Tidens hurtige gang er altid vanskelig at forstå. Det er for eksempel ikke til at forstå, at 2015-udgaven af Aktuel Nordisk Odontologi er den 40. udgave af årbogen, der dermed grundigt har dokumenteret sin berettigelse. Baggrunden for denne bog er, som sagt flere gange før på dette sted, de mange kompetente forfattere, der så positivt har takket ja til at bidrage med artikler, hvori de lader kollegerne få del i deres erfaringer. Stor tak til dem.
Pelle Guldborg Hansen, Johannes Schuldt-Jensen & Andreas Rathmann Jensen
Good dental practice is as much about behaviour as technical treat-ments and expertise. Most importantly, successful dental practice requires trivial compliance from the patients, but this is often ob-structed in complex ways by patients themselves. In this article, we outline the classical approach to behaviour change and argue that interventions should be rooted in proper diagnoses of non-com-pliance, rather than in the rationality-based assumptions of this framework. We then argue by illustration for the relevancy of be-havioural sciences in dental practice and identify three specific, ex-perimental insights from the behavioural sciences that may easily be applied and tested. The three examples illustrate the habit of flossing regularly, how to reduce no-shows in patient treatments by introducing proper commitment devices, and how experiments on retrospective pain experience may relate to retention.
Cecilie Gjerde & Nils-Erik Fiehn
A tooth can be a threat to us in three different ways; in itself, via the pulp and the periodontal ligament, and when it is removed.
Using teeth as a biting tool may cause lethal bite wounds, but may also introduce bacteria into the tissues, and thereby infections.
The oral cavity is the entry to the gastrointestinal tract, to the airways, and to our immune system and has several defense mechan isms against infections. The local, oral bacteria are import-ant in the defense against exogenous bacteria when in a hemostasis with the host, but may also act opportunistically and cause infec-tions. Serious infections in teeth or jaws are rare after the introduc-tion of antibiotics and improved oral care, but they can still be life threatening if not treated properly. Proper, clinical diagnosis and pus evacuation is of critical importance, and hospitalizing must be considered in serious cases.
Complications when removing the tooth is best avoided and handled through a thorough medical history and clinical examina-tion. The operators’ clinical skills and expertise are important.
Identification of unknown, odontogenic foci is a challenging task for a dentist. However, the task is important, as a number of pa-tients with affected general health have a odontogenic focus. A clear example of this is indocarditis which appears to be caused by bacteremia – a life threatening condition. In many cases, oral bac-teria are involved which underlines the importance of identifying the foci.
The problem must be solved in a systematic manner. The jour-nal is the foundation, containing a complete anamnesis and a thor-ough, clinical examination. The findings are supported by an x-ray examination, and a cone-beam scanning is a valuable tool if a con-ventional x-ray examination is not sufficient. However, to interpret and understand the findings, knowledge of the anatomy in the re-gion is important.
This chapter contains three examples of identification of un-known foci.
Osteonecrosis of the jaws (ONJ), in layman’s terms “dead bone” or “dead jaw”, is a severe complication to anti-resorptive treatment with bisphosphonate, denosumab, and certain chemotherapeutic drugs. These drugs are used against osteoporosis and various malig-nant conditions (breast cancer, prostate cancer, multiple myeloma) with metastases in the skeleton. ONJ can cause pain, loss of teeth and parts of the jaws, and loss of masticatory function. Thus, ONJ is a severe cancer related complication, or ostoporosis treatment complication. ONJ was first reported in 2003, and during the last 10 year, a large number of cases have been reported worldwide.
Inger Sofie Dragland & Hilde Molvig Kopperud
Chitosan, a natural, carbohydrate polymer derived from the de-acetylation of chitin, is the second most common polymer found in nature after cellulose. Chitosan is produced commercially from crab and shrimp shell wastes with different degrees of deacetylation and molecular masses. Because of chitosan’s promising biological acti-vities, including non-toxicity and antimicrobial activity, it is used for a variety of purposes in food production, medicine, agriculture, cosmetics, and biotechnology. The mechanism behind chitosan’s antimicrobial activity is still somewhat uncertain. The main theory is that positively charged amino groups of chitosan participate in an electrostatic interaction with negatively charged groups in the cell surface of bacteria, resulting in damage to the cell wall, influencing the permeability or barrier properties.
