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2nd quarter 2014 • volume 15 no. 2 • ISSN 1018-1466
OHASA
JOURNAL
O 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 So u t h A f r i c a
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Scientific Work Cited: 1. Addy M. Int Dent J. 2002;52(suppl 5):367-375.
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CONTENTS
EDITORIAL
news
2 Right on schedule
N Swart
12 Oral hygienists ecstatic about
Independent Private Practice approval
3 From the president’s desk
Review
S Lamprecht
Guest editorial
13 Extrinsic stains and management:
a new insight
4 Alliance for a cavity free future
S Prathap, H Rajesh, VA Boloor and
AS Rao
Material Report
Ethics
5 The effect of three whitening oral
rinses on enamel micro-hardness
19 The ethics of advertising
E Potgieter, Y Osman, SR Grobler
Prof. S Naidoo
ohasa news
Research
21 Guidelines for authors
9 Services rendered and barriers faced
by public sector oral hygienists in two
provinces of South Africa
Continuous professional
development
U Govender, A Bhayat, M Rudolph
22CPD questionnaire
Editorial committee
Managing Editor Natasha Swart, Tel: (012) 319 2687, Cell: 082 414 1142, E-mail: [email protected], [email protected] | Co-Editors Renè du Bruyn, E-mail: rene.dubruyn@‌up.‌ac.‌za;
Marie Ferreira, E-mail: [email protected]; Stella Lamprecht, E-mail: [email protected]; Candida Kruger, E-mail: [email protected]
OHASA Office
PO Box 830, Newlands, 0049 | Fax: 086 696 7313 | E-mail: [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] | Physical: 345 Festival Street, Hatfield, Pretoria 0083 |
Postal: PO Box 12999, Hatfield, Pretoria 0028 | Website: www.kashan.co.za | Sub-editors Caro Heard; Isabel Botha | Layout and Design Hein le Roux
ISSN 1018-1466 © 2014 All rights reserved in text: OHASA. © 2014 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.
Published by
On behalf of
Member of
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.
2nd quarter 2014 • volume 15 no. 2
PAGE 1
EDITORIAL
RIGHT ON
SCHEDULE
Being more productive while maintaining a healthy worK‑life
balance can be challenging.
As you may have noticed, the OHASA Journal has
had a facelift – a brand new look and feel! I am
pleased to welcome Kashan Advertising as our
new publishers of the OHASA Journal. The editorial
committee and I are really looking forward working
with you and building a lasting partnership. I would
also like to express my gratitude to the OHASA
EXCO and members for their sustained support to
make this change possible.
I’m delighted to announce that the Journal will be
delivered to you on a quarterly basis, and will now
only be distributed to OHASA members, where in
the past it was made available to all oral hygienists
registered with the HPCSA. This will be an exclusive
benefit for you as an OHASA member. As an OHASA
member you can also complete your online CPDs at
the following website: www.ohasa.co.za.
There is a quiet revolution unfolding in South
Africa’s oral hygienist world. From treating patients,
managing a practice and starting up a new practice,
to home offices and running a household, we are
enlisting the help of experts to guide us in how to
juggle daily tasks more efficiently, and few would
disagree that effective time management is the
key to unlocking productivity.
Making the most of our money-earning potential
is one reason we are working hard at wringing
more out of our waking hours. But we also want
to shake off the stress that comes with being
trapped under a load of projects that seem to
have developed a life of their own. We want to
have much more fun too – and the only way we
can achieve this is by freeing up more space in
our busy days.
The professionals who coach executives to
help fine-tune their management styles have a
message for all of us: achieving a good work-life
balance requires strategic thinking. In some cases,
deep soul-searching is needed to figure out what’s
holding us back from tackling unpleasant chores.
More often than not, it is simply a case of facing up
to our distractions and saying “No” – to ourselves
and to others.
Andrew Horton, a successful South African
entrepreneur who is in demand as a motivational
speaker on the international circuit, specialises
in helping teams develop techniques to optimise
the use of available time. He carefully studied the
behaviour of the world’s super-achievers, using
this to create customised time-management
programmes for his clients.
According to Horton, “we need to remember time
is in short supply in everyone’s lives, including for
people such as Bill Gates and Donald Trump. They
have the same amount of time we do, but they get
so much more done. This is because they’ve got
routines, sets of success habits”.
Horton compares the time management dilemma
to filling a jar (representing your time) with large
stones (goal-specific tasks), small stones (priority
tasks), sand (important tasks) and water (your to-do
list). Randomly filling the jar means that you may
never use it to its full potential. “You will feel like
you have been working, but you have achieved
nothing”. So many people do the easy stuff first (the
to-do list) and delay on the goal-specific activities,
which means they may get to the end of the day
without doing anything really important. Have a
Natasha Swart
Managing editor
systematic, habitual approach to tackling the big
things first. If you mix up your tasks, you can’t focus,
is the strategist’s advice.
Tracey Foulkes, the CEO of Get Organised South
Africa, is fastidious about her time management.
Although she currently has a big client list and is
planning on expanding, she still spends quality
time with her children and her husband. Unlike
many other career women who may feel stretched,
Foulkes doesn’t feel guilty about not spending
enough time with her family or her work, because
she fits everything in. Her blueprint for time
management looks a lot like a school timetable.
This is her lifesaver. She believes in setting goals
and in prioritising “high-value, high-reward tasks”.
It may sound very rigid, but there is a lesson
that rings out loud and clear: we can all make a
lot more of the time we have, simply by focusing
sharply on the work that really counts and offloading
unimportant stuff. As Foulkes puts it, “Make the
work fit the time you’ve given it. Don’t extend the
time to fit the task.” ●
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 health care by representing, protecting and advancing the profession in partnership with stakeholders.
OHASA National Executive Committee
President Stella Lamprecht Vice-President Karen Paulse Secretariat Natasha Swart Treasurer Marie Ferreira Additional Member Maggie Naidoo SADA Liaison Petro Steyn; Susan Burger
ohasa branch chairpersons and representatives
Gauteng Branch Representative Natasha Swart, Cell: 082 414 1142, E-mail: [email protected], [email protected]
Chairperson Stella Lamprecht, Cell: 082 890 6949, E-mail: [email protected]
Eastern Cape Branch Representative Marie Ferreira, Cell: 082 897 6252, E-mail: [email protected], [email protected]
Chairperson Mart-Marié Potgieter, Cell: 083 661 9382 a/h, E-mail: [email protected]
Kwazulu-Natal Branch Representative Maggie Naidoo, Cell: 083 777 9420, E-mail: [email protected]
Chairperson Suzette Pirow, Cell: 082 568 0173, E-mail: [email protected]
Western CaPe Branch Representative Karen Paulse, Cell: 083 357 8759, E-mail: [email protected]
Chairperson Gail Smith, Cell: 083 422 7020, E-mail: [email protected]
PAGE 2
OHASA JOURNAL
EDITORIAL
From the
president’s desk
Stella Lamprecht
OHASA president
2nd quarter 2014 • volume 15 no. 2
Dear OHASA Members and Colleagues
Welcome to the second quarter. Since the
promulgation of Independent Practice, it is heartwarming to see that we have had numerous
members attend the required Level 3 first-aid
course and congratulations to those of you who
have already registered for Independent Practice.
At the moment there are eleven registered
independent oral hygiene practitioners. For
those who still intend to register for Independent
Practice, please complete the latest Form 189A by
either downloading it from the HPCSA website,
or alternatively, obtaining it from me and please
remember to stamp it with the official practice
stamp. Please note further that the Level 3 FirstAid Certificate must be signed by a Notary and
not a Commissioner of Oaths. Expanded functions
must also be registered. Independent Practice was
one of the main objectives that OHASA set out
to achieve, and now that we have achieved that
goal, it is time to focus on our other objectives.
The South African Chapter of the Alliance for
a Cavity Free Future (ACFF) will be signed on
25 June 2014 at the International Association of
Dental Research (IADR). I would like to appeal to
each and every hygienist and our Allied members
to pledge support for this cause. To some degree,
most South Africans have dental knowledge but
unfortunately not everyone is fortunate enough
to be able to afford dental services. It is therefore
imperative that we expand the dental knowledge of
every South African so that we can drive prevention
of caries. Remember that the prevention of oral
disease is not our only objective, we need to ensure
overall health as well.
The Public and Professional Relations Committee
(PPRC) is driving the promotion of our profession,
not only amongst professionals but to the public as
well. It is imperative that the vital link between oral
health and overall health is seen and understood. We
had a successful World Oral Health Day with some
of the local newspapers running articles, and the
PPRC is planning further drives in the future – we
will inform you accordingly.
SADA 2014 had a very successful oral hygiene
programme and one of the international lecturers
was kind enough to give us her lecture to ensure
that every dental practitioner is aware of bites,
bruises and other signs of child abuse, so that we
may prevent abuse and neglect through dental
awareness. Pamphlets will be printed and distributed
to members.
OHASA is also focussing on bringing to book
beautician’s who advertise tooth whitening. If you
see an advert in this regard, please take a photo
and send it to me.
I would like to thank the members of the DTO
Board for ensuring that our fees weren’t increased.
I am very aware of how hard you have worked to
cut costs so as to ensure that our fees remain the
same. As a reminder, the HPCSA fees were due
by 31 March 2014 for the 2014/2015 registration.
Voluntary erasure should also have been done
before 31 March to avoid having to pay fees while
not practicing.
OHASA wishes to thank the dental traders for
their continuous support/donations and sponsorship
of its activities.
God Bless
Stella ●
PAGE 3
GUEST EDITORIAL
ALLIANCE FOR A
CAVITY-FREE FUTURE
Samantha Naidoo
•Dr Nadia Mohamed – Paediatric Dentistry, UWC
• Prof. Jeff Yengopal – Community Dentistry, Wits
•Dr Johan Smit – National Department of Health
• Prof. PJ van Wyk – Community Dentistry, UP
• Prof. Ayo-Yusuf Dean – Medunsa Campus, UL
•Ms Stella Lamprecht – President, OHASA
•Ms Angelique Kearney – OHASA
•Dr Mpho Molete – Wits
•Dr D Thekiso – Wits
•Dr Y Kolisa – Wits
•Mr Lesley Naidoo – President, SADTA
•Ms Desiree Pillay – SADTA
•Dr Khanyi Makwakwa – SADA
Professor Sue Naidoo, Deputy Dean of Research at UWC and the expert panel.
Tooth decay is the most common chronic disease
on the planet, affecting five billion people, or nearly
80 percent of the world’s population. This disease
often restricts activities in school, at work and at home,
causing millions of school and work hours to be lost
each year the world over. Moreover, the psychosocial
impact of these diseases often significantly diminishes
the quality of life. It is for these reasons that a group
of key experts and opinion leaders have joined hands
to tackle this debilitating problem.
The Alliance for a Cavity-Free Future (ACFF) is
a worldwide group of experts who have joined
together. Their aim is to promote integrated
clinical and public health action so as to stop caries
initiation and progression in order to move towards
PAGE 4
a Cavity‑Free Future for all age groups. Overall, the
group believes that global collaborative action is
needed to challenge global leaders and other regional
and local stakeholders to learn the importance
of caries as a disease continuum. The ACFF will
serve to encourage participation in action toward
the delivery of comprehensive caries prevention
and management that can positively influence the
continuing problem of caries.
The Kick-off Meeting of the South African Chapter
of the Alliance for a Cavity-Free Future was held on
the 13 March 2014 at Emperors Palace. The meeting
was facilitated by Prof. Sue Naidoo – Deputy Dean
of Research at UWC and the expert panel that
attended included:
This gathering allowed the South African experts
to join together and discuss the importance of
optimally managing the growing caries incidence
from a South African perspective, with the plan
being to practically combat this disease.
There was strong support for the ACFF concept
and the potential impact it could play in the future
of Oral Health in South Africa. All parties committed
to the goals of the Alliance and to signing an ACFF
declaration on 26 June 2014 at the official ACFF
launch meeting, which will be held around the
IADR Congress in Cape Town. The declaration
calls for global collaborative action to challenge
health care leaders and stakeholders to learn the
importance of caries as a disease continuum, by
recognising that cavities are preventable, and to
develop comprehensive programmes for prevention
and management. ●
For more information about the ACFF, please visit:
www.AllianceForACavityFreeFuture.org
OHASA JOURNAL
Material Report
The effect of three whitening oral rinses on
enamel micro-hardness
E Potgieter, Y Osman, SR Grobler*
* Oral and Dental Research Institute, Faculty of Dentistry, University of the Western Cape, Tygerberg. E-mail: [email protected]
Summary
The purpose of this study was to determine the
effect on human enamel micro-hardness of three
over-the-counter whitening oral rinses available in
South Africa. Enamel fragments were gathered into
three groups of 15 each. One group was exposed
to Colgate Plax Whitening Blancheur, the second
group to White Glo 2 in 1 and the third to Plus White,
in each case for periods recommended by the
respective manufacturers. Surface micro-hardness of
all groups was measured before and after a 14‑day
treatment period. pH levels of the oral rinses were
also determined with a combination pH electrode.
Pre- and post-treatment data were analysed by the
Wilcoxon Rank-Sum Test. According to the microhardness values no significant (p>0.05) enamel
damage was found as a result of treatment. However,
it was observed that Colgate Plax and White Glo
decreased the enamel hardness, an early sign of
enamel damage, while Plus White showed a small
increase in hardness. The three whitening oral rinses
on the South African market do not damage the tooth
enamel significantly when used as recommended by
the manufacturers. However, extending the contact
period and increasing the frequency of application
might lead to damage of enamel.
