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
| content editorial Healthy teeth, gingivae and beyond Magda Wojtkiewicz prevention Preventive vs reparative dentistry during COVID-19 Dr Hadal C. Kishore page 06 Dental ﬁ tness: The future concept of sustainable dentistry Prof. Ivo Krejci 03 06 08 prevention & psychology “Behavioural change is the main pillar of the future dental practice” Kasper Mussche 10 Neuro-inﬂ ammation possible link between periodontitis and depression 12 An interview with Drs Elena Figuero and Borja García-Bueno Meditative toothbrushing Dr Sushil Koirala page 24 interview 14 “A patient should attend hygiene visits as often as he or she visits the hairdresser or beautician” An interview with Dr Witold Jurczyński Getting through: Insights on treating paediatric dental patients with autism 24 An interview with Dr Mandy Ashley and Amanda Smith 20 practice management page 42 Starting an oral health revolution Victoria Wilson industry The impact of COVID-19 on dentistry Dr Mikael Zimmerman trends & applications 30 32 36 40 A new era of advanced dental restorative materials has begun Monique Mehler Moving away from amalgam: New online tool helps dentists chose suitable restorative materials Jeremy Booth sustainable dentistry Sustainable dentistry is a philosophy that offers the best version of ourselves 42 An interview with Dr Primitivo Roig Environmental sustainability in endodontics Monique Mehler about the publisher submission guidelines international imprint 46 48 50 Cover image courtesy of Nebojsa Tatomirov/Shutterstock.com 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 04 prevention 1 2021
| prevention Preventive vs reparative dentistry during COVID-19 and beyond Dr Hadal C. Kishore, India The COVID-19 pandemic has turned the world topsy- turvy, and dentistry is no exception. Many dental prac- tices have had to make major changes to their set-ups and adapt to the constantly changing scenario. Many patients were left in the lurch and some deprived of even emergency dental care during the height of the pandemic for the better part of last year. Such an unprecedented scenario has both frustrated the dental fraternity and forced it to think innovatively as to how to overcome this grim situation. Teledentistry and online consultations are an extension of this innovative process. Dentists have been compelled to use strin- gent protocols and adapt to a new normal. Many prac- tices have had to cut down on patient intake owing to these new disinfection and social distancing require- ments. Some practices succumbed, and stronger ones bounced back with new vigour. A few ofﬁces are still trying hard to limp back to normality. At this juncture, it is worth pondering the impact of all these factors on dental patients. Many patients have had to miss their routine dental check-ups. Many orthodontic patients with ﬁxed appliances have been kept waiting for their next appointment. The stress associated with the pandemic and loss of jobs has not helped patients ei- ther with respect to their oral health. A work from home culture for adults and online schooling for children has kept people for long hours at home and encouraged the habit of frequent snacking. All this, coupled with mask mouth syndrome, which includes symptoms like tooth decay, gingivitis, halitosis, angular cheilitis, has played An old English proverb says, “A stitch in time saves nine”. In a similar vein, I like to tell our patients: “Brush your teeth twice and mind the gaps, and you will be ﬁ ne.” “The doctor of the future will give no medicine but will interest his patients in the care of the human frame, in diet and in the cause and prevention of disease.” — Thomas Edison havoc with the oral health of the majority of the global population. This situation opens up a Pandora’s box of questions, the most important of them being, where do we go from here? What is that we as dentists can do to help our patients to cope better? Contemplating these questions, I could not think of a better solution than education and prevention. The paradigm shift towards immediate solutions and lucrative implant and prosthetically oriented dentistry has not helped the preventive cause either. Even though many patients might accept a prosthetically oriented treatment plan, we dentists have to reﬂect and ask ourselves whether this is what patients really need. Are patients really satisﬁed with prosthetic solutions, or do they merely accept them because they feel like they have no choice? Comparing the different aspects of preventive and re- parative dentistry from a patient’s perspective, we realise that there is really only one obvious choice and that is prevention. Education, motivation and prevention all go hand in hand and are all continuous lifelong processes. They can require a great deal of effort and yet are very rewarding. This holds true for both the dentist and the patient. 06 prevention 1 2021
