Geistlich News Global - Edition 1-2022 by Geistlich_Pharma

GEISTLICH BIOMATERIALS

VOLUME 18, ISSUE 1, 2022

FOCUS PAGE 10

OUTSIDE THE BOX PAGE 30

OUTSIDE THE BOX PAGE 31

When complications happen.

An inside view of the new bone.

When cells resonate.

From understanding the human error, to acknowledgment, prevention and managing the complications.

Synchrotron image analysis unveils the three-dimensional microstructure of newly regenerated bone.

Music healing power can bring changes at the cellular level, even in cells that are not geared to receive sound.

Cover photo: ©iStockphoto, zsv3207

LEADING REGENERATION.

100

GEISTLICH NEWS 1-2022

Editorial

Change has become a constant companion. Complications are part of everyday life, at work and at home. Often described differently as challenges, complications can be everything from everyday minor incidents to fundamental problems. Human Factors are major drivers for complications but also the only solution to them. Human errors may lead to a chain of unfortunate events. The human mind, the ability to think and solve problems, is the key to overcoming obstacles and handling complications. “Better safe than sorry” is probably the most certain way to prevent complications and risks. At the same time, playing it safe may create barriers and prevent innovation and growth. Risk mitigation might lead to undesired side-effects, which again can lead to additional complications. So what is the solution? One step could be expectation management. This is a key leadership capability, especially in the so called VUCA world, where things are no longer predictable or controllable. Change has become a constant companion. It is therefore important to provide at least some process security, as the world, as we know it, becomes more volatile, uncertain, complex and ambiguous. We can read more about expectation management in Isabella Rocchietta’s interview on page 22.

Photo: Roger Schuler

Another solution could be to address the Human Factors directly. It is understood that interactions among humans, with our various traits, values, experience and behaviors, is the basis for our unique culture. Supportive and constructive cultures have the strength to transform complications into solutions, or even successes. And it is human nature to make mistakes. We can read more on the Human Factors and error in dentistry from Simon Wright and Ulpee Darbar on page 14.

A collaborative, trustful and innovative culture enables both approaches: handling and preventing complications. Personally, I am honored to work in such a culture. We hope we have inspired you to read about complications and dealing with them when they happen in your daily work.

Yours, Susanne Grund Director Corporate Human Resources, Geistlich Pharma

Issue 1 | 2022

NEWS

With Meta Technologies It’s time to make difficult things easy.

7 Less peri-implant bone loss in regenerated bone 8

A digital guide to preventive treatments

9 Join Geistlich at the EuroPerio 10. Precision for your construction masterpiece

10 Complications:

handling and prevention From understanding the human error, to acknowledgment, prevention and managing the complications. FOCUS

“Patient age alone is never a limiting factor.” Frauke Müller | Switzerland

“The main factor in the etiology of error is time pressure.” Interview with Simon Wright and Ulpee Darbar | United Kingdom

17 “Control of risk indicators may limit peri-implantitis and eventually implant loss.” Interview with Giovanni E. Salvi | Switzerland

20 “Treating dehiscences requires time and patience.” 22 “The most important time is the time we dedicate to patients.” Interview with Isabella Rocchietta | United Kingdom

GEISTLICH NEWS 1-2022

Illustration: Quaint

Interview with Amely Hartmann | Germany

THE

COMBINED GRAFT TECHNIQUE

OUTSIDE THE BOX

“Orthodontic treatment can start shortly after regenerative surgery.” Interview with Christina Tietmann and Karin Jepsen | Germany

Five questions for five experts

Navigation inside the 3-D pore structure of regenerated bone Yong-Gun Kim | Republic of Korea

When cells resonate. Klaus Duffner

34 The combined graft technique

Geistlich Mucograft and autologous tissue come together for better esthetics and less pain. Istvan Urban explains. ®

Illustration: © Studio Nippoldt, Berlin

OSTEOLOGY FOUNDATION

The Osteology Foundation. One of a kind in dentistry INTERVIEW

38 39

A chat with Ronald Jung Publishing information

IMPRINT Magazine for customers and friends of Geistlich Biomaterials Volume 18, Issue 1, 2022 Publisher ©2022 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.com Editor 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.

All premium tools in one hand

Meta Technologies have become an integral part of Geistlich Pharma. Together with Meta, Geistlich expands its premium offering as the regeneration specialist and provides clinicians with a wider range of state-of-the-art solutions in the field of oral regeneration.

SMARTSCRAPER All in-one, from harvesting to grafting

Geistlich Pharma has been working with Meta Technologies for many years now. Both companies are family-owned and committed to the long-term perspective and offer premium solutions.

Dr. Mauro Merli Italy

I had the pleasure of testing the MICROSS and I was very impressed: this bone harvesting device facilitates the removal of bone chips from the mandibular ramus-body allowing controlled and precise movement. It’s easy to handle and sufficient bone tissue is collected efficiently with a few easy movements, in total safety.

SafeScraper ® TWIST Minimally invasive with maximum access

MICROSS Minimally invasive cortical bone collector

It’s time to make difficult things easy… such as bone grafting in the posterior regions. S

Small granules, 0.25–1 mm

> Extraction socket > Minor and major bone augmentation > Sinus floor lift > Peri-implantitis induced bony defects Find out more

GEISTLICH NEWS 1-2022

Large granules, 1–2 mm

> Major bone augmentation > Sinus floor lift

Discover Geistlich Bio-Oss Pen®, user-friendly applicator filled with Geistlich Bio-Oss® granules.

Less peri-implant bone loss in regenerated bone 10-year outcome of sinus lift and staged implant placements vs. implantation in native bone¹

Retrospective case-series study with 86 patients

Implant predictability and complication rate after lateral window sinus lift using the sagittal technique

92 sinus lifts 209 implants

TREATMENT GROUPS Severe bone atrophy

Moderate bone atrophy

0.1–3.5 mm

Control

3.5–7 mm

Lateral sinus floor augmentation using Geistlich Bio-Oss® and Geistlich Bio-Gide® and staged implant placement

Implants placed in native bone in the canine or premolar areas – no GBR needed

RESULTS AT 10-YEAR FOLLOW-UP > Less peri-implant bone loss in regenerated

> 98.6 % implant survival rate 3 implants failed within 10 years

bone vs native Mean peri-implant bone level loss at 10-year follow-up (weighted average)

> 3.35 % prevalence of peri-implantitis 7 implants – no difference between groups

No complications in 97 % of the grafted sites Complications handled with antibiotics, graft rinsing and additional healing period

CONCLUSION

Severe atrophy

Moderate atrophy

Control

Adequate soft-tissue management and optimal biomaterials selection lead to less wound dehiscence which in turn leads to less marginal bone loss around implants in regenerated bone.

Reference 1

Urban IA, et al.: Clin Oral Implants Res. 2021; 32(1):60-74.

(clinical study) NEWS

A digital guide to preventive treatments

Talking about regeneration

PERIODONTAL REGENERATION FILL THE GAP RIDGE PRESERVATION

“Prevention is better than cure”. That’s why our New Daily Practice website focuses on treatments that prevent tissue loss in the first place, rather than how to repair larger defects later on. Periodontal regeneration, filling the gap and ridge

preservation are the exciting techniques featured on the recently upgraded site. Delivered in English and Portuguese, the New Daily Practice website will also be available in Spanish, French and Korean.

Decision Trees See your treatment options at a glance, to make an informed decision Technique Videos View in detail how the treatments are done Calculators Compare the benefits and costs of prevention versus classic treatments Checklists Boost your knowledge with the latest research and clincial recommendations

An innovative feature of the New Daily Practice website is the Patient Information section. In a series of short videos, experienced clinicians explain how they discuss preventive regeneration with their patients. You, too, can share your approach and recommendations by uploading your own explanatory video.

The Geistlich New Daily Practice website is a straightforward guide on how to achieve successful prevention. For predictable results in my daily practice, I use Geistlich Bio-Oss® Collagen and Geistlich Mucograft® Seal or FGG to seal the socket. For cases with loss of buccal bone, I use Geistlich Bio-Gide® Shape to support the bone substitute. Prof. Fabio Vidal, Brazil

new-daily-practice.com

GEISTLICH NEWS 1-2022

Start your own short video today and join the conversation!

Photos: ©iStockphoto, Thatphichai Yodsri | Geistlich Pharma

Patient Education Tips and tricks on how to discuss preventive regeneration with patients

The road to Copenhagen goes through the EuroPerio Series

Geistlich Industry Forum, June 16th 2022, 12:30-14:00

Meet Geistlich at the EuroPerio 10 in Copenhagen.

Periodontal Regeneration, from Challenge to Opportunity Lisa Heitz-Mayfield Periodontally compromised patients: Saving teeth or placing implants? Vanessa Ruiz-Magaz Ensuring long-term compliance: All I learned from treating periodontal patient

Dedicated to Prevention by Regeneration

Martina Stefanini Recession coverage: A step-by-step guide for predictability

Geistlich Hands-on Workshop, June 15th 2022 – 13:45-16:45

Save the bone and save the implant with soft tissue augmentation

Nadja Naenni

Daniel Thoma

Precision for your construction masterpiece.

Photos: ©iStockphoto, shapecharge | EuroPerio 10

Yxoss SurgiGide® is ReOss’ new tailor-made 3-D printed drilling template 1. Digital

2. Comprehensive

3. Versatile

Based on your patient’s imaging data & requiring no additional software

Precise & safe implant planning following all relevant parameters

Multiple case-specific variants from pre-drill only to complete implant insertion

Wax-up

Implant positions

Yxoss SurgiGide®

Yxoss CBR® (optional)

NEWS

FOCUS

Complications: handling & prevention

Illustration: Quaint

Medical errors, miscommunication or pre-existing medical conditions: what are the root causes of complications? Can we prevent the complications in the first place? What comes next when they happen?

