Australasian Dental Practice Mar/Apr 2021

Australasian

DENTAL PRACTICE THE BUSINESS MAGAZINE FOR DENTISTS

Vol. 32 No. 2

MARCH/APRIL 2021

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

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VOLUME 32 | NUMBER 2 MARCH/APRIL 2021

contents | REGULARS

On the cover...

The Nobel Biocare N1 implant system is a landmark innovation created to empower clinicians with simplicity and confidence.

management

68 Fee setting economics for dentists Overcoming COVID-necessary barriers for a 74 better patient experience 76 Sale disclosure: Telling the team 78 Very interesting stats to look at

briefs 8 10 one man’s opinion 12 in my practice 14 mouth wide shut 16 spectrum 58 CPD centre 60 abstracts 62 the cutting edge 146 new products

marketing

80 How to get more high-quality patients

finance

READ ME FOR

CPD

facebook.com/dentalpracticenow

82 Are you red, green or amber? more changes coming to 86 Even Income Protection cover

Income-splitting and the ATO traffic light set:

twitter.com/adpmagazine

instagram.com/dentevents

www.dentalpractice.com.au

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

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

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

March/April 2021

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contents | FEATURES

VOLUME 32 | NUMBER 2 MARCH/APRIL 2021

infection control

clinical excellence 90

102

90 virus: Why it matters reprocessing without the 94 Instrument “black box” or “magic window” Back to basics: Best practices 98 for masks Different strains of the SARS-CoV-2

READ ME FOR

CPD

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102 Biomimetic solutions for restorative dentistry Delayed implant placement with a thin 108 and defective buccal bone wall Treating the causes of Class III is equally 110 important in the permanent dentition

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CPD

118

surgery design 134

Implant placement with simultaneous EthOss grafting for healing enhancement One solution and three patients

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134 The Endodontic Practice is born

148 A modern marvel in orthodontics March/April 2021

Case report on maxillary compromised ® Pro Arch and Digital Workflow

118 dentition treated with Straumann

Clinical use of Biodentine pulpotomies

128 in anterior and posterior primary teeth

Australasian Dental Practice

7

briefs | NEWS Now we’re set...

S

ince my last column, we took the decision to move the Digital Dentistry and Dental Technology event back to its original dates of

By Joseph Allbeury September 10-11, 2021. It remains at the Novotel Sydney Brighton Beach.

We had originally chosen the dates in May because the FDI World Dental Congress was being staged in Sydney in September and we didn’t want the events to clash. However, once FDI moved to a purely virtual event, it cleared the way to move the event back to our preferred window.

And of course there were other reasons too.

COVID-19 regulations restricting venues to one person per two square metres was an issue for staging the event in its traditional format in May, so moving the event back alleviated that major problem. And more people will be vaccinated by September, mitigating the risk of COVID-19 in the community... and the chance of snap lock downs.

And apart from that, moving the event back is allowing us more time to create an amazing programme more akin to the experiences of 2018 and 2019.

The 2019 event offered delegates a choice of 8 concurrent streams over the two days, with some 110 education sessions presented by 50+ speakers. This is somewhat daunting to organise, of course and requires time to prepare. Coming off the Christmas lockdown at the end of 2020 and through the New Year break, we had lost the required momentum.

Now that we’re set for September 10-11, it’s full steam ahead and the event is coming together at apace. The 2021 event was always going to be different to previous... and future events... notably because international speakers will not be accessible. In keeping with tradition, however, Digital Dentistry and Dental Technology 2021 will feature a stellar line-up of talent drawn from the coalface of digital dental clinics and laboratories in Australia–Real solutions presented by real people with unprecedented access to the information you need to transition from analogue to digital and then take your work to the next level.

Given this is the third instalment of Digital Dentistry and Dental Technology, we’re also endeavouring to include both introductory and more advanced sessions to offer something for everyone. The hands-on sessions that were a hit in 2019 will also be back... plus the usual sessions on scanning and digital impressions, milling, 3D printing, CBCT and software with digital workflows for crown and bridge, implants, orthodontics and more.

Having said all of that, I will finally say thank you for your patience to everyone who has registered for the event.

Know that we are working to provide the best event possible for September 10-11 and we look forward to seeing you all there. And if you are yet to register, you can still SAVE 25% so don’t delay! Full details are available at www.dentaltechnology.com.au.

Stay safe and have a successful 2021.

Joseph Allbeury, Editor and Publisher

8 Australasian Dental Practice

Dr Phillip Palmer resigns from Prime

s of 1 March 2021, Dr Phillip Palmer has resigned from any day-to-day involvement with Prime Practice. Dr Palmer was the founder and Chairman of Prime Practice having started the company 25 years ago, with the aim of improving the professional, clinical and financial lives of dentists. He has become known as one of Australia’s leading experts on the business of dentistry. During his time at Prime, he wrote some 90+ published articles. Today, Prime has grown into a multi-faceted training and consultancy business with over 40 employees serving communities in Australia, New Zealand, North America and many parts of Asia. Through Prime, Phillip has helped many thousands of practice owners understand and thrive in the business side of their practices.

A

Henry Schein One appoints new specialist

s Henry Schein One Australia has appointed Mr Steven Komninos as Business Development Specialist for Victoria, SA and Tasmania. Within this role, he will empower dental clinics with solutions for optimising their practice management, increase patient retention and increase business growth. “I’m very excited to have joined a Fortune 500 company as well as the global leader in dental software and practice management solutions,” Mr Komninos said. “I’m looking forward to helping dental practices achieve better health outcomes for their patients whilst having more efficient workflows.” Mr Komninos has more than 20 years of experience in helping businesses overcome their challenges to achieve outstanding results. His experience includes working in the IT and software industry, training as computer service engineer and 12 years in providing CAD and data management solutions. His advice for dental practices wanting to optimise their business is to not be afraid of change - to change is to grow! At Henry Schein One, we can guide you on your journey to excellence. Top performing dental practices who have changed their software to EXACT and joined the Customer Success Program have gone on to achieve 44% revenue growth at the end of 12 months [data on file].” Take the first step towards accelerating your practice performance with a free business review. Contact Steven at steven.komninos@henryscheinone.com.au or 0400-882-047.

A

Dentevents makes finding a venue easy

ith the continuing return to face-to-face learning in 2021 and beyond, Dentevents.com has added a new Find Venues feature to help event organisers. “We have several hundred venues set-up in Dentevents.com and this new feature allows you to search for venues that other organisers of dental events use,” said Dentevents publisher Joseph Allbeury. “This is particularly useful for smaller venues and venues outside capital cities. Each venue includes a list of future and past events at the venue, as well as contact details and other information. To try the Find Venues feature, simply select it from the Home Page menu.”

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March/April 2021

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

One man’s opinion...

A

By Georges Fast

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

www.dentevents.com

• Dental education calendar • Register for all popular dental events

www.dentevents.tv

• Watch all the latest videos about dentistry

www.dentist.com.au • Find-a-dentist in Australia

www.dentist.co.nz

• Find-a-dentist in New Zealand

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

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

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• eLABORATE™ magazine online

Sign up now. It’s Free.

10 Australasian Dental Practice

“We have dentists providing treatment with one eye on the rebate that the patient is likely to get rather than what they know is best for the patient...”

casual observation of what is currently happening in the world outside Australia and having an influence here, brings to mind other periods in recent history such as the goings on in the Weimar republic in Germany in the 1920s and the period of the “false war” in England between the declaration of war on Germany in September 1939 and the commencement of hostilities in early 1940.

The abandonment of values that had developed in society over millennia in the pursuit of instant gratification, with no thought of future implications, is something that has led to an abandonment of responsibility for one’s own actions and a search for a scapegoat to blame for any adverse outcome.

The net result of this is that one doesn’t need to take responsibility for one’s own behaviour because a demonstration of victimhood will result in financial compensation and the supposed perpetrator’s (or their employer’s) insurance covering the costs.

Without wanting to be involved in judging the decisions of various State Governments in imposing differing levels of restriction on their citizens, one has to assume that these were based on the advice they got from their health departments in combination with their ability to deal with any outbreaks and were imposed solely to protect their citizens. It beggars belief that the moment that these restrictions were eased, huge numbers of people invaded entertainment venues, shopping centres, cafes and restaurants in celebration, abandoning all precautions that were in place an hour earlier. It is reminiscent of sheep being released into a paddock from a holding pen or primary school children escaping the classroom into the playground. No thought was being given as to why restrictions had been in place. There was a total abrogation of responsibility for one’s own welfare to the authorities.

It is late March and we have a developing situation where a close contact of a confirmed case was tested for the virus and told to self-isolate at home until the results were in. He then held a party at home, attended by some of his friends. The next day his results came back positive and now another two of the guests tested positive and contact tracing has had to be ramped up. Another case of a person who didn’t take responsibility for themselves and applied the regulations literally.

A parallel exists in our profession, if you try to micromanage dentists so they fit in with certain statistical parameters, you overregulate them and interfere with the control of their practices it results in a diminution of the quality of clinical outcomes and a lack of total involvement or commitment to the patient. We have patients in trouble unable to access their dentist outside of normal hours, having to rely on emergency services for pain relief. We have dentists providing treatment with one eye on the rebate that the patient is likely to get rather than what they know is best for the patient.

We have a situation in corporate run practices where the patient needing multiple appointments gets treated by a different dentist each time.

Once regulators, be they Government appointed or health fund influenced, take control of dental treatment, it becomes easy for dentists to divorce themselves from a feeling of total responsibility for the result and be more concerned with the process.

We are becoming convinced that as long as all the boxes are ticked, the result doesn’t matter. Except that it does! Our profession is unusual amongst the health professions in that we always leave tracks; damage to a tooth because of careless or inappropriate dentistry will remain a problem for the life of that tooth.

Sadly, for the first time in the era of modern dentistry we are witnessing a decline in the general standard of restorative dentistry directly as a result of regulatory interference and increasing control being exerted by dental health funds.

March/April 2021

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INNOVATIVE SOLUTIONS THAT MAKE DENTISTRY ENJOYABLE

spectrum | NEWS

In my practice...

By Christopher Ho

T

“Disposable cheek guards are the ultimate in saliva control, keeping the parotid gland salivary output in check for 15 minutes - they can absorb and retain 30-times their own weight in moisture and more importantly, they keep the cheek from being caught or lacerated with our rotary handpieces...”

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

Dry Tips (Microbrush Corporation)

been the mainstay of many a dentist and their restorations over time. It is provided with tooth primers which are self-etching adhesive bonds that also contain MDP, with the cements available with 5 different colours including universal, clear, brown, white and opaque. These are also available with try-in pastes.

The author prefers the opaque cements for darker stumps/substrates, or metal resin bonded bridge retainers..

Expasyl Exact xpasyl is a unique Kaolin-based paste gently placed in the sulcus to obtain temporary retraction as well as a completely dry field with haemostasis. It exerts a gentle pressure of 10g to open the sulcus by 1 mm, allowing retraction and haemostasis in less than 2 minutes. It’s a painless technique, meaning no anaesthesia is required and can save time with crown preparations in not having to utilise retraction cord. The paste exerts a mechanical action as the paste places gentle pressure against the tissue while the Kaolin soaks up the sulcular fluid. The chemical action of aluminium chloride allows haemostasis of the soft tissues. After using this product for over a decade and seeing many competitors come onto the market with similar products, Expasyl has launched Expasyl Exact which are disposable unidose capsules that can be used in normal composite resin applicator guns. This makes it simpler and even easier to use, negating the need for the additional applicator gun. The consistency remains the same and the unidose capsule is able to access the sulcus with ease.

E hese disposable cheek guards are the ultimate in saliva control, keeping the parotid gland salivary output in check for 15 minutes - far outlasting cotton rolls and other absorbent pads.

They are flexible and can accommodate cheek movements while being very comfortable for patients. They can absorb and retain 30-times their own weight in moisture and more importantly, they keep the cheek from being caught or lacerated with our rotary handpieces. They are available in two different kinds of backing, either white or a reflective panel. This reflective panel helps to reflect light into the oral cavity, however the author prefers the white panel dry tip..

T

Panavia V5 resin cement (Kuraray Noritake) anavia resin cement has been the gold standard in resin cements and is a dual-cure, colour-stable, fluoride-releasing resin cement with a single-bottle, simplified self-etching primer and a single bottle universal restoration primer.

The success has been due to the development of an innovative monomer that was developed by Kuraray in 1981 called 10-MDP. The ability of this monomer to bond to ceramics, natural tooth structure and metal has

P

12 Australasian Dental Practice

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

He graduated with First Class Honours from the University of Sydney and has completed postgraduate qualifications in Oral Implants as well as a Masters of Clinical Dentistry in Prosthodontics from the University of London. He completed his Doctorate in Clinical Dentistry in Prosthodontics at the University of Sydney. He is a Faculty member of GIDE, a Visiting Lecturer at Kings College London and the editor of the Wiley-Blackwell textbook “Practical Procedures in Aesthetic Dentistry”.

March/April 2021

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spectrum | NEWS

Look out for these warning signs...

I

By David Moffet

“When your collections start to level off, it means that in reality, your business is going backwards. This is because with inflation [even at low levels], the cost of living is increasing on a daily basis and over a week, over a month, or over a year, the value of a dollar earned is becoming less and less...”

meet a lot of dentists who hit a glass ceiling.

Their dental practices stop growing.

Their monthly production plateaus.

And let me tell you this: When it happens, this is scary.

It’s scary because when your business’s monthly production levels off, three things happen.

Firstly, when your collections start to level off, it means that in reality, your business is going backwards. This is because with inflation [even at low levels], the cost of living is increasing on a daily basis and over a week, over a month, or over a year, the value of a dollar earned is becoming less and less.

And so in reality, when you plateau, your business is actually going backwards.

And I know, because between the years of 1992 and 1996, my annual collections plateaued.

“The fact that your business income is plateauing is a WARNING SIGN that things are perilously dangerous and that urgent action needs to be taken to accelerate away from complacency.

It can be done...”

And I placated myself with excuses that this was OK because I believed that my annual income was fine because my practice was collecting double what the average dental practice was doing at the time.

And to me that made the plateauing OK...

Until I met a dentist whose practice was producing double what mine was and so I knew then and there that I needed to shift my thinking. Because in business, if it has been done, it can be done.

IF IT HAS BEEN DONE, IT CAN BE DONE. And it can be done again.

And again.

Secondly, if your business income is plateauing, your profits are most likely decreasing because of increased costs and expenses for your business.

Rental agreements have built-in regular annual increases.

Wages and salaries paid always rise with time. And materials and utility costs always rise.

Your profits are being eroded by time.

14 Australasian Dental Practice

Thirdly, you can guarantee this fact: If your business collections are plateauing, there is opportunity for a competitor in your industry to simply overtake you while you are treading water and marking time.

My good friend Dr Charles Samaris was told once: “If you’re not growing, you’re actually dying.”

So why does this happen?

I believe that complacency is the issue.

I believe that at some point in time, as business owners, we stop trying to grow and we impose glass ceilings on ourselves.

And it takes thought and action to break away from this.

Whether it is a self-limiting belief that creeps into our psychy, or whether it’s a belief that we are not worthy of the rewards from growth, it is really only a belief.

It is not a fact.

And as a belief it can be replaced with a more positive belief.

Abraham Maslow said: “One can choose to go back toward safety or forward toward growth. Growth must be chosen again and again; fear must be overcome again and again.”

The fear of the future needs to be overcome.

Fear is False Evidence Appearing Real.

The fact that your business income is plateauing is a WARNING SIGN that things are perilously dangerous and that urgent action needs to be taken to accelerate away from complacency.

It can be done.

It is up to you to make those changes and to make that necessary shift in thinking.

You owe it to yourself to do so. You owe it to your family to do so. You owe it to your customers and your staff to choose growth.

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

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

March/April 2021

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spectrum | NEWS COVER STORY

Nobel Biocare N1™ System: Reshaping implantology to change the way you treat patients

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he Nobel Biocare N1 implant system is a landmark innovation created to empower clinicians with simplicity and confidence.

Designed and developed by rethinking some of the fundamentals behind implantology, it is a complete system featuring new concepts in site preparation, implant macroshape, prosthetic connections, emergence profile and more, all created to support clinicians at every step.

And, ultimately, to optimise the treatment experience of patients.

Reshaping implantology in just three steps: Direct - Shape - Place system bringing control and simplicity to clinicians, the Nobel Biocare N1 treatment journey can be encapsulated in just three simple words. Direct. Shape. Place.

Site preparation commences with the OsseoDirector™ instrument, setting the depth and direction of the Nobel Biocare N1 Implant. With its tapered body, featuring cutting flutes with side cutting capability, it allows change in direction when creating the pilot osteotomy.1 What comes next truly makes the Nobel Biocare N1 system stand apart. The OsseoShaper™ protocol: a simplified and biologically driven site preparation technique. Replacing the conventional array of high-speed drills, the OsseoShaper instrument gently “shapes” the osteotomy by rotating at a low speed - 50 rpm - and without irrigation. In doing so, it reduces heat and causes less trauma compared to high-speed drills, thereby preserving osteogenic material.2 Because of the design of this instrument, many of the bone chips produced during site preparation are also deposited into the osteotomy when the instrument is reversed.2,3 Furthermore, this instrument shapes the osteotomy to match the shape of the co-packed Nobel Biocare N1 Implant.2

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16 Australasian Dental Practice

Figure 1. The Nobel Biocare N1 system reshapes implantology in just three steps: Direct - Shape - Place.

Confidence for clinicians, greater comfort for patients s well as respecting the biology behind osseointegration, one of the OsseoShaper concept’s most prominent distinctions is the greater comfort it provides for patients during site preparation, thanks to its reduction in noise and vibration compared to conventional drilling.4 The protocol also increases time efficiency: in a survey of clinicians, over 80% of the implants were placed with as few as two site preparation steps.5 The technique can also assist decision making for the clinician.6 Torques generated using the OsseoShaper concept guide the surgical workflow, assist in bone evaluation and provide an early prediction of implant stability.

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March/April 2021

spectrum | NEWS Stable from the start: An implant designed for immediate placement and function ngineered for implant stability and early tissue integration, the Nobel Biocare N1 Implant is optimised for immediate placement and function.8,9 Specifically made to match the shape of the site created by the OsseoShaper instrument, it has a slightly tapered body that engages well in extraction sockets.

Perhaps the most distinctive visible feature of this implant is its trioval-shaped implant neck. This design, as shown in a preclinical study, reduces stress on cortical bone and is more stable compared to a round implant, and subsequently promotes fast osseointegration.9

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Figure 2. The OsseoDirector (left) is the first instrument in the Nobel Biocare N1 system site preparation protocol that defines the final implant position. The OsseoShaper instrument (center) creates a specific osteotomy for the co-packed Nobel Biocare N1 Implant. Engineered for stability and early tissue integration, the Nobel Biocare N1 Implant (right) is optimised for immediate placement and function.

Slide prosthetics into place, restore with confidence ust like the Nobel Biocare N1 Implant, the prosthetic connection features the trioval shape. This means that with the fully indexed trioval conical connection (TCC), all the prosthetic components simply slide into place.

The innovative TCC adds several key benefits to this system.

Firstly, the clinical screw only engages when the abutment is fully centered into the correctly seated position, helping the clinician restore with confidence. Secondly, the trioval shape ensures a 360° consistent width of the implant wall and platform shift, designed for excellent strength and soft tissue management.10

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Figure 3. The trioval conical connection (TCC) allows abutments to slide into place.

March/April 2021

And thirdly, all TCC abutments are slim restorative components that achieve a strong and tight connection, with a torque of only 20 Ncm.10 Thanks to this smaller tightening torque (Compared to 35 Ncm prosthetic components with Unigrip or Omnigrip interface), the system features restorative components with smaller screw heads and screw channels to maximise aesthetics.11

Prosthetics designed to support soft tissue maintenance and aesthetics eaturing dedicated prosthetics with optimised emergence profiles, surfaces, and trioval shapes, the Nobel Biocare N1 system showcases the wisdom of the Mucointegration™ era for soft tissue maintenance and aesthetics.

Nobel Biocare has taken this opportunity to design the prosthetic components from the ground up, allowing slim and harmonised emergence profiles across the whole portfolio. This slim emergence profile flares out for a smooth transition towards the crown or bridge, and it is designed to achieve generous soft tissue volume, long-term tissue stability, aesthetics and restorative flexibility.

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“Every aspect of the N1 system, from site preparation, macro design, multi zone surface, connection and comprehensive tissue or implant level prosthetics has been designed to optimise and enhance the biological response, both immediately and long term.

Yet it is incredibly predictable and straightforward to use. N1 is quite simply the best implant system available...”

Clinical A/Prof Glen Liddelow The Nobel Biocare N1 Base is a two-piece abutment placed at the time of surgery and left in situ to preserve the connective tissue structure throughout the restorative workflow, in favour of marginal bone preservation and soft tissue health.12,13 Available in three different heights, it offers flexibility over a lifetime and can be replaced without removing the full implant.

Science behind the system n a mission to rethink implantology, this new concept originated with a research team undertaking a ‘back to basics’ approach, interrogating some fundamental biological principles.

Osseointegration is the very foundation of dental implant treatment, yet this pre-clinical research observed how conventional implant site preparation contributes to bone resorption. A clear ‘zone of death’ with dying osteocytes around the osteotomy was identified, caused by the heat and trauma of high-speed drilling.2 While irrigation is normally used to reduce heat, irrigation manifests its own drawbacks by washing away vital bone chips and osseous coagulum, which offer the osteogenic potential to stimulate bone formation and enhance the viability of the implant site.2

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spectrum | NEWS

G Figure 4. The slim emergence profile is designed for long-term tissue stability, aesthetics and restorative flexibility.

Four years of pre-clinical biological studies drove the development of the OsseoShaper concept. The site preparation protocol was designed to minimise the zone of death and to preserve osteogenic materials in and around the osteotomy. A biologically driven design, the low-speed OsseoShaper instrument reduces heat and trauma compared to conventional high-speed drills and eliminates the need for irrigation. As a result, pre-clinical studies have demonstrated that this site preparation concept enables earlier bone formation in the osteotomy and achieves a more viable site compared to conventional drilling protocols.2

Figure 5. Biologically driven design. Left: Green represents the dying cells, apoptic osteocytes. With the standard drill (top), a zone of dying cells is clearly visible around the osteotomy on day 0. With an OsseoShaper instrument, most apoptic osteocytes are seen inside osseous coagulum, retained in the osteotomy. Right: Blue represents new bone formation. In the standard drill group (top), minimal bone formation is seen after 7 days. The osteotomies in the OsseoShaper group (bottom) show more bone formation.

Images from pre-clinical study. Chen CH, Coyac BR, Arioka M, et al. A Novel Osteotomy Preparation Technique to Preserve Implant Site Viability and Enhance Osteogenesis. J Clin Med. 2019;8(2):1-13.

Embracing the Mucointegration™ principle he system utilises Nobel Biocare’s latest developments in surface science with the Xeal™ abutment surface and TiUltra™ implant surface, designed to optimise tissue integration at every level.

The Xeal surface is available on the Nobel Biocare N1 Base and Multi-unit Abutments, possessing surface chemistry and topography specially designed to promote

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soft tissue attachment.14 TiUltra, featured on the N1 Implant, is an ultra-hydrophilic, multizone, anodised surface with a gradual topography from collar to apex.15,16,17 After over 5 years of pre-clinical research and clinical use since 2017, every aspect of the Nobel Biocare N1 system stands out. From the way it is designed, to the way it embraces biology, to the pioneering surfaces, it is an innovation to reshape implantology for clinicians and patients.

References 1. Data on file.

2. Chen CH, Coyac BR, Arioka M, et al.

A Novel Osteotomy Preparation Technique to Preserve Implant Site Viability and Enhance Osteogenesis. J Clin Med. 2019;8(2):1-13.

3. Coyac, B.R.; Salvi, G; Leahy, B; Salmon, B; Hoffmann, W, Helms J., A novel system exploits bone debris for implant osseointegration. Journal of Clinical Periodontology.

4. Zemp J, Velikov S, Weißbrot S, et al. New Low-speed Site Preparation Protocol Significantly Reduces Noise.

J Dent Res. 2020;99 (Spec Iss A):3053.

5. Data on file.

6. Data on file.

7. Velikov S, Susin C, Heuberger P, Iras-

torza-Landa A. A New Site Preparation Protocol That Supports Bone Quality Evaluation and Provides Predictable Implant Insertion Torque. J Clin Med. 2020;9(2).

8. Velikov S, Camenzind M, Fabech J, et al. Stability of a New Trioval Implant in Bone Surrogate Model. J Dent Res. 2020;99 (Spec Iss A):3052.

9. Yin, X.; Li, J.; Hoffmann, W.; Gasser, A.; Brunski, J.B.; Helms, J.A. Mechanical and Biological Advantages of a Tri-Oval Implant Design. J. Clin. Med. 2019, 8, 427. Link: https://www.mdpi. com/2077-0383/8/4/427.

10. Velikov, S, Fabech, J and Heuberger P. (2019), Mechanical properties of a novel conical connection. Clin Oral Impl Res, 30: 216-216. doi:10.1111/clr.174_13509.

18 Australasian Dental Practice

11. Data on file.

12. Wang QQ, et al, One-time versus repeated abutment connection for platform-switched implant: A systematic review and meta-analysis, PLoS One 2017;12(10).

13. Tallarico M, et al. Definitive Abutments Placed at Implant Insertion and Never Removed: Is It an Effective Approach? A Systematic Review and Meta-Analysis of Randomized Controlled Trials;J Oral Maxillofac Sug 2018;76(2).

14. Susin C, Finger Stadler A, Fiorini T, et al. Safety and efficacy of a novel anodized abutment on soft tissue healing in Yucatan mini-pigs. Clin Implant Dent Relat Res 2019;21(Suppl 1):34-43.

15. Milleret V, Lienemann PS, Gasser A, et al. Rational design and in vitro characterization of novel dental implant and abutment surfaces for balancing clinical and biological needs.

Clin Implant Dent Relat Res 2019;21(Suppl 1):15-24.

16. Wennerberg A, Albrektsson T, Chrcanovic B. Long-term clinical outcome of implants with different surface modifications. Eur J Oral Implantol 2018;11(Suppl 1):S123-S136.

17. Milleret V, Lienemann PS, Bauer S, Ehrbar M. Quantitative in vitro comparison of the thrombogenicity of commercial dental implants. Clin Implant Dent Relat Res 2019;21 (Suppl 1):8-14.

March/April 2021

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GalvoSurge® A NEW APPROACH TO

implant cleaning Struggling with periimplant complications?

This procedure cleans any titanium dental implant by creating hydrogen bubbles that break away the biofilm from the implant surface, leaving it clean and ready for re-osseointegration

nobelbiocare.com/galvosurge GMT73971 GB 2103 © Nobel Biocare Services AG, 2021. All rights reserved. Distributed by: Nobel Biocare. Legal manufacturer: GalvoSurge Dental AG, Nöllenstrasse 15a, CH-9443 Widnau, Switzerland.

Nobel Biocare, the Nobel Biocare logotype and all other trademarks are, if nothing else is stated or is evident from the context in a certain case, trademarks of Nobel Biocare. Please refer to nobelbiocare.com/ trademarks for more information. Product images are not necessarily to scale. All product images are for illustration purposes only and may not be an exact representation of the product. Disclaimer: Some products may not be regulatory cleared/released for sale in all markets. Please contact the local Nobel Biocare sales office for current product assortment and availability. For prescription use only. Caution: Federal (United States) law restricts this device to sale by or on the order of a licensed clinician, medical professional or physician. See Instructions For Use for full prescribing information, including indications, contraindications, warnings and precautions.

spectrum | NEWS

The first radiopaque universal adhesive New 3M™ Scotchbond™ Universal Plus Adhesive takes universal adhesives to the next level

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early a decade ago, 3M introduced the first truly universal adhesive. Since then, 3M Scotchbond Universal Adhesive has been clinically proven and has become the world’s most researched universal adhesive.1 Now, Scotchbond Universal Plus Adhesive takes universal adhesives to the next level. It features all the benefits of the original plus new features to add even greater control and predictability.

Scotchbond Universal Plus Adhesive offers a dentine-like radiopacity to reduce the risk of X-ray misdiagnosis and invasive overtreatment. Moreover, it can bond and seal caries-affected dentine to support minimally invasive preparation guidelines and maximise preservation of natural tooth structure. It provides gold standard adhesion to all dental substrates and restorative materials, including glass ceramics, with a formulation free of BPA derivatives like Bis-GMA. Scotchbond Universal Plus Adhesive has full dualand self-cure compatibility, eliminating the need for an additional dual-cure activator bottle when working with dual-cure composite cements and core build-up materials. Finally, the new universal adhesive forms a fully aligned two-component system with the new 3M RelyX™ Universal Resin Cement, offering excellent bond strength for virtually all dual-cure resin cement indications.

Like its predecessor, Scotchbond Universal Plus Adhesive is suitable for all direct and indirect indications and all etching techniques without the need for a separate primer or silane. And there is still virtually no post-operative sensitivity.2 Offering greater control and predictability, Scotchbond Universal Plus Adhesive is your new go-to adhesive that provides consistent results and patient satisfaction.

More information about 3M’s next generation universal adhesive and the new 3M RelyX Universal Resin Cement is available at GO.3M.com/sbuadp

20 Australasian Dental Practice

Always refer to the product instructions for use.

1. 3M Data on File.

2. 3M Data on File.

About 3M Oral Care M Oral Care promotes lifelong oral wellness through inventive solutions that help oral care professionals achieve greater clinical, professional and personal success. Learn more at 3M.com.au/oralcare or 3M.co.nz/oralcare.

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About 3M. M apply science in collaborative ways to improve lives daily. With $33 billion in sales, their 93,000 employees connect with customers all around the world.

Learn more about 3M’s creative solutions to the world’s problems at www.3M.com.

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March/April 2021

3M™ Scotchbond™ Universal Plus Adhesive

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3M™ Scotchbond™ Universal Plus Adhesive takes universal adhesives to the next level. Introducing the first radiopaque universal adhesive.

All the benefits of the original 3M™ Scotchbond™ Universal Adhesive. Plus even greater control and predictability.

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GO.3M.com/sbuadp 3M Oral Care 3M Australia Pty Limited Building A, 1 Rivett Road, North Ryde, NSW 2113 | 1300 363 454 | 3M.com.au 3M New Zealand Limited 94 Apollo Drive, Rosedale, Auckland 0632 | 0800 808 182 | 3M.co.nz 3M and Scotchbond are trademarks of 3M Company or 3M Deutschland GmbH. © 3M 2021. All rights reserved.

spectrum | NEWS

$90,000 Ultimate Practice Makeover on offer to one lucky dentist - Apply now!

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perfect day for a great many dentists is to arrive at work, have their appointment book full of the work they love to do and have an infrastructure around them running like a well-oiled machine.

You’re working as hard as you want to and the financial rewards are rolling in, funding a nice home, regular holidays, private schools for your kids and money in the bank besides.

For some dentists, however, that dream is proving elusive. You studied hard at dental school and have attended all the right post-graduate clinical programs supporting your particular areas of interest.

But somewhere in the mire of transition from simply being a great dentist to a great dental practice owner, the wheels fell off.

But take heart! Great dentists are not necessarily great at business. The key to owning a successful dental practice is actually not so much about becoming great at business as recognising that you need help to do so.

There are a plethora of service organisations in Australia today that have sprouted up in support of the skills dentists now need to bring to bear to run a successful practice.

So the real question is how do you know what you need to do and who the best people are to help you take your practice from good to great?

If you’re a practice owner that feels your potential is far from being at its fullest, then we invite you to apply for a firstof-its-kind experiment on the cause and effect of all of these services being brought to bear on your practice over an intensive 6-month period. Enter the Ultimate Practice Makeover competition now and it could help give your practice the kick start it needs for you to realise your dream.

Accepting the challenge ustralia’s Number 1 Google ranked dental marketer, Angus Pryor, together with a host of renowned consultants, trainers and industry experts, have joined forces to accept a challenge.

“As the publisher of Australasian Dental Practice, I’ve known Angus for a number of years now; I’ve read his articles, watched his video presentations and heard him speak at events on several occasions,” said Joseph Allbeury. “But like many dentists, I’m always curious

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Entering the competition o enter the competition to win the Ultimate Practice Makeover, you need to make a two-minute video about you and your practice. Full details of what to include can be found on the website. If you win, be prepared for an amazing adventure as Angus and the Makeover Crew descend on your practice and enact a plan to take it to new heights. And remember, every step of your journey will be videoed and streamed on Dentevents.TV, so if you’re shy, think twice before you apply!

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IN!TheUltimate...

W Practice Makeover WIN a complete public image update valued at over $90,000! as to how much of a difference dental marketing, and indeed many of the other services that often fill the pages of this magazine, actually makes.

