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Coronectomy: Patients with comorbidities, carious teeth and associated cyst
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Coronectomy: Patients with comorbidities, carious teeth and associated cyst
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Coronectomy Oral Surgery
Patients with comorbidities, carious teeth and associated cyst - Nine year’s experience Abstract
Dr Parmanand Dhanrajani BDS, MDS, MSc, MSC, FRACDS, FDSRCS, FFDRCSI Oral Surgeon firstname.lastname@example.org
Dr Mark Smith BDS, MQIHC Technical Consultant – Dental 403 George Street, Sydney, NSW 2000 Australia
Aim: The paper presents a retrospective study of patients who underwent coronectomy from 2012-2019. An earlier paper (Dhanrajani et al 1) described in detail the surgical procedure with modifications. The present paper is an evaluation of postcoronectomy pain, migration of roots and follow-up of patients with comorbidities and/or decayed teeth. Material and Methods: A retrospective study involving lower third molar surgery performed by a single surgeon in an outpatient extraction clinic under local anaesthesia as well as in the day surgery under general anaesthesia was conducted from January 2012 to December 2019. A total of 5,497 lower third molars were removed. In the cohort of 1,543 (28.06%) teeth removed in outpatient under local anaesthesia, 109 (1.98%) were coronectomies and of 3,954 (71.93%) removed under general anaesthesia, 305 (5.54%) were coronectomies.
This study also discusses the advantages of the modified procedure as well as intrapulpal deposition of local anaesthetic to control post-surgical pain. Results: The results demonstrate that: • coronectomy is a safe and viable technique for the surgical management of wisdom teeth at high risk of neurosensory loss. • Intra pulpal deposition of local anaesthetic intraoperatively reduced the post coronectomy pain significantly. • The modification in surgical technique did help reduce the post-surgical complications such as wound dehiscence. • Migration of roots does occur but to quantify the amount is challenging. • Follow-up results with patients with comorbidities and decayed teeth are encouraging.
Clinical Relevance This study presents the outcome and follow-up of post-coronectomy patients managed to date with particular emphasis on the clinical difficulties encountered routinely including: • Use of intra-pulpal deposit of xylocaine with adrenaline following coronectomy helps reduces post-surgical pain significantly. • Practical difficulties achieved during the procedure like primary closure leading to wound dehiscence.
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Coronectomy - Patients with comorbidities, carious teeth and associated cyst
â&#x20AC;˘ Outlines advantages of modified procedure to achieve optimal closure and reduce chances of wound dehiscence during healing phase. â&#x20AC;˘ Follow-up on medically compromised patients and decayed teeth, previously considered as contraindicated in the literature.
Introduction Coronectomy is recognised as a procedure performed in patients whose lower third molar roots are proximate to the inferior alveolar nerve and where surgical removal may result in neuropraxia 2, 3, 4, 5, 6. The acceptance of this procedure has been increasing by documented evidence of reduction in risk of IAN injuries and the number of patients is willing to consent for this alternative technique 7,8,9. The oral and maxillofacial community has welcomed this procedure as a means to lessen the burden of medico-legal issues and facilitate patient quality of life 10, 11, 12, 13.
1,543 (28.06%) teeth removed under local anaesthesia, 109 (1.98%) were coronectomies and of 3,954 (71.93%) removed under general anaesthesia, 305 (5.54%) were coronectomies (Fig 1). The initial study reported on a total of 3,654 lower third molars which were removed during the period of 20122016. Out of 855 (23.4%) teeth removed under local anaesthesia, coronectomy accounted for 42 (4.9%) of the total ; 2,799 (76.6%) were removed under general anaesthesia, of which 172 (6.1%) were coronectomies. During the period 2016-2019, a total of 1,843 lower third molars were removed. Of which 688 (37.33%) were under local anaesthetic and 1,155 (62.66%) were under general anaesthesia and 200 (10.85%) were coronectomies. Of 200, 133 (7.21%) were performed under general anaesthetic and 67 (3.63%) under local anaesthetic.
In our first paper (Dhanrajani et al 1) we presented the outcomes of coronectomies performed from 2012-2016. A modification of the coronectomy procedure was described, indications and advantages for the modified technique were listed and extension of the indications to include patients with comorbidities and/or carious teeth as well as associated cysts were outlined. This paper extends the earlier study and reviews patients who were treated with coronectomy from 2012 to 2019. It will address the following: 1. Modified coronectomy 2. Complete removal of the tooth 3. Post coronectomy pain 4. Migration of roots 5. Dehiscence of the wound 6. Decayed teeth 7. Medically compromised patients
Figure 1: Pie chart showing number of patients treated under general and local anaesthetics.
Materials & Methods
Pre-operative assessment of patients included clinical examination and orthopantomograph (OPG). An assessment of the type and degree of impaction and the course of the inferior dental canal (IDC) in relation to the tooth was conducted for each patient.
A total of 5,497 lower third molars were extracted by a single surgeon (PD) at the HCF Dental Centres, the Strathfield Private Hospital and the Holroyd Private Hospital, all located in metropolitan Sydney, Australia. Of
Cone Beam CT scan (CBCT) was utilised for further assessment of the patient when any of the following radiologic findings of the IDC in association with the tooth was noted on OPG:
Coronectomy - Patients with comorbidities, carious teeth and associated cyst
• Darkening of the mandibular third molar roots. • Interruption of radiopaque lines of IDC. • Diversion of the course of the canal by mandibular third molar roots. • Narrowing of the canal as it passes over the root. The option of coronectomy was offered to a patient when there was evidence of moderate to high risk of damage to the inferior alveolar nerve (IAN) if the tooth were to be removed completely. The features of moderate to high risk are: • Tooth root perforation by the IDC fortunately a rare phenomenon; • Lingual position of the IDC in relation to mandibular third molar roots; • Narrowing and grooving of the mandibular third molar roots by the IDC; • Loss of lingual cortex occurs frequently if the root is positioned between the missing lingual cortex and the IDC. All patients were consented for coronectomy. They were also consented for complete removal of the tooth intraoperatively if the remaining portion of root was mobilised or coronectomy failed. Patients referred from their dentist with the option of coronectomy were provided with a detailed explanation, based on clinical and radiographic evaluation, of the risks and benefits of coronectomy versus complete removal. The patient group for whom coronectomy has been considered to be contraindicated are those with systemic comorbidities such as diabetes, are immunocompromised, having liver, kidney and joint or connective tissue involvement or on medication for osteoporosis such bisphosphonates and denosumab. Patients in this group have continued to be treated successfully. All the patients with comorbidities were consulted with their respective physician for their advice and opinion prior to the procedure. Similarly, patients in whom the wisdom teeth are carious have continued to be treated successfully if the caries was limited to dentine with no pulpal involvement and did not extend to the roots of the tooth. Patients in whom pathology was associated with lower third molars were also included in the study. The procedure for all patients commenced as a standard coronectomy by sectioning the crown near the cemento-
enamel junction (CEJ). At this stage of the procedure the wound was evaluated to assess whether primary closure was achievable while maintaining a collar of bone of 3-4 mm height around the roots. If this was not the case, then the procedure was modified. In the modified technique the crown is sectioned at or below the furcation by further reduction of the height of the roots utilising a Tungsten Carbide bur (Densply HP Rd 8) to achieve a good skirt of alveolar bone around the roots and advancement of a buccal flap to achieve good postoperative bone and soft tissue healing. 2% Xylocaine with 1:80,000 adrenaline few drops were deposited intrapulpal before closure of the socket. The lingual periosteum was not reflected to avoid lingual nerve injury. A 3/0 plain catgut suture (Ethicon, USA) was used in the majority of cases. All the patients were prescribed Amoxicillin 500 mg eight hourly for five days and for patients allergic to penicillin, Clindamycin 300mg 12 hourly for five days. They were also prescribed simple Paracetamol 500-1000mg every 4-6 hourly and/or Non-steroidal anti-inflammatory drug such as Ibuprofen 600mg every eight hourly post-operative for three days. All patients were reviewed one week after surgery with an Orthopantomograph. Further follow-up was undertaken at six months, 12 months and yearly intervals. Although a post-operative orthopantomograph was not mandatory it served to show the patient the outcome of the procedure as well as facilitating comparison of root migration during long-term follow-up. Patients were contacted 24 hours post-operatively to assess pain and nerve function. Post-operative pain was measured subjectively by using the visual analogue scale (VAS) where 0 is equivalent to no pain and 10 to be excruciating pain.. Altered sensation was also assessed subjectively by using cotton wool and blunt probe.
Results Age/Sex The patients in the standard coronectomy group were comparatively younger (mean age 25 years) than those patients in the modified coronectomy group (mean age 41.55 years). January 2021
The patientâ&#x20AC;&#x2122;s age is important in treatment planning. There was a similar count of male and female patients. (Fig 2)
operative pain following coronectomy. Our study in 2017 reported a higher incidence of pain on the VAS scale of 7-8 or even 9 in some patients. Since 2016, all the patients who underwent coronectomies were supplemented by few drops of 2% Xylocaine with adrenaline intrapulpally. This appears to have contributed to improved pain control post-operatively. The VAS scale showed pain ranged from 3-5 in most of the patients (Fig 3). The reduction in VAS score is significant (p <0.02).
2. Migration of roots
Figure 2: Chart/Graph shows distribution of age and sex and distribution of standard and modified coronectomy.
The results achieved so far are elaborated as follows: 1. Post-operative Pain
Present study showed migration of roots following coronectomy on follow-ups. Migration was more often seen in younger patients as compared to patients over forty years of age. This was our clinical finding as the OPG machines were difficult to standardise to measure root migration accurately. Although all the patients reports are done by a single surgeon, but the source of the patients came from different centres and orthopantomograms were taken by different individuals. None of the patients in this study required re-operation due to migration of roots.
Post-operative pain or discomfort is experienced to some extent by all patients after dentoalveolar surgery, but as the conservative management results in less tissue disturbance, postoperative pain should be reduced. This was supported by Renton et al. 2,11,15 but Hatano et al. 16 reported that the incidence of postoperative pain was greater in the coronectomy group. There is no obvious explanation for increased pain in our experience. This can be attributed to initial pulpitis due to exposure of the nerve endings in pulp after sectioning of the tooth. There was no difference in incidence of pain between carious and non-carious teeth. Some authors have recommended pre-operative antibiotics in order to prevent transient bacteraemia leading to pain 16,17,18. Kim et al 2014 17 and Senciman el al 18 recommended vital pulp therapy option to treat the remaining root left following coronectomy to avoid complications such as pain migration. Unfortunately, these were isolated cases which had no support in literature.
3. Complete removal of teeth
Injecting 2% Xylocaine with adrenaline 1:80,000 intra pulpally following completion of the procedure before closure of the area was instrumental in controlling post-
2016-2018 period had revealed significant increase of complete removal of teeth who were consented for coronectomies with no post-op paraesthesia (Fig 4).
Figure 3: Graph showing VAS scale score.
Oral Surgery Coronectomy - Patients with comorbidities, carious teeth and associated cyst
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Figure 4: Graph showing complete removal of teeth consented for coronectomy.
This finding was more seen in patients with a. conical roots and b. young patients where root was not fully mature, and roots were loose following coronectomies cuts.
4. Dehiscence of wound A second complication seen was wound dehiscence. Criteria for wound dehiscence used was gap in the socket causing food trap and not due to post-operative infection. In present study over all wound dehiscence incidences was seen in 49 patients (12%). The gap/ dehiscence was very minimal especially in the distolingual aspect of second lower molars, and none required second surgery which eventually healed with mouthwash and local irrigation using a monojet tip syringe (Covidien, Sydney, NSW, Australia). None of the patients with wound dehiscence were prescribed antibiotics.
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Figure 5: Pie chart showing incidence of gap/dehiscence of wound.
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Coronectomy - Patients with comorbidities, carious teeth and associated cyst
5. Nerve Paraesthesia/anaesthesia There was one incidence of nerve paraesthesia or anaesthesia reported in patients having coronectomies done during 2012-2018. It was associated to nerve to mylohoid. Patient reported to have paraesthesia around the chin which lasted over 6 months.
Of the patients on immunosuppressant medication (14/4.51%) 8 had standard and 6 had modified coronectomy procedures. Most of immune suppressed had liver, kidney and joint involvement. (Fig 6)
6. Modified Coronectomy Modified coronectomy was carried out in situations where it was felt that the post-surgical anatomy would not allow a passive primary closure of the socket. This has been advantageous in achieving good post-operative outcomes. The surgical area heals well primarily without getting dehiscence or gap there by avoiding food trap and subsequent infection. This has also helped in favourable periodontal health around lower second molars. Figure 7: Pie chart showing patients included with carious teeth and associated cysts.
7. Medically compromised patients Patients with the following co-morbidities were included in this study since last nine years: mainly osteoporosis, diabetes, immune-compromised Of those patients on osteoporosis medication, 9 (2.17%) had standard coronectomy (6 were on bisphosphonate and 3 were taking denosumab) and 5 (1.20%) had the modified procedure and were on denosumab. Patients with diabetes mellitus total (42/13.54%); 31 had a standard coronectomy and 11 had the modified technique. Nineteen patients were type I diabetic, controlled with insulin and 23 were type II controlled by oral hypoglycaemic drugs. HbA1c level was in the range 4.9% to 6.3%.
8. Carious teeth A total of 68 (16.42%) patients with coronal caries (i.e. not involving the pulp) underwent coronectomy. Of these 30 (7.72%) had a standard coronectomy and 38 (9.17%) had modified coronectomy (Fig 7). Nineteen cases in this study were associated with cystic lesions, out of these four were odontogenic keratocyst and remaining were follicular/dentigerous cyst.
9. Re-operation There was one case in this study where the root was to be removed due to recurrent infection. She was fit and well and came from 4th decade age group. This was buccohorizontal impaction. It is very difficult to predict which patient might require re-operation.
Follow-up Follow-up varied in this study from 4 months to three years. The majority of the cases were treated in the period 2015 to 2018. The mean follow-up period was 16 months (Fig 8). Figure 2: Table showing comorbidities included in study.
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Coronectomy - Patients with comorbidities, carious teeth and associated cyst
being over-utilised for fear of medicolegal repercussions. In answer to this question the profession must remain mindful of the debilitating effect of neuropraxia of the IAN particularly where this results in neurogenic pain.21,22.23 For this reason, discussion of coronectomy with patients is always worthwhile where the risk of IAN injury is likely; it is clear that the severity of post-operative complications with coronectomy will be less than the neurogenic pain associated with neuropraxia.21,22,23,24
Figure 8: Graph showing period of follow-ups.
