DT Pakistan No. 4, 2014

News / Stop hurting your patients! Deliver the “WOW experience” and watch your practice grow / Diagnosis 2014: The things you need to know for successful endodontic treatment / News / Expert symposium on implantology encourages patient centric treatment approach

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PUBLISHED IN PAKISTAN

Stop hurting your
patients! Deliver the
“WOW experience”
and watch your
practice grow

www.dental-tribune.com.pk

Page 2

Diagnosis 2014:
The things you
need to know for
successful endodontic
treatment

Page 4

JULY, 2014 - No. 04 Vol.1

Expert symposium
on implantology
encourages patient
centric treatment
approach

Page 8

IDP camps provide unique FDA changes

Polio vaccination
opportunity

recommendations
on lidocaine for
teething pain
DT Pakistan Report

W

DT Pakistan Report

T

he presence of thousands of children from
North Waziristan in Pakistan's camps for
internally displaced persons (IDPs) offers
an unexpected opportunity for anti-polio teams
to vaccinate those who could not previously be
accessed. Experts say that this is an excellent
opportunity and must not be missed. Areas of

N.Waziristan were previously thought inaccessible
because of the prevalent law and order situations.
Hundreds of Thousands of children were not
vaccinated because militants in the affected areas
had opposed the vaccination campaigns. This is
thought to have contributed to the various polio
Continued from page 11

with the Geneva-based dental
federation. The 102nd edition
will be held at the India Expo
Centre in Greater Noida in
Uttar Pradesh from 11 to 14
September. According to the
FDI, it has received significant
interest, with more than
10,000 registrations in early
July.
The son of a freedom
fighter, Mukherjee has held a
number of high political
positions in his country,
including in the Ministry of Finance, which he headed
before being elected president. The 78-year-old member
of the ruling United Progressive Alliance has also
periodically held seats in India's upper and lower houses
for over 50 years. He has served as head of state since
mid-2012, when he was elected in a landslide win against
leftist rival candidate Purno Agitok Sangma.
Mukherjee is the 13th holder of the office of president,
which was established after India gained independence
from Great Britain in 1947.

The President
of India to
inaugurate
FDI 2014
DT Pakistan Report

N

ew Dehli: The upcoming Annual World Dental
Congress (AWDC) of the FDI World Dental
Federation in New Delhi will see a visit by the
highest political figure in India. President Pranab Mukherjee
will inaugurate the opening ceremony on Thursday, 11
September, the FDI confirmed last week.
Mukherjee recently accepted an invitation from the
Indian Dental Association in Mumbai to join the
international event, which is being organised in partnership

ashington: The Food and Drug
Administration (FDA) announced that a
box warning on prescription products
containing viscous lidocaine solution is now required
that states that such products should not be used to
treat teething pain in children. In response, a U.S.
trade association has voiced concerns that such
suggestions create confusion among consumers and
health care providers. It has urged the FDA to clarify
its announcement.
A box warning on a drug label is the FDA's
strongest warning. In the current case, the agency
required a new box warning for oral viscous lidocaine
2 percent solution because it is not approved to treat
teething pain and could cause serious harm in infants.
In its safety announcement issued on June 26, the
FDA called upon health care professionals not to
prescribe or recommend this product for teething pain.
In addition, the agency instructed parents and
caregivers to use a chilled teething ring or to rub the
child's gums with a finger to relieve the symptoms.
The FDA further emphasized that topical pain relievers
rubbed on the gums are not necessary. When
Continued from page 11

Amalgam
recycling
starts in Brazil
DT Pakistan Report

B

razil: Together with the
Universidade Federal
Fluminense, one of the
largest universities in Brazil, Dental
Recycling International (DRI), a
dental waste management company,
has initiated a pilot project that aims
to promote environmentally friendly
disposal of dental amalgam in
Brazil.
DRI announced that it will be
installing amalgam separators at the
university's Faculty of Dentistry and
providing a number of chairside
amalgam recycling kits.
Continued from page 11

[2] =>

2 DENTAL TRIBUNE Pakistan Edition July 2014

Clinical Practice

Stop hurting your patients! Deliver the “WOW
experience” and watch your practice grow
By Dr. Steven G. Goldberg, USA
very dentist is looking to grow his or
her practice, and we are all looking
to bring in as many new patients as
we can. Numerous excellent articles have
been written by many highly successful
clinicians and marketing gurus on a myriad
of ways to grow your practice.
According to Dr. Joe Blaes, editor of
Dental Economics, speaking of the DentalVibe
Injection Comfort
System in his
column “Pearls for
your practice”
(January 2011),
“The best WOW
experience that we
can give in dental
practices is to not
hurt our patients.
You will get more referrals from patients if
you have a pain-free practice than any other
marketing tool you can use. [...] DentalVibe’s
synchronized percussive vibration provides
an ideal way to administer anesthetic
injections, anywhere in the mouth, without
discomfort. DentalVibe is cordless, portable,
and easily affordable for every office.”
The fact is that as dentists we are so
focused on our technical skills while we are
performing our craft that we lose sight of one
of the most important issues on the business
side of dentistry: the patients’ perspective.
They are desperately afraid that we are going
to hurt them. Many people are so afraid of
pain that they avoid going to the dentist
altogether. According to worlddental.org,
studies by the Dental Fears Research Clinic
in Seattle, Washington, report that upwards
of 40 million Americans avoid going to the
dentist because of this fear. This is quite
alarming when you consider the negative
health effects directly related to poor oral
health.
Consider the following scenario. You
spend half an hour with a new patient, treating
tooth 14 with an MOD composite bonded
filling. You carefully excavate the decay,
skilfully prepare the tooth with perfect
cavosurface margins, etch, prime, place
adhesive and composite, and cure for the
appropriate period. You spend a great deal of
time creating a beautifully artistic
representation of occlusal anatomy, and even
place secondary grooves in the marginal
ridges. Then you polish like you have never
polished before. You are proud of the artistic
piece that you have created and you have
provided a tremendous service to your patient.
However, when your patient goes home
and reports back to his or her family and
friends about his or her dental experience, is
the patient going to tell them how wonderful
your secondary grooves are? More likely,
what the patient will say is whether you hurt
him or her.
What patients remember is the very
beginning of the appointment, the dreaded
dental injection. If you anesthetise your
patients painlessly, you will be considered a
painless dentist. After all, dentistry does not
hurt. A filling does not hurt, an extraction
does not hurt, and even a root canal does not
hurt, because once your patient is anesthetised,

