DT Asia Pacific No. 4, 2015

News / Business / Growing CAD/CAM abutment adoption vs increasingly popular discount implants / “It is very difficult to escape from your professional status” / Avoiding irreversible dental treatment / IPS e.max CAD and Zenostar: Monolithic brothers / Innovations with lasers could lead regenerative dentistry / Virtual reality simulation / Going (unintentionally) green: The unexpected bonus of switching to CAD/CAM and same-day dentistry

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DTAP0415_01-03_News 24.04.15 15:56 Seite 1

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

Dental implants
Opposing pricing trends
in Asia Pacific market
Page

Orofacial pain
Avoiding irreversible
dental treatment
Page

NO. 4 VOL. 13
Dental education
Indications and perspectives for VR simulation

Page

slows
Physicists shed light on geographic tongue Graphene
dental diseases

Research provides new insights into dynamics of inexplicable condition
DTI

REHOVOT, Israel: Physicists
at the Weizmann Institute of
Science in Israel have clarified
the intricate dynamics underpinning a tongue condition
that has puzzled the medical
community
for
decades.
Known as benign migratory
glossitis or geographic tongue
(GT), the condition affects
around 2 per cent of the global
population and is characterised by evolving red patches
on the surface of the tongue
that may resemble a map.
The red patches appear due
to loss of one of the four types of
lingual papillae, tiny hair-like
protrusions that cover the surface of the tongue. The affected
type, called filiform papillae, is
mainly distributed in the anterior two-thirds of the tongue. Despite extensive research, the exact cause of GT, a benign and
mostly painless condition, remains unknown.
In their study, the researchers performed a number
of numerical simulations to

Chinese researchers have
found that graphene oxide, a compound of carbon, oxygen and hydrogen, is effective against a number of pathogens that cause dental
caries and periodontitis. As previous studies have demonstrated
that graphene oxide can inhibit
the growth of some bacterial
strains without harming mammalian cells, they investigated the
material’s antimicrobial properties for three specific oral bacteria
that are associated with tooth
decay and certain forms of periodontal disease.
For the study, the researchers
used graphene oxide nano-sheets
and observed that they significantly slowed the growth of dental
pathogens. Tests using electron
microscopy showed that the cell
walls and membranes of the bacteria had lost their integrity. They
thus concluded that graphene
oxide nano-sheets could have potential application in dental care
and therapy.

Benign migratory glossitis affects around 2 per cent of the global population. (Photo Angel Simon / shutterstock.com)

closely examine and visualise
the development of GT, and devised a new way of identifying
the severity of individual cases.
“We hope these results can be

used by physicians as a practical
way of assessing the severity of
the condition based on the characteristic patterns observed,”
said lead author of the study Dr

Gabriel Seiden, a researcher at
the Weizmann Institute of Science in Rehovot in Israel.
‡ DT page 2

Given the rise in antibiotic resistance over the past decade, they
also believe that their findings
could help address the need for a
new approach to treating bacterial
diseases. DT
AD

AP slow in
adoption of
CAD/CAM

DTI staff presenting the new DT UK edition at the Dentistry Show in Birmingham.
Previously published by a partner in London, the new edition is produced under
a new editorial team and boasts a modern, more reader-friendly layout.

Fluoridation
linked to ADHD

HIV test close to
completion

Fluoridated water could be an
environmental risk factor for attention deficit hyperactivity disorder (ADHD), one of the most common neurodevelopmental disorders of children today. In a study,
researchers from Canada found
that the prevalence of ADHD increased with wider exposure to
fluoridated water in the US. DT

Dental researchers in New
York have received a US$1.5 million grant from the US National Institutes of Health to complete the
development of a rapid blood and
saliva test for HIV/AIDS. They believe that the device will benefit
people in remote areas with only
limited access to advanced diagnostics. DT

The latest report by international market research and consulting group iData Research
shows that the penetration rate
of CAD/CAM prostheses in the
Asia Pacific region has been
limited by difficult economic
circumstances in countries like
Japan, South Korea, Australia
and China. In particular, the
economic recession has slowed
unit sales growth as dental laboratories facing budget constraints. Growth is expected
from stand-alone scanners that
laboratories increasingly prefer
over high-priced milling systems in order to expand their
networks of scanners to support
their full in-lab CAD/CAM system, the report states. The AsiaPacific market for dental prostheses and CAD/CAM devices is
currently valued at over US$10
billion. DT

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Bendererstr. 2 | FL-9494 Schaan | Liechtenstein | Tel.: +423 / 235 35 35 | Fax: +423 / 235 33 60

[2] =>

DTAP0415_01-03_News 24.04.15 15:56 Seite 2

DENTAL TRIBUNE Asia Pacific Edition No. 4/2015

Asia News

ﬂ DT page 1

The scientists approached
the problem of GT as if it were an
excitable medium—a spatially
distributed, dynamic system
with the ability to propagate signals without damping. A forest
fire is a classic example of an excitable medium: it travels as a
wave from its initiation point and
regenerates with every tree it ignites.
This is in contrast to passive
wave propagation, which is
characterised by a gradual
damping of the signal amplitude
due to friction. However, after a
wave has passed through, excitable media have to reconstitute before they can support the
passing of another wave. In this
way, a fire can spread through a
forest, but it cannot return to a
burnt spot until the vegetation
has regrown.
The study found that GT can
spread across the tongue in two
different ways, each of which has
distinguishing characteristics
that could be used to diagnose
severity. The researchers discovered that the condition,
which typically starts as small
spots on the tongue, can continue to gradually expand in circular patterns until the whole
tongue becomes affected. Once
affected, the tongue then heals
itself. Alternatively, the condition can develop through the formation of spiral patterns. The
simulations showed that these
spirals evolve in regions of the
tongue that are still recovering,
causing re-excitation of that particular region.

ally affected and subsequently
healed, the propagation of spiral
patterns involves a continuous,
self-sustaining excitation of recovering regions, implying a
more acute condition that will
linger for a relatively long period
of time,” Seiden explained.
Just as the development of
forest fires can be strongly affected by external conditions,
such as the strength of the wind,
conditions surrounding the
tongue may have important consequences for the dynamics of
GT, according to the researchers.
In their study, they give the
example of GT observed in a
1-year-old boy who developed
the characteristic lesions on
multiple occasions along the
tongue’s edge adjacent to the
growing teeth, implying that the
continuous rubbing of the
tongue against the gingiva may
trigger the condition.
“Going forward, we intend to
collaborate with physicians and
dentists who treat GT patients to
obtain valuable—and often
scarce—empirical data regarding the dynamic evolution of the
condition,” Seiden concluded.
“This will allow for further, more
quantitative explorations of GT,
and may eventually lead to a
firmer understanding of what
causes the condition.” DT

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.

“While the propagation of
small circular lesions results in
the whole tongue being gradu-

Wine wears down teeth quicker
than previously thought
DT Asia Pacific

ADELAIDE, Australia: Wine
lovers may seriously harm their
teeth if they do not take preventative measures against erosion, new research from the
University of Adelaide suggests.
According to an article published in the latest edition of the
Australian Dental Journal,
demineralisation occurs as
early as 10 minutes after
enamel has been exposed to the
organic acids of the beverage.
This places wine-tasters, for
example, at increased risk of
tooth wear, the researchers said.
Previous research only found a
softening effect in teeth exposed
to wine after 1 hour.
Professional tasters usually
test up to 150 wines per day, and
wine judges even more. With
wine-tasting, the beverage is retained in the mouth for up to 60
seconds before it is spat out.
In order to assess the demineralisation during wine-tasting, the team simulated the conditions of the process in a laboratory, exposing extracted third
molars repeatedly to white wine
and artificial saliva. After 1 and 10
minutes, a nano-scratch test was
conducted and the result was an
increasing scratch depth.
Surface roughness of the
enamel also increased by almost
200 per cent. Reflecting on the
findings, the researchers recommended that professionals take

early preventative measures, including the application of remineralisation agents, such as
calcium, phosphate and fluoride,
to minimise the risks of erosion.
Chewing gum and skipping
toothbrushing the morning before the wine-tasting are additional measures that could lessen
the occupational hazard, they
said in the report.
"After a wine tasting, the teeth
are likely to be much softer, so we
recommend rinsing with water,
and when it comes time to clean
the teeth, just putting some
toothpaste on your finger and
cleaning with that,” remarked
Associate Professor Sue Bastian

from the university’s School of
Agriculture, Food and Wine,
which also teaches wine-making, about the results. “Cleaning
with a brush when teeth are soft
runs the risk of damaging the
enamel.”
With pH values of 3 and 4, the
acidity of wine is comparable to
most soft drinks, which, owing to
their high concentration of organic acids, are reported to be the
main cause of the increase in
tooth wear around the globe, particularly among children. Most
professional wine organisations,
however, currently do not recommend any special precautions
for their members. DT

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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.
© 2015, Dental Tribune International GmbH. All rights reserved.
Dental Tribune makes every effort to report clinical information and manufacturer’s product news accurately, but cannot assume 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
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[3] =>

DTAP0415_01-03_News 24.04.15 15:56 Seite 3

DENTAL TRIBUNE Asia Pacific Edition No. 4/2015

Asia News

3

One system for better restoration
DENTSPLY exhibits premium material collection at APDC congress in Singapore
DTI

SINGAPORE: At the sixth
International Congress on Adhesive Dentistry (IAD), held recently in Bangkok in Thailand,
dental consumables manufacturer DENTSPLY launched
“one”, its collection of premium,
high-performance
restorative materials that were
designed not only to be easy to
use, but also to allow dentists to
achieve outstanding clinical results.

