DT Pakistan No. 4, 2016

Pakistani Dentists win at APDF / News / The New Frontier of Interceptive Aesthetic Orthodontics / Intraoral Device for the treatment of Sleep Apnea / Two approaches and one goal / Study: Graft can help improve gums’ support for existing implants

Open PDF View E-paper Edit Epaper Edit Epaper ads save

Table of contents

Open Link

) [16] => Array ( [image_url] => Array ( [2000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/71496-ef2432d1/2000/page-15.jpg [1000] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/71496-ef2432d1/1000/page-15.jpg [200] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/71496-ef2432d1/200/page-15.jpg ) [key] => Array ( [2000] => 71496-ef2432d1/2000/page-15.jpg [1000] => 71496-ef2432d1/1000/page-15.jpg [200] => 71496-ef2432d1/200/page-15.jpg ) [ads] => Array ( [0] => Array ( [post_data] => WP_Post Object ( [ID] => 71499 [post_author] => 0 [post_date] => 2024-10-23 08:11:01 [post_date_gmt] => 2024-10-23 08:11:01 [post_content] => [post_title] => epaper-71496-page-16-ad-71499 [post_excerpt] => [post_status] => publish [comment_status] => closed [ping_status] => closed [post_password] => [post_name] => epaper-71496-page-16-ad-71499 [to_ping] => [pinged] => [post_modified] => 2024-10-23 08:11:01 [post_modified_gmt] => 2024-10-23 08:11:01 [post_content_filtered] => [post_parent] => 0 [guid] => https://e.dental-tribune.com/ad/epaper-71496-page-16-ad/ [menu_order] => 0 [post_type] => ad [post_mime_type] => [comment_count] => 0 [filter] => raw ) [id] => 71499 [id_hash] => cebdd15593bb0ccff776faffe083339070dcf6cdab6b6d35e14c3873358266c8 [post_type] => ad [post_date] => 2024-10-23 08:11:01 [fields] => Array ( [url] => http://www.dtstudyclub.com/ [link] => URL ) [permalink] => https://e.dental-tribune.com/ad/epaper-71496-page-16-ad-71499/ [post_title] => epaper-71496-page-16-ad-71499 [post_status] => publish [position] => -0.54,-0.11,99.77,99.92 [belongs_to_epaper] => 71496 [page] => 16 [cached] => false ) ) [html_content] =>

Open Link

) ) [pdf_filetime] => 1729671061 [s3_key] => 71496-ef2432d1 [pdf] => DTPAK0416.pdf [pdf_location_url] => https://e.dental-tribune.com/tmp/dental-tribune-com/71496/DTPAK0416.pdf [pdf_location_local] => /var/www/vhosts/e.dental-tribune.com/httpdocs/tmp/dental-tribune-com/71496/DTPAK0416.pdf [should_regen_pages] => 1 [pdf_url] => https://epaper-dental-tribune.s3.eu-central-1.amazonaws.com/71496-ef2432d1/epaper.pdf [pages_text] => Array ( [1] =>

PUBLISHED IN PAKISTAN

www.dental-tribune.com.pk
The New Frontier of
Interceptive Aesthetic
Orthodontics

Researchers examine
how providers
implement ...
Page 4

NEWS

JULY, 2016 - Issue No. 04 Vol.3

CLINICAL PRACTICE

Page 6

Intraoral Device for
the treatment of Sleep
Apnea

CLINICAL PRACTICE

Page 7

streamlines PG
Pakistani Dentists win at APDF Punjab
induction system
DT Pakistan Report

K

Editor - Online
Haseeb Uddin

ARACHI - Pakistan's three renowned
dental surgeons - Dr Mahmood Shah,
Dr Anwar Saeed and Dr Asif Niaz Arain
- have brought laurels to the country by winning
coveted posts in the APDF's (Asia Pacific Dental
Federation) recent elections held in Hong Kong.
The APDF office-bearers' elections took place on
the last day of the 38th Asia Pacific Dental
Congress (APDC 2016) held at Hong KongEditor
Lebanon,
- Onlineetc., did not participate in the APDF's
Uddinprocess owing to the Holy month of
Convention and Exhibition Centre from June 17Haseeb
election
to 19.
Ramazan.
According to the details, Dr Mahmood Shah,
The 38th Asia Pacific Dental Congress APDC
whose opponent was from the Philippines, clinched was hosted by Hong Kong Dental Association in
the post of APDF's Chairman for Oral Diseases collaboration with the APDF and supported by
Commission, Dr Anwar Saeed bagged the post of FDI World Dental Federation.
APDF's Chairman for Dental Public Health
As the theme of the congress was "Advancing
Commission after defeating his counterpart from Dentistry with Modern Science and Technology",
Taiwan, while Dr Asif Niaz Arain became the distinguished international speakers shared
APDF's vice president. All of them were re-elected. significant new developments and scientific
Sources said that the three Pakistani surgeons advancements.
got the APDF's prestigious posts although a number
The APDC-2016 also featured a comprehensive
of delegates of the congress, belonging to the trade exhibition, showcasing newest materials and
Muslim countries such as Saudi Arabia, Jordan, technology in dentistry.

DT Pakistan Report

L

AHORE - Punjab's healthcare and medical
education department has centralised its
postgraduate induction system so that doctors
seeking training in teaching hospitals across
the province could be inducted purely on merit.
Admissions under the new policy will be made
through Centralised Admission Test (CAT) to be
conducted by the Joint Admission Commission
(JAC) once a year for entrance into MD/MDS
programmes.
The other salient features of the policy are as follows:
Now every candidate will have to join his/her
place of induction for training in accordance with
the new merit formula whether his/her institute falls
in south Punjab or other city.
There shall be no test for candidates who already
passed FCPS Part-I and aspiring for induction as
PG trainee for FCPS -II. There shall be merit
determination formula for the candidates (Academic
and Experience Marks 50+ Examination Marks
35=85 marks).
The stipendiary PG trainee seats allocated by the

MARKETS FLOODED WITH OVER 100 BRANDS OF INFERIOR QUALITY BETEL NUTS

Oral cancer increasing ‘geometrically’ in Pakistan: Dr Sajjad
DT Pakistan Report

K

ARACHI - Prominent ENT surgeon
Dr Qaiser Sajjad has said that oral cancer
is increasing `geometrically' in Pakistan
and attributed the disease to the habit of eating betel
nuts (Chalia) in different forms, gutka, J.M and
Panprag and use of tobacco.
Underscoring the need for creating awareness
about health hazards of chalia, sweet supari, gutka,
Dr Sajjad, who is also finance secretary of Pakistan
Medical Association (Centre), demanded of the
government to impose a ban on the import of chalia
and bring an immediate halt to the sale,
manufacturing and marketing of gutka and sweet
supari across the country
Talking about the hazards of betel nut, he said:
"Even a good quality chalia can cause problems
like cancer as the juice of betel nut is carcinogen
(any substance that, when exposed to living tissues,
may cause the production of cancer).
In support of his contention that even good quality
chalia could cause oral cancer, Dr Sajjad recalled
that though the renowned playwright and a former
adviser to Sindh chief minister on cultural affairs,

Fatima Surayya Bajia, popularly known as Bajia
Aapa, died a natural death, she had earlier developed
oral cancer because of her habit of chewing betel
nut and the stuff she used to take was of best quality.
"Bajia Aapa was fully recovered from her oral
cancer problem because she timely contacted doctors
and had successful treatment," he added.
Citing another example in this regard, he said
that prominent radio artiste and broadcaster, Imtiaz
Saheb, who too used to eat good quality chalia and
smoke cigarettes had become victim of cancer of
vocal cord.
Terming fungal-infested betel nuts and sweet

supari `poison', Dr Sajjad said that betel nuts are
highly dangerous because it is adulterated
with chemicals, blood, charas, while sweet supari
contains artificial colour which is nothing but textile
colour -, a carcinogen.
Dr Sajjad, who had been practicing in Karachi
for the last 35 years and had collected data
about the victims of gutka, chalia, etc., deplored
that though the country's market is flooded with as
many as 122 different brands of inferior quality
chalia and sweet supari, there is no check and
balance on their sale. "We don't produce betel nuts,
but a huge amount of precious foreign exchange
was being wasted on the import of fungal-infested
betel nuts in the country and the same is being sold
in markets in attractive packing.
Elaborating, he said that it has also been proved
that when fungus-infested betel nut is routinely
taken, it acts as a carcinogen and thus causes liver
cancer. "Juice of betel nut and artificial colour are
carcinogen, he warned.
At the outset, Dr Sajjad, who had wide experience
of treating oral cancer patients, said that the disease
is, definitely, hundred per cent curable provided it
Continued on page 10

