DT Asia Pacific No. 3, 2015

Asia News / World News / Business / Knowledge can save lives / Trends & Applications / Endo Tribune Asia Pacific Edition

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DENTAL TRIBUNE

DENTAL TRIBUNE Asia Pacific Edition No. 3/2015

18 News & Opinions

The World’s Dental Newspaper · Asia Pacific Edition

PUBLISHED IN HONG KONG

www.dental-tribune.asia

A new global player
DTI visited MIS
headquarters in Israel
Page

NO. 3 VOL. 13

Eating disorders
Understanding
and treating patients

Page

Special Tribune
News & trends
from endodontics

Page

17–23

Billions to suffer from untreated decay Stricter
Dental neglect affects a third of the world’s population, according to report

regulations

The Australian Dental Industry Association (ADIA) has
advised the government panel
currently reviewing medical device regulation in Australia to
strengthen the regulatory framework for dental laboratory products. In particular, ADIA pointed
out that there is a need for an
obligatory statement of manufacture to be provided to patients
and retained by dentists.

DTI

LONDON, UK: Despite worldwide efforts to improve oral
health, a new global study has
revealed that 35 per cent of the
world’s population currently suffer from untreated caries lesions
in their permanent teeth. It also
found that 621 million children
worldwide have tooth decay that
goes untreated.

ADIA’s recommendations
arise from the increasing prevalence of dental laboratory products sourced from overseas and
the inability to readily identify
the source of the products, the
association stated.

To make things worse, hundreds of millions of new cases are
expected to add to the burden of
dental decay annually owing to
neglected treatment, according
to the paper published by researchers from the UK, the US
and Australia in the latest Journal
of Dental Research.
Even developed countries are
affected, with one in three people
in the UK suffering the consequences of neglected treatment,
along with one in five in the USA,
for example.

Hundreds of millions of new cases are expected to add to the burden annually. (Photo Greta Gabaglio)

The findings which are part of
latest Global Burden of Disease
study involved a systematic review of all data on untreated den-

tal decay, leading to a comprehensive report on rates of tooth
decay for all countries, age
groups and genders from 1990

and 2010. The team said to have
analysed 192 studies of 1.5 million children aged 1 to 14 years
old, across 74 countries, and

186 studies of 3.2 million people
aged five years or older, across
67 countries.
DT page 2

While the regulatory standards for design, performance
and manufacture of these devices
are appropriate and do not require revision, ADIA believes that
there is a need to consider revision of regulations governing the
information provided to patients.
It has thus called for a new regulation that will require companies
that offer custom-made medical
devices to provide a statement of
manufacture in the future. DT
AD

Thorough dental care helps
retain youthful looks
DTI

SHARNBROOK, UK/LEIDEN,
Netherlands: A new study on
lifestyle and appearance has
linked personal effort in oral hygiene to perception of facial age.
The findings suggest that people
with good dental routines and
overall oral health can appear up
to ten years younger.
A team of scientists at Unilever
and Leiden University in the
Netherlands evaluated various
lifestyle factors, such as smoking,
sun-bathing and oral care, in relation to perceived facial age. The
results showed that, along with
other factors, thorough oral care,
including flossing and regular
brushing routines, can have longterm effects on the preservation of
a youthful look.
In order to determine perceived facial age, the researchers

photographed about 800 people
with their mouths closed. The
portraits were then shown to
60 assessors, who estimated the
age of each individual within a
range of 5 years. The average
perceived age of each person was
then compared with the lifestyle
factors collected via questionnaires. The study group included
smokers and non-smokers from
the Netherlands and England
aged 45 to 75.
The researchers found that
Dutch women with few remaining teeth were associated with
a total perceived facial age of
10.9 years higher than their actual
age. In comparison, Dutch men
with dentures who did not floss
were significantly associated with
a total perceived facial age of
9.3 years higher. Similar findings
were made in the British group, as
English women who cleaned their
teeth only once a day and wore

dentures had a total perceived
facial age of 9.1 years higher than
women with natural teeth and a
comprehensive oral routine.
“The number of teeth and the
condition of the surrounding
gums are known to directly influence the appearance of overlying
tissues. For example, people
look younger with their mouths
closed after receiving new dentures, and the number of teeth or
the use of dentures has been
linked to lip size and the appearance of the labio-mental fold,”
stated Dr David Gunn, a senior
scientist at Unilever.
The authors stressed that
oral care aspects could possibly
have been proxies of other
lifestyle factors, such as diet.
However, dental aspects were
significantly associated with perceived facial age in the groups
studied. DT

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DENTAL TRIBUNE Asia Pacific Edition No. 3/2015

Asia News

Oceania to implement
the Minamata Convention
DT Asia Pacific

DT page 1

“We have seen a clear shift in
the burden of tooth decay from
children to adults. The current
perception that low levels of
decay in childhood will continue
throughout life seems incorrect,” said lead author Prof. Wagner Marcenes from the Queen
Mary University in London. “It is
alarming to see prevention and
treatment of tooth decay has
been neglected at this level because if left untreated it can
cause severe pain, mouth infection and it can negatively impact
children’s growth.”

ing oral health promotion activities to the work environment
is necessary to maintain good
oral health to reduce the major
biological, social and financial
burden on individuals and
healthcare systems.”

Marcenes explained that the
study underscores the vital need
to develop effective oral health
promotion strategies.
“The fact that a preventable
oral disease like tooth decay is
the most prevalent of all diseases
and injuries examined in our
report is quite disturbing and
should serve as a wake-up call to
policymakers to increase their
focus on the importance of dental
health,” he continued. “Extend-

Prof. Wagner Marcenes

Tooth decay is the fourth
most expensive chronic disease
to treat, and if left untreated, can
lead to poor productivity at work
and absenteeism in adults and
poor school attendance and performance in children, studies
have shown. DT

APIA, Samoa: The first subregional meeting on the Minamata
Convention on Mercury in the
Oceania region was held in
Samoa’s capital, Apia, from 19 to
21 January. The workshop aimed
to support Pacific islands in the
early ratification of the convention and implementation of
measures to protect human
health and the environment from
the adverse effects of mercury.
The meeting was attended
by representatives of the Cook
Islands, Federated States of Micronesia, Kiribati, the Marshall
Islands, Nauru, Palau, Papua
New Guinea, Samoa, Tonga and
Vanuatu. Over the course of three
days, participants were introduced to the various articles of
the convention and learnt about
the actions that countries are required to take in implementing it
at a national level. Samoa’s Prime
Minister Tuilaepa Lupesoliai
Sailele Malielegaoi called upon
United Nations Environment
Programme, the Secretariat of
the Pacific Regional Environment Programme and other UN
agencies to assist Pacific island
countries in this effort.
Malielegaoi’s country was
among the 87 countries that first
signed the treaty in October
2013. At a regional conference
held last year, it recognised that
the sound management of waste
and chemicals is crucial for
the protection of human health
and the environment. However,

icant source of mercury released
into the environment.

there are limitations of adequate institutional and border
controls for managing mercury
and other hazardous wastes, as
well as a significant lack of data
regarding levels of mercury,
particularly in Pacific fish,
Malielegaoi said.

Since the signing of the treaty,
workshops have been organised
in different parts of the world
in support of the ratification and
early implementation of the Minamata Convention on Mercury.
According to the United Nations
Environment Programme, the
aim of workshops is to improve
understanding of the convention, as well as familiarise parties
with the process of signing, ratification and implementation.

The Minamata Convention
on Mercury was signed in October 2013. In adopting the treaty,
governments agreed on the development and implementation
of national strategies to reduce
or eliminate the production and
industrial use of the harmful
substance. The treaty has implications for the dental industry,
among others, as dental amalgam contains about 50 per cent
mercury. It is considered a signif-

Informing participants about
available sources of support and
creating opportunities for exchange and action in the subregions
are also part of the process. DT

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Group Editor/Managing
Editor DT Asia Pacific

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Tel.: +49 341 48474-107

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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

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Published by Dental Tribune Asia Pacific Ltd.
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responsibility for the validity of product claims, or for typographical errors. The publishers also do not assume responsibility
for product names or claims, or statements made by advertisers.
Opinions expressed by authors are their own and may not reflect
those of Dental Tribune International.

