Hygiene Tribune Middle East & Africa No.6, 2020

Hygiene Tribune Middle East & Africa No.6, 2020

The dental hygienist in times of COVID-19 / Interview: “With a healthy oral cavity, the effects of hormonal fluctuations on periodontal health will be minimal”

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The dental hygienist in times of COVID-19
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Interview: “With a healthy oral cavity, the effects of hormonal fluctuations on periodontal health will be minimal”
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www.dental-tribune.me

PUBLISHED IN DUBAI

November-December 2020 | No. 6, Vol. 10

The dental hygienist in times of COVID-19

In the second phase of the coronavirus emergency, in which we must
live with COVID-19 at least until a
vaccine has been found, some of
these revised protocols could be
useful strategies to contain the pandemic and reduce cross-infection
in dental practices. For dentists and
dental hygienists 2.0, greater attention must be paid to the use of specific personal protective equipment
(PPE), a rational flowchart of the
sterilisation and sanitisation cycles,
the reduction of aerosols and their
bacterial and viral load, and ventilation of the practice.2

Appointment flowchart
This is a premise for a necessary reorganisation of the dental practice,
but not for a revolutionary change.3
The reorganisation of the dental office will take place through an optimisation process of the management protocols for cross-infection,
in particular with regard to airborne
infections. In March 2020, at the
start of the pandemic, the New York
Times published an estimate of

The report showed that, of course,
medical professionals who treat
COVID-19 patients on a daily basis
are at the greatest risk. However,
dentists and dental hygienists fall
into the same risk category owing to
aerosols and droplets produced during virtually all dental procedures.
During procedures involving the use
of aerosol sprays turbines, micromotors, air polishing and ultrasound,
the aerosols generated may contain
patients’ potentially infective saliva
and blood, emitting these into the
environment.5
Several strategies have been proposed for dental professionals, such
as telephone triage, waiting room
management and new appointment
schedule, and detailed protocols
and guidelines have been published
by health authorities in countries
throughout the world to minimise
the risk of infection in dental practices.
The dental practice must principally
focus on the following:
•
reduction of the bacterial load
in the patient’s mouth in order
to minimise bacterial airborne
contamination;
•
working safely;
•
reduction of the amount of
aerosol generated;
•
use of high-power suction during dental procedures;
•
use of non-thermal plasma
technologies to filter the air
•
and neutralise bacteria and airborne viruses;
•
use of environmental air decontamination systems (ozone
generators, ultraviolet and hydrogen peroxide ejectors);6
•
careful decontamination of all
surfaces; and
•
use of appropriate PPE to protect the eyes, face, mouth and
nose.5,7

© Anna Jurkovska/Shutterstock.com

In 2001, the concept of the human
microbiome was first introduced by
Joshua Lederberg. The microbiome
consists of the entire genomic heritage of microorganisms and biochemical interactions with the host.1
Knowledge of the microbiome has
profoundly changed oral hygienists’
and dentists’ clinical approach to
controlling oral infections. Futhermore, the modern modus operandi,
has increasingly forced us to reduce
treatment time and biological and
economic costs and therefore carry
out minimally invasive interventions with excellent results through
periodontal support therapy. In this
scenario, the patient becomes the
protagonist and is no longer only the
object of our therapy.

workers’ risk of being infected with
SARS-CoV-2.4

Fig
.2

By Dr Annamaria Genovesi, Giacomo Oldoini, Dr Saverio Cosola &
Prof. Ugo Covani, Italy

The modified full-mouth disinfection protocol and its important role in the COVID-19 era
Minimally invasive non-surgical
therapy has been widely used in
dental practice with the main objective of decontaminating periodontal
pockets to the highest possible degree using a minimally invasive approach. The Istituto Stomatologico
Toscano follows this principle by carrying out the modified full-mouth
disinfection (MFMD) protocol developed by Dr Genovesi. In 2014,
this protocol was established with
the aim of reducing the inflammation and bacterial load of periodontal pockets before proceeding with

instrumentation in order to reduce
the risk of bacteremia.8 It consists
of a two-step approach. During the
first appointment, the patient is instructed and motivated to maintain
correct oral hygiene at home and
employ chlorhexidine or other antimicrobial substances for 15 days.9 After about ten to 15 days after the motivation session, the patient usually
presents with significantly improved
clinical parameters already—less
plaque and bleeding—and, hence,
lower levels of inflammation and
better trophism. During this second
appointment, a full-mouth disinfection (FMD) is performed.
In a clinical study published by our
group, which compared different
FMD protocols, we observed that

