issn 2567-286X • Vol. 5 • Issue 1/2021 1/21 prevention prevention prevention international magazine for oral health prevention & psychology “Behavioural change is the main pillar of the future dental practice” interview “A patient should attend hygiene visits as often as he or she visits the hairdresser or beautician” industry The impact of COVID-19 on dentistry

editorial | Magda Wojtkiewicz Managing Editor Healthy teeth, gingivae and beyond Preventive dentistry helps maintain good oral health. It is a combination of regular dental check-ups with good habits like twice daily brushing and flossing. Preventive dental care is key to keeping teeth and gingivae healthy— but it goes beyond that. Good oral health can impact general health: more and more studies suggest that there is a link between periodontal disease and systemic dis- eases like diabetes and cardiovascular disease. Much of preventive dental care starts with patients. The COVID-19 pandemic has increased awareness and inter- est in preventive dental care as well as home self-care, which hopefully will remain. But still patients rely on dental professionals to learn about the best available methods and products for maintaining good oral health and physical well-being. Every dental professional should create the opportunity to explain to his or her patients that regular preventive dental examination provides many benefits to oral health, such as: – It lowers the risk of developing dental caries, periodon- tal disease and more serious dental problems. – Early identification of dental problems may help mini- mise treatment and cost. – It enables the dental professional to perform a full examination of the mouth, jaw, neck, etc. to identify any related problems. – It helps reduce dental problems related to some chronic medical conditions. Diabetes, osteoporosis, certain cancers and eating disorders can all have an effect on dental and oral health. For people with chronic conditions, regular preventive dental care is an import- ant part of holistic health. – It helps in the diagnosis of systemic disease with an oral health association, such as cardiovascular disease, pulmonary disease, diabetes, orthopaedic implant failure and kidney disease. Preventive dental care is an important part of overall health, and healthy teeth and gingivae can positively impact the morbidity, mortality and healthcare costs associated with systemic disease; therefore, it should never be neglected. – It helps promote good oral hygiene habits, such as brushing teeth at least twice a day and flossing. Magda Wojtkiewicz Managing Editor prevention 1 2021 03

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“Doctor” is an academic title derived from the noun of the Latin verb doce–re, meaning “to teach”. prevention | m o c . k c o s t r e t t u h S / n e s s a c . r l © The satisfaction that emerges from this endeavour has to be experienced to be believed. as toothbrushing and use of interdental cleaners could be demonstrated. Many dentists might feel that they have been educating their patients ever since they started practising. How- ever, it seems prudent to consider whether we are doing enough and whether there is anything more that patients expect from us and we could deliver in this regard. Adult behaviour can be modified only by education through highlighting the relevance of the problem and encouraging constant practice until improved habits have formed. Hands-on mentoring and training of patients in the use of the correct techniques for brushing and inter- dental care will go a long way towards promotion of oral health. Constant reminders, sharing of educational con- tent and interaction through digital communication with patients can establish healthy habits and is an excellent method for dentists to build rapport with patients and their families. For a start, novel ideas can be employed, such as arranging an education session for patients during which to debunk myths and provide facts regarding oral health and disease. Traditionally, we have educated patients only on matters pertaining to their oral condition. Holisti- cally educating them on all aspects of oral health and dis- ease will better prepare them to handle their dental needs of the future and inculcate healthy habits. Appointments can be scheduled for the entire family, and activities such Every step in the right direction is the start of something amazing. “Prevent or perish” should be the new mantra for success in the current times. Let the revolution of education and prevention begin. about Dr Hadal Chandrasekhara Kishore has over a decade’s experience as a consultant periodontist and is from Bangalore in India. He holds a BDS and MDS in Periodontics from Krishnadevaraya College of Dental Sciences and Hospital in Bangalore. Dr Kishore places great emphasis on patient education alongside treatment, in order to create a motivated and educated patient, as he believes this is benefi cial to the patient, the dentist and society at large. He is a postgraduate guide and associate professor at Krishnadevaraya College of Dental Sciences and Hospital and is a much sought-after speaker in dental circles. He has over 15 international and national publications to his name. The fi rst iTOP lecturer from India, Dr Kishore completed the iTOP Teacher seminar in Prague in the Czech Republic and is head of education at Curaden India. prevention 1 2021 07

prevention | are determined together with the patient. In this first phase, the goals should be realistic and not too ambitious. If clinical symptoms already exist or if there are factors such as calculus or imperfect restorations that could hinder the optimal imple- mentation of dental fitness, these are professionally treated. The next step is the personalised selection of the dental fitness exercises and tools as well as the definition of the dental fitness programme through which the patient can achieve his or her personal goals. The dental fitness exer- cises and tools are physically presented to the patient and practically taught. The patient then practises first in the den- tal office under supervision until he or she has mastered the exercises and then performs them at home once or twice a day. Within two to three months, the patient is recalled in for a control appointment and, if necessary, for the correc- tion of his exercises. It is also possible to adapt or refine the recommended tools and excercises if the patient, who in fact becomes a client, is not able to reach the agreed goals. The next control and remotivation appointment takes place after another two to three months. If the outcome of this appointment is satisfactory and the patient has not devel- oped any further subclinical symptoms, it is possible to enter the lifelong monitoring phase. Depending on the indi- vidual situation, the monitoring intervals are between three and 24 months, and the next monitoring interval is individ- ually determined at each subsequent session based on the actual screening of preclinical symptoms. If preclinical symptoms are diagnosed in one of the monitoring sessions, the first approach is to try to stop the progress of these symptoms with the patient’s help by intensifying his per- sonal dental fitness efforts. A short-term monitoring interval is temporarily set for this purpose. If the measures taken have led to the arresting of the symptoms, it is possible to switch back to a longer monitoring interval. In case of symptom pro- gression, the personal dental coach will use professional non- invasive methods to try to stop it. Minimally invasive profes- sional measures are only required if the patient has not attended monitoring sessions for a lengthy period for whatever reason leading to clinical symptoms which make such procedures necessary. However, this should be the absolute exception. Implementation feasibility for dental fi tness Owing to the relatively low aggressiveness of caries and peri- odontitis progression in the vast majority of cases, a rather relaxed fitness programme is sufficient for most patients. Assuming appropriate information, instruction and motiva- tion of the patient, it is postulated that the dental fitness con- cept can be successfully communicated and applied not only to highly motivated, but also to relatively unmotivated patients. In many cases, a monitoring session scheduled every 12 to 24 months may be sufficient to prevent the ap- pearance of clinical symptoms, especially if the screening for preclinical symptoms is regularly applied so that in case of progression, these symptoms may be arrested by appropri- ate non-invasive professional therapeutic measures. Costs of dental fi tness In a patient with good compliance and a life expectancy of more than 80 years, it is estimated that lifelong dental fitness can be financed at the price of two implant-supported crowns— and this not only for a single tooth, but for the entire dentition. The role of the dentist in dental fi tness In the dental fitness context, the dentist is no longer a dental technician working on patients as is the case in traditional repair-oriented dentistry. Rather, he or she is a personal dental coach who, thanks to his or her expert knowledge and social skills, enables the patient to maintain his or her own teeth in good health for the rest of his or her life with the least investment of time and money. Advantages of dental fi tness The dental fitness concept has many advantages for patients: with a minimal investment of time and money, they can preserve their natural teeth until the end of their lives, resulting in the best possible sustainability as of today. But there are also several advantages for dentists. The concept offers the opportunity to lead a team of collaborators who can take care of the major part of the labour needed, thus taking care of a much larger number of patients than the individual dentist alone. As a result, dentists become health managers, focusing mainly on diagnostics and planning, as well as on human resources, business and opera- tional management. When working clinically on patients, they carry out relatively low-risk, micro-invasive and high-quality interven- tions. This may increase job satisfaction and attractiveness and reduce stress levels for both dental professionals and patients. Editorial note: This article was first published in Swiss Dental Journal, 2018, vol. 18, no. 1. about Prof. Ivo Krejci is professor and chairman of the Division of Cariology and Endodontology and director of the department of preventive dentistry and primary dental care at the University of Geneva in Switzerland, where he maintains an intramural private practice. He also serves as the scientifi c consultant for the school of dental hygienists in Geneva. Over the course of his career, Prof. Krejci has written over 350 articles and book chapters on topics in restorative dentistry, as well as several textbooks. Furthermore, he has supervised more than 60 doctoral theses and has lectured at numerous international scientifi c meetings and continuing education courses. He can be contacted at ivo.krejci@unige.ch. prevention 1 2021 09

