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Volume XV, Number III, 2008
100 YEARS COMMITMENT TO DENTAL EXCELLENCE G. Tamer Holding
Cavex Centennial
ISSN 1026 261X
The ART approach to manage dental caries
Volume XV, Number III, 2008 EDITORIAL TEAM Alfred Naaman, Nada Naaman, Jihad Fakhoury, Dona Raad, Antoine Saadé, Lina Chamseddine, Tarek Kotob, Mohammed Rifai, Bilal Koleilat, Mohammad H. Al-Jammaz COORDINATOR Eliane Jkayem ART DEPARTMENT Krystel Kouyoumdjis SUBSCRIPTION Micheline Assaf, Nariman Nehmeh ADVERTISING Josiane Younes PHOTOGRAPHY Albert Saykali TRANSLATION Gisèle Wakim, Marielle Khoury DIRECTOR Tony Dib ISSN 1026-261X
DENTAL NEWS – Sami Solh Ave., G. Younis Bldg. POB: 116-5515 Beirut, Lebanon. Tel: 961-3-30 30 48 Fax: 961-1-38 46 57 Email: info@dentalnews.com Website: www.dentalnews.com
CONTENTS CONTENTS CONTENTS CONTENTS
11 13
International Calendar
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One- or Two- Visit Endodontic Treatment: Answering a Common Endodontic Question Dr. Richard E. Mounce
27
Sleep-Breathing Disorders and Dentistry Dr. Aamir Khalid Hassan
32
A Predictable Apical Biological Seal in Endodontic Therapy by Using Emdogain in Animal Models Dr. Jamal BouJbara, Dr. James A. Wallace
42
The Influence of Parents' Dental Health Knowledge and Dental Health Practices on Caries Experience of Their Children Dr. Walid Aldeeweli
50 52
Book Review: All-Ceramics at a Glance
56 74
Cavex Centennial Special Coverage
INTERNATIONAL REVIEW BOARD Pr. M.A. Bassiouny BDS, DMD, MSc, Ph.D. Director International Program, Temple University, Philadelphia, USA. Pr. N.F. Bissada D.D.S., M.S.D Professor and Chairman, Department of Periodontics, Case Western Reserve University, USA. Pr. Jean-Louis Brouillet D.C.D, D.S.O. Chairman, Department of Restorative Dentistry, Aix-Marseille II, France. Pierre Colon D.C.D., D.S.O. Maître de conférence des universités, Paris, France. Dr. Jean-Claude Franquin, Directeur de l’Unité de Recherche ER116, Marseille, France. Pr. Gilles Koubi D.C.D., D.S.O. Department of Restorative Dentistry, Aix-Marseille II, France. Pr. Guido Goracci. University LA SAPIENZA, School of Medicine & Dentistry, Roma, Italia. Dr. Olivier Hue, Faculté de chirurgie dentaire de Paris VII, rue Garancière, Paris, France. Brian J. Millar BDS, FDSRCS, Ph.D. Guy’s, King’s, and St. Thomas’ College School of Medecine & Dentistry, London, UK. Pr. Dr. Klaus Ott, Director of the Clinics of Westfälischen Wilhelms-University, Münster, Germany. Wilhelm-Joseph Pertot DEA, Maître de conférence, Aix-Marseille II, France. Pr. James L. Gutmann, Professor and Director, Graduate Endodontics, Baylor College of Dentistry, Dallas, Texas, USA. Pr. Dr. Alfred Renk, Bayerische Julius-Maximilians-University, Würzburg, Germany. Dr. Philippe Roche-Poggi DEA. Maître de conférence des universités, Aix-Marseille II, France. Michel Sixou D.C.D., D.E.A. Department of Priodontology, Toulouse, France. Pr. M. Sharawy B.D.S., Ph.D. Professor and Director, Department of Oral biology, Medical College of Georgia, Augusta, Georgia, USA.
The Atraumatic Restorative Treatment (ART) Approach to Manage Dental Caries: Development and application Dr. Nabil Beiruti
G. Tamer Holding 100 years commitment to dental excellence
PRODUCT REVIEW
DENTAL NEWS IS A QUARTERLY MAGAZINE DISTRIBUTED MAINLY IN THE MIDDLE EAST & NORTH AFRICA IN COLLABORATION WITH THE COUNCIL OF DENTAL SOCIETIES FOR THE GCC. Statements and opinions expressed in the articles and communications herein are those of the author(s) and not necessarily those of the Editor(s) or publisher. No part of this magazine may be reproduced in any form, either electronic or mechanical, without the express written permission of the publisher.
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October 8 – 11, 2008 The 36th International Expodental, Fiera Milano City, Italy Email: expodental@expodental.it October 16 – 18, 2008 Beirut International Dental Meeting 2008 Tel/Fax: 961 1 611222 - 611555 Contact: Dr. Antoine Karam, President of The Lebanese Dental Association Email: BIDM2008@LDA.org.lb Website: www.LDA.org.lb/BIDM2008 October 16 – 18, 2008 The 12th International Symposium on Dentofacial Development and Function, Cairo, Egypt Email: drashraf@aast.edu Website: www.dfdfcairo.com October 18 – 20, 2008 Riyadh International Dental & Pharmacy Meeting, Riyadh, Intercontinental Hotel Email: dean@riyadh.edu.sa Website: http://www.riyadh.edu.sa October 24 – 25, 2008 LUMINEERS SMILE DESIGN WORKSHOPS, LE MERIDIEN, Dubai, U.A.E. Fax: 001 313 582 0300 Email: berrydentist@yahoo.com Website: http://www.denmat.com October 24 – 25, 2008 The 3rd CAD/CAM Computerized Dentistry International Conference, Crowne Plaza Hotel, Dubai, U.A.E Website: http://www.cappmea.com October 28 – 31, 2008 The 16th Alexandria International Dental Congress Tel/Fax: 203 4811787 Email: info@aidc-egypt.org Website: www.aidc-egypt.org
November 12–14, 2008 The Yemen Dental Association Scientific Conference & The International Dental Exhibition and Conference, Sanaa-Yemen. Tel: 00967 - 1 - 414897 Mobile: 00967 - 777477133 Fax: 00967-1-506006 P.O. Box: 4015 Email: zakari_1994@yahoo.com November 19 – 21, 2008 The 1st Jordanian and the 7th Arabic Congress of Pediatric Dentistry Dead Sea Resort and Spa, Jordan Contact: Dr. Othman Ajlouni Email: othmanajlouni@yahoo.com November 23 – 25, 2008 The 5th Gulf Dental Association Conference, Kuwait Email: info@kda.org.kw Website: http://www.kda.org.kw November 28 – December 3, 2008 Greater New York Dental Meeting, New York Website: http://www.gnydm.com December 17 – 18, 2008 The 15th Oman Dental Conference, Grand Hyatt Muscat, Sultanate of Oman Email: odc2008@oman-dental.org Website: www.oman-dental.org March 10 – 12, 2009 AEEDC Dubai, Dubai International Convention & Exhibition Center Email: index@emirates.net.ae Website: http://aeedc.com March 24 – 28, 2009 The IDS 2009, Cologne. Website: http://www.ids-cologne.de
ADVERTISING INDEX ACTEON 75 - A-DEC 71 - AMANNGIRRBACH 16 - BELMONT 67 - BEYOND 51 - BIEN AIR 69 - BIOMET 3I 53 - BLUE X 65 - CASTELLINI 26 - CAVEX 54 - COLTENE WHALEDENT 49 - DISCUS DENTAL 30 - DR. WILD 4, 5 - DUERR 31 - EMS 35 - GC 10 - GSK C2, 37 - HU-FRIEDY 19 - INTENSIV 25 - IVOCLAR – VIVADENT 1, C4 KAVO C3 - KAVO – GENDEX 63 - KERR 20, 59 - KETTENBACH 48 - KING’S UNIVERSITY 12 - KOMET 55 - LEONE 41 - MECTRON 45 - METASYS 72 - MICRO MEGA 77 - MOCOM 40 - MORITA 29 - NEWTOM 6, 7 - NOBEL BIOCARE 43 - NSK 80 - S-DENTI 46 - SHOFU 33 - SIRONA 15 - SOREDEX 79 - SULTAN 8, 9 SVENSKA 64 - SYBRON ENDO 23 - VITA 47 - VOCO 24 - W&H 61 - ZHERMACK 2 - ZIMMER 39
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The Atraumatic Restorative Treatment (ART) Approach to Manage Dental Caries Development and application <By Nabil Beiruti*
ABSTRACT The epidemiological studies in the Eastern Mediterranean countries showed high prevalence of dental caries among populations, especially children, and most dentine lesions are untreated. The traditional approach to treat decayed teeth is very costly, more unrealistic and not affordable for individuals and governments in most countries. Therefore, alternatives are needed to treat caries. The Atraumatic Restorative Treatment (ART) approach was developed and supported by WHO. It is a minimal intervention approach that removes demineralized tooth tissues using hand instruments only and restores cavities with glass-ionomer cement. Many studies carried out in different countries have proved the effectiveness of ART as preventive and curative approach.
INTRODUCTION Dental caries is one of the most prevalent infectious diseases in all ages and in all communities. It affects quality of life and daily life (pain, eating disorders, school, work…), in addition to causing health, social and economic problems. Reduced oral health-related quality of life is associated with poor clinical status and reduced access to care.(1) The caries process is now well-understood; much of it has been described extensively in the dental literature. Dental caries is a bacterially-based disease. When it progresses, acid produced by bacterial action on dietary fermentable carbohydrates diffuses into the tooth and dissolves the carbonated hydroxyapatite mineral – a process called demineralization. If this process is not halted or reversed via remineralization, the redeposition of mineral via saliva – it eventually becomes a frank cavity.(2)
* DDS, DDPH, PhD. Former Director of the WHO Demonstration, Training and Research Centre for Oral Health, Damascus, Syrian Arab Republic.
DENTAL NEWS, VOLUME XV, NUMBER III, 2008
The analyzing of oral health status in the year 2000 in the Eastern Mediterranean Countries showed high prevalence of dental caries with increasing, and largely untreated dentin lesions. The traditional procedures of treating carious teeth were based on using expensive electrical equipment and employing highly-trained dental personnel and most countries could not afford it. An innovative approach has been established to manage dental caries: The Atraumatic Restorative Treatment (ART).(3, 4) The aim of this paper is to describe this approach, its development and application as a curative and preventive model.
