DT Pakistan No. 6, 2018

News / Interview / Clinical Implantology

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PUBLISHED IN PAKISTAN

www.dental-tribune.com.pk

Page 4

Implants should only
be inserted when
periodontal ...

1st Convocation
University of Health
Sciences

An exlusive interview
with Dr Asif Niaz Arain

INTERVIEW

NOVEMBER, 2018 - Issue No. 06 Vol.5

Page 6

CONVOCATION

Mercury-free

CLINICAL IMPLANTOLOGY

healthcare initiative

DT Pakistan Report

I

SLAMABAD - Realising that
exposure to mercury is injurious
to health, the
federal government is
planning to embark on
a countrywide
initiative to free health
facilities from
equipment and
products made of the
silvery toxic metal.
Under the MercuryFree Healthcare
Programme being
developed by the
Ministry of National
Health Services,
Regulations and
Coordination in consultation with
stakeholders, all mercury-containing
medical devices will be phased out
by 2020 with their safe alternatives
coming in. The initiative is being taken

to protect people from the devastating
health consequences that can arise
from mercury use.

Currently, mercury is used in dental
amalgam (fillings), thermometers,
blood pressure devices, fixatives,
preservatives, lab chemicals, cleaners
and other medical products, though

the World Health Organisation
identifies it as one of the top 10
chemicals, which can endanger and
harm health.
According to the
UN agency, which
coordinates
international health
activities and helps
governments in
improving health
services, mercury can
have significant
harmful effects on the
nervous, digestive and
immune system and
on lungs and kidneys,
and its excess
exposure can even be
fatal. It is known to be extremely
harmful to the foetus, and even if
exposed at low doses in the womb,
the developing baby can experience
Continued on Page 15

Request for increase
in health budget
tabled to PM
DT Pakistan Report

I

SLAMABAD - While
p l e d g i n g
transformational
changes in the health sector,
particularly in public sector
hospitals where patients are
generally denied appropriate
attention, treatment and
respect, Minister for Health
Aamer Mehmood Kiani
claimed having tabled a
request to the Prime
Minister for increasing the
country's health budget to 2
per cent of the GDP in the
next budget.

Addressing a symposium
oTransforming
HealthCare at the Pakistan
Institute of Medical
Sciences (PIMS), Aamer
appreciated the executive
director of PIMS Dr Amjad
for bringing about
improvements,
commissioning needed
equipment, and renovating
dilapidated wards, but
maintained that a lot still
needs to be done for
improved patient services
and care.
President Arif Alvi was

INCREASE
Health Budget
the chief guest.
"Patients should be treated
with respect. Our vision is
to strengthen PIMS as a
premier tertiary care
institute in academics,
research and innovative
clinical ground-breaking
procedures," Aamer stated
at the symposium, which
focuses on current research,
technological advances, and
hands-on practice through
training workshops for
medical, dental and nursing

professionals and
postgraduate students.
Aamer pledged to turn
Islamabad into a model
health city. "We want to
introduce a pro-poor health
system, starting from
Islamabad district, as a
model to revive people's
confidence in the public
sector's capacity to deliver
quality healthcare. Concrete
steps have been taken to
improve the health sector,"
the minister stated.

Page 8

100-day

performance
report on

health sector
DT Pakistan Report

I

SLAMABAD - Following suit
from other ministries and
departments, the federal health
ministry presented its three-month
performance report to Prime
Minister Imran Khan, highlighting
how it prepared an ordinance on the
apex medical education regulator.
According to sources in the health
m i n i s t r y, i t s t h r e e - m o n t h
performance report states that the
ministry worked to prepare an
ordinance to
amend the
Pakistan

Medical
and Dental Council's
(PMDC) laws and that this
ordinance has been sent to the
federal cabinet for approval.
Moreover, the report noted that the
ministry had, for the first time in
the history of the country, started
working on a system which would
help control infectious diseases at
the ports of entry for all those who
were either coming or leaving the
country. The system has been
introduced at 19 entry points to the
country including international
airports, seaports and land ports.
The system includes installation and
deployment of necessary facilities
and equipping staff at all ports with
the requisite equipment and training.
Moreover, soon this staff will have
special uniforms.
Sources said that with the federal
government abolishing the Capital
Administration and Development
Division (CADD), all health-related
institutions in the federal capital
were now being managed by the
Continued on Page 15

[2] => Dt pages.FH10

NEWS

2 DENTAL TRIBUNE Pakistan Edition November 2018

PPMA notifies regarding
increase in drug prices

Publisher/CEO
Syed Hashim A. Hasan
hashim@dental-tribune.com.pk
Editor Clinical Research
Dr. Inayatullah Padhiar
Editors Research & Public Health
Prof. Dr. Ayyaz Ali Khan
Editor - Online
Haseeb Uddin
Designing & Layout
Sh. M. Sadiq Ali

Dental Tribune Pakistan

3rd floor, Mahmood Centre, BC-11, Block-9
Clifton, Karachi, Pakistan.
Tel.: +92 21 35378440-2 | Fax: +92 21 35836940
www.dental-tribune.com.pk
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Dental Tribune Pakistan cannot assume
responsibility for the validity of product claims or
for typographical errors. The publisher also does
not assume responsibility for product names or
statements made by advertisers. Opinions expressed
by authors are their own and may not reflect of
Dental Tribune Pakistan.

International Imprint
Publisher/Chief Executive Officer Torsten R. Oemus

DT Pakistan Report

K

ARACHI - Addressing a
press conference in Karachi,
Central Chairman, Pakistan
Pharmaceutical Manufacturers'
Association (PPMA), Mr Zahid Saeed,
urged the federal government to allow
local drug manufacturers to rationally
increase the prices of medicines,
considering the alarming inflationary
trends in Pakistan's economy.
He also mentioned that approximately
250 medicines have virtually vanished
from Pakistan's Pharmaceutical
market, as some manufacturers found
it unfeasible to produce drugs at

irrational pricing. The manufacturing
cost of medicines has increased up to
60 percent, there has been record
devaluation of rupee, followed by the
increase in duties and taxes of the
pharmaceutical industry.
Zahid Saeed also highlighted the
federal government's reluctance in
notifying new prices for certain
medicines, despite passing of a year
since the Drug Pricing Committee
(DPC) passed its recommendation.
He demanded that the government's
new drug pricing mechanism should
include the factor of fluctuation in our
local currency's value to keep the

pharmaceutical industry viable for
continuance of its production.
Ex-PPMA Chairman, Dr Kaiser
Waheed also spoke regarding the
implementation of a new drug pricing
policy.
PPMA leaders demanded the Prime
Minister, Federal Minister, and
Secretary for Ministry of National
Health Services, Regulation and
Coordination, and the Drug Regulatory
Authority of Pakistan (DRAP) to
immediately take notice of the
situation and implement corrective
measures to benefit the Pharmaceutical
industry and patients.