Discussion Coronectomy has been proposed as a valid treatment option to reduce the risk of IAN injury in selected cases5, 6, 7, 11, 12 . It is becoming the standard of care to assess its applicability during the development of the treatment plan and to explain the advantages and disadvantages during consultation19, 20, 21, 22. The technique was brought to the attention of the profession by the first publication by Pogrel et al in 20047 and has gained popularity internationally since then; however, it still remains controversial in its applications such as inclusion of patients with comorbidities and carious teeth. To date there have been randomised control trials of coronectomies by Leung et al. 200910, Renton 200511, Hatano et al. 200916 and Pogrel et al. 20047. All these studies have recommended coronectomy as an acceptable procedure to reduce the risk of nerve injury in symptomatic mandibular third molar removal. Studies on root migration have been reported in literature varies from 4 to 7 mm from 12 months to 24 months and this ceases by 24 months. (Leung et al 20123 , Dolanmaz19 and Knutsson20). The present study was not able to standardize the OPG and patients in study were referred from different centres as well as the x-rays were done by referring dentist. Our clinical observation supports the view of migration of roots. Migration is seen most commonly during â&#x20AC;˘ first year of follow-up and â&#x20AC;˘ more often in younger patients With the increased acceptance of coronectomy the question must be asked as to whether the procedure is
There was one patient in the present study were the root required to be removed and second procedure was done. This was during the first 6 months of followup. The patient had recurrent pain and infection in the area of surgery and OPG showed root had migrated with widening of periodontal space. Pogrel (2015) 13 in a review of 742 patients, who underwent coronectomy, reported that six had subsequent infection which required removal of roots and 31% showed root migration. This led him to the conclusion that coronectomy should be considered in patients older than 25 years, where there appears to be intimate relationship between the roots of a retained lower third molar and IDN, in circumstances where it is not contraindicated. It can be used on younger patients with high risk of IDN damage23,24,25,26. The present study suggests that there may be a role for coronectomy in young individuals at high risk of IAN damage. If the nerve damage does occur, it is more likely to recover and less likely to result in permanent damage. There was no permanent nerve damage or long term paraesthesia in extraction group of patients in this study. One patient had paraesthesia of left chin for over four months in the coronectomy. Successful management and inclusion of carious teeth and patients with comorbidities is acknowledging wider support since we initially reported in 20181. It was encouraging to see recent study by Patel et al 202021, offering coronectomy of mandibular third molars with caries or resorption at the risk of inferior alveolar nerve injury. The days are not for when we will see studies offering coronectomies to patients with comorbidities. Our experiences suggest coronectomies can be successfully carried out in patients with decayed teeth and in patients with co-morbid systemic diseases such as diabetes mellitus, on steroids, other immunosuppressants and/or bisphosphonates and denosamub. January 2021
Coronectomy - Patients with comorbidities, carious teeth and associated cyst
Present study has shown significant reduction of postoperative pain by injecting few drops of local anaesthetics intra-pulpal. Although this is purely our finding which is encouraging and yet to be acknowledged in the future to compare. This study suggests a trial would be necessary to demonstrate the link between using intra-pulpal local anaesthetics and reduce pain experience.
1. Dhanrajani PJ, Smith M. Coronectomy: A recognised procedure? Oral Surg 2018;11:4:273-282. 2. Renton T. Notes on Coronectomy. Br Dent J 2012;212;323-326
In our study the incidence of wound dehiscence was considerably less. This can be attributed to better surgical planning, meticulous tissue handling, and modified coronectomy technique used. Patients were followed regularly by clinical reviews or calling them by phone. All the patient had contact details of surgeon in case of any emergencies or advices.
3. Patel V, Kwok J, Sproat C, McGurk M. To Retrieve or not to Retrieve the Coronectomy Root The Clinical Dilemma. Dental Update 2013;40;370-376 4. Leung YY, Cheung LK. Coronectomy of the Lower Third Molar Is Safe Within the First 3 Years. Journal of Oral and Maxillofacial Surgery 2012;70;1515-1522
The flowchart (Fig 9) provides guidance in the decisionmaking process for selection of coronectomy.
5. McArdle L, McDonald F, Jones J. Distal cervical caries in the mandibular second molar: an indication for the prophylactic removal of third molar teeth? Update. British Journal of Oral and Maxillofacial Surgery 2014;52;185-189 6. Gleeson C, Patel V, Kwok J, Sproat C. Coronectomy practice. Paper 1. Technique and trouble-shooting British Journal of Oral and Maxillofacial Surgery 2012;50;739-744 7. Pogrel MA, Lee JJ, Muff DF. Coronectomy: A technique to protect the inferior alveolar nerve. Journal of Oral and Maxillofacial Surgery 2004;62;(12): 1447-1452 8. Oâ&#x20AC;&#x2122;Riordan BC. Coronectomy (intentional partial odontectomy of lower third molars). Oral Surg Oral Med Oral Pathol Oral Radiol Endo 2004; 98;(3):274-80 9. Pogrel MA. Partial Odontectomy. Oral and Maxillofacial Surgery Clinics of North America 19 2007;19;85-91
Figure 9: Flow chart of decision making for coronectomies.
10. Leung YY, Cheung LK. Safety of coronectomy versus excision of wisdom teeth: A randomized controlled trial. Oral Surg Oral Med
Oral Pathol Oral Radiol Endod 2009;108;821-827 11. Renton T, Hankins M, Sproat C, McGurk M. A randomised con-
Coronectomy has demonstrated its effectiveness and safety in the the management of cases where the roots of a mandibular third molar are proximate to the inferior alveolar nerve. The outcomes of the present study demonstrate that it is effective in patients with decayed teeth third molars and in those who are medically compromised.
trolled clinical trial to compare the incidence of injury to the inferior alveolar nerve as a result of coronectomy and removal of mandibular third molars. British Journal of Oral and Maxillofacial Surgery 2005;43;7-12 12. Renton T. Update on coronectomy. A safer way to remove highrisk mandibular third molars. Dental Update 2013;40:362-368
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Coronectomy - Patients with comorbidities, carious teeth and associated cyst
13. Pogrel A. Coronectomy partial odontectomy or intentional root retention. Oral
17. Kim YB, Joo WH, Min KS. Coronectomy of lower
Maxillofac Surg N Am 2015;27:373-382.
third molar in combination with vital pulp therapy. Eur J Dent. 2014;8(3):416-418.
14. Patel V, Gleeson CF, Kwok J, Sproat C. Coronectomy practice. Paper 2: complications and long-term management. British Journal of Oral and Maxillofacial Surgery
18. Sencimen M, Ortakoglu K, Ayclin C, Aydintug YS,
Ozyigit A, Ozen T, Gunaydin Y. Is endodontic treatment necessary during coronectomy procedure?
15. Renton T. Risk assessment of M3Ms and decisions on ordering a CBCT and pre-
Journal of Oral and Maxillofacial Surgery 2010;
scribing coronectomy. Dent Update 2017;44:957-976.
16. Hatano Y, Kurita K, Kuroiwa Y, Yuasa H, Ariji E. Clinical evaluations of coronec-
19. Dolanmaz D, Yildirim G, Isik K, Kucik K, Ozturk
tomy (intentional partial odontectomy) for mandibular third molars using dental
A. A preferable technique for protecting the inferior
computerised tomography: a case-control study. Journal of Oral and Maxillofacial
alveolar nerve: Coronectomy. Journal of Oral and
Surgery 2009; 67;(9)1806-14
Maxillofacial Surgery 2009; 67;(6):1234-8 20. Knutsson K, Lysell Leif, Rohlin M. Postoperative status after partial removal of the mandibular third molar. Swedish Dental Journal 1989;13:15-22. 21. Patel N, Patel D, Sproat C, Beneng K, Patel V. Coronectomy of mandibular third molars with caries or resorption at risk of inferior alveolar nerve injury. Oral Surg 2020;12:(4):4-11. 22. Drage NA, Renton T. Inferior alveolar nerve injury related to mandibular third molar surgery: an unusual case presentation. Oral Surg Oral Med Oral Pathol Oral Radiol Endo 2002;93:(3):358-361 23. Williams M, Tollervey D. Lower third molar surgery- consent and coronectomy. British Dental Journal 2016;220:287-288. 24. Long H, Zhou Y, Liao L, Pyakurel U, Wang Y, Lai W. Coronectomy vs Total removal of third molar extraction: A systematic Review. J Dent Res 2012;91(7): 659-665. 25. Matzen LH, Christensen J, Hintze H, Schou S, Wenzel A. Influence of cone beam CT on treatment plan before surgical intervention of mandibular third
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At home vital teeth bleaching: how to optimize a safe and stable result Abstract
Neila Zokkar Professor, Department of Restorative Dentistry-Endodontics, Faculty of Dental Medicine, Monastir, Tunisia
Faced with the evolution of modern society which attaches great importance to aesthetics and appearance, as well as the media coverage of the criteria of the «beautiful smile», the demand to have «white teeth» has increased in recent years.
Marwen Ouni Post graduate Student, Department of Restorative Dentistry-Endodontics, Faculty of Dental Medicine, Monastir, Tunisia
Hana Serrag Post graduate Student, Department of Restorative Dentistry-Endodontics, Faculty of Dental Medicine, Monastir, Tunisia
Emna Hidoussi Assistant Professor, Department of Restorative DentistryEndodontics, Faculty of Dental Medicine, Monastir, Tunisia
Over time, various strategies have been used to recover the natural color of the tooth, one of which, vital teeth bleaching is the most effective and cautious treatment procedure. Several whitening systems have been described that can be split into two different categories: in-office and at-home whitening systems.
The present article aims to address, through a case report, the interests of at home technique in the treatment of extrinsic teeth dyschromia and to discuss the side effects of this treatment, as well as the precautions to be taken to avoid these undesirable effects and to ensure the stability of the outcome over time. Keywords: home whitening, smile, dyschromia, stability of the result, carbamide peroxide, mechanism of tooth sensitivity
Introduction «The smile is an element of unconscious expression and communication, like touch», underlines Bernard Andrieu, body philosopher. Faced with the evolution of modern society which attaches great importance to aesthetics and appearance, as well as the media coverage of the criteria of the «beautiful smile», the demand to have «white teeth» has increased in recent years. The growing desire for a better look and a whiter smile has made tooth whitening as a common dental treatment. It has grown into one of the fastest developing fields of esthetic dentistry, providing a more conservative treatment approach for discolored teeth compared to other restorative methods 1. The aim of this paper was to address, through a case report, the interests of at home technique in the treatment of extrinsic teeth dyschromia and to discuss the side effects of this treatment, as well as the precautions to be taken to avoid these undesirable effects and to ensure the stability of the outcome over time.
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At home vital teeth bleaching: how to optimize a safe and stable result
Case report A 25-year-old patient in good general health condition consults for dyschromia. The intra-oral examination shows good oral hygiene. The dyschromia is of extrinsic origin, this led us to the ambulatory bleaching technique which is the safest technique for this type of dyschromia. Pre-operative photos are taken (Figure 1). The patient’s initial shade is an A3,5.
The first session is devoted to discussing the necessary precautions, after signing the informed consent. Then we took impressions in order to make compressive aligners. The choice was towards a whitening gel with a low concentration of hydrogen peroxide (16% of carbamide peroxide): Mix Night 16%.
Then, dental scaling has been performed. The patient will be checked every week with photos taken. Figure 1: Pre-operative view
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In order to give the patient a basis for comparison; we started with the whitening of the upper arch (Figure 2+3).
Figure 5: Five weeks follow up
Figure 2: Two weeks follow up
Figure 6: Six weeks follow up
In order to have a homogeneous result, we ended with a week of bleaching two arches (figure 7). Figure 3: Three weeks follow up
The lower arch is taken care of after 3 weeks from the start of whitening of the upper arch (figure 4). Fig. 4 Figure 7: Seven weeks follow up: Final result
And for the stabilization of the result obtained, a week of treatment is scheduled after four months (Figures8+9). This procedure will be repeated every four months for two years. Figure 4: Four weeks follow up
Fig. 8 During the treatment of the lower arch, moderate tenderness was felt by the patient; so, our attitude was oriented towards treatment with a desensitizing gel by wearing trays filled with this gel 10 minutes before the whitening procedure begins; which made it easier for the patient to complete the lower arch whitening procedure (figure 5+6). Figure 8: Four months follow up
At home vital teeth bleaching: how to optimize a safe and stable result
Figure 9: Result after one week treatement
Discussion Over time, several whitening systems have been described that can be split into two different categories: in-office and at-home whitening systems. According to the literature, there were many side effects reported with â&#x20AC;&#x2DC;in-office whitening systemsâ&#x20AC;&#x2122;, such as the high cost, the long chair time, and the regular occurrence of unintended effects on soft and hard oral tissues. 2 On the other hand, at home whitening systems are commercially available, and easy to use. The vast number of bleaching gels and protocols tested by randomized controlled trials prohibit clinicians from concluding explicitly which protocol has an improved whitening effect. Some studies assume that at-home bleaching is safer and more stable than in-office protocol2. Others showed that for both methods, the effects were equivalent instantly and at long-term 4, 5. Similar controversy exists in terms of teeth sensitivity. Some authors have shown that in-office bleaching occurs a higher tooth sensitivity than at-home protocol, whereas other studies report similar tooth sensitivity 6, 7 or even higher tooth sensitivity of the at home procedure than the in-office protocol.8 The mechanism of tooth sensitivity caused by bleaching agents is not well known currently. Researchers have speculated that initial diffusion of peroxide into the pulp chamber through enamel and dentine can contribute to pulp inflammation and nerve activity 9. Other investigators have hypothesized that bleaching agents could release cellular factors such as ATP and prostaglandins which could excite or disrupt the pulp tissues 10. Another theory which is currently not well known is the hydrodynamics of intradental nerve
stimulation and neuropeptide release in response to this treatment 11. Also, Glycerin, contained in most bleaching agents as a carrier, is hydrophilic which causes dehydration of tooth structure during bleaching treatment. This can contribute to tooth sensitivity as well 12. According to the literature, it affects between 37% and 90% of patients with at-home bleaching and between 16.7% and 100% of patients with in-office bleaching 13, 14. The major part of patients report mild sensitivity while 10% experience moderate and only 4% may experience severe sensitivity 15. Symptoms are observed at an early stage of the therapy, usually after 2-3 days, and can continue for 3-4 hours after tray removal. 16 In the case of at-home bleaching, the occurrence of hypersensitivity increases with the frequency of changes in bleaching solution, particularly if they are changed more than once a day 12. The bleaching intervals should be reduced for the better rapid result. Modifications and improvements to bleaching products have also been made. Potassium nitrate and sodium fluoride as desensitizers are commonly used. These agents can be stored in bleaching gel and administered during treatment using a personalized tray. The precise mechanism of action of potassium nitrate and sodium fluoride to minimize tooth sensitivity in the tooth whitening process is not well known 17. Potassium ions are likely to be an active component reducing dentinal sensory nerve activity due to K+ depolarizing activity 18. Fluoride, on the other hand, treats dentinal sensitivity likely by covering exposed dentinal tubules or reducing fluid flow to the pulp and covering the transfer of stimuli. Different modes of distribution of desensitizing agents were reported in the literature. Some authors have added desensitizing gel to the teeth buccal surface without disrupting it for ten minutes 10. Others, used desensitizing agents as adjuvants to the bleaching gel 19. However, according to a meta analysis study conducted by Costacurta et al. in March 2020 20; the addition of potassium nitrate to carbamide peroxide gel did not reduce the risk and intensity of tooth sensitivity during athome bleaching. Generally, patients with cracked tooth syndrome or with tooth sensitivity should be warned. January 2021
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At home vital teeth bleaching: how to optimize a safe and stable result
Conclusion Gingival and mucosal irritations are another side effect of home whitening technique. Commonly, an ill-fitting tray that affects the gingiva and/or the use of excessive material may cause soft tissue inflammation. Management requires simple adjustment and polishing of the tray and or instructing the patient to use less material 16. Concerning the systemic effects, patients rarely report gastrointestinal or mucosal irritations, like burning palate and throat burning, and mild stomach or intestines upsets. 21 In this context, several literature studies suggest that the use of low hydrogen peroxide concentrations in tooth bleaching is still safe 22. Concerning side effects on dental hard tissues, contradictions are reported in the available literature. Some electron microscopic scanning studies recorded changes in the enamel surface morphology after application of carbamide peroxide or hydrogen peroxide; with increased enamel structure porosity, demineralization, lower protein concentration, organic matrix degradation, and calcium-phosphate-ratios alteration 23. While others reported no changes in the morphology of the enamel 24. Sulieman et al. reported that 35% hydrogen peroxide did not damage enamel or dentine, and that the pH of the products used can have the adverse effects listed in the literature 25.
