DT Nordic No. 3, 2016

Nordic News / World News / Business / Interview with Dr Claudio Pinheiro Fernandes - Brazil: “ Going green is our business - not somebody else’s - but everybody’s responsibility” / Improving patient experience in daily dental practice / Evaluating the cariogenicity of food ingredients / Possibilities and risks of digital techniques in implant dentistry / Minimally invasive veneer restoration with a ceramic-based restorative material

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DENTALTRIBUNE
The World’s Dental Newspaper · Nordic Edition
www.dental-tribune.com

INTERVIEW

Established in 2015, the Eklund
Foundation for Odontological
Research and Education has announced the first four projects to
receive funding.

For Dr Claudio Pinheiro Fernandes,
going green is not an option,
but the responsibility of all—an
interview about sustainability in
dentistry.

” Page 2

” Page 7

KNOW YOUR PATIENTS

Shutterstock.com

GRANT RECIPIENTS

Vol. 2, No. 3
Peter Bering on how practitioners
can improve communication with
their patients and thereby boost
treatment acceptance.

Published in Scandinavia

” Page 8

Hidden periapical periodontitis Caffeine
© Stas Walenga/Shutterstock.com

By DTI
HELSINKI, Finland: A new study at
the University of Helsinki has
found that hidden periapical periodontitis increased the risk of
coronary artery disease (a cardiovascular disease). According to the
researchers, infections of the root
tip of a tooth are very common—
about one in four Finns suffered
from at least one in the study
group—and are often unnoticed
by patients, as they can be present
without obvious symptoms.
Although there is a great deal
of research on the connection between oral infections and many
common chronic diseases, such
as heart disease and diabetes,
periapical periodontitis has been
investigated relatively little in
this context. In the recent study,
58 per cent of the patients, who
presented with symptoms requiring examination via coronary

Periapical periodontitis is very common and often has no obvious symptoms. New findings from the University of Helsinki
indicate that the condition could be a risk factor for acute coronary syndrome.

angiogram, had one or more such
inflammatory lesions.
“Acute coronary syndrome is
2.7 times more common among

patients with untreated teeth in
need of root canal treatment
than among patients without
this issue,” said lead author Dr
John Liljestrand. Moreover, the

study found that periapical periodontitis was connected with a
high level of serum antibodies
” Page 2

toothpaste
By DTI
NEW YORK, USA: Introducing the
world’s first caffeinated toothpaste, Power Toothpaste, two
young US entrepreneurs want to
ease people’s start into the day.
Unlike coffee, which takes up
to an hour to be fully absorbed
through the stomach, Power
Toothpaste begins working immediately, being absorbed through
the gingivae, according to the
company’s founders Dan Meropol
and Ian Nappier.

After a year of research, development, formula refinement,
a partnership with a Food and
Drug Administration-compliant
American manufacturer, and
a drove of press coverage, the
toothpaste can now be ordered
online for the unit price of
$14.99 at the company’s website:
www.powertoothpaste.com.
AD

Antibiotics in dentistry
By DTI
COPENHAGEN, Denmark: The
Danish Health Authority has released new national guidelines
addressing the use of antibiotics
in dental care. “Antibiotic-resistant

bacteria are a growing problem
that can cause even minor infections to become life-threatening.
Therefore, we hope that the
national clinical guidelines will
help to reduce the use of antibiotics,” stated Dr Karen Geismar,

a dentist and chairperson of the
working group that drafted the
new guidelines.
“It is important to emphasise
that in some cases treatment requires the use of antibiotics; however, it should not be a routine
treatment in dentistry,” Geismar
emphasised. “Our recommendations are based on the careful
consideration of the expected effects of a treatment with antibiotics and the patient’s risk of an oral
infection in relation to the overall
problem—the increase of antibiotic-resistant bacteria.”
According to the health authority, the new guidelines aim
to ensure uniform quality treatment across the country and
are primarily targeted at private
practitioners who regularly prescribe antibiotics in their practice. In the past, various studies
have indicated an alarming
overuse of antibiotics in general
dental practice.

The Danish Health Authority has recently issued national clinical guidelines
aimed at curbing the use of antibiotics in dental practice.

Dental Tribune International

ESSENTIAL
DENTAL MEDIA

More information can be found
at www.sundhedsstyrelsen.dk.
www.dental-tribune.com

[2] =>

NORDIC NEWS

Dental Tribune Nordic Edition | 3/2016

Eklund Foundation announces
first grant recipients
By DTI
MALMÖ, Sweden: Established in
2015 by Swedish oral care company TePe, the Eklund Foundation
for Odontological Research and
Education has announced the first
four projects to receive funding.
Through a total of SEK1.56 million
(€160,913) granted, the foundation
will be supporting oral health research in Sweden, Italy and the
Netherlands on topics such as the
association between periodontitis
and rheumatoid arthritis, complications in implant treatment and
peri-implant disease.
For their study titled “Oral
conditions in patients with rheumatoid arthritis: A populationbased case–control study”, Prof.
Stefan Renvert and his research
team from Kristianstad University will receive SEK708,426
(€73,913), the largest portion of the
funding. “Today there are scien-

tific studies both supporting and
not supporting a connection between periodontitis and rheumatoid arthritis, and this study may
contribute towards shedding light
on the possible connection between both these diseases,” said
the foundation’s board on its decision to support the project.
A grant of SEK311,766 (€32,000)
has been awarded to Dr Alexa
Laheij from the Academic Centre
for Dentistry Amsterdam in the
Netherlands for her project titled
“The oral cavity as a source of
febrile neutropenia: An observational study in patients with solid
tumors treated with myelosuppressive chemotherapy”. Furthermore, Dr Paolo Ghensi from the
University of Trento in Italy will
receive SEK389,707 (€40,000) for
his project titled “Metagenomic
profiling of the microbiome associated with peri-implant diseases
through high-resolution shotgun

This is the first funding of
research and education in oral
health to be granted by the Eklund
Foundation since its establishment in 2015. “We are happy
to be able to contribute to the
important odontological research
of today,” said Joel Eklund, CEO
of TePe and Chairman of the foundation. Applications were open
for international projects in all
fields of dentistry from 1 to 31 May
2016.

sequencing”. Fellow Italian researcher Dr Eriberto Bressan from
the University of Padova and his
team have been granted the sum
of SEK146,140 (€15,000) for their
study titled “Primary prevention
of complications in implant treatments: Protocol for maintenance
of dental implants”.

The next round of applications for funding will run over the
same period in 2017. According
to the company, projects related
to periodontology, implantology
and cariology, as well as applications from postdoctoral researchers, will again be prioritised in the
selection process.
More information about the
application process can be found
at www.eklundfoundation.org.

Sweden: New age assessment
method for young refugees
By DTI
STOCKHOLM, Sweden: Starting in
2017, Sweden’s National Board of
Forensic Medicine will be using
a new age assessment system for
unaccompanied child refugees
that is based on radiographs of
third molars and knee joints. By
examining both indicators, the

15 and 17 years of age aroused suspicion in the past. With the new
estimation system, officials hope
to resolve uncertain cases, the
agency announced at a press conference last week.

