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EuroCondenser Newsletter of the Academy of Operative Dentistry European Section

Vol. 10 Issue No.1. 2008

In this issue: • Editorial – Looking forward and looking backward – Chris Lynch • AODES Geneva 2007:

The future of Operative Dentistry – JF. Roulet Selected abstracts from the AODES 2007 Poster Presentations

• AODES Leuven 2004 Revisited: Narcodontics, a justified approach for rampant caries? – F. Vinckier Rampant caries towards a better understanding - D. Declerck Discussion – S. Alaluusua

• European Union opinion on direct filling materials. • AODES 2008 Meeting, Athens June 27th 2008 • Editorial contacts • Membership • How to join the Academy of Operative Dentistry

EDITORIAL

Looking forward and looking backward… As I write to you, I am conscious that the month of January is named in honour of Janus, the Roman god of gates, doorways, and beginning and ends. So where are we, in the AODES at the beginning of 2008? Looking into the past, there are many proud achievements for us, not least of which is the fact that the AODES is now in existence for ten years. The primary objective of the AODES is “to promote excellence in operative dentistry in Europe”… I think it is fair to say that looking at the way the AODES has grown and developed, the quality of the research and developments that have been produced from within the AODES, along with the excellent annual meetings, that the AODES is living up to its aim. However, looking forward, there is more for us to do! We must continue to develop the AODES over the next number of years, further increasing our membership, while leading the changes in clinical techniques and research to adapt to continuous evolution within the field of operative dentistry. This issue of EuroCondenser offers summaries of some of the presentations at the AODES meeting in Geneva. This meeting was a great success, and congratulations go to Prof Dr. Ivo Krejci and his local organizing team for hosting such an impressive and successful event. It was most encouraging to see a wide variety of posters being presented by our (often younger) colleagues throughout Europe.

Looking forward into 2008, what important matters can I bring to your attention? Firstly, the European Commission, in consultation with the Scientific Committee on Emerging and Newly Identified Health Risks (SCENIHR), is inviting comment on the scientific opinion on “The safety of dental amalgam and alternative dental restoration materials for patients and users”… this is certainly an emotive and important subject for many dentists in Europe. Further information on this consultation process is given later in this issue of EuroCondenser. Secondly, I would remind readers of the forthcoming AODES 2008 meeting to be held in Athens on June 27th. The title of this year’s meeting is: “Direct vs. indirect aesthetic restorations: Materials, techniques and clinical performance”. Certainly this promises to be an exciting meeting. Further details are given later in this issue. Finally, I finish with a request that readers of EuroCondenser will continue to supply me with material to publish in future issues, such as summaries/ results from relevant postgraduate theses, reports/ reviews of papers or journal articles that they have read elsewhere which may be of interest to readers of EuroCondenser, and full-length articles on Operative Dentistry. The future success of EuroCondenser is our responsibility. I wish you a happy and successful 2008! Chris Lynch Editor Cardiff University School of Dentistry, United Kingdom. Email: lynchcd@cardiff.ac.uk

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AODES Geneva 2007: The Future of Operative Dentistry J.-F. Roulet There are many different ways to predict the future. One would be the analysis of actual trends and developments in order to derive conclusions for your own field connected to these developments. In order to do this, accessibility to worldwide data and their management is important. Another mechanism would be to do some extrapolations, which is dangerous. The best way is still to have imagination. When the time is ready, far-fetched ideas may happen. Today’s dental world is characterized by a caries decline in the industrialized nations, and by the existence of excellent and durable restorative materials and adhesives. However the caries is not evenly distributed: approximately 20% of the children have 80% of the caries. Unfortunately this is linked to the social status, making preventive programs difficult. Therefore, different needs for restorative therapy can be identified. Analysis and future of resin composites Resin composites have reached a very high degree of sophistication. Intelligent filler size distributions with an abundance of different filler materials allow the developer to find optimal combinations to reach very high filler loads and excellent performance (Fig 1). So far the monomers used are based on acrylate chemistry. Ormocers and compomers can be seen as intelligent alternatives, but their setting reaction is still based on free radical polymerization based of acrylate chemistry. Further composite developments go towards lower polymerization shrinkage. Epoxy based monomers, however, require cationic polymerization. This material class poses great challenges to the chemists, before the composites will show as good performance as the best “conventional” materials. Analysis and future of adhesives The simple act of bonding resins to tooth hard tissue has yielded a multitude of products, which can be divided into different “families” according to the application techniques. They require chemically demanding and complex monomers with high production costs. Besides the fact, that there are reliable products, new development goals can be formulated. Actually the trend is toward fast and easy. But self-repairing adhesives are conceivable, as well as more heavily filled adhesives which would be used as restorative materials. Smart materials are also possible, e.g. including a “leakage indicator”. On the other side, adhesives penetrating carious tissue could allow development of a form of dentistry that did not require mechanical caries removal, or drilling.

Analysis and future of ceramics Ceramics exist in many forms, but dental ceramics are very special, due to the requirement of translucency and tooth color. These so-called aesthetic ceramics show moderate mechanical strength. On the other hand, high strength ceramics are quite opaque. For the future high strength translucent tooth colored ceramics are needed to simplify the production techniques. With CAD/CAM technology all known ceramics can be milled into dental restorations. For Zirconium oxide CAD/CAM is the only possibility for individualization of ceramic blocks. It is not clear if in the future small and inexpensive solutions such as Cerec (Fig. 2) or large milling centers using industry grade machines will be the predominant way accepted by dentists for the production of ceramic restorations. It is obvious that milling is a very uneconomic procedure. For the future, building up technologies should be used also for ceramics, as they are introduced in metal technology already. Biology: the true breakthrough Understanding biology will open new possibilities for dental treatment, because the intervention will be with the same powerful tools as nature is using. As an example, knowing the signal factors with which the microorganisms in the plaque are communicating it seems possible to give harness this and disrupt a biofilm (Fig. 3). With monoclonal antibodies (MAB) one can specifically target microorganisms. If the “homing device” (MAB) is combined with an antimicrobial peptide, the microorganism (e.g. streptococcus mutans) can be selectively eliminated without harming the remaining microbial population. Taking this one step further, could salivary glands, not to produce saliva only, but also monoclonal antibodies to target specific microorganisms, thereby reducing the occurrence of caries or periodontal disease? (Fig. 4) Conclusions Let’s use an analogy to make a prediction of big, biologically based changes in dentistry: think back to 1869. Meyer and Mendeleev have discovered the Periodic System. This can be seen as knowledge of the basic system or in language the characters. In the following years nuclear physics boomed and it took 75 years to the application of the knowledge: on July 16 1945 the first nuclear bomb was detonated in the desert of Almagordo in the USA. If we transfer this into biology: Watson and Crick discovered the DNA in 1953 (the characters). In 2002 the human genome project was accomplished (the words). Now we need to write the world literature. If it takes as long as in nuclear physics/chemistry, one can expect after 2028 applications on a larger scale of biological knowledge in all life sciences. Therefore, the future dentist • Will master sophisticated reconstructive techniques • Will be an expert in causal therapy (prevention) • Must have extensive biological knowledge and

know how in order to offer to the patient the best possible treatment outcome.

The future will be very exciting!

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Figures Fig. 1 Optimal filler composition and high filler load allow high surface gloss (after polishing) and good wear characteristics at the same time (Tetric EvoCeram. Fig 1 a and b: SEM. Even at very high magnification (Fig. 1b) the surface is very smooth. Fig 1 c and d. show the same material at the same magnification, but with material contrast. The diversity of fillers and their distribution can be seen easily. 1a 1b 1c

1d Fig. 2 The future dental office will include much more digital equipment Fig. 3 Understanding signalling factors of the bacteria to bacteria communication, one can influence the plaque

Smart plaque control

Rinse with signaling factorsRinse with signaling factors

Fig. 4 Imagine salivary glands which would be reprogrammed to produce antibodies against streptococcus mutans

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AODES Geneva 2007: Abstracts from the poster presentations Characterization of oral films formed in the presence of a cpp-acp agent: an in situ study. Rahiotis Christos, Kakaboura Afrodite, Eliades George Dept. of Operative Dentistry and Dept. of Basic Sciences and Oral Biology, University of Athens, Greece Objectives: This study compared the morphological appearance and the molecular composition of intra-oral integuments formed in situ on Ge crystals in the presence or absence of the commercially available anrticarious paste (Tooth Mousse, GC Int) based on casein phosphopeptide-amorphous calcium phosphate complex CPP-ACP . Materials and methods: Six volunteers participated in the study. A removable orthodontic appliance with a custom-made retainer was fabricated for each patiënt. Ge crystals were mounted in the retainers and were placed intraorally for 30 min, 8 h, 24 h and l week time periods. The surfaces of another series of Ge crystals were treated with the commercial CPP-ACP agent and afterwards were placed intraorally for the same time periods as above. All the intra-orally exposed Ge surfaces were examined by: a) reflected light microscopy, b) micro-MIR-FTIR spectroscopy and c) scanning electron (SE) microscopy plus EDS analysis. Results: The observations under light and scanning electron microscopy revealed a delay in biofllm formation on Ge surfaces treated with the tested agent in comparison to the analogues with no treatment. The micro MIR-FTIR spectra showed that the presence of CPP-ACP agent favored the nucleation and crystallization of Ca -P crystals on Ge surfaces. The EDS analysis recorded a significant increase in K and Cl on the no-treated Ge surfaces. On the contrary, an increase in Ca concentration was detected on the treated surfaces. Conclusions: The presence of CCP-ACP agent delayed the biofilm formation and favored the nucleation and crystallization of Ca -P crystals, maintaining the formation of new apatite as well as its precursor's forms.