Key words: enamel micro-hardness, oral rinses,
whitening.
Acronyms
OTC:over-the-counter
VHN:Vickers Hardness Values
INTRODUCTION
Today’s society has the expectation that people
should have exceptionally white (and straight)
teeth. Oral rinses have become a popular means
for whitening the teeth.
Different bleaching techniques have been
advocated over time. The demand in dental practice
2nd quarter 2014 • volume 15 no. 2
for tooth whitening to lighten discoloured teeth has
increased exponentially over the last decade.1 Most
whitening methods include the use of peroxide
bleaching agents.2 Tooth bleaching occurs by the
diffusion of the bleaching agent in and through
enamel/dentine where oxidation takes place with
a resulting decomposition of organic pigments,
particularly within the dentine.3 Tooth whitening
therefore involves direct contact of a bleaching
agent with the enamel/dentine for periods of time
which vary according to the directions determined
by the manufacturers. This occasioned concerns
about the possible adverse effects of such strong
oxidising agents on enamel/dentine. The available
literature is contradictory.2 Some studies reported
changes in the surface morphology of enamel
following bleaching with carbamide peroxide or
hydrogen peroxide products, while others reported
no alterations.4‑12 For example, Hegedüsa et al, in an
atomic force microscopy study, demonstrated that
carbamide peroxide and hydrogen peroxide were
capable of causing alterations in the enamel surface.13
According to Pugh, low concentrations of hydrogen
peroxide are not expected to adversely affect the
enamel and pulpal enzymes.14 However, a recent
study revealed that Opalescence products having
four different peroxide concentrations, (from 3.35‑15%
H2O2), all damaged enamel, which was most severe
when teeth were treated for longer periods.3 From
the literature it becomes clear that variations in the
different bleaching products and their concentrations,
as well as the specific bleaching agent and its pH;
the application periods; heat and light sources; as
well as the type of original tooth discolouration; all
influence the effect on enamel or dentine.2
Sales of over-the-counter (OTC) tooth-whitening
products have escalated because of heightened
consumer demand for aesthetic care together with
energetic promotion by product manufacturers. The
items are available in pharmacies, department stores
and on the internet. Many are marketed directly
to consumers. The cost is much less than in-office
whitening treatment delivered by a dental health
professional. The availability of these products is
not controlled in South Africa nor in many other
countries. One study did find that enamel surfaces
treated with over-the-counter bleaching products
did not show any significant colour improvement
whilst no significant changes in micro-hardness
values from baseline were recorded.5 However,
over-the-counter bleaching products have not
undergone rigorous testing and hence their efficacy
and safety have not been explored. On the South
African market only a few oral rinses for tooth
whitening are available OTC. Therefore, the purpose
of this in vitro study was to determine the effect of
three OTC whitening oral rinses on human enamel
micro-hardness.
MATERIALS AND METHODS
Specimen preparation
Freshly extracted, non-carious human molar teeth
were collected and stored in water, with a few
preservative thymol crystals. The roots were
removed using a double-sided diamond saw
driven by a low-speed motor (Metaserv, Universal
Polisher, UK). Enamel blocks of 5x5 mm2 sectioned
longitudinally to the crowns, were examined under
a stereomicroscope (10x magnification) and any
with stains or cracks were discarded.2,3 Forty five
selected enamel blocks were individually embedded
in acrylic in 1 cm high PVC rings which had been
cut from 25 mm diameter electrical tubing. The
samples were set horizontally with the enamel
surface exposed above the acrylic.2,3 The enamel
was finely polished using water cooled carbide
paper up to a grit of 1,200. The specimens were
randomly divided into three treatment groups with
15 specimens each.
One group was exposed to Colgate Plax Whitening
Blancheur (Colgate-Palmolive, Brazil) (CPW) for
1 minute twice a day, the second group to PAGE 5
Material Report
Table 1: Composition of the Rinses
100.00
Composition
a. Colgate Plax Whitening Blancheur
Aqua, Sorbitol, Alcohol, 4% Hydrogen Peroxide, Poloxamer 338, Polysorbate
20, Methylsalicylate, Menthol, Sodium Saccharin.
b. White Glo 2 in 1
Purified Water, Ethanol 95SG, Sorbitol, Polysorbate 80, Eucalyptol, Methyl
Salicylate, Menthol Crystal, Cetylpyridinum Chloride, Benzoic Acid, Sodium
Saccharin, Caramel.
c. Plus White
Water, Glycerin, Poloxomer 338, Flavour, Sodium Saccharin, Cetylpyridinum
Bromide, FD&C Blue, Tetrasodium EDTA, Disodium EDTA, Methylparaben.
Table 2: The mean pH and the length of exposure time for each of the oral rinses and the median Vickers
micro-hardness values for each group before and after treatment.
Product
pH
a. Colgate Plax Whitening Blancheur
3.74
Total exposure
time (min)
Before
treatment
After
treatment
28
318
301
b. White Glo 2 in 1
3.59
14
308
295
c. Plus White
5.00
14
301
311
White Glo 2 in 1 (Sunpac Ltd, Gauteng, South Africa)
(WG) for 30 seconds twice a day and the third to Plus
White (CCA Industries Inc., USA) (PW) for 30 seconds
twice daily., The exposure times were according to
the manufacturer’s instructions. The trial extended
over 14 days. Between applications the samples
were stored in artificial saliva.2 Table 1 presents the
composition of each of the whitening oral rinses, as
provided by the respective manufacturer.
7.0 (Beckman Instruments Irvine, CA, USA) and
the electrode response to the buffer solutions
was checked (and recalibrated if necessary) after
every six sample measurements. Three samples of
each product were measured, and the electrode
was then completely cleaned by thorough washing
and rinsing with distilled water before the next set
of readings was taken. The mean pH values were
recorded and noted (Table 2).
Micro-hardness measurement
Surface micro-hardness of the enamel specimens
was measured on each, using a digital hardness
tester with a diamond indenter (Zwick Roell Indentec,
ZHV; Indentec UK).2,3 The saliva stored specimens
were gently wiped with a tissue paper, rinsed
with distilled water and tissue blot-dried before
each micro-hardness measurement. Before any
treatment, four indentations were made on the
polished enamel surface of each enamel block with
a 300 g load applied for 15 seconds. This enabled
the determination of base-line hardness values.
The process was repeated after 14 days of active
bleaching treatment, with the new indents being
placed about 10 µm from the baseline indents.2,3
All data were saved as Vickers Hardness Values
(VHN), destined for statistical analysis (Wilcoxon
Rank-Sum Test). The before and after data were
compared, each sample serving as its own control.
The pH levels of the oral rinses were also
measured, using an Orion Expandable ion Analyser
EA940 (Orion Research Inc. MA, USA) and an Orion
9165BNWP Sure-Flow®, Epoxy-body combination pH
electrode (Thermo Electron Corporation, Beverley,
MA, USA). The pH electrode was calibrated using
three buffer solutions of pH values 3.0, 4.0 and
RESULTS
The median Vickers micro-hardness values of the
test specimens before and after the 14 day treatment
period are reflected in Table 2. Box and Whisker
plots were prepared to indicate the distribution of
the micro-hardness values (Figure 1) for: the groups
treated respectively, by Colgate Plax Whitening
Blancheur, White Glo 2 in 1 and Plus White. In Figure
1, the top line shows the maximum and the bottom
line, the minimum hardness values, while the box
part shows the location of 50% of the values. The
line in the box depicts the median hardness value of
the difference in micro-hardness between base‑line
and after treatment.
The Wilcoxon Rank-Sum Test showed no statistically
significant differences, (at a 5% level), between
baseline values and the values obtained after a 14
day treatment period for all three different oral rinses.
PAGE 6
DISCUSSION
It is evident from the literature that many factors
such as different bleaching agents with differing
concentrations, type and concentration of acid,
pH, temperature, exposure time and frequency
of exposure, can all contribute to enamel erosion/
demineralisation.2,3,4 The initial stage of caries
50.00
Difference in hardness
Product
0.00
-50.00
-100.00
Colgate Plax
Plus White
White Glo
Figure 1: Box and Whisker plot showing the maximum,
minimum, 25th percentile, median and 75th percentile
differences in micro-hardness values.
development has been identified as surfacesoftening lesions of enamel.15 Today it is generally
accepted that micro-hardness determinations give
a reliable indication of this softening (damage/
demineralisation), of enamel or dentine and this
criterion is now employed worldwide for this
purpose.2,3,16‑19
Most solutions with low pH levels are known
to soften and erode enamel.10,11,20 According to
Goldstein, the acidic property of the bleaching
agents can also cause changes in the mineral
content of enamel and may therefore result
in damage to dental structures even under
prescribed conditions.21 Minor alterations of the
enamel may facilitate the future penetration of
bacteria, debris or staining substances, affecting
the success of bleaching.5 The pH values of the
three oral rinses used in this study, ranged from
3.59 to 5.00 (Table 2). Such acidic levels would
normally be considered as hazardous towards teeth
and could be expected to decrease the enamel
hardness. Significant enamel demineralisation
and root resorption have been reported when
the pH falls below 5.2.22 Some studies reported
demineralisation of enamel at a pH below 5.2,
while others reported a pH of 5.5 as the critical
pH.23,24 However, Dawes recently reported that
the critical pH at which enamel starts to soften,
should rather be regarded as being in a range of
5.1 to 6.5, depending also on the concentrations
of calcium and phosphate present in the solution.25
Most solutions/beverages which are known to
soften enamel and produce dental erosion have
low pH levels.26-28 In an in vitro study, Hunter et al
observed that increasing the frequency of
exposure to a drink having a low pH resulted in
OHASA JOURNAL
Material Report
a non‑proportional increase in dental erosion.29
Reducing the frequency of exposure by half did
not result in a similar reduction in tissue loss.
The pH of whitening products changes inside
the oral cavity during the bleaching process.
However, it is not known if the change in pH
occurs at the same rate for products containing
hydrogen peroxide or carbamide peroxide or if
this pH change would adversely affect oral soft
and hard tissues.22 Of the three oral rinses tested,
Colgate Plax contains hydrogen peroxide while the
other two probably depend mainly on the acidity
of the rinse to whiten teeth (Table 1). An overall
lowering in the median enamel hardness values
as a result of the normal treatment by the three
rinses was demonstrated, although these changes
were not statistically significant (Figure 1). The
sample treated with Colgate Plax recorded the
greatest decrease in enamel hardness, followed
by the White Glo sample. These two oral rinses
have the lowest pH values (3.74 and 3.59; Table 2)
which gives an indication of a strong relationship
between acidity and the extent of enamel damage
by demineralisation. On the other hand, treatment
with Plus White (Table 2), with a higher pH of
5.0, gave a small increase in the hardness for
the third group. Perhaps it is of relevance that
the total exposure time of Colgate Plax (28 min)
was twice that of the other two products. That
may be expected to contribute to the relatively
greater softening of enamel by Colgate Plax in
comparison with the effects seen in the sample
treated with White Glo, even though that product
has a somewhat lower pH (3.59 vs. 3.74).
The whitening effects of the three oral rinses,
(Colgate Plax Whitening Blancheur, White Glo
2 in 1 and Plus White), have been reported to
be unsuccessful when applied according to the
manufacturers’ instructions.30 It is likely that if users
cannot see changes in the whiteness of their teeth
they will tend to practise longer exposure periods to
the oral rinses and to reduce the intervals between
rinses This will diminish the time when teeth are
bathed in saliva, thereby reducing the associated
remineralisation effects and increasing the chances
of significant damage to enamel.
CONCLUSION
This study confirms that over the counter whitening
rinses do affect the enamel surfaces and cautions
users not to extend the application periods and
frequency of use beyond the recommendations
of the manufacturers because of possible enamel
damage.
10. Brunton PA, Aminian A, Pretty LA. Vital tooth bleaching in
dental practice: Novel bleaching systems. Dent Update
2006; 33: 57-62.
11. Sulieman M. An overview of bleaching techniques:
In-surgery or power bleaching. Dent Update 2005;
32: 101-8.
12. Pretty IA, Brunton PA, Aminian A, Davies RM, Ellwood
RP. Vital tooth bleaching in dental practice: 3.
Biological, dental and legal issues. Dent Update 2006;
422-31.
13. Hegedüsa C, Bisteya T, Flóra-Nagya E, Keszthelyia G,
Jeneib An atomic force microscopy study on the effect
of bleaching agents on enamel surface. J Dent 1999;
27: 509–15.
14. Pugh G Jr, Zaidel L, Lin N, Stranick M, Bagley D. High
levels of hydrogen peroxide in overnight tooth-whitening
formulas: effects on enamel and pulp. J Esthet rest Dent
2005; 17: 40-5.
15.Ulukapi H. Effect of different bleaching techniques on
enamel surface microhardness. Quintessence Int 2007;
38: 358, e201-5.
16. Shannon H, Spencer P, Gross K, Tira D. Characterization
of enamel exposed to 10% carbamide peroxide bleaching
agents. Quintessence Int 1993; 24: 39-44.
17. Joiner A. Review of the effects of peroxide on enamel
and den- tine properties. J Dent 2007; 35: 889-96.
18. Feagin F, Koulourides T, Pigman W. The characterization
of enamel surface demineralization, remineralization,
and associated hardness changes in human and bovine
material. Arch Oral Biol 1969;
14: 1407-17.
19. Koulourides T, Volker JF. Changes of enamel
microhardness in the human mouth. Ala J Med Sci 1964;
1: 435-7.
20.Majeed A, Grobler SR, Moola MH. The pH of various
tooth-whitening products on the South African market. SA
Dent J 2011; 66: 278-81.
