DT Pakistan No. 1, 2016
National News / Cast mounting using MaxAlign: The clinical component / DNES ’15: Educate Patients and provide treatment options: Experts / Coronary heart disease patients with no teeth have nearly double risk of death
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[1] =>
PUBLISHED IN PAKISTAN
4th International
PAO Conference
Quest for Excellence
NATIONAL NEWS
Page 2
www.dental-tribune.com.pk
JANUARY, 2016 - Issue No. 01 Vol.3
4th International
PPA Conference
Think Globally Act
Locally
Click here! Digital
impression margination
made easy
NATIONAL NEWS
Page 4
CLINICAL PRACTICE
49TH CPSP CONVOCATION
Prof Lehri
Raheel Sharif
elected PMDC
president
Haseeb
Editor - Online
Haseeb Uddin
Editor Online
awarded honorary
fellowship of CPSP
Uddin
DT Pakistan Report
I
DT Pakistan Report
SLAMABAD - The 49th Convocation of College
of Physicians and Surgeons Pakistan (CPSP) was
held here at the Jinnah Convention Centre.
The chief guest, COAS General Raheel Sharif was also
conferred upon the honorary fellowship of the CPSP for
his achievements at convocation. The CPSP citation reads:
"General Raheel Sharif through his vision, resolve, sincerity
and commitment against terrorism has become a leading
figure of our times."
Speaking on the occasion, General Raheel Sharif
said:"Today, by the grace of Allah Almighty, an
environment had been created where fear and
retribution from the terrorists and criminals had been
significantly reduced. However, relative security needs
to be transformed into an enduring peace and stability for
the nation. A unified national approach is important to
bring the armed forces' endeavors to a logical end."
COAS paid tribute to sacrifices of citizens and soldiers
in achieving this stability and peace.
Felicitating the graduating students, General Sharif said:"To
Page 7
I
steer the country towards success, we need to invest in
our future generations. To this end, every individual,
especially the educated professionals, have an enormous
responsibility. It is my belief that today's Fellows will rise
and shine as the future of Pakistan," he added.
The COAS praised the college for improving
postgraduate medical education and health care services
in the country.
Earlier, in his welcome address, CPSP president Prof
Zafarullah Chaudhry acknowledged the COAS
contributions and strenuous efforts for peace and stability
Continued on page 14
SLAMABAD - The group led
by Professor Shabbir Lehri had
a clean sweep in the PMDC
elections who is currently the
principal of Bolan medical college.
Members of Pakistan Medical and
Dental Council (PMDC) elected Prof
Dr Shabbir Lehri as President and
Prof Dr Abid Farooqi as Vice
President.
The council members also elected
members of the Executive Committee
of PMDC comprising Dr Farukh Ijaz,
Dr Taj Muhammad, Dr Aamir
Hussain, Dr Feroz Jahangir, Dr
Shafiqur Rehman and Dr Mussarat
Hussain.
PMDC’s new President Prof Dr
Shabbir Lehri said that he would try
his best to make PMDC one of the
world’s best medical regulatory
authorities.
EDUCATION & INNOVATION TRANSFER
AEEDC Dubai - A Global platform
for the Dental World
D
DT Pakistan Report
UBAI - AEEDC Dubai is the pioneering
and largest dental event in the Middle East,
North Africa and South Asia region, held
under the patronage of His Highness Sheikh Hamdan
Bin Rashid Al Maktoum, Deputy Ruler of Dubai,
Minister of Finance, and President of the Dubai
Health Authority.
The 20th edition of the UAE International Dental
Conference & Arab Dental Exhibition - AEEDC
Dubai 2016 themed, "Education & Innovation
Transfer" will take place at the state-of-the-art
Dubai International Convention & Exhibition Centre
(DICEC) from 2nd to 4 February. Dental News
Pakistan is the media partner of the event.
AEEDC Dubai 2016 conference will present a
very comprehensive scientific program highlighting
the latest topics and clinical cases in the field of
dentistry. Several continuing dental programs will
be hosted at AEEDC Dubai 2016 focusing on the
most up-to-date scientific information and advanced
dental solutions. In addition, AEEDC pre-conference
courses named as the Dubai World Dental Meeting
- DWDM will run 3 days prior to the conference
offering a variety of highly specialized courses.
This year marking the 20th anniversary of the event,
the topics of this mega event will include
Keeping up with its tradition, AEEDC Dubai
conference will present an extremely comprehensive
scientific program on the latest advances &
researches in various specialties of Dentistry, where
in most eminent speakers around the globe will
share their expertise with our audience. AEEDC
Dubai conference is held in cooperation with Dubai
Health Authority - DHA Government of Dubai.