According to Sweden’s Migration Agency, 70 per cent of refugees who claimed to be between

“Every X-ray will be assessed
by two experts,” said forensic examiner Dr Elias Palm, who is in
charge of forensic age estimation
at the National Board of Forensic
Medicine. “For an assessment to
be complete, the experts have
to reach the same conclusion.”
According to Palm, both parts of
the body to be assessed develop at
different times, the knee joint later
in life and the teeth at an earlier
stage. For this reason, age determination with the new method will
likely be more accurate.

new method promises to resolve
concerns regarding current age
calculations that are mainly based
on dental examinations and have
been criticised as being unreliable
and inaccurate.

The voluntary age tests, which
will be implemented in the first
quarter of 2017, will be conducted

“ Page 1
related to common bacteria causing such infections.
The study was carried out
at the Department of Oral and
Maxillofacial Diseases of the university, in cooperation with the
Heart and Lung Centre at Helsinki
University Hospital. It examined
the coronary arteries of 508 patients with a mean age of 62, of

whom 36 per cent had stable coronary artery disease, 33 per cent
suffered from acute coronary
syndrome, and 31 per cent had
acute coronary syndrome-like results, but no significant coronary
artery disease.
Periapical periodontitis is an
immune response to microbial
infection in the dental pulp,
most commonly caused by caries.
The often symptomless infections

are usually detected by chance in
radiographs, the researchers said.
In light of the findings, root canal
treatment of an infected tooth
may reduce the risk of heart disease; however, additional research
is needed to confirm the relationship between the two conditions,
they said.
According to figures from the
World Health Organization, cardiovascular disease is the primary

separately at dental clinics and
MRI departments. Overall, it is estimated that about 4,000 to 18,000
examinations will be carried out.
“There is no method to medically determine the exact age of
an individual, but by studying
which phase a person is in, you
can draw approximate conclusions,” Palm remarked.
Determining whether a person is over or under 18 is important for processing of the asylum
application and the different entitlements that apply to child asylum seekers, such as free education and health care. In the recent
refugee crisis, Sweden has accommodated more child asylum seekers than any other country in Europe has. In 2015, the country took
in more than 35,000 unaccompanied minors, according to figures
from the Migration Agency.

cause of death globally. In 2012, an
estimated 17.5 million people died
from cardiovascular disease, representing 31 per cent of all global
deaths. Of these, 7.4 million were
due to coronary artery disease
and 6.7 million were due to stroke.
The study, titled “Association of
endodontic lesions with coronary
artery disease”, was published online ahead of print on 27 July in the
Journal of Dental Research.

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INTERNATIONAL EDITORIAL BOARD:
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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

Published by DT Asia Pacific Ltd.
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All rights reserved. Dental Tribune makes every effort
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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
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International. Scan this code
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[3] =>

NORDIC NEWS

Reducing dental
anxiety with cartoons
By DTI
HUDDINGE, Sweden & RIYADH, Saudi
Arabia: Sometimes a little distraction is all it takes to lessen children’s
fear of the dentist and consequently
improve treatment outcomes. In a
clinical trial jointly conducted by
researchers in Sweden and Saudi
Arabia, children who watched cartoons through video glasses during
treatment exhibited significantly
less anxiety and showed more cooperation than did children who
had no audiovisual distraction.
Dental anxiety is very common
in children. It is estimated that
about one in five school-aged children are afraid to visit the dentist
to some degree. Studies have shown
that children with dental phobia
experience more dental pain and
are more disruptive during treatment. Investigating means to address these anxiety issues in a
child-oriented manner, the present
study evaluated the effectiveness of
viewing videotaped cartoons with
an eyeglass system, Merlin i-theatre
(Merlin Digital General Trading), in
a group of children receiving dental
restorative treatment.
The study examined 56 children
of 7 to 9 years of age in three separate treatment visits that involved
an oral examination, injection with
a local anaesthetic and tooth restoration. The treatment was undertaken at a dental clinic at King Saud
University in Saudi Arabia. All of the
children involved had exhibited
some kind of dental anxiety in the
past and were referred to the clinic
for behaviour management. In the
trial, one half was randomly chosen
to watch their favourite cartoons
through the eyeglasses, while the
control group had no audiovisual
distraction during treatment.
When measuring anxiety levels
and cooperative behaviour in both
groups, the researchers found that
the children in the distraction group
exhibited significantly less anxiety
and showed more cooperation—particularly during the local anaesthetic
injection—than the control group
did. In determining indirect measures of anxiety, such as vital signs,
including blood pressure and pulse,
they further found that the average
pulse rate of children without video
distraction was significantly higher
during the injection than in children
in the distraction group. However,
the children themselves, who rated
their perceived treatment-related
pain and anxiety during each procedure, did not echo this difference.

and ensure that they can be given
the dental treatment they need, the
researchers concluded.
The study, titled “Effects of
audiovisual distraction on chil-

dren’s behaviour during dental
treatment: A randomized controlled clinical trial”, was published online on 13 July in the
Acta Odontologica Scandinavica
journal.

03
© Al-Khotani et al.

Dental Tribune Nordic Edition | 3/2016

Researchers from Karolinska Institutet in Sweden and King Saud University in
Saudi Arabia have investigated whether audiovisual distraction during dental
treatment may help children to overcome their fear of the dentist.
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[4] =>

04

WORLD NEWS

Dental Tribune Nordic Edition | 3/2016

By DTI
FREIBURG, Germany: Based on the
results of a pilot study in Germany,
people suffering from gingivitis
and periodontal disease should
perhaps consider changing their
eating patterns in order to improve
their oral health. In the study, participants who followed a diet low in
carbohydrates and rich in omega-3
fatty acids, vitamins C and D, antioxidants and fibre for four weeks
showed significantly lower inflammation values than did participants in the group who did not
change their diet.
Aiming to test the hypothesis
that diet helps reduce inflammation—a connection that diet-based
studies have already proved in
part—lead author Dr Johan Wölber
from the University of Freiburg and
his colleagues investigated the impact of an oral health-optimised diet
on periodontal health in a group of
patients with a history of gingivitis.
Of the 15 participants who were
otherwise accustomed to a diet rich
in carbohydrates, ten were asked to
follow a list of restricted and recommended foods and meals, while
five continued with their typical
eating patterns. People who smoked,
were taking antibiotics, or had
carbohydrate- or insulin-related

© Oleksandra Naumenko/Shutterstock.com

Impact of an oral health-optimised diet

The findings of a small sample size study in Germany have shown that an oral health-optimised diet could significantly reduce
gingival and periodontal inflammation in a clinically important range without any changes in oral hygiene performance.

diseases, such as diabetes, were
excluded from the study. Apart
from not using interdental cleaners, participants were advised not
to change their oral health routines
throughout the study period.
Dietary instructions in the
experimental group included restricting the amount of fructose,
disaccharides, sweetened beverages and meals, flour-containing
foods, rice and potatoes as far as
possible. Fruits and vegetables
(polysaccharides) were excluded

from this as long as the total
amount of carbohydrates was
considered. The dietary protocol
further included the daily intake
of omega-3 fatty acids (such as fish
oil capsules, a portion of sea-fish,
two spoons of flaxseed oil), a restriction in the amount of transfatty acids as far as possible (such
as fried meals, crisps, donuts,
croissants, etc.) and a reduction
in omega-6 fatty acids as far as possible (such as safflower oil, grapeseed oil, sunflower oil, margarine,
sesame oil and maize oil).

