Australasian Dental Practice Jan/Feb 2022 by dentalcommunity

Australasian

DENTAL PRACTICE THE BUSINESS MAGAZINE FOR DENTISTS

Vol. 33 No. 1

JANUARY/FEBRUARY 2022

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

Organised by Dentevents

a division of Main Street Publishing Pty Ltd ABN 74 065 490 655

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

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

VOLUME 33 | NUMBER 1 JANUARY/FEBRUARY 2022

contents | REGULARS

On the cover... KaVo Imaging offers a full range of intraoral and extraoral imaging solutions from CBCT, panoramic and cephalometric units to intraoral sensors and PSP scanners and cutting edge software.

management

8 10 12 14 16 20 56 58 60 154

68 Selling your dental practice important step in getting the right people 72 Anon your bus Beware of strangers offering candy: 74 Why sellers need to take a cautious approach with a new dental aggregator

briefs one man’s opinion in my practice mouth wide shut

76 Is the door to your dental practice open?

outside in

marketing

spectrum

uncomfortable truth about competition 78 The in dentistry...

CPD centre abstracts the cutting edge

finance

80 84 “Your Future, Your Super” - Explained 88 Setting yourself up for the year ahead

Your associate dentists and payroll tax: What! Why and how much?

READ ME FOR

CPD

new products

facebook.com/dentalpracticenow

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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

© 2022 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.

January/February 2022

Australasian Dental Practice

contents | FEATURES

VOLUME 33 | NUMBER 1 JANUARY/FEBRUARY 2022

infection control

clinical excellence 90

108

Case studies illustrating the aesthetic application spectrum of Tetric Prime in the anterior region

120

Simplifying fixed orthodontics by treating the causes

124 READ ME FOR

CPD

Into 2022 and the next phase

90 of the COVID-19 pandemic A-dec offers dental unit biofilm 98 testing service Hills Family Dental Centre trusts Mocom 100 for its infection control Instrument management 104 systems improve your practice

READ ME FOR

CPD READ ME FOR

CPD

From the implant planning to the

124 resin provisional - Case example with Zirkonzahn.Implant-Planner

READ ME FOR

CPD

128

surgery design 142 Immediate full-arch restoration with TLX

128 implant system: 1-year follow-up with

straightforward direct-to-implant restorative concept in periodontally compromised patient

138

Biodentine™ in the management of complex root perforations

142 The sky is the limit for WA orthodontist 148 Willow Dental a case study in design January/February 2022

Australasian Dental Practice

briefs | NEWS Enough noise...

he new year is well and truly upon us and whilst COVID-19 is still hanging around, it at last seems to be moving in By Joseph Allbeury the right direction. New years are of course a time for making resolutions and equally, for looking back at the year gone by. Whilst there are both positives and negatives to be drawn from 2021, there are a list of things that I would like to see the back of... like endless images of politicians on TV and the rantings of the disaffected on [anti]social media - If you’re having a bad day or someone hurts your feelings, Google “resilience” and move on... No need to record the moment in history for all to judge you by in the saner times ahead. And TikTok is officially now both the most visited website on earth and the single biggest threat to the advancement of the human race. Don’t watch–Don’t contribute! Mainstream media has divested itself of all credibility and the need to constantly post on websites to try and lure visitors in with “click bait” means that any “tweet” is hot news! I’m over Zoom calls and webinars and I will celebrate the day I no longer have to “check in” to shops and restaurants or wear a mask in public. And I could go on. 2022 is the time to return to core business, to being productive and to getting things done. To setting personal goals that are real, not ethereal. To clearing our mind of the fog of the pandemic and focussing on what matters most. Get your mind healthy, get your body healthy, distance yourself from all the noise of the world and focus on the things that matter most to you. Professionally, 2022 is the time to regain pace - put your pedal to the metal! Grow your business and grow your skills. Face-to-face learning and in-person interactions are back and offer you the pure experience of dedicating your most precious commodity - your undivided attention - to listening and learning, exchanging and interacting. June 3-4, we’re looking forward to welcoming everyone back to our long awaited Digital Dentistry & Dental Technology 2022 event and we hope you will join us. We’re working with almost 50 speakers to create a new and unique experience over the two days, with multiple streams on the gamut of topics surrounding the digitalisation of dentistry. The event is the perfect opportunity for both clinicians and technicians to engage and interact. If you haven’t signed up already, visit www.dentaltechnology.com.au - early bird rates still apply. And August 5-6, we’re creating a brand new large scale event called Dental Economics 2022 that is designed to help practices succeed and grow. This 2-day multi-stream multispeaker event again offers you the choice to craft your own learning experience based on your individual needs. Visit www.dentaleconomics.com.au for info and to register. The world has certainly changed and the definition of normal is still under debate, but the time for action has come! Joseph Allbeury, Editor and Publisher

8 Australasian Dental Practice

Neoss appoints new ANZ country manager

eoss® has appointed Mr Joel Marshall as Country Manager for Australia and New Zealand. Mr Marshall will be driving the continued expansion of offerings in Neoss Australia and New Zealand, with oversight of direct sales professionals and all other staff in the region. Mr Marshall joined Neoss in 2016 in a move towards sales and by 2020 had taken on the role of National Sales Manager in Australia. Prior to sales work, Mr Marshall worked as a dental technician for eight years, a role which not only yielded significant experience of complex implant cases and CAD/CAM technology, but also led to teaching and installing CAD/CAM systems for multiple labs. “Mr Marshall has had tremendous success as a sales manager since he joined Neoss in 2016. I am confident that his extensive knowledge and experience in the dental industry, combined with his background as a dental technician, will support our intention to expand our footprint in Australia and New Zealand,” said Dr Robert Gottlander, CEO and President of Neoss. Mr Marshall has taken on his new role at an exciting time for the company. Neoss has been focused more than ever on developing market-leading dental solutions and “intelligently simple” procedures designed to deliver better patient care and shorter procedure times. “I’m really looking forward to this new challenge as Country Manager for Neoss Australia and New Zealand and continuing the excellent growth we’re having. It’s exciting to continue working with a company that’s undoubtedly a pioneer in dental innovation, and improves patient care,” Mr Marshall said.

3Shape settles Align Technology dispute

Shape, a global leader in digital solutions for dentistry and Align Technology, Inc., the creators of Invisalign®, have settled the ongoing patent infringement and antitrust legal disputes between the two companies. The terms of the settlement are confidential. Following the settlement, Align Technology will continue its current practice of accepting scans from 3Shape TRIOS 2 and 3Shape TRIOS 3 intraoral scanners in certain jurisdictions outside the United States. Jakob Just-Bomholt, CEO of 3Shape, commented, “I am pleased that we have reached a fair and equitable agreement with Align Technology after four years of legal infights. This agreement will now allow us to focus even more on what we do best: developing innovative technology solutions for dentists and dental labs to improve patient care.” 3Shape partners with industry leaders to give dental professionals open choices for their patient care as well as supporting professionals’ continued education. 3Shape’s solution portfolio includes the multiple award-winning 3Shape TRIOS® intraoral scanner and dental lab scanners, design services and market-leading scanning and design software solutions for both dental practices and labs.

January/February 2022

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

One man’s opinion...

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

www.elaborate.com.au

• eLABORATE™ magazine online

“Dentists are starting to find out the hard way that once the health funds have sucked them in by promising all sorts of benefits... they become trapped...”

here is a very old story about a man who was holding a large dog on a leash. He is approached by someone who asks him if his dog bites. He answers that his dog doesn’t bite. The person then attempts to pat the dog and is bitten on the hand, whereupon he questions the man, saying that he thought that he said that his dog didn’t bite. The man answers that his dog doesn’t bite but this is not his dog. I’m currently on my last day in isolation, having tested positive for COVID. We had made a reservation for a very extravagant 4-day break, including a formal New Year’s Eve function, at one of Victoria’s premier destinations. It was our birthday present to each other and we had been looking forward to it for some time. The car was packed. My wife woke up with a scratchy throat and feeling lethargic; I, on the other hand, felt perfectly fine. We decided that the responsible thing to do was to do a rapid antigen test. Hers was negative; I tested positive! I couldn’t believe it, so I retested again... and was positive again! I then queued up for 2 hours for a PCR test and was told that I would have the results in 24 to 48 hours, in the meantime I had to isolate until a result came through. 48 hours still gave us time to arrive for the New Year’s Eve function. We called the resort who were very grateful and accommodating. 48 hours later and with no result (it took over 80 hours before I got official confirmation that I had tested positive), we once again called the resort and suggested to them that they might be able to get someone off the waiting list to take our place. The payment was non-refundable and we knew this when we paid it. My immediate thought was that it didn’t matter because I had paid it by American Express on my Platinum card, which includes travel and holiday insurance. I have had an American Express Platinum card since they first came out. It attracts a significant annual fee and I have on occasion availed myself of the concierge services that it provides, but the main reason for having it was the travel insurance that it’s supposed to provide. I remember going through it when I first “joined” and it was better and more cost-effective than buying a separate policy every time I travelled. In over 20 years, I have never needed to make a claim on the travel insurance. We recently received a notice that as of March 2022, cancellations due to COVID would no longer be covered and considering the Pandemic situation, that made sense to me. When I called American Express to lodge my claim, however, I was informed that because I hadn’t prepaid for flights or for a public carrier, I wasn’t covered for accommodation costs. Apparently it is in the fine print! The Resort is 120 kilometres from home, so flying is hardly an option. The genius I was dealing with suggested that if we had decided to go by a regular bus or train service and prepaid the fares, all would have been well. There is no train to the town in question, I generally don’t travel by bus and certainly not when I have suitcases with me. Dealing with insurance companies and health funds is always a little like that - it’s all in the appendices and sub clauses of the contract. Dentists are starting to find out the hard way that once the health funds have sucked them in by promising all sorts of benefits when they become preferred providers, they become trapped and find it impossible to extricate themselves without suffering significant pain. They too should have read the fine print! Not dissimilar to what happened to Australian soldiers who availed themselves of the services offered by the brothels in Cairo in World War 1! The dog that bit me apparently wasn’t theirs!

