Geistlich News - Edition 1, 2021 (English) by Geistlich_Pharma

GEISTLICH BIOMATERIALS

VOLUME 16, ISSUE 1, 2021

FOCUS PAGE 12

OUTSIDE THE BOX PAGE 28

INTERVIEW PAGE 38

Preventing tooth loss.

Practicing in the “new normal.”

Walking for a good cause.

With the current state-of-the-art treatments even “hopeless teeth” can survive.

Clinicians from five continents share experiences about dealing with lockdown, re-opening and patient concerns.

A charity run to support Turma do Bem. The NGO makes dental treatments available for the victims of violence.

Cover photo: Wang Zhao

LEADING REGENERATION.

100

GEISTLICH NEWS 1-2021

Editorial

Start of a new era You have my utmost respect in this challenging time dominated by coronavirus. In no time at all you have had to adjust your working day to new circumstances and cope with a great deal of uncertainty. Despite all the obstacles, you have safely and expertly cared for your patients. I am delighted that our patients have so much confidence in your actions and in Geistlich’s products. Geistlich Pharma has totally dedicated itself to regeneration, and the last 16 years of this have been decisively influenced by our CEO Paul Note. He has proved to be a prudent visionary, who has always had an eye on the market and a feel for our firm’s dynamic, sustainable development. The close cooperation with you, our clinical users and scientists, has been key. During all these years at Geistlich, he has invested a great deal in this cooperation in order to achieve the best results for our patients. As of the middle of this year, we must say farewell and wish him all the best in the next stage of his life.

Photo: Ed. Geistlich Söhne AG

I would like to revisit a couple of defining moments in the era of our CEO Paul Note. He is characterized by his personal approach not only to our customers, but also to his colleagues and our partners. His dedication has created no less than nine new subsidiaries on five continents and the business’s continued strong growth. The ways we interact with you and opportunities for this have developed in a variety of ways during this time – the latest achievement is our “Geistlich + YOU” online congress, which has been taken place again in February 2021 following your extraordinarily positive feedback. Under Paul Note’s leadership, our product portfolio has been enhanced by new, pioneering products and new product variants adapted to your needs. In 2014, for example, this brought the company a prestigious innovation award for the first soft tissue regeneration matrix, Geistlich Mucograft®. Paul Note always based his actions firmly on Geistlich’s five core values – Pioneer, Scientific, Connected, Regeneration Expert and Family. This has played a critical role in further securing your trust in our products and

company. It is highly gratifying for me that, in conjunction with you, Geistlich has advanced regenerative dental medicine and is still setting the pace. After many years of extremely meritorious work, it is an honor for me to extend grateful thanks to Paul Note on behalf of the Board of Directors, Executive Committee and our 700-plus employees around the world for his contribution. At the same time, his departure signals the start of a new era, to which we welcome Mr Ralf Halbach. We wish him much happiness on joining the Geistlich family and, as of mid-2021, will be placing Geistlich’s operational fate confidently in his hands.

Yours, Dr. Andreas Geistlich President of the Board of Directors, Geistlich Pharma

Issue 1 | 2021

NEWS

“We want to carry the message of regeneration”

Sporting Achievement & Solidarity

“GEISTLICH BIO-GIDE® gives you additional safety”

Interview with Paul Note | CEO of Geistlich Pharma AG

10 A little innovation can make a big difference 1 1

Discover “The New Daily Practice”

12 Prevent Tooth Loss Do hopeless teeth still exist? Or can we change each prognosis to good? What are the new therapies and materials? FOCUS

13 “Hope for the hopeless!” Interview with Dr. Pierpaolo Cortellini | Italy

16 When orthodontic treatment causes perio problems Dr. Scott H. Froum | USA

18 “Nobody wants to hide their smile” Interview with Dr. Frank Bröseler | Germany

22 Saving teeth affected by large periapical defects

Illustration: Quaint

Prof. Jose Mauricio Paradella de Camargo | Brazil

GEISTLICH NEWS 1-2021

OUTSIDE THE BOX

“The right collagen membrane can improve the clinical outcomes” Interview with Drs. R Gilbert Triplett and Jay P Malmquist | USA

Orthodontic tooth movement makes new bone formation Dr. Pal Nagy | Hungary

28 Five experts practicing in the pandemic

answered our questions about the impact of the pandemic on their professional lives. 34

On the road to find the ideal barrier membrane Dr. Jordi Caballé-Serrano | Spain OSTEOLOGY FOUNDATION

“Every cloud has a silver lining” INTERVIEW

Photo: Wang Zhao

38 39

A chat with Amanda Monteiro Publishing information

IMPRINT Magazine for customers and friends of Geistlich Biomaterials Volume 16, Issue 1, 2021 Publisher ©2019 Geistlich Pharma AG Business Unit Biomaterials Bahnhofstr. 40 6110 Wolhusen, Switzerland Tel. +41 41 492 55 55 Fax +41 41 492 56 39 biomaterials@geistlich.ch Editor Dr. Marjan Gilani, Verena Vermeulen Layout Niki Bossert Publication frequency 2 × a year Circulation 20,000 copies in various languages worldwide GEISTLICH NEWS content is created with the utmost care. The content created by third-parties, however, does not necessarily match the opinion of Geistlich Pharma AG. Geistlich Pharma AG, therefore, neither guarantees the correctness, completeness and topicality of the content provided by third parties nor liability for damages of a material or non-material nature incurred by using third-party information or using erroneous and incomplete third-party information unless there is proven culpable intent or gross negligence on the part of Geistlich Pharma AG.

Commitment to our core values

“We want to carry the message of regeneration” Interview with Paul Note conducted by Thomas Pfyffer

You have been running the company since 2006. If you compare Geistlich Pharma today with the company of yesterday: What main difference do you notice – what things have not changed? Paul Note: The massive increase in size with unchanged core values is striking. We hold our values just as high as we build on our tradition as regeneration experts. When we started in 2006, we had 150 employees, now we are currently approaching the 800 mark. Five times more employees is a proud achievement, and the values of the company make a relevant contribution as the cement and guidance for our attitude, our development.

How did you manage to achieve sustainability in the company’s values and DNA despite the impressive growth? For me, two points stand out: Firstly, we

always placed our location in Central Switzerland at the center of our activities. True to the philosophy of “everything under one roof”, we have concentrated and maintained our research & development, production and all central services at our two Swiss locations. It was essential for us to maintain this vertical logic. Secondly, it was important for us to grow from within, i.e. organically. Before the dynamic development of the last few years and until today, we hardly had the size for acquisitions. These two priorities have enabled us to continue to live up to our core values and to develop them further.

How are the last 15 years reflected in Geistlich’s network? As always, we place great value on our scientific network, which we claim for the development of our products and services. From this we ultimately derive

“The human being is always in the foreground.”

GEISTLICH NEWS 1-2021

benefits for our customers. So we have expanded this network into a global network. Each new subsidiary helps us to build bridges to universities and key opinion leaders in different countries and to establish, maintain and anchor contacts to the best in their field. While we started with three subsidiaries in 2006, we are now represented in the markets with twelve subsidiaries, i.e., we are virtually “on first-name terms” with the local communities in twelve countries. Especially with this network, we refer to our five core values “Scientific”, “Regeneration Expert", “Connected”, “Pioneer” and “Family”.

Photo: Geistlich Pharma | ©iStockphoto, malerapaso

Paul Note has been at the helm of Geistlich Pharma for 16 years. On the occasion of the handover to the new CEO Ralf P. Halbach in mid-2021, we look back with him on the eventful and expansive time at Geistlich.

“Geistlich employees and their vision have made the difference in all our successes and milestones.”

How do you experience the upheavals of the Corona crisis?

What role does it play that Geistlich is family-owned?

Photo: Roger Schuler

A big one! The Geistlich family guarantees stability and a long-term perspective. The close and constructive cooperation between the Executive Board and the Board of Directors was decisive for the match. In my function, and I can speak for the entire Executive Board, I always had the full backing of the Board of Directors (Verwaltungsrat).

Please recall the most relevant milestones and achievements of your era. First of all, we transformed the three existing sister companies in the UK, Germany

and Italy into subsidiaries. In the following years, nine more subsidiaries were added, enabling us to have a direct and personal local presence in growing and developing dental markets. Another significant milestone was the creation of the Surgery Business Unit in 2007, which complemented our Biomaterials and Medical Business Units. We have also continued the commitment to our Osteology Foundation, On Foundation and Osteo Science Foundation to specifically support research and education as well as nurture young talent. A highlight for me was winning the Central Switzerland Innovation Award for our products three times in the last 25 years. Being on top of the podium with our products was a reward for our comprehensive commitment to research and development and a great source of satisfaction for everyone.