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DENTAL TRIBUNE Asia Pacific Edition No. 3/2015

World News

WAUPS extends invitation to Korea congress
on ultrasonic piezoelectric surgery
DTI

DAEGU, South Korea: The
World Academy of Ultrasonic
Piezoelectric Bone Surgery
(WAUPS) is inviting dental professionals interested in the field
to attend its next congress, which
is to be held in Busan in South
Korea from 1 to 3 May. It will be
the largest event ever hosted by
the organisation. The meetings
on Jeju Island and in Gyeongju
in South Korea and in Tokyo in
Japan all saw an overall attendance of 700 each.

and foster friendships. He said
that early bird registration ends
on 31 March.
To be held at the Haeundae
Grand Hotel in Busan, the event
will feature distinguished speakers of international repute from
Korea and overseas. Among oth-

ers, the organisation has invited
Prof. Dong-Seok Sohn, Chairman of the Department of Oral
and Maxillofacial Surgery at the
Catholic University of Daegu, to
present as part of the scientific
programme. Drs Cleopatra Nacopoulos (Greece), Domenico
Baldi, Enzo Rossi and Ezio Gheno

(all from Italy), as well as Dr Eric
Park (USA), are also going to attend as international speakers.
The programme will be complemented by a number of precongress courses and workshops. In addition, WAUPS will
hold one of the largest dental

trade exhibitions in the field, presenting innovative products and
offering discounts to registered
participants.
The first international academy specialising in ultrasonic
piezoelectric surgery, WAUPS
was established in 2012. DT
AD

Congress Chairman Jung-Uk
Heo has encouraged professionals to attend the congress, as it
will be a great opportunity to
exchange scientific information

LIFELIKE ESTHETICS –
EFFICIENTLY PRESSED

Women
chew
differently
DT Asia Pacific

JECHEON, Korea: In a comparison of bite size, grams of food
ingested per minute, chewing
power and total meal duration,
among other factors, researchers
from Korea have found substantial differences between the
sexes for each parameter. While
men took larger bites and ate
faster, women chewed at the
same pace as men did but gave
more chews per mouthful, thus
increasing their meal duration
significantly.
The study included 24 men
and 24 women. Using electrodes
attached to the skin overlying
the muscles of mastication, the
researchers measured bite size,
chewing power, chews per gram,
the total number of chews, and
other factors while the participants chewed a portion of 152 g
of boiled rice.
The analysis found that bite
size and chewing power were
significantly higher in the male
than in the female participants.
Eating rate was also significantly
faster in men than in women.
Chews per gram were significantly higher in females than in
males; however, chewing speed
did not differ between the sexes.
Therefore, meal duration was
significantly longer for women
than for men.
“The results of this study
clearly showed that females take
smaller bites and chew thoroughly with a weaker chewing
power than males, while they
consume the same amount of
staple food,” the researchers
concluded. DT

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Opinion

DENTAL TRIBUNE Asia Pacific Edition No. 3/2015

Dear
Reader

Platform

4

Dr Sushil Koirala
Nepal

At the end of 2014, the Asian
Academy of Aesthetic Dentistry
(AAAD), which is the pioneer aesthetic dental organisation in Asia,
held its 13th biennial meeting and
scientific conference in Foshan
in China jointly with the Foshan
Academy of Esthetic Dentistry.
At the conference, Chinese clinicians learnt about the growing
global trends and participants
from other countries learnt about
the rapid development of China in
the field of aesthetic dentistry.

Daniel Zimmermann
DTI

By the time you read these
words, I will again be at the International Dental Show, which is
taking place from 10 to 14 March in
Cologne in Germany.
A regular participant since
2005, I have watched the event
grow into one of the largest dental
industry showcases in the world,
packed with all the latest tools and
gadgets to make a dentist’s heart
rejoice. It is an irony that at the same
time a new report has estimated
that over two billion people around
the world are suffering from untreated dental diseases, and it is
predicted that the numbers will not
improve significantly any time soon.
When one considers this in
light of all the fancy technology for
advanced treatment nowadays,
it is clear that research and development should be directed into
pursuing preventive treatments
and products and that it is essential
to invest in prevention. DT
Yours sincerely,
Daniel Zimmermann
Group Editor
Dental Tribune International

Dental Tribune welcomes comments,
suggestions and complaints at
newsroom@dental-tribune.com.
For quick access to
our contact form,
you may also scan the
following QR code.

The right number of dentists?
A letter from Dr Rick Olive, Federal President of the Australian Dental Association, and
Len Crocombe, Chairman of the association’s Dental Workforce and Education Committee
The article “Dental migration:
A forgotten perspective” (Dental
Tribune Asia Pacific, 11/2014, page 10)
gives an interesting account from
the migrating dentist’s point of view.
It discusses how to streamline dentist migration policy, but misses the
main issue that the aim of immigration policy in countries such as
Australia is to help ensure that Australia has the right numbers and mix
of dental practitioners to address
the oral health needs and requirements of its citizens. It should be
asked whether it is appropriate that
countries such as Australia, which
can afford to train its own dental
practitioners, be importing dental
practitioners, many of whom come
from developing countries with
greater oral health needs and lower
dental practitioner numbers.
A recent report from Health
Workforce Australia that addressed
the central question of “what is the
right number in the oral health
workforce and the right mix in
the oral workforce to best meet

changing policy and demographic
requirements to 2025?” found that
there are too many dentists, dental
hygienists, dental therapists and
oral health therapists entering the
workforce in Australia to meet current and projected demand.

To quote from the report:
“Seven alternative planning projection workforce scenarios were
developed, examining changes in
demand, immigration, the number
of graduates, productivity, an existing workforce supply in excess of
demand, an existing workforce
supply in excess of demand, and existing workforce demand in excess
of supply. All scenarios presented
the same result—that across the
projection period the supply of the
oral dental workforce is projected
to exceed the demand.”
The worsening oversupply in
the dental workforce is due to
a number of factors: growth in
the number of students graduating from Australian universities,

changes to international student
visa conditions that allow students
to remain and work in Australia,
a significant increase in the number of dentists entering Australia
through temporary and permanent
migration pathways, ease of migration through the Trans-Tasman
Mutual Recognition Agreement,
and an increase in training numbers
of allied dental practitioners.
Australian graduates and migrating dentists are now finding
meaningful employment difficult to
achieve. Several state governments
have removed dentists from their
Skilled Occupation List. For these
reasons, the Australian Dental Association is seeking the removal of
the occupations of dentist and
dental specialist from the Skilled
Occupation List from the Commonwealth and remaining state governments and advises many dentists
considering migrating to Australia
to realistically assess their prospects of employment before they
move to Australia. DT

An international programme
of this magnitude always helps
to promote professional collaboration, friendship and opportunities to share knowledge and
skills among clinicians and academics in the region. With the
rapid development of information and communication technology, AAAD is now planning to
launch an e-learning platform
to provide the most cost-effective
aesthetic dentistry educational
opportunities to young dental
professionals in Asia. This will
be developed with the active participation of member countries’
key clinicians and through joint
collaboration with various likeminded professional academies,
dental schools and dental experts,
as well as dental companies
around the world. DT

Contact Info
Dr Sushil Koirala is President
of the Asian Academy of Aesthetic Dentistry and a regular
contributor to Dental Tribune.
Dr Koirala can be contacted at
drsushilkoirala@gmail.com.

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6

DENTAL TRIBUNE Asia Pacific Edition No. 3/2015

World News

Implant survival
as good in diabetics as
in healthy patients
DTI

SAN ANTONIO, USA: Diabetic
patients with poor glycaemic
AD

FDI 2015BANGKOK
Annual World Dental Congress
22 - 25 September 2015 - Bangkok Thailand

Deadline for early bird registration
15 June 2015

control may be rejected as candidates for dental implants because the condition has long
been associated with adverse

effects, such as slow healing
and high infection risk. A new
study, however, has shown that
even patients with poorly controlled diabetes have a high
success rate with implants after
one year.
In order to evaluate the effects of glycaemic levels on
implant-related outcomes, researchers at the University of
Texas Health Science Center at
San Antonio studied the data
of 110 edentulous patients who
received mandibular implantsupported overdentures.
The participants were divided into three groups: patients
without diabetes, patients with
controlled diabetes and patients with poorly controlled
diabetes.
After a follow-up period of
one year, the researchers found
no significant differences between the study groups. Diabetic and non-diabetic patients
had a nearly 100 per cent implant survival rate.
Participants with poorly
controlled diabetes only required a longer period for the
implant to heal before placing
the dentures, explained Dr
Thomas Oates, the interim Associate Dean for Research and
Assistant Dean for Clinical
Research at the university. He
is also a professor and vice
chairperson in the Department
of Periodontics.
Overall, only two implants
failed during the study period
but were later replaced with
new implants. These implants
healed and did not fail over the
course of one year.
The findings of the study indicate that the effects of hyperglycemia on implant therapy
remain uncertain. In addition,
they suggest that patients with
compromised glycemic control
may gain important benefits
from implant therapy with respect to dietary management of
their diabetic condition.
However, more investigation is needed before drawing
major conclusions, Oates stated.

www.fdi2015bangkok.org
www.fdiworldental.org

Diabetes is one of the most
common systemic conditions
in the US. According to the
Centers for Disease Control
and Prevention, the number of
Americans with diagnosed diabetes more than tripled from
5.6 million in 1980 to 20.9 million in 2011.
It is estimated that more
than 90 per cent of patients with
diabetes in the US have Type 2
diabetes. DT

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DENTAL TRIBUNE Asia Pacific Edition No. 3/2015

Business

“It is our mission to simplify
dental implantology”
DTI visits the MIS headquarters and main production facility in Israel
In addition to the new MCENTER
Europe, the company will be entering the premium segment for dental implants with the launch of a
new implant system later this year.
It has a truly innovative design and
consists of high-quality implants
that are completely new in the market and will fit within the premium
segment. MIS plans to offer this
new implant system to its global
distributors at the end the second
quarter of 2015, for local distribution worldwide.