21. Goldstein RE, Garber DA. (1995) complete dental
bleaching. Quintessence publishing: Chicago, Berlin and
London. Green-wall LH. (1992a) Home bleaching.
22.Leonard RH Jr, Austin SM, Haywood VB, Bentley CD.
Change in pH of plaque and 10% carbamide peroxide
solution during night- guard vital bleaching treatment.
Quintessence Int 1994; 25: 819-23.
23.Driessens FC, Theuns HM, Borggreven JM, van Dijk JW.
Solubility behaviour of whole human enamel. Caries Res
1986; 20: 103-10.
24.Barron RP, Carmichael RP, Marcon Ma, Sàndor GK. Dental
erosion in gastroesophageal reflux disease. J Can Dent
Assoc 2003; 69: 84-9.
25.Dawes c. What is the critical ph and why does a tooth
dissolve in acid? J can Dent Assoc 2003; 69: 722-4.
26.Attin T, Meyer K, Hellwig E, Buchalla W, Lennon AM. Effect
of mineral supplements to citric acid on enamel erosion.
Arch Oral Biol 2003; 48: 753-9.
27.Lussi A, Kohler N, Zero D, Schaffner M, Megert B.
A comparison of the erosive potential of different
beverages in primary and permanent teeth using an in
vitro model. Eur J Oral Sci 2000; 108: 110-4.
28.Lussi A, Jaeggi T, Jaeggi-schärer S. Prediction of the
erosive potential of some beverages. Caries Res 1995;
29: 349-54.
29.Hunter ML, West NX, Hughes JA, Newcombe RG, Addy
M. Relative susceptibility of deciduous and permanent
dental hard tissues to erosion by a low pH fruit drink in
vitro. J Dent 2000; 28: 265-70.
30.Potgieter E, Grobler SR. Whitening efficacy of three overthe-counter oral rinses. SA Dent J 2011; 66: 128-31.
Ethics statement: For the purpose of this study
only extracted teeth were used. These were all
discarded specimens collected from the Department
of Maxillofacial and Oral surgery, Faculty of Dentistry,
UWC.
Acknowledgement: This study is financially
supported by the DDF fund of the South African
Dental Association and the UWC.
Disclaimer: The South African Dental Association
does not necessarily support the findings or
conclusions made in this article.
Declaration: No conflict of interest declared. ●
References
1. Fearon J. Tooth whitening: concepts and controversies.
J Irish Dent Assoc 2007; 53: 132-40.
2. Grobler SR, Majeed A, Moola MH. Effect of various toothwhitening products on enamel microhardness. SA Dent J
2009; 64: 474-9.
3.Majeed A, Grobler SR, Moola MH, Rossouw RJ, Kotze
TJ van W. Effect of four different Opalescence toothwhitening products on enamel micro-hardness. SA Dent J
2008; 63: 282-6.
4. Basting RT, Rodriques Jr AL, Serra MC. The effects of
seven carbamide peroxide bleaching agents on enamel
microhardness over time. J AM Dent Assoc 2003; 134:
1335-42.
5.Awliya WY. (2009) The effect of six bleaching products on
enamel whitening and microhardness. Available: http://
repository.ksu.edu.sa/jspui/handle/123456789/7284.
(accessed 19 October 2010)
6. Pinto CF, de Oliveira R, Cavalli V, Giannini M.
Peroxide bleaching agent effects on enamel surface
microhardness, roughness and morphology. Braz Oral
Res 2004; 18: 306-11.
7.Lopes GC, Bonissoni L, Baratieri LN, Vieira Lcc, Monteiro
Jr s. Effect of bleaching agents on the hardness and
morphology of enamel. J esthet restor Dent 2002;
14: 24-30.
8.Auschill TM, Hellwig E, Schmidale S, Sculean A, Arweiler
NB. Efficacy, side- effects and patient’s acceptance of
different bleaching techniques (OTC in-office, at-home).
Oper Dent 2005; 30-2: 156-63.
9.Cadenaro M, Breschi L, Nucci C, Antoniolli F, Visintini E,
Prati C, Matis BA, DI Lenarda R. Effect of two in-office
whitening agents on the enamel surface in vivo: a
morphological and non-contact profilometric study. Oper
Dent 2008; 33-2: 127-34.
2nd quarter 2014 • volume 15 no. 2
PAGE 7
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References: 1. Greenspan DC. J Clin Dent 2010;21(Spec Iss):61–65. 2. LaTorre G, et al. J Clin Dent 2010;21(3):72-76. 3. Burwell A et al. J Clin Dent 2010;21(Spec Iss):66–71. 4. West NX et al. J Clin Dent
2011;22(Spec Iss):82-89. 5. Earl J et al. J Clin Dent 2011;22(Spec Iss):62-67. 6. Efflandt SE et al. J Mater Sci Mater Med 2002;26(6):557-565. 7. Zhong JP et al. The kinetics of bioactive ceramics part VII: Binding
of collagen to hydroxyapatite and bioactive glass. In Bioceramics 7, (eds) OH Andersson, R-P Happonen, A Yli-Urpo, Butterworth-Heinemann, London, pp61–66. 8. Parkinson C et al. J Clin Dent 2011;22(Spec
Issue):74-81. 9. Earl J et al. J Clin Dent 2011;22(Spec Iss):68-73. 10. Wang Z et al. J Dent 2010; 38:400−410. 11. Touchstone research February 2014.
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PAGE 8
OHASA JOURNAL
Research
SERVICES RENDERED
AND BARRIERS FACED
BY PUBLIC SECTOR ORAL HYGIENISTS IN
TWO PROVINCES OF SOUTH AFRICA
U Govender, A Bhayat, M Rudolph
Oral hygienists (OHs) drive oral disease preventive
programmes and promote good health practices.
South Africa (SA) has a shortage of this cadre of
health worker especially in the public sector.
This 2009 project was the first effort to determine
the professional activities performed, barriers
faced and work-related issues that affected OHs
employed at that time in Gauteng and in KwaZuluNatal. The cross-sectional descriptive study used
a self-administered questionnaire developed after
a comprehensive literature review. The response
rate was 78% (n=32). Almost all (94%) respondents
gave “providing a service to the community” as the
main reason for working in the public sector, where
they were committed to offering preventive oral
and dental services at clinics and in the community.
Common employment problems were poor salaries
(94%), lack of resources (81%) and the perception
that opportunities for promotion are limited (78%),
compounded by poor recognition of the services
provided by OHs. In order to more effectively utilise
the skills and commitment of OHs in delivering
preventive dentistry in the public sector, such
problems facing the profession should be addressed.
INTRODUCTION
The South African National Department of Health
in 2005 adopted a re-evaluated National Oral
Health strategy which determined how oral health
care should be delivered in the various provinces.1
The implication and application of this strategy
as it applies to oral hygienists (OHs) is of great
importance as it requires them to be in the forefront
in the delivery of preventive oral health services and
promoting health. OHs are regarded as the drivers
of prevention programmes for the control of dental
caries and periodontal diseases.2
The profile of oral disease in South Africa suggests
that most preventive oral health services have
the potential to make a significant impact on
2nd quarter 2014 • volume 15 no. 2
dental treatment needs.3 Since the majority of the
population (80%) depends on the public health
sector for dental treatment, OHs in the public
sector have a crucial role to play in the provision
of oral health services.3 OHs could, by their efforts
in preventive dentistry, reduce the prevalence and
prevent the progression of oral diseases which
could otherwise result in early tooth loss4 and the
consequent demand for rehabilitative dentistry
requiring additionally skilled personnel (dentists)
and expensive special resources.
There is evidence of increasing frustration among
OHs employed in the public sector, reflecting
problems which limit their opportunities to perform
their full range of clinical and non-clinical duties.5 This
could be due to factors such as lack of resources,
problems in management, lagging morale, poor
salaries and the low priority that prevention of oral
diseases is given within the public sector.5
In South Africa, the public oral health sector
offers clinic and community-based oral hygienist
services. The clinic-based services usually include
examinations, oral hygiene instruction, scaling,
polishing, root planing, fissure sealants and
professional topical fluoride treatments. The
community-based services are performed at
sites away from the dental clinic such as schools,
crèches, HIV institutions and other community
facilities where the focus is on primary prevention.
These approaches include oral health promotion
and protection initiatives that incorporate oral
health education, brushing, fluoride and fissure
sealant programmes. Oral hygienists are therefore
responsible for developing, implementing and
co‑ordinating the preventive dentistry programmes
at schools, a main component of community-based
oral health care services.
No recent work has been done to describe and
justify the role of public sector OHs in South Africa.
Optimal utilisation of OHs in delivery of disease
prevention strategies may depend on determining
their current role in the public sector. The purpose of
this study was therefore to determine the activities
of, and the barriers faced by OHs employed in the
public sector in Gauteng (GP) and KwaZulu-Natal
(KZN) provinces of South Africa.
Methodology
This was a cross-sectional descriptive study. The
study population consisted of all OHs registered
with the Health Professions Council of South Africa
who were in either full-time or part-time employment
within the public sectors in GP and KZN provinces
during 2009. The human resource records of the
oral health services in GP and KZN showed that
21 and 20 OHs were employed in these provinces
respectively (n=41). All received a hand-delivered
questionnaire. Participants were provided with
an addressed postage paid envelope in which to
return the self-administered questionnaire. The
initial response after a six week period was less
than 50%. A second set of questionnaires was
sent out and after an additional four weeks, those
completed questionnaires received by that stage
were accepted as constituting the final sample size.
Questionnaire
The questionnaire comprised 15 closed and two openended questions formulated to obtain information
about demographics, activities performed and barriers
faced whilst working as an oral hygienist within the
public sector. The activities were separated into
two groups, community-based and clinic-based
services. The work timetable provided a maximum
of ten sessions per week. The common schedule
required that in the morning session the OHs went
out to schools, satellite clinics, crèches and mobile
dental units to offer community-based services and
in the afternoon session they performed multiple
clinical services in dental clinics. OHs were PAGE 9
Research
asked to indicate the types of services and treatments
they offered, in general, for each of the ten sessions
in a representative week. The questionnaire required
an estimate of the number of sessions spent on
a weekly basis in offering the following services
both in the communities and in the dental clinics:
examinations, brushing programmes, brushing and
fluoride programmes, scaling, polishing and root
planing, fissure sealants, HIV related procedures,
topical fluoride applications, temporary restorations,
administering local anaesthetics and re-cementing
of crowns and bridges.
The questionnaire was piloted amongst OH staff
members at the University of the Witwatersrand,
Johannesburg. Ethical approval was obtained
from the human research ethics committee at the
University of Witwatersrand and permission to conduct
the study was granted by the Departments of Oral
Health services in both provinces. Anonymity and
confidentiality were ensured. Data was analysed
using the Epi Info software package.
RESULTS
The response rate was 78% (n=32) and the majority
(94%) of responding OHs were employed full-time.
The mean number of years of service was 9.43 years
(SD = ±6.5). The breakdown according to the level
of employment and distribution is shown in Table 1.
The 32 completed questionnaires gave information
on a total of 320 sessions. These were divided into
clinical- and community-based services. The numbers
of sessions spent on each treatment activity were then
totalled and the means were calculated (Table 2). Of
the ten sessions per week, three quarters (74%) of
respondents spent five sessions rendering communitybased services and five sessions rendering clinical
services. In the community-based sessions, most
involved the imparting of oral health education (OHE)
(38%) and the monitoring and implementing of brushing
programmes (24%). Only 4 sessions (3%) were spent
on other services such as the placement of glass
ionomer cements (GIC) or temporary restorations.
Of all possible services, 90% were provided at
schools, 57% at HIV institutions and 43% at crèches.
For the clinic-based services, most sessions were
spent carrying out scaling and polishing and/or root
planing (25%), examinations (19%) and OHE (14%).
Other services (7%) included the administration of
local anaesthetics and the placement of temporary
restorations. There was no statistical relationship
between clinical and community services and most
OHs divided their time equally. The clinic-based
PAGE 10
afternoon activities involved treatment of individual
patients. Almost two thirds (61%) of respondents
provided services to fewer than 20 patients per
week while the remaining 39% reported treating
more than 20 patients per week.
More than 90% of respondents cited “providing
a service to the community” as their main reason
for working in the public sector. Almost two thirds
(63%) remained in the public sector because of
professional satisfaction while 37% indicated that
they continued to work in the public sector because
of job security.
Figure 1 shows the problems reported by the OHs.
Almost all (94%) of the OHs indicated that salaries in
the public sector were not competitive; 81% reported
that there was a shortage of resources and 78%
observed a lack of opportunities for promotion and
a shortage of either OHs or dental nurses. Half of
the respondents reported low staff morale. There
were two open ended questions related firstly to the
problems or barriers that OHs faced and secondly
to the possible improvements that could be made
to facilitate and enhance the working conditions
amongst OHs in the public sector. The answers to
the first question were similar and the following three
themes were identified. There was a generalised
perception that the salaries were inadequate and
some of the responses included: “Managers do
not see the need for us to be promoted for better
salaries”; “Poor motivation for promotion and salaries”;
“No recognition given for academic achievements”;
“Salaries must be reviewed as oral hygiene is one
of the essential services in primary health care”.
Many felt that there was a shortage of equipment
and staff and these were some comments: “Two
Mobile Dental Units for eight oral hygienists”; “Not
enough dental materials, as that is dependent on
the availability of funds”; “Too few oral hygienists”;
“I am the only oral hygienist in the region”; “Schools
have more than 500 children, difficult to manage”.