I am very pleased with how flexible and agile our organization has adapted to the new circumstances. Specifically, the shift to virtual work and cooperation has been very successful and has culminated in our online congress “Geistlich + YOU”. Our widespread network has been very helpful in maintaining and cultivating contacts. Nevertheless, I miss the personal contact with our partners around the world, which has always been very close to my heart. Shared experiences simply cannot be substituted 100 % by virtual tools.

What would you like to pass on to your successor Ralf P. Halbach? All the technological developments mentioned are very important. But let's not forget: People matter most! I am proud of our competent employees with vision. They have made the difference in all our successes and milestones. Our staff deserves our continued active support – they give an enormous amount back to the company. Mr Note, thank you very much for this interview.

NEWS

Sporting Achievement & Solidarity

325 EMPLOYEES COVERED A DISTANCE OF 3988 KM AND RAISED 21 860 US DOLLARS: THESE ARE THE IMPRESSIVE FACTS FROM THE FIRST STAGING OF THE “GEISTLICH CHARITY WALK & RUN.” What began in the New Zealand sun, continued in the humidity and rain of Switzerland to end successfully in the USA and Brazil. Geistlich employees from a total of 13 countries hiked and ran for a good cause. Geistlich has long maintained the tradition of making an annual donation to a deserving NGO. But on October 10, however, it was all about more: personal commitment. Geistlich multiplied every kilometer covered by five US dollars.

One day, many winners This year’s donation goes to the Brazilian NGO Turma do Bem (Class of Good) and its project Apolônias do Bem (Apolonies of Good)*. Specifically, it will support women who are victims of domestic violence and whose teeth have suffered. As the day drew to a close in the Americas, it was time to take stock: On October 10, 2020 there were only winners: Numerous small groups and individual runners and hikers contributed to the success of the event with many kilometers. The day’s main winner is solidarity. *More information on page 38

GEISTLICH NEWS 1-2021

Reinforce, Revascularize, Regenerate

H C I L T S I E “G ® E B I O-G I D

Dr. Isabella Rocchietta UK

fety”

al sa n o i t i d d a u o y s give

Illustration: Geistlich Pharma

Dr. Sascha A. Jovanovic USA “I have used Geistlich Bio-Gide® in combination with Non-Perforated PTFE TR-membranes* for vertical and horizontal GBR over the last 25 years. It acts as extra protection for the periphery of the bone graft mix, sealing the borders of the grafted site, which may be otherwise compromised.”

“When performing vertical GBR using PTFE membranes, I additionally use Geistlich BioGide® to enable complete coverage of all the particles (autogenous and Geistlich Bio-Oss®) in proximity of the adjacent teeth.”

Prof. Istvan Urban Hungary “I have used Geistlich Bio-Gide® on top of the perforated membrane in over 100 cases. The rationale is to filter out fibroblast in-growth at the same time allowing transvascularization to take place.”

* Cytoplast™ Titanium-Reinforced HD-PTFE Membranes (non-perforated)

Prof. Darko Bozic Croatia “Geistlich Bio-Gide® gives you additional safety, in cases when we have a thin phenotype and we utilize a non-resorbable membrane for GBR, and it can protect and give additional support to soft tissues and protect the surgical area in a case of a small exposure.”

NEWS

Prevent volume loss after immediate implant placement

A little innovation can make a big difference Without filling the gap After 1 year

Geistlich Bio-Oss® Collagen 50 mg has been developed especially for filling the gap in immediate implant placement.

22% horizontal bone volume loss

Immediate implant placement typically results in a void between the buccal bone wall and the implants inserted.1 Implants alone, placed without preventive regenerative measures into fresh extraction sockets, cannot maintain the ridge volume.2, 3

Filling the gap with Geistlich Bio-Oss® Collagen and Geistlich Bio-Gide

Bone resorption2 22% horizontal volume lost

After 1 year

1.7mm vertical loss

92% horizontal bone volume preservation

Fill the gap: A shield for success Filling the peri-implant gap with Geistlich Bio-Oss® Collagen and Geistlich Bio-Gide® preserves 92 % of the original ridge width, and resultes in better soft tissue and bone tissue outcomes than immediate implants alone.2 Want to find out more about immediate implant placement and “fill the gap” with Geistlich Bio-Oss® Collagen 50 mg? For further information, please contact your local partner.

Scan a see how nd it works

Maximize bone volume preservation2 92% horizontal volume preserved

References 1

Girlanda FF, et al.: Clin Oral Investig. 2019;23(10):3885-93. (clinical study)

2 Cardaropoli D, et al.: Int J Periodontics Restorative Dent. 2014;34(5):631-7. (clinical study) 3 Vignoletti F, Sanz M: Periodontol 2000. 2014;66(1):132-52. (clinical study)

GEISTLICH NEWS 1-2021

Illustrations: Quaint

0.6 mm vertical loss

A digital guide to preventive regenerative treatments

Discover “The New Daily Practice” LIVE

and acce

ssible fro

1 APRIL

2021 on!

The “New Daily Practice” webpage allows dentists to learn more about preventive regenerative treatments in a playful and interactive way. There is a trend towards using regenerative treatments, not only to reconstruct big defects, but also to prevent tissue loss, simplify treatments and minimize complications. During and after the corona pandemic, these aspects are more pertinent than ever because they help to make workflows easier and reduce costs.

about preventive regenerative treatments in current dentistry.

An ideal starting point

So, which of the preventive approaches pay off? Which ones decrease surgical time and lower the costs for complication handling? What is their benefit in the long run? And what is the best approach to discuss preventive measures with patients?

The webpage “New Daily Practice” offers easy orientation in a broad field of treatments. Interactive and animated infographics, decision trees, and literature overviews give a quick outline of the values and benefits of different options. An interactive section about “Patient information” invites professionals to share their expertise related to patient information in the field of preventive regenerative dentistry.

To support clinicians who are new in this field and seek orientation, Geistlich Biomaterials has created an information hub

Join it – and be part of the experience! For further information, please contact your local partner.

Support for clinicians

FIG. 1: With interactive infographics,

videos, animations and knowledge

Photo: ©iStockphoto, Thatphichai Yodsri | Geistlich Pharma

snacks “The New Daily Practice” webpage offers easy-to-digest information on preventive regenerative treatments.

Share your experiences with others! How do you inform your patients about preventive regenerative treatments such as Ridge Preservation, filling the gap, saving teeth or soft tissue augmentation? Upload a video and share your experience with others.

FIG. 2: Find information on these preventive

regenerative treatments in “The New Daily Practice”: periodontal regeneration, filling the gap, Ridge Preservation and preventive soft-tissue regeneration.

NEWS

FOCUS

Prevent Tooth Loss

Illustration: Quiant

Do hopeless teeth still exist? Or can we change each prognosis to good? What are the new therapies and materials?

GEISTLICH NEWS 1-2021

Long-term outcome of periodontal regenerative therapy

Hope for the hopeless! Dr. Pierpaolo Cortellini | Italy Via C Botta 16, 50136 Firenze Interview conducted by Verena Vermeulen

Over the past 20-years Dr. Pierpaolo Cortellini has shown that a “hopeless tooth” is anything but hopeless. We discussed long-term outcomes, cost-efficiency and reasonable beliefs and expectations. Dr. Cortellini, you have saved so many so-called hopeless teeth in your career – does the expression “hopeless tooth” still mean anything to you? Dr. Cortellini (smiles): Well, what is hopeless depends not only on the condition itself, but also on the treatment you can provide. So, teeth we would have called hopeless some years ago are not anymore. Over time we have developed better therapeutic solutions. But 360-degree horizontal destruction of the bone up to the apex – that would of course still make a tooth hopeless, also for me.

Sometimes, we hear that the “pendulum is swinging back” – from replacing teeth to saving teeth. Do you see this trend also? Yes. For example, for economic reasons. We have just published a paper showing that saving severely compromised teeth is less expensive than replacing them – both immediately and in the long run.1, 2 If a huge amount of bone is destroyed and bone and soft tissue augmentations would be necessary to place an implant, the costs of replacement may be double the cost of saving existing teeth.

There are further reasons why patients prefer to keep their own teeth. Some find it holistic and “more natural.” Others have heard about peri-implantitis, and their concerns are justified. In periodontally compromised patients, the risk for peri-implantitis is high.

