Dental Faculty

Clinical Updates

Our new Rapid Clinical Updates Series is here!

Stay up to date in just 3 minutes with the latest clinical research in all aspects of dentistry.

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IMPLANTS

IMPLANTS

Cluster failure in dental implants. Real or imaginary?

Some studies indicate that implant failures are commonly concentrated in a few patients. Chrcamovic BR et al, 2017 identified and analysed dental implant failure among subjects of a retrospective study which included patients receiving at least three implants only. Patients presenting with at least three implant failures were classified as presenting with “cluster behaviour”. There were 1406 patients with 3 or more implants (8337 implants, 592 failures). 4.77% of patients presented cluster behaviour with 56.8% of all implant failures.

Clinical implication: Antidepressants and bruxism are potential negative factors exerting a statistically significant influence on the high failure rates in cluster patients. Bruxism is suggested to generate overload of prosthetic rehabilitations on implants which could possibly cause implant failure.

Practical application: The negative factors at the implant level were short implants, and poor bone quality. Medications which reduce acid gastric production (proton pump inhibitors) decrease calcium absorption.  The imbalance of calcium may to some degree affect osseointegration. There is 2.23 times more likelihood of implant failure in smokers than non-smokers. Smoking is thought to be related to its effect in osteogenesis and angiogenesis. The odds of implant failure decrease by 2.2% for every 1-year increase in the patient’s age which could be related to the lower prevalence of bruxism among the elderly in relation to younger adults.

Reference: Chrcanovic, B.R., Kisch, J., Albrektsson, T. and Wennerberg, A., 2017. Analysis of risk factors for cluster behavior of dental implant failures. Clinical implant dentistry and related research19(4), pp.632-642.

GENERAL DENTISTRY

GENERAL DENTISTRY

Sports related oral injuries examined

Participating in contact sports carries an increased risk of sustaining dental trauma with sporting accidents accounting for 10-39% of all dental injuries in children. Orthodontic treatment is most commonly carries out in adolescence, a peak time for sustaining dental injuries during sporting activities (Parker K et al, 2017). The American Dental Association have produced guidelines to which specific sports require a mouthguard. Some of the sports include acrobatics, basketball, bicycling, boxing, equestrian and extreme sports, field hockey, gymnastics, martial arts, rugby, skateboarding, shot put, skiing, skydiving, water polo, weightlifting and wrestling.

Clinical implication: An increased overjet and incompetent lips can predispose patients to an increased risk of dental trauma. Patients undergoing orthodontic treatment should wear a mouthguard while participating in contact sports. During fixed appliance orthodontic therapy, patients can use a mouth-formed mouthguard which can be moulded around the brackets and can be remoulded as teeth move. Alternatively, patients can use custom-made mouthguards which can be designed to incorporate a cut out channel for the orthodontic appliance and also allow space for tooth movement.

Practical application: When taking impressions for custom-made mouthguards, the full functional depth of the sulcus should be captured as well as the most terminal molars. Studies examining the protective capabilities of mouthguards have found the optimal thickness to be 4 mm. To increase mouthguard wear in children, it is necessary to educate parents about the necessity and the benefits of mouthguard use.

References: Parker, K., Marlow, B., Patel, N. and Gill, D.S., 2017. A review of mouthguards: effectiveness, types, characteristics and indications for use. British dental journal222(8), p.629.

American Dental Association Council on Access, Prevention and Interprofessional Relations; ADA Council on Scientific Affairs. Using mouthguards to reduce the incidence of sports-related oral injuries. J Am Dent Assoc 2006;137: 1712-1720.

PRACTICE MANAGEMENT

PRACTICE MANAGEMENT

Capacity and Consent: document carefully

Dentists must gain consent from their patients for examination and treatment. When faced with situations where patients either lack capacity or their capacity is questioned, the dental team should be aware of the legal and ethical considerations involved in assessment of capacity (Burke S et al, 2017). Capacity is decision and time specific.

Clinical implication:  Assessment of capacity is carried out in two stages:

  1. Does the patient have an impairment of or disturbance of their mind?
  2. If they do, is the person able to:
  3. Understand the information, including the risks and benefits
  4. Retain the information for long enough to make a decision
  5. Weigh up the options relation the decision
  6. Communicate their decision by verbal or non-verbal means?
  7. Retain the memory of that decision.

If the answer to any of these questions is ‘NO”, then at that time, the dentist can have reasonable belief that the patient lacks capacity for that particular decision.

Practical application: Where an adult is deemed to lack capacity for a decision, usually treatment is then provided in the best interests of the patient. Should capacity to consent be lacking and operative treatment is indicated, a discussion of treatment and modalities may be required with those close to the patient to determine the best option in the individual circumstances. Where a person is authorised to act on a patient’s behalf, a copy of the legal document pertaining to the authority should be retained in the clinical notes either directly or scanned into the online patient file.

Reference: Burke, S., Kwasnicki, A., Thompson, S., Park, T. and Macpherson, A., 2017. Consent and capacity–considerations for the dental team part 2: adults lacking capacity. Dental Update44(8), pp.762-772.

ORTHODONTICS

ORTHODONTICS

Which of your orthodontic patients are more likely to be satisfied with outcomes?

Adult patients often have complex treatment needs in addition to the predisposing malocclusion. Orthodontic treatment may be selected as part of interdisciplinary treatment for restoration or rehabilitation after tooth loss or periodontal breakdown or to prevent further deterioration caused by oral diseases. A survey of the level of satisfaction for orthodontic treatment among adult patients was conducted (Lee R et al, 2018).

Clinical implication: The main treatment goals of orthodontic treatment were considered to be improved facial appearance, eating and chewing, tooth alignment and confident smile and self-image. Patients over 50 were more satisfied with treatment than younger patients and men were more satisfied than women. The level of satisfaction for tooth alignment and confident smile and self-image were significantly higher than facial appearance and eating and chewing.

Practical application: The age group of 50 and above indicated a higher level of satisfaction in terms of treatment cost, intention to recommend and total satisfaction than younger age groups. The overall satisfaction ratio of adult orthodontic patients was 85%. Treatment satisfaction was positively related to motivation, whereas it was negatively related to discomfort caused by treatment.

Reference: Lee, R., Hwang, S., Lim, H., Cha, J.Y., Kim, K.H. and Chung, C.J., 2018. Treatment satisfaction and its influencing factors among adult orthodontic patients. American Journal of Orthodontics and Dentofacial Orthopedics153(6), pp.808-817.

DENTAL MATERIALS

DENTAL MATERIALS

Composite resin exhibits lowest failure rate in primary teeth in ideal conditions

Several restorative materials with specific indications are used for filling cavities in primary teeth. Electronic databases were searched to find longitudinal clinical studies evaluating the longevity of posterior restorations placed with different materials in primary teeth with at least one-year follow-up (Chisini LA et al,2018) and the reasons for failure.

Clinical implication: Composite resin showed the lowest annual failure rate (AFR) (1.7-12.9%) and metal-reinforced glass ionomer cement (MRGI) exhibited the highest AFR (10.0-29.9%). However, the overall success rate for composite resin was 79.3%. Stainless steel crowns (SCC) had the highest success rate (96.1%) followed by resin-modified glass ionomer (RMGI) (93.6%) and compomer (91.2%), whereas MRGI showed the lowest success rate (57.4%). Restorations placed under rubber dam showed a greater success rate (93.6%) than those placed without it (77.5%) and class I restorations failed less (7.6%) than class II (14.7%).

Practical application:  In paediatric dentistry, patient-related factors can play an important role when considering behaviour management. The high variation among materials can be due to children’s behaviour which affects the quality of the procedure as it demands a short appointment and a controlled environment. Composite resin success is highly technique sensitive. As it is sometimes impossible to properly isolate teeth to perform composite restorations, GIC and RMGI and compomer are alternatives. Secondary caries was the main reason for failure for composite or GIC in this study (36.5%). The release of fluoride by GIC did not affect the longevity of the restorations.

Reference: Chisini, L.A., Collares, K., Cademartori, M.G., de Oliveira, L.J.C., Conde, M.C.M., Demarco, F.F. and Corrêa, M.B., 2018. Restorations in primary teeth: a systematic review on survival and reasons for failures. International journal of paediatric dentistry28(2), pp.123-139.

ORAL MEDICINE

ORAL MEDICINE

Early diagnosis of oral lesions critical

The dentist has the responsibility to detect early and diagnose oral lesions. A written health history should be verified and reviewed at all appointments which should include past health history, including medications, trauma, diet, previous surgeries and habits. Many oral lesions are manifestations of systemic conditions (Gonzalez M et al, 2018).

Clinical implication:  Investigate and document:

  1. How long has the lesion been present?
  2. Has the lesion changed in size, shape or colour since detection?
  3. Is the lesion causing discomfort?
  4. Is there altered sensation of surrounding tissues or palpable lymph nodes?
  5. Are there any constitutional symptoms?

The evaluating clinician must not only see the affected area but also see the patient’s entire appearance for the appropriate diagnosis. Proper inspection and depiction of a lesion should be documented in the patient’s chart.

Practical application:  The most classical sign of oral cancer is an indurated lesion with raised asymmetric borders. Paraesthesia or neuropathies can develop as the depth of the penetration increases. The most important treatment is for the clinician to have an accurate differential diagnosis. Biopsy is then used to evaluate or confirm the diagnosis.

Reference: Gonzalez, M., Bourland, T.C. and Guerrero, C.A., 2016. Evaluation and Biopsy Technique for Oral Lesions. p.103. From: Manual of Minor Oral Surgery for the General Dentist, Second Edition. Edited by Pushkar Mehraand Richard D’Innocenzo. © 2016 John Wiley & Sons.

PROSTHODONTICS

PROSTHRODONTICS

Impact of interocclusal appliance on Sleep Bruxism

Bruxism is a repetitive muscular activity, characterised by the clenching or grinding of teeth and/or prosthesis; this condition has two distinct circadian manifestations, i.e. it occurs during sleep (sleep bruxism – SB) or while the patient is awake (awake bruxism). Rosar JV et al, 2017 evaluated the effect of interocclusal appliance use on maximal bite force, sleep quality and salivary cortisol levels in adults with SB diagnosed by polysomnography.

Clinical implication:  A diagnosis of SB was established by 3 groups of criteria:

  1. Report of sounds and nocturnal tooth grinding, at least 3 days/week, mainly reported by the room partner, either associated with or without pain and/or facial and/or cervical muscles fatigue, joint and /or dental discomfort upon wakening and fractured restorations or cusps.
  2. Presence of wear facets on enamel or dentine, polished and shiny between opposing teeth, detected during clinical examination and mandibular excursions.
  3. The electromyographic analysis of SB episodes was performed and the diagnosis was classified as positive when the index was above 2 episodes per hour of sleep; when above or equal to 4 episodes/hour, the patient was classified as having high frequency SB.

Practical application: There was a significant increase in maximal bite force on both sides (left/right) during the interocclusal therapy, less muscle pain/tiredness upon awakening, improved muscle symptomatology and improved range of mandibular movements. After one month of therapy there was a significant decrease in salivary cortisol levels which was concomitant with improved sleep quality. Sleep deprivation is thought to be a stressor and induces elevations of cortisol levels in humans. Sleep hygiene measure and behavioural techniques have been proposed to prevent SB episodes, such as avoiding electronic appliances, drinking alcohol and caffeine derivatives and relaxing techniques at night and before bedtime.

Reference: Rosar, J.V., de Souza Barbosa, T., Dias, I.O.V., Kobayashi, F.Y., Costa, Y.M., Gavião, M.B.D., Bonjardim, L.R. and Castelo, P.M., 2017. Effect of interocclusal appliance on bite force, sleep quality, salivary cortisol levels and signs and symptoms of temporomandibular dysfunction in adults with sleep bruxism. Archives of Oral Biology82, pp.62-70. and salivary cortisol levels in adults with SB diagnosed by polysomnography.

AESTHETICS

AESTHETICS

Latest protocols and technology for shade taking

Practical guidelines for colour matching enable the dentist to select a shade which will ultimately match the adjacent natural teeth. The dentist must appreciate the role of the 3 dimensional nature of colour (Goldstein R, 2018).

Clinical application: It is not advisable to use natural light for dental colour matching. Daylight is highly variable in colour temperature and intensity and tinted windows further limit tis option. A huge selection of appropriate ceiling, portable (floor and table lamps) and hand-held lights are available such as Demetron Shade Light (KerrHawe), Ritelite (AdDent), Optilume Trueshade (Optident). Upon bleaching, teeth become less chromatic, lighter and less red. VITA Bleachedguide 3D-Master should be used for monitoring whitening.

Practical application: Colour matching distance should be 25-35cm. A grey card should be observed between two colour matching trials. A digital image converted to a grey scale may be a good way to match value. Dental colour matching instruments and systems have potential advantage over visual shade matching due to their objectivity and ability to quantify differences in colour. SpectroShade Micro (MHT Optic Research) uses a digital camera connected to an LED spectrophotometer and an internal computer with storage capacity. It measures the complete tooth surface and provides a “colour map”. VITA Easyshade V is the newest-generation spectrophotometer for tooth colour matching, communication, reproduction and verification. The software VITA Assist and smartphone application VITA mobileAssist allow Bluetooth communication between surgery and laboratory and communication with patients.

Reference: Ronald E. Goldstein’s Esthetics in Dentistry, Third Edition 2018.

PERIODONTICS

PERIODONTICS

Latest on perio abscess treatment

A periodontal abscess is defined as “a localised accumulation of pus within the gingival wall of a periodontal pocket resulting in the destruction of the collagen fibre attachment and the loss of nearby alveolar bone” (Wadia R and Ide M, 2017). In a study of general practice in the UK, 6-7% of patients treated in a one-month period suffered from a periodontal abscess, which made it the third most prevalent infection demanding emergency treatment after dento-alveolar abscess and peri-corinitis. A periodontal abscess may represent disease exacerbation of existing periodontitis in the presence of complex pocket morphology, furcation involvement or a vertical defect.

Clinical implication: The most prominent sign is the presence of an ovoid elevation in the gingiva along the lateral part of the root. The abscess is usually associated with a deep periodontal pocket with bleeding and tenderness on probing. Suppuration may also occur through a fistula or through the periodontal pocket opening and may be spontaneous or following finger pressure. Increased tooth mobility and tenderness to percussion are common. The patient may report the tooth feeling of being “high” in the occlusion.

Practical application: The first phase of treatment involves control of the acute condition. If the tooth can be saved, drainage needs to be established either through the pocket or with an external incision. The periodontal pocket should be thoroughly debrided. Occlusal adjustment may help provide immediate relief. Systemic antibiotics are only required if there are clear signs of systemic involvement. As most periodontal abscesses occur in a pre-existing periodontal pocket, long-term management should be evaluated after the acute phase resolves.

Reference: Wadia, R. and Ide, M., 2017. Periodontal emergencies in general practice. Primary Dental Journal6(2), pp.46-51.

PRACTICE MANAGEMENT

PRACTICE MANAGEMENT

Does your patient really consent to treatment

Obtaining valid consent from your patients that will stand in a court of law and hold strong involves more time and thought from the prudent dentist (Bayliss CL, 2017). Three basic factors need to be present when obtaining valid consent:
1. The patient must have the capacity.
2. The decision from the patient must be voluntary.
3. The patient must be informed.

Clinical implication: Discussion(s) with the patient should include all details of the diagnosis and the likely prognosis if the condition is left untreated. Any uncertainties about the diagnosis including options for more investigations before treatment should be reviewed. All treatment options need to be clearly understood by the patient. The reason for a proposed investigation or treatment and details of procedures or therapies must be explained in non-jargon language. As well as the benefits and the chances of success for each option, any discussion of any serious or often occurring risks are vital. How and when the patient’s condition and any side effects will be monitored or reassessed requires clear explanation.

Practical application: A generic tick box form does not constitute consent in a court of law just because the patient has signed on the dotted line. When a consent form is used, and the patient does not understand the information that he/she has signed against, the consent is not valid. Allow adequate “thinking time” for patients so that they can consider all options before making a decision. Re-confirm the consent to ensure the patient is happy to proceed. Supplement verbal discussion with clear written information.

Reference: Bayliss, C.L., 2017. Informed consent: what’s new? Dental Update, 44(2), pp.109-113.

PERIODONTICS

PERIODONTICS

Ideal treatment for necrotising periodontal diseases

Necrotising periodontal diseases are considered the most severe inflammatory lesions associated with oral biofilm. These include necrotising gingivitis (NG) and necrotizing periodontitis (NP). It has been suggested that these conditions may be different stages of the same disease.

Clinical implication: The mandibular anterior teeth are most commonly affected. NG will be associated with necrosis and ulcers in the free gingiva. These lesions usually start in the interdental papilla and typically have a “punched out” appearance. The severity of the pain experienced by the patient is dependent on the severity and extension of the lesions. The bouts of pain usually increase with eating and oral hygiene practices. Both NG and NP may be associated with untreated HIV/AIDS or other diseases and drugs that may, directly or indirectly, have an immuno-suppressant effect.

Practical application:
Superficial debridement to remove soft and mineralised deposits should be carefully performed. Ultrasonic instrumentation is advised to ensure minimum pressure over the ulcerated soft tissue. The debridement may be performed daily, getting deeper as the patient’s tolerance improves, lasting for as long as the acute phase lasts (usually 2-4 days). Use of chlorhexidine 0.2% daily is recommended. Systemic microbials should be implemented such as Metronidazole 400mg three times a day for five days.

Reference: Wadia, R. and Ide, M., 2017. Periodontal emergencies in general practice. Primary dental journal, 6(2), pp.46-51.

GENERAL PRACTICE

GENERAL PRACTICE 1

Best LA technique for mandibular molars!

Achieving profound anaesthesia is a great challenge in mandibular molars particularly in teeth with symptomatic irreversible pulpitis. Saatchi M et al, 2018 evaluated the anesthetic efficacy of the Gow Gates nerve block (GGNB), the inferior alveolar nerve block (IANB) and their combination for mandibular molars in 150 patients diagnosed with symptomatic irreversible pulpitis. The patients randomly received 2 GGNB injections, 2 IANB injections or 1 GGNB injection plus 1 IANB injection of 1.8ml 2% lidocaine with 1:80,00 epinephrine. Access cavity preparation was initiated 15 minutes after injections. Lip numbness was a requisite for all of the patients.

Clinical implication: The success rates of anaesthesia were 40% for GGNB, 44% for IANB and 70% for GGNB and IANB groups respectively. There was no statistically significant difference in the success rate of anesthesia between GGNB and IANB.
The deposition of local anaesthetic solution at 2 different sites along the nerve trunk blocks transmission of pain impulses better than deposition of local anaesthetic solution at 1 site.

Practical application: A combination of GGNB and IANB could improve the efficacy of anaesthesia in mandibular molars with symptomatic irreversible pulpitis but supplemental injections such as intraligamentary, intraosseous or intrapulpal injections may still be needed.

Reference: Saatchi, M., Shafiee, M., Khademi, A. and Memarzadeh, B., 2018. Anesthetic Efficacy of Gow-Gates Nerve Block, Inferior Alveolar Nerve Block, and Their Combination in Mandibular Molars with Symptomatic Irreversible Pulpitis: A Prospective, Randomized Clinical Trial. Journal of endodontics, 44(3), pp.384-388.

ORTHODONTICS

ORTHODONTICS

Bullying from dento-facial issues: a real problem

Social media can provide new and valuable information about the causes and social issues associated with oral health-related bullying. Specific coping mechanisms may minimise the negative effects of bullying. Chan A et al, 2018 investigated the relationship between dentofacial features/orthodontic treatment and bullying by analysing the personal account of victims on Twitter.

Clinical implication: Significant deviations in dentofacial features often attracts teasing with the most common features being missing teeth, shape and colour of teeth and prominent maxillary anterior teeth. In addition to their pre-existing malocclusions, victims were often bullied for other personal traits or attributes.
Bullied individuals reported a diverse range of psychological impacts and coping mechanisms. Family members were found to play both a contributory and mediatory role in bullying.

Practical application: The psychological and psychosocial impacts or oral health-related bullying can be profound. Clinicians should be aware that treatment seeking may be triggered by an underlying emotional stress in the form of bullying. It is important for the clinician to collect patient narratives, determine the motivating factors for seeking treatment and establish patient’s aesthetic expectations at the onset of care and commitment to compliance. Patients who report some bullying experiences need to be made aware that orthodontic treatment can either attract further bullying or may result in its cessation following starting treatment.

Reference: Chan, A., Antoun, J.S., Morgaine, K.C. and Farella, M., 2017. Accounts of bullying on Twitter in relation to dentofacial features and orthodontic treatment. Journal of oral rehabilitation, 44(4), pp.244-250.

IMPLANTS

IMPLANTS

Survival rates of implants in patients with head and neck cancer

The number of patients with head and neck cancer who have undergone oral rehabilitation with implant-supported prostheses has increased over the last decade. Dental implant restorations in irradiated patients may be influenced not only by local factors but also by systemic factors such as osteoporosis and diabetes. Curi MM et al, 2018 analysed the long-term success and factors potentially influencing the success of implants placed in patients with head and neck cancer who underwent radiation therapy with a minimum total dose of 50Gy from 1995-2010. The mean follow-up after implant installation was 7.4 years. In this study, the time interval between the end of radiotherapy and dental implant surgery was 23.7 months.

Clinical implication: The overall 5-year survival rate for all implants was 92.9%. Sex and the mode of radiation therapy deliver had a statistically significant influence on implant survival. The 5-year success rates were 98.9% for male patients and 81.6% for female patients. Patients treated with conventional conformal radiotherapy presented with a significantly lower probability of implant success than those treated in intensity modulated radiation therapy (IMRT).

Practical application: In irradiated patients, a healthy periodontal condition is often jeopardised by the generalized atrophy of the oral mucosa and significant decrease in the amount of keratinised gingiva around the implants. These altered oral conditions may make patients more susceptible to developing soft tissue reactions and peri-implantitis.

Reference: Curi, M.M., Condezo, A.F.B., Ribeiro, K. and Cardoso, C.L., 2018. Long-term success of dental implants in patients with head and neck cancer after radiation therapy. International journal of oral and maxillofacial surgery, 47(6), pp.783-788.

ORAL MEDICINE

ORAL MEDICINE

Use of antidepressants in dentistry

The utilisation of drugs in dentistry typically involves the evaluation of medications such as opioids, anxiolytics and sedatives. Lino, P.A., et al 2017 reviewed scientific evidence of the efficacy of the use of antidepressants to control chronic or acute pain in dentistry.

Clinical implication: Selective serotonin re-uptake inhibitors (paroxetine and sertraline) are equally effective equally well-tolerated for short-term treatment of burning mouth syndrome. Patients who are diagnosed with atypical facial pain responded well to Dosulepin (dothiepin) a tricyclic anti-depressant. Amitryptyline another tricyclic anti-depressant is effective for the treatment of chronic orofacial pain. Some head and neck cancer patients with radiation-induced mucositis pain may experience enough pain control on tricyclic anti-depressants alone (42% of patients).

Practical application: Amitryptyline can be used as a supportive treatment for chronic pain due to TMJ disorders. 25mg/day of the drug has been shown to significantly reduce pain and discomfort without producing any adverse effects.
Moghadamnia AA et al, 2009 evaluated the use of amitriptyline gel in resistant dental pain (periapical pain in cases in which the local anaesthetic alone does not produce a sufficient level of pain control) and found this product may be effective as a complementary therapeutic agent to local anaesthetics for the treatment of pain related to irreversible pulpitis.

References: Lino, P.A., Martins, C.C., Miranda, G.F.P.C., de Souza e Silva, M.E. and de Abreu, M.H.N.G., 2018. Use of antidepressants in dentistry: A systematic review. Oral diseases, 24(7), pp.1168-1184.

Moghadamnia, A.A., Partovi, M., Mohammadianfar, I., Madani, Z., Zabihi, E., Hamidi, M.R. and Baradaran, M., 2009. Evaluation of the effect of locally administered amitriptyline gel as adjunct to local anesthetics in irreversible pulpitis pain. Indian Journal of Dental Research, 20(1), p.3.

PROSTHODONTICS
PROSTHODONTICS

Risk factors and Sleep Bruxism

“Sleep bruxism is a rhythmic activation of masticatory muscles characterised by grinding and/or clenching of the teeth and/or bracing or thrusting of the mandible during sleep (Castroflorio T et al, 2017)”. Castroflorio T et al, systematically reviewed the literature to assess the relationship between risk factors and sleep bruxism (SB) in adults ≥ 18 years.

Clinical implication: Bruxism can seriously affect life quality through dental and orofacial problems such as tooth wear, masticatory muscle tenderness and pain, headache and temporomandibular disorders. Diagnosis of “definite SB should be based on self-report, clinical examination, and polysomnographic recording, preferably along with audio/video recordings.

Practical application: There is a strong association between SB, GERD and history of SB during childhood. Clinicians should be aware that patients presenting with those clinical signs and symptoms are potentially, actual SB patients. A genetic predisposition might explain the onset of SB in childhood and its probable lifelong persistency. Psychological and behavioural factors and alcohol consumption showed moderate association with SB. Smokers more than alcoholic drinkers seem to be more predisposed to SB. The association of SB and sleep disturbances appear to be stronger for snoring than for any other sleep disorder.

Reference: Castroflorio, T., Bargellini, A., Rossini, G., Cugliari, G. and Deregibus, A., 2017. Sleep bruxism and related risk factors in adults: a systematic literature review. Archives of oral biology, 83, pp.25-32.

AESTHETICS
AESTHETICS

Understanding visual tension in aesthetics

Clinicians and dental technicians may underestimate what is deemed aesthetic by laypersons and dental professionals. Magne P et al, 2018 defined the relative importance of symmetry, visual tension and balance in the smile. Images of a Caucasian women were altered to reproduce symmetry, various visual tensions, distinct tooth shapes and colour changes. A 12-queston survey was presented to 128 individuals, including 81 dental professionals and 47 laypersons. The survey asked individuals to choose the most desirable and beautiful images in a choice of images.

Clinical implication: “White spot” visual tension appeared more of a problem when found on canines rather than laterals. The focus in the smile goes first to central incisors and then canines and the lateral incisors seem to have less visual weight. A rotated right canine was preferred by both groups over the rotated left canine. Square-shaped teeth were preferred over ovoid and triangular ones.

Practical application: Lateral incisors appear to be the teeth with more natural variations in shape and position when compared with central incisors and canines.
Symmetrical smiles were largely preferred by both laypersons and dental professionals. Facial asymmetry attractiveness demonstrates our uniqueness or charm. Visual tension was more problematic when located on the right side of the viewer (left side of the patient). Both professionals and laypersons preferred tooth colour to be brighter than the colour of the eye sclera. As visual perception is a key element for the dental professional, a very good approach to develop adequate visual perception is to draw. Drawing requires perceptual skills (edges, spaces, relationship, light and shadows) which are all significant for the dental professional (Edwards B, 2012).

References: Magne, P., Salem, P. and Magne, M., 2018. Influence of symmetry and balance on visual perception of a white female smile. The Journal of prosthetic dentistry, 120(4), pp.573-582.

Edwards, B., 2012. Drawing on the right side of the brain: The definitive. Penguin.

MATERIAL

MATERIAL 1

Nonrestorative treatments for carious lesions: when and where

An expert panel conducted a systematic review and proposed evidence-based clinical recommendation for the arrest or reversal of noncavitated and cavitated dental caries using non-restorative treatments in children and adults (Slayton RL et al, 2018).

Clinical implication: Of the most effective interventions, the panel recommended 38% silver diamine fluoride (SDF), sealants, 5% sodium fluoride varnish, 1.23% acidulated phosphate gel and 5,000 ppm fluoride (1.1% sodium fluoride) toothpaste or gel. The committee provided against the use of 10% casein phosphopeptide-amorphous calcium phosphate.

Practical application:

  1. To arrest or reverse non-cavitated carious lesions in both primary and permanent teeth clinicians prioritise the use of :
    a.   Sealants plus 5% NaF varnish on occlusal surfaces
    b.   5% NaF varnish on approximal surfaces
    c. 1.23% APF gel or 5% NaF varnish alone on buccal or lingual surfaces
  2. To arrest or reverse non-cavitated and cavitated lesions on root surfaces of permanent teeth the use of 1.1% NaF toothpaste or gel is advised.
  3. To arrest advanced cavitated carious lesions on coronal surfaces of primary and permanent teeth, clinicians should use 38% SDF biannually.

