Oral Hygiene May/Jun 2023

oral hygiene , therapy , infection control , management and more ...

VOL.33 NO.3

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LUNOS® PROPHY POWDER ® LUNOS PROPHY POWDER – PERIO COMBI (TREHALOSE) PERIO COMBI (TREHALOSE) – BENEFICIAL FOR WOUND HEALING BENEFICIAL FOR WOUND HEALING

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in terms of cell response and in contrast in of cell response and inpowder. contrast to terms Glycine-based prophylaxis to Glycine-based prophylaxis powder.

A recent in-vitro study (Weusmann et al. 2021) has trehalose has no pro-inflammatory shown A recentthat in-vitro study (Weusmann et al. 2021) has and no on human trehalose has effects no pro-inflammatory shown thatpro-apoptotic gingival fibroblasts. Wound healing of gingival and no pro-apoptotic effects on human tissue is, in fibroblasts. contrast to glycine, not negatively gingival Wound healing of influengingival ced (Fig. 1). tissue is, in contrast to glycine, not negatively influenced (Fig. 1).

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Lunos® Prophy Powder Perio Combi, based on ® trehalose, can Powder be usedPerio for supraand subgingival Lunos Prophy Combi, based on air-polishing prophylaxis as welland as to support trehalose, canin be used for suprasubgingival periodontal or air-polishing in periimplantitis prophylaxis astherapy. well as to support periodontal or periimplantitis therapy.

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Fig. 1: Wound closure of human gingival fibroblasts (HGF) in the glycineofand trehalose over 48 h. (HGF) in Fig. presence 1: Woundofclosure human gingival fibroblasts *significant difference from all groups the presence of glycine and trehalose over 48 h. °significant control *significant difference difference to from all groups Derived from (Weusmann et al. 2021). °significant difference to control Derived from (Weusmann et al. 2021).

Thus, the authors suggest that in terms of cell response, trehalose-based Thus, the authors suggest thatair-polishing in terms of cell powder trehalose-based might be more beneficial than response, air-polishing glycinebased powder for air-polishing. powder might be more beneficial than glycine- based powder for air-polishing.

Weusmann, Jens; Deschner, James; Imber, Jean-Claude; Damanaki, Anna; Leguizamón, Natalia D. P.; Nogueira, V. B. (2021): effects of glycine and trehalose air-polishing powders onP.; Weusmann,Andressa Jens; Deschner, James;Cellular Imber, Jean-Claude; Damanaki, Anna; Leguizamón, Natalia D. human gingival fibroblasts in vitro.

In: Clinical oral investigations.

DOI: 10.1007/s00784-021-04130-0.

Nogueira, Andressa V. B. (2021): Cellular effects of glycine and trehalose air-polishing powders on

VOLUME 33 | NUMBER 3 MAY/JUNE 2023

OH | CONTENTS

On the cover...

Dental manufacturer and wholesaler Ozdent’s GO2 Dentagenie range of innovative, sustainable oral care products is on a mission to improve and simplify oral health care for all Australians

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CPD

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BIAS IN DENTISTRY

4 BRIEFS 6 NEWS & EVENTS 16 CPD CENTRE 20 ABSTRACTS

Patients trust dental professionals to provide accurate and unbiased recommendations on how to maintain good oral health, however biases can lead to suboptimal care and outcomes reports Tabitha Acret

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CPD

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THE CHALLENGES FOR PREVENTION WITH AN AGEING POPULATION: PART 1. FOCUSSING ON THE PATIENT Across Australia and New Zealand, the ageing population is posing considerable challenges explains Prof. Laurie Walsh

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CPD

SUSTAINABILITY IN DENTISTRY: PART 1 PLASTICS AND BIODEGRADABILITY In the first part of this series of articles on sustainability in dentistry, Prof.

Laurie Walsh focuses on understanding plastics, especially biodegradable plastics and the issues around recycling of plastics.

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READ ME FOR

CPD

HOW TO ENCOURAGE PROPER ORAL HYGIENE CARE FOR TEENS AND YOUNG ADULTS While it makes sense to give young people their space to assert themselves in certain situations, allowing them to be lax in their oral hygiene care is ill-advised

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Oral Hygiene (formerly Auxiliary) ISSN 1323-4919 is printed in Australia and published six times per year by Main Street Publishing P/L ABN 74 065 490 655 • PO Box 586, Cammeray 2062

Telephone: (02) 9929-1900 Facsimile: (02) 9929-1999 Email: info@dentist.com.au © 2023. All rights reserved. The contents of this magazine are copyright and must not be reproduced without the written permission of the publisher. Permission to reprint may be obtained upon application. Correspondence and manuscripts for publication are welcome. Although all care is taken, the editor and publisher will not accept responsibility for the opinions expressed by contributors to this magazine, or for loss or damage to material submitted for publication.

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in | BRIEF

A reminder to tune into the Disrupting Dentistry Podcast

Pandemic PPE price gouging

reminder to tune into the Disrupting Dentistry podcast, now with more than 50 episodes in the can since its launch in 2021. Produced by our own dental hygienist Tabitha Acret and her bestie, fellow dental hygienist Melissa Obrotka from New Jersey, the podcast covers a broad range of topics including Product Creation; Dental Phobias; Technology in Dentistry; Career Development; Dental Anxiety; Making a Professional Comeback; Alternative Career Paths in Orthodontics; Menopause; Red flags in the dental practice; Disrupting the Profession; Brain Health and more. Scan the QR code on your iPhone or Google “Disrupting Dentistry podcast” to find a version for your platform of choice.

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Do I REELY have to use Reels in social media? f we’ve learnt anything about social media in 2023, it’s that nothing stays the same. While the main players in social media are reasonably consistent from one year to the next, appearing strongly in each of them is a constantly evolving field.

One area that is getting a lot of attention is the ubiquitous Reel. A Reel is a short piece of video, typically between 15 and 90 seconds, designed to capture people’s attention.

Reels can be used on Facebook, Instagram, YouTube (aka Shorts) and TikTok, so there is the potential to use the same material multiple times on different channels. And reels/videos achieve a double whammy in terms of engaging potential patients because...

There is a growing trend of users watching more video online - CISCO 1 found that 80% of internet traffic in 2020 was video, compared to just 50% in 2016 while online video consumption has been on the rise with the current average viewer spending 17 hours a week watching digital videos in 2023; and media platforms prioritise “Reels” over text or images i.e. if you a 2 Social deliver an identical message via Reels or a different technique, the Reel will almost certainly get more views.

Here are some other benefits of Reels: Stand out from other dentists: in the past few months at live events, I’ve asked literally hundreds of dentists in Australia whether they are using video to promote their practice. Based on my survey, only around 5-10% are doing so which is a huge opportunity you can capitalise on; Communication and virality: Reels allow you to create captivating videos that leave a lasting impression. They offer potential virality by being featured on content feeds plus dedicated Reels sections, helping you expand your audience and gain brand exposure; and Authentic Connection: With Reels, you can share behind-the-scenes, educational material and entertaining content in a friendly and conversational tone to establish a genuine connection.

In summary, utilising Reels in your social media strategy in 2023 can help you capture attention, boost your reach and create meaningful connections with your audience.

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• • •

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

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As the world prepared and responded to the COVID-19 pandemic in early 2020, a rapid increase in demand for personal protective equipment (PPE) led to severe shortages worldwide. In a 151-bed hospital located in Chicago, Illinois, PPE market prices paid were tracked during the first surge of the pandemic (April-June 2020), in terms of the maximum cost per unit (CPU) of PPE, compared with pre-pandemic (April-June 2019) prices in US dollars. The analysis included disposable gowns, N95 respirators, face masks and gloves. PPE prices were significantly higher during the first wave of the pandemic compared to prepandemic prices. The CPU for gloves increased from $0.05 to $0.12; surgical face masks from $0.05 to $0.45; N95 respirators from $0.98 to $7.40; and disposable gowns from $0.87 to $6.60.

Based on the peak prices, the CPU for gloves rose by 2.5 times, face masks by 11 times, N95 respirators by 8 times, and gowns by 13.7 times compared with the pre-pandemic price. Before the pandemic, hospitals were spending ˜$7 per patient on PPE and this rose to $20.40 during the first wave of COVID-19 in August 2020. Multiple factors likely contributed to high prices, including demand shock, disrupted supply chains and a rush to acquire PPE by healthcare systems and by the general population alike. The global PPE supply chain did not properly operate to meet the demands of healthcare systems across the world.

Many factors such as the shortage of raw materials, export bans and restraints in logistics contributed to 4-6 month backlogs for global supply orders of PPE. Several strategies for pandemic-specific supply-chain management can be suggested: global PPE standards, production changeover, joint procurement, multiple sourcing, monitoring PPE use and visibility of orders, improving supply systems and sharing responsibility and improving domestic manufacturing surge capacity during the event.