“So with a view to finding out once and for all, I issued Angus with a challenge!

Find a dental practice in need of some TLC and fix it! To his credit, Angus accepted the challenge with fervour and the Ultimate Practice Makeover was born!

“Angus has recruited a formidable team to help with the Makeover as well as a range of products and services that will ensure the practice chosen will, as he put it, go from wallflower to sunflower.

“My final stipulation to Angus was that every second of this unique experiment must be filmed for our new Dentevents.TV dental video streaming website so every dentist can see the results as they unfold.”

The makeover he Ultimate Practice Makeover is currently valued at over $90,000 and includes everything required to completely reinvent your public image.

Angus and the Makeover Crew will create an individual road map for your future success and tailor the contents of the prize around your exact needs.

Part of this will include working on your brand identify and ensuring you have the right name for your practice, logo, colour scheme and website address.

The most tangible component of the Makeover is an update of the reception and waiting area of your practice valued at $40,000, courtesy of leading surgery design and construction company, Medifit.

This will ensure your practice has a fresh,

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www.ultimatepracticemakeover.com.au 22 Australasian Dental Practice

March/April 2021

dentevents.tv

Entries Close 31st May

IN!TheUltimate...

W Practice Makeover ORIGINAL productions

WIN a complete public image update valued at over $90,000!

If you love being a dentist but recognise that your practice is not where it needs to be, then take heart!

For the first time ever, you could win the “Ultimate Practice Makeover” valued at over $90,000! This package of products and services will completely update the public image of your dental practice and get you and your staff trained and on track for business success over a 6-month journey.

The prize, valued at over $90,000, includes a new website, new branding, new uniforms, coaching for you, training for the whole team, an update of your reception area, signage and more (check the website for the growing list).

To enter, you need to make a video on your smartphone or other device and make it fun!

Tell us why you want to change! The video should also include: To be eligible to enter, all you need is a dental • Information on you, your practice and team practice and a smartphone or camera to video your show us the team at work entry!

• Where your practice is located Plus, if you win, you’ll need to be ready for a fun • Why you think you need help adventure as your practice is transformed from • Any stories of how you’ve tried to grow the wallflower to sunflower. practice in the past and what the result was Your practice’s journey will be documented on • What you’re really like - don’t be afraid to inject video and your results published for other practices your personality into your video as we want to to see - and follow along - so be prepared for some see the real you! fun in the spirit of reality television as your practice • Do not include anything in your video you do not is tuned for maximum patients orErskine competitors to will see provide as the patient contemporary and invitingsuccess. look and feel You personally will want receiveyour one-on-one Oral Care mayestabbe published Dentevents.TV orwill proin keeping with new brand, ready for marketer, coaching with Dr Jessevideos Green, who welcomeon packs whilst SpeedPix Australia’s #1 your Google ranked dental elsewhere. all the new patients who will be beating a lished Savvy Dentist to support dentists to vide software and a tablet computer to Angus Pryor, will manage your makeover, roping in path to your door once your new marketing develop financial intelligence, have more make chairside patient education easy. a range of experts to help along the way. Together, Once selected as the winner by the expert judging regime is in place. time and work less, create highthe performance premium listing on dentist.com.au they’ll bring the public image of your practice panel, “experiment”Your begins!

Legendary While is creatingand yourensure marketing teamsare and master thedental art of patient flow. Angus combined with acomprehensive into theAngus 21st century that you marketer Pryor (and team of otherSearch maximising your opportunities for success. plan, Jayne Bandy from Dental Phone Channel D will beconsultants) installed on a will TV in Optimisation ensure workEngine with you over thewill next 6 patients Excellence and Call Tracking Excellence your waiting area to prompt patients to are flocking to your brand new website. months to transform your practice.

By the end of the journey, your practice will look will train your team in how to ensure start conversations about treatment.

So if your practice needs help to get better and function better and your new patient now! every caller ends up in your dental chair Centaur SoftwareApply numbers and turnover will grow. And you will have will provide you with to the next level and you’re looking for a for treatment.

And you and your team will Dental4Windows practice management fun adventure, enter the Ultimate Practice a plan to maintain your success for the future. also receive stylish new uniforms.

software or $5,000 of services.

Makeover before 31 May, 2021.

Sponsored by... ™

www.ultimatepracticemakeover.com.au March/April 2021

Australasian Dental Practice

23

dentevents.tv

Entries Close 31st May

IN!TheUltimate...

W Practice Makeover ORIGINAL productions

WIN a complete public image update valued at over $90,000!

If you love being a dentist but recognise that your practice is not where it needs to be, then take heart!

For the first time ever, you could win the “Ultimate Practice Makeover” valued at over $90,000! This package of products and services will completely update the public image of your dental practice and get you and your staff trained and on track for business success over a 6-month journey.

The prize, valued at over $90,000, includes a new website, new branding, new uniforms, coaching for you, training for the whole team, an update of your reception area, signage and more (check the website for the growing list).

To enter, you need to make a video on your smartphone or other device and make it fun!

Tell us why you want to change! The video should also include: To be eligible to enter, all you need is a dental • Information on you, your practice and team practice and a smartphone or camera to video your show us the team at work entry!

• Where your practice is located Plus, if you win, you’ll need to be ready for a fun • Why you think you need help adventure as your practice is transformed from • Any stories of how you’ve tried to grow the wallflower to sunflower. practice in the past and what the result was Your practice’s journey will be documented on • What you’re really like - don’t be afraid to inject video and your results published for other practices your personality into your video as we want to to see - and follow along - so be prepared for some see the real you! fun in the spirit of reality television as your practice • Do not include anything in your video you do not is tuned for maximum success. want your patients or competitors to see as the videos may be published on Dentevents.TV or Australia’s #1 Google ranked dental marketer, elsewhere.

Angus Pryor, will manage your makeover, roping in a range of experts to help along the way. Together, Once selected as the winner by the expert judging they’ll bring the public image of your practice panel, the “experiment” begins! Legendary into the 21st century and ensure that you are dental marketer Angus Pryor (and a team of other maximising your opportunities for success. consultants) will work with you over the next 6 months to transform your practice.

By the end of the journey, your practice will look better and function better and your new patient Apply now! numbers and turnover will grow. And you will have a plan to maintain your success for the future.

Sponsored by... ™

PRIZE INCLUDES… •

A full marketing review of your practice with a “SWOT” style analysis ($3500 value)

•

Development of a marketing strategy for July to December 2021 ($2000 value)

•

Full branding package - logo, colours, style guide and more... ($1000 value)

•

New website and SEO package ($12,000 value)

•

Refresh of your waiting area and signage valued at up to $40,000

•

Online marketing including dentist.com.au premium upgrade ($2000 value)

•

New uniforms, patient welcome packs and more... ($2500 value)

•

Marketing consultancy for 6 months to help you “stay on plan” ($10,000 value)

•

Training for you and your team ($2000 value)

•

Telephone answering training ($3500 value)

•

Treatment presentation coaching ($2000 value)

•

New practice management software (if required) ($5000 value)

•

A clear roadmap for your future success Priceless!

•

And more…

Reception and waiting area update Your marketing must match the look and feel of your practice when patients arrive so as part of the prize, Medifit, Australia’s oldest and most accomplished dental surgery design and construction company will makeover the public face of your practice to ensure your patients are WOW’d every single time.

The team from Medifit will work with you to enhance the reception and waiting area of your practice to ensure it delivers on patient expectations. Every practice is different and Medifit will craft a bespoke solution based on your individual situation that could include upgrading your shopfront and signage, new waiting room furniture, reception desk and lighting, an updated colour scheme and more up to the value of $40,000.

Medifit will consult with you and the practice makeover marketing team, providing you with 3D renderings of how your practice will look right through to delivering the upgrade, working around your schedule to ensure minimal disruption. Your reception and waiting area and public image will shine once Medifit have worked their magic. The entire experience will be filmed for broadcast on Dentevents.tv and elsewhere, as well as featured in magazines so everyone in the profession can understand the advantage of working with an experienced, professional dental practice design and construction company like Medifit.

See www.UltimatePracticeMakeover.com.au for full details Terms & Conditions • Entry is open to all privately owned dental practices in Australia.

• All entries must be made by the owner of the practice or an authorised representative of the owner.

• The only valid method of entry is through the creation of a video. Videos must be uploaded to www.UltimatePracticeMakeover.com.au. Videos can be created on a smartphone, tablet, etc but must have clear audio and video properties (i.e. we need to be able to see and hear it!).

• All participants in the videos agree that the videos can be used for promoting the competition. All entries may be displayed on Dentevents.TV for public viewing.

• The videos become the property of and may be displayed on dentevents.tv and other websites.

• The videos must not contain material that is considered to be offensive to any gender, cultural group, race, etc and should not contain nudity or profanity.

• The videos should be no more than 2 minutes in length.

• The “prize” incorporates a bespoke, interactive consulting process (and supporting products) tailored to the winning practice. By entering, you agree to participate in this consulting process which will be filmed and appear on Dentevents.TV and elsewhere, and as part of written articles that include photographs published in Australasian Dental Practice magazine, Oral Hygiene magazine and elsewhere both in print and online.

• As part of the consulting process, you agree to disclose information related to various metrics of your practice at the beginning and the end of the “makeover” for the purposes of publishing the results as a quantifiable outcome. For example, the show may disclose that the turnover of the practice increased by $100,000, or new patient numbers increased from 20 to 40 per month.

• FULL TERMS AND CONDITIONS ARE ON THE WEBSITE

spectrum | NEWS

IvoSmile App helps dentists and labs to envision a patient’s new smile together

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ugmented reality makes it possible: The IvoSmile app from Ivoclar Vivadent enables immediate 3D real-time visualisation of aesthetic dental treatments for the first time. The new, optimised version of the app now allows complete CAD integration into 3Shape Dental System software.

Up until now, the IvoSmile software application has been particularly popular for patient consultations conducted by dentists. It helps dentists to generate leads and contributes towards increased treatment acceptance. Its functions have now been greatly expanded. From now on, dental practices and dental laboratories will be linked by comprehensive CAD integration. This means that Ivoclar Vivadent has now solved another problem often experienced by dentists: communication issues with the laboratory.

Increase treatment acceptance voSmile is an innovative app that enables dental professionals to show their patients aesthetic treatment options in just a few minutes and without obligation. Through augmented reality, the iPad or iPhone becomes a virtual mirror. The patient sees themselves with a new smile during the consultation itself. Using a virtual representation of a possible aesthetic treatment allows the treatment goal to be communicated more easily and made more comprehensible for the patient.

IvoSmile is a convincing consultation tool that involves the patient, evokes an emotional response and significantly increases acceptance of a treatment.

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CAD integration into the 3Shape Dental System hanks to the new IvoSmile Add-on for the 3Shape Dental System, full CAD integration is now possible with the new version of the app. Through the interface, IvoSmile data can be easily sent to the laboratory, with the lab then able to send the

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26 Australasian Dental Practice

design data back to the practice via Dental System. This allows treatment proposals to be impressively presented to the patient and effectively coordinated between the laboratory and dentist. This simplifies and improves communication between practice and laboratory and helps dentists and dental technicians to jointly develop a patient’s new smile.

“I have always been a great fan of the powerful patient engagement enabled by the innovative and unique Augmented Reality engine of IvoSmile,” said Rune Fisker, Vice President for Product Strategy, 3Shape. “With the new version of IvoSmile, together with the IvoSmile add-on for 3Shape Dental System software, we can now exactly replicate the visualised smile by a full integration into the lab’s digital CAD/CAM process. The data is not only imported from IvoSmile into our Dental System, but also imported back from the laboratory into IvoSmile”

Envision a new smile together he patient not only sees himself with the treatment proposal from a tooth library but can virtually test the designed restoration provided by the laboratory in

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3D and in real time. Thus, the dentist can increase the quality of the consultation and treatment acceptance. The CAD integration makes it easier for practices and labs to prevent misunderstandings and to avoid reworking or making multiple restorations.

New, intuitive user interface he app’s new interface optimises usability and helps users to navigate and design. A step-by-step guide takes users through the app and explains all the functions, features and innovations. In addition, the new version allows users to import photos of patients. As of now, IvoSmile has full functionality on the iPhone as well.

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Free 30-day trial voSmile is available from the App Store for iPad and iPhone. To get to know and try out the App, IvoSmile can be tested with full functionality for 30 days without obligation. The 30-day trial period is free of charge and ends automatically.

The IvoSmile Add-on is available from Ivoclar Vivadent and 3Shape distributors.

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For more info, visit www.ivosmile.com

March/April 2021

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spectrum | NEWS

Streaming now on www.dentevents.tv

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entevents.tv is a brand new website for the dental profession that offers a broad range of video-based content focussed on all aspects of dentistry - from clinical, to technology, to management, marketing and more. Sign in for FREE and watch hundreds of on-demand videos, with more being added every day. Some videos even offer CPD! A selection of videos that will interest dentists and specialists appear below - or browse the website for many many more.

Hit me with your best shot Presented by Dr Stanley Malamed Duration 1:31:32 AVAILABLE ON DEMAND CPD 1.5 Hours In this program Professor Malamed will discuss the means to making dental local anesthetic injections both more effective and more comfortable - even with pulpitis.

13 Orthocryl LC how-to videos Duration Various AVAILABLE ON DEMAND Videos step-by-step instructions; Fixing wire elements; Preventing air bubbles; Using disco glitter; Cartridge tip opening; Smoothing out the surface; Finishing your orthodontic appliance; Embedding an expansion screw; Avoiding the air-inhibition layer; Testing the expansion screw; Repairing an orthodontic appliance; and Repairing a PMMA-appliance using Orthocryl® LC.

DenTechKnow - Digital Dentures Presented by Terence Whitty Duration 0:17:41 AVAILABLE ON DEMAND In this episode of DenTechKnow, Terry Whitty explores the state-of-the-art of digital dentures. This hot topic has been the focus of digital dentistry for the past few years with hardware, software and materials companies collaborating to try and provide a fully digital solution. Terry investigates what is possible at this point in time when it comes to producing dentures using the various solutions on offer and what we can expect in the future.

Infection Control Boot Camp Presented by Prof. Laurence Walsh Duration 7:08:14 AVAILABLE ON DEMAND CPD 6.0 Hours Learn firsthand from Australia’s leading authority on infection prevention and control in dentistry about recent changes in infection control that have come in over the past 12 months. This paid online learning program spans 27 video modules watched on-demand over more than 7 hours.

Watch hundreds of videos on-demand for FREE at www.dentevents.tv

28 Australasian Dental Practice

March/April 2021

STREAMING NOW ON-DEMAND

Dentevents.TV is a brand new dental video streaming service Watch a growing list of hundreds of videos related to dentistry all in one place

www.dentevents.tv

spectrum | NEWS

New look for popular dental websites

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wo of Australia’s most popular websites for the dental profession have been undergoing major updates throughout 2020 and into the first quarter of 2021, with both www.dentalcommunity.com.au and www.dentevents.com being given a fresh new look and added functionality.

“The demand for online services jumped during the COVID-19 lockdown and we’ve updated our websites in response to the changing times,” said Mr Joseph Allbeury, publisher of these websites as well as Australasian Dental Practice.

“Apart from updating the overall look of Dentevents.com, we added a lot of new functionality to support organisers of LIVE webinars. And now, with the return to face-to-face learning, we’re adding more features to help organisers ticket, market and manage their events. One neat new feature is the ability to search for a venue to host a dental event. We have several hundred venues in the database, so you can now find a venue that has previously hosted a dental event, which is particularly ideal if you’re looking for a space outside the capital cities.

“Dentevents.com is a turnkey solution for anyone looking to organise a dental event, whether face-to-face or online and we’re continually adding new features based on user demand,” Mr Allbeury said.

Responsive design he Dental Community website home page has now also been completely updated to a new “responsive” format that works on any device.

“Our eight websites all work in unison to provide the dental profession with a variety of different types of information and a growing range of services,” Mr Allbeury said. “The Dental Community website is the centrepiece of all of these as it allows the profession to login, manage their own information and access the services we offer. Most of the work we have been doing on the Dental Community requires you to login to use it, however, we have finally revamped the public face of the site and it is now in a responsive format that adapts to any device.”

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30 Australasian Dental Practice

Logging your CPD he CPD Education Centre within the Dental Community has also now been expanded to integrate the new video streaming website, www.dentevents.tv, to allow CPD tracking and list incomplete videos. Any CPD accrued from events a clinician has registered for using Dentevents.com or through CPD Questionnaires or through videos watched on Dentevents.tv is automatically logged.

And now, a new feature allows you to create CPD records for CPD accrued in other ways, allowing you to keep a record of all your CPD hours in one place.

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Article Archive he Dental Community Article Archive now boasts over 13,500 articles from current and past editions of Australasian Dental Practice, Oral Hygiene and eLABORATE magazines.

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“The Archive is an amazing resource chronicling the last 32 years of the dental profession,” Mr Allbeury said. “Whilst we continue to enrich the content itself, we have also now completely revamped the functionality of the Archive with a particular focus on making the content easily read on smartphones and tablets.

“As soon as we publish a magazine, the content is available online and can be easily read on screen. We have chosen a serif font in a larger than normal size to facilitate this further. You also still have the option of downloading a PDF of the article as it appeared in the magazine.

“The search features have also been enhanced to help you find what you’re looking for more easily.”

New easy sign-up feature igning up to the Dental Community can now be completed using the new “Sign In” feature on the website.

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March/April 2021

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dentevents presents...

Infection Control

BOOT CAMP 2020 BOOT CAMP ON DEMAND ONLINE LEARNING PROGRAMME

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

6

HOURS CPD

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

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

hygiene and hand care practices. n n Addressing common errors in personal protective equipment. n n Biofilm

reduction strategies. n n Efficiency-based measures to improve workflow in instrument reprocessing and patient changeover. n n Correct

operation of mechanical cleaners and steam sterilisers. n n Wrapping and batch control identification. n n Requirements

for record keeping for instrument reprocessing. n n Correct use of chemical and biological indicators.

Register Now: www.boosterinjection.com.au

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

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

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

REGISTRATION FEES

REGISTRATION INCLUDES n n

Dentists Others

$660 inc inc gst gst $330 inc inc gst gst

n n n n n n

dentevents.tv

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On-Demand access to 26 Online Learning Videos (Over 6 hours of education).

Online Learning Companion Booklet.

Suggested Reading Material Booklet.

Access to regular Q&A Webinar(s).

Online Questionnaire to earn 6 Hours of CPD.

Infection Infection Contol Contol Boot Boot Camp Camp is is presented presented by

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

Register Now: www.boosterinjection.com.au

spectrum | NEWS

The dentures of the future are digital: Amann Girrbach offers dentists system solutions for the dental practices of tomorrow

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igitisation offers dentists tremendous opportunities, especially in the field of prosthetics. This is where the classic boundaries between clinicians and dental technicians become partially blurred. Increasingly, patients are being treated quickly and directly with straightforward restorations in the dental practice. Therefore, previously separate fields of work are becoming interlinked.

Amann Girrbach will be showcasing lucrative avenues of cooperation and new technical opportunities in a virtual congress and expo, the AG.Live CON, from

34 Australasian Dental Practice

April 20-24, bringing together renowned dentists and dental technicians with leading minds in research. The Austrian company will also be presenting its new, pioneering cooperation platform AG.Live there. This is an example of how Amann Girrbach creates sophisticated system solutions for tomorrow’s everyday dental practice: the platform makes it extremely easy for clinicians and laboratories to connect with each other. It provides infrastructure and patient case management with a level of consistency and efficiency which has never been achieved before. For example, this enables clinicians to work closely with laboratories to provide a simple, modular gateway to direct restoration.

As a pioneer in dental CAD/CAM and materials technology, Amann Girrbach has become one of the leading innovators and preferred full-service providers in digital restorative dentistry. The sophisticated system solutions ensure maximum precision, impeccable function, flawless aesthetics and comprehensive protection. Amann Girrbach is also a predestined partner for dentists, driven by its philosophy of being at the forefront of innovation in all fields, while making the systems affordable for everyone - even smaller businesses.

For info and registration for the virtual congress, visit show.aglivecon.digital

March/April 2021

#DentistryUnified

Fon 02 8575 8675 sales@innovatiodentalsupplies.com.au www.innovatiodentalsupplies.com.au

register to unify: show.aglivecon.digital

Amann Girrbach AG Fon +43 5523 62333-105 www.amanngirrbach.com

spectrum | NEWS

CS ScanFlow update makes scanning faster, more secure and sharable

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arestream Dental’s most recent scanner acquisition software update, CS ScanFlow v1.0.3, continues to deliver an enhanced scanning experience with new benefits that reduce steps in the scanning process, protect data, make working with third parties easier and even encourage patients to share their virtual smiles on social media. CS ScanFlow is the advanced software that powers the CS 3700 intraoral scanner and is also available for the CS 3600 intraoral scanner.

Typically, shiny or reflective surfaces, such as metal, full ceramic brackets, crowns and resins would need to be sprayed with powder or microetched so as not to interfere with the digital scan. However, the new anti-reflective mode optimises scanning shiny or reflective surfaces, eliminating a step in the process, so users can start scanning right away while still generating a highquality rendering of reflective surfaces on the digital impression.

“Anti-reflective mode in CS ScanFlow v1.0.3 addresses and resolves the challenges encountered when scanning metal, reflective and semi-transparent surfaces, making it possible to scan even the hardest of cases,” Dr Paweł Paszkiewicz, founder of Estetique Center, Polanica-Zdrój, Poland said.

Of course, security is a concern whenever working with digital files, so CS ScanFlow v1.0.3 includes access to secure digital impression file conversion tools via cloud-based Microsoft Azure. Now, scanned datasets can only be exchanged with third parties that have logged in and provided their credentials, adding an additional layer of safety around patient privacy. This new feature has the added time-saving benefit of eliminating the need to update the CS Mesh Converter on all computers in the practice when a new version of CS ScanFlow is available.

CS ScanFlow v1.0.3 also enables optimal treatment planning and the ideal appliance fit with its new bite capture capability.

Users can obtain up to five - instead of the previous three bites in addition to the normal one to get an extensive view of the patient’s overall occlusion. All five bites can be exported to a lab or used in third-party software such as exocad or Blenderfordental with an articulator add-on.

36 Australasian Dental Practice

“From a prosthodontic perspective, the ability to now record five bites in the same scan is revolutionary,” Dr Paszkiewicz said.

“To be able to obtain maximum intercuspation (MIP), anterior guidance, centric relation (CR) and left and right canine guidance truly expands the digital capability of prosthodontic treatment planning and workflow.”

Now, users can also display the scan onscreen in the same orientation as the patient’s mouth with Smart Position mode for a more intuitive scanning experience. Previously, the arch was displayed upside-down whilst scanning, but with a more natural scan reflected on the computer users can better track the tip position and follow the scan progression.

To help drive patient engagement right from the start of treatment, practices can even create an animated MP4 file of the digital impression after completing the acquisition. This file can be emailed to patients and is ideal for sharing on social media.

Giving patients a shareable “keepsake” creates excitement and can help promote a practice on social channels. Doctors can also share the video with referring doctors to provide a 3D view of the case.

“These improvements to CS ScanFlow come based on the requests of users whose valuable feedback makes the software more efficient and the scanning experience better,” Ed Shellard, DMD, chief dental officer, Carestream Dental, said. Other userinspired new updates include scan preservation for refinement; an enhanced cutting tool; intuitive scanner identification and connection; and many others.

Subscribers of Carestream Dental’s CS Advantage plan will automatically receive an email with the link to upload CS ScanFlow v1.0.3. Users who are not currently enrolled in a CS Advantage plan but would like to upgrade to CS ScanFlow can make a one-time software upgrade purchase through Carestream Dental.

To learn more about CS ScanFlow, the CS 3700 or CS 3600, the CS Solutions CAD/CAM portfolio or any of Carestream Dental’s innovative solutions, visit carestreamdental.com/csscanflow or contact 1800-223-603 or email anz-enquiries@csdental.com.

March/April 2021

CS SCANFLOW Unbounded Workflows. Endless Possibilities.

Enter the next era of intraoral scanning with Carestream Dental CS 3600 and CS 3700 intraoral scanners and CS ScanFlow software. Proven accuracy. Open files. Unlimited workflow capacity.

Expanded processing options. One-click export. Touchscreen capabilities. With completely open workflow and advanced features, the possibilities are endless.

To see what’s new, visit carestreamdental.com/CSScanFlow Contact us on 1800 223 603 or anz-enquiries@csdental.com

A BIT MORE… A BIT MORE… OTHER BRANDS

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2010, Septoject XL was evaluated by 11 U Endodontics The clinicians involved rated Septoject XL

Biodentine saves pulps EVEN with signs and symptoms Biodentine saves pulps EVEN with signs and symptoms outcomes for your littlest patients with Hu-Friedy Stainless Steel Pedo Crowns. ™ of irreversible pulpitis* first all-in-one biocompatible and bioactive substitute, Biodentine saves pulps EVEN with signs and symptoms htverand mesio-distal width “Best Productdentin 2010”. of irreversible pulpitis* why dentists favor our impeccable fit.

Perfect for your patients. Easy for you.As the ™ brings one-of-a-kind benefi ts for the treatment of Biodentine ™ ™ fully replaces dentin wherever it’s damaged.

Biodentine of irreversible pulpitis* For vital pulpistherapy, comes the perfect fit, Hu-Friedy just right. bulk-filling the cavity with Biodentine ed andtopre-crimped for ™ simple placement

up to 85%** irreversible pulpitis cases: ™ of brings one-of-a-kind benefi ts for and the treatment of Biodentine brings one-of-a-kind benefi ts for the treatment of Biodentine makes your procedure better, easier faster: ™ ™ helps Biodentine up to 85%** of irreversible pulpitis cases: • Vital Pulp Therapy allowing complete dentin bridge formation OVE OUR anatomy STAINLESS STEEL PEDO CROWNS: cclusal that the tooth pulpitis benefi brings one-of-a-kind of remineralization of dentin, preserves the pulp Biodentine up tomatches 85%** of natural irreversible cases:ts for the treatmentthe •upPulp healing promotion: proven biocompatibility and bioactivity vitality and promotes pulp healing. It replaces dentin with similar to Therapy 85%** ofallowing irreversible pulpitis cases:bridge • Vital width complete dentin formation •Pulp Minimally Invasive treatment preserving the tooth structure Vital Pulp risk Therapy allowing complete bridge formation and mesio-distal •• Reduced of failure: strong sealing dentin properties biological and mechanical properties.

Vital Pulp Therapy allowing complete dentin bridge formation • Minimally Invasive treatment the tooth structure d and pre-crimped simple placement Immediate Pain relief your patients’ comfort Minimally Invasive treatment preserving thepulp tooth ••forOnly one material to fifor llpreserving the cavity from the to structure the top ™ clusal anatomy that matches the natural tooth Improving on Biodentine Minimally Invasive treatment preserving the tooth structure • Immediate Pain relief for your patients’ comfort Bio-Bulk fi lling procedure for an easier protocole •• Similar mechanical behavior as natural dentin: ideal for bulk fillingclinical implementation, you can now bond Immediate Pain relief for your patients’ comfort ™ in the same visit and perform the the composite onto Biodentine •• Immediate Painprocedure relief patients’ comfort • Bio-Bulk llingenamel procedure forfor anyour easier protocole Bio-Bulk filling for The fifinal restoration willan beeasier placedprotocole within 6 months. full restoration in a single session.

INE AT HU-FRIEDY.COM/PerfectFit • Bio-Bulk filling procedure for an easier protocole

MANAGING

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AIN FOR nature PAIN FOR NE AT HU-FRIEDY.COM/PerfectFit Innovativebyby nature To enjoy the clinical benefits of the first and only dentin in a capsule, Innovative

YOUR

, LLC. All rights reserved.

YOUR

ask your dental distributor for Biodentine™.

Innovative by nature Innovative by nature Innovative RACTICE by nature PRACTICE

LC. All rights reserved.

Exclusively available in New Zealand from

PRACTICE

Exclusively available in Australia from

Please visit our website for more information Call 0508 486 252 Please our website more information www.septodont.com Please visit ourvisit website for morefor information Please visit our website for more information 855 www.henryschein.co.nz Orders 1300 65 88 22 www.henryschein.com.au www.ivoclarvivadent.co.nz www.septodont.com www.septodont.com *If haemostasis 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) Please visit our website for information Learn more with www.septodont.com more

855 www.henryschein.co.nz ** Taha et al., 2018 the Biodentine™ brochure

Orders 1300 65 88 22 www.henryschein.com.au

spectrum | NEWS

Part-time practice runs full time on Core Practice

K

ojonup Dental Clinic, three hours south east of Perth on the drive to Albany, is only open for business one day a week. Dr Asheen Behari, looking for a distraction from his role as one of the principal dentists of a large, busy, now corporateowned practice in suburban Perth, took over the tiny clinic 7 years ago from the retiring incumbent of 33 years.

“I just saw the practice advertised for sale, came down here to check it out and thought this is pretty nice,” Dr Behari said. “It’s very different to the city practice. It’s on a property, so there’s plenty of space and you have a bit of an experience of being in the country. I like coming here as it gets me out of the city.”

Dr Behari said that the practice was operating three days a week when he took over, with a strong following amongst local residents.

“I thought I can only give up one day a week and maybe not every week, so I came at it from that angle,” he said. “I didn’t need to do it because I wanted to work harder; I was doing it to enjoy the experience and I approached it from that perspective.”

Dr Behari knew that finding the right practice management software would be key to running a part-time practice remotely.

“I went looking for a cloud-based solution and I looked at all the contemporary practice management software available offering this,” he said. “A further criteria was where the cloud servers are located, as I didn’t want to have speed issues when uploading digital x-rays.

“In the end, Core Practice ticked all the boxes. It’s an Australian product, developed and hosted in Australia and has all the features I need.

“For me, the best part of having Core Practice is that I have access to my appointment book from any device at any time.

The second greatest benefit is the two-way SMS feature for confirming appointments and finally, it’s really simple to use.”

Dr Behari said that automation of patient reminders using SMS was particularly invaluable.

40 Australasian Dental Practice

“The SMS reminder feature is brilliant. It’s a two-way text, so it updates their appointment in Core Practice when they reply to confirm. If a patient sends you a message, you see an exclamation mark in the system alerting you to the message. There’s also an SMS chat function, which is really good as it allows you to chat via SMS with your patients, all managed and recorded within Core Practice, rather than on your private mobile phone.

“The banking, invoicing, reporting, patient records and all the usual features of practice management software are easy to use too.

It has everything I need to run the practice in a simple manner.”

Kojonup Dental Clinic opens on Fridays and is staffed by two receptionist/nurses. “One of the team is a Kojonup local who also works at the visitors centre and the other works for the local Dental Health service,” Dr Behari said. “We also had a dental therapist working for a while, but she went home to New Zealand.

So we’re looking to fill that role now.

“Core Practice is very intuitive and very straightforward to use and it has been easy for everyone to learn. If you have a reasonable understanding of how computer software works, it’s easy to master. We only needed a few hours of training to be up and running. After that, you can figure most things out on your own.

We’ve also called the support line a few times and they’ve always been very helpful at pointing us in the right direction.”

Dr Behari said there is no advertising necessary for the practice, with the patients being exclusively from the local area.

“Being in the country, all the patients know the practice is staffed on a Friday, so people call on a Friday. But if a patient does happen to ring during the week, then anyone can still book in an appointment even though the physical practice is closed as Core Practice is cloud based.

“Core Practice has made owning a part-time country practice the pleasure that I wanted it to be. It caters perfectly to my needs and the needs of my patients and team.”

For info, visit www.corepractice.com.au or call 1300-863-514.

March/April 2021

spectrum | NEWS

Ivoclar Vivadent Academy launches

I

voclar Vivadent has launched the Ivoclar Vivadent Academy, a new one-stop educational resource centre. It offers trusted, cutting edge in-person learning, partnered with contemporary virtual education from dental experts from across the globe - all in one easy to navigate place.

The Ivoclar Vivadent Academy offers first class education for the dental practice and laboratory, with courses and resources specifically developed for clinicians, hygienists, and technicians across all levels of experience. Through this new learning centre, all dental professionals now have the ability to shape the learning experiences they need for professional growth.

Education when, where and how it’s needed vailable across a multitude of platforms, dental professionals can now advance their education at home, the office or even on the go. If in-person, hands on learning is preferred, the Ivoclar Vivadent Academy learning centers across the

A

42 Australasian Dental Practice

globe offer comprehensive and practiceoriented further education programs in a personalised environment.

or in-person, Ivoclar Vivadent Academy offers a multitude of ways to reach educational goals and to earn CPD credit.

Tailored learning approach

Personalised training

voclar Vivadent Academy understands that people like to learn differently.