It is difficult to achieve an optimum level of dentine moisture
prior to the application of an adhesive. Overwet or overdry dentine
can lead to insufficient sealing, resulting in microleakage and postoperative sensitivity. Prime&bond
one ETCH & RINSE offers a tech-

nique-tolerant solution, providing
high bond strength and reliable
performance even on overwet or
overdry dentine, according to
DENTSPLY.
The literature often recommends using a self-etch adhesive

in cavities with a large proportion
of exposed dentine in order to
minimise the risk of post-operative sensitivity. However, etchand-rinse adhesives have shown
superior long-term results on
enamel.
Prime&bond
one
SELECT combines the advan-

tages of both techniques. It provides high bond strength with all
etching techniques (self-etch,
etch and rinse, and selective
enamel etch) and delivers reliable
performance even on overdry
dentine, resulting in virtually no
post-operative sensitivity. DT
AD

LIFELIKE ESTHETICS –
EFFICIENTLY PRESSED

According to the company, the
“one” collection consists of
ceram.x one, a composite available in different translucencies
for everyday aesthetics (ceram.x
one UNIVERSAL) and highly aesthetic restorations (ceram.x one
DENTIN & ENAMEL). It also contains two bonding systems, one
for
total-etch
applications
(prime&bond one ETCH &
RINSE) and one for self-etch, selective enamel etch and totaletch applications (prime&bond
one SELECT).
Covering the full VITA (VITA
Zahnfabrik) shade range with
just seven shades, ceram.x one
UNIVERSAL is extremely simple
and easy to use, the company said.
With intermediate translucency
ranging between natural enamel
and dentine, ceram.x one
UNIVERSAL offers a powerful
chameleon effect to facilitate natural, lifelike restorations and is
ideal for everyday use. While
many composite systems offer a
myriad of shades and translucencies, making it difficult to match
the colour of the natural teeth,
ceram.x one DENTIN & ENAMEL
replicates the structure of natural
teeth utilizing just two translucencies: dentine shades that
mimic natural dentine and
enamel shades that mimic natural enamel. Also covering the full
VITA shade range, it enables
highly aesthetic, natural restorations with only four dentine and
three enamel shades.

IPS e.max PRESS MULTI
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www.ivoclarvivadent.com
Ivoclar Vivadent AG
Bendererstr. 2 | 9494 Schaan | Liechtenstein | Tel.: +423 235 35 35 | Fax: +423 235 33 60

[4] =>

DTAP0415_04_Opinion 24.04.15 14:25 Seite 1

DENTAL TRIBUNE Asia Pacific Edition No. 4/2015

Opinion

“Shouldn't we say something?”

Difficulties mastered are opportunities won
would like to thank our former
partners for their years of commitment and wish them best of luck for
their future endeavours.
Daniel Zimmermann
DTI

These words from one of
Britain’s most famous statesman
Winston Churchill aptly describe
the recent relaunch of Dental
Tribune UK. The new edition is the
result of months of reorientation
and repositioning that will see the
return of an active participant in
the British dental publishing
scene. At this opportunity, we

Our publishing group has come
a long way since the first edition of
Dental Tribune UK was launched
in 2007. From a few publishers operating in key markets only, it has
grown into a large-scale global operation with offices and representatives in almost every corner of the
globe; to borrow a famous historical phrase, the sun never sets on
the Dental Tribune International
(DTI) network, as somewhere in

the world a Dental Tribune publisher or partner is always working.
And our expansion is still far from
over: coinciding with the relaunch
of the UK edition, Dental Tribune
has introduced its first-ever Nordic
edition at the SCANDEFA show in
Copenhagen in Denmark to serve
all markets in Scandinavia and Finland. Developed as a pan-regional
title, the new edition will cover and
analyse everything dentistry in the
region, as well as internationally.
With four editions per year and
published in English only, it builds
on the substantial knowledge and
publishing expertise that has dis-

tinguished Dental Tribune partners in almost every corner of the
world for the last two decades.
While remaining a print publisher at heart, DTI is constantly
venturing forward in other areas,
most notably continuing professional education and events. While
the Dental Tribune Study Club has
been providing free online education at an international and local
level for the last seven years, the
new Clinical Masters series will offer high-quality CE in selected areas, including implantology, endodontics and aesthetic dentistry.

Moreover, last year saw the successful première of the Digital
Dentistry Show, a show within a
show expo format that will see further geographical and topical expansion in 2015.
For information and updates on
all our exciting new projects, I invite you to visit our website at
www.dental-tribune.com. DT
Sincerely,
Daniel Zimmermann
Group Editor
Dental Tribune International

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[5] =>

DTAP0415_05_WorldNews 24.04.15 14:26 Seite 1

DENTAL TRIBUNE Asia Pacific Edition No. 4/2015

World News

Increasing number of European
adolescents brush teeth twice a day
DTI

GHENT, Belgium/JYVÄSKYLÄ,
Finland/COPENHAGEN, Denmark: An international team of
researchers has studied the daily
frequency of toothbrushing in
adolescents from 20 different
countries and regions in Europe
between 1994 and 2010. The researchers found that the prevalence of brushing more than once
a day has increased in most of the
surveyed countries and regions
over time, with the highest increase observed in Estonia,
Latvia, Russia, Finland and Flemish Belgium.
“From a public health perspective, improvement of toothbrushing
habits is important in preventing
the most common dental diseases,
but even more so in reducing common risk factors for the main noncommunicable diseases,” the researchers stated in the study. According to them, brushing twice a
day is one the most important selfcare methods and has become a
universal recommendation worldwide in order to maintain good oral
health. In light of recent findings regarding the association between
oral disease and the four main noncommunicable
diseases—diabetes, cancer, cardiovascular disease and respiratory disease—the
importance of regular toothbrushing has increased even more.
For their study, the researchers
from the University of Jyväskylä in
Finland, Ghent University in Belgium and the National Institute of
Public Health in Denmark used data
from five consecutive Health Behaviour in School-aged Children
(HBSC) surveys conducted between 1994 and 2010.
The HBSC research network is
an international alliance of researchers that collaborate on the
survey of schoolchildren. The
HBSC collects data on 11-, 13- and
15-year-old boys’ and girls’ health
and well-being, social environments and health behaviours. The
researchers chose these age groups
because they mark a period of increased autonomy that can influence how a person’s health and
health-related behaviours develop.
The cross-national survey, initiated
in 1982, is conducted every four
years in 44 countries and regions
across Europe and North America
in collaboration with the World
Health Organization’s Regional Office for Europe.
The scientists determined the
frequency of toothbrushing by
analysing the adolescents’ answers
to the mandatory HBSC question in
this regard, including study year,
country, sex and age as variables.
The 20 countries considered in the
study included various central,
eastern and northern European
countries, as well as Russia and
Canada.
In most of these countries, the
prevalence of brushing twice a day

has increased significantly, while
the cross-national differences have
diminished. In 1994, the rate of adolescents brushing their teeth twice a
day ranged from 30 to 86 per cent. In
2010, between 50 and 81 per cent of
the surveyed children said that they
brushed twice every day.

In 1994, the countries with the
lowest prevalence of brushing
twice a day included Lithuania (30
per cent), Latvia (34 per cent), Russia (38 per cent), Finland (38 per
cent), Estonia (42 per cent) and
Flemish Belgium (43 per cent). By

2010, between 50 and 60 per cent of
the children in all of these countries
brushed twice a day.
The countries with the highest
rate of adolescents brushing their
teeth twice a day in 1994 were Sweden (86 per cent), Denmark (80 per

cent), Norway (75 per cent) and
Germany (73 per cent). By 2010,
Sweden’s rate had decreased to 81
per cent and Denmark’s to 76 per
cent. Norway’s rate remained at 75
per cent, while Germany’s increased to 80 per cent.
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[6] =>

DTAP0415_06_ADDE 24.04.15 15:15 Seite 1

6

DENTAL TRIBUNE Asia Pacific Edition No. 4/2015

Business

European dental markets trend towards
group practices and consolidation
DTI

COLOGNE, Germany: Latest
market figures released by the
Federation of the European
Dental Industry (FIDE), in cooperation with the Association of

European
Dental
Dealers
(ADDE), last month at the International Dental Show in
Cologne, indicate rapid changes
toward a digital dentistry manifesting in overall trends to a
more global approach with

group practices and consolidations throughout dental markets
in Europe. The organisation’s
2015 market survey also revealed that the number of European dentists has slightly increased to a total of 276,090 in

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2014 compared to 270,045 the
year before.
A contrary trend showed in
the number of dental offices and
dental laboratories. While the
numbers of the former remained

flat on average, the total figures of
labs in Europe has decreased in
almost every surveyed country.
According to ADDE President
Dominique Deschietere, given
the growing numbers of practicing dentists this development either indicates a trend to group
practices or consolidation.
While the number of dental
technicians has remained steady
or slightly decreased in all countries except Hungary, the number of dental hygienists increased in all countries of the survey. This development is especially prominent in the UK, with
the number of dental hygienists
growing distinctively compared
to 2013. As Deschietere has put it,
this seems to be a result of the
evermore “bending of the laws”
in this area.
On the supply channels side,
the percentage of direct sales
from manufacturers remained
steady in most countries, and the
share of products purchased via

Dominique Deschietere
(Photo Kristine Hübner, DTI)

e-mail or internet is constantly
if only slightly, increasing compared to the previous year. Further, the figures indicate that the
sales volume of equipment has
dropped in 2014, while sales of
sundries and consumables remained stable on average.
“Dentists continue to treat patients,” Deschietere pointed out.
“Consumables and sundries, not
new equipment like CAD/CAM
units or intra-oral X-ray units,
kept the figures up during the last
years.”
To this date the gathering of
information on new technologies
seems to be the weak point of
the survey. Although Germany
shows a jump in the numbers of
intra-oral scanners installed,
most countries are not collecting
data on the subject so far, explained Deschietere.

www.fdi2015bangkok.org
www.fdiworldental.org

The annual ADDE/FIDE survey, which is conducted through
its national associations since
1998 and represents the interests
of more than 960 dental dealer
organisations, covers the most
relevant topics and trends for the
European Dental Industry, such
as the number of customers and
end users, sales values for the
main product categories, the use
of computer and e-commerce,
sales segments, distribution
channels as well as VAT charges
and their impact on the market.
DT

[7] =>

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Tribune Group GmbH is the ADA CERP provider. ADA CERP is a service
of the American Dental Association to assist dental professionals in
identifying quality providers of continuing dental education. ADA CERP
does not approve or endorse individual courses or instructors, nor does it
imply acceptance of credit hours by boards of dentistry.

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Tribune Group GmbH i is designated as an Approved PACE Program Provider by the
Academy of General Dentistry. The formal continuing dental education programs of this
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maintenance credit. Approval does not imply acceptance by a state or provincial board of
dentistry or AGD endorsement.

