prevention international No. 1, 2018

Cover / Editorial / Content / European Federation of Periodontology celebrates general assembly in Vienna / Interview with Prof. Søren Jepsen, Scientifi c Chair of EuroPerio9 / The holistic connection between oral and general health / Eklund Foundation—Supporting research in odontology / “Dental implants require more attention” / Gain a child, lose a tooth? / Pregnant women are hardly informed about the importance of oral health / Oral microbiota, intestinal microbiota and inflammatory bowel disease / We have an enormous infl uence on children’s overall health / The oral biofilm: What you should know / Gingival health benefits of enzymes and proteins in toothpaste / When to avoid implants / Oral hygiene instructions and patient motivation with and without dental hygienists / “We’re all about prevention” / Patient motivation techniques / My Guided Biofi lm Therapy journey / Knowing-doing gap in dentistry / Already cleaning or still polishing? / Patient satisfaction is key / “Prevention is not just for children and young people” / Ozone therapy in dentistry: notably effective in accelerating pre- and postoperative healing / Manufacturer News / When prophylaxis means everything and nothing / International Events / How to send us your work? / Imprint

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issn 2567-286X • Vol. 2 • Issue 1/2018

1/18

prevention
international magazine for oral health

science of prophylaxis

The holistic connection between
oral and general health

peri-implantitis

When to avoid implants

practical prophylaxis

“Prevention is not just for
children and young people”

[2] =>

Le microbe n´est rien,
le terrain c´est tout
since 1892

r

OZONE THERAPY
FOR DENTISTS

o ne W

ate

Oz

SAFE AND EFFECTIVE

O

Oi

Means to ameliorate the terrain.
Ozone Water in combination
with ozonated oil for periodontitis,
periimplantitis treatment
n at e d
and in oral surgery.
zo

MADE IN GERMANY

l

Booth 11.09C
www.hoffmann-dental.com

[3] =>

editorial

|

Magda Wojtkiewicz
Managing Editor

“Actually, prevention is the key”
Dear Readers,
I have been working as an editor at Dental Tribune
International for over twelve years and as a clinical
editor for its specialist publications, I have witnessed
tremendous changes in many fields of dentistry. In only
a few years, analogue become digital and the approach to
diagnostics, treatment planning, implant placement and
restorative treatment changed completely in dentistry.
Currently, the dental professional can design a new smile
for a patient before he or she even sits on the dental
chair. There are so many new techniques and technologies to apply, but is this really the direction in which
dentistry should be developing first of all?
A representative YouGov survey performed in 2017
found that one in three adults in the UK do not brush their
teeth twice a day, including a third of men. According
to a research conducted in 2015 by renowned toothpaste manufacturer, over 90 per cent of citizens of one
of the European countries believe that eating an apple
substitutes for brushing. Figures provided by National
Smile Month, the UK’s largest and longest-running campaign to promote good oral health, show that a third of
all children starting school each year have signs of dental
caries and tooth extractions are the main reason children
are admitted to hospital for general anaesthesia.
These are only some of the frightening figures that
continue to shock with information about the low level of
oral health worldwide.
There are still patients who think that they do not have
to clean their prostheses and parents who do not brush

their children’s primary teeth because, after all, they will
fall out anyway.
Despite the efforts of the FDI World Dental Federation,
the leading global body committed to oral health, which
organises educational programmes and awareness
campaigns, the level of oral health, even in developed
countries like the UK and most of the EU countries, is
still unsatisfactory and many people only visit the dentist
once they already have a problem.
Therefore, in my opinion, there is a great need to make
people aware of the risks and health implications that
come with poor oral hygiene and that prevention is the
key to a beautiful smile, not zirconia crowns or dental
implants. Prosthetic solutions are necessity when prevention fails, but dental professionals should be primarily
focused on prevention, should they not?
I feel very grateful that, after so many years of writing
and editing articles on how to improve prosthetic solutions, I am finally involved in producing a publication
about how to prevent oral disease and maintain good
oral health, because I believe that this should be a direction in which dentistry should develop primarily.
With this in mind, I wish you all happy reading of this
year’s first issue of the prevention magazine and hope
that the articles will be informative to you and offer you
ideas for efficient application in your practice.
Yours sincerely,
Magda Wojtkiewicz
Managing Editor

prevention
1 2018

03

[4] =>

| content
editorial
“Actually, prevention is the key”

03

Magda Wojtkiewicz

theory of prophylaxis
European Federation of Periodontology news

06

science of prophylaxis
page 06

The holistic connection between oral and general health

10

Eklund Foundation—Supporting research in odontology

14

“Dental implants require more attention”

16

systemic diseases

page 28

Gain a child, lose a tooth?

18

Pregnant women are hardly informed about the importance of oral health

22

Oral microbiota, intestinal microbiota and inflammatory bowel disease

26

We have an enormous influence on children’s overall health

28

biofilm
The oral biofilm: What you should know

32

Gingival health benefits of enzymes and proteins in toothpaste

36

peri-implantitis
When to avoid implants

38

special: dental hygiene
page 38

Oral hygiene instructions and patient motivation

42

“We’re all about prevention”

48

Patient motivation techniques

50

My Guided Biofilm Therapy journey

52

psychology of prophylaxis
Knowing-doing gap in dentistry

54

practical prophylaxis
Cover image courtesy of
EMS – Electro Medical Systems S.A.
(Guided Biofilm Therapy campaign, Miami)
1/18

issn 2567-286X • Vol. 2 • Issue 1/2018

prevention

56

Patient satisfaction is key

60

“Prevention is not just for children and young people”

64

Ozone therapy in dentistry

66

manufacturer news

68

special

international magazine for oral health

When prophylaxis means everything and nothing

72

international events

76

about the publisher

science of prophylaxis

The holistic connection between
oral and general health

peri-implantitis

When to avoid implants

practical prophylaxis

“Prevention is not just for
children and young people”

04

Already cleaning or still polishing?

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1 2018

submission guidelines

77

international imprint

78

[5] =>

Eklund Foundation for
Odontological Research
and Education

The Eklund Foundation for Odontological Research and Education was established in 2015 to support research and education
in the odontological field. It rests on a donation of MSEK 50 by the Eklund family, founders of the Swedish oral hygiene company
TePe Munhygienprodukter AB.

The Eklund Foundation supports international research and education within the dental
field. In 2018, the foundation is distributing approximately €160,000 to high-quality projects in
odontology. The foundation welcomes applicants from all fields of dentistry and will
particularly prioritize projects related to periodontology, implantology and cariology.
“The foundation is a way for us to show our appreciation and create something that will contribute
to knowledge and development within the odontological field for many years to come.”
Joel Eklund, CEO, TePe Munhygienprodukter AB

AD181151INT

Next application period will be open May, 2019.
Learn more on www.eklundfoundation.org

[6] =>

| theory of prophylaxis
European Federation of Periodontology

European Federation of Periodontology celebrates
general assembly in Vienna
Raising awareness of the importance of keeping gingivae healthy
throughout a whole lifetime, particularly among people aged over
60, is one of the new priorities of the European Federation of Periodontology (EFP), the leading global organisation on periodontal
science and practice. Other aims include strengthening the leadership of the EFP around the world and promoting the status of
periodontology among dentists and other health professionals.

gathered in Vienna in Austria on 17 March to celebrate the EFP’s
annual general assembly and to discuss future projects. Highlights
of the meeting included the appointment of Prof. Anton Sculean as
new EFP President, the launch of the EFP mobile app, the international dissemination of the Perio and Caries project, and reports on
the final preparations for European Gum Health Day 2018 in May
and the EuroPerio9 congress in June.

More than 75 experts and officers from 30 national scientific
societies specialising in periodontal health and implant dentistry

Sculean, chair of the department of periodontology and executive director of the School of Dental Medicine at the University of
Bern in Switzerland, has taken over the helm as EFP President
from Prof. Gernot Wimmer, Senior Scientist and Privatdozent at the

Medical University of Graz in Austria. Other major appointments by
the assembly included Prof. Lior Shapira (Israel) as new executive
committee officer and coordinator of European Gum Health Day 2019,
and Prof. Filippo Graziani (Italy) as President-elect. In addition,
Prof. Nicola West (UK) and Dr Monique Danser (the Netherlands)
will join the EFP’s executive committee in 2019 as secretary general and treasurer, respectively.
The EFP’s general assembly included the official announcement
of European Gum Health Day 2018, to be celebrated on 12 May to
raise public awareness across Europe of the importance of keeping gingivae healthy throughout life. “Health begins with healthy
gums” is the slogan chosen by the EFP to remind authorities and
the public that gingival health is an achievable and cost-effective
way to improve general health, public health and quality of life.

Prof. Anton Sculean

By joining European Gum Health Day 2018, more than 25 national
societies of periodontology are organising at the national level
a wide range of public events, conferences, communication
projects, periodontal check-ups and other activities, under the
coordination of Dr Xavier Struillou, who is making sure that their
messages are aligned.
EuroPerio9—The world-leading congress
Participants of the Vienna general assembly were informed of
the latest preparations for EuroPerio9, which will take place in
Amsterdam in the Netherlands between 20 and 23 June and is
widely regarded as the world’s leading congress in periodontology and implant dentistry. Registration for EuroPerio9 is open
and attracting numerous attendees, journalists and companies.
The recently finalised scientific programme features innovative
session formats, and more than 100 presentations will be deliv-

Prof. Lior Shapira

06

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|

ered by world-class speakers, supported by a record number
of more than 1,700 abstracts, which will be presented via
oral presentations, poster discussions and e-posters.
Furthermore, the EFP officially launched the phase of
international dissemination of its Perio and Caries project, supported by Colgate, which allows all EFP-affiliated societies to take advantage of a wide array of scientific and educational content, including brochures,
reports, infographics, videos and other material.
The Perio and Caries awareness project builds on
the knowledge extracted from Perio Workshop 2016,
the top-level scientific conference organised by the
EFP jointly with the European Organisation for Caries
Research in November 2016 in La Granja in Spain. EFPaffiliated societies are offered all Perio and Caries publications free and encouraged to disseminate, edit or translate
them if they wish. This process has proved successful with a
similar initiative previously developed by the EFP, the Oral Health
and Pregnancy project, supported by Oral-B, which is now being
disseminated by 20 national member societies in their respective
languages and countries.
EFP Graduate Research Prizes in Periodontology
The first prize of the EFP Graduate Research Prizes in Periodontology, which is given to the best research from EFP-accredited
graduate perio programmes, was awarded to the study “At least
three phenotypes exist among periodontitis patients”, authored by
Dr Chryssa Delatola, Prof. Bruno Loos, Dr Evgeni Levin and Dr Marja
Laine from the Netherlands. The second prize was given to research
titled “Reduced platelet hyper-reactivity and platelet-leukocyte aggregation after periodontal therapy”, a paper written by Dr Efthymios
Arvanitidis, Dr Sergio Bizzarro, Dr Elena Álvarez Rodríguez, Prof.
Bruno Loos and Dr Elena Nicu, also from the Netherlands. The third
prize went to the study “Oral health in relation to all-cause mortality: The IPC cohort study” by Dr Nicolas Danchin from France,
Prof. David Batty from the UK and Prof. Philippe Bouchard from
France. Concerning personal recognition, Prof. Jan Wennström
received the EFP Distinguished Scientist Award, and Prof. Stefan
Renvert the EFP Distinguished Service Award.
Strengthening the message
“As the EFP reinforces its leadership and its role as the world benchmark in gingival health and periodontal disease, it is time for us to
strengthen the message that gingival health brings not only oral
health but also overall health, well-being and quality of life throughout a whole lifetime, and particularly among the population aged over
60,” highlighted Sculean. “I am deeply happy and honoured to lead
this exciting time for the EFP and for periodontology in Europe, as we’ll
keep working on promoting its acknowledgement as a recognised
dental specialty in all EFP countries, and on turning it into an area
of interest for dentists, dental students and patients across Europe.”

the
aim of
tackling the
hidden epidemic of periodontal
disease. Now I’m ready to continue to contribute to the success of exciting forthcoming EFP projects, starting with EuroPerio9 next June.”
Other major outcomes of the Vienna general assembly were the
launch of the EFP app for accessing key EFP content via smartphones and tablets, recognition of the Lithuanian periodontology
society as a full-member society and the decision to hold Perio
Master Clinic 2019 in Hong Kong next year.
EFP—The global benchmark in periodontology
The EFP is the driving force behind EuroPerio—the world’s
leading congress in periodontology and implant dentistry—and
Perio Workshop, a globally leading meeting on periodontal science. It is an umbrella non-profit organisation that brings together
30 national scientific societies of periodontology in Europe, northern Africa and the Middle East, which together comprise about
14,000 specialist dentists, researchers and other members of the
dental team focused on improving periodontal science and practice. The EFP also edits the Journal of Clinical Periodontology, one
of the most authoritative scientific publications in this field.
More information can be obtained at www.efp.org.

Wimmer said, “I am proud that this 2018 general assembly has
brought together here in Vienna many of the most brilliant periodontal scientists, clinicians and teachers in the world, to review
progress made over the last year and to prepare future action with

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07

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| theory of prophylaxis
European Federation of Periodontology

Interview with Prof. Søren Jepsen, Scientific Chair of EuroPerio9
This year’s EuroPerio, the world’s leading congress in periodontology and implant dentistry, is expected to attract up to 10,000
periodontists and members of the dental team to learn about the
latest in periodontal research and clinical practice, in June in Amsterdam in the Netherlands. In this interview, Prof. Søren Jepsen,
past President of the European Federation of Periodontology (EFP)
and Scientific Chair of EuroPerio9, outlines the event’s scientific
programme, which features more than 100 top-level speakers
and many innovations. The detailed programme is available at
www.efp.org/europerio9/programme/scientific/index.html.

Prof. Søren Jepsen

Why should a dentist or a hygienist consider attending EuroPerio9?
Because EuroPerio9 is their opportunity to obtain the best insight
on periodontology and implant dentistry available in the world until
2021—when EuroPerio10 takes place. EuroPerio9 has gathered
the best pool of talented speakers from Europe and around the
world for an audience that is increasingly global too. We’ll enjoy a
great venue in a city as attractive and well-connected as Amsterdam. And then there are the events of the networking programme,
the fact that all happens in only four days and the choice between
four parallel tracks of presentations according to the attendee’s
interests. All in all, attending EuroPerio9 is the most enjoyable and
cost-effective way to be fully updated on the best in periodontology
and implant dentistry available today.
Will EuroPerio9 be similar to EuroPerio8 (London, UK, 2015) and
EuroPerio7 (Vienna, Austria, 2012)?
It will be definitely unique! We have created the Team Session
track, which is more inclusive than the previous separate track for
dental hygienists. We have added more sessions on the afternoon
of Wednesday, 20 June, to take better advantage of the time before
the official opening ceremony. We have arranged sessions in such

prevention
1 2018

a way that many more dental professionals will be able to present
their short oral presentations and posters for discussion. We have
included the well-established stars in the specialty and have more
women speakers and young speakers than ever before. We have
built on the best of our successful experiences and we have added
a number of new formats.
What are those new formats?
We have designed eight new formats. First, on the opening day,
we will have a special double session with the Japanese Society
of Periodontology, one on biofilm and anti-infective therapy, the
other on regenerative periodontal and implant therapy. Second,

the Perio Talks will offer fresh, TED Talk-style presentations given
at the first EFP Alumni Symposium. Third is a lively debate about
the use of antibiotics, led by Profs. Andrea Mombelli and David
Herrera, in which attendees will be able to use their smartphones as
voting devices. Fourth, for the first time, a live surgery session will
take place at a EuroPerio congress. A new, rarely performed procedure with implants will be carried out by Prof. Giovanni Zucchelli
and Dr Martina Stefanini at the Academisch Centrum Tandheelkunde Amsterdam dental school and broadcast in real time.
The fifth major innovation is the interdisciplinary treatment planning
session, in which cases will be shown and the audience will choose
between different options for treatment. Sixth is a 3-D session with
Dr Pierpaolo Cortellini and Prof. Stefan Renvert on reconstructive surgery on teeth and implants, in a large auditorium. Seventh is the EFP
Perio Contest, for which presentations will be judged not only by an
expert panel but also by social media voting before the congress. The
three final contestants will be invited to present their work on stage
on the last day of the congress. Eighth is the Nightmare Session, in
which Drs Mario Roccuzzo, Giulio Rasperini, Jean-Louis Giovannoli
and Caroline Fouque will explore treatments that went badly.
Being Scientific Chair of EuroPerio9 sounds like quite a
challenge. How has the experience been?
It is, indeed, an incredible challenge, but also an opportunity to work
with a wonderful team of periodontists and professional organisers. Together, we have worked hard to put together a high-quality
programme with the latest research in the field, the best professionals and the new formats I mentioned. I hope that EuroPerio9
will provide attendees with a fruitful and unforgettable experience!

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theory of prophylaxis

European Federation of Periodontology

Periodontal disease and caries—The most common human conditions
Periodontal disease and dental caries are the two most
widespread oral conditions in the world and in fact the two most
prevalent non-communicable human diseases. Both are preventable1 and share common genetic, aetiological and environmental
factors. Given that they follow different trajectories, they have
traditionally been studied separately. Not anymore.
For the first time, the European Federation of Periodontology (EFP)
has put forward a new, common approach by launching Perio and
Caries, an ambitious Europe-wide project aimed at raising awareness among scientists, health practitioners and the public about
the associated causes, risk factors, interactions and prevention
measures than may affect both periodontal disease and dental
caries. The core element of the Perio and Caries project is the
newly created dedicated site perioandcaries.efp.org, which contains a wealth of educational materials, which are freely available
and downloadable. These publications include a specially written
scientific report compiled by Prof. Nicola West, as well as five
targeted recommendation brochures, each providing concise advice for oral health professionals, other healthcare professionals,
researchers, policymakers and the population at large.
The Perio and Caries initiative, sponsored by Colgate, has been
designed to disseminate the outcomes of Perio Workshop 2016,
a major scientific meeting held in La Granja in
Spain and jointly organised by the EFP and European Organisation for Caries Research (ORCA).
It was co-chaired by Prof. Mariano Sanz (EFP)
and Prof. Andreas Schulte (ORCA). All Perio and
Caries publications are based on the knowledge
generated at Perio Workshop 2016.
Based on the contributions from 75 leading global
cariologists and periodontologists organised
in four working groups, Perio Workshop 2016
pioneered the exploration of the boundaries
between dental caries and periodontal disease.
It reviewed all available scientific evidence on
common links between these oral conditions, including identified similarities—and the distinct
characteristics of each—and recommended clear preventative
strategies to help tackle them.
The scientific conclusions of Perio Workshop 2016 are publicly
available in a special open-access supplement of the EFP-edited
Journal of Clinical Periodontology.2 Furthermore, the Perio and
Caries site offers a series of related videos, news, additional
documentation and all the scientific papers produced by the four
working groups at Perio Workshop 2016, which examined the role
of microbial biofilms; the interaction of lifestyle, behaviour and
systemic disease; prevention and control; and age-related effects,
all in relation to dental caries and periodontal disease.

Available free to everybody
Perio and Caries materials are to be shared with all 30 EFP-affiliated
national societies of periodontology in Europe, northern Africa, the
Middle East and the Caucasus, and their members—around 14,000
periodontists, other dentists, researchers and other oral healthcare
professionals interested in gingival health. Stakeholders can freely
take advantage of this Perio and Caries content in their dental
practices, schools, laboratories and companies. The same applies
to any other people who may be interested. “The project Perio and
Caries disseminates for the first time a new approach to dental
caries and periodontal disease as connected conditions,” explained
Prof. Mariano Sanz. “Building on the outcomes of Perio Workshop
2016, Perio and Caries pays attention to the common risk factors
that make people lose their teeth because of caries, periodontitis
or both. Emphasis has been put on patients’ quality of life, not only
how these widespread oral diseases impact upon their well-being,
but also the reverse situation, how socioeconomic factors heavily
influence the prevention, development and treatment of these diseases.”
“Sugar intake, smoking and excess weight are
the three key factors to be reduced in order to
help tackle both periodontal disease and caries,”
pointed out Prof. Iain Chapple, Secretary General
of the EFP and co-chair of one of Perio Workshop 2016’s working groups. “By bringing down
carbohydrate intake to less than 25 gramme per
day, by fighting and ideally eliminating the smoking habit, and by avoiding obesity, we are not
only improving our general health, but having a
meaningful, positive impact against periodontal
disease and dental caries.”
“The main message of Perio and Caries is that tooth loss, periodontal disease and caries are nearly always preventable,” concluded
West. “Following simple recommendations such as brushing teeth
with fluoride toothpaste twice a day, reducing the amount of sugar
and starch in the diet, staying away from tobacco, and seeing your
dentist twice a year would improve dental and overall health, as well
as alleviate the economic burden of periodontal disease and dental
caries. We hope that medical professionals will heed our campaign’s
motto: ‘Teeth are for a lifetime. Take action!’ and will guide their
patients accordingly.”
Editorial note: A list of references can be obtained from the publisher.

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| science of prophylaxis

The holistic connection
between oral and general health
By DTI

To discuss about the future in holistic healthcare education, prevention met up with Dr Marzia Massignani,
Global Scientific Affairs Manager for Sunstar, at the
company’s new Étoy headquarters in Switzerland—

just a stone’s throw from the beautiful Lake Geneva.
“The holistic connection between oral and general
health really is our main focus,” she explained. “By taking care of your oral health, you are taking care of your
general health. Interestingly, there is still so much that
can and needs to be studied in this field. The biggest
challenge, however, is gaining people’s attention. People are being bombarded with information in the form
of blogs, journals, social media, and so on. Obviously,
oral and general health information easily get lost along
the way.”

Where did Sunstar’s holistic approach to well-being
originate?
Dr Marzia Massignani: Prior to his death of complications from diabetes, Kunio Kaneda, Sunstar founder,
made it very clear in his last few hours of conversations
with his son, Hiroo, that he wanted him to search for the
best professionals working around diabetes. As a representative of Sunstar at the Sunstar Portside Symposium in
Kobe in Japan in 1987, Hiroo addressed the link between
diabetes and oral health. There had been a number of
studies done before, but by bringing this link to the attention of the scientific community and promoting research
on the subject, he really opened up the way for a new field
of study that is now widely accepted and researched. Of
course, this vision has now been taken up and driven by
the third generation, led by CEO Yoshihiro Kaneda.
Is there a difference in how oral health and other
medical specialists regard this interconnection?
We have been doing research on how diabetes associations communicate with patients and found that this
link sometimes is not stressed enough. We gained the
impression that this idea is still not widely accepted in the
medical community and that there is more input provided
by periodontists than diabetes researchers at present.
However, in World Health Organization reports and the
International Diabetes Federation guidelines, diabetes is
already described as being linked to periodontal disease
and vice versa. Moreover, as part of a project Sunstar
funded, the European Federation of Periodontology and
the International Diabetes Federation released a number
of new guidelines for dental professionals, medical professionals and patients. So, although more organisations
are starting to address this link, Sunstar still has an important role in educating the wider public and supporting
health professionals.

