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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
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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
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
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
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
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
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
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
RESEARch
PAGE 74th quarter 2019 • volume 20 no. 4
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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PAGE 8 OHASA JOURNAL
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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PAGE 94th quarter 2019 • volume 20 no. 4
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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
PAGE 10 OHASA JOURNAL
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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
PAGE 114th quarter 2019 • volume 20 no. 4
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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PAGE 12 OHASA JOURNAL
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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PAGE 134th quarter 2019 • volume 20 no. 4
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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PAGE 14 OHASA JOURNAL
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.
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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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PAGE 16 OHASA JOURNAL
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.
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PAGE 174th quarter 2019 • volume 20 no. 4
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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PAGE 18 OHASA JOURNAL
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
EThIcS
PAGE 194th quarter 2019 • volume 20 no. 4
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.
EThIcS
PAGE 20 OHASA JOURNAL
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?
EThIcS
PAGE 214th quarter 2019 • volume 20 no. 4
PAGE 22 OHASA JOURNAL
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
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
PAGE 24 OHASA JOURNAL
PAGE 254th quarter 2019 • volume 20 no. 4
PFZA/201902006
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
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
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
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
OHASAJOURNAL
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OHASAJOURNAL
PAGE 30 OHASA JOURNAL
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• 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
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
®
• Fluoride for cavity protection• Reveals & targets food particles• Alcohol & sugar free
Ltd 2018
A Fun Way to ProtectKids Teeth
ZA/LI/18-0853a
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
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