prevention & psychology | The right tools and techniques: during iTOP seminars, dental students as well as practicing dental professionals learn the ins and outs of perfect biofi lm removal. them. Motivation is half the battle. It leads to an intention, but there is no reward to keep a new habit alive. In order to instil a new habit, you need to identify an existing prob- lem in the patient and set an achievable goal to solve it. Of course, these problems vary from patient to patient. But when you listen to the patient and propose routines that solve existing problems, you can dance instead of fight.” Rui gave interdental brushing as an example. Most pa- tients do not realise the need or are simply too busy with their lives to think about brushing interdentally daily, but by pointing out symptoms such as bad breath or bleeding on brushing, dental hygienists confront patients with a problem to work on. The next step is setting achievable goals, such as using interdental brushes. Rui said: “Grad- ually going from one plan to another is moving from in- tention to action. This is a long-term journey with the pa- tient. In doing so, in-depth feedback and before and after comparisons are crucial. Simply put, the work of a den- tal hygienist is helping patients to become autonomous.” Shifting the paradigm The dental hygiene students at the Polytechnic Institute of Portalegre go through the full iTOP programme—iTOP stands for individually trained oral prophylaxis. This inter- national programme teaches dental students and practis- ing dental professionals alike perfect prevention by putting prevention theory into hands-on practice. Students learn optimal, atraumatic plaque control with the most effi- cient tools and techniques, based on the latest research. A great deal of emphasis is placed on interdental brushing. “ITOP goes deep into biofilm control and behavioural change,” Rui said. “Teaching skills is not enough when you don’t consider the patient; that is the gap iTOP is filling in a growing number of dental universities around the world. Most universities do not teach students how to guide each individual patient towards better health. It also confronts dental professionals with how they are brushing and al- lows them to reflect about their skills. As a consequence, they find it easier to empathise with patients in turn.” According to Rui, educational programmes such as iTOP will be a game-changer in shifting the paradigm regarding dental hygiene. “I never use the word ‘cleaning’ to describe the job of dental hygiene, because the last thing a dental hygienist does is cleaning the teeth of a patient. What stu- dents learn in iTOP is therapeutic. You cannot control peri- odontal disease if you do not control biofilm. I need to read my patient, understand the disease, and set goals and a treatment plan. I want my students to understand that our job is to help control gingivitis, caries or biofilm accumula- tion. It would be wrong to call that cleaning. It is therapy.” “Dental hygiene is where dentistry and psychology meet.” “Patients need to feel good during an appointment,” Rui concluded. “Patients should feel comfortable asking questions and that they are in good hands with dental pro- fessionals who take their time to explain and work out an individualised plan. I feel that education is already changing for the better and catching up with this need, and iTOP is a good starting point. At the end of the day, what sets a successful practice apart are good dentist–patient relation- ships, and dental hygienists are the missing link here.” m o c . k c o t s r e t t u h S / s c e d D © i prevention 1 2021 11

prevention & psychology | Future research should be performed in different exper- imental scenarios and in patients in the long term. If our finding is confirmed, the management of periodontitis might be included as a preventive coadjuvant treatment against depression. Did the research pose any major challenge, and if so, what was it? García‐Bueno: The biggest challenge was creating a com- bined animal model of periodontitis and depression. There are multiple experimental models for both and multiple possible combinations. We spent a long time improving the experimental design to be able to produce some of the characteristic pathophysiological alterations of both pathologies. At the end, we found a combination that al- lowed us to produce synergic effects at multiple levels in the animals exposed to both pathological stimuli. Periodontitis is a very complex disease, and scientists have been able to link it to a vast range of different ill- nesses, such as cardiovascular problems, cancer and metabolic syndrome. How will your findings add to the understanding of periodontitis as a whole? Figuero: Our findings support the view of periodontitis as a pathological condition with the potential to directly affect the central nervous system, in addition to its impli- cations for other systemic diseases. Periodontal effects in neurological and neurodegenerative diseases such as Alzheimer’s disease have been explored, but our results, among others, suggest that periodontitis could some- how be contributing to some of the behavioural and cog- nitive alterations in susceptible neuropsychiatric patients. Increasing scientific evidence from epidemiological studies has been presented in recent years on the relationship between poor oral health and mental health conditions (including psychosis and affective disorders). Depression is one of the most common mental dis- orders worldwide, and according to the World Health Organization, more than 264 million people of all ages suffer from mild to severe depressive episodes. How- ever, it is likely that there are many unreported cases. Do you think these statistics imply the need for closer collaboration between psychologists and dental pro- fessionals? What could that look like? García‐Bueno: The epidemiological data shows an increasing comorbidity between depression and peri- odontitis. Severe periodontitis (currently Stage III and IV periodontitis) is the sixth most prevalent chronic non- communicable disease worldwide, affecting more than 700 million individuals. Therefore, considering the high prevalence of both conditions, closer collaboration be- tween psychologists, psychiatrists and dental profession- als is more necessary than ever. These respective health- care professionals should make their patients aware of the possible relationship between both clinical entities, and we can even affirm the essential informative and preven- tive role of primary care physicians, who are often the first line of contact with patients with psychiatric symptoms. What are the future plans for your research on this matter? Figuero: Our immediate aims for the future are to further characterise the relationship between periodontitis and depression, exploring complementary molecular and cel- lular pathways in our combined experimental model and searching for novel biomarkers. In addition, we will tune up a new experimental model with a more severe clinical state of periodontitis in which we will evaluate the impact of periodontal therapy (supra- and subgingival debridement combined with an antiseptic agent), and we will also try to establish a reliable model by which to study the effect of periodontitis on psychiatric illnesses such as schizo- phrenia. At the end, we expect to translate all the preclinical find- ings to the clinical arena, designing clinical trials in order to improve the symptomatology of patients diagnosed with depression, schizophrenia or other neuropsychiatric disorders using strategies based on the improvement of their periodontal health. Although a growing body of evidence indicates that de- pression may be associated with periodontitis, the literature is still controversial, raising questions on whether peri- odontitis is a cause, a consequence or just a concurrence of depression. Future preclinical and clinical research should seek to shed light on the bidirectional potential of the relationship between both pathologies. about Dr Elena Figuero is a full-time associate professor in periodontics in the Department of Dental Clinical Specialties in the Faculty of Dentistry at the Complutense University of Madrid in Spain. In this Faculty, she is the vice dean for quality and international; she directs the research methodol- ogy in dentistry and the periodontal clinic postgraduate programmes and she coordinates the Etiology and Therapy of Periodontal and Peri-implant Diseases research group. Dr Borja García-Bueno is a full-time associate professor at the Complutense University of Madrid in Spain. He works in the Department of Pharmacology and Toxicology, where he oversees the Molecular Neuropsychopharmacology research group. Furthermore, he is a member of the Spanish scientifi c network of mental health disease. m o c . k c o t t s s r r e t t u h S / t r a . T S © prevention 1 2021 13

