THE D3 GROUP ISSUE #13 MARCH 2020 D3G DISPATCH News about Developmental Dental Defects (D3s), The D3 Group, and the Chalky Teeth Campaign.

COMMENT FROM THE CUSP: Going viral Commiserations to everyone disrupted by the pandemic crisis, and hallelujah to science and technology for providing humanity an unprecedentedly strong path to recovery. Just 3 weeks ago, a colleague praised D3G's recent progress as "going viral"– not knowing the next day we'd be in the midst of a COVID-19 scare that has consumed life down under since. With D3G now affected by the bad connotation of improvement") emerge, usually directed at authors "going viral", this first issue of 2020 relays a mixture of and/or reviewing. It seems appropriate that D3G use ups, downs and uncertainties – unfortunately the April CE it's clinico-scientific strengths to improve both ends event in Toronto has been postponed and the October of the system and that this will be a great topic for Symposium remains on track but uncertainly so. On the our upcoming symposium. bright side we share some wonderful examples of "D3 Take care, and do the world a favour by communicating love", provide further reasons to "think beyond MIH" the importance of science! and to communicate translationally, and dip a cautious toe into the murky waters of research publication quality. Unsurprisingly the latter is frequently discussed amongst D3-Mike | Mike Hubbard D3ers and diverse grumbles (aka "opportunities for D3G Founder-Director

NEWS: Feel the D3 love :-)

Given growing tensions with COVID-19, we're thrilled the first 3 months of 2020 delivered a wonderful triad of "feel the D3 love" moments that'll surely help us through this challenge and beyond.

In an amazing D3-world-first, thePacific Smiles Group (PSG) ran a fundraiser at their annual practitioner conference (aptly dubbed "Inspire") and produced a stunning $10,000 donation for D3G!! Could this be any timelier given the financial strain D3G will face this year (like everyone else)? Spurring the giving, an artist wowed all by producing 3 artworks for auction – each within the 3 minutes taken to play a song of its famous subject. PSG is a pace-setting dental service organisation with over 90 practices across eastern Australia, all of which have Sam's Storybook to hand. This emergent educational collaboration is unique for the sector and traces back to a GC Australasia function where D3-Mike met D3er Caroline Townsend, a PSG regional leader with first-hand concerns about Molar Hypomin. Mutual admiration has since grown around several shared values including the spectacular "family spirit" evident at the conference. A special thanks to PSG practitioners and exhibiting companies for their generosity, and to PSG leadership (including D3ers Alison Hughes and Melissa Dorn, and pivots Walter Reid, Alex Abrahams and Phil McKenzie) for their ongoing "love of D3G". We hope others will feel inspired to follow your lead! continued on pg 2 >

D3G DISPATCH ISSUE #13 PG1 > continued from pg 1

Second, D3G endorsers NZDOHTA kindly invited Teeth” that not only addresses top-down management D3-Mike to present at a CE event for community oral but also uses clinical data to improve policy. We thank health practitioners held in Christchurch. As outlined NZDOHTA president Arish Naresh for this initiative and recently (Dispatch 10-12), dental & oral health therapists generous support (donation plus Sam sponsorship), and manage the D3 frontline of New Zealand's school dental Kim Heslop for local organisation. service, backed in Christchurch by the nation's first Third, long-term D3 supporters ANZSPD again shouted "Hypomin Clinic". A popular Q&A session contributed D3G a table at their conference held this year in Hobart – by clinic manager & D3er, Tule Misa, helped make the capital of Australia's spectacular island state, Tasmania. this an engaging experience where was learned heaps D3-Mike valued exchanging ideas with existing and new by presenters and audience alike! Pleasingly, Sam's D3ers, particularly about the Toronto symposium and allied Storybook was provided to all attendees plus every developments. A COVID-19 scare at the conference other community dental practitioner in the Canterbury venue provided an unexpected sequel but fortunately & regions. Discussions with West Coast Martin Lee it transpired that all attendees were spared. Our thanks (regional clinical director and prized D3 recruit) bolstered to ANZSPD president Sue Taji and the organisers who the idea of a national plan for "Kiwi Kids with Chalky managed the event and viral bombshell with aplomb.