Good news for periodontists? Well, there is more patient demand, but practioner expertise is becoming less and less. A few experts and scientists could bring periodontal expertise back into the limelight, and this would be beneficial.

You performed a randomized clinical trial with so-called hopeless teeth. 25 hopeless teeth were replaced with

implants, and 25 were treated with a regenerative approach. How many of them survived? 23 out of 25. These were teeth with chronic perio-endo lesions and/or attachment loss up to the apex or beyond. After 5-years we changed their prognosis from “hopeless” to “good.” The tenyear observation had a few patient dropouts and one tooth was lost.1, 2

Only one? Dr. Cortellini (smiles): Yes. It was a grandmother who got kicked by her baby grandchild. She lost three teeth, and one of these was included in our study.

Could this high percentage of saved “hopeless” teeth be achieved in other dental offices? Or is your own experience with GTR procedures more predictable? Several factors are key: expertise for sure, but also a multi-disciplinary team including endodontists, hygienists, periodontists and prosthodontists. But the most important

“In periodontally compromised patients, the risk for periimplantitis is high.”

FOCUS

factor is patient selection. You cannot achieve a predictable outcome in a patient with bad oral hygiene or in smokers or patients with uncontrolled diabetes. And patient selection also includes selecting the right defect configuration – vertical bone defects of a certain depth next to a stable tooth. The latter is also important. If we cannot control tooth mobility, we cannot regenerate bone.

Did you see differences in patient satisfaction when saving teeth versus replacing teeth? Patient reported outcomes with regards to health, esthetics and function were simi-

lar in both groups. But patients with saved teeth were happier. Most implant patients said they would have preferred to keep their teeth.

regeneration group. Open flap debridement means that the root surfaces are cleaned after flap elevation, but the periodontium is not regenerated.

In addition to comparing saving versus replacing, you also compared different treatment approaches for saving teeth – for example, open flap debridement versus regenerative periodontal therapy.3 What did this comparison reveal?

Therefore, the teeth in the open flap debridement group had deeper residual pockets after treatment, and the gain in clinical attachment was smaller. We measured only 2.5 mm compared to 5.3 mm in the regeneration group. So, these teeth were more difficult to maintain.

Over the twenty-year observation period we lost two teeth in the open flap debridement group and no teeth in the

How about treatment costs – which approach pays off in the long run? We also analyzed treatment costs over 20-years.3 The regenerative approach is certainly more expensive in the beginning compared to open flap debridement. But if you compare the costs over 20-years, open flap debridement becomes the more expensive approach – because recurrences need to be treated.

“The idea of saving teeth instead of replacing them is receiving more attention.” Discussion with Prof. Cortellini in Florence.

GEISTLICH NEWS 1-2021

Techniques include open flap debridement alone, bone substitutes, resorbable membranes, form-stable membranes and enamel-matrix protein. In 1994 we published the first version of the algorithm, then we modified it slightly over time. The most recent version is in a book from the Italian society of periodontology (Fig. 1). Basically, this is still my treatment spectrum, depending on the anatomy and defect configuration.

Photo: Geistlich Pharma

You and Maurizio Tonetti developed an algorithm for how to proceed in different situations. Which treatments and materials are included there?

ACC E S S

FIG. 1: Treatment algorithm for periodontal regenerative therapy

≥ 2 mm

The possibility of regenerating periodontal support in horizontal defects would certainly be a breakthrough. We don’t have the expertise to treat zero-wall defects – or so called 360-degree horizontal defects. We just have to accept that condition. Whoever offered something clinically applicable to solve this problem would find a huge market.

Final question: would you encourage your colleagues to save more teeth instead of replacing them?

FL AP DE SIGN

What would be a breakthrough in regenerative therapy for teeth? Or is no further breakthrough needed?

RE G EN E RATIVE S TRATEGY

So, there are two options for dentists who are reluctant to save teeth: send your patients to somebody who knows how to do it, or become an expert yourself.

≤ 2 mm

MPPT

SPPF

Modified Papilla Preservation Technique

Simplified Papilla Preservation Flap

Crestal incision

Intrabony defect Involving 3–4 sides of the root, very severe

Involving 1–2 sides of the root Cleansable from buccal

Yes

Absolutely. This has been my true belief from the very beginning of my clinical and research life. And meanwhile, the idea of saving teeth instead of replacing them is receiving more attention.

Edentulous ridge next to defect

Interdental space width

M-MIST

MIST

Modified Minimally Invasive Surgical Technique

Minimally Invasive Surgical Technique

Extended flap

Any defect anatomy

No regenerative material

EMD

Containing defect

Non containing defect

EMD Enamel-Matrix Derivative

EMD + graft

Containing defect

Non containing defect

EMD

Barrier Barrier + graft EMD + graft

References Cortellini P, et al.: J Clin Periodontol 2011;

Illustration: Quaint

38(10):915-24. (clinical study) 2 Cortellini P, et al.: J Clin Periodontol 2020;

47(6):768-776. (clinical study) 3 Cortellini P, et al: J Clin Periodontol 2017;

44(1): 58-66. (clinical study)

FOCUS

Teeth beyond repair?

When orthodontic treatment causes perio problems Dr. Scott H. Froum | USA Periodontics & Implantology Diplomate American Board of Periodontology

There are many advantages vere mobility and a periodontal abscess. around tooth 12 and was referred to an that can come with saving The patient was a 27-year-old female endodontist for lesion drainage. Both with no contributory medical history, teeth 11 and 12 were diagnosed as hopenatural teeth. The good stated allergies, and taking no medica- less, with localized 15-mm probing news is that, in the era of tions. depths, and class III mobility (#12 being depressible). The Cone Beam Computadvanced biomaterials and When things didn’t go as ed Tomography (CBCT) and peri-apical surgical techniques, it is planned radiography showed loss of both buccal sometimes possible to The patient had started orthodontic and palatal plates. Nevertheless, both save hopeless teeth. What treatment using a clear aligner 6-months teeth still had blood supply as shown by prior to visiting my office. The ortho- the vitality pulp test. The patient asked for does it take to save teeth dontic treatment was for correction of a second opinion and was referred to us. that have been diagnosed an Angle class II malocclusion with as beyond repair? moderate maxillary incisor spacing, se- Periodontal treatments and This case study reports the details of a regenerative periodontal treatment of teeth #11 and 12 (FDI system) with se-

vere overjet, and maxillary incisor proclination. 6 months into treatment, with weekly changes of the computer-generated aligners, she developed an abscess

“Teeth given a poor to hopeless prognosis may be amenable to repair.”

GEISTLICH NEWS 1-2021

regenerative procedures

The comprehensive periodontal examination confirmed the probing depths and class III mobility. We explained the risks of therapy and poor prognosis of both teeth to the patient and she signed an informed consent. Front teeth (#13-23) were splinted using a Ribbond periodontal splint, and occlusion was adjusted to light contact. A full-thickness flap was elevated, and the defect was detoxified with a combination of a 9.3-micron CO2 laser and 24 % EDTA. After detoxification, we confirmed a one-wall defect with a 7-mm intrabony periodontal pocket. We grafted the defect with Geistlich Bio-Oss® Collagen, which has an excellent scaffolding ability and is very helpful in this indication.1 Then, we covered the bone graft using L-PRF™ for a better angiogenic response of the tissues.

FIG. 1: A case for regenerative treatment of hopeless teeth. B

Photos: Scott Froum

| A Before orthodontic treatment. | B Peri-apical CBCT prior to periodontal treatment. | C Teeth (#13–23) splinted. | D 7-mm intrabony pocket after

Photos: Scott Froum

Functional and esthetic teeth after being saved The patient was followed for 12 months, with cautious attention to regular visits and dental hygiene. At 1-year follow-up and re-entry for enhancing the soft tissue profile, it was clear that the defect was completely filled with new bone, with an intimate adaptation to teeth #11 and 12. A peri-apical radiograph taken at the time

confirms the clinical findings. This case highlights the importance of evaluating current diagnosis matrices in the era of enhanced biomaterials. With proper use of biomaterials, enhanced detoxification protocols, surgical technique, and patient compliance, teeth given a poor to hopeless prognosis may be amenable to repair. 2-4

References 1

Girlanda FF et al.: Clin Oral Investig 2019;

23 (10), 3885-93. (clinical study) 2 Cortellini P, et al.: J Clin Periodontol 2020;

47(6):768-776. (clinical study) 3 Bröseler F, et al.: J Clin Periodontol 2017;

44:520-9. (clinical study) 4 Sculean A, et al.: riodontol 2000 2015;

68(1):182-216. (clinical study)

FOCUS

Periodontal Regenerative Therapy

“Nobody wants to hide their smile” Dr. Frank Bröseler | Germany Private Practice for Periodontology Aachen Interview conducted by Verena Vermeulen

Dr. Frank Bröseler has been practicing periodontal regenerative therapy for 20 years with great success and has investigated what really matters for patients. We spoke to him about goals, expectations and the best time to re-motivate patients. Dr. Bröseler, you published a retrospective study about periodontal regenerative therapy in a large day-to-day patient population.1 What did you want to find out? Dr. Bröseler: We were interested in whether the very good results from wellknown, prospective studies2, 3 could be confirmed in a normal practice environment. In prospective studies, selected patients are treated – patients without major health problems, with good compliance, non-smokers, etc. But what is the success of a therapy when treating any Tom, Dick and Harry? For instance, patients who suffer from diabetes or have less than perfect oral hygiene?