The respondents also felt that there was low
staff morale as confirmed by these responses:
“Have been employed for seven years and am still
a junior level oral hygienist”; “Employed for 12 years
as a dental assistant; “Studied for three years and
employed for eight years as an oral hygienist in the
same institution and still employed at a junior level”.
There were only two responses to the second
question, regarding the possible improvements
and both were of the opinion that more resources
should be allocated in order to allow OHs to carry
out their core duties.
Table 1: Level of employment and distribution of OHs by province
Level of employment
GP
KZN
Total number OHs
Junior
4
8
12 (37%)
Senior
1
4
5 (16%)
Chief
10
5
15 (47%)
Assistant director
0
0
0 (0%)
15 (47%)
17 (53%)
32 (100%)
Total
Table 2: Mean number of procedures performed per week in the community and in the clinic (n=320)
Number of sessions per week spent on average on
various procedures
Community-based (%)
Examinations
Clinic-based (%)
19 (13)
34 (19)
Oral health education (OHE)
55 (38)
24 (14)
Brushing programmes only
35 (24)
0
Brushing and fluoride programmes
10 (8)
0
Scaling, polishing and root planing
6 (4)
44 (25)
Fissure sealants
7 (5)
26 (15)
HIV related procedures
7 (5)
15 (8)
0
21 (12)
Topical fluoride applications
Other procedures
Total
4 (3)
13 (7)
143 (100)
177 (100)
OHASA JOURNAL
Research
100%
94%
90%
81%
80%
78%
78%
75%
70%
60%
50%
50%
40%
30%
20%
0%
Low
salaries
Lack of
resources
Lack of
promotion
Lack of human
resources
Poor
management
Low staff
morale
FIGURE 1: Problems as reported by the OHs which limit their scope of work (N=32)
DISCUSSION
The response rate was much higher than for both the
National surveys6,7 which reported response rates
of 47% and 51% respectively. This could be due to
the study questionnaires being hand delivered; a
focus on only two provinces and as a result of the
follow-up. The majority (90%) of community-based
services were provided to learners at schools, and
logically these were usually morning sessions as
determined by schools to prevent undue interference
with the school curriculum. More than a half of
the clinical sessions delivered by OHs (52%) were
spent in providing OHE to individuals and to the
community (Table 2). OHE is an essential part of health
promotion and education as it aims to control plaque
accumulation and to influence dietary practices for
the prevention of oral diseases.
Examination, charting and screening is necessary
for early identification of those patients at high-risk
for dental caries and periodontal diseases. More
than 10% of OHs reported doing examinations in the
community. This not only assists in early diagnosis of
oral diseases, but more importantly, non-restorative
needs such as OHE can be addressed by OHs.8
In SA, the most common need in children is
preventive services which include fissure sealants.4
The low response for fissure sealants (5%) was
not unexpected due to the frequent reports of
inadequate and insufficient dental facilities, staff
members, equipment and materials. Access to mobile
dental units (MDUs), portable dental equipment and
adequate supply of materials would greatly facilitate
the provision of fissure sealants in the community,
an activity which is regarded as an effective and
efficient preventive intervention. More than half
of the OHs performed activities at HIV institutions.
Due to the high prevalence of HIV/AIDS (30.2%) in
South Africa10 there has been an increase in the
2nd quarter 2014 • volume 15 no. 2
number of institutions established for the care of
patients suffering from HIV/AIDS. Studies indicate
that over 50% of patients with HIV/AIDS present with
oral lesions associated with HIV.11 Oral hygienists
therefore have a valuable role to play in the oral
health care of these patients.
The low numbers of other procedures that were
being performed (3%), could be attributed to a
lack of need for these services, the inability of the
OHs to perform these functions, the environment
not being conducive or a lack of the necessary
materials and facilities.
Almost two thirds of respondents provided
services to less than 20 patients per week in
the two hour afternoon sessions devoted to
individual treatment. This could be due to the
length of time each procedure takes, the low
utilisation of services, low clinic attendances,
failed appointments or the lack of awareness of
oral health in the population.12 A quarter of all the
clinical sessions per week (25%) were utilised
for the delivery of scaling, polishing and root
planing procedures. This was not surprising as
the National Oral Health Survey12 reported that
the presence of calculus and gingivitis was the
most common periodontal condition amongst
adults. Almost 15% of OHs reported providing
OHE to individual patients. OHE is important to
create awareness and promote good oral health
practices in individual patients and the community.
If OHs performed the examination and chartings,
OHE, scaling, polishing and root planing, greater
opportunities and additional time would be created
for dentists to perform more complex procedures.
The role of the OH is therefore not only to provide
preventive services but also to facilitate a more
effective and efficient delivery of comprehensive
services by the dentists.
Just over 10% of OHs applied topical fluoride
and a similar number (12%) placed fissure sealants
to patients seen at the dental clinics. These are
procedures essential for the prevention and control
of dental caries.
Oral hygienists can be employed at four levels in
the public sector with clear guidelines regarding their
remuneration. The lowest remuneration is at a junior
level, increasing to a senior, chief and the highest
being assistant director. In both KZN and GP, OHs
were employed at only three levels, with almost half
as chief OHs. No OH was employed as an assistant
director. More than 90% of OHs reported that the
salary structure in the public sector was poor and
not competitive with that of the private sector. This
was coupled with the lack of promotion opportunities
(78%) as the main reason for the low staff morale.
Many felt that they had remained too long at the
same level of employment in spite of meeting the
requirements for promotion and advancement. It
is expected that with the introduction of the new
dispensation for public workers and the possible
introduction of over-time for OHs, these issues
could be addressed.13 It was felt that there was a
lack of recognition of the profession and insufficient
motivation by their managers to the respective
Departments of Health to improve salaries or to
create opportunities for promotion. Oral hygienists
also reported that academic achievements were
not recognised towards enhanced remuneration
or promotion.
Almost 80% reported a shortage of either OHs
or dental nurses in the workplace. In Australia the
high demand for OHs in the private sector has
empowered public sector OHs to demand better
salaries. Oral hygienists in Australia, Denmark and
Switzerland receive the highest remuneration when
compared with their international counterparts.2
Gordon and Rayner7 reported that OHs felt that more
public sector positions should be created in SA.
Bhayat et al13 observed that in South Africa less
than 10% of all OHs worked in the public sector,
which is one reason for the lack of sustainable
and effective community preventive oral health
programmes. And yet, ninety four percent of OHs
cited “providing a service to the community” as
the main reason for working in the public sector.
Similarly other studies in both private and public
sectors in SA have reported that 94% of OHs
believed they provided a worthwhile service to
the public and contributed to community health
which in turn provided career satisfaction.6,7 PAGE 11
Research
More than 60% said they remained in their jobs
because of professional satisfaction. This was
consistent with the findings of Gordon and Rayner7
who reported that the majority of OHs were satisfied
with their choice of career. Almost eighty percent of OHs considered that
too few OHs were employed in the public sector.
These findings were similar to those reported by
Gordon and Rayner.7 The poor OH to population ratio
limited the provision of comprehensive preventive
programmes. Oral hygienists experienced challenges
accessing resources such as finances, transport,
MDUs, equipment and dental materials. Bhayat et
al5 reported that the lack of OHs and poor working
conditions impacted on the implementation of
public preventive programmes. The lack of human
and other resources has a direct effect on the level
and quality of oral health services being provided
in the public sector.
Seventy five percent of OHs indicated they
experienced problems with management in their
facilities. This could be attributed to most dental
clinics being managed by clinicians (doctors and
nurses) who must deal with many other medical
emergencies on a daily basis. Oral health and oral
hygiene in particular may inevitably be neglected.
The efficacy of OHs in the public sector is related to
the support and attitudes of their supervising dentists
or managers. Mutual recognition of professional
expertise and contribution could help ease some
of the tension and conflict that may be present, as
has been suggested by other studies.2
CONCLUSION
It is evident that the role of OHs is to be a leader
and provider in oral health education and promotion
with the objective to increase oral health awareness
and to decrease the need for curative care. In order
for this cadre to be effectively utilised, however,
several issues need to be addressed. These include
recognition of the services provided by OHs, creation
of opportunities for promotion, improvement of
salaries and enhanced provision of resources.
Declaration: No conflict of interest declared. ●
References
1. South African National Oral health strategy [online], 2005.
Department of health, Oral health Directorate, Pretoria.
Available from: http://www.doh.goz.za/docs/index.html
(accessed: 16/03/2011).
2. Baltutis LM, Gussy MG, Morgan MV. The role of the
dental hygienist in the public health sector; an Australian
perspective. International Dental Journal 2000; 50: 29-35.
3.Van Wyk PJ, Louw AJ, Du Plessis JB. Caries status and
treatment needs in South Africa: report of the 1999-2002
National children’s Oral health survey. South African
Dental Journal 2004: 59; 238-42.
4.Van Wyk PJ, Van Wyk C. Oral health in South Africa.
International Dental Journal 2004: 54; 373-7.
5. Bhayat A, Yengopal V, Rudolph MJ, Govender U, Vayej
A. Attitudes of South African oral hygienists towards
compulsory community service. International Journal of
Dental hygiene 2008; 6: 8-12.
6.Van Wyk CW, Toogood S, Scholtz L et al. South African
oral hygienists: their profile and perception of their
profession and career. South African Dental Journal
1998:53; 537-46.
7. Gordon NA, Rayner CA. A National survey of Oral
hygienists in South Africa. South African Dental Journal
2004: 59; 184-8.
8. Öhrn K, Crossner CG, Börgesson I, Taube A. Accuracy of
dental hygienists in diagnosing dental decay. Community
Dentistry and Oral epidemiology 1996: 24; 182-6.
9. Holtshousen WSJ, Smit A. A cost-efficiency analysis of
mobile dental clinics in the public services. South African
Dental Journal 2007: 62; 334-40.
10. National HIV and syphilis antenatal sero-prevalence
survey in South Africa in 2009 [online], 2010. National
Department of health, available from: www.doh.gov.za/
docs/reports/2010/ hiv.pdf (accessed: 15/12/2011).
11. Yengopal V, Naidoo S. Do oral lesions associated with
HIV affect quality of life? Oral surg Oral Med Oral Pathol
Oral Radiol Endod 2008: 10; 890-7.
12. National Oral Health Survey, South Africa 1988/89.
Compiled by PJ van Wyk. 1994. Government Press.
Pretoria.
13.Department of Public Service and Administration.
Republic of South Africa. Circular No 1 [online],
2007. Available from: www. dpsa.gov.za/documents
(accessed: 13/12/2011)
Oral hygienists ecstatic about
Independent Private
Practice approval
The first group of OHASA members in KwaZulu-Natal got ready to apply for
Independent Private Practice by attending the Expansions of Clinical Functions
Course at the University of KwaZulu-Natal (UKZN) from 13–18 January 2014. The
members who attended the course are (from left to right): Ilana Moodley (UKZN
lecturer), Shaya Pillay (EC), Tanya Johannes (GP), Dr Shenuka Singh (UKZN lecturer),
Suzette Pirow (KZN), Deidre Agar (KZN), Marita Enslin (KZN), Jenny Bartlett (KZN)
and Maggie Naidoo (KZN).
A number of members also completed the Level 3 First Aid Course by Save‑a‑Life,
which took place between 8 February and 1 March 2014. They are from left to right,
back row: Tabassum Ali (KZN), Penelope Mhlungu (KZN), Londiwe Thwala(KZN),
Phindile Sokhulu (KZN), Jenny Bartlett (KZN), Maggie Naidoo (KZN), and front row:
Deidre Agar (KZN), Ayanda Khazi (KZN), Suzette Pirow (KZN), Susan van Rooyen
(KZN) and Leigh-Ann de Sousa (KZN).
We would sincerely like to thank everybody that contributed towards making our dream of achieving Independent Private Practice a reality!
PAGE 12
OHASA JOURNAL
Review
Extrinsic stains
and management:
A new insight
S Prathap, H Rajesh, VA Boloor and AS Rao
Dept. of Periodontics, Yenepoya Dental College, Nithyananda Nagar Post, Deralakatte, Mangalore-575018, Karnataka, India
[email protected]; +91 9980433489
Abstract
Tooth discoloration is a frequent dental finding
associated with clinical and aesthetic problems.
It differs in aetiology, appearance, composition,
location and severity. Knowledge of the aetiology
of tooth staining is of importance to dental
surgeons in order to enable a correct diagnosis.
The practitioners should also have the basic
understanding of the mechanism of stain formation
before carrying out any treatment procedures
which will facilitate better treatment outcomes.
Recently there have been advancements in the
various treatment options in this field. This article
is a comprehensive review on extrinsic stains and
the treatment modalities.
Keywords: Tooth discoloration, aesthetic problems,
tooth staining, treatment outcomes, extrinsic stains.
Introduction
It is widely recognised that today’s youth and
appearance oriented culture prizes an attractive
smile and white teeth, with sales of whitening
products rising dramatically in the past decade.
Some of these products are sold as ‘over the counter
products’ and have no professional involvement in
their application. The correct diagnosis for the cause
of colour discoloration is important as, invariably, it
has profound effect on treatment outcomes. It would
seem reasonable, therefore that dental practitioners
have an understanding of the aetiology of tooth
colour discoloration in order to make a diagnosis
and enable the appropriate treatment to be carried
out (Aryan, 2005). Dental stains differ in aetiology,
2nd quarter 2014 • volume 15 no. 2
appearance, composition, location, severity and
degree of adherence. Attraction of material to the
tooth surface plays a critical role in the deposition of
extrinsic dental stains. However, the mechanism that
determines the adhesion strength is not completely
understood (Tirth et al., 2009).
