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MAY 2020 ISSN No. 2519-0105 – Online Edition THE SOUTH AFRICAN
Volume 75 Number 4 ISSN No. 1029-4864 – Print Edition DENTAL ASSOCIATION

Prof Bertram Cohen CBE

in uniform during the
Second World War

new
SENSITIVITY & GUM

With clinically
proven Dual relief

Prof Bertram Cohen CBE

A South African dentist who achieved
world wide recognition for his outstand- No.1 DENTIST
ing contributions to oral pathology, Pro-
fessor Bertram Cohen was the first
RECOMMENDED BRAND
Nuffield Research Professor at the Royal FOR SENSITIVE TEETH*
Colleges of Surgery, England.
*GFK New expert performance tracking 2018.
He served in the Second World War in
the South African Medical Corps. A fine For any product safety issues, please contact
start to a life of service. GSK on +27 11 745 6001 or 0800 118 274.
Trademarks are own or licensed by the GSK
group of companies.
SADJ
T H E S O U T H A F R I C A N D E N TA L J O U R N A L

CONTENTS
EDITORIAL OFFICE
EDITORIAL
Managing Editor
COVID-19: An opportunity for oral healthcare to define its own future 172
Prof NH Wood
in South Africa? - NH Wood
Editorial Assistant
Mr Dumi Ngoepe
COMMUNIQUE
Email: [email protected]
Personal protective equipment under and after COVID-19 need a rethink 173
- KC Makhubele
Sub-editors
Prof N Mohamed REVIEW
Prof P Owen COVID-19: Focus on masks and respirators – Implications for oral 175
Prof L Sykes health-care workers - R Mulder, N Layloo, S Mulder van Staden
Prof J Yengopal
RESEARCH
Please direct all correspondence to: Comparison of forward and reverse single-file reciprocation for root canal 183
South African Dental Association instrumentation in curved mandibular molar canals - a Micro-CT analysis
Private Bag 1, Houghton 2041 - PJ van der Vyver, M Vorster, F Paleker, ZI Vally
Tel: +27 (0)11 484 5288
Fax: +27 (0)11 642 5718
Sterilisation and single-use of endodontic files - a short report 189
Email: [email protected]
- GD Buchanan, MY Gamieldien, S Tredoux, N Warren
Editorial Board
Dr P Brijlal: University of the Western Cape
The microbiology of head and neck space infections at the Maxillofacial 192
Prof T Dandajena: Private Practice USA Clinic at Livingstone Hospital - N Singh, S Ngwenya, J Molepo
Prof W G Evans: University of the Witwatersrand
Dr H Gluckman: Private Practice Student perceptions of clinical experiences in endodontic access 198
Dr M Hellig: University of the Witwatersrand
cavity preparations - P Gwengu, C Jonker
Prof B Kramer: University of the Witwatersrand
Prof AJ Louw: University of the Western Cape
Dr N Mohamed: University of the Western Cape
Prof J Morkel: University of the Western Cape
Prof MPS Sethusa: Sefako Makgatho Health
Sciences University
Prof L Shangase: University of Pretoria
Prof L Sykes: University of Pretoria
Prof AJ van Zyl: Private Practice
Prof NH Wood: Sefako Makgatho Health
Sciences University

SADA OFFICE BEARERS

National Council
President: Dr PD Moipolai
Vice-President: Dr P Mathai

SADA Board of Directors Our Front Cover for this Issue...

Chairperson: Dr R Putter
Vice-chairperson: Dr N Osman
The theme for the Front Cover of the South African Dental Journal this year
provides for some historical figures, some characters illuminating dental history
Dr SJ Swanepoel
and some important achievements in South African Dental history. The May
Dr SY Pieters
issue draws focus to a highly distinguished Dentist born in South Africa.
Dr FC Meyer
Read more on page 171.
Dr EK Naidoo
Dr KL Mafanya Prof Bert Cohen
Mr K Nyatsumba A South African dentist who achieved worldwide recognition
Mr KC Makhubele (CEO) for his outstanding contributions to oral pathology, Professor
Bert Cohen was the first Nuffield Research Professor at the
Royal Colleges of Surgery, England. He served in the Second
World War in the South African Medical Corps. A fine start to
a life of service.

Published by: On behalf of:

THE SOUTH AFRICAN

DENTAL ASSOCIATION
SADJ
T H E S O U T H A F R I C A N D E N TA L J O U R N A L

CONTENTS
SADA OFFICE BEARERS
Chairpersons of Board Sub-Committees
CASE REPORT
Focal dermal hypoplasia - a radiographic case report - Z Yakoob, C Nel 208
Operations Committee: Dr N Osman
Audit & Risk Committee: Dr FC Meyer
Strategy, Social & Ethics Committee: Dr SY Pieters
Lichenoid Granulomatous Stomatitis - an oral medicine case book 211
Dental Practice Committee: Dr SJ Swanepoel
- L Robinson, AW van Zyl, WFP van Heerden
Human Resources
& Remuneration Committee: Mr K Nyatsumba CLINICAL W INDOW
What’s new for the clinician? - Excerpts from and summaries of recently 214
Chairperson of DDF Board of Trustees published papers - V Yengopal
Dr B Beilinsohn

RADIOLOGY CASE
PRODUCTION OFFICE Maxillofacial Radiology 180 - CJ Nortjé 218
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a Division of Life-Long Learning Solutions CC
Tel: +27 (0)10 020 1013
ETHICS
Yes, you can say no - LM Sykes, E Crafford, A Fortuin 219
Publisher and Project manager
Mr René Smulders
CPD
CPD questionnaire 223
GENERAL AND ADVERTISING ENQUIRIES
Mr René Smulders AUTHOR GUIDELINES
Email: [email protected] Instructions to authors and author’s checklist 225

Design and Layout CLASSIFIEDS

Ms Reine Combrinck www.sada.co.za - Smalls advertising placement procedure and rules
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Website smalls advertising / CPD Enquiries and

Member contact detail update
South African Dental Association
Tel: +27 (0)11 484 5288
Email: [email protected]

Editorial, Advertising and Copyright Policy

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 does not represent the official policy of the South African Dental Association or its associates, unless an
express statement accompanies the item in question. All articles published as Original Research Papers are refereed, and articles
published under Clinical Practice or Reviewed Notes are submitted for peer review.
The publication of advertisements of materials or services does not imply an endorsement by the Association or a submitting author,
should such material feature as part of or appear in the vicinity of any contribution, unless an express statement accompanies the
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Published by: On behalf of: While every effort is made to ensure accurate reproduction, the authors, advisors, publishers and their employees or agents shall not
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DENTAL ASSOCIATION Dental Association. © 2020 Life-Long Learning Solutions CC.
www.sada.co.za / SADJ Vol. 75 No. 4
FRONT COVER PICTURE <
171

Prof Bertram Cohen CBE

A South African dentist ascended in 1960 to an appoint- Programme committee of the International Conference
ment as the first Nuffield Research Professor of Dental of the Dental Association and then in 1954 was award-
Science at the Royal College of Surgeons of England, ed a Cecil John Adams memorial travelling fellowship
a position he was to hold for more than two decades. which he took up at Hammersmith Hospital in London.
There he conducted research in salivary gland function
He had qualified at Wits in 1942 and was to lead a life and bone pathology.
of service and great academic distinction, vide the list of
degrees: BDS Witwatersrand 1942, HDD RCS Edin 1947, Bert Cohen did return again to South Africa but he was
MSD Northwestern 1948, DDS Witwatersrand 1959, FDS destined for further recognition… and by 1957 held ap-
RCS 1961, FFD RCSI 1964, FRCPPath 1965, FDS RCS pointment as the Leverhulme Research Fellow in Oral
Edin 1967, DDSc Newcastle 1981, FRCS 1984. Pathology at the Royal College of Surgeons in the Uni-
ted Kingdom. He recognised that fundamental research
Born and schooled in Johannesburg, Bert Cohen regis- in dental pathology must be based upon the principles of
tered at Wits in the Faculty of Dentistry, became President general human pathology.
of the Dental Students Society, played first team squash
and cricket, conducted research into oral disease and on That was his guiding concept and his contributions to
graduation enlisted in the South African Medical Corps. research on head and neck cancers were outstanding,
recognised in 1983 by his post-retirement appointment
He served in Egypt and Italy during the Second World on the Tumour Panel of the Imperial Cancer Research
War. There is an account of how a sparrow settled on Fund. Honoured in 1982 by the Queen, he was elevated
his shoulder …and remained ensconced there for five to Commander of the British Empire (CBE).
full days! Perhaps the bird sensed something unusual
about the man. Certainly Bert went on to achieve high Professor Cohen held the accolades of the profession
accolades in the profession. as a highly skilled diagnostic oral pathologist in head and
neck cancer. His consuming interest and a major contri-
bution was in dental caries, his objective being the
development of an effective vaccine …sadly not yet
achieved... but the impact of his work on caries and
on periodontal disease has been immense. In 1976 he
co-edited Scientific Foundations of Dentistry, a book with
contributions from 60 prominent scientists, surely a re-
cognition of the respect in which he was held worldwide.

Scientific Foundations of Dentistry, co-edited by Prof Bertram Cohen in

1976.

It may not be surprising that a man of such enterprise

Prof Bertram Cohen on the banks of the Arno, near Florence, during the
Second World War. A small bird settled on his shoulder and stayed there had wide interests in art and literature, distinguishing him-
for five days, prompting the locals to name him 'Captain Uccellino', or self when, using radiological techniques, he identified the
'Little Bird'. Image Source: https://www.theguardian.com/education2014 authenticity of a Holbein painting. Indeed, in 1980, Bert
/apr/10/bert-cohen-obituary.
Cohen delivered a lecture on “A tale of two paintings”
After returning to South Africa he was appointed to the dealing with the provenance of two Holbein paintings
full time staff at Wits, where he lectured with distinction belonging to the Company of Barbers and the Royal
and conducted research... but only for six months as he College of Surgeons.
earned a scholarship to Northwestern University, USA
where he gained a Masters degree in Dental Science in Professor Cohen passed away in 2014, aged 95. Descri-
1948. bed as a “brilliant, unusual, commanding man”, he was a
supreme professional and his record confers accolades
Back at Wits as a senior lecturer, Bert Cohen continued on the country of his birth and education, South Africa.
his academic enterprise in lecturing and in securing Story Source: https://www.the guardian.com/education2014/apr/10/bert
grants to sustain his research. He chaired the Scientific -cohen-obituary.
172 >
EDITORIAL

COVID-19: An opportunity for oral

healthcare to define its own future in
South Africa?
SADJ May 2020, Vol. 75 No. 4 p172

NH Wood

The responsibilities of the dentist and of other oral disabled with regard to access to dental care. It is now
healthcare professionals can be broadly explained as the up to us to continue to find revolutionary ways to bring
prevention, diagnosis and treatment of the diseases and oral healthcare services and information to all of our
disorders of the hard and soft tissues of the mouth, in patients, irrespective of their background and location.
order to improve the overall well-being of a person and/
or community. This responsibility extends beyond the In addition to planning for income protection of our peers
single individual to involve the collective as a profession, and colleagues, consolidating strategies to deliver much
and is without any hesitation, essential. One common needed oral healthcare to all our communities must also
thread in the questions that I frequently see raised in be considered for this difficult time. These should include
discussions involving professional bodies, is one where delivery-of-care strategy alongside costs-coverage and the
practitioners raise concern for the protection of their staff, provision of PPE and other essential materials. Advances
for their families, and their patients and communities in healthcare technology and improvements in equipment
from COVID-19; but almost always it has the connection and material technology certainly improves access, ease
to income protection. By and large, when the hands of and efficiency of service delivery; but does this necessa-
dentists are idle, they do not earn. This has placed the rily imply an increase in cost to the operator and/or the
practices and livelihoods of many of our colleagues and patient? Studies will be needed to provide us with definite
friends under considerable strain. answers and directions to obtain longer-term solutions,
even for the post-Covid future. We are yet to see the
The national lockdown is not all negative for most in- sequalae of this unusual situation, both in terms of oral
dustries. Instead, many organisations and companies health outcomes in our population due to selected ser-
have been forced to enter the 4th industrial revolution vice provision, and of the lack of income of oral health-
because of COVID-19. care professionals.

However, the national lockdown (now at level 4 to curb Dental education is also being closely scrutinized. As
the spread of SARS-CoV-2) has dentistry and oral health- practicing professionals, we have access to webinars,
care facing many challenges while we are trying to keep online seminars and discussions for our continued pro-
up with the numerous changes in our work environment. fessional development. However, our universities are
A more immediate and obvious change is the impact compelled to provide more creative solutions to facilitate
on information technology and communication systems, online teaching and learning. Although still in develop-
and another is the influence on our infection control ment, novel ways for clinical skills-transfer is currently a
procedures and policies. globally-focussed topic, as is the financial impact on
dental training in the current milieu. Clinical exposure
As healthcare professionals in the time of COVID-19, for purposes of training of our undergraduate and post-
we still have responsibilities towards our patients, com- graduate students is limited to the extreme, and con-
munities and peers. Many patients will struggle with cern for the 2020 academic year is deepening.
access to any form of oral healthcare, with some only
having access to those clinics and practices able to I am hopeful that, with the impeding reform of national
provide basic care to alleviate pain and sepsis. In addi- healthcare, decision- and policy-makers will use this
tion to the vital interventions directed to manage pain opportunity to take this into consideration, and to in-
and sepsis, oral healthcare professionals have an im- clude the dental and oral health societies and represen-
portant role to play in primary healthcare, such as tative bodies in their planning processes. I would like to
screening for diabetes, for hypertension, and even in remind you to access the SADA resources available to
tobacco-intervention. all our members. Specifics and regular updates during
the lockdown can be found at https://www.sada.co.za/
We are also faced with equity issues of those vulne- clinical-resources/ with a list of accessible documents
rable communities such as the elderly, the poor, and the intended to guide us through this COVID-19 maze.

Thank you for your continued support and I give you

Neil H Wood: Managing editor. Email: [email protected]
this May issue of the SADJ.
www.sada.co.za / SADJ Vol. 75 No. 4
COMMUNIQUE <
173

Personal protective equipment under

and after COVID-19 need a rethink
SADJ May 2020, Vol. 75 No. 4 p173

KC Makhubele

Today as I write this article, it is with the backdrop of the

speech On Thursday, the 23 April wherein President Cyril
Ramaphosa announced that the country would resume
economic activity in a phased approach from 1 May.

He said “...We have developed an approach that deter-

mines the measures we should have in place based on
the direction of the pandemic in our country. As part of
this approach, there will be five coronavirus level (1- 5).
What we are facing is a pandemic, all countries affected
have approached it differently. We applaud the Govern-
ment of SA in the timely and considered manner in which
they are managing the pandemic.”

But one has to ask - or at least this question has crossed

many people’s mind - what will the world look like when
it emerges from the life of lockdowns, quarantine and To step up the protection of patients, staff and themsel-
isolation and the rampant ravages of COVID-19? What ves, and the new SADA guidelines, dentists will have to
will South Africa look like? Close to our heart, how will procure a huge amount of PPE and these requirements
dentistry look like? will without a doubt increase the overhead for every dental
practice. These anticipated increases in overhead were
The choices that are being made now and the political not taken into account in the fees in place before the
outcomes that will follow are critical to determining South pandemic. I also feel very strongly that third-party funders
Africa’s future. Therefore, predicting what will happen after should not bundle the fee for temporary procedures per-
the pandemic is difficult, not least because we have little formed or extraoral imaging conducted during the pan-
information about how long the outbreak and restrictions demic with the payment for the permanent procedure that
will last. may be submitted in the future. It will be inappropriate
for any third-party benefit program to unfairly place the
As a rare event, we have limited historical evidence even cost burden on dentists by disallowing or bundling charges
with the learning from the Spanish flue; as an unexpec- for PPE on the pretext that the payment for additional
ted event, little thought has been given to how to deal required PPE is included in the payment for any other
with it - when our Minister of Finance made his budget procedure billed for the visit.
recently, he had no idea what would hit South Africa.
We have to all readjust our contribution to life in the “new” The above factors may create an environment that may
and “reconfigured “country. be unsustainable for dental practices. I, therefore, call
upon our partners to pay special attention to these con-
The pandemic will last longer and its effects felt long sequences and support payment for PPE as we all strive
after it has disappeared. The issue of high-level hygiene to keep our patients and communities of South Africa
is amongst the issues that will be high on the mind of healthy. There is also discussion underway for dentists to
dentistry more than any other health care sectors. It is in join the public national fight against the Coronavirus
this light that I am urging third-party funders to alter their and there is a chance that some of the dental practices
fees without delays and unnecessary long-drawn dis- may be converted into COVID-19 testing centres. This
cussions, to account for the increasing cost of personal adds more weight to have this discussion and a solution
protective equipment that dentists are using to protect sooner than later.
themselves, their staff and patients.
If everyone is moving forward together, then success
These organisations should adjust their benefit programs takes care of itself. - Henry Ford
either the maximum allowable fees for all procedures
or allow a standard fee per date of service per patient to This is not a fight that one profession can fight alone, it
accommodate the rising costs of PPE. SADA is currently requires joint efforts, it requires all stakeholders, it requires
working on guidelines that should have been published foresight and it requires us to put the health of the
at the publication of this article. communities above all else.
174 >
COMMUNIQUE

Notice of Amendment:
20 th Annual General Meeting (AGM) of
The South African Dental Association NPC (SADA)

Amended Notice is hereby given that the 20th Annual General Meeting (AGM) of the South
African Dental Association (SADA) will be held on Wednesday, 17 June 2020 at 18h00 at the
SADA Head Office, 31 Princess of Wales Terrace, Parktown, Johannesburg (opp. Sunnyside
Hotel) pending the lifting by that date of the lockdown restrictions and prohibition of gatherings
due to COVID-19. If these restrictions are not lifted, the meeting will be conducted entirely
by electronic communication due to the COVID-19 pandemic and requirements of social distan-
cing, which will be facilitated from the SADA head office above or contracted providers.

In the event that SADA is required to conduct the AGM entirely by electronic communication due
to restrictions of movement and gatherings, we will provide necessary information in order to
enable members, or their proxies, to access the available medium or means of electronic
communication (link to join the electronic meeting).

Members are advised that they must have access to a computer or smart device or dial up faci-
lity in order to join the online meeting. In view of extraordinary circumstances and to ensure
maximum participation of voting members on resolutions tabled at an AGM, we call for early
return of proxies from members who are unable to attend.

Questions from members: We are also encouraging members to raise questions prior to the
AGM, thereby allowing those not in attendance, the opportunity to raise issues which can then
be dealt with at the AGM or referred to National Council meeting. The questions and answers
covered in the AGM will, following the meeting, be published on the Association’s website.

The full Agenda and supporting document for the meeting will be sent to members and posted
on the SADA website in due course.

SADA is your Association and your voice counts.

P Govan
Head Legal & Corporate
20 April 2020

THE SOUTH AFRICAN

DENTAL ASSOCIATION
http://dx.doi.org/10.17159/2519-0105/2020/v75no4a1
The SADJ is licensed under Creative Commons Licence CC-BY-NC-4.0. REVIEW <
175

COVID-19: Focus on masks

and respirators – Implications for oral
health-care workers
SADJ May 2020, Vol. 75 No. 4 p175 - p182

R Mulder1, N Layloo2, S Mulder van Staden3

INTRODUCTION
The emergence of the novel human coronavirus (Severe rous pathways to pathogenic micro-organisms (such as
acute respiratory syndrome coronavirus 2; abbreviated as: viruses and bacteria) that infect the oral cavity and res-
SARS-CoV-2) generally known as COVID-19 is a global piratory tract of a patient.1
health concern.1 On 11 February 2020, the World Health
Organization (WHO) named the novel viral pneumonia as Potential routes of transmission of viruses include: 4
“Corona Virus Disease” (COVID -19). The International
Committee on Taxonomy of Viruses (ICTV) suggested this Contact transmission:
novel coronavirus be named “SARS-CoV-2” due to the
phylogenetic and taxonomic analysis of this virus.2 Thus, • • Refers to infections from infected person to a sus-
both terms are utilised interchangeably in the literature. ceptible individual through the transfer of virus-laden
respiratory secretions. This transfer can be directly (via
Undoubtedly, COVID-19 will change the way we prac- physical contact) or indirectly (via intermediate surfaces
tice dentistry with vast implications for Oral health-care or objects).
workers (OHCW) and practice staff. Additionally, if rigo-
rous safety protocols are not implemented based on a Droplet transmission:
risk assessment outlined by the CDC, the dental practice
can potentially become a nexus for disease transmission •• Refers to infections transmitted by deposition of virus
due to the high volume of aerosol production on a daily laden respiratory droplets expelled from an infected
basis. Personal protective equipment (PPE), staff training person onto mucosal surfaces (eyes, nose, mouth).
and practice disinfection protocols have now especially
become important in the light of the current pandemic. Aerosol transmission:

This is not a fight that one profession can fight alone, it •• Refers to infection via inhalation of virus laden fine
requires joint efforts, it requires all stakeholders, it requi- respiratory droplets (aerosols) through the air. These
res foresight and it requires us to put the health of the aerosols are generated either directly from fine res-
communities above all else. piratory droplets expelled from infected person or when
any aerosol generating procedure is performed on
ORAL HEALTH-CARE WORKERS (OHCW) an infected person. Aerosols thus refer to particles in
suspension.
OHCW face an overall elevated risk of exposure to
various infectious diseases. 3 The dental setting and Figure 1 demonstrates the potential routes of COVID-19
wide range of procedures expose the OHCW via nume- transmission in the dental practice. OHCW can be ex-
posed to COVID-19 via direct and indirect transmission
pathways. Direct routes of transmission include exposure
Author affiliations: to droplets and aerosols generated during dental pro-
1. Riaan Mulder: BChD, MSc, PhD, Senior Lecturer, Department of
Restorative Dentistry, University of the Western Cape, Cape Town, cedures. Indirect routes of transmission include the
South Africa. contact of the OHCW to contaminated surfaces in the
ORCID Number: 0000-0002-8722-7632 dental practice as well as exposed auxiliary staff.
2. Nazreen Layloo: BChD, Lecturer, Department of Restorative Den-
tistry, University of the Western Cape, Cape Town, South Africa.
3. Suné Mulder van Staden: BChD, MChD(OMP), Senior Lecturer, The classification COVID-19 as an infectious agent being
Department of Oral Medicine and Periodontics, University of the “aerosol-transmissible” has significant implications for
Western Cape, Cape Town, South Africa.
ORCID Number: 0000-0003-3847-9451
OHCW and the type of Personal Protective Equipment
Corresponding author: Riaan Mulder (PPE) that is required.5
Department of Restorative Dentistry, University of the Western Cape,
Cape Town, South Africa.
Established routes of transmission of COVID-19 in
Email: [email protected]
Author contributions: humans includes direct transmission (through cough,
1. Riaan Mulder: First author - 33% sneeze, droplet inhalation) and contact transmission
2. Nazreen Layloo: Second author - 33% (contact via oral, nasal and eye mucous membranes).2
3. Suné Mulder van Staden: Third author - 33%
Evidence suggests that even non-symptomatic indivi-
176 >
REVIEW

Susceptible
Airborne
individuals

Droplets
and aerosol

D ro p
a n d a e le ts Dental practice with Oral health-care
ro s o ls Direct contact
aerosol producing worker
procedures
v
t
Infected patient ac
o nt
spreading droplets tc
r ec Auxillary staff
and aerosol di
Cont
a m in In of the practice
a t io n
of su Surfaces of the
rface
s ntac t
whole dental ct co
practice I n d ir e

Figure 1. Adapted illustration of transmission routes of COVID-19 in the dental setting.3

duals can spread COVID-19 with high efficiency. Case Countries are adopting various strategies to drastically
studies from The Peoples Republic of China have also increase the production of this form of PPE. The question
demonstrated that even after recovery from acute ill- however remains: “Can a mask really protect you from
ness patients continued to shed high amounts of the catching the virus?” More importantly: “Are these masks
virus.3 protecting health care workers from contracting the
dreaded COVID-19?” The answer to this question needs
Dental practices carry a very high risk of COVD-19 to contemplate the size of the COVID-19 virus and the
transmission due to close proximity of the oral cavity level of determined filtration that masks and respirators
and face-to-face communication with patients. The pro- currently offer.
cedures conducted in daily practice causes repeated
exposure of the OHCW to aerosol, blood and saliva.2 It is important to note that not all masks and respirators
products perform optimally in all clinical settings. Masks
Studies utilizing viral culture methods have shown that and respirators present only one component of PPE.
Covid-19 is present in saliva samples.6 Currently, ocular
symptoms are not commonly associated with COVID-19 OHCW should correctly select and apply masks and
infection. However, analysis of conjunctival samples from respirators in the clinical environment. This require an
confirmed cases of COVID-19, suggests that transmis- in-depth knowledge and understanding of droplet and
sion is not limited to the respiratory tract and that eye aerosol transmission, to place the COVID-19 pandemic
exposure may be an effective pathway for the virus to into perspective.
enter the body.2
AEROSOLS AND DROPLETS IN DAILY LIFE
MASKS AS PART OF DAILY PPE
Dental literature has demonstrated that many dental pro-
The utilization of the correct PPE is not only limited to cedures produce aerosols and droplets that are con-
the dental practitioner. The entire dental team should be taminated with pathogenic micro-organisms, such as a
equipped and trained in the use of the correct PPE and bacteria and viruses.9
disinfection protocols. A survey under dental assistants
from the Limpopo province reported that a mere 76.3% It is important to realise that all individuals are ex-
wore masks during dental procedures.7 posed to aerosols and droplet in daily life. Table 1
provides insight to understanding the implications of
For the OHCW the mask will become an essential PPE particle size of an aerosol and droplet, since particle
item of practice as COVID-19 continues to spread. The sizes have significant implications for disease trans-
World Health Organisation (WHO), currently recommends mission.4,5
that individuals who show signs of respiratory symptoms
(cough and difficulty breathing) with fever, should wear Both droplets and aerosols are generated during cough-
a mask and seek medical attention.8 ing, sneezing, talking and even exhaling.4 Normal daily
activities such as speaking and breathing have recorded
The world is contemplating as to whether all indivi- predominant particle sizes of 1 μm, regardless of voice
duals wearing masks in public would help to flatten the amplitude projected.12,13,14
curve of the spread. This is a growing concern as many
countries are reportedly running out of facemasks and The particles generated from coughing have a greater
respirators. velocity and range between 0.57 to 0.89 μm (average
www.sada.co.za / SADJ Vol. 75 No. 4
REVIEW <
177