Sin tax

on cigarettes, sugary
beverages draws flak

I

Dan Wunderlich

Director Content

Claudia Duschek

Clinical Editors

Nathalie Schüller
Magda Wojtkiewicz

Editor & Social Media Manager Monique Mehler
Editors

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Assistant Editor &
Video Producer

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Project Manager Online

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Product Manager Surgical
Tribune & DDS.WORLD

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Database Management & CRM Annachiara Sorbo

DT Pakistan Report
SLAMABAD Minister of National
Health Services
Aamir Mehmood Kiani
recently announced the
government's plan of
imposing sin tax on
cigarettes, tobacco and soft
drinks. He stated that sin
tax imposition was one of
the routes to higher
healthcare budget.
Pakistan will be the
second country after the
Philippines to impose a sin
tax on cigarettes.
Ever since the
announcement of 'gunnah

Chief Financial Officer

tax' on cigarettes
and beverages,
there has been an uproar
from masses on social
media. People in Pakistan
have taken exception to the
use of the word gunnah
(sin) in the term 'gunnah
tax.'
Pakistan Tehreek-e-Insaf
(PTI) minister Faisal
Vawda also joined the
chorus against the move.
Vawda tweeted, "I'm a
chain cigarette smoker
myself, and I appreciate all
the measures taken by the
government to discourage

Media Sales Managers

smoking and I understand
it's injurious to health but
this term 'Gunnah Tax' is
inappropriate. If this is
gunnah, then what would
we name and term the
actual gunnahs."
People creating a fuss
over the term 'sin tax'
probably do not realize that
PTI did not invent it. In
fact sin tax was introduced
as levy on products that
were injurious to health,
like tobacco and alcohol.
The UK and USA were

among the first countries
to impose this tax several
years ago.
Citing the examples of
the UAE and the UK,
Director General of
National Health Services
Asad Hafeez said that a tax
on cigarettes and sugary
beverages is being imposed
in 45 other countries. He
also explained how India
uses the money received
from imposing a tax on
gutka and pan masala in
the healthcare sector.

Melissa Brown (International)
Hélène Carpentier (Western Europe)
Matthias Diessner (Key Accounts)
Weridiana Mageswki (Latin America)
Barbora Solarova(Eastern Europe)
Peter Witteczek (Asia Pacific)
Executive Producer

Gernot Meyer

Advertising Disposition

Marius Mezger

Dental Tribune International GmbH

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Tel.: +49 341 48 474 302 | Fax: +49 341 48 474 173
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©2018, Dental Tribune International GmbH.
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makes every effort to report clinical information
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cannot assume responsibility for the validity of
product claims, or for typographical errors. The
publishers also do not assume responsibility for
product names, claims, or statements made by
advertisers. Opinions expressed by authors are their
own and may not reflect those of Dental Tribune
International.

[3] => Dt pages.FH10

[4] => Dt pages.FH10

INTERVIEW

4 DENTAL TRIBUNE Pakistan Edition November 2018

PDA needs to be run
professionally to
achieve its objectives:

Dr Asif Niaz Arain
D

By Dr Abbas Naqvi

Dental Tribune Pakistan: How will
you describe Pakistan's
role/participation in global
organized dentistry?
Dr Asif Niaz Arain: World Dental
Federation's role is policy making
for different issues. Issues like
amalgam usage, oral hygiene
awareness etc. Alhamdulillah,
Pakistan has been part and parcel of
policy making in the FDI, and we
have been playing our role quiet
actively. Our President of Pakistan,
Dr Arif Alvi, whom we are very
proud of, was member of the FDI
council for about 4 years. His son Dr
Awab Alvi has represented Pakistan
in the World Dental Federation as
well. So, they have been part and
parcel of making policies.
DTP: Who are the people apart from
yourself and Dr Alvi, who have been
actively representing Pakistan on
these platforms in the past decade
or so?
ANA: There are a couple of people
actually, namely Dr Mahmood Shah
and Dr Anwar Saeed. They have been
participating very regularly. I, myself,
have been attending World Dental
Congress since 1994. Very rarely do
I miss them. So, every time there is
a flag ceremony at such events, we
have been there to raise the Pakistani
flag and to represent Pakistan; and
we have been there to discuss and
offer opinions on several issues; and
have contributed in policy making.
DTP: When you look back, how
effective have we been?
ANA: We have been quite effective

with making policies. As I said, Dr
Arif Alvi has been very actively
involved in policy making. After a
policy is made and FDI has officiated
it, the FDI, unfortunately, cannot do
much about its execution; they can
only guide the dental associations to
carry on with its implementation.

r Asif Niaz Arain is a graduate of 1981. He became affiliated
with Pakistan Dental Association (PDA) in 1987. From 2002
to 2005, he served as the General Secretary of PDA. In 2002, Dr
Asif Arain was nominated by the PDA as National Liaison officer
(NLO) to represent Pakistan in World Dental Congress, which he
did for about 10 years. After a break of five years, in 2018 Dr Asif
Arain was again appointed by the PDA to represent Pakistan at the
FDI World Dental Congress in Buenos Aires, Argentina, where our
Editor Overseas, Dr Abbas Naqvi, asked him a few exclusive questions
for our readers.
Currently, Dr Asif Niaz Arain is the Vice President of Asia Pacific
Dental Federation (APDF).
programmes, and Dr Ayyaz Ali Khan
conducted them in Punjab. The funds
are very limited, because FDI does
not receive a lot of funding. Certain
manufacturers at times release funds
for awareness activities and we use