Dental caries The epidemiological studies in the 90s showed that dental caries prevalence has declined markedly over the past 25 years in most industrialized countries due to use of fluorides in different types and improving of oral hygiene practice, but, it is still increasing and largely untreated in many developing countries. Data collected from Eastern Mediterranean Countries showed that the prevalence of dental caries among 6-year-old children varies between %30-92, and between %29-93 among 12-year olds. Most decayed teeth in both deciduous and permanent dentitions are untreated, at least 90% and 55% of the dentinal lesions in the deciduous and permanent dentitions need treatments.(5) Several studies have demonstrated that the occlusal surface of the first permanent molar is the site in the dentition which is most frequently attacked by dental caries.(6)
Minimal intervention treatment Alternative approaches are innovated to help in providing feasible and affordable dental care to more people based on adopting the minimal intervention treatment concept(7) also called preservative Correspondence address: Dr Nabil Beiruti Jesser Alabiad Square Damascus, Syria Tel.: +963 11 3333778 Fax: +963 11 3115400 Email: nbeiruti@net.sy THE ART APPROACH TO MANAGE DENTAL CARIES
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dentistry. This concept is considered as a consequence of increasing our understanding of the pathological process of dental caries and availability of better adhesive filling materials. This concept includes the following principles: • Remineralization of early lesions. • Reduction in cariogenic bacteria in order to eliminate the risk of further demineralization and cavitation. • Minimum surgical intervention of cavitated lesions. • Repair rather than replacement of defective restorations. • Using of adhesive restorative materials such as glass-ionomer cements. • Caries control in pits and fissures. *DMFT is the index for measuring the extent to which a population is affected by caries, which in a group of individuals counts the average number of teeth that are Decayed(D), Missing(M) (because of caries), and Filled(F). Several minimal intervention treatment techniques have been described in the literature, including: preventive resin restorations (PRR), "tunnel" and "internal" restorations, preventive glass-ionomer restorations, posterial aproximal "miniboxes" and microchips and the Atraumatic Restorative Treatment approach (ART) which will be described in this article because considerable number of trials have been carried out to prove its effectiveness and it was supported by WHO.(8)
The Atraumatic Restorative Treatment Approach (ART) This approach is a logical technique based upon sound scientifically based principles. It is a restorative and preventive procedure, largely pain-free, maximally preventive and minimally invasive. It requires no electrically driven equipment, no water supply, and local anesthesia is seldom used. It depends on removing carious tooth substances using hand instruments only and then restoring the cavity and adjacent fissures with high-viscosity glass ionomer cements; GICs adhere strongly to tooth tissues and release fluoride. It is less sensitive to moisture and pulpal biocompatible, a simple procedure for application to the tooth, requiring no elaborate or expensive apparatus.(9)
Development of ART approach ART Approach was developed in the mid-1980s by the WHO Collaborating Centre for Oral Health at the University of Groningen, the Netherlands, in cooperation with Dr. Jo Frencken, as a new model to control dental caries in developing countries and deprived communities as well as under-served populations of industrialized countries.(10) In 1994, ART approach was presented at the headquarters of the World Health Organization on World Health Day on April 7 as preventive and curative approach to manage dental caries and recommended member states to adopt this approach into their oral health strategies. Between 1995-2000, many trials were carried out in Pakistan by Dr. van Amerongen, in China by Dr. Christopher Holmgren, and in Syria by Dr. Nabil Beiruti and Dr. Jo Frencken. More studies have been conducted
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THE ART APPROACH TO MANAGE DENTAL CARIES
- or are still in progress - in many communities in developing and developed countries around the world. The results of these trials have been published in scientific journals and have shown that ART approach was effective, feasible and acceptable. In 1995, a symposium devoted to ART was held at the International Association for Dental Research (IADR), Singapore meeting and the proceedings have been published in a special volume of the Journal of Public Health Dentistry.(11) A special commission of the International Dental Federation (FDI) reviewed ART approach and presented its report at the annual meeting in Barcelona in 1998 and has since been published. Additionally, a symposium on ART was held in 1998 at the annual meeting of the American Association of Public Health Dentistry, and there is considerable world-wide interest in the use of ART technique to manage dental caries in projects in some industrialized countries (Australia, New Zealand, Italy, USA, Finland…). Since 1996, many training workshops were organized by WHO in Syria, Tunisia, Lebanon, Jordan, Oman, Kuwait, Egypt and other countries in the region to introduce ART and to encourage to apply it in communities.
Effectiveness of ART approach SURVIVAL
OF
ART
RESTORATIONS
Although ART is still relatively new, the last decade showed a considerable number of publications presenting results of clinical and field trials on it carried out in developing and developed countries. Before 1995, low-viscous GICs have been used, the preventive effect was high, but the retention rate was low. The studies carried out later used high-viscous GICs and showed better retention rates. The new material has been applied and showed survival rates after three years of between 85% and 88% and compared favorably with amalgam restorations placed under similar conditions.(12) A clinical trial carried out in Kuwait compared ART restorations with amalgam technique in primary molars and showed in a 2-year followup that 89.6% of all ART restorations were considered successful. The failure rate of the comparable pairs of ART and amalgam restorations was 5.7%. There was no significant difference in success rate between ART and amalgam techniques.(13) Dr. Abid A. conducted a study in Tunisia and found that 45.73% of one-surface ART restorations in permanent teeth had survived, as well as 54.96% of one-surface sealants in permanent teeth and 27.85% of one-surface ART restorations in primary teeth. Caries was found in only 19 teeth after 3 years.(14) Two clinical comparison trials carried out at the WHO Oral Health Centre in Damascus, Syria showed that the 3-year cumulative survival rates of single-surface ART and amalgam restorations were 86.1% and 79.6%, respectively in deciduous teeth(15) and 82.1% and 76.9% respectively for permanent teeth.(16) An evaluation carried out after 6.3 years for the children who participated in the last study showed that cumulative survival rates of ART and amalgam restorations became 69.1% and 57.0%, respectively.(17) These results declare that restorations produced with the ART approach, with high-viscosity glass ionomer, survived longer than
DENTAL NEWS, VOLUME XV, NUMBER III, 2008
those produced with the traditional approach (with amalgam) in deciduous and permanent teeth of young children. It was concluded that ART could be adopted as the treatment of choice for use in schools and outreach oral health programs.
ART
SEALANTS
The application of fissure sealants to the occlusal surfaces significantly reduced the onset of carious lesions at these sites. Resin-based sealants have been tested and applied for many years, and have generally shown to be an effective method of caries prevention for children and young adults although the material appears to be technique sensitive, moisture intolerant and needs dental units for applying. Glass ionomer cements have been introduced to be alternative fissure-sealing systems. They have been shown to be promising for caries prevention and the interest in their use has increased in the 90s; they are applied in the same way as ART restorations. Glass ionomers are less sensitive to moisture, and could be applied easily in simple environments by dentists and auxiliaries.(18) Two studies using high-filled GIC sealants achieved better retention over 3 years (about 70%) and fissure caries prevention (0-4%) than those for earlier GIC.(19,20) A systematic review carried out to determine the difference in preventive dentine lesions development between resin-based and glassionomer showed no evidence that neither resin based nor glassionomer sealant material is superior in preventing dentine lesions development in pits and fissure over time.(21) This conclusion encourages to apply ART high-viscosity glass ionomer sealants instead of resin-based to prevent dental caries. A five-year clinical study was carried out at the WHO Oral Health Centre in Damascus to investigate the caries preventive effect of glass-ionomer sealants, placed according to ART procedure, in comparison to resin-based sealants over time and the caries preventive effect after complete disappearance of sealant material.(22) The results of the study showed that caries preventive effect of ART high-viscosity glass-ionomer sealants was between 3.1 and 4.5 times higher than that of resin-based sealants after 3- to 5-years. Furthermore, high-viscosity (ART) glass-ionomer sealants appear to have a four times higher chance of preventing caries development in re-exposed pits and fissures of occlusal surfaces in first molars than what is achieved using light-cured composite resin sealant material over 1- to 3-year period.
ART application technique RESTORATIONS 1- Preparation of the ART instruments: mouth mirror, probe, tweezers, excavators in different sizes, dental hatchet, applier/carver, mixing spatula and pad, matrix band and plastic strip, mixing-hand high viscous glass-ionomer cements and other miscellaneous materials (cotton wool pellets and roles, petroleum jelly..) 2-Isolation of the operating site by using of cotton wool rolls. 3- Examining the decayed tooth after removing plaque or food debris from the pits and fissures with a probe and cleaning the tooth surface by rubbing with a wet cotton pellet, followed by drying the surface with a dry pellet.
DENTAL NEWS, VOLUME XV, NUMBER III, 2008
4- Gaining access to the carious lesion: If the opening to the cavity is small, a dental hatchet is used to widen the entrance for access. The corner of the hatchet is placed in the deepest part of the pit or fissure, it is rotated backwards and forwards to break the unsupported and brittle demineralized enamel. The cavity entrance is increased to at least 1mm. That permits access for the smallest excavator.
Figure 1
Figure 2
Figure 3
Figure 1: The position of the dental hatchet in the cavity entrance. Figure 2: Movements of the dental hatchet to enlarge opening of the cavity access. Figure 3: Removing of soft dentine by using the excavator.
5- Removal of soft dentine by using the excavator in suitable size starting from the enamel-dentine junction then from the floor of cavity. The cavity is cleaned with a wet cotton pellet followed by a dry pellet. The stained and discolored dentine that is hard should be retained.
Figure 4
Figure 5
Figure 6
Figure 4: Cavity entrance opened to permit access for excavator. Figure 5: Caries removal using small excavator. Figure 6: Opening of cavity further for improved access with the blade of the hatchet.
6- Conditioning the cavity and adjacent pits and fissures to remove the smear layer in order to improve chemical bonding of glassionomer to the tooth tissues. This can be achieved either by the use of a dentine conditioner or the liquid component of the glassionomer itself which contains a solution of 25-40% polyacrylic acid. The conditioner is applied to the cavity and pits and fissures using a wet cotton pellet for 15 seconds. The cavity and pits and fissures are washed with a pellets dipped in clean water and then dried carefully with clean and dry pellets. Compressed air should not be used. 7- Mixing the glass-ionomer. The high-viscous glass-ionomer cement (for ART) should be used following the manufacturer' s instructions. 8- Restoring the cavity and filling the pits and fissures. The mixed glass-ionomer is inserted into the cavity in small increments using the applier/carver instrument then additional mixture is placed in adjacent THE ART APPROACH TO MANAGE DENTAL CARIES
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pits and fissures. The gloved index finger is rubbed with small amount of petroleum jelly and used to press the glass-ionomer firmly into the cavity and pits and fissures (Press-finger technique). After a few seconds the finger is removed sideways. The excess of materials are removed from the outer margins of the occlusal surface with the carver.
Finally, ART currently is an effective minimal intervention approach to the control of caries. It is applicable in private and public dental clinics and in disadvantaged communities. It is anticipated that the principles adopted by ART, namely those of minimal intervention and maximal prevention will herald a new direction for the future of dentistry.
Acknowledgment I would like to thank Dr. Jo Frencken, the Director of the WHO Collaborating Centre for Oral Health, Nijmegen, the Netherlands, for giving me the permission to reprint some photos from his book "Atraumatic Restorative Treatment for Dental Caries".
Figure 7
Figure 8
Figure 9
Figure 7: Placing the glass-ionomer in the cavity and over the pits and fissures. Figure 8: Firm finger pressure is applied over the occlusal surface. Figure 9: Excess filling material visible at the outer margins of the occlusal surface.
