Australasian Dental Practice Sep/Oct 2021

Australasian

DENTAL PRACTICE THE BUSINESS MAGAZINE FOR DENTISTS

Vol. 32 No. 5

SEPTEMBER/OCTOBER 2021

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www.dentevents.com • info@dentist.com.au • Tel: (02) 9929 1900 • Fax: (02) 9929 1999

www.dentevents.com • info@dentist.com.au • Tel: (02) 9929 1900 • Fax: (02) 9929 1999

www.dentaltechnology.com.au www.dentaltechnology.com.au

VOLUME 32 | NUMBER 5 SEPTEMBER/OCTOBER 2021

contents | REGULARS

On the cover...

Piksters Bamboo Interdental Brushes are sustainably sourced and 97% biodegradable!

management

briefs 8 10 one man’s opinion 12 in my practice 14 mouth wide shut 16 outside in 18 spectrum 64 book review 66 CPD centre 68 abstracts 70 the cutting edge 154 new products

dentists buying practices 78 What need to know 80 Enough is enough!

84 Confidentiality agreement FAQS 86 Are you using a checklist on your calls?

marketing

88 practice growth winners....

10,000 hours later, here are my TOP 5

finance ETFs provide a shortcut 90 How to diversification

READ ME FOR

CPD

facebook.com/dentalpracticenow

twitter.com/adpmagazine

instagram.com/dentevents

www.dentalpractice.com.au

Publisher & Editor: Joseph Allbeury Clinical Editor: Dr David Roessler Technology Editor: Prof. Laurence J. Walsh Infection Control Editor: Prof. Laurence J. Walsh Senior Contributing Editor: Dr Christopher CK Ho Columnists: Dr Georges Fast, Dr Paul Coceancig, Gary Pammer, Phillip Win, Dr David Moffet, Graham Middleton, Simon Palmer, Julie Parker, Jayne Bandy, Angus Pryor Design & Production: Jasper Communications Australasian Dental Practice™ ISSN 1445-5269 is printed in Australia and published six times per year by Main Street Publishing Pty Limited ABN 74 065 490 655 PO Box 586, Cammeray NSW 2062 Tel: (02) 9929-1900 Fax: (02) 9929-1999 Email: info@dentist.com.au

© 2021 All rights reserved. The contents of this magazine are copyright and must not be reproduced without the written permission of the publisher. Permission to reprint may be obtained upon application. Correspondence and manuscripts for publication are welcome. Although all care is taken, the editor and publisher will not accept responsibility for the opinions expressed by contributors to this magazine, or for loss or damage to material submitted for publication.

Subscriptions: Australia and NZ: A$99.00 per year includes OralHygiene™ and eLABORATE™ magazines; Overseas Airmail: A$220.00 per year.

September/October 2021

Australasian Dental Practice

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contents | FEATURES

VOLUME 32 | NUMBER 5 SEPTEMBER/OCTOBER 2021

infection control

clinical excellence 94

120

Recent developments in vital dental

108 bleaching and the emergence of new

READ ME FOR

CPD

options with peroxy carboxylic acids

COVID-19: What is likely to happen in the next part of the pandemic journey

94 Have proactive conversations to 100 help patients feel safe

104 Why who made your mask matters

READ ME FOR

CPD

Optimising oral health in frail older people

114 RImmediate and non-central implant 120 placement in a molar root socket: implant

READ ME FOR

CPD

crown with cantilever design

138

surgery design 148 Aesthetic camouflage and correction of

128 trauma-involved incisor hypomineralisation New Shining 3D Aoralscan 3 intraoral scanner road test

148 Cairns Specialist Dental is born

132 Anterior restoration with CAD/CAM veneers 138 made of VITABLOCS TriLuxe forte Case report: Partial pulpotomy on a 142 lower permanent incisor with complicated fracture of the crown and open apex using Biodentine™ - 13-month follow-up

September/October 2021

Australasian Dental Practice

7

briefs | NEWS It’s over, right...

L

ife is giving the appearance of normality again in Sydney after the latest lockdown lifted and with the promise of no more

By Joseph Allbeury to come, all we can do now is proceed accordingly (though a tad cautiously for the next little while at least).

So we’re planning in earnest for 2022 with some new events, some popular existing events and a few surprises along the way to boot.

Before I get into that though, I’m excited to welcome a new writer on board this edition as a regular columnist for the magazine. Dr Lani Guy is a recent graduate of UQ so knows something already about life on the tools, but her insight from a past life as a management consultant provides a unique perspective that complements our already rich pool of writing talent. Her first column appears on page 16.

Event wise, we will finally stage the third instalment of Digital Dentistry and Dental Technology in Sydney on June 3-4, 2022... and thank you one and all for your patience! Trying to run events over the last two years has been nothing short of a demoralising experience. So if you came to Digital Dentistry and Dental Technology 2019, you will remember what an amazing event it was. Close to 500 people participated in the event, with over 50 speakers delivering 110 education sessions over the two day program. Dentists and Dental Technicians all mingled as one to network, share ideas and have fun! So I look forward to seeing everyone there again and if you haven’t signed up yet, tickets are still half price until the New Year.

Following a similar format, we’re also introducing a new two-day event entitled Dental Economics 2022 on August 5-6, 2022. After the past two years of ups and downs with the COVID-19 pandemic, this event is designed to enable private practices that are ready and willing to grow. This multi-stream event has something for the entire practice with sessions on Leadership and Inspiration, Practice Management, Marketing, Finance, Hygiene, Communications and much more. Presenting will be a number of Australian Dentists who currently run their own successful large group practices as well as an outstanding line-up of industry professionals who will provide case based insight exploring how to grow and succeed in the Australian dental health sector.

This event will evolve over the next few months, so keep an eye on www.dentaleconomics.com.au to see how it unfolds. And again, sign up early and save 75%.

A reminder too that IDEM Singapore is back on again in April. Australia has a quarantine-free travel bubble with Singapore (at the moment at least), so this could be a good start to dipping your toe back into international travel.

So whilst 2021 has been another year of hurry up and wait, we look towards 2022 with confident hope that while COVID-19 will be in our lives, it will not control our lives.

Stay safe!

Joseph Allbeury, Editor and Publisher

8 Australasian Dental Practice

D4W now integrated with 3Shape TRIOS

entaur Software’s Dental4Windows (D4W) patient management system is now integrated with the 3Shape TRIOS intraoral scanner. The integration enables a more streamlined workflow for dental professionals. The integration allows D4W to pass patient information to the 3Shape TRIOS software without having to fill in data twice. The patient’s information is automatically transferred and registered in preparation for a TRIOS 3D scan. The integration eliminates the tenuous task of manually registering a patient in both systems and enables doctors to run their practice more efficiently and productively. The D4W link can also be used to launch and view patient impressions in 3Shape software, eliminating the need to consistently search for patients in the software. “We are very excited about the integration. Superior patient care is at the core of 3Shape. The integration will help doctors and their team save time and make their daily workflows more efficient”, said Peter Tabor, regional manager 3Shape Oceania. The integration is available on Dental4Windows software version 4.7.7.8 and higher.

C

D4W now integrated with 3Shape TRIOS

voclar Vivadent has extended its line of popular dental adhesives. The new Adhese Universal DC delivers the same strong performance as the original product and additionally features dual-cure properties. The fact that the adhesive can either be light or self-cured allows it to be used in many different situations. The single-component adhesive is suitable for cases where self-curing is required or desired in the placement of indirect restorations. Adhese Universal DC is ideal for the placement of direct fillings and for the adhesive cementation of indirect restorations.

It features the same high quality as the clinically proven Adhese Universal. Its salient characteristics include high bonding values of >25 MPa on wet and dry dentine and an integrated desensitizing effect. Adhese Universal DC is designed for use with Variolink Esthetic DC. This powerful duo is recommended for the adhesive cementation of all restorative materials (e.g. root posts, opaque oxide and silicate ceramics as well as metal-ceramics). Adhese Universal DC is the ideal complement to the Variolink Esthetic system - especially in clinical situations where completely selfcuring methods are required or desired. In conjunction with Variolink, Adhese, Universal DC is used in the self-cure mode - irrespective of the etching technique employed. The bonding results are excellent. The new adhesive is available in Free Stand® Single Dose units together with initiator-coated applicators in two sizes: Regular and Small/Endo. For more info, call 1300-486-252 or email orders.au@ivoclarvivadent.com. In New Zealand, call 0508-486-252 or email orders.nz@ivoclarvivadent.com.

I

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spectrum | NEWS Online Resources for the Dental Profession...

One man’s opinion...

I

By Georges Fast

www.dentalcommunity.com.au • Update your personal details • Update your practice on dentist.com.au • Manage your subscriptions • Read 13,500 articles from past magazines • Log your CPD points • Answer CPD Questionnaires • Run your own dental events • Create online discussions • And more...

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• Find-a-dentist in New Zealand

www.dentalpractice.com.au • Australasian Dental Practice™ online

www.oralhygiene.com.au • Oral Hygiene™ magazine online

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• eLABORATE™ magazine online

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10 Australasian Dental Practice

“Victoria has paid for its traditional prosperity by becoming complacent and electing and re-electing a government comprised of those least capable to lead...”

am writing this column during the last weekend in September in Melbourne, which now has the distinction of being locked down for a longer period than any other city in the world!

Victoria has paid for its traditional prosperity by becoming complacent and electing and re-electing to power a government comprised of those least capable to lead, succeed or even sustain themselves (and abundantly rewarding themselves financially!). All paid for with borrowed money and by increasing taxes on a diminishing pool of producers.

According to George Bernard Shaw, a government that robs Peter to pay Paul can always rely on the support of Paul but as Margaret Thatcher said: “You sooner or later run out of other people’s money to spend”.

Thomas Jefferson said more than 200 years ago that “A Government big enough to give you everything you want is big enough to take everything you have”. Another quote that resonates currently in Victoria as a result of the emergency powers that the Upper House granted to the current incumbents is one by P. J. O’Rourke: “Giving money and power to government is like giving whisky and car keys to teenage boys”.

It is indeed interesting how similar problems have been handled differently “We owe a considerable debt by the various States, depending more of gratitude to those who on their political persuasion than on any logical, well-considered assessments. have managed to convince We have seen poorly educated bureauthe politicians we provide an crats, totally out of their depth and with a essential service...” poor understanding of health processes, making up rules at the behest of political advisers, who have one eye firmly on what policies will get them re-elected. The appointment of politicised chief medical officers, quickly promoted and given titles and roles that they may have had difficulty attaining in an apolitical academic environment, is contributing to the chaos many of us are experiencing.

To quote John Stuart Mill: “The only purpose for which power can be rightfully exercised over any member of a civilised community, against his will, is to prevent harm to others. His own good, either physical or moral is not a sufficient warrant”.

Why am I writing this in a journal aimed at the dental profession? Arguably we have been spared the worst restrictions for a substantial part of this period and we owe a considerable debt of gratitude to the elected officials and other leaders of our profession who have managed to convince the politicians that we provide an essential service in a safe environment, with arguably the highest standards of infection control of any profession. They also forcefully presented the argument that there were no documented valid reasons to shut down dental practices and that delaying dental treatment would lead to what would have been preventable emergencies. I also believe that a private advertising campaign that was ready to go and about to be launched in Victoria added some ammunition.

Dental practices have had large increases in overheads that are undoubtedly putting pressure on private practice owners. We can moderate those overheads by running longer appointments to minimise the number of changeovers, but we can’t decrease the cost of extra disposables and PPE, nor can we load this increased cost onto our dental fees at a time when a significant portion of our patients are also suffering financially. Therefore, we need to be conscious of minimising waste and using our time and our staff more efficiently, thereby ensuring that the fine balance between survival and profitability doesn’t tilt in the wrong direction.

September/October 2021

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spectrum | NEWS

In my practice...

By Christopher Ho

T

“In my practice, we have multiple articulation systems, however we prefer the Artex articulators from Amann Girrbach which are light-weight, being made of carbon fibre and ergonomic to hold and work with.

They come in both Arcon and non-Arcon designs...”

his issue we look into some products and equipment that I use in practice. We look at some recently released new products and elaborate on how their use can be applied in practice. Investing in the right armamentarium allows clinical practice to be simpler and more enjoyable for the wet-fingered dentist and hopefully, this column provides the reader with some of the latest “tools of the trade”.

EVE Diapro polishers

he insertion of indirect ceramic restorations often necessitates adjustment of the ceramic surfaces, whether it is proximal contacts or occlusal adjustment, no matter how well your restoration is fabricated. One of the objectives of polishing ceramics is to remove any surface flaws or micro fractures resulting from adjustment, as well as ensuring the surface is smooth to minimise potential antagonist wear. I use the Diapro HP range that can be used extraorally or in the laboratory. This consists of a 3-step polishing system for all porcelain materials like lithium disiliate, zirconia, feldspathic porcelains as well as metals. It allows for surface adjustment without having to perform any additional glazing. When having to adjust intraorally, the Diapro RA Twist is recommended due to the spiral nature of the polishers allowing adaptation onto irregular anatomical surfaces.

T

articulators from Amann Girrbach which are light-weight, being made of carbon fibre and ergonomic to hold and work with. They come in both Arcon and nonArcon designs and possess different settings for those dentists that wish to adjust condylar angles as well as immediate and progressive side shifts.

The majority of clinicians will use average values for the settings and will love the simplicity of this semi-adjustable articulator. It’s a very simple system to use and easy to clean and maintain which is so important when showing patients.

Hu-Friedy Temporary Crown Remover emoving temporary crown and bridgework is made much simpler by having the correct tools and using this tungsten carbide tipped needle holder instrument made by Hu-Friedy provides better grip and intraoral visibility when removing provisional restorations. Rather than using instruments around delicate margins of your tooth preparations, this remover can grip onto provisionals, breaking the provisional cement layer which is more brittle and then securely remove it without any damage to the underlying tooth preparation.

R

Artex articulators (Amann Girrbach) nalysing models in both static and dynamic positions is fundamental in occlual assessment as well as being able to design and deliver restorations that fit into a desired occlusal scheme. With the advent of digital dentistry, many times this is now anaylsed digitally, however there is nothing like analysing on articulated models. In my practice, we have multiple articulation systems, however we prefer the Artex

A

12 Australasian Dental Practice

About the author Dr Christopher Ho is a Specialist Prosthodontist in Sydney.

He is Head of School of Australasian College of Dental Practitioners, Visiting Lecturer at Kings College London, Adjunct A/Prof at University of Puthisastra and Editor of the WileyBlackwell textbook “Practical Procedures in Aesthetic Dentistry” and “Practical Procedures in Implant Dentistry”.

September/October 2021

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spectrum | NEWS

Always and always have a written agreement

I

By David Moffet

“A friend of mine spent more time explaining what would happen on the dissolution of a business contract than he spent on writing what would actually be involved in the performance of the contractual business engagement...”

hear of so many people out there having “verbal” agreements with one another over matters that should have written documentation.

As dentists, we know how difficult it can be to extract payment from unscrupulous clients who choose not to pay us for the services we provide, because the dental industry is structured for clients to pay for their dental work AFTER they receive it, rather than before.

That’s just how it’s always been done...

But these days, there’s a lot of businesses out there where customers now pay in advance for goods and services.

When you go to a concert...

W

hen you go to a concert, you don’t pay for the performance as you queue to exit the concert hall.

“As dentists, we know how difficult it can be to extract payment from unscrupulous clients who choose not to pay us for the services we provide, because the dental industry is structured for clients to pay for their dental work AFTER they receive it, rather than before...”

In fact, in most cases with musical and theatrical productions, you pay for your ticket often months in advance.

When you travel... hen you travel, you most often purchase your travel and accommodation well in advance of your actual journey dates, so that you are secure with the thought that your plane seat and your hotel room that have been reserved just for you, will indeed be there for you on the dates requested.

W

When you buy a book… hen you buy a book, you pay for the book before you read it. You certainly don’t pay for the book AFTER you’ve taken it home and read it, do you?

W

That’s just how things get done these days…

M

ost business is now conducted with a payment in advance.

That’s just how things are done.

14 Australasian Dental Practice

If there is a failure in this arrangement when some expectations of one or both parties are not met, then there are processes available for the settlement of any disputes.

A friend of mine once said: friend of mine once said, that it’s very difficult to start writing the pre-nup [prenuptial] agreement when your marriage is in the divorce court.

This same friend spent more time [and length] explaining what would happen on the dissolution of a business contract than he spent on writing what would actually be involved in the performance of the contractual business engagement.

This is because he wanted it to be crystal clear that when it was time for parties to go their separate ways, that the path of dissolution had already been decided upon.

A

Because if you don’t... t doesn’t matter how close your family is, and how good a friend you are, and how “nice” a person appears, people change.

I

And lie.

And let you down.

It will happen.

It does happen.

So the easiest way to reduce disappointment is to take the time and to get all contingencies listed and handled and signed for ahead of time.

To be sure.

To be certain.

To be sure and certain.

About the author Dr David Moffet is a dentist and a #1 Amazon Bestselling author.

He is the inventor of The Ultimate Patient Experience™, a simple to implement patient retention system he used to build and subsequently sell (for several million dollars) his very successful dental practice [of 28 years] located in Parramatta in working class western Sydney. David recently retired from wet-fingered dentistry and now spends his time lecturing and coaching private dental clients in the USA, Canada, Great Britain, Europe and Australia and New Zealand on how to improve their practices. David can be contacted at david@theUPE.com or visit www.theUltimatePatientExperience.com.

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spectrum | NEWS

Is business a dirty word?

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By Lani Guy

“The important takeaway is really just that the ability to survive is no longer dependent on the quality or price of your product or service; it is based on handing control to the customer in a way that the customer perceives value (called value competition)...”

EXICOLOGY (noun) is a branch of linguistics concerned with the signification and application of words.

We don’t tend to pay attention to the words we use; they are so ingrained that we don’t give them a moment’s thought.

But perhaps we should; the words we use tell us where we’ve been and our underlying assumptions about the most fundamental

In some instances, they don’t even want to pay for it with fido currencies. Yes, here in Australia right now, there are already practices trading accepting payments with crypto currencies and blockchain technology.

So, what does this mean for today’s enterprise? In short, it means that an enterprise survives and thrives only to the extent it can engage with, delight and inspire the consumer.

Business consultants break this into four tenants of competition under IR4.0. I include them for the interested reader; of things. although they are so wrapped up in management-speak that they When looked at this way, it pays to take pause and think are likely to be pretty meaningless for most dental practices. “what do our words say about us?” And does this match where The important takeaway is really just that the ability to surwe are now and, more importantly, where we’re going? vive is no longer dependent on the quality or price of your In dentistry, think about the most product or service; it is based on basic thing of all, what we call our handing control to the customer in a EVOLVING enterprise and those we serve. “Pracway that the customer perceives value CUSTOMER NEEDS tice” and “patients”. Not, “business” (called value competition). & EXPECTATIONS and “customer”.

And you can’t compete on value Why? without a Digital Strategy (DiSx) and COGNITIVE Because as dentists we practice a Customer Journey. Even QueensTECHNOLOGY & with the majority of our enterprise land Health has one (and has for AUTOMATION focussed on manufacturing and proseveral years now). You can check duction serving the needs (not wants) out their DiSx as far back as 2016 at ALLIANCES, of our patients; the budding area of www.health.qld.gov.au.

PARTNERSHIPS & cosmetic dentistry being the obvious Value competition is a tall order OPEN INNOVATION exception. for any enterprise to meet, let alone Few dentists would deny that denone which finds itself in the dental LEAN COST STRUCTURES TO tistry involves a certain amount of industry.

REINVEST THE CUSTOMER sales. But, sales and marketing efforts So, what is a practice, or will you EXPERIENCE are tightly constrained by patient forgive me at this stage if I say dental needs and beleaguered by a dizzying business, supposed to do? swag of potential ethical and legal minefields. Our products and The answer isn’t simple, but it begins with recognition that services are closely regulated and our digital presence is simiwhere we have been is not where we are now and certainly not larly monitored and tethered. And, last but not least, there is an where we are going. inherent conflict of interest in health for profits as seen by PriFacebook, Insta, Twitter and Google Reviews are working vate Health Insurance funds and the Corporate influx. for most practices now; albeit with some loss of profits to PriIt is no surprise then that the words “business” and “cusvate Health Insurance funds and Corporates. But they won’t tomer” are considered dirty words by most dental practitioners. take us where we want to go and won’t nearly be enough to If we step back from this mindset for a while, the mindset compete where we are going. in which practices are not businesses and patients are not cusWhich is why we need to change the way we think about our tomers, we see that this manufacturing approach to enterprise enterprise and those we serve; could we say our practices are a was long ago abandoned by most industries in recognition of business and our patients are our customers if only to ourselves? today’s rapidly changing business landscape; a landscape which has changed so much that it has been coined the Fourth IndusLani Guy is a University of Queensland trained General Dentist trial Revolution, or IR4.0 for short. working in private practice. In a prior life, Lani was a manageIn this landscape, which we now call an “ecosystem” in ment consultant. She has a Bachelors, Masters and Doctorate in recognition of increasing competition and enterprise interconbusiness along with a Bachelors in psychology and has spoken nectedness, the customer is king. They tell us what they want, globally on the topic of digital disruption and IR4.0. She has a when they want it (now), how they want it (green, high quality special interest in evidence-based improvement techniques and and digital) and what they want to pay for it (little to nothing). disruptive innovation... as well as healthcare.

16 Australasian Dental Practice

September/October 2021

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spectrum | NEWS

New combination furnace for quick crystallisation, sintering and glazing

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or more than 40 years, Ivoclar Vivadent has been presenting continuous innovations in the field of dental furnaces with its Programat® series. Now, the success story continues with the introduction of the all new Programat CS6. The new combination furnace can crystalise, sinter and glaze all-ceramic restorations faster than ever before with unsurpassed aesthetic results.

Ivoclar Vivadent, a leading provider of integrated solutions for high-quality dental applications with a comprehensive range of products and systems for dentists, once again demonstrates its innovational leadership with the new addition to the family of Programat furnaces. The all new Programat CS6 combination furnace allows a quicker crystallisation, sintering and glazing process. With the new Programat CS6, IPS e.max® CAD lithium disilicate restorations can now be crystallised in just over eleven minutes.1 Additionally, this open system boasts new proprietary vacuum technology which speeds up the sintering of zirconia restorations, such as IPS e.max ZirCAD.

No longer sacrifice aesthetics for speed he exciting new technology behind the Programat CS6 furnace enhances both speed and aesthetics. The new opening process supports and accelerates the pre-drying process by strategically controlling the hot air rising from the firing chamber to dry restorations from underneath. Furthermore, the opening lift technology helps to cool restorations faster by removing the restoration from the hot firing chamber. The proprietary vacuum function accelerates the sintering process, while simultaneously improving the aesthetics of your zirconia restorations. High-quality, aesthetic results are achieved case after case despite the short program durations.

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Designed for your practice ollowing their self-imposed goal of a customer-centric value chain, the teams at Ivoclar Vivadent developed the product with full focus on chairside needs.

The status of the restorations within the new Programat CS6 can be easily monitored wherever the user is by looking at the Optical Status Display (OSD) at the base of the furnace. The OSD conveys the operational status through colour representation. Operating the Programat CS6 is simple and fast. Its modern colour touchscreen is easy to use and is highly durable.

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Offering the dentist full control over the temperature, the Programat CS6 delivers consistent and reliable results. Furthermore, the temperature calibration can easily be conducted on site at the practice, ensuring that the high-quality results of the restorations won’t fade over time.

With multiple firing options, it is easy to refine or enhance restorations.

Open System

Focus on your patients, not your furnace

n addition to pre-installed programs for Ivoclar Vivadent materials, programs for third-party materials can be created independently and with ease. No matter what material you choose, the Programat CS6 speeds up your practice.

he new Programat CS6 ensures that each case is quickly and consistently completed, allowing dentists to focus on their patients, not their furnace.

For more info, call 1300-486-252 or email orders.au@ivoclarvivadent.com. In New Zealand , call 0508-486-252 or email orders.nz@ivoclarvivadent.com

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I

1. Arnold L, IPS e.max CAD crystallization program durations of Programat CS2, CS3 and CS6, Test Report, Ivoclar Vivadent, 2021.

18 Australasian Dental Practice

September/October 2021

The wait is almost over IPS e.max® CAD in just over

11

min.

Programat® CS6 ✓ Quickly crystalise and sinter your restorations ✓ Achieve outstanding aesthetic results case after case ✓ Open system offers you flexibility and peace of mind

Coming soon! Register your interest with your local Territory Manager today.

ivoclarvivadent.com | 1300 486 252

Ca l ca ini s Cl se r llin Ca fo g s se Ca l ca ini Cl r fo g Callin Case and Receive

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Clinical Satchel A Geistlich h A Geistlic Clinical Satchel Minor Bone Minor Bone Augmentation Augmentation

Major Bone Major Bone Augmentation Augmentation

Gain of Gain ofTissue Keratinised Keratinised Tissue

Recession Recession Coverage Coverage

Sinus Floor Sinus Floor Elevation Elevation

Extraction Extraction Sockets Sockets

Periodontitis Periodontitis

SUBMIT SUBMIT

NOW! NOW!

H S E F K R IN T H S E R K -FREHABILITAHTE THIN ERATE

E AT ER REGAIN - REGEN E - REHABILITATE AT ER N GE REGAIN RE

Submission Date: Submission Date: 1st October – 30th November 2021

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by Geis preted emphasise ns as inter We explicitly ded. publicatio scientific cannot be exclu aries of errors ain summ studies, pages cont of the cited aries. ns following er: The ts and conclusio nt of the summ laim Disc conte the resul e for the knowledge responsibl be held cannot

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Clinical Panellists: Clinical Prof LisaPanellists: Heitz-Mayfield Prof Lisa Heitz-Mayfield Prof Lisa Heitz-Mayfield Dr Barbara Woodhouse Dr Barbara Woodhouse Dr George Alexopoulos Dr George Alexopoulos Selected Clinical Cases Selected Clinical Cases will be published in 2022*** will be published in 2022 Announcement Date Announcement Date 10th December 2021 10th December 2021

For For more more information information please please contact contact your your local local For more information please contact Geistlich Product Product Specialist Specialist or or call call 1800 1800your 776 local 326.

Geistlich 776 326. *Geistlich Product Specialist or call 1800 776 326. *Dental magazines, Geistlich microsite or clinical brochures Dental magazines, Geistlich microsite or clinical brochures *

Dental magazines, Geistlich microsite or clinical brochures

THINK FRESHHABILITATE GENERATE - REHABILITATE

R EGENERATE - RE RE IN -- R AIN EGA REG

s t is ll e n a P l s a t ic is n ll li e C n a 's P h l c a li t ic is n e li C G 's h c Geistli Lisa Heitz-Mayfield Lisa Heitz-Mayfield

Professor Lisa Heitz-Mayfield, an Adelaide graduate, obtained a Master’s in periodontology (1996) and PhD Professor Lisa Heitz-Mayfield, an Adelaide graduate, obtained a Master’s in periodontology (1996) and PhD (1998) from Lund University, Sweden. Her doctorate focused on periodontal and peri-implant regeneration.

(1998) from Lund University, Sweden. Her doctorate focused on periodontal and peri-implant regeneration.

She received a scholarship to the Brånemark Osseointegration Centre, Sweden, and an ITI Scholarship to She received a scholarship to the Brånemark Osseointegration Centre, Sweden, and an ITI Scholarship to the University of Bern, Switzerland where she was Head of the Oral Microbiology Research Laboratory the University of Bern, Switzerland where she was Head of the Oral Microbiology Research Laboratory from 1999 to 2003. She was awarded the André Schroeder Research Prize in Implant Dentistry in 2002. from 1999 to 2003. She was awarded the André Schroeder Research Prize in Implant Dentistry in 2002.

Her positions include Adjunct Professor at the International Research Collaborative, University of Western Her positions include Adjunct Professor at the International Research Collaborative, University of Western Australia, Associate Professor at the University of Sydney, and Honorary Professor at the University of Hong Australia, Associate Professor at the University of Sydney, and Honorary Professor at the University of Hong Kong and the University of Notre Dame. She is the Chair of the ITI Research committee and member of the Kong and the University of Notre Dame. She is the Chair of the ITI Research committee and member of the Board of Directors of the International Team for Implantology. She was appointed Editor-in-Chief of the Board of Directors of the International Team for Implantology. She was appointed Editor-in-Chief of the journal Clinical Oral Implants Research in 2016. Prof Heitz-Mayfield was elected as a member of the Board journal Clinical Oral Implants Research in 2016. Prof Heitz-Mayfield was elected as a member of the Board of Directors of The Osteology Foundation in 2018. She maintains a specialist periodontal practice in Perth. of Directors of The Osteology Foundation in 2018. She maintains a specialist periodontal practice in Perth.

Barbara Woodhouse Barbara Woodhouse

Dr Barbara Woodhouse BDsc (hons MDSc MBBS FRACDS FFDRCS(Irel) FRACDS(OMS) FADI FICD FPFA Dr Barbara Woodhouse BDsc (hons MDSc MBBS FRACDS FFDRCS(Irel) FRACDS(OMS) FADI FICD FPFA is both a dental and medical practitioner who has practised in both rural and urban, public and private is both a dental and medical practitioner who has practised in both rural and urban, public and private settings, and teaches and examines at undergraduate, graduate and post graduate levels in both disciplines, settings, and teaches and examines at undergraduate, graduate and post graduate levels in both disciplines, nationally and internationally. She is currently in specialist practice in Brisbane, practising the full scope nationally and internationally. She is currently in specialist practice in Brisbane, practising the full scope of Oral and Maxillofacial Surgery from dentoalveolar, through orthognathic and head and neck surgery, of Oral and Maxillofacial Surgery from dentoalveolar, through orthognathic and head and neck surgery, including providing an extensive tertiary referral implant service. She is active on many hospital committees, including providing an extensive tertiary referral implant service. She is active on many hospital committees, general and specialist medical and dental societies, and sits on the board of the Royal Australasian College general and specialist medical and dental societies, and sits on the board of the Royal Australasian College of Dental Surgeons of Dental Surgeons

George Alexopoulos George Alexopoulos

Dr George Alexopoulos graduated BDSc from The University of Melbourne in 1997 and worked in a variety Dr George Alexopoulos graduated BDSc from The University of Melbourne in 1997 and worked in a variety of private and public dental settings. He was awarded an MBA from Monash University in 2003, a Masters of private and public dental settings. He was awarded an MBA from Monash University in 2003, a Masters of Science (Oral Implantology) from the J.W. Goethe University of Frankfurt in 2014, and a PhD from The of Science (Oral Implantology) from the J.W. Goethe University of Frankfurt in 2014, and a PhD from The University of Melbourne in 2021. Dr Alexopoulos has an interest in the fields of oral implantology and University of Melbourne in 2021. Dr Alexopoulos has an interest in the fields of oral implantology and oral tissue regeneration. He is currently the Clinical Science and Education Manager for Geistlich Pharma oral tissue regeneration. He is currently the Clinical Science and Education Manager for Geistlich Pharma Australia/New Zealand; a role that enables him to continue pursuing his interest in oral regeneration, Australia/New Zealand; a role that enables him to continue pursuing his interest in oral regeneration, research, and education. With years of clinical experience to draw upon, Dr Alexopoulos can be of assistance research, and education. With years of clinical experience to draw upon, Dr Alexopoulos can be of assistance to both experienced and less experienced clinicians in their practice of implantology and oral regeneration. to both experienced and less experienced clinicians in their practice of implantology and oral regeneration.

To To submit submit

1. Scan the QR code to access the Geistlich Clinical Case Submission Platform 1. Scan the QR code to access the Geistlich Clinical Case Submission Platform 2. Click on the therapeutic area of your choice 2. Click on the therapeutic area of your choice 3. Fill in the details 3. Fill in the details 4. Submit 4. Submit

spectrum | NEWS

ADA NSW and ADIA team up to host new SIDCON22 conference and expo

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orld-class speakers, cutting-edge industry exhibitions and a stellar line-up of social events will all feature as part of a new landmark event for the Australian dental profession.

The Australian Dental Industry Association (ADIA) and the Australian Dental Association New South Wales (ADA NSW) have joined forces to deliver Australia’s largest oral health and networking event of 2022.

Bringing together the flagship ADX Sydney exhibition and the inaugural Sydney International Dental Conference (SIDCON22), this blockbuster combined event will take place from March 16-19, 2022 at the International Convention Centre Sydney.

Thousands of dental professionals, including dentists and their practice teams, hygienists, prosthetists, therapists, dental students, recent graduates and industry representatives are expected to attend the event, which will connect all aspects of dentistry for the first time.

Three-time Paralympic gold medallist Kurt Fearnley AO will be among the line-up of leading Australian and international speakers featured in the SIDCON22

22 Australasian Dental Practice

program, which will present the latest developments across a range of oral health and other topics, including business administration, science and health and well-being.

Delegates will then head over to the ADX Sydney Exhibition, which runs from March 17-19, to explore the latest in dental technology and innovation.

ment to delivering the best possible value and services for them.”

With free childcare onsite, delegates will be able to connect with friends and colleagues through a host of social and networking events on offer, including the popular 2022 Australian Dental Industry Awards and Women in Dentistry Breakfast. Other events will include the

ADA NSW President Dr Kathleen Matthews said SIDCON22 was an unmissable event for the Australian dental profession.

“We are hugely excited to unite with ADIA for this event, which will help further empower dental professionals and improve the delivery of oral health in Australian,” Dr Matthews said. “Dentistry plays a critical role in the overall well-being of Australians and SIDCON22 will allow dental practitioners and their teams to unite, share ideas and discover a wealth of new innovations to advance the profession.

“With our current membership levels at a 15-year high, ADA NSW continues to lead the way in supporting our members.

This event further underlines our commit-

SIDCON22 gala event cocktail party at the Big Top in Sydney’s Luna Park, a recent graduates’ party at Darling Harbour’s Madame Tussauds and the SIDCON22 Golf Day. “The combination of ADX Sydney and SIDCON22 underlines our commitment to delivering the best possible value for our respective members,” ADIA CEO Kym De Britt said. “I expect the combined event will bring more than 10,000 delegates through the doors and over the next six years grow to be one of the largest oral health events in the Asia-Pacific Region.”

More information on SIDCON22 is available at www.sidcon.com.au.

September/October 2021

E E Y R F TR EN

REGISTER NOW

16 -17 March 2022

17-19 March 2022 Highlights include: • Extended opening hours • Free childcare • Free business growth seminars

• Women In Dentistry Breakfast • ADA NSW Centre for Professional Development CPD program

International Convention Centre, Sydney

#ADXexpo #ADXSydney @ADXexpo

Plan now to attend

adx.sydney

/ ADXexpo @adxexpo

AUSTRALIA’S PREMIER DENTAL EVENT

spectrum | NEWS

Waterpik® Water Flosser: An effective alternative to subgingival antibiotic treatment for periodontal maintenance patients

Periodontal maintenance following scaling and root planing, comparing minocycline treatment to daily oral irrigation with water Genovesi AM, Lorenzi C, Lyle DM et al. Minerva Stomatol 2013; 62(Suppl. 1 to NO. 12):1-9. Study conducted at the Tuscan Stomatologic Institute, Department of Dentistry, Versilia General Hospital, Lido di Camaiore (LU), Italy.

Objective

A

ssess the efficacy of daily Waterpik®Water Flossing in comparison to subgingival minocycline treatment for subjects with moderate to severe periodontitis.

Methodology n this single-center, parallel, single blind, randomized clinical study, thirty subjects with moderate to severe periodontitis were placed into a minocycline-treated group or a Water Flossing group.

Scaling and root planing was carried out, and both groups received instruction on proper home-based oral hygiene. One group was administered minocycline inside their deepest periodontal pockets at the initial hygiene visit. The second group was instructed to use a Waterpik® Water Flosser once a day. Clinical and microbiological parameters were measured at baseline and repeated after 30 days.

I

Results oth the Waterpik® Water Flosser and minocycline treatment groups experienced a significant reduction in all clinical parameters tested at thirty days. The Water Flosser group reduced bleeding 81% vs. 76% for the minocycline group. Moreover, both procedures effectively reduced the typical parameters of periodontitis (bleeding on probing, pocket depth, and clinical attachment levels).

B

Conclusion

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he Waterpik®Water Flosser is an effective alternative to subgingival antibiotics for periodontal maintenance patients over a 30 day period.

24 Australasian Dental Practice

September/October 2021

The Easy and Most Effective Way to Floss!™

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1. Terms & Conditions apply. Please visit Waterpik.com.au/shop for more information. 2. Independent clinical studies. Go to Waterpik.com.au for details.

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DENTAL dentevents presents...

ECONOMICS

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Dental Economics is a brand new event for 2022 created to help dental practices GROW. Whether you own a practice or want to own a practice, whether you’re a clinician or part of the team, whether you’re new to the profession or a seasoned veteran, Dental Economics is a festival of ideas and information that will empower you to revisit how you think and work in dentistry today.

The multi-stream, multi-session format allows participants to create their own program, with presentations, forums, workshops and round tables delivered by leading Australian dentists operating large practices over multiple locations; experienced experts in corporate structures, employment, finance and taxation; practice management gurus; marketing and social media consultants; internet and defamation lawyers; and much more.

Grow your private practice and Grow your team at Dental Economics 2022

www.dentaleconomics.com.au

TWO DAYS • 6 CONCURRENT EDUCATION STREAMS 40+ TOP SPEAKERS • 60+ EDUCATION SESSIONS

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FRIDAY 5 AUGUST 9.00am - 5.00pm - education 5.00pm - 7.00pm - happy hour

Multiple lectures and workshops are being run concurrently to allow you to build your own program to suit your specific interests. Price is all inclusive.

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VENUE DETAILS Novotel Sydney Brighton Beach - The Grand Parade, Brighton-Le-Sands NSW 2216 - Close to Sydney Domestic and International Airports Check the website for details of discounted accommodation rates for the conference • Ample parking available at the hotel

Organised by Dentevents™ a division of Main Street Publishing Pty Ltd ABN 74 065 490 655

www.dentevents.com • info@dentist.com.au • Tel: (02) 9929 1900 • Fax: (02) 9929 1999

www.dentaleconomics.com.au

spectrum | NEWS

Pola Light patient kit now in 9.5% HP

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DI Limited has launched Pola Light, an advanced tooth whitening system that combines Pola’s award-winning whitening formulas, with an LED mouthpiece that helps accelerate the whitening procedure.

The Pola Light system comes with Pola Day 9.5% hydrogen peroxide gel.

Pola Light is easy and comfortable to use at home, with treatment options from just 20 minutes a day. The gels are fast acting and are formulated to safely remove long term stains in as little as 5 days. The high viscosity, neutral pH tooth whitening gel ensures the greatest patient comfort in a take home kit. The unique blend of soothers, conditioners and high-water content also assist in reducing sensitivity.

The Pola LED mouthpiece is dual arch and a universal size, removing the need for chair time and custom trays - saving both the patient and the clinician time.

The Pola Light premium packaging is crafted to elevate the appeal of Pola Light

above other less effective pharmacy and on-line solutions on the market. This gives clinicians the confidence and support to convince customers of the benefits of professional tooth whitening.

The Pola tooth whitening range has successfully treated millions of patients worldwide. SDI has an ongoing commit-

ment to providing better tooth whitening solutions that are safe, simple and effective.

Pola Light system is also available in a 6% hydrogen peroxide gel kit that comes with a bonus inclusion of Pola Luminate.

For more information, please visit SDI at www.sdi.com.au.

Control aerosols... control risk...

M

anagement of aerosols is an important part of day-to-day infection control - and has become even more front of mind during the current COVID-19 pandemic.

Aerosol capture in the dental surgery can be especially challenging in twohanded dentistry situations as well as in more complex four-handed dental procedures. Sometimes there are simply not enough hands to do the job, making you wish you had a “third hand” to hold onto something when you quite literally have your hands full.

Well now you can! Thanks to a simple and practical solution from A-dec - the world’s leading dental equipment manufacturer, the A-dec ‘Third Hand’ HVE Holder securely positions the HVE tip to within an inch (25mm) of the oral cavity, delivering precise, effortless aerosol capture while keeping your hands free for

28 Australasian Dental Practice

other instruments and activities chairside.

It’s a simple, affordable way to bring more functionality to your surgery.

When needed, the A-dec Third Hand can go instantly from “hands-free” to “hands-on” by simply lifting the HVE line out of the holder for direct control of the suction tip.

The flexible design of the Third Hand easily attaches to the headrest glide bar of most A-dec chairs, with no special tools or modification required.

The reversible attachment easily adjusts for right- or left-handed clinicians and four-handed procedures.

The A-dec Third Hand HVE Holder is such a simple and effective hands-free solution for extra-oral aerosol capture that you’ll wonder how you ever did without it!

For more information, to locate your local A-dec dealer or A-dec Territory manager, call 1800-225-010 or visit the website at http://australia.a-dec.com

September/October 2021

DBA announces DBA announces DBA announces DBA announces NEW TEETH DBA announces NEW TEETH NEW TEETH WHITENING NEW TEETH DBA announces WHITENING

WHITENING WHITENING FACT SHEET! WHITENING NEW TEETH FACT SHEET! FACT FACT SHEET! SHEET! WHITENING ‘‘FACT …confirms practitioners SHEET! …confirms practitioners …confirms practitioners provide higher ‘‘can …confirms practitioners …confirms practitioners can provide higher can provide higher concentration take-home can provide higher provide higher ‘can …confirms practitioners concentration take-home concentration teeth whiteningtake-home products concentration take-home concentration take-home teeth whitening products can provide higher teeth whitening products to patients. teeth whitening products ’ teeth whitening products to patients. concentration take-home ’ to patients. to patients. ’ to patients.

Dental Board AHPRA Aug 2021 teeth whitening products ’ 13th Dental Board AHPRA 13th Aug 2021 Dental Board AHPRA 13th Aug 2021 https://www.dentalboard.gov.au/ Dental Board AHPRA 13th Aug 2021 to patients. ’ Dental Board AHPRA 13th Aug 2021 https://www.dentalboard.gov.au/ News/2021-08-13-updated-fact-sheethttps://www.dentalboard.gov.au/

OFFICIAL 202 1 OFFICIAL 202 1 TEETH WHITENING PARTNER OFFICIAL 202 1 OFFICIAL 202 1 TEETH WHITENING PARTNER TEETH WHITENING PARTNER OFFICIAL 202 1 TEETH WHITENING PARTNER TEETH WHITENING PARTNER OFFICIAL 202 202 11 OFFICIAL TEETH WHITENING WHITENING PARTNER PARTNER TEETH

SDI Pola is pleased to advise the Dental Board has updated its fact sheet on teeth SDI Pola is to advise the Dental has updated its fact on teeth whitening products to patients for useBoard at home, under practitioner instruction.

