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Child-friendly dentistry Clinical case: managing severe Early Childhood Caries IaDR symposium highlights EQUIA as reliable restorative solution The proďŹ ts and ethics of paediatric dentistry
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4 The use of ART in managing severe Early Childhood Caries: a clinical case By Drs Soraya Leal and Simone Otero
9 Addressing MIH successfully with Fuji Triage By Dr Mattieu Derbanne
13 Minimum intervention and the child patient By Dr Bhupinder Dawett
18 Highlighting calcified or non-calcified biofilms: new technologies for cario-periodontal prophylaxis
30 IADR symposium highlights mounting evidence of EQUIA as reliable restorative solution 33 The profits and ethics of paediatric dentistry Dr Alun Rees
36 Delivering oral healthcare to remote areas Dr Andrew Bartram
38 Product Showcase Protecting partially erupted teeth
By Drs Michel Blique and Sophie Grosse
24 Managing the dental treatment of a child suffering from severe food polyallergies By Dr Michel Blique
Disclaimer: MID is published for GC Europe by Apexhub Ltd. All rights reserved.
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clinical case
By Professors Soraya Leal and Simone Otero
The use of ART in managing severe Early Childhood Caries: a clinical case Early Childhood Caries (ECC) is a significant and growing public health problem in many countries (1,2). We identify ECC under the following conditions: if a child under the age of 6 has at least 1 or more cavitated or noncavitated lesions, is missing a tooth due to caries or has a filled tooth (Figure 1a). If a sign of a carious lesion in a smooth tooth surface is present in a child younger than 3 or when a cavitated lesion, missing or filled smooth tooth surfaces in primary maxillary anterior teeth (Figure 1b) or a decayed, missing, or filled score of ≥ 4 (age 3), ≥ 5 (age 4), or ≥ 6 (age 5) surfaces occurs between 3 and 5 years-old, we refer to it as severe Early Childhood Caries (S-ECC) (3). Children with S-ECC suffer from pain, sepsis, have a lowered quality of life, a higher risk of developing new carious lesions in both primary and permanent dentition(4) and a high cost for treatment. It is obvious that S-ECC should be prevented. However, parents usually seek treatment when the problem is already present. The combination of the child’s age, the severity of the carious lesions and parents’ anxiety in relation to the treatment make the management of S-ECC a big challenge for the dental professional. In terms of management, Atraumatic Restorative 4
Treatment (ART) is considered the most appropriate tertiary preventive measure (5). Compared to the traditional approach in young children, ART was found to be less painful (6). Additionally, ART is less traumatic and friendlier than conventional treatment interventions, as the most common fear-inducing aspects related to dental treatment, namely the needle and the drill (7,8), are hardly required. Therefore, ART can be considered an excellent approach to introduce a young child to the dental environment when invasive interventions are required. Clinical report A 3 year-old boy attended the paediatric dental unit at the University of Brasília Hospital accompanied by his mother, who reported as the chief complaint, the presence of cavitated dentinal lesions in the front teeth of the upper jaw of her son. The intake interview with the mother revealed the use of bottle at sleeping time with sugary content coupled with a high cariogenic diet during the day and poorly performed tooth brushing. The drinking water system in Brasília City is fluoridated (0.7 ppm). An intraoral examination revealed the presence of cavitated dentinal lesions
“The combination of the child’s age, the severity of the carious lesions and parents’ anxiety in relation to the treatment make the management of S-ECC a big challenge for the dental professional” involving the mesial surfaces of the 51 and 61 (Figure 2a) and in the occlusal surfaces of all first primary molars (Figures 2b-e). He had white spot lesions on all the front teeth of the upper jaw and on the buccal surfaces the first primary molars (Figure 2d), indicating high caries activity.
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Treatment ●● First appointment: the mother was instructed to clean her child’s teeth with fluoridated toothpaste regularly, to reduce the sugar intake during the day and about the importance of removing the bottle at sleeping time. She was told that the restorative treatment could only 2
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b Figure 1: Examples of Early Childhood Caries (a) and severe Early Childhood Caries (b). In figure 1a, cavitated and non-cavitated lesions are observed on the tooth 52, 51 and 61, respectively, in a child of 5 years-old. In b, all front maxillary teeth are affected by cavitated dentine lesions in a child of 2 years-old.
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Figure 2: Baseline pictures. Cavitated dentine lesions in teeth 51 and 52 (a) and cavitated dentine lesions in the occlusal surfaces of all 1st primary molars (b-e). Active white spot lesions are observed in the front teeth (a) and in the buccal surface of tooth 84 (d). 5
clinical case
start if all the instructions were carried out properly at home. ●● Second appointment, a week later: The child’s teeth were well cleaned and the mother had followed the advice regarding sugar consumption. The restorative treatment was implemented according to the ART approach considering: a) The child’s age: the patient was just 3 years-old and it was his first dental visit. In selecting the ART approach, only hand instruments are used, which are much more child-friendly than the drill and the needle. It also allows the dentist to talk to the child because there is no noise from the drill and suction. b) The child’s high caries activity: The ART approach includes sealant restorations. Cavities that are accompanied by white spot lesions, like the one shown in Figure 2d, can be restored while pits and fissures prone to develop caries can be sealed at the same time. c) High-viscosity glass-ionomer cement (GIC): This material is often used with ART and the newer products have improved properties for higher survival of ART restorations/sealants and aesthetics. Teeth 51 and 61 were treated during the 2nd appointment (Figure 2a). Firstly, they were isolated with cotton wool rolls, then the thin enamel was fractured using a hatchet. Thereafter, carious dentine was removed with hand instruments commencing at the dentine-enamel junction and ending at the pulpal wall (Figure 3b). This is a good strategy to guarantee no or a low level of discomfort during cavity cleaning. Thereafter, the cavity was cleaned with a wet cotton pellet 6
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Figure 3: Cavities after unsupported enamel removal using hand instruments (a) and after cavity cleaning (b). Restorations with GIC (Fuji Extra) immediately after placement (c) .
followed by a dry one. Polyacrylic acid was used to condition the cavity for 15-20 seconds, followed by flushing it and then drying it with dry cotton wool pellets. The GIC used was a powder-liquid Fuji IX GP Extra (GC). The material was inserted into the cavity with an applicator and a plastic band was used to keep the material in position while curing. After that, the band was removed along with any excess glass ionomer with a carver. A thin layer of petroleum jelly was applied to the surface to protect the restorations. The mother was instructed that food intake should be avoided in the following hour. Figure 3c shows the restoration immediately after placement. ●● Third appointment: Oral hygiene was checked and this time, teeth 54 and 64 were treated (Figures 4a, 4c). The same procedure as for the 51 and 61 were followed. However, as the restorations were performed on occlusal
“ART can be considered an excellent approach to introduce a young child to the dental environment when invasive interventions are required” surfaces, the press-finger technique was used. After the cavity and adjacent pits and fissures were filled with GIC, the material was pressed down with the index finger (covered with a thin layer of petroleum jelly) for 20 seconds. The excess GIC was removed, the bite was checked with articulator paper and the procedure was completed with the application of a layer of petroleum jelly for protection. ●● Fourth appointment: Teeth 74 and 84 were restored using the ART approach (Figures 4eh). At the end of each session, fluoride varnish (Duraphat - Colgate) was applied to facilitate remineralisation of the white spot lesions. The a 6 month follow-up pictures are presented in Figure 5. Discussion and conclusion Oral health education and prevention are the cornerstones of restorative treatment success. For that reason, restorations should be placed only if parents are aware of their responsibility in supervising their children at home. In our case, the mother was collaborative and, in parallel with the
4 a
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Figure 4: Cavities of teeth 54 (a), 64 (c), 74 (g) and 84 (e) prepared after cleaning with hand instruments and post-restoration (b, d, h and f). 5
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Figure 5: Clinical aspect of the restorations placed on teeth 51 and 61 (a), 74 (c) and 84 (b) after 6 months.
actions at home, professional preventive measures were implemented during the restorative sessions through positive reinforcements and the use of fluoridated varnish. 7
clinical case
We know that younger children are the ones who complain most about pain (6) and that the sight, sound and the sensation of the drill are rated as one of the most fear-eliciting stimuli (9) in the dental setting. Therefore, the decision to manage S-ECC by the ART approach seems to be the most logical treatment strategy, even for children who have a positive attitude to receiving dental treatment, but at times, act with reservation. And finally, the mechanical improvement of the high-viscosity GIC, observed in the last decade, allows the dentist to perform restorations that are aesthetically acceptable, durable, and have the advantage of being a biological restorative material. In conclusion, the ART approach worked very well for the young boy and it is considered a good treatment strategy for managing S-ECC.