Reference: Slayton, R.L., Urquhart, O., Araujo, M.W., Fontana, M., Guzmán-Armstrong, S., Nascimento, M.M., Nový, B.B., Tinanoff, N., Weyant, R.J., Wolff, M.S. and Young, D.A., 2018. Evidence-based clinical practice guideline on nonrestorative treatments for carious lesions: a report from the American Dental Association. The Journal of the American Dental Association, 149(10), pp.837-849.

PRACTICE MANAGEMENT

PRACTICE MANAGEMENT

Patient burnout: a very real problem in every day practice

“Complex dental care will often involve a long series of regular, possibly stressful appointments over an elongated time interval. More complex treatment options, high and often unrealistic patient expectations coupled with a focus on treatment instead of care can contribute to the possible development of an emotionally exhausted patient. Patient burnout is an entity in its own right” (Bain C and Jerome L, 2018).

Clinical implication: Four patient groups are particularly vulnerable to burnout:
1.Patients with limited experience of complex and advanced dental care.
2.Patients who mainly focus in on a specific end result (often of a cosmetic nature).
3.Patients whose circumstances alter during a long treatment plan.
4.Patients who require extensive retreatment as previous complex dental treatment is failing.

Practical application: In order to minimise patient burnout the following suggestions are recommended:
1.Avoid inaccurate communications re time frame , risks as well as benefits, costs and different treatment options.
2. Put all communications in writing in clear non-dental jargon which is easy to understand.
3. Keep talking throughout treatment. At each visit, remind the patient what is planned and get consent.
4. Undersell and overdeliver.
5. Follow the KISS rule – “Keep it simple stupid.”
6. Show empathy and listen to the patient.

Reference: Bain, C. and Jerome, L., 2018. Patient and Dentist Burnout-A Two-Way Relationship. Dental Update, 45(1), pp.22-31.

ORAL MEDICINE

ORAL MEDICINE 1

Bisphosphonates must be taken correctly

Bisphosphonates are used to manage a number of conditions including treatment and prevention of osteoporosis, bone metastases, multiple myeloma and Paget’s disease of bone. Oral alendronic acid, the most commonly prescribed bisphosphonate to treat and prevent osteoporosis acts to reduce bone resorption by inhibiting osteoclasts.

Clinical implication: Well recognized adverse effects of bisphosphonates include osteonecrosis of the jaw and external auditory meatus and atypical femoral fractures. Oral ulceration is caused by alendronic acid when it is left in contact with oral mucosa for a prolonged period of time (Finn D et al, 2018).

Practical application: Alendronic acid should be swallowed whole upon arising for the day with a full glass of water (not less than 200 ml). Health and social workers should be made aware of how to administer alendronic acid correctly. They should also be aware of patients who are more at risk of “pouching” medication such as mentally compromised patient with either dementia, learning disabilities or those with neuromuscular conditions.

Reference: Finn, D., Field, A., Rajlawat, B. and Randall, C., 2018. Oral Mucosal Ulceration Induced by Alendronic Acid: A Case Series. Dental Update, 45(1), pp.38-42.

PERIODONTICS

PERIODONTICS

Periodontitis and systemic disease

The 2017 World Workshop have interpreted available literature and found that there is sufficient evidence to consider necrotising periodontitis as a separate disease entity. Periodontitis is considered as a direct manifestation of systemic disease. “The primary diagnosis should be the systemic disease according to the International Statistical Classification of Disease”. There is currently insufficient evidence to consider aggressive and chronic periodontitis as two pathologically distinct diseases (Tonetti MS et al, 2018).

Clinical implication: Necrotising periodontitis is characterised by a history of pain, ulceration of the gingival margin and/or fibrin deposits at sites with characteristically decapitated gingival papillae and in some cases, exposure of marginal bone.
Periodontitis is characterised by microbially-associated host-mediated inflammation that results in loss of attachment.

Practical application: A patient is a periodontitis case in the context of clinical care if:
a. Interdental CAL is detectable at ≥ 2 non-adjacent teeth OR
b. Buccal or oral CAL ≥ 3 mm with pocketing >3 mm is detectable at ≥ 2 teeth and the observed CAL cannot be ascribed to non-periodontal causes such as:
1. Gingival recession of traumatic origin
2. Dental caries extending to the cervical area of the tooth
3. Presence of CAL on the distal aspect of a second molar
4. Endodontic lesion draining through the marginal periodontium
5. Occurrence of a vertical root fracture

Reference: Tonetti, M.S., Greenwell, H. and Kornman, K.S., 2018. Staging and grading of periodontitis: Framework and proposal of a new classification and case definition. Journal of periodontology, 89, pp.S159-S172.

GENERAL PRACTICE

GENERAL PRACTICE

Diabetes and Periodontitis: a strong connection

Diabetes is a chronic disease which has significant effects on the immune system and increases inflammatory responses (Yeung V and Chandan J, 2018). Type I diabetes is characterised by deficient insulin production in the body. The degree of insulin resistance varies in Type 2 diabetes depending upon disease progression.

Clinical implication: Type II diabetic patients have shown an increased prevalence of active caries and root surface caries compared with non-diabetics. This may be attributed to reduced salivary flow reported in diabetes patients from the disturbed glycaemic control. Periodontal disease in diabetics is significantly greater in severity.
If oral surgery is planned, it is advisable to have HbA1c levels tested prior to surgical treatment. HbA1c levels can be used to measure long-term glycaemic control.
Oral candidiasis may be prevalent in patients with higher levels of HbA1c.  There is an increased risk of candidiasis when mucosal coverage is incorporated into design of prostheses.

Practical application: Elevated blood glucose levels may be associated with the formation of periodontal abscesses. A similar response to non-surgical periodontal therapy is seen in diabetes patients with good glycaemic control as in non-diabetes healthy control patients. Females with well-established diabetes have more periapical lesion associations with root-treated teeth than short-duration diabetic and non-diabetic women. Whilst the European Society of Endodontology consider a periapical lesion persistent four years after endodontic treatment as post-treatment disease, reconsideration of the time period of four years may be prudent in diabetic patients. Poor glycaemic control increases risk of peri-implantitis and is associated with reduced osseointegration.

Reference: Yeung, V. and Chandan, J., 2018. The impact of diabetes on treatment in general dental practice. Dental Update, 45(2), pp.120-128.

AESTHETICS

AESTHETICS

E-cigs and colour variations

The use of electronic cigarettes (ECIGs) has recently increased as an alternative to conventional smoking products. ECIGs heat a liquid (e-liquid) using an atomiser. When the ECIG is activated, the vapors condense into an aerosol inhaled by the smoker and thus “vaping” generates fewer chemical compounds than cigarette smoking as no combustion is involved. Pintado‐Palomino K et al, 2018 studied bovine enamel specimens with aerosols treated with different e-liquid flavours (neutral, menthol and tobacco) and nicotine content (0, 12, and 18 mg). The initial colour assessment was performed using a spectrophotometer.

Clinical implication: Luminosity was reduced by aerosols with almost all levels of nicotine content and neutral and menthol flavours. It is the tar and ash from cigarettes that stain the teeth. Vapes do not contain this.

Practical application: Electronic cigarettes can cause perceptible changes in tooth colour. However, the nicotine contained in e-cigarettes can still give the teeth a yellow tinge. Menthol and tobacco e-liquids may alter the enamel colour decreasing the yellowness of enamel compared to neutral-liquid.

Reference: Pintado‐Palomino, K., de Almeida, C.V.V.B., Oliveira‐Santos, C., Pires‐de‐Souza, F.P. and Tirapelli, C., The effect of electronic cigarettes on dental enamel color. Journal of Esthetic and Restorative Dentistry.

IMPLANTS

IMPLANTS

Inflammatory response varies with restorative material

Sanz‐Sánchez I et al, 2018 evaluated the evidence on the effect of the abutment material on the stability and health of the peri-implant hard tissues.  Cases with at least 6 months of follow-up were included and meta-analyses were done to compare abutment materials vs titanium. The impact of various abutment materials on bone changes, probing depths, plaque level and peri-implant mucosal inflammation were studied.

Clinical implication: When changes in the marginal bone loss were assessed over time, there was no significant difference between the different abutment materials when compared with titanium. Titanium abutments showed higher inflammatory responses through increased BOP values over time when compared with zirconia abutments. Use of a spectrophotometer indicated significant benefits when using ceramic abutments mainly on the colour appearance of the peri-implant soft tissues.

Practical application: The mean onset of peri-implantitis occurs within 3 years of function. A threshold of 1.5-2 mm of bone loss defines a peri-implantitis case.
The risk of abutment fracture is related to the thickness of the material and ultimately to the position and angulation of the implant with the respect to the final restoration. Metal interfaces within ceramic abutments reduce complications. There was significant bone loss over time for all the materials except titanium nitride.
The peri-implant mucosal thickness is of importance to render pleasing results as the abutment material evokes minimal colour changes in thicker tissues (more than 3 mm).

Reference: Sanz‐Sánchez, I., Sanz‐Martín, I., Carrillo de Albornoz, A., Figuero, E. and Sanz, M., 2018. Biological effect of the abutment material on the stability of peri‐implant marginal bone levels: A systematic review and meta‐analysis. Clinical oral implants research.

ORTHODONTICS

ORTHODONTICS

Dealing with trauma to anterior dentition with orthodontics

Due to their prominence and arch position, anterior teeth are the teeth most commonly involved in dental trauma. Traumatic incisal intrusion accounts for 0.3-1.9% of traumas affecting the permanent dentition. Carty O et al, 2018 have provided guidelines for the orthodontic extrusion of maxillary incisors following intrusive luxation in the mixed dentition.

Clinical implication: Common clinical findings when examining an intrusive luxation include short clinical crown height relative to adjacent teeth, immobility, high metallic (ankylotic) sound, bleeding at the gingival margin and negative pulp testing. Use a paralleling technique with the images of two radiographs to examine traumatised teeth. This increases the ability to diagnose root or alveolar fractures. Radiographically, an intruded tooth is likely to show a loss, or partial loss, of the periodontal ligament space. The CEJ will be located apically relative to neighbouring teeth and may even be apical to the marginal bone level.
All teeth with closed apices, regardless of the severity of the intrusion and all teeth with open apices that suffer severe intrusions lose vitality.  Orthodontic methods of extrusion employ either the use of fixed or removable appliances. Due to the increased likelihood of pulpal necrosis, low forces should be selected and vitality monitored until the end of retention period if endodontic treatment is not completed.

Practical application: An immature root with < 7 mm intrusion will either lead to spontaneous repositioning or if no movement in 2-4 weeks, do orthodontic repositioning.
An immature root with  > 7 mm intrusion will need either surgical repositioning or orthodontic repositioning.
A mature root with < 3 mm intrusion will either lead to lead to spontaneous repositioning or if no movement in 2-4 weeks, do orthodontic repositioning.
A mature root with 3-7 mm intrusion will need surgical repositioning or orthodontic repositioning.
A mature root with > 7 mm intrusion will need surgical repositioning and endodontics.

Reference: Carty, O., Hennessy, J. and Al-Awadhi, E.A., 2018. A guide to the orthodontic extrusion of traumatized permanent incisors in the mixed dentition. Dental Update, 45(5), pp.427-433.

MATERIALS

MATERIALS

Latest concepts on pulp capping materials

Exposure of the dental pulp may happen owing to external stimuli, such as caries removal (carious exposure), preparation of a cavity without caries (mechanical exposure) and accidental injuries of the dental coronal part (traumatic pulp exposure). The type of exposure can be a predictor of successful direct pulp capping. Age and capping material can have significant effects on the survival rate after vital treatment of exposed carious pulp. Didilescu AC et al, 2018 compared the effects of various pulp-capping materials – mineral trioxide aggregate (MTA), calcium hydroxide (CH) and bonding agents on hard-tissue barrier formation using histologic assessments.

Clinical implication: Biodentine, which is based on calcium silicate has similar properties to CH and MTA with positive effects on pulp cells that promote reparative tertiary dentine formation. MTA stimulates dentine bridge formation in exposed pulps and this may be due to a combination of its sealing ability, biocompatibility and alkalinity. Use of bonding materials as pulp capping agents does not result in hard-tissue barriers.

Practical application: MTA has better effects than CH regarding dental pulp protection in the capping of mechanical pulp exposures. Bonding agents are inferior to CH.

Reference: Didilescu, A.C., Cristache, C.M., Andrei, M., Voicu, G. and Perlea, P., 2018. The effect of dental pulp-capping materials on hard-tissue barrier formation: A systematic review and meta-analysis. The Journal of the American Dental Association.

PROSTHODONTICS

PROSTHODONTICS 1

Dahl appliance protocol reviewed for tooth wear

Tooth wear (TW) also known as tooth surface loss is increasing in incidence in young patients. The causes of toothwear are multifactorial. TW has been termed pathological when extensive areas of dentine are exposed. Achieving space for the restoration of worn anterior teeth is critical. Dahl introduced a concept to create space to restore worn anterior teeth where such space was absent. Originally, the technique involved using a removable appliance on the palatal aspects of anterior teeth affected by TW to later versions of CoCr appliances cemented to the teeth to now using either freehand build-up of resin composite or a clear preformed vacuum-formed matrix obtained from a diagnostic wax-up. Recent systematic review of composite used in wear cases, suggesting survival rates of over 90% at 2.5 years and that increasing the OVD resulted in posterior occlusion re-establishment within 18 months for 91% of patients (Coulter J and McCracken G, 2018).

Clinical implication: Patients should be advised of various events when using the Dahl approach. Anterior teeth will receive adhesive resin composite to cover exposed dentine and prevent them from further wear. Chewing on back teeth will not occur for 3-6 months until the back teeth eventually erupt. Chewing will be resumed in 3-6 months. Lisping may be experienced as a result of the change of shape of the upper anterior teeth. Anterior teeth may be tender to bite on for a few days. If there are crowns or bridges posteriorly, then these restorations will probably require replacement. Use etch and rinse systems when the retention of the restoration is mainly achieved by the bond to dentine.

Practical application: When planning and managing tooth wear, particularly when attempting the Dahl approach consider the importance of underlying skeletal pattern in patients who then adapt to an anterior postural position to occlude in maximum intercuspidation.  The Dahl approach is not without difficulties and can be particularly challenging in cases of Class II skeletal classifications. Use a deprogramming device to assist in defining centric relation (CR) and allow the condyle position to translate distally towards CR rather than rotating alone.

Reference: Coulter, J. and McCracken, G., 2018. Complications in managing tooth wear; exploring a potential pitfall of using the Dahl approach–a case study. Dental Update, 45(4),

PEDODONTICS

PEDODONTICS

Alternative approach with stainless steel crowns

Stainless steel crowns (SSCs) have been advised to restore multiple surface carious lesions, generalised/local developmental enamel/dentine defects after pulp treatment or to restore carious lesions in children with high caries risk independent of the number of surfaces (Santamaria RM et al, 2018).

Clinical implication: Conventionally, complete caries removal and tooth trimming was deemed necessary before fitting a SCC usually requiring local anaesthesia. The use of SSCs for treatment of carious primary teeth or following pulp treatment may reduce the long-term failure risk compared to fillings. The Hall Technique (HT) is a less invasive biological approach using SCCs (without caries removal or tooth preparation) to restore carious teeth. The lesion is sealed under a SSC using GIC. The HT can be used to treat young patients with limited attention spans.

Practical application: The HT is indicated for management of asymptomatic dentine carious primary molars without pulp involvement. If there is evidence of pain or other signs or symptoms of irreversible pulpitis, these teeth are unsuitable for the HT and require conventional treatment with pulp therapy or exodontia. After crown cementation the occlusal vertical dimension equilibrates after a few weeks. The primary dentition can adjust to a slightly open bite caused by the HT.

Reference: Santamaría, R.M., Pawlowitz, L., Schmoeckel, J., Alkilzy, M. and Splieth, C.H., 2018. Use of stainless steel crowns to restore primary molars in Germany: Questionnaire‐based cross‐sectional analysis. International journal of paediatric dentistry.

ORTHODONTICS

ORTHODONTICS

Congenitally missing upper laterals: open or close?

The best treatment alternatives for patients with maxillary lateral incisor agenesis were compared. The options presented were orthodontic space closure by canine substitution, implant-supported or tooth-supported prostheses and tooth transplantation (Silveira GS, de Almeida NV et al, 2016).

Clinical implication: Maxillary lateral incisor agenesis is a common developmental anomaly with an incidence ranging from 1.55-1.78%. When evaluating the options, one must consider the patient’s age, facial profile, lip line, canine morphology, condition of adjacent teeth, amount of crowding and patient preferences.

Practical application: Orthodontic space closure by canine substitution involves less cost and time, avoids tooth extraction in the case of severe crowding and can be done before the patient is fully grown. Aesthetic treatment is needed to modify the morphology of both canines to mimic lateral incisors and the first premolars to imitate the mesialised canines.

Opening the space for an implant-supported prosthesis is another common option. The survival rate is around 90% at 10 years.  This option can pose long-term aesthetic challenges, including progressive infraocclusion of the prosthetic crown as a result of continuous eruption of the adjacent teeth.

Autotransplantation of premolars before complete root formation into the missing maxillary lateral incisors’ spaces has a long-term survival and success rates of 90% and 79% respectively and is indicated in cases of multiple agenesis and performed in growing patients.

Reference: Silveira, G.S., de Almeida, N.V., Pereira, D.M.T., Mattos, C.T. and Mucha, J.N., 2016. Prosthetic replacement vs space closure for maxillary lateral incisor agenesis: A systematic review. American Journal of Orthodontics and Dentofacial Orthopedics, 150(2), pp.228-237.

PRACTICE MANAGEMENT

PRACTICE MANAGEMENT

Speak up! I can’t hear you!

The American Dental Association (ADA) Council on Dental Practice’s Dental Wellness Advisory Committee with the ADA Health Policy Institute conducted a survey to study the well-being of dentists. One of the topics covered was the possible effect occupational noise had on hearing.

Clinical implication: About 32% of dentists indicated hearing problems (HP). Dentists over 40 and men were more likely (41%) to report HP than other gender and age groups. Most (63%) of dentists had not sought the services of an audiologist. Occupational hearing loss is one of the most common work-related illnesses in the US. Over 30 million people are exposed to chemicals some of which are harmful to the ear and hazardous to hearing.

Practical application: To reduce the risk of developing noise-related HP, dentists should implement preventive measures. This should include judicious use and maintenance of rotary equipment, minimising or isolating laboratory procedures, reducing ambient noise levels and use of personal protection equipment such as ear plugs. Regular annual audiometry check-ups could help detect hearing loss before impairment occurs.

Reference: Palenik, C.J., 2018. I can’t hear you. Dental Update, 45(7), pp.670-673.

ORAL MEDICINE

ORAL MEDICINE

Give the Bong the Gong!

Oral yeasts, mainly Candida are commensal oral microbes. The carriage rate of oral Candida species in healthy subjects ranges between 17-75%. Chemicals in tobacco act as sources of nutrition for Candida species. The oral carriage of Candida was compared in waterpipe smokers (WS), cigarette smokers (CS) and non-smokers (NS) (Akram Z, 2018).

Clinical implication: A significant risk factor for increased oral Candida carriage is habitual tobacco usage. The waterpipe (synonymous with goza, hookah, narghile and shisha) is a form of smoking that involves the passage of charcoal-heated air through a perforated aluminium foil and across flavoured tobacco to become smoke which bubbles through the water before being inhaled. The tobacco in waterpipes contains 2-4% nicotine. Periodontal inflammatory conditions have been shown to be worse in WS and CS than in NS.

Practical application: WS impairs pulmonary function, causes tachycardia and hypertension. One session of WS is equivalent to smoking nearly 100 cigarettes. Oral Candida carriage is significantly more frequent among WS and CS than among NS. Both WS and CS are at an increased risk of developing oral Candida infections and are equally hazardous to health.

Reference: Akram, Z., Al-Kheraif, A.A., Kellesarian, S.V., Vohra, F. and Javed, F., 2018. Comparison of oral Candida carriage in waterpipe smokers, cigarette smokers, and non-smokers. Journal of Oral Science 60(1), pp.115-120

GENERAL PRACTICE

GENERAL PRACTICE

Best LA for kids!

Over the last few years many studies have shown that articaine hydrochloride has demonstrated a general tendency to outperform lidocaine hydrochloride for dental treatment. There has been no clear agreement however, on which LA solution is more efficacious in dental treatment for children (Tong HJ et al, 2018).

Clinical implication: There was no difference between patient self-reported pain between articaine and lidocaine during treatment procedures. When mandibular posterior teeth in young patients were anesthetised, clinicians reported 100% success with IDN blocks and 68% success with infiltration. The occurrence of adverse events post-operatively was found to be similarly low when comparing between articaine and lidocaine injections following treatment in paediatric patients; thus, articaine is equally safe for use in paediatric patients.

Practical application: Children have been reported to cry more during infiltration anaesthesia than block anaesthesia (Arrow P, 2012). Articaine was found to be more superior in terms of reducing pain intensity post-procedure and have longer lasting effect on soft tissue numbness. This could lead to undesirable outcomes of lip and cheek biting in children.

References: Tong, H.J., Alzahrani, F.S., Sim, Y.F., Tahmassebi, J.F. and Duggal, M., 2018. Anaesthetic efficacy of articaine versus lidocaine in children’s dentistry: a systematic review and meta‐analysis. International journal of paediatric dentistry.

Arrow, P., 2012. A comparison of articaine 4% and lignocaine 2% in block and infiltration analgesia in children. Australian Dental Journal 57(3), pp.325-333.

PERIODONTICS

PERIODONTICS

Mucositis and peri-implantitis: defining these terms clearly

Biological complications associated with dental implants are mostly inflammatory conditions of the soft tissues and bone surrounding implants and their restorative components, which are induced by the accumulation of bacterial biofilm (Renvert S et al, 2018).

Clinical implication: Peri-implant health is based on absence of peri-implant signs of soft tissue inflammation (redness, swelling, profuse bleeding on probing) and no additional bone loss following initial healing. Mucositis is defined as bleeding on probing combined with no radiographic evidence of bone level changes. Up to 3 mm of bone loss from the implant platform has defined peri-implant mucositis (Trullenque-Eriksson A and Moya BG, 2015).

Practical application: Radiographic evaluation should include an image taken at baseline (suprastructure in place) that clearly allows for identification of an implant-reference point and distinct visualisation of implant threads for future reference as well as assessment.
Changes ≥ 2mm any time point during or after the first year should be considered as pathologic- i.e.. progressive peri-implant infection or other local factors such as excess cement and looseness/fracture of implant components.

References: Renvert, S., Persson, G.R., Pirih, F.Q. and Camargo, P.M., 2018. Peri‐implant health, peri‐implant mucositis, and peri‐implantitis: Case definitions and diagnostic considerations. Journal of Clinical Periodontology 45, pp.S278-S285.

Trullenque-Eriksson, A. and Moya, B.G., 2015. Retrospective Long-Term Evaluation of Dental Implants in Totally and Partially Edentulous Patients: Part II Periimplant Disease. Implant Dentistry, 24(2), pp.217-221.

IMPLANTOLOGY

IMPLANTOLOGY

Angulated screw abutments and aesthetics

Angulated screw channel system abutments (ASCs) have recently been introduced to address the problem with visible screw channel access that may compromise aesthetics. ASCs allow the screw access to be modified up to 25 degrees relative to the implant axis. However a widened channel which may cause thinning of the facial ceramic which is needed at the implant screw head to allow for proper engagement of the screwdriver.

Clinical implication: The Shatoshi Sakamoto (SS) abutment consists of a custom titanium metal insert and zirconia coping in which the access hole is located in an aesthetic position with an angulated screw channel system. Around the platform, titanium is used as the metal insert which can be thinned so clinicians can design normal crown dimensions with less overcontouring while providing more space for soft tissue. The zirconia coping is cemented onto the custom metal insert. The margin of the metal frame is located 1.3-1.8 mm subgingivally and designed to be as smooth as possible to minimise the cement layer.

Practical application: With this SS abutment, the zirconia occupies the remainder of the soft tissue sulcus so the metal insert is not visible thus overcoming aesthetic concerns. The metal insert of the SS abutment possesses a high chimney height so that it can optimise mechanical retention.

Reference: Sakamoto, S., Ro, M., Al Ardah, A. and Goodacre, C., 2017. Esthetic abutment design for angulated screw channels: A technical report. The Journal of Prosthetic Dentistry

PROSTHODONTICS
PROSTHODONTICS

Tooth wear: be conservative, be additive!

Severe tooth wear is defined as loss of greater than or equal to 1/3 of the clinical crown, with exposure of dentine. Pathological tooth wear is defined as “Tooth wear atypical for age, causing pain or discomfort, functional problems, deterioration in aesthetics, which, if progressing, may give rise to complications of increasing complexity” e.g. a young patient may have erosive tooth wear into dentine, but it may not be severe (Loomans B and Opdam N, 2018).
Active tooth wear is defined as ongoing and often variable and can be spasmodic/episodic rather than linear. Some tooth wear is natural and progressive. Typical (physiological) enamel wear is 15-29 microns per year. Most studies suggest males show more advanced wear than females.

Clinical implication: Some clinical signs and symptoms of tooth wear include tooth sensitivity, pulpal complications (loss of vitality), tooth discolouration/loss of acceptable aesthetics/loss of tooth form, fracture and loss of restorations and increased cheek/tongue/lip biting. Occlusal changes may include loss of anterior guidance, dentoalveolar compensation, increased freeway space and reduced/compromised masticatory efficiency (Hemmings K et al, 2018).

Practical application: Resist the request for restorative intervention where wear is insignificant and inactive. Avoid definitive treatment while disease is active. Wherever possible, treatment should be additive rather than subtractive. Restorations (including composites and crowns) do not prevent wear, merely modify the rate, location and nature of wear.

References: Hemmings, K., Truman, A., Shah, S. and Chauhan, R., 2018. Tooth wear guidelines for the bsrd part 1: aetiology, diagnosis and prevention. Dental Update, 45(6), pp.483-495.

Loomans, B. and Opdam, N., 2018. A guide to managing tooth wear: the Radboud philosophy. British Dental Journal 224(5), p.348.

AESTHETIC DENTISTRY

AESTHETIC DENTISTRY

Most of our patients really don’t like upper anterior midline diastemas.

Anterior maxillary spacing has been shown to be one of the most undesirable influences on self-perceived dental appearance. A maxillary midline diastema (MMD) is often stated by patients as an issue during consultations. MMD is defined as a space more than 0.5 mm between the mesial surfaces of the 2 upper central incisors. Tooth size in particular has been emphasised as the main element of an aesthetic smile design. Upper anterior tooth widths average 8.5 mm for upper centrals, 6.5 mm for laterals and 7.5 mm for canines. 80% of the patient population falls within ±0.5 mm of these values.

Clinical implication: A caries-free patient presented who was not happy with the spaces between her upper teeth (Romaro MF et al, 2018). Smile analysis showed a 3 mm diastema between the upper centrals, 0.5mm between the upper canines and lateral incisors and an average smile line with 75-100% of the clinical crown height of the upper incisors displayed. The patient presented with a Class I dental relationship and desired limited orthodontics which focused on reducing the MMD from 3 mm to 1 mm. After orthodontic treatment, composite resins were used to close the remaining MMD and stabilise the teeth.

Practical application: Using limited orthodontics for MMD closure with segmental arch wire from central incisor to central incisor with an elastomeric chain is predictable as long as retraction of the incisors is not required. A MMD more than 2 mm in the mixed dentition is not likely to spontaneously close.

Reference: Romero, M.F., Babb, C.S., Brenes, C. and Haddock, F.J., 2018. A multidisciplinary approach to the management of a maxillary midline diastema: A clinical report. The Journal of Prosthetic Dentistry, 119(4), pp.502-505.

IMPLANTOLOGY

IMPLANTOLOGY

I want it and I want it now!

