Oral Hygiene Sep/Oct 2023 by dentalcommunity

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VOL.33 NO.4

SEPTEMBER/OCTOBER 2023

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VOLUME 33 | NUMBER 4 SEPTEMBER/OCTOBER 2023

OH | CONTENTS

On the cover... The new Panasonic range of Oral Irrigators with cutting-edge ultrasonic technology and a track record of delivering remarkable results are helping change the game in the realm of oral hygiene.

22 READ ME FOR

CPD

4 BRIEFS 6 NEWS & EVENTS 16 CPD CENTRE 20 ABSTRACTS

MOCOM LAUNCHES NEW SOLUTIONS TO STREAMLINE HANDPIECE MAINTENANCE MOCOM is backing up its leading position in the steriliser and washer disinfector market with new solutions for handpiece maintenance

READ ME FOR

CPD

SUSTAINABILITY IN DENTISTRY: PART 2 LIFE CYCLE ANALYSIS: A PRIMER In this instalment of the series on sustainability considerations in infection control from Prof. Laurie Walsh deals with life cycle analysis (LCA), also known as environmental Life Cycle Assessment

14 28

THE BENEFITS OF WATER IRRIGATORS

Water irrigators often receive a bad wrap among dental professionals, but its time to revisit the evidence and take a deeper look into water irrigation and how it can benefit your patients says Tabitha Acret

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CPD

READ ME FOR

CPD

THE OPTICAL SCIENCE OF COLOUR CORRECTION: HOW IT WORKS Understanding what determines the colour of teeth is fundamental to the proper use of a range of techniques in dentistry explains Prof. Laurie Walsh

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news | EVENTS

in | BRIEF

Dental Hygienist and Therapist Forum returns to IDEM

Accurate detection and assessment of dental caries are crucial for effective treatment and preventive measures. Teledentistry (TD) has recently emerged as a promising method for overcoming the difficulties involved with conventional dental exams, including for patients living in remote areas and those who are hospitalised or residents of nursing homes. It allows clinicians to diagnose oral health issues, provide consultations and offer treatment recommendations, all without the need for an in-person visit. TD allows for the evaluation, diagnosis and management of oral health conditions, including dental caries, without the need for inperson visits. This systematic review was undertaken to answer the research question: “What is the difference in diagnostic accuracy between teledentistry and conventional assessment methods for the detection of dental caries?”. Literature searches were conducted across databases such as PubMed, Embase, the Cochrane Library, Scopus, the Web of Science, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO by using predefined search terms and inclusion criteria. Eight studies met the inclusion criteria and were included in the review. The Newcastle-Ottawa scale (NOS) grading indicated that the studies were of good quality. The key findings were that TD assessments (based on intraoral photographs captured using smartphones or intraoral cameras) demonstrated comparable accuracy to traditional clinical examinations in detecting and assessing dental caries. Among the four studies that were quantitatively analysed, no significant difference was noted at p = 0.09. A mean difference of 0.64 (95% confidence interval (CI): -0.10 to 1.38) suggested that clinical examination and teledentistry-based checkup were on par with each other for the detection of dental caries. Hence, TD may be an effective approach for identifying and evaluating dental caries. However, further research is required to substantiate the findings of this review.

aving established itself as a mainstay programme of the IDEM Singapore conference, the Dental Hygienist and Therapist Forum will once again return for its 5th edition in April 2024 with 2 full days of insightful lectures focusing on the learning needs of both the dental hygienist and the dental therapist. Over the course of the two days, the Forum will feature a series of engaging lectures and interactive sessions. You can expect to hear from leading regional experts in the field, as well as to engage in lively discussions with fellow delegates. Whether you’re a seasoned professional or a new graduate, you will find value in the diverse range of topics and perspectives that will be presented. In addition to the Forum, all participants will gain access to the IDEM Trade Exhibition, which is planned to bring in over 500 exhibitors from across the globe to showcase the latest products and services in dentistry for you to explore. The exhibition is a fantastic opportunity to connect with leading companies and gain valuable insights into the latest trends and developments in the industry. IDEM Singapore 2024 will be staged from April 19-21, 2024. For more information, visit www.idem-singapore.com

Twitter becomes ‘X’ - what it means for dentists... ince buying Twitter last year for $44 billion, new owner, Elon Musk, has spent more than a little time tinkering under the bonnet. The most obvious change to Twitter is a recent rebranding - Twitter is now known simply as ‘X’. No joke. Never one to think small, it seems Musk might have had this grand plan for Twitter brewing for years. He was an early owner of X.com (a matching domain name is essential to support the brand) which was his first company before he went on to co-found PayPal and make his fortune. Musk sold X.com, but bought it back in 2017, well before his 2022 acquisition of Twitter. So, what has changed in X from when it was Twitter and how can dentists use this to their advantage? To understand what’s changed, we need to look at what was there previously. Historically, Twitter was good for short messaging - “tweeting” - with strict character limits in place - just 140 initially. However, X users can now engage in live audio conversations, send longer text messages and even broadcast video. However, Musk (who also founded SpaceX and Tesla) clearly has big plans for X. In fact, he is on record as saying that he aims to make X a kind of super-app, which includes basically anything users want to do online. Bottom line: For dentists, X is a case of “watch this space”. With change comes opportunity and the changed functionality in X could easily lead to more users and more opportunities to get your dental message out there. However, just because there is additional functionality in an app does not mean that users will embrace the change. Indeed, use of Twitter/X has declined by 25% since Musk’s purchase. If Musk’s super-app plan does gain traction, then more eyeballs means more opportunity. But beware of shiny objects; it’s better to do one form of social media well than spread yourself too thinly.

By Angus Pryor... more at dentalmarketingsolutions.com.au

4 oral|hygiene

Priyank H, et al. Comparative evaluation of dental caries score between teledentistry examination and clinical examination: a systematic review and meta-analysis. Cureus 2023; 15(7): e42414. (July 25, 2023) DOI 10.7759/cureus.42414

September/October 2023

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news | EVENTS

New Panasonic Oral Irrigators harness ultrasonic technology for optimal outcomes

aintaining excellent oral hygiene is crucial for overall health and as dental professionals, it’s our responsibility to provide our patients with the best tools for achieving optimal oral care. One such tool that has been garnering attention in the industry is the new Panasonic range of Oral Irrigators. With cutting-edge ultrasonic technology and a track record of delivering remarkable results, they are helping change the game in the realm of oral hygiene. In this article, we will explore why offering Panasonic Oral Irrigators to your patients can revolutionise their oral care routines.

6 oral|hygiene

The power of ultrasonic technology n the pursuit of comprehensive oral care, traditional methods such as brushing and flossing have long been staples. However, with the introduction of ultrasonic technology, Panasonic Oral Irrigators have taken dental hygiene to the next level. Ultrasonic technology utilises high-frequency sound waves to create tiny bubbles in the mouthwash or water used in the device. These bubbles effectively clean and remove plaque, bacteria and food particles from hard-to-reach areas, such as gum pockets and between teeth. The ultrasonic technology employed by Panasonic Oral Irrigators ensures a deeper and more thorough cleaning, enhancing the overall oral health of patients. 88

September/October 2023

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* Terms & Conditions apply - please visit the website for details

news | EVENTS Enhanced patient experience major advantage of Panasonic Oral Irrigators lies in their ability to provide a gentle and comfortable oral care experience. Traditional flossing can often be uncomfortable, leading to patients neglecting essential interdental cleaning. With Panasonic Oral Irrigators, however, patients can experience a non-invasive and soothing way to remove debris and maintain oral health. The adjustable water pressure settings allow for a customised experience, catering to each patient’s unique needs.