January/February 2022

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spectrum | NEWS

In my practice... By Christopher Ho

“Although intraoral scanning has done away with a lot of the conventional impressions and bite registrations that we once did, there is still a need for a physical registration at times. My favourite bite registration material is Jet Bite Blue, which has a whipped cream consistency that sets super fast...”

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”.

Surgic Pro (NSK)

Jet Bite Blue (Coltene)

his surgical motor from NSK can be used for both oral surgery and implantology. There are many surgical motors on the market and after using many different units, it is still one of my favourites. It is compact, durable and designed well from an infection control and ease of setup for the team perspective. One of the major advantages over competitor products is the fact that the handpieces are much lighter in weight, allowing precise control while carrying out surgery. It’s an intuitive surgical kit that provides accuracy with drilling and provides torque up to 80Ncm. This range of torque and the drilling speed allows maximum safety. The speed ranges from 200-40,000rpm. Additionally, the LED illumination offers 32,000 Lux, giving you additional lighting in often difficult surgical environments. The handpiece and cords are autoclavable, thermodisinfectable and are completely brushless, providing a maintenance-free design. The unit also comes with a movable stand as well as the ability to combine with a Variosurg 3 for piezosurgery, providing minimal invasive surgery.

T lthough intraoral scanning has done away with a lot of the conventional impressions and bite registrations that we once did, there is still a need for a physical registration at times. My favourite bite registration material is Jet Bite Blue, which has a whipped cream consistency that sets super fast. For those that prefer a slower set, Jet Bite is the solution. The material has great accuracy yet is still flexible enough to trim easily and cut. It can be used for bite registrations and even for pickup implant impressions if there are not heavy undercuts. An additional use can be to seal rubber dam as in full arch split rubber dam procedures.

Surgical Scalpel Blade No. 12 (Swann-Morton) he No.12 is a small, pointed, crescent shaped blade sharpened along the inside edge of the curve. It is sometimes utilised as a suture cutter but often used for flap incisions, especially in the posterior regions of the mouth where a straight blade may be ineffective. Another tip in restorative procedures is to use the No. 12 blade for removing excess polymerised composite resin on the facial and interproximal region of the tooth during restoration procedures or removing excess polymerised cement when adhesively bonding indirect restorations.

12 Australasian Dental Practice

About the author Dr Christopher Ho is a Specialist Prosthodontist in Sydney. He is Head of School of Australasian College of Dental Practitioners, Visiting Lecturer at Kings College London, Adjunct A/Prof at University of Puthisastra and Editor of the WileyBlackwell textbook “Practical Procedures in Aesthetic Dentistry” and “Practical Procedures in Implant Dentistry”.

January/February 2022

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spectrum | NEWS

Is it time for a personal soundcheck?

By David Moffet

“Although careless mistakes may have been innocuous and harmless, it only takes one instance where the careless phrase accidentally offends someone who decides that they will take their business elsewhere and suddenly you’re wondering what the heck just happened to your business...”

efore performing, recording musicians, singers and public speakers always run through a soundcheck to ensure that their equipment is working well and that their voices and their instruments are also tuned and functioning well. But what about you? As everyday run-of-the-mill ordinary garden variety people, do you ever encounter someone who uses a word, or a phrase, that is: • Meaningless; • Pointless; or • Overused. Maybe it’s someone you work with? Or it’s someone you know personally? Or it may even be you?

We’ve even heard a twenty-year-old receptionist calling multiple callers “Love” and “Darls” no matter what their age and gender might be... In this case, a little bit more COACHING of the receptionist was required to address and correct the careless language being used.

Although these mistakes may have been harmless... lthough these careless mistakes may have been innocuous and harmless, it only takes one instance where the careless phrase accidentally offends someone who decides that they will take their business elsewhere, and also tell their friends about it, and suddenly you’re wondering what the heck just happened to your business?

And the thing is...

Many years ago... any years ago, I won a weekend away on a television game show. When the contestants were interviewed privately after the weekend away, one of my fellow contestants pointed out to the viewers that I had an annoying habit of calling everybody I spoke to as “Pal”. I can imagine how annoying that continued repetition would feel to other people... but for me, I was oblivious to the fact that I had fallen into this lazy habit.

When we listen to telephone recordings... hen Jayne [from Dental Phone Excellence] and I listen to telephone recordings at our clients’ dental practices, we hear conversational PATTERNS that we need to address and improve upon. Often these patterns are simply lazy habits of speech where people are comfortable using CARELESS LANGUAGE rather than understanding the importance of using PURPOSE with every word spoken. Right up there on the leader board of careless language are the well-worn phrases: “Not a problem.” and “No worries.” Both these phrases are lazy and contain double negatives. Alternative phrases that would work much better would be: “You’re very welcome.” and “It’s my absolute pleasure.” which are both framed in the positive. And are far better choices.

14 Australasian Dental Practice

nd the thing is, for every one person that you might find out about, there’s probably another ten people offended who you don’t ever hear from who just take their business somewhere else.

That’s why... nd that’s why every person in every business needs to be open minded to CONSTRUCTIVE CRITIQUE about the language they use and the words they say. Because anything except BEST PRACTICE is really unacceptable, no matter whether you’re the business owner, a seasoned pro, or the new recruit.

That’s why McDonalds staff have scripts to follow. It’s because everything affects everything...

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.

January/February 2022

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spectrum | NEWS

Is a spade a spade?

By Lani Guy

Digital disruption isn’t adopting technology to replace analogue forms of production. And it isn’t any given product, solution or technology. It is a pervasive societal reference to how the age of the customer is changing the way we do business reflected in the technological basis of society...”

he term on everyone’s lips nowadays seems to be disruptive digital dentistry. And when we dentists talk about disruptive digital dentistry, we refer to the automation of workflow and production with technological enablers such as intraoral scanners, 3D printing and CAD/CAM, patient management and recall systems. But let’s take a step back and talk about what this actually means in the broader business environment before circling back to dentistry and asking are we calling a spade a spade? Let’s begin by pinning down what digital disruption is by looking at what it’s not. Take the banking industry as an example. The banking industry is a strange historical concept you give someone your money and then pay that person to get it back. Now, at its outset, the banking industry was very powerful and protected by insurmountable barriers to entry and exit. This meant there were very few players and very little consumer power; and the way banks did business reflected this - customers interacted with banks through a network of capital-heavy branches which provided a very limited window of time during which customers could access their money. Weekend, evening, mobile and digital access to services were unfathomable. When the idea of an ATM was first introduced, they cost many thousands of dollars per machine, took up enormous amounts of space, had very limited functional capability and required enormous customer education. But as technology capability grew and costs reduced, the viability of ATMs increased. Customers no longer needed to be trained in how to use ATMs and the reduced size and cost of machines meant sufficient machines could be deployed to form a viable network. This changed the way banks operated; increasing accessibility to anytime, anywhere and reducing the overheads of staff and branches. So, ATMs are disruption and they do use digital solutions, but ATMs are NOT digital disruption. Why? Because ATMs did not fundamentally change the underlying business model on which banking is built. Customers still deposit their money to the bank, who safeguards it, until such time the customer requests access... for a fee. The same can be said for internet banking and other forms of digital banking technology - including email and phone banking transfers. So, what has digitally disrupted banking? Anything at all? The answer is yes - there are major digital disruptions challenging the business model supporting banking as we know it - and they can be found in two main waves. First, we have players allowing customers to send their money via email. Now hang on a minute, I just said this is not digital disruption. And that’s true for the banks who do it. It’s not true for players like Facebook who do not charge their customers anything at all for using their product because they are not in the business of transferring money. They are in the business of customer