Pakistan has been part and
parcel of policy making
in the FDI, and we have
been playing our role
quiet actively.
Awareness about issues like oral
health problems, maintenance of oral
hygiene and especially training
children for it, is important. Media,
such as social platforms are used for
this reason.
DTP: How has the PDA kept up
with transferring the policies that
we contribute to, to benefit the
people of Pakistan?
ANA: Policies can only be translated
simply through various media. I don't
know how the PDA does it, I'm not
the part and parcel of PDA anymore,
but I think they try through
newsletters or dental publications.
One or two times we had the chance
to get some funds for awareness
programmes. Back in 2007 or 2008,
we got a budget for oral health

them for that purpose. Whenever, we
get a chance, we did it very well.
Pakistan has been playing its role
very responsibly.
DTP: How do you see Pakistan's
future in global organized dentistry?
A N A : We h a v e b e e n w e l l represented in FDI and Asia Pacific
Dental Federation, which the regional
organization of FDI. We have been
officers in APDC since last 12 years.
The top benefit of being part of such
large-scale associations is that you
get to organize educational programs
in your country. In 2006, the Asia
Pacific Dental Congress was held in
Karachi. Unfortunately, due to
security concerns we lost our chances
in 2015 and 2017. We were allotted
APDC for the two years but were

unable to execute it since due to our
circumstances, our security problems
people were not willing to come to
Pakistan. Insha'Allah, when the
security problems will be solved in
Pakistan, foreign people will be
happy to come. We will again
conduct some dental congresses for
the betterment of dental education.
DTP: In the last 15 years, we have
only seen 5 Pakistani dentists
attaining international stature. Why
is that? Is there no replacement of
these 5 people?
ANA: People have to take initiative.
Very few people want to spend
money from their own pockets, since
you don't get any support from our
association. Whenever we travel for
representation we do so by our own
expenditures. Government doesn't
take any interest in sending their
people to attend these congresses. So
unfortunately, not many people are
interested in sparing the time to go
to attend these conference.
DTP: How is it with other
organizations in other countries?
Should it be the PDA's responsibility
to finance its country's
representation?
ANA: Let's take Indian Dental
Association for example. They have
a budget of many, many millions of
rupees, and they fund 8 to 10 people
to attend these congresses, but
unfortunately, in the case of Pakistan
Dental Association, they don't have
funds enough to even finance one
participation in these congresses.
Continued on page 06

[5] => Dt pages.FH10

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CONVOCATION

6 DENTAL TRIBUNE Pakistan Edition November 2018

1ST CONVOCATION
UNIVERSITY OF
HEALTH SCIENCES

IADSR raises
bar of CPD
standards
DT Pakistan Report

L

AHORE - Institute of Advance
Dental Sciences & Research
(IADSR) held its First
Convocation at the University of Health
Sciences, Lahore on December 9th.
Professor Javed Akram, Vice Chancellor
UHS, was the Chief Guest, and Professor
Paul Tipton from U.K. was the Guest of
Honor for the occasion.
Professor Paul Tipton kept a 250 plus
audience glued to their seat during his
marathon three-hour session on Occlusion.
Starting from the very basics he took his
enthralled audience along to finer details
of occlusion management. Prof. Tipton is
rated as one of the most influential
speakers in dentistry globally; this
proactive and participatory session
witnessed his command on the subject.
Prof. Tipton conferred the Professional
Diploma in Advance General Dentistry
to the successful participants, while Prof.
Javed Akram honored the faculty of the
course with Certificates of Appreciation.
At the end Professor Ayyaz Ali Khan,
National Coordinator, IADSR presented
plaques to the worthy guests.

An exclusive interview with

Dr Asif Niaz Arain ...
Continued from page 4

DTP: From your experience of local
organized dentistry, why do you think
the PDA does not have funds?
ANA: What is PDA? PDA is a
collection of dental surgeons of
Pakistan. Unfortunately, we expect
that PDA should spend from its
pocket. This is unfortunate. There are
so many of us yet no one is really
ready to pay even a decent amount
of money as membership fee to
Pakistan Dental Association.
DTP: Associations generate funds
from sponsorships, which realize
when sponsors see value. Is it not
fair to say that PDA has failed to
create value for sponsors?
ANA: No, I don't think PDA has
failed. It is just that we are not very
well organized. You can say that we
have not channelized the things well,
because usually the dental
manufacturers or suppliers are the
ones that fund the PDA activities in
Pakistan. Now there is a separate
association for them and so sometimes
we don't get enough funds. If we
become better organized if we will

have some power and influence like
in other countries. National Dental
Association (NDA) has a very
powerful role in the certification of
the dentists.
DTP: Please tell us about the next
position you are vouching for and
what's your manifesto?
ANA: I have been nominated by
Pakistan Dental Association to run in
the elections for a post in Dental
Practice Committee. First point from
the agenda that I have in mind is that
young dentists in our country don't
have proper guidance in regards to
setting up their clinics, designing their
clinics or their practices. There should
be certain plans in place to guide
these young dentists.
DTP: What is your message for the
profession?
A N A : We h a v e S o c i e t y o f
Maxillofacial Surgeon, we have
Society of Prosthodontics, we have
Society of Orthodontists in Pakistan,
but when you are not organized, you
can do nothing on the larger scale.
Yes, you can do better for your own
self but you cannot do anything better
on the larger scale. It has to be a

triangle. At the tip of the triangle there
should be Pakistan Dental
Association. Every person should be
the part and parcel of that. You will
find many groups forming
themselves. What is the problem?
Why can't they all get together, sit
together and solve the problem, if
there is some personal problem. Only
one organization can be effective.
When you form a triangle, a pyramid,
then only can you be more influential,
and then you can make policies and
go to the government. So my advice
to the young dentists is that they
should respect the Pakistan Dental
Association. If they have any issue,
they should come up and talk about
it but by remaining within the
framework of one association, not
splitting up into different groups.
Unity is the only survival. If you don't
have unity, you can't do anything.
That is my message to the youngsters.
We have played our part, now there
must come some youngsters who
should take over. If there is some
restriction for them in taking over,
please come up. Use media for your
problems. If they have some issue
with the central council they should
come up, so that it could be solved,

but should remain in one house. Like
parents and children, they should
respect the seniors and the seniors
should respect the juniors. It should
go both ways.
DTP: Are the seniors willing to
delegate?
ANA: Yeah, why not? Who can live
forever, nobody can live forever. In
Asia, we have a new central council.
There are so many young people.
Apart from Dr Mahmood Shah and
Dr Anwar Saeed, the rest of the
council is of young people. So, why
can't the young people come up? If
there are some issues, they should be
solved.