[2] =>

NEWS

2 DENTAL TRIBUNE Pakistan Edition July 2016

A case for single-use hand instruments in
general dental practice

Editor Clinical Research:
Dr. Inayatullah Padhiar

By Robert Jagger

Editors Research & Public Health
Prof. Dr. Ayyaz Ali Khan

A

wide range of single-use disposable dental and
surgical instruments is now produced by a number
of manufacturers. Instruments are available for
purchase either singly or as procedure kits and are priced
to be a realistic alternative to decontaminating reusable
instruments.1 Paradoxically, single-use instrumentation is
rarely seen as a viable alternative by dental professionals,
who typically associate single-use instruments with cheap
unreliable plastic devices and a very limited product range.
In reality, there are mirrors, probes, restorative
instruments, endodontic instruments, minor oral surgical
instruments and extraction forceps for both adult and
paediatric use. Procedure packs too are available for
specific procedures and contain all of the necessary
instruments. Examples of packs include those for dental
and periodontal examination, restorative procedures,
maxillofacial biopsy, minor oral surgery, and periodontal
microsurgery. This article seeks to challenge current
clinician perceptions of single-use instrumentation by
examining the potential benefits of high-quality singleuse instruments in daily practice.
Quality
Single-use instruments can be of extremely high quality
and may be almost indistinguishable in use from reusable
instruments. Clinicians often comment that they are
impressed by their quality and functionality and that they
appear far too good to throw away after just one use.
These instruments are a significant step forwards from
the poorer quality equipment that was previously available.
Before selecting a supplier of single-use instruments,
however, it is critical to ensure that they comply fully
with all relevant British and European medical device
regulatory standards and that they are manufactured from
medical-grade surgical steel and undergo rigorous inprocess quality assurance checks and batch testing.
Purchasing instruments from a supplier approved by the
British Dental Industry Association will provide
practitioners with assurance that they are dealing with
an appropriately regulated manufacturer.
Sterilisation
One of the most significant changes to have affected the
dental profession in recent years has been the adoption
of rigorous sterilisation and cross-contamination
procedures (HTM 01-05: Decontamination in Primary
Care Dental Practices).2 Dangers posed by prion diseases,
such as variant Creutzfeldt–Jakob Disease (vCJD), remain
even with the most effective dental sterilisation processes.
The prion associated with vCJD is able to survive steam
autoclaving under standard exposure conditions, 2
suggesting that some reusable surgical instruments are
potentially being utilised in a contaminated state. Use of
single-use disposable instruments ensures that instruments
are not contaminated, protecting patients and clinical
staff alike.
Costs
Most general dental practices are now equipped with
HTM 01-05-compliant equipment. Reprocessing dental
instrument trays, however, inevitably leads to significant
wear and tear and ultimately instrument damage. Regular
sharpening (and replacement) of reusable instruments
too is necessary for instruments such as luxators, chisels
and elevators. This can add substantial costs to the
reprocessing of reusable instruments. Reprocessing
protocols dictate that a dental practice must hold significant
stock of expensive reusable instruments, much of which
often lies redundant at any given point in time.
Single-use instruments can provide a cost-effective
contingency to cover unexpected emergency situations
in which reusable instruments may be unavailable, for
example when managing unplanned surgical complications

Publisher/CEO
Syed Hashim A. Hasan
hashim@dental-tribune.com.pk

Editor - Online
Haseeb Uddin
Designing & Layouting
Sh. M. Sadiq Ali

Dental Tribune Pakistan

or when washer disinfectors or sterilisers are inoperable
and significant clinical time may be lost while waiting
for the arrival of a skilled service engineer. Single-use
instruments enable clinicians to forecast true procedure
costs accurately, as there are no hidden costs associated
with the decontamination, sterilisation and packaging of
reusable instrumentation.
Convenience
Among other applications, single-use packs allow rapid
and efficient management of dental extractions that
become complicated by, for example, crown fracture.
Contingency stock of single-use surgical packs
(comprising integral single-use scalpel handles and blades,
tissue retractors, periosteal elevators, dental elevators
and suture packs) enables highly convenient, efficient
and cost-effective management of complications.
Single-use conservation and examination packs provide
a cost-effective means of extending the length of daily
clinic treatment sessions, especially towards the end of
the day, when access to sterile reusable instruments may
be compromised owing to sterilisation equipment
downtime or cleaning routines (when nursing staff are
therefore unavailable for clinical duties).
In endodontics, clinicians can more effectively identify
and control procedure costs and maximise their return
on time-consuming and costly procedures with the use
of single-use rubber dams and root canal obturation packs.
Safety-conscious patients are increasingly requesting that
single-use instruments be used for their treatment because
they feel more comfortable if the hand instruments used
to perform their procedure are brand new and have never
been used on another patient. Single-use instruments
eliminate infection prevention concerns associated with
the reprocessing of reusable instruments.
Single-use dental scalers are an efficient solution for
dentists, dental hygienists and dental therapists, since
every instrument is guaranteed to be sharp for every
procedure, enabling reduced treatment times and less
patient discomfort. The Instrapac Periodontal
Microsurgery Pack (Robinson Healthcare) is designed
to facilitate complex periodontal surgical procedures in
a cost-effective way, ensuring that instruments are always
functional and sterile. Robinson’s soft-tissue biopsy packs
provide an off-the-shelf sterile, cost-effective solution
for performing intra-oral tissue biopsies, particularly in
general practice, where these procedures are often
performed infrequently.
In implant dentistry, single-use periotomes and
microsurgery packs provide a cost-effective solution for
procedures that require precision and speed.
Moreover, single-use conservation and surgical packs
offer benefits when managing medically vulnerable
patients, including those with immunocompromising
conditions and those requiring dental treatment before
elective cardiac and renal surgery and pre- and post-head
a n d n e c k r a d i o t h e r a p y a n d c h e m o t h e r a p y.
Environmental impact
It is often forgotten that decontamination and sterilisation
procedures consume large amounts of energy, water,
cleaning fluids and consumables, with associated significant
environmental impact. Single-use surgical instruments
are designated as a specialist clinical waste stream and as
Continued on page 14

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

International Imprint
Group Editor

Daniel Zimmermann
newsroom@dental-tribune.com
Tel.:+44 161 112 1830
Clinical Editor

Magda Wojtkiewicz
Online Editors/Social Media Manager

Claudia Duschek
Editor

Anne Faulmann
Editorial Assistant

Kristin Hübner
Copy Editors

Sabrina Raaff
Hans Motschmann
Publisher/President/CEO

Torsten Oemus
Chief Financial Officer

Dan Wunderlich
Chief Technology Officer

Serban Veres
Business Development Manager

Claudia Salwiczek-Majonek
Jr. Manager Business Development

Sarah Schubert
Project Manager Online

Tom Carvalho
Event Manager

Lars Hoffmann
Education Manager

Christiane Ferret
International PR & Project Manager

Marc Chalupsky
Marketing & Sales Services

Nicole Andrä
Event Services

Esther Wodarski
Accounting Services

Karen Hamatschek
Anja Maywald
Manuela Hunger
Media Sales Managers

Matthias Diessner (Key Accounts)
Melissa Brown (International)
Antje Kahnt (International)
Peter Witteczek (Asia Pacific)
Weridiana Mageswki (Latin America)
Maria Kaiser (North America)
Hélène Carpentier (Europe)
Barbora Solarova(Eastern Europe)
Executive Producer
Gernot Meyer
Advertising Disposition
Marius Mezger