Resin composites are now the most used dental restoration material in the Nordic countries. Annual failure rate for composite fillings seems to be 1-3 %, but individual studies have reported higher numbers. The main reason for the replacement of composite fillings is the development of secondary caries. To prevent such a development, experiments with antimicrobial agents incorporated in resin composites are carried out. Chitosan has shown an antimi-crobial effect against oral bacteria and is tested for the use as an antimicrobial agent in composites and other dental materials and oral hygiene products.
Anne-Lise Maseng Aas, Tove I. Wigen & Anne B. Skaare
Traumatic injuries to permanent teeth are common. Correct emer-gency treatment may be decisive for the prognosis of the injured teeth. Adequate clinical and radiographic examinations are neces-sary to make correct diagnosis, which is the basis for choice of im-mediate treatment and the next follow-up. In this article, a syste-matic examination of the dental trauma patient in general and the emergency treatments of three types of injury, complicated crown fracture (enamel-dentin-pulp fracture), root fracture, and avulsion, are described. In case of complicated crown frac ture, partial pulpo-tomy should be the first choice of treatment. Root frac ture has good prognosis, and root canal treatment should only be performed in the coronal segment when there are signs of pulp necrosis. Hand-ling of the avulsed tooth at the site of the accident and immediately after the avulsion is of utmost importance for the long-term prog-nosis. All dentists should be able to provide immediate treatment to a dental trauma patient. The follow-up to dental injuries requires both knowledge and skills.
Torgils Lægreid & Harald Gjengedal
Many different materials and techniques are available for restoring posterior teeth. As a result, the clinical decision-making is challeng-ing as the influence of several factors related to the tooth, material, patient and operator must be taken into consideration. There are great variations among dentists’ clinical decisions, but the overall philosophy should be minimally invasive and biological and the focus ideally should move from longevity of the restoration to long-evity of the tooth. The first choice should be the least invasive: direct composite. Neither literature nor the user manuals from the manufacturers place any restrictions on the extension of composi-te restorations. However, if there are technical difficulties in using proper matrix technique or achieving acceptable anatomic contour, or if parafunctional activities are present, indirect restorative tech-niques should be considered.
John E. Tibballs & Bjørn Einar Dahl
With equipment for computer-aided design and manufacturing (CAD/CAM) in the dental office, the dentist again becomes his own dental technician. While the equipment itself is not subject to health-related regulation, the European Medical Devices Directive imposes requirements on the prosthodontic devices it produces. As a manufacturer of custom-made, medical devices, the dental offi-ce is required to document its ability to ensure that the produced prostheses function satisfactorily, and that any failure to meet the defined quality criteria is followed up systematically.
The capability to analyse the cause of failure is essential to the systematic improvement of quality. In the face of market forces favouring interoperable components rather than a vertically in-tegrated CAD/CAM system, this requirement places an increased responsibility on the dental office to use the comprehensive data generated by the CAD system to understand the reasons for a cli-nical failure or the need for rework of a prosthetic device, and to prevent recurrence of the problem. Frequently, knowledge of the behaviour of materials both during production and in the finished prosthesis is needed in order to attain the necessary understanding of sub-optimal, clinical performance.
Louise Hauge Matzen & Ann Wenzel
A radiographic examination is meant to support the clinical exami-nation of mandibular third molars aiding the surgeon to establish a treatment plan. When deciding on which radiographic method to use, the ALARA-principle should always be kept in mind, and for most general dental practitioners a periapical examination is the only available method in the clinic. Studies have shown however that in around 25 % of the cases, it is impossible to obtain a suf-ficient periapical image; therefore panoramic imaging is the sta-te-of-the-art method where this unit is available. In cases of over-projection between the third molar and the mandibular canal in the panoramic image and specific signs that a close contact exists between the molar and the mandibular canal, an additional 3D radiographic examination (CBCT) may be indicated to explore if there is direct contact between the third molar and the mandibular canal indicated by no bony separation between these structures. A direct contact as seen in CBCT-sections has been shown to be the most important factor with an impact on deciding on performing a coronectomy instead of removing the whole tooth. Studies, where the full tooth was removed seem to indicate, that the use of CBCT does not change the outcome for the patient with regard to sensory disturbances to the inferior alveolar nerve and moreover, the costs and the radiation burden to the patient are higher for CBCT than for conventional 2D methods.
