Dental Lab London

In light of recent news about the changing approach to dental care providers with HIV/AIDs being permitted to participate in care again after a long ban, I thought we could focus today on discussion immune system disorders in the patient.

Immune System Disorders

Some forms of periodontal disease may be more severe in individuals affected with immune system disorders, and patients with HIV may experience especially severe forms of periodontal disease.

Incidence of necrotizing periodontal diseases may increase in the patient with AIDS. Special considerations for immune system disorder patients with periodontal disease include:

1.  Consultation/coordination of treatment with patient’s physician as necessary.

2.  Controlling associated mucosal diseases and acute periodontal infections.

3.  If indicated, administration of systemic or local medications in a manner that avoids opportunistic infections and adverse drug interactions.

Outcome Assessment

The predictability of the outcome may be enhanced through close medical/dental coordination. Satisfactory outcome of therapy in systemic disorder patientss may include:

1.  Significant reduction of clinical signs of gingival inflammation;

2.  Reduction of probing depths;

3.  Stabilization or gain of clinical attachment;

4.  Reduction of clinically detectable plaque to a level compatible with gingival health;

5.  Control of acute symptoms.

Because of the complexity of systemic factors, it may not be possible to control periodontal diseases. A reasonable treatment objective here is to slow progression of the periodontal disease which may be characterized by:

1.  Persistent inflammation/infection of the gingival tissues;

2.  Persistent or increasing probing depths;

3.  Lack of stability of clinical attachment;

4.  Persistent clinically detectable plaque levels not compatible with gingival health;

5.  Radiographic evidence of progressive bone loss.

In patients where the periodontal condition does not resolve, additional therapy may be required as well as further evaluation of the patient’s systemic condition.

I hope this article was enlightening, especially in relation to new events. If you have any comments, or questions, about this subject get in touch. Leave your thoughts in a comment here, or find me on social media:

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We’ve been discussing a lot of different topics in dentistry, and today we’re hitting on a subject not often broached, even in mainstream health discussion: craniofacial developmental disorders.

Developmental Disorders

Craniofacial birth defects include manifestations like cleft lip or palate, eyes too closely or widely spaced, deformed ears, eyes mismatched in colour, and facial asymmetries.

Surgery, dental care, psychological counselling, and rehabilitation may help to ameliorate the problems but often at great cost and over many years.

Although each developmental craniofacial disease or syndrome is relatively rare, the number of children affected worldwide is in the millions.

In addition, craniofacial defects form a substantial component of many other developmental birth defects, largely because they occur very early in gestation, when many of the same genes that orchestrate the development of the brain, head, face, and mouth are also directing the development of the limbs and many vital internal organs.

As such, these conditions are something a dentist may eventually have to accommodate.

Altered Branchial Arch Morphogenesis (Cleft Lip/Palate and Cleft Palate)

Among the most common of birth defects are clefts of the lip with or without cleft palate and cleft palate alone.

Cleft lip/palate and cleft palate are distinct conditions with different patterns of inheritance and embryological origins.

These anomalies result from the failure of the first branchial arches to complete fusion processes.

Clefting can occur independently or as part of a larger syndrome that may include mental retardation and defects of the heart and other organs.

Not all cases of clefting are inherited; a number of teratogens (environmental agents that can cause birth defects) have been implicated, as well as defects in essential nutrients such as folic acid.

Treacher Collins Syndrome —Mandibulofacial Dysostosis

Children with Treacher Collins syndrome have downward-sloping eyelids; depressed cheekbones; a large mouth; deformed ears with conductive deafness; a small, receding chin and lower jaw; a highly arched or cleft palate; and severe dental malocclusion.

Pierre Robin Syndrome

Deficient development of the first-branchial-arch-derived mandibular portion results in the lower jaw’s being set far back in relation to the forehead.

As a result, the tongue is set back and may obstruct the posterior airway, compromising respiration. Cleft palate may be another consequence.

DiGeorge Syndrome

The primary defect in the DiGeorge syndrome results from altered development of the fourth branchial arch and the third and fourth pharyngeal pouches.