Adam and Eve
had many
advantages, but
the principal one
was, that they
escaped teething.
~Mark Twain

[7] => Dt pages.FH10

[8] => Dt pages.FH10

8 DENTAL TRIBUNE Pakistan Edition November 2018

CLINICAL IMPLANTOLOGY

Implants should only be inserted when
periodontal conditions are stable
By Dr. Jan H. Koch

iofilm is the most
significant cause of
inflammatory bone
loss around teeth and implants.
Diagnostics, biofilm
management and, where
necessary, treatment help in
patients with this problem. The
W&H No Implantology
without Periodontology
workflow should provide
stable tissue prior to
implantation through
prevention, and implant
success in the long term
through aftercare-something
that is advantageous to both
the patient and the treatment
team.
Implant treatment can
significantly improve quality
of life after tooth loss. The
long-term prognosis is
generally good, but biological
complications are common.
Peri-implantitis and its
preliminary stage, mucositis,
occur in a substantial
proportion of patients. As is
the case for periodontitis and
gingivitis, oral biofilm is the
main cause. This microbial
biocoenosis can also
encourage the development of
severe systemic disease in the
event of pathological changes,
such as endocarditis and
inflammatory bowel disease.
The only difference in the
microbial flora in periodontitis
and peri-implantitis is in the
detail.8 Compared with
healthy conditions, the quantity
and aggressiveness of the
pathogenic microorganisms
change in both diseases. Bone
loss around implants is
generally more rapid and leads
to more extensive defects than
when it occurs around teeth.
Accordingly, preventative care
is advised even before implant
treatment.
Determining risks and
providing periodontal
treatment
Periodontitis is a key risk
factor for peri-implant
inflammation. This means
untreated periodontitis patients
have an increased risk of periimplant inflammation through
to implant loss. The risk is also
higher when patients who are
initially treated are not
included in a supportive
periodontitis treatment/recall
programme.

Leading periodontists
therefore recommend carrying
out a screening procedure
before implant treatment using,
for example, the periodontal
screening index or periodontal
screening and recording.
Bleeding on probing and
pocket depths are determined
at selected positions. An
extensive check of the
periodontal status should be
carried out if the results are
abnormal.
Taking a careful medical
history, including previous
systemic exposure, is also
important. This provides
important information about
increased risk of inflammation,
for example in patients with
diabetes that is not being
optimally managed.
Furthermore, patients should
be informed of the risks
relating to implants.
Where necessary, initial
periodontal treatment is carried
out. First, professional tooth
cleaning establishes healthy
gingival conditions. In this
procedure, calculus (Fig. 1)
and biofilm (Fig. 2) are
removed as far as the gingival
sulcus. In combination with
careful instruction on oral
hygiene, this gives the patient
the basis for long-term
freedom from inflammation.
Removal of subgingival
coatings (debridement) is
carried out using sonic or
ultrasonic devices and special
periodontal tips as initial
periodontal treatment (Fig. 3).
Manual instruments can also
be used. Further surgical
and/or regenerative measures
may be necessary, depending
on the situation.
Periodontal aftercare for longterm success
In the periodontal aftercare
subsequent to implantation,
soft (biofilm) and hard
coatings are regularly
professionally and
mechanically removed. In the
subgingival and supragingival
areas, ultrasonic devices are
generally used for this
(Fig. 4), in combination with
manual instruments where
necessary. Alternatively,
subgingival air polishing can
be used in combination with
periodontal attachments and
powders.
Checking for individual risk

factors, such as smoking and
diabetes, and working towards
a healthy lifestyle are also
recommended for a good longterm prognosis after
periodontitis treatment. If the
patient had severe periodontitis
before the initial treatment, the
recall frequency will be
increased accordingly, partially
to prevent peri-implant
inflammation.
Proactive implant treatment
If the patient has received good
preventative treatment and
where necessary has received
preliminary periodontal
treatment, implant treatment
can be planned. A suboptimal
implant-supported prosthesis
increases the likelihood of
biofilm forming. In order to
avoid this, the correct implant
position, sufficient distances
from adjacent teeth and an
ideal axial alignment should
be considered during the
planning phase. A sufficiently
sized bone site and soft tissue
that is well supplied with blood
are needed for successful
implant healing and a good
long-term prognosis. Prior or
simultaneous augmentation
may be needed to achieve this.
In contrast to this, the time at
which the implant is inserted
and the treatment is provided
plays a less significant role.
In order to support
predictable and stable implant
treatment, it is also necessary
to prepare the implant bed
using suitable methods and
equipment. This can be
achieved using highperformance implantology
motors in combination with
surgical contra-angle
handpieces. Using a low speed
and an ample supply of sterile
cooling fluid is essential during
preparation. Otherwise, the
bone can overheat and affect
the healing process.
Alternatively, the implant bed
can be prepared with piezosurgical systems, for which
special sets of instruments are
available. Bone can be worked
on in a gentle yet highly
effective manner using other
special instruments.
Indications include alveolar
ridge splitting, surgical tooth
removal, and the preparation
of bone blocks or lateral
windows for augmentation.
Continued on page 12

Fig. 1: Calculus removal using an ultrasound (W&H Tigon (+) with a 3U tip) is a key part
of professional tooth cleaning. (Photograph: W&H)

Fig. 2: Rotary cleaning with prophylaxis polishing cups and brushes (W&H Proxeo prophylaxis
contra-angle handpiece) ensures smooth surfaces on teeth. It enables patients to check biofilm
effectively at home. (Photograph: W&H)(Photograph: W&H)

Fig. 3: If marginal periodontitis is diagnosed, the initial debridement can be carried out very
efficiently with an air scaler (sonar technology, W&H Proxeo with 1AP tip). (Photograph: W&H)

Fig. 4: Ultrasound devices are particularly suitable for UPT, for example in combination with
periodontal tips (W&H Tigon (+) with 1P tip). (Photograph: W&H)

Fig. 5: Implants and suprastructures are routinely cleaned, for example using ultrasound devices
and special plastic instruments (W&H Tigon (+) with 1I tip). (Photograph: W&H)