DTI

MIS Implants Technologies is
a global specialist in the development and production of
advanced dental implantology
products and solutions. The
company, which started as a family-run business, was founded
in 1995—a time when not many
people understood the potential
of dental implants, CEO Idan
Kleifeld told Dental Tribune
International (DTI) at a meeting
at the beginning of 2015.
Since its beginnings, MIS has
seen significant growth, especially
within the past ten years. “Today,
the company has succeeded in
building a recognised global brand
in the market and is the only nonpremium company operating on a
global scale,” Kleifeld said. Headquartered in Israel, MIS currently
has operations in 65 countries
worldwide, covering major dental
markets, such as the US, China and
Germany, through a well-established network of local distributors.
In 2009, MIS moved operations
to a large purpose-built production
complex located in a new high-tech
industrial park in northern Israel.
“Our location adds to our uniqueness. Israel is a country of high
innovation and offers particularly
favourable conditions for manufacturing, because of the quality
of education and people’s high
levels of motivation. Furthermore,

The name MIS originally stood
for “Medical Implant Systems”.
However, it is also an acronym
that reflects the company’s main
maxim to “Make it Simple”. “It is

MIS headquarters (Photos courtesy of MIS, Israel)

DTI further learnt that MIS
primarily produces for stock, as
products must be shipped to local
distributors within two working
days. For increased efficiency,
processes controlling quality, sterilisation, packaging and storage
are largely automated. This allows
MIS to produce over 800,000 implants per year.
The production site in Israel has
a dedicated training centre with
a fully equipped dental clinic for
live surgeries. Kleifeld said, “We
see education as an important tool
to acquire new customers, es-

dentistry hub in Berlin
in Germany, in order
to meet the needs of
its growing customer
base in central Europe. The centre offers
direct services provided by locals to local
customers, bringing
all MIS digital dentistry products together in one location.
It is aimed at providing a comprehensive
range of services to clinicians through advanced digital
dentistry and CAD/CAM technologies that facilitate fast and accurate
surgical implant procedures with
reduced chairside time and greater
predictability in outcomes.
“We are extremely excited
about the opening of the new

MCENTER Europe facility, and
especially proud to be able to offer
MIS quality and simplicity in providing our customers throughout
the region with highly accurate and
efficient guided implant placement
procedures and CAD/CAM solutions,” said Christian Hebbecker,
MCENTER Europe Manager.

our mission to simplify dental implantology and, in order to become
the preferred choice of dentists
worldwide, we offer new and innovative products based on simple,
creative solutions. Design and
handling are made simpler, and
all products are engineered to allow efficient, time-saving surgical

“We are set to become the largest
global dental implant producer.”
Production.—Right: MIS Implants Technologies CEO Idan Kleifeld.

salaries are much lower than
in competitor countries, making
manufacturing especially profitable,” he stated.
The MIS building in the Bar-Lev
Industrial Park spans about 10,000 m²
and has two production floors with
50 Swiss high-precision machines
running 24 hours a day from Sunday
to Friday. “The facility was designed
and built for growth. In the near
future, our automatic warehouse,
which currently covers only half of
its potential total area, will double in
size,” Kleifeld explained.

pecially in developing
markets. It is an important driver in this business, and we offer doctors both fundamental
and advanced training
courses on MIS products
and protocols.”
In 2015, MIS will be
introducing some important innovations.
Only recently, the company officially opened
its MCENTER Europe,
the new MIS digital

procedures,” Kleifeld said.
“With this simplified approach, we are set to become
the largest global dental implant producer,” he added.
However, the “Make It
Simple” motto appears to
apply to more than the company’s products. The MIS
philosophy defines almost all
areas of the business (from
human resources to production), and the organisational
structure is simple and characterised by flat hierarchies.
“Make it Simple” embodies
the start-up mentality that remains vibrant in a company
that has become one of the
largest in the global dental
implant market. DT

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DENTAL TRIBUNE Asia Pacific Edition No. 3/2015

10 Trends & Applications

Knowledge can save lives
Understanding and treating patients with eating disorders
Heart and major organs

General

• Cardiac arrhythmias, and cardiac arrest related
to electrolyte imbalance (especially low potassium),
dehydration, or starvation-induced atrophy
of the myocardium
• Slow pulse rate
• Low blood pressure
• Impaired capacity to think, due to starvation-related brain
changes
• Kidney damage
• Liver damage due to starvation or substance abuse14
• Hypothyroidism
• Infertility related to amenorrhoea

• Dehydration, malnutrition
• Fatigue
• Electrolyte imbalance
• Hypoglycaemia
• Anaemia
• Low white blood cell count, and impaired immunity
• Slow metabolism
• Osteoporosis
• Loss of muscle mass, causing stick-like limbs

Skin (especially with anorexia)
• Extremely dry, scaly, itchy skin with a grey cast15
• Decreased scalp hair, which is short and brittle
• Increased lanugo hair—fine hair on the body and arms (the
body’s attempt to retain heat after excessive loss of body fat)
• Bloodshot eyes and broken capillaries (petechiae) of the skin
around the eyes, related to forced vomiting

Digestive system

Extremities

• Abdominal pain
• Chronic constipation
• Poor muscle tone of the colon,
and incontinence related to misuse of laxatives
• Ruptured oesophagus, or Mallory–Weiss lesions
(gastro-oesophageal laceration syndrome), due to vomiting
• Gastric bleeding
• Stomach might rupture during bingeing
• Swollen parotid glands and sore throat related to purging

• Clubbed fingers16 related to cardiac complications
or overuse of laxatives
• Cold hands and feet related to peripheral vasoconstriction
• Russell’s sign: calluses, scars or abrasions on the knuckles
of the dominant hand, related to inserting the fingers
in the mouth to induce vomiting
• Carotenoderma, orange pigmentation of skin,
especially on the palms of the hands,
related to excessive intake of foods containing carotene

Table 1: Medical complications of eating disorders.12, 13

AD

Linda Douglas
Canada

PRINT
L
DIGITA N
TIO
EDUCA
EVENTS

According to the US National
Institute of Dental and Craniofacial Research, 28 per cent of
patients with bulimia are first
diagnosed at a dental appointment. Although dentists are in
an ideal position to detect the
warning signs of eating disorders, research has found that
knowledge of the oral and
physical signs of these conditions is often limited.1
Nevertheless, we have an
ethical obligation to increase
our knowledge and participate in
secondary prevention of eating
disorders, as it could improve
prognosis and even be a lifesaver
for some patients. Research has
shown that such disorders have
the highest mortality rate of all
psychiatric illnesses.2 We need
to initiate timely interventions,
to minimise damage to the oral
hard and soft tissue, and instigate
medical referral for access to
specialists in treating eating disorders.

An overview
of eating disorders

The DTI publishing group is composed of the world’s leading
dental trade publishers that reach more than 650,000 dentists
in more than 90 countries.

Eating disorders are psychiatric illnesses characterised by
disordered eating and disturbed
attitudes to eating and body image. They are often accompanied
by inappropriate, dangerous
methods of weight control. The
three most common eating disorders are bulimia nervosa
(binge–purge), anorexia nervosa
(starvation) and binge-eating
disorder (bingeing without purging).3 There are variations of disordered eating, including eating
disorders not otherwise specified.4 These include diabulimia,5
where individuals intentionally
take insufficient insulin in order
to lose weight; anorexia athletica, which is obsessive, excessive
exercising to the point of being

detrimental to health; and bigorexia, or muscle dysmorphia,
where the individual perceives
his or her body to be underdeveloped, despite having a large,
muscular physique. Orthorexia
nervosa is an obsession with
the quantity and quality of the
food consumed. The compulsive,
excessive intake of food during
the hours normally reserved for
sleep—often getting up multiple
times during the night to eat—
is called night eating syndrome.
Finally, there is pica, the persistent eating of non-food substances, and various food-related
phobias.
The UK has the highest rate
of eating disorders in Europe.
Recent figures suggest that 1 in
100 British women have a clinically diagnosed eating disorder.6
In the US, anorexia nervosa is the
third most common chronic illness among adolescents.7 Eating
disorders occur mostly in females aged 15–25, but also occur
in males, in children as young as
7 years of age, and in people aged
over 50.
As one of the most common
eating disorders, bulimia nervosa is characterised by a pattern of consumption of massive
amounts of food (binge eating)
and recurrent inappropriate
weight control behaviours. These
include purging through selfinduced vomiting, abuse of
laxatives and other substances,
as well as behaviours such as
fasting (not eating for at least
24 hours) or excessive exercise.
The weight of bulimic individuals
tends to fluctuate, but remains
within normal limits. About onethird of bulimics have a history of
anorexia nervosa, and some
have a history of obesity.
During bingeing, bulimic individuals usually consume between 1,500 and 3,000 calories