prevention & psychology | monise with the ecology of commensal bacteria, fungi, and viruses, but also should be able to defend against patho- genic microbes. In fact, the oral microbiota is altered in sit- uations when the immune system is dysregulated.14 There are a number of human diseases or conditions that disturb the balance of the host immune system and have an effect on the host’s oral microbiota. The human oral cavity is an ecosystem, and like all ecosys- tems, the oral ecosystem is a combination of many different components (e.g. bacteria, fungi, metabolic compounds, host cells and salivary constituents), and in one way or another, this system maintains a balance. It is important to note that the bacterial communities can vary between dif- ferent collection sites in the oral cavity. Variations in oral microbial diversity in different oral sites, especially between the mucosal and dental sites and between saliva and den- tal sites, have been observed.15 A recent study demon- strated that the buccal mucosa, gingivae and hard palate had similar microbiota, whereas the saliva, tongue, tonsils, throat, and supra- and subgingival plaque each had distinc- tive communities.16 To date, saliva serves as the best oral compartment to look for differences in the microbial com- position in a variety of human diseases, as it captures the closest true representative microbiota in the oral cavity.17–20 When we talk about the healing capacity of biological tissue, we need to understand that interactions between saliva, diet, the oral microflora, tooth surfaces and the oral mucosa support a dynamic state of equilibrium (healthy condition)21, 22 in the oral cavity as an integral part of an ecosystem. Oral health and disease are influenced by bal- ances or imbalances between these components (Fig. 1). Consequently, preventive and treatment strategies should aim to maintain or re-establish balance with a more holistic view of preventive, diagnostic and treatment strategies in contrast to the traditional methods that focus on a limited number of pathogenic factors.23 Global oral health burden 2 3 well documented in the literature.30–40 Hence, oral disease is considered the most significant global oral health burden.25 The impact of oral disease on the global economy involves direct and indirect treatment costs41, 42 and can have a huge negative economic impact on society. WHO estimated that oral disease is the fourth most expensive disease to treat in most industrialised countries.43 In addition to the direct and indirect treatment costs and economic impacts, oral disease has a large impact on people’s daily lives and is re- sponsible for the yearly loss of millions of school and work hours around the world.41–45 Hence even from an economic point of view, the improvement in the oral health of the pop- ulation may be highly beneficial and could further increase people’s well-being.42 The concept and methods regarding the treatment of caries are changing in light of new research evidence based on the fact that caries is a behaviour- and diet-dependent disease with bacterial participation, and the treatment plan should consider the healing capacity of biological tissue.46–49 Pre- venting the occurrence of carious lesions should remain the primary aim of any oral care plan, and treating caries as an infectious disease with the unnecessary removal of sound tissue and replacement with restorative mate- rials is no longer acceptable within the field of dentistry. The author advocates the Vedic Smile concept,50 which Caries and periodontal disease pose an enormous burden on mankind as non-communicable diseases. A high propor- tion of the world’s population (approximately 90%) suffers from oral disease at some point in their lives,24 and caries and periodontal disease are the most common chronic dis- eases causing severe pain in the later stages.25, 26 It has been estimated that almost 100% of adults and 60–90% of schoolchildren worldwide suffer from caries (Fig. 2) , and about 20–50% of the global population suffers from peri- odontal disease.27 Severe periodontitis (Fig. 3) is the sixth most prevalent disease in the world and may lead to tooth loss.27, 28 Moreover, growing research is showing that there is a strong correlation between oral disease and major non-communicable diseases such as diabetes and cardio- vascular disease.24, 29 A strong interaction has been shown to exist between oral health and mental health that has been 4 prevention 1 2021 15

prevention & psychology | mental distress is more apparent today than ever. Distracti- bility, loneliness, depression and anxiety are all on the rise, creating an emerging crisis in mental health and a grow- ing deficit in our collective well-being.86–88 Research has studied interventions that improve well-being through the use of various forms of self-regulation,89 including psycho- therapy,90, 91 positive psychology interventions92, 93 and con- templative practices like meditation.94–100 Hence, MTB em- phasises mindfulness in order to lower the harmful effects of distraction, which has been shown to impair executive function101 and to increase stress, anxiety102 and attention- deficit/hyperactivity disorder symptoms.103, 104 It is to be noted that being informed and being aware are two dif- ferent things at the level of the mind. For example, a smoker may be fully informed about the negative consequences of smoking tobacco on overall health and well-being in the long term; however, if this piece of information is not syn- thesised at the conscious level of mind, then the person cannot quit smoking easily. Compassion Kindness is a key component in enhancing mental health that helps to maintain quality of life. A person lacking in self-compassion for his or her health or body parts could easily become a victim of multiple diseases in a lifetime and may cause self-harm to health and happiness. It is the author’s long-term clinical findings that a person who ne- glects his or her oral hygiene generally neglects his or her overall health, and oral hygiene status can be a good in- dicator in understanding a person’s self-compassion level towards his or her quality of life. Hence, the MTB tech- nique is designed to cultivate self-compassion towards the teeth, gingivae, and other parts of the mouth and body and to help patients to keep their mouths healthy and minds happy, thereby improving quality of life. Teaching self- compassion at an early age could be a smart approach to self-care, and by cultivating kindness towards each tooth as an individual “being”, this MTB practice encour- ages children to keep their teeth clean and adopt good oral hygiene habits. Practice Toothbrushing is a behavioural daily habit; hence, it is not easily altered, even after professional oral hygiene instruc- tion in the clinical setting, and multiple studies have shown that patients’ adherence to a proper daily oral hygiene reg- imen generally remains poor,54, 55 and even a large num- ber of adults clean their teeth less than the recommended time56 and have been shown to have problems achieving oral cleanliness through self-performed oral hygiene. The act of toothbrushing is a science-based skill that requires at least basic oral hygiene education and suitable skill train- ing, which must teach the art of toothbrushing with the right protocol. Moreover, from the movement science viewpoint, skill training requires many repetitions of the same move- ments to incorporate them into an individual’s habitual mo- tor programme. In this regard, one needs to understand the role of practice (repetition) with the aware and com- passionate mind in the act of toothbrushing. An aware and self-compassionate mind can easily realise the importance of learning the right skill of toothbrushing and using it prop- erly as a lifelong responsibility. The MTB concept encour- ages the user to continue practising good cultural oral hy- giene habits that exist in his or her society. For example, rinsing the mouth two to three times vigorously after each meal with water is a deeply rooted oral hygiene practice in Nepal. The author has been recommending to his patients to keep on practising such good cultural habits. 6 prevention 1 2021 17