GEISTLICH NEWS 1-2022

Dentistry for the aging population

“Patient age alone is never a limiting factor.” Frauke Müller | Switzerland Professor and chair of gerodontology and removable prosthodontics University Clinic of Dental Medicine, Geneva

We age healthier and live longer than we did a few decades ago. What does this mean for the oral health of elderly patients? Gerodontology facts A geriatric patient shows physiological signs of aging, e.g., decline in mobility and function, tactile perception, vision and manual dexterity. These signs are generally progressive and irreversible up to the point that the patient may become dependent on help for their daily activities. When we provide a denture for such a patient, special considerations are necessary. Also, the legal contexts, e.g., patient consent and compliance, are different compared with younger patients. Gerodontology is a specialty combining all disciplines of dentistry. It also overlaps with other disciplines, e.g., nutrition and public health. We still do not have many independent gerodontology departments worldwide, but the specialty is becoming more recognized, and university structures are adapting.

Our life expectancy has changed over the decades. Some 50 years ago, geriatric dentistry was barely developed, and there was a reason for that. The average age of the edentulous patient cohort was often 50–60, which is no longer the case.

Now we have studies with 85+ as the patients’ average age. We lose teeth much later in life, due to our healthier lifestyles, and there have been developments in dental materials, implants and regenerative dentistry. If all goes well, we can keep all our teeth right to the end. But due to much longer life expectancy, we may still experience some tooth loss. And edentulous patients are quite different from the ones we had 50 years ago. They are much older! Their mucosa is more fragile and inelastic. Their spongiosa becomes more brittle and affects the alveolar crest. The bony structure of joint articular tubercle is also subject to atrophy, so there are a lot of changes in the temporomandibular joints. We also have loosening of the ligament structures and atrophy of muscle bulk. Patients may lose about 40% of their musculature over their lifetimes,

which leads to less precise and less coordinated motor skills. We also see changes in the central nervous system and neuroplasticity, whereby the brain cannot easily adapt to the movement patterns of a new dental arch. All these factors should be considered when we define the occlusion for an elderly persons' prosthesis.

Do teeth age faster than the rest of the body? The oral cavity is part of the general human organism and may age the same way. Sometimes chronic oral diseases are the first indicators of something happening to the body. For example, with the onset of neurodegenerative disease, we lose weight in a very short time. The first sign is usually when dentures loosen. Patients come to see us, even if denture relining was done just six months previously. Analyses show the patient has weight loss and should be sent for more in-depth evaluations.

Osseointegration happens in older age too. Elderly patients should benefit from what modern dentistry offers, just like younger patients. Implants are very helpful for elderly patients, e.g., for retention of dentures. We also know that osseointegration happens in older age. In fact, the survival rates for implants are very good – over a 10-year observation period, 9 out of 10 implants will still be in place.¹ Age

“Elderly patients should benefit from what implant and regenerative dentistry offers, just like younger patients.”

FOCUS

itself is not a limiting factor for implant therapy. Also, there is no limit to using biomaterials for reducing morbidity.

When an implant is not the first choice. Sometimes a disease or the side effect of treatments contraindicate implant therapy. Cancer alone is not a contraindication. But when it is treated with radiotherapy or chemotherapy, or when the patient receives antiresorptive, bisphosphonate therapy for the treatment of bone metastases, then implant therapy may not be the best option. Also, I do not recommend implants when signs of cognitive decline and related deterioration of motor coordination are diagnosed. Alzheimers and dementia are progressive, and we do not have a treatment for them yet. So we need to provide appropriate retention, e.g., with adhesives. It may be less comfortable and less pleasant, but at the end of the day, we will be able to keep the patient’s mouth clean. Without the appropriate oral hygiene, every solid surface in the mouth may crystalize biofilms, which could later cause aspiration pneumonia. In elderly people, oral hygiene has a preventative effect on mortality from pneumonia.²

Geistlich Podcast All Ears on Regeneration

Complication rate increases with dexterity decline. We know that the risks of complications in the elderly are similar to those in younger patients as long as the patients can accomplish independent hygiene.¹ The risks increase when they are not able to perform oral hygiene themselves. In this case, we need to accompany our patients along their journey of functional decline, e.g., by de-sophisticating the denture and simplifying retention step-by-step. For example, when the patient is not able to clean the fixed prosthesis anymore, we can change it to a removable prosthesis, probably with bars or stud attachments. When manual dexterity declines further, we can change the abutment for ball attachment, or magnets, and at the end of the process, when the patient becomes too fragile, it may be prudent to remove the abutment, fill the component with provisional reline, and prescribe denture adhesives.

Compliance and the paradox of geriatric dentistry. Elderly patients are a dentist’s dream customers. They are punctual, they have time for follow-up visits, and they still believe in the white coat, which means they take doctors’ advice very seriously. And they can also be less demanding than younger patients. We call this the “paradox of geriatric dentistry,” whereby patients better accept situations that the dentist considers dissatisfactory or requiring urgent treatment. This attitude may create a discrepancy between treatment need and demand. Nevertheless, the patient’s inability to follow our instructions, due to their dexterity, func-

tional or cognitive decline, should not be considered “non-compliance.” Above 90, one out of three patients may have dementia. Although we may see the first signs, diagnosis should be confirmed by a specialist. Yet diagnosis is important, because it will have a big impact on our treatment planning. Approximately 6–8 years may pass between diagnoses of dementia and death, and towards the end the patient may not be able to comply with hygiene measures or dental treatments. This is why dementia patients have more untreated caries and/ or periodontal disease, a higher prevalence of tooth loss and also difficulties using their dentures.

We can’t leave these patients alone. Professional ethics oblige us to follow the patients and make sure they have access to care and oral hygiene. As these patients generally visit their doctors more often than their dentist, physicians and also family members can help detect issues. We need manpower for primary screening, and it is easy to train a family member to supervise the patient or support them when dependency increases. Most patients arrive at our office accompanied by a son, sister or partner who is somewhat fitter. We train these “caregivers” how to supervise oral hygiene or handle dentures, and we point out the weak points and important issues, along with what they need to do when they occur.

Digital dentistry is the future. Of all technical advances, digital dentistry has made the biggest impact on gerodontology by bringing access to many

Listen to the podcast and interview with Prof. Müller on “All Ears on Regeneration”.

“The risks of complications are similar to those in younger patients as long as the patients can accomplish independent hygiene.”

Elderly patients can be less demanding than younger patients, and accept situations that the dentist considers dissatisfactory or requiring urgent treatment.

Photo: Frauke Müller

more patients in rural areas and institutions. Clinical situations can be documented and sent to the diagnostic or support center. The workflows are much faster and reduce waiting time. With intraoral scanners, chair-time is much easier for patients who are afraid of impression-taking, gagging, and vomiting. And ultimately, we can provide the patient with a cost-efficient denture that is very similar to high-end prosthetics. 3-D printed dentures are versatile, accessible and comparable to milled, completely removable prostheses.³ In a double-blind, randomized, crossover study, we asked patients which dentures they preferred to keep, 3-D printed or milled, with both options available free of charge. The milled denture needed more adjustment in terms of clinical chairside time. Also, professionals could see the differences and say the printed denture was not as pretty. But it was quite amazing how patients liked both dentures similarly.

We can save the printed denture file on a computer and reprint it again when the denture is lost in the nursing home – something that happens quite often. Also, the price is attractive. Based on data from Switzerland, the printing cost is one-third of what a dental technician would charge, so the patient saves money by using CAD/CAM techniques. And in the near future when the price falls further, traditional relining technology will be more expensive than milling a new denture.

Esthetics are important at any age. We did a hypothetical study, where we asked a young and an elderly cohort: “If you had a denture, would you like it to look like the teeth you have now, or would you take the opportunity to have bright white flawless teeth?”⁴ The results were amazingly similar. Two-thirds of each group wanted to have a natural appearance consistent with their age,

and one-third said they would choose white teeth aligned like a string of pearls. And aesthetics is where patients should always have the last word!

Elderly patients are full of stories. Every moment with elderly patients is special and unforgettable. I remember one of my patients with an implantsupported denture that he could not insert easily since his stroke. After adjustments I placed the denture easily. He looked at me and said, “Wow, if you keep up this good work, one day you are going to be somebody!

References 1

Srinivasan M, et al.: Clin Oral Implants Res. 2017;

28(8):920-30. (clinical study) 2

Sjögren P, et al.: J Am Geriatr Soc. 2008; 56(11):2124-30. (clinical study)

Srinivasan M, et al.: J Dent. 2021; 9:103842.

(clinical study) 4

Hartmann R, Müller F. Gerodontology. 2004;

21(1):10-6. (clinical study)

FOCUS

Human factors, errors and patient safety

“The main factor in the etiology of error is time pressure.” Simon Wright MBE | United Kingdom Director of the ICE Hospital and Postgraduate Training Centre, UK

Ulpee Darbar | United Kingdom Consultant in Restorative Dentistry and Director of Dental Education at Eastman Dental Hospital, UK Interview conducted by Marjan Gilani

Dental teams make at least two errors per day, of which 1.4% may lead to an adverse event.¹ In this interview, the deputy and chairperson of the Advisory Board for Human Factors in Dentistry in the UK expand on the topics of awareness, errors and patient safety. Prof. Wright, when did you become interested in the topic of Human Factors and Errors in dentistry? Prof. Wright: My interest in the subject originated from a passion to drive safety in our teaching clinics. We wanted to develop protocols and processes that would help the students ensure that teaching clinics were as safe as possible. We listened to the work of our good friend Franck Renouard speaking about Human Factors at a conference, and his work² resonated with our thinking. What we were trying to do was exactly what Franck was talking about. When we introduced Human Factors into our clinics we started seeing not only what errors and mishaps occur but also the barriers that stop people from being open about them.

GEISTLICH NEWS 1-2022

How was it for you Dr. Darbar? Dr. Darbar: I work in a university hospital and in a dental practice too, so I am exposed to a wide range of challenges and mishaps of varying kinds. My personal experience was the observation that things were not working according to plan, but when trying to address the issue, people did not want to come forward, as they feared being blamed. These challenges made my team look at things differently. Our methods of using afteraction reviews showed that a simple mishap was clouded by multiple factors that we today refer to as Human Factors. After discussing with Simon, we realized that we were in different ways trying to address a number of the issues that were aligned, but in different settings. This was the beginning of the

National Advisory Board for Human Factors in Dentistry (NABHF), which was established in July 2018.

