DT UK No. 3, 2015

UK News / World News / Business / Anatomical pin: A clinical case report / Going (unintentionally) green: The unexpected bonus of switching to CAD/CAM and same-day dentistry / Implant Tribune United Kingdom Edition

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DTUK0315_01_Title 24.07.15 13:12 Seite 1

DENTAL TRIBUNE
The World’s Dental Newspaper · United Kingdom Edition
www.dental-tribune.co.uk

Published in London

Vol. 9, No. 3

DENTAL CIRCLE

BRANDING

IMPLANT TRIBUNE

Members and partners of the
ambitious platform recently met
in London to celebrate the future
of professional social media.

With an ever-increasing level of
choice for patients,it is more important than ever for dental businesses
to stand out from the growd.

Read the latest news and developments from the fields of implant
dentistry in our specialty section
included in this issue.

” Page 4

” Page 9

” Page 17

Halitosis
New report says parents to blame association
launched

for children’s poor oral health

In order to address the lack of scientific data on halitosis, the International Association for Halitosis Research (IAHR) was officially formed
on 5 June at a meeting of leading halitosis researchers during EuroPerio8
in London. As new insights into the
problem of bad breath are rapidly expanding, the IAHR aims to promote
research on all aspects of halitosis
and its related issues and to distribute and publicise the research. “Not
only do we need to create awareness
among the public, but we should also
enhance the information and treatment advice for professionals,” president Dr Edwin Winkel from the
Netherlands said.

By DTI
MANCHESTER, UK: A lack of knowledge
about the importance of early oral
health care measures and the availability of treatment among parents
has led to almost every seventh child
aged 8 or under in the UK having
never seen a dentist, according to a
new report by dental group mydentist
in Manchester. The survey also found
that one in ten of those children who
had actually seen a dentist had at least
one filling done, resulting in an estimated burden of £22 million annually
for the National Health Service.
The report is in line with new findings by the Faculty of Dental Surgery
at the Royal College of Surgeons of
England earlier this week that oral
health among the nation’s youth is
worsening, with more children than
ever sent to hospitals for tooth extractions owing to severe decay. While the
Royal College of Surgeons has identified increasing sugar consumption as
the main contributor, the mydentist
report blames parents who are unaware of or fail to implement appropriate oral health care measures at
home for the dental problems.

Many parents also failed to identify
things that are actually beneficial to
their children’s health, such as fluoride, which 13 per cent considered to
be harmful.

Among its findings are that only a
quarter of the children of the parents

On the contrary, almost a fifth of
the parents thought that acidic bev-

Despite more children in the UK suffering from dental problems, many have never been taken to a dentist.

surveyed brushed their teeth for the
recommended two minutes twice daily.

erages like fruit smoothies, a major
contributor to tooth erosion, would
benefit their children’s teeth.
The mydentist survey was conducted among 2,000 parents
throughout the UK. It found that
those in Wales were most likely to
take their children to see a dentist
early on. Children living in the North
West also scored higher in terms of

Maltreatment case settled
with ﬁve ﬁgure number
By DTI
CHELMSFORD, UK: A dentist from
Benfleet in Essex is reported to have
paid an amount of £16,000 to settle
a lawsuit by a former patient over
allegations of maltreatment. Charges
against him included having damaged the facial nerves of the 49-yearold civil servant, Graham Hancock,
during a third molar extraction at his
dental practice in Chelmsford.
Hancock told the Essex Chronicle
that he had suffered from continuous facial pain, numbness and loss of

taste after having undergone the procedure in late 2013.After his condition
worsened, he was sent to King’s College Hospital in London for specialist
treatment.
The case was taken to court after
other oral surgeons found the dentist’s work to have been unprofessional. Among other things, he failed
to take a radiograph to identify the
risks of the procedure and to inform
the patient of other treatment options, Hancock’s solicitors said. Currently working at a dental practice in
Basildon, the dentist is reported to

personal oral hygiene, brushing their
teeth for longer than youngsters in
any other region.

PRINT
L
DIGITA N
IO
T
A
C
EDU
EVENTS

have not admitted liability despite
having agreed to pay the five-figure
settlement.
He has also been under surveillance
by the General Dental Council on several charges of misconduct and poor
professional performance, including
allegations of not having maintained
appropriate standards of infection
control and having exposed patients
to dental panoramic radiography
without justification while working
at his former practice in Southendon-Sea between September 2010 and
October 2012.

Despite affecting a vast number of
people worldwide, sound epidemiologic data on halitosis is rare. While 9 in
10 cases of halitosis are attributable to
tongue coating, gingivitis, periodontitis and other conditions in the oral
cavity, a minority of cases are caused
by systemic diseases or conditions.

The DTI publishing group is composed of the world’s leading
dental trade publishers that reach more than 650,000 dentists
in more than 90 countries.

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DTUK0315_02_News 24.07.15 13:13 Seite 1

UK NEWS

Dental Tribune United Kingdom Edition | 3/2015

Leeds collaborates over future
of oral health care in Europe
Using de-identified data from
millions of health records across
Europe, the researchers will work
with dental professionals and insurers to identify effective strategies for preventing disease in each
country. Providing continuous
feedback to shape best practice, a
set of key performance indicators
will be developed against which
dentists and health care systems
can measure themselves.

By DTI
LEEDS, UK: Dental treatments cost an
estimated €79 billion a year across
the EU, yet dental diseases are almost
entirely preventable. A new research
project, funded through a €6 million
grant from the EU, aims to bring
about a shift in dental care practices,
from a focus on treating teeth by
extraction and fillings to more ef-

fective oral health care treatments
to prevent disease in the first place.
The four-year project will be led
by the University of Leeds, in
conjunction with the Academic
Centre for Dentistry Amsterdam
and Heidelberg University, in collaboration with NHS England, as
well as universities and dental insurers from across Europe.

“The World Health Organization
has said that dental diseases are
the most common chronic diseases
known to man. We want to change
this,” said Prof. Helen Whelton, Dean
of the University of Leeds’s School
of Dentistry and project lead. “The
hope is that, by continually assessing and feeding back the performance of dental professionals and
healthcare systems in keeping teeth
healthy, it will foster change in practices and encourage a move to more
preventive dental care.”
“We will be using secure, de-identified medical records to develop
a model with a focus on preventing
dental problems, which gives den-

tists and health systems the ability
to measure their success in making
patients healthier,” Whelton explained. “We will be looking at things
such as how long teeth remain
healthy with no need for treatment
or, at country level, the amount
spent on extractions each year. This
information can be compared across
different systems and countries.”
The project will have access to
eight European patient record
databases from countries including Britain, Denmark, Germany,
Hungary, Ireland and the Netherlands. In addition to hearing the
views of professionals and insurers, the project will consult with
patients in the participant countries to identify their preferences
and gain their perspectives on the
dental care they receive.
“This is a fantastic example of
collaboration between universities,
the public sector and the private sector, with the aim of improving the
dental health of an entire continent,
and we hope this will feed in to the
reform of healthcare systems globally,” Whelton concluded.

IMPRINT
PUBLISHER:
Torsten OEMUS
GROUP EDITOR/MANAGING EDITOR DT AP & UK:
Daniel ZIMMERMANN
newsroom@dental-tribune.com
CLINICAL EDITOR:
Magda WOJTKIEWICZ
ONLINE EDITOR:
Claudia DUSCHEK
ASSISTANT EDITORS:
Anne FAULMANN, Kristin HÜBNER
COPY EDITORS:
Sabrina RAAFF, Hans MOTSCHMANN
PRESIDENT/CEO:
Torsten OEMUS
CFO/COO:
Dan WUNDERLICH
MEDIA SALES MANAGERS:
Matthias DIESSNER
Peter WITTECZEK
Maria KAISER
Melissa BROWN
Weridiana MAGESWKI
Hélène CARPENTIER
Antje KAHNT
MARKETING & SALES SERVICES:
Nicole ANDRAE
ACCOUNTING:
Karen HAMATSCHEK
BUSINESS DEVELOPMENT:
Claudia SALWICZEK
EXECUTIVE PRODUCER:
Gernot MEYER
AD PRODUCTION:
Marius MEZGER
DESIGNER:
Franziska DACHSEL
INTERNATIONAL EDITORIAL BOARD:
Dr Nasser Barghi, Ceramics, USA
Dr Karl Behr, Endodontics, Germany
Dr George Freedman, Esthetics, Canada

Most Brits avoid showing their
teeth in photographs
By DTI

29 per cent do not even use toothpaste. One in five also admitted
that they regularly use chewing
gum as a substitute for brushing
their teeth.

LONDON, UK: Say “cheese”! Although
it is meant to make people smile,
this cue apparently induces the
opposite in many British people.
According to a new survey, eight
out of ten worry about how their
teeth look in photographs, with
almost every second person wishing he or she could change the
appearance of his or her dentition
altogether.
The research, which was initiated
by global health care company
Bupa, surveyed 2,000 people on
their dental habits and attitudes towards brushing their teeth. As the
answers revealed, the British are far
from being a tooth-proud nation.
An astonishing 81 per cent of the
respondents worried about the
appearance of their teeth in photographs, with 28 per cent of them
refusing to smile in pictures at all
for fear of their teeth looking unattractive in photographs or on
social media.
Fourty-two per cent of those
polled confessed that their teeth
were the number one thing they
would change about themselves,
35 per cent admitted to being em-

Commenting on the research,
Dr Steven Preddy, Dental Clinical
Director of Bupa Dental Services,
said: “Worryingly, our research
highlights how many people are
ignoring the art of brushing their
teeth properly. Modern, state-ofthe-art electronic toothbrushes
and interdental tools provide a
wealth of different ways to clean.
So there should be no excuse for
not brushing for two minutes twice
every day, and in conjunction with
seeing a dentist regularly, we encourage people not to neglect their
teeth and gums!”
barrassed about the appearance
of their teeth and 63 per cent said
they wished they were whiter and
cleaner.
It would appear that the ever present sparkling celebrity teeth are fuelling these feelings of dental inadequacy, as 53 per cent said they feel
pressured to have impeccable teeth
because of those displayed by modern celebrities and public figures.

Shying away from smiling in
photographs is one thing, but the
British’s anxiety about their teeth
appears to be linked to a serious
lack of oral hygiene knowledge. Of
those surveyed, 47 per cent admitted that they do not know how to
brush their teeth properly. The
poll further found that half of the
respondents do not use mouthwash, 9 per cent share a toothbrush
with someone else and, alarmingly,

In terms of UK regions, respondents from South East England
were the most responsible teeth
cleaners with 74 per cent brushing twice daily as recommended,
followed by Scotland (67 per cent)
and Northern Ireland (64 per cent).
The worst offending region was
Yorkshire and the Humber region,
where only 53 per cent of respondents brush twice a day.

Dr Howard Glazer, Cariology, USA
Prof. Dr I. Krejci, Conservative Dentistry, Switzerland
Dr Edward Lynch, Restorative, Ireland
Dr Ziv Mazor, Implantology, Israel
Prof. Dr Georg Meyer, Restorative, Germany
Prof. Dr Rudolph Slavicek, Function, Austria
Dr Marius Steigmann, Implantology, Germany

Published by DTI.
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responsibility for the validity of product claims,
or for typographical errors. The publishers also do
not assume responsibility for product names or
claims, or statements made by advertisers. Opinions
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MORE BONE Where it Matters Most...

