Editorial

Author’s Information
Dental Update invites submission of articles
pertinent to general dental practice. Articles should
be well-written, authoritative and fully illustrated.
Manuscripts should be prepared following the
Guidelines for Authors published in the December
2023 issue (additional copies are available from FJ Trevor Burke
the Editor on request). Authors are advised to
submit a synopsis before writing an article. The
opinions expressed in this publication are those
of the authors and are not necessarily those of the
editorial staff or the members of the Editorial Board.
Sustainability and
Leaking Restorations
The journal is listed in Index to Dental Literature,
Current Opinion in Dentistry and other databases.

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Full UK £184 Sustainability has, rightly, become a much-addressed subject in relation to clinical dentistry, let alone
Digital Subscription £131 to the world in general. It is something that has interested me for some time – first addressing the topic
Retired GDP £93 in 1998, when it wasn’t called sustainability, but a ‘green issue’! Therefore, 25 years ago, published on
Student UK Full (2 years only) £54 St Patrick’s Day (hence the ‘green’ relevance!), I wrote about ‘green’ problems1 related to amalgam and
Foundation Year (1 year only) £74 the handling of its waste, the very poor biodegradability of latex gloves and polyvinylsiloxane (PVS)
11 issues per year impression materials, disposable single-use items used in the surgery, bags of dental surgery waste, the
Single copies £26 paper mountain, and chemicals used in developing radiographs. At that time, I wasn’t able to propose
any solutions other than changing from amalgam to resin composite, using early digital radiography,
Single copies non UK £38
and early CAD-CAM as a potential solution for the PVS mountain, and I wrote that the latter techniques
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might become increasingly competitive in real cost, to match their reduced cost to the environment.
Move on to 2003,2 as well as ‘green’ being a colour in the wavelength range 575–500 nanometres,
For all changes of address and subscription I suggested that the tooth face was where green issues could be employed, in respect that resin
enquiries please contact: composite could be placed in much less invasive cavities (especially regarding Class IIs) than amalgam,
Dental Update Subscriptions and that minimal-intervention resin-retained bridges held advantages over conventional bridges in
Mark Allen Group. Unit A 1–5, Dinton Business Park, terms of ‘greenness’. Regarding prevention, I suggested that the ultimate green cavity was none at all!
Catherine Ford Road, Dinton, Salisbury SP3 5HZ Move on to the present, and, principally by way of two research groups, one led by Prof Nicolas
Freephone: 0800 137201 Martin in Sheffield, the other by Professor Brett Duane in Trinity College, Dublin, the idea of green
Telephone: 01722 716997 dentistry has evolved into environmental sustainability. In that regard, McKeever recently stated that
climate change is the greatest anthropogenic threat to human health recorded in history,3 with the
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impacts of climate change being confirmed by a Climate Change Panel as uncontrolled greenhouse
Managing Director: Stuart Thompson
gases.4 Groundbreaking research into sustainability and travel related to dentistry5 has underlined the
Editor: Fiona Creagh
fact that reducing patient and staff travel is an important factor to be considered. This might be the case,
Senior Graphic Designer/Production: Lisa Dunbar but I wonder if the latter is something of a non sequitur (for those who did not study Latin at school, it is
posh for ‘illogical conclusion’!), given that dental treatment cannot be carried out unless the staff get to
where their equipment, materials and dental team are, much the same as when going to a theatre, one
needs to get to where the stage and actors are: in other words, many ‘things’ cannot happen without
Part of travel to something/somewhere.