[9] =>

DTAP0415_09_Naz_Colgate 24.04.15 16:26 Seite 9

DENTAL TRIBUNE Asia Pacific Edition No. 4/2015

Business

Google Mobile Armageddon and what it means
Naz Haque
UK

Google has just released an update that will prioritise mobilefriendly websites. It is indeed
widely known that online audiences are moving to smart phone
and tablet computers. At Dental
Focus, we have seen massive
shifts in the online audience over
the last few years to the point
now where most clients see a
minimum of 55 per cent of their
organic audience visits from mobile devices.
Websites and marketing
campaigns achieve higher conversions when they are mobile
optimised. The diagram below
shows a marketing campaign we
are running at the moment. In
this, we achieved 10,835 sessions
over 30 days. The blue bar indicates the total sessions and the
orange bar segments the mobile
and tablet audience. In all traffic
sources, mobile has the lion’s
share of the market. In this project, we invested heavily in
Google pay per click and 95 per
cent of conversions were via mobile.
To qualify this trend further,
consider that desktop sales have
started to decline significantly
since 2005. After 2013, the

growth in purchases of mobile
devices (mobiles, tablets and
phablets) has continued to outgrow desktop sales. Google focuses on its users and anyone
who wants to have a presence on

to which it must adhere. The
website must not make use of any
mobile-incompatible animations created with software like
Adobe Flash. This appears as a
black space in a mobile screen

Acquisition
Sessions

New Sessions in %

All Sessions
Mobile and Tablets

10,835
7,782

1 – Paid Search

6,474
4,728

2 – Organic Search

2,750
1,872

3 – Direct

801
560

4 – Social

10,835
610

5 – Referral

72.70 %
70.25 %

New Users
7,877
5,467

73
12

Google is directed to follow its
guidelines to serve these users.
In this instance, such users are
dentists’ existing and prospective patients. Therefore, it is
really important that your website deliver to their online expectations or Google will not present
your website to them.

and serves no purpose. The text
on your website should be readable on mobile devices without
the user needing to resize or

zoom. Responsive websites will
automatically adjust to serve
readability factors.
User experience has always
been a core area from Google’s
perspective, and mobile-friendly
websites have links separated
sufficiently to allow a user to
make a selection with ease.
Google provides a platform to
check whether websites are
mobile-friendly. Just type in your
website address at the following
link: https://www.google.com/
webmasters/tools/mobilefriendly/.
There is no reason to panic if
your website is not ready by 21
April; however, expect to lose
more customers to businesses
with mobile-friendly websites, as
they will be favoured by Google.
The company has such a massive
job to do reading the entire Internet, it is unlikely you will start
suffering from 12.01 a.m., but you
can expect to see your rankings
diminish over time, especially on
a mobile device search.

Your presence on Google is
directly affected by your competition, so if your practice is in the
middle of nowhere with limited
competition you will live another
day, but surely it is time that you
start to think how to best serve
your audience before it is too late.
DT

Contact Info
Naz Haque, aka
the Scientist, is
Operations Manager at Dental
Focus. He has
a background in
mobile and network computing,
and has experience supporting a
wide range of blue-chip brands,
from Apple to Xerox. As an expert
in search engine optimisation,
Naz is passionate about helping
clients develop strategies to enhance their brand and increase
the return on investment from
their dental practice websites.

For your website to be mobilefriendly, there are specific factors

Colgate introduces
new toothpaste for
cavity prevention
DTI

SINGAPORE: Colgate has introduced a new toothpaste at the
Asia Pacific Dental Conference
in Singapore that contains
Sugar Acid Neutralizer, which
the company developed to combat sugar acids that arise when
common oral bacteria react
with food residue in the mouth.
This reaction can cause the
tooth enamel to weaken and
leads to an increasing risk of cavities.
The latest addition to the company’s oral care line promises to
fight tooth decay in two clinically
proven ways. Firstly, the patented
Sugar Acid Neutralizer deactivates harmful sugar acids in the
mouth. Secondly, fluoride and calcium additives, which have
proven to prevent cavity formation by reducing demineralisation, are aimed at strengthening
and restoring the tooth enamel.

Dr Kuan Chee Keong, President of the Singapore Dental Association, acclaimed the new toothpaste: “Sugar acids are the number one cause of cavities and we
now have the ability to protect our
teeth with this new technology.
The landscape of dental technology is always changing for the better and it is always exciting to witness new breakthrough technologies that will help us reduce the advent of caries. With these
discoveries, our goal of a cavityfree future is within reach.”
Despite continuing education
on the importance of good oral
care habits to prevent cavities,
caries affects 60–90 per cent of
schoolchildren and the majority of
adults worldwide, according to
data from the National Children’s
Oral Health Foundation. One of
the main factors promoting tooth
decay and cavities is a high intake
of sugary drinks and foods, and
this appears to be a major problem
in Singapore. According to the
country’s Health Promotion
Board, the sugar consumption in
Singapore is more than twice that
of the World Health Organization’s recommended annual intake of approximately 9 kg a year.
Overall, the average sugar consumption in the country increased
by 10 per cent from 2009 to 2012. DT

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[10] =>

DTAP0415_10_ImplantMarket 24.04.15 16:54 Seite 10

10 Trends & Applications

DENTAL TRIBUNE Asia Pacific Edition No. 4/2015

Growing CAD/CAM abutment
adoption vs increasingly
popular discount implants
Opposing pricing trends to influence Asia Pacific dental implant market
Dr Kamran Zamanian
& Celine Mashkoor
Canada

The various countries in the Asia
Pacific region are all expected to
demonstrate an increasing demand for dental implant treatments as a result of growing consumer awareness, the ageing population, growing accessibility
(such as through the National
Health Insurance Service coverage in South Korea), as well as
greater product availability and
other influencing factors. Traditionally, premium implant companies have dominated the dental
implant market globally. However, in recent years, discounted
implants have become increasingly popular, especially in the
Asia Pacific region.

greatly depressed the ASP of the final
abutment market, growing adoption of CAD/CAM abutments is set to
stimulate the final abutment market
by pulling the ASP upwards. Therefore, the dental implant market is set
to grow in all four countries included in the Asia Pacific region in
this report, namely Australia, South
Korea, Japan and China, despite
varying pricing trends.
In the Asia Pacific dental implant
market, consumer awareness, cultural tendencies and domestic regulations vary greatly. South Korea
represents the most highly developed dental implant market as a result of being home to a number of
global leading dental implant companies. This in turn has led to a high
level of consumer awareness and
early accessibility to a variety of den-

Fig. 1: Unit analysis of dental implant fixtures for Australia. By 2021, units of premium
implants will drop dramatically to represent 42% of the overall dental implant fixtures
in the country. (Source: iData Research Inc.)

The growth of the discount implant segment will emerge at the expense of the premium segment and
as a result is set to limit market
growth for dental implant fixtures
by lowering the market’s overall av-

tal implant products. However, the
dental implant market in South Korea is also highly discount dominant
and led by domestic implant producer OSSTEM IMPLANT and as a
result demonstrated the lowest re-

70 % of the domestic market. Consequently, Australia demonstrated the
highest dental implant fixture ASP in
the region at US$345 in 2014. An increasing number of general practitioners are being trained in dental
implant procedures in Australia,
and general practitioners have been
observed to be more cost sensitive
relative to specialists. As a result of a
growing number of general practitioners in the market, consumer
preferences are shifting towards
discounted solutions. Discount implant companies from the US and
South Korea have recently been
gaining market share in Australia.
Throughout the forecast period, the
premium segment of the market is
expected to grow at far lower annual
growth rates relative to the discount
and value segments in Australia. By
2021, it is expected that discount implants will represent 43 % of the
overall units in the Australian market.
The Japanese and Chinese markets for dental implants are also
dominated by premium companies.
In recent years, OSSTEM IMPLANT
has had a significant impact on the
Chinese market, however, especially as a result of the training programme offered by the company’s
Advanced Dental Implant Research
and Education Center. All segments
of the dental implant market in
China are expected to demonstrate
double-digit annual growth. However, the discount market is set to
grow far more dramatically
throughout the forecast period. By
2021, discount implant fixtures are
set to represent over 50 % of the
overall units in the Chinese dental
implant market.
The shift towards discount implants in Japan is expected to be far
less dramatic, especially owing to
cultural barriers that limit the success of Korean dental implant companies. The premium implant segment is expected to remain the dominant dental implant market
throughout the forecast period. Unit
representation of discount implants
is expected to increase slightly from
12.5 % currently to 14.6 % by 2021.

Fig. 2: China’s dental implant market. The adoption of CAD/CAM final abutments,
which are more expensive, and a growing discount implant segment are set to result
in the final abutment market representing a larger portion of the dental implant market throughout the forecast period.

erage selling price (ASP). In contrast, the final abutment market is
set to experience an increasing ASP
owing to the growing adoption of
CAD/CAM abutments in the place of
stock abutments. While commoditisation of stock abutments has

gional dental implant ASP of US$86
in 2014.
In contrast, the Australian market remains highly dominated by
leading premium implant companies, which collectively held over

The growing acceptance of discount implants has been driven by
Korean companies. The regional
market leader, OSSTEM IMPLANT,
held a 21.9 % share of the total dental
implant market for the Asia Pacific
region in 2014. The company has invested significantly in marketing efforts, which has led to the growing
popularity of its products. Throughout the forecast period, OSSTEM
IMPLANT and other discount implant companies, such as MegaGen,
Dentium and Neobiotech, are expected to capitalise on the growing

Fig. 3: OSSTEM IMPLANT, a Korean discount dental implant company, led the Asia
Pacific market for dental implant fixtures and final abutments in 2014. The company
is expected to continue to capitalise on the growing popularity of discount implants.

Fig. 4: Growing CAD/CAM abutment market vs declining unit share of stock and custom cast abutments. (Source: iData Research Inc.)

popularity of discount implants. In
contrast, premium implant companies, such as Straumann and Nobel
Biocare, are expected to face increasing competitive pressures, especially in China and Australia.