| prevention Dental ﬁ tness: The future concept of sustainable dentistry Prof. Ivo Krejci, Switzerland Dental ﬁtness is a concept of modern dentistry focused on tooth preservation and aims to maintain the lifelong clin- ical health of teeth. To achieve this goal, a highly specialised personal dental coach is proposed to patients who would like to beneﬁt from this concept. restorative and periodontal treatments, and in particular tooth extraction, become the exception. This paradigm shift has been conceived of as dental ﬁtness by the author, together with Daniela Krejci-Sparr. Introduction Caries and periodontitis are among the most common chronic, incurable, multifactorial diseases in the world, and one of their peculiarities is the infection of the oral bioﬁlm with potentially cario- and periodonto-pathogenic bacteria. Since infection is unavoidable in the social context, the vast majority of the population may harbour these bacteria in the oral cavity for life. Although periodontitis is most likely and caries probably related to medical problems, neither disease, in contrast to several chronic medical conditions, leads to premature death. This may be one of the main rea- sons why caries as well as periodontitis are perceived by the population as bothersome but not threatening. The current treatment concept for combating caries and peri- odontitis is based on imperfect basic prevention and tempo- rary cope with late symptoms represented by cavitated car- ious lesions and deep periodontal pockets. This concept is complex and extremely expensive. Furthermore, it does not remedy the causes of the diseases, because a causal therapy that would lead to complete healing is currently not available. Once affected by symptoms of periodontitis and/or caries, the patient remains a lifelong nursing case, and the more se- vere the symptoms become during his life, the more complex and expensive the temporary treatments become. Finally, many teeth have to be extracted because their preservation is no longer possible for technical and/or ﬁnancial reasons. It is not difﬁcult to deduce from these statements that further research efforts in the ﬁeld of treatment of late symptoms will not solve the problem. Much more promising for the future are modern approaches that deal with the causes of caries and periodontitis in order to extirpate both pandemic diseases. They rely on the rapid development of sequencing technologies, epigenetics, big data and machine learning, to name but a few. Until that time, a paradigm shift is possible for today’s clin- ical routine, aiming to reﬁne symptom control with patients’ collaboration using modern diagnosis, personalised pre- vention and non-invasive treatment of preclinical symp- toms to such an extent that complex and cost-intensive Goal of dental ﬁ tness Dental ﬁtness aims to keep people’s teeth healthy throughout their entire lives. Within this concept, dental health is deﬁned as the absence of clinical symptoms, but allows for preclinical symptoms which must be arrested at this level. The aim is to keep the natural biological structures clinically healthy in order to avoid having to reconstruct or regenerate them. In patients who are already affected by clinical symptoms, dental ﬁtness is intended to halt or at least to slow their progression as much as possible and to prevent the occurrence of new clinical symptoms. Prerequisites for dental ﬁ tness In order to successfully implement the concept, several pre- requisites must be fulﬁlled. The most important and difﬁcult one is getting patients interested in the concept. The health- ier they feel and the younger they are, the more difﬁcult it is to persuade them of the necessity of the concept for their life- long oral health. Yet, it is precisely in this group that it makes the most sense to introduce such a concept. The second pre- requisite is a precise diagnosis, which entails the recognition of symptoms in their preclinical early stage. The third pre- requisite is the adaptation of the organisation, the ﬁnancial plan as well as the staff of the dental ofﬁce to the concept. The fourth prerequisite is the speciﬁc high-tech infrastructure and expertise necessary for putting dental ﬁtness into practice. Practical implementation of dental ﬁ tness Dental ﬁtness is based on the concept of medical ﬁtness. At the ﬁrst appointment, for which the patient should not be in the dental chair, the concept of dental ﬁtness is ex- plained and any questions are answered. In case this ap- pointment cannot be charged to the patient, it might be regarded as a marketing investment. It is crucial to convey the awareness that only the patient himself or herself can keep his or her teeth healthy and that he or she must take respon- sibility for his or her own dentition. If the patient is really inter- ested and ready to participate in the programme, several ba- sic parameters for the dental ﬁtness concept are determined at the following appointment, during which, based on a pre- cise diagnosis, the individual personal goals of dental ﬁtness 08 prevention 1 2021
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 firstname.lastname@example.org. prevention 1 2021 09
| prevention & psychology Neuro-inﬂ ammation possible link between periodontitis and depression An interview with Drs Elena Figuero and Borja García-Bueno, Spain Both severe periodontitis and depression are serious conditions with a vast array of risk factors and symptoms that affect around 700 million and 300 million people, re- spectively, worldwide. New research by scientists from Spain has looked into possible mechanisms linking de- pression and periodontitis at behavioural, microbiological and molecular levels. Their ﬁndings suggest a likely relation between the two mediated by neuro-inﬂammation caused by bacteria present in the oral cavity. In an interview with prevention, Drs Elena Figuero and Borja García‐Bueno, two of the researchers, gave some insight into their work, which could be of great signiﬁcance for many patients with depression or periodontitis. Drs Figuero and García‐Bueno, what inspired you to investigate a correlation between periodontitis and depression? Figuero: The idea arose through a collaboration between the Etiology and Therapy of Periodontal and Peri-implant Diseases and Molecular Neuropsychopharmacology re- search groups at the Complutense University of