Deficiencies affecting the thymus, parathyroid glands, and the great vessels that derive from these structures result.

The facial features are subtle and include a squared-off nasal tip, small mouth, and widely spaced eyes.

I hope this article serves to broaden awareness of these conditions, but I would like to hear more about how dentists are overcoming these challenges in their practice.

If you treat patients with these or similar craniofacial conditions, feel free to get in touch. Leave a comment here, or find me on social media:

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We’ve been speaking recently about the dental implant treatment process. Today, let’s look at an actual patient, her initial evaluation and treatment.

The patient, a white 65 year old female, is a heavy smoker and a heavy drinker.

Previous dental care in the maxillary arch is failing; radiographs reveal no salvageable teeth, but adequate bone in the anterior maxilla to accommodate 13-15 mm. implants.

Sinuses are large, the posterior maxilla is ruled out as a site for implants, and she exhibits Class III skeletal occlusion.

Due to financial considerations, complex overdenture and a crown and bridge restoration were ruled out.

The final prosthetic design choice was a simple overdenture with a bar and retaining clips.

The use of four implants, for stability, was discussed. The patient’s smoking and drinking was significant as was the use of immediate implants.

The patient’s Class III skeletal occlusion and poor oral hygiene was afforded much consideration in the overall treatment plan. A discussion was initiated based on the complexity of the procedure and the predicted outcome of the treatment.

The patient was advised as to the problems associated with her smoking, drinking and poor oral hygiene. Following these discussions, she gave final approval for the proposed treatment plan.

The remaining maxillary teeth were extracted, implants placed, and an immediate denture was inserted. Healing was uneventful and six months later the implants were uncovered.

A bar was constructed and the final prosthesis was processed with four retaining clips.

The patient’s drinking was a problem throughout treatment in terms of her remembering the type of prosthesis that was being constructed. Ultimately, however, the treatment was completed to the patient’s satisfaction.

What this case study demonstrates is the powerful new world we have at our disposal as dental professionals. On my side, we have the latest technology to fabricate the restorations to make situations like the above a success.

On the other, we have dental professionals able to overcome someone with a torrid oral hygiene history to supply them with a comfortable, healthy smile.

Biterite offers a wide variety of solutions for implants, from cad/cam design to custom zirconia abutments.

If you have any thoughts or questions, feel free to get in touch by leaving a comment here or finding me on social media:

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Understanding oral health means understanding the most basic root of most oral health problems, from the basic to the advanced: gum disease, or gingivitis.

I hope this article is illuminating on this most important of dental subjects.

Gingivitis

The effects of early gingivitis, as dental professionals are aware, are reversible with adequate oral hygiene, although a gingival infection may persist for months or years, yet never progress to periodontitis.

Numerous attempts have been made to pinpoint which microorganisms in the supragingival plaque are the culprits in gingivitis.

Gingival inflammation may be influenced by steroid hormones, occurring as puberty gingivitis, pregnancy gingivitis, and gingivitis associated with birth control medication or steroid therapy.

Certain prescription drugs can also lead to gingival overgrowth and inflammation —these include the antiepileptic drug phenytoin (Dilantin); cyclosporine, an immunosuppressive therapy for transplant patients; and various calcium channel blockers used in heart disease.

A form of gingivitis common fifty years ago, but relatively rare today, is acute necrotizing ulcerative gingivitis, also known as Vincent’s infection or trench mouth.

People under extreme stress have an increased susceptibility to this condition, and an association between smoking and this type of gingivitis is well recognized and was demonstrated as early as 1946; it has also been seen in HIV-positive patients.

Adult Periodontitis

Adult periodontitis often begins in adolescence but is usually not clinically significant until the mid-30s; prevalence and severity increase do not accelerate with age.

Most researchers agree periodontitis results from a mixed infection but a particular group of gram-negative bacteria are key to the process.

The bacteria most frequently cited are Porphyromonas gingivalis, Prevotella intermedia, Bacteroides forsythus, Treponema denticola, and Actinobacillus actinomycetemcomitans.

