Oral Hygiene May/June 2021

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

VOL.31 NO.3

MAY/JUNE 2021

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Dental Installations Miranda (02) 9526 3500

Alldent Port Melbourne (03) 9646 3939

Dental Depot Windsor (07) 3857 0011

Dental Intelligence Concepts Malaga Edwardstown (08) 9244 8888 8177 0600

Presidental Silverwater Warners Bay 1800 773 743 Warners Bay Tristan’s Dental 1800 773 743 Equipment Service Campbelltown Tristan’s Dental (02) 9820 8086 Equipment Service Campbelltown (02) 9820 8086

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VOLUME 31 | NUMBER 3 MAY/JUNE 2021

OH | CONTENTS

On the cover...

The Piksters® Bamboo Range is made from biodegradable and sustainably grown bamboo and sold in 100% recycled biodegradable packaging.

READ ME FOR

CPD

12

COMMUNICATION IS KING

4 BRIEFS 6 NEWS & EVENTS 16 CPD CENTRE 20 ABSTRACTS

Communication is essential to our lives; we communicate daily with our family, friends, colleagues and... patients. The way we communicate with our patients can make all the difference to their understanding of their health, making favourable changes and attaining positive outcomes more achievable explains Tabitha Acret

READ ME FOR

CPD

22

CONTEMPORARY USES OF CPP-ACP TECHNOLOGIES IN 2021: PART 2 Prof. Laurie Walsh discusses current concepts for the use of casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) technologies in their role as a prebiotic agent that can modulate the behaviour of dental plaque biofilms

facebook.com/auxiliarynow

Annual Subscriptions: Australia or NZ: OralHygiene $22.00 p.a.

Overseas: A$38.00 p.a.

Australasian Dental Practice (including OralHygiene) $99.00p.a.

SUBSCRIBE ONLINE at http://shop.dentalpractice.com.au

twitter.com/auxiliarynow Publisher & Editor: Joseph Allbeury

28

READ ME FOR

CPD

FACE MASK PERFORMANCE: ARE YOU PROTECTED? Dr John A. Molinari and Peri Nelson present a study on mask resistance to fluids, aerosols and bacterial penetration

32

READ ME FOR

CPD

FOUR CHANGES TO INFECTION PREVENTION AND CONTROL THAT MADE A DIFFERENCE Dental professionals have gone aboveand-beyond to address infection risks and keep their practices safe during the COVID pandemic. Here are four critical changes that practices made (and should continue to make) in order to keep up the good work

instagram.com/dentevents www.oralhygiene.com.au

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 © 2021. 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.

news | EVENTS New “easy add” and update for www.dentist.com.au

t’s now easier than ever to add or update your dental practice on Australia’s #1 find-a-dentist website - www.dentist.com.au. A new option allows you to add all your information using a simple form with your practice being added or updated within 24 hours of submission. “If you have a login to the Dental Community website, then adding and updating practices has always been easy,” said Joseph Allbeury, publisher of this magazine and dentist.com.au. “However, if you’re checking out your information on the web and end up on dentist.com.au, then how to add or update your details was less straighforward. “By adding this form, it alleviates the need to email or call us and it captures all the information that we need.” Around a million searches a year are made on dentist.com.au by the public looking for a dentist. Ensuring your practice is listed and the information is correct will directly result in more patients in your dental chair. “Dentist. com.au is such a success because it lists every dental practice and every dental practitioner in Australia [and New Zealand on dentist.co.nz],” Mr Allbeury said.

“There is no charge to be listed and our goal is to list every private practice, corporate practice, health fund clinic, public dental clinic and denture clinic.”

Every dental professional in Australia and New Zealand is entitled to a free login to www.dentalcommunity.com.au where you are able to control your presence on dentist.com.au (and dentist.co.nz). To obtain a free login, click the Sign In button on www.dentalcommunity.com.au or to use the “easy add” function, visit dentist.com.au/information-for-dentists

I

New Colgate recyclable Trial Bags olgate Professional Oral Care has introduced new environmentally-friendly recyclable Trial Bags that are ideal for dental practices to use in their oral health promotion. The Trial Bags are supplied complimentary with a minimum order of 144 product “sets” comprising Colgate Plax Mouthwash 60mL; a Colgate toothbrush; Colgate Total fluoride toothpaste 40g; and Colgate Total Dental Floss travel size. Practices can also opt to customise the products included in the pack based on their individual requirements. Once the patient no longer has a use for the Trial Bag, they can help the environment by placing it in their kerbside recycling bin. Available from Henry Schein on Tel: 1300-658-822 or see www.henryschein.com.au.

C

4 oral|hygiene

in | BRIEF Researchers from Penn Dental Medicine say they have made new discoveries in the search for disrupting a biofilm that can lead to early childhood tooth decay. The findings build on previous research that discovered that a dental plaque that gives rise to ECC is composed of both a bacterial species and a fungus. In an attempt to eliminate the plaque, researchers applied three different mannan-degrading enzymes to a biofilm growing on a tooth-like surface in a human saliva medium, leaving it for five minutes. Following the treatment, the overall biofilm volume and thickness were reduced along with the bacteriayeast interactions. The researchers kept the application time relatively short at five minutes though they hope to see activity in the two minutes recommended for tooth brushing. They also said a non-alcohol-based mouthwash with these enzymes added could potentially be used as a preventive measure against ECC. Two new kinds of dental care providers could soon be authorised in Wisconsin, with the state Legislature taking up bipartisan proposals to allow dental therapists and workers known as “expanded function dental auxiliaries”.

Dental therapists are authorised in 13 states, including Michigan and Minnesota, which became the first state to pass such legislation in 2009. Dental therapists, mid-level practitioners similar to physician assistants, were long opposed by the Wisconsin Dental Association (WDA) who said that therapists’ ability to do fillings and oral exams would make them too much like dentists.

Under a new state mandate in New Mexico, public school students who recently relocated to the state or are transferring to a new district or charter school, are required to have had a dental exam within the past year to enroll. Effective July 1, the rule applies to new students at all grade levels. The dental exam requirement was passed in 2019 as part of a larger dental health bill intended to expand access to oral health care in the state. The Santa Fe school board recently approved a policy to ensure compliance with the rule.

May/June 2021

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news | EVENTS

8 great websites for dental professionals

www.oralhygiene.com.au Magazine

www.dentalpractice.com.au Magazine

www.elaborate.com.au Magazine

www.dentalcommunity.com.au Professional Portal

www.dentevents.tv Dental Video Streaming

www.dentevents.com Events Calendar

www.dentist.com.au FInd-a-dentist - Australia

www.dentist.co.nz Find-a-dentist - New Zealand

8

websites catering to all the needs of the dental profession have now been updated to optimise their performance across all devices.

Brand new websites have also been created for Australasian Dental Practice, Oral Hygiene and eLABORATE magazines.

6 oral|hygiene

“8 websites may seem like a lot but each fulfils a role in the dental profession,” said Joseph Allbeury, publisher of this magazine and all of the websites. “Whether you are looking for news, product info, events to attend, videos to stream and more, we have it covered. We even help dental practices attract patients through dentist.com.au and dentist.co.nz.”

May/June 2021

Colgate® Optic White™ Professional Whitening System To Order: 1800-262-111 www.henryschein.com.au

dentevents.tv

Entries Close 31st July

IN!TheUltimate...

W Practice Makeover ORIGINAL productions

WIN a complete public image update valued at over $90,000!

If you love being a dentist but recognise that your practice is not where it needs to be, then take heart!

For the first time ever, you could win the “Ultimate Practice Makeover” valued at over $90,000! This package of products and services will completely update the public image of your dental practice and get you and your staff trained and on track for business success over a 6-month journey.

To be eligible to enter, all you need is a dental practice in Australia and some details (via video or text) to support your entry.

The prize, valued at over $90,000, includes a new website, new branding, new uniforms, coaching for you, training for the whole team, an update of your reception area, signage and more (check the website for the growing list).

To be eligible to enter, all you need is a dental practice in Australia and either (i) 250 words describing why you should win, or (ii) a short video to support your entry!

Tell us why you want to change! You can include details such as: • Information on you, your practice and team show us the team at work Plus, if you win, you’ll need to be ready for a fun • Where your practice is located adventure as your practice is transformed from wallflower to sunflower.

• Why you think you need help • Any stories of how you’ve tried to grow the Your practice’s journey will be documented on practice in the past and what the result was video and your results published for other practices to see - and follow along - so be prepared for some • What you’re really like - don’t be afraid to inject fun in the spirit of reality television as your practice your personality as we want to see the real you! is tuned for maximum success.

• Do not include anything in your entry you do not want your patients or competitors to see as the Australia’s #1 Google ranked dental marketer, content may be published on Dentevents.TV or Angus Pryor, will manage your makeover, roping in elsewhere. a range of experts to help along the way. Together, they’ll bring the public image of your practice Once selected as the winner by the expert judging into the 21st century and ensure that you are panel, the “experiment” begins! Legendary maximising your opportunities for success. dental marketer Angus Pryor (and a team of other consultants) will work with you over the next 6 By the end of the journey, your practice will look months to transform your practice. better and function better and your new patient numbers and turnover will grow. And you will have Apply now! a plan to maintain your success for the future.