you are practising painless dentistry.
if Publisher/CEO
EditorBut
- Online
Haseeb
Uddin Syed Hashim A. Hasan
you hurt your patients during the
injection
hashim.hasan@dental-tribune.com.pk
process, you are no longer considered a
Editor Clinical Research:
painless dentist.
Dr. Inayatullah Padhiar
With the use of the DentalVibe Injection
Research & Public Health
Comfort System now in its second generation, Editors
Prof. Dr. Ayyaz Ali Khan
as an adjunct to the injection process, you no
Editorial Assistance
longer have to hurt your patients to help them. Dr. Ahmed Ali
This patented, award-winning device utilises
Editor - Online
revolutionary VibraPulse technology to send Haseeb Uddin
soothing, pulsed, percussive vibrations deep Graphics Designer
i n t o t h e o r a l Sh. M. Sadiq Ali
mucosa during the
Dental Tribune Pakistan
d e l i v e r y o f a n 3rd floor, Mahmood Centre, BC-11, Block-9
i n j e c t i o n . T h i s Clifton, Karachi, Pakistan.
s t i m u l a t i o n i s Tel.: +92 21 35378440-2 | Fax: +92 21 35836940
perceived by the www.dental-tribune.com.pk info@dental-tribune.com.pk
s u b m u c o s a l Dental Tribune Pakistan cannot assume responsibility for the validity of
sensory receptors, product claims or for typographical errors. The publisher also does not
responsibility for product names or statements made by advertisers.
sending a message assume
Opinions expressed by authors are their own and may not reflect of
t o t h e b r a i n , Dental Tribune Pakistan.
effectively closing the neural pain “gate”,
International Imprint
allowing for the comfortable administration
Daniel Zimmermann
of intra-oral injections. Adults and children Group Editor
newsroom@dental-tribune.com
have reported painless injections and dentists
Tel.:+49 341 48 474 107
report less stress during the injection process.
The device is cordless, portable, nonMagda Wojtkiewicz
threatening, easily affordable, has been Clinical Editor
Yvonne Bachmann
receiving rave reviews all around the world Online Editors
Claudia Duschek
from key opinion leaders in dentistry, and
has been featured on all of the TV news Copy Editors
Sabrina Raaff
networks.
Hans Motschmann
DentalVibe is based on the Gate Control
Torsten Oemus
Theory of Pain, proposed by Drs Ronald Publisher/President/CEO
Chief
Financial
Officer
Dan Wunderlich
Melzack and Patrick Wall of McGill
Claudia Salwiczek
University, and published in the Science Business Development Manager
Events
Manager
Lars Hoffmann
journal in 1965. According to this theory,
Matthias Diessner
there is a gating mechanism located in the Media Sales Managers
dorsal horn of the spinal cord. This gating
(Key Accounts)
mechanism either permits or prevents the
Melissa Brown
sensation of pain from travelling up the
(International)
spinothalamic tract to the brain. When the
Peter Witteczek
DentalVibe is used simultaneously during the
(Asia Pacific)
administration of an injection, the pulsed
Maria Kaiser
vibratory impulses generated by the device
(North America)
travel along thick myelinated A beta nerve
Weridiana Mageswki
fibres 37.5 times faster to the brain than the
(Latin America)
sensation of pain from the injection, which
Hélène Carpentier
travels along thin unmyelinated C nerve fibres.
(Europe)
As the vibration sensation reaches the brain
first, a signal is sent to a synapse in the spinal Marketing & Sales Services
Nadine Dehmel
cord, activating inhibitory interneurons that
Nicole Andrä
prevent the action of projection neurons,
thereby shutting a gate, blocking the pain Accounting
Karen Hamatschek
from the injection.
Anja Maywald
This is one dental product that holds
Manuela Hunger
universal appeal to consumers. Nobody wants
Gernot Meyer
to feel pain and these days patients are no Executive Producer
longer willing to accept it, as they may have
Dental Tribune International
in years gone by. Therefore, Bing Innovations,
Holbeinstr. 29, 04229 Leipzig, Germany
the developer of DentalVibe, has launched a
Tel.: +49 341 48 474 302 | Fax: +49 341 48 474 173
multimillion-dollar patient-awareness
info@dental-tribune.com | www.dental-tribune.com
campaign, including TV commercials, print
advertisements, cinema advertising, Internet Regional Offices
banner advertisements and a web-based
dentist locator. This tremendous effort is Asia Pacific
effectively educating tens of millions of Dental Tribune Asia Pacific Limited
consumers on the wonderful benefits of Room A, 20/F, Harvard Commercial Building,
DentalVibe for virtually painless injections 105–111 Thomson Road, Wanchai, Hong Kong
and driving patients to those dentists who Tel.: +852 3113 6177 | Fax: +8523113 6199
use it.
Give your patients the “WOW experience” The Americas
with DentalVibe, so that both you and your Tribune America, LLC
patient’s can enjoy our wonderful profession 116 West 23rd Street, Ste. 500, New York, N.Y. 10011, USA
Tel.: +1 212 244 7181 | Fax: +1 212 244 7185
a little bit more.