In addition, each participant
had to ensure the daily intake
of antioxidants (a handful of berries, a cup of green tea or coffee,
etc.), a source of vitamin C (such as
two kiwis, one orange or one bell
pepper) and a source of vitamin D
(15 minutes of unprotected exposure to the sun, nutritional supplementation, 300 g of avocado,
etc.). In order to ensure all participants followed these recommendations, they were asked to document their daily intake in a food
diary.

After four weeks, participants
in the low-carb group showed
significantly reduced gingival and
periodontal inflammation compared with the control group.
According to the researchers, reducing carbohydrates in particular led to a significant improvement in the gingival index,
bleeding on probing and the periodontal inflamed surface area. Although the study had its limitations—mainly the small study
group, the loose dietary instructions and the difficulty in ensuring the participants’ compliance
with the nutritional protocol,
among other factors—the presented dietary pattern significantly reduced periodontal inflammation in the study group,
the researchers concluded.
In total, the results support the
assumption that modern Western
eating habits, including consumption of refined carbohydrates and
a high omega-6 to omega-3 fatty
acid ratio, promote inflammatory
processes, they wrote.
The study, titled “An oral health
optimized diet can reduce gingival and periodontal inflammation
in humans—A randomized controlled pilot study”, was published
online on 26 July in the BMC Oral
Health journal.

Malocclusion affects posture and balance
By DTI

The studies, a collaboration
between the Department of Cell
Biology, Physiology and Immunology at the University of Barcelona
and the Department of Sport Science at the University of Innsbruck, found a relationship between malocclusion and postural
control. Both studies provide conclusive data that shows that postural control is improved—both in
static and dynamic equilibrium—
when various malocclusions are
corrected by positioning the jaw in
a neutral position.
The first study took into account the type of dental occlusion
and whether there had been previous orthodontic treatment. The
results showed that alterations in
alignment of the teeth were related to poorer control of static
balance.

© Aisylu Ahmadieva/Shutterstock.com

BARCELONA, Spain/INNSBRUCK, Austria:
In recent years, there has been
increasing medical interest in correcting teeth that are not perfectly
aligned in order to resolve diastemas and crowding and to prevent
problems such as jaw pain. Two
studies, carried out by Spanish
and Austrian researchers, have
now provided evidence that dental
occlusion is associated with the
control of posture and balance.

“When there is a malocclusion,
it is classified according to scientifically established criteria. What is
relevant in the study is that malocclusions have also been associated with different motor and
physiological alterations,” JuliàSánchez explained. This relationship is not as obvious in everyday
static conditions, although there
may be conditions associated with
pathologies, such as obesity, that
worsen the body’s instability, thus
decreasing postural control and increasing the risk of falls.

The impact of oral health on general health is a topic of current prominence.
The latest research has found a connection between malocclusion and posture
and balance problems.

The second study assessed the
type of dental occlusion, control
of posture and physical fatigue
in order to analyse a possible relationship between these factors.
It demonstrated that balance improved when malocclusions were
corrected, and that the latter had a
greater impact on postural control
when subjects were fatigued than
when they were rested.
“When the subjects were tired,
their balance was worse under

both stable and unstable conditions. Under static conditions, the
factor that had the greatest impact on imbalance was fatigue. In
contrast, a significant relationship
between exhaustion and dental
occlusion was observed under conditions of maximum instability,”
said lead author Dr Sonia JuliàSánchez, a researcher at the Department of Cell Biology, Physiology and Immunology at the
University of Barcelona’s Faculty
of Biology.

In athletes, this relationship
can play a crucial role in how well
they ultimately perform, as well as
in the prevention of injuries such
as sprains, strains and fractures
caused by unexpected instability
as fatigue increases and motor control capacity decreases. “Therefore,
it would be helpful for both the
general population and athletes to
consider correcting dental occlusions to improve postural control
and thus prevent possible falls and
instability due to a lack of motor
system response,” added JuliàSánchez.
“Postural control is the result
of a complex system that includes
different sensory and motor elements arising from visual, somatosensory and vestibular information,” explained the expert.

In recent years, there has been
increasing scientific interest in the
relationship between the stomatognathic system—the set of organs
and tissues that allow us to eat, talk,
chew, swallow and smile—and postural control. The link may have
a neurophysiological explanation.
There is a reciprocal influence between the trigeminal nerve and the
vestibular nucleus, which are responsible for masticatory function
and balance control, respectively,
as well as between the muscles of
mastication and of the neck. This influence would explain why dental
malocclusions negatively affect postural control. Up until now, however,
there was no conclusive research.
“The main problem stems from the
fact that the majority of these studies had statically assessed balance
under conditions of total stability,
which in practice has little actual
application in the control of posture while in action,” Julià-Sánchez
pointed out.
The first study, titled “Dental
occlusion influences the standing
balance on an unstable platform”,
was published in the October 2015
issue of the Motor Control journal.
The second study, titled “The influence of dental occlusion on the
body balance in unstable platform
increases after high intensity exercise”, was published in Volume 617
of Neuroscience Letters.

[5] =>

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[6] =>

BUSINESS

Dental Tribune Nordic Edition | 3/2016

World Summit Tour 2017:
A novel experience in implant dentistry
By DTI

hands-on workshops and various
parallel sessions. Overall, around
150 speakers and moderators will
be participating in the four tour
stops to discuss the latest ideas,
innovations and scientific data
in their area of expertise. Moreover, each tour stop will feature
a poster competition in two categories: clinical application and
research.

Held on the premise that inspiration and confidence matter,
the interactive scientific congress
will visit Tokyo in Japan on 18
and 19 February, San Diego in the
US on 12 and 13 May, Nice in France
on 23 and 24 June, and Shanghai in
China on 25 and 26 November.
The objective of the World
Summit Tour is to inspire clini-

MÖLNDAL, Sweden: Next year,
Dentsply Sirona Implants will be
welcoming dental professionals
from all over the world to the
World Summit Tour, a scientific
congress on implant dentistry. According to the company, which is
the world’s largest manufacturer
of professional dental products
and equipment, the combination
of distinguished international
speakers and a multifaceted programme render this state-of-theart congress unique in the dental
industry.

Spanning the globe, the Dentsply Sirona World Summit Tour will travel to Tokyo, San Diego, Nice and Shanghai in 2017.

cians and researchers to share
their scientific knowledge and
clinical experience and discover
the latest developments in implant dentistry. Owing to the mix

of international and local speakers, each two-day tour stop will
be exclusive to the participating
audience. This will give dental
professionals the opportunity to

attend a congress that is both
geographically nearby and tailored to the needs of the regional
market. In addition to general sessions, the programme will include

The scientific programme is
being compiled by the international scientific committee, which
consists of acclaimed scientists
Prof. Jan Lindhe (Sweden), Prof.
Clark Stanford (US), Prof. Christoph Hämmerle (Switzerland),
Prof. Tomas Albrektsson (Sweden),
Prof. Ye Lin (China), Prof. Meike
Stiesch-Scholz (Germany) and
Prof. Tetsu Takahashi (Japan).
More information about the
World Summit Tour, registration dates, venues and scientific
programme can be found at
www.worldsummittour.com.

TePe receives prize for Planmeca’s new
export achievements PlanMill 40 S
By DTI

“We are very honored to be
recognised for our export achieve-

STOCKHOLM, Sweden: Swedish
oral hygiene company TePe was
awarded the Export Hermes prize
at the Stockholm Chamber of

recognises the company’s exceptional export strategy and success
in international markets.