0.63 μm).15 Sneezing reportedly produces the largest posed to between 0.014 µl to 0.12 µl aerosolised saliva
droplet with an approximate particle size of 360.1 μm.16 during a 15 minute peak exposure period.
Studies have demonstrated that 1 µm particles have suf-
ficient volume to transmit diseases from one person to Based on the results obtained, the study calculated that
another. Despite their small size, however, these micron- if a patient with Mycobacterium tuberculosis (M. tuber-
scale particles are sufficiently large enough to carry a culosis) was treated, the practitioner could potentially
variety of respiratory pathogens such the measles virus have inhaled between 0.98 to 8.40 colony forming units
(0.05 - 0.5 µm)17, influenza virus (0.1-1 μm)18 and Myco- (cfu) of M. tuberculosis, resulting in infection. Airborne
bacterium tuberculosis (1- 3 μm).19 M. tuberculosis is the main route of transmission gene-
rated by coughs and sneezes with droplet nuclei 1-5 µm
Recent work by Yan et al. has confirmed that significant in size.25
amounts of influenza viral RNA are present in small
particles (<5 μm) emitted by influenza-infected individuals Studies have shown that COVID-19 become airborne
during natural breathing, even without the infected in- through aerosols and droplets, generated during medical
dividual coughing or sneezing.20 and dental procedures.26 Dental practice generated drop-
lets and aerosols from infected patients are likely to
The risk of transmission with COVID-19 becomes ap- contaminate the whole surfaces in a dental practice.2
parent when the particle size ranging between 0.06
and 0.14 µm is considered.21 Thus, COVID-19 can be Studies investigating generated 5µm COVID-19 parti-
considered as a ‘small particle’ microbe with a high cles, reported that they remained viable for the dura-
potential risk of airborne transmission. tion of the 3 hour in vitro experiment. Further to this,
COVID-19 was demonstrated to be the most stable
Table 1. Particle sizes and implications of transmission. when it remained on plastic and stainless steel sur-
Particle size Implications for transmission
faces, compared to copper and cardboard.
< 5-10µm This is aerosol and can be smaller than 5 µm as well.
‘small particles’ Although the COVID-19 virus reduced in virility over
Aerodynamic diameter that follow airflow streamlines.
time, viable particles were present up to 72 hours
Mainly short range transmission4 and long range if
after application to these surfaces. The half-live of aero-
strong air currents present.
solised Covid-19 in the air had a virility of about 1.1 hours.26
Readily penetrates the airways all the way down to
the alveolar space (causing lower respiratory tract in- The problem that therefore exists with COVID-19, is the
fections LRT).4 ability to settle on surfaces within the practice, where it can
High risk for airborne transmission.10,11 survive for extended periods of time.
> 20µm This splatter than can travel 15-120 cm from
‘large particles’ the patient.
REDUCTION OF AEROSOL
Follow a more ballistic trajectory (i.e. falling mostly
under the influence of gravity – where the droplets are In 1963 Miller et al. demonstrated that polishing cups,
too large to follow inhalation airflow streamlines.
air turbines with water spray and polishing restorations
Most likely impact respiratory epithelial mucosa sur-
faces or trapped by cilia before reaching lower respi-
with a bristle brush generated particles with various
ratory tract (LRT). levels of microbial contamination.10
Associated with upper respiratory tract (URT)
infections.10,11 Besides the guidelines that the Centres for Disease
Control and WHO will advise in due time, OHCW can
AEROSOLS IN DENTISTRY start to reduce the microbial load in the oral cavities
of patients with pre-procedural mouth rinses27, tooth
In the dental practice, aerosols are produced by equip- brushing before the visit28 and high volume evacuation29
ment such as ultrasonic scalers and fast hand pieces. next to the aerosol generating equipment.30
Aerosolised water from dental equipment can range from
aerosol to splatter (0.001 µm to 50 µm). Aerosols with According to “Guideline for Diagnosis and Treatment of
particles greater than 100 µm, settle quickly to the floor Novel Coronavirus Pneumonia” (National Health Com-
and other surfaces.22 Aerosols become suspended in the mission) chlorhexidine as a pre-procedural mouth rinse
air when the particle size is smaller than 50 µm.23 may not be effective to kill COVID-19. COVID-19
is vulnerable to oxidation, thus pre-procedural mouth
Dental lasers are included as an aerosol producing pro- rinses containing oxidative agents such as 1% hydro-
cedures due to the generation of the lasers plume. For gen peroxide or 0,2% povidone are recommended to
lasers high-efficiency particulate filtration respirator to the reduce the salivary load of microbes (including COVID-19
efficiency of 99.75% at 0.1μm have been suggested.24 carriage).2
For dental lasers this would therefore be a respirator
with a rating of N99, N100 or FFP3. Additionally, studies have also concluded that the use
of rubber dams significantly reduce the contamination
A Study evaluating the air quality in a dental setting to the OHCW and the surrounding dental environment.31
with dental procedures such as extractions, air turbine Lastly disposable protective clothing and a protective
with water spray and ultrasonic procedures, found that face shield (as recommended by the CDC) additionally
the micro-organism level in the dental surgery generally aid in the protection from splatter droplets, since droplets
took 10-30 minutes to return to normal. This study also escape the high volume evacuation due to the air stream
calculated that the practitioner and assistant was ex- flowing from the dental equipment.32
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REVIEW

MASKS AND RESPIRATORS have ratings as R95 or P95 based on the industry
with the same level of filtration to particles. In terms
There are various masks and respirators available in the of the recommended N95, the European equivalent is
medical profession. Facial filtering protective equipment FFP2 and for N99 it is FFP3.36
can be categorised into two broad categories, namely
masks and respirators. They are fundamentally different in Additionally, some more expensive respirators will be
their intended use and the level of protection they provide. approved by the National Institute for Occupational
Safety and Health (NIOSH) in the United States to have
An ear loop mask primarily assists in preventing transmis- the characteristics of both a respirator and a surgical
sion of biological particles (e.g. bacteria and viruses) mask (i.e. fluid-resistant to splash, splatter of blood and
expelled by the wearer. Many ear loop masks offer some other bodily fluids) for use in theatres.
level of fluid resistance. The particle filter capabilities vary.
High quality earloop masks are expected to possess a The N95 respirator provides 8-12 times more protection,
meanSurgical Mask
particle filter size of 4µm. N95 Respirator than a surgical mask with exposure to particles with a
size between 0.04-1.3 µm.37
Figure 2. An example of a mask and respirator.33

Surgical masks (predominantly worn in theatre) have National Institute for Occupational Safety and Health
the primary purpose of preventing biological particles in have produced valuable videos regarding PPE that can
droplet form infecting the health care practitioner. The be viewed at the following online addresses:
expelled droplets and aerosol generated by the prac- https://www.cdc.gov/niosh/docs/video/default.html
titioner (by breathing, talking, sneezing etc.) is filtered
to prevent contamination of the surgical environment.34
MANUFACTURE REGULATIONS
Surgical masks are also designed to be fluid-resistant to PERTAINING TO MASKS
splash and splatter of blood and other bodily fluids dur-
ing a procedure. A high quality surgical mask can filter Respirators are certified through the Centre of Disease
mean particle sizes of 2.7µm. Control (CDC) and the National Institute for Occupa-
tional Safety and Health (NIOSH) in the United States.
The limitation of surgical masks are that they are not All respirators in the United States need to comply with
necessarily designed to seal tightly to the face, thus air a complete respiratory program in accordance with the
can potentially leak around the edges. Hence, they do not Occupational Safety and Health Administration (OSHA).36
completely reduce the exposure to airborne particles.35 Each country has a performance standards to which the
respirators must be produced. In South Africa, the per-
Respirators create an effective facial seal to cover the formance standard is approved by the South African
nose and mouth, aiding in preventing inhalation of hazar- Bureau of Standards (SABS) and the National Regulator
dous airborne particles, gases and vapours. Respira- for Compulsory Specifications (NRCS) under SANS 103
tors offer varying degrees of filtration, based on their 38: 2009. This is the equivalent performance standard
classification. from Europe EN149: 2001.

Three key criteria are required for a respirator to be The Respiratory Protection Standards require all health
effective:36 care professionals to use respirators with tight fitting
face pieces. Health care professionals also need to
1. The filter materials in the various layers used in the be adequately trained in the proper use, safe doffing
respirator needs to be extremely effective at captur- and disposal of these respirators and can view various
ing hazardous particles. videos to educate them on donning and doffing:

2. The respirator needs to fit snugly around the wearers https://www.cdc.gov/niosh/npptl/topics/respirators/disp

face to create and maintain an effective facial seal. _part/donningdoffing.html.
This seal minimises the amount of particles that are
able to enter through gaps found between the skin Health care professionals also need to be knowledgeable
and the respirator. on the medical conditions that provide contraindications
of using respirators.36 Heart conditions, lung disease
3. The respirator needs to be put-on (don) and removed and psychological conditions like claustrophobia could
(doff) correctly. be contra-indications to those clinicians. In the United
States, OSHA recommend the evaluation of the staff
Respirators have various descriptive criteria (letters) based member by a medical practitioner with a medical ques-
on their resistance to oil. The letter in the name of the tionnaire to evaluate the medical history and safety of
respirator rated as N, R or P. This rating is important in the intended respirator for that practitioner. The question-
industry because some industrial oils can degrade the naire can be obtained at this link:
filter performance so it does not filter properly for that
environment. Respirators are rated ‘N’, if they are Not https://www.osha.gov/laws-regs/regulations/standard
resistant to oil, ‘R’ if somewhat Resistant to oil, and ‘P’ number/1910/1910.134AppC.
if strongly resistant (oil Proof).
Furthermore, it is a requirement from OSHA that all
The numerical value refers to the filtration capacity of healthcare workers are expected to perform all activi-
the respirator. Therefore, a N95 respirator could also ties with suspected or confirmed cases of COVID-19
www.sada.co.za / SADJ Vol. 75 No. 4
REVIEW <
179

wearing respiratory protection. A filtering face piece such 6. Mould the nosepiece of the respirator over the bridge
as a N95 respirator is recommended as it seals the of your nose to obtain a tight seal.
face covering the mouth and nose. It also has the ability
to remove 95% of airborne particles from the users 7. Perform a fit check to ensure there is a good seal
breathing air due to the built in filter.36 against the skin.

The CE marking and the performance standard of the The video illustrating this procedure is available at:
respirator must be visible on the respirator, as well as on
the packaging. Table 2 presents detail of the standard https://www.cdc.gov/vhf/ebola/hcp/ppe-training/n95res-
of testing, based on the various geographical locations pirator_gown/donning_09.html
where the respirators were manufactured.
RESPIRATORS WITH VALVES
The Food and Drug administration in the Unites States
released Table 2 on 28 March 2020 of allowed respira- The main purpose of a respirator valve is to decrease
tors against the COVID -19 pandemic for importation to breathing resistance during exhalation. This has no impact
the United States. on the respirators ability to provide adequate respira-
tory protection to the OHCW. The design of the valves
FACIAL FIT AND SEAL TESTING allows exhaled air to exit during exhalation and to tightly
close during inhalation, consequently preventing any in-
An adequately fitted respirator is of utmost importance haled air from entering the valve during inhalation.
to ensure there is no leakage around the edges of the
respirator. The respirator needs to seal tightly and com- Due to the nature of the valve - it should not be re-
pletely on the wearer’s face. It is important to follow the commended to OHCW, since exhaled particles exiting
user instructions and follow a user seal check before the respirator through the valve will contaminate the
entering a contaminated or sterile environment.35 environment or sterile field in theatre. Thus, they are
not recommended for OHCW, as they could become
The seal of the respirator should be evaluated by feeling the nexus for local transmission.
for exhaled air moving past the edges of the respirator.
Any area where the seal is inadequate should be inves- RE-USE OF RESPIRATORS
tigated for facial hair and materials/cloth that may inter-
fere with the respirator making contact with the skin. In theory, the respirator can provide eight hours of res-
piratory filtration. The largest risk of cross-contamination
If the wearer is unable to shave then a Powered Air from the respirator to the OHCW is during doffing of the
Purifying Respirator (PAPR) should be considered as an respirator and then self-inoculation from surface droplets.
alternative. Some PAPR’s are designed to fit under the Wearing an ear loop mask or face shield, over the res-
wearers chin or at the neck making them a suitable pirator could protect the respirator from surface con-
alternative.35 tamination. The only truly viable option to reduce the daily
numbers of respirators is to don the respirator and keep
DONNING A PPE RESPIRATOR38 it on for the duration of the clinical day, with ear loop
mask replacement after every patient.
1. Ensure adequate hand hygiene or first layer of cloves.
In this time of COVID-19 with a worldwide shortage
2. Hold the respirator in the palm of your hand with the of PPE, the extended use of respirators is frequent.
straps facing the floor. A respirator manufacturer has conducted research on
the sterilisation procedures for respirators and assessed
3. Place the respirator on your face covering your nose their subsequent filtration capacity. The four main crite-
and mouth. ria for successful disinfection investigated included the
following:
4. Pull the bottom strap up and over top of your head,
and put it behind your head below your ears. 1). Be effective against the target organism (COVID-19).
2). Not damage the respirator’s filtration.
5. Take the upper strap and put it behind your head 3). Not affect the respirator’s fit.
towards the crown of your head. 4). Be safe for the person wearing the respirator (e.g. no
off-gassing of chemicals into the breathing zone).

Table 2. COVID-19 respirators imported to United States.

Jurisdiction Made to performance standard Acceptable product classifications Standards / Guidance documents
Australia AS/NZS 1716:2012 P3, P2 AS/NZS 1715:2009
Brazil ABNT/NBR 13698:2011 PFF3, PFF2 Fundacentro CDU 614.894
Europe EN 149-2001 FFP3, FFP2 EN 529:2005
Japan JMHLW-2000 DS/DL3, DS/DL2 JIS T8150: 2006
Korea KMOEL-2017-64 Special 1st KOSHA GUIDE H-82-2015
USA / Canada NIOSH / FDA Health Canada Licence N95 surgical respirator NIOSH approved
Mexico NOM-116-2009 N100, P100, R100, N99, P99, R99, N95, P95, R95 NOM-116
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REVIEW

The various disinfection methods assessed in this study WHO AND CDC ADVICE TO HEALTH CARE
included:
WORKERS
1). Ionizing radiation. The WHO and CDC have published a table of recom-
2). Ethylene oxide. mendations to curb the spread of COVID-19 in health
3). Ultraviolet germicidal irradiation (UVGI). care facilities. This table is continuously in flux and up-
4). Microwave-generated stream (MGS). dates are available on the websites of the CDC and
5). Moist heat. WHO, as the COVID-19 pandemic is further studied and
knowledge increases.
These disinfection methods did not completely meet
the set out criteria, to be justified as successful. As of CONCLUSION
27 March 2020, no disinfection method has met all
four of these key criteria, and without all four, the During daily dental procedures, aerosol production is
method is not acceptable. 3M is now working with often unavoidable. Due to the nature of the dental
several major sterilization and disinfection companies setting and current findings in the literature, it is the
and consulting with external experts to develop an opinion of the authors that only N95/FFP 2 (or equivalent
effective disinfection method. 3M is working towards respirators) are recommended for OHCW during this
a solution to meet the abovementioned criteria.39 COVID-19 pandemic.
The CDC therefore have stated discarding recommen-
dations for respirators, to prevent a significant risk for OHCW additionally should take the steps outlined to
contact transmission, self-inoculation or reduced func- minimise aerosol production and adhere to the current
tionality 40: recommendations of disinfection protocols as set out by
the CDC.
1). Discard respirators following use during aerosol ge-
nerating procedures. Declaration

2). Discard respirators contaminated with blood, res- The authors declare no conflict of interest.
piratory or nasal secretions, or other bodily fluids
from patients.
Table 3. Transmission-based precautions and specific infection pre-
ventive and control measures as recommended by WHO and CDC
3). Discard respirators following close contact with any for health-care facilities.42
patient co-infected with an infectious disease requiring Type of
Rationale Measures
precautions
contact precautions in Table 2.
Standard To minimise the spread of in- Practice hand hygiene
fection within healthcare fa-
Use of PPE
4). Consider the use of a cleansable face shield over a
41 cilities from direct contact of
contaminations Practice respiratory etiquette
respirator and/or other steps (e.g. masking patients,
Environmental cleaning
use of engineering controls), when feasible to reduce and disinfection
surface contamination of the respirator. Proper handling of patient
care equipment and waste
management
5). Hang used non-contaminated respirators in a desig-
Proper handling of needles and
nated storage area or keep them in a clean, breathable other sharps
container such as a paper bag between uses. Contact To minimise the spread of in- Proper use of PPE including
fections particularly by hand- disposable gloves and gowns
to-hand contact and self-in-
6). To minimize potential cross-contamination, store res- oculation of nasal and/or
Appropriate patient placement
in a single room or with patient
pirators so that they do not touch each other and the conjunctival mucosa
infected by some pathogen
person using the respirator is clearly identified. Limit patient movement and mi-
nimise patient contact
7). Storage containers should be disposed of or clean- Environmental cleaning and
disinfection of the patient room
ed regularly.
Droplet To minimise the spread of re- Proper use of PPE including
spiratory infections that are surgical mask when entering
8). Clean hands with soap and water or an alcohol- transmitted predominantly via the patient’s room

based hand sanitizer before and after touching or large droplets (>5µm) in short Appropriate patient placement
distance in a single room or with patient
adjusting the respirator (if necessary for comfort or infected by same pathogen.
to maintain fit). Limit patient movement and
ensure that patients wear sur-
gical mask when outside their
9). Avoid touching the inside of the respirator. If in- rooms.
advertent contact occurs with the inside of the Airborne To minimise the spread of Proper use of PPE including
respirator, discard the respirator and perform hand respiratory infections that are N95/FFP2 or equivalent partic-
transmitted through inhalation ulate respirator.
hygiene as described above.
of infectious aerosols (≤5µm) Isolation of patient in single,
over a long distance airborne isolation infection
10). Use a pair of clean (non-sterile) gloves when donning room (AIIR).

a used respirator and performing a user seal check. Limit patient movement and en-
sure that patients wear surgical
Discard gloves after the respirator is donned and after mask when outside their rooms.
any adjustments are made to ensure the respirator is Contact, droplet and airborne precautions are considered as transmission-based
creating an effective facial seal. precautions that should be implemented in addition to standard precautions.
www.sada.co.za / SADJ Vol. 75 No. 4
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181

Table 4. Technical details on masks and respirators

Category Cloth masks Surgical masks N95 (3M)
Model 1860S Model 1870+ VFlex
Can be used as No Yes Yes Yes Yes
a medical device
Filter efficiency Currently no published Does not provide the wearer ≥95% of airborne particles ≥95% of airborne particles ≥95% of airborne particles
research available on with a protection from inhala- (Both large and small). (Both large and small). (Both large and small).
efficacy of cloth masks. tion of small airborne particles.
Not considered respiratory pro-
tection.
Purpose Used to block large particles/ Reduces the wearers Reduces the wearers ex- Reduces the wearers
droplets that may contain exposure to large droplets/ posure to large droplets/ exposure to large droplets/
micro-organisms. particles and smaller particles and smaller par- particles and smaller
Protects the patient from the particle aerosols. ticle aerosols. particle aerosols.
wearer’s respiratory emissions.
Face seal fit Loose/ill-fitting. Loose fitting. Tight fitting, seals over Tight fitting, seals over Tight fitting, seals over
mouth and nose mouth and nose. mouth and nose.

User seal check No. No. Yes – required every time Yes – required every time Yes – required every time
requirement its put on. its put on. its put on.
Leakage Leakage can occur Leakage occurs around the When correctly put on and When correctly put on and When correctly put on and
through the fabric and edges of the mask between the fitted - minimal leakage fitted - minimal leakage fitted - minimal leakage
around the edges of face and mask. occurs. occurs. occurs.
the mask.
Fluid resistance Not fluid resistant 0.04µm-1.3 µm Splashes at 120mm Hg. Splashes at 160 mm Hg. Splashes at 80mm Hg.
Not resistant to oil Not resistant to oil. Not resistant to oil.
Valve/no valve No No No valve No valve No valve

Use limitation Non-surgical/medical. Disposable. Should ideally be discar- Should ideally be discar- Should ideally be discar-
Needs to be washed Discard after each patient en- ded after each patient or ded after each patient or ded after each patient or
frequently. counter. after an aerosol producing after an aerosol producing after an aerosol producing
procedure. procedure. procedure.
Discarded if damaged or Discarded if damaged or Discarded if damaged or
deformed or the seal is deformed or the seal is deformed or the seal is
defective. defective. defective.
Should be discarded if Should be discarded if Should be discarded if
it becomes contaminated it becomes contaminated it becomes contaminated
with blood or other bodily with blood or other bodily with blood or other bodily
fluids from patients. fluids from patients. fluids from patients.

Category N99 N100 FFP2 FFP3

Can be used as Yes Yes Yes Yes
a medical device
Filter efficiency ≥99% of airborne particles ≥99.97% of airborne particles ≥94% of airborne particles ≥99% of airborne particles
(Both large and small). (Both large and small). (Both large and small). (Both large and small).
Purpose Reduces the wearers exposure to Reduces the wearers exposure to Reduces the wearers exposure to Reduces the wearers exposure to
large droplets/particles and smaller large droplets/particles and smaller large droplets/particles and smaller large droplets/particles and smaller
particle aerosols. particle aerosols. particle aerosols. particle aerosols.
Face seal fit Tight fitting, seals over mouth Tight fitting, seals over mouth Tight fitting, seals over mouth Tight fitting, seals over mouth
and nose. and nose. and nose. and nose.
User seal check Yes – required every time its put on Yes – required every time its put on Yes – required every time its put on Yes – required every time its put on
equirement
Leakage Minimal leakage occurs when cor- Minimal leakage occurs when cor- Minimal leakage occurs when cor- Minimal leakage occurs when cor-
rectly put on and fitted. rectly put on and fitted. rectly put on and fitted. rectly put on and fitted.
Fluid Resistance Not resistant to oil Not resistant to oil Strongly resistant to oil Strongly resistant to oil
Valve/No Valve No valve No valve Could be valved Could be valved
Use limitation Should ideally be discarded after Should ideally be discarded after Should ideally be discarded after Should ideally be discarded after
each patient or after an aerosol each patient or after an aerosol each patient or after an aerosol each patient or after an aerosol
producing procedure. producing procedure. producing procedure. producing procedure.
Discarded if damaged or deformed Discarded if damaged or deformed Discarded if damaged or deformed Discarded if damaged or deformed
or the seal is defective. or the seal is defective. or the seal is defective. or the seal is defective.
Should be discarded if it becomes Should be discarded if it becomes Should be discarded if it becomes Should be discarded if it becomes
contaminated with blood or other contaminated with blood or other contaminated with blood or other contaminated with blood or other
bodily fluids from patients. bodily fluids from patients. bodily fluids from patients. bodily fluids from patients.

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24. Convissar R. Principles and Practice of Laser Dentistry. 2nd
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The SADJ is licensed under Creative Commons Licence CC-BY-NC-4.0. RESEARCH < 183

Comparison of forward and reverse

single-file reciprocation for root canal
instrumentation in curved mandibular
molar canals - a Micro-CT analysis
SADJ May 2020, Vol. 75 No. 4 p183 - p188

PJ van der Vyver1, M Vorster2, F Paleker3, ZI Vally4

ABSTRACT
To compare (i) canal centering ability and transportation of ProGlider / ProTaper Next X2 yields better results for
of Primary WaveOne Gold in combination with WaveOne transportation and centering ability apically compared to
Gold Glider with ProTaper Next X2 in combination with WaveOne Gold Glider in combination with Primary Wave-
ProGlider using Micro-CT, and (ii) difference in final pre- One Gold.
paration times between these two preparation groups.
Mesiobuccal canals of 50 mandibular first molars were Keywords
used. Teeth were randomly divided into two preparation Centering ability, ProTaper Next, reciprocation, trans-
groups. Results were analysed using a one-way analysis portation, WaveOne Gold.
of variance (ANOVA).
INTRODUCTION
Apically, ProGlider/ProTaper Next X2 demonstrated better
centering ratio values and lower transportation values Preparation and shaping of curved root canals can result
compared to WaveOne Gold Glider/Primary WaveOne in iatrogenic errors including but not limited to apical
Gold (p < .05). No differences were found in the mean canal transportation, uncentered preparations, ledge for-
combined centering ratios and transportation values be- mation, or perforation in curved canals.1
tween groups (p > .05).
Advances in metallurgy have produced more super-elas-
No statistically significant differences between the canal tic nickel titanium (NiTi) files that manufacturers claim
preparation times were found (p < .06). The combination are strong enough to resist the forces of torsion while
maintaining enough flexibility to follow complicated root
Author affiliations: canal anatomy.2
1. Peet J van der Vyver: BChD, PG Dip Dent (Endo), PG Dip Dent
(Aesthet Dent), MSc, PhD (Pret), Department of Odontology,
School of Dentistry, Faculty of Health Sciences, University of In addition endodontic motors have undergone enhance-
Pretoria, Pretoria, South Africa Oral and Dental Hospital, Pretoria, ment with regard to torque control and kinematics that
South Africa.
ORCID Number: 0000-0003-1951-6042
are adjustable in several directions, which offer more
2. Martin Vorster: BChD, PG Dip Dent (Endo), MSc (Pret), Department effective and safer shaping of root canals.3 Recently,
of Odontology, School of Dentistry, Faculty of Health Sciences, the Root Pro CL (Medidenta, Las Vegas, USA) and
University of Pretoria, Pretoria, South Africa Oral and Dental
E-Connect S (Eighteeth Medical, Changzou, China) en-
Hospital, Pretoria, South Africa.
ORCID Number: 0000-0003-4470-1530 dodontic motors were launched that allow clinicians to
3. Farzana Paleker: BChD (Stell), Dip Odont (Endo), MSc (Pret), use rotary instruments in a forward reciprocating motion.
Department of Odontology, School of Dentistry, Faculty of Health
Sciences, University of Pretoria, Pretoria, South Africa Oral and
Dental Hospital, Pretoria, South Africa. WaveOne Gold (Dentsply Sirona, Ballaigues, Switzerland)
ORCID Number: 0000-0002-9110-5208 is a reciprocating root-canal shaping system manufac-
4. Zunaid I Vally: BDS, MDent (Prosthodontics), Department of tured from Gold-Wire and exhibits a unique alternating
Odontology, School of Dentistry, Faculty of Health Sciences,
University of Pretoria, Pretoria, South Africa Oral and Dental off-centered parallelogram-shaped cross-section and a
Hospital, Pretoria, South Africa. progressively decreasing percentage taper design.4
Corresponding author: Peet J van der Vyver
Postal address: PO Box 2609, Cresta, 2118, South Africa.
Tel. no.: +27 (0)11 781 1020
The Primary WaveOne Gold instrument (PWOG) (25/07)
Fax no.: +27 (0)11 781 1392 is 50% more resistant to cyclic fatigue, 80% more flex-
Email: [email protected] ible and 23% more efficient than its NiTi predecessor,
Author contributions:
the conventional Primary WaveOne instrument (Dentsply
1. Peet J van der Vyver: Principal investigator. Data collection, ana-
lysis, scientific writing and editing - 40% Sirona) manufactured from M-Wire.5
2. Martin Vorster: Scientific writing and editing - 20%
3. Farzana Paleker: Scientific writing and editing - 20% ProTaper Next (Dentsply Sirona) is a rotary root-canal
4. Zunaid I Vally: Scientific writing and editing - 20%
shaping system constructed of M-Wire NiTi, making it
184 >
RESEARCH

almost 400% more resistant to cyclic fatigue than con- To our knowledge, no study has yet compared the pre-
ventional NiTi.6 ProTaper Next (PTN) features a bilateral paration times, centering ability, and transportation values
symmetrical rectangular cross-section, with an offset axis of WOGG/PWOG to PG/PTN used in RM in curved
of rotation (except in the last 3 mm of the instrument (D0 mandibular molar canals. The null hypothesis proposed
– D3), allowing it to experience a rotational phenomenon is that there is no difference in preparation times and
known as precession or swagger.7 between forward and reverse reciprocating motion with
regard to centering ability and canal transportation.
Contemporary single-file mechanical glide path prepa-
ration systems like the reciprocating WaveOne Gold MATERIALS AND METHODS
Glider (Dentsply Sirona) and the rotating ProGlider file Selection of teeth
(Dentsply Sirona) have been introduced in recent years.
The WaveOne Gold Glider (WOGG) is made from Gold- Mesiobuccal canals of 50 human mandibular first mo-
Wire while the ProGlider (PG) file is manufactured from lars, extracted for reasons unrelated to this study, were
flexible memory nickel-titanium wire (M-Wire). selected after obtaining written informed consent.

Preservation of the original canal anatomy and remaining Teeth were stored in distilled water at 4 ˚C until use.
dentine thickness has been shown to improve the out- The Schneider method was used to evaluate canal
come of endodontic treatment. Micro-computed tomo- curvature and only previously untreated mesiobuccal root
graphy (Micro-CT) has emerged as a useful analytical canals with curvatures between 25˚ and 35˚ and radii of
system that provides non-destructive and highly accu- equal to or less than 10 mm were used.14
rate analyses of the effects of endodontic instrumen-
tation on root canal anatomy. Extensive information can The selected teeth were scanned (pre-instrumentation
be obtained from Micro-CT evaluation and slices can scan) using the XTH 225 ST micro-focus X-ray computed
be recreated in a two- or three-dimensional plane with tomography system at the Micro-focus X-ray Radiogra-
either simultaneous or separate assessment of internal phy and Tomography facility (MIXRAD) at the South
and external structures.8 African Nuclear Energy Corporation (NECSA).