WEB UPDATES: ""1-in-5 kids have MH"

In a long-awaited development that bolsters our "think beyond MIH" philosophy (see Dispatch 12), we're now saying "1-in-5 kids have chalky molars" instead of "1-in-6 kids have Molar Hypomin" (e.g. here and here). Referring to hypomineralised "6-year molars", the original "1-in-6" tagline was introduced in 2013 to launch 1-in-5 D3G's website and Chalky Teeth Campaign (media release). Translationally, this public health message was "cutting edge" because it reduced prevalence data schoolchildren (then averaging 15.9% across 42 studies) and a complex HAVE clinical concept (Molar-Incisor Hypomineralisation) into CHALKY TEETH simple terms with scientific advantage. Recent introduction enabled inclusion of "2 year molars" alongside 6-year of "chalky molars" as a conversational bridge from molars, the "1-in-5 kids" claim is now well-justified – "chalky teeth" added further traction – scientists and recognising an offset for those who have both their 2-year practitioners alike can now talk logically about "chalky and 6-year molars affected, and an increment for those enamel" for example. And as increased prevalence data with hypomin 12-year molars.

ROAD TO TORONTO: Great progress despite bump!

Oh the irony of having "attacking key questions" as postponed? We're starting to think perhaps not realising our symposium theme – now we're being (self-) attacked some "global projects" under consideration could benefit with an array of unexpected questions, many of which from longer pre-incubation. Conversely, given widespread you'll certainly share. Foremost, will the event go ahead excitement about this event, it's clear the sooner it gets in October as planned? – we simply don't know at this underway the better. Please let us know your thoughts stage but work continues on the presumption it will. and concerns, and we'll strive to keep you informed of Realistically however, October may be too soon for some ours (contact Ben and/or Mike). still rebuilding their post-crisis lives – yet for others it might Meanwhile, from the "great news department", we're be the brain-stirring jolt of fresh air needed for return to pleased to report two fabulous keynote speakers are normal. Can the event still be organised in time given locked in (both are translational scientists working in current turmoil, and will depressed economics curtail healthcare) and a growing variety of organisations the sponsorship needed to swing this paradigm-shifting engaged including IAPD, NIDCR, NCATS, Forsyth event? And actually, would the event suffer by being Institute, ASO and NZAO. The symposium design continued on pg 3 >

D3G DISPATCH ISSUE #13 PG2 > continued from pg 2 is shaping up nicely around the idea of a “cross-sector experience for all (not just the organisers!). Despite conversation about better management and prevention the new uncertainties, it remains likely this event will of chalky teeth”. We’ll keep updating the symposium be oversubscribed as numbers will be capped for quality's webpage as plans evolve (e.g. see new concept chart), sake. Consequently, pre-bookings will be opened for D3G hoping to make “the road to Toronto" a learning members (only) soon.