A collaboration between the
Foundation for Export Development and the Swedish Chambers
of Commerce, the award honours
Swedish companies that have
expanded internationally in an
innovative way,
for example by
establishing a
presence in new
markets, by gaining market share
or by placing
Sweden on the
map in new industries.
“Through its
complete range
of quality dental
products, TePe
has developed
into a worldleading export
company that
contributes to a
world with more
smiles,” said the
jury on its decision.
TePe has subsidiaries in Germany, Italy, the
Netherlands and
the UK and distributors in over
60 countries. The privately held
company was founded in 1965
and is headquartered in Malmö
in Sweden.

TePe CEO Joel Eklund with Helen Richenzhagen, Global Sales Director at TePe, at the award ceremony
in August. The Export Hermes prize is awarded annually and aims to encourage companies to continue
to strengthen Sweden globally.

Commerce World Trade Day on
30 August. The prize, which was
handed over to TePe CEO Joel
Eklund by Swedish Minister for
EU Affairs and Trade Ann Linde,

ments,” Eklund said on the occasion. “We have doubled our turnover over the last five years and
see good opportunities for continued growth.”

By DTI
HELSINKI, Finland: In September,
Finnish dental manufacturer
Planmeca introduced its latest
milling unit for dental clinics,
Planmeca PlanMill 40 S. Designed
for the chairside fabrication of
metal-free dental restorations and
appliances, the device will replace
its predecessor, Planmeca PlanMill 40, in the company’s product
line. PlanMill 40 S
can be ordered as
of now, with deliveries starting during
the fourth
quarter of
2016.
“The S in
the product’s
name stands
for Smart—
which is exactly what the unit
brings to the table,” explained
Jukka Kanerva, Vice President of
Dental Care Units and CAD/CAM
Solutions at Planmeca. According
to Kanerva, the milling unit will
introduce a level of quality, precision and performance that has
not yet been seen in the dental
industry. “From usability to performance, the new unit has been
built to achieve the smartest and
most efficient milling experience
in the field,” Kanerva said.

The new milling unit stands
out with its intelligent maintenance features, smart tool paths,
expanded range of applications
and automated tool changer for
ten tools. It can be combined with
the Planmeca PlanScan intraoral scanner and the Planmeca
PlanCAD Easy design software as
part of the Planmeca FIT chairside
CAD/CAM system.

According to the company,
Planmeca PlanMill 40 S is immediately available for orders
everywhere except in North
America.
Headquartered in Helsinki,
Planmeca distributes its products
in over 120 countries worldwide.
In 2015, the Planmeca Group
generated a turnover of approximately €734 million.

[7] =>

Dental Tribune Nordic Edition | 3/2016

OPINION

“Going green is our business, not somebody
else’s, but everybody’s responsibility”
An interview with Dr Claudio Pinheiro Fernandes, Brazil
By Kristin Hübner, DTI
Measures to reduce waste and
pollution and to conserve natural
resources such as water and energy
already play a major role in many aspects of daily life. Likewise, acting in
an environmentally friendly manner
is becoming increasingly impor tant
in dentistry as well. Dental Tribune
spoke with Dr Claudio Pinheiro
Fernandes, head of the Sustainable
Dentistry Center at Fluminense
Federal University in Nova Friburgo
in Brazil and consultant to the FDI
World Dental Federation’s Science
Committee, about sustainability
principles in dentistry, the preservation of natural resources and the
economic dynamics of going green.
Dental Tribune: Being environmentally friendly is becoming increasingly important in everyday
life. When did this topic first gain
momentum in dentistry?
Dr Claudio Pinheiro Fernandes:
Sustainability is relevant to everyone and we face this challenge
every day. Every single newspaper
that one opens includes something about climate change or
sustainable development. It is the
responsibility of dentistry too to
become involved as a profession to
pursue sustainability in the field of
oral health for the good of society.
The dental profession is being
challenged by the increasing demand for better oral health care
for more people in more countries
than ever. At the same time, we
have the challenge of needing to do
so using less resources. In this context, the question of how exactly
we are to do that arises.
What can dentists do and what defines a sustainable practice?
As dentists, we have to realise
that there are certain aspects and
areas of our work that can be organised better. From a procedural
point of view and concerning the
equipment used, there are certain
sustainability principles to consider. Take a simple example: when
one buys a refrigerator or an air
conditioner today, one looks for energy efficiency labels that indicate
the most efficient device in terms
of its energy use. This means that it
is good both for one’s pocket, being
cheaper to run, and for the environment, since it needs less energy.
Why do we not have this kind of
labelling on dental equipment? We
could introduce energy-efficient
dental equipment, with labels indicating the device’s energy use. That
would be one way of going green.
Another thing to keep in mind
is how much water we use. That
is an extremely important issue
in dentistry. A dentist uses eight

times more water than the average
person does—a large volume! Usually the equipment used in daily
practice causes this high consumption. For example, some brands of
suction equipment use clean water
to drive the suction mechanism.
On average, they use 200 litres
per hour and this water goes from
the pumps directly to the drain.
Of course, suction is important,
but could we not apply different
technologies to achieve the same
results? Do we have to waste clean
water for this?
In many respects, dentists cannot
implement a shift themselves alone;
awareness of the importance of
sustainability is important on the
company side as well.
That is why the FDI is taking a
stand on the sustainability issue
right now. The whole thing started
back in 2012 during the Rio+20
meeting, the United Nations Conference on Sustainable Development, in which the FDI had decided
to participate. Back then, we had
already begun collecting information and thinking about what we
could do in dentistry. I represented
the FDI in those meetings and I was
able to see how much we could do
even without going to a great deal
of trouble. For example, the most
sustainable thing to do is to focus
on prevention. If we act on prevention of oral disease, this would reduce the need for extensive treatment and the related use of products and, in particular, the associated generation of a large volume
of waste, as well as the substantial
amount of water and energy required, and the large carbon footprint that all of this creates.
Speaking of waste management,
what should dentists consider?
A great deal of waste is generated in dentistry and some of it
very toxic. Another issue that the
FDI has pursued is the Minamata
Convention on Mercury, which includes the phase-down of dental
amalgam. We have to face our responsibility of dealing with amalgam waste, for example. Nordic
countries are a good example in
this regard, having implemented
well-established amalgam management practices for many years.
One area in which we could do
a great deal more is the management of recyclable materials. All
the disposable materials that we
use in dentistry generate hundreds
of kilograms of waste every day.
What can we do to address recycling of those materials? A considerable amount of waste is generated with disposable barriers,
gloves and masks. Much of this
could be safely recycled with current technologies.