Patients prefer to be rehabilitated with fixed prostheses as soon as possible if the risk of early implant failure is not substantially increased. If there is enough bone volume to place implants with a flapless procedure, this is associated with less post-operative pain and oedema. Cannizzaro G et al, 2018 evaluated the long-term effectiveness of 6.6mm long flapless-placed single implants loaded immediately or early loaded at 6 weeks. Implants were inserted with an insertion torque superior to 40Ncm. Provisional crowns were put in slight occlusal contact and replaced with definitive crowns 3 months after loading. Patients were followed for 9 years after loading.

Clinical implication: Peri-implant bone loss was not significantly different for patients with immediately loaded implants or for early loaded ones.

Practical application: Shorter implants should be considered as an alternative to bone augmentation procedures, especially in the posterior mandible. Similar, if not better success rates for implants as short as 4 mm are an alternative to longer implants placed in augmented bone (Bolle C et al, 2017).

References: Bolle, C., Felice, P., Barausse, C., Pistilli, V., Trullenque-Eriksson, A. and Esposito, M., 2018. 4 mm long vs longer implants in augmented bone in posterior atrophic jaws: 1-year post-loading results from a multicentre randomised controlled trial. European journal of oral implantology, 11(1).

Cannizzaro, G., Felice, P., Trullenque-Eriksson, A., Lazzarini, M., Velasco-Ortega, E. and Esposito, M., 2018. Immediate vs early loading of 6.6 mm flapless-placed single implants: 9 years after-loading report of a split-mouth randomised controlled trial. European journal of oral implantology, 11(2).

AESTHETIC DENTISTRY

AESTHETIC DENTISTRY 1

Zirconia ideal for rehab of bruxers.

The most controversial treatment request for heavy grinders is to improve aesthetics, as they do not normally have problems chewing. The extensive grinding forces in these patients require a restorative material with adequate wear and fracture resistant properties. Hansen TL et al, 2018 assessed patients with severe tooth wear including at least 1/3 of the coronal tooth substances in the aesthetic zone. All patients were men aged 35-67 years and were in need of prosthetic rehabilitation due to severe tooth wear. Zirconia was chosen as the material for the restorations.

Clinical implication: No biological complications were registered in 94% of the crowns and technical complications were registered in two patients. All patients were satisfied with the aesthetic and function of the monolithic zirconia crowns and would choose the same treatment modality if they were to be treated again.

Practical application: Despite the absence of a night splint with participants who had parafunctional habits, high chipping rates of the zirconia which could have been expected, did not occur. Monolithic zirconia crowns may provide a valid treatment modality of severe tooth wear in the aesthetic zone where minimally invasive treatment fails.

Reference: Hansen, T.L., Schriwer, C., Øilo, M. and Gjengedal, H., 2018. Monolithic zirconia crowns in the aesthetic zone in heavy grinders with severe tooth wear–An observational case-series. Journal of Dentistry, 72, pp.14-20.

PERIODONTICS

PERIODONTICS

Diagnosis of Endo-Perio Lesions revisited

Endondontic-periodontic lesions (EPL) involve both the pulp and periodontal tissues and may occur in acute or chronic forms (Herrera D, 2018). An established EPL is always associated with varying degrees of microbial contamination of the pulp and supporting periodontal tissues. Microbial studies have shown a great similarity between the microbiota found in the root canals and periodontal pockets.

Clinical implication: The main risk factors for the occurrence of EPL are
endodontic and/or periodontal infections, trauma and/or iatrogenic events. The most common signs and symptoms associated with a tooth affected by EPL are deep periodontal pockets reaching or close to apex and negative or altered response to pulp vitality tests. Other signs include bone resorption in the apical of furcation area, spontaneous pain or pain on palpation and percussion, pus, tooth mobility, sinus tract, crown and gingival colour alterations.

Practical application: When an EPL is associated with a recent traumatic or iatrogenic event (root fracture or perforation), the most common manifestation is an abscess accompanied by pain. EPL in subjects with periodontitis normally present with slow and chronic progression without evident symptoms. Identify the occurrence of trauma, endodontic instrumentation or post preparation. Detailed clinical and radiographic examinations should be done to seek presence of perforations, fractures and cracks or external root resorption.

Reference: Herrera, D., Retamal‐Valdes, B., Alonso, B. and Feres, M., 2018. Acute periodontal lesions (periodontal abscesses and necrotizing periodontal diseases) and endo‐periodontal lesions. Journal of clinical Periodontology, 45, pp. S78-S94.

GENERAL PRACTICE

GENERAL PRACTICE

Root caries lesions: why do restorations fail faster?

Cervical dentine surfaces are more often exposed to the oral environment and thus the risk for developing root carious lesions will be increased. Studies have shown that the annual failure rate (AFR) for Class V restorations due to non-carious cervical lesions and for Class II restorations varied between 1.9-5.8%. Wierichs RJ et al, 2018 analysed factors influencing the survival of restorative treatments of one- and two-surface active cervical (root) caries lesions (CCLs).

Clinical implication: The AFR was 1.82% for one-surface restorations and 3.25% for two-surface restorations. A proximal extension of a solely cervical restoration has a greater influence on the failure rate than a proximal extension of an occlusal restoration. Use of composite, resin-modified GIC or compomer was associated with a longer time to restoration failure than GIC.

Practical application:
Restorative treatment of CCLs is a viable way to manage one-surface CCLs. There was a significant relation between the frequency of check-ups per annum and failure rate of one- and two-surface CCLs. Patients visiting dental practices more often had significantly lower survival times for direct restorations. The chance to incorrectly identify a sufficient restoration as insufficient increases with an increasing number of check-ups per year. Higher patient age was associated with a shorter time for cervical restoration failure.

Reference: Wierichs, R.J., Kramer, E.J. and Meyer-Lueckel, H., 2018. Risk factors for failure of class V restorations of carious cervical lesions in general dental practices. Journal of dentistry, 77, pp.87-92.

PRACTICE MANAGEMENT

PRACTICE MANAGEMENT

Importance of inter-personal skills is paramount to success in practice

Patients judge a clinician by the way in which the clinician interacts with them. Communication is the key for a successful dentist-patient relationship which empower the patient with the knowledge required to make an informed decision about their oral health (Yanniotis AM, 2018). Ask the right questions so that open communication exists.

Clinical implication: The dentist has to manage any problem and lead to a solution. Avoid downplaying the seriousness of a patient’s concerns. Acknowledge any problem openly. Listen empathically and allow time for the patient to express their concerns and ask them what they want to resolve the problem. Act accordingly so the patient feels heard and resolve the issue immediately. Follow-up is essential.

Practical application: If patients are treated as fully informed partners in their care, they will be loyal and continue care with you. Positive patient’s experiences result in higher acceptance rates for a recommended treatment and the likelihood of greater referrals (Canadian Dental Association). If a patient perceives care at a certain level but expected something more or different, then they will be dissatisfied (Patient satisfaction=Perception-Expectations).

Reference: Yiannikos, Anna Maria, 2017. Successful communication in your daily practice Part I: Grumbling patients. roots, [Online]. 4, 36-37. Available at: https://www.dental-tribune.com/epaper/ce-magazines/roots-international/roots-international-no-4-2017-[36-37].pdf [Accessed 2 October 2018].

 ORO-FACIAL PAIN

ORO-FACIAL PAIN

Stress, Pain, Depression and TMD often linked

Chronic pain remains extremely challenging to manage clinically (Klasser GD et al, 2018). Nevalainen N et al, 2017 studied the association between stress level and chronic facial pain, while controlling for the effect of depression on this association, during a three-year follow-up in a general population. Information about stress level, depression and facial pain were collected using questionnaires at the age of 31 years. Stress level was measured using a specified Index. Depression was assessed using a separate checklist.

Clinical implication: Of the subjects having high stress level at baseline, 73.3% had chronic facial pain, and 26.7% were pain-free three years later. Regression analysis showed that high stress level in a 31 year old increased the risk for chronic facial pain three years later. Depression was associated statistically significantly with chronic facial pain.

Practical application: Psychological disorders and psychosocial impairment are highly prevalent in TMD patients. High stress level is connected with increased risk for chronic facial pain. This association seems to mediate through depression. It is now recognised that genetic factors play a role in the aetiology of persistent pain conditions by modulating underlying processes such as nociceptive sensitivity, psychological well- being, inflammation and autonomic response (Smith SB et al, 2011).

References: Nevalainen, N., Lähdesmäki, R., Mäki, P., Ek, E., Taanila, A., Pesonen, P. and Sipilä, K., 2017. Association of stress and depression with chronic facial pain: A case-control study based on the Northern Finland 1966 Birth Cohort. CRANIO®, 35(3), pp.187-191.

Klasser, G.D., Manfredini, D., Goulet, J.P. and De Laat, A., 2018. Oro‐facial pain and temporomandibular disorders classification systems: A critical appraisal and future directions. Journal of oral rehabilitation, 45(3), pp.258-268.

Smith SB, Maixner DW, Greenspan JD, et al. Potential genetic risk factors for chronic TMD: genetic associations from the OPPERA case control study. J Pain. 2011;12(11 Suppl): T92-T101.

DENTAL MATERIALS

DENTAL MATERIALS

Colour stability of veneer luting agents can vary considerably

Long-term colour stability is essential to achieve long-term success with laminate veneers. The use of evaluation paste can predict the outcome after cementation. The high translucency of laminate veneers confers natural tooth appearance through the lens effect. However, the low masking ability means that discolouration can be visible through the ceramic. As the veneer is thin, the properties of the resin cement dictate the final colour of veneers. Lee S et al, 2018 evaluated the colour stability of laminate veneers through aging by using various ceramic and resin cement systems.

Clinical implication: High translucency (HT) lithium disilicate ceramics exhibited greater colour changes upon aging. The lower the brightness of resin cement, the higher the colour stability of veneers.

Practical application:
Transparent shade cements are advised for HT ceramics in clinical situations. When luting 0.5 mm-thick laminate veneers with dual polymerizing cement, light polymerisation did not yield better colour stability than dual polymerisation over time.

Reference: Lee, S.M. and Choi, Y.S., 2018. Effect of ceramic material and resin cement systems on the color stability of laminate veneers after accelerated aging. The Journal of Prosthetic Dentistry

ORAL MEDICINE

ORAL MEDICINE

Careful diagnosis protocols required in oral malignancy

The most common oral malignancy is squamous cell carcinoma. Rarely, malignant salivary gland tumours and oral lymphoma may present in the oral cavity and should raise clinical suspicion. Non-Hodgkin’s lymphoma can present intra- or extra-nodally including the oral cavity. Most adult presentations of Non-Hodgkin’s lymphoma are Diffuse Large B Cell Lymphoma (DLBCL).

Clinical implication: 58% of oral lymphomas are DLBCL with a mean age at presentation of 62-71 years. The most common oral site is Waldeyer’s ring (an arch of lymphoid tissue at the posterior junction of the soft palate and oropharynx), the palate, maxilla and mandible. There may be non-specific signs which may mislead the clinician or present mimicking other oral malignancies such as a non-healing ulcer or the sudden onset of a rapidly growing swelling or dental pathological processes.

Practical application: Symptoms of atypical facial pain or numbness may be present without any organic signs. This will aid the clinician to consider systemic disease or a malignant process. Imaging is critical and may reveal bone lesions or oral presentation of metastatic disease which should be included in the differential diagnosis. Many patients require extensive long-term follow-up from multiple specialities to allow early diagnosis of disease progression.

Reference: Allsobrook, O.F., Bakri, I., Farthing, P.M., Morley, N.J. and Hegarty, A.M., 2018. Oral lymphoma: a case series. Dental Update, 45(7), pp.641-644.

ORTHODONTICS

ORTHODONTICS 1

Alternative concept for early treatment of skeletal Class III examined

Early treatment of skeletal Class III patients is usually handled with the use of maxillary protraction face mask which are often accompanied by adverse dentoalveolar effects. Gonzalez IGH and Lopez EG 2018 reviewed an alternative approach proposed by Dr. De Clerck employing the use of skeletal anchorage.

Clinical implication: Temporary anchorage devices (TADs) consisting of two titanium plates fixed with mini implants are placed in the zygomatic process of the maxilla and two side plates between the lower canine on the right and left. After healing, orthodontic forces are applied by using intermaxillary elastics on each side with a class III force vector to move the maxilla forward and down and the mandible back and up.

An acrylic resin plate or placement of resin stops to increase vertical dimension and achieve overjet may also be used. The elastics will be removed when a positive overjet is achieved. Continuous forces exerted by the intraoral intermaxillary elastics in skeletal class III patient have shown better results than use of intermittent forces of extraoral elastics with a facemask. Maxillary advancement as well as an improvement of facial aesthetics while reducing dentoalveolar adverse effects is apparent.

Practical application: CBCT must be used to detect the most calcified areas of the zygomatic process of the maxilla for proper mechanical retention. The best age for stability is for patients who are at least 11. The initial elastics must exert a force of 150g each side and after one month it increases to 250gms. In order to determine the force, the patient must be in intercuspidation. The time of traction is 12.5 months of 24-hour use. In some patient, the implementation of this technique, may be enough to either avoid orthognathic surgery in the future or at least reduce the severity of the surgical correction after the patient has completed growth.

Reference: González, I.G.H. and López, E.G., 2016. Maxillary protraction through skeletal anchorage in growing patients. Literature review. Revista Mexicana de Ortodoncia, 4(3), pp.e153-e156.

PRACTICE MANAGEMENT

PRACTICE MANAGEMENT 1

How time efficient are you?

The American Association of Dental Office Management (AADOM) is a unique organisation that provides dental practice managers and administrators the business tools they need to run a successful practice – educational webinars and practice management training.
One of the key criteria for success is exceptional time management skills (Colicchio H, 2018).

Clinical implication: Practice managers understand that working efficiently impacts team morale, patient retention and production.

Practical application:
1. Prioritise Tasks – At the start of each day, create a short “to-do” list.
Weekly or monthly routines can be changed to ensure important jobs are not missed.
2. Practice managers should delegate other duties to team members and
cross-train.
3. Time-tracking software systems are available that can analyse data on a daily, weekly, and monthly basis.

Reference: Colicchio, Heather, 2018. Time Management: A Foundational Key to Practice (and Personal) Success. Compendium, [Online]. Volume 39, Issue 5. Available at: https://www.aegisdentalnetwork.com/cced/2018/05/time-management-a-foundational-key-to-practice-and-personal-success [Accessed 25 September 2018].

GENERAL PRACTICE

GENERAL PRACTICE

Be accurate in what you say to patients and document everything

Young dentists are required to adapt to the business side of general practice as well as be proactive and be aware of the litigious environment in which they practice. Al Hassin A, 2017 coined the phrase “defensive dentistry’’ and how it may affect clinicians.

Clinical implication:  Some clinicians may deny treatments that they could reasonably offer but would not due to the risk of a possible escalating complaint, even despite discussion of all the risks and gaining “informed consent”. The critical elements of informed consent that must be explained by the dentist are:
1. Indicated procedure is stated in understandable terms
2. Reasons/Benefits/Alternatives/Consequences/No treatment for the procedure
3. Risks associated with the procedure

Practical application: The trust relationship between clinician and the patient is as crucial in the management of the patient as the treatment itself. Communication with patients and colleagues is vital, especially patients who are confused or unsure. Do not be averse to second opinion diagnoses.

Reference: Al Hassan, A., 2017. Defensive dentistry and the young dentist–this isn’t what we signed up for. British dental journal, 223(10), p.757.

PERIODONTICS

PERIODONTICS

ANUG and systemic risk factors: the latest thoughts

The World Workshop in Periodontology 2017 described necrotising periodontal disease (NPD) as an infectious condition. NPD patients are often susceptible to future recurrence of disease (Herrera D et al, 2018).

Clinical implication: Predisposing factors play a main role by the downregulation of the host immune response facilitating bacterial pathogenicity. These factors include psychological stress and insufficient sleep, poor diet, alcohol and tobacco consumption, inadequate oral hygiene, pre-existing gingivitis, and systemic conditions.

Practical application: The use of systemic antimicrobials may be considered in cases that show unsatisfactory response to debridement or show systemic effects (fever and/or malaise). Metronidazole (250 mg, every 8 h) may be an appropriate first choice of drug because it is active against strict anaerobes. Patients continuously exposed to a severe systemic compromise have a higher risk of suffering from necrotising periodontal disease and of faster and more severe progression (from necrotising gingivitis to necrotising periodontitis and even to necrotising stomatitis and Noma). In severely immune-compromised patients, bone sequestrum can occur.

References: Malek, R., Gharibi, A., Khlil, N. and Kissa, J., 2017. Necrotizing ulcerative gingivitis. Contemporary clinical dentistry, 8(3), p.496.

Herrera, D., Retamal‐Valdes, B., Alonso, B. and Feres, M., 2018. Acute periodontal lesions (periodontal abscesses and necrotizing periodontal diseases) and endo‐periodontal lesions. Journal of clinical periodontology, 45, pp.S78-S94.

PROSTHODONTICS

PROSTHODONTICS

Digital work flows for C and B: is it worth investing in a scanner?

A central concept to intraoral scanning in the surgery is to provide faster input for prosthesis workflow without the use of conventional dental processes and materials (Duello GV, 2018). When data is captured via an intraoral device, workflow can start immediately in the laboratory once the STL file is sent via an internet connection. An open STL file can be sent to most laboratories and then imported into design software.

Clinical implication: State of the art software helps the dental team and patients understand upfront the diagnosis, risks/benefits, costs and informed consent necessary to perform interdisciplinary care. Documents, files and viewers are cloud-based and allow global access.

Practical application: All-digital solutions offer a “green” effect as data is distributed via the internet reducing the need for carbon-based transportation involved in the manufacturing and delivering of the prosthesis. The decision to purchase an open or closed system should be based on practice objectives, patient preferences and economics, i.e. return on investment associated with any digital dentistry system.

Reference:  Duello GV, 2018. Intraoral Scanning for Single-Tooth Implant Prosthetics: Rationale for a Digital Protocol. Compendium of continuing education in dentistry (Jamesburg, NJ: 1995), 39(1), pp.28-34.

 

IMPLANTOLOGY

IMPLANTOLOGY

Immediate implantation in infected sites: risks and outcomes

Immediate implantation has been established to shorten the waiting time before definitive restoration. This approach remains controversial for a tooth with a periodontal or periapical lesion. Chen H et al, 2018, searched the literature to see if patients who need immediate implant treatment in the aesthetic zone are more at risk if the implant is placed into an infected site rather than a healthy site and what can be done during treatment to improve the prognosis.

Clinical implication: Compared with healthy sites, immediate implant placement in infected sites in the aesthetic zone showed similar survival rates (97.6% vs. 98.4% respectively). There were no statistically significant differences in bone level changes or in gingival level changes between the two groups.

Practical application: Infected sites should be thoroughly curetted to remove any granulation tissue and all other remnants of soft tissue to reduce inflammatory activity. For most patients undergoing dental implant treatment, different types and doses of antibiotics are prescribed with no direct clinical evidence to support such a protocol (Hita-Inglesias C et al, 2016). However, until more evidence proves otherwise systemic antibiotics are recommended in the treatment plan. Exposing the implant to 0.1g/L of chlorhexidine solution for 60 seconds has shown to significantly reduce subsequent coverage by Streptoccus gordonii on implants. Immediate zero-contact interim restorations in the aesthetic zone are prudent. Definitive restorations require effective load management.

Reference: Chen, H., Zhang, G., Weigl, P. and Gu, X., 2018. Immediate placement of dental implants into infected versus noninfected sites in the esthetic zone: A systematic review and meta-analysis. The Journal of prosthetic dentistry.

ORAL MEDICINE

ORAL MEDICINE 1

Managing Xerostomia symptoms

Hyposalivation and xerostomia are frequent problems (63%-93%) in head and neck patients after radiotherapy with consequences of oral health and quality of life. Barbe AG, 2017 reviewed an extensive study of the efficacy of available treatments with respect to changes in xerostomia and developed evidence-based guidelines to manage radiotherapy-induced hyposalivation and xerostomia.

Clinical implication: Patients with hyposalivation suffer from oral discomfort, taste disturbances, difficulties in speaking, swallowing and chewing and increased risk of dental disease especially combined with damage caused by radiation. Systemic pilocarpine and cevimeline should represent the first line of therapy in head and neck cancer survivors with radiation-induced xerostomia and hyposalivation.

Practical application:
The often-occurring side effects of the suggested medications pilocarpine and cevimeline include nausea, sweating and increased urinary frequency. Interdisciplinary management with the physician is encouraged to advise the patient of the risk-benefit analysis before recommending these products as many elderly patients suffer from additional morbidities. Inform patients of other symptom-relieving products such as saliva substitutes, mouth care systems, acupuncture, transcutaneous electrical nerve stimulation or low-level laser.

Reference:  Barbe, A.G., 2017. Long-term Use of the Sialogogue Medications Pilocarpine and Cevimeline Can Reduce Xerostomia Symptoms and Increase Salivary Flow in Head and Neck Cancer Survivors After Radiotherapy. Journal of Evidence Based Dental Practice, 17(3), pp.268-270.

DENTAL MATERIALS

DENTAL MATERIALS 350

Silane: does it really help?

Conventionally, the surface of glass ceramics is etched with hydrofluoric acid followed by application of silane coupling agent prior to cementation with composite cement. The hydrofluoric acid reacts with the glassy matrix and exposes the crystalline structure. Silane allows a chemical bond between the silicon oxides from the ceramic and the organic matrix of the composite cement. Prado M et al 2018, evaluated the microshear bond strength of composite cement bonded to two machined glass ceramics and its durability comparing conventional surface conditioning (hydrofluoric acid and silane) to a one-step self-etching primer (Monobond Etch & Prime).

Clinical implication: The conventional ceramic treatment presented statistically higher mean microshear bond strength than the simplified method. Silane increases the wettability of the ceramic surface.

Practical application: Monobond Etch and Prime had stable bonding after aging. The application of silane as a separate step is recommended prior to cementation of Lithium Disilicate reinforced glass‐ceramic independent of the presence of silane within the universal adhesive solution.

Reference: Prado, M., Prochnow, C., Marchionatti, A.M.E., Baldissara, P., Valandro, L.F. and Wandscher, V.F., 2018. Ceramic Surface Treatment with a Single-component Primer: Resin Adhesion to Glass Ceramics. Journal of Adhesive Dentistry, 20(2).

AESTHETIC DENTISTRY

AESTHETIC DENTISTRY

What do patients consider to be unaesthetic?

Designing the teeth in the confines of the gingival architecture impacts smile aesthetics considerably. Batra P et al, 2018 determined the perceptions of laypeople to variations in soft tissue aesthetics during smiling. An ideal smile photograph was intentionally altered to produce variations in gingival inflammation, pigmentation, contour, and the position of the free gingival margins (with and without recession), zeniths and interdental papilla.

Clinical implication: Alteration of gingival contour and gingival zenith had the least impact on smile aesthetics. Changes in the free gingival margin with and without recession were moderately perceived.

Practical application: Laypersons considered unilateral or asymmetric alterations more unaesthetic compared with bilateral or generalized alterations for factors such as free gingival margin without recession and colour changes caused by inflammation and pigmentation. The untrained eye seemed to be more sensitive to changes in the central incisors than in the lateral incisors or canines when changes were unilateral rather than bilateral. A bilateral change was only noted as unaesthetic when it was an extreme alteration e.g. 3mm gingival recession and a 3mm black triangle in the 6 maxillary anterior teeth.

Reference: Batra, P., Daing, A., Azam, I., Miglani, R. and Bhardwaj, A., 2018. Impact of altered gingival characteristics on smile esthetics: Laypersons’ perspectives by Q sort methodology. American Journal of Orthodontics and Dentofacial Orthopedics, 154(1), pp.82-90.

ORTHODONTICS

ORTHODONTICS

Diagnosis of facial asymmetry – a systematic approach

Facial asymmetry is defined as the presence of a clinically significant variation between the two halves of the face that the patient is concerned about and that can be quantified by the clinician (Srivastava D et al, 2017).

Clinical implication: Facial asymmetries more commonly manifest in the mandible and chin as it forms the skeletal support for soft tissues of the lower face. The clinical presentation of facial asymmetry conditions involving the TMJ include:

1.Progressive development and worsening of facial asymmetry during early teen years or later in life with/without skeletal soft tissue and occlusal changes.
2.Progessively worsening Class III occlusal relationship with contralateral crossbite and mandibular and chin deviation to the opposite side.
3.Unilateral vertical lengthening of face and jaws with lateral open bite on the involved side.
4.Development and progressive worsening of anterior open bite in conjunction with Class II occlusion.

Practical application: The positions of three anatomical areas should be studied – the maxilla, mandibular body and symphysis in relation to the facial midline and the presence of occlusal canting has been recommended. Frontal view, superior view and submental views are suggested in order to make the most accurate diagnosis.

Reference: Srivastava, D., Singh, H., Mishra, S., Sharma, P., Kapoor, P. and Chandra, L., 2017. Facial asymmetry revisited: Part I-diagnosis and treatment planning. Journal of oral biology and craniofacial research.

AESTHETIC DENTISTRY

AESTHETIC DENTISTRY

What looks attractive to you?

Baker RS et al, 2018 conducted a study on the objective assessment of the contribution of dental and facial attractiveness in men via eye tracking. Facial images of men rated as unattractive, average and attractive were digitally manipulated and paired with validated oral images, Index of Orthodontic Treatment Need (IOTN). IOTN levels were no treatment need, borderline treatment need and definite treatment need. Sixty-four raters were included in the data analysis. Each rater was calibrated by the eye tracker and randomly viewed the composite images for 3 seconds, twice for reliability.

Clinical implication:

  1. Visual attention to the mouth was the greatest in men of average facial attractiveness, irrespective of dental aesthetics.
  2. In borderline dental aesthetics, the eye and the mouth were statistically indistinguishable, but in the most unaesthetic dental attractiveness level, the mouth exceeded the eye. The most unaesthetic malocclusion does significantly attract and affect visual attention in men irrespective of background facial attractiveness. In women, mean visual attention to the mouth did not exceed that to the eye in density or duration at any attractiveness level.
  3. Male and female raters showed differences in their visual attention to faces of men. Women view the eyes more than men do when viewing men.

Dental attractiveness for men is not tied to facial attractiveness levels.

Practical application:

  1. Laypersons gave significant visual attention to poor dental aesthetics in men, and this was irrespective of background attractiveness, which was counter to what was seen in women.
  2. Treatment for the most unaesthetic dentition could benefit men at all levels of background facial attractiveness.

Reference: Baker, R.S., Fields, H.W., Beck, F.M., Firestone, A.R. and Rosenstiel, S.F., 2018. Objective assessment of the contribution of dental esthetics and facial attractiveness in men via eye tracking. American Journal of Orthodontics and Dentofacial Orthopedics, 153(4), pp.523-533.

ORTHODONTICS

ORTHODONTICS

App on mobile to encourage tooth brushing

The effect of using mobile applications active reminders to improve oral hygiene in comparison to verbal oral hygiene instructions was investigated by Alkadhi OH et al, 2017. Two-arm parallel randomised controlled trials were done at orthodontic clinics at university hospitals. Forty-four 12-year-old and older subjects participants were involved in the study. Subjects undergoing orthodontic treatment with fixed appliances were randomly assigned to one of two groups using simple randomisation. Group I: subjects received a mobile application that sends active reminders of oral hygiene three times a day Group II: subjects received verbal oral hygiene instructions during their routine orthodontic visits. The gingival index and plaque index were assessed.

Clinical implication: Mean differences for pIaque score and Gingival index for Group I were reduced but did not significantly change for Group II.

Practical application: Poor oral hygiene is the most important factor in enamel demineralisation during orthodontic treatment. By sending text messages to the patient once a week or three times a week to the patients or their parents can improve the patient’s oral hygiene. Sending motivational text messages to patients has shown an increase in tooth brushing after 3, 6 and 9 weeks.

Reference: Alkadhi, O.H., Zahid, M.N., Almanea, R.S., Althaqeb, H.K., Alharbi, T.H. and Ajwa, N.M., 2017. The effect of using mobile applications for improving oral hygiene in patients with orthodontic fixed appliances: a randomised controlled trial. Journal of orthodontics, 44(3), pp.157-163.