Reciprocating files currently available on the market This system has a spatial resolution capability of 0.001
are designed for use in a reverse motion. This motion - 0.006 mm.15 Samples were placed on a stable sup-
employs a greater engaging counter-clockwise (CCW) port and a series of sequential two-dimensional (2D)
angle (left-cutting) with a non-cutting disengaging clock- x-ray images were captured as the samples were rotated
wise (CW) angle. However, some authors suggest that through 360°. These images were then reconstructed
reciprocating motion (RM) with a CW rotation greater to generate three-dimensional (3D) volumetric representa-
than the CCW motion (forward reciprocation or right- tions of each tooth. Reconstruction and visualization of
cutting) could expand the use of conventional rotary the Micro-CT images were done using VGStudioMax
files typically designed for continuous CW rotation. 9,10 visualization software (Volume Graphics GmbH, Heidel-
berg, Germany).
Yared3 was the first to propose a canal preparation
technique with a F2 ProTaper Universal (Dentsply Sirona) After access cavity preparation with an Endo-Access
NiTi rotary instrument used in forward reciprocation. burr (Dentsply Sirona) ensuring straight line access, the
The study showed great potential in the reduction of mesiobuccal canals were explored with a size 0.08 K-file
the number of instruments, in minimising possible cross (KF) and canals were negotiated to patency under a
contamination and in alleviating operator anxiety of the surgical microscope (Zumax Medical Co. Ltd, Suzhou,
possibility of instrument failure.3 China).

In 2010, numerous authors11-13 also confirmed that the Working length was determined by subtracting 0.5 mm
forward reciprocating movement promoted an extended from the length of the canal measured to the major
cyclic fatigue life of ProTaper Universal instruments (Dent- apical terminus. The specimens were coded and ran-
sply Sirona) in comparison with conventional rotation. domly divided into two equal experimental groups for
Gavini et al.9 compared the Reciproc R25 file (VDW, glide path preparation. A single operator performed the
Munich, Germany) in continuous rotation and forward glide path preparation and shaping for each system.
reciprocation motion. The file group used in forward reci-
procating motion fractured in 163,28 seconds, whereas All reciprocating and rotary files were operated by Root
the continuous rotation file group fractured in 357.56 Pro CL (Medidenta) cordless endodontic motor. RC Prep
seconds.9 (Premier, Pennsylvania, USA) was used as a lubricating
agent and 3% sodium hypochlorite for canal irrigation.
The aim of this in vitro study was to investigate and Each file was used to prepare one canal only before
compare root canal instrumentation of two single-glide being discarded. Glide path preparation and shaping
path preparation and shaping system combinations used times were recorded with an electronic stopwatch.
in RM in curved mesiobuccal root canals of extracted
human mandibular molars: WOGG with the PWOG WOGG/PWOG group
(in reverse reciprocation according to the manufactur-
er’s instructions) and PG with the PTN X2 (in forward In each of the 25 canals a pre-curved stainless-steel size
reciprocation, not used according to the manufacturer’s 0.10 KF was negotiated to working length with increasing
instructions). amplitudes of 1-3 mm to ensure an initial manually re-
www.sada.co.za / SADJ Vol. 75 No. 4
RESEARCH < 185

producible glide path. Each canal in this group was These levels represent the apical, middle, and coronal
enlarged using WOGG, followed by shaping with PWOG thirds of the roots with a high risk and incidence of
- both in a reverse RM. Reverse RM was characterized iatrogenic errors.16 A cross-section at levels 3 mm, 5 mm
by a CCW movement of 150° and a CW movement of 30°. and 7mm was evaluated using the following equations:17

PG/PTN X2 group Canal transportation = (M1- M2) – (D1- D2)

Canal-centering ratio = (M1-M2)/(D1-D2) or (D1-D2)/
In each of the 25 canals a pre-curved stainless-steel size (M1- M 2).
0.10 KF was negotiated to working length with increasing
amplitudes of 1–3 mm to ensure an initial manually Where:
reproducible glide path. M1: Shortest distance from the mesial margin of tooth
measured to the mesial margin of uninstrumented canal.
Each canal in this group was enlarged using PG, followed M2: Shortest distance from mesial margin of tooth
by shaping with the X2 PTN – both in a forward RM, not measured to the mesial margin of the instrumented canal.
according to the manufacturer’s instructions. Forward RM D1: Shortest distance from the distal margin of tooth
was characterized by a CW movement of 150° and a CCW measured to the distal margin of the uninstrumented canal.
movement of 30°. D2: Shortest distance from the distal margin of tooth
measured to the distal margin of the instrumented canal.
A post-instrumentation scan was taken of each sample
after final shaping. The VGStudioMax software (Volume A value/ratio closest to 1 indicated perfect centering abi-
Graphics GmbH) was used to superimpose images from lity, whereas transportation was measured in millimetres.
the final shaping scan over the images from the pre- A transportation value closest to 0 indicated no trans-
instrumentation scan. This allowed for assessment of portation. The higher the value the greater the transpor-
the canal transportation and centering ability of the tation.17
two groups. The method used by Elnaghy and Elsaka16
was used to measure canal transportation and centering
Statistical analysis
ability (Fig. 1).
Mean and standard deviations for centering ability, canal
transportation, and canal preparation times were deter-
mined for each group and one-way analysis of variance
(ANOVA) was used to statistically compare groups.
Centering ratio and transportation values showed para-
metric distributions. Statistical procedures were per-
formed on SAS Release 9.3 (SAS Institute Inc., Cary,
NC) running under Microsoft Windows (Microsoft Corp.,
Redmond, WA) and statistical significance was set at
A B p < .05.
Figure 1. Cone-beam computed tomographic images indicating (A) pre -
and (B) post- instrumentation measurements for determining canal trans- RESULTS
portation and centering ratio.
Canal Transportation and Centering Ratio
Centering ratio and canal transportation were measured
at three different lengths from the anatomical apex of Tables 1 and 2 show the mean and standard deviation
the mesiobuccal canals roots. In this study, 3 levels (3, values of the centering ability ratios and canal transpor-
5 and 7 mm) were chosen to evaluate transportation and tation at the three different levels for the different groups,
centering ability. respectively. PG/PTN X2 demonstrated a statistically sig

Table 1. Statistical Analysis of Mean Centering Ratio Values for the Tested Group.
System Apical Midroot Coronal Combined

Mean ± SD Min–Max Mean ± SD Min–Max Mean ± SD Min–Max Mean ± SD Min–Max

Mean SD Mean SD Mean SD Mean SD
WOGG/PWOG 0.36a ± 0.30 0.035 – 1.100 0.45a ± 0.29 0.031 – 0.952 0.35a ± 0.26 0.063 – 0.921 0.40a ± 0.27 0.029 – 1.100
PG/PTN X2 0.62b± 0.33 0.072 – 0.993 0.48a ± 0.22 0.106 – 0.898 0.31a ± 0.21 0.021 – 0.750 0.48a ± 0.28 0.021 – 0.993
P value .0189 .470 .459 .120
Mean values with the same superscript letters were not statistically different at p < .05 using the ANOVA test.

Table 2. Statistical Analysis of Mean Transportation (mm) for the Tested Groups.
System Apical Midroot Coronal Combined

Mean ± SD Min–Max Mean ± SD Min–Max Mean ± SD Min–Max Mean ± SD Min–Max

Mean SD Mean SD Mean SD Mean SD
WOGG/PWOG 0.132a ± 0.061 0.032 – 0.211 0.098a ± 0.056 0.015 – 0.287 0.201a ± 0.168 0.006 – 0.956 0.14a ± 0.13 0.006 – 0.956
PG/PTN X2 0.067b ± 0.068 0.001 – 0.229 0.225a ± 0.364 0.0 15 – 1.080 0.264a ± 0.276 0.035 – 1.356 0.19a ± 0.28 0.001 – 1.356
P value .0129 .1176 .3294 .210
Mean values with the same superscript letters were not statistically different at p < .05 using the ANOVA test.
186 >
RESEARCH

nificantly better centering ratio value than WOGG/PWOG DISCUSSION

(p < .05) at the apical level. At the midroot and coronal
levels, there was no statistically significant difference be- The two single-glide path/shaping groups used in this
tween the centering ratio values of the two groups (p>.05). study displayed significant centering and transportation
After shaping, PG/PTN X2 demonstrated a statistically sig- differences only at the apical level. At this level PG/PTN
nificantly lower apical canal transportation value (p<.05). X2 displayed statistically significantly lower mean canal
At the midroot and coronal levels, there was no statisti- transportation and better centering ability values than
cally significant difference between the transportation val- WOGG/PWOG. The endodontic files included in this
ues of the two groups (p > .05). No statistically significant study have different cross-sections, diameters, tapers,
difference was found in the mean combined centering ra- alloy types, and tip designs and were used in either a
tios and transportation values of the two groups (p > .05). reverse or forward reciprocating motion.

The representative sample images (Fig. 2) depict the Several studies have shown that instruments with greater
typical axial canal changes after canal preparation with flexibility produce more centered preparations. 18,19 The
WOGG/PWOG, and PG/PTN X2 in forward reciprocation. flexibility of an endodontic instrument is influenced by
In every representative figure, the black outline represents the composition and thermo-mechanical treatment of
the original canal shape and red indicates the effect of the metallic alloy, the size of the instrument, and its
root canal preparation. No instrument fracture was ob- cross-sectional design.20,21
served in any of the test group.
Instruments like WOGG/PWOG, which are manufactured
WOGG/PWOG
in reverse reciprocation
PG/PTN X2
in forward reciprocation
from Gold-Wire super-metal, are said to possess im-
proved metallurgic properties and therefore increased
flexibility when compared to instruments made from con-
ventional NiTi and M-Wire, like PG and PTN.22 The study
3mm
by Uygun et al.22 found that ProTaper Gold files (Dentsply
Sirona) had higher cyclic fatigue resistance owing to
their flexibility compared to the NiTi ProTaper Universal
(PTU)(Dentsply Sirona) and M-Wire PTN files at all levels
examined.

In the present study however, significantly more favour-

able transportation and centering values were observed
5mm in the apical region following use of the M-Wire glide
path/shaping group. Other design features like the final
shaping size might also explain these results. Tip sizes
of the shaping files used in this study were 25/07 for
PWOG and 25/06 for PTN X2.22

The cross-sectional design of WaveOne Gold, modified

from the design of its predecessor, WaveOne (Dentsply
7mm Sirona), is also said to increase its flexibility.23 Results
obtained here might be due to the file design of PG
and PTN X2, which manufacturers claim reduces con-
tact between these files and the dentine walls. The
parallelogram-shaped cross-sectional design of PWOG
Figure 2. Pre-instrumentation and post-root canal preparation Micro-CT is said to limit engagement of the file and dentine to
images with red markings showing the effect of root canal preparation only one or two points of contact at any given stage
and points of measurement used to determine canal transportation and
of canal preparation, which improves the safety of the
centering ratio.
file with less taper-lock and screw-in effect.
Canal preparation times
The design features and the swaggering movement of
Table 3 depicts the mean and standard deviation values of PTN used in CR reportedly present the following advan-
the mean canal preparation times for the different groups. tages: reduction in taper-lock, screw-in effect and stress
There was no statistically significant difference between on the file, and minimal risk of instrument fracture be-
the canal preparation times for the two groups (p < .06). cause of the reduced amount of contact between the
instrument blades and the dentine walls; increased cut-
Table 3. Statistical Analysis of Mean Canal Preparation Times ting efficiency and range; and activation of the irrigation
for the Tested Groups
solution in the canal, moving the solution into canal irre-
System Mean ± SD Min–Max gularities thereby cleaning areas that are not touched
Mean SD by the instrument.24,25
WOGG/PWOG 48.69a ± 7.97 36.65 – 61.65
PG/PTN X2 42.98a ± 10.15 27.21 – 64.66 The motion in which the PG and PTN X2 files were used
P value .06 in this study might also have contributed to the results
Mean values with the same superscript letters were not statistically different at displayed in the apical region. The file taper, design,
p < .05 using the ANOVA test.
cross-section, and/or metallurgy of these two files might
www.sada.co.za / SADJ Vol. 75 No. 4
RESEARCH < 187

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two groups, but the combination of PG and PTN X2 in 1997; 23: 503-7.
forward RM yielded significantly better results for both 20. Tripi TR, Bonaccorso A, Condorelli GG. Cyclic fatigue of
transportation and centering ability at the apical level. different nickel-titanium endodontic rotary instruments. Oral
Surg, Oral Med, Oral Pathol, Oral Radiol Endod 2006; 102:
The results of this study suggest that PG/PTN X2 may 106-14.
be used in a forward reciprocating motion. However,
further research and clinical studies will be necessary to
validate this concept.
188 >
RESEARCH

21. Turpin YL, Chagneau F, Vulcain JM. Impact of two theore-

tical cross-sections on torsional and bending stresses of
nickel-titanium root canal instrument models. J Endod.
2000; 26: 414-7.
22. Uygun AD, Kol E, Topcu MKC, et al. Variations in cyclic fa-
tigue resistance among ProTaper Gold, ProTaper Next and
ProTaper Universal instruments at different levels. Int Endod J.
2016; 49: 494-9.
23. Özyürek T, Yilmaz K, Uslu G. Shaping ability of Reciproc,
WaveOne GOLD , and HyFlex EDM single-file systems in
simulated S-shaped canals. J Endod. 2017; 43: 805-9.
24. Ruddle CJ, Machtou P, West JD. The shaping movement: Fifth
generation technology. Dent Today. 2013; 32: 94, 96-9.
25. Van der Vyver PJ. Management of an upper first molar with
three mesiobuccal root canals. Endod Pract. 2013; 8: 21-5.
26. Espir CG, Nascimento-Mendes CA, Guerreiro-Tanomaru JM,
et al. Counterclockwise or clockwise reciprocating motion
for oval root canal preparation: a Micro-CT analysis. Int
Endod J. 2018; 51: 541-8.
27. Fidler Aleš. Kinematics of 2 reciprocating endodontic motors:
The difference between actual and set values. J Endod 2014;
40(7): 990-4.
28. Plotino G, Grande NM, Testarelli L, et al. Cyclic fatigue
of Reciproc and Wave-One reciprocating instruments. Int
Endod J. 2012; 45: 614-8.
29. Paque F, Zehnder M, De-Deus G. Microtomography-based
comparison of reciprocating single-file F2 ProTaper technique
versus rotary full sequence. J Endod. 2011; 37: 1394-7.
30. Franco V, Fabiani C, Taschieri S, et al. Investigation on the
shaping ability of nickel–titanium files when used with a recipro-
cating motion. J Endod. 2011; 37: 1398-401.

Do the CPD questionnaire on page 223

The Continuous Professional Development (CPD) section provides for twenty general questions and five
ethics questions. The section provides members with a valuable source of CPD points whilst also achieving
the objective of CPD, to assure continuing education. The importance of continuing professional development
should not be underestimated, it is a career-long obligation for practicing professionals.

Online CPD in 6 Easy Steps

1 Go to the SADA website www.sada.co.za.
2 Log into the ‘member only’ section with your unique SADA username and password.
3 Select the CPD navigation tab.
4 Select the questionnaire that you wish to complete.
5 Enter your multiple choice answers. Please note that you have two attempts to obtain at least 70%.
6 View and print your CPD certificate.
http://dx.doi.org/10.17159/2519-0105/2020/v75no4a3
The SADJ is licensed under Creative Commons Licence CC-BY-NC-4.0. RESEARCH < 189

Sterilisation and single-use of

endodontic files - a short report
SADJ May 2020, Vol. 75 No. 4 p189 - p191

GD Buchanan1, MY Gamieldien2, S Tredoux3, N Warren4

ABSTRACT instruments are not necessarily being adhered to. The

adoption of single-use protocols of endodontic files in
Introduction a South African dental setting is higher than previously
In many countries, endodontic files continue to be steril- reported.
ised and reused in multiple clinical cases as the alter-
native of single-use of these instruments is avoided due Keywords
to financial reasons. Endodontic files, single-use, sterilisation, survey.

Methods
INTRODUCTION
A survey was performed including South African general
dental practitioners and specialist prosthodontists to de- In modern dental practice, both hand and engine-driv-
termine the current endodontic file sterilisation methods en endodontic files are used for cleaning and shaping
in place and the adoption rate of single-use protocols procedures of root canal treatment. During this process,
of both hand and engine-driven instruments. these instruments become contaminated with micro-
organisms and appropriate cross-contamination and ste-
Results rilisation procedures are necessary if endodontic files are
The majority of respondents (76.6%, n=141/184) indica- to be reused on multiple cases.1
ted autoclaving endodontic files prior to reuse. Almost a
quarter of the respondents (23.4%, (n=43/184) used only Whilst it is common practice to reprocess many dental
cold sterilisation. instruments, the intricate designs of some make effec-
tive cleaning and sterilising a challenge. For this reason
Some respondents (2,8%, n=5/181) indicated not steri- several instruments are considered disposable or single-
lising their files at all. A low number of respondents had use items.2
adopted the single-use of endodontic hand files (10.9%,
n=20/184). Engine-driven files were used only once and Previous authors have supported the recommendation
discarded by 18.5% (n=34/184) of respondents. for the single-use of both hand and rotary endodontic
files due to the inability to adequately reprocess these
Conclusion instruments,2-4 however this view has been debated.5
It appears that, at times, acceptable infection preven- Despite these findings, dentists in many countries con-
tion and control practices regarding the sterilisation these tinue to reprocess and reuse rotary and hand files in
multiple cases following sterilisation procedures.

Author affiliations: It has been previously reported that infection prevention

1. Glynn D Buchanan: BChD, PDD (Endo), MSc (Dent), Department
of Odontology, School of Dentistry, University of Pretoria, Pretoria,
and control practices in a South African dental setting
South Africa. may at times be inadequate.6,7 The sterilisation methods
ORCID Number: 0000-0003-2957-166X used by South African dental practitioners specifically for
2. Mohamed Y Gamieldien: BChD, PGDipDent (Oral Surg), MSc the reprocessing of endodontic files is currently unclear.
(Anat), Department of Maxillofacial and Oral Surgery, School of
Dentistry, University of Pretoria, Pretoria, South Africa.
3. Sheree Tredoux: BChD, PDD (Endo), Department of Odontology, Furthermore, the proportion of South African practitio-
School of Dentistry, University of Pretoria, Pretoria, South Africa. ners who have adopted single-use protocols, pertaining
4. Nichola Warren: BChD, PGDipDent (Endo), MSc (Odont), De-
partment of Odontology, School of Dentistry, University of only to endodontic hand files, has only been previously
Pretoria, Pretoria, South Africa. reported on in one major city. 8
Corresponding author: Glynn D Buchanan
Oral and Dental Hospital, 31 Bophelo Road, Prinshof Campus, Riviera,
Pretoria, 0002, South Africa.
This study aimed to determine the sterilisation methods
Email: [email protected] used by South African dental practitioners in the repro-
Author contributions: cessing of both engine-driven as well as endodontic hand
All authors have contributed significantly and are in agreement with the
manuscript.
files, and to quantify the proportion of practitioners who
1. Glynn D Buchanan: Conceived the study, wrote, reviewed and practice single-use of these instruments.
edited the manuscript - 40%
2. Mohamed Y Gamieldien: Conceived the study and wrote, re-
viewed and edited the manuscript - 30% MATERIALS AND METHODS
3. Sheree Tredoux: Conceived the study and wrote, reviewed and
edited the manuscript - 20% A cross-sectional, observational study was conducted.
4. Nichola Warren: Conceived the study and wrote, reviewed and A multiple-choice survey was designed using an online
edited the manuscript - 10%
program (Qualtrics, Provo, Utah) and electronically mailed
190 >
RESEARCH

to 61 members of the Academy of Prosthodontics, Sterilisation methods used for endodontic files
South Africa (APSA) and 3191 South African General
Dental Practitioners (GDPs) registered in the South Only two sterilisation methods were reportedly used for
African Dental Association (SADA) database. the reprocessing of endodontic files. More than three-
quarters of the respondents (76.6%, n=141/184) indica-
The survey was circulated on social media platforms ted sterilising files using a steam autoclave.
to increase visibility to the target groups. A quantitative
design consisting of questions with multiple-choice an- Cold sterilant solutions were used by almost one-quarter
swers was completed by participants. The questions of the respondents (23.4%, n=43/184). Nine respon-
included: dents practiced single-use of endodontic files and were
excluded from analysis as they did not sterilise and
•• Demographic information. reprocess files.

•• Sterilisation methods used for endodontic instruments.

Sterilisation before first use
•• Sterilisation conducted prior to first use of new files. With regards to initial sterilisation procedures (i.e. when
removing endodontic files from the manufacturer’s pack-
•• Sterilisation conducted prior to re-use. aging), the majority of respondents (71.5%, n=139/193)
indicated that they did not sterilise endodontic files prior
•• Single-use of endodontic hand files. to first patient use. The remaining 28.5% (n=55/193) in-
dicated completing a pre-use sterilisation cycle.
•• Single-use of engine-driven files.
Sterilisation before re-use
Data was collected and exported as comma-separated
values (CSV file format) for evaluation in Microsoft Excel Almost all the respondents who reused their endodontic
2016, analysed and expressed as simple percentages files (97,2%, n=176/181) indicated routinely sterilising
of the total number of respondents. the files prior to re-use on subsequent cases. A small
number (2,8%, n=5/181) indicated the opposite.
Only private practice GDPs and SPs routinely performing
endodontic treatment were included in this investigation. Twelve respondents (n=12/193) did not answer this
GDPs and SPs not engaged in the clinical practice of question as they practiced either single-use of their files
endodontics and those employed outside of a private or did not sterilise endodontic files (or a combination of
practice setting, such as community-service (a compul- these reasons).
sory internship year in South Africa), public-sector den-
tists and full-time academics were excluded.
Single-use of endodontic hand files
The research proposal for this study was approved by Only 10.9% (n=20/184) of respondents reported practis-
the Faculty of Health Sciences Research Ethics Com- ing single-use of endodontic hand files. The remaining
mittee, University of Pretoria (Protocol number 331/2018). 89.1% (n=164/184) reused hand files on multiple cases
following reprocessing procedures. Nine respondents did
not answer this question as they indicated not using
RESULTS
hand files routinely.
An electronic mail containing a link to the survey was
sent to both APSA members (n=61) and SADA members
Single-use of engine-driven files
(n=3191). In total, 215 responses were returned by the
cut-off date. The overall response rate was 6.6% of the Rotary and reciprocating files were reprocessed and re-
total number surveyed (n = 215 / 3252). used on multiple cases by the majority of respondents
(81.5%, n=150/184).
Almost ten percent of the total respondents (9.7%,
n=21/215) indicated not performing private practice The remaining respondents (18.5%, n=34/184) indicated
endodontic treatment and were excluded. Another res- practicing single-use of these instruments. Nine respon-
pondent provided irrational answers to several questions dents did not answer this question as they did not use
and was therefore ruled out for inclusion. Analysis was engine-driven files routinely.
subsequently performed on the valid responses provi-
ded by the remaining 193 participants (89.8% of total
DISCUSSION
respondents).
Although the overall response rate of this survey was
low, the response rate was in line with previous South
Demographics
African survey findings conducted on similar cohorts.9
Of the 193 participants, 46.1% (n =89) were male and Furthermore, the survey was completed by respondents
53.9% ( n =104) were female. Eleven participants (5.7%, from all nine South African provinces and valuable in-
n=11/193) were SPs and the remainder were GDPs formation was therefore collected from a wide geogra-
(94.3%, n=182). A wide distribution was found in relation phical distribution. The responses of prosthodontists were
to age and number of years of experience. All South included in the present study as South Africa does not
African provinces were represented. train specialist endodontists.10
www.sada.co.za / SADJ Vol. 75 No. 4
RESEARCH < 191

A previous study reported that the single-use of endo- CONCLUSION

dontic files had not been adopted by any general dental
practitioners surveyed in one major South African city.8 Within the limitations of this study, the majority of South
The results of the present study, which included both African GDPs and SPs were demonstrated to reuse
a greater number and wider distribution of South African endodontic files on multiple clinical cases following re-
dentists, are in disagreement with the previous findings. processing procedures. A large number of respondents
This finding highlights the importance of obtaining repre- used acceptable methods of sterilisation for reprocess-
sentative sample sizes, and cautions against the extra- ing endodontic files. A significant proportion however
polation of the results of smaller scientific investigations continue to use unacceptable methods such as cold
to a broader population. sterilisation with glutaraldehyde solution.

The philosophy regarding single-use of endodontic in- Whilst only a limited number of South African dental
struments originated in the United Kingdom in response practitioners have adopted the routine practice of single-
to concerns surrounding the potential spread of prion use of both engine-driven and hand endodontic files,
disease11 as a result of the inability to adequately clean this number is higher than previously reported.
and sterilise endodontic files and reamers.2 This view was
however not universally shared.5 Whilst several benefits Declaration
of a single-use approach exist, such as a reduced risk The Author(s) declare that there is no conflict of interest.
of file separation12 and no risk of cross contamination 2,
the reprocessing and reuse of endodontic files will likely Funding
continue in many countries due to the increased cost This research did not receive any specific grant from
associated with single-use protocols of endodontic funding agencies in the public, commercial, or not-for-
instruments.8 profit sectors.

When any dental instruments are to be reused, they must References

be both thoroughly cleaned of bioburden and sterilised to 1. Carrotte P. Endodontics: Part 5. Basic instruments and
materials for root canal treatment. Br Dent J. 2004; 197(8):
prevent cross-contamination between patients. Although
45 - 64.
sterilisation may be achieved by several different meth- 2. Walker JT, Dickinson J, Sutton JM, Raven NDH, Marsh PD.
ods, semi-critical and critical instruments - such as en- Cleanability of dental instruments - implications of residual
dodontic files - should be sterilised by autoclave.13 When protein and risks from Creutzfeldt-Jakob disease. Br Dent J.
considering multiple or single-use of any dental instru- 2007; 203(7): 395 - 401.
ment, manufacturer recommendations in conjunction with 3. Letters S, Smith A, McHugh S, Bagg J. A study of visual and
ISO 17664 : 2017 and local regulatory guidelines should blood contamination on reprocessed endodontic files from
be followed at all times.2 general dental practice. Br Dent J. 2005; 199(8): 522 - 25.
4. Morrison A, Conrod S. Dental burs and endodontic files: are
routine sterilization procedures effective? J Can Dent Assoc.
Previous investigations have demonstrated that endodon- 2009; 75(1): 39.
tic files and burs are not sterile at the time of purchase and 5. Messer H, Parashos P, Moule A. Should Endodontic Files
that sterilisation should be performed prior to first use.4 Be Single-Use Only? A Position Paper From The Australian
Less than one-third of the respondents to the present And New Zealand Academy of Endodontists. Aust Endod J.
survey complied with this recommendation. 2003; 29(3): 143–5.
6. Mehtar S, Shisana O, Mosala T, Dunbar R. Infection control
In recent times, however, manufacturers have created practices in public dental care services: findings from one
South African Province. J Hosp Infect. 2007; 66(1): 65-70.
pre-sterilised, single-use endodontic instruments which
7. Buchanan GD, Warren N, Gamieldien MY. Debris contami-
do not need to be sterilised prior to initial use.14 It is nation of endodontic hand files in dental practice. S Afr
unknown how widespread the use of such pre-steril- Dent J. 2018; 73(6): 440- 4.
ised endodontic files are, but this possibility may have 8. Buchanan GD, Warren N. Single-use of endodontic hand files:
contributed to the high number of respondents who in- perceptions and practise. J Infect Prev. 2019; 20(1): 32- 6.
dicated not sterilising their files prior to initial use. Future 9. Snyman L, van der Berg-Cloete S, White J. The perceptions
studies may investigate to provide clarity on this issue. of South African dentists on strategic management to ensure
a viable dental practice. S Afr Dent J. 2016; 71(1): 12- 8.
10. Fernandes NA, Herbst D, Postma TC, Bunn BK. The pre-
The finding that nearly one quarter of respondents con-
valence of second canals in the mesiobuccal root of maxil-
tinue to use cold sterilisation as the sole means of re- lary molars: A cone beam computed tomography study.
processing endodontic files was disappointing. Placement Aust Endod J. 2018; 1 - 5.
of endodontic files in cold sterilant solutions, such as 11. Head MW, Ritchie D, McLoughlin V, Ironside JW. Investiga-
glutaraldehyde, has been demonstrated to be inferior tion of PrPres in dental tissues in variant CJD. Br Dent J.
to steam methods and is no longer recommended as a 2003; 195(6): 339 - 43.
primary means for the sterilisation of endodontic files.13 12. Yared G. In vitro study of the torsional properties of new
and used profile nickel titanium rotary files. J Endod 2004;
30(6): 410-2.
Additionally, it has been demonstrated that cold sterilis-
13. Hurtt CA, Rossman LE. The sterilization of endodontic hand
ing solutions, such as glutaraldehyde, may take up to
files. J Endod. 1996; 22(6): 321- 2.
ten hours to sterilise an instrument.15 The finding that 14. Webber J. Shaping canals with confidence: WaveOne Gold
some respondents of the present study did not sterilise single-file recipocating system. Roots. 2015; 1(3): 34 - 40.
endodontic files at all before reuse was alarming. It is 15. Özalp N, Ökte Z, Özcelik B. The Rapid Sterilization of Gutta-
however possible that these respondents misunderstood Percha Cones with Sodium Hypochlorite and Glutaraldehyde.
the question. J Endod. 2006; 32(12): 1202-4.
192 > http://dx.doi.org/10.17159/2519-0105/2020/v75no4a4
The SADJ is licensed under Creative Commons Licence CC-BY-NC-4.0.

