DT Asia Pacific

Therapy of craniofacial defects successful / Asia News / Opinion / World News / Business / An interview with Domenico Scala - CEO of Nobel Biocare / Fixed prosthodontic management of a mutilated dentition: A team approach / An interview with Dr Stuart Smith - GSK / Sub-gingival biofilm: A therapeutic challenge / An interview with Matthias Kaiser - CEO of Kaiser Dental Laboratory / Miniscrews—a focal point in practice (Part 6) / An interview with Bella Monse about the ‘Fit for School’ initiative in the Philippines

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DTAP0709_01-03_TitleNews

17.08.2009

18:21 Uhr

Seite 1

DENTAL TRIBUNE
The World’s Dental Newspaper · Asia Pacific Edition
PUBLISHED IN HONG KONG

www.dental-tribune.asia

NO. 7+8 VOL. 7

Scala speaks

Periodontics

Fit for School

The CEO of Nobel Biocare
on Procera and the market

Minimally invasive
biofilm management

A public health project
in the Philippines

Page

Therapy of craniofacial defects successful Philippines

to hold
world record
medical day

Daniel Zimmermann
DTI

HONG KONG/LEIPZIG, Germany:
At a meeting on regenerative medicine and stem cell research in China, clinicians from Spain presented
what could be a breakthrough in
the treatment of craniofacial defects. With the help of Bone Repair
Cells (BRCs) developed by the US
company Aastrom Biosciences
Inc., patients experienced new
bone formation and nerve recovery
in cases of severe mandibular
osteoradionecrosis and osteomyelitis. Bone Repair Cells are derived
from a small sample of the patient’s
bone marrow, which is processed
using Aastrom’s proprietary Tissue
Repair Cell (TRC) technology to
generate larger numbers of stem
and early progenitor cells with enhanced therapeutic potential.
“The outcome of these treatments with BRCs has been very satisfactory. We observed early bone
formation in the afflicted areas that
eventually resulted in complete
healing,” said Dr Jose Mendonca,
Director of the Head and Neck
Surgery Unit of Hospital POLUSA in
Lugo in Spain and previously a
Clinical and Research Fellow in
Oral and Maxillofacial Surgery at

The Philippine Charity Sweepstakes Office has announced that
it will run the world’s largest single-day medical mission in early
September. The mission, which is
part of the organisation’s 75th anniversary celebrations, aims to
provide simultaneous medical
and dental treatment to a record
number of beneficiaries in the
country’s 42,000 districts, also
called barangays.

Dr Jose Mendonca during his presentation in Dalian in China. His research on stem cells for the treatment of craniofacial
defects has shown promising results.(DTI/Photo Courtesy by the China Medicinal Biotech Association)

the UCLA School of Dentistry. “Unexpected therapeutic results from
treatment with BRCs include peripheral nerve regeneration or repair, new skin formation and proliferation in blood vessels in ischemic
areas. The results open a promising
pathway for the treatment of some
patients where conventional therapies fail or do not exist.”
Ethical approval for compassionate use of TRC-based products

was granted by the Spanish Ministry of Health.
In May 2008, Aastrom announced the re-prioritisation of its
clinical development programmes
to focus primarily on cardiovascular applications, thus discontinuing further patient enrolment
in the US Phase III ON-CORE bone
regeneration clinical trial. The
company does not anticipate new
clinical bone activity or reactivat-

ing the Phase III ON-CORE trial at
the present time but will continue
to treat patients on a compassionate-use basis in Spain. “Our bone
programme remains open for partnering. Encouraging compassionate-use treatments such as those
noted by Dr Mendonca strengthen
our bone programme portfolio, especially in the EU,” said Dr Sheldon
A. Schaffer, Aastrom’s Vice-President of Corporate Development
and Intellectual Property. DT

According to the organisation’s director Jose R. Taruc V, the
agency will attempt to gain world
prominence by gaining entry into
the Guinness World Records,
while reaching out to marginalised members of society who
need quality medical assistance.
He said they intend to achieve
this world record by clustering
barangays and mobilising their
25 district offices nationwide, as
well as enlisting the support of
local government units (including the police and the military),
church groups and other nongovernmental organisations. DT
AD

Millions of
new HIV
infections

This photo shows a Ganlea holotype fossil jaw (lateral view) recently found in Myanmar. The findings support a new theory that humans may have been evolved in Asia.
ASIA NEWS, page 2
(DTI/Photo Laurent Marivaux)

Dental pain afflicts
redheads more

New implant coating
shows improvement

A recent US study has found
that genetics may be behind the
increased incidence of dental
pain in people with red hair. The
study identified a new melanocortin-1 receptor gene found in
skin, hair and eyes that plays a
role in processing pain, anxiety
and fear in the human brain. DT

A research team in Israel
has developed a new way to electrochemically deposit synthetic
hydroxyapatite onto dental implants. Instead of spraying the
coating with plasma, the implant
is placed into a bath of electrolyte
solution, to which an electric
current is applied. DT

A new report by the organisation UNAIDS has called on countries in Asia and the Pacific region
to scale up HIV prevention programmes and structural interventions for men with high risk sexual
behaviour. The report released at
the 9th International Congress on
AIDS in Asia and the Pacific in Bali,
Indonesia, notes that men who buy
sex constitute the largest infected
population group—and most of
them are either married or will
get married. This puts a number
of 50 million women, often perceived as ‘low-risk’ because they
only have sex with their husbands,
at risk of HIV infection.
Despite being in a relationship,
at least 75 million men regularly
buy sex from sex workers in Asia,
and a further 20 million men have
sex with other men or are injecting
drug users, according to UNAIDS
figures. DT

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[2] => untitled

DTAP0709_01-03_TitleNews

17.08.2009

18:21 Uhr

Seite 2

AD

Asia News

Malaysia takes on shortage of
dentists
Malaysian National News Agency

PENANG, Malaysia: As a first
step to establishing a National
Oral Health Center, the Health
Ministry of Malaysia has announced the formation of a Center of Excellence for dentistry in
several hospitals nationwide.
The centre will be opened in
stages later this year and cover
various disciplines, such as
mouth-cancer screenings and
dental surgery, Health Minister
Datuk Seri Liow Tiong Lai told
reporters at the Malaysian Dental Association’s AGM held in
George Town last week.
The Health Minister added
that the centre will be crucial for
dental experts in his country to
enhance their specialties in-line
with current technological advancements. As oral health is becoming more complex, there is
need for expertise and specialisation, he said. This year, the

Health Minister Datuk Seri Liow Tiong Lai (second from right) shakes hand
with nurses after launching the International Nurses’ Day Celebration and
Seminar in May. (DTI/Photo file)

government has already given
out 36 scholarships to students in
selected fields of dentistry compared to 29 last year.
Malaysia is facing a shortage
of dentists and needs to increase
their numbers in order to cope
with the increasing demand for
dental care. According to ministry
figures, only 60 per cent of posts
for dental officers in the Health
Ministry were filled in 2008 and

only 56 per cent of all dental specialist posts. The Health Minister
said that his ministry aims to
triple the number of dentists and
increase the ratio of dentists to
the population from slightly over
1:8,000 to 1:4,000 by the year 2017.
On 31 December 2008, there
were 3,410 dentists in Malaysia,
of which 241 were specialists. DT
(Edited by Daniel Zimmermann)

Ancient teeth question origin of men
Daniel Zimmermann
DTI

HONG KONG/LEIPZIG, Germany: Humans may have been
evolved from primates in Asia,
fossils found in Myanmar suggest. The jawbones and teeth of
the primate related to a family of
Asian anthropoids are ten times
older than Lucy, the famous
African hominid, and challenge
common theories that the ancestors of humans came from Africa.
According to paleontologist Dr Chris Beard from the

Carnegie Museum of Natural
History in Pittsburgh, USA, the
jawbones found in 2005 featured greatly enlarged canine
teeth that distinguish the animal, also called Ganlea megacanina, from prosimians,
a family of earlier and primitive primates that did not evolve
into monkeys or apes. Heavy
dental abrasion also indicated
that Ganlea used its canine
teeth to open tough tropical
fruits and extract the nutritious seeds contained inside,
a type of feeding adaptation
that has never been docu-

mented among prosimian primates.
“These findings show that
early Asian anthropoids had
already assumed the modern
ecological role of modern
monkeys 38 million years ago,”
Dr Beard said. Recent paleoanthropological research has
been focusing on evidence that
anthropoids originated from
prosimian primates and some
scientists also argued that primates such as Ganlea megacanina were not anthropoids
at all. DT

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Licensing by Dental Tribune International

Publisher Torsten Oemus

Group Editor/Managing
Editor DT Asia Pacific

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newsroom@dental-tribune.com
Tel.: +49-341/4 84 74-107

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International Editorial Board
Dr Nasser Barghi, Ceramics, USA
Dr Karl Behr, Endodontics, Germany
Dr George Freedman, Esthetics, Canada
Dr Howard Glazer, Cariology, USA
Prof. Dr I. Krejci, Conservative Dentistry, Switzerland
Dr Edward Lynch, Restorative, Ireland
Dr Ziv Mazor, Implantology, Israel
Prof. Dr Georg Meyer, Restorative, Germany
Prof. Dr Rudolph Slavicek, Function, Austria
Dr Marius Steigmann, Implantology, Germany

DENTAL TRIBUNE
The World’s Dental Newspaper · Asia Pacific Edition

Published by Dental Tribune Asia Pacific Ltd.
© 2009, Dental Tribune International GmbH. All rights reserved.
Dental Tribune makes every effort to report clinical information
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responsibility for the validity of product claims, or for typographical errors. The publishers also do not assume responsibility for
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Opinions expressed by authors are their own and may not reflect
those of Dental Tribune International.

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[3] => untitled

DTAP0709_01-03_TitleNews

17.08.2009

18:21 Uhr

Seite 3

DENTAL TRIBUNE Asia Pacific Edition

Asia News

Micronesia study confirms oral health benefits of xylitol
Claudia Salwiczek
DTI

Recently, the use of a xylitol
syrup rinse was confirmed to be

Beijing
targets
health
The government of Beijing has
announced a ten-year plan for
raising the average life span of its
citizens through increasing health
awareness and the improvement
of health care services. Further objectives are to reduce obesity rates
in primary and middle schools, as
well as to lower mortality rates
amongst pregnant women and
babies, city officials told reporters
at a press conference in August.
Improved dental hygiene will also
be a point of focus, they said.

effective protection against tooth
decay. Researchers, who conducted a study in the Republic of
the Marshall Islands where the
caries rate is two to three times
that of the typical American or
European community, found
that 16 ml of xylitol syrup could
prevent up to 70 per cent of
decayed teeth. The findings
were presented in the July issue
of the Archives of Pediatrics &

Adolescent Medicine, and demonstrate the first evidence (to the
authors’ knowledge) that xylitol
is “effective for the prevention
of decay in primary teeth for
toddlers.”
Scientists in Finland first discovered the beneficial uses of
xylitol in dentistry in the early
1970s. Studies led by Profs. Kauko
K. Mäkinen and Arje Schein at

the Institute of Dentistry at the
University of Turku proved that
xylitol, which occurs as a sugar
in the fibres of many fruits and
vegetables, inhibits the adhesion
of the caries-causing oral bacterium Streptococcus mutans.
Xylitol is widely used in a
number of dental care products,
including chewing gum, toothpaste and mouth rinses. DT

Xylitol is widely used in oral care products
like chewing gum. (DTI/Photo Yellowj)

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A complete nano-optimized restorative system

Living conditions and lifestyles
have changed rapidly in major
Chinese cities like Beijing and
Shanghai. An unhealthy diet rich
in sugars, low exposure to fluoride
in general and a lack of tradition in
personal care and oral hygiene are
major factors in increasing dental
caries incidence rates. Growing
tobacco consumption and excessive use of alcohol have also increased the risk of periodontal
disease and oral cancer. Beijing
has invested US$2 million in recent years on caries prevention
programmes but needs to do more
to improve oral health status
amongst its citizens. According to
the third national oral epidemiological survey in 2008, over 90 per
cent of people in the city suffer
from some form of oral disease.

new

Fang Laiying, director of the
Beijing Municipal Health Bureau,
said that the municipal government hopes to improve the health
of locals comprehensively through
the plan’s implementation. He said
the incidence of chronic, noninfectious diseases has been on
the rise in recent years, including
high blood pressure, diabetes and
coronary disease. The municipal
government will work intensively
to achieve the plan’s objectives,
through popularising health information, such as correct toothbrushing, and advocating healthy
food, tobacco control and more
exercise. Efforts will also be made
to further dental health care, eye
care, personal health awareness,
and safeguard the health of mothers and infants.
Laiying added that a committee for health promotion with
personnel from 16 governmental
departments had been set up by
the municipal government to
oversee the efforts of urban districts, suburban counties and relevant government departments in
implementing the plan. The funds
necessary for implementing the
plan will be provided for in the city
monetary budget, he said. DT

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[4] => untitled

DTAP0709_04-05_News

18.08.2009

10:46 Uhr

Seite 1

Opinion

DENTAL TRIBUNE Asia Pacific Edition

Dear
reader,

Lifelong
oral health
for all

Daniel Zimmermann
DTI

“This
species
is getting
more eccentric,
don’t you think?”