[9] => Dt pages.FH10

[10] => Dt pages.FH10

NEWS

10 DENTAL TRIBUNE Pakistan Edition November 2018

IDS 2019 to present
latest digital strategies
in orthodontics

C

OLOGNE, GERMANY Digital technologies are
changing the tools and
solutions available in orthodontics.
Organisers of the upcoming
International Dental Show (IDS),
taking place from 12 to 16 March
2019 in Cologne, say visitors will
have the opportunity to experience
the latest developments in
orthodontics regarding diagnostics,
therapy planning, therapy and
aftercare.
In the areas of diagnostics and therapy
planning, owners of established
practices have a number of options
regarding upgrades to new
technologies, while founders of new
practices are now relying almost
exclusively on digitalised tools and
workflows. According to the IDS
organisers, 3-D radiographic units,
intra-oral scanners, and the virtual
set-up and design of orthodontic

equipment are just a few examples of
the tools and procedures that visitors
to the exhibition will be able to
experience.
Many of the changes that digital
technologies have effected in
orthodontics are irrefutable and their
benefits are clear, such as in aligner
therapy, where digital technologies
now dominate preparatory measures
for aesthetic dentistry. Regarding
some of the emerging digital tools,
however, such as support through
artificial intelligence (AI), their scale
of influence remains to be seen. At
IDS, visitors will have the opportunity
to inspect a number of different
products related to aligner therapy
treatment, such as software and virtual
reality options for the subclassification
of complex tooth movements, and to
learn about the trend towards the use
of AI support to warn of extreme tooth
movements. According to the show

Digital technologies are driving orthodontics forward.
(Photograph: Koelnmesse/IDS Cologne)
organisers, AI-aided support of this
nature is becoming more conceivable
as the databases that would
substantiate these tools continue to
grow.
The forthcoming instalment of the
biennial trade fair will help practice
owners learn about the developments
that are driving orthodontics forward.
"IDS 2019 will help visitors advance
forward in all these points,"
commented Mark Stephen Pace,
Chairman of the Association of the
German Dental Industry (VDDI), in
a press release. "This is important
because carrying out a consistent

orthodontic treatment at an early point
in time enables the avoidance of
complications in later years from the
very beginning. The world's biggest
showcase for dental medicine and
dental technology in Cologne from
12 to 16 March 2019 contributes
greatly to this," he said.
IDS takes place at the Koelnmesse
fairground in Cologne every two years
and is organised by the Gesellschaft
zur Förderung der Dental-Industrie,
the commercial enterprise of the
VDDI, in collaboration with
Koelnmesse. - Dental Tribune
International

COP2 focuses on
dental amalgam
By Anita Vazquez Tibau

G

E N E V A ,
SWITZERLAND The second meeting
of the Conference of the
Parties (COP2) to the
Minamata Convention on
Mercury was held at the
International Conference
Centre Geneva from 19 to 23
November. It was determined
in this session that all future
COP meetings will be held in
Geneva. The Minamata treaty,
which came into force on 16
August 2017, now has 128
signatories, and 101 countries
have ratified it. As at the first
COP meeting, dental amalgam
continued to be a major focal
point at COP2.
Say No To Mercury, an
Australian non-governmental
organisation, joined forces
with the International
Academy of Oral Medicine
and Toxicology (IAOMT),
whose representatives span the
globe, including Brazil, Chile,
Italy, the Philippines, Slovenia
and South Africa. They
submitted a joint paper titled
Dental AmalgamA Major
Topic at COP2, which
identified the following

pathways: dental office
wastewater, dental waste going
into landfills, air discharge
from dental offices,
incineration of dental waste,
cremation, burial, human
waste, mercury vapour from
breathing, and illegally sold
dental mercury for artisanal
and small-scale gold mining.
Harmonised custom codes
were also addressed to include
not only bulk mercury for
dental use, but also
encapsulated dental amalgam.
In addition, all parties and nonparties to the convention were
asked to consider
implementing steps to reduce
or eliminate the environmental
pathways created by the use
of mercury from dental
amalgam, including
mandatory mercury amalgam
separators. This was in
accordance with the Minamata
Conventions nine measures
to phase down the use of
dental amalgam, namely
promoting the use of best
environmental practices in
dental facilities to reduce
releases of mercury and
mercury compounds to water
and land.

Claudia Marin Diez, Anita Tibau, Lisa Matriste, Lillian Ebuen, Maria Theologides and Damir
Skripec Larisseger (from left) got together for a group photo at COP2 in Switzerland.
(Photograph: Anita Tibau)

Throughout the week, Say No
To Mercury and IAOMT
members met with delegates
to discuss strategies for
implementation of these nine
measures to phase down dental
amalgam use. A luncheon
meeting was held with
Mohammed Khashashneh
(Jordan), vice president of the
group of Asian and Pacific
country members of COP,
along with industrial engineer
Ali Sabra of Lebanon, who
wish to arrange a regional
meeting with both parties and
non-parties in cooperation
with all relevant stakeholders;
including ministries of health,
IGOs, dental associations, and
NGOs of the convention on

mercury-free dentistry,
incorporating how to properly
manage dental mercury waste.
Say No To Mercury and
IAOMT also held discussions
with Brazil, in which
environmental analyst Camila
Boechat and environmental
health officer Luisa Gregorio
of the Ministry of Health in
Brazil shared perspectives on
mercury-free dentistry. They
were pleased that the first
conference on mercury and
human health to be held under
the Fiocruz ministry of health
would follow COP2, in Rio
de Janeiro in Brazil on 29 and
30 November. There, Dr
Sandra Hacon will be
presenting on the Minamata

Convention, and President of
the IAOMT Brazilian Chapter
Dr Martha Faissol will be
discussing safe removal of
dental amalgam.
The Africa group was
extremely vocal in its concerns
on dental amalgam, and the
urgency to stop its use in order
to protect the health of women
and children. Many of the
participants were in support
of following the European
Unions ban of dental
amalgam for children under
15 and pregnant or
breastfeeding women that
came into effect on 1 July
2018.
The Latin America and
Continued on page 15