prevention & psychology | toothbrushing and oral massage using protective tooth- paste or mouthwash generally helps in biological repair (remineralisation or healing) of the hard and soft tissue in the oral cavity. However, if the oral ecosystem disharmony factors are on the higher side, then signs and symptoms of disharmony, like bleeding gingivae, dental hypersensi- tivity, halitosis, demineralised white spots, micro-decay and non-carious tooth lesions, such as erosion, abrasion and attrition, become evident, and this requires profes- sional care for repair and maintenance. Vedic Smile always emphasises the use of smart technology and materials, such as bioactive restorative materials and non-invasive or microinvasive techniques, for the repair and maintenance of such early defects by dental professionals. Teaching the right protocol in the right approach at the right time is necessary for any cognitive skill training that involves the movement of body parts or motor skill. Tooth- brushing activity as mentioned is an art and science of keeping the mouth healthy and the mind relaxed. The art component of toothbrushing requires skills for correct movement of the hand and brushing motion for long-term oral health benefits. The skill learned with awareness and proper practice (repetition) at the right age is easily con- verted into behavioural habits. The efficacy of toothbrush- ing depends on multiple factors, such as age, awareness, motivation, quality of the toothbrush, brushing frequency, brushing duration, brushing force and toothbrushing mo- tion. It is to be noted that the aim of MTB is not limited to keeping the mouth clean and healthy, but extends to help- ing to brush up the mind by reducing day-to-day anxiety and stress, making it fresh and happy. MTB: Hands-on training programme and appeal Over 30 years of clinical dentistry, the author has found that the patients visiting his dental clinic lack self-compassion for their oral structures and are not very familiar with the proper brushing technique. Moreover, it is also difficult to teach correct brushing skills in the busy clinical setting with only quick professional instruction. As mentioned earlier, toothbrushing is a skill-based behavioural habit and is dif- ficult to change for the majority of individuals in their teens or adults. Therefore, the author has designed an exclusive MTB hands-on training programme targeting schoolchil- dren who are at an early stage of their lives. The hands-on training focuses on the idea that any hand skill teaching requires proper motor skill training, along with ongoing follow-up, evaluation and monitoring. It is a well-established fact that repetition is the key approach to converting a good health protocol into a habit, and early school age is the best time to foster healthy oral habits among children. MTB hands-on training is designed as a package of a ba- sic dental check-up, caries risk assessment, oral hygiene awareness, and a step-by-step hands-on training pro- gramme in a small group with the aim of engaging and encouraging the children to regularly practise MTB at home 8 and at school and to develop a habit of keeping in touch with their dentist at least once a year. The MTB certifica- tion system is incorporated into the programme to make the children feel proud and happy about participating and learning good habits. To help promote this oral hygiene mission, the author has also established the Chetu kids’ club, which has the mon- key Chetu as a mascot (Fig. 8) to symbolise that we need to tame our monkey minds first and only then will it be easy to convert any good health practice into a habit. The silent MTB mantra “I LOVE you” is used during toothbrushing so that kids start adopting the art of self-compassion and gratitude in their lives. The author appeals to all schools, dental colleges, and dental clinics to incorporate the MTB hands-on training programme as an inbuilt curriculum and support service. In this regard, the author, in joint collabora- tion with the Oral Health Innovation Center of the Punyaarjan Foundation in Nepal, is in the process of developing a comprehensive MTB hands-on training manual to support schools, oral healthcare organisations and dental clinics around the world to conduct well-organised MTB hands-on training. A copy of the training manual will be freely available at www.punyaarjanfoundation.org.np after October 2021. Editorial note: A list of references is available from the publisher. This article originally appeared in Smart Oral Care, Vol. 1, No. 1 (March–August 2021), and an edited version is provided here with permission from the publisher. contact Dr Sushil Koirala is the president of and chief instructor at the Vedic Smile Academy in Kathmandu in Nepal. He maintains a successful private practice in Kathmandu. He can be contacted at drsushilkoirala@gmail.com. prevention 1 2021 19

interview | he or she should adjust appropriate hygiene methods and measures to meet the patient’s needs. From my observations, I have concluded that the key to periodontal disease prevention is the maintenance of good hygiene in the interdental spaces, as food debris, and therefore bacteria, accumulate there. To clean these areas effectively, one needs to floss regularly; however, the interdental brush seems to be an even more effec- tive tool. Electric interdental brushes have appeared on the market as well, and their effectiveness and efficiency cannot be overestimated! It should be emphasised that well-known irrigators are not the best tools, nor the only ones, for cleaning these spaces. The layer of biofilm formed is hydrophobic, so it can only be removed un- der high pressure, by tedious and systematic flossing or, preferably, with an interdental brush. I would like to draw your attention to issues of individual hygiene too. Sometimes 50-year-old patients need to be taught the correct cleaning methods from the beginning be- cause their current ones are simply ineffective. My observa- tions indicate that patients’ awareness of flossing is still low. Which patients do you meet most often? The patient profile has been visibly changing over the years. We meet cases of extreme negligence less and less frequently. More often we meet patients who suffer from bruxism. Unfortunately, they constitute more than 60% of all patients. A significant number of patients are women who face periodontal problems owing to endo- crine disorders. Is it true that the dentist can identify many disturb- ing symptoms? A dentist is sometimes a kind of a therapist. Having evaluated the condition of the oral cavity, a dentist can assess how stressed the patient is, which may constitute an indication for referring him or her to another specialist. This imbalance is additionally boosted by functional dis- orders resulting from the tension and pace of life. This, in turn, leads to the loss of the hard tissues of the tooth in the cervical area. Thus, the work of a dentist requires responsibility, knowledge, experience, a predisposition for the work, patience and passion. What should a professional hygiene procedure look like? In addition to everyday hygiene performed at home, which is the key to success, the patient should visit the dental office for professional in-office hygiene at least twice a year. Methods used in professional hygiene are signifi- cantly changing each year, not only because new devices appear, but also because patients’ awareness increases. prevention 1 2021 21

interview | Where, in your opinion, is the line drawn between the general dentist’s and the hygienist’s competences, and when is the intervention of a periodontist nec- essary? Most periodontal problems can be solved by implementing non-surgical methods. This means that a well-performed hygiene procedure, consisting of deep scaling, systematic cleaning of periodontal pockets, and removal of biofilm and dental plaque is the key to success. Such work can be done by teams consisting of dentists and hygienists. There is a practical indicator to help in diagnosis, the Periodontal Screening and Recording index, a modifi- cation of the community periodontal index of treatment needs, which should be used by each practitioner. This test helps to place the patient in a specific group requir- ing basic treatment and to distinguish him from a patient already requiring the intervention of a periodontist. The scale indicates: (1) bleeding during probing, (2) the pres- ence of calculus, (3) the presence of periodontal pockets from 3.5 mm to 5.5 mm in depth, and (4) the presence of periodontal pockets above 6 mm deep. It is assumed that the first two groups of patients on the four-point scale are eligible for treatment by dentists without specialisation and that, when the pocket depth of 3.5 mm is exceeded, patients require a specialist’s treatment. The device men- tioned above indicates many possibilities in this range, and as a result, prophylaxis reaches a much higher level. When I hear conversations about prophylaxis, I as- sume that the greater the patients’ awareness is, the smaller the number of difficult cases resulting from years of negligence there will be. Isn’t there a conflict between prophylaxis and profitability? In the West, periodontal diseases were very much un- der control; however, the recent wave of immigration has changed the statistics. For example, Scandinavia, a region where prophylaxis was at the highest level, was flooded with immigrants. It changed the situation a great deal. Owing to the fact that there had been no difficult cases of periodontal diseases, there were no specialists who were able to deal with this new situation. Now, they have to face these problems and perhaps learn about many issues anew. Primary prophylaxis among patients with active disease may decrease, but there is also secondary prophylaxis, which refers to those patients who have recovered from the disease. In their case, prevention is very difficult. If the patient has recovered from an advanced disease, GBT makes it easier for us to maintain the treatment results. However, we need to help patients because, owing to the periodontal loss and therefore difficult local conditions, maintaining good hygiene at home is difficult for them. For many years to come, we will still meet many patients with periodontal diseases and caries. These problems are caused not only by the fast pace of life but also by the low awareness of oral hygiene in those countries where medicine is less developed. It is interesting that periodon- tal problems equally concern those patients with a good awareness of hygiene rules and who sometimes even excessively follow the recommendations and those who are not able to implement even basic hygiene methods. Therefore, what strategy should be adopted to fight against periodontal diseases? Let’s take a look at the example of the comprehensive treatment of non-carious cervical lesions, including ab- fraction or abrasion. Nowadays, most dentists deal with functional disorders. One of Zucchelli’s practical con- cepts is that we must first find the reason for a problem and then combine the restorative treatment of cavities with periodontal coverage of recessions. This concept is highly complicated, but it helps the patients a great deal. “For many years to come, we will still meet many patients with periodontal diseases and caries.” The number of patients who have recovered is growing. The effects of this therapy are good-looking teeth, un- exposed roots and lack of hypersensitivity. The conclu- sion is clear: even if one problem seems to be finished, you need to keep your eyes open because another may have just begun. What conditions, in your opinion, should be met so that patient–hygienist–dentist cooperation can be fully effective? How can success be achieved in the whole process of hygienic care and then be main- tained at a satisfactory level for as long as possible? The prerequisite for effective therapy is the profes- sional supragingival and subgingival hygienic procedure. Supplementation with vitamin D3 is increasingly being scientifically documented and is also recommended by Polskie Towarzystwo Stomatologiczne (the Polish associ- ation of stomatology), mainly by Prof. Marzena Dominiak, who discusses this subject in many lectures. Basic (non-surgical) therapy is crucial. I’m totally opposed to implementing physical therapy, for example laser therapy, pocket rinsing, PerioChip and ozone therapy, if we don’t start with the basic therapy. I recommend such activities, but only if the basic hygiene procedure has been previously performed. This is where the con- cept of GBT works perfectly. prevention 1 2021 23