Christopher H. Fox
USA

A friend of mine recently had
a bacterial infection. In telling
me about his problems, the first
thing he mentioned was that
he had experienced symptoms of
dry mouth and matured biofilm.
He had also suffered from hypersensitive teeth.
My friend’s example, though
trivial in nature, is a good example
by which to demonstrate the way
the oral cavity functions as a window to our inside world. The latest
research has shown that it can be
a very reliable indicator of our
inner state of health. Every day,
the salivary glands secretes over
1.5 litres of saliva into the oral
cavity, carrying with it valuable
information. These biomarkers
can be from sites of disease, or the
salivary glands themselves can
produce surrogate biomarkers of
disease. The good news is that
the information provided by these
can be obtained non-invasively,
painlessly and with no embarrassment to the patient—without
needles or cringing.
Owing to these salivary properties, a dental examination today
is no longer only about teeth and
gums. Dentists should be aware
that they are probably the first
to detect signs of systematic diseases in their patients. Take
HIV/Aids for example: despite
new, effective medication, the
latest infection rates still demonstrate a continued increase in
poor and developing countries
alike. According to a recent report
by UNAIDS, for example, an estimated 50 million women in Asia
alone are at risk of becoming infected with HIV/Aids by their intimate partners in the next decade.
Early detection could significantly reduce morbidity here.
Oral fluid testing technologies are under development and
already in use in several dental
offices in Europe and the US.
It will be years, perhaps even
decades, before these tests are a
regular part of every visit to the
dentist, but there is no doubt that
they will play a valuable part in
the management and control of
worldwide epidemics, such as
HIV/Aids or cancer. DT
Yours sincerely,
Daniel Zimmermann
Group Editor
Dental Tribune International

Dental Tribune
welcomes comments,
suggestions and
complaints at feedback@
dental-tribune.com

Continuing the mission of advancing research and increasing
knowledge for the improvement of
oral health worldwide, the International Association for Dental
Research (IADR) has organized the
9th World Congress on Preventive
Dentistry (WCPD) in Phuket, Thailand. The objective of the WCPD is
to provide an international forum
for the presentation and exchange
of current information on the prevention of oral diseases, and to
facilitate the transfer of this information into practice.

ASEAN agreement
penalises Filipino dentists
services, thus raising the level of
care to a level consistent with that
in the rest of the world. This minimises errors and maltreatment.
Dr Leo Gerald R. de Castro
Philippines

The ASEAN member countries’
decision on foreign reciprocity
or the Mutual Recognition Agreement comes at the heels of the economic global recession. The need
for economic survival for everyone
amidst these stressful times has
become a primary concern; hence,
it is likely that many view this
agreement as addressing a most
important issue.

However, as a member of the
academe, a part of me views the
agreement as a noble programme;
yet, the other part disagrees because not all member countries are
on an equal footing. The accumulation of Continuing Professional
Education (CPE) units is an obligation of the professional in his or
her desire to further his or her
skills. This ensures patients of a
high level of quality of treatment.
Unfortunately, not all participating

came mandatory again, for which
we are so thankful, but unfortunately, the almost ten-year lull took
away precious credit units earned
by our dentists.
As a certain amount of CPE
units is required of an applicant, it
is possible that dentists from countries with no clear set of rules on
their acquisition and recording
may be denied employment, simply because their governments
have not taken steps to ensure that
all credit units earned by attending
seminars, symposiums, conventions and the like have been properly recorded in the educational
programme of their professional
regulating bodies.

“In-depth consultation [...] should
that in-depth consultation
have taken place prior to forging ties withI feel
the various heads of professions involved in this agreement
with our ASEAN neighbours”
should have taken place prior to
On a broader aspect, I see cooperation at work amongst the
member countries because we
come to the assistance of professionals in need of employment and
patients with professional health
care needs wherever they may be.
The Philippines boasts of quite a
number of dental professionals
every year and we see this as an
opportunity for us to alleviate the
growing need for health workers in
the ASEAN region. This reciprocal
act of employing health workers
internationally signals the need
to apply a standardised guideline
procedure to the delivery of health

countries in the ASEAN region
have established guidelines set by
the professional regulating bodies
of their particular governments on
this matter. Unlike countries such
as Singapore, Taiwan, Japan and
Korea, to name a few, who had
these guidelines long before this
agreement took place, the system
in the Philippines was stopped for
almost ten years, owing to a bill
filed by a senator who argued that
earning CPE units be optional
rather than mandatory. Recently,
owing to the passage of the new
dental law in the Philippines, the
acquisition of CPE credit units be-

forging ties with our ASEAN neighbours. This could have led to further ironing out of kinks in the
programme, thereby making it a
better-laid out foreign reciprocity
programme, which is fairly beneficial to all the health care providers
in our region. DT

Under the theme, Community
Participation and Global Alliances
for Lifelong Oral Health for All,
particular attention will be paid
to involvement of communities and
organizations in initiating, planning, implementing and evaluating
oral health programme. The programme will bring together the latest preventive science with health
policies and best practices for community implementation and evaluation, and will build on previous
declarations and resolutions, such
as the WCPD 2005 Liverpool Declaration and the WHO 2007 World
Health Assembly Oral Health Resolution, with a bias toward action.
The theme will be presented in
four sessions: Global Actions for
Oral Health Related to General
Health, Community Participation
for Oral Health Promotion and
Evaluation, Fluoride and Health,
and Oral Health Literacy; and two
symposia: Management of Early
Childhood Caries and Comprehensive Oral Care for the Elderly. IADR
Immediate Past President and
Chair of the Scientific Committee
J.M. (Bob) ten Cate said that the
WCPD theme closely aligns with
the mission of IADR. He added that
good oral health is an integral part
of overall health, and the WCPD
programme will help raise awareness of oral health issues and solutions. He said that IADR is pleased
to provide a global platform for researchers, the practicing community, and public health practitioners
to identify best practices in implementing effective communitybased oral health policies, identify
research gaps, and evaluate public
health interventions.
The congress will culminate
with a declaration, resulting from
the ideas shared and progress
made among participants. DT

Contact Info

Dr Leo Gerald R. de Castro is
President of the Philippine Dental Association (PDA). He can
be contacted at oralimplants@
hotmail.com.

Christopher H. Fox is the Executive Director of the International Dental Association
of Dental Research. He can be
contacted at cfox@iadr.org.

[5] => untitled

DTAP0709_04-05_News

18.08.2009

10:46 Uhr

Seite 2

DENTAL TRIBUNE Asia Pacific Edition

World News

FDA says mercury dental fillings not harmful
Reuters

WASHINGTON, DC, USA: The
US Food and Drug Administration said recently silver-coloured
dental fillings that contain mercury are safe for patients, reversing an earlier caution against their
use in certain patients, including
pregnant women and children.
While elemental mercury has
been associated with adverse
health effects at high exposures,
the levels released by dental amalgam fillings are not high enough
to cause harm in patients, the FDA
said, citing an agency review of
roughly 200 scientific studies.
In 2006, Moms Against Mercury and three other groups sued
the FDA to have mercury fillings
removed from the US market.
Later that year, an FDA panel of
outside experts said most people
would not be harmed but that
more information was needed.
But Susan Runner, acting director for the FDA division that
oversees dental devices, said there
was no “causal link” between
amalgam fillings and health problems. “The best available scientific
evidence supports the conclusion
that patients with dental amalgam
fillings are not at risk,” she told reporters on a conference call. Over
the past 20 years, the agency has
received just 141 reports of problems in patients with the fillings,
she added.
That conclusion counters a
statement the agency made last
June that the fillings may cause
health problems in pregnant
women, children and fetuses.

To the Editor

The FDA’s decision could impact makers of metal fillings,
which include Dentsply International Inc and Danaher Corp’s unit
Kerr, as well as distributors such as
Henry Schein Inc and Patterson
Cos Inc.
According to the American
Dental Association (ADA), about
30 per cent of fillings given to
patients are mercury-filled, with
a growing number of patients

instead opting for lighter, toothcoloured options such as resin
composites. The ADA, which represents the dental industry, backed
the FDA’s decision not to restrict
mercury fillings, saying alternatives are also considered “moderate risk” by the FDA. “The FDA
has left the decision about dental
treatment right where it needs to
be—between the dentist and the
patient,” ADA President Dr John
Findley said in a statement.

But Charlie Brown, a lawyer for
Consumers for Dental Choice, said
poorer people or those who receive
their health care through large
institutions such as the US military
are more likely to receive the
cheaper, silver-coloured fillings
and are at greater risk for harm.
“Most consumers, and most
dentists, have already switched to
the main alternative, resin composite,” said Brown, whose group

was part of the lawsuit settlement
last June that called on the agency
to issue more specific rules. His
group is now weighing its legal
options, he said.
Moms Against Mercury President Amy Carson said she was disappointed in the FDA’s reversal.
Her group, along with several
others, filed a new petition with
the FDA on Tuesday, again calling
for a ban on mercury fillings, she
added. DT
(Edited by Daniel Zimmermann)
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estimates I’ve received). I would have
to go into my rent budget for three
months to do this—and then face
eviction. I would have been better off if
I never worked a day in my life or came
to this country as an illegal immigrant;
they are covered. That’s what one
gets for working twenty-five years and
becoming disabled, I guess. Seem fair
to you?
Carol Dobson, 11 Jul., 2009

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[6] => untitled

DTAP0709_06-07_News

17.08.2009

18:26 Uhr

Seite 1

DENTAL TRIBUNE Asia Pacific Edition

World News

UK universities say no to British applicants

Universities of Kent students celebrate
graduation in 2008.(DTI/Photo Courtesy by The University of Kent)

Universities in the UK are
reported to exploit a government policy that keeps British
applicants out, while leaving no
restrictions in terms of international applicants. According
to newest figures released by
the Higher Education Statistics
Agency in London, the number
of domestic higher education
(HE) students enrolling at UK
universities has stalled lately,
while that of students coming to

study from overseas has continued to rise.
After the US, Britain is currently the second most popular
choice of destination for HE students. More than one university
student in seven is from outside
Britain, and those from outside
the EU bring in 8 to 10 per cent
of the total income of British universities, paying almost £1.9 billion in tuition fees last year.

The government has refused
to fund enough places in order
to accept extra applicants from
the UK, even though the statistics are dampening hopes of
the current administration of
reaching the target of 50 per
cent of 18- to 30-year-olds with
a university education by 2010.
Even after clearance, some
20,000 to 40,000 are expected to
be left with no place at all this
autumn.

Currently, there are 8,500 students enrolled in UK dental
schools, of which 750 are from
outside the EU. DT

Nanotech
makes
fillings
last longer
Paula Hinely
USA

HONG KONG/LEIPZIG, Germany/
AUGUSTA, GA, USA: A US research
project is currently investigating
a new technique that may extend
the longevity of dental fillings.
Dr Franklin Tay, Associate Professor of Endodontics at the Medical
College of Georgia School of Dentistry, has been awarded a twoyear US$250,000 grant from the
US National Institute of Dental and
Craniofacial Research for the investigation of the prevention of the
ageing and degradation of resindentine bonding. This is to be
accomplished by feeding minerals
back into the collagen network
through guided tissue remineralisation (GTR), which is a new
nanotechnology process of growing extremely small, mineral-rich
crystals and guiding them into the
demineralised gaps between collagen fibres.

PERFECT FIT BY DESIGN
In combining Soft Tissue and Bone Level implants with a comprehensive prosthetic portfolio,
Straumann has devised one system for all indications. The Straumann ® Dental Implant System –
excellent product quality designed for convincing, naturally esthetic outcomes.

Dr Tay’s idea originated from
his examination of the way crystals form in nature, such as in
egg and abalone shells. The crystals, called hydroxyapatite, bond
when proteins and minerals interact.
Dr Tay will use calcium phosphate, which is the primary component of dentine, enamel and
bone, and two protein analogues,
also found in dentine, to mimic
nature, while controlling the
size of each crystal. In theory, the
crystals should lock the minerals
into the hybrid layer and prevent
it from degrading.

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“Instead of dentists replacing
teeth with failed bonds, we’re
hoping that using these crystals
during the bond-making process
will provide the strength to save
the bonds,” Dr Tay says. “Our
end goal is that this material will
repair a cavity on its own so that
dentists don’t have to fill the
tooth.”
According to research presented in the Journal of the American
Dental Association, half of all
composite resin tooth-coloured
restorations fail within ten years,
and about 60 per cent of all operative dentistry is conducted to
replace them. If Dr Tay’s concept
of GTR is successful, he will create
a delivery system with which to
apply the crystals to the hybrid
layer following the acid-etching
process. DT
(Edited by Claudia Salwiczek, DTI)

AD_A4_SDIS_APAC_high.pdf 1

17.07.09 11:57

[7] => untitled

DTAP0709_06-07_News

17.08.2009

18:26 Uhr

Seite 2

DENTAL TRIBUNE Asia Pacific Edition

World News

“These are exciting times in which we live”
An interview with Prof. Thimios Mitsiadis, Head of the Institute for
Oral Biology at the University of Zurich, on stem cell research in dentistry
DTI: Prof. Mitsiadis, which
factors determine the formation
of enamel?
Prof. Thimios Mitsiadis: This
is a very complex process, which is
determined by the dental epithelium at a very early stage and different to that of the skin epithelium
that covers the body. There is a
multitude of transcription factors,
one of which is Ptx2, which governs
the formation of oral and dental epithelium. Based on this, there are
other transcription factors. At the
moment, we only know of Tbx1,
which co-forms the ameloblasts.
Of course, there are further transcription factors that we do not yet
know much about and that are regulated by certain growth factors.
The transcription factors occur
within a very tight time frame to
form enamel. It is a highly complex
process from the beginning to the
final formation.

These are exciting times in
which we live. It is evident that
in the near future—in about 20
to 30 years—we will be able to
create new tissue with the aid
of microbiology and genetics.
Clinical studies that examine the
use of dental stem cells for the
regeneration of jaw bone are al-

ready underway. This is proof that
progress in this regard is being
made. We just need more information on how to achieve natural
protection.
What progress has been
made in stem cell research for
the formation of enamel?

We recently formed a European consortium with researchers
working with stem cells in Germany, Finland, Switzerland, Italy
and France. The consortium’s objective is to isolate stem cells from
teeth, the face and the head, and
to use them to generate products.
With stem cells, for example, na-

tural implants could be produced.
There are also tests being conducted in Italy to recreate teeth, but
in my opinion this is far too complex
to be realised at the moment. At this
stage, we should only concentrate
on creating tissue as a replacement
for damaged or destroyed material,
such as dentine and dental tissue.
Thank you very much for the
interview. DT
This interview originally appeared in
DT Germany No. 4, Vol. 7, 2009. Translation was provided by Annemarie
Fischer, Germany.
AD

Which factors may disrupt
the formation of enamel?
Dental enamel can be damaged from the start because there
are genetic factors that disrupt the
correct formation of enamel. However, epigenetic factors that occur
during the course of a pregnancy,
for example, result in a deterioration of dental enamel through
discolouration.
In addition, we are currently
examining the effects of fluoride.
Fluoride protects the tooth but may
also lead to its decomposition during the process of dental enamel
formation. Other epigenetic factors, such as the consumption of
alcohol, can affect the formation
of dental enamel.