16 Australasian Dental Practice

relationships and they want that relationship so badly they are willing to give away products and services for free. And when they get enough relationships, they will do something else altogether with that relationship which is unrelated to sending money. The second wave of blockchain disruptors has more disruptive potential. Blockchain disruptors shift control to customer-controlled domains over which no individual or corporation, i.e. banks, have control and by doing so removes the tenant that enabled banks to penalise people for safeguarding their money it completely removes centralisation which gave rise to banking institutions and thereby removes the legitimacy and necessity of banking as we know it. You may be thinking that blockchain isn’t relevant to the dental industry. And you’d be wrong; these technologies are already setting up shop in the dental domain. So now we know digital disruption isn’t adopting technology to replace analogue forms of production and workflow. And it isn’t any given product, solution or technology. It is a pervasive societal reference to how the age of the customer is changing the way we do business reflected in the technological basis of society as it stands in any one given point in time. I repeat, digital disruptions are the changes that industries need to make because the customer controls what businesses do and how they do it. If you need a refresher on what the age of the consumer is, take a quick peek back at my article in the last edition. If we synthesise the information I’ve given you so far, we see that in digital disruption: 1. The service is always the relationship and never the product or service; 2. The customer controls the product or services and owns the infrastructure on which it is delivered; and 3. Commoditisation is king - customers don’t really care who services them; the quickest, cheapest and best provider wins! Let’s circle back now to digital dentistry; how does workflow automation and replacement of analogue production stack up? Are they digital? Yes. Are they disruptive? Yes. Are they digital disruption? No. This is not to say that digital dentistry as it is discussed within the dental industry is not important. To the contrary, digital solutions have the ability to improve the customer experience and production efficiency. But they are not disrupting or transforming dentistry in the way we mean when we call for disruptive innovation. We need one more spade, because the spade we have is not a spade. Lani Guy is a University of Queensland trained General Dentist working in private practice. In a prior life, Lani was a management consultant. She has a Bachelors, Masters and Doctorate in business along with a Bachelors in psychology and has spoken globally on the topic of digital disruption and IR4.0. She has a special interest in evidence-based improvement techniques and disruptive innovation... as well as healthcare.

January/February 2022

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spectrum | NEWS

Dental Economics 2022 designed to help you grow your dental practice

ental Economics is a brand new major event for 2022 that is designed to help you and your private dental practice GROW. The event is perfect for principal dentists, employed dentists, new graduates, senior clinicians, practice managers, dental hygienists, oral health therapists and clinical and business support team members. After two years of uncertainty, 2022 and beyond is the time to start getting back on track - growing your practice, starting a new practice, building your revenue, honing your systems, adding more chairs or opening in new locations. Whatever your plan, Dental Economics 2022 will provide you with the tools, ideas and inspiration from the absolute best in the business to go to the next level. Dental Economics 2022 is a 2-day multi-stream event that allows you to create your own program - on the fly. The event is staged at the Novotel Sydney Brighton Beach - close to Sydney Airport with ample parking and easy access. Throughout the two days, you can choose from over 50 different lectures, workshops and forums to tailor a program to meet your exact requirements (or bring your entire team to cover all the bases). Dental Economics 2022 offers a total of 12 hours of CPD organised into six concurrent education streams under the topics of:

Leadership n this interactive forum, hear Australian dentists who are running large private dental practices over multiple locations, large group practices or practices with a range of unique business models, franchises and concepts be interviewed on stage, give insight into the future trends of private dental practice and answer your questions. Gain first hand insight into how large successful dental practices have overcome challenges to grow, evolve and prosper that you can apply and adapt to your own situation.

Practice Management articipate in lectures, workshops and forums with the best dental management consultants in Australia who will offer advice and insight from decades of experience working with private dental practices in Australia.

Finance nderstand how to navigate the unique financial and legal requirements of dental practices from legal, accounting and financial advisers who create dental practice structures for large group and corporate practices. Sessions on trusts, insurances, superannuation, buying and selling practices, starting up a brand new practice, securing premises and more will be featured.

Attention entrepreneurial dentists, practice managers and owners ental Economics 2022 is looking for entrepreneurial dentists, practice managers and business owners who want to share their stories of success with their colleagues as part of an interactive forum. If you have a large practice or group of practices or an interesting idea or business model and would like to participate, then please contact Joseph Allbeury at joseph@dentist.com.au to start a conversation about presenting at Dental Economic 2022.

20 Australasian Dental Practice

Marketing arketing your dental practice successfully is a key driver for growth. Hear from clinicians, business owners and consultants about what works and what doesn’t. Sessions on websites, social media, video marketing, advertising and more will all be incorporated into a range of fun and interactive educational sessions.

Hygiene Department or the first time in Australia, this program for dental hygienists, oral health therapists and hygiene coordinators will present a range of sessions from inspiring clinicians and consultants that will change the way you view your career and your clinical practice. From looking at concepts for growing hygiene revenue and clinical engagement, to the exploration of the dental spa concept to mobile dentistry and domicillary care models, a broad range of topics will be covered designed to help dental hygienists and oral health therapists rethink their role in the practice and their overall dental career.

Communications ommunication is the key to starting and growing a practice. This stream will offer insight, tips and advice on a range of techniques and technologies that can help your practice grow, increase your efficiency and reduce your overheads.

Brought to you by Dentevents, Dental Economics 2022 will deliver unprecedented access to the most knowledgeable and entrepreneurial clinicians, business owners and consultants in Australia today. Dental Economics 2022 will feature over 60 education sessions in six concurent streams and the program is updated and evolving on a continual basis at www.dentaleconomics.com.au. Full price registration is $880 per person. Register before March 5 and pay only $330 per person. Price increases $110 per month.

January/February 2022

Organising a dental event, lecture, congress, trade show or webinar?

GO EXPRESS»»»»» If you’re organising any kind of post-graduate dental education, event or webinar, listing your event on the dentevents.com continuing education calendar is now easier than ever. No username, no password and no need to login - add your event by simply visiting dentevents.com, clicking on Adding Events and then selecting Express Listing. Complete all the details on the form and click SUBMIT. An email containing a link to edit or update the event will be sent to you that also allows you to track the approval status. After the event is checked, it will be posted to dentevents.com. Advanced functionality For event organisers who already use Dentevents to manage their events through www.dentalcommunity.com.au and use the registration, payment and ticketing tools, this system should continue to be used as normal. Tools for event organisers Dentevents.com offers event organisers a full suite of marketing, ticketing, payment, registration and event management tools cost-effectively and on-demand. Full information is available at the newly updated Dentevents.com website.

Visit www.dentevents.com Published by Main Street Publishing Pty Ltd • PO Box 586 Cammeray NSW 2062 • Call (02) 9929 1900

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ECONOMICS SYDNEY 5-6 AUGUST 2022 NOVOTEL SYDNEY BRIGHTON BEACH REGISTER NOW and SAVE 50% Dental Economics is a brand new event for 2022 created to help dental practices GROW. Whether you own a practice or want to own a practice, whether you’re a clinician or part of the team, whether you’re new to the profession or a seasoned veteran, Dental Economics is a festival of ideas and information that will empower you to revisit how you think and work in dentistry today. The multi-stream, multi-session format allows participants to create their own program, with presentations, forums, workshops and round tables delivered by leading Australian dentists operating large practices over multiple locations; experienced experts in corporate structures, employment, finance and taxation; practice management gurus; marketing and social media consultants; internet and defamation lawyers; and much more.

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

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spectrum | NEWS

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

orld-class speakers, cutting-edge industry exhibitions and a stellar line-up of social events will all feature as part of a new landmark event for the Australian dental profession. The Australian Dental Industry Association (ADIA) and the Australian Dental Association New South Wales (ADA NSW) have joined forces to deliver Australia’s largest oral health and networking event of 2022. Bringing together the flagship ADX Sydney exhibition and the inaugural Sydney International Dental Conference (SIDCON22), this blockbuster combined event will take place from March 16-19, 2022 at the International Convention Centre Sydney. Thousands of dental professionals, including dentists and their practice teams, hygienists, prosthetists, therapists, dental students, recent graduates and industry representatives are expected to attend the event, which will connect all aspects of dentistry for the first time. Three-time Paralympic gold medallist Kurt Fearnley AO will be among the line-up of leading Australian and international speakers featured in the SIDCON22

24 Australasian Dental Practice

program, which will present the latest developments across a range of oral health and other topics, including business administration, science and health and well-being. Delegates will then head over to the ADX Sydney Exhibition, which runs from March 17-19, to explore the latest in dental technology and innovation.