Normal variations in tooth colour: A basic
understanding of the elements of tooth colour
is important for many aspects in dentistry. Teeth
are typically composed of various colours and a
gradation of colour occurs in an individual tooth
from gingival margin to the incisal edge of the
tooth. Near the gingival margin, teeth often have
a darker appearance because of close proximity
of the dentine below the enamel. In most people
canine teeth are darker than central and lateral
incisors and young people characteristically have
lighter teeth, particularly in the primary dentition.
Teeth become darker as a physiological age
change; this may be partly caused by laying down
of secondary dentine, incorporation of extrinsic
stains and gradual wear of enamel allowing a
greater influence on colour of the underlying
dentine. Tooth wear and gingival recession can
directly or indirectly affect tooth colour. The science
of colour is important in dentistry with regard to
colour perception and description, and can be
improved with training.
The viewing conditions are extremely important
and variables, such as the light source, time of
day, surrounding conditions and the angle of tooth
viewed, affect the apparent tooth colour. Light is
composed of differing wavelengths and the same
tooth, viewed under different conditions, will
exhibit a different colour, a phenomenon known
as metamerism (Watts and Addy, 2001).
Classification of tooth discoloration
Intrinsic discoloration: Intrinsic discoloration occurs
following a change to the structural composition or
thickness of the dental hard tissues. The normal colour
of teeth is determined by the blue, green and pink
tints of the enamel and is reinforced by the yellow
through the brown shades of dentine beneath. A
number of metabolic diseases and systemic factors are
known to affect the developing dentition and cause
discoloration as a consequence, and local factors
such as injury are also recognised. These include:
1.Alkaptonuria.
2.Congenital erythropoietic porphyria.
3.Congenital hyperbilirubinaemia.
4.Amelogenesis imperfect.
5.Dentinogenesis imperfect.
6.Tetracycline staining.
7.Fluorosis.
8. Enamel hypoplasia.
9. Pulpal haemorrhagic products.
10.Root resorption.
11.Ageing.
Extrinsic discoloration: Extrinsic discoloration is
outside the tooth substance and lies on the tooth
surface or in the acquired pellicle. The origin of
the stain may be:
1.Metallic
2.Non-metallic PAGE 13
Review
Table 1: Types of stains, source, appearance and common sites
Types of stains
Source and predisposing factors
Appearance on the tooth surface
Common sites
Brown stain
The colour is due to tannin from intake of
coffee and tea.
Causes: Insufficient brushing; Inadequate
cleansing action of dentifrice; Chromogenic
bacteria.
Thin, translucent, acquired bacteria‑free
pigment pellicle.
1. Buccal surface of maxillary molars.
2.Lingual surface of mandibular incisors.
Black stain
1.Coal tar combustion products due to
smoking.
2. Penetration of pits and fissures, enamel and
dentine by tobacco juices.
3.Iron-containing oral solutions.
4. Exposure to iron, manganese, silver.
These are tenacious dark brown or black with
brown discoloration.
1.Involves all the teeth.
2.Common on pits and fissures.
Black stain
More common in woman, may occur in
excellent oral hygiene. High tendency for
recurrence:
1.Associated with low incidence of caries in
children.
2.Chromogenic bacteria – e.g. Gram positive
rods – Actimomyces species Bacteriodes
melaninogenicus.
3.Iron-containing oral solutions.
This is a thin black line, firmly attached on tooth 1. Near the gingival margin of facial and lingual
surface.
surface of a tooth.
2.Diffuse patch on the proximal surface may
be seen.
Orange stain
Chromogenic bacteria Serratia marcescens,
Flavobactraium lutescens. Exposure to chromic
acid fumes in factory workers (Manuel et al.,
2010).
Green stain
Children are frequently affected due to
inadequate daily plaque removal, chromogenic
bacterial deposits or decomposed hemoglobin.
1. Fluorescent bacteria – Penicillium.
2. Fungi – Aspergillus.
3.Associated with children with TB or cervical
lymph node.
4.Copper salts in mouth rinse (Manuel et al.,
2010).
5. Exposure to copper and nickel in the
environment in factory workers (Manuel
et al., 2010).
These are green or greenish yellow stains of
considerable thickness. This type of stain is
considered as stained remnants of enamel
cuticles.
Metallic stain
This type of stain is caused by metals and
metallic salts. Metals are penetrated into
tooth substances and produce permanent
discolouration or they bind with pellicle and
produce surface stain.
Source of metals:
1.Introduction of metals into oral cavity.
2.Metal containing dust inhalation by workers.
3.Oral administration of drugs.
Some metals that cause stains:
Generalised appearance on all the teeth.
Copper dust – Green stain
Iron dust – Brown stain
Magnesium – Black stain
Silver — Black stain
Iodine — Black stain
Nickel — Green stain
Metal penetrating into tooth substance causes
permanent discoloration whereas that which
binds with pellicle causes surface stain (Manuel
et al., 2010).
Yellowish brown
stains
Chlorhexidine has an affinity for sulphate and
acidic groups such as those found in pellicle,
plaque constituents, carious lesions and
bacterial cell walls. So it is retained into oral
cavity and stained oral tissues. (Manuel et al.,
2010).
Yellowish brown to brownish. The stains are
not permanent in nature. They can be removed
with proper brushing with dentifrice.
Yellow
Essential oil and phenolic mouth rinse (Manuel
et al., 2010).
Golden brown
stains
Due to use of stannous fluoride (Mosby’s Dental
Dictionary, 2008).
Violet to black
Presence of potassium permanganate in mouth
rinses (Manuel et al., 2010).
Red-black
Use of betel leaves and nuts commonly seen in
adults and children in the Eastern Hemisphere,
where betel leaves and nuts are used as
stimulants (Mosby’s Dental Dictionary, 2008).
PAGE 14
Both facial and lingual surface of anterior teeth.
Facial surface of maxillary anterior teeth.
1.Cervical and interproximal area of the teeth.
2. Plaque and other restorations.
3.Dorsum of tongue.
Thick, hard, dark brown or black extrinsic stain Facial, lingual and occlusal surfaces of both
left on the teeth after chewing the leaves of the anterior and posterior teeth.
betel palm (Mosby’s Dental Dictionary, 2008).
OHASA JOURNAL
Review
Internalised discoloration: Internalised discoloration
is the incorporation of an extrinsic stain within the
tooth substance following dental development. It
occurs in enamel defects and in the porous surface
of exposed dentine. The routes by which pigments
may become internalised are:
1.Developmental defects.
2.Acquired defects.
a)Tooth wear and gingival recession.
b)Dental caries.
c)Restorative materials (Manuel et al., 2010).
Extrinsic tooth discoloration: The causes of extrinsic
staining can be divided into two categories:
a) Direct extrinsic tooth staining: Those compounds
which are incorporated into the pellicle and
produce a stain as a result of their basic colour.
b) Indirect extrinsic tooth staining: Those which
lead to staining caused by chemical interaction
at the tooth surface.
Direct extrinsic tooth staining has a multi-factorial
aetiology with chromogens derived from dietary
sources or habitually placed in the mouth (Figure
1). These organic chromogens are taken up by the
pellicle and the colour imparted is determined by the
natural colour of the chromogen. Tobacco smoking
and chewing are known to cause staining, as are
particular beverages such as tea and coffee (Figure
2 and 3). The colour seen on the tooth is thought
to be derived from polyphenolic compounds which
provide the colour in food (Pearson, 1976). Indirect
extrinsic tooth staining is associated with cationic
antiseptics and metal salts. The agent is without
colour or a different colour from the stain produced
on the tooth surface. Interest in the mechanisms of
extrinsic tooth staining was rekindled in 1971 with the
observation by Flotra et al. (1971) that tooth staining
increases with the use of chlorhexidine (Figure 4).
Classification of extrinsic tooth staining
Extrinsic tooth discoloration has usually been
classified according to its origin, whether metallic
or non-metallic (Gorlin and Goldman, 1971).
Non-metallic stains: The non-metallic extrinsic stains
are adsorbed onto tooth surface deposits such
as plaque or the acquired pellicle. The possible
aetiological agents include dietary components,
beverages, tobacco, mouth rinses and other
medicaments. Chromogenic bacteria have been
cited in children (Figure 5 and 6). Particular colours
of staining are said to be associated with certain
mouths, for instance, green and orange in children
2nd quarter 2014 • volume 15 no. 2
with poor oral hygiene and black/brown stains in
children with good oral hygiene and low caries
experience (Theilade et al., 1973). Conclusive
evidence for the chromogenic bacterial mechanism
has not been forthcoming. The most convincing
evidence for the extrinsic method of tooth staining
comes from the differing amount of stain found in
a smokers and non-smokers (Ness et al., 1977).
FIGURE 1: Stains due to betel nut.
Metallic stains: Extrinsic staining of teeth may be
associated with occupational exposure to metallic
salts and with a number of medicines containing metal
salts (Addy and Roberts 1981). The characteristic black
staining of teeth in people using iron supplements
and iron factory workers is well documented (Nordbo
et al., 1982). In a study conducted on school going
students on black stains, scrapings were taken from
5 students and were subjected to analysis for trace
elements. Trace element analysis was done by (ICP)
Inductively Coupled Photo spectrometry. Out of 5
scrapings, 3 showed presence of ferrous ions of
about 2.56%, calcium ions 17.15% and magnesium
ions 0.72%, while the remaining 2 samples showed
calcium 14.86%, magnesium ions 0.82% and no
presence of ferrous ions (Tirth et al., 2009). Copper
causes a green stain in mouth rinses containing
copper salts (Waerhag et al., 1984) and in workers
in contact with the metal in industries (Dayan et
al., 1983) (Table 1).
A number of other metals have associated colours
such as potassium permanganate producing a
violet to black colour when used in mouth rinses;
silver nitrate salt used in dentistry causes a grey
colour, and stannous fluoride causes a golden
brown discoloration (Ellingsen et al., 1982). It was
previously thought that the mechanism of stain
production was related to the production of the
sulphide salt of the particular metal involved (Moran
et al., 1991). This is perhaps not surprising since
the extrinsic stain coincided with the colour of the
sulphide of the metal concerned. However, those
proposing the hypothesis appeared not to consider
the complexity of the chemical process necessary
to produce a metal sulphide. As mentioned earlier
the interest aroused by the staining noted with use
of chlorhexidine mouth rinse has prompted renewed
interest in the mechanism of stain formation. For
this reason most of the research into stain formation
has been carried out on chlorhexidine, although
there are other antiseptics which cause staining
to a lesser extent and the mechanism proposed
could be applicable to staining found with polyvalent
metals. The characteristic staining of the tongue
and teeth noted by Flotra and co-workers in 1971 is
not peculiar to chlorhexidine; it has been reported
in other cationic antiseptics, the essential FIGURE 2: Smoking stains.
FIGURE 3: Tobacco stains.
FIGURE 4: Chlorhexidine stains.
FIGURE 5: Orange stains due to chromogenic bacteria.
FIGURE 6: Black stains due to chromogenic bacteria.
PAGE 15
Review
oil/phenolic mouth rinse ‘Listerine’ and following
prolonged use of delmopinol mouthrinses (Claydon
et al., 1996). There is great individual variation in the
degree of staining from person to person. This makes
explanation more difficult as it may be caused by
intrinsic factors, differences in extrinsic factors or both.
No longer accepted theories of stain formation with
chlorhexidine include breakdown of chlorhexidine
in the oral cavity to form parachloroaniline (Gjermo
et al., 1973) and also that chlorhexidine may reduce
bacterial activity such that partly metabolised sugars
are broken down and then degraded over time to
produce brown-colour compounds (Davies et al.,
1970). Most recent debate has centred around three
possible mechanisms.
Non-enzymatic browning reactions: Berk (1976)
suggested that the protein and carbohydrate in
the acquired pellicle could undergo a series of
condensation and polymerisation reactions leading
to colour discoloration of the acquired pellicle.
Chlorhexidine may accelerate formation of the
acquired pellicle and also catalyse steps in the
Maillard reaction (Yates et al., 1993). Observation of
furfurals, intermediate products in Maillard reactions,
in brown-discoloured pellicle has lent support to the
theory (Nordbo, 1977), but the evidence is inconclusive
(Eriksen et al., 1985). Moreover, these authors did
not consider at all the same staining phenomenon
observed with the numerous other antiseptics.
The formation of the pigmented sulphides of
iron and tin: this theory suggests that chlorhexidine
denatures the acquired pellicle to expose sulphur
radicals. The exposed radicals would then be able to
react with the metal ions to form the metal sulphide.
Warner and co-workers have shown increased levels
of iron in chlorhexidine treated individuals compared
with water controls; no evidence was shown for tin
(Warner et al., 1993). They then went on to conclude
that the chromophore was not a sulphide, but a
sulphur containing organic compound and metal
ion complex and that chlorhexidine promoted the
deposition of sulphate proteins. However, somewhat
anomalously although the amount of stain and iron
levels were increased.
Management of stains
Proper diet and habits: Extrinsic staining caused by
foods, beverages, or habits (e.g., smoking, chewing
tobacco, coffee and tea) is treated with a thorough
dental prophylaxis and cessation of dietary or other
contributory habits to prevent further staining (Azer
et al., 2011).
Tooth brushing: Effective tooth brushing twice a day
with a dentifrice helps to prevent extrinsic staining.
PAGE 16
Most dentifrices contain an abrasive, a detergent,
and an anti-tartar agent. In addition, some dentifrices
now contain tooth-whitening agents.
