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 Dentistry, 28(6), pp.382-396.
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 Periodontology, 88(12), pp.1297-1308.
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 Periodontology, 88(12), pp.1339-1347.
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 Endodontics, 42(9), pp.1314-1319.
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 Association, 148(8), pp.584-594.
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].
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 Dentistry, 41(1), pp.E13-E22.
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.
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 Association, 148(6), pp.369-376.
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.
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 Association, 147(11), pp.891-896.
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.
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 Dentistry, 119(1), pp.53-59.
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 Orthopedics, 151(1), pp.28-52.
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 dentistry, 2017.
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].
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 Dentistry, 119(3), pp.354-362.
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 research, 95(9), pp.985-994.
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 Dentistry, 55, pp.1-6.
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 Research, 27(4), pp.491-496.
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.
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.
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 periodontology, 44(2), pp.225-234.
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].
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].
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.
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 Implants, 31(6).
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 research, 14(4), pp.612-621.
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:
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 periodontology, 88(2), pp.144-152.
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 dentistry, 44, pp.57-63.
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 Association, 149(2), pp.132-138.
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 Association, 149(2), pp.81-85.
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 Association, 147(10), pp.817-825.
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 Rehabilitation, 43(11), pp.813-823.
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.
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.
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.
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.
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.
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.
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 Investigations, 17(2), pp.475-482