Madrid. The former group has extensive research experience on periodontal disease and its implications for other systemic diseases, such as cardiovascular disease and diabetes, adverse pregnancy outcomes and obesity (what is called periodontal medicine). The latter group has a line of re- search focused on the study of the role of the origin and consequences of neuro-inﬂammation in the molecular, cellular, behavioural and cognitive alterations observed in patients diagnosed with several major neuropsychiat- ric illnesses, including depression, and in experimental models of these complex illnesses. In particular, a possible inﬂammatory origin of depression was explored, the intestinal microbiota being the ﬁrst can- didate. Once this was demonstrated, the next step was to explore other bodily areas and conditions in which bacte- rial dysbiosis could take place, and this led to periodonti- tis. Therefore, both groups decided to create a common line of research in order to determine whether periodontitis could be a source of neuro-inﬂammation in a rat model re- sembling many pathophysiological features of depression. In your study, you analysed the possible mechanisms linking depression and periodontitis at behavioural, microbiological and molecular levels through a pre- clinical in vivo model. Can you please elaborate on what you did and what your ﬁndings were? García‐Bueno: Brieﬂy, Wistar rats were submitted to a mixed in vivo model based on the induction of perio- dontitis by oral gavage of Porphyromonas gingivalis and Fusobacterium nucleatum over 12 weeks, followed by a three-week period of chronic mild stress induction. There were three experimental groups, one with peri- odontitis and chronic mild stress, the second with periodontitis without chronic mild stress, and the third with chronic mild stress without periodontitis, and one control group (with neither periodontitis nor chronic mild stress). We ﬁrst validated the induction of periodontitis and de- pression (periodontal clinical variables, alveolar bone levels and depressive-like behaviour) and then determined mi- crobial counts and inﬂammatory mediators in brain frontal cortex, as well as other peripheral markers to explore the possible mechanisms involved in the relationship between both conditions. The principal ﬁndings were the presence of increased gingival inﬂammation, alveolar bone loss, depressive-like phenotype and inﬂammatory response in the brains of an- imals with both periodontitis and depression. Additionally, the presence of F. nucleatum in the brain was reported in this combined group. You concluded that neuro-inﬂammation induced by F. nucleatum might be the linking mechanism between periodontitis and depression. What do your ﬁndings mean for future research in this ﬁeld? Figuero: To our knowledge, this is the ﬁrst time that peri- odontopathogens have been detected in the brains of rats exposed to a combined model of periodontitis and depression, and the presence of F. nucleatum might be considered a direct origin of neuro-inﬂammation. However, the signiﬁcance and impact on depressive behaviours of a possible F. nucleatum translocation from the mouth still needs further conﬁrmation. Once we know the aetiology, we could design therapeutic strategies to block this pro- cess and its negative consequences in the structures and functions of the brain. 12 prevention 1 2021
| prevention & psychology Meditative toothbrushing A smarter way to a healthy mouth and a happy mind Dr Sushil Koirala, Nepal 1 Introduction The concept of holistic health (harmony of the mind, the body, behaviour and the environment) is well recognised and deeply rooted in Vedic culture, which has been ex- plained in the Ayurvedic literature. Contemporarily however, health practice and recognition of health-related quality of life (holistic health) began only after the World Health Orga- nization (WHO) expanded the deﬁnition of health to “a state of complete physical, mental, and social well-being and not merely the absence of disease or inﬁrmity” in 1948.1 This resulted in the paradigm shift of health and disease from a medical model to a biopsychosocial model. It is simple to understand and logical to think that any disease that can interfere with the activities of daily life may have an adverse effect on general quality of life. It is evident from the litera- ture that the notion of health-related quality of life started to emerge in the late 1960s and slowly impacted the oral health industry as well. Hence, the concept of oral health-related quality of life is a relatively new but rapidly growing phe- nomenon that has emerged over the past two decades.2 Several authors have explored the evolution of oral health- related quality of life and documented the circumstances that have led to its prominence.2–4 Oral health-related qual- ity of life describes the individual’s subjective perspective based on the presenting oral symptoms and experiences, allowing researchers to establish a relationship between oral and general health.5 Good oral hygiene results in a mouth that looks healthy, is free of odour, assists in the nutrition of the physical body, enhances social interaction, and promotes self-esteem and feelings of well-being.6 Oral health and disease are determined by a variety of factors from different organisational levels, including mo- lecular, cellular, individual and social levels, and their inter- actions.7–9 The human mouth is host to one of the most diverse microbiomes in the body,10 having a complex micro- biome consisting of bacteria, archaea, protozoa, fungi and viruses.11 These bacteria are responsible for two common diseases of the human mouth: periodontal and dental car- ies. Oral disease, including caries and periodontal disease, is among the most common diseases all over the world, affecting almost every age and geographic community.12 With over 1,000 species of bacteria being commensal res- idents in the oral cavity, the oral cavity by far contains the second most complex microﬂora in the body after the gut.13 In the oral cavity, the immune system not only has to har- 14 prevention 1 2021
