Australasian Dental Practice Nov/Dec 2023 by dentalcommunity

Australasian

DENTAL PRACTICE THE BUSINESS MAGAZINE FOR DENTISTS

Vol. 34 No. 5

NOVEMBER/DECEMBER 2023

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VOLUME 34 | NUMBER 5 NOVEMBER/DECEMBER 2023

contents | REGULARS

On the cover... Orascoptic has unveiled its latest ground-breaking addition to the Ergo™ loupe series, the HDL Ergo 5.0x, representing a pinnacle in ergonomic magnification...

management

8 briefs 10 one man’s opinion 12 mouth wide shut 14 commentary 16 spectrum 60 CPD centre 62 abstracts 64 the cutting edge 146 new products

72 your dental practice with 76 Transform the power of a compelling purpose 78 The role of insurance in practice purchase 80 Simple ways to help your team stay focused Dental practice valuation: Facts dentists should know!

marketing

82 If Apple ran your dental practice

READ ME FOR

finance

CPD

facebook.com/dentalpracticenow

How long will $2 million last in retirement in Australia?

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 Jesse Green, Garry 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

© 2023 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.

November/December 2023

Australasian Dental Practice 5

contents | FEATURES

VOLUME 34 | NUMBER 5 NOVEMBER/DECEMBER 2023

infection control

clinical excellence 90

198

Human factors and the pressures of CPD delivering accurate information in dental practice: An ongoing challenge

104

Block selection for monolithic CAD/CAM restorations

READ ME FOR

108

190COVID-19: New challenges for 2024

READ ME FOR

CPD

surgery design

108 A guide to modern occlusal splints

READ ME FOR

CPD

A freedom alternative to the

116 consequences of bruxing 134

122

134 About Smiles opens at Circular Quay TGA approved implant prosthetic components 140 New look signals fresh approach to dentistry 122 for more than 140 systems Deep restoration with Biodentine™: From the 130 pulp floor to top of the cavity November/December 2023

Australasian Dental Practice 7

briefs | NEWS Another year over...

OrthoED appoints marketing director

s another year ticks over, already my once vivid memories of the COVID-19 pandemic are slipping away. By Joseph Allbeury The beginning of the year will mark four years since the world stopped. As crowds fill the shops, depart to travel the globe and celebrate in unison at the festive end of the year, it’s hard to believe that it’s never always been that way. It’s easy to forget that airlines were grounded. Working from home was the norm, as was home schooling. Travel was restricted. Zoom boomed (and not the teeth whitening system). Toilet paper became a hot commodity as well as hand sanitiser and masks. Pet sales skyrocketed. Streaming services ran hot. As did Peleton. Conspiracy theories abounded. Medical science broke new ground. People queued for PCR and RAT tests... and for vaccination after vaccination. 773 million people caught COVID. And almost seven million people died. And then, somewhere in between, COVID became like any other cold or flu and life rapidly returned to normal. And not the “new normal”. The old one. The pandemic potentially had the abilty to draw a line in the sand as to how the world worked but in its aftermath, much of what changed out of necessity simply changed back. During COVID, online video conferencing tools were seized upon to continue interaction and education. While there were and are a number of these tools available, none entered the vernacular more so than Zoom. We all knew exactly what a Zoom was and how it worked. But if there was a barometer for it’s popularity, then perhaps its share price is telling. At the start of 2020, one share in Zoom Video Communications was priced at around US$72. And at the end of 2023, it’s pretty much exactly the same. However, at the height of the pandemic in October 2020, that same share was worth US$559! Face-to-face education, with its ability to secure focus and isolate the attention of delegates, again reigns supreme... though webinars definitely are still a thing. Another tale from the stock market is interactive exercise company Peloton. Their shares traded at US$31 in January 2020. In December 2023, that same share is only US$6. But in between, in January 2021, it spiked to US$167. Working from home has perhaps become the most lasting and contentious carry over of COVID. Some companies went “all in”, permanently divesting office space in favour of work from home. Many more are now battling to get workers to return full time to the office. And many hybrids of that exist in between. For the dental profession however, that has never been an option. So as another year ticks over in the ever-changing history of the world, we should remember COVID, how it changed us all and what we’ve all learned as a result. Enjoy the edition... Joseph Allbeury, Editor and Publisher

8 Australasian Dental Practice

he OrthoED Institute has appointed Marton Jakab to the role of Marketing Director. Mr Jakab’s marketing, strategy and management experience spans more than 30 years. The most recent 8 years have been in the healthcare design and construction space. “Marton is well-regarded in the healthcare industry and he will drive growth and brand for our various businesses headed up by founder and head tutor,” Dr Geoff Hall. Dr Hall has been lecturing for decades and has trained over 1,000 dentists in orthodontics in Australia. “Having Marton join us at this stage of our journey is perfect timing,” Dr Hall said. “He has a particular set of skills that will be beneficial to us and he will play a crucial role in the future growth of our businesses. Marton will be working across a range of my business interests with our General Manager, Robyn Wood. Marton’s knowledge in business as well as across all marketing mediums, advertising and communication is second to none and we look forward to having him join the team”.

Toothbrushing lowers rates of pneumonia new study conducted by Brigham and Women’s Hospital in Boston, USA examined whether daily toothbrushing among hospitalised patients is associated with lower rates of hospitalacquired pneumonia and other outcomes. The team conducted a systematic review and meta-analysis to determine the association between daily toothbrushing and hospital-acquired pneumonia. Using a variety of databases, the researchers collected and analysed randomised clinical trials from around the world that compared the effect of regular oral care with toothbrushing versus oral care without toothbrushing on the occurrence of hospitalacquired pneumonia and other outcomes. The team’s analysis found that daily toothbrushing was associated with a significantly lower risk for hospital-acquired pneumonia and ICU mortality. In addition, the investigators identified that toothbrushing for patients in the ICU was associated with fewer days of mechanical ventilation and a shorter length of stay in the ICU. Most of the studies in the team’s review explored the role of a teeth-cleaning regimen in adults in the ICU. Only two of the 15 studies included in the authors’ analysis evaluated the impact of toothbrushing in non-ventilated patients. The researchers are hopeful that the protective effect of toothbrushing will extend to non-ICU patients but additional studies focusing on this population are needed to clarify if in fact this is the case.

November/December 2023

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spectrum | NEWS

One man’s opinion... “Our only hope now is that common sense will ultimately prevail and the market, that is our patients, will figure out that this is not the way they want their health services delivered. This will take time and a lot of people in the meantime will suffer unnecessary grief...”

W By Georges Fast

e live in interesting times. It would appear that reason and common sense take second place behind how people feel or what they believe in, no matter how bizarre these beliefs may be. One can’t help but find parallels between the current world situation and the scenes depicted in the film “Cabaret”, which screened in 1972 and depicted life in Germany during the Weimar Republic in the 1920s when morals and social morays were replaced by anarchy and debauchery in a breakdown of a rational society. On the one hand, anybody in a position of power must assess every word they utter to make sure that it can’t be misinterpreted as being racist, sexist or offensive to some self-selected minority group that identifies as being disadvantaged at some time in the past, no matter how long ago and how tenuous the link. On the other hand, people promoting the latest fashion and fads can dictate to the rest of society how they should live their lives. A few of the many examples of this new imperative... n In an attempt to eliminate the use of cars, certain munici-

palities are forcing developers to restrict the number of car spaces in new developments to 30% of apartments. That this results in full shopping centre car parks and congested streets appears to be of little concern to these people. The inconvenience caused to the largely silent majority who still have to rely on using their cars for transport is seen as a price worth paying in the pursuit of their new religion.

n My practice is located in an older suburb that has seen a rapid

increase in density with older homes being demolished and replaced by new apartment blocks. Parking for my patients is becoming progressively more difficult and yet our local Council, despite many objections has (for a fee) let cafés and other food outlets occupy so called “parklets”, thus further reducing the number of parking spaces that are available to the public. These things might have made sense during the COVID lockdowns with restrictions on the number of people allowed indoors. It will be interesting to see how many of these will remain viable during the next cold and rainy Melbourne winter.

n The saying that “If you don’t have a plan you will become

part of someone else’s plan” has never resonated as much as it does now. We have a situation where we are getting rid of coal-fired power stations before we have built viable alternate sources of energy. We are virtually forcing people to get rid

10 Australasian Dental Practice

of petrol and diesel powered cars before we have effective substitutes, let alone sufficient power generation to keep these charged. The result of this can already be seen in Switzerland where there were periods recently when the population was told not to charge their cars or blackouts would occur. n We have governments that have restricted gas exploration

and placed a cap on the price that producers can charge. Inevitably this will drive explorers to move somewhere else if they find it more profitable to do so and thus reduce the amount of gas available to our community. It seems not to have occurred to our parliamentarians to follow this reasoned train of thought!

Thus replacing what logic would dictate makes sense by what sounds good in theory is the “New Way”. Dentistry is not immune from this trend, where the use of “influencers” is encouraging patients to choose their health providers so that they can feel connected with these glamorous, self-defined “leading lights” of society instead of considering logically if this is best for them. There are ructions in our profession with many being concerned by Corporate- and Insurance-owned practices prescribing how their employed dentists should perform dental treatment and what treatment they should perform. There is also the issue of who is ultimately responsible for an adverse outcome if the employee dentist was following instructions from their employer. We have instances where Health Funds have redirected patients who had been referred to specialists to their own nonspecialist dentists by claiming that their employees could carry out the procedure. It’s just another example of what can be achieved when marketing subsumes logic. The Australian Dental Association, which in reality is little more than an association of dentists and has no legislative authority, is powerless to deal with this problem other than by lobbying AHPRA and the Dental Board. The Boards, which are no longer controlled by professionals, possibly don’t understand the reason for our concerns and are more likely to be swayed by well-funded corporates who will try to convince them that they are more efficient at providing cost-effective treatment to the public. The time to deal with this issue was many years ago when investors were first eyeing off the provision of dentistry as a source of revenue. Our only hope now is that common sense will ultimately prevail and the market, that is our patients, will figure out that this is not the way they want their health services delivered. This will take time and a lot of people in the meantime will suffer unnecessary grief.

November/December 2023

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spectrum | NEWS

Why coaching won’t work in your business...

By David Moffet

“When people are looking for an easier way, the first thing they usually do is they stop doing the necessary work required. They stop doing the exercises. They stop doing the laps. They stop lifting the weights. Successful athletes and sports stars always train harder than the game or the event will be...”

here’s been some interesting discussion recently in dental forums as to the VALUE and PERCEIVED VALUE of coaching services to help grow a dental practice. So let’s try and take emotion out of the discussion and look at things logically... Firstly: It’s human nature for most people to believe that they can do things themselves rather than pay money for somebody else to help them, assist them or advise them. And usually, the smarter or more intelligent that person is [or believes they are], the more they believe that they are smart enough to do things successfully on their own. Even if having somebody else there gets the job done more quickly, or achieves a better result... There’s just this certain feeling of pride and accomplishment in not having to give credit to someone else or anyone else... Yet... some people just don’t get it... It’s not a sign of weakness to pay someone to mow your lawn on a Saturday while you could be relaxing, or playing with your kids, or taking your wife to lunch, or working on your business... and in reality, the guy you pay to mow your lawn will do a better job than you will and in less time and with less complaining... Secondly: Statistically, at age 65, 95% of the population are either still working or dependant on third party financial assistance. Or they’ve died. Which means that at age 65, most people are either dead, or broke. Or dead broke. It’s a fact of life. Thirdly: “If it has been done it can be done.” This is true in business. Anything that has worked successfully in business will work again. The reason people fail to succeed in business is because they deviate from the proven path of success. And when they deviate, they never apportion blame on themselves and their deviation as being the cause of the failure. More often than not, they will point the finger of blame anywhere else than at themselves. I believe that the main reason for failure in business is that people are looking for shortcuts that aren’t there while travelling along the pathway to success. Fourthly: DO THE WORK! JUST DO IT. Legendary golfer Ben Hogan said this about his success as a professional golfer: “If you can’t outplay them, outwork them.” And he also said: “I always outworked everybody. Work never bothered me like it bothers some people”. When people are looking for an easier way, the first thing they usually do is they stop doing the necessary work required. They stop doing the exercises. They stop doing the laps. They stop lifting the weights. Successful athletes and sports stars always train harder than the game or the event will be. Michael Jordan said that he always trained harder than a game would be. He said that way, when things got tough during a game, he knew that he could get through the game, because games were not as tough to endure as his own training sessions were.

12 Australasian Dental Practice

Sadly, in business, not many people ever put themselves under that much extra pressure. And that’s probably why the majority of people underachieve in the workplace... because they just don’t do the work required. Steve Hunter said it best: “Successful people are ordinary people that consistently do the hard things that most ordinary people find too hard to do.” And that’s why people say that coaching doesn’t work, or that it didn’t work for them... I get it. The first coach that I engaged for my business was a disaster that ended up in a legal battle. It wasn’t the sort of coaching that I wanted. Fortunately for me, I quickly found a second coach who I worked with for six and a half years and during that time my dental practice grew dramatically and tripled its production. Putting it bluntly... Coaching works when the client does the work. When the client listens and trusts and acts, then the coaching advice works and works wonders. I’ve been working with a client for ten months now who has totally trusted the coaching process and has seen a 44% increase in her dental practice collections during the second quarter of 2023 compared to the second quarter of 2022. And all that improvement has been achieved without working any more hours, without doing any more marketing and without adding any more staff. The only thing that this client did was that she trusted the coaching process and she trusted her coach’s recommendations. Stupid is as stupid does... Paying for business coaching and ignoring the coach’s recommendations and not doing the necessary work is like paying for university education and not going to classes. Success doesn’t happen by osmosis. We read that most diets fail. It’s not that the diet fails. It’s that the people who start dieting fail to stick to the discipline of dieting. There’s a simple answer as to why coaching isn’t working for most people in their business. And that answer is found in the mirror...

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 practice [of 28 years] 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 see TheUltimatePatientExperience.com.

November/December 2023

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spectrum | NEWS

The resurrection of Melbourne’s CBD

By Kia Pajouhesh

“With the national economy no longer booming, corporations face a new dilemma: productivity! Spooked by social researchers casting doubt on WFH productivity, business leaders are now talking up the importance of a return to the office in maintaining a healthy work culture...”

“People who need people are the luckiest people in the world...” Barbara Streisand, People

ace-to-face service industries - notably hospitality, retail and health services - have historically attracted some of the most people-loving workers in our society. And Melbourne’s CBD has long boasted some of the very best of these services, catering to its high density of citizens who live and work in the city. Pre-COVID, our cherished city laneways and historic arcades teemed with thriving day-trading hospitality and retail businesses. Commercial buildings such as the Manchester Unity Building served as vertical microcosms of quintessential Melbourne where some of our most talented personal service providers plied their trade - hairdressers, tailors, jewellers and dentists among them. Post-COVID, workers spoiled for choice due to record low unemployment began to demand more flexible working arrangements. Enter the normalisation of “work from home” (WFH), previously a privilege known only to self-employed professionals in select industries and white collar contractors familiar with the benefits of less travel time and more personal time. A booming economy, combined with a tightening labour market, now saw corporate Australia hyping the availability of WFH arrangements in competing for the best recruits. Big business could save on office rental costs and access labour outside their travel radius. But what about the legion of service industry workers, with little or no prospect of WFH flexibility due to the nature of their work? Service provision businesses in Melbourne’s CBD, their cash reserves already stretched during lockdowns, increasingly suffered the double whammy of rapidly rising overheads and depleted foot traffic. That was topped off by an outgoing tide of workers known as “the great resignation” - in the dental industry alone, a crippling one-quarter of dental nurses left and moved into non face-to-face industries. The daytime service economy of central Melbourne was decimated - and many small businesses, sadly, collapsed. The CBD became a wasteland of empty shops and arcades. Fast forward to the present. With the national economy no longer booming, corporations face a new dilemma: productivity! Spooked by social researchers casting doubt on WFH productivity, business leaders are now talking up the importance of a return to the office in maintaining a healthy work culture. The one-size-fits-all approach taken by big business, contradicted by workers fighting for improved work-life balance, has fuelled the current industrial battles playing out between workers’ unions and some larger companies.

14 Australasian Dental Practice

My own privately owned business, Smile Solutions, has for three decades offered flexible work arrangements and a 4-day working week for improved happiness - an essential attribute for the provision of empathetic service to paying clients. This point of difference has contributed to our enviable record for staff retention and patient care. Our most valuable lesson learnt about work flexibility is that the need for it varies greatly from person to person and a wise employer adapts their offering to suit each individual rather than taking a cookie-cutter approach. Furthermore, human engagement in the workplace depends on the presentation of a culture value proposition. Today, as the pendulum swings back towards more workers choosing the benefits of workplace inter-connection, the most forward-thinking business leaders are not giving up their CBD office spaces but instead incorporating into them improved staff amenity and workspaces that are more spacious and interactive. In recent months, Smile Solutions has seen a significant increase in CBD businesses joining our corporate dental programs, presenting their workers with an additional incentive to visit the CBD for a number of dental visits each year. CBD service businesses offering more socially interactive workplaces are enjoying a resurgence of job applications, as the most people-loving members of our community are finding their way back to human-facing service industries. Business leaders and a growing numbers of workers, to the benefit of CBD service providers, are again recognising that people need people! And so to future prospects. Government and business leaders wanting to further invigorate Melbourne’s CBD daytrading economy (which still lags well behind its roaring night economy) would do well to consider promoting and supporting goodwill CBD businesses - those that forge lasting interpersonal relationships: hairdressers, GPs, dentists, specialists, jewellers, tailors, dry cleaners, florists, beauticians and shoe cobblers, to name a few. These anchor businesses willingly lure current city workers into their businesses and draw ex-workers back into the city. Importantly, their established goodwill in turn creates substantial flow-on for other major face-to-face services, including retail and hospitality.

About the author Dr Kia Pajouhesh founded Smile Solutions on Collins Street in 1993 with only 8 patients. Today it is the largest single-location general and specialist dental practice in Australia, occupying five floors and the tower of the Manchester Unity Building and servicing more than 200,000 patients. The facility engages over 80 clinicians, including 20 board registered specialists as part of Collins Street Specialist Centre.

November/December 2023

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spectrum | NEWS

Orascoptic™ unveils highest Ergo magnification yet with HDL Ergo™ 5.0x

rascoptic, a frontrunner in cutting-edge dental technology, has unveiled its latest ground-breaking addition to the Ergo™ loupe series, the HDL Ergo 5.0x. This innovation represents a pinnacle in ergonomic magnification, elevating both precision and practitioner comfort in dental procedures. This loupe integrates state-of-the-art refractive prisms to enable clinicians to maintain an upright posture, significantly reducing neck tilt during procedures. One of the hallmark features of this new loupe is its verified 5.0x magnification capability. This advancement not only enhances vision clarity but also prioritises the practitioner’s comfort by promoting better posture. By addressing ergonomic concerns, the HDL Ergo 5.0x aims to mitigate the physical strain often associated with prolonged dental procedures, thereby enhancing the overall well-being of dental professionals.

16 Australasian Dental Practice

The HDL Ergo 5.0x loupe is the latest in Orascoptic’s series of loupes. It stands as their highest Ergo magnification ever. Orascoptic Ergo is also available in 3.0x and 3.5x in a wide range of colours and frames including Rydon™, Phantom™, Triumph™, Tempo™, Tempo Refined Fit, Dragonfly™ NEO, Dragonfly PRO and Victory™. All optical systems employ glass lenses and feature anti-scratch and anti-reflective coatings. Working distance and declination angle are customised to each user. Loupe packages are available that include side shields; a head strap; personalised storage case; an optical screwdriver; and a cleaning cloth. For those interested in experiencing this revolutionary technology, further details about the Ergo line can be found at www.orascoptic.com/en-au, or call us on 1800-643-603 to chat with your Orascoptic Specialist.

November/December 2023

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briefs | NEWS Decoding dental content that breaks the internet... ANGUS PRYOR

n the age of social media, the power of viral content cannot be underestimated. But what’s the secret behind dental content that captures the internet’s attention and spreads like wildfire? Let’s uncover the viral formula that turns ordinary dental posts into online sensations. First and foremost, relatability is key. People engage with content that resonates with their everyday lives. Dental posts that address common concerns like teeth whitening tips, cavity prevention, or even funny dental anecdotes tend to strike a chord with a wide audience. Using language that is friendly, approachable and easy to understand ensures that the message reaches everyone, regardless of their dental expertise. Visual appeal is another vital ingredient. Eye-catching images and videos draw viewers in, making them more likely to stop scrolling and pay atten-

tion. Before-and-after pictures of dental procedures, animations explaining oral hygiene techniques and behind-thescenes glimpses of the dental office create a visually engaging experience. High-quality, clear visuals make the content not only informative but also aes-

thetically pleasing, encouraging viewers to share it with their friends and family. Additionally, interactivity plays a crucial role. Dental quizzes, polls and interactive challenges invite viewers to participate actively. People enjoy testing their knowledge and sharing their results,

fostering a sense of community around the content. Encouraging viewers to comment, like and share helps in amplifying the reach of the post, making it more likely to go viral. Lastly, humour and positivity are contagious. Incorporating a light-hearted touch into dental content, such as dental-related jokes or heartwarming patient stories can create an emotional connection with the audience. Positive vibes not only make the content shareable but also enhance the overall online experience for viewers. In conclusion, the viral formula for dental content involves relatability, visual appeal, interactivity and a sprinkle of humour and positivity. By understanding and incorporating these elements, dental professionals can create content that resonates with the audience, breaks the internet and spreads smiles far and wide. More at dentalmarketingsolutions.com.au

Twitter becomes ‘X’ - what it means for dentists... ANGUS PRYOR

ince buying Twitter last year for $44 billion, new owner, Elon Musk, has spent more than a little time tinkering under the bonnet. The most obvious change to Twitter is a recent rebranding Twitter is now known simply as ‘X’. No joke. Never one to think small, it seems Musk might have had this grand plan for Twitter brewing for years. He was an early owner of X.com (a matching domain name is essential to support the brand) which was his first company before he went on to co-found PayPal and make his fortune. Musk sold X.com, but bought it back in 2017, well before his 2022 acquisition of Twitter.

18 Australasian Dental Practice

So, what has changed in X from when it was Twitter and how can dentists use this to their advantage? To understand what’s changed, we need to look at what was there previously. Historically, Twitter was good for short messaging “tweeting” - with strict character limits in place - just 140 initially. However, X users can now engage in live audio conversations, send longer text messages and even broadcast video. However, Musk (who also founded SpaceX and Tesla) clearly has big plans for X. In fact, he is on record as saying that he aims to make X a kind of super-app, which includes basically anything users want to do online.

Bottom line: For dentists, X is a case of “watch this space”. With change comes opportunity and the changed functionality in X could easily lead to more users and more opportunities to get your dental message out there. However, just because there is additional functionality in an app does not mean that users will embrace the change. Indeed, use of Twitter/X has declined by 25% since Musk’s purchase. If Musk’s super-app plan does gain traction, then more eyeballs means more opportunity. But beware of shiny objects; it’s better to do one form of social media well than spread yourself too thinly. More at dentalmarketingsolutions.com.au

November/December 2023

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dentevents presents...

Exiting Your Dental Practice and Maximising Your Outcome How to get the right result when selling one of your greatest assets

| MELBOURNE* : MAY 11 BRISBANE :: JUNE 22 ADELAIDE : JUNE 1 || BRISBANE SYDNEY* : MARCH 9

*organised in conjunction with the australian dental association

in new south wales and victoria

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.

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

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?

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

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

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

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

How do you handle staff discretion, confidentiality and disclosure?

Legal agreements

Effective strategies for transferring patients effectively from seller to buyer

What to do next post sale: post-sale strategies

Tax implications and strategies when selling

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

Dr Tatiana Repetto-Bauckhage (Project Management, Peru), Christian Brutzer, Chief Commercial Officer (Steering Committee), Dr med. Dent. Philipp Schneider (Project Management, Ghana and Cambodia), Markus Heinz, Chief Executive Officer (Steering Committee) and Christina Zeller, Supervisory Board Member responsible for CSR (Steering Committee).

Ivoclar unveils Ivoclar Joy aid program

ointly with the Ivoclar Vivadent Charity Foundation, the Ivoclar Group has been supporting a variety of social projects around the world for many years, with the aim to help people in less privileged regions. Celebrating its 100-year anniversary, the Liechtenstein-based family business is now unveiling its own aid program called Ivoclar Joy. The program’s main beneficiaries will be children and young people across three continents. Comprising a workforce of roughly 3,700 employees, the group of companies has been dedicated to ensuring that people have the best possible oral health and quality of life worldwide for a century. Following several years of determined work, the Ivoclar Group launched its own international aid program called Ivoclar Joy in 2022, at the behest of Christina Zeller, Supervisory Board Member responsible for CSR. The program is accompanied by a steering committee and an operational project management team. With Ivoclar Joy, the company’s primary goal is to provide dental care to children and young people in underserviced regions worldwide. In addition, the program aims

22 Australasian Dental Practice

to raise awareness about oral health in these groups to enhance their potential for a positive and successful future. After having laid the groundwork, Ivoclar is now unveiling its aid program to the public as part of its anniversary celebration.

Global commitment he focus of Ivoclar Joy is to provide on-location dental care in the form of preventive measures, minor restorative procedures, basic fillings and surgical interventions. The leading provider of integrated solutions has already set up base stations in Ghana, Cambodia and Peru, treating over 2000 patients (as of June 2023). “Going forward, the goal is to involve interested Ivoclar employees around the world in the years to come and establish our aid program in additional locations,” Ms Zeller said.

Portable dental units hree portable dental units allow the local teams of professionals to deliver dental procedures in all three of the above countries, including remote regions. The

portable units, which have demonstrated their effectiveness in international aid projects, are outfitted with a range of dental equipment, including a high-performance suction system, three-way syringe and an ultrasonic element with LED light. The portable units are regularly supplied with instruments and materials from Ivoclar. The program encompasses additional activities such as advancing the skills of local dental professionals and delivering oral healthcare education at schools, fully covering all related expenses.

Three pillars of responsibility t www.ivoclar.com/en_li/ivoclarjoy, the Group of Companies presents detailed insights into the projects of its charitable commitment. The family business places maximum importance on sustainable action and impact, both in its charitable endeavours and as a core principle of its entrepreneurial approach. In its 2022 CSR report, the Ivoclar Group emphasises as an integral part of an interconnected system the significance of all three pillars of sustainability. For more info, see www.ivoclar.com.

November/December 2023

“

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.

spectrum | NEWS

RayFace has all of IDS 2023 smiling

rawling the many halls of the International Dental Show, IDS 2023, in March in Cologne, Germany, the replication of solutions was apparent at every turn. Implants, intraoral scanners, 3D printers, CBCT systems, benchtop mills and the like all enjoyed the rarefied pedestal of innovation drivers at various points in history but alas are now commonplace with myriad choices available at every level. At the IDS, we are looking for different. New. And the question is always what is the next big thing? What will drive the next technological change in dentistry? What will give us leverage and allow us to stand out from the crowd? At IDS 2023, that stand out product was clearly RayFace. Whereas 3D facial scanning is not brand new per se, through RayFace, Ray has defined the category, established the benchmark and attributed purpose to what otherwise could be dismissed as novelty.

24 Australasian Dental Practice

RayFace is a desktop 3D facial scanner that captures a highly accurate extraoral scan of your patient in 1-2 seconds. This scan then integrates with intraoral scans and CBCT data to form an invaluable aid in treating cosmetic and full arch cases, digital dentures and more. By using this advanced digital technology from diagnosis to treatment, the new genre of “Face Driven Dentistry” has been created by considering the patient’s overall facial features - beyond the smile alone - enabling dentists to achieve a high level of accuracy in diagnosis and treatment planning for better, more predictable and aesthetic outcomes. At IDS 2023, Ray showcased all of its cutting-edge made in Korea digital imaging solutions - RayScan CBCT, intraoral scanners, 3D printers and CAD/CAM software, which are highly innovative and can be tailored to the specific needs of each dental practice. However, RayFace took centre stage, occupying the majority of the expansive exhibition space.

