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NEW Next generation technology HASA JOURNAL OFFICIAL MOUTHPIECE OF THE ORAL HYGIENISTS’ ASSOCIATION OF SOUTH AFRICA 4 TH QUARTER 2019 VOLUME 20 NO. 4 ISSN 1018-1466 C E L E B R A T I N G 4 0 Y E A R S - I M P R O V I N G P E O P L E S L I V E S T H R O U G H O R A L H E A L T H -

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Page 1: HASA · 2019-12-10 · -–˛ˆ˚ˇ˚˘ ˝ ˇ˙˝˚ ˇ ˆ HASA JOURNAL Official mOuthpiece f the Oral O ygienists’ h ssOaciatiOn Of sOuth africa 4th quarter 2019 • volume 20 no

NEW Next generation technology

HASAJOURNALO f f i c i a l m O u t h p i e c e O f t h e O r a l h y g i e n i s t s ’ a s s O c i a t i O n O f s O u t h a f r i c a

4th quarter 2019 • volume 20 no. 4 • ISSn 1018-1466

celebrating 40 years - imp

ro

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g peoples lives through o

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Page 3: HASA · 2019-12-10 · -–˛ˆ˚ˇ˚˘ ˝ ˇ˙˝˚ ˇ ˆ HASA JOURNAL Official mOuthpiece f the Oral O ygienists’ h ssOaciatiOn Of sOuth africa 4th quarter 2019 • volume 20 no

EDITORIAL2 From the editor’s Desk rugShana CaDer

3 message from the Former President angelIque Kearney

GUEST EDITORIAL4 From the vice President’s Desk gaIl SmIth

RESEARch6 autoimmune Diseases and oral

health: 30-year Follow-up of a Swedish Cohort

anna JulKunen, anna marIa heIKKInen,

BIrgItta SöDer, Per-öSten SöDer, Sanna

toPPIla-SalmI anD JuKKa h. meurman

10 aesthetic management of Dental Fluorosis

vIShal KhanDelwal, ullal ananD nayaK,

PrathIBha ananD nayaK, nuPur nInawe

13 Periodontal Disease – risk Factors and treatment options

thomaS K. maDIBa, ahmeD Bhayat

17 understanding the Principles of ethics in health Care: a Systematic analysis of qualitative Information

vanIShree m. KemParaJ, umaShanKar g.

KaDalur

23 2019 South african national oral health month Celebrations

Ka mothuPI anD tB moKale

24 witsies Sink their teeth into oral health Projects

JaBulIle mBatha

OhASA nEwS26 news from the regions

30 ohaSa Journal advertising rates for 2020

31 application for ohaSa membership for 2020

CONTENTS

EDITORIAL COMMITTEE

managing editor

Rugshana Cader | Tel: (021) 937 3123/(021) 370 4409 | Cell: 082 710 7103 | E-mail: [email protected] or [email protected]

Co-editors

Anri Bernardo, E-mail: [email protected] | Lesley Vorster, E-mail: [email protected]

Stella Lamprecht, E-mail: [email protected]

OHASA OFFICE

PO Box 830, Newlands, 0049 | Fax: 086 696 7313 | E-mail: [email protected] | [email protected] | Website: http://www.ohasa.co.za

PUBLISHER

Kashan advertising | Reg. 1996/056808/23 | E-mail: [email protected]

PRODUCTION OFFICE

Kashan advertising | Tel: (012) 342 8163 | Fax: 086 645 0474 | E-mail: [email protected] | Website: www.kashan.co.za

Sub-editor: Caro Heard | layout and Design: Kashan Advertising

ISSN 1018-1466 © 2019 All rights reserved in text: OHASA. © 2019 All rights reserved in design: Kashan Advertising. OHASA Journal is published four times a year on behalf of (OHASA), the Oral Hygienists’ Association of South Africa.

No part of this publication may be reproduced or transmitted in any form, by any means, electronic or mechanical, including photocopying, recording or any information storage or retrieval system, without written permission from the editor.

Opinions and statements of whatever nature are published under the authority of the submitting author, and the inclusion or exclusion of any medicine or procedure; do not necessarily reflect the view of the editor, The Oral Hygienists’ Association of South Africa or Kashan Advertising. While every effort is made to ensure accurate reproduction, the authors, advisors, publishers and their employees or agents shall not be responsible, or in any way liable for errors, omissions or inaccuracies in the publication, whether arising from negligence or otherwise or for any consequences arising therefrom. The publication of advertisements in this magazine does not imply an endorsement by the publisher or its editorial office/board and does not guarantee any claims made for products by their manufacturers.

Published by

On behalf of

Member of

PAGE 14th quarter 2019 • volume 20 no. 4

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GO BOKKE!!!!!! Our blood runs GREEN! OHASA

echoes the sentiment of a nation as we congratulate

the Springboks on their outstanding achievement

in winning the Rugby World Cup for the third time

in Japan.

Their thrilling and comprehensive victory over a

vanquished Lions team in the final galvanised our

country. We sat glued to our television screens as our

boys in green and gold stretched every muscle and

sinew to bring the Cup home. We forgot about the

problems our country faces – the economic crisis,

the crime, the poverty. That Saturday, and the days

that followed the victory, were all celebrations of

being South African. The euphoria we felt as the

final whistle sounded felt like a cloudburst over

an entire country, drenching us in a strong sense

of patriotism, nationalism and belonging – One

Team One Nation.

Sadly, the euphoria will not last forever. The

final whistle has blown, the celebrations have died

down and the stark reality of our daily grind will

wear us down. However, our Springbok rugby team

represents HOPE, for all of us. It is perfectly fine

to only celebrate the rugby that the team played

but closer analysis and reflection tells us so much

more. This team provides the formula that we can

all follow to ensure success in our individual lives,

in our organisations, and indeed, in our country.

When we look at our World Cup Rugby squad

we see a group of thirty young men from diverse

cultures, backgrounds and races, united in a single

cause – to win the Cup. They lived with each other

for weeks on end to gel as a unit and to break down

the barriers that might potentially keep them apart.

Thirty individuals merged into a single unit, united

in purpose and clear in focus. For each member

of the team, the goal was the same. Differences

were set aside, distractions were banished to the

side-lines and all that remained was the singular

FOCUS to succeed. Coupled with this unwavering

focus, was the sense of camaraderie, the sense

of belonging to a TEAM. Whilst there is always a

leadership hierarchy, everyone there knew that

they belonged to a team and if the team won, then

everyone won. Some players were not selected for

the first team to play the ‘big’ matches. Nevertheless,

they loudly supported and encouraged each other.

There were no tantrums, no dramas; they were a

united team in which the joys of triumph would be

shared. And what a triumph it was!

Now allow me to apply that same philosophy to

our organisation, OHASA. We too are made up of

individuals from different cultures, backgrounds and

races. Some persons form the leadership and are

accountable to the organisation. No one individual

can act outside the norms and standards of the

organisation. We too are a team. However, if we

were all committed to the aims and objectives of

OHASA, I dare say we would enjoy even greater

success. We all need to FOCUS on what our goal

is – to grow our organisation so that it can play a

meaningful role in the health sector of our country.

This cannot be the task of just a few people. It

requires a collective effort, for our team to rally

around our stated purpose. It is perfectly acceptable

to have differences and to raise criticisms, as long

as this is done with respect and serves to move the

organisation forward. The success of OHASA does

not lie in the opinions and efforts of a few individuals;

it lies in TEAM OHASA. Let us be clear in our focus

and let us work together in achieving our goals.

Any chain is only as strong as its weakest link……

A crucial dimension of being part of a team is

having the ability to listen to the voices of others. At

the OHASA Journal, we have indeed listened to our

loyal readers. Concerns, particularly regarding the

questionnaire at the end of the Journal, have been

raised. We have listened and we have acted and

questions will now immediately follow each article.

This should make reading and learning easier and

indeed, should enhance your engagement with the

Journal. Please let us know what you think of this

change and notify us of any other suggestions you

may have to improve your mouthpiece.

In the blink of an eye, another year has passed.

On behalf of everyone at the Journal, we wish

you well over the festive season and the holidays.

Please take some time off for yourself and rest! It is

not too late to grab some of that Springbok magic

and gold dust, sprinkle it on yourself … and be the

magical, awesome person YOU are. ●

frOm THE

EdiTOr’S dESk

Rugshana cadermanaging editor

EDITORIAL

OHASA NATIONAL ExECUTIVE COMMITTEE

President Stella Lamprecht | Immediate Past President Stella Lamprecht | vice-President Gail Smith | Secretariat Anri Bernardo | treasurer Suné Herman

additional members Mart-Marié Potgieter, Elaine Johnson | ohaSaJ editor Rugshana Cader

OHASA BRANCH CHAIRPERSONS AND REPRESENTATIVES

gauteng BranCh | Chairperson Kaokie Sepuru | Cell: 072 902 4115 | E-mail: [email protected]

eaStern CaPe BranCh | Chairperson Shaya Pillay | Cell: 083 415 0027 | E-mail: [email protected]

Kwazulu-natal BranCh | Chairperson Kathy Dolloway | Cell: 060 992 5803 | E-mail: [email protected]

weStern CaPe BranCh | Chairperson Anri Bernardo | Cell: 084 583 5891 | E-mail: [email protected]

OhASA’S VISIOn Ohasa is a dedicated, dynamic, professional association representing hygienists as invaluable members of the health profession team.

OhASA’S MISSIOn Ohasa aims to promote quality oral healthcare by representing, protecting and advancing the profession in partnership with stakeholders.

PAGE 2 OHASA JOURNAL

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EDITORIAL

fOrmEr PrESidENTmESSAgE frOm THE

Many years ago, newly qualified, young and enthusiastic, I attended my first OHASA meeting in Pretoria.

Elize Oosthuizen / van Zyl was the president, whom I looked up to (still do) and admired, I left with a wonderful feeling of euphoria.

I thought to myself, how I would one day love to stand in her shoes and lead.

Using her leadership example and striving too for OHASA to succeed.

Many years later my dream came true, and I was privileged enough to take the stand.

A big responsibility but a very enriching experience, not a moment was bland.

I met so many amazing people and visited interesting places.

I have grown so much on a personal level and learnt to handle a crisis,

look at each problem with calmness and mindfulness,

brainstorm all the solutions using your creativeness,

do then what is right, not what is easy nor what is popular.

For any association to succeed it should always be focused on WE and not me.

So thank you to everyone involved with OHASA, your support, kindness, chats, hard work and dedication…. all gestures that have no price tag, it’s free.

Start each day with a positive thought and a grateful heart,

it will not allow depression, emptiness and sadness to take you apart.

We are all different. Don’t judge, understand instead.

Being president has helped my passion for my profession grow.

It has stretched my capabilities, challenged my thinking in what I did and didn’t know.

I had a strong purpose to keep OHASA moving forward, to grow – passion is sometimes not enough,

If you want to fly, you have to sometimes give up what weighs you down no matter how tough.

This is not good-bye, I will still see you at our seminars and meetings – I still do care… (very much).

Stay positive about our profession and our country, uplifted in daily prayer.

Yours in Love and Respect

angelique Kearney ●

Angelique Kearneyformer Ohasa president

PAGE 34th quarter 2019 • volume 20 no. 4

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As 2019 is slowly drawing to a close and we

prepare for 2020, let us reflect on OHASA and the

past year. CHANGE is inevitable so it is important

to embrace it. CHANGE is constant and we need

to be positive about it.

The year started off well in the different branches

where we successfully hosted breakfast meetings

and half- and full-day seminars. At our seminar days

we cover a broad range of topics in order to keep

our members and other oral health practitioners

abreast of what is changing in our dynamic field

of oral health.

OHASA was represented at the HOD/ISDH 2019,

held in Brisbane Australia in August. The theme of

the Symposium was LEAD which stands for:

l - Leadership

e - Empowerment

a - Advances

D - Diversity

We can use this theme within OHASA. Through

leadership we empower our members to advance

in oral health and in our Diversity we unite as Oral

Hygienists.

Mrs Angelique Kearney resigned as OHASA

President in September 20l9. As the Exco we had

planned a Strategic Planning Meeting for the day

before the AGM was hosted in Gauteng and at this

meeting we successfully put a plan in place for the

interim period. We also went through our Constitution

and realised that changes are necessary and that

we need to adjust certain parts of our Constitution.

We are in the process of consulting with a law firm

to make the necessary changes. Our Constitution

is our guide and no organisation can run without

a Constitution. When the changes are ready we

will vote on the motions and implement them at

our next AGM.

Mrs Stella Lamprecht, our Immediate Past

President, will stand in till our term comes to an

end in December 2020. The rest of the Exco is

me, Gail Smith, as Vice President, Anri Bernardo

as Secretary and Suné Herman as Treasurer.

Mr Cole Gilbert is shadowing on the National Exco

in the interim period. We encourage members to

become involved at branch level and when it is time

to elect new committees to stand for positions at

branch and national level. Let us use the theme

LEAD. Let us, as OHASA, unite as our National Rugby

Team just did and bring the CHANGE.

I want to thank our Dental Traders for their

ongoing support and assure them that we are loyal

partners in the Dental Industry.

To our members and other health professionals I

wish you a blessed holiday season with your loved

ones and let us shine our light wherever we go.

God Bless

gail smith

OHASA Vice President ●

frOm THE

ViCE PrESidENT’S dESk

Gail SmithOhasa Vice president

GUEST EDITORIAL

PAGE 4 OHASA JOURNAL

www.panasonic.com/za

Int Dentistry Panasonic Ad A4 052019 FIN.indd 1 2019/05/17 14:23

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PAGE 54th quarter 2019 • volume 20 no. 4

www.panasonic.com/za

Int Dentistry Panasonic Ad A4 052019 FIN.indd 1 2019/05/17 14:23

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RESEARch

Anna Julkunen1, Anna Maria Heikkinen1, Birgitta Söder2,*, Per-Östen Söder2, Sanna Toppila-Salmi1 and Jukka H. Meurman1

1 Department of Oral and Maxillofacial Diseases, University of Helsinki and Helsinki University Hospital, 00014 Helsinki, Finland; [email protected] (A.J.); anna.m.heikkinen@helsinki. fi

(A.M.H.); [email protected] (S.T.-S.); [email protected] (J.H.M.)