About the authors Professors Soraya Leal and Simone Moraes Otero are Associate Professors of Paediatric Dentistry at the University BrasĂlia - BrasĂlia, Brazil. Both are specialist in Pediatric Dentistry with more than 20 years of experience with a great interest in Early Childhood Caries prevention and management.
References 1- American Academy of Pediatric Dentistry. Symposium on the prevention of oral disease in children and adolescents. Chicago, Ill; November 11-12, 2005: Conference papers. Pediatr Dent 2006: 28: 96-198 2- Borutta A, Wagner M, Kneist S. Early Childhood Caries: a multi-factorial disease. OHDMBSC 2010; IX: 32-38. 3- Drury TF, Horowitz AM, Ismail AI, et al. Diagnosing and reporting early childhood caries for research purposes. J Public Health Dent 1999; 59: 192-197. 4- Finucane D. Rationale for restoration of carious primary teeth: A review. Eur Arch Paediatr Dent 2012; 13: 281-292. 5- Davies GN. Early childhood caries - a synopsis. Community Dent Epidemiol 1998; 26: Suppl 1: 106-116. 6- de Menezes Abreu DM, Leal SC, Frencken JE. Self-report of pain in children treated according to the atraumatic restorative treatment and the conventional restorative traetment - a pilot study. J Clin Pediatr Dent 34: 151-155. 7- Theo CS, Foong W, Lui HH, Vignehsa E, Elliot J, Milgrom P. Prevalence of dental fear in young adult Singaporeans. Int Dent J 1990; 40: 37-42. 8- Topaloglu-Ak A, Eden E, Frencken JE. Perceived dental anxiety among schoolchildren treated trough three caries removal approached. J Appl Oral Sci 2007; 15: 235-240. 9- Taani DQ, El-Qaderi SS, Abu Alhajia ES. Dental anxiety in children and its relationship to dental caries and gingival condition. Int J Dent Hyg 2005; 3: 83-87. 8
treatment strategy
By Dr Matthieu Derbanne
Addressing MIH successfully with Fuji Triage I graduated from Paris Descartes University School of Dentistry in 2001. My focus towards paediatric dentistry began very early during my clinical apprenticeship. I’ve always had a good relationship with children and the thought of practising dentistry with them was a challenge I wanted to take. I opened my practice as an exclusive paediatric dentist in 2003 in Paris. Since then, I have expanded my skills and knowledge in paediatric dentistry and dental biomaterials under the guidance of the late Professor Michel Degrange. His mentoring was instrumental in the way I practice dentistry today, focusing on minimally invasive dentistry and favouring adhesive restorative techniques over the more traditionally invasive ones. One specific topic I have been focusing on is the management of MIH which ranks among the top reasons for children to see a dentist. According to the literature, restorations in hypomineralised molars appear to fail frequently and there is little evidence-based literature to facilitate clinical decisions on cavity design and material choice. Furthermore, the traditional way of dealing with MIH is not always the most conservative one. For instance, pre-formed paediatric crowns have a long record of clinical success, allowing for complete restoration of the anatomy and function of the degraded teeth, however the cost in
terms of sound dental tissue can be higher than desirable particularly when the crown is worn and needs to be replaced. Despite this, they still are a very good choice when dealing with MIH affected molars which might not be fully erupted. However, considering the biological cost and aesthetic shortcomings, I have devised a multi-step approach to the management of these molars. I use a three factor approach to make my therapeutic decision: ●● Degree of eruption of the affected teeth ●● Severity of degradation ●● Other parameters These factors will serve as a guide for choosing the material and restoration technique. Factor 1 The first factor to consider is the extent to which the teeth are erupted. It is widely known that adhesive, minimally invasive dentistry often implies the use of isolation like a dental dam. However, its placement can be challenging when dealing with half erupted teeth, leading to insufficient isolation and saliva leakage on the operating field. These situations are not uncommon. A solution provided in the literature is the use of remineralisation/desensitisation techniques prior to restoration when the latter is not possible. However, these non-invasive 9
treatment strategy
therapeutic means require high compliance from the patient and direct family, and is therefore not always achievable. At the same time, quick pain relief is often the reason why such a patient would visit the practice and this cannot be achieved with the technique. I usually choose a temporary restoration with glass ionomer cement(GIC) like Fuji Triage by GC. The rationale for the choice of this kind of material is its ease of use and placement, its relative tolerance towards moisture and the fact that fluoride release can help us achieve remineralisation while limiting sensitivity. This however implies that further care will be needed to improve the prognosis of the degraded teeth. The lifespan of such a restoration could indeed be very short, particularly when it comes into contact with the opposing teeth. Despite this, we find this a good way of addressing the issues around sensitivity and pain relief while not compromising the structural integrity of the tooth structure in the long run by drilling. In cases where the teeth are more erupted and therefore being used more, a material with higher resistance is required. We assess the possibility of maintaining a waterproof operating field in order to choose between a composite restoration when good isolation is possible and Resin Modified Glass Ionomer Cement (RM-GIC) like Fuji II LC when isolation is adequate but not perfect. The rationale for this choice is again dictated by the ease and speed of use and placement. While a composite requires longer application, denying the possibility of placement in case of adequate but imperfect isolation, RM-GIC allows for bulk placement followed by light polymerisation. However, we only use this material when the sufficient isolation 10
can be achieved. Composite is only used in conjunction with perfect operating field isolation. It must be noted, however, that all the restoration we make with young patients, whether GIC, RM-GIC or composite, are considered to be temporary. Having to restore degraded, not fully erupted teeth, we usually cannot asses or remove all odd looking enamel (white or brown spotted). In our experience, some spotted areas can degrade quickly while the teeth are still functioning, other times they don’t and we have found no prediction factor. Keeping minimum intervention in mind, we usually choose to keep as much enamel as possible allowing for supra gingival limits of our restorations whenever possible. This approach, while conservative, has some drawbacks. The temporary nature of the restoration implies high compliance and regular recall visits to monitor the treated teeth, a factor that is out of the practitioner’s control. Factor 2 The severity of degradation is also taken into account choosing a restorative technique. Adhesive restorations are known to allow for reinforcement of the degraded tooth structure. Composite restoration is then preferred when possible for highly degraded teeth. The benefits brought by the use of GIC and derivatives in terms of fluoride release are then abandoned, but can be achieved through topical fluoridation. While aesthetic, non-invasive treatments options with GIC, RM-GIC or composite are current and adequate in terms of minimal intervention, the use of the pre-formed paediatric crown is still the
“According to the literature, restorations in hypomineralised molars appear to fail frequently and there is little evidence-based literature to facilitate clinical decisions on cavity design and material choice” option of choice with highly degraded MIH molars, with the benefits added in terms of longevity and ease of use being far superior. Factor 3 Other parameters taken into account are patient compliance (if measurable), occlusion, hygiene, and dietary habits, allowing us to assess a risk factor and determine a more precise prognosis for the affected teeth. We believe, for instance, that extraction might be the treatment of choice when all four first molars are severely affected, occlusion is correct, and third molars stems are present with a high risk patient. Extraction should however be conducted at the right time in terms of growth and teeth evolution, requiring temporary restoration of the affected teeth to prevent pain and further degradation. RM and RM-GIC are, in our humble opinion, materials of choice for that matter. Top strategies for managing MIH patients Managing patients with MIH can be quite challenging as it is often accompanied with dental pain, discomfort and anxiety. Our top strategies for managing these patients are:
Never use instruments on a patient that can cause anxiety. While the patient might be suffering from dental pathologies, we do believe that getting to know each other before treatment allows mutual confidence to build and anxiety to relieve before engaging in complex procedures. ●● Always use local anaesthesia, even for the simplest treatment. We believe that the slight discomfort resulting from dental anaesthesia is far more bearable than iatrogenic pain. ●● Tell, Show, Do has long been advocated as a method to build confidence with younger patients. We use Tell, Show what needs to be shown, Do, a slight but useful variation of the academic thinking considering the size of the needle used for mandibular block infiltration. ●● Always work in a fun and friendly atmosphere. Our practice’s walls are covered with patients’ drawings and we try to always smile. Aside from treatment, we believe that prevention is an essential part of our job starting with a previsit interview, allowing us to pinpoint wrong dietary or hygiene habits, the correction of which is the first step towards healthier teeth. We think that no medical prevention measure can be ●●
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treatment strategy
efficient if no hygiene or dietary habit correction is made when dealing with such high risk patients. Medical preventive measures taken at our practice are: Dental hygiene teaching, topical fluoridation for high risk patients, as well as pit and fissures sealing when deemed necessary. Regarding dental sealant, we still think that they should be applied as soon as possible using resin based material, known for their efficacy and lifespan. However, with regard to the high risk patient, we feel strongly that GIC (Fuji Triage) can be used as a temporary sealing material, especially when the teeth are not fully erupted. For older patients who did not benefit from this preventive treatment, we assess the risk by carefully observing the anatomy of the teeth at risk, while taking future risk factors into account (for instance, orthodontic treatment) to determine the need for pit and fissure sealing.