And what did you discover? We analyzed 1008 teeth in 176 patients over ten years. All patients were treated according to our standard algorithm (Fig. 1). Despite the range of impairments in a normal patient population, we had the same treatment success as shown in the prospective studies. Radiographic bone fill was 3.8 mm after one year and remained stable for up to

GEISTLICH NEWS 1-2021

ten years. You might compare this to the amount of bone gain with open flap debridement alone which is about 0.95 mm.4 A higher amount of bone gain was achieved in deep defects, and probing pocket depths were significantly reduced and remained shallow over the observation period.

Some dentists find regenerative periodontal therapy too unpredictable. Do you agree? Not at all. Our daily experience and clinical studies show that the opposite is true. But you do have to learn the right way to go about it. Young dentists often lack proper surgical training and must catch up with additional learning. This is demanding for the beginners, but without a very good education, nothing works out.

“Periodontitis is a chronic disease requiring a high level of compliance and very good oral hygiene for life.” Dr. Bröseler has more than 20 years of expertise with regenerative periodontal therapy.

“Patients never ask us to ‘fill their bony defects.’ They want to be healthy again.”

You also investigated how patients perceive the outcome of periodontal therapy.5 Which factor was most important for satisfaction? It’s important to bear in mind: that patients come to us because they have complaints, like bleeding gums, a bad taste in their mouth or loose teeth. They never ask us to “fill their bony defects.” They want to be healthy again. If this can be achieved, they accept small imperfections, for example, in esthetics, that sometimes cannot be fully achieved.

Photo: Frank Bröseler

So, esthetics aren’t the main concern? No, they’re not. But depening on the patient, the esthetic outcome can still be very important. Everyone wants to be able to laugh without worries. Nobody wants to have to hide a smile behind their hand. And we can achieve this good esthetic result with regenerative periodontics.

FOCUS

FIG. 1: Periodontal regenerative

therapy step-by-step

P R E- SU RG IC AL P HAS E Non-surgical anti-infective therapy In case of ongoing problems, further examinations through physician and/or microbial testing, optionally

SURGICAL PH ASE

1. Access flap with or without vertical releasing incisions.

4. If soft tissue is compromised (roughly 10 % of cases), Emdogain® is added.

2. Removal of granulation tissue.

5. The defect is filled with Geistlich Bio-Oss® Collagen.

3. Root planing.

6. In non-contained defects Geistlich Bio-Gide® Perio is added, without suture or pins.

P OS T - SU RG IC AL P H A S E 0.2 % Chlorhexidine 3×/day over postoperative wound-healing period, optionally 8. In case of mobility: teeth are stabilized through removable or non-removable splinting.

*Adjunctive antibiotic peri-operative medication (i.e. amoxicillin and metronidazole, accordíng to individual preposition and findings, optionally

GEISTLICH NEWS 1-2021

No use of interdental brushes etc., until keratinized tissue is regenerated 10–14 days post-surgery suture removal

First 6-months with short recall interval and professional tooth cleaning without subgingival instrumentation Re-evaluation (clinically and radiographically) 1-year after surgery, beginning of individual systematic supportive treatment

Illustration: Quiant

7. Tension-free wound closure of coronally advanced flap with horizontal mattress suture and additional sutures at vertical incisions.

“Where there’s an intact papilla, plaque cannot easily get in.”

Or let’s rather say regenerative periodontology is the first step toward a very good esthetic result, because in case of high esthetic demands, further treatments such as soft tissue plastic surgery or orthodontics are probably also needed.

In your publication patients were more satisfied after regenerative therapy compared with scaling and root planing or open flap debridement.5 Why? They felt regenerative treatment had been very successful, although they started out from a very difficult situation. Scaling and root planing (SRP) is easier to perform, but it leads to disease recurrence far more frequently than regenerative therapy. And open flap debridement (OFD) causes a gum recession. The consequences are sensitive teeth, poorer esthetics and more difficult oral hygiene – all of which may cause patient dissatisfaction.

Patients must be highly compliant for many years. Is there a critical point when the motivation becomes lower and patients must be re-motivated? After about three years the process of regeneration is completed, a new status quo is reached. Then there is a risk that patients will become overconfident and too optimistic and, therefore, less thorough

with their oral hygiene. We have to remind them that periodontitis is a chronic disease requiring a high level of compliance and very good oral hygiene for life.

What specific steps do you take to re-motivate patients? After five years we ascertain the radiographic status and discuss it at length with the patients. We discuss the prognosis for all their teeth and illustrate with the colors red, yellow and green. We stress what has been achieved, but we also share literature about relapse rates and emphasize: “You can’t sit back now.”

Are patients concerned about preserving teeth? For most, yes. Natural teeth have many advantages. It’s easier to chew with natural teeth, and they are not as susceptible as implants to infectious disease. Implant marketing advertisement is very positive, and some patients believe that implants last forever. But the prognosis for an implant is only about 12-years.6 We can preserve the patient's natural teeth that long, and for most, probably longer. Although regenerative periodontal therapy might be complex, it is always more cost-effective than an implant.

Do patients follow your recommendations? Usually they do. If something is financially impossible, you have to lower your goals. Then we might opt for a healthy situation with diminished esthetics, for example. For patients with very high expectations, we follow periodontal therapy with orthodontics, because periodontal diseases are often accompanied by dislocation of the teeth. Restoring the correct tooth position and natural anatomy, including papillae, is the best way to prevent recurrence. Where there’s an intact papilla, plaque has a harder time invading the periodontal tissues. The results are wonderful, but given the time and therapy required, the treatment is much more expensive.

Your own treatment algorithm is based not only on scientific data, but also on cost-balance. How long have you been working with this algorithm? The algorithm has been the same for many years. I plan therapy exclusively according to medical criteria and the cost plan is based on this. I’ve never worked for profit. The profit comes instead from the fact that a very satisfied patient recommends our practice to others.

References 1

Bröseler F, et al.: J Clin Periodontol 2017;

44 : 520-29. (clinical study) 2 Cortelini P & Tonetti MS.: Periodontol 2000 2015;

68(1): 282-307. (systematic review) 3 Sculean A, et al.: Periodontol 2000 2015;

68(1): 182-216. (systematic review) 4 Graziani F, et al.: J Clin Periodontol 2012;

39(2): 145-56. (systematic review) 5 Franke M, et al.: Oral Health Prev Dent 2015;

13: 163-68. (clinical study) 6 Derks J, et al.: J Dent Res 2016; 95(1): 43-49.

(clinical study)

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Regenerative approach using endodontic microsurgery

Saving teeth affected by large periapical defects Prof Jose Mauricio Paradella de Camargo | Brazil Campinas Association of the Surgeon Dentists (ACDC) Campinas, São Paulo

Instead of extracting or replacing teeth with dental implants, endodontists prefer to prolong the functionality of teeth with traumatized roots. Today advances in technology, procedures and biomaterials allow endodontists to save teeth at an outstanding rate of success. For saving teeth, clinical success depends heavily on the effectiveness of both periodontal and endodontic treatments.1 In fact, teeth lost during periodontal treatment and so-called “hopeless teeth” are often associated with endodontic problems. In non-surgical, endodontic treatments, clinicians carefully remove the decay, inflamed or infected pulp, clean, disinfect and shape the root canals, and place a filling to seal the canal. The success rate of this treatment is lower with extensive periapical lesions. In such cases, surgical endodontic treatment is an alternative.

Periapical lesions rank among the most common pathological lesions in alveolar bone.2 Such lesions result in bone defects, and when defects are large, the body fails to regenerate new bone to fill them, and connective tissue may invade the bone defect and impair clinical outcomes.3 Grafting a bone substitute into a defect and covering it with a resorbable membrane can help the body correct the defect. In regenerative endodontic treatments for large defects, as with regenerative periodontal therapy, clinicians use autogenous bone and biomaterials, if not a mixture of both.