Colour Matching of Try-in Pastes with their Corresponding Resin cements. Gaintantzopoulou M,* Kabouropoulos D, Kakaboura A, Vougiouklakis G. Dept. of Operative Dentistry, School of Dentistry, Un. Of Athens, Greece Objectives: To investigate the colour matching of try-in pastes with their corresponding resin cements. Methods: Two shades of four resin cements, polymerized by light- (LC) and dual-cured (DC) modes each one, were tested: a) Calibra [Transluscent (CT) and Medium (CM)], b) Clearfil [Clear (CC) and Universal (CU)], c) Insure [Clear (IC) and Red-Yellow-Universal (IU)], d) Variolink II [Trancluscent (VT) and Yellow (VY)]. Two groups per resin cement for each shade and one group corresponding try-in paste (tp) were prepared (n=8). Colour measurements were performed with a colorimeter according to the CIEL*a*b* system, through a 1 mm-thick porcelain disc. Colorimetric evaluation was conducted immediately after sample photo-polymerization (baseline) and after 24hour storage (24h). Colour differences (AE*) were calculated between: 1) resin cement at LC and DC modes (baseline) -corresponding try-in paste (baseline) and 2) resin cement at LC and DC mode (baseline)-(24h). The results were analyzed by independent two-way Anova and Sheffe's statistical tests (a=0.05). Results: The results of the colour differences are presented in following Table: Material AE baseline

(tp-LC)

AE baseline

(tp-DC)

AELC

(baseline-

24h)

AEDC

(baseline-

24h) CT 6.35±0.34d 5.84±0.22e 1.55±0.51c 1.03±0.26ab

CM 6.68±0.32d 5.64±0.41e 1.48±0.42c 0.61±0.29b

CC 2.73±0.25b 2.65±0.13c 1.10±0.34bc 1.24±0.25a

CU 2.01±0.08+ 2.46±0.15bc 0.72±0.13ab 0.59±0.18b

IC 3.97±0.43c 4.01±0.19bc 1.08±0.23bc 0.65±0.35ab

IU 3.50±0.33c 2.02±0.60ab 0.73±0.32ab 0.43±0.11b

VT 1.46±0.11a 1.62±0.26a 0.50±0.04ab 0.75±0.18ab

VY 1.60±0.12a 1.81±0.24a 0.44±0.14a 0.80±0.19ab

Same lower case letters exhibit no statistically significant differences within the column groups. Conclusions: Colour differences between resin cements and their corresponding try-in pastes varied among the brands and a high interaction between the factors mode of cure and material was detected. Both shades of Calibra showed the highest and Variolink II the lowest colour differences between the try-in paste and the resin cements in light- and dual-cured mode. Colour changes of resin cements after 24 hours post curing in most cases, were not perceptible since AE* values were not higher than 1.

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Destruction of tooth structure during quartz fibre reinforced endodontic post removal S. Brindley. J.D. Satterthwaite, University Dental Hospital Manchester, Manchester, UK Objectives: To compare two methods for removal of quartz fibre-reinforced endodontic posts in relation to the volume of tooth tissue removed during the removal process. Materials and methods: 20 extracted, single rooted, human premolar teeth were de-coronated and root treated in a standardised manner. A N°2 RTD DT Lightpost was cemented to a depth of 10mm. Teeth were randomly assigned to two groups of equal size. Post removal was undertaken using either a specifically designed manufacturer’s re -access kit (group A) or a 10 mm tapered diamond coated bur (group B). Micro-computerised three-dimensional tomography (3D Micro-CT) was used to create a 3-dimensional reconstruction of each sample before and after the removal of the endodontic post. The excess volume of material removed together with the volume of dentine removed was calculated. Results: The excess volume of material removed in group B (mean 28.85; SD 7.13) was greater than that in group A (mean 10.83; SD 4.28). This difference is statistically significant: p<0.001. The volume of dentine removed in group B (mean 11.71; SD 3.76) was greater than that in group A (mean 22.64; SD 5.58). This difference is statistically significant: p<0.001. Conclusions: The removal of a quartz fibre -reinforced endodontic post results in the removal of excess tissue. The use of a tapered diamond bur to remove such a post results in a significantly greater volume of dentine removal than the manufacturer's re -access kit. Gap evaluation in ultraconservative esthetic restorations Nikolinakos N*., Lagouvardos P. Objective: The aim of this study was to test by x-ray micro -tomography the zero hypothesis that filling materials are equally effective in filling the spaces in ultra conservative cavities. Materials and methods: Forty cavities were prepared in ten recently extracted teeth. The cavities prepared in 2.5 mm depth, with 0.8mm and 1.0 mm in diameter burs. The cavities were imaged using computerized X-ray microtomography (Skyscan Model 1072 micro XCT, Sky Scan Aartselaar, Belgium), filled with one of four different materials (Aelite Flo/Bisco-AF, Perma Flo/Ultradent-PF, Fuji IX GP/GC-FU, Aelite Aesthetic

Enamel/Bisco-AA) and thermocycled (500 cycles from 5 °C to 55 °C), before a second series of tomographs was taken. Following a specific protocol, Volume fraction (Vf) percent of empty spaces in the filled cavities was estimated using the available software. Results: The results showed the following Vf% values: AF-O,72±0,34612, FU-9,84±7,41598, AA-3,043±2,01999 and PF-1,443±1,58753. Kruskal-Wallis test showed significant differences between groups (H=20,9 p<0,05) which located in the groups AF#FU, AF#AA, FU#PF using multiple comparisons. Pearson's correlation between Vf% and volume, length or width of the initial cavity, showed no significant correlation with these parameters independently of the filling material (0,127 / 0,153 / 0,117 respectively). However, taking into account the filling material, FU and AA showed significant correlations, equally significant to all three parameters. Conclusions: 1. There were differences between materials in the Vf% of the gap created during condensation in the cavity. 2. Low viscosity composite resins showed the lowest gap formation (Vf%). 3. Length, width and volume are not correlated with the gap formation (Vf%), only when the material is not taken into consideration. Novel strategy to optimize bonding to radicular dentin Bertossa Bruno, Barthelemy Jonathan, Krejci Ivo, Bouillaguet Serge School of Dentistry, University of Geneva, Switzerland Objective: This study tested the hypothesis that bond strengths of filling materials to radicular dentin may be optimized using an indirect dentin bonding procedure with an acrylic core material. Material and methods: Roots of human teeth were endodontically prepared and obturated with either EndoREZ, Epiphany or the bonding of an acrylic point with SE Bond using a direct or an indirect bonding technique. Bond strengths of endodontic sealers to radicular dentin were measured using a thin slice push-out test. Results: Push-out strengths of EndoREZ and Epiphany to radicular dentin were less than 5 MPa. The direct bonding technique with acrylic points and the self-etching adhesive had push-out strengths of 10 MPa, increasing to 18 MPa with the indirect technique. Conclusion: The use of the indirect bonding protocol with an acrylic point to compensate for polymerization stresses appears to be a viable means for optimizing bond strengths of endodontic filling materials to radicular dentin.

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Direct splinting: presentation of three clinical techniques

Maria Anagnostou, Efstratios Papazoglou, George Mountouris, George Vougiouklakis.