The microbiology of head and neck space

infections at the Maxillofacial Clinic at
Livingstone Hospital
SADJ May 2020, Vol. 75 No. 4 p192 - p197

N Singh1, S Ngwenya2, J Molepo3

ABSTRACT
Introduction
Head and neck space infections remain one of the most Bacteroides species and Staphylococcus aureus display-
commonly encountered conditions at Maxillofacial clinics ed sensitivity to clindamycin and amoxicillin with clavu-
countrywide. Patients admitted with these infections tend lanic acid. Viridans streptococci were sensitive to both
to have prolonged hospital stays and often require inten- penicillin and clindamycin.
sive care support. This places financial and logistic con-
straints on our health care system. There are also growing Conclusion
concerns, worldwide, regarding antibiotic resistance. Bacteroides species were the most commonly isolated
bacteria, followed by Viridans streptococci and Staphy-
Aims and objectives lococcus aureus.
To determine the microbial spectrum of head and neck
space infections in patients admitted to the Maxillo-Facial
INTRODUCTION
clinic at Livingstone Hospital in the Eastern Cape over a
period of 5 years. Patients admitted with deep space head and neck
infections tend to have prolonged hospital stays and
Methods often require intensive care support, which places finan-
Demographic, clinical and laboratory data was retrieved cial and logistic constraints on our health care system.
from the medical records of 140 patients presenting with There are also growing concerns, worldwide, regarding
head and neck space infections. antibiotic resistance.

Results Several studies reported that odontogenic infections

Most patients were males aged 21- 40 years. The most were identified as the most common source of head
common cause of head and neck infections was non- and neck infections.1-3 Infiltration through fascial spaces
odontogenic. The submandibular space was the most is an important factor to consider in the evaluation of
commonly implicated. Gram positive facultative anaerobes head and neck space infections. The submandibular
were most commonly identified. space was the most frequently involved fascial space in
both single4-8 and multiple space infections.2,3
Author affiliations:
1. Nerisha Singh: BChD, PDD (Implantology), MSc (Dentistry), MSc Head and neck space infections are caused by both
Dent Student, Department of Oral Pathology, School of Oral aerobic and anaerobic microorganisms. The most fre-
Health Sciences, Faculty of Health Sciences, University of the
Witwatersrand, Johannesburg, South Africa.
quently isolated aerobic bacterium was Streptococcus
ORCID Number: 0000-0002-2704-7031 viridans 6 while Bacteroides was the most common
2. Sizakele Ngwenya: BSc, BDS, MDent (Oral Pathology), Head, anaerobic bacterium.3,8 Molomo et al.5 and Cabral et al.9
Department of Oral Pathology, School of Oral Health Sciences,
reported Staphylococcus aureus to be the most com-
Faculty of Health Sciences, University of the Witwatersrand,
Johannesburg, South Africa. monly isolated organism.
ORCID Number: 0000-0002-9397-5178
3. Julitha Molepo: ND, BSc, BSc (Hons), MS, PhD, Head, Department Effective management consists of surgical drainage
of Oral Biological Sciences, School of Oral Health Sciences,
Faculty of Health Sciences, University of the Witwatersrand, and the administration of the appropriate antibiotic.
Johannesburg, South Africa. Staphylococcus aureus, Streptococcus mitis/oralis and
ORCID Number: 0000-0002-5547-097X Morganella morganii displayed high resistance levels
Corresponding author: Julitha Molepo
Head: Department of Oral Biological Sciences, against amoxicillin.7,10
University of the Witwatersrand, Johannesburg,
Faculty of Health Sciences, School of Oral Health Sciences, Amoxicillin with clavulanic acid was reported as the
7 York Road, Parktown, South Africa.
Email: [email protected]
most effective antibiotic for the most commonly iso-
Author contributions: lated organisms, 7 therefore it was recommended as
1. Nerisha Singh: Conceptualisation, data collection, analysis and the empirical drug of choice in head and neck space
interpretation; first draft, revision, final write-up - 30%
infections.7,8
2. Sizakele Ngwenya: Conceptualisation and design, data analysis
and interpretation, first draft, revision, final write-up and approval
- 35% This study focussed on the microbial spectrum and
3. Julitha Molepo: Conceptualisation and design, data analysis and antibiotic sensitivity patterns in patients with head and
interpretation, first draft, revision, final write-up and approval - 35%
neck space infections over a 5 year period, in order to
www.sada.co.za / SADJ Vol. 75 No. 4 <
193

improve guidelines for appropriate antibiotic prescrip- Head and neck infections appeared to be least com-
tion, thus decreasing the length of hospital stays and mon in patients older than 60 years, with only 3
contributing to the fight against antimicrobial resistance. patients (2%) falling into this category.

Sixty four patients presented with an odontogenic

MATERIALS AND METHODS cause of infection, while 81 presented with a non-
odontogenic cause. Periapical lesions presented in
Study design
the majority of patients with an odontogenic cause
This was a retrospective study which comprised the of infection (n=32; 50%), followed by alveolar osteitis
analysis of patient variables (age, gender and source of (n=22; 34%), pericoronitis (n=4; 10%) and periodon-
infection), microbial spectrum and antibiotic sensitivity titis (n=4; 6%). Where the aetiology was non-odonto-
patterns in patients presenting with head and neck genic, 60 patients (74%) presented with infection of an
space infections at the Maxillo-Facial Clinic, Livingstone unknown aetiology, followed by trauma (n=18; 22%).
Hospital, Eastern Cape, South Africa.
Distribution of fascial space involvement
Sampling method
The majority (n=81) of patients had only a single space
Cases were selected using the convenience sampling involved, while 54 had multiple fascial space involve-
method. The admissions book at the Maxillofacial cli- ment. In 10 cases the fascial space remained unidenti-
nic was analysed to identify all patients with head fied. The submandibular space was the most commonly
and neck space infections admitted to the clinic at involved with a total of 50 (62%) patients presenting with
Livingstone Hospital from the 1 st of January 2012 to infection in this space.
the 31st of December 2016.
Ten cases involved the buccal space (1%), eight, the
The medical records of all identified patients were re- submental (10%), six, the peri-orbital (8%) and three,
viewed. All patients who had microbial culture and the zygomatic space (4%). The submasseteric, para-
sensitivity tests performed were included in the study. pharyngeal, superior labial and temporal spaces were
This study was approved by the Wits Human Research less commonly affected and presented with one case
Ethics Committee (Ethical Clearance number: M170719), each. These results are presented in Figure 1.
the Eastern Cape Department of Health and the Natio-
nal Health Laboratory Services. Of the 54 patients that presented with multiple space
involvement, 31 (57%) had two spaces affected, 22
(41%) had three spaces affected and only one (2%) had
Data collection
4 fascial spaces being affected.
Demographic, clinical and laboratory data was retrieved
from the medical records of 140 patients presenting The most commonly implicated spaces in cases with
with head and neck space infection. The variables ana- multiple space involvement was the submandibular (35
lysed included age, gender, source of infection, fascial cases, 64.9%), followed by the sublingual (15 cases,
spaces involved, microorganisms identified and antibiotic 27.7%) and submental (14 cases, 26%) spaces (Figure 2).
sensitivity.
The spectrum of microorganisms isolated
Microorganisms are considered to be sensitive when
they cannot grow in the presence of a drug, resistant Thirty eight different types of microorganisms were isola-
when they can grow and intermediate when a higher ted (Table 1). The most commonly isolated bacteria were
dose of the antibiotic is required to prevent growth. Bacteroides species (16.7%) followed by Viridans strepto-
cocci (11%) and Staphylococcus aureus (8.6%).
Data analysis
Less commonly isolated were coagulase negative
Descriptive and inferential statistics were computed for Streptococcus (3.8%), Streptococcus constellatus (4.8%);
all variables. Bivariate analysis was used for identifying alpha, beta and non-haemolytic Streptococcus (3.3%);
associations. P-value based on the Chi-square test was Morganella morganii species (3.8%); Streptococcus an-
utilised. A p-value of <0.05 was considered to be sta- ginosus (3.8%) and Streptococcus mitis/oralis (3.8%).
tistically significant.
Antibiotic sensitivities
RESULTS Bacteroides species, found in 35 specimens, was 100%
Patient demographic and clinical data sensitive to metronidazole, carbapenems, piperacillin, clin-
damycin, cefoxitin, chloramphenicol and amoxicillin with
The majority of patients presenting with head and clavulanic acid.
neck space infections were male (n=97; 67%), while
only 48 (33%) were female. Eighty five patients (59%) Six of the 25 isolates of Viridans streptococci showed
were 21 to 40 years of age. The youngest patient was resistance to erythromycin/azithromycin (24%), while 15
13 months and the oldest, 92 years old. Thirty six displayed sensitivity (60%). Four (16%) of the isolates
patients (25%) fell into the 41-60 year age category, displayed resistance to clindamycin while 16 (64%)
while 21 patients (14%) were between 0-20 years old. showed sensitivity.
194 >

Seven isolates showed sensitivity to penicillin and am-

picillin (28%) while only one showed resistance (4%). Number of cases presenting with single
fascial space involvement
Four isolates were sensitive to cefotaxime and ceftri-
axone (16%) while one (4%) was resistant. Four isolates 1% 1%
were sensitive to vancomycin (16%) and one to linezolid 4%
1% 1%
(4%).

Staphylococcus aureus was isolated in 18 specimens,

8%
and showed 100% resistance to penicillin and 44.4%
(eight isolates) resistance to trimethoprim-sulphameth-
axazole. Seven isolates (38.9%), however, showed sen- 10%
sitivity to trimethoprim-sulphamethaxazole. There was
83.3% (15 isolates) with sensitivity to cloxacillin, while
11.1% (two isolates) showed resistance.
12%

Clindamycin was effective in 77.8% (14 isolates) but re- 62%

sistance was noted in 16.7% (3 isolates). Erythromycin/

azithromycin was also effective against staphylococci,
showing sensitivity rates of 72.2% (13 isolates) and a
Submandibular Submasseteric
Table 1. List of isolated micro-organisms. Buccal Parapharyngeal
Submental Superior labial
Micro-organism No of isolates Percentages Peri-orbital Temporal
Zygomatic
Acinetobacter baumannii complex 2 1
Burkholderia cepacia 3 1.4
Figure 1. Number of cases presenting with single fascial space involvement.
Escherichia coli 1 0.5
40
Klebsiella oxytoca 1 0.5
35
Klebsiella pneumoniae 3 1.4
30
Proteus species 1 0.5
25
Pseudomonas aeruginosa 3 1.4 20
Pseudomonas putida 1 0.5 64.9%
15
Coagulase negative staphylococcus 9 4.3 10
27.7% 26%
Bacteriodes 35 16.7 5
Enterobacter cloacae complex 4 1.9 0
Submandibular Sublingual Submental
Gram negative bacillus 6 2.9
Submandibular Sublingual Submental
Haemophilus parainfluenzae 1 0.5
Figure 2. The most common fascial spaces implicated in multiple space
Morganella morganii 8 3.8 involvement.
Cornybacterium species 4 1.9
Table 2. Antimicrobial sensitivity of Bacteroides species.
Gemella morbillorum 1 0.5
Micrococcus species 1 0.5 Antimicrobial Tested Sensitive Resistant

Staphylococcus species 4 1.9 Amoxicillin-clavulanic acid 35 35 0

Staphylococcus aureus 18 8.6 Clindamycin 35 35 0
Candida albicans 3 1.4 Metronidazole 35 35 0
Yeast - not Candida albicans 3 1.4 Cefoxitin 35 35 0
Normal oral flora 1 0.5 Chloramphenicol 35 35 0
Staphylococcus epidermidis 7 3.3
Table 3. Antimicrobial sensitivity of Staphylococcus aureus.
Staphylococcus haemolyticus 3 1.4
Intermediate
Streptococcus anginosus 8 3.8 Antimicrobial Tested Sensitive Resistant
sensititve
Streptococcus alpha haemolytic 7 3.3 Penicillin 18 0 18 0
Streptococcus beta haemolytic 6 2.9 Erythromycin 18 13 3 2
Streptococcus bovis 4 1.9 Clindamycin 18 14 3 1
Streptococcus constellatus 10 4.8 Cloxacillin 18 15 2 1
Streptococcus cristatus 1 0.5 Vancomycin 18 1 0 17
Streptococcus group A 3 1.4
Table 4. Antimicrobial sensitivity of Viridans streptococci.
Streptococcus group C 1 0.5
Intermediate
Streptococcus group F 4 1.9 Antimicrobial Tested Sensitive Resistant
sensititve
Streptococcus mitis/oralis 8 3.8 1st Line Penicillin 21 7 1 13
Streptococcus non-haemolytic 6 2.9 Erythromycin 21 15 6 0
Streptococcus pyogenes 1 0.5 Clindamycin 21 16 4 1
Streptococcus sanguinis 1 0.5 2nd Line Cefotaxime 21 4 1 16
Streptococcus warneri 1 0.5 Vancomycin 21 4 0 17
Viridans streptococcus 25 11.9 Linezolid 21 1 0 20
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195

low resistance of 5.5% (two isolates). With regard to flora and antibiotic sensitivity patterns in patients with
tetracycline, 3 isolates (16.7%) were resistant and 38.9% head and neck space infections and in so doing, pro-
(seven isolates) were found to be sensitive Only one vide a better understanding on the management of
case (5.5%) was sensitive to vancomycin. these infections.

Other commonly isolated microbes and their sensitivities In the current study, 145 patients who had pus aspirates
patterns are displayed in Tables 2, 3 and 4 respectively. and swabs taken were selected as the sample population.
The age of the patients that commonly presented with
Sensitivity of isolates to commonly prescribed head and neck space infections ranged from 21 to 40
antibiotics years. This outcome is similar to the age distribution
described in other published works.3,4,5 Similar to the
Twenty two of the isolates were sensitive to amoxi- findings of previous studies,2,5,7,8 head and neck space
cillin with clavulanic acid (15.2%), 28 were sensitive to infections were more common in males than females in
penicillin (19.3%) and 61 to erythromycin/azithromycin our study.
(42.1%). The majority of the isolates (95) were sensitive
to clindamycin (65.5%). Results are shown in Figure 3. Our study showed single fascial spaces to be more
commonly involved in the head and neck space infec-
tions than multiple spaces. This result corroborates the
findings of Ye et al.11 Conversely, Ibeyemi et al.12 repor-
Commonly prescribed antibiotics

ted multiple space involvement as being more common.

In the current study, the most common single space
involved was the submandibular space, followed by the
buccal and submental space, a finding that is in agree-
ment with that of Singh et al.8

A South African study by Molomo et al.5 showed the

submandibular space to be the most commonly involved
followed by the submental space. While Molomo et al.5
did not report on multiple fascial space involvement, our
study showed that the submandibular, sublingual and
0 20 40 60 80 100
Number of isolates
submental spaces were most often implicated in multi-
Erythromycin/azithromycin Amoxicillin with clavulanic acid
ple fascial space involvement. However the submandib-
Clindamycin Penicillin ular space was reported as the most common followed
by the submental and lateral pharyngeal spaces by other
Figure 3. Sensitivity of commonly prescribed antibiotics.
researchers.4,6
Statistical analysis
Most infections in our study were non-odontogenic in
Statistically significant association was observed between origin (56%). This is contrary to the findings by Boscolo-
age and aetiology (p=0.000); age and fascial space (p= Rizzo et al.1 who reported odontogenic infection as the
0.005), gender and presence of microorganism (p=0.007). most common cause. Odontogenic causes of infection
in the current study comprised 50% periapical lesions,
The presence of microorganisms was statistically sig- 34% alveolar osteitis, 10 % pericoronitis and 6% perio-
nificantly associated with antibiotic sensitivity (p= 0.000) dontitis. In contrast, a previous study reported 71%,
and resistance ( p=0.000) profiles. Similarly the gender 17%, 6%, and 1% of odontogenic causes of infection
was significantly associated with the antibiotic sensitivity to be due to pulpitis, periodontitis, alveolar osteitis and
profiles. needle tracts respectively.2

Bacteroides species was the most commonly isolated

DISCUSSION
anaerobic bacterium in this study and was found in
Head and neck infections may result in serious morbi- 15% of cases. Although not the most commonly isolated
dity and mortality. Early recognition of these infections, microorganism in other studies, Bacteroides fragilis and
a thorough understanding of microorganisms involved Bacteroides corrodens did appear in smaller concen-
and their sensitivity patterns are critical in their efficient trations of 5% and 2.5% of cases respectively, in the
management. In addition to surgical incision and drain- study by Walia et al.10 In contrast, the most commonly
age, antibiotic therapy is vital for successful treatment. isolated microorganisms in a study by Molomo et al.5
were aerobic.
In order to administer antibiotics effectively, microbiological
data on the infection is required. However, information In the current study, Viridans streptococci were the se-
on the microbiology and antibiotic susceptibility requires cond most isolated microorganisms, which contradicts
time, and subsequently antibiotics are administered prior other studies where Streptococcus viridans species were
to obtaining the aspirate results.11 the most isolated microorganisms.5-7

Thus, the selection of the appropriate antibiotics is Staphylococcus aureus was the third most isolated
essential for successful treatment of these infections. microorganism in our study in 8.6% cases. This finding
The purpose of this study was to identify the microbial is contrary to previous studies where Staphylococcus
196 >

aureus was found in higher numbers. A study by Molomo Shah et al.7 reported a higher sensitivity rate of 100% to
et al.5 reported 14% cases while Shah et al.7 reported amoxicillin with clavulanic acid and a lower resistance
16%. Staphylococcus aureus observed in our study of 31.3% to amoxicillin.
could have occurred secondary to contamination from
the skin and introduced during treatment. The isolation Clindamycin was found to be highly effective against
of Staphylococcus aureus has clinical significance, as the three most commonly isolated bacteria in the cur-
strains resistant to routinely used antibiotics have been rent study. This efficacy was reiterated in studies by
reported.13 Bahl et al.3, Fating et al.4, Molomo et al.5 and Singh et
al.8 in which aerobic organisms isolated were sensitive
Similarly to Molomo et al.5 the gram negative aerobes to clindamycin. However, severe side effects like pseu-
isolated in our study included Klebsiella, Enterobacter domembranous colitis and the emergence of antibiotic
and Pseudomonas species. The presence of gram neg- resistance, make this antibiotic unsuitable as the first
ative bacilli was also reported by Walia et al.10 In addi- line drug for the treatment of head and neck space
tion, Prevotella was the most commonly isolated gram infections. Clindamycin should therefore be reserved
negative bacillus in a study by Singh et al.8 occurring in for severe penicillin resistant infections to curtail the in-
25.81% of the specimens. creasing resistance.

One unanticipated finding was the identification of Mor- Viridans streptococci and Staphylococcus aureus show-
ganella morganii complex which were isolated in 3% of ed high sensitivity rates to erythromycin/azithromycin in
cases. Although Morganella morganii has a wide dis- agreement with the findings reported by Molomo et al.5
tribution, it is considered an uncommon cause of com- However the opposite result was obtained in the study
munity-acquired infection and it is most often encoun- by Singh et al.8 where all isolates displayed low sensiti-
tered in postoperative and other nosocomial infections vity rates to erythromycin (38.89%).
such as urinary tract infections. This microorganism was
isolated in an aspirate from an HIV positive patient. There was a statistically significant association between
age and aetiology (p = 0.000). Older patients in the
The source of infection was a mandibular reconstruc- 51-60 and greater than 60 years age groups presen-
tion plate that had caused chronic sepsis. A previous ted more commonly with unknown causes of infection.
study by Ho et al.14 also reported a rare case of Ludwig’s The younger patients in the 0-20 and 21-30 years age
angina caused by Morganella Morgani. Enterobacter groups were more commonly affected by odontogenic
cloacae is a member of the normal gut flora in many infections including alveolar osteitis, periodontal and
humans and is not usually a primary pathogen. periapical abscesses.

Some strains have been associated with urinary and This finding could be ascribed to the low socio-eco-
respiratory tract infections in immunocompromised indivi- nomic groups comprising the majority of patients pre-
duals.15 Candida albicans was found in 1.4% of cases senting at public hospitals. These patients are inade-
in our study, which is contrary to 5% and 2.5% occur- quately exposed to oral health education and are at
rence in previous studies.5,10 greater risk for the development of tooth decay and the
associated odontogenic infections. This finding was
In the current study, Bacteroides species was 100% reiterated in the study by Bahl et al.3, who reported the
sensitive to metronidazole, carbapenems, piperacillin, highest incidence of odontogenic infections in patients
clindamycin, cefoxitin, chloramphenicol and amoxicillin in the third decade of life.
with clavulanic acid. The South American study by
Fernandez-Canigia et al.16 showed similar high sensitivity There was likewise a statistically significant association
rates of 100% to metronidazole and tigecycline, 99% to between the age and fascial space ( p = 0.005), with
imipenem and piperacillin-tazobactam, 96% to ampicillin- the majority of patients presenting with single space
sulbactam and 91% to moxifloxacin. However, lower involvement. This correlates with the findings of Walia et
sensitivity rates against cefoxitin (72%) and clindamycin al.10, where single space involvement was significantly
(52%) were also observed. more common. Patients younger than 40 years presen-
ted more commonly with single space involvement,
Viridans streptococci displayed highest sensitivities to while the older patients in the 5th decade of life presen-
erythromycin/azithromycin (60%) and clindamycin (64%). ted more commonly with multiple space involvement.
In contrast, Shah et al.7 reported high sensitivity levels
of 100% to carbenicillin, amikacin and imipenem and The association between gender and the presence of
89.4% to ceftriaxone. Our results also differed from the microorganisms was also statistically significant (p =
findings of Rega et al.6 and Molomo et al.5 where the 0.007). The majority of specimens were acquired from
highest sensitivity rates to penicillin was reported as males. This was consistent with studies by Bahl et al. 3,
87.1% and 97% respectively. Fating et al.4 and Walia et al.10 where the majority of iso-
lates were obtained from male patients. However, more
In the current study, Staphylococcus aureus showed sen- microorganisms were identified in females (45 of 48 pa-
sitivities of 83.3% to cloxacillin, 77.8% to clindamycin tients or 94%) than in males (72 of 97 patients or 74%).
and 72.2% to erythromycin/azithromycin while Molomo
et al.5 reported sensitivities of 70%, 90% and 83% res- Moreover there was statistically significant association
pectively. Although Molomo et al.5 reported 31% resis- between the presence of microorganisms and antibiotic
tance, this microbe showed 100% resistance to penicillin. sensitivity (p = 0.000) and resistance (p = 0.000) profiles.
www.sada.co.za / SADJ Vol. 75 No. 4 <
197

This is understandable, as the microorganisms isolated References

would have displayed either sensitivity or resistance to 1. Boscolo-Rizzo P, Da Mosto MC. Submandibular space in-
a specific antibiotic. fection: a potentially lethal infection. Inter J Infec Dis. 2009;
13: 327- 33.
2. Mathew GC, Ranganathan LK, Ghandi S et al. Odontogenic
It was similarly noted that gender of the patient was maxillofacial space infections at a tertiary care centre in
significantly associated with antibiotic sensitivity profiles. North India: a five year retrospective study. Int J Infec Dis.
Thirty nine of 48 female patients (81.2%) that presented 2012; 16: e296-e302.
with head and neck space infections displayed micro- 3. Bahl R, Sandhu S, Singh K, Sahai N, Gupta M. Odonto-
organisms that were sensitive to particular antibiotics. genic infections: Microbiology and management. Contemp
Clin Dent. 2014; 5: 307-11.
4. Fating NS, Saikrishna D, Vijay Kumar GS, Shetty SK, Rao
CONCLUSION MR. Detection of bacterial flora in orofacial space infections
and their antibiotic sensitivity profile. J Maxillofac Oral Surg.
The predominant microorganisms responsible for head
2014; 13: 525 -32.
and neck infections were gram positive facultative anae- 5. Molomo EM, Motloba DP, Bouckaert MM, Tlholoe MM.
robes. Bacteroides species were the most commonly Bacteriology and management of orofacial infections in a
isolated bacteria, followed by Viridans streptococci and Maxillofacial and Oral Surgery Clinic, South Africa. S Afr
Staphylococcus aureus. Dent J. 2016; 71: 474-7.
6. Rega AJ, Aziz SR, Ziccardi VB. Microbiology and antibiotic
Most infections occurred in the third and fourth decades sensitivities of deep neck space infections. J Oral Maxillofac
of life. Patients older than 50 years presented more Surg. 2004; 62: 25-6.
7. Shah A, Ramola V, Nautiyal V. Aerobic microbiology and
commonly with non-odontogenic causes of infection,
culture sensitivity of head and neck space infection of
while younger patients more frequently presented with odontogenic origin. Nat J Maxillofac Surg. 2016; 7: 56-61.
odontogenic causes of infection. Patients younger than 8. Singh M, Kambalimath DH, Gupta KC. Management of
40 years presented more commonly with single space odontogenic space infection with microbiology study. J
involvement, while the older patients in the 5th decade Maxillofac Oral Surg. 2014; 13: 133-9.
of life presented more commonly with multiple space 9. Cabral M, Gowrishankar S, Amerally P. Investigation of the
involvement. Microorganisms were more frequently iso- microbiology and antibiotic sensitivity of skin and soft tissue
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Surg. 2016; 54: 124-5.
range of 21- 40 years.
10. Walia IS, Borle RM, Mehendiratta D, Yadav AO. Microbio-
logy and antibiotic sensitivity of head and neck space in-
The most commonly isolated microorganisms (Bacte- fections of odontogenic origin. J Maxillofac Oral Surg. 2013;
roides species, Staphylococcus aureus, Viridans strepto- 13: 16-21.
cocci) in the current study were sensitive to clindamycin. 11. Ye L, Liu Y, Geng A-L, Fu H-Y. Microbiological examination
Bacteroides species was found to be 100% sensitive to to investigate the differences in microorganisms and anti
amoxicillin with clavulanic acid. biotic sensitivity of head and neck space infections. Biomed
Res. 2017; 28: 290-4.
12. Ibeyemi ST, Okoje–Adesomoju VN, Dada-Adegbola HO,
Limitations Arotiba JT. Pattern of orofacial bacterial infections in a ter-
tiary hospital in southwest Nigeria. J West Afr Coll Surg.
This was a retrospective study which limited the variables 2014; 4: 112- 41.
that could be studied. The method of collection of the 13. Costa SF, Miceli MH, Anaissie EJ. Mucosa or skin as source
aspirates may have influenced the microbiology results, of coagulase-negative Staphylococcal bacteraemia? Lancet
especially if the anatomical site of collection was not Infec Dis. 2004; 4: 278 - 86.
adequately cleaned with an alcohol swab prior to the 14. Ho MP, Tsai KC, Yen SL, Lu CL, Chen CH. A rare cause of
procedure. Ludwig’s angina by Morganella morganii. J Infec. 2006; 53:
e191-4.
15. Stock I, Gruger T, Weidemann, B. Natural antibiotic suscep-
Since the Maxillofacial clinic at Livingstone Hospital is tibility of strains of the Enterobacter cloacae complex. Int J
a tertiary care centre, it is likely that most patients Antimicr Agents. 2001; 18: 537- 45.
included in this study would have received antibiotics 16. Fernadez-Canigia L, Legaria MC, Castello L et al. First na-
prior to admission. Therefore the emergence of resis- tional survey of antibiotic susceptibility of the Bacteroides
tant strains due to administration of these antimicrobial fragilis group: Emerging resistance to carbapenems in Ar-
agents may not have been accurately assessed. gentina. Antimicr Agents Chem. 2012; 56: 1309-14.