Dr Marzia Massignani

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In the process, we have developed a virtual reality tool
showcasing the connection between oral and general
health. It is a purely scientific and non-commercial project that is to be launched at the upcoming EuroPerio9
congress in June. In fact, we already showed it at the
last International Diabetes Federation congress because
we wanted to gain the attention of diabetes specialists
too. If we connect a new medium that people have not
experienced yet to our holistic health message, there is

[11] =>

science of prophylaxis

a greater likelihood that they will remember it. So far, I can
say it has worked.
Another way of gaining people’s attention is the Perio
Link Award. Can you tell me more about that?
Oral and general health concern everybody. However,
although there are a great number of excellent papers
that explore the link between them—well-executed and
with solid results—they are usually not available to the
general public and this is wrong! Science is for everyone.
The only way to encourage people to like science and
become involved is to break it down in a way that everybody understands. For this reason, and also to promote
research in the field, we established the Perio Link Award.
For the Perio Link Award, the Sunstar Foundation’s scientific committee selected what they felt were the most
influential scientific papers of the last three years on the
oral and general health link. The nominees for the award
were asked to explain their research in a one-minute video.
Some nominees had difficulty in doing this because they
had never been asked to do this before. In order to spread

their scientific research, the nominees were then asked
to share their videos and collect votes. The project with
the most votes would receive a monetary prize, as well as
an expenses-paid visit to this year’s EuroPerio congress
in Amsterdam in the Netherlands. It was pleasing to see
how some scientists employed their networks to spread
their message. Some healthy competition between different teams of course also contributes to spreading the
message.
How do Sunstar’s various product groups relate to
each other based on the holistic view that mouth and
body are interconnected?
Industrialisation has largely led to specialisations in
products and professions and too often there is no link
with other fields. Cross-disciplinary thinkers are valuable
to break silos. Sunstar, for instance, connects a number of different business units. So how are toothbrushes
connected with motorbikes, brakes or sealants? Simple:
health and safety. Inflammation, for example, is common
to a number of diseases, such as diabetes, periodontitis,
dementia and obesity. It is a connector and a starting

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| science of prophylaxis

© Jepsen S, Sanz M, Stadlinger B, Terheyden H. Cell-to-Cell Communication: Oral Health and General Health—
The Links between Periodontitis, Atherosclerosis, and Diabetes. Quintessence Publishing Group, Berlin, 2015.

point. When one considers inflammation and ways of
preventing it from a holistic perspective, the solution lies
in avoiding stress, sleeping well, and ensuring good oral
health and quality of life.
Do you think that has something to do with Sunstar
being a Japanese company?
Japanese culture definitely has an impact on what
we do. Many companies in Japan are very specialised
and pursue nothing less than perfection. That of course
is something that we strive for as well. Apart from that,
Sunstar is a product of our chairman and CEO’s vision.
Their business decisions are informed by their collaboration with people from all over the world and being open
to seeing things from different perspectives. One could
say that they are holistic thinkers themselves.
Have you incorporated Sunstar’s 360° approach to
health into your personal life?
Oh yes, very much so. And to be honest, I feel extremely thankful. It was only after starting my job at
Sunstar that I heard about the connection between oral
and general health, and I have noticed, in talking to friends,
that I have become very evangelical about the subject
myself! Personally, I have started to think about things
I had never considered before, such as the possible role
of mindfulness in enhancing mental health and reduc-

prevention
1 2018

ing stress through various relaxation methods. There is
a proven link between stress and inflammation, and I am
interested in holistic ways to reduce it. My work here has
greatly changed my way of experiencing life, as well as
my way of communicating.
Finally, what are your wishes and recommendations
for dental professionals?
My greatest wish is for dental professionals to spend a
little bit more time in talking to their patients. A good oral
health routine, including using interdental brushes and
going to the dentist at regular intervals, is the gateway
to good general health. Dentists have a tremendous opportunity in passing on this knowledge to their patients.
If they would take an extra five minutes to do that, we
would see an overall improvement in quality of life.
Of course, it would also help if governments will include
oral health and care in their agenda and prioritise it. As political changes are driven by people, we need to support oral
care and health professionals in educating their patients.
The Perio Link Award demonstrates that the supporting
research is there and that the data is excellent. These
are no fairy tales. We need to make people aware and
empower them.
Thank you very much for the interview.

[13] =>

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[14] =>

| science of prophylaxis

Eklund Foundation—
Supporting research in odontology
By DTI

The Eklund Foundation for Odontological Research
and Education was established to support high-quality
research in the field of dentistry. It was launched with a
donation of €5.5 million by the Eklund family, founders
of the Swedish oral hygiene company TePe Munhygienprodukter. Key in reviewing the research projects and
presenting the applications under consideration to the
board is Dr Anna Nilvéus Olofsson, Manager of Odontology and Scientific Affairs at TePe.
First of all, what constitutes a perfect research project for the Eklund Foundation?
Dr Anna Nilvéus Olofsson: Applicants from all fields of
dentistry are welcome, though we prioritise periodontol-

ogy, implantology and cariology. The applications are assessed on well-defined criteria: novelty and originality,
feasibility and scientific quality of the proposed research,
and lastly, the merits of the applicants, as well as the quality of their applications. Every year, we receive a significant number of high-quality applications and are pleased
to be able to select projects that really stand out.
What is your greatest challenge in selecting successful applicants?
We see it as an opportunity to contribute to high-quality
research, rather than a challenge. The real challenges are
tackled by the researchers, whereas it is our privilege to
support them.

Riccardo Guazzo, Eriberto Bressan and co-applicant Luca Sbricoli (absent on photo) from University of Padova
(Italy), received funds from Eklund Foundation in 2017, here together with Dr Anna Nilvéus Olofsson,
Manager Odontology and Scientific Affairs and Joel Eklund, CEO, TePe Oral Hygiene Products.

[15] =>

science of prophylaxis

How can the results of the research projects be integrated into dental practice?
It depends on the aim and characteristics of the projects, but as the research process often runs for an
extended period of time, the outcome cannot be realised
in practice before the results are thoroughly analysed
and compiled. The majority of the applications for funding
are in their initial stages, and we expect a number of our
selected projects to have strong clinical relevance in the
long run.
For instance, we know for a fact that globally there is
a growing elderly population with more implants and
prosthetic constructions. Research results will contribute
to knowledge about how to address these challenges.
Another highly topical research focus is the connection
between oral and general health, which may influence
medicine from a wider perspective. We look forward to
seeing how the funded projects will contribute to odontological knowledge and what clinical impact they will have
in the future.
How does the Eklund Foundation differ from other
organisations that support research in the field of
dentistry?
Some foundations work locally, while others—such
as the Eklund Foundation—work globally. Many different types of foundations are needed to support as much
high-quality research as possible, and there is no competition between them. It is important to stress that research has to be carried out independently from company
interests in order for it to be unbiased. Thus, the Eklund
Foundation operates entirely independently from TePe.
The foundation is a way for the owners of TePe to show
their appreciation for the dental profession and create
something that will contribute to knowledge and development in the field of odontology for many years to come.
Do you see dentistry becoming more medical, embracing prevention and primary prophylaxis?
Prevention already plays a big role and will become
even more prominent in the future. Good oral hygiene
and good oral health have turned out to be of wider importance than initially thought. Oral health is not merely
about brushing one’s teeth, cleaning interdentally and
having a good oral health routine; rather, it is about maintaining a healthy lifestyle, of which oral hygiene is an essential part. In recognition of this, TePe was recently
awarded a life science prize. This is a clear indication
that oral hygiene belongs to the domain of life sciences,
and it pleases me to see oral health being placed in a
wider health context.
Is TePe’s philosophy reflected in the Eklund Foundation in any way?
Although they exist independently of each other, both
TePe and the Eklund Foundation place high value on

Dr Anna Nilvéus Olofsson

close relationships with the dental community. TePe was
founded in close collaboration with the profession and
listens to their specific needs and issues, which in turn
translates into the development of new products. The
goal is not merely to develop visually attractive oral health
products; every product has a clinical relevance. As a
dentist, I can thus fully endorse TePe’s product portfolio.
Lastly, how can researchers apply for funding?
All information regarding the application process is
available at www.eklundfoundation.org, including the
application form and clear instructions on how to apply.
The application period opens in May each year, and the
projects that will receive funding are announced in the
autumn.

info
Facts about the Eklund Foundation
– Founded in 2015 by the Eklund family
– Supported by a donation of €5.5 million
– Next application period starts in May 2019
– More information is available at www.eklundfoundation.org

prevention
1 2018

[16] =>

| science of prophylaxis

“Dental implants
require more attention”
By DTI

One of the applicants to be awarded a grant by the
Eklund Foundation for Odontological Research and
Education in 2017 was Dr Riccardo Guazzo, who combines his research at the dental clinic of the University
of Padua with running a private practice in Vicenza in
Italy. Through their research project titled “Peri-implant
disease in elderly population: Epidemiology and treatment strategy of an emerging problem”, Riccardo and

16

prevention
1 2018

his team seek to address the increasingly prevalent
problem of peri-implantitis in ageing populations, with the
ultimate aim of developing effective prevention and treatment strategies.
Your research topic is peri-implant disease in the
elderly population. Why is this such an important
subject?

[17] =>

science of prophylaxis

Dr Riccardo Guazzo: Dental implants are the biggest
revolution in dentistry of the last 30 years. They allow
restoration of masticatory function and improvement of
patients’ quality of life from an aesthetic, psychological
and functional point of view. More and more patients are
being treated with dental implants: over 15 million implants were placed in 2013, of which 1.3 million were in
Italy alone. The purpose of our study is to assess the
prevalence of peri-implant disease in elderly dependent patient
populations by studying nursing home residents in the province of Padua in Italy. The constant increase in the use of dental
implants and their associated inflammatory pathologies, as well
as the increase in the number of
elderly patients in nursing homes,
underlines the originality and relevance of our study. Furthermore,
this study will be the precursor to
a wider programme that will aim
to prevent peri-implant disease
and ensure optimal peri-implant
tissue health and maintenance.
Why did you decide to explore
this specific topic?
According to the 2015 official
data from the Italian National Institute of Statistics, the average life expectancy in Italy for
women and men was 83 and 79.6 years, respectively.
More and more elderly people go to nursing homes because they gradually lose the ability to maintain an independent life and carry out normal everyday activities,
including proper oral hygiene. The last is a fundamental prerequisite for long-term maintenance of dental implants. Inadequate oral hygiene can lead to inflammation of hard and soft peri-implant tissue. Symptoms of
peri-implant disease are pain, abscesses, bleeding, halitosis and difficulty chewing. All of these symptoms result
in a reduced quality of life.
Does your research focus on a specific region? Are
there significant differences between countries?
A great number of people in various countries have
implant-supported prostheses. We decided to start our
research in the Padua area because there are more than
62 nursing homes in the city, giving us an estimated sample size of 3,000 subjects. Initially though, we will screen
patients from a smaller sample.
Why did your topic resonate so well with the Eklund
Foundation?
The aim of the study is to investigate the prevalence of
dental implants and peri-implant pathologies in nursing
home residents. The Eklund Foundation promotes scien-

tific research aimed at improving people’s quality of life,
so our research fits perfectly with that aim.
How has the Eklund Foundation’s funding helped you
in your research?
Funding is essential for the project. We are employing staff and need specific instruments to conduct our
research. We are also providing scholarships and have

to cover travel and publication costs. Almost all scientific
research has expenses related to staff and equipment.
Funding is very important because internal resources are
often insufficient.
How do you think the increasing importance of primary prophylaxis will influence implantology?
We hope that the use of dental implants will become
more and more accurate through improved knowledge
and techniques. Our wish is that primary prophylaxis will
be pursued as a way to maintain and improve the health
of the tissue surrounding dental implants as efficiently
as possible. The longer this tissue remains intact, the longer people with dental implants will enjoy good oral and
general health.
What do you want dental professionals to take from
your research?
Dental professionals must remember that primary prevention is crucial to proper maintenance of dental implants. We must do everything in our power to prevent
and, if necessary, treat peri-implant disease. In doing so,
information is key. Patients must be informed about the
undisputed advantages of dental implants, but also about
possible complications and maintenance techniques. We
must remember that dental implants require more attention and preventative care than natural teeth do.

prevention
1 2018

[18] =>

| systemic diseases

Gain a child, lose a tooth?
By Prof. Nicole Arweiler, Germany

The most important physiological, hormonal and perhaps also most beautiful changes in a woman’s life
occur during pregnancy. And the mouth is one of the
main areas involved in these changes. Although gingival
inflammation during pregnancy tends to increase—even
with correct oral hygiene—pregnancy gingivitis does not
normally cause lasting damage to the periodontium. In
the post-partum phase, even women with periodontitis
who did not receive periodontal treatment during their
pregnancy show an improvement in all clinical periodontal parameters. So all is well, right? Unfortunately not.

The research agrees: pregnant women require special
oral hygiene instructions, owing to hormonal changes,
in order to avoid periodontitis. This is because periodontal treatment can be nerve-racking, time-consuming and
bad for their health.
How important is periodontal health for pregnancy
really? Its significance is actually increasing with current
research findings. Pregnancy gingivitis is one of the most
important periodontal diseases. Like other forms of gingivitis, untreated it can lead to periodontitis. No specific
type of periodontitis is linked to pregnancy, but periodontitis seems to be a potential risk factor for negative pregnancy outcomes. But how strong are the connections
between periodontitis and negative pregnancy outcomes
like premature birth, low birthweight and pre-eclampsia
really? More on that later.
The legislature has already known for decades about the
importance of periodontal health for expectant mothers
(e.g. the maternal health passport guides women in
Germany and Austria through pregnancy). Federal committees and health insurance companies also require that
gynaecologists and dentists speak about the importance
of oral hygiene for mother and child in the last trimester as
needed. Unfortunately, the reality is that only 5 to 10 per
cent of pregnant women worldwide see a dentist during
pregnancy. Certainly, socioeconomic status, fear and
perhaps also apathy mean that many patients avoid the
dentist. Many expectant mothers say they do not have
time to go to the dentist several times. “Gain a child, lose
a tooth,” as your grandmother used to say.

What is pregnancy gingivitis?
Various periodontal diseases, including pregnancy gingivitis, granuloma gravidarum (pregnancy tumour, also
epulis gravidarum) and periodontitis, affect the (oral)
health of pregnant women. Pregnancy gingivitis is therefore among the classic gingival diseases. Besides plaqueinduced gingival disease, pregnancy gingivitis ranks among
the diseases altered by systemic factors. This includes
hormonal influences, like puberty, menstruation, pregnancy and diabetes mellitus or even blood disorders.
In appearance and form, pregnancy gingivitis does
not differ from classic gingivitis, but it does differ in prevalence. Already in 1933, Ziskin et al. spoke of a 30 to
100 per cent occurrence.1 In more recent studies,2–4 this
varied between 38 per cent and 93.7 per cent. Gingivitis has

prevention
1 2018

[19] =>

systemic diseases

been found to correlate with hormone level and plaque. In
the second and third trimesters, pregnant women generally notice an increase in gingivitis and bleeding, since
the body produces the steroid hormones progesterone and oestrogen more strongly. The more
plaque, the higher the risk of gingivitis.

of.

N ic

o le

Arw
e il e

The causes of pregnancy gingivitis, however, seem to be more complicated than
previously believed. Even small quantities of
plaque in pregnant women lead to an excessive inflammatory reaction in the susceptible tissue. Not only does the immune system change, but so do blood circulation and
the cell system. The entire oral mucosa prepares for the birth. The practice team must
therefore pay particular attention to the dental
biofilm. Progesterone and oestrogen directly
promote the pathogens Prevotella intermedia
and Porphyromonas gingivalis. Indirectly, the soft
tissue is more sensitive to bacteria that reach the
oral cavity.

Does pregnancy gingivitis lead to premature
birth?
Generally, science assumes that periodontal inflammation plays an important role in pregnancy complications. Periodontitis as a chronic inflammation is ultimately
caused by a bacterial infection and thus represents a
potential source of circulating inflammatory biomarkers.
These inflammatory mediators spread throughout the
entire body and are related to possible negative pregnancy outcomes. In studies on periodontitis in pregnant
women, the occurrence of the disease varied between
0 per cent5 and 61 per cent.3
Clinical studies further suggest that bacteria, like
P. gingivalis, Treponema denticola, Tannerella forsythia
and Fusobacterium nucleatum, from the oral cavity colonise the foetus and the placenta, with blood being the
most likely transfer medium. These periodontal pathogens may therefore represent a risk factor for negative
pregnancy outcomes, including low birthweight, premature birth and pre-eclampsia (high blood pressure).
Actually, there is still no clear proof to support the connection between periodontitis and negative pregnancy
outcomes. Some studies indicate that there could be a
link. Further studies are needed, however, to understand
the complex biological processes. Three facts remain.
First, a pre-existing periodontal condition in the woman
can exacerbate periodontitis during pregnancy. Second,
after the birth, the periodontal status of women with periodontitis improves without active periodontal therapy.
However, the disease does not disappear and can even
worsen after the birth. Third, pregnancy gingivitis alone
does not lead to negative pregnancy outcomes.

Treatment
and prevention
Whether the mouth is healthy, has gingivitis or even
periodontitis, nowadays, organisations and researchers
recommend that pregnant women make three visits to
the dentist, ideally once per trimester. This way, dentists
can advise them comprehensively in the first trimester. The
second trimester is suitable for a professional tooth cleaning and, if necessary, periodontitis treatment. The practice
team should use the third trimester for consultation on the
dental health of the baby. Ideally, prophylaxis should begin
for the child during pregnancy. Different studies show how
important it is to educate women during pregnancy and right
after the birth in order to reduce the risk of caries in children.
In the dentist’s office, pregnant patients should learn
everything important about the development of dental caries, routes of infection and nutrition; however, the
emphasis here is not just on the information, but also on
targeted, preventative therapy. Expectant mothers who
become enthusiastic about prophylaxis pass this experience on to their children. This way, prophylaxis for the
child, the first primary prophylaxis even before the birth,
becomes the focus of dentistry.

Mechanical and professional plaque control
Mechanical plaque control has always been the focus
of pregnancy prophylaxis. Brushing with a toothbrush with

prevention
1 2018

[20] =>

| systemic diseases
soft bristles and fluoride toothpaste, and using instruments
for interdental care and, if necessary, chemical plaque
control are key instruments for the prevention of gingivitis
and periodontitis even before pregnancy. That is why, for
example, Oral-B recommends electric toothbrushes with
oscillating rotations. At the same time, every system of
mechanical plaque control is suitable in principle, whether
manual or electric, as long as the correct technique is used
regularly and with persistence (120 seconds).
In the case of gingivitis, toothpastes with antibacterial
agents such as stannous fluoride are beneficial, and mouth
rinsing solutions are suitable as additional therapy. For acute
gingivitis, patients should use chlorhexidine therapeutically
for a short time, best in a concentration of 0.1 to 0.2 per cent
or 1 per cent. Different meta-analyses have found that chlorhexidine can be used with confidence during pregnancy.
Long-term chemical plaque control is suitable for pregnant
women with nausea and poor oral hygiene, particularly in
the molar area. Other alternatives, such as tea tree oil and
propolis, have not shown any effectiveness in studies.

What to keep in mind with periodontal therapy
If the practice team has to treat pregnant patients
for periodontitis, neither has any special procedures to
be considered first. Research shows that non-surgical
periodontal therapy is safe and sensible during the second trimester. Scaling and root planing are quite pos-

sible during pregnancy. Radiographs can be taken and
local anaesthesia can be administered without additional
risk to the foetus or the mother. Articaine is the agent of
choice in this case. Periodontal therapy does not reduce
the occurrence of negative pregnancy issues. However,
it can lower the frequency of negative pregnancy outcomes in women at high risk of pregnancy complications
or who respond better to periodontal treatment.

Modern pregnancy prophylaxis
Professional tooth cleaning as part of modern biofilm
management is an indispensable component of gingivitis
and periodontal therapy in the context of a prophylaxis
session. Professional tooth cleaning, in combination with
oral hygiene products and instructions, clearly reduces
moderate or severe gingivitis. The second trimester is
therefore best suited for professional tooth cleaning. At
this point, nausea has usually disappeared and the patient can stay lying down for a whole hour.
An optimal pregnancy prophylaxis also includes nutrition from a dentistry point of view. Here patients should
not limit themselves, but enjoy their pregnancy. Nevertheless, patients should forgo acidic foods and beverages. A craving for sour and sweet foods, often in high
frequency, also increases the risk of caries or an erosive change in the tooth enamel. In addition, the buffering capacity and rinsing function of the saliva is reduced
during pregnancy; the mouth tends to be dry, which promotes the development of dental caries. Even allegedly
healthy foods and drinks, like fruits or fruit juices, which
are acidic, can quickly damage the tooth enamel.
Speaking of erosion, morning sickness also leads to the
production of gastric acid, which can again lead to dental erosion of varying intensity. Toothbrushing should be
avoided after an episode. The pellicle needs two hours to
reform after vomiting. Helpful means of neutralising are the
consumption of milk, cheese and, above all, chewing gum.
Instead of brushing right after, antibacterial mouth rinsing
solutions and fluoride rinsing solutions are suitable first.
Pregnancy is a major challenge with regard to teeth and
gingivae. The main task of periodontal treatment during
pregnancy is to improve the periodontal and overall
health of pregnant women. Oral hygiene training and nutrition advice reduce plaque and gingivitis and thus periodontitis. With respect to affecting negative pregnancy
outcomes, intervention even before pregnancy may be
more effective. If the practice team controls the gingivitis
and so avoids periodontitis, it has made its contribution
to a problem-free pregnancy. In all cases, prevention is
better than cure and every tooth counts.
Editorial note: A list of references can be obtained from
the publisher.

[21] =>

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To be used as an adjuvant to Scaling and Root
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[22] =>

| systemic diseases

Pregnant women are hardly informed
about the importance of oral health
By DTI

A new mother herself, pregnancy gingivitis has become a subject close to Dr Anja Carina Borer’s heart.
She set up a joint campaign between Oral-B and the
European Federation of Periodontology (EFP), which promotes oral health during pregnancy and educates health
professionals and the wider public on the issue. Originally trained as a dentist in Mainz in Germany, Anja now
serves as Professional and Scientific Relations Manager
Europe at Procter & Gamble in Geneva in Switzerland,
where we met with her for some questions and answers
on the subject. Fittingly, she brought along her 4-monthold daughter, who cooed quietly in her pram throughout
the interview.

Oral-B and the EFP have touched upon a very important and personal topic, in that periodontal disease could affect the developing baby.
Dr Anja Carina Borer: Yes. Gingivitis is a well-known
side-effect during pregnancy and the latest data shows
that practically every pregnant woman suffers from it. The
number of bleeding sites is about three times higher in
pregnant women than in the average adult. Even I, a dentist equipped with more than enough scientifically sound

prevention
1 2018

Oral-B products, experienced some gingival bleeding for
the first time in my life! As we know, untreated gingivitis can lead to periodontitis, the inflammatory burden of
which can negatively impact pregnancy. Although more
consistent in-depth studies are necessary, periodontitis
during pregnancy has already been linked with premature
birth, low birthweight and pre-eclampsia. This topic is important as most pregnant women are not aware of this
problem and therefore often do not recognize the warning signs of gum problems such as bleeding or sensitive
gums. With our campaign, we want to inform women and
make sure they take good care of their oral health and
see a dental professional in order to prevent possible oral
health problems and pregnancy complications.
How can periodontitis lead to these complications?
Clinical studies suggest that bacteria from the oral cavity
—specific microorganisms associated with periodontitis—
colonise the foetus and the placenta, with blood as the
most likely vehicle of transmission. As a consequence,
the presence of periodontal bacteria in the feto-placental unit may activate a local immune or inflammatory response that might negatively affect the pregnancy.

[23] =>

systemic diseases

To me, this really is a very personal matter, as I fell
pregnant while establishing the cooperation concerning pregnancy gingivitis with the EFP. I find it worrying
that pregnant women are hardly ever informed about the
importance of good oral health during pregnancy. Therefore, I was passionate about establishing the Oral-B/EFP
cooperation and lead the joint campaign. Our aim is to
better educate dental professionals and medical professionals in general, as well as the wider public, on the
importance of good oral health during pregnancy.

Dr Anja Carina Borer with her 4-month-old daughter.

Could you explain the changes in the bodies of pregnant women that cause pregnancy gingivitis?
The biggest hormonal changes in a woman’s life take
place during pregnancy. It is a period of great change
and obviously the mouth is one of the main areas affected
by such changes, which in itself can lead to gingivitis.