2 Department of Dental Medicine, Karolinska Institutet, BOx 4064, 14104 Huddinge, Stockholm, Sweden; [email protected]

* Correspondence: [email protected]; Tel.: +46-761-009-511

Source: Dent. J. 2018, 6, 1; doi:10.3390/dj6010001

AuTOimmuNE diSEASES ANd OrAl HEAlTH:30-YEAr fOllOw-uP Of A SwEdiSH COHOrT

introDuction

Autoimmune diseases are rare pathological states

arising from an abnormal immune response to

substances and tissues that are normally present

in the body. These diseases are multifactorial,

heterogeneous and variable conditions that may

exist in several organs and cell types [1,2]. The

pathomechanisms of autoimmunity are multifactorial

and mostly unknown [1]. The stability and functionality

of tissues is a complex and strictly regulated process

where immune system plays a role [2]. Pathogens can

affect the regulation and autoimmunity reactions may

follow [2]. Infection can induce autoimmunity either

via the innate or adaptive immune responses [3].

A strong link has indeed been shown between

viral, bacterial and other microbial infections and

autoimmunity [3,4]. However, there are many factors

that affect autoimmune diseases, like genetics, age,

gender, reproductive status, and hormones [2,5].

Smoking tobacco also associates with autoimmune

diseases but this has not been observed regarding

snuff use [6,7].

From a clinical perspective there are two ways to

categorize autoimmune diseases; organ-specific or

systemic [8]. In organ-specific autoimmune diseases

the expression of autoimmunity is limited to specific

organs, for example on insulin-producing β-cells in

pancreas in Type-1 diabetes mellitus [8,9].

In systemic autoimmune diseases autoimmunity

affects multiple organs, such as seen in rheumatoid

arthritis (RA) [10]. Some of the immune-mediated

diseases also affect oral mucosa [11]. These findings

can in fact be the first signs of manifestation of an

autoimmune disease [11]. Oral infections as such

up-regulate a number of systemic inflammatory

reactions which, in turn, play a role in the development

of many systemic diseases [11].

The American Autoimmune Related Diseases

Association (AARDA) identifies 80–100 different

autoimmune diseases and at least 40 additional

diseases have been suspected to have autoimmune

characteristics [12]. Autoimmune diseases are chronic,

often progressing and severe [12].

Periodontitis is a multifactorial inflammatory

disease where tissues around the teeth can destruct

and finally leading to loss of teeth [13]. Periodontal

pocket depth ≥5 mm is considered as severe clinical

attachment loss [14]. Periodontitis is associated with

a number of diseases like the above-mentioned RA

and diabetes [15,16]. Since 1985 we have investigated

systematically the associations between oral

infections, periodontitis in particular, with several

general diseases in a Swedish population cohort. Our

studies have shown statistically significant associations

between poor oral health and cardiovascular

diseases and cancer [17–19]. In the same cohort

we now investigated the incidence of autoimmune

diseases with respect to the patients’ oral health

parameters. The aim of this study was to examine if

poor oral health indeed associates with autoimmune

diseases, in the infection or inflammation paradigm.

The hypothesis was that poor oral health reflects in

the incidence of autoimmune diseases.

materials anD methoDs

At baseline in 1985, a cohort of 3 273 subjects was

randomly selected from the registry file of all inhabitants

in the Stockholm region who were born on the 20th

of any month from 1945 to 1954. Of them 1 676

individuals replied to the invitation and participated

in the baseline study. They underwent a clinical oral

examination and filled out a structured questionnaire.

Basic characteristics and health behavioral such as

smoking and snuff use habits and working status were

registered (Table 1). The clinical examination included

measures for plaque index (PI) [20], gingival index

(GI) [20,21], calculus index (CI), recording periodontal

pockets and missing teeth (Table 2). CI was scored

from 0 (no calculus) to 3 (abundant calculus) according

to Greene and Vermillion [22]. Depth of periodontal

pockets was measured from all teeth with a Hu-Friedy

(PCPUNC 15) periodontal probe (Hu-friedy, Chicago,

IL, USA) and pockets ≥5 mm were registered. The

number of teeth was also registered. Periodontal

pockets and missing teeth (both categorized as yes/

no) were used in the analyses. Details of the baseline

study have been earlier published [23,24]. There

were no patients with dentures in the present data.

abstract

Oral infections up-regulate a number of systemic inflammatory reactions that, in turn, play a role in the

development of systemic diseases. We investigated the association between oral health and autoimmune

diseases in a cohort of Swedish adults. Hypothesis was that poor oral health associates with incidence

of autoimmune diseases. Overall 1 676 subjects aged 30–40 years old from Stockholm County (Sweden)

participated in this study in 1985. Subjects were randomly selected from the registry file of Stockholm

region and were followed-up for 30 years. Their hospital and open health care admissions (World

Health Organization ICD 9 and 10 codes) were recorded from the Swedish national health registers. The

association between the diagnosed autoimmune disease and the oral health variables were statistically

analyzed. In all, 50 patients with autoimmune diagnoses were detected from the data. Plaque index

was significantly higher in the autoimmune disease group (≥median 35 (70%) vs. <median 872 (54%),

p = 0.030). No statistical difference was found in gingival index, calculus index, missing teeth, periodontal

pockets, smoking or snuff use between patients with and without autoimmune disease. Our study

hypothesis was partly confirmed. The result showed that subjects with a higher plaque index, marker

of poor oral hygiene, were more likely to develop autoimmune diseases in 30 years.

Keywords: autoimmune disease; oral health; association; plaque index; follow-up study

PAGE 6 OHASA JOURNAL

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table 1: Characteristics and health habits of patients without and with autoimmune disease

number of patients

patients with no autoimmune Disease

n = 1626 (%)

patients with autoimmune Disease

n = 50 (%) p-valuea

sexMaleFemale

812 (50)814 (50)

26 (52)24 (48)

0.886

smokingCurrent smokerFormer smokerNon-smoker

595 (36.5)432 (26.5)599 (37)

21 (42)13 (26)16 (32)

0.710

snuff useCurrent snufferFormer snufferNon-snuffer

b

89 (5)28 (2)

1 367 (84)

c

5 (10)0 (0)

37 (74)

0.289

WorkingCurrentlyNot currently

1 488 (92)138 (8)

42 (84)8 (16)

0.073

a p-value by Fisher’s exact test; b No data of 142 patients; c No data of eight patients.

table 2: oral health status of the patients without and with autoimmune disease

patients with no autoimmune Disease

n = 1626 (%)

patients with autoimmune Disease

n = 50 (%) p-valuea

Periodontal pockets 5 mmYesNo

277 (17)1 349 (83)

9 (18)41 (82)

0.849

Missing teethYesNo

720 (44)906 (56)

23 (46)27 (54)

0.885

Plaque index (median 0.67)0.00–0.660.67–3.00

b

749 (46)872 (54)

15 (30)35 (70)

0.030

Gingival index (median 1.19)0.00–1.181.19–3.00

804 (49)822 (51)

23 (46)27 (54)

0.668

Calculus index (median 0.17)0–0.160.17–3.00

c

538 (33)1 083 (67)

10 (20)40 (80)

0.065

a p-value by Fisher’s exact test; b No data of five patients; c No data of five patients.

In the present study we used a modified list of autoimmune diseases published by AARDA [12]. Only

diseases with literature evidence of autoimmunity as main etiology were accepted in the list (Table 3).

table 3: autoimmune diseases in the material

autoimmune Disease icD 10 number of patients

Ankylosing spondylitis1

Crohn’s disease2

Colitis ulcerosa3

Diabetes mellitus Type-14

Graves’ disease5

Guillain-Barré syndrome6

Henoch-Schönlein purpura7

Lichen planus8

Psoriasis9

Rheumatic disease10

Sicca syndrome (e.g., Sjögren)11

Systemic lupus erythematosus12

Wegener’s granulomatosis13

277 (17)1 349 (83)

9 (18)41 (82)

1 Includes: ankylosing spondylitis (ICD-9 720); 2 Includes: Crohn’s disease of large intestine without complications (K50.1), Crohn’s disease, unspecified, without complications (K50.9); 3 Includes: Ulcerative colitis, unspecified (K51.9), Ulcerative (chronic) rectosigmoiditis (K51.3); 4 Includes: Type 1 diabetes mellitus (E10.0), Type 1 diabetes mellitus without complications (E10.9); 5 Includes: Graves’ disease; 6 Includes: Guillain-Barre syndrome (G61.0); 7 Includes: Henoch-Schönlein purpura (ICD9 287); 8 Includes: other lichen planus (L43.8); 9 Includes: Psoriasis (L40.0), psoriasis, unspecified (L40.9); 10 Includes: crystal arthropathy (M11.9), lethal midline granuloma (ICD9 446.3), myalgia (M79.1), other rheumatoid arthritis with rheumatoid factor of multiple site (M05.8), other seropositive rheumatoid arthritis (M05.8), primary osteoarthritis of other joints (M19.0), rheumatic fever without mention of heart involvement (I00.9), seropositive rheumatoid arthritis, unspecified (M05.9), unilateral primary osteoarthritis of hip (M16.1), unilateral primary osteoarthritis of knee (M17.1); 11 Sicca syndrome (M35.0); 12 includes: systemic lupus erythematosus, unspecified (M32.9); 13 includes: Wegener’s granulomatosis (M31.3).

ethical consiDerations

The study was approved by the Ethics Committee

of the Karolinska Institutet and Huddinge University

Hospital in Sweden (Dnr 101/85 and revised in

2012/590-32). The study is in accordance with the

Declaration of Helsinki.

autoimmune relateD Diseases anD

socioeconomic Data

Data about autoimmune-related diseases were

obtained from the Centre of Epidemiology, Swedish

National Board of Health and Welfare, Sweden. The

data were classified according to the World Health

Organization International Statistical Classification of

Diseases and Related Health Problems (ICD-9 and

ICD-10). Socioeconomic data were further obtained

from the National Statistics Centre, Örebro, Sweden,

based on the 1985 file. The cumulated data for the

disease incidence from 1985 to 2015 were statistically

analysed with the clinical data from 1985.

Data analysis

Statistical analyses were carried out by the SPSS

Base 15.0 Statistical Software Package (SPSS Inc.,

Chicago, IL, USA). Comparisons were made by

cross-tabulation, chi-square test, and binary logistic

regression. Median values of PI, GI and CI were

calculated. We analyzed the association between

patients with and without autoimmune disease

and the following variables: sex, smoking (current

smoker/ex-smoker/non-smoker), snuff use (current

snuffer/ex-snuffer/non-snuffer), working status (yes/

no currently working), ≥5 mm periodontal pockets

(yes/no), missing teeth (yes/no) and median values

of PI, GI, and CI scores, respectively. p-values less

than 0.05 were considered statistically significant.

results

Patient characteristics are given in Table 1. The

autoimmune diagnoses found among the patients

are given in Table 3. The subjects were separated

into two groups: patients with (N = 50) and with no

(N = 1626) autoimmune disease (Table 2). Their oral

health and background variables were statistically

analyzed and compared to each other. The gender

distribution was the same in both groups. Smoking

and snuff use did not differ significantly between

the groups. However, a trend was found according

to patients with autoimmune disease being on

average more seldom in working life than those

with no autoimmune disease diagnosis.

Oral health data showed no difference between

groups in the number of periodontal pockets or

missing teeth. The autoimmune patients with

≥5 mm periodontal pockets were diagnosed with

diabetes mellitus Type-1 (three patients), rheumatic

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diseases (4 patients), Henoch-Schönlein purpura

(one patient), and colitis ulcerosa (one patient).

Twenty-three patients (46%) with autoimmune

disease and 720 patients (44%) without autoimmune

disease had missing teeth (p = 0.885). The number

of missing teeth per person varied: 1–6 among the

autoimmune disease patients, 1–28 among patients

with no autoimmune disease, respectively.

The presence of autoimmune disease associated

with higher PI (crude odds ratio (OR) = 2.00, 95%

confidence interval (CI) = 1.09–3.70, p = 0.016).

When adjusted by gender and use of snuff the

result remained the same (adjusted OR = 2.30, 95%

CI = 1.17–4.56, p = 0.016). No statistical significant

difference was found in GI scores of patients with

and without autoimmune disease diagnosis. CI scores

did not either differ between the groups (Table 2).

Discussion

This study was made to investigate if oral health

parameters, with emphasis in periodontitis, associate

with the presence of autoimmune disease as we had

hypothesized. The main finding was that only PI was

significantly higher among the autoimmune disease

group compared with those without autoimmune

disease. High PI reflects poor oral hygiene and

may, thus, cause upregulating of cytokines and

inflammatory mediators in the tooth supporting

tissues. However, the gingival index was no higher in

the autoimmune disease group which finding, in this

perspective, was surprising. One would expect that

the accumulation of dental plaque links to gingival

inflammation, too, but this was not the case in the

present material. Here the patients’ medication

may also have an effect because anti-inflammatory

drugs were frequently used by these patients. Data

on medication, however, were not in our disposal,

which is a limitation of our study.

The role of infections in the etiology and

development of autoimmune diseases is not

clear [25]. There have been numerous theories how

infections could cause autoimmunity for example by

molecular mimicry [25]. In the 1950s a theory was

presented that self-reactivity (as in autoimmunity)

was some kind of failure of the immune system but

today it is known that these are normal reactions

in regeneration and healing processes [25]. For

example dead or dysfunctional cells must be

eliminated and removed [25]. Autoantibodies also

have a significant role in infections, especially in

viral infections, which have been connected to the

development of autoimmune diseases [25].

In our cohort, most of the autoimmune diseases

were rheumatic disease or Type-1 diabetes. It is

known that periodontal disease associates with RA

and diabetes, so this finding was not new [26–28].

Patients with rheumatic diseases may have problems

with manual dexterity and consequent difficulties

in cleaning the teeth. If the rheumatic disease has

been present already in 1985 at the baseline of

this study, or before, perhaps this might be one

factor explaining why the patients with autoimmune

diseases as a group had higher PI scores compared

with the healthy ones.

To the best of our knowledge the present

investigation is the first study to evaluate oral health

and the incidence of all autoimmune diseases in the

same study ethnically homogenous population. At

the time when this cohort study was commenced

the Swedish population was mainly homogenous

Caucasian, which is a strength even though the

results might not be generalized to other populations.

The limitations of our study, however, are the

lack of data of health habits, such as alcohol use

and tooth brushing frequency, which had not been

recorded. The number of subjects with autoimmune

disease was small even though originally more than

3000 subjects had been enrolled to the study;

thus, the statistical power remained weak. The

fact that the exact time when the diagnosis was

made was not included in the register files also

was a weakness. Likewise, it was not possible to

assess the patients’ liability, such as having close

relatives with autoimmunity. Furthermore, the exact

reason for teeth loss remains unclear. As well as

the relationship of bacterial infection and systemic

disease could only be speculated without supporting

inflammatory data.

conclusions

The subjects with a higher plaque index appeared

to be more likely to develop autoimmune diseases

in 30 years. Furthermore, patients with autoimmune

diseases also were less frequently in working life

probably due to their disease.