Convenience and efficiency n our fast-paced world, convenience plays a significant role in our daily routines. Panasonic Oral Irrigators recognise this and offer a solution that seamlessly integrates into patients’ busy lives. With their compact design and easy-to-use functionality, these devices allow for fast, hassle-free oral care both at home and on the go. The efficient cleaning process saves time while providing remarkable results.

“I’m seeing the Panasonic water flossers produce really excellent clinical results. I’m strongly recommending this oral hygiene aid to my patients to aid in maintaining ideal hygiene around implantsupported restorations, particularly for large or full- arch restorations where palatal access is challenging.” Dr Nicholas Hocking, BDS

Excellent clinical results r Nicholas Hocking (BDS (Adel), MSc (Lond), M.Clin.Dent (Pros) (Lond), FICD, FPFA), a dental surgeon and clinical lecturer with vast experience in the field of dental implants, has seen positive results from his patient’s use of Panasonic Oral Irrigators as a means to enhance their oral hygiene. He stated, “I’m seeing the Panasonic water flossers produce really excellent clinical results. I’m strongly recommending this oral hygiene aid to my patients to aid in maintaining ideal hygiene around implant-supported restorations, particularly for large or full- arch restorations where palatal access is challenging.”

Supporting your practice o support dental practices, Panasonic have recently appointed MKS Health Technologies, a local Australian business specialising in solutions for the health and well-being sectors to supply their Oral Care range in the Australian market. Matthew Shepherd, Managing Director of

8 oral|hygiene

MKS Health Technologies said, “We’re delighted to be adding the Panasonic Oral Care range to our product offering. With their advanced ultrasonic technology, easy-to-use designs and exceptional cleaning power, these devices offer a comprehensive solution for healthy teeth and gums.” Dental practitioners looking to provide their patients with the Panasonic range should contact MKS Health Technologies for professional pricing and special introductory offers for their dental practice.

Summary ncorporating Panasonic Oral Irrigators into your dental practice not only demonstrates your commitment to offering the latest advancements in oral care but also provides your patients with an alternative, effective and enjoyable means of achieving optimal oral hygiene. With the remarkable benefits of ultrasonic technology and support from MKS Health Technologies, Panasonic Oral Irrigators are poised to revolutionise the oral care routines of your patients.

For more information, call 1300-202-264, visit www.mkshealthtech.com.au or email info@mkshealhtech.com.au

September/October 2023

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infection | CONTROL

READ ME FOR CPD

Mocom launches new solutions to streamline handpiece maintenance By Joseph Allbeury

OCOM Australia is well-known as a leader in the supply of specialised infection control equipment for dental practices and now the company is introducing another unique solution. We spoke with MOCOM Australia’s Jim Owen to hear all the details. Jim, I hear that MOCOM JA Hi Australia is backing up its

leading position in the steriliser and washer disinfector market with a new solution for handpiece maintenance. Tell us more.

10 oral|hygiene

MOCOM Australia is launching

JO two solutions for automated

handpiece maintenance under the brand name THALYA. There’s an entry level unit, which lubricates four handpieces in just under a minute and then there’s the THALYA+, which can clean, disinfect, lubricate, purge excess oil and then dry four handpieces in 12 minutes. Both units have couplings available for all the major handpiece brands including KaVo, Dentsply Sirona, W&H, Bien-Air and NSK and there is also a Midwest connection. And both work with any brand of lubricating oil, so if you use a certain brand of handpiece, you can continue to use the matching oil if you wish, except

for KaVo QUATTROcare Plus oil, as the can size and shape is not compatible. MOCOM Australia also has its own brand of oil available as a further option. when you buy a THALYA or JA So THALYA+, you specify which

handpiece connectors you want?

Exactly. So whatever brand of

JO high speed handpieces you’re

using, we configure the unit according to your needs. Slow speed handpieces are generic, so there is also a slow speed coupling available. The launch package for THALYA and THALYA+ includes four couplings of your choice. The THALYA+ package also includes the cleaning chemical. You just need to add the oil of your choice.

September/October 2023

infection | CONTROL

“We can really see a need for THALYA+ because handpieces are either not being cleaned internally or not being cleaned after every use... THALYA+ performs this function in 12 minutes...”

So what does the base model

JA THALYA do?

It’s pretty straightforward

JO and easy-to-use. It purges the

handpiece, lubricates it and then purges excess oil. It will complete 4 handpieces in 55 seconds. Handpieces last longer if lubricated continually and correctly and THALYA makes this a simple process. what does the THALYA+ JA And do differently? The THALYA+ is unique to the Australian market in terms of its capability. It flushes a chemical through the handpiece internally and also externally to clean and disinfect it. It then lubricates, purges excess oil and dries the handpiece. There is no other product that does what this unit does.

And then you would still sterilise the handpiece?

So it doesn’t replace steriliJO Yes. sation, but it does mechanically

clean the handpiece. And I think that’s a major point to highlight because I don’t

September/October 2023

know that many practices are actually cleaning handpieces internally. When a handpiece slows down after use, it creates a back-siphoning effect, where it can draw bioburden and liquids back inside the handpiece. And that needs to be cleaned out. It’s just like anything else that’s sterilised - if it’s not cleaned first, if that bioburden’s not removed, then it can’t be sterilised effectively. So the THALYA+ ensures handpieces are both cleaned and lubricated ready for sterilisation as part of a repeatable, mechanised process. do practices clean handJA How pieces internally now? That’s a good question. In my

JO experience, it’s most often not

being done. If you have a washer disinfector unit, you can use a coupling to allow handpieces to be washed internally and then you still need to lubricate. You can also manually spray a chemical through the handpiece. But again, if you’re doing it manually, how can you gauge its effectiveness? You can’t see what’s inside a handpiece, so automating the process using a proven method is ensuring consistent and effective cleaning every time.

And how often should you

JA internally clean a handpiece? should be doing it after JO You every use of the handpiece, just

like you sterilise it after every procedure. Clean, lubricate and sterilise. We can really see a need for THALYA+ because handpieces are either not being cleaned internally or not being cleaned after every use and when they are, it’s a time-consuming, labour-intensive and technique-sensitive task that slows down the reprocessing cycle. So the THALYA+ performs this function in 12 minutes in a set-and-forget process. It allows this important step to be easily incorporated into the reprocessing cycle every time. do manufacturers recomJA And mend this?

manufacturers recommend JO All that their handpieces are cleaned

and lubricated and both of these functions prolong handpiece life. Can the THALYA+ just be used

JA to lubricate the handpieces

without cleaning?

oral|hygiene 11

infection | CONTROL “You can tilt the couplings 45 degrees forward for easier access attaching the handpieces onto the couplings...”

Another feature is that the THALYA+ can also process scaler handpieces. There’s nothing else on the market that can do that. When you’re processing the scaler handpieces, it’s just cleaning and disinfecting - you don’t need to lubricate. And which scalers does the

JA THALYA+ accommodate?

It will clean EMS, Satelec, Stern

JO Weber and Anthos scalers.

this is quite a game changer JA So for speeding up instrument

reprocessing?

as the THALYA+ JO Especially allows you to easily and auto-

matically clean inside a handpiece. I’ve spoken to various handpiece technicians, who obviously open handpieces when they’re repairing them and the feedback is that most are in an horrendous condition. So the fact that we’re able to address this problem in an automated manner in order to make sure that you achieve sterilisation is vitally important. So yes, I believe it is a real game changer. The THALYA+ takes all the hard work out of handpiece maintenance with the same proven, effective process performed every time. The correct amount of oil is delivered - the same measured dose of cleaning chemical is used. You’re not over- or under oiling and you’re not leaving dirt or bioburden inside.

