DT Nordic No. 1, 2015

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DENTAL TRIBUNE
The World’s Dental Newspaper · Nordic Edition
Vol. 1, No. 1

www.dental-tribune.com

PI BRÅNEMARK

A NEW GLOBAL PLAYER

NANO-HYBRID COMPOSITES

University of Gothenburg professor and
companion Tomas Albrektsson about his
recently passed friend and discoverer of
the concept of osseointegration.

DT recently visited the headquarters and main production
facility of MIS, an Israeli specialist in the development and
production of advanced
dental implantology products and solutions.

Aside from ceramic inlays, patients can now choose direct
composites as a functional and
aesthetic alternative to metal
restorations in the posterior
area.

” Page 4

” Page 6

” Page 8

IMPRINT

“The new Nordic edition you are holding in your
hands will cover and analyse everything dentistry
in the region, as well as internationally.”

PUBLISHER:
Torsten OEMUS
GROUP EDITOR/MANAGING EDITOR DT UNITED KINGDOM:
Daniel ZIMMERMANN
newsroom@dental-tribune.com
CLINICAL EDITOR:
Magda WOJTKIEWICZ
ONLINE EDITOR:
Claudia DUSCHEK
ASSISTANT EDITORS:
Anne FAULMANN, Kristin HÜBNER

© ixpert/Shutterstock.com

COPY EDITORS:
Sabrina RAAFF, Hans MOTSCHMANN
PRESIDENT/CEO:
Torsten OEMUS
CFO/COO:
Dan WUNDERLICH
MEDIA SALES MANAGERS:
Matthias DIESSNER
Peter WITTECZEK
Maria KAISER
Melissa BROWN
Weridiana MAGESWKI
Hélène CARPENTIER
MARKETING & SALES SERVICES:
Nadine DEHMEL
ACCOUNTING:
Karen HAMATSCHEK
BUSINESS DEVELOPMENT:
Claudia SALWICZEK
EXECUTIVE PRODUCER:
Gernot MEYER
AD PRODUCTION:
Marius MEZGER
DESIGNERS:
Matthias ABICHT, Alexander JAHN

Published by Dental Tribune International GmbH
Holbeinstr. 29
04229 Leipzig
Germany
Tel.: +49 341 48474-302
Fax: +49 341 48474-173
Internet: www.dental-tribune.com
E-mail: info@dental-tribune.com

Regional Offices
ASIA PACIFIC
DT Asia Pacific Ltd.
c/o Yonto Risio Communications Ltd,
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THE AMERICAS
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116 West 23rd Street, Suite 500, New York,
NY 10001, USA
Tel.: +1 212 244 7181
Fax: +1 212 224 7185

DENTAL TRIBUNE
The World’s Dental Newspaper · Nordic Edition

© 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 not reflect those of
Dental Tribune International.

Editorial
Dear reader,
The majestic tranquillity of the landscape, a liberal lifestyle and simple yet
timeless design—these are only some of
the distinguishing characteristics of countries in the northern part of Europe. What
they also have in common is extraordinary
dentistry. In 2008, Sweden, Norway and
Denmark were the first countries in the
world to ban dental amalgam, thereby setting a trend that has gained momentum recently with the signing of the Minamata
Convention on Mercury, which aims to
eradicate the industrial use of mercurycontaining products on a global scale.
It is also here in the north where, among
other important inventions, such as the air
turbine handpiece, the concept of dental
implantology was born with the breakthrough discovery of the possibility of integrating bone tissue with an artificial material like titanium by University of Gothenburg researcher Per-Ingvar Brånemark.
Sadly, the field lost one of its most ingenious and probably most modest personalities at the end of last year when he passed
away after a period of illness; we mourn
him.
His innovative spirit, however, has survived in the form of the many innovative
dental businesses based in the region. With
a strong focus on digital technologies,
these companies will continue to play an
important part in the way dentistry will be
conducted around the world in the future.
Something Nordic dentistry has been
missing is a speciality publication for the
approximately 25,000 professionals who
conduct their trade between the sandy
beaches of Lolland and the icy cold of the
Arctic Circle. Addressing this need is the latest edition to Dental Tribune International’s portfolio.
Developed as a pan-regional title, the
new Nordic edition you are holding in your
hands 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 distinguished Dental Tribune partners in almost every corner of the
world for the last two decades. We are
pleased to welcome you as a member of our

already extensive global readership of
600,000 dental professionals and look forward to your opinions and suggestions.
Sincerely,
The Dental Tribune Nordic editorial team

AD

P R IN T
L
DIGITA N
TIO
EDUCA
EVENTS

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.

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??????????
NEWS

Dental Tribune Nordic Edition | 1/2015

New research
on glass ionomer cements

Fig. 1: Dr Heloisa Bordallo, associate professor and materials researcher at the Niels Bohr Institute at the University of Copenhagen and Dr Ana Benetti, dentist
and researcher at the Odontological Institute at the University of Copenhagen, collaborated in the development of a strong material for tooth fillings made
out of glass ionomer cement. (Photo courtesy of Niels Bohr Institute, Denmark) – Fig. 2: Glass ionomer cement powder can be mixed with a liquid by hand
without the use of special equipment and the material does not need to be illuminated with a lamp to harden. (Photo courtesy of Niels Bohr Institute, Denmark) – Fig. 3: X-ray and neutron images show how porous the cement is. On the left are X-rays of teeth with fillings of glass ionomer cement, on the right are
images of the same teeth using neutron scattering. Pores and cracks are better visible in the X-ray images due to better resolution (a, c, e). The neutron images
suggest that interconnecting pores or cracks are filled with liquid (b, f), while some of the larger pores seem to be empty (d). (Photo courtesy of Benetti, A.R. et
al., Scientific Reports).

COPENHAGEN, Denmark: An interdisciplinary team of scientists from the Niels

Bohr Institute at the University of Copenhagen is developing a strong and easy-to-

1 Year Clinical Masters Program
TM

in Aesthetic and Restorative Dentistry
12 days of intensive live training with the Masters in Athens (GR) and Geneva (CH)

Three sessions with live patient treatment, hands-on practice, plus
online training under the Masters’ supervision.
Learn from the Masters of Aesthetic and Restorative Dentistry:

Registration information:
12 days of live training with the Masters
in Athens (GR), Geneva (CH) + self study

Curriculum fee: €9,900
(Based on your schedule, you can register for this program one session at a time.)

Collaborate
on your cases

University
of the Pacific

and access hours of
premium video training
and live webinars

you will receive
a certificate from the
University of the Pacific

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.