That’s why this new resource centre offers a multitude of ways to reach education goals. From articles and publications to on-demand videos, interactive webinars and in-person courses, the Ivoclar Vivadent Academy global team of experts have it covered. Even live webinar sessions remain available on-demand for three weeks following the live presentation to provide further flexibility.

I

Certificates for continuing education eceive a certificate of attendance with ease upon completion of each eligible program through the Ivoclar Vivadent academy. This certificate can be used towards CPD as Ivoclar Vivadent is an approved provider through AGD PACE. Whether learning is completed digitally

R

oth virtual and on-site programs for key product workflows are available for customised training. The type of training experience that best suits each practice or laboratory can be selected and personalised. Learn from the Ivoclar Vivadent Academy experts online, inoffice, at partner training centres or other suitable locations.

“Supporting our customers’ desire to learn by bringing them best-of-class education through a multi-learning online platform is the cornerstone of Ivoclar Vivadent innovation,” said Dr George Tysowsky, DDS, MPH, Head of Global Training and Education. “We are excited to continue to expand our efforts to provide our dentist and laboratory customers with relevant and useful learning experiences.”

B

Ivoclar Vivadent Academy is now open for registration at www.IvoclarVivadent.com.

March/April 2021

Getting more from my finance partner, means my patients get more from me. credabl.com.au 1300 CREDABL (1300 27 33 22)

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.

dentevents presents...

Exiting Your Dental Practice and Maximising Your Outcome How to get the right result when selling one of your greatest assets BRISBANE : JUN 19 | MELBOURNE* : JUL 24 | SYDNEY* : SEP 11

*organised

in conjunction with the australian dental association

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

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

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

6

HOURS CPD

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

Register Now: www.exitacademy.com.au

VITAL

INFORMATION for anyone within 5 years of EXITING

Presented by Simon Palmer With more than 15 years’ experience in dental practice sales, Simon Palmer has extensive knowledge of and insight into the complexities and sensitivities involved in buying and selling dental practices. Simon’s business - Practice Sale Search - sells more than 100 practices per year. He is a regular writer/contributor to dental publications and journals, and is regarded as an expert on dental practice purchases and sales in Australia and New Zealand.

TOPICS INCLUDE n

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

n

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

n

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

n

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

n

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

n

How do you handle staff discretion, confidentiality and disclosure?

n

Legal agreements

n

Effective strategies for transferring patients effectively from seller to buyer

n

What to do next post sale? Post-sale strategies?

n

Tax implications and strategies when selling

n

Guest expert finance, legal, accounting speakers

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

spectrum | NEWS

A new tool to build your dental empire

By Dr Michael Sernik

I

t’s become increasingly common to meet a dentist who has several practices. It’s also common to see them having to scale back because they got into trouble.

Large dental conglomerates go out of business because they make the same fatal mistake: they don’t understand the basic idea of first developing a qualitative model in each practice. If you bought practices that were successful because the principal dentist was always dealing with recurring inefficiencies and you then duplicate all these inefficiencies, you will be multiplying mistakes and the problems will hit the fan when there is a dip in the economy.

Just as the McDonalds franchise started with one location, it makes sense to get one model working smoothly before you start duplicating that model.

There are two ways to achieve growth. One way is very expensive and can send you broke and the other is free.

1. Quantitative growth - add more patients. Typically, you grow the practice via external marketing, which requires capital.

2. Qualitative growth happens when more patients make better treatment choices. That’s the hidden gold inside every practice because you’ve already got the patients. This type of growth doesn’t cost anything; the patients tend to be loyal and they refer more new patients.

46 Australasian Dental Practice

Ideally, you should first develop a qualitative model and then add the marketing - the quantitative model. That’s being smart.

The key factor in all business development is leverage: The ability to gain more benefits with less effort. There are several types of leverage in dentistry.

Clinical leverage his involves employing more clinicians. The starting point is the hygiene department. Hygienists typically earn 33% of their production. Assuming the dentist is already covering the fixed costs of the practice and assuming the consumables are roughly the same, whether it’s the dentist or the hygienist doing the work, the dentist is pocketing almost 66% of whatever the hygienist produces. Furthermore, with the right training, an hygienist will increase the amount of high value work that the patients select.

Since an hygienist’s hourly rate is lower than a dentist’s rate, if the principal dentist is employing dentists to do hygiene work, this is lowering that employee dentist’s income. When a dentist is being their own dental hygienist, they are willfully lowering their own hourly rate and lowering their income. Not smart.

From a business perspective, the only rational reason for not employing an hygienist is not being able to find one.

T

March/April 2021

Yesterday, the only patient who loved Dr Randolph was his mum...

Then he screened Channel D on the treatment room ceiling!

Channel D on the treatment room ceiling... Facing the street...

Channel D is the video room systemgets for your that getsand yourturns patients or in the waiting yourpractice patientsTVs engaged you engaged and and turns you team and your into rockstars. your intoteam rockstars!

Use the to get ato free Media Go to channeld.com andcode use MA99 code MA99 start yourStick.

2 Month FREE Trial For info or support, support@channeld.com Go to channeld.com for moreemail info, or email: support@channeld.com.

Made in Australia by Dr Michael Sernik • Fully integrates with the SernikSpeak System

spectrum | NEWS For dentists who have a practice manager and an hygienist, the next stage of leverage is to implement a system of extended team leverage.

Extended team leverage his is still rare in Australia. It’s better understood in the USA and it really is the future.

The clinical coordinator brings the patient through; takes x-rays, photos and digital scans, then has detailed clinical discussions with the patient. Finally, the dentist appears, examines the patient and leaves. The clinical coordinator discusses the treatment options. Sometimes, the clinician will spend some more time chatting, but the bulk of the important communication is with the clinical coordinator.

The whole idea is to have moved the role of “great communicator” to team members. If all the communications and clinical skills are in the hands of an employee dentist - that’s dangerous.

Your star dentist is probably looking to build their own empire!

It’s much easier to train lots of team members than trying to find the one perfect dentist. This leverage system significantly increases production and your employee dentists will earn more in your efficient practice than elsewhere... so they are more likely to stay.

T

Communications is the invisible foundation of every successful practice eaching technical skills, such as taking a scan or photos is relatively simple. But soft skills (communications skills) are the ultimate challenge. Normally, the team inherits their soft skills via passive absorption and by emulating a dentist. This is not ideal because replicating information in an unstructured way guarantees that the information gets degraded. As the enterprise grows, you’ll have the equivalent of the blind leading the blind.

Most dentists are poorly prepared to teach communications.

Dentists typically have developed their communications techniques via an ad hoc, reactive process - dealing with problems only as they arise. This system guarantees the recurrence of problems.

When a dentist tries to analyse how their communications fared, it can easily become a confusing blur. That’s because there was no real structure to their model. Their communications didn’t follow any clear rules and are essentially a gut-feel process. It’s also difficult to distinguish excellent communications from average.

When communications fails, there’s stress; the team is exhausted; patients make poorer choices; they don’t return; and they don’t refer. But the mere avoidance of open conflict is a crude measure of success. Like being a chess master, the advanced communicator is thinking multiple steps ahead, always preventing problems and leading the patients to make the best treatment choices.

T

Training he success of any dental enterprise is wholly dependent on the quality of training.

In general, there are 2 common complaints regarding training: 1. Most training, today, is online, however, online team training sessions are usually done in groups and this often interferes with production.

T

48 Australasian Dental Practice

2. Attending a course will deliver flashes of clarity but after a few days, that clarity dims. Studies that measure the Ebbinghaus Forgetting Curves show that 50-80% of new information will be forgotten within 24 hours and 98% in 30 days. This is the most significant flaw in training models.

Problem solved have created an entirely new online program that is designed specifically to create a system that takes Extended Team Leverage to its highest point. Importantly, it corrects the two flaws just mentioned.

It’s designed to be used as a standalone training tool for all clinicians and all team members. It thoroughly covers all front office and clinical scenarios imaginable.

The entire training is possible without the need to halt production because: • Each participant’s training is personalised.

• The videos are very short... often as short as 5 minutes so they can be viewed in short natural breaks during the day. They can be viewed by each individual or in small or large team settings when appropriate.

• Each team member’s competencies are tracked and visible to the managers and participants.

I

Training is only as good as how much is being used nlike other systems, the information will not be forgotten.

The problem of the Forgetting Curve has been solved using 30-second puzzles that can be completed on each team member’s phone at prescribed intervals. The system has been configured to be a non-intrusive, on-demand process. This intelligent algorithm reinforces the knowledge, based on each team member’s scores.

We’ve designed the system to be fun, non-intrusive and genuinely helpful.

Instead of the harried practice owner multi-tasking in the role of clinician, being the main communicator and in some practices, the practice manager and the hygienist... clinicians can focus just on the most important role - being a great dentist!

Whether your ambition is to create an empire or not, it makes perfect sense to first develop a strong, self-sustaining business model with a well-trained team. The Sernik System will give you and your team the skills and tools you’ll need to grow as big as you want.

U

Dr Michael Sernik is the CEO and creator of Channel D, dental videos designed to trigger conversations that will grow your practice. Simplicity in patient communications matters. Channel D is also perfect for treatment rooms. It plays silently and will trigger conversations on Dental topics that matter to you.

Visit www.ChannelD.com and use Code MA56 to start your trial.

SernikSpeak is a new program offering online communications training for dental practices. If you’re interested in finding out about the new SernikSpeak Communications program, just go to www.sernikspeak.com and register your interest.

March/April 2021

Ready for takeoff.

Introducing

.

With more information at your fingertips, a brand new look, and helpful user interface, ClearPilot puts you in the driver’s seat as you review and approve your cases.

Features • Easy-to-access comments and technician notes • Prescription details all in one place for side-by-side comparison • Treatment overview, movement table, and millimeter grids

ANZ2020-9-CPLADP

Scan the QR code or visit dr.clearcorrect.com to log in or become a provider.

The

to working with only high-quality patients Do you feel like you are on an endless hamster wheel, just trying to keep your practice growing in the face of increasing competition?

You provide an amazing service, but despite your all your efforts and good intentions, your day is a constant struggle to find high-quality patients, set yourself apart from the competition, and boost your production.

As if that weren’t enough, you’re competing against corporates and dealing with patients who seem to care about only one thing…

PRICE. A day in dentistry should be enjoyed not endured - yet, if you don’t learn these secrets, that’s exactly what you can expect more and more of . . . enduring your days away.

Imagine a day where every patient you see:

 regards you as a highly valued healthcare

professional, rather than just an expensive hassle

 is willing and open to accept your

recommendations for ethical treatment plans

 is a walking billboard for your practice, inviting friends and colleagues to become patients.

In this game changing masterclass, you will walk away with a complete understanding of where you have been going wrong, and the three instantly implementable strategies to turn it all around.

What you get Drawing from over 10,000 hours of consulting dentists all over Australia and internationally, multi-award-winning Practice Growth Specialist, Angus Pryor reveals his tried and tested high-quality patient blueprint.

This is his signature A-Z system, proven to propel even the most unprofitable dental practice into unstoppable momentum and growth. You will leave this LIVE event feeling a renewed excitement for your practice – but most important, with a reliable plan of success based on three simple steps: In this action-packed LIVE event, you’ll discover:

 what you are inadvertently doing to attract terrible clients  how your practice is failing the dental equivalent of dressing for success  why even if you could flick the switch, you’re not ready for great patients (yet).

BONUS: attend the live event and receive a FREE 6-pack of social media posts to promote you as a high quality practice Enjoy drinks and canapes from 6.30pm onwards. The presentation starts at 7pm.

Event details

Who is this for?

This LIVE event is perfect for dental practice owners, dental associates and practice managers not happy with the status quo but looking for the fast-track to a steady flow of high quality patients.

�

Mon 19 Jul 21, 6.30pm-9.00pm, central location (details TBC)

�

Key takeaways

 discover your pool of motivated, high-quality patients

Sydney Wed 21 Jul 21, 6.30pm-9.00pm, central location (details TBC)

 finally differentiate yourself and put an end to competing on price  understand why you can’t (and shouldn’t be) everything to everyone

Melbourne

�

 achieve a new outlook on attracting patients to your practice

Brisbane Mon 26 Jul 21, 6.30pm-9.00pm, central location (details TBC)

About Angus Australia’s number one Google-ranked dental marketer recipient of the 2020 marketing award from the Australian Dental Industry Association

number one Amazon ranked author international speaker

REGISTER NOW Visit www.HighQualityPatients.com.au to secure your spot.

Tickets are free but places are limited. Register now!

spectrum | NEWS

Figure 1. Prettau 3 Dispersive with Gradual-Triplex-Technology - A triple gradient of natural colour, flexural strength and translucency.

Zirconia from the Dolomites: Prettau® 3 Dispersive® with Gradual-Triplex Technology. For the patients you value

P

rettau Dispersive zirconia materials - Provided by the South Tyrolean company Zirkonzahn - are already provided with a gentle and natural colour shading during the manufacturing process thanks to a smooth, dispersive shade transition. With Gradual-TriplexTechnology, a triple gradient for the new Prettau® 3 Dispersive® zirconia has been developed: indeed, in addition to the smooth colouring gradient, also

52 Australasian Dental Practice

translucency and flexural strength levels change. Whereas the incisally increasing translucency results in a highly translucent incisal edge, the cervically increasing flexural strength results in an extremely high flexural strength at the tooth neck.

Accordingly, Prettau 3 Dispersive can be used for all kinds of zirconia restorations, although it is particularly suitable for monolithic rehabilitations.

For a final prosthesis with that colour matches with the patient’s natural tooth, a special shade guide is available.

Zirkonzahn Shade Guide Prettau Line is composed of monolithic zirconia sample teeth and exist in the shape of a premolar as well as upper and lower incisors (also with minimal cutback for individual characterisation). If the material of the shade guide used and the material of the zirconia crown are identical, the colour of the zirconia restoration corresponds 1:1 with the natural tooth colour of the patient.

For more info, visit www.zirkonzahn.com or contact info@zirkonzahn.com

March/April 2021

MORE INFORMATION

ZIRCONIA FROM THE DOLOMITES

PRETTAU® – THE MOST EXPENSIVE. FOR THE CLIENTS YOU VALUE. Prettau® 3 Dispersive® zirconia with Gradual-Triplex-Technology* on anodised titanium bar.

Material colour selected through the new Zirkonzahn Shade Guide Prettau® Line: a shade guide with monolithic zirconia sample teeth available in the shape of a premolar as well as lower and upper incisor (also customisable)

*Gradual-Triplex-Technology: The zirconia is already provided with colour, tanslucency and flexural strength gradients during the production process. This ensures a natural colouring, a highly translucent incisal edge and an extremely high flexural strength at the tooth neck.

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

spectrum | NEWS

Mastering periodontal regeneration

S

traumann ® Emdogain ® has earned the respect of thousands of periodontists, oral surgeons, implantologists and dentists around the world over the last 25 years.

Straumann Emdogain is the only biological solution that promotes the true regeneration of periodontal tissues and enhances oral wound healing.

After 25 years of clinical success, Straumann Emdogain is still unique in the field of regenerative dentistry. There is nothing quite like it. While alternative treatments only slow down the advancement of periodontitis, Straumann Emdogain can actually regenerate the tissues lost due to

periodontal disease. Straumann Emdogain has a respected legacy as an irreplaceable tool for periodontology backed by extensive and long-term clinical documentation covering various indications. Following decades of clinical success in regenerative

periodontal surgery and thanks to the introduction of a new applicator, Straumann Emdogain can now be applied flapless in periodontal pockets after scaling and root planing procedures for an improved nonsurgical outcome.

Botiss cerabone - Mastering protection

B

otiss cerabone® is one of the most commonly used bovine bone grafting materials in regenerative dental medicine. It is a dimensionally stable bone graft offering lifetime volume stability.

The unique 1200°C manufacturing process of cerabone removes all organic components for maximum safety and by utilising heat and water only, leads to a 100% pure natural bone mineral (free of chemical additives). Due to its exceptional high purity, cerabone provides dependable volume stability of the augmented site, which is particularly advantageous for support of the soft tissue in the aesthetic region, for preservation of the ridge shape and to protect autologous or allogenic bone from resorption.

The human-like bone structure of cerabone, with its three-dimensional porenetwork and bioactive surface result in excellent osteoconductive properties. It promotes the adhesion and invasion of bone forming cells resulting in complete integration of the granules into newly formed bone matrix.

The interconnected pores and superior hydrophilic surface of cerabone support the adhesion of proteins from the blood. cerabone binds and gradually releases

54 Australasian Dental Practice

signalling molecules thereby providing a long-term depot-effect. In addition, the 100% pure natural bone mineral acts as a calcium reservoir slowly releasing calcium ions important for bone remodelling. The long-term success of cerabone in regenera-

tive dentistry has been proven with more than one million patients treated worldwide over 15 years in various medical applications. Because of its long-term stability, cerabone may be specifically preferred in patients with less adequate bone quality.

March/April 2021

AESTHETIC DENTISTRY

Brand > Removable

Straumann® Biomaterials

Master any challenge.

COMPREHENSIVE Our comprehensive portfolio provides you with the choice you need to master any oral regeneration challenges.

INDIVIDUAL SOLUTIONS Tailored to your individual challenges.

POWERFUL Our powerful portfolio is backed by scientific evidence and powered by innovation.

Contact your local Straumann representative now or visit www.straumann.com.au.

Straumann Group Pty Ltd 7 Gateway Court Port Melbourne VIC 3207 Toll Free AU 1800 660 330 | NZ 0800 408 370 customerservice.au@straumann.com www.straumann.com.au

spectrum | NEWS

International Update New Pola Rapid: Super fast in-office whitening treatment

S

DI Limited is proud to announce the launch of Pola Rapid, a new in-office whitening treatment that safely whitens teeth in a super fast 24-minute application time - significantly faster than other alternative whitening options.

The specially formulated high viscosity 38% hydrogen peroxide gel enables a superior handling process with a faster application and removal time due to its non-stick attributes. Furthermore, Pola Rapid uses a vivid blue colour for ease of visibility and application.

Pola Rapid does not need an additional pre-desensitiser step. Instead, Pola Rapid uses a unique potassium nitrate and high water content ratio to maximise patient comfort and reduce treatment time. In addition, Pola Rapid contains fluoride to further strengthen teeth and protect against sensitivity.

No mixing required. The dual barrel syringe system automatically self-mixes as the whitening gel is applied directly to the tooth.

The supplied brush tip is sculpted to deliver a smooth and more precise application.

Pola Rapid delivers super fast results and is specially formulated to reduce sensitivity. The Pola tooth whitening range has successfully improved the smiles of millions of patients across over 100 countries. SDI has an ongoing commitment to providing better tooth whitening solutions that are safe, simple and effective. Pola Rapid is an Australian innovation and is available through all major dental distributors.

Pola Rapid is available in 1 or 3 patient kits.

For more information, visit www.sdi.com.au

56 Australasian Dental Practice

A new study by scientists at Kyoto University and the University of Fukui, Japan reports in Science Advances that an antibody for one gene - uterine sensitization associated gene-1 or USAG-1 - can stimulate tooth growth in mice suffering from tooth agenesis, a congenital condition. Although the normal adult mouth has 32 teeth, about 1% of the population has more or fewer due to congenital conditions. Scientists have explored the genetic causes for cases having too many teeth as clues for regenerating teeth in adults.

According to Katsu Takahashi, one of the lead authors of the study and a senior lecturer at the Kyoto University Graduate School of Medicine, the fundamental molecules responsible for tooth development have already been identified. “The morphogenesis of individual teeth depends on the interactions of several molecules including BMP, or bone morphogenetic protein, and Wnt signaling,” sayid Dr Takahashi. BMP and Wnt are involved in much more than tooth development. They modulate the growth of multiple organs and tissues well before the human body is even the size of a raisin. Consequently, drugs that directly affect their activity are commonly avoided, since side effects could affect the entire body.

Instead, the team targeted the factors that antagonize BMP and Wnt specifically in tooth development and focused on the gene USAG-1.

Part of A-dec’s headquarters in Newberg, Oregon, is being used to host a new drive-up COVID vaccination clinic with the goal of inoculating 2,000 people every Saturday. “There was a need in the community for a mass vaccination site,” said A-dec’s Mariah Robbins. “And we’ve got a 50-acre campus, so it worked out perfectly.

We’re just really thankful to be able to have this opportunity to support the community.” The clinic will run every Saturday until the pandemic is over.

The U.S. Department of Health and Human Services has expanded the group of qualified professionals able to administer the COVID-19 vaccine to include dentists. The Association of Dental Support Organizations said that “dentists are exceptionally qualified to administer vaccines and this decision will expand the vaccine distribution and reach even more people across the country, especially those living in health professional shortage areas.”

Immunize Nevada, Nevada’s only state-wide non-profit coalition dedicated to immunisations, has joined the Nevada Dental Association in supporting a bill introduced in the Nevada Legislature that would enable dentists throughout the state to administer vaccines.

The bill proposed by state Assemblyman P.K. O’Neill, the Republican from Carson City, would allow Nevada dentists to administer vaccinations for common diseases such as influenza and allow dentists to continue administering the COVID-19 vaccine. A recent Nevada Emergency Directive initially made it possible for dentists to administer the COVID-19 vaccine throughout the state. The bill acknowledges the ongoing need to improve Nevada’s overall vaccination rates and access to basic healthcare services and also addresses the need for dentists to help Nevadans during this ongoing pandemic. Oregon currently has a law allowing dentists to administer such vaccines. In addition, similar legislation has been submitted in several other states including Ohio, Massachusetts, New York, Idaho, Maryland, Rhode Island, Connecticut and Washington.

March/April 2021

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Contemporary uses of CPP-ACP technologies in 2021 Part 1. Remineralization and beyond

By Emeritus Professor Laurence J. Walsh AO

T

his article discusses current concepts for the use of casein phosphopeptide-amorphous calcium phosphate (CPPACP) technologies. This first part focusses on remineralisation, while the second part will explore the actions of CPP-ACP as a prebiotic agent that modulates the behaviour of dental plaque biofilms.

As a naturally derived remineralising technology, CPP-ACP is a partner to fluoride, providing the bioavailable calcium and phosphate ions required for remineralisation. Many contemporary uses of CPP-ACP incorporate fluorides of various types. CPP can bind and stabilise fluoride ions, delivering them in the ideal stoichiometric ratio (5:3:1 for calcium: phosphate: fluoride). A number of previous reviews have compared CPP-ACP as a proteinbased remineralising agent to those based purely on inorganic agents.1-5

Treatment of enamel white spot lesions with topical CPP-ACP crème or the past 20 years, a major focus of laboratory and clinical research into CPP-ACP has focussed on remineralising actions and related effects including white spot lesion (WSL) arrest and reversal.

This aspect continues to be the focus for research.

In a 2020 laboratory study, enamel blocks with WSL were treated twice daily with slurries of oral health products designed to replicate dilution with saliva during toothbrushing. When GC Tooth

F

Mousse Plus™ (TMP) was applied for 3 minutes, it enhanced the effectiveness of a fluoride toothpaste supplemented with sodium trimetaphosphate, improving surface hardness recovery and reducing the lesion depth after pH cycling. It also enhanced the concentrations of calcium and phosphate that were achieved in the enamel by remineralisation.6 This latter aspect is essential, because calcium is the rate limiting ingredient in remineralisation.

In a second study, enamel WSL were treated with an artificial saliva solution or a slurry of GC Tooth Mousse™ (TM), which is the version of CPP-ACP crème without fluoride. The treatment improved surface microhardness of the WSL, as well as its visible appearance. Examination of the treated lesions using scanning electron microscopy (SEM) revealed that voids between enamel prisms had been filled in by deposits of mineral.7 The ability to achieve mineral deposition deep within WSL is a unique characteristic of CPP-ACP and explains why it can cause visible regression of WSL so effectively.5 In a third 2020 laboratory study of enamel WSL, the lesions were treated with TM, TMP or a conventional fluoride varnish. The elemental composition of the lesions was assessed by energy dispersive X-ray spectroscopy, so that changes in the mineral content could be tracked. The greatest mineral gain occurred with TMP, which was superior to TM and then to fluoride varnish.8 This efficacy result has been seen in many past laboratory studies and in multiple in situ clinical studies where enamel slabs with

62 Australasian Dental Practice

standardised WSL are located in intraoral removable acrylic appliances. A 2020 in situ study of this type where the lesions were treated extraorally once a day for 3 minutes showed that both TM and TMP improved surface hardness and subsurface hardness. Both inhibited demineralisation of enamel despite the surface being exposed to a high cariogenic challenge in the appliance model, with superior results for TMP.9 There have been a number of systematic reviews published on the changes in WSL caused by CPP-ACP alone (as in TM) or when combined with fluoride (as in TMP).

A particular focus has been around WSL that occur around fixed orthodontic appliances. A 2019 systematic review on this topic included 9 randomised controlled trials (RCT) and 2 non-randomised controlled trials. All the studies used TM (with no fluoride) and this was applied daily as a topical treatment, typically using a finger just before bed. TM was effective in preventing WSL from developing, as well as in treating WSL that had developed around the brackets, to reduce their visible appearance. The review also concluded that TM neutralised the pH of the dental plaque that formed around fixed orthodontic brackets.10 Likewise, a 2021 systematic review brought together results from 26 clinical trials on orthodontic WSL and included data from 16 studies in a meta-analysis.

TMP was shown to be superior to topical fluoride alone in terms of causing regression of white spot lesions. Not only did it improve their visible appearance, there was a reduction in the amount of bacterial

Figure 1. The UK strain B.1.1.7 of the SARS-COV-2 virus. © NIAID

Different strains of the SARS-CoV-2 virus: Why it matters

By Emeritus Professor Laurence J. Walsh AO

I

n April 2021, a major point of interest is not just how many cases of COVID-19 are occurring in any given place, but rather which strain. This article discusses how the strain is identified and why that information is so important.

Detecting different strains of the virus

enomic sequencing is the method which is used to assess what strains of the virus are currently in circulation. Knowing that new strains have appeared has proved to be very important for containing outbreaks and for achieving effective suppression of community spread.

G

The use of genomic sequencing was not widely known to members of the public until the coronavirus pandemic. Nevertheless, the same technique has been used in Australia for many years to locate the original source of outbreaks of foodborne bacterial infections.

By routinely applying genomic sequencing techniques to SARS-CoV-2 coronaviruses, Australia is now in a unique position globally. Whenever a throat or nasal swab gives a COVID-19 positive result, the sample will be sent to a laboratory for genomic sequencing. Because of the relatively low number of total cases of COVID-19 in Australia, it has been possible to undertake genomic sequencing for almost every positive result.

90 Australasian Dental Practice

March/April 2021

March/April 2021

Question 1. Recent research at the University of Melbourne tested the addition of CPP-APP to sugary:

Question 6. Genomic sequencing for almost every COVID-19 positive throat or nasal swab is only being completed in:

a. Black cola drinks b. Yoghurt c. Ice cream d. Sports drinks e. Fanta

a. China b. USA c. Australia d. UK e. Russia

Question 2. Root surface caries arrest with GC Tooth Mousse was first published in the British Dental Journal in:

Question 7. Long COVID is:

a. 2001 b. 2005 c. 2007 d. 2017 Question 3. Laboratory studies using enamel slabs adding 0.2% (w/v) CPP-ACP reduced the erosivity potential of: a. Fanta™ b. Coke™ c. Sprite™ d. Minute Maid™ e. All of the above.

Question 4. When applying Tooth Mousse as a topical agent, immediate bond strengths of resin bonding agents are reduced by: a. 0.6% b. 1.1% c. 1.7% d. 2.1% e. Bond strength is unaffected.

Question 5. A relatively new concept is the addition of CPP-ACP into a bleaching gel:

a. A COVID-19 varient first detected in Long Island, New York. b. Any virulent strain of COVID that takes longer than 28 days to cure. c. Chronic health problems that persist after surviving COVID-19. d. A varient of COVID-19 with an elongated NSP6 non-structural protein.

Question 8. The Brazil strain of COVID-19 has: a. Three deletions and three mutations to the spike protein. b. Three mutations to the spike protein. c. Two deletions and three mutations to the spike protein. d. Three deletions and two mutations to the spike protein.

Question 9. Once a person has survived COVID-19 once: a. They are immune to future infections. b. They can be reinfected but the symptoms are mild. c. The symptoms are worse for a subsequent infection. d. They become an asymptomatic carrier.

Question 10. The South Africa strain of COVID has been dominant in: a. Europe b. United Kingdom c. India d. South America e. Russia

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 Mar/Apr 2021 questionnaire and then click START. A score greater than 80% is required to PASS and receive CPD.

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

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Instrument reprocessing without the “black box” or “magic window”

W

hen students are undergoing clinical training at dental school and there is a lot to learn, their attention is focussed on patient care, rather than on all of the “back of house” support functions that keep the clinic running, like the sterilising room. Instrument reprocessing is not handled by students, who will drop off used dirty instruments to the sterilising room and collect sterilised instruments from a dispensary, often without thinking very much about the “Black Box” of instrument reprocessing, or all the hard work that has gone on behind the “Magic Window” of the dispensary to make the instruments fit and safe for re-use.

Students need to understand what happens behind the “Magic Window”, since the responsibility for proper instrument reprocessing sits on the clinicians who are using the instruments in patient care. Dental clinicians need to understand the scope and importance of proper reprocessing and how it impacts the entire practice. It is more than just prevention cross contamination, since the processes must also be right from both a safety and compliance standpoint. There are several regulators that oversee infection prevention and control in dentistry - including the Dental Board of Australia and the public health units in states and territories.

94 Australasian Dental Practice

Back to basics: Best practices for masks

I

n the first months of the COVID-19 pandemic last year, there was a gross shortage of medical masks.

Thankfully, medical mask supply has now stabilised.

This article reminds mask wearers of some of the most important ways to ensure optimal respiratory protection.

1. Choose a mask from a reliable manufacturer hen demand for masks spiked during the pandemic, some manufacturers rushed to turn a quick profit by producing masks for domestic use in the fastest and cheapest way possible, on improvised machinery, using any materials they could find. Not only were most

W

of the masks they produced uncomfortable to wear and hard to breathe through, but they were not adequate for use in a health care setting. They failed to provide reliable respiratory protection. This has led to removal of some masks from the Australian Register of Therapeutic Goods.

That’s why it’s so important to use only medical masks that are certified to comply with Australian Standard 4381:2015.

98 Australasian Dental Practice

March/April 2021

March/April 2021

Question 11. Correct and proper instrument reprocessing is the responsibility of the:

Question 16. Masks used in dentistry should be certified to comply with Australian Standard:

a. The chairside nurse. b. The sterilisation area nurse. c. The treating clinician. d. The practice manager.

a. AS 4187:2014 b. AS 4381:2015 c. AS 4381:2002 d. AS 4031-1992

Question 12. When using cassettes in an optimal workflow, instruments are removed from the cassette:

Question 17. A Level 3 mask provides protection again fluid pressure of up to:

a. Chairside. b. On entering the sterilistion area. c. Prior to ultrasonic cleaning or automated washing. d. Prior to sterilisation. e. All of the above.

a. 80 mm Hg b. 120 mm Hg c. 140 mm Hg d. 160 mm Hg e. 180 mm Hg

Question 13. Using cassettes: a. Keeps instruments organised in sets. b. Mitigates the risks of sharps injury due to reduced instrument handling. c. Eliminates manual instrument cleaning and sorting. d. All of the above.

Question 14. The “magic window” is a reference to: a. Large internal windows into the sterilising room to give patients an opportunity to view reprocessing. b. The dispensary at dental school where students collected their instruments. c. The limited understanding of students about how instruments are reprocessed. d. All of the above.

Question 15. Patients are more impressed by instruments in a cassette than a scary pile of instruments on a tray:

Question 18. Masks should be changed: a. Between patients. b. As soon as it becomes wet, damaged or torn. c. If it becomes noticeably soiled, contaminated or hard to breathe through. d. If you have been wearing it for an extended period. e. All of the above.

Question 19. There is no need to change your mask if you pull it under your chin briefly to eat, drink or talk: a. True b. False Question 20. To determine whether a mask fits properly, check that it: a. Fits snugly over the nose and mouth. b. Fits snugly under the chin. c. There are no gaps at the sides of the face. d. All of the above.

a. True b. False

To retrieve your FREE Dental Community Login:

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

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abstracts | 2021

A summary of the latest research

By Prof Emer Laurence Walsh AO

Particle spread in dental practice

his systematic review aimed to identify which dental procedures generate droplets and aerosols with subsequent contamination and for these, characterise their pattern, spread and settle. Medline (OVID), Embase (OVID), Cochrane Central Register of Controlled Trials, Scopus, Web of Science and LILACS databases were searched for eligible studies from each database’s inception to 11/08/20. A total of 83 studies met the inclusion criteria and covered: ultrasonic scaling (USS, n = 44); highspeed air-rotor (HSAR, n = 31); oral surgery (n = 11); slow-speed handpiece (n = 4); air-water (triplex) syringe (n = 4); air-polishing (n = 4); prophylaxis (n = 2); and hand-scaling (n = 2). Although no studies investigated respiratory viruses, those on bacteria, blood-splatter and aerosol showed activities using powered devices produced greatest contamination. Contamination was found for all activities and at the furthest points studied.