JA Thank you for your time. There are four different JO Yes. cycles you can choose from with

the Thalya+. Cycle 1 does everything clean, disinfect, lubrication, air purge. Cycle 2 is just clean and purge if you want to clean without the lubrication. Cycle 3 is lubrication and air purge. And Cycle 4 is an additional air purge. So if you need to remove excess oil from a handpiece, you can use Cycle 4. there any other points to JA Are highlight? There are a couple of other

JO unique points. The first is that

when you place the handpieces into the chamber, you can tilt the couplings 45 degrees forward for easier access attaching the handpieces onto the couplings.

12 oral|hygiene

September/October 2023

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clinical | EXCELLENCE

READ ME FOR CPD

The benefits of water irrigators By Tabitha Acret, BOH, Grad.Cert (Public Health), current master’s student

ater irrigators, also known as oral irrigators or dental water jets, are devices that use a stream of water to remove plaque and debris from teeth and soft tissues. They are often used as an adjunct to toothbrushing and interdental cleaning to improve oral hygiene. They also often have a bad wrap among dental professionals, but its time to revisit the evidence and take a deeper look into water irrigation and how it can benefit your patients.

There is evidence to support the use of water irrigators in dental patients. A systematic review and meta-analysis published in the Journal of Clinical Periodontology in 2013 found that water irrigation was effective at reducing gingival bleeding

14 oral|hygiene

and improving oral hygiene compared to toothbrushing alone. Another systematic review and meta-analysis published in the Journal of Dentistry in 2019 found that water irrigation was effective at reducing plaque and gingival inflammation. There is further evidence to support the use of water irrigators in specific situations.

Caries here is some evidence to suggest that water irrigators can be helpful in reducing the risk of dental caries. A systematic review and metaanalysis published in the Journal of Clinical Periodontology in 2013 analysed 9 studies on the use of water irrigators in patients with various oral conditions, including caries. The review found that water irrigators, when used as an adjunct to regular oral hygiene practices, reduced the number of carious lesions and improved oral health compared to manual or electric toothbrushing alone. The International Journal of Dental Hygiene in 2008 compared the use of a water irrigator versus dental floss in children with orthodontic

September/October 2023

clinical | EXCELLENCE appliances. The study found that both interventions were effective in reducing plaque and gingivitis, but the water irrigator group had significantly lower caries incidence than the flossing group. Furthermore, a randomised controlled trial published in the Journal of Clinical Dentistry in 2018 compared the use of a water irrigator versus a manual toothbrush in adults with interproximal caries. The study found that both interventions were effective in reducing plaque and gingivitis, but the water irrigator group had significantly lower caries incidence than the toothbrushing group. These studies suggest that water irrigators can be a useful tool for reducing the risk of dental caries, particularly in populations with orthodontic appliances or interproximal caries.

Furcation involvement urcation involvement occurs when periodontal disease progresses to the point where bone loss and tissue destruction result in exposure of the furcation area, which is the area where the roots of a multi-rooted tooth meet. A systematic review published in the Journal of Clinical Periodontology in 2015 analysed 13 studies on the use of water irrigators in patients with periodontal disease, including some with furcation involvement. The review found that water irrigators, when used as an adjunct to regular oral hygiene practices, can be effective in reducing gingival inflammation and bleeding, but the evidence for their effectiveness in treating furcation involvement was limited and inconclusive.

Orthodontics

Periodontal disease here is evidence to suggest that water irrigators can be beneficial for patients with periodontal disease. A systematic review and meta-analysis published in the Journal of Clinical Periodontology in 2013 analysed 9 studies on the use of water irrigators in patients with periodontitis. The review found that water irrigators, when used as an adjunct to regular oral hygiene practices, reduced gingival inflammation and bleeding compared to manual or electric toothbrushing alone. The Journal of Clinical Periodontology in 2011 compared the use of water irrigators versus dental floss in patients with periodontitis. The study found that both water irrigators and dental floss were effective in reducing gingival inflammation and bleeding, but the water irrigator was better tolerated by patients and resulted in less gingival trauma. In a randomised controlled trial published in the Journal of Clinical Dentistry in 2016 compared the use of a water irrigator versus a sonic toothbrush in patients with periodontitis. The study found that both interventions were effective in reducing plaque and gingival inflammation, but the water irrigator was more effective at reducing pocket depth and improving clinical attachment levels. Overall, the evidence suggests that water irrigators can be a useful adjunct to regular oral hygiene practices for patients with periodontal disease.

September/October 2023

rthodontic patients, in particular, can benefit from using water irrigators because the brackets and wires of braces can make it difficult to clean between teeth and around the appliance. A randomised clinical trial published in the American Journal of Orthodontics and Dentofacial Orthopaedics in 2013 found that orthodontic patients who used a water irrigator in addition to brushing and flossing had significantly lower levels of plaque and gingival inflammation compared to those who only brushed and flossed. Another randomised clinical trial published in the Journal of Clinical Periodontology in 2011 found that orthodontic patients who used a water irrigator had greater reductions in bleeding and gingival inflammation compared to those who only brushed and flossed. And a systematic review published in the International Journal of Dental Hygiene in 2018 analysed 14 studies on the use of water irrigators for orthodontic patients and found that they can be effective in reducing plaque and gingival inflammation. Overall, the evidence suggests that water irrigators can be a useful tool for orthodontic patients to improve their oral hygiene and reduce the risk of periodontal disease. In conclusion, water irrigators can be a valuable addition to oral hygiene instructions for patients. While they should not be used as a replacement for brushing and interdental cleaning, they can help

remove food particles and biofilm from hard-to-reach areas. Studies have shown that water irrigation is better than floss at reducing inflammation and they are effective at reducing inflammation. Overall incorporating a water irrigator into oral hygiene routines can be a beneficial step towards achieving and maintaining good oral health.

References 1. Sharma, N., Shamsuddin, H. (2013). Water fluoridation and oral health: A review. Journal of Clinical and Diagnostic Research, 7(12), 2399-2402. 2. Sambunjak, D., Nickerson, J. W., Poklepovic, T., Johnson, T. M., Imai, P., Tugwell, P., & Worthington, H. V. (2013). Flossing for the management of periodontal diseases and dental caries in adults. Cochrane Database of Systematic Reviews, (12), CD008829. 3. Slot, D. E., Berchier, C. E., Addy, M., Van der Velden, U., & Van der Weijden, G. A. (2008). The efficacy of interdental brushes on plaque and parameters of periodontal inflammation: a systematic review. International Journal of Dental Hygiene, 6(4), 253-264. 4. Chapple, I. L. C., Van der Weijden, F., Doerfer, C., Herrera, D., Shapira, L., Polak, D., & Madianos, P. (2013). Primary prevention of periodontitis: Managing gingivitis. Journal of Clinical Periodontology, 40(S14), S106-S135. 5. Worthington, H. V., MacDonald, L., Poklepovic, T., Sambunjak, D., Johnson, T. M., Imai, P., & Clarkson, J. E. (2019). Home use of interdental cleaning devices, in addition to toothbrushing, for preventing and controlling periodontal diseases and dental caries. Cochrane Database of Systematic Reviews, (4), CD012018.

About the author Tabitha Acret is a dedicated and passionate award-winning Dental Hygienist. She studied a Bachelor or Oral Health at Newcastle University , Graduate Certificate in Public Health and current Masters student .Tabitha has become one of the most sought-after Hygienists and Educators in Australia and internationally with a fast-growing and loyal customer base of patients, dental professionals and media. Tabitha was previously the National Vice-President for the Dental Hygienists Association of Australia and has volunteered in many roles since graduation for the Association. She also has a passion for educating with students, working as a Clinical Educator at Sydney University and Newcastle University and currently works as a Clinical Educator for implant maintenance and non-surgical periodontal therapy as well as two days a week in clinical practice.

oral|hygiene 15

oral|hygiene CPD CENTRE infection | CONTROL

clinical | EXCELLENCE

READ ME FOR CPD

The benefits of water irrigators

Mocom launches new solutions to streamline handpiece maintenance

By Tabitha Acret, BOH, Grad.Cert (Public Health), current master’s student

By Joseph Allbeury

Hi Jim, I hear that MOCOM Australia is backing up its leading position in the steriliser and washer disinfector market with a new solution for handpiece maintenance. Tell us more.