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DTAP0315_10-13_Douglas 12.03.15 15:15 Seite 2

DENTAL TRIBUNE Asia Pacific Edition No. 3/2015
within 1 or 2 hours, and have
been known to consume as much
as 60,000 calories in one bulimic
binge. They typically eat sweet,
high-calorie foods, which are
easy to consume quickly, like
ice cream. This is followed by
depression, panic and guilt, and
a compulsion to purge. These
episodes occur at least twice
weekly over a period of several
months. Some bulimic individuals even vomit five or six times
per day. Most bulimics who die
do so in the act of purging.

by insertion of objects to induce
vomiting. Signs of nutritional
deficiencies occur, such as angular cheilitis, candidiasis, glossitis, and oral mucosal ulceration.
Individuals with eating disorders
also experience a dry mouth related to dehydration or xerogenic
medications, such as antidepressants and anxiolytics.
Vomit has a pH of about 3.8.
During purging, the vomit hits
the palatal aspects of the maxil1

DT page 12

Figs. 1 & 2: Severe dental erosion related to bulimic purging. (Produced with permission from Dr S. Weinstein)

Anorexia nervosa is characterised by a refusal to eat enough
to maintain body weight within
15 per cent of the minimal normal weight for age and height
(the anorexic individual is often
20 per cent to 40 per cent below a
healthy body weight); they have
an extreme fear of gaining weight;
and a distorted body image, which
results in patients believing that
they are fat, even when they are
emaciated; and amenorrhoea
(absence of menstruation).
A significant number of
anorectic individuals also purge,
and some have pica; they may
consume cotton balls soaked in
orange juice, for example, to
control hunger. The main difference between bulimia nervosa
and purging anorexia is that
the individual with anorexia is
underweight.
Binge-eating disorder is characterised by frequent consumption of abnormally large amounts
of food in one sitting, while feeling a loss of control over eating.
Individuals with this disorder do
not purge afterwards, but feel
depressed and guilty after overeating. Most individuals with
binge-eating disorder are obese,
with the related increased risks
of diabetes, heart disease, certain
cancers, and arthritis.

HKIDEAS
Hong Kong International Dental
Expo And Symposium

7 – 9 AUGUST
Early-bird Registration:
Deadline: 15 May 2015

Prevention

The aetiology of eating disorders is multifactorial and not
completely understood. Contributing factors, however, include living in a culture where
thinness is generally admired.
There are indeed unrealistic
depictions of beauty and thinness
in most media. At about 6 feet
(1.82 m) tall and 117 pounds
(53.07 kg), today’s fashion model
weighs 23 per cent less than the
average woman. Some overachieving perfectionists who do not fit
this questionable ideal develop
eating disorders. They have not
only a low self-esteem, but also a
distorted perception of body shape,
as well as a poor body image.8

Oral findings
Traumatic lesions on the palate and oropharynx are caused

Hong Kong Convention and Exhibition Centre
1 Expo Drive, Wanchai, Hong Kong
Preluminary Faculty
Professor Bilal Al-Nawas (Germany)
Professor Mark Bartold (Australia)
Dr. John Lin (Taiwan)
Dr. Derek Mahony (Australia)
Professor Chooi-gait Toh (Malaysia)
Dr. Patrick Tseng (Singapore)

Call for Abstracts:
Deadline: 15 April 2015

Aetiology

The risk of a female developing anorexia nervosa increases
ten to 20 times if she has a sibling
with the disorder. Eating disorders often occur in individuals
who have suffered physical or
psychological trauma,9 and are
frequently accompanied by other
psychiatric illnesses,10 such as
depression, anxiety,11 self-harm
(such as cutting), obsessive–
compulsive disorder, and chemical dependency.

Trends & Applications 11

Quality of Life

Evidence-based

Aesthetics

Longevity

Healthy Aging

Organizer

www.hkideas.org

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12 Trends & Applications

DENTAL TRIBUNE Asia Pacific Edition No. 3/2015
• Depression, anxiety
• Perfectionist, overachiever
• Low self-esteem
• Mood swings
• Guilt, shame
• Alienation, loneliness

• Obsessive thoughts about food, calories and weight
often weighing themselves several times per day.
• Secrecy and denial of their illness:
individuals with anorexia nervosa often dress
to hide their body shape, and they might put coins
in their pockets when being weighed.
• They often claim to have food allergies
in order to justify their restrictive diet.

• Social isolation
• Eating alone
• Compulsive behaviours
• Misperception of hunger and satiation

Table 2: Psychological aspects of
eating disorders.17

DT page 11

HIGH
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&217(17

lary anterior teeth. Dental erosion due to purging by vomiting
becomes apparent about six
months after onset.18 It eventually undermines the palatal
surfaces and leads to incisal
fractures and chipping, and overeruption of the mandibular anterior teeth. Erosion also occurs
in the posterior teeth, causing
perimolysis: tooth tissue surrounding restorations is eroded,
leaving the restorations with
a raised, island-like appearance.
Eroded occlusal contacts also
lead to loss of vertical dimension.

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Bulimics tend to consume
foods high in refined carbohydrates, and individuals with
eating disorders often consume
acidic diet beverages. Therefore,
they have a high caries risk and
impaired salivary buffering capacity. Dental hypersensitivity is
also common. The loss of bone
density increases the risk of jaw
fracture during extractions.

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Sri Lanka - Yu & Co - Tel: + 94 11 269 1740
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Dental management
of patients with
eating disorders19,20
Medical treatment21 of eating
disorders includes nutritional
therapy to treat the medical
complications and the starvation-related brain changes that
perpetuate the illness. This is
combined with psychotherapy
and medication, such as antidepressants. Individuals with eating disorders also need regular
dental visits in a supportive environment, for continuing care.
They must be regarded as medically compromised, owing to the
risk of grave medical complications, particularly cardiac arrest
due to electrolyte imbalance.
Thorough clinical assessment includes general appraisal, which begins the moment we greet our patient. We
should tactfully observe his or
her general demeanour, gait,
and facial symmetry. The skin
should also be observed for lesions and pallor, and the hands
for Russell’s sign or clubbed fingers. A comprehensive medical
history is needed, as well as
monitoring of the vital signs.
Extra-oral and intra-oral examination, as well as examination
of the oral hard and soft tissue,
is needed, plus comprehensive
documentation that includes detailed clinical notes, periodontal
charts, radiographs, intra-oral
photographs and study models
to monitor damage.

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DENTAL TRIBUNE Asia Pacific Edition No. 3/2015

Trends & Applications 13
with water reduces the protective properties of the saliva.
Instead, the oral pH should be
neutralised by rinsing with one
teaspoon of sodium bicarbonate
in 250 ml water, or with a product containing calcium and
phosphate ions. For additional
support, we can share information on resources for those
who struggle with eating disorders.23 With increased knowledge and vigilance, dental care
professionals can enhance detection of warning signs of
eating disorders, for improved

The SCOFF questions*
• Do you make yourself Sick because you feel uncomfortably full?
• Do you worry you have lost Control over how much you eat?
• Have you recently lost more than One stone (6.35 kg) in a three-month period?
• Do you believe yourself to be Fat when others say you are too thin?
• Would you say that Food dominates your life?
* One point for every “yes”; a score of ≥ 2 indicates a likely case of anorexia nervosa or bulimia.

patient care and favourable
outcomes. DT
Editorial note: A complete list of references is available from the publisher.

Contact Info
Linda Douglas
is a British dental hygienist currently residing
in Onta rio in
Canada. She can
be contacted at
lindadouglas@sympatico.ca.

Table 3: The SCOFF questionnaire
utilises an acronym in a simple fivequestion test devised for use by nonprofessionals to assess the possible
presence of an eating disorder.24

When an eating disorder is
suspected, this sensitive topic
needs to be approached in a nonjudgemental, non-threatening
manner. It is beyond our scope
of practice to diagnose eating
disorders, but we can present
the findings of our examination
to the patient.22 For example, if
there is dental erosion, we could
mention some possible causes,
like acidic drinks, acid reflux or
frequent vomiting. This gives
the patient an opportunity for
disclosure. If he or she discloses
his or her eating disorder to us,
he or she should be referred to
his or her physician. If he or she
is not ready to tell us, we can still
be supportive and initiate a prevention protocol based on our
clinical findings.
Definitive dental restorations cannot be completed while
a patient is purging regularly,
as acid erosion will compromise
the restorations. Only essential
restorative work should be
done, to limit tooth damage and
keep the patient free of pain.
Pending the patient’s recovery
from his or her eating disorder,
the dental hygienist can provide
interventions to limit damage to
the oral hard and soft tissue, and
relieve xerostomia and dental
hypersensitivity. During dental
hygiene appointments, such patients should be polished with
a non-abrasive fluoride paste.
A protocol to reduce caries risk
should include in-office fluoride varnish applications, plus
self-applied neutral fluoride,
and calcium and phosphate
products, such as NovaMin,
Recaldent and nano-hydroxyapatite, to remineralise and desensitise.
Xylitol-containing products,
such as toothpastes, gum and
candies, are also beneficial.
When used for 5 minutes, five
times per day, they stimulate
salivary flow, reduce the oral
population of cariogenic bacteria, and reduce oral acidity. Patients should brush three times
per day with a soft brush and
a toothpaste containing 5,000
ppm fluoride. They should clean
the interproximal embrasures
daily and clean their tongue too,
to remove biofilm and acid
residue.
A mouth guard can be used
to protect the dentition during
vomiting. Brushing directly after vomiting causes more loss
of tooth structure, and rinsing