The operator’s torso, operator’s arm and patient’s body were especially affected. Intra-study comparisons allowed construction of a proposed hierarchy of procedure contamination risk: higher (USS, HSAR, air-water syringe, air polishing, extractions using motorised handpieces); moderate (slow-speed handpieces, prophylaxis, extractions); and lower (air-water syringe [water only] and hand scaling). Air polishing demonstrated contamination of, in ascending order, the operator’s forehead; operator’s mouth; and patients’ chest. All studies identified contamination following use of the triplex syringe. Air and water used together (spray) generated more than air alone and water alone. Smaller particles remained in the air for more than 6 hours. Bacterial contamination from droplets was detectable 2 metres from patients.

Contamination from air polishing was found 3 metres from the dental chair. The findings inform discussion around AGPs and direct future research to support knowledge and decision making around COVID-19 and dental procedures.

T

Innes N, et al. A systematic review of droplet and aerosol generation in dentistry. J Dent. 2021;105:103556.

Droplets and aerosols from hygiene/perio

his systematic review examined the literature relating to splatter, droplet settle and aerosol for periodontal procedures and forms part of a wider body of research to understand the risk of contamination in relation to periodontal care procedures relevant to COVID-19. A search of the literature was carried out and a total of 50 studies were included in the review, with procedures including ultrasonic scaling (n = 44); air polishing (n = 4); prophylaxis (n = 2); and hand scaling (n = 3). Outcomes included bacterial (colony-forming units e.g. on settle plates) or blood contamination (e.g. visible splatter) and non-bacterial, non-blood (e.g. chemiluminescence or coloured dyes) contamination. All studies found contamination at all sites, although the contamination associated with hand scaling was very low. Contamination was identified in all of the studies even where suction was used at baseline. In terms of device settings and baseline suction, of the 44 ultrasonic papers only 15 mentioned power or device settings, and only 2 compared

T

60 Australasian Dental Practice

differences in the power settings of the ultrasonic units/devices.

Both studies found increased contamination arising from using higher power settings. Distribution of contamination varied in relation to operator position and was found on the operator, patient and assistant with higher levels around the head of the operator and the mouth and chest of the patient. Settle was identified 30 minutes after treatments had finished but returned to background levels when measured at or after an hour. It was concluded that ultrasonic scaling, air polishing and prophylaxis procedures produce contamination (splatter, droplets and aerosol) in the presence of suction, with some evidence showing droplets taking between 30 minutes and one hour to settle. Consideration should be given to infection control, areas of cleaning particularly around the patient and appropriate personal protective equipment, with particular attention to respiratory, facial and body protection for these procedures. In addition, the use of lower power settings should be considered to reduce the amount and spread of contamination.

Johnson IG, et al. Dental periodontal procedures: a systematic review of contamination in relation to COVID-19. BDJ Open 2021;7:15.

Droplets from electric toothbrushes

he COVID-19 pandemic has drawn attention to microbial transmission risk via aerosols in dental practice. Demonstration electric toothbrushes are used intraorally for patient education in correct brushing techniques. This study measured the size of droplets emitted by the moving part of the brush head of two demonstration oscillating-rotating electric toothbrushes - the new Oral-B iO with an Ultimate Clean brush head and the Oral-B Genius with a Cross-Action brush head (Procter & Gamble).

Measurement of droplet production and size was recorded in the laboratory in vitro using three methods: 1) Malvern Spraytec (a laser particle size measurement device with a detectable particle size of 0.1-2500 µm), using brushes mounted on a 3D-printed, two-shell form-fit fixture with a supply of tap water; 2) A DustTrak aerosol measurement device used with toothpaste slurry, with brushing simulated in the oral cavity of a phantom head; and 3) high-speed visualisation in a simulated-use situation in the oral cavity of a phantom head, with individual evaluation of tap water, water with detergent, 70% ethanol, glycerin and toothpaste slurry.

For both electric toothbrushes, the size of emitted droplets was consistently between 200 and 1200 µm, categorised as splatter because of their large size. No significant aerosol was detected during toothbrush operation. High-speed video also confirmed only splatter-sized droplets were generated during operation.

Together, these findings indicate that oscillating-rotating toothbrushes do not produce aerosol-sized particles during use. Such large droplets follow an arc and a ballistic trajectory similar to that of a bullet and upon descent, these droplets fall to the floor or nearby surfaces. Crucially, droplets of this size are too large to become suspended in the air, making them much easier to manage in a clinical setting.

T

Mark EP, et al. Droplet sizes emitted from demonstration electric toothbrushes. Int. J. Environ. Res. Public Health 2021;18: 2320.

March/April 2021

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Contemporary uses of CPP-ACP technologies in 2021 Part 1. Remineralization and beyond

By Emeritus Professor Laurence J. Walsh AO

T

his article discusses current concepts for the use of casein phosphopeptide-amorphous calcium phosphate (CPPACP) technologies. This first part focusses on remineralisation, while the second part will explore the actions of CPP-ACP as a prebiotic agent that modulates the behaviour of dental plaque biofilms.

As a naturally derived remineralising technology, CPP-ACP is a partner to fluoride, providing the bioavailable calcium and phosphate ions required for remineralisation. Many contemporary uses of CPP-ACP incorporate fluorides of various types. CPP can bind and stabilise fluoride ions, delivering them in the ideal stoichiometric ratio (5:3:1 for calcium: phosphate: fluoride). A number of previous reviews have compared CPP-ACP as a proteinbased remineralising agent to those based purely on inorganic agents.1-5

Treatment of enamel white spot lesions with topical CPP-ACP crème or the past 20 years, a major focus of laboratory and clinical research into CPP-ACP has focussed on remineralising actions and related effects including white spot lesion (WSL) arrest and reversal.

This aspect continues to be the focus for research.

In a 2020 laboratory study, enamel blocks with WSL were treated twice daily with slurries of oral health products designed to replicate dilution with saliva during toothbrushing. When GC Tooth

F

62 Australasian Dental Practice

Mousse Plus™ (TMP) was applied for 3 minutes, it enhanced the effectiveness of a fluoride toothpaste supplemented with sodium trimetaphosphate, improving surface hardness recovery and reducing the lesion depth after pH cycling. It also enhanced the concentrations of calcium and phosphate that were achieved in the enamel by remineralisation.6 This latter aspect is essential, because calcium is the rate limiting ingredient in remineralisation.

In a second study, enamel WSL were treated with an artificial saliva solution or a slurry of GC Tooth Mousse™ (TM), which is the version of CPP-ACP crème without fluoride. The treatment improved surface microhardness of the WSL, as well as its visible appearance. Examination of the treated lesions using scanning electron microscopy (SEM) revealed that voids between enamel prisms had been filled in by deposits of mineral.7 The ability to achieve mineral deposition deep within WSL is a unique characteristic of CPP-ACP and explains why it can cause visible regression of WSL so effectively.5 In a third 2020 laboratory study of enamel WSL, the lesions were treated with TM, TMP or a conventional fluoride varnish. The elemental composition of the lesions was assessed by energy dispersive X-ray spectroscopy, so that changes in the mineral content could be tracked. The greatest mineral gain occurred with TMP, which was superior to TM and then to fluoride varnish.8 This efficacy result has been seen in many past laboratory studies and in multiple in situ clinical studies where enamel slabs with

standardised WSL are located in intraoral removable acrylic appliances. A 2020 in situ study of this type where the lesions were treated extraorally once a day for 3 minutes showed that both TM and TMP improved surface hardness and subsurface hardness. Both inhibited demineralisation of enamel despite the surface being exposed to a high cariogenic challenge in the appliance model, with superior results for TMP.9 There have been a number of systematic reviews published on the changes in WSL caused by CPP-ACP alone (as in TM) or when combined with fluoride (as in TMP).

A particular focus has been around WSL that occur around fixed orthodontic appliances. A 2019 systematic review on this topic included 9 randomised controlled trials (RCT) and 2 non-randomised controlled trials. All the studies used TM (with no fluoride) and this was applied daily as a topical treatment, typically using a finger just before bed. TM was effective in preventing WSL from developing, as well as in treating WSL that had developed around the brackets, to reduce their visible appearance. The review also concluded that TM neutralised the pH of the dental plaque that formed around fixed orthodontic brackets.10 Likewise, a 2021 systematic review brought together results from 26 clinical trials on orthodontic WSL and included data from 16 studies in a meta-analysis.

TMP was shown to be superior to topical fluoride alone in terms of causing regression of white spot lesions. Not only did it improve their visible appearance, there was a reduction in the amount of bacterial

March/April 2021

the cutting | EDGE products that were trapped in the surface of the lesions, which are measured when lesions are assessed with the DIAGNOdent™ (KaVo Kerr). The conclusion from this review was that the topically applied CPP-ACP was superior to using topical fluoride alone for remineralising existing lesions and that it also has plaquereducing effects.11 Even higher up the evidence pyramid than systematic reviews are so-called “helicopter reviews” which bring together the findings of multiple systematic reviews and meta-analyses.

A helicopter review of the management of orthodontically induced WSL included 13 systematic reviews and/or meta-analyses.12 The authors concluded that CPP-ACP products were effective in both preventing and reversing orthodontic WSL. Using topical fluorides was much less effective than CPP-ACP for preventing WSL and there was unclear evidence around whether topical fluorides had any benefits for reversing WSL. Using fluoride-releasing adhesives had no effect in terms of preventing the development of orthodontic WSL.12

Tooth structure preservation nder the category of tooth structure preservation, a range of CPP-ACP applications have been explored in recent times. One of the most challenging situations is when patients undergo head and neck radiotherapy. Not only is there a massive reduction in salivary defences, but also the irradiation protocol itself causes damage to teeth and to supporting bone in the radiation field. A 2020 laboratory study examined various ways that surface damage to teeth from radiotherapy could be treated. It compared various protocols using TM, topical fluoride and resin infiltration of defects. TM was applied five days a week for four weeks using a microbrush. Both TM and the resin when used alone gave some filling in of the radiotherapy-created surface defects. Overall, the order of surface microhardness values after enamel irradiation from the highest to the lowest was as follows: infiltration resin + TM; then infiltration resin alone; then TM + fluoride; TM alone; and fluoride alone. Hence, the best protocol was combining the resin with TM.13 As well as effectively restoring the direct destruction

U

March/April 2021

of the enamel surface caused by irradiation, TM can promote remineralisation, even at low pH conditions. This aspect is critical because of the depressed resting salivary flow rate and acidic salivary pH that exists after radiotherapy.

The concept of promoting arrest of caries on root surfaces or in dentine has been in the literature for some time.14 Root surface caries arrest with TM was first published in the British Dental Journal in 2007,15 and was explored in more detail in the same journal exactly 10 years later, in a review on minimal intervention management of older patients.16 Extending this story even further, a 2020 laboratory study showed that the application of TM onto carious dentine improved the mineral density, lowered the porosity of the lesion and reduced the proteolytic activity of the overlying biofilm. Together, these actions improve the structural qualities of the site and hence bond strengths for resin were found to be enhanced.17 The study picks up on elements from the 2007 report where the TM-treated root surface lesions had hardened and there was a reduced load of bacteria present in the surface of the lesions.15

Desensitisation esensitising actions and prevention and protection from dental erosion using CPP-ACP have also been explored in detail. Problems of exposed sensitive dentine can occur in multiple ways in dental practice. One setting is following tooth preparation of a vital tooth, such as for a full coverage restoration. When considering what agent to apply to desensitise the tooth, the question arises whether the agent that is applied could adversely influence bond strengths. A 2021 systematic review of 32 studies, from which 18 were used in a meta-analysis, concluded that applying CPP-ACP as a topical agent, e.g. in the form of TM, had no negative effects on the immediate bond strengths when resin bonding agents were used.

This result contrasted with all other desensitisers that were explored, with the exception of arginine-CaCO3, since these all caused a reduction in micro-tensile bond strength. The authors concluded that topically applied CPP-ACP could be used safely to relieve tooth sensitivity after tooth preparation.18

D

Applications of varnishes containing CPP-ACP elivering CPP-ACP in the form of a varnish that also contains and releases fluoride is an attractive option. It is simple to perform and obviates issues around compliance with topical products.

Moreover, the CPP component binds and stabilises the fluoride, optimising its release in a concerted manner with calcium and phosphate ions.

There have been several studies of GC MI varnish™ (MIV) published in 2020.

This product is a varnish which contains the same level of sodium fluoride (5% by weight) as common fluoride varnishes, which equates to 22,600 ppm fluoride. A 2020 study of remineralisation of enamel WSL under varnishes compared MIV with Duraphat™, which also contains 22,600 ppm F. The enamel slabs were kept in artificial saliva for 14 days at body temperature. MIV was the superior product and gave the highest level of remineralisation. MIV caused significantly greater fluoride uptake than Duraphat (0.44 wt% vs. 0.24 wt%).19 A second study published in 2020 by another research team compared the effects of varnishes on WSL in enamel blocks from primary teeth. In that study, MIV was superior for enhancing the remineralisation of early caries lesions in primary teeth when compared to 3M ClinPro™ varnish, which also contains 22,600 ppm F as well as tricalcium phosphate.20 One explanation for the greater performance of MIV over other F varnishes is that it has higher release of bio-available fluoride ions,20 despite the various varnishes all having the same content of fluoride.

Studies using MIV to treat enamel lesions in the laboratory have revealed that this treatment improves the microstructural characteristics of the enamel.

The destroyed hydroxyapatite structure of WSL is largely rebuilt. Compared to the demineralised surface of the WSL, the treated enamel surface has greater regularity, higher molecular and structural organisation, and a smoother and harder surface.21 In addition, MIV treatment makes enamel more resistant to acid, with a lower loss of calcium after an acid challenge. This protective influence is superior to that seen with other fluoride therapies delivered in a varnish.21

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the cutting | EDGE By improving enamel hardness and acid resistance, MIV is an appealing agent for treating damaged and carious enamel. The clinical benefits of this approach can be seen in a 2020 study where 60 children with active WSL on their primary maxillary anterior teeth were treated with MIV. At the 6 month follow-up examination, all the white spot lesions in these children that had been treated with MIV had arrested and lesion size had reduced, indicating regression. The rate of complete arrest rate was lower for 3M ClinPro™ F-TCP varnish and for a conventional F varnish. The authors concluded that using MIV was a highly effective method for reversing and arresting white spot lesions in children.22 Similar concepts apply to root surface caries, where MIV promotes the incorporation of F into lesions and increases their mineral density and surface microhardness. In this particular setting, MIV has been shown to give a higher mineral content gain than 3M Clinpro varnish with TCP or Duraphat.23 Taking the concept of caries prevention to the challenging scenario of molarincisor hypomineralisation (MIH), some recent clinical work has described the use of MIV as part of a minimally interventive restorative care approach. A 2020 study reported the outcomes for 281 children aged 6-8 years, all of whom had advanced carious lesions (ICDAS scores 5-6), severe MIH and incomplete root formation of the permanent first molar teeth. A protocol of preventive oral care measures was established and repeated at each follow-up, including diet counselling, oral hygiene instruction, dental plaque control and topical application of MIV. In conjunction with this, selective carious tissue removal was undertaken, followed by interim restorations that were left for 6 months, after which time the teeth were restored with composite resin. This protocol achieved a clinical and radiographic success rate of 96.8% at 24 months after treatment.24 The small number of failures that did occur were not from caries, but rather from enamel fracture at restoration margins.

The protocol was able to maintain the marginal integrity of restorations as well as pulp vitality and the process of root formation was able to reach completion.

The use of MIV for protection against dental erosion has been the subject of a number of recent studies. In one study

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conducted in Brazil, enamel blocks were exposed 4 times per day for 3 days to Sprite Zero™ (pH 2.58), then varnish applied and the erosive challenge continued for a further 3 days. MIV was superior to Duraphat for protecting against tooth structure loss.25 Using a black cola soft drink as the erosive challenge, another 2020 study tested the ability of different varnishes to protect enamel from erosion by Coke™. MIV had the most protective and remineralising actions. It was also superior to ClinPro and to Duraphat in terms of calcium ion release.26

CPP-ACP incorporated into dental materials sing a logic similar to varnishes, there should be benefits from incorporating CPP-ACP into various restorative materials to allow pH-driven release of bioavailable calcium, phosphate and fluoride ions. A major difference conceptually from a varnish, which has a limited life, is that a permanent material such as a restorative material or a sealant could be recharged by the topical application of CPP-ACP from a crème, toothpaste, lozenge or other delivery method.

CPP-ACP has been incorporated into a glass ionomer cement (GC Fuji VII-EP™, also known in some markets as Fuji Triage-EP™). This high fluoride releasing GIC can be used for tooth surface protection, including for fissures of erupting teeth and for root surfaces. The protective benefits of CPP-ACP in GIC have been shown in studies of enamel surface sealing around fixed orthodontic brackets to protect those surfaces from dental caries.27 When using Fuji VII-EP, local application of TM is sufficient for recharging the material so that it releases higher levels of calcium, phosphate and fluoride ions over a prolonged period of time. This recharging will also give the Fuji VII-EP a greater surface hardness and improved resistance to acid dissolution.28 CPP-ACP has been added to other dental materials. One study reported adding it into a fissure sealant to give selective release of calcium ions at acidic pH conditions that may be seen inside cariogenic dental plaque.29 This material could also be recharged by exposure to topical CPP-ACP. Of interest, as the number of recharge cycles increased, so did the release of the ions that been taken up during recharging.

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A relatively new concept is the addition of CPP-ACP into a bleaching gel. Previously, application of TM or TMP has been used as a prelude to bleaching because of its ability to achieve lightening of tooth shade by maximising the reflectivity of enamel for short wavelength light.30,31 It has also been used in an alternating protocol with at-home bleaching gels to treat cervical dentinal hypersensitivity. A 2020 study tested the effect of mixing TMP with a 35% hydrogen peroxide bleaching gel in a 1:1 ratio. The study was conducted using a rat animal model, which allowed the investigators to assess not only the changes in tooth shade but also the histological effects of the bleaching process at the level of the dental pulp. The new combined protocol was shown to eliminate all histological signs of pulp changes, whilst giving the same overall colour change.32 This concept of maintaining bleaching efficiency whilst reducing patient responses is intriguing, and needs confirmation in clinical studies.

CPP-ACP as a food additive ecause of its preventive actions, it is logical to consider adding CPP-ACP into various foods and beverages that may pose a risk for enamel loss. As an example of a food, a yoghurt with a high sugar content (Danone™) was tested in recent research at the University of Melbourne. WSL were created in enamel slabs and exposed to artificial saliva containing either Danone yogurt alone, or the same yoghurt with added CPP-ACP (at either 0.2 or 0.5% w/w). The various yoghurt preparations were replaced each day over 2 weeks. The ordinary yogurt when used alone demineralised the enamel, creating larger subsurface lesions. This effect was inhibited by the addition of 0.2% CPPACP to the yogurt. When the level of CPP-ACP was raised to 0.5% CPP-ACP, there was a net mineral gain for the WSL and mineral content rose.33 Thus, for processed yogurts with added sugar, the risk of enamel demineralisation when they are consumed frequently by patients with poor oral hygiene practices consumed could be overcome by using CPP-ACP as a food additive. The same concept could be extended to other “risky” foods, as well as to beverages that are highly erosive, such as drinks with large amounts of citric acid or phosphoric acid, such as black cola drinks.

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March/April 2021

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the cutting | EDGE This idea of adding CPP-ACP to beverages has been explored for over 15 years.

CPP-ACP has been added to a range of sports drinks and softdrinks and in each case it was able to eliminate the ability of these to cause erosion.34,35 CPP-ACP in the form of TM has also been shown to reduce erosive wear on teeth and to protect tooth surfaces in patients whose occupation places them at risk (e.g. wine tasters).36,37 Continuing on such research themes throughout 2020, further research into the concept of adding CPP-ACP to carbonated beverages has been undertaken. Laboratory studies using enamel slabs exposed to Fanta™, Coke, Sprite™ and Minute Maid™ (a drink similar to Fanta) demonstrated that adding CPPACP at the level of 0.2% (w/v) reduced the erosivity potential of these beverages.

Moreover, the pH rose by more than 1 unit and the titratable acidity fell, indicating a

lower overall acid challenge for saliva to counteract.38 In the future it is likely that food additive applications will attract greater interest, since consumer awareness of the fundamental health issues around various

foods and drinks continues to rise. Using the supplementation approach, adding CPP-ACP could render a range of foods and drinks “dentally safe”.

Part 2 will appear in the next edition.

About the author Emeritus Professor Laurence J. Walsh AO is a specialist in special needs dentistry who is based in Brisbane, where he served for 36 years on the academic staff of the University of Queensland School of Dentistry, including 21 years as Professor of Dental Science and 10 years as the Head of School. Since retiring in December 2020, Laurie has remained active in hands-on bench research work, as well as in supervising over 15 research students at UQ who work in advanced technologies and biomaterials and in clinical microbiology. Laurie has served as Chief Examiner in Microbiology for the RACDS for 21 years and as the Editor of the ADA Infection Control Guidelines for 12 years. His published research work includes over 330 journal papers, with a citation count of over 15,400 citations in the literature. Laurie holds patents in 7 families of dental technologies. He is currently ranked in the top 0.25% of world scientists. Laurie was made an Officer of the Order of Australia in January 2018 and a life member of ADAQ in 2020 in recognition of his contributions to dentistry.

References 1. Walsh LJ. Evidence that demands a verdict: latest developments in remineralisation therapies. Australas Dent Pract 2009; 20(2):48-59.

2. Walsh LJ. Contemporary technologies for remineralisation therapies: A review.

Internat. Dent. 2014;11(6):6-16.

3. Walsh LJ. Topical CPP-ACP crèmes: beyond caries prevention. Internat Dent.

2014;9(4):48-58.

4. Fontana M, Walsh LJ, Amaechi BT, Ngo HC. Aids to remineralisation. In: Mount GJ, Hume WR, Ngo HC, Wolff MS (eds). Preservation and restoration of tooth structure, 3rd edn. 2016. Chichester, West Sussex, UK: John Wiley. pp. 67-80.

5. Walsh LJ. Molecular and pharmaceutical aspects of novel methods and materials for the prevention of tooth structure loss. Curr Pharm Biotechnol. 2017, 18(1): 45-51.

6. Goncalves FMC et al. Effect of fluoride, casein phosphopeptide-amorphous calcium phosphate and sodium trimetaphosphate combination treatment on the remineralisation of caries lesions: An in vitro study. Arch Oral Biol.

2021;122:105001.

7. Hua F et al. In vitro remineralisation of enamel white spot lesions with a carrier-based amorphous calcium phosphate delivery system. Clin Oral Investig.

2020;24(6):2079-2089.

8. Khanduri N et al. Quantitative evaluation of remineralising potential of three agents on artificially human enamel using scanning electron microscopy imaging and energy-dispersive analytical X-ray element analysis: An in vitro study. Dent Res J (Isfahan). 2020;17(5): 366-372.

9. De Oliviera PRA et al. Effect of CPPACP on remineralisation of artificial caries-like lesion: an in situ study. Braz Oral Res. 2020;34:e061.

10. Pithon MM et al. Effectiveness of casein phosphopeptide-amorphous calcium phosphate-containing products in the prevention and treatment of white spot lesions in orthodontic patients: A systematic review.

J Investig Clin Dent. 2019;10(2):e12391.

11. Sharda S et al. Remineralisation potential and caries preventive efficacy of CPP-ACP/Xylitol/Ozone/Bioactive glass and topical fluoride combined therapy versus fluoride mono-therapy - a systematic review and meta-analysis. Acta Odontol Scand. 2021;16;1-16.

12. Mounir Bakdach WM & Hadad R. Effectiveness of different adjunctive interventions in the management of orthodontically induced white spot lesions: A systematic review of systematic reviews and meta-analyses. Review Dent Med Probl. 2020;57(3):305-325.

13. Wu L et al. Effects of different anticaries procedures on microhardness and micromorphology of irradiated permanent enamel. Dent Mater J. 2020;39(1):118-125.

14. Walsh LJ. Tooth Mousse: latest research on clinical applications. Australas Dent Pract. 2010;21(5): 50-59.

15. Vlacic J, Meyers IA, Walsh LJ. Combined CPP-ACP and photoactivated disinfection (PAD) therapy in arresting root surface caries: a case report. Brit Dent J. 2007;203(8):457-459.

16. Walsh LJ. Minimal intervention management of the older patient. Brit Dent J. 2017; 223(3):151-161.

17. Moreira K et al. Impact of biomineralization on resin/biomineralized dentin bond longevity in a minimally invasive approach: An “in vitro” 18-month follow-up. Dent Mater. 2021 Feb 16;S0109-5641(21)00041-5.

18. Li F et al. Effects of desensitizers on adhesive-dentin bond strength: a systematic review and meta-analysis. J Adhes Dent. 2021;23(1):7-19.

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19. Shen P et al. Remineralisation and fluoride uptake of white spot lesions under dental varnishes. Aust Dent J. 2020;65(4):278-285.

20. Soares-Yoshikawa AL et al. Fluoride release and remineralising potential of varnishes in early caries lesions in primary teeth. Microsc Res Tech. 2020. Dec 5. doi: 10.1002/jemt.23662.

21. Swietlicka I et al. Near-surface studies of the changes to the structure and mechanical properties of human enamel under the action of fluoride varnish containing CPP-ACP compound. Biomolecules. 2020;10(5):765.

22. Radha S et al. Comparative evaluation of the remineralising efficacy of fluoride varnish and its combination varnishes on white spot lesions in children with ECC: a randomized clinical trial. Int J Clin Pediatr Dent. 2020;13(4):311-317.

23. Cai J et al. Remineralising effects of fluoride varnishes containing calcium phosphate on artificial root caries lesions with adjunctive application of proanthocyanidins. Dent Mater. 2021;37(1):143-157.

24. Gaton-Hernandez P et al. Minimally interventive restorative care of teeth with molar incisor hypomineralization and open apex-A 24-month longitudinal study.

Int J Paediatr Dent. 2020 Jan;30(1):4-10.

25. Alexandria A et al. Comparative Effects of CPP-ACP and xylitol F-varnishes on the reduction of tooth erosion and its progression. Braz Dent J. 2020;31(6):664-672.

26. Gokkaya B et al. Effect of a single application of CPP-ACPF varnish on the prevention of erosive tooth wear: An AAS, AFM and SMH study. Oral Health Prev Dent. 2020;18(1):311-318.

27. Yap J et al. Evaluation of a novel approach in the prevention of white spot lesions around orthodontic brackets. Aust Dent J. 2014;59(1):70-80.

28. Shen P et al. Recharge and increase in hardness of GIC with CPP-ACP/F. Dent Mater. 2020;36(12):1608-1614.

29. Memarpour M et al. Ion release and recharge from a fissure sealant containing amorphous calcium phosphate. PLoS One. 2020;15(11):e0241272.

30. Walsh LJ. Tooth lightening: a new concept of maximizing surface aesthetics.

Australas Dent Pract. 2008;19(2):48-50.

31. Brostek AM, Walsh LJ. Enhanced minimally invasive tooth whitening. Oral Health J. 2018 (December).

32. Barbosa JG et al. Bleaching gel mixed with MI Paste Plus reduces penetration of H2O2 and damage to pulp tissue and maintains bleaching effectiveness. Clin Oral Investig. 2020;24(3):1299-1309.

33. Shen P, et al. Addition of CPP-ACP to yogurt inhibits enamel subsurface demineralization. J Dent. 2020;103:103506.

34. Ramalingam L, Messer LB, Reynolds EC. Adding casein phosphopeptide– amorphous calcium phosphate to sports drinks to eliminate in vitro erosion.

Pediatr Dent 2005;27(1):61–67 35. Manton DJ, Cai F, Yuan Y, et al.

Effect of casein phosphopeptide– amorphous calcium phosphate added to acidic beverages on enamel erosion in vitro.

Aust Dent J 2010;55(2):275–279.

36. Ranjitkar S, Narayana T, Kaidonis JA, et al. The effect of casein phosphopeptide–amorphous calcium phosphate on erosive dentine wear. Aust Dent J 2009;54(1):101–107.

37. Piekarz C, Ranjitkar S, Hunt D, et al.

An in vitro assessment of the role of tooth mousse in preventing wine erosion. Aust Dent J 2008;53(1):22–25.

38.cVelagala D, et al. Enamel erosion: a possible preventive approach by casein phosphopeptide amorphous calcium phosphate - an in vitro study. Int J Clin Pediatr Dent. 2020;13(5):486-492.

March/April 2021

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practice | MANAGEMENT

Fee setting economics for dentists

By Graham Middleton

“Many dentists undercharge while some, relatively few, shamelessly overcharge and drive patients away...”

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ver the past 34 years, I’ve benchmarked the financial performance of a vast number of privately owned dental practices.

A substantial majority of those practices were not being conducted to the optimum financial outcome of the principal dentist and practice owner. One of the causes was inappropriate fee setting. Many practices can adopt fee-pricing strategies which will increase their revenue without damaging their practice, but there are preconditions. Preconditions to a proper fee-setting strategy are good practice presentation and quality chairside communication skills.

The chances are that if you took your partner to a carefully chosen restaurant for a special occasion, you paid well above the average restaurant price for the meal - but you didn’t mind because the décor was attractive, the service was excellent and the staff polite. The reality was that the owners of that restaurant were following a price searching strategy rather than being price takers. A fast service eatery nearby is satisfied with a price taking strategy. Presentation is functional but basic. You might choose to go

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there for a quick meal but would not take someone to it if you wanted them to be impressed.

In an economic sense, there are two distinct market conditions: price takers’ markets and price searchers’ markets. Most farmers and mineral producers are price takers while airlines and movie theatres are prominent examples of price searchers.

Some dentists are price takers and some price searchers and many are unclear as to what their fee structure should be.

Price taking markets rice taking markets commonly occur where a producer’s output is so small relative to the overall production of the goods that it has little influence in the pricing of the product. A classic example is that an individual farmer’s production of goods has negligible influence in the pricing of products. As such, a farmer sending fat lambs to market will receive a price consistent with the current overall market price because individual farmers have little scope for bargaining. One of the features of price taking markets is widespread knowledge of the overall price of the products sold within particular markets.

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practice | MANAGEMENT Price searching markets n price searching markets, there are a variety of consumers who are prepared to place different prices on a service provided. A business executive who needs to travel between Sydney and Melbourne on a regular basis will tend to do so at peak times and is prepared to pay more than a backpacker who is able to travel at off-peak times. Hence, airlines charge significantly more at peak times but search for ways to fill seats at non-peak times and have elaborate multi pricing techniques.

They do this by seeking those who are willing to pay a proportion of full fare and disguise the process by utilising various discount schemes. Economists refer to this process as peak load pricing.

Movie theatres tend to engage in a pure form of price searching. They do this by charging different prices to adults, children, seniors, pensioners, students, social groups and families at different times.

Their experience indicates that employed adults are willing to pay more than other movie goers, particularly at times of choice.

The “concessions” are a clever façade to disguise the fact that pricing differentials are arranged to extract the optimum price which each group is prepared to pay. It has little to do with altruism.

Not as well understood is that supermarket chains have different pricing schedules according to the economic surrounds of their stores and vary shelf space allocation according to product demand.

The traditional supermarket chains also vary store pricing schedules depending on whether they faced nearby competition from Aldi.

Another common form of price differentiation are off-peak rates for electricity and seniors’ concessions on public transport.

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Differences between price searchers and price takers n close examination, those who produce physical goods tend to fall into price taker categories, but there are significant exceptions. The De Beers diamond cartel is infamous for controlling the price of diamonds released to the market and is a price searcher in its most pure form.

Attempts by the Organization of Petroleum Exporting Countries (OPEC) to increase and control the price of crude oil

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sent an initial shock wave through global markets in the early 1970s, but its strategy proved to have overreached as non-members boosted oil extraction and demand fell faster than expected as motorists switched to more economical vehicles.

Trust between OPEC members periodically broke down as some produced more oil than their quota to meet financial needs and prices proved impossible to sustain.

Those who provide services are more likely to be price searchers - but once again where local circumstances induce many individuals to offer a similar service in an unregulated market with near perfect information, the individual will be forced to be a price taker. A key issue is the amount of information available to the user of the service.

Market information for dental services omplex services such as those provided by dentists invariably result in a situation whereby - even where there are several dental practices servicing the immediate area - the individual consumer has limited knowledge of the overall market. The majority of consumers are unaware of the fact that there may be a price differential between practices.

While some potential patients ring practices, I have seen overwhelming evidence that a substantial majority of patients new to an area choose a dentist based on the personal recommendation of friends, relatives and work colleagues rather than search by price. I have also observed that many patients will follow a dentist who has been forced to relocate rather than entrust their treatment to another dentist.