SDI Pola is pleased pleased to advise the Dental Board has updated its fact sheet sheet on teeth SDI Pola to the Board has updated its on whitening products to patients for use at home, practitioner instruction.

SDI Pola is is pleased pleased to advise advise the Dental Dental Board has under updated its fact fact sheet sheet on teeth teeth whitening products to patients for use at home, under practitioner instruction. whitening products to patients for use at home, under practitioner instruction.

The Dental Board of Australia website gives dentalunder practitioners an overview of the laws whitening products to patients for use at home, practitioner instruction.

The Dental Board of website dental practitioners an overview the and professional obligations applygives when they teethits whitening products as laws part SDI Pola is pleased toAustralia advise that the Dental Board has use updated fact sheet onof teeth The Dental Board of Australia website gives dental practitioners an overview of the laws The Dental Board of Australia website gives dental practitioners an of the laws and professional that apply when they use teeth whitening products as part The Dental Board ofprovides Australia website gives dental practitioners an overview overview of poisons the laws of their practice.

Itobligations links to useful such as medicines and whitening products to patients for use atinformation, home, under practitioner instruction. and professional obligations that apply when they use teeth whitening products as part and professional obligations that apply when they use teeth whitening products as part of their practice.

It provides links to useful information, such as medicines and poisons and professional obligations that apply when they use teeth whitening products as part legislation and now clarifies any past confusion. of their practice.

It provides links to useful information, such as medicines and poisons of their practice.

It provides links to useful information, such as medicines and poisons The Dental Board of Australia website gives dental practitioners an overview of the laws legislation and now clarifies any past confusion. of their practice.

It provides links to useful information, such as medicines and poisons legislation and now clarifies any past confusion. legislation and clarifies confusion. and professional obligations thatpast apply when they use teeth whitening products as part legislation and now now clarifies any any past confusion.

POLA HAS THE LARGEST OF PERCENTAGES TO SUIT YOUR of their practice.

It provides links toRANGE useful information, such as medicines and poisons POLA HAS THE LARGEST RANGE OF PERCENTAGES TO SUIT YOUR legislation and now clarifies any past confusion.

POLA HAS THE LARGEST RANGE OF PERCENTAGES TO SUIT POLA HAS THE LARGEST RANGE OF PERCENTAGES TO SUIT YOUR YOUR

https://www.dentalboard.gov.au/ News/2021-08-13-updated-fact-sheetteeth-whitening.aspx https://www.dentalboard.gov.au/ News/2021-08-13-updated-fact-sheetDental Board AHPRA 13th Aug 2021 News/2021-08-13-updated-fact-sheetteeth-whitening.aspx News/2021-08-13-updated-fact-sheetteeth-whitening.aspx teeth-whitening.aspx https://www.dentalboard.gov.au/ teeth-whitening.aspx News/2021-08-13-updated-fact-sheetteeth-whitening.aspx

Download the DBA Download DBA fact sheet the on teeth Download the DBA Download the DBA fact sheet on teeth whitening here.

Download the DBA fact sheet on teeth fact sheet on teeth whitening fact sheet here. on teeth whitening here. whitening whitening here. here.

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PATIENT AND CLINICAL NEEDS. PATIENT PATIENT AND AND CLINICAL CLINICAL NEEDS. NEEDS. POLA HAS THE LARGEST RANGE OF PERCENTAGES TO SUIT YOUR PATIENT PATIENT AND AND CLINICAL CLINICAL NEEDS. NEEDS. POLA HAS THE LARGEST RANGE OF PERCENTAGES TO SUIT YOUR PATIENT AND CLINICAL NEEDS. POLA DAY 6% : POLA POLA DAY DAY 6% 6% :: POLA DAY 6% : POLA DAY 6% :

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POLA NIGHT 10% : POLA POLA NIGHT NIGHT 10% 10% :: POLA NIGHT 10% : POLA NIGHT 10% : POLA NIGHT 16% : POLA NIGHT NIGHT 10% 16% POLA 16% :: POLA NIGHT 16% : POLA NIGHT 16% : POLA NIGHT 18% : POLA 18% POLA NIGHT NIGHT 16% 18% :: POLA NIGHT 18% : POLA NIGHT 18% : POLA NIGHT 22% : POLA NIGHT 18% : POLA NIGHT 22% 22% : POLA NIGHT 22% : POLA NIGHT 22% :

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COMPOSITES | GLASS IONOMERS | TOOTH WHITENING COMPOSITES || GLASS IONOMERS || TOOTH SDF RIVA STAR | CEMENTS | ADHESIVES |WHITENING ETCHANTS COMPOSITES IONOMERS WHITENING COMPOSITES || GLASS GLASS IONOMERS || TOOTH TOOTH WHITENING SDF RIVA STAR || CEMENTS || ADHESIVES ETCHANTS COMPOSITES GLASS IONOMERS TOOTH| ||EQUIPMENT WHITENING SEALANTS | AMALGAMS | ACCESSORIES SDF RIVA STAR CEMENTS ADHESIVES ETCHANTS SDF RIVA STAR || CEMENTS || ADHESIVES ||EQUIPMENT ETCHANTS SEALANTS | AMALGAMS | ACCESSORIES | SDF RIVA STAR CEMENTS ADHESIVES ETCHANTS SEALANTS | AMALGAMS | ACCESSORIES | EQUIPMENT SEALANTS | AMALGAMS | ACCESSORIES | EQUIPMENT COMPOSITES | GLASS IONOMERS | TOOTH WHITENING SEALANTS | AMALGAMS | ACCESSORIES | EQUIPMENT SDF RIVA STAR | CEMENTS | ADHESIVES | ETCHANTS orders phone| AMALGAMS 1300 65 88 22 | orders fax 1300 65 88 10 SEALANTS | ACCESSORIES | EQUIPMENT orders phone 1300 65 88 22 | orders fax 1300 65 88 10 orders phone 1300 65 88 22 | orders fax 1300 65 88 10 orders phone 1300 65 88 22 | orders fax 1300 65 88 10

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YOUR OUR YOUR OUR YOUR OUR YOUR OUR SMILE. VISION. YOUR OUR SMILE. VISION. SMILE. VISION. SMILE. VISION. Call 1800 337 003 SMILE. VISION. YOUR OUR Call 1800 337 003 Call 1800 337 003 www.sdi.com.au Call 1800 337 Call 1800VISION. 337 003 003 SMILE. www.sdi.com.au www.sdi.com.au www.sdi.com.au www.sdi.com.au Call 1800 337 003 www.sdi.com.au

spectrum | NEWS

Ivoclar Vivadent launches new generation Adhese Universal VivaPen

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voclar Vivadent, one of the world’s leading suppliers of integrated solutions for high-quality dental applications and a comprehensive product and systems portfolio for dentists and dental technicians, is the manufacturer of Adhese Universal, a light-curing single-component adhesive for direct and indirect restorations and all etching techniques. The bonding agent is applied from the unique VivaPen. A new generation of the pen-like applicator, which has been redesigned and made more user-friendly, is now being launched by the company.

The new, efficient version of the VivaPen provides up to three times more applications per millilitre of contents compared with conventional bottles.

New VivaPen - unique and efficient down to the last detail he redesigned VivaPen is very comfortable to handle. The pen’s “click” mechanism dispenses the exact amount of bonding agent needed and therefore ensures the quick and controlled direct intraoral application of restoratives. The bendable tip gives access to all areas of the mouth and all cavity sizes. As a result of the VivaPen’s streamlined shape, the view of the working field remains unobstructed. The fill level indicator built into the VivaPen provides constant information about the amount of adhesive that is still left in the pen.

T

30 Australasian Dental Practice

Adhese Universal quality that stands out he universal adhesive Adhese Universal achieves reliable high bond strength values (> 25 MPa) on enamel and dentine, irrespective of the etching protocol used or of the wet or dry condition of the tooth surface. Predictable high bond strength values allow practitioners to work with confidence. Adhese Universal features an integrated desensitising effect, which eliminates the need for a separate desensitising agent. Adhese Universal can be applied very thinly and therefore offers practitioners exceptional freedom in the fabrication of direct and indirect restorations. The adhesive establishes a sound foundation on which customised solutions and outstanding aesthetic results can be achieved.

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Efficiency times three he combination of Adhese Universal and the new VivaPen promises threefold efficiency: • Up to three times more applications - economically dispensed from the VivaPen. The simple “click” mechanism pumps the exact amount of adhesive needed. The adhesive does not have to be predispensed into a mixing well. This significantly reduces the amount of material wasted.

• Universal use - for direct and indirect restorations and all etching protocols.

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Adhese Universal is the ideal adhesive for bonding composites of the Tetric line. The product acts as an adhesive in the placement of indirect and direct restorations with light and dual-curing luting materials or as a primer for conditioning restorations made from Tetric CAD composite blocks.

• Three-second curing - fast and reliable process. Adhese Universal cures with conventional curing lights (with a light intensity of 2000 mW/cm2) in just 5 seconds. At a light intensity of 3000 mW/cm2, as provided by the Bluephase PowerCure from Ivoclar Vivadent, the curing process is reduced to only 3 secs.

About Ivoclar Vivadent Ivoclar Vivadent, headquartered in Schaan, Liechtenstein, is one of the world’s leading manufacturers of integrated solutions for high-quality dental applications. The company’s success is based on a comprehensive portfolio of products, systems and services, strong research and development capabilities and a clear commitment to training and further education. The company, which sells its products to around 130 countries, has 47 subsidiaries and branch offices and employs roughly 3,500 people worldwide.

For more info, call 1300-486-252 or email orders.au@ivoclarvivadent.com. In New Zealand , call 0508-486-252 or email orders.nz@ivoclarvivadent.com

September/October 2021

“

“

Communication and service has always been exceptional, and I have no hesitation in recommending Credabl across the board.

Dr Andrea King, Dentist

Getting more from my finance partner, means my patients get more from me.

Professional and personal finance solutions, tailored for you and turned around fast. When you partner with Credabl, you can expect all that and more. With a team of experienced finance specialists, we understand the medical sector so you can look forward to finance solutions that help you get on with business and looking after your patients.

You always get more with Credabl.

1300 27 33 22 credabl.com.au

Practice Purchase • Commercial Property • Goodwill Loans • Overdraft Facilities • Home Loans • Car Loans • Equipment & Fitout Finance • SMSF Lending The issuer and credit provider of these products and services is Credabl Pty Ltd (ACN 615 968 100) Australian Credit Licence No. (ACL) 499547.

ULTRA SAFETY PLUS TWIST safe & easy > Protects you and your staff from needle stick injuries > Complies with latest regulations > Intuitive device > Available with either sterile single use or sterilisable handle

FIT FIT II

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Biodentine Biodentine Biodentine Biodentine NEW ™ ™ ™™ ™ ™™ ™ ™

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in a dental school, Ultra Safety Plus was a the key success factor for avoiding needle stick injuries.

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PRACTICE ““First ever REPUTATION PRACTICE First SATISFACTION ever REPUTATION EFFICIENCY REPUTATION SATISFACTION REPUTATION EFFICIENCY IS IS EVERYTHING EVERYTHING Biological REPUTATION Biological REPUTATION the right one with Hu-Friedy the right one with Hu-Friedy SEPTANEST SEPTANEST Bulk Fill” Bulk Fill” SEPTANEST IS EVERYTHING ULTRA SAFETY PLUS INTRODUCTION

table outcomes for your littlest patients with Hu-Friedy Stainless Steel Pedo Crowns. table outcomes for your littlest patients with Hu-Friedy Stainless Steel Pedo Crowns. discover why dentists favor our impeccable fit. Perfect for your Irreversible patients. Easy for you. Pulpitis Pulpitis discover why dentists favor our impeccable fit. Perfect for your Irreversible patients. Easy for you.

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MANAGING Pulpitis Irreversible Pulpitis n it comes to the perfect fit, Hu-Friedy is just right.Irreversible MANAGING Pediatrics Endodontics MANAGING Irreversible Pulpitis ™ Biodentine saves pulps EVEN with signs and symptoms As world leader in Pain Management, Septodont TS LOVE OUR STAINLESS STEEL Pediatrics PEDO CROWNS: Endodontics MANAGING ™ Biodentine saves pulps EVEN with signs and symptoms ™ of world irreversible pulpitis* Ultra Safety with the new Twist Lock ™Plus As leader in Pain Management, Septodont Biodentine saves pulps EVEN with signs and symptoms TS OUR STAINLESS STEEL PEDO CROWNS: provides you products and services to help you Biodentine saves pulps EVEN with signs and symptoms ableLOVE outcomes for your littlest patients with Hu-Friedy Stainless Steel Pedo Crowns.

As leader in Pain Management, Septodont ™ of world irreversible pulpitis* ™ pulps Biodentine saves EVEN with signs and symptoms of irreversible pulpitis* provides you products and services to help you As the first all-in-one biocompatible and bioactive dentin substitute, Biodentine saves pulps EVEN with and symptoms eight and width patented design your safety device oflittlest irreversible pulpitis* able outcomes for your with Hu-Friedy Stainless Steel Pedo Crowns. administer experience, amongst those : As world leader inmakes Pain Management, Septodont iscover whymesio-distal dentists favor our patients impeccable fit.

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Biodentine brings one-of-a-kind benefi ts for the treatment of Biodentine of irreversible pulpitis* For vital pulp therapy, bulk-fi lling the cavity with Biodentine brings one-of-a-kind benefi ts for the treatment of Biodentine makes your procedure better, easier and faster: it comes the perfect fit, Hu-Friedy is justfirst right.experience, Septanest :of the choice of tsdentists with over administer painfree amongst those mmed andtopre-crimped for simple placement ™ 85%** ™ : up to irreversible pulpitis cases: world leader inone-of-a-kind Pain Management, Septodont ™CROWNS: helps of dentin, preserves the pulp brings one-of-a-kind benefi for the treatment of the Biodentine to As 85%** of irreversible pulpitis cases: • Vital Pulp Therapy allowing complete dentin bridge formation SeLOVE OURup STAINLESS STEEL PEDO occlusal anatomy that matches the natural tooth brings benefi ts Biodentine for the treatment of remineralization PRACTICE Biodentine makes your procedure better, easier and faster: up to 85%** of irreversible pulpitis cases: PRACTICE Septanest : the first choice of dentists with over Available with either sterile single-use or ™ bioactivity 150 million injections per year, provides you high • Pulp healing promotion: proven biocompatibility and As world leader in Pain Management, Septodont ™ helps the remineralization of dentin, dentin preserves pulp Biodentine vitality and promotes pulp healing.

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Innovative nature Innovative byby nature safe Plus, Withpatients Ultra Safety needle stick To injuries enjoy clinical benefitsforofBiodentine the first and. only dentin in a capsule, ask your the dental distributor Innovative by nature Innovative by nature Innovative by nature ask your dental distributor for Biodentine .

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Please visit our website for more information Call 0508 486 252 our website website for more information information Please visit our for more www.septodont.com Please visit our website for more information Please visit our website for more informationa controlled study. Brit Dent Call 0508 486 252 J.M Zakrzewska et al. Introducing safety syringes into a UK dental school – 200188 ; 190;22 88-92.

08 855 (1) www.henryschein.co.nz Orders 1300J65 www.henryschein.com.au www.ivoclarvivadent.co.nz Please visit our website for more information www.septodont.com www.septodont.com Please visit ourvisit website for morefor information www.septodont.com *If haemostasis cannot be achieved after full pulpotomy, a pulpectomy and a RCT should65 be carried out, www.henryschein.com.au provided the tooth is restorable (ESE Position Paper,Duncan et al. 2017) Please our website more information Learn more with 08 855 www.henryschein.co.nz Orders 1300 88 22 www.ivoclarvivadent.co.nz www.septodont.com

08 855 www.septodont.com www.henryschein.co.nz Orders 1300 65 88 22 www.henryschein.com.au ** Taha et al., 2018 www.septodont.com *If haemostasis cannot be achieved after full pulpotomy, a pulpectomy and a RCT should be carried out, provided the tooth is restorable (ESE Position Paper,Duncan et al. 2017) the Biodentine™ brochure

spectrum | NEWS

Expand ortho treatment in your practice

G

aining skills and experience in orthodontics increases your treatment options, quality of patient care and potentially your income!

Joseph Allbeury spoke to Dr Geoff Hall about the opening of The OrthoED Institute’s 2022 enrolments and why this is the must-do program for the new year.

Q A

Dr Hall, please tell us about The OrthoED Institute.

The OrthoED Institute is a private training institution for general dentists that covers the entire gamut of orthodontics, from diagnosis and treatment planning through to early treatment intervention and on to fixed braces. And obviously we also cover what’s very popular now, aligner therapy. It’s the ideal program for any general dentist that wants to learn more about orthodontics. It’s a comprehensive, structured learning program backed up with practical work and full support over a two-year period and beyond.

The system we teach is well-balanced and based on sound orthodontic principles. It’s not based on any specific appliances, bracket systems or aligner types. We’re purely providing orthodontic education to dentists so that they feel comfortable and confident in treating the majority of patients that walk through the door, reducing the need to refer simple cases out. Even more moderate cases can be completed in-house.

We also have an optional accredited post-graduate diploma program which is examination-based to add further weight to your studies.

We’ve tried to cover all the bases so our graduates have both the knowledge and practical experience to confidently treat the majority of the orthodontic needs of their patients.

Q A

Why do dentists need to learn more about orthodontics?

The reality is that every patient that comes in to see you should be orthodontically assessed, but quite often they’re not. This may be because the dentist doesn’t want to refer the patient out,

34 Australasian Dental Practice

but most of the time it’s because they don’t have the training to see that there is a problem in the first place.

Orthodontics is a fundamental part of any type of diagnosis for a patient, whether it be a young child or an adult, but it is often discounted in favour of more “destructive” dentistry like using crowns and veneers, because the dentist is more comfortable with restorative procedures. We want to equip dentists with more conservative techniques, whether it be using fixed braces, appliances or aligner therapy to achieve quality, predictable results efficiently.

Q A

At what stage of your career should you complete the OrthoED program?

That’s an interesting question because when we started, we thought the program would be taken up by dentists in their forties looking to expand their skills. But what we’re finding is that a lot of new graduates are participating because they now realise that orthodontics can be a big part of the treatment completed in general practices. And they want to learn these skills while they’re working for other people. I use the analogy that it’s a bit like referring out an upper central incisor endo case. An endodontist would laugh at it. And there are lots of those types of cases in orthodontics that are really best dealt with in the hands of the general dentist. But rather than referring them out, they’re being overlooked or dealt with in less ideal ways. Equally, it’s important to know when it’s best to refer a patient to a specialist colleague.

Q A

Who teaches the program?

The faculty are all specialist orthodontists and we’re here to support our students both throughout the program and beyond through our alumni program.

One of the questions general dentists often ask me is what happens if a case they are treating orthodontically goes awry and this is where being educated and backed by specialists is important. If there is ever a problem with a case in the future, then we’re here to support you with your diagnosis, planning and treatment delivery, as well as in any other way you may require.

Apart from the core faculty, we also have guest lecturers as well. We have some exciting things happening in 2022 with international lecturers coming out on behalf of OrthoED including Dr Donna Galante, who was the number one Invisalign instructor back in 2000 and 2017.

She’s lecturing exclusively for us on aligner therapy. Dr Galante is probably one of the top five aligner providers in the world.

We also have Dr Peter Sheridan, the expert on dental photography, giving a one day programme.

So we have lots of guests to make the programme even more balanced. We also have optional webinars at night and optional weekly treatment planning sessions, plus on-demand recordings you can watch any time. There is literally as much or as little extracurricular material and support as you want or require.

Q A

Is this a face-to-face program or virtual?

It’s a face-to-face learning program and there are eight modules to complete over a two-year period. There is the opportunity to do it online as well, but we can only offer intensive clinical support to students who are doing the course face-to-face.

It sounds like an amazing program. I believe you also have a treatment planning service for aligners anyone can use?

Q

That’s correct. It’s not just for OrthoED members to use. Aligners are such a big part of general dentistry now and for the future. So we’ve set up a treatment planning service purely for aligner providers whereby we do all of the setups and optimise the case for the dentist. We call this service CAPS - Complete Aligner Planning Service - and it’s open to any dentist. We work with Invisalign, SureSmile, Angel Align and SmileStyler and help general dentists offer aligners without having to worry about the set-up and optimising the digital treatment plan.

A

Thank you very much Dr Hall.

For info, visit www.orthotraining.com.au or email info@orthoed.com.au

September/October 2021

The Thesecret secretto toclear clearaligner aligner The secret to clear aligner success begins with effective success begins with effective The secret to clear aligner success begins with effective diagnosis and diagnosis andtreatment treatment success begins with effective diagnosis and treatment planning; a huge roadblock planning;aand ahuge huge roadblockfor for diagnosis treatment planning; roadblock for many With the manydentists. dentists.

With theright right planning; a huge roadblock for many dentists.

With the right education, dentists better education, dentists canright better many dentists.

With can the education, dentists can better understand proper understanddentists properdiagnosis, diagnosis, the education, can betterthe understand proper diagnosis, the stages stagesof ofplanning planning andmake makethe the understand proper and diagnosis, the stages of planning and make the best choices for the patient, bestchoices choices forthe the patient, stages of planning and make the best for patient, avoiding unnecessary avoiding unnecessary best choices for the patient, avoiding unnecessary complications and complications andpoor, poor, avoiding unnecessary complications and poor, unpredictable unpredictableoutcomes. outcomes. complications and poor, unpredictable outcomes. unpredictable outcomes.

Want Want to to take take back back Want to take back control control ofyour your Want to of take back control of your Clear cases ClearAligner Aligner cases control of your Clear Aligner cases and and produce produce Clear Aligner cases and produce predictable predictable and produce predictable outcomes, outcomes, every every predictable outcomes, every time? time? outcomes, every time? time?

With WithOrthoED’s OrthoED’snew newAligner AlignerTherapy Therapycourse coursebundle, bundle,the thecountry’s country’sleading leadingorthodontists orthodontistsare areready readyto to With OrthoED’s new Aligner Therapy course bundle, the country’s leading orthodontists are ready to teach you the principles of aligner treatment in as little as 5 days allowing you to plan, manage teach you the principles of aligner treatment in as little as 5 days allowing you to plan, manageand and teach you the principles of Therapy aligner treatment inconfidence as little as and 5 days allowing you to plan, manage and complete aavariety of aligner control and profitable.

With OrthoED’s new Aligner course bundle, the country’s leading orthodontists ready to complete variety ofclear clear alignercases caseswith with confidence andtotal total control andalso alsobe beare profitable. complete a variety of clear aligner cases with confidence and total control and also be profitable. teach you the principles of aligner treatment in as little as 5 days allowing you to plan, manage and complete a variety of clear aligner cases with confidence and total control and also be profitable.

THE THEORTHOED ORTHOEDCLEAR CLEARALIGNER ALIGNERTRAINING TRAININGBUNDLE BUNDLEINCLUDES: INCLUDES: THE ORTHOED CLEAR ALIGNER TRAINING BUNDLE INCLUDES: THE ORTHOED CLEAR ALIGNER TRAINING BUNDLE INCLUDES: Aligner AlignerEssentials Essentials(3 (3days) days) Aligner Essentials (3 days) where you’ll master the where you’ll master theessential essential where you’ll master the Aligner Essentials (3essential days) techniques for and techniques forplanning planning andtreating treatingcases cases

Advanced AdvancedAligners Aligners(2 (2days) days) Advanced Aligners (2 days) where you’ll learn advanced where you’ll learn advancedtechniques techniquesto to where you’ll learn advanced techniques to Advanced Aligners (2 days) bring more patients into your practice ,tackle bring more patients into your practice ,tackle

high-quality outcomes.

provide world-class results for your patients.

techniques planning and treating cases where you’llfor master theprofitably essential predictably, efficiently, predictably, efficiently, profitablyand andwith with predictably, efficiently, profitably and with techniques for planning and treating cases high-quality outcomes. high-quality outcomes. high-quality outcomes.profitably and with predictably, efficiently,

bring more into yourtechniques practice ,tackle where you’llpatients learn advanced to and more cases with morecomplex complex cases withtotal totalconfidence confidence and more complex cases with total confidence and bring more patients into your practice ,tackle provide world-class results for your patients. provide world-class results for your patients. provide world-class for your patients. more complex casesresults with total confidence and

Interested Interestedin inadvancing advancingyour yourcareer careerwith withbetter betterquality qualityclear clearaligner alignertreatments? treatments?

Interested in advancing your career with better quality clear aligner treatments?

The TheAligner AlignerEssentials Essentialsprogram programisisscheduled scheduledfor for19-21 19-21May May2022 2022in inSydney Sydneyand and16-18 16-18November November2022 2022in inMelbourne Melbourneand andthe the Interested in advancing your career with better quality clear aligner treatments?

TheAdvanced Aligner Essentials program scheduled for1-2 19-21 May 2022 in Sydney and 16-18 November 2022 in Melbourne and the Aligner program isisscheduled for December 2022 in Melbourne.

Purchase both together and save $650.

Advanced Aligner program is scheduled for 1-2 December 2022 in Melbourne. Purchase both together and save $650.

Advanced Aligner program is scheduled for 1-2 December 2022 in Melbourne. Purchase both together and save $650.

The Aligner Visit Essentials programwebsite is scheduled forfor 19-21 May 2022 in Sydney and 16-18 November 2022 in Melbourne and the the OrthoED today and before spaces are out.

Visit theprogram OrthoED website today formore moredetails details andto tobook bookyour yourtickets tickets before spaces aresold sold out.

Advanced Aligner is scheduled for 1-2 December 2022 in Melbourne.

Purchase both together and save $650.

Visit the OrthoED website today for more details and to book your tickets before spaces are sold out.

spectrum | NEWS

NeossONE™ - One Platform, Smart Prosthetics, three implant ranges

N

eossONE is a solution unique to the Neoss® Implant System - one prosthetic platform, across three implant ranges, including ALL implant diameters and abutments. Simply put, the same prosthetic components fit every implant.1 ONE Prosthetic Platform, ONE Impression Coping, ONE Kit! One prosthetic platform, across three implant ranges, means one impression coping, one implant replica and one abutment interface, facilitating treatments that are adaptable and versatile.

With fewer components in the system, complexity is reduced and time-efficiency is improved. All of which results in a truly cost-effective solution and predicable outcome.

Why choose the NeossONE Platform? n a market where simplicity is commonly claimed, Neoss has redefined its meaning. In contrast to traditional implant systems necessitating up to a thousand components, Neoss uses a minimum number of components to achieve the highest level of flexibility and functionality, without compromise. Utilising NeossONE, with its proven long-term clinical performance, enables integration of innovations in surgery and prosthetic rehabilitation, providing unique benefits for the whole dental team.

I

What does NeossONE™ provide for dental team? or clinicians, it means predictable aesthetics, soft tissue integration and prosthetic precision. The ingenuity lies not only in the NeossONE solution, but in the patented Neoss implant design that optimises stability in all bone qualities and conditions and eliminates the need for separate one- or two-stage designs. The benefits of both are clear: a predictable solution with shorter chair time2 and optimised inventory control.

“The NeossONE concept of a single restorative platform across an entire implant range is a huge benefit for our entire dental team. It offers elegant and comprehensive treatment solutions to achieve predictable long term results, whilst maintaining the simplicity of a reduced inventory,” said Dr Kavit N Shah, BDS, MFDS.RCS (Eng), M.Clin.Dent, MRD.RCS (Eng) from The London Centre for Prosthodontics.

For dental technicians, the NeossONE solution offers an intelligent and simple solution with less inventory of components, digital workflows supporting local production or central production for patient-specific solutions. This requires less effort and time to implement, gives maximum flexibility and strengthens relationships with the clinician’s team.

“I am probably one of the first customers of Neoss in the US (2006). I saw the ingenuity and technical advantages from the start; one prosthetic platform reduces inventory, eases communication and saves time,” said Steven Pigliacelli, CDT, MDT from Marotta Dental Studio Inc.

F

36 Australasian Dental Practice

The benefits are clear: reducing patient treatment time, optimising inventory control and patient outcomes.

About Neoss ounded in 2000, by a professor of prosthodontists and a specialist engineer, Neoss offers intelligent dental solutions that are intuitively simple to use. The company’s products are designed to allow dental professionals to provide reliable and cost-effective treatments to their patients with excellent longterm results. Leading with innovation and integrity, Neoss develops smart treatment solutions and works closely with each practice to drive Intelligent Simplicity, making the complex less complicated. Headquartered in Harrogate, UK, with research and development based in Gothenburg, Sweden, the company has established a global footprint with long-standing presence in key markets.

F

To find out more information about the NeossONE solution, visit www.neoss.com/en/products-solutions/neossone

References 1. Narrow diameter implant range excluded.

2. Customer feedback from the Neoss ProActive® Edge implant ambassador programme.

September/October 2021

NeossONE

TM

NeossONE™ is a solution unique to the Neoss® Implant System - one prosthetic platform, across three implant ranges, diameters ∅3.5mm - ∅6.5mm.

One Platform – Smart Prosthetics

ONE

ONE

Implant Inserter

Abutment Interface

ONE Scan Body

ONE

TM

Intelligent Simplicity

neoss.com

Neoss Australia Pty. Ltd

•

P.O Box 404

•

New Farm

•

QLD 4005

•

T +61 7 3216 0165

•

F +61 7 3216 0135

•

E info.au@neoss.com

spectrum | NEWS

Ivoclar Vivadent founding partner of new 3Shape Unite platform in digital dentistry. As a result of this union, users of 3Shape Unite have access to selected chairside and labside solutions from Ivoclar Vivadent, which are fully integrated in the system.

Designing a smile for patients part from the PrograScan One and PrograDesign chairside workflows, popular applications such as IvoSmile and IvoSmile Orthodontics will also soon be available on the 3Shape Unite platform.

A

Popular applications such as IvoSmile and IvoSmile Orthodontics will also be available on the 3Shape Unite platform shortly.

I

voclar Vivadent, one of the world’s leading suppliers of integrated solutions for high-quality dental applications with a comprehensive portfolio of products and systems for dentists and dental technicians, is an official founding partner of 3Shape Unite, a new open platform that brings together the solutions of leading dental companies for the benefit of dental practices and laboratories. The purpose of the platform is to improve patient care, enhance treatment quality and maximize workflow efficiency across multiple applications.

This partnership takes the collaboration of 3Shape and Ivoclar Vivadent to the next level and underscores their intention to work together on developing gamechanging oral healthcare solutions and on driving the digital transformation of dental medicine.

Digital technology is instrumental in speeding up and improving oral and dental treatments and in making them easier to control. Diego Gabathuler, CEO of Ivoclar Vivadent, elaborates: “In the coming years, digital workflows and

38 Australasian Dental Practice

integrated systems featuring artificial intelligence will open up entirely new possibilities for dental professionals, which will enable them to improve the aesthetics, quality and efficiency of their work - from monitoring at-home oral health routines to making diagnoses in the dental practice and carrying out minimally invasive, highly aesthetic procedures.”

Digital workflows, especially those that involve the applications from a variety of suppliers, reduce the number of treatment steps and accommodate a wide range of systems, thereby enhancing the efficiency of the dental practice.

3Shape Unite supports digital processes in dentistry he Unite platform from 3Shape allows users to customise, manage and develop workflows, while enjoying the support of a consistently growing app library in the Unite store. Furthermore, the platform establishes an easy and open connection between dental professionals and the appropriate partners and therefore simplifies clinical and technical processes

T

“The Unite platform from 3Shape allows users to customise, manage and develop workflows, while enjoying the support of a consistently growing app library in the Unite store...”

IvoSmile is an augmented reality app that is designed to assist dental professionals with their patient consultations.

Mr Gabathuler explains that by integrating IvoSmile into the consultation and treatment process, augmented reality technology can be used to provide patients with an idea of the possibilities that are available including a preview of their new smile. He added: “Our close partnership goes back many years. The integration of Ivoclar Vivadent workflows in 3Shape Unite represents the next step in our pioneering collaboration and will connect the dental industry even more closely. In addition, dentists and dental technicians will have easy access to all the features and benefits of the innovative solutions from Ivoclar Vivadent and 3Shape.”

For more information, contact Ivoclar Vivadent on 1300-IVOCLAR or in New Zealand, call 0508 IVOCLAR.

September/October 2021

3Shape TRIOS

A dental practice you can be proud of.

“

We are on the right path.

Dentist, San Sebastian, Spain

We think you’ll find your patients are happier1 and your practice more successful with TRIOS® intraoral scanners.

And we’ll make sure you have everything you need to get started quickly and continue on your digital journey when you’re ready. There’s both onboarding and opportunities for advanced learning.

Explore more at 3Shape.com

1. 80% of studies (4 of 5) show patients choose digital impressions over conventional (Chandran et al. 2019).

spectrum | NEWS

Dürr Dental celebrates 80th anniversary

By Joseph Allbeury

D

ÜRR DENTAL is well-known to dentists across Australia and indeed the world thanks to its powerhouse range of plant room equipment, innovative imaging solutions and hygiene products.

This year, the German family-owned business, based in Bietigheim-Bissingen, north of Stuttgart, is celebrating its 80th anniversary.

40 Australasian Dental Practice

Dürr Dental is currently led by CEO Martin Dürrstein, the third generation of the Dürr family, and we caught up with him recently following the end of the COVID-delayed International Dental Show in Cologne, Germany.

“IDS this year was a solid event for Dürr Dental,” Mr Dürrstein said. “Attendance was lower due to COVID but equally, the quality of the visitors was high. This event was of course part of the celebration of our 80th anniversary and we launched several new products and updates to our range.

“At Dürr Dental, we focus on what we call our three product pillars. We have imaging; we have air and suction; and we also have the hygiene line. So at the IDS, we launched the new Silver Airline compressors that are designed to be far more efficient and we updated our Power Tower solution with the Power Tower View range. We introduced a new surgical suction system designed for surgical purposes and we launched the new VistaScan Ultra View X-ray scanner plus AI enhancements to our VistaSoft imaging software.

September/October 2021

spectrum | NEWS

Dürr Dental is headquartered in Bietigheim-Bissingen, Germany.

Mr Dürrstein said that the brand new Tyscor+ suction range is an ideal example of a product that typifies Dürr Dental’s development goals, consuming 50% less energy and utilising completely new demand-driven smart technology.

“The Tyscor+ range is designed to grow with your practice,” he said. “If you extend your practice, you can add another suction unit that works in sync with the existing unit, rather than replacing it altogether. Up to three Tyscor+ suction motors can be connected to work as a team. As the demand on suction increases, the number of motors operating increases thanks to a system of smart communication. This increases the lifespan of our products, reduces energy consumption and reduces waste.

“Currently, our team is focused on smart solutions like this for the dental practice.

We’re developing cloud-based software and equipment, which can be connected and linked together. Our VistaSoft Cloud for example allows you to share X-ray images quickly and directly with other dentists or specialists.

“With the new VistaSoft 3.0, Dürr Dental brings artificial intelligence into the dental practice and increases the efficiency of everyday tasks. One new AI feature automatically rotates and adjust the X-ray images stored in a patient’s file for instance. Another feature is automatic

September/October 2021

tracing of the inferior alveolar nerve in 3D X-rays. These are small time savers but this use of artificial intelligence will continue to expand and cumulatively save a great deal of time by automating numerous tasks.

Dürr Dental CEO Martin Dürrstein.

“R&D is a big part of our history.

Today, we invest almost 10% of our revenue in R&D and the R&D team accounts for 14% of our workforce. We consider it a core competancy. And if you ask what are we working on? The answer is that we are continuously working on each of the

three pillars. How do we make each better for the environment, more energy efficient, more intuitive for the user and how do we increase connectivity, particularly for things like predictive maintenance. So we are continually working on the ‘next version’ of our products. We just launched the new VistaScan Ultra View imaging plate scanner at IDS, but already we’re thinking of what will the next generation be because a good product takes 3 or 4 years in R&D to be developed.”

Mr Dürrstein said that the company is also heavily invested in software development, particularly for its imaging products, including the use of artificial intelligence.

“We develop a lot of our software inhouse, but it’s also important that our software is open to additional features being added from elsewhere. In the area of artificial intelligence, for example, two hands are not enough to count the number of start-up companies developing solutions to make the doctor and the assistant’s life easier. We work with some of these to introduce innovation into our own software more rapidly than if we developed it in-house alone.

“It is a great benefit for our customers that we adopt an open architecture for our software, making it open to new developments for greater ease of use or increased diagnostic capabilities.”

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spectrum | NEWS

For 80 years, the Dürr Dental brand has been known for high end products “Made in Germany” and technical innovations.

How did it all start? With a root canal treatment and a broken dental drill!

80 years ago, Frida Dürr, the wife of precision engineer Wilhelm Dürr, had to visit the dentist. But during the root canal treatment, the dental drill broke and because it was very difficult to get new equipment because of World War II, the dentist had to finish the treatment manually.

Knowing about Wilhelm Dürr’s technical skills, the dentist gave his patient the broken drill to take home. It worked out: although Wilhelm Dürr had never repaired dental equipment before, he managed to fix it.

That’s how Dürr, who ran a precision workshop with his brother Karl, discovered a gap in the market almost accidentally. The brothers established their business in the dental industry and today, Dürr Dental is known as one of the international leaders in the market.

The name Dürr Dental stands for innovation and a proud history of countless developments and enhancements in modern dentistry. The invention of the suction system enabled dentists to treat their

42 Australasian Dental Practice

patients lying down for the first time - a major step forward in dental care. Dürr Dental has pioneered the development of effective spray mist extraction systems and the company also invented oil-free dental compressors. Dürr Dental has steadily refined and developed this technology and remains the industry specialist for what it calls the oil-free “heart of the practice” to this day.

New Products at IDS 2021 • VistaScan Ultra View PSP scanner • VistaSoft 3.0 imaging software with Artificial Intelligence (AI) • Hygoclave 50 / 50+ autoclaves • Tyscor + suction range • Silver Airline compressor range • Power Tower View range

Dürr Dental also has a pioneering role in value-preserving hygiene, low-pain therapy and with products offering the best protection for the practice team and the patient. This position has been further strengthened in recent times. Milestones in imaging, such as image plate technology, round off the extensive portfolio of Dürr Dental.

“We don’t just make dental products, we also accept responsibility for each product we sell in the dental field,” Mr Dürrstein said. “Therefore, it’s essential for us to provide training, expertise and excellent service. Our customers’ and their patients’ satisfaction are of utmost importance to us. As a result, the Dürr Dental Academy offers some 140 seminars for dental staff, technicians and students each year.”

After 80 years of innvoation and success, what does the next 80 years hold for Dürr Dental?

“That’s a good question,” Mr Dürrstein said. “Right now, we’re looking forward to the next decade and beyond. Again, our big drivers are connectivity of products and environmental friendliness. So from a big picture perspective, our development focusses on these two areas and then of course, we still need to innovate and continuously develop our products across the three pillars to take them to the next level. Making products better for the environment includes making them more energy efficient, longer lasting and more versatile. So keep watching this space.”

For more information on Dürr Dental, visit https://www.duerrdental.com/en/AU/

September/October 2021

COMPRESSED AIR | SUCTION | IMAGING | DENTAL CARE | HYGIENE

VistaScan Ultra View Simply intelligent and twice as efficient Modern, hygienic 7”glass touchscreen display

AI-based, intelligent assistance function

Scan simultaneously using 2 slots and save valuable time

The new VistaScan Ultra View The intelligent image plate scanner for maximum throughput and the best image quality in your practice.

For more information contact your local Dürr Dental representative:

Louis Manera

M: +61 412 959 525 E: louis.manera@duerrdental.com

Frank Schroeder

M: +61 405 288 713 E: frank.schroeder@duerrdental.com

Visit our website: duerrdental.com

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26 VIDEOS - 6+ HOURS OF EDUCATION INTERACTIVE Q&A SUPPORT WEBINARS Presented by Professor Laurence J. Walsh AO Learn firsthand from Australia’s leading authority on infection prevention and control in dentistry about recent changes in infection control that have come in over the past 12 months, including the new guidelines from NHMRC (May 2019), Hand Hygiene Australia (Sept 2019) and the CDNA (Dec 2018) as well as recent changes in Australian Standards and TGA regulations that are relevant to infection control. The course will provide a summary of how those changes interlink with one another.

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The course will cover practical implementation of the new requirements and what it means for everyday dental practice. Hear about the why and the how and keep up-to-date with the changes that are happening. Bring along your questions in writing or in person for one of the Q&A sessions that will be held during the day.

COURSE TOPICS This one day course will cover changes in regulations and guidelines from 2018 to 2020 including: n n Risk-based precautions. n n Hand

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FULL UPDATE! All the changes to Infection Control Guidelines in 2020

Professor Laurence Walsh AO is a clinically active specialist in special needs dentistry who is based at the University of Queensland in Brisbane. Laurie has been teaching infection control and clinical microbiology for over 25 years at postgraduate level and has been the chief examiner in microbiology for the RACDS for the past 20 years. He has presented invited courses and lectures on infection control across Australia and internationally. Laurie has written over 60 articles on infection control and in addition published over 320 journal papers and a further 190 technical reports and literature reviews. He serves on two committees of Standards Australia (personal protecting equipment; and instrument reprocessing) and in recent years has been an adviser to the Communicable Diseases Network of Australia and the Australian Commission on Safety and Quality in Health Care.

Laurie has been a member of the ADA Infection Control Committee since 1998. He has contributed to various protocols, guidelines and checklists and manuals used in Australia.

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by Dentevents, Dentevents, aa division division of of Main Main Street Street Publishing Publishing Pty Pty Ltd Ltd ABN ABN 74 74 065 065 490 490 655 655 •• www.dentevents.com www.dentevents.com •• info@dentist.com.au info@dentist.com.au ™ ™ Tel: (02) (02) 9929 Tel: 9929 1900 1900 •• Fax: Fax: (02) (02) 9929 9929 1999 1999 •• Infection Infection Contol Contol Boot Boot Camp Camp™ and and Dentevents Dentevents™ are are trademarks trademarks of of Main Main Street Street Publishing Publishing P/L P/L © © 2020 2020 Main Main Street Street Publishing Publishing Pty Pty Ltd Ltd

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spectrum | NEWS

2,500 intraoral scanning cases later... My TOP 10 discoveries

By Leif Svensson, Clinical Director, Affordable Denture & Implants

W

hat does Raphael Nadal’s left bicep have in common with my right scanning arm?

Well today ladies and gentlemen, marks my 2,500th intraoral scan case! The picture is of my right forearm today and the left side is how I used to look. When I started this digital journey, I jokingly asked FITBIT to include a new plugin for “number of intraoral scans taken”. Wouldn’t that be great!

46 Australasian Dental Practice

The journey towards becoming a digital practitioner ,500 scanning cases for me is a great milestone with lots of clinical highlights. In the midst of the 2,500, I was able to build a specialised training program for the largest TRIOS scanner roll out in Asia Pacific spanning some 100 locations with over 500 practitioners. I’ve had the opportunity to work with many hundreds of highly skilled practitioners along the journey and have learnt so much - especially in the world of digital implant planning and scanning.