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About the author Dr Mathieu A. Derbanne graduated from Paris Descartes Faculty of Dental Surgery in 2001 and he is a former junior lecturer in paediatric dentistry. Besides running a private practice limited to paediatric dentistry, he also holds a Master of Science (MSc) degree in biomaterials and a PhD student position, focusing its research in the field of Dental Adhesives. Dr Derbanne is also a member of the Academie De Dentisterie Adhesive (ADDA), Paris, pursuing the work of the late Professor Michel Degrange with the organisation of the “Batailles des adhĂŠsifsâ€? practical seminars focusing on dental adhesion, with more than 80 sessions to date in France, Belgium and Canada.
By Dr Bhupinder Dawett
Minimum intervention and the child patient When I inherited the patient base at our practice in 2000, one startling finding was that most of our patients had extensive restorations in their teeth, and that children especially were returning with cavitated lesions, some even after years of regular attendance. The team and I decided then, and do to this day, to have a strong emphasis on children’s dentistry. We firmly believe in the preventive approach and the younger we recruit our patients to this ethos the better. What drove our practice focus on MI in children was the fact that children were still presenting to our practice with carious lesions (e.g. buccal/ occlusal pits of erupting permanent molars) even when other factors such dietary behaviours and oral hygiene, were not showing anything of concern. After several practice forums and meetings we decided our goal was to see if we could reduce the incidence of dental caries to zero in children. This would involve identifying early carious lesions before cavitation so that we could monitor them and evaluate our preventive strategies. Hence began a process of evolving the dentistry we provided at our practice. We have been helped and encouraged enormously by Professor Chris Deery, Consultant in Paediatric Dentistry at the University of Sheffield. As a clinician I have been incredibly inspired by my practice team who have all taken on board our MI approach and continue to show creativity in developing our practice. Our
patient focus groups continue to help develop our practice by their constant encouragement and the value that they place our ethos and care. Because of this we have seen increased regular attendance and recruitment of new patients, and this I feel may play a significant part in reducing oral health inequalities in our community. Fuji Triage in practice One common finding that all our clinicians brought up was the issue of caries being instigated in partially erupted teeth, especially the permanent molars in children and commonly the third molars in adults. We found that other than trying to improve oral hygiene (with limited success) and fluoride varnish, we had little else in our armoury to tackle these teeth. We were also concerned that in high-risk children who seemed to attend less regularly, the preventive effect of fluoride varnish and oral health education may be limited. Traditional resin-based sealants were proving
“We firmly believe in the preventive approach and the younger we recruit our patients to this ethos the better� 13
treatment strategy
difficult to place and retain on partially erupted permanent molars given access and moisture control limitations. A glass ionomer (GI) based sealant suggested a better alternative for these teeth and after looking further at the research literature, Fuji Triage by GC was our material of choice. We have since applied this as standard to partially erupted permanent molars in children with high caries risk, and had good retention rates. There is also the thought that it may still be inferring some caries preventive effect, even if the patient does
not attend regularly. Our in-practice evaluation showed 85% of occlusal surfaces having complete visible retention of the sealant after 6 months. Other studies elsewhere have demonstrated that the sealant may still be present in the depths of the fissures when visibly it appears lost. Our top five strategies for successfully treating the child patient 1 Risk assessment and engaging child and parent when formulating care plan.
Here are three cases that illustrate some of the success we have had in managing the child patient with MI treatment strategies. Case 1 A male patient of 6 years presented with increased caries risk due to long term (sucrose containing) oral medication for epilepsy. His saliva also showed strep mutans counts were > 500/000 cfu/ml (Figure 1), salivary buffering capacity was low, and resting salivary pH was low. This concluded a high caries risk profile Figure 1. Strep mutans test – 1
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showing a positive 2 result The patient’s oral hygiene, whilst generally very good, was not ideal around his partially erupted lower first permanent molars. We decided, in addition to reinforcing oral hygiene, to seal the fissures in these PE molars. Part of the occlusal fissure system was visible and also the buccal pit. Fuji Triage was applied easily
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with no adverse reactions. The patient requested the white Fuji Triage on the LR6 and the pink version on LL6. At the 15-month review (Figure 2 and Figure 3) the sealants were still retained in the fissures. Even though patient’s oral hygiene needed reinforcing,
2 Offer alternatives, don’t just preach what they are doing wrong. Plus give parents written leaflets if possible. 3 Prescription of fluoride toothpastes and instructing to spit not rinse after use. 4 Use of painless treatments such as Fuji Triage, air abrasion, etc. 5 Use of all members of the dental team in a child’s MI care plan, and appropriate recall. Our top products that we use in our MI approach are:
“Our in-practice evaluation showed 85% of occlusal surfaces having complete visible retention of the sealant after 6 months”
LR7 being partially erupted was proving difficult for her to clean adequately, and she was undergoing a fall in dietary compliance. After prophylaxis of the LR7 the pits and fissures could be assessed (Figure 4). Figure 4. These showed some evidence of acid attack both occlusal and especially Case 2 buccal. After discussion with the A 14-year-old female patient patient and parent, Fuji Triage with fixed appliances with was applied to offer surface generally good oral hygiene presented for examination. The protection as an interim sealant the Fuji Triage was still in place and protecting this most vulnerable part of the tooth (Figure 1). Figure 2 and Figure 3. LR6 with white Fuji Triage, and LL6 with pink Fuji Triage 15 months after application.