Recommendations

A longer study period with a larger sample size evalua-

ting the microbial spectrum and resistance patterns may
be necessary to monitor developing trends.

Since odontogenic infection was found to be a com-

mon cause of head and neck space infections, parti-
cularly in the third and fourth decades of life, oral health
education should further emphasise the importance of
caries prevention, good oral hygiene practices, early
presentation and intervention to minimise the complica-
tions of pulpitis.
198 > http://dx.doi.org/10.17159/2519-0105/2020/v75no4a5
The SADJ is licensed under Creative Commons Licence CC-BY-NC-4.0.

Student perceptions of clinical experiences in

endodontic access cavity preparations
SADJ May 2020, Vol. 75 No. 4 p198 - p205

P Gwengu1, C Jonker2

ABSTRACT
Objectives
The aim of this study was to gain understanding into the The use of rotary burs in an incorrect manner and mis-
perceptions of undergraduate dental students regarding aligned angle of penetration is often a critical factor in
their levels of competence and confidence when pre- iatrogenic tooth damage.2 To prevent adverse outcomes
paring endodontic access cavities. like these, appropriately designed pre-clinical teaching
and learning strategies will be required.
Materials and method
Anonymous survey forms were given to 100 undergrad- Access cavity preparation is a crucial step to ensure
uate dental students at Sefako Makgatho Health Sciences successful root canal treatment. Incorrect techniques
University, School of Oral Health Sciences. Students were applied during the preparation of access cavities may
asked to indicate their self-confidence level by using lead to a variety of procedural accidents. These include
a 5 - point Likert scale as ‘not confident’, ‘manageable’, perforations, destruction of large amounts of healthy
‘comfortable and confident’,’ extremely confident’ and tooth structure and instrument fractures. In order to
‘never done it’. prevent these complications, dental students need to
become competent in preparing access cavities.
Results
The response rate was 75 % out of 100 students. The Patient safety has always been a concern during clinical
majority of the participants (88%) indicated that they teaching and learning of dental students. Thus the im-
would perform endodontic access cavity preparation with portance of ensuring that undergraduate students reach
ease on anterior teeth and the lowest (43%) confidence an acceptably high level of competence in their pre-
levels was indicated on multi-rooted posterior teeth. clinical learning and skills development prior to them
being allowed to manage and treat patients.3,4
Keywords
Perceptions, clinical experiences, endodontic access cavity At Sefako Makgatho University (SMU) Oral Health Centre,
preparation, teaching and learning. students have a very limited time to learn and practice
preparation of access cavities in their preclinical sessions;
nonetheless they are allowed to continue with their pre-
INTRODUCTION
clinical work for few additional sessions until they are
Endodontic treatment and management of patients is a ready to treat patients.
multi-fold approach. It involves the complete debride-
ment of infected tissues inside the root canal system A need therefore will always exist to improve endo-
and ultimately a root canal preparation which will meet dontic access cavity preparation skills of under-graduate
biological and mechanical needs.1 The first step in treat- dental students as they continue to manage complex
ing an endodontically affected tooth is the preparation clinical cases. Patient’s safety, prevention of complica-
of a proper access cavity.1 The use of rotary burs to tions and procedural accidents are constantly emphasized
create endodontic access cavities or locating root canal during preclinical and clinical training.
orifices can cause serious iatrogenic damage to the tooth
and greatly influence the prognosis and restorability. 1 Students at SMU are exposed to exponential clinical
training as well as community outreach programmes.
Author affiliations: Dental students begin both their pre-clinical and didactic
1. Pumela Gwengu: Dip OH, BDS, MPH, M Dent (Comm Dent), endodontic teaching in the fourth year of their 5-year
Department of Operative Dentistry, Sefako Makgatho Health Bachelor of Dental Surgery (BDS) degree. Dental students
Science University, Garankuwa, Pretoria, South Africa.
2. Casper Jonker: BCHD, Dip Odont, MSc, Department of Operative would prepare and fill six root canals from extracted
Dentistry, Sefako Makgatho Health Science University, Garankuwa, single-rooted teeth and four extracted bi-rooted teeth
Pretoria, South Africa. during their preclinical training. Students need to com-
ORCID Number: 0000-0002-9110-5208
Corresponding author: Pumela Gwengu
plete access cavities in all ten extracted teeth (six
Department of Operative Dentistry, Sefako Makgatho Health Science anterior and four premolars). Instructions are given on
University, Garankuwa, Pretoria, South Africa. both conventional stainless-steel files (k-files) as well as
Email: [email protected]
rotary files and radiographic images are taken for preoper-
Author contributions:
1. Pumela Gwengu: Principal researcher - 70%, writing of the article ative diagnosis.
- 60% and conceptual stage contribution - 10%
2. Casper Jonker: Researcher - 30%, writing of the article - 20%, and Teaching and training in endodontic discipline for BDS
conceptual stage contribution - 10%
4 students consists of two-hour theoretical lectures for
www.sada.co.za / SADJ Vol. 75 No. 4 <
199

a period of fifteen weeks, fourteen two-hour preclinical cally focused on endodontic access cavity preparation.6
sessions for a period of four weeks and upon satis- It is, however, well known that undergraduate dental
factory completion of the preclinical work, students are students struggle with the transition of preclinical
allowed to treat patients for one three-hour clinical ses- training to the clinical environment where they have to
sion weekly for a period of thirty weeks. deal with complex challenges such access cavities on
porcelain fused to metal crowns and other patient-
The main focus for BDS 4 students is clinical prepa- related factors. 7,8 Learners are said to struggle with
ration of single-rooted anterior teeth (four incisors or the skills obtained at the “School” and what they have
canines) as well as bi-rooted posterior teeth (two pre- learned, and transferring these skills and knowledge to
molars). Additional pre-clinical training in endodontics the clinical or work environment.9
is done for BDS 5 students with one four-hour session
weekly for a month. Fifth-year dental students would The validation for undertaking this study at Sefako Mak-
prepare and fill root canals of four extracted multi-rooted gatho University (SMU) Oral Health Centre is based on
teeth (molars). The focus is on completion of the access the following aspects; BDS4 students have limited time
cavity preparation on four extracted posterior teeth to learn and practice preparation of access cavities
(molars) plus instructions are given by highly skilled in their preclinical sessions; secondly, BDS4 students
clinicians on how to use the electronic apex locator and are booked patients who already received emergency
rotary files. root canal treatments and access cavity has already
been completed, hence this may impact students clinical
Management of more complex cases are carried out by skills in treating and managing complex and challenging
fifth year dental students as part of comprehensive pa- endodontic clinical cases. The study aimed to investigate
tient care under the supervision of experienced endo- student’s perceptions on their competency and confi-
dontic clinicians. An array of different clinical training dence levels in access cavity preparation in endodontics
platforms allows students to develop academically and at SMU oral health centre.
professionally. The build-up of knowledge as well as clini-
cal exposure to various oral diseases and conditions
METHODOLOGY
does assist in improving their clinical expertise.
Ethical clearance was obtained (SMUREC /D/181/2017)
Students in their fifth year of endodontic training receive prior to commencement of the study.
further clinical exposure in access cavity preparation at
the emergency clinic (Careline) where patients are seen A quantitative cross-sectional, observational survey was
for the first time. Difficult and extremely complex endo- conducted. One hundred dental students were invited
dontic cases that necessitate management under Dental to partake on a voluntary basis. Each participant was
Operating Microscope (DOM) are referred and managed requested to complete a self-administered questionnaire
by experienced endodontic clinicians. at that particular point of clinical training which was
closer to the end of the second semester in the 4th year
Student’s opinions are important and are a critical as- and 5th year of dental training. All dental students who
pect of academic course evaluation which can indicate were trained in endodontics consented to participate
where potential improvements in their Endodontic edu- in the study and those students were in year 4 and 5
cation and course outcomes can be addressed. How- of their study. Dental students who were not trained
ever, in recent years more academics have begun to in endodontics were excluded from the study.
acknowledge the role played by students in providing
course evaluation and inputs in a classroom environment. QUESTIONNAIRE
Evaluation processes must be timetabled and in-coop-
erated into the academic programme and completed A 26-question survey was developed based on past
independently and by other faculty members other than questionnaires that had been previously used success-
the course co-ordinators. Students in the higher learning fully by Davey and others in 2014.10 It was designed
environment must be encouraged to partake in these specifically for the study in English, together with the
evaluation processes. information sheet and consent forms. The question-
naires were used to evaluate the responses from 4 th
Student competence can be understood as a complex and 5 th year dental students using Likert scale format.
arrangement of a human being’s skills that are called
into play in a variety of situations.5 In fact, competence The first section of the questionnaire was on levels of
“carries the dual meaning that says there is a track competence and students rated their perceived com-
record of such achievement (competent performance) petency levels using “unsure”, “yes” and “no”.10-14 The
and also that the individual has the capability to perform remainder of the questionnaire assessed students per-
well in the future. It refers to good adaptation and not ceived levels of confidence and they classified this
necessarily to superb achievement”.5 Systematic com- using a 5 - point Likert scale with answers as ‘not
petence constitutes an individual’s skill in effectively confident’, ‘manageable’, ‘comfortable and confident’,
planning his or her work as well as the mastery of rele- ’extremely confident’ and ‘never done it’.10-14
vant techniques.5
The questionnaire assessed students’ experiences on:
There are numerous innovative approaches to address perceived competent levels on access cavity preparation
the problem of teaching psychomotor skills to under gra- and perceived competent levels on various endodon-
duate dental students, but none of these were specifi- tic tasks of creating access cavity. The closed-ended
200 >

questions were used to obtain information on dental and BDS 5 = 50 (notable excluding the five piloted stu-
student’s perceptions when performing endodontic ac- dents). Out of this total, 75 questionnaires were com-
cess cavity preparations. Dental student’s perception pleted in full and returned. Each questionnaire took ap-
of their competence level was self-rated and scored in proximately fifteen minutes to complete. Research ques-
the assessment tool. Students were not coerced to tionnaire was distributed and collected by a research
answer in a particular way and this was ensured by assistant upon completion. This gives a response rate
making use of an independent research assistant. of 75 % which was 72 % for BDS 5: 36 (48%) and 78% for
BDS 4: 39 (52%) (Table 1).
A pilot test of randomly selected small group of five Table 1. Students response rate.
students from the fifth-year group was performed by
Year No. contacted No. participated Response (%)
the research assistant to determine feasibility, content
clarity, the validity of the questionnaire and its accep- A 50 36 72.0

tability so that potential problems could be identified B 50 39 78.0

and resolved before commencing the study itself. Total 100 75 75.0

The students who participated in the pilot study were

Perceptions of competence levels when performing
voluntarily excluded from the main study. Some few
endodontic access cavities on anterior and
questions were reviewed as per input from the par-
posterior teeth
ticipants of the pilot study. Sufficient time was allowed
to create a relaxed environment without rushing or Out of 75 who completed the questionnaire, 70 (93.3%)
coercing students with an aim of obtaining a true re- confirmed that they were competent in endodontic ac-
flection of their perceptions. cess cavity preparation on anterior teeth and 47 (62.7%)
confirmed to be competent on the posterior teeth.
The background information regarding this research
topic was introduced by the investigators to the par- Of the 70 who confirmed that they were more compe-
ticipating students before consent was obtained. Re- tent in endodontic access cavity preparation on anterior
sponse bias was addressed by reassuring participants teeth 36 (48.0 %) were fourth-year dental students and
of their anonymity and that their participation in the 34 (45.3%) were fifth-year dental students. Of the 47
study was not going to influence students’ academic who confirmed that they were competent in endodontic
outcome. Response bias from participants was also access cavity preparation on posterior teeth 19 (25.3 %)
minimized by adding an “unsure” option in the ques- were fourth-year dental students and 28 (37.3%) were
tionnaire as part of response. Distribution and collection fifth-year dental students (Table 2).
of the questionnaires was managed by the indepen-
Table 2. Students perceptions of their competence when performing
dent research assistant to minimize students fear. endodontic access cavities.
Do you feel competent when Years of Study
performing endodontic access Total
STATISTICAL ANALYSIS cavities on 4th 5 th
An anterior tooth
Data was first captured in Microsoft Excel 2016 before
exporting to SPSS (Statistical Package for the Social Yes 36 (48.0%) 34 (45.3%) 70 (93.3%)
Sciences version 20, (SPSS Inc., Chicago, II, USA) No 0 (0.0%) 0 (0.0%) 0 (0.0%)
for analysis. Preliminary analysis of data was done Unsure 3 (4.0%) 2 (2.7%) 5 (6.7%)
where missing values and errors were checked and A posterior tooth
corrected. Reliability of the instrument was measured Yes 19 (25.3%) 28 (37.3%) 47 (62.7%)
using Cronbach’s Alpha. Two constructs (competency No 13 (17.3%) 4 (5.3%) 17 (22.7%)
and confidence) were defined in the study. Compe- Unsure 7 (9.3%) 4 (5.3%) 11 (14.7%)
tency and confidence scales recorded Cronbach’s alpha A single-rooted posterior tooth
values of 70.3% and 79.3% respectively. An overall
Yes 33 (44.0%) 32 (42.7%) 65 (86.7%)
Cronbach’s alpha value of 77.2 % was achieved. This
is a good overall level of internal consistency which is No 3 (4.0%) 0 (0.0%) 3 (4.0%)

above the 70.0 % threshold. Unsure 3 (4.0%) 4 (5.3%) 7 (9.3%)

A multi-rooted posterior tooth

Normality tests were performed using Kolmogorov- Yes 18 (24.0%) 24 (32.0%) 42 (56.0%)
Smirnova and indicated that the data of the study was No 14 (18.7%) 5 (6.7%) 19 (25.3%)
not normally distributed. Therefore, nonparametric sta- Unsure 7 (9.3%) 7 (9.3%) 14 (18.7%)
tistics and tests (such as frequencies, percentages, Chi
squared tests and Kruskal Wallis tests) were appropriate Furthermore, a noticeable difference was observed be-
to use in the study as opposed to parametric tests. tween the perceived competence levels of the single
rooted posterior teeth (BDS 4: 33 (44%) & BDS 5: 32
RESULTS (42.7 %) and multi-rooted posterior teeth (BDS 4: 18
(24.0 %) & BDS 5: 24 (32.0 %). However, none of the
The results of the pilot study were evaluated and the fifth-year dental students that reported that they were
content was adjusted before the questionnaires were incompetent in performing endodontic access cavity on
distributed the students. A total of 100 questionnaires anterior teeth and a few of them 4 (5.3%) confirmed that
were distributed to a target audience of 100 dental they were incompetent in endodontic access cavity on
students in the Bachelor of Dental Science, BDS 4 = 50 posterior teeth.
www.sada.co.za / SADJ Vol. 75 No. 4 <
201

A small number of fifth year dental students 2 (2.7%) Of the 17 (22.7 %) who confirmed that they were ex-
confirmed that they were not sure of their competency tremely confident in endodontic access cavity on an-
level for anterior teeth and 4 (5.3 %) for the posterior terior teeth with fractured clinical crown, they were
teeth (Figure 1). (BDS 4: 4 (5.3 %) & BDS 5: 13 (17.3%).

Perceptions of confidence levels when performing Perceptions of confidence levels when performing
endodontic access cavities on teeth with variable endodontic clinical stages during access cavity
dental status preparations
A certain number of fourth year dental students 10 Data revealed that there were 60 (80.0%) dental stu-
(13.3%) reported to be extremely confident when per- dents who reported that they were extremely confident in
forming endodontic access cavity on anterior teeth whilst delivering local anaesthesia for anterior and 49 (65.3 %)
there was about 3 (4.0%) students who were extremely were extremely confident for posterior teeth (Table 4).
confident in endodontic access cavity on posterior teeth
(Table 3). Most dental students 45 (60.0%) confirmed that they were
extremely confident in rubber dam placement on anterior
Additionally, there was only one (1.3%) 5th year dental teeth; BDS 4: 20 (26.7 %) and BDS 5: 25 (33.3%). There
students who reported that she/he was not confident were about 20(26.7%) students who perceived them-
in performing endodontic access cavity on posterior selves to be extremely confident in taking intra-oral x-
teeth. rays for the purpose of diagnosing clinical crown length;
BDS 4: 11 (14.7%) and BDS 5: 9 (12.0%) and there
There were some fourth-year dental students who stated were about 12 (16%) who were extremely confident and
that they never prepared endodontic access cavity on able to identify the depth of the access cavity on pre-
anterior teeth with massive carious lesion (BDS 4: 13 operative, intra-operative and post-operative x-rays; BDS
(17.3%) and on posterior teeth with massive carious 4: 6 (8.0%) and BDS 5: 6 (8.0%).
lesions (BDS 4: 12 (16.0%).
Of the 30 (40.0%) dental students out of 75 who con-
Most students 33 (45.8%) confirmed that that they firmed that they were comfortable and confident in bur
never prepared endodontic access cavity on anterior selection, these were BDS 4: 15 (20.0%) and BDS 5: 15
teeth with gold inlays (BDS4: 22(30.6%) and BDS 5: (20.0%). Fourteen (18.7%) dental students reported that
11 (15.3%). they were extremely confident in the creation of a coronal
flare on anterior teeth; BDS 4: 6 (8.0%) and BDS 5: 8
Of the 43 (57.3%) who confirmed that they never pre- (10.7%) and on posterior teeth BDS 4: 5 (6.7%) and BDS
pared endodontic access cavity on anterior teeth with 5: 1 (1.3%). There were some students 10 (13.3%) who
metal, porcelain or in ceramic crowns, there were (BDS confirmed that they have never done any coronal flare on
4: 29 (38.7 %) & BDS 5: 14 (18.7 %). posterior teeth; BDS 4: 9 (12.0%) and BDS 5: 1 (1.3%).

Competence access preparation for Anterior teeth Competence access preparation for single-rooted Posterior teeth

40 40
36
35 34 35 33 32
30 30
Frequency

Frequency

25 25
20 20
15 15
10 10
3 3 4
5 2 5 3
0 0 0
0 0
Yes No Unsure Yes No Unsure
BDS_IV BDS_V BDS_IV BDS_V

Competence access preparation for Posterior teeth Competence access preparation for multiple-rooted Posterior teeth
40 40
35 35 33 32
28
30
Frequency

30
Frequency

25 25
19
20 20
15 13 15
10 7 10
4 4 4
5 5 3 3
0 0
0
Yes No Unsure Yes No Unsure
BDS_IV BDS_V BDS_IV BDS_V

Figure 1. Students perceptions of their competence when performing endodontic access cavities.
202 >

Thirty nine (52%) dental students out of 75 reported that access cavity preparations for posterior teeth with crowns
they were extremely confident in the placement of inter- (metal, porcelain and in Ceramic).
appointment temporal restorations using Kalzinol and
IRM; BDS 4: 17 (22.7%) and BDS 5: 22 (29.3%) with an DISCUSSION
exception of one (1.3%) BDS 4 student who reported
that she/he was not confident in placing a temporal Dental student’s evaluation input is important to improve
restoration. the curriculum and to correct existing errors and to iden-
tify the missing elements of the curriculum.11 Student self-
assessments of their own proficiency serve as helpful
Statistical analysis
means to make a realistic evaluation of dental curricula
Kruskal-Wallis test was used to determine significant dif- and the assessment of the effectiveness of specific
ferences between the two groups (BDS 4 and BDS 5) courses. Students questionnaire are one of the impor-
on competency levels and confidence levels on access tant tools that can be used in collecting data for the
cavity preparations (Table 5). It was observed that there purpose of getting student’s input.12 At Sefako Makgatho
were significant (p < 0.05) differences between BDS 4 Health Science University where the study was conducted,
and BDS 5 on competency levels on access cavity pre- curriculum reviews are done for both theoretical and
parations for posterior teeth. There was no statistical clinical practise and these reviews includes dental stu-
evidence to suggest any differences between the two dents evaluation input.
groups on competency levels for anterior teeth, single
rooted posterior and multi-rooted posterior teeth. There Dental students are given enough opportunities to fine-
were highly statistically significant (p < 0.01) differences tune their clinical skills in access cavity preparation during
between BDS 4 and BDS 5 on confidence levels on their professional training. Management of endodontic pa-
access cavity preparations for anterior teeth with crowns tients are carried out by fifth-year dental students as
(metal, porcelain and in Ceramic) and anterior teeth with part of comprehensive patient care and they are super-
massive carious lesions. Statistically significant (p<0.05) vised by experienced endodontic clinicians. These stu-
differences were also observed on confidence levels on
How confident do you feel when Years of Study
performing endodontic access Total
Table 3. Students perceptions of their confidence when performing cavities on 4th 5 th
endodontic access cavities. A posterior tooth with massive
How confident do you feel when carious lesion
Years of Study
performing endodontic access Total Not confident at all 3 (4.0%) 5 (6.7%) 8 (10.7%)
cavities on 4th 5th
Manageable 11 (14.7%) 11 (14.7%) 22 (29.3%)
An anterior tooth
Comfortable & confident 9 (12.0%) 12 (16.0%) 21 (28.0%)
Not confident at all 0 (0.0%) 0 (0.0%) 0 (0.0%)
Extremely confident 4 (5.3%) 7 (9.3%) 11 (14.7%)
Manageable 5 (6.7%) 4 (5.3%) 9 (12.0%)
Never done it 12 (16.0%) 1 (1.3%) 13 (17.3%)
Comfortable & confident 24 (32.0%) 16 (21.3%) 40 (53.3%)
A heavily restored anterior tooth
Extremely confident 10 (13.3%) 16 (21.3%) 26 (34.7%) with composite
Never done it 0 (0.0%) 0 (0.0%) 0 (0.0%) Not confident at all 0 (0.0%) 1 (1.3%) 1 (1.3%)
A posterior tooth Manageable 14 (18.7%) 10 (13.3%) 24 (32.0%)
Not confident at all 5 (6.7%) 1 (1.3%) 6 (8.0%) Comfortable & confident 19 (25.3%) 13 (17.3%) 32 (42.7%)
Manageable 14 (18.7%) 13 (17.3%) 27 (36.0%) Extremely confident 1 (1.3%) 11 (14.7%) 12 (16.0%)
Comfortable & confident 11 (14.7%) 20 (26.7%) 31 (41.3%) Never done it 5 (6.7%) 1 (1.3%) 6 (8.0%)
Extremely confident 3 (4.0%) 2 (2.7%) 5 (6.7%) An anterior tooth restored with
gold inlay
Never done it 6 (8.0%) 0 (0.0%) 6 (8.0%)
Not confident at all 0 (0.0%) 1 (1.4%) 1 (1.4%)
A single-rooted posterior tooth
Manageable 8 (11.1%) 10 (13.9%) 18 (25.0%)
Not confident at all 2 (2.7%) 0 (0.0%) 2 (2.7%) Comfortable & confident 7 (9.7%) 9 (12.5%) 16 (22.2%)
Manageable 6 (8.0%) 4 (5.3%) 10 (13.3%) Extremely confident 2 (2.8%) 2 (2.8%) 4 (5.6%)
Comfortable & confident 22 (29.3%) 16 (21.3%) 38 (50.7%) Never done it 22 (30.6%) 11 (15.3%) 33 (45.8%)
Extremely confident 6 (8.0%) 16 (21.3%) 22 (29.3%) A crowned anterior tooth with any
Never done it 3 (4.0%) 0 (0.0%) 3 (4.0%) of these (porcelain or in ceramic
or metal)
A multi-rooted posterior tooth
Not confident at all 0 (0.0%) 2 (2.7%) 2 (2.7%)
Not confident at all 5 (6.7%) 2 (2.7%) 7 (9.3%)
Manageable 2 (2.7%) 9 (12.0%) 16 (21.3%)
Manageable 14 (18.7%) 15 (20.0%) 29 (38.7%)
Comfortable & confident 7 (9.3%) 9 (12.0%) 16 (21.3%)
Comfortable & confident 10 (13.3%) 16 (21.3%) 26 (34.7%)
Extremely confident 1 (1.3%) 2 (2.7%) 3 (4.0%)
Extremely confident 3 (4.0%) 3 (4.0%) 6 (8.0%)
Never done it 29 (38.7%) 14 (18.7%) 43 (57.3%)
Never done it 7 (9.3%) 0 (0.0%) 7 (9.3%)
A crowned posterior tooth with any
An anterior tooth with massive of these (porcelain or in ceramic
carious lesion or metal)
Not confident at all 0 (0.0%) 1 (1.3%) 1 (1.3%) Not confident at all 2 (2.7%) 1(1.3%) 3(4.0%)
Manageable 7 (9.3%) 10 (13.3%) 17 (22.7%) Manageable 2 (2.7%) 7(9.3%) 9(12.0%)
Comfortable & confident 14 (18.7%) 17 (22.7%) 31 (41.3%) Comfortable & confident 72(2.0%) 6(8.0%) 8(10.0%)
Extremely confident 5 (6.7%) 8 (10.7%) 13 (17.3%) Extremely confident 1(1.3%) 1(1.3%) 2(2.7%)
Never done it 13 (17.3%) 0 (0.0%) 13 (17.3%) Never done it 32(42.7%) 21(28.0%) 53(70.7%)
www.sada.co.za / SADJ Vol. 75 No. 4 <
203

dents are also exposed to integrated clinical dentistry and many studies have shown that molar endodontics is
students are responsible for all dental treatments of the a complex procedure in which students had the least
patients that are assigned to them. confidence.12-14 Davey and other researchers in 2015
were also in agreement to the fact that molar endodon-
The study aimed at understanding student’s perceptions tics is the most difficult clinical procedure.10
in terms of their confidence and competence levels in
their clinical experiences whilst performing endodontic Endodontic treatment can be quite challenging and may
access cavities. These findings on competency on access pose difficulties both in terms of clinical conditions of
cavity preparation on anterior teeth, single-rooted and that particular tooth such as massive carious lesion,
multi-rooted posterior teeth are in line with theoretical restored with clinical crowns and morphological charac-
expectations as it is stated in other studies.13 teristics of that particular tooth.12