[3] =>

[4] =>

Clinical Study

4 DENTAL TRIBUNE Pakistan Edition July 2014

Diagnosis 2014: The things you need to
know for successful endodontic treatment
Editor - Online
Haseeb Uddin

By Dr. Thomas Jovicich
roots

ce credit

This article qualifies for CE credit. To take the CE quiz,
log on to www.dtstudyclub.com. Click on ‘CE articles’
and search for this edition of the magazine. If you are not
registered with the site, you will be asked to do so before
taking the quiz. You may also access the quiz by using
the QR code below.

T

he goal of endodontic
treatment is for the clinician
to achieve an effective
cleaning and debridement of the root
canal system, including the smear
layer and all of its mechanical and
bacterial byproducts. Traditionally this
is accomplished via mechanical
instrumentation in conjunction with
chemical irrigants together and
actively engaged to completely
debride and sterilize the root canal
system.
The root canal system is a vast and
complex threedimensional structure
comprising deltas and lateral canals,
along with multiple branches off of
the main root canal system (Figs. 1,
2, 9).
Before the clinician can begin to
treat a patient in need of endodontic
treatment, he or she first must come
up with the proper diagnosis. Once
the diagnosis has been made, it then
must be integrated with the treatment
plan. Taking that treatment plan and
presenting it to the patient creates the
next challenge: creating value for the
patient. One of my most difficult
challenges as a working endodontist
is creating value for the patient in my
chair who has no pain and is here
because his or her dentist “saw
something” on the radiograph. Pain
is the greatest patient motivator we
have in dentistry today.
The focus of this article is on
diagnosis, and it is my goal to provide
the reader with a good grasp of
diagnosis as it relates to endodontic
treatment.
Endodontics is all about vision.
You have it. I have it. The dentist
down the street has it. Doing root
canals today is all about having the
confidence to make the proper
diagnosis. This is achieved through
repetition. The more you do it, the
easier it becomes. In addition, you
need consistency that is achieved
through positive reinforcement. Once
you believe you can do it and the
results support that, you then develop
competence. This allows you to retain
the skills you have worked hard to
hone. The most important trait to
utilize in clinical practice today is
common sense. This is what separates
the true artisans from tooth mechanics.
The key component to endodontic
treatment is diagnosis. It is based upon
using a multifocal approach that

involves:
patient report,
medical and dental history,
clinical signs and symptoms,
diagnostic testing,
radiographic findings,
restorability.
Taking and collating all of this
information will allow the clinician
to arrive at a proper and thorough
diagnosis. Let’s break these down and
delve into what needs to be done.
Patient report
This is the first opportunity to create
a road map to a diagnosis. The goal
is to ascertain the nature of the
problem. Step one: Ask the patient the
where the pain is located. Once you’ve
localized the area, it’s imperative to
ask a few more questions. The next
question should involve determining
pulpal vitality through the use of an
ice pencil. Other times the patient will
volunteer this information with a
statement like: “The minute I put
anything cold on this tooth, the pain
is present and quite intense.” This
information suggests that the pain may
be pulpal in origin. Because the
trigeminal nerve is involved in
endodontics, it is important to
determine any type of radiating pain.
It is not uncommon for maxillary pain
to radiate from the mandibular area
and vice versa. A final area of feedback
I want from patients relates to biting
and chewing. The patient’s report is
the foundation upon which we begin
the diagnostic procedure. Asking
probing and leading questions in “plain
English” will allow the patient to give
you critical diagnostic information.
Medical and dental history
Once you have the patient’s report,
probing his or her medical and dental
history gives clarity to the background.
What are the patient’s medical
allergies? What recent dental treatment
has the patient had? Was there any
mention of restorations placed that
were near or at the pulp? Many times
a patient will mention having heard
the dentist tell his assistant that they
were close to the pulp during the
excavation of decay. Asking detailed
questions enables you to enrich the
diagnostic canvas as to why the patient
is sitting in your chair.
Clinical signs and symptoms
By this point, you have listened to
the patient’s chief complaint and you
have taken radiographs or digital