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[12] => Dt pages.FH10

12 DENTAL TRIBUNE Pakistan Edition November 2018

CLINICAL IMPLANTOLOGY

Implant-supported fixed full-arch
rehabilitation without bone grafting

By Dr. Aizcorbe Vicente

Objective:
The objective of this article is
to assess the clinical,
radiographic and patientrelated outcomes of patients
with severe atrophy of the
maxilla (Cawood and Howell
Class V) rehabilitated with
fixed full-arch prostheses on
dental implants placed in
anatomical buttresses and
remnant bone.
Materials and methods
An
observational
retrospective clinical study was
performed with a minimum
follow-up period of 10 years.
An analysis of the following
parameters was performed: (a)
periimplant parameters (plaque
index, modified gingival index,
probing pocket depth and
keratinized mucosa width); (b)
marginal bone loss; (c) implant

survival rate; and (d) patient
satisfaction based on a visual
analog scale (VAS).
Results
Ten patients and 71 dental
implants were studied, with a
mean follow-up period of 126
months (range: 120144). The
mean plaque index was 1.0 ±
0.5, with a mean probing
pocket depth of 2.3 mm (range:
1.04.0 mm). Sixty-one
percent and 39% of the
implants presented a modified
gingival index of 1 and 2,
respectively, and the mean
keratinized mucosa width was
5.8 mm (range: 4.010.0 mm).
The mean marginal bone loss
of the implants was 0.7 ± 0.4
mm (range: 0.05.0 mm). The
implant survival rate was
97.2%, and the overall mean
patient satisfaction score was
90 (range: 0100). Prosthesis

Implants should only be ...
Continued from page 8

Highly advanced piezo-surgical devices
are also minimally invasive in soft
tissue.
Stability measurement and bone
surgery
Once the implant has been screwed
into its final position, the primary
stability can be safely and precisely
determined using resonance frequency
analysis. The technology is available
either separately or as an optional
module in an implantology motor. If
the ISQ (Implant Stability Quotient)
value measured is 66 or higher, early
intervention is possible, and if it is over
70, treatment must be provided
immediately.
An exposure protocol based on the
ISQ value improves the prognosis of
treatment. Simply measuring the torque
resistance, however, does not provide
the same level of clinical safety. If
reduced ISQ values are measured after
the implant has been inserted, a twophase protocol is generally chosen.
After exposure, a new measurement
can then be used to determine whether
osseointegration has been successful
(secondary stability) and loading will
be predictable at this point.
Hygiene-friendly prostheses
The emergence region should be
designed to ensure that it is atraumatic
to the tissue for long-lasting implant
restorations. The implant-abutment
connection, material, surface and
emergence profile must be
biocompatible and mechanically
resilient over the long term. The
transgingival components should also
be accessible for individual and
professional cleaning and for probing.
Definitively integrating abutments or

Control panoramic radiograph showing correct prosthetic fit.
cleaning ease scored lowest on
the VAS.
Conclusion
In our limited sample of
patients with severe maxillary
atrophy (Cawood and Howell
Class V), the placement of
dental implants in anatomical

other components at implant level
immediately ("one abutment, one time")
has also proved to be effective. In
combination with good hygiene and
correspondingly healthy tissue, this
concept can probably be used to achieve
a more stable attachment of the implant
to the oral cavity than if the components
have to be replaced several times - a
requirement for peri-implant health.
Whether it is with crowns, bridges,
partial or complete prostheses, the
implant-supported superstructure
should be designed so that the patient
can maintain it without any difficulty.
Additionally, a distance of at least 2
mm between the bone and the mucosal
edge of the prosthesis appears to be
advised to prevent infection and
subsequent bone loss.
Peri-implant aftercare
Experts recommend treatment
immediately after the initial occurrence
of symptoms of inflammation to avoid
peri-implant bone loss from the start.
Mucositis affects almost half of all
implants, and since patients often have
several implants, it occurs in a high
percentage of patients. The prophylactic
or periodontal recall programme
established after the implant has been
inserted should therefore be continued.
At-home oral hygiene should be
carefully tailored to the new prosthesis
and the patient accordingly instructed
on this. In combination with
professional biofilm management, good
preventative efficacy can be achieved
in this way.
The risk of peri-implantitis decreases
from 43.9 per cent (no recall) to 18.0
per cent if a patient receives a recall
appointment carried out carefully each
year, in other words by more than
half.36 Ultrasonic systems with special

buttresses and remnant bone,
associated with rehabilitation
with fixed full-arch prostheses,
was found to be an adequate
treatment option in the long
term regarding implant
survival, marginal bone loss,
periimplant clinical parameters

instruments that do not affect the
materials are suitable for this, such as
those made of PEEK (Fig. 5), or
appropriate manual instruments.
Mechanically preventing mucositis
As for periodontitis patients, periimplant recall includes regular
screening with a clinical check of both
periodontal and peri-implant tissue for
symptoms of inflammation, probing
and, where necessary, radiographic
diagnosis. A frequency of two to four
times a year has proved to be effective.
Deep probing values and bleeding occur
more commonly in patients with periimplantitis than in those with mucositis;
pus secretion only occurs in patients
with peri-implantitis.
If a patient has mucositis, professional
supragingival and subgingival biofilm
removal reduce the risk of the
inflammation advancing to periimplantitis. Local and systemic
antibiotics used as supportive measures
or air polishing, however, show no
additional benefit.
Treating peri-implantitis
Peri-implant bone loss can develop
even if good preventative care is
provided, for example if the patient's
oral hygiene is not sufficient. Most
minimal defects should be treated in a
non-surgical manner using peri-implant
debridement. Mechanical removal of
coatings using suitable ultrasonic
systems, supported by Er:YAG lasers,
antibacterial photodynamic treatment,
air polishing, or treatment with local
or systemic antibiotics, where
appropriate, has shown promising
results.
If closed treatment is no longer
possible, the defect must be surgically
exposed and carefully decontaminated.
This is carried out after flap preparation

and patient satisfaction.
Editorial note: The full article
was published in the 4/2018
issue of the Journal of Oral
Science and Rehabilitation. It
can be accessed free of charge
a t w w w. d t s c i e n c e . c o m .
- Dental Tribune International

by removing inflamed tissue and
cleaning the surface of the implant
using, for example, ultrasonic or piezosurgical systems. Measures designed
to regenerate the bone carried out after
this procedure have been successful.40
Special piezosurgical instruments are
available for the surgical treatment of
periodontal defects.
After treatment, the patient is once
again intensively instructed on oral
hygiene and made aware of the need
for continual recall. If necessary, the
frequency can be selected to be higher
than previously in line with periodontal
aftercare. If biofilm management
is carried out consistently, the
implantological results can remain
stable for several years even after the
periodontitis, mucositis or periimplantitis has healed.
No Implantology without
Periodontology
Successful implant treatment requires
consistent, long-term preventative
thinking. In each phase, this includes
regular periodontal and peri-implant
screening in combination with
individually tailored risk management,
oral hygiene training and professional
biofilm management where possible
for every patient.
Ideally, this preventative workflow
should start well before each restorative
measure, before periodontitis can
develop. It is essential if implant
prosthetic treatment is planned or has
already been integrated. Patients will
be pleased with the long-term success
of the treatment and will be pleased to
return to a practice or clinic they trust.
Editorial note: A list of references and
information is available from the
publisher. - Dental Tribune
International