How open is the dental community
regarding this? When it comes to
change, such as going digital, there
are early adopters and some that
find it difficult to adjust to something new.
That is a good point. Digital
dentistry represents a different
mindset on production. The primary objective is to have more
control and to be more efficient in
production; however, a third point
is that digital technology generates less emissions, since there is
less transportation and less product waste. This is just one example
that serves to demonstrate that
there are many more efficient
means of manufacture. Certainly,
digital dentistry is one of those
areas of increasing technology use
that results in greater sustainability. Science, technology and innovation play a key role in most
areas of business. Improvements
in efficiency, accessibility and costeffectiveness of products and processes may allow fulfilment of
global need in a more sustainable
way. Furthermore, dental research
needs to be directed towards improving sustainability in dentistry.
Dentistry may be considered a very
conservative profession. How difficult is it to change the predominant
mindset?
We are doing that already.
One way or another, people are
coming to realise that going green
is our business, not somebody
else’s, but everybody’s responsibility. We as dentists have to play our
part as well. In addition to efficient
equipment and waste management, we should consider the topic
of recycling, particularly in light of
all the products that we use in
daily practice.
I think that the most important thing is education. We need
to include education on sustainable development in undergraduate
programmes and in continuing
education programmes. That way,
new and experienced dentists
alike will learn how to actually
practise environmentally friendly
dentistry. The national dental associations too can do a great deal to
increase awareness and promote
sustainable development. A good
example is the Norwegian Dental
Association, which has decided to
include sustainability aspects of
dentistry in its agenda.
What is the situation right now? Is
the topic covered in the curriculum
at all?
There is a great deal going on
right now. I would say that we are
in the moment of great activity.
For example, the International
Organization for Standardization
has developed very good materials

Dr Claudio Pinheiro Fernandes

for action. There is also a United
Nations Educational, Scientific and
Cultural Organization platform for
integrating education on sustainable development. It is called Education for Sustainable Development.
In addition, it should be noted that
many universities are already going
green today. So, there is progress.
Behind it all, there is one
driving force, the United Nations’
2030 Agenda for Sustainable Development. This agenda has defined
17 sustainable development goals
that were adopted by all member
states in September 2015. This is
very recent, but we are on a schedule of looking into the reduction of
poverty, the reduction of hunger,
better health for more people and
more educational opportunities—
a number of issues that will improve the environment on the one
hand, as well as social and economic development on the other.
By utilising the environment in an
intelligent, sustainable manner, we
allow society to develop in a healthy
way. We need to have jobs, we need
to produce, but we can all do that
in a responsible manner and at the
same time sustain a good economy.
When it comes to food and clothing, an eco-friendly lifestyle is often
more expensive than the alternative. For dentists, is there an
economic barrier to going green as
well?
Yes, there are challenges regarding entry, and investment
is required because everything
must be reoriented to the future.
As with everything, it is very difficult to start all over again, but
when attitudes change, when dentists actively decide to pursue
sustainability, then they will start

reviewing their own procedures
and little by little implement
change. The good news is that, once
one actually starts to implement a
sustainable approach, it becomes
evident that energy and resources
were wasted before—which is not a
good business strategy. There will
be a return on investment. One’s
patients, one’s clients and the public will recognise one as an active
member of a responsible society.
It will take time and effort, but the
dental profession will achieve this.
So in the future it could be a selling
point for companies to identify
themselves as “green”.
Yes, this is already happening
in many business areas, because
the public is driving sustainability
awareness by seeking more sustainable alternatives. As always,
there may be some companies that
already say that about themselves
even if they have not achieved that
yet. However, standards have already been established to determine whether certain things have
been applied. Based on these indicators of sustainability, auditors
and reviewers are able to evaluate
objectively whether sustainability
is being achieved by the company.
Of course, investment is required in the beginning. However,
some business reports indicate that
going green can save as much as
40 per cent of costs on water, energy
and unnecessary product waste,
which is a great deal of money.
Many companies, big and small,
are already considering it their corporate responsibility to act for the
social and environmental good.
Thank you very much for the interview.

[8] =>

TRENDS & APPLICATIONS

Dental Tribune Nordic Edition | 3/2016

Improving patient experience in daily
dental practice
Five considerations to boost treatment acceptance
By Peter Bering, Denmark

However, 16 per cent of the
adult Danish population have
completely avoided going to the
dentist for the past five years.
Moreover, a Danish study has
shown that 64 per cent of patients

3. Treatment concerns: Almost
50 per cent of patients indicate
some level of treatment barrier
or anxiety. An estimated 19 per
cent of patients are so anxious
that it directly influences treatment, and almost 30 per cent
have specific stressors that are
often unknown to the staff
treating them.

According to a Wolters Kluwer
Health survey, 86 per cent of
patients believe they have to take
a more active role in their own
health care experience in order
to ensure a better quality of care.
Almost a third of patients expect
this experience to be the same as
any other customer experience,
that is complete with choices and
control.

distrust, especially when it
comes to financial issues, regardless of the dentist’s personal integrity. This often
causes patients to opt out of the
proposed treatment.

INSPIRATION, BUYING
AND NETWORKING
MUCH TO LOOK BACK ON - MORE TO LOOK FORWARD TO

50
YEARS
SCANDEFA
2017

refused a highly necessary, but
more extensive, treatment. This
article discusses five aspects to
consider in order to improve
patient experience and, thus,
treatment uptake in dental practice.
You have invested a great deal
of money in attracting new patients and they are starting to
tickle in. You thoroughly examine
patients and base your treatment recommendations on evidence-based methods and years
of experience. You always produce
a solid treatment plan and are
ready to deliver technical perfection. However, there is one problem: the patient does not opt for
the treatment.
Why is that so? You need to ask
yourself the following questions:
Are you aligned with the patient’s
desires? (e.g. I’d like to be able to
chew apples when I’m 80 years
old) Is the outcome of the treatment understood by the patient?
Is the outcome important to the
patient?

SCANDEFA invites you to exclusively meet the Scandinavian dental market
and sales partners in wonderful Copenhagen.
Why exhibit at SCANDEFA?
SCANDEFA is a leading, professional branding and
sales platform for the dental industry.

Who visits SCANDEFA?
In 2016 over 8,000 dentists, dental hygienists, dental
assistants and dental technicians visited SCANDEFA.

In 2017 we are pleased to present SCANDEFA with
two fair days and a more flexible course programme
at the Annual Meeting. In addition to sales, branding and customer care, the fair format gives you
the opportunity for networking, staff care, professional inspiration and competence development.
SCANDEFA is organised by Bella Center Copenhagen and held in collaboration with the Annual
Meeting organised by the Danish Dental Association (tandlaegeforeningen.dk).

For further statistical information please see
scandefa.dk

How to exhibit
Please book online at scandefa.dk or contact
Sales & Relation Manager Mia Clement Rosenvinge
mro@bellacenter.dk/+45 32 47 21 33.

Where to stay during SCANDEFA?
Two busy fair days require a lot of energy, and therefore a good night’s sleep and a delicious breakfast are
a must. We offer all of our exhibitors a special price
for our three hotels, AC Hotel Bella Sky Copenhagen
– Scandinavia’s largest design hotel, Hotel Crowne
Plaza – one of the leading sustainable hotels in
Denmark and 5 Copenhagen Marriott Hotel.

We also offer easy shuttle service transport between
the airport, Hotel Crowne Plaza and AC Hotel Bella
Sky Copenhagen.