KOS Implant

Dental erosion is a growing
problem, which is certainly
driven by the increase in life
expectancy. However, statistics
demonstrate that younger patients are also increasingly being
affected. What is the cause of
this development from your
point of view?
Yes, it is a fact that loss of
enamel has been detected mostly
in elderly people. In my opinion,
two factors have to be considered
here. Nowadays, we know much
about prevention, but in the past
many people did not take care of
their teeth sufficiently. General
health conditions and other diseases were considered more important. Research and medication
in these areas have improved significantly. Over time, however, we
realised that we had not paid sufficient attention to our many dental
problems.
Another possible reason is migration. We tend to travel more
and live in various countries. For
example, I was born in Greece, but
now live in Spain with my Spanish
wife. My children, therefore, possess features of both nations. This
may result in abnormalities and
deterioration of enamel.
What innovative perspectives have arisen from these new
findings?

See you on:
FDI
FD Annual World Dental Congress

2 - 5 September 2009
Stand L17

Dr. Ihde Dental GmbH · D-85386 Eching/Munich · Germany

www.implant.com

[8] => untitled

Anschnitt_DIN A3

24.04.2009

11:06 Uhr

Seite 1

[9] => untitled

DTAP0709_09_Business

17.08.2009

18:27 Uhr

Seite 1

DENTAL TRIBUNE Asia Pacific Edition

Business

Ihde Dental debuts at FDI Congress in Singapore
The German Swiss dental manufacturer Ihde Dental has announced
to participate at the FDI World Dental Congress in Singapore for the first
time. The company, which can look
back on a 50-year tradition in the
production of dental materials for
dental offices and laboratories in
Germany and Europe, has been producing implant systems since 1996.
Currently, they offer eight lines of
implants and accessories for all indications in oral implantology.

According to implantologist and
owner Dr Stefan Ihde, the company’s implant lines can be safely
used for all indications with some
lines designed to permit immediate
loading. The KOS implant, for example, allows this attractive treatment modality to be employed in
such a way that it is particularly appreciated by patients. The implant is
inserted transgingivally; the definitive restoration can be delivered
within only five days.

In addition, Dr Ihde has been
specialising in developing and improving the concept of disk implants, resulting in several integrated lines of basally osseointegrated (BOI) implants and their specific applications. This implant type
is suitable for use in situation with a
minimum vertical bone supply,
eliminating the need of harvesting
bone grafts from the iliac crest or
performing comprehensive bone
augmentation surgery.

Dental CAD/CAM technology offers
productivity, increases worldwide
Constantine Gart
& Dr Kamran Zamanian
USA

NEW YORK, NY, USA and VANCOUVER, BC, Canada: CAD/CAM
technology is undisputedly one of
the most important developments
in dentistry today. Especially on the
lab side, CAD/CAM technology is
expected to increase productivity,
enabling labs to meet the growing
demand for dental prosthetics and
other restoratives.
This growth is a result of the aging population and the increasing
demand for improved dental aesthetics. CAD/CAM technology has
met challenges in satisfying dental
laboratories’ expectations of what
this technology will bring to their
businesses. However, the technology is evolving at a rapid pace, as
new trends and technological capabilities are emerging, representing
the potential to surpass what it had
initially offered dental laboratories.
Zirconia is the primary driver of
CAD/CAM adoption, as the material
can be milled into a crown or bridge
only through an automated device,
most often a CAD/CAM system. Zirconia’s biocompatibility and high
aesthetic qualities have led to a
rapid increase in its use for dental
prosthetics.
For example, the number of
all-ceramic dental prosthetic units
is projected to grow at a CAGR of
10.8 per cent and 10.5 per cent in
the United States and Europe, respectively, over the next five years.
This is well above the growth rate of
other materials, such as porcelain
fused to metal (PFM), which will see
relatively flat growth.
While a large and growing
portion of dental technicians prefer
to use all-ceramic over traditional
materials, all-ceramic acceptance
has been met with resistance from
dentists. All-ceramic materials
have had above-average failure
rates, with limited long-term clinical data to validate their durability
and reliability. As a result, conservative dentists have continued to rely
on traditional material such as PFM.
However, the use of zirconia has
greatly improved the overall durability of all-ceramic material, as
zirconia is a stronger material than
porcelain. Despite the initial resistance, it is expected that zirconia
will continue to gain popularity as
CAD/CAM manufacturers invest in

research and development of zirconia for durability as well as to encourage its use through the education of dentists and lab technicians.
While zirconia has traditionally
been the primary driver of CAD/
CAM adoption, cost and production
efficiencies are becoming more important factors. CAD/CAM technology is becoming more flexible in
the type of services that it can offer
dental laboratories. This is especially crucial as the number of dental technicians worldwide is projected to drastically decline in the
future, due to the large number of
older and retiring dental technicians. In addition, there are fewer
dental technicians entering this
field due to insufficient monetary
compensation. This reduction in
work force numbers, coupled with
the increasing demand for dental
restorations brought on by the aging population, will create greater
demands on dental laboratories’
production capacity for prosthetics
and other restorations. Dental laboratories in the United States and
Europe are also under strain due to
competition from countries with
very low labor costs such as China,
Morocco, Turkey and Costa Rica.
The vast majority of dental laboratories around the world employ
less than five dental technicians.
Many of these laboratories hardly
have enough volume to warrant the
purchase of an expensive CAD/
CAM system with in-house milling
capabilities. To reach the smaller
players in the market, CAD/CAM
manufacturers such as 3M ESPE,
DENTSPLY and Nobel Biocare have
offered scanning units to dental laboratories, enabling the labs to scan
and outsource the digital restoration to be milled at other locations
(either a centralized milling facility
or dental laboratories with inhouse milling capability).
This purchasing option allows
large dental laboratories that generate sufficient volume and revenue to invest in a full CAD/CAM
system with in-house milling capability, whereas small to medium
sized dental labs have the option of
investing in a lower cost scanning
unit, simultaneously eliminating
the continuing production costs of
dental copings and frameworks.
Full CAD/CAM systems typically
involve one scanner unit and one
milling unit in-house. A stand-alone
scanner CAD/CAM system consists
of only a scanner unit, which sends

the digital impression to either
a centralized milling facility, or a
dental lab with milling capability.
The growing popularity of the two
purchasing options is evident in
the US and European markets, as
there is an approximate ratio of one
full CAD/CAM system to two standalone scanners in the total installed
base.
CAD/CAM systems are becoming increasingly more affordable to
dental laboratories as their prices
continue to drop. For example, in
the U.S. market, the average selling
prices (ASPs) of full systems and
scanners are expected to drop at
CAGRs of 4.9 per cent and 4.3 per
cent, respectively.
Manufactures and distributors
are offering financing programs to
help laboratories acquire the systems and, in some cases, are giving
the system away for free on the
condition that the labs manufacture
a certain number of proprietary
prosthetics. Likewise, the cost of
the copings and frameworks milled
by CAD/CAM systems are rapidly
dropping; this, coupled with rising
gold prices, has reduced the price
of a zirconia crown almost to par
with a gold crown. This has made
zirconia milled framework a strong
alternative to the traditional gold
crown.

All implant lines are continuously expanded, improved, and
updated in order to incorporate
and accommodate the most current
scientific findings in oral implantology. Ihde Dental also closely cooperates with well-renowned oral
implantologist to ensure that their
implants meet all the requirements
of everyday clinical practice.
All implants are produced in
Europe, meeting the most stringent
German and Swiss quality standards. Ihde Dental is present in
more than 20 countries through its
network of qualified resellers, who,
according to Dr Ihde, are committed to excellent service for their customers.
“We will continue to follow the
consistent path of international expansion with Asia being an important
key region for us,” explains export
consultant Gert Wieners. “This is
why we have decided to present our

Export consultant Gert Wieners.(DTI/
Photo Courtesy by Dr Ihde Dental)

product range at the FDI World Dental Congress in Singapore this year.”
Visitors of this year’s FDI Congress will find be able to find Dr Ihde
Dental at the World Dental Exhibition at booth L17. More information
about the company’s implant lines
and other product offers are available at www.ihde-dental.de and
www.implant.com. DT
AD

At la
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The powerful trio for manual processing
according to RKI1) of turbines and contra-angles.
1

There are many dentists that
only use PFM restorations and abstain from zirconia. To address this
issue, CAD/CAM technology is expanding beyond its initial capability
of milling only zirconia material and
dental devices, to include other materials, such as: non-precious alloys,
titanium, acrylic, resin, and even
final abutments. This technological
capability gives labs greater versatility in meeting customer needs
by offering a greater breadth of
materials and dental restorations.
The acceptance and integration
of CAD/CAM technology into dental laboratories appears to be inevitable. Despite the many challenges that this technology has
faced, ranging from uncertainty regarding the viability of zirconia material for dental prosthetics, to the
technology’s economical feasibility,
CAD/CAM technology has progressed and continues to adapt in
order to offer greater versatility in
services to both small and large
dental laboratories. DT
(Edited by Fred Michmershuizen, DTA)

[10] => untitled

DTAP0709_10_Business

17.08.2009

18:28 Uhr

Seite 1

DENTAL TRIBUNE Asia Pacific Edition

10 Business

“We are very pleased with the market
launch of NobelProcera.”
An interview with Domenico Scala, CEO of Nobel Biocare
LEIPZIG, Germany/ZÜRICH,
Switzerland: Nobel Biocare,
a world leader in restorative
and aesthetic dental solutions,
provides dental professionals
with root-to-tooth solutions,
including dental implants,
all-ceramic crowns, bridges
and laminates, guided surgery
planning, scanners, and biomaterials. Dental Tribune Group
editor Daniel Zimmermann
spoke to Domenico Scala, Nobel
Biocare CEO, about current
developments within the company and the dental market.
Mr Scala, Dr Rolf Soiron
has announced that he will
step down as the Chairman of
the Board of Nobel Biocare
in 2010. What will the consequences of his decision be, and
has a choice been made concerning his successor?

Domenico Scala: Dr Soiron
announced some time ago already that he would like to withdraw from one of his industry
positions. His retirement as
Chairman of Nobel Biocare will
thus come as no surprise at
the upcoming shareholders’
meeting in March 2010. Every
business appreciates having
a leader with Dr Soiron’s vision and personality at the
reins. His decision, however,
will have no influence on Nobel
Biocare’s current strategy. The
board will duly announce a
successor.

Even the dental market cannot remain entirely unharmed
by the current economic crisis.
This fact has been demonstrated
by the economic results of
various market participants for
several quarters. However, we
have worked intensively during
the last 18 months to prepare
Nobel Biocare for the future. We
constantly work at advancing the
company, and we steadily invest
in research and product development, in order to continue supplying our customers with attractive innovations and treatment
solutions.

The last quarterly results
were assessed rather negatively. To what extent were
these results due to economic
factors and to what extent
were they due to company
management?

What have these results
given rise to?
We are orienting ourselves
towards long-term goals. Our
strategic tasks and the needs
of our customers have become
our focus. Of course, we are

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O at 2 years intervals
O the most important Swiss dental fair, displaying over 5‘000 m2 exhibition space
O Basel: more visitors from neighbouring countries
O easy access from all directions
O registration on-line for exhibitors; log-in at www.dental2010.ch
O in collaboration with the most important Swiss dental associations
patronage:
Swiss Employers Association
of Dental Branch

partner:
Swiss Association of
Dental Assistants

media partners:

partner:
Swiss Dental Association

partner:
Swiss Federation of Dental
Laboratories

partner:
Swiss Dental Hygienist

REVUE DENTAIRE
ROMANDE

also working on our cost
structure.
Will the growing markets in Asia or South
America be able to absorb
the losses of the North
American and European
markets in the long run,
or do you believe the
economic situation will
show a relatively quickly Domenico Scala
recovery?
I’m hesitant to speculate
Even in these times, we invest
about the future. Currently,
in the development of new
prospects are simply too uncerproducts and solutions. Last year
tain. However, we can ascertain
we invested about €100 million.
that the dental market remains
Our product offensive at Nobelan attractive market with much
Procera is only one example.
opportunity in the long-term.
We are active in the implant
We would like to take advantage
segment, in which we are develof this opportunity and are workoping innovations. We also invest
ing towards this.
in the education and training of
our personnel and customers.
You have just signed an
IT services contract with
With the acquisition of OpComputer Sciences Corporatimet and AlphaBioTec, you
tion (CSC). Are you planning
have already responded to
for additional cost cutting?
changing market conditions.
Are you considering further
There is nothing unusual
takeovers?
about our collaboration with
CSC as our new IT partner, as we
Of course, we constantly
have different requirements and
investigate interesting options.
demands for our global IT infraHowever, we have decided not
structure to those we had some
to discuss concrete plans and
years ago. Optimising our costs is
projects.
only one of the advantages.
How has the market launch
of NobelProcera progressed,
As a market leader, what is
and what are the most signifiyour response to the circulatcant advantages of this system
ing acquisition rumours?
in comparison to conventional
These rumours have circusystems?
lated for some years and, therefore, no longer bother us. Rather,
We are very pleased with the
these rumours confirm that we
market launch of NobelProcera.
all move in an interesting and atThe new optical scanner and the
tractive market. As a matter of
accompanying innovative prosprinciple, we do not comment on
thetics software have been respeculations and rumours.
ceived with significant interest
by dental laboratories. The same
applies to our considerably exYou have identified the
panded product range in the
transformed communication
area of prosthetic dentistry. Both
culture as one of the most sigdentists and dental laboratories
nificant achievement in your
are enthusiastic about the future
work at Nobel Biocare. What
product range and its quality,
insights did you gain during
which sets new standards.
this transformation process,
and how was this knowledge
implemented?
Which benefits are on offer
for the dental therapist and the
Customers, researchers and
patient?
opinion leaders readily collaborate with Nobel Biocare and parFrom this year on, dentists
ticipate actively and willingly becan choose from an extensive
cause we listen and have much to
range of treatment procedures,
offer. Customers return and new
products and materials, in order
clients join us because they are
to provide his or her patient with
satisfied with our products and
the optimum solution. Theresolutions and Nobel Biocare’s
fore, patients will now receive
new direction. This development
a custom-made solution with the
encourages me to further pursue
best possible fit, functionality,
this innovative direction resand aesthetics.
olutely. However, we are selfcritical and know that we have
What is your evaluation of
to improve in terms of customer
your position in the growing
orientation, which is something
digital dentistry market?
that we continue working on.
We are well prepared for
increasing digitalisation in dentistry, and we intend further
In the present situation, it is
improving our position.
difficult to discuss investment.
What are your focal points in
the current and following busiThank you very much for
ness year?
the interview. DT

[11] => untitled

Anschnitt_DIN A3

13.08.2009

13:50 Uhr

Seite 1

www.idem-singapore.com

THE BUSINESS OF DENTISTRY

V
Annu isit us at
al Wo
rld De
n
Booth tal Congr
ess,
J27

INTERNATIONAL DENTAL
EXHIBITION AND MEETING
Scientific Conference: 15-18 April, 2010
Trade Exhibition: 16 -18 April, 2010

The Sourcing & Education Platform in the Asia Pacific
Join a turnout of over 6,000 manufacturers and distributors, potential partners, visitors and
delegates from across the globe. IDEM Singapore 2010 is enriched with opportunities from
trading and showcasing of high-quality dental equipment to learning and development in
the field of dental practice. This event is a “must-attend” for every dental and associated professionals.