Acknowledgments: The study was supported by

the Swedish Ministry of Health and Social Affairs

(grants F84/189), and by the Karolinska Institutet,

Stockholm, Sweden, and grants from the Finnish

Association of Otorhinolaryngology and Head

and Neck Surgery, the Finnish Female Dentist

Federation, the Finnish Medical Association, the

Ida Montin Foundation, the Jane and Aatos Erkko

Foundation, the Väinö and Laina Kivi Foundation

and the Dentists of Helsinki Region Federation.

Helsinki University Hospital funds provided the

infrastructure needed.

Author Contributions: Birgitta Söder and Per-Östen

Söder conceived and designed the experiments;

Per-Östen Söder performed the experiments; Anna

Julkunen and Anna Maria Heikkinen analyzed the

data; Jukka H. Meurman and Sanna Toppila-Salmi

contributed analysis tools; Anna Julkunen wrote

the paper. All the authors have commented the

paper and have participated to improve the paper.

Conflicts of Interest: The authors declare no

conflicts of interests regarding the publication of

this article. ●

abbreviations

AARDA The American Autoimmune Related

Diseases Association

CI Calculus index

GI Gingival index

PI Plaque index

RA Rheumatoid arthritis

references1. Damoiseaux, J.G.; Tervaert, J.W. The definition of

autoimmune disease: Are Koch’s postulates applicable?

Neth. J. Med. 2002, 60, 266–268.

2. Ercolini, A.M.; Miller, S.D. The role of infections in

autoimmune disease. Clin. Exp. Immunol. 2008, 155, 1–15.

3. Kivity, S.; Agmon-Levin, N.; Blank, M.; Shoenfeld, Y.

Infections and autoimmunity—Friends or foes? Trends

Immunol. 2009, 30, 409–414.

4. Galli, L.; Chiappini, E.; de Martino, M. Infections and

autoimmunity. Pediatr. Infect. Dis. J. 2012, 31, 1295–1297.

5. Selgrade, M.; Cooper, G.; Germolec, D.; Heindel, J.

Linking environmental agents and autoimmune disease:

An agenda for future research. Environ. Health Perspect.

1999, 107, 811–813.

6. Arnson, Y.; Shoenfeld, Y.; Amital, H. Effects of tobacco

smoke on immunity, inflammation and autoimmunity. J.

Autoimmun. 2010, 34, J258–J265.

7. Ludvigsson, J.F.; Nordenvall, C.; Jarvholm, B. Smoking,

use of moist snuff and risk of celiac disease: A

prospective study. BMC Gastroenterol. 2014, 14, 120.

8. Rosen, A.; Casciola-Rosen, L. Autoantigens as partners

in initiation and propagation of autoimmune rheumatic

diseases. Annu. Rev. Immunol. 2016, 34, 395–420.

9. Lesage, S.; Goodnow, C. Organ-specific autoimmune

disease: A deficiency of tolerogenic stimulation. J. Exp.

Med. 2001, 194, F31–F36.

10. Imazio, M. Pericardial involvement in systemic

inflammatory diseases. Heart 2011, 97, 1882–1892.

11. Bascones-Martinez, A.; Garcia-Garcia, V.; Meurman, J.H.;

Requena-Caballero, L. Immune-mediated diseases: What

can be found in the oral cavity? Int. J. Dermatol. 2015,

54, 258–270.

12. American Autoimmune Related Diseases Association,

Inc. American Autoimmune Related Diseases

Assosiation. Available online: http://www.aarda.org/

disease-list/ (accessed on 1 April 2015).

13. Nibali, L.; Farias, B.C.; Vajgel, A.; Tu, Y.K.; Donos, N.

Tooth loss in aggressive periodontitis a systematic

review. J. Dent. Res. 2013, 92, 868–875.

14. Anonymous. American academy of periodontology task

force report on the update to the 1999 classification of

periodontal diseases and conditions. J. Periodontol.

2015, 86, 835–838.

15. Berthelot, J.; Le Goff, B. Rheumatoid arthritis and

periodontal disease. Joint Bone Spine 2010, 77,

537–541.

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16. Sonnenschein, S.K.; Meyle, J. Local inflammatory

reactions in patients with diabetes and periodontitis.

Periodontol. 2000 2015, 69, 221–254.

17. Virtanen, E.; Soder, B.; Andersson, L.C.; Meurman, J.H.;

Soder, P. History of dental infections associates with

cancer in periodontally healthy subjects: A 24-year

follow-up study from Sweden. J. Cancer 2014, 5, 79–85.

18. Soder, B.; Meurman, J.H.; Soder, P. Dental calculus links

statistically to angina pectoris: 26-year observational

study. PLoS ONE 2016, 11, e0157797.

19. Soder, P.; Soder, B.; Nowak, J.; Jogestrand, T. Early

carotid atherosclerosis in subjects with periodontal

diseases. Stroke 2005, 36, 1195–1200.

20. Loe, H. The gingival index, the plaque index and the

retention index systems. J. Periodontol. 1967, 38.

21. Dolan, L.; Pendill, J.; Dedeke, J. Carranza’s Clinical

Periodontology; Saunders Elsevier: St. Louis, MO, USA,

2006.

22. Greene, J.; Vermillion, J. Simplified oral hygiene index. J.

Am. Dent. Assoc. 1964, 68, 7–13.

23. Soder, P.; Jin, L.; Soder, B.; Wikner, S. Periodontal status

in an urban adult-population in Sweden. Commun. Dent.

Oral Epidemiol. 1994, 22, 106–111.

24. Soder, B.; Jin, L.; Soder, P.; Wikner, S. Clinical

characteristics of destructive periodontitis in a risk group

of Swedish urban adults. Swed. Dent. J. 1995, 19, 9–15.

25. Root-Bernstein, R.; Fairweather, D. Complexities in the

relationship between infection and autoimmunity. Curr.

Allergy Asthma Rep. 2014, 14, 407.

26. Araujo, G.R.; Vaz, E.R.; Fujimura, P.T.; Fonseca, J.E.;

de Lima, L.M.; Canhao, H.; Venturini, G.; Cardozo, K.H.;

Carvalho, V.M.; Napimoga, M.H.; et. al. Improved

serological detection of rheumatoid arthritis: A highly

antigenic mimotope of carbonic anhydrase III selected

in a murine model by phage display. Arthritis Res. Ther.

2015, 17.

27. Fuggle, N.R.; Smith, T.O.; Kaul, A.; Sofat, N. Hand to

Mouth: A systematic review and meta-analysis of

the association between rheumatoid arthritis and

periodontitis. Front. Immunol. 2016, 7, 80.

28. Linhartova, P.B.; Kastovsky, J.; Lucanova, S.; Bartova, J.;

Poskerova, H.; Vokurka, J.; Fassmann, A.; Kankova, K.;

Holla, L.I. Interleukin-17A gene variability in patients

with type 1 diabetes mellitus and chronic periodontitis:

Its correlation with il-17 levels and the occurrence of

periodontopathic bacteria. Mediat. Inflamm. 2016, 2016.

CONTiNuiNg PrOfESSiONAl dEVElOPmENT QuESTiONNAirE – ArTiClE 1

autoimmune Diseases anD oral health

1.1 Which of the following statements is untrue? No statistically significant difference was

identified between patients with and without autoimmune conditions with respect to:

A. The plaque index

B. The calculus index

C. Periodontal pocketing

D. Smoking

1.2 The ICD 10 code for Sjögrens Syndrome is:

A. M31.1

B. M32

C. M35.0

D. M45

1.3 The most common autoimmune condition that affected the study participants was:

A. Diabetes mellitus Type-I

B. Rheumatoid disease

C. Crohn’s disease

D. Colitis ulcerosa

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Vishal Khandelwal1, Ullal Anand Nayak2, Prathibha Anand Nayak3, Nupur Ninawe4

1 Department of Pedodontics, Modern Dental College and Research Center, Indore, Madya Pradesh, India

2 Department of Pedodontics, MGM Dental College, Jaipur, Rajasthan, India

3 Department of Periodontics, Mahatma Gandhi Dental College, Jaipur, Rajasthan, India

4 Department of Pedodontics, VSPM Dental College, Nagpur, Maharashtra, India

* Correspondence: Dr Prathibha Anand Nayak, [email protected]

Source: BMJ Case Rep 2013. doi:10.1136/bcr-2013-010029

dENTAl fluOrOSiSAESTHETiC mANAgEmENT Of

bacKgrounD

While there is a range of restorative interventions that can be used to change

the appearance of fluorosed teeth, the goal of minimally invasive treatment

for mild-moderate fluorosis is the one that should be evaluated first. In this

presented case, a minimally invasive treatment option of microabrasion was

shown to be a satisfactory approach for the aesthetic treatment of moderate

fluorosis. This procedure is simple, easy to perform with no patient discomfort

and removes the stains permanently.

case presentation

A 12-year-old male patient was screened at the dental clinic for routine dental

care. His wanted us to remove and/or minimise the noticeable brown/ yellow

staining of his teeth. He wanted the least invasive and most cost-effective

treatment to change his smile. A review of his medical and dental history

revealed no contraindications to dental treatment. Considering his age, the

patient was not interested in treatment options that involved significant removal

of tooth structure, such as porcelain or composite resin veneers which had

previously been suggested to him by his previous dentist.

The patient’s desire to change the appearance of his teeth in the aesthetic

zone was to improve his smile and thereby his confidence. From the appearance

of his teeth, a diagnosis of mild to moderate fluorosis staining (determined by

using Dean’s Fluorosis Index) was present on the anterior and posterior teeth

in the aesthetic zone (white mottled enamel hypomineralisation), with the most

significant staining occurring on the maxillary anterior teeth; teeth no. 11 and

21 had dark brown streaks in the middle third of the facial surfaces (Figure 1).

A review of his history and a complete dental examination revealed he

was from Rajasthan, a state of India. He reported childhood friends as having

the same discolouration of their teeth. Rajasthan is associated with endemic

fluorosis. A treatment plan was presented to the patient that would fulfil his

request for minimally invasive treatment which proposed microabrasion of the

superficial enamel staining. Upon completion of treatment, the tooth shade

would be evaluated.

treatment

After a routine oral prophylaxis, the maxillary central incisors were isolated

with a dental dam to protect the gingival tissues from the acidic microabrasion

paste. A mixture of sodium bicarbonate and water was placed on the rubber

dam behind the teeth for protection in case of spillage (Figure 2).

summary

Significant numbers of patients visiting the paediatric dental clinics have

aesthetically objectionable brown stains and desire treatment for them.

Intrinsic tooth discolouration can be a significant aesthetic, and in some

instances, functional, problem. Dental fluorosis, tetracycline staining,

localised and chronological hypoplasia, and both amelogenesis and

dentinogenesis imperfecta can all produce a cosmetically unsatisfactory

dentition. The aetiology of intrinsic discolouration of enamel may sometimes

be deduced from the patient’s history, and one factor long associated

with the problem has been a high level of fluoride intake. Optimal use of

topical fluorides leads to a decrease in the caries prevalence but may show

an increase in the prevalence of fluorosis staining because of metabolic

alterations in the ameloblasts, causing a defective matrix formation and

improper calcification. A 12-year-old male patient was screened at the

dental clinic for routine dental care. He wanted us to remove and/or

minimise the noticeable brown/yellow staining of his teeth. He requested

the least invasive and most cost-effective treatment to change his smile.

Various treatment modalities are present for the treatment of fluorosis

stains. This report discusses the microabrasion technique in the patient

having dental fluorosis.

figure 1: Teeth no. 11 and 21 showing dark brown streaks in the middle third of the facial surfaces

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18% hydrochloric acid was mixed with pumice into slurry and a small amount

was applied to the labial surface with either a slowly rotating rubber cup or

rubbed over the surface for 5s1 It was then washed for 5s directly by the aspirator.

The procedure was repeated up to a maximum of 10×5s applications per tooth

until the stain is reduced.2,3 Any possible improvement would have occurred

by this time. Topical fluoride varnish (bifluorid 12 VOCO, GmbH, Germany) was

applied on the teeth for 3 min.

The procedure was repeated for three sittings, until a satisfactory cosmetic

outcome was achieved (Figure 3). In the final sitting the teeth were polished with

graded Soflex discs and prophylactic polishing pastes.

outcome anD folloW-up

The patient was satisfied with the final aesthetic result. The patient was

reviewed after 1 month for sensitivity testing.

Discussion

There is an ever-growing demand for aesthetic dental treatment. Treatment

modalities include crowns, bleaching, and ceramic or composite veneers. A

more conservative treatment option, enamel microabrasion, may be indicated

in certain clinical scenarios.4 Enamel microabrasion was developed in the

mid-1980s as a method of eliminating enamel discolouration defects and

improving the appearance of teeth.5

Such kind of treatment is appropriate since it aims at the maximum preservation

of the dental structures and avoids the damages that are inflicted during the

operative recovery of the dental surfaces affected with fluorosis.

When hydrochloric acid is used as slurry with pumice, the abrasive property

hastens the removal of the tooth structure by exposing a greater surface area

of enamel. An interesting effect of enamel microabrasion has been that the

appearance of some deeper enamel lesions can be improved, even if the

discoloured defect is not completely removed. The reflective and refractive

indices of the microabraded enamel are altered after treatment as the

surfaces re-mineralise. After enamel microabrasion treatment, a superficial

enamel structure may occur that has reflective and refractive properties that

mask residual subjacent discolouration. Donly et. al.6 showed that a dense

prismless layer is formed on the abraded enamel surface giving the tooth a

glass- like lustre appearance.

According to data from the relevant literature, microabrasion removes an

enamel layer between 100 and 200 μm.7,8

The active remineralisation using fluoride varnish ensures the resistance

of the enamel layer only to a minimum degree, reduced by microabrasion.

The method is not time-consuming and provides a solution for the complex

situation created by dental fluorosis.

While the exact reason for the colour change that occurs after microabrasion

is not known, the microabraded surface reflects and refracts light from the

tooth surface in such a way that mild imperfections in the underlying enamel

are camouflaged. The acid may also penetrate and bleach the organic

compounds within the enamel, which explains the improvement in tooth

colour. Mild surface abrasion of the enamel prisms with simultaneous acid

erosion leads to compaction of the mineralised tissue within the organic

region of the enamel, replacing the outer prism-free region. Light reflected

off and refracted through this new surface is thought to act differently than

light from an untreated enamel surface. In addition, subsurface stains may

be camouflaged by the optical properties of the newly microabraded surface.

Croll has named this phenomenon the ‘abrasion effect’. However, in this case

it reduced the stains but did not remove them completely.

Use of microabrasion in the treatment of dental fluorosis should be

performed cautiously. If after one cycle of 20 min no improvement is noted,

a labial veneer restoration should be considered as an alternative treatment.