In that regard, much of dentistry has to be face to face, or hand to mouth, therefore, including
MARK ALLEN DENTISTRY MEDIA (LTD)
staff travel in the whole sustainability scenario seems to me to have lost the view that life has to go on,
Floor 6, Quadrant House, Sutton SM2 5AS and that to keep actually doing anything carries with it an adverse carbon foot print. However, actions
such as combining appointments for a family, scheduling an appointment with a hygienist at the same
Telephone: 01483 304944 time as a check-up might be ways to reduce the environmental impact of dental appointments. On
Email: fiona.creagh@markallengroup.com
the other hand, it is shorter appointments, such as examinations, and many orthodontic treatments,
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that contribute the most, while lengthy appointments, for example for molar endodontics, contribute
Facebook: @dentalupdateuk the least.6 In restorative dentistry, one visit direct-placement restorations must surely be more
Twitter: @dentalupdateuk environmentally friendly than the multi-visit appointments needed for indirect restorations. But, perhaps
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we need to assume that, while commuting is contributory to dentistry-related carbon emissions and it
might give an incomplete message not to mention it, this is a necessary evil of modern life. I therefore
reflect that dental surgeries, or indeed any specialized activity, generally require a highly specialized
Please read our privacy policy, by visiting unit, therefore staff sustainability costs should be disregarded, unless, of course, they are flying in
http://privacypolicy.markallengroup.com. This will by helicopter!
explain how we process, use & safeguard your data. Many of the publications on the subject of sustainability address the need for prevention, but
few appear to have considered that another way of reducing the environmental impact of dental
restorations is to reduce unwarranted replacement of restorations that may be considered to have
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failed, given that reports have considered that 50%7 to 75%8 of all restorations are replacements of

December 2023 DentalUpdate 909

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 Editorial
failed restorations. In the past, this may have been a subjective decision on
the clinician’s behalf: for example, is the restoration in the upper premolar in
Figure 1 defective?
There is groundbreaking research by Professor Edwina Kidd (Emerita
Editorial Board member) and colleagues that might help to provide the
answer.9 In this work, which I feel has never received the publicity it deserves,
patients who required replacement restorations were included in their
study. A total of 330 sites on 175 teeth in 118 patients were measured for
marginal gaps (<0.4 mm or >0.4 mm), with each restoration being removed
using a turbine drill and sterile bur: a sample of dentine was removed from
the enamel–dentine junction beneath the site, and this was processed
microbiologically. Mutans streptococci colonies were counted on agar plates,
with lactobacilli and yeasts also being identified. To cut a long story short,
the narrow ditch (<0.4 mm) did not have significantly more bacteria than an
intact margin. However, the wider ditch (>0.4 mm) presented a different story
– there were significantly more micro-organisms present beneath the wider
marginal gaps, with a greater proportion of these being lactobacilli, which
readers will be aware are favoured by an acidic environment, in other words,
conditions favouring the development of active caries.
The authors, Kidd et al,9 stated that they chose the marginal defect
widths in their study because they equated to the tip of a BPE probe, whereas
choosing a wider variety of defects would have been too complicated to
apply in routine dentistry. According to this work, therefore, the restoration
in Figure 1 should be replaced if the margin defect that is visible is greater
than the width of a BPE probe tip, and if it is less, then monitoring or
repair is indicated, because the authors stated that ‘it might be prudent to
replace restorations where marginal gaps exceeded 0.4 mm’. They added
that colour change adjacent to an amalgam restoration should not trigger
its replacement.
However, colour change around resin composite restorations tells
a different story.10 Another research study involved 197 discrete sites in
72 patients who had tooth-coloured restorations requiring replacement.
Thirty sites (12 on enamel and 18 on dentine) were carious, and 167 sites
were clinically non-carious. After giving local anaesthetic and applying
rubber dam, margin sites were selected for microbiological sampling around
the margin of the restorations. For example, if in a single restoration where
part of the margin was stained and part not, both sites were sampled. The
colour of the margin was noted and the tip of a local anaesthesia needle was
used for the removal of plaque from the tooth–restoration interface, and the
restoration was then removed using an air turbine and sterile bur. A sample
of dentine was taken, and all the samples processed microbiologically. The
results indicated significantly more bacteria in samples from carious than
from non-carious sites: that may not be a surprise, but more bacteria were
found in dentine beneath stained margins. As in the previously quoted
research, plaque samples from ditched margins yielded more micro-
organisms as the width of the ditch increased, but only margins >0.4 mm
yielded more micro-organisms in dentine.
What is the message from this work? Soft dentine beneath tooth-
coloured restorations is heavily infected, but where the margin is not frankly
carious, no clinical criteria (not even margin staining) will reliably predict the
presence of this soft dentine. Therefore, in the absence of a patient concern
about a discoloured margin around a tooth-coloured restoration, there is no
indication from a caries viewpoint to replace a tooth-coloured restoration
that has a stained margin.