Biologically, that makes perfect sense, but how widely
accepted is this point of view?
Although clinical research on
the matter has existed for years,
it is still a fairly neglected topic.
Not only does it not receive
enough attention from dental
professionals, it is also largely
overseen by healthcare professionals such as gynaecologists
and midwives. When I was pregnant, I was warned about many
potential risks, ranging from flying to eating sushi or dying my
hair! I did enough research on
the aforementioned “risks” to
conclude that there is no scientific data to support these. However, no one—my gynaecologist
included—told me to go and
see a dental professional or take
care of my oral health.

prevention
1 2018

[24] =>

| systemic diseases
It is not for nothing that people used to say that women
gain a child and lose a tooth. During pregnancy, there is
a 150 times increase in oestrogen compared with the
amount during a normal menstrual cycle. This and the
increase of progesterone and other hormones lead to an
increased vascular permeability of gingival tissues, which
promotes gingival inflammation in the presence of dental
plaque. For women who have already developed periodontitis, the situation usually gets worse because of the
changed hormonal situation.
Apart from cardiovascular disease, periodontal disease is known complication of diabetes. What is the
risk of pregnant women with diabetes developing
periodontitis?

negatively impacts diabetes. Overall, it is important that
women with diabetes take care of their oral health before
and during pregnancy.
How do you integrate all of your findings in your
Oral-B seminars?
Oral-B’s mission is to promote oral health and work
closely with dental professionals to ensure optimal home
care. Our collaboration with the EFP serves as a way to
raise awareness about all matters concerning oral health
during pregnancy. Our educational activities such as the
Up-to-Date events are a way to communicate this and
support dental professionals in their objective to improve
oral health. We believe a healthy mouth is part of a healthy
body and promoting good oral health during pregnancy
is one way to help to achieve this.
How can general dental practitioners, periodontists
and dental hygienists integrate this last thought into
their daily practice?
It is important that they understand the connection
between oral and general health, be it the link between periodontitis and diabetes, as well as cardiovascular disease, or complications during
pregnancy. Gynaecologists, cardiologists and
endocrinologists too should be aware of this
connection. That being said, many women
avoid professional dental care during pregnancy and, conversely, many dental professionals are insecure about treating pregnant patients. However, female patients of
childbearing age should be informed about
the importance of oral health during pregnancy. This is especially important for patients who suffer from periodontitis. These
patients should be encouraged by dental
professionals to undergo treatment before
pregnancy. During pregnancy, non-surgical
periodontal therapy has been considered safe in
the second trimester.

For women who already have diabetes, the biggest
challenge is to keep their blood sugar under control.
Independent from this, a small percentage of women
develop diabetes during pregnancy. Although this type
of diabetes disappears after pregnancy, these women
need treatment in order to avoid serious complications.
Both groups, however, have a higher risk of developing
periodontal disease. It is important to note that treatment
is more likely to succeed if a person’s blood sugar levels
are under control. Vice versa, periodontal disease also

prevention
1 2018

Finally, what would your tips be for pregnant
women?
Women who have periodontitis must seek treatment
before pregnancy, whereas women who enjoy good oral
health should go and see a dentist or a dental hygienist
in the second trimester for a dental cleaning. Of course,
they should brush their teeth twice a day with a fluoride-containing toothpaste—even better is an antibacterial toothpaste containing stannous fluoride—and clean
their teeth interdentally. It is scientifically proven that
electric brushes such as our Genius toothbrush are particularly good for reducing plaque and gingival bleeding.
Moreover, they are a practical solution for women who
have less time to brush their teeth. There is no question
that all mothers with a baby will know exactly what I am
talking about.

[25] =>

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Schedule recall frequency
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Ask your patient if he
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PROBE AND SCREEN EVERY CLINICAL CASE
Healthy teeth, caries,
gingivitis, periodontitis
Healthy implants,
mucositis, peri-implantitis
Start by rinsing with
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02 DISCLOSE

MAKE YOUR PATIENT SMILE
Do a final check for
remaining biofilm Ensure
calculus is fully
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diagnose caries Protect
with fluoride

06 PIEZON®

REMOVE REMAINING CALCULUS
Use the minimally invasive EMS
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Clean > 10 mm pockets with
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REMOVE BIOFILM IN >4 TO 9 MM POCKETS
Use PLUS Powder on teeth and
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interdentally Use depth marked
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Show patient disclosed
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The color will guide the
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03 MOTIVATE

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Instruct your patients
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[26] =>

| systemic diseases

Oral microbiota, intestinal microbiota
and inflammatory bowel disease
By Prof. Denis Bourgeois, France

Intestinal microbiota
There exists a close relationship between the human
host and the intestinal microbiota—a mixed community
of microorganisms that protect the intestine from being
colonised by exogenous pathogens. In a healthy individual, the host and microbiota coexist in mutual harmony,
allowing both to function properly.1 The balance of the intestinal microbial ecosystem can be disrupted by a number of factors, such as antibiotics, vaccinations, certain
foods and stress. An intestinal bacterial disorder primarily
manifests in terms of quantitative changes in bacterial location, causing excessive bacterial growth in the intestine.
This can damage the intestinal mucosal barrier, thereby
releasing enterotoxins as a means to increase intestinal
epithelial permeability so that bacteria and products can
enter the intestinal lamellae, causing an immune dysregulation of the mucous membranes and inducing inflammatory bowel disease (IBD). Changes in intestinal microbes
are associated with the development of IBD.
IBD comprises a group of idiopathic diseases characterised by chronic inflammation of the bowel. This inflammation may affect any part of the gastrointestinal tract.
IBD represents a group of two principal intestinal disorders: Crohn’s disease (CD) and ulcerative colitis. These
two disorders have distinct clinical and pathological features, yet they do overlap.
The pathogenesis of CD is most notably associated
with a deterioration of the immune system, which becomes incapable of destroying bacteria, viruses and
other potentially harmful foreign organisms, as well as the
intestinal microbiota. There is currently good evidence
that the intestinal flora or microbiota plays a key role in
the development of IBD. Recent studies have shown that
certain strains of intestinal bacteria are responsible for
ulceration and chronic inflammation in IBD. Ulcerative
colitis, as opposed to what was initially believed, is not
an autoimmune disease, but rather an infectious disease
related to an imbalance in the intestinal microbiota.2
According to He et al., the CD microbiota is grouped
into two distinct meta-communities, which would indicate subject variation in the structure of the microbiome.3
Specific functional changes in the CD meta-community
show increased levels of pro-inflammatory hexa-acylated

prevention
1 2018

lipopolysaccharides and a reduced potential to synthesise short-chain fatty acids. Moreover, disruption of ecological networks in CD is associated with reduced growth
rates of many bacterial species. The authors concluded
that the microbiota of CD patients can be layered into
two distinct meta-communities, in which the most seriously disrupted meta-community exhibits functional potentials that substantially deviate from those of a healthy
individual, with a possible implication for the pathogenesis of CD.
Various explanations have been advanced, such as the
hygiene hypothesis, which blames the frequent use of
antibiotics and microbicidal compounds; the partial elimination of enteric microflora after suffering from infectious
acute gastroenteritis; certain food components, for example refined sugars used in developed countries, which
could promote the growth of certain types of bacterial
species; and even certain types of toothpaste.

Oral microbiome
Individuals’ oral microbiomes are highly specific at the
species level, although overall, the human oral microbiome is largely homogenous. If the symbiotic balance between the host and the microbiota of the oral cavity is disrupted, the microbiota may become harmful. Distinctions
in microbial composition have been found between carious and caries-free microbiomes, as well as periodontally diseased and periodontally healthy microbiomes.
Although caries and periodontitis are clearly bacterial
diseases, they are not infectious diseases in the classical
sense, since they result from a number of factors: commensal microbiota, host susceptibility and environmental
factors, such as diet and smoking.
The literature on interdental applied to carious lesions
is extremely limited. However, it has been established
that the effective presence of the red complex, particularly Porphyromonas gingivalis, a pathogen of heart disease and other systemic diseases, is a strong indicator
of the need to develop new methods to disrupt interdental biofilm through daily oral hygiene. Indeed, it has been
shown that low levels of P. gingivalis (< 0.01% of the total
load) were able to induce changes in the composition of
the biofilm.4 Likewise, the presence of Candidas albicans
in significant quantities in the interdental spaces is cause

[27] =>

systemic diseases

Understanding the interaction
between the intestinal
microbiota, pathogens and
the human host could lead
to new strategies, notably by
modifying the composition
of the intestinal microbiota.
Helicobacter pylori, a bacterium known to irritate the
stomach lining and induce
chronic gastritis, as well as
poor periodontal health.5
This observation is supported by existing literature
on the subject, which suggests that dental plaque
may harbour H. pylori and
cause recurrences of gastric infection.

Prof. Denis Bourgeois

for concern. Understanding the impact of such bacteria
and yeasts in the interdental spaces within an oral environment, including, of course, the salivary environment
—which have the potential to spread at any time of their
lives within the digestive tract—is a priority.

The relationship between the two
Though there is still much to be learnt about the interaction between the oral and intestinal microbiota, numerous recent studies have shed some light on it. By examining the oral health of patients with dyspepsia who were
candidates for diagnostic upper gastrointestinal endoscopies, Zaheda et al. found a direct relationship between

A 2017 study by Hujoel
and Lingström traced an
overview of the historical
role of nutrition in the development and prevention
of dental caries, gingival
bleeding and periodontal
disease.6 Given how much
recommendations on nutrition have changed over
time—the World Health
Organization has only since
2015 recommended the
restriction of sugar intake, for example—it is interesting
to see that the current evidence suggested a low-carbohydrate diet high in non-vegetable fats, micronutrients
(e.g. vitamin C and B12) and protein was correlated with
periodontal health. However, the ability to absorb these
nutrients can be influenced by gastrointestinal health.
As the Canadian Society of Intestinal Research has reported, the improper functioning of the gastrointestinal
tract can reduce nutrient absorption, leading to vitamin
and mineral deficiencies that may cause oral lesions and
tongue inflammation.
Editorial note: A list of references can be obtained from
the publisher.

prevention
1 2018

[28] =>

| systemic diseases

We have an enormous influence
on children’s overall health
By DTI

Parents of children with systemic disease often wonder in the dentist’s office what oral health problems they
can expect for their child. Depending on the type of
systemic disease, there can be complications in terms
of the child’s oral health. In this context, Dr Karolin Höfer,
senior physician at the University Hospital of Cologne,
studies oral disease in children with chronic renal insufficiency or congenital heart defects. In her presentation at the
Oral-B Up-to-Date event, she spoke about the typical oral
health problems of paediatric kidney and heart patients
based on her own research and compared these with
current systematic reviews. She then, in a very personal
interview gave helpful suggestions for the support and
treatment of these children in everyday life.
Dr Höfer, why do you like working with children?
Dr Karolin Höfer: My passion lies in working with children and young people; that’s why I specialised in paediatric dentistry, with a special focus on children with
systemic disease. In dentistry, we say: one either loves
it or leaves it.

ourselves: Are there correlations between these systemic
diseases and oral disease and/or disease that affects
tooth development? As dentists, we should know how
these systemic disease can affect oral health. We are
already aware of the well-known interactions with some
chronic diseases, such as congenital heart disease, diabetes mellitus, arthritis and chronic diseases of the bowel
and kidney.
What questions do dentists have to ask when treating these patients?
First of all, it is important to identify the child’s dental
problem. Secondly, it should be determined whether the
child has certain diseases and whether there are interactions with oral disease. And thirdly, which specialists in
other disciplines should be consulted before dental work
commences must be established.

With every one of my young patients, whether they
have a medical history or are healthy, I have to gain
their confidence on an emotional level first, aside from
the dentistry challenge. Working with children who are
traumatised and have medical histories in particular requires sensitive handling in order to build trust, which is
the foundation of successful treatment. Intuition, taking
sufficient time, patience and empathy are essential here.
Successful treatment of children with cancer or severe
heart problems or others at high risk is achievable by
using special techniques, such as ritualised behaviour
management. After a difficult treatment, having a child
smile and ask when he or she can come back is the best
endorsement in daily practice.

How do you see your position as a dentist within the
holistic therapy of these children?
I am not responsible for the patient’s entire medical
recovery. However, I see myself as a physician, mediator
and member of a team of paediatric specialists. When
we treat patients with systemic disease, we need to be
in contact with specialists from all disciplines. As experts
in oral health, we have an enormous influence on children’s overall health. Every dentist should consult with
the treating paediatricians of children with pre-existing
conditions. It’s about the overall well-being of the child.
Even a tooth cleaning can take on another meaning for
these children. Healthy people associate it with health,
well-being and aesthetics. For children with systemic disease, however, an intensive prophylaxis can have major
implications for their general health, for example, should
pathogenic bacteria enter the bloodstream of a child, say,
with immunosuppression.

What patients do you work with?
Most of my patients have a systemic disease and are
with me from birth up to age 25. The period between
ages 18 and 25 is considered a transition phase; from
child to adult. After careful paediatric treatment, a deterioration of the condition is frequently reported during
the transition phase. For example, we treat patients with
cystic fibrosis, congenital heart defects, chronic kidney
disease and immunosuppression, for example, after a
transplant or during cancer treatment. Every day, we ask

You work with children who have congenital disease. You have conducted interesting studies on the
prevalence of caries and gingivitis. What have your
results been?
If one considers the tooth decay process of healthy
children in Germany 20 years ago, about five teeth were
affected by tooth decay, while today, only one tooth on
average is affected. Up to 85 per cent of 3-year-olds have
no caries; however, the remainder may have up to four carious teeth. As I said, these figures involve healthy children.

prevention
1 2018

[29] =>

systemic diseases

Dr Karolin Höfer

Why should paediatric dentistry be interested in
such interactions?
If there are potentially about 700 different species of
bacteria in the mouth, and children with heart disease
have an increased risk of caries, the danger actually exists that these bacteria will reach the bloodstream via
the mouth. We are speaking here of bacteraemia. Bacteraemia is not a disease in itself and is not a risk for a
healthy patient; the immune system automatically fights
the invading bacteria. For patients with systemic disease,
the starting point is different. It is therefore not surprising that, with bacteraemia, oral streptococci, in particular the viridans streptococci, can be detected. Blood
cultures reveal, for example, that viridans streptococci,
as part of the oral cavity, are also responsible for 50 per
cent of infectious endocarditis cases. Of course, bacteraemia does not automatically lead to endocarditis. As I
said, a healthy body can normally deal with such bacteria. Patients with pre-existing conditions like heart disease, however, have a higher risk of endocarditis. Ideally,

children with a serious heart disease should have their
teeth cleaned prior to upcoming heart surgery.
How frequently does bacteraemia develop after dental procedures?
Occult bacteraemia can result from routine activities
such as toothbrushing, but of course also through different dental procedures. Bacteraemia develops most
frequently after surgeries like tooth extractions. Here,
the frequency is usually 100 per cent. These bacteria
can be released during periodontal procedures, such as
scaling and root planing, and even during professional
tooth cleaning, bacteria enter the bloodstream in around
40 per cent of patients. It is very interesting that, even after brushing and interdental care, the frequency of bacteraemia is about 68 per cent. As I said, a healthy body
normally deals with such bacteria, but the picture is different for patients with systemic disease, particularly children with congenital heart disease. If we find a carious
lesion in these children, we would treat this immediately
in consultation with the paediatric cardiologist in order
to avoid further infections. For our paediatric colleagues,
it is more difficult to diagnose carious lesions. We do,
however, have an excellent working relationship with
our colleagues from the paediatric clinic. They are well
trained and refer patients to us promptly and regularly for
check-ups before surgical procedures.
You also mentioned cystic fibrosis, a congenital
metabolic disease that leads to the formation of thick
mucus, for example in the lungs, intestine and liver.
What interactions have you observed between this
genetic defect and a patient’s dental status?

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1 2018

For children with systemic disease, the situation is different. Children with heart disease have a demonstrably
higher prevalence of caries. On average, four to seven
teeth are affected. Children with kidney disease have a
risk of caries comparable to that of healthy children; however, this group presents a much higher risk of developing
gingivitis. Gingivitis could thus be understood as enabling
bacteria to enter the bloodstream. Children with cystic
fibrosis also have a very low caries prevalence, but owing to the frequent intake of antibiotics, the composition
of their saliva is altered, so in this patient group, frequent
enamel hypoplasia has been determined.

[30] =>

| systemic diseases
Patients with cystic fibrosis often have an accumulation
of viruses, fungi and bacteria in their airways, which can
in turn lead to pneumonia. These patients are under constant drug therapy. As dentists, we should comply with
special hygiene regulations. We should be aware that the
particulate matter that normally develops during dental
treatment is to be avoided. One danger, for example, is
lung infections, which can be triggered by bacteria like
Pseudomonas aeruginosa. This risk can be prevented by
using an external water supply.
What measures do you recommend to reduce the
risk of bacteraemia for these risk groups?
We are currently conducting an intervention study in
collaboration with the paediatric nephrology division at
the University of Cologne. In addition to treating gingivitis
through intensive prophylaxis, the goal of the clinical trial
is to determine the bacterial risk after toothbrushing. For
bacteria identification, blood cultures and oral microbiomes are examined. We want to examine the influence of
a patient-centred intensive prophylaxis programme and
improved oral hygiene on the change in the oral microbiome. We hope in the long term to improve oral hygiene
through regular check-ups and instructions, and to implement an interdisciplinary prevention programme for
children with chronic kidney disease.
Furthermore, we hope to achieve a substantial improvement in oral health with targeted tooth cleaning and
intensive prophylaxis, and to eliminate the daily bacteraemia risk in children at risk, as well as carious lesions and

prevention
1 2018

gingivitis. This includes a regular recall system for these
high-risk patients adapted to their individual needs.
What are your recommendations for parents?
I would like children to look forward to their dental appointment with me. Through a very intensive relationship
with the children and their relatives, I replace the cliché of
an uncomfortable and angst-ridden dental visit with trust
in dental treatment. We should give today’s generation
of children a new perception about dentists. Of course,
for many parents who have a child with a systemic disease, oral hygiene is not their top priority. However, all
the results of my clinical trials to date have shown that
oral health has only a positive effect on the overall health
of children with systemic disease, but besides that, the
quality of life and self-confidence of my young patients
are enormously strengthened.
What is your appeal to your peers in practice?
It is enormously important to take children in dental
treatment in hand, accompany, explain and find a way
to bring dentistry goals in line with the systemic disease.
We must achieve oral health in children as quickly as possible and maintain it for the long term through individual
prevention programmes. The treatment of children with
systemic disease should always take place in consultation with the treating paediatrician. Every practice staff
member should contribute to paediatric dentistry being
perceived by parents as a specialist field in interdisciplinary cooperation with paediatricians and serving the
well-being of their children.

[31] =>

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[32] =>

| biofilm

The oral biofilm:
What you should know
By DTI

As research into the complexities of the oral microbiome—the community of microorganisms that exist in
the mouth—continues to progress, so too should our
own knowledge of it. Though the existence of dental
plaque has been known about for decades, dental caries
nevertheless remains the most common chronic disease
globally. The World Health Organization estimates that
60 to 90 per cent of school-aged children worldwide
suffer from caries and that 15 to 20 per cent of adults
between the ages of 35 and 44 have severe periodontal disease. Clearly, our approach to this issue needs to
change.

What is a biofilm?
A biofilm is a dense accumulation of bacteria, fungi
or protozoa that adhere to each other and to solid surfaces. In our bodies, biofilms develop on teeth, tissue
cells and the exterior of
implants. Though they
can have a positive role
in many environments,
the presence of certain
biofilms may also lead
to negative outcomes,
such as infection.
Once a microbial
cell has attached itself to a surface, it
produces an extracellular polymeric matrix.
This matrix essentially
helps not only to bond
these cells together,
but also to protect the
cells from external attacks. This community
of microbes, together
with their extracellular
product, constitutes a
biofilm.

Dr Phil Marsh, Professor of
Oral Microbiology at the University of Leeds in the UK.

prevention
1 2018

The microbial cells in biofilms in the human body are
generally resistant to antibiotic treatments and natural immune system responses, allowing them to subsequently
thrive. Because of this, biofilms are considered to be an
ideal state of existence for microbes.
Biofilm and infections
Biofilms are estimated to be the cause of somewhere
between 60 and 80 per cent of all bacterial infections
in the human body. Though there are certain strategies
to treat these infections that can prove successful, the
diversity of the oral microbiome and its habitats means
that special consideration must go into maintaining its
balance.
The composition of oral biofilms
Our mouths play host to a variety of biofilms, both good
and bad. Socransky et al. attempted to define this bacterial distribution in a 1998 study of the oral biofilms of
individuals both with and without periodontitis. In collecting over 13,000 dental plaque samples, they found
that there were six major complexes that could be consistently observed together. These complexes were then
colour-coded into red, orange, yellow, green, purple and
blue groups.
The blue, green, yellow and purple Socransky complexes were found to correlate to periodontal health,
whereas orange and red complexes generally indicated
the presence of periodontal disease. When present by
itself, Porphyromonas gingivalis—one component of the
red complex—can cause the loss of alveolar bone. When
found alongside Tannerella forsythia and Treponema
denticola, it often leads to periodontal disease, which
has itself been linked to a variety of systemic diseases.
Dental plaque biofilm
Dental plaque biofilm is most commonly found on the
surfaces of our teeth. It is most widespread when there
is a lack of correct oral hygiene. This biofilm is the primary causative factor for dental caries, periodontitis and
peri-implantitis.
If dental plaque biofilm is not removed via mechanical or chemical control within 24 hours of forming, it
will release virulent, acid-producing and acid-tolerating
bacteria, triggering an inflammatory response—gingivi-

[33] =>

biofilm

tis, the initial stage of periodontitis—from the gingiva and
the periodontium. Left alone, the bacteria can eventually
initiate alveolar bone loss, soft-tissue destruction, implant
failure, and other potential systemic issues.
Since dental plaque biofilm’s antagonistic behaviour
takes place in an environment with an incredibly diverse
microbiota, and because its cariogenic traits are not
emblematic of a particular species, its bacterial composition is somewhat unclear at this point. Despite this, our
understanding of other elements of dental plaque biofilm
continues to improve—indeed, its recognition as a biofilm
only occurred in the twenty-first century.
Removing dental plaque biofilm is still not that simple, however. For example, the fact that its cells have
the ability to express multiple types of adhesin (surface
structures that facilitate attachment) means that several
avenues of attachment might still be available to it, even
if a main method of adhesion were to be blocked.

Microbiomes
A microbiome is simply the community of microorganisms existing in a specific environment, particularly in the
human body.

The oral cavity is different to other human microbial
environments, as it contains several types of surfaces
for microbial colonisation, such as the teeth, mucosa,
tongue, attached gingiva and implants in cases of tooth
loss. In addition, teeth are the only non-shedding natural
surface in the human body. This allows for biofilm to accumulate on them relatively easily, a feature that is shared by
dental restorations, implants and other oral prostheses.
“There is a natural symbiotic relationship between the
host and the oral microbiome,” says Dr Phil Marsh, Professor of Oral Microbiology at the University of Leeds in
the UK. “The host provides a warm and favourable environment for microbial growth, and the oral microbiome
acts as a barrier to colonisation by exogenous microbes,
modulates the host’s immune response to prevent unwanted inflammation, and contributes to the regulation
of the cardiovascular system and other physiological
activities.”
In a 2017 study published in the Journal of Clinical
Periodontology, Marsh and Zaura sought to describe the
range of microbial interactions that take place in biofilms

Dr Thuy Do, a lecturer in microbiology at the University of Leeds.

in the oral microbiome. They found that these biofilms
display “emergent properties”, meaning that their characteristics cannot be understood by simply studying individual organisms. Instead, analysing how they function
and interact with one another proves to be more fruitful.
Maintaining a healthy, balanced oral microbiome involves processes that are, admittedly, still not entirely understood. However, there are certain factors that clearly
benefit oral health. Saliva, for example, is well known for
its rinsing function in the oral cavity and for its role in
initiating the digestive process by enabling chewing and
swallowing of food. So what exactly causes dysbiosis—
a microbial imbalance between harmful and protective
bacteria—to occur?
Dysbiosis and its causes
“There are various factors that can disturb the symbiotic relationship between the host and oral microbiota,
leading to dysbiosis and disease,” says Dr Thuy Do, a lecturer in microbiology at the University of Leeds. “Changes
in the conditions at oral sites, such as the accumulation
of dental biofilms from a lack of oral hygiene, may lead to
an inflammatory response from the host immune cells.”

prevention
1 2018

The oral microbiome
The oral microbiome is, along with the gut microbiome,
one of the two most diverse microbiotas in the human
body. The Human Oral Microbiome Database states that
there are approximately 700 prokaryotic taxa that have
been identified as existing in the oral cavity.