Over-the-counter products: Three types of whitening
toothpastes are manufactured. The first type, based
on use of an abrasive to remove extrinsic stains,
has been available for many years (Haywood and
Robinson, 1997; Council on Scientific Affairs, 1997). All
toothpastes, however, contain some abrasives and
are capable of potentially removing stains whether
they are labelled “whitening” or not. Toothpastes
with a high content of abrasives should not be
recommended for daily use. Secondly, the newer
whitening toothpastes contain a bleaching agent,
such as peroxide, but the Council on Scientific Affairs
of the American Dental Association (ADA) does not
recommend them for long-term use (Hosoya and
Johnston, 1989). Lastly, cosmetic toothpastes,
containing titanium dioxide, cover extrinsic stains
like paint covers a wall and do not change the
internal tooth colour (Haywood and Robinson, 1997).
Professional tooth cleaning: Some extrinsic stains
may be removed with ultrasonic cleaning, rotary
polishing with an abrasive prophylactic paste, or
air-jet polishing with an abrasive powder (Weaks
et al., 1984). However, these modalities can lead
to enamel removal; therefore, their repeated use
is undesirable (Croll, 1977).
Ultrasonic and sonic scaling: Ultrasonic and sonic
scalers are referred to as power-driven scalers. The
small, quick vibrations in combination with a water
flow give us a whole new level of effectiveness
in removal of deposits on the tooth surface. The
benefits of ultrasonic scaling include increased
efficiency of calculus removal and less need for
hand scaling. High vibrational energy generated in
the oscillation generator is conducted to the scaler
tip, causing vibrations with frequencies in the range
of 25,000–42,000 Hz. The amplitude ranges from
10 to 100 μm. Micro-vibration crushes and removes
calculus under cooling water. Ultrasonic and sonic
scalers vary in their efficiency in removing calculus
from the tooth surfaces. Sonic scalers are air-turbine
units that operate at low frequencies ranging between
3,000 and 8,000 cycles per sec (Cps). Tip movement
and the effect of root surfaces can vary significantly
depending on the shape of the tip and type of the
sonic scaler. In general, tip movement is orbital. Sonic
scalers provide a simple and inexpensive mechanism.
Sonic scalers have a high intensity noise level
because of the release of air pressure needed
for movement of the tip of the sonic hand-piece
(American Academy of Pediatric Dentistry, 2000).
Selective polishing: Selective polishing involves
polishing only the areas of stains. In this procedure,
the dental auxiliary can select specific teeth
to be polished using a prophylactic angle and
rubber cup with a fine paste, and can brush the
remaining teeth with a toothbrush to remove
bacterial biofilm on tooth surfaces. According to
the American Academy of Periodontology (2000)
and other sources (Mellberg, 1979), polishing for
approximately 30 sec with a prophylactic paste
containing pumice can remove between 0.6 µm and
4 µm of the outer enamel. The outer surface of the
enamel contains a natural component of fluoride,
with the highest amount of fluoride concentrated
on its surface. When using a prophylactic angle
with a prophylactic cup on this enamel-rich surface,
the dental hygienist may not only remove the
fluoride layer, but also introduce a rough surface
and/or scratches on the tooth surface, which can
contribute to the further harbouring of bacteria
on these surfaces.
Benefits: Minimises irreversible loss of enamel.
Prevents damage to the restorative surfaces
requires less time. More time can be spent on
patient education.
Prophylactic paste: Prophylactic pastes contain
abrasive, water, humectant, binder, sweetener,
flavouring and colouring agents. Prophylaxis
polishing agents are available in two basic forms:
dry powders, also referred to as flours that must
be mixed with a liquid (water, fluoride, or mouth
rinse) and commercially prepared polishing pastes
that are available in bulk or individual unit doses.
Dry powders or flours are not graded according to
grit, rather they are graded in order of increasing
fineness: F, FF, and FFF. Powders or flours with no
wetting agent represent the greatest quantity of
abrasives that can be applied per unit of time and
they create excessive heat. Therefore, the use of
dry abrasives or powder on a dry polishing cup is
contraindicated due to the potential for thermal
injury to natural teeth. The grit of commercially
prepared polishing pastes is graded from fine to
coarse, based on a standard sieve through which
the particles pass (Wilkins, 2009). The types of
abrasive particles used in polishing pastes vary
among the commercial varieties and from one grit
size to another, yet there is no industry standard
to define what these terms mean or what size the
abrasive particle must be. The types of abrasive
particles used in commercial prophylaxis polishing
pastes include flour of pumice, aluminium oxide,
silicon carbide, aluminium silicate, silicon dioxide,
carbide compounds, garnet, feldspar, zirconium
OHASA JOURNAL
Review
silicate, zirconium oxide, boron, and calcium
carbonate (Wilkins, 2009).
Others include emery, perlite, and silica.
Commercially prepared prophylaxis polishing
pastes combine abrasives with a binder, humectants,
colouring agent, preservatives, and flavouring
agents. Manufacturers generally do not disclose
the amount of ingredients in their polishing pastes
because the information is proprietary. However,
it is general knowledge that pumice and glycerine
are the most commonly used ingredients in
commercially prepared polishing pastes. Some
commercially prepared polishing pastes contain
fluoride. Fluoride in prophylaxis polishing pastes
is not a replacement for a fluoride treatment
(Wilkins, 2009).
Unfortunately, many dental hygienists use
whatever type of polishing paste is available on
every patient, regardless of the grit size. Even worse
is the fact that some dental hygienists subscribe
to the “coarse grit theory.” The premise for this
ill-advised idea is that the use of the coarsest
polishing paste available will remove the heaviest
amounts of stain as well as the lightest amounts,
thus saving time. Providers who polish in this
fashion ignore the professionally recommended
method of using the polishing grits in a progression
of coarse, medium, and fine applications, which
is supported by well-established science and is
applied not only in health care but in mechanical
polishing procedures in a variety of industries. In
an ideal setting the progression from coarse to
fine paste is best. In clinical practice, if a dental
hygienist is using medium grit paste it is best to
follow with fine grit. Coarse grit polishing pastes
can produce hypersensitivity and rough tooth
surfaces, and are only needed in situations of
heavy stain.
Proof of the widespread use of the “coarse pumice
theory” lies in the published sales of coarse grit as
the leading selling brand of polishing paste; 80% of
polishing paste sales are in coarse grit and 10% are
in medium grit. Coarse grit polishing pastes may
remove and accelerate staining and the retention
of dental plaque and calculus.
Port polisher: Port polisher consisting of orangewood
points is helpful in situations when aerosol should
not be produced, in abraded cervical areas, or
when electricity is not available. However slowness
of the procedure and the amount of hand strength
needed for instrumentation are its drawback.
Although highly abrasive in nature, polishing or
finishing strips present an option for inter-proximal
areas or line angles but should be cautiously used
to avoid cutting of soft tissues.
2nd quarter 2014 • volume 15 no. 2
New options and available evidence
For many years, the most notable advancement
in traditional polishing was the introduction of
prophy pastes in unit-dose cups. Since then, new
formulations of commercial polishing pastes have
been added to the polishing armamentarium. For
more than a decade, commercial polishing pastes
that contain perlite as an abrasive ingredient have
been available.
Prophy pastes containing perlite make claims
that the abrasive particles break down and become
less abrasive under pressure. Scientific evidence
supports the fact that the abrasive agents in these
products do break down under load (pressure).
However, scientific evidence supports the fact that
most abrasives in polishing pastes break down
under pressure. Amorphous calcium phosphate
(ACP) products that include a polishing paste claim
to remineralise enamel subsurface carious lesions.
These products are missing a body of research
in vivo. The current research exists only in vitro.
Three scientific questions need to be addressed:
Is it possible to burnish an ingredient such as ACP
into enamel with a polishing product that is abrasive
and meant to remove stain? What are the true
benefits of ACP or similar products such as casein
phosphopeptide-amorphous calcium phosphate
(CPP-ACP) over the known remineralisation properties
of fluoride? Why has fluoride been added to some
of these ACP and CPP-ACP products? Polishing
paste with calcium sodium phosphosilicate is a new
development. Calcium sodium phosphosilicate is a
bioactive glass that releases calcium and phosphorus
ions rapidly and is currently being incorporated into
other dental products. Scientific clinical research is
not available to support the claim that this product
immediately relieves dentinal hypersensitivity.
Some in vitro studies of ACP, CPP-ACP, and calcium
sodium phosphosilicate-containing products do
indicate clinical promise; however, the lack of in
vivo research to date is a matter of concern. It will
be a leap forward if the additives to polishing pastes
can remineralise carious lesions and immediately
relieve hypersensitivity on a long-term basis.
There is no doubt that polishing pastes are going
through a period of renewal as manufacturers are
looking for ways to add remarkably active ingredients
to such an inexpensive and easy delivery system. It
is challenging, however, for manufacturers to add
these novel ingredients while retaining the expected
performance of polishing pastes. Hopefully, the future
will bring about this much-needed research and the
introduction of new products (Litkowski et al., 1997).
Air jet polishing: Air polishing was first introduced
to the dental community in the late 1970s as a
mechanism to quickly and easily remove extrinsic
stain and soft deposits. It also helps minimise hand,
wrist, neck and eye fatigue like a cavitron tip, by
helping to remove stain quicker than scaling and
polishing the conventional way. Air polishing uses
a water soluble sodium bicarbonate mixture to help
in the removal of stain and plaque during a routine
dental hygiene appointment. Air polishing is great
to help in the removal of stain due to smoking,
coffee, tea, chlorhexidine and other extrinsic factors.
Aluminium trihydroxide is an alternative solution to
the sodium bicarbonate for patients who are sodium
restricted and have heavily stained enamel. Avoid
use on dentine, cementum and restorative resins.
Use of the air polisher for stain removal involves
three steps: patient selection and preparation,
clinician preparation, and the actual clinical technique.
Air polishing should follow a careful review of the
patient’s medical and dental history, and a thorough
examination of the oral hard and soft tissues.
Indications and contraindications, effects on hard
tissues, restorations, safety, and alternative uses
should be reviewed prior to treatment where the
use of the air polisher is planned. Preparation of the
patient should include an explanation of the procedure,
removal of contact lenses, an anti-microbial rinse,
application of a lubricant to the lips, placement of
safety glasses or a drape over the nose and eyes,
and placement of a plastic or disposable drape
over the patient’s clothing. Operators should use
universal precautions, including protective apparel,
a face shield or safety glasses with side shields,
gloves, and a well-fitting mask with high-filtration
capabilities. The actual air polishing technique
includes proper patient and operator positioning
for adequate access and direct vision, use of highspeed suction if an assistant is available, or use
of the saliva ejector and aerosol-reduction device
when working alone. The suction orifice of the saliva
ejector should be as close as possible to the tip. It
also may enhance patient comfort if a moistened
2x2 gauze square is placed over the tongue or lip
in the area being polished. Rapid, sweeping strokes
are recommended, with the tip directed at a 60˚
angle to the tooth for anterior teeth, 80˚ for posterior
teeth, and 90˚ for occlusals. Cupping the lip with the
forefinger and thumb allows the water to pool in the
vestibule for easier evacuation and minimal aerosol
dispersion. Polishing two to three teeth at a time
by fully depressing the foot pedal, then rinsing the
teeth and tongue by pressing the foot pedal half
way increases efficiency and minimises the saline
taste. A systematic approach to polishing all teeth
will increase efficiency. Polishing for five seconds or
less per tooth is usually adequate to remove most
of the stains. PAGE 17
Review
Conclusion
Tooth discoloration is a frequent dental finding
associated with clinical and aesthetic problems.
It differs in aetiology, appearance, composition,
location and severity. Knowledge of the aetiology
of tooth staining is of importance to dental surgeons
in order to enable a correct diagnosis to be made
when examining a discoloured dentition and allows
the dental practitioner to explain to the patient the
exact nature of the condition. In some instances, the
mechanism of staining may have an effect on the
outcome of treatment and influence the treatment
options the dentist will be able to offer to patients.
Dental auxiliaries must use good judgment when
considering coronal polishing and practice preventive
procedures as the standard of care, which means
that treatment must be individualised.
Patients may not be aware of the effects of
rubber-cup polishing on the enamel, so it is the job
of the dental assistant to educate patients on the
philosophy of polishing based solely on need. ●
13. Eriksen HM, Nordbo H, Kantanen H and Ellingsen JM.
1985. Chemical plaque control and extrinsic tooth
discoloration. A review of possible mechanisms. J. Clin.
Periodontol. 12: 345-350.
14. Flotra A. 1971. Side effects of chlorhexidine mouth
washes. Scand. J. Dent. Res. 79: 119-125.
15. Gjermo P, Rolla G and Arskaug L. 1973. Effect of dental
plaque formation and some in vitro properties of 12
biguanides. J. Periodontal. Res. 12: 81-88.
16. Gorlin RJ and Goldman HM. 1971. Environmental pathology
of the teeth. In: Thoma’s oral pathology. 6th ed. 1: 184-192.
17. Haywood VB and Robinson FG. 1997. Vital tooth
bleaching with night guard vital bleaching. In GolubEvans J(ed). Curr. Opin. Cosmet. Dent. 4: 45-52.
18. Hosoya Y and Johnston JW. 1989. Evaluation of various
cleaning and polishing methods on primary enamel.
J. Pedod. Spring. 13(3): 253-269.
19.Litkowski, LJ, Hack GD, Sheaffer HB and Greenspan DC.
1997. Occlusion of dentinal tubules by 45S5 Bioglass®.
In: Bioceramics 10, Proceedings of the 10th International
Symposium on Ceramics in Medicine. Sedel L, Rey C,
eds. Oxford, England: Aldent Press, pp 411-414.