pain during the treatment session as
well as inflammation and plaque indices were significantly lower in the
test group (MFMD) compared with
the control group (FMD) after ten
days of home treatment.10
In view of the current pandemic, this
two-step protocol allows the reduction of the duration of the treatment
session and therefore the duration
of exposure to potentially contaminating aerosols compared with FMD
in a single session. It should be emphasised that all this is carried out
by reducing the number of visits to
the dental practice (two) compared
with other protocols of non-surgical
sextant or quadrant therapy. Furthermore, the first motivation session can be carried out wearing PPE
and respecting the safety distances
to reduce or totally eliminate the risk
of contamination. Oral hygienists
could even consider the possibility
of performing this motivation session remotely, via a mobile app or
social networks, for example.

Motivation
We will certainly be able to enhance
and improve our communication
with and ability to motivate the patient if we dedicate more time to it,
perhaps even making a telephonic or
social network consultancy service
available for our patients in order
to minimise our intervention. The
success of the motivation session
depends greatly on the communication skills of the dental hygienist. In
a 10- to 120-minute session, the hygienist must motivate the patient to
change his or her habits radically—
and we all know how difficult it is to
change habits. To succeed, the dental
Fig. 1

Fig. 3

ÿPage E2

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HYGIENE TRIBUNE

Dental Tribune Middle East & Africa Edition | 6/2020

◊Page E1
hygienist must employ language
capable of engaging that specific patient, targeting his or her indi- vidual
cognitive and clinical characteristics.
This task is far from simple and is
the primary example of proactive
therapy, defined as such by Genovesi and Marconcini et al.,10 in which
the patient is placed at the centre of
the dialogue and becomes part of
the therapeutic path. The attribution
of responsibility generates a positive
change that will hopefully lead to a
long-term oral disease prevention
and oral health maintenance regime.
During the motivation session, the
microbiological principles of the oral
microbiota, the formation of biofilm, and the important interaction
between oral health and systemic
health are explained to the patient.

Mechanical procedure
The patient is instructed on correct
at-home oral hygiene, supported by
using the appropriate mechanical
cleaning tools. In our experience,
the sonic toothbrush represents
the gold standard of home care for
the patient because, owing to the
dynamic fluid action, it is able to remove plaque and effects a change to
the microbiota that corresponds to
health. For interdental cleaning, we
recommend silicone-bristle brushes
or air and water cleaning aids for
interdental spaces. These aids are
easy to use without any particular
manual ability, even where access
is more difficult, and unlike dental
floss, these tools are less harmful to
the gingivae and more effective.

Toothpastes and mouthwashes
The choice of toothpaste and mouthwash is essential for optimising the
clinical effectiveness of mechanical
instruments and to promote a state
of eubiosis. There are a very large
number of products dedicated to
oral home care on the market. Each
product has its indications and characteristics. Normally, chlorhexidine
is administered only for a very short
period of use—in the acute phase

or, more precisely, in the first phase
of MFMD. Later, it will be replaced
with proactive products. In the initial reactive phase, NitrAdine tablets
(PerioTabs; bonyf) or zinc- based
antimicrobial products can also be
suggested to patients. In the proactive phase, the products are based
on ozone, in the form of toothpastes
and gels with higher concentrations or ozonated water, or, in less
problematic situations, products
containing natural antiseptics; and
nanohydroxyapatite, propolis gel,
GLIC toothpaste and GLIC mouthwash (Polifarma Benessere) in diabetic patients; or other biomimetic
products.11

Operative session
During the operative session of
MFMD, the following operational
precautions must be considered.
Ultrasonic instrumentation
Aerosols generated by ultrasound
are an intrinsic feature of the devices.12 Therefore, in this situation
of high transmissibility of the virus,
it is preferable to limit the use of ultrasound in favour of manual tools.
If there are biofilm and non-calcified
deposits, it is also recommended
to reduce the level of irrigation and
power of the ultra- sonic devices.
In this scenario, it is highly recommended to use devices with which
one can better regulate the water
supply and reduce the amplitude of
movement of the insert, minimising
cavitation (Fig. 1). In situations where
the use of ultrasound at a higher
power is needed, it is important to
increase the safety precautions indicated by scientific societies, such as
PPE or efficient aspirators.
Sonic instruments
By nature, the sonic insert has a reduced aerosol production. It would
thus be useful to apply this technology wherever possible.
Vector technology
This technology exploits the shock