The extensive scientific program will include
Aesthetics, Anesthesia, Dental Emergency, Dental
Ergonomics, Dental Ethics, Dental Hygiene, Dental
Laboratory Technology, Dental Practice Growth
(Management and Marketing), Endodontics,
Continued on page 14
[2] =>
NATIONAL NEWS
2 DENTAL TRIBUNE Pakistan Edition January 2016
4TH INTERNATIONAL PAO CONFERENCE
Quest for
Excellence
Publisher/CEO
Syed Hashim A. Hasan
Editor
- Online
hashim@dental-tribune.com.pk
Editor Clinical Research:
Haseeb
Uddin Padhiar
Dr. Inayatullah
Editors Research & Public Health
Prof. Dr. Ayyaz Ali Khan
Editor - Online
Haseeb Uddin
DT Pakistan Report
Designing & Layouting
Sh. M. Sadiq Ali
K
ARACHI - The 4th International Conference
of Pakistan Association of Orthodontics held
at the prestigious Aga Khan University
Hospital in Karachi. The organizers did a tremendous
job by bringing in 13 international speakers from six
countries as speakers. Renowned orthodontists from
Pakistan also presented their state of the art lectures
and conduct workshops.
Dental Tribune Pakistan
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The conference formally started with the recitation from
the Holy Quran. The guests of honour of the event were
Dr Farhat Abbas, dean Aga Khan University with
conference patron renowned orthodontist Dr Arif Alvi,
Member National Assembly who is also the founder
president Pakistan Orthodontics Association.
Dr Farhat welcomed the delegates and emphasized the
need for such academic events for the exchange of
knowledge. He told the delegates to visit Northern part
of Pakistan for its beauty and also roam around in Karachi
which is a much safer city now.
The patron of the conference Dr Arif Alvi appreciated
the efforts of the organizers and stated that PAO has
organized itself well with flawless working and specially
mentioned holding of timely elections without fail. Talking
about Orthodontics, he said it is more challenging and
focus is always to revent relapse. Drawing comparison
with prostho, he said that even though Ortho is his passion
but he feels that prostho is more precise.
He hoped that the dentists of the future will have the
relapse issue on top of their minds. He lauded the efforts
of the organizers and urged the need for continuous flow
of knowledge using modern technologies like video
conferencing and also self-learning, he added.
Earlier the conference Chairman Dr Mubassar Fida in
his opening address welcomed the participants and shared
the aims and objectives of the conference. He highlighted
the presence of 13 international speakers and thanked
them for attending the event.
Dr Mubassar thanked his team and sponsors of the
event specially GSK, HenrySchein, CDS, 3M, Pfizer,
ClearPath, Shield and others. He also appreciated the
efforts of Dental News the media partners of the
conference.
The participants of the conference appreciated the efforts
of the organizing committee comprising Dr Mubbasar,
Dr Attiya, Dr Syed Shah Faisal and Dr Abdullah Kamran
who worked against time to make it happen.
The highlight of the conference included its extensive
workshops covering topics which were of great interest
for the practitioners as well as academicians. The sessions
and the workshops were carefully planned resulting in
overwhelming response as well as packed audience,
which is a rarity.
The conference chairman Dr Mubbasar Fida, Cochairperson Dr Attiya vice chairman Dr Syed Shah Faisal,
and Dr Abdullah conference secretary worked tirelessly
in making this event a huge success. There is an extensive
scientific programme in addition to more than state-ofthe-art workshops.
Continued on page 10
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[3] =>
[4] =>
NATIONAL NEWS
4 DENTAL TRIBUNE Pakistan Edition January 2016
DT Pakistan Report
K
ARACHI- Pakistan
Prosthodontics Association
hosted the 4th International
conference on 11th- 12th December
2015 with the theme, "Think Globally
Act Locally" which was a great
success, where eminent keynote
speakers from various reputed
institutions and organizations with
their resplendent presence graced the
occasion.
The PPA conference witnessed an
amalgamation of peerless speakers
who enlightened the crowd with their
knowledge and confabulated on
various newfangled topics related to
the field of dentistry.
The conference was organized by
Dental News under the aegis of PPA
with the support of Pakistan Dental
Association and Hamdard University
with Dental News and Dental Tribune
Pakistan as its media partners dealt
with the diagnosis, prevention, and
treatment of diseases of the teeth,
gums, and related structures of the
mouth and including the repair or
replacement of defective teeth.
The conference began with the Holy
Quran recitation which was followed
by formal inauguration by Prof Dr
Saqib Rashid. After inauguration
welcome Speech was
given by Chairperson
Scientific Committee; Dr
Najeeb Saad, Consultant
and Section Head of
Dentistry, Aga Khan
University, AIDC who
briefed about the
conference.
The inaugural ceremony was
followed by scientific Session. Prof
Dr Fazal Ghani began the session by
delivering lecture titled, "Knowing,
Assessing and Maintaining Clinical
Occlusal Stability". First lecture of
the session was continued by series
of invited lectures delivered by both
Honorable Guests and members of
the keynote forum. The list included
two international speakers; Dr M.L.
Theerathavaj Srithavaj, Dr Natdhanai
4TH INTERNATIONAL PPA CONFERENCE
Think Globally Act
Locally
Chotprasert and 13 national speakers;
Prof Dr Azad Ali Azad, Prof Dr Fazal
Ghani, Dr Hina Zafar, Prof Dr Mervyn
Hosein, Prof Dr Nazia Yazdanie, Dr
Ninette Banday, Dr Qayyum Akhtar,
Prof Dr Sajid Naeem, Dr Syed Abrar
Ali, Dr Syed Murtaza Raza Kazmi,
Dr Tehmina Asad, Dr Waqas Tanveer.