Postgraduate Clinic, Department of Operative Dentistry, University of Athens, Greece

Objective: Splinting is indicated for stabilization of mobile teeth with compromised periodontal support and for retention after orthodontic treatment and trauma. Splinting may be direct or indirect, intra-coronal or extra-coronal, temporary or permanent and removable or fixed. Several techniques and materials including wires, pins, nylon mesh, bonded reinforcing materials, and metal mesh have been proposed for direct splinting.

Presentation: Three techniques for direct splinting of anterior teeth with fibre reinforced composites or metal mesh are presented, which were developed in the Postgraduate Clinic of Operative Dentistry, University of Athens, Greece. In the first technique, the fibre strip was passively maintained on the lingual/palatal surfaces of the teeth to be splinted by passing stabilizing strands of dental floss through the interproximal areas of the teeth and lightly pulling the strands, using one hand and avoiding excessive force.

In the second technique, the fibre reinforced strip was covered and protected from light-polymerization using aluminium foil in order to avoid premature polymerization. The strip was gradually exposed and adapted to the lingual/palatal surfaces of the teeth to be splinted using suitable hand instruments and light cured.

In the third technique, a metal mesh was used as a splinting medium for teeth with compromised periodontal support. The metal mesh was transferred to the tooth surfaces for bonding using a thermoplastic sheet/mold, which has been formed using the cast of the patient and a vacuum or pressure device. This thermoplastic sheet maintains mobile teeth in the desired position during the splinting procedure. Ceramic laminate veneers and laminate bridges: presentation of four clinical cases Katerina Tagkalaki1, Maria Anagnostou, Marianna Gaintantzopoulou, Efstratios, Papazoglou, George Mountouris, George Vougiouklakis. Postgraduate Clinic, Department of Operative Dentistry, University of Athens, Greece Objective Ceramic laminate veneers are broadly used nowadays in aesthetic dentistry. Their main advantages which make them so popular are the optical properties and translucency of porcelain, which can resemble natural tooth structure, their colour stability, their satisfactory bond strength to enamel using resin cements and the good response of periodontal tissues to them. The application of ceramic laminate veneers in

representative clinical cases with various problems in the aesthetic zone treated in the Postgraduate Clinic of Operative Dentistry (School of Dentistry, University of Athens) will be described. Materials and methods The aesthetic rehabilitation of maxillary incisors in four patients with: 1) diastemata, 2) short clinical crowns, 3) tetracycline stains, and, 4) cheileoschisis with single missing tooth were selected for presentation. After collecting detailed Information concerning their dental history and their personal expectations, each case was studied with the use of radiographs, initial casts and diagnostic waxing as well as clinical photographs. All the possible treatment plans were presented and thoroughly explained to each patient including their cost. Results The first three patients decided to receive treatment with ceramic veneers and the forth decided to receive treatment with a laminate bridge. The aesthetic and functional result was quite satisfactory and all the patients were happy. Conclusion This confirms the need to individualize each case in order to meet the patient's needs and wishes especially in the aesthetically difficult and challenging maxillary and mandibular anterior region. Influence of dentists' characteristics on conservative therapies Sophie Doméjean-Orliaguet, John D. Featherstone, Stéphanie Tubert-Jeannin CHU, Service d'Odontologie, Clermont-Ferrand, France. Department of Preventive and Restorative Dental Sciences University of California at San Francisco Objective: To examine the influence of practitioners' characteristics on initial conservative therapies for vital teeth in France and to observe whether modern concepts of caries management (prevention, non-invasive and minimally invasive therapies) were integrated into general practice in 2005. Materials and methods: A random sample of private practitioners in Auvergne (France) (n=100) was asked to record characteristics of 35 consecutive conservative treatments. Results: 26 dentists returned 921 forms. Of all therapies, 66% were initial treatments (IT), of which 85% were restorations and 15% were non-invasive treatments (sealants or chemotherapies). The main reason for IT was primary caries (85%). The present survey only relates to IT (n=608). 8/10 treatment decisions were based on visual inspection. Care procedures (detection tools, restorative threshold, cavity design) varied significantly according to dentists' demographic characteristics (%", p<0.05). For an example, for

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occlusal lesions on posterior teeth, men made restorations at an earlier stage; dentists who graduated 11-20 years previously made restorations at a later stage; dentists who recently participated in continuing education made fewer restorations for enamel lesions. Conclusion: Dentists often used inappropriate detection tools; non-invasive therapies were rarely used; practitioners tended to intervene surgically for enamel lesions. Care procedures varied markedly according to dentists' characteristics. Thus, similar health findings among patients could result in different treatment proposals depending on the practitioner's profile. Since much dental treatment is irreversible, patients risk inappropriate interventions, with unknown health and economic consequences. Public health policy makers must work on solutions in order to reduce this variability. In vitro colorimetric evaluation of the efficacy of home bleaching and over-the-counter bleaching products Benbachir N, Dietschi D, Ardu S School of Dentistry, University of Geneva, Switzerland Obiective: Various bleaching modalities are now offered to patients, either monitored by the dental office or self-directed, for which relative efficiency is unknown. The aim of this in vitro study was to evaluate the ability of different bleaching products and protocols to lighten enamel and dentin. Method and Materials: Bovine tooth samples of standardized thickness (2.5 ± 0.025 mm) were prepared and stained with whole blood and hemolysate before being submitted to 7 different supervised or self-directed bleaching regimens: tray-based bleaching using 10% (Opalescence and Nitewhite) or light-activated 30% (Metatray) carbamide peroxide (CP), 6% (Zoom) or 9% (Treswhite) hydrogen peroxide (HP), strips (Whiteningstrips) and paint-on gel (Paint-on Plus) containing 8.1% and 6% hydrogen peroxide (HP), respectively. Colo rimetric measurements were performed on each sample side, according to the CIE L*a*b* system, before and after staining as well as after 5, 10 and recommended number of bleaching applications. Results: Color change after recommended number of applications (AEr) varied from 15.72 (Metatray) to 29.67 (Nitewhite) at enamel and 14.91 (Paint-on Plus) to 41.43 (Nitewhite) at dentin side; Nitewhite (10% CP) and Treswhite (9%HP) were more effective than Metatray (30% CP) and Paint-on (6% HP) after 5 or recommended number of applications. Conclusion: Tray-based systems produced the faster and better bleaching effect, whatever product and concentration used at both enamel and dentin sides.

OliCo Aesthetic in Restorative Dentistry - Clinical and Non-Contact 3D Assessment Renata Chalas, Teresa Bachanek, Miroslaw Orlowski, Bozena Tarczydlo Department of Conservative Dentistry, Medical University of Lublin, Poland Objective: The development of cosmetic dentistry and the increase in patients' consciousness and expectations led to the development of Nano-Ceramic Technology which allows making nano-filled-hybrid composite materials matching with modern aesthetic expectations. The aim of the study was the OliCo Aesthetic material's preliminary clinical observation and evaluation of the possibilities of applying it to same aesthetic reconstruction cases. Also, a non-contact measurement of surface texture of fillings was done. Material and Methods: The OliCo aesthetic nano-hybrid composite by Olident was applied into the all cavities (according to Black) in patients of the department of conservative dentistry in Lublin. Furthermore, the material was applied to some cases of front teeth aesthetic reconstructions. Additionally, directly after the fillings were done in some cases the plaster casts of patient’s teeth with restorations were made. The Proscan 2000 non-contact 3D surface measurement instrument (Scantron Industrial Products Limited, Great Britain) was used to assess the texture surface of the examined dental material. Results: In the preliminary clinical assessment the fillings obtained very good marks (score Alpha) according to Ryge's classification. Also all patients assessed fillings' showed superior aesthetics and smoothness of the surface. The obtained initial results from Proscan showed a perfect marginal adaptation of the composite to the hard tooth structures and its smooth surface. Conclusion: The short-term clinical and Proscan in-vitro observations allow to conclude that the OliCo aesthetic dental material meets the requirements of the modern nano-hybrid composites that are used for aesthetic tooth tissues reconstructions. Spectrophotometric evaluation of the efficacy of a new in-office bleaching technique Benbachir N, Argente A, Doudou W School of Dentistry, University of Geneva, Switzerland Objective: The aim of the present study was primary to quantitatively test the hypothesis that a new paint-on bleaching gel has the potential to lighten the colour of the tooth in the clinical situation and in addition to