Presentations on the technology by well-known dentists and prosthetists throughout the IDS saw the aisles around the stand regularly blocked with dentists and experts from different parts of the world including Australia and New Zealand impressed by this digital dental solution that will enable them to improve their workflow and enhance the patient experience... because apart from being a clinical tool, RayFace will add a 100% WOW factor to your practice and get your patients spreading the word. Ray’s large presence at IDS 2023 highlighted the company’s commitment to advancing the field of digital dentistry and facial scanning in particular and Ray’s innovative solutions are likely to play a key role in shaping the future of dental practice globally including Australia and New Zealand, one face at a time. For more information, contact Ray Australia on 1300-813-050 or visit the website www.rayaustralia.com.au

November/December 2023

spectrum | NEWS

IPS e.max® ZirCAD Prime for high-strength aesthetic restorations

he Ivoclar Group is one of the world’s leading manufacturers of integrated solutions for high-quality dental applications, offering a comprehensive portfolio of products and systems for dentists, dental technicians and dental hygienists. With the products of its IPS e.max ZirCAD Prime range, the company provides a high-strength and versatile zirconia that is distinguished by quality, stability and aesthetics, allowing patients to benefit from the best possible care. The Prime product family includes IPS e.max ZirCAD Prime and IPS e.max ZirCAD Prime Esthetic, representing exceptional high-quality characteristics and high-end aesthetics.

26 Australasian Dental Practice

Prime Zirconia: aesthetic and strong irconia is an all-ceramic material that has the properties required for longlasting restorations and can be used in diverse applications, ranging from single crowns to multi-unit bridges. Aesthetic yet strong, Prime Zirconia closely reproduces the function of the natural tooth structure. Zirconia restorations offer many advantages: They deliver impressive patient-specific aesthetics and provide high stability and versatility. So, Prime Zirconia is the material of choice for creating aesthetic and durable restorations in a diverse range of cases.

The essence: expertise rime Zirconia is reliable, has been clinically proven for years and is based on Ivoclar’s many years of material science expertise in the field of ceramics. In substance, the material combines competence and confidence as customers worldwide have trusted Ivoclar’s all-ceramic materials (IPS e.max) for many years. The continuously growing body of clinical studies confirms an excellent survival rate of 96 percent after five years for Prime Zirconia. “Our unique GT Technology is the key to Prime Zirconia’s genuine, trueto-nature progression of shade and

November/December 2023

spectrum | NEWS

translucency, exceptional accuracy of fit and efficient processing. Prime Zirconia represents high-end aesthetics that is well-received not only in the laboratory and dental practice but also when placed in the patient’s mouth. The material’s impressive high-quality characteristics are supported by a growing number of clinical studies and so we are proud to extend the ten-year IPS e.max guarantee to include Prime Zirconia restorations as well,” explains Tobias Specht, Senior Director Global Business Unit Labside Digital of the Ivoclar Group. “We are committed to making ongoing efforts to enhance the quality of our products and we value the active feedback and input from our customers. A new ring on the disc enables correct positioning and easy repositioning by means of an indicator mark. In addition, the ring gives dental technicians an extra layer of safety (e.g. against chipping or similar), which will have a positive impact on the efficiency of the dental laboratory and, as a result, on the entire workflow. Ultimately, our customers and our company have the same goal: to offer patients worldwide high-quality and durable final restorations.”

November/December 2023

Seamless workflow and IPS e.max guarantee voclar offers the right product for each individual step so that restorations made of Prime Zirconia can be optimally prepared and effortlessly cemented in the patient’s mouth. A carefully designed workflow with optimally coordinated products guides you through all stages. Individual products cross over with other workflows and simplify the coordination between practice and lab to ensure enhanced efficiency on both ends. Dentists can preview and discuss the desired outcome with their patients in advance. Digital impressions and swift data transfer to the dental lab enables an efficient and purpose-driven collaboration. Prime Zirconia restorations are fabricated in the lab and then sent to the practice, where they can be placed using a conventional, self-adhesive or adhesive cementation method. Cementation can be achieved using ZirCAD Cement, a highperformance resin-modified glass ionomer cement designed for everyday use. The cement delivers predictable cementation results case after case with its easy handling and quick clean-up.

Smooth surfaces and a lustrous finish can be attained with OptraGloss®. Using the OptraGloss universal polishers, ceramic restorations are polished to a high gloss in no time at all - ultimately, the most important outcome is to have patients smile with satisfaction. Ivoclar’s e.max family comprises zirconia ceramics (IPS e.max ZirCAD, IPS e.max ZirCAD Prime and IPS e.max ZirCAD Prime Esthetic), lithium disilicate ceramics (IPS e.max CAD and IPS e.max Press) and layering ceramics (IPS e.max Ceram). Customers worldwide have relied on the quality and aesthetics of e.max restorations for over 15 years. Backed by the placement of over 150 million restorations and supported by long-term clinical evidence, Ivoclar offers a ten-year guarantee so that dental professionals can continue to provide their patients with a healthy smile. For more information about Prime Zirconia, scan the QR code. To contact Ivoclar in Australia, call 1300-486-252 - orders.au@ivoclar.com or NZ 0508-486-252 orders.nz@ivoclar.com

Australasian Dental Practice 27

spectrum | NEWS

3D Printing in Dentistry 2024 focuses on Automation, Validation, Replication

he 2nd annual 3D Printing in Dentistry conference is again being staged at the ParkRoyal Darling Harbour, Sydney on Friday and Saturday, February 9 and 10, 2024. The theme of the event is Automation, Validation, Replication. “From the feedback we received, the inaugural 3D Printing in Dentistry event this year was a highly productive, interactive learning experience for delegates,” said Dentevents’ Joseph Allbeury, the organiser of the event and publisher of this magazine. “The lectures included a mix of clinicians and technicians detailing the use of 3D printing in their daily routines, presentations from material scientists and manufacturers as well as technical information on setting up, using and maintaining 3D printers. “When we craft multi-speaker events like this, we’re really trying to present the right information for delegates at the right time, presented by the best real world educators available. It gives delegates high level access to information in a concentrated form that will allow them to make better decisions, solve problems and grow their use and understanding of these burgeoning, gamechanging technologies.”

28 Australasian Dental Practice

Mr Allbeury said that the event included a high level of interaction between the audience and presenters, enhancing the learning experience and highlighting the commonality of issues faced in implementing 3D printing technologies into clinics and labs. “Many delegates came with questions and the format of the event allowed these to be answered, either directly through the presentations or via lively exchanges and Q&A’s with the presenters.” Mr Allbeury said that the event highlighted the level of complexity involved in the 3D printing process and the need for quality education focussed on establishing replicable processes, procedures and workflows to ensure optimal results. “For the 2024 event, we will again cover a broad range of topics covering hardware, software, materials and solutions, plus we’re adding sessions that focus on a couple of aspects of 3D printing that are driving future directions,” Mr Allbeury said. “One of these areas is automation, whereby many printer manufacturers are now looking at what happens beyond the build, working towards more autonomous operation. This is similar to the evolution we saw in milling machines with the addition of automated tool and material changing that allows mills to work

unattended, in some cases 24/7. 3D printers are evolving the same way, though through very different means. “Another area is the validated workflow. Particularly in 3D printing, where the finished product is the result of an essentially complex chemical process, the creation and validation of workflows that ensure 3D printed objects are accurately replicated time and again through printing, washing and curing to guarantee patient safety will only grow in importance to the point where government may well be involved in oversight.” Mr Allbeury said that they are currently engaging with key players in the 3D printing landscape in Australia and New Zealand to devise a programme that is representative of the current needs of local clinicians and dental technicians. “3D printing is clearly a game changer in dentistry and we are once again aiming to deliver a programme that will empower delegates to either take up the technology or take their current investment to an entirely new level. I hope that everyone interested in 3D printing in dentistry will join us in February for another fun, interactive and informative two days.” For more information or to register visit www.3dpd.com.au

November/December 2023

AUTOMATION • VALIDATION • REPLICATION

WHITTY

KLIJNSMA

ELSEY

DIAS

TAKAHASHI

KHAW

KAGAOAN

ANDERSON

Join Australia’s leading experts on dental 3D printing at this two day event exploring the applications of 3D printing in both the clinic and the laboratory. Visit the website for information and additional speakers. BOTH DAYS ARE DESIGNED FOR DENTISTS, SPECIALISTS, DENTAL PROSTHETISTS & TECHNICIANS PLUS A SPECIAL PRESENTATION BY THE THERAPEUTIC GOODS ADMINISTRATION

DAY ONE - FEB 9 - CLINICAL n Importance of validated workflows n In-house clear aligner production

n Full and partial digital denture workflows n Printed crowns - an update

n Applications of 3D printing in cosmetic dentistry n Printing Class IIa appliances in-house

n The advantages of outsourcing design n And more...

DAY TWO - FEB 10 - TECHNICAL n Latest advances in 3D printer materials n Autonomous printing solutions

n Automated post-processing solutions

n Artifical intelligence and design automation n Digital denture production n Debugging print failures

n Workflows for optimising 3D printed results n And more...

REGISTRATION FEES

DATE AND TIME

One Day

$660 inc gst

SYDNEY 9-10 February 2024

Two Days

$990 inc gst

Starts 8.30am | Ends 5.00pm | Rego opens 8.00am

sAVE $330 BEforE 9 jAnuAry 2024

ParkRoyal Sydney Darling

3D Printing in Dentistry is presented 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 • 3D Printing in Dentistry™ and Dentevents™ are trademarks of Main Street Publishing P/L © 2023 Main Street Publishing Pty Ltd

spectrum | NEWS

The Waterpik™ Water Flosser: Adding a Waterpik Water Flosser to a manual toothbrush is up to 3.1 times as effective as brushing alone Effectiveness of water flosser compared to manual toothbrush on clinical signs of inflammation: A randomized controlled trial

Goyal, CR, Lyle DM, Qaqish JG, Schuller R. Evaluation of the Addition of a Water Flosser to Manual Brushing on Gingival Health. J Clin Dent 2018; 29(4):81-86. Study conducted at All Sum Research Center LTD, Mississauga, Ontario, Canada.

(BOP) and the Modified Gingival Index (MGI) at baseline, two weeks and four weeks. The Rustogi Modified Navy Plaque Index (RMNPI) scores were measured at baseline, two weeks and four weeks. Both groups brushed as they normally do and used the toothpaste provided.

Objective

Results

o determine the effectiveness of a Waterpik™ Water Flosser in reducing clinical signs of inflammation as compared to brushing alone.

Methodology eventy two subjects were randomised equally into two groups in this four week, parallel clinical trial: ADA standard manual toothbrush and Waterpik™ Water Flosser (WF) or ADA standard manual toothbrush alone (MT). Inflammation was measured using bleeding on probing

30 Australasian Dental Practice

oth groups showed a significant reduction in BOP, MGI and RMNPI at four weeks (p<0.001, except marginal RMNPI for MT p=0.006). The WF group was significantly more effective for all clinical measures, improving BOP 3.1X, MGI 2.7X and Plaque 2.4X.

Conclusion his study demonstrates that a Waterpik Water Flosser and manual toothbrush are superior to brushing alone in the reduction of inflammation and dental plaque.

To book your free Professional Education Waterpik Lunch & Learn Session or to try Waterpik yourself at Professional Trial rates, visit www.waterpikshop.com.au or email professionalAU@waterpik.com

November/December 2023

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Lunch on us!* Book your free lunch and learn NOW and find out how Waterpik can benefit your practice and patients. professionalau@waterpik.com

Clinically Proven Results Untreated

Treated

Removes up to 99.9% of plaque from treated areas2

Up to 50% more effective for improving gum health vs floss2

Up to 2X as effective for improving gum health around implants vs string floss2

Up to 3X as effective for removing plaque around braces vs strong floss2

*Dependent upon location of practice. Sessions via face to face or Zoom. 1. Terms & Conditions apply. Please visit Waterpik.com.au/shop for more information. 2. Independent clinical studies. Go to Waterpik.com.au for details.

Visit www.waterpik.com.au for more information or email professionalau@waterpik.com

spectrum | NEWS

American Express® expands partnership with HICAPS

oinciding with the roll-out of HICAPS’ new best-in-class Trinity Payment Terminals, American Express has expanded its partnership with the leading healthcare claiming solution. This enables tens of thousands of healthcare providers across Australia to accept American Express and gives American Express Card Members the ability to earn Membership Rewards® points when visiting a HICAPS provider. The new Trinity Terminals, currently being rolled out, will see 90,000 HICAPS providers set up to accept American Express payments including dentists, chiropractors, physiotherapists, general practices and more. The rollout is expected to be complete by the end of 2024. The HICAPS Trinity Terminals are designed to streamline the patient payment experience with fast claim processing among 100% of private health insurers in Australia. For practices, this

32 Australasian Dental Practice

reduces the need to manually input claims, transactions and quoting - cutting down on administration. Robert Tedesco, Vice President & General Manager of Global Merchant Services at American Express said: “Digitisation and automation is a priority for many businesses wanting to simplify the payments process, both for customers and themselves. This announcement bolsters our commitment to supporting healthcare providers by removing friction at the checkout, while allowing our Card Members to earn reward points for essential health services. “71% of American Express Card Members say they are more likely to return to a business that accepts American Express*. With that, we hope healthcare providers will see increased customer loyalty and repeat business with American Express automatically enabled in their payment process.” Simon Terry, Executive for HICAPS said: “One of the most common pain

points for both practices and patients when it comes to paying a health bill is speed and flexibility. HICAPS is dedicated to delivering ease, speed and reliability and since 2014, we’ve achieved this in partnership with American Express. “We’re proud to support more than 90,000 healthcare providers across Australia and today’s announcement will help further reduce administration and complexity for practices, while offering more choice to patients.” For more info, visit www.hicaps.com.au * American Express commissioned internet panel survey conducted in April -May 2022 based on purchases made in the 6 months prior to the survey. Definition of American Express Card Members: Respondents who reported that they have an American Express Card and that they used that card to make purchases in the prior 6 months.

November/December 2023

spectrum | NEWS

Mocom launches new solutions to streamline handpiece maintenance By Joseph Allbeury

OCOM Australia is well-known as a leader in the supply of specialised infection control equipment for dental practices and now the company is introducing another unique solution. We spoke with MOCOM Australia’s Jim Owen to hear all the details. Hi Jim, I hear that MOCOM Aus-

JA tralia is backing up its leading

position in the steriliser and washer disinfector market with a new solution for handpiece maintenance. Tell us more. Australia is launching JO MOCOM two solutions for automated

handpiece maintenance under the brand name THALYA.

34 Australasian Dental Practice

There’s an entry level unit, which lubricates four handpieces in just under a minute and then there’s the THALYA+, which can clean, disinfect, lubricate, purge excess oil and then dry four handpieces in 12 minutes. Both units have couplings available for all the major handpiece brands including KaVo, Dentsply Sirona, W&H, Bien-Air and NSK and there is also a Midwest connection. And both work with any brand of lubricating oil, so if you use a certain brand of handpiece, you can continue to use the matching oil if you wish, except for KaVo QUATTROcare Plus oil, as the can size and shape is not compatible. MOCOM Australia also has its own brand of oil available as a further option.

when you buy a THALYA or JA So THALYA+, you specify which

handpiece connectors you want?

Exactly. So whatever brand of

JO high speed handpieces you’re

using, we configure the unit according to your needs. Slow speed handpieces are generic, so there is also a slow speed coupling available. The launch package for THALYA and THALYA+ includes four couplings of your choice. The THALYA+ package also includes the cleaning chemical. You just need to add the oil of your choice. what does the base model JA So THALYA do?

November/December 2023

spectrum | NEWS

“We can really see a need for THALYA+ because handpieces are either not being cleaned internally or not being cleaned after every use... THALYA+ performs this function in 12 minutes...”

It’s pretty straightforward and

JO easy-to-use. It purges the hand-

piece, lubricates it and then purges excess oil. It will complete 4 handpieces in 55 seconds. Handpieces last longer if lubricated continually and correctly and THALYA makes this a simple process. And what does the THALYA+

JA do differently?

The THALYA+ is unique to the

JO Australian market in terms of its

capability. It flushes a chemical through the handpiece internally and also externally to clean and disinfect it. It then lubricates, purges excess oil and dries the handpiece. There is no other product that does what this unit does.

And then you would still sterilise the handpiece? Yes. So it doesn’t replace sterili-

JO sation, but it does mechanically

clean the handpiece. And I think that’s a major point to highlight because I don’t know that many practices are actually cleaning handpieces internally. When a handpiece slows down after use, it creates

November/December 2023

a back-siphoning effect, where it can draw bioburden and liquids back inside the handpiece. And that needs to be cleaned out. It’s just like anything else that’s sterilised - if it’s not cleaned first, if that bioburden’s not removed, then it can’t be sterilised effectively. So the THALYA+ ensures handpieces are both cleaned and lubricated ready for sterilisation as part of a repeatable, mechanised process. do practices clean handJA How pieces internally now? a good question. In my JO That’s experience, it’s most often not

being done. If you have a washer disinfector unit, you can use a coupling to allow handpieces to be washed internally and then you still need to lubricate. You can also manually spray a chemical through the handpiece. But again, if you’re doing it manually, how can you gauge its effectiveness? You can’t see what’s inside a handpiece, so automating the process using a proven method is ensuring consistent and effective cleaning every time. how often should you interJA And nally clean a handpiece?

You should be doing it after every

JO use of the handpiece, just like you

sterilise it after every procedure. Clean, lubricate and sterilise. We can really see a need for THALYA+ because handpieces are either not being cleaned internally or not being cleaned after every use and when they are, it’s a time-consuming, labour-intensive and technique-sensitive task that slows down the reprocessing cycle. So the THALYA+ performs this function in 12 minutes in a set-and-forget process. It allows this important step to be easily incorporated into the reprocessing cycle every time. do manufacturers recomJA And mend this? manufacturers recommend JO All that their handpieces are cleaned

and lubricated and both of these functions prolong handpiece life.

the THALYA+ just be used JA Can to lubricate the handpieces

without cleaning?

There are four different JO Yes. cycles you can choose from with

Australasian Dental Practice 35

spectrum | NEWS “You can tilt the couplings 45 degrees forward for easier access attaching the handpieces onto the couplings...”

can do that. When you’re processing the scaler handpieces, it’s just cleaning and disinfecting - you don’t need to lubricate. And which scalers does the

JA THALYA+ accommodate?

It will clean EMS, Satelec, Stern

JO Weber and Anthos scalers.

this is quite a game changer JA So for speeding up instrument

reprocessing?

as the THALYA+ JO Especially allows you to easily and auto-

matically clean inside a handpiece. I’ve spoken to various handpiece technicians, who obviously open handpieces when they’re repairing them and the feedback is that most are in an horrendous condition. So the fact that we’re able to address this problem in an automated manner in order to make sure that you achieve sterilisation is vitally important. So yes, I believe it is a real game changer. The THALYA+ takes all the hard work out of handpiece maintenance with the same proven, effective process performed every time. The correct amount of oil is delivered - the same measured dose of cleaning chemical is used. You’re not over- or under oiling and you’re not leaving dirt or bioburden inside.

JA Thank you for your time. the Thalya+. Cycle 1 does everything clean, disinfect, lubrication, air purge. Cycle 2 is just clean and purge if you want to clean without the lubrication. Cycle 3 is lubrication and air purge. And Cycle 4 is an additional air purge. So if you need to remove excess oil from a handpiece, you can use Cycle 4. there any other points to JA Are highlight? There are a couple of other unique

JO points. The first is that when you

place the handpieces into the chamber, you can tilt the couplings 45 degrees forward for easier access attaching the handpieces onto the couplings. Another feature is that the THALYA+ can also process scaler handpieces. There’s nothing else on the market that

36 Australasian Dental Practice

November/December 2023

Total Handpiece Maintenance.

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spectrum | NEWS

Five-in-one CS 9600 3D system is a five-time Cellerant Best of Class Technology Award Winner This advanced dental imaging machine is now the winningest extraoral system of all

ontinual innovation and market-leading technology has earned Carestream Dental’s CS 9600 CBCT system its fifth-straight Cellerant Best of Class Technology Award. The system combines advanced hardware with powerful software to make sure doctors are always practising on the cutting edge. Available in three editions with 10, 12 and 14 fields of view (FOVs), the CS 9600 is sized to meet doctors’ needs so they can focus on the smallest detail of root morphology or zoom out to see the full picture, including the TMJ and sinuses. But the system doesn’t just capture high-quality images, it employs automation, guided assistance and artificial intelligence to capture the right image the first time. Patient positioning is easier and more intuitive so users can avoid mistakes that lead to retakes and instead focus on diagnosis and patient care. Plus, in addition to 2D and 3D imaging and object scanning, practices have the option to include face scanning or a scanning cephalometric arm, turning this five-time winner into an intuitive five-in-one system. It’s not just imaging that makes the system a winner; upgradeable software modules mean that the CS 9600 is always evolving to meet doctors’ needs as their practices grow. No matter the type of treatment a practitioner offers today, when it’s time to scale up, the CS 9600 can expand to handle prosthetic-driven implant planning, upper airway analysis and more.

38 Australasian Dental Practice

Third-party intraoral scanners can even be integrated into the CS 9600’s workflow so doctors can handle the most advanced treatment and care. The latest feature of CS Imaging version 8—the imaging hub that centralises and displays all a user’s Carestream Dental imaging data—lets users combine scans from intraoral scanners with images captured by their CS 9600 so they can do even more for their patients.

Cellerant Best of Class Awards he CS 9600 was selected to receive a 2023 Cellerant Best of Class Technology Award by a panel of prominent dental technology leaders. The Best of Class Technology Awards create awareness in the dental community of manufacturers that are leading the way in how practices will operate today and in the future. In addition to five Best of Class Technology Awards, the CS 9600 won a 2019 Edison Award seal in the Medical/Dental Diagnostics category and the Krakdent Medal of the Highest Quality from the International Fair KRAKDENT®.

For more info on the Cellerant Best of Class Awards and the 2023 winners, go to cellerantconsulting.com/about-best-of-class For info about the CS 9600, visit carestreamdental.com/CS9600 or contact Carestream Dental on (02) 9919-4500 or email anz-enquiries@csdental.com

November/December 2023

CS 9600 Cone Beam CT

Smarter and Better Than Ever. The smart way for your team to capture the high-quality images you need to achieve faster diagnoses and treatment plans. The CS 9600 features multiple advances including video-aided positioning guides and an intuitive SmartPad to enable you and your staff to achieve highquality, precise images on the first try, every time. And intuitive software and innovative metal artifacts reduction tools help you reach a more confident diagnosis.

For more information, please visit:

dentevents presents...

Miniature Implants: A unique system for minimally invasive treatment ONE DAY LECTURE - SYDNEY, MARCH 9, 2024 Presented by Dr Omid Allan This is an exclusive training course on the BioMiniatures Miniature Implant system, offering an opportunity to be the first to learn about this innovative system. The course includes hands-on education on the use of Miniature Implants for full and partial arch rehabilitation using a minimally invasive approach. Miniature Implants are narrow diameter implants with a unique self-drilling and self-advancing design which allows placing implants in very narrow alveolar ridges without needing complex and risky bone augmentation procedures. The course will enable you to restore dentitions in severely atrophic ridges with simplicity and confidence. This will include both surgical and prosthetic procedures.

Re g i s t e r No w : w w w. i m p la n t e d uc a t ion . au

Dr Omid Allan DDS, ADC, MFGDP, MSc (Aesthetic Dentistry) (King’s College London), MSc Oral Implantology (Goethe Frankfurt), FICOI

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Dr Omid Allan holds a Masters degree in Oral Implantology from Geothe University of Frankfurt and also a Masters degree in Aesthetic Dentistry from King’s College of London. He is the inventor of the miniature implant system and founder of BioMiniatures with extensive knowledge and experience in implant dentistry.

REGISTRATION FEES

DATES AND TIMES SYD Saturday, 9 Mar 2024

Dentists

$660 inc gst

Early Bird

$440 inc gst

save $220 - register by february 9

Starts 8.30am | Ends 4.30pm Rego opens 8.30am ParkRoyal Darling Harbour Sydney

Miniature Implants is presented by Dentevents, a division of Main Street Publishing Pty Ltd ABN 74 065 490 655 • www.dentevents.com • info@dentist.com.au Telephone: (02) 9929 1900 • Facsimile: (02) 9929 1999 • Dentevents™ is a trademarks of Main Street Publishing P/L © 2023 Main Street Publishing Pty Ltd

Re g i s t e r No w : w w w. i m p la n t e d uc a t ion . au

spectrum | NEWS

Peri-implantitis never sleeps: Catching up with Dr Frank Schwarz By Joseph Allbeury

rofessor Dr Frank Schwarz, Vice President and Chair of the Education Committee of the Osteology Foundation and a regular visitor to Australia, was one of the stellar presenters at Osteology Barcelona in April. We caught up with Dr Schwarz following his recent trip downunder, the importance of targeted education and his current research interests in peri-implantitis. Thank you again for your time. Good to see you again

always great from every perspective. The FS Australia’s country is of course amazing, but at the same time, I’ve

made so many friends over the years from Australia, so its always a great pleasure to catch up. I was in Brisbane, I was in Melbourne, I was in Sydney and I’m always fascinated about the level of knowledge and education that I see. And it is always amazing to share knowledge and to share, of course, visions for future projects. Excellent. And one of those future projects, is the new

JA after the great unpleasantness of the last few years.

JA National Osteology Group in Australia one of these?

FS Yes. Thank you.

The National Osteology Group Australia and New FS Yes. Zealand has just started and I was involved in the process

So you’ve just come back from Australia. How are we doing there?

42 Australasian Dental Practice

of launching it. Lisa Heitz-Mayfield is taking care of the group. I cannot give you too many details, but there’s an extremely wellorganised group of young clinicians leading it.

November/December 2023

spectrum | NEWS how does that come about? To launch a National JA And Osteology Group in a country or a region? It’s always the same setup. We identify the most suitable

FS people to lead it and then we have to define the needs

of the community. So those are not always the same. What you can successfully use in the United States may not easily apply to Europe or to Australia. That is the core mission in the beginning to identify the need for education and the right format. Australia is a huge country and it’s not so easy to organise face-to-face meetings, so you have to, of course, focus more on online education.

go for surgery. And what we can clearly figure out based on the available evidence is that we definitely benefit from reconstructive procedures or placing bone grafts, placing soft tissue grafts, improving the quality and the quantity of tissues that support implants. And again, this is bone and the soft tissue is a key element to keep implants and to satisfy the aesthetic outcomes that are crucial for the patient. Reconstructive procedures are on the rise, so we have more and more evidence supporting their application. This is one of the main backbones for the management of peri-implantitis. from the patient’s perspective, how do they react JA And to these large surgeries? How do they feel about under-

going treatment?

There is a big shift in patient expectations; they want to

FS keep their implant. This is one thing that is so obvious.

Not a single patient comes to our clinic to ask for an implant to be removed. So they will ask to keep the implant, to maintain the implant. And this makes the procedure even more important. If you cannot maintain the implant, you should definitely think about whether you should place implants in the future. If you don’t have a solution, then you shouldn’t start the implant placement at all. So the awareness is clearly shifting towards keeping implants. do you see any obstacles? Such as the financial JA And aspect for example? And is there a unique perspective as to how you

JA approach online education? Obviously we’ve had a lot

of experience in that during COVID. What can online do better to engage people more and to educate people better?

not so much about better education. As you say, FS It’s it’s about how to attract and engage with people who

would not travel to a conference, people that you would never see at a face-to-face symposium, simply because they cannot envision the benefits of attending a symposium. So once you have reached out and engaged with these people, you may also attract them to future symposia. At the end of the day, this is what we’re trying to do. Another core mission of the foundation is to educate people at different levels, not just expert clinicians. So it’s also about teaching beginners. This is why you may definitely benefit from the Osteology Foundation. It’s about how to apply materials and procedures in day-to-day clinical practice. And this is what we have seen over the past few years. We can learn more and more. So we’re always raising the bar. That’s very interesting. And in terms of your current

JA research, your current drivers, is peri-implantitis still

front of mind?

It’s still the hot topic and it’s ongoing. It never sleeps.