2

September/October 2021

spectrum | NEWS

Here are my top 10 learnings after scanning 2,500 dental cases

j k l m

GOOD HARDWARE - Do your research and get the best scanner you can afford!

BE FEARLESS - You will be nervous in your first 10 to 20 scans. That’s normal. After 100 you will be unstoppable. Get to 100 as soon as possible directly after your first training session. Be fearless!

IN SURGERY SETUP - Set your scanner up on the most versatile rolling stand you can find (unless you’re lucky enough to get a TRIOS MOVE+ (3Shape)). I have found several good scanner accessories from Anatomic4d but there are many great ones out there.

ADOPT GOOD SCANNING POSTURE - This is CRITICAL! Decide if you’re a stand up (front approaching) or sit down scanner (rear approach).

Then master positioning your body according to the arch and indication you are working on. I even think about posture as it relates to the quadrant I’m working on. Get your body into position so that you can always have the scanner head parallel to the area you are capturing. It’s good to learn and memorise these positions in your surgery.

n

SUPPORT THE SCANNER TIP - ALWAYS! At all times, try to achieve a Bipodised support position for your scanner tip with another finger or part of hand.

Your support finger should thus be supported by a patient landmark (tooth, sulcus and/or other). Note you may need to swap this support finger as you scan around the patient’s mouth. Use the support finger to steer the scanner. It’s a handy pivot and scanner head rotation point especially as you cross the patient midline. I also use scanner bipodisation positions to retract soft tissue whilst still capturing and supporting the scan head.

This is a great asset. Optragate (Ivoclar Vivadent) is good for when you are only capturing tooth surfaces.

When capturing soft tissue however, this form of retraction can get in the way. Finger retraction is the best. The retraction finger becomes the support bridge between your hand and the scanner head support and just rolls along clearing a path for your capture.

September/October 2021

o p q r s

BE CRITICAL OF YOUR SCANS - Don’t be afraid to ditch and go again.

TRIM - Trim your scans according to your appliance indication. Look for foreign detached and attached anomalies in your scans (especially if you do some non-AI scanning. Your finger will feature prominently in that movie!).

FIND A GOOD LAB - A lab that communicates really well with you. Some labs out there have direct tech links these days. Awesome support is key especially when starting out.

BE PATIENT WITH EDENTULOUS SCANS Edentulous areas are the hardest to scan of all, whether full or partial. Build up to it. Start small and increase as your confidence increases.

BE INVENTIVE - You don’t always have to follow the exact predefined manufacturer scan strategy (especially in cases with large edentulous areas). My general rule when there are missing teeth is to always start where the most amount of hard structures are. In this case: start where the most teeth are; then build your scan path from there.

About the author Leif Svensson is the Clinical Director of Affordable Dentures & Implants in Australia. He is an experienced clinical practitioner with a demonstrated history of working with industry professionals to achieve complex oral restorations especially in the realms of implant prosthesis. He is a business leader having founded and led the largest denture care roll out in Australia with over 44 locations. In addition to his clinical prowess, Leif established one of the largest dental laboratories in Australia as well as championing industry digital innovation for implant arch scanning. Leif works with both government and publicly listed corporate entities under some of the most demanding situations. His philosophy is always to be cautious if the task outcome cannot be undone, but fearless when innovation can be tested and repeated for the greater good of the patient.

Australasian Dental Practice

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spectrum | NEWS

Ultimate freedom comes not from just a wireless scanner, but true end-to-end workflows

I

t’s all about freedom: Freedom from wires, freedom to offer different treatment options and the freedom to partner with any third-party to provide care for patients. That’s the freedom that comes with the new CS 3800 intraoral scanner and its comprehensive workflow options.

Freedom from cables

he CS 3800 is one of the lightest and most compact and reliable wireless scanners on the market. Designed in collaboration with Studio F. A. Porsche, its slim, cordless design makes it easier to hold and gives users a more comfortable scanning experience.

To make it easier to capture interproximal areas and subgingival margins and improve soft tissue scanning, the CS 3800’s field of view (FOV) has been enlarged to 16 mm x 14 mm. This new increased FOV makes scanning edentulous patients even smoother. With a 21 mm depth of field, the CS 3800 can better

T

48 Australasian Dental Practice

capture emergence profiles, deep margins and post spaces to improve image quality.

For freedom to travel from operatory to operatory, the scanner can be combined with the new CS Voyager trolley and AIO medical-grade computer for optimal mobility.

The CS 3800 joins the CS 3700 and CS 3600 as the flagship scanner in Carestream Dental’s intraoral scanning portfolio.

All three scanners’ intuitive interfaces make them ideal for any doctor looking to start their digital workflow journey.

Freedom to offer different treatment his latest generation of scanner is more than just a high-performance digital impression device—it’s the first step to the ultimate freedom that a true end-to-end workflow allows. The scanner’s powerful software, CS ScanFlow 1.0.4, includes indications for restorations, implant-borne restorations, orthodontics, sleep devices and, new with this latest release of the software,

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September/October 2021

Freedom at your fingertips

The New Wireless CS 3800 Make the jump to a new level of intraoral scanning performance with the CS 3800. Compact and ultralight, it is designed for comfort and agility. A larger field of view and deeper depth of field with more frames per second, make it our fastest intraoral scanner yet. It provides an improved experience for both user and patient.

Carestreamdental.com/CS3800

spectrum | NEWS

dentures, giving doctors the ability to provide treatment for more patients no matter their clinical needs. Once an impression is captured, it can be seamlessly exported from CS ScanFlow to any number of platforms or modules: CS Model+ v5 for orthodontic treatment planning and designing clear aligner models, the prosthetic-driven Implant Planning module for implant planning or Swissmeda for designing surgical guides, to name just a few.

This latest version of the software - first introduced with the CS 3700 intraoral scanner - gives practices the freedom to choose the configuration that works best for them. A standard version of the software is available with the scanner, but clinicians have the the ability to upgrade to a more premium version as the needs of the practice grows.

Freedom to partner arestream Dental has always prided itself on accessible files and easy systems that allow doctors to explore options outside the company’s own portfolio. That’s why the CS 3800 is the gateway to an open and flexible digital ecosystem that gives doctors freedom to choose the components and partners that best fit their preferred workflow.

“When Carestream Dental’s CAD/CAM portfolio, CS Solutions, launched in 2013, it focused solely on restorations,” Ed Shellard, chief dental officer, Carestream Dental, said. “Since then, we’ve grown and expanded CS Solutions into something much bigger. Today, it’s all about the ‘connected practice,’ which allows doctors to combine equipment, software, data and thirdparties into endless possible workflows.”

Covering the whole patient journey, this unique end-to-end solution serves the broadest range of clinical, operational and financial tasks, with a growing community of partners and talent.

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50 Australasian Dental Practice

About Carestream Dental arestream Dental is committed to transforming dentistry, simplifying technology and changing lives. In this pursuit, we focus on providing the latest in high-quality scanning technology, the smartest chairside systems, the most intuitive practice management software, incredibly accurate imaging software and the data intelligence that helps continually refine patient outcomes. And we offer these solutions for the full range of dental and oral health professionals.

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To learn more about the CS 3800, CS ScanFlow or CS Solutions CAD/CAM portfolio, visit carestreamdental.com/CS3800 or email anz-enquiries@csdental.com.

September/October 2021

kulzer.com/one-shade

ONE FOR THE BASICS

NEW

Scan to learn how Adaptative Light Matching works

Venus Pearl ONE Shade.

Your one shade solution for everyday cases.

Always grab the right shade: With the incredible shade-matching properties of ONE shade the restoration becomes invisible by blending into any surrounding dentition.

Efficient handling: Non-slump qualities for easy carving and sculpting with a creamy, low-stick consistency.

Long-lasting restorations: Exceptional strength to resist chipping and fracture, with over 8 years proven clinical experience.

Try it out for yourself – with our Venus Pearl ONE Shade-Kit kulzer.com/try-one.

Everyday cases with Venus Diamond ONE Shade for a firm consistency and Venus Pearl ONE Shade for a creamy consistency.

For further information, please contact your local Kulzer Restorative Supplier TODAY!

Source: Dr. Edoardo Fossati, Turin, Italy

Source: Prof. Dr. Claus-Peter Ernst, Mainz, Germany

Kulzer Australia P/L E: info.australia@kulzer-dental.com Kulzer.com/australia © 2021 Kulzer GmbH. All Rights Reserved.

dentevents presents...

Exiting Your Dental Practice and Maximising Your Outcome How to get the right result when selling one of your greatest assets MELB* : MAR 5 | ADEL : APR 9 | SYD* : MAY 14 | BRIS : JUN 11

*organised

in conjunction with the australian dental association

A dental practice is usually one of the most valuable assets in a dentist’s life.

When it comes time to sell, many will do so with little understanding of the value of what they are selling and how to present it effectively to a buyer.

Others delay putting their practice on the market at an optimal time, fearful of what to do next and afraid of a loss of their identity.

6

HOURS CPD

This course explains: • How to prepare your practice for sale to optimise the price, terms and compatibility with a purchaser • Which exit strategy is right for your practice and why • When is an optimal time to maximise the return for your asset • Pitfalls owners fall into that devalue their practice in the final years of ownership • Steps owners can take to improve the outcome in the final years of ownership

Register Now: www.exitacademy.com.au

VITAL

INFORMATION for anyone within 5 years of EXITING

Presented by Simon Palmer With more than 20 years’ experience in dental practice sales, Simon Palmer has extensive knowledge of and insight into the complexities and sensitivities involved in buying and selling dental practices. Simon’s business - Practice Sale Search - sells more than 100 practices per year. He is a regular writer/contributor to dental publications and journals, and is regarded as an expert on dental practice purchases and sales in Australia and New Zealand.

TOPICS INCLUDE n

Exit planning: how do you get your practice ready to sell?

n

What are the pros and cons of the exit options/ strategies available to you?

n

Succession Planning: What do you need to do now to prepare?

n

What is the likely profile of the buyer for your practice and what will they be looking for?

n

Valuing Dental Practices: What/ where is the value in your practice?

n

How do you handle staff discretion, confidentiality and disclosure?

n

Legal agreements

n

Effective strategies for transferring patients effectively from seller to buyer

n

What to do next post sale: post-sale strategies

n

Tax implications and strategies when selling

n

Expert finance, legal, accounting speakers

Register Now: www.exitacademy.com.au Dentevents is a division of Main Street Publishing Pty Ltd ABN 74 065 490 655 • www.dentevents.com • info@dentist.com.au • Tel: (02) 9929 1900 • Fax: (02) 9929 1999

spectrum | NEWS

A-dec offers new biofilm testing device

D

uring this period of heightened focus on infection control within the dental practice, A-dec has introduced a useful new product to accurately and easily test the microbiological quality of dental unit water lines and surfaces in dental clinics.

The 2-Minute Water Control System rapidly and accurately determines the presence of biofilm in dental unit waterlines to enable monitoring and action as required.

A-dec Product Manager, Angie Wong, said the 2-Minute Water Control System provides accurate results in just two minutes, eliminating incubation periods or the need to send samples to a laboratory. A water sample is taken from the dental unit waterline and by adding a few drops of reagents, produces a result which is immediately interpreted and displayed on a Lumitester Smart device.

In the case of microbiological shifts, the dental team can then use the results to implement A-dec’s recommended maintain, monitor and shock waterline maintenance guide to ensure infection control protocols are maintained.

Mrs Wong said the advantage of this digital test device was rapid and accurate chairside results, without the long wait times and inaccurate manual verification methods of commonly used bacteria swab test kits.

The Lumitester uses ATP-metry - which measures the presence of Adenosine triphosphate (ATP) by counting the number of photons emitted by the bioluminescence reaction and displays the results in RLU (Relative Light Units). ATP is present in all living organisms, providing early warning of biofilm build-up at small concentrations. This technology is widely used in the food industry and medical settings to test for harmful biofilms. When used with the 2-Minute Water Control reagent kit, ATP is converted to colony forming units (CFU) to determine the bacterial load of the water sample.

“The ADA advises that it’s good practice to test water lines on a regular basis, for example 6-monthly or annually,” Mrs Wong said. “There has been no change in the ADA’s target level of 200 CFU/mL in dental unit waterlines, however, clinics often set their own levels such as 100 CFU/mL as a trigger point for action.”

When high counts are found, the waterlines will need to undergo additional shock or sanitising treatments. The 2-Minute Water Control System provides the following guidelines for action.

When a measurement is: • Below the warning threshold (conformity), the facility is under control and no additonal action is required.

• Between the warning threshold and the alarm threshold (enhanced monitoring i.e. more frequent testing), the facility does not present an immediate biohazard.* * A corrective action is recommended if three consecutive measurements are above the warning threshold • Above the alarm threshold (corrective action), the facility is not under control. A quick corrective action is recommended (shock treatment, cleaning, disinfection).

54 Australasian Dental Practice

The 2-minute water tester gives accurate and rapid test results of biofilm presence in dental unit waterlines when used with the accompanying water control reagent kits.

The Lumitester accurately detects the presence of surface contamination, to check infection control measures are effectively carried out.

Mrs Wong explained that dental unit waterlines were susceptible to biofilm build-up because of the narrow water passages in dental equipment and the slow movement of water through the water lines. The problem is greatly exacerbated if equipment has been left idle.

To satisfy the practical needs of Australian dentists, Mrs Wong said A-dec chose a luminometer that is quick and convenient and - above all - gives reliable results.

The Kikkoman Lumitester with LuciPac A3 swabs are also available to check and monitor surfaces on equipment and in surgeries.

“Independent laboratory testing confirms that the Kikkoman A3 technology provides detection of residues at levels much lower than other tests on the market by an order of magnitude or higher than competitive products,” Mrs Wong said.

“Kikkoman A3 technology showed a strong presence of residue while the competitive products produced test results indicating biofilm content below typical action levels, showing that Kikkoman A3 can reduce the risks from false negative results.”

This exclusive technology is available as a service - similar to annual autoclave validation, on a scheduled basis by authorised and qualified A-dec dealers.

For more information on the 2-minute water tester service, contact your local A-dec dealer. Dealer and A-dec Territory Manager details are available by calling 1800-225-010 or visit http://australia.a-dec.com

September/October 2021

A-DEC Optimal Infection Control

GET YOUR DENTAL WATERLINE CHECKED IN 2 MINS A-dec 2-minute DWL Digital Tester and Surface Swabs Kit A-dec’s chairside solution for instant dental unit water and surface swab test result. It is rapid, reliable, easy to use and economical to help improve health risk management.

“

It is good practice to test microbial levels in water from dental unit waterlines on a regular basis, for example, six-monthly or annually

”

ADA Guidelines for Infection Prevention and Control, Fourth Edition

Contact us about checking your dental waterline today

For more information a-dec@a-dec.com.au I 1800 225 010 I australia.a-dec.com @A_decAust

@A-dec AUS

© 2021 A-dec Inc. All rights reserved.

Chairs Delivery Systems Lights Monitor Mounts Cabinets Maintenance Imaging

spectrum | NEWS

Seeing is believing with SoproLIFE!

T

hey say seeing is believing. So is not seeing, not believing?

Well in some cases yes!

That’s where medical devices like X-rays and intraoral cameras come into their own.

Patients often don’t know or understand what procedures or treatments are required to address their problems.

They are also apprehensive of the costs and being “sold” unnecessary treatments by their practitioners, especially when money is tight.

Similarly, dental practitioners can only diagnose and treat what they can see. While loupes, X-rays and bulky microscopes may be of assistance in this respect, most examinations are still made by eye with just the help of a dental mirror.

This has proven ineffective in picking up problems, especially early interventions in asymptomatic cases. While many dentists and oral health therapists are confident in their visual assessments, even they “cannot see what they cannot see”.

Case in point is small fissures and failing restorations covering carious tissue and micro-cracks which may be allowing bacteria to enter the pulp or root.

Sometimes these fissures are completely benign. At other times they may be covering early onset caries and painful tooth decay. And not all are picked up by X-rays.

As one of the world’s leading medical imaging equipment manufacturers, Acteon has developed a range of easy to use and precise intraoral cameras to aid clinicians in their diagnosis.

See what lies beneath ncreasingly, intraoral cameras are being used for patient education and importantly, for the practitioner, are invaluable in increasing case acceptance. This makes the choice of a high-quality camera with additional built-in caries detector such as the unique SoproLIFE from Acteon a wise choice, both clinically and economically - providing a return on investment many times over.

Being able to display an image on the patient monitor has proven quite a game changer in many practices, according to A-dec Product Manager, Angie Wong.

“Many of our SoproLIFE customers are telling us that they no longer have to ‘sell’ treatments to patients,” she said.

“Instead, the patients gain trust in the dentist and are very willing to have their procedures performed and are even ‘selfdiagnosing’ some of their own oral health issues by what they can see, including cosmetic treatments.”

Sopro’s Macrovision provides up to 110 times magnification, revealing details otherwise not visible to the naked eye or with X-rays. This enables close monitoring of micro fractures and their development. Images can be captured at the swipe of a finger.

I

56 Australasian Dental Practice

The resultant images displayed on a video screen provide a strong visual indicator of problem areas such occlusal or interproximal decay - even in its earliest stages, together with demineralised dentine that is not visible to the naked eye or on X-ray images.

Healthy dentine glows bright green under fluorescence, while areas of demineralised dentine range from dull green to grey, indicating potential future trouble spots.

In “diagnostic” mode, caries - which may be hidden behind benign looking pits and fissures - glows dark red on the video monitor, indicating a problem requiring further investigation.

When used in close-up “treatment” mode during actual excavation of the tooth, SoproLIFE displays the extent of caries by the intensity of colour of the affected dentine. Angry red material indicates high-level caries infection, while orange shows affected scar tissue that may be conserved.

Minimally invasive dentistry he level of clinical detail obtained by SoproLIFE supports minimally invasive dentistry where only seriously infected caries is removed and as much natural tooth as possible can be preserved to encourage healing of the remaining tooth structure for a stronger restoration.

SoproLIFE is also a clear winner in patient education and case acceptance as it paints a powerful graphic image of the problems identified and enables “before” and “after” comparisons of teeth under examination.

All Sopro cameras provide an invaluable medico-legal record of all treatments performed. This is especially useful with new patients or those that have been referred on to establish a baseline of oral health.

T

Build patient trust hen used in this way, Sopro cameras build patient trust and confidence in the practitioner. It is truly a case of “seeing is believing” and strongly underpins case acceptance.

Experience has shown displaying these images to patients, involves them in case presentation and acceptance, making Sopro an extremely useful “practice builder” and education tool.

The SoproLIFE camera can be built into most A-dec delivery systems so it is instantly available at your fingertips or can connect via USB to a laptop to display live images.

Since its launch, SoproLIFE has successfully been implemented internationally and is a world leader in its field. It has won many awards and is even used as a reference for diagnosis in many prestigious universities.

W

For more information on the SOPROLIFE, contact your A-dec dealer on 1800-225-010 or visit acteongroup.com.

September/October 2021

Say goodbye to neck and back pain!

The uniquely designed PENTAX deflection prism allows the surgeon to view the surgical site with the greatest depth of field and enhanced vision, whilst maintaining the best possible working posture.

FROM $3995

+GST

To learn more and book an in-office demo, scan the QR code or visit osseogroup.com.au/pentax

spectrum | NEWS

Load your videos on Dentevents.TV

V

ideos on anything to do with dentistry can now be loaded by anyone through the Dental Comminity portal for streaming on Dentevents.TV. “Since we launched Dentevents.TV last year in response to the first of the COVID-19 lockdowns, we’ve painstakingly loaded hundreds of videos onto the platform on behalf of others,” said Joseph Allbeury, publisher of this magazine and Dentevents.TV. “Now we’ve released new functionality within www.dentalcommunity.com.au to allow anyone to DIY. You simply login, click Manage Your Videos and then Add Video to begin the upload process.

“With this next natural evolution of Dentevents.TV, we’re hoping to attract a more diverse range of content for the platform and in doing so, attract an even larger and more diverse audience.

New Dentevents.TV features include...

Ability to upload your own videos for streaming on www.dentevents.tv n Content can be anything dental! n Engage with your viewers like never before n Allocate CPD for watching your videos with or without a CPD quiz n Create your own channel and build an audience n Create your own private education platform n Monetise your videos to earn $$$ n

“To date, the content is largely based on recorded webinars and information relating to dental products,” Mr Allbeury said. “And we have also started producing our own content series as well, but we need much more. By allowing anyone to upload videos, we hope to be able to help content creators build their profiles.

“Educational content creators will have a platform to stream videos, issue CPD certificates to viewers or ask CPD quizzes.

Content can also be monetised on a payper-view or subscription basis if desired.”

Organising a dental event, l show or we New Expresscongress, Listings fortrade dentevents.com Sign in to www.dentalcommunity.com.au and you can start adding videos today!

D

entevents.com, the dental from that for webinar organisers, and A link will be emailed to you that can profession’s go-to source indeed all event organisers, is that more be used to edit the event if required, again of upcoming post-gradand more dental professionals will check without the need to login. uate dental education and Dentevents.com when looking to find out “Express Listings are not designed to events, has added a new replace Standand and Premium listings,” EXPRESS Listing option Mr Allbeury said. “Express Listings that can be used to rapidly add events to include less information than traditional the calendar without the need to login with Dentevents listings and do not include links a username and password. to the organiser, venue and speaker infor“Overall, we’ve added the new Express mation pages. Express listings also cannot Listing facility to Dentevents.com to accept registrations and payments for increase the number of events being listed events. The Express listings are designed on the calendar by making it a quick to rapidly add events to the calendar if 2-minute process,” said Dentevents.com you do not have a login. For everything publisher, Joseph Allbeury. “And more else, the traditional pathway applies.” specifically, we’re targeting webinar Mr Allbeury said the new Express Listevents with the Express Listing because ings were part of the ongoing evolution of the cycle of these events is far more rapid about upcoming events because the inforDentevents.com to provide a platform to than traditional face-to-face events. mation available is so comprehensive.” help event organisers reach greater audi“We’re seeing webinars promoted a To use the Express Listing, simply ences for their events as well as providing few days to a few weeks ahead of broadvisit www.dentevents.com, select Adding tools to accept registrations and payments, cast and so by facilitating rapid listing Events and then Express Listing. A form manage delegates and allocate CPD. onto Dentevents.com, we will see more is then displayed and once completed, If you’re organising any kind of post-graduate dental education, event or webinars being added. The outcome your eventyour will event be reviewed and posted.

For more information, see dent.events webinar, listing on the dentevents.com continuing education

GO EXPRESS»»»»» calendar is now easier than ever.

September/October 2021 58 Australasian Dental Practice No username, no password and no need to login - add your event

NEODENT e-EDUCATION Online content for you

Neodent® Discovery & Morning Talks

Neodent® Webinars

Neodent® Global e-Symposium

A series of on-demand lectures and exclusive interviews with international clinicians sharing best practices and tips.

Exclusive to Australia and New Zealand. Check out the full education program to access our on-demand and live webinars.

Register for our e-Symposium: Transforming Implantology on 8-9 December 2021.

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NEO026 09/21

CREATING NEW SMILES EVERYDAY

spectrum | NEWS

Zirkonzahn multi unit abutments Adapts between different implant systems and the screw-retained over structure

Figure 1. Straight Multi Unit Abutment without anti-rotation device and for multi-unit restorations. Available in five different gingival heights, they offer an extremely easy application and the best possible solution for every case.

Z

irkonzahn Multi Unit Abutments (MUA) come without an anti-rotation device and are available in both straight and angled geometry. In both cases, the MUA are adapted to different implant systems and their connection for the over structure is unified. In this way, the over structure can be directly - or with additional titanium bases screwed on different implant systems without any problems. A further advantage of the Zirkonzahn standardised connection is that using these new abutments, other components (like titanium bases, Scanmarkers, White Scanmarkers, laboratory analogues or transfer abutments) are reduced to one connection.

The straight Zirkonzahn Multi Unit Abutments are especially suited for multi-unit restorations (min. 2 elements). Furthermore, they are designed as one single piece to prevent bacterial penetration. On the other hand, the Zirkonzahn Multi Unit Abutment Angled 17°, besides the fixing of multi-unit restorations, serve particularly well for the fixing of single jobs (in the anterior tooth region). The most important characteristic of the Zirkonzahn MUA Angled 17° is that the secondary structure’s axis in relation to the implant’s axis can be inclined by the respective angles and therefore well-suited for implants with highly divergent paths of insertion. The angled MUA are designed as two pieces and are made of biocompatible titanium. For a secure fixing of the

60 Australasian Dental Practice

Figure 2. Zirkonzahn Multi Unit Abutments Angled are available with a 17° angle to compensate for any inclinations of the implants and two differently angled hex-implant connections.

They can be used for single and multi-unit restorations.

Zirkonzahn Multi Unit Abutments intraorally on the implant and the restoration on the abutment, the respective Zirkonzahn screwdrivers for Multi Unit Abutments can be used.

All Zirkonzahn Multi Unit Abutments offer the best possible solution for even the most complex cases since they are available in various heights and can be adapted to different gingival

“Depending on the position of the implant, with the two different connection types, the number of connection possibilities has doubled...” conditions. For increased biocompatibility and a reduced grey value, they are also available in gold-plated titanium.

Depending on the position of the implant, with the two different connection types, the number of connection possibilities has doubled: check if they are compatible with your implant system and get to know more about the company’s digital workflow!

For more information about Zirkonahn Multi Unit Abutments, visit www.zirkonzahn.com or contact Alphabond Dental Pty Ltd e-mail stan@alphabond.com.au or call (02) 9417-6660.

September/October 2021

SCAN THE CODE AND TEST THE SOFTWARE FOR FREE: DOWNLOAD THE DEMO VERSION "ZIRKONZAHN.IMPLANT-PLANNER VIEWER" CREATED PROJECTS CAN BE READ, VIEWED AND MODIFIED

ZIRKONZAHN.IMPLANT-PLANNER BACKWARD IMPLANT PLANNING BASED ON DIGITALLY MERGED PATIENT DATA (SUCH AS DICOM DATA, MODEL OR INTRAORAL SCANS AND 3D FACIAL SCANS)

Alphabond Dental Pty Ltd – T +61 2 9417 6660 – stan@alphabond.com.au – www.alphabond.com.au Zirkonzahn Worldwide – T +39 0474 066 680 – info@zirkonzahn.com – www.zirkonzahn.com

spectrum | NEWS

Henry Schein One International Update launches Customer Radar in EXACT

H

enry Schein One Australia and New Zealand has launched a Customer Radar platform in its EXACT dental software.

Customer Radar, enables practices to collect patient feedback after an appointment.

Practices can also invite patients that leave positive feedback to leave a review online on Google.

“Dental practices are always looking for ways to attract more new patients and those with a high number of Google reviews are more likely to appear and stand out at the top of the search results,” said Calvin Leung, Marketing Manager for Henry Schein One Australia and New Zealand. “Customer Radar will enable practices to quickly build up a healthy portfolio of authentic Google reviews.”

In addition, practices that collect feedback can identify and address issues early and even leverage positive feedback to motivate employees and boost staff morale.

Practices will also be able to understand the sentiment of their patients and if they are meeting their expectations.

To request a demo or to learn more about Customer Radar, simply contact Henry Schein One on 1300-889-668 or in New Zealand, call 0800-930-171 or visit henryscheinone.com.au or henryscheinone.co.nz.

62 Australasian Dental Practice

Rapid antigen tests (RATs) are a practical tool for identifying potentially infected individuals. One can not only isolate and identify infected patients, but also select the appropriate infection prevention and control measures for the patient.

According to the WHO, RATs have a minimum performance requirement set at ≥ 80% sensitivity and ≥ 97% specificity, which is lower than those for the reverse transcriptionquantitative polymerase chain reaction (RT-qPCR) tests. RATs perform best in cases with high viral load, in presymptomatic and early symptomatic cases. Even when RATs are available for use, it is recommended that all patients are triaged before any appointment (preferably by phone and prior to entering the dental office) to determine their COVID-19 status. In suspicious cases, RATs can be applied to identify a potential infection in a patient or a staff member. Positive results can then be sent for testing using RT-qPCR. In patients with a positive RAT result, only emergency treatments should be performed and using full risk-based precautions. To minimise risk, it is recommended to test dentists and their staff on a regular and frequent basis (e.g. twice or more each week) depending on the actual infection level in the community and the advice of local authorities. To incorporate RAT in the dental practice, aspects like additional time requirements, the incorporation of the test results in the practice workflow, staff training and the test costs need to be addressed.

Durner J et al. SARS-CoV-2 and regular patient treatment – from the use of rapid antigen testing up to treatment specific precaution measures.

Head Face Med. 2021;17:39. DOI: 10.1186/s13005-021-00289-9.

The World Health Organization (WHO) announced updates to its Model List of Essential Medicines for Adults and Children on October 1, three of which are dental treatments featured for the first time. The updated essential medicines list, which includes 20 new medicines for adults and 17 for children, had never deemed these dental preparations as essential until now.

The dental treatments that made the list are topical fluoride-containing preparations (such as toothpaste), glass ionomer cement and silver diamine fluoride. Sodium fluoride - without any further specification and as the only dental substance - has been on the WHO Model list since 1973 under the category of essential micronutrients, but has had no visible public health effect. This update of the WHO essential medicines list includes a new section on dental preparations and the previous listing for fluoride was transferred to the new section. The decision came months after the WHO adopted a resolution on oral health calling for the development of a global strategy action plan, and monitoring framework for improvement of oral health globally until 2031, its first resolution on oral health since 2007.

September/October 2021

ARE YOU DOING ALL YOU CAN FOR PAEDIATRIC PATIENTS? Most children have a developing malocclusion which is associated with craniofacial growth, breathing disorders and poor myofunctional habits.

Learn to identify these issues from the comfort of your own home!

START YOUR FREE ONLINE COURSE TODAY myoresearch.com/free-course-adp

book | REVIEW

Financial Success for Dentists - Rules for how to approach your dental career A book by Graham Middleton Review by Joseph Allbeury

I

t ain’t what you don’t know that gets you into trouble. It’s what you know for sure that just ain’t so. This profound statement of unknown origin, often wrongfully attributed to Mark Twain, pretty well sums up how a lot of dentists view the non-clinical aspects of dentistry.

Many dentists start (and sometimes end) their career clinging to myriad fallacies, often of equally unknown origin, about how dentistry works as a business and their role as its labour-force.

One common goal of all working in the profession, however, is typically to be financially successful; yet the path to achieving that success is often unclear.

Being a dentist is no longer a guaranteed smooth-sail across a sea of gold.

Fortunately, there are a veritable army of consultants, internet gurus, bloggers, influencers and the like out there who are only too happy to offer advice.

And like everything, the most successful people will pick and choose the advice they follow wisely from a variety of credible sources.

Graham Middleton, perhaps Australian dentistry’s original finance and management influencer, has published sage advice over the past 30 years through more than 150 articles in Australasian Dental Practice magazine, plus online, in email newsletters and a number of books.

Now retired from his career running a consultancy offering professional advice to dentists that included accounting services and practice valuations, his latest book, Financial Success for Dentists – Rules For How To Approach Your Dental Career, distils his wisdom into a wellpaced 200-page read.

Graham devotes chapters to everything from the ideal size and structure of

64 Australasian Dental Practice

successful dental practices, staffing, buying and selling practices, start-ups, partnership dynamics, associate agreements and owning and renting premises through to fee setting, finance, profit margins and ultimately retirement strategies.

Whereas the young could quickly dismiss Graham’s writings as old school and behind the times, nothing could be further from the truth. Why? Because Graham, as much as anything, chronicles the

eternal and unchanging toll human nature imposes on the dental setting and how that plays out when money... and greed... and jealousy... and ego... and power... and stupidity... are all in the mix.

Graham leans heavily on his real-world experiences that can only be gained from sorting out other peoples’ problems over a long career of consultancy. Using real life case studies - simplified and with names changes – he applies his considerable experience to solutions for common prob-

lems that many dentists may often only encounter once in their dental career.

Much of Graham’s advice incorporates a common-sense approach applied to the dynamics of dental practice ownership but equally, he highlights a number of “extinction level events” for both your professional and personal life, particularly in relation to buying into bad partnerships or investing in schemes that flog dead horses, to be ignored at your peril.

Graham’s writings have a distinct bias towards maintaining the vitality of private practice dentistry and championing the rights of individual dentists to successfully practice independently or in small groups, in many ways as the profession has always done. His strong aversion to the corporatisation of dentistry and the influence of private health insurers affecting the quality of care based on cost alone are evident throughout. Rather than wholesale opposition to the collective changing of the profession, however, Graham’s advocacy of the status quo is based on both what he believes is right for the profession and its patients as well as the practitioners delivering the care.

Anyone working in the dental profession in Australia will benefit from digesting Financial Success for Dentists – Rules For How To Approach Your Dental Career and its content will at some point resonate with the past, present or future of your dental career.

Financial Success for Dentists – Rules For How To Approach Your Dental Career is available by making a donation (minimum $60) to the Delany Foundation, a registered charity established by the Patrician Brothers, which contributes to schools in Papua New Guinea, Kenya and Ghana.

For more information or to donate, visit www.grahammiddleton.com.

September/October 2021

A new angle on treatment setups.

2.0

Faster, smarter, and more mobile than ever— your treatment setups are about to take flight.

P R O U D LY P R E S E N T I N G N E W F E AT U R E S Mobile view: Need to approve a case on the go? No problem. Mobile view keeps it simple so that you can take care of business any time, anywhere.

Multiview: view upper and lower arches in occlusion and independently all at the same time.

Occlusal heat map: Need to check on any heavy occlusal contacts? We’ve got just the tool for you.

Scan the QR or visit dr.clearcorrect.com to become a provider today!

To learn more, call Osseo Group at 1300 029 383 AUS or 09 973 5342 NZ

ONLINE CPD CENTRE the cutting | EDGE

infection | CONTROL

READ ME FOR CPD

READ ME FOR

CPD

COVID-19: What is likely to happen in the next part of the pandemic journey

Cleaning suction lines a practical approach

By Emeritus Professor Laurence J. Walsh AO

By Emeritus Professor Laurence J. Walsh AO

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dental suction system is designed to remove saliva, blood, remnants of dental hard tissue and dental materials and debris generated during clinical procedures from the mouth. By removing these, dental suction makes clinical procedures faster as well as safer. This is true whether one is working in a regular clinic with a dental chair or from a mobile dental delivery system.

This article outlines the science and practical considerations that support the proper treatment of dental suction lines, regardless of the nature of the dental service.

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s various parts of Australia begin reopening, it’s important to consider what the next 12 months may hold in terms of the pandemic. Based on the history of previous pandemics and on current public health planning strategies for pandemic management, a number of predictions can be made around what the next year may bring.

Effective suction for reducing aerosols ffective high volume evacuation is recognised as a key component of strategies that mitigate the risk of infection to dental staff, including from aerosolgenerating procedures performed on dental patients with upper respiratory tract infections. High-volume evacuation (HVE) using wide bore intraoral suction tips has been shown to be highly effective in reducing salivary contamination of the surrounding environment.

There is an extensive literature that supports the view that with correct placement of HVE, aerosols and spatter should be reduced by 90% or more.1-14 This makes maintaining the suction system a critical component of safe working practices in everyday dental practice.

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70 Australasian Dental Practice

Mutation he SARS-CoV-2 virus will continue to mutate1,2 and the designations will progressively move through the Greek alphabet. Due to replication errors that are typical for RNA viruses, spontaneous small mutations will occur frequently. Some

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of these may have no effect on the transmission and virulence of the virus and will largely pass unnoticed from a public health perspective. Other mutations will reduce the likelihood of transmission of the virus, particularly those that lower the affinity of binding of the virus to the ACE-2 receptor of human cells. Yet other mutations will make the virus more readily transmitted, or more stable in the environment. Typically, during the multiple waves of a viral pandemic, the virus becomes more readily transmitted but less virulent with successive waves of infection. This pattern was seen with the Spanish flu 100 years ago and with the swine flu in 2009.

Spontaneous small mutations, also known as antigenic drift, occur with human influenza viruses, so the same is expected for this particular coronavirus.3

94 Australasian Dental Practice

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September/October 2021

Question 1. Liquid from the saliva ejector’s low volume evacuation suction line can enter a patient’s mouth during use when:

Question 6. During multiple waves of a viral pandemic, a virus typically becomes:

a. Occlusion of the mouthpiece opening by the oral mucosa. b. There are oscillations in suction produced by operating other suction equipment. c. A patient sucks or close their lips around the saliva ejector. d. All of the above.

a. More readily transmitted and more virulent. b. More readily transmitted but less virulent. c. Less readily transmitted but more virulent. d. Less readily transmitted and less virulent.

Question 2. Flushing with an appropriate antimicrobial solution can fail because: a. Frequency of flushing is too low. b. Volume of product used is too low. c. Solution is too diluted. d. Tap water used for product dilution is hard. e. All of the above.

Question 3. High volume suction is defined as:

Question 7. A range of new therapies for treating severe cases of COVID-19 include: a. Humanised monoclonal antibodies. b. Therapies that reduce the host inflammatory response in the lungs. c. Therapies that make human cells more resistant to infection. d. All of the above.

Question 8. A dental operatory that is connected to a central air-conditioning system with air filtration capabilities shows a rapid decline in aerosols in around:

a. 40 L/min air b. 90 L/min air c. 159 L/min air d. 250 L/min air e. 350 L/min air

a. 10 minutes b. 30 minutes c. An hour d. Two hours

Question 4. Correct placement of HVE can reduce aerosols and spatter by over:

a. Rapid Allogen Treatment. b. Responsive Antigen Treatment. c. Rapid Antigen Test. d. Rapid Allogen Treatment.

a. 95% b. 90% c. 85% d. 80% Question 5. To dissolve mineral scale, suction system cleaners use: a. Weak acids. b. Strong acids. c. Mineral chelators. d. Calcium carbonate.

Question 9. A RAT is a:

Question 10. All commonly used commercial mouthrinses are effective against SARS-CoV-2: a. True b. False

INSTRUCTIONS: Australasian Dental Practice™ is now offering PAID subscribers the ability to gain 2 Hours CPD credit from reading articles in this edition of the magazine and answering the questions above. To participate, log in to the Dental Community website at www.dentalcommunity.com.au (call (02) 9929-1900 if you do not have a login) and click on the CPD Questionnaires link; select the Australasian Dental Practice Sep/Oct 2021 questionnaire and then click START. A score greater than 80% is required to PASS and receive CPD.

READ THE ARTICLES BELOW AND ANSWER THE QUESTIONS ONLINE AT WWW.DENTALCOMMUNITY.COM.AU - 2 HOURS OF CPD clinical | EXCELLENCE

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Optimising oral health in frail older people

Recent developments in vital dental bleaching and the emergence of new options with peroxy carboxylic acids

By Alan Deutsch and Emma Jay

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ost oral and dental problems in frail older people may not be obvious to relatives and health professionals. Older people do not see dentists regularly but receive regular care from medical and nursing professionals, so collaboration with dentists is important.

This is especially the case in residential aged care. Improved oral health outcomes are achievable using an interdisciplinary approach involving GPs, dentists, oral health therapists, dental prosthetists and nurses trained in oral health.

By Emeritus Professor Laurence J. Walsh AO

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ising expectations around personal appearance and awareness of tooth shade changes over the lifespan has promoted interest in vital tooth bleaching.1-3 All registered dental practitioners who are providing vital tooth bleaching have a duty of care to their patients to practise safely and effectively, regardless of whether bleaching is being done in the clinic or as part of a supervised program at home.

Moreover, justifying the treatment includes knowing the patient’s expectations of the procedure and products used and explaining the associated risks.4 This article provides an update in the regulatory framework and technology aspects of dental bleaching, drawing from the most recent literature available (up to September 2021).

Recent changes in the regulatory framework wide variety of kits for in-office bleaching use hydrogen peroxide (HP), typically at 25-35%. As this procedure is undertaken in the clinic, no current laws or regulations limit the types of products that are able to be used in that setting.

On the other hand, products for at-home bleaching typically use carbamide peroxide (CP) for extended applications or HP for short duration applications. Such CP and HP products are highly regulated, through the Dental Board of Australia, the Therapeutic Goods Administration (TGA) and the Australian Competition and Consumer Commission (ACCC).

In August 2021, the Dental Board of Australia changed its policies for at-home products that are dispensed to a dental patient and used for at-home bleaching as part of a supervised program. Their latest guidance4 reinforces the need to only use HP and CP products as the law allows and when the treatment can be justified. For compliance, clinicians must also take into account the relevant medicines and poisons laws (which dictate limits on HP and CP products) and Australian Consumer Laws (ACL). It is important to know that ACL require the disclosure by manufacturers of all ingredients used in their bleaching products. In this regard, some bleaching systems made in the USA are not legal because of inadequate product labelling and failure to disclose ingredients.

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As a result of the policy change in August 2021, high strength HP products may now come onto the Australian market, especially from the USA. A note of caution is needed. Choosing stronger HP products for at-home use with the goal of achieving greater colour changes in teeth5 may, however, come at the expense of greater loss of surface mineral and increased issues with pulpal responses (zingers) and soft tissue chemical burns and irritation.5-7 Likewise, for in-office use, some studies suggest keeping the HP concentration at or below the 15% level to reduce the possibility for alterations of enamel hardness and surface morphology.8 It must always be remembered that adverse enamel changes will increase with repeated applications of high concentration HP gels.6,7,9

raditionally, bleaching in dentistry has relied upon the use of oxidants based on HP. In fact, tooth bleaching using HP has a history that extends back more than 100 years.10 HP works through the generation of reactive oxygen species (ROS), including HO2• when the pH is alkaline. These ROS oxidise organic molecules.11 Various methods have been used to accelerate the degradation of HP in ways that increase the release of ROS, to reduce the application time and shorten treatment duration, or improve the end result.

As well as HP, adducts of HP have also been employed, such as carbamide peroxide (CP) and sodium percarbonate, as well as HP releasing compounds, such as sodium perborate. These give a gradual release of HP over time and hence work in the same way as HP, through the generation of ROS. The target molecules of HP and its derivative ROS include not only the organic molecules that cause stains, but also normal enamel proteins. This is why excessive and repeated use of HP products lowers the protein content of the enamel and increases its brittleness and causes the aesthetic problems of opacity from “overbleaching”.12,13 It also increases the permeability of the enamel after bleaching for a short period of time.

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Relationship between oral and systemic health

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here is a link between poor oral health and systemic disease.

There are correlations between adequate mastication and activities of daily living, nutritional status and quality of life.