Neutrophils (a type of white blood cell) and antibodies are the major immune defences against bacterial attack. The neutrophil/antibody axis is critical for full protection against periodontal diseases.

One of the strongest behavioural associations is with tobacco use. The risk of alveolar bone loss for heavy smokers is seven times greater than for those who have not smoked.

Cigarette smoking also may impair the normal host response in neutralizing infection. Smokers have decreased levels of salivary and serum immunoglobulins as well as depressed numbers of helper T cells.

Smoking also alters the cells that engulf and dispose of bacteria—neutrophils and other phagocytes—affecting their ability to clear pathogens.

Epidemiologic studies have found such additional factors as increasing age, infrequent dental visits, low education level, low income, co-morbidities, and inclusion in certain racial or ethnic populations are associated with increased prevalence of periodontitis.

Sex is another factor, with males tending to higher levels of periodontal diseases. Female hormones, though, may play a similar protective role as they do in protecting against osteoporosis.

More clinical attachment loss and edentulousness have been reported in osteoporotic than in nonosteoporotic women.

Studies have shown oestrogen replacement therapy in postmenopausal women not only gives protection against osteoporosis, but also results in fewer teeth lost to periodontal disease.

I hope this article serve to strengthen the translation of proven disease prevention approaches into health care practice, and personal lifestyle behaviours.

If you have any thoughts or questions, feel free to get in touch by leaving a comment here or finding me on social media:

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I’d like to start this week talking about the importance of placing implants in a succinct time frame after a tooth is removed. Hopefully you’ll find this discussion informative.

Immediate Implant Placement

If an implant is to be inserted into an extraction site, the timing of the extraction is important due to the potential for post-extraction bone resorption and ridge deformation.

Insertion of implants at the time of extraction (immediate placement) is viable if mechanical fixation can be achieved.

At present there are short-term data to support immediate placement of implants. Alternatively, implants can be inserted after complete healing of the extraction socket.

However, research is still needed on the quality of bone regenerated by such procedures and on the long-term survival analysis of the inserted implants.

Implant Complications And Maintenance

A failed implant is described as one that is clinically mobile, but an implant that shows progressive loss of supporting bone, but is clinically immobile, is also a failing implant.

Early implant failures denote a lack of initial integration while late failures and failing implants occur after initial integration, physiological remodelling, and loading.

Problems limited to the soft tissues surrounding implants and not involving the supporting bone have been defined as ‘ailing implants’ and, more recently, as biological complications.

Endosseous dental implants rarely fail beyond the first year after restoration. It has been suggested, however, that conventional periodontal therapy should be instituted if inflammation develops around an implant.

Furthermore, the microbiological findings related to healthy and failing implants are the same as those for healthy and periodontally compromised teeth.

Failing dental implants have been attributed to several factors, including bacterial infection, improper surgical procedures, and occlusal overload.

In one report, the terms infectious and traumatic failure were used to describe different clinical and microbiological features. Little information is available on the effect of occlusion on implant survival.

Currently, there is no direct evidence that non-axial loading is detrimental to the bone-implant interface, but abnormal occlusal loading will adversely affect components of an implant-supported prosthesis.

Furthermore, there are limited data regarding effects of splinting implants to natural teeth, and other data indicate that a lack of keratinized tissue attached to an abutment or machined surface implant will have no adverse effect on implant survival.

Patients should be on a regular monitoring recall schedule and maintenance programs should be designed on an individual basis.

Roughened implant abutment surfaces caused by different maintenance techniques have not been shown to increase implant complications.

Summary

Endosseous dental implants have revolutionized the fields of implants and periodontics and a great deal of information has been generated concerning their effectiveness and predictability.

Implant placement is a viable option in the treatment of partial and full edentulism and has become an integral facet of periodontal therapy. The available implants are remarkably successful.

However, there is no one ideal implant system.

Biterite offers a wide variety of solutions for implants, from cad/cam design to custom zirconia abutments.

If you have any thoughts or questions, feel free to get in touch by leaving a comment here or finding me on social media:

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Zirconium dioxide is integral for quality restorations

In my last two articles on zirconia, I spoke of zirconia and the differences which may be found in the product from various manufacturers.