The closing ceremony was followed
by speeches of Chief Guest; Mr Suwat
Karwook, consul General, Royal Thai
Consulate Karachi and Madam Sadia
Rashid; The Chancellor Hamdard
reach the end for which they are
striving" she added.
Dr. Tehmina Asad; President 4th
International PPA Conference,
Editor
- Online Pakistan delightfully
Karachi,
welcomed
Haseeb
Uddin all the delegates and quoted
that the theme of the conference
'Think Globally, Act Locally' will
help all dentists develop more region
and country specific approaches
towards practicing dentistry, rather
than going into mindless
globalization. She specified that the
conference will give participants a
platform to exchange ideas, discover
novel opportunities, reacquaint with
colleagues, make new friends, and
broaden their knowledge about
evidence-based Prosthodontics.
Apart from the speaker sessions, Post
Conference workshops were held at
different colleges by renowned
dentists. The list included Dr Fazal ur-Rehman Qazi, Prof Dr Saqib
Rashid, Dr Mehmood Hussain, Dr
Bushra, Dr Faisal Qayyum, Dr kashif
Aslam, Dr Zia Chaudry, Dr Sameer
Qureshi, Dr S Murtaza Raza Kazmi,
DR Talha, Dr Nadeem Hafeez
Khoker and Dr Syed Abrar Ali.
Conference even facilitated Post
Graduate Oral presentation
Competition in one of its sessions.
The first prize was awarded to Bolan
University.
Madam Sadia Rashid acknowledged
the participation of Hamdard
University as one of the collaborators
for the conference. In her speech she
talked about The Founder of Hamdard
University Pakistan, Shaheed Hakim
Mohammed and his achievements.
"We, as a University can do, is to
provide the best possible means the
environment, the courses, the teachers,
the equipment. It is for the students
to make best use of the knowledge to
Dental College, Second prize
was awarded to DIKIOHS
and third prize was awarded
to FJDC and AIFD.
The conference even
included the Poster
Competition with Theme:
Emerging trends in
Prosthodontics. First prize was given
to FJDC; second prize was achieved
by AIFD while third prize was given
to LUMHS.
The conference concluded with a vote
of thanks by Secretary PPA Dr
Mehmood Hussain, who conveyed
sincere and heartfelt gratitude to all
the experts specially the international
speakers, company representatives
and other eminent personalities who
supported the conference by
facilitating the discussion forums.
[5] =>
[6] =>
CLINICAL PRACTICE
6 DENTAL TRIBUNE Pakistan Edition January 2016
Cast mounting
using
MaxAlign: The
clinical component
Editor - Online
Haseeb Uddin
Fig. 1: Inaccurate mounting
Fig. 2: Tablet app
DT International
T
he importance of
records cannot be
overstated. Records
are a legal requirement, are
vital in assisting with
diagnoses, and facilitate
treatment planning, patient
comprehension and
l a b o r a t o r y
By Dr. Les Kalman communication.[1, 2] The
clinician has the choice between virtual or tangible
records, which may include casts, a facebow,
articulation and photographs.[3, 4] Accurately
mounted diagnostic casts provide an immense
amount of information for treatment and that
information will have an impact on the final
prosthodontic plan.[5]
Just as the correct mounting of casts provides
valuable information, so too does incorrect
mounting provide inaccurate information. In
addition, incorrect mounting may result in false
diagnoses and possibly even altered treatment
plans, based on errors in inter-arch space, occlusal
contacts and force directions (Fig. 1).[5]
Laboratory communication with the clinician
remains an important aspect, yet this has been
lacking.[6] Without records, communication with
the laboratory can be even more limited.
Communication tools must be employed[7,8] to
provide information so that laboratory technicians
can satisfy laboratory requisitions. Lack of
information results in guesswork, assumptions and
incorrect dental work that is ultimately returned
to the dental laboratory.[9]
Background: MaxAlign
The MaxAlign application (Max; Whip Mix) is
a communication tool for the clinician that captures
essential patient information. It is a tablet-based
technology that offers a unique set of records,
enabling the accurate mounting of casts complete
with a patient image. Max provides a calibrated
photograph with clinical information and a novel
technique for the mounting of casts. This case
report will explore the effective use of Max to
acquire clinical information that is vital for the
laboratory, third party insurance, the clinician and
the patient.
Clinical protocol
A healthy 36-year-old female patient with a noncontributory medical history presented for
consultation regarding elective anterior aesthetic
treatment. Records consisted of alginate
impressions using stock trays, which were poured
in JADE STONE (Whip Mix), and utilisation of
Max.