The economic argument goes much deeper than prices for the most routine treatments. Where a particular practice is more accessible, has better parking, a more personable receptionist, is better presented, whose chairside staff are better communicators and whose dentists have long-term relationships with patients, the overall experience is different and can be charged for on a differential basis. This is similar to the restaurant which, through presenting meals in a superior overall setting with attentive waiters, attractive décor and pleasing clean menus, is able to charge appreciably more than a competitor serving similar food but in an inferior

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setting with lower quality of service. This recognizes that the average price of a meal is only one of the criteria that restaurants are judged by and that attention to all the elements of the dining experience enable a restaurant to search for the combination of price and customer numbers which yields it the best overall result.

Many dentists undercharge while some, relatively few, shamelessly overcharge and drive patients away.

Most dental practices are price searchers rivately-owned and operated dental practices have many of the characteristics which differentiate price searchers’ markets and therefore there is a much greater scope for price searching with respect to dental treatment than many practitioners realise. This requires that the prerequisites be in place. The dentist who buys an established practice in a country town but doesn’t make the personal effort to relate to the town and simply raises prices by an immediate and substantial amount is inevitably going to experience a severe backlash from the community and may permanently drive away a significant portion of the patient list. By contrast the new dentist who joins the local golf club, makes a point of supporting the local football team, who shops locally and has the practice décor updated, taking care to consult staff, can then confidently adjust prices.

In particular instances in medium-size towns with an established practice, the owner has consulted me concerning competition from a second practice offering cut price dentistry. My advice has been to compete on presentation and service, not on price. The correct approach is to review practice presentation including painting and updating reception area furnishings, as well as dental operatories and to engage staff in the process of how to better present the practice and how to improve the patient experience. Ensure that pricing is higher than the new practice by a reasonable margin. It is preferable to be known as the best practice in town rather than the cheapest. In each case, that part of the local population better able to afford quality care remained loyal to their existing dental practice and the two practices differentiated themselves on more or less permanent lines.

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practice | MANAGEMENT Practice start-ups choice of position tart-up practices are not for the fainthearted and many do not achieve a sustainable state. Those which fail disappear quietly with substantial financial losses, never having gotten to a breakeven point. Those with substantial capital who choose their position well and have both the capital and personal fortitude to persevere do eventually build a practice and their hard learned lessons may make them stronger in the long term. They tend to start out being price takers, but gradually evolve into price searchers over time.

The evidence from veterinary practices has been that the best position to start a practice has been as close as possible to a large-size practice that has been purchased by a veterinary corporate! I had numerous reports from vets with practices which gained significant clientele when a competing practice was purchased by a corporate, as well as from vets who started practices near corporate practices and who quickly created profitable practices.

Logically, this should also apply to dental practices, albeit that there are some significant differences between the professions.

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How many dentists are too many? e all know that the ratio of dentists to the population has increased substantially but the raw figures tell us too little. If the proportion of female graduates has increased and the proportion of registered dentists choosing to work part time has increased the ratio of full-time equivalent dentists to the population may differ substantially. Some years back when ADA Inc lobbied the government to increase the number of dental schools and to step up dental immigration, it created a huge oversupply and was embarrassed. It then faced the difficulty of getting government to pare back dental immigration, but dental schools, once established, remained. The expression “be careful what you wish for” comes to mind.

A study by the consulting arm of a major accounting firm commissioned by the ADA took the easy path by comparing Australia’s ratio of dentists to population against OECD figures - which was meaningless as there were too many variables

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between countries concerning income, health insurance, government support and fluoridation. The real requirement was an exhaustive survey of dental practices and of dentists to find out precisely the number of practices with vacant or semi-vacant chairs with a capacity to have more patients and the number of dentists wishing to work more sessions. That would have been much more informative than a desk top comparison with OECD data. Right now, we do not know what the actual surplus of dentists available to

“The evidence from veterinary practices has been that the best position to start a practice has been as close as possible to a large-size practice that has been purchased by a veterinary corporate! I had numerous reports from vets with practices which gained significant clientele when a competing practice was purchased by a corporate, as well as from vets who started practices near corporate practices....” work full time to population in Australia is. Nor does dental need correlate with patient demand.

There are many Australians with the means to pay for quality dental care but who don’t regard it as important. This was demonstrated during the government’s non-means tested Chronic Disease Dental Scheme when many people who could afford dental treatment turned up with referral forms from their doctor to get $4,300 of free treatment but were unwilling to pay for subsequent treatment after the scheme was abandoned. This indicates that there is an unknown proportion of Australians who choose never to go to a dentist unless they are in severe pain or the service is free.

I have observed that there are many good dental practices which have

remained successful with consistent benchmark performance over the past 10 years. Despite the change in dental numbers and despite corporate hype, the proportion of dental fees earned by corporate dentists remains quite low in Australia. The misleading advertising by private health insurers which concentrates on extras cover reveals a major weakness of dental corporates who overly rely on extras insurance to generate patients.

There is substantial evidence that there is significant awareness that ancillary health insurance represents poor value for most consumers.

Why price search ll of the above points to the need for privately owned practices to be price searchers by presenting well to their local market and charging fees that their local market will bear. There is little point in adhering to a fee survey if that indicates a range of fees which is above or below what your patients are prepared to pay to have their dental treatment provided in your practice. Price searching is good for the economy because it adjusts the level of demand and acts to balance the number of dental chairs with the community’s other needs over time. Without price searching, there may be a tendency to provide dental services too cheaply, which encourages patients to demand significantly more dental attention than they actually need.

This phenomenon has occurred in medical general practice where Medicare has lowered the cost to the consumer with many receiving free (to the patient) consultations. Dentistry does not want fees falling to a point whereby talented school leavers are discouraged from entering the profession and there is long-term underinvestment in practice facilities, nor would dentists like the Medicare approach with general dentists doing only basic treatment and referring most patients to specialists. The dental profession dodged a bullet when the CDDS scheme proved so expensive to government that the scheme was terminated and moves by health bureaucrats to introduce a universal dental care scheme akin to Medicare lapsed.

What health bureaucrats seek tends to be heavily related to their self-interest to create larger bureaucracies with more promotion opportunities for themselves.

A

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practice | MANAGEMENT Demand schedule with marginal revenue onsider that a provider of a service is faced with a simple demand schedule and each day has 10 units to sell at no production cost whatsoever. At what price would the provider optimise their return?

As Table 1 demonstrates, they would achieve maximum revenue by selling either 5 or 6 units of their service per day.

In the real world, the cost of providing a service is never free and this requires a marginal cost column to be added. It also requires multiple types of treatment service to be reduced to an hourly rate of cost and charge so that net marginal daily revenue can be calculated.

C

expensive mixture of aircraft. In doing so, Virgin went from being a price searching business content with a profitable but limited slice of the market to unprofitability long before COVID-19. Accumulating losses over several years destroyed its shareholders capital as well as its bond holders. The lesson is that dentists need to ask themselves whether they want to have the best practice in town or the largest? Or whether to be profitable or simply be busy?

Price searchers optimise their return by finding the level at which increased dollars per patient give the greatest return vis a vis the reduced number of patients through the door. Hence established practices should concentrate on raising both the service standard and fee level to existing patients.

Table 1. Maximising revenue

Price $

Daily quantity demanded Total revenue $

Marginal daily revenue $

180

1

180

180

162

2

324

+144

144

3

432

+108

126

4

504

+72

108

5

540

+36

90

6

540

0

72

7

504

-36

54

8

432

-72

36

9

324

-108

18

10

180

-144

Profits are greatest at the margin; Costs can be saved at the margin

When to price search: Don’t be a virgin! here is a dichotomy of interest between those practitioners who set out to increase their average fees per patient but suffer a slight diminution in patient numbers and those who engage marketing consultants with the aim of getting more patients through the door. There may be scope for both, but it is important to differentiate when either is appropriate. The recent fate of Virgin Australia highlighted the failure of a business which was profitable operating a single type of aircraft on a limited number of high-demand routes, but which succumbed to marketing overtures to expand into unprofitable routes requiring an

T

ractice benchmarking over 30-plus years demonstrated that overwhelmingly, the most profitable single-owner dental practices had no more than three chairs (counting a dentist working two chairs alternatively as one chair). While exceptional dentists can be highly profitable as solo dentists, the desirability of having at least one other dentist to discuss treatment with is highly desirable. A solo ownership three chair practice is the optimum. Often the practice owner is the leading fee producer and since they aren’t paying another clinician to do the work

P

that they perform, the inevitable feature of successful three chair practices is that a significantly greater amount of profit is produced by the principal. After paying the other dentists the standard formula as contractors, the usual outcome is that about 80% of the profit is generated by the principal, often higher. Hence: • If the principal can squeeze in one extra procedure in a session by working efficiently there is a high profit percentage in that treatment item because costs including chairside assistants wage is largely met and only tiny marginal cost occurs; and • It can be a serious mistake to allow assistant dentists to have bookings spread over more sessions than are necessary to provide the treatment since additional marginal cost in extra chairside assistant wages are being paid for no extra income.

Awareness of marginal profit and marginal cost goes hand-in-hand with price searching.

The huge advantage of practice ownership versus corporate contracting here is no doubt whatsoever that dentists who acquire and conduct their own practices successfully are financially better off to the tune of millions of dollars over their career compared to those prepared to spend their dental careers working as contractors in corporate practices. No amount of corporate spin can disguise this truth.

T

Best wishes to all dentists, Graham Middleton

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

Dentists were the most numerous of his clients. He can be contacted at graham. george.middleton@gmail.com.

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

72 Australasian Dental Practice

March/April 2021

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practice | MANAGEMENT

Overcoming COVID-necessary barriers for a better patient experience How welcome - or unwelcome - are you making your patients feel?

By Julie Parker

P

rior to COVID, creating a welcoming experience for patients when they enter your practice was one of our higher priorities. When the pandemic hit, this objective was pushed to the side in place of new health and safety measures. We imagined this would be a temporary shift in focus.

It has been over a year now and we are still working with additional systems of infection control. While some systems will not be necessary long-term, others, I imagine, are here to stay.

Dental surgeries in Australia have been successful over the years in adapting to new infection threats and updating systems to ensure a safe environment for both patients and staff. COVID has been no different. However, this need not come at the expense of the patient experience.

Many dental practices have entrance signage warning patients not to enter if unwell or if there has been any contact with the virus. There are some practices I have seen who have their front door locked and a doorbell is rung and the patient quizzed before being allowed to enter. Upon entry, there are more signs, hand sanitisers and masks. Moving to the reception area, there is a masked-up receptionist behind a perspex screen. Patients must sit in the appropriate seat to avoid being too close to anyone else and when taken through to the surgery, are faced with clinical staff donned in surgical gowns, masks and face shields.

Communication is difficult.

Reading subtle facial cues and expressions is no longer possible.

74 Australasian Dental Practice

The muffled voices coming from behind the barriers, shields and masks are difficult to hear and understand.

There is limited opportunity to build rapport.

And no one sees each other smile.

This is not the experience dental practices would normally choose for their patients. We have always strived to create an environment that is calm, warm and friendly. Much effort is expended to ensure that patients are informed, educated and supported throughout their dental examination, diagnosis and selection of treatment options.

These objectives need not, and should not, change.

Overcoming the COVID barriers to a welcoming patient experience am going to discuss my thoughts on six COVID-induced barriers that I see as having a negative impact on the patient experience. And I will offer some ideas to overcome them.

A pre-requisite is that dental practices are only seeing healthy people who are not experiencing any symptoms of illness and who have not been in contact with the virus. Environmental cleaning is performed after each visitor to the practice.

An additional consideration is that every new system that a practice implements comes with staff time and practice expense to execute and maintain. An efficient, productive and happy working environment should only be establishing systems that have a clear purpose or solve a recurring problem.

I

Temperature testing his is a direct quote from the Australian Government Department of Health: “While in places like hospitals and aged care facilities, temperature checks may be useful as an extra precaution to protect vulnerable people, temperature checks are not as useful in other settings. This is because people with COVID-19 don’t always develop fever, or may be on medication that reduces their temperature. It is also possible that the person may have a temperature for another reason unrelated to COVID-19.

Also bear in mind that body temperature measurement is affected by the method used, the site, the time of day and the patient’s age, as well as their medical condition.”

Given that temperature testing is not considered useful in settings outside of hospitals and aged care facilities and that the results of the testing can be completely unrelated to COVID, I question whether this system needs to stay at all.

T

Visitor log he visitor log is certainly a system that can be avoided. These logs are a requirement of venues that do not have a way of tracking human movement. A few examples listed by the Health Department are sporting arenas, museums, movie theatres, places of worship and libraries.

Dental practices have dental software that tracks all appointments and houses patients contact details. Practitioners can easily log visitors who accompany patients within their clinical notes, such as “patient attended with mother”. Staff movement is registered through rosters and payroll information.

T

March/April 2021

practice | MANAGEMENT Surgical gowns he webinars that the ADA presented during the start of the pandemic which detailed how to make dental practices safe were excellent and very clear in their directives. Only seeing healthy patients who had no contact with the virus, performing environmental cleaning after each visitor, having the patients use a pre-procedural mouth rinse and reducing aerosols all combine to make our practices safe. There is no need to also wear surgical gowns to keep patients safe.

T

Hand sanitiser and-sanitising is likely here to stay.

Because of this, it is best if a proper hands-free hand-sanitising station is installed. Many practices have handpumps which creates a touch-point for everyone, making the hand sanitising pump itself a potential vehicle for crosscontamination. Installing a sleek, hygienic station that is easy to maintain and clean is a good move.

H

Perspex screens

Masks

’m hoping that the screens that have been installed in most practices can be removed at some stage. They are a physical barrier to patient interaction, are often reflective and difficult to see through when approaching and limit the available space for managing patient payments, treatment plans and other paperwork.

ask-wearing outside of the clinical areas is often needed, but only if a 1.5-metre distance cannot be maintained.

If you have proper distance, take off your mask when speaking with patients.

Let them see your welcoming face and friendly smile. Afford them the benefit of your effective communication.

I

M

COVID may be around for a long time.

Identifying ways to continually improve your patients’ experiences despite the additional infection control measures will help you to be around for a long time as well.

“The visitor log is a system that can be avoided. These logs are a requirement of venues that do not have a way of tracking movement...”

About the author

While these screens are in place, ensure they are tilted or have a non-reflective film so your patients can actually see the receptionist clearly. Clean them frequently and avoid wearing a mask in addition to sitting behind the screen. If you do, project your voice and speak clearly so patients can easily hear and understand you.

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

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March/April 2021

Australasian Dental Practice

75

practice | MANAGEMENT

Sale disclosure: Telling the team

By Simon Palmer

W

hen a practice owner is looking to sell their practice, they will often put off telling their staff about the sale for as long as possible. There are many reasons for this. Sometimes (often) they won’t want to tell the staff at all until after a deal has been locked in with a buyer.

When the sale is locked in and it’s time to tell the staff, the conversation is

76 Australasian Dental Practice

not always an easy one for the vendor to have (especially with long-standing staff).

We often get asked for guidance and best practice about how to tell the staff.

We find that this isn’t a conversation that you want to have multiple times with different staff members at different times.

News travels fast within a workplace and staff members talk to each other. Telling them one at a time may mean that the people you tell last have already heard (an unreliable account) of your message.

We find that best practice is to schedule a meeting to let as many staff members as

possible know at the same time. Here is an example of how this conversation with your team might be structured.

1. Introduce the meeting “I have asked you to come here because I have some news that I need to share with you all about some changes that will be happening in the practice in the near future.

“I have decided that the time has come for me to sell the practice. I have found a suitable buyer and we have recently come to an agreement.”

March/April 2021

practice | MANAGEMENT 2. Tell them the reason you have come to this decision to sell “This wasn’t an easy decision for me to make, but it’s a necessary one due to my fatigue/health issue/desire to retire or relocate in the future.”

3. Tell them about your plans “Before you ask, don’t worry, I’m not leaving the practice any time soon, just cutting down my days for now and I plan on taking some longer than usual holidays in the near future.”

4. Tell them why you didn’t disclose earlier “I would have told you earlier, but I wasn’t sure that I was definitely selling (it was only if I found the right person) and I didn’t want to worry you all needlessly.”

5. Reassure them about the buyer “I want you to know that the decision was made with some quality control. This practice and team are something that I am very proud of and that I would never leave it in the wrong hands.”

6. Tell them specifics about who the buyer is “His/her name is Dr Pat Jenkins. He/ she is 40 years old, lives/is moving close by in Smithville, is married with 3 kids in a local school, loves tennis and skiing and has a clinical special interest in kids and orthodontics - something that I feel that our practice needs”.

2021 DATES

19 June 24 July 11 September

March/April 2021

VENUE

7. Tell them their jobs are secure “I want to reassure you that the buyer wants you all to stay and will be offering you employment on the same/similar terms to your current position.

“The buyer and I: • want to show the patients as much continuity as possible, so that their loyalty and trust in the practice continue; • will be counting on you all to help make the transition as smooth as possible.”

“We find that this isn’t a conversation that you want to have multiple times with different staff members at different times.

News travels fast within a workplace and staff members talk to each other.

Telling them one at a time may mean that the people you tell last have already heard (an unreliable account) of your message...”

If you end the meeting at this point, the staff will more than likely leave with all kinds of questions and lots of concerns in their heads about the new owner and what lies ahead for them. They are usually concerned that they won’t like the new

Brisbane CBD ADA VB, South Yarra ADA NSW, St Leonards

boss, that their new boss won’t like them, or that their job will somehow now be in jeopardy.

It is not a good idea to let them have these concerns for long. The best practice is to have a meeting set up for the staff to meet with the new owner for an introductory morning tea or lunch as soon after the above meeting as possible.

8. Tell them when they can meet the new owner “If I was in your shoes, I might be anxious to meet the new buyer and see what they are like. They are keen to meet you too. We will be meeting them for lunch today across the road at XX/we will have a getting-to-know-you morning tea tomorrow.”

9. One last thing... patient communication “When we meet them tomorrow, they will have a strategy for when and how they want to be introduced to the patient base. I am going to ask that you hold off on telling anyone until then.”

About the author Simon Palmer is the managing director of Practice Sale Search. If you would like some assistance planning your exit from your practice or ideas about what you could do differently to maximise the result that is achievable, Practice Sale Search offers exit planning seminars across Australia and New Zealand every year (see www.exitacademy.com.au) and is available for a telephone consultation anytime on 1300-282-042.

TIME

9:00am – 4:00pm

Australasian Dental Practice

77

practice | MANAGEMENT

Very interesting stats to look at

By Jayne Bandy

I

am always looking at statistics and how they relate to your dental practice. Tracking and Measuring gives you so much vital information about the health of your business, yet many practices do not Measure and Track very much at all.

Have you ever thought about the statistics on answering calls in your practice?

Well, let’s look at some of the stats I have gathered and let me know what you think.

Did you know that Thursday, between 4 and 5pm is the best day and time, to call your patients? Have you been randomly making calls without thinking about the most effective time and day is to make these follow up calls? You could be wasting a lot of your time calling at the WRONG time and on the WRONG day.

44% of dental practices give up after just one follow up call.

If you call a patient with outstanding dental treatment and care and they are not ready, confirm a time with them to call again rather than believing they will never be ready to go ahead with treatment. This is a much better way to help your patients and book more appointments.

Only 11% of dental practices actually ask their patients, face to face for referrals.

You might believe you are asking your patients for referrals, but a sign at the front desk or something written on their treatment plan or invoice is never the same as actually asking. Start doing this and see what a difference it makes to your Patient Referral numbers. I know they will increase!

So many of your patients are more than happy to refer their family and friends but unless you remind them and give them a nudge, only a small number of your patients will. This is a fact!

You know I love this one: Continuous team training will give you 50% more appointments. You can see how this is always one of the best investments you will make in your dental practice business.

78 Australasian Dental Practice

The average company spends $10,000 to $15,000 each year on hiring people and only $2000/year on training. I found this stat very disappointing. All that money spent on hiring people who never stay.

Why not train your team more so they want to stay rather than being a revolving door of teams coming and going!

You may not be spending this amount on hiring people but how much are you spending each year on training? Why would you hire amazing people and not want them to grow and become more amazing in your business?

“Ask yourself this: How many patients do you lose each year that you could have kept? Do you know this number?

You already know this one: Keeping your patients, costs less than always trying to replace them with New Patients.

Ask yourself this: How many patients do you lose each year that you could have kept? Do you know this number?

When you’re speaking with your patients, did you know they are 63% more likely to remember what you said if you tell them a story. Why not share a patient’s experience with another patient, remembering your oath of privacy, of course.

Your patient will add to the story and make the whole conversation much more memorable and it will help your patient understand and take action.

There are many different stats when it comes to the percentage of unanswered calls in your dental practice. Do you know how many of your calls go unanswered?

You WILL be shocked once you know.

Did you know that on average 6 out of 10 phone calls are questions about the price of treatment and care?

You can see why it is so important that your team are well prepared for these calls and know exactly what to say and ask.

The stats coming out of call centres tell us that 85% of customers are not satisfied with their phone experience. What sort of patient experience are the people calling your dental practice getting?

Is it what you want?

These are all interesting stats that get you thinking about the performance and results at your dental practice. Start gathering your own stats. Track and Measure and know what is happening every day.

Learn from your stats and change what needs improving.

It is fascinating and fun to do!

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

March/April 2021

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How to get more high-quality patients

By Angus Pryor, MBA (Marketing)

I

n 2021, more than ever, the queries I’ve been getting have had a theme. Dentists are not just interested in attracting more patients to their practice, but more highquality patients.

This situation likely reflects the fact that for many dental practices, there is reasonable pent-up demand for their services from various COVID-related closures in recent times. Now that practices are fully open for business, dentists are craving quality over quantity.

In this article, we will look at how to attract high-quality patients to your practice.

80 Australasian Dental Practice

What is quality? ometimes, the best way to define something is to explore what it is not. Quality patients are not, for example, patients who: • Are unreliable in turning up to appointments; • Are interested in only minimal treatment options or are excessively price conscious; or • Attend the practice once, such as to take advantage of a special offer and never return.

Several studies suggest that attracting a new patient can be 6 to 7 times more expensive than maintaining an existing patient. With the above poor-quality patients, what the practice is doing is paying a premium to attract these new patients without getting a return of an ongoing relationship.

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marketing | INSIGHTS However, the group we want to focus on are high-quality patients. This groups can be defined by the following behaviour: • Reliable in turning up to appointments on time (and not cancelling or failing to attend); • Open to a range of ethical treatments offered - especially higher-end services; and • Faithful in sticking with the practice over the long term.

What makes someone a “bad” patient? efore we look at how to attract higher quality patients, it’s worth pausing for a moment and considering what makes someone a “bad” patient. We could be forgiven for thinking that some patients are somehow born bad or at least have become so by circumstance.

Certainly, if a patient has a very low income, the likelihood of them becoming a good and regular patient is pretty low, in the absence of government or other financial support.

However, I would argue that the reason some people are “bad” patients is simply due to a lack of education by their dentist.

I’ve worked with many practice management experts that emphasise: • The power of patient education such as informing patients of the benefits of good oral health and the risks of neglecting their oral health; and • Giving patients a compelling reason to return to the next appointment.

Many practices do not do this well.

Yet, I’ve heard some dentists proudly talk about how they managed to transform patients from reluctant, minimalist visitors to the practice, to card-carrying members of the “I love my dentist club”.

So, before we write off patients as fitting into the good or bad category, be aware of the role of the practice. Good practices convert more bad patients to good patients - almost regardless of the patients’ personal circumstances or historic experiences with dentists.

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All patients aren’t created equal espite the above, there will always be some consumers who are willing to pay more for what they perceive to be

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a higher quality service - and it’s quicker to attract this group than the above-mentioned process of converting bad patients to good patients which can take years in some cases.

In his book 80/20 Sales and Marketing, Author Perry Marshall looks at the impact of the 80/20 rule on marketing to consumers. In a dental context, the 80/20 rule may mean, for example, that 80% of your income comes from 20% of your patients.

This 20% are typically the kind of highquality patients that practices are seeking.

As a case in point, run the numbers for your own practice and compare total production for a 12-month period with what percentage of that spend comes from the top 20% of patients. You may be surprised.

However, Marshall makes an interesting comment that even within that 20% group, there is another 80/20 rule - kind of the 80/20 of the 80/20 - which focuses on just 4% of patients.

So, while 20% of patients may spend around four times as much as average patients at your practice, 4% or your patients may spend around 16 times as much as average patients! Some food for thought.

How to present your practice f you know that you’re shooting for this top 20% (or even the top 4%) of patients, how does this impact how you present your practice to the marketplace?

It’s worth remembering that everything you do is a part of your practice brand.

When one of these ready-made, highquality patients is looking around for a new dental practice, they are consciously or subconsciously picking up signals put out by your practice.

These signals are known as touch points. Individually, these touch points may not appear significant, but they add up to something big.

Examples of touch points for your practice include your website, your social media presence, your Google presence, how you answer the phone, what the practice looks like, your signage, where you’re located and so on.

My question to you is simply this - do all of these touch points at your practice add up to a picture that would attract that top 20% (or 4%) of patients? Because if they don’t, this is a key reason you’re not attracting high-quality patients.

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What about dentistry? bviously, you can’t attract highquality patients seeking high-end services if you don’t offer those services, but let’s assume you do.

Let’s assume your practice does implants and veneers and ortho and full mouth rehabs and so on. The mere fact of offering those services is, of course, no guarantee that you’ll attract high-quality patients to your practice.

And the reason why is very simple... patients have no reliable way of telling how good your dentistry is.

Instead, they have to rely on the touch points mentioned above as a proxy for the quality of your dentistry. If your marketing and branding efforts are high quality, they assume the service you offer is high quality too - regardless of whether that’s true or not.

If your marketing and branding efforts are inconsistent or ineffective, these potential patients will assume your dentistry is like that too.

Bottom line - attracting high-quality patients is not about the quality of dentistry you do, it’s about the signals your practice gives off that patients interpret as a marker of quality.

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Summary very practice wants more high-quality patients. These come about by 1) converting poor-quality patients into good ones; and 2) promoting your practice in such a way that patients assume you are high quality (they’ve got no reliable way of being able to tell).

To supplement this article, I’ve made a free training video for you, titled “The Top 5 Mistakes Aussie Dentists Make When Trying to Attract High-Quality Patients”. You can find it at www.AngusPryor.com/HQ.

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About the author Winner of the ADIA 2020 Marketing Award, Practice Growth Specialist Angus Pryor is a #1 Amazon bestselling author, marketer and international speaker.

For help with attracting higher-quality patients, visit www.AngusPryor.com and book an obligation-free call to talk to Angus or take advantage of free video training at www.AngusPryor.com/HQ.

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Income-splitting and the ATO traffic light set: Are you red, green or amber?

By Garry Pammer, BEc, LLB, CA, DIP.FS (FP)

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he ATO continues to delve into common arrangements used by dentists and other medical practitioners as well as accountants and lawyers to operate their practices.

In 2006, the ATO issued a ruling regarding the misuse of service trust arrangements.

In 2013, the ATO expressed concerns in an alert about arrangements involving practices structured as a partnership of discretionary trusts.

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In 2014 and 2017, the first version of a guide called “Assessing the risk: allocation of profits within professional firms” was released. In December 2017, the ATO indicated that it had suspended the application of those guidelines.

Recently, on 1 March 2021, the ATO published the new set of “Compliance and Risk Assessment Guidelines” to assist service practices to assess their “level of compliance risk” under the arrangements that are in place that involve profit-sharing or income-splitting.

This latest set of guidelines are far more complex and involved than the first version.

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finance | INVESTMENT The new allocation of profit guidelines he new guidelines are stated to apply to all professional services firm arrangements - including (but not limited to) medical, financial services, legal and accounting professions. Whilst the guidelines (PCG 2021/D2) are still in draft form and under consultation with professional tax and accounting bodies, they will apply from 1 July 2021.

The ATO are assessing risk under the general anti-tax avoidance provisions of Part IVA and the ATO is specifically concerned with practices that operate through trusts, companies and partnerships of discretionary trusts and how the profits from these practices are being taxed.

As the guidelines apply to any incomesplitting activities within business structures, you should ensure you understand your current structure, how it was established, what was recommended by your advisor and why, how you have used it, that arrangements are commercial and that their substance, the reality if you will, reflects their documented form.

Let’s explore how your profits are dealt with and what you can and can’t do if you want to stay under the radar in light of the ATO’s new guidance in this area.

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Personal Services Income rules good starting point when we’re looking at this area is to determine whether the income generated by the business is classified as personal services income (PSI). Income is PSI if it is mainly a reward for an individual’s personal efforts or skills. Even if income is received by a company, trust or partnership (which is known as a personal services entity), it can still be PSI. If the provisions apply, the PSI of an individual derived in an entity is attributed to the individual that performed the work. Attributed means that it is taxed in the hands of the individual rather that the entity. Basically, you may as well have continued as a sole trader.

If, however, we can determine that in fact a “personal services business” (PSB) is being carried on, then it is the entity, not the individual carrying on that personal services business, which is taxed. That is, attribution under the PSI provisions will have no application and the PSB income will not be taxed in the individual’s hands.

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It is, in fact, more complicated, but a general rule of thumb is that income will be treated as having been derived from the business structure, not the individual, if the practice has at least as many non-principal practitioners as principal practitioners.

Enter Part IVA he new guidelines mean that the ATO may still seek to apply the general antiavoidance provisions in Part IVA even where we have made out that a PSB is run by the practice entity. Specifically, if the entity is used as part of an income splitting arrangement (e.g. family beneficiaries) or an arrangement designed to retain profits in a lower tax entity (e.g. a company).

Your intention under Part IVA is irrelevant as it provides objective considerations. Again, it is more complicated but the provisions will apply if the following factors are present: 1. There is a scheme; 2. There is a tax benefit obtained; and 3. A dominant purpose of the scheme was to obtain a tax benefit.

It is always trite to say that the application of tax legislation, such as Part IVA, will depend on the facts in each case, but it is true. So let’s look at some of the factual matters for various entities used in dental practices that should ensure that Part IVA does not apply.

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Companies ased on my observations, companies are the most misused and misadvised entities within the dental industry and the most exposed under Part IVA. All I can say is if you use a practice company then review your position now.

The incorporation of dental practices are accepted structures but there have always been conditions as to their use and these seem to have been overlooked or ignored by practitioners and many of their advisors alike. By way of refresh I summarise some below.

The practice principal or principals, as most incorporated practices are large, should be the shareholders.

If the business operates through a company and there is no income splitting and no retention of profits in the company (for example, if the only advantage for income tax purposes was to access to greater

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superannuation benefits as an employee) then Part IVA should not apply.

If a genuine attempt is made to break even, a relatively small amount of taxable income may be retained by the company provided that income is distributed to the practice principal by way of a franked dividend in the following year.

So if you run a practice company that makes little or no attempt to distribute the whole of its income to the practice principal or principals by way of salary prior to the end of its financial year, or dividend the following year, has non-practitioner shareholders and retains income in the company, you will not be seen to be complying with the guidelines.

Trusts f the business operates through a trust, then the position is similar to that explained above for companies. The practice principal should receive income from the trust in relation to the personal services income that is commensurate with their duties and responsibilities. If the practice principal draws less than their duties and responsibilities are worth, then the principal should be the sole beneficiary of the trust in relation to that income.

As such, if there is profit to be distributed to family beneficiaries according to the terms of the trust deed, ensure that profit is not artificially inflated by understating the principal’s remuneration.

Worthy of separate consideration and discussion, the establishment of a commercially justifiable service trust is now paramount in structuring a dental practice. Profits not attributable to the practice principal’s income generating activities are still considered in the risk assessment scoring set out in the guidelines.

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Partnerships genuine dental partnership will be accepted for income tax purposes by the ATO. In this case, income or profits can be split between partners even though the services might have only been performed by one of the partners.

In a genuine partnership, your spouse would share equally in profits and losses and be jointly liable for debts and obligations. Part IVA will not apply even if one spouse is the main generator of the income.

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finance | INVESTMENT Table 1. Risk factors Risk factor

Score 1 2 3 4 5 6

Proportion of profit entitlement from the whole >90% of firm group returned in the hands of the IPP

>75% >60% >50% >25% to ≤90% to ≤75% to ≤60% to ≤50%

Total effective tax rate for income received from >40% the firm by the IPP and associated entities

>35% >30% >25% >20% ≤20% to ≤40% to ≤35% to ≤30% to ≤25%

Remuneration returned in the hands of the IPP >200% as a percentage of the commercial benchmark for the services provided to the firm

>150% >100% >90% >70% to ≤ to ≤ to ≤ to ≤ 200% 150% 100% 90%

≤25%

≤70%

Table 2. Determining your risk Partnerships of Discretionary Trusts t was back in November 2013 that the ATO released a taxpayer alert expressing concern about arrangements involving professional practices that are structured as a partnership of discretionary trusts.