IMPLANTOLOGY

IMPLANTOLOGY

Bleeding on Probing around implants

Bleeding on probing (BOP) is a long-recognised sign of periodontal disease. Bleeding on probing around implants is thought to be a predictor of peri-implantitis. Clinicians aim to reduce factors that may cause BOP to minimise the risk of peri-implantitis. Farina R et al, 2017 evaluated the association between the probability of a peri-implant site to be likely to bleed and patient and site characteristics in a large cohort of patients seeking care at a specialist periodontal clinic.

Clinical implication: The probability for a peri-implant site to bleed significantly increased with increasing probing depth. Women were more likely to have BOP around the implant than men. The probability of BOP around the implants was less posteriorly than anteriorly.

Practical application: Peri-implant BOP has a prognostic value. Its presence (or absence) is associated with the deterioration (or stability) of peri-implant conditions over time. Probing depth reduction should be seen as a treatment endpoint to control BOP in both prevention and therapeutic strategies of periodontal and peri-implant disease.

Reference: Farina, R., Filippi, M., Brazzioli, J., Tomasi, C. and Trombelli, L., 2017. Bleeding on probing around dental implants: a retrospective study of associated factors. Journal of clinical periodontology, 44(1), pp.115-122.

GENERAL PRACTICE

GENERAL PRACTICE

Prevent dry sockets with Chlorhex gel

The incidence of alveolar osteitis (AO) is reported to be 3-4% and its value may be extended to 45% during extraction of an impacted tooth. AO more commonly occurs in the mandible and in posterior tooth extraction. Post-operative complications include oedema, pain and trismus. The efficacy of chlorhexidine gel in the prevention of AO after mandibular third molar extraction was reviewed (Teshome A, 2017).

Clinical implication: The incidence of dry socket is highest in the third and fourth decades of life. This is probably due to the presence of well-developed alveolar bone and the relative infrequency of periodontal diseases in this age group makes tooth extraction more difficult. Treatment choices for AO are limited. The use of eugenol dressing, antibiotics, analgesic, lidocaine gel and irrigation of the socket are some methods utilised.

Practical application: Chlorhex gel application in the extraction socket of mandibular 3rd molars reduces the incidence of AO. Antibiotics reduce the incidence of AO when the first dose is given before surgery. However, antibiotics should not be used to prevent or treat dry socket in a non-immune compromised patient due to potential for resistant strains and hypersensitivity issues.

Reference: Teshome, A., 2017. The efficacy of chlorhexidine gel in the prevention of alveolar osteitis after mandibular third molar extraction: a systematic review and meta-analysis. BMC oral health, 17(1), p.82.

ORAL MEDICINE

ORAL MEDICINE

Squamous cell carcinomas most common

According to the American Cancer Society more than 80% of malignancies of new cancer cases diagnosed in the oral cavity and oropharynx will be squamous cell carcinomas. Various factors increase the risk of developing oral squamous cell carcinoma including increasing age, tobacco use, excessive alcohol use, immunosuppression, poor diet, history of potentially malignant disorders or malignant disorders and certain inherited diseases.

Clinical implication: Clinicians should perform conventional visual and tactile exam intraorally and extraorally after review of the full medical, dental and social history. Identify any type of mucosal or submucosal abnormality which can be observed in as many as 10% of patients e.g. leukoplakia, speckled leukoplakia or erythroplakia. The clinical and histopathologic progression of a leukoplakia over time is inconsistent in terms of predicting which lesions will progress and how quickly they may progress.

Practical application: Adult patients with clinical evidence of an oral mucosal lesion with an unknown clinical diagnosis considered to be seemingly innocuous or non-suspicious of malignancy or other symptoms should be reviewed periodically for further evaluation. If the lesion has not resolved, refer to a specialist. For adults with a clinically evident oral mucosal lesion considered to be suspicious of a premalignant lesion or malignant disorder or other symptoms, a biopsy should be performed.

Reference: Lingen, M.W., Abt, E., Agrawal, N., Chaturvedi, A.K., Cohen, E., D’Souza, G., Gurenlian, J., Kalmar, J.R., Kerr, A.R., Lambert, P.M. and Patton, L.L., 2017. Evidence-based clinical practice guideline for the evaluation of potentially malignant disorders in the oral cavity: a report of the American Dental Association. The Journal of the American Dental Association, 148(10), pp.712-727.

PERIODONTICS

PERIODONTICS

Relationship between periodontitis and peri-implantitis

Clinicians face difficulty when determining the prognosis of periodontally involved teeth in terms of whether to extract or retain such teeth. Periodontitis cannot be cured. It can only be controlled. Maintenance of periodontal health and prevention of disease recurrence depends on a high standard of biofilm control and correct lifestyle choices (Ower P, 2018).

Clinical implication: Long-term studies have shown results of non-surgical therapy were equivalent to those of surgical procedures even for deep sites with respect to mean attachment levels and prevention of tooth loss. A history of periodontitis even if stabilised, should be regarded as an independent risk factor for peri-implant disease.

Practical application: The prognosis of periodontally involved teeth is influenced by the biological response to therapy and self-care and this response is not predictable. Periodontal patients with pockets over 5 mm who have been provided with implants have a greater risk of developing peri-implantitis. There are correlations between poor oral hygiene and peri-implantitis and peri-implantitis and poor compliance with long-term supportive therapy. A key determinant of the survival of implants in the periodontally susceptible is the long-term maintenance of peri-implant health both by the patient and the clinician.

Reference: Ower, P., 2018. Prognostication in periodontics–science or art? Dental Update, 45(6), pp.496-505.

PRACTICE MANAGEMENT

PRACTICE MANAGEMENT

Are you really up to date with infection control?

Infection control has changed in recent years with the increasingly complex governmental guidelines, a growing awareness of liability exposure, and a public that is increasingly aware of, and concerned about, infection control breaches in medical and dental facilities. Grant L,2017 has highlighted the importance of an infection control practice co-ordinator.

Clinical implication: Every dental practice must have a written infection control plan. The Organization for Safety, Asepsis and Prevention (OSAP) (www.osap.org) assists dental practices in implementing this essential strategy. OSAP is a global community of clinicians, educators, consultants, researchers, and industry representatives who advocate for safe and infection-free delivery of oral healthcare.

Practical Application: A dedicated infection control coordinator (ICC) should be appointed – a person whose job includes staying up to date on infection control and prevention best practices, monitoring the products and techniques used, overseeing the practice’s exposure control plan and provide safety training to new employees.

Reference: Leslie E. Grant. 2018. Why Your Practice Needs an Infection Control Coordinator. [ONLINE] Available at: https://www.aegisdentalnetwork.com/cced/2017/06/why-your-practice-needs-an-infection-control-coordinator. [Accessed 28 August 2018].

DENTAL MATERIALS

DENTAL MATERIALS

Lithium disilicate v monolithic zirconia

Donovan T et al, 2018, have provided an evidence-based guide for clinicians to use when placing contemporary ceramic restorations. The elimination of metal costs and digital manufacturing capabilities and efficiencies has made the use of ceramic restorations very popular.

Clinical implication: Layered crowns are generally indicated for anterior teeth. Monolithic materials are appropriate for posterior teeth as these materials lack the translucency required for excellent aesthetic outcomes. With current computer software, a virtual full contour “wax-up” of the restoration is completed of the restoration and then virtually cut back allowing proper support of the veneering ceramic by the core. The guideline for layered zirconia restorations is that the maximum thickness of veneering ceramic should never exceed 2 mm.

Practical application: Mandibular incisors suit monolithic zirconia restorations as minimal tooth reduction is possible. Single anterior crowns are best restored with layered lithium disilicate. Bruxers are advised to have layered zirconia with only polished zirconia on the palatal surface. Premolars are suited to monolithic lithium disilicate or zirconia or layered zirconia depending on aesthetic demands and parafunctional activity of the patient.

Reference: Donovan, T.E., Alraheam, I.A. and Sulaiman, T.A., 2018. An evidence-based evaluation of contemporary dental ceramics. Dental Update, 45(6), pp.541-546.

PROSTHODONTICS

PROSTHODONTICS

Managing “awake” bruxism

The clinician can identify a patient with parafunctional habits by damage to tooth structure and the most accurate way is with mounted study models. There is no clinical evidence or literature support to indicate that occlusion plays a causal role in bruxism (Goldstein RE and Clark WA, 2017).

Clinical implication: A strong correlation exists between temporomandibular disorders and bruxism. Diurnal bruxism exacerbates TMD symptoms. Any patient who self-reports TMD, morning masticatory muscle pain or stiffness or joint noises should be considered a possible bruxer. Use of medications can cause bruxism especially SSRI and other drug classes that affect dopamine and neurotransmitters. Patients are taught the phrase: “lips together, teeth apart” to repeat when they find themselves bruxing. Providing 6 reminder stickers with this phrase are given to the patient to places in areas to help remember to relax the jaw – e.g. in the car, at desks/computers/ or other areas of daily stress.

Practical application: The best approach is the triple P approach: plates, psychological counselling and pharmacology (short-term). Cue conditioning has been proposed as a treatment option especially in children or mentally challenged individuals. Vocal or physical cues are repeated when a patient bruxes. Biofeedback by means of a small electrical impulse emitted during muscle activity ultimately stops the action of bruxism.

Reference: Goldstein, R.E. and Clark, W.A., 2017. The clinical management of awake bruxism. The Journal of the American Dental Association, 148(6), pp.387-391.

MATERIALS

Materials

Are glass ionomer cements suitable for pits and fissures?

Pit and fissure sealants are effective in preventing caries development in sound and in susceptible pits and fissure. Clinicians have used resin-based materials, compomers and glass ionomer cements (GICs). The ability of GICs and resin-based sealants (RBSs) was evaluated to assess the ability of the material to prevent the occurrence of caries and their retention in clinical studies (Alirezaei M et al, 2018).

Clinical implication: Retention of RBSs is higher than that of most of the GIC-based sealants in many studies due to the higher wear resistance and compressive strength, as well as micro-mechanical bonding to tooth structure.

Practical application: The caries prevention effect was similar for both groups of materials. GIC-based sealants may be a good alternative to RBSs especially in community procedures where there is limited equipment, no chairside assistant for the dentist or hygienist and hence limited isolation capacity and a considerable number of children at high risk of developing caries.

Reference: Alirezaei, M., Bagherian, A. and Shirazi, A.S., 2018. Glass ionomer cements as fissure sealing materials: yes or no?: A systematic review and meta-analysis. The Journal of the American Dental Association.

PROSTHODONTICS

Prosthodontics

Is sleep bruxism really harmful?

Sleep bruxism (SB) is a recurrent rhythmic activation of masticatory muscles, characterized by clenching and/or grinding of the teeth and/or by bracing or thrusting of the mandible during sleep (Jokubauskas, L and Baltrušaitytė, A 2018).

Clinical implication: Bruxism should be considered a behavior that may lead to harm, but not necessarily harmful dysfunction as such. SB may serve as a physiological goal and thus could be viewed as a possible mirror of underlying health conditions. SB should be viewed as a condition that requires management only when it has consequences. General treatment approaches include behavioural strategies, pharmacotherapy and intraoral devices.

Practical application: The nature of biofeedback is dependent on the circadian type of bruxism. In a state of being awake, the stimulation is aimed at raising awareness of bruxing activity thus prompting to relax jaw muscles as well as to control the thoughts that might have led to awake bruxing. Contingent electrical stimulation (CES) was shown to be effective in reducing SB-related motor activities after a short-term period. CES enables feedback to be provided as an electrical stimulus applied to the trigeminal area (skin, lip or masticatory muscles). This application elicits an inhibitory reflex response in contracting jaw-closing muscles. The possibility of local effects, such as biochemical changes in stimulated tissues sets CES apart from other form of biofeedback for SB.

Reference: Jokubauskas, L. and Baltrušaitytė, A., 2018. Efficacy of biofeedback therapy on sleep bruxism: A systematic review and meta‐analysis. Journal of Oral Rehabilitation45(6), pp.485-495.

PRACTICE MANAGEMENT

Practice Management

Body dysmorphia in dentistry: a real concern!

The patient experience covers a diverse range of aspects of care, including the staff and the environment, information provision and involving patients in shared decision-making about their care. Patient-centred care involves being proactive with patients to be involved in decision-making and to build good professional relationships which will enhance communication and trust (Kalsi JS et al, 2018).

Clinical implication: Ensure that a treatment plan is likely to meet the individual’s expectations. Any doubts must be fully explored with the patient before commencing treatment. If expectations are not met, this may result in the patient being dissatisfied. Patient burnout in dentistry is defined as an emotionally exhausted dental patient which can be minimised by good non-verbal, verbal and written communication, not progressing with complex treatment too fast, under promising and overdelivering and keeping treatments simple.

Practical application: Provision of high quality information is available in different formats, including audio-visual, social media and Apps. The effect of neurotic personality traits may reduce those levels of satisfaction even if the outcome is good from the clinician’s perspective. Body dysmorphic disorder (BDD) in the dental context, is when patients attend with excessive concern about a dental problem which is having a much greater impact on their life than would be anticipated considering the relative severity of the problem. The prevalence of BDD is 5% in the orthodontic and cosmetic dentistry population and 11% in the orthognathic population, compared with around 2% in the general population.

Reference: Kalsi, J.S., Hemmings, K.W. and Cunningham, S.J., 2018. Patient-centred care: how close to this are we? Dental Update45(6), pp.557-568.

PERIODONTICS

Periodontics

Antibiotics and periodontal attachment

There is reasonable evidence to suggest that the use of antibiotics as an adjunct to non-surgical therapy may provide modest improvements in clinical attachment gain and that this benefit is greater in deeper pockets and in patients suffering form aggressive forms of periodontitis. The optimal dose and duration of amoxicillin-plus-metronidazole prescribed as an adjunct to non-surgical periodontal therapy was studied by McGowan et al, 2018.

Clinical implication: The greatest change in clinical attachment levels and periodontal probing depths occur within the first 1-3 months after non-surgical treatment, healing and maturation of periodontal tissues continue for 9-12 months post-operatively. Systemic antibiotics should only be prescribed as an adjunct to mechanical instrumentation.

Practical application: There was no clinical meaningful difference between different doses or duration of amoxicillin-plus-metronidazole at 3 months post treatment. The highest dose for the shortest period of time has been suggested as a method for reducing the risk of antibiotic resistance. Use of 400mg/500mg or 500/500mg combinations of amoxicillin and metronidazole respectively administered for 7 days has been proposed.

Reference: McGowan, K., McGowan, T. and Ivanovski, S., 2018. Optimal dose and duration of amoxicillin‐plus‐metronidazole as an adjunct to non‐surgical periodontal therapy: A systematic review and meta‐analysis of randomized, placebo‐controlled trials. Journal of Clinical Periodontology45(1), pp.56-67.

ORAL SURGERY

Oral Surgery

Removal of third molars protocol in orthodontics

As oral hygiene around the world has improved and as orthodontists increasing employ a non-extraction treatment plan, the prevalence of impacted third molars may rise in the future. A modern classification describes third molars as being symptomatic or asymptomatic and disease free or disease positive (Hyam DH, 2018). Third molars can also be classified as being visible at the line of occlusion (i.e. functioning), visible but not at the line of occlusion (i.e. non-functional) or not visible (unerupted).

Clinical implication: There is now considerable evidence to support the removal of symptom free/disease positive third molars in young adults. The decision to prophylactically remove third molars in the post-orthodontic patient remains a purely clinical and patient preference derived decision.

Practical application: There is no consensus within the literature when third molars should be assessed. A third molar which has a periodontal probing depth of 4 mm or more is likely to experience an increase in that probing depth over time. That patient is also likely to develop clinically significant periodontal probing depths in the anterior dental arch if they have a pre-existing periodontal defect at the third molar. If surgery has not been advised, patients with known third molars should have regular review and be considered for reasonable regular radiological assessment. The degree of symptomatology and type of contraindication to surgery should be considered when deciding between a 2, 5, or 10-year review OPG interval.

Reference: Hyam, D.M., 2018. The contemporary management of third molars. Australian Dental Journal63, pp.S19-S26.

GENERAL PRACTICE

General practice

Tricalcium silicate best to protect the pulp

The clinician aims to seal the dentinal tubules opened during cavity preparation in order to prevent microleakage and, by extension, pulpal inflammation. Materials used in current practice include resin-modified glass ionomer cement, dentine-bonding agents, flowable resin-based composites, bulk fills which should be used in combination with a dentine-bonding agent e.g. SonicFill (Kerr) and therapeutic restorative cements: tricalcium silicate e.g. Biodentine(Septodont) which was specifically developed to protect the pulp. Biodentinehas a working time of six minutes and is set in 12 minutes from the start of mixing (Bonsor SJ, 2017).

Clinical implication: Dentine-bonding agents often contain HEMA and cannot be placed directly onto exposed pulpal tissue. The management of a vital asymptomatic tooth in contemporary practice would therefore involve leaving affected dentine overlaying the pulp if there was any risk of exposure and using a therapeutic lining material such as Biodentinein an attempt to facilitate pulpal healing. Tri-calcium silicates appears to be more effective than calcium hydroxide for maintaining long-term pulp vitality after direct pulp-capping.

Practical application: The intra-coronal indications for the use of Biodentine are as a dentine substitute, a lining material in deep cavities and where a pulpal exposure is encountered either during cavity preparation, following trauma or for pulpotomy in primary molars. It can be placed as a temporary or the material may be placed as a lining material and covered with resin composite or dental amalgam at the same appointment which is considered to be preferable. Placement of a definitive restoration within the first two days after pulp exposure contributed significantly to an increased pulpal survival rate.

Reference: Bonsor, S.J., 2017. Contemporary strategies and materials to protect the dental pulp. Dental Update44(8), pp.731-741.

IMPLANTOLOGY

Implantology

Screw loosening in implants

The principle of screw mechanics involves applying a torque force to produce elongation and tension that in turn develops a force within the screw knows as preload. The elastic recovery of the screw then pulls the components together resulting in a clamping force. Techniques that allow angulation correct for screw-retained implant-supported restorations are now available. However, whether angulation correction built into the head of the implant affects abutment screw loosening is unclear. Hotinksi E and Dudley J, 2018 did an in-vitro study to assess abutment screw loosening in angulation-correcting implants and straight implants subjected to simulated non-axial occlusal loading.

Clinical implication: The mean abutment screw torque loss was 59.8% for the angulation-correcting implant group and 68.7% for the straight implant group. A statistically significantly greater mean abutment screw removal torque was recorded in the angulation-correcting implant group compared with the straight implant group after 1,000,000 cycles of 50N which simulated 1 year of occlusal function.

Practical application: The angulation-correcting implant where the angulation correction is built into the head of the implant provides a convenient way to facilitate direct-to-implant screw retention and also resists screw loosening more than conventional straight implants.

Reference: Hotinski, E. and Dudley, J., 2018. Abutment screw loosening in angulation-correcting implants: An in vitro study. The Journal of Prosthetic Dentistry.

 

ORTHODONTICS

Orthodontics

Customised versus non-customised self-ligating brackets

Several orthodontic systems use new technologies which provide orthodontists with a package for treatment which consists of digital diagnostics, 3D digital planning and computer-designed customised brackets and arch wires. Penning EW et al, 2017 compared treatment outcomes using customised versus non-customised orthodontic treatment. A randomised controlled clinical trial involved 180 patients who were scheduled to receive full fixed orthodontic appliances. The orthodontic treatment was either going to be fully customised self-ligating brackets or non-customized self-ligating brackets.

Clinical implication: There was no reported difference in the treatment time between the two groups of patients and no differences in treatment outcomes.

Practical application: Compared with patients in the non-customised group, patients who received customised treatment had more loose brackets, a longer planning time, more complaints and were charged more in fees.

Reference: Penning, E.W., Peerlings, R.H.J., Govers, J.D.M., Rischen, R.J., Zinad, K., Bronkhorst, E.M., Breuning, K.H. and Kuijpers-Jagtman, A.M., 2017. Orthodontics with Customized versus Non-customized Appliances: A Randomized Controlled Clinical Trial. Journal of Dental Research96(13), pp.1498-1504.

 

AESTHETICS

Aesthetics

Management of fused incisors

Gemination is a malformation of a single tooth with a completely or partially bifid crown usually with a common root and root canal. Fusion is the union between 2 or more teeth that develop separately. The most common fused teeth are maxillary permanent and mandibular primary incisors or canines with premolars and molars rarely involved. Fused teeth are usually unilateral but have been reported bilaterally.

Clinical implication: Poor aesthetics is the major complaint of patients with a fused or geminated tooth due to increased width of the tooth and spacing between the teeth. The buccal and lingual grooves present on the crown extending sub-gingivally can impede plaque removal and increase the incidence of periodontal disease and caries.

Practical application: A multidisciplinary approach is advocated for patients with a geminated or fused tooth. Not all patients require extensive treatment. A conservative treatment plan should be considered (Ray S, 2018) such as the use of ceramic veneers as for the aesthetic management of fused teeth. Ray describes how a single ceramic veneer on the fused incisor was chosen to imitate two teeth. Tooth preparation for the ceramic veneers was minimal. During fabrication of the ceramic veneer, available interdental spaces were used to create anatomically attractive central and lateral incisors.

Reference: Ray, S., 2018. Esthetic management of fused incisors with ceramic veneers. The Journal of Prosthetic Dentistry.

 

ORAL MEDICINE

ORAL MEDICINENew radiation techniques have reduced side effects

Oral complications at 6 months after radiation therapy (RT) for head and neck cancer was studied (Lalla RV et al, 2017). RT for Head and Neck Cancer typically involves total doses of 6000-7000cGy, delivered in daily fractions over 6-7 weeks and is known to cause a number of complications. Intensity-modulated radiation therapy (IMRT) is now considered the standard of care for head and neck cancer. When IMRT is employed, it is possible to reduce the radiation dose to adjacent structures (such as salivary glands) thereby potentially reducing incidence and/or severity of oral complications. There is additional recovery of salivary flow beyond 6 months after RT has been reported when modern techniques are used.

Clinical implication: This study found more than a 50% reduction in mean stimulated whole salivary flow rate 6 months after the start of RT. This was in fact higher than that reported 6 months after RT using older treatment modalities. RT can cause inflammation and fibrosis of the muscles of mastication which can lead to reduced mouth opening. Lalla RV et al, found a 3mm reduction in mean maximal mouth opening for all subjects. At 6 months, 8.3% of subjects had some oral mucositis.

Practical application: Oral health and quality of life was reduced at 6 months with negative changes related to dry mouth, sticky saliva, swallowing solid foods and a sense of taste. Oral hygiene practices are very important after head and neck RT due to increased risks for dental caries and osteoradionecrosis. It is necessary to provide education and strong reinforcement on the need for aggressive preventive measures and supplemental fluoride therapies.

Reference: Lalla, R.V., Treister, N., Sollecito, T., Schmidt, B., Patton, L.L., Mohammadi, K., Hodges, J.S., Brennan, M.T. and OraRad Study Group, 2017. Oral complications at 6 months after radiation therapy for head and neck cancer. Oral diseases23(8), pp.1134-1143.

MATERIALS

MATERIALSFluoride releasing restorations show great promise

Fluoride-releasing restorations have a cario-static ability on enamel, cementum and dentin margins. Once the fluoride containing material is in place, it starts to leach fluoride into the surrounding tooth structure and the bioavailability of fluoride is increased in saliva and then taken up by plaque and enamel. After all original fluoride content is exhausted, the surface of the fluoride-containing restoration can be replenished when exposed to external fluoride and may act as a reservoir for future fluoride release (Abudawood S, and Donly KJ, 2017).

Clinical implication: The higher the fluoride content of the agent, the higher the recharging ability. Resin-modified glass ionomer showed less demineralisation at restoration margins when compared to non-fluoridated resin with the ability to form inhibition zones in dentin adjacent to restoration margins. Multiple topical fluoride agents are available with different abilities to re-charge dental restorations.

Practical application: Fluoride-containing restorative materials and supplementary topical fluoride agents are recommended in high caries risk patients or those with active caries or those who are non-compliant with maintaining oral hygiene.

Reference: Abudawood, S. and Donly, K.J., 2017. Fluoride release and re-release from various esthetic restorative materials. American Journal of Dentistry30(1), pp.47-51.

AESTHETICS

AESTHETICS  Can you bleach composites?

An increase in demand for improved aesthetics in dentistry has led to an increase in the use of ceramic and tooth-coloured resin composites. Composites may be either direct or indirect including CAD/CAM processed composites. CAD/CAM composites offer several advantages in terms of intraoral repairability. The colour and translucency changes of CAD/CAM composites to direct and indirect laboratory-processed composites after exposure to common staining solutions (tea, cola, coffee and red wine) was evaluated (Quek SHQ et al, 2018).

Clinical implication: All the composites in the study were susceptible to various degrees of discolouration and translucency changes after exposure to staining beverages. Red wine generally caused the most discolouration and translucency changes. CAD/CAM composites were more colour stable than direct and indirect materials however colour changes were still clinically perceptible.

Practical application: In-office bleaching for CAD/CAM and direct resin composites using 40% hydrogen peroxide can be an effective method to remove stains from dental restorations so restoration replacement as a result of discoloration may no longer be necessary (Alharbi A et al, 2018).

References: Quek, S.H.Q., Yap, A.U.J., Rosa, V., Tan, K.B.C. and Teoh, K.H., 2018. Effect of staining beverages on color and translucency of CAD/CAM composites. Journal of Esthetic and Restorative Dentistry.

Alharbi, A., Ardu, S., Bortolotto, T. and Krejci, I., 2018. In‐office bleaching efficacy on stain removal from CAD/CAM and direct resin composite materials. Journal of Esthetic and Restorative Dentistry30(1), pp.51-58.

PERIODONTICS

PERIODONTICSTopical anaesthetics for scaling are effective in right scenario

Conventional treatment for periodontitis includes scaling and root planning (SRP). About 30-40% of patients request local anaesthetic for pain control. The most commonly used anaesthetic used during SRP is infiltrative anaesthetic. However, this is associated with anxiety and pain, fear of needles and discomfort due to anaesthesic effect on soft tissues (Wambler LM et al, 2017). Intra-pocket topical anaesthetic could be an alternative to control pain during SRP. A variety of delivery methods are available – ointment, creams and gels.

Clinical implication: The risk of developing pain is similar for injected and topical anaesthesia during SRP. Injected anaesthetic decreases the intensity of pain more than anaesthetic gel and reduced the need for rescue anaesthetic (another application of topical or infiltrative) during SRP. However, there is pain caused by needle puncture. Injected anaesthesia lasts more than 1 hour.

Practical application: Intra-pocket anaesthetics have limited capacity for penetration because they have to make their way through the keratinised cells that protect the outer layer of the oral mucosa. Intra-pocket anaesthesia has a short duration of action of 15-20 minutes. The dentist can advise patients about the advantages and disadvantages of each anaesthetic administrative method. Patients who are anxious about and have a fear of needles will probably elect intra-pocket anaesthesia.

Reference: Wambier, L.M., de Geus, J.L., Boing, T.F., Chibinski, A.C.R., Wambier, D.S., Rego, R.O., Loguercio, A.D. and Reis, A., 2017. Intra-pocket topical anaesthetic versus injected anaesthetic for pain control during scaling and root planing in adult patients: Systematic review and meta-analysis. The Journal of the American Dental Association148(11), pp.814-824.

PREVENTIVE DENTISTRY

PREVENTIVE DENTISTRY

Beware of acidic beverages!

Hard tissue changes such an enamel hypo-mineralization, abrasion and erosion are apparent despite a global decline in tooth decay rates. Regular consumption of acidic beverages markedly decrease the saliva buffer capacity which consequently results in demineralization of tooth structure.

Clinical implication: When teeth that were exposed to different beverages were evaluated with pH less than 4 in an in vivo study, it was noted that the solubility of hydroxyapatite in both enamel and dentine increased (Tocolini DG et al, 2018). Natural juices, especially grapefruit and lemon juices, have an erosive capacity and change the surface roughness of enamel. Non-operative management techniques are advised such as re-mineralizing agents (Tooth Mousse). Reduced frequency of consumption and less contact time of erosive foods/drinks with the teeth is advised. Use of straws appropriately positioned and consumption of dairy products as a substitute is recommended (Buzalaf MAR et al, 2018).