Sponsored by... ™

PRIZE INCLUDES… •

Refresh of your waiting area and signage valued at up to $40,000

•

New website and SEO package ($12,000 value)

•

New practice management software (if required) ($5000 value)

•

Marketing consultancy for 6 months to help you “stay on plan” ($10,000 value)

•

Telephone answering training ($3500 value)

•

New uniforms, patient welcome packs and more... ($2500 value)

•

A full marketing review of your practice with a “SWOT” style analysis ($3500 value)

•

Online marketing including dentist.com.au premium upgrade ($2000 value)

•

Training for you and your team ($2000 value)

•

Treatment presentation coaching ($2000 value)

•

Development of a marketing strategy for six months ($2000 value)

•

Full branding package - logo, colours, style guide and more... ($1000 value)

•

A clear roadmap for your future success Priceless!

•

And more…

Reception and waiting area update Your marketing must match the look and feel of your practice when patients arrive so as part of the prize, Medifit, Australia’s oldest and most accomplished dental surgery design and construction company will makeover the public face of your practice to ensure your patients are WOW’d every single time.

The team from Medifit will work with you to enhance the reception and waiting area of your practice to ensure it delivers on patient expectations. Every practice is different and Medifit will craft a bespoke solution based on your individual situation that could include upgrading your shopfront and signage, new waiting room furniture, reception desk and lighting, an updated colour scheme and more up to the value of $40,000.

Medifit will consult with you and the practice makeover marketing team, providing you with 3D renderings of how your practice will look right through to delivering the upgrade, working around your schedule to ensure minimal disruption. Your reception and waiting area and public image will shine once Medifit have worked their magic. The entire experience will be filmed for broadcast on Dentevents.tv and elsewhere, as well as featured in magazines so everyone in the profession can understand the advantage of working with an experienced, professional dental practice design and construction company like Medifit.

See www.UltimatePracticeMakeover.com.au for full details Terms & Conditions • • • • • •

Entry is open to all privately owned dental practices in Australia.

All entries must be made by the owner of the practice or an authorised representative of the owner.

The only valid method of entry is by completing the entry form on www.UltimatePracticeMakeover.com.au including either a video or up to 250 words of text.

All content provided can be used for promoting the competition. All entries may be displayed on Dentevents.TV for public viewing.

The content provided becomes the property of and may be displayed on dentevents.tv and other websites.

The content provided must not contain material that is considered to be offensive to any gender, cultural group, race, etc and should not contain nudity or profanity.

• If you choose to supply a video, it should be no more than 2 minutes in length.

• The prize incorporates a bespoke, interactive consulting process (and supporting products) tailored to the winning practice. By entering, you agree to participate in this consulting process which will be filmed and appear on Dentevents.TV and elsewhere, and as part of written articles that include photographs published in Australasian Dental Practice magazine, Oral Hygiene magazine and elsewhere both in print and online.

• As part of the consulting process, you agree to disclose information related to various metrics of your practice at the beginning and the end of the “makeover” for the purposes of publishing the results as a quantifiable outcome. For example, the show may disclose that the turnover of the practice increased by $100,000, or new patient numbers increased from 20 to 40 per month.

• FULL TERMS AND CONDITIONS ARE ON THE WEBSITE

news | EVENTS

Streaming now on www.dentevents.tv

D

entevents.tv is a brand new website for the dental profession that offers a broad range of video-based content focussed on all aspects of dentistry - from clinical, to technology, to management, marketing and more. Sign in for FREE and watch hundreds of on-demand videos, with more being added every day. Some videos even offer CPD! A selection of videos that will interest dental hygienists and oral health therapists appear below - or browse the website for many many more.

Don’t Get Burned - Keys to Avoid and Remove Burnished Calculus Presented by Anna Pattison Duration 1:29:28 AVAILABLE ON DEMAND CPD 1.5 Hour Residual burnished calculus is a significant, persistent problem for all clinicians who perform non-surgical periodontal instrumentation.

Navigating the New Reality in Respiratory Protection Presented by Leann Keefer, RDH, BSEd, MSM Duration 1:17:44 AVAILABLE ON DEMAND CPD 1 Hour The importance of proper infection prevention and control protocols is at the forefront for healthcare providers of all segments.

Infection Control Boot Camp Presented by Prof. Laurence Walsh Duration 7:08:14 AVAILABLE ON DEMAND CPD 6.0 Hours Learn firsthand from Australia’s leading authority on infection prevention and control in dentistry about recent changes in infection control that have come in over the past 12 months. This paid online learning program spans 27 video modules watched on-demand over more than 7 hours.

The Oral Cancer Screening Exam: The Urgent Need for Change Presented by Jo-Anne Jones Duration 0:47:42 AVAILABLE ON DEMAND CPD 1.0 Hours The majority of oral and oropharyngeal cancer is discovered in the later stages. Due to late stage discovery, little more than 50% of those diagnosed today will be alive in five years.

Watch hundreds of videos on-demand for FREE at www.dentevents.tv

10 oral|hygiene

May/June 2021

STREAMING NOW ON-DEMAND

Dentevents.TV is a brand new dental video streaming service Watch a growing list of hundreds of videos related to dentistry all in one place

www.dentevents.tv

READ ME FOR

CPD

Communication is king

By Tabitha Acret

C

ommunication is essential to our lives; we communicate daily with our family, friends, colleagues and... patients. The way we communicate with our patients can make all the difference to their understanding of their health, making favourable changes and attaining positive outcomes more achievable.

For every appointment, effective patient communication should be the goal. We can help change a patient’s mindset, make them feel at ease during their appointment, lower anxiety, allow them to feel in control and engineer positive health outcomes.

12 oral|hygiene

Communicating with our patients is not just talking or informing, it has to be a mix of listening, talking and action. Active listening is the practice of really listening in a conversation and understanding what is being said, rather than not hearing what a patient is saying because we’re too focussed on forming our next talking point in our minds. Treatment plans should be a collaboration, not a one-sided event.

We need to know what our patients want, what are their needs and how can we fulfil this?

This communication process starts at the front desk staff before the patient enters the treatment room. Does your front desk team know how to communicate effectively with your patients, address patient concerns and create any appointments necessary? Do they know what questions to ask and what information they should provide

May/June 2021

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clinical | EXCELLENCE to the clinicians about what has been discussed on the phone or face-to-face during the appointment booking process.

This function allows the patient to be engaged earlier, feel heard and know the practice works as a team. When the patient has told the front desk staff information and it’s not communicated to the clinical staff, it can result in the same question being asked multiple times. This leads to the patient feeling like they’ve not been heard or even worse, feeling that they’re not important to you.

Front desk staff also have an important communication role in setting expectations for the patient. Things such as what time should they arrive; what, if anything, needs to be done in advance of arriving; what they should bring with them on the day; and what is the cancellation and payment policy. When this is communicated appropriately, it puts the wheels in motion for a successful appointment. When this is done poorly, it means the clinician is starting out on the back foot from the outset.

We can also communicate in the patient waiting room without talking but rather by having different technology and materials available to the patient. We can have dental videos playing on the waiting room tv that allow for education on conditions, complications and treatment options available at the practice (for example, see www.channeld.com).

Practice newsletters and educational brochures can also allow for patients to read about practice information, procedures and services.

As clinicians, when we start communicating with the patient, it is important that we sit in a position where we can make eye contact with the patient. If it’s the first time meeting them, remember to introduce yourself, listen to why the patient is there and explain what the process for the appointment will be.

One of the most important steps is to ASK permission. Once we start examining the patient, the communication does not stop.

Explain to the patient what you’re examining. This will obviously vary for different types of examinations, however our ultimate aim should be to encourage our patients to ask questions and be part of the process. The ideal outcome is for your patient to become an active member of the oral health team.

14 oral|hygiene

Again, in the surgery we don’t just communicate with wolds. Visual aids also play a huge role in helping communicate information to patients. There are many visual aids that can be used from computer programs, models, charting, photography and my favourite biofilm disclosing.

This is where communication plays a key role in the art of motivating our patient. It is at this stage where it is crucial that we use a “touch to teach” method and where we don’t just “talk at” our patient but rather work together as a team again. We need to remember not to use complicated dental jargon and

bleeding. Again, this information is also available to the clinician to use at the next review appointment.

Good communication comes from the whole dental team. We see it works when we have loyal patients who attend, and as a result we see increased patient satisfaction, reduced complaints and improved efficiency in the dental setting. When we communicate with care our patients are happier. We can do this by using empathy, active listening and making sure we are using correct tone and inflection. All of this will result in helping to send a message of caring to our patient.

use words that match our patient’s health literacy. Patients will only retain a percentage of what is told to them but if we combine our motivation and oral hygiene instructions with the key steps of tell, show and try, our patient is more likely to retain more information.

The communication continues with explaining the treatment and aftercare and future appointments needed. And it doesn’t have to end when the appointment ends. There have been many advances in technology in dentistry that not only improve home care and motivation, but also strengthen the relationship between clinician and patient.

Power toothbrushes are now available with AI technology and Apps that help the patient learn where and how long to brush for. They can also provide this data back to the dental clinician at review appointments. The BOB App can also help the patient with interdental cleaning and monitoring bleeding on interdental brushing and any reduction in

It’s important for health outcomes and for the health of the business. Its essential we continue to learn and grow our communication skills for the benefit of both ourselves and our patients.