9- The bite is checked and the high parts of restoration are removed with a carver or a large excavator. The restoration is recovered with petroleum jelly or varnish.
Figure 10
Figure 11
Figure 12
Figure 10: Checking the bite with articulating paper. Figure 11: ART restoration after the bite has been adjusted. Figure 12: The cavity is filled and the pits and fissures are sealed with glass-ionomer cement.
Fissure sealing The application of ART fissure sealants is similar to the application of ART restorations. The same procedures are followed, but cavity preparation is not undertaken.
Figure 13
Figure 14
Figure 15
Figure 13: Press-finger technique. Figure 14: Cross-section of ART sealant in occlusal surface. Figure 15: ART pit and fissure sealant.
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THE ART APPROACH TO MANAGE DENTAL CARIES
REFERENCES 1. U.S. Department of Health and Human Services. Oral Health in America: A report of the Surgeon General. Rockville, MD: U.S. Department of Health and Human Services, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000. 2. John D.B. Featherstone: The Science and Practice of Caries Prevention. JADA, Vol. 131, July 2000. 3. Frencken JE et al. Atraumatic Restorative Treatment (ART): rationale, technique and development. Journal of Public Health Dentistry, 1996; 56:135-40. 4. Oral Health Program. Milestone. Geneva, World Health Organization, 1998. 5. Beiruti N. Oral Health Situation, analysis data in EMRO countries, 2000. WHO/EMRO (Unpublished). 6. Carvalho J.C., Ekstrand K.R., & Thylstrup A.: Dental Plaque and Caries on Occlusal Surfaces of First Permanent Molars in Relation to Stage of Eruption. J Dent Res 68(5):773-779, May, 1989. 7. Tyas J.T, Anusavice K.J, Frencken J.E, Mount G.J. Minimal Intervention Dentistry- a review. FDI Commission Project Int Dent J 2000; 50:1-12. 8. Frencken J, Makoni F. A treatment technique for tooth decay in deprived communities. World Health (47th year) 1994; 1:15-17. 9. Kenneth J. Anusavis: Does ART have the place in preservative dentistry? Community Dent Oral Epidemiol 1999; 27:442-8. 10. Frencken JE, Pilot T, Songpaisan Y et al. Atraumatic Restorative Treatment (ART): Rational, technique and development. J Public Health Dent 1996 56: 135-140. 11. Siegal MD. Workshop on guidelines for sealant use. J Publ Health Dent. 1995; 55 (special issue) 259-311. 12. Frencken J E, Holmgren C J. How effective is ART in the management of dental caries? Community Dent Oral Epidemiol 1999 Dec; 27(6):423-30. 13. Honkala E, Behbehani J, Ibricevic H, Al-Jame G. The atraumatic restorative treatment (ART) approach to restoring primary teeth in a standard dental clinic. Int J Paediatr Dent. 2003 May; 13(3):172-9. 14. Abid A, Chkir F, Ben Salem K et al. Atraumatic Restorative Treatment and glass ionomer sealants in Tunisian children: survival after 3 years. East Mediter Health J 2002 8: 315-323. 15. Taifour D. Frencken J., Beiruti N., Van hof M., Triun G. Effectiveness of glass-ionomer (ART) and amalgam restorations in the deciduous dentition: Results after three years. Caries Res 2002; 36:437-444. 16. Taifour D, Frencken JE, Beiruti N, Van t Hof MA, Truin GJ, van Palenstein Helderman WH. Comparison between restorations in the permanent dentition produced by hand and rotary instrument-Survival after 3 years. Community Dent Oral Epidemiol 2003; 31:122-128. 17. Frencken JE, van' Hof MA, Taifour D: Effectiveness of ART and traditional amalgam approach in restoring single-surface cavities in posterior teeth of permanent dentitions in school children after 6.3 years. Community Dent Oral Epidemiol. 2007 Jun; 35(3):207-14. 18. Siegal MD. Workshop on guidelines for sealant use. J Publ Health Dent. 1995; 55 (special issue): 259-311. 19. Holmgren C J , Lo C E M, Hu D Y, et al. ART Restorations and sealants placed in Chinese school children, results after three years. Community Dent Oral Epidemiol 2000; 28: 314-320. 20. Frencken J C, Makoni F, Sithole W D. ART restorations and glass ionomer sealants in Zimbabwe: survival after 3 years. Community Dent Oral Epidemiol 1998; 26: 372-381. 21. Beiruti N, Frencken JE, van't Hof MA and van Palenstein Helderman WH. Caries-preventive effect of resin-based and glass ionomer sealants over time: a systematic review. Community Dent Oral Epidemiol 2006; 34: 403-4-9. 22. Beiruti N, Frencken JE, van't Hof MA and Tayfour D. Caries-Preventive Effect of a One-Time Application of Composite Resin and Glass Ionomer Sealants after 5 Years. Caries Res 2006; 40:52-59. DENTAL NEWS, VOLUME XV, NUMBER III, 2008
One- or Two-Visit Endodontic Treatment: Answering a Common Endodontic Question
<By Richard E. Mounce*
I
n my lecture travels, a common question from clinicians is to ask “When can I fill a tooth in one visit and when do I need two?” This column was written to answer this question in a clinically relevant way. Ideally, depending on the complexity of the case, the pre-operative diagnosis, the presence and absence of a periapical lesion, the probabilities of the treatment being one-visit or two-visit treatment must be considered and explained to the patients in advance. The choice of division of treatment into one or two visits may not always be clear and there is room for interpretation and debate of the endodontic literature on this point. A basis for one- and two-visit treatment is provided here.
A: One-visit treatment for vital teeth can be considered if: 1) The tooth is asymptomatic. 2) There is no swelling, no percussion, and/or no apical palpation sensitivity. 3) The tooth is clean and dry before obturation. 4) The treatment can be carried out well without time restrictions and in an optimal environment. For vital teeth, there is relatively little debate amongst the endodontic community as to the advisability of one-visit treatment in these clinical circumstances.
B) For non-vital teeth, with and without radiographic pathology, one-visit treatment can be considered if: 1) The tooth is asymptomatic. 2) There is no swelling, no percussion sensitivity, and no apical palpation sensitivity.
*DDS. Private endodontic practitioner, Vancouver, WA, USA.
DENTAL NEWS, VOLUME XV, NUMBER III, 2008
3) The tooth is clean and dry before obturation. 4) If the treatment can be carried out well without time restrictions and in an optimal environment
C) For non-vital teeth, two-visit treatment is indicated with and without radiographic pathology for teeth that are: 1) Symptomatic, and/or if swelling, percussion sensitivity, apical palpation sensitivity are present. 2) If the apex is not or cannot be made clean and dry before obturation. Canals that “weep” with purulence or cannot be dried with paper points for any reason, irrespective of the type of moisture are best treated in two visits. 3) If the treatment cannot be carried out well without time restrictions and in an optimal environment. Teeth that are initially non-vital, that fit into the category of C above (with and without a lesion) optimally should have calcium hydroxide placed between visits. UltraCal* is a functional and efficient way to place calcium hydroxide into the canal system with precise control. The plastic syringes of Ultra Cal have luer lock ends into which fits a Navi Tip syringe* tip *(Ultradent, South Jordan, UT, USA). Navi tips come in various lengths and calcium hydroxide can be injected with precision throughout the canal. For vital teeth being treated in two visits, calcium hydroxide is optional and uncommon. Caustic medicaments such as formocresol, steroid pastes, antibiotic pastes, etc are not recommended in cases of irreversible pulpitis that require two visits for whatever reason. In cases of retreatment that require two visits, even if the aforementioned issues in C above are not present (and the tooth is asymptomatic), optimally, calcium hydroxide is placed between visits.
Correspondence address: Email: RichardMounce@MounceEndo.com
ONE- OR TWO-VISIT ENDODONTIC TREATMENT
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As an aside, coincident to a discussion of the management of teeth that must be treated in two visits is the question of: when, if ever, a tooth should be left open. The subject is very controversial and beliefs on the issue can bring passionate differences of opinion amongst clinicians. As a starting place to answer this clinical issue, it should be stated that this scenario should be extremely rare for this to be even considered. If a necrotic tooth is accessed and purulent drainage emerges from the tooth, it can be dealt with in two primary fashions, one is to leave the tooth open for some period of time to let it drain, this may be 5 minutes or 30, but at some point, most often opening such a tooth will create drainage that stops. Ideally, the access is made as ideal as possible before the tooth is left open to drain. If the tooth drains productively, it is uneccessary initially to place instruments in the canal perhaps beyond the orifice enlargement mentioned below. This said, access should be made ideally and the tooth allowed to drain passively before instruments are placed into the canal. Canal shaping can and should came later. If the drainage stops, paper points can generally dry the canal without any further drainage (even though the apex is wet and the paper points are wet), calcium hydroxide is placed and the tooth can be closed for two-visit treatment. Alternatively, a capillary tip can be used (*Ultradent, South Jordan, UT, USA) which is attached to the high volume suction and it can be placed in the canal until the canal stops draining. Again, calcium hydroxide is placed and the tooth sealed. Usually, in the vast majority of cases, one or both of these two methods will allow the clinician to manage productive drainage of a non-vital tooth. It is rare, but possible that purulent drainage cannot be stopped despite all such measures. The degree of swelling present and the degree of discomfort are factors to be considered. If the patient is swollen as they very well might be and the tooth is open and drainage cannot be stopped there are two remaining options, one is to consider incision and drainage if the swelling is fluctuant. The other, as a treatment of last resort, considered acceptable, by some, is to leave the tooth open for no more than 24-48 hours. After this time, either the treatment can be completed or calcium hydroxide placed in 24-48 hours and the treatment completed at a third visit. It is important to mention, in addition to the recommendations above, that several concepts must certainly be held in mind in management of the cases described: 1) Visual and tactile command over the access cavity is essential. Ideally, the access will be made under the surgical operating microscope (SOM) (Global Surgical, St. Louis, MO, USA). SOM visualization would allow the clinician to know exactly where drainage was coming from (which canal, etc), if all of the canals had been located, if a fracture in the furcal floor might be present and/or if a vertical root fracture was present, etc. 2) Removal of the cervical dentinal triangle (when appropriate, in the treatment of such a case) and initial canal enlargement could be accomplished efficiently and safely using either 1) The K3 RNT orifice opener (which comes in three tapers .12, .10 and .08 and a fixed 25 tip size) or 2) the Twisted File (SybronEndo, Orange, CA, USA) (which
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ONE- OR TWO-VISIT ENDODONTIC TREATMENT
is available in the same tapers and tip size, in addition to other tapers, .04 and .12). Use of these instruments in the first steps of early coronal enlargement is rapid, safe, and highly efficient relative to using Gates Glidden drills. In the case of the TF, its use has the added advantage that often, approximately two thirds of the clinical cases encountered can be treated with one or two instruments, a significant advance relative to the other alternatives available in the marketplace at this time. Removal of the cervical dentinal triangle and initial management of the canal orifice can allow efficient use of the capillary tip mentioned above as required (Figures 1-2).