A significant association exists between the severity of periodontal disease, increasing tooth loss and carotid artery plaque.1 This may increase all-cause mortality in cardiovascular disease including ischaemic stroke.2 Chewing increases regional neural activity and cerebral blood flow.3,4 The number of teeth lost may be a predictor of cognitive decline and dementia.5-7 The bacteria that cause periodontal disease have been implicated in Alzheimer’s disease.8 There is an association between oral health and respiratory disease.9 Randomised controlled trials show that improved oral hygiene reduces the progression or occurrence of respiratory diseases and death from pneumonia among high-risk older adults living in residential care.10 Diabetes increases the risk for periodontitis. Periodontal inflammation negatively affects glycaemic control causing systemic complications. Severe periodontitis increases the risk of cardiorenal mortality 3.2 times. Periodontal treatment and better oral hygiene can improve metabolic control.11

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Why the choice of oxidant matters

Summary n

The importance of saliva ormal salivary function is essential in speech, digestion and swallowing. Saliva has antimicrobial activity and prevents decay and tooth wear. In healthy people, stimulated saliva has a high serous volume with higher bicarbonate buffering concentrations to neutralise mouth, food and plaque acids compared to resting saliva. High flow volumes are essential for effective buffering capacity, clearance of glucose and bacteria and swallowing.

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n

There is a link between oral health and systemic health.

Conditions such as dementia and pneumonia are associated with poor oral health.

Frail older people receive regular care from medical and nursing staff but tend not to see dentists regularly or only seek treatment when there is a dental problem. Collaboration between dentists and other health professionals is therefore increasingly important.

Oral health should be assessed regularly. This enables early referral to a dentist.

Anticholinergic drugs, particularly in polypharmacy, can have a profound deleterious effect on salivary function and oral health. A medication review may enable the anticholinergic burden to be reduced.

In addition to regular brushing, oral preventive products may be appropriate in frail older people.

In frail older people with decreased salivary function and poor oral hygiene, teeth may rapidly demineralise when not in a supersaturated solution of calcium and phosphate ions provided by saliva. Teeth will also decay more rapidly as mouth pH is unable to return to safe values due to a lack of buffering capacity, particularly if there is frequent snacking on sweet foods and drinks.

Salivary gland hypofunction and dry mouth Ps should be encouraged to ask patients about a dry mouth.

The prevalence of salivary gland hypofunction (measurable decrease in salivary flow) and xerostomia (subjective feeling of dry mouth) increases with age, the number of chronic conditions and is strongly associated with drugs. The prevalence of xerostomia can be over 50% for people taking more than five drugs and it has marked effects on oral health and quality of life.

Hyposalivation can significantly impact activities of daily living such as speaking, eating and sleeping. It may cause tingling, a decreased sense of taste, halitosis and difficulty in wearing dentures. It can increase the risk of opportunistic infections such as Candida albicans. Low saliva flow rates correspond to lower mucosal wetness and increase pathogenic aciduric microorganisms in the oropharynx, mouth and dental plaque (which can be inhaled).

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September/October 2021

Question 11. A dental pulp “zinger” response can trigger:

Question 16. To maintain oral health in high risk patients...

a. The release of neuropeptides. b. Apoptosis of cells. c. Low grade inflammation. d. Cytotoxic effects on dental pulp cells. e. All of the above.

a. Avoid mouthwashes or swabs containing alcohol, hydrogen peroxide, sodium bicarbonate, lemon and glycerin. b. Avoid confectionary with citric acid and sweet sticky foods. c. Discourage fruit juices, sugary drinks, caffeine, and frequency of snacking. d. Encourage eating of milk and cheese. e. All of the above.

Question 12. A compound completely unlike hydrogen peroxide that contains oxygen and can serve as an oxidant is: a. Dialkyl peroxides. b. Diacyl peroxides. c. Cyclic peroxides. d. Peroxy carboxylic acids. e. All of the above.

Question 13. Phthalimidoperoxycaproic acid whitens teeth by: a. Using an anti dihydroxylation reaction. b. Using an epoxidation reaction. c. The generation of reactive oxygen species.

Question 14. A benefit of using PAP for dental bleaching is there are:

Question 17. Asthma inhalers... a. Reduce saliva flow and lower its pH. b. Can cause gingivitis and gingival enlargement. c. Are beta2 agonists. d. Can alter your taste. e. All of the above.

Question 18. A significant association exists between the severity of periodontal disease, increasing tooth loss and carotid artery plaque: a. True b. False

a. No irritation of the gingiva or other oral soft tissues. b. No risk of gingival burns from solution leakage. c. No Zingers. d. Rapid whitening action. e. All of the above.

Question 19. Exposed nerves and root stumps...

Question 15. Surface microhardness is maintained or enhanced when using PAP+:

Question 20. The prevalence of xerostomia for people taking more than five drugs can be over:

a. True b. False

a. 10% b. 25% c. 50% d. 60% e. 65%

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Call (02) 9929 1900 or Email info@dentist.com.au

a. Are never symptom free. b. Act as wicks for oral bacteria to infect bone. c. Do not contribute to the inflammatory burden of the patient. d. All of the above.

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abstracts | 2021

A summary of the latest research

By Emer. Prof. Laurence Walsh AO

COVID-19 vaccines prevent transmission

n important question when making prognoses of the pandemic in the near future and of the need on nonpharmaceutical control measures is to what extent the vaccines reduce the likelihood of transmission from infected vaccinees. Several studies report high effectiveness of COVID-19 vaccines against SARS-CoV-2 infection and severe disease, however an important knowledge gap is the vaccine effectiveness against transmission (VET). This study presents estimates of the VET to household and other close contacts, based on data from the Netherlands covering the period from February to May 2021, using contact monitoring data. The Alpha variant of SARS-CoV-2 dominated during the study period. The final dataset contained 253,168 contacts of 113,582 index cases. During the study period, household members and other close contacts of confirmed cases needed to quarantine for 10 days post exposure. The secondary attack rate among household contacts was lower for fully vaccinated people (11%) compared to unvaccinated cases (31%), with an adjusted VET of 71% (95% confidence interval: 63-77). Stratified by vaccine received by the index case, VET values were 58% for AstraZeneca, 70% for Pfizer, and 88% for Moderna. The adjusted VET after only one vaccine dose was considerably lower than after two doses (15% for AstraZeneca, 26% for Pfizer and 51% for Moderna). Our study showed that the COVID-19 vaccines not only protect the recipient against SARS-CoV-2 infection, but also offer protection against transmission to close contacts after completing the full schedule.

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De Gier B, et al. Vaccine effectiveness against SARS-CoV-2 transmission and infections among household and other close contacts of confirmed cases, the Netherlands, February to May 2021. Euro Surveill.

2021;26(31):pii=2100640. DOI: 10.2807/1560-7917.

Engineering controls for safe dental practice

erosol generating procedures in dental health care can increase the risk of transmission of the virus. Due to the risk of infection of both dental healthcare workers and patients, additional infection control measures for all patients are strongly recommended when providing dental health care. While aerosols may not play a major role in transmission of COVID-19 in most daily activities, the situation is different in the dental clinic.

Water, in combination with compressed air used for coolant and spraying, causes aerosols which become contaminated with micro-organisms from the oral cavity. Dental staff operate at a distance of 60 cm or less from a patient’s oral cavity and the greatest microbiological contamination within dental clinics is within 1 m from the oral cavity, via both splashes and aerosols. Thirty minutes after aerosol formation, virus particles and bacteria can still be detected in the air of the treatment room. Thus, the air in the treatment room after an aerosol generating procedure should be regarded as contaminated. Dispersion of the virus throughout the dental clinic should be avoided, thus working under negative air pressure would be preferable, as clean air will be drawn from

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less contaminated areas towards the treatment room. At the same time, an active exhaust flow from the contaminated treatment room leads to removal of possible pathogens from the air. In most dental clinics, working under negative air pressure is not possible.

Sufficient ventilation in the room can dilute airborne viruses and natural ventilation can also be used, as well as waiting at least 30 minutes between patients.

Volgenant CMC et al. Infection control in dental health care during and after the SARS-CoV-2 outbreak. Oral Diseases. 2020;00:1–10. DOI: 10.1111/odi.13408.

Air handling, ventilation and dental aerosol generating procedures in dental practice

erosols, particularly when highly concentrated in enclosed environments, play an important role in the transmission of COVID-19. Aerosols in dental procedures are particles smaller than 5 μm that can remain suspended in air for hours. As a result of risks associated with COVID-19, within the UK the use of a resting period, known as the fallow time (FT), has been recommended to allow for settling of suspended aerosol following dental aerosol generating procedures (AGPs). In vitro simulation of fast handpiece cavity preparations using a manikin was conducted using an Optical Particle Sizer and a NanoScan device at baseline, during the procedure and after the fallow period. AGPs were simulated on a dental manikin in the Royal London Dental Hospital (London, UK) with mechanical ventilation with six air changes per hour through a centralised air exchange system. The same procedures were repeated in a private dental clinic in Harley Street, London, without natural ventilation. AGPs were carried out using an air turbine for 20 minutes while simulating cavity preparation of tooth 36 and crown preparation of 31 and 21, with air and water coolant at maximum flow. All procedures were carried out using a four-handed dentistry technique which included the assistant operating high-volume suction and a saliva ejector.

When AGPs were carried out in a room with no mechanical ventilation or air conditioning, baseline particle levels were not achieved even after resting the room for one hour. In contrast, when windows were opened after AGPs, there was an immediate reduction in particles. In airconditioned hospital environments, the particle count returned to baseline within ten minutes following the AGP. Careful four-handed dentistry with high volume suction is an important mitigating method. Effective central airconditioning with high-efficiency particulate air filtration, along with high-volume dental suction, resulted in reduction of fallow time to just 10 minutes. Non-ventilated rooms failed to reach baseline level even after one hour of fallow time. Hence AGPs are not recommended in dental surgeries where no ventilation is present or possible.

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Shahdad S et al. Fallow time determination in dentistry using aerosol measurement in mechanically and non-mechanically ventilated environments.

Brit Dent J. 19 July 2021 DOI: 10.1038/s41415-021-3369-1.

September/October 2021

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Cleaning suction lines a practical approach

By Emeritus Professor Laurence J. Walsh AO

A

dental suction system is designed to remove saliva, blood, remnants of dental hard tissue and dental materials and debris generated during clinical procedures from the mouth. By removing these, dental suction makes clinical procedures faster as well as safer. This is true whether one is working in a regular clinic with a dental chair or from a mobile dental delivery system.

This article outlines the science and practical considerations that support the proper treatment of dental suction lines, regardless of the nature of the dental service.

70 Australasian Dental Practice

Effective suction for reducing aerosols ffective high volume evacuation is recognised as a key component of strategies that mitigate the risk of infection to dental staff, including from aerosolgenerating procedures performed on dental patients with upper respiratory tract infections. High-volume evacuation (HVE) using wide bore intraoral suction tips has been shown to be highly effective in reducing salivary contamination of the surrounding environment.

There is an extensive literature that supports the view that with correct placement of HVE, aerosols and spatter should be reduced by 90% or more.1-14 This makes maintaining the suction system a critical component of safe working practices in everyday dental practice.

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September/October 2021

the cutting | EDGE HVE also reduces contamination in the areas immediately beyond the dental chair when open plan clinic designs are used, keeping the majority of contamination within 1.5 m of the patient’s head.

The reason for this is that suction removes smaller lighter droplets (aerosol) easily and it is these that likely cause more distant contamination. These considerations explain why dental suction with a wide bore aspiration tip fitted to HVE should be an essential component of dental treatment, especially for dental chairs in an open plan clinic layout.15

Suction line configurations urrent definitions for dental suction are as follows: low volume (40 L/min air), medium volume (159 L/min air) and high volume (250 L/min air).16 High volume suction hoses usually are equipped with special connectors and adapters into which wide bore (8 or 10 mm diameter) suction tips are fitted prior to each patient treatment. The tip will move ~4 litres of air per second, or more. HVE connectors often contain valves to regulate suction strength. They may also have metal or plastic adaptors to join various tips to the suction hose. In contrast, single patient-use saliva ejector tips (3-4 mm in diameter) are fitted to the low volume suction line. This line moves only ~1 litre of air per second or less.

HVE is essential during all aerosolgenerating procedures, including those using handpieces, ultrasonic and sonic devices, air polishing devices and hard tissue lasers.8,13,17 Different designs of suction tips and attachments can enhance the protective action of suction by better removal of aerosols during caries removal with a high-speed handpiece and other dental aerosol-generating procedures. As well, correct placement of the tip of the high-volume evacuator, facing the aerosol-generating procedure side, will significantly reduce the level of ultrafine particles produced during restorative dentistry.18,19 The Isolite ® illuminated isolation system attaches to the HVE connector and is designed for use by clinicians such as dental hygienists who are working without a dental assistant.

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September/October 2021

The Isolite is designed to provide simultaneous suction to both the maxillary and mandibular quadrants on one side, as well as illumination. Its performance for achieving aerosol reduction has been challenged, with a clinical study of its use during ultrasonic scaling showing no benefit over a saliva ejector. Neither the Isolite device nor the saliva ejector can effectively reduce aerosols and spatter during ultrasonic scaling.20

Saliva ejectors and low volume evacuation everal studies from the 1990s have shown that, under certain conditions, liquid from the saliva ejector’s low volume evacuation suction line can enter a patient’s mouth during use. This can occur in a transient way accidentally when there is occlusion of the mouthpiece opening by the oral mucosa, or when there are oscillations in suction produced by operating other suction equipment. It can also occur deliberately when patients apply greater suction force than what is provided by the saliva ejector, as they suck or close their lips around the saliva ejector.

In this case, the negative pressure in the patient’s mouth is greater than that in the saliva ejector, causing backflow of previously aspirated fluids. Gravity assists such backflow when the LVE suction tubing holding the tip is positioned above the patient’s mouth.21,22 Microbiological studies of saliva ejector low velocity suction lines reveal that these are coated with microbial biofilms. The dense deposits of metabolically active Gram-positive cocci and Gram-negative bacilli are embedded in an extensive polysaccharide matrix.23 Saliva ejector lines are just as contaminated as HVE suction lines and a wide variety of microorganisms are present. Hence, retraction of oral fluids and biofilm-derived microorganisms from contaminated suction hoses could potentially be a source of cross-contamination and cross-infection. When oral fluids from a previous patient are taken into the mouth, there is also the risk of transmission of viruses that may be present in saliva, including Epstein Barr virus, cytomegalovirus, Herpes Simplex and other herpes group viruses.24

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Removing hard deposits from suction lines veryday maintenance of suction lines is essential. These lines are prone to the accumulation of mineral deposits as well as microbial biofilms. Formation of mineral deposits can be promoted by materials suctioned from the oral cavity, like remnants of fluoride gels, prophy paste, abrasive powders and cements, because these contain anions (such as carbonates, phosphates, sulphates and hydroxides) that can form insoluble precipitates with metal cations (such as calcium, magnesium and aluminium). Mineral formation will be faster when the water exiting from the dental unit is hard, as hard water has higher levels of such anions and cations and a higher propensity to form mineral scale deposits. As hard deposits build up over time in dental suction lines, they reduce the effective diameter of the suction lines. They also provide a rough surface onto which microbial growth can occur.

To address hard deposits, periodic cleaning of suction lines using a product than can dissolve such deposits is needed.

While mineral deposits could in theory be dissolved away using strong acids (such as HCl), these will cause corrosion of metal components in the suction system (such as butterfly valves and solenoids), as well as numerous other bystander reactions. Working with concentrated HCl would also pose significant work health and safety issues for staff because of its volatile nature (generating highly irritant fumes) and its ability to cause soft tissue injuries.

As a result, suction system cleaners use mineral chelators, instead of strong acids, to dissolve mineral scale. These pose much less issues for OH&S and are less likely to cause corrosion of metal components (like valves) than strong acids. As they bind tightly to divalent and trivalent metal ions, they have a water softening action, which suppresses further formation of insoluble precipitates.

Phosphonates are stable under the low pH conditions that are best for dissolving away mineral deposits. Phosphonates are used widely in water treatment processes including desalination and reverse osmosis so their chemistry is well known. Phosphonates are the major active ingredient used in Eurosept Xtra Evac Cleaner®

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the cutting | EDGE Weekly Concentrate, which is designed for removing hard deposits from suction lines. This product has a low pH (<2) which assists in breaking down mineral deposits and amphoteric surfactants to increase the contact of the solution with the walls of the tubing.

Removing soft deposits from suction lines icrobial biofilms form in dental suction lines for several reasons. First, the suction hoses are repeatedly contaminated with oral microorganisms. These have multiple origins, including from coolants and irrigant solutions, tap water, dental unit waterlines and the patient’s dental plaque, saliva and blood.25-27 Second, the suction lines are often wet.

Flowing water provides a shear force along the walls of the lines. This provides an environment that is highly conducive to the growth and proliferation of microorganisms in a dense adherent biofilm.

Field studies show that heavy microbial contamination of the dental suction lines extends from the dental chair to the suction unit and thereafter from the suction unit drain lines.28 Third, a generous supply of proteins and other nutrients from saliva and blood ensures the rapid growth of many types of microorganisms as well as numerous species within one type. As an indicator of high levels of blood exposure, direct evidence for high levels of blood being retained on the inner surface of suction tips after periodontal debridement has been provided using the Kastle-Meyer reagent test, in which a colour change to purple indicates the presence of fresh or dried blood.29 Typical organisms that have been isolated from dental suction systems are listed in Table 1. Levels of Gram negative bacteria in dental suction line biofilms can exceed 500,000 CFU per square cm.

Similar issues have been found in medical suction systems used in hospitals, which have caused outbreaks of infection involving different opportunistic Gramnegative bacteria.30,31 An important pathogen found at high levels in dental suction lines is the Gram negative bacterium Pseudomonas aeruginosa, which is able to outcompete many other bacteria. It grows well in wet regions and on PVC and

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72 Australasian Dental Practice

Table 1. Microorganisms isolated from biofilms in suction lines

Gram negative bacteria • Pseudomonads including P. aeruginosa, P. fluorescens and P. putida • Alcaligenes xylosoxidans • Aeromonas salmonicida • Acidovorax temperans • Burkholderia cepacian • Comamonas acidovorans • Novosphingobium subarctica • Serratia marcescens • Sphingomonas spp. including S. aerolata, S. paucimobilis and S. trueperi • Stenotrophomonas maltophilia Gram positive bacteria • Bacillus spp.

• Streptococcus spp. including S. pneumoniae, S. salivarius and S. mitis • Staphylococcus spp. including S. aureus, S. epidermidis S. haemolyticus and S. warneri Fungi • Acremonium • Rhotodotorula • Cladosporium • Fusarium • Aurobasidum pullulans Data collated from multiple studies undertaken at Trinity College, Dublin, Ireland by M.A. Boyle and M.J. O’Donnell medical tubing.32-35 This is particularly relevant during the COVID-19 pandemic, as forced shutdowns may result in dental chairs remaining unused or under-used for extended periods of time. P. aeruginosa and other pathogens are able to remain viable during periods when nutrient levels are low. The presence of Pseudomonads explains why suction line biofilms can be coloured green, yellow or brown.

Suction line odours reakdown of proteins from saliva and blood that contain amino acids with sulphur atoms results in the release of volatile sulphur compounds (VSCs), such as hydrogen sulphide (H2S), methyl mercaptan (CH3SH) and dimethyl sulphide [(CH3)2S]. These have a characteristic unpleasant odour.36,37

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September/October 2021

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the cutting | EDGE Such odours will provide an unsatisfactory environment for both patients and staff when they accumulate during periods when the dental clinic airconditioning is not operated or if the dental operatory is poorly ventilated.38 More of such odours will be noticed in the dental operatory when biofilm levels in the lumen (i.e. on the internal walls) of the suction tubing are high. When this problem is found, the likely causal factors (Table 2) should be explored. Using the correct product at sufficient frequency (at least once per day at the end of the day) will minimise biofilm formation. When odours are present when the suction is off, indicating that biofilm levels are high, more frequent treatment (e.g. twice daily until the problem resolves) would be appropriate.

It is also important to note the problem of leakage from suction system hoses at their sites of attachment to the dental chair, caused by gradual loosening during use. One study of variations in microbial flora in dental suction lines reported the presence of some P. aeruginosa strains (such as serotype O:10, SpeI fingerprint group II) that seemed particularly well adapted to survive in dental suction systems and which may be particularly resistant to disinfection. In the situation reported, the suction lines had been disinfected after each clinical session (i.e. twice daily, Monday–Friday) with a phenolic disinfectant (PuliJet® from Cattani) in a process that took approximately 1 minute. This regular disinfection with Pulijet appeared to be ineffective at controlling bacterial contamination in the suction system. The very short contact time that the disinfectant had with the inside surfaces of the suction system (i.e. approximately 1 min) was also thought to be a contributory factor.24 Other studies also reinforce the point that dental suction systems become heavily contaminated during use and that conventional disinfection protocols may not be entirely effective at controlling this issue. Prolonged biofilm growth can lead to issues with the suction handpiece valves that are used to regulate suction strength either leaking or becoming stuck in one position. Leaks occur because extensive microbial biofilms on O-rings have caused these seals to perish. A stuck valve can be due to congealed blood, as well as corrosion of metal components.39

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Table 2. Factors that promote growth of biofilms in suction lines

Irregular/insufficient flushing with an appropriate antimicrobial solution • Frequency is too low • Volume of product used is too low • Exposure time for the product is too short • Product concentration is too low (incorrect dilution ratio, product expired, incorrect solvent used) • Tap water used for product dilution is hard Frequent surgical and periodontal debridement procedures where blood is generated, with insufficient flushing using water or saline at the end of the procedure Product compositions for disinfection rinciples for microbial control of biofilms in suction lines have parallels to those used for dental unit waterlines, particularly flushing and periodic aggressive chemical treatments to disrupt biofilms.40-42 An important distinction is that the nutrient environment is rich in the suction lines, resulting in more vigorous growth of microorganisms. The microbial diversity is greater, with bacteria, fungi and amoeba being present. This is why active ingredients with broad spectrum disinfecting actions are needed for treating dental suction lines and why dental suction lines must be disinfected regularly.43,44 It is not practical to detach suction hoses (for thermal disinfection) either after each patient or on a daily basis, hence aspiration of chemical disinfectants on a regular basis is needed. Most dental chair manufacturers suggest this be done at least once daily, at the end of the working day.

Field studies reveal that compliance with this recommended frequency of suction system disinfection varies widely.45 Products used for breaking down the matrix of biofilms and killing microorganisms will typically contain low foaming surfactants, as well as disinfectants and fragrances, with the latter providing a deodorising action. Using enzymes at neutral pH is a highly effective strategy for breaking down complex biofilms.

Eurosept Xtra Evac Cleaner® Daily is an example of an enzymatic cleaning concentrate, designed for daily cleaning and care

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of dental suction systems. This product is pH neutral and contains non-ionic low-foaming surfactants. These ensure maximal penetration of the enzymes into soft deposits of organic matter such as residues of blood, saliva and biofilms.

Chemical compatibility with suction system components and amalgam separators is another important consideration. Use of strong oxidants could lead to powdery corrosion of aluminium components such as manually operated suction butterfly control valves and suction tip connectors following prolonged use. These deposits of aluminium oxide can impair the action of the control valves and impair proper intake of air. This will not occur if the butterfly control valves and suction tip connectors are made from high-quality, acid-resistant steel as that will resist corrosion by strong oxidants such as hydrogen peroxide.46 A variety of factors can contribute to failure of suction line disinfection in the long term, including human errors (not following use protocols; incorrect product selection; incorrect dilution), as well as corrosion and deterioration of the suction lines and suction equipment.

Disinfectants used in suction cleaners designed for daily use will need a broad antimicrobial spectrum. When considering possible candidates, chemical inactivation, optimal pH, interactions with proteins and ecological effects in water systems are parameters to consider,

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the cutting | EDGE as well as the likelihood of corrosion.

Keeping close to a neutral pH is desirable for material compatibility.

Typically, suction cleaners are designed for both being used in the suction system and also being poured into the spittoon, at the same concentration. Follow the manufacturer’s instructions and check whether the product is low foaming before attempting to treat a spittoon.

Correct product handling and usage uction cleaners can combine the two functions of reducing biofilm and dealing with mineralised deposits, and various manufacturers have developed protocols around optimising both functions. Some have taken the approach of a frequent-use product where microbial

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References 1. Micik RE, Miller RL, Mazzarella MA, Ryge G. Studies on dental aerobiology, I: bacterial aerosols generated during dental procedures. J Dent Res. 1969; 48: 49-56.

2. Bentley CD et al. Evaluating spatter and aerosol contamination during dental procedures. J Am Dent. Assoc. 1994; 125: 579-584.

3. Bennett AM et al. Microbial aerosols in general dental practice. Br Dent J. 2000; 189: 664-667.

4. Leggat PA, Kedjarune U. Bacterial aerosols in the dental clinic: a review. Int Dent J. 2001; 51: 39-44 5. Jacks ME. A laboratory comparison of evacuation devices on aerosol reduction. J Dent Hyg. 2002; 76: 202-206.

6. Harrel SK, Molinari J. Aerosols and splatter in dentistry: A brief review of the literature and infection control implications. J Am Dent Assoc. 2004; 135, 429-437.

7. Timmerman MF et al. Atmospheric contamination during ultrasonic scaling. J Clin Periodontol 2004; 31: 458-462.

8. Harrel S K. Airborne spread of disease – the implications for dentistry. J Calif Dent Assoc. 2004; 32: 901-906.

9. Dahlke WO et al. Evaluation of the spatter-reduction effectiveness of two dry-field isolation techniques. JADA. 2012; 143: 1199-1204.

10. Zemouri C et al. A scoping review on bio-aerosols in healthcare and the dental environment. PLoS ONE 2017; 12(5), e0178007.

11. Kobza J et al. Do exposures to aerosols pose a risk to dental professionals? Occup Med. 2018; 68:454-458.

12. Liu MH et al. Removal efficiency of central vacuum system and protective masks to suspended particles from dental treatment. PLoS ONE 2019; 14: e0225644.

13. Meethill AP et al. Sources of SARS-CoV-2 and other microorganisms in dental aerosols. J Dent Res 2021; 1-7.

DOI: 10.1177/00220345211015948 14. Allison JR et al. Evaluating aerosol and splatter following dental procedures: addressing new challenges for oral health care and rehabilitation. J Oral Rehabil. 2021; 48:61-72.

15. Holliday R et al. Evaluating contaminated dental aerosol and splatter in an open plan clinic environment: Implications for the COVID-19 pandemic. J Dent. 2021; 105: 103565.

16. ISO 7494-2:2015 Dentistry. Dental units. Air, water, suction and wastewater systems.

17. Harrel S K, Molinari J. Aerosols and splatter in dentistry: a brief review of the literature and infection control implications. J Am Dent Assoc 2004; 135: 429-437.

18. Matys J, Grzech-Lesniak K. Dental aerosol as a hazard risk for dental workers. Materials 2020; 13: 5109.

19. Balanta-Melo J et al. Rubber dam isolation and highvolume suction reduce ultrafine dental aerosol particles: an experiment in a simulated patient. Appl Sci. 2020; 10: 6345.

20. Holloman JL et al. Comparison of suction device with saliva ejector for aerosol and spatter reduction during ultrasonic scaling. J Am Dent Assn 2015:146: 27-33.

21. Watson CM, Whitehouse RL. Possibility of cross-contamination between dental patients by means of the saliva ejector. J Am Dent Assoc. 1993; 124: 77-80.

22. Mann GL et al. Backflow in low-volume suction lines: the impact of pressure changes. J Am Dent Assoc 1996; 127: 611-615.

23. Barbeau J et al. Cross contamination potential of saliva ejectors used in dentistry. J Hosp Infect. 1998; 40: 3030311.

24. O’Donnell MJ et al. Bacterial contamination of dental chair units in a modern dental hospital caused by leakage from suction system hoses containing extensive biofilm. J Hosp Infect. 2005; 59: 348-360.

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25. Wirthlin MR et al. Formation and decontamination of biofilms in dental unit waterlines. J Periodontol 2003; 74: 1595-1609.

26. Szymanska J et al. Microbial contamination of dental unit waterlines. Ann Agric Environ Med. 2008; 15: 173-179.

27. Spagnolo AM et al. Microbial contamination of dental unit waterlines and potential risk of infection: a narrative review. Pathogens 2020; 9: 651.

28. Conte M et al. Microbiological contamination of compressed air used in dentistry: an investigation. J Env Health 2001; 64 :15-26.

29. Edmunds LM, Rawlinson A. The effect of cleaning on blood contamination in the dental surgery following periodontal procedures. Aust Dent J. 1998; 43: 349-353.

30. Blenkharn JIl, Hughes VM. Suction apparatus and hospital infection due to multiply-resistant Klebsiella aerogenes.

J Hosp Infect 1982; 3: 173-178.

31. Rubbo SD et al. Source of Pseudomonas aeruginosa infection in premature infants. J Hyg 1966; 64: 121-128.

32. Stoodley P et al. Biofilms as complex differentiated communities. Annu Rev Microbiol. 2002; 56: 187-209.

33. Mendis N et al. Comparison of virulence properties of Pseudomonas aeruginosa exposed to water and grown in rich broth. Can J Microbiol. 2014; 60: 777-781.

34. Rozej A et al. Structure and microbial diversity of biofilms on different pipe materials of a model drinking water distribution systems. World J Microbiol Biotechnol. 2015; 31: 37-47.

35. Ammann CG et al. Pseudomonas aeruginosa outcompetes other bacteria in the manifestation and maintenance of a biofilm in polyvinylchloride tubing as used in dental devices.

Arch Microbiol. 2016; 198: 389-391.

36. Tonzetich J. Direct gas chromatographic analysis of sulphur compounds in mouth air. Arch Oral Biol 1971; 16: 587–597.

37. Yaegaki K, Sanada K. Volatile sulfur compounds in mouth air from clinically healthy subjects with and without periodontal disease. J Periodont Res 1992; 21: 434-439.

38. Smith AJ. The devil is in the validation and design; managing the risk from opportunistic pathogens in the dental unit.

J Hosp Infect. 2021; 114: 61-62.

39. Boyle MA et al. Overcoming the problem of residual microbial contamination in dental suction units left by conventional disinfection using novel single component suction handpieces in combination with automated flood disinfection.

J Dent. 2015; 43: 1268-1279.

40. Fux CA et al. Survival strategies of infectious biofilms.

Trends Microbiol. 2005; 13: 34-40.

41. Walker JT, Marsh PD. Microbial biofilm formation in DUWS and their control using disinfectants. J Dent. 2007; 35: 721-730.

42. Garg SK et al. Dental unit waterline management: Historical perspectives and current trends. J Investig Clin Dent.

2012; 3: 247-252.

43. Costa D et al. Planktonic free-living amoebae susceptibility to dental unit waterlines disinfectants. Pathog Dis. 2017; 75: ftx099.

44. Yoon HY, Lee SY. Susceptibility of bacteria isolated from dental unit waterlines to disinfecting chemical agents.

J Gen Appl Microbiol. 2019; 64: 269-275.

45. Watson CM, Whitehouse RL. Possibility of cross-contamination between dental patients by means of the saliva ejector. J Am Dent Assn 1993; 124: 77-80.

46. O’Donnell MJ et al. Optimisation of the long-term efficacy of dental chair waterline disinfection by the identification and rectification of factors associated with waterline disinfection failure. J Dent. 2007; 35: 438-451.

control is paramount and a periodic use product (e.g. twice weekly) formulated to dissolve mineral deposits.

For efficient transport, products may be shipped as concentrates which are then diluted, typically with ordinary tap water.

The final mixture is then run through the suction system and/or poured down the spittoon.

Conclusions ental suction is essential for safe dental practice and HVE is a critical component of infection control work practices that remove aerosols and reduce their spread. The COVID-19 pandemic has made dental practices more aware of the importance of proper HVE. For proper performance, dental suction lines need regular attention to remove both hard deposits and microbial biofilms. The products used must remove these deposits while not causing corrosion or other forms of deterioration. Well designed products used in the right way will also ensure that problems such as the generation of odours do not occur when the dental chair is not in use.

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About the author Emeritus Professor Laurence J. Walsh AO is a specialist in special needs dentistry who is based in Brisbane, where he served for 36 years on the academic staff of the University of Queensland School of Dentistry, including 21 years as Professor of Dental Science and 10 years as the Head of School. Since retiring in December 2020, Laurie has remained active in hands-on bench research work, as well as in supervising over 15 research students at UQ who work in advanced technologies and biomaterials and in clinical microbiology. Laurie has served as Chief Examiner in Microbiology for the RACDS for 21 years and as the Editor of the ADA Infection Control Guidelines for 12 years.

His published research work includes over 330 journal papers, with a citation count of over 15,400 citations in the literature. Laurie holds patents in 7 families of dental technologies. He is currently ranked in the top 0.25% of world scientists. Laurie was made an Officer of the Order of Australia in January 2018 and a life member of ADAQ in 2020 in recognition of his contributions to dentistry.

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practice | MANAGEMENT

What dentists buying practices need to know

By Graham Middleton

“If you buy a practice off the best cosmetic dental salesman in town you have little chance of maintaining that level of fee production...”

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uch of the really important information about purchasing a practice lies beyond the range of what accountants can tell a prospective practice buyer and must be researched by the intending dental buyer. While a practice valuation from a source acceptable to banks is a normal requirement to obtaining finance for a practice purchase, these valuations usually neglect to touch upon data which lies in dental records, the pattern of appointments and patient invoices. This information cannot be found in the normal practice financials used by accountants in preparing a valuation.

Practices priced to perfection or containing hidden gold? magine two dental practices called “Practice Gold” and “Practice Copper”. Lee is looking for a practice to buy. Lee has been qualified for seven years and has grown an array of dental skills as well

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as developing effective chairside communication, but the practice in which Lee is employed has an owner who is many years away from retirement and hence unprepared to sell. Lee has looked at a few other offerings in the dental practice market place and honed in on Practice Gold and Practice Copper.

Features of Practice Gold ractice Gold is advertised for sale at an impressive price. An accountant’s valuation backs up the price. The accountant consulted by Lee is keen for his client to buy this practice and generate a significant annual accounting fee indefinitely.

Superficially it looks impressive with high fee generation per annum. Lee also looks at Practice Copper and decides to have a thorough examination of each.

After looking thoroughly at Practice Gold and after discussion with a couple of experienced dental friends, Lee comes to a number of conclusions: • The practice is only booked between one and two weeks in advance and there are often gaps in the dentist’s clinical day, but this is disguised by well above average fees per patient;

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September/October 2021

practice | MANAGEMENT • Examination of patient charges and item numbers indicate that there are an unusual percentage of high value item numbers suggesting that patients may be overserviced. The total number of patients on the books appear to be less than other practices of similar size; and • A monthly count of the total number of appointments compared to the corresponding months in the previous year and the year prior to that indicate that patient numbers treated are stagnant, but this is disguised by fee increases above the rate of inflation.

The accountant Lee has consulted has urged him to purchase Practice Gold, but Lee has doubts.

Lee also looks at Practice Copper ractice Copper has much lower average invoices than Practice Gold and the accountant has dismissed it as a possible buy albeit that it is cheaper. Lee decides to examine it further and finds that: • The practice is heavily booked many weeks in advance; • Examination of patient invoices reveal that, on average, the amount charged per invoice is well below that of Practice Gold; • A close examination of treatment records of recent patients reveals that treatment is invariably of a basic drill and fill nature, with scant evidence of advanced dental treatment options; • Fee adjustments have been modest; • ABS data reveals that the area surrounding the practice has a high level of home ownership and a low incidence of unemployment; • Digging further into practice records, Lee learns that Practice Copper has a far larger patient base than Practice Gold; • Lee compares data with that of the practice in which he works and realises that patients in Practice Copper have been underserviced and quite a lot of the gap is dentistry which Lee is capable of providing; and • Practice Copper’s premises are not of the same standard as those of Practice Gold. They are functional but could do with a spruce up.

Both practices are non-preferred provider practices.

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Although his accountant is urging him to buy Practice Gold, Lee reasons that, if he buys Practice Copper, he has much greater opportunity to grow fees by increasing the treatment options offered to patients. It is also cheaper than Practice Gold.

Lee buys Practice Copper. He also decides to spend on upgrading the presentation of the practice with repainting and re-carpeting and attending to a few pressing issues. He easily covers the interest on the additional borrowings with a fee increase which goes virtually unnoticed by patients.

Lee finds that many patients are prepared to have more advanced treatment and indeed some wonder why it had not previously been offered. He is able to fill his own surgery with quality dental treatment. A rev up of the assistant dentist in surgery two has been beneficial and Lee quickly fits out a third surgery toward building an optimum three chair single owner practice.

Meanwhile, the eventual purchaser of Practice Gold has found that it had been run in a manner which has mined every possible procedure and that appointments are in gentle decline.

The previous owner had a superb sales technique but patients were not as susceptible to advice from the new owner. It is still profitable, but the new owner worries about how to reverse the decline and recognises that it may be a significant time before fee increases can be contemplated.

The lessons • There is a great deal of information only a dentist buying a practice can source and which lies beyond the understanding of accountants; • If consulting an accountant for the first time, it is vital to assess their knowledge concerning dental practices. The best way to do this is to ask questions to which you already know the answers. There is a significant danger that dentists can be advised to make a bad practice purchase based on the accountant’s long-term interest in generating accounting fees and that the accountant concerned has very little knowledge of the business of dental practice;

• Some practices may be in gentle decline, but the decline can be covered up by fee increases up to a point where strong patient resistance develops; • It is critical to look at the total number of appointments and the size of the practice patient base. This is more easily done if you have comparative data from practices in which you have been employed; • It is critical to look at the type of dentistry performed and the procedures which are not performed but which lie within the skillset of the purchaser. If the dentist selling the practice has done a great deal of work that you will need to refer to specialists, the practice will not suit you; • Buyers must also examine Australian Bureau of Statics figures on the level of home ownership and the percentage of employment in the local area to gauge the level of dental treatment that the community can afford; • The wider a buyer’s own dental skillset, the greater the opportunity to provide an increased array of treatment to patients.

Remember, no two dentists’ skillsets are exactly alike; • Be careful to thoroughly examine the patient data of practices in glamorous locations. My observations are that the best practices are not in the most glamorous locations, nor are they in new developing areas with high mortgages and young families. The best practices are in in-between long-established suburbs with high rates of home ownership and low unemployment and – importantly - lower mortgages. There are also great opportunities in regional cities and large country towns; • Over 33 years of examining the financials of dental practices, I can definitely say that the most successful practices are not preferred providers to health funds; and • The optimum size practice for a single dental owner is three chairs but no more. A third chair should only be fitted if the principal dentist’s surgery is wellbooked several weeks in advance and the second surgery is fully utilised. The third should be built up a fully booked day at a time. In all good practices, the owner’s surgery produces the lion’s share of profit - often around 85 percent - because the owner is not paying another dentist to do that work.

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practice | MANAGEMENT Observations of practice purchases “Mo” is mislead o (not his real name) looked at a practice which was being sold by a pair of individuals well-known among dentists. A recent owner had died suddenly and the pair had bought the practice cheaply and quickly from his estate. They had hired a dentist to run the practice which had two surgeries, but very quickly the fees had dwindled to less than the capacity of one full time dentist. Mo was presented with three years’ financials preceding current ownership. He consulted an accountant who claimed expertise in advising practice buyers who looked at the financials, but asked no questions about current fees, practice banking or recent BAS statements and advised Mo to buy the practice. Mo also signed a tenancy agreement on the premises. Immediately following purchase, Mo found that the patient bookings had halved from what had been represented in the financials that had been presented. The accountant who advised the purchase had let him down badly. For the previous year, there had been no dentist in the practice known to patients or having the incentive to retain patients, let alone build the practice. Mo had paid far too much.

Subsequently, Mo sought advice elsewhere and began a painful practice rebuilding process which was successful over several years. As the lease on premises was approaching a renewal option, Mo purchased his own premises nearby and went to considerable effort to explain his forthcoming move to patients. Several years after his purchase - and after a lot of pain - Mo had created a viable practice in well-fitted premises. He had significant business debt but the future looks brighter.

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Bringing premises up to modern standards remember many years ago being consulted by a dentist I will call “Garry”. He had purchased a small run-down practice in a good location but in rented premises which the landlord was unwilling to sell.

Over a year had passed and there was little movement in fees. His question was whether he should cut his losses, sell and look for a better practice?

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Discussion with Garry revealed that there was no toilet in the practice. Patients had to go to one in the courtyard at the back of the premises. There was ample space but Garry was reluctant to spend on the landlord’s premises. He was persuaded to meet the expense and also to repaint the premises and regard the expenditure as an investment in marketing his practice. He also had a professional sign writer redo practice signage. The results were that his practice outshone others nearby.

Garry had first rate interpersonal skills and his number of new patients and patient referrals soared. He went on to have a successful career running a profitable practice. Previously patients had been reluctant to recommend the practice to their friends but after installing a toilet and redoing the décor, they were happy to do so.

It is important when considering purchasing a practice that the buyer has noted deficiencies in the premises fit out and has a plan to rectify them quickly. This also creates a bond with practice staff who inevitably have been waiting for things to be done. Older dentists selling practices have sometimes become unaware of a decline in the relative presentation of their premises compared to other practices and while long term patients continue to attend, they stop referring their friends.

The wrong practice to buy ong ago I was consulted by a young dentist who was considering a practice for sale. The practice was run as a solo dentist practice from city CBD premises and the owner was generating extraordinary fees. I estimated that his fees were about 3.5 times what an average dentist was producing at that time. It was obvious that the practice owner had a wide dental skillset and was also a good communicator resulting in lots of lucrative high end treatment plans being accepted by patients and a continuing stream of patient referrals. My questions to the young dentist were along the lines of: how much of the vendors work can you replace? What fees are you used to generating as an employed dentist? Would you feel comfortable selling high end cosmetic dental makeovers? And what do you expect to happen to the fees in the year after you buy the

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practice? The young dentist admitted that he could not replicate the vendor and was advised to look for a practice aligned with his abilities. Shortly afterwards, a different dentist consulted me about the same practice with similar results. Both had sensed that buying it might be risky but wanted to be certain that they were not passing up an opportunity. I learned that the practice was eventually sold to a corporate buyer.

The lesson f you buy a practice off the best cosmetic dental salesman in town you have little chance of maintaining that level of fee production.

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Buying out an associated practice owner hen buying out an associate, it is critical to determine the relationship with the continuing associate(s).

Important issues which need to be approached delicately concern whether the existing associateship agreement is adequate and, if not, whether the existing associates are agreeable to amending it. If it is not agreed before a new dentist buys, it is unlikely to be agreed afterwards.

Important issues concern the protocols governing the allocation of patients, including patients which the continuing associates are not able to treat but which normally flow to commonly employed dentists. It is also important to check the rules for sharing expenses and sharing of administrative responsibilities. Refer to the book Financial Success for Dentists (see below) for content of dental associateship agreements. Many associateship agreements are inadequate.