Uniquely Singapore: Where Great Things Happen
Now ranked among the world’s top cities for meetings, Singapore is also a country
with one of the most sophisticated dental markets. Come discover a world of unique
contrasts in Singapore and sample an exciting weekend in this beautiful multi
multi-cultural
cultural garden city
city.
Endorsed By:

Supported By:

In Cooperation With:
International
Sharon Ng
Tel: +65 6500 6722
Fax: +65 6296 2771
s.ng@koelnmesse.com.sg

Europe
Ms Daniela Basten
Tel: +49 221 821 3267
Fax: +49 221 821 3671
d.basten@koelnmesse.de

Held In:

Organizers:

Singapore Dental Association

[12] => untitled

DTAP0709_12-14_Cheng

17.08.2009

18:29 Uhr

Seite 1

DENTAL TRIBUNE Asia Pacific Edition

12 Trends & Applications

Fixed prosthodontic management
of a mutilated dentition: A team approach

Fig. 1

Fig. 2

Fig. 3

Fig. 1: Pre-treatment intra-oral frontal view, presenting with attrition, loss of posterior support, reduced VDO and compromised aesthetics.—Fig. 2: Pre-treatment intra-oral occlusal view of the maxilla, showing dental attrition and inadequately restored molars. The orthodontic arch wire was broken.—Fig. 3: Pre-treatment intra-oral occlusal view of the mandible, showing dental attrition and inadequately restored teeth. A few of the orthodontic brackets were debonded from the mandibular incisors.
Dr Ansgar Cheng & Dr Helena Lee
Singapore

Successful full mouth fixed
rehabilitation of a mutilated
dentition is always a prosthodontic and surgical challenge. Accurate diagnosis,
proper treatment planning,
prudent choice of prosthoAD

dontic materials and meticulous treatment execution
are essential for a successful
treatment outcome over a
long period. The treatment
of a partially edentulous oral
cavity using a combination
of immediate-loading and
delayed-loading implantsupported porcelain-fused-

to-metal and full-ceramic restorations is presented in this
report.

Introduction
Prudent clinical judgement
and careful balancing of the
risks and benefits of various
treatment options are essential
for a predictable long-term

treatment outcome for prosthodontic treatment. It is
known that loss of the vertical
dimension of occlusion (VDO)
may pose significant clinical
difficulties in prosthodontic
treatment. The clinical procedures for the re-establishment
of a new therapeutic vertical dimension of occlusion is seldom
taught in undergraduate dental
curricula. VDO is defined as
the superior–inferior measurement between two points when
the occluding elements are in
contact. Various methods have
been proposed for the clinical
assessment of the VDO. Loss of
the tooth structure does not
necessarily equate to loss of the
VDO, as the VDO may be maintained as a result of compensatory dental eruption. When the
clinical loss of the VDO is small,
accurate diagnosis can be difficult. In this case study, the
management objective was to
determine whether there was
any need for the re-establishment of the VDO in the case of
small loss and whether the proposed change in the VDO was
clinically acceptable. When the
loss of the VDO is small, any
change in the VDO should be
based on the amount of interocclusal space required to restore the dentition to proper
form and function. A significant alteration of the VDO
should be approached with
care, and unnecessary, excessive changes of the VDO should
be avoided. In general, a significant change of the VDO should
be monitored over an extended
period.

Improvements in macroscopic implant morphology
and surface treatments have
led to the reduction of healing
time and the concept of immediate loading of implants. Early
implant loading is a successful
protocol in selected cases.
Providing that sufficient bone
volume is available, flapless
surgical implant placement is
predictable and patients experience minimal post-surgical
discomfort.
The posterior maxilla presents a unique challenge to implant placement when minimal bone height remains inferior to the sinus floor. Pneumatisation of the maxillary sinus
occurs after extraction of molars. In addition, the posterior
maxilla has poorer bone quality, mainly Type IV bone.
Placement of implants in
grafted bone sites has a high
success rate of osseointegation. Several authors have reported an approximate 92 per
cent success rate of implants
after sinus augmentation.
However, immediate implant
loading under such conditions
is generally avoided. The low
failure rate may be attributed
to the placement of implants of
greater lengths in grafted bone
sites.
This case study describes
the team approach management of a mutilated dentition,
using different types of con DT page 13

Fig. 4

Fig. 4: Pre-treatment orthopantomogram X-ray, showing adequate endodontic
fillings, over-eruption of maxillary molars, inadequate occlusal support and inadequately restored teeth. Posterior mandible bone bed was diagnosed as Type 2B.

[13] => untitled

DTAP0709_12-14_Cheng

17.08.2009

18:29 Uhr

Seite 2

DENTAL TRIBUNE Asia Pacific Edition

Trends & Applications 13

maxilla after a healing period
of six months.

Influence of surface properties
on osseo-integration

DT Page 12

ventional and implant-supported fixed restorations with
immediate-loading and delayed-loading protocol.

Clinical report
A 38-year-old patient presented with multiple missing
teeth. The patient desired the
restoration of function and
aesthetics. He was undergoing
orthodontic treatment. He presented clinically with moderate dental attrition, defective
restorations, loss of posterior
support, discolouration, mild
loss of the VDO and compromised aesthetics (Figs. 1–3).
The pre-treatment radiograph
showed adequate endodontic
obturation, missing mandibular posterior teeth, overeruption of maxillary posterior
teeth and attrition of the
incisors. The dentition was
free from active dental caries
and periodontal probing was
within normal limits. The maxillary left molar region bone
bed was determined to be inadequate for the placement of
dental implants. The mandibular posterior bone bed was
diagnosed as Type 2B with sufficient bone density for early
implant-loading prosthodontic
treatment (Fig. 4).
The overall fixed prosthodontic treatment plan included
placement of endosseous implants in the mandibular posterior area for prosthodontic
rehabilitation, using the early implant-loading protocol;
placement of fixed restorations
in the maxilla and mandible;
sinus lift with bone augmentation on the patient’s left side;
and simultaneous bilateral
placement of implants in the
maxillary posterior area, using
the conventional two-stage
protocol. This was followed
by the placement of implantsupported prostheses in the

Maxillary and mandibular
diagnostic casts were made of
Type IV dental stone (SilkyRock, Whip Mix). The casts
were mounted on a semiadjustable articulator (Hanau,
Wide-vue, Teledyne Waterpik). Diagnostic wax-up was
carried out to restore the anterior teeth to proper form. The
resulting diagnostic wax-up
indicated that an increase of
1.0 mm in vertical dimension at
the incisal pin level was required to restore the patient’s
anterior teeth to proper form.
Such level of change of the
VDO had no practical need for
prolonged provisionalisation
before definitive prosthodontic treatment. The patient’s
maxillary right second and
third molars required a reduction of 2.5 mm gingivo-incisal
height, in order to re-establish
a proper occlusal plane. All the
natural teeth in the maxillary
and mandibular arches required full coverage restorations. The maxillary right second molar was restored with an
amalgam post-and-core foundation prior to full coverage
restoration preparation. An adequate pre-existing composite
resin core retained by a prefabricated post with sufficient ferrule was noted in the mandibular left second premolar.
On the day of teeth preparation, all teeth were prepared
to receive full crown restorations. In order to establish anterior guidance, the treatment
indicated that the restoration
of the anterior teeth should be
completed before or at the
same time as the implant-supported restorations. The anterior teeth were prepared in the
usual manner for complete
coverage crown restorations.
DT page 14

A biomechanical and histological study in the rabbit
Jan Gottlow, Sargon Barkarmo
& Lars Sennerby
Sweden

The first objective of the
present study was to compare
shear strengths at the boneimplant interface between
the SLActive implants and the
TiUnite implants. The second
objective was to compare the
bone-to-implant contact between the two different surfaces. The hypothesis of the
study was that SLActive implants would promote a superior osseo-integration to the
TiUnite implants, as evaluated
by biomechanical and
histological means.

per time point
placed in the
tibia were subject to shearstrength testing. Thereby,
the removal
torque values
were measured and the
shear-strength
values subsequently calculated. Histomorphometrical
investigation
was performed
on all implants.

Fig. 1: Shear strength (N/mm2) after ten days, three weeks
and six weeks after implant placement.
* p = 0.001 after three weeks; p = 0.002 after six weeks

At ten days of healing, the SLActive
implants yielded
higher mean shearstrength values than
the TiUnite implants
without statistical significance. At three
weeks and six weeks
of healing, the SLActive implants yielded
higher mean shearstrength values than
the TiUnite implants
(Fig. 1) with statistical
significance.

Thirty rabbits
with a minimum
age of 9 months were
chosen for the study.
Two test implants
(Standard Plus, Ø 4.1
mm, RN, SLActive,
8 mm) and two control implants (Replace Select Taper,
Ø 4.3 mm, TiUnite,
10 mm, corresponding to 8.5 mm TiUnite) were inserted
in the tibia, and one
test and one control
The histomorphoimplant were inserted
metrical investigation
in the femur. The left
for the second objecand right side were
tive of the study is still
randomised for test
in progress. Thus
SLActive
improves
the
and control imfar, this study strongplants. Ten rab- o s s e o - i n t e g r a t i o n . ly
suggests
that
(DTI/Photo Courtesy
bits per time point by Straumann)
the interface shear
were evaluated afstrength of titanium
ter ten days, three weeks
implants is significantly inand six weeks of healing.
fluenced by their surface
Ten test and control implants
characteristics. The SLActive

surface demonstrated higher
shear strength with statistical
significance in the tibia of
rabbits compared with the
TiUnite surface at three and
six weeks after implant placement. DT

Contact Info

Jan Gottlow is a licensed specialist in
Periodontics from Gothenburg in
Sweden. He can be contacted at
info.sg@straumann.com.

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[14] => untitled

DTAP0709_12-14_Cheng

17.08.2009

18:29 Uhr

Seite 3

DENTAL TRIBUNE Asia Pacific Edition

14 Trends & Applications
DT Page 13

Margins of the tooth preparations were kept supra-gingival,
and no gingival displacement
procedures on the prepared
teeth were necessary.
Upon completion of the
crown preparations, six endosseous implants (NobelReplace, Nobel Biocare) were
placed by the periodontist in
the posterior mandible using
a flapless surgical protocol.
All implants were placed with
45 Ncm insertion torque (Fig. 5).
No surgical template was used
during the surgical phase; the
prosthodontist was present
during the implant surgery to
ensure implant placement was
prosthodontically acceptable.
Pick-up type implant impression copings (NobelReplace,
Nobel Biocare) were attached
to the newly placed mandibular
implants. High-viscosity vinyl

clinical track record of this
restoration. In order to maximise the aesthetic outcome,
porcelain occlusal surfaces
were prescribed.

sion. The maxillary definitive impression was made in
the usual manner. A centric
relation record was made
with a vinyl polysiloxane material (Regisil PB, DENTSPLY
DeTrey).
The development of the
definitive crown restorations
was carried out as usual on the
definitive casts. Except for
the maxillary right molars,
all maxillary and mandibular
crowns supported by natural
teeth were restored with Cercon (DeguDent) full-ceramic
crowns. Prefabricated abutments (NobelReplace, Nobel
Biocare) were custom milled
with a six-degree taper in
the dental laboratory to facilitate the development of the
restorations. Splinted, cementretained, implant-supported
mandibular restorations with
porcelain occlusal surfaces
were made of porcelain fused
to metal material.

Fig. 6

Conclusion

Fig. 5

Fig.5:Completed tooth preparations for full coverage restorations at the approximated treatment VDO. Note the equi-gingival preparation margins. Implants
were placed immediately upon completion of crown preparations.

was followed by implant placement in the maxillary arch.
In the presence of the
prosthodontist, three endosseous implants (NobelReplace,
Nobel Biocare) were placed by
the periodontist in the right

Fig. 7

Fig. 6: Completed anterior full-ceramic crown restorations. Occlusal support was gained by definitive restorations on all
the natural teeth and mandibular implant-supported prostheses to maintain the newly established VDO.—Fig. 7:
Panoramic radiograph after insertion of the crowns. Additional implants were placed in the maxillary posterior areas.

earlier using resin-modified
glass-ionomer luting agent
(RelyX Unicem, ESPE; Figs. 8
& 9).

Discussion
Various newer implant clinical protocols and conventional two-stage delayed-loading implant protocols have
a high level of clinical predictability. In this report, a flapless implant procedure, singlestage implant placement, sinus
lift augmentation, and early
implant-loading and delayed
implant-loading techniques
were applied.