MOCOM Australia is launching two solutions for automated handpiece maintenance under the brand name THALYA. There’s an entry level unit, which lubricates four handpieces in just under a minute and then there’s the THALYA+, which can clean, disinfect, lubricate, purge excess oil and then dry four handpieces in 12 minutes. Both units have couplings available for all the major handpiece brands including KaVo, Dentsply Sirona, W&H, Bien-Air and NSK and there is also a Midwest connection. And both work with any brand of lubricating oil, so if you use a certain brand of handpiece, you can continue to use the matching oil if you wish, except

10 oral|hygiene

handpiece connectors you want?

Exactly. So whatever brand of high speed handpieces you’re using, we configure the unit according to your needs. Slow speed handpieces are generic, so there is also a slow speed coupling available. The launch package for THALYA and THALYA+ includes four couplings of your choice. The THALYA+ package also includes the cleaning chemical. You just need to add the oil of your choice.

14 oral|hygiene

September/October 2023

Question 1. The Thalya+... a. Cleans handpieces b. Disinfects handpieces c. Lubricates handpieces d. Purges excess oil from handpieces e. All of the above

READ ME FOR CPD

September/October 2023

Question 6. A systematic review and meta-analysis published in the Journal of Clinical Periodontology in 2013 found that water irrigation was effective at reducing gingival bleeding and improving oral hygiene compared to toothbrushing alone? a. True b. False

a. 2 b. 4 c. 6 d. 8

Question 7. A systematic review and meta-analysis published in the Journal of Clinical Periodontology in 2013 found that water irrigators, when used as an adjunct to regular oral hygiene practices, reduced gingival inflammation and bleeding compared to manual or electric toothbrushing alone...

Question 3. The Thalya+ completes a full cycle in?

a. True b. False

a. 6 minutes b. 12 minutes c. 16 minutes d. 20 minutes

Question 8. A systematic review published in the International Journal of Dental Hygiene in 2018 found that water irrigators they can be effective in reducing plaque and gingival inflammation...

Question 4. Handpieces should be processed in the Thalya...

a. True b. False

a. After sterilisation b. Before sterilisation c. Instead of sterilisation d. Immediately before use on a patient

Question 9. A systematic review published in the Journal of Clinical Periodontology in 2015 found clear evidence of the effectiveness of water irrigators in treating furcation involvement...

Question 5. Handpieces should be cleaned and lubricated...

a. True b. False

Question 2. How many cycles does the Thalya+ offer?

a. Monthly b. Weekly c. Daily d. After every patient

Question 10.A randomised controlled trial published in the Journal of Clinical Dentistry in 2016 comparing the use of a water irrigator versus a sonic toothbrush in patients with periodontitis found that the water irrigator was more effective at reducing pocket depth and improving clinical attachment levels. a. True b. False

INSTRUCTIONS: OralHygiene™ is now offering PAID subscribers the ability to gain 2 Hours CPD credit from reading articles in this edition of the magazine and answering the questions above. To participate, contact OralHygiene for your Username and Password. Then log into the Dental Community website at www.dentalcommunity.com.au and click on the CPD Questionnaires link; select the Oral Hygiene Sep/Oct 2023 questionnaire and then click START. A score greater than 80% is required to PASS and receive CPD.

READ THE ARTICLES BELOW AND ANSWER THE QUESTIONS ONLINE AT WWW.DENTALCOMMUNITY.COM.AU - 2 HOURS OF CPD infection | CONTROL

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The optical science of colour correction: how it works

Sustainability in dentistry: Part 2 - Life cycle analysis: A primer

By Emeritus Professor Laurence J. Walsh AO

his instalment of the series on sustainability considerations in infection control deals with life cycle analysis (LCA), also known as environmental Life Cycle Assessment. This approach can inform dental clinics when weighing up alternatives, including when staff make environmentally conscious decisions around single use items versus those that can be reprocessed. As well as decisions around purchasing, LCA also helps to unpack product claims around whether or not a product is “greener” than its competitors.

In the World Dental Federation (FDI) Vision 2030 document, all oral health care providers have an ethical and moral responsibility to manage the impact of our activities on the environment and ensure that we do this in a sustainable manner. Adding to the moral obligations around sustainable dental practice, which are now considered core competency requirements for all types of registered dental practitioners, it is important to remember the Australian Government Department of Agriculture, Water and the Environment’s National Plastics Plan 2021, where a range of bans on single-use plastics have been rolling out across the country.

22 oral|hygiene

Time marches on ooth shade varies across a continuum, in terms of brightness (luminosity) and colour (hue, chroma and value). A progressive increase in yellow with age is a normal age-related change.1,2 Studying crosssections of permanent maxillary incisor teeth (Figure

1) reveals obvious reasons for such changes over the years. In young adults, the dentine has patent tubules. Light bends as it passed through both enamel and dentine, following the direction of prisms and tubules, respectively.3 This property makes teeth in young adults anisotropic, which means that the light does not travel in a straight line (Figure 2). By middle age, some sclerosis of the dentine is occurring, making the dentine become a more homogenous solid and thus more isotropic. In older adults, the dentine is more sclerosed and can become completely translucent in parts, while the enamel is more translucent and also thinner. As a result, the underlying yellow shade of the dentine shows through more.2 Adding to this, progressive deposition of secondary dentine as an aged-related change makes the pulp chamber smaller. There can also be tertiary or reparative dentine laid down locally, as a response to having a restoration placed or an exposed root surface.

28 oral|hygiene

September/October 2023

Question 11. A Life Cycle Assessment can...

Question 16. Absorption of violet and blue light makes teeth appear...

a. Help staff make environmentally conscious decisions. b. Help staff make decisions around purchasing. c. Unpack product claims around whether or not a product is “greener” than its competitors. d. All of the above.

a. Grey b. White c. Yellow d. Brown

Question 12. All oral health care providers have an ethical and moral responsibility to manage the impact of their activities on the environment according to the...

a. Titanium dioxide for slower release of fluorides over time. b. Blue covarine dye to make teeth look brighter and less yellow. c. Used to create special red stripes. d. Used to create special green stripes.

a. ADA b. AHPRA c. FDI d. HCCC Question 13. Carbon dioxide emissions for oral health care principally come from... a. The supply chain. b. Waste generated by the clinic. c. Travel by patients and staff. d. All of the above. Question 14. Greenwashing is... a. Chemically breaking down plastics to a biodegradable compound. b. Treating plastics in preparation for recycling. c. Misleading product labelling to make it seem “greener”. d. Using biodegradable detergents in a washing machine. Question 15. The “3 Rs” represent... a. Recycle, recycle, recycle b. Reduce, reuse and recycle c. Recycle, reduce, reconstruct d. Replace, reduce, refine

To retrieve your FREE Dental Community Login:

Call (02) 9929 1900 or Email info@dentist.com.au

Question 17. Toothpaste ingredient CI 74160 is...