[34] =>

| biofilm
“The frequent intake of fermentable sugars in the diet,
along with a reduction in the flow of saliva, can lead to
dysbiosis,” adds Marsh. These sugars, by initiating the
development of dental caries, are metabolised into acid,
which generates a low pH level in the biofilm. As Peterson et al. demonstrated in a 2013 study, this low pH can
constrain the growth of many bacteria responsible for the
health of tooth enamel, decreasing the diversity of the
oral microbiome.
Some other common causes of dysbiosis include the
use of broad-spectrum antibiotics, smoking, physiological changes like pregnancy or puberty, and certain
diseases that are associated with periodontitis, such as
diabetes.

Dental implants and biofilm
As the popularity of dental implants continues to rise,
their use has become more successful in terms of both
aesthetics and function. However, even successful pro-

cedures can lead to peri-implant mucositis, an inflammatory lesion at the mucosal and bone level, which then can
progress to peri-implantitis, an inflammatory lesion of the
tissue surrounding the implant.
Peri-implantitis can develop for a number of reasons.
One of the most common is the presence of periodontal disease when the implant is placed. If the patient has
deep periodontal pockets filled with harmful bacteria, it
can lead to colonisation of biofilm around the implant and
possibly implant failure.
Dr Lisa Heitz-Mayfield is, among other roles, a university lecturer and a periodontist in private practice. As
implant specialist, she says that infection control prior
to and after implant placement is essential for control of
biofilm and peri-implantitis.
“Having good infection control before placing implants
is crucial, as it is the best way to prevent these infections
occurring later on,” she says. “A preventive approach requires several elements to work effectively: regular monitoring and supportive periodontal therapy with professional biofilm control, a healthy and regular at-home oral
hygiene routine, and controlling for other risk factors,
such as smoking and uncontrolled diabetes.”

Orthodontic patients and biofilm
Despite the advances in technology that have made
orthodontic appliances smaller and more comfortable
than ever, intraoral problems often arise from their use.
A 2014 study by Ren et al. published in Clinical Oral
Investigations estimated that at least 60 per cent of all
orthodontic patients develop at least one biofilm-related
complication. These complications develop primarily because the presence of orthodontic appliances can impede toothbrushing and other oral hygiene activities, rendering these techniques less effective in disrupting the
formation of dental plaque biofilm.
Chemical control
An alternative method of controlling dental plaque biofilm in orthodontic patients is chemical control through
the use of antimicrobials. Chlorhexidine is considered to
be the most effective antiseptic agent available, with numerous studies demonstrating its efficacy against dental
plaque when present in mouthwash.
However, Valen et al. found that prolonged daily use
of an antimicrobial might lead to resistance to not just
the applied substance but other antimicrobials as well.
With this in mind, they recommended that daily antimicrobial use for the control and eradication of biofilm should be limited to situations in which mechanical
cleaning and patient behavioural change are inadequate
or unachievable.

prevention
1 2018

[35] =>

biofilm

Controlling dental plaque biofilm
There are currently two primary ways of controlling dental plaque biofilm and establishing a healthy oral microbiome for the non-orthodontic patient: professional biofilm
management and individual manual biofilm management.
Professional biofilm management commonly involves
the removal of subgingival dental plaque and calculus
with the use of hand scalers, followed by tooth surface
polishing with rotary rubber cups and brushes. By removing this biofilm from periodontal pockets that have
formed, hand scaling is able to reduce gingival inflammation that may be present and prevent further damage
caused by its potential progression to periodontitis.
Dentists may choose to use an ultrasonic scaler instead if they wish to remove supragingival dental plaque
biofilm. These scalers feature a metal tip that vibrates at
20–45 kHz and follows a curved linear, elliptical or figure eight path. The tip is cooled with a water spray, in
which bubbles form and collapse as a consequence of
the ultrasonic waves of energy passing through. This effect, called cavitation, facilitates removal of dental plaque
and calculus.
When used by an experienced professional, an ultrasonic scaler can be faster and can cause less hand and
wrist fatigue than with a manual hand scaler. If used incorrectly, however, it can cause heat damage to the tooth.
Recent developments
In the inaugural issue of prevention magazine, Dr
Klaus-Dieter Bastendorf, a scientific adviser for the Swiss
Dental Academy, outlined recent developments in the
materials and technology for professional biofilm management. With the introduction of piezoceramic instruments and low-abrasion powders made of erythritol or
glycine, Bastendorf argues, modern professional biofilm
management is now safer, minimally invasive and more
comfortable for both the patient and dental practitioner.
In addition, the ability to disrupt both sub- and supragin-

gival biofilm in one procedure improves the efficiency of
these procedures, making it more likely that patients will
return for regular professional cleaning.
Recommendations for oral self-care
The easiest way for individuals to remove dental plaque
biofilm build-up themselves is through a consistent oral
hygiene routine. Regular use of a soft-bristled toothbrush,
dental floss and interdental brushes is essential. By disrupting the established layers of bacteria through effective cleaning, the protective layer of biofilm on the teeth—
the pellicle—will be able to reorganise and perform more
capably.
“Control of dental plaque biofilm begins with daily oral
hygiene,” asserts Marsh. “Meticulous cleaning of the
teeth and associated gingival tissue removes the bulk of
the biofilm that has developed in the time since the last
oral hygiene session.”

Working together
Regardless of the type of preventative measures taken
in controlling biofilm, it is essential that dental professionals cooperate with and motivate their patients to take
charge of their own oral health.
“The dentist and dental hygienist should work together
as a team in evaluating, treating and maintaining the oral
health status of the patients,” says Dr Rajiv Saini. “There
should be a greater emphasis on the modification of
behaviour of patients by providing them with education,
scientific facts and research data.”
Do’s sentiments on this relationship strongly reflect
Saini’s. “Dental professionals should advise patients
about effective oral hygiene and the impact of their diet
and lifestyle choices on their oral health, such as the risks
of a high carbohydrate diet or smoking for tooth decay,”
she recommends. “There is increasing evidence of the
link between oral health and general health, and maintaining a good oral microbiome may be in our best interest.”

prevention
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[36] =>

| biofilm

Gingival health benefits of enzymes
and proteins in toothpaste
By DTI

How healthy the gingivae are largely depends on the
balance of the oral microbiome. According to a review by
Kilian et al. in the British Dental Journal, our oral microbiome encompasses no less than 700 distinct bacterial
species that cover the teeth and oral mucosa and are attached to these surfaces as part of the oral biofilm.1 Ideally,
this microbiome is naturally in a state of balance—symbiosis—protecting our mouths from the over-proliferation of disease-promoting bacteria. However, the ingestion of fermentable sugars, smoking, stress, physiological
changes like pregnancy, or the frequent use of antibiotics
and antimicrobials can create an imbalance in the oral microbiome—dysbiosis—that in turn can lead to diseases
such as caries, gingivitis and periodontitis.

Toothpaste—The helpful assistant
Maintaining a healthy oral microbiome is clearly essential to good gingival health, but what measures can
we take to achieve this? According to Mogens Kilian,

Professor of Medical Microbiology at Aarhus University,
as well as Affiliate Professor of Bacterial population genetics at the University of Copenhagen, “The balance that
has been lost as a result of modern lifestyles can, in most
cases, be restored by improved oral hygiene, including
the use of toothpastes containing not only fluoride but
also other beneficial compounds, such as enzymes and
proteins occurring naturally in saliva.”

Fluoride in toothpaste
Fluoride, firstly, has been proven to provide effective
protection against the development of caries by hardening and remineralising tooth enamel. It also exerts an antibacterial effect. “The most dramatic success of dental
research is the discovery of the protective effects of fluoride,” said Kilian. “Virtually every commercial toothpaste
includes fluoride, which increases the resistance of tooth
enamel against caries. In this way an imbalanced oral microbiome can be restored in spite of the negative effects
of modern life.”

Enzymes and proteins—
Natural salivary components
Enzymes and proteins are naturally present in
saliva and are key to a healthy mouth. Each
person produces over one litre of saliva per
day on average. Made up of 99.4 per cent
water, saliva keeps the mouth lubricated
and comfortable, allowing one to speak,
chew, taste and swallow. The remaining 0.6 per cent of saliva is made up
of minerals, proteins and enzymes,
which all perform an integral role in
protecting and repairing the oral cavity. These salivary components are essential for maintaining good oral health,
since they protect the enamel of the
teeth, thereby helping to prevent dental
caries and ensure gingival health.
Saliva is also important in the formation of the
pellicle, the thin acellular organic film that forms on
oral surfaces after exposure to saliva. The pellicle is a
mostly bacteria-free protective film consisting of protein,
glycoprotein, lipids and salivary enzymes that forms on

36

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[37] =>

biofilm

the teeth, gingivae and oral mucosa. Inevitably, a build-up
of microorganisms, biofilm, can form on the pellicle and
threaten the enamel. The enzymes and proteins in saliva, however, are able to act extremely effectively against
unwanted bacteria, fungi and viruses, by restricting their
formation and breaking down potentially harmful sugars.

Zendium studies
A 2017 study by Adams, published in Scientific Reports,
showed how a toothpaste containing certain enzymes and
proteins can significantly shift the ecology of the plaque
microbiome at species level, resulting in a community with
a stronger association with gingival health.2 That year, two
other studies, presented at the oral health research congress of the Continental European and Scandinavian divisions of the International Association for Dental Research
in Vienna in Austria, shed light on how a toothpaste containing enzymes and proteins naturally present in saliva
positively affects gingival health. The two different teams
of scientists compared Zendium (Unilever), a commercial toothpaste that, in addition to fluoride, contains these
natural salivary components, with control fluoride toothpastes. One team did so in an epidemiological setting,
and the other in a clinical trial.

Epidemiological setting
An epidemiology study at the University of Copenhagen led by Prof. Anne Marie Lynge Pedersen, head
of the university’s Department of Odontology, examined
305 people regarding the long-term effects of their personal choice of toothpaste on their gingival health. Longterm Zendium users were found to have significantly
better gingival health than those who used regular, fluoride-only toothpastes. These results were irrespective of
diet and brushing or smoking habits. This landmark study

showed for the first time that long-term everyday use of a
toothpaste that contains enzymes and proteins positively
affects gingival health.

Clinical trial
A study in the UK at the Bristol Dental School’s Clinical
Trials Unit found similar results. Prof. Nicola West and her
colleagues examined the gingival health of 229 participants regarding plaque, inflammation and bleeding. After
13 weeks, the participants who had been brushing twice
a day with Zendium had significantly better gingival health
on all three parameters than the group that had been
brushing with a fluoride control toothpaste. Moreover,
83 per cent of the Zendium users had improved gingival
health. Speaking at the congress in Vienna, West said, “It
is very exciting to see two studies demonstrating the benefits brushing with Zendium can bring to gingival health.”

Prevention and the microbiome
Consistent with the findings of the Adams investigation, the two studies present evidence that a toothpaste
containing enzymes and proteins enhances the effects
of the innate immune factors in the oral cavity. The result
is a shift of the oral microbiome towards healthy symbiosis and improved gingival health. The number of bacteria associated with gingival health increases, and the
number of bacteria associated with periodontal disease
decreases. “With the new information that has become
available, it is clear that oral disease is the result of dysbiosis,” said Kilian. “Prevention is a crucial part of dentistry,
prevention aimed at restoring the balance within our oral
microbiome and between the microbiome and us.”
Editorial note: A list of references can be obtained from
the publisher.

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| peri-implantitis

im
When to avoid implants
By DTI
Drs Amparo Llorente and José Manuel Reuss in talks with Dental Tribune.

Located in the Salamanca district of Madrid, Spain’s
capital, Clínica Vilaboa was founded more than 30 years
ago by Drs Beatriz and Débora Vilaboa. With polished
hardwood floors and a stylishly minimalist interior, the
practice’s aesthetic emphasis is immediately evident. A
pioneer in aesthetic dentistry when first established, the
multilingual clinic has since expanded its focus to two
disciplines, implantology and prophylaxis—which may at
first seem contradictory. prevention spoke with practice
dentists Drs Amparo Llorente and José Manuel Reuss
about the clinic’s approach to prevention in implantology.
Why did you choose implantology?
Dr José Manuel Reuss: I was always very interested in
prosthetics and replacing what was missing. I am very
motivated by the fact of giving back what patients have
lost. The combination of prosthetics and surgery makes
implantology perfect for me.
Dr Amparo Llorente: I am a trained periodontist and
I am wholly dedicated to it. I look more at periodontal
disease and prevention of implants [laughs]. However,
I think I also have a good understanding of implants, so
we make a good team.

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Reuss: You definitely have a very good understanding!
What is your approach to implantology and prevention?
Reuss: It is very difficult to be able to tell a patient that
something should last for a lifetime, but this is our goal,
our wish and our belief. Placing an implant should naturally be our last solution once we have done everything to
save the natural tooth. When we do the treatment, we do
not want to have the implant last for only ten years. That
is not really a success. We want to provide a treatment
that lasts for a lifetime.
Llorente: The great thing about Dr Reuss is that, as an
implantologist, he is devoted to restoration and replacing.
However, whenever he sees a tooth that still has the potential to be maintained, he does everything to maintain
it. That is very important. Nowadays, implantology is so
fashionable. Everybody wants to place implants. Some
dentists see the implants only, but we should look at oral
health first. The patient needs to have an implant for a
lifetime. This involves good initial oral health and a wellplanned treatment.

[39] =>

peri-implantitis

Llorente: An implant is the best solution for a missing
tooth, but it is not an alternative for a tooth that can still be
saved. An implant is more expensive than maintaining the
natural tooth, so we try to preserve the tooth if we still can.
Do you think that implantology and prevention of
implants can work side by side?
Reuss: Prevention is the best thing one can do for
one’s patient in the long run. If we can get our patients
to believe in prevention and therefore come to the dentist
more regularly, it will be beneficial for all of us. However,
this is a long and bumpy road, as the patient’s oral care
mindset cannot be changed easily.
Llorente: Prophylaxis is the main way that conditions
like peri-implantitis can be prevented. We know that implant treatment requires follow-up; implants need to be
taken care of continuously, so it is very important to instruct and motivate patients to have regular check-ups
that are complemented by a good home oral hygiene
routine.
As a periodontist and implantologist, how do you
work together?
Reuss: In cases of severe periodontal disease, such
as aggressive periodontitis, we try to delay the implant
placement as far as possible. I am not talking about
weeks or months, but even years. If we need ten years
for a patient with periodontitis to have the necessary oral
health for implant placement, then we wait. Sometimes,
it depends on the patient; sometimes, it is the wrong approach to oral hygiene; sometimes, it is genetics. At the
same time, we have seen implant failure without any clear
reason.
Llorente: The major risk factors include bacterial contamination, a history of periodontitis and habits such as
smoking. This means that we need to look at the patient’s
habits and anatomy and the surgical protocol. These factors are more related to early loss. Another factor is the
prosthetic design.
What role does poor oral hygiene play in terms of implant success?

Reuss: When we see a patient with very poor oral hygiene, we do not place the implants. We are that radical.
We tell our patients that the periodontal tissue needs to
be strong. In the case of poor oral hygiene, the implant
will fall out eventually. We need to make sure that the
patient has good oral health habits. Edentulous patients
with a lack of good oral hygiene are not good candidates
for implants. We have to do several hygiene appointments first before continuing with implant placement.
How can we motivate the patient to use oral care
products more effectively and regularly?
Reuss: First of all, we have a growing awareness of oral
health among our patients. That helps a lot in the general
predisposition of patients. When they come to our practice, they have changed their dietary attitude and work
out more. They are starting to believe more in prevention.
They also come in every six months, while we only saw
them every two years in the past.
Llorente: In Spain, we still have this mindset that patients only come when they are in pain. Now, we are moving in this direction of coming at least every year. From
a periodontal perspective, I would like to see my patients
every three to six months, especially during maintenance
therapy. During the dental appointment, they already look
forward to the next appointment.
Reuss: We understand now that we have to work
with patients as a team. We can no longer simply provide treatment. We have to spend extra time educating
them, motivating them on how they can maintain and
preserve their oral health, which is ultimately their responsibility.
Do you also instruct your patients on how to use
toothbrushes, interdental cleaning tools and toothpaste?
Reuss: Our dental hygienists focus more on oral care
instructions. Their role in prevention is crucial. They establish a close relationship with the patient and make
sure that every patient gets the individual tools he or she
needs, be it toothbrushes, interdental brushes or floss.
Everything in our office is teamwork.
Llorente: Every patient is different, no doubt, but everyone needs interdental brushes, for example. I brush interdentally every day. As dentists, we need to make sure
that we reinforce oral hygiene measures every time the
patient visits. With improving oral health habits comes
greater satisfaction for the patient. The best thing in dentistry is that we can see the change. We can see how the
bleeding stops. And the patient feels it.
What do you think about CURAPROX products?
Reuss: Products that are easy to use help us progress
in our treatments quicker and provide patients with the

prevention
1 2018

So, you argue that implants should be avoided as
much as possible?
Reuss: Well, implants are a great treatment modality
and we are very thankful for this invention. However, implants should be delayed as far as possible. If we can
preserve the tooth for ten more years and then place
the implant, that is the way forward. Patients should not
have their teeth removed and replaced with implants instead. After implant treatment, patients need to be twice
as careful with their mouths. There is no way to go back
to another solution. The dentist needs to communicate
this as far as possible.

[40] =>

| peri-implantitis
tools to easily establish a positive home care dental regimen. CURAPROX’s products are often gentler than other
products, and this meant that it went against the general
trend of the market for the past few years. However, this
softness is extremely beneficial, as it helps to prevent
damage to tissue and teeth.
What role does the implant design play for oral hygiene?
Reuss: Implant prostheses are not easy to clean. The
implant has a very thin cylinder compared with the anatomy of the tooth. The design of the implant needs to
accommodate the structure of the overall anatomy, as
well as the neighbouring teeth.
In the case of missing periodontal tissue or of full-arch
restorations, we need to have a different implant design.
In any case, we use the design most suitable for oral
hygiene measures, especially in non-aesthetic areas. For
example, for lower arch rehabilitations, we try to have no
contact with the soft tissue. That is not possible in the upper arch. But we want to have implant surfaces that can
be polished easily. Interdental brushes and dental floss
also need to be used regularly. We work very closely with
the laboratory and have clear instructions. Tissue contact
continues to be crucial.
Finally, optimal prevention and oral health require
an interdisciplinary partnership. How do you work
with other medical doctors towards achieving overall health for your patients?
Reuss: As healthcare professionals, we see patients
every day who are sent to us by heart specialists, endocrinologists, and so on. This is because there is an intrinsic relationship, proved by many studies, between oral
health and overall health. For example, we have patients
who have been referred by cardiologists who have detected some form of cardiovascular disease and want
their patients to be orally healthy as soon as possible.
We also have diabetics referred to us by endocrinologists, often straight out of the hospital. This is because, if
they have anything wrong with their mouths, an infection
or anything that needs to be addressed, it is essential
that this issue is resolved so that the diabetes-related issues may also be resolved. Patients need to know about
these relationships.
Llorente: We always have to contact doctors if the
patient has a special need. Interestingly, medical doctors send us their patients with immunosuppression and
other conditions to get rid of the dental problems. In comparison with other medical disciplines, we can quickly
manage to control the inflammation and regain the microbial balance in the mouth, thereby helping the overall
immune system. The dental knowledge of general medical doctors is growing, as they understand the need for
a healthy mouth for general health.

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[41] =>

IMPROVES GINGIVAL HEALTH

BY BALANCING
*
THE ORAL MICROBIOME
Zendium is a fluoride toothpaste

users have a measurable improvement

with natural enzymes and proteins proven to

in gingival health.1** So in addition to your

balance the oral microbiome. New clinical

usual oral hygiene advice, recommend

evidence shows that 83% of Zendium

Zendium to patients with early gum problems.

To find out more, go to www.zendium.com

THE POWER OF NATURAL PROTECTION
*Refers to the oral plaque microbiome and the relative abundance of bacterial species with a known association with gum health or disease after 14 weeks of brushing twice a day with Zendium
when compared to baseline. **Refers to the results of a gum health study (UK 2017) on the 113 people who used Zendium (total subjects = 229) and a measurement of gingival health by the
Modified Gingival Index (Lobene) after 13 weeks. 1. West N et al. A toothpaste containing enzymes and proteins improves gingival health. Abstract presented at CED-IADR 2017.

[42] =>

| special: dental hygiene in Belgium

Oral hygiene instructions
and patient motivation
with and without dental hygienists
An interview with Dr Eric Thevissen, periodontist and pioneer of Belgian prophylaxis

Dr Thevissen, I wanted to talk to a dental hygienist in
Belgium. Why is that not yet possible?
Dr Eric Thevissen: Well, the good news is that, from June
2019 on, it will be possible to visit and talk to a dental hygienist in Flanders. Why Flanders has waited such a long
time to start the education and training of dental hygienists
is politically motivated and due, in large part, to the representative dental associations. Belgium has a long tradition of
one-dentist clinics, often working without dental assistants.
Since the introduction of a quite difficult admission exam for
dentistry in 1997, the discipline has attracted fewer students.
As a consequence, the number of graduating students has
dramatically decreased, while the demand for dental care
is continually increasing. Slowly, but surely, more and more
group practices have emerged, hiring dental assistants.
Back in 2006, the first meetings were organised between
universities and dental societies about the qualifications
needed to become a dental hygienist and the tasks that
could be delegated to them. As always, there were proponents and opponents, and it took a very long time before all
stakeholders agreed on the conditions and criteria needed
to start dental hygienist training in Leuven and Ghent.
Let’s talk about your study “The provision of oral hygiene instructions and patient motivation in a dental
care system without dental hygienists”. Please tell us
more about it.
Thirty years ago, I started working as a periodontist in
Hasselt with another colleague. Since we were the first
periodontists in this province, we had a flying start. After
a few years, I noticed that dentists were always referring
patients to our clinic with the same complaints, such as
bleeding gingivae or bad oral hygiene. In my opinion, treating bleeding gingivae or giving oral hygiene instructions
is the duty of every dentist and belongs in the sphere of
primary dental care rather than in secondary or specialist
care. Although we organised courses where a general dental practitioner (GDP) could learn about patient instruction
and guidance, I realised that we were considered by a large
number of GDPs to be dental hygienists rather than periodontists. The truth was that we were both, periodontists
and dental hygienists. This annoyed me because I knew
that in neighbouring countries periodontists could spend
their precious time on the work they were trained for.