Patel R, et al. Cost of personal protective equipment during the first wave of the coronavirus disease 2019 (COVID-19) pandemic. Infection Control & Hospital Epidemiology (2023), 1–2. doi:10.1017/ice.2023.115

May/June 2023

THE PREMIUM PROPHYLAXIS SYSTEM

CONTACT US TODAY FOR A FREE TRIAL! Mina Farag M: +61 437 799 323 E: mina.farag@duerrdental.com Scan QR code to find out more

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Innovative, sustainable oral care products

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t’s twelve months since dental manufacturer and wholesaler Ozdent launched the GO2 Dentagenie range of innovative, sustainable oral care products in Australia with a mission to improve and simplify oral health care.

“We’ve designed and developed a range of new, innovative, patented and patent pending products to meet consumer needs to improve the oral care category and simplify the daily oral care ritual,” said Ozdent General Manager Denise Goodwin.

And so far, the products are a hit, with the range being taken up by many retailers including Woolworths and David Jones, plus pharmacies and dental distributors.

“With only approximately 10 per cent of people flossing daily, for example, we’re attempting to introduce our products to the 90 per cent of people not flossing regularly, to help create healthier habits,” Ms Goodwin said.

“Not caring for your oral health can impact negatively on your overall health and wellbeing. We want to remove as many barriers to using the GO2 Dentagenie Oral Care range as possible.

Ozdent, through our work with universities, hospitals and dental professionals, feel it’s our obligation to increase the participation rate, which in turn will improve oral care health outcomes.”

The range he GO2 Dentagenie range currently comprises several products with more to come: • Flosspyx. The current Flosspyx range comes in Fine (for light teeth). Double (“twice the clean”) and Smooth (“gentle” floss tape), with all variants minty flavoured for “added freshness”.

• Dental Brushes. These are interdental brushes with “soft coated wire bristles, gentle to protect, firm enough to get the job done”.

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• Softstx. Two-in-one design with “super-soft”, minty, flexible bristles on one end and a firm textured toothpick on the other.

• Kiddo Flossers. These offer “berry awesome” infused floss with “jumbo” grip, promoted as being “great” for kids from “four to our tweens and adults and parents too”.

• Tongue Cleaner is “disposable, hygienic, always clean, always fresh. Just scrape tongue and toss.”

• Silver Flosspyx. “Australia’s first” antibacterial floss.

• Molar Flosspyx. Y-shaped to “easily” reach both front and back teeth.

• Kiddo Tongue Cleaner. Hygienic scraper to help remove bacteria from children’s tongues.

• Water Flosser. “A micro bubble blast flushes plaque and bacteria from between teeth and along the gum line.

Addressing sustainability zdent acknowledges that GO2 Dentagenie can’t save the world alone”, so it invites retailers and customers to live by the brand’s mantra, ‘Earth lovin’. We’re simply trying to be better, giving consumers a better choice from the strictly ‘all plastic’ options currently available.” Ms Goodwin said.

“We use paper-based packaging instead of 100 per cent plastic bags and our Flosspyx/Flosser and Tongue Cleaner ranges are made from post-consumer recycled plastic. This is plastic that has previously been made into a product, used, thrown away, collected, cleaned, reprocessed and remade into something new. Products made from post-consumer plastic close the loop, diverting plastic products from landfill and instead allowing them to be recycled - in its truest sense - into something else.”

The Dental Brush range is also made from a proprietary blend of corn starch and plastic.

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For more information or to obtain professional samples of the range, visit www.go2dentagenie.com.au/dental-professionals

May/June 2023

news | EVENTS

Top 6 questions clinicians ask about Ergo loupes

By Forest Rain Marcia

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rgo loupes belong to a relatively new category of loupes: ergonomic loupes, sometimes called refractive or deflection loupes due to the specific optics their oculars utilise.

Though deflection loupes were conceptualised more than a decade ago, they did not capture the hearts and minds of dental practitioners until their redesign by Admetec in 2020.

Ergo loupes by Admetec offered, for the first time, the potential for a fully ergonomic working position. Instead of the practitioner bending and contorting to see inside the patient’s mouth, the loupes do the work instead of the human - the very definition of an ergonomic tool!

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While awareness of ergonomic loupes is swiftly spreading among clinicians, for whom the benefits of a more natural, comfortable working position quickly become clear, some uncertainty still exists about adopting this new technology.

This article addresses the top 6 questions asked about Ergo loupes.

1. Are Ergo loupes really better for my posture? es! While the human body is designed to bend and twist, it is not designed to stay in a static, bent, or contorted position for extended periods. Doing so creates stress and strain on joints and ligaments that create micro-traumas (similar to carpal tunnel syndrome or tennis elbow). 88

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news | EVENTS These micro-traumas develop faster than the body can heal; the resulting cumulative trauma causes chronic, occupation-specific pain. Adopting a posture that aligns with the body’s natural, biomechanical design protects your health over time and reduces the risk of occupational chronic pain. For those who are already in pain, adopting a healthy ergonomic posture helps address the problem at its root cause, allowing the body to heal (or at least not create new trauma).

For those who are not yet in pain, an ergonomic posture is a preventative practice - just like dental professionals advising patients to maintain their teeth now to avoid cavities and root canals later.

Everyone is different; for some people, the adjustment period is faster than for others. For all users, it is recommended to patiently invest the time now and minimize the risk of occupational chronic pain later.

To adjust to Ergo we recommend gradually incorporating their use in your practice. Start off using the loupes only for a few patients and gradually increase their use. Another idea is to practice at home, using the loupes to read, eat a meal, etc. This will provide extra time to get accustomed to the loupes without the pressure of a precision-mandated, timesensitive operatory setting.

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3. Will I have trouble getting used to Ergo? ustomers report adjustment periods between one day and four weeks.

Just like learning how to drive, new techniques take some level of practice to master. Ergo loupes necessitate an adjustment period because it is a new way of seeing, like beginning to use multifocal glasses. The brain needs to adapt and learn to interpret what it is seeing and how to judge distances between what you see and where your hands are.

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6. Do I need to use a light with Ergo loupes? es, but this is true for all loupes.

Loupes and lights are two parts of the same solution and should be considered together. When you see better, you do better. It’s that simple. Using a headlight correctly illuminates your field of view, enabling you to see what you need, in the magnification you choose – the higher the magnification, the more powerful a headlight needed.

Basically, Ergo provides a more focused view than Galilean loupes, which means less light from the surroundings reaches the eyes through the magnifying lenses. The effect is similar to a camera shutter: when wide open, it lets in a large amount of light from the surroundings; when narrowed, less light comes in.

In addition, the extra optical elements (lenses, mirror, prism, etc) used in the Ergo loupes act as barriers through which light travels before reaching your pupils.

Subsequently, there is some degradation in light intensity. Admetec Ergo comes in the widest range of magnifications in the industry - up to 10x - and each has a different headlight that is suited for working with that magnification.

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2. Who shouldn’t be using Ergo? n general, we believe everyone who can, should use Ergo loupes. Practitioners invest years learning to help their patients but are taught very little about maintaining their own health and wellbeing as it relates to their profession. An ergonomic working position and healthy posture are good for everyone.

However, not all practitioners are able to use ergonomic loupes. First and foremost, working with Ergo loupes requires using a mirror. Some dental specialties necessitate holding other tools in the hands, making it impossible to also hold a mirror. For these doctors, Prismatic loupes are preferable. For those practitioners, we recommend taking more care to support their health with increased attention to an ergonomically correct environment and scheduling time to stretch and rest between treatments. Also, those who do not know how to use a mirror or are unwilling to learn will not be able to use Ergo.

focused image even if the wearer moves around (and even if the loupes are not perfectly fitted to the user). Galilean loupes are great, but they cannot provide the added benefit of enabling a healthy working position. Ergo loupes intuitively guide practitioners toward maintaining an ergonomic working posture and developing healthy work habits that will help protect their health and career longevity.

In other words, our advice is to start off the way that will most benefit you in the long run - with Ergo loupes.

4. What about performing extractions with Ergo? hile it is very common for doctors to perform extractions without using loupes at all, we have found that clinicians who have become accustomed to working with Ergo get so comfortable with them that they use them during extractions as well. Most of our customers report performing all procedures with Ergo loupes within 4-6 months of first wearing them.

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5. Should my first loupes be conventional Galilean or Ergo? tudents and other first-time loupes users are usually advised to start with conventional, Galilean loupes. This recommendation typically results from one of two scenarios: either the person providing the advice is unfamiliar with ergonomic loupes; or the advisor is simply more familiar with the wide field of view and depth of field offered by Galilean loupes.