Fig.3a

Fig.3b

Fig.1 Fig.2
Fig.1 Maxillary molar. Note the complex anatomy and multiple portals
of exit. (Photos/Provided by Thomas Jovicich, MS, DMD)
Fig.2 Mandibular molar. Note the curvature along with the multiple
portals of exit.
Fig.3a Maxillary central incisor with a periapical lesion. This is a
markedly calcified canal.
Fig.3b Maxillary central incisor with completed root canal using Sybron
TFA rotary nickel titanium instruments, Sealapex sealer.
Note the multiple portals of exit in the apical region.
images. It’s time to “test” the patient.
The “bite test” involves having the
patient attempt to reproduce the pain
through biting on an orangewood stick
or a cotton swab or a wet cotton roll.
If there is pain to bite, you are dealing
with some degree of pulpal
inflammation with secondary
involvement of the periodontal
ligament. Once you have this
information, the next step is to look
at your digital imaging and analyze
the relationship of the periodontal
ligament (pdl) to the root. Is there a
thickening? Is there a widening?
If the patient reports pain to bite
upon release, this infers that there may
be some structural root damage (Figs.
5a & b). At that point is it essential to
look at the occlusal surface of the
tooth, account for the type and age of
any restoration and inquire if any
recent dentistry has been done. In
addition, it is imperative to probe the
suspected tooth.
Probing from buccal to lingual with
at least four measurements per side is
the best barometer to assess
periodontal health. If you find an
isolated defect in any single probing,
you are most likely dealing with a
fracture of the root. Endodontic
treatment to confirm or rule out a
fracture is indicated in these clinical
situations.
Diagnostic testing
The percussion test involves using
the blunt end of a mouth mirror or
periodontal probe to assess for
periodontal inflammation. It is
imperative that the clinician gets a
frame of reference. This is
accomplished by testing the same
tooth on the opposite side of the arch.
In addition, it is prudent to test the
suspected tooth as well as the teeth
on either side. Testing should involve
both the occlusal and facial surfaces.
Thermal tests utilizing hot or cold
are the definitive modality to assess
pulpal vitality. There are a myriad of
ways to test with cold, including CO2
systems, refrigerant sprays and ice

cubes (pellets). I believe ice pellets
are the best way to test for cold
symptoms. In our practice, we use
anesthetic carpules that are filled up
with water and frozen.
This method is cheap, efficient and
plentiful. The goal is to reproduce the
patient’s symptoms. Many patients
who report pulpal hyperemia have
managed this symptom by utilizing
the opposite side of their mouth.
Temperature symptoms are a major
motivator for patients to seek dental
care.
Te s t i n g w i t h i c e i n v o l v e s
establishing a baseline to cold.
Typically, I chose to test the same
tooth on the opposite side or the
maxillary central incisor. I ask patients
to tell me when they feel an “electrical
shock or jolt” to the tooth. As soon as
they do that, I remove the ice from
the tooth. This is easily accomplished
on the buccal surface of the tooth at
the margin of the gingiva. When
porcelain restorations are present, I
strive to put the ice right at the margin
on or above any metal margins.
Sometimes it is necessary to apply
the ice on the lingual aspect of the
tooth. As unresponsive as porcelain
restorations can be, the clinician needs
to be aware that pulp testing gold
restorations can have the opposite
effect. This is because of the
metallurgical properties of gold. It is
an amazing conductor of temperature.
Always forewarn the patient when
testing gold-restored teeth.
Ask the patient if the cold on the
tooth reproduced his or her pain. Also,
ask if the pain lingered after you
removed the ice from the test site. If
the pain it is lingering, it is a sign of
irreversible pulpitis.
In some cases the pain can and does
radiate along the pathway of the
trigeminal nerve. Sometimes,
especially in the maxilla, referred pain
can be related to sinus issues, such as
sinusitis, allergic rhinitis and
rhinovirus.
If the patient does not respond to

[5] =>

Clinical Study

July 2014 Pakistan Edition DENTAL TRIBUNE 5

Fig.4a

Fig.4b
Fig.5a

Fig.6

Fig.5b

Fig.7

Fig.5a Cracked tooth syndrome.
Pre-treatment radiograph.
Fig.5b What can happen in a
cracked tooth when you obturate
with warm, vertical condensation
of gutta-percha.

Fig.6 Well-done endodontic
treatment of tooth #6. Notice the
multiple portals of exit as they
relate to the presence of lesions.
Fig.7 Know when to say when.
This dentist attempted to do an
endodontic procedure that
should not have been done.

Fig.8b

Fig.8a

Fig.8c

Fig.8a Initial digital image with a patient whose chief complaint was
mild pain to bite and chew.
Fig.8b Digital photo of the tooth after I extracted it, showing a gross
negligence. The tooth was perforated through the furcation, and guttapercha was placed in what the dentist thought was the root canal system.
Fig.9 The complexities of maxillary molar endodontics and multiple
portals of exit. Of note, I was never able to shape the MB2 canal.
any thermal tests, both hot and cold,
it is a sign that the pulp is necrotic,
dying or infected. In this instance,
studying the digital imaging may aid
the diagnosis. One caveat: It is possible
to have a necrotic pulp without being
able to quantify it via digital images
In many incipient pathology issues, it
takes approximately 90 to 120 days
for breakdown to manifest itself on
imaging. Today’s cone-beam imaging
technology can shorten that process
to 30 days. It is not uncommon to have
a patient in the chair with symptoms
that you cannot quantify
radiographically.
Radiographic findings
Radiographic findings (Figs. 8a
& b) are the road map for endodontics.
Thorough study and evaluation of
imaging allows the clinician to
determine a multitude of facts about
the tooth in question. What does the
image reveal? Can you see if there is
a widening of the pdl? If there is a
widening of the pdl, it is essential to
have the patient bite down on a bite
stick.
Once he or she does that, you must
ask if the pain, if present, is worse
upon bite or upon release of bite. The
latter is highly correlated with root

Fig.4a The presence of caries under
the margin of a restoration. The
caries extend to the pulp and will
need endodontic treatment.
Fig.4b The endodontic treatment
is completed. In this case, the
patient was lost to the practice for
three years and came back when
his face was swollen because of
incomplete treatment.

fracture. Once that is confirmed, the
next step is to prepare the patient for
a root canal.The dentist must
convincingly explain the procedure’s
value as well as caution the patient
about the possibility of losing the tooth
due to the fracture extending apical
from the cementoenamel junction
(CEJ). Is there a lesion (Figs. 3a & b)
present? This information allows me
to frame my diagnostic questions to
the patient. These include: Is the tooth
sensitive to cold? I know from the
lesion that the answer to that should
be no. If, however, the answer is yes,
it automatically triggers my mind to
look for another tooth.
Generally, speaking teeth with
lesions of endodontic origin (LEOs)
test non-vital to thermal or electric
pulp testing. In sequencing, I first ask
for the patient’s report, followed by
radiographic findings, which I then
augment with clinical testing to tie it
all together and arrive at a diagnosis.
Lastly, are caries present? The location
of caries is a determining factor as to
whether a root canal is needed (Figs.
4a & b).
Restorability
Restorability is an issue that has
been a hot topic in dentistry for years.