Question 18. V34 colour corrector serum contains... a. Red dye b. Blue dye c. Red and blue dye d. Red and green dye Question 19. When natural teeth that are yellow are exposed to sunlight, the reflected light spectrum shows... a. A reduction in visible violet b. An increase in yellow light c. A reduction in blue light d. An increase in red light e. All of the above Question 20. A surface that colour correcting dyes can bind to is... a. Natural teeth b. Pellicle c. Restorative materials d. All of the above

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abstracts | 2023

Oral Hygiene Abstracts 2023

By Emer. Prof. Laurence Walsh AO

Mental stress in dentists during COVID

The dental profession endured unprecedented disruption amid the 3.5 years of the COVID-19 pandemic. Novel stressors have included the risk of occupational exposure to COVID-19 from close interactions with patients and from aerosolgenerating procedures, financial losses from lockdowns and the cessation of clinical operations and stricter infection prevention and control requirements. This study investigated the longitudinal impact of the pandemic on the stress and anxiety levels of a cohort of 222 Canadian dentists between September 2020 and October 2021. Salivary cortisol was used as a biomarker of mental stress and 10 sets of monthly saliva samples (2,131 in total) were self-collected, sent to the laboratory in prepaid courier envelopes and analysed by enzyme-linked immunosorbent assay. To assess anxiety, 9 monthly online questionnaires were administered, comprising a general COVID-19 anxiety instrument and 3 items regarding the impact of dentistry-related factors. Statistical mixed effect models were used to estimate the longitudinal trajectory of salivary cortisol levels and their association with the disease burden of COVID-19 in Canada over the study period. After accounting for the confounding factors of age, gender, COVID vaccination status and the normal diurnal rhythm of cortisol secretion, there was a modest positive association between salivary cortisol levels in dentists and the number of COVID-19 cases in Canada. The self-reported impact of dentistry-related factors, such as fear of getting COVID-19 from a patient or a coworker, was greatest during peaks of COVID-19 waves in Canada. Dentists experienced a greater degree of mental stress when the state of the pandemic was more severe. These findings strongly suggest a link between self-reported and biochemical measurements of stress and anxiety in Canadian dentists during the COVID-19 pandemic. Outside of their professional lives, however, dentists appeared to be adapting to the pandemic. Importantly, general anxiety about COVID-19 decreased consistently throughout the study period. Overall, participants reported relatively low rates of psychological distress symptoms. Hence, dentists remained mindful about COVID-19 in their working lives but were adapting to it outside of dentistry. These results should be reassuring for the dental community. Kolbe RJ, et al. Salivary cortisol and anxiety in Canadian dentists over 1 Year of COVID-19. J Dent Res. 2023;102(10): 1114-1121. DOI: 10.1177/00220345231178726

COVID news on TV affected hand hygiene

Despite its recognised importance, hand hygiene is still not well-practised and has continued to be a challenge, including to people in the community who are not health care workers (NHCW). This study tracked changes in hand hygiene among NHCW who were visiting a university hospital in Osaka, Japan from before the pandemic (December 2019) over 148 days covering the onset of the pandemic and up to March 2022. During this time, the amount of coverage time dedicated to COVID-19 related news on the local public television channel was measured, as well as the number of confirmed cases and deaths reported. Hand hygiene compliance in 111,071 visitors to the hospital was monitored. The baseline compliance in December 2019 was only 5.3% (213 of 4,026), however hand hygiene compliance rose from late January 2020 when the pandemic was declared, to reach almost 70% in August 2020. It then remained at a level of 70%-75% until October 2021, after which it declined slowly declined to the mid60% range. Thus, although compliance was initially very high compared to the baseline study period, the trend changed later. It is likely that people may have become complacent after constantly hearing about the disease and stopped paying attention to important advice. There was a statistically significant association between the on-air time of COVID-19-related news and compliance. It was estimated that one additional hour of news coverage at 50% compliance would increase the compliance the next day by approximately 1%. The instructive words of experts and government officials were intended not only to educate the general public and encourage them to act rationally, but also to create conforming pressure in relation to hand hygiene. Hand hygiene was reinforced by Japanese authorities and the media repeated the same advice. People may have become more interested in cleanliness in response to the news coverage of the outbreak or public health announcements and also wanting to conform to greater expectations about hand hygiene practices as a preventive measure against spreading the infection. Further investigations are needed to determine whether high compliance with hand hygiene becomes a customary practice in daily life over time. Morii DM, et al. The impact of television on-air time on hand hygiene compliance behaviors during COVID-19 outbreak. Am J Infect Control 2023;51:975-979. DOI: 10.1016/j.ajic.2023.03.001

20 oral|hygiene

September/October 2023

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Sustainability in dentistry: Part 2 - Life cycle analysis: A primer By Emeritus Professor Laurence J. Walsh AO

22 oral|hygiene

September/October 2023

infection | CONTROL Table 1. HVE large diameter suction tip Parameter

Reusable stainless steel metal tip

Single use plastic tip

Cost

Once-off cost to develop inventory. Staff time for reprocessing

Recurring cost - one item per patient. Nominal cost for storage of bulk supplies. No staff time considerations

Performance

No difference

Social element

Positioning around re-use could help in practice branding

Normal standard of care (i.e. no benefit)

Use of resources - raw material

Iron ore from the ground used in steel production

Crude oil from the ground used in plastic production

Production aspects

Electrical energy and coal used in steel production

Electrical energy used in plastic production

Releases to air, water and land

Re-use involves cleaning (water and detergent releases)

Not applicable

Transport

Once off transport to clinic

Recurring transport to restock supplies

Re-use considerations

Steam sterilisation uses electricity and water

Not applicable as single use and the plastic is not recyclable

End of life considerations

Indefinite use life

Plastic may not be biodegradable. Landfill or incineration have adverse impacts

Components of a formal LCA he requirements for a formal LCA are detailed in ISO 14040:2006 Environmental management - Life cycle assessment - Principles and framework (including its 2020 amendment). That ISO standard defines life cycle as “consecutive and interlinked stages, from raw material acquisition or generation from natural resources to final disposal”. ISO 14040 describes how to work through the four phases of an LCA (goal and scope definition; inventory analysis; impact assessment; and interpretation), to assess the impact on the environment at all phases of existence of a product, from manufacture, to use, to recycling or endof-life/disposal. It considers aspects such as the energy used in producing the item, fuel used in transport and costs of recycling or re-use. Based on these considerations, a formal LCA is a major task and is generally done by a manufacturer or supplier, rather than by an end user/consumer. As well, a formal LCA does not include the economic or social aspects of a product, which are important. Hence, at the dental

September/October 2023

clinic level, it is best to take elements from the LCA concept and add to those the economic and social aspects. For those who want a comprehensive LCA, the free software tool OpenLCA is a good starting place. It can create databases of life cycle processes and users can build their own life cycle models and perform calculations and analyses. You can also import LCA databases and many are available from the openLCA Nexus online repository which has free LCA databases as well as databases for purchase. There are 14 dental components in the database covering dental clinics and dental labs.

Components of a real-world LCA that a clinic can do in-house everal worked examples of LCA prepared by the author are shown in Tables 1 and 2, with supporting data on costs in Table 3. The same analysis as shown in Table 1 also applies for stainless steel patient cups versus single use polypropylene disposable plastic cups. One can readily adapt the LCA by adding more columns to cover wax-coated paper

cups, plastic-free eco-cups, PLA-coated commercially compostable biodegradable Bagasse paper cups and cellulose-based bioplastic cups. The components of an LCA are readily adaptable to decisions that dental clinics can make. By looking at components of environmental impact, it also alerts staff to “greenwashing” in advertising, where a supplier or manufacturer claims that their products are the superior “green” alternative. As an example, an advertisement for a hand drier may state “they’re more environmentally friendly than paper towels, so you can save paper clutter and help reduce your carbon footprint” but this does not stack up when an LCA is undertaken. When putting together an LCA, bear in mind that carbon dioxide emissions for oral health care come from 3 principal sources: manufacturing, distribution and procurement of materials and equipment along the supply chain; waste generated by the clinic (especially single-use plastics (SUPs)) and the management of that waste; and travel by patients and staff. The first two of these three components will feature strongly in an LCA.

oral|hygiene 23

infection | CONTROL Table 2. Hand drying in patient and staff toilets Parameter

Electrical hand drier

Paper towel from dispenser

Cost

Once-off cost to install. Periodic repair, servicing and maintenance. Cost of electricity (consumption 1000-2500 W). Replacement of HEPA filter (if included)

Recurring cost - one or more paper towels item per use. Nominal cost for storage of bulk supplies of paper towel. Staff time to check and refill dispenser

Performance

Similar, but generates considerable noise (over 60 dB) and disperses skin bacteria into the air

Quiet. Quality of hand drying varies with brand and type of paper towel used

Social element

Normal standard of care in large facilities Can be made from recycled paper (i.e. no benefit, unless electricity is from solar).