“I use substitute biomaterials for periapical microsurgeries and have been pleased with the clinical outcomes.”

GEISTLICH NEWS 1-2021

Endodontists should diagnose the clinical situation, including access to the canal, location and anatomy of the teeth and surrounding tissues, and in the case of recurrence, the quality of the most recent endodontic treatment. Only then can a proper non-surgical or surgical treatment be performed.

Regenerative periapical microsurgery Regenerative periapical microsurgery employs fundamental principles of endodontics, periodontics and oral and restorative dentistry. The treatment generally aims at eliminating all factors that could cause periapical lesions, repairing the architecture of lost periapical tissue and preserving the structure and anatomy of the root and soft tissues. It is also important to prevent the recurrence of disease in long-term. Regenerative periapical microsurgery includes the following steps (Figure 1). 1. Enhanced magnification for minimal root resection; 2. Ultrasonic root apex preparation; 3. Retrograde obturation with a bio-ceramic root repair material; and 4. Guided Tissue Regeneration at the site of the bone defect.

FIG. 1: Regenerative periapical microsurgery to treat apical periodontitis around the mesiobuccal and distobuccal roots of tooth 17. B

Photos: Jose Mauricio Paradella de Camargo

| A Coronal and sagittal cone-bean computed tomography (CBCT) showing proximity of the periapical lesion and the maxillary sinus. | B Right occlusion

before treatment. | C Surgical 3D template to guide access. | D Osteotomy with Piezotome Cube (Acteon US) using the SL1 tip after the flap was raised. | E Osteotomy with Piezotome Cube (Acteon US) using the SL2 tip. | F Retro preparation on the mesiobuccal root with a Berutti tip (EMS Switzerland) under saline irrigation. | G Biocement Bio C Repair (Angelus, Brazil) placed in the mesiobuccal canal. | H 3 mm photography micromirror checking the retrofilling in the distobuccal root of the upper right second molar. | I Geistlich Bio-Oss® Small 0,5 g. (Geistlich Pharma AG, Switzerland) at the surgical site. | J Surgical cavity filled with Geistlich Bio-Oss® Small. | K Geistlich Bio-Gide® 25 × 25 membrane used to cover the graft. | L Final radiography post surgery.

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“Given the importance of using biomaterials with evidence of long-term benefits, Geistlich biomaterials are the gold standard.”

Regenerative periapical microsurgery success rates have increased significantly in recent years, thanks to advances in digital planning techniques, microscopy and microsurgical instruments, and biomaterials for Guided Tissue Regeneration.3-4

The choice of regenerative materials Although autogenous grafts are often considered the gold standard for regenerative dentistry, they are not always the best option. Due to the harvesting procedure, autogenous grafts are associated with greater pain and morbidity. In a systematic review Chavda and Levin (2018) found patients preferred non-autogenous bone graft substitutes, which require fewer days of hospitalization, involve less pain and shorten recovery time.5 The authors found no difference in implant success rate when the alveolar ridge was augmented using different bone grafts, including autogenous bone.5 I use substitute biomaterials for periapical microsurgeries and have been pleased with the clinical outcomes to date. The protocol has allowed me to help many patients preserve their hopeless, natural teeth and keep them healthy and functioning. Recently my colleagues and I published a clinical case report detailing the protocol and clinical outcome for managing a large radicular lesion with regenerative periapical microsurgery.3

GEISTLICH NEWS 1-2021

The cyst was 40 mm in its largest dimension and involved several anterior teeth, both cortical plates and an extension into the nasal floor. Due to the large size of the defect, we decided to use a mixture of Geistlich Bio-Oss® and autogenous bone from the mandibular ramus, along with platelet-rich fibrin. The clinical outcome was successful 4-years post-surgery (i.e., time of publication). Moreover, when we investigated the cone-beam computed tomography images, we observed well-integrated tissues, new cortical bone and similar radiopacity and trabecular form compared with adjacent, native bone. To date there are few studies focused on using biomaterials in periapical surgery. Thus, in seeking scientific evidence to explain bone regeneration inside periapical lesions, we rely primarily on studies conducted in other areas of regenerative therapy. Given the importance of using biomaterials with documented and high-level evidence of long-term benefits compared with other graft materials, Geistlich biomaterials are the gold standard.7-10

References 1

Bröseler F, et al.: J Clin Periodontol. 2017;

44(5):520-9. (clinical study) 2 Peters E, Lau M.: J Can Dent Assoc. 2003;

69(9):598–600. (review) 3 Camargo JMP, et al.: Oral Surgery. 2019; 12, 323-331.

(clinical study) 4 Floratos S and Kim S.: Dent Clin North Am. 2017;

61(1):81-91. (review) 5 Chavda S and Levin L.: J Oral Implantol. 2018;

44(1):74-84. (review) 6 Dietrich T, et al.: Oral Surg Oral Med Oral Pathol

Oral Radiol Endod. 2003;95(4):474-82. (clinical study) 7 Schwartz Z, et al.: J Periodontol. 2000;

71(8):1258-69. (Pre-clinical study) 8 Schneider, O. D. et al.: Acta Biomater. 2009;

5(5):1775-84. (Pre-clinical study) 9 Figueiredo M, et al.: J Biomed Mater Res B Appl

Biomater. 2010; 92(2):409-19. (Pre-clinical study) 10 Lee JS, et al.: Clin Implant Dent Relat Res. 2017;

19(1):140-50. (review)

Osteo Science Foundation – Collagen White Paper

“The right collagen membrane can improve the clinical outcomes” Interview with Drs. R Gilbert Triplett and Jay P Malmquist conducted by Todd Scantlebury

Drs. Gilbert Triplett and Jay P Malmquist published the Collagen White Paper in 2020. Up to now, over 8000 copies of the paper have been downloaded or distributed by Osteo Science Foundation. Drs Triplett and Malmquist, why did you write the Collagen White Paper?

quist

alm Dr. Jay P M

Photos: Gilbert Tiplett | Jay P Malmquist

Science f the Osteo first Chair o 14 0 in 2 Foundation

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Triplett

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Dr. Malmquist: I felt clinicians need an objective source for understanding collagens and collagen containing biomaterials as both commercial products and building blocks in regenerative procedures. As I recall the genesis of Guided Bone Regeneration and the continuous discussions about barriers versus membranes, collagen has always been in the limelight regarding the so-called “barrier of choice.” Collagen’s impact on implant dentistry and the basic lack of understanding clinicians have for collagen as an adjunct to healing, I thought it was important to define collagen products further. Dr. Triplett: Collagen is one of the most used biomaterials in dentistry and medicine, yet most practitioners know little about collagen products, and there’s scant scientific evidence for efficacy. Biomaterial companies have been reluctant to conduct comparative trials, so in many cases efficacy is based on anecdotal reports. One example: some collagen companies have not established how long their membranes function or even when they are resorbed. Busy practitioners may not assess their outcomes critically. Therefore, I was interested in

participating in this white paper both for my own knowledge and also for our profession.

Why collagen? Dr. Malmquist: A good question. For me it’s because it’s been the “go-to product” for barrier use in grafting. One has only to review the many product inserts, advertising and misstatements to understand the general lack of understanding that exists. So, when you hear someone say, “all collagens are the same,” that’s why we wrote the paper – to show there are differences. Some clinicians buy on price, but few understand how collagens affect the healing process or the real “cost” of their outcomes. Many clinicians are unaware of the different types of collagens or how they fit into the pathway of regeneration. We hope this paper will help. Dr. Triplett: Collagens are commonly utilized and have the potential to act as carriers for proteins, growth factors and live cells for tissue regeneration. Yet most clinicians do not know how or why to use one product versus another. Many times scientific evidence is lacking.

What do you think the key, take-home message of the paper is? Dr. Malmquist: That collagen is complex in nature, an adjunct to healing and variable in behavior. Certainly, the most important aspect is that collagens are not all the same, and they do not behave the same. Sourcing, cross-linking and processing are key elements in collagen’s behavior.

OUTSIDE THE BOX

You urge manufacturers to “… understand and provide evidence regarding how their collagens interact with healing tissues, especially if their collagen biomaterials are capable of providing regenerative results.” Why, and what makes regenerative results so special? Dr. Malmquist: Regeneration is critical to improved outcomes. So, the question of whether collagen provides a suitable regeneration platform is critical. Most collagen indications suggest it be used as an adjunct to healing under FDA protocols, and yet we see suggestions of further (off label) uses by the manufactures with little to no evidence. To my way of thinking, this is simply wrong. Unfortunately, this misdirection occurs not only with collagen but with many of the various bone grafting substitutes. There must be adequate science available to substantiate claims.