Clinicians should warn their patients of the benefits and potential side effects of teeth whitening. Higher concentrations of peroxide may improve the whitening result and minimize the length of application, although side effects like tooth sensitivity, and tooth hard tissues changes may also be increased with this form of procedures. However, higher concentrations of the bleaching agent than recommended could more likely cause damage to the gingival and dental tissues 29. At-home external bleaching did not demonstrate significant long-term complications if 10% carbamide peroxide was used as the bleaching agent. The whitening treatments have been continually improved until now. The latest methods for reducing the disconfort associated with these whitening procedures are not, according to recent clinical reports, entirely successful and also need to be refined 30, 31. It is still important to build a more powerful, reliable, and long-lasting therapy to achieve an optimal effect of whitening without any damage.
References 1. Farooq, I., Tooth-Bleaching: A Review of the Efficacy and Adverse Effects of Various Tooth Whitening Products. Journal of the College
Many authors recommend the addition of calcium and fluoride in bleaching agents to reduce enamel demineralization. However, according to Cavalli et al.â&#x20AC;&#x2122; study; even though experimental bleaching agents with calcium or fluoride reduced mineral loss, these agents were unable to reverse the enamel subsurface demineralization 26.
of Physicians and Surgeons--Pakistan: JCPSP, 2015. 25. 2. Parreiras, S., et al., Effects of Light Activated In-office Bleaching on Permeability, Microhardness, and Mineral Content of Enamel. Operative Dentistry, 2014. 39(5): p. E225-E230. 3. Matis, B.A., et al., Eight in-office tooth whitening systems evaluated in vivo: a pilot study. Oper Dent, 2007. 32(4): p. 322-7.
According to Darriba et al. 27, daytime application of athome bleaching for 3 weeks achieves greater bleaching results than for 2 weeks, immediately after treatment, one and 6 months afterwards. Another randomized trial 28 showed that at-home bleaching is time but not concentration dependent and its secondary effects depend on the active agent concentration; therefore, there is no need to use high concentration products. According to this study, the most effective protocol is low concentrations (10% carbamide peroxide) with longer time application (overnight use for three weeks are recommended).
4. Tay, L.Y., et al., Long-term efficacy of in-office and at-home bleaching: A 2-year double-blind randomized clinical trial. American journal of dentistry, 2012. 25: p. 199-204. 5. Giachetti, L., et al., A randomized clinical trial comparing at-home and in-office tooth whitening techniques: A nine-month follow-up. J Am Dent Assoc, 2010. 141(11): p. 1357-64. 6. Zekonis, R., et al., Clinical evaluation of in-office and at-home bleaching treatments. Oper Dent, 2003. 28(2): p. 114-21.
At home vital teeth bleaching: how to optimize a safe and stable result
7. Moghadam, F.V., et al., The degree of color change, rebound ef-
enamel and sensitivity: an in vivo study. Int J Dent Hyg, 2014. 12(2):
fect and sensitivity of bleached teeth associated with at-home and
power bleaching techniques: A randomized clinical trial. Eur J Dent, 2013. 7(4): p. 405-411.
20. Costacurta, A.O., et al., Does the addition of potassium nitrate to carbamide peroxide gel reduce sensitivity during at-home bleach-
8. Basting, R.T., et al., Clinical comparative study of the effective-
ing? Aust Dent J, 2020. 65(1): p. 70-82.
ness of and tooth sensitivity to 10% and 20% carbamide peroxide home-use and 35% and 38% hydrogen peroxide in-office bleaching
21. POHJOLA, R.M., et al., Sensitivity and Tooth Whitening Agents.
materials containing desensitizing agents. Oper Dent, 2012. 37(5):
Journal of Esthetic and Restorative Dentistry, 2002. 14(2): p. 85-91.
p. 464-73. 22. Alqahtani, M.Q., Tooth-bleaching procedures and their contro9. Kim, S., Neurovascular interactions in the dental pulp in health and
versial effects: A literature review. The Saudi dental journal, 2014.
inflammation. J Endod, 1990. 16(2): p. 48-53.
26(2): p. 33-46.
10. Reis, A., et al., Assessment of Tooth Sensitivity Using a Desen-
23. Pinto, C.F., et al., Peroxide bleaching agent effects on enamel
sitizer Before Light-activated Bleaching. Operative Dentistry, 2011.
surface microhardness, roughness and morphology. Braz Oral Res,
36(1): p. 12-17.
2004. 18(4): p. 306-11.
11. Markowitz, K., Pretty painful: why does tooth bleaching hurt?
24. Haywood, V.B., et al., Nightguard vital bleaching: effects on
Med Hypotheses, 2010. 74(5): p. 835-40.
enamel surface texture and diffusion. Quintessence Int, 1990. 21(10): p. 801-4.
12. Leonard, R.H., Jr., V.B. Haywood, and C. Phillips, Risk factors for developing tooth sensitivity and gingival irritation associated with
25. Sulieman, M., et al., A safety study in vitro for the effects of an
nightguard vital bleaching. Quintessence Int, 1997. 28(8): p. 527-34.
in-office bleaching system on the integrity of enamel and dentine. J Dent, 2004. 32(7): p. 581-90.
13. de Paula, E.A., et al., In-office bleaching with a two- and seven-day intervals between clinical sessions: A randomized clinical tri-
26. Cavalli, V., et al., Effects of experimental bleaching agents on the
al on tooth sensitivity. Journal of dentistry, 2015. 43(4): p. 424-429.
mineral content of sound and demineralized enamels. J Appl Oral Sci, 2018. 26: p. e20170589.
14. Bonafé, E., et al., Tooth sensitivity and efficacy of in-office bleaching in restored teeth. J Dent, 2013. 41(4): p. 363-9.
27. I, L.D., et al., Influence of treatment duration on the efficacy of at-home bleaching with daytime application: a randomized clinical
15. Jorgensen, M. and W. Carroll, Incidence of tooth sensitivity after
trial. Clin Oral Investig, 2019. 23(8): p. 3229-3237.
home whitening treatment. Journal of the American Dental Association (1939), 2002. 133: p. 1076-82; quiz 1094.
28. López Darriba, I., L. Novoa, and V.A. de la Peña, Efficacy of different protocols for at-home bleaching: A randomized clinical trial.
16. Sulieman, M., An Overview of Bleaching Techniques: 2. Night
Am J Dent, 2017. 30(6): p. 329-334.
Guard Vital Bleaching and Non-Vital Bleaching. Dental Update, 2005. 32(1): p. 39-46.
29. Pintado-Palomino, K., et al., A clinical, randomized, controlled study on the use of desensitizing agents during tooth bleaching. J
17. Wang, Y., et al., Evaluation of the efficacy of potassium nitrate
Dent, 2015. 43(9): p. 1099-1105.
and sodium fluoride as desensitizing agents during tooth bleaching treatment—A systematic review and meta-analysis. Journal of Den-
30. Rezende, M., et al., Tooth Sensitivity After Dental Bleaching With
tistry, 2015. 43(8): p. 913-923.
a Desensitizer-containing and a Desensitizer-free Bleaching Gel: A Systematic Review and Meta-analysis. Oper Dent, 2019. 44(2): p.
18. Fugaro, J.O., et al., Pulp reaction to vital bleaching. Oper Dent,
2004. 29(4): p. 363-8. 31. Vaez, S.C., et al., Preemptive use of etodolac on tooth sensitivity
19. Navarra, C.O., et al., The effects of two 10% carbamide perox-
after in-office bleaching: a randomized clinical trial. J Appl Oral Sci,
ide nightguard bleaching agents, with and without desensitizer, on
2018. 26: p. e20160473.
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Impact of Electronic Cigarettes on Oral Health Abstract Electronic cigarettes (e‑cigarettes) are widely available, and their use is increasing worldwide. They are promoted as a safer alternative to combustible cigarette smoking and as an effective smoking cessation aid. E‑cigarettes are designed to provide smokers with the desired nicotine dose without burning tobacco. They contain flavoured humectants that include nicotine in concentrations of 0–36 mg/ mL. Evidence suggests that e‑cigarettes are a better nicotine delivery method than combustible cigarettes and have reduced adverse general and oral health effects, compared with combustible cigarettes.
However, although e‑cigarettes might be an acceptable harm-reduction strategy, the differential effects of e‑cigarettes and combustible cigarettes have been based on self-reported perceptions. In addition, a growing number of young people, who have never engaged in combustible cigarette smoking, are smoking e‑cigarettes, which may not be harmless. We analyzed peer-reviewed publications available through PubMed to summarize the effects of e‑cigarettes on oral health.
The World Health Organization estimated that, in 2015, 19.9% of the world’s population over the age of 15 were smokers.1 The 2017 Canadian Tobacco, Alcohol and Drugs Survey found that the prevalence of current cigarette smoking was 15%, including about 17% of males and 13% of females.2 The prevalence in teens aged 15–19 years was about 8%, with 10% of males and 6% of females being current smokers. For those aged 20–24 years and those 25 years and older, the prevalence was 16%. Combustible cigarette smoking (CCS) has been causally associated with major morbidity and mortality.3 Indeed, numerous experimental and clinical investigations have linked tobacco use with over 25 diseases, including lung, heart and oral diseases, such as oral cancer.
Republished from the Canadian Dental Association
The oral cavity is the first site to encounter tobacco smoke, which comes in direct contact with soft and hard tissues. Several studies have linked smoking to an elevated risk of periodontal disease.4 Cigarette smoke has also been associated with various cancers. A meta-analysis showed that exposure to environmental tobacco smoke is prospectively associated with a significantly increased risk of lung cancer.5
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Smoking is also associated with oral cancers. Chher and colleagues6 reported a 4-fold increase in potentially malignant oral disorders among those who smoke tobacco. January 2021
In a retrospective clinicopathological study, of people with proven cases of oral cancer, 29.4% were only tobacco chewers, 25.5% were only smokers, 42.2% used both types of tobacco (smoke and smokeless) and 2.9% were not tobacco users. For those only chewing tobacco, 83.3% had oral cavity cancers, of which 6.7% were of the oro- and hypopharynx. Among those who only smoked tobacco, 69.2% cases were of the laryngeal and oroand hypopharyngeal, compared with 11.5% oral cavity cancers.7 Whatever the mode of tobacco use (smoking, chewing, etc.), there is a high risk of cancer development.
To counter the adverse effects of CCS on human health, various strategies have been introduced, including abstinence and nicotine replacement therapy (NRT).8 Available since early 1990, NRT products include gum, transdermal patches, nasal spray, inhalers and sublingual tablets and lozenges.
E‑cigarettes are powered by a non-rechargeable or rechargeable battery, which may be nickel-cadmium, nickel metal-hydride, lithium ion, alkaline and lithium polymer or lithium manganese.11 Many e‑cigarette devices use a lithium battery, offering the possibility of storing a large amount of energy in a compact space.
An e‑cigarette consists of a cylinder with a cartridge that serves as a reservoir for “vaping” substances on 1 end along with a mouthpiece. The cartridge can be prefilled or fillable. Various capacities have been designed, increasing from first to second and third generations of the e‑cigarette. E‑cigarette devices also contain a battery-powered heating element or atomizer that transforms the liquid into an aerosol, which is commonly and incorrectly termed “vapour” by suppliers.
Recent reports show that NRT increases the chances of successfully stopping smoking in those attempting to quit.9 However, long-term success rates are low, as are those for all cessation options.10 Thus, the possibility of another option available to smokers is appealing, and a new strategy, the electronic cigarette (e‑cigarette), has been introduced.
Methods This review summarizes scientific publications related to the interaction of e‑cigarettes with the oral cavity and the possible promotion of oral disease with the use of e‑cigarettes. For this purpose, we selected peer-reviewed articles using several search terms and databases, between 2012 and 2020. PubMed, Medline and Google Scholar were searched using the following groups of terms (electronic cigarette and oral health), (electronic cigarette and oral health and smoking), (electronic cigarette and oral health and smoking and nicotine replacement therapy), (electronic cigarette and oral health and smoking and cessation), (electronic cigarette and periodontal diseases), and (electronic cigarette and dental caries).
Since their commercialization in 2004, various improvements have resulted in several generations of e‑cigarette, with the most recent called pod-based e‑cigarettes. The pod-based style (the JUUL) consists of 2 main components: a liquid and heating coil-containing pod and a rechargeable battery. It is a low-powered, high-nicotine device in the shape of a USB flash drive.12
We examined the articles and selected those listed in the References of this review. We also included surveys published by Canadian Tobacco, Alcohol and Drugs Survey (CTADS)2 and the Centers for Disease Control and Prevention (CDC) Smoking & Tobacco Use website.3
Pods have a smooth, small “high-tech” look, which makes them unobtrusive and easy to use.13 Several types of pods are available, including opened and closed systems and those that have features of both these formats.14 Pod devices use nicotine salt “juice” in combination with
the humectants, vegetable glycerin (VG) and propylene glycol (PG), in the ratio of 30 or 40 to 60.14 Pods represent over 40% of the e‑cigarette retail market and are popular with teens.15
Between February and December 2017, the Canadian Tobacco, Alcohol and Drugs Survey (CTADS) was conducted by telephone interview of 16 349 respondents across all 10 provinces, representing a weighted total of 30.3 million Canadians aged 15 years and older.2
Liquids Used in E‑cigarettes
The data obtained showed that, in 2017, 15% of Canadians aged 15 years and older had tried an e‑cigarette, as had 23% of youth (15–19 years), 29% of young adults (20–24 years) and 13% of adults (≥ 25 years). More males (19%) than females (12%) had used an e‑cigarette. E‑cigarette use in the past 30 days was reported by 3% of Canadians aged 15 years and older, 6% of youth, 6% of young adults and 2% of adults. Among those who had used an e‑cigarette in the past 30 days, 65% were current smokers, 20% were former smokers and 15% had never smoked. Of those who had never smoked, 58% were youth and 33% were young adults.
Liquids used in e‑cigarettes are regulated under the Tobacco and Vaping Products Act and the Canada Consumer Product Safety Act. These liquids, with or without nicotine, are available in small sealed bottles of approximately 30 mL. In e‑cigarettes, they transfer nicotine from the device to the user’s airways in the form of aerosol.16 The humectants, PG and VG, are used as carrier solvents for nicotine and flavours present in the liquid. When heated, they form an aerosol that is then inhaled. PG is less viscous, producing greater throat stimulation and mimicking the feel of smoking, whereas VG is thick with a natural sweet flavour, producing the esthetically pleasing clouds of vapour for the user to exhale.17 To combine these sensations, a mixture of PG and VG is used. The ratio is based on personal preference regarding the balance among flavour, throat stimulation and vapour production.18 In addition, e‑cigarette liquids contain various attractive chemical flavours.19 Flavouring is the reason most frequently given by young people for starting and continuing to use e‑cigarettes.20 In 1 study,21 vapers ranked the selection of flavours and unique flavours as 2 of the most important factors affecting their choice between competing vape shops. Thousands of flavours have been designed and incorporated into e‑cigarette liquids, including tobacco, sweet flavours, menthol and various combinations to render e‑cigarettes more attractive to users.22
Prevalence of E‑Cigarette Use The emergence of e‑cigarettes has provided smokers with a new alternative way to acquire nicotine. Today, vaping is widespread among both conventional cigarette smokers and non-smokers, including adults and teens.23,24 Even though most countries have adopted legislation surrounding e‑cigarettes, their prevalence is increasing all over the world.