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until further eruption would allow for a conventional sealant. The LR7 buccal pit was minimally cleaned and the tooth was conditioned with GC conditioner (Figure 5) Figure 5. GC conditioner applied. The conditioning agent was then washed off and the tooth air-dried. Fuji Triage was then applied. Figure 6 shows the final sealant. Figure 6. Final glass ionomer 6
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treatment strategy
Caries risk assessments and patient education: GC Saliva-check buffer kit, GC saliva-check mutans ●● Diagnosis aids: Diagnodent, digital radiography, magnification ●● Prevention: fissure sealing, prescription of high fluoride toothpaste if indicated ●● Treatment: to name a few… air abrasion including Sylc prophy powder (Velopex Aquacut), GC G-ænial composite, GC Fuji IX and Fuji II glass ionomer cements ●●
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About the author
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The patient had a partially erupted UL7, which he was not cleaning adequately (Figure 7). He was awaiting orthodontic treatment, but oral hygiene needed improving first. Given his previous history of decay Case 3 experience, a positive strep A 15-year-old male presented mutans test and poor oral with poor oral hygiene generally. This was after several hygiene, he was deemed at high risk of caries. After attempts at reinforcing oral discussion with the patient and hygiene by our therapist had achieved limited improvement. the parent it was decided to sealant LR7 15 months later the tooth shows no evidence of caries progression in the buccal or occlusal surfaces.
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Dr Bhupinder Dawett qualified as a dentist from the University of Cardiff in 1993 and worked as an associate dentist in three NHS practices in Nottingham, UK. In 2000 he purchased a practice with his wife in Alfreton, Derbyshire, UK. This NHS 9
seal the UL7 with Fuji Triage. Figure 7. Partially erupted UL7. The tooth was then air polished and conditioned with GC conditioner (Figure 8). Fig 8. UL7 with GC conditioner applied. The conditioning agent was then washed off and the tooth air-dried. Fuji Triage was then applied. Figure 9 shows the final sealant. Figure 9. UL7 with GI sealant.
practice was extensively upgraded and its focus changed to MI. Having doubled its patient base the practice team consists of 4 other dentists, an oral health educator, dental therapist and extended duties dental nurses, and it is now involved in primary care research. Between 2010 and 2012 Dr Dawett was an in-practice research fellow with the National Institute for Health Research, and completed a Masters in Dental Public Health (with distinction) from the University of Manchester. The practice has won several
research awards to support studies that add to the evidence base for Minimal Intervention in general dental practice. Dr Dawett is also involved in the Masters in Advanced Minimal Intervention in Dentistry (AMID) course at Kings College, London.
Technique video: Surface protection with GC Fuji Triage
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toolkit
By Drs Michel Blique and Sophie Grosse
Highlighting calcified or non-calcified biofilms: new technologies for carioperiodontal prophylaxis Professional Prophylactic Cleaning of Dental Surfaces (PPCDS) is essential in periodontal treatment and in the prophylactic phase of noninvasive treatment of caries (1). It consists of removing biofilms as completely as possible from dental surfaces, root systems, inter-dental areas, from fillings and their edges (which are often uneven at a bacterial level) (2). Traditionally carried out by sight or using conventional plaque staining (often erythrosine-based), PPCDS has also evolved with new technologies.
Observing the way in which bacterial biofilms form and are structured on teeth is essential for the dental surgeon (3). We are now able to highlight these biofilms thanks to a new tri-tone plaque disclosing agent and the introduction of an intra-oral camera comprising of diodes that enable the autofluorescence of dental tissues (4) and calcified or non-calcified bacterial coatings which stick to them to be visualised. In this article we aim to briefly describe these technologies and to illustrate their use through a
Fig. 1b: Schematic Diagram of the Functioning of Triplaque ID Gel速 (Copyright G. Renaud & S. Bessard with their permission) 18
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Fig 2a: 1st appointment: the tri-tone disclosing agent provides a lot of information: lack of regular brushing, brush and dental floss efficacy. Presence of old (blue) biofilm. Area of acid biofilm (turquoise green). Fig. 2b: Checking of brushing one week after PPCDS: efficacy of plaque control and condition of hard and soft tissues are improved.
Fig. 3a: Schematic diagram of the image obtained with the Soprocare camera: Fig. 3b in “ Perio “ mode, gingival inflammation is accentuated, soft coatings appear in a whitegrey colour, calcified bacterial coatings in orange-yellow. 3c in “ Cario “ mode, warning areas of caries activity shown in red.
number of clinical situations.
To use, the gel is dispensed from its tube onto a brush which is applied directly to the teeth, then rinsed off. If the plaque is recent, young or sparse (a few hours), the smaller blue pigments are easily eliminated by rinsing. Only the large red molecules are held by this sparse biofilm (Figure 1b). This biofilm has a reduced capacity to demineralise hard tissues. Older (48 hours or more) and denser plaque will trap both red and blue pigments within
Tri-tone gel disclosing agent A tri-tone gel plaque disclosing agent, developed a few months ago, called GC Tri Plaque ID Gel, (Figure 1a) identifies young or mature plaque and includes a mixture of sucrose, red pigments (erythrosine E127), incorporated into a high molecular weight substrate and blue pigments (Green E), incorporated into low molecular weight substrate.
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toolkit
Fig. 4 to f: Good brusher, aged 60 years, but with areas not properly cleaned: 4a: Image acquired with SoproCare light “Daylight”, 4b: “Perio” mode, we observe the build-up of soft and calcified biofilm (orange), 4c: massage of the area with “Soft Picks”, 4d: removal of soft biofilms from the papilla, 4e: after energetic flossing: calcified biofilms remain, 4f: to the left, checking of the removal of calcified biofilms during PPCDS. the biofilm (Figure 1b). The older and denser the plaque, the more intense the blue colour becomes, ranging from violet to dark blue. This area, barely permeable to oxygen, will enable the development of MS and facultative anaerobic bacteria. In the presence of sucrose, stronger acids are generated, rapidly reaching pH 4.5, and can demineralise hard tissues. The red pigment is designed to be eliminated by the acid, and the blue pigment to highlight it and becomes
bright-turquoise (Figure 1b). Thus, a biofilm which creates conditions for demineralising decay is highlighted (5). The tri-tone disclosing agent gives the dental practitioner a great deal of information: in Figure 2a-b, we observe a lack of regular brushing (pink colouring) in areas (angle of the brush and need/ efficacy of dental floss), the presence of an old biofilm to inflamed and oedematous gingival areas and an area of biofilm acid (turquoise green).