About the author Tabitha Acret graduated from Newcastle University with a BOH and is currently studying her Masters in Public Health.

She was previously the National VicePresident 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.

Tabitha enjoys volunteering both locally and internationally to raise awareness and education of the benefits of good oral health and she was the winner of the 2018 leadership award in dental hygiene and 2019 award for clinical excellence.

May/June 2021

“

IF YOU DON’T HAVE CHANNEL D, I THINK YOU’RE NUTS...

Almost every day, a patient says to me....

“I love your videos” . Then they tell me something that they never knew before, or ask me a question.

That’s how the conversation starts, and those conversations inevitably lead to more work.

It’s like having a dental guru sitting next to each and every patient in reception, whispering ideas and planting questions in their head. They walk into the operatory interested in the right topics.

Without these conversations, we wouldn’t be doing half the treatments we do.

Look at the maths. I have 2-3 extra relevant conversations per day. That’s 10-15 per week.

40-60 per month. 480-720 per year. This all adds up to a ton of work and many personal referrals. The patients all think I created the content and I get compliments about it because it’s so personal.

This is nothing like boring dental videos showing scary procedures.

It’s a significant business builder and the cost is peanuts. Speaking of peanuts, that leads me back to my original statement, “if you don’t have Channel D, I think you’re nuts”.

Dr Brett Taylor, Sydney General dentist and super happy Channel D user

Try ChannelD for FREE and see the difference it can make to your practice... Sign up at ChannelD.com and use Promo Code AM58

www.channeld.com

oral|hygiene CPD CENTRE Cervitec -Line ®

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CPD

clinical | EXCELLENCE

READ ME FOR

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Beyond mutans streptococci he concept of beneficial influences of topical CPP-ACP on dental plaque volume, composition and metabolism has been building steadily over the past decade,1,2 however the foundations for this area of research were laid over 20 years ago in work around effects on the binding of bacteria to dental hard tissues and to salivary pellicle. Today it is recognized that such effects contribute to caries prevention in settings such as patients with fixed orthodontic appliances.

When topical forms of CPP-ACP, such as GC Tooth Mousse™ (TM) and Tooth Mousse Plus™ (TMP) are used, plaque levels around brackets are reduced.3 By 2013, it had become apparent that daily use of TM in infants and young children could drive a dramatic reduction in their levels of mutans streptococci.4,5 This provided a further rationale for topical use of CPP-ACP beyond its well known roles in remineralisation.6-8 This concept has matured to now incorporate the concept of CPP-ACP being a prebiotic agent, that supports the growth of those health-associated commensal bacteria that constrain the growth of cariogenic microorganisms.9-11

T

Communication is king

By Tabitha Acret

C

ommunication is essential to our lives; we communicate daily with our family, friends, colleagues and... patients. The way we communicate with our patients can make all the difference to their understanding of their health, making favourable changes and attaining positive outcomes more achievable.

For every appointment, effective patient communication should be the goal. We can help change a patient’s mindset, make them feel at ease during their appointment, lower anxiety, allow them to feel in control and engineer positive health outcomes.

Communicating with our patients is not just talking or informing, it has to be a mix of listening, talking and action. Active listening is the practice of really listening in a conversation and understanding what is being said, rather than not hearing what a patient is saying because we’re too focussed on forming our next talking point in our minds. Treatment plans should be a collaboration, not a one-sided event.

We need to know what our patients want, what are their needs and how can we fulfil this?

This communication process starts at the front desk staff before the patient enters the treatment room. Does yor front desk team know how to communicate effectively with your patients, address patient concerns and create any appointments necessary? Do they know what questions to ask and what information they should provide to the

12 oral|hygiene

May/June 2021

The effective duo for use in risk control www.ivoclarvivadent.com Tel: 03 9795 9599 l Freephone: 1300 IVOCLAR (486 252) Email: orders.au@ivoclarvivadent.com *One free sample per account. While stocks last.

Question 1. A key part of communicating with patients is: a. Listening b. Talking c. Action d. All of the above Question 2. It’s important that the front desk team communicate with the patient before the appointment to tell them: a. What time should they arrive. b. What needs to be done in advance of arriving. c. What they should bring with them on the day. d. What the cancellation and payment policies are. e. All of the above.

22 oral|hygiene

The concept of balance he concept of using prebiotic agents to support healthy commensals and thus achieve and maintain balance in the microbiome is well-established for the gut and is a tenet of modern gastroenterology.

The oral cavity is the start of the GI tract.

While it contains quite different organisms, the concepts of balance are equally relevant. Gut dysbiosis is known to lead to overgrowth of particular pathogenic bacteria or fungi. Using prebiotics to support

T

“Using prebiotics to support health-associated microorganisms provides a diverse microbiome that is more resistant to external influences, such as changes in diet and the use of broad-spectrum antibiotics...” health-associated microorganisms provides a diverse microbiome that, because of its diversity, is more resistant to external influences, such as changes in diet and the use of broad-spectrum antibiotics. The two classic examples of this are the antibiotic clindamycin creating a risk of overgrowth of Clostridium difficile, causing an enterocolitis and broad spectrum antibiotics causing a florid oral fungal overgrowth of Candida albicans. The latter organism is important for dental caries and the literature for the past decade has documented its role in dental caries. Having high oral levels of Candida species elevates the risk for caries by around two-fold.

In modern clinical practice, we do not need a microbiology laboratory to detect or diagnose dysbiosis in the dental plaque biofilm. We can identify that problem in real time using a clinical tool to assess dental plaque fermentation, namely GC TriPlaque ID Gel™. Thin young plaque binds only to the Rose Bengal red dye, while mature plaque binds and traps the dark blue dye. When the plaque biofilm generates acid by fermenting carbohydrate substrates, the red dye becomes clear and the dark blue dye changes colour to light blue/aquamarine. It provides a visual Stephan curve of the pH within the biofilm. This method can easily be used to track changes in individual patients over time, when areas are stained at follow-up visits. Such clinical tools can reveal how much the use of CPP-ACP in various delivery systems is changing the volume and metabolism of the dental plaque biofilm. Use of this particular tool is addressed under ADA item code 048.

Laboratory biofilm models o test prebiotic effects that support the growth of health-associated bacteria, it is necessary to use multispecies biofilm models. The first study of this type was conducted at the University of Queensland and published in 2019.12 Saliva-derived polymicrobial biofilms were grown for 96 hours in a cariogenic environment and treated every 12 hours with 2% CPP-ACP or vehicle control.

Microbial ecological effects of CPPACP were assessed based on the relative abundance of 14 specific caries- and health-associated -bacterial species.

In this complex biofilm model, CPP-

T

May/June 2021

Question 6. Having high oral levels of Candida species elevates the risk for caries by around: a. Two-fold. b. Three-fold. c. Four-fold. d. No change.

Question 7. With GC TriPlaque ID Gel™, thin young plaque appears: a. Dark blue b. Light blue/aquamarine c. Red d. Green

Question 3. The author’s favourite visual aid is:

Question 8. The combination of SnF2 and CPP-ACP inhibits enamel demineralisation by:

a. Computer programs b. Models c. Biofilm disclosing d. Charting e. Intraoral photos

a. 22% b. 57% c. 66% d. 72% e. 81%

Question 4. Good communication results in:

Question 9. CPP-ACP alters the composition of biofilm by suppressing levels of:

a. Loyal patients who attend. b. Increased patient satisfaction. c. Reduced complaints. d. Improved efficiency. e. All of the above.

Question 5. When clinicians communicate with patients, it is important to: a. Make eye contact. b. Introduce yourself. c. Listen to why the patient is there. d. Ask permission. e. All of the above.

a. Streptococcus sanguinis b. Streptococcus mitis c. Streptococcus salivarius d. Scardovia wiggsiae e. All of the above Question 10. CPP-ACP has been incorporated into: a. Fluoride Varnishes. b. Glass Ionomer Cements. c. Chewing Gum. d. Toothpaste. e. All of the above.

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/June 2021 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

infection | CONTROL

READ ME FOR

READ ME FOR

CPD

CPD

Face mask performance: Are you protected?

Four changes to infection prevention and control that made a difference

By John A. Molinari, PhD and Peri Nelson, BS

M

ask resistance to bacterial penetration was studied using an enclosed, specially fabricated 1.2m x 1m x 0.9m chamber around a dental chair (Figure 1). A mannequin head was mounted on a rod and fitted with a test mask before each experiment.

One investigator held the mannequin head in the chamber in front of a “patient” mannequin head (Dexter) with full dentition during testing. The indicator bacterial species used was Serratia marcescens. This is a Gram-negative bacillus that occurs naturally in soil and water and produces a red pigment at room temperature. It is associated with urinary and respiratory infections, endocarditis, osteomyelitis, septicaemia, wound infections, eye infections, and meningitis. A mixture of water-soluble red dye and S. marcescens was placed in the mannequin’s oral cavity. This fluid served as an analogue for the “patient’s saliva”.

The second mannequin head fitted with the worn face mask was mounted approximately 30 cm in front of the mouth of the “patient”. This masked head represented a dental clinician using a high-speed handpiece during treatment.