Impact of Electronic Cigarettes on Oral Health
The CTADS also found that, among Canadians aged 15 years and older who had an e‑cigarette in the past 30 days, 43% reported using a fruit-flavoured one, 22% tobacco flavoured and 14% candy/dessert flavoured. Most youth (69%) and young adults (62%) reported using a fruit flavour. In contrast, among adults (≥ 25 years), 33% reported using a fruit flavour and 29% reported using tobacco flavour. Of Canadians who had tried an e‑cigarette, 64% reported that the last e‑cigarette they used contained nicotine, 24% reported it did not contain nicotine and 12% were uncertain. Of current or former smokers, 32% reported using e‑cigarettes as a cessation aid in the past 2 years. The Canadian Student Tobacco, Alcohol and Drugs Survey, conducted in 2016–2017, showed that the prevalence of having tried an e‑cigarette had increased to 23% from 20% in 2014–2015. In the past 30 days, 10% of students had used an e‑cigarette, an increase from 6% in 2014–2015. Prevalence of e‑cigarette use in the past 30 days was higher among males (12%) than females (8%) and higher among those in grades 10–12 (15%) than for students in grades 7–9 (5%).2 Among students who used an e‑cigarette in the past 30 days, 57% had done so in the last 3 days, while 11% reported daily use. Daily use of e‑cigarettes in the past 30 days was higher among males (14%) than females (5%); 17% were current smokers, 12% were former smokers, 35% were experimental smokers or puffers and 36% January 2021
Impact of Electronic Cigarettes on Oral Health
indicated that they had never smoked a cigarette. Of students in grades 7–12, 13% had tried both cigarettes and e‑cigarettes. Of students who had tried both cigarettes and e‑cigarettes, 54% tried CCS first, while 35% first tried an e‑cigarette. The prevalence of trying an e‑cigarette first was higher among students in grades 7–9 (39%) than in grades 10–12 (34%).2
Comparative Health Effects of CCS and E‑Cigarettes E‑cigarettes are seen as a potentially safer smoking alternative to regular cigarettes.20,25 Several experimental and smoker-derived studies suggest that e‑cigarettes can indeed be seen as a harm reduction strategy for those engage in CCS. Nevertheless, some caution is needed to avoid giving the impression that e‑cigarettes are harmless, especially for young people who have never used CCS. Experimental Studies: Endothelial cells, exposed to extracts from combustible cigarettes or from e‑cigarettes showed greater inhibition of cell migration from the former, suggesting that e‑cigarettes do not delay wound healing processes, compared with combustible cigarettes.10 Human gingival epithelial cells exposed to cigarette smoke showed a much greater toxic effect compared with those exposed to e vapours. Indeed, cell growth was almost absent with CCS compared with e vapours; this was supported by high cell death with CCS but not with e‑cigarettes.26-28 Exposure of human lung epithelial carcinoma cells A549 to either e‑cigarette liquids or collected aerosols produced no meaningful toxic effects compared with CCS.29 Exposure of neonatal mice to e vapours during the first 10 days of their life resulted in modestly impaired lung growth, alveolar cell proliferation and lower total body weight.30 In a murine asthma model, exposure to e vapours increased airway inflammation, including an increase in eosinophil levels of Th1-cytokines (IL-4, IL-5, IL-13), OVA-specific IgE and hyperresponsiveness.31 Clinical Studies: In a clinical study,32 110 out of 350 smokers switched to e‑cigarettes for 120 days. These participants had an oral examination and completed a self-administered questionnaire on variations in certain aspects of general health and their need to use CCS. Clinical examinations at various times showed a reduced plaque index among most of the participants who had
used CCS for less than 10 years. Switching from CCS to e‑cigarettes also resulted in plaque index reduction for participants who used CCS for more than 10 years. In addition, bleeding index improved with the use of e‑cigarettes. The self-assessment questionnaire revealed that about 71% of e‑cigarette users felt an improvement in general health. Less than a third of participants felt no clear change in health status, either positive or negative. Only 2 participants indicated a worsening of their general health. Although not comparing CCS and e‑cigarette users at the same time, this study indicated oral health improvements from switching from CCS to e‑cigarettes. In another clinical study,33 105 participants were enrolled and randomly divided into 3 groups: (i) exclusively commercial e‑cigarette use, (ii) dual-use of commercial e‑cigarettes and their usual cigarette brand and (iii) discontinued use of all tobacco and nicotine products. Biochemical analysis showed a significant reduction in detrimental urinary biomarkers with the use of e‑cigarettes only. Dual users exhibited a 7–38% reduction in 8 of 9 urinary biomarkers. All e‑cigarettes users showed a significant decrease in exhaled CO. This observation was also supported by Adriaens and others,34 who studied 30 participants who were smokers for at least 3 years, smoked at least 10 cigarettes a day, had no intention of quitting smoking in the following 3 months and were willing to try several less harmful alternatives. This study showed e‑cigarette use over a short time significantly reduced exhaled CO, compared with CCS. These studies suggest that partial or complete substitution of CCS with e‑cigarettes reduced the exposure of smokers to hazardous products and improved health. January 2021
E‑cigarettes have also been reported to promote smoking cessation. In a Malaysian study35 that included 146 participants who were dual users and 69 who were sole e‑cigarette users, 20.5% of previous cigarette smokers who switched to e‑cigarettes quit smoking. This study suggests that quitting smoking could be easier if smokers use e‑cigarettes only, compared with dual use.
Concerns Regarding E‑Cigarette Use
A recent study36 of 210 smokers randomized to 3 groups (70 to nicotine e‑cigarettes, 70 nicotine free placebo e‑cigarettes and 70 to a control group) confirmed the efficacy and safety of e‑cigarettes over a short period, which led to a high cessation rate.
Concerns regarding e‑cigarettes pertain to the battery, PG, VG, the flavours and the availability of high concentrations of nicotine. The literature includes clinical cases of e‑cigarette explosions and fire causing damage to users; however, none have been reported in Canada.37-39 These incidents may be a result of mishandling devices or batteries or use of unregulated “mechanical mod” devices that can result in battery failure. The nicotine carrier solvents in vaping solutions may also be of concern and may have adverse effects for e‑cigarette users.
However, the majority of available studies related to the use of e‑cigarettes were generated from selfreported perceptions, which may not identify clinical manifestations or modifications that occur in the oral cavity of e‑cigarettes users. In addition, reported safety was based on short-term use of e‑cigarettes. As such, the effects of the various chemicals in e‑cigarettes, and their variable levels, on the oral cavity are still not known.
Some flavours used in e‑cigarette liquids have been reported to be toxic. Clapp and Jaspers40 suggested that e‑cigarette users, with an estimated consumption rate of 3 mL of e‑cigarette liquid a day, would be exposed to a level of diacetyl exceeding the 5 parts per billion limit established by the National Institute for Occupational Safety and Health and the Centers for Disease Control and Prevention (CDC).
THE RACE LEGACY SAFE. EFFICIENT. SOFT CONTROL.
SAFE. EASY. MINIMALLY INVASIVE.
The adverse effect of diacetyl-rich e‑cigarette liquid has also been confirmed by in vitro studies. Bronchial epithelial cells exposed to vaped flavoured liquids showed cell toxicity that was dependent on the level of diacetyl in the liquid.41 Diacetyl is not the only e‑cigarette chemical raising health concerns, as benzaldehyde has also been shown to be potentially harmful.42 In addition, the presence of flavour in nicotine rich liquid may alter nicotine’s pharmacokinetics and user behaviour. Indeed, in a study involving young adult e‑cigarette smokers, subjective reward value was reportedly higher with flavoured nicotine rich e‑cigarettes versus unflavoured products. Participants were found to work harder for puffs of flavoured e‑cigarette than unflavoured ones. Furthermore, the participants took twice as many flavoured e‑cigarette puffs than unflavoured ones. The authors concluded that flavouring enhanced the standard nicotine reward, leading to potential abuse in young adult smokers.43
Impact of Electronic Cigarettes on Oral Health
full-mouth plaque index and a probing depth > 4 mm were significantly higher among combustible cigarette smokers, followed by e‑cigarette users, compared with non-smokers. Gingival pain was also reported more often by combustible cigarette smokers than by e‑cigarettes users. However, although periodontal inflammation and self-perceived oral symptoms were higher with CCS, e‑cigarettes also contributed to adverse periodontal health for their users. These clinical studies suggest close e‑cigarette/oral periodontium interactions, which may lead to poor oral health (Table 1). Further studies are needed to validate these observations and determine the leading causes of these e‑cigarette adverse effects, as well as the mechanisms involved in the periodontal damage. Future studies should answer the question: to what extent are e‑cigarette–oral periodontium interactions associated with periodontal disease? E‑Cigarettes May Promote Dental Caries: PG and VG give e‑cigarette liquids their high viscosity. As a result, aerosols from these liquids are likely to adhere to exposed surfaces, such as the soft and hard tissues in the oral cavity, as well as dental implants. This interaction may, in turn, facilitate bacterial adhesion leading to oral infections, such as caries (Table 1). In addition, dental caries can be promoted by added flavours supplemented with sugars.58 Sucrose, sucralose and sugar alcohol are known additives to e‑cigarette liquids that enhance taste and fragrance.59,60
E‑cigarette safety and harm is still a matter of debate. In the United Kingdom, e‑cigarettes are regulated for safety and quality. They are considered safe, because they do not produce tar or carbon monoxide as CCS does. However, the regulation still warns that e‑cigarettes are not risk free.44 The CDC recently warned of possible health impairment from e‑cigarettes because of an association with mysterious lung diseases among certain e‑cigarette users.45 E‑Cigarettes May Promote Periodontal Disease: In a clinical study46 involving 3 groups (33 cigarette smokers, 31 e‑cigarette users and 30 never-smokers),
A recent study58 showed that e‑cigarette aerosols increased the adhesion of Streptococcus mutans to enamel and promoted biofilm formation. Indeed, enamel exposed to flavoured e‑cigarette aerosols showed decreased hardness, compared with that exposed to unflavoured controls. This bacteria-initiated enamel demineralization was associated with high levels of esters (ethyl butyrate, hexyl acetate and triacetin) found in e‑cigarette liquids. Because commercial e‑cigarette liquids contain several additives at various levels, including sucrose, sugar substitutes and acids, interactions with teeth could vary from one liquid to another.59,61 Additional studies are warranted to inform both users and dental professionals on the prevention of e‑cigaretteinduced caries. Indeed, a specific research question would be: what is the extent to which e‑cigarette aerosols increase dental caries incidence among users? January 2021
E‑Cigarettes May Have Adverse Effects on Teeth and Tooth-Supporting Tissue: With e‑cigarette use, the aerosol comes into direct contact with the teeth and may negatively affect tooth structure. Cho48 examined the association between e‑cigarette use and several oral symptoms among adolescents and revealed a significantly increased risk of damage to the teeth with vaping (Table 1). Indeed, 11.4% of those using e‑cigarettes self-reported a cracked or broken tooth in the last 12 months, 18.5% reported having experienced gingival pain and/or bleeding and 11.0% reported tongue pain, with and without inside cheek pain. These observations are supported by an in vitro study62 conducted with bovine enamel specimens exposed to aerosols from e‑cigarettes, using various liquid flavours (neutral, menthol and tobacco) and nicotine content (0, 12, and 18 mg). The study demonstrated that aerosols with various nicotine contents and flavours altered enamel colour and reduced luminosity; flavoured liquids caused greater colour change. These findings suggest that e‑cigarettes have negative effects on tooth structure and esthetics. Additional in vivo research is needed to validate such observations and to answer the question: to what extent does smoking e‑cigarettes affect the structure of teeth and their supporting tissues?
Effect of E‑Cigarettes on Dry Mouth and Other Forms of Irritation: In a study63 based on reports by e‑cigarette users for the last 30 days and with reported 30-day e‑cigarette use, it was shown that those who spent more on e‑cigarettes were more likely to report chest pain (9.9%), to notice blood when brushing their teeth (17.1%), to have sores or ulcers in their mouth (8.3%), and to have more than one cold (6.8%), than those with no spending on e‑cigarettes. These data support another study51 in which e‑cigarettes users reported sensitive teeth, mouth ulcers, headaches and cold symptoms. In a prospective proof-of-concept study64 monitoring modifications in the behaviour of smokers who switched to e‑cigarettes, the most frequently reported adverse events were throat/mouth irritation (35.6%), dry throat/ mouth (28.9%), headache (26.7%) and dry cough (22.2%). These findings suggest that e‑cigarettes may have negative effects on oral health by increasing mouth irritation, dry mouth and ulceration. Further studies are required to validate these observations and to answer the question: what is the extent to which e‑cigarette smoking is associated with dry mouth and other forms of irritation: among those who switch from CCS to e‑cigarettes and among e‑cigarette users who never engage in CCS?
Table 1: Potential adverse effects on the oral cavity attributed to the use of e‑cigarettes.
Conclusion Smoking is a global public health issue. Tobacco smoking is responsible for local and general health problems, which can be prevented by cessation. Although complete smoking cessation is the best outcome, the powerful addictive properties of nicotine represent an enormous obstacle, even for those with a strong desire to quit smoking. Various nicotine replacement strategies have been developed, including e‑cigarettes. Several self-reported and randomized studies suggest that e‑cigarettes are a harm-reduction strategy that may improve the oral and general health of smokers and may contribute to smoking cessation.
Impact of Electronic Cigarettes on Oral Health
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However, additional long-term clinical and user-based studies are needed to validate these observations. It is also important to note that a harm-reduction strategy is irrelevant for e‑cigarettes users who never engage in CCS. For the latter population, evidence of the adverse effects of e‑cigarettes on oral health is needed to inform policy, programs and practices.
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Recommendations and Knowledge Gaps
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Based on the available literature, it is possible to recommend the use of e‑cigarettes as a temporary alternative for harm reduction and as an aid to smoking cessation. For those who have never engaged in CCS, but use e‑cigarettes, oral health professionals may need to explain to these patients and their parents that the use of e‑cigarettes is not harmless. To advise their patients appropriately, oral health professionals are encouraged to learn more about e‑cigarette constituents and their possible effects on oral health.
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Oral health professionals may need to document observed modifications in the oral cavity of their patients, such as saliva thickening, unusual oral ulcers and the frequency of caries. It could be useful to record associated e‑cigarette use, type of liquid used, flavours preferred and nicotine concentration.
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Infection Control Dr. Hana Bougatef Post graduate student, conservative odontology & endodontics, Dpt. of dental medicine, EPS Sahloul, Sousse, Tunisia Dr. Mahmoud Smaoui Post graduate student, conservative odontology & endodontics, Dpt. of dental medicine, EPS Sahloul, Sousse, Tunisia Dr. Faten Khanfir University Hospital Assistant at the Dental University of Monastir, Tunisia Pr. Nabiha Douki Professor at the Dental University of Monastir, Tunisia Pr. Sonia Zouiten Professor at the Dental University of Monastir, Tunisia Pr. Faten Ben Amor Professor at the Dental University of Monastir, Tunisia
Dental University of Monastir, Research laboratory of oral health and rehabilitation, LR12ES11, 5000, Monastir, Tunisia
Dentist daily practice after the first coronavirus pandemic wave Abstract Severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) is the etiological agent of the severe acute respiratory syndrome corona virus disease 2019 (COVID-19). The coronavirus disease started firstly in Wuhan, China last December and have become a public health problem for not only China but also countries all over the world. Tunisia, for example, was for a time at stage 3 of the coronavirus epidemic. After applying vigorous and strict recommendations by the government, epidemiological monitoring parameters confirmed control of this epidemic. Therefore, with no vaccine until now, we should learn how to live with it and more
attention should be kept to avoid a second epidemic wave. Particularly, in dental settings, the risk of cross infection may be higher between dental practitioners and patients due to bioaerosol generation in the majority of dental procedures. Our aim in this paper is to sensitize clinicians about infectious risks in dental settings and provide recommended protocols for dental practitioners to avoid cross infection with corona virus 2 (SARS-CoV-2). Keywords: Coronavirus disease, dental setting, transmission, aerosol, contamination, prevention.