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DTUK0315_04_DentalCircle 24.07.15 13:13 Seite 1

UK NEWS

Dental Tribune United Kingdom Edition | 3/2015

Dental Circle meets in London to celebrate
future of professional social media
By DTI
LONDON, UK: With temperatures
skyrocketing last month in the capital, the organisers of Dental Circle
could not have chosen a better time to
hold its first major networking event.
Consequently, hundreds of members
of the professional social media website met in London to share ideas
and celebrate the achievements of
the ambitious platform.
And there was plenty to celebrate
at the event sponsored by dental implant solutions provider Straumann.
In just one year after launching, the
site has attracted over 3,000 members, a number that might not seem
high for a professional network, but
one that fits in perfectly with the
ethos founders Amit and Dev Patel
had in mind when launching the
site.Instead of being open to anyone, like Facebook or Twitter, the
network works similar to exclusive
social media sites like ELEQT, but
without the hurdle of having to pay
one’s way into it. Professionals interested in joining Dental Circle just
have to be registered with the General Dental Council and want to be
part of an ever-growing network of
professionals.
“In the current employment
market, young dentists are struggling to find jobs and make the
right connections. Specialists too

are receiving fewer referrals and
principal dentists are flooded with
ambiguous CVs from across the
world,” explains Amit Patel, who

Once approved, members are
given a personal profile page,
which they can customise with
their interests and achievements,

special interest groups to explore
or deepen their knowledge of
different aspects of dentistry.
These are led by mentors, includ-

courses and investing in dental
products and practices early on.
Our goal was to create a website
where they can find support from
a variety of professional sources,”
Patel said.
In addition to its online presence, which includes common social media websites like Facebook,
Dental Circle has recently begun
organising roadshow events that
give members and other professionals the opportunity to network with prominent experts, as
well as to try out the latest technologies and tools. Three of these
events, intended to cover clinical
topics ranging from short-term
orthodontics to posterior direct
restorations, are scheduled for
later this year in London, Leeds
and Manchester.
“The Dental Circle Roadshow
events are a new concept, aimed
at young dentists, helping to
build foundations, but also advance current techniques,” said
Dev Patel.

Amit Patel (right) celebrating with Dental Circle partners and friends. (Photographs Lloyd Goodall, UK)

is also a London-based dentist.
“Dental Circle is the professional
network for dental professionals,
with the aim of connecting all dentists, therapists, hygienists, nurses
and laboratory technicians.”

as well as the opportunity to upload images of their own cases and
share them with the rest of the
community. From these, the best
are awarded on a regular basis.
Furthermore, members can join

ing clinical gurus such as Chris Orr
and Zaki Kanaan.
“Young dentists are more ambitious than ever, looking to
advance their careers through

Registrations for each of the
one-day events, which are worth
seven hours of continuing professional development, are still
being accepted. Professionals interested in attending the workshops are invited to register at
dentalcircle.com/roadshow.

Capital prepares for
International Orthodontic Congress
By DTI
LONDON, UK: The International
Orthodontic Congress (IOC) is held
once every five years and offers
up to 10,000 orthodontists and
allied professionals a unique platform to meet, network and exchange knowledge and ideas with
their colleagues and peers from
across the globe. The World Federation of Orthodontists (WFO) and
the British Orthodontic Society,
the two largest dental specialist
groups in the UK with over
1,800 members collectively, will
be hosting the eighth edition of
the congress in London, from 27
to 30 September.

offering two scientific programmes
that will run in parallel. In addition to these programmes, a World
Village Day will take place, which
will comprise of seven parallel, fullday programmes. To date, 19 distinguished speakers have already
confirmed their participation.

The organiser expect to attract
more than 7,000 people. About
4,000 participants have already
signed up for the event. It will be officially opened on 27 September at the
ExCeL London Exhibition and Congress Centre in the heart of London’s
Royal Docks, with easy access to
central London. The venue is part of
a 100 acre site which includes three
on-site aboveground rail stations
and easy access to the underground
network and London City Airport.

The congress lectures and presentations will be held in English,
however, simultaneous translation
will be provided for some sessions.

In order to cater for both orthodontists and other dental health
professionals, such as dental technicians, hygienists, dental attendants
and office staff, the WFO will be

Alongside the scientific programme, attendees will have the
opportunity to learn more about
new products and technological
developments at the adjoining

exhibition that will run for the
duration of the congress.
In addition, during the course of
the congress, several social events
are planned for the evenings, including an international reception
at the famous Madame Tussauds
wax museum and a gala dinner at
the Old Billingsgate, an extraordinary and unique venue that is
situated in a prime position on the
River Thames which was once the
world’s largest fish market. Tickets
for these events can be purchased
upon registration.
According to the WFO, one of
the reasons the congress is taking

place in London is because of the
city’s heritage and its attractions
on offer. As a city of history and
culture, delegates will have numerous opportunities to enjoy
many of the sights, including castles and palaces; historical buildings and monuments; theatres
and opera houses and other
well-known places that were described by famous authors, such as
William Shakespeare and Charles
Dickens.
Online registration for the event
is open until 17 September online
but delegates can also register
on-site at the registration desk on
27 September.

[5] => Standard_300dpi

LONDON’S TOP 10
ATTRACTIONS

1. BRITISH
MUSEUM
The world-famous British
Museum exhibits the works
of man from prehistoric to
modern times, from around
the world. Highlights include
the Rosetta Stone, the
Parthenon sculptures and
the mummies in the Ancient
Egypt collection. Entry is
free but special exhibitions
require tickets.

6. SCIENCE
MUSEUM
From the future of space
travel to asking that difﬁcult
question: “who am I?”, the
Science Museum makes
your brain perform Olympicstandard mental gymnastics.
See, touch and experience
the major scientiﬁc advances
of the last 300 years; and
don’t forget the awesome
Imax cinema. Entry is free
but some exhibitions require
tickets.

2. NATIONAL 3. NATURAL
HISTORY
GALLERY
The crowning glory of
MUSEUM
Trafalgar Square, London’s

4.TATE
MODERN
Sitting grandly on the
banks of the Thames is Tate
Modern, Britain’s national
museum of modern and
contemporary art. Its unique
shape is due to it previously
being a power station. The
gallery’s restaurants offer
fabulous views across the
city. Entry is free but special
exhibitions require tickets.

5.THE
LONDON
EYE

National Gallery is a vast
space ﬁlled with Western
European paintings from the
13th to the 19th centuries.
In this iconic art gallery you
can ﬁnd works by masters
such as Van Gogh, da Vinci,
Botticelli, Constable, Renoir,
Titian and Stubbs. Entry is
free but special exhibitions
require tickets

As well as the permanent
(and permanently
fascinating!) dinosaur
exhibition, the Natural History
Museum boasts a collection
of the biggest, tallest and
rarest animals in the world.
See a life-sized blue whale,
a 40-million-year-old spider,
and the beautiful Central
Hall. Entry is free but special
exhibitions require tickets.

7. VICTORIA
& ALBERT
MUSEUM

8. TOWER OF 9. ROYAL
10. MADAME
LONDON
MUSEUMS
TUSSAUDS
Take a tour with one of the
Madame Tussauds, you’ll
GREENWICH Atcome
Yeoman Warders around
face-to-face with some

The V&A celebrates art and
design with 3,000 years’
worth of amazing artefacts
from around the world. A real
treasure trove of goodies,
you never know what you’ll
discover next: furniture,
paintings, sculpture, metal
work and textiles; the list
goes on and on… Entry is
free but special exhibitions
require you to purchase
tickets.

the Tower of London, one
of the world’s most famous
buildings. Discover its
900-year history as a royal
palace, prison and place
of execution, arsenal, jewel
house and zoo! Gaze up
at the White Tower, tiptoe
through a medieval king’s
bedchamber and marvel at
the Crown Jewels.

Visit the National Maritime
Museum - the world’s
largest maritime museum,
see the historic Queen’s
House, stand astride the
Prime Meridian at Royal
Observatory Greenwich
and explore the famous
Cutty Sark: all part of the
Royal Museums Greenwich.
Some are free to enter; some
charges apply.

The London Eye is a major
feature of London’s skyline.
It boasts some of London’s
best views from its 32
capsules, each weighing 10
tonnes and holding up to 25
people. Climb aboard for
a breathtaking experience,
with an unforgettable perspective of more than 55
of London’s most famous
landmarks – all in just 30
minutes!

of the world’s most famous
faces. From Shakespeare
to Lady Gaga you’ll meet
inﬂuential ﬁgures from
showbiz, sport, politics and
even royalty. Strike a pose
with Usain Bolt, get close to
One Direction or receive a
once-in-a-lifetime audience
with Her Majesty the Queen.

[6] => Standard_300dpi

DTUK0315_06_Bioemulation 24.07.15 13:14 Seite 1

WORLD NEWS

Dental Tribune United Kingdom Edition | 3/2015

Bio-Emulation movement
continues to grow
and techniques to
achieve high aesthetic
standards and emulate
nature using a histoanatomical approach.

phology function and aesthetics
was among the most requested.

about 200 people attended the
social events.

Over 95 per cent of attendees
who took part in a representative

This year’s colloquium was held
at the European School of Manage-

During the sessions, particularly
the workshops, attendees had the
opportunity to learn more about
the mechanical and optical properties of natural teeth and gain
knowledge on using existing techniques and materials. A considerable number of workshops were
fully booked; for instance, Dr Pascal
Magne’s session on dental mor-

evaluation survey said that they
would definitely recommend the
event to others. They were most satisfied with the choice of speakers
and topics in particular.

ment and Technology, a historical
site in the centre of Berlin, next to
the office of the German Ministry of
Foreign Affairs. The building, which
has landmark status today, was once
the state council building of the former German Democratic Republic.
After a lavish refurbishment in 2004
and 2005, it was transformed into
the current private business school.

GC Europe was the main sponsor
and SHOFU was the official partner.
In addition, the colloquium was
sponsored by Ivoclar Vivadent and
CROIXTURE, and supported by

By DTI
BERLIN, Germany: On 4 and 5 July, the
2015 Bio-Emulation Colloquium
was held in Berlin in Germany. The
event, which was organised by the
Dental Tribune International team
in close collaboration with the BioEmulation Group, attracted more
than twice the number of participants compared with last year.
Overall, more than 300 dentists and
dental technicians attended the extensive programme on biomimetics in dentistry, including 16 lectures
and 13 workshops.
After the successful première of
the Bio-Emulation Colloquium last
year in Santorini in Greece, this
year’s meeting was held under the
theme “Bio-Emulation Colloquium
360°”. Key opinion leaders in adhesive and restorative dentistry educated the participants on methods

Many of the participants took
advantage of the networking opportunities offered on the two
evenings of the meeting. Each day,

American Dental Systems, anaxdent
and Velopex International.
At the closing session in Berlin,
members of the Bio-Emulation
Group announced that the next
colloquium in 2016 will take place
in Barcelona in Spain. More Details
will be made available in due time
at www.bioemulationcampus.com.

Study reveals unrealistic
public expectations regarding implants
By DT Asia Paciﬁc
HONG KONG: Dental implants are
gaining increasing popularity in
the treatment of partially dentate
or edentulous patients, and both
the industry and dental professionals offer detailed information
about implant materials, functions and procedures.

about dental implants, but never
received one or had any dental consultation regarding dental implants.
The participants were divided
into six focus groups and had to

to thematic content analysis following a grounded theory approach.
The Chinese research team found
that the participants acquired information on dental implants

According to the researchers,
the participants expected dental
implants to restore patients’ appearance, function and quality
of life to absolute normality.
“They regarded dental implants

Overall, the study found that the
public is exposed to information
of varying quality and has some
unrealistic expectations regarding
dental implants. Such perceptions
may shape their care-seeking behaviours and decision-making
processes in one way or another,
the researchers said.

Yet, many people are not well informed and tend to overestimate
the functionality of implants,
while underestimating the expertise needed for implant dentistry.
These are the findings of a qualitative study conducted at the University of Hong Kong.

“The views and experiences
gathered in this qualitative study
could assist clinicians to better understand the public’s perspectives,
facilitate constructive patient–
dentist communication, and contribute to the creation of positive
clinical experiences in implant
dentistry,” they concluded.

The researchers aimed to evaluate the public’s acquisition of information and their perceptions
regarding dental implants, as well
as the effects of these perceptions
on their care-seeking and decisionmaking behaviour.
The study examined a sample of
28 adults between 35 and 64 years
old who had never been engaged
in a dentistry-related job. Moreover, for inclusion in the study,
participants had to have at least one
missing tooth and to have heard

The participants further underestimated the expertise needed to
carry out the clinical procedures
to place an implant. However, they
were deterred from seeking dental
implant treatment by the high
costs, invasiveness of the procedure, risks and possible complications.

Patients tend to overestimate the functionality of implants, new research has shown.

discuss dental implants and their
individual knowledge about them.
All of the group discussions were
transcribed verbatim and subjected

through various means, such as patient information boards, printed
advertisements, social media, and
personal connections.

as a panacea for all cases of missing teeth and overestimated their
functions and longevity,” the
scientists stated.