Fig. 9

Fig. 8: Occlusal view of completed definitive maxillary restorations with porcelain occlusal surfaces.—Fig. 9: Occlusal view
of completed definitive mandibular restorations with porcelain occlusal surfaces.

polysiloxane material (Aquasil
Ultra Heavy, DENTSPLY DeTrey) was carefully injected
onto all tooth preparations and
the implant impression copings. A stock polystyrene tray
loaded with putty material
(Aquasil Putty, DENTSPLY DeTrey) was seated over the entire dental arch to make the
definitive mandibular impres-

On the day of restoration
delivery, the mandibular implant abutments were torqued
down to 32 Ncm. The abutment
screw holes were sealed with
gutta-percha (Mynol, Block
Drug Company). All the definitive crowns were cemented in
resin-modified glass-ionomer
luting agent (RelyX Unicem,
ESPE). The insertion of crowns

Fig. 10

Fig. 10: Post-treatment intra-oral frontal view.

maxilla, using a flapless surgical protocol. The implants
were inserted with 45 Ncm
insertion torque. The implants
were placed in the left maxilla
with a simultaneous sinus lift
(Figs. 6 & 7). The sinus space
was augmented with a xenograft material (Bioss, Geistlich
Pharma).
After a six-month healing
period, the left maxillary implants were exposed. A definitive maxillary impression was
made as usual. The fabrication
of the definitive porcelainfused-to-metal implant-supported restorations was carried out in the usual manner on
the definitive casts. Splinted,
cement-retained, porcelainfused-to-metal restorations
with porcelain occlusal surfaces were prescribed for
the implant-supported maxillary posterior crowns. The
maxillary implant-supported
restorations were inserted in
the same manner described

Editorial note: A complete list of references is available from the publisher.

About the authors

The treatment required a
small increase in the VDO.
It was therefore necessary to
make impressions that registered all tooth preparations simultaneously.
The patient desired a high
level of aesthetics; full-ceramic restorations were chosen for the anterior teeth.
As the minimum core thickness for this full-ceramic system is 0.4 mm, this enabled
conservation of tooth structure
while achieving excellent aesthetics.

Fig. 8

The clinical management
of an aesthetically demanding,
complex functional prosthodontic rehabilitation is a clinical challenge. Various restorative materials were used for
this treatment. A combination
of full-ceramic restorations
and porcelain-fused-to-metal
restorations with porcelain
occlusal surfaces enhances
the overall aesthetic outcome,
as well as functional predictability. Various surgical
and implant-loading protocols
were used, to ensure optimal
results. DT

Traditional porcelain-fusedto-metal anterior crown restorations require the placement of labial crown margins
within the gingival sulcus, in
order to mask the transition
between the root surface and
the porcelain-fused-to-metal
restoration. By prescribing
full-ceramic restorations, intra-sulcular placement of
crown margins on the labial
surface becomes less important from an aesthetic standpoint.
In this report, the cervical
tooth structure of the anterior
teeth was free of caries, teeth
preparation margins were
made at the gingival level and
gingival retraction procedures
were eliminated. As gingival
retraction cord packing was
not required, mechanical
trauma to the gingival tissues
was reduced and significantly
less clinical time was required.
This is particularly beneficial
for individuals with thin gingival biotypes.
Porcelain-fused-to-metal
restorations were used in the
posterior teeth because of the
well-documented long-term

Dr Ansgar Cheng obtained his
dental training from the University of Hong Kong, his prosthodontics specialty training from
Northwestern University, USA,
and his Certificate in Maxillofacial Prosthodontics from UCLA,
USA. He is a Consultant Prosthodontist with Specialist Dental
Group in Singapore. Dr Cheng
can be contacted at drcheng@
specialistdentalgroup.com.

Dr Helena Lee obtained her
dental training at the National
University of Singapore and her
periodontics specialty training
from the University of London-Eastman Dental Institute,
UK. She is a consultant periodontist with Specialist Dental
Group™ in Singapore. Dr Lee
can be contacted at drlee@
specialistdentalgroup.com.
Specialist Dental Group:
www.specialistdentalgroup.com

[15] => untitled

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[16] => untitled

DTAP0709_16_GSK

17.08.2009

18:30 Uhr

Seite 1

DENTAL TRIBUNE Asia Pacific Edition

16 Special Feature

Managing oral health for good quality of life
An interview with Dr Stuart Smith, GSK
positive health behaviours can be
established at a young age.

Dr Stuart Smith has worked as
a dentist and teacher in several
dental hospitals and schools in the
UK. Recently, he became Vice
President of Global Dental Scientific and Professional Communications for GlaxoSmithKline
(GSK), a large multi-national
pharmaceutical company with an
extensive consumer healthcare
division. DT Asia Pacific editor
Claudia Salwiczek spoke with
Dr Smith about GSK’s approach
to oral care management.
Claudia Salwiczek: Dr Smith,
GSK is developing solutions for the
oral health management of customers throughout the world. In
your opinion, what impact do oral
diseases have on people’s lives?
Dr Stuart Smith: Oral diseases
can have a massive and varied impact on the lives of individuals, families and communities. Dental caries
has been declining in many markets
but remains a significant problem
around the world not only causing
pain for the individual but lost days of
schooling for children and work
days for adults. Gum diseases remain a common reason for tooth loss
which in turn can have a dramatic
impact on someone’s self esteem.
There is also increasing interest in
the links between edentulism and its
impact on systemic health and the
role that denture hygiene may have
in the process. Other oral diseases,
such as dentine hypersensitivity and
xerostomia, can also impact an individual’s quality of life with patients
having to modify the way they live
their lives to cope with the condition.
Hence improvements in prevention
and treatment of dental disease must
remain a high priority.
You have been with GSK for
15 years. How does your work
routine in a corporate environment compare to your university
experience?
Much of the work is very similar;
the objectives of dental academic
researchers and industry are very
closely aligned. Both are looking
for ways to improve preventive and
treatment outcomes for patients.
Our task is to provide products that
enable these improvements and
this research and development is
inevitably undertaken in collaboration with academic partners.
What does the development
process for new products look
like?
Oral healthcare fits perfectly
within the GSK company mission,
which is to help people to do more,
feel better and live longer. Within
consumer healthcare all products
that are developed must be expert
recommended and consumer preferred so this means we need to
work extensively with external experts to ensure that products we develop will deliver against the needs
of the dental profession.
To be successful as a company
we not only need to provide effective
products but products that patients
find acceptable and want to use.
It is critical that we understand the
needs and wishes of consumers to

You suggested earlier, that
patient compliance to oral care
instructions is still an issue…
Unfortunately yes. Dental professionals around the world are
working hard to modify patient behaviour on a daily basis. We are
aware that it is critical that the flavour
and mouthfeel of our products are
acceptable to drive compliance. It is
no good having a really effective
product if the patient won’t use it.

GSK is striving to serve the needs of patients of all ages. (DTI/Photo Courtesy by Monkey Business Images)

ensure that we provide products
that meet their requirements and
that they want to use. It doesn’t matter how effective a product is, it will
only work if it is used.
We typically work with independent global experts in each therapeutic area throughout new product development. This collaboration
is ongoing right from the beginning
of the project when professional insights and advice are sought right

bring them to market. (Editorial note:
For more information, please visit
www.innovation.gsk.com.)
It seems that you are also
working closely with HCPs…
Absolutely! GSK and HCPs strive
towards the same goal: understanding and serving the needs of the patients. In order to do so successfully,
good communication and a close
working relationship with HCPs are
essential.

profession and it is something we
are extremely proud of.
We have been able to provide
scientific support and educational
materials on dentine hypersensitivity to both healthcare professionals
and to patients and have been able
to increase patient attendance at
the dentist and encourage dialogue
about the condition between patient
and dentist. Through a thorough
understanding of the aetiology of

“The GSK company mission is to help people
to do more, feel better and live longer.”
through the research phase to publication of the work in scientific journals and scientific and educational
symposia. This provides the evidence that dental healthcare professionals (HCP) around the world
expect and demand.
So R&D has become globalised
as well?
It certainly seems that the world
is becoming a smaller place. Whilst
historically most R&D has been conducted in Europe and USA it is now
becoming much more evenly spread
throughout the world. GSK consumer healthcare has now established R&D facilities and capabilities
in India and China and are constantly
seeking ways of building collaborative relationships in Asia to ensure
we capitalise on the scientific expertise and capabilities in this region.
What are the benefits of these
relationships?
Through such collaborations
we access an extensive knowledge
base and gain insights into the specific oral health needs of the individual countries. We also recognise
that most important new therapeutic breakthroughs will be discovered by researchers in universities
spread throughout the world and
we embrace this through a system
of open innovation where we partner with the inventors and collaboratively develop products and

Where does the consumer factor in this process?
Consumers increasingly not
only want to be healthy but to be
happy with their smile and be
confident in social settings without
having to undertake avoiding habits
such as consumers with dentine hypersensitivity avoiding ice cream or
denture wearers having to avoid
hard foods. We spend much time
and money talking with consumers
both in groups and individually to
really understand how they feel and
what they want. The consumer insights that this generates enables us
to develop products or educational
materials that directly target the
needs of our customers.
Can you give us an example?
A simple example is that whilst
approximately one in three people
report suffering from dentine hypersensitivity only half of these
patients will actually mention it to
their dentist and so their pain may go
untreated.
With your Sensodyne toothpaste brand you say you have developed a solution for this problem.
Indeed. Sensodyne is the most
widely recommended toothpaste
by HCPs for the treatment of sensitive teeth. This success has been
achieved over many years of partnership between GSK and the dental

the condition, HCPs have been able
to provide consistent support for
their patients and successfully
manage dentine hypersensitivity.
This results in benefits for patients
and has a positive impact on how the
dental practice is perceived.
You say that people need to
be educated in order to achieve
a change in oral care behaviour.
What are some of the measures
GSK takes to facilitate this
change?
Positive health behaviour change
to prevent disease is generally very
difficult to implement. Dental disease is no different in this regard to
other conditions such as obesity, type
2 diabetes and reducing tobacco usage. GSK works with dental healthcare professionals to improve education amongst the profession and
also in its communication with consumers. We undertake programmes
to raise awareness of dental health,
dental disease and measures that
can be taken to control it. This can
also serve to increase regular visits
to the dentist and open dialogue between patients and dentists, which
all helps to facilitate positive health
behaviour change. Attitudes to dental health and personal responsibility for our own health are also
changing but take time as children’s
attitudes will be heavily influenced
by their parents experiences and
beliefs. It is hugely advantageous if

For some products such as
Aquafresh, the flavour and mouth
feel are a real bonus driving usage
since most people want the therapeutic benefits delivered by fluoride
but also like the sensorial experience
of brushing and the resulting feeling
of a freshly cleaned mouth and the
confidence that fresh breath brings.
It can be a similar situation with denture wearers who may well be embarrassed that they wear dentures
but find that keeping a denture clean
with Polident is a fast and effective
way of removing bacterial deposits.
The resulting reassurance that denture odour is controlled leads to
greater confidence in social settings
and improved quality of life. This
beneficial outcome provides positive
feedback and encouragement to
maintain the health behaviour. For
other products it is a tougher challenge to deliver the efficacy with
quite the same level of patient acceptance because the active ingredients
that are required for the product to
work can have a negative impact
on flavour. The task is then to deliver
the optimal sensory characteristics
without impacting the efficacy.
When a new product hits the shelf
extensive testing will have been undertaken with large groups of consumers who have used the products
at home in real life conditions for
prolonged periods to ensure patient
acceptability.
In summary, dental healthcare
professionals and consumers are
at the heart of everything we do.
It is our goal to develop products that
experts want to recommend and
patients want to use.
Thank you for this interview! DT
Editorial note: This interview was supported
by an educational grant from GlaxoSmithKline. For more information about the GSK
product range please visit www.gsk.com,
www.aquafresh.com, www.sensodyne.com
and www.polident.com.

Contact Info

Dr Stuart Smith can be contacted
at stuart.r.smith@gsk.com.

[17] => untitled

A3-out.pdf

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4/14/09

5:16:05 PM

[18] => untitled

DTAP0709_18-20_Walter

17.08.2009

18:32 Uhr

Seite 1

DENTAL TRIBUNE Asia Pacific Edition

18 Trends & Applications

Sub-gingival biofilm:
A therapeutic challenge
Minimally invasive biofilm management in periodontal recalls
Dr Clemens Walter & Dr Beate Mohr
Switzerland

The primary goal of periodontal-therapeutic methods is to introduce a needorientated individual oral
hygiene and to enable and
maintain perfect supra-gingival plaque control. After
systematic sub-gingival instrumentation of the diseased periodontium, regular
mechanical removal of the
sub-gingival biofilm by a

dentist or a dental hygienist
is required. This combination is considered the ‘gold
standard’ in periodontal
treatment and with consistent application can maintain periodontal health over
several decades.
A basic condition for the
formation and progression of
periodontal disease is an opportunistic infection that is
mostly poly-microbial with
pathogenic micro-organisms

Fig. 1: A microscopic picture of the sub-gingival biofilm, showing the enormous
complexity of oral flora.

of the oral biofilm. Biofilm
is an organised microbial
accumulation on a humid
surface (Fig. 1). This multilayered structure protects
bacteria from the immune
system of their host and from
anti-microbial agents, such
as local and systemic antibiotics.
No scientifically proven alternatives to the mechanical
removal of oral biofilm have
been found to date. The organ-

ised bacteria do not only operate directly. Damage to the periodontium is inflicted, without bacterial invasion, in the
corresponding compartments
of the periodontal apparatus
through the host’s immune reaction to the bacterial stimulus.
The progression of the disease, which varies from individual to individual, is determined by genetic, acquired
and partly-modifiable risk factors.

Fig. 2: Abrasion of enamel using a gracey curette.