The mannequins were exposed to aerosolised preparations of the red dye/ bacteria mixture for periods of either 5, 15 or 30 minutes. To accomplish this, a dental water-driven high speed handpiece was run by an investigator in the mouth of the patient mannequin, touching teeth and

creating aerosolised spatter. The masked mannequin was positioned as a clinician would be during treatment, in order that airborne droplet spatter from the “patient’s mouth” would contact the test masks as per clinical procedures. Handpieces were run for 30-second intervals until total exposure times were reached.

Masks were subsequently removed from the mannequin heads and visually inspected for detection of red spatter on

the outside and inside portions of the mask. Sterile cotton swabs moistened in tryptic soy broth were also used to culture the outside and inside surfaces of the masks. Aerobic S. marcescens microbial growth was evaluated by culturing collected specimens onto tryptic soy agar plates at room temperature for 48-72 hours. Bacterial growth patterns were then observed for the experimental exposure intervals with each mask type tested.

The objectives of this study were to:

Assess how extended use of different levels of fluid-resistant mask affects microbial penetration;

u v

Evaluate the penetration resistance of Medicom Safe+ face masks during specific intervals to aerosolised “red” spatter (fluid resistance) and resistance to aerosolised mixtures of water-soluble red dye mixed with a representative bacterial species (bacterial filtration); and

A

t this time last year, we were all collectively reeling from the onset of the COVID-19 pandemic and dealing with the challenges of managing a new virus.

And, in the midst of an unprecedented shutdown that nearly ground dentistry to a complete halt for a month, practices pivoted on the fly to implement the Australian Dental Association’s advice on infection prevention and control transmission based precautions that would enable practices to work safely at different levels of restriction.

Compare the penetration effectiveness of the Medicom Safe+ masks to masks from other manufacturers with level 1, 2 or 3 fluid resistance (as per AS 4381) and to non-medical (domestic) disposable masks with no rating for resistance to fluid penetration.

w

28 oral|hygiene

The past year has not been easy, to say the least. But the good news is that the Herculean effort that dental professionals put in to improve infection prevention and control has paid off. In a recent study conducted by the American Dental Association (AmDA) and the American Dental Hygienist Association (ADHA), researchers found that only 3.1% of surveyed dental hygienists had ever tested positive or been diagnosed with COVID-19 as of October 2020, despite being a high-risk group.

Additionally, the development and distribution of effective vaccines has already had a positive impact on the industry, with Australian dental professionals receiving vaccinations at high rates.

Figure 1.

32 oral|hygiene

May/June 2021

Question 11. What colour pigment does Serratia marcescens produce at room temperature? a. Green b. Blue-Green c. Red d. Yellow Question 12. In the study, ASTM performance level 3 masks could resist fluid splatter for a maximum of at least: a. 5 minutes b. 15 minutes c. 30 minutes d. 45 minutes e. Indefinitely Question 13. In the study, ASTM performance level 2 masks could resist fluid splatter for a maximum of at least: a. 5 minutes b. 10 minutes c. 15 minutes d. 30 minutes Question 14. Masks used in dentistry should be certified to comply with Australian Standard: a. AS 4187:2014 b. AS 4381:2015 c. AS 4381:2002 d. AS 4031-1992 Question 15. A Level 3 mask provides protection again fluid pressure of up to:

May/June 2021

Question 16. In the Hierarchy of Controls, PPE is: a. The first line of defence for protecting staff. b. Ranks higher than implementing social distancing measures. c. More important than telephone screening of patients. d. The last line of defence for protecting staff.

Question 17. Improved aerosol management practices include: a. The universal use of antimicrobial mouthrinses prior to procedures. b. Proper use of high volume suction. c. Use of rubber dam. d. All of the above.

Question 18. A recent survey in the US found that: a. 1.7% of surveyed dentists had tested positive to COVID-19. b. No respondents had tested positive to COVID-19. c. 3.1% of surveyed dental hygienists had tested positive to COVID-19. d. 55% of responde had been vaccinated.

Question 19. HuFriedy Harmony™ Ergonomic Scalers and Curettes minimise strain, fatigue and risk of injury to clinicians by reducing the pinch force in clinicians’ hands and pressure needed on the tooth: a. True b. False Question 20. Aerosols can be reduced by: a. Using hand instrumentation. b. Using less water spray on ultrasonic scalers. c. Reducing water spray on air turbine drills. d. All of the above.

a. 80 mm Hg b. 120 mm Hg c. 140 mm Hg d. 160 mm Hg e. 180 mm Hg

To retrieve your FREE Dental Community Login:

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

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6

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The course will cover 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. Bring along your questions in writing or in person for one of the Q&A sessions that will be held during the day.

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FULL UPDATE! All the changes to Infection Control Guidelines in 2020

Professor Laurence Walsh AO is a clinically active specialist in special needs dentistry who is based at the University of Queensland in Brisbane. Laurie has been teaching infection control and clinical microbiology for over 25 years at postgraduate level and has been the chief examiner in microbiology for the RACDS for the past 20 years. He has presented invited courses and lectures on infection control across Australia and internationally. Laurie has written over 60 articles on infection control and in addition published over 320 journal papers and a further 190 technical reports and literature reviews. He serves on two committees of Standards Australia (personal protecting equipment; and instrument reprocessing) and in recent years has been an adviser to the Communicable Diseases Network of Australia and the Australian Commission on Safety and Quality in Health Care.

Laurie has been a member of the ADA Infection Control Committee since 1998. He has contributed to various protocols, guidelines and checklists and manuals used in Australia.

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abstracts | 2021

Oral Hygiene Abstracts 2021

By Prof. Emer. Laurence Walsh AO

COVID-19 transmission reduces with better air quality management

In recent months, more attention has been paid to airborne transmission of SARS-CoV-2 and methods to reduce that. Studies of COVID-19 transmission in US schools have provided insight into how well various control measures work. To meet the educational, physical, social, and emotional needs of children, many US schools opened for in-person learning during September 2020 by implementing strategies to prevent transmission of COVID-19. The number of new cases of COVID-19 was 37% lower in schools that required teachers and staff members to use masks and 39% lower in schools that improved ventilation. Ventilation strategies that were beneficial included dilution methods such as opening door and windows and using fans (35% lower incidence) or using HEPA filters with or without using UV light (48% lower incidence). Mask requirements for teachers and staff members and improved ventilation are important strategies in addition to vaccination of teachers and staff members that schools could implement as part of a multicomponent approach to provide safer, in-person learning environments. Many of these principles will be relevant to other settings.

Gettings J et al. Mask use and ventilation Improvements to reduce COVID-19 incidence in elementary schools - Georgia, November 16 - December 11, 2020. Morbidity and Mortality Weekly Report 2021; 70: May 21

Gender and genetic background factors in COVID-19

There is an urgent need to understand the molecular determinants of SARS-CoV-2 infection, factors associated with COVID-19 heterogeneity and severity and therapeutic options for infected patients. The angiotensin converting enzyme 2 (ACE2) is a key host factor for viral entry, through binding of the viral spike protein, which permits viral entry, while proteolytic cleavage by host proteases, such as plasma membrane-associated type II transmembrane serine protease (TMPRSS2), mediates membrane fusion and release of the viral RNA into human cells. TMPRSS2 is essential for the establishment of airway infection. Patterns of ACE2 expression correlate with susceptibility to infection. Lower nasal epithelial ACE2 expression reported in children has been suggested to explain the milder disease observed in this population. In the lungs, surfactant-producing alveolar type 2 (AT2) cells are targeted by the virus. These AT2 cells may thus represent a potential viral reservoir for replication, or alternatively undergo viral-induced cell death to initiate lung barrier damage and inflammation. ACE2 may be linked with oestrogen receptor responses. There is stronger overall ACE2 and TMPRSS2 lung expression in males than females, which links with more severe COVID-19 disease at presentation, higher intensive care unit admission rates and higher case fatality rates. High ACE2 and TMPRSS2 levels in the elderly may contribute to increased viral infection rates. Human variants of ACE2 could alter the protein interface with the SARS-CoV-2 spike protein. Other important host factors involved in viral–host interactions, viral protein processing and immune function also contribute to severity. Understanding how regulation of host factor genes varies in physiological and pathological states might explain the heterogeneity observed in SARS-CoV-2 infection, help identify pathways for therapeutic development and identify patients most likely to progress to severe COVID-19.

Ong SYQ et al. From bedside to bench: regulation of host factors in SARS-CoV-2 infection. Exp Mol Med. 2021 Apr;53(4):483-494.

Are periodontal pockets a potential reservoir for SARS-CoV-2?

Many recent studies have explored interactions between periodontal health and COVID-19. Since the mid-1990s, viruses have been detected at higher levels in periodontitis sites than health sites, such as Epstein-Barr virus type 1 (43% vs 18%); while Herpes simplex virus and cytomegalovirus have been found in periodontal pockets (26-78% and 42-58%, respectively). Shot-gun DNA sequencing studies of subgingival plaque collected from periodontal disease patients have showed over 95% contained viruses. The initial viral infection of periodontal tissues could start either from direct infection coming from the mouth via saliva or from infected immune cells. The continuous inflammatory response present in affected sites of periodontal disease could bring mononuclear cells infected with the virus. ACE2, the main receptor for SARS-CoV2 entry into human cells, is present not only in the airway and lungs, but also in oral epithelial cells, nasopharyngeal mucosa and salivary glands. This results in high viral load in the oral cavity (in saliva and crevicular fluid), which reinforces the need in dental practices to use antimicrobial preprocedural rinses.