Dental Tribune International
Holbeinstr. 29, 04229 Leipzig, Germany
Tel.: +49 341 48 474 302 | Fax: +49 341 48 474 173
info@dental-tribune.com | www.dental-tribune.com

Regional Offices
Asia Pacific
Dental Tribune Asia Pacific Limited
Room A, 20/F, Harvard Commercial Building,
105–111 Thomson Road, Wanchai, Hong Kong
Tel.: +852 3113 6177 | Fax: +852 3113 6199

The Americas
Tribune America, LLC
116 West 23rd Street, Ste. 500, New York, N.Y.
10011, USA
Tel.: +1 212 244 7181 | Fax: +1 212 244 7185

[3] =>

[4] =>

NEWS

04 DENTAL TRIBUNE Pakistan Edition July 2016

Researchers examine how providers
implement caries risk assessment
protocol
By Robert Jagger

S

AN FRANCISCO,
USA - New research
has shown that
assessment of individual risk
of developing dental caries
can help dentists effectively
tailor prevention and
treatment efforts. The study
focused on how providers
implemented a protocol that
combines risk assessment
with personalized preventive
care and regular monitoring.
The researchers also
investigated how risk
assessments affected patients’
course of treatment and oral
health.
The Caries Management by
Risk
Assessment
(CAMBRA) protocol was
developed at the University
of California, San Francisco
School of Dentistry. In the
current study, a baseline
sample of 3,810 pediatric
patients at UCSF were
assessed using a 17-item form
that records multiple
environmental and behavioral
factors known to contribute
to caries, such as the patient’s
access to fluoridated water,
frequency of snacking, and

socio-economic status. The
predictive value of these risk
assessments was then
evaluated in a follow-up
group of 1,315 patients from
6 months old to 6 years old
from a largely low-income
urban population.
The researchers found that
dental care providers’ risk
assignments were correlated
with the risk of future decay,
s a i d s t u d y a u t h o r D r.
Benjamin Chaffee, assistant
professor and Director of the
Global Oral Health Program
at the dental school. At the
follow-up visits, only about
20 percent of the low-risk
patients presented with tooth
decay; however, nearly 70
percent of those in the highrisk group had decay.
“Risk assessment is
predictive—it tells you what
kinds of outcomes are going
to occur in a patient
population,” Chaffee said.
“Together with other studies,
our work has shown that
providers are willing and able
to use CAMBRA accurately,
that it doesn’t take a lot of
time to do it, and that it is
effective.”
Caries risk assessments like

CAMBRA help providers
account for factors known to
influence oral health and to
then tailor their approaches
to care according to the
designated risk level. For
example, a patient considered
as being at a high risk of
developing dental caries may
require more frequent
radiographs and dental
checkups than a patient
designated low risk.
“Dental caries, like so many
chronic diseases, follow a
social gradient,” Chaffee
further explained. “We want
providers to recognize that
our patients who come to us
from a lower socioeconomic
position are more likely to
face a heavier burden of
disease. It’s important to
consider that what is going
on beyond the dental chair is
contributing to the health
status of our patients.”
CAMBRA has the potential
to fundamentally change
dentistry, but this will be
gradual, Chaffee said. “The
traditional approach to dental
caries for the last 100 years
has been when a dentist sees
a cavity to fill it and restore
the tooth’s function, and that’s

An individualized risk assessment of an infant for
developing caries serves as the foundation for health
care providers to identify and understand a child’s risk
of early childhood caries
a critical aspect of what
dentists should be doing. But
in and of itself, this approach
doesn’t do anything to
prevent the disease from
occurring again. It treats the
symptom—the consequences
of disease —but it doesn’t get
after the causes of the
disease,” he concluded.
“More than half of the
schools and colleges of
dentistry in the US have
adopted CAMBRA in one
form or another as part of
their standard curriculum,”
said Dean of the School of
Dentistry Prof. John
Featherstone, who led the
research teams that devised
the protocol. “There are also
increasing numbers of faceto-face and online courses
that teach the CAMBRA
methods. I am encouraged by
the accelerated adoption of
CAMBRA in the field.”
According to the Centers

for Disease Control and
Prevention, approximately 23
percent of children aged 2–5
had dental caries in their
primary dentition in 2015.
Untreated tooth decay in
primary teeth among children
aged 2–8 was twice as high
for Hispanic and nonHispanic black children
compared with non-Hispanic
white children. In addition,
about three in five
adolescents aged 12–19 had
experienced dental caries in
their permanent dentition and
15 percent had untreated
tooth decay.
The study, titled “Caries
risk assessment item
importance: Risk designation
and caries status in children
under age 6,” was published
online and in the July print
issue of the JDR Clinical and
Translational Research, a new
offshoot of the Journal of
Dental Research. DT USA

Study: Gum disease may increase New biomaterial research aims to
lung cancer risk
increase safety of metal implants

S

C
Individuals with periodontal
disease have a 1.24-fold increased
risk of developing lung cancer.

A new research project will launch
in September to provide insights
into management of biofilms.

[5] =>

[6] =>

CLINICAL PRACTICE

6 DENTAL TRIBUNE Pakistan Edition July 2016

The New Frontier of Interceptive Aesthetic Orthodontics
By Dr. Tif Qureshi

H

ow the simple “3 –Step
Smile” can offer far more
than you might realize. Dr.
Tif Qureshi, discusses how the
treatment of mild and moderate
crowding has far more than just
cosmetic orthodontic objectives.
Currently in the market of dentistry
it seems as if they are 1000 short-term
orthodontic systems out there. The
term “cosmetic orthodontics” has been
around for a little while but in this
article we are going to take an
alternative view of what we can
achieve. The problem with the term
“cosmetic” is that it often suggests
things are being done just for visual
reasons. This article will argue that in
treating mild and moderate crowding

Fig 1: Uppers treated lowers
left 30 years on

Fig 6: After treatment weeks
later 2004

- Online is for life.
orthodontics
need to pick up a drill or damage any Editor
Haseeb
TheUddin
second point is even more
teeth.
This three-step approach we call the important- that in adults with mild or
‘three step smile’ through alignment moderate crowding, the arch length
bleaching and bonding. With the right will reduce regardless of whether the
components carried out at the right patient had orthodontics or not.
This is a critical point for all dentists
time it is possible to make the patient’s
own teeth look more beautiful without to understand especially anyone
the need for porcelain veneers or other carrying out restorative treatment.
That is the teeth you have restored,
irreversible procedures.
The most important article in that you may expect to remain same
dentistry that the profession seems to position through life will keep moving
miss! Br J Orthod. 1990 Aug; and the functional contacts will
17(3):235-41. Stability and relapse of change. It is one typical reason why
composite fillings classically chip on
dental arch alignment.
the front teeth. Basically if you have
Little RM
1. Arch length reduces following crowded it will get worse and arch
orthodontic treatment, but also does width will collapse which may have
so in untreated normal occlusions. 2. an effect on the patient’s guidance.
Arch width measured across the It also means that lower incisors,
mandibular canine teeth typically which have wear facets due to

Fig 2: Uppers treated
lowers left 25 years on

Fig 7: 10 years after IA
treatment 2015

Fig 11: Before treatment

cases we are potentially carrying out
an interceptive functional treatment.
There have been criticisms from
people suggesting that the cosmetic
orthodontics and short term
orthodontics causes anterior flaring
and loss of control of the anterior
occlusion. This may be true if there
has been no arch evaluation/ planning
or space creation strategy. If these
things have been carried out then
actually the opposite is true, and
arguably every better control of the
anterior occlusion than in any other
form of orthodontics.
This article will also look how
simple three-step approach can
massively improve the patient’s
appearance, their function and
intercept the continual crowding life
causes more problems without the