FS You never get to the point where you’re satisfied. It is

in fact a big topic, but you can easily break it down to a core message. The surgical treatment is the key. We have minimally invasive options to control peri-implantitis lesions so we have to

November/December 2023

It is not necessarily expensive. There are some costs

FS related to the procedures, but you have to calculate, on the

other hand, what is the investment for removing the implant and building a site for another implant. This is also very costly. This is even more costly and in many cases even more unpredictable. Do you feel clinicians need to “sell” the procedure to

JA the patient?

Yes. This is in fact a part of the story and you have to

FS communicate it well in advance - that complications may

be part of the implant - that’s life. And therefore communication is a key element.

Australasian Dental Practice 43

spectrum | NEWS

“Peri-implantitis is still the hot topic and it’s ongoing. It never sleeps. You never get to the point where you’re satisfied. It is in fact a big topic, but you can easily break it down to a core message...”

Peri-implantitis is of course just one topic I work on. We’re also currently focusing on what we call “pushing the limits in guided bone regeneration”. We have learned more and more about surgical techniques and this comes on top of new materials being introduced. As materials improve, does it

JA lessen the need for surgical skill? In the best case, the best sur-

FS gical procedure meets the best

material. That would be the optimal situation. And the products are being constantly improved. They are being constantly investigated for specific indications. And this is what we all bring together, the surgical techniques with the clear indication for the best products in specific indications. Fibro-Gide has been JA Geistlich launched in Australia since

we last met in Barcelona in 2019 and there’s a real push on the soft tissue side as a result. How do you see that playing out at the moment? Obviously we’ve had a lot of focus on bone. Now we’ve got a lot of focus on soft tissue. Exactly. And ideally you have to focus on both, though you cannot separate one from the other. And this is what we also see, surgical techniques that combine hard tissue and soft

44 Australasian Dental Practice

tissue regeneration at the same time in order to give more advanced and comprehensive treatment protocols. So you do not necessarily have to slice it into different steps. Soft tissue grafting has become mandatory and a crucial component for any implant-related surgeries. And is Australia on board with

JA this?

Definitely. It’s even at the fore-

FS front. We see countries where

the awareness is at a level that needs further improvement but Australia is already on board. And this is of course the scientific basis for education. If you’re not well-educated, you don’t see the need for something. The awareness comes from education and this is the key. And based on what we have seen in consensus meetings, looking back at the last Osteology Consensus Meeting, which was organized with the SEPA and with the German DGI, we just focused on clinical indications and applications for soft tissue grafting. So that was a whole consensus. We have a bunch of the latest evidence supporting a variety of different procedures, including replacement grafts.

JA Perfect. Thank you very much for your time. FS Thank you so much. November/December 2023

Geistlich Fibro-Gide

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spectrum | NEWS

New steriliser gets thumbs up! By David Petrikas

ractice manager, Janet Rome from Busy Smiles at West Ryde was one of the first in Australia to experience Dürr Dental’s revolutionary Hygoclave steriliser. At A-dec’s invitation, Mrs Rome road-tested the Hygoclave 40 side by side with the practice’s existing sterilisers to assess its suitability to the local market. She said she found it very easy and “straightforward” and easy to use, with the icon-based touchscreen menu making operation simple and intuitive. “It would be very easy to teach other people how to use it. In a busy steri room being able to just touch a button to start a cycle is a real advantage without having to go through menus. “At the same time it seems more ‘advanced’ and you had more information that came up on the

“You wouldn’t even know it was on if the lights weren’t on. It was also quite fast doing a cycle...” screen. It was quite obvious looking at the icons and you know what it is telling you.” One of the main things she noticed in its operation was that every cycle came out dry. “I’ve been doing this for a long and every now and then in processing if nurses haven’t dried instruments properly or over oiled a handpiece, they’d come out with moisture or oil spots and they’d need reprocessing. “But not with the Hygoclave. We didn’t have to reprocess anything.” Mrs Rome said the Hygoclave was also very quiet in operation. “You wouldn’t even know it was on if the lights weren’t on. It was also quite fast doing a cycle.” The automatic door closing and unlocking mechanism was another great feature of the Dürr Hygoclave. “The door on one of our other sterilisers often plays up and is hard to open. You’ve got to have quite good biceps to open it sometimes. “The Hygoclave never gave us any problems and it self-closes and unlocks again when you push the button.” For more info, call A-dec on 1800-225-010.

46 Australasian Dental Practice

Busy Smiles at West Ryde practice manager, Janet Rome.

A-dec product marketing manager, Shal Hafiz and A-dec technical specialist Dom Connolly with the new Dürr Hygoclave.

November/December 2023

Hygiene is in our DNA. The new Hygoclave 50.

5“ high-resolution colour touch display for intuitive navigation

3-fold flexible fresh water supply with integrated quality control

High-performance sterilization- and drying system

Integrated dust protection filter

With Hygoclave 50, Dürr Dental and A-dec offers dental practices a professional Class B solution that combines impressive performance with a well thought-out operating concept – for maximum efficiency and exceptional user friendliness designed to cope effortlessly with tough day-to-day working environments. Available with a volume of 17 or 22 litres. More information under www.duerrdental.com

Scan the QR code or call 1800 225 010 to contact your local A-dec dealer

All in view and documented thanks to connection to the practice network

dentevents presents...

Natural Morphology for Dentists SYDNEY • FRI 16 - SAT 17 FEBRUARY 2024 Presented by Massimiliano Zuppardi, MDT This 2-day program is designed for dentists who want to improve their knowledge of dental morphology and learn step-by-step protocols for achieving natural aesthetic restorations with improved techniques in wax up, ceramic and stain management and teeth reconstruction. The techniques could be applied to composite as well as digital design and manufacture.

LECTURE - Friday, 16 February

Morphology of anterior and posterior teeth n Natural teeth morphology transfer n Importance of morphology n Shape differentials between males and females n Margin creation and ideal emergence profiles n Preparations for Lithium Disilicate n Occlusal Plane alignment using DSD n Embrasure management n Shade map for cosmetic composite/ceramic reconstructions n Morphology shape map for the buccal and occlusal surface n The importance of the marginal crest n Cameras, lenses, flashes, soft boxes, additional light for portrait and intraoral photo/video workflow. n

Case presentations

HANDS-ON - Saturday, 17 February

How to achieve natural morphology every step of the way with a simplified protocol, applicable on multiple materials. This program takes place on a real cases - Bring Your Own! Learn powerful step-by-step techniques including: DSD settings, photos and software selection Choosing the right wax and tools n Working with loupes n Step-by-step tooth morphology reconstruction protocols n Crest and cuspid alignment to create the ideal relationship between uppers and lowers n How to select the right ingot for the milling protocol n Furnace set-up to optimise firing n Bur selection for refining and polishing n Defining shape, texture design and line angle n Staining technique and minimal build up to camouflage artefacts and to achieve smooth integration in situ n Hand and mechanical polishing for a perfect lustre n n

Participants will progress through all exercises including photo/video taking and digital smile design.

Re g i s t e r No w a t w w w. z up p a rd i . e ve n t s

Massimiliano Zuppardi

Master Dental Technician/Ceramist Since the 80’s, Massimiliano “Max” Zuppardi has been working with his father, Maestro Giuseppe Zuppardi, the first Oral Design Member as his partner and Mentor. In 1993, he established his own laboratory in Naples and became an Oral Design Member. Max specialises in complex implant cases and full mouth restorations, with a core focus on precision, bite, morphology and aesthetics. He has studied the most innovative materials and technology for dental restorations aiming to achieve the most lasting and natural looking prosthesis.

REGISTRATION FEES

HOURS CPD

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Having experience working in many countries, he has now established his business in Sydney, Australia, where he opened Zuppardi Dental Studio “Oral Design Down Under”. Mentored from master technicians such as Willi Geller, M.H.Poltz, P.Adar, D.Shultz M Magne and many more, Max has lectured internationally and the author of several publications on featured in the most important Dental Journals.

DATES AND TIMES Friday, 16 February 2024 to

Dentists

$2350 inc gst

Early Bird

$1950 inc gst

save $400 - register by January 3

Saturday, 17 February 2024 Starts 8.30am | Ends 5.30pm Rego opens 8.00am Venue: Oral Design Australia, Mosman, Sydney

Natural Morphology for Dentists is presented by Dentevents, a division of Main Street Publishing Pty Ltd ABN 74 065 490 655 • www.dentevents.com • info@dentist.com.au Telephone: (02) 9929 1900 • Facsimile: (02) 9929 1999 • Dentevents™ is a trademarks of Main Street Publishing P/L © 2023 Main Street Publishing Pty Ltd

Re g i s t e r No w a t w w w. z up p a rd i . e ve n t s

spectrum | NEWS

Take your dental skills to the next level Learn from orthodontic experts with interactive face-to-face or live stream courses... Powered by OrthoEd Mini Masters

Aligner Essentials

he OrthoED Mini Masters is a proven, fully accredited 2-year course that will allow you to deliver predictable, efficient, high quality and profitable orthodontic treatments for your patients. The 2023 face-to-face course is now SOLD OUT. The live-streamed course (which is available) is fully backed with full case support and mentorship to give you the confidence to take on more cases and provide predictable outcomes, every time. Learn how to: • Build a solid foundation in all areas of orthodontics; • Properly diagnose and deliver orthodontic treatment plans; • Save time and money on every orthodontic case; and • Complete cases quickly and successfully, allowing you to take on more cases and grow your bottom line. To learn more about this program visit: orthotraining.com.au/orthoed-mini-masters or scan the QR code below:

n the OrthoED Aligner Essentials module over 3 days, you’ll learn how to provide Clear Aligner treatments confidently, profitably and successfully, even if you have no experience with orthodontics or have struggled with treating patients with aligners in the past. The OrthoED Institute teaches you all of the principles of clear aligner treatment, allowing you to take on cases with confidence. Attend a face-to-face course or learn from the comfort of your home or office through a live streamed event. Through Aligner Essentials, learn how to: • Increase your practice profits; • Provide a better service to your patients; • Provide improved restorative treatments; • Increase your scope of practice; • Reduce referrals to specialists; and • Gain a strong competitive advantage. To learn more about his program visit: https://orthotraining.com.au/aligners or or scan the QR code below:

Advanced Aligner Module earn advanced aligner skills with this 2-day Advanced Aligner module. Learn from industry experts either through a face-to-face course or via the comfort of your home or office through a live streamed event. • Understand when, why and how to combine fixed appliances with clear aligners; • Learn how to manage difficult tooth movements using auxiliary tools and advanced biomechanics; • Learn how to handle early treatment cases for children and teens; a rapidly growing market; • Develop a deeper understanding of the pros and cons of DIY aligner treatments to advise and educate patients accordingly; and • Learn how to take on more complex, challenging cases without having to refer them to specialists. To learn more about this program visit: orthotraining.com.au/advanced-aligner-course or scan the QR code below:

Postgraduate Certificate in Clear Aligner Therapy et the ultimate certificate of acknowledgement in clear aligner treatment that will gain patients’ trust, improve your skills and drive more patients to your practice. The OrthoED’s Postgraduate Certificate in Clear Aligner Therapy is a reputable certification granted by EduQual, a globally-recognised awarding body in the UK. Only current students and graduates of the OrthoED’s Aligner Essentials and Advanced Aligners modules are eligible for this extra qualification. By becoming accredited, you and your practice will receive many invaluable benefits.

50 Australasian Dental Practice

• Gain credibility and win the trust of your patients; • Prove your commitment to learning and excellence; and • Demonstrate your understanding of the principles and techniques of aligner therapy through assessments and treatment planning cases; • Gain a competitive advantage in your local area. To learn more about this program visit: https://orthotraining.com.au/clear-aligner-therapy Visit www.orthotraining.com.au for more information on all of the OrthoED courses or call (03) 9108-0475.

November/December 2023

Growth Through Education

spectrum | NEWS

AALD 2024 set for Fraser Island

he Australasian Association of Laser Dentistry is once again planning another compelling conference from March 8-10, 2024 on picturesque Fraser Island, also known as K’gari. The event will be held at the Kingfisher Bay Resort on the World Heritage Listed island

Photons for the Future he theme for the 2024 Conference is “Photons for the Future” with lectures covering the State of the Art in Laser Restorative Dentistry; Hygiene/Periodontal related laser therapy; Laser surgical case selection and outcomes; and New Research Frontiers in Laser Dentistry as well as other topics. On Saturday afternoon, delegates have the option to participate in the Ultradent Amazing Race, Laser hands-on workshop or an afternoon of 3D printing.

52 Australasian Dental Practice

Speakers at the event include: • Emeritus Professor Laurence Walsh; • Professor Roy George; • Dr Mohammed Meer; • Dr Victor Lagunov; • Dr Lan Tran; • Dr David Cox; and • Dr Sachin Kulkarni.

Meeting Participants are invited to attend all lectures with lunch included Saturday and Sunday as well as the Ultradent Amazing Race on Saturday (Teambuilding) or the option of a handson session on Saturday afternoon. All Participants have included in their packages Breakfast Saturday and Sunday, Dinner Friday and Saturday night, one of which is a seafood buffet, drinks during dinner, Bush Tucker Taste & Talk Friday night with “Sunset by Septodont” dinner and Return boat transfers. Discounted rates have been applied for accommodation and these can be extended for 2 days either side of the Conference. Hotel rooms and Villas are available there may be some other options for larger families, but these need to be confirmed with the resort. For more information on the event, visit www.asnaald.com.au/copy-of-register

November/December 2023

AALD Conference 2024 at Kingfisher Bay Resort - K’gari (Fraser Island)

AALD Conference 2024 at K’gari (Fraser Island )Kingfisher Bay

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spectrum | NEWS

IDEM 2024 announces its return to April with dates confirmed for 19-21 April 2024

oelnmesse Pte Ltd and the Singapore Dental Association (SDA) have launched the 13th International Dental Exhibition and Meeting, IDEM 2024, which will return to its April dates from 19-21 April 2024 at the Marina Bay Sands. IDEM is the leading dental exhibition and conference in the Asia-Pacific region, attracting exhibitors and attendees from around the region. With the expansion of the exhibition space, the event is expected to host around 500 exhibitors and welcome more than 8000 attendees from 70 countries. Mathias Kuepper, Managing Director and Vice President Asia-Pacific, Koelnmesse Pte Ltd said, “We are excited to be working with our longstanding partners the Singapore Dental Association once again to bring IDEM 2024 to the dental community. After IDEM’s overwhelming success as an in-person event last year, we look forward to growing the show even more and providing international companies the ideal launchpad into the Asia-Pacific Market.”

54 Australasian Dental Practice

Dr Lawrence Yong, President of Singapore Dental Association, stated, “IDEM is a platform that provides dental professionals a unique opportunity to interact with the industry’s leading minds and leading companies. The IDEM 2024 conference theme combines expertise from both research and practice under the theme of ‘Exceptional Dentistry: Techniques, Technologies and Trends’ and will provide a platform for dental professionals to explore new advancements and innovations in the field that they can take back to their dental clinic.” The IDEM 2024 exhibition will fully maximise close to 17,000 square metres of floor space on a single level, moving all 3 conference tracks up to be consolidated on the first floor. The exhibition will also expand the number of meeting spaces, such as the business matching lounge, meeting pods and recharge points. The trade exhibition will feature over 500 exhibitors showcasing a wide range of products and services, including dental equipment, instruments, materials and software. In addition to the exhibition, IDEM 2024 will also feature

a comprehensive scientific conference programme running 3 parallel tracks and hands-on workshops. Major national pavilions such as Germany, Italy, USA, Switzerland and Brazil have already committed to expanding their presence at IDEM 2024, demonstrating the event’s increasing popularity and relevance in the dental community. “Without a doubt, the feedback from the France Pavilion exhibitors has been overwhelmingly positive regarding IDEM 2022. We are delighted to hear that they are satisfied with the event’s organisation, and we are proud to have provided them with a platform to showcase their products and services to a global audience. In fact, we are thrilled to announce that many of our pavilion exhibitors have already expressed their interest in returning for IDEM 2024, which is a testament to the value they see in this event.” Lae Douangpraseuth, Head of Business Development, The French Chamber of Commerce in Singapore said. For more information, visit the official website at www.idem-singapore.com.

November/December 2023

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spectrum | NEWS

International Update SDI launches game changing self Mouthrinses and their role in oral health curing composite

DI Limited has launched Stela, a new bulk fill flowable self-cure composite that is widely lauded as an amalgam replacement and the future of composites. This innovative restorative is the result of a partnership between SDI scientists and engineers from three leading Australian universities: the University of New South Wales; the University of Sydney; and the University of Wollongong. As a self-curing bulk fill composite, Stela offers an unlimited depth of cure with low polymerisation stress. Stela is applied in a simplified two-step process; primer and composite. This efficient 15 second process reduces your in-chair time by eliminating traditional preparation steps such as etch, bonding systems and light curing. Stela Primer contains a catalyst that initiates the curing process at the restoration interface and not from the occlusal surface like traditional light curing processes. This polymerisation sequence mitigates stress to enable a gap-free interface, reducing post-operative sensitivity and the risk of premature failure. The Stela initiator system starts a snap set fast cure to convert monomers into polymer chains. Simultaneously, these chains become rapidly and densely cross-linked to each other, forming a complex network. This network reliably binds fillers, resulting in impressive mechanical properties. With very high compressive and flexural strengths, Stela is the ultimate highperformance composite and the ideal amalgam replacement for Classes I, II, III and V. Both Stela Primer and Stela composite contain the 10-MDP monomer to ensure high bond strength to dentine and enamel, providing long lasting restorations with a flawless marginal seal. Stela also offers outstanding radiopacity of 308% Al to aid diagnosis. The formulation contains fluoride, calcium and strontium and is also BPA and HEMA free. Stela is available in either capsule or syringe delivery systems in one universal shade with chameleon effect for excellent aesthetic results. Stela is an Australian innovation, developed and manufactured in Australia and distributed to over 100 countries. For more information, contact SDI at www.sdi.com.au.

56 Australasian Dental Practice

ntimicrobial mouthwashes are considered to reduce dental plaque biofilm and thus the potential to prevent plaque-induced oral diseases, particularly periodontal diseases. The effectiveness of mouthwashes relates to this antiplaque role, as well as their tooth-whitening potential and ability to mask/mange malodour (halitosis). There is also a growing interest in the use of mouthwashes as an adjunctive measure in post-surgical and post-dental care, while the COVID-19 pandemic has given a new lease of life to mouthwashes as an oral antiseptic that may be useful in reducing the oral viral load. The mode of action of mouthwashes varies, depending on their active ingredients, concentrations and mode and frequency of use, as does their potential effectiveness. Irrespective of the mouthwash used, there appears to be strong evidence of their effectiveness in reducing plaque and this is an important consideration given that most oral diseases are plaque-related. There is also considerable evidence regarding the effectiveness of mouthwashes as an adjunct to conventional oral hygiene regimens for preventing and improving gingival health. Given the role of mouthwashes in gingivitis, it is assumed they have a role in preventing periodontitis and improving periodontal health, but evidence of their role and their effectiveness at this stage of disease is less readily available in terms of the quantity and quality of evidence. It remains to be seen, amongst the many agents described, which mouthwash would be “most effective” and this is not addressed here. There has also been a tsunami of interest in the antiviral properties of mouthwashes since the onset of the COVID-19 global pandemic and this continues to be of great interest, with more in vivo research required.

McGrath C et al. Effectiveness of mouthwashes in managing oral diseases and conditions: Do they have a role? Int Dent J. 2023 November DOI 10.1016/j.identj.2023.08.014

November/December 2023

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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 . Innovative by nature decreased fromby an average of 11.8 to 0 injuries per Innovative nature Innovative by nature Exclusively available Exclusively available (1) in New Zealand fromhours worked in Australia from Innovative by nature Exclusively available Exclusively available 1,000,000 ™

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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 our website for more information Call 0508 486 252 J.M Zakrzewska et 486 al. visit Introducing safety syringes into a UK dental school – a controlled study. Brit Dent J65 200188 ; 190;22 88-92. 08 855 (1) www.henryschein.co.nz Orders 1300 www.henryschein.com.au www.ivoclarvivadent.co.nz Call 0508 252 www.ivoclar.com 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

ONLINE CPD CENTRE the cutting | EDGE

infection | CONTROL

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CPD

Shining a light on blue diode laser curing

COVID-19: New challenges for 2024

By Emeritus Professor Laurence J. Walsh AO

he concept of using a laser for photopolymerisation of light cured dental materials has been around for more than 3 decades.1 During that time, there has been a dramatic transition from large argon ion gas lasers running on three-phase mains electrical power through to handheld battery-powered semiconductor diode lasers, with the change in physical size being matched by a reduction in complexity and in price, along with greatly enhanced portability (Figure 1). Blue light emitting diode lasers can undertake all the known functions of traditional LED or halogen dental curing lights2 and can offer short curing times like those previously used with plasma arc (PAC) lamps, but with greater effectiveness.

By Emeritus Professor Laurence J. Walsh AO

Understanding the technology he argon ion gas laser was the first system used for light curing in dentistry. This laser type produces two major wavelengths, 488 nm in the visible blue range, which is suitable for activating camphoroquinone, as well as 514.5 nm in the visible green range, with the ability to choose between the two. In some argon ion laser systems, it was also possible to choose the laser emission line of 458 nm. Argon ion lasers have been used extensively in ophthalmic surgery for many years and medical laser systems were adopted for use in dental practice in the early 1990s. A handful of systems of this type remain in operation in dental clinics in Australia.

64 Australasian Dental Practice

READ ME FOR

CPD

hen the World Health Organisation declared in May 2023 that the health emergency of the COVID-19 pandemic was over and downgraded the pandemic, they stressed that this symbolic announcement did not mean the end of health concerns from the SARS-CoV-2 virus. In fact, they pointed out that even though the emergency phase of the response was over, the

90 Australasian Dental Practice

November/December 2023

pandemic had not ended. At that time, there were spikes in cases in several regions of the world including China and the Middle East and across the globe, thousands of people were still dying from COVID every week. Indeed, there were around 65 million new coronavirus infections each week in China. The key take-home message from the WHO announcement was that the emergency has ended, but the global health threat has not gone away. The purpose of this article is to lay out some of the emerging concerns around the virus and the current challenges that it is posing to health systems worldwide.

November/December 2023

Question 1. Blue diode lasers for curing are becoming popular due to...

Question 6. COVID variant Omicron BA.2.96 is also known as...

a. Low cost. b. Speed of curing. c. Battery life. d. Lightweight design.

a. Eris b. Pirola c. Fornax d. Piranha

Question 2. The primary wavelength of a blue diode laser is...

Question 7. In 2022 in Australia, the top cause of death was...

a. 450 nm b. 460 nm c. 470 nm d. 488 nm

a. COVID-19. b. Ischaemic heart disease. c. Dementia. d. Cerebrovascular diseases. e. Malignant neoplasm of trachea, bronchus and lung.

Question 3. When compared to a standard LED curing light, a 1 second exposure with a blue diode laser gives the same effect as a... a. 2 second cure b. 5 second cure c. 10 second cure d. 20 second cure Question 4. When using a blue diode laser, patients and staff need to wear suitable laser protective eyewear within...

Question 8. The Touch Australian-made rapid antigen test does not test for... a. COVID-19 b. MRSA c. RSV d. Viral Influenza Question 9. During the pandemic, Australia gained onshore capability for...

a. 2m b. 5m c. 10m d. 20m

a. Producing surgical masks b. Producing respirators c. Mask and respirator testing d. All of the above

Question 5. The Monet 450 nm laser curing system has shown to polymerise...

Question 10. The Nobel Prize in medicine was awarded to the two scientists whose pioneering work led to the creation of mRNA vaccines:

a. Over a dozen brands of dental materials. b. Over 20 brands of dental materials. c. Over 30 brands of dental materials. d. Over 50 brands of dental materials.

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 Nov/Dec 2023 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 READ ME FOR

clinical | EXCELLENCE

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CPD

Human factors and the pressures of delivering accurate information in dental practice: An ongoing challenge By Emeritus Professor Laurence J. Walsh AO

ccurate information is essential for providing dental care that is both safe and effective. There are many places where information quality can be a problem in dental practice and this article explores that landscape, including the more obvious areas of radiographs, photographs, impressions and digital scans and going beyond those to consider problems with the source of the information and the processes used to collect it. Those discussions then lead to some practical

suggestions for improvement. For ease of illustration, a patient life-cycle approach will be used as the logical progression of issues, following a hypothetical patient from their initial presentation to the practice through to the completion of the treatment. In earlier articles, I explored the fact that clinicians may face insecurities and anxieties when confronted with the point that their examinations, charting, radiographs, scans and laboratory work items (such as impressions) may have errors. They may contain information that some clinicians cannot recognise, identify or interpret.

98 Australasian Dental Practice

November/December 2023

Question 11. Ensuring patient information is accurate, up-to-date and complete is asserted in Australian Privacy Principle number... a. 3 b. 5 c. 8 d. 10 e. 13 Question 12. Many medical history forms fail to ask questions about... a. Prescription medications. b. Recreational drug use. c. Alternative or natural therapies. d. Smoking and vaping. e. All of the above. Question 13. In the alphabetic classification scheme for adverse drug reactions, A stands for... a. Augmented b. Anaphylactic c. Allergic d. Anti-body Question 14. Areas often missed in treatment records include... a. Details of LA administered. b. Shade of restorative material used. c. Treatment options presented. d. Reasons for the prescription of medicines. e. All of the above. Question 15. In the ACT framework, C stands for... a. Communicate b. Concentrate c. Compile d. Connect

To retrieve your FREE Dental Community Login:

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

CPD

A freedom alternative to the consequences of bruxing Digital copy denture fabrication for a bruxing/clenching patient By Marc Wagenseil DD, RDT

ften, we encounter patients who exhibit bruxing/ clenching habits, which can cause premature wear of denture teeth. Treating this condition is difficult and frustrating as treatment options can be uncomfortable or expensive if dentures require replacement more frequently. An opportunity arose to challenge me to consider an alternative treatment option and craft a digital copy denture to address possible premature wearing of a denture due to suspected bruxing. The combination of traditional experience with emerging digital technology provided inspiration to “get out of

one’s own way” and, ergo, challenge professional complacency. This article explores the treatment option of how to manage the consequences of bruxing/clenching, not the causes associated with it and how to prevent them.

Patient case n existing patient to the practice presented for a recall appointment with an approximate two-and-a-half-year-old complete upper denture to natural lower dentition. Having been a patient for many years, she has exhibited bruxing/clenching tendencies, which have been present for decades. Many treatment options during her life have been explored with limited or no success.