What’s your advice to young clinicians trying to sort through the variety of biomaterials available today? Dr. Malmquist: Always depend on the basis of science for determining the best outcome for your patients. This means using products and techniques that are science based and that provide reproducible results. Stay away from gimmicks and

GEISTLICH NEWS 1-2021

“Our advice to young clinicians is to use the products that are steeped in science and evidence.”

unsound science. Understand how products fit into your patient’s healing process. Stay away from products that have no evidence, no real basis for use. For instance, does freeze dried allogeneic bone contain BMP? Probably not, and yet you see this advertised over and over in company literature. Be aware of false or misleading information, look for evidence, listen to the experts that use the products correctly, and make sure they have no conflicts of interest... Is this person being paid for his or her endorsement? This is a very egregious world right now. So, the bottom-line answer is: use products that are steeped in science and evidence.

What is the future for collagen biomaterials and how will this affect the coming generation of surgeons and their patients? Dr. Malmquist: The future for collagen biomaterials is endless. 3-D constructs will be commonplace, they will be formed with 3-D printing, and they will be embedded with various antibiotics, growth factors and bone proteins. They will also be used as cell carriers, with their bioactive surfaces recruiting cells for faster and better healing. The future is immense for all of us. The interplay of science, regeneration and the improvement of outcomes will influence not only products but lives for years to come. Collagen will be the backbone of

many of these projects. To understand collagen is to understand the future of regeneration in medicine and dentistry. Dr. Triplett: Besides the current use as barrier membranes, hemostatics, etc., the use of collagen in tissue engineering for regeneration of tissue will be a game changer. Collagen scaffolds have been demonstrated to have an effect on the cellular activity within and adjacent to tissue constructs, thus serving as an active rather than passive agent and providing biological interactions and better performance in biological systems.

Will there be more Osteo Science publications like the Collagen White Paper? Dr. Malmquist: Yes, there will .... our thinking at the Foundation is that we should also write papers concerning growth factors, blood modifiers and associated products to help further define this area of regeneration. The only limiting factor is time. We certainly have the reservoir of talent to do this. Dr. Triplett: Absolutely. This is only the beginning. You can download the Collagen White Paper at:

www.osteoscience.org/ advances

Illustration: Quiant

Dr. Triplett: There is utility for the right collagens in hemostasis, clot stabilization, rapid angiogenesis/ vascularization and healing of soft and hard tissues. The right collagens and surgical techniques can provide improved outcomes without complications or morbidity, while also being cost effective and providing better patient care.

Histology

Orthodontic tooth movement makes new bone formation Dr. Pal Nagy DMD | Hungary Department of Periodontology Semmelweis University

FIG. 1

Histologic images were obtained during an ongoing randomized controlled trial. After flap elevation, debridement of the root surface and removal of the granular tissues, non-containing intrabony defects were filled with Geistlich Bio-Oss® and covered with Geistlich Bio-Gide®.1 Patients in the test group underwent postoperative Orthodontic tooth movement (OTM). In the control group, teeth remained splinted without OTM. At 9-month re-entry, bony core samples were harvested and analyzed. Geistlich Bio-Oss® was integrated into the newly formed bone in both groups. In the test group, the ratio of de novo bone formation was higher, and postoperative OTM appeared to induce remodeling interfering with the graft and promote new bone formation, particularly at compression sites.

FIG. 2

Histology: Peter Schüpbach

“The observation of multinucleated giant cells and cutting cones confirms the safety and predictability of periodontal bony regeneration combined with OTM using Geistlich Bio-Oss®.” FIG. 1: An intimate contact of new bone to graft paticles was observed,

characterized by bone extensions growing into the graft surface. FIG. 2: Cross section of the repairing part of remodeling “cutting cone.”

Osteoblasts secreting the newly formed woven bone.

Reference 1

Nagy P, et al.: Int J Periodontics Restorative Dent.

2019 11;40(3):321–30. (clinical study)

OUTSIDE THE BOX

Points of view

Coronavirus pandemic has hit everyone in the healthcare industry to some extent. It changed how we live, work, and socialize. We asked five clinicians from five countries about the impact of the pandemic on their professional lives as dental practitioners.

GEISTLICH NEWS 1-2021

Photo: ©iStock Editorial / Tzido

Five experts practicing in the pandemic

USA > First confirmed case on 21 January, 2020 > 72 620 Confirmed cases/1 million population* Dr. Liliana Aranguren | USA Periodontist and Dental Implant Surgeon in South Florida

> 398 435 Deaths

“Through resilience, pride and professional dedication, we can overcome almost anything.”

Dr. Aranguren, what was the immediate impact of the virus outbreak on your practice? Dr. Aranguren: We closed for all routine and non-essential care. We were available only for emergencies under high levels of disinfection. It was important to act quickly, as we always feel a great sense of responsibility to act in the best interest and safety of our patients, colleagues and community.

How did you communicate that with your patients?

Photo: Liliana Aranguren

We sent letters and emails, made phone calls and constantly updated our website with the latest information and the latest protocols we adopted to continue to provide the best service.

How was your practice recovery after the lockdown? It was a slow process. We modified the schedules and appointments to reduce

the traffic in the reception area, allowed more time for disinfection and maintained social distance for the safety of our patients and team. We also invested in new and improved Personal Protection Equipment (PPE) and ventilation systems. Gladly I can say that we are now back and providing the highest levels of infection control.

coffee makers and handouts were also removed from all the waiting rooms, and patients were asked to wear masks before entering the office.

What was your biggest lesson from living as a healthcare professional during the pandemic? I have learned that in order to survive we need to evolve and adapt to the circumstances. These have been weird times, but I can gladly say they have taught my team and me that through resilience, pride and professional dedication, we can overcome almost anything.

What were the hygiene protocols you used to protect your team and patients? We adopted a multi-tiered approach: temperature taken from each patient and team member, sanitization stations throughout the office, new PPE worn by all team members, installation of stateof-the art air purifying units with extraoral high evacuation units to absorb dental aerosols and contaminants, and periodic office “floggings” with hypochlorous acid, as is done in hospitals for maximum disinfection. Magazines,

“Our work during this period gave us a sense of accomplishment.”

*Data from World Health Organization 1.2021 OUTSIDE THE BOX

UNITED KINGDOM > First confirmed case on 31 January, 2020 > 51 642 Confirmed cases/1 million population* > 93 290 Deaths Dr. Safa Somi | United Kingdom Specialist in prosthodontics at Harrow Dental Practice

Dr. Somi, what was the immediate impact of the virus outbreak on your practice? Dr. Somi: All of a sudden we had to close the practice for everyone, even for the patients who were halfway through their treatments. Lockdown was a very stressful time for everyone, plus it imposed a large financial burden on us.

How did you communicate that with your patients? First, we called our patients and canceled appointments. Of course, everyone in the beginning was in shock. And when this state was over, we started to think of preparing ourselves for the next. We prepared patient videos, so they could understand what to expect when we re-opened. We informed them about the safety measures we had put in place. We wanted them to know that the dental office was one the safest places they could go.

They wrote to say how safe they felt, which encouraged new patients to come to our practice.

What were the hygiene protocols you used to protect you and your team? We ordered air purifiers, extra oral suctions, PPE masks and all our other cross-infection-control equipment, despite the financial burden. We accepted fewer patients per day. Also, we didn’t use the waiting room anymore: patients

were immediately escorted to the treatment room when they arrived.

What was your biggest lesson from living as a healthcare professional during the pandemic? We are still learning to live with this “new normal.” One of my lessons was overcoming panic and replacing it with anticipating the future. We also learned that investing in high-end safety measures pays back by creating more patient trust.

During lockdown we used the time and carefully planned a sound re-opening strategy. We installed best-in-class, cross-infection-control equipment. We trained our staff. So upon re-opening, our patients realized this hard work, acknowledged it and felt safe to come back. We had a lot of positive feedback from our patients, e.g., in Google reviews of the clinic in recent months.

GEISTLICH NEWS 1-2021

Working in mask, and near extra oral suction equipment.

Photo: Safa Somi

How was your practice recovery after the lockdown?