ROLE MODEL: UK's genetic testing for AI

In our past 3 issues (Dispatch 10-12) we've outlined how pioneering innovations within New Zealand's public health system – i.e. management plans, clinics and virtual orthodontic consultations for kids with Molar Hypomin (MH) – are spurring thoughts of a nationalised healthcare strategy for D3s. Besides MH, such a "D3 track" should include the genetic disorder amelogenesis imperfecta (AI) which, although quite rare, is often hugely troublesome for affected families and dentists alike. Asking how AI might best be managed within today's genomics revolution, a pioneer can be found in the UK's NHS which has made genetic testing for AI available since 2016. Their test covers 21 "AI genes" (i.e. involved in AI and downstream liabilities including general anaesthesia. allied syndromes) and can be "free" subject to referral Alan Mighell, an oral medicine specialist and D3G friend by a specialist paedodontist with informed consent from at University of Leeds, continues to play a central role the affected family. The genetic test is valuable because, in developing the service not least through his ongoing although AI often can be diagnosed from the extreme discovery of AI genes. Alan says the response has been disruption to all teeth, this isn't always so. A definitive highly positive despite some tests being negative due diagnosis can also reassure families at risk of psychological to undiscovered genes. With his focus now shifting from harm (guilt/blame) and help dentists to intervene early engaging the profession towards improving translation and optimise their management. Scientific understanding to patient care (e.g. via clinical management networks and researchers are other beneficiaries, particularly given & public education), he agrees there's exciting potential evidence that some types of AI may become preventable for cross-leveraging between AI, MH and other D3s as before long. The test's cost (≈US$1,000) is offset by the proposed for NZ. For more information, see here and potential for better clinical care and to ameliorate major here or contact Alan.

INTRODUCING: Cathy Boyce, D3G's 200th paid-up member

Having introduced our 100th subscriber only 20 months ago (Ben Ganss, Dispatch 6), we're thrilled to introduce oral health therapist Cathy Boyce as our 200th member – while totally nonscientific, such milestones should certainly be celebrated! Fortuitously (as with Ben), Cathy was well known to us thanks to an "insistent introduction" from Julie Barker – pioneering D3er and dental therapist of ADOHTA presidential fame – who thought Cathy's interest in silver fluorides (AgFs) and Molar Hypomin would be "right up our alley". Indeed, Cathy's experiences date way back to her training during the AgF heydays when Sydney dental academic Graham Craig invented what remain as two market-leading AgF products (RivaStar, CSDS). Having reconnected with Graham 3 years ago, Cathy has been researching the effects of AgFs on continued on pg 4 >

D3G DISPATCH ISSUE #13 PG3 > continued from pg 3 hypomineralised molars and found remarkable benefits – hypomineralised enamel, but this remains to be in most cases, comprehensive pain relief is achieved after quantified scientifically. Regards aesthetics, she says, one or two applications enabling subsequent restorations athough severely hypomineralised enamel does stain to be done without analgesia. Working mainly with black and this sometimes shows through the GIC children, she prefers to use the CSDS product because restoration, most families consider this a small penalty of its superior safety (i.e. neutral pH, unlike silver diamine given the relief from pain. Unsurprisingly, Cathy's fluorides whose strong alkalinity can burn soft tissues). Her knowledge on this subject is in high demand, leading impression is that the 2-step CSDS treatment (AgF plus her to establish a free educational resource at www. stannous fluoride) followed by a GIC restoration hardens armer.com.au. For more info, contact Cathy.

QUICK QUIZ: Delving into D3s

QUESTION 1 (easy) QUESTION 2 (harder) Research reports about Molar Hypomin are steadily In Molar Hypomin, do intact chalky opacities feature increasing – true or false? a protein originating from saliva?

Answers: see Suggestions Box on pg 6.

WOW FACTOR: Serial Molar Hypomin

Recently we've looked at "hypomineralised baby teeth" and "hypomineralised 12-year molars" as examples of early- and late-onset MH, respectively (Dispatch 9 & 10). Extending this theme of "thinking beyond MIH", we turn to the question of "serial hypomin" which cropped up when discussing "Polynesian pigmented teeth" (Dispatch 10).

The issue Besides 6-year molars being the commonest type of hypomineralised tooth ("hypomin 6s" or HM-6s), later-formed premolars and second-permanent ("12- year") molars are also prone to the same enamel defect ("demarcated opacities"). While it's common to find examples of each defect in different individuals – consistent with their tooth development being disrupted at different ages – can they all be found together in the same mouth?