Dr Eric Thevissen

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special: dental hygiene in Belgium

Around the same time, Prof. Hugo De Bruyn joined the
teaching staff of Ghent University’s Department of Dental
Sciences. Probably thanks to my publication, he asked me
to become one of his staff members. Working with Prof. De
Bruyn, one is quickly involved in clinical research and so
I had the opportunity to investigate, in depth, the questions
that had bothered me ever since I started my career. One
of these questions was the kind of oral hygiene instructions
GDPs provide to their patients.
Using questionnaire responses of 776 dental professionals gathered for various postgraduate courses in Flanders,
we were able to determine that, given the absence of dental
hygienists in Belgium, oral health instructions and patient
motivation appeared to be non-compliant with international
guidelines. Though dental professionals were concerned
with prevention, there were several mitigating factors working against them delivering this adequately.
The study mentioned lack of time, remuneration and
patient interest as complicating factors for the provision of preventative care. However, qualification, work
experience and time are crucial for providing oral hygiene instructions and patient motivation. Can dental
hygienists be seen as a solution to these problems?
It is my conviction that dental hygienists are the solution to these complicating factors. Prophylactic care will
be the main target of their work, since dentists are primarily trained for restorative care. Owing to factors such as the
decreasing number of graduating dental students, the increasing number of retiring dentists in the next ten years,
an ageing population and a higher demand for preventative
care, the stress of work increases and forces dentists to
manage their work time more strictly. Of course, GDPs prefer restorative and other more rewarding treatments. We all
know how time-consuming patient motivation techniques
for behaviour change can be. There is no dentist prepared
to spend that time on preventative care. Generally speaking, dentists are used to giving a basic package of information on oral hygiene to every patient and, depending
on compliance, they may want to spend more time on patient guidance. Here, dental hygienists can make the difference. They will be trained to insist on the importance of
behavioural change and will take the time to explain and
show how to perform proper home oral care.
You have also published studies on implants, such as
on implant design. What made you publish your study

titled “Attitude of dental hygienists, general practitioners and periodontists towards preventive oral
care: An exploratory study”? You could have just continued with your research on implant systems.
Indeed, the team around Prof. De Bruyn is very driven
by and focused on the outcome of implant therapy. To my
knowledge, the Department of Dental Sciences at Ghent
University published around 40 scientific articles in 2016,
the majority of which are related to implant therapy. The
subject of my PhD is not implant-related, but deals with
different relationships in dentistry: between the patient and
the dental professional, and between primary and secondary dental care, that is between GDPs and specialists.
What were the objectives and results of this study?
This second study was a step further than the first one.
In the first study, we looked for an explanation for the differences in patient motivation techniques between Flemish
GDPs and periodontists. In this second one, we compared
our rather unique Belgian system with the Dutch system,
a completely differently structured healthcare system including dental hygienists. We wanted to know if the Dutch
system represented the gold standard and how we were
situated in Flanders.
The results showed that periodontists and dental hygienists shared more common viewpoints than GDPs and hygienists did. What was remarkable was the fact that more
than 80 per cent of periodontists and dental hygienists
were satisfied with their efforts in informing and motivating
patients, compared with 38 per cent of GDPs. Secondly,
whereas GDPs indicated nurture as the factor most contributing to the oral hygiene level of the patient, periodontists and dental hygienists focused on the influence of the
dental practitioner and a patient-centred approach. In our
multivariate analysis, the presence of chairside assistants
seemed to be of major importance.
But, as always in questionnaire-based studies, the results can be biased by socially desirable answers and by
the inevitable structural differences between Belgium and
the Netherlands. One of these differences, for example, is
the fact that providing oral hygiene instructions is not reimbursed in the Belgian dental care system, as it is not considered an autonomous activity.
What should the role of the dental practitioner in the
successful treatment of periodontal disease be? What
does the patient need to do?
The role of the dental practitioner, in particular the GDP,
undoubtedly remains to keep a panoramic oversight over
everything that has to do with the dental and oral health of
the patient. Especially considering the introduction of dental hygienists in the near future in Belgium, the dentist’s role
as a supervising manager is important. It is my experience
that progressive problems often remain untreated until
complications or even complaints surface. A trigger seems

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In 2004, I took the initiative to set up a pilot study in Limburg with 65 referring dentists. We used the Dutch Periodontal Screening Index, a screening test for periodontal
status that had been introduced in the Netherlands a few
years earlier. We collected data from 814 patients. The results clearly showed that the screened age groups had, on
the whole, periodontal problems and that there was a high
need for treatment.

[44] =>

| special: dental hygiene in Belgium
to be needed to make the idea of treatment approachable
or acceptable. Unfortunately, waiting for this trigger often
leads to the loss of the tooth instead of its repair.
From the patients’ point of view, I am convinced that
some of them insist on not being treated for things they
do not complain about, as they see these treatments as
unnecessary.
If I personally have to undergo an annual medical
check-up, I would hope that all the exams needed are
performed, as this will set me at ease. Why then does this
appreciation not apply to oral health?
What are some of the oral hygiene instructions and patient motivational actions that you would recommend?
Thanks to research and clinical findings, lifestyle habits,
genetics, stress, hygiene, medication, age, nutrition and
different systemic factors have been shown to accelerate
the development of periodontal disease in the presence of
biofilm, activated by a hyperreactive or even a hypo-reactive immune system response. It is a fact that this sort of
risk analysis has become part of the graduate curriculum,
including counselling on healthy food habits or how to quit
smoking, detecting periodontal risk through assessment,
using caries detectors, and so on.
Firstly, the patient should demonstrate his or her home
care habits using his or her own toothbrush. We distinguish
four levels of patient information needs: the lowest level
is the patient who is almost totally ignorant about proper
home care; the second level is the patient who brushes his
or her teeth on autopilot without paying attention to any
technique, time duration or interdental cleaning; the third
level is the patient who regularly cleans even the interdental spaces, but unfortunately not frequently enough or not
with adequate instruments; and finally, the fourth level is
the patient who performs extremely well and needs none
or only minor adjustments, for example tongue brushing.

Often, prevention is neglected in dental practices in favour of diagnosis and restorative treatment. How can
dental professionals implement prophylaxis in their
daily practice, especially primary prophylaxis?
I would say, rather, that prevention is not neglected.
Sixty-five per cent of GDPs provide information about oral
hygiene as a standard procedure. Depending on compliance, the GDP may decide to spend more time on patient
guidance. This requires delicacy, as one cannot tell from a
patient’s face how motivated he or she is, nor what he or
she is interested in. This is not often asked of the patient,
so one could rather say there is not enough time spent on
communication.
I invite practitioners to do an experiment in their waiting
rooms. While the patient is waiting for his or her appointment, he or she can be given a short questionnaire asking
him or her to write down in a few words his or her understanding of proper home care and his or her personal ritual. The patient can then be asked if he or she would be
interested to know more about it. We use this method in
our clinic. In the waiting room, patients have time to reflect
and one might be surprised at how interested patients really are if one gives them the opportunity to communicate
and to prepare their questions in advance.

Finally, the dental professional should show enthusiasm
and keep on repeating until there are visible improvements.

To be honest, I think that primary prophylaxis is impossible to achieve because we do not control all the influencing
factors, of which some can be health- or patient-related.
It means that we need to try to prevent people from developing caries or periodontal disease. This is somewhat
futile, since caries and periodontal disease are the most
widespread infectious diseases present in almost every
patient. Twenty-five per cent of 5-year-old children have
bleeding gingivae, and this figure rises to 55 per cent for
15-year-olds. Primary prevention is like placing speed cameras on highways: it works all the time and for everyone,
it is highly effective and inexorably justified. Today, I heard
in the news that, thanks to these speed cameras and other
regulations, the number of persons killed by traffic every
year is diminishing. This is primary prevention. However,
I strongly believe in secondary prevention; it is the dentist’s
duty to examine and to intervene, preferably before detrimental clinical signs occur.

From your point of view, does the dentist spend enough
time on the diagnosis of a disease?
Of course, dentists are dutiful people who are concerned
with their jobs. Spending time to ensure correct diagnosis
is their core business. Examining patients means exploring and looking for mostly hidden troubles or discomforts.

How important are home care and high-quality oral
hygiene products such as those of CURAPROX?
It is a fact that oral hygiene devices are not considered as
pharmaceuticals and they therefore don’t have to be thoroughly tested. If a company designs a nice, good-looking
toothbrush, it is allowed to produce it and sell it, even if the

In accordance with the technique of motivational interviewing, we build up a conversation with the patient while
giving instructions, waiting for approval, repeating and
counselling. One needs two or three control sessions to
check his or her dexterity and oral cleaning performance.
Plaque disclosure remains a confronting but very effective
tool to show the results of the patient’s cleaning habits.

The next question is the most important one: is this problem acute enough that it should be treated immediately,
in the very near future, or can we wait and see how it develops? This is risk management and it is dependent on
multiple factors.

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special: dental hygiene in Belgium

brush does not meet the criteria desired in an
effective toothbrush.
Comparing the oral hygiene products from different companies, we see a variety of designs
and features. This is interesting because there is
no such thing as the perfect interdental brush.
There are always compromises to make and
what some patients like, may be rejected or disapproved of by others. We as dentists have only
an advisory, consultative role.
Nevertheless, CURAPROX makes Swiss-quality products designed by dental professionals,
and the company is willing to listen to advice on
how to improve its products.
What is the status of dental hygiene in Belgium? In other words, how does the Belgian
mouth look?
When I go abroad to congresses and meet with
peers, I feel their displeasure when they hear that
I come from Belgium. The first thing I am asked
is, how can you treat periodontal disease without
a dental hygienist? For them, it is like having bars
and pubs, but no beer.

Does the addition of dental hygienists make financial
sense or does prophylaxis make financial sense for
the dental practice if the practice already makes good
money with implants?
I understand your point of view that, in the perfect world
of prophylaxis, dental implants have no place because
everything should be done to prevent implant treatment.
I remember Prof. Jan Lindhe saying that, nowadays, too
many treatable teeth are extracted to be replaced by dental implants. As a periodontist I agree with Prof. Lindhe;
a dental implant is an effective instrument to rehabilitate
edentulous areas, but only after all other options have been

considered. But often life decides differently, and at Ghent
University, I see a lot of young people seeking dental care
because of, for example, fracture of one or more of the
front teeth owing to biking and other kinds of accidents,
sometimes under the influence of alcohol or drugs. These
students don’t want to wear removable dentures for life.
With respect to the first part of the question, of course
the addition of dental hygienists makes financial sense. The
purpose is to relieve dentists of those tasks that can be delegated to auxiliary staff. Secondly, dental hygienists will be
trained to communicate with patients about their problems
and questions. Delegating prophylactic care to the dental hygienist implies that more patients can be treated and
followed up on. We also must not forget patients who live
in nursing homes. Since nurses are not allowed to provide
dental treatment, we are glad that, in the near future, dental
hygienists will be available to give these people the necessary preventative care.
What kind of prophylaxis does the Belgian dentist perform in the office? How much time do you devote to
prophylaxis?

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I have read some articles in which the decayed,
missing and filled teeth and decayed, missing and
filled surfaces scores of children were compared
between different European countries. Though
Belgium was not top of the class, it wasn’t at
the bottom either. In articles from the US, it is reported that, at 30 years of age, 25 per cent of the
American population have mild periodontitis, 60 per cent
have chronic periodontitis and 15 per cent have aggressive periodontitis. This is exactly the same breakdown as in
Europe. The question is not about whether dental hygienists are necessary; the question is, what percentage of the
population do dentists reach and can afford to go to a dental hygienist on a regular basis? Despite all this, we seem to
be able to manage the periodontal situation in Belgium and
this was one of the reasons for the second study.

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| special: dental hygiene in Belgium
Supposing that patients go to their GDP
on a yearly basis, supragingival scaling
and scaling of shallow pockets is standard procedure. The Dutch Periodontal Screening Index is a perfect tool to
screen patients for periodontal disease
and treatment needs, but this index is
unfortunately not yet applied widely
enough, even though it is reimbursed. If
a GDP remarks that the gingivae bleed
easily or if the patient complains about
periodontal infection, then the periodontal probe is used and the patient will eventually be referred to a periodontist.
UC Leuven-Limburg and Artevelde University College (in Ghent) are offering a new
professional bachelor’s degree programme in
dental hygiene. Is that a breakthrough?
It certainly is. It is a pity that this programme is not yet
offered in the French-speaking part of Belgium. Let’s hope
they will follow with us as soon as possible to ensure the
levelling of our nation’s dental care. Since Leuven and
Ghent are the only Flemish universities where the dental
graduate curriculum can be followed, it is logical that dental hygienists will be trained at those same universities, and
that both professional groups will start to work together at
chairside from trainee level onwards.
When looking at your Dutch neighbours, what do you
think should be replicated in Belgium?
In the Netherlands, they have more than 50 years of
experience with dental hygienists. This profession is well
represented and has a strong, hardworking and lobbying
society. We in Belgium have always respected and admired the pioneering way of organising dental care in the
Netherlands. Although tough discussions have had to be
conducted, they have always reached a consensus. Today in the Netherlands, up to ten different levels of dental
professionals are distinguished, from specialists to dental
assistants. I don’t think we will ever see this development
in Belgium.
The advantage of us being behind is that we can copy
the best things that have proven to be solid and to work,
and delay the more complex or risky things until we see
how it works out there.
I hope that dental hygienists will integrate easily into the
dental workplace and that their future will be as bright as it
is in the Netherlands.
Finally, where do you see the future of Belgian dentistry?
When I graduated in 1986 as a periodontist I had two dreams,
the first of which was the official recognition of our diploma
as a specialist in periodontology and oral implantology.

prevention
1 2018

This
dream
was only
fulfilled in 2003.
My second dream was
that dental hygienists would be legalised to work in Belgium, and as you know, this will also become true from
2019 onwards. So, the future is bright. I fortunately did not
mention how long it would take before my dreams would
be fulfilled!
Looking back to ten years ago, taking digital impressions
with oral scanners was still a utopia; there were no navigation systems available for implant therapy, and we did
not yet have these composites with hydroxyapatite nanoparticles. Dentistry has evolved in such a rapid way that
the future is today.
However, in my opinion, the evolving trend towards cosmetic dentistry is almost alarming. There is nothing wrong
with the high demand for aesthetic dental treatments because it has been proven that these patients show more
compliance in cleaning their teeth, but there is a tendency
towards the belief that appearance is more important than
function. Many patients prefer whitening their front teeth to
periodontal treatment to save natural teeth. While they argue about periodontal therapy not being reimbursed by the
healthcare system, this point is not raised when they seek
aesthetic dental care.
Another rather regrettable observation is the fact that
stock-market-listed companies invest in dental clinics and
hire dentists as employees. Of course, this is a sign of
the times. Being the manager of a group clinic today has
turned into a full-time job that has almost nothing to do
with dentistry. Let’s hope that the financial management of
these clinics is not more important than the patients and
that the dentists working in the system still feel the same
responsibility towards their patients.
Thank you very much for the interview.

[47] =>

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[48] =>

| special: dental hygiene in UK

“We’re all about prevention”
By DTI

Mrs Ison, could you tell us a little bit about yourself
and your background?
Clare Ison: I initially started my career in dentistry in
1988 before becoming a qualified dental nurse in 1994—
back then, one didn’t have to become a qualified nurse
immediately, unlike now. At a point, I had a bit of a career
break, but I’ve come back to work in practice management. Though I also used my break to gain qualifications
in business management, I gained my post qualification
as an oral health educator as well.
What does being an oral health educator involve?
How do you become one?
It just means educating one’s patients about prevention—preventing any dental disease, whether it is peri-

prevention
1 2018

odontal disease or dental caries. Oral cancer is also on
the increase, so discussing that topic is important as
well. Dentists or hygienists refer patients to our clinic, and
once the patients are with us, we look at what the aims
of the appointment are. Though this differs for patients,
we always want them to go away from our clinic with the
motivation to take charge of their own oral health.
With respect to becoming an oral health educator, we
put our nurses through a nine-month-long online course
that is run by the British Dental Association. Though the
online aspect of it makes it somewhat easier to complete,
the content is quite in depth: there are case studies one
has go through, the way one conducts lessons is analysed, and there’s an exam at the end of it. It’s a great
programme that gives nurses a chance to get additional
skills and new responsibilities, and more nurses should
be encouraged by their practices to do this sort of stuff.
What do you specifically aim to educate your patients about?
We really want to emphasise the importance of keeping one’s mouth healthy. One doesn’t want them to see
the hygienist and think that that’s enough and not take
any action until they come back for another check-up six

Getting one’s patients to engage in preventative oral
health behaviours can be difficult at times. Helping them
to understand the importance of such care for longterm health is key to achieving this. With this in mind,
prevention magazine spoke with Clare Ison, a nurse and
oral health educator at Beaufort Dental Health Centre in
Burton-on-Trent in the UK, about what her roles entail
and how she motivates and educates her patients to take
ownership of their oral health.

[49] =>

special: dental hygiene in UK

Clare Ison

months later. They need to know how to practise good
oral hygiene at home, what the risk factors for certain oral
diseases are, and indeed, what even causes them. We
go right back to basics, what toothbrush and toothpaste
they use. It’s not judgemental, however; this is aimed
at providing them with a solid base of knowledge upon
which they can build.
We’re all about prevention. To be honest, why would
one keep treating a patient who has dental disease without informing him or her about what exactly was causing
that disease? If he or she has tooth decay, for example,
one can treat it by providing fillings, but one also needs
to explain what exactly is causing the decay so that the
patient can be aware of it and prevent it.
What type of patients do you have at your practice?
We welcome all ages and all patients, but we do like to
focus on children, as we can get them started at an early
age with a good education on oral health. At the end of
the day, they’re most likely to be shown how to clean their
teeth by their parents, and if there’s something wrong
with how they’ve been taught, we need to break the cycle
and improve the oral health of not just the children but
also hopefully the whole family.
How can you motivate patients to adopt good oral
hygiene practices?
We sometimes like to focus on the risk factors and
the issues that can potentially arise, such as tooth and
bone loss. However, it’s most important to show patients
support and guidance and provide them with a good

oral health education. If these are all right, the patients
will usually listen. Though this is sometimes a step-by-step
process for certain patients and can require multiple
sessions, it is ultimately worthwhile.
How many patients practise or understand the benefits of something like interdental cleaning?
Well, interdental cleaning is something that a lot of
patients don’t know about, because they often think
that a toothbrush cleans all of the tooth surfaces, and
so it’s quite difficult to implement in a daily oral routine.
However, if one demonstrates it to them not just on a
model but in their own mouths as well, one will often be
able to physically show them the removed plaque on the
interdental brush, the evidence of what is in the interdental space, and this can motivate them to adopt it in
their day-to-day routine.
What is the current situation regarding oral healthcare in the UK?
Overall, I would say it is quite good, yet there are still
some areas that can be addressed. Interdental cleaning,
as I mentioned, is not really something that is that popular
in the UK yet, and there’re also a lot of patients who think
that brushing their teeth only once a day, and not twice, is
acceptable. Though they might be hesitant at first, once
we’re able to educate patients and show them how removing plaque twice a day can improve their oral health
dramatically, we can really get them to change their oral
hygiene habits for the better.
Thank you very much for the interview.

prevention
1 2018

[50] =>

| special: dental hygiene in UK

Patient motivation techniques
By DTI
When it comes to motivating patients to maintain good
oral hygiene practices, a clear plan is essential given the
time constraints of most dental appointments. What this
plan entails, however, depends on what the most pressing issues to the patient are. prevention magazine spoke
with Sandy Basheda, a dental hygienist at the M & N Dental
Practice in Bedford in the UK, about how she structures her
oral hygiene appointments and the importance of building
relationships with patients.

Each oral hygiene appointment is scheduled for half
an hour and begins with a discussion about the patient’s
existing problems and current oral hygiene routine. I then
explain to the patient what the purpose of the appointment
is and what it will entail and conduct an assessment of his
or her oral health. Every patient is very different, and it really
depends on what he or she needs addressed as to how the
appointment will proceed from there.
How can you get patients to continue with good oral
hygiene practices after an appointment?
I think one has to build a relationship with them. They
have to trust one and understand what the benefits of oral
hygiene are, as they might not be aware that they have any
problems in the first place. For example, if smokers aren’t
experiencing any bleeding in their mouths, they might not
think that there’s anything to worry about. One needs to be
able to explain to them in a clear and understandable way
why taking care of their teeth is important not just for their
oral health but their overall health too.

Sandy Basheda

Ms Basheda, how did you first get started as a dental
hygienist at M & N Dental Practice?
Sandy Basheda: I’ve been working at M & N Dental
Practice for three years now. I started basically straight
after I graduated from the University of Liverpool with a
degree in dental hygiene and therapy. Prior to that, I had
a background in dental nursing, but I wanted more of
an instrumental role with dental patients, which led me to
hygiene and therapy.
What does your average day at work involve, and what
is the structure of your oral hygiene appointments?
I see many patients with periodontal problems and so
conduct a lot more hygiene right now than therapy. I also
deal with a lot of children that, unfortunately, have dental
caries due to a poor diet, lack of oral hygiene and likely
a lack of education on how to prevent it. It’s not a good
start for children if they have to have fillings put in or even
have their teeth pulled if it’s particularly bad—it doesn’t
give them a good first impression of the dentist.

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1 2018

But is it possible to achieve this all within half an hour?
Well, it’s not a lot of time, but we can always schedule an
hour-long appointment if it is necessary. I see many anxious
patients, patients who might not have been to the dentist in
ten to 15 years. With these patients, a shorter appointment
is often good in the beginning, because it means that they’re
not overwhelmed and that one can build up from there over
the ensuing sessions. By the second or third appointment,
they’re a bit more relaxed and eager for treatment.
How do you motivate your patients to take charge of
their own oral hygiene?
I think it’s mostly about re-educating patients on what
the correct and most effective cleaning methods are, what
products are best for them. It’s about finding something
that works for the patient, something that will get him or
her excited about taking care of his or her teeth and seeing the benefits. In dentistry, it can be difficult to engage in
a cooperative relationship with one’s patients—often, it’s
a one-way conversation with the professional giving the
patient instructions or advice on how to take care of himor herself. I like to leave that sort of instructional conversation to the beginning or the end of the appointment, as this
allows the patient to think, while in the chair, whether he or
she has any questions about anything I’ve said or what our
future appointments will entail. Being able to answer these
questions in a clear and understandable way is essential
to motivating patients.
Thank you very much for the interview.

[51] =>

[52] =>

| special: dental hygiene in UK

My Guided Biofilm Therapy journey
By Faye Donald, UK

Right now, I am sitting outside a small cafe overlooking
the vast and beautiful Lake Geneva. It is a crisp February
afternoon, yet I have chosen a table outside. I am sipping
a small glass of red wine and on the left side of my thick
winter coat I am wearing a badge given to me on my recent visit to the EMS head office. It reads, “I feel good”.

cleaner mouths from my surgery. I grew in confidence as
I became more familiar with the scope of clinical range my
AIRFLOW could offer, using it in areas difficult to reach,
previously non-responding sites, peri-implantitis sites that
I did not know what else to do with. I realised I was no longer looking at a problem; I was looking at a solution.

I smile to myself as I reflect on my journey so far, a journey
that I had thought was almost complete only to unexpectedly stumble upon another exciting pathway. Picture this:
I had graduated from dental school about 14 years before,
I thought I had gone as far as I could go clinically, I was honest, hard-working, kind and good at my job. Did that make
me successful? Or did that make me just good enough?

I was suddenly reawakened, eager and enthusiastic
about my work. The more I used AIRFLOW, the more it
impressed me. Treatment times were getting shorter, yet
results were getting better. I was dazzled by AIRFLOW’s
potential and the prospect of how far we could take it. That
said, there seemed to be no clear direction on when best
to use AIRFLOW. I was experimenting but without much
guidance.