interview | moderate to severe special needs individuals. I prefer to train the trainers on behaviour management so that they can confidently manage behavioural crises with- out hesitation and then they too can educate and train their staff. Please explain briefly for us what autism is and how it affects children. AS: Autism is a spectrum disorder characterised by so- cial and communication deficits as well as behavioural excesses, including sensory processing and dysregula- tion. A child with autism is often misunderstood as a dis- obedient child or one that just needs a little discipline. However, the brain is just so much more complex than that. A neurotypical individual accepts information into his or her brain constantly (think of your five senses) and interprets that information in ways that are generally so- cially appropriate. For individuals with autism, however, information that enters their brains is often interpreted in a way that comes off as socially inappropriate. For ex- ample, if an autistic child hears an emergency siren at a distance, he or she may begin to scream loudly. When neurotypical individuals observe this behaviour, they do not understand why this child is screaming, and perhaps they can’t even hear the siren themselves. Individuals with autism often benefit from modified sensory input— whether physical touch or tactile, noise levels, lights, etc.— increasing or decreasing the amount of stimuli to help them feel more regulated. Do you have any current statistics on the number of children with autism? Is the frequency of the disorder on the rise, and is it true that autism is more common in boys than in girls? AS: According to the Centers for Disease Control and Prevention, autism is on the rise. In 2000, one in 150 chil- dren were diagnosed as autistic, rising to one in 69 in 2012. Currently, one in 59 children are diagnosed with an autism spectrum disorder. Autism is reportedly four times more prevalent in boys than girls. When speaking with parents of children with autism, what have you found to be the biggest challenges that these parents face on a day-to-day basis, espe- cially when they have a medical or dental appoint- ment scheduled? AS: Children on the autism spectrum can’t always communicate their wants or needs appropriately and will often use other means to communicate. Screaming, crying, flopping or thrashing their body about, eloping and aggression are just a few of the behaviours that I’ve been asked to help parents manage when in public settings. The amount of physical, emotional and men- tal energy it requires for parents to get through a shop- ping trip with an autistic child (not to mention the stares or judgemental comments they may receive from by- standers) can be so exhausting that they just don’t want to do it any more. When arranging medical and dental appointments, most parents have reported long waits, required advanced scheduling, difficulty with resched- uling and cancelling of appointments. They have also reported difficulties when facing an emergency or an unexpected event. Parents have often cited the need to leave appointments early owing to challenging be- haviours in the lobby. When dealing with stressful situations, what are some of the most common behaviours that children with autism exhibit? AS: Tantrum behaviours are common. These look very different from child to child, but may include yelling, screaming, crying, flailing and flopping to the ground. Aggression is also very common: hitting, pulling hair and clothing, kicking and biting. Children may curse loudly or say other inappropriate things to escape the situa- tion. Self-injurious behaviours are very common. These can range from mild to severe head banging (with hands or against a hard surface), biting, scratching or pulling their hair out. Elopement from the situation, often by run- ning through the parking lot or out of the building, is also quite common. Parents often give in to these escape- maintained behaviours owing to safety concerns, feeling embarrassed, or being judged by others. prevention 1 2021 25

interview | autistic children and helped hundreds of kids in our area get desensitised to their dental visits to the point where they are no longer coded as a special patient in our sys- tem because they have graduated to regular dental visits in a regular dental chair. What protocol have you adopted, or do you have any procedures in place to streamline your appointments with special needs patients? MA: Because I designed my newest office myself, I had the freedom to create whatever I wanted. I designed it to accommodate a “Roll Up, Call Up” appointment sys- tem. Parents of children with special healthcare needs that may be disturbed by a busy waiting room or children needing to limit their exposure to others because of their immunocompromised condition can park at the back of the office in one of three designated Roll Up, Call Up parking spots. Once there, the parent calls the number on the posted sign and a SKY team member will bring out any necessary paperwork if it has not already been filled out online using our secure patient portal. The SKY team member will have the child’s exam or treatment room ready and will escort the family through a private entry directly into their treatment room, skip- ping the lobby entirely. Our families with severely autistic children, children in wheelchairs, and children undergo- ing chemotherapy or with an immunocompromised sta- tus love this option of skipping the front desk and having a concierge-like experience at the dentist. We have had so many parents thank us profusely and say that this is what they would love to see across all of their health- care experiences. Simply having the Roll Up, Call Up sys- tem in place has enabled me to treat kids and adults that might pose a danger to themselves or others in the waiting room. Providing this type of concierge service—the private entrances and the additional support—is very im- pressive. What is your motivation for providing this type of specialised care? MA: This is something we wanted to do because we wanted to respect our patient families. This system al- lows us to see both kids and adults, because some adults with behavioural issues cannot handle the waiting room either. It just takes that worry completely off the parents’ and caregivers’ minds, knowing that they will be ushered directly into a comfortable treatment area right away. Special dark, starry sky treatment rooms mimic a sensory environment and provide autistic kids with a way to become more relaxed during a dental exam and cleaning. How important is repetition and consistency when scheduling appointments with patients with autism? Do you always schedule the same assistant and room etc.? MA: If a child has done exceptionally well with a par- ticular assistant or hygienist, we will note that in our re- cord and try to have the same person with the child for the next appointment. But the vast majority of our patients with autism are comfortable with staff inter- changing because the flow of the appointment is the same. The flow of the appointment becomes the consistent part. Do you have any advice for dentists who are not sure how and when to schedule their patients? What are some of the protocols you have put into place that make scheduling treatment easier for your staff, patients and caregivers? MA: Initially, you could block an hour of hygiene time for kids with special healthcare needs. Start your appoint- ments 15–20 minutes early to allow the child to arrive and settle in. Like with most young kids, behaviour can dete- riorate during the day, so you might want to initially block off your last appointments of the day. As your staff get comfortable and kids see less deer in the headlights fear in your staff members’ eyes, you can open appointments later in the day for children with special healthcare needs. We have also found that many preschool children may not have a diagnosis yet, but are already exhibiting chal- lenging behaviours. We ask parents whether there are there any behavioural concerns they have about their child’s first dental visit. It’s been very helpful to know whether a child is being evaluated for autism before the first visit. Parents may be more willing to disclose their concerns when asked directly, especially if they have not yet received an official diagnosis. Before we started asking this question, we were presented with more than a few surprises with difficult behaviours in our more open areas. Now we are able to start appointments for kids with behavioural concerns in a more private area right from the start. prevention 1 2021 27