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The critical issue for buyers he key issue is that dentists buying practices must do most of their own due diligence to understand the suitability of practices they are considering. Elementary business valuation methods used by accountants do not comprehend the vital facts surrounding the practice patient base, the suite of treatments offered, the degree of referral and potential to generate increased fee income or the probability of buying a falling patient base and fee income.

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September/October 2021

practice | MANAGEMENT Warning

General Advice Warning

About the Author

ractice brokers tend to look for a quick sale. They do not favour dentists who ask them too many questions. It is best to express a strong interest and consider making an offer subject to appropriate due diligence. Due diligence will include inspecting practice treatment records, patient bills, recent business activity statements, practice banking statements and the appointment book over an extended period. Also insist on actual financials and supporting tax returns. Many financials are sanitised of assumed personal expenses by vendors accountants to an unusual degree. You need to see the actual items charged to the practice accounts and form a view as to which are truly not practice expenses. Remember practice brokers are after quick sales to earn their brokerage fee and move on. If due diligence turns up facts suggesting that the practice has not been fairly presented, it is permissible to withdraw your purchase offer.

Best wishes to all dentists.

The information contained in this article is unsolicited general information only, without regard to the reader’s individual financial objectives, financial situation or needs. The information contained on this article is general in nature and you should consider whether the information is appropriate to your needs, and where appropriate, seek professional advice from an accountant or financial adviser. It is not specific advice for any particular individual and is not intended to be relied upon by any person. Before making any decision about the information provided, you should consider the appropriateness of the information in this article, having regard to your objectives, financial situation and needs and consult your professional adviser. Any indicative information and assumptions used here are summarised, are not a product illustration or quote and also may change without notice to you, particularly if based on past performance. This notice must not be removed from this article.

Graham Middleton disposed of his interest in Synstrat group on 30 June 2020 and won’t be starting another business; he retains many friends in the dental profession. He spent the last 33 years of his working life advising health professionals on business and financial matters.

Dentists were the most numerous of his clients. He is the author of the recently published Financial Success for Dentists.

Dentists may obtain a copy of this by making a tax-deductible donation of minimum $60 to the Delany Foundation a registered charity which assists schools in Ghana, Kenya and Papua New Guinea then email Graham at graham.george.middleton@ gmail.com. A copy will be sent to you. All proceeds go to the Delany Foundation for its good work. Graham has paid for the printing and mail costs personally.

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8 great websites for dental professionals www.dentalcommunity.com.au professional portal

www.dentalpractice.com.au magazine

www.oralhygiene.com.au magazine

www.elaborate.com.au magazine

www.dentevents.com events calendar

www.dentevents.tv dental video streaming

www.dentist.com.au - australia

find-a-dentist

www.dentist.co.nz - new zealand

find-a-dentist

September/October 2021

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practice | MANAGEMENT

Enough is enough!

By Julie Parker

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ave you ever been in a situation that has become so progressively worse that you lose hope that it will ever improve?

Upon reflection, you can see how it got out of control.

There were numerous times that you could have changed course. You hadn’t realised that it would get this bad so you didn’t take action.

There are dental practice owners who experience this with their teams. Slowly, via one minor incident at a time, their team members exhibit less consideration for one another, bad attitudes in some become the norm and it is no longer an enjoyable space in which to be.

If this scenario describes your team culture, I have good news! Now is the perfect time to say “enough is enough!”

Never are we more motivated for change than when we are completely fed up with a current situation. We are exhausted from having to deal with the situation and it has become too painful to continue.

Normally, we resist change. Our default is to do the usual as it takes less energy and thought. We also resist change because there is “unknown” in change and how can we be sure we want the alternative?

However, when we can no longer accept the way things are, we seek change. We become willing to accept potential drawbacks that change may bring because we realise changing is our only option.

If your formerly pleasing team culture has slowly morphed into a toxic minefield, it is likely that other team members are thinking “enough is enough!” and, like you, are desperate for change.

Paving the way to change guru of mine has been Sandy Roth.

Sandy is from the USA and toured Australia many times, teaching dental teams to become better communicators with patients and with each other.

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Sandy has a series of five questions that can be helpful for dysfunctional teams to navigate their way to an improved team dynamic: 1. Where have we been?

2. Where are we now?

3. Where are we going?

4. How are we going to get there?

5. What role will each one of us play in getting there?

Gathering everyone together for a team brainstorming session and asking these questions is a great first step. Sending this list of questions prior to your gathering will help team members contemplate and prepare and come with open, rather than defensive, mindsets.

1. Where have we been? t can be helpful to discuss the foundations and behaviours that have built the team into what it is today. Identifying the dynamics that culminated into the team that exists today helps explain particular attitudes, habits and behaviours. Even in our personal lives, once we identify why we do the things we do, we understand ourselves better. We can then start making better decisions.

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2. Where are we now? ere you encourage team members to describe where the team is now working well and where it is not working well. What methods of communication, attitudes, behaviours and systems do you want to keep? What needs to be improved?

What needs to be eradicated?

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3. Where are we going? uild a picture of what a great team looks like. Gain everyone’s input. Ask questions, such as: • What are the characteristics of a great team member?

• What behaviours are to be avoided?

• How will we deliver/receive feedback?

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• How will we manage mistakes?

• How will we reward great performance?

• How will we manage unhelpful team member behaviour?

• How will we manage team conflict?

• How will we celebrate our wins?

• How will we foster our new and powerful Team Culture?

• How will we ensure there is an environment for open and frank communication?

• How will we encourage and get the best out of each other?

4. How are we going to get there? esign a plan for achieving your goal of a functional and happy team. Start with the end in mind and reverse engineer your journey. A simple starting point is to design better meetings with better agendas. You could even bring in an external chairman of the meeting, as many professional practices do, including legal, accounting and dental.

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5. What role will each one of us play in getting there? his is my favourite question as it delivers the clarity required to take action and establishes personal responsibility. It takes the shared, and therefore diluted, responsibility away from the team as a group down to each team member accountable for their personal behaviours.

Once you have identified your clear team goal and designed your plan forward, keep the level of importance and urgency high by fostering your new team culture. This is done in three ways.

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Talk It Up eep it as part of an ongoing discussion. Intend to speak about it daily. It may seem like a lot of effort, however, it doesn’t take long in reality and the impact is substantial.

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practice | MANAGEMENT Live It f the owners are not willing to acknowledge, promote and live all practice principles then they cannot expect employees to do so. It must start with setting the example from the top.

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Acknowledge others’ engagement t is pure gold when others follow your lead and start “talking up” and “living” the company vision and culture. Acknowledge these efforts one-on-one and also publicly. This way you are clearly communicating with the whole team “this is what success looks like”.

I have consulted at practices where the poor team dynamic has been in place for so long that it is unreasonable to expect confidence in future improvements. If this is the case with your team, then it is time for the owner or manager to drive the change by themselves.

Gather the team together and let everyone know that the topic is very important and attendance is crucial. If some team

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members have legitimate reasons for not attending, I suggest you record the meeting for them to view later.

Resist the tendency to soften the message and its importance. Your team will gauge from your demeanour how serious you actually are.

Start by listing down specific scenarios that are destructive to an enjoyable working environment. You do not need to mention names. The key here is to very clearly communicate the unhelpful or destructive behaviours.

Then, state with conviction, ”ENOUGH IS ENOUGH; this stops today”.

Depending upon whether team members show relief or become combative in response to your declaration, you either move through the next step on your own or with input and discussion from everyone.

The next step is to identify what a great, productive and happy team looks like.

Move through the questions listed above - “Where are we going?”, “How are we going to get there?” and “What role will each one of us play in getting there?”

Shifting the culture of a team requires strong, effective and consistent leadership.

This is not the time to be motivated by a need to be liked. It is a time to be firm and provide clear direction in a fair, supportive environment.

Conduct frequent conversations with team members one-on-one to coach them through the process. They will make mistakes along the way. That is a part of learning. Provide more positive alternative responses to situations if they slip up and reward the behaviours you want to be repeated.

No other team member has the authority to make such a fundamental shift in the daily operations of your dental practice than the owner and sometimes the manager. Use this power to empower your team - and practice - to build great success.

About the author Julie Parker Practice Success provides dental teams with coaching and training so they can work together and achieve successful outcomes for their dental practice. For more information, please contact Julie on 0407-657-729 or julie@julieparkerpracticesuccess.com.au

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September/October 2021

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practice | MANAGEMENT

Confidentiality agreement FAQS

By Simon Palmer and Harry Nicolaidis

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f you’re looking at buying a dental practice, it’s likely that you’ll be asked to sign a Confidentiality Agreement or Non-Disclosure Agreement (NDS) at some stage.

There are a lot of misconceptions about these agreements, what they mean and if they’re enforceable. In this article, we address some of the frequently asked questions that arise from these agreements.

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1. Why are confidentiality agreements necessary? uring a practice sale, it’s likely that a seller will share information with a buyer that they would not like shared in a wider context. This confidential information might include the financials of the practice, the details of its marketing efforts, payroll information about the staff, etc. For the seller to feel comfortable about sharing this information, the purchaser needs to agree to treat these disclosures confidentially.

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2. Does signing a confidentiality agreement mean that you cannot share the information with your spouse or advisors? uying a business will almost never be completed without the buyer discussing information regarding the deal with spouses and advisers (bank, accountant, lawyer). A confidentiality agreement usually has provisions to reflect that the confidential information may be used and shared in specific circumstances. That is, shared with their necessary advisors

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practice | MANAGEMENT (bank, accountant, lawyer, business partner, etc.), for the purposes of considering a specific opportunity. If they don’t, then the buyer should either seek an amendment or get a separate NDA for their spouse and advisors.

3. What happens if the confidential information that you have received becomes public knowledge are you still bound by the agreement?

“The principal purpose of putting a confidentiality agreement in place is to guide appropriate behaviour.

The fact that it creates legally enforceable obligations is ancillary to that purpose...” ypically, a confidentiality agreement will have exclusions for information that is or becomes publicly available or generally known to the public.

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4. Is a confidentiality agreement only in place to protect the seller? n a business sale transaction, confidentiality agreements are usually in place to protect the seller alone. However, there are many reasons that a buyer will also want a confidentiality agreement in place.

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A dentist looking at a dental practice to buy may be reluctant for their current boss to find out that they are looking, as there may be an implication that they intend to stop working at their current job to pursue the purchase.

For this reason, every Practice Sale Search practice for sale also includes a separate confidentiality agreement from the seller to give a buyer peace of mind that the buyer’s identity will be treated confidentially.

5. Is there a difference between a confidentiality agreement and a Non-Disclosure Agreement (NDA)? n a business sale interaction, there is unlikely to be any material difference between a confidentiality agreement and a Non-Disclosure Agreement. Irrespective of what they are called, both have the effect of protecting confidential information provided by one party to another.

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6. I have heard that NDAs and Confidentiality agreements cannot be enforced. Is this true? his is incorrect; significant penalties can absolutely be incurred if people misuse or inappropriately disclose information provided under a confidentiality agreement.

However, I think this question misses the point of these agreements.

The principal purpose of putting a confidentiality agreement in place is to guide appropriate behaviour. The fact that it creates legally enforceable obligations is ancillary to that purpose.

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If you are sharing sensitive information, you would want a confidentiality agreement for four reasons: • First and foremost, it is a written acknowledgement from the recipient that they recognise that the information received is commercially sensitive; • Secondly, you want acknowledgement that the information should not be shared unnecessarily, should be kept securely and that unauthorised disclosure could cause harm; • Thirdly, you want it to act as a deterrent in place for people who would otherwise be careless by disclosing this sensitive information; and • Finally, so that if there is unauthorised disclosure or misuse of this confidential information such that a loss flows from it, there is a legal pathway to appropriate compensation and recourse for that loss.

Hopefully the first three points will mean that the confidential information is secure and the fourth point - recourse- is rarely if ever necessary.

About the author Simon Palmer is the Managing Director of Practice Sale Search, Australia’s largest dental practice brokerage. If you’d like more info on practice sales or want to have a confidential discussion about your practice’s circumstances, email Simon at info@practicesalesearch.com.au or call 1300-282-042.

Harry Nicolaidis is a partner at K&L Gates and has acted for dental professionals in numerous matters involving the sale and purchase of businesses and in the preparation of a range of contracts for their practices. Call (07) 3233-1268 or email harry.nicolaidis@klgates.com.

Simon Palmer Managing Director

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practice | MANAGEMENT

Are you using a checklist on your calls?

By Jayne Bandy

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orking at the front office of a Dental Practice, is a great example of multitasking.

There are so many parts of what you do every day, including: • Answering Phone Calls • Follow Up Calls • Patient Arrivals • Patient Departures • Processing Payments • Treatment Discussions • Appointment Scheduling • Managing Payments • Health Insurance Claims • Listening and reassuring patients • Team Organisation • Ordering equipment and supplies and I am sure I have left a few out.

It would be a lovely thought if each of these daily activities happened one by one, but the reality is, many of these daily activities happen all at once.

So how do you stay on task to ensure that each of these activities are completed well?

That is always a challenge.

Having a checklist to follow to ensure nothing is left out is a great strategy. I know it has helped me over the years and the teams I work with.

So what sort of checklist do you need to successfully and effectively answer the phones?

There is so much to remember on each of the calls and each call is so different.

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“I know even after answering phones in a practice for over 20 years, you can get it wrong...”

The best way to answer calls well in your practice is to have a brilliant checklist to follow.

You want to have a written bullet point checklist that is easy to read, and should be kept next to the phone at all times, ready for your team to follow and not miss anything.

I know many teams believe that they have it all together and know what they are doing, especially if they have been doing this job for many years.

But I know even after answering phones in a dental practice for over 20 years, you can get it wrong.

You can become distracted and lose your focus.

A good checklist keeps you focused and on target for what you need to say and ask callers.

You avoid forgetting something or leaving an important part of your conversation to the end of the call which can be too late and often leads to NO APPOINTMENT being made.

The 8 Steps to The New Patient Call Checklist: This Checklist is the same checklist I used myself in my own practice, which enabled me to convert more calls to kept appointments.

This checklist is easy to follow and easy to action.

September/October 2021

practice | MANAGEMENT This checklist ensures you don’t miss out on anything and creates the very best first impression of your practice.

One of the most important parts and most overlooked parts of the New Patient Call is the end the call after you have scheduled the appointment.

A Checklist to follow, ensures everything is covered on the call.

At the end of the call, you want the caller to make a verbal commitment to their appointment, to ensure they show up.

Checklists are gold and I would love to see more Dental Offices using them to ensure nothing is missed on the calls and more appointments are made and kept.

If you would like The 8 Steps To The New Patient Call Checklist, email jayne@thedpe.com with your name and contact details and the CODE: 8STEPS To find out how I can teach your team to know what to say and ask your patients, to help them make more kept appointments and prevent cancellations, call me on 1300-378-044 or email jayne@thedpe.com

September/October 2021

About the author

Call Tracking Excellence is not a product IT’S A RESULT! With Call Tracking Excellence your team will learn the SAME exact processes Jayne used to: 1. Dramatically improve new patient call-in conversions to booked appointments.

2. Retain existing patient appointments and...

3. Prevent ongoing losses from appointment cancellations.

Visit www.calltrackingexcellence.com

Jayne began her career as an educator.

After spending several years teaching, she made the jump to dental practice management. Jayne served as a Practice Manager for a renowned dentist in Sydney for more than 25 years, having the opportunity to learn first-hand what works when it comes to building and maintaining patient relationships, how to convert leads over the phone and most importantly - what it takes to reach your practice goals. As the CEO and Founder of Dental Phone Excellence, Jayne strives to help practices convert more calls into appointments, reduce cancellations and help nurture effective patient communication that will result in increased profitability. Her past experience as an educator combined with her passion for practice management gives her a unique set of skills that allows your team to fully understand and take advantage of the tools she presents.

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marketing | INSIGHTS

10,000 hours later, here are my TOP 5 practice growth winners...

By Angus Pryor, MBA (Marketing)

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hen I first started in the dental industry, I’ll be honest... I didn’t really know what I was talking about. I had some good ideas, but they weren’t road-tested with real dental practices.

I’ve since come to discover that there are things that I thought would work, that don’t... and things that I thought would never work, but do. Hmmm, so much for my master’s degree in marketing!

Fast forward to 2021 and I’ve now got more than 10,000 hours of dental consulting under my belt (I counted recently). As a result, I’ve got a much clearer picture of the fastest ways to grow your practice.

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In this article, I’m going to reveal the five things I definitely would do if I owned my own practice.

1. Get your marketing in order his might seem like a no-brainer but now more than ever, optimising your dental marketing, in an increasingly competitive space, is not a maybe but a must.

I’ve had the pleasure of working with dental practices that are serious about their marketing and I see the results. I also regularly see the results of practices that don’t take their marketing seriously (they don’t invest time or money).

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marketing | INSIGHTS Often, I am speaking to this latter group when they are, in relative terms, clinging to the side of a life raft, as they’re experiencing a practice that’s going backwards.

Believe me, this is not a situation you want to be in.

The success of your practice, I assure you, is not largely based on your technical dental skills. The reason for this is simple; patients have no objective way of knowing whether you’re better or worse than the dentist down the street.

Your marketing activities are the proxy for your technical competence and the experience that patients can expect dealing with you. Market yourself well and they think your practice offers a great experience. Market yourself poorly and they assume your service is poor.

I’m yet to see a booming dental practice which has poor or non-existent marketing.

2. Get your customer service humming here are a lot of elements to this, but in simple terms, great customer service means that more of your patients walk out of your practice as raving fans.

Dental practices cannot afford to deliver service in the vein of so many GPs or specialists, where patients are treated as somehow subservient to the highfalutin healthcare professionals. There are just too many other dentists that patients can go to.

Gone are the days where you can expect your patients to stay with you if they were greeted by an unfriendly, officious receptionist, left waiting for an extended (unspecified) period and treated in surgery like they’re a mannequin.

As a case in point, I visited a specialist for the first-time last week and was kept waiting 50 minutes for my appointment to start. There was no mention from anyone that the doctor was running late. What do you think your retention rate would be like if you practised like that in dentistry, where patients are spoiled for choice?

Part of the raving fan experience is getting super clear on how to deliver each part of your client service experience like a well-choreographed (but authentic) performance. Parts of the “show” include how you answer the phone, how you welcome patients, how you take them into the surgery, how you treat them in the surgery and how you deal with them at the end of your appointment.

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Do this well and they’ll come back again and again and again (and tell their friends). Do this poorly... well, we know how that story ends.

Start by surveying your existing patients; hopefully you’ll be pleasantly surprised. If you’re not, well, you now know where to focus your attention then, don’t you.

3. Offer a wide range of dental services at your dental practice... and practice them

And on top of that, where I’ve seen practices embrace sedation, they enjoy something like a 30% growth in production over 12 months. They also get to do higher value work in a more relaxed environment for the dentist, the team and the patient (who is blissfully unaware of what’s happening). Everyone wins!

5. Hire capable consultants

hen I first joined the industry, I was very surprised to see how much money dental practices spend on equipment. Don’t get me wrong, I have absolutely no problem buying (and using) equipment that provides an enhanced experience for the patient, such as providing a faster or better service.

What is a concern for me, is the equipment that dentists buy on a whim, without sufficient thought about implementation.

Too often, because of a systems or marketing failure, this shiny new toy ends up as a dusty, very expensive paperweight.

Instead, practices need to integrate these extended range of services into their daily procedures and the internal/external practice marketing. Done well, this can be a real game-changer for the practice as more and more services are offered inhouse without the need to refer out. That’s good for patients and good for business.

hesitated to mention this one because this comment may seem self-serving.

But I’m not going to lie about what I see.

The practices I see thriving recognise that they should play to their strengths and get help with their weaknesses. That means paying for highly competent consultants to help them with the areas of their business that can generate a massive change in performance. Getting help in areas such as marketing, customer experience, practice management and so on are essential to creating a thriving practice. Let’s face it, these skills are not included in your formal education and the idea that you can successfully “wing it” based on your own gut feeling is frankly, just dreaming.

Part of the process of working with consultants is learning how to do things better, but also changing your mindset, which can often hold you back. The thinking that got you to where you are won’t get you to where you want to go. But if you can adopt the humility to recognise you don’t have all the answers and get help, the only way is up.

4. Offer sedation

Conclusion

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y virtue of my work with practices all over Australia, I’ve seen a number of them adopt sedation with great results.

And there’s a compelling reason to offer this service.

The cold hard facts are that 49% of Australians have some form of dental anxiety (Armfield, J (2010), ADJ Vol.55).

The idea of introducing a service for that group to be able to come to the dentist without fear (or even a memory of what happened) is an absolute no-brainer.

The other thing I have observed is that once practices do their first sedation case, everything changes. Suddenly, patients who want that service start coming out of the woodwork. Until taking that first step, many practices assume that patients just wouldn’t want this service. My experience is the complete opposite.

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ho doesn’t love practice growth?

For me and my business, I am constantly searching for practices with a growth mindset (but needing help) because we love helping practices grow. If I were starting my own practice, based on my experience with more than 10,000 hours consulting, these are the five areas I’d be focusing on to achieve the fastest growth.

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About the author Winner of the ADIA 2020 Marketing Award, Practice Growth Specialist, Angus Pryor is a #1 Amazon bestselling author, marketer and international speaker. For help with attracting more of your ideal patients (and fewer of the ones you don’t want), visit www.AngusPryor.com and book an obligation-free call.

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finance | INVESTMENT

How ETFs provide a shortcut to diversification

By Angela Reade, Associate Financial Adviser

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chieving a decent level of diversification in your investment portfolio can take a lot of time and money. In considering a portfolio of shares, individuals are often advised to have at least 12 stocks and anything up to 30 individual companies as the ideal. This can be unappealing for an investor to reach, costly to attain, timeconsuming to oversee and difficult to manage as it requires a detailed understanding of several individual companies.

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An Exchange Traded Fund (ETF) provides a shortcut to quickly address diversification. At its core, an ETF holds a basket of up to hundreds of individual shares and therefore can add exposure to a vast number of different companies indirectly to your portfolio with one single transaction. Each ETF may follow a particular index, sector or a particular thematic trend. For example, an ETF exists to track the SDPR S&P ASX200 Index (ASX:STW) whereby investing in this one product allows an investor’s funds to follow the performance of the underlying index and participate in both income and capital gains.

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finance | INVESTMENT

Figure 1. One year comparison of the S&P ASX200 Index ETF (in green) with blue chip stock CSL Limited (in blue).

Source: Yahoo Finance as at 28 Sept 2021 This is efficiency at its best, purchasing one product is far leaner than establishing a share portfolio and carefully selecting companies across all sectors being: financials, materials, energy, transportation, real estate, healthcare, retail, insurance, consumer staples... and this list could go further.

If an investor is seeking exposure to offshore markets, global equity ETFs are available on the ASX without the need for an international broking account.

Additionally, ETFs exist that are actively managed, meaning rather than tracking an index, the manager frequently monitors the performance of the underlying companies and sells the underperformers, thereby providing portfolio integrity.

Actively managed ETFs generally charge a higher investment fee at circa 1.0-1.5% while competition in the passively managed ETF market has driven fees to as low as 0.07%, a minuscule cost for the saving of time and effort and the provision of clear headspace.

one with lower price volatility as it offers the same return yet with less uncertainty.

Therefore, diversification aims to maximise returns in a manner that reduces risk.

It is best done by investing in areas of the market that each react differently to the same event i.e., with low correlation.

“By investing in different assets, we reduce the extreme price movements of the portfolio, often in a way which doesn’t reduce the overall return. Hence the appeal of an index tracking ETF - one can buy the ‘index’ which by nature is like buying the underlying companies, all with differing degrees of volatility...”

Why diversification matters? iversification is a big “thing” for those in portfolio management; investors are known to seek investment returns with reduced price volatility. If an investor is faced with a choice between two investments both generating approximately the same return, yet the first is capital stable, while the second has price volatility, then (generally speaking) investors prefer the

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By investing in different assets, we reduce the extreme price movements of the portfolio, often in a way which doesn’t reduce the overall return. Hence the appeal of an index tracking ETF - one can buy the “index” which by nature is like buying the underlying companies, all with differing degrees of volatility... providing a shortcut to diversification.

Figure 1 compares, over the calendar year, the S&P ASX200 Index ETF (ASX: STW) (in green) with a classic blue-chip company CSL Limited (ASX: CSL) (in blue). While both have generated positive returns, the ETF has done so with less “jumping around” and without negative returns. In contrast, CSL displays greater price movement and at many times is in negative territory, which for some would feel like a roller coaster. The key takeaway here is the reduction in price movement with similar returns.

Risk, if not understood or properly minimised, can cause havoc on portfolio performance (and an investor’s stress levels) and therefore diversification can assist with preserving capital. Broadening the assets an investor’s funds are exposed to by utilising ETFs can reduce price fluctuations and leave the portfolio to benefit from the overall market gains. This is particularly important for those that are either close to retirement as they seek to preserve their superannuation funds built up over a lifetime, or those seeking to liquidate their investments in the medium term.

Limitations hese products are not without their limitations because diversification will only address the reduction of price volatility specific to a company, while market volatility remains. For example, if the ASX200 Index declines, the value

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finance | INVESTMENT of your ETF investment will also fall, so even diversified ETFs can lose money over time as no amount of diversification will remove all risk.

Index tracking ETFs don’t offer the potential for above-market returns because by nature they offer the weighted average return of the sector. If seeking stellar outperformance, this requires selecting stocks exhibiting greater price movement. If seeking robust consistent performance, then an ETF is more likely to meet that need.

ETFs following niche sectors, for example banks, resources, or real estate, are readily available, however ETFs for newer sectors, like cryptocurrency are not available (at the time of writing) and the main issue lies in the lack of transparency regarding the quality of digital assets and the lack of fundamentals within the cryptocurrency sector.

Essentially diversification is always good; its just important to understand the limitations of how much good it can do and therein lies an understanding of the limits of ETFs.

To recap TFs are an easy and efficient way of dialling up a portfolio’s diversification in a readily available manner, with minimal cost all being easily accessible via a broker - the same means as buying and selling shares on the ASX. Avoid the analysis overwhelm of selecting specific companies and allow ETFs to provide a clear path to gaining diversified investment exposure for equity market returns.

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About the author Angela Reade is an Associate Financial Adviser at Profile Financial Services, with offices in the Sydney CBD, Parramatta, and Mudgee. Profile has operated for over 30 years and specialises in serving the wealth creation and protection needs of professionals and small business owners.

Many of Profile’s clients are dentists and they run regular education seminars on financial planning topics. To find out about upcoming seminars, or to book an obligation-free meeting, call (02) 9683-6422.

General advice warning This article is issued by Profile Financial Services Pty Ltd (ABN 32 090 146 802), holder of Australian Financial Services License No 226238. This information might contain unsolicited general information only, without regard to any investor’s individual objectives, financial situation or needs. It is not specific advice for any investor and is not intended to be relied upon by any person.

Before making any decision about the information provided, an investor should consider the appropriateness of the information in this article, having regard to their objectives, financial situation and needs and consult their adviser.

Any indicative information and assumptions used here are summarized, are not a product illustration or quote, and may change without notice to you, particularly if based on past performance.

This notice must not be removed from this article.

SAFety FirSt even fOr yOur

FinAnciAl AFFAirS Whether you’ve just started working, own your own practice or are considering retirement, Profile Financial Services can help you plan and secure your financial future. Just like good dentistry, in investing, prevention is better than cure! A sound financial plan can help anticipate and avoid risks before they damage your portfolio.

How safe are your investments?

To find out, contact Profile now to book an obligation-free initial meeting: (02) 9683 6422 Or visit our website www.profileservices.com.au

BUilDinG WeAltH SecUrity AFSl 226 238

Profile_SafetyAd_v3.indd 1

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Wealth managers for the dental industry

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infection | CONTROL

READ ME FOR

CPD

COVID-19: What is likely to happen in the next part of the pandemic journey

By Emeritus Professor Laurence J. Walsh AO

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s various parts of Australia begin reopening, it’s important to consider what the next 12 months may hold in terms of the pandemic. Based on the history of previous pandemics and on current public health planning strategies for pandemic management, a number of predictions can be made around what the next year may bring.

Mutation he SARS-CoV-2 virus will continue to mutate1,2 and the designations will progressively move through the Greek alphabet. Due to replication errors that are typical for RNA viruses, spontaneous small mutations will occur frequently. Some

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of these may have no effect on the transmission and virulence of the virus and will largely pass unnoticed from a public health perspective. Other mutations will reduce the likelihood of transmission of the virus, particularly those that lower the affinity of binding of the virus to the ACE-2 receptor of human cells. Yet other mutations will make the virus more readily transmitted, or more stable in the environment. Typically, during the multiple waves of a viral pandemic, the virus becomes more readily transmitted but less virulent with successive waves of infection. This pattern was seen with the Spanish flu 100 years ago and with the swine flu in 2009.

Spontaneous small mutations, also known as antigenic drift, occur with human influenza viruses, so the same is expected for this particular coronavirus.3

September/October 2021

infection | CONTROL Antigenic shift, which represents a more substantial change in the genetic material of the virus, could occur in a patient who is infected at the same point in time with two or more strains of the virus. This could lead to a more concerning variant with greater potential to spread through the community.

The likelihood that coronaviruses that are hosted by bats would escape their animal host and cause infections in humans was recognised over 20 years ago and there have been multiple near miss events where pandemics of coronavirus infection have been averted.

Australian virologists have been studying that coronavirus escape pathways for over two decades, based on the prediction that a human pandemic was highly likely to occur.

Vaccine boosters he patterns of mutation in the virus will affect the requirements for boosters of the vaccine. They will also affect the design of future vaccines and boosters, since it will be necessary to choose parts of the virus (epitopes) that provide protection to new variants of concern.4-6 In this context, it is possible that vaccines that have multiple epitopes, such as inactivated or attenuated viruses, may prove to be useful, since these will present to the human immune system multiple epitopes of the envelope of the virus, as well as the spike protein.

Tests to assess the level of immunity of an individual person will become increasingly important. Samples of blood or saliva may be used to track levels of protective antibody to SARS-CoV-2.

Knowing that a particular person’s levels of antibodies have waned below the level necessary to provide protection then provides the appropriate timing for a booster for this particular individual. Following such a personalised approach would maximise the value of using boosters, as it would identify those whose protective antibody response has a shorter duration than the median value in the population.

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Vaccines for people of all ages here are already moves to extend vaccination to children and this is appropriate given the fact that children

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can serve as reservoirs of infection for the virus and that in some children a rare inflammatory condition can lead to severe or fatal outcomes.7,8 Vaccination of children would also prevent the considerable public health impacts of “long COVID” over the lifetime of the child.

Mandatory vaccination oves around mandatory vaccination have progressed recently at supersonic speed, with multiple Australian jurisdictions moving to mandate vaccination for essential workers, including all those who work in healthcare in the public and private sectors.9-13 On October 1, AHPPC made clear its position supporting mandatory vaccination for all healthcare workers, which provides impetus to each jurisdiction to progress this through their own public health legislation and through the issue of public health directives.14

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Sequestration of the disease nalysis of vaccine hesitancy indicates that it is not distributed evenly across the population and tends to be focused in certain subgroups. Overseas data indicate that in countries where the rates of vaccination are high, COVID-19 sequesters into these communities.15 Very often, such communities will have significant social disadvantage and may have more limited access to health care in general. As a consequence, the severity of outcomes following infection with COVID-19 is likely to rise. Public health planning at the level of local government areas needs to consider where hotspots of vaccine hesitancy exist at the present time, as the same areas will be a reservoir for ongoing infections into the future.

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Targeted therapy for hospitalised cases range of new therapies for treating severe cases of COVID-19 have been developed, including humanised monoclonal antibodies16 and therapies that reduce the host inflammatory response in the lungs, or make human cells more resistant to infection by the virus. As these new therapies begin to be rolled out, the rates of “excess deaths” from COVID-19 and those who have access to such therapies should decline.

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RAT testing: from the clinic to the household level n September, the TGA granted approval for the use of rapid antigen tests in dental practice to assess staff and also patients requiring emergency care. Protocols for using such tests have been published recently.17 The TGA has subsequently initially approved three COVID-19 self-tests (two saliva based and one that uses a nasal swab) for consumer use in Australia from 1 November 2021.

Several Australian companies already manufacture rapid antigen tests for the international market, so following this approval, it is likely that such tests would be rapidly deployed into the general community. Australia has been one of the last OECD countries to permit the use of rapid antigen tests, which is an unusual point of history given that Australian manufacturing technology has been world leading in this particular field. With easy access to rapid antigen tests, individuals and the community will be able to assess their own status.

The wide deployment of rapid antigen tests will also have implications for how these are used for those undertaking international travel. It is likely that rapid antigen tests based on saliva samples will become more widely used, because of the convenience of sample collection, as opposed to those using swabs of the nasopharynx.

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Suppression versus elimination s individual local government areas and entire states and territories open up, public health authorities will be working from the standpoint of suppression, following what is known as “the hammer and the dance”. Empowered by the analysis of sewage for fragments of the virus and the wider use of rapid antigen tests, public health authorities will be able to better localise infection into specific geographical regions, to the level of a single suburb or below. As a result, any restrictions that need to be applied to the movement of people should be highly targeted and of relatively short duration. The need for massive lockdowns involving millions of people should decline sharply, as these more refined approaches become available.

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infection | CONTROL

Figure 1. InnoScreen™ COVID-19 Rapid Antigen Test made in Australia and designed to be administered by suitably trained healthcare practitioners.

When particular micro-regions are identified with unusually high levels of both asymptomatic and symptomatic infection, a vaccination blitz for that area will likely follow. This may use forms of the vaccine that only require a single injection, such as the Janssen vaccine.

Risk-based precautions n the “living with COVID” world, individuals with asymptomatic infections will continue to exist in the community and thus the use of sewage testing will continue to be important to identify where high numbers of such individuals may be located. Recognition of asymptomatic cases will improve with home-based rapid antigen testing, however it is naïve to assume that all possible cases in the community will be identified. Consequently, measures that can reduce the likelihood of transmission will continue to play an important role in the future.

Considering a hierarchy of controls, elimination is the most desirable and effective strategy, hence ensuring that vaccination levels are high in the community remains an essential goal. Using effective preprocedural mouth rinse for patients at the start of their dental appointment is a further mechanism for reducing

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Figure 2. From 1 November 2021, three COVID-19 self-tests (two saliva based and one that uses a nasal swab) have been approved for consumer use in Australia.

the likelihood that the patient saliva contains the virus. Extensive research efforts around preprocedural mouthrinses continues around the world, including clinical trials as well as laboratory assays of virus survival following exposure to different agents.18-24 Fortunately, all commonly used commercial mouthrinses are effective against SARS-CoV-2, meaning that any one dental practice has a wide range of agents to choose from.

Greater awareness of high volume suction he COVID-19 pandemic has focused attention on the important protective role of high volume suction to remove aerosols generated by the normal breathing and speaking of patients (i.e. aerosol generating behaviours, or AGBs) as well as from dental procedures that use the triplex syringe or powered devices that generate aerosols (i.e. AGPs). Use of a large diameter (8 or 10 mm) suction tip provides the most effective removal of air from the patients oral cavity and the surrounding region.25-28 Further research into the value of extraoral suction and filtration devices will determine whether these have value either in the operatory or public areas of the practice such as the waiting room.

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Air handling considerations he pandemic has brought attention onto the importance of air-conditioning systems and ventilation in reducing the level of viruses in the air and how this influences the waiting period or fallow time before an operatory can be used for the following patient.

Recent research from the UK29 highlights that operatories which have no air-conditioning (i.e. no mechanical ventilation) have high levels of aerosols that persist for over one hour, however the levels drops once the windows are opened and natural ventilation is allowed to occur.

On the other hand, a dental operatory that is connected to a central air-conditioning system which has air filtration capabilities shows a rapid decline in aerosol over 10 minutes, depending on the number of air changes per hour.

Some dental operatories in Australia use a split system where the air inside the operatory is recirculated and this is likely to give a scenario similar to that of rooms with no mechanical ventilation.

The topic of air handling in the dental practice (and the wider field of aerobiology) has some complexities and will be addressed in a future article.

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September/October 2021

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infection | CONTROL Conclusions

About the author

OVID-19 is likely to persist and sequester into parts of the community of Australia where it will remain for some years. The same pattern will be seen in parts of the world where access to health care is limited and the rollout of vaccination has been delayed.

At the global level, COVID-19 will persist for several years and this will influence international travel. Parts of the world where COVID-19 vaccination has yet to be deployed at scale (such as in sub-Saharan Africa) are likely to sustain moderately high rates of infection in the community.

On the other hand, the history of past pandemics has shown that there tends to be a strong economic rebound following a pandemic. In the case of the Spanish flu, this was the “Roaring 20s” which was an unheralded time of prosperity and social development in many parts of the world, which continued until the Great Depression.

In all likelihood, there will be further viral pandemics in the future, which could arise from coronaviruses or from influenza viruses. Australia is now in a better position than it was in 2019 to cope with such future pandemics. We now have onshore production of surgical masks and respirators, in both Adelaide and Brisbane, and a proper facility for testing the performance of such devices, which did not exist before the COVID-19 pandemic.

The ability of Australian researchers to develop vaccines and diagnostic tests has been enhanced greatly through the pandemic and this will be an advantage for future pandemics.

Last of all, but not least, most of the community has come to a better understanding of hygiene measures that will reduce the spread of respiratory viruses.

This is why there has been a spectacular decline in the number of cases of viral influenza in Australia during the COVID-19 pandemic.

It is often remarked that those who do not learn the lessons of the past are destined to repeat them. Fortunately, it seems that, from a public health perspective, some lessons have been learnt and some lessons from the past that have been forgotten have been revisited and refreshed for the modern age.

Emeritus Professor Laurence J. Walsh AO is a specialist in special needs dentistry who is based in Brisbane, where he served for 36 years on the academic staff of the University of Queensland School of Dentistry, including 21 years as Professor of Dental Science and 10 years as the Head of School. Since retiring in December 2020, Laurie has remained active in hands-on bench research work, as well as in supervising over 15 research students at UQ who work in advanced technologies and biomaterials and in clinical microbiology. Laurie has served as Chief Examiner in Microbiology for the RACDS for 21 years and as the Editor of the ADA Infection Control Guidelines for 12 years.

His published research work includes over 330 journal papers, with a citation count of over 15,400 citations in the literature. Laurie holds patents in 7 families of dental technologies. He is currently ranked in the top 0.25% of world scientists. Laurie was made an Officer of the Order of Australia in January 2018 and a life member of ADAQ in 2020 in recognition of his contributions to dentistry.

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References 1. Tian D et al. The global epidemic of SARS-CoV-2 variants and their mutational immune escape. J Med Virol. 2021 Oct 5. doi: 10.1002/jmv.27376.

2. Ciotti M et al. The COVID-19 pandemic: viral variants and vaccine efficacy. Crit Rev Clin Lab Sci. 2021 Oct 1:1-10. doi: 10.1080/10408363.2021.1979462.

3. Volkan E. COVID-19: structural considerations for virus pathogenesis, therapeutic strategies and vaccine design in the novel SARS-CoV-2 variants era. Mol Biotechnol. 2021 Oct;63(10):885-897. doi: 10.1007/ s12033-021-00353-4.

4. Mahmoodpoor A et al. SARS-CoV-2: unique challenges of the virus and vaccines. Immunol Invest. 2021 Oct; 50(7):802-809. doi: 10.1080/08820139.2021.1936009.

5. Tao K et al. The biological and clinical significance of emerging SARS-CoV-2 variants. Nat Rev Genet.

2021 Sep 17:1-17. doi: 10.1038/s41576-021-00408-x.

6. Bano I et al. Genetic drift in the genome of SARS COV-2 and its global health concern. J Med Virol.

2021 Sep 15. doi: 10.1002/jmv.27337.

7. Schulert GS et al. Host genetics of pediatric SARSCoV-2 COVID-19 and multisystem inflammatory syndrome in children. Curr Opin Pediatr. 2021 Sep 15. doi: 10.1097/MOP.0000000000001061.

8. Chauhan N et al. Optimizing testing regimes for the detection of COVID-19 in children and older adults.

Expert Rev Mol Diagn. 2021 Oct;21(10):999-1016. doi: 10.1080/14737159.2021.1962708.

9. Tasmania https://www.coronavirus.tas.gov.au/ important-community-updates/mandatory-vaccination-of-health-care-workers 10. Victoria https://mvec.mcri.edu.au/references/ covid-19-mandatory-vaccination-directions-in-victoria

11.

WA https://ww2.health.wa.gov.au/ About-us/Policy-frameworks/Public-Health/Mandatory-requirements/Communicable-Disease-Control/ Immunisation/COVID-19--Mandatory-Vaccinationand-Vaccination-Program-Policy 12. QLD https://www.childrens.health.qld.gov.au/ wp-content/uploads/PDF/COVID-19/mandatoryCOVID19-vaccination-faqs.pdf 13. NSW https://www.nsw.gov.au/covid-19/vaccination/requirements-for-workers 14. https://www.health.gov.au/news/ australian-health-protection-principal-committeeahppc-statement-on-mandatory-vaccination-of-allworkers-in-health-care-settings 15. Chau NVV et al. Oxford University Clinical Research Unit COVID-19 Research Group. The natural history and transmission potential of asymptomatic SARS-CoV-2 infection. Clin Infect Dis. 2020; 71(10):2679-2687.

16. Mornese Pinna S et al. Monoclonal antibodies for the treatment of COVID-19 patients: An umbrella to overcome the storm? Int Immunopharmacol.

2021 Sep 28;101(Pt A):108200. doi: 10.1016/j. intimp.2021.108200.

17. Durner J et al. SARS-CoV-2 and regular patient treatment – from the use of rapid antigen testing up to treatment specific precaution measures. Head Face Med. 2021;17:39. DOI: 10.1186/s13005-02100289-9.

18. Davies K et al. Effective in vitro inactivation of SARS-CoV-2 by commercially available mouthwashes. J Gen Virol. 2021;102(4):001578.

19. Xu C et al. Differential effects of antiseptic mouth rinses on SARS-CoV-2 infectivity in vitro. Pathogens.

2021;10(3):272.

20. Stathis C et al. Review of the use of nasal and oral antiseptics during a global pandemic. Future Microbiol. 2021;16(2):119-130.

21. Mateos-Moreno MV et al. Oral antiseptics against coronavirus: in-vitro and clinical evidence. J Hosp Infect. 2021;113:30-43.

22. Komine A et al. Virucidal activity of oral care products against SARS-CoV-2 in vitro. J Oral Maxillofac Surg Med Pathol. 2021;33(4):475-477.

