considered as adjunctive therapy for the non-surgical treat- ment of chronic periodontitis in dental practice. The positive eﬀect of CoQ10 in periodontal disease is noticeable and should be further explored. SOURCES: 1. Soni S, Agrawal PK, Sharma N, Chander S. Coenzyme Q10 and periodontal health: A review. Int J Oral and Maxillofac Pathol 2012;3:21–6 2. Zilmer M, Soomets U, Rehema A, Altraja S, Mahlapuu R, Porosk R Zilmer K, Kullisaar T, Kilk K, Kairane C, Salum T. Inimkeha põhilised biomolekulid (meditsiiniliselt tähtsamad ülesanded). Tartu 2018: 60-63. ISBN: 978-9985-2-2253-9 (e-raamat) 3. Ollema K, Pähkla E-R Parodondi haiguste ja seisundite klassiﬁkatsioon. Hambaarst 2019;4: 26−34 4. Bhusari BM, Mahajan R, Rajbhoj S, Shah P. Reactive Oxygen Species & Its Role in Periodontal Disease. IOSR & JDMS 2014;8(1):52-9 5. Preshaw PM, Seymour RA, Heasman PA. Current Concepts in Periodontal Pathogenesis. Dent Update 2004; 31:570-578 6. Vihalemm T. Vitamiin Q ehk ubikinoon, tänapäeval rohkem koensüüm Q, Biokeemik 2017 7. Talmaç AC. Antioxidants and Periodontal Diseases 2019. DOI:http://dx.doi.org/10.5772/intechopen.81815 Written by: Maria Zoga and Anna Jakovleva, University of Tartu (Estonia) Proofread by: Živa Antolin Design by: Raja’a Antar 36

ATHLETES AND THEIR ORAL HEALTH Is their performance striking out as is their oral health? B E Y O N D D E N T I S T R Y Oral health is an integral part of our overall health and wellbeing. When we encounter ‘health’ and ‘ath- letes’ in the same sentence the first thing that comes to our minds would probably be trauma, however, an overlooked aspect is their oral health. Studies have shown that athletes may have poor oral health includ- ing high levels of dental caries, dental erosion, and trauma.1 This incidence is encountered in athletes, de- spite their oral hygiene practices being good, such as brushing twice daily, which leads to question wheth- er their diet or their intense workouts could be the reason and if so does this affect their performance? Athlete diet – A bop or a flop? Athletes across the board generally do have a healthy diet however in- creased intake, frequency and dental contact time of carbohydrate-rich foods, sports nutrition products, and acidic car- bohydrate-containing sports and energy drinks may contribute to risks of dental erosion, caries, and inflammatory periodontal conditions in the athlete.2 A study conducted on athletes partici- pating in the London Olympics 2012 found high levels of oral disease in these athletes with caries at 55%, dental erosion at 44.6%, dental trauma at 30% and gingivitis or periodontitis at 76%.3 The consumption of energy drinks among ath- letes is quite common. These drinks contain high amounts of sugar and acid which would eventu- ally be detrimental to their oral health as stated above. The correlation between usage of sports drinks and dental erosion has been found signif- icant especially in anterior teeth.3 The products they consume are marketed with no accom- panying guidance in relation to oral health. Re- garding the oral health behaviors of athletes, in a cross-sectional study 94.2% of them reported brushing their teeth at least twice a day while 55.9% reported using additional methods such as flossing and interdental brushes and 40.9% reported using fluoride mouthwash. However, 28.2% were categorized as high consumers of sugar in their regular diet and 85.7% admitted to using sports drinks at least sometimes.4 Is working out wearing their teeth out? Upon the light of the aforementioned research results, diet appears to be an important factor in the detriment of athletes’ oral health, however alterations in saliva composition during exercise and immune suppression following in- tense effort are other factors that weigh in on oral disease susceptibility.5 In a study conduct- ed by Mulic et al, decreased stimulated salivary flow was observed during physical activity in 64% of the participant athletes. As they cite; earlier studies have also demonstrated that during ex- ercise the salivary flow rate is modified.6, 7 Factors leading to a decrease in salivary flow could be the increase in sympathetic activity causing vaso- constriction5, 8 and dehydration due to sweat and restricted fluid intake.5, 9 Moreover, several stud- ies have confirmed that gastroesophageal reflux may be associated with some types of tough ex- ercise5, 10, 11 like running and weightlifting and that reflux persisted through a 1- hour run.5, 10 Know- ing that high prevalence of dental erosion is asso- ciated with the presence of reflux symptoms in patients,12,13 it can be claimed that tough exercise is an indirect cause of dental erosion. 40

In regard to immunity, consistent exercise has been found to reduce incidence of infection rel- atively to a sedentary lifestyle. Nevertheless, strenuous exercise appears to potentially cause a temporary depression in lymphocyte prolifera- tion, neutrophil respiratory burst, and monocyte antigen presentation, which persists 3-24 hrs. post-exercise depending on the duration of the exercise session.14 In addition another study15 has found that exercising incites hormonal chang- es as a response, thus leading to an increased concentration in epinephrine, cortisol, growth hormone and prolactin plasma levels. These are hormones known for their immunomodulatory effects. Claims on depressed immunity after ses- sions of excessive exercise have been furtherly sustained by other studies16,17 indicating that a depression of resting serum and salivary immu- noglobulin concentration in athletes, due to long- term intensive training. Is this reflecting on their performance? Different studies reported that oral health had an impact on performance.3,21,22 In a research conducted by Locker et al.23 more than 40% of the athletes were bothered by their oral health, 28% reported an impact on quality of life and 18% reported an impact on their training and performance. Results implied that this impact was correlated with levels of caries.3, 23 However, other than these studies, most self-reported performance im- pact is correlated to dental trauma.21, 24, 25 Let’s talk prevention Prevention at an immunitary level may be an equivocal pursuit, considering the fact that methods of prevention (antioxidant supplementation and/or carbohydrate inges- tion during exercise) could attenuate the release of IL-6 from the muscles consequently affecting IL-6’s metabolic effects in lipolysis,18 reduce of post-exercise anti-inflammatory effects and gene expression in the exercised muscle.19 On the other hand, improving oral health through screening and motivating could prove to be beneficial. While the frequent usage of sugary and acidic sports beverages should not be condoned, athletes should be encouraged to substitute their energy drinks with electrolyte-combined water or sugar-free squash, and for post-exercise hydration milk could be a good substitute along with carbohydrate-containing healthy foods.4, 20 Routine dental check-ups should be incorporated in the general health check-ups for athletes, with trained staff assessing, treating where necessary and offering fluoride supplementation where needed, in ad- dition to oral hygiene motivation. Conclusion Oral health issues remain prevalent among athletes, affected by both the diet and stren- uous activity; however prevention is key to nip this problem in the bud – educating the athletes on the risks of high and frequent sugar intake and ben- efits of ameliorated dietary choices, also encouraging them to go to the dentist for frequent dental check- ups and/or fluoridation. This will potentially lead to better oral health or early detection of issues such as caries therefore enabling treatment – making for an improved overall performance and healthier lifestyle. The necessity arises to incorporate oral health promo- tion in sport within general health and performance promotion, preferably with the help of a trained spe- cialist in the field. 41 Written by: Silvi Domnori, Shukri M. Jama Proofread by: Shukri M. Jama Design by: Živa Antolin

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