The study, titled “Public perceptions of dental implants: A
qualitative study”, was published
online on 8 May in the Journal of
Dentistry.

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DTUK0315_07_Maekinen 24.07.15 13:15 Seite 1

Dental Tribune United Kingdom Edition | 3/2015

WORLD NEWS

“Xylitol is here to stay”
An interview with Professor Emeritus Kauko K. Mäkinen, Finland
During the early 1970’s, xylitol and
other natural sweeteners were extensively tested in Finland as potential replacements for sugar.The series of over
20 research reports,published together
in Acta Odontologica Scandinavica in
1975, became collectively known as the
“Turku Sugar Studies”. Approaching
the 40th anniversary of the publication,
Dental Tribune had the opportunity to
speak with Professor Emeritus Kauko
K. Mäkinen, who led the original Turku
research together with Arje Scheinin,
about xylitol’s impact on caries levels,
its popularity in Finland and the sweetener's future prospects.
Dental Tribune: Prof. Mäkinen, you
were involved in the first extensive
studies of xylitol in the seventies—
how far has the sweetener come since
then?
Prof. Emeritus Kauko K. Mäkinen:
The awareness of xylitol among consumers and healthcare professionals
has increased significantly since the
early 1970’s. However, knowledge
about xylitol is not equally distributed across the world. Although
awareness may approach 100 per cent
in Finland, the situation is different
in other countries and the level of

ment from the German Dental
Association.
When you did your research for the
Turku studies, did you expect to find
xylitol to be so beneficial, especially
for oral health?
We did not anticipate the magnitude of this preventative effect.
We considered it a welcome surprise.
Later, of course, after learning how
xylitol works and after we learned
to understand the chemical mechanisms involved, we started to regard the findings as natural and
expected.
Is there a measureable impact on
caries levels and dental health that
can be attributed to the sweetener?
We cannot give any figures of the
effect of xylitol in caries incidence
in the above instances. Overall caries
prevention takes place as a result of
multi-faceted efforts and programs,
xylitol being a part of the whole. It is
impossible to differentiate between
the effect of each individual preventative measure since all of them are
in action simultaneously, such as
tooth brushing, the use of fluorides,
the application of sealants, etc.

“Overall caries prevention takes
place as a result of multi-faceted
efforts and programs, xylitol
being a part of the whole.”
awareness depends on the level
of dental and medical education in
each country.
As you mentioned, in Finland, xylitol
seems to be a part of daily life?
Xylitol is indeed known by virtually all Finns and is also used by
most people in Finland on a daily
basis. Parents and grandparents have
adopted a habit of buying xylitol
gum, pastilles or lozenges for their
children and grandchildren. At many
day-care centres, children learn to
use xylitol after lunch.
In Germany, for example, you can buy
xylitol as a sweetener and it is also
added in gum, but it is not widely
known to the public as a mainstream
product. Why do you think there is
such a difference in “popularity”?
You are right about the situation in
Germany. I cannot help but wonder
why this could be, since xylitol was
discovered by German chemists and
its medical use in infusion therapy
is best known by German physicians.
It is possible that German dentists
do not value early caries prevention
as much as the dentists and the
authorities do in Scandinavia. One
would need a strong and committed
distributor and an official endorse-

The caries preventative effects of
xylitol that were reported in the literature are based on clinical trials.
Xylitol does, however, significantly
increase the efficacy of overall caries
prevention, provided that the use of
xylitol is habitual and is based on the
consumption of sufficiently-large
daily amounts that are taken at least
three to five times a day.
Do you have any data on how much
xylitol is consumed in Finland or
worldwide?
These figures are possessed by
xylitol manufacturers and they do
not provide any production-related
information to us. However, the
annual production worldwide must
be tens of thousands of tons since
xylitol is produced in China, Russia
and in other countries. The first true
xylitol plant in the world was in
Finland and was sold to DuPont a few
years ago. When production started
in Finland in the 1970’s, 3,000 to
50,000 tons were made during the
first few years, but overall, production is by far much larger now.
How should the sweetener be used in
daily life?
My current recommendation is
about 7–10 grams per day, evenly dis-

tributed throughout the day. The first
dose in the morning, the last after
oral hygiene at bedtime. Always after
meals and sugary snacks. Use it about
5 times a day, not less. Use two pellets
or one stick of gum but the gum must
be 100 % xylitol. One may “tolerate”
some maltitol in it, but no sorbitol,
unless the sorbitol amount is very
small (<5 %). Some companies use
only 5–10 % xylitol and call their
product“a xylitol gum”, which is false.
Are there any known side effects?
Regular consumers who use xylitol
for dental purposes have no side effects. If somebody accidentally consumes larger single doses, for example,
20–30 grams, some individuals may
have transient diarrhoea. However,
sorbitol, mannitol and common milk
causes much more severe symptoms.
Of course, small children must use
xylitol gum under parental guidance.

Professor Emeritus Kauko K. Mäkinen posing with a model of the xylitol molecule.

Do you think xylitol could be playing
a greater role in the future, maybe in
developing countries?
Xylitol is here to stay. We are
already using xylitol in developing
countries. Vietnam is one example
and, in thinking, it is still a developing country. Xylitol is currently

being used in hundreds of dental,
medical, cosmetic and other products all over the world. Its popularity is increasing steadily, but not
abruptly.
Thank you very much for the interview.
AD

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DTUK0315_08_SunstarOralB 24.07.15 13:15 Seite 1

BUSINESS

Dental Tribune United Kingdom Edition | 3/2015

Sunstar awards research and promotes
Barcelona session at EuroPerio8
By DTI
LONDON, UK: In order to promote
research on the association between
periodontal disease and diabetes, as
well as oral and systemic health, the
Sunstar Foundation has been organising scientific seminars around the
world since 2008. During Sunstarsponsored sessions at EuroPerio8,
international experts lectured on periodontitis and its oral and systemic
effects, as well as the role of nutrition in severe periodontitis and new
regenerative medicine options for
periodontal patients. Over 400 dental
professionals attended the sessions.
As a partner of the European Federation of Periodontology, Sunstar also
hosted the fifth World Perio Research
Awards, which were established in
2003. This year, the three winning
papers were those submitted by Dr
Lisi Tan et al. (first place) from China,
Dr Marjorie Jeffcoat et al. (second
place) from the US, and Dr André Luis
Caúla et al. (third place) from Brazil.
The awards recognise research advances in oral and systemic health.
Mayumi Kaneda, Sunstar’s global
public relations director, told Dental
Tribune in London: “For the Sunstar
Foundation, it is very important to
support researchers. I feel that this is
our mission as a foundation and we really believe that it helps the development of science and will also translate
to the patients in the end. The trophy
for the prize was designed by Italian

designer Claudio Bellini. It symbolises
an infinity sign and expresses our
wish for researchers never to stop
continuing their work. This trophy is
also granted to winners
of the Sunstar World
Dental Hygienist Award,
which application deadline will be this year on
31 December.”

Initiative (JSDEI) session, the fourth in
Europe, to be held on 6 November in
Barcelona in Spain. After the success of
the 2014 JSDEI seminar in Frankfurt/

speakers from Spain and the US.
Sunstar also announced that the
20th JSDEI event will be held in Singapore in January 2016. Again, experts

teraction between professionals; in
fact, the interactive aspect is very,
very important to us. We are trying to
make everybody comfortable enough
to ask questions, as we really
want to start discussions
between these professionals,” Dr Marzia Massignani,
Scientific Affairs Manager at
Sunstar, said.

“Sunstar is not only
This year, Sunstar will be
committed to supportintroducing a new interactive
ing clinical studies and
JSDEI concept to universities
science, but we’re also
across Europe. Students will
committed to promotbe able to take part in the
ing education. Being
event via a live webinar, enseen as a partner in
abling a greater audience
education at every stage
reach. “We are collaborating
is extremely important
with key universities from
to us. We really want to
different countries that inhelp professionals beclude JSDEI in their education
come aware that, from
schedule. So far, the feedback
the patient’s perspechas been very good and
tive, they are all key
several universities have alplayers when it comes to
ready agreed to be involved,”
achieving a better qualMassignani stated.
ity of life, which is actually our foundation’s
The seminar is supported
Dental Tribune in talks with Mayumi Kaneda (left), Sunstar’s global public relations director, and Dr Marzia
motto. We really believe Massignani, Scientiﬁc Affairs Manager.
by the Sunstar Group, the FDI
in it—in all our efforts
World Dental Federation and
we have that goal in mind. One examthe Sociedad Española de Periodonin the fields of general dentistry, periMain in Germany, which was attended
ple is the project done in collaboration
cia y Osteointegración (the Spanish
odontology, dental hygiene, diabetolby a record number of 350 delegates,
with Quintessence Publishing to prosociety of periodontology and osseoogy, nutrition, internal medicine and
the next seminar will again focus on
duce the latest chapter of the Cell-tointegration).
general medicine from all over the
the latest cutting-edge research on
Cell Communication oral and general
world are expected to attend.
the link between oral and systemic
health animated video which preDental professionals can learn
health—which is still frequently
miered at EuroPerio8,” Kaneda stated.
“Top key opinion leaders in the
underestimated. The format of the
more about and register for the events
field of periodontology and the field
meeting will encourage interaction
at www.jsdei-seminars.com. More inth
Sunstar also announced the 19
of diabetology will be lecturing. The
between participants at the sympoformation about the company can be
seminar is focused on promoting insium delivered by distinguished
found at www.sunstar.com.
Joslin–Sunstar Diabetes Education

With promising results from its app,
Oral-B reveals new trial and whitening kit
By DTI
LONDON, UK:Users of electric
toothbrushes are brushing
over twice as much as users of
manual toothbrushes, resulting in a worldwide trend of
improved oral care patterns,
the dental consumables manufacturer, Oral-B announced
at EuroPerio8 in London. This
promising data was retrieved
from its recently improved
Oral-B app, which is available
to users of its SmartSeries
power toothbrushes and allows dental professionals to
manage and follow the brushing habits of their patients
between appointments.

have always offered users a
great brushing experience,
they are now able to assist
patients in keeping up good
oral hygiene between dental
appointments, the company
said.

Delegates were also able
to experience the company’s newest Test Drive programme at one of Oral-B’s
brushing booths at EuroPerio. According to the company, this gave both dental
professionals and their patients the opportunity to
try out their power toothbrushes, without the risk of
cross-infection, by using special handles and replacement
In addition to extended Market Strategy & Planning Manager Charlie Fuller (left/with company representatives) presented the heads that feature a sealing
insert to prevent saliva from
brushing times, over half of additions to P&G's professional portfolio.
entering the brush. Further
the recorded brushing sesprotection is provided by a disposable
sions in the app included flossing,
consumer feedback, the company
which is more aligned to their dental
sheath that covers the handle itself.
rinsing and tongue cleaning. Through
deduced that users are encouraged
professionals’ recommendations.
After cleaning and disinfecting it,
a combination of these statistics and
to brush longer, but with less force,
While Oral-B power toothbrushes

the handle is ready to be used again
with a fresh head.
Exclusively distributed in Europe
by Henry Schein, Oral-B further revealed their 3D White Whitestrips,
which is an easy home-whitening
treatment that is said to offer results
that last up to 12 months. They use the
same enamel-safe whitening ingredient that dentists use, which reaches
below the enamel surface to remove
stains. While a dental professional
first applies the strips, consumers can
perform all the subsequent whitening
applications at home. The results are
visible within 14 days, according to
the company.
A Procter & Gamble oral care brand,
Oral-B was a diamond sponsor of
EuroPerio8. It also supported two
sessions that focused on the issue of
hypersensitivity, the other challenges
faced in periodontal therapy with
regards to aesthetic demands and
achieving long-term success.