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 5 focuses on preventing disease early on with an effective self- performed oral hygiene method, enforcement of regular dental check-up and a minimally invasive approach to early diagnosis of oral disease, its timely prevention and intervention with a patient-centric holistic care approach. Education and prevention Prevention is better than cure, and this can be applied in lowering the oral health disease burden in society. It has been documented that effective self-performed regu- lar oral hygiene has been identiﬁed as a key attribute in oral disease prevention.51, 52 During dental visits, the dental care team normally provides advice and instruction on oral health to patients based on the results of their clinical ex- aminations, to develop oral self-care skills for maintaining good oral hygiene.53 However, multiple studies have shown that patients’ adherence to a proper daily oral hygiene reg- imen generally remains poor,54–56 and even a large num- ber of adults clean their teeth less than the recommended number of times and duration57 and have been shown to have problems achieving oral cleanliness through self- performed oral hygiene. This demonstrates that aware- ness and cultivating self-compassion plays a major role in achieving optimal oral health. Increasing adherence to oral hygiene behaviour is regarded as essential in the preven- tion of caries and periodontal disease.58, 59 A lack of oral health awareness, self-compassion and self-regulatory skills is associated with a disinclination to change health behaviours to approach effective self-performed regular oral hygiene. Hence, we need to think of a smart approach to oral care that is healthy, reliable, simple and affordable to adopt as a daily routine in life. Scientiﬁc studies have 16 prevention 1 2021 already shown that toothbrushing is regarded as a key practice for self-performed oral care, and it depends on ef- fective behavioural change interventions that can enhance an individual’s ability to perform self-oral care as well as long-term dental habits critical for the maintenance of oral hygiene, which are the key factors for achieving good oral health.58, 60 Multiple research ﬁndings have already shown that self-care, behavioural change and diet modiﬁcation play a vital role in achieving a healthy mouth for the reduc- tion of the global burden of oral disease.61–64 Empowerment over persuasion is the key to successful oral health promotion while achieving good oral health.65 Moreover, oral health education has been considered one of the fundamentals in oral health promotion,66, 67 and a strong interaction between oral health and mental health has been well documented in the literature.68–78 With education, a child receives training and encourage- ment specially to stimulate the development of skills, for- mation of aptitude and creation of values, which lead to acting positively in relation to his or her oral health and other people’s oral health on a daily basis. The importance of oral health education programmes in schools (Fig. 4) is reported predominantly in the form of positive learning and behaviour in children.79–85 Hence, is necessary to promote new empowerment strategies to modify oral health habits based on the patient’s age, knowledge, attitudes, practices and abilities, and self-monitoring. Thus, there arises a need for inculcating healthy oral health habits as a daily life rou- tine. With this notion in mind, a unique technique has been formulated that encompasses the mind, the body and be- haviour to achieve a better quality of life by improving the oral health-related quality of life via a method as simple as toothbrushing. The meditative toothbrushing (MTB) tech- nique, as I like to call it, is a consciousness-based oral hy- giene practice and is a component of holistic healthcare. Meditative toothbrushing MTB is based on the Vedic Smile Dentistry50 concept (Fig. 5) of holistic care and focuses on the harmony of the mind, the body, behaviour and the environment (in this case, the oral ecosystem) of the person so that the person apprehends the core beneﬁts of MTB and adopts it as a health and happiness promotion habit. The MTB action emphasises the mind–body connection and combined mechanical act of toothbrushing with the simpliﬁed meditative approach in order to keep the mouth healthy and release mental stress. The fundamental aim of MTB is to be self-aware, nurture compassion and practise good oral habits as a behaviour. The concept of incorporating awareness, compassion and practice in the MTB process is brieﬂy explained below. Awareness Awareness is one of the key components of well-being. The importance of enhancing well-being and reducing
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