The 36th Australian Dental Congress
Brisbane Convention and Exhibition Centre - an AEG 1EARTH venue
Wednesday 25th to Sunday 29th March 2015

Invitation from the Congress Chairman
On behalf of the Local Organising Committee of the 36th Australian Dental Congress,
it is with great pleasure that I invite you to attend Congress and enjoy the river city of Brisbane.
Over three and a half days, highly acclaimed International and Australian speakers supported by contemporary
research, will present a wide range of subjects relevant to practice. These presentations will be complimented
by hands on workshops, Lunch and Learn sessions, speciﬁc programmes for members of the dental team.
Social activities will be available for relaxation purposes.
The Brisbane Convention and Exhibition Centre is adjacent to the Southbank Precinct on the banks of
the Brisbane River. Nearby is the Queensland Performing Arts Complex, the Queensland Museum and
the Queensland Art Gallery and Gallery of Modern Art. A comprehensive industry exhibition will be
held alongside the Congress enabling delegates access between scientiﬁc sessions to view
the latest in equipment and materials.
Come and join us for the scientiﬁc programme, the opportunity to meet
colleagues and the experience Brisbane has to offer.

Titanium sponsor:

Dr David H Thomson

Congress Chairman
36th Australian Dental Congress

Educating for Dental Excellence
facebook.com/adacongress twitter.com/adacongress youtube.com/adacongress adc2015.com

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14 Trends & Applications

DENTAL TRIBUNE Asia Pacific Edition No. 3/2015

Make good use of what you have
Fabrication of ultrathin veneers for invisible, non-invasive restorative dental treatment

Fig. 1: Portrait photograph of the patient before the treatment.—Fig. 2: Pre-op situation: the close-up view shows the aesthetic shortcomings of the teeth.—Fig. 3: Dentition after the careful removal of the old composite
restorations.—Figs. 4 & 5: The wax-up was crafted with an opaque wax.—Fig. 6: Trial run with the mock-up after surgical crown lengthening.—Fig. 7: Working model for the fabrication of the veneers on teeth #15–25.
Dr Necib Sen & CDT Hilal Kuday
Turkey

A systematic approach is essential
when the aim is to achieve the
best possible aesthetic results in
tight situations. Apart from the
tooth morphology, the parameters of brightness, opacity and
translucency have to be taken into
account.
A radiant smile suggests a positive attitude and plays an important
role in human interaction. When a
person’s smile is changed, this influences the way in which the person is perceived by others. In order
to change a patient’s smile in a way
that will be attractive and effective,

a wax-up and/or mock-up should
be used to determine the treatment
goal at the outset. This approach
also allows as much tooth structure
as possible to be preserved. Once a
favourable basis has been established, the permanent restoration
can be created, without any significant preparation in some cases.
A wax-up is an indispensible aid
in diagnosing and analysing the
individual restorative needs of the
patient, since it reflects the actual
conditions. Furthermore, the cementation protocol must be established at the beginning of the treatment, so that the wax-up can be used
to anticipate and avoid any possible
problems.

In the following case, a young
actress wished to have the composite
restorations on teeth #11 and 21 replaced with a long-lasting aesthetic
solution. In addition, the patient was
dissatisfied with the dark appearance
of her central incisors (Figs. 1 & 2).
The aim of the treatment was to apply non-invasive principles and use
only very little restorative material
to achieve an outstanding result.
First, the teeth were internally
whitened. Next, the old composite
restorations were carefully removed with the help of finishing
discs. The tooth surfaces remained
virtually untouched in the process
(Fig. 3). A special modelling wax
was used to create the wax-up, since

the space requirements were very
restricted. Owing to conventional
waxes demonstrating very low opacity, we decided to use the highly
opaque material Cx5 (ABI), which is
also used for sculpturing purposes.
This material exactly suited our
needs (Figs. 4 & 5). The shape, morphology and microtexture of the
final restoration were crafted in wax
and then submitted to the attending
dentist.
The wax try-in was checked in
the dental office and a few minor
modifications were made. We decided to give the patient a full
smile design treatment that would
involve teeth #15–25. For this purpose, the crowns were surgically

lengthened according to a state-ofthe-art protocol. After the healing
phase, an impression was taken
without the soft tissue having to be
retracted (Fig. 6).
In the next step, the waxed-up
veneers were converted into ceramic using a hot-pressing process
(IPS e.max Press, Ivoclar Vivadent).
For this purpose, the restoration
margins were carefully marked
with a red pen on the study model
(Fig. 7). The markings were made
on the labial surface approximately
0.3 mm from the gingival margin.
For the fabrication of the veneers,
we looked for a material that would
offer the highest possible level of
brightness (value). Furthermore,

Figs. 8–10: An examination that we undertook in our laboratory showed the effect that the existing dental enamel had on the brightness of the restorations. Dental enamel exhibits various levels of translucency.
Nevertheless, it can also effectively mask the duller appearance of dentine. As a result, we found that we could regulate the brightness value with only minimal enamel reduction.—Fig. 11: In order to make space
for the application of individual characteristics, the pressed veneers had to be cut back selectively.—Figs. 12 & 13: The marks made on the contact surfaces of the restorations were visible on the labial side and
could be removed accordingly.—Figs. 14 & 15: The ultrathin veneers were prepared for characterisation.—Fig. 16: The veneers were characterised with a very small amount of
DT page 16
layering ceramic.—Fig. 17: Try-in of the completed restorations.—Fig. 18: The restorations were placed with adhesive cement and then the margins were carefully finished.

[15] => Standard_300dpi

[16] => Standard_300dpi

16 Trends & Applications

DENTAL TRIBUNE Asia Pacific Edition No. 3/2015

DT page 14

Figs. 19 & 20: The cemented restorations in the patient’s mouth. The transition between the tooth and the ceramic is invisible.—Fig. 21: Post-op photograph of the patient.

the material would have to be able
to simulate the translucent properties of natural tooth structure.
AD

The IPS e.max Press Value ingots
exhibited the luminosity required
in this case, and they would allow

the desired translucent properties
to be achieved in the incisal areas
(Figs. 8–10). As mentioned, the

waxed-up restorations were reproduced in ceramic (Value 2 ingot)
using the familiar press technique.

The pressed veneers were approximately 0.3 mm thick. Consequently,
they were somewhat bulky in the
marginal area in particular. As a result, these areas would have to be
adjusted with silicon carbide burs
after the restorations were placed.
The plan was to characterise the
veneers with a layering ceramic.
Therefore, they had to be cut back
slightly. The ultrathin veneers were
ground with utmost precision, since
subsequent remeasuring is not recommended and can lead to flawed
results. We cut back the restorations
according to the markings we had
made (Fig. 11). These horizontal
and vertical lines had been drawn
on the contact surfaces of the restorations. Owing to the high translucency of the ceramic, these lines
were visible on the labial surfaces
and served as a guide for the removal of the restorative material
(Figs. 12 & 13). The finished cutback areas showed that very little
space was available for the characterisations (Figs. 14 & 15).
Only the incisal and central
areas were individualised as a result
(Figs. 16 & 17). The veneers were
finished and then sent to the dental
practice for placement. Since the
restorations were ultrathin, final
polishing would be done in the patient’s mouth.
The restorations were permanently seated using products in the
Variolink Veneer Cementation Kit
(Ivoclar Vivadent), which were used
according to the instructions of
the manufacturer. The restorations
were seated and the transitions to
the dental hard tissue were carefully
finished with silicon carbide burs
to attain the desired surface gloss
(Fig. 18). The veneers looked very
natural in the mouth. The ceramic
restorations were indiscernible from
the tooth structure (Figs. 19–21).

Conclusion
Non-invasive veneers offer many advantages, including maximum
preservation of the tooth structure.
In this case, we were able to satisfy
yet another patient with an aesthetic
restoration without having to remove any healthy tooth structure. DT

Author Info
Dr Necib Sen is
a dentist at Advanced Dental
Clinic in Istanbul in Turkey.

Author Info
Hilal Kuday is
a certified dental technician at
Hilalseramik in
Istanbul.