Fig 12: 9 weeks later

Fig 3: Relapsed comprehensive
treatment

Fig 8: Before treatment 2007

Fig 13: 7 years later 2014

reduces post-treatment whether the
case was expanded during treatment
or not. 3. Mandibular anterior
crowding during the post-treatment
phase is a continuing phenomenon
well into the 20-40 age bracket and
likely beyond. 4. Third molar absence
or presence, impacted or fully erupted,
seems to have little effect on the
occurrence or degree of relapse. 5.
The degree of post-retention anterior
crowding is both unpredictable and
variable and no pretreatment variables
either from clinical findings, casts, or
cephalometric radiographs before or
after treatment seem to be useful
predictors.
This 40 year study is so important
for two main reasons. The first
highlights the point now widely
accepted that retention after

This patient was treated 10 years
ago for mild crowding having relapsed
3 years after comprehensive treatment.
There was differential tooth wear
already visible and at the 10 years
follow up there’s been no irregular
wear because the teeth have been held
in the correct position. Her teeth were
aligned with an Inman Aligner in 4
weeks and fixed retained. The original
retainer has remained in place for 10
years. Being a regular patient, in GDP
practice, the retainer can be reviewed
at correct intervals. (Fig-5-7- Lucy)
This patient was only 21 and her
crowding was getting worse, as was
the differential tooth-wear on her
lower teeth. Her canine guidance was
collapsing and she was slowly moving
into group function. Her lower incisors
were starting the wear differentially.

Fig 4: relapsed comprehensive
treatment

Fig 5: Before treatment 2004

Fig 9: 9 weeks later 2007

Fig 14: Occlusal view

crowding caused by irregular dynamic
contacts, will get worse and wear
faster causing more dentine exposure
and darkening from the soaking of
stain.
These two patients were told 25-30
years ago that the upper teeth needed
treatment but the lowers were not
crowded enough to treat. At the time
they were not that crowded, but over
time as per the findings of Little’s
study the teeth have continued to
crowd causing the evident result. (Fig.
1,2)
These two patients both had
comprehensive orthodontics but no
fixed retainers were used and no longterm follow-up was carried out by
their orthodontist -as a result the
patient teeth relapsed almost to the
original position. (Fig 3,4)

Fig 10: 7 years later

Fig 15: Spacewize through
landmark points

After aligning her teeth in 9 weeks
and fix- retaining, her canine width
was increased and held, function
returned and 7 years later there has
been barely any increase in wear in
the lower edges Fig. 8 Cara.
Detailed case
This case example will go through
the steps needed for the three-step
smile, and outlined planning and
consenting processes involved.
This patient presented originally
wanting porcelain veneers. However
he was aware of the high costs and
that it would involve heavy preparation
on his teeth so he decided to consider
aligning his teeth. When he was shown
the results possible with combined
bleaching and bonding the patient
decided against veneers altogether.
Continued on page 12

[7] =>

CLINICAL PRACTICE

July 2016 Pakistan Edition DENTAL TRIBUNE 7

Intraoral Device for the treatment of Sleep Apnea
By Dr. Luis Gavin

B

ad sleep is the new
boogeyman, threatening the
overstimulated, overworked
masses with disease and even an early
death. Numerous scientific studies
from researchers around the world
have demonstrated the harmful effects
of sleep deprivation on human health.
When stress levels go up, people gain
weight and forget things.
Without shut-eye, the body doesn't
have a chance to produce enough
growth hormones to build itself back
up.
Sleep Apnea (SA) is a disorder that
causes pauses in breathing during sleep
that expose the heart to oxygen
deprivation. It is common in patients
with heart failure (HF) where it is
associated with increased risk of
hospitalizations and death.
In the treatment of snoring and sleepdisordered breathing the mandibular
repositioning devices are an
increasingly important instrument.
Its mechanism is based on the
advancement of the mandible, which
increases the dimensions of the upper
airways and the air flow during sleep.
Aim of this study was the investigation
of the efficiency and tolerability of
two types of adjustable devices: one
with screw jaw lateral excursion,
opening and jaw protusion, and TAP,
custom made appliances placed in 34
patients (24 men and 10women), mean
age 47 years old, undergoing an
ambulatory, uncontrolled sleep
screening before and after using the
appliance during one month (placed
onto the teeth during sleep).
Key Words
OSAS, sleep apnea, snoring,
protusion
Introduction
The OSA Syndrome (obstructive
sleep apnea syndrome) is one of the
clinical pictures that play an important
role in the chronic diseases. It has been
demonstrated that a timely diagnosis
and an adequate treatment can
decrease neurological consequences
and have a favorable effect on the
cardiovascular health status of affected
patients. Clinically it consists in the
obstruction of the air flow during sleep
that is caused by a partial or total
collapse of the upper airway structures.
These respiratory obstructions are
accompanied by “snoring” and
frequent arousals.
Patient have a number of symptoms:
daytime sleepiness and fatigue, due
to a restless sleep; morning headache,
loss of intellectual capacities and
nighttime micturition. Sleep apnea
affects approximately 7% of the adult
population, but the problem may be
underestimated, due to the growing
global prevalence of obesity. For
decades the continuous positive airway

pressure (CPAP) mask has been the
treatment option of choice, but its’
disadvantages, rejection and
intolerance on part of the patients
complicate the optimum compliance
of the therapy and it has lost its
therapeutic hegemony compared to
other available alternatives. This
resulted in the necessity of working
on other solutions that are equally
effective but more tolerable.
New option of this new therapeutic
line is based on the increasing interest
in the application of oral appliances,
especially of mandibular advancement
devices. The use of these devices is a
simple, noninvasive and completely
reversible treatment option that
achieves many advantages in
comparison to other treatment
solutions by an easy and immediate
therapeutic way. These systems
underwent technological
developments in the last years the
treatments of choice for patients who
suffer from with snoring and mild or
moderate sleep apnea.
Why is important the treatment of
snoring and sleep apnea? Importance
is based on the following reasons:
1. High prevalence in today’s society,
as various studies have demonstrated
in the last years. There exists an
incidence of 28% for snoring,
approximately 49% of adults snore
frequently and 35% habitually. The
prevalence of OSA ranges from 6-8%
in males and 4-6% in women among
the general adult, middle aged
population and this numbers increase
markedly with age.
2. It represents a problem in two
aspects, the social that converts these
patients in intolerable bed partners
and the more serious clinical impact
of significant morbidity. These impacts
can reach a noise level of about 7888dB (equal to the noise of a truck at
high speed on a highway). The limit
for hearing damages is estimated at
an intensity of 75 dB. Snoring disturbs
social and family relationships of
patients. Its psychological pressure
influences both lives, the daily routine
of people who snore, as well as the
every day life of people, who suffer
from the noisy consequences causing
problems in the partnerships.
3. Disordered breathing by sleep is
very habitual and, therefore, a
constant source of problems regarding
health and economic impacts. Poor
sleep habits aggravate the
impairments of health and quality of
life causing countless traffic accidents,
labor accidents and accidental home
injuries. The majority of these
disorders lead to drowsiness in its
clinical description, disabling affected
patients to drive. In all countries the
number of fatal accidents increases
constantly.
It s the first cause in men aged
between 16 and 25.