Details on www.TribuneCME.com
contact us at tel.: +49-341-484-74134
email: request@tribunecme.com

100 C.E.

CREDITS

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
program provider are accepted by AGD for Fellowship, Mastership, and membership
maintenance credit. Approval does not imply acceptance by a state or provincial board of
dentistry or AGD endorsement.

use material comprised of glass ionomer
cement for tooth fillings. The researchers
analysed the effect of different preparation
methods on the texture and durability of
the material.
Tooth fillings have to resist high mechanical forces, as well as bacteria and
chemicals. Since ancient times, a variety of
materials have been used, each with its advantages and drawbacks. According to the
scientists, amalgam, for example, is a
strong material, but has the disadvantage
of containing mercury. Some non-toxic options, such as composite materials based
on acrylate, however, have proven to have a
lower longevity under the harsh conditions
of the mouth in a number of studies and
need to be replaced more frequently. In addition, composite materials require an adhesive to bond the filling to the tooth.
In the current study, a glass ionomer cement was used as a restorative material because it is biocompatible and mercury-free,
according to the researchers.“Glass
ionomer cement has the advantage that it
does not need an intermediate layer of adhesive to bond to the tooth and it also has
the interesting property in that it releases
fluoride, which helps to prevent cavities.
The material also has good biological properties, while it is almost as strong. Our research therefore focuses on understanding
the connection between the microstructure of the material and its strength in order to improve its properties,” explained
Dr Ana Benetti, dentist and researcher at
the Faculty of Health and Medical Sciences
at the university.
When pulverised, glass ionomer cements
can be mixed with a liquid by hand without
the use of special equipment. Further, the
material does not need to be illuminated
with a lamp to harden, something that is
necessary for composite materials. The latter is an advantage in places with no electricity, such as remote parts of Africa, China
or South America.
Two problems with the current glass
ionomer cement are that the material is

porous and that tiny pockets in the cement
can retain fluid, which causes the cement to
crumble. The researchers therefore considered the best way to mix the cement to
avoid crumbling. They experimented with
two different types of pulverised cement.
One contained a blend of acid and was later
mixed with water. The other was acid-free
and blended with water containing an
acidic mixture.
In order to determine which preparation
process made the fillings most stable, the
researchers afterwards performed a series
of radiographic and neutron-scattering experiments that were carried out at the
Helmholtz Centre for Environmental Research in Berlin. “First, we took X-rays of the
teeth with the cement fillings. They show
the structure of the material. Glass
ionomer cement is porous and you can get
an accurate image in 3-D, which shows the
microstructure,” explained Dr Heloisa Bordallo, associate professor and materials researcher at the Niels Bohr Institute. Next,
the scientists captured images of the material using neutron scattering in order to visualise hydrogen atoms, which are found in
all liquids.

By comparing the radiographs with the
neutron images, the researchers determined which preparation process resulted
in a drier and thus more stable material.
“Experiments showed that the combination where the acid is mixed up in the cement, so you only have to add water to the
cement powder is the weakest material,”
explained Bordallo. The strongest material
resulted from cement powder mixed with
water that had had acid added to it. Thus, it
is better to have the acid in the water, since
it helps to bind the liquid faster and more
strongly to the cement and leaves less water in the pores, according to her.
However, the scientists concluded that at
this point of the development process
there is still too much loose liquid in the
pores of the material. Therefore, the research on glass ionomer cements will continue with new mixtures, including natural
minerals added to the cement, in future experiments.
The results of the latest research were
published online in the Scientific Reports
journal on 10 March in an article titled
“How mobile are protons in the structure of
dental glass ionomer cements?”.

[3] =>

NEWS

Dental Tribune Nordic Edition | 1/2015

Study finds e-learning as good as traditional training for health professionals
LONDON,UK: Electronic learning could
enable millions more students to train as
doctors and nurses worldwide, according to
the latest research. A review commissioned
by the World Health Organization (WHO)
and carried out by Imperial College London

While the study focused on the education of
students, DTI follows a similar approach to continuing education, offering webinars via its
Dental Tribune Study Club, which it launched

in 2009. The platform regularly offers free online courses and in several languages. The wide
range of topics includes general dentistry, digital dentistry, practice management, as well as

specialties, such as implantology and endodontology. The webinars are presented by
experienced speakers and participants are
awarded continuing education credits.
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Dr. H. Gräber

(DTI/Photo Odua Images)

researchers concluded that e-learning is
likely to be as effective as traditional methods for training health professionals. These
new findings support the approach to continuing education Dental Tribune International (DTI) has adopted with its free online
education platform for dental professionals.
The Imperial team, led by Dr Josip Car, carried out a systematic review of the scientific
literature to evaluate the effectiveness of
e-learning for undergraduate health professional education. They conducted separate
analyses on online learning, which requires
an Internet connection, and offline learning, delivered via CD-ROMs or USB flash
drives, for example.
The findings, drawn from a total of 108
studies, showed that students acquire
knowledge and skills through online and
offline e-learning as well as or better than
they do through traditional teaching.
E-learning, the use of electronic media
and devices in education, is already used by
some universities to support traditional
campus-based teaching or to enable distance learning. Wider use of e-learning
might help to address the need to train
more health workers across the globe. According to a recent WHO report, the world is
short of 7.2 million health care professionals, and the figure is growing.
The authors suggest that combining
e-learning with traditional teaching might
be suitable for health care training, as practical skills must also be acquired.
According to Car, from the School of Public Health at Imperial, “E-learning programmes could potentially help address
the shortage of healthcare workers by enabling greater access to education; especially in the developing world the need for
more health professionals is greatest.”

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15:11:58

[4] =>

NEWS

Dental Tribune Nordic Edition | 1/2015

Per-Ingvar Brånemark—
An innovative genius
Prof. Tomas Albrektsson, Sweden, remembers the man who changed dentistry with
the discovery of osseointegration of dental implants

Per-Ingvar Brånemark.

Per-Ingvar Brånemark passed away on 20
December 2014 at the age of 85. Throughout
his career as a researcher, he overcame fierce
opposition to dental implants and revolutionised methods for treating edentulous patients.
An extremely gifted scientist, Brånemark
was also as witty and quick on his feet as they
come. Various language editions of Reader’s
Digest, hardly considered a medical journal
of note, published an article in the late 1960s
about his research on microcirculation. At
the end of his first lecture about dental implants in Landskrona in Sweden in 1969, a
member of the audience, who turned out to
be a senior academic of Swedish dentistry,
rose and commented, “This may prove to be a
popular article, but I simply do not trust people who publish themselves in Reader’s Digest.” As it happened, that senior academic
was well known to the Swedish public for having recommended a particular brand of
toothpick. Brånemark immediately rose and
struck back, saying, “And I don’t trust people
who advertise themselves on the back of
boxes of toothpicks.”
Young and naive as I was, I thought they
were just poking fun at each other, but it
turned out to be the opening shot of an eightyear battle with the dental profession. When
someone cast aspersions on dental implants
several years later because Brånemark was
not a practitioner, he lost no time in replying,
“Teaching them anatomy is good enough for
me.”
Brånemark completed his medical training at Lund University in 1959 with a doctoral
thesis on microcirculation in the fibula of
rabbits. Grinding the bone to a state of
transparency permitted the use of intravital
microscopy to analyse the blood flow in both
bone and marrow tissue. The thesis, which
found wide recognition both in Sweden and
abroad, landed Brånemark an appointment
at the Department of Anatomy of the University of Gothenburg just a year later. He was
appointed as Associate Professor of Anatomy
(later received a full professorship) in 1963,
which qualified him for laboratories of his

own and the opportunity to surround himself with a team of researchers.
Brånemark continued to pursue his studies in microcirculation in animal models and
ultimately in humans. A plastic surgery technique was used to prepare soft-tissue cylinders on the inside of the upper arm. He then
inserted optical devices encased in titanium
that enabled intravital microscopy of microcirculation in male volunteers.
By the late 1960s, he was able to produce the
highest resolution images of human circulation in the history of medicine. Many people