wave produced in the periodontal
pocket by cavitation. It eliminates
uncontrolled oscillating movements and mechanical vibrations
and requires a reduced flow of water.
Therefore, the water is not sprayed
and aerosol production will be almost completely eliminated. For
this reason, this technology should
also be employed when possible in
order to reduce the generation of
aerosols.13
Use of prophylaxis powders
The powders have literally revolutionised the therapeutic approach
to the patient. We know that aerosol
produced during this kind of therapy is significant in terms of quantity
and waste. It is therefore important,
when there is a need, to modulate
their use, reducing the time of application, choosing powders suitable
for the clinical situation and preferably using trolley devices that optimise the effectiveness of the jet. The
reduction of aerosols is also favoured
by intermittent use of the device.
Periodontal cleaning
It is preferable to use subgingival tips
(Fig. 2), normally indicated for periodontal sites over 5mm deep. These
allow us to limit excesses of the jet
by directing it entirely into the periodontal pocket.
Supragingival cleaning
Micronised sodium bicarbonates
and calcium carbonates satisfy all
types of supragingival needs (restorative mate- rials, erosion, brackets, pigments, plaque and exposed
implant surfaces) and reduce the
duration of application. In this case,
choosing powders dedicated to the
sub- gingival area can be wrong because powders with lower abrasive
indices increase spraying duration
and therefore aerosols (and costs).
General use
The pedal should be used intermittently and never in a continuous jet,
greatly reducing waste and nebulisa-

tion caused by continuous spray of
the jet. Of course, we must not forget that it will be necessary to have
powerful aspirators that reduce the
spread of potentially contaminated
aerosols, the retractor connected to
the suction side and positioned near
the patient’s oral cavity.
Manual instruments
There is no doubt that, even if for a
short period, we must come back to
manual instrumentation, limiting
the use of ultrasound. In manual
instrumentation, it is important to
choose instruments that allow us
to be effective but also ergonomic.
Universal instruments, including
DSS1/ DSS2 curettes (with graduated
rod) or DS1/DS2 curettes (without
graduated rod) with a double working blade with perio-anatomical adaptations for anterior or posterior
sites, and M23 and M23F scalers, are
excellent tools. In this way, we can
meet the need to reduce the instrumentation time by optimising the
performance of non-surgical periodontal therapy (Fig. 3).

tion of airborne infections, analysing
the surface near the working area
using microbial cultures. The results
showed that ozone therapy might
be considered useful as a preoperative rinse for decontamination purposes, as well as to reduce airborne
contamination. Ozone therapy has
been reported as being effective for a
range of different virus types, including SARS-CoV.19
Editorial note:
A list of references can be obtained
from the publisher.
This article was originally published
in prevention-international magazine
for oral health, Vol. 4, Issue 2/2020.

About

Ozone therapy, laser therapy and
probiotics
Periodontal therapy can and must
also be supported on a professional
level by proactive agents and devices.14 For example, the efficacy of
professional use of ozone or probiotics has been highlighted by several publications by our institute,
and these substances may provide
a further therapeutic opportunity
in the hands of the dental hygienist
to preserve the patient’s periodontal
health,15,16 especially in this historic
time in which we must reduce aerosols, but still keep the oral cavity of
our patients healthy. In addition,
ozone is known to be non-specific
and broadly effective on bacteria,
fungi and viruses owing to its oxidising properties.17,18

The Istituto Stomatologico Toscano is
a foundation for clinical, research and
advanced training in dentistry in Lido
di Camaiore in Italy. It offers continuing and further education courses, as
well as conferences (currently postponed
or made available online). Its masters’
courses are provided in collaboration with
Saint Camillus International University
of Health and Medical Sciences in Rome
in Italy. A master’s degree in non-surgical
periodontal treatment for dental hygienists starts in January every year. It consists
of theoretical and practical lessons on one
weekend per month and individual study
for a final thesis, which is supported by
tutors. In addition, an international postgraduate programme is available for dentists (one- or two-year master’s degree).
More information can be found at www.
istitutostomatologicotoscano.it. Courses
are being conducted online on the institute’s own education platform currently
in order to guarantee students continuity
of training and pursuit of the educational
assessments, including thesis drafting and
research.

In a recent study, we evaluated the
effectiveness of pre-surgical rinsing
with ozonated water in the reduc-

The institute also organises free-of-charge
webinarswith Dr Simone Marconcini and
Prof. Ugo Covani.

DAC Universal wins
Red Dot Design Award 2020
By Dentsply Sirona

a high level of safety for the patient
and the practice team. The fully
automatic reprocessing allows for
cleaning, lubrication (if necessary),
and a thermal disinfection of up to
six instruments within approx. 15
minutes – by simply pressing a single button.