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

ADA NSW President Dr Kathleen Matthews said SIDCON22 was an unmissable event for the Australian dental profession. “We are hugely excited to unite with ADIA for this event, which will help further empower dental professionals and improve the delivery of oral health in Australian,” Dr Matthews said. “Dentistry plays a critical role in the overall well-being of Australians and SIDCON22 will allow dental practitioners and their teams to unite, share ideas and discover a wealth of new innovations to advance the profession. “With our current membership levels at a 15-year high, ADA NSW continues to lead the way in supporting our members. This event further underlines our commit-

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

January/February 2022

EE Y R F TR EN

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spectrum | NEWS

Benefits of water flossing for periodontal maintenance patients

eriodontal disease is one of the most common chronic conditions found in adults. In Australia, over 40% of adults aged 55 and over have moderate to severe periodontal disease.1 Smoking, uncontrolled diabetes and poor oral hygiene are well-established risk factors for the development of periodontitis.2 It has been associated with numerous systemic oral health conditions including cardiovascular disease,3 adverse pregnancy outcomes,4 cancer5 and cognitive decline.6 In November of 2018, the European Federation of Periodontology and the American Academy of Periodontology co-sponsored a World Workshop on the Classification of Periodontol and Periimplant Diseases and Conditions. This resulted in an update in the periodontal classification system, the first since 1999. The new system includes multi-dimensional staging and grading to allow for a more comprehensive, sophisticated and personalised approach to the identification, treatment and arrestment of periodontal disease.7 The definition of periodontal health was also considered by the workshop participants and defined as: “a state free from the absence of inflammation.8” The authors further concluded that periodontal health can be restored to an anatomically reduced periodontium.8 Thus, while treatment is vital for arresting periodontal disease, it also means that regular maintenance visits and daily self-care is essential for the optimal maintenance of patients who have been treated for periodontal disease. The Waterpik® Water Flosser (Figure 1) is a clinically proven tool for helping periodontal maintenance patients maintain good oral health.9-12 Six-month studies conducted during the 1990s found that water flossing consistently reduced inflammation and improved the oral health of periodontal maintenance patients.10-12

26 Australasian Dental Practice

Water flossing has been shown to reduce BOP by half over a 6-month time frame.11 People with the most BOP have been found to have the greatest reductions.10 When compared to rinsing with 0.12% chlorhexidine, water flossing with water was more effective at reducing BOP.12 Water Flossing has been found to be as effective as the local delivery of an antibiotic post scaling and root planing (SRP). Genovesi et al evaluated the difference between SRP followed by the local delivery of 1mg of minocycline into periodontal pockets and SRP followed by daily full-mouth water flossing with water for 30 days. The results demonstrated that both treatments effectively reduced bleeding on probing and improved pocket depth and clinical attachment at 30 days.

There were no statistical differences between the groups, thus showing that the Water Flosser is an effective alternative to subgingival antibiotics for periodontal maintenance patients over a 30-day period.9 Evidence indicates that a Water Flosser has the potential to disrupt bacteria up to 6 mm in a periodontal pocket.13,14 Studies documenting subgingival access in vivo for tooth brushing and flossing are limited. Conventional wisdom rather than scientific evidence says that toothbrushing typically reaches 1-2 mm and traditional dental floss up to 3 mm. The Waterpik Water Flosser is supported by more than 70 published scientific studies and five decades of use by the public. Continued 88

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spectrum | NEWS

IDEM Singapore postponed to October

riginally slated for 8-10 April, IDEM 2022 will now take place between 7-9 October 2022 instead. The organisers of IDEM, Koelnmesse and the Singapore Dental Association, made the decision to postpone the event in light of current travel and safety restrictions in the Asia-Pacific region. As the leading exhibition and conference for the dental industry in the Asia-Pacific, the aim of IDEM is to provide a comprehensive experience and bring together exhibitors and attendees from all over the world. With this in mind, the 12th edition of IDEM will take place between 7-9 October 2022 at Sands Expo and Convention Center; Marina Bay Sands instead of the originally scheduled dates of 8-10 April 2022. “IDEM 2022 is intended as an in-person event where practitioners can exchange valuable knowledge, network with other professionals and view new exhibits with the in-person element playing a central

role in the overall IDEM experience,” said Mathias Kuepper, Managing Director of Koelnmesse Pte Ltd. “The decision to postpone IDEM to the latter half of 2022 was not taken lightly despite receiving

strong interest and bookings from exhibitors and country pavilions. Before restrictions were tightened due to the Omicron variant, IDEM would have been on track for the in-person event in April. Ultimately, our goal as the organisers of IDEM is to bring together the Asia Pacific

dental community to experience the full offerings of IDEM in a safe manner.” IDEM Singapore is the leading dental exhibition and conference in the AsiaPacific region. Participants at IDEM 2022 can look forward to a series of programmes that cater to the dental community: • Trade Exhibition - the exhibition will feature close to 400 local and international exhibitors; • Scientific Conference - with the theme of Building Resilience in Dentistry, participants can look forward to over 30 conference sessions and workshops by industry-leading speakers around the world; and • IDEM 360 - a supplementary digital platform that offer participants networking options, booking of meeting slots and post-event content. Online registration is ongoing. Early birds who register for IDEM 2022 by 8 March 2022 will be offered a discounted rate. Visit www.idem-singapore.com for more information.

References It has earned the American Dental Association (ADA) Seal of Acceptance. Despite evidence to the contrary, some dental professionals believe that the product can increase probing depth or destroy attachment. A six-week study by Goyal et al evaluated the effect of the Water Flosser on gingival and epithelial tissue at multiple pressure settings including 90 and 100. At the conclusion of the study, the Water Flosser was more effective at reducing probing depth and improving clinical attachment than manual brushing and flossing or manual brushing alone. All subjects were negative for trauma or other adverse conditions.15 In conclusion, the Waterpik Water Flosser is an ideal choice for helping periodontal maintenance patients improve and maintain good oral health. To view exclusive professional trial offers visit www.waterpik.com.au/shop and to register your interest in a Waterpik Professional Lunch & Learn email: professionalAU@waterpik.com

28 Australasian Dental Practice

1. Manton DJ, Foley M, Gikas A, Ivanoski S. et al. 2018 Australia’s Oral Health Tracker: Tech-nical Paper, Australian Health Policy Collaboration, Victoria University, Melbourne. 2. Mariotti A, Hefti AF. Defining periodontal health. BMC Oral Health 2015, 15(Suppl 1): S6. 3. Lockhart PB, Bolger AF, Papanaou PN, Osinbowale O. et al. On behalf of the American Heart Association Rheumatic Fever, Endocarditis, and Kawasaki Disease Committee of the Council on Cardiovascular Disease in the Young, Council on Epidemiology and Prevention, Council on Peripheral Vascular Disease, and Council on Clinical Cardiology. Periodontal disease and atherosclerotic vascular disease: Does the evidence support an independent association? A scientific statement from the American Heart Association 2012. 125:00-00. 4. Offenbacher S, Katz V, Fertik G, Collins J. et al. Periodontal infection as a possible risk factor for preterm low birth weight. J Periodontol 1996; 67:1103-1113. 5. Michaud DS, Lu J, Peacock-Villada AY, Barber JR et al. Periodontal disease assessed using clinical dental measurements and cancer risk in the ARIC study. J Natl Cancer Inst 2018; 110:843-854. 6. Ide M, Harris M, Stevens A, Sussams R et al. Periodontitis and cognitive decline in Alz-heimer’s disease. PLoS ONE 2016; 11(3): e0151081.doi:10:10.1371/ journal.pone.0151081 7. Tonetti MS, Greenwell H, Korman KS. Staging and grading of periodontitis: Framework and proposal of a new classification system and case definition. J Periodontol 2018; 89*Suppl 1): S159-S172.

8. Lang NP, Bartold PM. Periodontal health. J Periodontol 2018; 89(Suppl 1): S9-S16. 9. Genovesi AM, Lorenzi C, Lyle DM, Marconcini S et al. Periodontal maintenance following scaling and root planing, comparing minocycline treatment to daily oral irrigation with wa-ter. Minerva Stomatol 2013; 62(Suppl. 1 No 12): 1-9. 10. Newman MG, Cattabriga M, Etienne D, Flemmig T et al. Effectiveness of adjunctive irrigation in early periodontitis: Multi-center evaluation. J Periodontol 1994; 65: 224-229. 11. Flemmig, TF, Epp B, Funkenhauser Z, Newman MG et al. Adjunctive supragingival irrigation with acetylsalicylic acid in periodontal supportive therapy. J Clin Periodontol 1995; 22: 427-433. 12. Flemmig TF et al. Supragingival irrigation with 0.06% chlorhexidine in naturally occurring gingivitis. I. 6-month clinical observations. J Periodontol 1990; 61: 112-117. 13. Cobb CM et al. Ultrastructural examination of human periodontal pockets following the use of an oral irrigation device in vivo. J Periodontol 1988; 59: 155-163. 14. Drisko CL et al. Comparison of dark-field microscopy and a flagella stain for monitoring the effect of a Water Pik on bacterial motility. J Periodontol, 1987; 58: 381-386. 15. Goyal CR, Qaqish JG, Schuller R, Lyle DM. Evaluation of the safety of a Water Flosser on gingival and epithelial tissue at different pressure settings. Compend Contin Ed Dent 2018; 39(Suppl 2): 8-13.

January/February 2022

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Did you know... Google Reviews now trump word of mouth recommendations? How a patient chooses a dentist is completely different to when you ﬁrst opened your practice? The worst thing you can do in marketing . . . is nothing?

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Every year, there are more dentists practicing in Australia than ever before … and this rate of growth is much faster than the growth of the Australian population.