optical device had fused into the bone, a
process that he eventually dubbed osseointegration. He revealed his incomparable
strength as a researcher at that very moment,
realising immediately that the discovery had
clinical potential and determining to focus on
the development of dental implants, an enterprise that had hitherto been regarded as beyond the scope of medical science.
Brånemark grasped the fundamental
truth that edentulousness represents a significant disability, particularly for people
who cannot tolerate dentures for some reason. He operated on his first patient in 1965, a
mere three years later. The academic community was largely distrustful and hostile to
the new approach. The debate was not put to
rest until 1977, when three professors at
Umeå University in Sweden announced that
Brånemark’s technique was the recommended first-line treatment. Opposition in
other countries eventually waned as well and
dental implants, originally manufactured by
a mechanic in the basement of the Department of Anatomy, scored one international
triumph after another.
Nowadays, an estimated 15–20 million osseointegrated dental implants are installed
every year, and a number of different academies in the field hold annual conferences attended by as many as 5,000 participants
each. The University of Gothenburg features
a permanent exhibit on osseointegration
technology and there is a museum in Brånemark’s honour at the Faculty of Stomatology
of Xi’an Jiaotong University in Xi’an in China.

inserted behind the ear. Hundreds of thousands of patients around the world have had
operations based on the technology initially
developed in Gothenburg under his direction. Those of us who were on the team at the
time will never forget a teenage girl who suffered from the effects of thalidomide. The
medicine had caused not only limb deformities, but also hearing loss in many patients.
Equipped with the new hearing device, she
learnt to speak flawlessly.
The team also targeted facial deformities
occasioned by congenital or acquired injuries. A number of implants installed in the
viscerocranium served as fasteners for silicon prostheses, a much more attractive option than attaching them to the patient’s
glasses. Since the first operation in 1977, the
use of the technology has become widespread internationally.
Titanium implants installed in the femur
were the next spin-off of Brånemark’s research. Patients with above-knee amputations cannot have socket prostheses around
soft tissue and may have to rely on a wheelchair to get around. Inserting titanium
screws in the femoral stumps permitted the
installation of a prosthesis and the ability to
walk again. I can still remember the first patient as if it were yesterday. Another teenage
girl had been run over by a streetcar in
Gothenburg and had above-knee amputations in both legs. She was consigned to
spending the rest of her life in a wheelchair.
The operation was highly successful and she
learnt to walk again.

Acclaimed around
the world

Dental Group Editor Daniel Zimmermann talking to Per-Ingvar Brånemark at a conference in Gothenburg in 2009. (Photos Archive)

are familiar with Lennart Nilsson’s photographs of circulation that were taken at Brånemark’s laboratories and developed at the Department of Anatomy. Brånemark used a hollow optical device surrounded by titanium to
study microcirculation in rabbit bone, permitting both bone and blood vessels to grow
through a cleft where they could be examined
by means of light microscopy. During such an
experiment in 1962, he discovered that the

The P-I Brånemark Institute has been also established in Bauru in Brazil.

Brånemark was fuelled by a passion to help
difficult-to-treat patients, and many of his
clinical discoveries from the first dental implant on were made in response to cases that
had been regarded as hopeless. His innovative genius, fortified by a large research laboratory at the Department of Anatomy, also
skyrocketed Gothenburg-based pharmaceutical companies like Nobel Biocare and Astra
Tech into leading positions in the global market. He was devoted to the academic community’s social responsibility long before many
of his colleagues were aware of, much less accepted, the concept. Ultimately, the world
came around and he was awarded honorary
doctoral degrees by 29 universities and honorary memberships by more than 50 scientific associations—not to mention the Royal
Swedish Academy of Engineering Sciences’s
medal for technical innovation, the Swedish
Society of Medicine’s Söderberg Prize, the European Inventor Award for Lifetime Achievement and many other distinctions around
the world. DT

Not only dentistry

Prof. Tomas Albrektsson

Back in the 1970s, Brånemark began collaborating with ear specialists and technicians
at Chalmers University of Technology to explore the additional potential of osseointegrated implants for developing hearing aids

is working as a professor at the
universities in Gothenburg and
Malmö in Sweden. He can be
contacted at tomas.albrektsson@biomaterials.gu.se.

[5] =>

[6] =>

BUSINESS

Dental Tribune Nordic Edition | 1/2015

“It is our mission
to simplify dental implantology”
DT visits the MIS headquarters and main production facility in Israel
MIS Implants Technologies is a global specialist in the development and production of
advanced dental implantology products and
solutions. The company, which started as a family-run business, was founded in 1995—a
time when not many people understood the
potential of dental implants, CEO Idan
Kleifeld told Dental Tribune (DT) at a meeting
at the beginning of 2015.
Since its beginnings, MIS has seen significant growth, especially within the past ten
years. “Today, the company has succeeded in
building a recognised global brand in the
market and is the only non-premium company operating on a global scale,” Kleifeld
said. Headquartered in Israel, MIS currently
has operations in 65 countries worldwide,
covering major dental markets, such as the
US, China and Germany, through a well-established network of local distributors.
In 2009, MIS moved operations to a large
purpose-built production complex located
in a new high-tech industrial park in northern Israel. “Our location adds to our uniqueness. Israel is a country of high innovation
and offers particularly favourable conditions
for manufacturing, because of the quality of
education and people’s high levels of motivation. Furthermore, salaries are much lower
than in competitor countries, making manufacturing especially profitable,” he stated.
The MIS building in the Bar-Lev Industrial
Park spans about 10,000 m² and has two production floors with 50 Swiss high-precision
machines running 24 hours a day from Sunday to Friday. “The facility was designed and
built for growth. In the near future, our automatic warehouse, which currently covers
only half of its potential total area, will double
in size,” Kleifeld explained.
DTI further learnt that MIS primarily produces for stock, as products must be shipped
to local distributors within two working days.
For increased efficiency, processes controlling quality, sterilisation, packaging and storage are largely automated. This allows MIS to
produce over 800,000 implants per year.
The production site in Israel has a dedicated training centre with a fully equipped
dental clinic for live surgeries. Kleifeld said,
“We see education as an important tool to acquire new customers, especially in developing markets. It is an important driver in this

MIS headquarters (Photos courtesy of MIS, Israel)

business, and we offer doctors both fundamental and advanced training courses on
MIS products and protocols.”
In 2015, MIS will be introducing some important innovations. Only recently, the
company officially opened its MCENTER Europe, the new MIS digital dentistry hub in
Berlin in Germany, in order to meet the needs
of its growing customer base in central Europe. The centre offers direct services provided by locals to local customers, bringing
all MIS digital dentistry products together in
one location. It is aimed at providing a comprehensive range of services to clinicians
through advanced digital dentistry and
CAD/CAM technologies that facilitate fast
and accurate surgical implant procedures
with reduced chairside time and greater predictability in outcomes.
“We are extremely excited about the opening of the new MCENTER Europe facility, and

Production.—Right: MIS Implants Technologies CEO Idan Kleifeld.