What is the core mission of the board? We want to raise awareness and understanding of human factors across all sectors in which dentistry is delivered, and work towards empowering a culture of openness in which “blame” is not the focus.³ Our aspiration is to move mindsets of dental care providers, teams, policymakers and regulators away from the fear of “retribution and reprimand” to one of openness, channeling the concept of “something will go wrong, and how are we going to deal with it,” and embedding this ethos into the day-to-day working environment.

Are there some clinical errors that happen more frequently? And if so, why? Latent risk factors, such as communication errors, equipment-, environment-, systems-related and stress and fatigue, play major roles in errors and mishaps. However, the consequences of common human error in dentistry, like wrong tooth extraction and wrong-site surgery, do not, in most cases, lead to fatality, and as such, the emphasis is based on patient safety. For example, staff working with experienced clinicians are often afraid to raise any concerns. An experienced clinician is fitting an implant screw-retained crown in a patient using some very small drivers. The nurse assisting tried to suggest the use of floss tied to the driver to stop it from falling. The clinician ignored the suggestion and continued with the treatment. During this time, the patient suddenly moved and the clinician dropped the driver into the mouth

which the patient subsequently swallowed. Fortunately the patient did not inhale the driver, but still had to go through the process of having a chest radiograph. Another example is when a patient presents with an emergency relating to a tooth that needs extraction. A decision to extract the tooth is made. Upon administering local anesthesia, there is an adverse event with the patient fainting, resulting in the extraction being aborted. At a subsequent visit, it transpires that fainting episodes had occurred at other, previous visits but were not documented in the clinical records. During analysis, it transpired that the dentist was always running late with appointments, as the clinic was overbooked and usually under a lot of pressure.

Photo: Advisory Board for Human Factors in Dentistry, UK

Is it possible to reduce the prevalence of errors caused by stress and fatigue? The main factor in the etiology of error is time pressure, and this is best addressed with better time management.¹ There are some simple things that a clinical team can do to minimize stress, after identifying the cause. If during clinic time there are frequent interruptions, e.g., with people walking in and out of the operatory, such interruption should be stopped. If the clinic is constantly running late, then using self reflection to identify what is going on and addressing the reasons will help to change things and when treating patients treatment plans should be kept simple and manageable to reduce risks. This should be done ideally individually but also as a team supporting each other. Clinicians often worry more about others than themselves. Unless we can raise our

Some of the representatives of the National Advisory Board for Human Factors in Dentistry. From left to right: Peter Dyer, Cemal Ucer, Ulpee Darbar, Fiona Ellwood, Len D’Cruz, Simon Wright, Priya Chohan, Hannah Pugh, Shareena IIlyas.

own awareness of the challenges and acknowledge the value of “me time” in keeping the balance, it can become an upward climb with no end in sight. And this may lead to a higher chance of mishaps occurring with a negative consequence on our wellbeing. Being open about these challenges is also invaluable in not feeling alone, especially as clinicians work in dental surgeries that are self-contained spaces. Asking for help early is critical to avoid risk. Taking these simple steps will help change mindsets and manage our mental resources, which are key parts of patient safety.

What other mindset changes are essential? Focusing on the individual who caused an error promotes a “blame culture” and overlooks the reason the error occurred in the first place. Thus, we need to change our mindset to consider a system-centered approach that acknowledges all humans

will make errors and that the underpinning systems and environments they work in should be designed to prevent such errors. Donald Berwick said, “We must accept human error as inevitable and design around that fact.” It is OK to make a mistake, but it is important to talk about it and learn from it as well as others learning from it. Changing mindsets is not easy at the best of times; however, if done in a proactive and non-threatening way, where retribution is not the reward, we may get to the point of encouraging openness and acknowledgement. In today’s healthcare system, a “we can do no wrong” approach is detrimental not only to patient care but also to ourselves, as evidenced by growing litigation. Unfortunately, evidence shows that certain personality types, such as the macho, impulsive, anti-authoritarian,

“A ‘we can do no wrong’ approach is detrimental not only to patient care but also to ourselves.”

FOCUS

“Understanding how to use digital dentistry correctly requires experience and learning at the analog level. ”

have a negative impact on patient safety and are particularly common in dental surgeons. A superiority bias makes dentists think they are better than other dentists and gives them a feeling of invincibility and infallibility that evokes the adage: “I never make mistakes, and it will never happen to me.” This means that if a mistake were to happen, they would not own up to it, or worse, would still not recognize the mistake at all. Such behaviors, with lack of understanding and fear of retribution, are the main barriers to reporting mishaps in dentistry, which is further compromised if there are no appropriate and easy to use reporting systems.

Do you remember the last time you made a clinical error? Prof. Wright: A few weeks ago, I had to cancel a surgical appointment and rebook the patient because the surgical guide could not be found. Our normal protocol is to check everything a couple of days before, but on this occasion the surgical guide was not listed as a required tool. The team had not checked the records and did not realize it was needed. As they explained, “Right now we are just so busy!” I had to take the comment to heart and revisit how we do things and include the point on the pre-operative check list. Using the WHO surgical checklist, which we have adopted for dental use, can be helpful.⁴ Dr. Darbar: I have been seeing a patient with learning difficulties for many years. Her last appointment had made before Covid pandemic and lockdown. I made three attempts at undertaking a telephone consultation, all unsuccessful, so I advised

GEISTLICH NEWS 1-2022

our administration team to contact the patient. The next thing I knew was that the patient’s father had made a formal complaint about how his daughter had been treated. The letter stated that I had refused to see the patient and had asked for her to be discharged. I was shocked and taken aback. I looked into what had gone on and unbeknown to me, the patient had been contacted by our administration team saying she was discharged. The complaint was resolved when I saw the patient with her father and explained the circumstances.

Are Human Factors taught in dental schools? Human Factors were only considered later on well into the professional lives of clinicians. However, as awareness of its importance to patient safety has risen, it is now being included in the undergraduate curriculum. But the way the topic is delivered varies by university, and most teach it as a separate module when it should underpin all core modules. In the UK at foundation level, immediate post registration training has now introduced Human Factors as a key learning concept, and both the National Health Services and Health Education England have embraced it in their concordance as well as in their safety agendas. Our Board is working with regulators to ensure that Human Factors is an integrated component in UK dental curricula.

What role does social media play? It is a powerful tool in raising awareness and sharing information. However, if not used properly, social media could also be

detrimental to the cause. It can help raise awareness that human factors encompass a number of components of which latent factors are major in dentistry. It can also be used to drive a mindset change and help clinicians move away from worry and fear about litigation, regulation and being judged by their peers, while also promoting the concept of “sharing is caring.”

Machines make fewer mistakes than humans. Will digital be the future of dentistry? Machines are subject to human error, either in their programming or operation. Digital workflows will change how we do dentistry, but in highly complex cases where they are most useful, there are significant limitations. Digital dentistry is a double-edged sword. It can simplify treatments only if the clinicians know what they are doing. To understand how to use digital dentistry correctly requires experience and learning at the analog level. Without this, it would be impossible to know where the mistakes can happen or have happened. After all, our patients will never be “digital,” and dentists attempting procedures beyond their skills but relying on digital workflows can create more complications than solutions.

References 1

Wright S, et al.: Faculty Dent J 2018; 9: 14–19.

Renouard F, et al.: Int J Oral Maxillofac Implants. 2017; 32(2):e55-e61.

‘Human factors’ board releases position paper. Br Dent J. 2020 Jul; 229(1):11.

Wright S, et al.: Br Dent J. 2018 19. Epub ahead of print. doi: 10.1038/sj.bdj.2018.861

Prevention is crucial, at all stages

“Control of risk indicators may limit periimplantitis and eventually implant loss.” Giovanni E. Salvi | Switzerland Associate Professor, Vice Chairman and Graduate Program Director University of Bern, School of Dental Medicine Interview conducted by Marjan Gilani

“Biological complications around implants are a reality we need to face,” says Giovanni Salvi, associate professor in the department of periodontology at the University of Bern. He believes clinicians can prevent implants from reaching the final stage of peri-implantitis, if problems are detected early. Prof. Salvi, explantation is an emotional burden for patients. How often do implants fail? Prof. Salvi: Early implant loss happens in about 1–2 % of cases when the process of osseointegration is disturbed.¹ This may occur because of reasons such as lack of primary stability, infection after placement or unintentional early loading. Late implant failures, on the other hand, may occur because of late diagnosis and lack of treatment of peri-implantitis. Peri-implantitis is an inflammatory disease initiated by bacterial biofilms. It is characterized by the presence of bleed-

ing on probing (BoP) and/ or suppuration, increased probing depths compared to previous examinations and by the presence of bone loss beyond normal crestal bone level changes resulting from initial bone remodeling.² The reported prevalence of peri-implantitis ranges from 1 to 47% (mean 22 %).³ However, the wide range of reported prevalence in the literature reflects the high heterogeneity of clinical and radiographic thresholds adopted for disease definition, which makes a precise estimate of the prevalence of peri-implantitis difficult.

“When we let an implant reach the final stage of periimplantitis, no one can perform a miracle to save it.”

What is the key to peri-implantitis control? Several risk indicators have been identified that may lead to the establishment and progression of peri-implantitis. Hence, control of such risk indicators may limit peri-implantitis and eventually implant loss. These risks may include poor self-performed plaque control⁴, tobacco consumption⁵, history of treated periodontitis⁶, restorations with inadequate access for plaque control⁷, presence of excess cement⁸, lack of compliance with regular supportive care⁹–¹⁰ and lack of treatment of peri-implant mucositis¹¹.

Can all implants be saved following peri-implantitis therapy? Unfortunately, not all implants can be saved in the long-term following therapy for peri-implantitis. For example, 5-years following surgical therapy of peri-implantitis with open flap debridement, adjunctive systemic antimicrobials and regular supportive care, implant loss was still observed in 17% of cases.¹²

How do you proceed when explantation is the only option? Implants having completely lost osseointegration are mobile and can be explanted without having to raise a mucoperiosteal flap. Hence, from a diagnostic

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point of view, assessing implant mobility is of no value since it reflects irreparable damage. If there is residual osseointegration and the implant is not mobile, one can use special instruments to unscrew the implant with or without raising a flap. And if the situation requires it, one can raise a flap and remove as little bone as necessary to unscrew the implant.