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evaluate the change of the tooth colour six months after the bleaching procedure. Method and materials: Ten adult subjects requesting a tooth bleaching were selected to participate in this randomized clinical trial involving a new in-office bleaching technique using VivaStyle Paint on Plus, originally designed as an OTC bleaching gel. Digital images and L*a*b* Spectrophotometric measurements were performed at baseline (I), after the bleaching treatment (PB), and 6 months after bleaching (6M). Differences in L*a*b* values were tested with a "repeated measures" analysis of variance (ANOVA). Differences in AE values were tested with a factorial analysis of variance (ANOVA). Results: Significant (p<0.05) differences were detected in L*, as well as in a* and b* values between initial (l) and post bleaching (PB), and between initial (I) and 6 months post-op (6M). In contrast, there was no significant difference between post bleaching (PB) and 6 months post-op (6M). Conclusions: This new bleaching technique proved to be efficient over a period of 6 months. It could be a less aggressive and handier alternative to traditional power bleaching techniques. Temperature rise during high-power LED polymerization and preventive measures to avoid heat accumulation I. Onisor, E. Asmussen, I. Krejci School of Dentistry, University of Geneva, Switzerland Purpose: To measure the temperature rise during indirect polymerization in vitro with 5 high-power LED’s and one high-power halogen lamp in a simulated oral environment, and to propose an effective technique to reduce temperature rise during polymerization. Materials and method: For groups A and B, 3x 20, 60 and 120s of irradiation, on an intact tooth and on a Cerec overlay restored one, were carried out with LEDememtron II. In groups C and D, during 3x120s of irradiation on the restored tooth with LEDemetron II and Tutu curing unit, compressed air, water and water spray from the dental unit were added as a cooling procedure. In group E, 3x120s of irradiation on the restored tooth, adding water spray, were carried out with every curing unit. In group F, irradiation was done directly on the thermocouple for 120s at a distance of O, 3 and 5mm, with: Bluephase 16i, Bluephase 18i exp., LEDemetron II, Tutu, SDI RadiiPlus and Optilux 501. In group G, the temperature of the compressed air, water and water spray delivered by the curing unit was measured. In group H, temperature rise in a 3cm deep thermo insulated well was measured during 120s of irradiation with LEDemetron II and Tutu.

Results: Temperature rise of +6.2°C inside the intact tooth and +7.7°C inside the restored one were registered after 3x120s of irradiation. Compressed air as a cooling procedure reduced the initial temperature with 4°C during irradiation with LEDemetron II, while water increased the temperature with 15.1 °C during Tutu light exposure. Water spray maintained the temperature during irradiation with every curing unit lower than 3.7°C. Temperature was influenced by the distance of irradiation for all curing units, excepting LEDemetron II. Heating of the air, in an insulated well, reached 43.5°C after 120s of irradiation with Tutu curing unit. Conclusions: Recent high-power LED curing units are developing high, dangerous temperature rise under long irradiation. An important component of the increase in temperature during polymerization is represented by the heating of the air around the irradiated object. Active tooth cooling with compressed air and with water spray, used after a short dry prepolymerization of the luting composite, is an effective, biocompatible method to reduce heating during indirect polymerization.

AODES Leuven 2004 Revisited:

Rampant caries: towards a better understanding

D. Declerck Professor of Operative Dentistry and Preventive Dentistry, Catholic University of Leuven, Belgium Introduction Rampant caries is a clinical disease pattern that can occur at different ages. The term is used to describe the situation where many teeth in the mouth are affected by carious lesions. Rampant caries can occur in very young children as a clinical entity for which at that age various names are used, such as “nursing bottle caries” (first introduced around 1965), nursing bottle mouth, nursing caries, baby bottle tooth decay, night bottle mouth, nursing bottle syndrome. In 1994 the Centres for Disease Control and Prevention decided to change the term in “Early Childhood Caries” (ECC) to replace “nursing caries”. ECC was defined as “any form of caries in infants and preschool children”. However, there is still a wide variation in case definitions and also in the diagnostic criteria used to designate Early Childhood Caries. This trend pinpoints towards a need for refinement and differentiation of the terminology used. Does carious destruction limited to the upper incisors of a very young child reflect the same underlying mechanisms as advanced destruction limited to the deciduous molars in an older child? Veerkamp & Weerheijm1 stated that the clinical picture is influenced by the stage of development of the dentition at the moment of the cariogenic challenge. The severity of dental caries also needs to be considered such as initial versus cavitated lesions.

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Clinical Picture Rampant caries is a clinical entity characterized by the presence of different lesions and often an unusual sequence of tooth destruction. There is an acute onset and rapid progression of the lesions. Surfaces usually at low risk are affected. There is a rapid destruction of coronal tissues and an early involvement of the dental pulp. Apart from this, pain and the presence of infection are often associated with it. Children with ECC that have pain or experience discomfort eat less, have problems with concentration and can exhibit negative behaviour.2 A recent survey in Flemish children showed that almost 4% of 3-year olds and 12% of 5-year olds experienced at least on one occasion a toothache.3 Epidemiology Although many authors report an important caries decline in recent decades, especially in the youngest age groups,4 a considerable proportion of children seems not to benefit from this result.5-7 There is a clear polarisation taking place: 50% of caries lesions can be found in 10-15% of the children. Reported prevalence data for ECC vary between 1% and more than 70%, depending on the population examined.8 Data obtained in Flemish children, again collected in the Smile for Life project, show the following picture: 90% of 3 yr-olds showed no signs of caries at cavitation level (diagnostic level d3); in 5 yr-olds this was the case in almost 67% of the children. A constant finding in all populations examined, is the fact that immigrant populations and ethnic minorities present higher disease levels. 9,10 It remains unclear what the underlying basis is for this finding. Cultural norms, differences in diet, child rearing practices and limited access to dental/medical care are possible explanations. Independent of race and ethnicity, ECC clusters in disadvantaged members of society. The underlying basis of this socio-demographic distribution of disease levels remains unexplained. This trend is also seen in our own country. In the Signal Tandmobiel® study, a longitudinal oral health follow-up study, a strong inverse relationship between educational level of the parents and the oral health of their child could be demonstrated. The percentage of cavity-free children was more than 70% in 7 year-old children from mothers that received education at a university level. In the group of children with mothers with lowest educational level (only primary school) this percentage dropped to less than 30%.11 Aetiology A review of the literature shows many inconsistencies in findings. More than 106 factors were found to be significantly related to the prevalence or incidence of Early Childhood Caries in 73 studies included in a systematic review published recently by Harris and co-authors.12 Different aetiological factors have been suggested as will be discussed hereafter.

Nursing practices 1 Night time bottle use A link with night-time bottle use is often suggested. However, the use of a bottle during the night is a widespread habit in many populations, reported by 18 up to 85% of parents, but of these children only a small proportion actually gets caries.13 In a recent survey conducted in Flanders (Smile for Life project),3 parents reported night-time bottle use in 45% of 3 yr-olds and 15% of 5 yr-olds. On the other hand, reports show that a high prevalence of caries is often not attributable to inappropriate bottle feeding.14,15 2 The content of the bottle Bovine milk is considered to be non-cariogenic. High calcium levels and presence of casein are thought to be responsible for this. Bowen and collaborators presented data showing that milk is not only non-cariogenic but should be considered as cariostatic .17 Small infants are bottle-fed using infant formula. The possible cariogenicity of these products needs also to be considered. The products examined by Bowen and co-authors showed a cariogenic potential up to 30% compared to that of a sucrose solution.18 Drinks containing sucrose are often presented to small children in a baby bottle. Their consumption is associated with 4 times higher Streptococcus mutans levels than when milk is consumed in a bottle.19,20 In addition, these solutions often have a low pH and evidence is accumulating on their erosive potential. The fact that many children with high consumption of fizzy drinks remain without caries development again shows that the link is certainly not conclusive. Human milk has a lower minera l content, a higher concentration of lactose and contains less protein than cow’s milk.21The possible association of prolonged or ‘at will’ breast-feeding with caries development remains controversial and is based mostly on case reports. Many of the studies performed in this field, lack methodological consistency. In a recent study no relationship could be demonstrated.22 3 The use of a pacifier Another habit often linked to the development of caries in young children is the use of a pacifier. In a recent evidence-based review of the literature, the authors concluded that evidence, although limited, does not suggest a strong or consistent association between pacifier use and childhood caries, and this irrespective of whether or not a sweetening solution was applied.23 All of the above show that there is no absolute link between nursing practices and caries development in young children. Plaque as a biofilm The findings of the previous studies underline the complexity of the caries process. It is a multi-factorial process, where many factors interact with each other and where compensation mechanisms between factors also need to be considered. Therefore we should look at caries from a different perspective and realize that many