In other words, Galilean loupes are easier to get used to, because they maintain a

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About the author Forest Rain Marcia is a Brand Manager at Admetec.

Byron Medical is the official distributor of Admetec solutions in Australia.

For more information, please contact admin@byronmedical.com.au

May/June 2023

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Transform your practice with cloud technology

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sing cloud technology has become the norm for many people, whether that is through Netflix™ and Amazon Prime™ to catch up on the latest shows, or by sharing content online with family and friends via Facebook™ or Instagram™. Industries worldwide have leveraged the power of the cloud to enhance and grow their businesses and Dentally from Henry Schein One is no different.

With the Health Care and Social Assistance industry projected to grow by over 15% in the next five years, making it one of the four fastest-growing industries in Australia*, there has never been a better time to start thinking about what the future looks like for your dental practice.

Dentally’s complete cloud enabled practice management software uses the latest cutting-edge technology to help you adapt to the challenges you face in dentistry every day and help you grow and plan for the future.

With Dentally, all patient information is stored securely in the cloud, accessible from anywhere with a secure internet connection. Simply Chrome and go!

Getting technical entally is one of a few, true cloudbased solutions, (SaaS - Software as a Service) using a network of multiple remote servers hosted online to store, manage and process data. In dentistry, the utilisation of cloud has enabled practices across the globe to overcome the challenges of the past few years – from keeping patients in the loop with Dentally Portal’s contactless journey, to overcoming staff shortages with flexible working capabilities.

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Why choose cloud? hen searching for ways to improve and grow your dental practice, today’s market can be confusing and crowded with the number of solutions available and finding the right one is a task in itself. Dentally know how crucial it can be to not only find something that will work best for you now, but to find something that is future proof!

You can be certain that with Dentally your software will scale with you as your practice grows.

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User security entally keeps everything in one place, eliminating the need for multiple software to run each aspect of the surgery. As a complete cloud solution, you will no longer need any onsite data storage as your data will be stored safely and securely, so you don’t have to.

Dentally automatically backs up and syncs any changes straight to the cloud. Not only does this save you money on server maintenance and expensive IT, it gives you the assurance that you are working and reporting in real time.

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Not just a software entally’s services go beyond futureproofing your business through practice management software. Their dedicated support team are always available on a live chat to help you get the best out of the software.

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You will also have access to the customer success programme, Dentally Elevate.

Spend one to one time with a trained team where you can get advice and new perspectives on growing and thriving as a business with the use of Dentally’s easy to use tools, such as: • Fast reporting - No more time wasted on loading screens; with Dentally’s live reporting tools, you get up-to-date results instantly.

• Intuitive automation features - Dentally’s automatic communications work in the background to remind and recall patients, freeing up time in surgery to continue to deliver exceptional patient care.

• Dentally Portal - Enhance your patient’s journey from beginning to end through online booking, payments and forms giving them convenient ways to keep on top of their own oral health.

• Live Dashboards - Dentally’s home screen has an overview of the practice data including white space, cancellations, revenue, etc. This snapshot of information is great for setting daily goals for your team.

The future is cloud entally is committed to giving users an intuitive, easy-to-use practice management solution and with the use of built-in features, you can keep everything running smoothly whilst saving time and resources in the process. Dentally takes the stress out of running your practice.

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Speak with the Dentally team today for a software demo and find out how it can help you thrive both now and in the future.

Visit Dentally.com, call 1300-889-668 or email help@dentally.com.au. * https://labourmarketinsights.gov.au/our-research/ employment-projections

May/June 2023

Welcome to the future in practice Faster, simpler practice management

Accessible from any location giving better work-life balance

Visit dentally.com to see how we can help.

Dentally from Henry Schein One, offers a complete cloud solution to help you run your practice more effectively. Spend more time on patient care and developing your practice, and less time on admin.

Clinical excellence with everything at your fingertips

Patient-centric features to deliver the experience people demand

Grow your practice with Elevate, our exclusive customer success programme

clinical | EXCELLENCE

READ ME FOR CPD

Bias in dentistry

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

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ental recommendations are an essential aspect of oral health care.

Patients trust dental professionals to provide accurate and unbiased recommendations on how to maintain good oral health. However, biases can influence dental recommendations, leading to suboptimal care and outcomes. Bias comes in many forms - from confirmation, cultural, gender and financial. It’s important to understand bias so that we can put strategies in place to avoid it.

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Confirmation bias onfirmation bias is a type of bias that occurs when dental professionals rely on their preconceived notions or beliefs rather than objective evidence to make recommendations.

A form of confirmation bias in dentistry is the way we make decisions on what we recommend to patients. An example of this is interdental cleaning. Many dental professionals recommend floss as their number one go-to tool for interdental cleaning. However, floss has very limited evidence to support its use and there is clear evidence that interdental brushes, where they fit, are better for biofilm removal and reduction in inflammation. A systematic review from Slot et al in 2020 showed interdental brushes to be superior to floss for interdental cleaning.

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clinical | EXCELLENCE However, despite strong evidence, many dental professionals continue to recommend floss. Why do they do this?

Confirmation Bias. This is the tendency to make decisions that support our preconceived beliefs while ignoring or discrediting those that do not. We believe that floss is the correct choice because of historical evidence and what advertising and other colleagues are doing.

We can also have confirmation bias when reading literature and evidence, in other words we believe what we want to believe; the way we take in the information, sort through it and use it in the clinical setting can also come with bias.

previous studies, including one that indicated women are more likely to be given sedatives for their pain and men given pain medication and concluded that women were more likely to be inadequately treated by healthcare providers.

Financial Bias inancial bias can also influence dental recommendations. Dental professionals may recommend procedures or treatments that are not necessary to generate more income. In a study from Ghoneim et al, it showed that dentists’ clinical decisions were directly influenced

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their recommendations on clinical evidence and not being influenced by external factors such as financial incentives.

In conclusion, biases can significantly influence dental recommendations, leading to suboptimal care and outcomes.

Confirmation bias, cultural bias, gender bias and financial bias are some of the types of bias that can occur. Strategies to mitigate bias include training, use of evidence-based guidelines, patient-centred care and professional autonomy. By recognising and mitigating bias, dental professionals can improve the quality of care provided, leading to better oral health outcomes for patients.

References

Cultural bias ultural bias can influence dental recommendations. For example, dental professionals may recommend certain dental procedures based on cultural norms rather than clinical evidence. A study in 2019 from Patel et al, found that cultural beliefs and practices influenced dental recommendations. The study found that dental professionals were more likely to recommend extractions rather than restorative procedures for patients from certain cultural groups.

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Gender bias ender bias can also play a role in dental recommendations. Dental professionals may recommend different treatments or procedures based on the patient’s gender. In 2001, University of Maryland academics Diane Hoffman and Anita Tarzian published The Girl Who Cried Pain, an analysis of the ways gender bias plays out in clinical pain management. They examined several

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by the financial challenges such as educational debt and large practice loans. The study suggests facing financial hardships, dentists may overtreat or recommend unnecessary procedures to alleviate some of their financial pressures, leading to overdiagnosis and overtreatment.

Strategies to mitigate bias raining dental professionals on how to recognise and mitigate bias is essential.

Training on cultural sensitivity, unconscious bias and implicit bias can improve the quality of care provided. Using evidence-based guidelines can also help mitigate bias in dental recommendations.

Evidence-based guidelines consider the latest research and provide a standardised approach to diagnosis and treatment.

Patient-centred care can also help mitigate bias in dental recommendations. Patient-centred care considers the patient’s preferences, values and beliefs in the decision-making process.

Finally, we should strive to maintain professional autonomy. This means basing

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1. Iske, J., Davis, D. M., Frances, C. & Gelbier, S. 1998.

The emotional effects of tooth loss in edentulous people.

British Dental Journal, 184, 90-93.

2. Ghoneim, A., Yu, B., Lawrence, H., Glogauer, M., Shankardass, K. & Quiñonez, C. 2020. What influences the clinical decision-making of dentists? A cross-sectional study. PLoS One, 15, e0233652.

3. Hoffmann, Diane E. and Tarzian, Anita J., The Girl Who Cried Pain: A Bias Against Women in the Treatment of Pain (2001). Available at SSRN: https://ssrn.com/ abstract=383803 or http://dx.doi.org/10.2139/ssrn.383803 4. Nickerson, R. S. 1998. Confirmation Bias: A Ubiquitous Phenomenon in Many Guises. Review of General Psychology, 2, 175-220.

5. Patel, N., Patel, S., Cotti, E., Bardini, G. & Mannocci, F. 2019. Unconscious Racial Bias May Affect Dentists’ Clinical Decisions on Tooth Restorability: A Randomized Clinical Trial. JDR Clin Trans Res, 4, 19-28.