Bertolini M et al. Periodontal disease in the COVID-19 era: potential reservoir and increased risk for SARS–CoV-2.

Pesquisa Brasileira em Odontopediatria e Clínica Integrada 2020; 20(supp1):e0134.

20 oral|hygiene

May/June 2021

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clinical | EXCELLENCE

READ ME FOR

CPD

Contemporary uses of CPP-ACP technologies in 2021 Part 2. Prebiotic actions

By Emeritus Professor Laurence J. Walsh AO

T

his article, the second in the series, discusses current concepts for the use of casein phosphopeptide-amorphous calcium phosphate (CPP-ACP) technologies in their role as a prebiotic agent that can modulate the behaviour of dental plaque biofilms.

Beyond mutans streptococci he concept of beneficial influences of topical CPP-ACP on dental plaque volume, composition and metabolism has been building steadily over the past decade,1,2 however the foundations for this area of research were laid over 20 years ago in work around effects on the binding of bacteria to dental hard tissues and to salivary pellicle. Today it is recognized that such effects contribute to caries prevention in settings such as patients with fixed orthodontic appliances.

When topical forms of CPP-ACP, such as GC Tooth Mousse™ (TM) and Tooth Mousse Plus™ (TMP) are used, plaque levels around brackets are reduced.3 By 2013, it had become apparent that daily use of TM in infants and young children could drive a dramatic reduction in their levels of mutans streptococci.4,5 This provided a further rationale for topical use of CPP-ACP beyond its well known roles in remineralisation.6-8 This concept has matured to now incorporate the concept of CPP-ACP being a prebiotic agent, that supports the growth of those health-associated commensal bacteria that constrain the growth of cariogenic microorganisms.9-11

T

22 oral|hygiene

The concept of balance he concept of using prebiotic agents to support healthy commensals and thus achieve and maintain balance in the microbiome is well-established for the gut and is a tenet of modern gastroenterology.

The oral cavity is the start of the GI tract.

While it contains quite different organisms, the concepts of balance are equally relevant. Gut dysbiosis is known to lead to overgrowth of particular pathogenic bacteria or fungi. Using prebiotics to support

T

“Using prebiotics to support health-associated microorganisms provides a diverse microbiome that is more resistant to external influences, such as changes in diet and the use of broad-spectrum antibiotics...” health-associated microorganisms provides a diverse microbiome that, because of its diversity, is more resistant to external influences, such as changes in diet and the use of broad-spectrum antibiotics. The two classic examples of this are the antibiotic clindamycin creating a risk of overgrowth of Clostridium difficile, causing an enterocolitis and broad spectrum antibiotics causing a florid oral fungal overgrowth of Candida albicans. The latter organism is important for dental caries and the literature for the past decade has documented its role in dental caries. Having high oral levels of Candida species elevates the risk for caries by around two-fold.

In modern clinical practice, we do not need a microbiology laboratory to detect or diagnose dysbiosis in the dental plaque biofilm. We can identify that problem in real time using a clinical tool to assess dental plaque fermentation, namely GC TriPlaque ID Gel™. Thin young plaque binds only to the Rose Bengal red dye, while mature plaque binds and traps the dark blue dye. When the plaque biofilm generates acid by fermenting carbohydrate substrates, the red dye becomes clear and the dark blue dye changes colour to light blue/aquamarine. It provides a visual Stephan curve of the pH within the biofilm. This method can easily be used to track changes in individual patients over time, when areas are stained at follow-up visits. Such clinical tools can reveal how much the use of CPP-ACP in various delivery systems is changing the volume and metabolism of the dental plaque biofilm. Use of this particular tool is addressed under ADA item code 048.

Laboratory biofilm models o test prebiotic effects that support the growth of health-associated bacteria, it is necessary to use multispecies biofilm models. The first study of this type was conducted at the University of Queensland and published in 2019.12 Saliva-derived polymicrobial biofilms were grown for 96 hours in a cariogenic environment and treated every 12 hours with 2% CPP-ACP or vehicle control.

Microbial ecological effects of CPPACP were assessed based on the relative abundance of 14 specific caries- and health-associated -bacterial species.

In this complex biofilm model, CPP-

T

May/June 2021

clinical | EXCELLENCE

Figure 1. GC Tooth Mousse.

ACP reduced the biofilm virulence (its disease-causing ability) as well as its biovolume. When the biofilm was exposed to sucrose, lactic acid production was reduced. CPP-ACP altered the composition of the biofilm. It suppressed levels of mutans streptococci and other cariogenic bacteria such as Scardovia wiggsiae.

CPP-ACP enriched health-associated bacteria. There were higher bacterial loads of commensals such as Streptococcus sanguinis (fold change 30.22), S. mitis (fold change 9.66), and S. salivarius (fold change 89.35).12 The elevation in levels of health-associated Streptococci is critical as these bacteria are involved in regulating the pH of the plaque biofilm, particularly through the arginine deaminase system (ADS). This metabolises arginine and produces ammonia, which elevates the pH to keep it around neutral.

This neutral pH discourages the growth of acid tolerant (aciduric) bacteria and fungi. By these pathways, CPP-ACP attenuates the virulence of the biofilm and promotes a beneficial microbial ecological change in the plaque biofilm.

A subsequent study at the University of Melbourne, also published in 2019, showed using a polymicrobial biofilm model that CPP-ACP could modify plaque composition.13 This followed on from earlier work published by the same team in 201614 which showed that CPPACP impaired biofilm formation by S. mutans on glass ionomer cement and moreover that it disrupted established biofilms of S. mutans. The 2019 study

May/June 2021

used a biofilm model of caries with 6 bacterial species that were grown on sound human enamel. The biofilm was exposed to sucrose 4 times each day to provide a cariogenic challenge. Twicedaily addition of either CPP-ACP or stannous fluoride (SnF2) reduced demineralisation by 50%. While SnF2 had only a slight effect on the composition

of the polymicrobial biofilm, CPP-ACP had strong prebiotic actions, suppressing the levels of Actinomyces naeslundii and Lactobacillus casei and increasing the level of S. sanguinis in the biofilm.

The combination of SnF2 and CPP-ACP resulted in a greater suppression of the acidogenic and aciduric bacteria and an impressive 72% inhibition of enamel demineralisation. When used together, the SnF2 and CPP-ACP interact with one another to form a nanofilament coating on the tooth surface. By cross-linking the CPP-ACP, the stannous ion helps to stabilise the nanocomplexes. This improves their binding to the tooth surface and the delivery of ions for remineralisation.15

Clinical trials of self-administered products 2019 clinical trial conducted at the University of Melbourne tested the prebiotic actions of CPP-ACP delivered using a sugar-free chewing gum.16 A total of 19 participants were involved in a threeleg cross-over, randomised, controlled

A

Figure 2. GC TriPlaque ID Gel assesses dental plaque fermentation. clinical trial. Subjects chewed a sugar-free gum with or without added CPP-ACP six times daily for 20 minutes over two weeks. Supragingival plaque was collected and analysed for bacterial composition. As was seen in the two biofilm studies in the laboratory in this clinical trial, CPP-ACP elevated levels of S. sanguinis and S. mitis when compared with the no gum intervention. All the species that were enhanced

by CPP-ACP treatment possessed either arginine deiminase, which was discussed earlier, or nitrate reductase, which is another alkali-producing enzyme system.

oral|hygiene

23

clinical | EXCELLENCE Overall, this clinical study revealed strong prebiotic effects from the CPPACP when it was delivered using a chewing gum, with increased proportions of health-associated bacterial species in the supragingival dental plaque biofilm.

Another randomised controlled clinical trial was conducted at the University of Queensland during 2018 and this was published in 2020.17 This study used CPPACP delivered in a fluoride toothpaste.

The bacterial loads of 14 key bacterial species (8 caries associated and 6 health associated) in the dental plaque of participants were measured using real-time quantitative polymerase chain reaction (PCR) analysis. It showed beneficial microbial ecological effects over 6 weeks of product use, compared with a toothpaste that was identical but lacked the CPP-ACP ingredient. Compared to the fluoride control dentifrice, the CPP-ACP dentifrice demonstrated suppression of S. mutans and elevation of S. sanguinis.

Taken together, these two clinical trials show that common delivery methods (i.e. chewing gum and fluoride toothpaste) are suitable for delivering CPP-ACP. These can drive species-level shifts in the ecology of the microbiome, resulting in a biofilm microbial community that is associated with health, rather than with dental caries.