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factors interact. We should consider caries as the result of an ecological shift that takes place at the level of the biofilm at the tooth-surface.24, 25 This shift leads to an imbalance between plaque fluid and tooth surface. We often forget that caries is an infectious disease. A constant finding in many surveys is the impact of Streptococcus mutans acquisition at a very young age. The younger a child gets infected with Streptococcus mutans, the higher his risk for caries development will be.26- 28

Tooth structure Another important risk factor appears to be the presence of developmental defects at the level of the enamel of primary teeth. Incomplete maturation (just after emergence of the tooth in the oral cavity) and the presence of structural defects are linked to an increased risk for caries development. Irregularities in the tooth surface predispose to plaque retention, increased Streptococcus mutans colonisation and decreased clearance of carbohydrates. Therefore developmental enamel defects should be regarded as a risk factor for early childhood caries. The relevance of enamel hypoplasia at a subclinical level remains to be determined. A recent review article concludes that the key factors involved in the pathogenesis of ECC are microflora, substrate, saliva and host together with the immature host defence system and developing bacterial flora.29 Other associations Other interesting associations need further exploration. Stress is now considered to influence the oral health of children considerably. And also smoking or passive smoking, is shown to be associated with caries development in the primary dentition.30-32

Management 1. Preventive approach Since the impact of ECC is enormous and this at different levels, prevention should receive ample attention. However, reported preventive initiatives have often shown only limited success. In educational and counselling intervention programs little evidence could be obtained for a reduction in disease prevalence. Professional interventions may be successful, but are hampered by the fact that the initial dental visit in many children takes place too late. This is certainly the case in groups of children at high risk for caries development. 2. Restorative treatment Treating children with ECC is time-consuming, expensive and difficult.33 Since in most cases the children are still very young and cannot cope with regular dental care delivery, treatment in a hospital setting will be necessary, making use of sedation or general anaesthesia, with all of its potential complications.34

Prognosis The removal and restoration of carious teeth will not arrest the disease process. Relapse rates of 37% after a period of only 6 months have been reported.35 Almeida and co-authors reported 17% re -treatments under general anaesthesia within 2 years following initial full-mouth rehabilitation.36 The impact of ECC is important. The presence of caries in the primary dentition remains the best predictor of caries development in the permanent dentition at a later age.37 ECC has also a considerable impact on the general development of the child. Body weight and height gain are negatively affected.38 Acs and collaborators showed that children with rampant caries presented significantly increased growth rates after dental rehabilitation under general anaesthesia.39 This catch-up growth resulted in the resolution of any differences compared to controls without caries experience. Not only is the child itself affected by the problem, but the whole family is involved. Almost 50% of parents reported an impact of their child having caries on parental activities (e.g. the need to take a day off at work to take the child to the dentist).40 Conclusion ECC is a clinical entity affecting simultaneously several teeth in the dentition. For the child involved this disease has severe consequences locally and also generally. Several nursing habits have been designated as a potential cause for this generalised breakdown of the teeth. However no absolute proof has been found for any of them. Today more attention is paid to the caries process itself and the reasons that can accelerate the rapid progress of the affection. Today ECC is regarded as a multifactorial, transmissible and infectious disease. It seems that children belonging to a lower socio-economic group are more prone to develop EEC. Preventive as well as extensive curative measures are needed to stop the breakdown of the dentition. In addition a thorough follow up is needed to avoid a relapse. References 1. Veerkamp JS, Weerheijm KL. Nursing-bottle caries: the

importance of a development perspective. ASDC J Dent Child. 1995;62(6):381-6

2. Low W, Tan S, Schwartz S. The effect of severe caries on

the quality of life in young chidren. Pediatr Dent 1999;6:325-6.

3. Declerck D, Leroy R, Martens L, Lesaffre E, Garcia-

Zattera MJ, Vanden Broucke S, Debyser M, Hoppenbrouwers K. Factors associated with prevalence and severity of caries experience in preschool children. Community Dent Oral Epidemiol 2007;35 (in press).

4. Marthaler T, Menghini G, Steiner M. Use of the Significant

Caries Index in quantifying the changes in caries in Switzerland from 1964 to 2000. Community Dent Oral Epidemiol. 2005;33(3):159-66.

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5. Marthaler TM, O'Mullane DM, Vrbic V. The prevalence of dental caries in Europe 1990-1995. ORCA Saturday afternoon symp osium 1995. Caries Res. 1996;30(4):237-55.

6. Truin GJ, Konig KG, Bronkhorst EM, Mulder J. Caries

prevalence amongst schoolchildren in The Hague between 1969 and 1993. Caries Res. 1994;28(3):176-80.

7. Truin GJ, Konig KG, Bronkhorst EM. Caries prevalence in

Belgium and The Netherlands. Int Dent J. 1994;44(4 Suppl 1):379-85.

8. Serwint JR, Mungo R, Negrete VF, Duggan AK, Korsch

BM. Child-rearing practices and nursing caries. Pediatrics. 1993;92(2):233-7.

9. Grindefjord M, Dahllof G, Ekstrom G, Hojer B, Modeer T.

Caries prevalence in 2.5-year-old children. Caries Res. 1993;27(6):505-10.

10. Verrips GH, Frencken JE, Kalsbeek H, ter Horst G, Filedt

Kok-Weimar TL. Risk indicators and potential risk factors for caries in 5-year-olds of different ethnic groups in Amsterdam. Community Dent Oral Epidemiol. 1992;20(5):256-60.

11. Vanobbergen J, Martens LC, Lesaffre E, Declerck D.

Parental occupational status related to dental caries experience in 7-year old children in Flanders (Belgium). Community Dental Health 2001;18:256-262.

12. Harris R, Nicoll AD, Adair PM, Pine CM. Risk factors for

dental caries in young children: a systematic review of the literature. Community Dent Health. 2004;21(Suppl):71-85. Review.

13. Kaste LM, Gift HC. Inappropriate infant bottle feeding.

Status of the Healthy People 2000 objective. Arch Pediatr Adolesc Med. 1995;149(7):786-91.

14. Matee M, van't Hof M, Maselle S, Mikx F, van Palenstein

Helderman W. Nursing caries, linear hypoplasia, and nursing and weaning habits in Tanzanian infants. Community Dent Oral Epidemiol. 1994;22(5 Pt 1):289-93.

15. Tinanoff N, O'Sullivan DM. Early childhood caries:

overview and recent findings. Pediatr Dent. 1997 Jan-Feb;19(1):12-6. Review.

16. Bowen WH, Pearson SK. Effect of milk on cariogenesis.

Caries Res. 1993;27(6):461-6. 17. Bowen WH, Pearson SK, VanWuyckhuyse BC, Tabak LA.

Influence of milk, lactose-reduced milk, and lactose on caries in desalivated rats. Caries Res. 1991;25(4):283-6

18. Bowen WH, Pearson SK, Rosalen PL, Miguel JC, Shih

AY. Assessing the cariogenic potential of some infant formulas, milk and sugar solutions. J Am Dent Assoc. 1997;128(7):865-71.

19. Bowen WH, Pearson SK, Falany JL. Influence of

sweetening agents in solution on dental caries in desalivated rats. Arch Oral Biol. 1990;35(10):839-44.

20. Mohan A, Morse DE, O’Sullivan DM, Tinanoff N. The relationship between botlle usage/content, age, and number of teeth with mutans streptococci colonization in 6-24-month-old children. Community Dent Oral Epidemiol 1998;26:12-20.

21. Darke SJ. Human milk versus cow's milk. J Hum Nutr.

1976;30(4):233-8. Review. 22. Rosenblatt A, Zarzar P. Breast-feeding and early childhood

caries: an assessment among Brazilian infants. Int J Paediatr Dent. 2004;14(6):439-45.

23. Peressini S. Pacifier use and early childhood caries: an

evidence-based study of the literature. J Can Dent Assoc. 2003;69(1):16-9. Review.

24. Fejerskov O. Changing paradigms in concepts on dental

caries: consequences for oral health care. Caries Res. 2004;38(3):182-91. Review.

25. Kidd EA, Fejerskov O. What constitutes dental caries?

Histopathology of carious enamel and dentin related to the action of cariogenic biofilms. J Dent Res. 2004;83 Spec No C:C35-8. Review.

26. van Houte, Gibs G, Butera C. Oral flora of children with

“nursing botlle caries”. J Dent Res 1982;61:382-5. 27. Alaluusua S, Renkonen OV. Streptococcus mutans

establishment and dental caries experience in children from 2 to 4 years old. Scand J Dent Res. 1983;91(6):453-7.