SCANDINAVIAN DENTAL FAIR
27 - 28 APRIL 2017

scandefa.dk

Do you know the answers to
all of these questions? Really
know? Or do you just think you
know? Before you invest time and
money in attracting patients to
your practice, consider these five
points:
1. Not knowing the patient’s preferences and desires: A concentrated focus on the professional
evaluation of dental health
needs and less on the patient’s
perception of his or her own
dental health, aesthetics and
outcomes may result in misalignment with the patient.
2. Lack of trust: The dental experience is based on trust, which
is influenced by factors such as
credibility, dependability and
level of self-interest. Certain
patient groups exhibit extreme

4. Black box communication: Not
sharing your reasoning, diagnostics or process with the
patient may be discomforting
to him or her. In addition, many
patients are not very explicit
or precise in their communication and rather passive, giving
the dentist very little to work
with.
5. Feelings: Dentistry is personal
and intimate. Patients may forget what you say and forget
what you did, but they will
never forget how you made
them feel.

Patient insight
and effective
communication
Converting treatment is a
matter of patient insight and
effective communication. Access
to research-based patient insights
can both positively influence
quality of care and lead to improved dentist–patient communication and relationships.
The dental experience is personal, memorable, and adds value
to patients’ lives. Thus, by creating
a better patient experience, you
can significantly improve treatment uptake. In short: know the
patient; determine the treatment.

Acknowledgement: The author wishes
to thank Simon Tucker from Profitable
Conversation for his valuable insights.

Peter Bering
is an experienced digital
business developer and
trend researcher working
with dental
clinics around the world to help
them grow their business. He regularly gives insight into his work
at copeit.com/blog-uk and can be
contacted at peter@copeit.com.

[9] =>

TRENDS & APPLICATIONS

Dental Tribune Nordic Edition | 3/2016

Evaluating the cariogenicity
of food ingredients
By Krista Salli, Finland
Worldwide, 60 to 90 per cent of
schoolchildren and nearly 100 per
cent of adults have dental caries,
making untreated tooth decay the
most common oral condition.1, 2
Caries and periodontal disease
share many risk factors with
non-communicable diseases, including tobacco use, high sugar
intake and lack of exercise.3
Therefore, behavioural changes are
needed to decrease the risk of developing these diseases. For caries
specifically, the frequency and
amount of sucrose consumption
should be reduced. 4 This improvement in dietary habits would be
beneficial to general health as well.
In some cases, such as studies
on food intake, body weight
maintenance, glycaemic response,
serum lipid profiles, blood pressure and the effects of sucrosecontaining medication, sucrose
or sucrose-containing products
are still used as a comparator in
clinical studies.5, 6 In dental cariesrelated randomised clinical trials,
the use of sucrose as a comparator
can be considered unethical, as
the correlation between sucrose
consumption and caries incidence
is well established. Consequently,
many of the studies investigating
the association between sucrose
consumption and caries are crosssectional or population studies.
To date, there are few nonrandomised interventions and
cohort studies that have evaluated this. A recent meta-analysis
on studies from as early as the
1950s found that collectively these
studies showed that oral health
outcomes improved as sucrose
consumption was reduced. 4 Diet
and nutrition can affect tooth
de- and remineralisation in both
protective and destructive ways.
Frequent consumption of fermentable carbohydrates increases acid
production and favours aciduric
bacteria and thus caries development, but a healthy diet, low in
added sucrose and high in calcium, fluoride and phosphate, can
benefit mineralisation.7

A. +4 °C

+37 °C
2

5
6
1a

Figs. 1a & b: (a) Schematic diagram of the dental simulator.28 1. Reservoir for artificial saliva/artificial saliva with test substances. 2. Inlet pump. 3. Simulation vessel with
constant stirring and added bacteria. 4. Sample collection during simulation. 5. Outlet pump. 6. Waste. (b) Photograph of the dental simulator.

in relation to caries.10 If possible, it
is suggested that animal trials
should be combined with plaque

Periodically, the appliances are
placed in experimental solutions,
and then caries development re-

like cheese, starch and cookies has
been evaluated using enamel slab
methods.8 The plaque pH method,

“Diet and nutrition can affect tooth
de- and remineralisation in both protective and
destructive ways.”
pH or intra-oral methods to gain
more information.8 Intra-oral or
enamel slab models utilise appliances with real or modelled
enamel or dentine that are kept
in the oral cavity by volunteers.

lated factors are measured.9 The
benefits of enamel slab experiments include the presence of
saliva, oral microbiota and mastication, in addition to test products. The cariogenicity of foods

which is a means of following the
pH of the plaque during and after
eating, is another useful tool for
evaluating acidogenicity of food
items.9 It should be noted that
acidogenicity is not equal to cario-

Therefore, in addition to clinical trials evaluating the cariogenicity of foods using comparators other than sucrose, different
ways of estimating the cariogenicity of foods or food ingredients
are needed. These include animal
trials, enamel slab experiments,
plaque pH evaluation and laboratory methods.8 Animal, mostly
rat, caries experiments provide
the means to control diet or single
food ingredients carefully.9
Animal studies have been
used to evaluate frequency and
amount of sucrose consumption,
starch and milk cariogenicity, and
frequency of fruit consumption

genicity, as foods or food ingredients may also have possible
protective factors.10

Fig. 2: The author presenting her latest research at the FDI Annual World Dental Congress in Poznań in Poland.

In addition to all the abovementioned methods, laboratory
models of varying degrees of
complexity exist. In these models,
depending on the research question, there may be no bacteria
present or they may be pure culture studies or multispecies models or use salivary microbes in
the model. These models cannot
evaluate caries development per
se, but factors that increase the
risk of caries, including demineralisation, acid production, oral
pathogen growth and microbial
dysbiosis.
Studies on determining the
cariogenicity of foods and food
ingredients are limited. Most research has focused on sucrose, various sucrose-containing products,
starch and alternative sweeteners,
such as polyols. Evaluations of
dairy products and fruits have
been performed too.10 Among the
polyols, xylitol has received interest since the 1970s when the Turku
sugar studies were performed.11
Xylitol is used widely as a sugar
substitute. It is not metabolised by
mutans streptococci, thus substituting sucrose with xylitol reduces
the substrate for acid-producing

[10] =>

Europe Clinical Masters Program
TM

in Esthetic and Restorative Dentistry
12 days of intensive live training with the Masters in Geneva (CH), Athens (GR), Milan (IT)

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

Online access to our
library of Lectures & Clinical Videos

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

Details on www.TribuneCME.com

Curriculum fee: €9,900

(Based on your schedule, you can register for this program one session at a time.)

Collaborate
on your cases
and access hours of
premium video training
and live webinars

University
of the Pacific
this course is created
in collaboration with
University of the Pacific

Tribune Group GmbH is an 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.

100

C.E.

CREDITS

Certificates will be
awarded upon completion

Tribune Group GmbH 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 province board of dentistry or AGD
endorsement. The current term of approval extends from 7/1/2014 to 6/30/2016.
Provider ID# 355051.