Practical application: Extra care must be taken with children regarding the consumption of acidified beverages. Early clinical diagnosis, identification of aetiologic factors involved is the key to prevention. Education and counselling of the patient is essential.

References: Buzalaf, M.A.R., Magalhães, A.C. and Rios, D., 2018. Prevention of erosive tooth wear: targeting nutritional and patient-related risks factors. British dental journal224(5), p.371.

Tocolini, D.G., Dalledone, M., Brancher, J.A., de Souza, J.F. and Gonzaga, C.C., 2018. Evaluation of the erosive capacity of children’s beverages on primary teeth enamel: An in vitro study. Journal of Clinical and Experimental Dentistry10(4), p.e383.

PRACTICE MANAGEMENT

PRACTICE MANAGEMENTDental nurse career progression: let’s talk about it

Mindak MT, 2017 examined aspects of the nurse’s role in order to provide recommendations for reducing staff turnover which disrupts the routine of the dentist and staff relationship continuity with patients. Most dentists viewed the major role of the dental nurse as anticipating the dentist’s needs. Nurses said that they saw a major part of their role to be acting as an intermediary between dentists and patients. Many nurses expressed a desire to expand their role and mentioned the lack of a career path and many make a decision to obtain further qualifications within dentistry.

 Clinical implication: In order to achieve better communication with all the staff, practice meetings are encouraged. Training of staff on an on-going basis is considered essential.

Practical application: Good communication involves active listening. Feedback of role performance helps to clarify discussion and self-disclosure so an atmosphere of trust and openness can be established. Staff should be able to make comments and suggestions. Praise and recognition are powerful ‘motivators’. Frank discussions about career pathways should always be encouraged.

Reference: Mindak, M.T., 2017. Service quality in dentistry: the role of the dental nurse. BDJ Team4(10), p.17177.

ORTHODONTICS

ORTHODONTICS

Bony changes from IPR? fact or fiction

Hellak A et al, 2018 used data sets to identify associations between treatment for adult crowding using Invisalign aligners, interproximal enamel reduction (IPR) and changes in volume of inter-radicular bone. CBCT scans for adult patients were examined retrospectively in order to measure 3D bone volume.

Clinical implication: Treatment of adult crowding using Invisalign and IPR, particularly in patients who are periodontally at risk, appears to have a positive effect on the inter-radicular bone volume at least in adult female patients. Although the roots ought to move closer to each other after removal of enamel during IPR, the positive effect of reshaping the dental arch appears to outweigh this at least in the mandible.

Practical application: IPR did not have any significant effect on the bone volume between anterior dental roots. The distribution pattern of changes in the inter-radicular distance was almost identical with and without IPR.

Reference: Hellak, A., Schmidt, N., Schauseil, M., Stein, S., Drechsler, T. and Korbmacher-Steiner, H.M., 2018. Influence on inter-radicular bone volume of Invisalign treatment for adult crowding with interproximal enamel reduction: a retrospective three-dimensional cone-beam computed tomography study. BMC Oral Health18(1), p.103.

IMPLANTS

IMPLANTSIs there a consensus on antibiotic usage for dental implant placement in healthy patients?

Dental practitioners and dental specialists are faced with a dilemma when prescribing antibiotics for patients undergoing implant placement procedures. Statistics show that 72-85.5% of dentists from Finland, India, Sweden, USA and UK are likely to prescribe routine antibiotics during a dental implant placement preoperatively and/or postoperatively, using a rule-based approach rather than considering each case on its own merits (Pyysalo M et al, 2014). Park J et al, 2017 conducted a review of databases to find out whether there is a consensus for antibiotic prescription in healthy patients undergoing implant placement.

Clinical implication: Antibiotics should ideally be confined to compromised patients where there are systemic signs of infection and not given to healthy patients.

Practical application: Antibiotics, when given either preoperatively or postoperatively did not improve clinical outcomes in dental implant treatment over a placebo. The use of postoperative antibiotics should only be warranted to those who are exhibiting signs of infections and the aid of innate and adaptive immunity proves to be inadequate.

References: Pyysalo, M., Helminen, M., Antalainen, A.K., Sándor, G.K. and Wolff, J., 2014. Antibiotic prophylaxis patterns of Finnish dentists performing dental implant surgery. Acta Odontologica Scandinavica72(8), pp.806-810.

Park, J., Tennant, M., Walsh, L.J. and Kruger, E., 2018. Is there a consensus on antibiotic usage for dental implant placement in healthy patients?. Australian Dental Journal63(1), pp.25-33.

PROSTHODONTICS

PROSTHODONTICS Stretching for TMD relief? Bring it on!

Exercise therapy is often advised for management of musculoskeletal disorders. Passive stretching has shown a reduction in electromyographic activity and increases the range of motion of joints. Muscle-stretching exercises tend to improve the elastic properties of tendons. Gouw S et al, 2017 proposed that a dysfunction in proprioception may be a factor in bruxism aetiology.

Clinical implication: Stretching exercises should be done frequently and repetitively to bring about changes in neuroplasticity. Exercises should not be done too intensively to prevent overstretching and thus microtrauma of the muscle fibres.

Practical application: Stretching should not be done for too long as stretching for more than 60 seconds can be detrimental (Kay AD and Blazevich A, 2012). Vibration is suggested in addition to stretching exercises. Vibration activates the muscle spindle and causes a feeling of muscle relaxation due to desensitisation.

Reference: Gouw, S., de Wijer, A., Creugers, N.H., Kalaykova, S.I. and Creugers, N.H., 2017. Bruxism: Is There an Indication for Muscle-Stretching Exercises?. International Journal of Prosthodontics30(2).

Kay, A.D. and Blazevich, A.J., 2012. Effect of acute static stretch on maximal muscle performance: a systematic review. Medicine & Science in Sports & Exercise44(1), pp.154-164.

EMERGENCY DENTISTRY

EMERGENCY DENTISTRY
Optimal avulsed tooth protocol

Tooth avulsion comprises 1-11% of all traumatic injuries to the permanent dentition. Avulsion severs the vascular and nerve supply and tears the periodontal ligament. Complete displacement from the socket results in damage to the PDL cells. The most recommended medium to store and transport avulsed teeth was reviewed (Adnan S & et al, 2018).

Clinical implication:
  The avulsed tooth must not be allowed to dry and be placed in a storage medium as soon as possible until replantation. Milk is considered the most viable option in terms of PDL cell viability and cost-effectiveness. Milk must be fresh and have been refridgerated. Pasteurised milk is not always available so other media are also suggested for different locations and situations. Propolis (derived from bees) has anti-inflammatory and antimicrobial properties and is available commercially. Coconut water is a naturally occurring sterile electrolyte, rich in proteins, vitamins and minerals. It may be a viable storage medium in some geographic locations.

Practical application: A tooth-preserving system containing essential nutrients is marketed as “SAVE A TOOTH” and is commercially available as it maintains PDL cell viability. The authors advise that an avulsed tooth be placed in Hank’s Basic Salt Solution (HBSS) for 30 minutes prior to replantation, regardless of the storage medium in which the tooth was placed before replantation.

Reference: Adnan, S., Lone, M.M., Khan, F.R., Hussain, S.M. and Ehsan, S., 2018. Which is the most recommended medium for the storage and transport of avulsed teeth? A systematic review. Dental Traumatology.

IMPLANTOLOGY

IMPLANTOLOGYPatient education protocols are essential for longevity

Patient education is important for the maintenance of dental implants. Dentists have a duty of care to provide patients with full clear and accurate information before, during and after their treatment (Coleman Al & et al, 2017). The patient should be provided with written information about maintaining optimum oral hygiene and regular dental assessment and maintenance responsibilities in the after-care program. A no-smoking written policy guideline is strongly advised as smoking is well known to be associated with a higher risk of failure.

Clinical application: Potential complications should be explained to the patient. If problems with pain, bleeding, suppuration, looseness or mobility of the implant restoration occurs, the patient should know to seek treatment as quickly as possible.

Practical implication: Sharing information (including technical details) with patients regarding their implant treatment is an important component of promoting long-term care and maintenance. An adverse incident may occur and the patient may not be able to attend the treating dentist. Companies such as Straumann provide patients with “Implant passports” which can be given to patients for their records. This is crucial if new componentry is required.

Reference: Coleman, A., Webb, L. and Nixon, P., 2017. Technique tips—patient information for implant maintenance. Dental Update, 44(7), pp.680-681.

PRACTICE MANAGEMENT

Cognitive Mode

Use cognitive behavioural therapy in your practice

Cognitive Behaviour therapy is a psychological approach to solving problems and was studied to measure effectiveness with patients with dental phobias. It aims to empower people to solve problems through addressing their thoughts and behaviours and seek to determine whether these are helping or hindering the problem-solving process (Newton T and Gallagher J, 2017).

Clinical implication: CBT has been suggested for dental phobias with a specific focus on the behavioural aspects of therapy. CBT led to sustained decreases in self-reported dental fear, both compared with controls and with similar patients treated under sedation.

Practical application: CBT is a problem-focused intervention which requires close co-operation between practitioner and patient and the patient is required to do “homework” outside of the formal sessions to strengthen the learning. The positive side is that a high-proportion of patients who are suitable for the CBCT approach can be treated without sedation (Kani E & et al, 2015). All dental staff require some training in the specific requirements of working with people with dental phobias.

References: Newton, T., Gallagher, J. and Wong, F., 2017. The care and cure of dental phobia: the use of cognitive behavioural therapy to complement conscious sedation. Faculty Dental Journal, 8(4), pp.160-163.

Kani, E., Asimakopoulou, K., Daly, B., Hare, J., Lewis, J., Scambler, S., Scott, S. and Newton, J.T., 2015. Characteristics of patients attending for cognitive behavioural therapy at one UK specialist unit for dental phobia and outcomes of treatment. British dental journal, 219(10), p.501.

PERIODONTICS

PERIODONTICSLatest periodontal diagnosis technique outlined

Periodontal disease remains one of the most complex diseases affecting the oral cavity. The differential diagnosis between chronic and aggressive periodontitis can be complex. The correct diagnosis is the key element in disease management. The complete periodontal examination consists of a detailed medical and dental history, clinical examination and radiographic examination. The authors reinforce a specific technique for accurate diagnosis.

Clinical implication: The required starting point is the Basic Periodontal Examiniation (BPE). This is a rapid screening tool that provides information regarding the next level of examination and treatment where pocketing depths greater than 3.5 mm require intervention. Individual periapical radiographs are the gold standard for accurate and detailed assessment of periodontal bony defects, bony pathology, subgingival calculus deposits and any furcations or apical involvement.

Practical application: The BPE score should be recorded with a WHO probe which has a ball end, 0.5 mm diameter and a black banding from 3.5-5.5 mm and 8.5-10.5 mm (Chatzistavrianou D and Blair F, 2017). A light probing force of 20-25 grams should be used. Probing depth 3.5-5.5 mm requires recording a 6-point pocket chart in the sextant only at a post-treatment review. Probing depths more than 5.5 mm requires a 6-point pocket chart for the entire dentition pre-treatment and post-treatment.

Reference: Chatzistavrianou, D. and Blair, F., 2017. Diagnosis and management of chronic and aggressive periodontitis part 1: periodontal assessment and diagnosis. Dental update, 44(4), pp.306-315.

GENERAL PRACTICE

GENERAL PRACTICEUpdate on trigeminal neuralgia diagnosis and treatment

Trigeminal neuralgia (TN) is an important neuropathic entity due to its severity, prevalence and the fact it overlaps other dental conditions. TN is often described as a lightning bolt-type pain that lasts for seconds up to 2 minutes. Common neuropathic pain descriptors are sharp, shooting, electrical, burning or tingling. Pulpal and periraducular pain e.g. symptomatic irreversible pulpitis or symptomatic apical periodontitis are often described as sharp or may be dull, achy or throbbing.

Clinical implication: 80% of patients with TN seek treatment from their dentist first. The differential diagnosis relies primarily on the pain history and absence of any observable pathosis (Spencer CJ, 2017). At the beginning stages of TN, symptoms can vary, at first resembling a toothache at a moderate pain level with perhaps an occasional electrical pain and this stage is known as pre-trigeminal neuralgia. Refer to a neurologist once TN is diagnosed. Management begins with prescription carbamazepine. This also confirms the diagnosis as it is efficacious in 90% of patients with TN but not useful in patients with most other pain symptoms. Often the first attack follows a dental visit, although there is no known direct connection.

Practical application:  For patients with TN-

1. All dental procedures must minimise pain input to the trigeminal system. Dental disease prevention is critical.

2. Elective procedures such as implant and aesthetic dentistry should be avoided. Cavitated carious lesions should receive the most conservative cavity design possible.

3. During any invasive dental treatment, keep the patient comfortable with profound and long-lasting local anaesthesia.

Reference: Christopher J. Spencer, 2017. Pain Management Neuropathic pain and tooth pain. Academy of General Dentistry, Mar/Apr; 65(2):20-22.

ORAL MEDICINE

ORAL MEDICINEAre you prescribing the correct antibiotics?

Severe odontogenic infections of the head and neck are the most frequent presentation which require emergency hospitalisation to oral and maxillofacial surgical units in Australia (Liau I & et al, 2018). Over-use or inappropriate selection of systemic antibiotic therapy is identified as a significant factor in the development of antibiotic-resistant bacterial strains. The use of systemic antibiotics should be restricted to the presence of severe deep space involvement or failure to respond to primary surgical therapy. Systemic antibiotics should only be adjunctive to surgical intervention.

Clinical implication: It has been shown that there is a moderate antibiotic resistance to first-line antibiotics, penicillin and amoxicillin, in odontogenic infections (10.8% and 9.7% respectively). Second-line antibiotics such amoxicillin/clavulanic acid or cephalosporins is quite low (3.2% and 2.2% respectively). Either benzylpenicillin or amoxicillin should be used in severe odontogenic infections with metronidazole to cover anaerobes. Clindamycin, the antibiotic of choice for penicillin-allergic patients has a low resistance rate of 3.8%.

Practical application: General dentists play a critical role as the front-line of treatment of odontogenic infections. The cause of the infection should be removed either through endodontic therapy or extraction with adjunctive use of first-line antibiotics. Close monitoring of the initial treatment is critical. Urgent referral to a specialist oral surgeon is required in non-responsive cases. Severe odontogenic infections have potential for airway compromise (e.g. extraoral swelling, trismus, difficulty swallowing, respiratory distress or systemically unwell).

Reference:
Liau, I., Han, J., Bayetto, K., May, B., Goss, A., Sambrook, P. and Cheng, A., 2018. Antibiotic resistance in severe odontogenic infections of the South Australian population: a 9‐year retrospective audit. Australian dental journal, 63(2), pp.187-192.

PROSTHODONTICS

PROSTHODONTICSHow heavy should the occlusion be on implant retained crowns?

Occlusal factors can initiate and cause progression of peri-implant deterioration (Graves CV & et al, 2016). Loss of integration can occur without inflammatory signs on marginal tissue such as deep probing depths or bleeding, thus attributing the loss of osseointegration to other factors, such as excessive occlusal loading.

Clinical implication: Plaque-induced peri-implantitis is associated with concomitant marginal bone loss which progresses in an apical direction. Plaque-induced peri-implantitis is described radiographically as “saucer-shaped” bone loss in which the bone loss occurs within the limitation of the inflamed tissue. Mobility is not present until complete osseointegration is lost. Peri-implant bone loss caused by occlusal overload can be corrected by eliminating the traumatic occlusion and often, mobility is the only sign as other inflammatory markers are absent.

Practical application: Embrace the concept of “implant-protected occlusion.”
1. “Passive occlusion” where only the working opposing cups makes contact with the crown at 3 or 4 small points when the natural teeth are in maximum occlusion.
2a.  Check bite force on implant with thin articulating paper (less than 25 microns) to first assess occlusal contacts. Relieve implant crown thus placing heavier forces on adjacent teeth.
2b. Then exert a stronger force into the articulating paper creating contact regions on both the implant and adjacent teeth.
3.   Be aware that the longer the crown height, the greater the crestal movement with lateral forces.

Reference: Graves CV, Harrel SK, Rossmann JA, et al. The Role of Occlusion in the Dental Implant and Peri-implant Condition: A Review. The Open Dentistry Journal. 2016;10:594-601.

ORTHODONTICS

ORTHODONTICSFacial impact of premolar extractions significant

A principal concern regarding premolar extraction is the effect it may have on facial aesthetics, especially soft tissue profile. The nasolabial angle and the distance of the anterior border of the upper and lower lips to the aesthetics plane (E-plane) are commonly used measures of soft tissue profile. Studies show that these two measures increase with orthodontic treatments that include extractions of teeth (Kirschneck C & et al, 2016). The changes in the soft tissue profile following extraction orthodontic treatment with either first or second premolars was studied (Omar Z & et al, 2018).

Clinical implication: Less retraction of both the upper and lower incisor teeth was observed to have taken place when the four second premolar teeth were removed. The position of both upper and lower lips was more protrusive both at pre-treatment and post-treatment in the treatment group that had four first premolar teeth removed. The amount of retraction achieved in second premolar extraction cases was less than half of the amount of retraction achieved in first premolar extraction cases.

Practical application: The pre-treatment position of the lower incisors and the amount of lower incisor tooth retraction desired should be carefully considered when contemplating the removal of premolar teeth. There was no statistically significant difference in the mean change in nasolabial angle or the upper and lower lip position relative to the E-plane between treatment groups. There was a positive linear relationship seen between the amount of change in the position (retraction) of the maxillary incisor teeth and the amount of change (retrusion) in both upper and lower lip position.

References: Kirschneck, C., Proff, P., Reicheneder, C. and Lippold, C., 2016. Short-term effects of systematic premolar extraction on lip profile, vertical dimension and cephalometric parameters in borderline patients for extraction therapy—a retrospective cohort study. Clinical oral investigations, 20(4), pp.865-874.
Omar, Z., Short, L., Banting, D.W. and Saltaji, H., 2018. Profile changes following extraction orthodontic treatment: A comparison of first versus second premolar extraction. International orthodontics, 16(1), pp.91-104.

AESTHETICS

AESTHETICSBleaching protocols re-examined

Questions are frequently raised by dentists and patients on tooth bleaching. Identify the correct aetiology in order to obtain an effective treatment. Intrinsic staining necessitates chemical bleaching. Intrinsic stains may be caused by trauma to a developing permanent tooth, tetracycline, fluorosis, amelogenesis and dentinogenesis imperfecta, hypoplasia, molar incisor hypomineralization, porphyria and aging.

Clinical implications:
1. Radiation or chemotherapy treatment for melanoma precludes vital bleaching. Wait until age 18 to bleach teeth. Previous allergies, including ingredients in bleaching materials, may contra-indicate bleaching treatment.
2. Cavities, micro-cracks and thinned enamel need to be treated before undergoing any whitening procedure. Recession and periodontitis patients should be discouraged from tooth whitening due to cementum exposure and hypersensitivity.
3. Combine at home plus in-office treatment for severe discoloration such as tetracycline, or teeth with C4, D4 shades. While using in-office systems, a tray is recommended as a follow-up treatment.
4. When using the ‘At Home Technique’, observe weekly to see any initial bleaching results. 2−5 weeks are required to obtain the desired results. More severe cases (e.g. tetracycline discoloration) require at least double the time and quantity.

Practical application:
1. Teeth exhibiting yellow or orange intrinsic discolorations usually respond better and faster than teeth exhibiting bluish-grey discolorations.
2. Lower concentrations of carbamide peroxide are used for at-home treatment. Higher concentrations of hydrogen peroxide are reserved for the practitioner.
3. If sensitivity is experienced during bleaching, use of non-steroidal anti-inflammatory drugs (NSAIDs) or the application ofa desensitizer based on fluoride, casein phosphopeptide-amorphous calcium phosphate or potassium nitrate is advised. Apply immediately after removal of the carbamide-filled tray.
4. As bleaching proceeds, a point is reached at which only hydrophilic colourless structures exist. This is calledthe saturation point. The dentist must know that bleaching mustbe stopped at or before the saturation point. Clinically, if the patient visits the dentist two successive times with no colour change, the dentist can conclude that the saturation point has been reached.
5. Bleaching is not a permanent treatment and that some periodic re-bleaching will be required. Usually retreatment can be accomplished with either one in-office session or a 3-week sequence of wearing a tray once a year.
Reference: Mchantaf, E., Mansour, H., Sabbagh, J., Feghali, M. and McConnell, R.J., 2017. Frequently asked questions about vital tooth whitening. Dental update, 44(1), pp.56-63.

DENTAL MATERIALS

DENTAL MATERIALSEffective sealant around orthodontic brackets identified

Fixed orthodontic braces cause an increased retention area for food residue and biofilm. The risk of developing white spot lesions increases with treatment duration. The concentration of S.mutans in saliva before removal of fixed braces is significantly higher compared with after-bracket removal. Inadequate oral hygiene causes increased biofilm accumulation around bracket bases and demineralisation can occur within a few weeks. Coordes SL & et al, 2018 compared different enamel surface sealants preventing demineralisation around brackets. Various products were tested in vitro.

Clinical implication: The tooth surfaces treated with PRO SEAL® showed no white spot lesions on the enamel surface after thermal, mechanical and chemical treatment. This was the only product tested that clearly demonstrated protection against decay.

Practical application: Fluoride ion release and absorption was an essential factor in the effectiveness of PRO SEAL® against enamel demineralization. It is recommended to start additional local fluoridation after 17 weeks in view of decreasing fluoride release over time. Good patient co-operation and compliance is needed which is challenging in adolescents. The protective effect of PRO SEAL® against decay is quickly lost during tooth cleaning with powder/water devices and must be replaced if necessary.

Reference: Coordes, S.L., Jost-Brinkmann, P.G., Präger, T.M., Bartzela, T., Visel, D., Jäcker, T. and Müller-Hartwich, R., 2018. A comparison of different sealants preventing demineralization around brackets. Journal of Orofacial Orthopedics/Fortschritte der Kieferorthopädie, 79(1), pp.49-56.

PERIODONTICS

PERIODONTICSErythritol – chlorhexidine combination aids peri-implant diseases

Peri-implant diseases, such as peri-implant mucositis and peri-implantitis are bacterial-driven infections. Peri-implant mucositis is a reversible inflammatory lesion located in the mucosa. Peri-implantitis affects the supporting bone and can lead to implant loss. Drago, L & et al, 2017 evaluated the antibiofilm activity of a new low-abrasive powder and assessed its ability to reduce previously developed microbial biofilm and to prevent its formation on titanium surfaces. Biofilm was grown on sandblasted titanium discs and treated with erythritol/0.3% chlorhexidine.  Earlier studies by Schwarz F & et al, 2016 reviewed air polishing used as adjunctive measure or as monotherapy resulted in significant clinical improvements (bleeding index or BOP scores) following a single or repeated nonsurgical treatment of peri-implant mucositis and/or peri-implantitis.

Clinical application: Erythritol/chlorhexidine combination displayed significant antimicrobial and antibiofilm activity against microorganisms isolated from peri-implantitis lesions.

Practical application: The use of a minimally invasive powder containing Erythritol/chlorhexidine has been developed for use in commercially available air-polishing devices. The powder has a fine granulometry (14 microns) which limits the damage to hard and soft tissues. The PERIOFLOW plastic nozzle of the EMS Electro Medical disrupts biofilm particularly on implants.

References: Drago, L., Bortolin, M., Taschieri, S., De Vecchi, E., Agrappi, S., Del Fabbro, M., Francetti, L. and Mattina, R., 2017. Erythritol/chlorhexidine combination reduces microbial biofilm and prevents its formation on titanium surfaces in vitro. Journal of Oral Pathology & Medicine46(8), pp.625-631.

Schwarz, F., Becker, K., Bastendorf, K.D., Cardaropoli, D., Chatfield, C., Dunn, I., Fletcher, P., Einwag, J., Louropoulou, A., Mombelli, A. and Ower, P., 2016. Recommendations on the clinical application of air polishing for the management of peri-implant mucositis and peri-implantitis. Quintessence international47(4), pp.293-296.

AESTHETIC DENTISTRY

AESTHETIC DENTISTRY 1.1Amelogenesis imperfecta

Amelogenesis imperfecta is a genetically inherited defect of enamel that affects primary and permanent dentitions and may be associated with other dental abnormalities and systemic syndromes. The severity may range from mild hypoplasia affecting aesthetics to a severely mutilated dentition compromising function. Treatment in these cases must be started as early as it is detected and usually spans over many years and has to be coordinated with the growth pattern. Proper motivation of the patient is crucial. Various authors collaborated to create multi-disciplinary treatment planning options. Prosthodontics, periodontal, endodontic and orthodontic consultations and possibly orthognathic surgery may be necessary.

Clinical implication: The extent, appearance and pulpal status will determine the type of restorations required. The patient may have decreased enamel thickness and dentine exposed which may cause severe sensitivity so a combination of both fixed prosthodontics solutions and conservative direct composite restorations may be required in different areas of the mouth. The earlier the diagnosis of amelogenesis imperfecta is confirmed, the better the outcome is. Optimal treatment approaches consist of early diagnosis and treatment approach and frequent dental recall appointments to prevent progressive occlusal wear or early destruction by caries. Currently, no comprehensive therapy recommendation is evident.

Practical application: Pre-treatment of teeth with 5% sodium hypochlorite is suggested for use before composite restorations to enhance the effect of acid etching (Naik, M. and Bansal, S., 2018). De-proteinisation with sodium hypochlorite reduces the organic content and allows better etching and ultimately better bond strength.

References: Naik, M. and Bansal, S., 2018. Diagnosis, treatment planning, and full-mouth rehabilitation in a case of amelogenesis imperfecta. Contemporary Clinical Dentistry9(1), p.128.

Strauch, S. and Hahnel, S., 2018. Restorative Treatment in Patients with Amelogenesis Imperfecta: A Review. Journal of Prosthodontics.

PRACTICE MANAGEMENT

PRACTICE MANAGEMENTSEO for your website 2018 style

One of the best ways to acquire ideal patients who pay, stay, and refer is to make the practice web presence as Google-friendly as possible (Peski, G, 2018). “This old school dental website SEO” logic and protocols is dead. Previously, web designers could “game” the system by coding certain words into the website as many times as possible. Google worked this out and changed its algorithm so that on-page text (the text on a website) became less important. Secondly, there was an increased use of social media. Google noted what people were saying on sites like Facebook, Twitter, and YouTube. It measured how much businesses were participating in the conversation. The more mentions and reviews a site receives, the more Google believes the business is a trusted, liked, and valued service provider in the community. So higher rankings on Google’s search engine pages occurred. Google’s algorithm changes SEO criteria frequently. Google’s review system became an integral part to SEO as well.

Clinical implication:  Proper SEO is not an easy endeavor: you cannot set it and forget it. SEO focus today is on social proof and needs positive reviews and mentions from your patients. This will show potential new patients that you are trustworthy. Social proof results in higher rankings and more organic referrals, which often turn into coveted patients.

Practical Application: Even if you stay on top of social commenting and responding, Google’s algorithm still measures thousands of complicated data points. Utilize a practice management team that does SEO—and only SEO. This requires data engineers to study thousands of data points and ranking mechanisms every single day.

Reference: Peski, G. (2018). ‘Old school’ dental website SEO is dead. [online] Dentaleconomics.com. Available at: https://www.dentaleconomics.com/articles/print/volume-108/issue-2/practice/old-school-dental-website-seo-is-dead.html [Accessed 16 Jul. 2018].

GENERAL PRACTICE

GENERAL PRACTICE 1Silver diamine fluoride use with partially edentulous caries

There are an increasing number of aging partially edentulous patients. The need to manage caries risk in patients with prostheses has increased particularly if these patients are compromised by medical (Sjögren’s syndrome, scleroderma), physical (fraility) or cognitive disabilities (dementia) or medication-induced xerostomia. Giusti et al (2017) examined Silver diamine fluoride (SDF) as an effective minimally invasive solution to this problem. SDF treats caries by forming a layer of silver protein conjugate on a carious surface and kills cariogenic bacteria in dentinal tubules penetrating 50-200 microns into dentine.