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Question 16. Bruxing or clenching for denture patients can... a. Cause premature wear to dentures b. Discolour denture teeth c. Make lower denture more stable d. None of the above Question 17. Treatments for the bruxing patient mentioned include... a. Hallucinogenic drugs b. Bionator appliance c. Splints and hypnotherapy d. Mandibular Block Question 18. For the treatment plan, the copy denture... a. Was altered significantly b. Was made in a Vita C3 c. Was not enhanced as it was performing well d. Was not needed Question 19. One reason the freedom in centric concept is important is because... a. Denture teeth are sensitive b. Denture teeth have no nerves and the patient cannot feel the teeth occlude c. Denture teeth made of polymers are terrible d. Denture teeth have a low CTE Question 20. A patient’s chew cycle is usually... a. The same for all patients b. Never important c. Better with interference d. Unique to each individual

abstracts | 2023

A summary of the latest research

By Emer. Prof. Laurence Walsh AO

Clinical patterns in brain fog in Long COVID

ong COVID or post-COVID condition (PCC) is a common complication following acute COVID-19 infection. PCC is a multi-systems disease with neurocognitive impairment frequently reported regardless of age. PCC is characterised by varying degrees of multi-system involvement including cardiorespiratory, neurologic, neurocognitive, musculoskeletal and others. Little is known about the risk factors, associated biomarkers and clinical trajectory of patients with this symptom. This study determined differences in clinical risk factors, associated biochemical markers and longitudinal clinical trajectories between patients with PCC with subjective neurocognitive symptoms (NC+) or without (NC−). A retrospective longitudinal cohort study was performed using a well-characterised provincial database of patients with clinically confirmed PCC separated into NC+ and NC− cohorts. Demographical, clinical and biochemical differences at initial consultation between the two patient cohorts were analysed in cross-section. Multivariate regression analyses were conducted to identify independent risk factors for neurocognitive impairment. Determination of the recovery trajectory was performed using serial assessments of patient-reported health-related quality of life (HR-QoL). Female gender, milder acute infection and pre-existing mental health diagnoses (such as depression and/or anxiety) were independently associated with subjective neurocognitive impairment at 8 months post-infection. Female gender was a significant risk factor for development of neurocognitive symptoms in ages 45-64 years but not in other age ranges. It remains unclear if this association is relevant to the pathogenesis of neurocognitive impairment or whether women with milder acute infections are simply more aware of their cognitive defects, although evidence involving task-related cognitive testing suggests that women do objectively perform more poorly than men post COVID-19 infection. NC+ patients demonstrated lower levels of antibody (IgG, IgG1 and IgG3) compared to NC− patients. This raises the possibility that humoral immunity derangements might be relevant for the development of neurocognitive symptoms. The NC+ cohort had poorer HR-QoL at initial consultation 8 months post-infection, with gradual improvement over 20 months post-infection. Neurocognitive impairment represents a severe phenotype of PCC, associated with unique risk factors, aberrancy in immune response and a delayed recovery trajectory. Those with risk factors for neurocognitive impairment can be identified early in the disease trajectory for more intense medical follow-up. Since this study examined patients from specialty long-COVID clinics, the findings might be selectively biased towards those with more severe PCC as those patients are more likely to seek care and referral to the long COVID clinic.

Yam GY et al. Characterizing long‑COVID brain fog: a retrospective cohort study. J Neurol. 2023;270:4640-4646.

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Brain fog in Long COVID and its parallels with post-viral syndromes

ost-acute sequelae of COVID-19 (PASC, ‘‘Long COVID’’) pose a significant global health challenge. The pathophysiology is unknown and no effective treatments have been found to date. Several hypotheses have been formulated to explain the aetiology of PASC, including viral persistence, chronic inflammation, hypercoagulability and autonomic dysfunction. Here, we propose a mechanism that links all four hypotheses in a single pathway and provides actionable insights for therapeutic interventions. We find that PASC are associated with serotonin reduction. Viral infection and type I interferon-driven inflammation reduce serotonin through three mechanisms: diminished intestinal absorption of the serotonin precursor tryptophan; platelet hyperactivation and thrombocytopenia, which impacts serotonin storage; and enhanced MAO-mediated serotonin turnover. Peripheral serotonin reduction, in turn, impedes the activity of the vagus nerve and thereby impairs hippocampal responses and memory. These findings provide a possible explanation for neurocognitive symptoms associated with viral persistence in Long COVID, which may extend to other post-viral syndromes. In principle, however, none of the mechanisms described in this study are unique to SARS-CoV-2 infection. The connection between serotonin reduction and vagus nerve dysfunction may thus be relevant beyond Long COVID. The fact that low serotonin levels are also found in non-viral conditions characterised by elevated interferon levels, such as systemic lupus erythematosus or multiple sclerosis, suggests that the pathway described in this study may even apply beyond viral infections.

Wong AC et al. Serotonin reduction in post-acute sequelae of viral infection Cell 2023; Cell 186:4851-4867.

November/December 2023

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the cutting | EDGE

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Shining a light on blue diode laser curing By Emeritus Professor Laurence J. Walsh AO

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the cutting | EDGE Argon ion gas lasers have a low electrical conversion efficiency, meaning that most of the incoming power from the three-phase mains electrical supply is converted into heat, which requires the system to have a large water and/ or air cooling system. This makes argon ion lasers very large and heavy units and also requires the dental practice to have a three-phase power outlet installed to service the high current demands of the laser system.3 Similar comments apply to helium-cadmium lasers which emit light at 441.6 nm, however these were never produced commercially for dental applications. There was also passing interest in diode pumped solid state (DPSS) lasers

“A 1-second laser exposure gives the same effect as a 10-second cure with a standard LED curing light and 3 seconds is directly comparable to 20 seconds with an LED curing light...” emitting light at 473 nm, however these are large units with flashlamps and water cooling that also need a mains power supply. They were never adopted into dental practice for light curing. The advent of blue light semiconductor diode lasers in the 1990s by Nakamura working at Nichia in Japan has considerably simplified the technology for generating visible blue light. Low-power versions of these same diode lasers are used today in a wide range of industrial and consumer devices, including Blu-ray™ players. Such lasers are now used widely in displays, lighting, welding and optical processing, as well as in medical lasers. Blue light diode lasers are typically constructed using deposited layers of gallium nitride (GaN) or indium gallium nitride (InGaN), with the latter being particularly efficient for generating light in the 445-465 nm range, which is useful for photopolymerisation. The typical wavelength of GaN diode lasers is 450 nm, which makes these ideal for activating traditional and novel photo-initiating agents. In recent years, single GaN emitters capable of optical outputs of up to 8 watts

November/December 2023

Figure 1. Laser sources for blue light curing used by the author, showing the considerable progress in the technology over 30 years. Panels A-C: HGM PC argon ion laser (1991); Panels D-F: HGM Compac argon ion laser (1993). Both these models had an output power of 4 watts and were large and heavy and required three-phase electrical power. Panel G: Monet battery-powered handheld GaN semiconductor diode laser (2023). Note the laser protective eyewear on the patient and staff members in panel F. in continuous wave mode at 442 nm have been described.4,5 Typical drive voltages for such components are between 4 and 6 V DC, with threshold current values in the order of 100 mA and maximum current flows up to 5 amperes, making them ideally suited for operation from lithium ion batteries and other low-voltage power sources. Today, most blue light semiconductor diode laser components are made in either Japan or in Poland, which are the two countries where much of the blue diode laser technology has been developed over the past 30 years.

Self-heating is an issue with GaN semiconductor diode lasers and this can affect their performance when used in continuous wave mode. With their electrical conversion efficiency being around 35%, a diode laser which is emitting 2 watts of light (optical power) will be producing about 4 watts of heat. If uncontrolled, heating occurs during prolonged use and this can lead to catastrophic optical damage (COD) within the diode laser.5,6 Fortunately, this scenario will not occur in dentistry because only short bursts are needed for curing, in the order of 1-3 seconds per burst.

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the cutting | EDGE Optical delivery system eing a point light source, the optical arrangement from a GaN diode laser allows a low divergence near parallel beam to be created which is optically homogeneous. As shown in Figure 2, with the Monet™ handheld laser system, the optics create a near parallel slightly diverging beam of approximately 8 mm in diameter. The low divergence means that there is little change in the power density (intensity) at the target as the working distance from the head of the laser to the tooth changes over several centimetres. This is unlike the situation for most curing lights where the beams diverge at larger angles from the head of the curing light tip and the power density falls away as the distance from the tooth increases, because of the inverse square law. Thus, the near parallel beam of the laser provides a major advantage over conventional curing lights for curing materials in deeper preparations and in posterior regions of the mouth where access is more difficult.

Practical considerations he first semiconductor diode laser designed for light curing was released into the dental market after gaining US FDA approval in 2021. The Monet™ laser (manufactured in the USA by the CAO Group Inc and distributed in Australia by BioMeDent) (Figure 3), is a 2 watt laser that can deliver 2 Joules in just 1 second, at a power density of some 5,303 mW/cm2. This power density is far greater than that which can be achieved by other curing light sources7 and is over 8 times the minimum level of 600 mW/cm2 used as a benchmark for curing lights for the past 30 years. The short exposure times used means that, with this laser, lower energy doses (in Joules) are needed to achieve adequate photopolymerisation for increments of resin composites up to 2.5 mm in depth. The high depth of cure which can be achieved for such laser systems means that there is a lower differential in hardness for resin composites for hardness of the surface versus hardness at a depth of 2 or 2.5 mm.

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Figure 2. A comparison of semiconductor diode lasers and high-intensity LED lights for photopolymerisation. Panel A: A spectral bandwidth plot showing intensity versus wavelength for a high-intensity LED light (Ultradent Valo) in dark blue versus the 450 nm Monet diode laser in red. Panel B shows the beam dispersion from the end of the curing light at the top of each image. Note the very small divergence for the laser and the much wider divergence for the LED light. This difference comes about because the laser is a point source of light and can be readily lensed to give a near parallel beam.

Table 1. A comparison of dental blue light curing systems Argon Parameter LED Halogen ion laser

Blue diode laser

Size and weight

Small

Medium

Large

Small

Power source

Battery

Mains

Battery

Primary wavelength

460 nm

470 nm

488 nm

450 nm

Spectral bandwidth

50 nm

100 nm

1 nm

5 nm

Conversion efficiency

33%

0.1%

35%

Beam collimation

Variable

Low

High

Cooling system

Fan or Fan passive

Water and air

Passive

Performance slight change in clinical approach is needed with diode laser curing, since repeated short bursts are used, rather than longer irradiation periods. A single 1 second cure is suitable for curing bonding agents, while when layering resin

composite materials, a single 1 second cure per layer is the normal approach. The surface of the resin will be hard to the touch after this 1 second period. With any light source, the depth of penetration through various dental restorative materials is influenced by the presence of

November/December 2023

the cutting | EDGE The depth of cure which is achieved varies according to the brand of resin composite and the shade, as well as the curing time used with the laser. As light passes through dental materials, light from a laser penetrates more than light from an LED of a similar wavelength, because the laser beam is both coherent and monochromatic. This means there is less destructive interference as scattering events occur within the material. The laser manufacturer (CAO Group Inc, Utah, USA) has provided a series of reference graphs9 showing the curing depth of various common resin composite materials, as measured using the ISO 4049:2019 standard. Another way of easily determining the influence of the laser for light curing is that a 1 second laser exposure gives the same effect as a 10 second cure with a standard LED curing light and 3 seconds is directly comparable to 20 seconds with an LED curing light.8 A clinician can also do a practical test themselves, by directly exposing the end of a syringe of resin composites material to the laser and then extruding the set material from the syringe and determining how far the setting reaction has progressed by assessing the hardness of the extruded composite with a probe. This simple practical test is the basis of the ISO standard and is a useful technique when planning to laser cure the material in a situation where there is no previous data at hand.

Safety for the dental pulp Figure 3. The major components of the Monet™ diode laser dental curing system. The main laser unit with its rechargeable battery attached is shown in panel B. A single pushbutton operates the laser. A set of 3 beam width reducing apertures and the 50% neutral density filter are shown in panel A. Laser protective eyewear is shown in panel C and the laser protective handheld paddle shield in panel D. The replaceable battery is shown in panel F and the battery charging base and stand for the laser in panel E. The base also contains a power meter to check for the proper operation of the laser. the various pigments which are used to create the unique shade of the material. A restorative material which has a more intense yellow colour will attenuate blue light more because of absorption. Longer or repeated exposures give enhanced depth of cure because of greater radiant exposure. This is why repeated bursts

November/December 2023

with longer 3 second exposures are preferred with this laser system, especially when bulk fill resin composites materials are being cured.8 The Monet 450 nm laser curing system has been tested with over 50 brands of light cured dental materials and has been shown to polymerise all of these.13-15

he short exposure times used with diode laser systems minimise the extent of thermal stress to the dental pulp. Because of the high efficiency of monomer conversion under the intense photon flux generated by laser irradiation, the light dose required for curing is less than for conventional light sources and less heat is generated within the bulk of the composite material itself during the period of irradiation.10,11 A useful clinical approach is to cure restorations in separate bursts of 1 second duration, bearing in mind that each separate exposure represents the curing period for approximately 2.5 mm of material. A gap in time between each of the exposures will reduce heat accumulation.12

Australasian Dental Practice 67

the cutting | EDGE For very large restorations that are being placed (e.g. complete coronal buildups larger than 8 mm in diameter), it is appropriate to do laser curing procedures with overlapping spots. A modified irradiation protocol is used when curing resin cements beneath zirconia crowns, with a 1 second cure beneath each cusp for a molar crown, which is repeated 3 times. Following the same approach, three curing cycles of 1 second each can be used with resin cements beneath veneers on anterior teeth. The extremely high power density of the laser means that penetration through translucent materials can be reliably achieved. This includes through various ceramic materials when the target to be cured is a resin cement beneath a veneer or a crown. It has been estimated from laboratory tests that a continuous (uninterrupted) exposure period of more than 5 seconds (well beyond the manufacturer’s recommended exposure time) would be needed to approach the threshold of 5.5°C at which thermal stress to the dental pulp becomes significant.13 One must also bear in mind that the temperature measured on the very top surface of a restoration will be higher with laser curing then when an LED is used, simply because of the greater power density of the light and the accelerated polymerisation reaction which is occurring on the top surface. This helps to achieve greater conversion of the resin and to increase its hardness. Nevertheless, the thermal stress at the level of the dental pulp will still be tolerable despite the warmer surface, due to the poor heat conduction of the material.

Safety for the soft tissues ntense visible blue light is strongly absorbed into haemoglobin.3 Consequently, it is important to avoid inadvertent exposure of gingival tissues when curing buccal or cervical restorations. To make this easy to do, a sized aperture can be applied over the laser tip to reduce the spot size down from the normal 8 mm to 6, 4 or 2 mm. Applying an aperture does not influence the divergence of the beam as it emanates through the aperture opening. The manufacturer also makes available a neutral density attenuator which will reduce the beam intensity by 50%. This is intended primarily for use when doing tack curing of veneers, rather than for procedures near soft tissues.

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Safety for staff and patients consequence of the low beam divergence of the Monet system beam is that the nominal ocular hazard distance (the distance within which laser protective eyewear must be worn) is quite high, at almost 10 metres. In practical terms, this means that the patient and everyone working in the dental operatory will fall within the nominal ocular hazard distance of the laser. Patients and staff need to wear suitable laser protective eyewear (e.g. optical density above 8) which attenuates the laser wavelength to below the level which can cause retinal damage to the eye (Figure 3).

“Driving the change from halogen lamps to LEDs was the greater reliability and performance of LEDs over halogen lamps and a reduction in the length of the curing time. Exactly the same issues are relevant now when considering the transition from an LED curing light to a diode laser curing system, with enhanced performance and reduced clinical time being the major benefits...” There is also a paddle filter available which also has a high optical density (OD of greater than 4) for additional use, as well as inserts that can be worn between the eye and magnifying loupes. Another option used by the author is a protective laser face shield, as this allows normal loupes to be worn beneath this.16 When compliance with wearing laser protective eyewear is excellent, staff can work with complete confidence and safety. After more than 30 years of using lasers for curing (Figure 1 Panel F), there have been no adverse events reported in the literature, which is a testament to the performance of the protective eyewear as well as to the training and clinical skill of those who have been doing laser curing over the past 3 decades.

The regulatory requirements for laser safety in a healthcare setting are outlined in Australian standard AS 4173:2018 Safe use of lasers and intense light sources in health care. This standard provides the platform for safety measures in those 3 jurisdictions within Australia (Queensland, Western Australia, Tasmania) where there is formal regulation of laser safety in dental practice. Since the Monet laser is manufactured in the United States, like other lasers of US origin, it is shipped with a US laser safety sign. This sign does not meet the Australian requirements, being red on black, instead of black on yellow. Clinics can create their own signage (e.g. by laser printing the required information onto yellow paper and then eliminating this) as long as they meet the requirements for specified wording on the laser sign (indicating that a Class 4 visible laser is in use). Information on laser safety requirements for the Australian setting can be obtained from online courses such as those presented by the author. Information on laser regulation is summarised in the ADA Practical Guide on Lasers. Extensive information on the processes for properly installing and commissioning a class 4 laser in an Australian dental practice can be obtained from the Australian Association for Laser Dentistry for those clinicians who are members of this association.

Conclusions ince its release in North America in 2021, the Monet handheld diode laser curing system has attracted great interest. Many studies on blue laser photopolymerisation have shown positive results,10-15,19-28 extending the literature from what had been done with previous generation blue light argon ion lasers. In both cases, the high power density of the laser light has been shown to improve the physical and mechanical properties of resin composite materials. Moreover, over recent years there have been important advances in the literature regarding the behaviour of contemporary resin composites materials during light curing, especially those materials used for bulk filling when exposed to bursts of high intensity light.29-36 This sizeable literature shows that contemporary materials can be cured successfully using short bursts of

November/December 2023

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the cutting | EDGE intense light, provided that the exposure conditions are optimised to align with the properties of the relevant material. This reinforces the need to access the manufacturer’s guide and also to perform a test cure (such as the syringe test mentioned previously) to confirm the correct number and length of irradiation cycles with the laser. Many major dental innovations require almost a generation for a change to become completely embedded in everyday clinical practice. LED curing lights were introduced in 2001 and now well over 20 years later it would be unusual to find a dental practice that was not using an LED light for photopolymerisation. Driving the change from halogen lamps to LEDs was the greater reliability and performance of LEDs over halogen lamps and a reduction in the length of the curing time. Exactly the same issues are relevant now when considering the transition from an LED curing light to a diode laser curing system, with enhanced performance and reduced clinical time being the major benefits. The question is whether this revolution will occur as quickly as the transition to LED curing and only time will tell.

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 400 journal papers, with a citation count of over 20,000 citations in the literature. Laurie holds patents in 8 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. Verheyen P, Walsh LJ. Photopolymerization. In: Moritz A, Beer F, Goharkay K, Schoop U, Strassl M, Verheyen P, Walsh LJ, Wernisch J, Winter E. Oral Laser Application. Berlin: Quintessence, 2006. pp. 139-192.

2. Walsh LJ. Extended applications of curing lights in dental practice. Australas Dent Pract. 2014;25(4): 70-73.

3. Walsh LJ. Laser fundamentals. In: Convissar RA (ed) Principles of Laser Dentistry, 3rd edition. St Louis: Elsevier Mosby. 2022. pp. 18-38. 4. Liang F, et al. GaN-based blue laser diode with 6.0 W of output power under continuous-wave operation at room temperature. J Semicond. 2021;42:112801.

5. Zhong Z, et al. Design and fabrication of high power InGaN blue laser diode over 8 W. Optics Laser Technol. 2021;139:106985. 6. Tian A, et al. Design and growth of GaN-based blue and green laser diodes. Sci China Mater. 2020;63(8):1348-1363.

7. Maucoski C, et al. Ability of short exposures from laser and quad-wave curing lights to photocure bulk-fill resin-based composites. Dent Mater. 2023;39(3):275-292. 8. Rocha MG, et al. Depth of cure of 10 resin-based composites light-activated using a laser diode, multipeak, and single-peak light-emitting diode curing lights. J Dent. 2022l;122:104141.

9. Depth matrix guide of different composites materials. https://caogroup.com/pages/monet-depthmatrix-guide 10. Maucoski C, et al. Temperature changes and hardness of resin-based composites light-cured with laser diode or light-emitting diode curing lights. Odontology 2023;111(2):387-400.

11. Maucoski C, et al. In vitro temperature changes in the pulp chamber caused by laser and Quadwave LED-light curing units. Odontology 2023;111(3):668-679. 12. Maucoski C, et al. In-vitro pulpal temperature increases when photo-curing bulk-fill resin-based composites using laser or light-emitting diode light curing units. J Esthet Restor Dent. 2023;35(4): 705-716.

13. Christensen GJ. Clinician’s Report (Feb. 2021) “Performance of New Curing Light”. 14. Christensen GJ. Clinician’s Report (Dec. 2021) “Buyer Guide”.

15. Christensen GJ. Clinician’s Report (July 2022; 15(7)) “Curing Light: Diode laser versus other light sources”. 16. Walsh LJ. Surgical magnification and eye protection for laser users. Australas Dent Pract. 2009;20(4): 104-108. 17. Mandic VN, et al. Blue laser for polymerization of bulk-fill composites: influence on polymerization kinetics. Nanomaterials (Basel) 2023; 13(2):303. 18. Tarle Z, et al. Polymerization of composites using pulsed laser. Eur J Oral Sci. 1995;103:394–398.

19. Anić I, et al. In vitro pulp chamber temperature rises associated with the argon laser polymerization of composite resin. Lasers Surg Med. 1996;19(4):438-444.

20. Meniga A, et al. Pulsed blue laser curing of hybrid composite resins. Biomaterials. 1997;18:1349–1354. 21. Cassoni A, Rodrigues JA. Argon laser: a light source alternative for photopolymerization and in-office tooth bleaching. Gen Dent. 2007;55(5): 416-419. 22. Lloret PR, et al. Flexural properties, microleakage, and degree of conversion of a resin polymerized with conventional light and argon laser. Quintessence Int. 2008;39(7):581-586. 23. Tielemans M, et al. Comparison of microleakages of photo-cured composites using three different light sources: halogen lamp, LED and argon laser: an in vitro study. Lasers Med Sci. 2009;24(1):1-5. 24. Mirsasaani SS, et al. Photopolymerization of a dental nanocomposite as restorative material using the argon laser. Lasers Med Sci. 2011;26(5): 553-561. 25. Mirsasaani SS, et al. Measurement of solubility and water sorption of dental nanocomposites light cured by argon laser. IEEE Trans Nanobioscience 2013;12(1):41-46. 26. Pahlevan A, et al. Effect of LED and argon laser on degree of conversion and temperature rise of hybrid and low shrinkage composite resins. Open Dent J. 2016;10:538-545. 27. De Santis R, et al. Mechanical and thermal properties of dental composites cured with CAD/ CAM assisted solid-state laser. Materials (Basel) 2018;11(4):504. 28. Kalidass P, et al. In vitro study - comparative evaluation of bond strengths of stainless steel brackets and ceramic brackets after curing with the argon laser and the conventional visible light. J Pharm Bioallied Sci. 2022;14(Suppl 1):S688-S692. 29. Par M, et al. Effect of rapid high-intensity lightcuring on polymerization shrinkage properties of conventional and bulk-fill composites. J Dent. 2020;101:103448. 30. Par M, et al. The effect of rapid high-intensity light-curing on micromechanical properties of bulkfill and conventional resin composites. Sci Rep. 2020;10:10560. 31. Par M, et al. Rapid high-intensity light-curing of bulk-fill composites: A quantitative analysis of marginal integrity. J Dent. 2021;111:103708. 32. Par M, et al. Polymerization kinetics and development of polymerization shrinkage stress in rapid high-intensity light-curing. Polymers 2022;14:3296. 33. Al Nahedh HN, et al. The effect of different light-curing units and tip distances on the polymerization efficiency of bulk-fill materials. Oper Dent. 2022;47(4):E197-E210. 34. Jakupović S, et al. Assessment of microhardness of conventional and bulk-fill resin composites using different light-curing intensity. Polymers (Basel) 2023;15(10):2250. 35. Burrer P, et al. Effect of polymerization mode on shrinkage kinetics and degree of conversion of dualcuring bulk-fill resin composites. Clin Oral Investig. 2023;27(6):3169-3180. 36. Odum NC, et al. Fast curing with high-power curing lights affects depth of cure and post-gel shrinkage and increases temperature in bulk-fill composites. Oper Dent. 2023;48(1):98-107.

November/December 2023

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practice | MANAGEMENT

Dental practice valuation: Facts dentists should know! By Graham Middleton

“I am aware of many cases where potential buyers were given poor advice by accountants... Dentists who should have seized an opportunity passed it up only to spend years regretting their decision...”

began valuing dental practices in 1992 and in time, dentists became my biggest client group. Upon cofounding the Synstrat Group in 1994, practice valuations became one of the services distinguishing us from competing accounting and financial service businesses. I remained the partner primarily responsible for the valuation service for many years, overseeing accountants assisting in that role and indeed, up until my retirement from the group on 30/06/2020, remained a co-signatory responsible for checking the correctness of the content. Over many years, I completed or had a significant oversight for a very large number of dental and to a lesser degree veterinary practice valuations amounting to many hundreds of practices. Possibly more than any other individual in Australia. Periodically when somebody, sometimes a lawyer, produced a valuation signed off elsewhere, I noticed that slabs of wording and methodology had been copied from a valuation I had completed previously. As they say “imitation is the sincerest form of flattery”.

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Purposes of dental practice valuations dental practice valuation may be required for a variety of purposes including: • To determine a fair value for sale and purchase of a practice jointly commissioned by the two parties to the transaction or in the absence of joint agreement by one of the parties to the proposed transaction; • To determine the value of a dental associateship, as defined, within a dental practice; • For dispute resolution between two parties. For example, two associates engaged in a dispute obtain a valuation for one buying out the other. Note: the conditions of the buyout must first be agreed as they impact on valuation; • To provide comfort to a bank lender; • For family court purposes to assist in financial settlement following a relationship break down; • A veteran practice owner seeking guidance as to the worth of their practice prior to considering sale and retirement; or • A dentist confronted with an unrealistic valuation on behalf of another party needs clarification as to the veracity of the other valuation, particularly if signed off by a person not known to provide regular valuations of dental practices or having significant involvement in providing business advice to dentists.

November/December 2023

practice | MANAGEMENT Key factors in dental practice value ey factors which make dental practices worth significantly more or less than other practices of similar fee size include: • Unsuitable premises requiring substantial refurbishment and additional fit out or in some cases relocation involving a complete new fit out; • Rental cost much greater than the norm which is typically slightly below 4 percent of annual gross dental fees generated by the practice within. The greater the rental percentage of gross fees, the less the practice profits over and above the dentist’s own wages, i.e. their personal opportunity cost (See below). In this context, dental premises in major shopping centres sometimes have rent of a magnitude which renders a dental practice near worthless and sometimes unsaleable; and • Non-clinical staff costs are too high. As a guideline, if the wages and superannuation costs are higher than the average of approximately 17.6 percent of gross dental fees, it signals that there are significant issues to be addressed. Many good practices have lower costs than this by keeping appointments tight and hence not utilising too much chairside assistant time and by keeping fees up to that which can be sustained in the practices local market which is far more relevant than wider fee surveys.

Poor acquisition advice am aware of many cases where potential buyers of practices were given poor advice by accountants unaware of how to value or assess dental practices. Dentists who should have seized an opportunity passed it up only to spend years regretting their decision. Probably some never got an opportunity as good again and will end their dental career far worse off financially than should have been the case.

Examples of bad practice purchase strategy xample one: A dentist with a huge personal following who provided expensive high-end dentistry in a capital city CBD practice. Individual dentists

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consulted me about buying the practice to which my question to each in turn was: “Are you confident of being able to attract three times the value of dentistry performed by a typical dentist and are you able to provide the necessary comprehensive dental treatment plans including treatment referred to specialists by most other dentists?”. Each in turn reconsidered and withdrew their interest. A couple of years later, I noticed that the practice had been purchased by a dental corporate who would have found it impossible to replace that dentist at the conclusion of their contractual work out period. xample two: A high-end dentist who produced $2 million of fees per year in his own surgery employed an assistant dentist in his second surgery who was employed to do the routine work that the principal dentist either could not fit into his schedule or was less interested in and produced $500,000 of fees per year. Several corporates looked at the practice and realised the risk, but one thought it saw opportunity and bought for an impressive price with a multi-year work-out agreement with a target that the vendor was able to meet. The delayed portion of the sale price was paid progressively over three years. By the 2-year point, the corporate realised that they had no way of replacing the fees produced by the former owner and begged him to extend his stay beyond three years. He demanded a higher fee percentage, longer holiday breaks and a shorter clinical week. He was irreplaceable as the only dentists capable of replicating him already owned and operated successful practices.