Fig. 5a & 5b: For the patient who does it, or thinks they are doing it well, it is a long and steep learning curve. 20
“The highlighting of bacterial coatings, whether soft or calcified, which must be removed by brushing or via prophylactic treatment in the dentist’s chair, is made easier by these new chemical or physical disclosure systems. They will change our approach to these important treatments for dental and gum health.” Fluorescence and selective chromatic amplification: a new approach to highlighting biofilms SOPROCARE™ (Figure 3a) is an intraoral highperformance camera equipped with white and blue LEDs. The light produced is absorbed by dental tissue and displayed in the form of
fluorescence. The signal is thus captured and then chromatically improved. This enables the characterisation of hard and soft tissues and amelo-dentinal caries, calcified or non-calcified dental plaque and gingival inflammation to be shown. Fig. 6 a to d: 66-year-old patient, maintenance check-up: 6a: Initial state, 6b: after application of Triplaque ID gel, 6c: new application of Triplaque ID gel for per-operative check and finish, 6d: following the use of a calcium sodium phosphosilicate based air polisher during PPCDS, complete removal of biofilms. 21
toolkit
Fig. 7 a to b: 69 year-old patient, maintenance check-up: 7a: Image acquired with SoproCare in “Perio” mode during PPCDS: residual calcified biofilms are observed (orange), 7b: seen after using a calcium sodium phosphosilicate based air polisher Figures 3b and 3c show the fluorescence image obtained with selective chromatic amplification in PERIO mode (Figure 3b) and CARIO mode (Figure 3c). In figures 4a and 4b, we observe the image obtained after exposure to white light (Figure 4a) then blue and white light with selective chromatic amplification (PERIO mode) (Figure 4b). The benefits of using these tools in your practice include: ●● Providing information for the patient and the practitioner when making decisions. It makes the invisible visible: these new technologies therefore help the patient and the practitioner (6) to be more effective in terms of dental prophylaxis. ●● Highlighting before the removal of soft coatings. When this involves the regular removal of bacterial biofilms by brushing and home treatments, our level of requirement is high. And for the patient who does it, or thinks they are doing it well, it is a long and steep learning curve. Only the objective analysis of results produced can help the patient to understand 22
what we really expect from them (Figures 5a and 5b). With the SOPROCARE™ camera, information can be shared very quickly, in one or two clicks, and enables soft or calcified coatings and marginal inflammation to be identified (Figures 4a-f ). Testing the efficacy of the removal of biofilms by the practitioner during PPCDS can be easily performed using the tri-tone disclosing agent (Figures 6a-d). ●● For calcified coatings: fluorescence enables very quick preoperative disclosure of soft and calcified bacterial coatings. With its considerable magnification and independent lighting, the SOPROCARE™ gives a new dimension to the prophylactic treatment of surfaces and during caries and periodontal treatments (Figures 7 a-c).
Conclusion The highlighting of bacterial coatings, whether soft or calcified, which must be removed by brushing or via prophylactic treatment in the dentist’s chair, is made easier by these new chemical or physical disclosure systems. They will change our approach to these important treatments for dental and gum health. About the authors Dr Michel Blique received a Diploma from the Faculty of Dental Surgery, Nancy and works as a University Associate in Paediatric Dentistry at the Faculty of Dental Surgery, Nancy, France. In addition he runs a private practice in France and Luxembourg, limited to minimally invasive and prophylactic dentistry and to medical periodontics. Dr Sophie Grosse has a Diploma from Faculty of Dental Surgery, Nancy, and is a University Associate in Paediatric Dentistry at the Faculty of Dental Surgery, Nancy, France. She works in private practice in Nancy, France.
BIBLIOGRAPHY 1. Axelsson P, NystrĂśm B, Lindhe J. The long-term effect of a plaque control program on tooth mortality, caries and periodontal disease in adults. Results after 30 years of maintenance. J Clin Periodontol. 2004 Sep;31(9):749-57. 2. Goodson JM, Palys MD, Carpino E, Regan EO, Sweeney M, Socransky SS-Microbiological changes associated with dental prophylaxis. J Am Dent Assoc. 2004 Nov; 135(11): 1559-64 3. Axelsson P. and Lindhe J. - Effect of controlled oral hygiene procedures on caries and periodontal disease in adults. Results after 6 years J Clin Periodontol 1981; 8(3): 239-248 4. Banerjee A,Yasseri M, Munson M. A method for the detection and quantification of bacteria in human carious dentine using fluorescent in situ hybridization. J Dent 2002; 30: 359-363. 5. Walsh Laurence J.- Recent Developments in Chairside Diagnostics for Dental Plaque Assessment: Dental Inc. Sep/Oct 2009 6. Mary J.O Incorporation of digital imaging into dental hygiene practice. Journal of dental hygiene March 1997; Vol.71 (2); 71-75
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how to use Tri Plaque ID Gel from GC
People often need to see something before they believe it GC Tri Plaque ID Gel can not only differentiate between old and new plaque in a few easy steps, this unique gel can also highlight exactly where the bacteria are most active by disclosing the acidic pH. This additional information will be a great help in your daily practise to motivate your patients to improve their oral hygiene.
Tri Plaque ID Gel =
Red pigment
Sucrose
Bacteria
NEw PlaquE
Extra high risk PlaquE
When a plaque biofilm is sparse, the blue pigment is easily washed off which leaves behind the red pigment showing a pink / red result.
The sucrose in GC Tri Plaque ID Gel will be metabolized by the acidogenic bacteria within the high risk plaque biofilm. The resulting acid produced lowers the plaque pH (<pH4,5) and this makes the red pigment disappear which leaves the light blue colour.
Old PlaquE (> 48hr) When a plaque biofilm has matured, its structure is dense, so both the blue and red pigments are trapped which forms a blue / purple layer.
Extra high risk PlaquE
Three tones, three easy steps to ensure patient compliance
1
Apply the gel with a swab, micro brush or a cotton pellet
2 Package 004273 40 g Tube (36mL)
Gently rinse the area with water spray and suction. Plaque is revealed on teeth in three tones: • red/pink - newly formed plaque • blue/purple - old plaque (more than 48 hours) • light blue – high risk plaque
3
After diagnosis, simply brush the teeth to remove the disclosing gel.
In the pursuit of preventive dentistry you and your patients need as many tools as possible in order to achieve optimal oral health. GC Tri Plaque ID Gel can become an invaluable part of your daily diagnosis routine.
24
Dr. G. Ghani, United Kingdom
Acid
Blue pigment
technique
By Dr Michel Blique
Managing the dental treatment of a child suffering from severe food polyallergies Food allergies are among the most frequent. Reactions are often limited but multiple severe food polyallergies do exist. In this case, anaphylactic shock is present, with a quick and violent bodily reaction to an allergen which triggers the release of a large number of substances in the body (1). These substances can cause a generalised skin rash, an angioedema (pale pink to red eruption and subcutaneous swelling, with breathing difficulties, intense burning sensation) and occasionally loss of consciousness. These symptoms are characteristic: the patient is agitated and distressed, will feel a strong itching sensation and can experience a generalised skin rash. They can also experience abdominal pains accompanied by nausea and vomiting or diarrhoea. Breathing is difficult, blood pressure falls and the heart rate increases. The extremities become cold, 1
and convulsions can occur. In the most extreme cases, they can suffer a cardiac arrest. Presentation of the case In the case of this young 12-year-old patient (Figure 1), whose main treatment plan we will describe hereafter, these manifestations of the allergy are a matter of life and death. His parents easily recognise these symptoms and know in a general sense how to detect them before it is too late. They must constantly carry an emergency kit containing an adrenaline auto-injector, cortisone, an antihistamine and a table of specific instructions written by his doctor from the Allergy department at CHU in Luxembourg, where he lives. The allergic symptoms appeared very early, even while as a baby he was breastfed. At 9 months, he was hospitalised with a rash caused by several 2a
2b
25
technique
drops of beer which had fallen from an empty can that he had got hold of and tipped over onto his leg, causing second-degree burns. Several years later, following the ingestion of otherwise authorised soya milk, he suffered anaphylactic shock to the point of entering a coma, which required him to be transported from Luxembourg to the childrenâ&#x20AC;&#x2122;s intensive care unit at Nancy University Hospital. He later suffered a severe angioedema at the hospital itself, during a testing session with eggs.