Clinical implication:  Age-related gingival recession exposes root surfaces that are more susceptible to caries. Patients with substance-abuse problems (including methamphetamine) face similar problems. SDF should not be used in desquamative gingivitis or mucositis. Use of SDF in patients allergic to silver is an absolute contraindication.

Practical application: Discuss risks, benefits and alternatives with patient and inform them about dark staining of caries-infected root surfaces and brief metallic taste. Obtain informed consent.

The following technique is advised by Giusti L & et al, 2017:

  1. Isolate the area well and lubricate the lips.
  2. Apply 1 drop of 38% SDF to affected root surface with micro-brush for 1 minute.
  3. Apply GIC to cavitated surface to restore cleansable contours as needed.
  4. Repeat bi-annually to maintain caries arrest

Reference: Giusti, L., Steinborn, C. and Steinborn, M., 2017. Use of silver diamine fluoride for the maintenance of dental prostheses in a high caries-risk patient: A medical management approach. The Journal of Prosthetic Dentistry.

ORAL MEDICINE

ORAL MEDICINE 1Diagnosis and treatment of multiple myeloma

Multiple myeloma (MM) is one of the most frequent haematologic malignancies globally. Patients with MM are living longer due to advances in therapy – immunomodulatory drugs, proteasome inhibitors, monoclonal antibodies and anti-resorptive drugs including bisphosphonates (BPs). BPs inhibit the progression of osteoclastic activity in patients with MM and have been used to reduce the occurrence of bone fractures and pain. BPs also increase bone mineral density when associated with anti-myeloma agents.

Clinical implication: Faria KM & et al, 2018 demonstrated that regardless of IV BP therapy, radiographic patterns of MM in the jawbones include solitary bone lesions, multiple osteolytic lesions, diffuse osteoporosis, diffuse sclerosis and lamina dura abnormalities. The detection of osteolytic lesions has a pivotal role in decision-making protocols and treatment protocols as the International Myeloma Working Group advises the use of BP therapy in patients with active MM and at least one osteolytic lesion.

Practical application: Panoramic radiographs are well-established as an optimum radiographic examination regimen for patients with a diagnosis of MM.

BP therapy affects radiographic patterns of MM in the jawbones by decreasing the presence of solitary osteolytic lesion, increasing lamina dura abnormalities and causing non-healing alveolar sockets. Routine dental radiographic examination is advised to detect MRONJ in patients with MM. Osteosclerosis is an indicator of the risk of developing MRONJ in patients exposed to IV BP therapy.

Reference: Faria, K.M., Ribeiro, A.C.P., Brandão, T.B., Silva, W.G., Lopes, M.A., Pereira, J., Alves, M.C., Gueiros, L.A., Shintaku, W.H., Migliorati, C.A. and Santos-Silva, A.R., 2018. Radiographic patterns of multiple myeloma in the jawbones of patients treated with intravenous bisphosphonates. The Journal of the American Dental Association149(5), pp.382-391.

IMPLANTOLOGY

IMPLANTOLOGYFractured implant screw diagnosis technique

Although implant dentistry is associated with satisfactory long-term clinical and patient-centric outcomes, implant complications have also increased. Mechanical complications include a 3.9% incidence of fractured implant abutment screws and 6.7% incidence of loosened implant abutment screws.

Clinical implication: Loosening is often the precursor to a fractured screw. Completely retrieving the fractured abutment screws without damaging the implant is a clinical challenge. A repair or rescue device for the retrieval of the fractured implant abutment screws may be needed.  However, whether the screw was completely retrieved or the inner implant body was damaged may by uncertain.

Practical application: Igarashi K and Afrashtehfar KI, 2017 have described a technique which may be the most predictable way at the moment to clinically assess the internal implant body known as the “Bernese silicone replica technique”.  After retrieving the fractured abutment screw with a repair device, rinse with 10ml saline. Air dry the inner implant fixture and clean with micro-brush. Insert light body as deeply as possible into the implant body and then inject light body until it extrudes from the implant shoulder. Keep injecting until excess material is about 5mm coronally from the shoulder of the implant. Insert a wooden wedge as deeply as possible into the middle of the impression. Allow to set and remove the internal implant negative pattern by turning anti-clockwise. Compare the removed pattern with a control silicone pattern which should be compared with a pattern from an undamaged implant.

Reference: Igarashi, K. and Afrashtehfar, K.I., 2017. Clinical assessment of fractured implant abutment screws: The Bernese silicone replica technique. The Journal of Prosthetic Dentistry.

ORTHODONTICS

ORTHODONTICS

Apical root resorption with clear aligners

Orthodontically induced inflammatory root resorption (OIIRR) is a well-documented common result of fixed appliance orthodontic therapy. Severe root resorption is defined as loss of root length more than 25% on both maxillary central incisors as shown on panoramic images. However, both panoramic and intraoral radiography underestimate root length. A retrospective study by Aman C & et al, 2018 used CBCT to investigate the incidence and severity of OIIRR in patients who had comprehensive treatment with clear aligners. CBCT overcomes the limitations of panoramic and periapical radiography as results are highly reproducible, specific and sensitive.

Clinical implication: The prevalence of severe root resorption defined as both maxillary central incisors experiencing greater than 25% reduction in root length was found to be 1.25%. Percentage of change in root length for Class I malocclusion was significantly lower than for Class II malocclusions with less than a half-step molar Class II. The percentage of change in root length did not differ significantly from other classes of malocclusion.

Practical application: Post-treatment approximation of root apices relative to the palatal cortical plate showed the strongest association for increased OIIRR. This study concurred with other studies that found male subjects experienced more root resorption than female subjects.

Reference: Aman, C., Azevedo, B., Bednar, E., Chandiramami, S., German, D., Nicholson, E., Nicholson, K. and Scarfe, W.C., 2018. Apical root resorption during orthodontic treatment with clear aligners: A retrospective study using cone-beam computed tomography. American Journal of Orthodontics and Dentofacial Orthopaedics153(6), pp.842-851.

PROSTHODONTICS

PROSTHODONTICSManaging dental implications of childhood cancers

Chemotherapy is the first line of treatment used to treat many childhood cancers e.g. leukaemia and lymphoma and has shown improved survival rates. Typically, the chemotherapy regimen can last 1-3 years and the predicted 5-year survival rate for children and adolescents diagnosed with cancer has risen by up to 82%. The most common dental findings of a patient subject to chemotherapy at a young age include: delayed eruption, hypodontia, hypoplasia, microdontia, thin roots with enlarged pulps and root canal systems, arrested tooth development and tooth agenesis (Rizvi N & et al, 2018).

Clinical implication: Minimally destructive restorative techniques using composite and fibre reinforcement does not incur further damage being done to worn teeth.

There is a 19% chance of teeth developing endodontic complications when indirect restorations are used to restore the worn dentition.

Practical application: Management of edentulous spaces requires an appreciation of the need to restore the space and risks and benefits of doing so. Providing fixed minimally destructive such as resin-retained bridges or fibre-reinforced bridges and removable prostheses can be appropriate in many cases. An essential consideration is whether informed consent has been given to the patient of all the risks and alternative treatments.

Reference: Rizvi, N., Kelleher, M.G. and Majithia, M., 2018. Child cancers: managing the complications of childhood chemotherapy in the adult dentition. Dental Update45(5), pp.439-446.

GENERAL DENTISTRY

GENERAL DENTISTRYConsumption of fluoridated milk protects dental enamel

The effect on enamel of varying the frequency of consumption of 1.0 mg Fluoride (F) in milk once per day, twice per day or once every other day under cariogenic challenge in situ was studied by Malinowski, M., et al., 2017. In a controlled study, subjects wore an intra-oral lower removable appliance with enamel slabs for three weeks during each study arm. Subjects used F-free toothpaste, the cariogenic challenge comprising of five 2 min dippings per day in a 12% sucrose solution. Subjects dipped the appliances in 50 ml of 5.0 ppm fluoridated milk for five minutes during the test period once per day, twice per day, and once every other day and drank 200 ml of the same milk, once per day, twice per day (100 ml each time), or once every other day (200 ml) immediately on re-inserting their appliance in order to replicate topical and systemic effects. Slabs were analysed with surface microhardness (SMH) for protection against further demineralisation and transverse microradiography (TMR) to assess changes in mineralisation.

Clinical implication: Using SMH, 200 ml of 5.0 ppm F milk once per day was significantly better than 100 ml of 5.0 ppm F twice/day (p < 0.05) and 200 ml once every other day, but not significantly. Using TMR there was a statistically significant difference in mineral loss of enamel between baseline and treatment for all groups, but not between groups.

Practical application: It is optimal to drink 200 ml of 5.0 ppm F milk daily or every other day to protect enamel against further demineralisation. Drinking either 100ml of 5.0 ppm F twice daily or 200 ml daily or every other day is effective in promoting remineralisation.

Reference: Malinowski, M., Toumba, K.J., Strafford, S.M. and Duggal, M.S., 2017. The effect on dental enamel of the frequency of consumption of fluoridated milk with a cariogenic challenge in situ. Journal of dentistry.

PERIODONTICS

PERIODONTICSPeriodontal status of tooth adjacent to implant

The association between the periodontal status at the near and away sites of the teeth (according to implant) and the implant status (without/with peri-implantitis) was examined in a total 560 sites of 70 teeth/implant sets by Sung, C.E., 2018. Fifty-three subjects with existing dental implants and chronic periodontitis were examined. Seventy implants were categorised into peri-implantitis and healthy/mucositis groups. The periodontal and peri-implant status, including probing depth (PD), clinical attachment level (CAL), and gingival recession (GR) were measured at 6 sites around the implants and the teeth adjacent and contralateral to those implants. A significantly different mean PD and CAL were noted at the near sites of the teeth adjacent to the implants with peri-implantitis when compared with the away sites of adjacent and contralateral teeth and the near sites of contralateral teeth. The presence of peri-implantitis and tooth location were significantly associated with the values of the PD and CAL of the teeth.

Clinical implication: The existence of peri-implantitis is significantly associated with the periodontal measurements of the remaining teeth close to the implant.

Practical application: Implants showing signs of peri-implantitis contain subgingival microbiota similar to that around natural teeth with periodontal disease. A history of periodontitis as a possible risk factor for peri-implantitis.

Reference: Sung, C.E., Chiang, C.Y., Chiu, H.C., Shieh, Y.S., Lin, F.G. and Fu, E., 2018. Periodontal status of tooth adjacent to implant with peri-implantitis. Journal of dentistry.

PROSTHODONTICS

PROSTHODONTICSThe associations of pain symptoms with visible cracks

The associations of types of pain (pain on biting, pain due to cold stimuli or spontaneous pain) with crack-level, tooth-level and patient-level characteristics in posterior teeth with visible cracks were analysed by Hilton, T.J., et al., 2017. Subjects each had a single, vital posterior tooth with at least one observable external crack (cracked teeth); 2858 cracked teeth from 209 dentists were enrolled. Data were collected at the patient-, tooth-, and crack-level. Overall, 45% of cracked teeth had one or more symptoms. Pain to cold was the most common symptom, which occurred in 37% of cracked teeth. Pain on biting (16%) and spontaneous pain (11%) were less common. Sixty-five percent of symptomatic cracked teeth had only one type of symptom, of these 78% were painful only to cold.

Clinical implication: Positive associations for various combinations of pain symptoms were present with cracks that: (1) were on molars; (2) were in occlusion; (3) had a wear facet through enamel; (4) had caries; (5) were evident on a radiograph; (6) ran in more than one direction; (7) blocked transilluminated light; (8) connected with another crack; (9) extended onto the root; (10) extended in more than one direction; or (11) were on the distal surface. No patient-, tooth- or crack-level characteristic was significantly associated with pain to cold alone.

Practical application: Although often considered the most reliable diagnosis for a cracked tooth, pain on biting is not the most common symptom of a tooth with a visible crack, but rather pain to cold.

Reference: Hilton, T.J., Funkhouser, E., Ferracane, J.L., Gordan, V.V., Huff, K.D., Barna, J., Mungia, R., Marker, T., Gilbert, G.H. and National Dental PBRN Collaborative Group, 2017. Associations of Types of Pain with Crack-Level, Tooth-Level and Patient-Level Characteristics in Posterior Teeth with Visible Cracks: Findings from the National Dental Practice-Based Research Network. Journal of dentistry.

IMPLANTS

IMPLANTSImplant or root canal treatment has a higher survival rates?

Chatzopoulos, G.S., et al., 2018 assessed and compared the survival rates of implant and root canal treatment and investigated the effect of patient and tooth related variables on the treatment outcome in a large-scale population-based study. A total of 13,434 records of patients who had implant (33.6%) or root canal therapy (66.4%) were included. The survival rate analysis revealed the majority of the implants were removed within the first year (58.8%), while only 35.2% of the root canal treatments failed in the same time period. The overall survival rate was significantly higher for implant therapy (98.3%) compared to root canal treatment (72.7%).

Clinical implication: A statistically significant association was found between treatment, age and anxiety with treatment failure for both implants and root canal treatment.

Practical application: Although both root canal and implant treatments are sound options with high survival rates; root canal therapy exhibited a significantly higher failure rate.

Reference: Chatzopoulos, G.S., Koidou, V.P., Lunos, S. and Wolff, L.F., 2018. Implant and root canal treatment: Survival rates and factors associated with treatment outcome. Journal of dentistry71, pp.61-66.

ORAL MEDICINE

ORAL MEDICINE

Effect of low-energy laser therapy on pain relief and wound healing

Recurrent apthous stomatitis (RAS) is very painful and affects quality of life. There is no current effective established therapy for RAS. Suter, VGA, et al., 2017 conducted a systematic review of databases to assess the effects of lower level laser therapy on relief of pain, wound healing and episode frequency in patients with RAS.

Clinical implication: LLLT decreased immediate pain statistically more than triamcinolone acetonide (medium- to strong-potency corticosteroid) or placebo. LLTL decreased late pain more than topical corticosteroids, topical solcoseryl or granofurin, placebo or no treatment. The light wavelength (658 nm) used for the laser managed both pain and inflammation.

Practical application: LLLT improved wound healing statistically more than triamcinolone acetonide, topical solcoseryl or granofurin, placebo or no treatment. Using light wavelength (658 nm) for the laser led to very efficient management of both pain and inflammation symptoms. Low-energy laser therapy applied is a reliable therapeutic modality to treat chronic (RAS).

Reference: Suter, V.G., Sjölund, S. and Bornstein, M.M., 2017. Effect of laser on pain relief and wound healing of recurrent aphthous stomatitis: a systematic review. Lasers in medical science32(4), pp.953-963.

PRACTICE MANAGEMENT

PRACTICE MANAGEMENT

Should you manage you practice using the cloud?

Jensen A., 2018 says this is the year of the cloud. The cloud enables the user to have a smaller footprint. No server or hefty workstation is needed to power management software. Servers are expensive, require monitoring and have high maintenance. Servers are subject to security regulations.

Clinical implication: There are no hassles with management software upgrades and moving to the cloud gives access to enterprise-class technology. Data can always be embraced on the cloud and provides greater data security. The cloud embraces your practice data, showing “love” from multiple servers in multiple geographic locations.

Practical application: Data backup occurs to the last keystroke. There are no backup worried. If data must be restored, you get back to exactly where you left off. Manage the practice in the cloud.

Reference: Andy Jensen. 2018. The top 3 reasons to give the cloud a little love. [ONLINE] Available at: https://www.dentaleconomics.com/articles/print/volume-108/issue-2/science-tech/the-top-3-reasons-to-give-the-cloud-a-little-love.html. [Accessed 30 June 2018].

MATERIALS

MATERIALSComparing four desensitizing toothpastes

Dentine hypersensitivity (DH) can cause a sharp, sudden, painful reaction when the teeth are exposed to hot, cold, chemical, mechanical, touch, or osmotic (sweet or salt) stimuli and cannot be attributed to any other form of dental pathology or defect. DH is a sudden short sharp pain best explained by hydrodynamic theory. The aim of the present study was to compare the tubule occluding efficacy of four different desensitizing dentifrices under scanning electron microscope (SEM). Sixty-two dentin blocks obtained from extracted human molars were randomly divided into five groups: Group 1 – no treatment; Group 2 – Pepsodent Pro-sensitive relief and repair; Group 3 – Sensodyne repair and protect ; Group 4 – Remin Pro ; Group 5 – Test toothpaste containing 15% nano-hydroxyapatite (n-HA) crystals . The specimens were brushed for 2 min/day for 14 days and stored in artificial saliva. After final brushing, specimens were gold sputtered and viewed under SEM at ×2000 magnification and analysed.

Clinical implication: All test groups showed significant increase in dentin tubule occlusion as compared to control group.

Practical application: Remin Pro and a Test toothpaste containing 15% nano-hydroxyapatite (n-HA) crystals had the highest percentage of tubules occlusion and was significantly different from other groups and can thereby reduce the pain and discomfort caused by DH.

Reference: Jena, A., Kala, S. and Shashirekha, G., 2017. Comparing the effectiveness of four desensitizing toothpastes on dentinal tubule occlusion: A scanning electron microscope analysis. Journal of conservative dentistry: JCD20(4), p.269.

AESTHETICS

AESTHETICSTreating fluorosis using a conservative restorative approach

Hoyle, P., et al., 2017 reviewed conservative management techniques available for managing the aesthetic impact of fluorosis from mild to severely affected patients. Fluoride dentifrices in developed countries has caused an increase in incidence of mild and very mild forms of fluorosis. Fluoridated water is a well-recognised risk factor of fluorosis. WHO guidelines of fluoride in drinking water upper limit is 1.5 mg-F/L. A particular cohort of patients in some Ethiopian areas experienced 10mg-F/L in the water. The prevalence of dental fluorosis in that area ranges from 70%−100% with 35% being affected by the severe form. As the severity of fluorosis increases so does the porosity and fluoride content of the sub-surface enamel, resulting in increased extrinsic staining.

Clinical implication: Management of dental fluorosis is dependent upon its severity.  Suggested treatment options include:1. Bleaching; 2. Micro/macroabrasion; 3. Composite restorations; 4. Veneers; 5. Full crowns. Enamel microabrasion is the uses simultaneous erosion and abrasion to remove the superficial enamel. It is intended to remove between 50−200 μm of enamel. This enamel removal is pressure dependant. Hydrochloric acid (18%) is used most commonly for microabrasion. Home bleaching using soft-plastic, vacuum-formed night guards, either with or without reservoirs, in conjunction with 10% carbamide peroxide has been used. The patient, usually on a nightly basis, uses these for 2−6 week periods. If bleaching is to be used with composites, allow two-weeks before composite placement to allow both for shade regression and for any residual oxygen to diffuse away, as it is thought to have a detrimental effect on composite bonding.

Practical application: A conservative restorative approach can be used to mask even severe fluorosis. Consideration of such techniques in treatment planning is required to reduce the biological cost of using more traditional methods.

Reference: Hoyle, P., Webb, L. and Nixon, P., 2017. Severe fluorosis treated by microabrasion and composite veneers. Dental Update44(2), pp.93-98.

ORTHODONTICS

ORTHODONTICSFactors associated with discontinued and abandoned treatment

McDougall N., et al., 2017 studied factors associated with discontinued and abandoned treatment. The rates of discontinued treatment have been show to remain consistently at 8% or higher.

Clinical implication: Discontinuation is much more likely with removable appliances compared with fixed appliances. Pre-adolescents are generally more adherent especially with functional appliances. Parental influence diminishes with age. Patients with greater perception of their malocclusion are likely to be adherent.

Practical application: A lack of patient compliance lies at the heart of the phenomenon of discontinued treatment. The most ideal patient-dentist relationship combines the thoughts of the patient with the knowledge and expertise of the dentist. A warm, caring clinician with a calm confident approach is likely to induce better adherence and patient satisfaction.

Reference: McDougall, N.I., McDonald, J. and Sherriff, A., 2017. Factors associated with discontinued and abandoned treatment in primary care orthodontic practice part 1. Orthodontic Update10(1), pp.8-14.

PERIODONTICS

PERIODONTICSMethamphetamine impact on periodontium

Methamphetamine (MA) use is associated with extensive dental caries and periodontal disease. Spolsky, V.W., et al., studied the prevalence and severity of periodontal disease in a sample of 546 MA users. Periodontal assessments were completed in 546 adults. More than 69% were also cigarette smokers and more than 55% were medium to high MA users.

Clinical implication: MA users had a high prevalence and severity of destructive periodontal disease. The frequency of MA use had minimal impact on the severity of periodontal disease.

Practical application: Although an MA user can be at high risk of developing periodontal disease, behavioral factors such as smoking and consuming sugary beverages are more deleterious than MA use alone. These facts will help the clinician manage treatment of MA users.

Reference: Spolsky, V.W., Clague, J., Murphy, D.A., Vitero, S., Dye, B.A., Belin, T.R. and Shetty, V., 2018. Periodontal status of current methamphetamine users. The Journal of the American Dental Association149(3), pp.174-183. 

ORAL SURGERY

ORAL SURGERY 1Rinsing 3rd molar extraction sites is inferior to irrigation

Pain, trismus and swelling after third-molar removal can compromise oral hygiene and inhibit the healing process.

The accumulation of food debris in the surgical area increases the risk of infection and dry socket. Cho, G., et al., compared irrigation with medicated rinsing after third-molar removal.

Clinical implication: There was significantly less pain, alveolar osteitis, food impaction and facial swelling 7 days after surgery among patients who used irrigation of the surgical site compared with patients who rinse with the same chlorhexidine solution.

Practical application: Routine patient-administered irrigation of the surgical area with 0.2% chlorhexidine solution after third-molar removal reduces the incidence of dry socket. Dry socket occurs in 25-35% of patients after removal of impacted lower third molars which is about 10 times more often than after removal of teeth from all other sites.

Reference: Cho, H., David, M.C., Lynham, A.J. and Hsu, E., 2018. Effectiveness of irrigation with chlorhexidine after removal of mandibular third molars: a randomised controlled trial. British Journal of Oral and Maxillofacial Surgery56(1), pp.54-59. 

ANALGESIA AND PAIN MANAGEMENT

ANALGESIA AND PAIN MANAGEMENT

Do we really need to prescribe opioids?

Effective pain management is a priority in dental practice. Moore, P.A., et al., summarized the available evidence on the benefits and harms of analgesic agents associated with orally administered medication or medication combinations for relief of acute pain. Reviews were inclusive of all age populations.

The data identified combinations of ibuprofen and paracetamol as having the highest association with treatment benefits in adult patients and the highest proportion of patients who experienced pain relief.

Clinical implication: Relief of postoperative pain in dental practice with the use of non-steroidal anti-inflammatory drugs with or without paracetamol is equal or superior to that provided by opioid-containing medications.

Practical application: The combination of 400mg of ibuprofen plus 1000mg of paracetamol was found to be superior to any opioid-containing medication or medication combination studied. The implications of this study suggest that prescribing narcotic or opioid medications, with their abundance of side effects and propensity for addiction, may not be necessary in clinical practice.

Reference: Moore, P.A., Ziegler, K.M., Lipman, R.D., Aminoshariae, A., Carrasco-Labra, A. and Mariotti, A., 2018. Benefits and harms associated with analgesic medications used in the management of acute dental pain: An overview of systematic reviews.The Journal of the American Dental Association149(4), pp.256-265.

PRACTICE MANAGEMENT

PRACTICE MANAGEMENT

Does your patient really listen to you?

A patient’s ability to recollect and understand treatment information during the consultative process plays an important role in decision making for proposed treatment. Moreira, N.C.F., et al., systematically reviewed nineteen studies assessing recollection or comprehension of dental informed consent in adults.

Clinical implication: Patients in general report that they understand information given to them but they may have limited grasp of the details. Given that they are often in a stressful clinical environment, patients often accede to treatment options which they do not fully comprehend in order to extricate themselves from the immediate stress. This can lead to post-operative confusion, anxiety and possible conflict.

Accurate documentation and record taking, including visual imagery and videography, are excellent adjuncts to a standard consultation to ensure that the patients do actually comprehend treatment options completely.

Practical Application:  Clinicians should try and include adjunctive resources for patients such as leaflets, decision boards and audio-visual material when sharing important treatment information with patients. Dentists should not only rely on a patient’s self-reported understanding of information as it may not be a true representation of their real comprehension. Periodic repetition of comprehension and recollection of information is imperative. This is particularly relevant in complex multi-discipline treatment plans such as orthodontics, implants, periodontics and aesthetic augmentation.

Reference:  Moreira, N.C.F., Pachêco-Pereira, C., Keenan, L., Cummings, G. and Flores-Mir, C., 2016. Informed consent comprehension and recollection in adult dental patients: A systematic review. The Journal of the American Dental Association147(8), pp.605-619. 

CROWN AND BRIDGEWORK

CROWN AND BRIDGEWORK

Monolithic zirconia exhibits low failure rates

The demand for all-ceramic materials has increased for reasons of aesthetics, wear resistance, colour stability and the high cost of noble metals. Sulaiman, T.A., et al., studied the failure rate of monolithic zirconia restorations due to fracture up to 5 years of clinical performance. The overall fracture rate of up to 5 years for all restorations (anterior and posterior) was 1.09%.

Clinical implication: Fracture rates were higher for anterior single crowns and than for posterior single crowns. Fracture rates of bridges were higher than single crowns. Fracture rates of posterior bridges were fewer than anterior bridges.

Practical application: Indirect restorations made from monolithic zirconia exhibit a low fracture rate up to 5 years which are vastly superior to lithium disilicate or other silicone dioxide all-ceramics. In particular, prostheses fabricated in the posterior segments of the mouth seem more resistant to failure in spite of greater mechanical loading. Many dentists do not adequately provide enough occlusal (palatal) reduction in crown preparations in the anterior maxilla and compromise the strength significantly. It is imperative that this reduction be considered carefully when prescribing any all ceramic crown or bridge.

Reference: Sulaiman, T.A., Abdulmajeed, A.A., Donovan, T.E., Cooper, L.F. and Walter, R., 2016. Fracture rate of monolithic zirconia restorations up to 5 years: A dental laboratory survey. Journal of Prosthetic Dentistry116(3), pp.436-439.

 

ORTHODONTICS

ORTHODONTICS

White spot lesions after orthodontic therapy

White spot lesions (WSLs) are a problem commonly found in patients who use orthodontic devices. Fluoride varnish can reduce WSLs during orthodontic treatment with fixed appliances. Rahimi, F., et al., 2017 conducted a systematic review to evaluate the efficacy of fluoride varnish compared with other agents for preventing WSLs during orthodontic treatment.  Out of 432 studies searched from the databases, 14 studies were included in the systematic review. The review showed that fluoride varnish combined with chlorhexidine (CHX) may be a good treatment for WSLs after orthodontic treatment, especially for a 6-month period and that resin infiltration might also be effective for preventing WSLs.

Clinical implication: Fluoride varnish combined with CHX could be an effective treatment for WSLs after orthodontic procedures. It is best that fluoride varnish be available for 6-month period of treatment, at least. The study review also demonstrated or concluded that treatment with resin infiltration in conjunction with fluoride varnish is a promising combination for controlling proximal lesions (e.g. WSLs).

Practical application: The first 6 months are very important in the development of WSLs as the majority of adolescent patients need to adapt their hygienic practices to the requirements of orthodontic therapy.

Reference: Rahimi, F., Sadeghi, M. and Mozaffari, H.R., 2017. Efficacy of fluoride varnish for prevention of white spot lesions during orthodontic treatment with fixed appliances: A systematic review study. Biomedical Research and Therapy4(08), pp.1513-1526.

PROSTHODONTICS

PROSTHODONTICS 1Are intra-oral scanners more accurate?

There has been a rise in popularity of digital impression taking and questions have been raised about accuracy, reliability and cost effectiveness.  Tsirogiannis, P. et al., 2016 systematically compared outcomes of available studies investigating marginal fit of single tooth-supported ceramic crowns made from digital impressions with conventional impression methods and analyzed the data.