Additional recent evidence for changes in microbial composition can be seen in studies of high caries risk children that were conducted in Jordan. GC Tooth Mousse was used as a toothpaste, or in conjunction with a 500 ppm fluoride toothpaste, versus the fluoride toothpaste alone. Paediatric dentists supervised all the school-based brushing sessions. The subjects were 4-5 year old children and all had at least one WSL or cavity on their primary anterior teeth. Changes in lesions were tracked using quantitative light fluorescence, comparing the baseline to the situation after 3 and 6 months of treatment. There was mineral gain and a reduction in lesion size in all three groups, for baseline versus 3 months or 6 months. Using TM alone was just as effective as using the F dentifrice.18 When levels of S. mutans in the saliva were assessed, the greatest reduction in S. mutans levels occurred in the children using CPP-ACP, either with TM alone or when TM was combined with the fluoride toothpaste.19 These results reinforce earlier findings that CPP-ACP when used

24 oral|hygiene

on a daily basis in the form of TM drives a reduction in the load of S. mutans in plaque in children and in teenage orthodontic patients.5,20 Ideally, for daily use, a properly designed dentifrice (toothpaste) should be used. A CPP-ACP dentifrice has been developed with the same level of CPP-ACP (10% w/w) as TM and TMP and this product (MI Paste One™) is available in North America. As well as delivering exactly the same calcium and phosphate ions as TM, this dentifrice has unusually high fluoride bioavailability. A 2021 study of bioavailable fluoride in 6 commercial F toothpastes containing different types of calcium and

“Over the past 20 years, a cohesive story has emerged that CPP-ACP is an effective prebiotic agent. These beneficial effects have been seen with many delivery systems and the effects are similar, regardless of the delivery system that has been used. The choice of delivery system relates to the patient’s clinical need and their likely compliance with selfperformed measures...” fluoride revealed that those with calcium carbonate generated poorly soluble fluoride phases and so had lower levels of available F (27% to 61%). In contrast, the CPP-ACP toothpaste had 97% of the fluoride in a bioavailable form.21 This reflects the ability of the CPP component to stabilise fluoride and calcium.

Reducing the need for compliance: Clinical trials of varnish and GIC n terms of compliance, using a varnish to deliver CPP-ACP removes the need for patients to use a particular chewing gum, crème or toothpaste every day.

There is now evidence that frequent applications of CPP-ACP in a fluoride varnish (GC MI Varnish™) also provides prebiotic actions. A recent study conducted in Indonesia tracked changes

I

in the plaque microbiome in children with caries who received CPP-ACP/F varnish weekly for 4 weeks. The treatment modulated the dysbiotic cariogenic microbiome, moving this towards a healthier community with more healthassociated protective species.22 This finding adds to the results of other recent studies that show that the same protocol applying the CPP-ACP/F varnish weekly for 4 weeks gives a useful reduction in levels of S. mutans in most individuals (average reduction of 172 fold, which is a log reduction of 2.237).23 This beneficial effect adds to the ability of this same CPP-ACP/F varnish to exert useful chemical actions, including the ability to recharge ion-leaching restorative materials and thus add to their reservoir for re-release of ions such as fluoride.24 Another method for sustained delivery of CPP-ACP which resolves compliance issues is to incorporate the CPP-ACP into a glass ionomer. Fuji VII-EP™ (also known in some markets as Fuji TriageEP™ has CPP-ACP (5% w/w) distributed through the GIC matrix, providing release of calcium and phosphate ions as well as fluoride ions.25 The released calcium and fluoride ions reduce acid production by the biofilm. As well as causing a useful (39%) reduction in bacterial biofilm volume, the inclusion of CPP-ACP into GIC also lowers the cariogenicity of the plaque biofilm on the GIC restoration surface and around its margins, driving lower levels of S. mutans, and higher levels of S. gordonii, a key health-associated bacterial species.26

Conclusions ver the past 20 years, a cohesive story has emerged that CPP-ACP is an effective prebiotic agent. These beneficial effects have been seen with many delivery systems (topical crème, toothpaste, chewing gum and GIC) and the effects are similar, regardless of the delivery system that has been used. The choice of delivery system relates to the patient’s clinical need and their likely compliance with self-performed measures.

For patients with compliance concerns, varnishes and GIC are suitable sustained delivery systems. These differ in that varnishes are a short-term measure, while a GIC is a permanent restoration and its CPP-ACP loading can be recharged by topical application of CPP-ACP.

O

May/June 2021

clinical | EXCELLENCE Since CPP-ACP fosters a healthassociated oral microbiome, CPP-ACP provides a valuable long term strategy for maintaining a healthy oral biofilm. Fostering health-associated bacteria exploits the point that these bacteria are the natural antagonists of cariogenic aciduric microorganisms. It is highly desirable to have elevated levels of health-associated bacteria, including S. sanguinis and S. gordonii and to maintain that situation across the lifespan. Adding to this, it is clear that the long term use of CPP-ACP can influence dental patient’s awareness of their oral health. Qualitative research work has shown that long term at-home use of a topical CPP-ACP product such as TMP is more complex than a dental patient simply being compliant with advice they have received from a dental professional. For adhering to a new oral hygiene routine that included daily self applications of TMP, patients were found to take on an active and independent role in their oral health care. They understood the significance of applying TMP daily.

Hence, rather than being passive recipients of advice, they took control of their oral hygiene care and this gave them positive outcomes as they began to experience the results, with a more comfortable mouth and teeth that were now less vulnerable to destruction. In other words, the positive changes in oral health experienced by patients that were driven by the chemical and microbial effects of the TMP were accompanied by empowerment.27 This creates a virtuous feedback loop, encouraging sustained changes in oral care behaviours over time, to maintain oral health.

A final point of reflection is that, when considered over the long term, the biological effects of CPP-ACP (as a prebiotic) may well be equally as important as its chemical effects (through remineralisation). Combining both actions explains why, in high risk situations such as fixed orthodontic appliance therapy, daily use of CPP-ACP can both prevent caries occurring and help reverse its actions on the enamel.3 Fortunately, we are now in the position of having both the diagnostic tools to identify, track and monitor the problem of biofilm dysbiosis and an effective solution, in the form of CPP-ACP as a prebiotic, plus changes to diet and lifestyle. The challenge for clinicians is to choose from the available approaches that which matches the patient’s clinical need and then to titrate the interventions as required.

May/June 2021

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 330 journal papers, with a citation count of over 15,400 citations in the literature. Laurie holds patents in 7 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.

References 1. Walsh LJ. Topical CPP-ACP crèmes: beyond caries prevention. Internat Dent. 2014;9(4):48-58.

2. Walsh LJ. Molecular and pharmaceutical aspects of novel methods and materials for the prevention of tooth structure loss. Curr Pharm Biotechnol. 2017, 18(1): 45-51.

3. Mounir Bakdach WM & Hadad R. Effectiveness of different adjunctive interventions in the management of orthodontically induced white spot lesions: A systematic review of systematic reviews and meta-analyses. Review Dent Med Probl.

2020;57(3):305-325.

4. Plonka K et al. A randomized controlled clinical trial comparing a remineralizing paste with an antibacterial gel to prevent early childhood caries. Pediatr Dent. 2013;35(1):8-12.

5. Pukallus ML et al. A randomized controlled trial of a 10 percent CPP-ACP cream to reduce mutans streptococci colonization. Pediatr Dent. 2013; 35(7): 550-555.

6. Walsh LJ. Altering dental plaque biofilm ecology using CPP-ACP. Auxiliary 2014; 24(5):22-24.

7. Walsh LJ. Expanding applications for CPP-ACP technology: lessons from across the globe. Australas Dent Pract. 2014; 25(5):62-66.

8. Philip N. State of the art enamel remineralization systems: the next frontier in caries management.

Caries Res. 2019;53(3):284-295.

9. Philip N et al. Ecological approaches to dental caries prevention: paradigm shift or shibboleth? Caries Res. 2018;52:153-165.

10. Philip N, Walsh LJ. Beyond Streptococcus mutans: Clinical implications of the evolving dental caries aetiological paradigms and its associated microbiome. Brit Dent J. 2018. 224(4):219-225.

11. Philip NV, Walsh LJ. The potential ecological effects of casein phosphopeptide-amorphous calcium phosphate in dental caries prevention. Aust Dent J. 2019;64(1):66-71.

12. Philip N et al. Casein phosphopeptide-amorphous calcium phosphate attenuates virulence and modulates microbial ecology of saliva-derived polymicrobial biofilms. Caries Res. 2019;53(6):643-649.

13. Dashper SG et al. CPP-ACP promotes SnF2 efficacy in a polymicrobial caries model. J Dent Res. 2019;98(2):218-224.

14. Dashper SG et al. Casein phosphopeptide-amorphous calcium phosphate reduces Streptococcus mutans biofilm development on glass ionomer cement and disrupts established biofilms. PLoS One. 2016;11(9):e0162322.

15. Fernando JR et al. Self-assembly of dental surface nanofilaments and remineralisation by SnF 2 and CPP-ACP nanocomplexes. Sci Rep. 2019;9(1):1285.

16. Fernando JR et al. The prebiotic effect of CPP-ACP sugar-free chewing gum. J Dent. 2019;91:103225.

17. Philip N et al. Randomized controlled study to evaluate microbial ecological effects of CPP-ACP and cranberry on dental plaque. JDR Clin Trans Res. 2020;5(2):118-126.

18. Al-Batayneh OB et al. Assessment of the effects of a fluoride dentifrice and GC Tooth Mousse on early caries lesions in primary anterior teeth using quantitative light-induced fluorescence: a randomised clinical trial. Eur Arch Paediatr Dent. 2020;21(1):85-93.

19. Al-Batayneh OB et al. Effect of CPP-ACP on Streptococcus mutans in saliva of high caries-risk preschool children: a randomized clinical trial. Randomized Controlled Trial Eur Arch Paediatr Dent.

2020;21(3):339-346.