Emphasis on CAD/CAM
In the dental implant market,
the final abutment market is undergoing an opposing pricing trend relative to dental implant fixtures.
CAD/CAM abutments are being increasingly utilised in the place of
cheaply produced stock abutments.
CAD/CAM development has been
relatively rapid in the Asia Pacific
region in recent years. A growing
number of CAD/CAM milling centres have emerged to produce
CAD/CAM abutments for the dental
implant market. The overall region
is set to demonstrate significant
growth in the CAD/CAM segment
for final abutments. In contrast to
the dental implant fixture market,
where discount products are gaining share, the overall final abutment
market is set to demonstrate an increasing ASP. CAD/CAM final abutments are relatively more expensive than stock abutments, which
have traditionally dominated the
market. The shift towards
CAD/CAM abutments is set to be
most significant in China. For the
overall region, units of CAD/CAM
abutments are set to grow at a com-

pound annual growth rate of 22.1 %.
By 2021, CAD/CAM abutments are
forecast to represent 31.6 % of the
overall abutment units in Asia Pacific.

Conclusion
Overall, the dental implant market, including fixtures and abutments, is set to grow at a compound
annual growth rate of 11.5 % for the
Asia Pacific region. The unit growth
will far outweigh the ASP effects, and
the dental implant market will grow
to reach a higher penetration ratio
for the overall Asia Pacific region. DT

Author Info
Dr Kamran Zamanian is a market research analyst for iData
Research (www.
idataresearch.com) in Canada.
He can be contacted at info@
idataresearch.net

Author Info
Celine Mashkoor is also a
market research
analyst at iData
Research.

[11] =>

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[12] =>

DTAP0415_12_Smith 24.04.15 15:42 Seite 1

DENTAL TRIBUNE Asia Pacific Edition No. 4/2015

12 Trends & Applications

“It is very difficult to escape from your
professional status”
An interview with practice manager Gary Smith, Australia

Practice manager Gary Smith

Having been actively involved in the health care business for over 30 years, Sydneybased practice manager Gary

Smith is well aware of the shifting demands practitioners are
facing today. Increasing service
levels, changing expectations of
patients, and achieving a competitive edge through up-todate technology and procedures place increasing pressure
on health care professionals in
terms of both their time and resources, he said. At the recent
Australian Dental Congress in
Brisbane, Dental Tribune Asia
Pacific had the opportunity to
talk to him about this subject,
and why new technology might
not necessarily help reduce the
burden.
Dental Tribune Asia Pacific:
Mr Smith, has the dental business changed much, and what

“For too long in the health
care profession have we allowed the tail to wag the dog.”
are the main challenges of today compared with the past?
Gary Smith: The changing
expectations of patients are one of
the greatest challenges the industry has faced over the years. Patients’ demands are increasing,
along with their expectations of
the level of service to be provided.
The acceptance of the level provided by dental practitioners at
times may differ from the level of
service the patient actually expects, however.

European Academy of Esthetic Dentistry
29th Annual Congress

Florence May 28-30, 2015

Treatment Planning Session
Moderator: Aris TRIPODAKIS
Speakers: Christian COACHMAN , Inaki GAMBORENA,
Siegfried MARQUARDT, Larry BRECHT

Restorative Session
Moderator: Guido BRACCHETTI
Speakers: Bernard TOUATI, Nitzan BICHACHO,
Federico FERRARIS, Vincent FEHMER

Perio-Implant Session

The scientific program has been organized in such a way
that the excellence of the artists of the Renaissance period
will be reached again by the speakers who will present
how to give back to patients a beautiful smile. All topics
involved in this difficult task will be analized and discussed
by leading authors in their fields. The conservative, the
prosthetic, periodontal, orthodontic and maxillofacial
approach will be covered to obtain not only beautiful
teeth but a “renaissanced” smile within a beautiful face.

Speaker: Roberto RE

The social events will be organized in the most traditional
and famous attractions of Florence such as The Galleria
dell’Accademia, home of the David Statue, the Uffizi Gallery
and Palazzo Vecchio but we will also guide the partecipants
into the “hidden Florence” with its shops where textiles
are manifactured the way they were in the Renaissance
period, shoes are hand made and personalized for the
client, artisan perfumes are produced for personal use and
for the house.

Ortho-Maxillofacial Session

We will be waiting for you ready to share with enthusiasm
the best in science, art, food and enjoyment.

Moderator: Gerd KÖRNER
Speakers: Maurizio TONETTI, Leonardo TROMBELLI,
Ueli GRUNDER, Tidu MANKOO

Special Guest Session

Moderator: Massimo RONCHIN
Speakers: Renato COCCONI, Mirco RAFFAINI

John McLean Honorary Lecture

President

Local Chairman

Dr. Giano Ricci

Dr. Andrea Ricci

Moderator: David WINKLER
Speaker: Dan NATHANSON

Peter Schärer Honorary Tx Planning
Session
Moderator: Jaime GIL
Speaker: Tal MORR and Stefan PAUL

Official Congress website:

www. eaed2015.org

The intrusion of government’s
and health insurers’ requirements has changed over the
years, and I believe that the provision of services will become more
complicated as a result of further
involvement of these two groups.
Of course, one of the greatest
challenges remains the running
of a small to medium enterprise.
This, as well as the increasing red
tape and making a profit, will always pose a challenge.
Are practitioners today
more likely to neglect their
work–life balance in favour of
patients?
This depends on the age group
of the practitioners and whether
they are owners or contractors.
Veterans, baby boomers and Generation X practitioners generally
struggle with work–life balance
and have a tendency to put their
patient first. Generation Y practitioners in contrast are very much
aware of their work–lifestyle balance.
Many developed countries
continue to see an increase in
the demand for dental care;
what about Australia? And is
there a disparity regarding the
coverage of dental health care
between rural and urban areas?
There appears to be a shortage
of qualified dentists, but it is all
about the distribution of the professionals. There is indeed a disparity between the urban and the
remote rural areas, and it usually
needs a very special person to set
up a private business in remote
places. This can be a substantial
financial and time commitment.
Is daily practice more stressful for clinicians working in rural areas compared with those
in the cities?
Yes, it is. In most rural areas,
the reality is that you are available
24 hours a day, 7 days a week. It is
very difficult to escape from your
professional status, and there is
an expectation—whether right or
wrong—that you are available
even when you are shopping or
out to dinner.
The challenge we have is to
continue to provide a level of service to our patients with a workforce that places work–lifestyle
balance at the forefront of their
working career.
According to the Australian
Work and Life Index, it is not
only about how much you

work, but also when it is during
unsocial hours. What are the
first warning signs?
There are certain areas of the
working life of a practitioner that,
if not checked, may lead to a poor
work–life balance. These stressors include managing a solo
practice, missed appointments,
patient dissatisfaction with treatment, insurance problems, encroachment, as well as regulations of governmental agencies.
Lack of quiet time, such as not
having breaks from your work, is
also a sign that something is not
right. Of course, the main sign is
burn-out as a result of the level of
demands placed on the practitioner.
How do new technologies influence the work of clinicians?
Are they actually time-saving
tools as advertised or do they
add even more stress, since
practitioners have to constantly keep up and engage with
the latest developments?
I once read the following: “We
work harder and longer to save to
purchase labour-saving devices”.
How true this is. The competitive
edge you have over another
nowadays is up-to-date technology and procedures. It is patients
that drive this prominence of
technology in our business. We
have to be seen to have the equipment that allows us to perform the
latest procedures.
Of course, this increases the
practice’s overheads, not only in
the purchase of the technology,
but also in the running costs to use
the technology, including the
costs to increase the skill sets of
staff through learning and the
maintenance of the technology.
Could you list some strategies to achieve healthy work
routines?
The most effective strategy in
the first instance is to recognise
and accept that there is a
work–life balance problem. Once
it can be identified, it is then a matter of putting a series of strategies
in place to manage the problem.
These strategies may include the
employment of a practice manager, mentoring other staff to take
over certain aspects of the business, and increasing clinical staff
to relieve work overload.
Certainly, all these come at a
cost to the business, but the practitioner has to determine what he
or she wants out of the business.
For too long in the health care profession have we allowed the tail to
wag the dog; it is time for practitioners to take control of their own
strategy and destiny.
Thank you very much for this
interview. DT

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DTAP0415_14-15_Orofacial 24.04.15 14:30 Seite 1

14 Trends & Applications

DENTAL TRIBUNE Asia Pacific Edition No. 4/2015

Avoiding irreversible
dental treatment
Types of orofacial pain and understanding them correctly
Prof. Joanna Zakrzewska
London, UK

Pain is one of the most complex
health conditions encountered,
as it affects not only the sufferers,
but also the community in which
they live. It is often associated
with other co-morbidities, especially anxiety, depression and
chronic pain elsewhere. In the
orofacial region, the most commonly reported pain is dental,
and this inevitably requires a
visit to a dentist, who in most instances can provide a cure. However, there are other pains encountered in the orofacial region
that can become chronic, defined as pain that has been present for over three months. These
pains need to be diagnosed correctly, as their management is
different.
At present, we have no biomarkers for chronic pain, and the
only way we can make a diagnosis
is to listen carefully to the history
the patient gives. We need to elicit
the key features of pain, for example onset, duration, location,
severity, character, provoking and
relieving factors, as well as the impact on quality of life and activities
of daily living. It is essential to determine the presence of other illnesses, especially other chronic
pain. Chronic orofacial pain has a
AD

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DIGITA N
IO
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EDUCA
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significant psychological impact,
as the face used to express pain
from other parts of the body is now
in pain itself. Patients with chronic
orofacial pain are also confused as
to whom they should consult, a
dentist or a doctor. Their choice of
health care provider will significantly affect both first-line treatment and subsequent referral.
Pain is notoriously difficult to
communicate and poor communication of pain is cited as the main
barrier to treatment and management. This “unsharability” of pain
can be correlated with its resistance to language. This results in
an intense burden of suffering and
isolation for the individual. It is
further compounded when patients do not have the requisite language skills. Yet we know that
words may help a clinician in the
differential diagnosis; for example, patients with musculoskeletal
pain will use words such as
“heavy”, “aching” and “nagging”,
whereas those with neurological
causes will describe their pain as
“burning”, “pins and needles”,
“shooting” and “stabbing”.
We also try to measure pain using a scale of 1 to 10, but do these
verbal measures really capture
the experiences of those with facial pain? This question recently
led to a project with a visual artist

to create photographic images of
pain. Thus images were co-created by the artist Deborah Padfield
and facial pain sufferers, aiming to
reflect the individual experience
of pain. A selection of these images
were then made into pain cards,
which are now being used with
other pain patients to help improve mutual understanding and
communication between doctors
and patients. They appear to be
helpful in describing the characteristics of the pain, as well as initiating discussions about its impact.

palpated, the same character pain
is elicited.
A careful history is essential in
order to identify any potential red
flags. It is important to check for
possible temporal arteritis in any-

one over the age of 50 having his or
her first episode, as prompt treatment with steroids is required to
prevent blindness. Any history of
malignancy, neurological deficits,
weight loss or severe trismus will
require prompt investigation.