It was tough. General practice was a slog, a battle.
Regulations were getting stricter, time was getting more
restricted and budgets were getting tighter. I struggled to
remain motivated, and I fear my patients did too. It felt almost like the tools to treat active periodontal disease were
in abundance, with advice from all corners, but maintaining patients was something that just was not focused on.
I would reinforce, retreat as necessary and hope for the
best.
However, there was something happening in the dental
world that was long overdue, a change in our treatment
methods. Painfully slowly, we saw the decline of instrumentation, replaced by more minimally invasive treatment
modalities. Rethinking what we had been taught, we cautiously stepped out of the shadows of old-fashioned treatment and into a modern, forward-thinking, results-based,
patient-centred approach. All of a sudden, we were discussing biofilm instead of calculus. We were giving oral
hygiene instruction before scaling. There was a revolution
occurring in front of our very eyes.
I was first introduced to AIRFLOW when I switched practices and quickly grew to appreciate it. Soon, I was using
AIRFLOW on every patient and seeing cleaner mouths and
happier patients. Though I initially used it for its stain removal benefits, I read up some more and especially looked
at studies on periodontal powders. I experimented more
and more and it seemed to do no wrong. Patients drove
much of the change; they had started to request it, having
seen and felt the difference first hand.
Patients started to book specifically with me, as the gentle AIRFLOW treatment left their mouths feeling better than
ever. They were experiencing lower bleeding scores and

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Then came the great Guided Biofilm Therapy (GBT)
launch in 2015. As an advocate of AIRFLOW, EMS invited
me to Switzerland to witness the unveiling of this longawaited concept. I sat in that room and it was like finding
the holy grail. This was the road map we had all been missing. I watched presentations from world-renowned specialists who had found success with AIRFLOW. At first,
I felt overwhelmed to be on the same speaker schedule,
but when they displayed their clinical cases, I realised that
my results were similar to theirs.
When my turn to speak came, I felt proud to show my
work. I stood tall and told them what I knew. AIRFLOW
was the common denominator, the bridge that connected
the specialist to the hygienist. Back in general practice,
I had renewed confidence. I took the GBT protocol and
added my own flare. I no longer spoke of disease but of
prevention. I was empowered and motivated, and so were
my patients.
I made contact with a practice that had been recently
purchased by a young and enthusiastic dentist who was
looking for someone to revitalise his quadrant-scalingfocused hygiene department. At that time, his hygiene
bookings consisted of just Tuesday afternoons and even
that time could not be filled. The practice was losing money
and the struggle was very real.
I pitched the GBT concept to the new principal, who
had a vision of creating a slick preventative- and prophylaxis-centred practice. It took a great leap of faith for him
to trust me and invest in the AIRFLOW equipment, particularly given the scepticism that surrounded the whole
department. However, within 12 weeks, we had gone from

[53] =>

special: dental hygiene in UK

one half-filled afternoon per week to two full days of oral
hygiene appointments. After six months, we were at full
hygiene surgery capacity of three days per week. The
demand was so high, we could barely keep up. We advertised wherever we could and ran free AIRFLOW promotional days based around GBT to raise awareness and
money for charity. Our first “Drop in for a Free AIRFLOW”
day was a huge success, with local businesses donating
raffle prizes and local media broadcasting from our waiting
room. It was an unqualified success.

the award with pride and dedicated it to the incredible
individuals who have developed AIRFLOW into the game
changer that it is today.
Life in general practice in the UK for many hygienists
is gruelling. Twenty-minute appointments are not uncommon and packing in assessment, motivation, full-mouth
scaling, polishing and home care in this time is very difficult, leaving both hygienists and patients unmotivated. It
does not need to be this way. GBT has transformed my

I performed AIRFLOW treatment on 34 new patients that
day—free of charge. Those were 34 people who otherwise might not have experienced the pain-free comfort
and results that AIRFLOW offers. One year on and of those
34 patients, 23 are now regular paying patients. Who
knows how much other business was generated from the
ripple effect of people talking about our ethos and our
pain-free treatments.

clinical practice and it can change others too. I would go
as far as to say I am unrecognisable from the hygienist
I was five years ago. My appointments are measured, controlled and, most importantly, complete. Treatment is carried out without compromise and to the highest standard.
Most importantly, my patients feel empowered and motivated to take charge of their own oral health. I feel in control, I feel inspired and, true to EMS, “I feel good”!

I was motivated to share my knowledge and unleash
GBT’s potential for other hygienists in the UK. I took to social media and rapidly made a name for myself on the hygiene forum as the go-to AIRFLOW guru. Requests to run
courses came thick and fast, and I travelled the length and
breadth of the country practising, teaching and dreaming
about GBT.

The future

To my utter shock and amazement, in November 2017,
I won the award for Best Hygienist at the Oral Health
Awards. I was humbled and honoured, and accepted

In my opinion, there is a new revolution taking place:
the rise of AIRFLOW and GBT. My passion lies in sharing
this knowledge, skill and experience and in providing hygienists with the tools to be the best they can be. I invite
hygienists into my surgery free of charge to observe and
learn before returning the favour at their practices. I will
not stop until every single hygienist in the UK has heard of
GBT and I have founded the very first GBT practice in the
UK. And then I will take on America! Just you watch me…

prevention
1 2018

Geneva Lake © Voronin76/Shutterstock.com

Faye Donald

[54] =>

| psychology of prophylaxis

Knowing-doing gap in dentistry
By Dr Ana Stevanović, Switzerland

dental disease is due to nothing other than biofilm, are our
predictions on the future of oral health still so pessimistic?
Despite dentistry’s knowledge of these facts and predictions, results indicate that not enough is being done.
There is a vast difference between knowing and doing,
a gap between intention to make a change and the action
of bringing about such a change. It is a gap that dental
professionals experience daily. So the question is simple: how do we bridge the gap between
knowledge and action?
Dr Ana Stevanović

According to a 2002 study by Douglas CW in
The Journal of Prosthetic Dentistry, 38 million adults in
the US will be in need of one or two complete dentures by
2020. What is being done to address this shocking prognosis? There are more than 14 million implant placements
per year worldwide. Consequently, the efforts invested in
preventing implant complications have risen significantly.
But are we doing enough to reduce the need for implants
in the first place? Why, when we know that 99 per cent of

As a dentist, communication with my
patients was never an easy part of my
job. For example, telling a patient to brush
better. What does brushing better even
mean? If I simply advised the patient to
apply the Bass technique, I would see
100 different forms of the technique.

A changing world
without change
A colleague once commented that patients are responsible for their own oral
health. I could not agree more. However,
as medical experts, do we not first have
to empower patients by providing the
knowledge and teaching them the skills
necessary to assume full responsibility?
The truth is that most patients received
their oral care instruction from their parents. This contrasts with the modern approach of individual prophylaxis and this
is the gap that must be bridged.
Present-day dentistry does not seem to
allow enough time for proper training and
instruction. Either patients are not willing
to pay for this service or the dental professional does not have the necessary
time during an appointment to provide this
service. Most countries do not have the
luxury of a one-hour appointment with a
dental hygiene specialist, which would allow enough time for cleaning and instruction. Switzerland is one exception. Other
countries need to follow its example in order to implement an effective knowledge
transfer during dental appointments.

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1 2018

[55] =>

psychology of prophylaxis

One thing we will always have to deal with is the mindset of our patients: “I get decay no matter what I do or
how much I brush”, “My parents too had bad teeth”, or
“A tooth can be easily replaced today.” Patients are, firstly,
quick to put the blame on their parents or point the finger
at dental professionals. Secondly, dentistry is still associated with a great deal of discomfort. Lastly, patients know
about many of the treatments and solutions available.
Charles-Edward Winslow, founder of the Yale School
of Public Health in the US, once said that it a duty of
each generation to redefine “unacceptable”. Is 38 million
Americans with at least one complete denture not absolutely unacceptable? We live in such a fast-changing
world that we have lost our connection with our mission
and at times also with our patients. The time has come
to change the status quo.

Change must be accepted
How do we bring about this change? The answer
seems too simple to be true. Through the service of
coaching. Nowadays, there is hardly a product sold
without a value-added service. No treatment without
maintenance. No dental practice without dental hygiene.
In-depth instructions have become crucial for the success of a product. Is a dental office not an accumulation
of service efforts? Why, then, since we as dental professionals have the competence, do we not include coaching as a value-added service in a dental practice?
Successful coaching in dentistry depends on three
crucial factors: establishing personal connections, developing trust, and growing relationships. Patients should
become part of a long-term relationship with the office.
It is not about regularly bringing in new patients, but
cultivating the ones the practice already has. The most
modern practice and the friendliest team will avail nothing
if the patients do not stay with the practice.
Personalised connection through individual coaching
is key to building a long-term relationship. No technology can replace a durable connection between a dental
professional and a patient. Digitalisation cannot replace
trust.

A programme designed for change
This is why Curaden brought individually trained oral
prophylaxis (iTOP) to life. This is a programme introduced
20 years ago by Dr Jiri Sedelmayer, an established dentist and past professor at the University of Hamburg in
Germany. During his time at the university, he realised
that dental students studied every detail about restoration, but knew nothing about keeping their own mouths

healthy. Dental students were never practically taught
any techniques to maintain their own oral health. This realisation led to the establishment of iTOP—to train future
dental professionals.
What began in 2006 as a single two-day course has
since grown and been attended by more than 14,000
dental professionals worldwide. iTOP operates with the
support of over 200 instructors in 44 countries. In our
seminars, we do not differentiate between a dental hygienist, dental nurse, dentist or oral surgeon. All of their
daily work contributes likewise to shifting the paradigm
from restoration to lifelong oral health. Each of their endeavours aspires to the best for their own health and
the health of their family members, friends and patients.
All of them share one common understanding: a clean
tooth cannot become diseased.
The iTOP programme is based on three simple criteria:
acceptable, effective, non-traumatic. These pillars are the
foundation for all oral healthcare products that Curaden
offers to its clients.

Knowing is good, action is better
In order to achieve clean teeth, we employ a unique
practical training concept called “touch to teach”. It is
based on the idea of the dental professional experiencing and practising the iTOP techniques on him- or herself first, before teaching it to others. No phantom model
will ever replace the feeling of a toothbrush, interdental
brush and solo brush on one’s own teeth and gingivae.
Oral health needs to be taught individually and practically. Sometimes it is necessary to go back to the basics
to achieve change in the future.
There continues to be a huge gap between knowing
and doing. But let me be clear: what we know, we should
apply repeatedly, every single day. It is our job to repair
teeth, but it is our mission to keep our patients healthy.
We should not confuse our job with our mission. Only
then will we, 20 years from now, have those 38 million
people smiling with their own healthy teeth denture-free.

about
Dr Ana Stevanović is Head of
Professional Education at Curaden.
She has spoken at numerous events
on the importance of a paradigm shift
in dentistry and bridging the knowingdoing gap in preventative oral care.
Her background as a dentist, manager
and development coach aids her in
utilising her work with both dental
professionals and patients to help shape a change in the
mindset of individuals in order to change the future of oral care.

prevention
1 2018

Unacceptable status quo

[56] =>

| practical prophylaxis

Already cleaning or still polishing?
By Adina Mauder, Germany

Caries and periodontitis are avoidable. Dental plaque
resulting from microbial colonisation of tooth surfaces
is seen as an aetiological factor for caries and periodontitis, the most common infectious diseases in the
Western world. Biofilms are complex 3-D structures in
which, for example, bacteria are encased in a mucoid extracellular matrix. They do not just occur in the oral cavity,
but on all boundary surfaces that are moist and warm.
Their significance regarding the occurrence of problems
such as periodontitis and caries has been scientifically
acknowledged. Science has been trying for years to find
efficient means and methods to remove and prevent
biofilm.
Although we have new findings on biofilm, we are still
using instruments and materials from a time when the aetiology revolved around sub- and supragingival calculus.
Why do we first remove calculus with hand instruments
and electric scalers despite the focus falling here on living
biofilm?

ig
.

Gu
ide
d

Bio

film

The
rapy

prot
ocol.

prevention
1 2018

Why do we still polish with rubber cups and brushes,
which are proven to harm hard- and soft-tissue? Why do
we use four methods to remove biofilm: ultrasound, rubber cups, hand instruments and polishing compound?
Is there not just one method that is completely painless,
more effective and saves time?
We are fortunately now seeing a further paradigm shift
in terms of procedure and the performance of prophylaxis. A procedure known as Guided Biofilm Therapy
(GBT) has become the new protocol for the examination
appointment with the clinician. Based on numerous scientific studies and jointly developed by specialists at universities and dental practices and Swiss company EMS,
GBT is now increasingly popular. I myself am delighted
to be able to offer my patients this simple and pleasant
treatment, which above all ensures gentler treatment of
the tooth substance.
What is GBT? It is very simple: GBT is my concept
for success, a procedural protocol, divided into several
steps that are easy to explain. They are establishment
of findings, disclosing; patient education, including performance of oral hygiene at home;
remotivation of the patient; sub- and
supragingival biofilm management
with the appropriate instruments,
gentle treatment that is really
necessary; quality control;
recommendations; and individual assessment of the
recall interval.
In GBT, it is especially
important to disclose
the tooth deposits that
cause harm. It is what
the clinician discovers
here that guide the clinician when performing oral
prophylaxis. This is how we
achieve optimum results for
the benefit of patients, treating them with the least invasive
method while ensuring maximum
comfort. GBT is suitable for healthy
patients, including children; patients with
orthodontic appliances; and those with caries,
gingivitis, periodontitis, peri-implant mucositis or
peri-implantitis.

[57] =>

practical prophylaxis

Fig. 2

Fig. 3

Fig. 4
Fig. 2: Before Guided Biofilm Therapy, the
biofilm is only partly visible. Fig. 3: Colouring
with Mira-2-Ton (Hager & Werken). Colour prior
to cleaning the maxillary and mandibular teeth.
Fig. 4: Checking after cleaning the maxillary
and mandibular teeth using a modern method.

What GBT means for me
GBT has changed not just my work procedures, but
also me personally. I have been a dental hygienist for
18 years and also work as a dental coach at the Swiss
Dental Academy. In my seminars, I place importance
on individual prophylactic treatment concepts. I do not
concentrate solely on removing calculus, but also on
biofilm. After all, it should be the task of the team at the
dental surgery to offer optimum, personalised prophylactic treatment for lifelong oral health. At the surgery, we
should apply an individual concept that combines the latest findings with a better quality of life for the patient and
greater earnings for the dentist.
For me, this concept is GBT. Since I learnt about GBT,
my work tray has undergone a radical change. I need
fewer instruments, but use the ones I have far more effectively. I too have changed. From being a cheerful sort
of person anyway, I have now become even happier.
I enjoy my work more and see how patients are willing
to come back. After all, they have just received gentle

treatment, as well as had an informative discussion about
personal oral hygiene with me. I see how happy patients
feel, and how happy I feel as well.

The eight steps of GBT
What is the secret of GBT? In a nutshell: hand instruments and traditional polishing make way for ultrasonic
instrumentation PIEZON NO PAIN and AIRFLOW with
low-abrasion erythritol-based PLUS powder. GBT combines these technologies in eight successive treatment
steps.
Step 1: Findings
We perform no treatment without thorough screening
for caries and periodontal disease, which we accomplish
using conventional tests, for example periodontal screening index, approximal plaque index and sulcus bleeding
index. To ensure exact reproducibility of the indices, it is
advisable for the entire prophylaxis team at the dental
surgery to agree on documenting and evaluating their
findings according to one specific index and system.

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| practical prophylaxis
Disclosing helps the clinician even more. We are able to
target biofilm more accurately and increase the success
of its removal. Studies have shown that, without disclosing, some 20 per cent of biofilm is left in place, particularly when it is supragingival. Only clinicians who use
disclosing agent are able to remove up to 100 per cent of
supragingival deposits. This also means that, if there is
nothing there, it does not have to be removed. In the past,
we cleaned every tooth, but left half the deposits behind.
Step 3: Motivation and oral hygiene instruction
Motivation is the driving force behind patient satisfaction. Disclosing is thus the basis for successful instruction and motivation of patients to perform oral hygiene
at home. Only when patients understand their situation
will they remain motivated. Motivation and personalised
instruction are therefore a central and exacting element
of GBT. For oral hygiene at home, I recommend using
suitable aids that are individually tailored to the patient’s
needs.

Adina Mauder

I strongly recommend Philips Sonicare toothbrushes
(31,000 brush head movements), and Philips AirFloss
owing to its dynamic sonic technology and minimally invasive efficacy. The success of patients in cleaning their
teeth using these technologies or a combination of them
after instruction leads to excellent results in terms of oral
hygiene. I have seen even greater success as regards
stabilisation, particularly in the case of patients with periodontal disease or unsatisfactory lifestyles.

We need to know whether the patient takes medication, suffers from systemic disease (e.g. diabetes), has a
pacemaker or possibly has any allergies. The anamnesis
must be clarified in detail. The data filtered here allows us
to decide which technical instruments and materials can
be used during the prophylaxis session without putting
the health of the patient or the clinician at risk. Visual inspection of the patient’s teeth is followed by examination
of the mucosa in the oral cavity. It is important to note
that, before treatment, we always start by administering
a mouthwash to protect both the patient and the clinician.
Step 2: Disclosing
Coloured biofilm is the best way to show patients the
correct cleaning action (techniques) in their individual case.
We use disclosing agent to motivate them. By making biofilm visible to patients, they understand their problems better, and this is proven to result in greater compliance.

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Step 4: AIRFLOW
We first remove the biofilm. Why the biofilm first? It is
very simple: as already mentioned above, calculus has
never caused disease on its own. The main reason for
many problems in the oral cavity is the quality of the biofilm, and its adverse processes and effects—far-reaching, even affecting the entire body. If we remove the biofilm first, we are eliminating bacteria and so stopping
disease.
We can also remove stains successfully with an efficient procedure that has been learnt. Deposits of all
kinds, including calculus, are identified more easily while
working, becoming visible both supra- and subgingivally.
This allows us to target them more accurately in our work.
We protect our patients from being treated unnecessarily. That should be a consideration of all treatments
performed on patients.
We consider more carefully what instruments are in
fact necessary and select them accordingly. We should
step in only where there is a real need for treatment. It is
now easy to remove young calculus and stains. We are
gentler on the patient in our work. It has now become
possible to apply an approach that is extremely gentle,
minimally invasive, atraumatic and precisely targeted to

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the specific problems of each patient. This new cleaning
technology is also effective when teeth are malaligned or
very close together, and with surfaces that are not easily
accessible and impossible to reach with a polishing cup
and brush. We can also clean the tongue and palate. If
the necks of the teeth are exposed, we can likewise deal
with this without damaging the cementum or dentine.
Whether a patient has gingivitis, periodontitis or periimplantitis: AIRFLOW and PLUS powder allow us to work
subgingivally down to a sulcus depth of up to 4 mm. Anyone who has ever caught rubber cups on orthodontic
appliances and then administered a powder–water treatment jet will not want to do without this new method.
Step 5: PERIOFLOW
When it comes to removing subgingival biofilm, in 4 to
9 mm periodontal and peri-implant pockets, I recommend
using PERIOFLOW. The PERIOFLOW nozzle has enabled
the treatment of millions of periodontal pockets, and we
have achieved excellent results in the case of peri-implantitis, for example. I recommend using it six to eight
weeks after initial therapy. When doing so, it is important
to ensure you do not work horizontally on the tooth and
the pocket, but pocket by pocket, proceeding slowly and
without pressure, ensuring an extremely gentle action.
Working vertically is necessary here.

the patient’s general anamnesis, diet, reconstructions,
anatomical structures, cleaning habits and general state
of oral hygiene.

Conclusion
We should ask ourselves every day: What is the efficacy and benefit of each method? What is the effect
of cleaning? What are the clinical parameters like? How
much time can I take? What safety does the method offer me with hard- and soft-tissue and restoratives? What
level of comfort can I offer patients? How do I guarantee
the health of my patients? Hand instruments and conventional polishing do not provide satisfactory solutions, but
GBT is already able to do so.
GBT is a scientific concept for success at every dental surgery, offering intelligent guidance for every clinician. GBT is not only a safe and reliable procedure that
smooths your path toward success, it also ensures even
better treatment and dental prophylaxis results. I recommend that your entire team at the surgery try out GBT
once—you will be delighted with it.

Step 6: PIEZON
If calculus is present, I opt for the latest technology:
PIEZON. PIEZON NO PAIN is based on piezoceramic
energy conversion of linear movements. Hand instruments are overshadowed here. PIEZON is not only highly
precise, but also intelligent and minimally invasive. The
PS tip is ideal for supra- and subgingival application,
while the PI instrument can also be used on titanium or
ceramic surfaces. The instrument is moved over the surface of the teeth without applying pressure (the PS instrument is held parallel to the tooth surface), to avoid any
loss of tooth substance or changes to surface structures.
Patients find this procedure very pleasant.
Step 7: Control
We must check that we have removed all biofilm and
calculus. This is what patients expect of a professional in
our field. I recommend performing this check with a fine
probe and a pair of dental loupes. The chemical plaque
check is followed by final examination and final diagnosis by the dentist.
Step 8: Recall
Our aim is long-term stabilisation, preservation of tooth
substance and avoidance of disease. This will only succeed with regular recall. The patient should leave the
dental surgery with a recall appointment, which must be
scheduled at once based on the findings. This depends
on numerous individual factors and risks, which include

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Patient satisfaction is key
An interview on the opening of a new practice

Dr Ines Laible and Maike Laible

Radiant and healthy teeth throughout life—that is the
ultimate goal of the practice run by Dr Ines Laible and
Maike Laible. The practice opened in late 2017 near Stuttgart in Germany and saw a real rush of patients within a few
weeks—the magic formula: only the best for prophylaxis.
In pursuit of radiantly beautiful smiles on patients’ faces,
the two dentists opted exclusively for state-of-the-art technology and equipment. prevention spoke with Dr Ines
Laible and her sister-in-law Maike Laible four weeks after
the opening of the new practice. The conversation touched
on how best to plan the opening of a new practice, the
importance of good patient education, and the decision
to rely on the latest ultrasonic and powder jet equipment.
Congratulations on the new practice. Why did you
choose to open a new practice rather than enter someone else’s employment?
Dr Ines Laible: I always wanted to be self-employed
rather than being permanently on the payroll. We had ideas
and dreams of our own practice early on and we wanted
to fulfil them. A regular salaried position was never really
an option. However, the search for premises was very difficult and tedious. In addition, we didn’t want to stick with a
specific dental depot because of dental units. So we talked
to the bank, reached an agreement and decided to go for
very high-quality equipment and the new premises.

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Maike Laible: I worked for years as a dental surgeon in
various practices. I often encountered very old technology,
but also old treatment methods. I realised pretty quickly
that I wanted my own practice. That’s when every dentist
wonders whether to take over an established practice or
start a new one.
Dr Ines Laible: I never wanted to take on a practice alone.
Of course, we didn’t just want an old practice that would
basically have to be renovated for the same money as it
would take to start a new one. So we decided to start
afresh. My husband called the local business development
unit, and a few weeks later, we received a call to say that
the owner of a new building could very well imagine a dental practice there. Even when premises for the practice had
been found, we had to wait another three years, since everything still had to be built. Rome wasn’t built in a day, but
we’re sitting here now!
How long did it take to set things up, from putting up
the first wall to receiving the first patient?
Dr Ines Laible: At the beginning of November, after years
of hard planning, the walls in the premises were erected
and the floor with all the wiring had been laid. Then everything went very quickly. Together with the architect and
an amazingly dedicated team, we got the whole practice

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together within two weeks. Up to 30 expert craftspeople were in our practice every day. And we were there in
the midst of it all. We were able to plan and furnish our
space, and we had free rein and lots of fun. There were
no compromises to be made. On 20 November, we
welcomed the first patients.
Opening a new business involves a great deal of
marketing to make yourself known quickly.
Dr Ines Laible: We were naturally visible long before
the practice opened. We had been distributing flyers
since October and taking out ads and participated in
an autumn festival with a stand to gain publicity. In the
end, we welcomed over 300 people to the opening, allowing people to have a look at the practice without any fear.
Maike Laible: The logo design wasn’t easy either. We
looked at different designs, gathered impressions and tried
to find a nice colour. At the beginning, we wanted to combine blue with a tooth.
Dr Ines Laible: But then the architect came and said,
Nothing with teeth! That’s what everyone has!
Maike Laible: So we chose pink, a strikingly feminine
colour considering the male-dominated businesses in
the town of Fellbach. The colour and style are reflected
throughout the practice and our communications. Even the
“2” in our logo fits—and we did, in fact, incorporate a tooth
and two “L”s, for “Laible”.
Dr Ines Laible: Of course, an informative website with
fresh colours and good images is as important as having a
Facebook page. We dentists are people too and celebrate
Christmas like everyone else. If our patients can follow us
on Facebook and evaluate us, this is a great opportunity.
The comments prove you right: “Super practice, great
emergency service, sensational interaction even
with children!”, “When you feel so well cared for, you
even like going to the dentist.”,
“Brand-new modern practice with
a super team and great practitioners! Highly recommended.”
Maike Laible: The patient is king,
not just a number. Many practices with long opening hours also
have many practitioners. There’s
no kind of connection or trust. After root canal therapy, the patient
goes somewhere else. In contrast,
we want to participate in the development of patients and give them
radiantly beautiful and healthy teeth.

Maike Laible:
We focus on educating
patients and providing comprehensive information about
the treatment. Our patients know why something is being
done and that makes them feel better. That’s good for us.
Dr Ines Laible: The key thing is, of course, patient satisfaction. We achieve this through a pleasant atmosphere,
friendly, well-trained staff, and responsible treatment for
the benefit of patients, as well as through communication. It is important that patients understand everything,
and they need to get feedback from dentists during their
treatment.
Maike Laible: A patient told me today that she now understands why we consider prophylaxis to be so important
and how we perform it. Many dentists don’t explain things.
Patients then think, for example, that dentists just use prophylaxis to make money when they haven’t found anything
else that’s profitable.