Intraoral device

Intraoral device

Lateral view vertical dimension opening

Lateral view relevant jaw advancement with
competent, comfortable lips seal

Frontal view with lateral excursion for
patient comfort

Frontal view initial opening ,
visible screw

Age median
(Standar Deviation)
SARISFACTTION Median
(Standard Deviation)
Sex (% women)
Table 2

IAM
IR
IDO
EPW
Table 2

IAM
IR
IDO
EPW
Table 3

Before DAM 1
7.7
9.17
3.93
8.6

DAM 1

DAM 2

P

49.1 (10.5)

48.2 (9.2)

0.644

4.5 (0.7)

4.6 (0.6)

0.983

27

27

0

After DAM 2 P (Wilcoxom)
5.17
0.002
8.23
0.001
2.93
0.01
6.07
0.006

Before DAM 1 After DAM 2 P (Wilcoxom)
12.3
7.17
0.001
14.23
10.67
0.001
6.43
4.47
0.003
11.63
6.73
0.001

DAM 1

DAM 2

P

Difference IAH

-3.43

-4.17

-0.333

Differene IR
Table 4

-4.23

-4.57

-0.783

4. The access to diagnosis possibilities
is the major problem facing the
specialists, as only about 6 to 9% of
the population with relevant OSA is
diagnosed. Clinical researchers seek
for diagnostic alternatives to the costly
polysomnography that is currently
the first diagnosis commendation (6).
The OSAS is rarely known to the
public. The lack of diagnosis is the
main medical problem to solve.

Recent studies show that in only 7%
of medical examinations of primary
care, explicit references regarding
possible sleep disorders are included.
This incorrect diagnosis involves fatal
consequences because the pathology
is ignored by patients that, without
being diagnosed, do not know how
to justify and cope with the symptoms
that they face day by day.
Continued on page 14

[8] =>

CLINICAL PRACTICE

July 2016 Pakistan Edition DENTAL TRIBUNE 08

Two approaches and one goal
By Dr. Eduardo Mahn

S

tate-of-the-art CAD/CAM
materials are offering clinicians
the possibility of producing
certain types of restorations in the
dental practice using a semi-direct
technique. Ceramic veneers, for
example, are easy to fabricate in-office
with IPS CAD Multi, without the need
for glazing.
Recently developed restorative
materials have opened up a myriad of
exciting possibilities for dental
practitioners. In the restoration of
anterior teeth, clinicians have to select
the most appropriate material for the
case at hand on the basis of specific
criteria. In situations where teeth show
signs of erosion, abrasion, abfraction
or a combination of these phenomena,
practitioners will tend towards using
ceramics or composite resins,
depending on how much intact tooth
structure remains available.
Traditionally, composites are used for
Class III, IV and V defects. However,
ceramic veneers are preferred in cases
where a large amount of tooth structure
is missing or a major change is planned
(e.g. smile makeover).
The challenge
When two central incisors need
esthetic enhancement, the choice of
approach is not so clear. Irrespective
of the material used a minimally
invasive route involving very little
preparation of the tooth structure can
be taken nowadays due to the high
strength of modern materials (e.g.
lithium disilicate glass-ceramic).
Nevertheless, it is important to
remember that minimal preparation is
an option, only if the teeth are properly
aligned. As long as the desired changes
of the tooth shape and shade are small,
preparation can be limited to the
enamel.
In many cases, however, orthodontic
treatment is needed before the tooth
position and/or shape can be optimized
by means of restorative procedures.
This minimally invasive approach
requires the dental practitioner to
convince the patient of the necessity
of undergoing preliminary orthodontic
treatment.
The solution
It is our aim to remove as little of
the tooth structure as possible in every
case that we treat. With modern
materials such as lithium disilicate or
leucite-reinforced ceramics, we can
confidently press or mill veneers that
are as thin as 0.5 mm and even 0.3
mm. One of the main advantages
offered by this type of ceramic is its
wide range of applications. Until a
few years ago, the treatment with
indirect restorations required at least
two appointments.
Ceramic materials such as IPS
Empress CAD allow dental
practitioners to produce polychromatic

monolithic veneers and crowns in less
than one hour, without having to glaze
them. Nonetheless, many dentists still
believe that dental technicians with
their well-honed manual skills produce
better esthetic results than a machine,
and they do not see the need to
embrace digital technology. As a result
of this point of view and the high
acquisition costs of the milling
machines some clinicians are reluctant
to invest in this technology. On the
basis of the present clinical case study
we would like to highlight the
following aspects: the importance of
having the right treatment plan, the
possibilities currently available for the
fabrication of veneers, the potential
of the press and CAD/CAM
techniques and the latest
improvements made in the field of
cementation.
Clinical case
Patient history
A thirty-one-year-old female patient
came to our office because she was
dissatisfied with her anterior teeth.
She complained about the
misalignment of the upper and lower
central incisors (Fig. 1). A detailed
clinical examination revealed that the
composite restorations in these teeth
were defective. As a result of erosion,
a considerable amount of tooth
structure had been lost. In addition,
the misalignment of tooth 21 and 41
in particular was quite obvious. The
treatment plan presented to the patient
included initial orthodontic treatment
followed by minimal preparation of
the two central incisors for two
ceramic veneers. The patient was
subsequently referred to an
orthodontist for treatment.
Unfortunately, it took more than a year
before she presented to the practice
again. At this consultation, we were
quite surprised to find that the two
central incisors had been restored with
poorly finished direct composite
veneers (Fig. 2). Many clinicians
simply underestimate the challenging
nature of this type of restoration, and
this was a case in point. In addition to
preventing any contamination of the
working field, the clinician must also
accomplish the arduous task of
creating an appropriate emergence
profile, proper contours and contact
areas and producing a suitable micro
and macro-texture, and all this within
a single appointment.
The treatment
The composite veneers had to be
removed and replaced with new ones.
In this particular case, the advantages
of using the indirect technique were
obvious. The patient agreed to have
two ceramic veneers made for her. For
this purpose impressions were taken
and a master cast was produced. This
working model provides the dental
technician with the opportunity to
evaluate the situation in detail. He or

Fig 1: Initial situation: The patient was
referred to an orthodontist.

Fig 2: One year later when the patient
returned to the practice, the teeth showed
unsatisfactory composite veneers.

Fig 3: The veneers were removed and the
teeth were transilluminated to identify any
composite residue.

Fig 4: The two-cord technique was used
for the impression. The retraction cords
remained in the sulcus.

Fig 5: Temporary restoration

Fig 6: Try-in of the Fig 7: Try-in of the
IPS e.max Press HT polished IPS e.max
A1 veneers
CAD A1 veneers
(fabricated in the
(fabricated in the
laboratory)
dental office)

Fig 8a: Try-in of the veneers
with a light try-in paste (Light+)

Fig 8b: Try-in of the veneers
with a light try-in paste (Light+)

Fig 9a: Try-in of the veneers with a
dark try-in paste (Warm+)

Fig 9b: Try-in of the veneers
with a dark try-in paste (Warm+

she has the time to think about possible
ways of correcting the misalignment.
Dentists do not have this “luxury” of
time when they are treating a patient
in the dental chair. They have to finish
the restorations as quickly as possible
in order to prevent contamination of
the treatment field and keep chair time
to a minimum for the comfort of the
patient. In the present case, an
additional hurdle had to be overcome:
Any composite material that might
have remained on the tooth structure
had to be clearly identified and
carefully removed without damaging
the healthy tooth structure.
Transillumination with white LED
light came in useful for this purpose
(Fig. 3). Next, the teeth were prepared,
retraction cords were placed and an
impression (Virtual) was taken (Fig.