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DTUK0315_09_Maskery 24.07.15 13:16 Seite 1

Dental Tribune United Kingdom Edition | 3/2015

BUSINESS

Why dentistry needs branding
By Amanda Maskery, UK
Owning a dental practice or group
has always presented challenges,
but the marketplace has never been
more crowded than it is now. With
an ever-increasing level of choice for
patients, it is more important than
ever for dental businesses to stand
out from the crowd. While we of
course all know the value of providing a first-rate customer service,
and that will always remain the
most important factor, how many
of us recognise the importance of
creating and building a brand?
Generally, in dentistry, branding
has not been regarded in the same
way it is in the corporate world,
where multi-national businesses
expand on the strength of their
brands. But now, with the growth of
dental corporates and multi-practice groups, branding is becoming
an increasingly important factor.
That is not to say that branding is
only the domain of the big players.
Creating a brand which is unique
and people can identify, talk about,
recommend to others and remember is just as important for a single
practice, and in some situations

even more so, where there are
other local competitors for existing and potential clients to choose
from.
Effective branding is also important when looking to expand, franchise or sell one’s business. When
dentists are adding another site to
their existing portfolio, doing so
under a brand will enable people
to know who is moving into their
area, and can help give confidence
that this is an established dental
business taking over their local
site. One example being a business in North East England I act
for, the Burgess & Hyder Dental
Group, who now operate 11 clinics
across the region under their
brand. They are welcomed into
each area as their brand is widely
known, as is the quality associated
with it.
Equally in franchising, the importance of a strong brand is crucial to enable a business to thrive
in other areas relies on an existing
strength of reputation. Through
being part of that recognisable

brand, patients will know that
each site under that umbrella will
offer the same levels of service and
quality. Another of my clients,
Damira Dental, has recently rebranded from Aspire Dental Care,
and is pursuing a franchising
model under its new and fresh
identity. The business, which has
14 sites across the South of England, has amassed a strong reputation during its eight years in
operation, and the strength of its
service coupled with its branding
will allow that to be replicated
across the UK.

The creation of a brand identity,
which can help support the expansion of a business, can also be
of great importance when it comes
to selling. It is much easier to market a business which is well known
and has invested time and effort
in standing out from the crowd.
To a potential buyer, they are important factors in instilling the
confidence to take on a site in a new
territory.
In this day and age of dentistry
being an increasingly competitive
business, distinguishing oneself

from the many other players has
never been more important, and is
something that must be given due
consideration.

Amanda Maskery
is one of the UK’s
leading den tal
lawyers. She is
Chair of the Association of Specialist Providers to
Dentists (ASPD) in
the UK and a Partner at Sintons law
ﬁrm in Newcastle. She can be contacted at
amanda.maskery@sintons.co.uk.
AD

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DTUK0315_10_Haque 24.07.15 13:17 Seite 1

10

BUSINESS

Dental Tribune United Kingdom Edition | 3/2015

Online dentistry should be more
active on Facebook
It is commonly accepted that
Facebook is one of the largest and
most important online platforms
in 2015. As it continues to dominate
the social media landscape and
hold a massive captive audience,
the critical question is, are you
utilising Facebook and, if not, why
not?

© nevodka

By Naz Haque, Dental Focus

Early 2015 statistics from We
Are Social established that there
were 1.366 billion active Facebook
users in January 2015, 83 per cent
of whom were accessing Facebook
from mobile devices. Consider
that the average social media user
clocks in 2.2 hours of usage per
day (15.4 hours per week), while
the average daily TV viewing time
AD

them adverts relevant to their
habits. The data gathered from
a pixel can be used to create a
lookalike audience. Facebook will
monitor habits and trends in the
behaviour of visitors to your
pages and then duplicate this on
a larger scale by identifying users
on Facebook who mirror these
habits within the parameters you
set, such as a 5 kilometre radius
of your location.
There is one other trick Facebook
pixel has up its sleeve: it allows
you to upload e-mail addresses
of customers/buyers so you can
specifically target them with adverts too—just make sure you
have their consent.

for a professional is now reduced
to 1.2 hours per day (8.4 hours per
week)—you can see how social
media is driving and changing
people’s habits.
This year, Facebook has been
pushing the Facebook pixel, which
could loosely be compared to
a website cookie. These can be
created from your Facebook business page and then placed into
the coding back-end of your web-

Most websites are now mobile
friendly and most Facebook users
are on mobiles. This increases the
chance of your adverts being seen
even further. The average cost of
a click on Facebook is 27p, you
can send targeted adverts to a
specific qualified audience and
buy data to a mirror audience for
next to nothing, and the return
on investment (£150 + take-home
trays) can be very attractive.
Considering all these points,
I would make use of this oppor-

“Most websites are now
mobile friendly and
most Facebook users
are on mobiles.”
site. The strength of these pixels
is that they recognise visitors
from your website and put you
in a position to display adverts
to this audience via Facebook.
The real beauty is when one fully
recognises the power of the pixel.
Your audience may have found
your website via Google, Bing,
Yahoo!, Yell or word of mouth.
The Facebook pixel tracks them
and any pages they visit on your
site. If a potential customer visits
your tooth whitening page, for
example, you can then show
them tooth whitening adverts.
Or if one looks at an Invisalign
page, you can show them your
Invisalign offer.
Essentially, you first qualify
your audience and then show

tunity as soon as possible in 2015
before everyone else does and
drives up the cost of a click to
something comparable to Google
(a minimum of £2.50+).

Naz Haque, aka
the Scientist, is
Operations Manager at Dental
Focus. He has
a background in
mobile and network computing,
and has experience supporting
a wide range of blue-chip brands, from
Apple to Xerox. As an expert in search engine
optimisation, Naz is passionate about helping clients develop strategies to enhance their
brand and increase the return on investment
from their dental practice websites. He can
be contacted at naz@dentalfocus.com.

[11] => Standard_300dpi

6 Months Clinical Masters Program
TM

in Aesthetic and Restorative Dentistry
8 days of intensive live training with the Masters in Dubai (UAE)

2 sessions, hands-on in each session, plus online learning and mentoring.
Learn from the Masters of Aesthetic and Restorative Dentistry:

Registration information:
8 days of live training with the Masters
in Dubai (UAE) + self study

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

Curriculum fee: €6,900
(Based on your schedule, you can register for this program one session at a time.)

Collaborate
on your cases

University
of the Paciﬁc

and access hours of
premium video training
and live webinars

you will receive
a certiﬁcate from the
University of the Paciﬁc

Tribune Group GmbH is the ADA CERP provider. ADA CERP is a service
of the American Dental Association to assist dental professionals in
identifying quality providers of continuing dental education. ADA CERP
does not approve or endorse individual courses or instructors, nor does it
imply acceptance of credit hours by boards of dentistry.

100

C.E.

CREDITS

Tribune Group GmbH i is designated as an Approved PACE Program Provider by the
Academy of General Dentistry. The formal continuing dental education programs of this
program provider are accepted by AGD for Fellowship, Mastership, and membership
maintenance credit. Approval does not imply acceptance by a state or provincial board of
dentistry or AGD endorsement.

[12] => Standard_300dpi

DTUK0315_12_14_Goyata 24.07.15 13:18 Seite 1

TRENDS & APPLICATIONS

12

Dental Tribune United Kingdom Edition | 3/2015

Anatomical pin: A clinical case report
By Profs. Frederico dos Reis Goyatá & Orlando Izolani Neto, Brazil

2

1

5

4

8

Endodontic treatment of teeth
with significant coronal destruction is a very common clinical procedure in the restorative clinical
practice. When we are faced with
this clinical situation, there will be
an eminent need for the use of
intra-radicular retainers to obtain
greater stability and retention of
the restoration to the remaining
teeth.1, 2
The use of an anatomical pin is
proposed for the rehabilitation

6

9

7

10

of anterior teeth with extensively compromised root canals
and with significant loss of dentine tissue.3 In this restorative
method, in addition to the fibreglass pin, a compound resin is
used to model the radicular conduit with the objective of reducing the space that would be filled
by the resin cement.
In this way, the combination
of two restorative materials (pin
and compound resin) will serve

and behave biomechanically as
a replacement of the dentine
structure lost.4
Anatomical pins have an extremely favourable prognosis in
cases of fragile roots due to loss
of dentine structure and they
contribute significantly to the rehabilitation of the tooth in terms
of both masticatory function and
aesthetics.5 In addition, the fibreglass pins have a more uniform
distribution of tension in the

13

12

15

3

16

11

occlusal and radicular regions
compared with metal pins.6 Etching and silanisation of the pins
are of the utmost importance for
promoting interfacial adherence,
especially in the region prepared
for the core.7, 8
This study reports on a clinical
case that demonstrates the
preparation technique for the
anatomical pin, using fibreglass
pins and compound resin, in
a maxillary central incisor with

14

17

18

weakened roots, with the objective of re-establishing the coronal
portion of the tooth.

Case report
A young male patient came
into the integrated dentistry
clinic at Universidade Severino
Sombra needing restorative
treatment of tooth #21. In the
clinical and radiographic examination, significant coronal destruction and satisfactory en-

[13] => Standard_300dpi

A 4 day course “Soft Tissue surgery and Regeneration
in Periodontology and Implantology”
21-24 October 2015, a total of 4 days in Dubai (UAE)

On location session with hands on practice
under the Masters’ supervision.

24
C.E. CREDITS

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[14] => Standard_300dpi

DTUK0315_12_14_Goyata 24.07.15 13:19 Seite 2

TRENDS & APPLICATIONS

dodontic treatment were noted
(Figs. 1–3).
Restoration with an anatomical pin was proposed to the pa-

Dental Tribune United Kingdom Edition | 3/2015

tient, in order to recover the function and aesthetics of the tooth
and provide for future rehabilitation of the tooth with a full
ceramic crown.

First, the decayed tissue was
removed from the remaining
tooth structure and the fibreglass pin was selected (Exacto
# 3, Angelus), as well as the ac-

cessory pins (Reforpin, Angelus;
Fig. 4).
The radicular conduit was isolated with mineral oil and the compound resin was applied (Fill Magic
NT Premium, Vigodent/COLTENE)
over the remaining tooth with
the aid of a #1/2 Suprafill spatula
(SS White; Figs. 5 & 6).
After filling of the conduit with
resin, the Exacto pin and the presilanised accessory pins (Silano,
Angelus) were inserted with the
application of an adhesive (FusionDuralink, Angelus; Figs. 7–9). Next,
the initial photoactivation was
conducted on the pin and resin for
20 seconds.

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ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providersof continuing dental education.
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Finally, the coronal reconstruction was performed with the
previously used compound resin
in incremental portions and
photoactivation was conducted
(Figs. 10 & 11).
A marking was made on the
most incisal portion of the pins to
guide the subsequent cropping of
the pins (Fig. 12). The anatomical pin
was then removed and the final
photoactivation was performed
for 40 seconds (Fig. 13). Soon after,
the pin was adapted to the remaining coronal structure (Fig. 14).
After the preparation phase of
the anatomical pin and coronal
portion of the core with compound resin, preparation for adhesive cementation to the remaining tooth began (Fig. 15).
Acid etching of the pin was
performed for 30 seconds, and
then it was washed and dried. The
silane was then applied (Silano)
for 20 seconds, as well as the
adhesive (Fusion-Duralink) with
subsequent photoactivation for
20 seconds (Figs. 16–18).
After the anatomical pin had
been prepared, acid etching was
performed on the remaining tooth
for 20 seconds, followed by washing and drying it lightly to leave
the dentine moist (Fig. 19). The
dentine primer and the adhesive

(Fusion-Duralink system) were
applied and then photoactivated
for 20 seconds (Fig. 20).
The cementation was done
with auto-polymerisable resin cement, waiting a period of 5 minutes for the cement to chemically
set (Figs. 21 & 22). Once the cementation of the anatomical pin was
finished, the adhesive was applied to the coronal portion and
photoactivated for 20 seconds,
and the compound resin was applied in incremental portions for
creation of the core (Figs. 23 & 24).
In order to complete the restorative process, the prosthetic
preparation of the core was performed for future seating of a full
ceramic crown (Fig. 25).

Conclusion
The anatomical pin constituted
a clinical alternative for coronal
and radicular reconstruction of
endodontically treated teeth with
significant destruction of dentine.
In addition to rehabilitating the
tooth, this clinical approach promotes a more balanced distribution of masticatory forces without compromising the remaining
tooth structure, minimising the
risk of radicular fracture.
Moreover, this restorative alternative provides the possibility
of an aesthetic result with the use
of a metal-free full crown.
Editorial note: A complete list of references
is available from the publisher.