6. Slot, D. E., Valkenburg, C. & Van Der Weijden, G. A. F. 2020. Mechanical plaque removal of periodontal maintenance patients: A systematic review and network meta-analysis. J Clin Periodontol, 47 Suppl 22, 107-124.

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About the author

Tabitha Acret graduated from Newcastle University with a Bachelor of Oral Health and is currently studying her Masters in Public Health. She was previously the National Vice-President for the DHAA. Tabitha currently works as a clinical educator for implant maintenance and non-surgical periodontal therapy and lectures nationally and internationally on motivating patients, implant maintenance, disease prevention and periodontal therapy. Outside of her busy work life of lecturing and working clinically in private practice, Tabitha enjoys volunteering both locally and internationally to raise awareness and education of the benefits of good oral health. She was the winner of the 2018 leadership award in dental hygiene and 2019 award for clinical excellence.

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The challenges for prevention with an ageing population: Part 1. Focussing on the patient

Bias in dentistry

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

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ental recommendations are an essential aspect of oral health care.

Patients trust dental professionals to provide accurate and unbiased recommendations on how to maintain good oral health. However, biases can influence dental recommendations, leading to suboptimal care and outcomes. Bias comes in many forms - from confirmation, cultural, gender and financial. It’s important to understand bias so that we can put strategies in place to avoid it.

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Confirmation bias

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cross Australia and New Zealand, the ageing population is posing considerable challenges to health insurance, availability of places in residential aged care, workforce demands in residential aged care, rising demand for hospitalisation and changing patterns of oral health care.

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Question 1. Relying on preconceived notions or beliefs rather than objective evidence to make recommendations leads to: a. Confirmation bias b. Cultural bias c. Gender bias d. Financial bias e. All of the above Question 2. Recommending extractions rather than restorative procedures for patients from certain ethnic groups is termed: a. Confirmation bias b. Cultural bias c. Gender bias d. Financial bias e. All of the above Question 3. A study indicating women are more likely to be given sedatives for their pain and men pain medication is an example of: a. Confirmation bias b. Cultural bias c. Gender bias d. Financial bias e. All of the above Question 4. A clinician who overtreats or recommends unnecessary procedures to increase their income is an example of: a. Confirmation bias b. Cultural bias c. Gender bias d. Financial bias e. All of the above Question 5. Bias can lead to suboptimal care and outcomes: a. True b. False

By Emeritus Professor Laurence J. Walsh AO

onfirmation bias is a type of bias that occurs when dental professionals rely on their preconceived notions or beliefs rather than objective evidence to make recommendations.

A form of confirmation bias in dentistry is the way we make decisions on what we recommend to patients. An example of this is interdental cleaning. Many dental professionals recommend floss as their number one go-to tool for interdental cleaning. However, floss has very limited evidence to support its use and there is clear evidence that interdental brushes, where they fit, are better for biofilm removal and reduction in inflammation. A systematic review from Slot et al in 2020 showed interdental brushes to be superior to floss for interdental cleaning.

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This is impacting on the professional lives of not only the oral health workforce but all those involved in the wider health system. This article is the first part of a series that explores issues around managing elderly patients.

The perfect storm? educed levels of complete edentulism and greater retention of natural teeth have created a situation where the demands for maintenance of the natural dentition, to address issues such as root surface caries and destructive periodontitis, are rising.

R

May/June 2023

Question 6. What percentage of men over 65 suffer from arthritis? a. 12% b. 27% c. 41% d. 50% e. 62% Question 7. ADL stands for... a. Arthritic Disability Level b. Activities of Daily Living c. Acute Diabetic Lymphangitis d. Activities for Diabetic Living Question 8. Prescription medicines used to manage hypertension can cause... a. Salivary gland hypofunction. b. Gingival overgrowth. c. Unprogrammed coughing. d. All of the above.

Question 9. A key element of the successful oral health management of elderly patients is to analyse the impact on oral health of... a. Prescription oral medications. b. Non-oral prescription medications such as inhalers, patches, injections, etc. c. Over-the-counter medicines purchased at a pharmacy. d. Alternative health products. e. All of the above.

Question 10. In 2021, the life expectancy at birth for men is over... a. 73 years b. 79 years c. 80 years d. 84 years

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 May/Jun 2023 questionnaire and then click START. A score greater than 80% is required to PASS and receive CPD.

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Sustainability in dentistry: Part 1 - Plastics and biodegradability

By Emeritus Professor Laurence J. Walsh AO

“Staff should have an awareness of what product labels mean on plastic items, including the ‘triangular chasing arrows’ symbol...”

I

n the first part of this series of articles on sustainability in dentistry, the focus is understanding plastics, especially biodegradable plastics and the issues around recycling of plastics. Later instalments will address other topics within sustainability, including using the life cycle analysis (LCA) to compare different options for equipment and materials and how facility design can enhance sustainability in dental practice.

Understanding this topic links to the newly published (July 2023) updated Australian Dental Council statement of the expected competencies for new graduates from dental education programs of any type, which includes as a core competency the need to “recognise the environmental

How to encourage proper oral hygiene care for teens and young adults

impacts of health care provision and use resources responsibly, making decisions that support environmentally sustainable healthcare”.

Which plastic is what? able 1 provides a list of common plastic materials, dividing these into the fossil-based varieties and those that are biologically-based polymers, also known as bioplastics. Note that this term bioplastic does not necessarily mean that a biologically-based plastic will be more sustainable than a fossil-based plastic. Adding to the complexity around this topic is inconsistent labelling regarding the features of various types of plastics, contradictory information regarding their LCA and “greenwashing” where the product labelling is misleading.

There are many single use plastic items used in dental practices. Plastics are also used in the packaging of items, in PPE and in sterilisation pouches (Table 1).

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26 oral|hygiene

W

e all know that a hallmark of the teen years is to rebel and push back on the rules.

While it makes sense to give young people their space to assert themselves in certain situations, allowing them to be lax in their oral hygiene care is ill-advised.

It can be difficult to convince teens and young adults to make their oral hygiene a priority, especially when they struggle with a number of age-related issues.

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Question 11. Being able to recognise the environmental impacts of health care provision is an expected new graduate competency detailed in a statement from the: a. Australian Dental Association b. Australian Dental Council c. Australian Health Practitioner Regulation Agency d. Dental Board of Australia Question 12. Greenwashing is...

Oral hygiene care barriers among teens and young adults eenagers juggle a lot. School, friends, sports and extracurricular activities keep them busy enough, so it’s no surprise that they often neglect their oral hygiene care.

Complicating matters even more, teens develop harmful habits that have oral health consequences like consuming energy drinks and vaping. Reports suggest as many as 13% of teenagers have one untreated cavity that can lead to infection if not addressed.

There are other factors that prevent teens from practicing proper oral hygiene care.

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Question 16. A teenager typically cares about having a healthy smile because it helps improve their... a. Job prospects. b. Marks at school. c. Social life. d. Overall systemic health.

Question 17. Smoking and vaping can lead to:

a. Chemically breaking down plastics to a biodegradable compound. b. Treating plastics in preparation for recycling. c. Misleading product labelling to make it seem more biodegradable. d. Using biodegradable detergents in a washing machine.

a. Bad breath. b. Tooth staining. c. Periodontal disease. d. Oral and throat cancers. e. All of the above.

Question 13. A bioplastic is typically made from:

Question 18. A good food to recommend to teenagers is:

a. Plants b. Natural polymers c. Natural monomers used to create polymers. d. Any of the above

a. Whole-grain products, such as cereals, breads and crackers. b. Dairy products, such as milk, cheese and unsweetened yogurt. c. Meats, fish, chicken and eggs. d. Legumes and nuts. e. All of the above.

Question 14. A biodegradable plastic made using starch and sugar is... a. Polyhyroxyalkanoates b. Polycaprolactone c. Polybutylene succinate d. Polyglycolic acid Question 15. What percentage of a plastic must be converted into carbon dioxide gas within 6 months to satisfy ISO 13432? a. 30% b. 50% c. 70% d. 90%

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Question 19. A teenagers oral health can be affected by: a. Consuming energy drinks. b. Vaping. c. Tongue piercings. d. Orthodontic brackets and appliances. e. All of the above.

Question 20. According to the article, what percentage of teens have untreated cavities that could lead to infection? a. 8% b. 11% c. 13% d. 18%

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Learn from Australia’s leading authority on infection prevention and control in dentistry about recent changes in infection control including from the Dental Board of Australia (July 2022), the ADA (4th edition guidelines August 2021 and the ADA Risk management principles for dentistry during the COVID-19 pandemic (October 2021)), the new guidelines

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from NHMRC (May 2019), Hand Hygiene Australia (Sept 2019) and the CDNA (Dec 2018) as well as recent changes in Australian Standards and TGA regulations that are relevant to infection control.