23. Eduardo FP et al. Salivary SARS-CoV-2 load reduction with mouthwash use: A randomized pilot clinical trial. Heliyon. 2021;7(6):e07346.

24. Seneviratne CJ et al. Efficacy of commercial mouth-rinses on SARS-CoV-2 viral load in saliva: randomized control trial in Singapore. Infection.

2021;49(2):305-311.

25. Meethill AP et al. Sources of SARS-CoV-2 and other microorganisms in dental aerosols. J Dent Res. 2021; 1-7. DOI: 10.1177/00220345211015948.

26. Allison JR et al. Evaluating aerosol and splatter following dental procedures: addressing new challenges for oral health care and rehabilitation. J Oral Rehabil. 2021; 48:61-72.

27. Holliday R et al. Evaluating contaminated dental aerosol and splatter in an open plan clinic environment: Implications for the COVID-19 pandemic. J Dent. 2021; 105: 103565.

28. Balanta-Melo J et al. Rubber dam isolation and high-volume suction reduce ultrafine dental aerosol particles: an experiment in a simulated patient. Appl Sci. 2020; 10: 6345.

29. Shahdad S et al. Fallow time determination in dentistry using aerosol measurement in mechanically and non-mechanically ventilated environments. Brit Dent J. 19 July 2021 DOI: 10.1038/s41415-021-3369-1.

September/October 2021

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infection | CONTROL

Have proactive conversations to help patients feel safe

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ith the ongoing threat of the COVID-19 pandemic, patients continue to be reluctant to visit dental clinics. Over 10% of patients - both adults and children - have delayed health care, including dental care, despite admitting the need for care.

Patient communication is key to alleviating the fears that keep patients from returning to your dental practice.

The best way to alleviate these concerns is to be proactive with communication, so patients know - even before asking - that you’re taking every precaution to keep them safe and prevent infection. So, be sure to develop a communications plan that will ensure patients receive consistent, clear and accurate information about your infection control practices. Your outreach can include channels like social media posts, an email bulletin to patients, signage in your practice itself and perhaps most importantly, staff-patient communications.

Why is patient communication important?

Be prepared to have candid conversations

s the pandemic continues, many patients continue to practice caution and may be eager to avoid places where they can’t remain masked, such as at a dental practice.

We don’t have to point out that patients have a tendency to delay cleanings and regular check-ups to begin with, so the pandemic-related concerns only exacerbate the problem.

hen you think about who spends the most time with patients, it’s often front office staff and dental assistants. But the truth is, patients who have questions may approach anyone in the practice. That’s why everyone needs to be fully trained and prepared to talk with patients about the safety measures the practice is taking and any concerns they have, regardless of their role.

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You should be well-versed in the latest protocols so you can answer patients’ most common questions about safety, sterilization, and anything else your patients present.

One way to keep abreast of the latest guidelines pertaining to COVID and infection prevention is to make use of the ADA COVID-19 microsite, which helps all members of the dental team members stay up-to-date on the latest topics.

September/October 2021

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HFL-482AUS/1220 • Accurate occlusal anatomy thatpractice, matches©2020 the natural tooth • Accurate occlusal anatomy thatpractice, matches the natural tooth protect the efficiency of your while helping protect your patients, your staff and theyour efficiency instrument of your investment. while helping • Accurate occlusal anatomy thatpractice, matches the natural tooth protect your patients, your staff and your instrument investment. the efficiency of your while helping

Learn How to Scale in Perfect Harmony at Hu-Friedy.com/Harmony Hu-Friedy.com/H Hu-Friedy.com/Harmony

To learn more about how IMS can enhance VISIT USCo., ONLINE AT HU-FRIEDY.COM/PerfectFit Hu-Friedy Mfg. LLC, 1666 how E. Touhy Ave., Desenhance Plaines, IL 60018 | Hu-Friedy.com To learn more about IMS your practice visit Hu-Friedy.com/Infinity VISIT US ONLINE AT HU-FRIEDY.COM/PerfectFit ToHu-Fried learn more about howcan IMS can enhance ©2016 y Mfg. Co., All rights reserved.

All company and product names are of Hu-Friedy Mfg. Co., LLC, VISIT USLLC.ONLINE ATtrademarks HU-FRIEDY.COM/PerfectFit your practice visit Hu-Friedy.com/Infinity ©2016 Hu-Fried y Mfg. Co.,companies, LLC. All rights reserved. its affiliates or related unless otherwise noted.member of ©2017 Hu-Friedy Mfg. Co., LLC. Allis rights reserved.

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infection | CONTROL Patient arrival and the practice environment e prepared to answer the most common questions patients might ask: • At what stages are masks a requirement in the practice?

• Why do your staff wear masks?

• Is there space to socially distance in the waiting room?

• Can patients bring someone with them or do they need to arrive alone?

• Under what situations can parents and caregivers be in the treatment room?

B

Even if your dental practice has a designated Infection Prevention Coordinator (IPC), consider allocating time for your team to review requirements and any changes and then collectively update your patient communication plan. This will allow your entire team to share the most current information with patients and walk them through your processes, while also knowing they can come to the IPC with any questions they aren’t sure how to answer.

Infection control ost patients don’t know much about infection control in dentistry.

Encourage your team to initiate a conversation and proactively answer questions

M

Talk to patients about each step in the process our patients need to be comfortable with every step your practice takes to ensure their safety. If they don’t trust you, you might lose them as patients altogether.

Walk your patients through reprocessing, cleaning and sterilisation, room turn-over and the necessary PPE your staff members wear during cleanings and procedures. Offer a tour of your sterilisation room so they can see the stages of instrument reprocessing before their visit.

If you use instrument cassettes, explain their advantages for organisation and patient safety.

When it comes to helping patients become more comfortable with your safety measures and practices, there really is no such thing as too much information.

ou should be able to give patients an overview of your process to make them feel more comfortable. This includes areas like:

Y

102 Australasian Dental Practice

f you use an instrument management system (IMS), visually this can look much more reassuring to patients than a collection of loose instruments on a tray.

Plus, if the instruments are neatly organized and standardised, treatment will proceed more smoothly, which helps reduce patient anxiety.

Encourage your team to show patients the IMS™ Cassettes you use and explain how they work, which can answer questions patients may not know they have.

Questions include: • What does your practice do with instruments after they’ve been used on patients?

• Why do you clean and sterilise instruments between each patient?

• How does your practice sterilise the instruments?

• How do patients know the instruments are sterile when they are used?

• What does your practcie do with items you can’t sterilise using steam?

I

Surface disinfection astly, be ready to answer questions about how the environmental surfaces in your practice are cleaned and disinfected. During the course of treatment, lots of surfaces can potentially be contaminated from direct spray or splatter, which could lead to these types of questions from patients: • Why are some surfaces in the practice covered in plastic barriers?

• How will patients know the surfaces not covered by plastic are clean?

• What products does your clinic use to treat such surfaces?

It’s perfectly normal for patients to experience some fear or concern about their dental visit while COVID-19 is still an issue in the community, but it shouldn’t stand in the way of them getting the quality of care that they need.

You’ve done the work to safeguard your practice and implement best practice protocols to prevent infection and keep patients safe. Now you just have to make sure you can proactively have the conversations with patients to make them feel more comfortable about coming into the practice - and leaving with a healthier smile.

L

Y

Provide detailed information about your protocols

Instrument sterilisation

about the actions your practice takes to protect patients, which can be an opportunity to introduce the role of the Infection Control Coordinator.

Questions to pre-emptively answer include: • What is infection control and why this is important for health and safety when attending for dental care?

• What steps does your clinic take for infection control?

• How can patients know that the clinic is doing everything it can for infection control?

• What disinfectants does your clinic use?

• What should patients do if they become ill just before their appointment?

• What are the procedures for clinical staff to call in if they’re sick?

September/October 2021

YOUYOU REQUIRE MAXIMUM EFFICIENCY. YOU REQUIRE MAXIMUM EFFIC REQUIRE MAXIMUM EFFICIENCY. YOUYOU DEMAND COMPLETE ORGANIZATION. YOU DEMAND COMPLETE DEMAND COMPLETE ORGANIZATION. HUFRIEDYGROUP INTRODUCES HUFRIEDYG YOUYOU NEED ENSURED SAFETY. HUFRIEDYGROUP YOU NEED ENSURED S NEED ENSURED SAFETY. INTRODUCES ™ ™ YOU DESERVE INFINITE CONFIDENCE. YOU DESERVE HUFRIEDYGROUP INTRODUCES YOU DESERVE INFINITE CONFIDENCE. HUFRIEDYG HUFRIEDYGROUP INTRODUCES

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YOU REQUIRE MAXIMUM EFFICIENCY. SCIENTIFICALLY PROVEN ERGONOMIC SCIENTIFICA SCIENTIFICALLY PROVEN ERGONOMIC YOU DEMAND COMPLETE ORGANIZ SCALERS AND CURETTES SCALERS AN SCALERS AND CURETTES HUFRIEDYGROUP YOU NEED ENSURED SAFETY. SCIENTIFICALLY PROVEN ERGONOMIC SCIENTIFICA SCIENTIFICALLY PROVEN ERGONOMIC DESERVE INFIN HUFRIEDYGROUP SCALERS AND CURETTES YOU SCALERS AN SCALERS AND CURETTES

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To more about how IMS can Hu-Friedy Mfg. LLC, 1666 E. Touhy Ave., Desenhance Plaines, IL 60018 | Hu-Friedy.com VISIT USCo., ONLINE AT about HU-FRIEDY.COM/PerfectFit To learn learn more about how IMS enhance VISIT US ONLINE AT HU-FRIEDY.COM/PerfectFit To learn more howcan IMS can enhance All company and product names are trademarks of Hu-Friedy Mfg. Co., LLC, VISIT US ONLINE AT HU-FRIEDY.COM/PerfectFit your practice visit Hu-Friedy.com/Infinity ©2016 Hu-Fried y Mfg. Co., LLC. All rights reserved. your practice visit ©2016 Hu-Fried y Mfg. Co., LLC. All Hu-Friedy.com/Infinity rights reserved. its affiliates or related companies, unless otherwise noted. your practice visit Hu-Friedy.com/Infinity ©2016 Hu-Fried y Mfg. Co., LLC. All rights reserved. ©2017 Mfg. Co., rights reserved. ©2021 Hu-Friedy Co.,All rights reserved. ©2017 Hu-Friedy Hu-Friedy Mfg.Mfg. Co., LLC. LLC. AllLLC. rightsAll reserved.

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To learn about how IMS can enhance VISIT more US ONLINE AT HU-FRIEDY.COM/PerfectFit your©2016 practice visit Hu-Friedy.com/Infinity Hu-Fried y Mfg. Co., LLC. All rights reserved.

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infection | CONTROL

Why who made your mask matters

W

hen COVID-19 created an unprecedented demand for personal protective equipment (PPE), many countries were caught off guard. Without sufficient stockpiles of items such as masks, gowns and gloves, shortages developed in these disposable items. As demand began to surpass available supply from reputable manufacturers, clinicians tried to source these from wherever they could. Around the world, some companies were eager to profit from the increased demand for consumer level masks, as well as masks for health care. It is fair to say that some of these

104 Australasian Dental Practice

manufacturers had no medical device manufacturing experience and no knowledge of the regulatory requirements that are in place in Australia to keep healthcare professionals safe. There has been confusion over domestic use personal masks (that have no splash protection) and masks for healthcare. The TGA has expressed concerns regarding the quality and performance of masks for healthcare.

Masks for use in healthcare need to have protection from fluid penetration, be approved by the TGA for medical use and meet the filtration and splash protection requirements of AS 4381:2015.

Many imported masks and products sold online do not meet these requirements.

Using inferior masks puts users at risk of

infection in the workplace. In the midst of the COVID-19 pandemic and dealing with a virus that is as highly transmissible as SARS-CoV-2 (and the Delta variant in particular), choosing a mask that meets these standards is more important than ever.

In some cases, poor quality masks could even contain potentially harmful materials* that pose a risk to health.

Producing face masks suitable for use in a healthcare setting requires considerable knowledge and experience in the fabrication technologies that are used. It needs high-quality raw materials, state-of-the art manufacturing techniques and stringent quality controls, so that the masks meet the regulatory requirements.

September/October 2021

infection | CONTROL

“Many masks are tested in the USA (at Nelson Labs in Utah), however on-shore mask testing was developed in Australia in 2020 so performance testing is now typically done within Australia...”

A face mask meets the TGA definition of a medical device when the following claims are made. Either the mask is to be used for the prevention of the transmission of disease between people, or the mask is intended for use in health services. According to the TGA, if the manufacturer’s labelling, advertising or documentation contains such claims above, the mask is considered to be a medical device and it must be included in the Australian Register of Therapeutic Goods (ARTG). Masks for use in dentistry must be included in the ARTG before being imported into or supplied in Australia, exported from Australia, or advertised in Australia.

Masks that are non-sterile are regulated as Class I medical devices, however, the TGA has put in place more rigour and a validation process for masks included in the ARTG, including an audit of the evidence held by the manufacturer to demonstrate the performance and the quality of the mask.

September/October 2021

Australian standard for medical face masks S 4381:2015 Single-use face masks for use in health care classifies masks into three levels (1, 2, 3) based on their resistance to fluid penetration. Resistance to fluid penetration is measured using synthetic blood at pressures of 80, 120 or 160mm Hg. Note that consumer masks are not required to have fluid resistance, but despite this they can be used by the general public in non-healthcare settings to reduce the risk of the spread of infections, particularly in epidemic or pandemic situations.

For healthcare settings, level 1 surgical masks have low fluid splash resistance (80 mm Hg) and are used for procedures where no splash of body fluids is expected (e.g. denture prosthetics).

Masks with medium level fluid splash resistance (120 mm Hg) are used for routine procedures in dentistry where some splash of body fluids is expected,

A

while masks with high level fluid splash resistance (160 mm Hg) are designed for settings where arterial squirting to the face may occur (e.g. paramedics, orthopaedic surgery, cardiac surgery, limb amputations, etc). The test methods are ASTM F2101-14 or EN 14683:2014.

Many masks are tested in the USA (at Nelson Labs in Utah), however on-shore mask testing was developed in Australia in 2020 so performance testing is now typically done within Australia.

Bacterial filtration efficiency (BFE) measures how well a mask filters out bacteria. AS 4381 specifies testing with a droplet size of 3.0 microns containing Staphylococcus aureus (average size 0.60.8 microns). A minimum 95% filtration rate is required for level 1 masks. Level 2 and level 3 masks must have bacterial filtration rates greater than 98%.

AS 4381 does not provide a requirement for particle filtration efficiency (PFE) (e.g. for particles from 0.1-0.3 microns) as surgical masks are primarily designed

Australasian Dental Practice

105

infection | CONTROL

to keep cross contamination between the health care worker and the patient to a minimum. The AS 4381 standard directs those clinical staff who need respiratory protection to the two Australian standards that apply to respirators, especially AS/NZS 1716:2012 Respiratory protective devices (Guidance on the selection, use and maintenance of respirators is given in AS/NZS 1715: 2009 Selection, use and maintenance of respiratory protective equipment).

The Pressure Differential (Delta P) measures air flow resistance and so provides an objective measure of breathability. The test method is described in EN 14683:2014. Delta P is measured in units of mm H2O/cm2. The lower the value, the more breathable the mask is. Delta P for Level 1 masks must be less than 4.0 and for level 2 and 3 masks it must be less than 5.0.

When you wear masks during the whole day, comfort matters eputable medical mask manufacturers have a vested interest in maintaining their reputation for providing masks that are comfortable to wear during the

R

106 Australasian Dental Practice

working day in clinic. This is why high ratings for breathability and comfort are important.

Medicom have been manufacturing masks and other items of PPE for healthcare

“Medicom developed its medical mask expertise by working in close collaboration with the healthcare professionals who wear them.

By investing in ongoing research and development, premium raw materials and state-of-the art machinery, the company continues to produce innovative, premium-quality masks...” for over 33 years and has the know-how regarding surgical masks that provide reliable protection, as well as exceptional breathability and comfort, even for those with sensitive skin. Medicom developed its medical mask expertise by working

in close collaboration with the healthcare professionals who wear them. By investing in ongoing research and development, premium raw materials and state-of-the art machinery, the company continues to produce innovative, premium-quality masks that meet the needs and preferences of those who wear them.

The Medicom SAFE+MASK PREMIER PLUS earloop mask is well-suited to routine use in dentistry. It has level 2 fluid resistance. The earloops are soft and strong and ample in length, so there is less pulling needed. The nosepiece is readily adjusted for achieving a comfortable fit to the nose.

Whatever mask you choose, be sure you are wearing it properly surgical mask can only protect effectively if it is worn correctly. That means there should be no gaps along the sides of the mask between the mask and the face and that the mask should extend from the bridge of the nose to the chin. It is critical that the mask covers not only the mouth, but also the nose. To ensure adequate coverage of the nose, masks should not be worn below or at the tip of the nose.

A

September/October 2021

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clinical | EXCELLENCE

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CPD

Recent developments in vital dental bleaching and the emergence of new options with peroxy carboxylic acids

By Emeritus Professor Laurence J. Walsh AO

R

ising expectations around personal appearance and awareness of tooth shade changes over the lifespan has promoted interest in vital tooth bleaching.1-3 All registered dental practitioners who are providing vital tooth bleaching have a duty of care to their patients to practise safely and effectively, regardless of whether bleaching is being done in the clinic or as part of a supervised program at home.

Moreover, justifying the treatment includes knowing the patient’s expectations of the procedure and products used and explaining the associated risks.4 This article provides an update in the regulatory framework and technology aspects of dental bleaching, drawing from the most recent literature available (up to September 2021).

Recent changes in the regulatory framework wide variety of kits for in-office bleaching use hydrogen peroxide (HP), typically at 25-35%. As this procedure is undertaken in the clinic, no current laws or regulations limit the types of products that are able to be used in that setting.

On the other hand, products for at-home bleaching typically use carbamide peroxide (CP) for extended applications or HP for short duration applications. Such CP and HP products are highly regulated, through the Dental Board of Australia, the Therapeutic Goods Administration (TGA) and the Australian Competition and Consumer Commission (ACCC).

In August 2021, the Dental Board of Australia changed its policies for at-home products that are dispensed to a dental patient and used for at-home bleaching as part of a supervised program. Their latest guidance4 reinforces the need to only use HP and CP products as the law allows and when the treatment can be justified. For compliance, clinicians must also take into account the relevant medicines and poisons laws (which dictate limits on HP and CP products) and Australian Consumer Laws (ACL). It is important to know that ACL require the disclosure by manufacturers of all ingredients used in their bleaching products. In this regard, some bleaching systems made in the USA are not legal because of inadequate product labelling and failure to disclose ingredients.

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As a result of the policy change in August 2021, high strength HP products may now come onto the Australian market, especially from the USA. A note of caution is needed. Choosing stronger HP products for at-home use with the goal of achieving greater colour changes in teeth5 may, however, come at the expense of greater loss of surface mineral and increased issues with pulpal responses (zingers) and soft tissue chemical burns and irritation.5-7 Likewise, for in-office use, some studies suggest keeping the HP concentration at or below the 15% level to reduce the possibility for alterations of enamel hardness and surface morphology.8 It must always be remembered that adverse enamel changes will increase with repeated applications of high concentration HP gels.6,7,9

Why the choice of oxidant matters raditionally, bleaching in dentistry has relied upon the use of oxidants based on HP. In fact, tooth bleaching using HP has a history that extends back more than 100 years.10 HP works through the generation of reactive oxygen species (ROS), including HO2• when the pH is alkaline. These ROS oxidise organic molecules.11 Various methods have been used to accelerate the degradation of HP in ways that increase the release of ROS, to reduce the application time and shorten treatment duration, or improve the end result.

As well as HP, adducts of HP have also been employed, such as carbamide peroxide (CP) and sodium percarbonate, as well as HP releasing compounds, such as sodium perborate. These give a gradual release of HP over time and hence work in the same way as HP, through the generation of ROS. The target molecules of HP and its derivative ROS include not only the organic molecules that cause stains, but also normal enamel proteins. This is why excessive and repeated use of HP products lowers the protein content of the enamel and increases its brittleness and causes the aesthetic problems of opacity from “overbleaching”.12,13 It also increases the permeability of the enamel after bleaching for a short period of time.

T

September/October 2021

clinical | EXCELLENCE At the same time, the ROS generated from HP are attenuated by a number of oral defence systems, including enzyme-based components of saliva that are found within pellicle and by the polyphenol components of extrinsic stains from highly coloured foods. This means that attention has to be paid to the careful removal of pellicle and extrinsic surface stains before the bleaching gel is applied to the teeth during in-office bleaching.

A further issue is that in order to stabilise HP, it is shipped at a very low (acidic) pH, so if the pH is not adjusted upwards immediately before the product is applied onto the tooth surface, demineralisation of enamel will occur.

Safety considerations with ROS n important safety consideration is that when used at concentrations above 6%, HP is a chemical irritant for oral soft tissues, causing injury through lipid peroxidation of human cell membranes. Oxidation of phospholipids present in those membranes and in the membranes of lysosomes leads to leakage of cell contents, oxidative stress and cell death.14 HP and its derivatives penetrate through teeth, by way of the interprismatic substance of enamel, to reach the dentine. From here, they can reach the dental pulp in a timeframe of 15 minutes or longer.15-18 Faster penetration occurs in smaller teeth and otherwise when the enamel is thinner or has structural defects.19 The rate of penetration is directly proportional to the HP concentration and the contact time of the gel on the enamel surface.20 Within the dental pulp, a “zinger” response is triggered as ROS are neutralised by dental pulp defence systems, such as the enzyme catalase.21 When ROS reach the dental pulp, they can also trigger the release of neuropeptides, the apoptosis of cells and transient low grade inflammation.22,23 Animal model studies24-27 and cell culture studies28-32 have shown that HP and ROS that reach the dental pulp may cause cytotoxic effects on dental pulp cells and short-term injury. Bleaching protocols using high HP concentrations exert more aggressive actions on odontoblastlike cells in these model systems.33 Hence, more attention is now being directed to methods of in-office bleaching that reduce ROS penetration through tooth structure, such as using lower strength HP gels and shorter contact times.34,35 What happens in humans in vivo during an in-office bleaching treatment with a HP gel is not as severe as what has been reported in rodent and canine studies. Typically, in humans there is a slight disruption to the odontoblastic layer, which appears as a transient change and then only in a minority of patients.36 Having said this, there have been some reports of marked histological changes in lower incisor teeth in teenage patients after exposure to highly concentrated in-office bleaching gels (e.g. 38% HP for 45 minutes).

The reported changes include zones of partial necrosis of the coronal pulp tissue in lower incisor teeth, which have a low thickness of enamel and dentine and a relatively large dental pulp size. Similar changes were not seen in bleached premolar teeth in the same patients. Even in the more markedly affected lower incisor teeth, it appears that the pulp tissue recovers fully and returns to a normal structural organisation, with reversal of the damage and a return to normal after several days.37-39 These histological findings are linked to the fact that even when patients report “zingers” or intense tooth sensitivity during the first days after in-office bleaching, those symptoms subside over time, with the teeth remaining vital.40

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The lack of correlation between laboratory systems and the human clinical situation likely reflects the impossibility of reproducing all the parameters that determine how the human pulp-dentine complex will react to a chemical insult. The lack of similarity between animal studies of dental pulp histology and human studies is most likely due to the pulp-dentine complex of different species showing different responses to chemical insults, hence results in rodents and canines cannot be extrapolated directly to humans.41-43 Arguably, some of the most important issues with the high concentration HP products used for in office bleaching are the high potential for adverse effects for the dental soft and hard tissues.

Enamel surface erosion, softening and lower mineral content has been reported after use of some commercial HP gels designed for in-office bleaching.5-9,44 Use of an intense light source to warm the HP gel and facilitate its breakdown45-47 can improve the overall bleaching effect48-54 and this approach has become more common since the early 2000s. The benefits vary between products depending on which light-absorbing agents have been included in the gel. This explains why variations in the role and importance of light have been reported in the literature.55-59 Nevertheless, it is important to remember that excessive light exposure can cause heat-related stress to the dental pulp60-63 and increase pain sensations during in-office bleaching.64,65

Peroxy carboxylic acids as an alternative approach ased on the foregoing discussion, it is clear that conventional bleaching technologies based on HP and its derivatives come with a range of issues. All the concerns outlined above must be addressed when providing patient care with these products, to achieve both safety and effectiveness.

Ideally, going back to first principles, it would be desirable to use oxidant technologies that provide good cosmetic results when used for vital tooth bleaching, without damaging the dental hard and soft tissues, in a way that gives a timely clinical result, with fewer or no side effects, both at the time of treatment and with multiple or repeated treatments. As well, an alternative method that simplifies the treatment process would be desirable for both patients and clinicians.

Considering alternative oxidants, there are numerous compounds that contain oxygen and can serve as oxidants, but which have a structure completely unlike that of HP. Examples of the many categories of such compounds include dialkyl peroxides, diacyl peroxides, cyclic peroxides and peroxy carboxylic acids (PCA). Such compounds are used in industrial bleaching and the chemistry of each has been documented for over 100 years.

B

Key features of peroxy carboxylic acids for dental bleaching CA have a number of interesting characteristics which come about because the oxygen-to-oxygen single bond present in a PCA molecule is very easily broken, releasing an oxygen atom, which is then incorporated into the target molecule in a reaction known as epoxidation. No ROS are involved in the bleaching actions of PCA. The greater the electron density of the

P

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Figure 1. Typical reactions of phthalimidoperoxycaproic acid (PAP) with organic substrates, showing epoxidation outcomes where the terminal oxygen atom from PAP is inserted into the target molecule, thus altering its structure.

double bond in the target molecule, the more susceptible it is to this special type of attack from PCA. This unique chemical fact, which has been known for over 100 years, makes PCA ideal for attacking most molecules that cause discolouration in teeth, as these have aromatic rings or double bonds in their structure.

Another advantage of using PCA is that the epoxidation reaction occurs extremely quickly. This high level of reactivity is documented extensively in the organic chemistry and industrial bleaching literature.

One particular PCA known as phthalimidoperoxycaproic acid (PAP) has recently been used in dental bleaching products, as an alternative to the traditional approach based on HP and ROS. The oxidising action of PAP rapidly breaks down ring structures and conjugated double bonds in complex coloured molecules, thereby removing their ability to absorb light. These reactions are shown schematically in Figure 1.

When used in either at-home or in-office dental bleaching for vital teeth, PCA has a range of features that are clinically relevant.

As already noted, the oxidant chemistry of PCA such as PAP follows the epoxidation pathway, rather than using ROS. As a consequence of this, PAP does not cause lipid peroxidation of human cell membranes and thus does not cause irritation of the gingiva or other oral soft tissues.66 In other words, the substitution of PAP for HP eliminates the well-known risk of gingival burns from leakage of HP. Consequently, when undertaking in-office bleaching, there is no requirement to place a gingival barrier to protect the tissues. This gives a considerable time saving for the procedure.

PAP can be formulated with various mineral supplements to both conserve dental hard tissues during bleaching and to boost remineralisation. These include calcium-lactate-gluconate, as a source of calcium ions,66 or nano-hydroxyapatite as in the case of HiSmile PAP+®. The nano size of these particles provides an

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enormous surface area, leading to saturation of the fluid environment with apatite mineral. This prevents any dissolution (erosion) or softening of the enamel during bleaching. Independent laboratory studies of enamel surface features at the nano scale have shown that after exposure to PAP+ surface loss does not occur and that surface microhardness is maintained or enhanced (Figure 2 panels A and B). This contrasts with the effects of conventional HP and CP gels on enamel when used under exactly the same exposure conditions, which cause mineral loss. Other studies using scanning electron microscopy to assess surface change have shown that no degradation of the enamel surface occurs even after more extensive exposure to PAP bleaching gels (7 days x 15 minutes per day).67 The published literature on PAP-based approaches shows that they provide useful bleaching effects clinically and this is supported by laboratory studies using standardised assessments (Figure 2 panel C). Overall, despite PAP being a much larger molecule than HP (molecular weights 277.3 versus 34 grams per mole), PAP has a higher specific activity, with 5% PAP being approximately equivalent to 3% hydrogen peroxide and 12% PAP being equal to 8% hydrogen peroxide in terms of comparison of the bleaching effects that are achieved. The bleaching effects occur faster and are more consistent than with those from HP.66,67 Studies of performance of PAP in the clinical environment show that changes in tooth colour occur very quickly and are sustained at 24 hours after treatment with almost no relapse.66 This is partly because of the fact that the product does not cause mineral surface loss and hence there is no relapse from remineralisation. Adding to this, product formulations are designed to minimise dehydration of the teeth during bleaching, which reduces the rehydration component of rebound. The components of the gel that provide its viscosity and other properties (such as fillers, flavours and sweeteners) do not cause any change to the shade of teeth.66

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clinical | EXCELLENCE Finally and perhaps most importantly, clinical studies also show that PAP bleaching gels are tolerated well and do not cause the characteristic zingers which accompany the use of high concentration HP when used for in-office bleaching.67 With PAP bleaching gels, there are no zingers because there is no HP and ROS penetrating through to the pulp, which are the cause of the zinger response.

HiSmile PAP+ gel has a range of special characteristics, including enhanced stability and shelf life, making it suitable for at home bleaching in a gel with a neutral pH. Inclusion of nanoparticles of apatite mineral not only assist in maintaining the integrity of the tooth surface,68 but may also help reduce the formation of external stains on the freshly bleached tooth surface immediately after treatment.

As well as nanoparticles of hydroxyapatite, a readily soluble source of potassium ions is included in PAP+ gel, to prevent sensitivity, including from dehydration during treatment. Application of this gel to the teeth does not cause sensitivity, even if the material comes in contact with exposed root surfaces or exposed dentine.

The same active PCA ingredient in PAP+ gel can also be formulated at a higher concentration with an alkaline activator which raises the pH to potentiate the bleaching action, making it suitable for in-office bleaching (Figure 2 panel C). PAP+ gels can be activated using an LED array with a shorter wavelength of light than traditional composite curing lamps, which has a high photon energy and matches key absorbing characteristics of the stained molecules present in teeth, causing photodegradation of these.69,70

A 120 100 80 60 40 20 0 Water

B

n summary, the current literature identifies a number of caveats and concerns that need to be considered when commencing a course of bleaching treatment, either at-home or in-office. There are now options in terms of PCA as an alternative oxidant technology to HP. This article has provided an introduction to this alternative system and its unique chemical characteristics.

About the author Emeritus Professor Laurence J. Walsh AO is a specialist in special needs dentistry who is based in Brisbane, where he served for 36 years on the academic staff of the University of Queensland School of Dentistry, including 21 years as Professor of Dental Science and 10 years as the Head of School.

Since retiring in December 2020, Laurie has remained active in hands-on bench research work, as well as in supervising over 15 research students at UQ who work in advanced technologies and biomaterials and in clinical microbiology. Laurie has served as Chief Examiner in Microbiology for the RACDS for 21 years and as the Editor of the ADA Infection Control Guidelines for 12 years. His published research work includes over 330 journal papers, with a citation count of over 15,400 citations in the literature. Laurie holds patents in 7 families of dental technologies. He is currently ranked in the top 0.25% of world scientists.

Laurie was made an Officer of the Order of Australia in January 2018 and a life member of ADAQ in 2020 in recognition of his contributions to dentistry.

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PAP+

HP 6%

HP 35%

CP 35%

Change in surface microhardness

20 0 Water

PAP+

HP 6%

HP 35%

CP 35%

Water

PAP+

HP 6%

HP 35%

CP 35%

-20 -40 -60 -80 -100

Conclusions

I

Surface Erosion (in nm)

C

Mean shade change

20

15

10

5

0 Water

PAP+

HP 6%

HP 35%

CP 35%

Figure 2. Effects of HP, CP and PAP gels under identical conditions (6 x 10-minute exposures) when tested in the laboratory on bovine teeth. Panel A shows erosion of the surface in nanometres, while panel B shows changes in surface microhardness (right), with distilled water as a control. Note that the PAP gel did not cause surface erosion or a reduction in surface microhardness, unlike the other commercial products tested. Effects on teeth stained using complex mixtures of polyphenols are shown in panel C. PAP provided a greater bleaching effect on stains than HP or CP gels. Information presented in these graphs was calculated using data from independent research laboratory tests (Intertek, Cheshire, UK).

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clinical | EXCELLENCE References 1. Alkhatib MN, et al. Prevalence of self-assessed tooth discolouration in the United Kingdom. J Dent 2004;32:561–566.

2. Joiner A. Tooth colour: a review of the literature. J Dent 2004;32(Suppl. 1):3-12.

3. Joiner A. The bleaching of teeth: a review of the literature. J Dent 2006;34:412-419.

4. Dental Board of Australia. Guidance for registered dental practitioners: Using and supplying teeth whitening products. Fact sheet, 13 August 2021.

5. Borges AB, et al. Effect of hydrogen peroxide concentration on enamel color and microhardness.

Operative Dent 2015;40:96-101.

6. Azer SS, et al. Effect of home bleaching systems on enamel nanohardness and elastic modulus. J Dent 2009;37:185-190.

7. Azrak B, et al. Influence of bleaching agents on surface roughness of sound or eroded dental enamel specimens. J Esthet Restor Dent 2010;22:391-399.

8. Grazioli G, et al. Bleaching and enamel surface interactions resulting from the use of highly concentrated bleaching gels. Arch Oral Biol 2018;87:157-162.

9. D’Amario M, et al. Histomorphologic alterations of human enamel after repeated applications of a bleaching agent. Int J Immunopathol Pharmacol 2012;25:1021-1027.

10. Davidi MP, et al. The effect of a mild increase in temperature on tooth bleaching. Quintess Int 2008;39:771-775.

11. Eimar H, et al. Hydrogen peroxide whitens teeth by oxidizing the organic structure. J Dent 2012;40 (Suppl 2):e25-e33.

12. Bistey T, et al. In vitro FT-IR study of the effects of hydrogen peroxide on superficial tooth enamel.

J Dent 2007;35:325-330.

13. Kwon SR, Wertz PW. Review of the mechanism of tooth whitening. J Esthet Restor Dent 2015;27: 240-257.

14. Walsh LJ. Safety issues relating to the use of hydrogen peroxide in dentistry. Aust Dent J 2000;45:257-269.

15. Cooper JS, et al. Penetration of the pulp chamber by carbamide peroxide bleaching agents. J Endod 1992;18:315-317.

16. Rodrigues LM, et al. Permeability of different groups of maxillary teeth after 38% hydrogen peroxide internal bleaching. Braz Dent J 2009;20:303-306.

17. Marson F, et al. Penetration of hydrogen peroxide and degradation rate of different bleaching products.

Oper Dent 2015;40:72-79.

18. Cintra LTA, et al. Penetration capacity, color alteration and biological response of two In-office bleaching protocols. Braz Dent J 2016;27:169-175.

19. Briso ALF, et al. Transenamel and transdentinal penetration of hydrogen peroxide applied to cracked or microabrasioned enamel. Operative Dent 2014;39:166-173.

20. Camargo SEA, et al. Penetration of 38% hydrogen peroxide into the pulp chamber in bovine and human teeth submitted to office bleach technique. J Endod 2007;33:1074-1077.

21. Markowitz K. Pretty painful: why does tooth bleaching hurt? Med Hypoth 2010;74:835-840.

22. Caviedes-Bucheli J, et al. The effect of tooth bleaching on substance P expression in human of tooth bleaching on substance P expression in human dental pulp. J Endod 2008;34:1462-1465.

23. Costa CAS, et al. Human pulp responses to inoffice tooth bleaching. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:e59-e64.

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24. Seale NS, et al. Pulpal reaction to bleaching of teeth in dogs. J Dent Res 1981;60:948-953.

25. Seale NS, et al. Pulpal response to bleaching of teeth in dogs. Pediatr Dent 1985;7:209-214.

26. Cintra L T, et al. The number of bleaching sessions influences pulp tissue damage in rat teeth. J Endod 2013;39: 1576-1580.

27. Benetti F, et al. Hydrogen peroxide induces cell proliferation and apoptosis in pulp of rats after dental bleaching in vivo. Effects of the dental bleaching in pulp. Arch Oral Biol 2017;81:103-109.

28. Coldebella CR, et al. Indirect cytotoxicity of a 35% hydrogen peroxide bleaching gel on cultures of odontoblast-like cells. Braz Dent J 2009;20:267-274.

29. Trindade FZ, et al. Trans-enamel and trans-dentinal cytotoxic effects of a 35% H2O2 bleaching gel on cultured odontoblast cell lines after consecutive applications. Int Endod J 2009;42:516-524.

30. Soares DG, et al. Efficacy and cytotoxicity of a bleaching gel after short application times on dental enamel. Clin Oral Invest 2013;17:1901-1909.

31. Cintra LT, et al. The number of bleaching sessions influences pulp tissue damage in rat teeth. J Endod 2013;39:1576-1580.

32. Soares DG, et al. Responses of human dental pulp cells after application of a low-concentration bleaching gel to enamel. Arch Oral Biol 2015;60:1428-1436.

33. De Almeida LCA, et al. Color alteration, hydrogen peroxide diffusion, and cytotoxicity caused by in-office bleaching protocols. Clin Oral Invest 2015;19:673-680.

34. Soares DG, et al. Concentrations of and application protocols for hydrogen peroxide bleaching gels: Effects on pulp cell viability and whitening efficacy. J Dent 2014;42:185-198.

35. Soares DG, et al. Effective tooth bleaching protocols capable of reducing H2O2 diffusion through enamel and dentine. J Dent 2014;42:351-358.

36. Kina JF, et al. Response of human pulps after professionally applied vital tooth bleaching. Int Endod J 2010;43:572-580.

37. de Souza Costa CA, et al. Human pulp responses to in-office tooth bleaching. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2010;109:59-64.

38. Roderjan DA, et al. Histopathological features of dental pulp tissue from bleached mandibular incisors.

J Mat Sci Eng B 2014;4:178-185.

39. Roderjan D A, et al. Response of human pulps to different in-office bleaching techniques: Preliminary findings. Braz Dent J 2015;26:242-248.

40. Martin J, et al. Dentin hypersensitivity after teeth bleaching with in-office systems. Randomized clinical trial. Am J Dent 2013;26:10-14.

41. Wennberg A et al. Biological evaluation of dental restorative materials – a comparison of different methods. J Biomed Mat Res 1983;17:23-36.

42. Browne RM. Animal tests for biocompatibility of dental materials – relevance, advantages and limitations. J Dent 1994;22:S21-S24.

43. Costa CAS, et al. Biocompatibility of resin-based materials used as pulp-capping agents. Int Endod J 2003;36:831-839.

44. Al-Salehi SK, et al. Effect of 24 h nonstop H2O2 concentration on bovine enamel and dentine mineral content and microhardness. J Dent 2007;35:845-850.

45. Baxendale J, Wilson J. The photolysis of hydrogen peroxide at high light intensities. Trans Faraday Soc 1957;52:344-356.

46. Garcia Einschlag F, et al. Effect of temperature on hydrogen peroxide photolysis in aqueous solution.

J Photochem Photobiol A Chem 1997;110:235-242.

47. Haywood VB. In-office bleaching: lights applications, and outcomes. Curr Pract 2009;16:3-6.

48. Ontiveros JC. In-office vital bleaching with adjunct light. Dent Clin North Am 2011;55:241-253.

49. Tavares M, et al. Light augments tooth whitening with peroxide. J Am Dent Assn 2003;134:167-175.

50. Luk K, et al. Effect of light energy on peroxide tooth bleaching. J Am Dent Assn 2004;135:194-201.

51. Sulieman M, et al. Comparison of three inoffice bleaching systems based on 35% hydrogen peroxide with different light activators. Am J Dent 2005;18:194-197.

52. Ziemba SL, et al. Clinical evaluation of a novel dental whitening lamp and light-catalyzed peroxide gel. J Clin Dent 2005;16:123-127.

53. Bennett Z, Walsh LJ. Efficacy of LED versus KTP laser activation of photodynamic bleaching of tetracycline-stained dentine. Lasers Med Sci 2015;30:1823-1828.

54. De Moor RJG, et al. Insight into the chemistry of laser-activated bleaching. Scientif World J 2015; 2015:650492.

55. Marson FC, et al. Clinical evaluation of inoffice dental bleaching treatments with and without the use of light-activation sources. Operative Dent 2008;33:15-22.

56. Calatayud JO, et al. Clinical efficacy of a bleaching system based on hydrogen peroxide with or without light activation. Eur J Esthetic Dent 2010;5:216-224.

57. Buchalla W, Attin T. External bleaching therapy with activation by heat, light or laser – a systematic review. Dent Mat 2007;23:586-596.

58. Alomari Q, El Daraa E. A randomised clinical trial of in-office dental bleaching with or without light activation. J Contemp Dent Pract 2010;11:E017-024.

59. Gurgan S, et al. Different light-activated in-office bleaching systems: a clinical evaluation. Lasers Med Sci 2010;25:817-822.

60. Zach L, Cohen G. Pulp response to externally applied heat. Oral Surg Oral Med Oral Pathol 1965;19:515-530.

61. Seale NS, et al. Pulpal reaction to bleaching of teeth in dogs. J Dent Res 1981;60:948-953.

62. Baik JW, et al. Effect of light enhanced bleaching on in vitro surface and intrapulpal temperature rise. J Esthet Restor Dent 2001;13:370-378.

63. Eldeniz AU, et al. Pulpal temperature rise during light-activated bleaching. J Biomed Mat Res B: Appl Biomat 2005; 72:254-259.

64. Kossatz S, et al. Effect of light activation on tooth sensitivity after in-office bleaching. Operative Denty 2011;36:251-257.

65. He L-B, et al. The effects of light on bleaching and tooth sensitivity during in-office vital bleaching: A systematic review and meta-analysis. J Dent 2012;40:644-653.

66. Bizhang M, et al. Effectiveness of a new nonhydrogen peroxide bleaching agent after single use - a double-blind placebo-controlled short-term study. J Appl Oral Sci 2017;25(5):575-584.

67. Qin J, et al. A bio-safety tooth-whitening composite gels with novel phthalimide peroxy caproic acid. Composites Commun 2019;13:107-111.

68. Kim YS, et al. Effect of nano-carbonate apatite to prevent re-stain after dental bleaching in vitro. J Dent 2011;39:636-642.

69. Zanin F. Recent advances in dental bleaching with laser and LEDs. Photomed Laser Surg 2016;34:135-136.

70. Kury M, et al. Effect of violet LED light on inoffice bleaching protocols: a randomized controlled clinical trial. J Appl Oral Sci 2020;28:e20190720.

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clinical | EXCELLENCE

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CPD

Optimising oral health in frail older people

By Alan Deutsch and Emma Jay

M

ost oral and dental problems in frail older people may not be obvious to relatives and health professionals. Older people do not see dentists regularly but receive regular care from medical and nursing professionals, so collaboration with dentists is important.