Once a dental or oral mucosal
cause of pain has been excluded,
the commonest cause of pain in the
lower part of the face is temporomandibular disorders (TMD).
TMD can present as clicking or
locking of the jaw and can come on
suddenly. It can present on only
one side or both. Pain in the muscles of mastication with or without
pain in the joint itself is the commonest form of this group of disorders. It is very common and up to
20 per cent of cases can become
chronic.

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.

The pain is centred in the preauricular area and can spread
down the mandible and neck, as
well as up to the forehead. It can be
associated with clicks on opening
or closing and rarely with reduced
opening. The pain is described as
dull, aching, sore and occasionally
sharp. When the main muscles are

Orofacial pain can have many non-dental causes

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DTAP0415_14-15_Orofacial 24.04.15 14:30 Seite 2

DENTAL TRIBUNE Asia Pacific Edition No. 4/2015
Traditional TMD has been
managed by dentists with the provision of a variety of intra-oral appliances. They do provide pain
relief, but this may be due to the
natural history of the condition.
Current data from the world’s
largest study on TMD in the US
has highlighted that the most
common provoking factors are
psychosocial. There is increasing
evidence that patients with TMD
also experience pain in other
parts of the body and are more
likely to be headache and migraine sufferers. This data therefore suggests that our approach to
management of these conditions
needs to be radically changed to
include a more holistic approach
as described below.
A condition with increasing
incidence is persistent dentoalveolar pain, also known as atypical
facial pain. This is pain in the region of the teeth and/or toothbearing area in which a dental
cause cannot be identified. In
some cases, the pain is related to
nerve injury. This can occur after
extraction of teeth, especially
third molars, as well as after root
canal work, implants or facial
trauma.
This pain is often not identified and leads to extensive irreversible, unnecessary dental
treatment. It is probably a neuropathic pain and so needs to be
managed in the same manner as
other reported neuropathic pains
according to guidelines. Drugs
such as anti-depressants and
anti-convulsants are helpful; opioids are of no help in these conditions. However, management
with medications alone is insufficient. Patients need to be given an
explanation about pain and how it
is influenced by past experiences,
mood, attention, significant life
events, as well as genetic variability.
Evidence shows that chronic
pain outcomes are improved
when a biopsychosocial approach
is used. Cognitive behaviour therapy needs to be delivered by multidisciplinary teams that include
clinical psychologists and physical therapists.
Pain that remains intra-oral
and does not radiate externally is
burning mouth syndrome. This is
defined as a burning pain or discomfort often present continuously on the tongue and other
parts of the oral mucosa. There
are no local or systematic factors
to account for this pain, and often
it is associated with altered taste
and changes in salivary flow. Its
highest incidence is in perimenopausal women, and so it had
for many years been labelled as a
psychological pain; however, recent research has now shown that
this is also a neuropathic pain
with abnormalities especially in
perception of warmth and cold.
There have been a number of
randomised controlled trials performed, but the evidence of any
efficacy is low. Cognitive behaviour therapy is effective, especially if it includes a careful explanation of the potential causes of
this condition and a reassurance
that it is not cancerous.

Another rare pain that dentists
often see is trigeminal neuralgia. It
is defined as a “sudden, usually
unilateral, severe, brief, stabbing,
recurrent pain in the distribution
of one or more branches of the fifth
cranial nerve” that is provoked by
light touch activities. It has a highly
significant impact on quality of life
and if poorly managed leads to depression. In some rare cases, it is
caused by multiple sclerosis or tumours, but its cause is unknown in
the majority of patients. Many patients will have compression of the
nerve inside the skull. The pain of-

Trends & Applications 15

ten presents in the mouth, leading
patients to believe that the cause is
dental and to ask dentists to investigate.
Again, many patients will undergo unnecessary irreversible
treatment until patient or dentist
realises that it is non-dental. In the
early stages, the pain is highly responsive to anti-convulsants, either carbamazepine or oxcarbazepine, and all guidelines suggest this as the first-line drug type.
However, for trigeminal neuralgia,
there is a wide range of treatments,

both medical and surgical, and so
patients need to be seen not only by
neurologists or oral physicians, but
also by neurosurgeons. In correctly diagnosed patients, surgical
outcomes can give the longest pain
relief periods.
It is increasingly important that
dentists recognise that there are
many non-dental causes of orofacial pain. Time needs to be spent in
eliciting a careful history, and irreversible dental treatment must be
avoided. Chronic orofacial pain
patients will have better outcomes

if managed by specialist teams
with multidisciplinary staff. DT

Author Info
Prof.
Joanna
Zakrzewska
leads the largest
UK multidisciplinary
facial
pain unit at University College London Hospitals NHS Foundation Trust.
She can be contacted at
j.zakrzewska@ ucl.ac.
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DTAP0415_16-17_Hajny 24.04.15 16:53 Seite 16

16 Trends & Applications

DENTAL TRIBUNE Asia Pacific Edition No. 4/2015

IPS e.max CAD and Zenostar:
Monolithic brothers
Fabricating individualised monolithic restorations

Fig. 1

Fig. 4

Fig. 7

Fig. 3

Fig. 2

Fig. 5

Fig. 6

Fig. 8

Fig. 9

Fig. 1: Pretreatment view of the lips.—Fig. 2: The pretreatment situation with OptraGate (Ivoclar Vivadent).—Fig. 3: Pretreatment lateral view with OptraGate.—Fig. 4: Clinical situation after removal
of maxillary crowns.—Fig. 5: Wieland workstation and zirconia block.—Fig. 6: Design of the bridge from tooth #23 to 26 in the 3Shape software.—Fig. 7: Design of the cantilever bridge from tooth #33
to 35 with a pontic at tooth #36 and a bridge from tooth #45 to 47.—Fig. 8: Virtual articulation was used to establish the functional characteristics.—Fig. 9: The monolithic zirconia bridges before cementation.
Dr Petr Hajný
Czech Republic

Aesthetic and functional rehabilitation of the anterior dental arch and occlusal height
can be completed in a single
day using IPS e.max CAD
(Ivoclar Vivadent) lithium disilicate ceramics in combination with CAD/CAM technology. In this case, the CEREC
system (Sirona) was used. The
articulation was assessed with
help of T-Scan technology
(Tekscan), which provided excellent results.
Until recently, closing lateral
gaps in patients who refuse implant treatment posed a problem
with timescales for us. For these
cases, zirconia bridges proved to
be a valuable solution. In order
to be able to treat our patients
within a few hours, 48 hours at
maximum, we were looking for
a means of speeding up, or simplifying, this treatment modality. After considering the results
of scientific studies investigating the surface properties and

wear of various polished monolithic zirconia restorations, we
decided to use the Zenotec
CAD/CAM system (Wieland
Dental), as it allowed us to mill
even extensive bridges from zirconia.
In this case, a 60-year-old female patient presented to our
practice complaining about the
colour and length of her teeth.
They had previously been restored with metal–ceramic
crowns in the anterior and
bridges in the posterior region,
and were completely invisible
during speaking and smiling
(Figs. 1–3). The patient desired a
very bright smile, a Hollywood
white smile. She refused implant therapy to close the gaps in
the posterior region. For this
reason, we decided to use all-ceramic bridges. The plan was to
manufacture a bridge spanning
from tooth #23 to 26, a cantilever
bridge from tooth #33 to 35 with
a pontic at tooth #36 and a bridge
from tooth #45 to 47.
Unfortunately, the gingival
tissue was in a poor condition,

which was mainly attributed to
the impact of the metal–ceramic
restorations. Figure 4 shows the
need to increase the vertical dimension. With the help of a
bleach shade guide, the patient
decided on BL2. She did not want
this shade to be toned down with
materials of a darker hue. We
therefore decided to use the unstained, or pure, shade variant for
the fabrication of the Zenostar
bridges (Ivoclar Vivadent) and IPS
e.max CAD LT blocks in the BL2
bleach shade (Fig. 5). Under
normal circumstances, we use
IPS e.max CAD for the fabrication of three-unit bridges up to
the second premolar. This case,
however, required four-unit
bridges and a cantilever bridge
in the posterior region. IPS
e.max CAD does not cover these
indications.

Clinical procedure
After removing the existing
restorations, we inserted FRC
Postec (Ivoclar Vivadent) glassfibre-reinforced composite root
canal posts into teeth #21, 23, 35,

44 and 45. This was followed by
the placement of MultiCore
Flow (Ivoclar Vivadent) core
build-up composite. As the next
step, we replaced all existing
single restorations with crowns
made of IPS e.max CAD milled
with the CEREC MC XL
CAD/CAM system and IPS e.max
CAD LT blocks in shade BL2
(staining technique). The occlusal height was raised on the
same day and temporarily stabilised with Telio CAD (Ivoclar
Vivadent) bridges.
The anterior mandibular
teeth were restored with laminate veneers made of IPS e.max
CAD (staining technique). Prior
to placing the Telio CAD bridges
with Telio CS Link (Ivoclar Vivadent), impressions were
taken using Virtual 380 (Ivoclar
Vivadent). A bite record of the
new vertical dimension was
taken with Virtual CADbite
(Ivoclar Vivadent) silicone material. The bridges were manufactured using a Wieland scanner and a Zenotec mini-milling
unit.