28. Kohler B, Andreen I, Jonsson B. The earlier the

colonization by mutans streptococci, the higher the caries prevalence at 4 years of age. Oral Microbiol Immunol. 1988;3(1):14-7.

29. Ramalingam L, Messer LB. Early childhood caries : an

update. Singapore Dent J 2004;26(1):21-9 30. Williams SA, Kwan SY, Parsons S. Parental smoking

practices and caries experience in pre-school children. Caries Res. 2000;34(2):117-22.

31. Aligne CA, Moss ME, Auinger P, Weitzman M.

Association of pediatric dental caries with passive smoking. JAMA. 2003;12;289(10):1258-64.

32. Shenkin JD, Broffitt B, Levy SM, Warren JJ. The

association between environmental tobacco smoke and primary tooth caries. J Public Health Dent. 2004;64(3):184-6.

33. Cook HW, Duncan WK, De Ball S, Berg B. The cost of

nursing caries in a Native American Head Start population. J Clin Pediatr Dent. 1994;18(2):139-42.

34. Milnes AR, Rubin CW, Karpa M, Tate R. A retrospective

analysis of the costs associated with the treatment of nursing caries in a remote Canadian aboriginal preschool population. Community Dent Oral Epidemiol. 1993 Oct;21(5):253-60.

35. Chase I, Berkowitz RJ, Mundorff-Shrestha SA, Proskin

HM, Weinstein P, Billings R. Clinical outcomes for Early Childhood Caries (ECC): the influence of salivary mutans streptococci levels. Eur J Paediatr Dent. 2004 Sep;5(3):143-6.

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36. Almeida AG, Roseman MM, Sheff M, Huntington N,

Hughes CV. Future caries susceptibility in children with early childhood caries following treatment under general anesthesia. Pediatr Dent. 2000;22(4):302-6.

37. Peretz B, Ram D, Azo E, Efrat Y. Preschool caries as an

indicator of future caries: a longitudinal study. Pediatr Dent. 2003;25(2):114-8.

38. Ayhan H, Suskan E, Yildirim S. The effect of nursing or

rampant caries on height, body weight and head circumference. J Clin Pediatr Dent 1996;20:209-12.

39. Acs G, Lodolini G, Cisneros GL. Effect of nursing caries

on body weight in a pediatric population. Pediatr Dent 1992;14:302-5.

40. Locker D, Jokovic A, Stephens M, Kenny D, Tompson B,

Guyatt G. Family impact of child oral and oro-facial conditions. Community Dent Oral Epidemiol. 2002 Dec;30(6):438-48.

AODES Leuven 2004 Revisited: Narcodontics, a justified approach for rampant caries? Frans Vinckier Professor of Oral Pathology, Pedodontics and Operative Dentistry, Catholic University of Leuven, Belgium Introduction Pre-school children with rampant caries require extensive dental rehabilitation, often including complex interventions. The choice of the method of treatment depends on several factors such as: the age of the child, the level of cooperation of the child, the extent of decay present, parental motivation, knowledge and expertise of the dentist and availability of treatment facilities. General anesthesia is often the method of choice for the treatment of very young children with rampant caries because dental treatment can be a frightening experience. Children younger than 3 years have underdeveloped coping skills and do not cooperate. It is very difficult to administer them pain control and accomplish the necessary dental treatment without compromising the long term cooperation of the child. The majority of the children can be adequately treated using behavior techniques such as “Tell, Show and Do”.1,2 But the child with rampant caries needs an extensive and complex treatment,3 including restorative treatment, pulp therapy and extractions. The oral or inhalation sedation enhances the cooperation of the child but it is still very difficult to perform high quality restorative procedures such as bonded composite restorations. 4 Treatment under general anaesthesia is often the only possibility for the delivery of quality

dental care.5 In addition children with rampant caries are often more anxious than normal children. Children with rampant caries must be treated because the caries affects their quality of life. Dental rehabilitation has a statistically significant effect in alleviating the complaint of pain, of reversing eating problems and improving sleep.6-9

An infected deciduous tooth must be treated because of the risk of local or general spread of the infection. Children with cardiac diseases such as Fallot’s tetralogy are at high risk for transient bacteremia witch can lead to abscesses in tissues like brain, liver and lungs. Multiple abscesses in the brain cause brain damage and may even lead to epilepsy. The aim of this paper is to report on treatment regimes for ramp ant caries under general anaesthesia in our clinic, and to describe some factors associated with this. Procedure of general anesthesia Pre-operative assessment All children are seen pre-operatively at a first consultation at the pediatric dental clinic. Personal patient information is collected. A medical risk history and a dental history are assembled. The reason for referral, and the parents' greatest concern about their child's oral health are collected.

Referrals in %

75

1

222

dentist

physician

own intiative

pediatrician

Origins for referral in our clinic for a general anesthesia.

The oral examination is carried out by a dentist using a plane mouth mirror and a dental probe and with appropriate dental lighting. Clinical data are completed with findings from a radiological examination using an OPG. Intra-oral radiographs are difficult to obtain because of the poor cooperation of most patients. If necessary, these are taken during general anesthesia. In addition to this clinical examination, oral health habits are recorded. A treatment plan has to be conceived and is proposed to the parents with alternative treatment modalities, all of them are discussed. When the decision is made to opt for a general anesthesia in order to perform the necessary treatment, the nurse schedules the patient, explains all practical details and distributes some brochures with information about the procedure and instructions to the parents. Parents receive a telephone number where they can obtain additional information. Written informed consent has to be obtained from the parents. If there is a medical problem, the patient is summoned for a medical examination. The medical risk history is sent to the anaesthesiologist. He or she prepares the medical file.

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Day of anesthesia On the day of treatment, parents and children are welcomed at the day-stay clinic in the morning. Specially trained nurses take care of the children and their parents. Children are not allowed to drink or eat in a period of 6 hours prior to the general anesthesia. They receive premedication 30 minutes before induction. For this purpose midazolam (Dormicum®, Roche, 0.4 mg/kg body weight) is used. The drug is administered orally as syrup. When the oral route can not be used because the child refuses to take the syrup, the solution is given by anal route using a syringe. Induction is done by inhalation technique, while parents can stay with their child. The anaesthesia is provided by an intravenous line and the children receive propofol (Diprivan®, Zeneca, 2.0mg/kg b.w., fentanyl 1µg/kg b.w. and atropine 0.2mg/kg b.w.). The intubation is done by nasal route when possible. The anesthesia is maintained by Sevoflurane. Blood pressure, oxygenation, carbon dioxide retention and cardiac functioning are continuously monitored. All children are intubated. The dentist prefers the intubation by the nasal route. To prevent aspiration of oral secretions and foreign materials an oropharyngeal pack has to be placed. In most cases, anesthesia is maintained by sevoflurane. Patients are monitored continuously during the whole procedure. The dental treatment is performed by one operator who is assisted by a nurse and a second dentist. First, all restorative treatment is performed. The operator avoids treatment with doubtful prognosis. Extractions are carried out at the end of the procedure. Antibiotics are administered when procedures carrying a risk of bacteremia (extractions) are performed. The antibiotic used is ampicillin (50 mg/kg b.w.). In cases of allergy to penicillin, clindamycin (20 mg/kg b.w.) is used. After completion of the treatment, the child is transferred to the recovery area for approximately 30 minutes and then returns to the day-stay clinic where the child stays for approximately 2 hours until discharge.

