Så er der igen adgang til en ny udgave af årets faglige opdatering
for de skandinaviske tandklinikker.
Klinisk anvendelse af fluor, glasionomer og plast i cariesbehandlingen,og artikler om protetiske problemstillinger, herunder om livskvalitetved protetisk rehabilitering, fylder meget i Aktuel Nordisk Odontologi i år. Andre temaer er allergi og anafylaktisk shock, som enhver skal kunne håndtere i klinikken. Halitose er også et aktueltemne, som på trods af stor udbredelse stadig er et tabubelagt.
Der skal også i år lyde en hjertelig tak til de mange skandinavi ske
forfattere, der beredvilligt har stillet deres kompetence til rådighed
for bogen, der herved atter tilbyder en let vej til den nødven dige
Rigtig god læsning!
Evidence for the clinical use of fluoride
The caries-preventive benefits of fluoride are recognized by dental researchers and practitioners worldwide. Fluoride, ranked among one of the globe’s greatest public health achievements, acts locally by affecting the balance between mineral loss and mineral gain in tooth tissues. In high concentrations, fluoride may also act as a metabolic inhibitor in the oral biofilm, thereby reducing ecological acid stress. In recent years, the clinical efficacy has been established through systematic reviews conducted by several Health Techno-logy Agency’s. This chapter presents the evidence for caries pre-vention, using community based, self- and professionally applied fluoride interventions. The quality of evidence was graded in four levels accord ing to the GRADE system; strong, moderate, limited, and insufficient. For primary prevention, twice daily use of fluori-de toothpaste presented the highest level of evidence, irrespecti-ve of age. Professional applications of fluoride varnish 2-4 times a year displayed moderate level of evidence, especially in children/adole scents and frail elderly with root caries. The prevented frac-tion was 24 % for toothpaste and 40 % for varnish. The evidence for the community-based methods was insufficient due to lack of high- quality research. Likewise, for secondary caries prevention, evidence for fluoride was insufficient, forming a gap of knowledge for future research.
Mats Jontell & Palle Holmstrup
Allergic reactions are relatively rare in the dental office. Never the-less, it is important for the dentist to be able to identify allergic reac-tions and to act accordingly. The type of allergic reactions may be immediate (Type I), for instance related to latex, penicillin, or food components, or delayed (Type IV), for instance related to amalgam, gold, palladium, composite, or nickel. In most cases, the clinical features described below are sufficient for the correct diagnosis.
Eva Rye Rasmussen, Jan Tagesen, Kristinna Mey
Anaphylactic reactions can potentially become very severe, and
even lethal, if not treated correctly and in time. Several of the medications
and materials regularly used by dentists may trigger anaphylactic
reactions or shocks in predisposed patients. Deaths due
to anaphylactic shock in the dentist’s chair has repeatedly been
describ ed in the literature. It is therefore essential for dentists to
recognize the symptoms of anaphylaxis and to be familiar with the
treatment algorithm. This chapter describes the epidemiology, clinical
presentation and pathophysiology of anaphylaxis. An updated
overview of the recently proposed treatment algorithm, including
a detailed guide to emergency airway management, is also presented.
Finally, a case of severe anaphylactic shock in a dental setting
is described and discussed.
Alix Young Vik
Halitosis – causes and treatment
Halitosis, also known as bad breath or oral malodour, is a term
used to describe noticeably unpleasant odour coming from the
mouth or respiratory system. This condition is reported to affect
about 25 % of the population on a daily basis. Morning bad breath,
experienced by many upon waking in the morning, most likely
due to local oral conditions, is usually only a temporary problem
that can be easily prevented or treated. However, some cases of
halitosis, especially those associated with extra-oral causes, can be
more chronic and can adversely affect a person’s social and work
situation. Dental health workers regularly meet patients who either
complain of bad breath or have halitosis without being aware of the
situation. Knowledge of the usual causes of halitosis and treatment
methods for oral malodour should therefore be mandatory. In this
short overview, the most common physiological and pathological
oral causes of halitosis will be described, as simple preventiv and
treatment strategies well as possible extra-oral causes. The overview
will present simple, preventive, and treatment strategies with
a focus on the oral cavity.
Ivar Espelid & Jon E. Dahl
Glass ionomer – a suitable restorative
material in deciduous teeth?