These structures do warrant detailed separate consideration, beyond the scope of this article, however at a high level, the ATO is concerned that the relevant taxpayers, among other things, may not have: • Given legal effect to the structure that they are purportedly using. For example, are you holding yourself out as the partner in your dealings with your patients? Not as a Director of your trustee company?

• Correctly accounted for the tax consequences associated with the structure.

For example, if you and your partners restructured into a partnership of discretionary trusts, does income that used to flow directly to each practice principal now flow to a range of other family member taxpayers through the trust?

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The guidelines process s you would expect, there is a degree of complexity to these rules. Several tax calculations will need to be performed in order to complete the risk-assessment process. That process needs to be conducted annually, based on the prior year’s pattern of distributions.

Some of the key steps and items that will need to be reviewed include: 1. Eligibility test 2. Gateway Test 1 3. Gateway Test 2 4. Risk Score Calculations 5. Determine Risk Rating

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Aggregate score Risk zone Risk level against first two factors

Aggregate of all three factors*

Green

Low risk

≤7

≤10

Amber

Moderate risk

8

11 & 12

High risk

≥9

≥13

Red

Eligibility conditions review of your overall arrangements will need to be undertaken to ensure that you satisfy all the requirements and preconditions to be eligible to risk assess.

Pre-conditions include those discussed above in this article. For example, if the income being generated is personal services income (PSI) it should be dealt with under the existing PSI rules. It is only if you are found to conduct a personal services business (PSB) that you are able to use the ATO’s risk-assessment approach.

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The two “Gateways” ateway 1 requires a commercial rationale for the business structure and the way in which profits are distributed. The ATO expects that the arrangement would reflect the commercial needs of the dental practice. You need to show more than simply providing a tax advantage!

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ateway 2 requires an assessment of whether any high-risk features are present. Examples include arrangements that are covered by a Taxpayer Alert, such as partnerships of discretionary trusts mentioned above. It would also include company structure matters such as dividend access shares held by an associated entity of the practice principal.

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The risk-assessment approach f the two Gateways are satisfied, then the practice principal can self-assess their risk level against the ATO’s risk assessment factors. This involves allocating a score for each factor, which are then added up to determine the risk zone.

Risk assessment factor 1 provides a score, depending on the profit returned-personally in the hands of the practice principal as a proportion of the total amount of income to which the practitioner and their associated entities are collectively entitled.

The lower the proportion, the higher the risk score.

Risk assessment factor 2 provides a score, depending on the total effective tax rate of the practice principal and the associated group entities.

The lower the overall effective tax rate, the higher the risk score.

Risk assessment factor 3 requires the consideration of the commercial benchmark for the dental services and then expresses the remuneration provided in the practice and returned in the hands of the practice principal as a percentage of that.

This measures that the practitioner is receiving assessable income from the practice firm in their own hands, reflecting an appropriate return for the services they provide.

The lower the principal’s remuneration against the professional benchmark, the higher the risk score.

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finance | INVESTMENT Notwithstanding the logic, the ATO does acknowledge that this factor is difficult to determine accurately. Something that the ADA might be able to provide some guidance on.

Given the difficulty in benchmarking, this third risk assessment is optional.

However, if you have high risk factor scores at one and two then determining the third may well lower your overall rating.

Determining your “risk level” cores for each factor are calculated based on Table 1.

Table 1 is a tax accountant’s dream and a dental practitioner’s nightmare!

Table 2 sets out the risk level based on the scores obtained by using Table 1.

The aggregate score under these tests will then determine the risk zone and level that applies to you.

As far as your traffic light colour goes, you want to be Green - Low Risk. Whilst everyone’s personal driving habits vary (road rules notwithstanding), in these

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guidelines, an amber light does mean slow it down and assess how you are travelling - it does not mean go faster!

Outcomes can be very marginal. For example, two practice principals use only the first two tests and: • The first finds that 51% of the firm profit is allocated to himself and his family group pays an average of 31% tax on the practice’s income. His aggregate score is 7 - Low Risk - Green.

• The second finds that 50% of the firm profit is allocated to himself and his family group pays an average of 29% tax on the practice’s income. His aggregate score is 9 - High Risk - Red.

What to do now? t can be seen how the guidelines might apply to any income-splitting activities within your practice’s business structures.

To reiterate my comment at the outset then, you should ensure you understand: 1. Your current structure; 2. How it was established;

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3. What was recommended by your advisor, and why: and 4. How you have used it, specifically that arrangements are commercial and that their substance, the reality if you will, reflects their documented form.

The guidelines will be applied after 30 June 2021. We will be assessing the risk factors for our clients when undertaking their 30 June 2021 forecasts and year-end tax planning. As always, we would be happy to help you clarify how these rules may apply in your circumstances.

About the author Garry Pammer is a Director of Specialist Accounting & Business Advisory, specialising in providing advice to dentists.

This advice is not only in respect of taxation and accounting but also planning for your financial wellbeing, superannuation, practice management and the buying and selling of dental practices. For a free assessment of your position and to see how you can achieve your goals, please do not hesitate to call Garry on 1300-221-486.

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Even more changes coming to Income Protection cover

By Sacha Loutkovsky, Senior Risk Adviser

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o you have Income Protection (IP) cover? Have you noticed the premiums increasing substantially over the past few years and continuing to rise? There is a reason for this increase and something is being done about it.

In December 2019,1 the Australian Prudential Regulation Authority (APRA) handed down parameters to ensure sustainable pricing on retail IP policies (those generally available through a Financial or Risk Adviser). Part of APRA’s job is to ensure that premiums remain as stable as possible to avoid both policy holders and insurers exiting the market and to ensure insurers remain profitable. In the 12 months to June 2020, Australian insurers lost $1.3 billion on IP cover.

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The first major change to IP cover put in place after 01/04/2020 was that agreed value benefit payments were abolished on new Income Protection policies. You can read more about this change in Income Protection is about to change forever - review yours now!

(Australasian Dental Pracice Jan/Feb 2020).

In September 2020, APRA released a further change. This article will cover what we consider to be key changes, however a comprehensive summary can be found on APRA’s website.1 It is important to note that IP policy holders up to 31/03/2020 are not affected by the below changes. These changes are to come into effect from 1 October 2021.

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finance | INVESTMENT Change 1 For those individuals on a predominately stable income, the IP benefit will be based on the life insured’s income over the preceding 12 months.

The intent of this change is to ensure that the monthly benefit paid is linked to the actual income being earned at time of claim and encourage the life insured to return to work sooner.

APRA realised that a whole section of the workforce was missed (e.g.: self-employed people, gig economy workers, people returning from maternity/ paternity leave) and so they released a secondary measure.

Change 1a For individuals in occupations with substantially variable income, the IP benefit will be based on the life insured’s income averaged over an appropriate period.

This is a welcome addition. However, what is not clear is the definition of an “appropriate period of time” and the definition of “substantially variable income”.

“For benefit payments beyond 6 months, the insurance benefits will not exceed 70% of the life insured’s income. If you are on claim for longer than 6 months, your benefits will drop to 70% of your income...”

Based on what we have seen in IP product design, already an “appropriate period of time” appears to be 3 years and many insurers have adopted 3 years as their time frame to assess income against.

Further work needs to be done on this.

Change 2 Insurance benefits will not exceed 90% of the life insured’s income for the first 6 months of benefit payments.

To meet these parameters, it is possible that ancillary benefits relating to specific injury and more will cease.

Change 3 For benefit payments beyond 6 months, the insurance benefits will not exceed 70% of the life insured’s income.

If you are on claim for longer than 6 months, your benefits will drop to 70% of your income. For current policy holders, it is 75% from the time your claim is approved.

This measure clearly shows that APRA wants to encourage people to get back to work. There is concern about the capping of benefits for severely disabled people who cannot return to work. It is possible

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To find out, contact Profile now to book an obligation-free initial meeting: (02) 9683 6422 Or visit our website www.profileservices.com.au

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March/April 2021

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Wealth managers for the dental industry

18/03/11 2:04 PM

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finance | INVESTMENT that 70% Income Protection alone may not be enough financial support and it is likely that other covers such as Total and Permanent Disability (TPD) cover and Trauma cover may need to do the heavy lifting.

At your 5-year renewal mark the insurer is within their right to offer a policy with different terms and conditions to the policy you have had. You may lose benefits depending on what has changed in product design in the preceding 5 years.

Change 4

Profile’s insight

Policy term shall not exceed 5 years.

A new IP contract will only last 5 years.

Once 5 years is up, the insured will have to re-apply for cover. This is a severe measure that will have serious ramifications.

Change 5 After the initial 5 years, the policy may be renewed without medical underwriting, but income, occupation and dangerous pastimes/sports will need to be reviewed and confirmed.

Once your 5-year term of IP insurance is up you will need to answer a series of questions to get it back for another 5 years and then again in another 5 years, etc.

Medical changes do not need to be disclosed, which is a big win. However, you will need to answer questions on your occupation, income and current dangerous activities. This could be problematic and result in special clauses to a new 5-year term or potentially no cover offered at all.

For example: • If you leave dentistry and become a real estate developer, it is unlikely you will have your 5-year IP term renewed under the same conditions, or even at all.

• If you have taken up a hazardous activity such as mountaineering, you may have special terms on the renewed contract.

Change 6 After the initial 5 years, the terms and conditions issued on the new policy must be based on the policy on issue at time of renewal.

Current IP policies are generous, which has been a good thing for clients as they can be well covered in terms of how much they can receive in the event of a claim and the terms under which they can claim.

“A new Income Protection contract will only last 5 years. Once 5 years is up, the insured will have to re-apply for cover. This is a severe measure that will have serious ramifications...

Once your 5-year term of Income Protection insurance is up you will need to answer a series of questions to get it back for another 5 years and then again in another 5 years, etc...”

However, these generous policies are why your IP premium is increasing rapidly each year. The losses incurred on these “race to the top” products mean that an external governing body had to step in. If you hold current Income Protection with all the bells and whistles and are not already complaining about premium increases, you soon will be. The insurers will increase pricing to get you off the old, generous, unsustainable products and onto these new products.

What can you do? hese changes do not come in until October 2021 and IP policies available right now do not reflect the above.

If you fall into any of the following categories, you may want to contact your Financial or Risk Adviser to consider your options before the generous policies are gone forever: • You do not have Income Protection but know you need it because you can’t survive without income and/or have people who depend on you to provide for them; • Only have Income Protection through your industry super fund; • Are self-employed or contracting; • Are considering starting a family; • Have retail Income Protection already but have had a change in circumstances such as a change in occupation or income, medical change, want to review any loadings or exclusions; • Have retail income Protection already on an Indemnity basis; • Have retail Income Protection already on either a 2- or 5-year benefit period; • Are not sure whether these changes affect you - seek qualified advice!

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About the author Sacha Loutkovsky is a Senior Risk Adviser at Profile Financial Services, a privately owned and self-licensed fee-based financial planning firm, with offices in the Sydney CBD, Parramatta and Mudgee.

Profile has operated for over 30 years and specialises in serving the wealth creation and protection needs of professionals and small business owners. Many of Profile’s clients are dentists and they run regular education seminars on financial planning topics. To find out about upcoming seminars or to book an obligation-free meeting, call (02) 9683-6422.

Reference 1. https://www.apra.gov.au/final-individual-disabilityincome-insurance-sustainability-measures

General advice warning This article is issued by Profile Financial Services Pty Ltd (ABN 32 090 146 802), holder of Australian Financial Services License No 226238. This information might contain unsolicited general information only, without regard to any client’s individual objectives, financial situation or needs. It is not specific advice for any client and is not intended to be relied upon by any person. Before making any decision about the information provided, a client should consider the appropriateness of the information in this article, having regard to their objectives, financial situation and needs and consult their adviser. Any indicative information and assumptions used here are summarized, are not a product illustration or quote, and may change without notice to you, particularly if based on past performance. This notice must not be removed from this article.

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infection | CONTROL

READ ME FOR

CPD

Figure 1. The UK strain B.1.1.7 of the SARS-COV-2 virus. © NIAID

Different strains of the SARS-CoV-2 virus: Why it matters

By Emeritus Professor Laurence J. Walsh AO

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n April 2021, a major point of interest is not just how many cases of COVID-19 are occurring in any given place, but rather which strain. This article discusses how the strain is identified and why that information is so important.

Detecting different strains of the virus

enomic sequencing is the method which is used to assess what strains of the virus are currently in circulation. Knowing that new strains have appeared has proved to be very important for containing outbreaks and for achieving effective suppression of community spread.

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The use of genomic sequencing was not widely known to members of the public until the coronavirus pandemic. Nevertheless, the same technique has been used in Australia for many years to locate the original source of outbreaks of foodborne bacterial infections.

By routinely applying genomic sequencing techniques to SARS-CoV-2 coronaviruses, Australia is now in a unique position globally. Whenever a throat or nasal swab gives a COVID-19 positive result, the sample will be sent to a laboratory for genomic sequencing. Because of the relatively low number of total cases of COVID-19 in Australia, it has been possible to undertake genomic sequencing for almost every positive result.

March/April 2021

infection | CONTROL This, in turn, has allowed public health authorities in Australia to detect variants of concern very early when they arrive in returning travellers, such as particular strains from the UK, South Africa, Brazil and Japan. The strains can then be tracked over time in order to see whether these have been transmitted to the local community.

As the SARS-CoV-2 virus continues to mutate and evolve, genomic sequencing technology will prove fundamental to tracking down the variants of the virus that are more contagious - and therefore more difficult to contain.

As the third wave of infection progresses through the northern hemisphere, the statistical probability increases for a single person to host more than one strain at the same time and from that, there is a greater likelihood that new variants will emerge. Because of genomic sequencing technology, it is now possible to look for clustering of cases that have originated from a single source. This can greatly help in understanding how particular strains are being transmitted within the community and how the virus is evolving over time.

Virus variants of concern s of April 2021, there are three major emerging SARS-CoV-2 variants of concern. All three share a common set of deletions in a particular non-structural protein known as NSP6, indicating that at some point in time, they all shared a common origin. In light of the greater transmissibility of these three strains, without stringent infection prevention and control measures being in place, concerns are that the third global wave of COVID-19 infection during mid-2021 will be even more serious than the first and the second waves in 2020.

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South Africa strain he South Africa strain (B.1.351) first appeared in early August 2020. It has three deletions and three mutations to the spike protein which allows the virus to bind to human tissues. This variant is highly transmissible, with estimates of the increased transmissibility ranging from 1.2 to 2.13 times, with an average of 1.5 times.

Fortunately, the disease caused by this strain is not any more severe than previous circulating strains, so there is no significant change in the risk of hospitalisation

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or fatal outcomes. The South Africa strain has been dominant in Africa, Australia, India, China and North America.

UK strain he UK strain (B.1.1.7) first appeared in September 2020. It has two deletions and three mutations to the spike protein.

This variant shows moderately increased transmissibility, in the order of 36% to 75%. Importantly, this particular strain is not only more contagious, but also more virulent. Contracting it increases the risk of more severe illness resulting in hospitalisation or a fatal outcome. The UK strain is a major source of infection across both North America and South America, as well as throughout Europe, South-East Asia and most recently Australia. By the middle of March 2021, some 111 countries had reported the UK strain causing infections within their populations.

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Brazil strain he Brazil strain (also known as the Japan strain, or P.1) first appeared in December 2020. It has three mutations to the spike protein. This variant also shows much higher transmissibility than previous variants, but it remains to be determined whether it has an increased ability to cause more serious disease. This is an important strain in both North America and South America and is also showing significant increases in prevalence in Europe. At the time of writing, this strain had not yet been identified in Australia. None of the countries with borders close to Australia, including New Zealand and countries in Oceania and Southeast Asia, have the Brazil strain.

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Will the vaccines work against these SARS-CoV-2 variants? hile all vaccines that are used in Australia will have been tested thoroughly for both safety and effectiveness in properly conducted clinical trials, lingering doubts remain regarding the effectiveness of existing vaccines as the virus continues to change over time.

The UK strain is covered well by the Pfizer and AstraZeneca vaccines.

For the South Africa strain, existing vaccines appears to offer decreased protection, suggesting that the risk of infection despite vaccination could be higher.

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Recent research has indicated that the Johnson & Johnson vaccine has better efficacy against the South African variant than against other variants of SARSCoV-2. In South Africa itself, a lower vaccine efficacy has been reported for the AstraZeneca vaccine, with an efficacy of only 22% for preventing mild-to-moderate disease, but that statistic comes from a small sample size of just over 2000 adults.

There is insufficient information regarding the Brazil strain in terms of whether vaccine protection is reduced for this variant or not. Current data are still suggesting that the available vaccines are quite efficacious against this variant.1,2

The virtuous cycle he greater the proportion of the community who are successfully immunised against COVID-19, the less the possibility of spread within the community at large and hence the less opportunities there will be for the virus to mutate. This creates a type of virtuous cycle. On the other hand, when immunisation rates are zero or very low and infection rates in the community are very high, as is currently the case in Papua New Guinea, the situation is favourable for additional mutations to occur.

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Long COVID uring an initial COVID-19 infection, there is damage to a number of key organs. Following an acute infection with COVID-19, those who survive, regardless of their age, can experience late sequelae including fatigue, cough, shortness of breath, joint pain and chest pain as the most common symptoms. There are also less common but more serious complications which have been reported in the literature, including acute kidney injury, permanent loss of the sense of smell, disordered sleep, memory impairment, depression, mood changes and anxiety.

The existing literature indicates that those who were more severely ill and were hospitalised but survived will show the greatest long-term impairment and reductions in the quality of life. The particular cluster of these symptoms which patients experience on a chronic basis after surviving COVID-19 are now described as either “post acute sequelae of COVID-19” (PASC) or as “long COVID“.3

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infection | CONTROL Re-infection t is well now recognised that people who have had infection with COVID-19 can be infected again. Hence, having survived the infection once is absolutely no insurance of future protection. In fact, the opposite is true, since symptoms are worse for the second infection than for the first. One reason for this may be because of organ damage sustained during the initial COVID-19 infection, which makes the person more susceptible to severe forms of illness when they encounter the virus for a second time.

One of the earliest reports of re-infection came from a nursing home in Kentucky in the U.S. where five residents experienced COVID-19 twice, with an interval between the two episodes of more than three months.

During the first outbreak, two residents had mild symptoms and three were asymptomatic - but all returned positive PCR tests. Over the following months, all five returned at least four negative PCR tests.

However, at a later time point, all five were reinfected with COVID-19. This time, all five experienced significantly more severe clinical illness and one patient succumbed.

COVID-19 re-infection was also described recently in a cohort of over 500,000 people in Denmark who were tested from February 2020 to December 2020.4 The overall re-infection rate was much higher in those aged 65 and older than those aged less than 65 years, by a factor of around two-fold. This may reflect the fact that patients of advanced age do not show as strong a protective immune response following natural infection with the virus and therefore their level of protective immunity is much less.

Given the high rates of fatal outcomes for COVID-19 infection for residents of residential aged care facilities in Australia, the spectre of re-infection is particularly concerning. This emphasises why elderly patients were given a high priority in the rollout of the COVID-19 vaccine.

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Will the vaccine protect healthcare workers? ublished on March 30, 2021 was an interesting study which assessed outcomes for almost 4000 healthcare workers across eight locations in the United States who had received the Pfizer vaccine or the Moderna vaccine over a period of 18

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weeks.5 Both vaccines were highly effective when two doses were received, with an overall effectiveness rate of some 90% - a value which is consistent with previous data from phase 3 clinical trials.

Importantly, this study demonstrated that these vaccines reduced the risk for both symptomatic and asymptomatic infection in healthcare workers, meaning that they were no longer able to transmit the virus despite their frequent close contact with members of the public. Protective benefits were seen after the first dose of the vaccine, once a period of 14 days had elapsed, with an effectiveness at this time of some 80%. This is consistent with earlier studies showing that effectiveness after a single dose of the vaccine was around 72%. This is not to argue for having only a single dose, but rather to point out that there is some useful level of protection after the first dose and that level of protection increases further once the second dose has been received.

Adverse events urrent data on adverse events from vaccines show rates that are not substantially different from other common vaccines, in the order of around 4.5 cases of anaphylaxis per million doses of vaccine administered. In almost all cases, the timely administration of adrenaline has prevented any major adverse health outcomes. When COVID-19 vaccines have been administered to residents of aged care facilities, the rates of death and causes of death are no different from normal and continue at the background rate.6

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What will the future hold? ased on the analysis of past epidemics, it can be expected that SARS-CoV-2 will continue to mutate relatively often and is likely to become more contagious over an extended period of time. At the same time, there are likely to be mutations that may reduce the virulence of the virus. As new strains develop, the need for updating the existing vaccines will be paramount.

This will likely result in annual immunisation programs, in the same way as is done for influenza. Once the point is reached where the majority of the adult population has been successfully immunised, the ability of the virus to spread within the community will be greatly reduced. Thus,

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the frequency of outbreaks and the associated lockdowns and restrictions should decline over time. In the interim period, measures such as physical distancing, the wearing of masks in certain public spaces and an increased emphasis on cleaning and disinfection of high touch surfaces will continue as the “new normal”.

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

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

References 1. Mahdi SA, et al. Efficacy of the ChAdOx1 nCoV-10 Covid-19 vaccine against the B.1.351 variant. NEJM 2021, March 16, 2021.

2. McIntyre P, et al. Covid-19 vaccines - are we there yet? Aust prescriber 2021;44(1):19-25.

3. Huang C, et al. 6-month consequences of Covid-19 in patients discharged from hospital: a cohort study.

Lancet 2021:397:220-232.

4. Hansen CH, et al. assessment of protection against reinfection with SARS-CoV-2 among 4 million PCRtested individuals in Denmark in 2020: a population level observational study. Lancet 2021: March 2021.

5. Thompson MG, et al. Interim Estimates of Vaccine Effectiveness of BNT162b2 and mRNA-1273 COVID-19 Vaccines in Preventing SARS-CoV-2 Infection Among Health Care Personnel, First Responders, and Other Essential and Frontline Workers - Eight U.S. Locations, December 2020– March 2021. MMWR 2021;70. March 29, 2021.

6. WHO statement on AstraZeneca COVID-19 vaccine safety signals. WHO, March 17, 2021.

March/April 2021

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infection | CONTROL

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Instrument reprocessing without the “black box” or “magic window”

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hen students are undergoing clinical training at dental school and there is a lot to learn, their attention is focussed on patient care, rather than on all of the “back of house” support functions that keep the clinic running, like the sterilising room. Instrument reprocessing is not handled by students, who will drop off used dirty instruments to the sterilising room and collect sterilised instruments from a dispensary, often without thinking very much about the “Black Box” of instrument reprocessing, or all the hard work that has gone on behind the “Magic Window” of the dispensary to make the instruments fit and safe for re-use.

Students need to understand what happens behind the “Magic Window”, since the responsibility for proper instrument reprocessing sits on the clinicians who are using the instruments in patient care. Dental clinicians need to understand the scope and importance of proper reprocessing and how it impacts the entire practice. It is more than just prevention cross contamination, since the processes must also be right from both a safety and compliance standpoint. There are several regulators that oversee infection prevention and control in dentistry - including the Dental Board of Australia and the public health units in states and territories.

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infection | CONTROL Younger clinicians often don’t realise that while they might assign the instrument reprocessing tasks to their staff, they are ultimately responsible for ensuring their practice is meeting all required standards. These clinicians need to have a good understanding of the steps in reprocessing. This aspect is also important when bringing on a new staff member.

So, to both inform and refresh, here are three key insights about instrument reprocessing:

1. Instrument Management Systems improve efficiency and safety

2. Instrument reprocessing requires specific PPE roper PPE must always be worn when reprocessing contaminated patient equipment. This includes using gloves when handling instruments and cassettes following patient treatment and utility gloves in the sterilising room when loading cassettes into ultrasonic cleaners or into instrument washers. Utility gloves should not be bulky and should enable tactical sensitivity.

Contaminated utility gloves should only be worn on the dirty side of the sterilisation area and should be disinfected according to the manufacturer’s instructions.

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3. Instrument reprocessing is a patient showcase opportunity ore than ever, patients are looking for reassurance that dental practices are emphasising infection prevention and control and instrument reprocessing can be a good aspect of the practice to showcase.

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“Some practices feature a large window into the sterilising room to give patients an opportunity to view instrument reprocessing...”

As an example, some practices feature a glass wall or large internal windows into the sterilising room to give patients an opportunity to view reprocessing and see the steps being performed.

Additionally, the practice website can give patients a virtual tour of the sterilising room so they can see for themselves how much effort the practice puts into cleanliness, organisation and safety.

If your practice uses IMS Cassettes, you can open the cassette in front of the patient as a demonstration. A well-organised and nicely presented cassette can make a world of difference when compared to a tray of loosely arranged instruments. nstrument reprocessing takes time and handling contaminated instruments is a safety risk for staff. Instrument Management Systems like the IMS™ Cassette from Hu-Friedy address those challenges because they are designed to keep instruments organized and intact throughout the entire process, from cleaning to chairside. Many dental schools already use cassettes for this reason, so some students will already be familiar with the concept.

IMS cassettes eliminate time-consuming tasks like manual instrument cleaning and sorting, while making it easy to standardise procedural set-ups and to train new staff. Those small time-savings throughout the day add-up and lead to more time spent with patients in the chair.

Cassettes provide safety benefits because the handling of contaminated sharp items is minimised. The instruments stay secured throughout the entire reprocessing cycle, reducing the risk of injury or exposure to bloodborne pathogens.

Instrument Management Systems provide better efficiency and improved safety, which is ultimately a win-win for all involved in instrument reprocessing.

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March/April 2021

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infection | CONTROL

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Back to basics: Best practices for masks

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n the first months of the COVID-19 pandemic last year, there was a gross shortage of medical masks.

Thankfully, medical mask supply has now stabilised.

This article reminds mask wearers of some of the most important ways to ensure optimal respiratory protection.

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1. Choose a mask from a reliable manufacturer hen demand for masks spiked during the pandemic, some manufacturers rushed to turn a quick profit by producing masks for domestic use in the fastest and cheapest way possible, on improvised machinery, using any materials they could find. Not only were most

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of the masks they produced uncomfortable to wear and hard to breathe through, but they were not adequate for use in a health care setting. They failed to provide reliable respiratory protection. This has led to removal of some masks from the Australian Register of Therapeutic Goods.

That’s why it’s so important to use only medical masks that are certified to comply with Australian Standard 4381:2015.

March/April 2021

infection | CONTROL Medical grade face masks are medical devices that are subject to stringent regulatory requirements. Only highly specialised medical mask manufacturers have the knowledge, experience, premium raw materials, state-of-the-art machinery and tight quality controls necessary to produce them.

2. Wear your mask correctly ven the most well-made mask can only protect if it is worn correctly. To ensure that you’re protected, follow these mask donning instructions: • Before putting on a mask, always perform hand hygiene by either handwashing or by applying a TGAapproved alcohol-based hand gel and rubbing that for at least 20 seconds;.

• Remove the mask from its packaging and inspect it for tears or holes; never use a damaged mask; • Ensure that the nose piece is at the top and that the pleats face outwards and downwards; • For coloured masks, ensure that the white side is against your facial skin and the coloured side is facing out, away from your face; • Place the mask over your nose and mouth and extend it under your chin; • Adjust the nosepiece so that it fits securely over the bridge of your nose; • Adjust the mask so that it lies closely against the sides of your face to minimise gaps; • Slip the earloops over each ear (for an earloop mask) or tie the ties behind your head (for a tie-on mask) to hold the mask securely in place; and • Once your mask is on, be sure not to touch it while you’re wearing it.

Important: Remember to NEVER pull your mask under your chin, even briefly to eat, drink or talk.

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3. Make sure your mask fits properly • To determine whether a mask fits properly, check that it fits snugly over the nose and mouth and under the chin and that there are no gaps at the sides of the face; • If a mask is too big, it creates gaps that allow contaminants to enter and escape; • A mask designed with an adjustable nose piece will create the best possible seal around your nose and cheeks.

March/April 2021

4. Choose the right level of splash protection edical masks should be selected based on the level of splash protection required for their intended use.

Level 1 masks have the lowest splash resistance (80 mm Hg fluid pressure).

They are intended for procedures where there is no anticipated fluid splashing, e.g. dental prosthetic work, or ortho adjustments, where the triplex syringe is not used.

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Level 2 masks provide higher splash resistance (120 mm Hg). They are intended for routine dental procedures of all types (both restorative and surgical), where there will be some likely exposure to aerosols, spray and/or fluids.

Level 3 provide the highest splash protection (160 mm Hg) and are intended for use in settings where arterial spurting is likely (e.g. orthopaedic and cardiac surgery).

No mask provides an airtight seal. In some settings, a surgical respirator is needed as part of risk-based precautions.

5. Look for special features hether you have sensitive skin, wear glasses or simply feel claustrophobic in ordinary masks, there is a specialty mask for you.

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• If you wear glasses: Find a mask that fits closely over your nose or one that has a nose wire to limit fogging.

Choosing a mask with an anti-fog film or strip also helps.

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The Medicom SoftSkin Anti-Fog Earloop Mask™ with Air Space™ technology has a unique fog-free strip integrated into the adjustable nosepiece to minimise fogging and ensure clear vision when wearing loupes or eyewear.

• If you feel claustrophobic in ordinary masks: Look for a mask that creates a larger breathing space between the mask and your face. n The Medicom Safe+Mask TailorMade™ earloop mask has innovative dual-fit nose and chin pieces that adjust to form a tight seal around the

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infection | CONTROL

face reducing gapping and ensuring a personalised fit, making it ideal for those who feel claustrophobic in ordinary masks.

• If you have sensitive skin: Choose a mask with an inner layer made of materials that are gentle on your skin. n The Medicom SafeMask ® SofSkin earloop mask is designed especially for those with sensitive skin. It is ultra-soft and lightweight with a breathable inner layer and unique wicking technology that keeps the face dry and comfortable.

• To prevent fluids or other substances from entering the eyes: Choose a mask with a protective shield or visor. There are a range of visor masks available. n The Medicom Premier Elite ™ ProShield mask with visor combines a level 3 earloop face mask with an integrated visor to protect the eyes.

6. Know when to change your mask • Between patients: Wear a new mask for every patient.

• As soon as it becomes wet: A mask that becomes wet, whether from sweat, breath or other substances, loses its ability to filter pathogens.

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• If it becomes damaged or torn: A damaged or torn mask could allow pathogens to enter or escape the mask.

If you notice any tears or damage, change your mask immediately.

• If it becomes noticeably soiled or contaminated or hard to breathe through.

• If you have been wearing it for an extended period: The longer a mask is worn, the greater the risk for infectious particles to become deposited on its surface.

7. Remove your mask safely o minimise the risk of cross-contamination when removing a mask, handle it only by the earloops or ties and never touch the front. To safely remove your mask: • Begin by stretching the earloops up and over your ears (for an earloop mask) or untying the ties behind your head (for a tie-on mask).

• Next, bring the outside corners of the mask together so that the contaminated front of the mask is no longer exposed.

• Take care not to touch your eyes, nose or mouth while removing a mask and disinfect your hands with soap and water or hand sanitiser immediately after removing a mask.

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8. Safely dispose of single-use masks ingle-use facemasks should be used once and then discarded as follows: • After safely removing the mask, immediately dispose of it, according to your local waste regulations.

• Perform hand hygiene immediately after discarding a mask.

• Do not carry a used mask around your arm or wrist or pull it down to rest under your chin or around your neck.

• Never share your mask with others.

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References

1. Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic, Centers for Disease Control and Prevention, updated Feb. 10, 2021. https://www.cdc. gov/coronavirus/2019-ncov/hcp/infection-controlrecommendations.html 2. The Right Mask for the Task, Johns Hopkins Bloomberg School of Public Health, https://www. jhsph.edu/covid-19/articles/the-right-mask-forthe-task.html 3. Chughtai AA, Stelzer-Braid S, Rawlinson W, Pontivivo G, Wang Q, Pan Y, et al. Contamination by respiratory viruses on outer surface of medical masks used by hospital healthcare workers.

BMC Infect Dis. 2019;19(1):491. Available from: https://doi.org/10.1186/s12879-019-4109-x.

March/April 2021

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clinical | EXCELLENCE

Figure 1. The sea urchin spine offers a proven patent from nature, which was implemented in the development of the VITA ENAMIC hybrid ceramic (Image source: © Nick Hobgood 2010 Wikimedia Commons).