Complications of general anesthesia. Of the 100 normal healthy children treated in our hospital there were no complications during the anesthesia. 4 children did vomit after anesthesia, 1 had a fever and 1 showed a rash due to the premedication. After treatment 3 children complained of nausea and a sore throat. At the moment of discharge 92% were alert, 6% felt weak and tired and 2% felt dizzy. Future caries susceptibility in children with rampant caries Although the general etiology of rampant caries appears to be similar to that of other types of caries, its predisposing factors are still unclear. The biology of

rampant caries may be modified by factors unique to young children: the implantation of cariogenic bacteria, immaturity of the host defense systems and behavioral patterns associated with feeding and oral hygiene in early childhood.10 Rampant caries is known to be characterized microbiologically by dense oral populations of streptococci mutans. Scientific evidence strongly suggests that the development of rampant caries occurs in three stages. The first stage is characterized by the primary infection of the oral cavity with Streptococci mutans. The second stage is characterized by the accumulation of these organisms to pathogenic levels as a consequence of frequent and prolonged exposure to cariogenic substrates. And finally, a rapid demineralisation and cavitation of enamel occurs resulting in rampant dental caries.11 The colonization by Streptococci mutans is stable over time. Over a two-year period, levels of Streptococci mutans were fairly stable; high levels of infection tended to stay high and were associated with subsequent development of caries.12 On the other hand, teeth with undetectable levels of streptococci mutans developed no caries. This indicates that children with rampant caries are highly susceptible to the development of caries in later years when compared to caries-free children. Therapeutic approaches to minimize risk for relapse must also address the control of etiologic risk factors. The relative high rate of retreatment suggests that early and frequent intervention with comprehensive and aggressive restorative treatment could have a profound effect on the oral health of these children. This way of treatment and therapeutic approaches to minimize the risk for new carious lesions must emphasize the need to control etiologic risk factors.13 Despite increased preventive measurements implemented for children who experienced rampant caries; this group of children is still highly predisposed to greater caries incidence in later years. In addition to nutritional counseling and fluoride therapy, more aggressive antimicrobial therapies may be required to prevent the future development of carious lesions. Conclusion Although the prevalence of dental caries in infants and young children has decreased considerably in recent years, it continues to affect many children in a general population. Rampant caries is a term to describe an infectious disease with a typical pattern of carious lesions in infants, toddlers and preschool children. Teeth in the upper jaw are more often decayed than in the lower jaw. Maxillary primary incisors and mandibular and maxillary primary molars show the highest disease prevalence compared to lower incisors and canines. Patient behavior and cooperation, age and the extent of restorative treatment required are major determinants in selecting the mode of treatment. Clinical management of rampant caries mostly requires general anesthesia. This method of treatment allows extensive rehabilitation, including restorative and endodontic treatment and extractions, in one single visit. Despite the higher risk associated to general anesthesia, it's a well-accepted

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method of treatment because of an immediate improvement in oral health and aspects of quality of life for the children and their families. Regular follow-up consultations are necessary after general anesthesia because of the greater susceptibility for new carious lesions caused by the higher level of Streptococci mutans even after total rehabilitation. A lot of studies show a poor compliance to these follow-up appointments. To modify the course of rampant caries, there is a great need for preventive regimens, including antimicrobial therapies, in addition to a more aggressive restorative approach during general anesthesia. References 1. Addelston HK, Child Parent Training. Fort Rev Chicago

Dent Soc, 1959;38:358-66. 2. Andlaw RJ et al; Techniques of behavior management. A

manual of Pediatric Dentistry, Churchill Livingstone, New York, 1996;17-28.

3. Bohaty B. Spencer P., Trends in dental treatment rendered

under general anesthesia, 1978 to 1990. J of Clinical Pediatric Dentistry, 1992;16:222-24.

4. Duperon DF, Early childhood caries: a continuing

dilemma. J Calif Dent Assoc, 1995;45:15-25 5. Acs et al. The effect of dental rehabilitation on the body

weight of children with early childhood caries. Pediatric Dentistry, 1999;21:109-13

6. Low et al. The effect of severe caries on the quality of life

in young children. Pediatric Dentistry, 1999;21:325-26 7. Thomas C, Primosch RE, Changes in incremental weight

and well-being of children with rampant caries following complete dental rehabilitation. Pediatric Dentistry, 2002;24:109-13.

8. Anderson HK, Drummond BK, Thomson WM. Changes in

aspects of children's oral-health-related quality of life following dental treatment under general anesthesia. International Journal of Pediatric Dentistry, 2004;14:317-25.

9. Seow WK. Biological mechanisms of early childhood

caries. Community dent Oral Epid, 1998;26: supplement 1:8-27

10. Berkowitz R. Etiology of nursing caries: a microbiologie

perpsective. J Public Health, 1996;56:51-5. 11. Burt BA, Loesche WJ, Eklund SA, Earnest RW. Stability

of Streptococcus mutans and its relationship to caries in a child population over two years. Caries Res, 1983;17:532-42

12. Tinanoff N, O'Sullivan OM. Early childhood caries:

overview and recent findings. Pediatrice dentistry, 1997;19:12-15.

13. Peretz B, Eidelman E. Dental health of children and

strategies for prevention. Community Dental Health, Gluck GM, Morganstein EDS, St. Louis, Mosby, 1998;107-18.

AODES Leuven 2004 Revisited:

Discussion of the papers: “Rampant Caries: towards a better understanding” and “Narcodontics, a justified approach for rampant caries” Satu Alaluusua Professor of Pedodontics and Cariology, University Dental School and Children’s Hospital, Helsinki, Finland. Introduction Every year at the Children’s Hospital 130 children are treated under general anaesthesia. A good half of them are diagnosed with cancer. Others suffer from different medical pathologies and some children are prepared for transplantation. Their dentition is treated as soon as they are diagnosed in order to eliminate the risk of an infection during the subsequent treatment. It is the aim of the dental team to make them caries free, before a medical treatment can start or transplantation is carried out. The operating team consists of one nurse, one student nurse, an anesthesiologist and a dentist. The treatment time (general anesthesia) in Leuven is shorter than in our clinic probably because their team has a second dentist in their group. Definition An overview of publications in PubMed from 1965 to 2004 teaches us that the terminology for multiple caries lesions in the same dentition of children is very different. Some authors call it rampant caries (94) others early childhood caries (187), nursing bottle caries (224), baby bottle caries (296) or nursing caries (437). As the terminology is quite different from one author to the other, one has to study the different publications because very often rampant caries was also present in the cases studied under a different name. Etiology of rampant caries Breastfeeding is a delicate issue. Does prolonged breastfeeding cause caries or not? 1 In Finland this subject is genuine and often debated over the internet by the mothers. An article review done by the Cochrane Collaboration shows that breastfeeding during the night over a period of one year (beyond eruption of teeth = prolonged breastfeeding) may be associated with early childhood caries. Human milk contains 7g/dl lactose; which is fermented by Streptococcus Mutans. The plaque of children under 2 years of age was examined. The results of an in vivo investigation2 show that the children who drink human milk have a lower pH in their plaque than those who drink water or bovine milk. But the difference is not significant. Sucrose in the same study causes a more severe pH drop. S. Mutans is essential in the development of caries in young children. The colonization of these bacteria correlates with early caries development. S. Mutans in

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order to realize adhesion to enamel synthesizes glucans from sucrose, but not from lactose. Lactose is not the one that augments the colonization of S. Mutans but it takes somehow part in the pH drop. Rampant caries must therefore be regarded as a transmissible infectious disease.3-8 Preventive measures From some prospective studies is known that children from a lower socio-economic background and also those from a different ethnic origin are more prone to develop rampant caries. Family factors seem to have an important impact on the dental health of the children. 9 This observation raises several questions. Do we put enough effort in the education of the parents, a personal education and an education of the society? What do we do to prevent caries in young children? Do we have effective routes for delivery of knowledge? How many resources can we put to prevention? And if resources are limited what would be the target age? In the Netherlands a very instructive video clip was made to warn the parents for bottle drinking. Instead, being less dangerous in caries advancement, a cup should be given to the child for drinking.10 The process starts already when teeth erupt, therefore is it very important to influence at a very early age. The colonization of streptococci starts immediately after the eruption of the first teeth. At that stage our influence has to start in order to limit the intake of sugar in food and beverages. In Finland we try to influence the parents in health centers, maternity centers, and centers for infants. This is done by nurses, hygienists and dentists. The caries prevalence in primary teeth is the best predictor for the situation in the permanent dentition.11 Many cases have high caries prevalence both in the primary dentition and in the permanent dentition. But in some cases there is no caries in the permanent dentition. The only way to prevent is to influence the parents early enough. Curative treatment Early extraction can lead to the necessity of very expensive orthodontic treatment at a later age because of the loss of space in the dental arch. It is important to treat young children and if this is not possible it is better to send the child to a place where he can be treated. When the child grows up he will cooperate and it will be easier to treat them, a second general anesthesia will not be necessary. Thus the message is clear, try to do the necessary dental treatment in an early stage in order to avoid extractions that will comp licate all further treatment. The best way remains to influence the parents as soon as possible helping them to avoid the destruction of the dentition of their child by effective preventive measures and an also by an early contact with their dentist.

References 1. Hallostein AL, Wendt LK, Mejare I, Birhed D,

Hakansson C, Lindvall AM, Edwardson S, Koch G. Dental caries and prolonged breast-feeding in 18-month-old Swedish children. Int J Paediatr Dent 1995;5:149-55.