It is my view that the lessons from these research studies provide useful
information from the sustainability point of view in relation to unnecessary
replacement of restorations whose margins may be considered defective.
While Dental Update generally tries to publish articles that are high
on practical, useful information for clinicians, the year 2023 has seen two
outstanding examples of excellent, sound, contemporary clinical advice
in the shape of the special issues published this year, one being the 50th
Anniversary issue, the other being the Tooth Wear special issue published last
month. Much thanks are due to all the contributors of these issues. However,
from time to time, we receive an article that describes a treatment technique
that not many of us will aspire to ever carry out, but which may, nonetheless,
910 DentalUpdate
pg909-910 Trevor Editorial.indd 910
Figure 1.
be considered to present a treatment modality that might benefit some of
our patients. The article on zygomatic implants falls into that category.
Finally, as we approach the end of another year of Dental Update, I wish
all readers, everywhere, Season’s Greetings. I also thank you, the readers
of Dental Update, for continuing to subscribe to our journal during these
challenging financial times – I hope that you have enjoyed this year’s issues,
and also to have found the contents valuable. I also wish to thank the
Editorial Board for their input and wisdom, our superb authors for sifting
through the voluminous dental literature and telling us what it really means
by way of the review articles that they write, our peer reviewers for their
advice and, finally, the excellent team at Guildford, namely, Fiona Creagh
and Lisa Dunbar, Rob Yates and Stuart Thompson, for producing each super
issue. And, if readers who may indulge in some alcoholic refreshment over
the festive time missed the warnings in the 2017 article ‘Advice for Festive
drinkers’,11 the reference to it is below, please spare a thought for the wine
tasters who have to try the drinks before they get to market and the hazards
that they face, as detailed in the article starting on page 923! Finally, may I
wish all readers a happy and peaceful, and above all healthy, 2024.
PS: Editorial Board member, Damien Walmsley was recently highly
commended in Landscape Photographer of the year for one picture with
another commended. The picture of the tree stumps is from Washington
state and was one of his photographs in the monovisions, international black
and white competition. I am pleased, as part of our festive relaxation, to
publish some of his work in this issue of Dental Update and on its cover.
References
1. Burke FJT A green issue. Dent Update 1998; 15: 49.
2. Burke FJT. Green dentistry. Dent Update 2003; 30: 109.
3. McKeever A. Why climate change is still the greatest threat to human life. 2021.
Available at: www.nationalgeographic.com/science/article/why-climate-change-is-still-
the-greatest-threat-to-human-health (accessed November 2023).
4. The Intergovernmental Panel on Climate Change (2022). Sixth evaluation report.
August. Cambridge and New York, NY:IPCC.
5. Duane B, Steinbach I, Ramasubbu D et al. Environmental sustainability and travel within
the dental practice. Br Dent J 2019; 226: 525–530. https://doi.org/10.1038/s41415-019-
0115-z
6. Ahmed T, Brierley C, Barber S. Sustainability in orthodontics: challenges and
opportunities for improving our environmental impact. J Orthod 2023; 50: 310–317.
https://doi.org/10.1177/14653125231170882
7. Javidi H, Tickle M, Aggarwal VR. Repair vs replacement of failed restorations in general
dental practice: factors influencing treatment choices and outcomes. Br Dent J 2015;
218: E2. https://doi.org/10.1038/sj.bdj.2014.1165
8. Kidd EA, Toffenetti F, Mjör IA. Secondary caries. Int Dent J 1992; 42: 127–138.
9. Kidd EA, Joyston-Bechal S, Beighton D. Marginal ditching and staining as a predictor of
secondary caries around amalgam restorations: a clinical and microbiological study. J
Dent Res 1995; 74: 1206–1211. https://doi.org/10.1177/00220345950740051001
10. Kidd EA, Beighton D. Prediction of secondary caries around tooth-colored restorations: a
clinical and microbiological study. J Dent Res 1996; 75: 1942–1946. https://doi.org/10.11
77/00220345960750120501
11. Hadis MA, Palin WM, Perryer DG, Burke FJT. Advice for festive drinkers. Dent Update 2017;
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