In this study, all dental students were competent in When different types of teeth were scored by dental stu-
access cavity preparation on anterior teeth as opposed dents in terms of self-confidence levels, it was observed
to posterior teeth. This is not unexpected because that molar endodontic access cavity preparation yielded
relatively lower values and these results are consistent
Table 4. Students perceptions of their confidence when performing with the results of previous studies.13,15,16
endodontic clinical stages during access cavity preparation.
How confident do you feel when
performing these endodontic
Years of Study
Total
Notable from the results of this study, is that most of
clinical stages 4th 5th the fourth-year dental students have never attempted
Delivery of local anesthesia for an complex access cavity preparation. This assertion has
anterior tooth
been demonstrated by the highly statistically significant
Not confident at all 0 (0.0%) 0 (0.0%) 0 (0.0%) levels between BDS 4 and BDS 5 on access cavity
Manageable 1 (1.3%) 1 (1.3%) 2 (2.3.0%) preparations of anterior teeth with crowns (metal, por-
Comfortable & confident 5 (6.7%) 7 (9.3%) 12 (16.0%) celain and in Ceramic).
Extremely confident 30 (40.0%) 30 (40.0%) 60 (80.0%)
Never done it 1 (1.3%) 0 (0.0%) 1 (1.3%) How confident do you feel when Years of Study
performing these endodontic Total
Delivery of local anesthesia for a
clinical stages 4th 5 th
posterior tooth
Pre-operative, intra-operative
Not confident at all 0 (0.0%) 0 (0.0%) 0 (0.0%) and post-operative radiographic
Manageable 3 (4.0%) 3 (4.0%) 6 (8.0%) interpretation of depth and size of
access cavity
Comfortable & confident 9 (12.0%) 8 (10.7%) 17 (22.7%)
Not confident at all 1 (1.3%) 1 (1.3%) 2 (2.0%)
Extremely confident 24 (32.0%) 25 (33.3%) 49 (65.3%)
Manageable 12 (16.0%) 5 (6.7%) 17 (22.7%)
Never done it 3 (4.0%) 0 (0.0%) 3 (4.0%)
Comfortable & confident 19 (25.3%) 24 (32.0%) 43 (57.3%)
Rubber dam placement on an
anterior tooth Extremely confident 6 (8.0%) 6 (8.0%) 12 (16.0%)
Not confident at all 0 (0.0%) 1 (1.3%) 1 (1.3%) Never done it 1 (1.3%) 0 (0.0%) 1 (1.3%)
Manageable 4 (5.3%) 3 (4.0%) 7 (9.3%) At selecting the type of a bur that
you would use
Comfortable & confident 15 (20.0%) 7 (9.3%) 22 (29.3%)
Not confident at all 1 (1.3%) 1 (1.3%) 2 (2.7%)
Extremely confident 20 (26.7%) 25 (33.3%) 45 (60.0%)
Manageable 8 (10.7%) 6 (8.0%) 14 (18.7%)
Never done it 0 (0.0%) 0 (0.0%) 0 (0.0%)
Comfortable & confident 15 (20.0%) 15 (20.0%) 30 (40.0%)
Rubber dam placement on a pos-
terior tooth Extremely confident 15 (20.0%) 14 (18.7%) 29 (38.7%)
Not confident at all 0 (0.0%) 4 (5.3%) 4 (5.3%) Never done it 0 (0.0%) 0 (0.0%) 0 (0.0%)
Manageable 6 (8.0%) 8 (10.7%) 14 (18.7%) At coronal flare creation for an
anterior tooth
Comfortable & confident 13 (17.3%) 8 (10.7%) 21 28.0%)
Not confident at all 3 (4.0%) 0 (0.0%) 3 (4.0%)
Extremely confident 19 (25.3%) 16 (21.3%) 35 (46.7%)
Manageable 11 (14.7%) 13 (17.3%) 24 (32.0%)
Never done it 1 (1.3%) 0 (0.0%) 1 (1.3%)
Comfortable & confident 17 (22.7%) 14 (18.7%) 31 (41.3%)
Pre-operative, intra-operative
and post-operative radiographic Extremely confident 6 (8.0%) 8 (10.7%) 14 (18.7%)
interpretation of size, shape and Never done it 2 (2.7%) 1 (1.3%) 3 (4.0%)
content of pulpal chamber
At coronal flare creation for a
Not confident at all 1 (1.4%) 1 (1.4%) 2 (2.7%) posterior tooth
Manageable 9 (12.2%) 4 (5.4%) 13 (17.6%) Not confident at all 3 (4.0%) 2 (2.7%) 5 (6.7%)
Comfortable & confident 23 (31.1%) 26 (35.1%) 49 (66.2%) Manageable 12 (16.0%) 20 (26.7%) 32 (42.7%)
Extremely confident 6 (8.1%) 4 (5.4%) 10 (13.5%) Comfortable & confident 10 (13.3%) 12 (16.0%) 22 (29.3%)
Never done it 0 (0.0%) 0 (0.0%) 0 (0.0%) Extremely confident 5 (6.7%) 1 (1.3%) 6 (8.0%)
Pre-operative, intra-operative Never done it 9 (12.0%) 1 (1.3%) 10 (13.3%)
and post-operative radiographic
interpretation for measuring clinical At placing an inter-appointment
crown length temporal restoration
Not confident at all 0 (0.0%) 1 (1.3%) 1 (1.3%) Not confident at all 1 (1.3%) 0 (0.0%) 1 (1.3%)
Manageable 9 (12.0%) 6 (8.0%) 15 (20.0%) Manageable 6 (8.0%) 5 (6.7%) 11 (14.7%)
Comfortable & confident 19 (25.3%) 20 (26.7%) 39 (52.0%) Comfortable & confident 15 (20.0%) 8 (10.7%) 23 (30.7%)
Extremely confident 11 (14.7%) 9 (12.0%) 20 (26.7%) Extremely confident 17 (22.7%) 22 (29.3%) 39 (52.0%)
Never done it 0 (0.0%) 0 (0.0%) 0 (0.0%) Never done it 0 (0.0%) 1 (1.3%) 1 (1.3%)
204 >

Furthermore, highly statistically significant level were The significant variations that are shown between BDS
observed between the two groups on access cavity 4 and BDS 5 students in this study is a clear indication
preparations for anterior teeth with massive carious of non-clinical exposure to complex and challenging en-
lesions. This also confirms the validation of the study dondontic cases at an emergency unit. The findings
because fourth-year dental students do not rotate at may prompt Sefako Makgatho Health Science University
an emergency unit (Careline), where most of the emer- to reconsider the endodontic theoretical and clinical
gency root canal treatments, access cavity preparations course by in cooperating the necessary curriculum
on teeth with various clinical status, complex and chal- changes. Changing of the endodontic programme may
lenging clinical cases are being managed. Therefore, also assist students to be able to progress in clinical
this absence of rotation by fourth-year dental students knowledge and expertise. Endodontic education at this
at Careline must be seen as a shortcoming of our institution should be improved by adding the clinical
institutional planning and curriculum design. rotations for BDS 4 students at an emergency unit and
gradually introduce them to complex access cavity
Students also reported lower confidence levels in delivery preparations.
of local anaesthetics on posterior teeth, these findings
are in line with previous studies whereby it was stated
CONCLUSION
by students that the most difficult areas in terms of
obtaining anaesthesia was on posterior teeth.17,18 In ad- The results showed students’ lower confidence levels
dition, students confirmed lower confidence levels in in the more challenging aspects of endodontic access
rubber dam placement for posterior teeth. cavity preparation and these findings varied in some
instances according to the year of study, complexity of
A previous study by Tanalp and other authors in 2013 the case as well as the practical steps of endodontic
stated that rubber dam application was one of the access cavity.
endodontic clinical steps where students reported the
lowest confidences.12 However, rubber dam application The significance of this research study is to provide
is a prerequisite and students are not allowed to com- the dental institution with valuable information that can
plete their treatments without the use of this significant improve student’s skills on endodontic access cavity pre-
apparatus at Sefako Makgatho Health Science University. paration regarding the readiness of students to manage
Rubber dam is also an indispensable element of en- complex and challenging endodontic access cavities.
dodontic clinical practice and is not only a valuable tool
but an ethical and medico-legal prerequisite for dental
practitioners.12

In our study, it was also observed that confidence levels

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208 >
CASE REPORT http://dx.doi.org/10.17159/2519-0105/2020/v75no4a6
The SADJ is licensed under Creative Commons Licence CC-BY-NC-4.0.

Focal dermal hypoplasia

- a radiographic case report
SADJ May 2020, Vol. 75 No. 4 p208 - p210

Z Yakoob1, C Nel2

ABSTRACT
Focal dermal hypoplasia (FDH) is an unusual X-linked Over 280 cases have been reported in the literature,
dominant disorder that affects ectoderm and mesoderm with a small number of these reporting oral and dental
derived tissues with females affected in 90% of cases. features.3 The reported dental abnormalities associated
A case report of a 12 year old female diagnosed with with this condition include; hypodontia, enamel hypo-
FDH is presented. The dental significance of these pa- plasia and structural alterations such as taurodontism
tients are multifactorial and dental management should and abnormal root morphology.
be focused on prevention and regular monitory visits.
Disturbances in eruption and ectopic teeth are also a
Restoration of functionality should be addressed by a common finding.3 One study reports the presence of
combination of orthodontic, basic restorative and pros- enamel defects in the form of vertical grooves that run
thodontic disciplines. Due to the multisystem involvement along the Blaschko lines, as a strong indicative factor
and the dental complexities of patients suffering from for FDH.6
FDH a multidisciplinary approach is required for optimal
patient care. •• Enamel hypoplasia. Sparse hair
•• Microdontia.
Keywords •• Disturbances in eruption,
teeth position and number.
Focal dermal hypoplasia, Goltz-Gorlin syndrome, Ecto- •• Abnormal root morphology. Atrophic skin

dermal Dysplasia.

INTRODUCTION
Focal dermal hypoplasia (FDH), also known as Goltz-
Gorlin syndrome was first reported in 1962 by Goltz, Syndactyly/limb
malformations
Peterson, Gorlin and Ravitz.1 FDH is an unusual X-lin- Nail dystrophy

ked dominant disorder that affects ectoderm and meso-

derm derived tissues.2

The PORCN (porcupine O-acyltransferase) gene muta-

tion can be inherited or occur sporadically, with females
affected in 90% of cases.3,4 FDH is characterized by
a wide range of multisystem abnormalities and all pa-
tients present with dermatological conditions. The eyes,
teeth, skeletal, urinary, gastrointestinal, cardiovascular
and central nervous systems may all present with mani-
festations (Figure 1).3,5
Figure 1. Most common conditions associated with FDH.4

Author affiliations:
1. Zarah Yakoob: BChD (UWC), PG Dip Dent (Maxillofacial Ra- CASE DESCRIPTION
diology) (UWC), MSc (Maxillofacial Radiology) (UWC), Faculty
of Health Sciences, Department of Oral Pathology and Oral A 12 year old female diagnosed with FDH reported to
Biology, University of Pretoria. our institution seeking dental care. The diagnosis was
ORCID Number: 0000-0003-1966-5574
2. Chané Nel: BChD (UP), MSc Maxillofacial Radiology (UP), Faculty made by a geneticist at infancy. She has been man-
of Health Sciences. Department of Oral Pathology and Oral aged for numerous multisystem conditions since birth
Biology, University of Pretoria. and was referred to our institution for further dental and
ORCID Number: 0000-0003-4047-6356
Corresponding author: Zarah Yakoob
orthodontic management.
Pretoria Oral and Dental Hospital, Corner of Dr Savage and Steve Biko
Road, Pretoria, South Africa. The patient has a history of surgical treatment for
Email: [email protected]
the correction of syndactyly of the hands (Figure 2).
Author contributions:
1. Zarah Yakoob: First draft, revision, final write-up and final approval The patient’s toes have not been surgically corrected
- 50% (Figure 3). The patient has been reportedly struggling
2. Chané Nel: Conceptualization, first draft, revision, final write-up with chronic conjunctivitis, middle ear infections and
and approval - 50%
dermatitis.
www.sada.co.za / SADJ Vol. 75 No. 4
CASE REPORT < 209

A B

Figure 2. Preoperative radiograph (A) of right Clinical picture (B) of hands after surgical correction.
hand exhibiting syndactyly. Soft tissue union of
the right index and middle finger.

Figure 3. Current clinical presentation and previous radiographs of feet. The middle and distal phalanges of the middle toe on the right foot
On the right foot the proximal, middle and distal phalanges of the index is also missing. On the left foot soft tissue union is visualised between
toe are missing. the middle and fourth toe.

Figure 4. Clinical photograph demonstrating patchy skin, Figure 5. Panoramic radiograph of the patient exhibiting enamel hypo-
gingival enlargement and enamel hypoplasia. plasia and hypodontia.

Figure 6. Axial and coronal CBCT slice exhibiting mandibular bone.

210 >
CASE REPORT

The extra-oral examination revealed sparse hair, dystro- Due to the multisystem involvement and the dental
phic nails and red patchy skin. The intra-oral examination complexities of patients suffering from FDH a multi-
revealed microstomia, generalized inflammatory gingival disciplinary approach is required for optimal patient care.
enlargement and numerous missing and mal-aligned teeth
(Figure 4). Declaration
The authors declare no conflict of interest.
The visualization of vertical grooving of the anterior
teeth was not feasible due to the altered eruption and Ethical considerations
alignment. The patient was subsequently referred for 'All procedures followed were in accordance with the
radiographic assessment. The panoramic radiograph ethical standards of the responsible committee on
(Figure 5) revealed an elongated left condylar neck human experimentation (institutional and national) and
and interrupted calcification of the right stylohyoid with the Helsinki Declaration of 1975, as revised in
ligament. Generalized enamel hypoplasia and hypo- 2008 (5).
dontia was the most striking radiographic finding.
Informed consent was obtained from all patients for
Radicular hypoplasia was also visible on 43 and 22. being included in the study.
Overlap and crowding of maxillary anterior teeth and a
disto-angular impaction in the right mandibular corpus This article does not contain any studies with human
was noted. The bone in the 4th quadrant had an irregular or animal subjects performed by any of the authors.
presentation and the decision was then made to take
a CBCT scan of the area (Figure 6). References
1. Nathwani S, Martin K, Bunyan R. Focal dermal hypo-
The CBCT scan revealed thin crestal bone in the area of plasia: A novel finding in disguise. J Oral Biol Craniofacial
the 4th quadrant with intact cortication. This explains the Res. 2018; 8(2): 143 - 6.
2. Yesodharan D, Buschenfelde UMZ, Kutsche K, Nair KM,
irregular appearance of the bone seen on the panora-
Nampoothiri S. Goltz-Gorlin Syndrome: Revisiting the Cli-
mic radiograph as the thin bony crest was outside of nical Spectrum. Indian J Pediatr. 2018; 85(12): 1067- 72.
the panoramic focal trough. The excess mobile soft 3. Wang L, Jin X, Zhao X, Liu D, Hu T, Li W, et al. Focal der-
tissue in the 4th quadrant was excised under general mal hy poplasia: Updates. Oral Dis. 2 014; 20(1): 17 - 24.
anaesthesia and submitted for histology. 4. Grzeschik KH, Bornholdt D, Oeffner F, Konig A, del
Carmen Boente M, Enders H, et al. Deficiency of PORCN,
The histological features were that of inflammatory a regulator of Wnt signaling, is associated with focal
fibrous hyperplasia. The 55, 54 and 43 were also ex- dermal hypoplasia. Nat Genet. 2007; 39(7): 833 - 5.
5. Ghosh SK, Dutta A, Sarkar S, Nag SS, Biwas SK,
tracted during this procedure. A carious 46 was also
Mandal P. Focal dermal hypoplasia (Goltz Syndrome):
detected on the radiograph and was subsequently A cross-sectional study from Eastern India. Indian J
restored. The patient was assessed by maxillofacial Dermatol. 2017; 62(5): 498 - 504.
surgeons, orthodontists and a geneticist during her 6. Gysin S, Itin P. Blaschko Linear Enamel Defects – A
visit at our institution and was further managed by Marker for Focal Dermal Hypoplasia: Case Report of
the pedodontics department for restorative and pre- Focal Dermal Hypoplasia. Case Rep Dermatol. 2015; 7(2):
ventive care. Initial verbal consent and later written 90 - 4.
informed consent was obtained from the mother of the 7. Basha S, Noor Mohamed R, Swamy HS. Association
between enamel hypoplasia and dental caries in pri-
child to continue with the study. Ethical approval was
mary second molars and permanent first molars: A 3-
obtained from the University of Pretoria Ethics com- year follow-up study. Ann Trop Med Public Heal. 2016;
mittee (Reference number: 143 /2019). 9(1): 4-11.

DISCUSSION
A three year follow up study found that enamel hypo-
plasia is a significant risk factor for caries development.7
Therefore patients with FDH have increased suscepti-
bility to caries formation due to the hypoplastic enamel.
Additionally, hypoplastic enamel is significant as it is
associated with altered aesthetics and increased denti-
nal sensitivity.

Masticatory functionality is impaired due to the hypo-

dontia and ectopic teeth with few teeth in full occlusion.
The microstomia influences oral hygiene practices which
often leads to gingivitis and a higher prevalence of
caries of the susceptible enamel. Dental treatments
and interventions should be focused on prevention
with regular dental check-ups, fissure sealants and
topical fluoride application. Restoration of function-
ality should be addressed by a combination of ortho-
dontic, basic restorative and prosthodontic disciplines.
http://dx.doi.org/10.17159/2519-0105/2020/v75no4a7
The SADJ is licensed under Creative Commons Licence CC-BY-NC-4.0. CASE REPORT < 211

Lichenoid Granulomatous Stomatitis

- an oral medicine case book
SADJ May 2020, Vol. 75 No. 4 p211 - p213

L Robinson1, AW van Zyl 2, WFP van Heerden 3

CASE REPORT
A 72-year-old male patient presented with a painful area perineural and perivascular distribution (Figures 2 & 3).
on the labial mucosa of the upper lip adjacent to No foreign material was noted under polarised light.
tooth 12. He complained of a non-healing “bruise” on Periodic acid–Schiff (PAS) and Ziehl-Neelsen histoche-
the inside of his lip that had been present for about mical stains failed to highlight any fungal elements or
4-weeks. The patient was a non-smoker and reported acid-fast bacilli respectively.
taking anti-hypertensive medication (Lisinopril, hydrochlo-
rothiazide) for 10-years. A prior colonoscopy 4 years In conclusion, a final diagnosis of lichenoid granulomatous
ago revealed adenomas. stomatitis was made.

On examination, a swelling was noted with the overlying The patient was followed-up one month after total exci-
mucosa appearing erosive and erythematous with peri- sion of the lesion to reassess for further treatment. He
pheral white striae, clinically similar to lichen planus. reported that healing was uneventful, and all symptoms
The lesion also involved the facial gingiva associated had disappeared after the excision biopsy. Intra-oral exa-
with teeth 12 & 22 (Figure 1). This red-white lesion was mination showed an absence of any clinical signs in the
excised as well as minor salivary glands that extruded original area (Figure 4).
during the biopsy procedure. No additional pharma-
cotherapeutic agents were administered. The patient will be followed-up for routine examination
every few months and was instructed to immediately re-
The specimen submitted from the lip lesion consisted of a port back should symptoms reappear.
mucosa-covered tissue fragment measuring 12x5x4mm.
Histological evaluation confirmed the presence of a tis-
DISCUSSION
sue fragment surfaced by stratified squamous epithelium
with areas of hyperparakeratosis, as well as vacuolar The presence of lichenoid inflammation with concomitant
degeneration of the basal cell layer with associated granulomatous inflammation is an uncommon observa-
apoptotic bodies. A band-like lymphohistiocytic infiltrate tion within the oral cavity. Many diseases are typified
was seen in the underlying superficial lamina propria. by either lichenoid or granulomatous inflammation. 1
Secondarily, varying degrees of granulomatous inflam- However when both patterns occur simultaneously,
mation within the superficial lichenoid inflammatory infil- problems arise in determining which pattern represents
trate was noted. These poorly formed granulomas were the primary disease process, or whether the coexistence
composed of epithelioid macrophages, however no of both patterns represents a distinctive disease entity.
giant cells or central necrosis could be appreciated.
Additionally, lymphoid follicles were seen, with a striking The term lichenoid granulomatous stomatitis (LGS) was
first described in literature by Robinson et al. in 2006.1
Lichenoid inflammation may render the oral mucosa
Author affiliations:
susceptible to the ingress of foreign material, resulting in
1. Liam Robinson: BChD, PDD (Maxillofacial Radiology), PDD
(Forensic Odontology), Department of Oral Pathology and Oral granuloma formation. LGS has been reported in cases
Biology, School of Dentistry, Faculty of Health Sciences, of foreign body gingivitis. In a series of 61 foreign body
University of Pretoria. gingivitis cases, investigators reported the presence of
ORCID Number: 0000-0002-0549-7824
2. André W van Zyl: BChD, MChD, Private Practice Periodontist, both patterns of inflammation in 26% of biopsies studied.2
Hermanus & Honorary Professor, Department of Oral Medicine In the present case, no foreign material could be identi-
and Periodontics, Faculty of Health Sciences, University of fied under polarised light.
Witwatersrand.
3. Willie FP van Heerden: BChD, MChD, FC Path (SA) Oral Path,
PhD, DSc, Department of Oral Pathology and Oral Biology, School To date the largest review by Hakeem et al.3 in 2019
of Dentistry, Faculty of Health Sciences, University of Pretoria. identified 47 patients with LGS. In this study, patient
ORCID Number: 0000-0003-2494-667X
Corresponding author: Willie FP van Heerden
demographics showed a female predilection of 1.9 :1
Department of Oral Pathology and Oral Biology, University of Pretoria, with a mean age of 59 years. Seventy-nine percent of
South Africa. patients were older than 55 years. Patients commonly
Email: [email protected]
presented with a solitary lesion, with most cases occur-
Author contributions:
1. Liam Robinson: Principle author - 50% ring on the attached gingiva followed by the buccal
2. André W van Zyl: Clinical case, treatment and follow-up - 25% mucosa and vestibule. With regards to clinical descrip-
3. Willie FP van Heerden: Diagnosis, histological images and tion, 38% were described as erythroleukoplakia, 36% as
advisor - 25%
leukoplakia, and 26% as purely erythematous lesions.
212 >
CASE REPORT

There was an equal incidence of presentation amongst presence of fungal hyphae was not associated with
patients regarding painful or non-painful lesions. The a lichenoid inflammatory reaction. 1 Secondly, granulo-
clinical impressions for all cases in this study (for which matous inflammation is typical of deep mycoses and
multiple were listed in some instances) included lichen not superficial candidosis.
planus (17 cases), dysplasia/carcinoma in situ/squamous
cell carcinoma (11 cases), vesiculobullous lesions (9 Patients taking certain medications may develop LGS,
cases), trauma-associated (5 cases), leukoplakia (5 cases), which may ultimately resolve with discontinuation of the
allergy (2 cases) and other differentials (4 cases). No clini- medication.3 Additionally, the case review by Robinson
cal diagnosis was reported in 7 cases.3 et al., reported two patients known to be on medica-
tions that have an association with lichenoid eruptions,
Histologically, LGS consists of three distinctive com- namely Naproxen (Non-steroidal anti-inflammatory drug),
ponents. First, is the presence of lichenoid inflammation, Atenolol (β-adrenoceptor blocker), and Ramipril (Angio-
characterised by hyperkeratosis, basal cell degeneration tensin-converting enzyme inhibitor).4 Furthermore, these
with associated apoptotic bodies and a band-like groups of drugs have also been implicated in both
lymphohistiocytic inflammatory cell infiltrate. Secondly, lichenoid and granulomatous dermatitis.
variable degrees of granulomatous inflammation can be
seen throughout the corium. Importantly, all granulomas Equally rare is the presence of both patterns of inflam-
consist of epithelioid macrophages without giant cells or mation in dermatological conditions. Lichenoid granulo-
areas of necrosis. Thirdly, lymphoid follicles are present matous dermatitis (LGD) was first described by Gonzalez
in the corium showing a prominent perineural distribution.1 in 1986.5 A study by Magro and Crowson6 reported a
series of 40 patients with skin lesions showing lichenoid
Additional studies ruling out infective agents and foreign dermatitis with a granulomatous component. The maj-
material should be performed in suspected cases. A study ority of these cases had confounding medical problems
of six cases of LGS by Robinson et al.1 found that associated with the disease, however one-fifth of the cases
were considered idiopathic. Furthermore, in 12 cases an
fungal hyphae were detected in the superficial epithelial infective cause was implicated. The agent was either a
layers in a single case. The significance of which was
unknown. However, studies have shown that the v i r a l

Figure 3. H&E-stained section showing a poorly formed granuloma

(white arrow) within the superficial inflammatory cell infiltrate (original
magnification x 200).

Figure 1. Initial clinical presentation.

Figure 2. H&E-stained section showing the band-like inflammatory cell

infiltrate (white arrows) and lymphoid aggregates in a perineural and
perivascular distribution (black arrows) (original magnification x 40). Figure 4. Clinical presentation one month post initial biopsy.
www.sada.co.za / SADJ Vol. 75 No. 4
CASE REPORT < 213

or bacterial infection and not fungal in origin.6 Both inf-

lammatory patterns have also been reported to coexist
in a rare skin condition, lupus erythematosus profundus.7

In total approximately 57 cases have been previously

reported as LGD. The gender ratio reported in the
prior cases showed a slight female predilection of 1.3:1
with mean age of 48 years. The trunk, arms, and legs
were the most common location. Dermatologic lesions
mostly presented as erythematous or as maculopapular
entities.6,8-9

Although many similarities were found when comparing

histological features of LGS and LGD, some important
differences were noted. Cases from the oral mucosa
did not show an interstitial array between collagen fibers
surrounded by palisaded histiocytes, granuloma annu-
lare-like appearance, focal Langhans giant cells or
granulomatous vasculitis. Additionally, a prominent peri-
vascular inflammatory infiltrate, as seen in LGS cases,
was not emphasised in descriptions of lesions involving
the skin.3

Literature is sparse regarding the treatment of LGS,

however, it appears to respond well to similar regimens
used in treating conventional lichen planus.3

References
1. Max Robinson C, Oxley JD, Weir J, Eveson JW. Lichenoid
and granulomatous stomatitis: An entity or a non-specific in-
flammatory process? J Oral Pathol Med. 2006; 35(5): 262-7.
2. Gordon SC, Daley TD. Foreign body gingivitis: Clinical and
microscopic features of 61 cases. Oral Surg Oral Med Oral
Pathol Oral Radiol Endod. 1997; 83(5): 562-70.
3. Hakeem A, Bhattacharyya I, Aljabri M, Bindakhil M, Pachigar K,
Islam MN, et al. Lichenoid reaction with granulomatous sto-
matitis: A retrospective histologic study of 47 patients. J Oral
Pathol Med. 2019; 48(9): 846 -54.
4. Scully C, Bagan JV. Adverse drug reactions in the orofacial
region. Crit Rev Oral Biol Med. 2004; 15(4): 221- 39.
5. Gonzalez JG, Marcus MD, Cruz DJ. Giant cell lichenoid der-
matitis. J Am Acad Dermatol. 1986; 15(1): 87- 92.
6. Magro CM, Crowson AN. Lichenoid and granulomatous der-
matitis. Int J Dermatol. 2000; 39(2): 126 -33.
7. Crowson AN, Magro C. The cutaneous pathology of lupus
erythematosus: A review. J Cutan Pathol. 2001; 28(1): 1-23.
8. Bulur I, Gokalp H, Erdem O, Gurer M. A rare form of liche-
noid tissue reaction: Lichenoid granulomatous dermatitis.
J Med Cases. 2015; 6: 95-7.
9. Ghasemibasir H, Khezrian L, Sobhan MR. Lichenoid and
granulomatous dermatitis: Report of two cases from Iran.
Iran J Derm. 2015; 18(3): 136-9.
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CLINICAL WINDOW http://dx.doi.org/10.17159/2519-0105/2019/v75no4a8
The SADJ is licensed under Creative Commons Licence CC-BY-NC-4.0.

What’s new for the clinician?

- Excerpts from and summaries
of recently published papers
SADJ May 2020, Vol. 75 No. 4 p214 - p217

Compiled and edited by V Yengopal

1. Alvogel versus absorbable gelatin sponge as palatal

wound dressings following epithelialized free gingival
graft harvest
K Ehab, O Abouldahab, A Hassan, KM El-Sayed. Alvogel and absorbable gelatin sponge as
palatal wound dressings following epithelialized free gingival graft harvest: a randomized clinical
trial. Clinical Oral Investigations. 2020; Mar 6:1-9.