Introduction Cornavirus disease, also called COVID-19, is the latest infectious disease started in the area of Wuhan, China, and has rapidly spread across the world. The etiologic agent is the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). 33 On January 30, 2020, the World Health Organization (WHO) declared the rampant spread of SARS-CoV-2 and its associated disease (COVID-19) a public health emergency. 32 Like most of the countries all over the world, Tunisia has not been spared from the coronavirus. Since March 22, 2020, Tunisia has passed to stage 3 of the coronavirus epidemics. Thus, the Tunisian government has declared total containment from April 19, 2020 until May 4, 2020. After a gradual and favourable reduction of general containment, now, epidemiological monitoring parameters confirm control of the risk of indigenous transmission and the persistence of an exclusive risk related to imported cases. January 2021
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These decisions to reduce restrictions on containment and resuming economic activities with the borders opening confront the question of how to avoid a new spread of the SARS-Cov-2 virus that could be generated by the entry of virus carriers. Therefore, vigorous measures for prevention and appropriate recommendations for dental practice are suggested for patient screening, infection control strategies, and patient management protocol. Based on our experience, guidelines and research, this article aims to sensitize clinicians about infectious risk in dental settings and provides recommended protocols for dental practitioners to avoid another epidemic wave.
Routes of Transmission The routes of transmission are direct contact, and droplet and possible aerosol transmissions. 9 Consequently, coughing or sneezing by an infected person can cause virus spread for individuals in close contact (within a radius of approximately 6 feet). This led to the recommendation of social distancing to minimize community spread of the disease. The second route of transmission is if droplets of SARS-CoV-2 land on inanimate objects located nearby an infected individual and are subsequently touched by other individuals. In fact, SARS CoV-2 can remain viable in aerosol and survive up to 3 days on inanimate surfaces at room temperature, with preference in humid conditions. 35 Thus, hand contact with contaminated surfaces may lead to virus transfer to the eyes, nose, or mouth, resulting in a new case of infection. 9 Thatâ&#x20AC;&#x2122;s why, disinfection of objects and hand washing are essential for halting the spread of this disease. 2
Infectious risk in dental settings In affected patients, it has been proved that this coronavirus is abundantly present in nasopharyngeal and salivary secretions. So, it spreads easily through respiratory droplet/contact with nature. 2 Due to their proximity to the oral cavity, dentists and dental assistants are therefore highly exposed to the virus, in particular during procedures that generate airborne contamination. This involves the suspension
Dentist daily practice after the first coronavirus epidemic wave
of potentially contaminated saliva in an aerosol. These aerosols are mainly generated by the use of rotary or ultrasonic instruments, but also when using air/water syringes. 12, 28 Unfortunately, due to the characteristics of dental setting, patient management generate significant amounts of droplets and aerosols, posing high risks of nosocomial infection. The standard protective measures in daily clinical work are not effective enough to prevent the spread of COVID-19. 26 When a person coughs, sneezes, laughs, or talks, big and small droplets are generated. Due to gravity, big droplets fall to the ground. Therefore, droplet transmission requires close physical proximity with an infected individual. On the other hand, small droplets may remain in the air for a longer time and travel further before they can enter the respiratory tract or contaminate surfaces. 9 In addition to coughing and sneezing, dental treatments including the use of a high-speed handpiece or ultrasonic instruments with water coolant could make secretions, saliva or blood aerosolize to the surrounding area. 26, 9 Often these bioaerosols are contaminated with bacteria and viruses, and can float in the air for a time and be inhaled by another person. 9 Moreover, infections can occur through the puncture of sharp instruments or direct contact between mucous membranes and contaminated hands. 21 The virus has been shown to be present in human saliva. 8 Moreover, oral mucosal cells have been shown to strongly express the ACE2 (angiotensin converting enzyme 2) receptor on their surface, which is conducive to the adhesion of CoV-2-SARS. 36 Additionally, salivary glands also appear to be a potential reservoir for CoV-2-SARS, especially in asymptomatic patients, which may explain a resurgence of the virus in the oral cavity during salivation. 37 These observations thus place the oral cavity as an important risk area for transmission of this pathogen.
Oral manifestations General symptoms such as cough, weakness, myalgia were the most common symptoms. Some clinical case reports have suggested that SARS-CoV-2 may have many oral manifestations. 3 There have been some COVID-19 cases reporting oral manifestations. 25, 31, 22, 5 January 2021
Some studies proved that the damage of respiratory tract and other organs showed with coronavirus infection can be attributed to the distribution of angiotensinconverting enzyme 2 (ACE2) receptors in the human system. 38 Therefore, cells with ACE2 receptor distribution may become host cells for the virus and further cause inflammatory reactions in related organs and tissues, such as the tongue mucosa and salivary glands. 36
Dentist daily practice after the first coronavirus epidemic wave
ventilate the room to evacuate the aerosols as quickly as possible. • Vacuuming: clean filters, test vacuuming and carry out disinfection with the usual product. • Floors and surfaces: carry out a cleaning of the floors and a treatment of the surfaces with virucidal disinfectant detergent products (standard NF EN 14476).
In addition, COVID-19 acute infection treatment and repercussion on the deterioration of systemic health could potentially contribute to negative outcomes concerning oral health. It can lead to various opportunistic fungal infections, recurrent oral herpes simplex virus (HSV-1) infection, oral unspecific ulcerations, fixed drug eruptions, dysgeusia, xerostomia linked to decreased salivary flow, ulcerations and gingivitis. 6, 1, 24 Further studies are needed to investigate the oral manifestations of COVID-19.
Patient management in daily practice
2- Waiting area
During the covid-19 outbreak, pulpal or periapical lesions, cellulitis and abscess were the most common reason for patient visits to the emergency room. Nonemergency dental procedures were postponed with medical prescription if needed. Now, after the favourable transition of the coronavirus epidemic in many countries, patient management in dental sector is starting to get back to normal daily practice.
All patients should cover their nose and mouth with a mask. Post a cough etiquette instruction at the entrance of the waiting room. When coughing or sneezing, patients should cover their nose with their elbow, instruct them to dispose used tissues into a waste bin immediately after use and ensure hand hygiene.
However, if adequate precautions are not taken, the dental office can potentially expose patients to cross contamination and can become potential carriers of the disease. 2 Thus, special precautions in a dental setting should carefully be taken. Based on our experience, relevant guidelines and research, we can enumerate some:
1- Back to the activity As after each prolonged closure, before the firm reopens, it is necessary to carry out the following operations: • Cold water: purge the entire water circuit for 5 minutes. Do the same with the equipment of the chair (micromotor cords, multifunction syringe...) • Hot water: completely drain the water storage equipment by opening all hot water points. If possible,
Waiting area should be well ventilated without draught generation. For rooms with natural ventilation, 60 L/s per patient is considered adequate ventilation. Spatial separation of at least 1 m should be maintained between patients. 9
3- Ventilation and air conditioning of premises - Like any workplace, a treatment room must have a supply of fresh air, either through natural ventilation (window or other opening) or through mechanical ventilation. The minimum fresh air flow rate is 45 m3 per hour per occupant. - It is recommended to identify the type of existing ventilation. The devices allow the supply of fresh air and the extraction of stale air and to check their correct operation, contacting the installer if necessary. - With regard to SARS-CoV-2, there is a need for additional air renewal, due to the potential contaminated January 2021
aerosols remaining in suspension in the treatment room, even if the first objective for the practitioner is to reduce the quantity emitted. - After each aerosol-generating procedure, it is therefore necessary to ensure maximum renewal of the air in the treatment room before admitting a new patient. - When an aerosol-generating treatment is performed and during the ventilation phase, the door of the treatment room must be closed. In addition, the nursing staff present must be equipped with suitable protection.
each patient visit, especially surfaces in close proximity to the operating areas. Surface disinfectants contain 0.5% hydrogen peroxide or 62%–71% ethanol for small surfaces. 18 The WHO recommends the use of sodium hypochlorite for environmental cleaning with concentration of 0.1%, which is effective against coronaviruses in 1 min. 18
5- Patient screening
23, 29, 16
* Air conditioning: - Room air conditioners generally do not ventilate the room. The indoor unit takes the air from the room and returns it to the desired temperature. 15, 27 - Recirculating air systems such as air conditioners, whether or not they are equipped with filters, should be shut down as much as possible to avoid dispersion of the generated aerosol and contamination of all surfaces in the room. - The use of air conditioning in the treatment room remains possible outside the periods when aerosols are produced or still in suspension (i.e. after the end of the ventilation following the aerosolizing procedure). - If air conditioning is used, it is recommended: • To use the most efficient filters possible from a health point of view, in relation to the technical compatibility of the installation. • To change the filters regularly (if possible every week) following the recommendation guides (Ministry, UNICLIMA) - When using an all-new air handling unit to condition the air, the usual temperature and humidity settings must be maintained. 15, 27
4- Surfaces disinfection Clinic staff should make sure to disinfect inanimate surfaces in both waiting and operating areas using chemicals recently approved for COVID-19 and maintain a dry environment to curb the spread of SARS-CoV-2.17 They should ensure that environmental cleaning and disinfection procedures are followed consistently and correctly after each patient. In fact, routine cleaning and disinfection are appropriate for SARS-CoV-2 in healthcare settings, including those patients-care areas in which aerosol-generating procedures are performed. Surfaces are disinfected after
Dentists should take a thorough medical history from each patient and confirm the health status at each recall visit. This should include personal, travel, and epidemiological history. Temperature and lower respiratory tract symptoms should be closely monitored. Do not forget that symptoms of fever and fatigue could be caused by acute dental infection. 9
6- Patient placement *Ideally, dental treatment should be provided in individual patient rooms whenever possible. *For dental facilities with open floor plans, to prevent the spread of pathogens there should be: -At least 6 feet of space between patient chairs. -Physical barriers between patient chairs. Easy-to-clean floor-to-ceiling barriers will enhance effectiveness of portable HEPA air filtration systems (check to make sure that extending barriers to the ceiling will not interfere with fire sprinkler systems). Dental chair should be oriented parallel to the direction of airflow if possible. *Where feasible, consider patient orientation carefully, placing the patient’s head near the return air vents, away from pedestrian corridors, and toward the rear wall when using vestibule-type office layouts. 4
Infection Control Dentist daily practice after the first coronavirus epidemic wave
7- Patient volume Number
Ensure to account for the time required to clean and disinfect dental chair between patients when calculating your daily patient volume. Appointment scheduling: Upon resumption of activity, each practitioner must give preference to patients who have received urgent care during the containment period and patients whose care had been on hold when the containment was put in place. The organization of appointments must: - Allow Essential measures and precautions during oral care after deconfinement - Allow Carrying out disinfection and ventilation procedures between each patient - Prevent people from staying in the waiting room. In case of group practices, it may be appropriate to provide staggered schedules. - Encourage the grouping of procedures over a long session. 4
8- Personal Protective Equipment (PPE) Personal protective equipment (PPE) can form an effective barrier against aerosols generated from the operative site. Dentists should respect the use of PPE and select the appropriate equipment to provide it to medical staff. They must receive training on and demonstrate an understanding of: *when to use PPE *what PPE is necessary *how to properly don, use, and doff PPE in a manner to prevent self-contamination *how to properly dispose of or disinfect and maintain PPE *the limitations of PPE - Protective eyewear and face shields: infectious droplets could easily contaminate the dentist through contact with the mucous membranes in the eyes. Protective eyewear, or face shield should be worn to protect the eyes from bioaerosols and droplets created during dental procedure, then they should be disinfected between patients. - Face masks: at minimum, a surgical mask should be used. It offers both source control and protection for the wearer against exposure to splashes and sprays of infectious material from others.
When performing aerosol generating procedures, a particulate respirator that is at least as protective as a National Institute for Occupational Safety and Health (NIOSH)-certified N95, European Standard Filtering Face Piece 2 (EU FFP2), or equivalent, were used. It is advisable to use them judiciously and follow the Centers for Disease Control and Prevention guidelines for N95 respirator use and reuse. 30
the ears) and pull it away from the face without touching the front. • Respirator: Remove the bottom strap by touching only the strap and bring it carefully over the head. Grasp the top strap and bring it carefully over the head, and then pull the respirator away from the face without touching the front of the respirator. 7. Perform hand hygiene. 4, 10
There are multiple sequences recommended for donning and doffing PPE. One suggested sequence includes: *Before entering a patient room or care area: 1. Perform hand hygiene. 2. Put on a clean gown or protective clothing that covers personal clothing and skin likely to be soiled with blood, saliva, or other potentially infectious materials. 3. Put on a surgical mask or respirator. 4. Mask ties should be secured on the crown of the head (top tie) and the base of the neck (bottom tie). If the mask has loops, hook them appropriately around your ears. 5. Respirator straps should be placed on the crown of the head (top strap) and the base of the neck (bottom strap). Perform a user seal check each time you put on the respirator. 6. Put on eye protection: Personal eyeglasses and contact lenses are NOT considered adequate eye protection. 7. Perform hand hygiene. 8. Put on clean non-sterile gloves: Gloves should be changed if they become torn or heavily contaminated. 9. Enter the patient room.
9- Hand hygiene
*After dental care: 1. Remove gloves. 2. Remove gown or protective clothing and discard the gown in a dedicated container for waste or linen. o Discard disposable gowns after each use. o Launder cloth gowns or protective clothing after each use. 3. Exit the patient room or care area. 4. Perform hand hygiene. 5. Remove eye protection. • Remove it carefully. Do not touch the front of the eye protection. • Clean and disinfect reusable eye protection, according to manufacturer’s reprocessing instructions prior to reuse. • Discard disposable eye protection after use. 6. Remove and discard surgical mask or respirator. • Do not touch the front of the respirator or mask. • Surgical mask: Carefully untie the mask (or unhook from
Use ABHR (Alcohol-based hand rub) with 60-95% alcohol or wash hands with soap and water for at least 20 seconds. The WHO (2020c) stated that hand hygiene includes either cleansing hands with an alcohol based hand rub or with soap and water; both methods are equally effective. ABHRs are preferred if the hands are not visibly soiled; if the hands are visibly soiled, water and soap should be used. The WHO recommended formulations based on 80% ethanol or 75% 2-propanol to be effective against coronavirus. 18 As suggested by WHO (2009), hand hygiene should be performed before touching a patient, before any cleaning or aseptic procedure is performed, after exposure to body fluid, after touching a patient, and after touching a patient’s surroundings. 9
Before and after all patient contact, contact with potentially infectious material, and before putting on and after removing personal protective equipment (PPE), including gloves. Hand hygiene after removing PPE is particularly important to remove any pathogens that might have been transferred to bare hands during the removal process. Dental healthcare facilities should ensure that hand hygiene supplies are readily available to all medical staff in every care location.
Dentist daily practice after the first coronavirus epidemic wave
To limit the risk of aerobiocontamination with SARSCoV-2, the use of preoperative antiseptic mouthwashes has been proposed in several international publications.