The Max app was downloaded onto a Samsung
tablet (provided) and launched (Fig. 2). Patient
information was input (Fig. 3). The tablet was
positioned in the tablet clamps (provided) and the
clamps were tightened to ensure a vertical
orientation (Fig. 4). The tablet must be placed such
Fig. 3: Patient information
Fig.4: Tablet stand
Fig. 6: Max capture mode
Fig. 8: Recording occlusion
Fig. 5: Patient–tablet position
Fig. 7: Patient image
Fig. 9: Inputting occlusion
that the Samsung logo is on the right, so that the
camera is located to the right. The patient was in
the upright position, with the occlusal plane parallel
to the floor, while the tablet was placed on the
instrument delivery stand (Fig. 5). Max has
anatomical guides for positioning: maxillary incisor
midline and edge, location of orbits and inferior
facial outline. The delivery stand was positioned
close enough to the patient for her facial features
to line up with the guides on Max (Fig. 6). Cheek
retractors were employed to offer a clear view of
the dentition (Fig. 6). Once the patient was in the
correct position, the “arm auto capture” button
was pressed. The tablet then captured a photograph,
with a flash, of the patient (Fig. 7). Once the
photograph has been taken, the clinician has the
ability to maximise patient position by sizing or
moving the image. The width of the central incisors
can be selected from the boxes (Fig. 7). Once
completed, the image is saved.
The next step is to verify occlusion. This was
done with standard 8 µ shimstock while the patient
is in maximum intercuspation (Fig. 8). The contacts
were observed and input into the second Max
screen (Fig. 9). This screen represents the quadrants
of the dentition, and each box represents a tooth.
Fig. 10: Mounted case
In order to record occlusion, one touches the box
that corresponds to the teeth contacting (Fig. 9).
The image and record of occlusion are saved and
the operator has the option to exit the app or
proceed with the laboratory component. If the
mounting will be delegated to a laboratory, this
concludes the clinical component of Max. The
clinical information can then be e-mailed to the
respective laboratory as a JPEG or PDF file. The
laboratory would utilise the information according
to the instructions in Max, as well as the
peripherals, to mount a set of casts accurately (Fig.
10).
Discussion
Based on the records and examination, the
following were determined: Class I occlusion,
20% overbite, 0/2 mm overjet, canine guidance
and evidence of a parafunctional habit. The
diagnosis included mildly discoloured anterior
composites and bruxism. The patient was presented
with several treatment plans, ranging from
preoperative whitening followed by minimally
invasive composite replacement to anterior
porcelain veneers. An occlusal splint was also
recommended. Although she was undecided on
Continued on page 07
[7] =>
CLINICAL PRACTICE
January 2016 Pakistan Edition DENTAL TRIBUNE 7
Click here! Digital impression margination
made easy
By Alex Touchstone, DDS
O
ne of the primary reasons I embraced
CAD/CAM dentistry 20 years ago was
the promise that the chairside digital
workflow offered in exercising more control over
every aspect of the restorative process. Even today,
the idea of creating quality dental restorations in
one visit for my patients is quite appealing.
I have found, however, that in order to cause the
vision to crystalize into a beautiful IPS e.max CAD
restoration for a patient, I need more than just the
furnace required to crystalize the restoration. I need
a clinical technique that is precise, repeatable and
efficient.
While the CAD/CAM workflow is composed of
many steps, each essential in their own respect,
this “quick tip” will focus on establishing clear,
clean and dry preparation margins in support of the
digital impression and restoration bonding processes.
Preparation before preparation
Before we spin up the turbine on the handpiece,
two steps will lay the foundation for success. The
first is to evaluate the patient’s periodontal status
and consider any treatment required to achieve
periodontal stability, because we know that
excessive bleeding during the procedure will place
the outcome at risk. The second is to consider
whether the preparation margins are to be
subgingival and, if so, place a length of dry, knitted
retraction cord (Knit-Pak, Premier Dental Products,
Plymouth Meeting, Pa.).
As a guide for what size cord to use, determine
the minimum probing depth in the region of the
sulcus that will adjoin a subgingival margin and
then subtract that number by “1” to arrive at the
cord size. So, for instance, if the minimum probing
depths for the facial and interproximals for the
teeth to be veneered was 2 mm, then the #1 cord
was placed. It is important to place the required
cord prior to beginning the preps as they will provide
some protection against soft-tissue trauma imparted
by the bur during preparation.
Another hedge against insulting the gingiva during
preparation is to use a finishing grit diamond bur
(round-end taper 782.8F, Premier Dental Products)
to finalize the position of subgingival margins.
Cast mounting using MaxAlign: The
clinical component
Continued from page 06
the treatment modality, the records
obtained with Max provided valuable
information for the clinician, the
patient and third-party insurance. If
treatment is to proceed, important
information on occlusion, guidance
and aesthetic determinants will be
accurately conveyed to the laboratory.
Utilisation of the clinical
component of Max provided a very
simple approach to capturing the
clinical data. The process was
straightforward, the anatomical
guides proved very useful and the
record of occlusion provided
additional crucial information that is
often omitted.
There were no software glitches or
errors during operation. The patient
In this case, the veneer preparation impression is captured using the Planmeca PlanScan scanner
(Planmeca USA, Roselle, Ill.). During live scanning, the margins are clear and visible on the screen,
just as they are in the mouth.
Even with these hemorrhage prevention measures,
some bleeding may occur and/or the tissues may
become edematous during the preparation process.