The course provides a summary of how those changes interlink with one another and also covers practical implementation of the new requirements and what it means for everyday dental practice. Hear about the why and the how and keep up-to-date with the changes that are happening.

COURSE TOPICS This one day course will cover changes in regulations and guidelines from 2018 to 2022 including: n Risk-based precautions. n Hand hygiene and hand care practices. n Addressing common errors in personal protective equipment. n Biofilm reduction strategies. n Efficiency-based measures to improve workflow in instrument reprocessing and patient changeover. n Correct operation of mechanical cleaners and steam sterilisers. n Wrapping and batch control identification. n Requirements for record keeping for instrument reprocessing. n Correct use of chemical and biological indicators.

Register Now: www.boosterinjection.com.au

FULL UPDATE! All the changes to Infection Control Updated in 2022

Laurie Walsh is a specialist in special needs dentistry who is based at the University of Queensland in Brisbane, where he is an emeritus professor. Laurie has been teaching and researching in the areas of infection control and clinical microbiology for over 25 years and was chief examiner in microbiology for the RACDS for 21 years. His recent research work includes multiple elements of infection control, such as mapping splatter and aerosols, COVID vaccines and novel antiviral and antibacterial agents. Laurie has been a member of the ADA Infection Control Committee since 1998 and has served as its chair for a total of 8 years, across 2 terms. He has contributed to various protocols, guidelines and checklists for infection control used in Australia and represented dentistry on 4 committees of Standards Australia and on panels of the Communicable Diseases Network of Australia and of the Australian Commission on Safety and Quality in Health Care.

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abstracts | 2023

Oral Hygiene Abstracts 2023

By Emer. Prof. Laurence Walsh AO

Risk factors for Long COVID in HC workers

Long COVID is an important public health issue, with an overall global estimated pooled prevalence of 43% (95% CI, 39%-46%), with a prevalence of 54% (95% CI, 44%-63%) in hospitalised patients and 34% (95% CI, 25%-46%) in non-hospitalised patients. This study determined risk factors for the development of long coronavirus disease 2019 (COVID-19) in healthcare personnel (HCP).

A case-control study design was used, following an HCW who had confirmed symptomatic COVID-19 while working in a Brazilian healthcare system between March 1, 2020 and July 15, 2022. Cases were defined as those having long COVID according to the US CDC definition. Controls were defined as HCW who had documented COVID-19 infection but did not develop long COVID. In total, of 7,051 HCW diagnosed with COVID-19, some 1,933 (27.4%) developed long COVID. These were compared to 5,118 (72.6%) who had been infected but did not develop long COVID. Multiple logistic regression was used to assess the association between exposure variables and long COVID during 180 days of follow-up. Around half of the HCW with long COVID (51.8%) had experienced three or more symptoms. The most common symptoms were headache (53.4%), followed by myalgia or arthralgia (46.6%) and nasal congestion (45.1%). Factors positively associated with the development of long COVID were female gender (OR, 1.21; 95% CI, 1.05-1.39), greater age (OR, 1.01; 95% CI, 1.00-1.02) and 2 or more bouts of COVID-19 infection (OR, 1.27; 95% CI, 1.07-1.50). Long COVID was less likely to develop in those infected with the delta variant (OR, 0.30; 95% CI, 0.170.50) or with the omicron variant (OR, 0.49; 95% CI, 0.30-0.78). There was a dramatically lower likelihood of developing long COVID after receiving 4 COVID-19 vaccine doses prior to infection (OR, 0.05; 95% CI, 0.01-0.19). Overall, these results show that long COVID can be common in Health Care Workers. This is not surprising because Health Care Workers have been identified as more vulnerable to infection due to occupational exposure. Older females and those who have had >1 bout of infection are most at risk, while the maintenance of immunity via vaccination was highly protective. The identification of risk and protective factors can facilitate the development of targeted prevention strategies for individuals with elevated risk of developing long COVID. Marra AR, et al. Risk factors for long coronavirus disease 2019 (long COVID) among healthcare personnel, Brazil, 2020–2022.

Infection Control & Hospital Epidemiology (2023), 1–7. doi:10.1017/ice.2023.95

UVC devices put to the test in the real world

Ultraviolet-C (UV-C) light room-decontamination devices are not well regulated and there are no standard test protocols to demonstrate efficacy. This is an important concern because variations in test methods can markedly impact reductions of pathogens achieved by UV-C and devices may vary substantially in efficacy. It would be advantageous for healthcare facilities to have access to do-it-yourself test protocols to evaluate UV-C efficacy to compare devices being considered for purchase and to test devices intermittently to ensure appropriate performance. This study developed a do-it-yourself test protocol for UV-C room decontamination devices that would require limited or no onsite microbiological expertise.

The approach used commercial Bacillus atrophaeus spores to assess the efficacy of UV-C light room-decontamination devices. B.atrophaeus is non-pathogenic with no safety concerns. The test protocol involved 10 minutes of exposure to steel disk carriers aseptically adhered to petri-dish bottoms positioned parallel to lamps 0.914 m from the device at the midpoint of the lamps. For each device, 10 disks exposed to UV-C were aseptically transferred to tubes containing 2 mL trypticase soy broth that were incubated for up to 7 days. The percentages of disks with positive cultures were calculated. Overall, 4 UV-C devices based on low pressure mercury lamps reduced B. atrophaeus by ≥3 log10 colony-forming units in 10 minutes (Tru-D, Rapid Disinfector, Guardian, UVDI-360), whereas a smaller device (Vortex-UV) required 60 minutes. For devices that have relatively low UV-C output, better results may be achieved with longer cycle times and/or by placing multiple devices in the room. Of 10 in-use devices, only 1 was ineffective. The findings provided proof of concept that this protocol could be useful for onsite evaluation of UV-C light room-decontamination devices. The proposed test method requires limited or no onsite microbiological expertise. Colorimetric indicators and irradiance measurements using a radiometer could also be useful as adjunctive methods to assess UV-C dose delivery.

Cadnum JL, Donskey CJ. A do-it-yourself test protocol using commercial Bacillus atrophaeus spores to evaluate the effectiveness of ultraviolet-C light room-decontamination devices. Infection Control & Hospital Epidemiology (2023), 1–4. doi:10.1017/ice.2023.24

20 oral|hygiene

May/June 2023

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The challenges for prevention with an ageing population: Part 1. Focussing on the patient

By Emeritus Professor Laurence J. Walsh AO

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cross Australia and New Zealand, the ageing population is posing considerable challenges to health insurance, availability of places in residential aged care, workforce demands in residential aged care, rising demand for hospitalisation and changing patterns of oral health care.

22 oral|hygiene

This is impacting on the professional lives of not only the oral health workforce but all those involved in the wider health system. This article is the first part of a series that explores issues around managing elderly patients.

The perfect storm? educed levels of complete edentulism and greater retention of natural teeth have created a situation where the demands for maintenance of the natural dentition, to address issues such as root surface caries and destructive periodontitis, are rising.

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May/June 2023

clinical | EXCELLENCE At the same time, there is increasing demand to maintain dental implants and prostheses of various types and reduced demand for replacement of complete dentures. Today, many patients expect to keep most of their natural teeth. Having more dentate elderly patients who have greater medical complexity creates a perfect storm.

If one looks at the demographics for both Australia and New Zealand, the steady growth in population has been accompanied over the last 40 years by an increase in life expectancy and in the median age of the population. Taking data for both countries together, life expectancy at birth for men has risen from 73 years in 1991 to over 80 years in 2021 and for women from 79 years to 84 years. A greater proportion of the population is now in the older age groups, particularly due to the “baby boomer” group. Over the next 10-12 years, around one quarter of the ANZ population will be aged 65 years or more and around one in eight people will be 75 or more.

A patient’s physical well-being and medical status will impact their quality of life, as well as and their ability to undertake activities of daily living (ADLs) (Figure 1B). Age-related reductions in hearing, vision, short-term memory, mobility and dexterity mean that more support is needed for performing activities of daily living, especially for those who are aged 85 years and above. As well as the accumulated effects of ageing that could be described as normal wear and tear, many systemic conditions are more prevalent in the elderly and a patient’s oral health can be impacted directly by systemic disease as well as by medications that are used to manage or treat those conditions. Salivary gland hypofunction is common in elderly patients because of polypharmacy (Figure 1C,D).

Rising pill burden and its consequences here are many challenges that surface when individuals live for longer. It is common to see that elderly patients are being managed for hypertension and arthritis, as these are the two most common conditions in elderly individuals across the ANZ region.