The wow The picture shows a child with demarcated opacities present on a 6-year molar (HM-6), a premolar (HM-5) and a 12-year molar (HM-7). Notably in the bottom jaw (lower at an intermediate time. It follows that dental development panel), only 1 out of 4 premolars ("4s & 5s") was affected in this child was disrupted at various times from infancy and both 6-year molars ("6s") were normal. So this case through to about 6-years old. Presuming the cause was fits the sporadic" hypomineralisation" pattern that's a "illness" (being disease and/or allied medication), did defining feature of MH. Secondly, we can say it comprises this child suffer different illnesses at different ages or did a mixture of "mid-onset" (HM-6) and "late-onset" (HM-5, the same illness recur? Unfortunately the unremarkable HM-7) MH – making it an example of "serial MH". medical history gave no clues. Translational message? Questions arising This case illustrates the importance of viewing MH as a spectrum disorder and extending questions about Asking how this pattern could've come about, we start causation beyond "sick babies". Many thanks to with the 6-year molars which are at risk of such damage Melbourne paedodontist Daniel Andreasen-Cocker for during infancy – i.e. when their enamel is being hardened sharing this case. As usual, readers are invited to comment inside the jaw. For 12-year molars, this " MH onset on our appraisal and to send other educational cases for period" is 4 or 5 years later, whereas premolars harden future issues – please contact D3-Mike.

D3G DISPATCH ISSUE #13 PG4 D3 LITERATURE: Keeping you current!

Clinical Feature: Learning from mistakes It's pleasing to see D3G is becoming not only a respected being distanced – weren't the authors or reviewers aware place of learning but also a friendly forum where members this report had been listed on D3G's public database can share half-baked ideas and vent their frustrations. In for months? – and D3G's prominent USA perspective this light, and absolutely not wanting to stand on toes, not being acknowledged at all. The cognoscenti will we thought it would be constructive to critique a recent also complain the study is statistically underpowered, its publication that's triggered discontent amongst some unusually broad age range carries diagnostic concerns, respected experts in our D3 family. It must be emphasised and the claims about genetic causation lack balance. this is far from a solitary example – yet it's unusual for With so much room for improvement, whose problem a prominent journal to be involved and so all the more is it and what should be done, both now and moving reason to look and learn. The main grumble relates to an forwards? While it might be argued from an awareness- erroneous interpretation of what constitutes Molar-Incisor building standpoint that "any news is good news", the Hypomineralisation or MIH (aka "chalky 6-year molars"). unarguable quest for good science is clearly undermined With over 100 prevalence studies as guidance, we all by the abovementioned flaws. Asking what" can be done should know that MIH pertains to permanent teeth and to stop influential journals propagating fundamental unknown (idiopathic) causation only – hence hypomin errors?", it's noteworthy that several editors seek D3G likely due to local trauma or infection is excluded. So it's advice regards reviewer selection. We think there's surprising the authors chose to include primary teeth and much food for thought here, and that the upcoming not exclude a subject with cleft palate (given hypomin in D3 symposium will be a great opportunity to advance the latter is often attributable to surgical trauma). The this discussion. Read more here, and feel welcome to reported prevalence of "MIH" is therefore wrong – share your thoughts. Thanks go to those D3ers whose it should be 8%, not 10%, if both exclusions are made constructive inputs helped shape this message and the – and cannot be compared legitimately with literature journal concerned with whom we're now engaged in that's "obeyed the MIH rules". Secondary concerns relate ameliorative dialogue. to the single prior study of MIH prevalence in USA