Dentsply Sirona’s DAC Universal
was awarded with a Red Dot Award
for Product Design. The product impressed the jury with an intuitive
and visually appealing user interface.
With DAC Universal, Dentsply Sirona
offers an infection control system
with a fully automatic reprocessing workflow. Due to COVID-19, this
year’s award winners were honoured
during the Red Dot Design Week.

Intuitive workflow for a high
level of safety
The jury was impressed with
Dentsply Sirona’s DAC Universal,
emphasizing both its “sleek appearance that expresses efficiency and

With DAC Universal, Dentsply Sirona
adds a Red Dot Award to the company’s portfolio in 2020. Among
more than 6,500 product applications, DAC Universal convinced the
jury with its high design quality and
intuitive user interface. The awardwinning product was presented at
the Red Dot Design Week, which
took place as a virtual event due to
COVID-19.
cleanliness” and the “thoughtful
functionality, [which] saves dental
practices a lot of time in terms of
everyday tasks.” DAC Universal was
launched in 2019 with a complete
facelift and numerous changes,

“For me DAC Universal is the best
solution on the market today for
fast reprocessing of contra angles
and turbines. Information given by
the display is easy to understand
as well as cycle time remaining,”
explains dental assistant Jane Mikkelsen in Hinnerup, Denmark, who
had the opportunity to assist Dentsply Sirona with early testing of the
product. “The design of the lids of
the new DAC are excellent and help
to minimize direct contact with hot
surfaces. When removing the lid, it
is no longer possible to come into
contact with hot metal, as the lid has
been redesigned.”

including a touch display with intuitive user interface and a guided “The award confirms our key objecmaintenance workflow. With DAC tives as a leading dental company in
Universal, Dentsply Sirona offers an the global market: Bringing together
infection control system with a clear excellent functionality and premiand effective workflow that ensures um design in products that meet all

requirements of dental professionals
and continuously improve the experience for patients,” said Michael
Geil, Group Vice President Equipment and Instruments at Dentsply
Sirona.

For more information about the full
Dentsply Sirona portfolio please contact
your local representative.

Dentsply Sirona
21st Floor, The Bay Gate Tower
Business Bay, Al Sa’ada Street
Dubai, United Arab Emirates
Tel.: +971 (0)4 523 0600
Web: www.dentsplysirona.com/en
E-mail: MEA-Marketing@dentsplysirona.com

[3] => DTMEA_No.5. Vol.10_HT.indd

Dental Tribune Middle East & Africa Edition | 6/2020

HYGIENE TRIBUNE

By Jeremy Booth, Dental Tribune International
Changes in sex hormone levels are
associated with the onset and progression of periodontal disease. Dr
Ali Çekici, an associate professor at
the department of periodontics of
the faculty of dentistry at Istanbul
University in Turkey, recently held
a webinar on the topic, and his lecture generated significant interest
from the international dental community, particularly in relation to
periodontal problems experienced
during pregnancy. In a conversation
with prevention, Dr Çekici addressed
the importance of taking sex hormones into account when planning
and providing periodontal care.

Dr Çekici, what are the specific
periods in life during which sex
hormone changes affect periodontal tissue?
Sex hormones play a crucial part in a
person’s life in terms of growth, healing and host response to infections.

It has long been known that sex hormones may have potential effects
on oral tissue, mainly periodontal
tissue such as gingiva and alveolar
bone. There are certain periods in life
when sex hormone levels increase or
decrease physiologically. Since these
changes are physiological, their effects on oral tissue should not be
considered a pathology or a disease.
Puberty, the menstrual cycle, pregnancy and menopause are the main
episodes in life during which sex
hormone levels change drastically.
Also testosterone level changes in
men may have effects on oral tissue.

How do changes in sex hormone levels in different periods of life affect oral health?
Sex hormones have the ability to
alter oral tissue balance in specific
ways. One of these is changes to the
oral microflora. For example, one of
the well-known periodonto-pathogenic bacteria, Prevotella intermedia,
can use oestrogen and progesterone
as a growth factor. Also, the behav-

iour of different types of oral tissue
cells changes owing to fluctuations
in sex hormone levels. Epithelial
cells, fibroblasts and immune system cells, especially, can act differently when there is an increase in
oestrogen and progesterone levels.

