ASID - Australian Society of Implant Dentistry

Welcome to this edition of the ASID (NSW Branch) Newsletter. A very warm welcome goes out to all new members for whom this will be their first newsletter. The intent of the Newsletter is to inform and to disseminate knowledge on all things relating to dental implantology. If any member has any interesting information, ideas, techniques, or details of meetings or courses throughout the world which might be of interest to members, please give the details to the secretary so they may be included in the next newsletter.

Members will by now be aware that we now have two membership categories in response to feedback from members (yes, we do listen to our members). We have a Gold membership for those members who are able to attend dinner meetings frequently and a Silver membership for those who find it difficult to attend so often, such as country members. All members are of course encouraged to attend meetings, and members will always be made welcome at our meetings regardless of their frequency of attendance.

A reminder to those who have not yet returned their subscriptions - please do so as soon as possible.

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There has now been made an impressive lapel badge which will be sent to all members on payment of their current subscription-wear it with pride.

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Wednesday Nov 26 ASID (NSW Branch ) Xmas Dinner Meeting .Guest lecturer Dr Fred Marishel –subject : Successful Financial Management for the Implantologist.

March 11-13 1998 – ASID Levels 1 & 2 Accreditation Courses in association with ADA Congress Perth

May 1998 ASID (NSW Branch) 1Day Seminar on Implantology for Dental Assistants and Technicians –details to be advised.

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At the last general meeting of the A.S.I.D. (NSW Branch) our member Gerry Marish , suggested the formation of the above program. The program has 2 objectives :-

1. When a member is performing a major implant placement procedure and requires the assistance of a colleague for an extensive implant surgical procedure as often the chairside assistant is not adequately experienced to assist by herself nor the understanding of the procedure which an Implant oriented dentist would have. That means that the member requiring assistance would ring from the list of members who have indicated their willingness to be involved and arrange a suitable time and day for assistance with the procedure. In return at some future date the member would reciprocate.

2. Those who require more experience can learn from the practitioner that they assist or who assists them.

Members who feel they may be interested in participating in this new program are urged to complete the enclosed form and return it to the secretary who will compile the list of participants and return it to all those involved.

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Surgery in the posterior mandible is fraught with risks to the inferior dental nerve and its terminal branch, the mental nerve. Whilst computerised tomography may help in locating these structures, it is costly and not always possible. The Orthopantomogram remains the most common and cost effective tool, but accurate visualisation of the inferior dental canals and the mental foramina is often difficult because of the superimposition of structures and because primary and secondary shadows are cast by the right and left jaws when they are close to, and opposite to the film respectively. These shadows can cause shadows or radiolucencies, which are artefacts.

Dharmar has found that by lowering the patient’s head and tilting their Frankfurt plane down 5 degrees to the reference plane of the OPG machine, the primary, secondary and false shadows are shifted out of the line of the mandibular canals, allowing their visualisation more clearly. Whilst this may increase the extent of the magnification of the film, Dharmar suggests it is possible to measure and assess this distortion when planning for implant placement. Readers might be better advised not to use OPGS for making measurements in any circumstance, using them merely as an overview for locating structures and their approximately relevant positions.

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The wound healing process is known to be a very complex, dynamic process, whereby metabolic and nutritional factors directly influence this highly integrated process. Nutrients have a profound effect on the healing process. There are many influential mechanisms involved in the wound healing process which are sensitive to specific nutrients. Problems of wound healing and wound infection are interrelated; what affects one affects the other. For example, when wound healing is impaired, infection can be a frequent complication; when wound infection is present, healing is delayed.

Wound healing can be recognised in three phases after tissue injury or surgery: Inflammatory Phase, Proliferative Phase, and Remodelling Phase. Healing during these phases follows a complex, sequential pattern, whereby specific nutrients are vital. Any number of metabolic and nutritional factors can disrupt the healing sequence thereby affecting the body’s ability to heal postoperatively. The magnitude of effect that nutrition has on wound healing is great and often overlooked.

In order to appreciate the relevance of specific nutrients involved in the wound-healing process, it is necessary to identify their roles during the healing process. Adequate nutrition is essential for the regeneration of tissue during normal wound healing. Nutrients function both individually and cooperatively in the wound-healing process. As documented in the literature, nutrients known to have a direct impact on the wound healing process will be discussed.

In the U.S., protein deficiency is uncommon. However, certain situations predispose patients to inadequate protein intake: certain chronic illnesses, alcoholism, lack of proper dentition, poverty, or even the common practice of decreased intake prior to surgery. These common situations in combination with increased metabolic needs as a result of surgery set the patient up for protein inadequacies, if not deprivation. Adequate protein intake in a protein-deprived patient even one week prior to surgery can improve wound healing and is of greater importance than relying on protein and fat stores. Numerous studies associate protein deficiency with impaired wound healing and decreased resistance to infection. Specifically, inadequate protein impairs fibroblastic proliferation, neoangiogenesis, collagen synthesis, and wound remodelling. The provision of adequate protein improves wound healing and resistance to infection.