Can the use of biomaterials help following explantation? First, patients should be informed about the indications, origin and scientific documentation of the biomaterials used following explantation. As illustrated in the clinical case (Fig. 1), following explantation it may be necessary to use biomaterials as adjuncts to the reconstruction of the alveolar crest with an autologous bone block. This may be accomplished by using a deproteinized bovine bone material (Geistlich BioOss® or Geistlich Bio-Oss Collagen®) covered with layers of a resorbable collagen barrier membrane (Geistlich Bio-Gide®). In cases of augmentation of the peri-implant soft tissue volume, the use of a collagen matrix (Geistlich Fibro-Gide®) may be considered.

Are implants placed after explantation still predictable? Following explantation, a reevaluation of the clinical and radiographic situation is indicated. Depending on the chief complaint of the patient and the residual risks, several options for the new prosthetic rehabilitation should be considered. These may involve removable as well as fixed tooth- or implant-supported reconstructions. Despite the lower survival rate of implants placed in sites of previous explantation¹³, a new treatment plan, including the use of new implants, may be considered.

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“The wide range of reported prevalence of peri-implantitis in the literature reflects the high heterogeneity of clinical and radiographic thresholds adopted for disease definition.”

How do you prepare patients for implant complications, including implant loss? Sometimes patients are not sufficiently informed about long-term technical and biological implant complications. Signs of early complications, such as soft tissue inflammation and initial bone loss, are not accompanied by symptoms detectable by the patient, such as pain and implant mobility.Therefore, early diagnosis by dental professionals¹⁴ and therapy of initial complications⁹, ¹¹ are highly recommended to prevent greater damage or even implant loss.

When was the last time you had to explant an implant? An explantation should not be the first choice when complications occur. Very recently, however, I had an explantation that was unavoidable after a large-diameter implant had been placed in the esthetic area immediately following tooth extraction, without respecting a correct prosthetic positioning, and restored with a single-unit crown that was not accessible for plaque control.

References 1

Esposito M, et al.: Eur J Oral Sci. 1998; 106(1):527-51. (systematic review)

Berglundh T, et al.: J Periodontol. 2018; 89 Suppl 1:S313-S318. (consensus report)

Derks J, Tomasi C.: J Clin Periodontol. 2015; 42 Suppl 16:S158-71. (clinical study)

Ferreira SD, et al.: J Clin Periodontol. 2006; 33(12):929-35. (clinical study)

Heitz-Mayfield LJ, Huynh-Ba G.: Int J Oral Maxillofac Implants. 2009; 24 Suppl:39-68; 33(12):929-35.

(clinical study) 6

Sgolastra F, et al: Clin Oral Implants Res. 2015; 26(4):e8-e16. (meta-analysis)

Serino G, Ström C.: Clin Oral Implants Res. 2009; 20(2):169-74. (clinical study)

Wilson TG Jr.: J Periodontol. 2009; 80(9):1388-92. (clinical study)

Roccuzzo M, et al.: Clin Oral Implants Res. 2014; 25(10):1105-12. (clinical study)

10 Monje A, et al.: J Periodontol. 2017; 88(10):1030-1041. (clinical study) 11 Costa FO, et al.: J Clin Periodontol. 2012;39(2):173-81. (clinical study) 12 Heitz-Mayfield LJA, et al.: Clin Oral Implants Res. 2018; 29(1):1-6. (clinical study) 13 Machtei EE, et al.: Clin Oral Implants Res. 2008; 19(3):259-64. (clinical study) 14 Salvi GE, Zitzmann NU.: Int J Oral Maxillofac Implants. 2014; 29 Suppl:292-307. (systematic review)

Fig. 1: Failed prevention:

A 33 years old patient had lost teeth 12 and 13 (FDI Dental scheme) in a sports accident. He had received a buccally placed implant immediately after site augmentation. The site had shown early infection and soft tissue healing was suboptimal. After the diagnosis of peri-implantitis, the patient was referred to Bern university clinics for treatment. C

| A Initial clinical situation of implant-sup-

ported crown in area 13 with mesial cantilever extension. | B Periapical radiograph documenting extensive bone loss around the bone level implant in area 13. | C Intrasurgical situation of bone level implant 13 before explantation. | D Sinus floor elevation and G

bone block from the retromolar area used for augmentation of the site 13 (courtesy of Prof.

Photos: Giovanni E. Salvi, Vivianne Chappuis

V. Chappuis, University of Bern, Switzerland). | E Bone block covered with Geistlich

Bio-Gide® (courtesy of Prof. V. Chappuis, University of Bern, Switzerland). | F New screw-retained crown on implant 13 with mesial cantilever extension. | G Periapical radiograph of the new tissue level implant in area 13. | H Smile line of the patient following delivery of the new implant-supported reconstruction.

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Membrane exposure: complication or not?

“Treating dehiscences requires time and patience.” Amely Hartmann | Germany Oral surgeon, Private Practice Dr. Seiler and colleagues, MVZ GmbH, Germany Interview conducted by Marjan Gilani

Amely Hartmann is an oral surgeon who has contributed to the clinical development of Yxoss CBR® since its early days.¹ She answered our questions about membrane exposure after major bone augmentation with 3-D printed mesh. Dr. Hartman, let’s start with a frequently asked question: how predictable are implants placed in regenerated bone with 3-D mesh technique? Dr. Hartmann: The implants are very predictable. Different studies show implant placement is possible in 100% of cases,²-⁵ with an implant survival rate of almost 98% after 5 years of follow-up.³ And this is no surprise – implants are predictable since we place them in the patient’s own, regenerated and vital bone. In practice it is easy to see the stability and vitality of bone volume when the implants are inserted.

“Membrane exposure doesn’t necessarily mean complications.”

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Does the etiology of the defects affect the success rate? In my experience, etiology does not play a major role, though scars from previous surgeries may lead to more difficulties when handling soft tissue.

Still, dehiscence is a complication that can occur during major bone augmentation with Yxoss CBR®… No therapeutic approach in such a difficult area is without disadvantages. But morbidity is lower with Yxoss CBR® compared to harvesting bone blocks from intra- and extraoral donor sites or the iliac crest. Exposure occurs in 20–30 % of cases with Yxoss CBR®, but we have shown this doesn’t have an impact on the survival rate of implants and long-term clinical outcomes.

What does this mean? One factor is time – when exposures occur.⁵ Early exposure happens within the first four weeks after surgery, mostly due to wrong surgical handling of the soft tissue and putting too much tension on it.

To avoid this, wound closure should be without tension. I always insert additional deep sutures with resorbable materials. Early exposure may also happen when the soft tissue edges are not well protected by the dressing template (suck down splint), so the patient can play with their tongue in the area. It is why using a dressing template has positive effects. When the early exposure happens, we visit the patient in closer time intervals, e.g. weekly, and clean the area with the saline solution without disturbing wound healing. On the other hand, the exposures which happen later are often due to mechanical factors e.g. when the patient has no pain, feels good, and gets careless during the healing period. In this scenario, I prescribe 0.05–0.1 % Chlorhexidine solution which patients can use for disinfecting the area on their own.

Once exposure occurs, when do surgeons need to wait and see, and when do they need to intervene? We should remember that exposure doesn’t necessarily mean complications. Of course, we hope no exposures occur, but I personally do not panic if they do. When we panic we may immediately want to re-suture or remove the mesh, which are more harmful. Instead, we should have the patience to wait. But, of course, we must deal with infections.

How do you discuss exposure with your patients? Well, you must talk to them in advance – tell them that there is always a risk of

| A Intraoperative fitting of the customized

titanium scaffold- see the extensive deficiency in the alveolar ridge. | B The augmented site with autologous

bone chips mixed with Geistlich Bio-Oss® granules in a 50:50 ratio augmentation. | C Geistlich Bio-Gide® membrane is used to

cover the customized mesh. | D Protection of the soft tissue edges, after suturing, using a dressing template. | E Radiological evaluation after insertion of implants into the regenerated alveolar ridge.

exposure, and if it happens, you will keep it under control. There will be more frequent visits, and patients should be reassured that they can contact you if they have questions or problems. There is always benefit in having this dialog with patients in the beginning.

Photo: Amely Hartmann, Private Practice Dr. Seiler and colleagues

Is it possible to reduce the risk of exposure? Definitely. The risk for exposure depends a lot on the surgeon’s experience in following the protocols.¹ Today I have much less exposure than when I started. I use a two-step suturing approach, with resorbable sutures first and then non-resorbable sutures on top, without any tension. I also use Geistlich Bio-Gide® to cover the mesh, and a wound dressing template. It is important to look at the soft tissue vascularity and biology. Our general protocol involves Geistlich Bio-Oss® and autologous bone in a 1:1 ratio.

When was the last time you dealt with exposure? Three months ago. I had a patient with exposure in the augmented area in the maxilla. We maintained and controlled the exposed area for half a year. There

was no infection, and no huge bone loss after removal of the mesh, so implants were placed as planned. In general, in cases with major infection, I prescribe antibiotics. But usually cleaning the mesh is enough. And if we have more bone loss after mesh exposure, I use Geistlich Bio-Oss® granules for alignment.

Are there situations in which you must do something immediately? Yes, for example, when there is an infection, or when there is a lot of food impaction. Then I clean the site with saline solution and prescribe antibiotics to control the situation. But I have never removed the mesh just because of exposure.

In case of exposure and inflammation, we may partialy lose bone. Early exposures with infection are more dangerous and should be watched carefully. But even then, we will not lose all the bone, but only a small part. And then, after we remove the mesh, a small GBR for alignment is usually enough.⁷ Re-suturing, re-opening, and early removal of the mesh are the most common mistakes in dealing with exposures.

Is “patience” the right plan in other exposure scenarios other than Yxoss CBR®? I remember some cases of membrane exposure with bone blocks. With blocks, revascularization is difficult. You may lose the block. So the problem is bigger, and an intervention more necessary.