20.Madan C, Bains R and Bains VK. 2009. Tooth polishing:
Relevance in present day periodontal practice.
J. Ind. Soc. Periodontol. 13(1): 58-59.
21.Manuel ST, Abhishek P and Kundabala S. 2010. Etiology
of tooth discoloration-a review. MNig. Dent. J.
18(2): 56-63.
22.Mellberg JR. 1979. The relative abrasivity of dental
prophylactic pastes and abrasives on enamel and dentin.
Clin. Prev. Dent. 1(1): 13-18.
23.Moran J, Addy M, Pal D and Newcombe R. 1991.
Comparison of phenolic 0.2% chlorhexidine products
on the development of plaque and gingivitis. Clin. Prev.
Dent. 13: 31-35.
24.Mosby’s Dental Dictionary. 2008. 2nd ed. © 2008
Elsevier, Inc. All rights reserved. 79(2): 219-221.
25.Ness L, Rosekrans DL and Welford JF. 1977. An
epidemiologic study of factors affecting extrinsic staining
of teeth in an English population. Community Dent. Oral
Epidemiol. 5: 55-60.
26.Nordbo H. 1977. Color discoloration of dental pellicle by
tannic acid. Acta. Odontol. Scand. 35: 305-310.
27. Nordbo H, Eriksen HM, Rolla G, Attramadal A and
Solheim H. 1982. Iron staining of the acquired enamel
pellicle after exposure to tannic acid or chlorhexidine.
Scand. J. Dent. Res. 90: 117-123.
28.Pearson D. 1976. The chemical analysis of foods. 7th ed.
London: Churchill Livingstone, pp 1-450.
29.Theilade J, Slots J and Fejerskov S. 1973. The ultrasound
of black stain on human primary teeth. Scand. J. Dent.
Res. 81: 528-532.
30.Tirth A, Srivastava BK, Nagarajappa R, Tangade P and
Ravishankar TL. 2009. An investigation into black tooth
stain among school children in Chakkar Ka Milak of
Moradabad City. Ind. J. Oral Health Comm. Dent.
3(2): 34-37.
31. Waerhag M, Gjermo P, Rolla G and Johansen JR. 1984.
Comparison of the effect of chlorhexidine and CuSO4 on
plaque formation and development of gingivitis. J. Clin.
Periodontol. 11: 176-180.
32.Warner RR, Myers MC, Burns J and Mitra S. 1993.
Analytical electron microscopy of chlorhexidine induced
stain in humans: Direct evidence for metal induced stain.
J. Periodont. Res. 28: 255-265.
33.Watts A and Addy M. 2001. Tooth color discoloration and
staining: A review of literature. Br. Dent. J. 190(6): 309-316.
34.Weaks LM, Lescher NB, Barnes CM and Holroyd SV. 1984.
Clinical evaluation of the Prophy-Jet as an instrument for
routine removal of tooth stain and plaque. J. Periodontol.
55(8): 486-488.
35.Wilkins EM. 2009. Clinical practice of the dental
hygienist. 10th ed. Philadelphia Lippincott Williams and
Wilkins. pp 727-740.
36. Yates R, Jenkins S, Newcombe RG, Wade WG, Moran J
and Addy MA. 1993. 6 month home usage trail of
1%chlorhexidine toothpaste. Effects on plaque, gingivitis,
calculus and tooth staining. J. Clin. Periodontol. 20: 130-138.
References
1.Addy M, and Roberts WR. 1981. The use of
polymethylmethacrylate to compare the adsoprtion
of staining reactions of some cationic antiseptics.
J. Periodontol. 52: 380-385.
2.American Academy of Pediatric Dentistry. 2000. The role of
prophylaxis in pediatric dentistry. Pediatr. Dent. 22(7): 37.
3.American Dental Hygienists’ Association. 1999. Oral
Health Information: Tooth Whitening Systems. Retrieved
from http://www.adha.org/oralhealth/whitening.htm.
4.Aryan H. 2005. Tooth whitening industry opens wide
with myriad procedures and products. San Diego UnionTribune.
5.Azer SS, Hague AL and Johnston WM. 2011. Effect of
bleaching on tooth color discoloration from food colorant
in vitro. J. Dent. 39(3): e52-56.
6. Berk Z. 1976. Non-enzymatic browning. In: Braveman’s
introduction to the biochemistry of foods. Amsterdam:
Elsevier. pp 149-167.
7.Claydon N, Hunter L and Moran J. 1996. A 6-month home
usage trail of 0.1% and 0.2% delmopinol mouthwashes.
Effects on plaque, gingivitis, supragingival calculus and
tooth staining. J. Clin. Periodontol. 23: 220-228.
8.Council on Scientific Affairs. 1997. ADA position statement
on the safety of hydrogen peroxide-containing dental
products intended for home use. Adopted by the
American Dental Association Board of Trustees, April 14,
Chicago, IL 60611.
9.Croll TP. 1997. Enamel micro-abrasion: Observations after
10 years. J. Am. Dent. Assoc. 128 (Suppl.): 45S-50S.
10.Davies RM, Jensen SB, Schiott CR and Loe H. 1970.
The effect of topical application of chlorhexidine on
the bacterial colonization of the teeth and gingiva.
J. Periodont. Res. 5: 96-101.
11.Dayan D, Heifferman A, Gorski M and Begleiter A. 1983.
Tooth color discoloration- extrinsic and intrinsic factors.
Quintessence Int. 2: 195-199.
12. Ellingsen JE, Eriksen HM and Rolla G. 1982. Extrinsic
dental stain caused by stannous fluoride. Scand. J. Dent.
Res. 90: 9-13.
PAGE 18
OHASA JOURNAL
Ethics
THE ETHICS OF
ADVERTISING
Prof. S Naidoo: BDS (Lon), LDS.RCS (Eng), MDPH (Lon), DDPH.RCS (Eng), MChD (Comm Dent),
PhD (US), PG Dipl Int Research Ethics (UCT). Senior Professor and Principal Specialist, Faculty of
Dentistry, University of the Western Cape.
Readers are invited to submit ethical queries or dilemmas to Prof. S Naidoo, Department of
Community Dentistry, Private Bag X1, Tygerberg 7505 or e-mail: [email protected]
Case scenario: I have been practicing as an oral
hygienist for a few years now with a special focus on
paediatric patients even though I have not had any
specialist training in treating children. With the recent
global economic downturns I have noticed that my
once thriving practice is showing little growth. I am
now considering launching an advertising campaign
highlighting my specialised focus on oral hygiene
care for children. Would this be ethical?
Commentary
As members of the Health Professions Council of
South Africa, oral hygienists are bound by the ethical
rules of conduct under the Health Professions Act
of 1974.1 The following rules in the Schedule are
clear with regards to advertising, and what and how
information about one’s practice is disseminated:
Item 3. Advertising and canvassing or touting
1.A practitioner shall be allowed to advertise
his or her services or permit, sanction or
acquiesce to such advertisement: Provided
that the advertisement is not unprofessional,
untruthful, deceptive or misleading or causes
consumers unwarranted anxiety that they may
be suffering from any health condition.
2.A practitioner shall not canvass or tout or allow
canvassing or touting to be done for patients
on his or her behalf.
2nd quarter 2014 • volume 15 no. 2
Item 4. Information on professional stationery
1.A practitioner shall print or have printed on
letterheads, account forms and electronic
stationery information pertaining only to
such practitioner’s: (a) name; (b) profession;
(c) registered category; (d) speciality or subspeciality or field of professional practice (if any);
(e) registered qualifications or other academic
qualifications or honorary degrees in abbreviated
form; (f) registration number; (g) addresses
(including email address); (h) telephone and
fax numbers; (i) practice or consultation hours;
(j) practice code number; and (k) dispensing
licence number (if any).
2.A group of practitioners practising as a juristic
person which is exempted from registration
in terms of section 54A of the Act or a group
of practitioners practising in partnership,
shall print or have printed on letterheads,
account forms and electronic stationery
information pertaining only to such juristic
person or partnership practitioners’: (a) name; (b)
profession; (c) registered category; (d) speciality
or sub-speciality or field of professional practice
(if any); (e) registered qualifications or other
academic qualifications or honorary degrees
in abbreviated form; (f) registration number;
(g) addresses (including email address); (h)
telephone and fax numbers; (i) business hours;
(j) practice code number; (k) exemption from
registration in terms of section 54A of the Act;
and (l) dispensing licence number (if any).
3.A practitioner shall not use prescription forms
or envelopes on which the name or address of
a pharmacist is printed.
Item 5. Naming of a practice
1.A practitioner shall use his or her own name or the
name of a registered practitioner or practitioners
with whom he or she is in partnership or with
whom he or she practises as a juristic person,
as a name for his or her private practice.
2.A practitioner referred to in sub-rule (1) may
retain the name of such private practice even if
another practitioner, partner of such partnership
or member of such juristic person is no longer
part of such private practice: Provided that the
express consent of the past practitioner or, in
the case of a deceased practitioner the consent
of the executor of his or her estate or his or her
next-of-kin, has been obtained.
3.A practitioner shall not use, in the name of his or
her private practice, the expression “hospital”,
“clinic” or “institute” or any other expression
which may give the impression that such private
practice forms part of, or is in association with,
a hospital, clinic or institute.
Item 6. Itinerant practice
A practitioner may conduct a regularly recurring
itinerant practice at a place where another practitioner
is established if, in such itinerant practice, such
practitioner renders the same level of service to
patients, at the same fee as the service which he
or she would render in the area in which he or she
is conducting a resident practice. PAGE 19
Ethics
The advertising of professional services has always
been tightly regulated, but there is a fine line between
advertising that is effective and advertising that is
unethical. In particular, canvassing of and touting
for patients are strictly forbidden under the Health
Professions Act.1 Touting means “conduct which draws
attention, either verbally or by means of printed or
electronic media, to one’s offers, guarantees or
material benefits that do not fall in the categories
of professional services or items, but are linked to
the rendering of a professional service or designed
to entice the public to the professional practice”
and canvassing refers to “conduct which draws
attention, either verbally or by means of printed
or electronic media, to one’s personal qualities,
superior knowledge, quality of service, professional
guarantees or best practice”.1
Advertising varies from the subtle, for example in
the form of practice plaques, professional stationery
and fridge magnets or to the more blatant flowery
advertisements in the media where the intention
is to capture the attention of potential patients.
Liebenberg2 has reported that “one of the most
powerful effects of advertising has been to teach
a national tolerance of deceit, embellishment,
misrepresentation and distortion; it is the norm to
expect advertising to be deliberately misleading.
According to the code of the Advertising Standards
Authority of South Africa (ASA)3 – “Advertising is
a service to the public and, as such, should be
informative, factual, honest, decent and truthful…
and all advertisements should be prepared with a
sense of responsibility to the consumer”.
• Honesty (Section II 2) – advertisements should not
be framed as to abuse the trust of the consumer
or exploit his lack of experience or knowledge.
•Truthfulness – substantiation (Section II 4.1) –
before advertising is published, advertisers shall
hold in their possession documentary evidence
that is up-to-date and current, that is capable of
objective substantiation.
•Misleading Claims (Section II 4.2.1) – advertisements
should not contain any statement or visual
presentation which, directly, or by implication,
omission, ambiguity, inaccuracy, exaggerated claim
or otherwise, is likely to mislead the consumer.
They should not misuse research results from
technical or scientific literature and any expert
opinion claimed in support of the product must
be substantiated by independent evidence.
It is the professional and ethical responsibility of
the oral hygienist to educate their patients about
their condition and to advise and offer them the best
possible options for care. Price advertising must
be explicit in such a way that the consumer must
know what the expected price is for an advertised
professional item or service. Phrases like “conditions
apply” must be avoided in advertisements as
they are considered misleading and deceptive,
otherwise such conditions must be explicitly stated
in advertisements. Patients are best served when
their money is spent on efficacious products that
work without deception. As a health professional, you
need to draw attention to any manipulative and/or
misleading advertising that negatively affects your
practice and patients. It could be argued that direct
marketing is good for the oral hygiene profession,
but it should be founded on truth not on deception.
Ethical considerations
Respect for patient autonomy requires one to
tell the truth. Advertising claims that are false or
misleading violate the respect for patient autonomy
and are unethical. Patients may not be able to fully
understand, comprehend and assimilate the nuances
of their diagnosis and treatment recommendations
and therefore rely on their oral hygienist to be
truthful with them. The danger of advertising your
services is that the profession could exploit the
fears, hopes, pain and desires of the consumers
so as to attract patients. Claims of superior service,
unique therapies, promises, guarantees or reduced
costs could deceive the patient and cause false
expectations. Not all patients are discerning about
advertisements and three potential audiences for
advertising have been described by Ozar4 as the
hardened, the wholly receptive and the reflective
consumer. The hardened consumer doubts the
validity of any advertising claims while the wholly
receptive consumer accepts these claims as truth.
In between is the reflective consumer, who weighs
up the merits of the advertisement and makes an
informed choice. In the drafting of an advertisement,
an ethical oral hygienist must carefully consider
what is communicated, particularly to the wholly
receptive consumer. Deceiving patients about what
one is able to provide shows lack of respect for
one’s patients and their autonomy. In deceiving
one’s patients, one is also violating their rights. If a
sense of fairness does not prevail in the treatment
of patients, the principle of justice is violated.
In the above case scenario, the oral hygienist says
that they intend to mention that they “specialise” in
treating children. The wholly receptive consumer
may interpret the term “specialise” to assume
that they have specialty training and certification.