Fact:

Potential patients have more choices for a dentist (and more ways to choose) than ever before

Fact:

If you don’t adapt your marketing to keep up with changes in consumer behaviour, you will get left behind with only fewer patients and declining proﬁts to look forward to

It’s time

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Fortunately, all is not lost. There are ways to reverse this ugly trend and get you back on track. Join multi-award winning, Practice Growth Specialist, Angus Pryor, to discover:

The easy way to remove yourself from the ‘race to the bottom’ (endlessly lowering prices) and instead, have YOU as the only entrant in a one-horse race The 5-minute hack that overnight, will have you showing up prominently online in neighbouring suburbs to expand your reach Three simple steps you can implement tomorrow morning to give your practice aperceivable boost in new patients The number one mistake you’re making with your website that is driving away potential patients (instead of attracting them) – and what to do about it The social media strategy that will have you standing out like a bride in white at a heavy metal concert, rather than blending in with the (faceless) crowd A step-by-step guide to dominate your competitors in 2022, get your practice growing again, boost your conﬁdence, and bring you back thejoy of doing dentistry

Multi-award-winning Practice Growth Specialist, Angus Pryor, is an author, marketer, and international speaker. He is the number one Google-ranked dental marketer in Australia. In 2020, Angus’ marketing agency was recognised with the highly coveted marketing award from the Australian Dental Industry Association. Angus is an Amazon number one bestselling author from hisbook ‘The Dental Practice Proﬁt System – 5 Steps To Higher Patients And Higher Proﬁts’. He has written extensively in a range of industry publications including DentistryIQ, Australasian Dental Practice, and ADA’s News Bulletin. He has been quoted on ABC, NBC and Fox TV.

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spectrum | NEWS

IMCRC collaboration is developing laser for cutting edge robotic dentistry

Figure 1. A schematic view of the assembly that locates the intra-oral module onto the tooth of the crown.

collaborative research project between the Innovative Manufacturing Cooperative Research Centre (IMCRC), dental technology company Dentroid Technologies and Griffith University is bringing Australians one step closer to accessing comfortable, pain free dentistry. The project, worth $650,000 in research effort (cash and inkind), will develop a high-power laser micro-electro-mechanical systems (MEMS) mirror (or “micromirror”) for the world’s first in-mouth laser-enabled robotic assistive device. By replacing the traditional drill mechanism with gentle lasers, the innovative device will help dentists to provide patients ultraprecise and needle-free dental treatment with unprecedented convenience and speed. Dr Jason Coonan, IMCRC’s Deputy CEO, said that with automation and robotic assistance in dentistry still in its early stages, IMCRC was proud to be co-funding the development of this tremendously exciting technology as well as laying the foundation for manufacturing the MEMS mirror in Australia. “This research collaboration has wide-ranging impacts, from improving oral health for many populations across the world to leveraging Australia’s position as a global leader in dental excellence,” he said. “As this project demonstrates, effective collaboration between industry and research partners is the key to delivering mutually beneficial translational research outcomes that grow Australia’s medical technology manufacturing industry and create global export opportunities.”

32 Australasian Dental Practice

Figure 2. A schematic of the patented Dentroid intra-oral device, which clamps onto a tooth and delivers a laser beam for precise ablation of carious tooth structure or restorative materials. The cylinders are connections to the laser and the control panel. Dr Omar Zuaiter, CEO of Dentroid Technologies said that the IMCRC research collaboration would enable Dentroid to deliver a device that would meet the growing demand for quality dental care and improve access for remote and disadvantaged communities. “We’re excited to join forces with IMCRC and Griffith University to develop this world first micromirror. IMCRC’s funding will enable us to ultimately manufacture the in-mouth robotic assistive device that will herald a new era of accessible dentistry,” he said. “Because our in-mouth device is compact, portable and easy to use, it can facilitate early screening and diagnosis of dental issues and then help administer the right treatment at the right time. “The device will also enable remote and mobile dentistry, a game changer when it comes to improving access and quality of oral healthcare across Australia.” Griffith University Professor Dzung Dao said he was delighted to be collaborating with IMCRC and Dentroid to assist with the development of such a cutting edge and impactful product. “This collaborative research and development model means Griffith University can leverage our resources and technology to help Dentroid overcome barriers and develop, scale-up and deploy a locally made product of global significance,” he said. “It also provides our researchers and students the opportunity to learn from industry SMEs and hone their understanding of Australia’s manufacturing landscape, allowing them to up-skill and add value when working on future projects.”

January/February 2022

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With unprecedented scan speeds allowing you to scan a quadrant in 25 seconds, full arch in 1 minute, and With unprecedented scanaspeeds allowing you to scan With unprecedented allowing you to scan anquadrant entire ortho inscan 3 minutes, the 3 a in 25case seconds, aspeeds full arch inAORALSCAN 1 minute, and a quadrant in faster 25case seconds, a full arch 1 minute, and3 IOS promises appointment times and a more an entire ortho in 3 minutes, theinAORALSCAN an entire ortho caseappointment in 3 minutes, times the AORALSCAN comfortable patient experience. IOS promises faster and a more3 IOS promises faster appointment times and a more comfortable patient experience. comfortable experience. When you’re patient done scanning, its hassle-free exporting of STL and full-colour PLY scans,its along with theexporting license-free When you’re done scanning, hassle-free of When you’re doneyou scanning, its hassle-free exporting of operation, means send to aswith many or as few labs STL and full-colour PLYcan scans, along the license-free STL and full-colour PLYcan scans, along the as you like. operation, means you send to aswith many orlicense-free as few labs operation, as you like.means you can send to as many or as few labs as youscanner like. Every package comes pre-installed with a suite of intuitive, doctor-friendly software, including: Every scanner package comes pre-installed with a suite Every scanner package comes pre-installed with a suite of intuitive, doctor-friendly software, including: of intuitive, doctor-friendly software, including: Scan software - Intraoral scanning Scan - Intraoral scanning Orthosoftware simulator - Chairside orthodontic simulation Scan software Intraoral scanning Ortho simulator Chairside orthodontic Healthcheck - Intraoral scaner camera + intraoralsimulation Ortho simulator Chairside orthodontic simulation Healthcheck Intraoral scaner intraoral camera + Lab cloud - Seamlessly send scans your lab Healthcheck Intraoral scaner intraoral camera + Lab cloud - Seamlessly scans your Model builder - Base andsend export models tolab a chairside printer Lab cloud - Seamlessly scans your Model builder - Base andsend export models tolab a chairside printer Model - Base and export to a chairside printer Unlike builder many other scanners onmodels the market, there are no ongoing fees, and on updates are free andare Unlike manylicense other scanners the market, there Unlike manyensuring other scanners on market, there automated, youand enjoy the latest features as no ongoing license fees, updates are free andare no ongoing license fees, and updates are free and they’re released. automated, ensuring you enjoy the latest features as automated, ensuring you enjoy the latest features as they’re released. they’re released. When you buy the AORALSCAN 3 IOS from Osseo Group, you’ll receive the scanner, PC, trolley, ongoing When you buy the AORALSCAN 3 IOSand from Osseo Group, When you the AORALSCAN IOSand from Osseo Group, clinical andbuy technical support for3one low price. you’ll receive the scanner, PC, trolley, ongoing you’ll receive the scanner, PC, trolley, clinical and technical support for oneand low ongoing price. clinical and technical support for one low price.

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spectrum | NEWS

CS 9600 named 3-time winner of Cellerant Best of Class techology award

or the CS 9600 CBCT system, three really is a magic number. The most intelligent CBCT extraoral imaging system on the market has received a 2021 Cellerant Best of Class Technology Award. This is the third year in a row the CS 9600 has been honored by the Cellerant Consulting Group and it’s the only extraoral imaging system to have been recognized more than once. “To have won three times in a row in such a competitive space speaks to Carestream Dental’s commitment to technological innovation and the needs of practitioners,” Lou Shuman DMD, CAGS, creator and founder of the Cellerant Best of Class Technology Awards, said. “I know I speak for the whole panel in congratulating the Carestream Dental team for such success in its efforts.” Known as Carestream Dental’s “smartest” imaging system, the CS 9600 is more than powerful imaging and advanced software. It’s the smart features that make patient positioning easier; the artificial intelligence that automatically detects and traces the Frankfort plane; the pre-set programs; the quality control tools; and the auto-detection when the wrong accessory is selected that all go into making the system a winner. Today, there are more than 1,000 CS 9600 systems installed worldwide that have captured a combined 1.5 million acquisitions. “Of all the extraoral systems I have used, the CS 9600’s ability to visualise and properly align the patient in the scanning field is unparalleled,” Andrew Johnson, DDS, MDS, CDT, FACP, surgical prosthodontist and founder of Omnismile in Northwest Arkansas, said. “With previous CBCT systems, it was a shot in the dark trying to align even a single large scan, much less an isolated small field. The intuitive alignment tools of my CS 9600 make it the fastest CBCT unit for me to use and the easiest system to delegate to my staff.” “The CS 9600 really represents the future direction of dentistry and of Carestream

34 Australasian Dental Practice

Dental,” Ed Shellard, DMD, chief dental officer, Carestream Dental, said. “Software reduces scatter caused by metal artifacts so doctors can be sure of what they’re seeing on the screen. Cameras and guides guarantee first-time-right positioning. Put simply, its algorithms and data drive success. That’s what we’re seeing more of in the industry as a whole and it’s what you’ll continue to see in future Carestream Dental innovations.”