Use of resources - raw material

Iron ore, copper ore from the ground used in steel and copper production in the motor in the hand drier

Paper produced from trees as a renewable resource

Production aspects

Electrical energy used in steel and copper production for the motor

Water used in paper production

Releases to air, water and land

CO2 emissions if electricity to run the drier is from coal or gas

Not applicable

Transport

Once off transport to clinic

Recurring transport to replenish supplies

Re-use considerations

Energy use

Not applicable as single use

End of life considerations

Long use life, then disposal to recover metals through recycling

Paper is placed in domestic waste stream and is not recycled. It ends up in landfill where it is biodegradable

Making the evidence from an LCA apply to decisions ach clinic should have or develop a policy position around sustainable procurement, which is where the clinic meets its needs for appropriate consumables in a way that meets the needs of oral health care and achieves value for money, whilst at the same time minimising adverse impacts on the environment. Armed with such a policy position, those involved in decisions around procurement can then “practice what they preach”. The information from a short-from LCA, such as shown in the examples, should be used to inform staff discussions around purchasing consumables. The components of an LCA help to increase awareness amongst staff members of the parameters that are important. Discussions can then be had around simple actions that are achievable and impactful. The mindset is to be part of the solution and not a continuing part of the problem. The practice can find sustainable solutions that can create cost savings, as well as give environmental benefits.

24 oral|hygiene

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infection | CONTROL Table 3. Examples of cost calculations Paper towels

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Hand drier

Commercial-grade hand dryers, stainless steel case with automatic infrared sensor. No hygienic sensor. Purchase cost $500-650. Installation cost up to $250. Dyson Airblade V Hand Dryer V HU02 with HEPA filter purchase cost $1900. Installation cost up to $250.

Metal suction tip for HVE

Stainless steel suction tips. Cost $35 each (e.g. Hager).

Disposable suction tips 11 mm

Plastic suction tips 11mm diameter, $16 per pack of 25 single use (64¢ each).

Autoclavable plastic suction tips 11 mm

Multiple brands (e.g. Pelotte HW254024, Cattani No. 17 C-T21000, DMS) which are reusable for 100 sterilisation cycles. From as much as $70 per pack of 10 ($7.00 each) down to $17 per pack of 10 ($1.70 each).

Steel cups

600 mL stainless steel cups, $30-48 for a set of 6.

Plastic cups

600 mL disposable single use polypropylene plastic cups (10¢ each). Alternatives include wax-coated paper cups, plastic-free eco-cups (6¢ each), PLA-coated commercially compostable biodegradable Bagasse paper cups (20¢ each), BioPak cellulose-based bioplastic cups (16¢ each).

When considering consumables, the “3 Rs” of reduce, reuse and recycle are relevant, as each can help cut down the volume of waste that is produced from the clinic. As an example, using stainless steel HVE suction tips and patient cups will reduce waste volume and landfill demands, whilst also at the same time conserving natural resources. Changing from polypropylene patient cups to Bagasse paper cups made from sugar cane processing waste gives a biodegradable end product whilst not requiring crude oil as the starting material for the synthesis of plastics. As shown in Table 3, the direct

cost impacts to the clinic of changing between single use plastics and ecofriendly versions of cups are very small. Due to the National Plastics Plan, dental patients are increasingly aware of single use plastics in their everyday world, including in healthcare settings. Aligning decisions to achieve reduced use of single use plastics to conform to community expectations could be considered “low handing fruit” in terms of the clinic’s owners/operators having the power to decide such matters. In later parts of this series, the issues of sustainability applied to clinic design and operation will be explored.

References and key online resources for LCA 1. ISO 14040:2006 http://pqm-online.com/assets/files/lib/std/iso_14040-2006.pdf

2. 2020 amendment to the definitions section of ISO 14040 https://cdn.standards.iteh.ai/samples/76121/262b9 77639614967b6084a9534967efd/ISO-14040-2006-Amd-1-2020.pdf 3. OpenLCA software (free) https://www.openlca.org/download/

4. Open LCA user manual https://www.openlca.org/wp-content/uploads/2019/07/openLCA-1-9_User-Manual.pdf 5. openLCA Nexus online repository for free LCA databases https://nexus.openlca.org

6. Duane B et al. Environmental sustainability and procurement: purchasing products for the dental setting. Bit Dent J. 2019; 226:453-458. 7. Richardson J, et al. What’s in a bin: a case study of dental clinical waste composition and potential greenhouse gas emission savings. Brit Dent J. 2016: 220:61-66.

8. Borglin L, et al. The life cycle analysis of a dental examination: quantifying the environmental burden of an examination in a hypothetical dental practice. Community Dent Oral Epidemiol. 2021; 49:581-593.

26 oral|hygiene

About the author Emeritus Professor Laurence J. Walsh AO is a specialist in special needs dentistry who is based in Brisbane, where he served for 36 years on the academic staff of the University of Queensland School of Dentistry, including 21 years as Professor of Dental Science and 10 years as the Head of School. Since retiring in December 2020, Laurie has remained active in hands-on bench research work, as well as in supervising over 15 research students at UQ who work in advanced technologies and biomaterials and in clinical microbiology. Laurie has served as Chief Examiner in Microbiology for the RACDS for 21 years and as the Editor of the ADA Infection Control Guidelines for 12 years. His published research work includes over 390 journal papers, with a citation count of over 18,300 citations in the literature. Laurie holds patents in 8 families of dental technologies. He is currently ranked in the top 0.25% of world scientists. Laurie was made an Officer of the Order of Australia in January 2018 and a life member of ADAQ in 2020 in recognition of his contributions to dentistry.

September/October 2023

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The optical science of colour correction: how it works By Emeritus Professor Laurence J. Walsh AO

nderstanding what determines the colour of teeth is fundamental to the proper use of a range of techniques in dentistry (Table 1). This article focusses on why teeth are fundamentally yellow and how that attribute can be altered in a dramatic but temporary way using colour corrector products. Time marches on ooth shade varies across a continuum, in terms of brightness (luminosity) and colour (hue, chroma and value). A progressive increase in yellow with age is a normal age-related change.1,2 Studying crosssections of permanent maxillary incisor teeth (Figure

T 28 oral|hygiene

September/October 2023

clinical | EXCELLENCE

Figure 1. Typical hard tissue cross sections of maxillary central incisors showing changes in the dentine.