Its meaning has evolved as technology
has become the backbone of modern
dentistry. Prior to the incorporation
of implant dentistry, restorability had
a very different meaning. Dentists
were much more motivated to save
teeth. Options and creativity were
necessary for clinical success, both
in endodontics as well as in restorative
dentistry.
Technology has taken away one
form of resourcefulness and replaced
it with the promise of a panacea. It
has become far too easy for general
dentists to recommend removal of a
tooth to a patient with the promise
that an implant will save the day.
‘In modern endodontics, as
technology advances and we bring
on file systems that shape more
efficiently and safely—and we
develop a greater understanding of
the role of irrigation in endo dontics—we can offer higher success
rates than at any time in history.’
Historically speaking, the diagnosis
of a tooth being non-restorable came
after a myriad of attempts to save the
tooth. Every aspect of dentistry came
into play. Periodontists did osseous
surgery and root amputations.
Endodontists performed conventional
endodontics and, if necessary, surgical
intervention to do everything possible
to save the tooth. Decisions involving
the long-term prognosis of the tooth
were relevant. Decisions about the
type of restoration were discussed.
Decisions about the osseous health of
the roots and surrounding bone
structures were relevant.
The goal of every specialist is to
be an extension of the general dentist’s
practice. To that end, deciding whether
a tooth was restorable or not was, at
a minimum, a conversation to be had
between the specialist and the general
dentist.
Leap forward to the new
millennium, and dentists no longer
fight to save teeth. Dentists realize
the financial windfall that implants
offer their practices. Dentists can
attend a myriad of continuing
education courses over a weekend and
on Monday become nascent

implantologists. This fact makes
diagnosis and saving a tooth the most
important facet of restorative dentistry
moving forward.
Treatment planning and
restorability are integral to success
both for the patient and the dentist. A
patient in pain presents a unique
opportunity for the dentist. Many
questions need to be asked and
answered. Among them: What can
the dentist do to manage the pain?
What is the cause of the pain? How
long has the patient been in pain?
Once the initial triage phase is
complete, other factors must be
addressed. These include: Is the tooth
restorable? If endodontic treatment is
indicated, what further treatment will
be needed? Is there a need for
periodontal intervention? If so, what
type of treatment is it? Osseous
surgery? Does the tooth need
crownlengthening surgery? How will
these procedures affect the adjacent
teeth?
The above paragraph speaks
volumes as to the complexities of
treatment planning in dentistry today.
Every day in offices around the world,
a patient visits his or her dentist in
pain. How the dentist responds to this
will go a long way in determining the
patient’s dental well-being. A well
rounded practice with high moral fiber
will enable the dentist and patient to
work synergistically to develop a
realistic treatment plan.
The last essential ingredient to
success is that the dentist knows
“when to say when” (Fig. 7). As a
specialist and lecturer, I believe that
if a general dentist does roughly 80
per cent of the endodontic cases that
walk in the door of his practice and
refers out the remaining 20 per cent,
he or she will have a very busy
endodontic practice. In the past five
years, especially since the decline in
the economy and busyness of
practices, more than 50 per cent of
my practice consists of retreatment.
The general dentist should have never
attempted more than half of those
cases. I can only speculate how much
more there would be if dentists didn’t
have implants to fall back upon.
Implants vs. endodontic treatment
The next aspect of the diagnostic
conundrum is the increasing role
implants play in treatment planning.
When I first began practicing
endodontics in 1988, implants were
in their nascent stages. If a patient
had a root canal and continued to
experience pain or discomfort, both
the dentist and the endodontist had a
myriad of choices, from retreatment
to surgical correction. In 2013, the
knee-jerk reaction to placing implants
has never been greater. More and more
general dentists go to weekend
“seminars/courses,” and on Monday
morning they are placing implants.
Much of this is based on the
financially lucrative aspect of
Continued from page 11

[6] =>

6 DENTAL TRIBUNE Pakistan Edition July 2014

Periodontal
therapy may improve
heart health in highrisk populations

Henry Schein acquires
Sirona Dental’s French
distribution business
Editor - Online
Haseeb Uddin

S

ydney, Australia: The findings of a new study indicate
that, in addition to treating periodontal disease,
periodontal therapy could have a considerable systemic
impact. Researchers have found that a single session of nonsurgical treatment for periodontal disease significantly reduced
the thickness of artery walls, a risk factor for heart disease,
in patients.
The study was conducted at various research institutions
throughout Australia and focused on Aboriginal Australians,
a high-risk group for both periodontal disease and

cardiovascular disease. In order to assess the effect of
periodontal treatment on cardiovascular health, 273 Aboriginal
Australians aged 18 and over with periodontitis were recruited.
Half of the participants received full-mouth periodontal scaling
during a single visit while the controls received no treatment.
After a period of 12 months, the researchers measured
changes in carotid intima-media thickness and observed a
significant decline in thickening of artery walls in the treatment
group but not in the control group. “The effect is comparable
to a 30 per cent fall in low-density lipoprotein cholesterol,