4). The patient was provided with a
temporary restoration, which was
made with a temporary crown and
bridge material (Telio® CS C&B,
shade A1) and cemented with a dualcuring luting composite (Telio CS
Link) (Fig. 5).
Fabrication of the restorations
Two different routes were pursued
in the fabrication of the veneers. We
instructed our lab technician to make
two ceramic veneers using the press
technique with IPS e.max Press (shade
HT A1, stained). At the same time, we
milled two ceramic veneers with our
in-office CAD/CAM machine using
an IPS Empress CAD Multi block
(shade A1). The veneers made in the
dental office were not glazed, just
polished. Figures 6 and 7 allow the
Continued on page 14

[9] =>

[10] =>

10 DENTAL TRIBUNE Pakistan Edition July 2016

Study: Graft can help improve gums’
support for existing implants

ental implants are usually needed when teeth
are lost because of gum disease or injury
to the soft tissues that support and protect
the teeth. These same problems can affect the soft
tissue that protects dental implants. These clinical
soft-tissue issues can make it a challenge to place
fixed dentures or crowns. A recent article in the
Journal of Oral Implantology explains how a newer
type of xenograft can help improve the existing softtissue support for existing dental implants.
A stent helps the oral surgeon properly place a
soft-tissue graft that ensures the soft tissue stays in
its desired position during the first few days of
healing.
It’s best to augment soft tissue before placing
dental implants, but this is not always possible. The
oral surgeon may discover after the implant surgery
that additional soft tissue is required.
Several types of soft-tissue grafts made of tissue
from humans or another species, such as domestic
pig, can be used. The author of this article used a
porcine collagen xenograft to augment the existing
soft tissue. Other researchers have studied the
collagen xenograft and found it to be as effective as
other graft materials. However, previous studies

typically used porcine collagen xenograft with natural
teeth, not dental implants.
The article outlines the process used to augment
the gingival soft tissue of 11 patients who had fixed
partial dentures or splinted crowns. All patients
underwent the same procedure. The surgeon removed
the stents five to seven days post-surgery and checked
for healing. In the subsequent four to 12 weeks, the
surgeon evaluated how well the soft tissue had healed.
In all cases, the surgeon controlled bleeding early
on to avoid the collection of blood under the stent.
The author placed the xenograft to cover the surgical
wound, and then strategically placed a stent made
of a bis-acryl material and quickly shaped the material
before it hardened.
The author noted the importance of using a piece
of collagen that is 8 to 10 mm wide and as long as
needed to fill the surgical wound. Narrower collagen
pieces did not create enough supporting tissue for
the implants.
All patients healed uneventfully. However, the
new soft tissue was not the thick, protective type of
keratinized tissue that typically surrounds teeth.
Instead, it appeared to be an immobile form of a
softer, elastic tissue similar to that lining the floor

An article in the Journal of Oral Implantology
explains how a newer type of xenograft can help
improve support for existing dental implants.

of the mouth and cheeks. Not withstanding this
variation, the new tissue created protection for the
dental implants from distortion that is frequently
caused by the pull of facial muscles.
The author concluded that the graft was effective
in providing the intended support for the existing
dental implants. “This work may provide a quicker
way for implant dentists to provide the necessary
protective soft tissue for atrophic edentulous sites
with fewer morbidities,” said Dr. Dennis Flanagan,
author of the article. “However, as with previous
and concurrent work, the resulting type and amount
of keratinized tissue is not predictable.”
Full text of the article, “Stented Porcine Collagen
Matrix to Treat Inadequate Facial Attached Tissue
of Dental Implant Supported Fixed Partial Dentures,”
Journal of Oral Implantology, Vol. 42, No. 2, 2016,
is now available at www.joionline.org/doi/full/
10.1563/aaid-joi-D-15-00050. DT, USA

Two approaches and one ...
Continued from page 08

perspective. This experiment illustrates
the esthetic potential of modern
ceramics. Both types of restorations
blend in beautifully with their
surroundings.
The appearance of the veneers
produced with the help of CAD/CAM
technology came very close to that of
the manually manufactured version.
Nevertheless, in the end we opted for
the lab-fabricated veneers (IPS e.max
Press) with the consent of the patient,
since we were able to achieve a
slightly better match to the
neighbouring teeth by staining the
restorations.
Placement
Figures 8 and 9 show the try-in
pastes (Variolink Esthetic LC) on the
prepared teeth. The most suitable
composite cement was determined on
the basis of two differently coloured
pastes. Two extreme options were
compared: Light+ and Warm+. The
difference was clearly visible when
the pastes were applied. Even though

Fig 10: Enamel etching with
phosphoric acid

Fig 12: Removal of excess
composite cement

Fig 11: Application of a single-component
adhesive (Adhese Universal)

Fig 13: Light-curing with
Bluephase Style
polymerization lights with
water cooling

the darker shade (Warm+) was very
close to that of the natural tooth
structure and would have worked well
with the veneers, we ended up
choosing the lighter shade. This was
a typical decision. In most cases, we
tend to prefer the lighter version, since
it provides a better contrast to the tooth
structure and therefore renders the

Oral cancer increasing ...
Continued from front page

was timely diagnosed and treated.
In this regard, he advised the people not to take
even a small ulcer (Chala) lightly, saying that if
a small ulcer continues to persist for 15-20 days
even after its treatment, it is required to be
investigated through biopsy. "Biopsy is a simple
test for diagnosing the growth of ulcer.
Urging the people to avoid eating chalia in any
form, sweet supari, gutka, Dr Sajjad said that one
must know that diagnosis and treatment of oral
cancer is very costly and if an oral cancer patient
undergoes surgery, he or she might be requiring

Fig 14: The
result: The patient
with the ceramic
veneers in place

removal of excess cement easier and
faster. Before the veneers were seated,
retraction cords were placed and the
enamel was etched; the dentin
remained unetched. Adhese Universal
was used as the bonding agent to place
the veneers (Figs 10 and 11). Then
the excess luting composite was
carefully removed and a glycerine gel

expensive chemotherapy or radiation process.
RHINITIS: Talking of other ENT-related diseases,
he said that rhinitis, sinusitis and tonsillitis are
common among Karachiites, while allergic rhinitis
is also prevalent, particularly among children.
Causes of the diseases, he added, include polluted
atmosphere, sedentary lifestyle and unbalanced
dietary habits.
Most of the ENT problems are due to
environmental pollution, habit of drinking cold
water, beverages and the poisonous fumes being
emitted by vehicular traffic in the city, he said,
adding passive smoking and mushroom growth of
Sheesha cafes were causing havoc with the lives
of the young generation.

(Liquid Strip) was applied (Fig. 12).
This gel prevents the formation of an
oxygen inhibition layer at the margins.
The luting composite was cured with
two curing lights (Bluephase Style)
simultaneously and cooled with plenty
of water (Fig. 13). Figure 14 shows
the harmonious result produced by the
lithium disilicate veneers.
Conclusion
State-of-the-art restorative materials
have immense potential. Depending
on the particular requirements of the
patient and the indication, they allow
a suitable treatment option to be found
quickly and easily. The case presented
here shows that highly esthetic ceramic
veneers can be fabricated with minimal
effort using in-office equipment (IPS
Empress CAD). Nevertheless, pressed
ceramic veneers were chosen for this
patient, since they offered the
possibility of applying stains, through
which a very close match to the
neighbouring teeth could be attained.
In principle, however, highly esthetic
results can be achieved with both
approaches if the appropriate treatment
protocol is followed. DT, Chile

New biomaterial research ...
Continued from page 04

been given in vivo. The team will develop a new
approach using acoustic-sensitive liposomes for
ultrasound-mediated drug release and then monitor
the real-time drug concentrations in deep tissue.
“The ability to control the release of therapeutics
in targeted tissues with a desired spatial distribution
and at an adjustable rate according to the drug
response of each individual is important for
personalized medicine,” said staff engineer Dr.
Jian Ling of SwRI’s Department of Pharmaceuticals
and Bioengineering. DT, USA