Location and fee base n respect to capital cities, longestablished practices in established middle-income suburbs are best, whereas practices in outlying new population growth areas have many young families with substantial mortgages and less income than those in established areas. Often, new planned suburbs don’t have suitable sites for dentists other than in expensive to rent spaces in shopping centres. At the other extreme, practices in very expensive suburbs have very high rents for often inadequate space and experience too much

competition. They may be unsaleable if extremely high rent causes the income of the dental owners to be below their personal opportunity cost (See below). Practices in substantial regional cities having an array of education choices for families and are often nearly as attractive as capital cities. Their distance from a capital city will influence their relative value. • Established practices in established middle income suburbs have large loyal dental patient lists who, with careful handover, offer a high probability of continuing stable, gently increasing dental income. Most have quite low capitalisation rates and hence highervalue (See below re: handover). • Health fund preferred provider practices are worth considerably less per dollar of fees. Having a high proportion of patients tied to preferred provider arrangements is highly restrictive in the choice of services. Preferred provider arrangements are also difficult to break away from. • Practices in free standing premises with attached patient parking are desirable. Their convenience encourages patient retention. • Nature of treatment. The more advanced the treatment plans making up a high proportion of dental income, the fewer will be the pool of potential dental buyers who can provide that level of treatment or who have the personal charisma to attract those type of patients and their like for like referrals. Sometimes, the only dentists capable of reproducing a practice’s mixture of treatment are experienced practitioners owning similar practices who are not potential buyers. In situations where an assistant dentist has been carefully mentored, having built up expertise over several years, if the existing principal undertakes to remain in the practice for several years and agrees to an appropriate allocation of new patients, the sale of an associateship may have considerable value. Such practices are extremely lucrative to a talented buyer, but handovers require considerable mentoring. Practices in remote small towns lacking an array of education choices and other facilities have little market appeal and hence little value. Or put another way, they have a high capitalisation rate and hence a low value.

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practice | MANAGEMENT Practices with highest valuation characteristics • These are established two or three surgery practices in middle class suburbs of major cities; • They are non-preferred provider practices with the principal being the highest fee generator; • Their assistant dentists’ bookings are kept tight to maximise the use of chairside assistants; • They practice from attractive owned premises with a rental valuation factor of about 4 percent of gross dental fees and good patient parking; • They have long-term patients with a history of ready acceptance of advanced treatment plans. These are not oversold but rather occur naturally over time; • There are tasteful pictures mounted on the ceilings in the patients’ vision when reclining. They do not have video players/television on the ceiling. The surgeries have attractive window spaces; • They do not have practice managers other than a courtesy title for an experienced receptionist. The cost of employing a full-time practice manager far outweighs their economic benefit. They are profit destroyers rather than profit enhancers. A part time bookkeeper who visits fortnightly to reconcile the bank account, prepare the bill payment schedule for the owners’ approval and organizes the staff payroll is more cost effective; and • They may have an hygienist/OHT to do tasks that the principal dentist does not wish to do but I have seen no evidence that their presence makes practices more profitable than practices where all clinical treatment is provided by dentists.

Example valuation key elements of a sound practice located in an established suburb of a capital city ere is a valuation of a hypothetical dental practice located in a long-settled middle income suburb. The practice has three surgeries with one occupied by the dental owner. The other two are occupied by a combination of two dentists working a combined seven days per week and a dental hygienist or dental therapist working 2.5 days per week. The principal works four full clinical days.

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Total dental fees are $1,800,000 split as follows: • Fees generated by practice owner $800,000; • Fees generated by the two assistant dentists $750,000; and • Fees generated by the dental hygienist/ therapist $250,000. The premises are owned by the principal dentist’s family trust. Rental valuations indicate that the rent has been correctly set at $72,000 per annum. There is on-site parking for dentists and six spots for patients. Reasonable street parking is available within a short walking distance. Non-clinical staff park in the street. Achieving a good price for the practice will be subject to either purchase of the premises at valuation or a long-term lease with suitable options such as a 4-year lease with two 4-year lease renewal options. Or better still, 5-year options. Since the cost of fitting out alternative premises is substantial, guaranteed long-term occupancy is vital. The practice goodwill is owned personally by the principal dentist and spouse and is then licensed to be operated by a company under a lease arrangement. This provides the owners with the best capital gains tax outcome on sale. The assistant dentists are contracted on the most commonly accepted formula: Contractor payments = 40 percent of (fees collected minus laboratory costs)

Private sale versus corporate sale arrangements corporate buyer who is able to contract the principal as lead dentist for the next three years and therefore lock in a high probability of patient retention may pay significantly more for a practice than would a dentist buying with a short handover who is prepared to accept a reasonable amount of personal risk. If a corporate offer is contingent on assistant dentists signing contracts to work for the corporate, then an assistant dentist is entitled to ask “What is in the deal for me if I agree to sign and give up other career options. i.e. why not make them sign on subject to a fee?”. This will be the case where there is a high fee generating assistant dentist (say

above $600,000 of fees) who has worked in the practice for an extended period and has a substantial personal following with high conversion rate and substantial personal referrals. Corporates have learned through bad experiences that they need to restrict practice purchases to practices with at least three dentists and suitable contractual continuity of key dentists.

Dental earnings before depreciation interest and tax (DEBDIT) he following are relevant inclusions in DEBDIT: • Contractor payments to assistant dentists/hygienist in lieu of salary and superannuation. $370,000 • Principal dentists’ superannuation $27,500 • Spouse superannuation contribution. $27,500 • Salary paid to principal dentist’s spouse minus allowance for value of work done in practice. $90,000 added back. • Motor vehicle benefit net of contribution as per FBT choice $25,000. A non-dental expense so added to DEBDIT. • Excess travel and dental education expenses regarded as discretionary spending beyond a necessary amount. Estimated excess including travel and accommodation at attractive location. $23,000 add back. • Rent adjustment to market if the rent being charged by a related owner differs from market rental value. In this case nil. Note average rent paid by practices outside of shopping centres is approximately 4 percent of dental income. • Profit as per accounts. $437,000 • Interest paid less interest received. $15,000 • Depreciation of equipment as per accounts. $11,000

The practice transaction is of proprietorship which is made up of practice goodwill and practice equipment. Equipment is the total of all equipment, furniture and office machines used in the operation of the practice. DEBDIT Items above total $1,026,000 DEBDIT equals 57 percent of fees.

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practice | MANAGEMENT The conventional split between goodwill and equipment value.

Dental opportunity cost (DOC) his assumes that all clinical work is done by dentists at arms-length including treatment provided by the practice owner and is derived using the widely recognised formula:

Clinical salary package costs = 40 percent of (clinical salaries – laboratory cost) In this case this is estimated to be 37 percent of fees. 37% of $1,800,000 = $666,000

Earnings before depreciation interest and taxes (EBDIT) The formula for EBDIT is as follows: EBDIT = DEBDIT – DOC In this example: $ 1,026,000 - $666,000 = $360,000 EBDIT is the figure usually capitalized to find the value of practice proprietorship. Note: EBDIT is sometimes referred to as EBITDA.

Capitalization of EBDIT his requires the choice of a capitalisation rate. In this example of a non-preferred provider practice located in an established suburb of a state capital city with premises available for sale or long-term lease at commercial rate, the appropriate capitalisation rate is 30 percent. Capitalising EBDIT of $360,000 at 30 percent ($360,000 divided by 0.30) results in a capital value of $1,200,000. Note that a practice in a less favourable location or having less presentable premises would have a higher capitalisation rate and hence lower value. Some practices with excessive rents, such as those located in shopping centres and captive of punitive rental agreements not only have much lower DEBDIT as a result but are sometimes extremely difficult to sell. In extreme cases, I have seen dentists walk away rather than exercise lease renewal options. Note: Some valuers utilise an EBDIT (or EBITDA) multiple rather than a capitalisation rate. A capitalisation rate of 30 percent equals a multiple of 3.333 times. A capitalisation rate of 25 percent equals a multiple of 4 times.

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y convention all equipment as defined above is sold at current written down value for taxation depreciation purposes.

Goodwill value = Proprietorship value equipment written down value.

Assumptions and normal conventions attached to sale good handover is a condition of sale. This should not be confused with conditions attached to sale to dental corporates usually requiring the vendor dentist to remain in the practice as lead dentist for a substantial fee earn-out period. The vendor is responsible for paying out staff accrued entitlements or alternatively, they are carried over by agreement with a payout figure offset against practice proprietorship as a settlement discount. Practice name, telephone numbers, internet listings and practice website are transferred as representing part of practice goodwill. Practice debtors and creditors remain the responsibility of the vendor. Practice dental records are appropriately maintained. All equipment is handed over clear title with the vendor paying out any financing obligations. The premises are available for purchase or alternatively a long-term lease on fair commercial terms is available to the practice purchaser. The consumable stock on hand is valued separately at time of handover by valuing unopened packages at supplier’s invoice prices net of settlement discounts and the stock value is added to the settlement figure. The vendor agrees to an appropriate exclusion clause. As a guideline, the vendor of a practice in a major city agrees not to work as a dentist within ten miles/16 kilometres of the practice for a period of two years from the date at which they cease work in the practice following sale. It is a mistake to seek overly lengthy exclusion periods or unrealistic distances as the courts are unlikely to enforce them. It is best to have an enforceable exclusion arrangement. In country practices, the exclusion zone is normally the town in which the practice is located.

Cost of valuations... What is reasonable? ome valuers charge what can only be regarded as excessive amounts on the basis that they view the client assignment as a one off and do not expect ongoing business. Provided that all the practice/practice company and services trust where applicable are provided in good order, other information such as clinical staff salaries and superannuation are identified separately, laboratory costs are separated from purchased materials and current rental agreement is supported by premises valuation where premises are owned then a realistic valuation fee will be about $5,000 to $7,000. Where there are unusual circumstances such as multiple practice sights or complex partnerships or large dental associateships involved, fees will be higher. This also applies where there is a necessity for a valuer to appear as a witness in a court.

Further valuable advice lease read my book “Financial success for dentists”. See my website at grahammiddleton. com for valuable information. Payment for the book is via donation to the Delany Foundation, a registered charity. All costs of printing and mailing are met by the author.

About the Author Graham Middleton disposed of his interest in Synstrat group on 30 June 2020 and won’t be starting another business; he spent the later 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 by making a 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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practice | MANAGEMENT

Transform your dental practice with the power of a compelling purpose By Julie Parker

dentifying the purpose of your dental practice is claimed to be highly important. And, in principle, I agree. The purpose of an organisation can help to align team members and other stakeholders to work brilliantly together. Team members can experience higher levels of motivation because they each feel like they are working towards a greater good, towards something of deep value. Purpose can be the North Star of your practice, clearly guiding the behaviours of those working within it. The reason I say I agree with the importance of purpose in principle only is because we can only have high expectations of its impact if the purpose is sufficiently compelling. I often help dental practices to identify their purpose. Initial inquiries result in some common responses: • Our purpose is to help people be healthier. • Our purpose is to deliver high-level patient care. • Our purpose is to help people be happier. Although these kinds of responses are accurate, are they inspiring enough, are they compelling enough, to deliver on the promise of serving as a North Star for the practice? I don’t think so. I think purpose needs to be bigger, more specific and more meaningful. In 2020, there was an episode of the SBS TV series, Insight, that I believe holds the key. The episode is called The Dental Gap and it was aired to help shine a light on why so many Australians are struggling with poor dental health. It asks the question, “What effect does bad teeth have on your life?”.

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Watching the stories of discomfort, trauma and shame of the participants being interviewed opened my eyes to a world I have not seen, despite working in dental practices for 36 years. These people had completely neglected dentitions. Active disease, daily pain and inability to eat and speak normally was experienced by many of the audience members who had the chance to share their stories.

As I reflected on this Insight episode, I imagined how my motivation would have been different as a young dental assistant had I worked in a practice that treated patients at this desperate stage of need. I think I would have been quite different. The Dental Gap program asks the question, “what would life be like with bad teeth”. The appearance of missing, broken-down and decayed teeth would have you embarrassed to smile, avoid

The reasons for their poor oral health ranged from dental phobia, inability to afford dental services and embarrassment and fears of being judged by the dental team. As their oral conditions worsened, they felt less able to overcome the barriers and reach out for help. During my career, I could count on one hand the number of extreme cases that I had witnessed. And, I think that this could be the case for many of your dental team members. There are certainly dental practices in particular areas or who offer specific services that would see these kinds of patients more commonly, but it was not my experience.

being photographed and covering your mouth with your hand every time you spoke. The reduced function with just a partial dentition and no prosthetic replacements would dictate what foods you could include in your diet and prevent frequenting restaurants, preferring to eat only soft, easy to eat foods. Your poor diet then negatively impacts on your general health as you struggle for adequate nutrition. Untreated periodontal disease means the remaining teeth are at various stages of mobility, further contributing to eating and speech problems. You know you have bad breath and you’re embarrassed when you notice people around you step back to avoid the odour.

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practice | MANAGEMENT Every day, you experience some degree of discomfort and pain due to infected and/or exposed nerves. The constant active infection in your mouth creates and exacerbates overall bad health conditions. With these kinds of physical setbacks, consider some of the emotional and psychological repercussions: • Embarrassment and shame; • Social isolation; • Low self-esteem; • Fear of rejection; and • Depression. How does such a person, with these physical and mental barriers, achieve professional, intimate and social goals? How could such a person build a happy life? I think the answer is... they don’t! The life of one who struggles with bad teeth is not enjoyable. The impact on life is one of limits and alienation. And the only way to turn things around is to do the one thing that creates terror: see a dentist! Dental teams aiding patients in such dire straits find a deeper sense of purpose compared to those primarily dealing with

patients in good oral health. Teams guide patients in dire straits through transformative treatments, witnessing not only physical but also mental health transformations. I consider it valuable and essential for all dental teams, regardles of their types of patients, to consider and articulate the true purpose of their practice. Sandy Roth, my dental patient communications guru from the USA, has often stated that dental practices help their patients to feel better, function better, look better and enjoy greater peace of mind. This wonderful phrase covers it all! Without dental practices, the public would almost all fall within a range of failing oral health. To be part of rectifying and avoiding this scenario is something that can be highly compelling, inspiring, and motivating. To establish a clear and compelling purpose in your dental practice, I recommend gathering your team to watch The Dental Gap. Immersing yourselves in the extreme end of oral health challenges can catalyse heightened awareness among

your team members. Discussing the hardships faced by those with poor oral health can illuminate the profound impacts that your profession can have. This heightened awareness has the potential to not only uncover your practice’s real and true purpose but also to make it your team’s guiding North Star, steering everyone’s actions towards a transformative experience for all stakeholders.

About the author Julie Parker is a Dental Practice Management Consultant and Team Educator. At the age of 33, Julie became the first non-dentist to own a dental practice in Australia. Julie is Co-Founder of Julie Parker Practice Success and CoFounder of Dental Business Mastery. Visit julieparkerpracticesuccess.com.au and dentalbusinessmastery.com.au to find how Julie can help your dental practice be more successful. You will find information about consulting programs, online courses, podcasts, free downloads and more.

View the SBS video at https://www.sbs.com.au/ondemand/news-series/insight/insight-2020/insight-s2020-ep14/1727614531792

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November/December 2023

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practice | MANAGEMENT

The role of insurance in practice purchase

hen first-time practice buyers are looking at an opportunity, they are often too focussed on business plans, arranging finance, renovation or reinvestment to spend much time thinking about insurance. When insurance is thought about during the purchase process, it’s often dismissed as discretionary, optional and overly pessimistic... that is, until the buyer gets close to the finish line and realises that their finance provider and/or landlord may only approve their loan or tenancy if insurance cover has been arranged. We asked the experts at Credabl finance and Experien Insurance Services (Experien) to give us clarity on what insurances a buyer may need to have in place to complete a practice purchase.

What insurances would you typically need to have to get a bank loan to purchase a dental practice? nfortunately, the risk of illness, injury and other perils may not be insignificant over a long period of time. The bank requires insurance so that the buyer’s ability to repay the loan is protected, should something happen. The insurances required can vary on a deal-by-deal basis, (e.g., a high loanto-value ratio may trigger different requirements to a low loan-to-value ratio),

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but often a bank will want Life Insurance, Income Protection and/or Business insurance in place as a condition of the loan. If applicable, the bank will most likely: • Want the insurance in place prior to the loan being settled and/or in the process of being established; • Require ongoing confirmation that the insurance is in place and, in some situations, they may own the policy (with the borrower paying the premiums) to ensure any claims paid go to the intended purpose; and • Require to be named on the policy as an “interested party”, to give them adequate protection.

What insurances would you typically need to have in a commercial lease of a dental practice premises? andlords will usually request $20 Million of Public Liability and also glass insurance as a minimum requirement in order to approve a lease of their premises. Some may want comfort that there is also insurance for the contents (including the fit out). And, in single-tenanted buildings (e.g., a stand-alone house converted into a practice), the landlord may require the tenant to pay the cost of the building insurance. Since most sales are subject to the purchaser either buying or leasing the premises and the premises lease is dependent upon insurance, it’s a good idea to be looking

ADELAIDE 1 June

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By Simon Palmer into insurance for the premises with plenty of time up your sleave, so as not to hold up settlement of the practice purchase.

What information would you need to provide in order to get these insurances and how long will it take? epending on the type of insurance required, getting insurance can take as little as a couple of days to as much as a few weeks to set up. Gathering the necessary information to apply for insurance can take time, e.g: • Life insurance policies may need a medical assessment; and • Premises lease - an insurer might need construction information for the property.

For info about Experien, or the insurances mentioned, visit www.experien.com.au. For info about Credabl, or the insurances mentioned, visit www.credabl.com.au..

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

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practice | MANAGEMENT

Simple ways to help your team stay focused By Jayne Bandy

e are always looking at different ways to help us stay focused and increase efficiency, both at home

and work. In today’s world, it’s very easy to lose track and start doing too many things at once. There are so many distractions that cause us to lose our focus! I always have a giggle when I hear how some people are better at multitasking than others. I believe multitasking is over-rated. What do you think? I see many people multitasking all the time and all I see is lots of tasks being completed, but not very well. So, how can you help your team stay focused on each task at work and do them well? One simple way is to let your team have some say in their workspace. Let your team be involved in the styling of your patient lounge and their desk. Many team members have a keen sense of style and their input is valuable. Did you know that studies have shown an increase in the productivity of employees who have had a level of control over their workspace? Another simple way to help your team be more productive in the workplace is to use green and blue tones in the practice décor. Being surrounded by these two colours are proven to help boost focus. A few indoor plants will also help revitalise a patient lounge and give your team a fresh outlook. Now here is an important way to help your team stay focused - your team needs regular breaks. When team members return from a short break, they are more refreshed and ready to get back to task with more focus. Why not have something to help your team while they take a short break such as

80 Australasian Dental Practice

colouring books, crosswords, or puzzles. Something to keep their brain active and energised, while they are away from the focus of their task. Another very simple way to help your team stay focused is to praise your team when they have done a good job or made headway in a task. There is nothing better than receiving encouragement. For some reason, many adults forget to

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 the website to find out how to get started. It’s that easy! www.calltrackingexcellence.com

give encouragement and praise to other adults, thinking this is something you do with children. The reality is that you need encouragement no matter what your age. A daily work plan so your team know what the day looks like is essential. Of course, an early morning team huddle is the perfect place to help your team start being focused for the day. Being clear and knowing what to do for the day is a fabulous way to stay focused. Make sure the daily plan is written down so it can be checked off when completed. The morning huddle could also be a place where the whole team is gathered

and an opportunity to tell a team member what a brilliant job they did the day before. Help your team set some goals. This can start as a team building exercise where each person has 4-5 goals they are focusing on at work. Remember to have regular one-on-one performance catch ups. This is a great time to discuss staying focused and different strategies the team can use to help them stay focused. Always keep in mind that each person in your team stays focused differently. What helps one person stay on task may be very different to what another person needs. So find out what helps your team stay focused and suggest some of the simple ways I’ve shared with you. 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

About the author Jayne began her career as an educator. After spending several years teaching, she made the jump to practice management, serving as a Practice Manager for a renowned dentist in Sydney for more than 25 years, giving her first-hand experience at 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 helps practices convert more calls into appointments, reduce cancellations and 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.

November/December 2023

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If Apple ran your dental practice By Angus Pryor, MBA (Marketing)

n every industry, there are often “better” or maybe even the “best” way of doing things. And certainly, there is merit in modelling what the most successful people in your industry have done - why reinvent the wheel? However, from time to time, it’s important to look outside the industry for inspiration. In this article, we’ll take a brief trip to “Imagination-land” and consider how Apple™ would run your dental practice.

Success leaves clues hile not everyone loves Apple and its products, there is one simple fact you can’t deny. As the most valuable company on the planet (their market capitalisation in Nov 2023 was AUD $4.5 trillion), they must be doing something right

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in a business context. So, what lessons can we take from Apple’s success and apply them to the field of dentistry? In my mind, if we were forced to describe Apple’s characteristics in just 3 words, it would be “innovation”, “quality” and “ease of use”. For this exercise, we’re going to focus particularly on innovation. Let’s take a look through Apple’s eyes at a dental practice.

Innovation pple’s innovation is on many levels. Certainly, they’ve had incredible innovation in the products they’ve developed – but this is easier to do in their pure technology field rather than a space like healthcare. There are some basics in the dental field that even Apple can’t ignore. In simplest terms, a visit to the dentist comprises:

November/December 2023

marketing | INSIGHTS 1. A discussion of what a patient wants (not every practice does this); 2. An examination and assessment of their oral health; and 3. The necessary steps to get the desired outcome. So, how would Apple innovate this process in dentistry? We don’t know for sure, but we can draw some insights from what Apple has done with a retail experience – which is quite different to most other retailers. This includes pre-booked appointments online, helpful, engaged staff and lots of Apple toys to play with in store. Anyway, returning to the 3 essential steps, let’s check it out Apple-style...

What the patient wants? ow would Apple handle the discussion of what a patient wants? In my mind, this would comprise a simulated before and after video, allowing patients to “try on” a smile before they discuss with the dentist what’s involved in achieving it. Knowing Apple, this part of the process would NOT take place in the dental chair, but in a much more comfortable and modern setting. Perhaps, every patient gets shown to a comfortable chair (they may be offered a drink or a snack), given an iPad and headphones. From there, patients go through a stepby-step process to scan their teeth, answer a few questions, then the app shows them a video of what their smile could look like based on their answers. This kind of innovation alone could completely transform patients’ feelings about attending the dentist - half of Australians have some form of dental anxiety. With Apple’s involvement, dentistry could become a sought-after, pleasurable experience rather than a “grudge buy”. If this process were (i) done for every patient and (ii) seamlessly integrated with the experience in surgery, I’d wager that the increase in cosmetic and functional procedures at that practice would be exponential. One of the big challenges in dentistry is that so much of what happens is basically invisible to the patient who lies there with their mouth open, but can’t see a thing. I don’t think Apple would allow that to continue.

November/December 2023

Oral health examination s part of the examination, I’m thinking Apple would build a “pre-examination” check into step one of the process, as listed above. As well as modelling potential before and after scenarios, the scan/images could flag potential dental problems, such as cavities, swelling, bite issues and more. Rather than doing the dentist out of a job, such initial issues could be flagged for the dentist to (i) double-check when they see the patient (to confirm the diagnosis from the software) and (ii) discuss the options with the patient. I believe the dentist will always have a role in providing education, advice and reassurance for patients. In an increasingly technical world, the human touch is more important than ever. This is not lost on Apple - an appointment at an Apple store is still with a person.

Achieving the outcome nce the patient and dentist have agreed on the desired outcome, it’s up to the dentist to deliver that outcome. There would be the capacity for various innovations via robot assisted dentistry, real time scanning, optimised sedation delivery and more. However, because we’re talking Apple here, a key component would be what the patient does while the dentist is achieving the outcome. Knowing Apple, the patient would be given virtual goggles (Apple currently retails something called Vision Pro) with two main options. For a handful patients, they may want to see what’s going on - there would be the capacity for a “dentist-cam” that the patient could tune in to. Much more likely, though, is some form of video distraction for the patient so they can watch something that helps them forget where they are. Built into the video is the capacity for the dentist to deliver messages to the patient on screen at important parts of the procedure – open, rinse, etc.

A bridge too far? hile what we’ve discussed may seem like fantasy to some readers, the reality is that most of the elements I’ve described are already possible. Apps such as Smilo.ai can do a basic scan of the teeth,

do some diagnosis and offer for the patient to see simple before and after pictures. Nevertheless, I’m yet to see a practice that has committed to something akin to the three-step process I’ve outlined here for their patient experience. It may be easier to set this up from scratch than slowly integrate it into an existing practice, but this kind of transformation would dramatically help a practice stand out from others. Even if you don’t decide to dramatically transform your practice along the lines of what I’ve discussed above, there is still the opportunity to take a leaf out of Apple’s book. Whether you draw inspiration from Apple... or Kmart, McDonalds, Virgin or others... there is always merit in reimagining the service that you offer to your patients. Once you’ve come up with a plan, you can always run small tests to see how your patients respond to your innovations. Rest assured, if you do nothing to improve your services over time, you will slowly kill your business.

Summary (not very technical) friend of mine said something interesting to me about Apple products: “they just work”. For you to summon your inner-Apple, consider the innovative changes you can make at your practice that provide a similar experience. Even if you don’t embrace the (slightly) far-out thinking suggested in this article, allow one idea to generate another and implement a trial to test the reaction within the practice and from your patients.

About the author Multi-award-winning Practice Growth Specialist, Angus Pryor, is an author, marketer and international speaker. He is the #1 Google-ranked dental marketer in Australia. In 2023, Angus’ team at Dental Marketing Solutions received the ADIA’s marketing award. More details are at www.DentalMarketingSolutions.com.au. For a smarter, cheaper solution to finding great team members doing particular tasks, there is a solution. To find out how to unlock the gold in your practice from incomplete treatment plans, reactivations and more (and to access free sources), visit www.DentalStars.com.au.

Australasian Dental Practice 83

finance | INVESTMENT

How long will $2 million last in retirement in Australia? By Kurt Ohlsen, Senior Financial Adviser

etirement planning is a critical aspect of financial well-being and understanding how long your savings will last is essential for a secure future. This article aims to address the question of how long $2 million will last in retirement in Australia. We will explore various factors including living expenses, taxes and flexibility to provide a comprehensive analysis.

Living expenses and lifestyle etermining living expenses during retirement is vital for estimating the longevity of $2 million. Expenses can vary significantly depending on

84 Australasian Dental Practice

one’s lifestyle choices, location and personal circumstances. In Australia, the Association of Superannuation Funds of Australia (ASFA) provides guidelines for retirement budgets. According to ASFA’s Retirement Standard, a comfortable retirement for a single person requires around $49,462 per year, while a couple needs approximately $69,691 annually. These figures encompass essential needs, leisure activities and occasional travel. While it can be interesting to reflect on what the average person needs for a comfortable retirement, the best guide is to look at what you have been spending to date and then just back out any big ticket expenses like mortgage repayments and private school fees (assuming they have finished by retirement) and add any new expense line items you might want given more time on your hands (such as for travel).

November/December 2023

finance | INVESTMENT Figure 1 shows that with living expenses of $120,000 (Refer below for assumptions) you shouldn’t have any worries about running out of retirement capital, but if increased to $150,000, things are starting to get questionable, especially if a few big unplanned expenses come up or you have great longevity. At living expenses of $200,000, it is going to be important that you have a Plan B in place, such as downsizing the home at some stage. A lot of people consider a 2-stage spending pattern in retirement, thinking they will spend a lot early on with extra travel and as they get older, this will stop. While reduced travel may be a reality, a lot of the time this does not result in lower spending levels due to increased medical, home care and other assistance costs. Keep in mind that if you’re spending your annual budget each year, you may well run out of funds sooner than planned. A lot of people incur quite significant expenses on an irregular basis. Some of the more common ones are car updates, helping children with home deposits, children’s weddings, children’s divorces and out-of-pocket medical expenses.

Figure 1. How long will $2 million last in retirement based on annual living expenses.

Taxes and superannuation ustralia’s superannuation system plays a crucial role in retirement planning. Withdrawals from superannuation are generally tax-free for individuals aged 60 and above. Earnings

within the superannuation environment are either taxed concessionally (15%) while in accumulation phase or tax free once used to commence an accountbased pension.

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Australasian Dental Practice 85

finance | INVESTMENT $2 million in investment capital split between a couple in the tax-free pension environment is far more valuable than if the exact same investments are held personally. If your $2 million of investments (split between both of your pension accounts) are earning 6% p.a., that is $120,000 p.a. that you have available to spend before you’re drawing down on capital. If you hold those same investments personally (in joint names) there is only going to be $97,866 left after you’ve paid $22,134 of income tax between you (based on 2022-23 rates).