Today I’d like to share with you the results of a five-year clinical evaluation of 3M™ ESPE™ Lava™ Crowns and Bridges.

Prof. P. Pospiech together with Dr. F. P. Nothdurft and Dr. P. R. Rountree from the University of Munich published their data at the Conference of the Pan European Federation of the IADR in Dublin, Ireland, not too long ago.

Thirty-one bridges were placed beginning in October, 2000. All abutment teeth were prepared for full crowns with a maximum 1.2 mm chamfer. Impressions were made with a polyether material (Impregum™ F Polyether from 3M ESPE).

All restorations were cemented conventionally with the glass-ionomer cement Ketac™ Cem from 3M ESPE. Recalls took place after one year, three years, and in March, 2006 after a five year observation period.

At each recall the fit of the restoration, occurrences of secondary caries, fracture, discoloration of the marginal gingiva, and allergic reactions were recorded. After five years, 15 bridges could be evaluated clinically.

• The survival of six bridges could be confirmed by questioning patients by phone.
• One bridge was lost for endodontic reasons after one year in service.
• One patient wearing two bridges died after the three year recall.
• Seven patients could not be recalled (the last recall examinations were conducted at the three year mark for these patients).

After five years, no failures were recorded. Slight chipping of veneering porcelain was seen in some cases but did not warrant repair or replacement. No allergenic reactions or negative influences on the marginal gingiva were observed.

The clinicians observed a high level of performance for Lava zirconia-based posterior bridges after five years of clinical service.

As I said in the last two posts, the more you know about Biterite and our products, equipment and services, the better we can serve your patients’ aesthetic and practical needs.

Please feel free to call or email us with your questions or concerns. You can also leave a comment here or find me on social media:

As always, I welcome your questions, comments and suggestions.

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Biterite, as an approved Lava design Centre equipped with a Lava ST scanner, holds firm to the idea that the more you, the dental clinician, know about the materials and processes available to you from us the better we both can provide your patients with the very best aesthetic and practical outcomes.

CAD/CAM technology had made it possible to prepare restorations out of high strength ceramics like zirconia. This is due in part to the high flexural strength (almost two times higher compared to alumina) and high fracture toughness of the zirconia ceramic material.

Several companies are offering zirconia materials in dentistry and these materials are chemically similar, consisting of 3% yttrium oxide treated tetragonal zirconia polycrystals.

In many cases they are also treated with a very small concentration of alumina to prevent leaching of the yttrium oxide. This combination ensures the safety and longevity of zirconia restorations.

Even though zirconia from various manufacturers can be chemically similar does not mean that they are necessarily the same.

Loaves of bread are often chemically similar, but many factors outside of chemistry influence the final result; i.e., ingredients and baking process, the skill of the baker.

Although the zirconia ceramic is chemically similar, once processed, it can exhibit different mechanical and optical characteristics.

Working with zirconia, I really can experience the differences in machinability (e.g., wet milling and dry milling) and in sintering (e.g., temperature for Vita™ YZ-Cube > 1,530°C; temperature for 3M™ ESPE™ Lava™ Frameworks > 1,500°C; temperature for Cercon™ > 1,350°C).

As I pointed out at the start of this blog post, the more you know about Biterite’s work, including our products, equipment and services, the better we can serve your patients’ aesthetic and practical needs.

Please feel free to call or email us with your questions or concerns. You can also leave a comment here or find me on social media:

As always, I welcome your questions, comments and suggestions.

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In my commitment to discussing the horizons of dentistry, I’ve got an overview of periodontitis associated with systemic conditions.

It should not need to be said, as much as it should be said, that patients affected by periodontal disease with underlying systemic factors should be informed about the significance of the systemic condition to the periodontal disease process.

They should also be told of the periodontal disease process, including therapeutic alternatives, potential complications, expected results, and their responsibilities in treatment.

It’s of great importance to advise the patient of the consequences of failure to treat periodontitis appropriately.