Figure 1: K3 Shapers SybronEndo, Orange, CA, USA)
Figure 2: The Twisted File (SybronEndo, Orange, CA, USA) A clinically-relevant discussion of the rationale behind one- and two-visit treatment as well as the uncommon employment of the technique of leaving a tooth open for any period of time has been presented. Emphasis has been placed on the importance of preoperatively determining the diagnosis and tailoring the treatment to manage clinical situation rapidly and efficiently. Feedback is welcome. Dr. Mounce offers intensive customized endodontic single day training programs in his office for groups of 1-2 doctors. For information, contact Dennis at 360-891-9111 or write to RichardMounce@MounceEndo.com. Dr. Mounce lectures globally and is widely published.
DENTAL NEWS, VOLUME XV, NUMBER III, 2008
Sleep-Breathing Disorders
and Dentistry
<By Aamir Khalid Hassan*
INTRODUCTION Many people experience difficulties to have good sleep, which affects their day life. This may be attributed to backache, neck pain, stomach problems and breathing difficulty while sleeping. Dentists are the first to identify those patients and treat them. This article aims to investigate mouth breathing and other breathing difficulties in dentistry.
Breathing difficulties The relation between breathing and oral health is very serious, as well as the relation between breathing and sleep disorders, and oral health and sleep disorders.(1,2,3) Any nasal defects or airway obstruction such as adenoid hypertrophy, congenital hypertrophy, tonsil hypertrophy, retruded maxilla, retruded mandible, obesity causing tongue, uvula and throat tissue enlargement impair respiration. Consequently, the patient starts mouth breathing, which affects badly the form of the palate (excessive molar eruption, clockwise rotation of the mandible, increased anterior vertical dimension and face height, retrognathia and open bite, low tongue posture leading to reduced lateral expansion and anterior development of maxilla; high narrow palate); among other conditions, craniofacial malformation, malocclusion and jaw deformation; anterior open bite, posterior crossbite, and excessive appearance of maxillary anterior teeth and gum.(2,3,4) This will increase the chances for caries, affect periodontal status, and cause halitosis and tonsillitis.(1,2) Abnormal craniofacial formation causes the airway obstruction, which results in breathing difficulties, sleep apnea, and sleep disorders. It was found that infants fed only on bottle milk (artificial milk) have greater chances to develop mouth breathing, tongue thrusting, and palatal arch deformation; these symptoms are expected to appear at the age of two years.(2,4) Mouth breathing affects the quality of breathed air, because nasal breathing usually passes the air to the nasal sinuses, where nitric oxide is then liberated. Nitric oxide is essential for human health, as it is an antibacterial-growth agent, and it improves oxygen absorption and transport throughout the body.(4,5)
*BDS, MDS. Dental Consultant, Qatar Armed Forces, Doha, Qatar.
DENTAL NEWS, VOLUME XV, NUMBER III, 2008
Therefore, a joint work of dental, ENT and orthopedic experts should be recommended when doing case assessment and management; most of the cases need time and patient cooperation. Early treatment of any airway obstruction is necessary to maintain normal growth and developments and facilitate the success of orthodontic-orthopedic treatments.(5,6) Orthodontic treatment is required as a preventive measure on the detection of airway dysfunction and craniofacial malformation starting from early childhood to overcome the results of mouth breathing by the use of rapid expansion appliances; is an easy and simple method of treating impaired nasal respiration at age (4-30), while the ENT specialists have the upper hand in early airway treatment.(5,6) Obstructive Sleep Apnea Syndrome (OSAS) is one major hazard that affects most of mouth breathers; this condition is defined as repetitive occurrence of upper airway obstruction during sleep (apnea, which is a cessation airflow for 10 seconds) associated with reduced blood oxygen level;(6,7) the patient will have gasping, snoring, choking, repeated arousals through the night, tiredness feeling after a long night sleep, dry mouth, morning headache, absence of dreams, fatigue, decreased libido, depression. In severe cases it may cause hypoxemia and pulmonary hypertension, chronic CO2 retention and polycythemia.(6,7) The effects of OSAS on the cardiovascular system include hypertension, cardiac arrhythmia, myocardial infarction and cerebral vascular changes. All these advance effects could be hazardous to the patient's life.(6,7,8,9) Incidence of OSAS rises with age.(1,2) It is caused by obstruction of upper airway leading to disrupted sleep, therefore patients fall asleep during the day, and could endanger themselves while working. Most of the time patients do not know about their symptoms.(6,8) Overnight polysomnography, respiratory disturbance index, a good interpreted cephalometric radiograph and oxyhemoglobin saturation are the diagnostic methods mostly used to detect the cases.(4,6,8) Dentists acknowledge OSAS cases when the following are present: loud snoring, high potentiality of day sleep, dry mouth, and mouth breathing.
Correspondence address: Dr Aamir Khalid Hassan Qatar Armed Forces, Doha, Qatar Email: amiralagidi@hotmail.com SLEEP-BREATHING DISORDERS AND DENTISTRY
27
TREATMENT A- NON-SURGICAL TREATMENT 1. Obesity treatment.(8,9) 2. Positive airway pressure machine: A heavy machine worn on the head, that produces noise, and drying of mouth and nose.(8,9,10) 3. Medication: Protriptyline (atricyclic antidepressant), medroxyprogestrone.(8,10) 4. Non sleep apnea dental orthotics (NADOs): Mandibular advancement devices.(6-10) The theory behind the use of these oral appliances depends upon the control of the mandible to which the tongue is connected, therefore anything which brings the mandible forward (protrusion) will tend to lift the tongue and epiglottis away from the back of the throat, relieving (partially or completely) the airway constriction caused by muscles relaxation during sleep. This appliance should be used by patients who have good number of supported teeth in both arches, and at least one clear nasal airway. Patients with any temporomandibular joint dysfunction must be carefully evaluated and monitored before using such devices. These appliances can be used as bite guard (bruxism treatment), snore guard, and OSAS guard. The appliances are made of silicones, or acrylic resin. Impression are taken, and models are poured in plaster. Bite registration is taken after requesting the patient to protrude his mandible as much as possible without straining (3-5mm), then sent to the laboratory. Ready- made appliances can be made when the patient is instructed to bite into a double-sided prefabricated plastic tray lined with flexible thermal plastic. This polymer can be directly molded in the mouth after being
REFERENCES 1- Bahamman A, Kryger M; Decision making in obstructive sleep disordered breathing; putting it all together. Otolaryngol. Clin North Am 1999; 32(2):333-48. 2- Michael JR; A case for full coverage hard acrylic non sleep apnea dental orthotics. J Can Dent Assoc 2006; 72(3):239-41. 3- Goodday RHB, Precious DS, Morrison AD, Robertson CG; Obstructive Sleep Apnea Syndrome; diagnosis and management. Can Dent Assoc. 2001; 67(11):652-8. 4- Schedin U, Norman M, Gustafsson LE, Herin P, Frostell D; Endogenous nitric oxide in the upper airways of healthy newborn infants. Pediatr. Res.1996 Jul; 40:148-51. 5- Lundberg JO, Farkas-Szallasi T, Weitzberg E, Rinder J, Lidholm J, Anggaard A, Hokfelt T, Lundberg JM, Alving K; High nitric oxide production in human paranasal sinuses. Nat. Med 1995; 1(4):370-3. 6- Clark GT, Sohn JW, Hong CN; Treating obstructive sleep apnea and snoring; assessment of the anterior mandible positioning device, J Am Dent Assoc 2000;131(6):765-71. 7- Goodday RH; Nasal airway resistance and obstruction sleep apnea syndrome.
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SLEEP-BREATHING DISORDERS AND DENTISTRY
heated in boiling water. Fitting is quite simple, does not require any special tools and can be completed within a few minutes. However, these appliances may cause limited tooth mobility, and TMJ problems over time. All these appliances make the pharyngeal space to open up, thereby the velocity of the inspired air decreases apnea and snoring is reduced by reducing the air over the soft tissues. There are many types of such appliances, including: • SILENT NITE: These are made of upper and lower arches silicone trays attached together by pairs of plastic hinges. • KLEARWAY: These are complicated, made from silicon, with jackscrew that allows for minute adjustment. Two-wires project forward from the upper tray to be attached to the lower arch. • NAPA: These are made of hard acrylic, held in position by 8 clasps. They have a lip supporter to maintain breathing. • SNORE AID: These are used mainly for upper edentulous patients. They have extra-oral lip shield to hold the lower jaw forward. • HERBST: These are made of silicone or acrylic. They are composed of two arches attached firmly to the teeth and to each other by adjustable bars on both sides. • SILENCER: It is two transparent splints, one for the upper jaw and one for the lower jaw, the latter being held in position by 2 connectors fixed laterally to the splint.
B- SURGICAL TREATMENT Tracheostomy, uvuloplalatopharyngeoplasty (shortening soft palate, removing uvula and lateral and posterior pharyngeal wall mucosa from the oral pharynx. Orthognathic surgery (advancement of mandible, maxilla and chin).
Oral Maxillofac Surg Clin North Am 1997; 9(2):167-177. 8- Shepard JW Jr; Hypertension, cardiac arrhytmias, myocardial infarction and stock in relation to obstructive sleep apnea. Clin Chest Med 1992; 13(3):437-58. 9- Sanders MH, Grundel CA, Rogers RM; Patient compliance with nasal CAPA therapy for sleep apnea. Chest 1986; 90(3):303-3. 10- Young T, Palta M, Dempsey J, Skatrud J, Weber S, Bader S; The occurrence of sleep-disordered breathing in middle-aged adults. Engl J Med 1993; 328(17):1230-5. 11- Principato JJ; Upper airway obstruction and craniofacial morphology. Otolaryngol Head Neck Surg.1991 Jun; 104(6):881-90. 12- Mohsenin N, Mostofi MT, Mohsenin V; The role of oral appliances in treating obstructive sleep apnea. J Am. Dent. Assoc. Apr. 2003; 134(4):442-9. 13- Riley RW, Powell N, Guilleminault C; Current surgical concepts for treating obstructive sleep apnea syndrome. J Oral Maxillofac Surg 1987; 45(2):149-57. 14- Powell NB, Riley RW; Obsructive sleep apnea; orthognathic surgery perspectives, past, present and future. Oral Maxillofac Surg Clin North AM 1990; 2(4):843-56.
DENTAL NEWS, VOLUME XV, NUMBER III, 2008
A Predictable Apical Biological Seal in Endodontic Therapy by Using Emdogain in Animal Models <By Jamal M. BouJbara,* James A. Wallace**
ABSTRACT
INTRODUCTION
Objective: To obtain an apical biological seal by inducing cementogenesis by the use of enamel matrix protein (Emdogain) during obturation.