[13] => Dt pages.FH10

[14] => Dt pages.FH10

NEWS

14 DENTAL TRIBUNE Pakistan Edition November 2018

Women with edentulism more
likely to develop hypertension

U F FA L O , N . Y. ,
USA- Despite
multiple crosssectional, epidemiologic
studies suggesting an
association between
periodontal disease and
edentulism,
and
hypertension, the exact
relationship between them
remains unclear. In a new
study, researchers from the
University at Buffalo have
found that postmenopausal
women who have
experienced tooth loss have
a higher risk of developing
high blood pressure.
In the Women's Health
Initiative-Observational
Study, researchers looked at
data from 36,692
postmenopausal women in
the U.S., who were followed
annually-from initial
periodontal assessment in
1998 through to 2015-for
newly
diagnosed
hypertension.
According to the
researchers, an association
was found between tooth loss
and hypertension risk among
postmenopausal women,
who had an approximately
20 per cent higher chance of
developing hypertension.
The association was also
stronger among younger

A new study has revealed that postmenopausal women
who have experienced tooth loss may be at a higher risk
of developing hypertension.
(Photograph: ivandan/Shutterstock)
women and those with a
larger body mass index.
However, there was no
association found between
periodontal disease and
hypertension.
The researchers suggested
that a possible explanation
for the results is that when
people lose teeth, they may
change their diets to
incorporate softer and more
processed foods. These
changes in their dietary
patterns could then be a
contributing factor towards
their
developing
hypertension. Researchers
therefore believe that

improved dental hygiene
among those at risk for tooth
loss, as well as preventive
measures, such as closer
blood pressure monitoring,
dietary modifications,
physical activity and weight
loss may reduce risks of
developing blood pressure
problems.
The study, titled "Association
of periodontal disease and
edentulism with hypertension
risk in postmenopausal
women" was published
on 4 December in the
American Journal of
Hypertension. - Dental
Tribune International

Straumann partners with
Z-SYSTEMS to offer widest
range of ceramic implants

Z-SYSTEM's new two-piece ceramic implant features a
ceramic connection screw, making it the first two-piece,
screw-retained dental implant to be completely metaland plastic-free. (Image: Z-SYSTEMS)

ASEL, SWITZERLAND - Straumann, global leader
in tooth replacement and orthodontic solutions, has
entered a strategic partnership with Swiss-based
international leader in ceramic dental implant systems, ZSYSTEMS. The two companies have signed an agreement
that provides Straumann with a 34 per cent stake in ZSYSTEMS, and in return, Z-SYSTEMS will receive a capital
injection to expand its production capabilities and develop
its pipeline.
Straumann has obtained exclusive distribution rights in
most major markets for Z-SYSTEMs next generation
implant line, which complements their current PURE Ceramic
Implant system. The new implant has a bone-level, twopiece design for prosthetic flexibility and convenient
handling. Unlike other implants, it features a ceramic
connection screw, making it the first two-piece, screwretained dental implant to be completely metal- and plasticfree. Straumann plans to launch the new line in 2019.
We are convinced that ceramic implants offer substantial
growth opportunities and will continue to gain popularity,
Continued on page 15

Combination of breast milk and babies saliva
shapes healthy oral microbiome, study suggests

I S B A N E ,
AUSTRALIA There is much debate
of the pros and cons of breastand bottle-feeding. A research
team from the Queensland
University of Technology
(QUT), in collaboration with
the University of Queensland,
both in Australia, has found
that breastfeeding, at least in
terms of oral health of the
baby, is beneficial.
According to lead author Dr
Emma Sweeney, from the
Institute of Health and
Biomedical Innovation at
QUT, the team's earlier studies
had found significant
differences in the prevalence
of key bacteria in the mouths

of breastfed and formula-fed
babies and that breastmilk and
saliva interactions boost innate
immunity by acting in synergy
to regulate the oral
microbiome of newborn
babies.
For the recent study, a
variety of microorganisms
were exposed to breastmilk
and saliva mixtures. The
results showed that
inhibited growth of
the microorganisms
took
place
immediately and for
up to one day
regardless of
whether
the
microorganisms were
considered pathogenic or

commensal in an infant's
mouth.
"Our findings suggest that
breastmilk is more than a
simple source of nutrition for
babies because it plays an
important role in shaping a
healthy oral microbiome,"
said Sweeney. "Our
previous research found
that the interaction of
neonatal saliva and
breast milk releases
antibacterial
compounds,
including hydrogen
peroxide. The release
of this chemical
compound also
activates the lactoperoxidase
system, which produces

additional compounds that
also have antibacterial activity,
and these compounds are
capable of regulating the
growth of microorganisms,"
she added.
According to the research team,
the composition of a baby's
mouth microbiota has an
important role in its health and
well-being and also has an impact
on infections and diseases in
babies' early lives.
The study, titled "The effect of
breastmilk and saliva
combinations on the in vitro
growth of oral pathogenic and
commensal microorganisms",
was published online in Scientific
Reports on 11 October 2018.
- Dental Tribune International.

[15] => Dt pages.FH10

NEWS

E

TOY, Switzerland:
The role dental
hygienists play within
the dental industry can
sometimes be overlooked,
with some curtail work often
taking place before a dentist
has even seen the patient.
Presented by the SUNSTAR
Foundation and supported by
the International Symposium
on Dental Hygiene (ISDH),
the World Dental Hygienist
Awards recognise dental
hygienists who have made a
significant contribution to
dental hygiene science,
patients and the broader
community. Presented every
two years at ISDH, entries for
this years awards close on 14
January 2019.
The 2019 ISDH will take
place in August in Brisbane,
Australia. As per previous
years, the winners of the
Dental Hygienist Awards are
chosen by an independent
selection committee. These
awards are an excellent
opportunity to give visibility
to a crucial profession in the

November 2018 Pakistan Edition DENTAL TRIBUNE 15

Last call for entries for the
World Dental Hygienist Awards

Presented every two years at the International Symposium on Dental Hygiene, the
World Dental Hygienist Awards recognises dental hygienists who have made a significant
contribution to their field. (Photograph: Anna Jurkovska/Shutterstock)
oral health field.
Unfortunately, the dental
hygienists role is often
underrated, although it is key
to show patients how to
maintain a proper oral care