Further treatment with acid can result in an unaesthetic, dished out effect or

unaesthetic reduction in the mesial distal curvature of the labial surface and

may also cause postoperative sensitivity.

Enamel microabrasion, however, cannot solve all tooth discolouration

problems. Dentinal discolouration such as that seen with dentinogenesis

imperfecta, tetracycline staining or tooth darkening associated with

devitalisation or endodontic therapy cannot be affected by microabrasion;

other colour correction methods are necessary in such cases. Likewise,

deep enamel hypoplastic defects, once removed, leave a tooth form defect

that requires replacement of lost anatomic structure with tooth-coloured

restorative material. Sometimes you cannot be certain as to the depth of

a lesion; therefore, it is unknown whether enamel microabrasion by itself

will be the best treatment. In such cases, there is no risk to attempting

microabrasion when composite resin bonding can subsequently be

performed, as necessary.

figure 3: Satisfactory cosmetic outcome

figure 2: Rubber dam application to prevent spillage

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CONTiNuiNg PrOfESSiONAl dEVElOPmENT QuESTiONNAirE – ArTiClE 2

aesthetic management of Dental fluorosis

2.1 For which of the following clinical scenarios is microabrasion indicated?

A. A non-vital, discoloured tooth

B. Mild to moderate fluorosis

C. Tetracycline staining

D. Dentinogenesis imperfecta

2.2 Intrinsic dental staining can be both an aesthetic and functional

problem.

True or False?

2.3 Which of the following statements regarding the microabrasion

technique is incorrect?

A. The affected teeth are isolated with a rubber dam

B. An 18% hydrochloric (HCl) acid and pumice slurry is prepared

C. The acidic pumice slurry is then applied to the buccal surface

of an affected tooth for 5 seconds using a nylon bristled

polishing brush rotating at high speed

D. Post treatment, topical fluoride varnish is applied for 3 minutes

2.4 According to the authors, the maximum number of times that the

acidic pumice slurry may be applied to an affected tooth in one

dental appointment is:

A. 12

B. 10

C. 8

D. 6

2.5 Possible reasons as to why enamel microabrasion improves the

appearance of mild to moderate fluorosis include:

A. The ‘abrasion effect’

B. The hydrochloric acid used penetrates and bleaches organic

compounds present within the enamel

C. Abrasion combined with acid erosion promotes dispersion of

mineralised tissue within the organic region of enamel

D. A and B

2.6 Which of the following is not a potential side effect of enamel

microabrasion?

A. Increased darkening of the intrinsic dental stain

B. Loss of the mesial distal curvature of the buccal tooth surface

C. Post-operative dental sensitivity

D. Dished out appearance

learning points

• A minimally invasive treatment option of microabrasion was shown to be

a satisfactory approach for the aesthetic treatment of moderate fluorosis.

• This procedure is simple, easy to perform.

• No patient discomfort and removes the stains permanently.

• The procedure does not require anaesthesia.

• Multiple teeth can be treated at one time.

Competing interests: None.

Patient consent: Obtained.

Provenance and peer review: Not commissioned; externally peer reviewed. ●

references1. Ismail AI, Hasson H. Fluoride supplements, dental caries and fluorosis: a systematic

review. J Am Dent Assoc 2008;139:1457–68.

2. Wray A, Welbury R. Treatment of intrinsic discoloration in permanent anterior teeth in

children and adolescents. http://www.rcseng.ac.uk/fds/publicationsclinicalguidelines/

clinical_guidelines/documents/discolor. pdf

3. Croll TP. Enamel microabrasion for removal of superficial dysmineralization and

decalcification defects. J Am Dent Assoc 1990;120:411–15.

4. Lynch CD, McConnell RJ. The use of microabrasion to remove discoloured enamel: a

clinical report. J Prosthet Dent 2003;90:417–19.

5. Croll TP. Enamel microabrasion: 10 year's experience. Asian J Aesthet Dent 1995;3:9–15.

6. Donly KJ, O’Neill M, Croll T. Enamel microabrasion: a microscopic evaluation of the

‘abrosion effect’. Quintessence Int 1992;23:175–9.

7. Tong LS, Pang MK, Mok NY, et. al. The effects of etching, micro-abrasion, and bleaching on

surface enamel. J Dent Res 1993;72:67–71.

8. Dalzell DP, Howes RI, Hubler PM. Microabrasion: effect of time, number of applications,

and pressure on enamel loss. Pediatr Dent 1995;17:207–11.

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Thomas K. Madiba1, Ahmed Bhayat2

1 B.Dent Ther, BDS, DHSM, MChD (Community Dentistry), Department of Community Dentistry, School of Dentistry, University of Pretoria, Pretoria, South Africa

2 BDS, MSc, MPH, M Dent (Community Dentistry), Department of Community Dentistry, School of Dentistry, University of Pretoria, Pretoria, South Africa

* Corresponding author: Thomas Madiba, Department of Community Dentistry, School of Dentistry, University of Pretoria, Pretoria, South Africa. Tel: +27 (0)12 319 2417 Email: [email protected]

Source: SADJ October 2018, Vol. 73 No. 9 p571–p575

– riSk fACTOrS ANd TrEATmENT OPTiONS

acronyms

LGE: Linear Gingival Erythema

NUG: Necrotising Ulcerative Gingivitis

NUP: Necrotising Ulcerative Periodontitis

PD: Periodontal Disease

SES: Socioeconomic Status

summary

Periodontal disease (PD) encompasses both gingivitis and periodontitis. Both

are initiated by plaque and are influenced by the immune and inflammatory

responses of each individual. In addition, PD is modified by several risk factors

including smoking, medications, alcohol, age, gender and systemic diseases.

Gingivitis affects 50–90% of adults worldwide and is reversible by simple,

effective oral hygiene and lifestyle changes. Between 10–15% of the global

adult population suffer from progressive periodontitis, which if left unattended,

results in halitosis, pain and loss of teeth.

As dental plaque is the principal etiological factor in the pathogenesis of

PD, effective oral hygiene and plaque removal is the most important strategy

in the prevention of this disease. There is also evidence that PD has several

modifiable risk factors in common with certain non-communicable chronic

diseases like diabetes. Therefore, to prevent PD, the approach of controlling

the common risk factors could be an effective strategy.

Potential risk-factor entry points are reduction of tobacco use, reduction in

consumption of harmful levels of alcohol, a healthy diet and good nutrition and

improvement of personal hygiene. Whilst PD is not contagious it can become extremely

common and debilitating, given the ideal environment. This paper discusses the

risk factors and identifies options by which PD can be prevented and reduced.

introDuction

Periodontal disease (PD) encompasses a cluster of diseases that result in

inflammatory responses and chronic destruction of the tissues that surround

and support the teeth, namely the gingiva, periodontal ligament, cementum

and alveolar bone (collectively referred to as the “periodontium”).1, 2 It therefore

refers to both gingivitis and periodontitis.1, 2

Gingivitis is an inflammatory condition of the soft tissues (gingiva) surrounding

the teeth whilst periodontitis involves the destruction of the supporting structures

of the teeth and periodontium.2

Clinical signs of a healthy periodontium include: maintenance of a

functional periodontal attachment level, minimal or no recession with no loss

of interproximal bone; and, where present, functional dental implants, all in

the absence of inflammation.3 (Fig. 1).

Both gingivitis and periodontitis are initiated by plaque and are influenced

by the immune and inflammatory responses of the individual. Both conditions

are modified by several factors including smoking, medication, age and

systemic diseases.

Gingivitis affects 50–90% of adults worldwide (Fig. 2) and is readily reversible

by simple, effective good oral hygiene and lifestyle changes.4

Gingivitis can be defined as the presence of gingival inflammation, whereby

the gum can appear reddened, swollen, and may easily bleed, but without

loss of connective tissue attachment.

Periodontitis can be defined as the presence of gingival inflammation

at sites where there has been a pathological loss of attachment. This loss

of attachment contributes to pocket formation. The rate of progression of

periodontitis is neither predictable nor steady.

The disease is considered to progress in relatively short episodes of rapid

tissue destruction, sometimes followed by some repair, and mostly by prolonged

periods of dormancy (Fig. 3).3

PEriOdONTAl diSEASE

figure 1: Healthy gums

figure 2: mild gingivitis

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Severe periodontitis can result in loosening of teeth, occasional pain and

discomfort, impaired mastication, and eventual tooth loss.4 Periodontitis does

not affect all teeth evenly but has individual and site predilection; approximately

10–15% of the global adult population suffer from progressive periodontitis.2

role of plaque in periodontal disease

Dental plaque is the principal etiological factor in the pathogenesis of

PD. The presence of plaque is necessary, but is not of itself sufficient, for

periodontal disease to occur.

A variety of disease patterns, both between different individuals and

between different sites in the mouth within the same individual can be

related to: the host response, the modifying effect of various risk factors

and the bacterial attack from dental plaque, involving mostly Gram-negative,

anaerobic bacteria growing in subgingival sites.1,3

Calcified plaque (calculus) does not have a major role in the pathogenesis

of periodontal disease, although it does act as a ’retention web’ for bacteria

and interferes with the ability to perform personal oral hygiene.

Studies have shown that microorganisms quickly colonize clean tooth

surfaces after cessation of oral hygiene procedures and that within a few

days microscopic and clinical signs of gingivitis can be observed.5 At this

point these changes can be reversed, provided the individual resumes

adequate tooth cleaning procedures.

Gingivitis is a result of the microorganisms within the plaque releasing

products that induce tissue inflammation. Most individuals develop clinical

signs of gingivitis after 10–20 days of plaque accumulation.5 It has been

noted that not all patients will develop periodontitis following gingivitis and

therefore those who do must have a unique response to microbial plaque.

The teeth specificity and predilection in periodontal disease probably

localise to the sites of retention of plaque where oral hygiene is inadequate

or in areas of calculus formation, restorative overhangs or poor margins of

crowns. In normal situations, more than six months may pass before the lesion

of gingivitis changes to periodontits.6

microbiology of periodontal disease

About 300 to 400 bacterial species are found in sub-gingival plaque but only

about 10 to 20 species may play a role in the pathogenesis of destructive

PD.2 It is only those species that are able to colonize that result in damage to

periodontal tissues. Colonization requires the ability to attach to periodontal

tissues, to multiply, to compete with other microbes within the oral environment

and the resilience to survive the host defense mechanisms.

The microbes involved with PD are largely gram negative anaerobic bacilli,

as mentioned, with some anaerobic cocci and a large quantity of anaerobic

spirochetes. The main organisms linked with deep destructive periodontal

lesions are Porphyromonas gingivalis, Prevotella inter-media, Bacteroides

forsythus, Actinobacillus actinomycetumcomitans, and Treponema denticola.2

risk factors associated with periodontitis

Periodontal disease is considered to have multiple risk factors. According to one

author the term “risk factor refers to an aspect of personal behaviour or lifestyle,

an environmental exposure, or inherited characteristics, which on the basis of

epidemiological evidence is known to be associated with a health related condition”.7

Risk factors therefore are part of the causal chain for a particular disease or can

lead to an exposure of an individual to a disease and therefore the presence of

risk factors implies a direct increase in the probability of the disease occurring.

Destructive periodontal disease is a consequence of the interaction of

genetic, environmental, host and microbial factors.8 Risk factors for periodontal

disease include genetics, age, gender, smoking, socioeconomic factors and

some systemic diseases.

age

The prevalence of periodontal disease is seen to increase with age, while the

extent and severity also increases with advancing age.9

However, it is not clear whether becoming older is related to an increased

susceptibility to periodontal disease or whether the cumulative effects of

disease over a lifetime may explain the increased prevalence of disease in

older people.2

Some authors suggest that up until 70 years of age the rate of periodontal

destruction is the same throughout adulthood; age per se is not a risk factor

for people under 70.10, 11

In South Africa life expectancy increased from 59 years in 2000 to 63.6 years

in 2016.12 This increase in life expectancy is considered mainly due to the mass

roll out of Antiretroviral (ARV) treatment for HIV and its positive consequences.

The increased life expectancy would result in an increased geriatric population

requiring oral health treatment especially for periodontal diseases.

socioeconomic status

A possible relationship between PD and socioeconomic status (SES) was found

in several studies.13-15 Gingival condition is directly related to SES with evidence

of poor gingival health and is more prevalent in persons from a low SES.

The relationship between SES and periodontitis is less direct. It can be

certain that gingival health is better among individuals with higher education

and with a more secure income.16 South Africa has a high unemployment

rate of around 27% and coupled to this is a high disparity between the rich

and the poor.17, 18

These factors combined with poor education and low levels of knowledge

all indicate that the prevalence of periodontal diseases will increase in the

next few years, placing an added burden on the public oral health sector.

race and gender

Destructive periodontitis is consistently more prevalent in males than females

which could be due to lifestyle choices of males which include an increased

alcohol and smoking consumption.9

PD also has been reported to be more prevalent amongst blacks than whites

with a Brazilian study reporting that groups of blacks have a three times higher

risk of periodontal destruction compared with whites of the same age cohort.14

This could be due to lifestyle choices and genetic factors and may be applicable

to similar South African populations. The distribution of PD within countries also

differs according to race or ethnic group regarding prevalence and severity.19

figure 3: periodontitis

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South Africa comprises 81% Black African and just over 51% of all South Africans

are females.20 These factors also impact on the prevalence of PDs and clinicians

should be aware of these risk factors when examining and treating their patients.

smoking

A consistent, positive association between smoking and loss of periodontal

attachment has been reported and confirmed in many studies.21, 22 Smoking

alone accounts for more than 50% of PD cases.

The prevalence of smoking is higher in the uneducated, poorer communities

and low-income earners compared with their more affluent and educated

counterparts.9 Other studies have reported that smokers were five times more

likely to have a periodontal emergency compared with non-smokers.23

The disease is more prevalent, extensive and severe among current smokers,

and occurs least amongst those who have never smoked. It has been proven that

those who smoke over many years have considerably higher periodontal disease

rates, and that this occurs even with cannabis smoking, suggesting that it is the

smoking, rather than any specific characteristic of tobacco, that is responsible.24

Although South Africa has seen a decrease in the national tobacco consumption,

tobacco use remains prevalent in certain underprivileged and marginalized

communities.25

Added to this, studies have reported an increase of electronic cigarette and

water pipe smoking and long term research is required on the effects of these

innovative habits on the oral cavity.26

genetics

There is a growing body of evidence from studies that genetic factors predispose

individuals to periodontal disease. This is seen especially in the rare and more severe

forms of periodontitis like early onset periodontitis, now classified as aggressive

periodontitis,27 where family studies have provided good evidence for a prominent

genetic role.28, 29 A gene mutation for pre-pubertal periodontitis has been identified.30

systemic disease

Systemic disease can adversely affect host defense systems and therefore

can act as risk factors for PD.2 Among the associations observed between oral

health status and chronic systemic diseases, the link between PD and diabetes

mellitus is the most consistent.31

Periodontal diseases are well established as a complication of diabetes, and

have been considered the sixth most common complication of diabetes.32, 33

In a study of Brazilian individuals with poorly controlled type 2 diabetes,

significantly higher levels of periodontal pockets and loss of attachment were

found compared with controls.34

Although HIV disease has a relatively minor effect on the progression of

chronic periodontitis compared with other pathogenic factors, patients who

are HIV-positive and immunosuppressed can present with distinctive forms of

necrotising gingivitis and periodontitis.35

Diseases of the oral cavity strongly associated with HIV are: linear gingival

erythema (LGE), necrotising ulcerative gingivitis (NUG) and necrotising ulcerative

periodontitis (NUP). It has been proven that the presence of NUP and NUG may

offer a significant diagnostic, as well as a prognostic, value.36

periodontitis and stress

It is well known that cardiovascular disease, diabetes, and other chronic

diseases are related to psychosocial factors, but there is also evidence that

stress is linked to periodontal disease.