The gingiva covering the hard palate is composed of MATERIALS AND METHODS
three histologic layers: the orthokeratinized epithelium,
the coarse subepithelial connective tissue (the lamina pro- This was a prospective, randomized clinical trial with a
pria), with its high proportion of inter-cellular substance, parallel design that sought to investigate the effects of
and the submucosa, attaching the lamina propria to the Alvogel (intervention group) versus absorbable gelatin
periosteum of the underlying bone.1 sponge (control group) as palatal wound dressing
agents, on the incidence and severity of postoperative
Clinically, the hard palate gingiva is harvested (donor pain, amount of analgesic consumption, post-surgical
tissue) for tissue grafting in a variety of sites in the bleeding, and palatal wound re-epithelization, following
body, e.g., the hip and ocular regions. Postoperative epithelialized free gingival graft harvesting.
pain and bleeding at these donor sites on the hard
palate are most common complication following free Thirty six healthy patients scheduled for different perio-
gingival palatal graft harvesting until complete re- dontal and peri-implant plastic surgeries, requiring pal-
epithelization. atal mucosal graft harvesting, either epithelialized or
de-epithelialized, were recruited for this trial. Patients
Although various agents have been suggested to pro- with severe gagging reflex, smoking patients, pregnant
tect the denuded donor areas of the palate, including or lactating females, patients with psychiatric disorder,
stents, collagen- gel tin scaffolds, resorbable gelatin patients with coagulation disorders, patients with known
sponge, oxidized cellulose and sterile gauze combined allergies to any of the used agents, and diabetic patients
with external pressure, platelet-rich fibrin (PRF), medici- were excluded.
nal plant extract dry socket (MPE), platelet concen-
trates and equine-derived collagen, currently, no gold Before the procedure, all patients received full mouth
standard exists.1 supra- and subgingival scaling and detailed oral hygiene
instructions. Patients were then randomized into interven-
Ehab and colleagues from Egypt (2020)1 reported on a tion (receiving Alvogel as a dressing for their palatal
trial that sought to clinically compare for the first time wounds) and control (receiving the absorbable gelatin
the effects of Alvogel (used commonly for the manage- sponge as a dressing for their palatal wounds) groups,
ment of dry socket [alveolar osteitis ] ) versus absorb- with an allocation ratio 1:1.
able gelatin sponge as a palatal wound dressing on the
incidence and severity of postoperative pain, amount Blinding of the participants and outcome assessor was
of analgesic consumption, post-surgical bleeding, and possible but the operators placing the test materials
palatal wound re-epithelization, following epithelialized could not be blinded. The primary surgical site requiring
free gingival graft harvesting in a randomized controlled soft tissue grafting was prepared using a standardized
clinical trial. protocol on both groups. The graft was used as it is or
de-epithelialized extraorally, according to the purpose it
Veerasamy Yengopal: BChD, BScHons, MChD, PhD, Community
was harvested for.
Dentistry Department, School of Oral Health Sciences, University
of Witwatersrand, Medical School, no. 7 York Road, Parktown 2193,
South Africa. The graft dimensions (width and length) and the thick-
ORCID Number: 0000-0003-4284-3367 ness of the residual palatal mucosa in a midpoint of the
Email: [email protected]
wound area were recorded, using William’s graduated
www.sada.co.za / SADJ Vol. 75 No. 4
CLINICAL WINDOW <
215

periodontal probe. In the intervention group, the de- At 1, 2, 3, 4, and 5 days, significantly higher patient-
nuded palatal area was superficially covered with a reported VAS pain scores were noted in the control
continuous thin layer of Alvogel (Septodont), while in the as compared with the intervention group. At days 6 and
control group, absorbable gelatin sponge (Cutanplast 7, no significant differences were notable between the
Standard) was cut to the palatal wound size and applied. groups. The control group continued to demonstrate sig-
Following manual compression of the wound area, both nificantly higher pain scores from days 8 to 12.
agents were secured in place using compressive palatal
sling sutures. Again, on the 13th and 14th days, no significant differen-
ces were notable in the pain scores between the two
After the procedure and placement of Alvogel or gelatin groups. Over time, a significant decrease in pain scores
sponge, every patient was given 1 g amoxicillin plus cla- was notable independently in the intervention group and
vulanic acid twice per day for 6 days and 150 mg bi- the control group (within group comparison).
profenid for 7 days when needed. Patients were advised
to rinse twice a day with 0.12% chlorhexidine HCL solu- A significantly higher number of analgesic tablets were
tion for 3 weeks following the surgery. Sutures were consumed by patients in the control group in contrast to
removed 14 days following the surgery. The Alvogel the intervention group over the first 7 days of the healing
and the gelatin sponge were not removed postopera- period (Table 5, Mann-Whitney U test).
tively and disintegrated, and were incorporated into the
healing tissues over the healing period. Up to 3 weeks following the palatal graft harvesting, no
complete re-epithelization was noted in any of the cases
Patient-reported daily VAS pain scores (scores vary of the intervention or control groups. At 4 weeks, no
between 0 and 10. 0, no pain; 1, minimal pain; 5, significant differences were notable between groups, with
moderate pain; 10, severe pain) for 2 weeks post-sur- 22.2% of subjects in the intervention and 11.1% sub-
gically were defined as the study’s primary outcome. jects in the control group demonstrating complete re-
epithelization of their palatal engraftment sites. At 5
Post-surgical bleeding and complete re-epithelialization weeks postoperatively, all subjects in both groups de-
of the palatal wound over the follow-up period of 5 monstrated complete re-epithelization of their palatal.
weeks until complete healing were achieved in addition No postoperative bleeding was reported in any of the
to the number of analgesic tablets consumed over 7 groups.
days (1st week) were defined as secondary outcomes.
CONCLUSION
Re-epithelization of the palatal wound was evaluated
using the H2O2 test. Briefly, the healing area to be The trial results suggest that Alvogel is a viable option
evaluated was dried, and 3% H2O2 was sprinkled on as a practical palatal dressing agent, comparable with
the wound. If the epithelium was still discontinuous, absorbable gelatin sponge, in haemostasis, pain reduction,
H2O2 diffuses into the palatal connective tissue, where and palatal wound re-epithelization supporting properties.
the enzyme catalase acts on H2O2, releasing water
and oxygen and clinically producing bubbles on the Implications for practice
wound surface. Complete healing scores were recorded Alvogel, could be considered as another viable option
as a dichotomous variable (yes/no). Re-epithelization of to protect the denuded donor areas of the palate when
the palatal wounds was evaluated weekly for 5 weeks undertaking grafting procedures in the palate.
postoperatively.
Reference
1. Ehab K, Abouldahab O, Hassan A, El-Sayed KM. Alvogel
RESULTS and absorbable gelatin sponge as palatal wound dressings
Thirty-six patients were recruited for the present ran- following epithelialized free gingival graft harvest: a ran-
domized clinical trial. Clinical Oral Investigations. 2020; Mar
domized controlled clinical trial: 18 patients in the inter-
6:1-9.
vention (13 females and 5 males, mean age 31.3 years)
and 18 patients in the control group (11 females and 7
males, mean age 34.1 years). The intervention and con-
trol groups were balanced for age and gender (p > 0.05).

There were no dropouts and all patients in both groups

completed the follow-up period until complete healing
postoperatively. No adverse effects were reported in any of
the groups.

Although the harvested grafts varied in their width (5 to

15 mm) and length (8 to 22 mm), according to the muco-
gingival procedure they were harvested for, no significant
differences were noted in the harvested graft dimen-
sions between the intervention and the control groups.
The remaining palatal tissue thickness varied between 0
and 2 mm, with significantly lower palatal tissue thickness
noted in the control group.
216 >
CLINICAL WINDOW

2. Comparison of four different suture materials as

regards oral wound healing, microbial colonization,
tissue reaction and clinical features
Dragovic M, Pejovic M, Stepic J, Colic S, Dozic B, Dragovic S, Lazarevic M, Nikolic N,
Milasin J, Milicic B. Comparison of four different suture materials in respect to oral wound
healing, microbial colonization, tissue reaction and clinical features-randomized clinical study.
Clinical oral investigations. 2019; Jul 24: 1-5.

Sutures support the damaged or injured tissues until standard triangular flap was performed with the vertical
continuity of surface and enough tensile strength is re- releasing incision made at the distal part of interdental
gained during the process of wound healing. 1 Oral papilla between first and second molar. Several inter-
wound healing follows the well-known general principles rupted sutures were placed in order to obtain primary
of wound healing but with certain peculiarities. wound healing. After a period of 4-5 weeks, impacted
molars from the other side were extracted following the
First of all, oral mucosa is colonized by bacteria which, described procedure. Each wound was closed with a
in conjunction with food detritus, form biofilm and faci- different suture material taking care of equal distribu-
litate wound infection. Secondly, oral wounds cannot tion between jaws. Suture positions for the first patient
be immobilized due to the function of oral tissues. were determined by toss of a coin and after that, clock-
Lastly, these wounds are often in contact with avascular wise rotation was done until each suture material
structures (enamel, ceramic, metal) and thus devoid of was placed in every quadrant equal number of times.
active metabolic exchange during the healing process.1 Stitches were removed 7 days postoperatively.

Clinically, there are two types of wound healing: healing Patients were given uniform postoperative instructions
by primary intention, resulting in regeneration of specific which included antibiotics regime (amoxicillin 500 mg
tissues with the same characteristics as the tissue prior or clindamycin 300 mg) and rinsing with chlorhexidine
to trauma and healing by secondary intention where the solution 0.2%, three times a day for 7 days. Patients
tissue is not regenerated but only repaired and replaced were also told to apply cold packs immediately after
with nonspecific scar tissue.1 surgical procedure until bedtime with breaks on every
15 min. Before the operation and the day after, 4 mg of
In contemporary oral surgery, primary healing enabled dexamethasone was administered in order to reduce
by the use of sutures along with an adequate intra- postoperative swelling and patient discomfort. For pain
operative handling of soft tissues is an absolute impera- control, ibuprofen 400 mg was prescribed four times a
tive in order to obtain optimal functional and aesthetic day for the first 2 days postoperatively.
long-term results.
The suture materials used in this study were Sofsilk®
Sutures can increase the risk of postoperative as oral (non-absorbable natural multifilament wax coated silk);
microbes can attach themselves to the surfaces of the Surgipro® (non-absorbable synthetic monofilament poly-
suture material. Sutures also can induce inflammatory propylene); Polysorb® (absorbable multifilament co-
reactions due to them being foreign bodies introdu- polymer of glicolide and lactase 9:1- Lactose® coated
ced into the oral cavity during wound repair/treatment. with Ca-stearate and Ε-caprolactone); and Caprosyn®
(absorbable monofilament co-polymer of E-caprolactone,
Dragovic and colleagues (2019)1 reported on a trial that glicolide, trimethylen carbonate, lactase 6:2:2:1-Polygly-
sought to compare four different suture materials used tone 6221®). All sutures were applied with a 4–0 gauge
in oral surgery in terms of their biocompatibility, degree with 19 mm, 3/8 circle “reverse cutting” needle.
of bacterial colonization and inflammatory reaction, influ-
ence on wound healing, and basic clinical parameters. In order to visualize the surface and the structure of
sutures, samples of all materials used in this trial were
chosen randomly and analyzed using scanning electron
MATERIALS AND METHODS
microscopy (SEM).
A total of 32 patients (21 females and 11 males) aged
18 -25 indicated for surgical extraction of four totally In order to assess suture material biocompatibility, an
impacted wisdom teeth were included in the study. MTT (3 - (4, 5- dimethylthiazolyl-2)-2, 5 diphenyltetrazolium
Only healthy patients, non-smokers without systemic bromide) assay was done using gingival fibroblasts
and/or oral diseases, were included. Using standard obtained from a healthy male patient, 18 years old. The
surgical protocols, unilateral upper and lower wisdom cells were cultured at 37°C in humidified atmosphere
teeth have been extracted at the same time. containing 5% CO 2. Ten thousand cells were seeded
onto a 96-well plate. After 24 h, four different suture
In the mandible, an envelope design for the mucoperi- materials were suspended in 100 μl of growth medium
osteal flap was used with sulcular incision going from with cells. The growth medium was replaced every se-
the first molar, engaging second molar and extending cond day. After 7 days, MTT was added to each well,
buccally along the external oblique ridge. In the maxilla, incubated for 4 h, and the supernatant with suture ma-
www.sada.co.za / SADJ Vol. 75 No. 4
CLINICAL WINDOW <
217

terials was discarded. Precipitates were dissolved in val fibroblast the most. Moreover, a statistically significant
100 μl dimethyl sulfoxide (Sigma-Aldrich) by shaking at difference in percentage of viable fibroblast around this
37 °C. Optical density (OD) was measured at 540 nm suture compared to NA-Mono (Surgipro®) and A-Mono
using an ELISA reader. The percentage of viable cells (Caprosyn®) (p = 0.023*, p = 0.004* respectively) was
was calculated using the following formula: % of viable observed.
cells = OD (sample)/OD (control) × 100. All experiments
were done in triplicate. For micro-organism quantifica- A total of 128 suture samples were examined for
tion, PCR testing was done. microbial adherence, and significantly lower amount of
microbial load was found on monofilament compared to
For histological analysis, one knot of every suture ma- multifilament sutures. Statistically significant differences
terial from each patient was obtained on the day of were found between suture types compared between
the removal and immersed in 10% neutrally buffered them (p = 0.000*) except for the comparison of NA-
formalin solution. Only the part of the suture that was Multi (Sofsilk®) and A - Multi (Polysorb®) (p = 0.243).
implanted in the tissue was sectioned. Individual sec- Clinically, there was significantly better healing around
tions were stained with hematoxylin and eosin (H&E) all synthetic materials NA-Mono (Surgipro®), A-Mono
and examined under optical microscope. Inflammatory (Caprosyn®), and A-Multi (Polysorb®) compared to na-
cells were counted on three different sections of each tural multifilament NA-Multi (Sofsilk®) both on the third
suture sample and according to average number, indi- and seventh day postoperatively.
rect assessment of inflammatory reaction was scored
as follows: Significant statistical differences were found between
all sutures regarding the ease of handling and ease of
(1). No inflammatory reaction (0 inflammatory cells). removal. For suture removal pain, statistically signifi-
(2). Mild inflammatory reaction (< 30 inflammatory cells). cant difference was found between all sutures except
(3). Moderate inflammatory reaction (30 - 60 inflamma- between NA-Multi (Sofsilk®) and A-Multi (Polysorb®)
tory cells). (p = 0.849). Although NA-Mono (Surgipro®) caused the
(4). Strong inflammatory reaction (> 60 inflammatory cells). greatest discomfort to patients among all suture types,
the statistical significance was found only for the
Clinical assessments were done on the first, third, and seventh day postoperatively between this suture and
seventh days postoperatively. Soft tissue healing was NA-Multi (Sofsilk®) and A-Mono (Caprosyn®) (p = 0.037*,
judged by the oral surgeon with the help of a healing p = 0.003* respectively). NA-Mono (Surgipro®) was the
index (HI). Using a visual analogue scale (VAS), the suture that exhibited the least postoperative amount
operator rated threads with respect to ease of intrao- of slack compared to all other sutures throughout the
perative handling immediately after the intervention and entire postoperative period.
ease of removal 7 days later.
In the linear regression model in which microbial adher-
Patients, using the same scale, evaluated the discom- ence was used as dependent variable, the following
fort and suture removal pain for each type of suture. explanatory variables were found to be independent
Postoperative amount of slack was assessed for every predictors of variabilities among patients: suture type,
suture material with the help of graduated probe UNC suture slack (seventh day), ease of suture removal, post-
15. The knot was carefully lifted with cotton pliers, and operative infection.
the distance from the knot to the tissue was measured
to the nearest 0.5 mm. In the lower jaw, this proce-
CONCLUSIONS
dure was carried out on the suture which was placed
at the interdental papilla between first and second molar. Non-resorbable polypropylene sutures showed superior
In the upper jaw, measuring was done on the suture clinical characteristics among all sutures. Moreover, the
placed at the mesial corner of the mucoperiosteal flap. best healing of soft tissue and the least inflammatory
reaction was found around this thread. The poorest soft
RESULTS tissue healing was found around non-resorbable silk
suture. This suture elicited strongest inflammatory reac-
All suture threads were analyzed, and substantially more tion and showed the greatest microbial adherence affi-
amount of dental plaque was found on multifilament nity compared to alternative sutures.
sutures compared to monofilament ones as seen on
representative micrographs. Microscopic analysis show- Implications for practice
ed more pronounced inflammatory reaction around mul- Monofilament synthetic suture should be used in order
tifilament sutures, as a significantly higher number of in- to obtain the best soft tissue healing, reduce the risk
flammatory cells were found around these sutures com- of postoperative infection, and alleviate the suturing
pared to monofilaments. The highest number of inflam- after oral surgery procedures.
matory cells was found around NA-Multi (Sofsilk®) and
the smallest number around NA-Mono (Surgipro®). A Reference
statistical difference in the number of inflammatory cells 1. Dragovic M, Pejovic M, Stepic J, Colic S, Dozic B, Dragovic S,
was also found between all sutures compared between Lazarevic M, Nikolic N, Milasin J, Milicic B. Comparison of
them, except between NA-Multi (Sofsilk®) and A-Multi four different suture materials in respect to oral wound
healing, microbial colonization, tissue reaction and clinical
(Polysorb®). Moreover, incidence and degree of inflam-
features - randomized clinical study. Clinical oral investiga-
matory reaction differed significantly among all sutures
tions. 2019; Jul 24: 1-5.
NA-Multi (Sofsilk®) was the suture that attracted gingi-
218 >
RADIOLOGY CASE http://dx.doi.org/10.17159/2519-0105/2020/v75no4a9
The SADJ is licensed under Creative Commons Licence CC-BY-NC-4.0.

Maxillofacial Radiology 180

SADJ May 2020, Vol. 75 No. 4 p218

CJ Nortjé

Figures, A & B are images of a patient who presented with underlying fractures of the body on the right side and
angle of the mandible on the left side. Discuss the most important radiological features discernible on the radio-
graphs and what are your conclusions?

A B

C D

Image Layer Analysis

Position of round object Round object as imaged
within layer on film Anterior Posterior

Magnified &
Outside Centre Narrowed

In Centre Magnified &

Round

Inside Centre
Magnified &
Widened

E F

INTERPRETATION
The most important findings are: Figure A shows ligature What it means is that a small error in the positioning of
wiring of the bilateral fractures and the presence of a the patient may cause diagnostic problems for example
pellet (blue arrow). However the posterior-anterior man- if it gets close to the edge of the layer or when the struc-
dible radiograph (Fig. B) of the same patient shows mul- ture is not exactly in the middle of the layer, may result
tiple pellets which are not discernible on the pantomo- in misdiagnosis. If something is not in the layer, you would
graph (Fig. A).The blue arrow in Figure A represents the not be able to observe it. The many birdshot present
same blue arrow in Figure B. To illustrate to you how in Figure B, are not discernible in the pantomograph
easy it is to have a problem I want to illustrate the fol- because the birdshot was not in the layer. However when
lowing case. Looking at the cropped pantomograph (Fig. something is in the middle of the layer it has its nice
C) we see a missing tooth in the right lower jaw, as well configuration and a perfect shape. Looking at Figure F
as a supernumerary tooth. But if you examine the patient you will notice that the metal ball has a perfectly round
clinically, you will notice that there are two supernumer- shape if it is in the centre of the layer (red arrow). However
ary teeth (Fig. D) in the lower left mandible, which is not if the object is close to the edge of the layer towards
depicted on the radiograph because the supernumerary the film (buccally) you will notice that it is narrow (yellow
teeth are not present in the layer (focal trough) (Fig. E). arrow) and if the object is on lingual side of the layer,
the object appears to be widened (green arrow).
Christoffel J Nortjé: BChD, PhD, ABOMR, DSc. Faculty of Dentistry,
University of the Western Cape. Reference
ORCID Number: 0000-0002-9717-5514 1. Langlais RP, Langland OE, Nortje CJ: Diagnostic Imaging of
Email: [email protected] the Jaws. 1st edition. Williams & Wilkens. 1995; 225 - 65.
http://dx.doi.org/10.17159/2519-0105/2020/v75no4a10
The SADJ is licensed under Creative Commons Licence CC-BY-NC-4.0. ETHICS <
219

Yes, you can say no

SADJ May 2020, Vol. 75 No. 4 p219 - p222

LM Sykes1, E Crafford2, A Fortuin3

INTRODUCTION
Quality dental care begins with determining the patient’s ment, immaturity, or defective faculties of reasoning”,
understanding of the dental treatment, their expectations, and is meant to protect that subject from dangerous
attaining all the diagnostic information and compiling a choices that are not truly their own.1 It is often not regard-
treatment plan best suited to each individual.1 Once a ed as truly paternalistic if the agent’s liberty- limiting
decision has been made to undertake treatment, the actions are performed to either protect the subject from
clinician may adopt a paternalistic approach or could harm, or from receiving no benefits, or to confirm that
lean towards respecting patient autonomy.2 their decisions were truly voluntary. Note that agents’
motives matter!
In the former, the clinician takes on an authoritative role
and imposes the treatment plan on the patient, while in Hard paternalism often includes politically, morally, or
the latter there is more emphasis on the doctor : patient ethically controversial issues such as government legis-
relationship and it is the patient who ultimately decides lation regarding wearing of seat belts, prohibition of re-
on what treatment will be performed. If there is a lack creational drugs or water fluoridation.4
of agreement between the two, the practitioner may be
faced with a legal and/or ethical dilemma.2 When deciding if it is liberty-limiting one has to consider
whether it is justified and to what extent. Pope (2004)3
In legal terms, paternalism has been defined as “Restric- proposed that an action may be regarded as justifiable
tion of a subjects self-regarding conduct primarily for hard paternalism if the agent’s liberty-limiting intervention
the good of that same subject”.3 However many disputes met four criteria: the agent must:
have arisen over its use and justification in the health
care setting. 1. intentionally limit the subject’s liberty;
2. believe their actions will contribute to the subject’s
Confusion and disagreement has been compounded by welfare and must intervene with a benevolent motive
the fact that there are no clear boundaries between either to confer a benefit or to prevent the subject from
what should be considered “soft” (weak) paternalism, and harm;
what constitutes “hard” (strong) paternalism. Soft pater- 3. show benevolence independent of the subject’s
nalism can be justified on the basis that the individual preferences; and
“lacks the requisite decision-making capacity to en- 4. disregard the fact that the subject’s actions are
gage in the restricted conduct”. This includes situa- voluntary, or deliberately limits their voluntary conduct.
tions where their decision was: “not factually informed;
not adequately understood; coerced; or not substantially To further distinguish between hard paternalism and ty-
voluntary”. rannical dictatorship, the liberty-limiting action of the
clinician must be “subject focused”, altruistic, benevolent
Maturity and mental capacity have also been mentioned and aim to confer benefit or avert harm.3 Note, that he
as factors to consider. Soft paternalism does not call for states it must be “benevolent” not necessarily “beneficent”.
the constraint of any decision, but rather for the con- Once again it is a matter of intent. The former refers to
straint of an “impaired decision” due to a person’s “com- the agent’s will (volens) to do good (bene), while the latter
pulsion, misinformation, impetousness, clouded judge- refers to the actual action of doing (facere) good (bene).

In medical terms, paternalism refers to “acting without

Author affiliations:
1. Leanne M Sykes: BSc, BDS, MDent, IRENSA, Dip Forensic consent or overriding a persons wishes, wants or actions,
Path, Dip ESMEA, Head of Department of Prosthodontics, in order to benefit the patient or prevent harm to them”.3
University of Pretoria, Pretoria, South Africa. Strong paternalism is when the clinician overrides com-
ORCID Number: 0000-0002-2002-6238
2. Elmine Crafford: BBChD, BChD Hons, Oral Medicine, MChD OMP, petent patient’s wishes and is rejected as it violates
Senior Specialist Department of Oral Medicine and Periodontics, their autonomy and falsely presumes knowing what is
University of Pretoria, Pretoria, South Africa. best for them.3 Weak paternalism refers to acting for the
3. Alwyn Fortuin: BChD, PDD, MDent, Specialist Department of
Prosthodontics, University of Pretoria, Pretoria, South Africa.
benefit of an incompetent patient and may be justified
Corresponding author: Leanne M Sykes in order to restore their competence, or to prevent them
Head of Department of Prosthodontics, University of Pretoria, Pre- from harm, and as such may be justified.5
toria, South Africa.
Email: [email protected]
Author contributions: At the same, it is a social, political, and moral obligation to
1. Leanne M Sykes: Principal author - 60% respect an individual’s autonomy and self-determination.
2. Elmine Crafford: Second author - 20% Proponents of this right argue that the beneficence of
3. Alwyn Fortuin: Third author - 20%
paternalism may be at the expense of autonomy, how-
220 >
ETHICS

ever they often fail to consider the benevolence of the derstood all the risks, and was willing to take full
action. It is also situation specific, and open to change. responsibility, would you then agree to treat her?
A clinician’s opinions and subsequent actions could vary
depending on the circumstances at that time. The im- Only 6% more dentists (41%) now agreed to treat de-
portant issue to consider is the intention that guided spite the added psychological perspective (Figure 1).
their judgment and decision. This was clearly illustrated There was concern that the patient needed psycholo-
by results of one survey question described below. gical rather than dental intervention, which made some
even more reluctant to treat her.
SURVEY DESIGN
I am not a trained psychologist but would be alert to
In the same survey as was reported on in the ethics issues of body dysmorphia and suggest pre-counselling.
paper of April 20206, dental practitioners were asked to
complete a questionnaire in which a number of practice- I would have to consider the risks of acquiescing to
related ethical scenarios and questions were posed. treatment demands being made in that context.
One question related to patient autonomy, beneficence,
non-maleficence, paternalism, and informed consent. She must seek other help, this is not an emergency.

A case scenario was presented in four parts with ad- No, this is intrinsically wrong.
ditional information given progressively in order to see if
and how the respondents’ opinions changed depending In that case I would whiten them for her only.
on the circumstances. Over 40 dentists completed the
questionnaire, and the results are presented below. c). Ethical behaviour refers not only to the act of doing
good (beneficence), but also to the duty of pre-
venting harm. If she now said that she knew of a
RESULTS
technician who was willing to carry out the work
The case read as follows: “A young attractive lady comes for her. You were concerned that this person was
to your rooms and asks you to place veneers on all not a trained clinician, and may provide a poor
her anterior teeth in order to give her a bright, A1 smile. service. Would you then concede to treat in order
to prevent possible harm?
All of her teeth are sound, and in your opinion she
already has an attractive and natural looking smile. Opinions did not change despite the added informa-
You educate her as to all the risks involved in the tion to consider the risks of harm. Thirty three percent
procedure but she is still adamant that she wants to agreed to treat and 67% refused (Figure 1).
go ahead with the treatment.”
Further comments were received when asked to elabo-
a). In terms of respect for patient autonomy, would you rate on any of the above questions. Many advised
concede to treat? to get a second opinion from another dentist. Other
comments included:
Only 35% of the respondents said they would treat,
(Figure 1) some having added provisos such as: “I would As a health care practitioner I have a duty and responsi-
only treat if full consent had been given and if I know I bility not to do harm. If “it is not broken, why fix it” – we
can do the work well”. Sixty five percent said they are also educators if there is no need for treatment do
would not treat with many stating that they would not force it.
advise her to seek a second opinion.
I’ll strongly advise a second opinion and get her to sign
70%
that this was not life threatening or an emergency and
60%
so didn’t need me to treat her at that time.
50%
Regardless of her arguments, if I think it’s a clinically in-
40%
correct decision I still will not treat. Healthy enamel can-
30%
not be bought - for everything else there is MasterCard
20%
(sic).
10%

0% I believe in a healthy mouth preservation and my duty

Autonomy Mental health Avoid harm
to inform patients
Yes No
Figure 1. Clinicians’ responses to the three questions posed in parts a), b) The patient is informed of what her rights are and
and c) of the case scenario. what the role of the dentist / and other professio-
nals is
b). The WHO defines health as “a state of complete
physical, mental, and social well-being, and not As long as you have informed her and made a docu-
merely an absence of disease or infirmity”. With ment of all discussions, you can let her make her
this in mind, if the patient pleaded that she was own decision
experiencing emotional and psychological distress
as a result of being self-conscious, that she un- I would rather discuss all the aspects of tooth bleaching.
www.sada.co.za / SADJ Vol. 75 No. 4
ETHICS <
221

Those whose opinion was altered by her final argument DISCUSSION

gave reasons such as:
Traditionally in medicine and dentistry, the clinician, being
Yes, in this case if it’s the patient’s choice and her wish, the trained professional, was presumed to know what was
I’d rather she gets professional treatment by me than the best for their patients, and thus justified in making
someone else. treatment decision for them.