If nothing is done to mitigate the bleeding or edema,
the quality of the digital impression and, later in
the procedure, the adhesive bond will both be
compromised.
The next line of defense against these clinical
complications is application of a hemostatic
retraction paste for two minutes (Traxodent, Premier
Dental Products). This is followed by copious
rinsing and thorough drying. When drying the area,
care should be taken to thoroughly dry each sulcus
as the cord in place acts as a wick for moisture,
and it will require more time to dry than the teeth
themselves.
It is also helpful during the procedure to use a
soft-tissue retraction device to gain better access
and to prevent the retraction paste from being
displaced during the two-minute material action
period (Comfort-View, Premier Dental Products).
After rinsing and drying, one should inspect the
margins carefully and expect to clearly see them
from the occlusal and/or facial aspect.
At this point, the digital impression may proceed
with ease. In the case pictured, the veneer
preparation impression was captured using the
also found the process extremely
quick and comfortable.
Max has several safeguards to
guarantee optimisation. There is a
sensor to ensure it is prop erly
positioned when taking the
photograph of the patient. If it is not
properly positioned, image capture
will not occur. Calibration may be
required in order to ensure that the
sensor is correctly set. This is
achieved by positioning the tablet
vertically in the stand and then
pressing the “calibrate sensor” button.
The sensitivity of the positioning
sensor may also be adjusted with the
“adjust sensitivity” button. If the
clinician has become frustrated and
must take the image immediately,
there is a “force capture” button that
will override the sensor and take an
image.
Planmeca PlanScan scanner (Planmeca USA,
Roselle, Ill.). During live scanning, the margins
are clear and visible on the screen, just as they were
in the mouth.
A quality digital impression will carry over to a
higher degree of confidence in subsequent steps,
such as marking the margins on the virtual model.
Preparation is critical to achieving the final result
for a patient. While the design process is not shown
here, you can see the precision of this patient’s
restoration, milled with Planmeca PlanMill40.
Re-application of Traxodent (Premier Dental
Products) prior to bonding, using the same technique
previously described, will help to ensure that the
marginal areas of the teeth are dry and exposed.
The combined use of a general soft-tissue retractor
(Comfort View), dry cord (Knit-Pak) and hemostatic
retraction paste (Traxodent), described herein, have
the combined effect of supporting an ideal treatment
outcome as illustrated in the post-treatment
appearance of these veneers.
While this clinical workflow was presented in
the context of chairside digital CAD/CAM dentistry
using the Planmeca FIT system (Planmeca USA),
one should appreciate its application for all types
of digital or physical fixed restorative impressions
as well as adhesive bonding procedures.
Future development may
consider the option of saving
the image in STL format. This
would enable various output
options and use with other
digital image and design
software.
Conclusion
Max provides a novel and
innovative approach to the
mounting of casts using a tablet,
reinforcing the anatomical and
aesthetic considerations when
establishing a simulated patient case.
The accurately mounted tangible casts
provide substantial information for
diagnostic and treatment planning,
beneficial to dental students, new
graduates and experienced clinicians.
Compared with traditional
approaches, such as facebow transfer,
Max provides an easy, efficient and
accurate method for clinical
information acquisition that has
benefits for both the clinician and
patient. Its ease of use would perhaps
encourage clinicians to consider uti
- lising Max as a vehicle for obtaining
crucial clinical data.
This would enable greater overall
communication, improved success in
prosthesis fabrication, and a more
satisfying experience for the patient
and clinician.
[8] =>
[9] =>
[10] =>
NATIONAL NEWS
10 DENTAL TRIBUNE Pakistan Edition January 2016
DNES ’15: Educate Patients and provide treatment
options: Experts
Editor - Online
Haseeb Uddin
ARACHI - A successful Experts
Symposium in partnership with Baqai
Dental College, Pakistan Dental
Symposium included Prof Kashif Ikram and
Dr Irfan Qureshi both very distinguished and wellknown names in the implant industry.
The programme was conducted in a new and novel
setting with both distinguished implant practitioners
FDSRC (Eng) FFDRCS (Ireland) and Dr Irfan
Qureshi MSc London, Diplomate ICOI, Diplomate
Implant Dentistry RCS (Edinburgh) and HoD at Sir
Syed College of Medical Sciences enthralled the
audience with practical tips and guidance.
Association, an Academy of Orofacial Aesthetics
and Glowpak International here in Karachi. The
symposium titled “ How to have a Successful Implant
Practice”.
The speakers at the Dental News Experts
taking turns while presenting. Both the distinguished
dentists who are running their own successful
practices shared their personal experiences and
explained the do’s and don’ts for running a successful
implant practice.Prof Kashif Ikram, principal Baqai,
Like all DNES programmes this was also a huge
success with packed audience keen to learn from the
experts. The programme has 3 CDE hours.
Prof Mahmood Haider, Prof Saqib Rashid and Dr
Mazhar also graced the occasion.
DT Pakistan Report
K
4th International PAO
Conference Quest for Excellence
Continued from page 02
More than 13 international
speakers attended the moot
besides the elite of the dental
profession from across Pakistan
converged on a single platform
to make this event a success.