References 1

Hartmann A, et al.: Clin Implant Dent Relat Res. 2021; 23(1):3-4. (clinical study)

Hartmann A, Seiler M.: BMC Oral Health. 2020; 20(1):36. (clinical study)

Hartmann A, et al.: Implant Dent 2019; 28:543-550. (clinical study)

Sagheb K, et al.: Int J Implant Dent. 2017; 3(1):36. (clinical study)

Chiapasco M, et al.: Clin Oral Implants Res. 2021; 32(4):498-510. (clinical study)

Volkmann A et al.: Implantologie 2020; 28(1):79–86. (clinical study)

Seiler M et al.: J Oral Sci Rehabil 2018; 4 (1/2018), 38-46. (clinical study)

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Handling Patient Expectations

“The most important time is the time we dedicate to patients.” Isabella Rocchietta | UK Honorary Senior Research Associate, department of Periodontology, UCL Eastman Dental Institute, London Private Practice London. www.ID2courses.com Interview conducted by Marjan Gilani

Giving bad news isn’t easy. Getting bad news is even harder. How can clinicians ease understanding and support patients when the risks of complication are high?

Dr. Rocchietta: I never promise perfection, even though I know the results could be close to perfect. Perfection and 100% success don’t exist in medicine, by definition. Instead, I try to under promise and over deliver. For example, when a case demands high esthetics, I’d rather say that we will strive to achieve “natural harmony” than “perfect results.” We need to evaluate the initial conditions, make sure that the diagnosis has been performed thoroughly, and subsequently inform the patient about all the risks and possibilities. A common mistake in clinics is that patients come in

“When we take the time to educate patients, they are much more compliant.”

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with a missing or fractured tooth, and we start the therapy by focusing only on that problem, without looking at the surrounding issues. Obviously, this is even more important when we treat a referred, failed case. We should always stay humble, understand all the risks of the procedure we perform, and explain to the patient why the situation could have a less favorable outcome. Patients get tired of all the treatment processes, and the financial stakes are high. Patients should get all of this information, including the risks, several days before surgery in a written consent form. This way they have time to consider and understand the procedure and tend to have more realistic expectations.

Does this mean you talk about technical complications? How do you help patients, who are not medical professionals, understand? Patients are different. Some have full trust and do not want to hear any explanation, and some search for cases online and watch YouTube videos be-

Photo: Xxxxxxxxxxxxxxxxxxxxx

Dr. Rocchietta, patients love a miracle. What do you do when you know that the results patients expect cannot be achieved?

“The accessibility of medical information has made a massive difference.”

Did your online visits begin with the pandemic? Yes, and telemedicine is indeed a valuable and powerful tool. It became a crucial topic with the pandemic. During the lockdown, the only way we could talk to our patients, reassure them or give them advice and postoperative instructions, was through online visits.

What are the most powerful communication tools? With all the digital tools we have nowadays, telemedicine is much easier.

fore the visit. We need to adjust according to who the patients are and what they can understand. A lot of this comes with experience. In school nobody teaches us how to be psychologists. But there is one unchanging fact: when we take the time to educate patients, and they understand the procedures, they are much more compliant.

Have you ever found yourself worrying about complications more than your patients worry? All the time. Clinicians know what could happen, which makes them worry more. Severe periodontal disease can cause bleeding on probing and other symp-

toms, but not necessarily pain. So, the patient is completely unaware of what is going on in their mouths. We need to be very strict when it comes to review and follow-up appointments. Before starting the treatment, I always make sure the patients are available for visits every week for the first month, every two weeks for the second month, and then once a month thereafter. And they need to comply with post-operative instructions. With all the digital tools we have nowadays, telemedicine is much easier. Sometimes we have a Zoom meeting to make sure that patients understand post-op instructions, or they send us a quick photo instead of planning a face-to-face visit.

Technology helps. But the most important asset is the time we dedicate to patients. I use 3-D models that can be easily and cost-effectively built from CBCT scans. Also, photography is an enormous help. We have a large screen where we show all the collected diagnostic data so we can better and more fully discuss patient conditions and prognoses. So they can consider and digest the information after the first consultation. We also give patients written reports including PowerPoints of intraoral images and radiographs.

Communications failure: What’s the most common cause? I think it is time management – always being in rush or late so we do not have the time to spend for one-to-one exchange with the patient. Reserving and dedicating this time completely changes the outcome, especially when understanding possible post-operative outcomes and homecare are more critical. Once the trust

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is built, even if something doesn't go as planned, the patient understands, and it will be okay.

Do you remember the last time you dealt with a complication caused by miscommunication?

Can a communication protocol reduce the risks of complications? For sure. I think the most important measure to avoid complications is communication between the team members. All teams members should be on the same page, including what the patient has been told so stress levels stay under control.

All team members should be on the same page, so stress levels stay under control.

How should communication be implemented in the real world? By training, checklists, regular staff meetings, … and spending all the time necessary to talk to the team, to reassure and encourage them. Rather than the surgeons, for patients it's almost more important that the receptionists and nurses are kind and attentive. Patients accept that surgeons are less talkative and have less time, but they open up, chit-chat, cry and tell their stories to the nurses. If patients feel we are a safe and experienced

“The most important measure to avoid complications is communication between the team members.”

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team, they trust and listen more than if they find the team disorganized and stressed. And we don’t just see a patient half an hour before the operation. We see them when they go to the hygienist, for checkups, assessments and reevaluations. We have a lot of opportunities to communicate with them at various stages, to build our relationship and bring them to where we hope they will arrive in their therapy. The team should know how important this relationship is.

Are patient-clinician relationships easier today? Yes. A decade ago, there was almost no communication between patients and clinicians. The doctor was the key healthcare provider – the one who dictated the rules patients had to follow. The accessibility of medical information has made a massive difference. Anyone can find out about a procedure and better understand our therapies.

Photo: Isabella Rocchietta

A few months ago, I had to perform a vertical augmentation GBR in a very large defect. The patient flew back to his home city and continued the therapy with the referral dentist who did not follow our post-op guidelines – maybe he had not read our email. The patient got a fixed resin retained restoration that was too tall and impacted the soft tissue, opening it up. He had to come back to our office. We reopened the case, removed the membrane, saved what could be saved and redid the GBR. Not so pleasant.

Interdisciplinary approach for patients with stage-IV periodontitis

“Orthodontic treatment can start shortly after regenerative surgery.” Christina Tietmann | Germany Periodontist, Private Practice for Periodontology Aachen

Karin Jepsen | Germany Priv. Doz., Center for Dental and Oral Medicine University of Bonn Interview conducted by Verena Vermeulen

We discussed two publications documenting treatment of stage IV periodontitis. Both studies were about the combination of regenerative periodontal surgery and orthodontic tooth movement. Is this a valuable combination? Whom does it help? Dr. Tietmann, we are talking about patients with stage IV periodontitis. What characterizes them? Dr. Tietmann: These patients show severe attachment loss and vertical bone loss. The most visible sign of stage IV periodontitis is pathological tooth migration, the typical drifting and flaring of the anterior teeth. You can usually see these patients hiding their smile because they are unhappy about the compromised esthetics. Furthermore, they suffer from functional problems due to the loss of teeth in the posterior region and tooth mobility.

When they come to your office, what is their expectation? Major concern is to keep their own dentition. Due to the esthetic and functional changes they want to get the migrated

teeth realigned and regain esthetics and masticatory function. Very often, pathologic tooth migration of an anterior tooth is the first sign for the patients which makes them seeking – periodontal – treatment. A lot of the patients already had many dental visits and were told their teeth would have to be extracted and would need either implants or removable prostheses.

Implant placement in a patient with a history of severe periodontitis is also not very predictable… That’s true. Periodontal problems must be solved first, before implants can be placed, and still there is a threat of peri-implantitis, because a history of periodontitis is a risk factor for implants. Within the days of periimplantitis it is the major goal to keep the natural dentition as long as possible.

How do you usually treat such patients? It’s a three-step approach. The first step is always to control the infection – antiinfective treatment must be finished before moving on. Second step is periodontal regenerative surgery. This means that I open a flap with minimally invasive surgical techniques to clean the defect and the root and use biomaterials to regenerate the vertical bony defect. It is crucial to stabilize the blood clot during the healing period of regenerative therapy for successful results in mobile teeth. This can be done either by retainers or by implementing the orthodontic appliance before periodontal regenerative surgery starts. And then, the final step is orthodontic treatment. In our retrospective study we started orthodontic tooth movements 3 months postoperatively. Orthodontic counselling has to take place early in the treatment – during anti-infective therapy and before moving on to regenerative therapy. You need to develop a joint vision about the interdisciplinary treatment plan - communication between periodontist und orthodontist is very important in these complex cases.

You published a retrospective study including 48-patients who received periodontal regenerative surgery plus orthodontic treatment, and you had followups up to 4-years.¹ What did you learn? At 1-year we found a mean radiographical bone gain of 4.67 mm (see infographic). Also, the pocket reduction was impressive with 87 % pocket closure. These findings remained stable or even improved

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“For patients with stage-IV periodontitis, this combined approach is less costly in the long run and more predictable than implant therapy.” Dr. Tietmann

over time. We only lost 3 out of 526 teeth, not for periodontal but for endodontic reasons. It is important to mention that a majority of these teeth was considered to be “hopeless” at the beginning of the treatment.

What feedback did you get from patients? Most striking for them was that they could keep their teeth and could smile again. But also regaining function and being able to chew again was very important.

Were they also happy with the cost-benefit ratio of the treatment? Yes, even if this treatment is expensive I always put the costs into perspective by comparing them with the costs of an implant solution. For such patients, this combined approach is less costly in the long run and more predictable than implant therapy.

Dr. Jepsen, you also investigated this combined approach in a multi-center RCT of 43-patients.² You focused on the best time point to start the orthodontic treatment. What options are there, and what did you learn? Dr. Jepsen: We investigated how timing of orthodontic therapy affects outcomes of regenerative periodontal surgery. So far there had not been any prospective randomized controlled clinical trials on this topic. The aim of our study – that was supported by an advanced researcher grant from the Osteology Foundation – was to compare the early initiation of

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orthodontic therapy – four weeks – and late orthodontic therapy – six months – following regenerative surgery to treat intrabony defects in patients with stage IV periodontitis and pathologic tooth migration and to establish the clinical superiority of one treatment protocol. It was a joint effort of teams from Germany, Italy and Spain.