Extraoral imaging such as panoramic radiography or cone-beam computed tomographic imaging should be used to avoid gagging or cough reflex that may occur with intraoral imaging. When intraoral imaging is mandated, sensors should be well protected to prevent perforation and cross contamination. 34
Preprocedural mouth rinse is one of the most effective methods of reducing the proportion of microorganisms in oral aerosols. Previous studies have shown that SARSCoV and MERS-CoV were highly sensitive to povidone mouth rinse. 7 Some recommend the use of chlorhexidine, others, hydrogen peroxide, or povidone-iodine. Therefore, preprocedural mouth rinse with 0.2% povidone-iodine might reduce the load of corona viruses in saliva. 20 Another alternative would be to use 0.5-1% hydrogen peroxide mouth rinse, as it has nonspecific virucidal activity against corona viruses. 18 In addition, it has been proven that CHX is effective against several infectious viruses, including herpes simple virus (HSV), human immunodeficiency virus (HIV), and hepatitis B virus (HBV). About 0.12% CHX can be used as a preprocedural mouth rinse. 34
14- Aerosol Dentists should avoid aerosol-generating procedures whenever possible and prefer procedures, reducing the quantity of aerosol produced in the environment. Minimize the use of ultrasonic instruments, high-speed handpieces, and the air/water syringes to reduce the risk of generating contaminated aerosols. 2 Prioritize minimally invasive/atraumatic restorative techniques (hand instruments only). Reduce the quantity of aerosols created (red ring contra-angle rather than a turbine, minimum water flow required, limit the use of ultrasound, no use of an air-polisher...) During the operating sessions, the dentist should use handpieces equipped with anti-reflux devices to avoid cross-infections. 33
15- The dental chair Must be equipped with a disinfection circuit and will be fully disinfected after each patient. All equipment and instruments should be in covered storage, such as drawers and cabinets, and away from potential contamination.
11- Rubber dam Dentists should use a rubber dam in all aerosol-generating procedures. It may be advantageous to place the rubber dam so that it covers the nose. 2
12- Devices Use of disposable (single-use) devices such as mouth mirror, syringes, and blood pressure cuff to prevent cross contamination. 9
Any supplies and equipment that are exposed but not used during the procedure should be considered contaminated and should be disposed of or reprocessed properly after completion of the procedure.
16- Removal/filter of contaminated air There are several methods to remove/filter contaminate air in treatment areas; the two most commonly used devices include the inexpensive, high volume evacuator (HVE) and the expensive high efficiency particulate arrestor (HEPA) filters. 9
17- At the end of each half day - Disinfection of aspirations - Decontamination of suction filters - Cleaning of waiting room surfaces if the waiting room has been used - Seal waste bags with gloves and perform hand hygiene afterwards.
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18- At the end of the day
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Floor cleaning (HCSP, 10 April 2020) 13 - Wet scrubbing-disinfecting (do not use a vacuum cleaner) - Use of a product in accordance with standard NF EN 14476 or, failing this, bleach at a concentration of 0.5% - Respect the contact time necessary for the product to be effective. - For unsoiled and non-wetted PPE, disposed of in the household waste stream (HCSP, 19 March 2020) 14 - Use a bag dedicated to this waste - Do not transfer the bag - Double the bag with a second bag - Close the bag and store it for 24 hours before putting it away.
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1st COLTENE CinePosium presents European dental stars Depending on the size of the screen and your Internet connection, following online seminars in a team, on your own computer can sometimes be extremely tedious. In November, COLTENE is therefore celebrating the premiere of a very special format: an exciting mix of technical presentations on a stage near you, with international live circuits and networking events that will conquer the big screen. Leaving you to decide whether you want to be there live in the cinema or experience the symposium online.
participants. In this way, members of the inexorably growing, global COLTENE Community will experience an exciting exchange of blows beyond any national or departmental boundaries under the motto «From Root to Crown».
The blockbuster among the training courses At the European CinePosium, the internationally leading dental specialist COLTENE will present seminar content in a completely new dimension for the first time. On Tuesday, November 17, 2020, top-class specialists from the fields of endodontics and restorative dentistry will welcome interested cinema and online participants live from Athens, Berlin, Milan and Warsaw to the CinePosium. An informative and entertaining afternoon with international stars of the dental industry awaits you. Running from 12 noon – 7pm, the kick-off will be moderated by Prof. Dr. Ivo Krejci in Milan, while the other cities and online participants will be connected live. Endodontic experts such as Prof. Dr. Eugenio Pedullà, Dr. Walid Nehme and Dr. Antonis Chaniotis will give lectures from their respective movie theaters. The second part of the symposium will feature lectures on the future of restorative dentistry by Dr. Mile Churlinov from Warsaw and Dr. Jürgen Wahlmann from Berlin.
To add to the event, typical cinema snacks, as well as small regional delicacies will be provided for the physical during the networking on the red carpet. Interested dentists and practice teams can now register online for an exclusive visit to one of the four major European cities. Those who cannot get hold of one of the strictly limited tickets, will have the opportunity to follow the presentations and Q & A sessions from home in via live streaming whilst still being able to post their personal questions to the dental VIPs in the chat area. This autumn, not only James Bond, but also the topic of bonding is expected to be a hot topic internationally. Website: www.coltene-cineposium.de
Between the presentations, the speakers will meet for a virtual «round table» to discuss live questions from the audience as well as questions from our online
Revolutionary app ushers in new era of digital dentistry Innovation Dr. Waël Bizri CEO, Toothpick
Q&A with Dr. Waël Bizri Toothpick gives industry stakeholders something to smile about A ground-breaking mobile application which uses the latest technology to provide dental practitioners, dental product suppliers and other industry stakeholders with an easy-tonavigate, streamlined ecosystem was launched in the United Arab Emirates (UAE), Lebanon, Egypt and Qatar. The app’s creators first had the idea for Toothpick back in 2018. The brainchild of four young Lebanese entrepreneurs, Toothpick is set to revolutionize the marketplace by bringing together various facets of the dental industry under one digital user-friendly umbrella. Three of its creators are dentists, while the fourth is an IT expert. All of them have expertise in their field, gained either across the region or in Silicon Valley. By accessing the tech platform, industry players will be able to browse, compare prices and purchase their supplies and equipment conveniently and efficiently via a one-stop e-shop. This must-have industry tool also offers practitioners access to a wide range of industry information, such as events and courses, news updates and partnership opportunities.
Dental News met Dr. Waël Bizri, the CEO of Toothpick, to understand more from him about his project. Dental News: Your platform is a mobile application. Why did you choose to do it exclusively for mobiles and not as a website that can be opened on different devices? Dr. Waël Bizri: We chose to start with the apps as an entry point to make it user friendly for the dentist and we are currently developing a state-of-the-art ordering website that will an addition to the user experience, making toothpick accessible by the dentist on all platforms and desktops. DN: “Toothpick is your dental ecosystem”: which advantages does it have on the environment?
Toothpick is adding the components of the dental industry together via its online platform, hence the dental ecosystem. Beginning with the marketplace that will digitize the Dental Suppliers with their customized systems. Integrating the full supply chain that will allow dentists to order from all their local suppliers and have their products delivered in one bag. DN: Can you please tell us about the different kinds of equipment that you are selling on your platform? Using the backend systems catered to dental suppliers, you can find all local supplier products on Toothpick. From Perishable, Disposable, and fast-moving items, to small equipment and tools the dentist and laboratories use. Aside from that we also January 2021
have a special inquiry section that displays all machines and dental units with all sterilization equipment. Basically, everything the dental market has to offer from the products to the descriptions and related information with the price can be found on Toothpick.
DN: When we say that your platform is the largest online dental hub in the MEA region, what do we really mean? Which advantages does it include compared with other online hubs in the same category in the region? Toothpick is the first Dental marketplace, present in Uae, Lebanon, Egypt, and Qatar. We have over 120 dental suppliers from these 4 countries integrating all their supplies and catalogs on Toothpick app. We offer a true one-stopshop in all these countries allowing the dentist to actually buy from all their local suppliers and have them received in one bag at enhanced service and maximum efficiency at a discounted cost. Allowing the industry to go online around the clock, connecting the dental suppliers to the dentist on a higher technology approach. Since we are a technology company our enhanced systems have integrated logistics, tracking, and other procurement systems that give us a unique and soul stand out as the leading dental tech movement in the region. DN: Is your application targeting only dentists? The target segments are Dentists, Dental Students, and Dental Laboratories that can find all their products on the app. We also cater to Universities and Top clinics with our Systems, toothpick Gold, and Toothpick Uni. DN: Since the application is user friendly, are you planning to expand your service in the future, from B to B to B to C? We are currently focusing on the Industry as a B2B solution. Following the marketplace, we are developing in-house clinic management systems that can digitize the workflow of the clinics and match it with the marketplace solution. We believe that our end goal is to add the Patient and in this case the end consumer to the platform to allow better connection and service across the industry.
DN: Which advantages will this change give you? When this occurs, it will revolutionize Dental Healthcare. By connecting all the dots across the industry together, we can optimize and correct all problems and shortcomings that occur daily. DN: Which infrastructure does it require and do you see that it can work in all MEA countries? Do you think that consumers will be interested in buying dental equipment that is used for daily routine, in case they will be available on your platform? We believe that across all countries and ages there will be similarities and differences. We choose to build on the similarities which we find are vast and abundant. The technological era has already begun. The dentist has encountered vast solutions to his daily life using the smartphone in his pocket. That same smartphone can allow him to access his industry via Toothpick. Why Not? If we can have all our local suppliers, courses, systems in one place and still connect to the businesses we work with daily but with uplifted solutions, wouldnâ&#x20AC;&#x2122;t that be a win-win situation for all! It can take some time for the shift to happen, but it has to start someplace and it has to start now. DN: Which other future plans do you have? Toothpick wants to change the dental industry and make a difference. Our goal is to create technology that can be simply used yet have a big impact. We look at the problems every dentist, supplier, the institution can face and we study these problems to come up with tested solutions that can solve them. Today we are operational and growing in 4 countries. We aspire to expand across 10 countries by 2022. Developing our technologies, systems, and relations we want to build the biggest dental tech solution of the twentyfirst century.
More information about Toothpick can be found at: www.toothpickapp.com
Race evo: Safe. Efficient. Soft control. A Legacy Improved Through Evolution RACE® EVO is the ultimate evolution of our popular and proven RaCe rotary system. Highly dependable original RaCe features combined with proprietary heat treatment and higher rotation speed capability, make RACE® EVO instruments even safer, easier to control and more efficient than ever before.
• Exclusive heat treatment combined with legacy RaCe features provide the perfect combination of strength, durability and control. With unmatched resistance to cyclic fatigue, optimised yet non-intrusive cutting efficiency, and a low screwing effect, RACE® EVO is designed to be safe. • RACE® EVO specific heat treatment provides unprecedented mechanical properties, which in turn allow higher speed for quicker and more comfortable treatment for patients. • The RaCe design and over 20 years of trusted performance associated with higher speed, bring improved efficiency with a familiar feel to RACE® EVO instruments.
RACE® EVO allows you to choose your therapeutic approach. Our full selection of instruments lets you successfully treat various canal anatomies. Simply start with your basic instrument sequence, then easily switch to the next size for wider canal shaping when necessary. website: www.fkg.ch
Composan LCM & Composan LCM flow Light-curing micro-hybrid composites Composan LCM is a universal light-curing micro-hybrid composite suitable for fillings in the anterior & posterior area and for the inlay technique. Its high filler content and well-balanced resin matrix guarantee minimal abrasion, low polymerisation shrinkage, as well as high compressive and transverse strength.
Perfect aesthetic results Composan LCM convinces with its great colour stability, excellent polishing properties, perfect adaptation to the natural tooth colour and its toothlike brilliance. Therefore, fillings made of Composan LCM meet the highest aesthetic requirements of dentists and patients.
Also available as a flowable version Composan LCM flow is suitable for various indications like minimally invasive preparation, fillings of class III to V, extended fissure sealing etc. Moreover, it is ideal for
linings under composites due to its easy application and perfect adaption to the cavity walls / tooth substance. Composan LCM flow levels out irregularities of the cavity floor and reinforces the bonding layer. Due to its elastic properties the material is also highly stress absorbing. Its low viscosity ensures good wetting capability and highly aesthetic results. website: www.promedica.de January 2021
The first ever press ceramic with VITA shade match formula! Zirconia-reinforced lithium disilicate press ceramic system for highly esthetic and durable results with efficient processing. For the production of delicate reconstructions, such as veneers and inlays/onlays, as well as highly esthetic, full/partial crowns and tripartite bridges, up to the second premolars. The press ceramic system includes press ceramic pellets in two levels of translucency (T/HT) and two sizes (S, L), muffle system, investment material and liquid, as well as press plungers.
• Efficient Achieve efficient, highly accurate press results through a minimized reaction layer, as the material and investment material are ideally matched.
• Durable Highly durable restorations, thanks to zirconia-reinforced lithium disilicate ceramic with very high stability (> 500 MPa).
The advantages • Brilliant Brilliant, multi-faceted play of shade and light, thanks to material with natural translucence, opalescence and fluorescence.
• True-to-shade Reliably reproduce tooth shades, thanks to press pellets with very good fidelity and perfectly matched system components.
Expodental Meeting: see you in Rimini, from 17 to 19 June 2021 This new year has just begun and we can finally start imagining the end of the terrible crisis that marked year 2020: indeed, the vaccination campaign started worldwide and hopefully will be able to stem the most severe pandemic of the last 100 years.
If the recovery is certainly on its way, it is still premature to imagine exactly when this will happen. For this reason, the UNIDI Board of Directors has just decided to reschedule Expodental Meeting in June when, it is likely to be assumed, there will be more favorable conditions for the safe conduct of the event. A shift that, once again, is dictated by the will of the organizers to ensure exhibitors and visitors a safe and profitable edition of Expodental Meeting. A trade fair event, respectful of the operational health protocols for our sector, that will allow us to meet and experience the exhibition and its scientific program, free from the worries of contagion.
«Today, considering what happened in 2020 and the studies on the epidemic, it is impossibile to foresee the nearest future. However, it is certainly conceivable that the month of June could represent the ideal season for our restart» says Gianfranco Berrutti, UNIDI President. «Postponing Expodental Meeting to June also takes into account the changed exhibition calendar and the willingness of exhibitors and visitors to meet again. We are convinced that the 2021 edition of Expodental Meeting can truly represent an opportunity for the entire sector, nationally and internationally, to re-affirm the centrality of the role of our fair as a fundamental promotional and business tool». Rendez-vous in Rimini, then, from 17 to 19 June 2021, with a large exhibition area and an even richer scientific and training program for all visitors.
29 June - 1 July 2021
Take Time One year ago, no one had a clue on what the coming year will look like or what it was hiding. Then before the first quarter ends, a cascade of unprecedented disastrous events falls on our heads. Confined and confused facing an invisible foe. An enemy that is yet to be deciphered, decoded, and to discover its effect on humankind. As tumultuous as it has been, the year 2020 has also taught us a lot about ourselves, especially in terms of patience, responsiveness, creativity, and family values. In the midst of this healthcare emergency, the international medical community searched for the most effective treatment for the COVID-19 pandemic. The frontline responders and the dental profession continued delivering care to their patients while protecting themselves and their community from a further spread of the novel coronavirus. Even though they were highly exposed to the virus, they did not fail to maintain the wellbeing of sick people.