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Panel A: Greater medical complexity in elderly patients comes with a larger “pill burden” and an increased likelihood of adverse drug reactions as well as salivary gland hypofunction.

Panel B: The ability to open a pill bottle is a quick test for manual dexterity. A person who cannot do this will likely struggle with toothbrushing.

Panel C: Typical frothy white saliva on the soft palate indicating salivary gland hypofunction.

Panel D: Saliva test results from the GC SalivaCheck Buffer test kit that raise concerns of salivary gland disease. The upper part shows the buffer test pads. The buffer capacity is unusually low. The lower left strip shows an acidic resting salivary pH, while the lower right strip shows that the pH of the stimulated saliva is below the normal range.

Panel E: Typical appearance of neglected oral hygiene in a nursing home resident.

Panel F: A broken down dentition in a dependant patient who has been living in a nursing home. The incisal edges show erosive destruction.

Panel G: various toothbrush modifications to make the brush handle easier to hold.

Panel H: A laptop and intraoral camera used for teledentistry remote oral assessments. The image shows Dr Candy Fung from the UQ special needs dentistry program who has been conducting teledentistry in nursing homes.

oral|hygiene 23

clinical | EXCELLENCE

Prescription medicines used to manage hypertension can cause a range of impacts on oral health, including salivary gland hypofunction (beta-blockers), gingival overgrowth (calcium channel blockers) and unprogrammed coughing (ACE inhibitors) as common examples.

Knowing which medicines patients take and why they take them, is essential for safe and effective oral health care provision (Figure 1A).

As the total pill burden of an elderly patient increases, so does their risk of developing adverse oral changes as a result of polypharmacy. Many elderly patients will show reduced production of saliva at rest (Figure 1C), with an increase in the risk for dental caries, dental erosion, cervical dentinal hypersensitivity and oral fungal infections. The acidic oral environment in these patients poses a major challenge for effective dental maintenance.

A key element of the successful oral health management of elderly patients is to correctly chart their medical trajectory and take note of medical events, medical conditions and medications that can adversely impact oral health. It is important not to just focus narrowly on “the pills that they are taking” and which are

24 oral|hygiene

presented in a pill organiser. One must also ask about medications they are having in ways other than in pills that are swallowed (e.g. inhalers, patches, injections).

One must also ask about over-the-counter medicines purchased at a pharmacy and about alternative health products, as both are very commonly used.

For elderly patients, processes around absorbing, distributing, metabolising and excreting drugs are impaired, due to reduced liver function and kidney function, amongst other things. As a result, the therapeutic window (the concentration range where the drug is safe and effective) is much narrower than in a young patient. This means that drugs are more likely to accumulate and cause toxic effects in elderly patients because they are not cleared or metabolised very well. Adding to this, many elderly patients have a low body mass and this must be taken into account whenever considering what the toxic dose may be (e.g. for dental local anaesthetics).

Rapid oral health decline aring for individuals who have invested much effort and expense in retaining their natural teeth becomes espe-

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cially challenging when those individuals are no longer able to perform their own oral care. Because of greater retention of teeth, there is a large surface area that must be managed during regular tooth cleaning and this can pose a great challenge to a patient - and even more so to a carer who is trying to perform oral hygiene for them.

As the oral hygiene standard collapses (Figure 1E), the dentition deteriorates, with dental caries and periodontitis being major drivers of tooth loss. Unmanaged conditions such as reflux are common in elderly patients and this can also cause substantial loss of tooth structure (Figure 1F).

Contributing factors he oral health of an elderly patient will often change suddenly for the worse when they move from living at home to a supported living environment. The key drivers are the changes in their lifestyle and diet, with a much higher frequency of exposure to preprepared food with a high load of carbohydrates. When this is combined with a requirement for nursing home staff to assist with tooth cleaning, it is common to see a downward spiral in oral health, which is often termed rapid oral health deterioration (ROhD).

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clinical | EXCELLENCE This becomes a tipping point in terms of the survival of the dentition. Teeth can become ring-barked by caries and the unsupported crown then breaks off, leaving a root stump behind.

Often a trajectory of decline begins after some major life changing event which makes the patient suddenly more frail and less able to care for themselves.

Other important triggers can include the loss of a partner and a move from independent living in the community to living in a residential aged care facility (RACF). Hence, when tooth loss now occurs, it is in the context of

Comorbidities ost large studies of elderly cohorts in Australia and New Zealand report that around 50% of men or women over the age of 65 suffer from arthritis. This can affect their general mobility, as well as their manual dexterity. The latter will influence their ability to use a conventional manual toothbrush effectively. A range of modifications can be undertaken to make the brush handle easier to hold (Figure 1G).

There is a great opportunity for dental professionals to educate carers and nursing

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ADLs and typically live in the community in an independent way with little if any restrictions on their life. A person with low dependency is using an aid like a walking stick or walking frame, to enhance their mobility, but otherwise is independent for many aspects of living.

The third category are patients with high dependency who are typically described as being medically frail. These patients need support for most or all of their activities of daily living, even the basic most basic ones, such as personal hygiene and oral care. Individuals can reach this last stage through a gradual trajectory of decline from health through to frailty through to dependency. Alternatively, they can progress quickly from health through to dependency because of a single serious event, such as a stroke or a major fall or accident. They suddenly become frail and now will live the remainder of their life with a significant disability.

The next article will explore some of the more common medical issues faced by elderly patients and how these influence the safe provision of oral health care.

About the author

significant personal loss that has already occurred (loss of the partner, loss of independence and greater reliability on others).

The loss of teeth affects the ability to chew and alters the way that patients select foods. This, in turn, affects their nutrition and their general health. It is important to realise that effective oral health care must not only aim to support a dentition which is comfortable and free of pain, but also one that can provide sufficient function in terms of chewing nutritious foods. In some situations, the shortened dental arch approach can be very useful because it reduces the complexity for tooth cleaning, yet maintains the patient’s ability to eat a suitable range of foods.

May/June 2023

staff in RACF, both on-site and also through teledentistry (Figure 1H). Both can improve their ability to undertake oral health assessments using standardised tools (such as the oral health assessment tool, OHAT) and to correctly identify when patients require a dental referral to address an oral health issue. Such tools help in care planning for residents, as well as in communication between nursing home staff and external clinicians.

Rating dependency ased on the need for support and their ability to undertake ADLs, a useful way to think about elderly patients is to classify them in terms of their dependency.

Robust patients can do a full range of

B

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.

oral|hygiene 25

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Sustainability in dentistry: Part 1 - Plastics and biodegradability

By Emeritus Professor Laurence J. Walsh AO

“Staff should have an awareness of what product labels mean on plastic items, including the ‘triangular chasing arrows’ symbol...”

26 oral|hygiene

I

n the first part of this series of articles on sustainability in dentistry, the focus is understanding plastics, especially biodegradable plastics and the issues around recycling of plastics. Later instalments will address other topics within sustainability, including using the life cycle analysis (LCA) to compare different options for equipment and materials and how facility design can enhance sustainability in dental practice.

Understanding this topic links to the newly published (July 2023) updated Australian Dental Council statement of the expected competencies for new graduates from dental education programs of any type, which includes as a core competency the need to “recognise the environmental

impacts of health care provision and use resources responsibly, making decisions that support environmentally sustainable healthcare”.

Which plastic is what? able 1 provides a list of common plastic materials, dividing these into the fossil-based varieties and those that are biologically-based polymers, also known as bioplastics. Note that this term bioplastic does not necessarily mean that a biologically-based plastic will be more sustainable than a fossil-based plastic. Adding to the complexity around this topic is inconsistent labelling regarding the features of various types of plastics, contradictory information regarding their LCA and “greenwashing” where the product labelling is misleading.

There are many single use plastic items used in dental practices. Plastics are also used in the packaging of items, in PPE and in sterilisation pouches (Table 1).

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May/June 2023

infection | CONTROL Each of these plastic materials has different properties (physical strength, flexibility, permeability, etc) that reflect its unique chemical structure, specifically what monomer has been used as the building block in the polymer.

An important aspect for any plastic material is how much it will be affected by temperature, since this will dictate whether the particular plastic item will sustain exposure to a washer disinfector cycle or a steam steriliser cycle without melting. Many plastic materials used in dental practice are made from lowfusing thermoplastic materials where the polymer is formed into its final shape using low temperature heat. As a result of this, when exposed to hot water (65°C) or to a steam steriliser cycle (134°C), the material will revert from its shape into an unformed mass of polymer, making it impossible to reuse. This design feature is used deliberately to prevent single use plastic items being reprocessed.