interview | “If we can get kids settled back in their room before they have time to become upset, we are starting off ahead of the game.” Would you please comment on the belief that one can only see autistic patients on certain days because special needs patients require longer appointments? MA: A lot of associates are told by an older dentist that it’s just not possible to see severely autistic kids, kids with wheelchairs, kids with Tourette’s syndrome or kids with severe medical issues on the same day as “regu- lar patients”. However, I have found that it is completely possible. We see so many kids with all of these health- care needs, especially kids on the autism spectrum. They don’t take any longer—except maybe on the first visit. This mindset that you can only see special needs pa- tients on certain days needs to go away. The trend is towards integration rather than some kind of quarantine that compartmentalises these kids and assigns them a special time that they can be seen. People with special health needs need to be integrated into a regular sched- ule with the same access to healthcare as the general population. What advice would you give paediatric dental resi- dents on treating autistic patients when they get into private practice, and what challenge would you set your peers in private practice regarding treating this unique and growing population? MA: I think residents should get all the experience they can during their programmes. They shouldn’t let their at- tending handle all of the communication with the parents. As residents, they need to be able to directly commu- nicate with families and learn what problems they have with accessing dental care. They should ask the moms how it went with parking, getting to the dental clinic, get- ting through the door to the operatory, etc. They need to get a good idea of all the challenges these families are facing before they give them advice on better brushing techniques. On average, care of an autistic child costs an estimated US$60,000 a year or more through childhood, the bulk of the costs in special services and lost wages related to increased demands on one or both parents. Costs increase with the occurrence of intellectual disability. Editorial note: This article originally appeared in Shift Magazine (autumn 2019), and an edited version is pro- vided here with permission from Sprig Oral Health Technologies. about Dr Mandy Ashley, originally from upstate New York, followed an interesting pathway into paediatric dentistry. After graduating from the University of Pennsylvania in the US in 1999 with a dental degree and master’s degree in education, Dr Ashley embarked on an 11-year adventure as a general dentist in Utqiaġvik in Alaska. She brought dentistry to the villages along the Arctic Ocean and started a dental assisting programme for local residents. In 2012, she finished her paediatric dental residency at the Ohio State University and moved to Bowling Green in Kentucky, both in the US, to raise her family and start a private practice: SKY Pediatric Dentistry. In her spare time, Dr Ashley plays hockey and travels the world with her family, hoping to inspire her kids to enjoy big adventures of their own some day! Amanda Smith received her master’s degree in applied behaviour analysis in 2010 from National University in the US. She is a Board Certified Behavior Analyst with over a decade of experience working with children with autism spectrum disorders and other developmental issues, whether at home or school, or in other community My challenge for newly minted paediatric dentists is to look at the practice they are joining or creating and de- fine one way that they can increase access for kids with special healthcare needs. It might be as simple as cre- ating a way for families to wait in the car until their room is ready, or converting a consultation room to a sensory room to allow for a more relaxing non-traditional treat- ment environment. Paediatric dentists can aim to be- come the healthcare provider that anchors the family of special needs kids to good experiences with easy access to care. settings. She currently works for a local county office of education as the behaviourist for all county special education programmes. She enjoys volunteering for organisations such as Make-A-Wish Foundation and the Global Autism Project that support children and their families and help to improve their quality of life. In 2018, she travelled with the Global Autism Project to Nairobi in Kenya to work with an autism school as a member of a team of specialists to train staff and promote autism awareness within their community. In her spare time, she loves spending time with her husband, Stephen, and two young boys, Hayden and Ayrton. prevention 1 2021 29

practice management | m o c . k c o t s r e t t u h S / e p a c s n a b r U © If someone needed some tips on how to approach com- panies for sponsorship, whether it was drafting a letter or making a phone call, I have been there to guide them, but actually my presence was essentially to help them explore their full potential and uncover the answers for themselves. I have witnessed so many of my colleagues feeling frustrated and convinced that their opportunities in practice were limited and limiting. I heard of a dental nurse who left to join the police force in order to have a more fulfilling and exciting role. It does not have to come to that. We are so much needed as a workforce to sup- port oral health improvements, and oral health promotion has huge potential. You need to investigate possibilities and obtain the support and guidance that could assist you in developing your ideas. Practice owners certainly do not want to lose invaluable members of staff just because they believe that their role has limited potential and are merely unaware of what other opportunities could be possible. My mentees have proved that the sky is the limit, and I am excited by the prospect of developing yet more projects with the next cohort for my upcoming course in November. I am also delighted to say that Philips has offered to con- tinue with its sponsorship. As a result, any dental profes- sional with an idea (large or small) for a new oral health promotion venture will receive an initial consultancy ses- sion with me to discuss their prospective project free of charge. In addition, they will be entered into a competi- tion to win a Sonicare toothbrush.1 For a free consultancy session and the opportunity to win a Sonicare tooth- brush, please let me know in 30 words why a Sonicare would be best in your hands! Entries should be e-mailed to info@victoria-wilson.com by 8 October 2021. 1 Terms and conditions: – Entries must be e-mailed to Victoria Wilson by 8 October 2021. – Only UK entrants will be accepted. – Entries should be 30 words or less. – Entries should include contact details (name, e-mail address and telephone number). – The winning entrant will be notified by Victoria Wilson by 11 October 2021. contact Victoria Wilson can be contacted at info@smile-revolution.net. For more information about the next Smile Revolution course please visit www.smile-revolution.net. www.smile-revolution.net www.smilerevolutiongrowthhub.com prevention 1 2021 31

Standard precautions remain essentials Adherence to infection prevention and control practices is essential to providing safe, high-quality patient care across all healthcare settings. Standard precautions are the basic practices that apply to all patient care, regard- less of the patient’s suspected or confirmed infectious state, and apply to all settings where care is delivered (Fig. 1). These practices include hand hygiene, personal protective equipment (PPE) and disinfection protocols and help deter infection transmission among practitioners and patients.1 The outpatient nature of the dental practice—which fea- tures a high-volume patient turnover and a wide range of treatments—requires reliable, carefully integrated hygiene routines. Therefore, the fundamental preventive measures of standard precautions remain in place. Gloves Gloves are an essential element of standard precautions (Fig. 2). Dental practitioners should wear medical gloves whenever it can be reasonably anticipated that contact with blood or other potentially infectious materials, mucous membranes, non-intact skin, potentially contaminated skin or contaminated equipment could occur. Gloves not only offer barrier protection from microorganisms, but also in accidental needlestick injuries or tears from sharp instru- ments, significantly reduce the volume of blood transferred and the associated risk of cross-contamination.2 New virus protection protocols Because the primary transmission pathways of SARS- CoV-2 include direct exposure to droplets expelled from sneezing or speaking, contact with mucous membranes or contact with virus-covered surfaces, additional safety pre- cautions have been widely adopted among dental clinics. Patient check-in Patients are now asked to reschedule visits if they are experiencing any COVID-19 symptoms, and patient flows are organised to avoid crowding at the front desk and waiting room. Pre-visit patient evaluation includes mea- suring body temperature with a non-touch thermometer and having patients complete a health status questionnaire (Fig. 3).3–5 Further precautions include installing hand sa- nitiser dispensers in waiting rooms and providing patients with face masks while attending non-treatment visits.6 industry | 4 (i.e. alcohol-based hand sanitiser, whether foam or gel) or surgical hand antisepsis.7 Gloves are not a substitute for hand hygiene. When a task requires gloves, practitioners should always perform hand hygiene prior to donning gloves and before touching the patient or patient environment.7 Invisible danger: Bioaerosols During dental procedures, airborne particles are produced by rotary and aerosol-generating instruments (Fig. 5). They can include dentine–enamel debris, a dentine smear layer, or fragments of composite, provisional cement or paste. Bioaerosols, including saliva, blood and other biological fluids, are also released into the air. High levels of bioaero- sol contamination are found on goggles and masks of dental operators and assistants. The air quality in dental clinics has been shown to become extremely polluted by aerial microbiota after the most common dental procedures. Aerosol generated by an ultrasonic device can remain suspended in the air for thirty minutes after the procedure. Microbial aerosols in the den- tal clinic can spread up to 2.5 m in diameter horizontally and 1.0 m in diameter vertically. Surprisingly, studies have shown a higher bacterial load in the bioaerosols measured 1.5 m from the oral cavity than those within 1.0 m from the patient.8 Many variables are involved in the aerodynamics of bio- aerosols. They not only can remain suspended for a long time, but are also diffused by air turbulences created by instruments and operator movements. Indoor temperature e d i . s e g a m y t t e g / n o t e S a t i n a T © Focus on hand hygiene Hand hygiene is considered the most important preventive measure to reduce the risk of transmission of microorgan- isms between dentists and patients (Fig. 4). Proper hand hygiene means thoroughly cleaning both hands using soap and water, antiseptic handwash or antiseptic hand rub 5 prevention 1 2021 33