especially proud to be able to offer MIS quality and simplicity in providing our customers throughout the region with highly
accurate and efficient guided implant place-

high-quality implants that
are completely new in the
market and will fit within
the premium segment.
MIS plans to offer this new
implant system to its
global distributors at the
end the second quarter of
2015, for local distribution
worldwide.
The name MIS originally
stood for “Medical Implant
Systems”. However, it is
also an acronym that reflects the company’s main
maxim to “Make it Simple”. “It is our mission to
simplify dental implantology and, in order to become the preferred choice
of dentists worldwide, we
offer new and innovative
products based on simple,
creative solutions. Design
and handling are made
simpler, and all products
are engineered to allow efficient, time-saving surgical procedures,” Kleifeld
said. “With this simplified
approach, we are set to become the largest global
dental implant producer,” he added.
However, the “Make It Simple” motto appears to apply to more than the company’s
products. The MIS philosophy defines almost

“We are set to become the largest global
dental implant producer.”
ment procedures and CAD/CAM solutions,”
said Christian Hebbecker, MCENTER Europe
Manager.
In addition to the new MCENTER Europe,
the company will be entering the premium
segment for dental implants with the launch
of a new implant system later this year. It has
a truly innovative design and consists of

all areas of the business (from human resources to production), and the organisational structure is simple and characterised
by flat hierarchies. “Make it Simple” embodies the start-up mentality that remains vibrant in a company that has become one of
the largest in the global dental implant market.

[7] =>

BUSINESS

Dental Tribune Nordic Edition | 1/2015

VGi evo from NewTom boosts standard
CBTC performance
Innovative system features SHARP 2D technology and Eco Scan
Pioneers of CBCT imaging in the dental
industry, NewTom creates solutions for
clinical diagnostics. An efficient international distribution network, research and
development spanning over two decades,
and reliability have made NewTom a
benchmark in 2-D and 3-D radiology. Its 5G
Cone Beam 3-D imaging system, for example, is capable of scanning numerous
anatomical areas, including the dental
structures, small joints, and the maxillofacial and cervical regions. GiANO is a hybrid
2-D device upgradable to full 3-D.
Representing the engineering evolution
of the NewTom range and its latest addition
is VGi evo, which performs 3-D imaging,
panoramic imaging, teleradiography and
2-D sequential imaging. The device introduces a new image chain, which includes
features that increase standard CBCT performance, such as an enlarged flat panel
sensor, with an improved signal–noise ratio and a rotating anode generator with a
0.3 mm focal spot.
Owing to 51 scan modes, NewTom VGi evo
provides specialists with a system that
adapts to the specific needs of different
clinical applications. The field of view

For safeguarding the health of both patient and operator, the device uses pulsed
emission, which activates the X-ray source

only when required, and a standard examination entails only 1.8 seconds of total exposure. In addition, VGi evo features the

new Eco Scan mode (available for all fields
of view) that, combined with SafeBeam
technology, further reduces the dose.
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NewTom has also introduced the innovative SHARP 2D technology, which enables
VGi evo to generate a complete set of 2-D
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[8] =>

TRENDS & APPLICATIONS

Dental Tribune Nordic Edition | 1/2015

Functional and aesthetic alternatives
to metal restorations
Nano-hybrid composites have become the material of choice in the posterior region
Prof. Jürgen Manhart, Germany
Composites have been in use for approximately three decades as an aesthetic alternative to metal restorations in the load-bearing
posterior region.1 Early clinical data on composites used in the posterior region collected
in the early 1980s was not encouraging, primarily owing to insufficient mechanical
properties. The low abrasion resistance of
those composite materials led to loss of
restoration contours. Fractures, marginal deterioration and leakage after polymerisation
shrinkage were other reasons for the limited
longevity of those restorations.2–5
Predominantly in recent years, it has been
possible to reduce these inadequacies greatly
through further developments in composite
materials and adhesive systems.6 Nevertheless, the negative effects of polymerisation
shrinkage, such as poor marginal integrity,
insufficient adherence to the cavity walls or
cusp deflections, are still the greatest problem with composite-based materials.7 According to the type and size of the inorganic
fillers used, composites can be categorised
into8 conventional macro-filled composites,
micro-filled composites and hybrid composites.
With the introduction of innovative composite derivatives, particularly in the last 10
to 12 years, further classifications, for example by filler content (affects the viscosity of
the composite) or by differences in the
monomer matrix (classic methacrylates,
acid-modified methacrylates, ormocers with
an inorganic–organic compound matrix,
ring-opening silorane systems), have increased in importance.9 Composites are
processed in incremental layers, usually in
single increments with a maximum layer
thickness of 2 mm. The individual increments are each polymerised separately, with
exposure times of 10–40 seconds depending
on the light intensity of the curing device and
shade/translucency of the respective composite paste.
Direct composite restorations have become an essential, integral component in the
therapy spectrum of modern restorative
dentistry. They are used, among other reasons, because of the broad range of application, the conservative and adhesive stabilisation of the dental hard tissue, as well as the
economical and time-saving procedure followed, in comparison with indirect restoration alternatives.10

The joint statement by the Deutsche
Gesellschaft für Zahnerhaltung (German Society for Conservative Dentistry) and the
Deutsche Gesellschaft für Zahn-, Mund- und
Kieferheilkunde (German Society of Dental
and Maxillofacial Sciences) on direct composite restorations in the posterior region
(indications and longevity) in 2005 summarises the scientifically verified range of
application of direct composites,10 which are
indicated for the restoration of Class I, Class II
(including replacement of individual cusps),
as well as Class V lesions.
Restricted indications include cases with
restricted accessibility, limited imaging of
the working area, unstable marginal adaptations or problematic proximal contact
shapes, as well as cases involving insufficient
oral hygiene (especially in interdental
spaces) or severe parafunction and missing
occlusal support of the antagonist tooth on
enamel.
Clinicians should decide against the use of
direct composites if patients lack the ability
to achieve adequate moisture control (risk of
contamination of the cavity with blood,
saliva or sulcular fluid) or have allergies to the
constituents of composites and adhesives.

Hybrid composites
Nowadays, hybrid composites are the material of choice when using a direct restoration technique for the permanent treatment
of larger primary carious lesions or the replacement of older, insufficient restorations
in the posterior region. Prerequisites are the
correct use of the matrix technique and adequate moisture control of the cavity.11 Hybrid
composites contain a mixture of ground
glass or quartz fillers with a particle size in the
micrometre range and fumed silica microfillers. As the grinding technology for the
production of glass fillers has consistently
improved, a distinction can now be made between hybrid composites (mean particle size
of < 10 µm), fine-particle hybrid composites
(mean particle size of < 5 µm), ultrafine-particle hybrid composites (mean particle size of
< 3 µm) and submicron-filled hybrid composites (mean particle size of < 1 µm).9
Owing to their filler technology and content, hybrid composites have the necessary
physical and mechanical properties for successful clinically permanent restoration of

even large anterior Class IV cavities
and load-bearing posterior Class I
and II cavities. Modern types with
fine, ultrafine and submicronfilled particles now also ensure excellent polishing properties of the
surface with long-term retention
of the surface gloss. They can therefore be
used for all Black’s classes of cavity, which is
the reason that they are referred to as universal composites. These composites can be applied either in a highly aesthetic polychromatic multilayer technique with different
dentine, body and enamel shades, or in the incremental single-shade technique.
Nanotechnology-modified hybrid composites have been successfully established
on the market for a number of years and represent an interesting new development
based on the most recent research. Aside
from ground glass fillers, they make use of
nano-fillers that are similar in size to microfillers. However, the individual, non-agglomerated nanomers are more evenly distributed throughout the organic matrix. The
filler content, as well as the excellent mechanical properties, corresponds to that of
regular hybrid composites. Nanotechnology-modified composites are currently used
as universal composites in the anterior and
posterior regions.