The restorations were designed with 3Shape software
(Figs. 6–8). In order to reconstruct the bridge from tooth #23
to 26, the canine, the first premolar and the second premolar of
the first quadrant were mirrored, while the first molar was
reconstructed on the basis of
data retrieved from the 3Shape
library. From the beginning, the
contours of the molar were very
clear and detailed. Therefore,
no additional manual fissure adjustment was necessary. The
restorations were milled, sintered in a Programat S1 furnace
(Ivoclar Vivadent) and then customised by applying stains from
the Zenostar Art Module in the
staining technique. Finally, the
occlusal contact points were
polished (Fig. 9).
On the second day, the temporary Telio CAD bridges were
removed and the teeth were
cleaned with chlorhexidinecontaining Cervitec Liquid
(Ivoclar Vivadent) mouthrinse.
A try-in was performed without
any problems and additional ad-

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DTAP0415_16-17_Hajny 24.04.15 16:53 Seite 17

DENTAL TRIBUNE Asia Pacific Edition No. 4/2015

Trends & Applications 17

Fig. 11

Fig. 12

Fig. 10

Fig. 13

Fig. 10: The monolithic restorations after 11 months: IPS e.max CAD restorations and Zenostar.—Fig. 11: Anterior view of the rehabilitation.—Fig. 12: Post-treatment view of the lips: the outcome fulfilled
the patient’s wishes.—Fig. 13: Close-up of the monolithic IPS e.max CAD crowns fabricated using the staining technique.

justments were not required.
The restorations were then
cleaned with Ivoclean and
silanised with Monobond Plus
(both Ivoclar Vivadent).
The preparations were pretreated with Multilink Primer A
and B and then seated using
Multilink Automix luting composite (yellow shade; both
Ivoclar Vivadent). After the luting composite had been precured with a Bluephase (Ivoclar
Vivadent) curing light and the
excess material had been removed, the restorations were
permanently cemented in place
by activating the Turbo mode of
the curing light a number of

times. Articulation and occlusal
contact points were assessed
with a T-Scan device and then
the occlusal surfaces were polished (Figs. 10 & 11).

Conclusion
A slight difference in brightness between the Zenostar zirconia bridges and the IPS e.max
CAD crowns was noticeable.
With hindsight, we would adjust
the shade of the Zenostar
framework with Zenostar Color
Zr (Ivoclar Vivadent)colouring
solution before conducting the
sintering process to adapt the
brightness level in such cases.
As an alternative, a pre-shaded

block could be used instead of
adjusting the shade later by
means of the staining technique.
For the patient, her new
bright smile was simply a wish
came true (Figs. 12 & 13). From
our point of view, the 3Shape
software was very efficient in
completing the rehabilitation.
Tooth shapes were easy to copy.
An initial proposal for the design of the occlusal surface of
the posterior teeth was immediately available and could be adjusted quickly and predictably.
The restorations showed a
smooth surface and clearly contoured fissures both on the

screen and after milling in the
four-axis milling unit.
As further adjustments were
not necessary, we were able to
seat the restorations straightaway. Monolithic zirconia
restorations have shown similar, if not lower, levels of enamel
wear on antagonists to other ceramic restorations in clinical
applications. By using monolithic restorations, we are able
to complete certain cases in a
single day. If we consider a recent investigation that evaluated the enamel wear caused by
monolithic zirconia crowns and
other ceramic materials and
compared these results with the

enamel wear caused by natural
antagonists, we may conclude
that we chose a functional and
sensible solution. DT

Reference
Stober, T., Bermejo, J.L., Rammelsberg,
P., & Schmitter, M., “Enamel Wear
Caused by Monolithic Zirconia Crowns
After Six Months of Clinical Use”, J Oral
Rehabil, 41/4 (2014), 314–22.

Contact Info
Dr Petr Hajný is
a
dentist
in
Prague in the
Czech Republic.
He can be contacted at cerec.hajny@email.cz.

[18] =>

DTAP0415_18-19_Arany 24.04.15 15:40 Seite 22

18 Trends & Applications

DENTAL TRIBUNE Asia Pacific Edition No. 4/2015

Innovations with lasers could
lead regenerative dentistry
Praveen R. Arany
USA

With this year, 2015, being designated as the year of light, the
acknowledgment for the key
role of light in multitude areas
of our very existence and more
specifically, in areas of human
health are being widely promulgated.1 Many references to
the beneficial effects of light
and specifically sunlight are re-

such as surgery, oncology, dermatology and ophthalmology.
First discoveries
Following the invention of
this exciting new tool, early biological concerns focused around
the safety of this new device with
natural comparisons being
drawn to ionizing forms of electromagnetic radiation. Among
the early pioneering studies, An-

field from its basic terminology
that prevents accurate indexing
of the literature, to appropriate
disease or biological responsespecific clinical dose recommendations appear to be major barriers. Nonetheless, development
of low power applications has
also shown significant progress
specifically in the areas of traumatic brain injury, post-traumatic stress disorders, reversal

doses (3 J/cm2, 10 mW/cm2, 5
minutes). We performed a, thorough literature search to evaluate possible biological pathways
involved in promoting wound
healing. There appeared to be
distinct correlations with reported use of exogenous TGF-␤1
and laser treatments in wound
healing.
Based on these observations,
we assessed the laser-treated

modalities such as proteases, extreme pH, heat, ionizing radiation and integrin binding among
others. The early wound has
abundant latent TGF-␤ from degranulating platelets present in
the early wounds.
We observed low power laser
treatments were capable of activating the latent TGF-␤1 complex. To further pursue this observation mechanistically, we
noted that near infra-red laser
was capable of generating reactive oxygen species (ROS). This
highly reactive, transient chemical intermediate was sensed by a
key methionine residue on the latent TGF-␤1 complex that resulted in a change in its conformation, resulting in its activation.20

Study 2:
Dentin regeneration

Fig. 1: The use of various wavelengths at different doses can be used for various
clinical applications. The following acronyms are used in this figure PBM—
Photobiomodulation; enPDT—Photodynamic therapy with endogenous chromophores and exPDT—Photodynamic therapy with exogenous chromophores
(dyes).

plete in the literature across
ancient civilisations.
Notably, the ability of concentrated light radiation in the management of lupus vulgaris by
Niels Ryberg Finsen received the
Nobel Prize in Medicine and
Physiology in 1903.2 The all-pervasive nature of opto-photoelectronics in our current society is
readily evident such as the simplest supermarket laser scanners and optical communications to precision medical lasers
and more recent laser weapon
systems. This is also perhaps best
highlighted by this year’s Nobel
Prize in Physics to the inventors
of the blue light emitting diodes
(LEDs), a simple invention with
profound impact on our current
society.3

Clinical laser application
Dentistry has historically
been a leading clinical specialty
in adoption of new technologies.
Light has been a central part of
clinical dentistry from evolutions
of operating lights and fibre optic
illuminations to light cured
restorations and more recently,
optical imaging. Although lasers
were commercially available
since 1960’s, the first dental laser
for hard tissue applications was
approved by the US FDA in 1997.
Adoption for high power soft tissue applications has always been
popular in many medical fields

dre Mester reported a peculiar
phenomenon—high doses destroyed tissue in a precise and
predictable manner but very low
doses produced a startling improvement in wound healing and
promoted hair growth.4, 5 This
was a surprising discovery on
many accounts.
While high energy electromagnetic radiation, such as
Gamma, X-rays and Ultraviolet,
were able to achieve significant
linear energy transfer generating biological damage (nucleic
acid strand breaks), the effects of
visible (and later infra-red)
lasers did not appear to fall
within these routine biological
responses (Fig. 1). With much
excitement, these initial observations spurred many investigations for the use of low powered
lasers and other light devices (including filter-based broad light
sources and LEDs) in many clinical and lab research studies.
Barriers in application
Unfortunately, a combination
of the complexity of the early
technology and a lack of understanding of its biological mechanisms has resulted in significant
discrepancies in their reported
therapeutic benefits. Hence, the
lack of robust clinical efficacy
has largely relegated the field to
being side-lined as a pseudo-scientific and alternative medicine
field. Current problems in the

Fig. 2: Therapeutic outline utilizing laser-generated ROS activated TGF- b 1 to
direct differentiation of dental stem cells and pre-odontoblasts to induce dentin
matrix and subsequent mineralization.

of methanol toxicity and wound
healing. 6-15 In more recent years,
mechanistic insights into lightbiological tissue interactions
have contributed to our better
understanding for the therapeutic applications of laser therapy.16-18
Defining photobiomodulation
Our operational definition for
Photobiomodulation (PBM) is a
form of phototherapy that utilises
non-ionizing sources (including
broad light, LEDs and Lasers) in
the visible and infrared spectrum
that result in therapeutic benefits
such as alleviation of pain or inflammation, immunomodulation and promotion of wound
healing and tissue regeneration.
PBM is a non-thermal process involving photophysical and photochemical events at various
length scales resulting in beneficial photobiological responses.
Its clinical applications could be
appended as PBM therapy.

healing response of oral tissues
for TGF-␤1 expression and noted
increased expression immediately post treatment and at 14
days.19 The increase at 14 days
correlated well with an increase
in monocyte-macrophage influx,
wellknown cellular sources of
TGF-1. We next looked into the
increased early expression of active TGF-1 in these wounds.TGF␤1 is secreted as a latent growth
factor complex when associated
with a Latency Associated Peptide (LAP). The activation
process involves dissociation of
LAP from active TGF-␤1 dimer
that is well-documented with a
wide range of physio-chemical

Having noted the effects of
low power lasers on promoting
oral mucosal wound healing in
the prior study, we extended our
clinical applications to dentin regeneration where TGF-␤1 has
been shown to play a pivotal role
in dentin physiology.21-25 We
noted the ability of low power
lasers to promote dentin regeneration using human dental stem
cells. To validate these observations, rodent pre-odontoblasts
(MDPC-23) cells grown in a polymeric scaffold, simulating a 3-D
niche were treated with low
power lasers.
Laser treatments were able to
induce dentin differentiation as
evident by increased dentin-specific matrix deposition and mineralisation. To confirm the role of
TGF-␤ in vivo, transgenic mice
with lack of TGF-␤ receptor in all
cells capable of inducing dentin
(utilising a Dentin Sialophosphoprotein specific transgene) were
generated. Experiments in these
mice did not demonstrate any
significant dentin induction following laser treatment validating the critical role of TGF-␤ activation in mediating its effects.
Previous studies have shown
the therapeutic benefits of supplementing exogenous (recombinant) TGF-␤ for reparative

Study 1: Activating TGF-␤1
Based on prior reports, we began studies in 1999 to establish
the parameters of the near infrared laser to effectively promote oral wound healing at low

Fig. 3: Potential routes to move the field of PBM towards mainstream clinical dentistry. The wavy path from lab research to clinics is meant to reflect the multistep,
tortuous basic science explorations in a wide range of topics that need to come together to aid in clinical translation.