Inflammatory reactions of the pulp and periapical tissue have tormented humanity for thousands of years. Microorganisms enter the pulp chamber through direct carious exposure, uncovered dentinal tubules, cracks in enamel and dentine or through exposed lateral canals. Non-vital or necrotic pulp are defenseless against microbial invasion. Microbes and their by-products reach the periapical tissue through the apical foramen and elicit an inflammatory response. This response induces resorption of the surrounding bone, which is often visible in radiograph as a localized periapical radiolucency. The inflammatory reaction may also stimulate epithelial cells in the periodontal membrane to proliferate and form a periapical cyst.
Material and Methods: 16 teeth were used from 4 monkeys. 4 teeth were taken as control; in the 12 experimental teeth, canals were prepared with hand and rotary files. Emdogain was placed in the canal system in direct vicinity of the anatomic apex and obturated with lateral condensation. 5 weeks later 3mm of the root apex was resected and prepared for observation under bright field and polarized microscopy at different magnifications. Results: Bright Field Microscopy – At different magnifications the experimental teeth showed the deposition of acellular cementum lining the root surface with insertion of periodontal ligament fibers. Polarized Microscopy – Differentiated the dentinal tubule structure, the cementum lining the root surface and the intrinsic fiber arrangement parallel to the canal. Control teeth did not show any remarkable findings except for the consistent presence of inflammatory cells. There was no deposition of cementum. Conclusion: The study found amelogenin is biologically acceptable to the periapical tissues, it does not inhibit healing, and enhances regeneration by cementogenesis, so initiating an apical biological seal.
*MDS, DDS. Endodontist, Deputy Head of Endodontics Unit Bnaid Al-Gar Dental Center State of Kuwait
Historically, aim of endodontic treatment has been to save the tooth. The main objective of endodontic therapy is to obtain an apical biological seal, as the goal, by mechanical and chemical debridement of the entire pulp cavity and root canal system and finally, obturation of this system with an inert filling material. The three main functions of obturation are to entomb any bacteria remaining within the root canal system; to stop the influx of periapical tissue-derived fluid from re-entering the root canal to feed the surviving bacteria; and to prevent coronal leakage of bacteria. Different authors have reported the formation of the apical biological seal after obturation. The clinician must then choose a path of treatment that will result in the best possible cleaning and shaping of the root canal system coupled with an obturation technique that will provide a high level of three-dimensional
Correspondence address: Dr. Jamal M. BouJbara P.O.B: 789 Salmiya, 22008
**DDS, MDS, MSD, MS Director, Division of Endodontics School of Dental Medicine University of Pittsburgh
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DENTAL NEWS, VOLUME XV, NUMBER III, 2008
Figure 1: Mouth prop being used to hold the monkey's mouth open.
Figure 2: Accessing of each root canal system.
Figure 4: Final file used in each canal was size #25.
Figure 5: Canal debridement using rotary instrumentation.
seal, apically, laterally, and coronally within the confines of the root canal system. Thus the formation of cementum which seals the apical foramen later is vital towards obtaining a natural apical biological seal. With regard to prognosis of conventional endodontic treatment, there are numerous studies to substantiate the placement of the root canal filling within the confines of the tooth root. The Washington Study by Ingle (1976) reported 91.54% success with no difference between surgical and non-surgical therapy. Bender and Seltzer (1963) reported that underfilled and flush-filled teeth were more successful than overfilled teeth. Most of these studies reported that success was more predictable in most teeth when the obturation is within 1mm from the radiographic apex. Thus, the cementodentinal junction acts as a biological stop for the placement of the obturating material, and at the same time provides the stimulus for the formation of the apical seal. The formation of the biological apical seal is an important parameter for the success of endodontic therapy. Studies into the embryologic development of the tooth highlighted the role of the enamel matrix proteins, of which amelogenin is a principal constituent. Payenter and Pudy (1958), Selvig (1963), Formicola et al (1971) reported that cementum formation begins when Hertwig's epithelial root sheath (HERS) which contains amelogenin is exposed to the newly formed dentin to induce cementogenesis to form acellular cementum. The function of cementum is to attach the periodontal fibers to the tooth.
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A PREDICTABLE APICAL BIOLOGICAL SEAL IN ENDODONTIC THERAPY
Figure 3: Estimation of canal working lengths via apex locator.
Figure 6: EMDOGAIN, (BIORA AB INTERNATIONAL, Malmo, Sweden).
Research into enamel matrix proteins or amelogenin for periodontal regeneration over the years has yielded results. It had regained the attachment apparatus of the periodontium lost because of periodontitis. Hammarstorm et al (1997) in monkeys was able to show 60% 70% regeneration of acellular cementum that firmly attached to the root dentin with regenerated collagen fiber insertion into the alveolar bone proper. Studies by Mellonig (1999) in humans showed clinically and histologically that amelogenin favors the formation of a new attachment apparatus characterized by the presence of acellular cementum with collagen fibers insertion in new alveolar bone. In endodontics, use of amelogenin is based on the rationale its use would enhance the predictability of the formation of the apical biological seal after obturation thus enhancing the prognosis of the treated tooth. A pilot project to demonstrate the use of amelogenin at therapy by Wallace et al (1999) was not successful, as their approach did not allow the identification of the structure of interest. Thus, the aim of the present study is to use a more precise method employing immuno-histochemical stain specific for amelogenin to identify cementogenesis formation as it relates to formation of a biological seal in root canal therapy. The enamel matrix protein harvested from developing porcine teeth is called enamel matrix derivative (EMDOGAIN). Stable, freeze-dried enamel matrix derivative has been purified (Emdogain, Biora) for use in periodontal tissue regeneration. The previous literature review indicates that the endodontic objective of an apical biological seal may
DENTAL NEWS, VOLUME XV, NUMBER III, 2008
Figure 7: Placement of Emdogain
Figure 8: Obturation of root canal systems via lateral condensation.
Figure 10: Reflection of full thickness mucoperiosteal flap.
Figure 11: Resection of apical three millimeters of each root.
be enhanced by the utilization of amelogenin at the apex during obturation. The purpose of this project is to study the amelogenin (Emdogain) on cementogenesis as it relates to formation of a biological seal in root canal therapy.
DISCUSSION Periodontal regeneration is described as “healing after periodontal treatment that results in the renewal of lost supporting tissues including new acellular cementum attached to the underlying dentin surface, a new periodontal ligament with functionally-oriented collagen fibers inserting into the new cementum, and new alveolar bone attached to the periodontal ligament” (Hirooka, 1998). The enamel matrix proteins have been used to encourage periodontal regeneration. They have been found to be active during embryogenesis producing cementum, periodontal ligament and supporting bone (Caton, 1997). Studies have suggested that enamel matrix proteins have resulted in the genesis of periodontal supporting tissues, which are similar to those formed during tooth development. Amelogenin is an enamel extracellular matrix protein which is secreted at the beginning of enamel development. It is necessary for normal formation and is believed to be involved in controlling the growth and orientation of apatite crystals during enamel maturation. Furthermore, in developing human teeth amelogenin was found to be present in the area where cementogenesis is initiated and a cementum-like tissue was formed when cells of the dental follicle were exposed to enamel matrix.
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A PREDICTABLE APICAL BIOLOGICAL SEAL IN ENDODONTIC THERAPY
Figure 9: Clinical evaluation of operative area.
In this study the use of amelogenin appears to enhance formation of a biological seal in root canal therapy. This study showed complete resolution of the repair processes associated with the endodontic instrumentation trauma. Cementogenesis along with the regeneration of the periodontal ligament and supporting bone proceeded in a timely fashion. Significantly there was no evidence of operative or post operative hemorrhage and the apical areas were totally free of inflammatory cells or exudates. This may translate into the lack of discomfort associated with this technique and material as the animals' post-operative behavior was not suggestive of discomfort. Therefore, no analgesics were deemed necessary. The surgical procedures of root canal therapy involving anesthesia, instrumentation, placement of amelogenin followed by gutta-percha obturation and cementation proved dependable. A previous study (in which the author participated) with placement of amelogenin solution demonstrated that the gel form of utilized amelogenin was superior. The microscopic technique utilized proved adequate to evaluate the placement and biological behavior of tissue. The surgical procedures used to obtain the specimens were very functionable. It was evident that identification of the root apex with highspeed burs prior to utilization of the trephine to obtain the sample was effective. The trephine used was 3mm in diameter cylinder with
DENTAL NEWS, VOLUME XV, NUMBER III, 2008
a cutting edge and attached to a slow speed hand piece. A problem was noted in removal of the core osseous samples. Some destruction was observed if great core was not used, otherwise this technique proved adequate. Bright field microscopy at the 40x, 100x, and 450x proved adequate in most situations to distinguish dentin, cementum, periodontal ligament (Sharpey's fibers), bone, sealer, amelogenin, and gutta-percha. It is significant that the size of the major foramen in this specimen was an #80 file, as this was the size of file utilized. This size was chosen so we could place the needle of the amelogenin syringe close to the apex. It is significant that some of the accessory canals were completely sealed by cementum, from the new cementum deposition at the apex, as in forming a biological seal. The smear layer evident in most histological sections was composed of debris from instrumentation, which reduced the ability to identify dentinal tubules. Due to the fibrous arrangement of cementum and dentin polarized microscopy was applied to the study. Thus the polarizing microscopy enabled the identification of cementum versus dentin via their intrinsic fiber characteristics. Also noted was that sealer is identifiable as bright white opaque image. The amelogenin did not polarize but appeared as crystalline like gel or a granular amorphous, eosinophilic material. The lack of inflammation in all specimens demonstrated the biological acceptability of this material. The fact that healing was not inhibited supports the use of this material as a cementogenesis-stimulating agent. It is especially significant that all instrumentation was at least 1-2mm past the anatomic foramen. There are more studies in progress, which are designed to further identify and characterize the function of amelogenin (Emdogain).
CONCLUSION Based on the present study the following conclusions are drawn: 1. Amelogenin is biologically acceptable to the periodontium. 2. Amelogenin does not inhibit healing and healing time is reduced. 3. Amelogenin may enhance regeneration by cementogenesis. 4. This is an effective technique to study amelogenin in monkeys
UNDER BRIGHT FIELD MICROSCOPY 40x. You see the root apex that has been instrumented. Endodontic sealer is evident (S). Accessory canals are demonstrated (B). Evident are: Dentin (C), Cementum (D), Periodontal Ligament (E), Bone (F), Granular amorphous, eosinophilic material (X).
100X You see a large apical canal lined by cementum with non-descript material occupying the center of the canal. Cementum (C), Granular amorphous, eosinophilic material (X), Periodontal ligament (P).
450x At this magnification dentin is evident by its tubules, non-descript material in the center will be stained by amelogenin antibody. Dentin (D), Cementum (C), Sealer (S), Granular amorphous, eosinophilic material (X).
UNDER POLARIZED MICROSCOPY 40x You can see the dental fiber orientation versus the apical canal - with sealer. Granular amorphous, eosinophilic material (X). Sealer (S), Cementum (C), Dentin (D).
100x You can now see dental fibers orientation versus the cemental fibers orientation and an enlarged endodontic sealer image. Granular amorphous, eosinophilic material (X), Sealer (S), Cementum (C), Dentin (D).