Clinical case
The following clinical case describes the replacement of an amalgam restoration in the
maxilla with the nano-hybrid composite
GrandioSO (VOCO) using the single-shade
layer technique.
A 39-year-old female patient visited our
surgery with the wish to have her last remaining amalgam restoration, on tooth #16, replaced with a tooth-coloured composite
restoration. The tooth was not sensitive to
percussion and responded positively to a
sensitivity test using a cold spray. After thorough cleaning with a fluoride-free prophylaxis paste and a rubber cup (Fig. 1), the shade
was chosen based on the moist tooth, while
avoiding strong colour contrasts with the immediate surroundings and before applying
the rubber dam (Fig. 2). The reversible lightening process caused by loss of moisture on
the tooth surface, as well as the strong contrast against the coloured rubber dam, would

otherwise have made it impossible to select
the correct shade.
Figure 3 shows the situation after the removal of the amalgam restoration. After excavation and the subsequent finishing of the
cavity margins, a rubber dam was applied
(Fig. 4). The rubber dam isolates the operating
site from the oral cavity, facilitates clean and
effective work, and guarantees that the working area remains clean of contaminating substances such as blood, sulcular fluid and
saliva. Contamination of the enamel and
dentine would result in distinctly poorer adhesion of the composite to the dental hard
tissue and endanger the long-term success of
a restoration with optimal marginal integrity. Additionally, the rubber dam protects the patient from irritating substances,
such as the adhesive used. The rubber dam is
thus an essential aid to simplify the working
process and ensure quality in the adhesive
technique. The minimal effort required to
apply the rubber dam is compensated for by
avoiding the need to change wet cotton rolls
and the patient’s requests for rinsing.
The next step of treatment involved the application of the adhesive technique. Figure 5
shows the application of ample amounts of
the universal bonding agent Futurabond DC
(VOCO) to the enamel and dentine. After it
had been rubbed in for 20 seconds, the solvent was carefully evaporated with compressed air. Then the bonding agent was polymerised with light for 10 seconds (Fig. 6), resulting in a shiny cavity surface evenly covered with adhesive (Fig. 7).
This should be carefully checked before the
restorative material is applied, since any areas of the cavity that appear dull are an indication that an insufficient amount of adhesive has been applied to those sites. In the
worst case, this could result in reduced bond
strength of the restoration and in reduced
dentinal sealing, which may lead to postoperative sensitivity. Should such areas be found
during the visual inspection, an additional
amount of bonding agent is again selectively
applied to those areas.

Fig. 1: Situation before treatment: old amalgam restoration in a maxillary molar. –
Fig. 2: Shade selection with the composite-specific shade guide. – Fig. 3: Situation
after removal of the old restoration. – Fig. 4: After excavation, the tooth was isolated
from the oral cavity using a rubber dam. – Fig. 5: Application of the bonding agent
Futurabond DC to enamel and dentine with a mini-brush. – Fig. 6: Light polymerisation of the bonding agent. – Fig. 7: The cavity, evenly covered with adhesive, has a
shiny surface. – Fig. 8: First horizontal increment of GrandioSO composite and subsequent polymerisation. –

[9] =>

[10] =>

TRENDS & APPLICATIONS

Dental Tribune Nordic Edition | 1/2015

Fig. 9: With the second increment, the mesiopalatal cusp was modelled and subsequently polymerised. – Fig. 10: With the third increment, the distopalatal cusp was modelled and subsequently polymerised. –
Fig. 11: Modelling the remaining occlusal surface. – Fig. 12: Final light curing. – Fig. 13: The result after finishing and polishing. The tooth shape and aesthetics were successfully restored.

The cavity was subsequently restored with
GrandioSO in the single-shade layer technique. The initial step involved the placement of a 2 mm thick horizontal increment
AD

in Shade A2 directly from one of the caps into
the defect (Fig. 8), followed by 10 seconds of
polymerisation with an LED curing light (intensity of > 800 mW/cm2). This created a

level cavity floor on which the occlusal relief
could then be finalised by further sequential
composite increments in the oblique layer
technique. First, the mesiopalatal cusp was

carefully sculpted and then polymerised for
10 seconds (Fig. 9). The distopalatal cusp and
the palatal extension of the cavity were then
built up with composite and light cured
(Fig. 10). Next the mesiobuccal and distobuccal cusps were each carefully shaped in two
more increments (Fig. 11) and, again, each
subjected to a 10-second polymerisation cycle (Fig. 12). When shaping the occlusal
anatomy, clinicians should take care to carefully model the surface details and remove
excess material while still plastic. This will facilitate the subsequent finishing procedure
significantly and limit it to just a few steps.
After removal of the rubber dam, the composite restoration already showed good occlusal contours. After finishing with fine-grit
diamond burs and preliminary polishing
with diamond-impregnated polishers (Dimanto, VOCO), the dynamic and static occlusion was checked with articulating paper and
any remaining slight interferences were adjusted. The subsequent high-gloss polishing
was performed with reduced pressure on the
Dimanto polishers and optimised the lustre
of the restorative material. The final result
(Fig. 13) shows that functionally and aesthetically pleasing restoration of the affected
tooth was achieved.
The importance of direct composite-based
restorative materials will continue to increase in the future. These are scientifically
proven high-quality permanent restorations
for the masticatory load-bearing posterior
region, and their reliability has been documented in the literature. The results of a comprehensive meta-analysis have shown that
the annual failure rates are not statistically
different to those of amalgam restorations.12
Minimally invasive treatment protocols, in
combination with the ability to detect carious lesions earlier, also have a positive effect
on the survival rates of such restorations.
In order to ensure a high-quality direct
composite restoration with good marginal
adaptation, however, a careful matrix technique (involving proximal areas), an effective dentine adhesive, correct processing of
the restorative material, and the achievement of a sufficient level of polymerisation
of the composite are still required.
A distinct increase in aesthetic awareness
in recent years means that much of the population is no longer willing to accept metal
restorations and request tooth-coloured alternatives. Aside from ceramic inlay restorations, patients can choose direct composite
restorations as a permanent treatment. Their
performance, even in the masticatory loadbearing posterior region, has been proven in
many clinical studies.
Editorial note: A complete list of references is
available from the publisher.

Prof. Dr Jürgen Manhart
is a professor in the Department of Restorative Dentistry
and Periodontology at the
University of Munich in Germany. He can be contacted at
manhart@manhart.com.