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DENTAL TRIBUNE Asia Pacific Edition No. 4/2015
dentin, this study suggests the
use of low power lasers can activate endogenous latent TGF-␤1
present naturally in the pulpdentin complex to drive differentiation of resident dental stem
cells (Fig. 2). Thus, this therapy
can utilise the inherent repairregenerative responses naturally present in native tissues.

Clinical Applications of
Laser-Dentin induction
These observations have potent clinical implications where
dentin would need to be therapeutically generated. The two
directly relevant clinical scenarios are for pulp capping following deep carious lesions and for
dentin desensitisation. In the
former case, removal of decayed
or damaged tooth structure approximating the pulp (close to or
clear exposure) that require the
use of pulp capping agents (such
as Calcium hydroxide) could be
potentially replaced with low
power laser treatments.

sponses.27-29 The ability to selectively activate them in a spatiotemporally defined manner in
vivo using low power lasers provides a significant clinical tool
for various therapeutic interventions.
Questions on precise wavelengths, clinical protocol (delivery and dose ranges) and context
of the pathophysiological response are all critical issues that
need to be explored rigorously to
enable further effective clinical
translation of this therapy.30

Trends & Applications 19

Further, the ability to effectively
move this therapy into mainstream clinical dentistry will require more basic research, development of robust clinical
standards and education at various levels (basic dental training
and
continued
education)
(Fig. 3).
In the current era of personalised medicine and strategies to
utilise sophisticated technologies and pharmaceuticals to individualise health care, the significant promise of lasers in clin-

ical dentistry may indeed be the
leading, pivotal technology that
ushers in the new era of regenerative dentistry.
Acknowledgement
This work was supported by
the intramural research program of the National Institute of
Dental and Craniofacial research, National Institutes of the
Health. DT
Editorial note: A list of references is
available from the publisher.

Contact Info
Praveen R.
Arany is an
Assistant Clinical Investigator at the US
National Institutes of Health's Cell Regulation
and Control Unit in Bethesda in
the USA. He can be contacted at
praveenarany@gmail.com.
AD

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

In the second scenario,the
use of low power laser treatments on exposed dentinal
tubules could potentially generate an intrinsic dentin barrier
that would relieve tooth sensitivity. This would be more effective
than our current approach to extrinsically occlude exposed
tubules modes.
The two major limitations of
the current study were that we
noted
calcifications
interspersed throughout the pulp
chamber, spatially distinct from
the laser-biological tissue interface. We believe this is perhaps a
combination of the inherent
near-infrared laser wavelength
that readily permeates throughout biological tissue as well as
the soluble nature of the activated molecules. This could be
potentially addressed by better
optical focusing techniques and
use of specific reagents that absorb the radiant energy and spatially restrict the biological interphase.
A second limitation in this
study was the observation that
laser-generated dentin was a
tertiary or reparative form that
lacks pristine tubular structure.
It appears that additional cues
both biophysical (architecture)
and biochemical (soluble, organizational), are likely necessary
to promote morphodifferentiation of the newly induced dentin.
In attempts to further explore
these molecular mechanisms,
we have more recently extended
developed a polymeric scaffold
system with precise morphogen
fields.26 Using this model, we
were able to extend our observations with dental stem cells and
laser-activated TGF-␤1 mediated dentin differentiation to
mesenchymal stem cells suggesting this approach could have
significant potential with other
stem cell types as well.

Conclusion
Both ROS and TGF-␤ are central biological mediators in a
wide range of biological re-

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[20] =>

DTAP0415_20_Bridges 24.04.15 14:33 Seite 20

20 Trends & Applications

DENTAL TRIBUNE Asia Pacific Edition No. 4/2015

Virtual reality simulation
Indications and perspectives for the technology in the
field of dental education
Dr Susan Bridges, Suzanne Perry &
Prof. Michael Burrow
Hong Kong & Australia

Virtual reality (VR) simulation inevitably conjures up
images of futuristic technology, imaginary worlds or complex robotic devices. What it

Fig. 1: A sketch of an early phantom
head simulator.

may not initially suggest is the
use of virtual technology as a
means of training dental students and dentists, facilitating
the development of skills in a
safe and relaxed environment.
An increase in demand for
simulation units over the last
ten to 15 years has indicated
growing interest from dental
schools, suggesting a certain
confidence that simulation systems have potential as a recognised form of dental skills training in the future. Using technology inspired primarily from the
flight simulation industry, den-

tal simulators are now able to
create an environment in which
users can practise clinical procedures, such as restorative
dentistry, endodontics, periodontal assessment, implant
placement and even dental extractions.
These systems are a far cry
from the first phantom head
simulator created in the early
1900s that attempted to represent the oral cavity with a relatively primitive set of upper and
lower dental casts mounted on a
metal pole (Fig. 1). Although
phantom head systems are now
the mainstay for undergraduate
training, educationalists are becoming more aware of the additional benefits of VR simulation,
such as the ability to repeat the
same task many times, providing real-time feedback leading
to a reduction in supervision,
and the benefits of students being able to practise in their free
time without laboratory supervisors. Other benefits of VR simulators include the reduction of
consumable costs incurred with
plastic teeth and the elimination of water system management issues, reducing the possibility of water-borne infections
such as Legionella.
Undoubtedly, the initial cost
of the VR simulators is a major
deterrent and, with additional
concerns regarding possible
lack of realism to the clinical situation, it is natural that many
suggest the need for more evi-

dence-based research prior to
committing to such an investment. In the limited literature
on VR dental simulation, studies
have been mixed but, in general, are positive about the use
of the technology for dental
training. Research has shown
that procedural learning on VR
simulators may be more effective than with the traditional
phantom head and may reduce
the number of staff–student
interactions without a reduction in the quality of the practical work.
In contrast, other research
has shown that dental performance may be no better using VR
simulation and that some students prefer their training to be
on phantom heads. Naturally,
further research will be needed
to establish the effectiveness of
the technology.

What are haptics?
The addition of haptics to VR
technology creates a dimension
of sensory feedback for the user.
The word itself originates from
the Greek work haptikos, which
means “to touch or grasp”.
There are many examples of
haptic simulation in modernday technology, such as in gaming and the vibration component of a mobile phone. The aim
of haptics in many cases, and especially simulation, is to improve the realism of the virtual
experience. In dentistry, for example, when carrying out a cav-

Fig. 2: The Simodont Dental Trainer (Moog) haptic VR simulator.

ity preparation on a haptic VR
simulator, there is a difference
in hardness felt when cutting
from enamel to dentine, and if
the pulp is damaged an instant
loss of resistance occurs, producing a realistic sensation of
drilling through the roof of the
pulp chamber (Figs. 2 & 3).
Naturally, the important
question is, does the addition of
haptic technology really make a
difference when learning using
VR simulation? To answer this,
we have to delve into surgical
research for which a stronger
evidence base exists, specifically in the area of laparoscopy.
A review of the use of haptics in
surgery suggested that the addition of haptics to simulation can
reduce surgical errors and is especially beneficial in the early
stages of learning a new skill
task. Other studies have shown
that the addition of haptics may
improve overall performance of
surgical skills and may be beneficial when a trainee is first exposed to a clinical situation. In
dentistry, small-scale studies of
haptic VR simulators suggest
that they are at least as good as
phantom heads in training undergraduates.

The future of VR simulation
in dentistry

Currently, exciting research
involving the universities of
Hong Kong and Melbourne is
looking into gaining solid evidence concerning the use of
haptic VR simulation in the dental undergraduate curriculum.
By utilising neuroimaging techniques, identification of the
traits an expert usually displays
can occur, which in turn can be
built into training pathways to
enhance the effectiveness of
procedural learning.

Fig. 3: An image of a cut tooth from the Simodont haptic VR simulator.

Initial findings have suggested that distinct differences
may be apparent in the brains of
dental experts and novices during a simulated clinical task

when using a dental haptic VR
simulator. Further work in this
area is to be carried out, with additional investigation into the
positioning of haptic VR simulation within a curriculum and
considering its effectiveness
compared with traditional
phantom head training techniques.
Already it can be seen that
the area of VR in dentistry and
especially that of haptic VR simulation is proving an interesting
development, offering encouraging prospects for the future
skills-based training of dentists.
The evidence is limited, however, so, prior to commending
this technology as the mainstay
of training in dental undergraduate curricula, there is a compelling need to expand the current research base. DT

Author Info
Dr Susan Bridges is an associate professor at
the Faculty of Education at the
University
of
Hong Kong in
China. She can be
contacted at sbridges@ hku.hk.
Suzanne Perry is
a PhD candidate
at the Faculty of
Education at the
University
of
Hong Kong. She
can be contacted
at sueperr@hku.
hk.

Dr
Michael
Burrow is Professor and Chair
of Biomaterials
at the Melbourne
Dental School at
the University of
Melbourne in
Australia. He can be contacted at
mfburrow@ unimelb.edu.au.

[21] =>

[22] =>

DTAP0415_22-23_Strom 24.04.15 15:33 Seite 1

22 Trends & Applications

DENTAL TRIBUNE Asia Pacific Edition No. 4/2015

Going (unintentionally) green:
The unexpected bonus of switching to CAD/CAM and
same-day dentistry
Dr Joel Strom
USA

With dentistry as innovative
and dynamic as it is, the
progress made and the exciting
new trends that result are often
judged in terms of the technological or financial: We can update our equipment to have a

tistry to their patients; that is, they
condense the restorative process
of multiple appointments over
several weeks down to one
appointment lasting a few short
hours. Clinicians can digitally
scan the patient’s teeth and design the restoration(s) right then
and there. Once approved, the
restoration(s) can be milled and

while remaining chairside, providing patients with that “wow”
factor as they see what digital
technology is allowing dentists to
do. Once designed, the restorations can be immediately milled
in the office and tried in the patient’s mouth, so a perfect fit and
high-quality aesthetics are affirmed at the same appointment.

Digital practice equal green
practices

Since CAD/CAM technology
was first introduced decades ago,
early adopters and technology
enthusiasts have encouraged integration of these systems for various practical and financial reasons. Though generally a substantial initial investment, practices that upgrade to digital
technology find that streamlined
procedures and happier patients
lead to a significant return on investment.