20. Shen P, et al. Bioavailable fluoride in calciumcontaining dentifrices. Sci Rep. 2021;11(1):146.

21. Sharda S et al. Remineralization potential and caries preventive efficacy of CPP-ACP/Xylitol/ Ozone/Bioactive glass and topical fluoride combined therapy versus fluoride mono-therapy - a systematic review and meta-analysis. Acta Odontol Scand. 2021.

Jan 16;1-16.

22. Widyarman AS et al. Casein phosphopeptideamorphous calcium phosphate fluoride treatment enriches the symbiotic dental plaque microbiome in children. J Dent. 2021;106:103582.

23. Apriani A et al. Caries activity and ph level changes after fluoride varnish and casein phosphopeptides-amorphous calcium phosphate application on children’s saliva. Contemp Clin Dent. 2020;11(2): 126-130.

24. Ruengrungsom C et al. Evaluation of F, Ca, and P release and microhardness of eleven ion-leaching restorative materials and the recharge efficacy using a new Ca/P containing fluoride varnish. J Dent. 2020; 102:103474.

25. Mazzaoui SA et al. Incorporation of casein phosphopeptide-amorphous calcium phosphate into a glass-ionomer cement. J Dent Res. 2003;82(11):914-8.

26. Mao B et al. Casein phosphopeptide-amorphous calcium phosphate modified glass ionomer cement attenuates demineralization and modulates biofilm composition in dental caries. Dent Mater J. 2021;40(1):84-93.

27. Sbaraini A et al. Experiences of oral health: before, during and after becoming a regular user of GC Tooth Mousse Plus®. BMC Oral Health 2021;21:14.

oral|hygiene

25

The

to working with only high-quality patients Do you feel like you are on an endless hamster wheel, just trying to keep your practice growing in the face of increasing competition?

You provide an amazing service, but despite your all your efforts and good intentions, your day is a constant struggle to find high-quality patients, set yourself apart from the competition, and boost your production.

As if that weren’t enough, you’re competing against corporates and dealing with patients who seem to care about only one thing…

PRICE. A day in dentistry should be enjoyed not endured - yet, if you don’t learn these secrets, that’s exactly what you can expect more and more of . . . enduring your days away.

Imagine a day where every patient you see:

 regards you as a highly valued healthcare

professional, rather than just an expensive hassle

 is willing and open to accept your

recommendations for ethical treatment plans

 is a walking billboard for your practice, inviting friends and colleagues to become patients.

In this game changing masterclass, you will walk away with a complete understanding of where you have been going wrong, and the three instantly implementable strategies to turn it all around.

What you get Drawing from over 10,000 hours of consulting dentists all over Australia and internationally, multi-award-winning Practice Growth Specialist, Angus Pryor reveals his tried and tested high-quality patient blueprint.

This is his signature A-Z system, proven to propel even the most unprofitable dental practice into unstoppable momentum and growth. You will leave this LIVE event feeling a renewed excitement for your practice – but most important, with a reliable plan of success based on three simple steps: In this action-packed LIVE event, you’ll discover:

 what you are inadvertently doing to attract terrible clients  how your practice is failing the dental equivalent of dressing for success  why even if you could flick the switch, you’re not ready for great patients (yet).

BONUS: attend the live event and receive a FREE 6-pack of social media posts to promote you as a high quality practice Enjoy drinks and canapes from 6.30pm onwards. The presentation starts at 7pm.

Event details

Who is this for?

This LIVE event is perfect for dental practice owners, dental associates and practice managers not happy with the status quo but looking for the fast-track to a steady flow of high quality patients.

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Mon 19 Jul 21, 6.30pm-9.00pm, central location (details TBC)

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Key takeaways

 discover your pool of motivated, high-quality patients

Sydney Wed 21 Jul 21, 6.30pm-9.00pm, central location (details TBC)

 finally differentiate yourself and put an end to competing on price  understand why you can’t (and shouldn’t be) everything to everyone

Melbourne

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 achieve a new outlook on attracting patients to your practice

Brisbane Mon 26 Jul 21, 6.30pm-9.00pm, central location (details TBC)

About Angus Australia’s number one Google-ranked dental marketer recipient of the 2020 marketing award from the Australian Dental Industry Association

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REGISTER NOW Visit www.HighQualityPatients.com.au to secure your spot.

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infection | CONTROL

READ ME FOR

CPD

Face mask performance: Are you protected?

By John A. Molinari, PhD and Peri Nelson, BS

M

ask resistance to bacterial penetration was studied using an enclosed, specially fabricated 1.2m x 1m x 0.9m chamber around a dental chair (Figure 1). A mannequin head was mounted on a rod and fitted with a test mask before each experiment.

One investigator held the mannequin head in the chamber in front of a “patient” mannequin head (Dexter) with full dentition during testing. The indicator bacterial species used was Serratia marcescens. This is a Gram-negative bacillus that occurs naturally in soil and water and produces a red pigment at room temperature. It is associated with urinary and respiratory infections, endocarditis, osteomyelitis, septicaemia, wound infections, eye infections, and meningitis. A mixture of water-soluble red dye and S. marcescens was placed in the mannequin’s oral cavity. This fluid served as an analogue for the “patient’s saliva”.

The second mannequin head fitted with the worn face mask was mounted approximately 30 cm in front of the mouth of the “patient”. This masked head represented a dental clinician using a high-speed handpiece during treatment.

The mannequins were exposed to aerosolised preparations of the red dye/ bacteria mixture for periods of either 5, 15 or 30 minutes. To accomplish this, a dental water-driven high speed handpiece was run by an investigator in the mouth of the patient mannequin, touching teeth and

28 oral|hygiene

creating aerosolised spatter. The masked mannequin was positioned as a clinician would be during treatment, in order that airborne droplet spatter from the “patient’s mouth” would contact the test masks as per clinical procedures. Handpieces were run for 30-second intervals until total exposure times were reached.

Masks were subsequently removed from the mannequin heads and visually inspected for detection of red spatter on

the outside and inside portions of the mask. Sterile cotton swabs moistened in tryptic soy broth were also used to culture the outside and inside surfaces of the masks. Aerobic S. marcescens microbial growth was evaluated by culturing collected specimens onto tryptic soy agar plates at room temperature for 48-72 hours. Bacterial growth patterns were then observed for the experimental exposure intervals with each mask type tested.

The objectives of this study were to:

Assess how extended use of different levels of fluid-resistant mask affects microbial penetration;

u v

Evaluate the penetration resistance of Medicom Safe+ face masks during specific intervals to aerosolised “red” spatter (fluid resistance) and resistance to aerosolised mixtures of water-soluble red dye mixed with a representative bacterial species (bacterial filtration); and

Compare the penetration effectiveness of the Medicom Safe+ masks to masks from other manufacturers with level 1, 2 or 3 fluid resistance (as per AS 4381) and to non-medical (domestic) disposable masks with no rating for resistance to fluid penetration.

w

Figure 1.

May/June 2021

infection | CONTROL After 5 minutes of splatter/aerosol exposure Non-ASTM performance

Figure 2. Non-rated mask performance.

ASTM performance level 1

Figure 3. Fluid resistance level 1. The rated masks provides superior protection over a non-rated masks.

After 15 minutes of splatter/aerosol exposure ASTM performance level 1

Figure 4. Fluid resistance level 1. Note the presence of dye after 15 minutes of aerosol exposure.

ASTM performance level 2

Figure 5. Fluid resistance level 2. Note absence of dye penetration. Level 2 provides superior protection compared to level 1.

After 30 minutes of splatter/aerosol exposure ASTM performance level 3 Results: Red Dye Penetration Studies bservation of exposed masks showed that, in general, the higher fluid resistance (Level 3) Medicom Premier Elite Mask was able to resist red dye penetration better than Level 1 and Level 2 masks after 15-minute exposure times.

Red dye was seen on the inside surfaces of both low level performance masks by the end of the 15-minute intervals. Most of the Level 1 and Level 2 masks showed evidence of dye penetration by the 15-minute test interval. However, the inside portion of the Level 2 Medicom Premier Plus Mask demonstrated little, if any, red colour after treatment.

O

May/June 2021

Figure 6. Fluid resistance level 3. Even after 30 minutes, only a single spot of dye on the inside was noted. Medicom level 3 masks were superior to level 1 masks for procedures with high splatter/aerosol exposure.

oral|hygiene

29

www.medicom-australia.com

infection | CONTROL

www.medicom-australia.com Bacterial Challenge Studies

A summary of the bacterial challenge results is shown inwww.medicom-australia.com Table 1.

www.medicom-australia.com Table 1. Bacterial Penetration Results Following Mask Challenge with S. marscescens* Mask

Fluid resistance 5 minutes 15 minutes

Moulded Face Mask, Alt. brand 1 —

Fail Fail

Procedure Mask, Alt. brand 2 —

Fail Fail

Procedure Mask, Alt. brand 3 1

Fail Fail

Procedure Mask, Alt. brand 4

1

Pass Fail

Procedure Mask, Alt. brand 5

2

Pass Fail*

Premier Mask, Medicom

1

Pass Fail

Premier Plus Mask, Medicom

2

Pass Fail

Premier Elite Mask, Medicom

3

Pass Pass

*Pass = no bacterial growth, failed = bacterial growth

30 YEARS OF PRIDE EMPOWERING

failed the 15-minute bacterial challenges.