The type of investments you choose can have a big impact on the cash and flexibility they can provide. This is particularly important when your plan has you drawing down on your investment capital over time. While property can be a great investment to accumulate wealth, it can be far less effective at funding your retirement needs - especially if you only have 1 or 2 properties and very little other investment reserves. This is because if the net rent is not meeting your living expense, you cannot just “sell the bathroom” to fund

for tailoring a retirement plan that looks to optimise the longevity of funds and help you work towards a comfortable retirement. Remember, proper planning today can lead to a worry-free tomorrow. * Assumptions - Couple aged 67, $1 million each in superannuation pension accounts earning 6% p.a, own their own home, living expenses indexed with CPI of 1.9% annually.

General advice warning This communication is issued by Profile Financial Services Pty Ltd. (ABN 32 090 146 802), holder of Australian Financial Services Licence and Australian Credit Licence No. 226238. It contains information and general advice only and does not take into account any investor’s individual objectives, financial situation or needs. It should not be relied on by any individual. Before making any decision about the information provided, investors should consider its appropriateness having regards to their personal objectives, situation and needs, and consult their adviser. Any indicative information and assumptions used here are summarised, are not a product illustration or quote, and may change without notice to you, particularly if based on past performance.

About the author

This will mean you will need to spend less or draw harder on your investment capital to receive the same amount to spend.

Investment strategy and flexibility he investment strategy adopted during retirement significantly impacts the duration of $2 million. Conservative investment options such as cash and fixed deposits offer some stability but may not provide sufficient growth to combat inflation and living expenses over an extended period. On the other hand, investing in growth-oriented assets like stocks or real estate carries more risk but has the potential for higher returns over the long term. Balancing risk and return based on individual circumstances, risk tolerance and required rates of return is crucial.

86 Australasian Dental Practice

your upcoming new car purchase. In comparison, other investments such as shares and managed funds are far easier to access small parcels of the capital - for example, if the dividends from your share portfolio are not meeting your income needs, you can sell a handful of shares.

Summary 2 million can provide a substantial foundation for retirement. However, several factors are going to influence if it will last long enough for you. Your living expenses, taxes and investment strategy are all going to have a big impact. It’s crucial to consider individual circumstances, including desired lifestyle and personal expectations, while accounting for unexpected expenses and inflation. Seeking professional financial advice is invaluable

Kurt Ohlsen is a Senior Financial Adviser at Profile Financial Services Pty Ltd (AFSL 226238), a privately owned and self-licensed fee-based financial planning firm that specialises in working with dental professionals. Kurt’s passion for planning is to help people make their own, wellinformed financial choices by breaking down complex information and situations and identifying the important issues that need to be addressed. He has a particular interest in helping people plan for and transition to their retirement. Kurt holds a Bachelor of Agricultural Economics (Majoring in Corporate Finance, Economics and Agricultural Economics) and an Advanced Diploma of Financial Planning. He is a member of both the Financial Advice Association of Australia (FAAA) and the Self-Managed Super Association. Kurt can be contacted on (02) 9683-6422, kurt.ohlsen@profileservices.com.au or visit www.profileservices.com.au).

November/December 2023

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infection | CONTROL

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COVID-19: New challenges for 2024 By Emeritus Professor Laurence J. Walsh AO

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November/December 2023

infection | CONTROL Table 1. Major variants and subvariants of SARS-CoV-2 Variants of concern and subvariants uring the pandemic, mutations in the virus have led to the emergence of numerous major variants and their associated subvariants. Table 1 summarises the more common of these, from a very long list of recorded mutations in the virus, while Table 2 summarises some of the major impacts of these multiple mutations. Increases in transmissibility have been noted with all the major variants of concern. Hospitalisation rates increased dramatically for Alpha and for Delta (by 52% and by 85% respectively), while the Omicron variant showed a reduction in hospitalisation of 57% compared to Delta. Likewise, both Alpha and Delta had higher mortality (up by 59% and 137% respectively), while Omicron caused mortality at a rate some 63% less than that of Delta. Changes in the virus have also altered response patterns to vaccines and driven the development of further vaccines that can cover emerging strains, such as bivalent and polyvalent vaccines. There has also been more interest in vaccination strategies, such as “mix and match”, to maximise the benefit of available vaccines. The public health benefit of mass vaccination is now well documented, particularly its role in reducing severe cases, hospitalisations and deaths. For example, for the 12-month period from December 2020 to December 2021, COVID-19 vaccines prevented an additional 14.4 to 19.8 million deaths across 185 countries.1 As well as the obvious implications of viral mutations causing disease in human populations, especially severe disease in elderly and immune compromised individuals, there are concerns that further mutations can occur within an individual host. This is possible when an immune compromised patient has persisting infection over a long period of time, during which time the virus mutates sufficiently to escape protective host antibody responses. As well as generating further variants of the virus, there is also the risk that spread can occur from humans to animals and then back from those animals to other humans. A large number of animal species can be infected with the SARS-CoV-2 virus and some of those can then allow the virus to spread from animal reservoir of infection back to people in the community.

November/December 2023

Date

Emergence

Variants with high circulation rates

2019

China

Wild type (original strain)

2020

Alpha

2020

South Africa

Beta

2020

Brazil

Gamma

2020

India

Delta

Delta with K417N (Delta Plus)

2021

Omicron

South Africa

2021

Omicron BA.1, BA 1.1, BA.2, BA.4, BA.5,

2022

Omicron XBB, XBB 1.5, XBB 1.16, EG.5

2023

Omicron BA.2.96 (Pirola), EG.5.1 (Eris), FL.1.5.1 (Fornax)

Table 2. Major impacts of viral mutation Increased transmissibility Altered symptom pattern and altered course of disease Reduced effectiveness of previous vaccines, and differential vaccine effectiveness Recurrent disease episodes increasing the risk of long Covid Well-known examples of this for SARS-CoV-2 are domestic cats and golden hamsters.2 Animal hosts can also themselves generate further variants of the virus, that then spread back to people.

The problem that just won’t go away OVID-19 continues to be an important contributor to morbidity and mortality in Australia. A report released by the Australian Bureau of Statistics in September 2023 identified that COVID-19 was the third leading cause of death in Victoria, New South Wales, South Australia and the ACT in 2022. It was responsible for 10,000 of the 190,000 deaths in 2022 across the country, which was approximately 1 in 20. This is the first time that an infectious disease has been in the top 5 causes of death for Australia since 1970. Not surprisingly, the top two causes of death in Australia in 2022 were ischaemic heart disease and dementia. Overall, in 2022 COVID-19 caused more deaths in men (5,484) than women (4,387). Those who died had a median age at death of 86 years.

Where to from here? he impacts of the COVID-19 pandemic continue to be seen in hospital wards (with around 2,000 to 3,000 hospitalised patients per week) and mortuaries (with around 200 deaths per week). A summary of recent Australian data from November 2023 is presented in Figure 1. This shows outbreaks in nursing homes across the country and prescriptions for antiviral medicines in at-risk patients for severe illness. Note the cyclical nature of both and the trend towards an increase in October 2023 heading into the next wave, at the same cycle period of approximately 5 months. As of late 2023, the major circulating variants were Eris, Pirola and Fornax. Eris first appeared in Australia in April 2023. Pirola was flagged as a major issue in the mass media on 15 November 2023 and is a major variant circulating in Australia in late 2023. Pirola most likely evolved over several months in a person who had a chronic infection.

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infection | CONTROL Pirola is of particular interest because of its very large difference from its BA.2 ancestor, representing a change in 33 amino acids in the spike protein. For scale, this is similar to the difference between Omicron and Delta and was critical to how well Omicron spread globally. This type of change would normally only occur over multiple generations of a virus, rather than in one single event. The concern is that Pirola could be the starting point or platform for another whole lineage of highly contagious variants. Due to the complete relaxation of restrictions on travel and movement, international travellers are now moving variants of COVID-19 around the world at a similar rate as occurred in early 2020. Even though little genomic sequencing is now being done for strains of SARSCoV-2, by September 2023, Pirola had been identified in more than 15 countries, including Australia and had become a major circulating strain in the UK. Eris, Pirola and Fornax are all highly contagious and cause similar rates of mortality as their predecessors in the Omicron lineage. Severe disease from these new subvariants can be protected against with the latest generations of Moderna and other vaccines, including those developed to the XBB.1.5 strain. This is one reason why the Australian Federal government began promoting a further COVID vaccination round for at-risk elderly and immune compromised patients in late October 2023. As can be seen from Figure 1, waves of COVID in Australia are typically spaced around 5 months apart. At early November 2023, trend data showed the beginning of another wave, in line with that overall pattern. Whether the cycle period eventually stretches out from 5 to 12 months in a stable long-term pattern, like influenza, peaking in the winter months rather than the summer, remains to be seen. A further concern for early 2024 is not only a surge in acute cases, but also an increased likelihood of complications from long COVID for those who experience yet another episode of infection. One of the most common and concerning aspects of long COVID is brain fog, which is now thought to be due to both persisting inflammation due to host responses to viral components in the brain, as well as fusion of individual neurons, causing

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Figure 1. Two key indicators for the severity of COVID-19 in Australia. The top panel shows the number of nursing homes with outbreaks of COVID. The lower panel shows PBS prescriptions for antiviral medicines in community dwelling patients who are at risk for severe illness, especially those aged 70 years and above, who account for the majority of such prescriptions. Note that peaks follow a cycle of approximately 5 months. problems and thinking, loss of taste and smell, headaches and other neurological symptoms. It has been known for some time that SARS-CoV-2 virus can be found in the brain tissue of patients with long COVID many months after they were first infected. However, the recent discovery at Macquarie University of fusion of neurons caused by the SARS-CoV-2 virus provides further insights into why thinking patterns become altered in individuals who are suffering from long COVID.

Vaccine developments he technology of vaccines against COVID-19 attracted considerable interest when in early October 2023 the Nobel Prize in medicine was awarded to the two scientists, Katalin Kariko and Drew Weissman, whose pioneering work led to the creation of mRNA vaccines.

In several areas of the world, attempts are now being made to produce so-called universal vaccines that can target not only current and future strains of coronaviruses but also other viruses. These typically use nanoparticles to which fragments from various strains are attached. The immune responses that are generated relate to blocking receptor binding domains on cells, rather than binding to the spike protein, as this undergoes frequent mutations. Moderna has been working for some time on a combination vaccine covering viral influenza as well as coronaviruses and this work has now progressed to phase 3 clinical trials, with successful results being found for the concept in earlier clinical trials. Using combination vaccines reduces the number of infections and so enhances compliance, lowers vaccine hesitancy and simplifies mass vaccination approaches.

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infection | CONTROL

Figure 2. An example of an Australian-made rapid antigen test that uses a nasal swab to collect a sample which is then run in 3 parallel solid-phase immunoassays to test for COVID-19, viral influenza and respiratory syncytial virus (RSV). High rates of vaccination in the community could lead to herd immunity, which is estimated to occur for human influenza when over 55% of adults under 65 are immunised. Current rates for influenza immunisation are less than half of that target. Mass immunisation with a combination vaccine to COVID-19 and influenza would save lives by preventing both. A 2023 report from the NSW Productivity Commission estimated that almost 500 lives in New South Wales could be saved in one year because of the impacts on influenza alone.

94 Australasian Dental Practice

Issues with vaccine tampering by anti-vax healthcare workers came to prominence in mid-2023 when the NSW Health Care Complaints Commission prosecuted a complaint against a registered nurse. She attended a Chemist Warehouse with a family member for COVID-19 vaccinations and on both occasions tampered with the syringes that the pharmacists had prepared to administer the vaccine, replacing the vaccine with normal saline. At the time, the nurse was subject to a NSW public health order issued in 2021 under section 7 of the NSW Public Health Act 2020 that required her to be vaccinated against

COVID-19 in order to continue working as a registered nurse. In its decision of 12 September 2023, the Tribunal found the nurse guilty of unsatisfactory professional conduct and professional misconduct, suspended her registration for 3 months and imposed a condition following the period of suspension that she attend for counselling with a psychologist or counsellor. They stated that “We are comfortably satisfied the practitioner’s deliberate and/ or reckless behaviour was objectively improper because it was inappropriate, abnormal and irregular when judged against the practitioner’s codes of conduct.

November/December 2023

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infection | CONTROL “Consequently, the practitioner has been guilty of unsatisfactory professional conduct. For completeness we also find that practitioner’s behaviour was also objectively unethical”.3

Learning from the past reater emphasis on screening individuals using rapid throughput methods such as rapid antigen tests has been common in the latter phase of the pandemic. In May 2023, the first rapid antigen test that could screen for 3 viruses (SARS-CoV-2, human influenza virus and respiratory syncytial virus) was approved by the TGA. This RAT test is manufactured in Sydney by Touch Biotechnology and has a response time of 15 minutes (Figure 2). Imported RAT tests that also screen for the same 3 viruses are also available, such as Fluorecare from the Chinese manufacturer Shenzhen Microprofit Biotech. At the September 2023 FDI conference in Sydney, the closing symposium explored the lessons from the pandemic for the future. An Australian Centre for Disease Control is being set up, with the intention to model some aspects from its US counterpart, the CDC. The Australian federal government committed $90.9 million in the 2023-24 May budget to support its establishment within the Department of Health and Aged Care from 1 January 2024. The Australian Government Chief Medical Officer will serve as head of the interim Australian CDC. The key areas of work for the Australian CDC are around (1) ensuring ongoing pandemic preparedness; (2) leading the national response to future health emergencies; and (3) working to prevent and control non-communicable (chronic) and communicable (infectious) diseases. Based on the budget statements, the initial work of this agency will focus strongly from the outset on pandemic preparedness and preventing communicable diseases. During the pandemic, Australia gained onshore capability for producing surgical masks and respirators and also for testing masks and respirators. There was also a dramatic increase in biotechnology capabilities for producing vaccines and also rapid antigen tests. Such capabilities will be valuable for future waves of COVID-19 and for later epidemics and pandemics of respiratory viral infections.

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Conclusions he old adage that “those who fail to learn from the past are destined to repeat the same mistakes in the future“ is directly relevant to the COVID-19 pandemic. As healthcare workers, dental clinicians need to maintain a watching brief on what is happening in terms of disease outbreaks in communities that they serve and to pay particular attention to managing risks for patients at high risk of severe disease from COVID-19. In the summer of 2023 going into 2024, it’s easy to forget the lessons of the past 3 years, but the pathogen has not gone away and will be with us for the foreseeable future. In the world of “living with COVID”, ongoing vigilance is necessary.

References 1. Watson OJ et al. Global impact of the first year of COVID-19 vaccination: a mathematical modelling study. Lancet Infectious Diseases 2022; 22(9):1293-1302. 2. Sila T et al. Suspected cat-to-human transmission of SARS-CoV-2, Thailand, July-September 2021. Emerging Infectious Diseases 2022;28(7):1485-1488. 3. Health Care Complaints Commission v Parmenter [2023] NSWCATOD 136. URL https://www.caselaw.nsw.gov.au/decision/18a6d2ab5caf54618c97ac22

November/December 2023

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Human factors and the pressures of delivering accurate information in dental practice: An ongoing challenge By Emeritus Professor Laurence J. Walsh AO

98 Australasian Dental Practice

November/December 2023

clinical | EXCELLENCE For example, there may be errors present that relate to technique and the clinician can tell something is wrong but is unsure of what has gone wrong. As discussed previously, such issues around perception are multifactorial, with anxiety being a common factor that affects performance, from perception through to the analysis of “what went wrong and why”. Adding to this, the emphasis on the fundamental need for accurate information triggers anxiety - not only for clinical practice - but in other activities in life - because it sets up the expectation of precision and that entails judgement. As will be discussed below, a range of processes generate information about patients. The more the process of generating accurate information is understood, the less will be the anxiety about that process. Conversely, the less well the process is understood, the greater the anxiety and the more unreliable the information that will be collected.

Why is accurate information essential? ustralian Privacy Principle (APP) 10 is around the quality of personal information. Under this principle, clinicians “must take such steps (if any) as are reasonable in the circumstances to ensure that the personal information that they collect from patients is accurate, up-todate and complete”. If errors are identified (such as those described below), clinicians “must take such steps (if any) as are reasonable in the circumstances to ensure that the personal information that they use or disclose is, accurate, up-to-date, complete and relevant”. This covers both information collected by the practice about patients and information sent out from the practice about patients, e.g. as items of laboratory work or as referral letters. There is no justification for clinicians passing on inaccurate patient information, according to APP 10 or the Dental Board of Australia Code of Conduct. Clause 1.1 of that code states that “Patient care is your primary concern in clinical practice. Providing good care includes that you assess the patient, taking into account their history, views and an appropriate physical examination where relevant”. Section 8.3 is on the topic of Health records and states that “Maintaining clear

November/December 2023

and accurate health records is essential for the continuing good care of patients. Good practice includes that you keep accurate, up-to-date, factual, objective and legible records that report relevant details of clinical history, clinical findings, investigations, information given to patients, medication and other management in a form that can be understood by other health practitioners”.

Initial presentation hen a new patient contacts a private dental practice by telephone, they will most likely speak to the front desk reception staff or perhaps to the practice manager. It is at this point where the patient will express their initial intention to seek a dental visit and the reasons behind that. This then brings up the issue

“Some practices have triaging flowcharts that reception staff are required to follow when patients call requesting an urgent appointment. A well-written flowchart will distinguish between situations that are truly an emergency; urgent dental visits; and non-urgent visits...” of triaging, where new patients may be identified as attending for a routine examination (e.g. having recently relocated to the catchment area of the practice), versus needing to attend to have an urgent dental issue addressed. Beyond simply asking what the reason for the appointment is, the reception staff may seek general information on where the problem is located (e.g. in the case of a toothache) and may ask about private health insurance coverage. At this juncture, there are other key pieces of information that would be quite informative if the problem was a toothache (e.g. the duration, exacerbating and relieving factors and systemic signs and symptoms) but a receptionist may not have been trained to ask such questions.

The level of experience of dental reception staff can vary enormously. Some may be former or currently working dental assistants, who have considerable health literacy and possess relevant dental knowledge, while others may have experience working as a medical receptionist. Issues arise when the reception staff who are taking the call have no past relevant background and only possess general knowledge about dental problems. Some practices have triaging flowcharts that reception staff are required to follow when patients call requesting an urgent appointment. A well-written flowchart will identify the points when it is essential for a dentist, dental hygienist or oral health therapist to call the patient back at a convenient time to seek further information, prior to the appointment. It will also distinguish between situations that are truly an emergency (requiring treatment within 60 minutes); urgent dental visits (requiring treatment within 24 hours); and non-urgent visits. An effective triage approach will make sure that dental appointments are available for those patients in need of urgent care. An important addition to a triaging process is, for patients with special health care needs, to inquire about the patient’s ability to talk, provide informed consent and mobilise. A good triage checklist ensures that patients are always asked about any special requirements that they have for accessing a dental practice and attending care. This could range from the need for an access ramp because of a wheelchair or walking frame, through to the need for an interpreter or an attending carer. Where the patient does not have capacity, it is critical to record the details of consent from the enduring power of attorney or other relevant person providing consent for treatment. If the patient has special health care needs, it’s good practice to record the formal assessment of their capacity to provide consent.

Medical history hen completing a medical history questionnaire, patients may forget elements of their previous medical history, or may be unwilling to disclose them, because of fear of embarrassment, or fear of discrimination. The latter can arise when the patient has a mental health

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clinical | EXCELLENCE condition or a blood-borne viral disease. When asked on a form regarding current medications, many patients will identify that prescribed tablets that they take would need to be listed, but they often forget many other important elements of medical history, such as 6 monthly injections of denosumab (Prolia) as an antiresorptive agent and medicines that they take in forms other than tablets (including drops, inhalers, patches, etc). Many medical history forms do not properly assess patients for allergies that may be encountered in the dental environment, nor do they properly distinguish between allergies and other forms of adverse drug reactions (Table 1). A major deficit in information collection is that most medical history questionnaires do not ask the patient about alternative or natural therapies that the patient is currently using. This has major implications for bleeding risk when there is high consumption of ginger, fish oil and turmeric, as common examples. When the clinician reviews the medical history, the next area where problems with accuracy can occur is correctly interpreting the information the patient has provided, both in written form and verbally. Patients will often provide confusing information about adverse drug reactions. Two different classification schemes for adverse drug reactions are shown in Table 1. In the alphabetic scheme on the left, type B reactions (bizarre) include immunological reactions such as true allergies. Many patients will experience an elevated heart rate during the administration of a dental local anaesthetic injection and wrongly attribute this to allergy, when in fact it is a predictable reaction in line with the pharmacology of the agent being administered. When asking questions to patients about adverse drug reactions, a useful scheme is to try to separate those based on their timeframe (immediate, early and late) since this can help to identify the nature of the response. Some common examples of adverse drug reactions include: type A (augmented) reactions such as depressed salivary flow at rest in patients on medications with anticholinergic actions, while for type D (delayed) unprogrammed chewing like jaw movements (tardive dyskinesia) following long-term use of antipsychotic medicines or benzodiazepines. Overall, type A adverse drug reactions account for around 80% of

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adverse reactions and have high morbidity but low mortality, whereas type B bizarre reactions are uncommon, but can have both high morbidity and a risk of mortality should acute anaphylaxis occur. Medical histories must always try to identify situations where caution is needed due to a patient’s underlying systemic condition, or drugs that they are taking where interactions can be problematic. A classic example is patients who are anticoagulated using warfarin and who are then recommended to use a topical azole antifungal agent such as miconazole. An important part of medical history taking which is often overlooked is that patients are not asked about drugs that

“When dental radiographs are taken in the practice, it’s important that the relevant features are recorded in the clinical notes. It is not uncommon to see selection bias, where a radiograph is taken to explore a particular issue (such as an impacted or missing tooth), but other features on the film are missed because the entire film has not been systematically examined...” they have recently stopped or changed. Typically, they are only asked about the drugs that they are currently taking. There are many implications for medications that have been recently stopped, including those which control mental health disorders and those that alter bleeding risk, as two examples. There will sometimes be situations where the patient themselves cannot give their medical history and instead it is given by a partner or carer. This introduces an opportunity for error in the information. A printout of the patient’s medicines from their treating doctor or community pharmacist can be quite useful as this will give the correct drug name as well as the dosing protocol.

Clinical examination he next area where inaccuracy can occur is in clinical examination. Common examples include: incorrect identification of teeth that are present and teeth that are missing, both in the mouth and on radiographs; incorrect measurement of probing depths because of the presence of subgingival calculus deposits; failure to recognise and record tooth coloured restorations; and a failure to record overhanging restorations. For endodontic treatment, errors can arise because of structures that are not visible on periapical radiographs or OPGs, because of limited resolution or because of overlapping. Cone beam imaging is much better for detecting periapical pathology and also variations in root canal anatomy. An example of such a variation is the middle mesial canal in permanent mandibular 1st and 2nd molars. The prevalence of this variation differs according to the ethnicity of the patient. On the other hand, the presence of a 2nd mesiobuccal canal (MB2) in the mesiobuccal root of a maxillary 1st molar is to be expected and should be looked for in all cases. When dental radiographs are taken in the practice, it’s important that the relevant features are recorded in the clinical notes. It is not uncommon to see selection bias, where a radiograph is taken to explore a particular issue (such as an impacted or missing tooth), but other features on the film are missed because the entire film has not been examined in a systematic manner. In the case of an OPG, the posterior mandible and the maxillary sinus regions are two places that are often not looked at carefully, because of a narrow focus on only the dentition.

Clinical procedures uch work has been done to develop various safety checklists for surgical procedures. The use of such checklists as a routine measure ensures consistency and reduces errors. Such checklists cover all the requirements before commencing the procedure and also include reminders to give postoperative instructions and to arrange necessary follow-up.

November/December 2023

clinical | EXCELLENCE A simple way of thinking about such checklists is that they are framed into an ACT framework: A for acknowledge; C for concentrate; and T for talk. The acknowledge component includes checking the correct patient, procedure and site in the mouth and verifying that all required materials and equipment are present and ready for use. The C component focusses on procedural steps that must be done in a certain sequence within the overall workflow. The T component focuses on the conversation that is had with the patient at the end of the procedure, regarding their expected clinical course, including issues around pain, swelling and altered sensation, as relevant. Patients will be put at ease if clear information is given to them regarding access to non-scheduled care should problems arise, including access to advice by telephone from the clinician.

Dental laboratory work ental impressions are a major place where inaccurate information creates downstream problems, both for those working in the dental lab and for the clinician once the work is returned. Photographic images, radiographs, digital scans and impressions are all forms of patient information and so they need to be free from error and not tampered with. To understand some of the issues with impressions, the issue of multi-fluid flow needs to be considered. Displacement velocity in multi-fluid flow is the velocity at which one fluid displaces another. It is a measure of the relative motion of the two fluids one to another and is influenced by the viscosity of the fluids, the density of the fluids, the interfacial tension between the fluids and the pressure gradient across the interface. When an impression is taken in the presence of water, saliva and blood, the interactions between fluids that occur are complex. If a putty wash impression is being taken, there are 2 fluids from the impression material side and 3 fluids from the patient’s side. The substrate comprises two different surfaces, namely the tooth and the adjacent gingival tissue. Hence, with interfaces between 5 fluids and 2 surfaces there are 5040 possible combinations (7 factorial). The water has the lowest viscosity and the medium body material the highest of the 5 fluids. At

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Table 1. Simplified classifications of adverse drug reactions Alphabetical

Mechanistic

A - augmented

Hypersensitivity (allergy)

B – bizarre

Photosensitivity

C – chronic

Mutagenicity (altered genes)

D - delayed

Carcinogenicity (causing cancer)

E - end of use

Teratogenicity (foetal abnormality)

F - failure of therapy

Idiosyncrasy

Cytotoxicity

Table 2. Key anchor points for information accuracy Images and records that use biometrics fall within the definition of personal information under the Privacy Act. This is why the collection, use and distribution of those is governed by the Australian Privacy Principles (APPs) (Office of the Australian Privacy Commissioner, OAIC). The Privacy Act defines personal information as “information or opinion, whether true or not and whether recorded in a material form or not, about an identified individual, or an individual who is reasonably identifiable”. Personal information may be recorded on paper and in electronic records, X-rays, CT scans, videos, photos and audio recordings. Victoria, New South Wales and the Australian Capital Territory have their own health records legislation regulating the handling of health information, as detailed in sets of principles. Such principles operate concurrently to the Privacy Act but are broadly consistent with the APPs. Their respective definitions of personal information and health information are also broadly similar. It is important that records are accurate, up-to-date, comprehensive and legible. Clinicians must take reasonable steps to ensure the health information and notes they hold are well-organised. Records should at all times be sufficiently detailed and accessible to allow another clinician to continue the management of the patient (Privacy and managing health information in general practice. Royal Australian College of General Practitioners, 2017). Dentists are obliged to maintain accurate, contemporaneous records of health and personal information about their patients. All health records must be managed in accordance with relevant legislative requirements such as privacy and eHealth legislation and the Board’s Codes, Policies and Guidelines (ADA Policy Statement 6.15 - Dental Informatics and Digital Health, 2010). If it is determined that the information is inaccurate, incomplete, misleading or out of date, then reasonable steps need to be taken to correct this (an example of policy - taken from Metro North Hospital and Health Service Procedure 006229: Documentation in Oral Health Clinical Record). each interface between the fluids there is relative motion of two fluids one to the other. There is also movement of each fluid against the tooth (non-compressible enamel and dentine), however the whole

tooth can be displaced bodily because the periodontal ligament acts like a Voight element. Viscous fluids can compress the gingiva because of its water, hyaluronic acid proteoglycan content.