M

elville, N.Y., USA: Henry Schein has acquired Sirona Direct, the French
dental distribution business of Sirona Dental Systems. In addition to its
acquisition of Sirona Direct, Henry Schein has entered into an exclusive
distribution agreement with Sirona Dental Systems for the promotion and distribution
of Sirona's full line of dental equipment, including the CEREC CAD/CAM system, to
practitioners in most of France, including the Paris region.
With sales of approximately $14 million, Sirona Direct is the exclusive distributor
of dental equipment for Sirona Dental Systems in Paris and Normandy.
Over the past several years, Henry Schein has acquired other businesses in France
with exclusive regional distribution agreements for products manufactured by Sirona
Dental Systems. These acquisitions, coupled with the acquisition and distribution
agreements announced now, establish Henry Schein as Sirona Dental Systems’ exclusive
distributor to practitioners across most of France.
“We are pleased to exclusively represent Sirona's high-quality, innovative products
across the vast majority of France,” said Vincent Junod, vice president of Henry Schein
European Dental Group , western region, and managing director of Henry Schein France.
“France is an important and growing dental market, and Henry Schein is committed to
providing the French dental community with a comprehensive offering to meet all of
its practice needs. Sirona's innovative products are an important part of our ConnectDental
platform, which is designed to bring the latest digital dental solutions to the practitioners
we serve in this rapidly changing dental marketplace.”
Continued from page 11

Dental Tribune Pakistan
hosts iftar dinner

K

arachi: Dental Tribune recently hosted an Iftar dinner for the dental and allied
profession at the Pearl Continental Hotel Karachi. The dinner was attended
by Pakistan Dental Association President, office bearers of the association,
senior dental surgeons and members of the Dental Trade and Manufacturers Association.

commonly referred to as bad cholesterol, which is associated
with a decreased risk of heart disease,” said study co-author
Dr Michael Skilton from the University of Sydney. “It is also
equivalent to the effects of reversing four years of aging, 8
kg/m2 lower body mass index, or 25 mm Hg lower systolic
blood pressure.”
However, the researchers found no effect of periodontal
therapy on arterial stiffness, another indicator of atherosclerotic
vascular disease. There were no significant differences between
the groups in pulse wave velocity at three months or 12
months, according to the study.
The findings may have important implications for the
treatment of high-risk populations, such as Indigenous
Australians. According to the researchers, periodontal disease
is twice as common in Aboriginal Australians as in the rest
of the population. An estimated 90 per cent of Aboriginal
adults suffer from periodontal disease.
The study, titled “Effect of periodontal therapy on arterial
structure and function among Aboriginal Australians”, was
published online on 23 June in the Hypertension journal
ahead of print.

[7] =>

[8] =>

Implantology

8 DENTAL TRIBUNE Pakistan Edition July 2014

Expert symposium on implantology
encourages patient centric treatment approach
DT Pakistan Report
arachi-Expert Symposium
on Implantology was
organized and conducted at
Royal Rodale Club, Karachi, which
attracted participation from all leading
colleges. The Key Clinical Speakers
for the event were Prof. Dr. Navid
Rashid, Dr. Yawar Abidi, Dr. Sameer
Quraeshi and Dr. Irfan Qureshi. The
Gold Sponsors of the event were
Henry Schein and Chughtai Dental

K

that implants involves 4 eyes and 4
hands, which means having a very
good assistant is mandatory.
Angulations is important for the
success of implants and patients
history is a must as the dentist must
know if the patient is suffering from
any disease like diabetes, osteoporosis
or some other illness which may affect
the bone absorption.
Dr. Syed Yawar Ali Abidi; a Fellow

Prosthetics actually determines
the success of a clinical implant.
He said that most clinicians err in the
prosthetic element, and it is because
of this that implant failures are seen.
Dr. Irfan Qureshi, MSc in
Prosthodontics from King’s College;
Diplomate of the RCS and ICOI,
currently the Head, Department
of Prosthetics at SSDC, well-known
both nationally and internationally for

NASDAQ 100® Index, Henry Schein
employs nearly 17,000 Team Schein
Members and serves more than
800,000 customers.
The Company has entered Pakistan
Market and taken it by storm with the
introduction of products and solutions.
The Company offers a comprehensive
selection of products and services,
including value-added solutions for
operating efficient practices and

Supply.
The Guests of Honours for the
event were Dr. Asif Niaz Arain,
Dr. Anwar Saeed and Dr. Mahmood
Shah for their extraordinary
performance at the APDF elections.
The proceedings started with the
recitation from the holy Quran
followed by Prof. Dr. Navid Rashid
a well-known Oral Surgeon, President
PDA Karachi Chapter and Principal
of Liaquat College of Medicine and
Dentistry was the first speaker of the
evening. Dr. Navid highlighted the
importance of anticipation as this
helps minimal complications since
one has planned the case well before
the treatment is done. He said that
there have been various advancements
in the field of Clinical Implantology,
and now with the availability of Bones
and Membranes - the chances of
failure have reduced considerably.
Addressing a full house, Dr. Navid
Rashid, stressed the need of getting
patient’s consent about the procedure
in writing so as to avoid legal issues
later. Prof. Navid’s presentation on
complications in Implantology was
an eye opener for the audience
focusing issues which are seldom
talked about.
Sharing his experiences he said
that with the advent of 3D technology,
dentists stand to gain a lot more which
will eventually benefit the patients.
He said that ideal safety margin of
2mm is a must and always remember