Protein plays a vital role in each phase of the wound healing process. Protein is required for white blood cell functions, including bacterial phagocytosis, fibroblastic proliferation, and reparative collagen accumulation.

Several individual amino acids appear to be involved in the inflammatory response and other early phases of wound healing. Sulphur-containing amino acids, cisteine and methionine, prevent prolonging the inflammatory phase by decreasing the amount of protein destroyed during this phase. Additionally, these amino acids play important roles in fibroblastic proliferation and reparative collagen accumulation, and play important roles in antioxidant production.

Arginine, supplied either by diet or synthesized by the body, is another amino acid which has important roles both in maintaining the immune system and in wound healing. Arginine appears to be essential during injury or stress, and may improve wound healing by increasing collagen synthesis. When given as a supplement, arginine promotes wound healing. It appears to be most effective when given in the first three days of wound healing, during the period of inflammation and fibroblast activity. However, optimal amounts of arginine supplementation remain inconclusive. Arginine enhances immune function in both animals and humans. In healthy humans, arginine increases the deposition of total protein and hydroxyproline in the wound. In addition, arginine promotes retention of nitrogen and decreases protein catabolism. It is likely that arginine’s immune-stimulating effects require adequate energy and protein sources.

A diet rich in carbohydrates spares protein from being degraded for energy use. Glucose needs to be available and metabolized normally in order for the energy requirements of leukocytes and fibroblasts to be met.

Long standing diabetes and / or poorly controlled diabetes is associated with impaired healing and decreased resistance to infection. Diabetes is a major yet common health problem, with approximately 18 million diabetics in the U.S. Hyperglycaemia is associated with decreased leukocyte function and phagocytosis. An acute lack of insulin and hyperglycaemia may slow healing. High levels of glucose interfere with the cellular transport of ascorbic acid into fibroblasts and leukocytes, and cause decreased leukocyte activity. In addition, chronic hyperglycaemis may also be associated with impaired acute inflammatory response, decreased resistance to infection, and impaired wound repair. Maintaining normal blood sugar levels is of utmost importance during injury, surgery, illness and infection.

Dietary fats provide energy and the essential fatty acids (EFAs) linoleic acid, from the omega-6 family and a-linoleic acid from the omega-3 family. These fatty acids are important constituents of cell membrane phospholipids and are considered essential since they prevent deficiency symptoms and cannot be synthesized by the body. Linoleic acid is primarily found in vegetable seed oils, such as soybean and canola oils. Fish oils, especially those from cold-water fish (sardines, tuna, salmon), are rich sources of linoleic acid derivatives, eicosapentoic acid (EPA) and docosahexaenoic acid (DHA). Linoleic acid is supplied by most vegetable oils: safflower, corn, soybean, cottonseed.

These fatty acid families are precursors of inflammatory mediators (prostoglandins, thromboxanes, and leukotrines), which have hormone-like properties, one of which is immune function. Each family exhibits different eicosanoids. For example, arachidonic acid (omega-6) is a precursor of prostoglandin thromboxane A2, which causes platelet aggegration, clot formation, and vasoconstriction. Omega-3 fatty acids produce prostacyclin, which has opposite effects, preventing clot formation and causing vasodilation. In addition, omega-3s decrease production arachidonic acid. Studies show that omega-3s preferentially replace omega-6 fatty acids in phospholipids. A clinical effect of diets high in omega-3 fatty acids is reduced inflammation. Thus, fats are involved in the healing process in significant ways.

Vitamins and minerals affect wound healing in a variety of ways. Some are essential to wound repair, with a deficiency resulting in impaired or delayed wound healing. Other micronutrients augment wound healing when given as a supplement. Because vitamins and minerals are interrelated, the action of one may influence the action of another. Vitamins and minerals known to have a direct effect on the wound healing process are discussed below.

Ascorbic acid plays a direct role in all three phases of wound healing: improved neutrophil and macrophage function, fibroblast maturation, and hydroxylation of proline and lysine in procollagen. Hydroxyproline is required for cross-linking, giving strength to the scar. Stress associated with injury, wound healing, and smoking increases vitamin C needs. However, whether or not ascorbic acid supplementation effectively improves the wound healing process is still controversial. A potential complication of excessive vitamin C supplementation is calcium oxalate stones.

Vitamin A plays a different role in each stage of the wound healing process. In the early inflammatory phase, vitamin A increases the number of monocytes and macrophages, and reverses the inhibitory effects of corticosteroids. During the proliferation phase, vitamin A stimulates fibroblast differentiation and collagen synthesis and cross-linking, increasing the bursting strength of the wound. Topical vitamin A has been shown to increase epithelialization of the wound. Vitamin A also assists in the maintenance of serum iron levels.

The main function of vitamin E is to maintain cell membrane and intracellular membrane integrity, primarily by protection against oxidation. Vitamin E enhances immune response, including phagocytosis. Although vitamin E is extremely safe, even in chronic high doses exceeding 1 g/day, excess vitamin E can delay wound healing by interfering with vitamin A and can cause bleeding related to platelet dysfunction.