AUSTRALIA > First confirmed case on 25 January, 2020 > 1127 Confirmed cases/1 million population* > 909 Deaths

Dr. Alistair Graham | Australia Dental surgeon in Mona Vale

patients and keep communicating with them. They were very understanding. The crisis affected everybody; they knew that we were affected too.

How was your practice recovery after the lockdown?

“During restrictions, we could only relieve pain and infections, but it was great to be able to help the community in our small way.”

During the shutdown we stayed connected as a team, shared training and webinars and learned from each other. We followed all the safety protocols and communicated that we were doing so to our patients. But still we worried whether patients would want to come back. The opposite was true; they fully trusted us. That was nice to learn.

Dr. Graham, what was the immediate impact of the virus outbreak on your practice?

What were the hygiene protocols you used to protect your team and patients?

Dr.Graham: The virus came slowly to Australia. It was only in March 2020 that the number of cases in New South Wales increased. Regulations then allowed us to accept only emergency cases for about six weeks. Afterward we could re-open under strict conditions, e.g., for non-aerosol generating procedures.

A lot of protocols, such as standard cross-infection control, extra personal

protective equipment and sterilizing instruments, were always in place. In addition, we asked our patients to stay outside until we called them in for the treatment session. We also had more hand sanitizer available, and we took away unnecessary objects, such as water bottles and magazines in the waiting room, or a chair at the payment desk.

What was your main learning from living as a healthcare professional during the pandemic? Appreciating the things we used to take for granted, like how we interact with our patients. Also, maintaining a high standard, whether in patient care or cross-infection-control protocols. We continuously reviewed our work and deliberately kept the team stimulated and challenged during the shutdown. This helped us stay prepared when we re-opened.

Photos: Alistair Graham

How did you communicate with your patients? First, we called the patients with standing appointments and informed them. Then we created e-mail newsletters for all patients in our database. We also followed that up with social media posts. We wanted to stay connected with our

“Starting the working week with a zoom staff meeting. We discuss the emergency patients and how the week will operate.”

OUTSIDE THE BOX

BRAZIL > First confirmed case on 26 February, 2020 > 40 336 Confirmed cases/1 million population* > 211 491 Deaths

Dr. Marcelo Nunes | Brazil University professor and dental surgeon in São Paulo

What were the hygiene protocols you used to protect your team and patients?

“Longer intervals between patient visits reduced the risk of contact at reception.”

Dr. Nunes, what was the immediate impact of the virus outbreak on your practice? Dr. Nunes: The immediate impact was the sudden interruption of all my clinical and academic activities. It generated the need to find a quick way to adapt to the new conditions of online courses and events in general.

How did you communicate that with your patients?

protocol will remain and will allow us greater control over the risks of contagion. The current situation will provide a new setting that will generate less disease spread. From an economic perspective, the pandemic had an unprecedented financial impact on our patients. We had to revise the high-cost treatment protocols and adapt them to patient budgets, so as not to compromise financial reserves.

Patient visits were distributed with longer intervals between patients, Upon reaching the clinic, patients are immediately taken to the bathroom for hand hygiene with antiseptics and 70 % alcohol gel. Air filtration and sterilization systems were implemented for the reception area and the clinic. All dental professionals and technical assistants must use the PPE recommended by the responsible authorities.

What was your biggest lesson from living as a healthcare professional during the pandemic? Leaving my comfort zone and adapting to the new reality of clinical practice and online events. I also had to look for new teaching methods that could maintain the quality, and the interaction with students.

How was your practice recovery after the lockdown? The recovery of my practice came through a more rigorous clinical protocol for biosafety, which is currently perfectly manageable. I see that this new

GEISTLICH NEWS 1-2021

“I believe that the newly adopted biosafety protocols will stay, and will allow us greater control over the risks of contagion.”

Photo: Marcelo Nunes

Mainly via WhatsApp. We explained to the patients the risks and impacts on health caused by contagion of the new corona virus.

CHINA > First confirmed case in late November 2019 > 68 Confirmed cases/1 million population* > 4808 Deaths Dr. Zhu Zhenghong | China The CEO of Taikang Bybo Dental

Dr. Zhu, what was the immediate impact of the virus outbreak on your practice? Dr. Zhu: From February to April we closed all clinics for general treatment, and until June for surgery. Taikang Bybo is the largest dental chain in China. With our huge costs, such as rental, utilities and labor, and no revenue, our cash flow was under great pressure.

How did you communicate that with your patients? For example, we started to organize some livestream programs to answer the patients’ questions. Our focus was healthcare during the pandemic, so patients could understand how an office visit could be avoided or when emergency treatment was necessary. I was surprised that during our first stream we had 100 000 participants. This inspired me to launch an online program, i.e., a charity event, with all benefits donated to Wuhan.

our model, called “Heartwarming GO PLUS,” to cover a wide range of treatments for all family members in a prepaid plan. It also establishes better communication between our dentists and customers.

What were the hygiene protocols you used to protect your team and patients? We strengthened our epidemic prevention and control measures. We established and expanded the online appointment and consulting platforms. Patients were precisely screened and triaged be-

fore treatment. Cross-infection control equipment was expanded. Also, all our healthcare staff took courses about prevention and control.

What was your biggest lesson from living as a healthcare professional during the pandemic? “Crisis” is a choice between “threat” and “opportunity.” We started to sensitively transform and digitize our work. We learned how to reduce losses, to recover and serve our patients, so as to finally overcome the challenge of the epidemic.

Photo: Wang Zhao

How was your practice recovery after the lockdown? Although it is now under control in China, this pandemic is a global crisis. It is unclear when it will end and how it will impact the oral health sector in the future. Something that helped our recovery after lockdown was the Taikang Bybo insurance model. In China, basic insurance does not cover the cost of most dental treatments. We launched

Patient’s temperature measured at reception.

OUTSIDE THE BOX

ON THE ROAD

TO FIND THE IDEAL BARRIER MEMBRANE

JORDI CABALLÉ-SERRANO is an oral surgeon & a scientific researcher.

Bern

As a clinician, I want a long-lasting good outcome for my patients when using the guided bone regeneration concept. Barcelo

As a scientist, I know the collagen membranes on the market are structured differently, so should have different regenerative properties.

At a dental congress in Bern

Studies show barrier membranes are important for the success of Guided Bone Regeneration (GBR) in implant dentistry.1

BUT which barrier membrane should I use? Should it look like periosteum?

Concentric lamellae Spongy bone

Periosteum

Fullthickness flap

Central canal

Releasing incision Osteocyte Blood vessel

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Nerve

Osteon

Once damaged in GBR, the periosteum needs 4-6 weeks to repair.2-3

Illustrations: Studio Nippoldt, Berlin

PERIOSTEUM is a dense layer of vascular connective tissue that covers most of our bones. It serves as a protection and as a channel for blood supplies and nutrients and provides progenitor cells for tissue regeneration.

We need to use a collagen membrane which replaces the periosteum until it is repaired. Nothing more and nothing less.

We need a FULLY biocompatible membrane, that allows vascularization and protects the bone underneath.

The collagen membranes have different properties. They are made from different resources and have been processed differently by manufacturers.

Conversations with Prof. Dr. Dieter Bosshardt, University of Bern

Let us test them in the lab, and see what kind of differences they have.

PHYSICAL AND MECHANICAL CHARACTERIZATION Geistlich Bio-Gide® showed all the physical and mechanical properties required for a membrane, e.g. for GBR.4 Botiss Collprotect®

Geistlich Bio-Gide®

Botiss Jason®

Tension

Genoss™ Collagen membrane – P

Lamina OsteoBiol®

Stiffness

Absorption

Wettability

Data normalized for the parameters which need to be either maximized or minimized, e.g. to achieve the highest wettability, as seen in Geistlich Bio-Gide®. With regards to stiffness, green lines mean: normalized to clinical cases where low stiffness is desired; black dashed lines mean: normalized to cases where high stiffness is desired.

Wanted membrane

Geistlich Bio-Gide®

Biocompatible

Easy to handle

Space maintainer

Bioactivation5

As a scientist, I want to understand the relationship between the structure and properties of the biomaterials.

It helps me as a clinician to choose the most trusted, as well as clinically and scientifically proven membrane for my patients.