A statement of this nature may convey a false
message of superiority over other colleagues and
such advertisements can have the effect of casting
reflection on the probity and professional skills of
colleagues and constitutes unprofessional conduct.
During oral hygiene training, knowledge and
skills are acquired that allow the oral hygienist to
provide these to the patient – this is an obligation
of beneficence. This principle is clearly breached if
an oral hygienist claims to be able to provide special
care if he/she lacks the knowledge and skills to do
so. By advertising services that one is not trained to
provide, the risk-benefit ratio is tilted in the direction
of high risk and low benefit. As such, the concept
of harm to the patient becomes an important issue
and the principle of non-maleficence (do no harm)
becomes significant.5
Concluding remarks
Using the principle-based approach to ethics it
can be seen how easily all four of the key ethical
principles (autonomy, justice, beneficence and
non-maleficence) can be violated, together with
other values such as honesty and prudence.
Furthermore, there are also legal violations in terms
of the Health Professions Act, which states that a
practitioner shall be allowed to advertise his/her
services “…provided that the advertisement is not
unprofessional, untruthful, deceptive or misleading…”.1
When designing advertisements or advertising their
services, oral hygienists need to ensure that they
comply with the rules, regulations and guidelines
of all the relevant authorities. ●
References
. Ethical Rules of Conduct for Practitioner Registered
under the Health Professions Act, 1974 in Government
Gazette R717/4August 2006 amended by Ethical Rules in
Government Gazette R68/2 February 2009.
2.Liebenberg W. Masters of esthetic dentists another white
lie? J Compilation 2006; 18: 155-160
PAGE 20
3.Advertising Standards Authority of South Africa. Available
at http://www.asasa.org.za
4.Ozar DT. Professional ethics and dental advertising. Calif
Dent Assoc J 1994; 22: 27-29.
5.Moodley K, Naidoo S. Ethics and the dental team. Van
Schaik Publishers, Pretoria, 2010.
Acknowledgement: With grateful thanks to Mr Punkaj Govan,
Legal Advisor, SADA for his erudite and insightful comments.
OHASA JOURNAL
OHASA NEWS
Guidelines for
Authors
OHASA Journal has produced these guidelines to assist prospective authors. The Journal will
consider for publication full-length research papers, clinical case reports, review articles, short
communications, letters to the editor and professional issues.
PLEASE SUBMIT MANUSCRIPTS TO:
Natasha Swart
Managing Editor, OHASA Journal
PO Box 75715
Lynnwood Ridge
Pretoria
0040
Tel: +27 12 3192687
Fax: +27 12 3192146
Email:[email protected]
[email protected]
MANUSCRIPTS
Each manuscript should be sent either on a CD, or
electronically via email as an attachment.
COPYRIGHT
The submission of the manuscript by the authors
means that the authors automatically agree to
assign exclusive copyright to OHASA Journal if and
when the manuscript is accepted for publication.
PEER REVIEW
Upon receipt by the Editor, manuscripts are sent to
two independent referees approved by the Editor.
Manuscripts will not be returned to authors.
LENGTH OF CONTRIBUTIONS
For research papers and case reports authors
should ideally limit their work to 2,500 words.
Tables and figures must be allowed for in the final
count. (Approx. 100-500 words, depending on size).
TITLES
Titles must be descriptive and succinct.
ABSTRACTS
A structured abstract of research papers and case
reports is required. It should include objectives,
2nd quarter 2014 • volume 15 no. 2
methods, results and conclusions and state the
purpose of the study, basic procedures, main
findings and principal conclusions. It may be up
to 200 words and should be able to stand alone.
TABLES
Tables should be numbered consecutively with Arabic
numerals. A caption should accompany each table.
references cited, and only these, must be listed
at the end of the paper. This should include the
names and initials of all authors unless they are
more than six when only the first three should be
given followed by et al. in italics. The authors’ names
are followed by the title of the article; the title of
the journal abbreviated according to the style of
Index Medicus or the Index to Dental Literature; the
year of publication; the volume number; first and
last page numbers in full. Titles of books should be
followed by the place of publication, the publisher
and the year.
ILLUSTRATIONS
Illustrations must be submitted in a format and
quality suitable for reproduction – i.e., in the case of
graphics, high resolution (300 dpi) - in the Journal.
The Editor and Publisher reserve the right to reject
illustrations or figures based upon poor quality of
submitted materials. Appropriate consent must have
been obtained by the author for any illustration
showing a patient.
EXAMPLES
Reference to a journal article
Lewis MAO, Lee SM, Potts AJC and Nutes SJ. Mucous
membrane pemphigoid in childhood. Dent Health
2000; 39 (3): 10-11.
LEGENDS
Legends should be typed double-spaced in
consecutive order on a separate page. They
should be brief and specific.
Reference to a book
Cawson RA and Odell EN. Essentials of Oral
Pathology and Oral Medicine. London: Churchill
Livingston, 1998.
ACKNOWLEDGEMENTS
Acknowledge persons who have made substantive
contributions to the study. Authors are expected to
disclose any commercial or other relationships that
could constitute a conflict of interest.
Reference to a chapter in a book
Bergenholtz G and Hasselgren G. Endodontics and
Periodontics. In: Lindhe J, Karring T and Lang NP
(eds.) Clinical Periodontology and Implant Dentistry,
pp 296-326, Copenhagen: Munksgaard, 1997.
REFERENCES
The author is responsible for the accuracy of the
reference list at the end of the article. All references
must be in the Vancouver style. Number references
consecutively in the order in which they appear
in the text and these numbers should appear
as superscripts each time the author is cited. All
The Editor reserves the right to edit material for
clarity of style and to suit the space available. A full
copy of Guidelines for Authors is available on request
from the Editor. ●
PAGE 21
Continuous professional development
CPD
QUESTIONNAIRE
Test code – OHASA14
No. 2 2014
General
The effect of three whitening oral rinses on enamel micro-hardness
1. Tooth bleaching occurs by the diffusion of the bleaching agent in and
through enamel/dentine where oxidation takes place with a resulting
decomposition of organic pigments, particularly within the dentine.
a.True
b.False
2. The following factors influence the effect of bleaching on enamel or dentine:
a.Variations in the different bleaching products and their concentrations
b.The application periods
c.The type of original tooth discoloration
d.All of the above
e. None of the above
3. The acidic property of the bleaching agents can also cause changes in the
mineral content of enamel and may therefore result in damage to dental
structures even under prescribed conditions.
a.True
b.False
4.The three oral rinses tested in this study all contain hydrogen peroxide.
a.True
b.False
5. The whitening effects of the three oral rinses have been reported to be
unsuccessful when applied according to the manufacturers’ instructions.
a.True
b.False
Services rendered and barriers faced by Public Sector Oral Hygienists in
two provinces of South Africa
6.Oral hygienists are regarded as the drivers of prevention programmes for
the control of dental caries and periodontal diseases.
a.True
b.False
7.There is evidence of increasing frustration among oral hygienists employed
in the public sector due to:
a. Problems in management
b.Lagging morale
c. Poor salaries
d.All of the above
e. None of the above
PAGE 22
Instructions for completing the CPD questionaire will be
e-mailed to each OHASA member. If you do not receive your
e-mail, please contact the Editor.
8.Community-based services are performed at sites away from the dental
clinic such as schools, crèches, churches and HIV institutions.
a.True
b.False
9.The purpose of the questionnaire used in this study was to obtain information
about:
a.Demographics
b.Activities performed
c. Barriers faced whilst working as an oral hygienist within the public
sector
d. b and c
e. a, b and c
10.75% of respondents indicated that of the ten sessions per week, four
sessions are spent on rendering community-based services and six sessions
on clinical services.
a.True
b.False
11. 63% of respondents remained in the public sector because of professional
satisfaction while 37% indicated that they continued to work in the public
sector because of job security.
a.True
b.False
12.Oral health education is an essential part of health promotion and education
as it aims to control plaque accumulation and to influence dietary practices
for the prevention of oral diseases.
a.True
b.False
13.Low numbers of other procedures were reported and could be attributed
to:
a.Lack of need for these services
b.The inability of oral hygienists to perform these functions
c.Lack of necessary materials and facilities
d.All of the above
e. None of the above
14.The low staff morale reported by oral hygienists was due to lack of promotion
opportunities.
a.True
b.False
OHASA JOURNAL
®
15.The efficacy of oral hygienists in the public sector is related to the support
and attitudes of their supervising dentists or managers.
Adds zero alcohol to the LISTERINE® ran
a.True
b.False
Extrinsic stains and management: A new insight
16.Dental stains differ in aetiology, appearance, composition, location, severity
and degree of adherence.
a.True
b.False
17.Teeth become darker as a physiological age change. This may partly be
caused by:
a.Laying down of secondary dentine
b.Incorporation of extrinsic stains
c. Gradual wear of enamel allowing a greater influence on colour of the
underlying dentine
d.All of the above
e. None of the above
18.Direct extrinsic tooth staining is caused by compounds which are incorporated
into the pellicle and produce a stain as a result of their basic colour.
a.True
b.False
19.Particular colours of staining are said to be associated with certain mouths,
for instance black/brown in children with poor oral hygiene and green and
orange with children with good oral hygiene and low caries experience.
a.True
b.False
20.A number of metals have associated discoloration of the teeth such as
stannous fluoride causing a golden brown discoloration and silver nitrate
salt causing a violet to black colour.
a.True
b.False
21.The protein and carbohydrate in the acquired pellicle could undergo a
series of condensation and polymerisation reactions leading to colour
discoloration of the acquired pellicle.
a.True
b.False
2nd quarter 2014 • volume 15 no. 2
PAGE 23
PAGE 23
®
Continuous professional development
Adds zero alcohol to the LISTERINE range
®
22.All toothpastes contain some abrasives and are capable of potentially
removing stains whether they are labelled “whitening” or not.
a.True
b.False
23.Polishing for approximately 30 seconds with a prophylactic paste can
remove between 0.6 µm and 4 µm of the outer enamel.
a.True
b.False
24.The use of the coarsest polishing paste available to remove the heaviest
amount of stain as well as the lightest amounts, thus saving time.
a.Coarse grit theory
b.Coarse pumice theory
25.When doing air scaling the patient has to be prepared doing the following:
a.Lubricant to the lips
b.Removal of contact lenses
c.An anti-microbial rinse
d. a and c
e. a, b and c
Ethical
The Ethics of Advertising
26.A practitioner is allowed to advertise his or her services provided that the
advertisement is not unprofessional, untruthful, deceptive or misleading.
a.True
b.False
27.Canvassing of and touting for patients are allowed under the Health
Professions Act.
a.True
b.False
28.Advertising is a service to the public and as such should be:
a.Informative and factual
b. Honest and truthful
c. Prepared with a sense of responsibility to the consumer
d.All of the above
e. None of the above
29.Advertising claims that are false or misleading violate the respect for
patient autonomy and are unethical.
a.True
b.False
30.In the drafting of an advertisement, an ethical oral hygienist must carefully
consider what is communicated particularly to the reflective consumer.
a.True
b.False
PAGE 24
PAGE 24
OHASA JOURNAL
South Africa’s leading brand for sore mouth and throat 1
A 5 star for oral
solution health
ntiseptic
nti-inflammatory
nalgesic
naesthetic (local)
Reference: 1. IMS Total Private Market Value MAT. March 2013. (R02A. Pharyngeal Preparations).
Scheduling status: S1 Proprietary name (and dosage form): ANDOLEX-C Oral Rinse. Composition: Each 15 mL contains: Benzydamine HCI 22.5 mg,
Chlorhexidine gluconate 18 mg, Alcohol 9 % v/v. Registration number: 31/16.4/0143 [Act 101/1965] Scheduling status: S1 Proprietary name (and
dosage form): ANDOLEX-C ORAL GEL. Composition: Benzydamine HCI 10 mg/ g, Cetylpyridinium Chloride 1 mg/ g. Registration number: 33/16.4/0285
[Act 101/1965]
Name and business address of applicant: iNova Pharmaceuticals (Pty) Limited, Co. Reg. No. 1952/001640/07, 15e Riley Road, Bedfordview.
Tel. No. (011) 087 0000 www.inovapharma.co.za For full prescribing information, refer to the individual package inserts as approved by the medicines
regulatory authority. Further information is available on request from iNova Pharmaceuticals. IN879/13
®
®
Adds zero alcoholin
to delivering
the LISTERINEefficacy
range
A breakthrough
without alcohol
LISTERINE® ZERO™
contains 4 Essential Oils
to deliver the following
benefits: 2
• Protects against germs that
promote plaque.
• Protects against germs that
cause bad breath.
• Strengthens tooth enamel
even in hard-to-reach areas.
• Contains 220 ppm (0.05 %)
fluoride for enamel
protection and to protect
against cavities.
LISTeRIne® ZeRO™
protects against
plaque-forming
bacteria
49 %
more than a non
alcohol-containing
cPc mouthwash 3
Average Log, Relative Light Units (RLU) following LISTERINE®
ZERO™ 4.88 (95 % Cl 4.56 – 5.20) and non-alcoholic CPC 6.83
(95 % Cl 6.76 – 6.90).
Study designed to determine bacteria kill using saliva
inoculated Flow-through mixed biofilm model.
RefeRenceS: 1. Euromonitor International. 2. LISTERINE® ZERO™ approved package insert. 3. Data on file D, microbiology dossier, McNEIL-PPC, Inc.
® Trademark. ©Johnson & Johnson (Pty) Ltd 2014. LPPRxxxx/xx. AZLIS088
THE WORLD’S #1 MOUTHWASH1