In his daily life, foodstuffs such as fish (cod, salmon) cause vomiting and very strong abdominal pains, while traces of egg yolks cause swelling in the mouth and vomiting. The child suffers asthma attacks when near raw cheeses such as camembert (he simply needs to be near the cheese, and must therefore avoid cheese stands in supermarkets). At home, the main allergens that have been identified are exotic fruits, animal proteins, notably those in milk, legumes, sesame, and gluten. Life is therefore far from simple for this family, but the parents, who suffer from allergies themselves, manage daily life and his medical follow-up with a lot of energy, vigilance, good humour and gratitude for the doctors and dentists. However, the necessary precautions and risk to life involved in this case have led
3a
3b
3c
3d
3e
3f
3g
3h
26
several dentists to decline, and not want to provide care. After initial caries had been diagnosed (Figures 2a-b), the 12-year-old was sent to the Paediatric Dentistry services at the Faculty in Nancy, which in turn sent him to us and facilitated the handover to private consultation with us in Luxembourg at the end of 2009, in order to help the follow-up of treatments by the family. In the context of dental treatment, we were asked to avoid latex, rinsing the mouth, cutaneous contact with disinfectants and the use of anaesthetic without preservatives or vasoconstrictors. We must select a reduced number of special instruments and dental materials which have been tested beforehand. Each product must have an established and verified composition, and in some cases allergenic tests must be carried out. It was agreed with the Head of the Department for Paediatric Dentistry in the Dental Faculty of Nancy and the parents that a prophylactic approach should be used straight away to stop the carious process that had already begun, then once the required special instruments for the dental treatment and orthodontics had been defined, move towards active treatment (preventative sealants (Figures 3 a-h), and minimally invasive restorations, necessary temporary tooth 4
5
extractions during orthodontics). The Minimal Intervention Treatment Plan (MITP) (2) followed and the factors susceptible to the risk of caries were researched and identified: ●● brushing carried out, but inadequately ●● cariogenic and unvaried diet, due to a large number of disallowed foods ●● limited saliva buffer capacity, resting pH at 6.5, elevated concentration of lactobacillus in saliva. Conversely, the support and involvement of the parents, as well as the observance and follow-up of treatments is exceptional. For obvious reasons, prophylactic treatment is limited to special instruments authorised by allergists and includes the following: Every 3 months, prophylactic cleaning of dental surfaces with brushes and fluoride toothpaste with 1250ppm of amino-fluoride (Elmex without menthol®). Later, the fluoride varnish at 1000ppm, Fluor Protector® from Vivadent®, will be authorised. After several months of research, exchanges with the manufacturers and tests, the following will be authorised for use: ●● Alumina powder 27µ Velopex for treatment by air abrasion ●● GC Cavity Conditioner® for surface preparation ●● GC Fuji Triage for preventative sealants (Figures 3a-i) 6a
27
technique
GC Fuji IX GP Extra for restorations (3 lesions ICDAS-4) ●● Alphacaine N from Dentsply for local anaesthetic, necessary for extraction of temporary teeth. The same precautions will be taken simultaneously by the orthodontist regarding impressions, bonds, materials and equipment used. The orthodontic treatment will begin after 9 months, and will end 3 years later. For almost 4 years, we will carry out a strict quarterly prophylactic follow-up: ●● plaque control and improved action at each appointment ●● prophylactic cleaning with ultrasonic devices followed by polishing with brushes and fluoride toothpaste (Figures 4-6) ●● checking high-risk areas (fissures and demineralised areas underneath brackets observed with a fluorescent camera by SOPROCARE™(Figure 6a)) ●● application of fluoride varnish to identified risk zones ●●
Discussion Is this situation exceptional? Perhaps not, as in the USA the prevalence of food allergies is estimated to be at 6-8% for children under 2 years of age and 1.5% for adults. Among the European 6b
28
population, it varies for all combined ages from 1.4 to 3.8%. In France, the prevalence of food allergies has recently been evaluated by an extensive epidemiological study to be between 2.1 and 3.8% (1). This risk could reach 20-40% if one parent has a history of allergies or 40-60% if both parents do. The dental practitioner confronted with a request for dental treatment in this context can legitimately be concerned, especially if the patient has already experienced severe episodes (coma and hospitalisation as in the case of our patient). However, the majority of deaths linked to a severe allergic reaction are a result of a delay in treatment. The occurrence of a severe reaction requires the patient to stay in hospital for at least 24 hours due to the risk of a possible relapse (delayed phase of the allergy). The information garnered from the patient and those close to them (i.e. the dentist) regarding the correct treatment in the case of an allergic reaction is important, as is carrying a card explaining the nature of the allergy in question once they have had an examination. It is essential to have, as in the case of our patient, a chart that helps decision-making regarding treatment in an emergency (1-3). What should we take away from this experience? ●● The need for transparency and mutually shared information between the family, the medical team and the dental team is essential. Precise information and unambiguous questions and responses on the part of the doctors and the family have helped us in our treatment choices, along with our contact with product manufacturers before use.
“In France, the prevalence of food allergies has recently been evaluated by an extensive epidemiological study to be between 2.1 and 3.8%” ●●
●●
●● The family of our patient for their support and The manufacturers we contacted were able to refer us to the right person in their company and help throughout all the necessary stages. could respond precisely about the composition ●● Dr Laetitia Lavoix and Mr Piyush Kandelwal of GC of their products in writing. Europe, Mr Yves Lavenant of Velopex France, Ms Carole Belon of Ivoclar Vivadent, the company Our experience and confidence in the treatment Dentsply. of carious or periodontal prophylaxis has helped us to quickly control the carious issue using simple and limited techniques, and to offer Bibliography treatments with minimal risk for implementation.
Conclusions As with many ‘unusual’ clinical situations or ‘difficult’ patients, knowing about and adopting a prophylactic approach with minimal dentistry is an enormous advantage for the practitioner (and the patient). These simple treatments often bring effective solutions to help avoid stress and risks to the dental team and the family. Bringing health to such patients in the long term contributes to the daily pleasure of our dental practices that are often so difficult. Acknowledgements ●● Dr Dominique Droz, Head of the Department for Paediatric Dentistry in the Dental Faculty of Nancy, for her belief and her help. ●● Dr Odile Hutereau, orthodontist at LuxembourgLimpertsberg. ●● Dr Morel-Codreanu and Dr Morisset, allergists, Centre Hospitalier de Luxembourg.
1. L’allergie alimentaire et digestive chez l’adulte Stéphane Nancey et al. Gastroentérologie Clinique et Biologique Vol. 29, N° 3 – March 2005 pp. 255-265 2. Doméjean-Orliaguet, S. et al. Minimum Intervention Treatment Plan (MITP) – practical implementation in general dental practice J Minim Interv Dent 2009; 2: 103-23 3. Allergies Alimentaires: Etat des lieux et propositions d’orientations. Carine Dubuisson, et col. AFSSA 2002 Derns.
About the author Dr Michel Blique received a Diploma from the Faculty of Dental Surgery, Nancy and works as a University Associate in Paediatric Dentistry at the Faculty of Dental Surgery, Nancy, France. In addition he runs a private practice in France and Luxembourg, limited to minimally invasive and prophylactic dentistry and to medical periodontics. 29
dental research
Researchers and clinicians share latest results for two-step restorative solution by GC
IADR symposium highlights mounting evidence of EQUIA as reliable long- term restorative solution EQUIA, a glass ionomer based restorative system from GC, received overwhelmingly positive reviews at a clinical symposium attended by prominent dental researchers from around Europe. The 46th meeting of the Continental European Division of the IADR took place in September in Florence, Italy, where a symposium on the latest trends in glass ionomer science was held by GC Europe, a global leader in dental materials. Distinguished scientists and clinicians gathered at the event to exchange ideas, share knowledge and present their data on GC’s EQUIA restorative system. The main clinical findings for EQUIA included: ●● When coated with highly filled resin coating, GIC shows improved mechanical strength ●● A perfect seal of surface porosities, cracks and improved acid resistance is attainable with EQUIA Coat ●● 48 month clinical trial results show EQUIA is a durable material for class I and II restorations ●● Randomised control trial (RCT ) shows survival rate for EQUIA restorations was 99.5% after 12 months and 96.3% after 24 months Evolution of glass ionomer materials Professor Avijit Banerjee, opened the symposium with his presentation on the uses and abuses 30
of glass ionomer cements (GICs) in dentistry. Banerjee, a professor of cariology and restorative dentistry at Guy’s Dental Hospital, at King’s College London, the Institute of Dentistry, is an internationally renowned researcher in the fields of cariology and minimum intervention dentistry. He outlined the clinical advantages and disadvantages of GICs and referred to various clinical trials and key systematic reviews which present significant evidence for this field. For Banerjee, further research and development would provide an improvement in its physical and chemical properties, giving GIC the potential to halt the carious process, making it a material ideally suited to minimum intervention dentistry. GICs and composite in perfect harmony: EQUIA Professor Ulrich Lohbauer (University Hospital of Erlangen, Germany) explored the mechanical performance of GICs with an in vitro assessment. As a specialist in dental biomaterials, Lohbauer’s presentation focused specifically on GICs with a composite coating. His lecture considered the general maturation process of GICs, which only achieve their mechanical stability over a period of time. Against this backdrop, Lohbauer believes
Glass ionomer technology symposium presenters (left to right) Dr Uli Lobhauer, GC Europe President Mr Eckhard Maedel, Professor Avijit Banerjee, Professor Servil Gurgan, GC IAG Executive Vice President Mr Henri Lenn, Dr Thomas Klinke and GC Europe product manager Dr Piyush Khandelwal.