Leading orthodontic practitioners
from across Pakistan also
presented their lecturers and
conducted workshops.
Dr Arif Alvi was the most
sought after local speaker and
had a fully packed audience, he
was presenting after a couple of
years.
The conference workshops
received an overwhelming
response held at the prestigious
Aga Khan University Hospital.
The conference was organized
by the Pakistan Orthodontics
Association in collaboration with
Dental News and Dental Tribune.
[11] =>
[12] =>
HEALTH INSIDER
12 DENTAL TRIBUNE Pakistan Edition January 2016
Coronary heart disease patients with no teeth
have nearly double risk of death
Editor - Online
Haseeb Uddin
DT International
oronary heart disease patients with no teeth
have nearly double the risk of death as those
with all of their teeth, according to research
recently published in the European Journal of
Preventive Cardiology.[1] The study with more than
15,000 patients from 39 countries found that levels
of tooth loss were linearly associated with increasing
death rates.
“The relationship between dental health, particularly
periodontal disease, and cardiovascular disease has
received increasing attention over the past 20 years,”
said lead author Dr. Ola Vedin, cardiologist at Uppsala
University Hospital and Uppsala Clinical Research
Center in Uppsala, Sweden. “However it has been
insufficiently investigated among patients with
established coronary heart disease who are at
especially high risk of adverse events and death and
in need of intensive prevention measures.”
Analysis included 15,456 patients from 39 countries
on five continents
This was the first study to prospectively assess the
relationship between tooth loss and outcomes in
patients with coronary heart disease (CHD). The
results are from a substudy of the STABILITY trial2,
which evaluated the effects of the Lp-PLA2 inhibitor
darapladib versus placebo in patients with CHD.
The analysis included 15,456 patients from 39
countries on five continents from the STABILITY
trial.[2] At the beginning of the study, patients
C
DT International
By Crawford Bain, UK
raditionally, dentists have
been taught that both dental
caries and periodontal disease
develop and progress as a direct result
of patients’ over-frequent
consumption of refined sugars and
patients’ failure to remove bacterial
plaque effectively. Miller’s acidogenic
theory of caries development and the
non-specific plaque hypothesis based
on Loe’s work in the 1960s allow
dentists to present a simple causeand-effect explanation to patients.
Since then, the dental profession has
blamed patients’ poor oral hygiene
for periodontal breakdown and dental
caries while often failing to diagnose
and treat other contributing causative
factors.
Unfortunately, while plaque is
generally a necessary ingredient of
common dental diseases, the
explanation contained in these theories
of its pivotal role is simplistic given
current knowledge. This brief article
will attempt to put the more significant
risk factors in context.
Plaque
Gingivitis is a natural bodily
response to bacterial accumulation
and as such is non-specific. Effective
plaque removal will generally reverse
gingivitis. The concept of inevitable
progression from gingivitis to
destructive periodontitis if oral
hygiene is not good is, however,
flawed. Figure 1 shows a 46-year-old
T
Researchers are connecting levels of tooth loss
— due primarily to poor dental hygiene that
leads to periodontal disease — with increasing
rates of death and stroke.
(Photo: Judith Hakze, Freeimages.com)
completed a questionnaire about lifestyle factors
(smoking, physical activity, etc), psychosocial factors
and number of teeth in five categories (26-32
[considered all teeth remaining], 20-25, 15-19, 1-14
and none).
Patients were followed for an average of 3.7 years.
Associations between tooth loss and outcomes were
calculated after adjusting for cardiovascular risk
factors and socioeconomic status. The primary
outcome was major cardiovascular events (a
composite of cardiovascular death, myocardial
infarction and stroke).
Patients with a high level of tooth loss were older,
smokers, female, less active and more likely to have
diabetes, higher blood pressure, higher body mass
index and lower education.
During follow up there were 1,543 major
cardiovascular events, 705 cardiovascular deaths,
1,120 deaths from any cause and 301 strokes.
After adjusting for cardiovascular risk factors and
socioeconomic status, every increase in category of
tooth loss was associated with a 6 percent increased
risk of major cardiovascular events, 17 percent
increased risk of cardiovascular death, 16 percent
increased risk of all-cause death and 14 percent
increased risk of stroke.
746 patients had a myocardial infarction during
the study
Compared with those with all of their teeth, after
adjusting for risk factors and socioeconomic status,
the group with no teeth had a 27 percent increased
risk of major cardiovascular events, 85 percent
increased risk of cardiovascular death, 81 percent
increased risk of all-cause death and 67 percent
increased risk of stroke.
“The risk increase was linear, with the highest risk
in those with no remaining teeth,” said Vedin. “For
example, the risks of cardiovascular death and allcause death were almost double to those with all
teeth remaining. Heart disease and gum disease share
many risk factors such as smoking and diabetes, but
we adjusted for these in our analysis and found a
seemingly independent relationship between the two
conditions.