[11] =>

[12] =>

12 DENTAL TRIBUNE Pakistan Edition July 2016
A full 3D digital setup was produced by the Simultaneous bleaching
Towards the last part of treatment bleaching
laboratory based on this curve - this was checked
Continued from page 06
by the dentist before going ahead. A 3-D model trays were made the patient started bleaches teeth
simultaneously. Impressions were taken and super
After a full examination and orthodontic was then produced the before and after positions.
Editor - Online
aligners
assessment, our first step was to decide on a The patient has shown the print before anyHaseeb
Uddinsealed trays were made on the nearly aligned teeth
landmark reference tooth. This is a tooth, which were built. This ensured he was fully consented - 6% Day white whitening from Philips was given
is considered aesthetic by the patient and aesthetic that he understood the potential compromises of to the patient with full instructions. He carried out
whitening once to twice a day for 35 minutes at
a time.
At two weeks notice a significant improvement
in the tooth colour.
A mockup outline was carried out using flowable
composite- and the patient was happy with the
proposed build-ups, which involved 4 teeth.
Edge Bonding
2 weeks later the edges were permanently built
using Venus Diamond and a very simple 2-layer
Fig 16: Chin up view before
Fig 17: Printed model set to spacewize
Fig 18: Before treatment
reverse triangle technique. No preparation was
required.
The retainer was fitted on the same day using a
jig made on an impression post alignment. This
was bonded using Venus Flow.
Conclusion
Fig 20: Occlusal after
Fig 21: Before treatment
Fig 22: 2 year review
Fig 19: After 3 step smile
One can see the natural- looking end result of this
treatment with retainer
patient. He was thrilled with the fact that the
treatment simply made his own teeth look as good
only treating the anterior teeth. The patient as they possibly could, rather than totally changing
and functional to the clinician.
An Arch evaluation and an occlusal trace is reviewed the models in his hand and was happy his appearance and feeling as if someone else’s
carried out with this reference point in mind using with what was proposed. The 3-D models were teeth were in his mouth. More significant is the
Spacewize software, so that the 3-D setup created returned to the lab and an upper Inman aligner fact that this could be done by any dentist with
by the technician following the exact prescription and lower Clear Smile aligners were built on the the simple “Three step smile” alignment bleaching
and bonding, with far less risk, better consenting
of the dentist. In this case it was decided that the setups.
A full Inman Aligner space creation guide with and arguably a far more natural outcome than
canines were in an ideal position so we certainly
should not be flared on the set up. The curve provided that outlined not only IPR but also PPR traditional veneer preparations. With upper and
strictly dictated the position to be achieved (Fig (predictive proximal reduction) -understanding lower fixed retainers in position canine widths
this makes the difference between average aesthetic and guidance can also be maintained meaning
SW trace).
reduced chance of composite fracture better longIt was discovered when considering the landmark and superb aesthetic results.
point in looking at a chin up view, that to achieve AProgressive space creation was carried out over term function and better long-term aesthetics. The
the ideal upper position, a lower tooth was in the a period of 12 weeks. The patient’s teeth started 2 year follow up showed no changes in occlusal
contacts or shifts in guidance. DT, UK
way and would need treatment. (Fig) to align.

The New Frontier of Interceptive ...

Punjab streamlines PG ...
Continued from front page
government shall exclusively be
reserved for private candidates only.
No in-service doctor (government
servant) shall be adjusted against
these seats.
The in-service employees shall also
apply through the new system. If
selected on merit through matching
system, they shall be admitted against
the only deputation seats reserved at
Post Graduate Medical Institute
(PGMI), University of Health
Sciences (UHS) and King Edward
Medical University (KEMU) as per
merit. However, where no deputation
seats are allocated, the in-service
candidates shall be placed according
to the merit as determined by the
JAC through central matching
system.
The government employees eligible
and wishing to pursue PG training
along with salary from the
government are required to complete
two years government service on
credit with Primary and Secondary
Healthcare and SHC& ME
Departments.
The health department would
highlight the total number of PG slots
in each institute as per need. Under

the new policy, every institute shall
forward details of vacant slots to the
department. One advertisement shall
be published to seek applications.
Each candidate requiring induction
must mention the choice of institute
and specialty he/she wishes to take
up.
All the graduates must fulfill
eligibility criteria with basic medical
qualification of MBBS/BDS or
equivalent medical qualification
recognised by Pakistan Medical and
Dental Council along with certificate
of one year's 'house job' experience.
There would be no admission on
honorary basis except those allocated
by the government and widely
advertised. However, the candidates
admitted through old scheme are
allowed to complete their remaining
period of training. No institution shall
be allowed to grant admission to any
candidate in any course in violation
of this policy. The candidates from
other provinces/foreign countries
shall be admitted against quota seats
reserved by the government at 3 per
cent of the total allocated seats, at
each university/institution.
Migration/re-registration and
induction for private institute trainees
at public sector institutions shall not
be allowed at any stage. However,

public institute trainees shall be
allowed to change supervisor by the
respective head/principal of
institution subject to fulfillment
requirements, and availability of paid
slot only after one year of training.
The case shall be presented before
the hardship committee once a year
for approval.
Applicants already pursuing
training or registered for training at
any institute shall not be eligible to
apply for fresh induction at other or
same institute and they may be
excluded from the merit list. If any
applicant is found to have concealed
earlier registration or training at the
time of induction and subsequently
identified,
his/her
enrollment/induction shall stand
cancelled without any notice.
The candidate shall opt for the subspecialty at the time of submission
of application for PG training. The
trainees inducted for two years
preliminary training shall be
automatically shifted to the subspecialties/departments of the same
institute for final three years training
without any procedural formality
subject to availability of slot.
Induction of PG trainee shall be
carried out against all programmes
offered by the government subject to

accreditation and recognition by
PMDC.

Study: Gum disease ...
Continued from page 04
body of literature that associates
periodontal disease with other
conditions in the body, including
diabetes and heart disease,” said
Wayne A. Aldredge, DMD, New
Jersey periodontist and president of
the American Academy of
Periodontology (AAP), which
publishes the Journal of
Periodontology. “While additional
research is needed on the possible
links between lung cancer and
periodontal disease, we know for sure
that taking care of your teeth and
gums can reduce periodontal disease
risk and possibly the risk of other
systemic conditions.”
Periodontal disease affects one of
every two Americans age 30 and
older and is 2.5 times more prevalent
than diabetes.
According to the American Cancer
Society, lung cancer is the leading
cause of cancer death in men and
women. About 158,000 Americans
are expected to die from lung cancer
this year. More people die of lung
cancer than colon, breast and prostate
cancers combined. DT, USA

[13] =>

[14] =>

14 DENTAL TRIBUNE Pakistan Edition June 2016

A case for single-use ...
Continued from page 02
such must be disposed of in accordance
with UK and European clinical waste
Editor - Online
management regulations. Historically,
Haseeb Uddin
this has meant that they were disposed
of alongside clinical sharps waste and
ultimately conveyed to incineration
and landfill. This has previously raised
concerns over their adverse
environmental impact.
However, a recent innovative
partnership between Robinson
Healthcare and one of the country’s
largest specialist health care waste
management companies, Healthcare
Environmental Group (HEG), has led
to the development of a unique UKwide recycling programme for singleuse surgical-steel instruments. Under
this initiative, HEG is now able to
provide dental practices with a unique
reusable Healthcare Sharps waste
container. The company has a fleet of
dedicated, regulation-compliant,
purpose-designed vehicles and the
capacity to service individual dental
practices and clinics with scheduled
waste container collections and
deliveries. Containers are tracked from
practice to recycling station using GPS
track and trace technology. Depending
on the annual volume of steel recycled,
HEG is potentially able to offer a
payback to dental practices that use
the Healthcare Sharps recycling
service. Overall, HEG operates nine
processing and energy recovery sites
across the UK, providing an energy
recovery programme that maximises
the environmental benefits.
Conclusion
The use of high-quality single-use
instruments can provide significant
advantages to dentists in general dental
practice, particularly in terms of
sterility, convenience, efficiencies and
reduced operating costs. Packs, such
as surgical, restorative, periodontal
and implant packs, can be particularly
helpful. The purchase costs of the
single-use instrument option are less
significant when the substantial hidden
costs of reusable instruments are
considered, and their cost in use is
typically significantly less than the
reusable instrument option.
Furthermore, recent advances in the
way that these instruments may be
recycled have effectively addressed
environmental concerns. DT UK &
Ireland