that new approaches to restorative therapy have been developed with GICs, which should overcome the shortcomings in mechanical properties (such as low fracture toughness, flexural strength and surface hardness), improve aesthetic results and decrease sensitivity during the maturation stage. One such example is the EQUIA restorative system, consisting of a highly viscous (EQUIA Fil) glass ionomer cement coupled with a nano-filled, light-curing composite lacquer (EQUIA Coat). According to Lohbauer, in-vitro examinations have shown that EQUIA Coat protects the cement surface from acid erosion, setting it apart from conventional GICs. He also presented data which confirmed EQUIA’s suitability as a modern restorative material for the class II fillings due to the positive effect the coating has on
the GIC physical properties. Lohbauer expressly advised the audience to follow the manufacturer instructions meticulously in relation to the coating and to consider the indications in order to achieve best results. Promising results with far-reaching consequences The symposium continued with Professor Sevil Gurgan (Hacettepe University, Ankara, Turkey), who has worked for more than 30 years at Hacettepe University’s Faculty of Dentistry. Professor Gurgan presented the latest results of her team’s research on EQUIA, a four-year randomised clinical trial to evaluate the clinical performance of a glass ionomer restorative system, and showed EQUIA’s capabilities in class I and II restorations in comparison with composites over a period 31
dental research
of four years. The research included 140 lesions, which were restored either with EQUIA or the comparable material, Gradia Direct Posterior (GC) in combination with G-Bond (GC). The results after 48 months revealed that in none of the remaining 126 restorations at this point in time (76 class I and 50 class II) had any reduction in performance in terms of retention, secondary caries, surface structure, postoperative sensitivity and colour stability. Only moderately significant differences compared with the baseline level were found in relation to marginal integrity and discolouration for both restorative materials. Gurgan concluded from these results that both materials have similar clinical performance after 48 months, which makes them appropriate filling alternatives for the examined Class I and II cavities.
months and 96.3% after 24 months. All the fillings (n=644) were evaluated as clinically positive and no significant differences were determined in terms of longevity between the two materials. The findings show good clinical performance for both materials throughout the period of research, while Klinke says the ongoing follow-ups confirm the current results. Klinke pointed out that to achieve the ideal durability of a restoration, the manufacturer’s indications should always be followed to the letter.
Paving the way for modern dentistry The sheer number of findings and trial results presented at the symposium demonstrated that glass ionomer-based systems such as EQUIA have good clinical performance over the periods examined (up to 48 months). It also underlined the potential of glass ionomers combined with Practice-based research yields positive composites for restorative therapy. In summary, outcomes it is clear that the evolution of restorative Dr Thomas Klinke (University of Greifswald, materials continues and innovations such as glass Germany) then added to Gurgan’s impressive trial ionomer-based Equia benefit not only from the results the findings of a unique study. As the title, ‘EQUIA - RCT in the field: longevity after 24 months’ advantages of GIC and composites, but pave the way to the future of modern dental treatment. suggests, Klinke presented 24-month results of a prospective, randomised, double-blind clinical To read more about Equia by GC visit trial of EQUIA that will run for five years (Professor http://focus.gceurope.com/equia/ Reiner Biffar, Dr Thomas Klinke, Centre for Dental, Oral and Maxillofacial Surgery, University Hospital Greifswald). The research is characterised by its unique study design, which was conceived for observation in the field and is intended to reflect real everyday life in practice. A total of 3,194 dentists were invited to do eight one or two stage fillings in their practices using EQUIA Fil or Fuji IX Fast (GC) based on the manufacturer’s instructions. The survival rate for EQUIA was 99.5% after 12 32
dental business
By Alun Rees
The profits and ethics of paediatric dentistry The current economic climate has made it important for all businesses to look for multiple income streams to safeguard profit. This is much the same for dentistry. I believe paediatric dentistry can become an excellent patient revenue generator if it is based on a foundation of preventive care and minimum intervention dentistry. For many practice owners, this will require a paradigm shift. In this age of niche markets, accept that your paediatric practice is a separate entity from your adult practice and needs a different approach. Within this niche are several sub-niches including the new born, the pre-schoolers, ages 6-11, and secondary school. Cutting across these sub-niches come the risk factors which determine the best way to decide when to review, what messages are appropriate, when, what and if preventive measures are indicated. As it is with every element of child growth, the aim is to produce adults who are capable of reaching their full potential, whether that be physical, intellectual or emotional. Don’t we as dentists owe it to our patients to do our share?
a fat face to the dentist that my family ‘used’. Like a lot of practices in those days there were daily GA sessions. I was pinned in a chair, a black rubber gas mask was applied, a tumble into a few minutes of oblivion and I woke spitting blood minus five deciduous teeth and one permanent molar. The result one very frightened little boy and another four years of dentist-free existence. The next time I struck lucky I was seen by Mrs Denise O’Leary, at a practice local to our home. Denise, like my mother, was from Cork and the pair of them would gossip about mutual acquaintances during my repeated visits for repair. What made her special was that she never
Bad memories, fond memories and 40-yearold amalgam fillings My introduction to dental care was typical for the baby boomers whose parents celebrated the removal of sugar rationing by spoiling us with sweet treats. At the age of seven I was taken with 33
dental business
once talked down to me, I was, in her eyes, just a younger person not a ‘child’. At the first visit she explained that one of my teeth (I now know it was my lower left first molar) was beyond saving and would need to be removed. I was offered the choice of a GA or local anaesthetic, having been terrified by my last encounter with the rubber mask I chose the local. I can still remember her skillfully ‘palming’ the extraction forceps and the way she supported my mandible whilst giving the tooth a couple of squishy lateral movements before it was out and away and I was spitting copious amounts of blood into the white porcelain spittoon. Visits thereafter were six monthly and usually, but not always, seemed to involve treatment, that said the work she did was pretty good and more than four decades later the amalgams are still functioning.