In general, all B vitamins are important for wound healing. Riboflavin (B2), pyridoxine (B6), and pantothenic acid (B5) in particular have important roles in the healing process.

Riboflavin deficiency results in delayed epithelialization, decreased total collagen content in wounds, a slowed rate of wound contraction, and an impaired collagen cross-linking, resulting in reduced tensile strength of the wound. A deficiency of pyridoxine produces similar effects. Pantothenic acid is important in collagen production, and has been shown to increase skin strength and fibroblastic scar tissue.

Iron is required for life; the primary function of iron is as a carrier of oxygen. In wound healing, iron is required for hydroxylation in collagen synthesis.

Iron-deficiency anaemia is a common problem for women of childbearing age, and anaemic patients exhibit delayed wound healing. Specifically, iron deficiency may interfere with leukocyte bactericidal activity, thus increasing susceptibility to infection!s.

Vitamin C enhances nonhaeme iron absorption; increased zinc and copper appear to decrease absorption. In turn, excessive iron can lead to a zinc deficiency.

Copper is of direct importance in wound healing. Lysyl oxidase is a copper-containing enzyme which catalyzes the oxidation of lysyl residues on collagen, adding strength by increasing collagen cross-linking. Copper deficiency results in iron deficiency, since the majority of copper is transported on ceruloplasmin, which oxidizes ferrous to ferric ion.

Zinc is required in wound healing, antioxidant defenses, and for rapidly proliferating tissue such as epithelium. Zinc deficiency leads to impaired immunity and wound healing. Calcium and iron interfere with zinc absorption. Zinc deficiency impairs production of retinol-binding protein, and consequently, vitamin A transport, possibly leading to a vitamin A deficiency. Although toxicity is rare, excess zinc can lead to a copper deficiency and anaemia.

Few studies have reported the role of manganese and wound healing. However, it is known that manganese is required for the formation of procollagen fibres and the ground substance in wound healing.

Selenium aids the wound healing process by protecting against cell oxidation. Selenium and vitamin E are closely related; a deficiency of one may be partially corrected by replacement of the other. One study observed reduced collagen breakdown upon administration of both vitamin E and selenium in rats.

Although vitamins, certain trace metals are essential during the healing process, supplementing with certain nutrients remains somewhat controversial and inconclusive.

Nutrients are directly involved throughout the wound healing process and are vital to the tissue reparative process. Adequate nutrition promotes wound healing, enhances immunocompetence, decreases susceptibility to infection, and optimizes patient outcome.

It depends on your definition of kinky. We do however have an excellent range of videos on many aspects of implantology. Contact Andrew Taylor on 94392090 to arrange for video hire. Another benefit of ASID membership.

A list of videos and audio tapes is available on request, and on the web site.

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The NSW Branch has set up it’s own web site. There is lots of information on society matters, including the latest Newsletter. Archived copies of Newsletters will be available, starting from this edition. There are also some excellent links to other dental sites. Absolutely a must for all those on the Internet (is there anybody not on the Internet now?)

Please visit the site. If you can offer any comments or suggestions, or have an interesting article or Tit-bit that you think would be of interest to other members, please mail them to Ken Lipworth at This e-mail address is being protected from spambots. You need JavaScript enabled to view it

The web site URL is http://www.triode.net.au/~ken/asid.htm

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As a trial the ASID (NSW Branch) has a block advertisement in the next Yellow Pages.

An answering service will handle enquiries and members of the executive will then follow these up. If a request is made for the names of practitioners involved in implants then a list of practitioners in the area will be made available, with no individual recommendation. This list will be drawn up from members who wish to be included. It is envisaged that members on this list will have completed the accreditation program and be actively involved and experienced in implantology, although those who have not yet been accredited but feel they should be on the list by virtue of their experience, will be considered.

Please fill in the enclosed form and return it to the secretary if you wish to be included.

If you don’t consider yourself to be experienced enough at present to accept referrals but at some later time wish to be included, then you can advise the secretary when you wish to be included and your name will be added to the list.

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� I wish to have my name added to the list to accept referrals for implants.

� I have completed the ASID Implant Accreditation Programme and have been accredited.

� I have not at this stage been accredited, however by virtue of my experience detailed below, I wish to be included.

I hereby request that my details be made available on the list of members of the ASID (NSW Branch), which is available for access by the public on the Association’s Internet Web site.

Signature: ………………….……..............……….. Date: .……………

I wish to be included in this innovative programme : yes ˜ no ˜

If yes, as an assistant � a ‘mentor’

If assisting, my preferred days and times are .................................................................

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Name .......................................................................................................

Address .................................................................................................................

....................................................................................................Post code.................

Telephone .............................................. Fax .............................................

Implant experience and implant system/s used

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Dr G John Berne, Hon Secretary ASID (NSW Branch),