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A PREDICTABLE APICAL BIOLOGICAL SEAL IN ENDODONTIC THERAPY
DENTAL NEWS, VOLUME XV, NUMBER III, 2008
REFERENCES 1. Brooks, S. J., Robison, C., Kirkham, J. and Bonass, W. A. Biochemistry and molecular of Amelogenin Proteins of Developing Dental Enamel. Archives of Oral Biology. 1995; 40: 1-14. 2. Burch, J.G., Julen, S. The relationship of the apical foramen to the anatomic apex of the root. Oral Surg Oral Med Oral Pathol, 1972; 34: 262-267. 3. Dow, P., and Ingle, J. I. Isotope determination of root canal failure. Oral Surg Oral Med Oral Pathol, 1955; 8: 1100. 4. Green, D. Stereomicroscopic study of 700 root apices of the maxillary and mandibular posterior teeth. Oral Surg Oral Med Oral Pathol, 1960; 13: 738-733. 5. Hamamoto, Y., Nakajima, T., Ozawa, H. and Uchida, T. Production of Amelogenin by Enamel Epithelium of Hertwig's Root Sheath. Oral Surg Oral Med Oral Pathol, 1996; 81: 703-709. 6. Hammarstorm, L., Heiji, L., Gestrelius, S. Periodontal Regeneration in Buccal Dehiscence Model in Monkeys after Application of Enamel Matrix Proteins. J. Perio. 1997; 44: 669-677. 7. Hammarstorm, L. Enamel Matrix, Cementum Development and Regeneration. J. Clin. Periodontol. 1997; 24: 658-668. 8. Harty, F. J., Parkins, B. J., Wengraf, A. M. Success Rate in Root Canal Therapy. A Retrospective Study of Conventional Cases. British Dental Journal 1970; 20: 65-70. 9. Heiji, L. Enamel Matrix Derivative (Emdogain) in the Treatment of Intrabony Periodontal Defects. J. Clin. Periodont. 1997; 24: 705-714. 10. Hirooka, H. The biologic concept for the use of enamel matrix protein: True Periodontal regeneration. Quintessence Internat. 1998; 29:10, 621. 11. Ingle, J. I., Taintor J.F. Modern endodontinc therapy. Endodontics, Philadelphia. Lea and Febiger. 1976; 34-37. 12. Kennedy D.D., Simpson M. S. The hallow tube controversy. J. of the British Endodont. Society. 1969; Apr-Jan: 3(2): 25-23. 13. Kuttler, Y. Microscopic investigation of root apexes. JADA. 1955; 50: 455-552.
14. Listgarten, M.A., Kamin, A. The development of a cementum layer over the enamel surface of a rabbit molars– A light and electron microscopic study. Arch Oral Biol. 1969; 14: 961-985. 15. Mellonig, J.T. Enamel matrix derivative for periodontal reconstructive surgery: technique and clinical and histologic case report. Int. J Periodont Rest Dent. 1999; 19:9-19. 16. Nyman, S., Lindhe, J., Karring, T., Rylander, H. New Attachment Following Surgical Treatment of Human Periodontal Disease. J. Clin Periodontology. 1982; 9: 290-296. 17. Palmer, M.J., Wiene, F.S., Healey, H.J. Position of the apical foramen in relation to endodontic therapy. J. Canad Den Ass. 1971; 8: 305-308. 18. Paynter K. J, and Pudy, G. A study of the structure, chemical nature and development of cementum in the rat. 1958; 131: 233-251. 19. Polson, M. Periodontal Regeneration, current status and directions. Quintessence Publishing Co, Inc. 1994. 20. Rickert, U. G., and Dixon, C. M. The Controlling of Root Surgery, Internat. Dent. Congress (8th), 1931; Tr. Sect. IIIa: 15. 21. Schonfeld, S. E. and Salvkin, H. C. Demonstration of enamel matrix proteins on root-analogue surfaces of rabbit permanent incisor teeth. 1977; 24: 223-229. 22. Sculean, A., Donos, N., Windisch, P., Brecx, M., Gera, I., Reich, E., Karring, T. Healing of Human Intrabony Defect Following Treatment with Enamel Matrix Proteins or Guided Tissue Regeneration. J. Periodont. Research. 1999; 34: 310-322. 23. Seltzer, S., Bender, I.B. Factors Affecting Successful Repair Root Canal Therapy. JADA, 1963; 67: 651-662. 24. Slavkin, H. C. and Boyde, A. Cementum: An epithelial secretory product? Journal of Dental Research. 1975; 53, 157: 409. 25. Swartz, D.B., Skedmore, A. E., Griffin, J. A. Twenty years of endodontic success and failure. J Endod, 1983):9: 1983; 9: 198-202. 26. Wallace J. An eight-week study utilizing Emdogain in endodontics to create a biological seal. (A pilot study). University of Pittsburgh. 1999.
The Influence of Parents' Dental Health Knowledge and Dental Health Practices on Caries Experience of Their Children <By Walid Aldeeweli*
ABSTRACT The purpose of the present study is to determine parents' dental health knowledge and its relationship to caries experience of their children. Materials and Methods - The dental records of 100 children were reviewed to assess their caries experience by calculating DMFT and deft. Meanwhile, questionnaires were handed to parents/legal guardians to gather information regarding their dental health knowledge. Results and conclusion - Children of parents who know the dental health status of their children tend to have less caries experience than children of parents who do not. The findings of the current study point to the need for including parents in preventive dentistry rather than only concentrating on the child.
INTRODUCTION
One hundred children, between the ages of 3-15 years (51 male, 49 female) living in fluoridated communities, participated in the present study during their visits at Dimock Community Health Center, Boston Medical Center, and East Boston Neighborhood Health Center. Informed consent was obtained from parents/legal guardians to participate in the present study. The dental records of these children were reviewed to assess their caries experience by calculating DMFT and deft.(3,4) Questionnaires (English and Spanish) were handed to parents/legal guardians to be answered during the recall visit. The purpose of the questionnaire was to gather information regarding the parents' dental health knowledge and the dental health practices of their children.
Children learn from their parents, and this fact is significant when discussing the role of the family in facilitating utilization of dental services. Parents have a responsibility to give guidance to children in establishing good dental health habits and practices in the home. Parents can begin teaching their children good dental hygiene from an early age. Even before teeth erupt, parents can wipe the infant's gums with a soft cloth after feedings, thus helping to condition the child to oral hygiene.(1) Placing the spotlight on the family as an agent for oral health promotion provides a new perspective in the prevention and control of oral disease.(2) Thus, parents existing dental health knowledge should be determined in order to know the role they will be able to play in educating their children about dental health. The purpose of this study is to determine the influence of parents' dental health knowledge and dental health practices on caries experience of their children.
The questionnaire, presented in Figure 1, consisted of 21 yes or no questions comprising six different question categories: 1) Child's dental/oral health care 2) Child's perception of dental visits 3) Parents' concerns for their child dental health 4) Parents' perceptions of dental health 5) Child's oral care habits 6) Snacking habits. One-sided t-test for independent samples was used to determine if a statistical difference exists between the means of combined DMFT+deft for participating children. Combined DMFT+deft was used in the analysis, because both primary and permanent teeth were present in almost all of the study participants. Children undergoing orthodontic treatment, special needs children, and children with systemic diseases such as heart problems, diabetes,
*DDS. DScD. Consultant in Pediatric Dentistry, Dental Department, New Mowasat Hospital, Kuwait.
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MATERIALS AND METHODS
Correspondence address: Dr. Walid Aldeeweli POB 950, Salmeya Zip Code: 22010, State of Kuwait Tel: 965 968-3074 Fax: 965 573-2278 Email: aldeeweli@hotmail.com
THE INFLUENCE OF PARENTS' DENTAL HEALTH KNOWLEDGE ON CHILDRENS’ CARIES EXPERIENCE
DENTAL NEWS, VOLUME XV, NUMBER III, 2008
1. Do you know how long has it been since your child's last dental oral exam? 2. Do you remember the last dental procedure that was done to your child? 3. Do you know what dental procedure will be performed on your child today? 4. Do you expect your child to have caries today? 5. Does your child have a dental problem today? 6. Does your child like going to the dentist’s? 7. Has your child had a toothache recently? 8. Do you think that people should visit the dental clinic only when in pain? 9. Do you routinely have a dental checkup? 10. In general, do you think that your child has good oral hygiene? 11. Do you think that teethbrushing only is enough to have healthy intact teeth? 12. Does your child brush his/her teeth? 13. If yes, does he/she brush more than once a day regularly? 14. Do you supervise him/her while brushing his / her teeth? 15. Does your child use toothpaste containing fluoride? 16. Does your child use a mouth rinse? 17. If yes, do you supervise him/her while rinsing? 18. Does your child use dental floss? 19. If yes, do you supervise him/her while flossing? 20. Does your child have snacks between meals more than once? 21. If yes, does he/she brush his/ her teeth after snacking? Figure 1: The questions handed to parents to gather information regarding their dental health knowledge.
asthma, blood diseases, or those who required medical permission to have dental examination were excluded from the study.
RESULTS The review of the dental records showed that for all 100 children who partcipated in the study the mean deft was 3.0, the mean DMFT was 1.9 and the mean combined DMFT+ deft was 4.8. The mean DMFT, deft, combined DMFT+deft and the percentage of caries-free in the study population are shown in Table 1. The first set of questions were about dental/oral health care for children. The average combined DMFT+deft for children of parents who remembered the time their child's last dental examination was 4.3 compared to 6.3 for those who could not remember. This difference between the two groups was significant (t40=2.21; p=0.016). However, no significant difference was observed between parents who remembered the last dental procedure that was done to their child and those who could not remember. There was a significant difference between the average combined DMFT+deft for children
whose parents knew the procedure that will be performed at the recall visit (4.0) and for those whose parents did not know the procedure (5.7) (t87=2.32; p=0.011). No significant difference (t45=1.58; p=0.079) was observed between children of parents who expected their child to have dental caries and those who did not. Curiously, the difference between averaged combined DMFT+deft for children whose parents believed they had a dental problem at the day of the recall visit and the children whose parents did not believe they had a dental problem was also not significant. Children whose parents indicated that they liked to go to the dentist's had an average combined DMFT+deft of 4.4 while children who did not like to go to the dentist's had an average combined DMFT+deft of 5.9. The difference was statistically significant (t53=1.79; p=0.039). However, no significant difference was observed between children who had a toothache recently and those who had not with respect to average combined DMFT+deft. The combined average of DMFT+deft did not differ for parents who think that people should visit dental clinic only when in pain and those who do not. Children whose parents have routine dental examinations had an average combined DMFT+deft of 4.5 which is lower than for those children (5.7) who have parents that do not have routine dental examinations. The difference was significant between the two groups (t58=1.62; p=0.054). The differences in deft, DMFT and average combined DMFT+deft are illustrated in Figure 2. There was a significant difference between the caries experience (t23=1.72; p=0.049) of children of parents who think that teethbrushing alone is enough to have intact teeth and those children of parents who think that teethbrushing is not enough to have intact teeth. The relationship between children's oral care habits such as teethbrushing, the use of a mouth rinse, flossing and the use of toothpaste containing fluoride and caries experience in both groups is shown in Figure 3. There was a significant difference between children who brush their teeth once a day regularly and others who brush more than once a day regularly with respect to average combined DMFT+deft (t26=1.66; p=0.054). Children who are supervised by their parents while brushing their teeth had average combined DMFT+deft lower than children who were not supervised (t58=1.89; p=0.013). Average combined DMFT+deft was 4.1 for the children
TABLE 1. Mean of deft, DMFT, combined DMFT+ deft and percentage of caries free children in the study population. Sex deft DMFT DMFT + deft % Male Female Total
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3.3 2.6 3
2.1 1.6 1.9
5.4 4.2 4.8
13.7 16.3 30
Figure 2: Mean of deft, DMFT, DMFT + deft of children whose parents have routine dental exams and children of parents who do not have routine dental exams.