How can this connection and
trust be fostered?

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How did the first few weeks go?
Dr Ines Laible: Within a few weeks, we were booked up
for the next one to two weeks, and we still have a large
influx of new patients. Prophylaxis is a very big focus at
the practice. We’re lucky to still have two further treatment
rooms. We need to equip them with treatment units and
hire a new worker for prophylaxis. We can say that after
just a few weeks. At the beginning, we told our employee,
whose job it is to take care of registration and office management, that she would also have to carry out a prophylaxis session here and there. Now, she performs seven
to eight prophylaxis sessions per day and has no time at
all for admin. And all after such a short time! I think our
success has to do with our new equipment but also with
prophylaxis.
Maike Laible: Patients soon realised that prophylaxis is
the most important thing for us. But only those who are
shown and taught prophylaxis can achieve good oral
health. If patients don’t see it, how are they supposed to
understand it? I don’t know how to repair a car and why it
costs so much, but if the mechanic explains it to me, I feel
better and have more confidence. One can even build on
top of the Leaning Tower of Pisa, but the basic substance
has to be right first.
On the topic of equipment, you opted for the AIRFLOW
Prophylaxis Master from EMS. Why this device?
Dr Ines Laible: I focus on periodontics and implantology.
Prophylaxis is, of course, essential here. We told ourselves
early on that, if we want to offer and carry out prophylaxis sensibly, it would have to be with EMS’s new device.
We can offer painless, safe and complete cleaning with
the Prophylaxis Master. This is good for our patients and,
of course, for us too.

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Maike Laible: We were also familiar with the previous
models and were always satisfied. Plus, neither of us had
done a professional tooth cleaning for a long time. At the
same time, I recently had a patient with calculus as hard as
bone. The PIEZON was able to remove the calculus quickly
and easily, without any pain for the patient.
Dr Ines Laible: I have already had several patients who
have said they had never had such thorough tooth cleaning.
Other patients told me that prophylaxis was always painful. After explaining to them that prophylaxis is extremely
important to prevent and treat periodontal disease, they
all said that they hadn’t felt a thing after being treated with
the Prophylaxis Master. Our patients are really impressed.
How do you approach tooth cleaning?
Maike Laible: We offer professional tooth cleaning sessions of at least one hour. Explaining things plays a major
part in this. As dentists, we also talk a lot about tooth
cleaning and interdental cleaning.
Dr Ines Laible: We also almost always use staining.
Staining is an important factor: the dentist and patient
see what needs to be done and where the patient’s oral
hygiene can be improved at home. Staining motivates
patients and brings them back to the practice.
What’s the future for the Laible practice?
Dr Ines Laible: We will definitely need a second or third
EMS device soon. Our goal is to use a careful recall system and sensitive prophylaxis to deliver great results for
patients if they come for prophylaxis twice a year and have
healthy teeth.
Maike Laible: We want lifelong wellness for teeth.

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| practical prophylaxis

“Prevention is not just for children
and young people”
An interview with Prof. Ivo Krejci on lifelong dental coaching

Three years ago, Professor of Cariology and Endodontology Ivo Krejci (University of Geneva, Switzerland)
published an article titled “Lebenslanges ‘DentalCoaching’
anstelle ästhetischer Zahnmedizin” [lifelong dental coaching
instead of aesthetic dentistry] in which he made the case
that professional motivation, instruction and check-ups, as
well as precise, non-invasive therapies, should be the core
competence of a practice team in order to maintain oral
health, prevention spoke with him about his assertions.
Prof. Krejci, what is your main message when it comes
to modern caries prophylaxis?
Prof. Ivo Krejci: The aim of modern dentistry is not the
temporary repair of heavy clinical symptoms in the form of
large decaying lesions and deep periodontal pockets, but
rather the lifelong dental health of the population, which
I define as the absence of clinical symptoms. My article focused on one aspect of this concept, namely the causes,
symptoms and treatment of caries, a chronic lifelong infection of the biofilm, the clinical symptoms of which, in the
form of decaying lesions, are still some of the most common reasons for extractions. I am aware that I am speaking
against the common teaching opinion, which treats caries
and periodontitis as non-communicable diseases, but it
would be too much for this interview to explain the reasons
for this stance in detail.
Besides increasingly criticised fluoridation, bioavailable
calcium, acid neutralisation and harmless sugar substitutes
can be identified as important factors in preventing caries symptoms in so far as the patient doesn’t want to curb
excess sugar consumption. Three further measures are at
least just as important: firstly, early diagnosis of the initial
caries; secondly, the lifelong, periodical professional motivation, instruction and monitoring of an efficient, atraumatic
home dental care routine in the sense of primary prevention;
and thirdly, the use of non-invasive adhesive composite restoration to stop or at least delay subclinical caries symptoms
in the sense of secondary prophylaxis. Direct and indirect
minimally invasive composite restoration complement this
philosophy in patients entering into this concept with existing large decaying lesions or with existing restorations.
Why do we still separate periodontitis prophylaxis and
caries prophylaxis?
It’s difficult to say, as both problems have to do with immunology and a pathogenic biofilm. This separation makes

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no sense at all. We should always speak of simultaneous
caries and periodontitis prophylaxis, not of separate problems. Depending on the individual patient’s situation, the
focus may be more on caries and/or periodontitis prophylaxis, but it shouldn’t be forgotten that a lifelong prevention-orientated concept should take not just caries
and periodontitis into account, but also erosion, abrasion,
trauma, dental misalignment and infraction.
You mentioned pathogenic biofilm. What do you recommend: completely remove or disrupt the biofilm?
The biofilm actually protects our teeth, so is vital for survival. Its permanent removal from the mouth would therefore
be counter-productive. Through its currently unpreventable
infection with bacteria that cause caries and periodontitis,
it becomes potentially pathogenic. This pathogenicity can
only develop if two conditions are present: firstly, the biofilm must be sufficiently structured, which requires around
24 to 48 hours after its formation, and secondly, certain
parameters must be present. An example of this is the repeated excess of sugar in the caries process.
These deductions form the basis of the preventative concept: we accept the infected and potentially pathogenic
biofilm and do not remove it permanently from the mouth.
We acknowledge that a change in the conditions—for example, through a drastic reduction in sugar consumption—
would be very welcome, but difficult to implement in the
long term in practice. We therefore approach the structure
of the biofilm and prevent its pathogenicity from developing. The solution is simple: we just have to regularly, that
is every 24 hours, disrupt the structure of the biofilm intensively on all surfaces of the tooth. Chemicals and medications don’t help a great deal, as the biofilm has very potent
defence mechanisms.
In your article, you spoke about lifelong dental coaching. What do you mean by that?
Prevention is not just for children and young people. As
caries and periodontitis are lifelong infections and decaying
lesions, periodontal pockets, erosion, abrasions, trauma
and dental infractions can arise at any age, lifelong prophylaxis is unavoidable. This lifelong dental coaching is based
on the preventative measures already mentioned, complemented by regular professional monitoring with high-tech
diagnostics to catch symptoms in the subclinical stage,
thereby allowing non-invasive therapy where needed.

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practical prophylaxis

We know that it takes years for clinically evident symp
toms to develop in caries and periodontitis alike. If diagnos
tics are carried out with sufficient reliability and if diagnostic
methods are available that catch symptoms in the subclin
ical stage, one will have enough time to tackle these with
non-invasive methods.
As dentists, we only tackle the symptoms of caries with
our restorative methods. For technical and practical rea
sons, we used to only treat symptoms at a later stage,
when the decaying lesions had already developed into
cavities, because diagnostics weren’t as advanced and
restorative therapy was based on macro-mechanical prin
ciples. We needed the hole so that we had something to
fill. Today, this concept hasn’t really changed in principle.
From a professional perspective, we are still treating symp
toms, but we have other diagnostic tools and therapies,
so we don’t need macro-retentions for restoration. This lets
us act much earlier and use non-invasive therapies.
Should we be concentrating on primary or secondary
prophylaxis?
Individual primary prophylaxis is the foundation of every
thing, but nobody’s perfect. With the primary prophylaxis
tools we have today alone, we will not be able to save
humanity; despite our best efforts, symptoms will arise.
That’s why our concept is not solely based on primary pro
phylaxis. It also integrates secondary prophylaxis, which
aims to halt symptoms non-invasively in the early stages so
that they do not become more clinically serious. Non-inva
sive secondary prevention seems to me the tool of choice,

given our current circumstances and the resources we
have available today.
What role does individual home oral hygiene play in
caries prophylaxis in your opinion?
Individual home oral care by the patient is the most im
portant aspect for me. It might sound presumptuous, but
many people can’t brush and don’t know which tools,
products and techniques are the best and most efficient
for their individual situations. I am convinced that oral care
at home can only have a long-term effect when it is over
seen by a dental professional. This professional cannot
heal the patient, and it wouldn’t make sense for the pro
fessional to perfectly remove the patient’s biofilm each day,
as this would require that the patient come to the prac
tice every day. Even if he or she could afford this, it would
lead to public transport chaos and would make very little
sense. Therefore, it is more sensible to delegate this job to
the patient and inform, educate and monitor him or her as
needed, as well as correct and motivate when necessary,
not just once, but again and again.
Manual or electric toothbrush, floss or interdental brush,
toothpaste with or without fluoride—the individual case
should stipulate what tools are needed. As dental profes
sionals, we have the knowledge to provide the correct di
agnosis and to advise the patient on which tools, products
and techniques would be the most effective, quickest and
cheapest for his or her individual circumstances. We can
still get involved if professional therapy is needed and be
fore clinically visible symptoms arise.
Finally, how’s your own oral hygiene?
Very good. Although I had to live through the dentistry
of the 1960s as a child, I still have all my own vital teeth
and they’re all doing well. It helps that my wife is a dental
hygienist. She’s the best thing that could have happened
to me in many respects.

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© Robert Adrian Hillman/Shutterstock.com

Therapy, diagnostics, prevention
—what are your concrete recommendations?
We cannot predict reliably
enough how much of a risk a pa
tient has of developing symptoms
in the form of decaying lesions or
periodontal pockets. It is even more
difficult to do this for specific areas
of the tooth. And even if we could,
things can change at any time. The
risk of too little or too much preven
tion on the wrong tooth surface is
therefore very high. This applies to
erosion, abrasions and infractions
in the same way. That’s why it is
Prof. Ivo Krejci
more efficient in today’s dentistry
to wait for symptoms to develop,
providing site-specific risk information. However, if we wait
long enough for the symptoms to be clinically visible, it’s
already too late and we fall back on dentistry from the nine
teenth century. If one has the diagnostic opportunity to rec
ognise symptoms long before their clinical manifestation,
such a concept suddenly becomes very interesting.

|

65

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| practical prophylaxis

Ozone therapy in dentistry:
notably effective in accelerating
pre- and postoperative healing
By DTI
Over the last few decades, the use of ozone in dentistry has been established as an effective, minimally invasive therapeutic modality with an increasing number
of applications. Sixty years after Dr Joachim Hänsler
patented his OZONOSAN, the first medical ozone water
generator with an exact dosage output, family-owned
company Dr. J. Hänsler has become a leader in ozone
technology with applications in medical and dental
hygiene. We interviewed Managing Director Dr Renate
Viebahn-Hänsler, who is also a board member of the European Committee of the International Ozone Association,
and Yvonne Hoffmann, Managing Director of Hoffmann
Dental Manufaktur, which took over the global sales and
distribution of the OZONOSAN dental water unit in 2017.
What is ozone used for in dentistry?
Dr Renate Viebahn-Hänsler: The use of ozone in dentistry extends back to the 1930s, which is when scientists

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first discovered its properties and started to use it for a
number of applications, such as wound cleansing, mouth
rinsing and disinfecting. Ozone is also notably effective in
accelerating pre- and postoperative healing of the oral
mucosa. Nowadays, ozone therapy in dentistry is mainly
used in clinics for holistic dentistry, but owing to its disinfectant properties, ozonised water could be of great help
after dental implant surgery and should be introduced
in periodontal treatment, as well as any form of oral or
dental surgery, in the future.
How did you become aware of ozone’s potential?
Viebahn-Hänsler: I have been in the medical ozone
business for over 30 years. In this time, a significant
amount of research on the topic has been conducted,
including much research specifically related to dentistry.
Those who are interested can find these publications
listed on our website, www.ozonosan.de.

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practical prophylaxis

Yvonne Hoffmann: In 2014, Hoffmann Dental took over
Proxidentis Dentale Biomaterialien, a producer of natural
oral health products, including ozone oil for periodontal
treatment. After learning about ozone oil, it was only a
small step towards developing ozone water rinses.
What are the differences in application between
ozone as a gas mixture and ozone dissolved in water?
Viebahn-Hänsler: Gaseous ozone cannot possibly act
as a disinfectant. Owing to its polar molecular structure,
ozone has great solubility in a polar solvent like water.
As hydrogen bonds stabilise ozone, ozone’s half-life
in water by far exceeds that of its gaseous version. As
such, we recommend ozone water or oil for disinfecting
wounds, not an ozone–oxygen gas mixture. Moreover,
the gas mixture cannot be used safely in dentistry owing
its toxicity to the respiratory epithelium. Ozone water,
however, can be used as a mouthwash to rinse wounds
and periodontal pockets. Owing to its pronounced disinfectant and healing effects, ozone is a perfect alternative to tooth cleaning with sugar alcohols or sodium
bicarbonate.

Dr Renate Viebahn-Hänsler

Ozone water must be generated on-site. Is training
necessary?
Viebahn-Hänsler: Our ozone water generator is subject
to the Medical Device Act and requires instruction and
training by a medical device consultant. Nonetheless, its
handling is very simple.
How does ozone inhibit anaerobic periodonto-pathogenic bacteria? What advantages does it have over
conventional periodontal treatment?
Hoffmann: Rinsing with ozone water followed by the
application of ozone oil is a great complement to conventional periodontal treatment or professional dental
cleaning.
Viebahn-Hänsler: Ozone water does not distinguish
between aerobic and anaerobic bacteria. It destroys the
cell membrane and ultimately the DNA/RNA of bacteria
and viruses that come into direct contact with the ozone
molecules. Additionally, ozone water improves healing
processes by activating the cellular metabolism.
Hoffmann: Ozone oil works differently in that it only
kills anaerobic bacteria, which are the bacteria specifically linked to periodontal disease. Because of its density, ozone oil easily adheres to interdental spaces and
periodontal pockets, where it is retained for longer than
ozone water.
Unlike chlorhexidine, ozone water and ozone oil in
excessive amounts cannot possibly lead to altered taste
or tooth discoloration. They do not provoke any allergies,
have no known side-effects and are a safe, effective

Yvonne Hoffmann

way to reduce the postoperative use of antibiotics and
cortisone.
What are the benefits of ozone beyond dentistry?
Is it used elsewhere?
Viebahn-Hänsler: Medical ozone is used for wound
disinfection and treating chronic inflammatory diseases.
Other therapeutic applications are auto-haemotherapy,
in which the patient’s blood is exposed to ozone and then
reinjected, or rectal insufflation.
Hoffmann: Ozone is also used in water purification
in municipal waterworks to destroy bacteria and parasites such as Cryptosporidium and Giardia. Unnoticed
by most of us, it is also used in public swimming pools
to reduce the total chlorine level needed to improve the
water quality.

prevention
1 2018

[68] =>

| manufacturer news
optimal management of interdental biofilm

Optimal prophylaxis with
interdental brushes
An increasing number of dental
professionals are emphasising the
importance of interdental brushes in
primary, secondary and tertiary prophylaxis. These interdental cleaners are indispensable
when it comes to optimal management of interdental biofilm to
maintain oral health.
In dentistry (and medicine), there are three types of prevention:
primary, secondary and tertiary. Primary prevention is concerned
with avoiding diseases and their causes. Four factors are important here: good oral hygiene, a healthy diet, professional preventative measures (such as fluoridation, cleaning and fissure sealing)
and education. While patients are able to remove supragingival
biofilm through manual plaque control, subgingival biofilm can
only be eliminated by a professional cleaning. Primary prevention,
especially daily oral care, forms the foundation to prevent caries,
periodontal disease and other inflammation, keeping the mouth
healthy. This reflects modern practice philosophy: it is best when
the patient is already healthy when he or she enters the practice.
This requires proper instruction in oral care, establishing good oral
hygiene habits, and the use of the optimal products and techniques in perfect combination.
Secondary prevention aims to slow down the progression of disease, for example during the development of periodontal disease
or peri-implant mucositis. Secondary prophylaxis diagnoses
caries and periodontal disease as early as possible, proactively
remineralises enamel and treats orthodontic misalignment early
on. Tertiary prevention begins when tooth function has been lost.
Secondary and tertiary prophylaxis are everyday matters in many
Swiss dental practices, but primary prophylaxis is our ambitious
aim. Owing to modern dental prevention, the team can ensure that
a patient keeps his or her teeth for life. How can we achieve the
best possible prophylaxis?
Modern prophylaxis encompasses the following factors and steps:
recognising the patient’s individual problems in maintaining his or
her oral health and his or her daily oral care habits, removing supragingival plaque and calculus, providing individual instruction on
the use of oral hygiene tools, establishing a bleeding index, monitoring via radiographs, providing nutritional advice and following
a fluoridation programme. Furthermore, prophylaxis individually
adapted to the patient ensures the therapy’s long-term success.
Properly coached oral health practitioners are indispensable.
That is where CURAPROX comes in. Individual coaching programmes with the best products, personal advice and preventative instruction for patients on how to use the oral hygiene
products ensure the therapy’s success. CURAPROX products and
educational concepts are the key to prophylaxis that is successful

prevention
1 2018

in the long run. Proper and regular use
of high-quality toothbrushes, dental floss
and, most importantly, interdental brushes
from CURAPROX means that patients achieve complete cleaning.
CURAPROX is an indispensable part of any prophylactic treatment.
Healthy gaps need care
Today, the focus of biofilm management is on the interdental area.
A toothbrush only cleans around 60–70 per cent of the surface
area of the teeth, the remaining 30–40 per cent being interdental
surfaces and thus impossible for a toothbrush to access. From the
perspective of optimised prophylaxis, CURAPROX offers the finest
interdental brushes on the market, providing a more effective and
gentler alternative to dental floss. The interdental brushes in the
CPS prime and CPS perio lines are easy to use and long-lasting. Owing to technological innovations, CURAPROX interdental
brushes are produced with long, fine bristles and very thin CURAL
wires. The wire means that the bristles are very pliable, ensuring
a thorough clean—even of the smallest interdental spaces. Before and after every professional tooth cleaning, the practice team
should recommend the use of CURAPROX interdental brushes and
thoroughly instruct patients in their use.
The fine CPS prime is ideal for closed interdental spaces. In a
study titled “Efficacy of interdental calibrated brushes on bleeding reduction in adults: A 3-month randomized controlled clinical
trial”, French researchers at the University of Lyon spent three
months investigating whether interdental brushes could reduce
interproximal bleeding in patients with gingivitis. One test group
used a manual toothbrush twice a day, while the other group also
used CPS prime interdental brushes. The researchers used a calibrated colorimetric probe to establish the size of the interdental
spaces and therefore the correct brush sizes. The result was that
interproximal bleeding was reduced by 47 per cent after one week
and 71 per cent after three months.
Secondary prophylaxis just with the CPS perio
Many dental practices now offer secondary prophylaxis programmes. As soon as the active therapy phase is complete, the
patient follows a specific periodontal care protocol that takes into
account his or her oral health status, for example if the patient’s
papillae are badly injured or if there are black triangles. Regardless
of the method used in periodontal treatment, the periodontist’s
work only constitutes around 30 per cent of the treatment’s success. Patients themselves are responsible for the other 70 per cent.
Cleaning interdental spaces is an intrinsic part of secondary
prophylaxis. The CPS perio is ideal for periodontal patients: it

[69] =>

manufacturer news

is sufficiently rigid to clean efficiently enough to contribute to
secondary prophylaxis, yet soft enough to avoid causing any
discomfort. Most interdental brushes do not fill the whole interdental space and are far too hard, their use resulting in pain. The
CPS perio is the first choice for secondary prophylaxis. Owing to
extra-long and -fine bristles, it cleans the large spaces between
bridges, crowns or fillings both effectively and gently. An especially strong core is used in the CPS perio to ensure that the
bristles are stable.
The practice team’s use of a calibrated CURAPROX Interdental Access Probe to determine the correct sizes of the interdental brushes

needed will support patients in optimal primary and secondary
prophylaxis. The chairside box for dental professionals includes
pre-mounted CPS prime and CPS perio brushes, as well as Interdental Access Probes to precisely measure interdental spaces.
Holders can be reused as required. All interdental brushes and
probes can be hygienically and tidily stored in the treatment unit
within easy reach.
In summary, CURAPROX interdental brushes with their long, stable
bristles can reach and clean pockets and other critical interdental
areas to prevent periodontal disease and caries. This reflects the
latest understanding of prophylaxis.

improving long-term outcomes

Chronic Periodontitis: Probiotics as valuable adjuvants
to Scaling and Root Planing
Periodontal disease is a widespread condition that affects a significant portion of Europe’s adult population. Studies show that 3
out of 4 adults develop some form of gum disease in their lifetime.
A growing body of evidence indicates that Periodontal disease in
its most severe form may not only severely damage the oral cavity
and lead to tooth loss, but also be a risk factor for
challenging systemic conditions such as diabetes, coronary artery disease and pulmonary disease. New treatment options in
the form of advanced probiotics—to be
administered as adjuvants to SRP—are
now available to improve the long-term
outcomes of Chronic Periodontal disease
management.
Optimising Chronic Periodontitis treatment with probiotic bacteria.
Scaling and Root Planing is the treatment of choice for Chronic
Periodontitis. Yet one of the important challenges professionals
face following SRP is the frequent re-colonisation of the treated
niches by pathogenic bacteria, even when combined with antibiotics.1 By supplementing SRP with probiotic treatment, professionals can hinder this re-colonization of the oral cavity by pathogens
and allow their patients to profit from the antimicrobial and anti-inflammatory properties of oral probiotics.2,3

immune response via CD4+T helper and IgA production5 and reinforce the natural defences of the mouth.8
Clinical studies have shown Lactobacillus reuteri Prodentis to
be an effective adjuvant to SRP for the treatment of Chronic
Periodontitis.
When used as an adjuvant to SRP, Lactobacillus reuteri
Prodentis has been clinically proven to significantly
improve critical clinical parameters,1,6,9–11 reducing Plaque Index, Gingival Index, Bleeding on
Probing, Probing Pocket Depth and increasing
Clinical Attachment Level in deep pockets. Lactobacillus reuteri Prodentis has also been shown to
reduce the risk of Periodontitis disease progression, the
number of sites in need of surgery,1,6 the number of Periodontal
pathogens,1,6 and to deliver long-lasting clinical improvement in
Chronic Periodontitis.6,10
Sunstar, a global leader in oral health, brings you oral care solutions boosted by Lactobacillus reuteri Prodentis.
A list of references can be obtained from the publisher.