Common plastic materials that are used in dentistry include polypropylene (in surgical masks and respirators), polyethylene and polyethylene terephthalate (PET) in packaging and in containers of various types and polyvinylchloride (PVC) in rigid plastics. The plastics used in packaging and in PPE have the shortest working life, because of single use. As a particular example, during the COVID-19 pandemic, it was estimated that hundreds of millions of facemasks were used, of which around 80% ended up in landfill, with the remainder most likely to have been incinerated as medical waste.

Understanding bioplastics bioplastic is typically made from a renewable resource (such as plants), by extracting natural polymers (starch, proteins, natural rubber, etc), or by using monomers from plants as building blocks to create polymers. Depending upon their type, bioplastics can contribute to circular economies by using renewable plant-based non-fossil resources and then having improved end-of-life outcomes through reuse or biodegradation. In each case, an assessment of the entire lifecycle of the bioplastic using the LCA approach is necessary.

The challenges of introducing more bioplastics into dentistry include their greater cost, lower efficiency for manu-

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May/June 2023

facturing than fossil-based plastics, limited recycling opportunities and a lack of composting facilities. There are environmental impacts associated with agricultural production. An inherent challenge with bioplastics is competition with food production when considering agricultural land use.

Bioplastics are attracting considerable interest because they have a lower carbon footprint than fossil-based plastics. Some of them are compatible with

Understanding plastic recycling or effective recycling of plastics, proper waste stream segregation is essential, to make sure that the recycled plastic is free of contamination.

Some waste plastics can be mechanically recycled using heat and force, to create plastics of new shapes and sizes.

This is often referred to as downcycling, since mechanical recycling often results

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Table 1. A “ready reckoner” for understanding different types of plastics and bio-plastics Group 1. Non-biodegradable durable plastics that are chemically polymerised, durable and largely resistant to hydrolysis Fossil-based:

polystyrene (PS), polyethylene terephthalate (PET), polyvinylchloride (PVC), polyethylene (PE), polypropylene (PP)

Biologically based: Bio-PE, Bio-PP, Bio-PET, Bio-polycarbonate, bio-polyurethane, polyethylene furanoate (PEF) Group 2. Biodegradable plastics that are susceptible to hydrolysis Fossil-based:

polybutylene adipate-co-terephthalate (PBAT), polyvinyl alcohol (PVA), Polybutylene succinate (PBS)

Biologically based: cellulose, polylactic acid (PLA), bio-PBS, polyhyroxyalkanoates (PHA) existing recycling streams, while others may undergo biodegradation if the environmental characteristics for degradation are suitable (particularly the presence of certain microorganisms and the appropriate temperature).

Understanding microplastics ost commonly, microplastic particles are created by the degradation of plastics, from exposure to ultraviolet light or from abrasion by contact with other items. The typical upper size limit for microplastic particles is around 1 mm. As these particles become smaller, their surface area increases and hence also does their ability to bind and carry various contaminants.

At the global scale, a growing concern is the generation of microplastics from plastic waste which has ended up in the ocean because of poor waste management practices. Microplastics in the ocean may reduce the ability of phytoplankton to capture carbon dioxide and sediment this into deep ocean soil.

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in reductions in tensile strength or other physical characteristics. While mechanical recycling produces limited options compared to chemical recycling, it is far less complex and expensive to undertake.

Chemical recycling involves breaking plastic polymers into their component monomers so that those can be used to rebuild new polymers. It is not used widely and currently accounts for less than 1% of all plastic recycling. The process uses solvents and catalysts that present their own environmental impacts.

For plastics such as polyethylene and polypropylene, pyrolysis can be achieved by exposing these to high temperatures (200 to 800°C) in the absence of oxygen.

This recreates hydrocarbon oil or gas, that can then be used for constructing new polymers.

Which polymers are biodegradable? s shown in Table 1, a range of biodegradable plastics exist. The key types of interest for dentistry are summarised as follows:

A

oral|hygiene 27

infection | CONTROL • Polylactic acid (PLA) is made through the condensation of lactic acid which has been generated from the fermentation of sugar. Because of its brittle nature, it is typically blended with other biological polymers to create useful materials. As one example, single use cutlery has been developed using PLA. • Polybutylene succinate (PBS) is produced from starch and sugar. This is a more flexible polymer than PLA and less prone to break.

• Polyhyroxyalkanoates (PHAs) are produced from food residues and liquefied plastic wastes using bacteria.

By controlling the size of the repeating unit, the resulting polymer can be made rigid and brittle, or soft and flexible.

• Polyvinyl alcohol (PVA) is the only vinyl polymer that is readily biodegradable.

• Polycaprolactone (PCL) is used in sutures and in implantable devices such as scaffolds used for tissue engineering. It undergoes hydrolysis, both within human tissues and within the environment, where it is readily broken down by bacteria and fungi in seawater within several weeks.

• Polyglycolic acid (PGL) can be combined with polylactic acid (PLA) to create a copolymer (PLGA) that has high biocompatibility and degrades faster than PCL. This has attracted interest for use as scaffolds in tissue engineering applications. By altering the properties of the PLGA, its mechanical stiffness and degradation rates can be tuned.

• Cellulose is the most abundant natural polymer and can be processed into a range of materials. It can also be added to existing bioplastics to enhance their strength. While cellulose is degradable, the related compound of cellulose acetate degrades extremely slowly.

Understanding biodegradation ach polymer which can undergo biodegradation has specific requirements in terms of the processes involved, including the presence of bacteria, the type of bacteria, the temperature range and the presence of moisture, oxygen or ultraviolet light.

E

28 oral|hygiene

The rate of biodegradation varies according to the chemical structure of the polymer and whether any stabilisers were added to it during its production.

When higher temperatures are used, this increases the susceptibility of polymers to chemical, enzymatic and microbial degradation.

Achieving a suitable temperature and maintaining this for a sufficient length of time may be problematic in home-based or practice-based composting facilities.

It is important to ensure that when

ISO 13432 specifies biodegradation as meaning that at least 90% of the material is converted into carbon dioxide gas in an inoculum derived from compost at a temperature of 58°C after a period of 6 months.

Aerobic composting generates carbon dioxide, whereas anaerobic composting generates methane gas, which can be used for generating electricity by combustion, that will in turn produce carbon dioxide. Biological recycling processes using specific microorganisms can break down polymers into their individual

composting is used, the plastics decompose completely and are not simply fragmented into microplastic particles.

When biodegradation is undertaken at industrial scale, it can achieve complete digestion of a biodegradable plastic, while the same time avoiding the formation of microplastics or the generation of other contaminants. Disintegration means that at least 90% of the material is now in particles that are smaller than 2 mm in size after 3 months of being kept at temperatures between 40-70°C, depending on the particular ISO standard.

The ISO standards for biodegradation of polymers focus on industrial composting facilities and on practical composting process times of up to 8 weeks. Several ISO standards also address degradation that would occur if the plastics are in the ocean.

monomers allowing them to be reused.

For certain plastics such as polyethylene furanoate (PEF), this provides the optimal means for recycling the plastic back into a form that can be reused.

Staff in dental practices are becoming more aware of life-cycle considerations for plastic items used in their practice.

At the consumer level, the removal of disposable plastic shopping bags and plastic straws and their replacements with alternatives are examples of how substitution can be applied. When it comes to biodegradation, the situation is more complex because of the array of different international standards regarding biodegradation of plastics (Table 2). The ISO standards on biodegradation describe the specific conditions required for industrial composting (under EN 13432) and for degradation in ocean water.

May/June 2023

A brand by

munglobal.com.au

infection | CONTROL Avoiding “wishcycling” taff in dental practice should have an awareness of what product labels mean on plastic items, including the “triangular chasing arrows” symbol that appears on some products. This does not necessarily mean that the item can be placed in a recycling bin (a problem known as “wishcycling”). It is important to check with your local council regarding their specific requirements for what can be placed in council kerbside

S

Conclusions here are significant moves to greater use of degradable bioplastics at the global scale and this is a very positive development. Having said that, sustainability considerations depend strongly on how the material is made and how it can be recycled, rather than it simply being made from a renewable resource.

This is why life cycle analysis is so important as it looks at all aspects of environmental impact.

T

Table 2. ISO standards for biodegradation of plastics Aerobic biodegradation in water (ISO 14851, 14852) Anaerobic biodegradation in water (ISO 14853) Aerobic composting (ISO 14855) Anaerobic high solid decomposition (ISO 15985) Aerobic soil burial (ISO 17556) Disintegration at a pilot scale (ISO 16929) Disintegration at laboratory scale (ISO 20200)

Table 3. Degradation of polymers Degradable by industrial composting, biologically based: polylactic acid (PLA), polyglycolic acid (PGA) Degradable by industrial composting, fossil-based: polyvinyl alcohol (PVA), polycaprolactone (PCL), polybutylene succinate (PBS) Non-degradable, biologically based: Bio-PE, Bio-PET, polyethylene furanoate (PEF) Non-degradable, fossil-based: Polystyrene, polypropylene, polyvinylchloride, polyethylene, PET recycling bins. Staff also need to be aware of facilities that exist for recycling specific containers where a rebate is provided as an incentive for this.