Biomimetic solutions for restorative dentistry

By Dr med. dent. Andreas Reiger

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ll life is problem solving,” noted the Austrian natural philosopher Karl Popper. In fact, nature has many patents to offer that have been tried over a long period of time and have proven to be an advantage in the struggle for survival. In the field of bionics, a combination of words from biology and technology, people try to understand the blueprints of nature that have evolved and been optimised over millions of years and translate them into technical innovations. In order to withstand the enormous effects of force, the steel pipe towers of wind turbines, for example, mimic corn stalks in their structure. In dentistry as well, bionic material solutions that mimic the functionality of the natural hard tooth substance represent a promising approach for long-term, stable restorations.

In addition to functionality, however, the shade effect and degree of translucency must also be imitated in order to produce an aesthetic restoration.

This makes the development of biomimetic dental materials a challenge.

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Understanding biology f we look at the tooth crown from the perspective of a materials scientist, it is made up of two completely different materials. On the outside is the hardest substance in the body, the crystalline and primarily inorganic tooth enamel, with a bending tensile strength of 80-100 MPa and a flexural modulus of 70 GPa. The robust enamel protects the tooth from mechanical damage caused by chewing. Underneath is the softer and more organic dentine with a lower bending tensile strength of 20-40 MPa and a lower flexural modulus of 15 GPa,1 that enables the tooth crown to compensate for chewing forces by elastic deformation.2 The tooth crown is therefore a successful hybrid of very different material properties which has proven itself over the course of evolution.

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Figure 2. The glass-ceramic veneers on the upper jaw incisors looked lifeless.

Figure 3. The angular characteristics of the restorations were not implemented according to the aesthetic rules.

Figure 4. There was an uneven cutting edge and a lack of harmony with the lower lip.

Figure 5. The preparation could be carried out minimally invasively due to the thin layer of the hybrid ceramic.

Figure 6. A scanned wax-up provided orientation when designing the veneers in the CEREC software.

Figure 7. The virtual construction of the four veneers in the vestibular view.

Figure 9. The progression of the incisal edge and the angular features could be optimised due to the low minimum layer thickness.

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Figure 8. When positioning the veneers in the multichromatic block, the shade and translucency progression could be controlled.

Figure 10. The curve of the dental arch was now also levelled from the vestibular level.

Figure 11. The morphology and surface texture of the hybrid ceramic veneers looked absolutely natural.

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clinical | EXCELLENCE

Figure 12. The provisional cement filling on 36 was gradually removed to provide the defect with a hybrid ceramic inlay.

Figure 13. The defect in the distal box extended far subgingivally, so a gingivectomy had to be performed for the scan.

Figure 14. The cavity after haemostasis and thread placement immediately before the scan.

Figure 15. The virtual cavity with a defined preparation margin.

Figure 16. The constructed inlay made of super-translucent VITA ENAMIC ST.

Figure 17. The constructed inlay was virtually positioned in the block for computer-aided manufacturing.

Hardness versus flexibility he natural properties of the hard tooth substance have long been neglected in material developments. Monolithic restorations made of zirconia with a bending tensile strength of up to 1,200 MPa3 and a high flexural modulus of 257 GPa are becoming increasingly popular with practitioners. Such restorations can be quickly and economically manufactured. They are robust and allow conventional cementing. However, it can be assumed that these restorations do not functionally harmonise with the anatomical structures and physiology of the stomatognathic system, due to their material properties. Clinical studies show that high bending tensile strength does not automatically mean high long-term stability. For example, restorations with a toothlike flexural modulus on implants rigidly embedded in the bone had a higher survival rate than materials with a higher flexural modulus that were more resistant to bending tension.4 The possibility of absorbing chewing forces could therefore prove to be an evolutionary advantage. Due to the possibility of being able to fix ceramic restorations fully adhesively, a lower bending tensile strength loses relevance.5

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Successful sea urchin spine patent ea urchin spines are extremely robust and have been tried and tested for 500 million years. Their spines can withstand great forces and even allow the sea animal to drill into hard rock. The spines primarily consist of a brittle calcite crystal.

In order to prevent the crystal lattice from splintering and increase the resistance to breakage, the inside of the spine is also crossed by gelatinous proteins. Organic material is embedded in the cavities of a dominantly inorganic matrix.6 In attempts to break a sea urchin spine, the first signs of cracking did not show up until over 2,000 N.7 The dual network of a pressureresistant crystal lattice and a tensile organic matrix is able to withstand large forces without damage, something that many careless bathing tourists have painfully felt. This particular principle has been used with success in the construction industry for centuries in the form of reinforced concrete. Steel guarantees tensile strength, while concrete is pressure-resistant, which, in combination, still ensures the desired stability for television towers, bridges and high-rise buildings today.8

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clinical | EXCELLENCE

Figure 18. After grinding and finishing, the occlusal surface of the inlay was etched with hydrofluoric acid.

Figure 19. After thorough removal of the hydrofluoric acid and drying, silanisation followed.

Figure 20. The fissures were characterised with VITA ENAMIC STAINS in brownish and finally sealed with VITA ENAMIC GLAZE.

Figure 21. The final light curing of stains and glaze with the polymerisation lamp.

Figure 22. The super-translucent hybrid ceramic inlay shows an excellent chameleon effect.

Biomimetic hybrid ceramic he basic principle of the sea urchin was also implemented in the development of the VITA ENAMIC hybrid ceramic.

A porous, pre-sintered, inorganic feldspar ceramic block (86% by weight) is infiltrated with an organic polymer (14%) under pressure and heat, creating a dual, interlocking network.9 The feldspar ceramic is pressure-resistant, the polymer guarantees tensile strength. The hybrid material combination was developed in such a balanced manner that the hybrid ceramic corresponds to the “material properties” of the natural tooth structure. With 30 GPa, the flexural modulus of VITA ENAMIC lies between that of enamel and dentin and not at or below the level of dentin, as with all other CAD/CAM hybrid materials.10,11 Excessive material flexibility can lead to a deformation of the material under chewing stress and to a de-cementation. Due to the dominance of feldspar, the abrasion corresponds to that of natural tooth enamel, which ensures a sustainable functional integration of hybrid ceramic restorations.12,13 The dual network also enables thinner layer thicknesses and more precise edge areas than with all-ceramic CAD/CAM materials, which enables a minimally invasive restoration.14 Due to the tensile strength stabilisation with the polymer network, the bending tensile strength is above that of enamel and dentin at 160 MPa.15 In clinical use, microcracks in the ceramic are also stopped at the interfaces with the polymer and do not continue to progress over time.16

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Everything else is composite ll other CAD/CAM materials, which are incorrectly and misleadingly called hybrid ceramics, composite ceramics or nanoceramics, are highly filled composites.17 Ground inorganic fillers are embedded in an organic polymer matrix. No retentive etching pattern with hydrofluoric acid can be performed on these composite materials. In some cases, zirconia fillers are used that cannot be etched at all. The conditioning must therefore be done with a sandblaster.18 When using it, care must be taken to reach all areas. If sandblasting is too strong, there is a risk of damaging the structure or the delicate edge areas. Due to its dominant feldspar ceramic content (75% by volume), the hybrid ceramic VITA ENAMIC can be etched and silanised analogously to feldspar and glass ceramic and also achieves comparable adhesion values with adhesive bonding.19 This safe procedure has been proven, is uncomplicated and can be widely used without any technical effort. The better colour stability compared to composite blocks also results from the dominance of the colouring ceramic component.20 The following shows how two clinical cases can be solved with the super-translucent and multichromatic VITA ENAMIC material variant chairside and without firing.

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clinical | EXCELLENCE Case history 1 with multi-chromatic VITA ENAMIC multiColor (Figures 2-11) young patient was treated with glass-ceramic veneers at the incisors. She was dissatisfied with the aesthetics. The veneers looked dull and lifeless. The progression of the incisal edge did not harmonise with the curve of the lips and was asymmetrical.

The tooth axes were irregular and unsettling to the patient. As a result, the veneers looked shapeless and unnatural. The new restoration was to be carried out with the multichromatic hybrid ceramic VITA ENAMIC multiColor with integrated shade and translucency in six finely nuanced layers. The reduced minimum layer thicknesses of up to 0.2 millimetres made a minimally invasive restoration possible, where the aesthetic rules could be consistently implemented. CAD/CAM, elaboration, polishing and adhesive integration could be realised without firing within five hours. The veneers supported by hard tooth substance were able to fully develop their aesthetic and minimally invasive potential with thin layers.

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Case history 2 with super-translucent VITA ENAMIC ST (Figures 12-22) provisional glass ionomer filling (MOD) was to be replaced with a definitive solution in a 36-year-old female patient.

Due to the class II cavity extending in the vestibulo-oral direction and the strongly extended and subgingivally positioned distal box, the defect was to be treated with the super-translucent hybrid ceramic VITA ENAMIC ST in order to stabilise the tooth for the long term and to be able to design optimal contact areas in the proximal region. After the digital workflow, the inlay was finalised with a fine stone and a rubber polisher. The occlusal surface was then conditioned with hydrofluoric acid gel and silane in order to characterise the fissures with VITA ENAMIC STAINS. After curing with the polymerisation lamp, the occlusal surface was finally sealed with VITA ENAMIC GLAZE (both from VITA Zahnfabrik, Germany) and light-cured. After the CAD/ CAM-supported production without subsequent firing and the fully adhesive integration in one session, the super-translucent restoration showed a pronounced chameleon effect and visually fused with the natural tooth structure.

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A piece of nature in practice and laboratory hanks to its biomimetic properties and reliable, fully adhesive attachment options, the hybrid ceramic VITA ENAMIC, forms a harmonious, functional unit with the remaining tooth substance. The material can be efficiently manufactured in a digital workflow. Time-consuming crystallisation, sintering, healing and individualisation firings are no longer necessary, so that an even more complex restoration is possible in just one session. The integrated shade and translucency progression or the pronounced chameleon effect of the two different material variants simulates the shade and effect of the natural tooth structure, depending on the indication area, which enables functional and aesthetic single tooth restorations, according to the patent of nature.

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About the author Dr. med. dent. Andreas Reiger studied dental medicine in Heidelberg, Germany and is in private practice in oral surgery and dentistry in Talheim. He is a CEREC mentor for the German Association for Computer-supported Dentistry, a freelance CEREC trainer, beta tester for Sirona CEREC SW and materials tester for VITA Zahnfabrik.

References 1. Kern M. Hybrid- und Verbundwerkstoffe mit schmelzähnlichen Eigenschaften.

Fest und doch elastisch [Hybrid and composite substances with tooth enamel-like properties. Firm and yet elastic]. dzw Zahntechnik 2016(3): 6-9.

2. Gordon J. Structures - Why Things Don’t Fall Down. Strain Energy and Modern Fracture Mechanics. New York: Da Capo Press 1978: 70-109.

3. Kern M. Biomechanische Merkmale im Fokus [Biomechanical properties in focus]. ZWL Zahntechnik Wirtschaft Labor 2016(5): 24-30.

4. Magne P, Oderich E, Boff LL, Cardaso AC, Belder UC. Fatigue Resistance and Failure Mode of CAD/CAM Composite Resin Implant Abutments Restored with Type III Composite Resin and Porcelain Veneers. Clin Oral Implants Res 2011; 22(11): 1275-81.

5. Burke FJ, Fleming GJ, Nathanson D, Marquis PM. Are Adhesive Technologies Needed to Support Ceramics? An Assessment of the Current Evidence. J Adhes Dent 2002; 4(1): 7-22.

6. Knippers J, Schmid U, Speck T: Bionik. In: Stuttgarter Beiträge zur Naturkunde, Serie C. Bauprinzipien und Strukturdesign von Seeigeln - Vorbilder für bioinspirierte Konstruktionen [Stuttgart contributions on natural science, Series C. Building principles and structural design of sea urchins - role models for bio-inspired constructions]. 2017 (82): 82-93.

7. Presser V, Kohler C, Živcová Z, Berthold C, Nickel KG, Schultheiß S, Gregorová E, Pabst W. Sea Urchin Spines as a Model-System for Permeable, Light-Weight Ceramics with Graceful Failure Behavior. Part II. Mechanical Behavior of Sea Urchin Spine Inspired Porous Aluminum Oxide Ceramics under Compression.

Journal of Bionic Engineering 2009; 6(4): 357-364.

8. Scheerer S, Proske U. Stahlbeton [reinforced concrete] for Beginners. Grundlagen für die Bemessung und Konstruktion [Basics for dimensioning and construction].

Springer Verlag, Berlin 2008.

9. He LH, Swain M. A Novel Polymer-Infiltrated Ceramic Dental Material. Dent Mater 2011; 27(6): 527-34.

10. Zimmermann M. Perfektion im Umgang mit neuen Materialien [Perfection in handling new materials]. Presentation for the master course of the DGCZ on 18 June 2015 in Munich.

11. Kern M. Biomechanische Merkmale im Fokus [Biomechanical properties in focus]. ZWL Zahntechnik Wirtschaft Labor 2016(5): 24-30.

12. Dirxen C, Blunck U, Preissner S. Clinical Performance of a New Biomimetic Double Network Material. Open Dent J. 2013(7): 118-122.

13. Krejci, I. Wear of CEREC and Other Restorative Materials. In: Proceedings of the International Symposium on Computer Restorations: State of the Art of the CEREC Method. Berlin: Quintessence Verlag 1991, 245-251.

14. Awada A, Nathanson D. Mechanical Properties of Resin-Ceramic CAD/CAM Restorative Materials. J Prosthet Dent 2015; 114(4): 587-93.

15. Internal investigation, VITA R&D, Technical and scientific documentation.

Date of issue: 10/2015.

16. Coldea A, Swain MV, Thiel N. In-Vitro Strength Degradation of Dental Ceramics and Novel PICN Material by Sharp Indentation. J Mech Behav Biomed Mater 2013 Oct; 26(10): 34-42.

17. Spitznagel FA, Horvath SD, Guess PC, Blatz MB. Resin Bond to Indirect Composite and New Ceramic/Polymer Materials: a Review of the Literature. J Esthet Restor Dent 2014; 26(6): 382-393.

18. Conejo, J. Research Report of University of Pennsylvania. School of Dental Medicine, Philadelphia, USA, 02/2016.

19. Tian T. Evaluation of Bonding Durability Between CAD/CAM Ceramics and Resin Cement. IADR 2013, Boston, USA [Test report published as poster abstract].

20. Schürmann MG, C. Olms. Shade Stability of Polymer-Infiltrated and Resin Nano Ceramics. Open Dent J 2018; 18; 12:791-800.

Originally published in DENTALZEITUNG 1/2019, OEMUS MEDIA AG, Germany.

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MINIMALLY INVASIVE? NO PROBLEM!

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Thanks to high resilience, VITA ENAMIC enables fabrication of minimally invasive restorations. Natural tooth structure can be preserved due to reduced wall thickness.

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clinical | EXCELLENCE case report

Delayed implant placement with a thin and defective buccal bone wall

By Dr Daniele Cardaropoli, Torino, Italy Aim: Delayed implant placement to restore tooth 34. Minimally invasive procedure without mobilisation of the flap to cover the graft: healing by secondary intention (open healing).

a

b

Figure 1. Pre-surgery occlusal view.

Figure 2. Raising of a flap was necessary to remove the tooth because of the internal root resorption (34).

Figure 3. Empty alveolus with a thin and defective bone wall.

Figure 4. Geistlich Bio-Gide® Shape a) with the smooth side (outwards) and b) the rough side (inwards).

Figure 5. Geistlich Bio-Gide® Shape in place, applied dry within the alveolus.

Figure 6. After application of the collagen membrane, the alveolus is filled with Geistlich Bio-Oss® Collagen.

Figure 7. Suturing with three single knots each on buccal and lingual site to fix the bone graft and one additional suturing to maintain the papillae.

Figure 8. Clinical situation one week after extraction. Geistlich Bio-Gide® was left exposed and the wound heals uneventfully by secondary intention.

Figure 9. Clinical situation immediately after suture removal 2 weeks after extraction.

Figure 10. Follow-up 4 weeks after tooth extraction.

Figure 11. Ridge preservation provided an optimal ridge width for implant placement without regrafting 5 months post-extraction.

Figure 12. Soft tissue conditioning 9 months after tooth extraction.

Conclusion: Geistlich Bio-Gide® Shape in combination with Geistlich Bio-Oss® Collagen largely preserved the ridge dimensions after tooth extraction. Implant can be placed without need for a second bone grafting at time of implant placement.

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® Geistlich Bio-Gide Geistlich Bio-Gide®

Architect Architect the the Future Future 3 Optimal bone regeneration 3 Optimal bone regeneration 3 Excellent wound healing 3 Excellent wound healing 3 Proven long-term studies 3 Proven long-term studies 3 Predictable results 3 Predictable results

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The The bilayer bilayer matters! matters!

References: References: 1. Becker J et al., Clin Oral Implant Res. 2009, 20(7) :742-749 2.

Perelman-Karmon al.,Implant Int J Periodontics Dent.2013,32(4):459-465 1. Becker J et al., Clin et Oral Res. 2009,Restorative 20(7) :742-749 3.

RE, et al., Clinet Oral Res. 2012Restorative Jun 15. doi: Dent.2013,32(4):459-465 10.1111/J.16000501.2012.02522.x 2. Jung Perelman-Karmon al., Implants Int J Periodontics 4. Jung BuserRE, D. et et al., al., Clin J Periodontol.

2011;82(3):342-349 *NCBI PubMed – 3.

Oral Implants Res. 2012 Jun 15. doi: 10.1111/J.16000501.2012.02522.x Search terms: “Bio-Gide” OR“Bio 4. https://pubmed.ncbi.nlm.nih.gov Buser D. et al., J Periodontol. 2011;82(3):342-349 *NCBI PubMed – Gide” Access date: 03-08-20 https://pubmed.ncbi.nlm.nih.gov Search terms: “Bio-Gide” OR“Bio Gide” Access date: 03-08-20

clinical | EXCELLENCE

Treating the causes of Class III is equally important in the permanent dentition What options exist to simplify the treatment and stability of Class III by addressing the underlying muscular causes in non-growing patients?

By Dr Emad Ahangari, BOH Dent Sc (Griffith), GDipDent (Griffith)

C

lass III malocclusion is viewed by some clinicians as an entirely separate category of malocclusion and perceived to be a difficult problem to correct and retain. Many patients are either subjected to ineffective early treatments or they’re treated invasively later in life with extractions and surgery. This is undoubtedly due to the confusion surrounding the aetiology of Class III, but how true are these perceptions and is there a better way we should be approaching the problem?

The outdated genetic explanation of Class III has progressively been replaced

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by an epigenetic one over the past few years by modern research. Although isolated genes have been associated with Class III malocclusion, researchers have concluded that these genes are activated by various genetic triggers, such as forward positioning of the mandible.1 The impacts of muscle patterns, especially the tongue, on the development of the dentofacial structures is well understood in orthodontics. 2 Studies have shown that Class III patients tend to have a tongue which rests in the lower arch and pushes forward3 and this may be associated with various factors like enlarged tonsils or atypical habits.4 This invariably leads to forward posturing of the man-

dible, underdevelopment of the maxilla and ultimately, the development of Class III malocclusion. Orthodontics generally overlooks these factors, which may explain why Class III treatment has always been difficult and unstable at any age.

It follows from this knowledge that early treatment of these causes is not only crucial in children, but that even in adults, treatment of the underlying muscular causes of Class III will allow treatment to progress more effectively and promote better stability. To date, however, solutions for correction of the underlying breathing and muscular causes of all malocclusions, including Class III, have been very hard to come by.

March/April 2021

MOST CHILDREN HAVE NO CARIES BUT ALMOST ALL HAVE A DEVELOPING MALOCCLUSION Early evaluation and diagnosis of the underlying causes of malocclusion in childhood have benefits that go beyond just straightening teeth.

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clinical | EXCELLENCE The Myobrace for Interceptive Class III (i-3) appliance range was created by Myofunctional Research Co. (MRC) to provide practitioners with a solution for growing children with developing Class III. Like all Myobrace appliances, the i-3 series works on correction of poor muscle position and behaviour while encouraging nasal breathing, but also contains unique features to manage the phenotype of Class III malocclusion. The system has stood the test of time, demonstrating its effectiveness in correcting and promoting stability in Class III patients accross the world.

As practitioners continued to use this system and see its power in intercepting Class III malocclusion, they began to see the value of adopting the same approach in their adult patients who had these underlying factors ignored. Driven by this demand, MRC has now released the Myobrace for Permanent Class III (P-3) series.

The P-3 series is a three stage appliance system, specifically designed for treatment of Class III in the permanent dentition and has the same breathing and myofunctional features of the interceptive series.

This includes the tongue tag and tongue elevators to lift the tongue into the correct position in the roof of the mouth, while having a double arch design to promote nasal breathing. Unique to the P-3 series is that each appliance has a 3mm sagittal anterior offset which puts extra force on the permanent anterior teeth to provide dental compensation for Class III malocclusion.

This effectively treats the underlying causes, while correcting the dental Class III pattern.

The P-3 series has three appliances which represent the three stages of treatment required to correct patients with a Class III pattern in the permanent dentition. The first stage or P-3N appliance is soft and flexible, giving it the ability to

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adapt to any archform or malocclusion and focuses on initial improvement of breathing and muscle function.

The second stage or P-3 appliance incorporates MRC’s revolutionary Dynamicore™ which is a hard inner frame surrounded by soft silicone, providing arch development while retaining comfort.

Finally, the P-3H is the firmest material which makes it ideal for final dental alignment and retention of the archform, as well as the correction to Class I. Although treatment in the permanent dentition for Class III is not as desirable as preventative early treatment with the interceptive i-3 series, the P-3 appliances allow clinicians to provide treatment for patients who missed the opportunity for early treatment or were treated with mechanics alone and had the underlying causes ignored.

For more information on this topic, please visit the Myofunctional Research Co website at www.myoresearch.com and check out the Appliances or Online Courses page today!

References 1. Xue et al. Genes, genetics, and Class III malocclusion. Orthod Craniofac Res 2010;13:69–74.

2. Proffit. Contempory Orthodontics 6th Ed. Section II. Chapter 5.

3. Primozic et al. The association of tongue posture with the dentoalveolar maxillary and mandibular morphology in Class III malocclusion: a controlled study.

Eur J Orthod. 2013 Jun;35(3):388-93.

4. Iwasaki et al. Relationships among nasal resistance, adenoids, tonsils, and tongue posture and maxillofacial form in Class II and Class III children.

American J Orthod Dentofacial Orthop. 2017 May;151(5):929-940.

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clinical | EXCELLENCE

Implant placement with simultaneous EthOss grafting

By Dr Peter Fairbairn

A

female patient, 77 years of age, presented for treatment. The patient was on HRT, a non-smoker and non-diabetic. A draining abscess was present in the 36 region and was sent to the Endodontist for evaluation who verified the tooth could not be saved.

Routine protocol (published in 2015) by the author was utilized. This involves a 3-4 week healing period following extraction followed by simultaneous implant placement and graft with EthOss®, a synthetic graft particulate.

At 4 weeks post-extraction, soft tissue healing allowed a flap to be raised and the site was degranulated extensively using curettes and EthOss degranulation burs.

There was extensive bone loss due to the infected nature of the extracted tooth, particularly on the distal root surface of the premolar. One of the key benefits of the 4 week healing period using this Protocol is that it not only allows for soft tissue closure but also allows the host macrophages to help clean the site prior to implant and graft placement.

Figure 1. Initial situation: A draining absess in tooth 36.

Figure 2. Flap raised 4 weeks following extraction to allow for soft tissue healing.

Figure 3. Site cleaned with EthOss Degranulation Bur, removing all soft tissue.

Figure 4. X-ray prior to simultaneous implant placement and grafting. Note 3-4mm to the IAN, however key factor here is angle of the mandible.

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clinical | EXCELLENCE

Figure 5. Implant placement - drifted slightly distal.

Figure 6. Implant placement.

Figure 7. Root socket grafted with EthOss.

Figure 8. Additional grafting. Material dried with sterile gauze for 5 minutes before flap repositioned and sutured closed.

Figure 9. X-ray at placement - approximately 2.5mm to IAN and 1.5mm to angle of mandible so very low primary stability.

Figure 10. Uncovered at 12 weeks and healing cap fitted. Image shows 2 weeks later, patient returned for final restoration.

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Figure 11. Final crown, screw-retained.

Figure 12. Implant loaded, Bluem oxygenated healing gel to improve soft tissue.

Figure 13. Implant loaded.

Figure 14. X-ray at 2 years; graft will have turned over to new host bone.

The implant, a Paltop 4.2 x 8.5mm, was then placed into the bifurcation. The root sockets and mesial defect were grafted with EthOss and the material was encouraged to set by holding a dry, sterile gauze over the graft for 4 minutes. A collagen membrane was not used in this case. The built-in Calcium Sulphate cell occlusive binder within EthOss removes the need for a separate membrane.

The flap was repositioned with primary closure and the site was left to heal for 12 weeks. A healing cap was then fitted by making an incision in the soft tissue and opening the site. The case was loaded one week later with an Osstell stability reading of 76 ISQ.

Due to the age of the patient and the reduced upper dentition, it was decided to only have 1 molar and not place another implant.

Both patient and clinician are pleased with the outcome.

Conclusion s the graft will turn over fully to host bone, the two year follow up shows a nice stable site and healthy hard and soft tissue along with restoration of the hard tissue distal to the premolar.

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About the author Peter is visiting Professor at the University of Detroit Mercy School of Dentistry (USA) and Director of Education of the Association of Dental Implantology (UK) as well as past president of the London Dental Fellowship. He has placed Dental Implants since 1991 at the Scarsdale Dental Clinic in West London and has performed over 5,500 successful graft procedures with synthetic materials. He has written numerous published articles, Pubmed studies (both clinical and animal) as well as chapters in two published books. He has lectured in over 30 countries globally in the last 10 years.

March/April 2021

T h e b u i l t- i n ca l ci u m s u l p h a te b i n d e r i n Et h O s s b o n e g r a f t m a te r i a l h e l p s s ta b i l i s e g r a f t s a n d p r eve nt s of t t i s s u e i n g r e s s , e l i m i n a t i n g t h e n e e d fo r a t r a d i t i o n a l co l l a g e n m e m b r a n e.

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clinical | EXCELLENCE

Case report on maxillary compromised dentition treated with Straumann® Pro Arch and Digital Workflow

By Tran Thanh Phong, DDS

Figure 1.

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Figure 2.

his case describes how a full arch rehabilitation with computerised digital planning (coDiagnostiX) and Straumann Guided Surgery, treated with immediate implant placement and immediate screw-retained CAD/CAM provisionalisation led to an outstanding treatment outcome.

Successful immediate implant placement associated with immediate loading remains one of the biggest clinical challenges. In addition to the placement of an implant immediately into the socket, the creation of an immediate screw-retained CAD/CAM provisional restoration is critical for an optimal aesthetic outcome. When using a conventional approach, the procedures require an extensive number of patient appointments and chair-time for the dentist and the patient. Fortunately, nowadays digital workflows can be implemented in our practice and with this, our treatments could be considerably shortened.

In the following case report, a digital workflow allowed us to have an efficient and predictable treatment protocol for the immediate implant placement and the prosthetic restoration design, including the individual emergence profiles prior to the surgery. This also led to an excellent patient experience and satisfaction. The goal of this clinical report is, therefore, to introduce an innovative one-step surgical approach for immediate screw-retained CAD/CAM provisionalisation by using the latest technological improvements in prosthetic and surgical planning software and seamlessly integrating the dental technician into the development of the digital treatment planning and new prosthetics options.

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Figure 14.

Figure 15.

Figure 16.

Figure 17.

Figure 18.

Figure 19.

Initial Situation 51-year-old male patient, smoker (<10 cigarettes per day), with a good general health condition; presented in the clinic with missing molars in quadrants 2 and 4, class 3 mobility on teeth 24 and 17 and decayed roots and gum inflammation, without abscess nor sinusitis on 16.

A

The anterior zone showed different levels of recession, bone resorption and deep periodontal pockets on tooth 12 and 22 which led the patient to complain about an aesthetically unsatisfying restoration (Figures 1-2).

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Treatment planning ollowing the clinical and radiographic assessments, the patient was introduced to two different treatment options.

The first one included the maintenance of the canines by treating their recession and bone resorption which has exposed more than half of the roots, implant placement on the incisors region with soft tissue grafting and extractions of the remaining posterior teeth and implant treatment after GBR and sinus lifting. Moreover, in this option, the final restoration carried an implant - supported bridge on the region of 14-16, 12-22, 24-26 and crowns on 13 and 23 after three months.

F

Figure 20.

The second option consisted of an extraction of all the remining teeth of the maxilla and restoration of the full arch with the Pro Arch concept. This consisted of the placement of four Straumann BLX implants immediately after extraction in the region of teeth 15, 12, 22 and 25 with a fully digitalised approach, using guided surgery and a preoperative prosthetic screw-retained CAD/CAM restoration right after surgery and a final restoration placed 6 to 12 months later.

The total treatment time for the first option was estimated at 1 year and 8 months, resulting in a higher number of visits, longer chair-time and higher costs in comparison to the second option.

March/April 2021

clinical | EXCELLENCE

Figure 21.

Figure 22.

Figure 23.

Figure 24.

Figure 25.

Figure 26.

Figure 27.

Figure 28.

Figure 29.

The reliable and short treatment protocol and unavailability of our patient to visit the clinic for a considerably long period of time, made the patient choose the second option.

Note: The patient will receive an holistic treatment approach for the lower dentition. However, the current COVID-19 situation forced treatment to be delayed.

radiographic DICOM data and the prosthetic design project STL file were matched in coDiagnostiX ™(Figures 7-9). The pin fixation guide, bone reduction guide, surgical guide and bite registration guide were all designed with coDiagnostiX™ (Figures 10-13) and produced using 3D printing technology.

ment selected from Straumann library (Figure 15). The implant placement guide was on the model leveraging the high stability that we could gain from palatal support (Figure 16-17). After printing the model, the BLX implant analogues were positioned using the template for navigation. The digital planning using coDiagnostiX (Version 9.14) allowed the dental technician to identify all the necessary parameters related to implant position (Figures 18-22). Emergence profiles were set-up on the model (Figure 23). The model was scanned using the scan bodies and a CAD/CAM temporary restoration was designed and milled (PMMA-based restoration material) (Figures 24-29).

Implant placement planning he STL file was taken to record the patient’s current oral situation and DSD file, the future prosthetic design was created with software for the lab (Figures 3-6). The three-dimensional

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Prosthetic design planning o design the prosthetic digitally, we firstly selected the screw-retained abutment (SRA) angle and gingival height (Figure 14). We then created the patient model on which we could connect the Straumann BLX Implant with SRA abut-

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Figure 30a.

Figure 30b.

Figure 31.

Figure 32.

Figure 33.

Figure 34.

Figure 35.

Figure 36.

Figure 37.

Figure 38.

Figure 39.

guide (Figures 31-36). Four implants (Straumann® BLX ø 4.5 mm RB SLActive® 12mm Roxolid®) were placed, two straights in the anterior zone and two titled implants in the posterior zone. All implants were stabilised with a torque of 50 N/cm (Figures 37-43) and the SRAs were placed on top, with an angulation of 30º on the posterior implants (angled 30°, ø 4.6 mm, GH 3,5) and 17º on the anterior implant (angled 17°, ø 4.6 mm, GH 3,5) (Figures 44-45). The bite registration guide was

fixed with pins and the open tray impression copings wre placed on the SRAs of the anterior implants, which were fixed with the guide using flowable composite and then sent to the lab (Figures 46-50). Afterwards, we checked the temporary CAD/ CAM bridge which was designed before surgery (Figure 51) and finally, protective caps were placed on the SRAs followed by bone grafting using Cerabone® Granulate with a 1-2mm grain size, on the extraction socket and suture (Figures 52- 54).

Guided surgery n the day of surgery, we prepared the surgical protocol provided by the implant planning software, which guided us on the drilling sequence and the use of the appropriate instruments for the implant bed preparation (Figures 30ab). After the fixation pins were allocated, the teeth 17, 16, 15, 13, 12, 22, 23 and 24 were atraumatic extracted and followed by alveolectomy, using a bone reduction

O

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clinical | EXCELLENCE

Figure 40.

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Figure 48.

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Figure 51.

Figure 52.

Figure 53.

Figure 54.

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“Immediate implant placement associated with immediate loading is a predictable protocol with some variables...”

Figure 55.

Figure 56.

Figure 57.

Figure 58.

Impression taking for temporary Zirconia bridge ue to circumstances, the patient was not able to visit the clinic periodically for follow-ups, therefore we decided to use an immediate PMMA bridge for a short time and design an immediate temporary bridge on zirconia material to optimise the condition and patient experience while he was not able to visit our clinic.

For the impressions, we used open tray impression copings (Figure 55) and together with the bite registration were transferred to the lab (Figure 56-57).

The PMMA bridge was screwed on the SRAs and the DSD file was taken (Figure 58).

D

Figure 59.

Figure 60.

Figure 61.