Invasiveness
of the instrumentation
Currently, several established and new, innovative instruments are available for the
removal of the sub-gingival
biofilm, as well as the scaling
and root planing of the diseased periodontium. In addition to the removal of biofilm,
the establishment of a biocompatible root surface (even,
hard and decontaminated) is
a priority during initial instrumentation. For this, hand instruments, such as gracey
curettes (Fig. 2) and ultrasonic
scalers with diamond tips, are
indicated.
However, there can be several undesirable side effects
with such a course of treatment.
Patients often find the instrumentation of the diseased
periodontium an unpleasant
experience. Moreover, gingival recession may occur as a result of the treatment, which
can lead to aesthetic impairment and dentine hypersensitivity. Long-term treatment of
the root surface contributes
substantially to the erosion of
enamel, which can result in
long brittle teeth.
During initial sub-gingival
instrumentation, all concretions and calculi should be removed as far as possible.
Supportive periodontal therapy
(SPT) of the periodontium entails removal of the biofilm.
Accordingly, minimally invasive and patient-friendly procedures like biofilm management
are favoured in SPT (Fig. 3).

Air-abrasive polishers
in periodontal therapy

Fig. 3: Instruments for mechanical periodontal therapy. Decreasing abrasivity –
Gracey curettes > diamond-tip of an ultrasonic scaler > Perio-Flow nozzle

Fig. 4: Increased effective range of the air–powder mixture is achieved through a
special nozzle.

In recent years, scientific
interest has centred around the
development of air-abrasive
polishers for supra-gingival
and sub-gingival application.
These systems use a mixture
of an abrasive powder and water blasted onto the surface of
the tooth. Application angles vary depending on the type of unit.
Initial variants using sodium
bicarbonate or aluminium oxide powder were not approved
for sub-gingival instrumentation. The application of sodium
bicarbonate with a grain size
of 250 µm resulted in massive
dentine and cementum damage. In addition, trauma of the
gingiva was observed.
The high degree of abrasiveness of these materials
required the development of

Fig. 5: The user-friendly touchpad of the Air-Flow Maste, EMS.

Fig. 6: Open peri-implantitis treatment using an air polisher.

DT page 20

[19] => untitled

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[20] => untitled

DTAP0709_18-20_Walter

17.08.2009

18:32 Uhr

Seite 2

DENTAL TRIBUNE Asia Pacific Edition

20 Trends & Applications
DT Page 18

new air-powder polishers, especially for sub-gingival application in periodontal therapy.
The development of new air
polishers focused on the reduction of the grain size and
sub-gingival application through
a special attachment.

The new generation
of air-abrasive polishers
The recently launched glycine-based powder Air-Flow
AD

Powder Perio (EMS, Switzerland) with a grain size of approximately 25 µm (d 50) allows
sub-gingival instrumentation
without damage to the cementum or gingiva. The powder-air
mixture and rinse water are introduced sub-gingivally with a
fine, flexible attachment. The
triple-injector system causes
spinning at the application site,
which extends the effective
range (Fig. 4). A follow-up polish of the instrumented surfaces with rubber cups is often

unnecessary, owing to this powder’s reduced abrasiveness.
The nozzle is for single use only.
Options for supra-gingival
and sub-gingival application
have been combined into one
single device (Air-Flow Master, EMS, Fig. 5). Based on indication and the required abrasion, users can select various
powder grain sizes:
• A Sodium bicarbonate-based
powder (Air-Flow Powder

Classic) with a grain size of
approximately 65 µm (d 50)
and rounded particles with
a smooth surface is recommended for the supragingival
removal of stains as well as
before bleaching fissure sealing sessions.
• A glycine-based powder
(Air-Flow Powder Soft) with
a grain size of approximately 65 µm (d 50) is recommended by the manufacturer
for supra-gingival cleaning

and in cases of difficult access
due to an orthodontic appliance.

Evidence and first personal
experiences
A recently published clinical study has shown promising results regarding the efficiency of Air-Flow applications containing glycine in SPT.
According to the results, gentle
and quick removal of the subgingival biofilm is possible
up to a pocket depth of 4 mm.
Significant irritation of the
marginal gingiva was not observed. Surprisingly, patients
found the instrumentation using air abrasion a more pleasant experience than instrumentation using traditional
methods.
The first clinical experiences in Basel confirmed a
high acceptance rate amongst
patients. The procedure with
minimally abrasive glycine
powder is especially recommended for patients diagnosed
with periodontitis with minor
dental calculus formation.
Closed or open peri-implantitis therapy is a further indication for treatment (Fig. 6).
Before treatment, the patient should be protected with
safety glasses, protective attire
and a sufficient layer of Vaseline
on the lips. A prudent suction of
the aerosols by the dental assistant further protects the patient
and facilitates treatment. Access to higher pocket depths is
critical and could be improved
with the introduction of a more
gracile and rigid nozzle.
To summarise, it can concluded that at present minimally abrasive powder–air
mixtures are a good alternative
for SPT, owing to their low
damage potential for periodontal tissue and high patient
acceptance rate. DT

This article first appeared
in Dental Tribune Switzerland
No.11, Vol. 6, 2008. Translation
was provided by Annemarie
Fischer, Germany.

Contact Info

Dr Clemens Walter is assistant
medical director of the Clinic
for Periodontology, Endodontology and Cariology at the
University of Basel in Switzerland. He can be contacted at
clemens.walter@unibas.ch.

[21] => untitled

DTAP0709_21_Kaiser

17.08.2009

18:33 Uhr

Seite 1

DENTAL TRIBUNE Asia Pacific Edition

Trends & Applications 21

High-quality dental lab work from Singapore
An interview with Matthias Kaiser, CEO of Kaiser Dental Laboratory
Matthias Kaiser was an English and French language
teacher before becoming CEO
of Kaiser Dental Laboratory
in Germany. Today, he leads a
team of four dental technicians in Singapore that produces and delivers dental
prostheses for dentists in Asia
and Europe. Dental Tribune
Group Editor Daniel Zimmermann spoke with him about
the working conditions in
Singapore and his opinion of
the dental laboratory market
in Asia.
Daniel Zimmermann: Mr
Kaiser, where did the idea of
establishing a dental laboratory in Singapore originate?
Matthias Kaiser: The idea
came from my brother Christoph, who was hired by a French
dental laboratory in the mid1980s but was dissatisfied with
quality standards. With his wife
Farida, he founded the Kaiser
Dental Laboratory in Singapore
in 1987. We later followed with
proDentum in Berlin for sales in
Germany.
Quality standards in technology and service were more
important to us than being the
cheapest supplier in the market. Throughout the years, this
concept has brought us a very
stable business. We have seen
many competitors copying our
concept and constantly looking for favourable locations
throughout the region; however, they still buy work that is
more sophisticated from us.
Since the 1990s, a number
of Asian countries, such as
Singapore, have experienced
considerable economic growth
rates. What impact have these
developments had on the dental market?
Dentistry is and will remain
primarily a handicraft. Large
entities like in other manufacturing areas, such as the textile
industry, are not imitable. Even

though there are quite a number of large laboratories in
China, individual training and
technical routine remain a
problem. In the last couple of
years, all other international
laboratories have left Singapore and are now producing in
China or Vietnam. However,
conditions and quality standards in these countries vary
to a high degree.
In a recent interview with
DT Asia Pacific, the president
of STD Lab Management in
Beijing estimated that there
are 8,000 dental laboratories
in China. What is your opinion of this potential?
It is a question of quality and
demand. In China, everything is
mass-produced, but everyone
who purchases dental prostheses in that country will soon realise the importance of quality
and how difficult it is to retain
quality in mass production.
I think that Chinese laboratories will be producing for the
expanding middle class in the
country itself.
Have you thought of entering the Chinese market?

A dental technician at Kaiser Dental Laboratory in Singapore. (DTI/Photo Courtesy of proDentum)

we would be on the same technological level again but more
advanced in terms of organisation and marketing. The current trend shows that our view
on this is on the right track.

bution structures or via the
Internet?
We usually take the established routes because our efforts to install an IT-based processing system have failed in

“A well-trained dental technician
in Singapore can earn as much
as a technician in Berlin”
Of course. When you receive
an offer to buy an all-ceramic
restoration for only €8, you
start thinking about this option. However, when you see
the product itself, you know
that the purchasing of dentures
cannot be approached in the
same manner as the purchasing
of fabrics.
We are patiently waiting for
costs to explode in China. Then,

How do the working conditions in Singapore compare to those in Germany or
Europe?
A well-trained dental technician in Singapore can earn as
much as a technician in Berlin
or any other part of Europe.
Although we have experienced
an increased cost of living in
recent years, efficient labour
organisation, the optimal utilisation of resources, and very
low ancillary labour costs
make production here still
attractive, so patients in Germany and other countries can
save a lot. As our laboratory
in Singapore is certified by
the German Technical Supervisory Association (TÜV), the
basic conditions for production
are more or less the same as
those in Germany.
Which markets do you
primarily serve?
Approximately 70 per cent
of our prosthetic work goes
to Germany and Austria, and
10 per cent to Norway and the
Netherlands. The 20 per cent
remainder goes to the fastest
growing markets of Singapore
and its neighbouring countries, where high-quality dental laboratory work is in demand.

A patient receives treatment at Kaiser’s new dental clinic. (DTI/Photo Courtesy of
proDentum)

Do you offer your services via established distri-

the past owing to the lack of
a standard interface to the
dentist.
At the International Dental Show in Cologne it was
evident than automated production of dental prostheses
is the future. What do you
think of this development and
will Asia soon follow the
trend?
In Asia, where people customarily love new technology,
these trends are likely to be followed much more quickly than
in Europe. However, it seems
that there is a long way ahead
before all these technologies
are able to replace the entire
production process. If some
day the price for a CAD/CAMproduced all-ceramic restoration is the same as that for
a crown produced by hand by
a dental technician in China
or Singapore, things will probably change. Then we would
no longer need to import laboratory work from abroad. I do
not see this happening for a
long time.
You recently opened a dental clinic. What services do
you offer there?
At the clinic, we are working with patients from Singapore who are in particular
need of high-quality implantology. There are many expa-

triates from Germany here
and so we would like to hire
German dentists. Unfortunately, the Singapore Dental
Association is refusing to give
us permission to hire them,
even though we have already
received applications from
highly-qualified applicants.
But we will continue to work
on this matter.
Singapore has recently
become a strong player in the
medical and dental tourism
market. Do you intend to
participate in this market as
well?
We believe that this could
be a good investment, although
only a few people would be
willing to travel from Europe
to Singapore. What we cannot
predict at the moment is
whether patients from more
developed countries in the
region will come to Singapore
to seek dental treatment. The
number of enquiries from Indonesia or Malaysia is noticeably growing. Meanwhile, we
are looking for investors who
would like to participate in the
clinic’s expansion and support
our marketing campaigns. And
we are looking for Singaporean
dentists who speak German
well!
Are you planning any
special activities for the FDI
Congress?
Instead of distributing pictures and brochures, we invite
all dentists to see our laboratory facilities ‘in action’ and to
speak with our dental technicians and management about
possible collaboration. Whoever is interested can just contact us; we’ll pick her or him up
at the hotel and bring her or
him back to the hotel again.
Our staff speak Mandarin,
Malay, English and German.
Thank you very much for
the interview. DT

[22] => untitled

DTAP0709_22-24_Ludwig

17.08.2009

18:36 Uhr

Seite 1

DENTAL TRIBUNE Asia Pacific Edition

22 Trends & Applications

Miniscrews—a focal point in practice
Six-part series by Dr Björn Ludwig, Dr Bettina Glasl, Dr Thomas Lietz & Prof. Jörg A. Lisson—Part VI

Complications
and risks
Preliminary remarks
The use of miniscrews facilitates many aspects of orthodontic treatments and in some
cases actually makes such treatments possible. But miniscrewbased treatments, in common with
all medical procedures, are not
without their problems, complications and risks. It should be borne
in mind that medical progress is
only possible thanks to the pioneers and patients who are willing
to enter uncharted regions. The
major phase of miniscrew trials began in 2000. Today, the use of miniscrews is becoming increasingly
established and consolidated,
which means that the potential and
limitations of miniscrews are also
ever more apparent.

Miniscrews: Complications and risks
Objective reasons

Iatrogenic problems

Constructive
causes
Processrelated causes

Pre-operative causes
Intra-operative causes

Fig. 3: The physiological movement of
a tooth can, in some circumstances,
cause micro-movements of a screw, resulting in its failure.

Fig. 4a

Fig. 4b

Figs. 4a & b: If dental film is used, only
the right-angle technique will supply
useful information (a). The use of an
unsuitable radiology technique not
only exposes the patient to unnecessary stress, but is also worthless for
treatment planning purposes (b).

A single problem or mistake
during the planning and implementation of a miniscrew procedure can have various consequences and result in a number
of complications. Often, a whole
sequence of adverse events is
triggered. At first glance, there is
frequently no direct connection
between the origin and outcome of
a problem and/or a complication
and its cause. Obviously, there are

Class D1

Post-operative
causes
• Pathological

Influence of practitioner

Class D2

problems

• Insertion process

Thick compact bone/dense spongiosa
Anterior upper jaw/ PM region of lower jaw ¨ good primary stability

• Mechanical

• Insertion site

Almost entirely homogeneous compact bone
Anterior lower jaw ¨ good primary stability

factors

• Screw fracture

Class D3

• Habits

Thin compact bone/dense spongiosa
Posterior lower jaw/posterior upper jaw ¨ limited primary stability

• Experience

Class D4

Thin compact bone/sparse spongiosa

Premature loss or failure of the screw

Posterior upper jaw (retromolar) ¨ poor primary stability

Fig. 1: There are many possible causes of the premature loss of
miniscrews.The most common of these are practitioner-related.

Fig. 2: Classification of bone quality according to Misch
(1990) and Lekholm & Zarb (1985).

still several areas that have not
been sufficiently researched. But
we are becoming increasingly
aware of what works well, what
lies in the grey area between success and failure and what is bound
to fail (Table 1). Because of this,
it is essential that the patient is
informed of the potential risks and
the availability of alternative treatments. The most common complication is the loss of a miniscrew.