and an Associate Professor and Head,
Department of Operative Dentistry
DIKIOHS - DOW University, director
for MDS and Supervisor of the FCPS
programme. Dr. Yawar during the
course of his presentation explained
how it is important to treat each patient
with an assigned treatment protocol.
He gave a comprehensive clinical
presentation comparing and
d i ff e r e n t i a t i n g i m p l a n t s a n d
endodontics. Dr. Yawar Abidi in his
presentation stressed the need of
mentorship and said that the focus of
our treatment should be patient
centered and self-centered. Citing his
experience he said that he has
seen complications in 34% of the
patients after 5 years, so implant
complications are not rare and 95%
implants are just serving for 5 years.
Based on his experiences he feels that
Endo should be the treatment of
choice and implants should be the last
option. Dr. Yawar also pointed
towards the high incidence of periimplantitis. He said that this is a
problem of growing concern, and
proper implant placement protocols
must be followed to ensure that such
problems don’t occur.
Dr. Sameer Quraeshi, Masters in
Clinical Science from the University
of Manchester and an Asst. Professor
Department of Prosthetics at FJDC,
is a renowned prosthodontist and
consultant implantologist. Dr. Sameer
laid special emphasis on how Implant

his sound understanding of the subject.
Dr. Irfan gave a comprehensive
presentation on case selection,
insertion protocols and implant
prosthetics. He said that Success or
failure of implants depends on the
health of the person receiving it, drugs
which impact the chances of
osseointegration and the health of the
tissues in the mouth. The amount of
stress that will be put on the implant
and fixture during normal function is
also evaluated. Planning the position
and number of implants is key to the
long-term health of the prosthetic
since biomechanical forces created
during chewing can be significant.
The position of implants is determined
by the position and angle of adjacent
teeth, lab simulations or by using
computed tomography with
CAD/CAM simulations and surgical
guides called stents. The prerequisites
to long-term success of
osseointegrated dental implants are
healthy bone and gingiva.
The programme’s gold sponsor was
Henry Schein represented in Pakistan
by Chughtai Dental Supplies. Henry
Schein, Inc. is the world’s largest
provider of health care products and
services to office-based dental, animal
health and medical practitioners. The
Company also serves dental
laboratories, government and
institutional health care clinics, and
other alternate care sites. A Fortune
500® Company and a member of the

delivering high-quality care. Henry
Schein operates through a centralized
and automated distribution network,
with a selection of more than 96,000
branded products and Henry Schein
private-brand products in stock, as
well as more than 110,000 additional
products available as special-order
items. The Company also offers its
customers exclusive, innovative
technology solutions, including
practice management software and ecommerce solutions, as well as a
broad range of financial services.
The programme offered 2 credit
hours to all the registered participants
courtesy ICOI and the symposium
ensured that the audience take back
latest advancements in clinical
Implantology. Speaking to Dental
News, Dr. Fahmed Patel one of the
leading Practitioners of Pakistan said,
‘I would like to congratulate the entire
team of Dental News for such a wellorganized event. I have never seen a
program so well coordinated and
planned.’
The program saw virality on the
social media, both Facebook and
Twitter. Participants were encouraged
to engage using #DNES14. Dental
News has received numerous emails
to conduct more programs focusing
on other specialties; ‘I want Dental
News to conduct programs on all
specialties especially endodontics’,
said Dr. Muhammad Ali who is an
MCPS Trainee at FJDC.

[9] =>

[10] =>

[11] =>

July 2014

IDP camps provide unique Polio Henry Schein acquires Sirona Dental’s French
distribution business
vaccination opportunity
Continued from front page
cases reported in from 2008 onwards.
“We have begun vaccination campaigns and are working
with relevant government departments. In numerous camps
we have vaccinated children and adults the polio virus”, said
a vaccination official while speaking to Dental Tribune
Pakistan.
Camps hold 900,000 IDPs. Nearly 1 Million people have
been displaced since the Military Operation began last month.
Officials fear that an outbreak of any epidemic can prove
deadly. Repeated appeals have been made to the Government
to ensure safe drinking water. They fear that an outbreak of
diahhorea would prove fatal.
Officials have said the IDP camps would also be included
in future vaccination campaigns. “Emergency outreach
immunisation sessions are planned - to cover children
accommodated in schools, government or private premises,”
officials said. “Special training had been given to teams to
vaccinate and register all children based with host families.”
Officials have expressed hope that the Polio virus would be
eliminated from Pakistan soon.

FDA changes recommendations
on lidocaine for teething pain
Continued from front page
administered incorrectly, viscous lidocaine can cause seizures,
severe brain injury and heart problems. Of the 22 cases of
adverse reactions to the product that were reviewed by the FDA,
six cases resulted in death, three were categorized as lifethreatening, 11 required hospitalization, and two required
medical intervention. In many cases, caregivers did not follow
the prescriber's directions or gave additional doses.
Moreover, the FDA encouraged parents and caregivers once
more not to use topical over-the-counter medications containing
benzocaine for teething pain. In 2011, the agency had warned
that using such gels for mouth pain could cause
methemoglobinemia, a rare but life-threatening blood disorder.
In response to the benzocaine announcement, the Consumer
Healthcare Products Association (CHPA), a trade association
representing leading manufacturers and suppliers of over-thecounter medicines and dietary supplements, issued a press
release stating that the FDA's suggestion regarding benzocaine
does a disservice to parents and caregivers who use FDAapproved gels and medicines containing the anesthetic. The
association criticized the FDA for not providing any data to
support its change to the recommendations in 2011.
“Consumers should continue to have confidence that these
medicines can be used safely and appropriately by following
the label. We urge the FDA to clarify its position to consumers
and follow the appropriate regulatory path,” CHPA said.
The FDA stated that, since the issuance of the 2011 warning
on benzocaine, it has received six new reports of
methemoglobinemia cases in infants under the age of 2 associated
with over-the-counter benzocaine gels and liquids.