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clinical | EXCELLENCE Once the impression tray has been placed into the mouth, the temperature of the impression materials will increase and that will reduce their working time. As the impression sits in place, there will be various degrees of mixing between the 5 different fluids and that will change their density, which in turn affects their displacement velocity in multi-fluid flow. Based on the above, the problems of multi-fluid flow are worsened when more fluids are present; this emphasises the need for removing water, saliva and blood before taking an impression. Another practical point that arises is the influence of applying excessive force to the tray. This is often done in the mistaken belief that it will give a better impression, however it is more likely to makes things worse. Using the tray as a reference point against which fluid motion is measured, when more force is applied to the tray, the behaviour of the wash impression material alters. The viscosity of the wash impression material can change because of shear thinning. In this process, the filler particles clump together and the liquid part flows more quickly in a stream. This can create issues as variations in the amount of filler at any one place cause dimensional errors as materials undergo their setting reactions. Even more importantly, around teeth rapid changes in flow direction occur and the greater displacement velocity creates the characteristic drags that are seen on impressions. When alginate impressions are taken, inaccuracies can arise because of gain or loss of water, according to how the impressions have been stored before they have been poured up. Problems with surface reproduction of fine detail can occur when incorrect procedures are used to decontaminate the impression at the chairside. Together, these forms of error add together and can lead to items being fabricated that do not fit.

Treatment records he final aspect of information accuracy that will be discussed relates to completing documentation at the end of the patient appointment. An essential point is that treatment records are there to facilitate the patient’s health journey and therefore the notes need to provide sufficient information that another clinician could

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take over the patient’s care (Table 2). The level of detail provided must be sufficient to identify what has been done and why. Common areas that are missed include: details of local anaesthetics that have been given; details of the shades of restorative materials that have been used; details of spacing and lining materials; details of temporary restorations and how they have been cemented; details of options for treatment that have been presented to the patient; and reasons for the prescription of medicines, such as antibiotics. An important part of treatment notes is the aspect of “where to from here?” which outlines the anticipated future treatment

“Common areas that are missed include details of local anaesthetics given; details of restorative material shades; details of pacing and lining materials; details of temporary restorations and how they have been cemented; details of options for treatment that have been presented to the patient; and reasons for the prescription of medicines...” for the patient and their particular requirements for maintenance appointments and review visits. This part of the notes should also record advice given to the patient about the use of home care products and any specific advice of things that they should avoid doing for specific time periods. If the patient has been sent to a specialist or another colleague, or referred to a radiology centre for a particular radiograph, those details also will need to be recorded. Their presence in the notes will be a reminder to follow up these at the next appointment. If the patient requires follow-up by telephone after the appointment (e.g. the night after a surgical procedure to check on their well-being), details of that telephone call need to be included into the notes.

Conclusions his article has highlighted some of the major areas where inaccuracies can occur along the patient journey in a dental practice. Some key anchor points are given in Table 2 for further reflection and benchmarking. A well-run clinic will have systems and procedures in place that anticipate that human errors can occur, but will be less likely to when there are consistent processes in place to check what is happening. It is important for practice owners to be vigilant around how new patients are screened by telephone by reception staff. Using flowcharts and standardised scripts can help ensure that effective triaging occurs. The ultimate responsibility for proper triage of patients lies with clinicians. Rendering a diagnosis is not within the scope of a receptionist or a dental assistant, so staff need to be aware of those situations where a clinician needs to speak with the patient. Non-clinical staff need to be aware of their own limitations in their ability to triage patients and work in a way that does not generate additional risk for the clinicians in the practice.

November/December 2023

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Block selection for monolithic CAD/CAM restorations By Matt Race

onolithic CAD/CAM restorations have become the industry standard over the past decade, nearly eliminating the need entirely for layered solutions. Today’s industrial milling and printing capabilities, coupled with industry leading restorative materials, provide everything needed to deliver monolithic solutions for most present day clinical restorative needs. Monolithic restorations provide far stronger results than any of yesterday’s layered porcelain results and enable professionals to not only perfectly match the shapes of adjacent teeth but also mimic their shade, translucency and other characteristics. Even when presented with discoloured preparations, we can easily provide high level aesthetic results using a basic understanding of preparation technique and block selection. Basically the darker a prepared tooth, the more aggressive the preparation should be. And likewise, when preparing reasonably aesthetic teeth for veneers, the more minimally invasive we can be.

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After the preparation is complete, we then need to decide on the best material to not only mask any discolouration but also provide the relevant translucency level required to mimic the surrounding dentition.

Case report aron presented with a 11 restoration which he was not completely happy with (Figures 1-2). Originally made as a layered PFM restoration, it not only presented poorly in shape but was far from the mark with regards to value, chroma and opacity. After assement of the pre-opertive photos (Figure 3), it was decided that with a more aggressive preparation, improved shape and optimal block selection, we would be able to achieve a more aesthetically pleasing result. We all know digital photography is paramount for decisions around block selection, value, shape and labial characterisation so it is important to get premium photographs with the relevent shade tabs in place for proper shade assessment (Figures 4-5). All shade photographs should be taken prior to the preparation being done to eliminate any synereasis of the sourounding dentition which could spoil the final shade selection.

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clinical | EXCELLENCE

Figures 1-2. Inital situation: The patient was unhappy with the layered PFM restoration of the central (11).

Figure 3. Intraoral pre-opertive image.

Figures 4-5. Photographs documenting shade selection.

Figure 6. Determining stump shade.

Figure 7. Digital impression.

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clinical | EXCELLENCE

Figures 8-9. The 21 natural tooth is used as a mirror to easily generate the shape of the crown .

Figures 10-11. Final restoration of 11 in situ, milled using a medium translucency (MT) lithium disilicate CAD/CAM block.

Figure 12. Final restoration in situ.

Figure 13. Final restoration in situ.

After the preparation is complete and retraction has been placed, another photograph should be taken to communicate the shade of the preparation (Figure 6). This, along with the amount of labial reduction that has been made, will be the key aspects to block selection for the case. The impression is taken and the file is sent for the restoration to be created (Figure 7). After initial inspection of the digital impression, the file is imported for design. The 21 natural tooth is used as a mirror to easily generate the shape of the crown and final alterations are made as required to ensure proper function, aesthetics and phonetics (Figures 8-9). The file is then nested into CAM software and milled ready for completion. This particular case was milled using a medium translucency (MT) lithium disilicate CAD/CAM block which will ensure the underlying discoloured stump will be adequately masked whilst still providing the relevant translucency to blend in with the surrounding teeth.

The restoration is completed and returned to the clinic for placement (Figures 10-12). Figure 13 shows the final restoration in situ showing how indirect monolithic CAD/CAM restorations can provide far better restorative solutions in challenging single anterior cases.

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The author wishes to thank Dr Michael Ghobrial from Sure Dental in Brisbane.

About the author Matt Race is a Director of Race Dental, Australia’s largest Dental Laboratory, an LVI Master Technician and 3M ESPE Trainer and Demonstrator. He shares his wealth of experience as a specialist Crown, Bridge and Implant Technician, extensively training and developing this skill set in the industry. Matt is an advocate for the benefits of streamlined digital workflows and has a passion for Cosmetic Smile Design.

November/December 2023

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clinical | EXCELLENCE

A guide to modern occlusal splints By Terry Whitty

ral splints come in an abundance of designs and are amongst the most popular non-surgical means by which dentists treat pain in the jaw muscles and TMJ, often known as temporomandibular disorders (TMD). They are also used for bruxism (nocturnal grinding), clenching and repositioning the mandible. In orthodontic specialties, splints are often used as a device to assist in permanent bite opening and also to stop brackets being dislodged as well as post treatment retention and stabilisation. Splints are also great at reducing damage to veneers and other long term dental restorations.

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Despite the extensive use of oral splints, their mechanisms of action remain controversial and the jury is still out on a definitive scientific explanation of their effect. The good news is that if the various hypotheses that have been proposed to explain their apparent efficacy (i.e., true therapeutic value) are inconclusive, then results of anecdotal evidence from patients at least would appear to show that treatment success is relatively high. Even if treatment is not completely explained, they can still be used effectively for many cases. The decision to prescribe a particular splint is based on several important factors, including the findings from the examination, the differential diagnosis and an understanding of the effects of each splint design. The basic types of occlusal splints are permissive, directive (sometimes known as non-permissive splints), hydrostatic and silicone.

November/December 2023

clinical | EXCELLENCE

Figures 1-2. Flat Plane splint with cuspit rise for disclusion.

Figure 3. Anterior repositioning splint.

Permissive splints ermissive splints are designed to eliminate undesirable occlusal contacts and promote harmonious masticatory muscle function. The primary function of these splints is to alter the occlusion so that teeth do not interfere with complete seating of the condyles and to control muscle forces. These are often termed flat plane appliances and two classic designs of permissive splints are full contact and anterior midpoint contact splints. Full contact permissive splints can be made on the upper or lower arch. While upper splints are very popular because they are relatively easy to make, lower splints are more techniquesensitive in construction but may have certain advantages that make them a better choice for clinicians. These advantages include: 1. Fewer speech changes (compared with upper splints); 2. Lower visibility in social settings; 3. Shallower anterior ramps; 4. Less tooth soreness when retention is gained exclusively on the lingual of the lower posterior teeth; and 5. Better patient compliance when instructed to wear their splints during the day as well as at bedtime

Figure 4. An example of an anterior splint, this variation is called a Sved appliance.

November/December 2023

Figure 5. Gelb MORA splint.

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clinical | EXCELLENCE

Figure 6. Milled flat plane splint.

Figure 7. 3D printed splint.

With the advent of digital design and manufacture, the lower splint can now be made with predictable fit while also being comfortable for the patient, however consideration of the occlusal situation and the overjet of the patient is important to acheive a full contact splint. The benefits of full contact permissive splints include: 1. Elimination of discrepancies between seated joints and seated occlusion; 2. A large surface area of shared biting force; 3. Reduced joint loading; 4. Idealised functional occlusion; and 5. The opportunity to observe the patient for occlusal and joint stability over time.

Figure 8. Milled POM splint.

Anterior midpoint contact permissive splints are designed to disengage all teeth except the incisors. This accomplishes several objectives including removing occlusal interferences to complete joint seating on closure while simultaneously, allowing freedom for full seating of the mandibular condyles when the elevator muscles contract on closure. It also encourages release of the lateral pterygoid and anterior neck positioning muscles on closure. It must be pointed out that with these appliances, there is a risk of tooth intrusion and one way to help avoid this is contact from canine-to-canine. The other is to make the splint on the upper teeth and use an auxiliary thermoformed appliance on the lower, similar to an invisible retainer, as this will help distribute the forces. This will also solve any issues of posterior super eruption.

Figure 9. Intraoral scans are far more reliable now for splints than full arch traditional impressions.

110 Australasian Dental Practice

November/December 2023

clinical | EXCELLENCE

Figure 10-12. Non-permissive splint design.

Figures 13-14. Designing a flat plane splint in CAD.

Figures 15-16. Digital articulators. It is not satisfactory to just open the bite to construct the splint.

Directive splints irective or non-permissive splints guide or hold the mandibular condyles away from the fully seated joint position when a painful joint problem is present. Whereas permissive splints clear the occlusion to allow the condyles to be fully seated superiorly/anteriorly by the elevator muscles, directive splints prevent full seating of the joints by guiding the mandible into a forward posture on closure into the occlusal splint. Often these types of splints will have guiding ramps or occlusal indexing to guide the patient or hold them into the desired position.

November/December 2023

Some clinicians use a non-permissive splint with their own therapy driven procedure to treat the patient, however non permissive splints have been used to treat TMJ issues since the 1950’s. Anterior repositioning directive splints are often useful in two scenarios of joint management: severe trauma with retrodiscal edema and chronic painful disc displacement disorders. Examples of anteror repositiong splints are the MORA (Mandibular Orthotic Repositioning Appliance), also referred to as a Gelb splint.

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clinical | EXCELLENCE

Figure 17. Wax construction bite.

Figure 18. Using cotton rolls to achieve initial construction bite.

Figure 19-20. Silcone bite registration is often inaccurate.

Hydrostatic splints ydrostatic splints, e.g. The Aqualizer®, function by separating the teeth and it is claimed that the fluid inside the splint is distributed evenly and “balances” the occlusion. This is probably not a good choice for bruxism as patients often bite through these devices. As a diagnostic device, however, they may be useful. Soft rubber splints also function by separating the teeth, however, do not often provide the characteristics necessary for successful splint therapy. These splints can exacerbate bruxism, possibly due to premature posterior contact related to the fact that these splints cannot be balanced in the same way hard splints can be.

Construction bite hen constructing a splint, people often believe that placing two models or scans on an articulator - be it a real or virtual one - and opening the articulator to simulate a bite opening, then making the splint accordingly to that bite opening, will yield accurate results. This may work in some cases but often,

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especially with TMD patients and bruxers, nothing could be further from the truth. In the real world, it just does not cut it. Fortunately, a better way is available. One of the most frustrating aspects of oral splints tends to be grinding in of the bite in the mouth which can be a tedious task and frankly, just wastes valuable chair time. Amazingly, this can be eliminated in most cases and dramatically reduced in the rest. A little extra time taking a “construction bite” while the patient is in the chair can really mean the difference between success and failure as this type of bite will definitely help. The construction bite may be a new concept to some, but in the orthodontic world, it’s a must when making functional appliances for example. It’s a bite that is taken in a specific position that the appliance will then be manufactured to exactly. The idea being if the jaw relationship can be captured at a specific point, then it follows the appliance will fit exactly to that recorded jaw relationship. This can easily be applied to oral splints as well. The concept is the same and is to simply take a bite that simulates exactly where the splint will be in the patient’s mouth and of course be careful not to over-close the patient or have the patient go into protrusion during this bite taking.

November/December 2023

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TGATGA NOTES TGA NOTES NOTES : We: We have : have We always have always always worked worked worked within within the within the guidelines guidelines the guidelines of the of the TGA of TGA the and TGA and and TGA TGA TGA NOTES TGA NOTES TGA TGA NOTES NOTES NOTES : NOTES We : We : have We have : : We : have We We always have always have have always always worked always always worked worked worked worked within worked within within the within within the within guidelines the guidelines the guidelines the the guidelines guidelines guidelines of of the of the TGA the of of TGA of the TGA the the and TGA and TGA TGA and and nownow with now with thewith the newnew the regulations new regulations regulations we we continue continue we continue to do to so. do toso. Ifdo you Ifso. you have If you have any have any and anyand now now now with with now now now with the the with with with new the new the new the the regulations regulations new new new regulations regulations regulations regulations we we we continue we continue we we continue continue continue to to do to do so. do to so. to todo Ifso. do do If you so. you Ifso. so. you have IfIf have Ifyou you have you any have any have have anyany any any concerns concerns concerns please please don’t please don’t hesitate don’t hesitate hesitate tocontinue contact to contact to contact us for us more for us more for information. more information. information. concerns concerns concerns concerns concerns concerns please please please please don’t please please don’t don’t hesitate don’t hesitate don’t don’t hesitate hesitate hesitate hesitate toto contact to contact contact toto tocontact contact us contact us for us for more us for us more usfor more for for information. more information. more more information. information. information. information.

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clinical | EXCELLENCE

Most importantly, always check the posterior opening of the construction bite; many agree that ideally this should be 2-3mm in the thinnest sections or largest cusp to shallowest fossa. The idea is that a “micro thin” splint usually leads to breakage and the reality is a few mm or more of posterior opening is easily tolerated by the majority of patients. There are many ways to take a construction bite and various tools to assist you, but the simple use of bite wax is most likely the easiest method as long as the patient does not over-close. Of course, many opt for the convenience of various bite registration silicones as these are easily dispensed in the mouth and when used with caution, can work very well. The downside of these materials are they can distort easily on setting and get brittle, so can break easily. Always go for a good quality hard but flexible material that can be trimmed with a scalpel if need be by the dental laboratory for a correct fit. Leaf Gauges and George Gauges can be useful as they help with measuring anterior opening, but be aware it’s the posterior opening that is often overlooked as it’s the hardest to see and its very important that that is the correct opening too.

Intraoral scanning f course, a construction bite can be used with an intraoral scan as well; it’s done in a similar way and then the scan is taken of the bite relationship. The software will then match the upper and lower scans to this construction bite, ready for design to the exact recorded bite relationship. With a bit of practice, you will be taking a construction bite quite easily and quickly and ultimately, it will make a massive difference to your whole splint experience and more importantly, will save you a ton of time.

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Materials

here are various materials available for splint fabrication. Arguably, the best and most trusted is PMMA which can be traditionally processed or milled using state-of-theart milling machines to achieve very high-quality results. 3D printing is also popular nowadays and is receiving growing attention, however the strength and longevity of the splint resin can be questionable. For special cases, POM (Polyoxymethylene) can be used. It is also known as acetyl resin.

Conclusion ith the trend being to digitally design and manufacture splints, there is no excuse for an illfitting splint, as parameters can be directly dialed in and reproduced with every splint. However, every splint is unique so the designer and manufacturer still need to understand the nuances and do not expect AI to do everything!

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.

November/December 2023

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A freedom alternative to the consequences of bruxing Digital copy denture fabrication for a bruxing/clenching patient By Marc Wagenseil DD, RDT

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clinical | EXCELLENCE These treatments have included hard and soft maxillary and mandibular splints, meditation, medications and hypnosis. The patient has learned trigger points which influence her bruxing and has also accepted the premature wearing of the denture teeth and with it, more frequent denture replacement. She must always wear the denture at night for temporomandibular joint support. Considering her condition, the existing denture was crafted with VITA Excell Anteriors and Lingoform Posteriors. These teeth were chosen for aesthetics, material durability (acrylic-glass) and Freedom in Centric design. A more detailed explanation is to follow.

“Freedom in Centric was incorporated into the current denture to eliminate the occlusion as a trigger. Part of the reasoning is that the denture should do no harm...”

Although the denture was performing well during her recall appointment, slight premature wear was noted and discussions began on pre-emptive options. Prior to her becoming a patient, her previous dentures had been crafted from acrylic teeth, which were well worn within a few years and fractured often. The current VITA product used in her denture was performing well and much better than acrylic teeth had. Since the option was now available, the decision was made to craft a digital copy of the existing denture, which she would wear at night or in trigger point situations. The thought was to have the copy denture bear the brunt of the consequences of bruxing/clenching and not the “good” denture. The existing denture was scanned using 3Shape and a copy made from Dentca tooth shade printable resin. This material was chosen with the expectation that it would be more durable than acrylic.

November/December 2023

Oval/Circular

Ovoid

Tear drop/Vertical

Figure 1. Patients chew in a teardrop pattern unique to each individual.

Figure 2. The left image shows the freedom in centric area where the patient is not “locked in” due to a flat and wide fossa without cusp interference. The right image shows how a patient would typically be “locked in”.

Treatment plan n drafting the treatment plan, the copy denture would not be enhanced as the current denture was performing well. It functioned, fit, was comfortable, had not fractured and was not causing any issues to the supporting structures as had occured in previous dentures. The copy denture was to be worn at night or in trigger point situations.

Background information and theory

Freedom in Centric reedom in Centric is defined as “A flat area in the central fossae upon which opposing cusps contact, which permits a degree of freedom (0.5-1 mm) in eccentric movements uninfluenced by tooth inclines.” (Schuyler CH. Freedom in Centric. Dent Clin North Am. 1969;13:681-686.). All natural dentition have this concept, yet only a very few specific denture teeth available have it incorporated.

Why Freedom in Centric is important in dentures

Existing denture teeth tandard teeth available and used in most dentures are functional, with 10, 20 or 30-degree variety with the working and balancing cusp concept. However, the teeth are locked into a centric position and have no Freedom in Centric. Yes, they work and balance, but there is no “wiggle-room” in centric. In cases of single dentures, these denture teeth are ground into the natural teeth to achieve maximum contact and overlap and have no Freedom in Centric.

his concept is important as denture teeth have no nerves. As such, a patient cannot feel when the teeth occlude or if they occlude properly. The important fact to remember is that there is food between the teeth during chewing and it is not possible to achieve perfect centric contact each and every time like we can achieve on an articulator during fabrication. What compounds the issue is that dentures are subject to moving as they fit against soft tissue.

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Figure 3. The denture within the scanner.

Figure 4. Occlusal view of scan.

Figure 5. Frontal view of scan.

Figure 6. Fitting (Intaglio) surface scanned perfectly.

Figure 7. Occlusal view of existing and copy denture.

Figure 8. Frontal view of existing and copy denture. Combine these points and it is not conceivable to think a denture patient can achieve perfect centric each time. This provides a reason as to why natural dentition has Freedom in Centric, even though we can feel our teeth, as it is not possible

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Figure 9. Existing and copy denture.

to achieve perfect centric each time we chew. With this in mind, the concern is the working cusps hitting the corresponding guiding planes, sliding into position. The hit and slide aspect is a source of denture issues and ill fit. When present, because

the patient cannot directly feel it, they will try to grind away the offending contact, exasperating the bruxing/clenching condition. This is also often misdiagnosed. Freedom in Centric thus provides stability to dentures.

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clinical | EXCELLENCE Why Freedom in Centric was important in this treatment n considering that the upper denture rests against soft tissue and opposes a more rigid natural dentition, it is subject to dislodging forces. Combine this with the patient’s neurological impulse to brux/ clench; functional occlusion becomes paramount–functional in that there are no hit and slide contacts occurring within function to act as a trigger for bruxing/ clenching. Freedom in Centric was incorporated into the current denture to eliminate the occlusion as a trigger cause. Part of the reasoning was that the denture should “do no harm”.

“Patients often look to us to be their superheroes. In some situations, this can be a daunting task given treatment modalities. The combination of traditional experience with emerging digital technology provided inspiration to “get out of one’s own way” and, ergo, challenge professional complacency...” The theory concept of this occlusion is that the teeth do not appear “knuckle tight” as one would usually expect. It was of open concept, free in centric and free within function.

The patient chew cycle patient chews in a teardrop pattern and is unique to each individual. Some patterns are more horizontal, others more vertical (Figure 1). The cusps, especially the non-working cusps of the buccal and lingual lowers, must not interfere while functioning within the chewing cycle of the patient. If there is interference, the cusps hit and then slide into position. As discussed previously, this hit and slide cannot be felt by the patient (Figure 2).

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The digital design he existing denture was scanned and then designed using 3Shape. The copy denture was inserted and checked. As it was a replica of the existing, no refinements were necessary. Upon follow-up two, four and eight weeks post-insertion, the patient was wearing the copy denture as instructed and no discomfort was reported.

Key take away points • Freedom in Centric designed occlusion, regardless of fabrication or platform used, provides denture stability and flexibility. • The hit and slide on the guiding planes of cusps is the primary cause of common denture issues. • Managing the hit and slide contacts provides a stable fit and, in this situation, control of bruxing/clenching. The denture is not acting as a trigger or causing bruxing/clenching as the patient is not trying to grind away an interfering contact. • A “Freedom in Centric” copy denture is proving useful as a positive and affordable treatment option in bruxing/ clenching patients.

Conclusion atients often look to us to be their superheroes. In some situations, this can be a daunting task given treatment modalities. The combination of traditional experience with emerging digital technology provided inspiration to “get out of one’s own way” and, ergo, challenge professional complacency. This article explored a “new” and trending treatment option for managing the consequences of bruxing/clenching. Freedom in Centric is the ability to move within centric contact, thus not locking in a “bite”. This phenomenon is only incorporated in a few denture teeth and allows for flexibility in setup arrangements to suit patient requirements. Understanding this theory provided confidence to explore this digital copy denture treatment plan. We, as denture professionals, do not slap teeth together as we strive to be a superhero to our patients. The type of teeth you use matters in

traditional or digital fabrication as we strive to “do no harm”, so please seek out and consider Freedom in Centric posterior teeth. “Freedom is Good!”.

Acknowledgement The author thanks his patient, VITA, Aurum Lab Calgary and Jason Atwood from core3d Calgary.

About the author Marc Wagenseil is a licensed denturist and dental technician with 35 years of direct patient care. He is a specialist in the field of oral biology, including the prosthetics that function within. A key opinion leader and subject matter expert, Mr Wagenseil has lectured extensively on oral biology, anatomy, biological chewing function, biomechanics and prosthetic (implant and digital supported) design and fabrication, providing hands-on, in-depth education internationally. As the owner of Heritage Denture Centre and Heritage Dental Lab in Edmonton, AB, Canada, he has spent his career focusing on how dentures integrate in the mouth and body and inspires a unique awareness of occlusion and professional growth. Mr Wagenseil also provides professional consulting services on dental prosthetics and treatment services related to improving technical, marketing and education activities. Originally printed in the Fall 2022 issue of Denturism Canada - reprinted with permission from The Denturist Association of Canada, the author and the publisher.

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November/December 2023

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Lively, natural and highly esthetic VITAPAN EXCELL anterior teeth and VITAPAN LINGOFORM posterior teeth are a perfectly matched multifunctional combination for all established prosthetic concepts.

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TGA approved implant prosthetic components for more than 140 systems

Figure 1. Zirkonzahn’s wide range of TGA approved implant prosthetics components, available for more than 140 implant systems.

Figures 2-3. Multi Unit Abutments straight and angled (17°) are excellent for complicated full arches where the screw channels are strongly divergent. They can be used for all types of works, from bars and Prettau® Bridges to even small bridges or single crowns with uncomfortable implant positions.

irkonzahn’s portfolio of implant prosthetic components, available for more than 140 implant systems and produced entirely in South Tyrol, Italy, is comprised of a great range of products: titanium bases, Scanmarkers, White Scanmarkers, ScanAnalogs (laboratory analogues used as scanmarkers), impression copings, laboratory analogues, Multi Unit Abutments, Raw-Abutments® and healing caps. In addition, the product line has recently been expanded with innovations: • Zirkonzahn LOC-Connector, a snap attachment system for implants and bars to fix removable dental prostheses on the implant;

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• Multi Unit Abutments 17° and 30°, characterised by a 17° or 30° angle to compensate for any implant inclinations and with two different anti‑rotation connection types which allow intermediate positions; • Titanium Bases K85, with the chimney height adjustable to the individual tooth length; • Titanium Bases K80 Angled Screw Channel, with a chimney height adjustable to the tooth length and the possibility to tilt the screw access channel from 0° to 30°; and • White Metal Scanmarkers, reusable scanbodies to acquire the implant position and orientation during intraoral and model scans.

November/December 2023

clinical | EXCELLENCE

Figure 4. MUAs can be used for indications requiring different divergence degrees. Indeed, they can be purchased with different connections (hexagonal, square, triangular and octagonal): each connection is available in two different typologies (1 and 2), so that the number of connection possibilities is doubled.

Figure 5. Titanium Bases HEX K85, with adjustable chimney height.

Figure 6. Titanium Bases K80 Angled Screw Channel (ASC), with adjustable access channel that can be tilted from 0-30°.

Titanium Bases K85 and K80 Angled Screw Channel (ASC)

Multi Unit Abutment (MUA) 17° and 30° ulti Unit Abutments (MUA) exist in varied heights and are especially suited for multi-unit restorations. Connection to secondary structures are unified so the latter can be screwed directly – or with additional titanium bases – on different implants. Due to a standardised connection, additional components such as titanium bases, Scanmarkers, etc, are reduced to one connection to compensate for divergences. Multi Unit Abutments are available in two versions – straight or angled. • Straight MUAs are characterised by a non hex connection without anti-rotational features to simplify multi-unit restorations. Their application is extremely easy, because all implant types have been adapted to a standard platform. Available in five gingival heights for flexible treatment options, Zirkonzahn Multi Unit Abutments are used in combination with conical titanium bases. • New Multi Unit Abutments Angled are currently available with a 17° or 30° angle to compensate for any implant inclination and two different anti-rotation connection types which allow intermediate positions. MUAs are incorporated to correct the insertion direction of structures retained by divergent implants. Offering a variety of platforms (hex, square, triangular, octagonal), each geometry is available in two different typologies, effectively doubling the connection possibilities.

November/December 2023

s with all Zirkonzahn implant prosthetic components, our titanium bases are manufactured with high-quality medical titanium alloy. Our portfolio of titanium bases recently expanded with the addition of new innovations for flexible and patient-specific restorative design:

• Titanium Bases K85 can be individually shortened for optimal adaptation to the respective tooth length. Available in conical or parallel chimney, the Titanium Bases K85 are equipped with or without an anti-rotation device as well as anti-rotation connection. • Titanium Bases K80 Angled Screw Channel (ASC) combine two advantages in one product. On the one hand, the adjustable chimney height ensures optimal stability and force distribution. On the other hand, the screw channel can be tilted up to 30° to compensate for nonoptimal implant positions. Depending on the intended use, the titanium bases are available with or without antirotation device as well as anti-rotation connection.