“Many patients in the study had lost teeth so we
are not talking about a few individuals here,”
Continued on page 14
Reassessing risk factors
for periodontal disease
Fig. 1:
Patient at presentation
(he requested extraction of all
mandibular teeth)
Fig. 2: The same patient one month
after scaling and polishing (he asked
how he could maintain the teeth in
this condition)
patient with non-existent oral hygiene
over several years. Figure 2 shows
the same patient one month later after
around 90 min of scaling and
polishing by a student dental
hygienist. He had no active caries and
no more than 10% bone loss.
It has become increasingly evident
that while some patients are
“susceptible” to periodontal
breakdown, others are more
“resistant”. Common among these
host-based factors leading to greater
breakdown are the presence of
diabetes and a smoking habit.
Diabetes
Several authors have demonstrated
a clear relationship between degree
of hyperglycaemia and severity of
periodontitis, and the risk of cardiorenal mortality (ischaemic heart
disease and diabetic nephropathy
combined) is three times higher in
diabetics with severe periodontitis
than in diabetics without severe
periodontitis.[1] Javed et al. showed
that scaling and root planing in
prediabetics reduced glycated
haemoglobin (HbA1c) by 1% at three
months,[2] and reductions in HbA1c
of 0.3–1% have been confirmed in
several other studies in both Type 1
and Type 2 diabetics. There are
estimated to be 745,940 diabetics in
the United Arab Emirates. In 304,000
of those cases, the condition has not
been diagnosed, and 934,300 people
have impaired glucose tolerance, a
prediabetic state of hyperglycaemia,
or elevated levels of blood sugar.[3]
In the UK Prospective Diabetes
Study, it was shown that Type 2
diabetics who reduce their HbA1c
level by 1% are 19% less likely to
suffer cataracts, 16% less likely to
suffer heart failure and 43% less likely
Continued on page 14
[13] =>
[14] =>
14 DENTAL TRIBUNE Pakistan Edition January 2016
Dr Irfan appointed Examiner International Symposium
at Seoul, South Korea
by RCS Edinburgh
Editor - Online
Haseeb Uddin
K
ARACHI- Dr Irfan Qureshi, one of the most
renowned Implantologsists of the country
was recently appointed examiner for
Implant Dentistry by the Royal College of Surgeons,
Edinburgh for a period of 5 years.
Implantology is a rapidly growing field and is one
of the most popular and cutting edge treatment option
for tooth replacement. There are other examiners from
Pakistan appointed by Royal College of Surgeons in the past but Dr Qureshi`s
achievement is unique because he is the first and the only examiner appointed
for Implant Dentistry by the Royal College of Surgeons, Diploma Implant
Dentistry and a prized exam and the most expensive dental exam conducted
by the college.
In 2013 Dr Irfan Qureshi became the first and so far the only Pakistan based
dentist to earn the Diploma Implant Dentistry from Royal College of Surgeons
Edinburgh.
He recently completed the necessary paperwork and underwent examiners
training at The Royal College of Surgeons Edinburgh. The college is known
as one of the best in the world for examination and assessment.
Dr Irfan continues to strive hard in his efforts to excel.
Raheel Sharif awarded honorary
fellowship of CPSP
Continued from front page
in the country, his remarkable
achievements against terrorism and for
modernizing the health care system in
Pakistan Army.
AEEDC Dubai - A Global platform
for the Dental World
Continued from front page
F o u r / S i x H a n d e d D e n t i s t r y,
Hypnodontics, Infection Control, Laser
Dentistry, Microscopic Dentistry, Oral
and Maxillofacial Surgery, Oral
I m p l a n t o l o g y, O r a l / M e d i c a l
Photography, Oral Pathology, Oral
Medicine, Orthodontics, Pediatric
D e n t i s t r y, P e r i o d o n t o l o g y,
Prosthodontics, Restorative Dentistry
and Robotic in Dentistry.
AEEDC Dubai 2016 exhibition is the
gateway to the emerging and far-reaching
dental market in the MENASA region
and all the movers and shakers of the
region will be there.
Coronary heart disease patients with
no teeth....
Continued from page 12
continued Vedin. “Around 16 percent of
patients had no teeth and roughly 40
percent were missing half of their teeth.”
During the study period, 746 patients
had a myocardial infarction. There was
a numerically increased risk of
myocardial infarction for every increase
in tooth loss, but this was not significant
after adjustment for risk factors and
socioeconomic status. Vedin said, “We
found no association between number
of teeth and risk of myocardial infarction.
This was puzzling (because) we had
robust associations with other
cardiovascular outcomes, including
stroke.”
Tooth loss could identify patients who
need more prevention efforts
Gum disease is one of the most
common causes of tooth loss. The
inflammation from gum disease is
thought to trigger the atherosclerotic
process and may explain the associations
observed in the study. Poor dental
hygiene is one of the strongest risk
factors for gum disease.
“This was an observational study so
we cannot conclude that gum disease
directly causes adverse events in heart
patients,” Vedin said. “But tooth loss
could be an easy and inexpensive way
to identify patients at higher risk who
need more intense prevention efforts.
While we can’t yet advise patients to
look after their teeth to lower their
cardiovascular risk, the positive effects
of brushing and flossing are well
established. The potential for additional
positive effects on cardiovascular health
would be a bonus.”