[11] =>

TRENDS & APPLICATIONS

Dental Tribune Nordic Edition | 3/2016

“We have used this dental simulator to successfully
investigate the effect of sucrose and xylitol on growth
and adhesion of Streptococcus mutans and S. sobrinus.”
oral bacteria and in the long term
leads to caries prevention.12, 13 Xylitol increases salivary flow like other
sweet products do.14, 15 It has other
beneficial effects on oral health,
including the decrease of plaque
acidogenicity 16, 17 and the reduction of the amount of plaque.13, 18, 19
Xylitol is able to inhibit the growth
of several bacterial species, especially Streptococcus mutans,20–22
without disturbing the commensal oral microbiota.23, 24 The European food safety authorities have
recognised this and chewing gum
with 100 % xylitol as a sweetener
has a health claim of reducing
caries in children.
In order to ethically and reproducibly study the effects of xylitol
and its mechanisms of action in
comparison with sucrose, in vitro
models are indispensable tools.
Our team has developed an in vitro
model of the oral cavity with constant temperature and mixing,
using a constant-flow artificial saliva as medium and hydroxyapatitecoated discs in whole human saliva
as artificial teeth (Figs. 1a & b).25–28
We have used this dental simulator to successfully investigate the
effect of sucrose and xylitol on
growth and adhesion of Streptococcus mutans and S. sobrinus.27
This model can be used to evaluate
planktonic bacterial growth and
bacterial attachment of different
bacteria on the artificial tooth
surface. The results obtained thus
far suggest that with this model it
is possible to simulate the effects
of sucrose and xylitol on the tested
bacteria as previously observed in
clinical trials. Sucrose increased
the amount of all four tested planktonic and adhered S. mutans and
S. sobrinus strains. Xylitol, however, decreased all but one of the
tested strains.26
Of course, the short-term in
vitro evaluations described above
cannot show direct effect on caries,
a multifactorial disease that develops slowly. Nevertheless, effects on
the amounts of bacterial species
that have been clearly connected
to caries and can contribute to reducing the risk of maternal transfer
of mutans streptococci to the infant are valuable.29–31 Furthermore,
reducing the amount of attached
or adhered bacteria can translate
to less dental plaque with less
harmful bacteria and in this manner reduce the acidogenic burden
and prevent enamel dissolution.
Recently, I presented our newest findings at the FDI Annual
World Dental Congress in Poznań in
Poland (Fig. 2). The model appears to
be suitable for testing the influence
of confectionary and confectionary

ingredients on the colonisation of
mutans streptococci and may thus

be useful in the development of
tooth-friendly products.

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

Krista Salli has
a master’s degree in biochemistry and
is part of the
Global Health
and Nutrition
Science team
at DuPont Nutrition and Health in
Kantvik in Finland. In her doctoral
project, she is investigating cariogenic
biofilm inhibition with xylitol. She can
be contacted at krista.salli@dupont.com.
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12

TRENDS & APPLICATIONS

Dental Tribune Nordic Edition | 3/2016

Possibilities and risks of digital
techniques in implant dentistry
An interview with Dr Margareta Hultin, Sweden
© Anne Faulmann/DTI

By Anne Faulmann, DTI
Implant dentistry is constantly
advancing. New research results,
the rapid development of digital
technologies and increasing experience in clinical practice change
the way implantologists work. This
may lead to a rethinking of already
established treatment approaches.
At the 2016 European Association for Osseointegration congress,
which took place in Paris in France
from 29 September to 1 October,
Dental Tribune spoke to presenter
Dr Margareta Hultin about her discussion topic of immediate CAD/
CAM restoration and recent developments in implant dentistry.
Dental Tribune: Dr Hultin, how has
implant dentistry developed in recent years, and what new insights
have changed the way implantologists work?
Dr Margareta Hultin: Implant
dentistry has developed in several
areas in recent years, such as grafting and augmentation procedures,
as well as treatments for optimising and predicting the aesthetic
result after rehabilitation. On the
one hand, improvements in implant treatment can be attributed
to a better understanding of how
both the hard- and soft-tissue
anatomy—for example, the role of
thickness, width and positioning of
keratinised tissue—influence the
long-term outcome and aesthetic
result. On the other hand, 3-D radiographic imaging techniques have
greatly improved individual assessment of hard tissue with regard
to jaw anatomy and bone volume
in treatment planning.
Digital dentistry is increasingly relevant in dental practice nowadays.

Dr Margareta Hultin at the EAO congress in Paris in September. Hultin is a senior lecturer at the Department of Dental Medicine
at Karolinska Institutet in Stockholm and has more than 15 years of experience in research and education in implantology.

“3-D radiographic imaging techniques
have greatly improved individual
assessment of hard tissue with regard
to jaw anatomy and bone volume
in treatment planning.”
How has digital technology changed
implant dentistry, and what are its
main advantages?

Digital technology can support
dentists in several steps of restorative treatment, from cone beam
© Alex Mit/Shutterstock.com

computed tomography and the
virtual planning of implant positions through to prosthesis manufacture for immediate function.
Also, virtual planning can be transferred to the actual clinical setting
by fabricating surgical guides
for flapless implant placement.
The main advantage of digital
techniques is the ability to plan
and optimise the positioning of
implants in a prosthetically driven
manner. Moreover, computer-

guided techniques can help decrease postoperative discomfort
and allow immediate function, as
they enable implant placement
with minimal surgical trauma.
In addition, these techniques
can offer a useful alternative to
bone augmentation in severely resorbed jawbone, as they facilitate
optimal positioning of implants
in the available bone.
In your lecture at this year’s EAO congress in the “Things we stopped in
our practice due to failures” session,
you have discussed immediate CAD/
CAM restoration. What are potential
complications of immediate CAD/
CAM restoration, and why is this
treatment approach prone to failure?
Although computer-guided
techniques for implant placement
can offer advantages for both the
dentist and the patient, guided
implant surgery is technically demanding and not free of specific
procedure-related complications.
For example, the drilling template
may fracture or there may be complications related to limited access
and visibility when using a flapless
approach. This can lead to deviations in implant positioning and
ultimately a poorly fitting prosthesis. Moreover, high aesthetic
demands may be difficult to completely foresee, since computerguided implant positioning carries
the risk of overlooking the ideal location of an implant with regard to
the soft tissue. Therefore, the skills
and experience of a clinician who
wants to use these techniques need
to go far beyond those necessary
for regular implant surgery.
What alternative treatment protocol do you recommend for less experienced clinicians?
A good option is to use digital
techniques for implant placement
in combination with traditional
protocols for prosthesis manufacture. For example, a templateguided flapless surgery for implant
placement can be combined with
a traditional protocol for unloaded
healing and the fabrication of a
permanent prosthesis.

“...guided implant surgery
is technically demanding
and not free of specific
procedure-related
complications.”

[13] =>

[14] =>

TRENDS & APPLICATIONS

Dental Tribune Nordic Edition | 3/2016

Minimally invasive veneer restoration
with a ceramic-based restorative material
A case report
By Mauricio Watanabe, Brazil
Aesthetics is an aspect that plays
an important role in modern dentistry. As ever more patients desire
a “perfect” smile, dentists are increasingly being called upon to produce highly aesthetic restorations
and optimise the natural situation.
Reshaping of the teeth is a safe procedure with a predictable result
and can be routinely performed
to create a more appealing and
harmonious smile. However, it requires corresponding diagnostics
and treatment planning that takes
both aesthetic and functional aspects into consideration. The employment of minimally invasive
techniques to preserve the tooth
substance and neighbouring structures and the use of dental materials with the highest possible
stability and biocompatibility are
essential too. Restoration with indirect composite veneers is one
possible treatment.