Caries is not inevitable and it can be controlled ●● Too many parents think that caries isn’t important - how can the disease responsible for a large number of paediatric hospital admissions not be important? ●● Dentists don’t take children’s dentistry seriously and are using the same excuses now that they did a quarter of a century for their behaviour ●● Dentist’s children get cavities, how come? ●●
Solutions ●● Identify the micro-niches in your practice ●● See children on separate visits from parents otherwise you are asking the parent to bring all their baggage to every visit. There will be confusion about messages given as there is no ‘one size fits all’ ●● Delegate the vast majority of the time spent during children’s ‘routine’ appointments. But remember it’s never routine for them it’s always Fundamental lessons in delivering paediatric special ●● Make the visits memorable for all the right dental care It was my visits to her, the way that she gained and reasons (more important) never lost my trust that inspired ●● Never attempt active treatment on under 11year my interest in dentistry. The fundamental lessons I olds after school. Why? They’re knackered that’s learned consumed and provided the basic ground why, possibly so are you so it’s hardly the best rules for my practice. start to a session where you both need to be at ●● People are individuals whatever their age your best ●● You only get one chance to make a good ●● Tailor the preventive advice given to the impression individual and change the way that the advice is ●● It’s not the child’s fault that they have cavities, given to include all learning styles Remember that the disease controlled, dentally it’s the fault of the person who either buys or confident children of today become the dental provides the cash for the sugar ●● Habits can be changed but it’s easier if they are consumers of tomorrow who are able to choose the benefits of elective dentistry without having never started ●● Dental practices can be intimidating places for to consider the baggage of their past. I think that’s what’s called a win-win. small people 34
“I believe paediatric dentistry can become an excellent patient revenue generator if it is based on a foundation of preventive care and minimum intervention dentistry” Child-friendly clinical interventions With the philosophy of Minimal Intervention the stages of Diagnosis, Prevention and Treatment become less defined and merge into one continuum of Disease Control. The lives of patients and dental team are made easier by use of the appropriate GC products. At assessment and review TriPlaque ID Gel shows age and acidogenicity of plaque and Saliva-Check Buffer assesses flow rate, viscosity, consistency, pH and buffering capacity are an adjunct to diagnosis and an aid to communication. Tooth Mouse provides extra protection in the under-6s and during orthodontic treatment and MI Paste Plus can be used for children over six years of age. For added protection of fissures in newly erupted teeth Triage is a godsend giving high fluoride release and ease of use. Once ‘active’ intervention is indicated then a product like EQUIA fits in to Minimal Intervention practice, as it requires less removal of tooth structure than traditional materials is highly adhesive and aesthetic. Of course there are Fuji IX, Fuji II other ionomers together with the full range of composite alternatives mean that patient needs can be fully met. Successful, gentle management of child patients is a great way to market your practice. It seems perverse logic that parents will ‘test’ you out on
their children before permitting you the privilege of treating them but that is often the case. If you are seen to care for the youngest members of the family then it follows that you must care for all. You only have one opportunity to make a good impression so don’t let it slip away and never forget that school gate gossip can both boost or destroy a reputation. About Alun Rees Dr Alun Rees trained in Newcastle and started his career as an oral surgery resident, before working as an associate in a range of different practices. With this solid foundation, Alun went on to launch two practices in the space of just 15 months, a challenge in the toughest economic conditions. After years of hard work Alun finally sold his awardwinning business in 2005. Alun now runs Dental Business Partners to offer specific and specialised support for dentists, by dentists. He has served as a media representative for both the BDA and BDHF and is an authority consulted by the media and has featured on BBC2, Sky TV and various radio stations. 35
outreach
Dr Andrew Bartram
Delivering oral healthcare to remote areas The Amchi Programme is a collaboration between Wisdomtooth, the University of Manipal and the European Dental Students Association. The Amchis are Tibetan Buddhist nuns who are the local health care providers in the Ladakh region of Jammu and Kashmir, high in the Himalayas of Northern India. The goal of the Amchi Programme is to correct the shortfall in care, train the Amchis in line with the WHO ART programme and empower them to help their fellows, making a self-sustainable improvement in the health of the local population. In 2012, 44 dentists, dental students and associated healthcare workers from 14 countries and 4 continents travelled to Ladakh to take part in the Amchi project. In an area the size of Britain with a population of 180,000, there are four dentists working in only one location. Due to the mountainous terrain, extreme weather and altitudes in excess of 3,500m the majority of the population of the region cannot access any healthcare for much of the year.
36
The Amchi travel the countryside in the summer months providing traditional Tibetan medicine and care to the local population. Due to the dearth of oral care available, the burden of care falls upon the Amchi who have no training in dealing with oral disease. Why Ladakh? The answer is simple. Ladakh is a remote and isolated region with a very clear need for treatment. Therefore it is a part of the world where simple interventions can have a positive effect on the local population. Also, as a student, travelling to such a location is a very special experience. Ladakh is a region that is steeped in culture and heritage that dates back to neolithic times. The aims of the programme are education, prevention and treatment, in that order. We pride ourselves on making simple interventions that are cost-effective and have far reaching benefits. In the initial phases of the programme, those requiring direct care will receive it from the outreach team. As time passes, the Amchi will
â&#x20AC;&#x153;it is a part of the world where simple interventions can have a positive effect on the local populationâ&#x20AC;? provide the required care, first in association with outreach teams, but eventually visiting dentists will provide only a supervisory role. Due to the recent influx of western dietary practices, levels of decay have risen dramatically. There is an obvious difference between the decay rates of parents and their children. We hope to use this to demonstrate to parents the consequences of a high sugar diet, thus modifying health behaviours in their children and making a simple intervention with positive benefits. By the end of the year we aim to ensure that the Amchis are proficient in independent placement of fissure sealants. We are grateful to GC for supplying us with Fuji Triage sealant for this purpose. Fuji Triage is the ideal material for our work in this area given its ease of use, placement and evaluation and also its fluoride leaching properties. It is something which we can teach the Amchis to use and place in conditions which are certainly sub-optimal, in comparison to a dental surgery. However, thanks to the qualities of the material we should still be able to get good results.
Connect with the programme Twitter: @Amchiprogramme Facebook: www.facebook.com/amchiproject Email: Amchi2012@gmail.com Donate: www.justgiving.com/Amchi-dentaloutreach About the author Dr Andrew Bartram MBBS (Dist.) MRCS Ed, BA, TCD Sch. is a fourth year Trinity College Dublin dental student and official EDSA delegate for the Republic of Ireland. He is originally from Beamish in the north east of England, studied medicine and served his time as a junior doctor and underwent basic surgical training in Newcastle upon Tyne before moving to Dublin to pursue a career in oral and maxillofacial surgery.
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product showcase
Protecting partially erupted teeth One of the treatment strategies that research is showing to be key in treating the child patient is to protect partially erupted teeth with Fuji Triage from GC. Fact 1: It is difficult to isolate a partially erupted molar, when the tooth is partially covered by an operculum. Resin-based sealants need a dry environment for their bonding effectiveness.(1,2) However: Fuji Triage is moisture tolerant and offers chemical adhesion to tooth structure, even in a moist environment.(3,4) Fact 2: Resin-based sealants rely on enamel etching and micromechanical retention. Etching aprismatic enamel does not provide a microretentive surface for an effective resin bond.(3) However: Fuji Triage, being a glass ionomer, allows chemical adhesion, even to aprismatic enamel. ●● Clinical studies indicate that Fuji Triage has similar retention compared to resin sealants at 24 months and report reduced instances of marginal stains and caries in the teeth.(3) ●● The retention of small amounts of glass ionomer sealants could be sufficient to prevent caries in the pits and fissures of teeth(5) Fluoride-modified hydroxyapatite is much more caries resistant.(3) ●● Once the tooth is fully erupted, you still have the option to either renew the existing glass ionomer sealant or place a resin-based sealant. 38
Academic references 1. Locker et al. The use of pit and fissure sealants in preventing caries in the permanent dentition of children. Br Dent J 2003; 195: 375-8. 2. Smallridge et al. Int. J Paediatr. Dent 2000;10:79-83 3. Antonson et al. Twenty-four month clinical evaluation of fissure sealants on partially erupted permanent first molars: Glass ionomer versus resin-based sealant. JADA 2012;143:115-122. 4. Beiruti et al. Comm Dent Oral Epidemiol 2006;34:403-409. 5. I Mejáre, IA Mjör. Glass ionomer and resinbased fissure sealants: a clinical study. Scand J Dent Res, 1990:98:345-350.
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