industry | COVID-19 implications in oral and overall health Now more than ever, it is important to provide routine and preventive care to preserve oral health. Not only are neglected or postponed dental visits a risk factor for severe infections, but poor oral health shows a direct connection to SARS-CoV-2 infection and to a higher risk of severe illness in patients with COVID-19.20 Furthermore, among COVID-19 patients, pro-inflammatory cytokines and oxidative stress known to contribute to the development of periodontal disease and other metabolic diseases, such as obesity, diabetes mellitus and cardio vascular risk, are highly elevated. Recent studies show that oral manifestations are com- monly observed in about 45% of COVID-19 patients. Salivary glands, tonsils and the tongue are highly sensitive in the case of SARS-CoV-2 infection. The development of infection causes loss of taste and smell and blisters on the tongue in COVID-19 patients. Studies also show that the pathogenic microbiome found in different parts of the body, such as the oral cav- ity, lungs and gut, enhances inflammation and oxida- tive burden. Periodontal disease associated with Gram- negative bacteria can aggravate COVID-19 symptoms. Pathobionts of the oral cavity play a critical role in increas- ing the inflammatory response and cytokine storm. Many dental treatments could alter the oral environ- ment, influencing microbial, dental, mucosal and peri- odontal parameters. Risk analysis of dental procedures according to the level of infectiousness and the ap- propriate protection required accordingly is of utmost importance.21 8 Conclusion There are many ways in which dentistry will change after the COVID-19 pandemic. Experiences during the pandemic have demonstrated a need for further devel- opment of hygiene, cross-contamination infection control and disease prevention. Experience with SARS-CoV-2 has also provided significant evidence concerning the ways in which oral health status affects general health and morbidity. Dentistry is playing an increasingly vital role in modern healthcare systems. During the pandemic, many patients have opted to post- pone dental appointments or have them cancelled owing to dental clinic closures. Consequently, the daily workload for most dental clinics was substantially reduced. Now is a good time to prioritise education and training, quality as- sessment, and equipment service and maintenance. Doing so will ensure that clinics are prepared for the surge of patients returning for treatment as COVID-19 cases decline. Scan this QR code for the recommended infection prevention and control (IPC) prac- tices for routine dental healthcare delivery. New efforts prove effective Editorial note: A list of references is available from the publisher. Checklist Despite the many avenues for SARS-CoV-2 transmis- sion, recent studies show that the likelihood of dental pro- fessionals becoming infected in the dental clinic is low. A recent article describes how, at the Wuhan University stomatology hospital in China, among the 320 staff who provided treatment to 2,025 dental emergency patients since the outbreak of COVID-19, none were infected while providing dental service.22 This indicates that comprehen- sive measures such as utilising advanced PPE and envi- ronmental disinfection can prevent cross-contamination in the dental practice (Fig. 8).22, 23 Additionally, recent statistics from the US showed that less than 1% of the 2,195 dentists surveyed had con- tracted COVID-19.24 The authors concluded that the recommended additional PPE and disinfecting and social distancing precautions may be sufficient in dental prac- tices to control transmission of SARS-CoV-2.24 about Dr Mikael Zimmerman is a prominent professional in quality assurance, hygiene and infection control in dentistry. He is also a well-known international lecturer and consultant in both the dental and medical field. Dr Zimmerman works in development and education concerning cross-contamination, quality assurance and quality development in the dental field. Dr Zimmerman has been an adviser to the Swedish foreign ministry on hygiene and infection control and to the Swedish armed forces in the development of the medical care system to be used by the Nordic Battlegroup. Dr Zimmerman is a member of the subgroup for dental professionals within Strama, the Swedish strategic programme against antibiotic resistance. prevention 1 2021 35 © Ansell Ltd

trends & applications | 1 Fig. 1: The control composite (top) shows bacterial growth after 1 hour and a thick biofilm after 24 hours. The antibacterial filler (bottom) shows broken down bacteria after 1 hour and no live bacteria on the surface after 24 hours, respectively. (All images: © Nobio) that results from shrinkage on polymerisation), debond- ing, technique sensitivity and the degradation of resin by oral bacteria. As reported in a market analysis published by Grand View Research, in the US alone, 200 million cavities are treated every year, and that means about 133 million dental fillings that will fail.3 necessity at times. This is where Prof. Weiss and his com- pany Nobio come in, offering a technology that “trans- forms materials, products and surfaces to antimicrobial, with its revolutionary particles, providing strong, safe and durable bio-protection, for life”. How it works In an interview with Dental Tribune International (DTI), Prof. Weiss stressed that preventive oral healthcare is the only answer to addressing oral disease, and restorative care cannot do so; however, restorative treatment is a In essence, Nobio’s quaternary ammonium silica (QASi) particles exert concentrated electrostatic stress on bac- teria that come in direct contact with the restorative 2 Fig. 2: A detailed illustration of Nobio’s quaternary ammonium silica technology demonstrates how the material works in the oral cavity. prevention 1 2021 37

trends & applications | 3 Fig. 3: The in situ denture models show the enamel and composite slabs which were used in the University of California, San Francisco clinical trial. a clinical trial that tested the antibacterial composite in 25 patients who wore mandibular partial dentures with acrylic flanges on both sides of the mouth.7 The research- ers recessed a human enamel slab and a composite sep- arated by a tiny gap into the flanges, employing Infinix in one flange and a standard composite as a control in the other. The participants were not aware of which side of the denture contained which composite. This gap model simulated a faulty tooth–restoration interface and then exposed it to cariogenic challenge. After a four-week wearing period, samples were as- sessed in the laboratory using cross-sectional micro- hardness testing of the enamel. The UCSF researchers found that the average mineral loss for the Nobio side was significantly lower (nearly 70%) than for the control side in every patient. key opinion leaders around the world, and according to Prof. Weiss, the feedback has been very positive so far. Perhaps, it is rather paradoxical to ask Prof. Weiss where he thinks the future of dental materials is heading, since it seems that he and his team have just set a new gold stan- dard, but for him, the vision is very clear: “We want every possible material to be equipped with Nobio technology so that patients can benefit from this new generation of mate- rials that can shift the balance towards remineralisation and health.” Indeed, Prof. Weiss confirmed that the company is already working on core build-up materials used in root canal therapy. Orthodontic cements and PMMA-based resins for partial and complete dentures are next on the agenda. Editorial note: A list of references is available from the publisher. Welcome to the future about In late summer 2020, the start-up, which Prof. Weiss founded in 2015 with Dr Julia Rothman, received FDA clearance to commercially distribute Infinix. Reporting on this achievement, local online newspaper the Times of Israel concluded that the clearance “gives Nobio access to the [US] $1.4 billion dental materials market”. In his interview with DTI, Prof. Weiss said that the COVID-19 pandemic had changed the original roll-out plans for the products. Infinix was to have been made available at the end of 2020 in Israel and the US, but that was changed to spring 2021. In the meantime, free prod- uct samples have been distributed to many practising Besides his role at Nobio and many other positions during his career, Prof. Ervin Weiss has trained hundreds of students of dentistry and dental research, published over 150 research articles, and presented more than 200 lectures, abstracts and research studies at international conferences in Israel and abroad. He holds fifteen patents in the fields of dentistry and microbiology. He lives and works in Tel Aviv in Israel, where he runs a dental office specialised in oral rehabilitation together with Dr Michal Dekel-Steinkeller. prevention 1 2021 39