This is especially the case in residential aged care. Improved oral health outcomes are achievable using an interdisciplinary approach involving GPs, dentists, oral health therapists, dental prosthetists and nurses trained in oral health.

Relationship between oral and systemic health here is a link between poor oral health and systemic disease.

There are correlations between adequate mastication and activities of daily living, nutritional status and quality of life.

A significant association exists between the severity of periodontal disease, increasing tooth loss and carotid artery plaque.1 This may increase all-cause mortality in cardiovascular disease including ischaemic stroke.2 Chewing increases regional neural activity and cerebral blood flow.3,4 The number of teeth lost may be a predictor of cognitive decline and dementia.5-7 The bacteria that cause periodontal disease have been implicated in Alzheimer’s disease.8 There is an association between oral health and respiratory disease.9 Randomised controlled trials show that improved oral hygiene reduces the progression or occurrence of respiratory diseases and death from pneumonia among high-risk older adults living in residential care.10 Diabetes increases the risk for periodontitis. Periodontal inflammation negatively affects glycaemic control causing systemic complications. Severe periodontitis increases the risk of cardiorenal mortality 3.2 times. Periodontal treatment and better oral hygiene can improve metabolic control.11

T

The importance of saliva ormal salivary function is essential in speech, digestion and swallowing. Saliva has antimicrobial activity and prevents decay and tooth wear. In healthy people, stimulated saliva has a high serous volume with higher bicarbonate buffering concentrations to neutralise mouth, food and plaque acids compared to resting saliva. High flow volumes are essential for effective buffering capacity, clearance of glucose and bacteria and swallowing.

N

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Summary There is a link between oral health and systemic health.

Conditions such as dementia and pneumonia are associated with poor oral health. n Frail older people receive regular care from medical and nursing staff but tend not to see dentists regularly or only seek treatment when there is a dental problem. Collaboration between dentists and other health professionals is therefore increasingly important. n Oral health should be assessed regularly. This enables early referral to a dentist. n Anticholinergic drugs, particularly in polypharmacy, can have a profound deleterious effect on salivary function and oral health. A medication review may enable the anticholinergic burden to be reduced. n In addition to regular brushing, oral preventive products may be appropriate in frail older people. n

In frail older people with decreased salivary function and poor oral hygiene, teeth may rapidly demineralise when not in a supersaturated solution of calcium and phosphate ions provided by saliva. Teeth will also decay more rapidly as mouth pH is unable to return to safe values due to a lack of buffering capacity, particularly if there is frequent snacking on sweet foods and drinks.

Salivary gland hypofunction and dry mouth Ps should be encouraged to ask patients about a dry mouth.

The prevalence of salivary gland hypofunction (measurable decrease in salivary flow) and xerostomia (subjective feeling of dry mouth) increases with age, the number of chronic conditions and is strongly associated with drugs. The prevalence of xerostomia can be over 50% for people taking more than five drugs and it has marked effects on oral health and quality of life.

Hyposalivation can significantly impact activities of daily living such as speaking, eating and sleeping. It may cause tingling, a decreased sense of taste, halitosis and difficulty in wearing dentures. It can increase the risk of opportunistic infections such as Candida albicans. Low saliva flow rates correspond to lower mucosal wetness and increase pathogenic aciduric microorganisms in the oropharynx, mouth and dental plaque (which can be inhaled).

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Figure 1. Root caries. Advanced root caries involving the nerve and extending under the gumline. Crowns will snap off to leave root stumps. Visual examination alone may not be able to detect decay under the gumline and in the back of the mouth.

Figure 3. Infected root stumps. Multiple roots stumps with infections in the bone in a patient with dementia. This is a common finding and removing all teeth will require a general anaesthetic.

Figure 2. Tooth decay. Decaying teeth in a relatively clean mouth of a person with dementia. Salivary gland hypofunction may be involved in the progression of decay.

tooth. Exposed nerves and root stumps, even when symptom free, act as wicks for oral bacteria to infect bone. This can cause multiple chronic dental abscesses adding to the inflammatory burden of the patient.

Treatment may require hospitalisation to remove teeth due to recurring dental infections, when there is a lack of cooperation as in dementia or delirium, or when the airway and swallowing may become compromised during dental procedures (Figure 3).

Silver fluorides are potent biocides that can prevent and stop caries.14 They also improve gingival health when applied topically to susceptible teeth every 3-6 months. Drilling is often not required so applications are non-threatening and ideal for frail or fearful patients showing challenging behaviours.

Symptom-free chronic infections in bone, arising from infected nerves or from periodontitis, are common findings on dental radiographs but may not be obvious on a visual examination. If untreated these infections can complicate medical conditions and future management.

Drugs can affect oral health Tooth decay in older people ooth decay is manageable if treated promptly so early referral is important. Root surface decay is common in older people (Figures 1 and 2). It is more difficult to detect than decay affecting the crowns of the teeth (coronal caries) and progresses much more rapidly. In 10 Sydney residential aged-care facilities, 46% of residents (mean age 86.9 years) had 1-3 decayed teeth and 7% had more than four decayed teeth on entry.12 In another study of 19 facilities in Melbourne, 68% of residents had coronal caries (mean 2.6) and 77% had root caries (mean 5).13 Tooth loss has further effects on nutrition, systemic health, quality of life and the ability to socialise. Every effort should be made to prevent decay progressing to the pulp (nerve) of the

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significant association exists between prescription medicines, saliva function and rapidly progressing multiple decaying teeth.15 Many drugs prescribed for older patients have anticholinergic activity. These may cause a marked decrease in saliva flow as they prevent parasympathetic (cholinergic) activity at the muscarinic receptors in salivary glands.16 Polypharmacy is common in older people.17 Different classes of drugs have different levels of anticholinergic activity and can add to the overall anticholinergic burden. In general, medicines for urinary incontinence, antidepressants and antipsychotics have the greatest effects and are significantly associated with xerostomia and salivary gland hypofunction.18-21 In complex cases, a medication review with a pharmacist may be appropriate.

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clinical | EXCELLENCE Box 1. Maintaining oral care in older people according to risk Healthy, robust patients

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se fluoride toothpaste containing 1450 parts per million (most toothpastes), twice daily. Fluoride prevents decay and remineralises teeth. Fluoride binds calcium, forming fluorapatite which dissolves at a lower pH. Use a soft toothbrush. Brushing is very important to mechanically remove biofilm from teeth, gums, tongue and all denture surfaces.

Use an interproximal brush to clean between teeth.

To clean dentures, use mild soap, white vinegar (dilute 1:4 to remove calcific deposits) or cleanser. Leave dentures out at night to dry. Disinfect with commercial denture cleanser 1-2 times per week. Ensure denture cleanser is suitable for plastic or part metal dentures.

High-risk patients

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void mouthwashes or swabs containing alcohol, hydrogen peroxide, sodium bicarbonate, lemon and glycerin. Avoid confectionary with citric acid and sweet sticky foods. Discourage fruit juices, sugary drinks, caffeine, and frequency of snacking.

Encourage eating of milk and cheese.

Ensure adequate hydration for saliva production - 2-2.5 L fluid a day (minimum 1.6 L/day), frequently and after meals. Note that older people may have an altered urge to drink and may have difficulty swallowing.

Use pea size amounts of high-fluoride toothpaste (5000 parts per million), 1-2 times a day. This remineralises teeth and prevents or slows decay. Do not swallow. Spit but do not rinse so product stays on teeth.

Casein phosphopeptide amorphous calcium phosphate cream remineralises teeth and is used as an adjunct after fluoride. Use 1-2 times a day. Add water to cream if mouth is dry. Leave a small amount on the teeth and do not rinse. Not suitable if the patient has a milk protein allergy, but can be used if lactose intolerant.

Use sugar-free gum 4-6 times a day after meals. Chewing neutralises mouth and plaque acids, aids in glucose clearance and maintains saliva gland function. Excessive consumption may have a laxative effect.

Frequently use artificial saliva and high pH oral lubricant (should not contain citric acid) on all oral tissues and under dentures for temporary symptomatic relief of dry mouth. Use a water-based moisturiser on lips.

The anticholinergic burden may be minimised by considering the following: • Order a medication review and deprescribe when possible.22 • Switch to a drug with less anticholinergic activity.19-21 • Reduce the dose as anticholinergic effects are dose related.

• Administer drugs during the day rather than at night. Resting saliva is lowest at night and higher during the day.

• Divide the dose into smaller doses throughout the day.

• Check for adverse drug interactions that cause increased drug concentrations due to inhibition of drug metabolism or clearance.

Commonly used drugs with adverse oral effects ral adverse drug reactions are common, varying in nature and severity.23 The corticosteroid inhalers used in asthma and chronic obstructive pulmonary disease can cause pharyngitis, oral mucositis (ulcerations) and candidiasis, particularly in the elderly. The inhalers used to relieve acute asthma, such as salbutamol and terbutaline, are beta2 agonists. They reduce saliva flow and lower its pH causing increased decay rates and tooth wear.

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Very high-risk patients (also use same products as with high-risk patients)

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on-staining chlorhexidine gluconate toothpaste (0.05 or 0.12%) at night can be used long term in older people and has prolonged, broad-spectrum antiseptic activity which reduces oral biofilm. Spit out but do not rinse.

In some products increased concentrations of chlorhexidine gluconate can stain teeth (reversible), alter taste and increase calculus (tartar) formation. Use 0.5% gel in localised areas or rinse with 0.2% short term for acute infections. As chlorhexidine is deactivated by fluoride in toothpastes, use high-fluoride toothpaste in the morning and chlorhexidine in the evening.

Palliative care patients

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pply water-based lip moisturiser (not petroleum-based). Use spray bottle applications for oral lubricants and alcohol and stain-free 2% chlorhexidine.

Clean teeth with low-strength sodium bicarbonate oral swabs, 2% chlorhexidine gluconate oral swabs (alcohol free), or both, to improve oral health and quality of life.

These interventions can be delivered by nurses or carers after meals and as needed.

Additional adverse reactions are taste alterations, gingivitis and gingival enlargement.24 Patients should be instructed to rinse and gargle with water after using their inhalers. They should also use a daily fluoride rinse.

Bruxism and dyskinesia are associated with the selective serotonin reuptake inhibitors and antipsychotic drugs. Metoclopramide may be associated with tardive dyskinesia which may persist and be irreversible, especially in older people. Uncontrolled movements of the tongue and lips make denture wearing exceedingly difficult.23 Calcium channel blockers, valproate, phenytoin and cyclosporin can cause gingival enlargement. Anticoagulants can cause bleeding from the gums. Drugs associated with lichenoid sensitivity reactions are non-steroidal anti-inflammatory drugs and antihypertensives, including beta blockers, ACE inhibitors and diuretics.24 Cutaneous lichenoid hypersensitivity reactions may resemble oral lichen planus.

Rarely, antiresorptive drugs such as bisphosphonates and denosumab can cause osteonecrosis of the jaw. This can be spontaneous from denture trauma, or occur after extractions due to poor bone healing. It is advisable for GPs to refer patients for

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clinical | EXCELLENCE Box 2. Resources to support oral health in older people Oral health care domain: Care of older people toolkit

South Australian Dental Service Contains links to: Staff portfolio, Professional portfolio, Dental treatment pathway flow chart

Oral Health Assessment Tool video South Australia Health

Oral health care for older people in NSW: carer support package NSW Health

Instruction video on denture care Dental Rescue, NSW

Anticholinergic Burden (ACB) Score Calculator

By Rebecca King and Steve Rabino ACB calculator Anticholinergic medicines and scores Reducing ACB risk

The anticholinergic burden: therapeutic brief Veterans’ MATES, Department of Veterans’ Affairs

Instruction video on assisted brushing in residential aged-care facilities Dental Rescue, NSW

dental examinations with dental radiographs before starting bisphosphonates or denosumab, before cardiac or major surgery and before head and neck radiotherapy. Radiotherapy adversely affects bone healing at extraction sites and markedly decreases saliva function resulting in increased decay rates.

Chemotherapy drugs, such as 5-fluorouracil, cisplatin, methotrexate and hydroxyurea can cause painful oral ulcers and ulcerative mucositis.24

Patient assessment and referral Ps and residential aged-care nurses should be encouraged to look into patients’ mouths to assess oral health. Use a strong light (preferably a headlight) with gauze to wipe teeth and gums and two dental mirrors. One mirror is used to retract lips and tongue and the other to visualise soft tissues and teeth.

These aids greatly assist screening for decaying teeth, ulcers, dental infections and oral cancers. Most oral ulcerations either heal themselves or resolve after simple dental intervention within 2-3 weeks. Any area that persists longer than three weeks may be suspicious.

There is an Oral Health Assessment Tool that can be used

by GPs, residential aged-care nurses and allied health professionals, but requires some training to use. It is a validated tool to detect early oral problems and provides guidance on when to refer to a dentist. There are 8 categories to assess - lips, tongue, gums and tissues, saliva, natural teeth, dentures, oral cleanliness and pain. They are scored as healthy, changes, unhealthy or needing referral.

Referrals by GPs to dentists should be routine and ideally part of over 75 years of age health assessments or chronic disease management plans. It is often difficult for dentists to obtain a full medical history and medicines list from older patients.

Dentists may need to phone GPs to ask about co-morbidities and the patients’ medicines, particularly anticoagulant drugs.

Dental referral is also encouraged before receiving a residential or home-care package. The better someone’s oral health is before entering a facility, the better their long-term systemic and oral health outcomes will be.

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Risk indicators and risk stratification Patients are evaluated for the risk of: • Oral infections and pain from decaying teeth, root stumps and periodontitis.

• Aspiration pneumonia from salivary gland hypofunction together with poor swallowing ability and poor oral hygiene.

• Adequate nutrition from poor chewing ability and denture stability, pain.

• Psychosocial problems and depression related to poor anterior aesthetics, poor chewing ability or pain.

Assessing a person’s degree of risk can help to guide patient management and referral to a dentist (Box 1).

Useful oral health screening questions for older people able to self-report are:25 • Have you had pain in your mouth while chewing?

• Have you lost any fillings, or do you need a dental visit for any other reason?

• Have you avoided laughing or smiling?

• Have you had to interrupt meals due to dental pain, unstable dentures that hurt, difficulty swallowing, mouth being too dry, inappropriate diet or embarrassment?

Older people who may not be able to self-report oral health issues may be at very high risk when three or more of these problems occur together: • Not seen a dentist for two or more years.

• High-dependency care needs (e.g. requires assistance for activities of daily living, such as toileting, weak grip strength) and unable to physically brush their teeth.

• Cognitive impairment which interferes with their ability to brush their own teeth.

• Polypharmacy including medicines with anticholinergic effects.

• A sublingual resting saliva pH* below 5.8 (healthy pH 6.8-7.8, acidic 6-6.6, highly acidic <5-5.8), or difficulty wetting a disposable dental sponge micro-brush placed under the tongue for two seconds to wet pH paper outside the mouth.26

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clinical | EXCELLENCE Table 1. Oral care product list (Adapted from reference 27) Purpose Product Brand Remineralise teeth and prevent or slow decay

High-fluoride toothpaste (5000 parts per million)

Casein phosphopeptide GC Tooth Mousse amorphous calcium phosphate cream

Cleaning between teeth

Interproximal brushes

Ask pharmacist for advice

Denture maintenance

Liquid soap

Ask pharmacist for advice

Denture cleansers

Disinfect and clean dentures

White vinegar

Dissolves calcific deposits

Stabilising poor-fitting Denture adhesive dentures that cause cream/powder/strips ulcers and sore spots

3M Clinpro 5000 (3M) Neutrafluor 5000 (Colgate)

Comment Do not swallow, leave on teeth Use 1-2 times a day Leave on teeth Adjunct after fluoride

Brush all denture surfaces

Biotene Dry Mouth Denture Grip Reline or remake dentures Polident For other products ask pharmacist

Temporary palliative For artificial saliva, use Ask pharmacist for advice relief of dry mouth high pH oral lubricant

without citric acid

Delivered via oral spray, oral rinse, gel, swabs or dissolving tablets Before bed / Before eating / On and under dentures / As needed

Bleeding gums (gingivitis) Brush gums with Curasept 0.05 or 0.12%

chlorhexidine

gluconate toothpaste

If unable to brush use non-staining, alcohol-free products Long-term use Do not use chlorhexidine with toothpastes containing sodium lauryl sulphate or fluoride

Hydration Water

2-2.5 L/day Stop sweet, sticky, fruity drinks

Saliva function Sugar-free gum

Improves saliva function 4 times a day Excessive use may cause diarrhoea

Ulcers or denture sore spots

Warm saline

3-4 times a day

Chlorhexidine Curasept ADS 350 gluconate gel 0.5%

Short-term use Localised topical area

Anti-inflammatory

mouth gel or paste

Difflam Ora-Sed Jel Kenalog in Orabase (steroid)

Oral health in residential facilities entists tend to treat residents only for acute dental problems and not for routine preventive care. Frail older people who cannot maintain their own oral health require daily preventative care best delivered by nurses and carers trained in assisted brushing. This should be supported by regular professional cleanings and fluoride applications by oral health therapists. Access to periodic assessments and regular oral care should be emphasised.

It would help if the person’s dentist is included in the admission paperwork when they go into an aged-care facility. Currently there is no protocol to notify dentists when their patients enter residential care. Some dental records, particularly dental implant specifications and oral health assessments, including dental X-rays, should

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be linked into medical records and transferred to the patient’s residential aged-care facility. It is important for the dentist to communicate about treatment with the care team at the aged-care facility. For example, aggressive treatment of oral cancers may not be advisable for the very frail. Palliative care may be more appropriate involving only adequate analgesia and a tailored diet.

Maintaining oral care reventative oral products can help to reduce oral biofilm, remineralise teeth and improve saliva function and should be tailored to individual risk (Box 1). Many patients and carers often have difficulty understanding the use of multiple products so a simple handout for them is helpful with the appropriate

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clinical | EXCELLENCE products circled (Table 1).27 Using the links shown in Box 2, including the Oral Health Assessment Tool, raises the importance of oral health in a residential facility. There are practical training guides to help nursing staff gain the knowledge and confidence to assess residents and carry out preventive interventions.28

Conclusion Ps are encouraged to look into the mouths of their patients to make oral health assessments and assess dental risk based on frailty and dependency in order to make early referrals to a dentist when required. Topical interventions are recommended based on risk and can prevent tooth decay. Polypharmacy is common in frail older people and some drugs can reduce saliva production. GPs should therefore prescribe drugs with the lowest anticholinergic affects to better maintain saliva function and oral health.

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* To test sublingual resting saliva, place a disposable dental sponge micro-brush under the tongue for two seconds. It is normal to be able to wet pH paper. If the pH paper cannot be made wet, it is likely the patient has salivary gland hypofunction or lacks adequate hydration at rest. Full saliva testing of frail or fearful older people may not be practical. The benefits of saliva testing in this cohort have not been assessed in a randomised controlled trial. However, assessment of sublingual resting saliva pH offers a simple, quantitative and repeatable test of mouth acidity and quality of resting saliva, and can be performed in general practice and residential aged-care settings.26

About the authors A general dental practitioner in Sydney experienced in aged care dentistry, Dr Alan Deutsch is a member of the Oral Health Reference Group, Centre for Research and Education on Ageing (CERA) and is completing a Masters of Philosophy (Dentistry) by research. Dr Deutsch is the lead researcher in a collaborative pilot study between the Dementia Collaborative Research Centre (DCRC) NSW University, CERA Sydney University and Montefiore Nursing Home. He has a special interest in the effects of dry mouth and in the use of silver fluorides in the elderly.

Dr Emma Jay is a specialist in special needs dentistry. She has completed further study in autism, mental health and intellectual disabilities through Sydney University and was appointed staff specialist Sydney Local Health District from 2012-15. Dr Jay is a clinical tutor and lecturer in Special Needs Dentistry for the University of Sydney, DMD program. Her interests are in behaviour and pain management for local anaesthesia and is the principle author of a study on treatment planning in special needs dentistry.

Originally published in Australian Prescriber Vol 44 : No 5 : October 2021 for the benefit of all healthcare practitioners.

Reprinted with permission.

Further reading Australian Institute of Health and Welfare. Older Australia at a glance. AIHW: Canberra; 2018. https://doi.org/10.25816/5ec5bda5ed178

References 1. Desvarieux M, Demmer RT, Rundek T, BodenAlbala B, Jacobs DR Jr, Papapanou PN, et al.; Oral Infections and Vascular Disease Epidemiology Study (INVEST). Relationship between periodontal disease, tooth loss, and carotid artery plaque: the Oral Infections and Vascular Disease Epidemiology Study (INVEST). Stroke 2003;34:2120-5. https:// doi.org/10.1161/01.STR.0000085086.50957.22 2. Holmlund A, Holm G, Lind L. Number of teeth as a predictor of cardiovascular mortality in a cohort of 7,674 subjects followed for 12 years. J Periodontol 2010;81:870-6. https://doi.org/10.1902/ jop.2010.090680 3. Weijenberg RA, Scherder EJ, Lobbezoo F. Mastication for the mind--the relationship between mastication and cognition in ageing and dementia.

Neurosci Biobehav Rev 2011;35:483-97. https://doi. org/10.1016/j.neubiorev.2010.06.002 4. Kim HY, Jang MS, Chung CP, Paik DI, Park YD, Patton LL, et al. Chewing function impacts oral health-related quality of life among institutionalized and community-dwelling Korean elders. Community Dent Oral Epidemiol 2009;37:468-76. https:// doi.org/10.1111/j.1600-0528.2009.00489.x 5. Cerutti-Kopplin D, Feine J, Padilha DM, de Souza RF, Ahmadi M, Rompré P, et al.

Tooth loss increases the risk of diminished cognitive function: a systematic review and metaanalysis. JDR Clin Trans Res 2016;1:10-9. https:// doi.org/10.1177/2380084416633102 6. Stein PS, Desrosiers M, Donegan SJ, Yepes JF, Kryscio RJ. Tooth loss, dementia and neuropathology in the Nun study. J Am Dent Assoc 2007;138:1314-22. https://doi.org/10.14219/jada. archive.2007.0046 7. Takeuchi K, Ohara T, Furuta M, Takeshita T, Shibata Y, Hata J, et al. Tooth loss and risk of dementia

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in the community: the Hisayama Study. J Am Geriatr Soc 2017;65:e95-100. https://doi.org/10.1111/ jgs.14791 8. Dominy SS, Lynch C, Ermini F, Benedyk M, Marczyk A, Konradi A, et al. Porphyromonas gingivalis in Alzheimer’s disease brains: evidence for disease causation and treatment with small-molecule inhibitors. Sci Adv 2019;5:eaau3333. https:// doi.org/10.1126/sciadv.aau3333 9. Azarpazhooh A, Leake JL. Systematic review of the association between respiratory diseases and oral health. J Periodontol 2006;77:1465-82. https:// doi.org/10.1902/jop.2006.060010 10. Yoneyama T, Yoshida M, Ohrui T, Mukaiyama H, Okamoto H, Hoshiba K, et al.; Oral Care Working Group. Oral care reduces pneumonia in older patients in nursing homes. J Am Geriatr Soc 2002;50:430-3. https://doi.org/10.1046/ j.15325415.2002.50106.x 11. Casanova L, Hughes FJ, Preshaw PM. Diabetes and periodontal disease: a two-way relationship.

Br Dent J 2014;217:433-7. https://doi.org/10.1038/ sj.bdj.2014.907 12. Wright FA, Law G, Chu SK, Cullen JS, Le Couteur DG. Residential age care and domiciliary oral health services: Reach-OHT-The development of a metropolitan oral health programme in Sydney, Australia. Gerodontology 2017;34:420-6. https:// doi.org/10.1111/ger.12282 13. Silva M, Hopcraft M, Morgan M. Dental caries in Victorian nursing homes. Aust Dent J 2014;59:321-8. https://doi.org/10.1111/adj.12188 14. Deutsch A. An alternate technique of care using silver fluoride followed by stannous fluoride in the management of root caries in aged care. Spec Care Dentist 2016;36:85-92. https://doi.org/10.1111/ scd.12153

15. Moffat AK, Apajee J, Pratt NL, Blacker N, Le Blanc VT, Roughead EE. Use of medicines associated with dry mouth and dental visits in an Australian cohort. Aust Dent J 2020;65:189-95. https://doi.org/10.1111/adj.12750 16. Wolff A, Joshi RK, Ekström J, Aframian D, Pedersen AM, Proctor G, et al. A guide to medications inducing salivary gland dysfunction, xerostomia and subjective sialorrhea: a systematic review sponsored by the World Workshop on Oral Medicine VI. Drugs R D 2017;17:1-28.

17. Hilmer SN, Gnjidic D. Prescribing for frail older people. Aust Prescr 2017;40:174-8. https://doi. org/10.18773/austprescr.2017.055 18. Tan EC, Lexomboon D, Sandborgh-Englund G, Haasum Y, Johnell K. Medications that cause dry mouth as an adverse effect in older people: a systematic review and metaanalysis. J Am Geriatr Soc 2018;66:76-84. https://doi.org/10.1111/jgs.15151 19. Lertxundi U, Domingo-Echaburu S, Hernandez R, Peral J, Medrano J. Expert-based drug lists to measure anticholinergic burden: similar names, different results. Psychogeriatrics 2013;13:17-24. https://doi.org/10.1111/j.1479-8301.2012.00418.x 20. Salahudeen MS, Duffull SB, Nishtala PS. Anticholinergic burden quantified by anticholinergic risk scales and adverse outcomes in older people: a systematic review. BMC Geriatr 2015;15:31. https://doi.org/10.1186/s12877-015-0029-9 21. Boustani M, Campbell N, Munger S, Maidment I, Foxet C. Impact of anticholinergics on the aging brain: a review and practical application. Aging Health 2008;4:311-20. https://doi. org/10.2217/1745509X.4.3.311 22. Liacos M, Page AT, Etherton-Beer C. Deprescribing in older people. Aust Prescr 2020;43:114-20. https://doi.org/10.18773/austprescr.2020.033

23. Teoh L, Stewart K, Moses G. Where are oral and dental adverse drug effects in product information? Int J Pharm Pract 2020;28:591-8. https://doi. org/10.1111/ijpp.12650 24. Yuan A, Woo SB. Adverse drug events in the oral cavity. Oral Surg Oral Med Oral Pathol Oral Radiol 2015;119:35-47. https://doi.org/10.1016/j. oooo.2014.09.009 25. Slade GD. Oral health for older people: evaluation of the South Australian Dental Service Project.

Population Oral Health Series No. 6. Canberra: Australian Institute of Health and Welfare, and the Australian Research Centre for Population Oral Health; 2007. https://www.aihw.gov.au/reports/ dental-oral-health/oral-health-older-peoplesadental-service-project/contents/table-of-contents [cited 2021 Jul 13] 26. Walsh LJ. Clinical aspects of salivary biology for the dental clinician. Int Dent African Ed 2007;2:16-30. http://www.moderndentistrymedia. com/jan_feb2012/walsh.pdf [cited 2021 Jul 13] 27. South Australian Dental Service. Better oral health in residential care: professional portfolio: education and training program.

SA Health; Adelaide; 2008. www.sahealth. sa.gov.au/wps/wcm/connect/public+content/ sa+health+internet/clinical+resources/clin ical+programs+and+practice+guidelines/ older+people/care+of+older+people+toolkit/ oral+health+care+domain++care+of+older+people+toolkit [cited 2021 Jun 25] 28. Deutsch A, Siegel E, Cations M, Wright C, Naganathan V, Brodaty H. A pilot study on the feasibility of training nurses to formulate multicomponent oral health interventions in a residential aged care facility. Gerodontology 2017;34:469-78. https://doi.org/10.1111/ger.12295

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case report

Immediate and non-central implant placement in a molar root socket: implant crown with cantilever design

By Marina Siegenthaler, Sven Mühlemann, Ronald E. Jung

Figure 1. Initial situation - intraoral occlusal image of lower molar (36) presenting caries root.

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Figure 2. Intraoral occlusal image of lower molar (36) with missing crown.

he following clinical case report describes a successful immediate implant in a molar root socket using a Straumann® TLX Implant.

The implant design facilitated the achievement of primary stability without guided surgery and meeting the patient’s expectations, who was seeking to reduce the number of her visits to the clinic.

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Figure 3. Initial situation - periapical radiograph showing a molar (36) with interradicular and periapical infection.

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Figure 4. Cleansed socket with intact socket walls and septum after gentle extraction of molar roots by flap elevation.

Figure 5. Extraction of the remaining tooth in 3 fragments after sectioning.

Figure 6. Sequential implant site preparation: pilot drill into the mesial tooth socket.

Figure 7. Immediate implant placement into the mesial root socket (Straumann TLX SP, 4.5 RT; length: 12mm).

Treatment planning Figure 8. Fixation of healing cap according to the gingival height and application of bone substitute material into infrabony defects and distal root socket.

Initial situation systemically healthy 37-year-old female patient complaining of discomfort on the left side of the lower jaw presented to the Center of Dental Medicine, University of Zurich. She was seeking a dental treatment that would take less time and cost less money, with a reduced number of surgical interventions. The intraoral examination revealed root caries and a missing crown on tooth 36 (Figures 1-2). The radiographic examination showed a root canal therapy with a periapical lesion around the mesial root (Figure 3). The patient presented with bone type 2 and no anatomical defects. Oral hygiene was good.

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iscussion of the advantages, concerns and alternative treatment solutions with the patient, followed by collective and collaborative decision-making, was essential for a successful treatment plan that met our patient’s needs.

The patient’s history and expectations were considered and the decision was made to perform an immediate implant placement with a single crown with cantilever design.

The rationale of the treatment plan and steps included: • Molar tooth extraction preserving 2-3 root sockets; • Immediate implant placement in the mesial socket; • Use of a TLX implant to ensure the primary stability in the socket walls and optimal soft tissue behaviour; • Filling of gaps and remaining sockets using a xenogeneic graft material; • Use of a healing cap that allows the soft tissue contours to be preserved; and • Single crown with cantilever design to facilitate effective oral hygiene;

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Figure 9. Adaptive single and cross sutures without application of a protective membrane onto the bone substitute material.

Figure 10. Periapical radiograph confirming of implant position with healing cap in place.

Figure 11. Healing 1 week post implantation presenting healthy tissues.

Figure 12. Healing 1 week post implantation - post suture removal.

Surgical procedure he patient underwent local infiltration anesthesia (articaine 4% with epinephrine 1:100,000) and the inferior alveolar left nerve was blocked. An intrasulcular, supracrestal incision around tooth 36 and the neighbouring teeth was performed with a Swann Morton blade no. SM67. Following flap elevation, the remaining tooth located on the planned implant site was extracted after sectioning in three fragments (Figures 4-5).

A sequential implant site preparation was performed. Figure 6 shows the pilot drill indicator in the mesial root socket, where an immediate implant (Straumann TLX SP, 4.5 RT; length: 12 mm) was subsequently placed (Figure 7). The healing cap was selected according to the gingival height (2 mm) and a bone substitute material was placed in the infrabony defects and the distal root socket (Figure 8).

Adaptive single and cross sutures were placed without the application of a protective membrane on the bone substitute material (Figure 9). Next, a periapical radiograph confirmed the implant position and healing cap fit (Figure 10).

The following images show the healing one week post implantation with healthy, stage-appropriate tissues (Figure 11) and post suture removal (Figure 12).

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Prosthetic procedure t the 3-month follow-up visit after implant placement, the clinical examination showed an uneventful healing and healthy peri-implant soft tissues. Figures 13 and 14 exhibit the occlusal view with and without the healing cap.

Moreover, the radiographic assessment depicted expected bone remodeling around the implant neck (Figure 15).

After stable osseointegration was confirmed, digital impressions were taken using a scan body and the TRIOS 3 (3Shape) intraoral scanner. Figures 16 and 17 show the occlusal and vestibular views.

The acquired data was sent to CAD/CAM software and a monolithic implant crown with a distal cantilever was designed (Figures 18-19).

The monolithic zirconia implant crown (DD cube ONE ML; 4Y-TZP) was fabricated using a CAM system (Programill PM7) (Ivoclar Vivadent) and the screw was tightened following the manufacturer’s instructions (Figures 20-21).

Figure 22 shows the final implant crown on the digital implant model (Objet Eden, Stratasys). A titanium base abutment (Variobase®, AH 6 mm, TorcFit™ connection) was used for the screw-retained crown (Figures 23-24).

A

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clinical | EXCELLENCE

Figure 13. Uneventful healing 3 months after implant placement, occlusal view with healing cap.

Figure 14. Uneventful healing 3 months after implant placement, occlusal view without healing cap.

Figure 15. Periapical radiograph showing bone remodeling around implant neck after implant placement.

Figure 16. Optical impression taking (TRIOS 3, 3Shape) with scan body in situ, occlusal view.

September/October 2021

Figure 17. Optical impression taking (TRIOS 3, 3Shape) with scan body in situ, occlusal view.

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Figure 18. CAD (exocad) software of monolithic implant crown.

Figure 19. CAD (exocad) software of monolithic implant crown with distal cantilever design.

Figure 20. Try-in of monolithic zirconia implant crown fabricated by means of CAM (Programill PM7), occlusal view.

Figure 21. Try-in of monolithic zirconia implant crown (DD cube ONE ML; 4Y-TZP), buccal view.

Figure 22. Final implant crown on digital implant model (Objet Eden, Stratasys).

Figure 23. Screw-retained implant crown with titanium base abutment (VarioBase).

The final implant crown was delivered four months after surgery (Figure 25). The screw access was sealed with Teflon and composite after torquing to 35 Ncm. (Figures 26-28). Additionally, a periapical radiograph confirmed stable peri-implant bone tissues (Figure 29). Finally, oral hygiene instructions were provided to the patient.

Figure 24. Screw-retained implant crown with titanium base abutment (VarioBase, TorcFit connection).

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September/October 2021

EXCELLENCE IN IMMEDIACY EXCELLENCE IN IMMEDIACY

Straumann® TLX Implant System Straumann® TLX Implant System

Iconic Iconic Tissue Tissue Level Level meets meets Immediacy.

Immediacy.

DESIGNED FOR DESIGNED FOR IMMEDIATE IMMEDIATE PROTOCOLS PROTOCOLS Fully tapered implant

PERI-IMPLANT PERI-IMPLANT HEALTH HEALTH PRESERVATION PRESERVATION Reduced risk of nesting

SIMPLICITY SIMPLICITY AND AND EFFICIENCY EFFICIENCY One-stage process with

Fully tapered implant design for optimised design for stability. optimised primary

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Contact your Straumann Solution Contact Straumann Solution Specialistyour for more information or visit: Specialist for more information www.straumann.com.au/tlx or visit: www.straumann.com.au/tlx A0025/en/A/00 05/21 A0025/en/A/00 05/21

Straumann Pty Ltd/Straumann New Zealand Limited 7Straumann Gateway Court, Port Melbourne VIC 3207, Australia Pty Ltd/Straumann New Zealand Limited AU Toll FreeCourt, 1800 660 | NZ TollVIC Free 0800 408 370 7 Gateway Port 330 Melbourne 3207, Australia Email AU Tollcustomerservice.au@straumann.com Free 1800 660 330 | NZ Toll Free 0800 408 370 www.straumann.com.au Email customerservice.au@straumann.com www.straumann.co.nz www.straumann.com.au www.straumann.co.nz

©Institut Straumann AG, 2021. All rights reserved. Straumann® and/or other trademarks and logos from Straumann® mentioned herein are the trademarks or registered trademarks of Straumann Holding AG and/or its affiliates. ©Institut Straumann AG, 2021. All rights reserved. Straumann® and/or other trademarks and logos from Straumann® mentioned herein are the trademarks or registered trademarks of Straumann Holding AG and/or its affiliates.

Figure 25. Delivery of final implant crown and patient instruction regarding cleansability.

Figure 26. Screw access sealed with teflon and composite after torque control of 35 Ncm.

Figure 27. Buccal view with proper occlusion.

Figure 28. Frontal view.

About the authors

Figure 29. Periapical radiograph at crown delivery 4 months post-surgery.

Treatment outcomes he fully tapered implant design of the Straumann TLX contributed to the success of the immediate implant placement in a molar socket, with optimal primary stability. The advantages of this treatment included the reduced number of surgical interventions, reduced treatment time and treatment costs and easy implant placement in the molar root socket.

T

Tips from the experts mmediate implant placement directly into a molar root socket is recommended in the following clinical scenarios: • Periodontally healthy patients; • Minor or no infection prior to extraction; • When intact socket walls with no or minor dehiscence defects are present; • When under-preparation of the implant site is desired; and • To omit guided surgery.

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Dr. med. dent. Marina Siegenthaler graduated in Dental Medicine from the University of Bern, Switzerland. She is a resident physician at the Clinic of Reconstructive Dentistry, University of Zurich, Switzerland and is completing a 3-year postgraduate program which will lead to a specialisation in prosthodontics and a Master of Science in implantology.

PD Dr. med. dent. Sven Mühlemann has clinical and scientific focus areas in Implantology, Fixed Prosthodontics and Digital Technologies. He graduated in Dental Medicine from the University of Zurich, Switzerland and is part of the Faculty at the Clinic of Reconstructive Dentistry, Center of Dental Medicine, University of Zurich, Switzerland. Dr Mühlemann is lectures at a national and international level and is a renowned researcher with numerous scientific articles published in high ranked journals. He is President of the Swiss Society of Implantology (SGI), member of the Board of EAO Junior Committee and ITI Fellow.

Prof. Dr. med. dent., Ronald E. Jung, PhD is Head of Division of Implantology at the Clinic of Reconstructive Dentistry, Center of Dental Medicine, University of Zurich. He trained in oral surgery, prosthodontics and implant therapy. Dr Jung is an accomplished and internationally renowned lecturer and researcher, best known for his work in the field of hard and soft tissue management and his research on new technologies in implant dentistry.

He is President Elect of the EAO, Past President of the Swiss Society of Reconstructive Dentistry and member of the Board of Directors of the Osteology Foundation.

September/October 2021

“

IF YOU DON’T HAVE CHANNEL D, I THINK YOU’RE NUTS...

Almost every day, a patient says to me....

“I love your videos” . Then they tell me something that they never knew before, or ask me a question.

That’s how the conversation starts, and those conversations inevitably lead to more work.

It’s like having a dental guru sitting next to each and every patient in reception, whispering ideas and planting questions in their head. They walk into the operatory interested in the right topics.

Without these conversations, we wouldn’t be doing half the treatments we do.

Look at the maths. I have 2-3 extra relevant conversations per day. That’s 10-15 per week.

40-60 per month. 480-720 per year. This all adds up to a ton of work and many personal referrals. The patients all think I created the content and I get compliments about it because it’s so personal.

This is nothing like boring dental videos showing scary procedures.

It’s a significant business builder and the cost is peanuts. Speaking of peanuts, that leads me back to my original statement, “if you don’t have Channel D, I think you’re nuts”.

Dr Brett Taylor, Sydney General dentist and super happy Channel D user

Try ChannelD for FREE and see the difference it can make to your practice... Sign up at ChannelD.com and use Promo Code AM58

www.channeld.com

clinical | EXCELLENCE

Aesthetic camouflage and correction of trauma-involved incisor hypomineralisation

By Dr Clarence Tam, HBSC, DDS, AAACD, FIADFE

Figure 1.

A

healthy 11-year-old male presented on referral to the practice with a chief concern of unstable and irregular composite restorations affecting his maxillary central incisors. The teeth were initially described in a classic molar-incisor hypomineralisation pattern with an uncavitated, brown hypomineralisation lesion localised to tooth 11 and tooth 21MI status-post uncomplicated enamel fracture secondary to impact with a metal drink bottle (Figure 1).

The patient was described as being in a mid-mixed dentition state. Aesthetic treatment options were outlined including the possibility of pre-prosthetic whitening, which was refused by the parents after learning that further whitening procedures would need to likely be completed in the future as the remaining secondary teeth erupted intraorally, with the risk of colour variance with the bleached teeth. Whitening acts to decrease the chromatic aspects of the hypomineralised lesions and simultaneously lifts the value of the background shade, decreasing the visual contrast between lesion and tooth. Resin infiltration is always an option for uncavitated hypomineralised lesions, however, with residual

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Figure 2.

Figure 3. composite covering the teeth, structural deficits from trauma and the presence of chromatic regions within the area of organic rich hypomineralisation, a conservative reductive approach was elected, both to increase the predictability of bonding in the region and to visually eliminate the lesion of interest.

September/October 2021

clinical | EXCELLENCE

Figure 4.

Figure 5.

Figure 6.

Figure 7.

Treatment: hade selection was completed prior to the application of an 18% benzocaine/2% tetracaine-based topical anesthetic (Zap, Germiphene, Canada). It is known that dehydration decreases the water content, which increases the proportionate amount of air in a tooth, decreasing the refractive index from 1.33 (water) to 1.00 (air) thereby increasing the reflective index and thus the visual value and opacity (Figure 2).

Empress Direct (Ivoclar Vivadent) composite shade buttons were selected and placed overlapping the incisal region of tooth 22, which functioned as the colour reference tooth. Corresponding dentine shades were placed cervically, where the enamel was thinnest and the dentine hue most appreciable. A marked halo and sub halo translucency was noted as part of the colour map.

An enamel shade of A1 and a dentine shade of A2 was selected for the case (Figure 3).

Following topical anaesthesia application for 90 seconds and application of 1.4 carpules of a 2% Lignocaine with 1:100,000 adrenaline solution (Septodont) via buccal infiltration, the region was isolated with a split rubber dam with clamp anchors on the upper E’s (Figure 4).

The old restorative material was removed and the hypomineralised region conservatively reduced to expose an improved amount of inorganic substrate for bonding.

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September/October 2021

It was noted that there were hypomineralised regions in both the middle and incisal thirds of both 11 and 21. A partial thickness oblique fracture was noted in the enamel but did not penetrate to the palatal surface. It was decided to leave this area and reinforce it with bonded restorative material in the spirit of minimal invasion (Figure 5).

The surface was isolated for a total etch adhesive approach and the first thin lingual shelf region sculpted and defined with shade A2 Enamel with a halo of A2 Dentin (Empress Direct, Ivoclar Vivadent). This area was finessed as thin as possible in order to allow room for subsequent layers which would define the desired translucency in this zone.

Resin coating was achieved in the hypomineralised zone using 3 micro layers of A2 Tetric Evoflow (Ivoclar Vivadent) (Figure 6).

The area of hypomineralisation on both teeth were addressed with the next, thin A2 Dentin layer, which aimed to harmonise body value and chroma and create incisal reaching irregularities typical of internal dentine anatomy.

Greater definition and correction of the halo effect value was desired and achieved using a custom mixture of Empress Color White : Ochre in a 9:1 ratio. This was delivered to the halo using a custom fissure sculpting instrument (TNTAM1, Hu-Friedy Corp) (Figure 7).