The system is available in three versions with 10, 12 and 14 fields of view (FOV). In addition to 2D and 3D imaging and object scanning, practices have the option to include face scanning or a scanning cephalometric arm - making it a five-inone system. Additionally, the optional CS UpStream program can send data back to Carestream Dental’s support team to monitor historical performance and prevent downtime and maximise system availability. The CS 9600 has also been awarded a 2020 and 2019 Cellerant Best of Class Technology Award, as well as a 2019 Edison Award seal in the Medical/Dental Diagnostics category and the Krakdent Medal of the Highest Quality from the International Fair KRAKDENT®. Since the inaugural presentation in 2009, the Best of Class Technology Awards have grown to occupy a unique space in dentistry by creating awareness in the community of manufacturers that are driving the discussion as to how practices will operate now and in the future. For more information on the Cellerant Best of Class Awards and the 2021 Award Winners, go to cellerantconsulting.com/best-of-class-2021

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

C Features like these and more led to the CS 9600 being selected to receive the 2021 Cellerant Best of Class Technology Award by a panel of the most prominent technology leaders in dentistry: Paul Feuerstein, DMD, editor-in-chief of Dentistry Today; John Flucke, DDS, technology editor for Dental Products Report; Marty Jablow, DMD, known as America’s technology coach; Pamela Maragliano-Muniz, DMD, editor-in-chief of Dental Economics; Chris Salierno, DDS, chief dental officer of Tend; and Dr Lou Shuman.

For more information about the CS 9600, visit carestreamdental.com/CS9600. Learn more about Carestream Dental, and all its innovative solutions, at www.carestreamdental.com.

January/February 2022

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Get the right image, first time, Get the right image, first time, Get image, time, Introducing world’s most intelligent first CBCT scanner— Get the thetheright right image, first time, the CS 9600.the Featuring multiple advances including Introducing world’s most intelligent CBCT scanner— Introducing the world’s most intelligent CBCT scanner— video-aided positioning, superior Stellar technology, the CS 9600. Featuring multiple advances including Introducing the world’s most intelligent CBCT scanner— the CS 9600. Featuring multiple advances including stable seatedpositioning, positioning,superior innovative artifacts video-aided Stellar technology, the CS 9600. Featuring multiple advances including video-aided superior Stellar technology, management and the intuitive SmartPad, the CS 9600 stable seatedpositioning, positioning, innovative artifacts video-aided positioning, superior Stellar technology, stable seated positioning, innovative artifacts enables you and your staff to achieve high-quality, management and the intuitive SmartPad, the CS 9600 stable seated and positioning, innovative artifacts management the SmartPad, the CS 9600 precise images theintuitive first to try,achieve every time. enables you andon your staff high-quality, management andyour the intuitive SmartPad, the CS 9600 enables you and staff to achieve high-quality, precise images on the first try, every time. enables you and your staff to achieve high-quality, precise images on the first try, every time. precise images on the first try, every time.

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Learn more at carestreamdental.com/cs-9600 Learn more at carestreamdental.com/cs-9600 Learn more at 1800 carestreamdental.com/cs-9600 Contact us on 223 603 Learn more at carestreamdental.com/cs-9600 anz-enquiries@csdental.com Contact us on 1800 223 603 Contact us on 1800 223 603 anz-enquiries@csdental.com Contact us on 1800 223 603 anz-enquiries@csdental.com

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MANAGING Pulpitis Irreversible Pulpitis n it comes to the perfect fit, Hu-Friedy is just right.Irreversible MANAGING Pediatrics Endodontics MANAGING Irreversible Pulpitis ™ Biodentine saves pulps EVEN with signs and symptoms As world leader in Pain Management, Septodont TS LOVE OUR STAINLESS STEEL Pediatrics PEDO CROWNS: Endodontics MANAGING ™ Biodentine saves pulps EVEN with signs and symptoms ™ of world irreversible pulpitis* Ultra Safety with the new Twist Lock ™Plus As leader in Pain Management, Septodont Biodentine saves pulps EVEN with signs and symptoms TS OUR STAINLESS STEEL PEDO CROWNS: provides you products and services to help you Biodentine saves pulps EVEN with signs and symptoms ableLOVE outcomes for your littlest patients with Hu-Friedy Stainless Steel Pedo Crowns. 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Please visit our website for more information Call 0508 486 252 our website website for more information information Please our for more www.septodont.com Please visit ourvisit website for more information Please our website for more information Call 0508 486 252 J.M Zakrzewska et al. visit Introducing safety syringes into a UK dental school – a controlled study. Brit Dent J65 200188 ; 190;22 88-92. 08 855 (1) www.henryschein.co.nz Orders 1300 www.henryschein.com.au www.ivoclarvivadent.co.nz Please visit our website for more information www.septodont.com www.septodont.com Please visit ourvisit website for morefor information www.septodont.com *If haemostasis cannot be achieved after full pulpotomy, a pulpectomy and a RCT should65 be carried out, www.henryschein.com.au provided the tooth is restorable (ESE Position Paper,Duncan et al. 2017) Please our website more information Learn more with 08 855 www.henryschein.co.nz Orders 1300 88 22 www.ivoclarvivadent.co.nz www.septodont.com

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

spectrum | NEWS

Full steam ahead for Australia’s best digtal dentistry event June 3-6, 2022

igital Dentistry and Dental Technology 2022 is a matter of months away and registrations continue to grow for the 2-day face-to-face conference. The event is being held on Friday, June 3 and Saturday, June 4 at the Novotel Sydney Brighton Beach and if you haven’t registered already, then don’t miss this great experience (and early bird rates still apply). Digital Dentistry and Dental Technology 2022 brings dentists and specialists, technicians and prosthetists together in a single program, as it should be. Digital Dentistry and Dental Technology 2022 offers every delegate access to more than 100 session choices over two days that allows you to build your own program based on your needs. There is no need to register for any session, you can choose your program ahead of time, on the day or minute-by-minute.

Access to real knowledge he interactive nature of Digital Dentistry and Dental Technology 2022 means that you have unprecedented access to real knowledge and experience from almost 50 speakers who are immersed in the digital workflow every day and the hundreds of delegates who share the same challenges you do.

38 Australasian Dental Practice

Stellar range of speakers his year, we welcome a stellar and still growing line-up of speaking talent, both favourites from past editions as well as many new faces with knowledge and experience to share. From clinicians and technicians, inventors, product and software developers, don’t miss this unique all access educational opportunity. This year, we’re also continuing with the workshop stream including the opportunity to try scanning with all the latest intraoral scanners, all in one room, plus other workshops teaching, for example, stain and glaze techniques for monolithic restorations. Whether you’re a dentist, prosthetist or technician, whether your interests are in products like intraoral scanners, 3D printers, mills or solutions for digital dentures, orthodontics, implants or endo, this program will give you the opportunity to learn and explore. Digital Dentistry and Dental Technology 2022 is designed to be a fun learning experience. Located adjacent to the Sydney domestic airport, the Novotel Sydney Brighton Beach is an ideal venue - easy to fly-in or easy to park. Accommodation is available and full catering is provided.

To view the growing programme of education sessions or to register, visit at www.dentaltechnology.com.au.

January/February 2022

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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.

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. 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. n n

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

spectrum | NEWS

Keeping your details up-to-date on dentist.com.au just became far easier

ustralia’s number one find-a-dentist website www.dentist.com.au has introduced a new option that allows you to quickly request your practice to be listed or changes made to your existing listing. “Our goal continues to be to publish the most up-to-date and comprehensive list of practices and practitioners in both Australia and New Zealand to allow the general public to easily locate a dentist of their choice,” said Joseph Allbeury, publisher of dentist.com.au, dentist.co.nz and this magazine. “In order to facilitate that even further, we have introduced a new option to make the process of adding or updating your information far easier. “Simply click on the For Dentists link on the website and follow the instructions to display the update form. Once you’ve completed the form with all your details, your practice will be added or updated within a day or two.” Mr Allbeury said that the more information you include and the clearer you make the requested changes, the faster your information will be updated. “Please spell out if there is a change in circumstances, like a new owner at the practice or a name change or if you’ve moved. We process every request manually and if we have to do a lot of detective work, it delays the process,” he said. “We typically align all our information with the information on your website, so spell it out if your website doesn’t reflect the changes you’re requesting. We read it all! “Equally, if you don’t have a website at all, then let us know things like your opening hours for example.” All dental practices listed on the website must also have at least one dentist linked to the practice. If there is no dentist, or in the case of a denture clinic, no prosthetist, then the software blocks the listing from being displayed.