[11] =>

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[12] =>

TRENDS & APPLICATIONS

Dental Tribune Nordic Edition | 1/2015

Crisp images of the upper neck with
Planmeca’s CBCT device

Fig. 1: Seppo Villanen, Specialist in physical medicine and pain treatment (on the right) and Radiologist
Raija Mikkonen. – Fig. 2: Mika Mattila, Specialist in oral and maxillofacial radiology at Pantomo Oy,
uses Planmeca ProMax 3D to scan the patients referred to him by Seppo Villanen. (Images courtesy of
Juha Kienanen)

Two years ago, Seppo Villanen, a Finnish specialist in physical medicine and pain treatment, visited Planmeca’s stand at the Finnish
Medical Convention and saw a CBCT image of a
patient with an obvious sequel of a fracture in
the neck area. This gave him the idea of using
Planmeca’s 3-D imaging device for imaging patients with neck problems. The idea turned out

to be a success, and nearly 30 patients have now
been imaged in cooperation with Pantomo Oy,
a company offering dental X-ray imaging services.
Seppo Villanen has his practice at Mehiläinen
medical centre in the Helsinki metropolitan
area. The patients he has referred for a CBCT examination have mostly been patients suffering

from pain in the upper neck. “During a routine
MRI scan of the neck, the upper neck is usually
left outside the image, since the scan acquires
transverse slices from the C3 vertebra downwards. What’s more, a regular X-ray examination of the neck is routinely performed in a
manner that also leaves the upper neck outside
the image. CBCT imaging, on the other hand,
covers the entire upper neck, from the base of
the skull to the C4 vertebra, which is precisely
the area that is often missing from routine
studies.”
Villanen’s neck patients are referred to Oral
and Maxillofacial Radiology Centre Pantomo
Oy for imaging with Planmeca ProMax 3D, and
the images are interpreted by Radiologist Raija
Mikkonen at Terveystalo medical centre. “We
have cooperated with Raija for years”, says Villanen.
In most cases, CBCT imaging is done to support MRI imaging, since the methods complement each other. In some cases, however, a
CBCT scan is all that is needed: “It does not provide an insight into soft tissues, but if the image
is sufficient to provide an answer to the current
question, other methods are not needed.”
Conversely, bony structures do not show up
well in MRI images, and small bones can be easily confused with scar tissue. “In a CBCT image,
even small changes in the bone are plainly visible”, describes Mikkonen.

Thin slices, low radiation
doses and a natural head
position

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One of the many benefits of CBCT imaging is
the low radiation dose compared to a traditional CT scan. Moreover, the method produces
very thin slices, down to 0.16 mm. In hospitals,
trauma CT scans are usually performed with a
slice thickness of 2 mm, and MRI scans are
sometimes performed with a slice thickness of
up to 5 mm.
“The thinner the slice, the more reliable it is
when you are studying small things”, says Villanen. “Thin slices have better resolution and afford better measurements. A 2 mm slice does
reveal large fractures, but small avulsion fractures might remain undetected.”
Furthermore, a CBCT scan can be postprocessed to include all required slice thicknesses. “They can also be acquired in a high resolution CT scan, but that would produce an even
higher radiation dose”, describes Mikkonen.
Also, the patient position is better in a CBCT
scan than in a CT scan. A CT scan is acquired with
the patient lying down, whereas in a CBCT scan,
the patient is sitting up, allowing a more natural
head position. “In a lying position, the load of
the head is not completely natural. All in all, radiologists should make more use of functional

imaging, so that patients could be imaged in
their normal working positions, for example.”

Fast imaging
increases patient comfort
From the patient’s perspective, a CBCT scan is
quite pleasant—in addition to the low radiation dose, the procedure is quick. A regular MRI
scan takes about 20 to 30 minutes, and a functional MRI scan up to two hours, but a CBCT scan
is complete in less than a minute.
“Many patients have been surprised at the
brevity of the scan”, says Mika Mattila, Specialist
in oral and maxillofacial radiology, who is in
charge of imaging the neck patients referred to
Pantomo Oy by Villanen. “Planmeca’s device
has a handy cervical spine program that sets the
device automatically to the right position. The
only difference in patient positioning, compared to dental patients, is that the head of neck
patients must be turned with extreme caution.”
The open patient positioning also pleases patients with claustrophobia. “Some patients
may be very relieved by not having to go into a
tube for a scan.”

CBCT images
of trauma patients
Some of Villanen’s CBCT patients have sustained a neck or head injury in an accident: a car
accident, horse riding accident, a fall, or by a
heavy object falling on their head at a construction site. The patients range from 17 to 80 years
of age, and the majority of them are women.
“Research shows that, all other things being
equal, women are more prone to injuries in a car
crash than men. The head position is crucial in
a crash, and women often make the mistake of
first turning their head to see if the children in
the back seat are okay. You should not look back,
but protect yourself ”, says Villanen.
Villanen and Mikkonen state that the upper
neck is a relatively new area of interest in imaging and medicine. “The upper neck has been
somewhat of a no-man’s land, even though it is

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[13] =>

TRENDS & APPLICATIONS

Dental Tribune Nordic Edition | 1/2015

Pantomo too is very happy about this cooperation that has been going on for a few years
now. What started as a pilot experiment now
provides genuine benefits. “It is great to discover new applications for this imaging
method, since we can now obtain additional information and examine the cause of a patient’s
problems”, says Mattila.

CASE PRESENTATION
Fig. 4a: Marked loss of height at the right atlanto-axial joint (C1–C2). Calcification and small bone cysts
present in the bone under the articular surface. The structure of the bone is clearly visible.
Fig. 4b: Marked loss of height and osteophyte formation at the right atlanto-axial joint. A cyst under
the articular surface on the side of the C2 vertebra.

one of the most mobile joint systems in the
body. A neuroradiologist examines the brain,
while a radiologist usually examines the area
below the C3 vertebra. Treatment of a neck injury patient is a challenging multidisciplinary
effort that requires a clinician, a physiotherapist and a radiologist. If a brain or spinal injury
is also suspected, the team needs a neurologist
and a neuropsychologist as well.”
A CBCT scan is an economical imaging
method for which many insurance companies
have agreed to cover the costs, describes Villanen.

Patient case (Figs. 4a–d)
A 58-year-old woman, generally healthy.
During the past two years, her neck has become
so sore and stiff that she can no longer turn her
head. Dizziness spells. A lot of soreness on the

right side, at the vertebral level C1/C2. No inflammatory arthritis found.
CBCT imaging indications for the neck area:
– Determining the bony anatomy of the upper
neck on levels C0–C4 (not indicated for imaging ligaments);
– Fractures of the upper neck;
– Avulsion injuries of the upper neck;
– Differential diagnostics of arthrosis/rheumatoid arthritis of the upper neck;
– Subluxation and abnormal rotation positions
of the upper neck.
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A new standard
of resolution
CBCT images are also useful in examining
osteoporosis and degenerative changes, since
thin slices provide an accurate insight into
bone structure. “Compared to the resolution of
CT images, CBCT images are on a whole new
level”, states Villanen.
The Planmeca Romexis software suite is an
effective working tool for the radiologists: “The
software is fast, visual and easy to use, and various measurements and scrollings work well. It
is also a very visual tool in the training of physicians and physiotherapists.”