They should be told that this can result in progressive loss of periodontal supporting tissues, an adverse change in prognosis, tooth loss, and compromise of the dentition.

Of course, in the practice you would have to outline this in ‘layman’s’ terms, to make sure your patient is totally clear on the risks of systemic conditions.

Having been properly and fully advised your patient should be able to make informed decisions with regard to periodontal therapy.

A number of systemic factors are capable of affecting the periodontium and/or treatment of periodontal disease, and should particularly suspected in patients who exhibit periodontal inflammation or destruction which appears disproportionate to the local irritants.

You, the clinician, should be aware of systemic conditions and/or drugs that may be significant to periodontal diseases and of the steps necessary to evaluate them.

Your planning for periodontal therapy may then be modified according to the current medical status of the patients.

You should also bear in mind that periodontal organisms may be the source of infections elsewhere in the body and that those infections may also affect systemic health.

As always, I welcome your questions, comments and suggestions. Leave your thoughts here, or find me on social media:

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In my commitment to discussing dentistry, I present a second article on medication induced gingival hyperplasia.

Only a relatively small percentage of patients treated with the medications discussed on Monday will develop gingival overgrowth, it may be that these individuals have fibroblasts with an abnormal susceptibility.

Fibroblasts from overgrown gingiva in these patients clearly show elevated levels of protein synthesis, most of which is collagen.

In the susceptible patient, drug-associated gingival enlargement may be improved by meticulous plaque control, and regular periodontal maintenance therapy.

Periodontal maintenance therapy recommended for patients taking drugs associated with gingival enlargement is a three-month repeating cycle.

Included in each recall appointment should be detailed oral hygiene instruction and complete periodontal prophylaxis.

Removal of orthodontic bands and/or appliances should also be given clinical consideration.

The most effective treatment of drug-related gingival enlargement is withdrawal or substitution of medication.

When this treatment approach is followed it may be up to eight weeks for the resolution of gingival lesions.

Not all patients, however, will respond to this mode of treatment, especially those with long standing gingival lesions. Debridement with scaling and root planing has been to shown to offer some relief in gingival overgrowth patients.

Because of the frequent involvement of anterior labial gingiva, surgery is commonly performed for aesthetic reasons before any functional consequences are present. The classical surgical approach has been the external bevel gingivectomy.

A total or partial internal gingivectomy approach has also been suggested as an alternative.

Consultation with the immunosuppressed patient’s physician, regarding antibiotic and steroid coverage, should occur prior to any surgical treatment.

As always, I welcome your questions, comments and suggestions.

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In my continuing commitment to expanding the horizons of dentistry, I’m discussing medication induced gingival hyperplasia.

Today, more than twenty prescription medications are associated with gingival enlargement, with the number increasing.

Drugs associated with this problem can be broadly divided into three categories: anticonvulsants, calcium channel blockers.

Although the pharmacologic effect of each drug is different and directed toward various tissues, they all appear to act similarly on gingival connective tissue and have common clinical findings.

Calcium channel blockers, widely used for the management of cardiovascular disorders, are now recognized as a cause of gingival enlargement.

Among this large group of drugs, it has been found that the dihydropyridines are frequently implicated in unwanted gingival effects.

As early as 1994, it was reported that amlodipine, an agent of dihydropyridine, used for treatment of hypertension and angina, caused gingival overgrowth as side effect.

Gingival enlargement will frequently present within one to three months after treatment with an associated medication starts; it normally begins interdentally at papillae and is frequently found in the anterior segment of the labial surfaces.

Gingival lobulations gradually form and may appear inflamed or fibrotic in nature. Fibrotic enlargement is generally confined to the attached gingiva but may also extend coronally and interfere with aesthetics, mastication or speech.

Disfiguring gingival overgrowth may impair nutrition and access for oral hygiene, resulting in increased susceptibility to infection, caries, and disease.

The pathogenesis of gingival overgrowth is uncertain and treatment is largely limited to the maintenance of an improved level of oral hygiene and surgical removal of the overgrowth tissues.

As always, I welcomes your questions, comments and suggestions.

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