Occlusive for desired period

Back in Barcelona References: see page 39

References: see page 39 OUTSIDE THE BOX

Focus on Gustavo Avila-Ortiz

“Every cloud has a silver lining” Marie-Terese Mucha | Osteology Foundation

Gustavo became a member of THE BOX team in 2015 and stayed until 2019. His first group meeting in Zurich was also his first time in Switzerland. He loved all aspects of the experience: he met old friends, made new friends and learned about the culture and vision of the Foundation. In subsequent virtual and in-person group meetings, they worked cohesively with the guidance and support of the Osteology Foundation office to expand, refine and monitor the structure and content of THE BOX. In 2016, Gustavo also joined the “Expert Council family.” “I treasure the invitation back in 2016. It

is something that I carry with honour and pride. Since I joined this “family” I have mostly served as a reviewer of grant applications and was also involved in several symposia, either as a speaker or on the organising committee. It has been both enriching and stimulating.”

A family always enjoys coming together “Osteology Monaco 2016 was the first Osteology educational event that I had ever attended, and I very much enjoyed the experience,” remembers Gustavo. In addition to the great programme and its speakers, Gustavo had a wonderful time at the social events. He met a number of new friends again with whom he enjoys coming together. In 2018, he was invited by the Foundation to be a speaker in the main programme and a judge in the research competition at the National Osteology Symposium USA (Phoenix). The topic of his presentation was “Maxillary Sinus Augmentation.” He had the opportunity to share the podium with giants in the field and he learned tremendously from all of them. “Kudos to the chairpersons Pamela McClain and William Giannobile and the rest of the team for organising such a high quality event,” he says. In 2019, Gustavo participated in the annual meeting of the AAP (American Academy of Periodontology) as a speaker during the Osteology Foundation session. He shared the podium with Purnima Kumar, Frank Schwarz and Paul Rosen. The title of his presentation was “Optimizing Single Tooth Replacement by Leveraging on Regenerative Therapy and Digital Technologies.” He adds: “I am so pleased to see how the AAP and the Osteology Foundation, two organisations that occupy a special place in my heart, have established a solid and mutually beneficial collaboration. It is through these synergies that we grow stronger together.”

Gustavo on stage at the Osteology Session at AAP 2019

Photo: Daniele Micieli

Gustavo Avila-Ortiz was born in Granada, Spain. Currently he is a tenured full professor and the chair of the Department of Periodontics at the University of Iowa College of Dentistry in Iowa City (USA). Six years ago he got in contact with the Osteology Foundation for the first time. The Osteology Foundation talked to him about how his professional career has developed since then and how the Foundation has supported him in this process.

Every cloud has a silver lining Since early March this year, after the outbreak of the COVID-19 pandemic, our lives and routines have been affected significantly. If nothing else, the history of civilisation has proven that Homo sapiens is a species that knows how to respond and adapt to challenging circumstances. And that is exactly what the organising team for the National Osteology Symposium USA did: respond and adapt to the circumstances in order to keep their commitment of holding a quality National Osteology Symposium. “It was a pleasure to be part of such an engaged and dynamic group!” he thinks back, proudly. Gustavo used the blessing in disguise and embraced the responsibility of being the moderator of the live sessions with enthusiasm. To some extent it was uncharted territory for everyone. “It was fun to interact with speakers that were thousands of miles away, as well to be the voice of the hundreds of attendees that sent questions and comments as the live session went on,” he reminisces. After this digital experience we asked Gustavo about his general opinion of the importance of digitalisation: “The importance is huge! The experience with the Virtual Osteology Symposium USA in April, the Virtual Osteology Symposium Sydney in June and, more recently, the Virtual Osteology Research Academy in September has proven that this mode of divulging basic and clinical science works and offers outreaching opportunities for the future. I believe that it should be viewed as a complement, rather than a replacement to traditional, in-person scientific events.”

Grasp the opportunity Gustavo remembers the moment in July of this year when he received a notification from the Osteology Foundation, informing him that he and his team had been awarded an Osteology Researcher grant. The project is entitled: Spatial Co-Localization of Immune And Microbial Cell Populations In Peri-Implantitis Lesions: A Quantitative And Architectural Analysis. We asked Gustavo to explain the aim of the study: “Our primary aim is to investigate the host-microbial dynamics in peri-implantitis lesions, by determining the inflammatory milieu in the affected tissue, localising the key immune cells, and mapping the microbial species that co-localise in the same affected tissue. We expect this study to generate new information that will contribute to the knowledge base of the etiopathogenesis of periimplantitis lesions.”

Gustavo adds: “I am definitely intending to apply for Osteology Foundation grants in the future. I love the fact that there are different opportunities tailored to different career stages, including young and senior investigators, as well as large grants to support specific projects with great potential that require a major financial investment. There is no other organisation like the Osteology Foundation. It is committed to supporting research and education for the ultimate benefit of our patients. These grants are evidence of that.”

Gustavo’s future steps “I am very happy where I am now. I have had the fortune and privilege of meeting and interacting with so many amazing people since I started to work closely with the Osteology Foundation. I would be delighted to continue to work with the Foundation in the future. I am committed to helping further the core mission of the Foundation, as I very much identify with the spirit of linking science with practice in oral regeneration through quality research and education,” he says, rounding off the talk.

“Being active within the Osteology Foundation has been enriching and stimulating.”

OSTEOLOGY FOUNDATION

Interview

A chat with Amanda Monteiro Interview conducted by Thomas Pfyffer

The "Geistlich Charity Walk & Run" found an NGO (non-government organization/charity) in “Turma do Bem” that deserves full support. And in the person of Amanda Monteiro, Geistlich has a competent and motivating project collaborator. Ms. Monteiro, you have been working with “Turma do Bem” since 2015. What does this NGO do? A. Monteiro: Turma do Bem supports the vulnerable population, including teenagers and female victims of violence with serious oral health problems. Our mission is to make dental treatments available to those affected by all forms of abuse that leave marks on the body, face, and mind. In the last 18 years, the Apolônias program of Turma do Bem has helped more than 80 000 victims of violence.

the current context of the pandemic, the Charity Walk & Run initiative helped us continue our services in 2021, when it was very hard to raise funds due to the current crisis. Thank you so much, again!

How are Geistlich Pharma’s donations used in concrete terms? Thanks to the Geistlich Charity initiative, we can cover the costs of dental treatment for about 50 female victims of violence. Edentulism or having poor dental health change every aspect of life and well-being, the ability to find a job, or even being loved. These women will get their dignity and self-esteem back. It is no exaggeration to say these donations change lives. What is your wish for the year 2021? The coronavirus pandemic has drastically affected the lives of the poorest people in Brazil. We are concerned about very basic things for this population. I hope that we can change this and build a world in which everyone can smile.

How did the Greek god Apollo come to be in the name of your program? The program was named after Saint Apollonia. She died in 248 in Alexandria, after being arrested, tortured, and all her teeth being violently pulled out or shattered. She is popularly regarded as the patroness of dentistry. Where do you see the greatest need for action for “Turma do Bem” in the future? The great need is to meet the countless requests of women who have been victims of violence. Also, we need to keep our volunteers, a network of more than 17 400 dentists, engaged in the program.

What conclusions do you draw from your cooperation with Geistlich to date? Geistlich is a company with real social responsibility. It has been supporting the Apolônias do Bem program in Brazil for about two years, both financially and through the donation of biomaterials. In

GEISTLICH NEWS 1-2021

Monteiro is a social scientist and has been in charge of institutional relations of Turma do Bem since 2015. Also, she is manager of the “Apolônias do Bem” and “Dentista do Bem” projects.

Photo: Gustavo Aquino

What impact did the corona pandemic have on the cause you are pursuing with the “Apolonias do Bem” program? In Brazil every two minutes a woman becomes a victim of domestic violence. The number increased by 50 % during the lockdown period, and thus increased the number of requests for dental treatment. Psychologists say, tension due to social isolation, especially if women live with a violent male partner, and separation from their relatives and friends in this period, all contribute to the rising number of victims.

Issue 2 | 21 will be published in July / August 2021. FOCUS

The new daily practice > How cost-effective are preventive regenerative treatments? >P atient information in challenging situations >S aving time with smart treatment approaches > L atest evidence from scientific literature

References for page 34-35 1

Bassir SH, et al.: Int J Oral Maxillofac Implants. 2018;33(5):979-94.

2 Hasuike A, et al.: In Vivo. 2019;33(3):717-22. 3 Nakahara K, et al.: Int J Oral Maxillofac Implants. 2016; 31(4):785-92. 4 Caballé-Serrano J, et al.: J Mech Behav Biomed Mater. 2019;97:13-20. 5 Caballé Serano J, et al.: J Clin Exp Dent 2018; 10(5): c477-83

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Geistlich News - Edition 1, 2021 (English)

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OSTEOLOGY FOUNDATION

A chat with Amanda Monteiro

Publishing information

Orthodontic tooth movement makes new bone formation

OUTSIDE THE BOX