In conclusion, periapical or panoramic imaging is sufficient in most cases before removal of mandibular third molars, but CBCT may be suggested when one or more signs for a close contact be-tween the tooth and the canal are present in the 2D conventional image – if it is believed that CBCT will change the treatment or the treatment outcome for the patient.
Søren Schou, Odd Carsten Koldsland, Martin Saaby, Tord Berglundh & Flemming Isidor
The occurrence of peri-implantitis has been assessed in several stu-dies. Huge variations in the prevalence of peri-implantitis have been reported, mainly due to variations in the patients included in the studies as well as in the definition of peri-implantitis. Peri-implan-titis seems to be a significant clinical problem due to the increas-ing use of implants, especially in patients with various known risk factors. In addition, treatment of peri-implantitis is still complex and unpredictable, especially when advanced peri-implantitis le-sions have developed. Moreover, the peri-implantitis lesion may be so advanced that implant removal is the only treatment modality available. Due to the advanced peri-implantitis-induced alveolar bone loss, complex bone regenerative procedures are frequent-ly required before new implants can be inserted. Therefore, early diag nosis and adequate treatment of peri-implantitis are extremely important to minimize the risk of advanced disease development. Moreover, focus on known risk factors is also important, including meticulous infection control before implant treatment in patients with tooth loss due to periodontitis, optimal implant treatment, op-timal oral hygiene, and a systematic maintenance care program.
Ingegerd Mejàre, Sofia Tranæus & Thomas Davidson
The practice of evidence-based dentistry means integrating indi-vidual clinical expertise with the best available external clinical evidence from systematic research. Individual clinical expertise means the proficiency and judgment that individual clinicians ac-quire through clinical experience and clinical practice. It follows that a systematic review can help the clinician to gain knowledge about the evidence of a certain intervention or a certain diagnostic method. This article focuses on the rationale behind the systematic review and how it is conducted. The process starts by formulating one or more relevant questions. Inclusion and exclusion criteria are decided regarding study design, population, intervention, control, outcome, and outcome measures. The process then involves litera-ture search and data extraction of relevant, full text articles. Quality assessment of relevant studies, conducted by at least two indepen-dent readers, is performed using quality assessment forms. Based on the quality of the included studies, the results are summarized, and the quality of evidence is formulated. If the effects are uncer-tain, or if the question cannot be answered from existing research, a knowledge gap is present. The identification of such gaps is im-portant because they indicate the necessity of new research. Ethical and health economic aspects should also be integrated in a compre-hensive, systematic review.
Dental fear (DF) is one of the most common specific phobias, and the estimated prevalence in Scandinavia is reported to be 5 % among adults (1) and up to 9 % among children (2). Depending on the severity of DF, the patients are often impaired in the regularity of contact with the dental care, and patients suffering with DF more often experience an inferior oral health compared to other patients (3). The ways of treating DF mainly involves adequate psychologi-cal care, and a successful and well-used treatment is cognitive be-havior therapy (CBT). A meta-analysis which examined DF patients treated with CBT showed a significant reduction of fear, and that approximately 80 % of the treated patients continuously and inde-pendently received dental care (4). Various methods for mea suring DF have been used over the years. Dental Anxiety Scale (DAS) is the most common and well-known measuring tool and it is based on self-perceived grading of DF (5). Other measuring tools have been developed to include a more diverse assessment, for example Index of Dental Anxiety (IDAF) where cognitive, behavioral, emo-tional, and psychological aspects are taken into account (6). Re-search is ongoing to measure dental fear in more objective ways, for example through stress hormone levels in the saliva (7).
Normalt er det tandlægen, der spørger patienten, hvordan det går med tænderne. Men hvordan går det med tandlægerne? Inden for de sidste par år har undersøgelser fra både Dansk Tandlæge For-ening og Dansk Tandplejerforening vist, at tandlæger jævnligt har ondt. 69 % af de adspurgte oplever jævnligt smerter, som er jobre-laterede (1).
Undersøgelserne viser, at de steder, tandlæger oftest mærker ømhed i kroppen, er skuldre, nakke og lænd. Fingre og underarme er også nævnt som områder med hyppige smerter.