plaque from tooth surfaces and help to maintain the oral ecosystem. The process of cleaning by toothbrushing is a mechanical action that demands basic cleaning skills and proper tools. It is recommended that both the toothbrush (MTB recommends a toothbrush with soft and tapered bris- tles with a small head; Figs. 7a & b) and brushing motion should not harm the hard and soft tissue of the mouth and should be capable of removing food debris and dental plaque from the ﬂat tooth surfaces as well as the interdental areas effectively. MTB recommends cleaning all the interdental areas ﬁrst. Once they are cleaned properly, the mouth should be rinsed vigorously with water and then other tooth surfaces should be brushed completely. Regarding the toothbrushing motion, MTB suggests being logical and considering that the aim of brushing is to remove dental plaque from all interdental and ﬂat tooth surfaces. There- fore, vertical strokes from the gingivae towards the teeth are recommended for cleaning the interdental area and brief scrubbing in circular motion for the ﬂat surfaces. To keep a person fully aware and compassionate during the tooth cleaning process, MTB emphasises using a silent MTB mantra, “I LOVE you”, which helps to conﬁne the mind to the toothbrushing movement and reminds the brusher to clean all the interdental, lingual, occlusal and vestibular surfaces of each tooth meticulously. MTB recommends not using toothpaste or tooth gel during the cleaning step because the basic notion of this step is to focus on the mechanical cleaning effects of toothbrushing, increase the toothbrush- ing duration, stimulate the salivation mechanically, increase the visibility of tooth surfaces during brushing, and clean the tooth surfaces properly, such that they are ready to receive suitable chemical protection for its optimal effects. Protect Depending on the possibilities of exposure of the oral ecosystem to disharmony risk factors (Fig. 1), a suitable protective plan needs to be adopted. Use of ﬂuoridated toothpaste and antimicrobial mouthwash, application of ﬂuoride varnish, bioactive protective barriers for tooth sur- faces, pit and ﬁssure sealants, protective mouth guards (to protect against possible tooth damage due to mechan- ical forces), and diet modiﬁcation are a few examples of the protection approach and should be followed accord- ing to the dental professional’s recommendation. However, during self-oral care, tooth cleaning should be followed by oral massage of the teeth, gingivae and tongue using the recommended toothpaste, tooth gel, mouthwash, etc. in order to provide extra and effective bioactive protection against caries, periodontal disease and other oral diseases, as well as halitosis. For the prevention of caries, regular use of a small amount of ﬂuoridated toothpaste has been rec- ommended by multiple scientiﬁc and clinical studies.105–116 Hence, brief scrubbing and a circular toothbrush motion with a little toothpaste or tooth gel are recommended. The mouth should not immediately be rinsed after oral mas- sage with ﬂuoridated toothpaste; however, the excess toothpaste or tooth gel can be spat out properly. Regular 7a MTB: Three-step oral care The MTB protocol has simple three steps to keep the mouth clean and relax the mind, namely prepare, clean and protect (Fig. 6). Awareness of these three steps is the key to successful toothbrushing. Prepare The mind is like a monkey, and taming this monkey mind while brushing one’s teeth is the key idea of this preparation step. The monkey mind becomes calm and relaxed if we are able to instruct it with awareness and compassion by giving it some tools to employ. Before starting toothbrush- ing, the practitioner should fully be aware of the right in- struction to be given to the mind so that for the next three to four minutes the mind–body connection is achieved. MTB suggests following simple steps to tame the monkey mind: – Look into the mirror and have a quick glance into your mouth. – Check the condition of tooth surfaces by rolling your tongue all over tooth surfaces. – Be compassionate and grateful to your teeth for serving you since birth. – Give a happy smile and be ready to brush. – These simple steps help to focus the mind on the brush- ing movement and interrupt any distraction, thereby re- ducing stress and anxiety and bringing calmness within, such that the action of toothbrushing becomes enjoy- able and thus successful. Clean Various studies have shown that the main objective of tooth- brushing is to meticulously remove food debris and dental 7b 18 prevention 1 2021
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 email@example.com. prevention 1 2021 19
| interview “A patient should attend hygiene visits as often as he or she visits the hairdresser or beautician” An interview with Dr Witold Jurczyński, a periodontist from Poland By Grzegorz Rosiak, Dental Tribune Poland prevention magazine spoke with Dr Witold Jurczyński, one of the leading periodontists in Poland and a specialist in periodontal diseases and microsurgery, who explains what proper hygiene and the cooperation of the patient, hygienist and dentist should look like. He also talks about the profession of dental hygienist and about proper hy- giene not only as the key to a healthy oral cavity but also as the key to the health of the whole body. There is much discussion today about periodontal diseases. However, it can really never be too much, Dr Witold Jurczyński 20 prevention 1 2021 considering that, according to recent studies, the majority of the population still require professional hygiene procedures and suffer from periodontitis. Why is periodontitis such a dangerous disease? Periodontitis affects the periodontal tissues, including the bone surrounding the tooth, and its cause is improper hy- giene, which leads to gingivitis and the development of the disease itself. Unfortunately, as experience shows, individual hygiene is often not enough to enjoy good oral cavity health. It has been conﬁrmed that there is a correlation between