When everything was going too fast. The confinement has, in a way, given a break to a lot of people, under pressure, with unrestrained activity, consequently, it has put the record straight. Therefore, while confined, time stretched out indefinitely. Sometimes for the worse, but many times for the better too. Time management has become an art in order to discover ways for becoming more creative and for nurturing hobbies, old and new. It taught us to be more resilient and to take care of ourselves and our beloved ones. Without forgetting that many people have suffered, are suffering, and will still suffer from the pandemic: 2020 has shown us that we are able to adapt, even in an emergency, to a catastrophic situation. With ups and downs, sure, but it seems like a great lesson to apply in all other areas.
Dr. Tony Dib
Company name: 3Shape Country of origin: Denmark Website: www.3shape.com
3Shape is changing dentistry together with dental professionals across the world by developing innovations that provide superior dental care for patients. Our portfolio of 3D scanners and CAD/CAM software solutions includes the multiple award-winning 3Shape TRIOS intraoral scanner, as well as marketleading scanning and design software solutions for both dental practices and labs. Two graduate students founded 3Shape in Denmark’s capital in the year 2000. Today, 3Shape has over 1,600 employees serving customers in over 100 countries from an ever-growing number of 3Shape offices around the world. 3Shape’s products and innovations continue to challenge traditional methods, enabling dental professionals to treat more patients more effectively.
Noon Medical Supply Company Advanced Technology Company K.S.C.P
SAUDI ARABIA Algosaibi MELAT TRADING
STATE OF PALESTINE
Dentixx for Dental Equipment & Turnkey Solutions
UNITED ARAB EMIRATES
Al-Shara’a Dental Supplies FIA Group
Manshore Medical Supplies LLC
Al Mazroui Medical & Chemical Supplies LLC
Shine Tech Laxmi Dental
Abnaa Abdelhadi Natsheh
Newmed - Al Hayat Group
Mac Digital Dental Systems LLC Henry Schein Middle East Regional Office KB Oil DMCC Al Hayat Pharmaceuticals
3Shape TRIOS 4 with MOVE+ Advances in digital dental technology like the 3Shape TRIOS® 4 intraoral scanner and TRIOS MOVE+ enable dentists to perform increasingly consistent, predictable, and accurate treatment procedures. Patients benefit from improved comfort and involvement in treatment planning that engages and excites them about their options and predicted outcomes. The MOVE+ features an expanded, 15.6” HD touchscreen mounted on an ergonomic, adjustable arm. This helps dentists position the screen to share TRIOS intraoral scans with patients and acts as a canvas to design and discuss treatment plans. The screen and arm are attached to an elegant, easy-to-move stand with a PC that delivers fast and smooth scanning technology. The iconic, minimalist design is complemented by graceful details like subtle roundings and premium, brushed aluminum reflecting MOVE+’s Danish DNA. The TRIOS 4 continues 3Shape’s legacy of developing the most advanced, accurate intraoral scanners in the dental industry. A marriage of form and function, the wireless TRIOS 4 combines innovations like caries diagnostic aid and monitoring tools with a distinctive, ergonomic design that guarantees better patient and operator comfort.
Company name: Takara Belmont Corporation Country of origin: Japan Website: www.takarabelmont.co.jp/global/dental/ Takara Belmont has been contributing to people’s wish to stay healthy and beautiful through a century of our history. Founded in Japan in 1921, and we drew on our hydraulic technology and began manufacturing dental chairs in 1960s. Committing to the healthy life not only for patients, but also for dentists & staff, our products are designed and developed to support dentist, forging a bond of trust with their patients. Based on the spirit of Japanese manufacturing, each belmont chair is the result of more than 50 years of product research and development, meticulous engineering expertise and innovative production methods.
Through our worldwide network of offices and subsidiaries, Belmont continually monitors current industry and market needs as we strive to design and introduce high quality, creative products that help increase work efficiency and productivity.
MENA DISTRIBUTORS BAHRAIN
MEDICAL & PHARMACEUTICAL SERVICES CO. W.L.L. Tubli Area, Flat No. 16, Building No.111, Road No.13, Block 711, Manama Phone: +973 17 71 57 85 email@example.com
SAFWAN EGYPT 41, 10 Lebanon St., Mohandessen, Giza Phone: +20 2 33 02 27 92 firstname.lastname@example.org
ARDIN CO. 2nd Floor, No.86 Darya BLV Saadat Abad, Tehran Phone: +98 21 88 73 70 04 email@example.com TASVIR TEB HUMERS Unit 16, No.31, Mollasadra St, Tehran Phone: +98 21 22 22 91 55 firstname.lastname@example.org
NASEEM BAGHDAD COMPANY FOR MEDICAL & LABORATORY EQUIPMENT TRADING LTD. Al-Mansoor, Hay Dragh, Block No.603, Street No.17, Building No.11, Baghdad Phone: +964 1 54 81 25 email@example.com
KHOURY DENTAL EST. P.O. Box 306 Ammam Phone: +962 65 82 70 15 firstname.lastname@example.org
DENTMED (K) LTD 3rd Floor, Darshan Towers, Woodvale Grove, Westlands, P.O. Box 43873, Nairobi, 00100 Phone: +254 2 04 44 53 07 email@example.com
AL-SAYAFE MEDICAL & PHARMACEUTICAL SUPPLIES CO. W.L.L Behind Hajji Maarfie Clinic Block 2, Street No.73, Building No.98 Fourth Floor Bnaid Al Gar Phone: +965 22 45 49 24 firstname.lastname@example.org
FIMALCO DENTAL Mazraa-Mar Elias Street-Hariri Center 1st Floor, Beirut Phone: +961 1 30 24 32 email@example.com
MEDICAL& PHARMACEUTICAL SERVICES CO. L.L.C Al Qurum, Behind Sultan Centre Bldg. P.O. Box 209, 116, Muscat Phone: + 968 99 88 36 35 firstname.lastname@example.org
MEDESOLE WLL 3rd Floor, Building No.73, Street No.930, Bin Mahmoud, Doha Phone: + 974 44 35 80 37 email@example.com
MEDICAL & PHARMACEUTICAL SERVICES BASHIR SHAKIB AL JABRI & CO. LTD Rehab District, Palestine Street, Jeddah Phone: +966 1 26 70 04 30 firstname.lastname@example.org
RASD Medicines & Medical Equipment Import No.761, Block 22, Altaif, Khartoum Phone: +249 1 83 52 79 email@example.com
RADMED MEDICAL COMPANY No.344 Block 1, Al sitteen street, al jureif west khartoum Phone: +249 1 55 77 49 02 firstname.lastname@example.org
BH CO. DENTAL SUPPLIES Next to France Embassy, Al-Jusser AL-Abeead, Damascus Phone: +213 1 13 33 38 79 basel.hashem.co.gmail.com
MED PRO TUNISIA Building Integram Ang street Mexico & Argentina street 4et office No. 4 1002 Tunis, Belvedere Phone: +216 21 65 16 32 email@example.com
LIDER DIS Fevzi Cakmak Sokak No:11/5 Kizilay, Ankara Phone: +90 31 22 31 64 85 firstname.lastname@example.org
UNITED ARAB EMIRATES
CITY PHARMACY CO. P.O. Box 2098 Airport Rd., Abu Dhabi Phone: +971 26 32 30 16 email@example.com
YEMEN STORES FOR DRUGS & MEDICAL SUPPLIES P.O.Box 1465 Alzybairy Street, Y.R. Sana’a Amman St. Phone: +967 1 53 26 27 firstname.lastname@example.org
Company name: BISCO, INC. Country of origin: United States of America Website: www.bisco.com BISCO, a global leader in aesthetic dentistry continues to develop innovative products for contemporary dentistry. At BISCO “Adhesion is our passion” and we dedicate our lives to understanding and improving the bond. We understand the importance of the supporting layer of the restoration. Whether you are working with implants, zirconium, ceramics/lithium disilicate, or porcelain fused to metal we focus on dentistry from the bottom up so your patients can enjoy top down esthetics.
BISCO proudly manufactures its materials in the United States and markets its products through highly trained, focused distributors outside the United States. At BISCO, we understand that product quality, consistency and freshness are of great importance. BISCO Dental Products are available worldwide with award winning brand names such as ALL-BOND UNIVERSAL®, AELITE ™, DUO-LINK UNIVERSAL™, TheraCal LC ®, TheraCem® and Z-PRIME ™ Plus.
MENA DISTRIBUTORS EGYPT
ALEX DENT 31 El Rashidi St., Kasr EL Ainy Shaheen Medical Mall, Cairo Phone & Fax: (20100) 140-6378 email@example.com
ALPHA MEDICAL Shareq, Ahmed Al Jaber St. Dasman Complex, Block 1 9th Floor, Office 22 Code: 35153, Dasmah Phone: 965-2-2478611 firstname.lastname@example.org
NASSER TRADING & CONTRACTING Salwa Rd, Midmac Roundabout, Nawar Building, Doha Phone: (9744) 466-5409 email@example.com
IRAN DONYAYE KALAYE SINA (DKS) CO. #1, No.9 Vernous St. Keshavarz Blvd. Tehran 1415953131 Phone: 98-21-88998248 firstname.lastname@example.org
IRAQ MZK DENTAL PRODUCTS Platin Pharma Scientific Drug Bureau, Alsaadon, Almushajar street, Baghdad Phone: +964-7901454584
LEBANON DENTAL MEDICAL SUPPLIES - DMS Lebanon - Sed el Bouchreih Imad el Hachem Center, 2nd Floor, Beirut Phone: (961) 124-0444 email@example.com
AL RADWAN GROUP Dat Elmad complex, tower NO 5, H7 first floor, Tripoli Phone: (21891) 900-1106 firstname.lastname@example.org
BASAMAT MEDICAL SUPPLIES 125 Al-Razi Street Jabal Al-Hussein, Abdali Area Amman Phone: 962-6-5605395 email@example.com
DENTAL EXPERT Rue Ibnou Katir Lot 7, Maarif Extension, Casablanca Phone: (21262) 350-5758 firstname.lastname@example.org
SAUDI ARABIA CIGALAH BIO MEDICAL 5th. Floor, Al-Ma’moun Tower, Ali Bin Abi Taleb Street, Al-Sharafiyah District, Jeddah Phone: (96612) 231-6194 email@example.com
TUNISIA L’EXCELLENCE MEDICALE Avenue des Martyres, IMB Palmaruim 4 B71, Sfax 3000, Tunisia Phone: (2163) 153-8072 firstname.lastname@example.org
UNITED ARAB EMIRATES BIO LINK MEDICAL AND SURGICAL TRADING Office 301& 302, 3rd Floor Jumeirah Terrace Building, 2nd December St., Jumeirah 1, Dubai Phone: 971-4-3596242 email@example.com
YEMEN EZ DENTAL MATERIALS & SUPPLIES Mujahid St. Sana’a Phone: (96777) 022-2319 firstname.lastname@example.org
Dual-Cured Resin Modified Calcium Silicate Pulpotomy Treatment TheraCal PT is a biocompatible, dual-cured, resinmodified calcium silicate designed for pulpotomy treatment. TheraCal PT maintains tooth vitality by performing as a barrier and protectant of the dental pulpal complex.
from recurrent decay and other restorative materials. TheraCal PT’s physical properties resist breakdown and degradation leading to a durable seal. TheraCal PT is also indicated for direct and indirect pulp capping (liner) and as a base.
TheraCal PT’s chemical formulation consists of synthetic Portland Cement calcium silicate particles in a unique hydrophilic matrix which facilitates calcium release. TheraCal PT is radiopaque allowing for easy identification and differentiation
BISCO’s THERA brand includes TheraCal LC, TheraCem and now TheraCal PT. BISCO believes that better dentistry can be achieved when practicing the THERA way.
BISCO’s Dream Team BISCO’s is committed to solving clinical challenges through extensive research and product chemistry that ensure our team of restorative solutions not only work well, but perform well together. This award-winning group of restorative solutions is effective, universally compatible, easy to use and worry-free.
TheraCal LC is a light-cured, resin-modified calcium silicate. Its unique apatite stimulating ability makes it ideal for direct and indirect pulp capping and as a protective liner.
Z-PRIME Plus is a single-component priming agent used to enhance adhesion between indirect restorative materials and composite resin cements.
ALL-BOND UNIVERSAL® BISCO’s All-Bond Universal allows you to standardize clinical protocols for effective delivery of adhesion with a single-bottle.
Delivering a strong bond to zirconia and most substrates, along with easy clean up and high radiopacity, TheraCem® offers clinicians an effortless, reliable and durable cementation of indirect restorations. Yearbook 2021
Company name: DenMat Country of origin: United States of America Website: www.denmat.com Since 1974, DenMat has been a leader in high-quality dental products for dental professionals in more than 60 countries around the world. DenMat makes and assembles most of its products at its world headquarters on the Central Coast of California. DenMat offers three main product categories: Consumables, Small Equipment, and a full-service Dental Laboratory. DenMat’s consumables include the brands known and trusted: Geristore®, Core Paste®, Tenure®, Ultra-Bond®, Infinity®, Splash®, Precision®, Perfectemp®, and LumiBrite® and infection control. DenMat’s small equipment includes a broad suite of products, including NVpro3™,, and SOL™ soft-tissue diode lasers, Rotadent® PeriOptix™ magnification loupes and lights, Flashlite™ curing lights, & VizilitePRO for oral lesion screening. DenMat is the home of the world’s #1 patient-requested thin veneer, Lumineers®. Now better than ever and backed by
Thinnovation®: DenMat’s fresh multi-disciplinary approach to anterior esthetics using the latest generation of Lumineers, all hand-finished by skilled lab artisans in California. DenMat also features Snap-On Smile®, the ultimate provisional appliance. Each of DenMat’s more than 400 employees is focused on assuring that you—our dental customers—love our products and love your customer experience. We’re building one of the world’s great dental companies—one happy dentist at a time!
MENA DISTRIBUTORS www.denmat.com
For all inquiries please contact us: email@example.com
LumiPro® Headlight System
Maximize clarity, ergonomics and control The LumiPro® provides an unmatched output of uniform and natural bright light, and features an enhanced spot size to illuminate the entire oral cavity. This innovative headlight is notably smaller and lighter than previous models. Combined with this high-definition headlight is a sleek, new powerpack that provides a long-lasting charge of 10+ hours. Thanks to soft-touch on/off and intensity adjustments, this powerpack reduces the need to deglove — giving users greater convenience and control.
LumiPro Features • Uniform output of natural, bright light • Enhanced spot size to illuminate the entire oral cavity • Significantly smaller and lighter than most headlights in the market • Easy-to-use soft-touch on/off and intensity adjustments to reduce the need to deglove • 10+ hours of run time on high
Company name: Dentsply Sirona E-mail: MEA-Marketing@dentsplysirona.com Website: dentsplysirona.com Dentsply Sirona is the world’s largest manufacturer of professional dental products and technologies, with a history of innovation and service to the dental industry and patients worldwide. Dentsply Sirona develops, manufactures, and markets a comprehensive solutions offering including dental and oral health products as well as other consumable medical devices under a strong portfolio of world class brands. As The Dental Solutions Company™, Dentsply Sirona’s products provide innovative, high-quality and effective solutions to advance patient care and deliver better, safer and faster dentistry. With a sales presence in more than 120 countries, patients and practitioners virtually everywhere in the world rely on Dentsply Sirona.
MENA DISTRIBUTORS For a full list of Dentsply Sirona authorized distributors in the Middle East & North Africa please visit bit.ly/DSMENA-Distributors or scan the QR code
Neo Spectra™ ST Our decades of innovation in composite materials taught us what matters most to dentists. Neo Spectra™ ST is the successor of ceram.x® SphereTEC™ one, now a complete portfolio covering the full range of handling preferences and aesthetic needs with a single product line. SphereTEC® filler technology offers optimised performance in the areas that matter most, helping clinicians to achieve reliable, aesthetic results efficiently. What’s new? Two universal composite handling options.