Did you get a clear result? Dr. Jepsen: Yes. Clinical attachment gain at 12 months, our primary endpoint, improved in a similar way in both groups. No statistically significant differences between groups could be observed for CAL gain (see infographic). Results with early orthodontic therapy were at least as good as the results achieved after late orthodontic treatment. The outcomes suggest that initiation of orthodontic therapy is possible as early as four weeks after regenerative treatment of intrabony defects, and that significant clinical improvements can be achieved.

Did the result surprise you? Dr. Jepsen: It was what I had anticipated after having seen the results of previous case series. But guessing is not knowing. Now we know that starting orthodontic treatment early does not impair the healing of the periodontium, provided that they perform good oral hygiene and are compliant with supportive care. This will save our patients a lot of treatment time. Recently, I was invited as an expert to participate in the S3-Level Clinical Practice Guideline Workshop of the European Federation of Periodontology on the

treatment of stage IV periodontitis and I was delighted that our findings were well accepted and are now the basis for one of the recommendations.

Could early orthodontic tooth movement even stimulate periodontal wound healing? Dr. Jepsen: This is possible and it is what we and others assume, but such a conclusion cannot be drawn from a clinical study.

Dr. Tietmann, is this treatment combination of regenerative periodontal surgery and orthodontics recommendable in more cases? Dr. Tietmann: I think so. We compared the outcome of this combined approach with results from a previous study performed in our private practice when only regenerative periodontal surgery but no orthodontic tooth movement was done.³ Treatment including orthodontic tooth movement delivered around 0.7–0.8 mm more radiographic bone gain. The probing pocket depth was reduced even more with the combined therapy. These findings seem to indicate a possible “stimulating” effect of orthodontic tooth movement in the early healing phase on the regenerative outcomes.

You investigated the results over 4-years. What is key for a good, long-term result in such cases? Dr. Tietmann: Most important is the patients’ adherence. It’s a long therapy – will the patient comply the entire time? During treatment and afterwards, it is

OV E RV I E W

Dr. Jepsen et al.

Dr. Tietmann et al.

Type of study

Multi-center RCT

Retrospective cohort study

No. of patients

43 patients

48 patients (526 defects)

Question

Start orthodontic treatment Does the combination of periodontal already 4 weeks or 6 months after regenerative surgery and orthodontic regenerative periodontal surgery? treatment provide favourable results?

Primary endpoint

CAL change

Radiographic bone level

Follow-up

12 months

up to 4 years

R E S U LT S Mean PPD Reduction

very important to visit regularly with the patient depending on their needs in supportive therapy but at least every 3-months.

– 2.55 mm after 1 year – 2.88 mm after 2–4 years

– 4.2 mm for early OT – 3.9 mm for late OT Pocket closure (PPD ≤ 4 mm)

91 % of defects in early OT 85 % in late OT

On the one hand orthodontic treatment improves the results of periodontal treatment. On the other hand, many case reports show periodontal problems resulting from orthodontic treatment. Do you also experience such cases in your daily practice? Dr. Jepsen: Oh sure, we are facing very challenging problems. Over-expansion, especially in the lower anterior region, in combination with a thin periodontal phenotype can result in advanced gingival recession. In specific cases retainers in combination with malfunction may lead to very severe recessions on one or two teeth, this is called “wire syndrome.”⁴ Here we may find incisors with secondary malposition and roots completely outside the bony basis. Dr. Tietmann: We see this in our dental office as well. And it is not only an esthetic problem. I have had cases with endodontic infections where the apex was nearly exposed.

Illustration: Quiant

Dr. Jepsen: So true, and it is very difficult to treat such patients because extraction or placing implants are not an option.

Dr. Jepsen, what are the keys to treating such cases? Dr. Jepsen: We need to cooperate with orthodontists before recession coverage.

87 % of all defects Mean BL gain

4.67 mm after 1 year 4.85 mm after up to

Mean CAL gain

5.4 mm for early OT 4.5 mm for late OT

CO N C LUS I O N

It is safe to start orthodontic treatment already 4 weeks after periodontal regenerative surgery.

4 years

Tooth loss

0.57 %

The combination of periodontal surgery and consecutive orthodontic treatment works well in a real-life setting.

The findings of the two recent publications summarized.

Twisted retainers have to be removed, the affected tooth or teeth have to be moved back into their bony housing. Then, after completion of the ortho-treatment these gingival defects can be covered without any complications.

Do orthodontists know about iatrogenic problems after orthodontic treatment? Dr. Jepsen: More and more orthodon-

tists are aware of this problem. Today we receive many patients referred from orthodontists to evaluate whether their gingiva needs to be augmented before the orthodontic treatment starts. This can be done with grafts and also with soft tissue substitutes. Also, we hope that new EFP-guideline will further improve the close cooperation and communication between orthodontists and periodontists in the future.

References 1

Tietmann C, et al.: J Clin Periodontol 2021; 48:668-678. (clinical study)

Jepsen K et al.: J Clin Periodontol 2021; 48:1282-92 (clinical study)

Bröseler F, et al.: J Clin Periodontol 2017; 44:520-9. (clinical study)

Renkema AM, et al.: Am J Orthod Dentofacial Orthop. 2013; 143(2):206-12. (clinical study)

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Points of view

Five questions for five experts We asked five clinicians from five countries about patient information, Patient Report Outcome (PRO) and impacts on good long-term prognosis.

Irena Sailer | Switzerland

Nigam Buch | India

University of Geneva

Sanjivani Dental Treatment Centre

On their first visit, how often are patients eager to learn about treatment details?

Patients are very eager to know about all benefits and risks as well as the long-term outcomes of the treatments, and potential treatment alternatives are always part of the information.

Patients tend to come to us with expectations that treatments can be accomplished without much pain or time. But once we explain their radiographs and clinical options, they want to know more.

Has patient behavior changed recently?

The amount of information the patients arrive with for the first consultation has changed. Information is very often found on the internet, and patients can be significantly influenced before learning real details from healthcare providers.

The pandemic has impacted patients opting for more economic solutions. But more and more patients are asking for more predictable solutions with less time spent in the dental office.

Should every patient hear everything about therapies? I always explain all possibilities and document in the patient records that I have done so. This is a very important part of treatment documentation.

What are the most convincing patient information tools? Check out

Patient Information. Share how you do it!

Case examples are always great to have. They are very illustrative. We have developed a set of overview tables with data and indications, published in our recent book (Quintessence Publishing 2021)

Will PRO become more important in the future? Absolutely. Documentation is also important for legal and other reasons.

Should every patient hear everything about therapies? That depends on the patient’s age, medical condition, willingness to undergo complex treatment and finances, which are becoming important post-pandemic.

What are the most convincing patient information tools? Patients are more convinced after hearing success stories from their neighbors, family, friends or relatives and put complete faith in their doctors.

Will PRO become more important in the future? It is the most important feedback. It boosts moral, provides satisfaction for the hard work of the entire team and improves practice reputation.

Man Yi | China

Wendy Gill | Australia

Robert Carvalho da Silva | Brazil

Sichuan University

Alliance Periodontics and Implant Dentistry

Instituto Implanteperio, Consolação

On their first visit, how often are patients eager to learn about treatment details?

Most of the time. And I prefer to explain the pros and cons of possible treatment options thoroughly on the first visit.

Patients are usually interested in outcomes and not clinical details. Once they are satisfied about treatment, the main concerns are pain and cost.

In Brazil, patients want to know all possible treatment options, considering the cost, time, morbidity and effectiveness.

Has patient behavior changed recently? More patients search the Internet for medical information and may consult several specialists before making a decision. They might be aware of various options but not the details or differences.

Has patient behavior changed recently? The number of patients who are anxious seems to have decreased mainly because they have been able to establish what is reliable information on the internet.

Should every patient hear everything about therapies?

Every patient should be informed of all possibilities. Especially for patients with higher expectations or risks, it’s necessary to spend more time to build trust and prepare them for possible outcomes.

I always explain my reasonings for planned treatment, outline the individual patient’s risk factors and discuss where patients’ anxieties lie.

What are the most convincing patient information tools?

Visual information, e.g., videos or clinical cases help the patients understand the protocols. Also, digital esthetic mockups are valuable aids.

Predictability, longevity of results and clinical experience are probably the top of the list. Additionally, having multiple healthcare providers (e.g., hygienist) involved in discussions is also helpful.

Will PRO become more important in the future?

Yes. Different treatment protocols may lead to similar clinical results, but there could be a big difference in patient experience. PROs help us better understand patient perspectives.

It is an important topic in Australia at the research level. We need to be aware of the data available for PROs and be able to explain to patients what this means in real, clinical terms.

Has patient behavior changed recently? The “aware” kind of patients are much more common nowadays. People rely more on science and know the treatment options have increased over time, as information is more accessible (e.g., Google and dentists’ social media).

Should every patient hear everything about therapies? I always explain everything to my patients regarding cost, morbidity, time…, it’s very important. Here in Brazil we say that “if you talk first, it’s explanation; if you talk later, it’s an excuse.”

What are the most convincing patient information tools? In direct patient conversation for sure the best way to demonstrate that a given treatment is valid is case presentation with pre- and post-treatment images.

Will PRO become more important in the future? For sure. It may encourage other patients to accept treatment. Comfort immediately post-surgery and in the long run are key to patient treatment acceptance.

OUTSIDE THE BOX

Image analysis

Navigation inside the 3-D pore structure of regenerated bone Yong-Gun Kim | Republic of Korea Department of Periodontology, School of Dentistry, Kyungpook National University, South Korea

Fig. 1: | A High contrast micro-tomo-

graphy slices allow segmentation of the newly formed bone, Geistlich Bio-Oss®, and woven bone – pixel size 1.8 µm. | B & C 3-D reconstructed image of sample: purple showing the woven bone in the interface of remaining Geistlich Bio-Oss®

(white) and the newly formed bone (red).