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Fig. 4c: The dens has moved to the left in relation to the C1 vertebra. Osteophytes in the atlanto-axial joint.
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[14] =>

TRENDS & APPLICATIONS

Dental Tribune Nordic Edition | 1/2015

Diclofenac, dexamethasone
or laser phototherapy? Part I
Jan Tunér, Sweden

In the May 2013 edition of Photomedicine
and Laser Surgery, the editorial written by
Prof. Tina Karu is titled “Is it time to consider
photobiomodulation as a drug equivalent?”
Well, is it? Let us have a look and see what the
literature has to say about two very popular
drugs:
NSAIDs (non-steroidal anti-inflammatory
drugs) are the best sold pharmaceuticals
ever. The short-term effects on pain and inflammation are obvious and valuable. The
long-term effects, however, have been questioned and this is especially valid considering
the many side effects of NSAIDs. Millions of
patients are on long-term medication with
NSAIDs, and even lifelong. Indeed, many persons die from their medication. So an alternative option is required. I believe it is already
available: laser phototherapy! First, let us
have a look at the strength of the scientific evidence for NSAIDs as such, and long term use
of these in particular:
The meta-analysis by Bjordal1 on the effect
of NSAIDs on knee osteoarthritis pain appears to become important for the recognition and future development of LPT. Let us
read the abstract: The research group summarises that non-steroidal anti-inflammatory drugs (NSAIDs), including cyclo-oxygenase-2 inhibitors (coxibs), reduce short-term
pain associated with knee osteoarthritis only
slightly better than placebo, and long-term
use of these agents should be avoided. Up for
analysis were 23 placebo-controlled trials involving 10,845 patients, 7,767 of whom received NSAID therapy and 3,078 placebo
therapy. All in all 21 of the NSAID-studies were
funded by the pharmaceutical industry, and
the results of 13 of these studies were inflated
by patient selection bias as previous NSAIDusers were excluded if they had not previously responded favourably to NSAID. Such
an exclusion criterion for non-responders
has never been seen in any controlled trial of
LPT or other non-pharmacological therapies
of osteoarthritis. In the remaining ten unbiased NSAID-trials, the difference from
placebo was only 5.9 mm on a 100 mm pain
scale.

This is far less than established data on differences that are considered minimally perceptible (9 mm) or clinically relevant (12 mm)
for knee osteoarthritis patients. In addition,
none of the trials found any effects beyond
13 weeks. This bleak support for long term use
of NSAIDs is an excellent support for nonpharmaceutical methods, such as LPT. Diclofenac is one of the best-selling NSAIDs.
Several investigators have compared the effect of LPT and diclofenac.
The aim of a study by Marcos2 was to evaluate the short-term effects of LPT or sodium
diclofenac treatments on biochemical markers and biomechanical properties of inflamed Achilles tendons. Wistar rats Achilles
tendons (n = 6/group) were injected with
saline (control) or collagenase at peritendinous area of Achilles tendons. After one hour
animals were treated with two different
doses of LPT (810 nm, 1 and 3 J) at the sites of
the injections, or with intramuscular sodium
diclofenac. Regarding biochemical analyses,
LPT significantly decreased COX-2, TNF-alpha, MMP-3, MMP-9, and MMP-13 gene expression, as well as PGE2 production when
compared to collagenase group. Interestingly, diclofenac treatment only decreased
PGE2 levels. Biomechanical properties were
preserved in the laser-treated groups when
compared to collagenase and diclofenac
groups.
Ramos3 investigated the effects of LPT
(810 nm) in rat-induced skeletal muscle
strain. Male rats were anaesthetised with
halothane prior to the induction of muscle
strain. Previous studies have determined
that a force equal to 130 % of the body weight
corresponds to approximately 80 % of the ultimate rupture force of the muscle tendon
unit. In all animals, the right leg received a
controlled strain injury while the left leg
served as control. A small weight corresponding to 150 % of the total body weight was attached to the right leg in an appropriate apparatus and left to induce muscle strain twice
for 20 minutes with three-minute intervals.
Walking index, C-reactive protein, creatine
kinase, vascular extravasation and histologi-

cal analysis of the tibial muscle were performed after six, twelve and 24 hours of lesion induction. LPT in an energy-dependent
manner markedly or even completely reduced the Walking Index, leading to a better
quality of movement. C-reactive protein production was completely inhibited by laser
treatment, even more than observed with
Sodium diclofenac inhibition (positive control). Creative Kinase activity was also significantly reduced by laser irradiations. In conclusion, LPT operating in 810 nm markedly
reduced inflammation and muscle damage
after experimental muscle strain, leading to
a highly significant enhancement of walking
activity.
The aim of the study by de Almeida4 was to
analyse the effects of sodium diclofenac (topical application), cryotherapy, and LPT on
pro-inflammatory cytokine levels after a
controlled model of muscle injury.
For such, we performed a single trauma in
the tibialis anterior muscle of rats. After one
hour, animals were treated with sodium diclofenac (11.6 mg/g of solution), cryotherapy
(20 min), or LPT (904 nm; superpulsed;
700 Hz; 60 mW mean output power;
1.67 W/cm2; 1, 3, 6 or 9 J; 17, 50, 100 or 150 s). Assessment of interleukin-1 and interleukin-6
(IL-1 and IL-6) and tumour necrosis factor-alpha levels was performed at six hours after
trauma employing enzyme-linked immunosorbent assay method. LPT with 1 J dose
significantly decreased IL-1, IL-6, and TNF-alpha levels compared to non-treated injured
group as well as diclofenac and cryotherapy
groups. On the other hand, treatment with diclofenac and cryotherapy does not decrease
pro-inflammatory cytokine levels compared
to the non-treated injured group. Therefore,
the authors conclude that 904 nm LPT with 1 J

dose has better effects than topical application of diclofenac or cryotherapy in acute inflammatory phase after muscle trauma.
The purpose of a study by Albertini5 was to
investigate the effect of LPT on the acute inflammatory process. Male rats were used.
Paw oedema was induced by a sub-plantar injection of carrageenan, the paw volume was
measured before and one, two, three and four
hours after the injection, using a hydroplethysmometer. To investigate the action mechanism of the GaAlAs laser on inflammatory oedema, parallel studies were
performed using adrenalectomised rats or
rats treated with sodium diclofenac. Different laser irradiation protocols were employed for specific energy densities (EDs), exposure times and repetition rates. The rats
were irradiated with laser for 80 s each hour.
The EDs that produced an anti-inflammatory
effect were 1 and 2.5 J/cm2, reducing the
oedema by 27 % and 45.4 %, respectively. The
ED of 2.5 J/cm2 produced anti-inflammatory
effects similar to those produced by the cyclooxigenase inhibitor sodium diclofenac at
a dose of 1 mg/kg. In adrenalectomised animals, the laser irradiation failed to inhibit the
oedema. These results suggest that LPT possibly exerts its anti-inflammatory effects by
stimulating the release of adrenal corticosteroid hormones.
The aim of a work by Meneguzzo6 was to investigate the effects of infrared 810 nm on
the acute inflammatory process by the irradiation of lymph nodes, using the classical
model of carrageenan-induced rat paw
oedema. Thirty mice were randomly divided
into five groups. The inflammatory induction was performed in all groups by a subplantar injection of carrageenan (1 mg/paw).
The paw volume was measured before and