[17] => Standard_300dpi

ENDO TRIBUNE
The World’s Endodontic Newspaper · Asia Pacific Edition

PUBLISHED IN HONG KONG

www.dental-tribune.asia

Endo Congress
Dr Ibrahim Abu Tahun
about APEC 2015
Page

NO. 3 VOL. 13

Endo Products
What leading providers
have to offer

20

Page

Endo Business
An interview with
MICRO-MEGA reps

21

Page

22

The significance of radiographs
in endodontic therapy

Dr Safura Baharin
Malaysia

The success of any endodontic
therapy depends on adequate

Types
Intraoral

Extraoral

chemical and mechanical debridement of the infected root
canal. This requires basic
knowledge of the canal anatomy and the ability to identify

Advantages

Disadvantages

Conventional
periapical

• Cheap
• Widely used
• Low radiation dose
• Available
in most dental clinics
• Reduced chairside time owing to mobile use

• Sensitive technique
• Superimposition of
anatomical structures
• 2-D image
• Requires good
operator skills
• Requires high patient
tolerance
• No image modification

Digital
periapical

• Allows image
enhancement/modification
(contrast, brightness,
texture, size)
• Low radiation dose
• Immediate image display
(no image processing)
• Use of a mobile machine
is possible; therefore,
the patient does not have
to move around
for the radiograph
• Eliminates a film
processing procedure;
thus, processing error
can be avoided

• Small image area
(difficult to capture area
of interest accurately)
• Possible image
enlargement
• Difficult initial learning
process concerning
the manipulation
of the digital software

Dental
panoramic
tomogram

• Complete view of the entire
dentition

• 2-D image
• Requires larger office
space for the machine
• Image may not be clear
enough in certain
areas, particularly
in the anterior

CBCT

• 3-D image
• Image enhancement
• Image can
be modified
• Thorough assessment
of tooth

• High radiation dose
• Expensive
• Not readily available
• Requires skill to
interpret the image
• Requires larger office
space for the machine

Table 2: Types of radiographs and their advantages and disadvantages.

Factors

Rationale

• Angulation of the central beam

• Affects the position and size of the object

• Exposure time

• Affects the diagnostic quality of the radiograph

• Receptor sensitivity

• Affects the diagnostic quality of the radiograph

• Processing procedure

• Affects the diagnostic quality of the radiograph

• Viewing conditions

• Important for identifying normal anatomical
structures and presence of pathology

• Clinical experience of the observer

• An observer with more experience analysing
radiographs may be able to detect the presence
of pathology better.

• Superimposition of anatomic structures

• Affects the diagnostic quality of the radiograph

• Position of the tooth in the jaw

• Superimposition of anatomical structures, density of
surrounding bone, single- vs. multiple-rooted teeth

• Location of the lesion

• May be superimposed with anatomical structures, such
as the mental foramen, maxillary sinus or nasal sinus

any aberration in it. Studies
have shown that micro-organisms in the root canal system
reside in the main canal, the
canal’s ramification, the accessory or lateral root canal,
and even the dentinal tubules.
Therefore, optimal debridement can only be achieved if the
clinician is able to identify the
presence of additional canals
prior to or during treatment
(Table 1).
Currently, the only method
available to assess the root, the
root canal anatomy and its periradicular area preoperatively
is through dental radiographs.
Whether radiographs are performed intra-orally (periapical)
or extra-orally (dental panoramic
tomogram or cone beam computed tomography, CBCT), fractures,
resorptive defects or procedural
errors can also be identified this
way. Thorough examination of
radiographs is important, as it
can provide an indication of the
complexity of the treatment, including anticipated difficulties
(Table 2).
The use of CBCT has been
widely explored and its advantages are well documented.1, 2
While its benefits for diagnosis in
endodontic treatment cannot be
 ET page 18

Table 1: Factors and rationales when using a 2-D radiograph for diagnostic purposes.8
AD

The 10th World Endodontic Congress

IFEA

International Federation of Endodontic Associations

Endodontic Excellence at the Apex of Africa

2016
Cape Town, South Africa

[18] => Standard_300dpi

ENDO TRIBUNE Asia Pacific Edition No. 3/2015

18 Trends & Applications

Fig. 1: Presence of birooted mandibular premolar.—Fig. 2: Separated instrument in lower incisor.—Fig. 3: Inadequate root canal filling on lower left molar.—Fig. 4: Measuring the depth of pulp chamber
during cavity access preparation.
ET page 17

disputed, the American Association of Endodontists and the
American Academy of Oral and
Maxillofacial Radiology jointly
published a statement in 2011 in
which they stated that limited
volume should be preferred over
large volume and that this imaging technique should not be used
routinely for endodontic diagnosis or for screening purposes.
Furthermore, the clinician must
justify that the use of CBCT will be
of benefit to the patient and that
its use outweighs the potential
risks.3

Intra-oral radiographs, such
as conventional and digital periapical radiographs, are still routinely used as one of the important investigative tools during
endodontic examination and the
diagnosis stage. Even though it
has a few limitations, an appropriately taken and processed periapical radiograph can still provide enough information and
evidence to aid in diagnosis. An
acceptable periapical radiograph
must have adequate contrast and
no or minimal processing error
and include at least 3 mm of the
surrounding periapical area to
allow accurate assessment of the

tooth of interest and its surrounding area. Additional periapical
radiographs at different angulations (10–30 degrees horizontally
or vertically) could be taken to
determine the location of a periradicular lesion or any resorptive
defect present on the root and its
surface (internal or external).4–6
An earlier study has shown that
accuracy in detecting the presence of twin canals increased
using a periapical radiograph with
a horizontal shift.4 Another concluded that the detection of periapical lesions was more accurate
with an angulated radiograph.6
However, the degree of angula-

tion should not be excessive, as it
would result in overlapping of the
image or changes in the image
size, thus reducing the diagnostic
quality of such a radiograph.7
Periapical radiographs taken
at different angulations may be
necessary in order to determine
the number of root and root canals
of a tooth, especially in premolars
and molars. Several studies have
shown that radiographs taken at a
horizontal angle of 30 degrees improves the ability to determine the
canal type in premolar teeth.9, 6, 4
Periapical radiographs can be
taken either by using the paralleling or bisecting angle technique.

Dental radiographs are needed
for the assessment of the crown,
pulp chamber, root(s) and periradicular area of a particular tooth
(Table 3). Clinicians should make
it a routine to assess the entire
radiograph thoroughly (i.e. the adjacent teeth and its surrounding
tissue) before focusing on the tooth
of interest. It is essential to ensure
that the radiograph is mounted
correctly prior to assessment. This
is to prevent misdiagnosis or misinterpretation of the radiograph.
Use of magnification, such as a
magnifying glass, could aid in
detailed assessment of the radiograph. Restoration status and the
presence of a carious lesion or
periapical pathology on any tooth
should be identified, documented
and included in the treatment plan.
When assessing the radiograph of
the tooth of interest, the clinician
should start from the crown then
move towards the root and its periradicular area. Any findings must
be included in the documentation
and considered when deciding on
the treatment option.

The periapical radiograph
must have minimal distortion and
magnification, as any elongation
or foreshortening would result in
incorrect measurement of the
root canal length. Careful assessment of the root is essential to
identify any root aberration that
may be present (Fig. 1). It is quite
common to find a Chinese patient
with a C-shaped canal or other
Mongoloid trait with an aberrant
root or root canal anatomy.10
Thus, thorough assessment of
the radiograph is necessary to ascertain the presence of additional
roots or root canals and thereby
establish treatment difficulty.
Since endodontic therapy involves the treatment of the root
canal, which is not visible to the
naked eye, radiographs aid in
determining whether treatment
was carried out satisfactorily and
adequately.

Preoperative assessment
Dental radiographs are important in endodontic therapy to
determine tooth morphology, ascertain the cause of the dental
problem and provide an early assessment of the tooth of interest.
Based on a radiograph, the restorability of a tooth and the complexity of the treatment can be
assessed.
It also helps clinicians decide
whether he or she has the skills to
perform the treatment or should
refer the patient to a specialist.
The presence of a pulp stone in
the pulp chamber or another obstruction within the tooth or root
canal (e.g. a post, a pin, a separated instrument or root filling
material) can be determined
prior to treatment (Fig. 2). This is

Area

Factors assessed

Crown

• Caries (depth, location, extension)
• Restoration status
(secondary caries, margins,
depth, extension)

Assessment of the restorability
of the tooth and treatment
complexity.

Pulp
chamber

• Size, shape, location
of the pulp horn
• Distance to the occlusal surface
of the crown

Ensures the depth and direction
of the bur during access
Prevents iatrogenic perforation
of the tooth during access
preparation.

Root

Root
canal

• Number of roots
• Size of roots
• Curvature (degree, direction)
• Presence of accessory roots
• Crown–root ratio

• Number of root canals
• Size of canals
• Presence of accessory/
lateral root canals

Rationale

Determination of the number of
roots and root canals is important
to avoid missed and untreated
canals, which would result in
endodontic treatment failure.
The presence of excessive root
curvature would indicate the level
of difficulty of the treatment.
The clinician must pay extra
attention when treating sclerosed
or obliterated canals.
Use of magnification, such as
dental loupes or a microscope,
is recommended in this situation.

Table 3: Factors to consider during radiograph assessment.