Traditionally, amalgam has been used for Class II restorations in
primary teeth, but the use of amalgam has decreased in Scandinavia
during the latest few decades, and now, amalgam has been banned
in Norway and Sweden. Glass ionomer (GIC) adheres to tooth
substance and has been a popular alternative to amalgam, but the
traditional GIC products do not give as high longevity as amalgam
in Class II restorations. As the traditional GIC has been improved
(high viscous GIC), and GIC has been combined with resins (resin-
modified GIC and polyacrylic acid modified composite resin),
the longevity of restorations has improved. GIC containing materials
are technique sensitive. The placing of materials containing
resin should be done in steps when the thickness of the restoration
exceeds 2 mm. Composite can be used as the top layer (“sandwich”).
Uncured resin which may penetrate into the pulp and into
the oral environment represents a potential risk for adverse effects
although no scientific evidence exists so far. GIC contains fluoride
which is released from the restoration. The clinical importance
of this release has been disputed, but it is likely that this fluoride may have some caries preventive effect (secondary caries). Stainless
steel crowns are recommended for restoring extensive carious
lesions in primary molars.
Ana Raquel Benetti & Anne Peutzfeldt
Resin composite restorations in increments or in bulk?
So-called bulk-fill resin composites have been introduced in order
to fill deep cavities in one or two increments, thus simplifying an
otherwise elaborate, incremental restorative procedure. The prerequisite
for the use of bulk-fill composites is their claimed depth of
polymerization of 4 mm, obtained mainly through modification of
the photoinitiator system, thus allowing for placement of layers of
4 mm compared to the conventional 2 mm. This chapter describes
and discusses the composition, the physical properties, and the clinical
use of bulk-fill resin composites. Bulk-fill resin composites are
available in low-viscosity (or flowable) and high-viscosity versions.
Because of the lower filler volume needed to reduce the viscosity,
low-viscosity materials have decreased strength and must therefore
be covered by an occlusal layer of conventional resin composite.
Such a covering layer also alleviates any aesthetic issue caused by
the higher transparency or the limited number of shades of some
low-viscosity materials. Studies of depth of polymerization and
stress formation are still scarce, and results are often contradictory,
hindering the possibility of drawing any clear-cut conclusions. Additional
in vitro data and clinical studies are warranted, and in the
meantime, dentists are advised to apply a sound, critical approach
and stay well within the indications.
Matt Øilo, Ketil Kvam & John E. Tibballs
Fractures in dental ceramics: research and clinical experience
The main problem with ceramics as biomaterials is that they are
brittle. One focus of research and development has been on improving
the materials’ fracture strength and thereby increasing the clinical
success rates for dental, all-ceramic restorations. The most advanced
dental ceramics should, according to in vitro testing, be able
to withstand human mastication forces. Still, fractures occur more
often than we like. Comparison of clinical observations and in vitro
trials seeks to explain how and why these fractures occur. Fractographic
analysis is a methodology used to investigate un expected
failures. Fractures in a brittle material leave tell-tale features on the
fracture surfaces that can reveal both the origin of the fracture and
the direction of crack propagation through the structure. Until very
recently, fractography has only been applied to dental ceramics to a
very limited extent. The method has revealed that fractures which
occur in vivo usually start in the cervical margin, while fractures
that have been produced in vitro usually start occlusally. This explains
the discrepancy between fracture load in vitro and clinical
fracture rates. Through simulation in vitro of clinical fracture behavior,
we gain an understanding that suggests different strategies
for tooth preparation and crown design.
Nils Roar Gjerdet & Vibeke Ansteinsson
“Nano” is a term being increasingly used in marketing of dental
products. A nanometer (nm) is one billionth of a meter (10-9 m),
about 100.000 times smaller than the width of a human hair. Nanotechnology
is the application of processes on the nanoscale to create
e.g. materials with tailor-made properties.
Nanoparticles are nano-objects with at least one dimension between
1 and 100 nanometers. Such particles behave differently than
larger ones, partly due to the high surface/volume ratio. Today, the
main application of nanoparticles in dentistry is to be passive fillers
in restora tive materials, represented by the nanohybrids and nanocomposites.
Still, there is lack of long-term clinical data of “nanorestoratives”.
It appears that they represent an evolution rather
than a quantum leap.
Some materials include nanostructures with active functions;
one example is “nanosilver” used as an antibacterial agent. It is
like ly that the application of active and “intelligent” nanostructures
will increase, e.g. self-assembling mineral structures to obtain
Nanoparticles may cross biological barriers, which could represent
a potential biological risk, but this property could also be beneficial,
for example for targeted drug delivery.