Does every woman experience
periodontal disease during her
pregnancy?
It is very common for pregnant
women to suffer from swelling of
the gingivae and gingival bleeding during toothbrushing or even
just while eating food. It is true that
during pregnancy, owing to the tremendous increase in oestrogen and
progesterone levels, an extraordinary response by gingival epithelial
cells is likely to be seen. They overreact to dental biofilm bacteria and
this causes the swelling. For more
information on this, it is advisable
to consult the European Federation
of Periodontology’s (EFP’s) campaign
website on oral health and pregnancy, which includes infographics,

Sydney, Australia
26-29 September 2021
International Convention Centre

brochures, animations and a lot of
information for both dental professionals and patients.
It is important to know that, if a
woman’s oral health is good before
pregnancy, the effects of sex hormone fluctuations on periodontal
tissue will be minor. But if the woman already has ongoing inflammation of the periodontal tissue when
she falls pregnant, then the consequences will be severe, potentially
resulting in gingival enlargement
and benign tumours of the gingivae
(pyogenic granulomas).

What is the right timing for the
treatment of periodontal disease in pregnant women?
If a pregnant woman is suffering
from a periodontal disease during
pregnancy, it should be brought
under control, not only to relieve
the pregnant woman from the discomfort that the disease causes but
also to prevent adverse pregnancy
outcomes such as low birthweight
and preterm birth due to active periodontal inflammation. In addition,
severe periodontal disease may
prevent a pregnant woman eating
a well-balanced and healthy diet, or
limit her in doing so, and this may
affect her and her baby’s health. The
timing of the treatment is equally
important. The second trimester of
pregnancy is known to be safer for
dental procedures, but, according to
the level of disease, in some severe
cases, periodontal treatment may
start immediately after consulting
with the obstetrician.

Should periodontal treatment
be planned according to the
menstrual cycle?
Sex hormone level changes during
the menstrual cycle have a constant
physiological effect on the periodontal tissue. Some women may
experience major discomfort during menstruation. Also the risk of
aphthous ulcers in- creases during
menstruation. Similar effects might
be seen with use of oral contraceptive drugs. However, there is no evidence that we should avoid dental
or periodontal treatment during the
menstrual phase. It should always be
kept in mind that, with a healthy oral
cavity, the effects of hormonal fluctuations on periodontal health will
be minimal.

Does alveolar bone healing
change in postmenopausal
women? How does hormone
replacement therapy affect
this healing period?
There are several studies that have
attempted to link osteoporosis and
alveolar bone loss to periodontal
disease. What we can say is that during menopause a sudden drop in sex
hormone levels is linked with the
tendency to lose bone mass in time.
Not every postmenopausal woman
suffers from osteopenia or osteoporosis.

Educating for dental excellence
www.world-dental-congress.org

In the case of osteoporosis, the trabeculae of bone get thinner, and it
is likely but not proved that alveolar
bone loss might occur more easily in
the presence of periodontal disease.

kici, Istanbul Univer
li Çe
sity
A
,Tu
Dr
rk

Interview: “With a healthy oral cavity,
the effects of hormonal fluctuations on
periodontal health will be minimal”
ey

The healing of the bone during menopause is not significantly affected.
It should be kept in mind, however,
that in the case of osteoporosis, one
of the treatment methods include
the use of bisphosphonate drugs
orally or intravenously, which will
have drastic effects on the bone metabolism.

How do changes in testosterone levels affect periodontal
tissue?
Research shows that, when testosterone levels are high, alveolar bone
loss becomes more likely in the presence of periodontal inflammation.
The same effect is not found when
the testosterone levels decrease.
If there is no inflammation of the
periodontal tissue and oral health is
good, then the level of testosterone
does not create any difference in the
alveolar bone level change.

Your recent webinar on the impact of sex hormones on periodontal health was part of the
EFP Perio Sessions series. What
was it like to engage with other
dental professionals on this
topic?
Participating in the EFP Perio Sessions gave me an opportunity to
share knowledge and thoughts with
peers from over 55 countries. For me,
it was really exciting to address such
a diverse crowd from all over the
world, especially at a time when people were being affected severely by
the SARS-CoV-2 pandemic. In my webinar, the topic of periodontal problems during pregnancy received a lot
of attention and raised many questions. It was definitely a great experience for me and I sincerely hope that
it was for attendees as well.

The EFP Perio Sessions is a new
initiative—what can you tell us
about it?
I was the sixth guest speaker chosen
by the EFP to participate in this series of live webinars. It is open to all
dental professionals and focuses on
emerging issues in periodontics and
implant dentistry. The EFP will resume the programme after October,
and this is a first-class opportunity
for dental clinicians, scientists and
students to complete or update their
training.

Thank you for the interview.
Editorial note: This article was originally published in prevention-international magazine for oral health, Vol.
4, Issue 2/2020.

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