GEISTLICH NEWS 1-2022

ratio and distribution of new and substitute bone and their interfaces at different times, which is not possible using conventional µCT or historical histomorphometry. In our study, sinus floor augmentation was performed using the lateral approach and Geistlich Bio-Oss®.¹ After 6-months of uneventful healing, the bone biopsy specimens were collected during implant site preparation and cut into a cylindrical shape for tomography image acquisition (3 mm long and

2 mm diameter). After reconstruction of 3-D images from the tomography slices (Fig. 1A), the true structure of regenerated bone was revealed (Fig. 1B & C). Quantitative analysis indicated the volume fractions of new bone, Geistlich Bio-Oss® and woven bone were 29.44%, 13.39%, 13.29%, respectively.

Reference 1

Seo SJ, Kim YG.: J Synchrotron Radiat. 2020 1;

27(Pt 1):199-206.

Histology:Yong-Gun Kim

Synchrotron Radiation micro-computed tomography (SR-μCT) is based on high flux X-ray in a particle accelerator. The acquired images have a high resolution and allow simultaneous visualization of the specimen’s 3-D microstructure and quantitative analysis of the segments, along with their densities. With SR-μCT the intrinsic limitations of traditional histomorphometry microcopy, e.g., the 2-D nature of images or specimen defects during sectioning, are surmounted. It is also possible to study the bone regeneration dynamic, including the

Everything in life is vibration

When cells resonate.

Music can help treat many different kinds of diseases. Recent research has shown that extended exposure to sound can bring about changes at the cellular level and even in cells that are not geared to receive sound.

We have long been aware of music’s healing effect on the human body. Music therapy is being used for the treatment of psychological disorders, tinnitus, cardiovascular diseases and, lately, to help with neuronal development in premature babies.¹-² For example, a review of 73 randomized clinical studies from the year 2015 demonstrated that – largely irrespective of the kind of music – there were improvements in both participants’ anxiety states and levels of pain.³ Scientists have spent years trying to find out whether music not only effects overall healing processes, largely mediated via the brain, but also processes at the cellular level.

Bacteria and algae react to music. Bacteria and algae are at the bottom of the tree of life. Can music affect the growth and productivity of such simple cells? East Indian researchers wanted to know how bacteria or fungi grow under the influence of music, what metabolites are produced and whether there are changes in antibiotic sensitivity.⁴ A total of eight different kinds of microorganisms were exposed to the sound of classical, East Indian music at a frequency of 41 to 645 Hz and a volume of 95 to 110 dB. With the exception of Serratia marcescens, all the microbes tested exhibited better growth

“The size, granularity, and hormone binding capacities changed in cells exposed to classical music.”

GEISTLICH NEWS 1-2022

with music compared to the controls. Furthermore, the production of bacterial pigments (prodigiosin and violacein) and also the sensitivity to antibiotics were boosted. Compared with controls, cation concentrations (calcium and potassium) also proved to be significantly changed in test cultures exposed to sound. Finally, baker’s yeast Saccharomyces cerevisiae showed a higher tolerance to alcohol under the influence of music. Whereas the microbes were confronted with East Indian music, in another study micro-algae of the genus Haematococcus pluvialis were subjected to either the rather discordant piano piece “Blues for Elle” or “Far and Wide,” based on a flat frequency response.⁵ The algae were subjected to the music at about 60dB (the volume of speech) for a total of 8 hours over a period of 22 days. Interestingly, the scientists were able to find differences between the two pieces of music in relation to the production of algae: a growth rate of 0.03/ day was registered under the influence of “Blues for Elle,” 0.015/day for “Far and Wide” and 0.011/day with no music (control). Thus, under the influence of “Blues for Elle” the growth rate of the algae proved to be 58 percent higher than the protected algae control group.

utes. While the control cells that were not exposed to sound featured a typical histogram with two peaks (G0/G1 and G2/M phase), the serenaded breast cancer cells showed a significant cell concentration in the S phase (synthesis phase) and a cell reduction in the G/M phase. Furthermore, the cell size, cell granularity and hormone binding capacities of the cells exposed to classical music changed compared to the control population. In 2016 following the MCF-7 breast cancer cell test, additional cell lines of this carcinoma (incl. MDAMB-231) were also tested under the same musical conditions by the same researchers.⁷ After exposure for 48 hours and compared to the control, the percentage of living MCF-7 cells decreased under the influence of Beethoven and Ligeti (p<0.05). MBA-MD-231 breast cancer cells were

Breast cancer cell

Beethoven or Mozart? Human cells also react to music – and not just highly specialized mechanosensitive, hair receptor cells, which have been configured by nature to pick up acoustic waves. In a study published in the journal “Noise & Health” human breast cancer cells of MCF-7 line were subjected to music by three different composers: Mozart’s Sonata for two Pianos, Beethovens 5th Symphony or Ligetis’ Atmosphere.⁶ All three pieces were played at a volume between 70 and 100 dB for over 30 min-

Breast cancer cells (MCF-7) were exposed to Ligeti Atmosphères, Beethoven’s 5th Symphony and Mozart's Sonata for Two Pianos, and incubated for 48 h.

Klaus Duffner

even more sensitive initiating cell death under both Beethoven, Ligeti and Mozart compared to controls (p<0.05). The authors concluded that cell changes may not only be due to the kind of music exposure but also particular cell characteristics.

Cell proliferation and decrease in cells United States scientists exposed several strains of oral mucosa cells to a less sophisticated “musical” test, i.e., the sounds of an electric toothbrush.⁸ The cell cultures were exposed to he acoustic energy of a toothbrush twice a day in the laboratory for 0, 15, 30, 60 or 120 seconds over ten days at 261Hz with 87 dB (volume of a saxophone playing). Mucosa cells reacted differently depending on the duration of exposure. While sound expo-

sure for more than two times 30 seconds/ day increased the cells by 25.5 percent, two times 120 seconds/day of sound exposure resulted in a 30.9 percent decrease in cell number (p<0.001). Authors concluded that sound energy modifies the behavior of cells in culture. Conversely, collagen production by fibroblasts remained unimpacted by the exposure to sound and stayed at the same level in all groups.

Bone augmentation by nanovibrations Sound waves are mechanical vibrations which continue through the air as variations in pressure and density. Scottish scientists have been investigating the question of how vibrations affect the growth of stem cells. Not only chemical substances but also mechanical

SILENCE

Percentage of dead cells

SPEAKER

BEETHOVEN

stimuli can induce stem cells to differentiate into different cell types, such as bone, cartilage, ligaments or muscles. Adam Curtis, Professor for Cell Energy at the University of Glasgow realized that cells “creep around” on surfaces. How would such cells behave if they were subjected to minor vibrations on these surfaces? In fact, natural bodily processes, such as walking, breathing or kissing, also generate “nanovibrations” with a frequency range of around 970 Hz. Using a self-developed bioreactor, the Scottish researchers were able to show that irrespective of other external factors, mesenchymal stem cells differentiate into mineralized three-dimensional tissue when impacted by so-called nanokicking resonating at around 1 kHz.⁹ “Bone marrow-derived stem cells converted into osteoblasts on a large scale in our experiments, and without the use of chemical cocktails or highly complicated technology,” explained Matt Dalby of the Centre for Cell Engineering at the University of Glasgow.¹⁰ Apart from continuing the “bone work,” the team is now planning cooperations with rehabilitation specialists in order to help patients with bone marrow injuries. References

Musik als Heilmittel (https://www.scinexx.de/

dossierartikel/musik-als-heilmittel

LIGETI

Haslbeck FB, et al.: Neuroimage Clin. 2020; 25.

Hole J, et al.: Lancet. 2015 24; 386(10004):1659-71

Sarvaiya N, et al.: J Appl Biotechnol Bioeng. 2017;

Christwardana M, Hadiyanto H.: .: HAYATI Journal

2(6): 212‒9 of Biosciences. 2017; 24(3): 149-55

MOZART

Lestard Nd, et al.: Noise Health 2013; 15:307-14.

Lestard Nd, et al.: Evid Based Complement Alternat

Jones H, et al.: J Clin Periodontol. 2000; 27(11):832-8.

Tsimbouri, P.M., et al.: Nat Biomed Eng. 2017;

Med. 2016:6849473.

The three compositions increased significantly the percentage of dead cells (late apoptotic cells) compared to silence or magnetic field of a speaker ⁷ * Significant when compared with silence (p<0.05)

1, 758–70. 10 Medical news today. "Nanokicking" Stem Cells Offers Cheaper And Easier Way To Grow New Bone.

OUTSIDE THE BOX

THE

COMBINED GRAFT

TECHNIQUE

ISTVAN URBAN’s minimally invasive approach to create a maximum amount of keratinized tissue. ... and we need a huge graft to regenerate the lost keratinized tissue.

When building bone in a large defect, … ... we face a large displacement of the mucogingival line and vestibular loss due to larger bone volume we have to cover, …

A very painful experience for the patient that results in poor esthetics!

Lake Zurich, 2010 Shortly after a Geistlich Biofunctionality meeting – discussion about how to create additional keratinized tissue after bone regeneration in large defects.

Geistlich Mucograft® is a good cell collector. Can we use it to correct the large mucogingival defects?

Hmm… maybe we can transplant a mini free gingiva strip around the matrix… It will work as a source for cell migration and ingrowth into the matrix.

It should be something we can do?!

R&D

Yes, let’s do a study on this. I know that patients appreciate if we harvest only a tiny strip of 2-3 mm instead of a huge free gingival graft. 34

GEISTLICH NEWS 1-2022

But there is no keratinized tissue left in such a site to be collected. There is only mucosa and a lot of distortion!

COMBINED GRAFT TECHNIQUE First pilot study was conducted with 20 patients.1

1. Insufficient vestibular depth and keratinized tissue after a large bone augmentation procedure.

2. Trimming Geistlich Mucograft® to the size of the defect. Harvesting a strip of 2 mm width and 1-1.5 mm thick from the palate.

Histological staining and immunofluorescence examination

3. Geistlich Mucograft® covers the augmented area (open healing), with the palatal keratinized strip placed apically toward the vestibulum.