trends & applications | the site of the restoration, the condition of the remaining tooth structure, the depth and size of the lesion, the possi- bility to isolate, caries risk factors, economic considerations, and the physical and clinical properties of the different restorative options. The comparison table was later trans- formed into a decision tree, and after four further steps, the decision tree was finalised and approved. The decision tree was adapted into a user-friendly online educational tool that aims to facilitate identification of the most suitable restorative materials for each situation. The advice based on the experts’ consensus guides clini- cians step-by-step in identifying the appropriate restorative materials and procedures depending on the clinical situ- ation, taking into account key treatment factors such as time and cost efficiency, aesthetics, patient comfort and expectations, and preservation of tooth structure. According to Prof. Hickel, director of the Department of Operative Dentistry and Periodontology at Ludwig-Maxi- milians University of Munich, the new tool will help dentists to consider the various conditions of patients and teeth involved in dental restorations, and to make decisions on which material to use as an alternative to amalgam. “The phasing down of dental amalgam is happening in nearly all countries. In the European Union a termination may happen in the next five or eight years, but it will hap- pen eventually,” Hickel told Dental Tribune International. He said that a reduction in the use of dental amalgam was “The phasing down of dental amalgam is happening in nearly all countries” —Prof. Reinhard Hickel, Ludwig-Maximilians University of Munich happening at different speeds around the world, and that it was taking place for different reasons. He explained: “In the US, aesthetics has played a role and patients are opting for a more aesthetic restoration. In Scandinavian countries, environmental factors have been a motivating factor in the phase down—for many other countries, toxicity has also been a concern.” Hickel commented that younger clinicians will face fewer hurdles in adapting to the use of new restorative materials. “I would not describe the phase-down as being problem- atic, it will involve new techniques and education is the key. Dentists will have to learn about and gather new experience using a new generation of restorative materials,” he said. The Restorative Options Decision Tree tool can be ac- cessed at https://zingtree.com. m o c . k c o t s r e t t u h S / a e c r i O d v a D © Based on experts’ consensus, a new online educational tool helps clinicians in identifying the appropriate restorative materials and procedures. prevention 1 2021 41

sustainable dentistry | sustainable dentistry | basis of excellence. In a world where the focus seems to be primarily on technology and technique, it is important to remember the fundamental pillars of dentistry and the service provided to each patient. Sometimes the glamour or attractiveness of new developments can take us away from the fundamentals. We need innovation, we need mar- keting, and we need technological evolution, but none of these contributions will be profitable if they are not applied to sustainable, ethical, safe and quality dentistry. In other words, no icing on the cake will add value to our profession if we neglect our core business. What does sustainability in dentistry mean to you per- sonally? It means doing what I enjoy doing most in a way that is respectful not only to the environment but also to people. For me, that means taking care of the natural environment as well as the working environment of my clinic and taking care of my patients as well as my team and myself. For me, sustainable dentistry does not simply boil down to a green approach but to a whole philosophy that seeks to offer the best version of our services and ourselves over time, while also having a positive impact on everything around us. Excellence in dentistry should not only be limited to what we do within the oral cavity, nor should it be justified at any price. Excellence should also encompass everything that happens in the clinic and the impact our work has on soci- ety. Excellence must be accessible to the patient, profitable for the professional and sustainable for the environment. If it is not accessible, we cannot provide patients with our high-quality care; if it is not profitable, we will not be able to expand our service over time or continually re-invest in improvements; and if it is not sustainable, we will punish others and, in turn, ourselves with a more toxic and harm- ful world and work environment. What are the measures you have implemented in your practice that contribute to a greener future? I would like to clarify in my answer that, for me, the green aspect is just another pillar in a different way of practising dentistry. Sustainable dentistry must be more respectful to the environment as well as to people and their physical and mental well-being. In our clinic, we have implemented an entire philosophy and management model that includes several measures. In terms of the environment: use of recyclable and eco-friendly mate- rials in all possible processes; reduction of plastic as much as possible; recycling of waste; elimination of paper thanks to complete digitalisation in management and communication tools; and organisation of the agenda with a slow approach that reduces patient visits to the office and therefore reduces environmental pollution and the use of resources. And in terms of personal care: work schedules that are compatible with work–life balance; organisational charts with defined roles; individual professional development and support programmes; periodic networking and motivation sessions; thorough monitoring of patient and professional satisfaction through evaluation tools; and periodic produc- tivity, quality and profitability analyses. In my opinion, a professional who does not know how to take care of his or her practice, his or her team or him- or herself will hardly be able to take care of the environment. That is why, in our model, we pay special attention to making the change towards a greener dentistry by changing our way of working and our style of living. “[Sustainability] means doing what I enjoy doing most in a way that is respectful not only to the environment but also to people.” How would you say your colleagues are adapting to such measures? And what advice would you give a colleague who is hesitant about implementing them or to someone who is not fully convinced of the effects of climate change? I like to think that, by now, there is no one who is not con- vinced of the effects of climate change. I think it is not a question of being convinced about the problem but rather about finding the solution and our role in it. There are many who know the problem and few who know the solution. This is not a problem for a few, and therefore, the solution is not reserved for the minority. I think the main challenge lies in the fact that we, as profes- sionals, must slow down the pace of our work and lifestyle so that we can take better control of our agendas and give ourselves the opportunity to be able to perform with much greater calmness and awareness. I like to say that we live in a very fast world, so living slower will help us to take better care of everything and everyone. Each person must know that his or her contribution, no matter how small, adds up to the common mission. I am totally convinced that there is a much brighter, much more enriching and much more beneficial way of dentistry for everyone. Presently, there is no official body that governs what green dentistry really means. It is an optional step to take for dental professionals. Do you think there should be laws in this regard in order to enforce change? Any organisation or project aimed at improving dentistry should always be welcomed. However, in my personal prevention prevention 1 2021 43 43

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interview | Research suggests that staff and patient travel make up the most significant percentage of carbon dioxide emissions. Duane: Travel was central to earlier English and Scottish studies. In this study, we wanted to concentrate on the materials and processes over which we have a greater degree of control; hence we excluded travel. Borglin: In this way, we could focus on identifying other environmentally harmful processes more specific to an endodontic procedure. I have been conducting some research regarding eco-friendly dentistry, and my feeling is that sustain- ability is not a top priority for the average dental pro- fessional. Do you agree with this conclusion? And if so, what do you think are the main reasons that hold dentists back from reducing their carbon footprint? Duane: Many dentists are trying to survive financially and juggling all the additional protections needed for patients so when you mention sustainability, you can get blank looks. I think it wasn’t a priority at all say 5 years ago, but there is a growing number of dentists, especially in the younger generation which realise the importance and relevance of this area of dentistry. There are so many barriers to dentists being involved in sustainability and there are few facilitators. We need a comprehensive programme of education, an incentivisation programme; basically, sustainability needs to be normalised and embedded in everything we do. jurisdictions are considered to be of single use only, the drive towards more sustainable endodontics should firstly be aimed at reducing the number of patient visits. Single visit treatment will reduce factors such as the number of files, sterilisation costs, and patient and operator time. A second way to improve sustainability would be to limit exposure and to consider vital pulp treatment for cases exhibiting symptoms of pulpitis. “Single visit treatment will reduce factors such as the number of fi les, sterilisation costs, and patient and operator time.” The employment of minimally invasive techniques where possible reduces treatment times, cost and instrument use and, in doing so, the environmental burden. Finally, if local rules allow, and if compliance with cross-infection regulations can be ensured, instru- ments should be reused. Do you have any tips for the endodontic team on how they can reduce the environmental burden of endodontic care? Duncan: As modern root canal therapy uses a large number of instruments such as files, which in many Editorial note: The study, titled “Environmental sustain- ability in endodontics. A life cycle assessment (LCA) of a root canal treatment procedure”, was published on 1 December 2020 in BMC Oral Health. According to researchers, editors of journals need to be cognisant of sustainability in dentistry as a developing area and facilitate the publication of high-quality research. m o c . k c o t s r e t t u h S / 7 a l prevention 1 2021 47

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