Stressful life events, and marital problems are associated with PD, possibly

through physiologic responses that increase susceptibility and reduce the

immune response.9, 19

periodontitis and pregnancy

Studies have demonstrated that PD have been shown to increase the risk of adverse

pregnancy outcomes such as premature birth and low birth weight.37-39 Uterine

contractions are stimulated by oxytocin, which is produced by the hypothalamus

and by prostaglandins produced by the placenta. This process normally occurs in

the third trimester and leads to birth. However, chronic infection can stimulate the

inflammatory process, which leads to elevated amniotic levels of prostaglandins,

TNF-α, Interleukin-1 and -6. These mediators then lead to premature rupture of

membranes and pre-term labour. Other work has suggested that periodontal pathogens

may travel from the gingival sulcus to the placenta and stimulate pre-term birth.40

alcohol

High alcohol consumption increases the risk of a wide variety of conditions such

as increased blood pressure, liver cirrhosis, cardiovascular disease, diabetes,

and cancers of the mouth.19 Recent research also indicates that excessive alcohol

consumption is associated with increased severity of periodontal disease.41, 42

Alcohol consumption, tobacco use, and unhealthy diet commonly go together.

People who consume tobacco are more likely to drink alcohol and eat a diet

high in fats and sugars but low in fiber and polyunsaturated fatty acids. Those

who have a high consumption of tobacco and alcohol are thus more likely to

be at a higher risk of severe periodontal disease and oral cancer.19

local risk factors

Any plaque retentive feature such as restoration overhangs or deficiencies,

may contribute to the local risk of periodontal disease.2

conclusion

Risk factors work to change the susceptibility or resistance of individuals to

the disease. Risk factors for periodontal disease can be both systemic and

local, such as smoking; medical conditions, poorly controlled diabetes, possibly

obesity and stress play a significant role in the initiation and progression of PD.

The modification of these risk factors plays a strategic role in the management

of periodontal disease, accepting of course that some, such as race or genetics,

cannot be changed. The identification of high-risk patients is therefore essential

in the ultimate management and treatment of PDs.

As has been demonstrated, periodontal disease is highly linked to systemic

diseases such as diabetes and HIV. There is also evidence that periodontal

disease has several modifiable risk factors in common with certain non-

communicable chronic diseases and therefore to prevent periodontal disease

one can use the common risk factor approach.

It is therefore essential that clinicians adopt a holistic and systemic approach

to identify high risk patients and to recommend behaviour and lifestyle changes

to attain the common goal of preventing and managing PDs. ●

references1. xiong x, Buekens P, Fraser W, Beck J, Offenbacher S. Periodontal disease and adverse

pregnancy outcomes: a systematic review. BJOG. 2006;113(2):135–43.

2. Kinane DF. Causation and pathogenesis of periodontal disease. Periodontol 2000.

2001;25(1):8–20.

3. Beirne PV, Worthington HV, Clarkson JE. Routine scale and polish for periodontal health in

adults. The Cochrane Library. 2007.

4. Pihlstrom BL, Michalowicz BS, Johnson NW. Periodontal diseases. The Lancet.

2005;366(9499):1809–20.

5. Weijden G, Timmerman M, Danser M, Nijboer A, Saxton C, Velden U, et. al. Effect of pre-

experimental maintenance care duration on the development of gingivitis in a partial mouth

experimental gingivitis model. J Periodontal Res. 1994;29(3):168–73.

6. Brecx M, Fröhlicher I, Gehr P, Lang N. Stereological observations on long-term experimental

gingivitis in man. J Clin Periodontol. 1988;15(10):621–7.

7. Last JM. A dictionary of epidemiology. Oxford University Press, 1995. McMichael AJ, Anderson

HR, Brunekreef B, Cohen AJ. Inappropriate use of daily mortality analyses to estimate

longerterm mortality effects of air pollution. Int J Epidemiol. 1998;27:450–3.

RESEARch

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8. Zambon JJ. Periodontal diseases: microbial factors. Ann Periodontol. 1996;1(1):879–925.

9. Watt RG, Petersen PE. Periodontal health through public health-the case for oral health

promotion. Periodontol 2000. 2012;60(1):147–55.

10. Holm-Pedersen P, Agerbæk N, Theilade E. Experimental gingivitis in young and elderly

individuals. J Clin Periodontol. 1975;2(1):14–24.

11. Machtie E, Dunford R, Grossi S, Genco R. Cumulative nature of periodontal attachment loss.

J Periodontal Res. 1994;29(5):361–4.

12. World Health Organization. World Health Statistics : monitoring health for the Sustainable

Developmental Goals(SDGs). 2018. Licence: CC BY-NC-SA 3.0 IGO.Geneva

13. Beck JD, Koch GG, Rozier RG, Tudor GE. Prevalence and risk indicators for periodontal

attachment loss in a population of older community-dwelling blacks and whites. J Periodontol.

1990;61(8):521–8.

14. Gilbert GH. Racial and socioeconomic disparities in health from population-based research to

practice-based research: the example of oral health. J Dent Educ. 2005;69(9):1003–14.

15. Susin C, Oppermann RV, Haugejorden O, Albandar JM. Tooth loss and associated risk indicators

in an adult urban population from south Brazil. Acta Odontol Scand. 2005;63(2):85–93.

16. Al Jehani YA. Risk factors of periodontal disease: review of the literature. Int J Dent. 2014;2014.

17. Moalusi T. Statistics South Africa. Youth unemployment in SA increasing – where to

from here? HR Future. 2018;2018(Jul 2018):8–9. Accessed 17 October 2018. Available at

http:// www.statssa.gov.za/?p=11129

18. Ataguba JE, Akazili J, McIntyre D. Socioeconomic-related health inequality in South Africa:

evidence from General Household Surveys. Int J Equity Health. 2011;10(1):48.

19. Petersen PE, Ogawa H. Strengthening the prevention of periodontal disease: the WHO

approach. J Periodontol. 2005;76(12):2187–93.

20. Statistics South Africa. Mid-year population estimates. 2017. Assessed 17 October 2018.

Available at. http://www.statssa. gov.za/publications/P0302/P03022018.pdf

21. Haber J. Smoking is a major risk factor for periodontitis. Curr Opin Periodontol. 1993:12–8.

22. Haber J, Wattles J, Crowley M, Mandell R, Joshipura K, Kent RL. Evidence for cigarette

smoking as a major risk factor for periodontitis. J Periodontol. 1993;64(1):16–23.

23. Deutsch WM. Dental events during periods of isolation in the US submarine force. Mil Med.

2008;173(Supplement_1):29–37.

24. Thomson WM, Sheiham A, Spencer AJ. Sociobehavioral aspects of periodontal disease.

Periodontol 2000. 2012;60(1):54–63.

25. Teare J, Naicker N, Albers P, Mathee A. Prevalence of tobacco use in selected Johannesburg

suburbs. S Afr Med J. 2018;108(1):40–4.

26. Ramôa C, Eissenberg T, Sahingur S. Increasing popularity of waterpipe tobacco smoking and

electronic cigarette use: Implications for oral healthcare. J Periodontal Res. 2017; 52(5):813–23.

27. Wiebe CB, Putnins EE. The periodontal disease classification system of the American Academy

of Periodontology – an update. J Can Dent Assoc. 2000;66(11):594–9.

28. Hassell TM, Harris EL. Genetic influences in caries and periodontal diseases. Crit Rev Oral Biol

Medicine. 1995;6(4):319–42.

29. Michalowicz BS. Genetic and heritable risk factors in periodontal disease. J Periodontol.

1994;65(5s):479–88.

30. Hart T, Hart P, Michalec M, Zhang Y, Marazita M, Cooper M, et. al. Localisation of a gene

for prepubertal periodontitis to chromosome 11q14 and identification of a cathepsin C gene

mutation. J Med Genet. 2000;37(2):95–101.

31. Grossi SG, Genco RJ. Periodontal disease and diabetes mellitus: a two-way relationship.

Ann Periodontol. 1998;3(1):51–61.

32. Grossi SG, Skrepcinski FB, DeCaro T, Zambon JJ, Cummins D, Genco RJ. Response to

periodontal therapy in diabetics and smokers. J Periodontol. 1996;67(10s):1094–102.

33. Taylor GW, Burt BA, Becker MP, Genco RJ, Shlossman M. Glycemic control and alveolar bone

loss progression in type 2 diabetes. Ann Periodontol. 1998;3(1):30–9.

34. Novaes Jr AB, Gutierrez FG, Novaes AB. Periodontal disease progression in type II non-insulin-

dependent diabetes mellitus patients (NIDDM). Part I–Probing pocket depth and clinical

attachment. Braz Dent J. 1996;7(2):65–73.

35. Robinson PG, Adegboye A, Rowland R, Yeung S, Johnson N. Periodontal diseases and HIV

infection. Oral Dis. 2002;8(s2):144–50.

36. Mataftsi M, Skoura L, Sakellari D. HIV infection and periodontal diseases: an overview of the

post-HAART era. Oral Dis. 2011;17(1):13–25.

37. Offenbacher S, Katz V, Fertik G, Collins J, Boyd D, Maynor G, et. al. Periodontal infection as a

possible risk factor for preterm low birth weight. J Periodontol. 1996;67(10s):1103–13.

38. Jeffcoat MK, Geurs NC, Reddy MS, Cliver SP, Goldenberg RL, Hauth JC. Periodontal infection

and preterm birth: results of a prospective study. J Am Dent Assoc. 2001;132(7):875–80.

39. Scannapieco FA, Bush RB, Paju S. Periodontal disease as a risk factor for adverse pregnancy

outcomes. A systematic review. Ann Periodontol. 2003;8(1):70–8.

40. Gurenlian J. Inflammation: the relationship between oral health and systemic disease.

Dental Assistant (Chicago, Ill: 1994). 2009;78(2):8.

41. Tezal M, Grossi SG, Ho AW, Genco RJ. The effect of alcohol consumption on periodontal

disease. J Periodontol. 2001;72(2):183–9.

42. Pitiphat W, Merchant A, Rimm E, Joshipura K. Alcohol consumption increases periodontitis risk.

J Dent Res. 2003; 82(7):509–13.

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CONTiNuiNg PrOfESSiONAl dEVElOPmENT QuESTiONNAirE – ArTiClE 3

perioDontal Disease

3.1 Which of the following modifiers of periodontal disease cannot

be controlled for?

A. Smoking

B. Alcohol

C. Genetics

D. None of the above

3.2 Worldwide prevalence of progressive periodontitis in the adult

population is:

A. 50–90%

B. 30–45%

C. 25–30%

D. 10–15%

3.3 The pathogenesis of periodontitis is characterised by rapid,

active (tissue destructive) and prolonged, dormant phases.

True or False?

3.4 Population level socioeconomic, demographic and lifestyle

trends that are likely to increase the incidence and prevalence

of periodontal disease and burden imposed on the South African

health care system include:

A. Increase in life expectancy

B. Declines in tobacco consumption

C. High and increasing unemployment rate

D. Both A and C

3.5 The sixth most common complication of Diabetes mellitus is:

A. Cardiovascular Disease

B. Periodontal disease

C. Retinopathy

D. Nephropathy

3.6 Which of the following periodontal conditions is strongly associated

with HIV infection?

A. Aggressive periodontitis

B. Progressive periodontitis

C. Endodontic-Periodontal lesion

D. Necrotising ulcerative periodontitis

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uNdErSTANdiNg THE PriNCiPlES Of ETHiCS iN HEAlTH CArEA SYSTEmATiC ANAlYSiS Of QuAliTATiVE iNfOrmATiON

introDuction

All health care professionals have an obligation for

the duty of care in alleviating pain and minimize

suffering. Thus every action taken by the doctor

or health care professional constitute ethical

and moral dimension. This is guided by the set

of ethical principles aimed at improving the

quality of patient care by identifying, analysing

and attempting to resolve any issues arising in

practice. According to Beauchamp and Childress,

no one principle is higher than other and depends

on the context of given situation. Beauchamp and

Childress consider the four principles as prima

facie binding, i.e. they must be fulfilled, unless

they conflict on a particular occasion with an

equal or stronger principle.1

In the past clinical ethics was intended to be

defined by the clinical area that focused on for

instance, end of life care, consent, priority setting

or women‘s health. Despite incorporating ethical

teaching in medical curricula there is paucity in

knowledge of ethics among our practitioners.

Recognizing the importance of ethics in health care

practice the MCI and DCI has prescribed the teaching

hours of ethics to more at under graduate level.

To improve the ethical knowledge it is important

to understand the ethical issues or challenges

encountered in the present scenario. A thorough

review of literature would help us understand the

dilemmas and help to us formulate better research

in this regard.

Empirical research have shown that the evidence

that quantitative methods alone is not sufficient

since phenomena examined by ethics researchers

are deeply entwined into the fabric of professions,

organizations and human lives. Hence qualitative

methods have begun to play its role. Empirical

studies exploring the ethical dimension of the

physician practice mainly rely on interview, focus

group discussion and observation of clinical

practice. The systematic review in this regard is

an important tool for the evidence based medicine

and practice which aims to bring research closer

to decision making.2-7

In this systematic review an attempt has been

made to review articles which emphasize on

research which prioritizes the daily activities of the

doctor within the clinical encounter rather than on

the research which emphasize life threatening and

emergency situation.

methoDs

collection of data sources

To identify a comprehensive data search, different

strategies used for identifying qualitative research

papers in area of health care ethics was used. It

included “Semantic” based strategies, thesaurus,

free text terms relevant to qualitative research and

“broad-based” terms such as interview, focus group

discussion, qualitative research and also using citation

in health care ethics. Articles were searched in

medical, dental, nursing and social science literature.