Prof. Frederico dos Reis Goyatá is a Level I
adjunct professor and co-ordinator of
the dentistry programme at Universidade
Severino Sombra in Vassouras in Brazil.
He is also co-ordinator of the graduate programmes (improvement and specialisation
in prosthetic dentistry) at the Escola de
Aperfeiçoamento Proﬁssional (professional
development school) of the Associação
Brasileira de Odontologia (Brazilian dental
association) in Barra Mansa in Brazil.
Prof. Orlando Izolani Neto is a professor in
the integrated clinic of the dentistry programme at Universidade Severino Sombra.

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DTUK0315_15-16_Strom 24.07.15 13:20 Seite 1

Dental Tribune United Kingdom Edition | 3/2015

TRENDS & APPLICATIONS

Going (unintentionally) green
The unexpected bonus of switching to CAD/CAM and same-day dentistry
By Dr Joel Strom, USA
With dentistry as innovative and dynamic as it is, the progress made and
the exciting new trends that result
are often judged in terms of the technological or financial: We can update
our equipment to have a purely digital
office, or we can adopt new practices
and offer new procedures to our patients that bring in extra revenue.

that patients are not at risk for increased sensitivity or leakage while
wearing sometimes uncomfortable
provisionals for weeks. Finally, definitive restorations are fabricated
and placed within hours of scanning
and can be adjusted immediately, so
patients no longer have to wait for
that perfect laboratory restoration.

While these accomplishments are
certainly laudable, it is time for dentistry to measure its progress by different standards, ones that affect the
profession and the world as a whole.
In short, we can examine how our
practices and procedures influence
the environment and what dentistry
as a profession can do to ensure this
influence remains positive.

Clinicians, too, reap several benefits. Digital scans equal easier
“impressions” that enable accurate
reproductions of patients’ dentition.
Restorations can be designed in the
office without communication or
transfer to a dental laboratory, eliminating back-and-forth exchanges
that cause delays or less than optimal results. In fact, restorations can
now be fabricated with more patient
input, since intuitive CAD software
enables dentists to easily design
restorations on-screen while remaining chairside, providing patients with that “wow” factor as they
see what digital technology is allowing dentists to do. Once designed,
the restorations can be immediately

Fortunately, dental professionals
no longer have to choose between
advances in technology and what
is considered “eco-friendly.” In fact,
practice owners can assure themselves of the best of both worlds by
adopting digital technology, such
as in-office CAD/CAM systems such
as the Planmeca PlanScan
System (E4D Technologies).
While the practical and financial benefits of CAD/CAM
technology are well established, the environmental
benefits—though discussed
less often and perhaps not as
well understood—abound.

CAD/CAM: Why
dive into digital?

technology find that streamlined
procedures and happier patients lead
to a significant return on investment.
But switching to a CAD/CAM system provides an unanticipated bonus, one with a far broader impact.
Using an in-office CAD/CAM system is
one of the most environmentally conscious upgrades a practice can make,
offering both concrete and intangible
benefits for dental practices, their patients and the greater community.
CAD/CAM systems add to a practice’s green image with the many
small changes they allow the office
to implement. For example, now that
impressions are taken with a digital
scanner (PlanScan), traditional impressions—and all their associated
materials, such as disposable impression trays, impression material
and the water with which it is
mixed—are no longer necessary.
Clinicians who thought they were
only saving money (and storage
space) can rest easy at night knowing
they’re no longer contributing to the

An average dental practice uses 360 gallons of water per day. Think how much you
can save by getting rid of extra washing cycles.

methods adds up. Using digital technology not only streamlines the
process but ensures that materials,
time and money aren’t wasted.
Moreover, because traditional impressions aren’t needed with a digital workflow, equipment previously
used to perform these procedures,
such as a mixing gun for impression
material, are also no longer necessary.
While clinicians may think
they are only saving themselves hassle or time by purchasing an easier-to-use piece
of equipment, they’re also
saving energy—literally. With
digital technology, impression-taking instruments no
longer need to be run through
a wash cycle and sterilized. This
saves time, energy and water.

While it seems like saving
resources, particularly water,
isn’t possible in dental practices, small steps such as
these really add up. The EcoDentistry Association (EDA)
(www.ecodentistry.org) estimates that dental practices use
360 gallons of water per day.
This totals 57,000 gallons of
water per year, per practice. In
the United States alone, dental
practice water usage totals approximately 9 billion gallons
of water per year. This does not
even include dental laboratories, which must use substantial
amounts of water when mixing
and pouring models in stone
Switching to digital systems is beneﬁcial not only to clinicians and patients but to the environment as well. and cleaning their equipment.

Though not ubiquitous, digital technologies, particularly
in-office CAD/CAM systems,
are making their presence
known. Dental professionals who integrate these advanced technologies can offer
sameday dentistry to their
patients; that is, they condense
the restorative process of
multiple appointments over
several weeks down to one
appointment lasting a few
short hours. Clinicians can digitally scan the patient’s teeth
and design the restoration(s)
right then and there. Once approved, the restoration(s) can
be milled and seated immediately. Essentially, in-office CAD/CAM
systems are revolutionizing how
restorative dentistry is practiced.
This CAD/CAM revolution provides almost innumerable benefits
to patients. Multiple appointments
for one restoration become nonexistent, so patients no longer need
to make multiple trips to the dental
office. Digital scans eliminate the
need for messy, uncomfortable impressions that make patients gag
and are prone to errors. Temporary
restorations are no longer necessary,
removing that extra step from the
restorative process and ensuring

milled in the office and tried in the
patient’s mouth, so a perfect fit and
high-quality aesthetics are affirmed
at the same appointment.

Digital practice equal
green practices
Since CAD/CAM technology was
first introduced decades ago, early
adopters and technology enthusiasts have encouraged integration of
these systems for various practical
and financial reasons. Though generally a substantial initial investment,
practices that upgrade to digital

throwaway, disposable culture in
many health-care offices.
Additionally, because digital impressions can be viewed instantly
with software that allows users to see
potential errors, any mistakes are
quickly averted with a second digital
scan that requires no extra materials
or waste. It is not uncommon for dentists to take a second traditional impression because of errors caused by
saliva or air pockets in the impression
material or to have a backup on hand
in case there are problems down
the road. Over time, material waste
created using traditional impression

In addition to the above in-office
water issues, along with laboratories
and their respective procedures
that will always require water, these
staggering statistics spell out the
clear need for water conservation
whenever possible, and in-office
CAD/CAM supports this effort.

Greener materials:
Using all ceramics
instead of amalgam
Amalgam restorations had been
the standard of care in restorative
dentistry for decades. With material

science advancements, however, there
are new contenders for that title.
In particular, the use of all-ceramic
materials has significantly increased
in recent years, and when coupled
with in-office CAD/CAM systems,
their advantages are economical and
ecological, in addition to aesthetic,
biocompatible and functional.
The majority of the materials for
same day CAD/CAM dental procedures are generally composite or allceramic blocks, so there is no metal involved. These metal-free restorations
can often be used without reservation
for various indications, including
single-unit restorations, inlays and
onlays.1 While the benefits of these
materials have been expounded upon
(e.g., aesthetics, ease of use, wear, optical properties.), they provide tangible
environmental benefits as well.
For example, the longevity of allceramic restorations such as in-office
CAD/CAM designed inlays is well
documented.2 In addition to a highly aesthetic restoration, patients receive restorations that will last for
many years, without the concerns
associated with amalgam, such as
cracks, failures or potential mercury
toxicity. This potentially saves patients and clinicians time, money
and wasted resources that would be
spent traveling to and from the dental practice, taking more impressions
and fabricating new restorations.
Perhaps of greater consequence
is removing toxic metal from this
equation. All-ceramic and metal-free
restorations mean that dental practices no longer have to worry about
amalgam disposal and its accompanying mercury toxicity.
The Environmental Protection
Agency (EPA) estimates that nearly
50 per cent of all mercury entering
local wastewater treatment facilities
originates in dental offices.
Using CAD/CAM compatible materials such as all-ceramics lessens
or eliminates the contribution of
your dental office to environmental
mercury. It also means that dental
practices needn’t worry about using
an amalgam separator.

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DTUK0315_15-16_Strom 24.07.15 13:20 Seite 2

TRENDS & APPLICATIONS

16
Currently, the American Dental
Association (ADA) does not have
national regulations in place for
amalgam separators, so many dental practices and laboratories aren’t
compelled to use them.
Although designing and milling
all-ceramic materials still requires
energy and results in some waste
materials, can they really compare
with the toxic by products of metalbased restorations?
AD

Crunching
the numbers:
CAD/CAM math
In-office CAD/CAM systems provide more than just a clear conscience about saving the environment. There are real, tangible
benefits and savings that can easily be estimated to demonstrate
the immense value of this digital
technology.

Because same-day in-office
CAD/CAM dentistry reduces the
number of appointments from
two (or possibly more, if the restoration does not fit) to one, it stands
to reason that every dentist who incorporates these procedures would
positively impact the environment
by reducing the number of automobile trips patients make to the
practice. This would result in a
50 per cent reduction in gasoline
and oil product use.

Dental Tribune United Kingdom Edition | 3/2015

With a carbon content of 2,421
grams, one gallon of gasoline produces approximately 19.4 pounds
per gallon of carbon dioxide emissions. This is calculated by multiplying the carbon content (2,241) by
the amount of carbon that remains
unoxidized (0.99) by the ratio of the
molecular weight of CO2 (44) to the
molecular weight of carbon (12).
Using the state of California as an
example, where approximately 10 per

cent of the 100 million laboratory
dental restorations are completed in
the United States every year, we can
calculate an approximate savings. If
four gallons of gasoline are used for a
round trip to the dentist, a restoration
needing two appointments to complete would require eight gallons of
gasoline. But if these dental practices
adopted same-day in-office CAD/CAM
dentistry, that number could be cut in
half, saving four gallons of gasoline per
restoration. Four gallons of gasoline
multiplied by 10 million restorations
would equal a savings of 40 million
gallons of gasoline for restorative procedures in the state of California alone.
This, in turn, would equal a reduction
of carbon dioxide emissions by 776
million pounds per gallon each year
(assuming the previously calculated
19.4 pounds per gallon measurement).
If we extrapolate to the United
States as a whole, we can calculate that
this would equal 400 million gallons
of gasoline saved and 7,760 million
pounds per gallon of carbon dioxide
emissions eliminated, per year. This
would all be due solely to a reduction in
patient automobile trips to and from
the dentist for restorative procedures.
While same-day dental procedures
may not save the world, their potential
impact, even estimated, is undeniable.

Conclusion
In-office CAD/CAM systems’ advantages are limitless. In addition
to the clear financial and practical
benefits they bring, their positive
impact on the environment makes
the decision to upgrade even better.
They remove toxic, wasteful and
disposable materials and practices
from the equation, replacing them
with greener practices that have a
tangible influence. While the clinical
advantages of CAD/CAM systems and
same-day dentistry continue to be
rightfully celebrated, their ecological
advantages should not be overlooked.
Editorial note: This article was published
in CAD/CAM c.e. magazine No. 01/2014.

References
1. Della Bona A, Kelly JR. The clinical success of
all-ceramic restorations. J Am Dent Assoc.
2008;139:8S–13S.
2. Sjogren G, Molin M, van Dijken JW. A 10-year
prospective evaluation of CAD/CAMmanufactured (CEREC) ceramic inlays cemented with a chemically cured or dualcured resin composite. Int J Prosthodont.
2004;17(2):241–246.

Dr Joel Strom is a
former president
of the California State Dental
Board and former course director of “Ethics
in the Practice
of Dentistry” at
USC School of
Dentistry. He graduated from UOP
School of Dentistry in 1979 and completed an NIH post-doctoral fellowship
at Columbia University in 1983. He has
owned an E4D milling machine and
camera for ﬁve years and practices
general dentistry in Beverly Hills and
provides consultation and litigation
support in the dental health area, including corporate clients, governmental agencies and individual dentists.