Clinical case
A 20-year-old male patient
wanted to improve the aesthetics
of his smile (Fig. 1). Clinical examination showed a diastema between the maxillary central incisors (Fig. 2). The patient wanted
a quick solution without orthodontic treatment. By analysing
the photographs of the patient’s
face, we were able to establish that
the line running along the incisal
edges and cusp tips of the canines
of the maxillary anterior teeth did
not form a regular curve. In order
to attain an attractive smile, it
would thus be necessary to adapt
the shape of all four maxillary incisors in such a way that they
formed a positive smile line (Fig. 3).
During the lateral movements,
there was no contact between the

Fig. 1: A 20-year-old
patient presented for
dental treatment owing
to a diastema between
his maxillary central
incisors.—Fig. 2: The intra-oral view shows the
positions of the anterior
teeth and their morphology in more detail.
—Fig. 3: We established
that the four maxillary
incisors would need to
7
8
9
10
be treated if we were
to achieve a satisfactory
result.—Fig. 4: As treatment, we selected the fabrication of indirect restorations on a silicone model. This has advantages over the use of prefabricated veneers, as
producing them in-house allows for customisation and achievement of a better marginal seal.—Fig. 5: We selected the shade to be used during the first treatment session
by applying a small quantity of the material in each of the shades to the tooth, smoothing off the surface with a large metal spatula and then curing the material.
In this case, we decided on Shade A1.—Fig. 6: The restorative material (Admira Fusion) was applied directly to the finished silicone model. Spatulas were used to model
the teeth in accordance with the morphology of the corresponding group of teeth. In this case, veneers were to be used to restore a proper curve to the line connecting
the cusp tips of the canines and the incisal edges.—Fig. 7: After polymerisation, we removed the veneers from the model, finished them and polished them with rubber
grinders and polishers for ceramic restorations.—Fig. 8: Superimposing a photograph of the finished veneers over a photograph of the patient allows us to predict the
position and size of the restorations after treatment was complete.—Figs. 9–10: Try-in of the veneer on tooth #21. Note the direction of insertion. It was important to
observe the direction of insertion precisely when determining the order of insertion of the restorations, as no preparation was performed.

mandibular anterior teeth and
maxillary incisors, allowing the
possibility of lengthening them.
As the patient was young,
a minimally invasive technique

was required, and for this reason,
we decided on a procedure in
which preparation of the teeth
was not essential. We chose an indirect technique with the restorations made from Admira Fusion

(VOCO), a material containing
a ceramic matrix instead of the
conventional methacrylate-based
monomers, making it highly biocompatible. The use of indirect
veneers produced by the dentist

represents an alternative to prefabricated veneers. Producing the
veneers oneself offers further advantages, such as the low costs,
the possibility of individualising
the tooth shape, the reduced

Fig. 11: We used no. 000 retraction cords to retract the gingival margin for all the maxillary incisors.—Fig. 12: Phosphoric acid was applied to each tooth and allowed to act for 15 seconds. The neighbouring tooth
was protected with a separation strip made of polyester.—Fig. 13: Teeth #11 and 21 after etching with phosphoric acid and drying.—Fig. 14: The veneer for tooth #21. It was sand-blasted with aluminium oxide
to clean the interior surface.—Fig. 15: After application of the adhesive and drying, GrandioSO Flow in Shade A1 was used.—Fig. 16: View after placement of the restoration. We also removed all excess material
with a no. 5 probe prior to polymerisation.—Figs. 17 & 18: Views of the veneer restorations after completion.

[15] =>

TRENDS & APPLICATIONS

Dental Tribune Nordic Edition | 3/2016

thickness of the cement layer and
the improved marginal seal.
The use of a mock-up, the basis
for which was produced in this case
with die silicone (VOCO) (Fig. 4),
is advantageous for the simple
and quick fabrication of indirect
restorations. The matching shade
for the restorative material was
selected during the first treatment
session. This was done by applying
a small quantity of each of the
possible shades to the vestibular
surface of one of the teeth to be
restored and curing it. After comparing the shades, we decided on
Shade A1 (Fig. 5).
The restorative material was
applied to the silicone model with
a metal spatula for fabrication of
the actual mock-up and thus also
for the veneers (Fig. 6). During this
step, it is important to adhere to
the planning specifications determined based on the photograph
analysis. The aim was therefore to
lengthen the maxillary incisors.
Light curing was followed by finishing and polishing with rubber
polishers (Fig. 7). We then photographed the model and superimposed the image over a photograph of the patient smiling in
order to check whether the size
and alignment of the teeth were
correct (Fig. 8).
The veneers were adapted
directly to the patient’s teeth (Figs.
9 & 10). A considerable advantage
of this technique is the possibility
of checking whether the result
will satisfy expectations before
the treatment is completed. Trying in the restorations allows the
patient to see the result and request any changes. Once the marginal seal had been checked and
the patient was happy with the
aesthetics achieved, preparations
were made for placing the indirect
veneers. We chose the adhesive
Futurabond U (VOCO) in combination with the flowable composite
GrandioSO Flow (VOCO) in Shade
A1 for luting.
The gingival margin was retracted with a no. 000 retraction
cord (Fig. 11) and 37 % phosphoric
acid applied to the teeth for 15 seconds (Fig. 12). After rinsing with
water and drying of the etched
vestibular surfaces (Fig. 13), the
adhesive was applied, the solvent
dried with an airstream and light
curing performed for 10 seconds.
The interior surfaces of the veneers were sand-blasted with aluminium oxide (90 µm) at a pressure of 60 psi in order to clean and
roughen the surface. The homogeneous, clean surface of the interior of the veneer was evident
when viewed against the light
(Fig. 14).
In the next step, the adhesive
was applied to the same surface
and then dried with a light airstream. A small quantity of flowable composite was then distributed on the surface (Fig. 15) and the
veneer placed on the corresponding tooth (Fig. 16). After application, the excess composite was

Fig. 19: Contact between the anterior teeth during protrusive movements.—Figs. 20 & 21: After grinding of the veneers, there was no further contact between the
anterior teeth during lateral movements.—Figs. 22 & 23: Images of the veneers under indirect light. The details are clearly visible.—Figs. 24 & 25: View of the vestibular
and palatal aspects of the anterior teeth with a harmonious curve.—Figs. 26 & 27: A comparison of the patient’s before and after smile.

removed and light polymerisation
was then performed.
Once all of the veneers were in
position, the restoration margins
were finished with a no. 15C scalpel
and polished with rubber polishers. We assessed the results immediately upon completion (Figs.
17 & 18). Corresponding grinding
was carried out to ensure even
contact between the mandibular
incisors and maxillary central incisors during protrusive movements (Fig. 19). Grinding was also
employed to eliminate all contact
between the veneers and the mandibular teeth during lateral movements (Figs. 20 & 21).

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Views of the vestibular and
palatal aspects under indirect
light revealed that the details
had been well finished and that
the indirect restorations blended
harmoniously with the neighbouring structures (Figs. 22–25).
A comparison of the pre- and
postoperative views showed a
clear improvement of the tooth
aesthetics and the positive effect
this had on the patient’s smile
(Figs. 26 & 27).

Mauricio
Watanabe is
an expert in
the treatment
of gingival disease and maxillofacial surgery
and is a practising dentist in São Paulo in Brazil. He is
currently studying towards a doctorate in biomaterials at Universidade
Estadual Paulista in Araçatuba. He can
be contacted at mauriciowatanabe@
yahoo.com.br.

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can help maintain optimal oral health into old age. Visit the website to find out how to Live Mouth Smart.

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[cover] => DT Nordic No. 3, 2016

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