Choosing of the article aimed to include all relevant

studies related to ethical issues in healthcare ethics.

Only peer-reviewed articles pertaining to

qualitative studies in health care ethics and which

were published in English literature were included.

Thus there were 34 research articles pertaining to

the review in focus.

Data extraction was done. After verification of a

study‘s eligibility for inclusion in the review; study

details such as name of the study, authors, journal,

research design used, data collection, data analysis

methods, results and conclusion were determined

by the researcher and included in the final analysis

by all the authors.

Data analysis

For data analysis guidelines for critical review form

for qualitative studies developed by the McMaster

University Occupational Therapy was followed.4

results

There were 10 relevant qualitative studies collecting

the data regarding the ethical issues in health care

practice. The studies were related to use of ethical

principles such as autonomy, informed consent,

beneficiance, non-beneficiance, and justice in

health care decision making.

Vanishree M. Kemparaj1, Umashankar G. Kadalur2*

1 Department of Public Health Dentistry, Maaruthi Dental College, Bangalore/Rajiv Gandhi University of Health Sciences

2 Department of Public Health Dentistry, MR Ambedkar Dental College, Bangalore/Rajiv Gandhi University of Health Sciences, Bangalore, Karnataka, India

* Correspondence: Dr. Umashankar G Kadalur, E-mail: [email protected]

Source: Int J Community Med Public Health 2018;5:822–8.

abstract

Despite incorporating ethical teaching

in medical curricula there is paucity in

knowledge of ethics among our practitioners.

To improve the ethical knowledge it is

important to understand the ethical issues

or challenges encountered in the present

scenario. The issues encountered by the

health professionals helps to understand

how the ethical principles are in day to today

practice. Empirical researches have shown that

qualitative research brings research closer to

decision making. Hence data obtained from

peer-reviewed qualitative articles were used

for assessing ethical principles in every day

practice by health professional. The studies

have shown that autonomy, beneficence,

justices are some of the principles health

professionals consider before taking the

decisions in health care.

Keywords: Ethics, Health care, Qualitative

research, Informed consent.

EThIcS

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table 1: Showing the ethical dilemmas faced by the research participants in different research studies

author/year themes responses

1. Torjuul, Nordam, Sørlie

Respecting patients“I cannot remove any parts of a person's body unless they are accountable; unless they themselves comprehend that it is necessary”.

Resolving differences in opinions

“Sometimes you are asked to do something you do not think is right. You are for instance asked to do things in a particular way, and then you think that it is difficult to go against the decisions of those who are more experienced. It does not need to be anything strictly right or wrong, but minor things, like you would have chosen another type of drug”.

Incompetent colleagues“On the one hand you realize that surgery is complicated, and you cannot blame people for a single decision or a single action that is wrong”.

2. Ebbesen et. al.

beneficence

... We are employed here to produce drugs for the benefit of the patients, so we have to see things in a broader perspective... of course, that is not where your focus is when you are about to clone something and considering what restriction sites to apply. At that moment, the overall perspective is not the focus of your attention, but you have to keep it in the back of your mind as part of your daily activities in order for things to make sense in the end.

Autonomy Informed consent... if you were a seriously ill or terminally ill patient, I think I would accept just about any treatment, because you would accept the risk involved.

Justice

Just distribution

Resources are scarce and the number of patients in need of radiotherapy is increasing... you have so many patients and you want to be able to cure as many as possible from their cancer, which is, after all, the main problem. But what is the best way to do it so that the patients become most well-functioning afterwards, cosmetically and functionally?

3. Jafarey, Farooqui

InformationMost participants agreed that it was perfectly acceptable to use alternative words like “growth” or “mass” rather than use the term “cancer” and this did not amount to deception.

Apprehensions“I try and tell the patient all possible complications of a procedure so that if something does go wrong, at least he was forewarned. I however tend to loose patients also by this approach as they sometimes choose to go to a surgeon who does not alarm them with all the possibilities”.

4. Hurst, et. al.

Looking for assistanceWhen facing the ethical difficulties they described, most of the respondents looked for assistance. This could come from persons involved with the patient, or from persons trusted by the respondent for other reasons.

Avoiding conflictAn example in which avoidance of conflict meant not facing it is illustrated in the following situation. In this case, deception was used: the respondent did what he thought was right, and pretended to the patient‘s family that he had done what they thought was right.

5. Agledahl, et. al.

Break down

A female patient enters the practitioners‘ office, seems stressed and talks fast in broken Norwegian. She sinks into a chair. Patient: “I‘m so ill; I do not have the energy to do anything. My neck hurts, I‘m freezing, I‘m weak, I have to do an assignment, but this is not working out…” Doctor: “Your neck hurts?” Patient: “Yes, my throat is soar and I‘m aching here [pointing at the side of her neck]. I always get a soar throat, maybe every month. I thought I should have an operation…” Doctor: “Does it hurt anywhere else?” Patient: “Yes, my back hurts. And my chest. And my legs are hurting a bit too.”

Doctor: “A little bit of everywhere, I gather? Do you have fever?” Patient: “Yes.” Doctor: “Have you measured your temperature?” Patient: “No, I do not have a thermometer.” Doctor: “Then you must get hold of one! Do you have fever now?” Patient: “No, I don‘t think so.” [Feels her forehead] Doctor: “Do you have a cough?”.

Concretizing

Doctor I: She has been admitted for rehabilitation. She is poorly mobilized and nourished, and she is low in albumin. Nurse: Is she the one with the black toes? Doctor II: They are not black; they are poorly circulated. Doctor I: We have to at least mobilize her into a chair. Doctor II: She also has diarrhoea and a positive Hemofec. It is somewhat hard to interpret. But judging her blood values, everything looks better.

Categorizing

Interviewer: “Your first patient today mentioned that she had discomfort in her chest. What were your thoughts about that?” Doctor: “She brought it up somewhat late in the consultation and I was beginning to run out of time. It didn‘t sound that serious, and it wasn‘t anything acute, she had had it for several years. I could have taken a spirometry of course… Most likely it is muscular, she is sitting quite tense, like this.”

6. Rosenbaum, et. al.

Concern over telling the truth,“The biopsy came back that he had lung cancer... our attending wanted to wait until his primary attending came back a week later before telling him. We... myself and my intern, felt very uncomfortable waiting ... he [the patient] kept asking us, ‘Do you know the results?’... and we’d have to tell him... ‘we’re waiting for the results.’ Even though we knew.”

Preventing harm, “It felt difficult for us to live with the fact that we had done something to her that had killed her.... Sometimes I just feel really evil. Doing things to people. That’s my way of saying it. But I feel, a lot of times, we do different procedures to people that are — putting in lines or whatever — in their so-called best interest. I just wonder a lot of times whether it really is.”

Managing the limits of one‘s competence

“... I’m transferring them [a patient] to somebody and meeting resistance, just feeling uncomfortable because they [co-resident] say, ‘why didn‘t you do this?’ or ‘why didn‘t you do that?’ or ‘they‘re not really appropriate for me right now. You called me too soon.’ Just feeling like I‘d been inadequate, inadequately working up the patient and why would I call them prematurely. I feel that, actually, a lot.”

8. Braunack-Mayer

Accessibility

Dr Newton: I felt I looked after them [these patients who were elderly], to the best of my ability, in fact Extremely well. And at times I‘d put myself out a lot — not just a little bit — but a lot, on individual instances, and that had always been appreciated, or seemed to have been appreciated. And yes, I‘ll give you some beautiful examples. Some of these home visits I did when I went to pick the gentleman who had fallen often onto his wife, and couldn‘t move, I went because nobody else would go, and the family wouldn‘t go. The family said, no, get the doctor. And when I got there all I actually had to do was get him back on his feet, and make sure that they were all right. And that would happen, at virtually any hour of the day or night. They would ring, but I went. Well, I always went myself, and I never sent a locum … That‘s going beyond the call of duty, on the whole.

comprehensiveness

Dr Kingsford: specialists are a different type of doctor to a GP. I think specialists know a lot about a certain case. They can be very bright in one or two areas, but quite often they have no bedside manner at all … I mean, there‘s some very good specialists that are very good — like psychiatrists, — that they can talk to people very well, but so many of them are just technicians, purely technicians and very good technicians, but very poor doctors. I‘ve found this many times.

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Discussion

The most of the articles reviewed under this systematic

review acknowledge the importance of using ethical

principles in their day to day practice. A range of issues

were encountered by the health care professionals

in following the principles of ethics. Issues were

more getting complicated when one principle was

overridden by the other and this led to the confusion

as what has to be followed. Disagreement between

families and health care professionals, long waiting

list, access to needed health care, informed consent

and substitute decision making were viewed as the

top ethical challenges in health care practice.

research design

Most of the research design used phenomenology,

ethnography, Delphi method and grounded theory

approach which is opt for the qualitative research.

The assumption behind phenomenology is that there

is an essence to shared experience. It comes from

the social sciences and requires a researcher to

enter into an individual‘s life world and use the self

to interpret the individual or group experience. The

goal of ethnographic research is to tell the whole

story of a group‘s daily life, to identify the cultural

meanings, beliefs and social patterns of the group.

Grounded theory focus is on searching to identify the

core social processes within a given social situation.2-9

research method

The studies in this systematic review have utilized

interview, observation and focus group discussion

method which is most opt for qualitative research

method.

sample size

Malterud in his “Qualitative research: standards,

challenges and guidelines” mentions that even

though qualitative study utilizes small sample size

because of the many varied sample and clinical

situation assessed the study can be generalized

to other clinical situations.8,9

sampling technique

All the research studies used purposive sampling

and it is justified that the purpose is interpretive

explanation and not prediction of the conflicts and

challenges of health care ethics. Hence it is most

suitable for qualitative research.8,9

Data analysis

Most of the research used inductive reasoning

approach in which we move from specific observation

to broader generalizations and theories. Also called

as bottom up approach. Theoretical concepts and

relationship between the concepts have been

explained. The research studies enhanced their

validity by using two researchers reading, coding

and comparing the finding of research. Few studies

have also cross checked with the participants for

the validity of the concepts they formed finally.2-9

Data revealed that the participants in the research

studies encountered conflicts in adopting the

universal ethical principles before coming to

treatment decisions of the patient.

autonomy

Autonomy is respecting patient‘s wishes or decisions

about one‘s own body. The study done by Torjuul et. al.,

Ebbesen et. al., Jafarey et. al. is in line and agrees

to respect patient decisions regarding treatment.

In these studies health care professionals have

expressed a dilemma in adopting the ethical principle

when they think the patient‘s level of comprehension

is compromised or in case of vulnerable patient‘s

who is not able to decide on themselves or when

the patient is terminally ill and is ready to accept any

option the health care professionals suggest. And this

is in line with the study done by Julie et. al. where

the health care professionals have expressed the

dilemma to accept patient or family wishes when the

patient ability is compromised and in a study done by

Hurst et. al. the participants said that they avoided

the conflict by pretending to do what patient wanted.

In a study done by Jafarey suggest that the doctor

need to give sufficient time and consent should be

taken at a level the patient can understand to his

level of comprehension. When patient is terminally

ill the other substitute decision makers should

be consulted in taking decision about the patient

treatment. Regarding the necessary information

to be disclosed for consent the participants in the

study done by Jafarey agree that true information

should be disclosed while few participants have

contradictory statement that sometimes it is better

to use deceptive words.1,10-13

beneficience and non-maleficience

The doctor‘s first and foremost duty is not to

harm the patient the patient and next comes the

beneficience. Torjuul and Ebbesen in their study

have acknowledged the importance of beneficience

whether it is clinical practice or research. In a study

done by Julie et. al. the participants expressed the

dilemma regarding the principle non malefficience

wherein much medical procedure has both harmfull

and beneficial effect on the patient. In the study

done by Torjuul study indicate a dilemma of patient

expectation versus duty of doctor where the patient

walking with severe pain expects a miracle of cure as

they cannot see the connection between treatment

and illness.1,10,12 Mayer in his study his participants

stressed the importance of accessibility of patients

to the doctor and told that doctor may have to go

out of the way to help patient, sometimes home

visits in odd working hours. Participants felt that

general practitioners are more comprehensive in

assessing the patient need and specialists know lot

certain case and sometimes are purely technicians.17

Justice

This principle suggest regardless of caste, creed

and social status every individual should be treated

equally. In a study done by Ebbesen et. al. the

doctor‘s were in agreement to distribute the scarce

resources available so as to provide treatment to

as many patient‘s as possible. Residents in Julie

study reported to compromise in telling the truth

as they felt it could harm the patient. This involved

them in manipulating information in many ways like

delaying, framing or omitting information related to

their treatment.1,12 They also concluded that trust is

very important in doctor patient relationship and

continuity of care for long term.

In few articles the participants have raised

concern and dilemma related to the competences

of the dentist, various managements strategies of

the patients and importance of establishment of

ethical consultations committees.

competences

In a study done by Rosenbaum et. al. residents raised

concerns about their own competence in handling

patients. They were also concerned how their peers,

attending physician and superiors perceived their

competence. There was also tension of balancing

their professional responsibility to challenge, intervene

or report the inappropriate or inadequate behaviour

of their colleagues. This was in line with the study

done by Torjuul et. al. where in the respondents said

that they cannot blame other person for the wrong

that happens in treating patients.10,12

management of ethical practice

In a study done by Agledalal et. al. focus on how

doctors handle the moral aspects of the day-to-day

clinical practice. In this the doctor used the process

called clinical essential sing. The process consisted of

breaking down the clinical situation into smaller units

which are of manageable parts. The next approach was

to concretize by objectifying the patient‘s descriptions

and reach mutual understanding. The third approach

was to categorize the patient‘s symptoms which could

be entered into record and in an effort to focus the

attention the doctor‘s took existential filtering. The

next approach was the functional focus which draws

the doctor‘s attention to benefiting patient‘s physical

and mental function. Even though essentializing the

doctor disregarded for the patient‘s private feelings

their implicit clinical practice constantly emphasized

the moral value of benefiting patient‘s physical and

mental function.13 Nik-Sherina and Chirk-Jenn in their

study explains the challenges of maintaining the family

and professional role in treating family members.14

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frequency of ethical conflicts and

establishment of consultations

A study done by Hurst reported that there is indeed a

good frequency of encountering the ethical conflicts

by health care professionals and by being aware of

the ethical conflict help health care professionals

to manage the ethical problem effectively. They

suggested the importance of establishments of ethical

consultation committee in the hospitals. Subjects also

reported that when confronted with ethical difficulties

the doctor looked for assistance may be from person

involved with patient or whom he trusted.13

Draw back

Some researchers argue that synthesis of qualitative

research on the grounds that concept identified in

one setting is not applicable to others. This can be

overcome by checking that each transfer is valid

and understanding gained.