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Figure 7. The two different models: one with MUA, the other one with just the ScanAnalogs.

Figure 8. The digitisation of the model with regular Scanmarkers on MUA.

Figure 9. The digitisation of the model with White Scanmarkers directly on the analogues.

Figure 10. The digital wax-up matched to the scanned initial situation.

New implant components - Workflow and case example in Zirkonzahn.Software very treatment performed within the Zirkonzahn workflow begins with prescription entry in the Zirkonzahn.Archiv software - a database management system of cases. For the treatment below, we selected Wax-up element on six implants. The treatment is opened in the Zirkonzahn.Scan software, where models can be scanned or intraoral scans can be imported.

Figure 11. In the Zirkonzahn.Modellier software, implants and components are selected before starting the treatment. The software allows users to download only the library with the implants and components needed for the specific treatment.

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It is also possible to set -up and save the project in one of the virtual articulators available before starting the CAD-design. To demonstrate the versatile application and the possible solutions of Zirkonzahn implant prosthetic components, one implant model with angulated - not optimally placed - screw channels was prepared and a possible solution was shown: a wax-up scan was also incorporated in the Zirkonzahn.Scan project and two milled models with Scananalogs were created. On top of one of the modes, Zirkonzahn MUA were used to show the two different results.

Figure 12. The CAD software shows directly the threads for the selected screw channel.

November/December 2023

clinical | EXCELLENCE

Figure 13. The emergence profile can be drawn in order to design each implant area individually.

Figure 14. Margins can also be adapted and designed individually.

The project is imported into the CAD software (Zirkonzahn. Modellier or the add-on software Zirkonzahn.Modifier), for framework design. Prior to creating the bridge, the implant prosthetic components are selected from the Zirkonzahn implant library. Here, users choose the implant platform, capture and indexing method (Scanmarkers, White Scanmarkers or ScanAnalogs) and suitable titanium base. For example, implants placed at bone level or in close proximity are best captured with regular Scanmarkers and restored with Zirkonzahn Narrow titanium bases thanks to a minimised platform diameter. Sealing screws for threaded screw channels are also selected within the Zirkonzahn implant library. Once the implant prosthetic components are selected from the implant library, the bridge is designed and adapted to the implant prosthetic components with robust customisation options for the emergence profile, margins, screw channel inclination, etc.

Examples of possible combinations: • In this kind of treatment, the usage of conical titanium bases screwed directly on the restoration without Multi Unit Abutments is not appropriate because the implant holes appear on the vestibular area. The software permits to change the screw channels inclinations manually, however, without any MUA or Titanium Bases K80 Angled Screw Channel (ASC), the milling results can be incorrect if the angular modification of the channel is substantial. For this reason, for implants with a 0°-30° divergence Titanium Bases K80 are recommended, whereas for restorations with 60°-80° divergence or deep implants, MUAs are highly recommended for better outcomes. • The choice of MUA 17° on Scanmarkers with regular conical titanium bases changes the aesthetic outcome: indeed, the screw channels come out straight on the occlusal surface.

Figure 15. The usage of conical titanium bases screwed directly on the restoration without Multi Unit Abutment is not the best solution because the implant holes appear on the vestibular area.

Figure 16. The software permits to change the screw channel inclinations manually, however for precise outcomes, Titanium Bases K80 and MUAs 17° are highly recommended in the case of divergent implants.

Figure 17. The blue colour indicates that the digital Scanmarker is perfectly matched to the scanned one.

Figure 18. Using the MUA 17°, the screw channels come out straight on the occlusal surface, with no impact on the aesthetic result.

clinical | EXCELLENCE

Figure 19. With the Titanium Bases K80 Angled Screw Channel, each screw channel can be moved individually according to the implant inclination.

Figure 20. After merging the framework to the scan, the correct screw channel is selected from the library.

Figure 21. The screw channel is then matched with the desired inclination.

Figure 22. With the Titanium Bases K80 Angled Screw Channel, the restoration’s screw channels are visible on the occlusal surface, with no influence on the final restoration aesthetic. But they are difficult to be mill correctly in this specific case with the required inclination of the screw channels.

• With the usage of Titanium Bases K80 Angled Screw Channel, each channel can be moved individually according to the implant inclination, thanks to the specific opening that characterises these new titanium bases. In this case, the size 2.9 was selected. Once the framework design is merged, the right screw channel size can be chosen in the FreeForm tool and then matched to the restoration’s screw channels according to the correct inclination. The connection between the titanium base and the screw channel is perfectly fitting and will not cause imprecisions during milling.

factured at their production site in South Tyrol, Italy. In addition to legally prescribed warranty obligations – a warranty up to 30 years is offered on all Zirkonzahn implant abutments used (titanium bases, Multi Unit Abutments, Multi Unit Abutments Angled, Raw-Abutments as well as the corresponding screws). Within the current Zirkonzahn warranty regulation, they also explicitly include the implants from other manufacturers used with Zirkonzahn implant abutments.

A 30-year warranty for all Zirkonzahn implant abutments! or the manufacture of its implantsupported components, Zirkonzahn use a high-quality medical titanium alloy (Ti-6Al-4V ELI according to ASTM F136 and ISO 5832-3). As one of the world’s largest manufacturers, they meet the strictest quality criteria (ISO 13485 MDSAP; Medical Device Directive 93/42/EEC) and all of our components are conceived and manu-

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November/December 2023

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With or without anti-rotation connection, but with anti-rotation device on the chimney as well as cut-off marks for adjusting the height

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clinical | EXCELLENCE

Figures 23-25. An overview of the different outcomes according to the implant components used: the usage of White Scanmarkers with conical titanium bases screwed directly on the restoration without MUAs is not appropriate because the implant holes appear on the vestibular area. With the new MUAs 17° and titanium bases K80 Angled Screw Channel, the screw channels are visible on the occlusal surface, causing no impact on the final aesthetic result, but the screw channel area, milled with Titanium Bases K80 with an inclination of more than 30° might not deliver a perfect result. The MUA solution seemed to be the best one for this specific case.

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clinical | EXCELLENCE

Deep restoration with Biodentine™: From the pulp floor to top of the cavity By Dr Pedro Alexandre

arious lesions in the root region are a major challenge in daily clinical practice. In addition to being difficult to detect (diagnosis is often a radiographic finding), they are also very challenging due to their proximity to the pulp tissue and the difficulty of access for restorative procedures. Biodentine (Septodont) is a calcium silicate-based material that has, among its main properties, bioactivity, compressive strength and short setting time. These qualities make it possible to use Biodentine™ as a one-step filler in the case of conservative treatments of the pulp, with or without exposure.1,2,3 Unlike MTA, the indications of which are more focused on endodontics, Biodentine has demonstrated proven results in pulp regeneration.4 When compared to glass ionomers, Biodentine is more resistant and bioactive.3 The latter characteristic is not found in GICs, which are not indicated for placement directly on the pulp without another material as a liner or base, such as calcium hydroxide or MTA.5,6,7,8,9 Moreover, Biodentine does not cause discolouration of tooth structure like MTA does.10 Thus, it is an excellent option for cases of deep cavities, even those with direct pulp involvement.

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This clinical case report aims to show some of the characteristics and indications of Biodentine.

Case report 77-year-old patient presented to the dental clinic after five years without dental care. The clinical findings showed significant bone loss, chronic periodontitis and loss of some teeth that stabilised the occlusion. The patient reported cold sensitivity in tooth #46, especially when ingesting liquids. Periapical X-ray confirmed the findings of the clinical examination and root caries was also detected in the distal root of tooth #46, which answered positively to the sensitivity test (Figures 1-2). The treatment plan began with a focus on returning the patient to adequate periodontal health. In a subsequent session, with improved condition of the periodontium, the restoration of tooth #46 was performed. Under block anaesthesia of right inferior alveolar nerve and rubber dam isolation, the amalgam restoration was completely removed and access to the caries cavity obtained (Figures 3-5). Despite the proximity to the pulp tissue, no exposure occurred and the class II cavity was fully restored with Biodentine (Figures 6-8).

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clinical | EXCELLENCE

Figure 1. Initial clinical situation.

Figure 2. Initial X-ray.

Figure 3. Class II cavity prepared.

Figure 4. Septomatrix in position.

Figure 5. Cavity deep.

Figure 6. Biodentine™ applied in a Bio Bulk‑Fill approach.

Figure 7. Clinical situation after 12 minutes and the removal of the matrix.

Figure 8. Clinical situation after the removal of the rubber dam.

Figure 9. Follow-up X-ray 2 months postoperatively.

Figure 10. Biodentine™ restoration after 2 months.

better photo-activation of the surface layer. The restoration was then finished and polished, before removing the rubber dam and checking occlusion (Figure 17).

restoration did not harm the health of the tooth. It was felt that removal could cause more aggravation to the pulp tissue and consequent loss of pulp vitality. With regard to the periodontium, the subgingival treatment had the desired effect within two months. The occlusal adjustment allowed for a decrease in the mobility of two teeth that had previously displayed increased mobility due to vertical bone loss.

At two months’ follow-up, no symptoms were reported, no periapical lesion was observed radiographically and the clinical examination showed normal vitality (Figures 9-10). Thus, it was decided to perform the definitive restoration, leaving Biodentine as the definitive base. The Biodentine material was partially removed and a resin composite filling placed over it (Figure 11). Selective etching of enamel was done, followed by the application of an adhesive system (Palfique Bond®, Tokuyama) (Figures 12-13). After light-curing, the matrix system (SeptoMatrix, Septodont) was set and a large matrix with a soft ring was used for a better contour and proximal contact point (Figure 14). The restoration was started in the distal portion, changing the class II cavity into a class I cavity (Figure 15). Finally, the occlusal face was completed using Palfique LX5® composite (Figure 16). After lightcuring, glycerin gel was applied to allow

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Important observations irstly, it was decided not to remove the amalgam restoration on the mesial face because, although the amalgam corrosion had stained the tooth structure, the

Australasian Dental Practice 131

clinical | EXCELLENCE

Figure 11. Removal of the external part of Biodentine.

Figure 12. Selective etching of enamel.

Figure 13. Adhesive application.

Figure 14. Placement of a matrix system (Septomatrix, Septodont).

Figure 15. Reconstruction of the distal wall with composite.

Figure 16. Immediate finished restoration.

Figure 17. Clinical situation after finishing and polishing.

Discussion aries lesions close to the pulp are a challenge to both diagnose and access in our daily practice, as demonstrated in our reported case. Indirect pulp capping is a procedure that aims to preserve pulp vitality by avoiding endodontic treatment.5,6 Different materials have been used for indirect pulp capping over the years. Pastes based on calcium hydroxide, glass ionomer and MTA are presented in several studies as options for this treatment.5,6,7,8 However, the more effective materials in terms of bioactivity (MTA) do not have enough resistance to fill the entire cavity like Biodentine, which can be used as a single material to bulk-fill a cavity from pulp to crown for up to six months. In the present case, Biodentine remained for a period of two months, which was enough time for the signs and symptoms to resolve and a definitive restoration to be placed.

Conclusion iodentine is an excellent option for restoring teeth with deep cavities, with or without pulp exposure. Important properties such as bioactivity, resistance and short setting time, in addition to excellent plasticity, allow Biodentine to be easily placed in more challenging cases of difficult access and close pulp proximity, as reported in this clinical case.

About the author Dr Alexandre has a Masters Degree in Dental Materials from Santa Catarina Federal University, Brazil and a Post-Graduate qualification in Implant Dentistry. He is a specialist in periodontics, the co-author of the Dental Materials Book Series - ABENO and a Speaker at various dental congresses.

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References 1. Laurent P, Camps J, De Méo M, Déjou J, About I. Induction of specific cell responses to a Ca(3)SiO(5)based posterior restorative material. Dent Mater. 2008 Nov;24(11):1486-94. doi: 10.1016/j.dental.2008.02.020. Epub 2008 Apr 29. PMID: 18448160. 2. Kunert M, Lukomska-Szymanska M. Bio-Inductive Materials in Direct and Indirect Pulp Capping-A Review Article. Materials (Basel). 2020 Mar 7;13(5):1204. doi: 10.3390/ma13051204. PMID: 32155997; PMCID: PMC7085085. 3. Koubi G, Colon P, Franquin JC, Hartmann A, Richard G, Faure MO, Lambert G. Clinical evaluation of the performance and safety of a new dentine substitute, Biodentine™, in the restoration of posterior teeth - a prospective study. Clin Oral Investig. 2013 Jan;17(1):243-9. doi: 10.1007/s00784-012-0701-9. Epub 2012 Mar 14. PMID: 22411260; PMCID: PMC3536989. 4. Chauhan A, Dua P, Saini S, Mangla R, Butail A, Ahluwalia S. In vivo outcomes of indirect pulp treatment in primary posterior teeth: 6 months’ follow-up. Contemp Clin Dent 2018;9:S69-73. 5. Gurcan AT, Seymen F. Clinical and radiographic evaluation of indirect pulp capping with three different materials: a 2-year follow-up study. Eur J Paediatr Dent. 2019 Jun;20(2):105-110. doi: 10.23804/ ejpd.2019.20.02.04. PMID: 31246084.

6. Mathur VP, Dhillon JK, Logani A, Kalra G. Evaluation of indirect pulp capping using three different materials: A randomized control trial using cone-beam computed tomography. Indian J Dent Res. 2016 NovDec;27(6):623-629. doi: 10.4103/0970-9290.199588. PMID: 28169260. 7. Sahin N, Saygili S, Akcay M. Clinical, radiographic, and histological evaluation of three different pulp-capping materials in indirect pulp treatment of primary teeth: a randomized clinical trial. Clin Oral Investig. 2021. Jun;25(6):3945-3955. doi: 10.1007/s00784-020-03724-4. Epub 2021 Jan 6. PMID: 33404764. 8. Rahman B, Goswami M. Comparative Evaluation of Indirect Pulp Therapy in Young Permanent Teeth using Biodentine™ and Theracal: A Randomized Clinical Trial. J Clin Pediatr Dent. 2021 Jul 1;45(3):158-164. doi:10.17796/1053-4625-45.3.3. PMID: 34192759. 9. Kurun Aksoy M, Tulga Oz F, Orhan K. Evaluation of calcium (Ca2+) and hydroxide (OH-) ion diffusion rates of indirect pulp capping materials. Int J Artif Organs. 2017 Oct 27;40(11):641-646. doi: 10.5301/ijao.5000619. Epub 2017 Jul 8. PMID: 28708217. 10. Camilleri J. Staining Potential of Neo MTA Plus, MTA Plus, and Biodentine™ Used for Pulpotomy Procedures. J Endod. 2015 Jul;41(7):1139-45. doi: 10.1016/j. joen.2015.02.032. Epub 2015 Apr 15. PMID: 25887807.

November/December 2023

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surgery | DESIGN

About Smiles opens at Circular Quay

r Aodhan Docherty is no ordinary dentist. His journey into the world of dentistry was deeply rooted in personal experiences and a lifelong passion for the field. He fondly reminisces about his inspiration, the late John McGowan, a cherished family friend who also happened to be an exceptional dentist. Dr Docherty’s fascination with dentistry began at a tender age and from that point forward, he aspired to follow in the footsteps of his esteemed mentor.

134 Australasian Dental Practice

Dr Docherty’s academic journey was marked by dedication and excellence. He pursued his dental education at the prestigious University of Sydney, investing a total of 8.5 years in honing his expertise. His educational odyssey encompassed a Medical Science undergraduate degree, a Bachelor of Dentistry with Honors and a Graduate Diploma in Oral Implants. With these qualifications in hand, Dr Docherty embarked on his professional journey, which has now spanned 8 years of dedicated dental practice. Teaming up with his business partner, Dr Christopher Ho, Dr Docherty embarked on a mission to elevate the standards of

patient care and dental work in Sydney, joining a group of dental practices across the city, driven by a shared commitment to excellence. Their latest venture, About Smiles at Circular Quay, is uniquely focused on delivering transformative cosmetic smile solutions. The vision for About Smiles was clear from the outset. Dr Docherty and Dr Ho envisioned a dental practice that would be the epitome of style, chicness and high-end simplicity. The objective was to create an environment where patients could experience dentistry in a space that was not only aesthetically pleasing but also conducive to their comfort and well-being.

November/December 2023

Australasian Dental Practice 135

In a unique collaboration, Dr Docherty and Dr Ho reached out to a talented Portuguese designer to infuse About Smiles with the essence of Portuguese aesthetics. This designer’s expertise brought a touch of European charm to the project, setting the stage for a design solution that transcended borders and cultures. Medifit collaborated with the original designer to ensure the concept design complied with the National Construction Codes and Australian Standards in what was a difficult site. Upon completion, it’s clearly evident that these objectives have been flawlessly met. This custom-built clinic has been meticulously designed to mirror the high calibre of dentistry performed within its

136 Australasian Dental Practice

walls. From the warm and welcoming front-of-house team to the personable dental nurses and highly knowledgeable dentists, every aspect of the clinic is dedicated to patient comfort and satisfaction. Patients are ushered into a lounge area that exudes warmth and tranquility. Within the stunning treatment rooms, dental nurses ensure patients feel at ease. Here advanced dental technology meets contemporary Australian standards. And in the consultation room, highly skilled dentists engage in comprehensive discussions about treatment stages and plans, fostering trust and confidence in patients.

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Dr Aodhan Docherty and Dr Christopher Ho’s journey with Medifit is not a new one; it’s a relationship built on trust and confidence. About Smiles Dental Practice marks Dr Ho’s third collaboration with Medifit with his former Balmain dental practice being completed by Medifit in 2002. Medifit’s Sam Koranis said “Customer relationships are a key part of Medifit’s success over the past 22 years and our journey with Dr Chris Ho is testament to the value we place on building partnerships that are bigger than any one project. “Medifit has now built three stunning practices for Chris and we look forward to the next one. At About Smiles, Medifit were able to take a concept design sourced internationally and draw

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upon our design and construction experience to deliver a practical solution in an Australian dental context.” The tenancy was a difficult space and Medifit’s design team played a pivotal role in taking the Portuguese-inspired design solution and seamlessly integrating it into the contemporary Australian dental landscape. Their ability to transform a practice vision into stunning reality is a hallmark of Medifit and the end result is nothing short of incredible. Medifit’s proficiency in managing complex projects, even within demanding site conditions, is a testament to their extensive experience and dedication to the dental industry.

Australasian Dental Practice 137

Summary The Practice The Practice

About Smiles

Principals

Dr Aodhan Docherty and Dr Christopher Ho

Type of Practice

General

Location

Circular Quay, Sydney, New South Wales

Size

70 square metres

No of chairs

The Team Design

Luis Pedro Silva (Portugal) Medifit Design & Construct (Australia)

Construction

Medifit Design & Construct

Equipment Dental Units

Planmeca Compact iClassic V2

Autoclaves

MOCOM B Futura 22 with High Performance Vacuum Pump

Imaging

Morita Veraview iX intraoral x-ray Morita X800 medium FOV CBCT

Compressor

Cattani AC300Q

Suction

Cattani Turbo Smart B Cube

Practice Software

Zavy 360

“To fit three surgeries, steri, CBCT, staff room, waiting and reception in just 70m2 was a challenge in itself. Adding to the difficulty, constraints on ceiling heights required intelligent design solutions to meet the National Construction Codes whilst satisfying the desired design aesthetic. The Medifit team internally referred to the project as The Tardis, a miracle of small space design.” In summary, Dr Docherty ‘s experience with Medifit has been nothing short of exemplary. Medifit’s deep involvement in the dental industry, combined with their wealth of experience, has made the journey predictable and reliable. The end result is a dental practice that not only meets but exceeds expectations—a stylish, chic, high-end sanctuary where dental excellence, patient comfort and global design inspiration converge seamlessly in a contemporary Australian dental context. Dr Chris Ho added “a huge thanks goes to all of the staff at Medifit for their dedication in producing a great result. We appreciated that it was a difficult site but were confident that Sam Koranis and his team would relish the challenge and deliver the results we needed.”

138 Australasian Dental Practice

November/December 2023

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

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1300 728 133 www.medifit.com.au

surgery | DESIGN

New look signals fresh approach to dentistry By David Petrikas

n Sydney’s cosmopolitan Darlinghurst, you’ll find a dental practice like no other. And it’s not just the décor that sets it apart. That said, the oneoff design is all part of the “vibe” that communicates the philosophy of the owner and his staff. “Sage Space” looks nothing like a typical dental practice and bucks the trend of promoting expensive cosmetic and restorative dental treatments to patients, instead advocating a preventative approach to oral health.

140 Australasian Dental Practice

Practice owner, Dr Corbin Barry, believes dentistry has wrongly gone down the “drill and fill” and cosmetic dentistry path when the fundamental aspect is that if we look after our teeth, there wouldn’t be all this work for dentists. “Sometimes it’s as simple as brushing your teeth. Our goal here is we try to teach people that prevention is key to save money and time and pain through avoidable dental treatments,” Dr Barry says. Here it’s the hygienists, not the dentists who are at the front line of patient care. After an initial consultation in a relaxing

space with a personal carer, patients are ushered into one of the curtained-off private brushing stations. “The goal of this to give people a chance to disconnect from the outside world and learn to make brushing your teeth a daily dedicated ritual instead of that thing you do when you’re stressed and running late and picking up clothes. It’s not a rush job. “We play their favourite song and try to get them to relax and enjoy the treatments we offer and educate them about introducing good oral hygiene as part of their daily routine.”

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Equipment selection was another important part of the overall patient experience. “Our whole approach here is ‘less is more’ – that’s why we went with the A-dec 400 chair with the remote A-dec ‘Duo’ delivery system. “Patients only see the chair. The delivery system and instruments are tucked away behind.” The assistant’s instruments are also discretely positioned on the side of a round work surface which pivots into position at the head of the chair when needed. The LED dental operatory light also mounted remotely from the cabinetry behind. Dr Barry has used other chair brands but found the technical issues were hard to resolve even by service technicians.

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For that reason, he opted for the known reliability of A-dec, opting for the A-dec 400 with plush, sewn upholstery. “The A-dec is not only functional and reliable, it’s also stylish,” he said. And ergonomically, it supports the patient in total comfort. It is also better for the operator because of its thin, flexible backrest and articulating multi-position headrest which allow optimum patient positioning and an ergonomically correct, upright work position. The chosen Pecan colour upholstery works perfectly with the Portuguese cork flooring and other natural materials used throughout the practice.

Australasian Dental Practice 141

The inviting, aesthetically pleasing design is not just stroke of luck, with Dr Barry having a degree in interior design which he put to very good use in designing the practice and briefing his architect and building team. “I planned the layout together with the designer. I like the idea of the psychology of space. Not just an algorithm like most commercial builds. It’s more personal than that. “It needs to be specific to the demographic we are targeting to come in and to us as a brand. A practice in Western Sydney should be different to one in Mosman for example.” The result is more akin to a trendy café and luxury day spa feel. High-end therapeutic retail goods like candles and incense are on display and available for sale. Local Archibald Prize winning artist Laura Jones has works on display together with others from two art galleries which are on rotation through the space. “When we designed this, it was a lot about using texture and colour and combining different elements,” Dr Barry said. “A lot of dentists or the companies that do a lot of surgery fitouts use neutral colour palettes or maybe do a theme room. But I like to explore not just the design, but the psychology of spaces. People can be relaxed by being distracted by tactile materials and colours which helps settle them for dental treatment.

142 Australasian Dental Practice

“Patients are sometimes so distracted, that they only ‘see’ things on their second appointment as they haven’t been able to take in all the details on their first visit as each space has its own character.”

November/December 2023

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Summary The Practice The Practice

Sage Space

Practice Type

General

The Principal Location Size

No of chairs

Dr Corbin Barry Darlinghurst, Sydney, New South Wales 145 square metres 2+1

The Team Design

Dr Barry and Strutt Studios

Project Manager

Thanasi Bountros

Fitout

Project Director Installer

Impression Projects George Bekiaris

Dental Installations, Sydney

Equipment Dental Units Sterilisation Imaging

Compressor Suction

Software

Dr Barry said the spaces are separate themed rooms. There is the ‘Kalamata olive’ room and a ‘terracotta’ theme in the other surgery. Patient refresh areas are deliberately private and the patient consult/accounts room with its dark walls feels like an intimate softly-lit cocktail bar.

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A-dec 400 with A-dec 541B Duo delivery and A-dec 575L wall mount LED light Dürr Hydroclave 50 Plus Dexis OP 3D

Blok Jet Silent

Cattani Turbo Smart B and AC300 Zavy 360

Extensive use is made of Venetian plaster, curved walls, exposed grout and unique materials like eclectic chunky terrazzo and natural cork and timber flooring, providing a funky vibe throughout the practice. All of this is accentuated by mood lighting throughout. A third treatment room is set up for an osteopath with a special chair for massage and manipulation of the jaw to eliminate tension and help treat temporomandibular joint issues, working collaboratively with a sleep doctor and local ENT specialist. Moving beyond the osteopath’s room and past a curtained-off OPG room to the side is a generous staff breakout area. Amenities include not only the usual kitchen and dining area, but also a large bathroom and shower. Staff can change and go to the gym and come to work and have a shower or change and go out afterwards. There is also a washer and drier for uniforms, clothes and towels. Extending the versatility of the practice, the breakout area will also be used for casual evenings with talks from people in the local community to get to know the practice and other local people and businesses.

November/December 2023

A-dec 500 Pro: Experience a new level of connection. Everything you’ve come to appreciate about the A-dec 500 dental chair, is now available with a new delivery. Enabled with A-dec+ and an updatable software platform, the A-dec 500 Pro delivery system supports your dental team with a new level of connection.

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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.

New MOCOM THALYA handpiece care

New Piksers Ultra-fine 000 brush

MOCOM’s new Thalya and Thaylya+ are the dentist’s latest ally for effective maintenance of rotary instruments. Simple and user-friendly, these units allow perfect lubrication and purge maintenance of turbines and handpieces. To start using the machine, just connect to the compressed air feed and the power supply. Lubrication

The New Piksters Ultra-fine 000 Brush is a game changer. It’s so fine, it goes places no brush has gone before! Many hygienists have commented about this new 000 brush going into gaps that they could never get into before. So fine, they even had to add a new, smaller hole to the

and purge of 4 instruments is completed in less than a minute - Duct purge; Lubrication; and oil purge in 55 seconds. Available: Mocom Australia Mob: 0427-816-459 Tel: (08) 9244-4628 sales@mocomaustralia.com.au www.mocomaustralia.com.au

standard test gauge to confirm the significant difference. Available: Erskine Oral Care Tel: 1800-817-155 sales@piksters.com www.piksters.com

New A-dec 500 Pro delivery system

Cure up to 2.5 mm in 1 second!

The new generation A-dec Pro delivery systems - built to fit on the proven latest generation A-dec 500 and A-dec 300 patient chairs - are now being rolled out through A-dec dealers across the country. A-dec Pro heralds the new area of “Connectivity” in delivery systems, bringing tablet-style touchscreen technology and intelligent control on an allnew software-based platform.

The handheld Monet Laser is the first of its kind curing light. The collimated beam and consistent power of the Monet Laser create superior bond strength and a faster, deeper, more reliable cure. Cure up to 2.5 mm in 1-second! Each click of the Monet is a 1-second cure up to 2.5mm with an 8mm curing depth capacity. It cures composites, luting cements, adhesives and sealants and has been tested on over 50 brands of dental materials. Monet reduces shrinkage and debonding, reduces the potential for “soft bottoms” and features a consistent dispersion for a deep cure - Bulk fills in just 3 seconds! The compact laser includes optics for a parallel beam within the form-factor and an unrestricted rotatable head mechanism. Monet is covered by a two year warranty.

This brings the latest technology right into the dental surgery, supporting both the operator and the entire dental team in caring for patients, now and in the future.

Available: A-dec Australia Tel: 1800-225-010 australia.a-dec.com

146 Australasian Dental Practice

Available: Biomedent Tel: 1300-792-624 info@biomedent.com.au www. biomedent.com.au

November/December 2023

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