4. Increased vestibular depth and keratinized tissue three months later.

I think this is the biggest achievement in my whole bone grafting career. The regenerated tissue is keratinized without any differences as compared with normal keratinized tissue.

Staining of a treatment biopsy for keratin 14 (red) and DAPI (cell nuclei, blue) to confirm physiological distribution of basal keratinocytes (bottom).2

With a combined apically positioned autologous strip gingival graft and Geistlich Mucograft®, you gain 6.3 mm keratinized tissue on average.

You prevent patients suffering from a lot of pain. And the outcome is much better looking than with a free gingival graft. References: see page 39

Some facts about Geistlich Mucograft® • • • • •

Easy handling3 Adhere to the defect surface4 Fast infiltration of the soft-tissue cells5 Good soft-tissue cell ingrowth5, 6 Color and texture match with the surrounding tissue7

What a successful example of innovation and tissue engineering!

OUTSIDE THE BOX

The Osteology Foundation

One of a kind in dentistry Interview conducted by My To

The Osteology Foundation celebrates its 20th anniversary next year. We took the opportunity to talk to Kristian Tersar, Executive Director of the foundation and a member of the team for many years. He tells us about the beginnings and the development of the foundation and where it stands today. Tell us, Kristian Tersar: how did it all begin? The Osteology Foundation was founded in 2003 by Dr Peter Geistlich, together with Geistlich Pharma and like-minded experts, as an international and independent non-profit organisation. Dr Geistlich wanted the Osteology Foundation to be a platform that focuses on "Linking Science with Practice in Regeneration”, in other words, to promote research and education for the benefit of patients worldwide.

Can you explain how the foundation is organised? The Osteology Foundation Board defines the strategy, sets the objectives and distributes financial resources to the committees. Each Foundation Board member is assigned to one of the two committees: science or education. Furthermore, the Foundation Board elects the members of the Executive Board which is responsible for operations. They review all activities and assure good governance in line with the foundation’s objectives. Our team at the Osteology Office provides the support to implement the projects. A glance at our monthly Osteology News or our social media platforms shows how much we have grown.

And what are the foundation’s objectives and how is this implemented in practice? The foundation is committed to be the most attractive platform for research and education in oral tissue regeneration and all our projects are targeted to reach this goal.

GEISTLICH NEWS 1-2022

As a partner in research, we have financially supported more than 150 projects since 2004, resulting in more than 225 scientific publications across the entire spectrum of oral tissue regeneration. In addition to this, the Osteology Research Academy is running courses on research design and methodology to support researchers in their daily work. At the same time, we organise scientific education for practitioners in the form of International and National Symposia. The latter ones are organised by our very active National Osteology Groups. We also cooperate with other professional societies to increase our reach and join forces. On top of all that, we provide a platform to connect and exchange scientific knowledge, THE BOX – this is where your global community meets.

Geistlich is the main sponsor of the Osteology Foundation, so how does this impact the foundation’s work? Geistlich Pharma AG and the Osteology Foundation are in a relationship of founder and foundation. But the scientific independence created by its founder is the foundation’s most important asset. Independence is what enables the Osteology Foundation to achieve its outstanding position in the global oral regeneration community. The foundation stands for evidence-based knowledge transfer, without product promotion through the back door.

Photo: Osteology Foundation

Therefore, the Osteology Foundation is committed to follow the visions of Dr Peter Geistlich, a true philanthropist, who significantly shaped regenerative dentistry with his independent thinking and charisma. He always said: «The Osteology Foundation aims to be a guarantee for the advancement of evidence-based knowledge and to promote the continuing education of specialists as well as practitioners.»

“The Osteology Foundation is advancing evidence-based knowledge and promotes continuing education of specialists as well as practitioners.” Dr. Peter Geistlich

I also see this path in the collaboration between Geistlich Pharma AG and the Osteology Foundation. As mentioned, the foundation stands for evidence-based knowledge transfer and research funding, there is no place for products and sales activities. On the other hand, this unique platform only exists thanks to the provided funds. And precisely this must be an incentive for biomaterial customers to then place their trust in a manufacturer like Geistlich Pharma AG.

So, you are basically saying that the Osteology Foundation is independent from its founder?

That sounds almost too good to be true. Well, even Geistlich CEO Ralf Halbach, in his function as a member of the Osteology Foundation's Board, has no direct saying, be it with regard to the election of new Board Members and Expert Councillors or decisions on research funding and education programmes. It’s this core value which gives the Osteology Foundation a unique position in the dental foundation landscape. This was also honoured by the American Dental Association (ADA) through the certification as a CERP provider (Continuing Education Recognition Program). In a nutshell, the philanthropic approach of the founder enables the pursuit of a clearly defined goal: to generate knowledge about oral tissue regeneration and thereby improve patient care with evidence-based clinical practice.

How then does Geistlich benefit from the collaboration? The basic idea can be summarised under this principle: “From Profit to Purpose”. Recently, the Harvard Business Review wrote that “Companies are being pushed to consider the interests of all their stakeholders – including employees, customers, and the community – not just those of their shareholders.”

As far as research is concerned, one can absolutely say yes. As far as the implementation of continuing education events is concerned, the Osteology Office would be too small to manage them all by itself so we rely on the logistical support of Geistlich as well as the local know-how of its worldwide partners.

Your greatest wish for the future? Above all, that the pandemic situation will again allow more frequent face-to-face formats at events, so that even more clinicians can convince themselves of the quality of our training courses, but also of the enriching interpersonal exchange. In any case, you should register for the upcoming International Osteology Symposium, 27–29 April 2023, in Barcelona, to be part of the world’s most exciting platform for independent knowledge transfer in oral tissue regeneration. Thank you for the interview, Kristian Tersar!

The Osteology Foundation www.osteology.org The BOX www.osteology.org/the-box The International Symposium in Barcelona 2023 www.osteology.org/education/ international-symposia

OSTEOLOGY FOUNDATION

Interview

A chat with Ronald Jung Interview conducted by Marjan Gilani

In 2022 you took the reins as the University of Zurich’s new Chairman at the Clinic of Reconstructive Dentistry. Did you always want to be a dentist? Prof. Jung: Not before my early 20s. As a young man I was a professional and passionate soccer player with Grasshopper Club Zurich until I had a serious injury in a match. I underwent surgery five times. In the end, doctors couldn’t fully rebuild my fibula, but I became very interested in orthopedic surgery and bone biology. I started to study medicine, and when I met a pioneer of bone and soft-tissue regeneration in Switzerland, Dr. Hans-Peter Grimm, he convinced me to study dentistry. Geistlich was partly responsible for my becoming a dentist. Is your favorite topic clinical practice or fundamental research? I am more the conductor who puts together the “best possible team” for doing “what should be done,” whether it is fundamental or practical. We do it all for one simple reason: to provide better oral healthcare to people worldwide. This keeps me getting up every morning with so much positive energy, and I look forward to going to work.

What’s the most important take-home when working with Prof. Hämmerle? Fundamentally, great dentistry is not about knowing the most advanced techniques or having the most skilled hands, it’s about being able to make the right decisions at the right time. Has oral regeneration research changed over the years? There is a transition from hard- and soft- tissue dominated topics to interface science. Thanks to advances in imaging and modeling tools, we can better understand the mechanisms at the interface of bone, soft tissue and implants, even at the cellular and molecular level, which was not possible 20-years ago. Has the pandemic impacted your daily work? I used to travel a lot for work and meetings. Every time I had to sit in the airplane, my teenage daughter complained about my carbon

GEISTLICH NEWS 1-2022

Prof. Ronald Jung is Chairman of the Clinic of Reconstructive Dentistry, University of Zürich and best known for his work in the field of hard and soft tissue management and his research on new technologies in implant dentistry.

footprint (smiles) – but now my travel is significantly less. Most lectures and training changed to an online format. I see a lot of potential. A hands-on like vLab (at Geistlich + YOU) can reach more dentists worldwide than we ever imagined.

What is special about today’s students? They have a better sense of work-life balance. 20-years ago not everyone knew what the burnout is. I remember my father working all the time, either in his office or in the garden when he was home. And I am pretty much the same. You never find me sitting relaxed and reading a newspaper at home. But young people today know how to dedicate their resources in a more thoughtful way. What do you miss the most when you go abroad for work? I love to travel and learn about people, food, cultures, etc. I adapt to different situations easily – I do not have a rhythm or a morning routine, so jetlag does not bother me. But I must say, I miss my family!

Photos: Ronald Jung

Individual, or teamwork? Team, people and trust come first. It is important for me that my team members love going to work. After that, the performance comes by itself. I learned this in sports. For example, all championship level skiers are in pretty much the same physical condition. What delivers the best performance is always in the mind.

References for page 34-35 1

Urban IA et al.: Int J Periodontics Restorative Dent 2015; 35 (3), 345-53 (clinical study)

Urban IA, et al.: nt J Periodontics Restorative Dent 2019; 39(1):9-14 (clinical study)

Sanz M, et al.: J Clin Periodontol. 2009; 36(10):868-76 (clinical study)

Chevalier G et al.: Int J Periodontics Restorative Dent 2017; 37 (1), 117-23.(clinical study)

Ghanaati S et al.: Biomed Mater 2011; 6 (1), 015010. (pre-clinical)

Rocchietta I et al.: Int J Periodontics Restorative Dent 2012; 32 (1), e34-40. (pre-clinical)

McGuire MK, et al.: J Periodontol. 2021; 92(8):1088-95. (clinical study)

BACKGROUND

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Geistlich News Global - Edition 1-2022

Articles inside

The Osteology Foundation. One of a kind in dentistry

A chat with Ronald Jung

Publishing information

When cells resonate

Navigation inside the 3-D pore structure of regenerated bone

“The main factor in the etiology of error is time pressure.”

Five questions for five experts

“Control of risk indicators may limit peri-implantitis and eventually implant loss.”

“The most important time is the time we dedicate to patients.”

“Treating dehiscences requires time and patience.”

“Orthodontic treatment can start shortly after regenerative surgery.”

“Patient age alone is never a limiting factor.”

A digital guide to preventive treatments