Lactobacillus reuteri Prodentis: an advanced and clinically validated probiotic.
Lactobacillus reuteri Prodentis is an advanced probiotic bacteria of
human origin, adapted to reside in the oral cavity4,5 and able to
bind to saliva and oral mucosa.4 Lactobacillus reuteri Prodentis is composed of two patented strains of lactic acid with two
complementary modes of action. Together, the two strains have
been clinically proven to delay the re-colonisation of pathogenic
bacteria in cavities treated via SRP,1,6,7 provide anti-inflammatory
and antimicrobial properties,2 strengthen and enhance the host

prevention
1 2018

[70] =>

| manufacturer news
efficient method to keep gingivae and teeth healthy

TePe interdental brushes—25 years of high-quality oral hygiene
The first TePe interdental brushes were launched in 1993 with the
same aim they have today: preventative oral hygiene for everyone.
Today, 25 years later, the company celebrates worldwide success, with its interdental brushes being its leading product.
Odontological research has shown
that using an interdental brush regularly is an efficient method to keep
gingivae and teeth healthy. Good
oral health contributes to good
overall health.
“General health awareness has increased over the past several years,
and today, we see a broader understanding of how oral health is linked to
general health. In that context, TePe’s highquality interdental brushes fit perfectly as part of
people’s healthy oral care habits,” said Dr Anna Nilvéus
Olofsson, Manager of Odontology and Scientific Affairs at TePe.
TePe’s industry-leading interdental brushes are recognised
worldwide for their high-quality and efficiency. The original

TePe interdental brush range includes nine colour-coded sizes
to fit narrow and wider interdental spaces. Through the years,
the interdental brush range has been complemented with
two additional variants, one with softer filaments
for sensitive gingivae and one with an angled
brush head and a longer handle for easier
access between posterior teeth. The four
smallest sizes of the original TePe interdental brush have a flexible neck for
even better access.
Over five decades, TePe has evolved
from a small-scale Swedish company
into a high-tech enterprise with distribution in 60 countries. Based on the vision
of healthy teeth for everyone throughout
life, TePe continues to develop innovative
products and raise awareness of the importance
of preventative oral care. The company’s close partnership with the dental profession has been fruitful ever since
its founding in 1965, resulting in a wide range of high-quality oral
hygiene products. All production takes place at its headquarters
in Malmö in Sweden.

mission to improve the population’s gingival health

Dedication to innovation and partnerships with dental professionals
Oral-B has a long and rich history of being a true partner to dental
professionals. We are proud of our 69 years of consecutive innovation and continued mission to improve the population’s gingival
health since our establishment by a periodontist in 1949.

Periodontal disease is among humanity’s most common diseases.
It affects up to 50 per cent of the global population, despite being
largely preventable through good oral hygiene and preventative
policies addressing common risk factors.1, 2
Oral-B is the global leader in the toothbrushing market. Part of
Procter & Gamble, the brand includes toothbrushes and toothpastes for both children and adults, oral irrigators and interdental
products such as dental floss. Oral-B’s rechargeable oscillating-rotating electric toothbrush, with its iconic round brush heads,
has been validated consistently externally and internally by clinical research. Through decades of innovation and clinical research
by Procter & Gamble, its stabilised stannous fluoride toothpastes
have been shown to reduce gingival problems and provide protection from erosive tooth wear by creating a protective shield on
teeth against acids.
Procter & Gamble is a founding supporting partner of the Global
Periodontal Health Project led by the FDI World Dental Federation.
Over the course of three years (2017–2019), the project aims to
reduce the burden of periodontal disease by raising awareness of
its impact and of effective strategies and preventative measures
to control the disease.
A list of references can be obtained from the publisher.

prevention
1 2018

[71] =>

manufacturer news

natural enzymes and proteins

Zendium—The power of natural protection

Leading-edge science: Machine used for bacterial DNA extraction.

Our story begins almost 50 years ago, in
1969. Researchers of the day knew that
saliva was rich in enzymes and proteins
that could protect against infection and
disease. They had already shown that lac-

Lactoperoxidase system.

toperoxidase played a part in saliva’s ability
to inhibit bacterial growth. This inspired
Dr Henk Hoogendoorn, a Dutch microbiologist, to investigate the lactoperoxidase
enzyme system. He demonstrated that the
enzymatic reaction led to the production
of hypothiocyanite by hydrogen peroxide
and that hypothiocyanite had a natural
antibacterial effect against Streptococcus
mutans in plaque.
Hoogendoorn believed that a toothpaste
containing the right combination of enzymes and proteins could boost the mouth’s
natural antibacterial system. Over
the coming years, Hoogendoorn
collaborated with other scientists to investigate the potential of different enzyme
Zendium pack shots.

Gingival health- and periodontal disease-associated bacteria.

and protein combinations in toothpaste.
His formula was refined and tested until
he found the optimum balance: a groundbreaking toothpaste called Zendium. It is
only now with scientific advances, including
next-generation genomic sequencing, that
we are able to discover so much more about
how Zendium works and the positive effect
it has on the bacterial species in the mouth.
A landmark microbiomics study published in
2017 showed that Zendium significantly increased gingival health-associated bacteria
and reduced periodontal disease-associated
bacteria in gingival plaque, resulting in a
healthier gingival plaque microbiome. The
clinical benefits of this microbial shift were
demonstrated in two further studies, presented at the 2017 meeting of the Continental European and Scandinavian divisions of
the International Association for Dental
Research, that showed that Zendium users
had significantly better gingival health.
Zendium now contains natural enzymes
and proteins reflecting some of those
found in saliva. Zendium’s triple-enzyme
system of amyloglucosidase, glucose oxidase and lactoperoxidase works in a cascade to boost the levels of hydrogen peroxide in saliva and catalyse the formation
of hypothiocyanite. Zendium also contains

three other ingredients: lysozyme, lactoferrin and colostrum, as a source of immunoglobulin G, which can be found naturally in saliva and work in harmony with
enzymes to protect the mouth naturally.

Zendium’s ingredients: Natural enzymes and proteins. * Immunoglobulin G.

Zendium contains standard levels of fluoride (1,450 ppm as sodium fluoride) for
effective protection against caries and
contains no sodium lauryl sulphate, offering a gentle approach to oral care that is
suitable for all patients.
Today, Zendium is the number 1 trusted
brand in Scandinavia. Our goal is to
continue to enhance our understanding of the mouth’s natural defences,
deliver products that boost the protective power of saliva and promote
all-round oral health.
For more information, visit
www.zendium.com.

prevention
1 2018

[72] =>

| special

When prophylaxis means
everything and nothing
By DTI

Readers will likely remember Dr Klaus-Dieter Bastendorf
from the first edition of prevention, which introduced the
dentist from near Stuttgart in Germany and his modern
views on prophylaxis. Six months later, the retired dentist
shows no signs of quitting. Every day, he and his daughter champion lifelong oral health together, explaining the
importance of staining in biofilm management to peers,
among other things.
Few dentists speak so convincingly and with such
scientific sense when it comes to air polishing and the
use of erythritol as the powder of choice for biofilm removal. Few dentists profess with such passion that
biofilm-induced diseases such as dental caries and periodontitis can be prevented relatively easily through a
combination of recall, motivation and the latest powder
technology. And few dentists know that any patient seriously questioning whether two professional tooth clean-

prevention
1 2018

ing sessions and four new toothbrushes a year are really
necessary should look 10,000 km to the south-west first.
While we in western Europe often stumble on our
way to achieving modern prophylaxis, the road is much
rockier in remote Pucyura, located in central Peru, almost
3 hours drive west of the city of Cuzco. In the Andean
villages at an altitude of between 2,000 and 4,000 m,
people still speak Quechua. Life seems wretched and
modest—most of the inhabitants live in clay brick houses
without glazed windows. The trip to school sometimes takes 4 hours—each way. This remote location in
South America experienced a dental miracle, in which
Bastendorf played a significant role.
However, it is Margit and Uwe Meyer who actually
deserve the credit. The youthful couple from southern
Germany have been working with children in need for

[73] =>

special

years and support the non-profit children’s charity Plan
International. Uwe Meyer is a member of the board of
manufacturer of medical devices EMS based in Nyon in
Switzerland, known for its brands AIRFLOW and PIEZON.
In coordination with the aid organisation, the couple
visited their godchild Diana in January 2011 to do more
for the girl. At the village school, they both noticed a girl
who constantly hid her chin with both hands. Her name
was Guisela Ccanihua, 16 at the time, four years older
than her classmates, but smaller and more delicate.
When the Meyers approached the girl and spoke to her,
they were shocked with her appearance.

Two hours to eat a roll

Back in Germany, the Meyers considered how they
might help the girl. As time passed, the memories of
Guisela remained.
One night in 2011, orofacial and orthodontic specialist Dr Konrad Wangerin was interviewed by the SWR,
a regional public broadcasting corporation serving the
south-west of Germany, about new temporomandibular
joint treatments and the work of his sponsoring association, Förderverein Faziale Fehlbildungen [foundation
for facial malformations]. Wangerin is one of the world’s
leading specialists in the field of oral and maxillofacial
surgery. His association has been giving children all over
the world new faces since 1997. All the treating doctors waive their fees, with sponsors and donations covering the costs. The donations arrive in full where they
are needed, and even the administration is performed
by volunteers.
One night, Uwe Meyer, unable to sleep, was skipping through the channels and happened to see a rerun
of the interview with Wangerin. Insomnia is rarely considered a boon, but fate evidently intervened in this
instance. Meyer called Wangerin and told him about
Guisela. The Stuttgart-based specialist said that he

might be able to help her, but would have to take a look
at her himself. This is exactly the man I’m looking for,
Meyer thought after the call.
As luck would have it, Wangerin was planning a trip to a
convention in Chile and would make a stopover in Cuzco.
He and Meyer met for the first time in a hotel on the outskirts of town. It was 5.30 p.m. on 24 October 2011 when
Guisela met the maxillofacial surgeon too. The diagnosis
did not take long: post-traumatic ankylosis and a total
restriction of mandibular mobility. The ends of the lower
jaw had fractured, causing the entire posterior region of
the jaw to ossify—an exceptionally difficult and very rare
case even by European standards. And yet, Wangerin
was able to and had to help Guisela. “Otherwise she
would have been permanently limited to a liquid diet and
her ability to communicate would have been disrupted
for life,” said Wangerin, looking back.
While self-motivation, instruction and recall can change
the oral health of western European patients, it was fate
and coincidence that changed this Peruvian girl’s life.

Potato graters and organ theft
Barely three months later, Guisela and her mother,
Lorenza, landed in Germany. Their arrival soon attracted
the attention of the local press. A Peruvian woman living nearby cooked for and spoke with Guisela and
her mother. A Spanish-speaking speech therapist got
in touch and a psychologist was already there to help
Guisela in the clinic. Wangerin’s team opted to perform
the surgery at the Paracelsus hospital in Ostfildern-Ruit
near Stuttgart.
The entire time, Guisela and her mother stayed on the
Bastendorfs’ farm in Eislingen between Stuttgart and
Ulm. While her daughter was undergoing treatment,
Lorenza learned new recipes, better ways to cultivate the
family’s potatoes, and about the respectful interaction
between men and women. Sometimes a potato grater
is all it takes to permanently improve a person’s life.

prevention
1 2018

Guisela could have had a happy childhood, but an accident changed everything. When she was 4, she slipped
while tending sheep, fell on her chin and broke both
temporomandibular joints. The first aid station 4 hours’
walk away merely stopped the bleeding, but did not provide any further treatment. The fracture healed poorly,
causing inhibited mandibular growth and the adhesion
of the temporomandibular joints. As the years passed,
her ability to open her mouth became increasingly restricted. Ultimately, this was limited to 5 mm. It took her
2 hours to eat a soft roll. The girl’s face was severely
deformed and asymmetrical, and she suffered from malocclusion and severe respiratory problems. Daily oral
hygiene was out of the question. The child’s family hid
her for a long time, but in the end, she started school,
albeit four years late.

[74] =>

| special
To restore the joints, Wangerin’s team of specialists removed most of the bone in two operations. The surgeons
then severed the mandible and tilted it forward so that it
increased in size and also improved the appearance of
the chin area. An unexpected situation arose when taking
a blood sample. When the team inserted the needle and
the blood began to flow, both the mother and daughter
panicked. They had seen blood samples taken by pricking the fingertip, but never using a hypodermic needle.
Now the rumours that Guisela had only been brought
to Germany so that criminals could remove her organs
seemed to be confirmed. However, with their scant grasp
of the language and a great deal of empathy, the team
was able to restore the necessary trust.

tears of joy. The fact that the family lives in the Andes
at an altitude of almost 4,000 m means Guisela has a
high red blood cell count and this hastened her recovery. Bastendorf restored Guisela’s teeth, as well as her
mother’s, and in particular gave the girl the smile that
nobody had been able to see before.

The operations were a complete success. “Imagine,
being able to finally touch your lips with your tongue again
after 12 years,” recalled Wangerin. When Guisela stuck
her tongue out for the first time, her mother burst into

The surgery did not just change Guisela’s appearance.
Back in Peru, the girl immediately attracted the attention
of her classmates. For hours, she talked about her experiences in Germany, a country so far away from her
homeland. The young men suddenly started to make
eyes at the pretty girl, and her class chose her as their
speaker. She became interested in boys. For the first time
in her life, Guisela fell in love and was loved back.

From farewell to a new beginning
Three months and countless smiles later, it was time
to say goodbye. The thank-you party was attended by
more than 40 people, all of whom had either directly or
indirectly helped Guisela. Guisela thanked them shyly.
A small town in southern Germany said auf Wiedersehen.

Today, she lives happily with her husband and child
in a house and has made her dreams come true. Meyer
and Bastendorf supported the entire family with donations, enabling them to reach a standard of living equivalent to the average enjoyed by people in Pucyura. While
the family of six did not make use of the options to improve their education, Lorenza very gratefully accepted
many other donations in kind, for example the property
with road access, a gas stove and new furniture. An acquainted dentist takes care of the family’s oral health in
Cuzco on a quarterly basis.
Bastendorf and Meyer flew to Peru in November
last year and through their trip saw for themselves that
their help and their donations were worthwhile and had
changed lives for the better. They also realised that they
could not apply western European values, for example
offering a better education, to Lorenza’s family. The family is happy with the modest life that they now lead. And
what could be more important than having good health?
Whether in Eislingen or in Pucyura, we can make a
big difference with small gestures. Every day, all employees in a practice can motivate patients to improve their
oral hygiene. Every dentist and dental hygienist has the
expertise and tools to ensure lifelong oral health for their
patients. This must be the daily task of every dentist.
Every employee can also do something for those who
have not (yet) experienced this luxury. Anyone can help
children like Guisela through donations, volunteer work
and simply by sharing their stories. Readers who would
like to start helping today are invited to visit the website
of Förderverein Faziale Fehlbildungen, www.fffev.org.

prevention
1 2018

[75] =>

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Who visits SCANDEFA?
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In 2018 we are pleased to present
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Where to stay during SCANDEFA?
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ding and customer care, the
fair days require a lot of energy,
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We
Bella Center Copen- a must.
hotels, AC Hotel Bella Sky Copenhagen
SCANDEFA is organised by
with the Annual for our three
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Meeting organised by the
Plaza – one of the leading
Hotel.
ingen.dk).
Marriott
Copenhagen
(tandlaegeforen
5
tion
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12–13 April 2018
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How to exhibit
or contact
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transport between
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SCANDINAVIAN DENTAL
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VISIT: WWW.THEDENTISTRYSHOW.CO.UK

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Amsterdam, Netherlands
www.efp.org

is coming to

Dental Salon

BERLIN

Roots Summit

28 June –1 Julyy 2018
Berlin, German

www.ROOTS-SUMMIT.com

23–26 April 2018
Moscow, Russia
www.dental-expo.com/dental-salon/

28 June–1 July 2018
Berlin, Germany
www.roots-summit.com

BUENOS AIRES 2018

Buenos Aires

World Dental Congress

Argentina

5-8 September 2018

ENT
ITM
OMM
A PASSION FOR MANY, A C

FO

13th CAD/CAM &
Digital Dentistry Conference
4–5 May 2018
Dubai, UAE
www.cappmea.com

76

prevention
1 2018

LL
RA

FDI World Dental Congress

30 March 2018

ABSTRACT SUBMISSION
DEADLINE

1 June 2018

EARLY-BIRD
REGISTRATION DEADLINE
rg

www.world-dental-congress.o

5–8 September 2018
Buenos Aires, Argentina
www.world-dental-congress.org

[77] =>

© 32 pixels/Shutterstock.com

submission guidelines

|

How to send us your work?
Please note that all the textual components of your submission must be combined into one MS Word document.
Please do not submit multiple files for
each of these items:
· the complete article;
· all the image (tables, charts, photographs, etc.) captions;
· the complete list of sources consulted
and
· the author or contact information (biographical sketch, mailing address,
e-mail address, etc.).
In addition, images must not be embedded into the MS Word document. All
images must be submitted separately,
and details about such submission follow below under image requirements.

Text length
Article lengths can vary greatly—from
1,500 to 5,500 words—depending on
the subject matter. Our approach is that
if you need more or less words to do the
topic justice, then please make the article
as long or as short as necessary.
We can run an unusually long article in
multiple parts, but this usually entails a
topic for which each part can stand alone
because it contains so much information.
In short, we do not want to limit you in
terms of article length, so please use the
word count above as a general guideline
and if you have specific questions, please
do not hesitate to contact us.

Text formatting

Please use single spacing and make
sure that the text is left justified. Please
do not centre text on the page. Do not indent paragraphs, rather place a blank line
between paragraphs. Please do not add
tab stops.
Should you require a special layout,
please let the word processing programme you are using help you do this
formatting automatically. Similarly, should
you need to make a list, or add footnotes
or endnotes, please let the word processing programme do it for you automatically.
There are menus in every programme that
will enable you to do so. The fact is that
no matter how carefully done, errors can
creep in when you try to number footnotes
yourself.
Any formatting contrary to stated above
will require us to remove such formatting
before layout, which is very time-consuming. Please consider this when formatting
your document.

Image requirements
Please number images consecutively
throughout the article by using a new
number for each image. If it is imperative
that certain images are grouped together,
then use lowercase letters to designate
these in a group (for example, 2a, 2b, 2c).
Please place image references in your
article wherever they are appropriate,
whether in the middle or at the end of a
sentence. If you do not directly refer to the
image, place the reference at the end of
the sentence to which it relates enclosed
within brackets and before the period.
In addition, please note:

We also ask that you forego any special formatting beyond the use of italics
and boldface. If you would like to emphasise certain words within the text, please
only use italics (do not use underlining or
a larger font size). Boldface is reserved
for article headers. Please do not use underlining.

· We require images in TIF or JPEG format.
· These images must be no smaller than
6 x 6 cm in size at 300 DPI.
· These image files must be no smaller
than 80 KB in size (or they will print the
size of a postage stamp!).

Larger image files are always better,
and those approximately the size of 1 MB
are best. Thus, do not size large image
files down to meet our requirements but
send us the largest files available. (The
larger the starting image is in terms of
bytes, the more leeway the designer has
for resizing the image in order to fill up
more space should there be room available.)
Also, please remember that images
must not be embedded into the body of
the article submitted. Images must be
submitted separately to the textual submission.
You may submit images via e-mail, via
our FTP server or post a CD containing your images directly to us (please
contact us for the mailing address, as
this will depend upon the country from
which you will be mailing).
Please also send us a head shot of
yourself that is in accordance with the
requirements stated above so that it can
be printed with your article.

Abstracts
An abstract of your article is not required.

Author or contact information
The author’s contact information and
a head shot of the author are included at
the end of every article. Please note the
exact information you would like to appear in this section and format it according to the requirements stated above. A
short biographical sketch may precede
the contact information if you provide us
with the necessary information (60 words
or less).

Questions?
Magda Wojtkiewicz
(Managing Editor)
m.wojtkiewicz@dental-tribune.com

prevention
1 2018

77

[78] =>

| about the publisher

prevention
international magazine for oral health

Imprint
Publisher/President/CEO
Torsten R. Oemus
t.oemus@dental-tribune.com

Marketing & Sales Services
Nicole Andrä
Nadine Dehmel

Managing Editor
Magda Wojtkiewicz
m.wojtkiewicz@dental-tribune.com

Event Services/Project Manager
Tribune CME & CROIXTURE
Sarah Schubert

Editors
Marc Chalupsky
Brendan Day
Kasper Mussche

Executive Producer
Gernot Meyer

Designer
Franziska Schmid
Copy Editors
Sabrina Raaff
Ann-Katrin Paulick

Advertising Disposition
Marius Mezger
Accounting Services
Karen Hamatschek
Manuela Hunger
Anja Maywald

Chief Technology Officer
Serban Veres

International Media Sales
Matthias Diessner (Key Accounts)
Melissa Brown (International)
Antje Kahnt (International)
Peter Witteczek (Asia Pacific)
Weridiana Mageswki (Latin America)
Maria Kaiser (North America&Canada)
Hélène Carpentier (Western Europe)
Barbora Solarova (Eastern Europe)

Business Development Manager
Claudia Salwiczek-Majonek

International Offices

International Administration
Chief Financial Officer
Dan Wunderlich

Project Manager Online
Tom Carvalho
Editor &
Social Media Manager
Monique Mehler
E-Learning Manager
Lars Hoffmann
Education Director
Tribune CME
Christiane Ferret

Dental Tribune International
Holbeinstr. 29, 04229 Leipzig, Germany
Tel.: +49 341 48474-302
Fax: +49 341 48474-173
info@dental-tribune.com
www.dental-tribune.com
Dental Tribune Asia Pacific Ltd.
c/o Yonto Risio Communications Ltd.
Room 1406, Rightful Centre
12 Tak Hing Street, Jordan, Kowloon, Hong Kong
Tel.: +852 3113 6177
Fax: +852 3113 6199

Tribune America, LLC
116 West 23rd Street, Ste. 500,
New York, NY 10011, USA
Tel.: +1 212 244 7181
Fax: +1 212 244 7185
Contributors
Prof. Nicole Arweiler
Sandy Basheda
Dr Anja Carina Borer
Prof. Denis Bourgeois
Dr Peter Carls
Dr Thuy Do
Faye Donald
Dr Riccardo Guazzo
Yvonne Hoffmann
Dr Karolin Höfer
Clare Ison
Prof. Ivo Krejci
Dr Ines Laible
Maike Laible
Dr Amparo Llorente
Dr Phil Marsh
Dr Marzia Massignani
Adina Mauder
Dr Anna Nilvéus Olofsson
Dr José Manuel Reuss
Dr Ana Stevanović
Dr Eric Thevissen
Dr Renate Viebahn-Hänsler
Photo credits
Tom Carvalho
Andrej Dallmann
Luke Gribble
Vali Ivan

Printed by
Löhnert Druck
Handelsstraße 12
04420 Markranstädt
Germany

prevention international magazine for oral health is published by Dental Tribune International (DTI) and appears in 2018 with two issues. The magazine and all articles and illustrations therein
are protected by copyright. Any utilisation without the prior consent of editor and publisher is inadmissible and liable to prosecution. This applies in particular to duplicate copies, translations, microfilms,
and storage and processing in electronic systems. Reproductions, including extracts, may only be made with the permission of the publisher. Given no statement to the contrary, any submissions to the
editorial department are understood to be in agreement with a full or partial publishing of said submission. The editorial department reserves the right to check all submitted articles for formal errors and
factual authority, and to make amendments if necessary. No responsibility shall be taken for unsolicited books and manuscripts. Articles bearing symbols other than that of the editorial department, or which
are distinguished by the name of the author, represent the opinion of the aforementioned, and do not have to comply with the views of DTI. Responsibility for such articles shall be borne by the author.
Responsibility for advertisements and other specially labeled items shall not be borne by the editorial department. Likewise, no responsibility shall be assumed for information published about associations,
companies and commercial markets. All cases of consequential liability arising from inaccurate or faulty representation are excluded. General terms and conditions apply. Legal venue is Leipzig, Germany.

prevention
1 2018

[79] =>

bacterial
balance

lasting
freshness

six tastes
one formula

enzymatic
whitening

A TO OT H PA S T E F O R E AC H M O O D.

www.curaprox.com
#curaproxbeyou

[80] =>

LET’S HELP PATIENTS BRUSH

THEIR VERY BEST
ROUND CLEANS BETTER
FOR HEALTHIER GUMS

3D cleaning action removes more plaque
vs. a regular manual toothbrush

TRIPLE PRESSURE CONTROL
Reinforces gentle brushing

POSITION DETECTION

Brush pairs with the Oral-B App to help patients
improve brushing technique and target every zone

PRO-TIMER

Encourages brushing for at least 2 minutes

www.dentalcare.com

© 2018 P&G

ORAL-20626

) [page_count] => 80 [pdf_ping_data] => Array ( [page_count] => 80 [format] => PDF [width] => 648 [height] => 895 [colorspace] => COLORSPACE_UNDEFINED ) [linked_companies] => Array ( [ids] => Array ( ) ) [cover_url] => [cover_three] =>

[cover] => prevention international No. 1, 2018

Table of contents

[toc_titles] =>

[cached] => true )