Intraoral Device for the
treatment ...
Continued from page 07
To conclude, school and work absence
and the reduced capacity at work also
cause economic damages.
Objectives and hypotheses
Hypothesis
Mandibular advancement devices
(MAD) are efficient for the treatment
of snoring and mild to moderate sleep
apnea.
Objectives
1. Applying a nocturnal cardio-

respiratory and pulse oximetry
monitoring (“ApneaLink”) in a
qualified “snorer” population
evaluating the OSA grade
(mild/moderate) and if the patient is a
candidate for MAD treatment.
2. Describe the clinical findings of the
situation before and after treatment
with two types of mandibular
advancement devices in a series of
adult patients.
3. Comparative analysis of the
e ff e c t i v e n e s s o f m a n d i b u l a r
advancement devices by means of
objective and subjective criteria.
4. Evaluating the possibility of
implementing this system as an
efficient method for the treatment of
mild or moderate OSA and cases that
do not tolerate CPAP.
Methodology
Description and subject group
selection
The study group consists of 30 snoring
adults, with mild/moderate sleep apnea,
aged between 36 and 68 years, 8
women and 22 men, who were treated
with a mandibular advancement device
(MAD).
A complete dental examination was
performed to get more detailed
information about TMJ and dental and
bone structure. It included: periodontal
and dental examination, panoramic
radiography and lateral cephalometry,
evaluation of the tongue and soft
tissues and, finally, possible occlusion
defects.
Inclusion Criteria
- Snorers
- The patient should have the ability
to advance the mandible forward and
open it without significant limitations.
Exclusion Criteria
- Patients with severe OSAS
- Patients with rhino-pharyngeal
pathology
- Inappropriately dentition, periodontal
diseases without treatment
- Serious problems in the
temporomandibular joint (TMJ)
- Insufficient protrusion capacity
Methods
1. Cardio-respiratory polygraphy
2. Epworth test
3. Dental impressions
4. Appointment for adaptation and user
instructions
Used devices
Although there exist over three
hundred systems of mandibular
advancement devices, we have tested
two devices that have, in our opinion,
a greater international presence placing
them randomly among our study
group. The used devices were intraoral
with lateral excursion, opening and
protusion appliance and the TAP
appliance (Figs. 1 and 2).
Procedures
The study and evaluation were
performed by the same professional
with over 20 years of experience in
the treatment of mandibular
advancement devices. Objective and
subjective assessments were performed
prior to placement and after one month
of treatment.
The study subjects had to fill in the

Epworth test and undergo the
ApneaLink after one month of
treatment; they underwent also a
questionnaire of satisfaction that the
subjects answered in collaboration with
their partners. This test evaluates the
satisfaction of both regarding a better
quality of life and noise.
The analyzed variables were: age,
sex, MAD type, AHI before and after
the MAD therapy, risk index before
and after MAD therapy, Epworth index
before and after MAD therapy and the
level of satisfaction of the patient and
his partner after MAD therapy.
Analytic study
In table 2 the mean values of the
received indices before and after using
MAD1 during one month are
compared.
The comparison of the parameters
was taken by the Wilcoxon test, as it
is about paired and small quantity data.
In table 3 the same analysis for MAD
2 is repeated.
As reported in table 2, MAD1 has
decreased the mean value of all indices,
this diminution is statistically
significant (p<0.005) in all indices.
Also in the use of MAD2 appeared a
statistically significant (p<0.005)
diminution of all indices. To compare
both MADs we calculated the mean
values of the differences between the
indices before and after using each
MAD. In table 4 the mean values of
the differences (index after MAD –
index before MAD) for each type of
MAD and its comparison through the
test of the U of Mann-Whitney is
reported, as it is about two different
sample groups and the group size is
relatively small.
It can be evaluated that MAD2
achieves a greater reduction of all
indices than MAD1, although the only
statistically significant parameter
(p<0.005) is the EPW.
Conclusions
1) With regards to the medical
complications of snoring and OSA and
the social restrictions and the negative
effects on the quality of life the
physician should identify the patients
that need support. It is a public health
problem that can be easy diagnosed
and treated. Recent studies even
demonstrated that the consumption of
public resources is 2-3 times higher in
patients with non treated snoring and
OSA than in the population without
OSA.
2) Totally advisable for all patients to
obtain an objective valuation of the
multidisciplinary diagnosis results.
The specialist should perform a clinical
diagnosis, a prior nocturnal monitoring
and, after a period of adaptation, a new
clinical valuation and objective and
subjective examinations. The
experienced specialist dentist in the
treatment of sleep apnoea with MADs
should select adequate cases, perform
design and adaption of the devices and
control possible side effects through
a regular follow up.
3) We prove the efficiency of the
mandibular advancement devices was
proven. In both cases the mean values

of all indices decreased and this
diminution is statistically significant
(p< 0.05) in all indices.
4) Analysis of the efficiency between
both types of MADs shows that the
screw Lateral excursion, opening and
protusion appliance achieves a greater
reduction of all indices, although the
only statistically significant index was
the Epworth test result (p<0.05).
5) Our medical trial should be
performed through a cost and
efficiency analysis, as the basic
advantages of the treatment, like the
decrease of the morbidity rate in the
long and short term, are very evident.
6) This study support the use of cardio
respiratory polygraph monitoring for
the evaluation of sleep apnea detection
in subjects of high probability of
disease suspicion and a high prevalence
or in populations of high prevalence
of sleep breathing disorders. Although
the controlled PSG is the standard
diagnosis tool for sleep apnea, not all
patients have access to such a study
in the sleep unit. The sleep unit
installations could differ from the
patients sleeps standards, there exist
long waiting lists in the neumology
services, the sleep study is connected
with high costs and the patient’s
willingness to sleep one night in a
sleep unit undergoing a nocturnal PSG
without confirmed OSAS could be
very low. This results show that the
cardio respiratory polygraphy is a
useful complementary technology for
the diagnosis of sleep apnea, due to
the sensibility, specificity, and simple
use of the device and the resulting low
costs of the sleep study. The cardio
respiratory polygraphy can be useful
in situations where the PSG is a
practical principle or in populations
with high prevalence of sleep apnea
supporting the options of diagnosis
and treatment.
This could lead to a timely evaluation
of sleep apnea and a better attention
to the patient causing a better health
status and life style.
7) Can be conclude that the adjustable
mandibular repositioning device is an
efficient treatment alternative for
patients with snoring and sleep apnea.
The severity of the OSAS motivates
the specialist to get a better knowledge
about it and makes him aware of the
importance of its multidisciplinary
character. Including the participation
of a dentist that is well experienced in
the treatment of OSAS patients through
the use of MAD, a treatment alternative
with a high patients’ acceptance,
because of its low treatment costs and
high efficiency being an individualised
treatment option or in combination
with other treatments.
8) It s a good recommendation that the
public health authorities formulate a
valid preventive dentistry plan, as it
was demonstrated that the sleep apnea
problem is a sanitary priority of high
relevance because the efficiency of
mandibular advancement devices for
the treatment of snoring and mild and
moderate sleep apnea-hypoapnea.
DT, Spain

[15] =>

[16] =>

) [page_count] => 16 [pdf_ping_data] => Array ( [page_count] => 16 [format] => PDF [width] => 694 [height] => 1048 [colorspace] => COLORSPACE_UNDEFINED ) [linked_companies] => Array ( [ids] => Array ( ) ) [cover_url] => [cover_three] =>

[cover] => DT Pakistan No. 4, 2016

[toc] => Array ( [0] => Array ( [title] => Pakistani Dentists win at APDF [page] => 01 ) [1] => Array ( [title] => News [page] => 02 ) [2] => Array ( [title] => The New Frontier of Interceptive Aesthetic Orthodontics [page] => 06 ) [3] => Array ( [title] => Intraoral Device for the treatment of Sleep Apnea [page] => 07 ) [4] => Array ( [title] => Two approaches and one goal [page] => 08 ) [5] => Array ( [title] => Study: Graft can help improve gums’ support for existing implants [page] => 10 ) ) [toc_html] =>

Table of contents

[toc_titles] =>

[cached] => true )