Amalgam recycling starts in Brazil
Continued from front page
“This is the first initiative in Brazil to install mercury filters
in all dental equipment at a dental school and the experience
may serve as an example to other public and private institutions,"
said Dr. Claudio Fernandes, Director of the Center for
Advancement in Dental Standards at the university.
The university is also planning to include waste management
in the dental curriculum and its dental research. "We look forward
to various levels of education and scientific engagement about
dental amalgam separation and mercury recycling,” Fernandes
stated.
DRI President and CEO Marc M. Sussman said, “It is
remarkable to have the opportunity to work in a country with
the largest number of practicing dentists. DRI's presence in
Brazil, now and in the future, will aid the country's commitment
to sustainable development, as we seek to promote environmental
stewardship in the practice of dentistry.”

Continued from 6 page
Sirona Direct has headquarters in Paris and a showroom in Rouen. The company will
become part of Henry Schein France, which has served dental practitioners in the country
for more than two decades. The financial terms of the transactions were not disclosed.
Henry Schein expects the transactions to be neutral to its earnings per share for the
balance of 2014.
France is one of the largest European markets for dental products, with approximately
36,000 dentists serving a population of approximately 65.7 million people.

Diagnosis 2014: The things you need to know for
successful endodontic treatment
Continued from 5 page
implant dentistry.
This has created polarizing arguments: save the tooth via endodontic treatment, or
extract the tooth and place an implant. Too soon today, dentists will opt to extract a tooth
that has a questionable prognosis in favour of placing an implant. It is my opinion that
dentists should exhaust all possible options before opting to place an implant. Recently,
I treated two of my colleagues with cracked teeth who wanted to exhaust every option
(both were treated surgically). Ironically, they are two dentists who are heavy into implant
dentistry. There has never been a better time to employ the “Golden Rule” for treatment
planning.
What are the factors involved in the decision? Is there enough bone to support an
implant? Will you have to augment or condition the site? If you elect to do endodontic
treatment and it fails, are you willing to surgically try to save the tooth? If so, and it still
fails because of a fracture, by doing surgery have you destroyed the bone? Can the patient
afford to place an implant? And are they prepared for the amount of time they may be
edentulous in that spot? All of these situations merit a thorough and honest discussion
with the patient. In addition, the dentist needs to take into consideration the patient’s
motivation to go through these procedures. Many times I speak to patients about implants,
and they are surprised by the cost and shocked by the time it will take before they have
an implant crown functioning in their mouths.
In modern endodontics, as technology advances and we bring on file systems that
shape more efficiently and safely-and we develop a greater understanding of the role of
irrigation in endodontics - we can offer higher success rates than at any time in history.
This paradigm starts with understanding the patient’s symptoms and medical
contraindications, correlating them with the proper diagnosis and then having the ability
to honestly look in the mirror and decide that you can perform this treatment successfully.
These are the core decisions that need to occur on every level of dentistry. Successful
implementation of these values and diagnostic procedures will lead to a profitable and
stress-free practice.
Summary
Does the dentist have all of the salient dental facts? By asking for the patient’s
symptoms, you begin the diagnostic process. From there the journey begins. Next, does
the dentist understand the patient’s chief complaint and symptoms? Once I understand
what the patient is in my chair for, I calculate a path that will get me the most diagnostic
information. I will need to use imaging, thermal sensitivity tests and bite tests. Imaging
gives me the direction. Once I determine the vitality and take the periodontal health into
consideration, it’s time to discuss the diagnosis and treatment options with the patient.
I always present treatment in sequences. The first option for the patient would be to
take my findings “under advisement.” Those are patients who typically do not present
with pain and at that moment in time do not appreciate the need for a root canal. I never
worry about those people, because nine times out of 10 they will be back in my chair
sooner rather than later. The second choice revolves around the need for endodontic
treatment.
With this option, I create value for the need for treatment. Couple that with the patient
being in pain and wanting relief, and the decision and diagnosis is easy for this patient
type. The third option I give each and every patient involves letting him or her know that
extraction is a viable option for his or her tooth. With that, I explain if the site is a good
candidate to receive an implant and give him or her information on the time, cost and
procedure involved in placing an implant. It is legally very important that your consultation
and diagnosis involve every possible option.
In sum, the goal of diagnosis is to be able to collate the patient’s chief complaint with
his or her clinical symptoms. Once that is done, the dentist moves through a logical
progression of treatment options, with the goal of providing excellence (Fig. 6). In this
paradigm, both the patient and the dentist benefit from superior service and treatment.

author

roots

Dr. Thomas Jovicich, MS, DMD, is director of the West Valley Endodontic Group,
located in the San Fernando Valley of California. In addition to working in his private
practice, Jovicich has been a key opinion leader for Sybron Dental Specialties since
2000. He lectures around the world on current concepts and theories in endodontics.
Jovicich also hosts a learning lab in his office for dentists, teaching them endodontics
on their patients utilizing the latest state-of- the-art technology and materials through
the surgical microscope. He may be contacted at thomasjovicich@mac.com

[12] =>

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[cover] => DT Pakistan No. 4, 2014

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Table of contents

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