THE INFLUENCE OF PARENTS' DENTAL HEALTH KNOWLEDGE ON CHILDRENS’ CARIES EXPERIENCE
DENTAL NEWS, VOLUME XV, NUMBER III, 2008
DISCUSSION
Figure 3: Mean of combined DMFT+deft for children who brush their teeth more than once regularly, use of toothpaste containing fluoride, use of a mouth rinse and floss and others who do not.
who use dental floss and 5.3 for those who do not. The difference between the two groups was significant (t84=1.60; p=0.056). The average combined DMFT+deft shows no significant difference between children who snack between meals and those who do not. However the average combined DMFT+deft was significantly lower (t37=1.78; p=0.041) in children who brush after snacking.
This study demonstrates the relationship between parents' knowledge of the dental health and caries experience of their children. Children who liked to go to the dentist's had an average combined DMFT+deft that is significantly lower than children who did not like to go to the dentist's. This confirms the observations of Olivera et. al.(5) that children who perceived visiting the dental office as a negative experience were more likely to have dental caries than the ones who had a positive perception. Children who resist going to the dentist's out of fear, however, will tend to develop more dental disease because of lack of oral heath information and preventive services. Oral health care providers have to realize that they must cooperate with primary caregivers if they want to socialize children adequately concerning their oral health care.(6) Olivera et. al.(5) also stated in their study that children who go to the dentist's only when their teeth hurt or when they have advanced oral problems might have had a negative experience in the dental office. A study by Mattila(7) suggests that parents' dental hygiene habits, together with their educational backgrounds and/or child-reading
skills, are important in their children's dental health. The kind of preventive dentistry, which concentrates only on the oral health of the child, is inadequate. Attention must be focused on the oral health of the whole family, its dental health habits, and lifestyles. The findings of the current study infer that children of parents who know the dental health status of their children tend to have less caries experience than children of parents who do not which points to the need for including parents any preventive dentistry program rather than concentrating only on the child. Protection from infection of the dental structures depends largely on oral hygiene most of which is performed at home.(8) According to Cohen and Gift,(6) educating the general public and specifically parents, about the importance of establishing optimal oral health care habits early in life seems critical, parents cannot depend on their own observation to determine accurately a child's need. Early and regular visits to the family dentist are the responsibility of every parent for every child.
CONCLUSION The following conclusion can be made for this study: 1. Children of parents who know the dental health status of their children tend to have less caries experience than children of parents who do not. 2. Dental caries appears to be less in children who like to visit the dental office. 3. Proper daily oral hygiene practices like teethbrushing, the use of a mouth rinse, flossing and the use of toothpaste containing fluoride have a positive influence on caries status.
ACKNOWLEDGMENT The author would like to show his gratitude to Dr. Christopher V. Hughes, Associate Professor and Chairman, Department of Pediatric Dentistry at The Henry M. Goldman School of Dental Medicine for his valuable help, support and guidance during the study.
REFERENCES
1. Mathew M., Clark ,M.D., Manuel M. Preventive dentistry and the family physician. American Family Physician 53(2): 619-26, 631-2, 1996. 2. Rubinson L. Evaluating school dental health education programs. Journal of Dental Health 52: 62, 1982. 3. Klein H. & Palmer C. E. Studies of dental caries X. A procedure for the recording and statistical proceeding of dental examination findings. Journal of Dental Research 1940; 19:243-256. 4. Gruebbel A. O. A measurement of dental caries, and treatment service for deciduous teeth. Journal of Dental Research, June 1944; 23:163-68. 5. Erica R. Olivera, Sena Narendran, Dan Williamson. Oral health knowledge and attitudes and preventive practices of third grade school children. Pediatric Dentistry 22:5, 2000. 6. Lois K. Cohen, Helen C. Gift. Disease prevention and oral health promotion, Socio-dental sciences in action, The role of the family in preventing oral diseases. Copenhagen: Munksgaard, London, Dentaire International 1995; 271-30. 7. L. Mattila, P. Rautava, M. Sillanpaa, and P. Paunio. Caries in five -year-old children and associations with family-related factors. Journal of Dental Research 79(3): 875-881, 2000. 8. Carter- Hanson, C. Gadbury-Amyot, C. & Killoy, W. (1996). Comparison of the plaque removal efficacy of a new flossing aid (quick floss) to finger flossing. Journal of Clinical Periodontology 23, 873-878. 9. Downer MC. The 1993 national survey of children's dental health. British Dental Journal 178(11):407-12, 1995 June 10.
BOOK REVIEW BOOK REVIEW BOOK REVIEW BOOK REVIEW Title:
All-Ceramics at a Glance Authors:
Kunzelmann, K.-H., Kern, M., Pospiech, P., Raigrodski, A. J., Strassler, H.E., Mehl, A., Frankenberger, R., Reiss, B., Wiedhahn, K.
About this book
“
German and US Authors kick off potential best-seller. Up until a few years ago, the most commonly used materials to restore teeth were metal-based. For some time now, however, dentists and patients alike have preferentially chosen all-ceramics, because they are metal free, corrosion resistant, chemically inert, and thus highly biocompatible. In terms of durability, all-ceramic crowns are often superior to the “gold standard” metal-based restorations. All-ceramic restorations offer the dentist the option of conserving tooth substance while providing highly esthetic therapy solutions. It’s no wonder that the trend towards all-ceramic restorations is growing fast, and that all-ceramics can often substitute for metal in many indications. The use of all-ceramics for inlays, onlays, partial crowns, veneers, fixed partial dentures and implant suprastructures places special demands on material selection, preparation, manufacture, insertion and cementation. To make sure that all-ceramic restoration in both teaching and practice is supported by a solid foundation of clinical and technical certainty, two experienced American ceramic specialists have taken the initiative with German co-authors and Society for Dental Ceramics and produced a ceramics manual for the Englishspeaking professional community as well as the international dental market. Led by Ariel J. Raigrodski DMD, MS, University of Washington, Seattle, and Howard E. Strassler DMD, University of Maryland, Baltimore, ”All-Ceramics at a Glance“ has now been pub-
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BOOK REVIEW
”
lished. The manual is a practice-oriented guide to ceramic materials and CAD/CAM systems. The clinical application of all-ceramics in restorative and prosthetic dentistry is described concisely and illustrated richly. The German edition of this manual has already established itself as best-seller of the year. This vademecum of all-ceramic restoration consolidates international specialist knowledge, and – thanks to the authors’ years of experience – gives the clinical methodology a common denominator. Not just opinion makers, university and college instructors, and scientists with obligations to teaching, research, continuing education, and journalism, but also practitioners will find in this handbook a platform to define the quality standards of dentistry with all-ceramics. Kunzelmann, K.-H., Kern, M., Pospiech, P., Raigrodski, A. J., Strassler, H.E., Mehl, A., Frankenberger, R., Reiss, B., Wiedhahn, K.: AllCeramics at a Glance. 1st English Edition. 96 pages, size 8.26x8.26”, Hardcover, Sales Price 34.90 Euro, 49.00 US-$, ISBN 978-3-00021677-0, available by Dental News. Manfred Kern Society for Dental Ceramics (AG Keramik) info@ag-keramik.de
DENTAL NEWS, VOLUME XV, NUMBER III, 2008
100 years
“
Cavex
History made us, ambition drives us
” A century has passed since 2 pharmacists from Haarlem founded the company Keur&Sneltjes, known today as Cavex Holland BV. What started out as a company selling anesthetics in 1908, gradually evolved into the modern and versatile company Cavex is today. In 1920 amalgam production was started and shifted the companies' focus towards “restorative” dentistry. In the fourties Cavex first set foot abroad and began her worldwide adventure, followed by the introduction of his first alginate CA37 in the fifties, still one of the pillars of the company. In the seventies export blossomed and the name Keur&Sneltjes was replaced with Cavex Holland BV. Following the ongoing developments in the dental market composites were introduced in the nineties. Today Cavex is a well-known worldwide player on the dental market carrying a broad assortment of high quality products. Where the focus is mainly on alginate impression materials and the Quadrant composites, Cavex is also very successful in hygienic products, laboratory products, amalgams and cements. With ongoing innovation, a highly skilled staff and a well balanced assortment of high quality products we consider ourselves “fit for future” and all set to supply the global dental market for yet another century. Of course we would never have reached our centennial, if it wasn't for our loyal customers. So we would sincerely like to thank all our customers for making this milestone possible! For more information, please visit www.cavexcentennial.com
Cavex celebrates
100 years Interview with Mr. Hans Den Boer MD of Cavex
What are the main products Cavex is famous for? The most important product that we have been producing now for more than 50 years now is our Alginate, that's more than 50% of the sales of Cavex. The second product, from history, is amalgam, that we produced for more Mr. Hans Martin Den Boer, Cavex MD and Mr. than 80 years, but for future Buitenkamp International Sales Manager products, we try to come more into composites; since the amalgam market is not growing we are trying to replace amalgam with composite materials. Cavex is most famous for its alginate impression materials. Can you tell us about this success story? The success story started with CA 37. The 1952 trial in our laboratory after 37 trials of the Calcium Alginate sample, that really gave good result. From the beginning CA37 has been very well accepted by dentists. And during the last 50 years, the recipe has been even improved to make sure that we are far above nowadays international standards, so we really meet the needs of the dentist to have a good alginate impression material. Is alginate still produced out of natural maritime raw materials? Alginate is 100% produced from natural raw materials, and it's also the trick to be sure that even though we are depending on the consistency of the natural products, we can have in the output a constant product we can supply to the market, and I think it's also a success for Cavex. If you go back to the last 10 years, we really had a very constant quality despite the fact that we have to work with natural ingredients and sometimes because of the harvesting of the seaweeds. So we have done a good job I think. How important is quality in your production process at Cavex? Very much! First of all, high standards that we have for ourselves. We are an ISO certified company but beside that, we supply materials to the US and to Japan, just to mention a few. In Japan we reached the Japanese industrial standards. The same we have with the FDA. The
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FDA standards for quality are very high. So we will have again this year an FDA inspection, and last time without any problems we went through FDA inspection, showing that the quality standards that we have internally are far above the standards here. This being recognized by institutions like the Japanese standards and the FDA indicates that we really have a good quality in the production. This is also one of the reasons that we are so happy to have so many loyal employees with the company. By keeping the knowledge inside, and by having a lot of people that have been here for a long time, we can also make sure that we guarantee the quality of the production. What about the Quadrant line for esthetic dentistry? What is very important with the Quadrant Composites, is the Barium glass which gives its very specific properties. This is being easily recognized most in our “Anterior Shine” material; it has a consistency that is very easy to handle in the front, we can apply it with a small brush.Much like natural dentin, it contains some fluorescent material, like the vital dentin itself.