2. Erickson PR, Mazhari E. Investigation of the role of

human breast milk in caries development. Pediatr Dent 1999;21:86-90.

3. Alaluusua S, Nystrom M, Gronroos L, Peck L. Caries-

related microbiological findings in a group of teenagers and their parents. Caries Res 1989;23:49-54.

4. Alaluusua S. Transmission of streptococci. Proc Finn

Dent Soc 1991;87:443-7. 5. Early plaque accumulation-a sign for caries risk in young

children. Community Dent Oral Epidemiol 1994;22 :273-6.

6. Alaluusua S. Salivary counts of mutans streptococci and

lactobacilli and past caries experience in caries prediction. Caries Res 1993;27/1 :68-71.

7. Alaluusua S, Matto J, Gronroos l, Innita S, Torkko H,

Asikainen S, Jousimies-Somer H, Saarela M. Oral colonization by more than one clonal type of mutans streptococcus in children with nursing-botlle dental caries. Arch Oral Biol 1996;41:167-73.

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European Union opinion on direct filling materials. Public consultation on the Scientific Committee on Emerging and Newly Identified Health Risks (SCENIHR) preliminary report on the safety of dental amalgam and alternative dental restoration materials for patients and users The European Commission has requested the Scientific Committee on Emerging and Newly Identified Health Risks (SCENIHR) to prepare an opinion on the safety of dental amalgam and alternative dental restoration materials. The SCENIHR has approved a preliminary report on the safety of dental amalgam and alternative dental restoration materials to provide the Commission with a sound scientific basis for developing and implementing policies on dental restoration materials. The report addresses health effects and the safety of these materials for both patients and dental health professionals. It also addresses the question whether certain populations, such as pregnant women or children are particularly at risk. Interested parties are invited to send their comments on the preliminary opinion via the website: http://ec.europa.eu/yourvoice/ipm/forms/dispatch?form=scenhir2&lang=en I would recommend that as this policy may have far-reaching consequences for the practice of dentistry in Europe for years to come, many readers of EuroCondensor should consult this preliminary report, and submit an opinion, as they feel appropriate.

2008 AODES Conference The AODES 2008 meeting will be held in Athens on June 27th 2008. The title of this year’s meeting is: “Direct vs. indirect aesthetic restorations: Materials, techniques and clinical performance”. This year’s meeting is being organized by our President, Prof. George Vougiouklakis. Full details of the conference, including registration and accommodation, are available from: www.dent.uoa.gr/2008aodes. Important dates Deadline for Poster Abstract submission: April 1 2008. Registration: Deadline for pre-registration: May 9 2008. After May 10, all received registrations will be handled at the meeting as on-site registrations

The program for the meeting is as follows: 08.15am-09.15am Registration 09.15am-09.30am Welcoming and Opening

ceremony Morning session 09.30am-10.15am Materials and bonding techniques

for direct and indirect restorations Bart Van Meerbeek Leuven, Belgium

10.15am-11.00am Direct vs. indirect anterior

restorations Didier Dietschi Geneva, Switzerland

11.00am-11.30am Coffee break 11.30am-12.15pm Direct vs. indirect posterior

restorations Efstratios Papazoglou Athens, Greece

12.15pm-1.00pm Restoration of endodontically

treated teeth Marco Ferrari Siena, Italy 01.00pm-02.30pm Light Lunch & Poster Viewing Afternoon session 02.30pm-03.15pm Clinical performance of direct and

indirect restorations Reinhard Hickel Munich, Germany

03.15pm-05.30pm Operative/Conservative Dentistry

Undergraduate education in European Dental Schools

05.30pm-05.45pm Operative Dentistry Board Examination (USA) Jan Mitchell, USA

05.45pm-06.30pm Presentation of Poster Prize &

Celebration of 10th AODES anniversary

09.00pm-12.30am Congress Celebration Dinner The Local Organising Committee can be contacted by emailing: vouglou@dent.uoa.gr

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Contributions to EuroCondenser The Editor wishes to encourage AODES members to make contributions to future issues of the EuroCondenser. Contributions may take the form of scientific papers, short communications, case reports, descriptions of clinical techniques, or other communications, including letters to the Editor, thesis details or details of forthcoming events. Further details are available on request from the Editor of EuroCondenser – Chris Lynch (lynchcd@cardiff.ac.uk).

Editorial Contacts Editor: Chris Lynch Division of Adult Dental Health, Cardiff University School of Dentistry, Heath Park, Cardiff, CF14 4XY, United Kingdom. Tel: 44 (0)29 2074 4665 Fax: 44 (0)29 2074 3120 Email: lynchcd@cardiff.ac.uk Consulting Editor: Nairn Wilson Central Office King’s College London Dental Institute Floor 18, Guy’s Tower Guy’s Hospital London, SE1 9RT Tel: 44 (0)207 188 1164 Fax: 44 (0)207 188 1159 Email: nairn.wilson@kcl.ac.uk

MEMBERSHIP AODES has grown by c.10% per annum since it was established some ten years ago. Such growth is encouraging, but still leaves many colleagues who would benefit from membership to become members. Membership of the Academy and, in turn AODES, offers a great deal, including: • Opportunity to attend the Annual Meeting of the

Academy in Chicago at the time of the Mid-Winter Meeting. The Annual Meeting of the Academy, apart from being the best value continuing education in North America, is always a memorable event.

• Operative Dentistry, which is included in the subscription to the Academy, is the premier referred journal in the field. Operative Dentistry is amongst the top ten ranked journals in dentistry.

• AODES meetings in major centers around Europe, together with the opportunity to attend meetings of other European organizations. These meetings have brought together outstanding groups of speakers covering all aspects of operative and conservative dentistry.

• Involvement in the European Federation of Conservative Dentistry (EFCD) through AODES’s founding membership of the Federation. This involvement gives AOD/AODES members opportunity to attend EFCD ConsEuro meetings at most favourable rates.

• Free subscription to EuroCondenser, with opportunity to contribute to this publication and to use it to communicate with colleagues across Europe.

Immediate membership goals include at least one AOD/AODES member in each dental school in Europe. AODES already has many teachers and researchers included in its membership. Such members may wish to have their dental school join the Academy’s student award scheme and to have their students apply for one of the Academy’s Ralph Phillips Research Awards. Details of these opportunities are available on the Academy’s website (www.operativedentistry.com). Other membership goals are to encourage graduate students in all relevant areas (conservative/operative dentistry, cariology, aesthetic/cosmetic dentistry etc) to take advantage of the excellent student membership rates, and to have many more colleagues in practice with special interest and expertise in modern conservative/operative dentistry and related areas become members and thereby enrich the activities of the Section. How to become a member The application process for membership of the Academy, and in turn, AODES could not be easier. The application form may be downloaded from the Academy’s webiste: www.operativedentistry.com, but for convenience has been reproduced on the back page of this issue of EuroCondenser. If in any doubt, please contact the Academy Secretary: Dr Gregory E Smith Academy of Operative Dentistry PO Box 14996 Gainesville Florida 32604-2996 USA Tel: 001 352 392 4341/001 352 371 0296 Fax: 001 352 371 4882 Email: gesaod@ufl.edu

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Membership application form for The Academy of Operative Dentistry Name________________________________________________________________________________ Address______________________________________________________________________________ Telephone: Home______________________________________________________________________ Office______________________________________________________________________ Fax_________________________________________________________________________________ Email_______________________________________________________________________________ This application is for the following membership category: ____Active Membership ____Affiliate Membership (non-dentist) ____Student Membership ? Undergraduate ? Postgraduate Presently attending the following dental school: ________________________________________________________________________________________ Projected graduation date:___________________________________________________________________ Describe your practice of dentistry: ____Private Practice ____Military: ____Army ____Navy ____Air Force ____PHS ____Academic: ____Full-Time ____Part-Time University________________________________________________________________________________ Department_______________________________________________________________________________ ____Other____________________________________________________________________________________ Study Club Affiliation___________________________________________________________________________ Please tell us how you learned about the Academy: ____Professional colleague ___Dental school ____Website ___Operative Dentistry Journal Other:________________________________________________________________________________________ Signature:_______________________________ Date:________________________________________________ Sponsor:______________________________________________________________________________________ Please send your completed application to: Dr Gregory E Smith Secretary Academy of Operative Dentistry PO Box 14996 Gainesville Florida 32604-2996 USA Tel: 001 352 392 4341/001 352 371 0296 Fax: 001 352 371 4882 Email: greg679@cox.net