periodontal and other systemic diseases. Periodontal disease can lead to endocarditis, kidney inﬂammation, diabetes, hypertension, stroke, myocardial infarction and even Alzheimer’s disease. Periodontitis should not be ignored by pregnant women, as it may cause premature birth. Prof. Jan Potempa even claims, proving it by his research, that Porphyromonas gingivalis bacteria can be related to Alzheimer’s disease and other systemic diseases. I am sure that new research and evidence for other correlations will soon appear, so I feel conﬁdent in saying that periodontitis is a social disease which de- mands a serious and responsible approach. If oral hygiene is the key, how should it be performed? A proper hygiene procedure consists of several integral components. Our efforts will bear fruit if cooperation is maintained at all stages: starting from proper diagnostics, through perfect professional hygiene (combined with treatment, if necessary), ending with obtaining the pa- tient’s full cooperation. In fact, I believe that, if one of these elements does not work, the others will not ﬁll the gap. Could you describe the procedure during a dental visit to your practice? The procedure begins with the patient’s consultation with a specialist. Having assessed the condition of the periodontium, we decide on further treatment. The role of a clinician in this process is extremely important; how- ever, a hygienist’s role also must not be underestimated. It is the hygienist who is actually the patient’s coach, and
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 A hygiene procedure consists of several stages, but the cooperation and appropriate approach of the hygienist and the dentist are the most important. The dentist can apply various treatment options, whereas the hygienist plays a more educational and instructional role. The cru- cial element of the entire process is the individual hygiene performed at home by the patient. Most patients appear- ing in our ofﬁce request training in the correct method of brushing their teeth. I am very impressed by the Guided Bioﬁlm Therapy (GBT) concept. I consider it as a response to the fact that not every patient can cope with everyday hygiene, as they do not have the appropriate tools for the so-called maintenance phase, which is different from all other hygiene protocols. First of all, you need to treat the patient very gently: do not wear the teeth down, do not use curettage and do not use high-power ultrasounds, because the patient should feel comfortable throughout the procedure. The AIRFLOW Prophylaxis Master device, along with the entire therapy related on the GBT protocol, gives very clear instructions on how to deal with the patient in the maintenance phase. 22 prevention 1 2021 The aim of this phase is not only to maintain the healthy periodontium, but also to consolidate the efforts of the entire dental team as well as those of the patient. If this phase is not implemented, surely sooner or later these efforts will be undone by the patient, causing secondary caries and recurrence of inﬂammation. If the patient has maintenance procedures performed two to three times a year, his need to undergo periodontal treatment will signiﬁcantly decrease. The recommendation that a patient should attend hy- giene visits as often as he or she visits the hairdresser or beautician seems to be a good one. The periodontal treatment is part of a maintenance programme as well as effective prevention of other oral cavity diseases, and it means seeing a professional hygienist every three to six months. Attentive, cooperative patients, who listen to the hygienist’s instructions in the ﬁrst stage and strictly follow the instructions, require less frequent visits, possibly even only once every eight months. On average, patients at- tend hygiene visits every four months, but there are also those who visit us each month. These are patients whose manual dexterity is ineffective. You are a proponent and even an ambassador of the GBT idea. You have tested it with your patients and recognise its importance. What convinces you of the value of the GBT concept? I always support concepts if their positive effects can be noticed in practice. I’m in favour of promoting solutions which work effectively and bring tangible beneﬁts. What convinces me about the GBT concept is the use of mini- mally invasive procedures that are comfortable for a patient and that, at the same time, support the important educa- tion and motivation of the patient. Patients who ﬁnd the prophylactic procedure pleasant are more likely to come to their next appointment. The AIRFLOW device has a water heating function and a NO-PAIN system, which reduces the patient’s pain signiﬁcantly. The possibility of using various types of sand and sandblasting methods works especially well in challenging cases, for example among patients with implants and prosthetic restorations. What dominant trends have you observed in world periodontics? For years, we have been focusing on the least invasive and, if possible, non-surgical methods of bioﬁlm and plaque removal in order to minimise irritation and damage to peri- odontal tissues. If surgical interventions are necessary, I am also in favour of using minimally invasive techniques, both in the case of regenerative and resection procedures, and in mucogingival surgery. There are two schools which constantly inspire me: the German school (with specialists such as: Prof. Markus Hürzeler, Prof. Hannes Wachtel, Dr Wolfgang Boltz and Dr Otto Zur) and the Italian school (Prof. Giovanni Zucchelli, Prof. Giovan Paolo Pini Prato, Dr Pierpaolo Cortellini and Prof. Maurizio Tonetti).