Given the confusion that has existed around the recyclability of various plastics, it is important to be aware that there are changes in the labelling of recyclable plastics and that newer labels may be seen on plastic items that are imported from Europe or the UK. Some labels may indicate that certain products are not suitable for recycling. New labels could be found on items ranging from packaging materials through to PPE. There are moves afoot to try to standardise labelling internationally so that confusion (“greenwashing”) is avoided.

30 oral|hygiene

Looking to the future, there is growing interest in advanced recycling technologies (involving physical, chemical and biological processes) so that these become more efficient and more cost-effective. Manufacturers are thinking more about how plastic products can be designed to be recyclable, which may mean simplifying their design and using a single material rather than a multilayered material.

Ideally, a complete circular process could be created for many common plastics and the successful deployment of refund schemes for containers have shown that this can be effective when it is easy to do and well accepted at the community level.

Relying just on biodegradation will not solve all the problems of plastic pollution. Complete re-use is the goal for achieving circularity. Various regulatory incentives will no doubt drive progress in this space, as much as will the individual desire of each dental practice to be more environmentally sustainable.

Recommended reading 1. Geyer R, et al. Production, use, and fate of all plastics ever made. Sci. Adv. 2017; 3:25-29.

2. Harmsen PFH, et al. Green building blocks for bio-based plastics. Biofuel. Bioprod. Biorefin. 2014; 8:306-324.

3. Hottle T A, et al. Biopolymer production and end of life comparisons using life cycle assessment.

Resour. Conserv. Recycl. 2017; 122:295-306.

4. Hong M, Chen EYX. Chemically recyclable polymers: a circular economy approach to sustainability.

Green Chem. 2017; 19: 3692-3706.

5. Spierling S, et al. Bio-based plastics - A review of environmental, social and economic impact 6. assessments. J. Clean. Prod. 2018; 185:476-491.

7. Zheng J, Suh S. Strategies to reduce the global carbon footprint of plastics. Nat. Clim. Change 2019; 9:374-378.

8.Lamberti FM, et al. Recycling of bioplastics: routes and benefits. J. Polym. Environ. 2020; 28:2551–2571.

9.Rosenbloom JG, et al. Bioplastics for a circular economy. Nature Rev. Mater. 2022; 7:117-137.

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.

May/June 2023

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clinical | EXCELLENCE

READ ME FOR CPD

How to encourage proper oral hygiene care for teens and young adults

W

e all know that a hallmark of the teen years is to rebel and push back on the rules.

While it makes sense to give young people their space to assert themselves in certain situations, allowing them to be lax in their oral hygiene care is ill-advised.

It can be difficult to convince teens and young adults to make their oral hygiene a priority, especially when they struggle with a number of age-related issues.

32 oral|hygiene

Oral hygiene care barriers among teens and young adults eenagers juggle a lot. School, friends, sports and extracurricular activities keep them busy enough, so it’s no surprise that they often neglect their oral hygiene care.

Complicating matters even more, teens develop harmful habits that have oral health consequences like consuming energy drinks and vaping. Reports suggest as many as 13% of teenagers have one untreated cavity that can lead to infection if not addressed.

There are other factors that prevent teens from practising proper oral hygiene care.

T

May/June 2023

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clinical | EXCELLENCE These include: • Many teens have orthodontia which can make effective brushing and flossing difficult to achieve; and • Teens often don’t know or don’t follow recommended oral hygiene practices to care for mouth and tongue piercings.

Of course, there’s also the reality that teens are still learning to be independent. They may not yet have mastered the practice of proper oral home care routines and and need additional reminders.

Making a case for oral hygiene care to teens Focus on what matters to them

W

hen talking to teens, relate dental hygiene tips to what matters to them.

A healthy smile helps improve their social life eenagers and young adults tend to care about the impression they make on friends. One way to encourage oral hygiene compliance is to point out how it can make or break those impressions. For example, regular dental check ups and routine oral hygiene practices can prevent bad breath, stained teeth and cavities.

T

Smoking and vaping can have negative effects his is also a good time to share the risks to their general and oral health associated with smoking, vaping and chewing tobacco. These habits can lead to bad breath, tooth staining, periodontal disease and oral and throat cancers.

T

Practicing good oral hygiene makes teens a role model nother conversation to have with teens and young adults regarding proper oral hygiene is about the impact they can have on their younger siblings, friends or relatives. Remind them that their younger peers look up to them and will naturally emulate their behaviour.

This is their chance to be a role model and even partner up with younger siblings to show them how to properly brush and floss their teeth. While some young adults may not be interested in doing this, it’s very often how family dynamics play out.

Once you’ve talked to teens about why they should maintain their oral health, make sure to talk to them about the habits that make brushing and flossing even easier and more productive.

A

Diet and nutrition ost teenagers don’t think about the consequences of what they eat and drink. Most likely they don’t know that their favourite energy drinks, juices and soft drinks can lead to tooth decay. The same goes for chips, pretzels, gooey snacks and other foods that can stick to their teeth. Remind (or teach) teenagers to read food labels so they can see just how much sugar their food and drinks contain. Even with oversight and excellent oral hygiene habits, the use of fluoride toothpastes and professional fluoride varnish treatments are highly recommended for this age group.

M

Healthy food and drinks ecommend that parents keep fruits and vegetables on hand.

Other foods that you can recommend to teens include: • Whole-grain products, such as cereals, breads and crackers; • Dairy products, such as milk, cheese and unsweetened yogurt; • Meats, fish, chicken and eggs; • Legumes and nuts; and • Water or milk instead of fruit juice, fruit-flavoured drinks, flavoured water, energy drinks or soda.

Remind teens that they should floss or brush after each meal, especially if they have braces or a retainer. And always encourage them to drink water to wash away food debris.

R

Home hygiene ncourage teens to develop the habit of brushing their teeth with fluoridated toothpaste twice a day - typically after breakfast and before bed. One trick to share with them is to have them spit out the toothpaste after brushing without a water rinse.

Let them know that the small amount of fluoridated toothpaste in their mouths can help them prevent tooth decay.

While flossing is one of the habits most adults forget to do, it’s definitely a practice to encourage in teens so they’ll continue to do it as they mature. Show teens how to use dental floss and demonstrate how easily disposable flossers can be used. You may even suggest that they carry a small pack with them in a purse or backpack for when they eat out. Even if you sell it as a way to avoid the embarrassment of having food in their teeth, helping teens develop the habit can set them up for a lifetime of improved oral health.

Finally, show teens how their teeth and gums appear in a mirror or with an intraoral camera. Point out the colour their gums should be. Then challenge them to examine the inside of their mouths regularly, so they can identify potential problems.

E

Regular dental visits

Healthy oral hygiene habits for teens and young adults

ost teens and young adults aren’t able to schedule their own dental visits, but you can let them know that routine preventive checkups are important and help prevent cavities.

This way, teens may be more likely to ask their parents to schedule a follow up before leaving the office.

n addition to the materials you already give teenagers that list healthy dental hygiene habits, you may want to add tips from this list.

For more information about how HuFriedyGroup’s products and resources help dental professionals provide better care for patients, visit HuFriedyGroup.com.

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34 oral|hygiene

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May/June 2023

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NEW

Works in 3 mins

Material compatibility1,2

Daily use

Removes+ 99.9% of odour-causing bacteria*3-5 Lifts stains, removes discolouration6,7 Helps keep appliances looking clear1,2 Compatible with common dental appliance material1,2

Retainers Aligners Night Guards Mouthguards

For more information or to request free clinic samples, visit www.haleonhealthpartner.com or scan the QR code AU

+ When used as directed

* In vitro studies

NZ

Always read the label and follow the directions of use.

References: 1. Haleon data on file, 2020, Material Compatibility Testing, Fraunhofer Institute. 2. Haleon data on file, 2020, Compatibility testing of an aligner material, Fraunhofer Institute. 3. Haleon data on file, 2011, MD#024-11. 4. Haleon data on file, 2012, MD #012-12. 5. Haleon data on file, 2011, MD#040-10. 6. Haleon data on file, 2015, CP/MVR/EDCU/09. 7. Haleon data on file, 2016, CP/MVR/EDCU/15.

Trademarks are owned by or licensed to the Haleon group of companies. ©2022 Haleon group of companies or its licensor. PM-AU-POLD-22-00088 TAPS BG2560