[19] => Standard_300dpi

ENDO TRIBUNE Asia Pacific Edition No. 3/2015
important, as it will give the clinician some indication of the prognosis and any difficulties that
might occur during treatment. All
of these factors must be discussed
with the patient prior to treatment, so that he or she can decide whether to proceed with the
endodontic therapy.
While the use of a periapical
radiograph alone may be sufficient in most cases, supplementary radiographs may be needed if
the clinician finds that the tooth
may have additional roots or to ascertain the root curvature. Taking
another periapical radiograph at
a different horizontal angulation
(10–30 degrees) may therefore
be necessary. Again, care must
be taken to minimise the extent
of superimposition on adjacent
teeth. The SLOB rule (same lingual, opposite buccal) can be used
to determine the location of an
additional root or root canal.

voids. This can be confirmed by
taking a periapical radiograph
during treatment. Obturation
that is shorter or longer than the
working length may affect the
treatment outcome.

Post-operative assessment
After therapy has been completed, a periapical radiograph
should be taken to ensure that
the treatment was carried out
adequately. This will function as
a baseline when reviewing the
patient six to 12 months later.
From this immediate post-opera-

Trends & Applications 19

tive radiograph, the quality of the
final coronal restoration can be
ascertained and the size of the
periapical lesion, if present, can
be assessed. At the recall appointment, a new periapical
radiograph of the endodontically
treated tooth is taken to monitor
the healing of the periapical lesion and to confirm the success of
treatment. The presence of a new
periapical lesion or the enlargement of an existing one should be
noted, and necessary measures
should be taken to identify the
cause of treatment failure.

Conclusion
Using intra-oral radiographs
is the only method in endodontic
therapy that allows the clinician
to make an assessment of the root
and its supporting tissue. In order
to gain the full benefit of this radiograph, clinicians have to ensure
that it is appropriately exposed,
shows no processing errors and
has no or minimal image distortion. It also has to be correctly
mounted, labelled and dated.
Clinicians must be able to select
which radiograph is necessary to
aid in their endodontic diagnosis

based on the patient’s history and
clinical examination. DT

Contact Info
Dr Safura Baharin
is Head of Clinical
Services at the
Faculty of Dentistry of the National University
of Malaysia near
Kuala Lumpur in
Malaysia. She can be contacted at
safurabaharin@ukm.edu.my.
AD

Here is the absolute desinfection in Endodonties !

The size of the root canal can
also be assessed from the radiograph. This information will
provide some indication of the
complexity of the treatment and
the choice of the obturation material and technique. A tooth with
an open apex may require placement of a calcific barrier, such as
mineral trioxide aggregate, apically prior to obturation.
The status and quality of the
existing coronal restoration must
be assessed radiographically and
clinically. All defective restorations must be removed and replaced with either permanent or
temporary restorations. Any carious lesion must be noted, and the
depth of the lesion must be determined clinically. This is important in order to ensure that
the tooth is deemed restorable
prior to treatment. The clinician
must decide on how to restore
the tooth after completion of
endodontic therapy prior to initiation of treatment.
Posts, separated instruments
or root filling material within the
root canal may complicate the
endodontic treatment (Fig. 3).
The size and type of post will
determine the feasibility of removing such a post. A separated
instrument in the apical third of
the root and below the curved
root may be more difficult to
remove than a more coronally
located fragment.

Irrigation

During obturation, it is important that the root canal be
obturated to the predetermined
working length and have no

Desinfection

YOUR ROOT CANAL
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CONCEPT
PATENTED

Operative assessment
(treatment phase)
Working length is confirmed
and quality of obturation is
assessed during treatment to
ensure the treatment is carried
out satisfactorily. A periapical
radiograph may also be taken to
ascertain the correct angulation
of the bur or endodontic file when
negotiating a blocked or calcified
canal, during post space preparation and even during access
preparation through a calcified
pulp chamber (Fig. 4). This is essential for preventing procedural
errors, such as perforation of the
pulpal floor or canal wall.

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[20] => Standard_300dpi

20 Endo News

ENDO TRIBUNE Asia Pacific Edition No. 3/2015

“Our aim is to be a leading provider
of evidence-based endodontic CE”
An interview with APEC President Dr Ibrahim Abu Tahun, Jordan

Dr Ibrahim Abu Tahun

In early April, specialists and
other dental professionals
from the Middle East and Asia
Pacific regions will be gathering in the Jordanian capital of
AD

Amman for the 18th time to attend the scientific congress of
the Asian Pacific Endodontic
Confederation (APEC), which
will be held under the theme
“Next generation endodontics”. Dental Tribune Asia
Pacific had the opportunity to
speak with Dr Ibrahim Abu
Tahun, President of APEC and
Assistant Professor of Endodontics at the University of
Jordan’s Faculty of Dentistry,
about the congress and the
current state of the specialty in
his home country.

in the country and especially
in the capital?
Dr Ibrahim Abu Tahun:
The travel warnings released by
Western foreign offices did not
include Jordan or any part of it
at any stage. Our country has
officially condemned this crime
and Their Majesties the King and

Dental Tribune Asia Pacific:
Political tensions in the region
remain high, particularly after
the Charlie Hebdo massacre in
Paris earlier this year. How is
the current security situation

Queen of Jordan led world leaders
in the march against terrorism
in Paris.

His Majesty’s wise leadership
have made Jordan an oasis of
peace and one of the top ten
countries worldwide in terms of
security.

for the first time in our part of the
world, the 18th APEC conference
is going to attract dentists from
all over the Arab world and the
entire Asia Pacific region.

Could you give us an accurate view of the current status
of endodontics in Jordan?

What are the main topics,
and who is the conference
aimed at?

“...endodontics has experienced
significant progress in Jordan.”
Decades of political stability,
moderation and tolerance under

There is a general surplus of
dentists, both general practitioners and specialists, entering the
Jordanian market each year. The
total number of registered dentists
with the Jordanian Dental Association at the end of 2011 was slightly
over 7,000, and 10 per cent of these
were specialists. The kingdom
currently prides itself on having
the highest number of highly qualified dental professionals with
postgraduate qualifications compared with any other country in the
Middle East. Many of them have
been trained in Western Europe,
North America and Australia.
Is endodontics therefore a
recognised specialty in your
country?
In the past, Jordanian endodontists were members of the
Jordanian Society of Conservative Dentistry and had to practise
under the umbrella and regulations of the Jordanian Dental
Association. 2007 saw the establishment of the Jordanian Endodontic Society. Endodontics is
of the eight dental specialties
recognised by the Jordan Medical Council, which is the highest
medical authority responsible
for the organisation of the medical profession and specialisation in the country. Since then,
endodontics has experienced
significant progress in Jordan.
Ranked number one in scientific research in the Arab world
and 30th overall worldwide, the
Jordanian educational system attracts a large number of foreign
students. It is also home to many
foreign universities’ campuses.
The country is the region’s top
medical tourism destination, as
rated by the World Bank, and fifth
in the world overall, having everything from highly skilled doctors to state-of-the-art facilities.
Clinics here cater for all dentistry
needs. Plans are currently underway to make it a regional hub for
the training of medical staff in the
Middle East and North Africa.
How many visitors do you
expect for the APEC congress?
Around 1,000 participants
are expected to attend this large
international event. Organised

The theme of the conference
is “Next generation endodontics”.
The scientific programme, with
emphasis placed on Asian Pacific
experience, provided by speakers from the respective countries, will have two parallel sessions with world-leading experts
in the field, original clinical and
scientific research posters, as
well as pre- and post-congress
hands-on sessions, covering the
recent advancements and issues
in the field.
Our aim is to be a leading
provider of evidence-based continuing endodontic education
for the entire dental team and
anyone with a general interest in
endodontics.
How do you think the congress is going to affect endodontic treatment and diagnostics
in the future?
Such international meetings
always constitute a platform for
scientists and practitioners to
update their knowledge and
interact with the latest endodontic innovations worldwide to
improve their knowledge and
answer the ultimate question:
where do we stand?
In addition to the scientific
programme, what can participants look forward to in
Amman?
This pioneer endodontic
event in the Asia Pacific region is
intended to connect colleagues
from around the world to generate and update knowledge and
foster friendship. A wide range
of dental products, including instruments and other equipment,
will be on display by our industry
partners.
It is a great pleasure and
honour to welcome participants
to the country where some of the
earliest chapters of human civilisation were written. Travelling
to Jordan, with its rich heritage of
biblical and historical sites, will
provide visitors with a unique
opportunity to enjoy the warmth
and hospitality of our country
and its people.
Thank you very much for
the interview. ET

[21] => Standard_300dpi

ENDO TRIBUNE Asia Pacific Edition No. 3/2015

Endodontic imaging mode
available from Planmeca
DTI

Planmeca has introduced a
new imaging mode that was
developed especially for use in
endodontics and in cases dealing
with small anatomical details,
such as imaging of the ear. The
new mode, which produces extremely high-resolution images
with a very small voxel size of
only 75 μm, is available for all
Planmeca ProMax 3D imaging
units.