The Medicom Premier Plus and an alternative brand Level 2 masks demonstrated Bacterial Penetration Studies more resistance to microbial penetration, as only a few Serratia colonies were acterial cultures from the outer surdetected on the mask inside surfaces. faces of all of the masks tested were In contrast, the only masks shown to found to be heavily contaminated with S. completely resist S. marscescens penmarscescens after 5-, 15-, and 30-minute etration at 15-minutes was the Level 3 aerosol generating procedures. When Medicom Premier Elite Mask. It should be the inside mask material was sampled, noted here that a 30-minute bacterial chalresultant bacterial cultures showed that Medicom face masks manufactured state-of-the-art lenge also on no bacterial growth on the inner surfaces of the twoare non-rated Medicom is dedicated to revealed designing and the inside surface of designs this Level 3 mask. mask types in (Molded Face Mask and machinery ourproducing own factories.

Our innovative a wide range of personal and Mask) and the Level 1 fluid resistant premium materials ensure that Medicom masks provide equipment to face foster a safe, Conclusions mask demonstratedprotection bacterial penetration comfortable and efficient environment for and reliable protection, as well as exceptional breathability after the 5-minute exposure intervals. dental professionals to perform their his investigation studied the ability None of the other masks used in this comfort, even for those with sensitive skin or who feel everydaySerratia work. Your ofpatients trust face themasks to different available study showed red-pigmented claustrophobic in ordinary masks. Produced to the highest professional, and so can you.penetration by a water-soluble prevent penetration at that interval. standard complying with AS4381:2015 and registered with red dye and aerosolised suspensions As expected, the inside surface cultures of bacteria.

Airborne challenges to test from all of the Level 1 masks tested also TGA. Trust Mediicom masks to keep you safe.

Results:

masks were conducted using a high-speed handpiece for 5-, 15- and 30-minute intervals. The findings demonstrated that each of the non-rated masks and Level 1 masks failed both the red dye bacterial penetration test much more quickly than masks with Level 2 or level 3 splash resistance. While the two Level 2 masks were shown to allow only small numbers of red-pigmented S.marscesens through to the inside of the mask after 15-minutes Free samples exposure, the Medicom Premier Eliteavailable.

Simply scan code Free samples available. masks (Level 3) were able to prevent all and let us know what Simply scan code and let us detectable bacteria to penetrate for up to you are interested in.are know what you 30-minute challenge intervals.

Both the dye penetration and bacterial penetrainterested in. tion tests demonstrate that AS 4381 rated masks are significantly more protective than non-rated masks. Furthermore, level 3 masks outperform level 1 or level 2 when exposed for 15-30 minutes.

THE PROFESSIONALS WITHTRUST PRODUCING MASKS YOU CAN B THE PROFESSIONAL PRODUCTS

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Contact us at email: cs@medicom-australia.com | Phone: 1300 818 168 or visit www.medicom-australia.com

30 oral|hygiene

May/June 2021

www.medicom-australia.com www.medicom-australia.com

www.medicom-australia.com www.medicom-australia.com

30 YEARS OF PRIDE EMPOWERING THE PROFESSIONALS WITHTRUST PRODUCING MASKS YOU CAN THE PROFESSIONAL PRODUCTS

Medicom face masks are manufactured on state-of-the-art Medicom is dedicated to designing and machinery in ourproducing own factories.

Our range innovative designs and a wide of personal premium materials ensure that Medicom provide protection equipment to face fostermasks a safe, comfortable andexceptional efficient environment for and reliable protection, as well as breathability dental professionals to perform their comfort, even for those with sensitive skin or who feel everyday work. Your patients trust the claustrophobic in ordinary masks. Produced to the highest professional, and so can you. standard complying with AS4381:2015 and registered with TGA. Trust Medicom masks to keep you safe.

Safe+Mask® Premier Plus Earloop Masks 203515

SafeBasics™ Easy Fit Latex Powder Free Gloves 1188

SafeSeal® | Quattro Sterilisation Pouches 88000

Scan the QR code to

receive a FREE BOX Free samples available. of AS4381:2015 Simply scan code and let us Level 2 Mask know what you are interested in.

*1175 SafeTouch Slim Blue Nitrile PF Glove

*1266 Dental Dam

contact us at email: cs@medicom-australia.com Ph: 1300 818 168 or visit www.medicom-australia.com

Contact us at email: cs@medicom-australia.com | Phone: 1300 818 168 or visit www.medicom-australia.com 28052021-DN-AD-009-MAU V1

infection | CONTROL

READ ME FOR

CPD

Four changes to infection prevention and control that made a difference

A

t this time last year, we were all collectively reeling from the onset of the COVID-19 pandemic and dealing with the challenges of managing a new virus.

And, in the midst of an unprecedented shutdown that nearly ground dentistry to a complete halt for a month, practices pivoted on the fly to implement the Australian Dental Association’s advice on infection prevention and control transmission based precautions that would enable practices to work safely at different levels of restriction.

The past year has not been easy, to say the least. But the good news is that the Herculean effort that dental professionals put in to improve infection prevention and control has paid off. In a recent study conducted by the American Dental Association (AmDA) and the American Dental Hygienist Association (ADHA), researchers found that only 3.1% of surveyed dental hygienists had ever tested positive or been diagnosed with COVID-19 as of October 2020, despite being a high-risk group.

Additionally, the development and distribution of effective vaccines has already had a positive impact on the industry, with Australian dental professionals receiving vaccinations at high rates.

32 oral|hygiene

May/June 2021

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Learn How to Scale in Perfect Harmony at Hu-Friedy.com/Harmony Hu-Friedy.com/H Hu-Friedy.com/Harmony

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infection | CONTROL As infection rates among dentists and hygienists remain low and vaccination rates continue to rise, we may be turning a corner with the virus. But, if there is one lasting lesson from the last year, it’s that the risk of new infections is ever-present and infection prevention and control will remain a critical issue indefinitely.

Dental professionals have gone above-and-beyond to address infection risks and keep their practices safe. Here are four critical changes that practices made (and should continue to make) in order to keep up the good work:

to clinicians by reducing the pinch force in clinicians’ hands and pressure needed on the tooth, which may alleviate conditions caused by repetitive motions.

3. Better engineering and administrative controls n the Hierarchy of Controls, PPE is actually the last line of defence for protecting staff. Before PPE comes engineering and administrative controls (in addition to elimination and substitution strategies), which dental professionals successfully implemented in their practice. This included actions like re-arranging the waiting room to ensure the ability to physical distance patients and removing unnecessary and high touch items like magazines.

Practices have also successfully implemented new check-in procedures to limit the number of patients in the waiting room at any given time. Additionally, pre-appointment telephone screening and triage protocols, as described by the Australian Dental Association, have helped ensure that potentially unwell or infected patients could be identified and asked to reschedule prior to their appointments, while teledentistry provided new options for supporting patients.

I 1. Stringent Personal Protective Equipment (PPE) use hile PPE has always been a major part of the dental experience, the pandemic necessitated closer attention to the proper wearing of masks and other items of PPE, such as N95 respirators when there was moderate to substantial community spread. Dental staff have greater awareness of the risks associated with aerosol generating procedures.

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2. Improved aerosol management practices uring 2020 we learned more about the coronavirus and how it spreads through aerosol and droplets. This was the basis for restrictions on aerosol-generating equipment, and for the universal use of antimicrobial mouthrinses prior to procedures. Proper use of high volume suction and dental dam adds further control to aerosols. These measures have continued under level 1 restrictions even when patients show no signs of coronavirus infection.

Using less water spray on ultrasonic scalers and reducing water spray on air turbine drills are additional measures that equipment manufacturers have promoted. These help clinicians continue to practice safely.

Additionally, many practitioners began using hand instrumentation more often, to avoid generating aerosols in the first place.

New instrumentation like the HuFriedy Harmony™ Ergonomic Scalers and Curettes minimise strain, fatigue and risk of injury

D

34 oral|hygiene

4. Enhanced preparedness lthough the last year has been challenging, dental professionals (and patients) are now far more aware of infection prevention and control best practices than ever before. Dental professionals rose to the challenge of the pandemic and now are more prepared than ever to deal with the next challenge that comes their way.

Whether its instrument reprocessing and sterilization, waterline maintenance, hand hygiene, clinical techniques, or any other element of daily practice, infection prevention and control is a constant topic that requires attention.

Through the crucible of the pandemic, dental professionals have persevered to prioritise their safety and their patients’ safety. Ultimately, that preparedness and attention to detail will only serve as a benefit in the long run.

A

May/June 2021

YOUYOU REQUIRE MAXIMUM EFFICIENCY. YOU REQUIRE MAXIMUM EFFIC REQUIRE MAXIMUM EFFICIENCY. YOUYOU DEMAND COMPLETE ORGANIZATION. YOU DEMAND COMPLETE DEMAND COMPLETE ORGANIZATION. HUFRIEDYGROUP INTRODUCES HUFRIEDYG YOUYOU NEED ENSURED SAFETY. HUFRIEDYGROUP YOU NEED ENSURED S NEED ENSURED SAFETY. INTRODUCES ™ ™ YOU DESERVE INFINITE CONFIDENCE. YOU DESERVE HUFRIEDYGROUP INTRODUCES YOU DESERVE INFINITE CONFIDENCE. HUFRIEDYG HUFRIEDYGROUP INTRODUCES

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