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 We don’t have any restriction on the time or day that parents are allowed to book an appointment, but we do highlight their special healthcare needs status in our Dentrix schedule. After the practice had been open for a couple years, we were getting so many new families with kids on the autism spectrum that we had one morn- ing with eight new severely autistic children, and that did create a slight amount of mayhem with my staff and me trying to get all of the autistic children and our other pa- tients seen in the most timely, comfortable and accom- modating manner possible. After that special morning, we created a system where records of patients with spe- cial healthcare needs requiring additional doctor time are ﬂagged with a purple colour in our patient management system. Our staff know to stagger these purple appoint- ments throughout the day so that we can continue to ﬂow with all of our appointments in a timely manner and increase the comfort level of all patients. When treating a patient with autism, what are some techniques you use to manage behavioural out- bursts, and are there any times when you cancel patients or reschedule them because of these be- haviours? What do these interventions look like in your practice, and is there ever a time when it is best not to have a caregiver present? MA: I like parents or caregivers to be present whenever possible. The only times I have parents stay out of the room when treating autistic children is when the parent has requested it. Now that my practice is several years old, we are seeing teenage autistic patients who have been coming to us from the beginning, and we have some families who use our appointments to help build conﬁdence and independence skills. The parents trust that continued positive dental visits will help foster more independence and conﬁdence in their child. 28 prevention 1 2021 Sometimes kids are just having a bad day. We try to coach parents not to stack other appointments on top of a ﬁrst dental visit, but it happens sometimes anyway. If a child is screaming and ﬁghting their parent coming in the door and we see the plasters from recent shots, we do offer to reschedule, providing the option of a different day and an appointment earlier in the morning when we have a fresh start behaviourally. Our practice referral area is within a 100-mile [160 km] radius, so we have some families that want us to just push on and complete the visit despite a deterioration in behaviour. We can pivot from a more traditional dental cleaning in a dental chair to a stand-up, cordless prophy in a starry room if parents prefer. I try to minimise the number of times we expose our children with special needs to general anaesthesia ex- periences, so we also offer immobilisation if parents are present in the room and want to proceed in that way. Do you modify your “tell, show, do” desensitising protocol for children with autism or sensory dis - orders? MA: Yes, we even have appointments on days with no provider present so that kids can essentially model their dental visit without ever having someone look in their mouths. It’s like a dry run or mock visit. These are sched- uled on days I’m out of the ofﬁce or working in the hospi- tal. The whole ofﬁce and even the parking lot is very quiet and low-key, since there are no other patients. The child is able to have the mock X-ray taken, and he or she walks around the ofﬁce ﬁnding animals hidden on the walls. We call it our “Smile Safari”. After completing the safari, the patients receive a prize, even if they only ﬁnd one animal. The Smile Safari is a way for us to standardise the experience, especially for our staff, and it helps har- monise the experience for the patients. Do you train your staff speciﬁcally on how to prepare for appointments with autistic patients and other special needs children? MA: We have an orientation, basically providing our staff with a check sheet that outlines a step-by-step plan on how to accommodate special needs kids and lead them through a Smile Safari. Our staff are trained step by step how to do everything. What items do you have in your ofﬁce that can help prevent a behavioural outburst? MA: I feel like timing is everything when it comes to preventing outbursts. 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. We also have a lot of items, like the Herman Miller spinning chair and Gaiam bounce balls, that help kids let off steam if they need to during their dental appointment.
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 Starting an oral health revolution By Victoria Wilson, UK to witness the inception of some amazing projects, and I am able to follow up with their initiators in the longer term. Some of the journeys have been incredible. My mentees have so much enthusiasm and deﬁnitely have what it takes to bring their projects to fruition. However, they are so humble and work so hard that they frequently overlook how far they have come in their jour- neys, which makes them more inspiring and more relat- able. Oral health promotion can be initiated by any regis- tered dental professional regardless of differences in their nature or skills. They could be very conﬁdent or reserved, resourceful or lacking business skills—it all boils down to having an idea which can make a difference. They must identify the need, start small and incrementally scale the project to grow in impact. The audience can grow from one person to ten, then to thousands or even millions, de- pending on the audience the project is intended to serve. Interestingly, most of my mentees expressed some res- ervations or scepticism at the beginning of the course. Their main fears were that their ideas might not be good enough or big enough, or that, if they were not taken seriously, it might somehow not warrant being called a project, if it was not of the right size and scope. Many felt that they did not have the right competencies to take their projects to the next level. In truth, it is quite the reverse. I have been blown away by everything that has been presented to me. The proj- ects are compelling. They include: trying to make school snacks healthier with a petition currently circulating to reach Parliament; raising awareness of the issue of oral health in care homes and setting up appropriate training for carers; working closely with midwives to address oral