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DTUK0315_17-18_ITAlani 24.07.15 13:23 Seite 1

IMPLANT TRIBUNE
The World’s Implantology Newspaper · United Kingdom Edition
www.dental-tribune.co.uk

Published in London

Vol. 9, No. 3

Dental implantology: Evolution
or the road to ruin?
By Aws Alani, UK
Teeth are highly evolved structures
that have developed progressively
over millions of years in attempts to
protect themselves from caries and
periodontal diseases. Over the years,
many advances have been made that
can treat these various diseases predictably. Various strategies have been
developed to prevent or slow down
these problems given adequate patient compliance and appropriate
personal and professional maintenance.
Despite these very significant improvements, there are still instances
when patients are advised that one
or other tooth has to be extracted.
It is the obvious sadness, heartache
or despair that patients are caused by
this bad news that has driven, caring

clinicians to find ways to replace
teeth with various devices, including
dentures, bridges and implant-retained prostheses.
P.-I. Brånemark, now sadly deceased, famously quipped: “No one
should have to die with their teeth
in a glass of water beside their bed.”
His original inspiration coupled
with determination, intuition, passion and an ability to surround
himself with a great team of individuals with differing skills made
osseointegration much more predictable. Brånemark’s landmark
studies changed prosthetic dentistry
dramatically, but a careful look at
the design of these protocols and the
implants themselves reveal that they
were hugely different to the patient
selection protocols and the types of
implants being placed today.

Furthermore, the restorations supported on them were made of the established materials then and obeyed
traditional mechanical laws. In terms
of biological cleanability, the metal,
polished “high water” abutment design
allowed for optimal interproximal
cleaning, while the implant surface itself was also relatively smooth in comparison with the rougher surfaces we
often see today. Market saturation,

cost, profit and market share in many
technology-driven markets often pursue innovation of some sort of change
to help gain greater market share or
profit. The over-commercialisation of
dentistry generally creates a constant
turnover of supposedly new and better
products, where the common notion
of “if it ain’t broke don’t try to fix it” is
lost on many directors of marketing or
increasingly profit-driven CEOs.

Why and where?
Where this technological change
has taken implantology and what
the real reasons are that this was and
is happening need to be examined.
Increasingly, the shadow of periimplantitis looms likes a spectre
over the provision of implants. Unlike caries or periodontal disease,
there is very little consensus or reAD

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DTUK0315_17-18_ITAlani 24.07.15 13:23 Seite 2

IMPLANT NEWS

Implant Tribune United Kingdom Edition | 3/2015

search that can provide a predictable
cure for what now is now a new breed
of disease. Peri-implantitis is relentless once established within fine
threads of the implant, and the bone
resorption and soft-tissue problems
that follow can result in spectacular
problems. Part of the key issue probably lies in the surface exposed to
the susceptible patient’s oral environment, as most microbiologists
will allege. The bacterial content and
make-up of the biofilm is a reflection of the surface on which it resides. Implant surfaces have become
progressively rougher in order to
hasten the early osseointegration
processes and to try to provide patients with their restoration quicker
in an ever more competitive financial environment.
However, speed is not always helpful. Experience shows that some
things are better achieved gradually.
Once exposed to the environment
of a susceptible patient, the macrotopography of the threads provides
an ideal ecological niche for bacterial
proliferation. Further nano-level
features make the implant surface

Ethical, moral
and legal issues
These problems become much
more worrying when viewed from
ethical, valid consent and medicolegal perspectives. This is particularly
so when patients are convinced to
undergo elective extractions of teeth
that often seem reasonably intact or
treatable with conventional proven
treatment strategies.

a veritable inflammation super
highway for the pathogenic organisms. Predictably enough, the microorganisms found on the rough
surface are usually the common
pathogenic ones, but also some
species are found that have previously never been discovered in the
oral cavity.

Patient selection issues
We need to consider the types of
patients whom we are now accepting for implant provision. At King’s
College Hospital, the criteria for statesponsored implant provision largely
involve patients with hypodontia
and those who have suffered trauma.

Usually both cohorts are likely to
present with well-maintained, minimally restored dentition or with scope
for oral health improvement prior
to consideration for any restoration,
let alone an implant. Unfortunately,
we are unable to provide this treatment for smokers.
This is in stark contrast to the patients
who may be provided with implants
in general and specialist practice, such
as patients who are likely to have lost
teeth as a result of plaque-associated
diseases. Indeed, it could be considered
a paradox by many interested observers that some clinicians are providing
patientswithimplant-retainedrestorations when they have shown that they
are highly prone to plaque-associated
disease via tooth loss and have not
demonstrated any real capacity for
changing that. Patients who smoke,
those with a history of periodontitis
and those with poor oral hygiene are
well known to be at a very significantly
higher risk of peri-implantitis.

The Dental Tribune International
C.E. Magazines
www.dental-tribune.com

Biological versus
mechanical problems

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If we are being frank, the pathogenic
bacteria-induced diseases are not the
only long-term problem that we are
now seeing. The reported frequency of
mechanical complications has risen
over the years, but the reported problems are probably only the tip of the
iceberg, as many complications have
not and will not be reported for a
variety of understandable reasons.
Over time, the components of implants have shown notable weaknesses. Screw loosening, fractured
screws, loose abutments and the cracking of ceramic can be laborious and expensive to manage. One aspect, which
may be lost on some, is that since they
lack a periodontal ligament dental implants cannot and will never be able to
acclimatise to changing occlusal and
non-axial forces. These are very likely to
create stresses within the masticatory
system, thereby resulting in breakages.
These forces are compounded greatly
if patients exhibit parafunction on
a daily basis and that is sometimes an
unknown risk factor until it is too late.
The more implants that are placed, usuallythefewerteetharepresent,resulting
in a net reduction in physiological feedback and thereby creating an increased
chance of failure of some type.

It appears that there is a worrying
drift towards aggressive treatment
with extractions in order to provide
a supposed full-mouth rehabilitation
with multiple implants. The increasingly dubious practice of sacrificing
teeth for the sake of implants appears
to many concerned clinicians to be
quite irrational. As ethical oral health
practitioners, deliberately removing
saveable teeth for prosthetic replacement using implants as support appears to be consciously flying in the
face of increasingly apparent evidence of various complications with
implants and many would consider
that approach to be foolish. How
many “implantologists” doing that to
others would genuinely have it done
to themselves or done to some close
family member?

Planned obsolescence
A state-of-the-art implant today is
likely to be obsolete tomorrow. Electively removing teeth is irreversible
and replacing teeth with implantretained devices means that patients
are trapped in the era of the implantology in which these were placed and
restored, that means issues of machining, surface blasting, roughness,
platform switching, design and attempts at bone augmentation by
cow, coral or Californian substances.
The list goes on and on and will probably continue to expand with what
many might consider human experimentation without licence.
Now comes the time for implant
manufacturers to take stock of their
many “market-driven” mistakes, including fast initial integration with
the roughest possible surfaces. Instead
they need now to produce proven
(i.e. not speculative) designs to better
prevent these well-known problems
of infection and breakage.
A wiser, pragmatic approach appears to be to concentrate everyone’s
efforts on saving teeth and thereby eke
out their usefulness for the patient’s
lifetime. Recently, the legendary Prof.
Jan Lindhe, interviewed in the British
Dental Journal, summarised the state
of play as follows: “There is an overuse
of implants in the world and an underuse of teeth as targets for treatment.”

Aws Alani is
a Consultant in
Restorative Dentistry at Kings
College Hospital
in London, UK,
and a lead clinician for the
management of
congenital abnormalities. He can be contacted at
awsalani@hotmail.com.

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DUTK0315_19_OsstellStraumann 24.07.15 13:24 Seite 1

Implant Tribune United Kingdom Edition | 3/2015

IMPLANT NEWS

Managing patients with risk factors
By DTI

values to help guide treatment decisions and as a communication tool
with our referring dentists.”

GILLINGHAM, UK/GOTHENBURG, Sweden:
Requests for shorter treatment times
along with an increasing number of
patients with risk factors place greater
demands on dentists and technology.
Correctly assessing osseointegration
and implant stability and is key in
successful implant treatment. Using
traditional methods such as torque
and percussion tests are not suitable
for monitoring osseointegration, it
requires a more advanced diagnostic
tool.
Gain insight from these esteemed
periodontists on what they do to objectively and noninvasively identify
which implants are ready to load and
which ones need additional healing
time.

Dr Paul Rosen, Clinical Professor of
Periodontology & Oral Implantology
Temple University Kornberg School
of Dentistry in Philadelphia, USA,
also explains below why Osstell is
important in his practice.

Dr Pamela K. McClain

Dr Rachel Schallhorn

Drs Pamela K. McClain and Rachel
Schallhorn, both Diplomates of the
American Board of Periodontology,
have been using Osstell and the ISQ
scale (Booth 43d) for a number of years
now to measure primary implant
stability and osseointegration.

plant stability,” they say. “At the time
of placement if the ISQ is too low (depending on the location—anything
below 45) we will remove the fixture,
possibly graft and then wait another
3–6 months before trying to place
another fixture. We try to take the
measurement on the buccal/lingual,
and mesial/distal aspects and record
the highest and lowest values.”

is stable if the number was high to
begin with—over 65) we will release
the patient for restorative treatment.
It gives us and the patient a more
objective way to assess the implant
stability. If it’s not ready at that time
we continue to recheck every six

“We are currently using Osstell
when we place all implants to establish a baseline measurement of im-

McClain and Schallhorn add: “We
typically recheck the ISQ value at three
months. If the ISQ has improved (or

“THE REVU”
launched by
Straumann

By DTI
CRAWLEY, UK: To facilitate online
communication within the implant
industry, Straumann has recently
launched a new digital hub for dental
professionals in the UK and Ireland.
With a look of a stylish digital magazine, the THE REVU platform will feature news and clinical cases, among
other content covering everything
from the dentistry industry and marketing to business and education.
According to Straumann, THE REVU
is taking an original approach to blogging and video blogging (vlogging),
delivering the perfect combination of
branded and non-branded editorial
and video content. The platform will
launch with interactive questions and

Dr Paul Rosen

weeks until the ISQ has improved or
indicates stability.”
“Since we began using this device in
2009, our decision making process
has become more simple and objective. We will continue to use the Osstell

“Osstell use is critical for my implant practice. Every year, this device
more than pays for itself as there
are always several patients who heal
slowly or who have implants placed
with extremely low insertion torque.
This confounds my ability to predict
when healing has been adequate to
proceed to the restorative phase.
Osstell provides me with quantitative information necessary to make
informed decisions. No longer am
I the villain who slows up patient
care, but it is objective data about the
patient’s healing that becomes the
determining factor.”
AD

FDI 2015BANGKOK
Annual World Dental Congress
22 - 25 September 2015 - Bangkok Thailand

answers, scientific
reviews and an inside look into one
clinician’s journey
into implants. It will
tell a different story
every day by bringing new and informative content
to the fore in a clear
and simple manner, Straumann’s
Head of Marketing
and Business Development in the UK
and Ireland, Justin Annett, said.
“The launch of THE REVU is a fantastic opportunity to transform the
way we communicate online. Our
aim is to build an online community
that embraces not just our company
values, but all dental professionals
connected with implant dentistry
too,” he commented at the launch.
“Taking the leap into digital is
courageous, but one which we feel
continues to keep us at the forefront
of both our and our customers’ marketing activities.”
Dental professionals can access
the site via their computer, laptop or
mobile device at www.therevu.co.uk.

www.fdi2015bangkok.org
www.fdiworldental.org

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TRENDS & APPLICATIONS

Implant Tribune United Kingdom Edition | 3/2015

Peri-implantitis: Is it a crisis?
By Dr Michael R. Norton, UK
this condition is often asymptomatic to the patient and as such
is typically only diagnosed at
routine recall. Hence there is a
need to recognise that when implant treatment is completed the
patient should remain on annual
reviews for at least the first five
years, and thereafter once every
two years.
On presentation with mucositis
a combination of mechanical
debridement and sub-mucosal decontamination and antimicrobial
therapy are indicated. The treatment should be repeated three
times within a two week period, socalled Triple Therapy (Norton M).