Clinical Feature: Silver diamine fluoride and MH A question commonly faced by those managing non- severe cases of Molar Hypomin (MH) is how to control the toothache many children suffer when eating and toothbrushing. Such "enamel sensitivity" can occur even when the discoloured enamel surface appears intact thereby implying mechanistic differences from "sensitive dentine" (e.g. due to decay or receding gums). To combat this sensitivity, dental practitioners generally try the evidential base, and safety issues also feature. Given products developed for management of decay (fluorides, D3G's international reach it's great that, despite being calcium phosphates, sealants) – but, according to the focussed on UK practice (i.e. approved and off-label small amount of published research and much D3G belief, applications for the single available product), the variety these often prove inadequate on MH. Consequently, of formulations and licensing restrictions in other countries keen interest surrounds the rapidly growing use of silver are noted. Regards MH, the authors state that SDF "may fluorides to control dentine sensitivity and arrest decay also be useful for permanent molar teeth with MIH, as – might these products benefit MH management too? blocking the dentine tubules may reduce sensitivity". Raising great hope, a new review about the use of silver However, no research is cited and so, regardless of diamine fluoride (SDF) in dental practice co-authored by misnomer and mechanism, we're left asking whether SDF D3G friend Nicola Innes mentions MH desensitisation and other silver fluoride formulations are actually effective in its first line – but it transpires this has yet to become a against enamel sensitivity in MH. Secondly, to what extent research-backed recommendation. The article provides does the primary clinical disadvantage of silver fluorides a well-balanced tour through key aspects and issues – (permanent black staining of advanced decay) apply to the "whats, whys and hows", placing strong focus on non-severely hypomineralised enamel? Read more here. "atraumatic arrest of caries". Mechanisms of action,

D3G DISPATCH ISSUE #13 PG5 Other New Reports: Spotlighting Molar Hypomin A questionnaire study on perception and clinical management of molar incisor hypomineralisation (MIH) by Irish dentists. Wall A, Leith R. Eur Arch Paediatr Dent. 2020; [Epub ahead of print] PMID: 32185633 State-of-the-art on MIH. Part. 1 Definition and aepidemiology. Giuca MR, Lardani L, Pasini M, Beretta M, Gallusi G, Campanella V. Eur J Paediatr Dent. 2020; 21(1):80-82. PMID: 32183535 Restorative material choices for extensive carious lesions and hypomineralisation defects in children: a questionnaire survey among Finnish dentists. Wuollet E, Tseveenjav B, Furuholm J, Waltimo-Sirén J, Valen H, Mulic A, Ansteinsson V, Uhlen MM. Eur J Paediatr Dent. 2020; 21(1):29-34. PMID: 32183525 Relationship between Molar Incisor Hypomineralization (MIH) severity and cavitated carious lesions in schoolchildren. Villanueva Gutiérrez T, Barrera Ortega CC, García Pérez A, González-Aragón Pineda AE. Acta Odontol Latinoam. 2019; 32(3):133-140. PMID: 32176236 The prevalence of molar incisor hypomineralization of school children in and around Muvattupuzha, Kerala. Emmatty TB, Eby A, Joseph MJ, Bijimole J, Kavita K, Asif I. J Indian Soc Pedod Prev Dent. 2020; 38(1):14-19. PMID: 32174624 Comparison of four different treatment strategies in teeth with molar-incisor hypomineralization-related enamel breakdown- A retrospective cohort study. Linner T, Khazaei Y, Bücher K, Pfisterer J, Hickel R, Kühnisch J. Int J Paediatr Dent. 2020; [Epub ahead of print] PMID: 32112475 An Innovative Treatment Approach Using Digital Workflow and CAD-CAM Part 2: The Restoration of Molar Incisor Hypomineralization in Children. Davidovich E, Dagon S, Tamari I, Etinger M, Mijiritsky E. Int J Environ Res Public Health. 2020; 17(5). PMID: 32110963 Risk Factors Associated with Carious Lesions in Permanent First Molars in Children: A Seven-Year Retrospective Cohort Study. Llena C, Calabuig E, Sanz JL, Melo M. Int J Environ Res Public Health. 2020; 17(4). PMID: 32098396 Influence of customized therapy for molar incisor hypomineralization on children's oral hygiene and quality of life. Fütterer J, Ebel M, Bekes K, Klode C, Hirsch C. Clin Exp Dent Res. 2020; 6(1):33-43. PMID: 32067392 Molar Incisor Hypomineralization: Etiology, Clinical Aspects, and a Restorative Treatment Case Report. Sundfeld D, da Silva L, Kluppel OJ, Santin GC, de Oliveira R, Pacheco RR, Pini N. Oper Dent. 2020; [Epub ahead of print] PMID: 32053452 Relationship between deciduous molar hypomineralisation and parameters of bone metabolism in preschool children. Elger W, Illge C, Kiess W, Körner A, Kratzsch J, Schrock A, Hirsch C. Int Dent J. 2020; [Epub ahead of print] PMID: 32043580 In vivo Comparative Evaluation of Esthetics after Microabrasion and Microabrasion followed by Casein Phosphopeptide- Amorphous Calcium Fluoride Phosphate on Molar Incisor Hypomineralization-Affected Incisors. Bhandari R, Thakur S, Singhal P, Chauhan D, Jayam C, Jain T. Contemp Clin Dent. 2019; 10(1):9-15. PMID: 32015635 Knowledge and Management of First Permanent Molars with Enamel Hypomineralization among Dentists and Orthodontists. Craveia J, Rouas P, Carat T, Manton DJ, Boileau MJ, Garot E. J Clin Pediatr Dent. 2020; 44(1):20-27. PMID: 31995422 Strategies to optimize bonding of adhesive materials to molar-incisor hypomineralization-affected enamel: A systematic review. Lagarde M, Vennat E, Attal JP, Dursun E. Int J Paediatr Dent. 2020; [Epub ahead of print] PMID: 31990108 Association between developmental dental anomalies, early childhood caries and oral hygiene status of 3-5-year-old children in Ile-Ife, Nigeria. Folayan MO, Alade M, Adeniyi A, El Tantawi M, Finlayson TL. BMC Oral Health. 2019; 20(1):1. PMID: 31892323 Interactions with the aquaporin 5 gene increase the susceptibility to molar-incisor hypomineralization. Pang L, Li X, Wang K, Tao Y, Cui T, Xu Q, Lin H. Arch Oral Biol. 2020;111:104637. PMID: 31884335