hygiene and its impact on mothers and babies; and em- powering prisoners to look after their teeth and increase their self-esteem and conﬁdence by doing so. In my last mentoring session, I felt quite moved and was overwhelmed by how these people have also grown and felt increasingly empowered. The course has, in a way, become their moment to shine. Their voices are start- ing to be heard. They feel valued. They inspire and feel inspired, supported and listened to by their peers. They not only welcome ideas and guidance from one another, they also work collaboratively on one another’s projects, and the whole interaction and buzz has been more than I could ever have hoped for. Throughout my years working as a dental therapist, and subsequently, as a result of the Smile Revolution oral health promotion courses and the ongoing mentoring I provide, I have seen many dental professionals bursting with ideas to promote oral health; however, it was appar- ent that, for some, uncertainty about where to start and lack of conﬁdence were holding them back. To me, it always felt like a lost opportunity, not only for them, pro- fessionally and personally, but also for the people who could have beneﬁted from better oral health as a result of prospective initiatives which never saw the light of day. Nearly a year ago, I started a ﬁve-week business devel- opment course to help dental professionals launch an oral health promotion venture. My vision was of instilling conﬁdence in such people so that they could discover and explore opportunities and make an impact beyond the traditional clinical setting. Each course has a co- hort of no more than four people, and at its conclusion, I mentor the participants in order to help them bring their projects to life. Thanks to Philips Oral Healthcare, which had the far- sightedness to sponsor places on the courses and to support their mentoring too, we have had the opportunity 30 prevention 1 2021
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
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
| feature Dr Primitivo Roig currently leads dentalDoctors, an organisation specialising in training related to clinical management and leadership. He is a guest lecturer at the Harvard School of Dental Medicine in Boston in the US and combines teaching with clinical practice at his own clinic. He is also the founder of Clínicas W, the ﬁrst network of dentists and dental clinics based on the Slow Dentistry method. opinion, I am not really convinced that green dentistry should be championed by a speciﬁc body. Although it would be a great contribution if it existed, I think that the change should rather be led by regulatory bodies, univer- sities and institutions already in existence. Undoubtedly, I think they are the ones who should motivate the change by regulating professional practice in order to facilitate a change that is certainly necessary and beneﬁcial. Dentistry and dental professionals should never be a problem for anyone or anything; on the contrary, we should set an example and be part of the solution. Why then do we not pay sufﬁcient attention to an aspect as important as the impact made by our profession? It is not easy, and one cannot always set an example, but trying “For some, it is not important to do more, but to do better, and that is the best motivation to continue channelling excellence towards a much more sustainable model.” to improve every day and striving to contribute increases the reward of practising dentistry. Is there anything else you can think of that I haven’t covered? We live in a fast-paced world, where multitasking, uncon- trolled speed, stress, the need to be in multiple places at once and the lack of time can be considered as some of the viruses that almost no one talks about. Slowing down the pace of work in search of a greater balance where calmness and control gain ground over stress and chaos is possibly the greatest challenge we are facing and the greatest need we have in order to achieve a more sustainable dentistry. There are many ways to refer to the model of dentistry which I call Slow Dentistry. We were global pioneers in developing a method inspired by the Slow movement and this has helped us channel excellence regarding the professional, the patient and the environment in a much more sustainable way. The Slow movement has been in motion for many years, and dentistry is, and should be, a participant in a global movement shared with such diverse industries as fashion, gastronomy, health, education, tourism and lifestyle. For some, it is not important to do more, but to do better, and that is the best motivation to continue channelling excellence towards a much more sustain- able model. 44 prevention 1 2021
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| sustainable dentistry m o c . k c o t s r e t t u h S / a k T p o P i Environmental sustainability in endodontics By Monique Mehler, Dental Tribune International Over the years, researchers have investigated the total annual carbon footprint of dental services in various countries. Now, a life cycle assessment (LCA) was con- ducted at the Faculty of Dentistry at Malmö University in Sweden in order to investigate and evaluate the environ- mental impact of a routine two-visit root canal treatment. In an interview with Dental Tribune International, the three main authors Linnea Borglin, Drs Hal Duncan and Brett Duane shared some insights into the ﬁndings. What inspired your research team to analyse the global resource use and environmental output of the endodontic procedure? Borglin: This study originated from a master’s thesis at Malmö University. Duane: Stephanie Pekarsi, our co-author, Linnea and I tried to think of three fairly resource-intensive elements of dentistry that we should study and decided on peri- odontal treatment, an examination and an endodontic procedure. This paper came from the third study. Were there any challenges you had to face during the LCA? If so, what were they? Duane: It was a challenge measuring all the elements. Also trying to ﬁnd speciﬁc energy use of equipment, for example the autoclave and the washing detergent used to wash dental clothing! Why did you decide not to include travel to and from the dental clinic in your assessment methodology? 46 prevention 1 2021
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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