Success rate/failure rate

Fig. 3

Patient

Bone quality

How low is the failure rate—
or, to put it better, how high is the
success rate—of miniscrew procedures? It would be easy to reproduce the figures from published
studies, but these are not of use;
for example: the success rate is in
the range of 0 to 100 per cent. The
published results of clinical observation and ‘studies’ are all within
this range. So, do we now know
whether miniscrew XY is any good
or not? And is this a suitable criterion on which to base the evaluation of a system or therapeutic
approach?
A study by Behrens and Wiechmann reported failure rates of
miniscrews inserted in the lingual
mandible, for example, 100 per
cent for Dual-Top and 76.9 per cent
for AbsoAnchor. What does this actually mean? Is AbsoAnchor better
than Dual-Top? Here, cause and
effect can be easily confused. One
single region and a high rate of loss
of two screws—surely this means
that the insertion site was problematic or unsuitable. It seems
probable that the outcome would
be the same for all other miniscrews inserted at this location.
It should be borne in mind that it is
unwise to draw premature conclusions from figures alone. There
are many possible causes for the
loss or partial failure of miniscrews. As a rule, it is not the system itself that is at fault! The comparability of clinical situations and
experimental designs is a problematic area. Patients’ reactions
and their habits differ, the biomechanical concept can very greatly
and so on. What is frequently not
mentioned in published studies is
the level of experience of the operating practitioner at the start of the
study. This is an important factor in
determining outcome. In view of
the numerous influencing factors,
a direct comparison of different
studies is simply not possible.
Statistics themselves are of
little value because ultimately it is

individual experience that counts.
There must be a willingness to
learn, not only from one’s own mistakes, but also from those of others.
The success rate should be well
above 90 per cent, although a practitioner is unlikely to achieve this
when he or she first starts using
miniscrews. There is a clearly
demonstrable learning curve in
connection with this form of treatment, particularly with regard
to the insertion procedure. The
cause of most problems lies within
the surgical procedure itself.

Iatrogenic problems

duces the risk of damaging a root
(Fig. 3).
In the case of X-ray plates (particularly dental films), the direction of exposure, distortions arising from this and the possible loss
of information must all be taken
into account (Figs. 4a & b). The
spatial situation can also be assessed by reproducing the mucogingival line, the tooth axes and
roots on a model (Fig. 5). Information on the maximum length of
screw that can be used can be obtained by measuring the model
along the insertion axis (Fig. 6a).

This simple procedure helps prevent the risk of miniscrew perforation on the oral side (Figs. 6b & c).
The required direction of teeth
movement must also be considered during planning. This causes
the resultant spatial situation to
change during the course of treatment. A miniscrew must not interfere with or obstruct the desired
movement (Fig. 7).
Insertion
The first question (taking into
account possible complications)
is who should insert the screw?
There is much in favour of this being done by the orthodontist. Studies have shown that orthodontists
have a far better developed sensitivity in this regard. There is often
failure—in other words, the loss
of the miniscrew—if this is undertaken by ‘experienced’ implanters
because they tend to ignore or
be insufficiently aware of the
requirements for the insertion of
a miniscrew.
If the orthodontist is not to
insert the miniscrew personally,
a good line of communication with
the surgeon must be maintained.

As Figure 1 and Table 1 show,
there is a whole range of possible
causes of the loss of a miniscrew. In
view of their diversity, it is only be
possible to consider a few aspects
in the following discussion.

Planning and organisation
Careful planning is undoubtedly one of the main keys to
success. The same documentation
and information required for
other orthodontic procedures
are perfectly adequate when planning a miniscrew treatment. The
choice of biomechanical concept
for the approach should be based
on medical history, assessment
findings (including possible contraindications, see Overview 1),
diagnosis, and treatment objective. The general contraindications have been adopted from
those that apply to implant procedures. The actual effect of these
disorders and conditions on the
use/outcome of miniscrew procedures has not yet been determined.
Screw location
The best site for the screw
should be selected on the basis of
the biomechanical concept. The
following should be considered:

Fig. 5

Fig. 5: A good overview of the spatial situation can be obtained by reproducing
the muco-gingival line, the tooth axes and root contours on the model.

Fig. 6b

Fig. 6a

Fig. 6c

Figs. 6a–c: Measurement of the model along the insertion axis (a) provides information on the length of screw that can be used and helps prevent the risk of
perforation on the oral side (b & c).

• There should be at least 0.5 mm
bone around the screw on all
sides.
• The screw head should be positioned on inflammation-free,
attached gingival.
It is most important to determine the quantity and quality
of the bone at the selected site of
insertion. This will provide initial
indications of the quality to be
expected (Fig. 2). However, an
X-ray will only provide limited
information in this respect, although it will make it possible to
assess the spatial situation in two
dimensions. This prevents or re-

Fig. 7

Fig. 7: The desired mesialisation of the molars is not possible because of
the screw location and because the springs are too short.

[23] => untitled

DTAP0709_22-24_Ludwig

17.08.2009

18:36 Uhr

Seite 2

DENTAL TRIBUNE Asia Pacific Edition
Overview 1
Local contraindications:
• Quantitative and qualitative deficiency

of bone at the insertion site
• Insertion
– in the mobile mucosa
– on the lingual side of the mandible
– near extraction wounds,
dental follicles or deciduous teeth
• Poor oral hygiene
• Recurrent disorders of the oral mucosa
• Osteomyelitis
• Radiotherapy of the cranial region

General contraindications:
• Compromised immune system
• Therapy with corticosteroids
• Blood coagulation disorders
• Uncontrolled endocrine disorders
• Rheumatic disorders
• Disorders of the skeletal system
• Hepatic cirrhosis

Overview 2
Miniscrews with depth stop
Name of screw

Manufacturer

Aarhus Mini-Implant*
AbsoAnchor
Ancotek
BENEFIT
Infinitas
LOMAS **
S.I.N.-Implant System
ST Anchor Screw
tomas®-pin

Medicon
Dentos
Tekka
Mondeal
db orthodontics
Mondeal
Microparafuso Ortodontico
Surgi-tec
DENTAURUM

* Screw type: system 1.6 and one-point head
** as suitable to form of insertion

Otherwise, there is a risk of problems of the sort illustrated in Fig. 7.
Here, it is no longer possible to
achieve the aim of treatment
(mesialisation of the molars). This
is because the screws are in the
way and as they are in the wrong
location, the springs are too short
and thus ineffective. The correct
position for the screws would have
been between teeth 3 and 4. This
problem arose because of a misunderstanding and lack of communication between the orthodontist
and oral surgeon with regard to the
aim of treatment and the positioning of the screws. The surgeon was
unwilling to take risks and inserted the screws where there was
plenty of space. Perfectly understandable from the surgeon’s point
of view, but a mistake in this case
—an iatrogenic error!
It is only possible to test the
bone quality at the selected site
immediately prior to insertion. In
regions in which the bone quality
is likely to be D3 or D4 (Fig. 2),
a probe should be first inserted in
the bone. If the probe penetrates
deeply into the bone, the bone
quality is not adequate for the insertion of a miniscrew. A different
site should be selected.
The miniscrew must not be
in contact with the tooth root. If
this happens, the physiological
movement of the tooth can cause
persistent micro-movements of
the screw (Fig. 3). This impairs
the healing process and means
that secondary stability will not
be achieved. No periodontal complications will occur. Numerous
histological examinations have
demonstrated that there is complete healing of the periodontal
ligament after the removal of
a screw.
Some miniscrews have depth
stops (Overview 2). It should be-

Trends & Applications 23

come apparent if the stop touches
the bone surface during insertion,
providing the signal to stop screwing (Fig. 8c). However, depending
on clinical factors, such as bone
quality, site, angle of insertion and
the insertion technique, the moment of contact is not generally
detectable. There is thus the risk
of over-insertion, and the destruction of bone structure by the screw
thread. The effect is comparable
to that of a corkscrew. The initial
(or primary) stability of the screw
appears to be good, but the screw
is rapidly lost. In order to prevent
this, it is advisable to measure the
thickness of the gingiva prior to
insertion. When this is considered
in relation to the transgingival section, it is immediately apparent
how far the miniscrew can be inserted in the bone.

Checklist of the potential causes of the loss of miniscrews

The fracture of a miniscrew is
a rare occurrence. The following
parameters (alone or in combination) determine the risk of fracture:

2.1.1. Planning

• Screw design: thin screws (Ø<1.4
mm) and long screws (>10 mm)
tend to fracture more easily
• Anatomical factors
• Thick cortical layer (>2 mm)
without perforation
• Insertion conditions: too much
torque and/or inconsistent rate
of insertion.
Many problems arise because
of inadequate training or lack of
experience. There may well be a
higher rate of loss after the first five
to ten miniscrew treatments performed by an individual. The personal learning curve can be vastly
improved by practising on porcine
bone samples (Fig. 8). Various
clinical situations can be simulated (bone quality, effect of
drilling etc.). This training gives
the individual the necessary ‘feeling’ for bone and screw. In order
to minimise potential risks, particularly during insertion, it is
advisable to adopt a standardised
procedure for routine use.
Primary and secondary stability
The primary stability of a
miniscrew in the bone must be
good. Screw stability is mainly
determined by the cortical layer.
The screw elements inserted within the spongiosa contribute little
towards screw retention. The reasons for poor primary stability are:

There are many possible causes, but the probability of these occurring differs greatly.

Table 1

Source of information1

Grade of probability
High

Medium

Low

Almost never

Study

Empirical

Analogy

Assumption

1. Objective causes
1.1. Structural causes
Dependent on system used and can be controlled by the practitioner only in the selection of system.
Relation head/shaft length
ø gingival neck > ø head
Screw material
Relation of core diameter to
thread diameter < 1:1.3 (slight undercut)
Thread type
(self-drilling = SD, self-cutting = SC)
Incompatibility of pilot drill and miniscrew

•
•
st. steel

x
x
Ti/Ti coating

•

x
ST

•

x
x

1.2. Process-related causes
Industrial sterilisation
On-site sterilisation;
with disinfection, cleaning and sterilisation
On-site sterilisation; sterilisation only
without prior disinfection and cleaning

•

2. Iatrogenic problems
These problems are solely caused by the practitioner.

2.1. Pre-operative causes
Selection of the insertion site and the appliance
Unsuitable biomechanical concept
Site in lingual mandible
Site in retromolar maxilla
Insufficient bone or space
Screw too long
Screw near deciduous tooth,
dental folilicle or not yet ossified
extraction wound
Screw head near mobile mucosa or
band application site
Rotation of screw head against the thread
Direct anchorage
Gender

•

x
•

••
•

x
x
x

•

x
•

•

x
•

2.1.2. Preparation for insertion
Contamination of screw and instruments,
failure of hygiene procedure
No disinfecting mouthwash used

•

2.2. Intra-operative causes
2.2.1. Insertion site
Insufficient bone or space
No primary stability
Site in lingual mandible
Site in retromolar maxilla
Bone quality
Contact with root
Screw near deciduous tooth,
dental folilicle or not yet ossified
extraction wound
Screw head near mobile mucosa or
band application site
Screw too long, perforation of contralateral side

•••
•••

x
x

•••

x
•
••

x
x

•••

x
••

•••

2.2.2. Insertion technique
Insertion without prior perforation
(with punch) of the gingiva
Pilot drilling (ø of bore hole, technique, rate)
Tension in bone because of
no pilot drilling
Local overheating of bone due to lack of
cooling or excessive torque effect
Screw-in force (< 5 Ncm, > 10 Ncm)
Manual vs. machine insertion
Overwinding of screw/slipping
of screw in bone
Insufficient ‘feeling’ for bone and screw
Inadequate primary stability
Contact with root
Practitioner’s experience (learning curve)

•

x
•

•

x
x

•

•••

x
•

x
x

•••
••

••

2.2.3.Attachment to orthodontic appliance

• Inadequate bone material (quality/quantity);
• Overlarge bore hole due to
wrong drilling technique (e.g.
repeated insertion of the drill in
the hole, deviation from required
axis); and
• Unsuitable screw thread (design
of flanks and distance between
them: relation of shaft to external
diameter).
A miniscrew must have primary stability immediately on insertion, as stability cannot be subsequently achieved. If this is not
the case, it is best to remove the
screw and select an alternative
insertion site where the preconditions are better.
The regeneration of the bone
tissue required to achieve second DT page 24

•

Unsuitable biomechanical concept
Rotation of screw head against the thread
Immediate or subsequent use
Persistent micro-movements
(e.g. owing to direct attachment to elastic elements)

x
•

•

x
x

•

3. Patient/post-operative phase
Many problems can be avoided by documenting medical history and findings carefully and providing the patient with adequate information.

3.1. Patient status
•

Blood coagulation status
Disturbance of wound healing or bone regeneration
(e.g. in diabetes mellitus)
Tobacco and alcohol abuse
Immunosuppressive therapies (e.g. chemotherapy,
radiotherapy)
Osteoporosis

•

3.2. Phase of therapy
Immediate or subsequent use
Force vectors, unsuitable biomechanical concept
Poor hygiene
Inflammation (peri-mucositis, peri-implantitis)
Manipulation (habits, tongue play)
Gingival irritation

•

•
•••

x
x

•

1 Much of the information relating to the potential causes of miniscrew loss is not derived from studies but from the experiences reported by
various authors. That miniscrews are implants must also be taken into account. For this reason, it is highly probable that a great deal of
established information relating to the use of implants will also apply to miniscrews. But there are certain factors that can only be assumed
to be likely to cause the failure of miniscrews—but there is no empirical evidence to confirm this.

[24] => untitled

DTAP0709_22-24_Ludwig

17.08.2009

18:36 Uhr

Seite 3

DENTAL TRIBUNE Asia Pacific Edition

24 Trends & Applications
DT Page 23

ary stability commences shortly
after insertion (Fig. 9). If this
process is persistently inhibited
(e.g. by micro-movements of the
screw), the screw may be lost.
Force application
It is probable that using a
miniscrew immediately or later to
apply force has no influence on the
failure rate. Forces applied should
be such that no damage is caused
to the teeth to be moved. When
a miniscrew is coupled to elastic
chains or springs, micro-movements of the screw can result. The
distance between miniscrew and
the site of application of force of
any springs directly attached to
it should be kept to a minimum.
Otherwise, these will be ineffective (Fig. 7).

Fig. 8a

Fig. 8b

Fig. 8c

Figs. 8a–c: Porcine pelvic bone is good practice material because of the varying thickness of the compact bone (a & b). This
material can thus be used to simulate various insertion scenarios (c).