Figure 62.

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March/April 2021

EDENTULOUS PATIENTS EDENTULOUS PATIENTS

Straumann® Pro Arch

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High mechanical and primary stability STABILITY according to need.

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Contact your local Straumann Group Specialist now or visit www.straumann.com.au.

Contact your local Straumann Group Specialist now or visit www.straumann.com.au.

Straumann Group Pty Ltd 7 Gateway Court Port Melbourne VIC 3207 Toll Free AU 1800 660 330 | NZ 0800 408 370 Straumann Group Pty Ltd customerservice.au@straumann.com 7www.straumann.com.au Gateway Court Port Melbourne VIC 3207

clinical | EXCELLENCE

Figure 63.

Figure 64.

Figure 65.

Figure 66.

Lab procedures for temporary Zirconia bridge fter creating the master cast, we were able to scan and design the zirconia prosthesis (Figures 59-62).

The design of the zirconia frame was done by obtaining the information from the bite registration, the image of the temporary prosthetic design (Figure 6) and the mock copied by DSD with temporary PMMA bridge (Figure 58); at this moment we could apply a few modification to the zirconia frame.

The design of the temporary zirconia bridge that was created was sent to the milling unit and produced on a full contour zirconia disc.

The zirconia frame was then cemented on a Straumann Variobase coping as an interface to be screwed on SRA abutment (Figures 63-64).

A

126 Australasian Dental Practice

Five days follow up fter five days, the patient returned to the clinic, the fixed PMMA temporary bridge was removed and the temporary CAD/CAM zirconia bridge was placed allowing a passive fit on the abutments, with an initial hand tightening of each SRA screw up to 5 Ncm. After the seating was checked, the torque of each SRA screw was increased up to 35 Ncm and the bridge was screwed in at a torque of 15 Ncm. Occlusion was checked and contacts were inspected. Screw holes were sealed with PTFE and a temporary filling material (Figure 65). A panoramic X-ray was recorded and SRA screw positions were evaluated to confirm the perfect temporary bridge fit (Figure 66). Oral hygiene and diet instructions were given to the patient and a one-week follow-up appointment was scheduled.

A

Treatment outcomes mmediate implant placement associated with immediate loading is a predictable protocol with some variables. The digital tooth extraction was integrated with the production of a screw-retained CAD/ CAM provisional restoration prior to the surgery and was successfully achieved.

The entire treatment workflow was done fully digitally. Only a single surgical step was required to provide an entire individualised prosthetic rehabilitation.

I

About the author Dr Phong is an oral surgeon in private practice in Saigon, Vietnam. He is an ITI Speaker for the master clinician program in implant dentistry and an expert in digital implant dentistry and merging CAD/ CAM processes with digital workflows.

March/April 2021

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Straumann Group Pty Ltd 7 Gateway Court, Port Melbourne VIC 3207, Australia AU Toll Free 1800 660 330 | NZ Toll Free 0800 408 370 customerservice.au@straumann.com www.straumann.com.au

Digital Solutions

clinical | EXCELLENCE

Clinical use of Biodentine pulpotomies in anterior and posterior primary teeth

By Jarod W. Johnson, DDS

V

ital pulp therapy plays a key role in treatment of the primary dentition.

The American Academy of Pediatric Dentistry has established guidelines for vital pulp therapy.1 Pulpal therapy, specifically pulpotomies, can maintain a primary tooth and avoid potential problems such as pain, swelling, infection and premature tooth loss which can lead to the need for space maintenance, or in some cases more expensive dental procedures such as orthodontics.2 For years, formocresol has been considered the gold standard for pulpotomies in primary teeth.

Although highly successful, formocresol has long been known to possess carcinogenic and cytotoxic properties.3 Recently, consumers and practitioners have expressed concerns about the safety of dental materials used in children. Other traditional pulpotomy materials such as calcium hydroxide and ferric sulfate have left practitioners with more to be desired as they consistently have been shown

128 Australasian Dental Practice

to have inferior success rates when compared with formocresol.1 Developments made in the field of bioceramics, led by mineral trioxide aggregate (MTA), have generated new excitement around vital pulp therapy in primary teeth.

The most recent guidelines from the American Academy of Pediatric Dentistry on vital pulp therapy puts bioceramics such as MTA on the same tier of efficacy as formocresol. This development provides practitioners with sound evidence to make the switch to utilising bioceramics for pulpotomy treatment in the primary dentition.1 While MTA has demonstrated a highly successful clinical outcomes, it has multiple disadvantages. MTA stains when in contact with sodium hypochlorite which presents a cosmetic challenge for dentists, especially when treating teeth in the anterior region.4 The two to four hour setting time can make it difficult to treat teeth in a single visit and it has been known for its high cost and difficult handling properties.5 Newer products have been developed to help alleviate some of these concerns.

March/April 2021

clinical | EXCELLENCE

Figure 1. Local anaesthesia.

Figure 2. Rubber dam isolation.

Figure 3. Caries removal.

Figure 4. Pulpotomy to the level of the CEJ.

Figure 5. Disinfection using 6% NaOCl.

Figure 6. Biodentine placement.

Figure 7. Glass ionomer or IRM Base (Optional, not necessary if Biodentine is used as a base).

Figure 8. Allow Biodentine or Glass ionomer/IRM Base to set.

Figure 9. Prepare for final restoration.

Technique: Anterior pulpotomy (Figures 1-10) tudies show that pulpotomies have similar success rates as pulpectomies on vital anterior teeth.

Teeth #E and #F presented with deep carious lesions and inadequate remaining dentine thickness for indirect pulp therapy. The teeth were anaesthetised with local infiltration with 4% Articaine HCL with 1:100k epinephrine (Septodont).

Rubber dam isolation was obtained and caries removal was completed resulting in vital carious exposures on teeth #E and #F. The pulp was amputated to the level of the CEJ and disinfected with 6% NaOCl (Vista Dental). Biodentine was used the pulpotomy medicament and core buildup material. The teeth were restored with resin veneered stainless steel crowns (Kinder Krowns).

S

Figure 10. Final restoration.

Biodentine iodentine ™ (Septodont) has demonstrated a strong track record of clinical success. Biodentine is a calcium silicate material that contains tricalcium and dicalcium silicates, aluminum oxide and calcium chloride. It has demonstrated

B

March/April 2021

a wide variety of uses in both the primary and permanent dentitions. It can be used for indirect and direct pulp therapy, pulpotomies (full and partial), apical barriers (apexification), perforation repairs and obturation.6

Australasian Dental Practice

129

clinical | EXCELLENCE

Figure 11. Local anaesthesia.

Figure 12. Rubber dam isolation, caries removal.

Figure 13. Pulpotomy to the level of the CEJ.

Figure 14. Disinfection 6% NaOCl.

Figure 15. Biodentine placement.

Figure 16. Biodentine placement.

Figure 17. Preparation for stainless steel crown.

Figure 18. Final restoration.

Technique: Posterior pulpotomy (Figures 11-18) Handling properties ioceramics come in many different forms of mixing and delivery. Traditional MTA comes in a powder and liquid form and requires hand mixing. The powder to liquid ratio can impact the handling of the material and be frustrating for providers. Too much or too little water and the material will be difficult to place in the tooth.

One of the easiest bioceramics to handle, Biodentine is mixed with water and titrated into putty that handles like intermediate restorative material (IRM).6

B

Setting time raditional MTA has a long setting time, it takes approximately two to four hours to reach its final set. Newer bioceramics have a shorter set time, which is advantageous when providers are attempting to restore teeth at the same visit that pulp therapy is performed. Biodentine sets in 9-12 minutes, making single visit procedures predictable.6

T

130 Australasian Dental Practice

linical trials and the most recent systematic reviews show that Biodentine consistently performs at the same level clinically and radiographically as MTA. A 5-year-old presented with severe early childhood caries. The patient was referred from a general dentist due to the extent of decay present upon initial evaluation. The patient was asymptomatic at the time of presentation. Of note, the patient presented with carious lesion on tooth #S and #T. Radiographic examination showed no signs of furcal or apical pathosis; however, tooth #S had inadequate remaining dentine thickness. Both teeth were diagnosed with reversible pulpitis and normal apical tissues. Due to the extent of dental needs and cooperation of the patient, general anaesthesia was used as a behaviour management plan. Teeth #S and #T were anaesthetised with 4% Articaine HCL with 1:100k epinephrine (Septodont) and isolated with a rubber dam. Caries removal was completed, tooth #S resulted in a carious exposure. A pulpotomy was performed with 6% NaOCl (Vista Dental) and Biodentine (Septodont). In this case, the entire chamber was filled with Biodentine to act as a base. Both teeth were restored with stainless steel crowns (Hu-Friedy).

C

March/April 2021

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All implant diameters from 3.0 to 5.8 can be placed with the same instrument features, results.

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Call Kim Kim Bell Bell on on 021 021 712 712 758 758 for for further further information information Call Call Kim Bell on 021 712 758 for further information Call Kim Bell on 021 712 758 for further information Call Kim Bell on 021 712 758 for further information or visit BioHorizons online at www.biohorizons.com Call Kim Bell on 021 712 758 for further information or visit BioHorizons online at www.biohorizons.com or visit BioHorizons online atfor www.biohorizons.com Call Kim Bell on 021 712 758 further information or visit BioHorizons online at www.biohorizons.com Call Kim Bell on 021 712 758 for further information or visit BioHorizons online at www.biohorizons.com Call Kim Bell on 021 712 758 for further information or*Tapered visit BioHorizons online at www.biohorizons.com Plus, Tapered Tissue Level, Tapered Internal *Tapered Plus, Tapered Tissue Level, Tapered Internal and and Tapered Tapered 3.0 3.0 *Tapered Plus, Tapered Tissue Level, Tapered Internal and Tapered or visit BioHorizons online at www.biohorizons.com *Tapered Plus, Tapered Tapered Tissue Level, Level, Tapered Tapered Internal and Tapered Tapered 3.0 3.0 3.0 or visit BioHorizons online at www.biohorizons.com *Tapered Plus, Tissue Internal and or visit at www.biohorizons.com Call KimBioHorizons Bell on 021 online 712 758 for further information *Tapered Plus, Tapered Level, Tapered Internal for and Tapered 3.0 information Call Bell on 712 further Call Kim Kim BellTissue on 021 021 712758 758 for further information *Tapered *Tapered Plus, Plus, Tapered Tapered Tissue Tissue Level, Level, Tapered Tapered Internal Internal and and Tapered Tapered 3.0 3.0 *Tapered Plus, Tapered Tissue Level, Tapered Internal and Tapered 3.0 or visit BioHorizons online at www.biohorizons.com or visit BioHorizons online at www.biohorizons.com

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clinical | EXCELLENCE

Figure 19. Pre-op.

Figure 20. Recall: One year recall of Biodentine pulpotomies on (A) (J) (K) and (T) showing no signs of furcal or apical pathology.

Discolouration taining of bioceramic products is due to the use of bisthmuth oxide and sodium hypochlorite. When the two materials are used, a grey discolouration appears within the tooth structure. Bisthmuth oxide is used to add radiopacity to the traditional calcium silicates. Biodentine contains aluminum oxide to make the material radiopaque on radiographs and will not cause staining when in contact with sodium hypochlorite.4

S

Post-operative evaluation of pulpotomies ulpotomies should be evaluated clinically and radiographically six months after placement. Successful pulpotomies should be free of resorption, furcal or apical pathology radiographically. Clinically the patient should be asymptomatic and be free of signs of infection (sinus tract or abscess). After the initial re-evaluation they should be evaluated clinically at recalls and radiographically annually.7

P

Report of a clinical case (Figures 19-20) 6-year-old male presented for consultation after being referred from a general dentist. The patient had moderate discomfort to sweets in the mandibular right quadrant. A comprehensive oral

A

132 Australasian Dental Practice

evaluation was performed, and it was determined that the patient had multiple carious lesions. Periapical radiographs show decay on multiple teeth, and no furcal pathosis was apparent. Due to the extent of the decay on teeth #S, and #L they were deemed to be non-restorable.

Treatment he patient was treated in an outpatient setting under general anaesthesia due to the extent of dental needs and patient cooperation. The teeth were anaesthetised with local infiltration with 4% Articaine HCL with 1:100k epinephrine (Septodont) Teeth #L and #S were extracted, #J, #K and #T were treated with pulpotomies using 6% NaOCl (Vista Dental) and Biodentine (Septodont) and the teeth were restored with stainless steel crowns (HuFriedy). The patient returned for regular recall examination five months later.

Teeth #J, #K and #T remain aysymptomatic, free of swelling or sinus tract, and show no signs of apical or furcal pathosis.

T

Conclusion he advantages of bioceramics in vital pulp therapy are clear. Unlike formocresol, which causes pulpal necrosis and fixates the coronal portion of the apical pulp, bioceramics can help maintain a vital radicular pulp throughout the radicular root system.8,9

T

About the Author Dr Jarod Johnson has a private practice in Muscatine, Iowa. He has received advanced training in behaviour management, sedation, hospital dentistry, trauma, special health care needs, interceptive orthodontics, space maintenance, oral hygiene and dietary counseling. His energetic personality allows him to relate to kids on an individual level.

References 1. American Academy of Pediatric Dentistry. Use of Vital Pulp Therapies in Primary Teeth with Deep Caries Lesions. Pediatric Dentistry. 2017;39(5):E146-E159.

2. Casamassimo P, Fields H, McTigue D, Nowak A. Pediatric Dentistry: Infancy through Adolescense. 5th ed. St. Lous: Elsevier; 2013.

3. Lewis B. The obsolescense of formocresol. J Calif Dent Assoc. Feb 2010;38(2):102-7.

4. Camilleri J. Staining Potential of Neo MTA Plus, MTA, Plus, and Biodentine Used for Pulpotomy Procedures. J Endod. 2005;31(2):97-100.

5. Prati C, Gandolfi M. Calcium Silicate bioactive cements: Biological perspective and clinical applications. Dental Mater. April 2015;31(4):351-70.

6. Biodentine Active Biosilicate Technology IFU. Septodont USA. https://www.septodontusa.com/ sites/default/files/Biodentine%20IFU.pdf. Accessed December 16, 2019.

7. Hargreaves K, Cohen S. Cohen’s Pathways of the Pulp. 10 ed. St Lous: Mosby Elsevier; 2011.

8. Doyle W. A comparison of the formocresol pulpotomy technique with the calcium hydroxide pulpotomy technique. Bloomington: Uni of Indiana; 1961.

9. Stringhini MTA and Biodentine for primary teeth pulpotomy: a systematic review and metaanalysis of clinical trials. Clin Oral Investig. April 2019;23(4):1967-1976.

March/April 2021

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up to 85%** irreversible pulpitis cases: ™ of brings one-of-a-kind benefi ts for and the treatment of Biodentine brings one-of-a-kind benefi ts for the treatment of Biodentine makes your procedure better, easier faster: ™ ™ helps Biodentine up to 85%** of irreversible pulpitis cases: • Vital Pulp Therapy allowing complete dentin bridge formation OVE OUR anatomy STAINLESS STEEL PEDO CROWNS: occlusal that the tooth pulpitis benefi brings one-of-a-kind of remineralization of dentin, preserves the pulp Biodentine up tomatches 85%** of natural irreversible cases:ts for the treatmentthe •upPulp healing promotion: proven biocompatibility and bioactivity vitality and promotes pulp healing. It replaces dentin with similar to Therapy 85%** ofallowing irreversible pulpitis cases:bridge • Vital width complete dentin formation •Pulp Minimally Invasive treatment preserving the tooth structure Vital Pulp risk Therapy allowing complete bridge formation t and mesio-distal •• Reduced of failure: strong sealing dentin properties biological and mechanical properties.

Vital Pulp Therapy allowing complete dentin bridge formation • Minimally Invasive treatment the tooth structure Immediate Pain relief your patients’ comfort d and pre-crimped simple placement Minimally Invasive treatment preserving thepulp tooth ••forOnly one material to fifor llpreserving the cavity from the to structure the top ™ cclusal anatomy that matches the natural tooth Improving on Biodentine Minimally Invasive treatment preserving the tooth structure • Immediate Pain relief for your patients’ comfort Bio-Bulk fi lling procedure for an easier protocole •• Similar mechanical behavior as natural dentin: ideal for bulk fillingclinical implementation, you can now bond Immediate Pain relief for your patients’ comfort ™ the composite onto Biodentine in the same visit and perform the • Painprocedure relief patients’ comfort • Bio-Bulk llingenamel procedure forfor anyour easier protocole • Immediate Bio-Bulk filling for The fifinal restoration willan beeasier placedprotocole within 6 months. full restoration in a single session.

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Please visit our website for more information Call 0508 486 252 Please visit our website more information www.septodont.com Please visit our website for morefor information Please visit our website for more information 855 www.henryschein.co.nz Orders 1300 65 88 22 www.henryschein.com.au www.ivoclarvivadent.co.nz www.septodont.com www.septodont.com *If haemostasis be achieved full pulpotomy, a pulpectomy and a RCT should be carried out, provided the tooth is restorable (ESE Position Paper,Duncan et al. 2017) Please visitwithcannot our website forafter more information Learn more www.septodont.com

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www.septodont.com

Orders 1300 65 88 22 www.henryschein.com.au

*If haemostasis cannot be cannot achieved full pulpotomy, a pulpectomy and a RCTand should be carried out,carried provided tooth isthe restorable (ESE Position Paper,Duncan et al. 2017)et al. 2017) *If haemostasis beafter achieved after full pulpotomy, a pulpectomy a RCT should be out,the provided tooth is restorable (ESE Position Paper,Duncan ** Taha et al., 2018et al., 2018 ** Taha

surgery | DESIGN

The Endodontic Practice is born

D

r Gaurav Vasudeva’s decision to be a dentist was not a sudden one.

Growing up surrounded by family members working in various areas of health care, Gaurav’s interest in dentistry developed gradually. He wanted to be in a profession where he could contribute to society and the community.

Drawing influence from the dental care and treatment he experienced and his natural affinity for the technical and challenging aspects inherent in the field, Gaurav began his studies and initially qualified as a dentist in year 2000, before completing his post-graduate specialist training in specialist endodontics in 2005.

134 Australasian Dental Practice

Further to that, he completed a diplomate membership with Royal College of Surgeons Edinburgh by examination in the specialist field of Endodontics.

Approaching his 20th year in dentistry, Gaurav decided that the time was right to establish his own specialist endodontic practice and began searching for a company to help him realise his vision.

“Having worked in private, public and university hospitals over two decades, I realised the kind of specialist practice I wanted to have,” he said. “This was not only for my personal satisfaction and maintaining high standards of care but also for my patients, who could depend on me and trust my standard of care in a comfortable environment”.

In 2020, Gaurav contacted Medifit, having seen the company’s website and hearing positive anecdotes from his contemporaries. From the first meeting with Medift’s Sam Koranis, Gaurav knew he was in good hands.

“Sam Koranis [Medifit’s Managing Director] went out of his way to help me find and secure a property with no monetary benefits to him or the company.

I really appreciated that commitment.”

Sam said “Finding the right property, in the right location and at the right price point is crucial to the path for success of a new practice. My experience as an accountant gives me the ability to help mentor clients on cashflow strategies including the relative merits of purchasing

March/April 2021

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Australasian Dental Practice

135

or leasing and/or structuring their fitout costs for tax effectiveness. After viewing many properties with Gaurav, it became apparent the site in Applecross was the right solution.”

“I wanted a reputable company with considerable experience in dental design, especially one who had previously worked with a specialist with high demands in terms of IT cabling and microscope planning,” Gaurav said. “Medifit had great experience managing such projects and they delivered a quality job in a very short time.

136 Australasian Dental Practice

“Root canal treatment generally carries an unpleasant reputation amongst the public as it’s considered somewhat painful, even though it is undertaken to not only retain your existing teeth but to relieve pain. Keeping this in mind, I wanted a practice that doesn’t particularly resemble an intimidating clinical or hospital environment. It needed to have a relaxed and comfortable reception with a friendly and welcoming feel.”

Drawing on his experience, Gaurav had a clear idea of how he wanted his new practice to function.

March/April 2021

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Summary The Practice The Practice

The Endodontic Practice

Principals

Dr Gaurav Vasudeva

Type of Practice

Specialist Endodontic

Location

Applecross, Perth, Western Australia

Size

85 square metres

No of chairs

2

The Team Design

Medifit Design & Construct

Construction

Medifit Design & Construct

Equipment

“I wanted a very ergonomic setting both for patients and staff including the clinicians. The everyday workflow had to be smooth without interference in terms of the environment and repetitive movements should be unrestrictive. Everything must flow and needs to be where it is supposed to be with a minimalistic feel and no clutter.”

With this in mind, the Medifit design team set about coming up with a design solution that provided the optimal patient flow

138 Australasian Dental Practice

Dental Units

Morita Soaric

Autoclaves

Mocom B Futura

X-ray

Kavo Focus with CS Dental RVG Sensor

CBCT

Morita X800

Compressor

Dürr Duo

Suction

Dürr VS600

Software

TDO for Endodontics

to maximise productivity. A comfortable waiting area leads to a small corridor with two surgeries, a consult/OPG room and centrally-located sterilisation. Both surgeries have two points of entry/egress allowing for efficient movement between treatment spaces and their adjacent consult rooms. Texturally, light walls and wood make the space feel larger than its 85 square metres.

The overall effect is one of understated elegance, a blend of absolute professionalism with a familiar and approachable feel.

So, is Gaurav happy with the new practice?

“Medifit worked very well with me to incorporate all aspects without too much demolition of the existing property. Only a few internal walls needed to be partially removed and that helped keep the budget in check.

“They delivered exactly what I wanted. The look of the practice is actually better that what I had imagined. Everything has its place, hence the workflow is great considering the property was already subdivided with brick walls, being an old family home from the 1950s. They listened and delivered exactly to my brief in terms of design and the final product and they stuck to my budget. In addition, all work was done in a record time of 7 weeks with handover made 2 days before Christmas.

“Well done Medifit and thank you!”

Sam Koranis added “It’s a pleasure to meet clients who have a clear idea of what they require and we thank Gaurav for the opportunity to help him realise his practice vision. Working collaboratively with Gaurav, we have achieved a fantastic solution for his needs and I am sure the practice will be a great success.”

March/April 2021

first practice?

Since 2002, Australian Dentists and Dental Specialists have trusted Medifit to create state of the art practices with individual interior designs that boost productivity and enhance levels of care.

Whether it’s your first practice or your latest, we’ll help you create a dental practice that reflects your personal style and complements the way you work - and we do it with a friendly, no fuss approach using proven best practices.

Contact Medifit today for a no obligation consultation and experience our award winning service.

• SITE ASSESSMENTS • LEASE NEGOTIATION • FEASIBILITY STUDIES • COUNCIL SUBMISSIONS • ARCHITECTURAL DESIGN

• INTERIOR DESIGN • BUILDING CONSTRUCTION • PRACTICE FIT-OUTS • RENOVATIONS / REFRESHES • BRANDING & MARKETING

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1300 728 133 www.medifit.com.au

surgery | DESIGN

A modern marvel in orthodontics

By David Petrikas

S

ydney orthodontist, Dr Jessica Li and her partner, Patrick Mei, have together established an attractive bespoke practice, Marvel Orthodontics on Sydney’s upper north shore.

After doing their research and gathering together their own ideas, they engaged Perfect Practice to conduct the build which involved the complete conversion of a former retail food premises in the main shopping strip of Gordon.

The couple was quite clear that they did not want a typical “clinical” style practice, but something conveying modern simplicity with a “premium” boutique feel - reflecting the personalised care and experience they offer their patients.

140 Australasian Dental Practice

“I wanted the earthiness from natural colours and materials balanced with a stylish feel to create a ‘Zen’ look,” Dr Li said. “That’s the feeling we wanted for our patients so that it would be a relaxing and calming environment as we see a lot of kids, but also provides a welcoming feel for the parents as well.

“Looking after our staff is also a top priority for us, so we tried to incorporate their day-to-day experience into our design phase from the start,” Dr Li said.

The couple’s vision of a modern orthodontic practice has been significantly enhanced by an elegant and beautiful backlit rose gold logo with a stylised “M” representing an orthodontic bracket and wire wrapping around a tooth. Patients are greeted by a warmly lit reception

area with modern brass chandelier and the Marvel Orthodontics logo set behind a bold marble counter with its rose gold metal accent strip. A second carved wooden and metal “MO” logo adorns an adjacent wall.

Timber-toned floor coverings with a quirky ribbed grey carpeted insert and caramel ottoman, together with light coloured timber cabinetry and simple mix of modern grey fabric and upholstered white Eamesstyle seating adds a subtle sense of chic.

The modern, minimalist style benefits from the use of off-white walls, full glazing at the front and a corridor leading all the way to an office with a window at the rear, which overlooks the leafy suburb behind. This also allows natural lighting throughout the building.

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surgery | DESIGN

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141

Alcoves along the corridor have been carefully used to accommodate a patient vanity mirror and colourful, textured original artworks painted by Mr Mei’s very own artistic father.

Despite its relatively modest size, the space accommodates three fully equipped surgeries, an OPG room and U-shaped sterilisation room, plus staff and patient amenities and a private office at the rear.

An internal staircase accesses the plant room below.

Dr Li said an important part of the new practice was a balance of efficiency and personalised patient experience, which meant setting up with the right design and equipment suited to orthodontic work.

142 Australasian Dental Practice

March/April 2021

Mocom Tethys under bench washer disinfectors An Automated process providing perfect instrument cleaning and outstanding levels of disinfecton.

Ensures complete operator protection with full compliance to AS/NZS 4187-2014.

Washing

Decontamination

Disinfection

Drying

Personalise your accessories to suit all instrument configurations.

Including specialised racks for cassette systems.

Includes starter accessory rack pack.

1300 65 88 22 www.henryschein.com.au

M: 0427 816 459 • PH: (08) 9244 4628 • sales@mocomaustralia.com.au • www.mocomaustralia.com.au • equipment@henryschein.com.au • www.henryschein.com.au/equipment

Summary The Practice The Practice

Marvel Orthodontics

The Principal

Dr Jesse Li and Patrick Mei

Practice Type

Specialist Orthodontic

Location

Gordon, Sydney, New South Wales

Size

100 square metres

No of chairs

3

The Team Design

Perfect Practice

Construction & Joinery

Perfect Practice

Project Manager

Daniel Miles

Installer Presidental Equipment Dental Units

A-dec 400 + A-dec 300

Sterilisation

W&H Lara 22L

X-ray

NewTom GO

Intraoral Scanner

3Shape TRIOS

Compressor

Cattani KAC2000 AC200

Suction

Cattani CMT0000 Micro SMART

Software Ortho2Edge

Based on her previous experience working with a wide range of equipment brands, Dr Li chose A-dec for its reputation for reliability and also for its flexible configuration and ergonomics which made it perfect for orthodontic work.

After visiting the A-dec showroom in Mascot and consulting with Sydney-based equipment specialist, James Wallace from Presidental, Dr Li was able to come up with a package that met her requirements.

This includes a premium A-dec 400 chair with plush sewn upholstery for patient consults and longer procedures where chair comfort is paramount for the patient.

144 Australasian Dental Practice

The practice also has two A-dec 300 chairs with seamless formed upholstery for routine procedures such as orthodontic adjustments where patient turnover is rapid and a smooth seamless upholstery surface makes it easy to clean between patients.

Dr Li also specified wall-mounted delivery systems and ceilingmounted A-dec LED operatory lighting so that all the patient sees is a “bare chair” with no confronting dental instruments on it.

This also makes the chair much easier to access for patients and the dental team.

The discrete A-dec 300 delivery system is completely tucked away out of sight under a benchtop when not in use and can be easily positioned behind the head of the patient when instruments are required.

The A-dec chairs have also been chosen in three distinctive shades to give each surgery its own personality including a “silver pearl” (light dove grey) A-dec 300 in Surgery 1; a cyan (aqua blue) A-dec 400 chair in Surgery 2; and a paprika (spice orange) A-dec 300 in Surgery 3.

Dr Li said the entire dental fit-out and installation went smoothly and the practice had already received a number of walk-in patients as a result of its inviting décor and its convenient location in Gordon which is a transport hub for some of the North Shore’s best private schools.

March/April 2021

Flexibility Introducing A-dec 400, a thoughtful approach to productivity, ergonomics, and comfort. Elegance in a versatile package.

A-dec 400 marries form and function for less complexity and more style. Ergonomics to help you feel better. A delivery for a perfect fit. Left-right versatility for added productivity – truly ambidextrous.

FOR MORE INFORMATION, CONTACT YOUR A-DEC DEALER TODAY. Chairs Delivery Systems Lights Monitor Mounts Cabinets Handpieces Maintenance Sterilisation Imaging

For more information Email: a-dec@a-dec.com.au Phone: 1800 225 010 Visit: australia.a-dec.com @A_decAust @A-dec AUS © 2020 A-dec Inc. All rights reserved.

NSW/ACT

VIC

QLD

WA

Dental Installations Miranda (02) 9526 3500

Alldent Port Melbourne (03) 9646 3939

Dental Depot Windsor (07) 3857 0011

Dental Intelligence Malaga (08) 9244 8888

Presidental Silverwater 1800 773 743 Warners Bay 1800 773 743

Medi-Dent Braeside 1300 886 674

Medical Dental Solutions Currajong (07) 4728 2055 Loganholme (07) 3801 5797

West Coast Dental Depot Belmont (08) 9479 3244

Tristan’s Dental Equipment Service Campbelltown (02) 9820 8086

SA/NT Dental Concepts Edwardstown (08) 8177 0600

RJ Dental Sales and Service Mansfield (07) 3391 0208

NATIONAL Henry Schein Australia 1300 65 88 22

A-DEC SHOWROOMS BY APPOINTMENT SYDNEY

Unit 8, 5-9 Ricketty St MASCOT

MELBOURNE Suite 1, 260 Auburn Rd HAWTHORN

V99186

1800 225 010

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.

Ark Health partners with Kimberly-Clark Pola Rapid 38% hydrogen peroxide

Ark Health has partnered with Kimberly-Clark Professional™ (KCP) to add KCP’s range of Kleenex® and Scott® brand paper products to its infection control range. The range, which includes KCP’s most popular paper product Kleenex Compact Hand Towel, as well as other Kleenex and Scott brand hand towels, facial

tissues, wipers and absorbent pads, adds to Ark Health’s already comprehensive selection of infection control products. “With infection prevention and control front of mind for dental practices around the country, we are very excited to now offer Kimberly-Clark Professional’s high-quality products to our customers,” said Noah Shroot, Managing Director, Ark Health.

Available: Ark Health www.arkhealth.com.au Tel: 1800-422-227

New Pola Rapid in-office whitening treatment safely whitens teeth in a super fast 24-minute application time significantly faster than other alternative whitening options.

The specially formulated high viscosity gel enables a superior handling process with a faster application and removal time

due to its non-stick attributes.

Furthermore, Pola Rapid uses a vivid blue colour for ease of visibility and application and does not need an additional pre-desensitiser step.

Available: SDI Limited www.sdi.com.au

New Colgate recyclable Trial Bags

Easy activation capsule technology

Colgate Professional Oral Care has introduced new environmentally-friendly recyclable Trial Bags that are ideal for dental practices to use in their oral health promotion. The Trial Bags are supplied complimentary with a minimum order of 144 product “sets” comprising Colgate Plax Mouthwash 60mL; a Colgate toothbrush; Colgate Total fluoride toothpaste 40g; and Colgate Total Dental Floss travel size. Practices can also

Drawing on 50 years of dental research innovation, SDI is proud to announce the launch of Easy Activation Technology.

This innovation makes it 70% easier to press down and activate Riva glass ionomer capsules, making restoration preparation easier than ever. The Easy Activation technology is now available in all Riva Self Cure and Riva Light Cure product ranges. In addition to easier activation, the Easy Activation technology delivers improved extrusion control. Easy activation capsules are 70% easier to extrude than glass hybrid and

opt to customise the products included in the pack based on their individual requirements.

Once the patient no longer has a use for the Trial Bag, they can help the environment by placing it in their kerbside recycling bin.

Available: Henry Schein AU Tel: 1300-658-822 www.henryschein.com.au NZ Tel: 0800-808-855 www.henryschein.co.nz

146 Australasian Dental Practice

glass ionomer capsules from other manufacturers. This innovation minimises hand tremors and muscle stress, giving you more stability and control when placing restorations. Riva Self Cure and Riva Light Cure have restored the smiles of over 85 million people across 100 countries. Easy Activation Technology is an SDI Australian innovation that will make your restoration faster and easier than ever before.

Available: SDI Limited www.sdi.com.au

March/April 2021

Clear Clear Clear Clear Aligners Aligners Aligners Aligners are are are are now now now now more more more more affordable affordable affordable affordable than than than than ever ever ever ever and and and and made made made made right right right right here here here here !! ! ! v v v

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