More over most of the investigations are done by

the doctors themselves and hence are in a position

to understand the terminologies and meanings of

the clinical situations and thus minimizes the bias

in the study.

recommendations

1. Educating health care professionals- incorporating

theory base ethical teaching to clinical based

teaching. Making mandatory for health care

professionals to update their knowledge

though attending continuing medical education

programme. Studies have shown that professionals

justified the ethical issues more precisely after

the intensive course on bioethics.

2. Establishing ethical consultative committee

for advising when there is a disagreement or

conflict with the case.

3. Examining the patient‘s ethical perspective in

clinical situation.

conclusion

Ethical issues in health care practice are many.

Various factors autonomy, beneficence and other

principles were considered by the health professionals

to address the problem. Sometimes the issues are

emotionally challenging since the one principle of

ethics can be more important than the other. Getting

sensitized and training by the health professional

would help him to handle the clinical ethical situation

better. Thus adding the quality to the clinical care.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: Not required ●

references1. Ebbesen M, Pedersen BD. Empirical investigation of the

ethical reasoning of physicians and molecular biologists

– the importance of the four principles of biomedical

ethics. Am J Med. 2004;116:402–7.

2. Thomas J, Harden A. Methods for the thematic synthesis of

qualitative research in systematic reviews. ESRC National

Centre for Research Methods, NCRM Working Paper Series

Number (10/07). Available at: http://eppi.ioe.ac.uk/cms/

Default.aspx?tabid=188. Accessed on 3 August 2017.

3. Rogers WA. Ethical issues in public health: a qualitative

study of public health practice in Scotland. J Epidemiol

Community Health. 2004;58:446–50.

4. Reis S, Biderman A, Mitki R, Borkan JM. Secrets in

Primary Care: A Qualitative Exploration and Conceptual

Model. J General Internal Med. 2007;22:1246–53.

5. Praestegaard J, Gard G. The perceptions of Danish

physiotherapists on the ethical issues related to the

physiotherapist patient relationship during the first

session: a phenomenological approach. BMC Medical

Ethics. 2011;12:21.

6. Butters KJ. A qualitative study of the ethical practice of

newly graduated nurses working in mental health. A

thesis presented in partial fulfilment of the requirements

for the degree of Master of Philosophy in Nursing at

Massey University. 2008.

7. Malek JI, Geller G, Sugarman J. Intensive course

on health care professionals talking about cases in

bioethics: the effect of an intensive course on health

care professionals. J Med Ethics. 2000;26:131–6.

8. Marshall M. Sampling for qualitative research. Family

Practice. 1996;13:522–5.

9. Sbaraini ASM. How to do a grounded theory study: a

worked example of a study of dental practices. BMC

Med Res Methodol. 2011;11:128.

10. Torjuul K, Nordam A, Sørlie V. Action ethical dilemmas in

surgery: an interview study of practicing surgeons. BMC

Med Ethics. 2005;6:7.

11. Jafarey AM, Farooqui A. Informed consent in the

Pakistani milieu: the physician‘s perspective. J Med

Ethics. 2005;31:93–6.

12. Rosenbaum JR, Bradley EH. Sources of Ethical Conflict

in Medical Housestaff Training: A Qualitative Study. Am J

Med. 2004;116:402–7.

13. Agledahl KM, Førde R, Wifstad Å. Clinical essentialising:

a qualitative study of doctors‘ medical and moral

practice. Medicine, Health Care, and Philosophy.

2010;13(2):107–13.

14. Nik-Sherina H, Chirk-Jenn NG. Doctors treating family

members: A qualitative study among primary care

practitioners in a teaching hospital in Malaysia. Asia

Pacific J Family Med. 2006;5(2):1–6.

15. Hurst SA, Hull SC, DuVal G, Danis M. How physicians face

ethical difficulties: a qualitative analysis. J Med Ethics.

2005;31:7–14.

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CONTiNuiNg PrOfESSiONAl dEVElOPmENT QuESTiONNAirE – ArTiClE 4

unDerstanDing the principles of ethics in health care

4.1 Which of the following is not a core ethical principle in clinical practice?

A. Justice

B. Autonomy

C. Professional judgement

D. Non-maleficence

4.2 Which of the following represents a top ethical challenge encountered

in clinical practice?

A. Substitute decision making

B. Agreement between families and the health care provider

C. Equal access to health care services for all persons

D. Informed consent provided by a patient with full

comprehension of his/her diagnosis and treatment options

available

4.3 Ethnography, phenomenology and grounded theory represent

research methods frequently applied by researchers when conducting

qualitative research. Grounded theory is used to:

A. Interpret an individual or group experience through

observation by the researcher

B. Identify the core social processes within a given social

situation

C. Identify the cultural meanings, beliefs and social patterns of a

group

D. None of the above

4.4 Medical professionals may encounter an ethical dilemma in relation

to the principle of autonomy when:

A. A patient’s level of comprehension is adequate

B. A vulnerable patient cannot decide for him/herself

C. A terminally ill patient seeks only the ‘best’ treatment option

that aligns with his/her values

4.5 The principle of beneficence always supersedes non-maleficence.

True or False?

4.6 Identify the ethical principle that is being applied when health care

practitioners ensure that scarce resources are fairly distributed

to all persons according to need, regardless of other social and

demographic factors:

A. Beneficence

B. Non-maleficence

C. Veracity

D. Justice

4.7 Which of the following is not a component of clinical essentialising?

A. Obtain a broad overview of the clinical situation

B. Concretise the patient’s statements and reach a mutual

understanding

C. Categorise the patient’s symptoms

D. Focus on benefitting the patient’s physical and functional

status

4.8 Strategies that can be implemented to enable medical professionals

to deal more appropriately with clinical ethical decisions include:

A. Incorporation of theory-based ethical teaching into clinical

teaching

B. Establishment of an ethical consultative committee

C. Examination of the patient’s ethical perspective in a clinical

situation

D. All of the above

4.9 Every action taken by a medical professional constitutes an ethical/

moral dimension.

True or False?

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UnIVERSITY UPDATE

In celebration of National Oral Health Month, which this year was themed

“Healthy Mouth, Healthy Body”, the School of Oral Health Sciences at Wits

shared its expertise by offering free oral health screenings and individualised

oral education to Wits students and staff. This took take place on Thursday,

26 September 2019 at the Wits Health Sciences Campus.

Mr D Dandawa (IT) and Mr O Maunze (Marketing) created a poster to

advertise the event. This was then shared by Wits Communication on the

Wits Twitter and Facebook platforms. The team (Ms Tsholofelo Mokale and

Ms Kelebogile Mothupi) were interviewed at VOW FM on 25 September at

10:30 am on the Area Code show with Ms Boipelo Mooketsi. The interview

covered the following questions:

1. Why is oral health important?

Oral health is an integral part of general health. Almost every condition in

the body has signs and symptoms that occur in the mouth. Therefore, the

mouth is a very good indicator of the general health of a person. Good oral

health improves one's self-identity and quality of life. The ability to chew, eat,

and speak is intricately linked to a healthy mouth. A bright smile is a sign of

confidence that conveys the message that all is well.

2. What are some of the issues that concern oral health

professionals?

Oral diseases affect all individuals of all age groups, causing pain and discomfort,

and leading to days missed at work or school. Oral diseases are largely

preventable or can be treated. These include cavities, gingivitis, halitosis,

periodontitis, oro-dental traumas, oral manifestations of immunosuppressed

individuals and oral cancer. Being aware of any changes in the oral cavity and

not waiting for the pain or discomfort to escalate is important in maintaining

your teeth and gums thus, you are encouraged to get regular dental check-ups

to maintain a healthy smile.

3. five tips on maintaining oral health

• Brush your teeth twice daily for 2 minutes and remember to change your

brush every 3–4 months

• Floss frequently

• Have healthy eating habits

• Be aware of any changes in your oral cavity such as changes in the colour

of gums and teeth; sensitivity to cold or heat; clenching or grinding of teeth

• Get regular dental check-ups at Wits Oral Health Centre with our Oral

Hygiene Students, Dental Students, Oral Hygienists, Dental Therapists,

Dentists and Specialists.

The Dental Science Council (President: Miss Lisa Sibaca – BOHSc III; Deputy

Chair: Asanda Bhengu-BDS III; Social Media and Marketing: Ngcebo Malinga –

BDS III; and Happiness and Welfare’s Mr Ntando Majozi – BDS III) were involved

in the planning of the event and assisted by communicating with all student

groups. The third-year oral hygiene students advertised their Oral Health App

called ‘The Oral Health Bar’ during the event.

A total of 447 students and staff were screened. Most of the patients

presented with dental caries and gingivitis, which means that oral health

workers should focus on oral disease prevention and health promotion. The

patients received individualised oral health education and instruction based

on the different diagnoses, and referrals for treatment were made to Wits Oral

Health Centre. All patients were provided with free samples of toothpaste,

timers and pamphlets. Oral hygienists, dental therapists and dentists from

the Community Dentistry Department supervised the oral hygiene and dental

students during the screening of the patients.

GlaxoSmithKline sponsored the event and supplied the department with

t-shirts (for students and staff), banners, posters, Sensodyne toothpaste,

hour glasses (Aquafresh) and pens. The Department of Health supplied the

department with pamphlets.

The day was a great success and the Wits community indicated that there should

be more dental awareness and oral health promotion events in the faculty. ●

NATiONAl OrAl HEAlTH mONTH CElEBrATiONS

2019 SOuTH AfriCAN

Compiled by Ms KA Mothupi and Ms TB Mokale

Students and staff waiting to be screened in the mobile unit

One of the final year BOHSc students providing oral health screening in the mobile unit

PAGE 234th quarter 2019 • volume 20 no. 4

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WITS third-year oral health sciences students

launched a dentistry application and authored a

book to mark National Oral Health Day on Thursday,

26 September 2019.

Two groups of students worked on the projects

as a requirement for their community dentistry

project, which aims to improve South Africa’s

oral health.

The first group of six students authored a book

titled Learning: Big Health Smiles. The book is

aimed at primary school children at disadvantaged

schools, and explains teaching methods to improve

their oral hygiene.

Oral hygienist and lecturer, Patience Phakela, said

the book will help teachers educate children about

their dental hygiene. Speaking to Wits Vuvuzela, she

said “Not all residential areas have dental clinics,

so the community dentistry project is another way

to combat caries in our communities, and if this is

included in the curriculum at primary school it is

going to help.”

The group was scheduled to meet with an

official of the Department of Basic Education for

the second time on September 26, to discuss the

incorporation of the book into the South African

teaching curriculum.

One of the book’s authors, Lisa Sibaca, told Wits

Vuvuzela "We decided to write a book because we

want to leave a lifetime legacy instead of doing

a one-time project. The book will do more than

just oral health teaching; it will improve speech

development and confidence once children start

taking care of their teeth the right way."

The second group developed an application

called Oral Health Bar with information on how to

take care of one’s mouth, and common problems

experienced in the mouth.

One of the members of the second group,

Marguerite Brussow, said it was their vision to reach

as many South Africans as possible in the hope of

improving oral health and, in turn, the quality of life.

The application is available for download on the

website, oralhealthbar.wixsite.com, and is awaiting

review before being made accessible on Google

Play Store. ●

OrAl HEAlTH PrOjECTSwiTSiES SiNk THEir TEETH iNTO

UnIVERSITY UPDATE

By Jabulile Mbatha

Lecturer, Patience Phakela (centre), poses with third-year oral health students Photo: Jabulile Mbatha

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PAGE 254th quarter 2019 • volume 20 no. 4

PFZA/201902006

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gAuTENg BrANCH NEwSOHASA

The year is fast approaching its close and we now

have just a few weeks left in which to achieve all

the New Year’s resolutions made in the first week

of January 2019! Good luck!

For some of us, this year has felt like being on

a rollercoaster ride with some sudden stops and

reverses, and then randomly getting back on track

again – what a ride, but we made it!

Thank you to all the hygienists, dental therapists,

dental assistants, dental technicians and dentists

who have changed their patient's lives and created

a smile, and in doing so have brought our career to

the forefront, and made it one based on integrity,

honesty and compassion. You do not know how

impactful a new smile is to someone who hasn't

had one in years! Let us continue to give quality

service to all we have the opportunity to treat.

OHASA Gauteng enjoyed several events throughout

the year, culminating in the AGM that was held on

26 October 2019 at Emperor’s Palace. I am sure

that all the delegates in attendance enjoyed the day

and gained deeper insight into what each branch

is doing nationally. Our amazing speakers, Dr Riaz

Motara, a cardiologist, and Olga Niemkiekicz, the

founder of OLGANI, kept the audience enthralled

and captivated throughout their lectures and we

extend a big thank you to them.

We also need to thank the dental traders who

have supported us at every seminar, and sponsored

and donated dental goodies for all the delegates

and community service projects held throughout

the year. We look forward to a fruitful and eventful

2020 with you and your companies.

Thank you to the OHASA Gauteng Branch

members: Alma, Robin, Jamilah, Chante, Suné,

Stella and Angelique. You have been key elements

in all the events and plans that were implemented

and carried out this year.

To all the OHASA delegates who have shown

constant support and have been advocates for

our career, THANK YOU! OHASA would be nothing

without its members and we appreciate all the

feedback and suggestions on how we can better

our branch. May your festive season be filled with

joy and peace. We will see you in 2020.

OhASA nEwS

“The trick to not growing old is: Stay curious. Keep your teeth. Stay hopeful. Do everything gracefully, yet kick when you have to.”– Carew Papritz

GSK sponsored the WITS Oral Health Day

Students and lecturers having fun!

ohasa gauteng Dates for 2020: full day seminar – 7 march 2020

full day seminar – 6 June 2020

full day seminar – 3 october 2020

Please diarise these dates and look out for

e-mails that we will be sending regarding other

events that we will be hosting for you.

mmakaoka “Kaokie” sepuru

OHASA Gauteng Branch Chairperson ●

PAGE 26 OHASA JOURNAL

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EASTErN CAPE BrANCH NEwS OHASA

OHASA Eastern Cape held its CPD seminar on

14 September at the Radisson Blu in Summerstrand,

Port Elizabeth. We had thought-provoking lectures

and good interaction between the attendees and

the speakers and each other.

The lectures we enjoyed included:

• Client engagement and how to connect with your

client in a coaching way, and Conflict resolution

tools: Tools and skills to handle difficult patients

or situations successfully, presented by Elsa

van der Merwe from Shift Development and

Zintathu Consulting

• Dr Vikesh Gajjar shed some valuable light on

the Relevance of dental screening before joint

Arthroplasty and Antibiotic prophylaxis before

dental procedures in total joint Arthroplasty patients

• Phil de Villiers reiterated the importance of

fluoride in the Workshop on risk assessment

and intervention with Fluoride varnish using

the science from Cochran’s report and ADA

chair-side guidelines.