Features and Benefits
Neo Spectra™ ST composite offers optimised handling in a creamy and spreadable Low-Viscosity (LV) or a firm and packable High-Viscosity (HV) to accommodate your preference and technique for placement efficiency.
• Novel SphereTEC™ filler technology. • Exceptional handling comfort! Easy to adapt to cavity walls, margins and surfaces, no stock to the hand instrument, precise to sculpt, slump resistant and easy to extrude. • Extremely simple Cloud shade concept. • Exciting clinical results made easy. • Fast and easy polishing. • Extra glossy. • Great mechanical properties. • Excellent choice for long-lasting restorations.
For more information visit: dentsplysirona.com/neo-spectra
Digital Impression with Dentsply Sirona Primescan and Omnicam The basis for best treatment results is the precise depiction of reality in a virtual model. With Primescan, intraoral scanning delivers excellent results like never before. It opens a world of possibilities for you - decide for yourself which way you want to take. Simply scan and send with a click - to whom you want. Work as usual with your lab and the partners of your choice - with open data formats or in a validated, secure workflow. Whether in prosthetics, implantology, orthodontics or other areas - stay flexible. Take the first step and let us accompany you on your individual path to digital dentistry. Make your workflows better, faster, and safer with digital impressions by Dentsply Sirona.
Primescan AC Redefine your standards of outstanding accuracy and speed: Primescan enables all kinds of treatment, from single tooth to full arch. With Primescan intraoral scanning is now more accurate, faster and easier than ever before.
Omnicam AC In addition to the new superstar Primescan, the proven Omnicam is a real alternative. Omnicam is still one of the smallest scanners available. It is therefore particularly easy to handle, scans powder-free and in colour. For more than seven years, it has impressed users worldwide and is always up to date thanks to continuous software updates.
Omnicam AF New to the MENA region the Omnicam AF comprises the individual components of Omnicam including camera tray and PC. With more than 7 million scans per year, Omnicam is one of the most widely used scanners on the market â&#x20AC;&#x201C; now with the option of the Acquisition Center (AC) and the flexible tabletop unit (AF). For more information visit: dentsplysirona.com/digital-impression
Company name: Ultradent Products Inc. Country of origin: Salt Lake City, UT (USA) Website: www.ultradent.com Ultradent Products Inc. was founded in 1978 in Salt Lake City by Dr. Fischer dentist, researcher and university professor (now Founder & CEO Emeritus of Ultradent Products, Inc.) with the aim of improving the techniques and products used by dentists in the entire world, in order to solve patient problems faster and without invasive methods. Now, marking its 41st year as a family-owned, international dental supply and manufacturing company, Ultradent has continued its vision to improve oral health globally by creating better dental products that continue to set new industry standards.
Ultradent currently researches, designs, manufactures, and distributes more than 500 materials, devices, and instruments used by dentists around the world, has subsidiaries in 9 countries and sells products in over 125 countries. Ultradent also works to improve the quality of life and health of individuals through financial and charitable programs.
MENA DISTRIBUTORS ALGERIA
MAGHREB DENTAL INDUSTRY EURL Lot no 24, Zone de depot El Kerma, Oran Phone: 00 213 40 23 71 45 firstname.lastname@example.org
SMART DENT Almansoor street, beside zain communication bldg Bldg no. 3 Floor 2, Baghdad Phone: (00)7810775922 email@example.com
AFGHANISTAN MUHAMMAD AHMAD SABAWOON LTD Khushal Kan, Mina Block 32, Muqabil Sello, Kabul Phone: 0788-775555 firstname.lastname@example.org
BAHRAIN DENTAL WORLD & MEDICAL SUPPLIES Flat 15 bldg 285 block 706 P.O. Box 32013, Bahrein Phone: (00)973 (178) 96322 email@example.com
QATAR CEDARS DENTAL CENTER P.O. Box 47684 Al Hilal, Doha Phone: (00)974.44864088 firstname.lastname@example.org
ADVANCED TECHNOLOGIES Hawali 32060, P.O.Box 44558 Kuwait City Phone: (00)962795533513 email@example.com
DENTAL ERA Al-Abdel Latif Plaza, King Fahd Rd, 3RD Floor, Office # 306 P.O. Box 126122, Jeddah Phone: +966 12 2752 382 firstname.lastname@example.org
PM DENTAL Phone: (00)35722594050 email@example.com
ALBYAN ALMOTAGADED FOR IMPORTING OF EQUIP & MEDICAL SUPPLIES CO LTD Mohd Fkini St., Bldg No. 20, PO Box 82525, Tripoli Phone: (21) 333-3021 firstname.lastname@example.org
IRAN GOLNAR NIKAN DANDAN Unit 9, #64 Building, Opp Bahar St, Enghelab Ave P.O. Box: 1148836873, Tehran Phone: (00)9821 77533716 email@example.com
BILAL ENTERPRISES Chughtai1@hotmail.com
MALEK DENTAL & MEDICAL SUPPLY jo 75 Al Buhturi Street, 2nd Circle, Jabal Amman, P.O. Box 7067, Amman Phone: (00)7810775922 firstname.lastname@example.org
ELWAN DENTAL SUPPLIES 70 Merghani street 10th floor Managger, Cairo Phone: (00)202.33873883 email@example.com
PAK-MED DENTAL SUPPLIES firstname.lastname@example.org Phone: (00)92 52 325 722
MOROCCO A.M.E.D. 47, Rue de bruxelles, Casablanca Phone: (00)212.522823134 email@example.com
OMAN PIONEER TRADE & MEDICAL SUPPLY Khalid Al Said Investment Co. PO Box 77 PC 103, Muscat Phone: (00)68 9780 4272 firstname.lastname@example.org
SYRIA BADRIG AYDENIAN Shouhada street, Damascus Phone: (00)963 (11) 444 6429 email@example.com
TUNISIA DISTRI MED Av. De Madrid, Tunis Phone: (+216) 71 334 812 firstname.lastname@example.org
UNITED ARAB EMIRATES ELWAN TECHNICAL SUPPLIES P.O. Box 43305, Abu Dhabi Phone: (00)97126393292 email@example.com
Opalescence™ PF Whitening for Aligners New Opalescence™ PF Whitening for Aligners kit has all the benefits of the original Opalescence™ PF whitening and is ideal for use with orthodontic aligner trays. It is available in a convenient, portable 4-syringe kit so patients can carry their whitening gel with them and whiten at their convenience. You don’t have to create custom trays for patients who want to use Opalescence whitening, they place the whitening gel in their orthodontic aligners, allowing them to brighten and straighten their smile at the same time! • Ideal for use with orthodontic aligner trays • Features the same great benefits of our award-winning Opalescence™ PF formula • Available in 10% concentration for day or night wear • Regular flavor Opalescence™ PF for Aligners kit joins the award-winning line of dental whitening products Opalescence™ that increasingly becomes the ideal partner to completely improve the aesthetic of the smile.
Umbrella™ Tongue, Lip, and Cheek Retractor The Umbrella retractor is designed with a priority on ease of placement and patient comfort. To use the Umbrella retractor, a clinician simply presses the two tabs together, places it in the patient’s mouth, and it pops open. This retractor helps the patient’s mouth stay open in a natural and comfortable range while still allowing for the patient to fully open or close as needed. The retractor also opens the space between the teeth, lips, and cheeks in a way that encourages saliva to accumulate away from dentition and improves access for HVE. A new, innovative tongue-retraction design allows the tongue to comfortably rest behind the tongue guard. The Umbrella cheek retractor is ideal for a variety of procedures that require clear access without compromising patient comfort.
Company name: W&H Dentalwerk Bürmoos GmbH Country of origin: Austria Website: www.wh.com W&H - People Have Priority Headquartered in Bürmoos, Austria, the international W&H Group is a global leader in the development and manufacture of medical technology products. Passion and innovation are the motor of the company. High-quality product and service solutions, a modern corporate structure, a strong focus on research and development as well as social responsibility make W&H a locally and globally successful family business.
More than 1,200 employees contribute to the production of hardware and software products for use in the dental and medical industries. The precision instruments and high-end solutions are developed and produced at sites in Austria, Italy and Sweden. With worldwide subsidiaries and a comprehensive network of distribution partners, W&H is represented in 130 countries. The company’s focus is on export. Key sales markets include the USA, Europe and Asia.
MENA DISTRIBUTORS ALGERIA
PROMODENTA S.A.R.L. 21, Rue Boumenir Mouloud 26000 Médéa Algier Phone: + 213 550542182 firstname.lastname@example.org DENTAL QUEST 41, Rue Cheriet, Ali Cherif 31024 Oran Phone: +213 41332784 email@example.com
GULF COOPERATION FOR TECHNOLOGY Bldg No: 2038, Road: 4156, Block 341, Juffair, P.O. Box 2576, Manama Phone: +973 17239399 firstname.lastname@example.org
IMECO 4, Mohamed Moussa St., Azarita Alexandria Phone: +20 3 4871264 email@example.com 1, Mathaf El Manial St., El manial Cairo Phone: +20 2 25328679 firstname.lastname@example.org
APADANA TAK 45, Ghods Ave, Keshavarz Blvd, Tehran Phone: +98 2188965650 email@example.com PARSEH ETTIKAL CO. Suite#9, #329, Niavaran, Theran Phone: +98 2188545400 firstname.lastname@example.org
DHUA AL MUSHKAT COMANY Building 206/3/93-Khanzad, Kais Hachim Assaf, Erbil Phone: +964 7707437760 email@example.com
TRIDENT s.a.r.l. Moussa Farhat Center, Voie 13 Postal Code 4503 3003 Byblos Phone: +961 (9) 550750 firstname.lastname@example.org
UNITED ARAB EMIRATES
MEDICA GROUP Business Bay, Al Khaleej Al Tejari 1 Street, Vision Tower, 38th floor P.O. Box 31135 - Dubai Phone: +971 4 437 0669 email@example.com
ARAB MEDICAL & SCIENTIFIC ALLIANCE (A.M.S.A.) Khalil Salem Street - P.O. Box 2509 Tela’ Al-Ali, 11953 Amman Phone: +962 65528009 firstname.lastname@example.org ADVANCED TECHNOLOGY COMPANY Salem Al Mubarak Str., Salmiya, Cnr. Bahrain Str. - Block 62a, opp. Laila Tower, P.O. Box 44558, 32060 Hawally Phone: +965 22247240 email@example.com DENTAL SHARES s.a.r.l. Beirut-Sin El Fil-Tourass Bldg. 4th Fl P.O.Box 165597, Achrafieh-Beirut 1100-2050 Phone: +961 (1) 490990 firstname.lastname@example.org
ALBYAN ALMOTAGADED FOR IMPORTING OF EQUIPMENTS & MEDICAL SUPPLIES Equipments & Medical Supplies P.O. Box 8252, Mohamed Fkini Street Tripoli - Phone: +218 925088549 email@example.com LE MEDICO DENTAIRE S.A.R.L 22, Rue Ahmed Almaqri Racine 20050 Casablanca Phone: +212 22393433 firstname.lastname@example.org
ACCROS TRADING COMPANY P.O.Box 23006 - Doha Phone: +974 44816511 email@example.com
BAHWAN HEALTHCARE CENTRE LLC Al Rawaq Building, Second Floor, Street No. 58, Office 207 Building no 7, Al Qurum, Muscat Phone: +968 24650767 firstname.lastname@example.org AL-TURKI MEDICAL GROUP LTD (A.M.G.) Al-Turki Bldg. 46, Al-Bohtory St. off Al-Ahsa St., Al-Zahra District, P.O. Box 4952 Riyadh 11412 Phone: +966 4766828150 email@example.com OUZOUN TRADING CENTER Al-Telyani Av., Omar Al-Moukhtar, St. Alhabal Building, Damascus Phone: +963 114430548 firstname.lastname@example.org DISTRI-MED 24 Av. de Madrid, 1000 Tunis Phone: +216 71334812 email@example.com PRIME MEDICAL SUPPLIES EST. P.O. Box 44633, Abu Dhabi Phone: +971 26666037 firstname.lastname@example.org
AL-ZOMALA’A DENTAL CO. Taiz St. Opposite to Nasser workshop P.O.Box 15210, Sana’a Phone: +967 1472787 email@example.com
Constant innovation that inspires Innovative, high-performance and visually appealing – that’s the Synea range. As an important standard feature in dental practices, the Synea products provide users with safety and efficiency in their everyday use. Packed with innovation, Synea has been facilitating constant improvements in dental treatment for more than 20 years. Products bearing the Synea brand name combined with a slim profile, an elegant monobloc design and reliable performance began securing a place for themselves in dental practices all over the world as far back as 1998. After this initial success, one technical highlight followed the other hard on the heels. The first Synea generation cast its spell over dentists with its elegance and monobloc design in 1998.
W&H was the first manufacturer in the dental industry to integrate the LED into a turbine head. Finally, the light was where it was needed the most – close to the treatment site. But that wasn’t enough. With its 5x Ring LED+, integrated into the small head of the Synea Vision turbine, W&H underlined its position as the technology leader once again in 2014 and offered dentists a shadow-free view of the treatment site. With W&H’s LED innovations, dentists benefit not only from improved light conditions, but also from reliable functionality even after multiple hygienic reprocessing such as sterilization.
A must-have for every dentist With the sterilizable 5x Ring LED+, integrated in the small head of the Synea Vision turbine, W&H underlined its position as the technology leader in 2014. Dentists benefit from a shadow-free view of the treatment field.
Synea – a synonym for top quality “Made in Austria” meets the high standards placed on dental preparations. W&H has proven with innovative highlights that the company is a master of its craft and even capable of rendering the impossible possible. The focus is always on advancing the dentist’s work. Perfect combination of revolutionary technology and high quality service has allowed W&H as a reliable partner to set new standards in dental practices around the world. Synea products are and always have been the must-have for every user.
The head of the red contra-angle handpiece grew smaller with each of the three Synea generations. Today, compact dimensions ensure improved flexibility within the limited confines of the oral cavity. Dental News
Primary care of
• Unbeatably durable: Fully withstands masticatory forces, excellent physical properties1
13 miliolinos n restorat 2 worldwide!
• Unbeatably simple: Universal shade with chameleon effect, 4 mm bulk fill • Unbeatably quick: Exposure time of only 10 seconds (x-tra fil), applied in one layer – only 35 seconds total working time (Futurabond M+)
Tiba A et al., Journal of American Dental Association, 144(10), 1182-1183,2013.
based on sales figures
VOCO GmbH · Anton-Flettner-Straße 1-3 · 27472 Cuxhaven · Germany · Freecall 00 800 44 444 555 · www.voco.dental
Digital Dentistry Your Way Henry Schein ConnectDental® Making the right solutions work for you
• Most comprehensive line of digital materials: anterior, multi, 16+, Acetal, and more • Exceptional restorations that are aesthetic, strong, and metal-free
• Highly automated wet and dry milling and grinding • Utmost precision with maximum stability regardless of material
Rely on Us for innovative and efficient milling solutions
• High Temperature Furnace up to 1.506°C for outstanding results • Space for all common bridge sizes or up to 40 units in level
For more information about our Henry Schein ConnectDental Trusted Digital Solutions, please contact your local Henry Schein dealer or Ghassan.Nasser@henryschein.com or Rami.Aburadwan@henryschein.com