Construction

Manufacturing process

Preoperative

Premature loss of
miniscrews

Intraoperative

Skill of the practitioner

Postoperative

Post-operative complications

Fig. 9: Primary stability decreases while secondary stability Fig. 10: The reasons for the loss of miniscrews are related.
increases.There is a critical phase at the point of crossover of
the two effects in which there is a risk of screw loss.

Inflammation
There is a high probability that
a miniscrew will fail if peri-mucositis or peri-implantitis develop.
It is thus important to ensure that
the patient is appropriately informed (which includes instructions on oral hygiene) and that

follow-up is possible. During follow-up, examination of the screw
(status of the surrounding tissue,
stability of the screw) should be
carried out. The positioning of
attached elements (springs, extension arms) may cause the
development of pressure sores or

even ulceration of the mucosa.
This is something that should also
be monitored and treated as necessary.
Oral hygiene
The patient must ensure that
adequate hygiene is maintained

in the area around the miniscrew.
A normal toothbrush should be
used for this purpose. There is
evidence that electric toothbrushes, particularly those with
rotating heads, can loosen miniscrews, which can cause failure.
In addition to the cleaning technique itself, the frequency and
intensity of cleaning are undoubtedly also important. Very
frequent cleaning that results in
persistent micro-movement of
the screw could well be disadvantageous.

Duty of information
Prior to beginning any procedure, the patient must be informed
of the nature and effect of potential
risks, of alternative treatments
and of the consequences if no
treatment were to be provided.
It is a good idea to use pre-printed
material to gather information
on medical history and provide
information. These can act as an
aide-mémoire or prompt when interviewing the patient. Written
material should on no account be
used to replace personal dialogue.
The printed material used must
document (e.g. in the form of
a note) that the relevant verbal
information has been given to the
patient. It is not enough to have the
signature of the patient, a witness
and the practitioner.
Documentation
Documentation is an absolutely essential aspect. Treatment
records (patient card, X-ray plates,
models etc.) must clearly document the course of the procedure
and any problems or complications. Meticulous and accurate
documentation is very valuable if,
for example, a legal dispute ensues. Lawsuits are often lost owing
to incomplete documentation.
Insurance claims
If a patient suffers an injury
or registers a claim, it is advisable
to contact the policy provider. The
insurer will supervise all the financial and legal aspects.

Liability insurance

Summary

Orthodontists who wish to
insert miniscrews themselves in
their practices are frequently
unsure about aspects of indemnity insurance. Policies available
cover claims ranging from €1.5
to €5 million. When deciding on
the extent of cover required (and
thus the premiums that will need
to be paid), the particular circumstances of the practice need
to be considered. An indemnity
insurance policy will also cover
the practice’s personnel but
may exclude temporary employees. If there are any changes to the
activities profile in the practice,
the owner should verify that this is
covered by the policy. The insurer
will be happy to clarify this. There
are insurance companies that do
not differentiate between dental
practices and orthodontic practices as far as their policies are
concerned.

The main parameters that determine the clinical success of
a procedure are the bone quality
and space available at the planned
insertion site, the use of an insertion technique suitable for the
system employed, and the use of
a carefully considered biomechanical concept and the prevention of inflammation around the
miniscrew. There are many reasons for failure, and these are
interconnected, rather like the
pieces of a jigsaw puzzle (Fig. 10).

In cases in which an orthodontist is planning to personally
insert miniscrews (an approach
that has many advantages), this is
usually automatically covered by
the policy. This is what the policy
refers to when specifying ‘with
implants’ or ‘with surgery’. In any
case of doubt, however, policyholders should always contact
their insurers and inform them
of the extension of the range
of treatments provided, particularly if the policy does not
specifically cover surgical or implant procedures. In this case,
the annual premium is likely to be
increased by €20 to €50 (applicable at time of writing, June 2007).
In order to protect themselves
should a claim of negligence be
made, orthodontists should ensure that they follow certain basic
rules.

Concluding remarks
on the article series
These six articles cover many
aspects of bone anchorage using
miniscrews. The authors hope
that they have achieved the objectives set out at the beginning of the
series and provided the (as yet undecided) practitioner with a compendium of new information and
experiences. However, it is not
possible to discuss all aspects in
detail, even in an extensive series
of articles; thus, we refer interested practitioners to the relevant
literature. But all theory remains
just that if it is not applied in practice. We should be pleased if you,
our readers, found the courage
to use miniscrews routinely in
your work. And we—Dr Ludwig,
Dr Glasl (both Traben-Trarbach)
Dr Lietz (Neulingen) and Prof.
Lisson (Clinic of Orthodontics,
Saarland University Hospital)—
wish you every success. DT

Contact Info
Dr Björn Ludwig can be contacted
at bludwig@kieferorthopaediemosel.de.

[25] => untitled

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[26] => untitled

DTAP0709_26-27_Monse

17.08.2009

18:37 Uhr

Seite 1

DENTAL TRIBUNE Asia Pacific Edition

26 Trends & Applications

“Children are the best messengers for
introducing behaviour change into family life”
An interview with Bella Monse about the ‘Fit for School’ initiative in the Philippines
ways), where money for soft
drinks and junk food is available, while caries levels in remote areas are lower, most
probably owing to traditional
nutritional habits.

Daily brushing with fluoride toothpaste has shown promising results. (DTI/Photo Bella Monse)

The ‘Fit for School’ initiative
in the Philippines began in
1998 as a small-scale project
in Mindanao, one of the
southern Philippine islands,
incorporating 20 schools and
focusing on oral-health education and dental treatment.
Since then, it has developed
into a registered NGO committed to supporting government and non-government
agencies in conceptualising,
implementing, monitoring
and evaluating school health
programmes. Dental Tribune
International Group Editor
Daniel Zimmermann spoke
with Dr Bella Monse, a former dentist and now consultant of the German Development Corporation (GTZ) in
the Health and Nutrition
Section of the Department of
Education in the Philippines,
about the programme and
how could it is helping to improve the oral health status
of children throughout the
Asia Pacific region.
Daniel Zimmermann: Ms
Monse, you are going to introduce your country’s Fit
for School Health Programme
at the World Congress on
Preventive Dentistry in Thailand. Could you please explain what the programme
does?
Bella Monse: The NGO ‘Fit
for School’ supports the health
and education sector in the
Philippines in institutionalising an ‘Essential Health Care
Package for Filipino Children’.
This package implements daily
hand-washing with soap and
tooth-brushing with fluoride
toothpaste, as well as biannual
deworming, as an integrated
part of the public school system.

Children are the main actors as they carry out the activities in the same organised

true for other countries in Asia
as well. In the Philippines,
caries amongst public school

The ‘Fit for School’ programme recommends simple
interventions such as brushing teeth with fluoride toothpaste. Why can these measures not be implemented in
children’s homes?
During the last decades,
the Department of Education
has run health-education programmes promoting a healthy
diet and daily tooth-brushing
and giving advice to visit the
dentist twice a year. However,
despite these efforts, children
are eating junk food, not
brushing their teeth and not
visiting dentists. And how can
children do so, if regular toothbrushing is not a habit in family life, if toothbrushes and
toothpaste are not available,
and if there is no money to go
to the dentist, even if children
have toothache? Schools are
the most effective places to
introduce change, as children

“The oral-health status of children in
the Philippines is in an alarming state”
manner, like the daily flag ceremony, under the leadership
of classmates as group leaders.
This daily routine in schools is
familiarising children with
healthy habits and may induce
long-term behaviour change
in family life.
What are the main advantages of an integrated
school health programme?
In countries where diarrhoea and respiratory tract
infections are still the major
cause of death amongst children, two-thirds of the children are infected with soiltransmitted parasites (common worms), and virtually all
children suffer from untreated
dental caries, improvement
in personal hygiene, focusing
on hand-washing and toothbrushing is the base for any
health-care programme. Integration of oral health care into
general health care will mainstream advocacy, pool resources, avoid overlap and
simplify health programmes.
The latest National Oral
Health Survey has revealed
that 97 per cent of firstgraders in public schools in
the Philippines suffer from
tooth decay.
The oral-health status of
children in the Philippines is
in an alarming state, and this is

children remains completely
untreated, leading to unnecessary pain and intra-oral
infections. The National Oral
Health Survey revealed that
six-year-old children had on
average nine decayed teeth in
their mouth with 40 per cent of
these teeth presenting caries
with pulp involvement.

spend the majority of their day
with their classmates and the
teacher. Children are the best
messengers for introducing

behaviour change into family
life.
The programmes are
aimed primarily at school
children. Yet, figures from
watchdog organisations for
children’s rights estimate
that 16 per cent of young
children in the Philippines
work and thus do not attend
school.
This is a sad fact and the
real figures are even higher.
Only about 60 per cent of children finish elementary school.
All efforts have to be increased
to achieve universal primary
education, helping and encouraging parents to send
their children to school.
You recently completed
the first pilot programmes.
What was their outcome?
These pilot programmes
have already been scaled up to
national policy and currently
more than 630,000 children are
enrolled in the programme.
We expect that at the end of
the school year 2009/10 more
than a million school children
will participate in the programme. With regard to the institutionalisation process, one
of the most important outcomes of the pilot phase was
the need for clear policies,
mandating teachers to supervise the daily routine of handwashing and tooth-brushing
and integrate these into daily school activities. We also
learned a lot concerning partnership with the parents and

Twenty per cent of six-yearold children also reported
toothache during the time of
the survey and the condition is
the main reason for school absenteeism in the Philippines.
We have developed an index
to measure the consequences
of untreated caries—the PUFA
index—which will be presented during the World Congress on Preventive Dentistry
in Thailand.
What are the reasons for
the neglect of oral health
care and are there regional
differences?
The main reasons are an
unhealthy diet and lack of access to appropriate levels of
fluoride. Daily tooth-brushing
with fluoride toothpaste is not
yet a habit for the majority
of Filipino children in their
family life. The National Oral
Health Survey found the highest caries levels in highly urbanised areas and easily accessible areas (near high-

Deworming of a Filipino schoolgirl under direct observation of day care personnel. (DTI/Photo Ivan Sarenas)

[27] => untitled

DTAP0709_26-27_Monse

17.08.2009

18:37 Uhr

Seite 2

DENTAL TRIBUNE Asia Pacific Edition

Trends & Applications 27

gramme in terms of health
outcomes, academic performance and behaviour change.

“Countries that want to implement
similar programmes have to focus on
prevention and behaviour change”

teachers’ association and community involvement, which is
essential for the construction
of hand-washing and toothbrushing facilities.
With regard to the health
outcomes of the interventions,
hand-washing with soap has
proven around the globe to be
the most effective health-care
intervention in halving the
occurrence of infectious diseases (specifically diarrhoea
and respiratory infections).
Our research has shown that
daily fluoride tooth-brushing
reduces the caries increment
by 40 per cent and progression
into the pulp by 60 per cent,
while international published
data on mass deworming of
children provides the evidence for improved nutritional status and academic
performance.
Education Secretary Jesli
A. Lapus has announced
plans to extend the programme to six million children by the end of 2010. Is this
a realistic target?
The Philippines Education
Secretary is actively promoting this programme, and he
is accorded much attention
within the Philippines and in
the Asian region, especially in
light of the H1N1 pandemic, for
which hand-washing is important as well. The compelling
concept of the ‘Fit for School’
programme, addressing highimpact childhood diseases in
a comprehensive, yet simple,
and cost-effective package,
provides the backdrop for high
expectations for a fascinating
public health success story.
We aim to reach six million
children, which is nearly 50
per cent of public school children, by the end of 2012.
Backed by national and international health policies, ample evidence on effectiveness,
clear implementation strategies and support from influential partners, this is a realistic
target.
Dental hygiene has to be
maintained throughout life.
Do you expect the programme to have any longterm effects or is there need
for further oral-health promotion programmes later in
life?
Children are performing
daily tooth-brushing in school
and we expect that this will
lead to lifelong behaviour
change. It is known that children are the best messengers
and agents of change for promoting and introducing behaviour change in family life.
Limited data is available to
answer this question, but
promising results from research conducted in Scotland
amongst high-risk children
showed long-lasting effects,
evidenced by a reduction in
caries increment of 39 per
cent compared with control
children four years after the
termination of a school-based
fluoride tooth-brushing programme. We are just starting
a comprehensive research
project to evaluate the pro-

You said before that many
countries in Asia demonstrate similar oral-health
patterns amongst their youth.
What lessons can your programme provide for countries that aim to implement
similar programmes in their
schools?
Countries that want to implement similar programmes

have to focus on prevention and behaviour change.
Only a few evidence-based
interventions, which governments can afford for all

children, are necessary for
an essential school health
package that answers to the
demand and the local conditions of the public school

system in their respective
countries.
Thank you very much for
the interview. DT
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[28] => untitled

Anschnitt_DIN A3

05.08.2009

9:37 Uhr

Seite 1

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[cover] => DT Asia Pacific

[toc] => Array ( [0] => Array ( [title] => Therapy of craniofacial defects successful [page] => 01 ) [1] => Array ( [title] => Asia News [page] => 02 ) [2] => Array ( [title] => Opinion [page] => 04 ) [3] => Array ( [title] => World News [page] => 05 ) [4] => Array ( [title] => Business [page] => 09 ) [5] => Array ( [title] => An interview with Domenico Scala - CEO of Nobel Biocare [page] => 10 ) [6] => Array ( [title] => Fixed prosthodontic management of a mutilated dentition: A team approach [page] => 12 ) [7] => Array ( [title] => An interview with Dr Stuart Smith - GSK [page] => 16 ) [8] => Array ( [title] => Sub-gingival biofilm: A therapeutic challenge [page] => 18 ) [9] => Array ( [title] => An interview with Matthias Kaiser - CEO of Kaiser Dental Laboratory [page] => 21 ) [10] => Array ( [title] => Miniscrews—a focal point in practice (Part 6) [page] => 22 ) [11] => Array ( [title] => An interview with Bella Monse about the ‘Fit for School’ initiative in the Philippines [page] => 26 ) ) [toc_html] =>

Table of contents

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