Today’s use of nanotechnology in dentistry is simple, but there
is a formidable potential in diagnostics, prevention, and restoration
of damaged dental tissue.
Ann Wennerberg & Tomas Albrektsson
New surface modifications of oral implants
New implant surfaces continue to attract interest from scientists,
manufacturers, as well as from the implant market. New surface
modifications are commonly related to variations in nanotopography,
chemistry, and/or physical alterations. However, if one factor
is altered, inevitably others may change as well – a nanocoat, for
example, alters topography, but most likely, chemistry and possibly
hydrophilicity will be altered as well. Thus, it is very difficult to
know which individual factor will influence the biological response
to the greatest extent.
Most surface modifications are still aimed at improving the implant
incorporation into the bone, but some articles have been published
on surface variations to improve soft tissue adherence and
to establish antibacterial coats. Several studies report an improved
healing capacity in in vivo experiments, but more studies are required
to clarify the clinical relevance of such innovations.
Fixed Prosthodontics in limited economy
The pricing of fixed prosthodontics is similar within the Nordic
countries, due to tradition in the clinical and laboratory sectors.
Patients are, however, encouraged to seek internet price comparisons
by e.g. the Swedish National Insurance System and the Danish
Dental Association. At the same time, some reluctance against international
dental shopping is detected. However, import of laboratory
products from East Asia has grown considerably due to economy.
Apart from these general aspects, examples are given of cheap and
rational clinical treatments like: acceptance of the shortened dental
arch concept giving the greatest economic gain, fibre- reinforced
composite bridges that are quick, cheap, and reasonably effective,
two-unit bridges that are low price alternatives to removable partial
dentures as well as conventionally extended bridges, resin bonded
bridges that are low invasive, esthetic and cost-effective. Rationalization
is exemplified by one-cast post-crowns, posts and cores and
outer crown on the same master model, crowns in metal, immediate
pontics, and alternatives to precious metal. It is, however,
also discussed that a wider price range between simple cases and
complex risk patients could give a more correct pricing and cheaper
alternatives for the majority of patients.
Harald Gjengedal, Esben Boeskov Øzhayat & Einar Berg
Oral Health related Quality of Life
Oral health related quality of life, as part of the general concept
qua lity of life, is an expression of a person’s experience of and
coping with life, but limited to aspects of oral health. The concept
means different things to different people and is thus difficult to
define, measure and interpret unambiguously, and the measurements
are only meaningful at a group level. Nevertheless, relevant
literature allows some general conclusions to be drawn: Oral health
related quality of life is reduced as the number of remaining teeth
decreases; particularly when tooth loss occurs in the anterior region
of the mouth. Oral health related quality of life may be improved
when lost teeth are restored with a fixed partial denture, but only if
it had been adversely affected prior to the rehabilitation. However,
this improvement appears to wear off in time. For the completely
edentulous, a long term significant improvement is recorded if
their conventional mandibular denture is turned into an overdenture
retained by two implants. Based on this knowledge, prosthetic
rehabilitation should start with a structured interview where the
patient’s individual oral health related quality of life is revealed, so
that an optimal patient treatment may be administered.
Ellen M. Bruzell & Lill Tove N. Nilsen
Safe use of dental laser
Laser is employed for a variety of tooth and oral treatments. Numbers
from a national registry indicate that its use has doubled
during the latest five years. This increase has occurred despite, in
many instances, the lack of evidence of superior treatment outcome
relative to conventional or other new treatments. It is anticipated
that more clinical, high-quality investigations will reveal which laser
treatments are scientifically sound. This chapter includes a brief
review of laser technology, technical data, tissue effects and interactions
and factors influencing penetration depth. Literature examples
compare laser and conventional treatment. These conclude
that the advantage of laser treatment seem to be less post-operative
pain, and that the instrument is preferred by patients. The topic
of laser safety is dealt with in detail because many dental lasers
have the potential to cause injury. As in general phototherapy, the
medical use of laser must be optimized and justified. Laser operators
must adhere to safety requirements and regulations. Injuries on
vulnerable organs, such as the eye, skin, pulp, and respiratory tract
are described. An overview is given of the health professions which
are entitled to use the strongest lasers in medical/dental treatments
in the Nordic countries.