“Every practice on the website needs to have at least one dentist linked to it,” Mr Allbeury said. “And before we add a dentist to our system we check that the dentist - and indeed all practitioners in the system - are registered with AHPRA. If we cannot verify your registration record, then we don’t list you on dentist.com.au.” Mr Allbeury said that all practitioners are recorded in the system under the name they are registered under with AHPRA. However, practitioners can choose to have their information displayed using an alternative first name [preferred name]. “We ask that you list all the practitioners working at your practice on the form and it’s very helpful if you list the name you’re registered under too. Then you can also list your preferred name. We have lots of dentists called Robert who like to be known as Bob, for example. Or dentists using their middle name or a nickname or a Western name. It’s no problem, we just need to be able to verify you’re registered.” Mr Allbeury said that whilst using the form is quick and easy, using your Dental Community login to directly update your information remains the preferred option for managing your online presence.

“The best way to maintain your information remains logging in to the Dental Community website,” he said. “This gives you direct access to your own information and so many more options. “If you own a practice, it gives you full control over who works there and the information that is displayed, plus you can see live Google Analytics of who is looking at your information. “If you don’t own a practice, you can log in and link to the practices where you do work or remove yourself when you leave a practice. “You can sign up by visiting the website at www.dentalcommunity.com.au and start managing your own information. It’s simple and it’s free. “Either way, we encourage everyone to visit www.dentist.com.au and work with us to ensure your info is correct.” www.dentist.com.au processes over a million searches per annum from members of the public searching for a dentist. Whether you have a website, or particularly if you do not have a website, ensuring your details are accurately listed will help patients connect with you and your practice.

Add or update your details at www.dentist.com.au/information-for-dentists

42 Australasian Dental Practice

January/February 2022

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spectrum | NEWS

Load your videos on Dentevents.TV

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

New Dentevents.TV features include... n

n n

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

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

“Educational content creators will have a platform to stream videos, issue CPD certificates to viewers or ask CPD quizzes. Content can also be monetised on a payper-view or subscription basis if desired.”

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

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

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

2022 44 Australasian Dental PracticeNo username, no password and no need to login - addJanuary/February your event

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

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spectrum | NEWS

Zirkonzahn shade guides Monolithic Prettau® zirconia shade guides identical to the final restoration, in the shape of a premolar as well as upper and lower incisor are available now

ith the new Zirkonzahn Shade Guides, the patient’s tooth colour can be precisely determined on the basis of monolithic sample teeth made of zirconia. In this way, it is possible to determine the most suitable Prettau Dispersive® zirconia material in a safe and quick manner. The colour spectrum is inspired by the VITA classic range, comprised of 16 dentine colours (A1-D4) and 3 bleach shades. The sample teeth are monolithic and glazed with 3D Base Glaze.

“If the material of the shade guide and the material of the zirconia prosthesis are identical, it is ensured that the colour of the zirconia restoration corresponds 1:1 with the natural tooth colour of the patient...” Colour theory shows that shape and surface structure considerably influence the colour effect. Striving for perfection, the shade guides are built using Prettau Dispersive zirconia materials, in the shape of a premolar as well as lower and upper incisor. One-to-One Function: If the material of the shade guide and the material of the zirconia prosthesis are identical, it is ensured that the colour of the zirconia restoration corresponds 1:1 with the natural tooth colour of the patient. For individualists, the shade guides are also available with minimally reduced, sintered sample teeth (minimal cutback), which can be further characterised by the application of different incisal materials. This results in truly unique shade guides that precisely reflect individual approaches and aesthetic demands.

46 Australasian Dental Practice

Figure 1. Zirkonzahn Shade Guide Prettau Line – Monolithic zirconia shade guides identical to the final restoration, in the shape of a premolar as well as upper and lower incisor (also with minimal cutback for individual characterisation).

Figure 2. One-to-One Function: If the material of the shade guide and the material of the zirconia prosthesis are identical, it is ensured that the colour of the zirconia restoration corresponds 1:1 with the natural tooth colour of the patient. For the dental practice, it is recommended using the specially developed Zirkonzahn Shade Guide Prettau Line in the shape of a premolar as well as a lower and upper incisor (also with minimal cutback for individual characterisation),

to identify easily the natural tooth colour on the patient. For more information visit the website at www.zirkonzahn.com or contact us at stan@alphabond.com.au

January/February 2022

ZIRCONIA FROM THE DOLOMITES PRETTAU® – THE MOST EXPENSIVE. FOR THE PATIENTS YOU VALUE.

Prettau® 3 Dispersive® with Gradual-Triplex-Technology – the high quality zirconia is already provided with colour, translucency and flexural strenght gradients during the production process

New! Zirkonzahn Shade Guide Prettau® Line – Monolithic zirconia shade guides identical to the ﬁnal restoration, in the shape of a premolar as well as upper and lower incisor (also with minimal cutback for individual characterisation)

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

Osteon Medical digital dental implant business acquired by Keystone Dental

steon Medical, the Australian software-enabled dental implant-prosthetic innovator has merged with Keystone Dental Inc., the largest independent dental implant company in North America. Commenting on the deal, Osteon Medical’s founder and CEO, Michael Tuckman said “Osteon Medical’s industry-leading digital implant solution caught Keystone’s eye and turned what was initially a potential distribution relationship into a merger. “Keystone is the perfect partner for Osteon Medical. Their network and experience coupled with our innovation will enable us to simplify complex procedures through technological improvements, delivering tomorrow’s solutions today.” While the combined companies will continue to operate independently, Mr Tuckman said “The deal with Keystone will accelerate our research and development and our expansion into the US and EU markets, while providing career opportunities for our growing team.”

48 Australasian Dental Practice

Dental practitioners and dental laboratories in the US recently trialed Osteon Medical’s patented Nexus solutions with great success. One of Osteon’s most recent developments uses advanced scanning technology,

the patented Nexus iOS solution, to turn around customised, precision-made, titanium-based dental prosthetics. The easy-to-use, cloud-based ordering and transfer platform allows an end-to-end

digital experience which significantly reduces conventional treatment time and increases accuracy. “In our ongoing search for exceptional business partners, we are very pleased to be combining forces with Osteon Medical,” said Melker Nilsson, CEO of Keystone Dental Inc. “The combination of Keystone and Osteon enables us to offer a more comprehensive portfolio of unique and innovative solutions for our customers and partners, especially when it comes to digital workflows, increased efficiency and improved accuracy. The acquisition further provides Keystone with a significantly expanded and synergistic implant sales opportunity to both existing and new customers.” “From modest facilities in Ringwood, Victoria in 2013 we expanded our sales into Asia and are in the process of commissioning our Japanese manufacturing plant,” Mr Tuckman said. “The US has always been recognised as one of the largest markets and we are delighted Keystone Dental has recognised the benefits our technology has to offer them, their customers and the global dental implant market.”

January/February 2022

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62% of your patients 62% of your patients 62% of your patients want straighter teeth. want straighter teeth. want straighter want straighter teeth. teeth. Are you sitting on Are you sitting on Are you sitting on a goldmine? a goldmine? a a goldmine? goldmine?

Despite a slowdown in household disposable Despite Despite a slowdown in household disposable Despite a a slowdown slowdown in in household household disposable disposable Despite a slowdown in household disposable incomes and fewer people with private health incomes and fewer people with private health Despite a slowdown in household disposable incomes and fewer people with private health incomes and fewer people with private health incomes and fewer people with private health insurance, Australian dentists are sitting on a insurance, Australian dentists are sitting on a incomes and fewer people with private health insurance, Australian dentists are sitting on a insurance, Australian dentists are sitting on a insurance, Australian dentists are sitting on a goldmine. goldmine. insurance, Australian dentists are sitting on a goldmine. goldmine. goldmine. goldmine. Research by Orthodontics Australia shows that Research by Orthodontics Australia shows that Research by Orthodontics Australia shows that Research by Orthodontics Australia shows that Research by Orthodontics Australia shows that approximately 55% of Australians are selfapproximately 55% of Australians are selfResearch by Orthodontics Australia shows that approximately 55% of Australians are selfapproximately 55% of Australians are selfapproximately 55% of smile Australians are are self-willing conscious about their and 62% conscious about their smile and 62% approximately 55% of smile Australians are are self-willing conscious about their conscious about their smile and 62% are willing conscious about their smile and and 62% 62% are are willing willing to have their teeth straightened. to have their teeth straightened. conscious about their smile and 62% are willing to have their teeth straightened. to have their teeth straightened. to have their teeth straightened. to have their teeth straightened. Which explains why the Australian clear aligner Which explains why the Australian clear aligner Which explains why the Australian clear aligner Which explains why the Australian clear aligner Which explains why the Australian clear aligner market is expected to grow at a CAGR of market is expected to grow at a CAGR of Which explains why the Australian clear market is expected to grow at a CAGR of market is is expected expected to to grow grow at at a a CAGR CAGR of ofaligner market 28.7%; reaching a whopping USD 534.3 million 28.7%; a 534.3 market is expected to grow atUSD a CAGR 28.7%; reaching a whopping USD 534.3 million 28.7%; reaching reaching a whopping whopping USD 534.3ofmillion million 28.7%; reaching a whopping USD 534.3 million by 2028 by 2028 28.7%; reaching a whopping USD 534.3 million by 2028 by 2028 2028 by by 2028 Affordable, discreet and effective; clear Affordable, discreet and effective; clear Affordable, discreet and effective; clear Affordable, discreet and effective; clear Affordable, discreet and effective; clear aligners are here to stay. aligners are here to stay. Affordable, discreet and effective; clear aligners are here to stay. aligners are here to stay. aligners are here to stay. aligners are here to stay. Whether you’ve been holding off, dabbling Whether you’ve been holding off, dabbling Whether you’ve been holding off, dabbling Whether you’ve been holding off, dabbling Whether you’ve been holding off, dabbling in cases, or you’re looking to take on more in cases, or you’re looking to take on more Whether you’ve been holding off, dabbling in cases, or you’re looking to take on more in cases, or you’re looking to take on more in cases, or you’re looking to take on more complex cases, now is the time to level up your complex cases, now is the time to level up your in cases, or you’re looking to take on more complex cases, now is the time to level up your complex cases, now is the time to level up your complex cases, now is the time to level up your skills and tap into this growing demand. skills and tap into this growing demand. complex cases, now is the time to level up your skills and tap into this growing demand. skills and tap into this growing demand. skills and tap into this growing demand. skills and tap into this growing demand.