Clinical implication: In vivo studies showed mean marginal discrepancies of 69.2 microns and 56.1 microns calculated respectively for conventional and digital impressions respectively which were not significant statistically.

Practical application: Digital workflows utilizing intra-oral scanners for data capture perform equally well compared with conventional impression techniques. Comfort for the patient and speed of data transfer for external fabrication of prostheses are noteworthy advantages in favour of the digital process.

However, the onerous up-front capital investment and on-going costs associated with the manufacturing process make it very difficult to justify financially, especially for the single-chair practice and when clinical outcomes are similar between the techniques.

Regardless of the technique of data capture, principles of tooth preparation and soft tissue management must be adhered to meticulously.

Reference: Tsirogiannis, P., Reissmann, D.R. and Heydecke, G., 2016. Evaluation of the marginal fit of single-unit, complete-coverage ceramic restorations fabricated after digital and conventional impressions: a systematic review and meta-analysis. Journal of Prosthetic Dentistry116(3), pp.328-335.

IMPLANTS

IMPLANTS

Why do implants fail and what can I control?

Complications in implant-supported single crowns and multiple implant-supported bridges may be mechanical, biological or technical as discussed by Hanif, A. et al., 2017. Mechanical complications include screw loosening, screw-implant fracture and cement fracture. Technical complications include fracture of the framework and of veneering porcelain. Biological complications are subcategorized into early and late implant failures. Early failures are attributed to not placing the surgical implant under proper aseptic measures and the late complications are typically peri-implantitis and infections bred by bacterial plaque.

Clinical implication: Ensure during treatment planning stage that there is no biomechanical overload. Reducing the occlusal table, preventing heavy occlusal contacts, keeping shallow cuspal heights, and by providing adequate thickness of the overlying ceramic are critical factors for success. Ensure a passive fit to an implant framework.

Practical application: The clinician must consider that implant failure can occur at every stage of the process and undertake everything possible to minimize the likelihood of failure. Mechanical and technical failures are completely within the control of the clinician and failures in either of these realms and problems should rarely be seen if adequate attention to detail has taken place.

Generally, it takes about 5 years for the peri-implant disease process to progress and exhibit clinical signs and symptoms. The provision of regular hygiene visits and self-maintenance by the patient presents a heightened risk of failure.  Implant removal is warranted if there is more than 60% bone loss following peri-implantitis and evidence of mobility.

Reference: Hanif, A., Qureshi, S., Sheikh, Z. and Rashid, H., 2017. Complications in implant dentistry. European Journal of Dentistry11(1), p.135. 

AESTHETICS

AESTHETICSThe efficacy of in-office bleaching

The efficacy of in-office bleaching on stain removal from stained resin composite, ceramic, hybrid-ceramic and resin-based CAD/CAM blocks and direct resin composites was evaluated.

Alharbi, A. et al., collected samples that were made from nine different materials and were randomly divided into five groups: each stained with a particular staining solution and analysed with a spectrophotometer. Samples were then subjected to in-office bleaching with 40% hydrogen peroxide gel for one hour which is the maximum time advised in this in vitro study.

Clinical implication: In-office bleaching may be a suitable treatment for patients who wish to augment the aesthetics of hybrid-ceramic and resin-based CAD/CAM resin block restorations as a result of staining. Bleaching efficacy was limited in direct composite resins. Red wine caused the most staining in all groups of materials whilst coffee left the greatest residual colour change.

Practical application: Bleaching resulted in significant differences in ΔE (colour) values for all materials. Bleaching efficacy was highly influenced by material composition and staining solution. Residual colour values after bleaching for ceramic and hybrid ceramics ranged from -0.49 to 2.35, within the clinically acceptable maximum of 3.3. Values after bleaching for resin-based CAD/CAM ranged from -0.7 to 7.08 while direct resin composites values ranged from -1.47 to 25.13 Bleaching procedures, using 40% hydrogen peroxide for 40 minutes in the surgery can be an effective method to remove stains from dental restorations so that restoration replacement as a result of discoloration may not always be necessary.

Reference: Alharbi, A., Ardu, S., Bortolotto, T. and Krejci, I., 2018. In‐office bleaching efficacy on stain removal from CAD/CAM and direct resin composite materials. Journal of Esthetic and Restorative Dentistry30(1), pp.51-58.

PROSTHODONTICS

Prosthodontics 1Try to avoid occlusal adjustments of monolithic ceramic crowns

Surface characteristics of monolithic ceramic materials are not well understood, especially with respect to clinical adjustment and polishing and the potential for wear of the opposing dentition. Amaya-Pajares SP., et al., 2016 compared surface roughness of glazed and polished monolithic ceramic with the surface roughness produced by different polishing systems on adjusted monolithic ceramics. All materials presented smoother surfaces at baseline than after adjustment and finishing. Generally, polished zirconia was less rough than glazed zirconia.

Clinical implication: Different all ceramic materials tested performed better with certain polishing systems than with others. Ensure collecting information from the manufacturer as to the preferred polishing system for a specific ceramic.

Practical application: Ensure preparation and occlusal reduction guidelines have been meticulously followed and temporization is excellent in order to avoid the need to adjust and polish zirconia. Accurate bite records and use of quality impression materials and scanners will minimize the likelihood of corrupted inter-occlusal relationships and the need for adjustment.

Reference: Amaya‐Pajares, S.P., Ritter, A.V., Vera Resendiz, C., Henson, B.R., Culp, L. and Donovan, T.E., 2016. Effect of finishing and polishing on the surface roughness of four ceramic materials after occlusal adjustment. Journal of Esthetic and Restorative Dentistry28(6), pp.382-396.

IMPLANTS

IMPLANTSSmoking and bone loss: influence your patients!

The effect of smoking on the oral environment and its further influence on marginal bone loss around an implant during a 3-month bone-healing period was studied by Duan, X., et al., 2017. Saliva samples were collected preoperatively from 20 periodontally healthy patients with single tooth replacement. Half the patients were smokers, half were non-smokers. The Human Oral Microbiome Database for bacterial identification was employed. Porphyromonas gingivalis was found to be significantly more abundant in smokers, which was positively related to the severity of marginal bone loss during bone healing.

Clinical implication: Smoking shapes the salivary microbiome in states of clinical health and further may influence marginal bone loss during bone healing by creating high at-risk-for-harm communities.

Practical application: Cessation of smoking prior to implant therapy is highly recommended. Smokers who do not cease smoking and proceed with implant therapy should be warned about the heightened risk of marginal bone loss during healing.

Reference: Duan, X., Wu, T., Xu, X., Chen, D., Mo, A., Lei, Y., Cheng, L., Man, Y., Zhou, X., Wang, Y. and Yuan, Q., 2017. Smoking May Lead to Marginal Bone Loss Around Non‐Submerged Implants During Bone Healing by Altering Salivary Microbiome: A Prospective Study. Journal of Periodontology88(12), pp.1297-1308.

PERIODONTICS

PERIODONTICSReview your patient’s systemic and immunological status regularly to help control periodontitis

Host inflammatory and immune responses play an important role in aggressive periodontitis. Ronaldo Lira-Jr., et al., 2017 evaluated levels of various innate immunity-related markers including calprotectin and matrix metalloproteinase (MMP)-8 in serum and saliva from 40 patients with generalized aggressive periodontitis and those with gingivitis or a healthy periodontium.

Clinical implication: Salivary and serum levels of calprotectin and MMP-8 are elevated in patients with aggressive periodontitis. Underlying systemic and immunological factors are highly likely to be responsible for the expression of significant and rapid bone loss in the periodontium.

Practical application: Not all patients are accurate in the data that they provide when completing their medical history. Additionally, the most recent medical history and a complete list of medications should be reviewed every 3 years to ensure a clear understanding of the current systemic and immunological status of every patient. A thorough and up to date history can alert the clinician to contributing and complicating factors in the management of generalized aggressive periodontitis.

Reference: Lira‐Junior, R., Öztürk, V.Ö., Emingil, G., Bostanci, N. and Boström, E.A., 2017. Salivary and Serum Markers Related to Innate Immunity in Generalized Aggressive Periodontitis. Journal of Periodontology88(12), pp.1339-1347.

ANAESTHESIOLOGY

ANAESTHESIOLOGYMepivacaine more effective than lidocaine in endodontics but still not ideal 

Most clinicians are aware that achieving soft tissue anaesthesia does not guarantee the effectiveness of a block (conduction anaesthesia) or a painless clinical procedure. Patients often feel pain during endodontic treatment of teeth with irreversible pulpitis which can be very challenging for the patient and the dentist. Visconti, R.P et al., 2016 compared the anaesthetic efficacy of 2% mepivacaine (combined with 1:100,000 epinephrine) with 2% lidocaine (combined with 1:100,000 epinephrine) during pulpectomy of mandibular posterior teeth in 42 patients with irreversible pulpitis. Success rates, according to pain reports from patients during pulpectomy, were higher for mepivacaine solution (55%) than for lidocaine solution (14%).

Clinical implication: Mepivacaine resulted in more effective pain control during irreversible pulpitis treatments.

Practical application: Neither mepivacaine nor lidocaine provided high success rates to ensure complete pulpal anaesthesia. Consideration should be given for supplementary anaesthesia – i.e. intra-pulpal and use of non-steroidal anti-inflammatory agents prior to the procedure. Nitrous Oxide and IV sedation could be considered as adjunctive pain alleviation modalities if your patient encounters considerable discomfort.

Reference: Visconti, R.P., Tortamano, I.P. and Buscariolo, I.A., 2016. Comparison of the anaesthetic efficacy of mepivacaine and lidocaine in patients with irreversible pulpitis: A double-blind randomized clinical trial. Journal of Endodontics42(9), pp.1314-1319.

ORAL MEDICINE

ORAL MEDICINEMedication-related osteonecrosis responds better to surgical intervention

Patients with medication-related osteonecrosis of the jaw (MRONJ) often have signs and symptoms that include pain, swelling, exposed bone sequestrum, fistulae, erythema of soft tissue or pathologic fractures. The effectiveness of various management strategies used to treat medication-related osteonecrosis of the jaws (MRONJ) remains poorly understood. El Rabbabny, M., et al., 2017 evaluated the effectiveness of various treatment modalities used for MRONJ using a comprehensive search of various databases.

Clinical implication: Compared with medical treatment of local antimicrobials (with or without systemic antimicrobials), the investigators associated surgical treatment with higher odds of complete resolution of the condition. The effectiveness of other therapies such as bisphosphonate drug holidays and hyperbaric oxygen was uncertain.

Practical application: There are four drug classes associated with MRONJ: bisphosphonates, antiangiogenic drugs, RANKL inhibitors and m-TOR inhibitors. Patients on these medications should be advised of the possible complicating effects of these drugs in the oral cavity. Patients presenting with symptoms of MRONJ should be referred concurrently to an oral surgeon and oral medicine specialist for optimal management.

Reference: El-Rabbany, M., Sgro, A., Lam, D.K., Shah, P.S. and Azarpazhooh, A., 2017. Effectiveness of treatments for medication-related osteonecrosis of the jaw: A systematic review and meta-analysis. The Journal of the American Dental Association148(8), pp.584-594.

BUSINESS OF DENTISTRY

Business of DentistryLeveraging technology in your practice

Technologies such as intraoral scanners and CAD/CAM systems are poised to become industry standards in dentistry. Proper staff training will often be the key differentiator in how well the technology is deployed as reported by Kaye, G., 2018. Once the practice principal can recognise the talents, skill sets and personalities of their staff, this will affect the success of integration. Staff must be open to change and an awareness that successful adaptation to a new technology requires technological literacy. Technologically competent staff will likely be excited to learn and can generally quickly gain competency and leverage the practice.

Clinical implication: Professional training in all dental technologies provides the strongest foundation for successful integration. Dentists and staff can all participate in some form of online preparation prior to dedicated training days to ensure that all staff attains functional competency.

Practical Application: Staff should practice on models or each other to ensure a thorough understanding of the capabilities of the hardware and software employed and the outcomes that can be achieved. An understanding and appreciation of the benefits of the technology enables staff to market this within the practice seamlessly.

Reference: Kaye, G., 2018. Ask Dr. Kaye About Digital Dentistry–Digital Adoption: Training a staff in digital dental technology. [online] Dentaleconomics.com. Available at: https://www.dentaleconomics.com/articles/print/volume-108/issue-2/science-tech/ask-dr-kaye-about-digital-dentistry-digital-adoption-training-a-staff-in-digital-dental-technology.html [Accessed 28 May 2018].

 AESTHETICS

AESTHETICS 1Digital smile design a useful adjunct for dentist and patient

The aesthetics of the smile are related to the colour, shape, texture, dental alignment, gingival contour and the relationship of these factors with the face. Meereis, CTW., et al., 2016 presented a two-year follow-up for an aesthetic rehabilitation clinical case in which the method of digital smile design (DSD) was used to assist and improve diagnosis, communication and predictability of treatment through an aesthetic analysis of the assembly: (face, smile, periodontal tissue and teeth). The smile’s aesthetics were improved through gingival recontouring, dental home bleaching and a restorative procedure with thin porcelain laminate veneers using lithium disilicate glass-ceramic laminates. The proposed technique had an acceptable clinical performance at the end of a two-year follow-up.

Clinical implication: DSD can be used to increase professional/patient communication and to provide greater predictability for the smile’s aesthetic rehabilitation.

Practical application: Understanding and defining the end-point of your treatment plan is often straightforward for an experienced clinician. However, recent graduates and less experienced or unconfident practitioners can utilise DSD to plan, edit and amend their cases more effectively and also to communicate these end-points to their patients with greater clarity.

Reference: Meereis, C.T.W., de Souza, G.B.F., Albino, L.G.B., Ogliari, F.A., Piva, E. and Lima, G.S., 2016. Digital smile design for computer-assisted esthetic rehabilitation: two-year follow-up. Operative Dentistry41(1), pp.E13-E22.

DENTAL MATERIALS

Dental MaterialsCalcium Hydroxide for dentine remineralization of no benefit in stepwise treatments

Dentists often use calcium hydroxide liners during stepwise treatment of advanced caries to reduce the risk of pulp exposure. A 2-step carious tissue excavation technique is employed. During the first procedure, the clinician partly removes carious dentine and provisionally seals the cavity until stage 2 to allow dentine remineralization. Some 45-60 days later, complete excavation is done and a definitive restoration placed. Pereira MA., et al., 2017 studied 98 patients provisionally restored with RMGI with or without calcium hydroxide liner. After 90 days, it was found that the use of calcium hydroxide liner during stepwise caries excavation and use of a provisional restoration did not provide added benefit.

Clinical implication: There is no added benefit to using a calcium hydroxide liner under a RMGI during step-wise caries removal.

Practical implication: Use of simpler, well-sealed interim restorations may be enough to allow re-organization of carious dentine and subsequent longer-term remineralization.

Reference: Pereira, M.A., dos Santos-Júnior, R.B., Tavares, J.A., Oliveira, A.H., Leal, P.C., Takeshita, W.M., Barbosa-Júnior, A.M., Bertassoni, L.E.B. and Faria-e-Silva, A.L., 2017. No additional benefit of using a calcium hydroxide liner during stepwise caries removal: A randomized clinical trial. The Journal of the American Dental Association148(6), pp.369-376.

ORTHODONTICS

ORTHODONTICSRoot resorption: clear aligners far safer than fixed

Using removable aligners in orthodontic therapy has increased rapidly in recent years. The effects on root resorption remain unclear. Yi, J., et al., 2017 studied external root resorption in 80 non-extraction cases after clear aligner therapy or fixed orthodontic treatment.

Clinical implication: The overall external apical root resorption was significantly less with aligners than fixed orthodontic treatment.

Practical application: Light continual forces from aligners produce very few resorption complications. Patients should be advised at the initial consultation appointment of the possible complications associated with fixed orthodontic treatment.

Reference: Yi, J., Xiao, J., Li, Y., Li, X. and Zhao, Z., 2018. External apical root resorption in non-extraction cases after clear aligner therapy or fixed orthodontic treatment. Journal of Dental Sciences.

PERIODONTOLOGY

Clinical periodontitis and obstructive sleep apnoea

Gamsiz-Isik H, etal (2017) studied compared the prevalence of periodontitis in obstructive sleep apnoea (OSA) patients versus control patients by assessing clinical periodontal parameters and gingival crevicular fluid (GCF) levels of interleukin (IL)-1β, tumor necrosis factor (TNF)-α, and high-sensitive C-reactive protein (hs-CRP); serum hs-CRP was also sampled.

Clinical implication:  The results showed that the prevalence of periodontitis in the OSA group (96.4%) was significantly higher than in the control group (75%).  Severe periodontitis prevalence was higher in the OSA group than control group and all clinical periodontal parameters and GCF levels were significantly higher in OSA patients than in controls.

Practical application: The clinician should be mindful of the higher prevalence of OSA when patients exhibit clinical periodontitis.  Referral to a sleep physician is prudent.

Reference: Gamsiz‐Isik, H., Kiyan, E., Bingol, Z., Baser, U., Ademoglu, E. and Yalcin, F., 2017. Does Obstructive Sleep Apnea Increase the Risk for Periodontal Disease? A Case‐Control Study. Journal of periodontology, 88(5), pp.443-449.

ORAL MEDICINE

Oral Medicine 1Electronic cigarettes explosion

Electronic cigarettes are a relatively new nicotine-based product with a novel delivery system.  Research suggest that e-cigarette explosion involving the oral cavity are occurring more frequently.  Harrison R and Hicklin D Jr (2016) reported that the most commonly documented injuries to the oral cavity after an e-cigarette battery explosion include intraoral burns, luxation injuries, and chipped and fractured teeth.  The largest growing population of e-cigarette users is adolescents followed by young adults.

Clinical implication:  Patient education about the risks of this product is vital.  The risks of spontaneous failure and explosion of e-cigarettes should be discussed with patients who are considering using this device.  The use of e-cigarettes compounds the negative effects of nicotine with the unknown factor of the likely harmful constituents such as aldehydes, metal, volatile organic compounds and reactive oxygen species not found in tobacco smoke.

Practical implication:  Consumers can decrease the chance of a lithium battery explosion or fire by following the manufacturer’s instructions for charging the device.  The e-cigarette device should only be charged with the charger supplied with device.

Reference: Harrison, R. and Hicklin, D., 2016. Electronic cigarette explosions involving the oral cavity. The Journal of the American Dental Association147(11), pp.891-896.

 

GENERAL DENTISTRY

General dentistry 1Prevention of dental erosion

All fluoride sources help strengthen teeth against bacterial acids that cause caries.  However, excessive exposure to dietary acids, which can result in dental erosion, presents a more aggressive level of challenge compared to caries.  Despite the fact that almost all toothpastes contain fluoride, both the incidence and prevalence of dental erosion appear to be on the rise.  Noble WH and Faller RV (2018) assessed the comparative ability of fluoride agents to protect against dental erosion.  Daily use of a stabilised stannous fluoride dentifrice was shown to provide the most effective means of protecting teeth against the increasing risk of dental erosion and erosive tooth wear.

Clinical implication: Early intervention with both preventive and minimally invasive restorative management of erosive tooth wear will help preclude the need for future extensive and costly reconstructive procedures.

Practical application:  Prevention of dental erosion begins with behavioural modifications. Patients should decrease intakes of acidic foods and drinks.  Drinks should not be sipped or swished; using a straw will decrease the contact time between acids and teeth.  Patients with gastric reflux problems should see their physicians for management strategies.  Xerostomia is the most important biologic risk factor for dental erosion.  Staying well-hydrated is important as dehydration can decrease salivary flow.  Conservative restorative care using glass-ionomer cements and composite resins may be indicated.

Reference: Faller, R.V. and Noble, W.H., 2018. Protection From Dental Erosion: All Fluorides are Not Equal. Compendium of continuing education in dentistry (Jamesburg, NJ: 1995), 39(3), pp.e13-e17.

AESTHETICS

bleached teeth

Bleaching of non-vital anterior teeth

There are very few clinical trials which compare the effectiveness of the “walking bleaching” (WB) technique and the inside-outside (IO) technique used in a short daily regimen. Lise DP etal (2018) conducted the above study over 4 weeks and then compared colour changes after 1 year.  Discoloured and endodontically treated anterior teeth received a cervical seal and were randomly divided into groups according to the technique. In the WB group, a mix of sodium perborate and 20% hydrogen peroxide were applied in the pulp chambers, sealed and replaced weekly up to 4 weeks. In the IO group, 10% carbamide peroxide was applied in the pulp chambers with a syringe and custom-fitted trays were worn for 1hr/day for 4 weeks.

Both the WB and IO techniques presented similar effectiveness and resulted in significant changes after only 2 weeks.  Regardless of technique, the bleaching of non-vital anterior teeth is still a straightforward and cost-effective aesthetic approach that is usually visible and satisfactory.

Clinical Implications:  Bleaching of non-vital teeth for 4 weeks by WI bleaching (sodium perborate & 20% hydrogen peroxide) or IO (10% carbamide peroxide, 1hr/day) resulted in visible colour changes that were stable after 1 year.

Practical application:  Patients can be confident that simple economical techniques are available for improvement of discolouration of non-vital teeth without immediate recourse to definitive treatment.

Reference: Lise, D.P., Siedschlag, G., Bernardon, J.K. and Baratieri, L.N., 2018. Randomized clinical trial of 2 nonvital tooth bleaching techniques: A 1-year follow-up. Journal of Prosthetic Dentistry119(1), pp.53-59.

 

 ORTHODONTICS

Orthodontics

The effectiveness of orthodontic/orthopaedic appliance

A systematic review by Woon SC etal (2017) evaluated the effectiveness of orthodontic/orthopaedic methods used in the early treatment of Class III malocclusion in the short and long terms.  The selection criteria included trials of children between 7-12 years undergoing early treatment with any type of orthodontic/orthopaedic appliance compared to another appliance versus an untreated control group.  The primary outcome measure was correction of reverse overjet, and secondary outcomes included skeletal and soft tissue changes, quality of life, patient compliance, adverse effects and treatment time.

Clinical implication: The results for reverse overjet and ANB angle were statistically significant and favoured the group using a facemask, however there was lack of evidence on long-term benefits. There is some evidence regarding the chincup, tandem traction bow appliance and the removable mandibular retractor but the studies had a high risk of bias.

Practical application:  Further unbiased long-term studies are required to evaluate the early treatment effects for Class III malocclusion patients.

Reference: Woon, S.C. and Thiruvenkatachari, B., 2017. Early orthodontic treatment for Class III malocclusion: A systematic review and meta-analysis. American Journal of Orthodontics and Dentofacial Orthopedics151(1), pp.28-52.

 IMPLANTS

Implants

The outcomes of immediately loaded single implants in the anterior maxilla

Stanley M etal (2017) studied the outcomes of immediately loaded single implants in the anterior maxilla.  The inclusion criteria of the study were single-tooth placement in post-extraction sockets or healed sites of the anterior maxilla.  All implants were immediately loaded and followed for a 12 mth period after definitive crowns were placed.  The outcome measures were implant stability, survival and success.  The survival rate was found to be 100% at 12mths after placement of definitive crowns and no biological complications were found.  Two implants in the study had their prosthetic abutments loosened: the implant success was 95.2%.

Clinical implication: On immediate loading of single implants in the anterior maxilla a high survival rate of 100% was reported.

Practical application: Placing implants in fresh extraction sockets can reduce the number of surgical sessions from two to only one which is compatible with inserting implants with a flapless technique and is thus minimally invasive.  The insertion of an implant into a fresh extraction socket may help the correct 3D positioning of the fixture which will benefit the emergence profile.

Reference: Stanley, M., Braga, F.C. and Jordao, B.M., 2017. Immediate Loading of Single Implants in the Anterior Maxilla: A 1-Year Prospective Clinical Study on 34 Patients. International journal of dentistry2017.

BUSINESS OF DENTISTRY

difficult patient

Dealing with difficult patients

Patient management is complex and communication is essential for practice success. Yiannikos A (2018) discussed how to manage patients who grumble.  Listen attentively to what the patient has to say and try and understand the real problem.  Ensure that the patient feels their problem is acknowledged and that it will be resolved immediately.  This could be an advice like “do not rinse for 6 hrs” or a prescription such as “Use this cream, it will reduce the sensitivity”.  Follow-up is crucial as soon as practicable to check all is in order with the patient.  Ensure that the correct questions are asked.  The dentist is the manager and the leader of the clinical team and will inspire trust and confidence of the patient when the patient’s needs are understood.

Clinical implication: Unless the patient has a keen sense of being understood by the clinical team, even the most sophisticated dental surgery will not capture the patient.  Difficult patients require careful handling and management.  Dentist must be open to interprofessional dialogue with colleagues.

Practical application: Ensure dedicated time is allotted to clarify the patients’ understanding of all areas of dentistry and their obligations to treatment and subsequent maintenance.

Reference: Yiannikos, A.M., 2017. Successful communication in your daily practice Part I: Grumbling patients. roots – international magazine of endodontics, [Online]. No. 04. Available at: https://www.dental-tribune.com/clinical/successful-communication-in-your-daily-practice-part-i-grumbling-patients/ [Accessed 22 May 2018].

PROSTHODONTICS

Prosthodontics Sleep bruxism and ceramic restorations failure

Sleep bruxism is thought to be a risk factor for the failure of ceramic restorations.  De Souza MG etal (2017) performed a systematic review to determine whether sleep bruxism is associated with failure of ceramic restorations.  Over 1,400 patients aged from 19-71 yrs were evaluated and were followed up from 12-61 mths.  The failure rates ranged from 3.1-13% and analysis showed that there were no differences in the likelihood of ceramic restoration failure when comparing patients with and without sleep bruxism.

Clinical implication: The current available evidence is insufficient to claim if there is an association between sleep bruxism and ceramic restoration failure.

Practical application:  The clinician can be confident to employ ceramic restorations in patients with sleep bruxism but it may be prudent to suggest regular use of a night splint if the patient is not currently requiring any prosthesis for sleep apnoea.

Reference: de Souza Melo, G., Batistella, E.Â., Bertazzo-Silveira, E., Gonçalves, T.M.S.V., de Souza, B.D.M., Porporatti, A.L., Flores-Mir, C. and Canto, G.D.L., 2018. Association of sleep bruxism with ceramic restoration failure: A systematic review and meta-analysis. Journal of Prosthetic Dentistry119(3), pp.354-362.

MATERIALS

MaterialsThe survival rate of ceramic inlays, onlays and overlays

Important decisions for patient consideration include the prognosis of treatment options.

The survival and complication rates of different restorative materials are critical for the dentist and patient when discussing informed consent. Morimoto S etal (2016) systematically reviewed the survival rate of ceramic inlays, onlays and overlays.  Their analysis showed that the survival rate was 95% at 5 yrs and 91% at 10 yrs and complication rates were low overall.

Clinical implication: The clinician can be confident to advise patients that the success rate of inlays, onlays and overlays if ceramic is employed as the restorative material.

Practical application: Even with the low incidence of complications, fracture or chipping of the restorations or the teeth (or both) are possible.  If the restoration is deep enough, pulpal health may be irreversibly affected, and the patient should be advised accordingly.

Reference: Morimoto, S., Rebello de Sampaio, F.B.W., Braga, M.M., Sesma, N. and Özcan, M., 2016. Survival rate of resin and ceramic inlays, onlays, and overlays: a systematic review and meta-analysis. Journal of dental research95(9), pp.985-994.

PROSTHODONTICS

Risk of posterior all-ceramic crowns failure still high

Kassardjian V et al (2016) reviewed differences in survival of complete coverage crowns with all ceramic materials used in adults to restore anterior or posterior vital teeth and opposed by teeth, implant crowns were excluded. The study reviewed 3,937 articles between 1980-2014. The ceramic materials studied were slip cast alumina, lithium disilicate, leucite-reinforced glass ceramic, pure alumina and zirconia.  Anterior ceramic crowns were 50% less likely to fail than posterior ceramic crowns.

Clinical implication: Even though bonding techniques and all-ceramic material science have improved significantly in the last 35 yrs, failure rates of posterior crowns without metallic substructures continue to be an issue of concern.  Unless in the aesthetic zone or of prime importance to the patient, consider ceramo-metal crowns as your default option.  All zirconia crowns continue to show promise but consider abrasiveness and wear to the opposing dentition.

