Dental Faculty

Clinical Updates

Our new Rapid Clinical Updates Series is here!

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

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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