[15] =>

Dental Tribune Nordic Edition | 1/2015

1, 2, 3, 4 and 6 hours after the injection using a
plethysmometer. Myeloperoxidase (MPO)
activity was analysed as a specific marker of
neutrophil accumulation at the inflammatory site. The control group did not receive
any treatment (GC); GD group received
sodium diclofenac (1 mg/kg) 30 minutes before the carrageenan injection; GP group received laser irradiation directly on the paw
(1 Joule, 100 mW, 10 sec) one and two hours after the carrageenan injection; GLY group received laser irradiation (1 Joule, 100 mW,
10 sec) on the inguinal lymph nodes; GP+LY
group received laser irradiation on both paw
and lymph nodes one and two hours after the
carrageenan injection. MPO activity was similar in the sodium diclofenac as well as in the
GP and GLY groups, but significantly lower
than the GC and GP + LY groups. Paw oedema
was significantly inhibited in GP and GD
groups when compared to the other groups.
Interestingly, the GP+LY groups presented
the biggest oedema, even bigger than in the

TRENDS & APPLICATIONS

response that was significantly lower than in
CRG group over the time-course of the study,
especially in the LST group, which showed exuberant granulation tissue with intense vascularization, and deposition of newly formed
collagen fibres (three and seven days).
The aim of a study by de Almeida7 was to
analyse the effects of sodium diclofenac (topical application) and LPT on morphological
aspects and gene expression of biochemical
inflammatory markers. The researchers performed a single trauma in the tibialis anterior muscle of rats. After one hour, animals
were treated with sodium diclofenac
(11.6 mg/g of solution) or LPT (810 nm; continuous mode; 100 mW; 1, 3 or 9 J; 10, 30 or
90 s). Histological analysis and quantification of gene expression (real-time polymerase chain reaction-RT-PCR) of cyclooxygenase 1 and 2 (COX-1 and COX-2) and tumour
necrosis factor-alpha (TNF-alpha) were performed at six, twelve and 24 h after trauma.
LPT with all doses improved morphological

of the COX-2 isoform in collagenase-induced
tendinitis, LPT may have the potential to become a new and safer non-drug alternative to
coxibs.
The aim of the study by de Paiva Carvalho9
was to evaluate the effect of single and combined therapies (LPT, topical application of
diclofenac and intramuscular diclofenac) on
functional and biochemical aspects in an experimental model of controlled muscle
strain in rats. Muscle strain was induced by
overloading tibialis anterior muscle of rats.
Injured groups received either no treatment,
or a single treatment with topical or intramuscular diclofenac (TD and ID), or LPT (3 J,
810 nm, 100 mW) 1 h after injury. Walking
track analysis was the functional outcome
and biochemical analyses included mRNA
expression of COX-1 and COX-2 and blood levels of prostaglandin E2 (PGE2). All treatments
significantly decreased COX-1 and COX-2
gene expression compared to the injury
group. However, LPT showed better effects
than TD and ID regarding PGE2 levels and
walking track analysis. The author concludes
that LPT has more efficacy than topical and
intramuscular diclofenac in treatment of
muscle strain injury in acute stage.
Crystalopathies
are
inflammatory
pathologies caused by cellular reactions to
the deposition of crystals in the joints. The
anti-inflammatory effect of He-Ne laser and
that of the non-steroidal anti-inflammatory
drugs (NSAIDs) diclofenac, meloxicam, celecoxib, and rofecoxib was studied in acute and
chronic arthritis produced by hydroxyapatite and calcium pyrophosphate in rats. The

presence of the markers fibrinogen, L-citrulline, nitric oxide, and nitrotyrosine was
determined. In the study by Rubio10, crystals
were injected into the posterior limb joints of
the rats. A dose of 8 J/cm2 of energy from a
He-Ne laser was applied for three days in
some groups and for five days in other
groups. The levels of some of the biomarkers
were determined by spectrophotometry, and
that of nitrotyrosine was determined by
ELISA. In arthritic rats, the fibrinogen, L-citrulline, nitric oxide, and nitrotyrosine levels
increased in comparison to controls and to
the laser-treated arthritic groups. When comparing fibrinogen from arthritic rats with
disease induced by hydroxyapatite to
healthy and arthritic rats treated with
NSAIDs, the He-Ne laser decreased levels to
values similar to those seen in controls. Inflammatory and oxidative stress markers in
experimental crystalopathy are positively
modified by photobiostimulation.
Editorial note: To be continued with further
studies on the effectiveness of diclofenac and
LPT and conclusion in roots 3/2014. An list of
references is available from the author.

Dr Jan Tunér
specialised in the field of laser
phototherapy. He maintains a
private practice in Grängesberg in Sweden and can be contacted at
jan.tuner@swipnet.se.

control group. LPT showed an anti-inflammatory effect when the irradiation was performed on the site of lesion or at the correlated lymph nodes, but showed a pro-inflammatory effect when both paw and lymph
nodes were irradiated during the acute inflammatory process.
The aim of a study by Barretto23 was to investigate the analgesic and anti-inflammatory activity of LPT on the nociceptive behavioural as well as histomorphological aspects
induced by injection of formalin and carrageenan into the rat temporomandibular
joint. The 2.5 % formalin injection (FRG
group) induced behavioural responses characterized by rubbing the orofacial region and
flinching the head quickly, which were quantified for 45 min. The pre-treatment with systemic administration of diclofenac sodiumDFN group (10 mg/kg i.p.) or irradiation with
infrared LPT (LST group, 780 nm, 70 mW, 30 s,
2.1 J, 52.5 J/cm2), significantly reduced the formalin-induced nociceptive responses. The
1 % carrageenan injection (CRG group) induced inflammatory responses over the
time-course of the study (24 h, three and
seven days) characterised by the presence of
intense inflammatory infiltrate rich in neutrophils, scanty areas of liquefactive necrosis
and intense interstitial oedema, extensive
haemorrhagic areas, and enlargement of the
joint space on the region. The DFN and LST
groups showed an intensity of inflammatory

aspects of muscle tissue, showing better results than injury and diclofenac groups. All
LPT doses also decreased COX-2 compared to
injury group and to diclofenac group at 24 h
after trauma. In addition, LPT decreased TNFalpha compared both to injury and diclofenac groups. LPT mainly with dose of 9 J is
better than topical application of diclofenac
in acute inflammation after muscle trauma.
Yet another study by Marcos8 investigated
if a safer treatment such as LPT could reduce
tendinitis inflammation, and whether a possible pathway could be through inhibition of
either of the two-cyclooxygenase (COX) isoforms in inflammation. Wistar rats (six animals per group) were injected with saline
(control) or collagenase in their Achilles tendons. Then they were treated with three different doses of IR LPT (810 nm; 100 mW; 10 s,
30 s and 60 s; 3.57 W/cm2; 1 J, 3 J, 6 J) at the sites
of the injections, or intramuscular diclofenac, a nonselective COX inhibitor/
NSAID. It was found that LPT dose of 3 J significantly reduced inflammation through less
COX-2-derived gene expression and PGE2
production, and less oedema formation compared to non-irradiated controls. Diclofenac
controls exhibited significantly lower PGE2
cytokine levels at 6 h than collagenase control, but COX isoform 1-derived gene expression and cytokine PGE2 levels were not affected by treatments. As LPT seems to act on
inflammation through a selective inhibition

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[cover] => DT Nordic No. 1, 2015

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Table of contents

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News / Business / Trends and applications

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