Reassessing risk factors for
periodontal disease
Continued from page 12
to suffer amputation or death due to
peripheral vascular disease.
Clearly, not only will control of
diabetes facilitate management of
periodontitis, but also, probably more
importantly, effective management of
periodontitis is likely to have major
beneficial effects on the serious sequelae
of diabetes. Unfortunately, the medical
profession is largely ignorant of the
potential benefits of establishing and
maintaining periodontal health. The
publication Type 1 Diabetes in Adults:
National Clinical Guideline for Diagnosis
and Management in Primary and
Secondary Care (updated in July 2014)
was compiled by a consensus reference
group made up of 30 members.[4] These
included physicians, endocrinologists,
nurses, ophthalmologists, dieticians,
podiatrists and lay people, but no dentists.
Its 153 pages make no mention of
dentistry or periodontal disease. The
National Institute for Health and Care
Excellence document on Type 2 diabetes,
also updated in 2014, too fails to mention
dentistry or periodontal disease.
Smoking
We have known for over 20 years that
smoking increases the risk of periodontal
K
ARACHI- Dr. Abubakar Sheikh associate professor and Head of
Department of endodontic at Fatima Jinnah Dental College recently
attended the world Neobiotech International symposium at Seoul,
South Korea from Pakistan to present at the Core members meeting of the
Global Academy of
Osseointegration. Dr.
Abubakar Sheikh a
fellow of the College
of Physcians and
Surgeons of Pakistan
is a practicing
implantologist both
at the institute and
his private practice
for a number of
years.
His presentation and cases were highly appreciated by all the participants
and as a result he was also inducted as a member of the GAO core group
which will enable him to work and share knowledge and skills with the experts
in implantology from all over the world and to present internationally in future
also.
breakdown. Odds ratios for developing
periodontal disease as a result of smoking
constitute a range: 2.5,[5] 3.97 for current
smokers and 1.68 for former smokers,[6]
and 3.25 for light smokers to 7.28 for
heavy smokers.[7] A smoker with 20
pack years (20 cigarettes per day for 20
years) is up to 600% more likely to lose
teeth owing to periodontal disease,
whereas a patient with poor plaque
control has around a 15% risk of
progressing to destructive periodontitis.
Why then do we refer to hygiene phase
therapy when smoking is a much greater
risk factor than poor oral hygiene? How
many dentists spend as much time on
smoking cessation counselling as on oral
hygiene instruction?
Sugar
Traditionally, teaching on caries
prevention has focused on the number
of sugar exposures per day, especially
between meals. Academic paedodontists
suggest that provided there are two daily
exposures to fluoride in toothpaste, a
maximum of six sugar exposures a day
is unlikely to lead to significant enamel
decalcification in children. However, a
large study conducted in 2015 by
Bernabé et al. evaluated 1,702 adults
over 11 years and concluded that “the
amount of, but not the frequency of,
sugars intake was significantly associated
with DMFT [decayed, missing and filled
teeth] throughout the follow-up
period”.[8]
It thus appears that, at least in adults,
“how much” is more important than
“how often” with regard to sugar
consumption. This is all the more
significant since DMFT measures real
outcomes over significant time spans,
while many studies on both caries and
gingivitis are very short term and use
surrogate outcomes, such as
decalcification on an enamel sample, or
plaque and gingivitis indices as the basis
of their conclusions. Patients are only
really interested in real outcomes.
Obesity
The third National Health and
Nutrition Examination Survey showed
that body mass index was significantly
associated with periodontal disease.
Other studies have indicated a less strong
association, and with the compounding
variable of blood sugar levels in
prediabetics, it is presently unclear
whether obesity is in fact an independent
risk factor or is associated with the
established role of diabetes. Regardless,
obesity is a known risk factor for Type
2 diabetes and cardiovascular problems,
and it is part of the dental professional’s
role to inform patients of these
interrelationships.
Recent research in England has
suggested that 1.4 million obese patients
would benefit from gastric band or
bypass (bariatric) surgery. Currently,
around 8,000 people a year receive the
treatment on the National Health Service
(NHS). If all 1.4 million were offered
surgery, the researchers estimate it would
avert nearly 5,000 heart attacks and
40,000 cases of Type 2 diabetes over
four years.
They do not, however, discuss potential
costs of this surgery, which can vary
from £3,000 to £11,505, according to
NHS England. Assuming £5,000 per
procedure, this would total around an
additional £7 billion in health costs. Nor
is there much discussion on death rates
(0.5–1% with the present skill level of
surgeons). Even if surgical skills do not
diminish, we should anticipate between
7,000 and 14,000 additional deaths.
It is likely that comprehensive
periodontal treatment of all
obese/prediabetic patients would be
significantly less costly and, hopefully,
result in few if any fatalities.
Conclusion
It is clear that the simple story of plaque
control preventing progression of
common dental diseases is largely fiction
rather than evidence-based fact. While
effective oral hygiene will always be a
significant part of the management of
dental diseases, the modern dental
professional must be equally aware of
the other common risk factors outlined
in this article.
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