Mercury-free healthcare ...
Continued from front page

intellectual delays and problems during
childhood.
Under the health ministry's initiative,
policy guidelines will be developed for
stakeholders on how to phase out
mercury-based products, while a
complete ban will be slapped on the use
of mercury-containing amalgam for
restorative dental care.
Also, the medical and dental colleges'
curriculum will be changed accordingly;
strict regulations and legislation will be
introduced on the use of mercury in
cosmetics and fairness creams, and a
nationwide campaign will be begun to
raise public awareness of the hazards of
mercury-based products and equipment.
National Health Services and
Regulations Minister Aamir Mehmood
Kiani is understood to have directed the
relevant officers lately to turn the
programme, his brainchild, into a reality
without delay saying this will help
further the cause of healthcare in the
country as promised by the ruling PTI.
Experts welcome the ministry's plans
saying their successful execution will
go a long way in protecting the people
from the devastating health
consequences of mercury use. Dr Wasim
Khwaja of the Pakistan Institute of
Medical Sciences said that the mercury
dispersed into the ecosystem, remained
in the ecosystem for generations, causing
severe health and intellectual impairment
to the exposed populations.
"The mercury discarded and spilled
by healthcare settings makes its way
into the environment, where it
methylises and bio-accumulates in the
food supply, negatively impacting
human and environmental health," he
said.
The gastroenterologist said the

routine, and to detect some
oral problems at earlier
stages, said JoAnn
Gurenlian, President of the
American Dental Hygienists
Association.

removal of mercury-containing devices
and products from hospitals and clinics
would prevent doctors, health workers
and patients from the potentially highly
toxic levels of elemental mercury.
Noted dental surgeon Dr Pakiza Hyder
hailed the proposed ban on mercury
dental fillings saying it would protect
patients from poisoning, exhaustion,
emotional disturbance and high blood
pressure.
"Mercury is used in fillings commonly
known as silver fillings. It is mixed with
silver and copper to form a durable
mixture to lock in the quicksilver.
However, it is seen that toxic mercury
vapours leak and travel throughout the
body, and are deposited in the vital
organs causing multiple health
problems," she said.
Regretting the rampant use of mercury
fillings by hospitals and clinics, the
dental surgeon strongly felt that better
public awareness was the best way to
turn Pakistan into a mercury hazard-free
country.

100-day performance ...
Continued from front page

health ministry. Hence, the ministry had
embarked on a process to upgrade all
basic healthcare facilities in the federal
capital. To consolidate all the healthcare
facilities of the city under one ministry,
they were in the process of making new
appointments.
Moreover, plans to build four more
hospitals in Islamabad, especially with
help from Saudi Arabia, were underway.
In this regard, work on building a
hospital in Tarlai is expected to start
soon.
To regulate all public and private
healthcare facilities in the capital,
including clinics, hospices and even
health care professionals, a registration

The awards are divided into
two categories: research and
activity or project, with
professionals and students
competing separately. The
research entries may include

process is being initiated. For this
purpose, a healthcare commission and
healthcare regulatory authority are in
the process of being created.
The second phase of the Prime Minister's
Health Programme has also begun for
which the bid collection process has
been completed.
The ministry hopes that by the middle
of January next year, more than two
million people will get health coverage.
Additionally, this phase will also see
the funds provided for medical treatment
become more than double from Rs3.5
million to Rs7.2 million.
The health ministry has also worked
on revamping the apex drug regulator
of the country, the Drug Regulatory
Authority of Pakistan (DRAP). In this
regard, the aspects of medicine making
process, checking laboratories according
to international standards has been
emphasised and that soon level three
qualification will be achieved.
Sources, quoting the report, further
said it lists the measures which were
taken on family planning - as
recommended by a high-powered board
formed on controlling the country's
population.
Moreover, the government has decided
to impose a 'Sin' tax on cigarette and
other tobacco products which will
amount to two per cent tax on these
products, which will be contributed in
the development and progress of health
sector.

COP2 focuses on dental ...
Continued from page 10

Caribbean group also supported this
ban. The environmental project
coordinator for Honduras, Pablo
Rodríguez, shared his countrys pilot
project on eliminating products and
processes that use mercury in the health

both quantitative and
qualitative analyses that
provide important new
insights that contribute to the
body of knowledge in the oral
hygiene field. The total prize
money for the professional
and student category is
US$5,000 (4,407) and
US$2,000 (1,763),
respectively.
In the activity or project
category, entrants are required
to provide details of the
activities that have made a
key contribution to patients,
the community or the general
public. The positive impact of
the activities on the health of
a significant number of
individuals should be
empirically demonstrated,
with measurable outcomes
that demonstrate improved
health. The award is open to
individuals as well as groups,
with the total prize money for
the professional and student
entry totalling US$3,000
(2,644) and US$2,000,
respectively. - Dental Tribune
International

care sector in the four largest hospitals
in the country. They have eradicated the
use of medical devices that use mercury
and the use of dental amalgam in these
hospitals. He said that this project was
started in 2014 and is gaining
momentum and has now become the
model for his countrys transition out of
mercury use in the health care sector.
Representing VOCO dental materials,
Peter Hoffmann shared with participants
solutions for non-mercury dental
restorations. It is extremely important,
in particular for developing countries
and countries in transition, to learn to
use the atraumatic restorative treatment
(ART) technique. ART was developed
in Tanzania, more than 30 years ago as
an alternative to conventional dental
treatments.
A concerted commitment to end the
use of dental amalgam was evident
during COP2. Delegates throughout the
week agreed that this use of mercury
m u s t e n d . - D e n ta l Tr i b u n e
International

Straumann partners with ...
Continued from page 14

driven by increasing clinical experience
and the improved flexibility provided
by two-piece solutions, said Marco
Gadola, CEO of Straumann. Together
with Z-SYSTEMS, we offer the widest
range of ceramic implant options
supported by digital workflows and
biomaterial solutions. The combination
of our expertise, research capabilities,
sales power and global reach position
us as a leading force in the global
ceramic implant market.
We are very proud to partner with
the world leader in implant dentistry,
stated Ernst Thomke, member of the
board of directors of Z-SYSTEMS.
- Dental Tribune International

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[cover] => DT Pakistan No. 6, 2018

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Table of contents

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News / Interview / Clinical Implantology

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