In the US over 500,000 implants are
placed each year, whilst in the UK
that figure was around 140,000 for
2010. The prevalence of peri-implantitis has been reported to be up to
29 per cent 1 most notably in patients
whose implants are placed within
a partial dentition. This yields a
potentially vast number of implants,
possibly as many as 185,000 in the
US and UK alone that might succumb to some form of peri-implant
disease on an annual basis.
The bacteria found within periimplant lesions are similar to
those found in deeper periodontal
pockets,2, 3 and cross infection by
periodontopathogens as a primary
aetiology has been implicated as
a possible pathway. However the
wide variety of implant designs,
surfaces etc. make the treatment
of peri-implantitis much less predictable and subject to much
greater variability than periodontal disease, where natural teeth
present a known anatomy and well
defined surface structure.
In 2008 a systematic review4
of the literature regarding periimplantitis using PubMed and the
Cochrane library revealed little
consensus on the treatment of this
troublesome condition. One study
reported on the efficacy of submucosal debridement using ultrasonics or carbon fibre curettes5,
while two others compared the
effect of an Er:YAG laser against
that of mechanical debridement
and 2 % chlorhexidine as a combined therapy.6, 7
The first found similar results
between laser and combined therapies, while the second concluded
that the laser effect was limited to
a six month period. A further study
compared combinations of oral
hygiene instruction, mechanical
debridement and topical minocycline with a similar regime which
substituted 0.1% chlorhexidine as the
antimicrobial.8 The former seemed
to confer some benefit while the
latter showed limited or no clinical
improvements. Finally, a study comparing two bone regeneration proce-

dures reported clinically significant
improvements mediated by both.9
Nonetheless a multitude of
other studies have also been published reporting on the efficacy
of tetracycline10, CO2 laser11, and
photocatalytic decontamination
amongst others in the treatment of
peri-implantitis.12 Such a plethora
of therapies makes it difficult for

yet this has been a consistently
cited risk factor in many other
studies. Indeed in a study published
in the Swedish Dental Journal in
2010, the percentage of implants
with peri-implantitis was significantly increased for smokers compared to non-smokers (p = 0.04).14
Other factors that have been
implicated include excess cement,

the clinician to choose a regimen
that is both within the reach of the
average clinician and has some
documented reliability.

Risk factors
There have been a number of risk
factors cited for peri-implantitis.
Recently, in a study published in the
Journal of Clinical Periodontology,
a clear association was demonstrated through multi-level statistical analysis between risk of periimplantitis and location, specifically the maxilla, while overt periimplantitis was shown to be highly
correlated to patients with a predisposing history of periodontitis,
and being male.13 Surprisingly in
this particular study no correlation
was demonstrated with smoking,

poor oral hygiene, and prosthesis
design which are of course interrelated with some prostheses
making effective oral hygiene untenable, while others present deep
margins that make removal of excess cement almost impossible.

Warning signals
Peri-implantitis rarely presents
unannounced unless of course
the patient fails to be placed on a
regular recall programme or fails
to attend for regular review. Early
signs are often apparent in the
form of peri-implant mucositis.
This condition is characterised
by mucosal oedema, rubor and
bleeding on probing (BOP). By
definition it is not associated with
purulence or bone loss. However

The protocol is as follows:
1. Mechanical scaling of implant
surface with titanium or carbon
fibre curettes.
2. Sub-mucosal irrigation with 5–10 ml
chlorhexidine (0.2 %) per site, at
the deepest level of the pocket on
all sides of the implant.
3. Application of Minocycline Gel
2 % (Dentomycin, Henry Schein
Ltd) at the deepest level of the
pocket on all sides of the implant.

However once peri-implant mucositis has taken hold it is unfortunate that it is often exacerbated
by the design of implants today.
The presence of a rough surface,
taken to the top of an implant, and
the application of microthreads
or grooves have been proposed as
potential confounding factors for
the advance of the lesion due to
biofilm formation and bacterial
contamination of the surface which
leads to bone loss and further surface exposure. With advancing
bone loss it often results in colonisation of the deeper pockets with
well known periodontopathogens
and infection ensues. This then is
peri-implantitis.
Peri-implantitis is characterised
by the presence of vertical or crater-

like bone defects and spontaneous
purulence and bleeding on palpation (Figs. 1 & 2). It is typically
associated with deep peri-implant
pocketing > 5mm.
This condition is undoubtedly
of increasing concern due to some
principle factors, such as the almost exclusive use of roughened
implant surfaces, the treatment
of partially dentate patients with
a history of periodontal disease,
the placement of implants with
inadequate bone volume resulting
in facial dehiscences, as well as the
use of cement retained prostheses.
Implants with a micro-roughened surface texture have presented excellent long-term data
and until recently there has been
very little published in the literature demonstrating a susceptibility of these surfaces to this condition. However recent work by
Albouy et al 15, 16 has received widespread attention with concern for
the evidence that suggests some
modern micro-textured surfaces
may be completely resistant to
decontamination.16
Ultimately, if left unchecked and
untreated, it may become impossible to arrest the condition, leading
to wholesale failure of the case
(Figs. 3 & 4). Such failures impose a
tremendous strain and burden on
the clinician (let alone the patient),
destroying the confidence of a patient who has endured significant
expense and trauma and occasionally results in a breakdown of communication between both parties
that all too often sadly results in a
legal claim of negligence. Such claims
can be hard to defend for patients
where no warnings and/or supportive periodontal/peri-implant
therapy have been undertaken.
Treatment typically requires
surgical access to excise any fibrous capsule and for direct access
to the implant for surface decontamination. The author’s preference
until now has been to use chlorhexidine and tetracycline solution
for this purpose while others have
reported the use of citric acid and
hydrogen peroxide amongst others.17 The use of lasers has also been
extensively reported.6, 7, 18–20 However in a recent systematic review a
meta-analysis could only be done
for Er:YAG laser as the literature on
all other laser types was weak or
heterogenous.21
The author has recently completed the acquisition and treatment
of 20 patients in an efficacy study
using Er:YAG water laser (Morita,
AdvErl Evo) and it is hoped that
publication of the results will be
forthcoming. Indeed promising
data has already been published to
date using this same machine.22, 23
Nonetheless this methodology
remains outside the reach of most
general practitioners and has yet to
be proven predictably effective. As
such most attention therefore remains focused on physical debridement via surgical intervention and
topical antimicrobial therapies.

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Implant Tribune United Kingdom Edition | 3/2015

Open flap debridement, defect decontamination, and repair as well as
pocket elimination have all become
the mainstay of those treating this
condition.
So is there a crisis? The problem is
that there is no clear consensus on
the prevalence of the disease since
this will vary according to the cut off
values for the clinical parameters
measured24 and to date there appears
to have been little consensus of these
cut off values. As such estimates of
incidence of the disease appear to
vary from 28 to 56 per cent of subjects
and 12 to 43 per cent of implant sites.25
Furthermore there is an ongoing
controversy about the initiating
process of peri-implant disease since
it is potentially considered a primary
infection of periodontopathic origin
by some26 while others hold that it is
a secondary opportunistic infection
subsequent to bone loss caused by
other etiological factors27 such as
a provoked foreign body reaction or
iatrogenic dehiscence of the bone,
exogenous irritants such as dental
cement, bone loss through occlusal
overload etc. If the latter is true then
controlling the disease is theoretically made more simple by controlling the conditions for the implant,
such as ensuring adequate buccal
bone thickness, avoiding or controlling more carefully the use of dental
cement, and paying closer attention
to the occlusion.
In an effort to gauge the rate of
mucositis and peri-implantitis requiring surgical intervention, the
author audited his patient pool in the
year 2014. Out of a total of 191 patient
reviews constituting 795 implants
only 15 patients (7.9 per cent) required triple therapy at 20 implants
(2.5 per cent) for mucositis while
10 patients (5.2 per cent) required
surgical decontamination at 10 implants (1.3 per cent).
As can be seen this is well below
the figures proposed in the article
by Zitzmann & Berglundh (2005).25
This may of course reflect a more
liberal approach to cut off values
for parameters such as pocket depth
and bleeding on probing as proposed
Klinge in 2012.
Nonetheless after over 20 years
running a practice dedicated to implant dentistry the author’s own
audited failure rates indicate that
less than 1 per cent of implants present as late failures, owing to periimplantitis or fixture fracture as a
result of bone loss. This would corroborate the findings by Jemt et al
in which a cohort of patients already
diagnosed with peri-implant bone
loss showed a slow rate of additional
progressive bone loss over a 9-year
follow-up with an implant failure
rate of 3 per cent.28
In all likelihood it is the author’s
view that peri-implantitis is only a
crisis if we allow bad implant dentistry to persist where there is a lack
of control of the initiating factors as
described above, and that it is more
rather than less likely that it is the
result of a secondary opportunistic
infection rather than a direct suscep-

TRENDS & APPLICATIONS

21

“...there is no clear consensus on the
prevalence of the disease...”
tibility to primary infection of periodontopathic origin. However, there
will clearly be some patients with
a high genetic susceptibility with
other predisposing factors such as
the presence of untreated periodon-

tal disease, smoking and diabetes
who may well succumb as a result of
primary infection.
Furthermore there remains a clear
need to better define the different

types of peri-implant disease and to
establish a consensus as to the cut off
values for the different parameters
used to evaluate the disease so that
future figures for incidence and
prevalence are comparable.

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

Dr Michael R.
Norton runs a
practice dedicated to implant &
reconstructive dentistry in London
in the UK. He
can be contacted at drnorton@
nortonimplants.com
AD

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TRENDS & APPLICATIONS

Implant Tribune United Kingdom Edition | 3/2015

Making implantology affordable
Controlling costs and increasing access to dental implant treatment
By Dr Tuss Tambra, UK
All CE/FDA-marked systems meet the same standard whether affordable
or prestige brands.

Implant dentistry is an elective restorative treatment solution with a surgical component for dentally fit patients.
If properly executed, it is one
of the most successful and
clinically researched treatment modalities in dentistry.
Unfortunately, patients who
are not disease-free are being
treated with dental implants
and, as a result, the litigation
rate has risen sharply.
A success rate of 98 per
cent is almost universally
claimed when promoting
implant dentistry to patients. So, if implant dentistry is 98 per cent successful,
then why are more cases
failing and why is litigation
increasing? Lack of proper
training, poor treatment
planning and poor execution (surgical and restorative)
are undoubtedly the main
culprits. If a clinician has the 1a
appropriate surgical and
restorative training in dental implantology, does the brand of dental implant
used make a clinically significant difference to the success rate? Does paying more for the implant and restorative components really produce better
results? Why is price an issue?
Price should generally not prevent access to high-quality, wellresearched and effective dental treatment. However, the current pricing
structure in implantology means that
a huge proportion of patients do not
have the disposable income to cover
the costs of such treatment. The McGill
study demonstrated the numerous
benefits (functional, clinical, psychological and general health) for edentulous patients in whom dental implants were used to stabilise complete
dentures. The improvements in chewing efficiency, general health resulting
from an improved diet and general
well-being (more social interaction
owing to a lack of fear of teeth falling
out) shows the significant impact dental implants make in society as a whole.
How can this situation be changed
to allow more potential patients to
access dental implant treatment? First,
clinicians could significantly reduce
fees charged to patients. This can only
happen if the component and laboratory costs are reduced, with the dentist
passing the savings on to the patient.
Another option is that dental implant
companies reduce the prices of both
implants and restorative components. According to the industry, however, prices across the industry are
already competitive and companies
need to cover their business costs.
Is there an alternative to the above?
Clinicians cannot reduce charges
without assistance from the dental
implant companies and all dental
implant companies are private busi-

nesses with shareholders who want
to produce products (implants) that
benefit society and see some return
on their investment in terms of profit
generation.

Economic drivers
Market forces must come to bear
in dentistry. In the current global
economic climate, ignoring the financial implications of the decisions we
make is no longer an option. Patients
expect high-quality, safe and affordable treatment. For this to happen,
clinicians need to source products at
a reasonable price point, passing on
these savings directly to the patient,
reducing overheads and treatment
charges and, therefore, increasing access to treatment. Some of the prestige implant companies have already
felt the impact of the loss of market
share and have either bought out
competitors, created joint ventures or
incorporated competing products
into their product lines.
Do smaller implant providers offer
potential benefits? One is certainly

their ability to respond more quickly
to increased patient
expectations of treatment. The rapid expansion of digital
dentistry, CAD/CAM
technology and intra-oral scanning
is resulting in smaller companies
being able to provide clinicians with
a total, open-source guided surgery
and restorative solution. With larger
companies, the ability to change direction is much more difficult and
time-consuming; turning an oil tanker
takes more time than a dinghy.