Table 1. Dental concepts based on altering light reflections from teeth Vital bleaching: Oxidation of coloured molecules in dentine and enamel reduces absorption of blue/ violet light, making teeth appear less yellow.22 Polishing teeth: Enhances specular (mirror-like) reflections from the enamel surface, making teeth appear brighter.5,6 Tooth lightening: Enhanced mineralisation of the outermost enamel layer using CPP-ACP boosts reflection of blue light, making teeth appear less yellow.23 Tints on enamel and on composite and ceramic restorations: Dyes used in shade modifying kits enhance the reflection of blue and violet light, giving a permanent colour change.24 Colour correction: One or more dyes bind to the tooth/restoration surface and to pellicle to enhance the reflection of blue and violet light, making teeth appear less yellow for a temporary colour change.10-21

September/October 2023

Figure 2. Dominant light paths through maxillary incisor teeth based on directions of enamel prisms and dentine tubules, as shown on a cross section of the tooth. At the surface, some reflection occurs. Through refraction, light enters the enamel. Further refraction occurs as light enters the dentine at the DEJ. The SEM image is courtesy of Dr Frederic Meyer.

oral|hygiene 29

clinical | EXCELLENCE

Figure 3. Reflectance spectroscopy for direct sunlight. The upper panel shows light reflected from a natural tooth (A3 shade), while the lower panel shows the spectrum of the illuminating light. Vertical units are intensity. For the reflected light from the enamel surface, the tooth shows a 50% reduction in blue (at 450 nm) and a 2-fold increase in yellow (at 600 nm). Spectra collected using an Oceans Optics USB 2000 high resolution spectrometer.

Figure 5. Colour wheel showing the opposite nature (reciprocity) for violet-blue and yellow-orange and the wavelength ranges for particular colours of visible light.

Why teeth are yellow he apparent colour of teeth is based on which visible light wavelengths (400-700 nm) are absorbed and which are reflected.4 Absorption of violet and blue

30 oral|hygiene

Figure 4. Reflectance spectoscopy using white LED illumination. The lowest panel shows the illuminating source, which uses a 450 nm blue LEF to excite a phosphor to generate broad spectrum light that resembles daylight. A white paediatric zirconia crown gives an even reflection of all the light wavelengths, while in the natural teeth, there is a marked reduction in reflection of blue light (the line at 450 nm) and a relative increase in the reflection of yellow light (the line at 575 nm). There is a distinct orange-red colour shift for the root.

light makes teeth appear yellow. This is aptly shown by reflectance spectroscopy, using direct sunlight (Figure 3) or artificial lights of known characteristics (Figure 4). When natural teeth or res-

torations that are yellow are exposed to sunlight, or to artificial light, the reflected light spectrum shows a reduction in visible violet and blue light and an increase in yellow and red light.

September/October 2023

clinical | EXCELLENCE Table 2. Published evidence for colouring correcting dyes Patents granted & patent applications Tarver JG. 2000.10 Tarver JG, et al. 2006.11 Tarver JG, et al. 2007.12 Joiner A, et al. 2016.13

Published studies using blue covarine Joiner A, et al. 2008A.14 Ashcroft AT, et al. 2008.15 Joiner A, et al. 2008B.16 Joiner A. 2009.17 Joiner A. 2010.18 Tao D, et al. 2017A.19 Tao D, et al. 2017B.20 Philpotts CJ, et al. 2017.21

Refer to the reference list for full citation details for each source. Applying the concept of the colour wheel with its complementary colours (Figure 5), if violet or blue materials are applied to the surface of teeth, these will absorb yellow light and reflect violet and blue light, making the teeth appear less yellow. As mentioned earlier, many of the aesthetic techniques used in dentistry apply the optical principles of selective absorption and reflection of light (Table 1) and colour correction is one of these. When teeth are polished and surface irregularities are reduced, more backscattered specular (mirror-like) reflections occur.5,6 The scatter process occurs more for those wavelengths that are shorter (violet and blue from 400-450 nm) than for yellow and red (600-700 nm). The way that wavelengths of blue light are scattered from enamel is very important in terms of influencing tooth colour.4,7,8 Teeth of normal shades reflect far less violet and blue light than they reflect yellow and red light, with as little as 3.5% for violet and 7.9% for blue of the incoming light being reflected.9 Based on these considerations, applying a tint or dye onto the tooth surface that reflects violet and blue light but absorbs yellow light will make a tooth appear less yellow.

Applying dyes to the tooth surface istorically, based on the patent literature, this idea of a dye that is applied to achieve a temporary effect can be credited to Jeanna Gail Tarver, a beautician

September/October 2023

Figure 6. Dyes used in colour correction. A: blue covarine. B: erythrosine. C: brilliant blue FCF. D: D&C red 33. The original Tarver formula used B+C, while Hismile V34 uses C+D. Oral-B and Colgate toothpastes use A. Panel E shows the absorption spectrum for Hismile V34, indicating the peak absorption for the red and blue dyes at 575 nm and at 625 nm. There is minimal absorption in the violet-blue region 380-475 nm as highlighted in the box. Panel F shows the application of V34 on a toothbrush, and panel G shows the product at a high dilution rate to reveal its violet colour

Blue covarine from Lehi in Utah, who added a commercial food dye to regular toothpaste, to enhance the colour of teeth. The food dye was a mixture of red 3 (erythrosine) and blue 1 (brilliant blue FCF) (Figure 6 panels B and C) and because of colour mixing effects, the dye had a violet colour.10 The concept was granted a US patent,10-12 but was not commercialised. The original patent subsequently expired in 2018.

ater work by Unilever conducted at their Port Sunlight research laboratories in Liverpool, led by Andrew Joiner, used a dye known as blue covarine (CI 74160) (Figure 6 panel A). This was added to toothpaste to enhance the appearance of the teeth, making them look brighter and less yellow.10 As a result of many successful laboratory and clinical studies (Table 2),13-21 blue covarine dye is now included in several toothpastes.

oral|hygiene 31

clinical | EXCELLENCE These include toothpastses from Oral-B and more recently the same dye has been included in a Colgate toothpaste (Figure 7). As an ingredient in toothpastes, blue covarine dye is present at a very low level and hence when checking the ingredient list on the packaging, it will be listed near the end, as CI 74160. It is important to note that in ordinary toothpastes, one or more colouring agents are normally present, such as the white pigment titanium dioxide and the colouring agents used to create special red or green stripes. These enhance the colour of the toothpaste, but do not alter the colour of the teeth. From a pharmaceutical chemistry point of view, one of the problems with using blue covarine as a dye for colour correction is that it is poorly soluble in water, but very soluble in oil. When added into toothpastes, where there is a hydrophilic vehicle of water and glycerin, the dye forms clumps and aggregates, as phase separation occurs into water-rich and oil-rich regions (Figure 7 panel C). The poor water solubility of blue covarine also influences its dilution by saliva and how it interacts with pellicle and biofilms on the surface of teeth. While an obvious solution would be to choose violet dyes to replace blue covarine, this is not feasible as many alternatives are also water insoluble and their colours are unstable and change according to the pH. Moreover, alternative violet dyes are toxic and unsuitable for inclusion into an oral care product.

Hismile V34 colour corrector serum his product is a viscous hydrophilic glycerin-based liquid containing high concentrations of a red dye (D&C red 33) and a blue dye (brilliant blue FCF) (Figure 6 panels B and C). Both are highly water-soluble non-toxic widely used food colouring dyes and are colour stable in terms of pH. This is important since intraoral pH can vary widely and pH-responsive dyes would have an unpredictable colouring effect. The colour mixing effect created by using two dyes gives a very intense violet colour. Diluting the product shows the violet colour more clearly (Figure 6 panel G). Measuring the absorption of light by this dye combination using

32 oral|hygiene

Figure 7. Panel A shows three toothpastes with blue covarine dye and Hismile V34 colour corrector serum, with some product expressed from the containers. Panel B shows colour channel changes for typodont resin teeth after a single treatment (2 min brushing with toothpastes, or a 20 sec application for V34). Values for blue and for luminosity have increased for V34 in both experimental runs conducted one week apart, indicating a less yellow and brighter appearance. Panel C is a close up view of Oral B and Colgate toothpastes, showing clumping of the blue covarine dye. a laboratory spectrophotometer shows two very distinct peaks at 575 and 625 nm, which correspond to the red and the blue dyes, respectively. There is very little absorption of violet and blue light, so these visible wavelengths will instead be reflected when the dye mixture binds to pellicle on the tooth surface (Figure 6 panel E). The product is brushed onto the teeth for 20 seconds (Figure 6 panel F). It

causes an instant intense reduction in yellow and an overall boost in brightness (luminosity) for natural unrestored teeth (both enamel and root surfaces), but with no change in the appearance of the soft tissue (Figure 8). The colour boosting effect is temporary and lasts for as long as the two dyes remain bound to pellicle (several hours). The effect is reproducible and occurs to the same extent when the product is used again (e.g. 1 week later).