The patient would be educated by me and the scope Proponents of outside agent intervention argued that the
of practice of a technician and advised to get another choices individuals make do not always reflect their
dental opinion or psychological counselling, however, if true desires and preferences, and are often not in their
she chose to persist in spite of being provided all perti- own best interest. Carl Elliot went so far as to state that
nent information this would be a case of her exercising “People do not always mean what they say; they do not
her autonomy and she can do it. always say what they want; and they do not always want
what they say they want”.7 This radical opinion may have
Help her to prevent her suffering from future harm. led others to question the ethics of hard paternalism,
and the subsequent development of a more patient-
A few had strong opinions that were not swayed by centred approach.
the final argument:
Beauchamp and Childress were leaders in the field of
I said no as this case is a disaster waiting to happen. biomedical ethics when they published their “Principles
of Biomedical Ethics”.8 Since then there has been grow-
There is also a time to say NO. ing emphasis on the principles surrounding respect for
patients’ autonomy. 3 This holds that individuals have
Definitely not. the right to make their own choices, and develop their
own life plan. In the health care setting it translates into
There are many dentists around and the patient will informed consent, and requires a clinician to provide all
move on. necessary information for patients to make a free, intelli-
gent decision; ensure they understand the information;
This type of patient is a danger to the practice. and to recommend an ideal treatment option without
persuasion, pressure or coercion.5
Unfortunately I don’t like being forced into doing some-
thing so NO! They strongly supported the notion that “The core of
any clinical encounter in a health care setting is respect
for patients’ autonomy, and their right to chose or decline
The last question related to the issue of paternalism, a recommendation without intimidation or pressure, and
and whether this is ever justified in a health care setting. should be able to make decisions for themselves free
from controlling interference or influence”.8
d). Would you as an educated health care provider,
feel justified to take a paternalistic approach and Others have added that “respecting patients’ autonomy
refuse treatment based on your opinion that the yields satisfaction for that person directly, while inter-
procedure was both unnecessary and destructive? fering with their autonomy may be experienced as a
form of pain and suffering. Furthermore, when people
The majority (83%) felt justified that they could re- who are capable of making autonomous choices are
fuse treatment based on their training and judgement allowed to do so, their maximal well-being will almost
(Figure 2), and justified their decision with comments always be more efficiently produced than if someone
such as: else chooses instead”.9

Sound clinical rationale is not paternalistic and does not Many other authors have added to the literature on
conflict with patient autonomy. “patient-centeredness”, and the need to ensure that the
treatment plan is tailored to incorporate options for a
patient with respect to their individuality, values, ethnicity
100%
and social endowments.10 It has been postulated that
this type of communication would lead to better accep-
80% tance of treatment plans and improved interactions be-
tween patients and clinicians.10
60%

The patient-centred model further evolved to the shared

40% decision-making approach which entails the compilation
of several viable treatment options for a specific prob-
20% lem, presentation of the disadvantages and advantages
of each, and allowing the patient to choose which suited
0% them the most.11
Justified in saying no
Yes No
Figure 2. Responses on whether clinicians feel justification in refusing
This stratagem aims to bridge the gap between pater-
treatment. nalism and patient autonomy due to the nurturing of a
222 >
ETHICS

mutual trust between the opinion of the clinician and CONCLUSION

the decision-making process of the patient.11 It also leads
to complete informed consent by enhancing the patient’s Paternalism has been both “defended and attacked in
understanding and knowledge of each of the options clinical medicine, public health, health policy and the
and how each could address their specific problems.12 law”.15 It is no longer clear when, if and which types are
justified in clinical practice. Perhaps the best advice is
However, care should be taken to not indulge and to “always consider the patient’s best interest, do those
over-express information pertaining to a specific treat- acts that do more good than harm, not do those that
ment option that the clinician prefers. This practice could cause harm, and constantly maintain the highest
has been termed “nudging” and will inevitably lead to standards of care”.5
a libertarian paternalism wherein the patient tends to
make “the popular decision”.12 References
1. Goldstein RE. Esthetics in Dentistry (2nd Edition: Volume 1).
While these authors do concede that patient education 1998; Canada: B Decker.
is a prerequisite to decision making 9, the overarching 2. Lepping P, Palmstierna T, Raveesh BN (2016). Paternalism
v. autonomy – are we barking up the wrong tree? The British
sentiment is that autonomy is sacrosanct and dentists
Journal of Psychiatry 2016; 209: 95 -6. doi: 10.1192/bjp.
should not assume an “unwarranted degree of authority
bp.116.181032.
over their patients”.13 This has led to the concept of 3. Pope TM. Counting the dragon’s teeth and claws. Georgia
paternalism becoming frowned upon and even regarded State University Law Review. 2004; 23(4): 659-700.
as taboo by some medical professionals. 4. Beauchamp, TL. (1981). Paternalism and Refusals to sterilize,
in Rights and responsibilities in modern medicine. Ed. Marc D
Dworkin (1988) considered paternalism as “interference Basson. 1981; 137: 142
with a person’s liberty of action justified by reason refer- 5. Beauchamp, TL, and Childress, J. The principles of bio-
ring exclusively to the welfare of the person being medical ethics, 4th ed. Weak paternalism, acting for the bene-
coerced”.14 He further argued that it prevented people fit of an incompetent patient. 2000; Accessed at: www.
utcomchatt.org>docs>biomedics. On 27- 03 - 2020.
from doing what they had decided, interfered with how
6. Sykes, LM, Crafford, E, and Bradfield, C. From Pandemic, to
they arrived at their decisions, or attempted to substitute
Panic to “Pendemic”. SADJ. 2020; 75(3): 157-9.
one’s own judgement for theirs, in order to promote 7. Elliot, C. Meaning what you say. J Clinical Ethics. 1993; 61: 61.
their welfare. 8. Beauchamp TL, and Childress JF. In (eds): Principles of Bio-
medical Ethics, 5th ed. New York City: Oxford University Press.
His concern was that this presumption of being right 57-103.
and thus justified in trying to override the other person’s 9. Ozar, DT, and Sokol, DJ (2002): The relationship between
judgement denied them the opportunity to choose patient and professional. In (eds): Dental Ethics at Chairside:
their own actions and treated them as “less than Professional Principles and Practical Applications, 2 nd ed.
moral equals”.13,14 Washington: Georgetown University Press. 2002; 49.
10. Valérie Carrard, Marianne Schmid Mast & Gaëtan Cousin.
Beyond. 2016.
Where then does this leave the trained dental clinicians
11. “One Size Fits All”: Physician Nonverbal Adaptability to Pa-
who do not agree with their patient’s demands or desires? tients’ Need for Paternalism and Its Positive Consultation Out-
Even soft paternalism does not allow them to impose comes, Health Communication. 2015; 31(11), 1327-33, DOI:1
their views, as the patients in question are generally 0.1080/10410236.2015.1052871.
not considered to be incompetent. Thus, regardless of 12. Lewis, J. Does shared decision making respect a patient’s
whether their judgment is based on moral principles or relational autonomy? J Eval Clin Pract. 2019; 25: 1063 -9.
educated discretion, do they have the right (and courage) 13. Simkulet, W. Informed consent and nudging. Bioethics. 2019;
to disregard the patient’s autonomy, and refuse to treat? 33: 169 -84.
14. Reid, KI. Respect for patients’ autonomy. JADA. 2009 140;
470-4.
In the above survey it was evident that most dentists
15. Dworkin, G. The Theory and Practice of Autonomy. Cam-
held onto their original treatment decisions regardless of
bridge, England. Cambridge University Press. 1988; 121.
the added issues presented in the subsequent questions. 16. Beauchamp, TL. The Concept of Paternalism in Biomedical
In fact slightly more refused to treat when they sensed Ethics. 2009; Accessed at: www.degruyter.com>jfwe.2009.14.
they were being pressurised or manipulated by the issue-1>9783110208856.77xml. Accessed on 27-03-2020.
patient (67% vs. 65%). The overwhelming majority (83%)
felt justified to take a paternalistic approach and not treat
based on their moral principles or diagnostic reasoning.

How then do they justify a paternalistic decision centred

on their personal ethical views, experience, training, clini-
cal judgement, and desire to promote beneficence/non-
maleficence, especially if this goes against the principles
of respect for patient autonomy? There is no clear and
simple answer. However, a practitioner needs to recog-
nise that there are “limits on what each person can do
and that many treatment options are mixed, containing
both chance of benefit and risk of harm”. 5 So yes,
sometimes this does mean they can take a paternalistic
approach and be justified in saying no!
www.sada.co.za / SADJ Vol. 75 No. 4
CPD <
223

CPD questionnaire
This edition is accredited for a total of 3 CEUs: 1 ethical plus 2 general CEUs

GENERAL
COVID-19: Focus on masks and respirators Sterilisation and single-use of endodontic files
– Implications for oral-health care workers - a short report
1. Identify the CORRECT statement. The direct equi- 7. Identify the CORRECT statement. Which of the fol-
valent respirator to an N95 respirator is: lowing sterilisation methods is INAPPROPRIATE for
A. FFP3 respirator reprocessing endodontic files?
B. Surgical mask A. Autoclave
C. FFP2 B. Statim
D. N100 respirator C. Glutaraldehyde solution
D. Dry heat sterilisation
2. Identify the INCORRECT statement. Possible inter- E. All of the above
ventions to reduce the chance of COVID-19 trans-
mission to an OHCW are: 8. Identify the CORRECT statement. When should en-
A. The appropriate respirator dodontic files be sterilised?
B. Oxidative pre-procedural mouthrinse A. Before first use on a patient
C. Rubber dam B. After removal from the manufacturers packaging
D. Chlorhexidene pre-procedural mouthrinse C. After every patient
D. All of the above
3. Identify the CORRECT statement. E. None of the above
The size of SARS-CoV-2 is:
A. 1-3 μm 9. Identify the CORRECT statement. Which of the fol-
B. 0.06 and 0.14 µm lowing is NOT a benefit to a single-use approach?
C. 0.05–0.5 µm A. Decreased incidence of file separation
D. 0.63 μm B. No risk of cross-contamination
C. Lower overall cost to practitioners
4. Identify the INCORRECT statement regarding small D. All of the above
particles < 5-10 µm: E. None of the above
A. More likely to cause a upper respiratory tract
infection
The microbiology of head and neck space infections
B. High risk for airborne transmission
at the Maxillofacial Clinic at Livingstone Hospital
C. Has an aerodynamic diameter that follow airflow
streamlines 10. Identify the CORRECT statement. Name the 3 most
D. Mainly short range transmission when no strong common fascial spaces involved in head and neck
air currents are present infections.
A. Submandibular, submental and peri-orbital spaces
B. Submandibular, buccal and submental spaces
Comparison of forward and reverse single-file
C. Submental, buccal and periorbital spaces
reciprocation for root canal instrumentation in
D. Submental, peri-orbital and zygomatic spaces
curved mandibular molar canals
- a Micro-CT analysis
11. Identify the CORRECT statement. Viridans strepto-
5. Identify the CORRECT statement. In this study, the cocci showed the highest resistance to:
authors used Protaper Next in which motion? A. Erythromycin/azithromycin
A. Reverse reciprocation and rotation B. Clindamycin
B. Full rotation C. Cefotaxime/ceftriaxone
C. Forward reciprocation D. Vancomycin
D. Forward reciprocation and rotation
12. Identify the CORRECT statement. Statistically signi-
6. Identify the CORRECT statement. Yared et al. (2008) ficant association was observed between:
observed the following when using ProTaper Next F2 A. Age and fascial space
in forward reciprocating motion? B. Age and etiology
A. Less instruments were needed for canal instru- C. Gender and the presence of microorganisms
mentation D. All of the above
B. Cost of treatment increased
C. There was an increase in instrument fatigue
D. Instrumentation cross-contamination was observed
224 >
CPD

Student perceptions of clinical experiences in B. The operator or surgeon doing the procedure
endodontic access cavity preparations C. The assessor examining the outcome
D. A & C
13. Identify the CORRECT statement. Improper access E. A & B
cavity designs and incorrect techniques may lead to: F. A, B and C
A. Perforations
B. Destruction of healthy tooth structure Maxillofacial Radiology 180
C. Instrument fractures
D. All of the above 20. Identify the CORRECT statement. When a patient is
placed too far forward in a pantomographic mach-
14. Identify the CORRECT statement. When summarizing ine the following can be seen on the radiograph:
the results of the study, which tooth was the most A. The anterior teeth will appear very broad
challenging to treat in all phases of endodontics: B. The anterior teeth will appear very narrow
A. Maxillary canines C. The posterior teeth will overlap resulting in loss of
B. Mandibular incisors clarity on the image
C. Premolars D. The premolars will be blurred because they will be
D. Molars out of the focal trough
E. None of the above

ETHICS
Focal dermal hypoplasia
- a radiographic case report Yes you can say no
15. Identify the CORRECT statement. Focal dermal hypo- 21. Identify the CORRECT statement. Which of the follow-
plasia (FDH) an unusual X-linked disorder affecting: ing is NOT one of the four principles Medical Ethics
A. Mesoderm tissues as proposed by Beuchampos and Childress?
B. Ectoderm tissues A. Beneficence
C. Both mesoderm and ectoderm tissues B. Justice
D. None of the above C. Informed consent
D. Autonomy
16. Identify the CORRECT statement. FDH is character-
ized by a wide range of multisystem abnormalities, 22. Identify the CORRECT statement. Dentists are per-
with the most common involving: mitted to:
A. Dermatological, eyes, teeth, skeletal, urinary, gas- A. send patients for psychological counselling
trointestinal, cardiovascular and central nervous B. nudge patients towards making the best decision
systems C. refer patients to a technician for minor restorative
B. Dermatological, eyes and teeth only procedures
C. Eyes, teeth and skeletal systems D. All of the above
D. None of the above
23. Identify the CORRECT statement. The WHO definition
of health includes:
Lichenoid Granulomatous Stomatitis
A. absence of disease or infirmity
– an oral medicine case book
B. mental well-being
17. Identify the CORRECT statement. Lichenoid granulo- C. economic well-being
matous stomatitis is characterised by the following D. Only A and B above
histological features: E. All three: A, B, and C
A. Lichenoid inflammation with basal cell degeneration
and apoptotic bodies 24. Identify the CORRECT statement. Body dysmorphia
B. Varying degrees of granulomatous inflammation may include:
C. Lymphoid follicles with a perineural distribution A. an altered perception of self
D. All of the above B. an obsessive focus on others
C. a desire to change one’s image
18. Identify the CORRECT statement. Lichenoid granulo- D. Only A and B above
matous stomatitis may be associated with: E. Only A and C above
A. Fungal infection
B. Certain medications 25. Identify the CORRECT statement.
C. Dysplasia Benevolence refers to:
D. All of the above A. the act of doing good
B. the act of avoiding harm
C. the desire to do good
Clinical Windows
D. the desire to avoid harm
- What’s new for the clinician?
19. Identify the CORRECT statement. In the Ehab et al.
trial, blinding was possible for (choose the most cor-
rect option):
A. The patient
www.sada.co.za / SADJ Vol. 75 No. 4
AUTHOR GUIDELINES <
225

SADJ
T H E S O U T H A F R I C A N D E N TA L J O U R N A L

Instructions to authors THE SOUTH AFRICAN

DENTAL ASSOCIATION

Thank you for considering the submission of your work to the •• The front page of the manuscript should list the title of the
Journal for possible publication. We welcome papers which article, the author’s(s’) name(s), and their qualification(s), affili-
may be Original Research, Clinical Review, Case Reports, Clinical ations and positions held, telephone and fax numbers and
Communications, Letters or Notes. address(es), including Email address(es), if available. It is
especially important that details of the Corresponding Author
The South African Dental Journal (SADJ) is a peer reviewed, should be clearly stated.
Open Access Journal, published by the South African Dental •• Please submit on the front page a list of up to eight Keywords.
Association (SADA). The Journal primarily carries research articles •• In the case of multiple authors, the role played and the
which reflect oral and general health issues in Africa but also respective contribution made by each should be recorded. For
publishes papers covering the widest consideration of all health example: “Principal Researcher- 40%, Writing Article- 30%,
sciences. In addition, items of specific relevance to members Tissue Analysis- 20%, Microscopic Examination- 10%”, etc.
of the Association find dissemination through the Journal. •• A recent requirement is that authors should be registered
The Journal is published ten times each year in electronic format. with ORCID. This is a number registering you as an Open
Hard copy is available by arrangement. Researcher and Contributor. Go to the ORCID website home
page at https://orcid.org/ and follow the Three Easy Steps
We shall be obliged if your submission is prepared respecting indicated in green. Please submit the ORCID number with your
all the details listed in these Instructions. This facilitates our author details.
process and ensures more rapid responses to you. Please use
and submit the Checklist for Authors suplied on page 228 Title
for confirmation. Thank you. To be kept as brief, clear and unambiguous as possible.

Address for submission of articles Abstract

The Editorial Assistant, Mr Dumi Ngoepe, The abstract shall consist of not more than 200 words.
South African Dental Journal, South African Dental Association For research articles, the summary should be structured under
(SADA), Private Bag 1, Houghton 2041, South Africa. the following headings: Introduction, Aims and Objectives, Design,
Email addresses: [email protected] Methods, Results and Conclusions. Do not include references
[email protected] in the Abstract.
Please submit the paper in electronic format in Word and Figures
sparately in JPEG., accompanied by a covering letter signed by Text
the author(s). •• Articles should be clear and concise.
•• Text should be typed in Times New Roman font, size 11;
Language double-spaced with a 3 cm. margin on the sides, top and
All articles must be submitted in English. Spelling should be in bottom. Each page must be clearly numbered.
accord with the Shorter Oxford English Dictionary. •• Please include electronic numbering of lines throughout the
All articles must be submitted in English. Spelling should be in document.
accord with the Shorter Oxford English Dictionary. •• Tables should be clearly identified, using Roman numerals ie.
Table I, Table II etc.
Clinical Research •• Authors are requested to note and adhere to the current style
Articles should adhere to the protocols of the Helsinki Declaration of the Journal particularly with respect to paragraph settings
(https://www.wma.net/policies-post/wma-declaration-of-helsin- and headings.
ki-ethical-principles-for-medical-research-involving-human-sub-
jects/. Length of the article
In general, papers should be between 4000 and 5000 words,
Clinical Trials although this is flexible. The Editor reserves the right to edit
Clinical trials should conform to the Consort Statement (Con- the length of an article in conjunction with the author(s) and
solidated Statements of Reporting Trials) and Reviews to the SADJ reserves the right to charge for excess/additional pages.
PRISMA checklist (Preferred Reporting Items for Systematic The first four pages of original research papers published in
Reviews and Meta Analyses) (http://www.equator-network.org). the SADJ will be free of charge after which a charge of R500
per page or part thereof will be levied.
Authors
Authors should meet the criteria for authorship as in the documents Illustrations/graphics/photographs
of the International Committee of Medical Journal Editors (ICMJE): ••Illustrations/graphics/photographs must be appropriate to the
1. Substantial contributions to the conception or design of the content of the manuscript.
work or the acquisition, analysis or interpretation of data for ••Digital images with a DPI of at least 300 should be supplied.
the work, AND Photocopies and pdf. files of photographs are not acceptable.
2. Drafting the work or revising it critically for important intellec- ••Please note: Figures should be included in the text and sent
tual content, AND separately in jpg. format.
3. Final approval of the version to be published, AND ••The Figure numbers must be in Arabic numerals and clearly
4. Agreement to be accountable for all aspects of the work in identified for each illustration, graphic or photograph.
ensuring that questions related to the accuracy or integrity Please remember to record Figure numbers in the text.
of any part of the work are appropriately investigated and ••Permission: Where any text, tables or illustrations are used
resolved (www.icmje.org). from previously published work, permission must first be
226 >
AUTHOR GUIDELINES

obtained from the holder of copyright and a copy of the No articles that have been published previously, or that are
agreement must be submitted with the article. Suitable ack- currently being considered for publication elsewhere, will be
nowledgement must be recorded in the article. accepted. Authors are kindly requested to verify that their article
complies with this condition.
Continuing Professional Development
Please supply 4-5 Multiple-choice Questions (MCQ’s) with 4 Ethics
or 5 options per question related to your article. Questions must Where relevant, authors should indicate whether their research
have only one correct answer, and indicate this correct answer has been approved by the Ethics Committee of their Institution
clearly. or by other research ethics committees.

References Conflict of interest

•• References should be set out in the Vancouver style and Authors must disclose their involvement with any company
only approved abbreviations of journal titles should be either owned by them or from which they have received a grant
used (consult the List of Journals Indexed in Index Medicus or remuneration or with which they have an association, and
for these details at: must declare any other personal interest they may have which
http://www.nlm.nih.gov/tsd/serials/lji.html). would constitute a Conflict of Interest. These may include per-
•• References should be inserted seriatim in the text using sonal relationships, academic competition, or intellectual beliefs.
superscript numbers and should be listed at the end of the Should there be no applicable Conflicts of Interest this should
article in numerical order. also be so stated. The statement will be included at the end of
•• A reference in the text should appear as indicated: the text.
“...as the results of a previous study showed.23”
•• Where there are several papers referenced, the superscript Copyright
numbers would appear as: The South African Dental Journal is a peer reviewed, Open
“...previous studies have shown. 3,5,7,9-12,14” Access Journal, adhering to the Budapest Open Access Initiative:
•• Do not list the references alphabetically. “By ‘open access’ to this literature, we mean its free availability
•• It is the author’s responsibility to verify each reference from on the public internet, permitting any users to read, download,
its original source. Please note that an article may be rejected copy, distribute, print, search, or link to the full texts of these
if the referencing is inaccurate. articles, crawl them for indexing, pass them as data to software,
•• Names and initials of all authors should be given unless there or use them for any other lawful purpose, without financial, legal,
are more than six, in which case the first three names should be or technical barriers other than those inseparable from gaining
given, followed by ‘et al’. First and last page numbers should access to the internet itself. The only constraint on reproduction
be given. Where it is applicable the page numbers should be and distribution, and the only role for copyright in this domain,
abbreviated by omitting redundant numbers eg. pages 456 to should be to give authors control over the integrity of their
478 is recorded as 456-78, and 456 to 459 as 456-9, but 398 work and the right to be properly acknowledged and cited.”
to 401 is recorded as 398-401. https://access.okfn.org/definition/index.html
•• Notice that volume numbers are not given in bold, authors are
not linked by ‘and’ or ‘&’, and the year of publication appears The Managing Editor reserves the right to decline articles,
after the name of the journal. No item should appear in italics photographs or illustrations where products or services are
except for foreign terms, eg in vivo. mentioned that are not appropriate.

Journal references should appear thus: Submission

Smith NC, Haines A. The role of the dentist in public The paper should be submitted in one file including all Tables
health promotion. Br Dent J. 1983; 298: 249-51. and Figures and their accompanying Legends Figures should
also be submitted separately file in JPEG. format.
Book references should be set out as follows: Please submit the paper in electronic format in Word along with
Terblanche N. Principles of Periodontology, 4th ed. London: separate Figures in JPEG. format to: [email protected]
Butterworth, 1985: 96 -101. and to [email protected], accompanied by a covering letter
and the Declaration on page 227 signed by all the author(s).
Weinstein L, Swartz MN. Pathogenic properties of invading
microorganisms. In: Sodeman WA, Smith RT, eds. Pathologic Galley proofs
Physiology: Mechanisms of Disease. Philadelphia: WB Saunders, Changes/corrections to the proofs supplied to authors must
1974: 457-72. be returned to the publishers by email or by fax and not over
the telephone. Galley proofs must please be returned to the
Manuscripts accepted but not yet published may be included publishers within four days after receipt thereof.
as references followed by the words ‘in press’.
Editorial Policy
‘Unpublished observations’ and ‘personal communications’ may Authors may also wish to refer to the Editorial Policy of the
be cited in the text but not in the reference list. SADJ available on the SADA website.

Declaration Enquiries
All sources of funding, possible financial interest/s or incen- Enquiries regarding Journal matters can be directed to
tives in products or services mentioned in the article must Mr Dumi Ngoeped, Editorial Assistant, at SADA headquarters on:
be disclosed. Authors are kindly requested to read and sign the Tel: +27 (0)11 484 5288, Fax: +27 (0)11 642 5718,
attached declaration on page 227. Shared Line +27 (0)86 011 0725 or Email: [email protected].
www.sada.co.za / SADJ Vol. 75 No. 4
AUTHOR GUIDELINES <
227

Declaration by Author/s
Title:

Author/s:

I/We, the undersigned confirm and declare that:

1. This manuscript is my/our original work and I am/we are the owner/s of this manuscript and possess rights
of copyright.
2. I/we confirm that this manuscript has not been published previously and it is not currently considered for
publication elsewhere. Has this article been submitted to any other journal and if so, has it been rejected?
YES NO
3. For no consideration or royalty, I/we hereby assign, transfer and make over to SADA all the rights of copyright,
which have or will come into existence in relation to this manuscript.
4. I/we waive in favour of SADA or any successors in title any moral rights which may be vested in me/us.
5. The manuscript does not constitute an infringement of any copyright and I/we indemnify SADA against all
loss or damage, from any cause arising which SADA may sustain as a result of having been granted
copyrights to the manuscript.
6. The research has been approved by the Ethics Committee of my/our institution/s or the Ethics Committee/s
of other accredited research facilities.
7. I/we have disclosed in my/our Acknowledgments all sources of funding, possible financial interest/s or
incentives in products or services mentioned in the paper.

Initial(s) and Surname Signature Date

Initial(s) and Surname Signature Date

Initial(s) and Surname Signature Date

Initial(s) and Surname Signature Date

Initial(s) and Surname Signature Date

Initial(s) and Surname Signature Date

228 >
AUTHOR GUIDELINES

Author’s Checklist
Have you read the Instructions to Authors?

Are you submitting electronically?

Have you provided all author information including first names, affiliations,
qualifications, positions held, Department and Institution, ORCID number,
contact details?

Is the first author under the age of 35 on submission of the article?

Have you provided all details of the Communicating Author?

Have you submitted questions for the CPD section? (four or five multiple
choice, one correct answer)?

Have you submitted details of the contribution of each author... can be

percentage or descriptive... or both?

Have you confirmed the status of your paper in terms of any Conflict
of Interest?

Have you submitted the Clearance Certificate number when Ethical

permission has been required to undertake research or to publish data?

Does the paper adhere to the format requested in Instructions to Author?

Are the references quoted according to Journal policy, both in the text and
in the list of references?

Have all authors s igned the Letter of Submission?

www.sada.co.za / SADJ Vol. 75 No. 4
CLASSIFIEDS

Smalls advertising and placement

procedure
• All smalls advertisements are restricted to a maximum 100 words per advertisement.
• All advertisement requests are required in writing, submit to [email protected], with full
contact details of the advertiser which should include:
◆ ◆ the wording of the advertisement as you require it to be published;
◆ ◆ the members professional number; (will not be published);
◆ ◆ the members contact details (will not be published).
• Advertisement lifespan is two weeks from the date of upload.
• Advertisements to be repeated follow the same process as the original placement request.
• All advertisements which exceed a word count of 100 words will be forwarded to
our publishers E-Doc for further processing as a potential advertisement to be placed
in the SADJ electronically or as website advertising. E-Doc will contact you thereafter
regarding your requirements.
• SADA Members may place advertisements at no cost providing their annual member-
ship fees are either paid in full at the time of their request of a debit order request has
been lodged.
• Non-SADA Member advertisers will be charged R25 per word for placement of their advertisements.
• Advertisement must be paid in full prior to uploading on the web platform.
• Invoice may be settled telephonically with the use of a credit card to prevent delay of placement.
• Telephonically processed payments will result in uploading of advertisement within
24 hours of settlement.
• Advertiser remains liable for placement costs should payment be dishonoured and invoice remains
unpaid.

Contact details:
Ann Bayman
South African Dental Association www.sada.co.za
Tel: +27 (0)11 484 5288
Email: [email protected] THE SOUTH AFRICAN
DENTAL ASSOCIATION