DENTAL NEWS, VOLUME XV, NUMBER III, 2008
of leadership in the industry!
Where are your production facilities located? We are now here in Haarlem-the Netherlands. We have been here for 100 years on such a historical grounds but we are about to relocate to a new facility in 2 years time. We'll construct a complete new building where we will have the challenge to establish a new factory with more efficiency and better ergonomics. What is the share exported outside The Netherlands? 20% for The Netherlands and 80% is exported. What's the secret that helped Cavex reach 100 years? It's the People. Every highlight, whether it was amalgam, or CA 37, or whether it was in recent year Orthotrace, was due to the work of the people behind it, and I think by having a good quality of skilled people, loyal to the company. Plus, those people are not only focusing on what's going on in Holland, but they are ready to travel around the world to understand the culture, and that's important for the sales person, and it's important for the R&D person to focus on his possibilities in chemistry, not laying back, but they still be urged to improve the processes. I think that this is the Key of success for Cavex. The same strategy may help us reach another century. We don't have to stick only on what we have now, but to look around and create new history, and new highlights, and it's not easy. We observe the dentist in his work and communicate with him. We want to facilitate his work. We look forward to make the life of the orthodontist a little bit easier while taking an alginate impression, we came up for example with the “Orthotrace”. So in this way we want to continue, with the right people internally Picture from the R&D Laboratory DENTAL NEWS, VOLUME XV, NUMBER III, 2008
Picture of Cavex distributors from all over the world during the 100 years celebrations
and the right partners all over the world because they are our ears and our eyes and we are willing to listen to them. What's your final word to your customers? I hope that even though Cavex has a small part in their dental practice, it's recognized that it is a high quality of product that we supply, and I really do hope that whenever they have any feedback they will communicate it to us. And we promise that we will do something about it, to show them that our ears are open, and we are ready and prepared to listen to the whole world. Every dentist can go to the internet and send us an e-mail; this is an open invitation to challenge and test Cavex. We are not far away, we can almost sit at the chair of the dentist. CAVEX 100TH ANNIVERSARY
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PRODUCT REVIEW PRODUCT REVIEW PRODUCT REVIEW
Extraction Kit by Satelec® The Extraction Kit is the latest addition to the range of ultrasonic surgical tips from Satelec®. Compatible with PiezotomeTM and ImplantCenterTM power generators, this new kit of six tips has been especially developed for extractions (total or partial): avulsions, hemisections and root amputations. The Extraction Kit presents unarguable clinical advantages for the practitioner: - ease and speed: the slimness of these tips associated with ultrasonic technology facilitates their access inside the desmodontal space; - surgical safety: thanks to the selective cut, tips are inactive on soft tissue and sensitive anatomical components. Without any inertia, the regular to-and-fro movement decreases the risk of lesions on adjacent teeth and roots. The use of this kit will also provide benefit to patients who will experience: - swift and less traumatic treatment that respects the alveolar plate; - less post operative pain. This kit, which is directed mainly towards general practitioners and stomatologists, consists of: - Five LC tips intended for syndesmotomies and periradicular osteotomies. With differing shapes and orientations, they address the morphological constraints without damaging neighbouring tissue
and anatomical elements. Combined with the action of ultrasonic micro-oscillations, they achieve, with just a simple sweeping movement around the tooth, detachment of the periodontal ligament in order to facilitate avulsion of the tooth outside the alveolus. - One Ninja™ tip, with double saw-tooth edges, developed especially for hemisections and root amputations, this tip is also recommended for sectioning impacted teeth. The Ninja's selective and accurate cut allows the practitioner to achieve faster and less invasive surgery. Tel: +33 556 34 06 07 Fax: +33 556 34 92 92 E-mail: satelec@acteongroup.com
Colorise Dual Arch. 3 impressions in 1 Creating precise impressions, saving time and materials, are fundamental requirements for any dentist. Colorise Dual Arch is the new impression system developed to take three impressions at the same time: the detail of the preparation, the opposing arch and bite registration. Colorise Dual Arch combines all the advantages of the Colorise (chromatime technology, enzymatic hydrophilia, vanilla flavour), guaranteeing excellent results for prostheses with fewer elements. Chromatime Technology is the exclusive colour change solution applied for Colorise Dual Arch to indicate the end of the working time for Colorise Light and the end of the setting time for Colorise Rigid, thus guiding the dentist through every phase of the impression taking. The ideal physical-mechanical characteristics of the Colorise Dual Arch impression system, being thixotropic, easy to extrude and very fluid, the latter quality typical of Colorise Light, make it the best solution for creating perfect prostheses. Colorise Dual Arch is extremely easy to use, and the exclusive Intro Kit, designed specially to present this new system to all dentists, contains all the materials required to take the impression in the shortest time. Moreover, the illustrated guide contained in the Kit explains, step-bystep, how to take the impression with this new technique.
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The Colorise Dual Arch system includes: COLORISE RIGID - the rigid A-silicone with imperceptible consistency to the patient. COLORISE LIGHT - the thixotropic A-silicone and with a very low contact angle (just 12°). HI TRAY LIGHT DUAL ARCH - the disposable and transparent impression tray that simplifies positioning on the arch and ensures maximum comfort for the patient. Available in the following shapes: complete arch, anterior, quadrant, posterior, lower posterior. Website: www.zhermack.com E-mail: expo@zhermack.com
DENTAL NEWS, VOLUME XV, NUMBER III, 2008
PRODUCT REVIEW PRODUCT REVIEW PRODUCT REVIEW
ALTO® Surge by Micro-Mega ALTO® SURGE is a contra-angle for implantology and bone surgery including implant screwing, the drilling and polishing of ridge. It is adaptable to any motor types with a connection according to ISO 3964 (EN 23964). ALTO® Surge is very easy to dismount even the head cartridge is removable without tool: - easy cleaning maintenance - save time - respect of hygiene and sterilization rules Two stops (short and long) are available. Easy to adjust for the presetting of the drill depth which provides increased security when drilling in risk areas (sinuses, dental nerves) With ALTO® Surge you have the choice of irrigation: - Internal through the bur irrigation according to the Kirschner technique: the physiological serum comes direct through the bur. - External
On the contra-angle there are dismountable sprays clipped. Ideal weight combined with a perfect design confers an excellent and well balanced ergonomics for implantology and surgery. Pure lines and smooth surface are the guarantee of an easy cleaning ideally made with X-Cid®.
Website: www.micro-mega.com E-mail: export@micro-mega.com
LEONE IMPLANT SYSTEM: SEVERAL PROSTHETIC SOLUTIONS FOR MORE AND MORE NATURAL LOOKING OUTCOMES The Exacone™ implant system, developed to perfectly reproduce a natural tooth, is based on a solid abutment connected to the implant through a self-locking Morse taper and a inner hex for positioning and anti-rotation. The micrometric precision of the components and the absence of retaining screws make such a system one of the safest in the implantology field. Its reliability and mechanical stability are widely proved by the low incidence of long-term prosthetic complications. Due to such specific properties, the system allows lots of restorative options in addition to the traditional techniques. It is possible to mill the abutments directly inside the mouth, just like with natural teeth. Exacone™ implants may be restored with extra-oral cementation technique as well, that allows to completely and easily remove the cement in excess, achieving very good aesthetics. As an alternative an integrated abutment-crown may be prepared, a cementless solution allowing to save a lot of chairtime and to handy adjust the restoration directly chairside. Implant dentistry is getting closer and closer to prosthetics on natural teeth: the Exacone™ implant system is a unique solution in this direction, providing impressive restorative results, both aesthetic and functional.
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E-mail: info@leone.it Website: www.leone.it
DENTAL NEWS, VOLUME XV, NUMBER III, 2008
PRODUCT REVIEW PRODUCT REVIEW PRODUCT REVIEW
The SCANORA® 3D from Soredex: The most versatile cone beam 3D system with dedicated panoramic imaging With thirty years of experience in designing and manufacturing stateof-the-art dental panoramic and tomographic systems, SOREDEX is introducing the SCANORA® 3D, a cone beam 3D system that combines versatile fields of view and dedicated panoramic imaging. At a press of a button, the unit automatically switches between 3D and panoramic imaging modes, making it quick and efficient to use. With the SCANORA ® 3D, the advanced dental imaging required for diagnostics,implant treatment planning and oral surgery can now be done in your practice. More advanced procedures can be performed efficiently and safely. Diagnostic information can be obtained without delay and fewer referrals to outside facilities, for procedures such as medical CT examinations, are needed. The whole planning process, from the first contact through radiological examinations, case planning, treatment acceptance, and follow-up, can be handled in one practice - yours. 3D imaging is not just prestigious, it is clinically necessary. It allows you to improve patient care by enhancing diagnostic accuracy and performance. 3D imaging helps you work closely with your patients to plan and implement the best alternatives; all of which differentiates your practice from those using conventional imaging. The SCANORA ® 3D is a total 2D and 3D imaging solution that comes with a complete 3D software package for advanced diagnostics and treatment planning. Through DICOM sup-
port, the SCANORA ® 3D system integrates with other imaging software and modalities and is compatible with most specialty third party software, drill and surgical guide applications. Website: www.soredex.com E-mail: info@soredex.com
The enlargement factor of Ceramill Base from Amanngirrbach increases the range of indication of milling work Zirconium oxide is a high-performance material at the disposal of the dental laboratory for the production of ceramic crowns, braces and retainers. Until now, these advantages were only available to high-end dental laboratories. The new Ceramill System makes it possible for all dental technicians to achieve this added value in-house. The most recent innovation from AmannGirrbach makes use of the very latest copy milling techniques, so that you can produce your own zirconium oxide retainers. In your own laboratory, within a small space, to the highest precision standards - with low investment and extremely low costs per unit. To ensure continuously reproducible results and perfect fits, the user can precisely set the specific factor of each blank batch on the device. Additionally, the enlargement factor of Ceramill Base can also be used to control the fit of single crowns, inlays and single abutments. In doing so, the specific requirements for internal and external geometries are taken into account. The infinitely adjustable enlargement factor can be used to increase or reduce the dimensions of the framework. The actual fit can thereby be controlled and monitored. Labour-intensive finish-
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ing operations that could damage the material thus become redundant. E-mail: austria@amanngirrbach.com Website: www.amanngirrbach.com
DENTAL NEWS, VOLUME XV, NUMBER III, 2008