Key points of
consideration
when reviewing a
new implant system
Globally, all medical and dental
products undergo strict vetting procedures to ensure patient safety,
including product durability testing,
animal studies, human trials and
testing at universities. They are then
required to obtain a CE mark, FDA
approval or some other approval to
allow the products to be used in clinical dentistry. In short, once a product
has a CE/FDA mark, it meets all the
necessary testing and patient safety
requirements to be used on humans.

The next step is to assess all clinically relevant
criteria. Since there are
more than 1,300 dental
implant systems available, clinicians needs to
assess all available clinical and scientific data
and test the validity of
various claims made by
dental implant companies. If checking for certification/approval is the
first step for a clinician,
then the second should
be establishing how future proof the new implant is. In the early days of implantology, dozens of companies started
trading and most of them closed in
a relatively short period. For early
adopters of those systems, the risk
was not being able to restore or
maintain such systems, as parts
were no longer available. Therefore,
as a general dentist, one should verify
the length of time for which the
system has been on the market, who
the parent company is and what the
connection interface is (is it a clone
system of a well-known implant that
is no longer in patent?). In simple
terms, if the company ceases to trade,
can I still source components and
maintain my patients?

Implant-speciﬁc
considerations
A significant proportion of connection options (internal hex, external
hex, Morse taper and conical connections) are no longer in patent. The
clinical research on these has already
been done and their success rates have
been well documented in a multitude
of studies. As a result, most affordable
implant systems are adopting these
non-patented connections rather
than developing their own, meaning
that prosthetic components are
cross-compatible with other similar
systems.

A clone connection implant can
thus be restored with a high-end
restorative component provided by
another implant company or using
patent-free connections by opensource milling centres that can provide these components for significantly lower costs. One caveat with
open-source milling is to check the
quality of the milling provided in
order to avoid the complications
that arise from poorly fitting restorations.
Systems like the ICX now provide
non-precious metal blanks with premilled implant connection interfaces
and ceramic blanks bonded to adhesive base components. It is a premade
titanium implant connection that is
bonded to the all-ceramic block. It is
the milling of the implant connection
interface that is the most vital part of
the process, so if an open-source centre can obtain a pre-milled connection
blank, then its work is much reduced
and the dentist can be rest assured
of a high-quality component with an
accurate fit. The benefit of adhesive
bases in all-ceramic work is the improved strength of the connection
and reduced fracture rates compared
with all-ceramic abutments.
Is using one of the clone connections listed above an issue? All these
connections function with excellent
long-term, clinically documented
results. The key factor for success is
the closeness of fit between the internal/external implant connection
and the mating surface of the abutment, also called the micro-gap. This
produces a stable, rigid connection
with no abutment movement under
loading. A stable implant–abutment
interface combined with platform
switching is the key to bone preservation around the neck of the implant
and avoiding screw loosening.
How can one most easily compare
multiple connection platforms in a
simple and easy to understand way
without needing a degree in mechanical engineering? Engineer Holger
Zipprich from Goethe University
Frankfurt’s dental school in Germany
has produced real-time videos of

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several implant–abutment interface
responses to loading that are available
on YouTube. Once the videos have
been viewed, a rational decision as to
which connections are more stable
(rigid) under loading can be reached
and this information then applied to
selecting an implant system.
Does the system offer a wide range
of prosthetic, CAD/CAM and guided
surgery solutions for dental implant
treatment? Once a dental implant
system has gained some degree of
market penetration (or traction) and
has documented evidence to support
its clinical effectiveness, it is worthwhile taking an unbiased view of the
system. Hopefully, most glitches would
have been identified and corrected by
the early adopters, thus reducing the
risks for the more cautious clinicians.
A personal recommendation is
to focus on the restorative aspects
first (restoratively driven treatment).
Questions to be asked include whether
the system has a broad range of components for the various treatment
needs in implant dentistry, CAD/CAMbased treatment solutions and a
guided surgery solution for the surgical placement of dental implants.
If you are impressed by what you see,
then place a few implants and monitor them closely. If the treatment
outcomes are successful and you have
a positive impression of the system,
then there is no reason that
you should not add a costeffective solution to your
dental implant portfolio.
What impact does the
macro-geometry (implant
shape) and micro-geometry (surface treatment)
have in relation to longterm success? The surface
treatments applied to various implant systems are
designed to improve the
degree of osseointegration
and bone–implant contact.
This is extremely important for the long-term preservation
of bone around a dental implant.
However, is the surface treatment
that important when looking at immediate loading situations? In those
situations, it is the primary stability
of the dental implant, combined with
the closeness of fit to reduce micromovement of frameworks, that is
the key factor in determining longterm success. Any beneficial effects
of a surface treatment will occur postosseointegration and several months
after loading. So, are the macro-geometry of the implant and the physical
stability of the abutment connection
more important than the surface
treatment for long-term success or
vice versa?
Again, it depends on what the clinician is planning to do, immediate
loading or conventional delayed
protocols. Very little independent research has looked into the accuracy of
the claims made by implant systems,
and even less work has been done directly comparing the various implant
designs to evaluate different systems.
One group that has attempted such
an analysis is the Cochrane Collaboration and its reports are presented later
in the article.

TRENDS & APPLICATIONS

Primary stability is
mainly governed by the
Image No 2009_01444
implant thread design
and this directly affects
the insertion torque.
The implant–abutment
connection stability is
equally important. If this
was not the case, then
Image No 2009_01445
an implant inserted with
a low insertion torque
Position of the
and poor component fit
Measuring ranges
would be subject to prosthetic movement under
3a
occlusal loading with
loss of primary stability and implant
abutments, bars and frameworks for
the abutment? In Orale Implantologie
failure long before osseointegration
restoration with both ICX and other
in 2007, Berlin dentist Dr Stefan Wolf
would have occurred.
dental implants in addition to preSchermer examined the micro-gap
made components. Titanium, zircobetween the abutment and the deIf one is following conventional
nia and non-precious restorative
ntal implant connection interface of
delayed loading protocols, then the
components for ICX and other brands
several systems and showed that ICX
surface treatment, as well as the
are available and are supplied with the
implant–abutment micro-gap was
macro-geometry and connection
final prosthetic screw included. With
the smallest of all of those examined
stability, will affect long-term success.
some systems, the final screw is not
(Figs. 3a & b).
Do the larger prestige dental implant
included and must be purchased sepbrands provide dental implants with
arately. ICX also has a bespoke CBCT
Closeness of fit is directly related
the most ideal thread designs, best priguided surgery solution called Magelto movement of the abutment when
mary stability, and highest tolerances
lan that is also multi-implant system
under load. The fatigue test figures in
of fit of abutments and frameworks,
based. The dentist can either purchase
conjunction with the smallest microor do the various surface treatments
the software or upload the DICOM
gap figures show the ICX implant has
have a clinically significant improvefile to the parent company server and
a well-designed and rigid connection
ment in long-term success when comthe company will carry out the design
interface that is platform switched. The
pared with a so-called budget brand?
process and fabricate the guide once
macro-geometry of the implant with
Again, no real cross-comparison rethe design has been approved by the
self-tapping apical threads provides
search exists. The surface roughness
dentist. Magellan can also be used to
high insertion torques with excellent
of the dental implant is also of vital
produce guided surgery drill guides
primary stability. These are key comimportance, as research has found
for various dental implant systems,
ponents in preserving crestal bone
increased peri-implantitis associated
but at a fraction of the cost.
around an implant. In terms of surface
treatment, the ICX implant
has an etched and blasted
micro-roughened surface
(Ra of 1–3 μm) with a pure
titanium dioxide surface
with no additives.
The implant was previously described as having
a hydrophilic surface. However, this claim was successfully challenged by
Straumann and is no longer
used to describe the implant.
The surface is currently being updated.
with macro-roughened surfaces.
Smooth or machined surfaces clinically show reduced levels of osseointegration, so the current thinking
seems to be that micro-roughened
surfaces provide the optimum surface for osseointegration.

An affordable
implant solution
The low-cost system that will be used
here for comparison is the ICX system
manufactured by medentis medical in
Germany. On the market for several
years and well known in Europe, it has
recently arrived in the UK as part of
the company’s global expansion. All
of its research has been conducted and
validated by several prestigious institutions, adding weight to the product,
including the Fraunhofer Institute,
which conducted durability testing, as
well as universities in Cologne, Aachen
and Mainz, which also contributed
with clinical research. The Robert
Mathys Institute in Bettlach in Switzerland performed research on the microgap (tolerances of fit of abutments).
The ICX system has a well-developed
CAD/CAM workflow for fabricating

When considering an implant solution, a look at the total system costs involved with both surgical and restorative components can reduce the overall cost to the patient. The table shows
a price comparison of the ICX system
against multiple implant systems, both
prestige brands and cost-effective
systems based on 2013 costs in the UK.
In terms of cost and product content,
the ICX implant seems to provide a costeffective implant solution for patients.
How does the implant fare when
tested in the laboratory against the
prestige systems? The Fraunhofer
Institute conducted durability (ISO
14801) tests (Figs. 1a & b)on several implant systems, including Straumann
Bone Level implants. These tests
showed that the ICX implant was
more fatigue resistant than all of the
implants tested (Figs. 2a & b). Thus,
the implant has a durable, fatigueresistant connection interface.

The implant–
abutment interface
How stable is the connection when
viewed in terms of closeness of fit or the
micro-gap between the implant and

As a prosthodontist working in private practice most of what is outlined
above is how I personally approach
new implant systems. There is very
little clinical research comparing
the various dental implant systems
directly to one another and a significant proportion of studies published
cannot be directly cross-compared, as
there is no standard clinical method
for doing so. All of the variations in
implant geometry, surface treatment
and restorative solution in addition to
the operator variables (the surgeons
involved, their individual skill sets
and the correlation of the statistics)
all make such direct comparisons
between implant systems a potential
minefield.

has contributors in over 120 countries. Starting in 2003 with follow-up
reports conducted in 2005 and 2007,
the group published its latest evaluation last year.1 The full report can still
be accessed online, as can the previous
versions. It has led to intense online
debate by various dental implant
companies and clinicians largely because of its conclusions, which are
reproduced here directly from the
summary of the report: “Based on
the results of the included RCTs
(randomised controlled trials), we
found no evidence showing that
any particular type of dental implant
had superior long-term success. There
was limited evidence showing that
implants with relatively smooth
(turned) surfaces were less prone to
lose bone due to chronic infection
(peri-implantitis) than implants with
much rougher surfaces (titaniumplasma-sprayed). These findings were
based on several RCTs, often at high risk
of bias, with few participants and relatively short follow-up periods.”
In summary, use of a cost-effective
dental implant system (in the author’s
opinion) is justified in terms of economic savings to the patient and increasing the reach of dental implant
treatment to the wider public. It is
reasonable once the system has been
cleared for use in general dentistry
(CE mark, FDA approval) and should
be considered a viable clinical option
once the dentist has reviewed the
available clinical data (conventional
and guided surgery solutions) and
restorative treatment (conventional
and CAD/CAM-based) options. He or
she will then come to an informed decision, at which point he or she should
place and review a small number of
implants in varying clinical situations
and monitor the results.
Conflict of interests: Dr Tuss Tambra has
not received any payments or other inducements of any kind from any company
mentioned in the article.

Reference
1. Esposito, M., Ardebili, Y. & Worthington, H.V.,
“Interventions for Replacing Missing Teeth:
Different Types of Dental Implants”,
Cochrane Database of Systematic Reviews,
7 Article CD003815 (22 Jul 2014). accessed
9 Jul 2015.

Dr Tuss Tambra
is a registered
specialist prosthodontist from
Stafford in the
UK. He can be
contacted at
d r. t a m b r a @
hotmail.co.uk.

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