We are truly grateful to the following companies

for their contributions which added to the success

of our seminar!

• Colgate, for sponsoring Elsa’s costs to present to

us on the day and for spending the day with us.

• De Ville Enterprises for Phil’s cost to be with

us on the day.

• Prime Dental, Ivodent, Johnson & Johnson, Oral B,

GSK and Dental Warehouse for their displays and

sharing new product information at our seminar day.

Lucky draws were sponsored by:

• Oral B – won by Dr Mahlati

• Dental Warehouse – won by Ms Noekie Grobler,

Ms Shaya Pillay and Dr JPD Botha

• Prime Dental – won by Ms Jocelyn de Vos and

Dr Johann Pieters

• Ivodent – won by Ms Sanmari Botha

ohasa eastern cape Dates for 2020:breakfast meeting – 8 february 2020

cpD seminar – 30 may 2020

cpD seminar – 15 august 2020

Have a safe and blessed festive season!

Until we meet again! ●

OhASA nEwS

EC members with Elsa van der Merwe

EC CPD event

PAGE 274th quarter 2019 • volume 20 no. 4

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wESTErN CAPE BrANCH NEwSOHASA

We are getting closer to the end of an amazing 2019

and a very successful year for OHASA WC Branch. Our

last branch seminar, held at the River Club Conference

Venue on 7 September 2019, was a great success. The

day was filled with amazing, very insightful speakers;

loyal traders informing members about products on the

market; and a nice view over the golf course with the

good company of colleagues.

The OHASA AGM was held in Johannesburg on

26 October 2019. Gail Smith (OHASA Vice President),

Rugshana Cader (OHASA Journal Editor), Cole Gilbert

(President-elect) and I (Western Cape Branch Chair)

represented the OHASA Western Cape Branch at the

AGM. We had a very successful National Exco Strategic

Planning Meeting on the Friday, followed by the AGM on

the Saturday. I want to thank the OHASA Gauteng Branch

for hosting us and making us feel welcome in Gauteng.

My special thanks go to the following for making 2019 a

successful year: 2019 seminar speakers, OHASA Western

Cape members, non-members attending seminars, and

the OHASA Western Cape Branch and CPD committees.

Thank you too to the loyal traders that are always

there to support the oral hygiene profession and which

contributed to the success of 2019: Johnson & Johnson,

Colgate, Pierre Fabre, GSK, Prime Dental, Oral B, Ivodent,

Dental Warehouse and Wright Millners.

OhASA nEwS

Dr Rebecca Mocke (right) presenting at the OHASA Western Cape full-day seminar

Full-day seminar delegates enjoying tea and visiting the traders’ tables

Barbara van Wyk (left) from Johnson & Johnson presented the lucky draw prize to a seminar delegate Delegates attending OHASA Western Cape’s last full-day seminar for 2019

PAGE 28 OHASA JOURNAL

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OhASA nEwS

kwAZulu-NATAl BrANCH NEwS

OHASA

Our second full-day seminar on 5 October was held at the lovely eMakhosini Boutique Hotel in

Morningside, Durban.

We were fortunate to have a great line-up of speakers as follows:

• Dr Eubulus Timothy – Oral Health and healthy aging

• Dr Kiran Ramson – Current concepts in digital workflow and ceramic dentistry

• Dr Sikki Singh – Role of the Hygienist in Cleft Palate care

• Dr Shauntel Ambrose – Mastering your risk

• Dr Ian Erasmus – Efficacy of Fluorinol® for the inhibition of dental plaque, caries and periodontal

conditions

• Dr Ahmed Muslim – Consumer Protection Act.

We are very grateful to our traders – Oral B, Ivodent, Prime Dental, GSK and Johnson & Johnson for

exhibiting at our seminar and for the fantastic lucky draw prizes.

Dr Shauntel Ambrose and Mateenah Jajbay-Amod

Kathy Dolloway, Dr Kiran Ramson and Mateenah Jajbay-Amod Dr Ian Erasmus and Kathy Dolloway

ohasa KWaZulu-natal

Dates for 2020:first full-day seminar – 14 march 2020

second full-day seminar – 12 september 2020

If you are not on our mailing list and would like to be

notified of the KZN news, or wish to make any queries,

please contact Kathy at [email protected]

Warm regards

Kathy Dolloway

OHASA KwaZulu-Natal Branch Chairperson ●

Third-year Oral Hygiene students (UWC) presenting their research project – members present contributed to their project by completing their research questionnaire

Izanne Olivier (left) thanking Dr A Thomas (right) for his insightful presentation at the last full-day seminar

ohasa Western cape Dates for 2020:Keep an eye open for the e-mail regarding

membership for 2020.

proposeD seminar Dates for 2020

breakfast meeting – 29 february 2020

first full-day seminar – 18 april 2020

second full-day seminar – 15 august 2020

ohasa agm (cape town) – 31 october 2020

If you have any suggestions for our seminars for 2020

please email your ideas to [email protected]

The Western Cape Branch Committee and I

wish all our members, non-members and traders

a blessed festive season with your families and

friends. We look forward to seeing you all in 2020

and making it another successful year.

Cape Town Greetings

anri bernardo

OHASA Western Cape Branch Chairperson ●

PAGE 294th quarter 2019 • volume 20 no. 4

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OHASAJOURNAL

AdVErTiSiNg rATES fOr 2020 (Prices include VAT. No agency commission)

aDvert siZe WiDth x height (mm) rate

Front Cover Page

Trim 210 mm x 233 mm

R12 200.00

Bleed 220 mm x 243 mm

A4 Page

Trim 210 mm x 297 mm Inside front cover (IFC): R8 480.00

Inside back cover (IBC): R8 480.00

Outside back cover (OBC): R8 480.00

Inner page: R6 900.00

Advertorial: R5 450.00Bleed 220 mm x 307 mm

Double Page Spread (DPS)

Trim 420 mm x 297 mm

R13 320.00

Bleed 430 mm x 307 mm

Half Page – Horizontal

Trim 210 mm x 148 mm

R4 250.00

Bleed 220 mm x 158 mm

Third Page – Vertical

Trim 157.5 mm x 297 mm

R3 650.00

Bleed 167.5 mm x 307 mm

* Bleed area = 5 mm all around

Random position inserts R1 220.00

Specific position inserts R1 820.00

Classifieds (unlimited characters) R310.00

Banner on website Price available on request

DeaDlines

1st Quarter 14 February

2nd Quarter 15 May

3rd Quarter 14 August

4th Quarter 15 November

contact Details

Rugshana Cader (Managing Editor OHASA Journal)

Cellphone: 082 710 7103

Tel: 021 937 3123

E-mail: [email protected]

OHASAJOURNAL

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personal Details:

Title: Surname: First Name(s):

Preferred Name: Maiden Name:

ID Number: HPCSA No: OH/DA/DT/DP

Postal Address: Physical Address:

Postal Code: Postal Code:

Tel. (Work): OHASA Number:

Cell Phone: Tel. (Home):

E-mail Address: Independent Practice Supervised Practice

branch:

(Please mark all sections with x)

Western Cape Eastern Cape Gauteng KwaZulu-Natal

Current Member New Member

important notices:

1. all membership fees are Due on or before 28th february 2020.

2. all current members who renew and pay their membership fees after this date will be charged an additional administration fee of r250.00.

3. a 4-month interest free pay-off financial agreement is available (nov 2019–feb 2020).

4. all membership categories have full access to the ohasa website www.ohasa.co.za (own personal profile. cpD activities, etc.)

ohasa membership categories:

memberships mark with X membership information

core

(Any Dental Professional)

R660.00

• 4CPDQuestionnairesinsertedinOHASA Journal (4 x 3 CEUs per Questionnaire = 12 CEUs)

• Discountedfeeperfulldayseminar(R350.00incl.VAT)

• Novotingrights

full membership

(Oral Hygienist only)

R880.00

• 2Full-daysubsidisedCPDOHASASeminars(2x6CEUs=12CEUs)

• 4CPDQuestionnairesinsertedinOHASA Journal (4 x 3 CEUs per Questionnaire = 12 CEUs)

• 3rd Full day seminar at a discounted fee (R350.00 incl. VAT)

• FullMembershipOralHygienistshavevotingrights

associate

(If you are a qualified Oral Hygienist

but not registered with the HPCSA)

R880.00

• 2Full-daysubsidisedCPDOHASASeminars(2x6CEUs=12CEUs)

• 4CPDQuestionnairesinsertedinOHASA Journal (4 x 3 CEUs per Questionnaire = 12 CEUs)

• 3rd Full day seminar at a discounted fee (R350.00 incl. VAT)

• Novotingrights

allieD

Dental Assistant R1 441.00

Dental Therapist R1 771.00

Dentist R2 255.00

• 2Full-daysubsidisedCPDOHASASeminars(2x6CEUs=12CEUs)

• 4CPDQuestionnairesinsertedinOHASA Journal (4 x 3 CEUs per Questionnaire = 12 CEUs)

• 3rd Full day seminar at a discounted fee (350.00 incl. VAT)

• Novotingrights

honorary

(No membership fee applicable)

• 2Full-daysubsidisedCPDOHASASeminars(2x6CEUs=12CEUs)

• 4CPDQuestionnairesinsertedinOHASA Journal (4 x 3 CEUs per Questionnaire = 12 CEUs)

• R350.00perfull-dayOHASAseminar

• HonoraryMembershavevotingrights

APPliCATiON fOr OHASA mEmBErSHiP fOr 2020

Member of

PAGE 314th quarter 2019 • volume 20 no. 4

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APPLIcATIOn fOR OhASA MEMbERShIP fOR 2020

memberships mark with X membership information

retireD

(No membership fee applicable)

• 4CPDQuestionnairesinsertedinOHASA Journal (4 x 3 CEUs per Questionnaire = 12 CEUs)

• R350.00perfull-dayOHASAseminar

• Novotingrights

stuDent

(No membership fee applicable)

• 4CPDQuestionnairesinsertedinOHASA Journal (4 x 3 CEUs per Questionnaire = 12 CEUs)

• R350.00perfull-dayOHASASeminar

• Novotingrights

Donar

(No membership fee applicable)

• Peragreement

• Novotingrights

international Dentistry sa Journals

(Please mark all sections with x)

1. Annual subscription – 6 x journals r345.00

2. Online subscription option (Journal and 6 x CDP Questionnaires) r1 035.00

3. 10% discount if paid in full before 28/02/2020 r931.50

4. For CPD ONLY (Read journal online) r690.00

I understand that OHASA prefers to communicate with its members and applicants via email and SMS. OHASA does not communicate with applicants via postal

service. It is therefore important that I immediately notify OHASA of any change in details i.e. e-mail address or cellular contact number.

In order to provide you with the best possible service OHASA would like to inform you of other products, training and services within the profession.

May we send you this information via e-mail and sms? YES NO

signature: Date:

please complete this application form and email it with a copy of your payment and/or financial agreement to:

e-mail: [email protected] postal address:

OHASA Secretariat

PO Box 830

Newlands, Pretoria

0049

banKing Details:

OHASA National

ABSA Current Account

Account Number: 2870164818

Branch Code: 632005

Reference: HPCSA number, Surname

for office use only

Western Cape Eastern Cape Gauteng KwaZulu-Natal

HPCSA # OHASA Membership # Processing Date:

PAGE 32 OHASA JOURNAL

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®

• Fluoride for cavity protection• Reveals & targets food particles• Alcohol & sugar free

Ltd 2018

A Fun Way to ProtectKids Teeth

ZA/LI/18-0853a

Page 36: HASA · 2019-12-10 · -–˛ˆ˚ˇ˚˘ ˝ ˇ˙˝˚ ˇ ˆ HASA JOURNAL Official mOuthpiece f the Oral O ygienists’ h ssOaciatiOn Of sOuth africa 4th quarter 2019 • volume 20 no

Cutterguide : No Printing Process : Off set GD : SB32430 Size: 210 mm x 233 mm, Pages: 1 Colors : C M Y K (4 Colors) Native File :Adobe Indwsign CS6 Windows Generated in : Acrobat Distiller 10.0

With clinically proven Dual relief

No.1 DENTIST RECOMMENDED BRAND FOR SENSITIVE TEETH*

*GFK New expert performance tracking 2018.

For any product safety issues, please contact GSK on +27 11 745 6001 or 0800 118 274. Trademarks are own or licensed by the GSK group of companies.

& new

SENSITIVITY GUM

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Cutterguide : No Printing Process : Off set GD : SB32430 Size: 210 mm x 233 mm, Pages: 1 Colors : C M Y K (4 Colors) Native File :Adobe Indwsign CS6 Windows Generated in : Acrobat Distiller 10.0

With clinically proven Dual relief

No.1 DENTIST RECOMMENDED BRAND FOR SENSITIVE TEETH*

*GFK New expert performance tracking 2018.

For any product safety issues, please contact GSK on +27 11 745 6001 or 0800 118 274. Trademarks are own or licensed by the GSK group of companies.

& new

SENSITIVITY GUM

2019_SA_Sensodyne_JournalCover_GSKCH_167_D2.indd 1 4/29/2019 3:45:28 PM

Cutterguide : No Printing Process : Off set GD : SB32430 Size: 210 mm x 233 mm, Pages: 1 Colors : C M Y K (4 Colors) Native File :Adobe Indwsign CS6 Windows Generated in : Acrobat Distiller 10.0

With clinically proven Dual relief

No.1 DENTIST RECOMMENDED BRAND FOR SENSITIVE TEETH*

*GFK New expert performance tracking 2018.

For any product safety issues, please contact GSK on +27 11 745 6001 or 0800 118 274. Trademarks are own or licensed by the GSK group of companies.

& new

SENSITIVITY GUM

2019_SA_Sensodyne_JournalCover_GSKCH_167_D2.indd 1 4/29/2019 3:45:28 PM

Cutterguide : No Printing Process : Off set GD : SB32430 Size: 210 mm x 233 mm, Pages: 1 Colors : C M Y K (4 Colors) Native File :Adobe Indwsign CS6 Windows Generated in : Acrobat Distiller 10.0

With clinically proven Dual relief

No.1 DENTIST RECOMMENDED BRAND FOR SENSITIVE TEETH*

*GFK New expert performance tracking 2018.

For any product safety issues, please contact GSK on +27 11 745 6001 or 0800 118 274. Trademarks are own or licensed by the GSK group of companies.

& new

SENSITIVITY GUM

2019_SA_Sensodyne_JournalCover_GSKCH_167_D2.indd 1 4/29/2019 3:45:28 PM