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Figure 8.

Figure 9.

Figure 10.

Figure 11.

A degree of opalescence was desired between the incisal fingerlings and was thus applied using shade Opal Trans (Empress Direct, Ivoclar Vivadent) using an Optrasculpt instrument (Ivoclar Vivadent). Of note, use of the Optrasculpt instrument obviates or minimises the clinical need to use dipping resin, which has the ability to weaken or alter the physical properties of composite if used in excessive quantities.

Often, singular or multiple fine opaque connections to the dentine are seen from halo to dentine body internally. This was accomplished by using Empress Direct White and in this case, is placed superficial to the cured Opal Trans layer (Figure 8). The final A1 enamel layer was sculpted in place (Empress Direct, Ivoclar Vivadent) using the Optrasculpt instrument and primary anatomy shaped and defined (Figure 9).

Secondary anatomy was mapped and sculpted using a series of needle point and thin chamfer fine diamond burs (Mani) (Figure 10) before final finishing and polishing using abrasive discs and the Optragloss two-step polishing system, which nicely highlighted the secondary and tertiary anatomy (Figure 11).

Post-operative analysis indicates successful visual elimination of the areas of concern, reinstatement of incisal maverick and translucency features and offers a smooth, bio-anatomical surface that should rectify any concerns the patient has relative to smiling confidence for many years to come (Figure 13).

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Discussion ncisor hypomineralisation is a subset of molar-incisor hypomineralisation, a condition which is aesthetically and often functionally debilitating in affected individuals.

It features a multifactorial etiology affecting approximately 16% of the Northern European population in low or underfluoridated communities.1 The period of susceptibility is from 32 weeks in utero to 5.5 years of age and results in an enamel lesion defect that initiates from the level of the dentinoenamel junction (DEJ) and extends superficially.

Fluorosis lesions in contrast are due to the presence of excessive systemic levels of fluoride and feature extension from the surface towards the DEJ. The defect of MIH or incisal hypomineralisation is noted in the post-secretory stage of amelogenesis, which leaves a surface which is weak and susceptible to rapid post-eruptive breakdown from masticatory and environmental forces, increasing the risk of secondary decay. This resulting surface is defined as more irregular, porous with hydroxyapatite crystals unorganised, visually indistinct and deficient in volume. Crombie et al (2013) determined the inorganic content of affected enamel lesions as 58.8% (vol%) relative to unaffected enamel at 86%.2

I

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clinical | EXCELLENCE

Figure 12.

Strategies are graded from non-invasive to progressively more invasive depending on the desires of patient and guardian if applicable. Both hydrogen and carbamide peroxide-based whitening protocols have been used successfully with or without resin infiltration strategies, the latter having widely varying success in the literature.3 The patient in this case with the support of his mother decided that both pre-prosthetic whitening and resin infiltration were to have a limited cost:benefit ratio as other teeth yet to erupt intraorally may feature a darker chroma or value and require subsequent whitening. As there was already a deficient volume of enamel due to trauma, paired with the prominent chromatic hypomineralised lesion in 11, the decision was made to proceed with a reductive approach alone. This allows simultaneous

“Empress Direct was chosen as a direct restorative material as it exhibits extremely tight tolerances with respect to translucency, opacity and fluorescence relative to nature...” reduction in substrate high in organic content and increases the mineral density of the resulting substrate, simultaneously providing space for corrective resin layering with a more predictable adhesive shear bond strength.4 Empress Direct was chosen as a direct restorative material as it exhibits extremely tight tolerances with respect to translucency, opacity and fluorescence relative to nature. Barium glass diameters of 0.7 microns for dentine and 0.4 microns for enamel ensure clinical performance relative to strength and wear resistance as pertains to each layer.

Polymerisation shrinkage is controlled in the dentine layer which is often applied in a more generous application using prepolymers, which simultaneously increase its strength.

Radiopacity is boosted using ytterbium trifluoride, which also has fluoride release as an adjunct. It is a material designed to perform optically, clinically and functionally as optimally as possible using a resin composite enamel-dentine substitute and remains a gold standard in modern direct restorative armamentaria.

September/October 2021

Figure 13.

References 1. Weerheijm KL: Molar incisor hypomineralisation (MIH). Eur J Paediatr Dent 2003, 4:114-120.

2. Crombie, F, Manton DJ, Palamara JEA, Zalizniak I, J Cochrane N, Reynolds E. 2013. Characterisation of developmentally hypomineralised human enamel. J Dent.

41. 10.1016/j.jdent.2013.05.002.

3. Kumar H, Palamara JEA, Burrow MF, Manton DJ 2017 An investigation into the effect of a resin infiltrant on the micromechanical properties of hypomineralised enamel. Int J Paed Dent 27(5):399-411.

4. Fayle SA. 2003. Molar Incisor Hypomineralization: Restorative Management.

Eur J Paed Dent 3:121-126.

About the author Dr Clarence Tam is originally from Toronto, Canada, where she completed her Doctor of Dental Surgery and General Practice Residency in Pediatric Dentistry at the University of Western Ontario and the University of Toronto, respectively. Clarence’s Auckland practice has a focus on restorative and cosmetic dentistry and she strives to provide consistently exceptional care with each patient. She is well-published in both the local and international dental press, writing articles, reviewing submissions and developing prototype products and techniques in clinical dentistry.

She frequently and continually lectures internationally. Clarence has multi-faceted dental experience that extends across multiple tiers of leadership. She is the immediate past Chairperson and Director of the New Zealand Academy of Cosmetic Dentistry and is one of only two dentists in Australasia who are Board-Certified Accredited Members of the American Academy of Cosmetic Dentistry (AACD). Moreover, Clarence maintains Fellowship status with the International Academy for DentoFacial Esthetics.

Clarence is a Key Opinion leader for an array of global dental companies including Coltene, Kuraray Noritake, Hu-Friedy, J Morita Corp, Henry Schein, Ivoclar Vivadent, Kerr, GC Australasia, SDI and DentsplySirona. Moreover, she is the sole VOCO Fellow in New Zealand and Australia. Clarence participates in a number of charitable endeavours and takes great pride in achieving beautiful smiles for patients in and around her community. She sits on the board of Smiles For the Pacific, an educational trust and charity that aims to expand professional dentistry services across the entire South Pacific region. She is involved with Delta Gamma Sorority and aims to spearhead projects harmonious with Service for Sight in the South Pacific.

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New Shining 3D Aoralscan 3 intra oral scanner road test

By Terence Whitty

Figure 1. AoralScan 3 on Cradle.

Figure 2. Two tip sizes to choose from.

The larger has a 58% larger field of view than the previous model scanner.

Figure 3. Cart option.

I

NTRAORAL SCANNING has now become mainstream in dentistry and the uptake, especially in the US, Europe and Australia, has been phenomenal to say the least.

Acquisition is the first–and arguably the most important–component of the Digital Dentistry Workflow. The majority of dental labs now work with digital scans of the dentition, so intraoral scanning replaces the need for traditional impression taking and model pouring in the clinic and model scanning in the lab and importantly rests control of accurate 3D scan acquisition with the dentist.

Siemens first commercialised the intraoral scanner way back in 1985 with the launch of CEREC. Whereas the scan, design and mill workflow introduced by CEREC has endured, the subsequent increase in applications, the choices of technology now available and the outcomes possible have revolutionised dentistry.

132 Australasian Dental Practice

While intraoral scanning has been an option for over 35 years, it has only come into its own in the past decade or so. In recent times, the entry of multiple manufacturers into the market offering a range of products at all price points has seen scanning wands land in the hands of more dentists than ever. Confidence in digital intraoral impressions has surpassed analogue impressions and whilst clinical dentistry embraced going digital relatively recently, dental laboratories have had skin in the game for almost three decades and couldn’t wait for dentists to catch up.

Circa 2021 and the features available even on value-priced scanners is amazing. You can take scans for just about everything you would have taken a traditional impression for nowadays including diagnostic models, fixed and removable prosthetics, implant restorations, surgical guides, splints, aligners and other orthodontic appliances plus sleep devices.

September/October 2021

Figure 4. Scanning software interface wizard mode.

Figure 5. All software functions for scanning can be done with gestures from the scanner.

Figure 6. Co-ordinate adjustment.

Figure 7. Occlusal mapping.

Figure 8. Margin line detection and mapping.

Figure 9. Tooth number marking.

This article introduces the amazing Shining 3D AoralScan 3 intraoral scanner, which is packed with features, giving you food for thought when it comes to choosing a new scanner.

The AoralScan 3 is a high frame rate video-based scanner, which means it’s capturing a lot of pictures compared to the single shot camera scanners; more frames means more data to work with and ultimately greater ability to calculate precision and accuracy. It’s also a full colour scanner with realistic colour that gives you and your patients instant feedback and a certain “WOW factor” as you scan. The colour render engine is excellent and can be calibrated to suit your needs. The scanner is powderless, so no messy powder is needed and it will easily capture teeth, soft tissue, amalgam restorations and most shiny surfaces as well, saving valuable chair time in application and clean-up.

This third generation scanner has been completely redesigned from version 2 to be more ergonomic. It weighs in at at only 240 grams, making it one of the lightest scanners on the market.

However, it still feels solid and is designed to be held with ease.

The removable tips of the new Aoralscan 3 have been redesigned and are longer and narrower, making it easy to reach posterior teeth. There is also an additional smaller-sized tip for difficult access patients as well as children and the tips can be changed during the scanning process to cover every situation. The tips are heated to counter fogging so no erroneous or distorted images are introduced into the scan. The tips can also be autoclaved up to 100 times each - the scanner comes with 5 tips straight out of the box, so you’re good to go for your first 500 scans!

The scanning technology of the Aoralscan 3 has been improved in many ways, including a massive 58% increase in the field of view and the utilisation of a new imaging mechanism.

Improvements in the software accuracy has also been increased by 30%. The speed of scanning has been improved by 25% and the scan depth has been increased to 22mm. All these improvements effectively add up to a brand new scanner with far superior speed and accuracy than anything in its in its class.

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Figure 10. Undercut detection.

Figure 11. Direct Integration with exocad CAD software.

Figure 12. Proven Accuracy. Example colour coded deviation map.

Figure 13. Oral health report.

There is a new Artificial Intelligence function that allows you to scan away and not worry if you pick up a bit of cheek, tongue or your finger in the scan as the software will recognise this and automatically trim it away, leaving you with just the important parts of the scan - a nice feature indeed.

Using the Aoralscan 3 is very straightforward and Shining 3D have tried to make it as intuitive as possible - just pick up the scanner from the newly designed cradle and it’s ready to scan.

You just start scanning and you don’t need to touch a mouse or a screen as all functions can be executed from the scanner itself.

There is one button on the scanner plus built-in sensors which allow you to interact with the software hands-free using a menu on the screen and a series of gestures working through the scanning process - viewing the scans, tilting and panning can all be accomplished in this way. This is a very good way to work, especially in a dental surgery where touching surfaces needs to be kept to a minimum, not to mention the convenience of executing all software commands from the scanner itself.

Speaking of the software, it’s very easy to use with a wizard-type interface at your fingertips, making the whole process a breeze. As a bonus, the scanning software can directly integrate with the exocad suite of CAD software, making it a very powerful system indeed.

For scanning, just setup the type of job you would like to do and the software will automatically prompt you and tell you exactly what action needs to be taken next. For example, if you want to scan a case for two anterior implant sites, the software will tell you when to scan the tissue, the implant scan abutments (scan flags), the opposing dentition and of course the bite registration.

In fact, one of the most impressive actions is taking the bite registration where a small scan is taken in the registration area and alignment is performed automatically; it’s most impressive!

Remember, you could take a bite in CR or CO or in a specific bite such as a construction bite for a splint or a sleep device. Just use your normal bite technique with wax or bite registration material and scan away, making sure there is not too much overhang and you will nail it every time.

The software offers more features such as undercut detection - valuable when trying to get preps parallel, margin line detection, occlusion maps and an interesting new feature called the Oral Health Report.

After scanning, the software will generate an Oral Health Report which includes information such as existing dental caries, missing teeth, dental calculus, pigment, etc. The idea here is to give patients a visual report to help relay a better understanding of their oral health - a novel idea indeed.

Also, an orthodontic simulation module is included, allowing a virtual setup and a visual treatment plan for the patient. This is primarily aimed at clear aligner cases but can be adapted to traditional fixed appliances as well. Of course, we all know orthodontic simulation is a big deal nowadays, so no scanner is really complete without this function!

There is also a neat feature I really like where you can turn your scans into files that are ready to print on your favourite 3D printer.

You can even add labels; this is a really helpful feature.

The calibration module is simple and easy to use - just plug the head of the scanner into the calibration unit, press a button and the rest is automatic. The software will even tell you when it’s time to calibrate.

134 Australasian Dental Practice

September/October 2021

Affordable Digital Dentistry Affordable Digital Dentistry Has Finally Arrived Has Finally Arrived

The new Shining 3D Aoralscan 3 Intra Oral Scanner combines The new Shining 3D Aoralscan 3 Intra Oral Scanner combines amazing performance with unbeatable value amazing performance with unbeatable value

• •Powderless Powderless • •Full FullColour Colour • •Intelligent IntelligentScanning Scanning Fullsoftware softwareSuite Suite • •Full ongoingor or“Click” “Click” Fees • •NoNoongoing Compatiblewith withevery every major 3D 3D printer, printer,Mill Milland andSoftware Software • •Compatible Portable • •Portable Contactus ustoday today and and we

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clinical | EXCELLENCE

Figure 14. Cloud communication, storage and inspection portal.

Figure 15. Marking of teeth for Ortho simulation.

Figure 16. Ortho simulation Occlusal.

Figure 17. Ortho Simulation facial view.

Figure 18. Implant scan - note depth of tissue scan.

Figure 19. Scan markers in implant scan.

Finally there is a specific cloud data transmission platform that allows efficient communication between clinics and dental labs, or other clinics of course. It allows transfer of scans, data storage, order tracking and a streamlined communication system between dental surgery and laboratory. The scans are instantly available on your own computer as they are saved locally, so you have a choice if you wish to save them to the cloud as well.

With the Aoralscan 3 you get a heck of a lot of bang for your buck. It’s a fantastic, easy-to-use powderless colour scanner with speed and accuracy to please everyone. A solid and full software suite is included that will do everything that you will need it to plus there is exocad integration. If you really want to take it to the next level, the cloud portal and communication software is hard to beat with no annoying ongoing “click” fees or upgrade fees. All this at a price that is so affordable you can buy one for each surgery.

136 Australasian Dental Practice

For more information about the Shining 3D Aoralscan 3, visit https://www.fabdent.com.au/aoralscan.html

About the author Terence Whitty is a well-known dental technology key opinion leader and lectures nationally and internationally on a variety of dental technology and material science subjects. He is the founder and owner of Fabdent, a busy dental laboratory in Sydney specialising in high tech manufacturing. Using the latest advances in intra- and extra-oral scanning, CAD/CAM, milling, grinding and 3D printing, most specialties are covered including ortho, fixed and removable prosthetics, computerised implant planning and guidance, TMD, sleep appliances and paediatrics.

September/October 2021

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clinical | EXCELLENCE

Anterior restoration with CAD/CAM veneers made of VITABLOCS TriLuxe forte

By Dr David Jäger, Dr Martin Hammer and Carmen Scheibling

Figure 1. Initial situation with severe tetracycline discolouration on 11 and 21.

P

rosthetic restoration of the maxillary incisors is a challenging task for dentists and dental technicians.

In the following case study, the authors Dr David Jäger, Dr Martin Hammer and dental technician Carmen Scheibling, describe how they treated a complex initial clinical situation step-by-step with the CAD/CAM feldspar ceramics VITABLOCS TriLuxe forte (VITA Zahnfabrik, Germany).

Case study patient presented in the dental practice with severe discolouration caused by a course of tetracycline given to her as a child. The psychological strain on the 38-year-old patient was increased by the palatal inclination of teeth 11 and 21. She was looking for a quick and efficient solution which would meet her expectations in terms of aesthetics without having orthodontic

A

138 Australasian Dental Practice

Figure 2. Mock-up on 11 and 21 for defining the goal with the patient. pretreatment. The practitioners, the dental technician and the patient therefore decided on a digital workflow with feldspar ceramics VITA TriLuxe forte. The material allows for a natural look in the anterior tooth area thanks to its integrated shade gradient.

Mock-up phase wax-up was made using dental impressions and used as the foundation to discuss the treatment goals with the patient.

Using a silicone index and composites, mock-ups were produced similarly in the laboratory. The severely discoloured middle incisors were modified, as well as the length and gradient of the incisal edges for 12 and 22. “During the trial, the patient was quickly convinced of the potential positive results and decided on four veneers,” Carmen Scheibling reported at the final planning meeting. This was followed by a minimally invasive preparation of the teeth and impressions being taken.

A

September/October 2021

clinical | EXCELLENCE

Figure 3. Mock-ups on all incisors for leveling the gradient of the incisal edges.

Figure 4. Plaster model for digitalisation similar to the intraoral mock-ups.

Figure 5. Preparation is as minimally invasive as possible and limited to the enamel with retention grooves for the best adhesive bond possible.

Figure 6. Targeted reduction to harmonize the dental arch.

CAD/CAM process he mock-up was corrected and duplicated and the plaster model scanned in the laboratory. The master model made during the preparation was also digitalised. In order to cover the severe discolouration, it was decided to use the multi-chromatic VITABLOCS TriLuxe forte blank due to its integrated harmonic shade gradient. Thanks to the mock-up data set, the restorations could be created in the lab using the CEREC SW 3.8 design software and milled using the CEREC MC XL milling system (Dentsply Sirona, Germany).

T

Individualisation and integration o deepen the chroma in the cervical area even more, a wellbalanced mixture of VITA VM 9 CHROMA Plus 2 and CP3 was used during the individualisation. More light dynamics was acheived on the distal and mesial edges with EFFECT OPAL 2.

After the try-in, small corrections and the glaze firing, the final adhesive integration came next. The result was a happy and satisfied patient.

T Figure 7. The removal of tooth substances ensures that the discolouration is covered.

September/October 2021

Australasian Dental Practice

139

clinical | EXCELLENCE

Figure 8. Computer-aided design of veneer 21 using mock-up data.

Figure 9. Computer-aided design of veneer 11 using mock-up data.

Figure 10. Virtual position of the restoration in VITA TriLuxe forte block from mesial.

Figure 11. Lumen-side view of the virtual veneer restoration.

Figure 12. Try-in of the completed restorations with glycerin gel.

Figure 13. The aesthetic results after adhesive integration.

Originally published in das dental labor, Verlag Neuer Merkur, Germany. Reprinted with permission.

140 Australasian Dental Practice

September/October 2021

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clinical | EXCELLENCE

Case report: Partial pulpotomy on a lower permanent incisor with complicated fracture of the crown and open apex using Biodentine™ - 13-month follow-up

By A.I. Guzman de Hoyos, O. Rodríguez Villarreal, P. Reyes Martell Casale, C. Yañez Pérez and D.E. Molina Montoya

T

raumatology in paediatric dentistry is an important issue due to the early eruption of the permanent dentition and its consequences.

Trauma in paediatric dentistry often involves permanent tooth and the treatment needs to be carefully selected by the clinician. There are several factors that are determinant in the prognosis and/or success of the treatment, such as duration of pulpal exposure, irreversible pulpitis signs, root development and the clinical scenario.1,2 The objective of this article is to present a trauma case in which a permanent lower incisor is involved. Based on the radiographic analysis and the anamnesis, we decided to perform a partial pulpotomy. The biomaterial used was Biodentine (Septodont) and the tooth fragment was reattached. This is a 13-month partial pulpotomy follow-up.

142 Australasian Dental Practice

Introduction rown fractures and luxations occur more frequently of all dental injuries. An appropriate diagnosis and treatment plan are important for a good prognosis. The IADT (International Association of Dental Traumatology) has developed a consensus about the procedures that enhance the prognosis and treatment success.4 Complicated fractures of crowns should be managed as follows: In young patients with immature, still developing teeth, it’s advantageous to preserve pulp vitality by pulp capping or partial pulpotomy. This treatment is also the choice in young patients with completely formed teeth.4 If too much time elapses between accident and treatment and the pulp becomes necrotic, root canal treatment is indicated to preserve the tooth.4

C

September/October 2021

clinical | EXCELLENCE Figure 1. Initial situation.

Figure 2. Initial situation.

Figure 3. First radiograph.

Figure 5. Isolation achieved.

Figure 6. Partial pulpotomy.

Figure 7. Biodentine capsule and liquid.

Figure 8. Biodentine setting after 12 minutes.

Partial pulpotomy is defined as the removal of a small portion of coronal pulp tissue after exposure, followed by application of a biomaterial directly onto the remaining pulp tissue prior to placement of a permanent restoration.3 Partial pulpotomy is Vital Pulp Therapy (VPT). Vital pulp therapy of immature teeth is performed to encourage physiological development and formation of the root end and apical closure; this

September/October 2021

procedure is also referred to as apexogenesis.5,6 The aim of apexogenesis is the preservation of vital healthy pulp tissue so that continued root development with apical closure occurs.6,7 Historically, calcium hydroxide used to be the material of choice for vital pulp therapy. Later, upon introduction of mineral trioxide aggregate (MTA), this bioactive material became the gold standard. Recently, some other calcium-

Figure 4. Incisal view.

silicate based cements from this aggregate were invented such as calcium-enriched mixture (CEM) cement and Biodentine that can be favourable vital pulp therapy agents.6,7 Biodentine is a calcium-silicate based material and has several clinical applications. Biodentine is a bioactive inorganic calcium silicate-based cement that increases biomineralisation and pulp cell proliferation.8

Australasian Dental Practice

143

clinical | EXCELLENCE

Figure 9. Tooth was bevelled.

Figure 10. GC Premio bond after enamel selective etch.

Figure 11. Picture after light curing: frontal view.

Figure 12. After finish and polish.

Figure 13. Inmediatly post-op.

Figure 14. After 30 days.

Figure 15. 13-month radiographic control.

Figure 16. 13-month clinical control.

Its presentation consists of powder and liquid components. The powder contains tricalcium silicate, dicalcium silicate and calcium oxide; The liquid consists of calcium chloride and a carboxylate-based hydro-soluble polymer that serves as the water reducing agent.8 Biodentine is a very practical product; after 12 minutes, a final restoration can be over it to promote the restoration seal and enhance the prognosis avoiding leaking and contamination of the pulp.

Case report

144 Australasian Dental Practice

female patient 7 years and 6 months old arrives at our office with a dental trauma history. After the informed consent was signed, we perform our clinical review protocol. On the clinical exploration, we found a lower incisor with a complicated fracture of the crown, according to her mother’s testimony, it had been 2 hours since trauma occurred (Figures 1 and 2).

A

We proceeded to take a periapical X-ray and it was confirmed the communication of the pulp and the open apex. According to the the IADT, when a complicated fracture of the crown is present and there are no signs of irreversible pulpitis, we should maintain the pulpal vitality by performing a partial pulpotomy. In this case, the partial pulpotomy has 2 objectives: to maintain the pulp vitality and promote the apex closure (Figures 3 and 4).

September/October 2021

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ble outcomes for your littlest patients with Hu-Friedy Stainless Steel Pedo Crowns. cover why dentists favor our impeccable fit. Perfect for your Irreversible patients. Easy for you. Pulpitis Pulpitis Irreversible Pulpitis t comes to the perfect fit, Hu-Friedy is just right.Irreversible

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Biodentine saves pulps EVEN with signs and symptoms Biodentine saves pulps EVEN with signs and symptoms e outcomes for your littlest patients with Hu-Friedy Stainless Steel Pedo Crowns. ™ of irreversible pulpitis* As the first all-in-one biocompatible and bioactive dentin substitute, Biodentine saves pulps EVEN with signs and symptoms ht and width of irreversible pulpitis* over whymesio-distal dentists favor our impeccable fit.

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Biodentine ™ fully replaces of irreversible pulpitis* For vital pulp therapy, bulk-fi lling the cavity with Biodentine comes to the perfect fit, Hu-Friedy is just right. med and pre-crimped for ™ simple placement

up to 85%** irreversible pulpitis cases: ™ of brings one-of-a-kind benefi ts for and the treatment of Biodentine brings one-of-a-kind benefi ts for the treatment of Biodentine makes your procedure better, easier faster: ™ ™ helps Biodentine up to 85%** of irreversible pulpitis cases: • Vital Pulp Therapy allowing complete dentin bridge formation OVE OUR anatomy STAINLESS STEEL PEDO CROWNS: occlusal that the tooth pulpitis benefi brings one-of-a-kind of remineralization of dentin, preserves the pulp Biodentine up tomatches 85%** of natural irreversible cases:ts for the treatmentthe •upPulp healing promotion: proven biocompatibility and bioactivity vitality and promotes pulp healing. It replaces dentin with similar to Therapy 85%** ofallowing irreversible pulpitis cases:bridge • Vital width complete dentin formation •Pulp Minimally Invasive treatment preserving the tooth structure Vital Pulp risk Therapy allowing complete bridge formation t and mesio-distal •• Reduced of failure: strong sealing dentin properties biological and mechanical properties.

Vital Pulp Therapy allowing complete dentin bridge formation • Minimally Invasive treatment the tooth structure Immediate Pain relief your patients’ comfort d and pre-crimped simple placement Minimally Invasive treatment preserving thepulp tooth ••forOnly one material to fifor llpreserving the cavity from the to structure the top ™ cclusal anatomy that matches the natural tooth Improving on Biodentine Minimally Invasive treatment preserving the tooth structure • Immediate Pain relief for your patients’ comfort Bio-Bulk fi lling procedure for an easier protocole •• Similar mechanical behavior as natural dentin: ideal for bulk fillingclinical implementation, you can now bond Immediate Pain relief for your patients’ comfort ™ the composite onto Biodentine in the same visit and perform the • Painprocedure relief patients’ comfort • Bio-Bulk llingenamel procedure forfor anyour easier protocole • Immediate Bio-Bulk filling for The fifinal restoration willan beeasier placedprotocole within 6 months. full restoration in a single session.

INE AT HU-FRIEDY.COM/PerfectFit • Bio-Bulk filling procedure for an easier protocole

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Please visit our website for more information Call 0508 486 252 Please visit our website more information www.septodont.com Please visit our website for morefor information Please visit our website for more information 855 www.henryschein.co.nz Orders 1300 65 88 22 www.henryschein.com.au www.ivoclarvivadent.co.nz www.septodont.com www.septodont.com *If haemostasis be achieved full pulpotomy, a pulpectomy and a RCT should be carried out, provided the tooth is restorable (ESE Position Paper,Duncan et al. 2017) Please visitwithcannot our website forafter more information Learn more www.septodont.com

8 855 www.henryschein.co.nz ** Taha et al., 2018 the Biodentine™ brochure

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Orders 1300 65 88 22 www.henryschein.com.au

*If haemostasis cannot be cannot achieved full pulpotomy, a pulpectomy and a RCTand should be carried out,carried provided tooth isthe restorable (ESE Position Paper,Duncan et al. 2017)et al. 2017) *If haemostasis beafter achieved after full pulpotomy, a pulpectomy a RCT should be out,the provided tooth is restorable (ESE Position Paper,Duncan ** Taha et al., 2018et al., 2018 ** Taha

clinical | EXCELLENCE After the anesthesia (Scandonest, Septodont) was infiltrated, we proceed to tooth isolation with rubber dam and a clamp from Hu-Friedy. Partial pulpotomy was performed with a diamond ball bur and a high speed handpiece with water irrigation. The bleeding was controlled with sterile cotton pellets. Disinfection was made with sodium hypochlorite for 1 minute.

A Biodentine capsule was used as per the manufacturer instructions: the capsule was placed on the white capsule holder, the liquid container was detached and then 5 drops were poured

Discussion s the literature suggests, the treatment for complicated fractures of the crown depends on several factors such as root development, pulpal exposure duration and irreversible pulpitis among others.

In cases with an open apex, healthy pulp and short exposure time, partial pulpotomy could be done with a biomaterial such as Biodentine that promotes the pulpal health, apex closure and allows us to perform a definitive restoration on top of it.

A

Conclusion iodentine is a biomaterial with several indications. In cases of trauma, especially when pulp is involved, it can be used in order to preserve the pulp vitality and allow the correct development of the tooth. In this case, Biodentine was used in a partial pulpotomy on a lower central incisor and after 13 months follow up it, has promoted the apex closure and kept the pulp vitality.

The use of Biodentine in cases like this can be done with excellent clinical and radiographic results.

B

About the authors Aldo Ivan Guzman de Hoyos received his Master in Paediatric Dentistry at the Universidad Autónoma de Coahuila U.T. He teaches at the Universidad Autónoma de Durango Campus Monclova and the Teacher at Universidad AME, Monterrey Nuevo León as well as maintaining a private practice in Coahuila, México.

References

into the capsule. The capsule was mixed for 30 seconds, Biodentine was placed directly on the amputated pulp and was gently packed with a sterile pellet (Figures 5-8).

After Biodentine was placed, adhesive procedures were completed, the tooth fragment was beveled with a high speed diamond bur to enhance adhesion, selective enamel etch was performed with phosphoric acid (Ultra Etch, Ultradent) for 15 seconds and after rinsing and drying, Premio Bond (GC) was placed and after 20 seconds was light cured.

Reattachment was done with fluid resin (Brilliant Flow, Coltene) and then finishing and polishing were completed (Figures 9-12). The first radiograph was taken immediately postoperatively; the second radiograph was taken 30 days after treatment. Radiographs and follow-up pictures were also completed after 13 months (Figures 13-16).

146 Australasian Dental Practice

“The treatment for complicated fractures of the crown depends on several factors such as root development, pulpal exposure duration and irreversible pulpitis among others.

In cases with an open apex, healthy pulp and short exposure time, partial pulpotomy could be done with a biomaterial such as Biodentine that promotes the pulpal health, apex closure and allows us to perform a definitive restoration...”

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1. Luca Boschini F, Home management of crown fractures of two Home management of crown fractures of two central incisors complicated by exposure of the pulp, Giornale Italiano di Endodonzia (2018) 32, 76-79.

2. Viduskalne I, Care R. Analysis of the crown fractures and factors affecting pulp survival due to dental trauma. Stomatol Baltic Dent Maxillofac J 2010;12:109-15.

3. Duncan HF, Galler KM, Tomson PL, Simon S, El-Karim I, Kundzina R, Krastl G, Dammaschke T, Fransson H, Markvart M, Zehnder M, Bjørndal L, European society of endodontology position statement: Management of deep caries and the exposed pulp. doi: 10.1111/iej.13080.

Ensure predicta 4. Flores MT, Andersson L, Andreasen JO, BakEnsure predicta You’ll quickly di land LK, Malmgren B, Barnett F, Bourguignon C, DiAngelis A, Hicks L, Sigurdsson A, Trope M, TsukiYou’ll quickly di Because when boshi M, von Arx T. Guidelines for the management Because when of traumatic dental injuries. I. Fractures and luxations WHY DENTISTS of permanent teeth.

WHY DENTISTS 5. Hengameh Ashraf, Afsaneh Rahmati and Neda • Ideal heig Aminic, Vital Pulp Therapy with Calcium-Silicate heig Pre-trimm Cements: Report of Two Cases, Iran Endod J. 2017 • Ideal Winter; 12(1): 112–115. doi: 10.22037/iej.2017.23.

• Pre-trimm Accurate 6. Yazdani S, Jadidfard MP, Tahani B, Kazemian A, • Accurate Dianat O, Alim Marvasti L. Health Technology Assessment of CEM Pulpotomy in Permanent Molars with Irreversible Pulpitis. Iran Endod J. 2014;9(1):23-9.

7. Asgary S, Fazlyab M, Sabbagh S, Eghbal MJ. ©2016 Hu-Fried Mfg VISIT US yONL Outcomes of different vital pulp therapy techniques on symptomatic permanent teeth: a case series. Iran ©2016 Hu-Fried Mfg VISIT USyyONL ©2016 Hu-Fried Mfg. C Endod J. 2014;9(4):295-300. ©2016 Hu-Fried y Mfg. C 8. Khoshkhounejad M, Shokouhinejad N, Pirmoazen S. Regenerative Endodontic Treatment: Report of Two Cases with Different Clinical Management and Outcomes. J Dent (Teh) 2015;12(6):460.

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MANAGING Pulpitis Irreversible Pulpitis n it comes to the perfect fit, Hu-Friedy is just right.Irreversible MANAGING Pediatrics Endodontics MANAGING Irreversible Pulpitis ™ Biodentine saves pulps EVEN with signs and symptoms As world leader in Pain Management, Septodont TS LOVE OUR STAINLESS STEEL Pediatrics PEDO CROWNS: Endodontics MANAGING ™ Biodentine saves pulps EVEN with signs and symptoms ™ of world irreversible pulpitis* Ultra Safety with the new Twist Lock ™Plus As leader in Pain Management, Septodont Biodentine saves pulps EVEN with signs and symptoms TS OUR STAINLESS STEEL PEDO CROWNS: provides you products and services to help you Biodentine saves pulps EVEN with signs and symptoms ableLOVE outcomes for your littlest patients with Hu-Friedy Stainless Steel Pedo Crowns.

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Please visit our website for more information Call 0508 486 252 our website website for more information information Please our for more www.septodont.com Please visit ourvisit website for more information Please visit our website for more Call 0508 486 252 information 08 855 www.henryschein.co.nz Orders 1300 65 88 22 www.henryschein.com.au www.ivoclarvivadent.co.nz Please visit our website for more information www.septodont.com www.septodont.com Please visit ourvisit website for morefor information www.septodont.com *If haemostasis cannot be achieved after full pulpotomy, a pulpectomy and a RCT should65 be carried out, www.henryschein.com.au provided the tooth is restorable (ESE Position Paper,Duncan et al. 2017) Please our website more information Learn more with 08 855 www.henryschein.co.nz Orders 1300 88 22 www.ivoclarvivadent.co.nz www.septodont.com ** Taha et al., 2018

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surgery | DESIGN

Cairns Specialist Dental is born

D

r Brian James has been practising dentistry since completing his qualifications at the University of Queensland in 1987.

Part of the attraction to dentistry as a profession was the combination of science and technical ability and Brian excelled, later qualifying as a Specialist Periodontist in 1995. Brian’s technical aptitude and personable nature have earned him a great reputation as a leading specialist periodontist and implantologist and his skills have been in high demand ever since.

Brian is one of a growing number of specialists who have utilised the services

148 Australasian Dental Practice

of industry pioneer, Medifit Design & Construct, to deliver multiple practices throughout their dental careers. Medifit built Brian’s original practice, Cairns Periodontics in 2006 and followed this with his second, Great Alpine Dental, a few years later.

Cairns Periodontics, located in Earlville, had experienced steady growth since opening. Built as a three chair practice with a floor area of just 132m2 in 2006, by 2020 the practice’s growth was being restricted by the available space. It became clear new premises would need to be found to accommodate Brian’s future plans.

To this end, Brian secured a two storey property in nearby Manunda and set about canvassing offers from several suppliers

before deciding again to utilise Medifit to deliver his third practice.

“I returned to Medifit as I trust their knowledge and execution, Dr James said.

“They are specialists in their field and being a specialist myself, I can understand the concept of going to the best and getting it done right the first time. I have no regrets and recommend their services.”

Cairns Specialist Dental has a floor area of some 295m2 on the ground level with an additional 115m2 of utility and office space above it. Brian’s vision was for a practice that could accommodate several specialists and become a centre for excellence for the local dental community to refer patients with advanced or complicated treatment requirements.

September/October 2021

surgery | DESIGN

September/October 2021

Australasian Dental Practice

149

surgery | DESIGN

Cairns Specialist Dental is currently home to 3 specialists including Brian, covering Periodontics/Implantology, Endodontics and Prosthodontics and they are seeking complementary specialists to join their growing practice.

Entering Cairns Specialist Dental, one is struck by the understated elegance of the space. Eucalypt greens give way to light natural timber finishes to evoke a feeling of calm serenity. Subtle curves lend the space a softness and help to diminish any clinical feel.

The new practice contains six chairs, several offices, a generous and inviting waiting and reception area, recovery room, OPG and a centrally located steri and laboratory. Upstairs, there are several more offices, IT and a store room plus a large staff/ conference room that provides the perfect space for meetings and presentations. Brian is committed to industry development and the new meeting space upstairs has huge potential as a training area or a venue for local branch ADA meetings.

150 Australasian Dental Practice

Now in his third practice, Brian understands the importance of patient flow and the new space has been designed with this in mind. Patients enter and wait in the spacious waiting area before heading down the corridor for their procedures in specialist treatment rooms. A dedicated recovery room offers patients a quiet space to relax post treatment before making their way back past reception for payment and exit with minimal disturbance or unnecessary interaction with other patients.

September/October 2021

surgery | DESIGN

September/October 2021

Australasian Dental Practice

151

Summary The Practice The Practice

Cairns Specialist Dental

Principal

Dr Brian James

Type of Practice Specialist Periodontic, Prosthodontic and Endodontic Location

Manunda, Cairns, Queensland

Size

410 square metres

No of chairs

6

The Team Design

Medifit Design & Construct

Construction

Medifit Design & Construct

Equipment Dental Units

A-dec 200 and Adec 400

Autoclaves

Melag Vacuklav 41B+ and 43B+

X-ray

Vatech EzRay Air

CBCT

Dentsply Sirona Axeos

Compressor Cattani Suction Dmega Software Ultimo The end result is a highly efficient practice that delivers productivity benefits today, with the potential to expand the range of specialist dental services and the future patient base.

Medifit’s Sam Koranis has the last word: “I would like to thank Brian for his continued trust in Medifit to deliver great dental practices. We have worked with him for many years and delivered three fantastic practices that we are all justifiably proud of. Brian is a very talented specialist and we are delighted to have been chosen to realise his vision for Cairns Specialist Dental. The entire Medifit team and I wish him every success in the new practice.”

152 Australasian Dental Practice

September/October 2021

Practices that work with you Since 2002, Dentists and Dental Specialists all around Australia have trusted Medifit to create state of the art practices with individual interior designs that boost productivity and enhance levels of care.

Whether it’s your first practice or your latest, we’ll help you create a dental practice that reflects your personal style and complements the way you work - and we do it with a friendly, no fuss approach using proven best practices.

Contact Medifit today for a no obligation consultation and experience our award winning service.

• SITE ASSESSMENTS • LEASE NEGOTIATION • FEASIBILITY STUDIES • COUNCIL SUBMISSIONS • ARCHITECTURAL DESIGN

• INTERIOR DESIGN • BUILDING CONSTRUCTION • PRACTICE FIT-OUTS • RENOVATIONS / REFRESHES • BRANDING & MARKETING

MULTI AWARD WINNING HEALTHCARE DESIGN & CONSTRUCTION

2021 Master Builders Excellence in Construction Awards - Best Healthcare Building & Best Historical or Heritage Restoration or Renovation under $1.5m 2017/18 ASOFIA Best Medical Fitout • 2017/18 ASOFIA Best Use of Sponsors Product • 2017/18 & 2018/19 ASOFIA Best Design - Professional Suites

1300 728 133 www.medifit.com.au

new | PRODUCTS Information contained in this section is provided by the manufacturers or distributors.

Australasian Dental Practice does not assume responsibility for the accuracy of the data.

SmileLine K-Lite designed by Dr K Losada A-dec offers biofilm testing device

Modern dental composites and adhesives contain fluorophores which help in producing better aesthetic results. This gives them a fluorescent property.

The K-Lite is a ground breaking dental device that allows the removal of excess or unwanted dental materials such as composites or adhesives using these fluorescent properties.

Some of the examples include orthodontic brackets, attachments and retainers, residual cements etc. Its use in dental trauma (splint) and/or in the socalled Fluorescence-assisted

Identification Technique (FIT), however, were the two objectives that motivated Dr Losada to develop and produce the new lamp K-Lite in cooperation with the company Smile Line SA, Switzerland. It can also assist in the identification of certain bacterial by-products found in plaque, calculus and in infected dentine.

Available: Alphabond Dental Tel: (02) 9417-6660 info@alphabond.com.au www.alphabond.com.au

A-dec has introduced a useful new product to accurately and easily test the microbiological quality of dental unit water lines and surfaces in dental clinics.

The 2-Min Water Control System rapidly and accurately determines the presence of biofilm in dental unit waterlines, to enable monitoring and action as required, eliminating incubation periods or the need to send samples to a laboratory. A water sample is taken from the dental unit waterline and by adding a few drops of reagents, produces a result which is immediately interpreted and displayed on a Lumitester Smart device.

When high counts are found, the waterlines can then undergo additional shock or sanitising treatments.

Available: A-dec Dealers https://australia.a-dec.com Tel: 1800-225-010

Pola Light kit for patients now in 9.5%

New A-dec Third-Hand HVE Holder

Just in time for changes to teeth whitening products able to be dispensed by dentists, the Pola Light patient kit with Pola Day 9.5% hydrogen peroxide gel now has premium packaging crafted to elevate the appeal of Pola Light above less effective pharmacy and online solutions on the market.

This gives clinicians the confidence and support to convince customers of the benefits of professional tooth whitening.

Aerosol capture in the dental surgery can be especially challenging in two-handed dentistry situations as well as in more complex four-handed dental procedures. Sometimes there are simply not enough hands to do the job, making you wish you had a “third hand” to hold onto something when you quite literally have your hands full.

Well now you have! Thanks to a simple and practical solution from A-dec - the world’s leading dental equipment

Pola Light is easy and comfortable to use at home, with treatment options from just 20 minutes a day. The gels are fast acting and are formulated to safely remove long term stains in as little as 5 days.

The high viscosity, neutral pH tooth whitening gel ensures the greatest patient comfort in a take home kit.

Available: SDI Limited www.sdi.com.au

154 Australasian Dental Practice

manufacturer, the A-dec ‘Third Hand’ HVE Holder makes it easier to practice two-handed dentistry while maintaining essential aerosol control. The flexible ‘Third Hand’ securely positions the HVE tip to within an inch (25mm) of the oral cavity - delivering precise, effortless aerosol capture while keeping your hands free.

Available: A-dec Dealers https://australia.a-dec.com Tel: 1800-225-010

September/October 2021

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THERE’S AN A-DEC FOR EVERYONE Every dental practice is unique. That’s why A-dec offers a full line of dental chairs, with a wide variety of options and price points, all designed for comfort, performance, and reliability.

From the entry-level A-dec 200, the stylish A-dec 300, to the classic A-dec 400 and the premium A-dec 500, there’s an A-dec chair to fit your practice, your personal style, and your budget.

To see our award-winning family of A-dec dental chairs – scan the QR code and find the one that’s right for you.

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Contact your A-dec dealer today visit australia.a-dec.com/find-a-dealer