Dental Faculty

Clinical Updates

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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