Molar incisor hypomineralisation in Lebanon: prevalence and clinical characteristics. Elzein R, Chouery E, Abdel-Sater F, Bacho R, Ayoub F. Eur Arch Paediatr Dent. 2019; [Epub ahead of print] PMID: 31865536 SUGGESTIONS BOX Efficacy of low-level laser therapy associated with fluoride therapy for the In D3 family spirit, please desensitisation of molar-incisor hypomineralisation: Randomised clinical trial. Muniz RSC, Carvalho CN, Aranha ACC, Dias FMCS, Ferreira MC. Int J Paediatr Dent. 2019; contact us to share your [Epub ahead of print] PMID: 31808584 thoughts on how we might Molar incisor hypomineralisation and dental anomalies: A random or real improve this newsletter and association? Walshaw EG, Noble F, Conville R, Anne Lawson J, Hasmun N, Rodd H. other communications. Int J Paediatr Dent. 2019; [Epub ahead of print] PMID: 31790155 Distribution of Molar Incisor Hypomineralization in Ecuadorian children. Answers to quiz: Ordonez-Romero I, Jijon-Granja Y, Ubilla-Mazzini W, Porro-Porro L, Alvarez-Giler G. Q1: True, the annual publication rate has doubled over the past 5 years Dent Hypoth. 2019; 10, 65-69. Open access (see here) BSPD publishes MIH paper. Br Dent J. 2020; 228(3):144. PMID: 32060442 Q2: False, this chalky enamel contains lots of serum albumin which actually originates from For more Molar Hypomin reports see 2020 editions of D3G Dispatch blood (see here) and also go here >

Towards better understanding and care of people with D3s.

Copyright © 2020 thed3group.org | All rights reserved. D3G DISPATCH ISSUE #13 PG6