and artefact removal algorithms,
noise-free and crystal-clear images can be produced, the
Finnish dental equipment manufacturer said. With Planmeca
ARA, for example, artefacts resulting from metal restorations
and root fillings in the patient’s
mouth that cause shadows and

streaks in CBCT images can be
removed effectively. In addition,
the new Planmeca AINO Adaptive
Image Noise Optimiser is intended to reduce noise in CBCT
images resulting from a particularly low radiation dose or small
voxel size without losing valuable details. The company said

Endo Products 21
that the filter particularly improves image quality in the
endodontic mode, where noise
is inherent due to the extremely
small voxel size. It has also
proven useful when used in
accordance with the Planmeca
Ultra Low Dose protocol, where
noise is induced by the particularly low dose.
Planmeca AINO also allows
the reduction of exposure values
and consequently the radiation
dose in all other imaging modes,
according to Planmeca. ET
AD

According to Planmeca, the
new mode provides clinicians
with perfect visualisation of even
the smallest anatomical details.
Owing to new intelligent noise

Irrigatys
DTI

With endodontic treatment,
there is the risk of superinfection. The French laboratory
ITENA Clinical claims to have
solved this problem with its revolutionary Irrigatys handpiece.
This two-in-one device is used
for both irrigation and agitation
of the cleaning solution inside
the root canal. To achieve this,
the laboratory put a perforated
metal tip at the top of the handpiece to deliver the cleaning solution in an oscillating movement.
A removable tank allows the root
canal to be treated successively
using sodium hypochlorite and
EDTA. The irrigation line directs
the cleaning solution through the
metal tip.

Changing the DNA of NiTi

• 300% more resistance to separation
• No shape memory + Extreme flexibility = Superior Canal Tracking
• Regains shape after sterilization = Multi-use

Irrigatys is available with all
of its accessories in a starter kit.
The metal tips are available in
two sizes, 17 mm and 21 mm, to
cover all clinical cases. ET

www.coltene.com/contact
002319

The patented technology,
achieved after six years of research, optimises the results of
a very complex procedure, according to the company. Ambidextrous, light and flexible, the
device has excellent ergonomics, providing intuitive handling.
Irrigatys recharges on a charging station that can be fixed to
the chair.

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ENDO TRIBUNE Asia Pacific Edition No. 3/2015

22 Business

Endodontic treatment in the future
will be simpler and standardised
An exclusive interview with Drs Laurent Bataillard and Didier Lakomsky, MICRO-MEGA

Since 1905, MICROMEGA has been at
the heart of great
technological revolutions in the field of
dentistry. Today, the
French pioneering
company is still delivering turnkey endodontic solutions to Dr Laurent Bataillard
Dr Didier Lakomsky
practitioners around
duction, operations and managethe world. At the start of a series
ment until Sanavis recruited
of innovations, Dental Tribune
me. That is how I came to join
International recently travMICRO-MEGA—kind of a return
elled to Besançon in France
to the roots.
to meet Managing Director
Dr Laurent Bataillard and
Endodontics Business Unit Director Dr Didier Lakomsky to
discuss how their company
intends to reassert its global
reputation of French expertise,
which it established in 1907
when it introduced its first
nerve broach.

There is a strong product synergy today between the various group entities. MICROMEGA’s core business is
endodontics. Our historical
expertise started with the
nerve broach and is constantly
evolving with the latest technologies. Do things differently
and/or create something new
based on our knowledge—
that is our challenge for the years
to come.
French consumers seem to
be very sensitive when it comes

We invest in research, innovation, marketing, design and
training for the men and women
who are to become the main roleplayers of future innovations.
Training for these innovations
and the acquisition of new skills
needed for future professions
within the company are a central
part of our strategy. Each new development in dentistry and technology leads to training sessions
for our staff. That is why our
employees are strongly committed to their company and the
turnover rate is extremely low.

“Our aim is to continue our strong
development in Asia while consolidating
our position in Europe and the US.”

Dental Tribune: Dr Laurent
Bataillard, you have been the
Managing Director of MICROMEGA for almost a year now.
What is your background?
Dr Laurent Bataillard: I am a
physics engineer with a specialisation in metallurgy. The subject
of my doctoral dissertation was
in fact phase transformation in
nickel-titanium wires for use in
endodontics. After my doctorate,
I worked in the metalworking
industry for several years and
held various positions in research and development, pro-

What were the benefits of
the company’s takeover by the
Sanavis Group in 2009?
The Sanavis Group is one of
the ten most important dental
equipment suppliers in the
world. The grouping of the companies MICRO-MEGA, SciCan
and SycoTec is now able to offer
practitioners worldwide a comprehensive range of innovative solutions: endodontic files,
micro-motors, and complete retreatment and hygiene systems.

to the country of origin of the
products they buy. What does
“made in France” mean to you?
It reflects the intent, among
others, to maintain our industry
in France and in Besançon and
to avoid outsourcing of jobs
abroad. MICRO-MEGA has been
designing, manufacturing and
marketing dental surgical instruments in the heart of the
French watchmaking and microtechnology capital for over
a century now.

Furthermore, all production
stages, from the product design
to the delivery of the final product, take place under one roof.
This results in great flexibility
and quick response, an important synergy between the various
entities, perfect control of the
entire production process, as
well as optimised traceability
and follow-up.
Despite our international orientation, we need to remember

where we come from. We have
strengthened our presence in
Besançon and in France through
partnerships with university
hospitals and local practitioners,
and we are even considering patronage of a local modern concert hall.
How do you intend to implement your international development strategy?
By responding to everyone’s
needs closely. The Garniers, the
company’s founding family, have
always collaborated with the
great names in the history of
dentistry. These successful partnerships have brought about
revolutionary products, like the
nerve broach, the Giromatic (first
contra-angle with reciprocating
movement), the HERO 642 sequence (first MICRO-MEGA NiTi
sequence, developed by Profs. P.
Calas and J.-M. Vulcain), Revo-S
(NiTi sequence with three instruments, designed by Drs J.-P.
Mallet and F. Diemer) and One
Shape (first single instrument
in continuous rotation, developed by Profs. F. Pérez and M.
Guigand).
We are currently strengthening our presence all over the
world through conferences and
training for dentists. Our aim is
to continue our strong development in Asia while consolidating
our position in Europe and the
US. We work with the opinion
leaders of the main European
markets and conduct precisely
targeted studies in order to offer
complete and specific endodontic solutions corresponding
to practitioners’ habits. Our
strength lies in our products’
quality, simplicity, security and
efficiency: these are the keywords that define our day-to-day
work.
Is ecology a matter of concern for you?
Naturally, we try to recycle as
much as possible and to avoid
waste. We also seek ongoing improvement of our manufacturing
processes.
Dr Lakomsky, what is your
role in the company?

[23] => Standard_300dpi

ENDO TRIBUNE Asia Pacific Edition No. 3/2015
Dr Didier Lakomsky: MICROMEGA’s reputation is based on
technical expertise combined
with comprehensive networking
with dental professionals. My
role is to define and implement
high-performing products in
close co-operation with endodontic specialists, general
practitioners and distribution
partners worldwide. Ensuring
benefit from these exchanges
with practitioners, anticipating
future market needs and transforming them into relevant technical solutions are also part of
my function at MICRO-MEGA.
A structural consequence of my
work is the grouping of the marketing and the research and
development departments concerning product planning in the
short, medium and long term.
In this regard, I encourage and
support synergies.
What do you think endodontic treatment will look like
in the future?
Above all, it will be simpler
and more standardised. Continuous rotation and reciprocating
motion are currently enjoying
irrefutable success. This evolution—one could even call it a
revolution—has enabled general
practitioners to increase the
number of endodontic treatments
performed in their practice. Increasing endodontic treatment is
a trend that is likely to continue in
the coming years.

Business 23

The Dental Tribune International
C.E. Magazines
www.dental-tribune.com

In the future, endodontic
treatment will be quicker, but
will still respect bacterial prevention standards. Sodium hypochlorite may be replaced by
a new irrigation solution that
offers the same efficiency while
reducing the irrigation time.
We can expect solutions that
are more sophisticated and that
have scientifically proven effectiveness. The technological evolutions will extend gradually
over the next three to five years.
Practitioners will work with increasingly flexible and resistant
materials, allowing the treatment of even complex root
canals, and with imaging techniques like CBCT, offering an
extremely precise 3-D visualisation of the root canal structure
and enabling practitioners to
choose the appropriate treatment method according to the
anatomical and clinical complexity. This is often referred to as
stratification. In the longer term,
the introduction of pulp regeneration techniques according to
the clinical case is expected, with
diagnostic methods allowing the
evaluation of the reversibility of
a case of pulpitis.
What are MICRO-MEGA’s
objectives today?
Our goals are to provide general practitioners with solutions
that make endodontic treatment
reproducible and as simple as
possible, to enable them to increase their number of cases
and to improve their success
rate significantly. The last is a
fundamental condition for our
company’s success.
Thank you very much for
the interview. DT

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[cover] => DT Asia Pacific No. 3, 2015

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