Practical application: Based on current data, clinicians still need to be cautious about using ceramic crowns to restore posterior teeth.  Case selection, meticulous preparation and embracing ideal clinical protocols is crucial when considering using complete coverage all-ceramic materials.

Reference: Kassardjian, V., Varma, S., Andiappan, M., Creugers, N.H. and Bartlett, D., 2016. A systematic review and meta analysis of the longevity of anterior and posterior all-ceramic crowns. Journal of Dentistry55, pp.1-6.

IMPLANTS

Keratinized mucosa thickness essential for implant longevity

Roccuzzo M et al (2016) studied the presence and absence of keratinized tissue under soft-tissue conditions around the posterior mandibular implants of healthy or moderately periodontally compromised patients to understand the significance of peri-implant keratinised tissue for long-term tissue health and stability.  Lack of keratinised tissue was associated with higher plaque accumulation, greater soft-tissue recession and greater need for added antibiotic and/or surgical interventions to manage complications.

Clinical implication: Bony support of implants has been the primary focal point when considering the longevity of implant retained prostheses. Consideration of the keratinization of the mucosa needs to be factored into possible implant loss, peri-implant health, oral hygiene, soft-tissue recession and change in marginal bone levels.

Practical application: In carefully selected patients, especially in the edentulous posterior mandible, where ridge resorption leads to reduced vestibular depth and lack of keratinized tissue, peri-implant soft tissue grafting is suggested to facilitate long-term tissue health.

Implant planning involves careful assessment of not only hard tissues but consideration of soft tissue as well.  If extensive ridge resorption has occurred, consider soft tissue grafting.

Reference: Roccuzzo, M., Grasso, G. and Dalmasso, P., 2016. Keratinized mucosa around implants in partially edentulous posterior mandible: 10‐year results of a prospective comparative study. Clinical Oral Implants Research27(4), pp.491-496.

PERIODONTICS

Diabetes and periodontal health management 

Chapple IL and Genco R (2013) presented a consensus report on diabetes and systemic disease.  Severe periodontitis adversely affects glycaemic control in diabetes and glycaemia in non-diabetes subjects.  In diabetes patients, there is a direct and dose-dependent relationship between periodontitis severity and diabetes complications.  Increasing evidence supports elevated systemic inflammation resulting from the entry of periodontal organisms and their virulence factors into the circulation.

Clinical implication: Mechanical periodontal therapy is associated with approximately a 4% reduction in Haemoglobin A1c (HbA1C) at 3 mths.  HbA1c is a form of haemoglobin that is bound to glucose, the blood test for HbA1c level is routinely performed in people with type 1 and type 2 diabetes mellitus. The clinical impact is equivalent to adding a second drug to a pharmacological regime for diabetes.  No current evidence to support adjunctive use of antimicrobials for periodontal management of diabetes patients is indicated.

Practical application: One hypothesis to explain this damage in the periodontal tissues states that advanced glycosylation end products that appear in diabetic patients due to the hyperglycemia make the immune system hyper-reactive to dental plaque, increasing destruction of periodontal support.

Some patients have a more reactive immune system to oral plaque and diabetes inflammatory products, leading to more periodontal destruction in the mouth and more diabetic complications in the body.

Even though diabetic individuals have more severe periodontal disease, a successful periodontal treatment can be performed.  Elimination of plaque and calculus attached to the tooth, appropriate oral hygiene and periodontal control every 4 to 6 mths are the keys for success.  Treatment results can be improved in the short term with drug therapy but we have to keep in mind that more recurrence of periodontal disease will be observed in diabetic patients that have poor glycemic control.

Reference: Chapple, I.L., Genco, R. and Working Group 2 of the Joint EFP/AAP Workshop, 2013. Diabetes and periodontal diseases: consensus report of the Joint EFP/AAP Workshop on Periodontitis and Systemic Diseases. Journal of clinical periodontology, 40, pp.S106-S112.

DENTAL MATERIALS

Fissure sealants more effective when etched and with use of adhesive

A study by Unverdi G.E (2017) analysed 228 sealants on 57 children’s caries-free first permanent molars and compared sealant retention after the use of an adhesive with no adhesive and the performance of self-etch adhesives with traditional etch-and-rinse adhesives.

Clinical implication: Enamel etching was the key to sealant retention and that addition of an adhesive with the etching improved retention rates.

Practical application: Pit and fissure sealant is an effective means of preventing pit and fissure caries in primary and permanent teeth. Dentists should therefore be encouraged to apply pit and fissure sealants in combination with other preventive measures in patients at a high risk of caries.  Selection of sealant material is dependent on the patient’s age, child’s behavior, and the time of teeth eruption. Teeth that present with early non-cavitated carious lesions would also benefit from sealant application to prevent any caries progression.  Sealant placement is a sensitive procedure that should be performed in a moisture-controlled environment. Maintenance is essential and the reapplication of sealants, when required, is important to maximize the effectiveness of the treatment.

Reference: Unverdi, G.E., Atac, S.A. and Cehreli, Z.C., 2017. Effectiveness of pit and fissure sealants bonded with different adhesive systems: a prospective randomized controlled trial. Clinical oral investigations, 21(7), pp.2235-2243.

ORAL MEDICINE

Platelet Rich Fibrin application of huge benefit in surgical procedures

Castro AB et al (2017) reviewed the effects of platelet-rich fibrin (PRF) on surgical procedures such as sinus elevation, alveolar ridge preservation and implant surgery.

Clinical implication: Significant beneficial effects on bone regeneration and in implant surgery are suggested when PRF is applied. Given its ease of preparation, low cost and biological properties, PRF should be considered as a reliable option of treatment.  However, standardization of the clinical protocol is required to obtain reproducible results. The use of enough PRF clots or membranes seems to be crucial to obtain an optimal effect.

Practical application: PRF accelerated bone healing in sinus elevation procedures, reduced buccal plate resorption in alveolar socket healing and improved primary and secondary implant stability in implant surgery compared with controls.

Reference: Castro, A.B., Meschi, N., Temmerman, A., Pinto, N., Lambrechts, P., Teughels, W. and Quirynen, M., 2017. Regenerative potential of leucocyte‐and platelet‐rich fibrin. Part B: sinus floor elevation, alveolar ridge preservation and implant therapy. A systematic review. Journal of clinical periodontology44(2), pp.225-234.

BUSINESS OF DENTISTRY  

SEO and EDM’s

key to practice growth

Shuman L (2016) offers suggestions for improving a website’s relevance and rankings on search engines, especially in relation to promoting growth.

For a practice to thrive, patients must first be aware of the practice and also accept recommended treatments at a high rate.  This calls for effective communication both in the practice and beyond.  Use of electronic data messaging (EDM) campaigns to the patient base and social media should be used to keep in touch with existing patients and attract new ones.

Clinical implication: The practice website should feature unique content, have one key topic per page, have proper navigation and include site maps, backlinks and utilize tag optimisation.

Practical application: The use of the internet in modern practice as an educational and marketing tool is vital.  Correct presentation of material and easy-to-use practice websites are critical.

Reference: Lou Shuman. 2016. 6 Essential Elements of a Flawless Practice Launch. [ONLINE] Available at: http://pages.dentalproductsreport.com/6-essential-elements-of-a-flawless-practice-launch. [Accessed 7 May 2018].

FACIAL AESTHETICS

FACIAL AESTHETICS

Use of Botox useful to create facial harmony with aesthetic dental procedures

Cosmetic dental treatments are often not optimal due to extraoral soft tissue conditions and modalities which have been confined to intraoral treatment alone.  Roberts W and Roberts J (2017) found that Botulinum Toxin Type A (BTA) is useful in relaxing facial muscles to improve symmetry and balance and is adjunctive to aesthetic dentistry.  This treatment modality can impact significantly on the soft tissues around the mouth.

Clinical implication: The use of Botox (BTA) in conjunction with aesthetic dental procedures will help to complete a more natural and uniform appearance for patients.

Correction of prominent mandibular angle and facial asymmetry due to masseter muscle hypertrophy is becoming more common place.  Although prominent mandible angles mainly develop skeletally, it can also develop by bilateral masseter muscle hypertrophy, and facial asymmetry develops with unilateral masseter muscle hypertrophy.  In this case, a satisfactory therapeutic effect can be obtained using intramuscular BTA injections. In addition, injecting BTA into the masseter or temporalis muscle is effective in the treatment of bruxism.

Patients with TMD often experience mouth-opening limitations and BTA therapy can relax the adjacent masticatory muscles and thereby improve the muscle inflammation leading to improved mouth opening.

Practical application: Although BTA is currently the most commonly used toxin for the improvement of facial wrinkles, it has now been conventionally used in the treatment of muscular and bony facial asymmetry and TMD.

Reference: Roberts, W. and Roberts, J., 2017. Therapeutic use of Botulinum toxin. Available at:  www.ptifa.com [Accessed 7 May 2018].

 

 

ORTHODONTICS

ORTHODONTICS

Beware of diabetes in

adult orthodontic cases

More older individuals are undergoing orthodontic intervention and dentists see various patients with systemic co-morbidities, particularly diabetes as reviewed by Faruqui S et al  2018.

Poor bone turnover, encountered in diabetic patients, is a major contributing factor to bone destruction and misalignment of teeth. Diabetic patients must establish very tight control of their glycemic states and be kept under proper monitoring before getting into active orthodontic treatment.

Clinical implication: Diabetic patients who undergo orthodontic treatment while their glucose is poorly controlled had a very high risk of periodontal breakdown and the ensuing inflammation will increase the risk of unpredictable tooth movement.  Apply as light physiological forces as possible.  Diabetic patients who undergo orthodontic band placement, separator placement, or screw insertion are at high risk for developing oral infection and will require the use of prophylactic antibiotics before these procedures.  Simple adjustments do not need antibiotics.  Dentists should be aware of and ready to deal with potential diabetic emergencies that are likely to occur during orthodontic treatment.  Once early hypoglycemia symptoms are recognized, oral glucose is to be given in a dose of 50g. If the patient was unconscious, intramuscular glucagon 1mg or intravenous dextrose should be immediately infused.

Practical application: In order to avoid hypoglycemia in diabetic patients ensure the patient consumes a morning meal on the day of an orthodontic procedure. Try to schedule appointments early in the day.

Reference: Faruqui, S., Fida, M. and Shaikh, A., 2018. Factors affecting treatment duration–A dilemma in orthodontics. Journal of Ayub Medical College Abbottabad, 30(1), pp.16-21.

PROSTHODONTICS

Prosthodontics 1

Chewing efficacy: implant bridge v denture

Nogawa, T., et al, compared masticatory performance and occlusal force in mandibular conventional removable partial dentures and implant-supported fixed bridges.  In this study 44 Patients were treated at university clinic: 19 with implant-supported bridges and 25 with removable partial dentures.  Masticatory performance was measured and scanned data was subjected to computer analysis.

Clinical implication: There were no significant differences between the 2 groups with regard to oral function which measured masticatory performance and occlusal force.  More favourable subjective patient assessments of implant-supported bridges were more likely influenced by comfort and less by objective functional measures such as masticatory performance and occlusal force.

Practical application: Most dental professionals espouse the notion that implant-supported fixed prostheses deliver more efficacious masticatory function.  In relation to this study: hygiene, comfort and a sense of greater perceived well-being may be the deciding factor in whether or not a patient is offered an implant-supported partial denture or a conventional appliance.

Reference: Nogawa, T., Takayama, Y., Ishida, K. and Yokoyama, A., 2016. Comparison of Treatment Outcomes in Partially Edentulous Patients with Implant-Supported Fixed Prostheses and Removable Partial Dentures. International Journal of Oral & Maxillofacial Implants31(6).

IMPLANTS

Implants 1

Where and why do implants fail?

Del Fabbro M., et al, compared failure rates in implants that were either tilted with angulated abutments or were upright, the study involved 1992 implants on both arches.  The results showed 96% of the implants that failed within the first year had been placed in the maxilla with a larger proportion tilted beyond 10 degrees.

Clinical implication:  The maxilla typically has less bone mass than the mandible and this study supports the fact that there are higher failure rates for implants placed in the maxilla, especially with angled abutments.

Practical application:  Treatment planning must consider the higher incidence of failure rates in the maxilla and plan for sites that may need to be used at some future date and evaluate occlusal factors carefully in the design of the prosthesis.

Reference: Del Fabbro, M., Bellini, C.M., Romeo, D. and Francetti, L., Tilted implants for the rehabilitation of edentulous jaws: a systematic review. Clinical implant dentistry and related research14(4), pp.612-621.

PERIODONTICS

Periodontics 1

How many annual scaling and root planning sessions are needed and are antibiotics necessary?

Preus, HR., et al, compared 5-year clinical outcomes of scaling and root planing in a single session compared with 2 sessions, over a period of 21 days with and without the use of adjunctive metronidazole (MTZ) antibiotic therapy.  In this study, patients were divided into 4 groups:

  • Single session plus placebo;
  • Single session plus 400mg MTZ 3 times/day for 10 days starting 1 day before;
  • Two sessions over 21 days plus placebo;
  • Two sessions over 21 days plus MTZ starting 1 day before the 2nd session.

Periodontal maintenance therapy was performed to all patients at 3, 6 and 12 months and then every 6 months thereafter.

Clinical implication:  All treatments were effective in reducing signs of periodontitis. There were no meaningful clinical differences among the treatments, consequently dentists need to consider when planning treatment for patients with periodontitis.  It is pertinent to be cautious when prescribing antibiotic therapy for periodontal therapy.

Practical application:  Consistency of appointments should be the prime consideration when planning for periodontitis patients rather than relying on the use of antibiotics (with the exception of acute conditions) to minimize antibiotic resistance.

Reference: Preus, H.R., Gjermo, P. and Baelum, V., 2017. A Randomized Double‐Masked Clinical Trial Comparing Four Periodontitis Treatment Strategies: 5‐Year Tooth Loss Results. Journal of periodontology88(2), pp.144-152.

PREVENTIVE DENTISTRY

PREVENTIVE DENTISTRY

What is optimal topical fluoride regimen for arresting lesions in toddlers?

Duangthip D, et al, studied 304 young children between ages 3-4 yrs to compare the arresting ability of 3 different topical fluoride regimens on dentine caries (1670 tooth surfaces were included in this study).  Children with at least 1 active carious lesion into dentine were allocated one of three intervention groups:

Group 1:  1 application of 30% silver diamine fluoride (SDF) every 12mths;

Group 2:  3 applications (each at weekly intervals) of 30% SDF;

Group 3:  3 applications (each at weekly intervals) of 5% sodium fluoride varnish (NaF). 

Clinical implication:  After 18 months, the arrest rates were as follows:

Group 1: 40% – 1 application of SDF annually

Group 2: 35% – 3 applications (at weekly intervals) of SDF

Group 3: 27% – 3 applications (at weekly intervals) of 5% NaF varnish

This study found that annual or three consecutive weekly applications of SDF solution is more effective in arresting dentine caries in primary teeth than three consecutive weekly applications of NaF varnish.

Practical application:  Clinicians need to recognize the effectiveness of the arresting capabilities of effect of SDF as a treatment modality for caries management in paediatric patients.  Research also shows that SDF is more effective as a primary preventative than any other material, with the exception of sealants which are 10 x more expensive and need constant monitoring.

Reference: Duangthip, D., Chu, C.H. and Lo, E.C.M., 2016. A randomized clinical trial on arresting dentine caries in preschool children by topical fluorides—18 month results. Journal of dentistry44, pp.57-63.

ORAL MEDICINE

Oral Medicine 2Stopping anti-coagulants before extractions?

Doganay O., et al, reviewed 222 patients that underwent either extraction or other minor oral surgical procedures who were using anti-coagulants or antiplatelet medication.  The antiplatelet regimens included aspirin, clopidogrel, tricagrelor or dual antiplatelet therapy.

Clinical implication:  In this study the overall average frequency of postoperative bleeding was 4.9%.  The frequency of postoperative bleeding was as follows: aspirin 3.2%, clopidogrel 4.5%, tricagrelor 5.9% and dual antiplatelet therapy 8.3%.  None of the patients in this study experienced prolonged bleeding.

Practical application:  According to recommendations from published studies and guidelines, antiplatelet medications, including dual antiplatelet therapy should not be interrupted for tooth extractions or minor oral surgery.

Reference: Doganay, O., Atalay, B., Karadag, E., Aga, U. and Tugrul, M., 2018. Bleeding frequency of patients taking ticagrelor, aspirin, clopidogrel, and dual antiplatelet therapy after tooth extraction and minor oral surgery. The Journal of the American Dental Association149(2), pp.132-138.

BUSINESS OF DENTISTRY  

BUSINESS OF DENTISTRY

Your website and using SEO

Swirsky E.S. et al, discusses how dentists must demarcate themselves in their communities by hanging a so called “digital shingle”.  Techniques leveraging the ubiquitous interconnectivity of the Internet allow companies to transmit a powerful signal through the noise of the World Wide Web.  One methodology known as search engines optimization (SEO) affects the online visibility of a website.  By using SEO, patients can find information about conditions, procedures and providers through key words searches in addition to traditional marketing channels.  Ideally, advertising connects patient and provider, where patients are drawn to services aligned with their needs, and providers enhance their visibility to the public.

Clinical implication:  Market research suggests that 87% of dentists maintain some internet presence and 30% of patients say a dentist’s website influences their choice of provider.  SEO allows for inbound marketing which embraces the idea of pushing information out to customers instead of merely pulling their attention.

Practical application: Dentist’s internet marketing plan should incorporate SEO techniques that adhere to standards of professionalism.  A dentist’s website should be aimed at patient education and improving oral health, and marketers under contract must be made aware of relevant health Code guidelines and licensing issues to avoid the risk of false or misleading advertising.

Reference: Swirsky, E.S., Michaels, C., Stuefen, S. and Halasz, M., 2018. Hanging the digital shingle: Dental ethics and search engine optimization. The Journal of the American Dental Association149(2), pp.81-85.

 

ORTHODONTICS 

OrthodonticsMalocclusions in young children, can breastfeeding really reduce the risk?

Doğramacı, E.J., et al, performed a meta-analysis on 7 studies which focussed on the relationship of breastfeeding on malocclusion in young children.

They found that children who had been breastfed sub-optimally had an increased risk of developing malocclusions compared to those who breastfed optimally.  Optimal breastfeeding is exclusive, breastmilk only for 6 months, then breastfeeding with complementary feeding up to 2 years.

Clinical implication:  According to this review, young children with a history of sub-optimal breastfeeding have a higher prevalence and risk ratio for malocclusions.  These children have an increased risk of developing class II canine relationship, posterior crossbite and anterior open bite.

Practical application: Dental professionals should continue to encourage and promote breastfeeding; however, patients should be aware that children can still develop malocclusions, despite having received optimal breastfeeding, owing to the multifactorial aetiology of malocclusions.

Reference: Doğramacı, E.J., Peres, M.A. and Peres, K.G., 2016. Breast-feeding and malocclusions: the quality and level of evidence on the Internet for the public. The Journal of the American Dental Association147(10), pp.817-825.

IMPLANTS

DentalImplants_ThinkstockPhotos-493611999EDIT
Bruxers and failure rates

Chrcanovic BR. et al., (2017) reviewed a retrospective study which investigated the link between awake and sleep bruxism and the risk of implant failure and then compared bruxers with non-bruxers.  3549 implants in 994 patients were reviewed.  There were 179 implants that were registered failures (46 at abutment connection and 86 during the first year).  Implant failure rates were 13% for bruxers and 4.6% for non-bruxers.

Conclusion:  The model revealed bruxism to be a statistically significant risk factor for implant failure.

Practical application:  Bruxing patients who undergo tooth replacement with implants should be treatment planned for optimal strength at the abutment fixture interface and provided with a splint.

Reference: Chrcanovic, B.R., Kisch, J., Albrektsson, T. and Wennerberg, A., 2016. Bruxism and dental implant failures: a multilevel mixed effects parametric survival analysis approach. Journal of Oral Rehabilitation43(11), pp.813-823.

PROSTHODONTICS

abutment2

Non-vital teeth as abutments

Mizuno Y, et al., (2016) analysed the relationship between the type of edentulous spaces and tooth loss in RPD wearers.

102 consecutively treated patients with partial edentulism who were provided with RPD’s at a university-based clinic were evaluated to identify predictors of tooth loss.

Conclusion:  The presence of endodontically treated teeth at RPD placement was a significant predictor of future tooth loss.

Practical application: Avoid using endodontically treated teeth in critical retentive areas in partial denture design and plan for the possible failure of root treated teeth.

Reference: Mizuno, Y., Bryant, R. and Gonda, T., 2016. Predictors of Tooth Loss in Patients Wearing a Partial Removable Dental Prosthesis. The International Journal of Prosthodontics, 29(4), pp.399-402.

PERIODONTICS

cannabis

Cannabis side effects

Shariff JA. et al., (2017) examined the relationship between frequent recreational use of cannabis and periodontitis in adults.  Of the 1938 participants who were involved in the study, 26.8% were frequent recreational cannabis users.

Conclusion:  Bivariate analysis revealed a positive (harmful) association between frequent recreational cannabis and severe periodontitis in the entire sample as well as those who never used tobacco.

Practical application:  Educate patients who are in this high-risk category as to the implications of their habit. More frequent intervals for maintenance are advised.

Reference:  Shariff, J.A., Ahluwalia, K.P. and Papapanou, P.N., 2017.  Relationship between frequent recreational cannabis (marijuana and hashish) use and periodontitis in adults in the United States: National Health and Nutrition Examination Survey 2011 to 2012. Journal of Periodontology, 88(3), pp.273-280.

DENTAL MATERIALS

posterior composites

Longevity of Posterior Composites

Alvanforoush N, et al., (2017) compared published success rates for posterior composite restorations placed between 1995-2005 and 2006-2016.  The restorations had to be in place for at least 24 months.

The overall survival rate for the earlier and later decades were 89.4% and 86.9% respectively.  Restorations failure due to secondary caries in the earlier decade was 29.5% and in the later decade 25.7%.

Material fractures of 28.8% and tooth fractures of 3.5% were reported in the earlier decade but in the later decade, material fracture increased to 39.1% and tooth fracture had increased to 23.8%.

Conclusion: It was speculated that the increase in composite and tooth fracture was due to placing larger composite resin restorations during the latter decade.

Practical application:  Understand and respect the limitations of direct composite in larger restorations and utilize capping cusps to protect remaining tooth structure.

Reference:  Alvanforoush, N., Palamara, J., Wong, R.H. and Burrow, M.F., 2017. Comparison between published clinical success of direct resin composite restorations in vital posterior teeth in 1995–2005 and 2006–2016 periods. Australian Dental Journal, 62(2), pp.132-145.

ORAL MEDICINE

HPV

HPV Vaccine essential

Human papillomavirus (HPV) infection is a distinct risk factor for oropharyngeal squamous cell carcinoma (OPSCC) and HPV 16 is associated with most HPV-OPSCC. The incidence rates of HPV-OPSCC have been increasing for the last 3 decades. Tobacco-related head and neck squamous cell carcinoma rates are decreasing worldwide (Javadi P. et al., 2017). Herrero R., et al., (2013) published results of first randomized controlled trial showing the benefit of HPV vaccine.

Conclusion: There was a 93% vaccine efficacy in reducing oral HPV infection at 4-year follow-up.

Practical application: Patients should be screened for currency of HPV vaccine and should be mandatory on the medical history forms.

References:

  1. Javadi, P., Sharma, A., Zahnd, W.E. and Jenkins, W.D., 2017. Evolving disparities in the epidemiology of oral cavity and oropharyngeal cancers. Cancer Causes & Control, 28(6), pp.635-645.
  2. Herrero, R., Quint, W., Hildesheim, A., Gonzalez, P., Struijk, L., Katki, H.A., Porras, C., Schiffman, M., Rodriguez, A.C., Solomon, D. and Jimenez, S., 2013. Reduced prevalence of oral human papillomavirus (HPV) 4 years after bivalent HPV vaccination in a randomized clinical trial in Costa Rica. PloS one, 8(7), p.e68329.

BUSINESS OF DENTISTRY

teledent

Tele-dentistry enhances practices

Estai M. et al., (2016) explored Australian dental practitioners’ perceptions of the usefulness of tele-dentistry in improving dental practice and patient outcomes. Tele-dentistry is the remote provision of dental care, advice or treatment through the medium of information technology.  They designed a questionnaire assessing perceptions of dentists in four domains: usefulness of tele-dentistry for patients; usefulness of tele-dentistry for dental practice; capability of tele-dentistry to improve practice; and perceived concerns about the use of tele-dentistry.

Conclusion:  Most dentists agreed that tele-dentistry would improve dental practice through enhancing communication with peers, guidance and referral of new patients and improve patient management and increasing patient satisfaction. Concerns included with technical reliability, privacy, practice expenses, the cost of setting up tele-dentistry, surgery time and diagnostic accuracy.

Practical application:  Be mindful that dental technology is enhancing all aspects of dental practice. Those who do not embrace it will be left behind as patients are more and more technologically savvy and have expectations that are continually evolving.

Reference: Estai, M., Kruger, E. and Tennant, M., 2016. Perceptions of Australian dental practitioners about using telemedicine in dental practice. British Dental Journal, 220(1), p.25.

AESTHETIC DENTISTRY

toothmorph

Understanding tooth morphology

Mahn E. et al., (2017) evaluated different tooth shapes from different genders, matching them with traditional basic forms and proposed different hybrid shapes.  They also evaluated the percentage of correct gender identification of lay people, dentists and dental students.  Standardised digital photos were taken from 460 people and analyzed by 3 experts regarding genders and tooth forms: pure basic forms—oval (O), triangular (T), square (S) and rectangular (R); and combined hybrid forms—oval-rectangular (OR), triangular-rectangular (TR), triangular-oval (TO), square-oval with flat lateral incisors (SOF), and square-oval with scalloped lateral incisors (SOS).

Conclusion:  Pure forms were less prevalent in the population studied than hybrid ones and tooth gender selection among different evaluators was not significantly different.  The correlation of reported tooth shapes with specific genders was not reliably observed in natural smiles.  Pre-standardized pure tooth forms appeared less than hybrid ones, while the most frequently found in the population studied were TO, SOS and OR.

Practical application:  Tooth shapes should be selected according to patient wishes rather than by previously believed gender specific tooth shapes. Pure basic tooth forms should be complemented by adding of combination forms to more accurately portray those found in the patients’ dentition.  Listening to the expectations of the patient and utilizing digital diagnostic wax-ups will enhance final results.  Fabrication of excellent temporaries that will mimic the final restoration is encouraged.

Reference: Mahn, E., Walls, S., Jorquera, G., Valdés, A.M., Val, A. and Sampaio, C.S., 2017. Prevalence of tooth forms and their gender correlation. Journal of Esthetic and Restorative Dentistry.

ORTHODONTICS

mandibularadvancementspling

Changes to occlusion with use of advancement splints in apnoea

Doff M.J.H. et al., (2017) selected 51 patients  randomized to oral appliance therapy and 52 patients to CPAP therapy for treating mild to moderate sleep apnoea.  At baseline and after a 2-year follow-up, study models in full occlusion were analysed with respect to relevant variables.

Conclusion: Long-term use of an oral appliance resulted in small but significant dental changes compared with CPAP.  In the oral appliance group, overbite and overjet decreased respectively.  Furthermore, a significantly larger anterior–posterior change in the occlusion in the oral appliance group compared to the CPAP group. Both groups showed a significant decrease in number of occlusal contact points in the (pre)molar region.

Analysis revealed that the decrease in overbite was associated with the mean mandibular protrusion during follow-up. Oral appliance therapy should be considered as a lifelong treatment, and there is a risk of dental side effects to occur.

Practical application:  The patient should be informed of possible consequences of oral appliance therapy and this should be included in the consent process.

Reference:  Doff, M.H.J., Finnema, K.J., Hoekema, A., Wijkstra, P.J., de Bont, L.G.M. and Stegenga, B., 2017. Long-term oral appliance therapy in obstructive sleep apnoea syndrome: a controlled study on dental side effects. Clinical Oral Investigations17(2), pp.475-482