Switching to digital systems is beneficial not only to clinicians
and patients but to the environment as well.

purely digital office, or we can
adopt new practices and offer
new procedures to our patients
that bring in extra revenue.

seated immediately. Essentially,
in-office CAD/CAM systems are
revolutionizing how restorative
dentistry is practiced.

While these accomplishments are certainly laudable, it is
time for dentistry to measure its
progress by different standards,
ones that affect the profession
and the world as a whole. In short,
we can examine how our practices and procedures influence
the environment and what dentistry as a profession can do to ensure this influence remains positive.

This CAD/CAM revolution
provides almost innumerable
benefits to patients. Multiple appointments for one restoration
become non-existent, so patients
no longer need to make multiple
trips to the dental office. Digital
scans eliminate the need for
messy, uncomfortable impressions that make patients gag and
are prone to errors. Temporary
restorations are no longer necessary, removing that extra step
from the restorative process and
ensuring that patients are not at
risk for increased sensitivity or
leakage while wearing sometimes uncomfortable provisionals for weeks. Finally, definitive
restorations are fabricated and
placed within hours of scanning
and can be adjusted immediately,
so patients no longer have to wait
for that perfect laboratory
restoration.

Fortunately, dental professionals no longer have to choose
between advances in technology
and what is considered “ecofriendly.” In fact, practice owners
can assure themselves of the best
of both worlds by adopting digital
technology, such as in-office
CAD/CAM systems such as the
Planmeca PlanScan System (E4D
Technologies). While the practical and financial benefits of
CAD/CAM technology are well
established, the environmental
benefits—though discussed less
often and perhaps not as well understood—abound.

CAD/CAM:
Why dive into digital?

Though not ubiquitous, digital technologies, particularly inoffice CAD/CAM systems, are
making their presence known.
Dental
professionals
who
integrate these advanced technologies can offer sameday den-

Clinicians, too, reap several
benefits. Digital scans equal easier “impressions” that enable accurate reproductions of patients’
dentition. Restorations can be designed in the office without communication or transfer to a dental
laboratory, eliminating backand-forth exchanges that cause
delays or less than optimal results. In fact, restorations can
now be fabricated with more patient input, since intuitive CAD
software enables dentists to easily design restorations on-screen

But switching to a CAD/CAM
system provides an unanticipated bonus, one with a far
broader impact. Using an in-office CAD/CAM system is one of
the most environmentally conscious upgrades a practice can
make, offering both concrete and
intangible benefits for dental
practices, their patients and the
greater community.
CAD/CAM systems add to a
practice’s green image with the
many small changes they allow
the office to implement. For example, now that impressions are
taken with a digital scanner
(PlanScan), traditional impressions—and all their associated
materials, such as disposable impression trays, impression material and the water with which it is
mixed—are no longer necessary.
Clinicians who thought they were
only saving money (and storage

space) can rest easy at night
knowing they’re no longer contributing to the throwaway, disposable culture in many healthcare offices.
Additionally, because digital
impressions can be viewed instantly with software that allows
users to see potential errors, any
mistakes are quickly averted with
a second digital scan that requires no extra materials or
waste. It is not uncommon for
dentists to take a second traditional impression because of errors caused by saliva or air pockets in the impression material or
to have a backup on hand in case
there are problems down the
road. Over time, material waste
created using traditional impression methods adds up. Using digital technology not only streamlines the process but ensures that
materials, time and money aren’t
wasted.
Moreover, because traditional impressions aren’t needed
with a digital workflow, equipment previously used to perform
these procedures, such as a mixing gun for impression material,
are also no longer necessary.
While clinicians may think they
are only saving themselves hassle or time by purchasing an easier-to-use piece of equipment,
they’re also saving energy—literally. With digital technology, impression-taking instruments no
longer need to be run through a
wash cycle and sterilized. This
saves time, energy and water.
While it seems like saving resources, particularly water, isn’t
possible in dental practices, small
steps such as these really add up.
The Eco-Dentistry Association
(EDA) (www.ecodentistry.org)
estimates that dental practices
use 360 gallons of water per day.
This totals 57,000 gallons of water
per year, per practice. In the

United States alone, dental practice water usage totals approximately 9 billion gallons of water
per year. This does not even include dental laboratories, which
must use substantial amounts of
water when mixing and pouring
models in stone and cleaning
their equipment.
In addition to the above in-office water issues, along with laboratories and their respective
procedures that will always require water, these staggering statistics spell out the clear need for
water conservation whenever
possible, and in-office CAD/CAM
supports this effort.

Greener materials: Using all
ceramics instead of amalgam

Amalgam restorations had
been the standard of care in
restorative dentistry for decades.
With material science advancements, however, there are new
contenders for that title. In particular, the use of all-ceramic materials has significantly increased
in recent years, and when coupled with in-office CAD/CAM systems, their advantages are economical and ecological, in addition to aesthetic, biocompatible
and functional.
The majority of the materials
for same day CAD/CAM dental
procedures are generally composite or all-ceramic blocks, so
there is no metal involved. These
metal-free restorations can often
be used without reservation for
various indications, including
single-unit restorations, inlays
and onlays.1 While the benefits of
these materials have been expounded upon (e.g., aesthetics,
ease of use, wear, optical properties.), they provide tangible
environmental benefits as well.

For example, the longevity of
all-ceramic restorations such as
in-office CAD/CAM designed
inlays is well documented.2 In
addition to a highly aesthetic
restoration, patients receive
restorations that will last for
many years, without the concerns
associated with amalgam, such
as cracks, failures or potential
mercury toxicity. This potentially
saves patients and clinicians
time, money and wasted
resources that would be spent
traveling to and from the dental
practice, taking more impressions and fabricating new
restorations.

An average dental practice uses 360 gallons of water per day.
Think how much you can save by getting rid of extra washing cycles.

Perhaps of greater consequence is removing toxic metal
from this equation. All-ceramic
and metal-free restorations
mean that dental practices no
longer have to worry about amalgam disposal and its accompanying mercury toxicity.

[23] =>

DTAP0415_22-23_Strom 24.04.15 15:33 Seite 2

DENTAL TRIBUNE Asia Pacific Edition No. 4/2015
The Environmental Protection Agency (EPA) estimates that
nearly 50 per cent of all mercury
entering local wastewater treatment facilities originates in dental
offices.
Using CAD/CAM compatible
materials such as all-ceramics
lessens or eliminates the contribution of your dental office to environmental mercury. It also
means that dental practices
needn’t worry about using an
amalgam separator.
Currently, the American Dental Association (ADA) does not
have national regulations in place
for amalgam separators, so many
dental practices and laboratories
aren’t compelled to use them.
Although designing and milling
all-ceramic materials still requires energy and results in some
waste materials, can they really
compare with the toxic by products of metal-based restorations?

Crunching the numbers:
CAD/CAM math

In-office CAD/CAM systems
provide more than just a clear
conscience about saving the environment. There are real, tangible
benefits and savings that can easily be estimated to demonstrate
the immense value of this digital
technology.
Because same-day in-office
CAD/CAM dentistry reduces the
number of appointments from
two (or possibly more, if the
restoration does not fit) to one, it
stands to reason that every dentist
who incorporates these procedures would positively impact the
environment by reducing the
number of automobile trips patients make to the practice. This
would result in a 50 per cent reduction in gasoline and oil product use.

the previously calculated 19.4
pounds per gallon measurement).

world, their potential impact,
even estimated, is undeniable.

If we extrapolate to the United
States as a whole, we can calculate
that this would equal 400 million
gallons of gasoline saved and
7,760 million pounds per gallon of
carbon dioxide emissions eliminated, per year. This would all be
due solely to a reduction in patient
automobile trips to and from the
dentist for restorative procedures. While same-day dental
procedures may not save the

Conclusion
In-office CAD/CAM systems’
advantages are limitless. In addition to the clear financial and
practical benefits they bring, their
positive impact on the environment makes the decision to upgrade even better. They remove
toxic, wasteful and disposable
materials and practices from the
equation, replacing them with
greener practices that have a tan-

gible influence. While the clinical
advantages of CAD/CAM systems
and same-day dentistry continue
to be rightfully celebrated, their
ecological advantages should not
be overlooked. DT
Editorial note: This article was published in CAD/CAM C.E. Magazine
No. 01/2014.
References
1. Della Bona A, Kelly JR. The clinical
success of all-ceramic restorations. J
Am Dent Assoc. 2008; 139:8S–13S.
2. Sjogren G, Molin M, van Dijken JW.
A 10-year prospective evaluation of

CAD/CAM-manufactured (CEREC) ceramic inlays cemented with a chemically cured or dual-cured resin composite. Int J Prosthodont. 2004;17(2):241–
246.

Author Info
Dr Joel Strom is
working as a
dentist in the
Greater Los Angeles area in the
US. He can be contacted at
marcy@mydentaloffice.net.
AD

2015
7 – 9 AUGUST

HKIDEAS
Hong Kong International Dental
Expo And Symposium

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
Early-bird Registration:
Deadline: 15 May 2015

With a carbon content of 2,421
grams, one gallon of gasoline produces approximately 19.4 pounds
per gallon of carbon dioxide emissions. This is calculated by multiplying the carbon content (2,241)
by the amount of carbon that remains unoxidized (0.99) by the ratio of the molecular weight of CO2
(44) to the molecular weight of
carbon (12).
Using the state of California
as an example, where approximately 10 per cent of the 100 million laboratory dental restorations are completed in the United
States every year, we can calculate an approximate savings. If
four gallons of gasoline are used
for a round trip to the dentist, a
restoration needing two appointments to complete would require
eight gallons of gasoline. But if
these dental practices adopted
same-day in-office CAD/CAM
dentistry, that number could be
cut in half, saving four gallons of
gasoline per restoration. Four gallons of gasoline multiplied by 10
million restorations would equal
a savings of 40 million gallons of
gasoline for restorative procedures in the state of California
alone. This, in turn, would equal
a reduction of carbon dioxide
emissions by 776 million pounds
per gallon each year (assuming

Trends & Applications 23

Prevention

Quality of Life

Evidence-based

Aesthetics

Longevity

Healthy Aging

Organizer

www.hkideas.org

[24] =>

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[cover] => DT Asia Pacific No. 4, 2015

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Table of contents

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