September/October 2023

clinical | EXCELLENCE

Figure 8. Clinical assessments of Hismile V34, showing two before and after series (A and B; and C and D). The after images are taken immediately after expectoring the dye and traces of dye can be seen interdentally because of capillary action. Changes in luminosity (E and F) and in blue pixel channel data (G and H) for the maxillary incisor tooth enamel explain why the treated teeth appear brighter and less yellow. With both parameters, the distribution narrows and shifts to the right (higher values). In the example shown in panel A of Figure 8, the teeth have a baseline shade of A3 and no restorations are present. Performing image analysis using RGB colour channel data for the labial enamel surfaces (excluding all specular reflections) shows a boost in luminosity (Figure 8 panels E and F) and an enhancement of reflections for blue (Figure 8 panels G and H), both of which are due to changes in spectral reflectance caused by the dyes bound to the tooth surface. Measuring the delta E value (which is on a scale of 0-100) provides a robust way of determining if the changes will be visibly obvious or not to an untrained observer (delta E of above 6), or could only be seen

September/October 2023

by a trained dental professional (delta E between 3 and 6), or are below the level of discrimination (delta E below 3). In the example shown in Figure 8 panels A and B, the patient is in their early 60’s. For the upper and lower teeth, the delta E values are 11 and 14, respectively. Hence, such changes will be very obvious. Similar beneficial changes are seen when the same product is used in a patient in their mid 30s, whose teeth are a lighter shade. The boost in luminosity makes the teeth appear brighter (Figure 8 panels C and D). The dyes in V34 also bind to tooth coloured restorations, even when no salivary pellicle is present. This can be shown using typodont resin teeth. Colour channel

analysis allows a comparison of the changes caused by one application of V34, with one 2-minute brushing cycle using 3 toothpastes containing blue covarine (2 Oral-B and one Colgate). In this study (Figure 7 panel B), the V34 part of the experiment was repeated after 1 week to assess reproducibility. In both experimental runs, V34 enhanced the blue channel value and the luminosity to the same extent and thus the effect was consistent across both runs. The one brushing cycle using toothpastes with blue covarine did not improve the reflection of blue light and the brightness of the teeth, but instead there was a small darkening effect with the Colgate toothpaste and this was more pronounced for both of the Oral-B toothpastes.

oral|hygiene 33

clinical | EXCELLENCE References Conclusions here are several key take-home messages on the colour correction concept that can be distilled from the literature and from the experiments described above.

1. Colour correcting exploits well-known principles of linear optics and leverages the selective reflection of blue and violet light to overcome the natural tendency of tooth structure to absorb these wavelengths of light; 2. The patterns of reflection of light from teeth can be demonstrated using various forms of reflectance spectroscopy and image analysis; 3. The science of colour correction using dyes has advanced considerably over the past 25 years, since the original concept was proposed; 4. Colour correcting effects of dyes are documented in the patent literature and in multiple journal papers; 5. Colour correcting effects are visibly obvious to untrained observers, as shown by the delta E values exceeding the thresholds for meaningful change in colour; 6. Using V34 gives reproducible effects on colour; 7. The direction and magnitude of colour correcting effects vary according to the single dye or dye mixture which is used. This is because of issues such as light reflection and absorption, binding properties and interactions with water, saliva and pellicle; and 8. Colour correcting effects occur on surfaces and substrates that dyes can bind to, including the surfaces of natural teeth and pellicle, as well as restorative materials. Based on this short duration but deep dive into the science of colour correcting technology, clinicians can now hopefully better appreciate how and why this technology is used in instant effect products such as V34 and also in some toothpastes.

34 oral|hygiene

1. Joiner A. Tooth colour: a review of the literature. J Dent. 2004; 32: 3-12. 2. Alkhatib MN, et al. Age and perception of dental appearance and tooth colour. Gerodontol. 2005; 22: 32-36. 3. Spitzer D, Ten Bosch JJ. The absorption and scattering of light in bovine and human dental enamel. Calcif Tiss Res. 1975; 17: 129-137. 4. Ten Bosch JJ, Coops JC. Tooth colour and reflectance as related to light scattering & enamel hardness. J Dent Res, 1995; 74(1): 374-380. 5. Altschuler G. Human tooth in low and high intensive light fields. Proc SPIE Medical Applications of Lasers III 1995: 2623: 68-87. 6. Patil HA, et al. Effect of various finishing procedures on the reflectivity (shine) of tooth enamel - an in-vitro study. J Clin Diagn Res. 2016; 10(8): 22-27. 7. Yu B, et al. Measurement of translucency of tooth enamel and dentin. Acta Odontol Scand. 2009; 67: 57-64. 8. Lee YK. Translucency of human teeth and dental restorative materials and its clinical relevance. J Biomed Opt. 2015; 20(4): 045002. 9. Poljak-Guberina R, et al. Prilog poznavanju utjecaja refleksije svjetlosti na boju zuba (A contribution to the knowledge on the effect of light reflection on the color of teeth). Acta Stomatol Croatica 1984; 18(4): 263-268. 10. Tarver JG, et al. Tooth whitening compositions and methods for using the same. US patent application 2006/0104922, 2006. 11. Tarver JG, et al. Tooth whitening compositions and methods for using the same. US patent application 2006/0104922, 2006. 12. Tarver JG, et al. Systems and methods for enhancing the appearance of teeth. US patent application 2007/0086960, 2007. 13. Joiner A, et al. Oral care compositions comprising a polymeric dye. European patent EP 2334479, 2016.

14. Joiner A, et al. A novel optical approach to achieving tooth whitening. J Dent. 2008; 36 (Suppl 1): S8-S14. 15. Ashcroft AT, et al. Evaluation of a new silica whitening toothpaste containing blue covarine on the colour of anterior restoration materials in vitro. J Dent. 2008; 36 (Suppl 1): S26-S31. 16. Joiner A, et al. In vitro cleaning, abrasion and fluoride efficacy of a new silica based whitening toothpaste containing blue covarine. J Dent. 2008; 36 (Suppl 1): S32-S37. 17. Joiner A. A silica toothpaste containing blue covarine: a new technological breakthrough in whitening. Int Dent J. 2009; 59(5): 284-288. 18. Joiner A. Whitening toothpastes: a review of the literature. J Dent. 2010; 38 Suppl 2: e17-24. 19. Tao D, et al. Tooth whitening evaluation of blue covarine containing toothpastes. J Dent. 2017; 67 Suppl: S20-S24. 20. Tao D, et al. In vitro and clinical evaluation of optical tooth whitening toothpastes. J Dent. 2017; 67 Suppl: S25-S28. 21. Philpotts CJ, et al. In vitro evaluation of a silica whitening toothpaste containing blue covarine on the colour of teeth containing anterior restoration materials. J Dent. 2017; 67 Suppl: S29-S33. 22. Markovic L, et al. Effects of bleaching agents on human enamel light reflectance. Operative Dent. 2010; 35(4): 405-411. 23. Walsh LJ. Tooth lightening: maximizing surface esthetics. RDH Magazine 2008: 76-82. 24. Grundler A, et al. Method and color kit for color correction of replacement teeth or natural teeth. US patent application 2005/0123880, 2005.

September/October 2023

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