DIY clear aligners do not “cut out” dentists. Without a dental expert overseeing cases, DIY aligners can be a risky business. The diagnostic process is going to suffer. Patients might not be ready for aligners. Impressions made by the aligner company may not be accurate. Plus, the patient has no idea whether things are going well or not. Therefore, dentists with strong aligner skills are in demand. The OrthoED Institute helps dentists gain confidence and competence to take on aligner cases with a principle-based approach and hands on support.

Ready to find out more? Book a free 30 minute consultation with OrthoED to discuss your current aligner experience, requirements and to help choose the right orthodontic learning path for you.

Call 1300 073 427 to book your complimentary no obligation call or visit OrthoED.com.au to find out more

NOW YOU CAN TAKE ON ALIGNER NOW YOU CAN TAKE ON ALIGNER CASES WITH CONFIDENCE CASES WITH CONFIDENCE Enjoy clinically successful aligner cases, with profitable and Enjoy clinically successful aligner cases, with profitable and predictable outcomes, even if it’s your first time. predictable outcomes, even if it’s your first time. The OrthoED Institute’s convenient Clear Aligner training programs allow you to develop the confidence and skills toClear offerAligner exceptional standards of Orthodontic The OrthoED Institute’s convenient training programs allow you to treatments, regardless of your previous experience. develop the confidence and skills to offer exceptional standards of Orthodontic

treatments, regardless of your previous experience. Provide your patients with better clinical into a rapidlythat growing Provideoutcomes your patients with better Learn principles applymarket to all Tap clinical outcomes aligners and a variety of cases Learn principles that apply to all Improve patient experience aligners and a variety of cases Take on more cases with Improve patient experience Boost patient referrals and practice no matter how confidence, Take on more cases with complicated profits Boost patient referrals and practice confidence, no matter how profits complicated Increase job satisfaction Stand out from the competition Increase job satisfaction Stand out from the competition Tap into a rapidly growing market

For more information visit www.orthotraining.com.au or For call more 1300 information 073 427 for avisit freewww.orthotraining.com.au 30 minute consultation. or call 1300 073 427 for a free 30 minute consultation.

spectrum | NEWS

International Update Amann Girrbach optimizes all Ceramill Software

ith the Ceramill 4.0 update, Amann Girrbach integrates the exocad Galway Update and numerous other functions. Users can now work more intelligently and with greater clarity and efficiency in a uniform workflow - from the Ceramill Scan software and the Ceramill Mind through to the Ceramill Match 2 and Ceramill Motion. With the Auto-Morphing and Auto-Antagonist features, Amann Girrbach comes yet another step closer to AutoDesign. First, the Auto-Antagonist function determines the exact alignment of the two jaws based on an algorithm. Then the Auto-Morphing function automatically adapts the tooth anatomy to the antagonist and the surrounding area, as well as automatically changing the spacing and fissures. And finally, the result is harmonious integration into the patient’s dentition. The update offers a number of additional functions. For example, the insertion direction can be adjusted intuitively and conveniently. And an improved view on the indication provides the opportunity for an immediate assessment of the impact. Scaling, rotating, modifying as well as copying the connectors is possible from three different perspectives due to the MultiView feature enabling their adaptation to the restoration with perfect precision. The M-Smile feature not only recognises the eyes and lip lines, but also allows fabricating the matching mock-up for the patient with the aid of the 3D printer for a direct fitting - even before the final restoration. Other new features include the option of saving full dentures as standard libraries, the time-saving Auto-Articulation, as well as a more efficient algorithm which can reduce matching time by 37 percent (when using the Ceramill Map 600+) or up to 65 percent (when using the Ceramill Map 200+). An overview of the new update is presented in this video: https://www.amanngirrbach.com/mind-update-2021

52 Australasian Dental Practice

Recent studies have explored approved drugs that exhibit off label antiviral activities against SARS-CoV-2. These could be useful for treatment, especially if they are not impacted by SARS-CoV-2 mutations emerging in variants of concern. When coronaviruses replicate inside a cell, the virus hijacks the host cell stress response in the endoplasmic reticulum to modulate protein translation and protein folding. The receptors which control this known as sigma-1 and sigma-2 can be blockaded. This laboratory study evaluated the use of the antihistamine diphenhydramine as this can block the sigma receptors and may be able to inhibit drug resistant variants resulting from mutations. The study also explored whether antiviral activity could be improved by combining a sigma receptor ligand with lactoferrin, a naturally derived antiviral agent that binds distinct targets. We found that co-administration of lactoferrin with diphenhydramine in cell cultures of Vero E6 cells reduced SARSCoV-2 induced cytotoxicity. The antiviral enhancement effects of lactoferrin were more apparent at lower, therapeutically relevant concentrations of diphenhydramine. Combining lactoferrin with diphenhydramine resulted in synergistic effects on antiviral activity against SARS-CoV-2. Compounds we found effective in Vero E6 were also able to reduce infectious SARS-CoV-2 production following infection of human lung epithelial cells. These laboratory data suggest that sigma receptor ligands may have the potential to inhibit virus infection and/or decrease recovery time from COVID and could represent a potential therapeutic avenue for COVID-19 prevention and treatment. A limitation of this research is that there is no direct evidence of the relationship between viral infectivity in cell cultures and virus transmissibility in humans. It may be that cell culture-based testing is too sensitive a method to adequately represent what happens with viral transmission in humans. Ostrov DA et al. Highly specific sigma receptor ligands exhibit anti-viral properties in SARS-CoV-2 in all infected cells. Pathogens 2021; 10: 1514. Researchers from the University of Louisville School of Dentistry and their colleagues have discovered details of how proteins produced by oral epithelial cells protect humans against viruses entering the body through the mouth. They also found that oral bacteria can suppress the activity of these cells, increasing vulnerability to infection. A family of proteins known as interferon lambdas produced by epithelial cells in the mouth serve to protect humans from viral infection, but the oral bacteria Porphyromonas gingivalis reduces the production and effectiveness of those important frontline defenders. “Our studies identified certain pathogenic bacterial species, P. gingivalis, which cause periodontal disease, can completely suppress interferon production and severely enhance susceptibility to viral infection,” said Juhi Bagaitkar, assistant professor in the UofL Department of Oral Immunology and Infectious Disease. “These resident oral plaque bacteria play a key role in regulating anti-viral responses.” Rodriguez-Hernandez CJ, Sokoloski KJ, Stocke KS, Dukka H, Jin S, Metzler MA, Zaitsev K, Shpak B, Shen D, Miller DP, Artyomov MN, Lamont RJ, Bagaitkar J. Microbiome-mediated incapacitation of interferon lambda production in the oral mucosa. PNAS, 2021; 118 (51): e2105170118 DOI: 10.1073/pnas.2105170118

January/February 2022

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

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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.

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

VITAL

INFORMATION for anyone within 5 years of EXITING

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

TOPICS INCLUDE n

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

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

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

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

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

How do you handle staff discretion, confidentiality and disclosure?

Legal agreements

Effective strategies for transferring patients effectively from seller to buyer

What to do next post sale: post-sale strategies

Tax implications and strategies when selling

Expert finance, legal, accounting speakers

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New frontiers for laser-based methods for hard tissue preparation

Into 2022 and the next phase of the COVID-19 pandemic

By Emeritus Professor Laurence J. Walsh AO

ll modern laser applications are based on a detailed understanding of the way that the energy interacts with the target.1,2 As our understanding of laserto-target interactions has grown over the years, the concepts of laser-based methods for hard tissue preparation have evolved considerably. Today we now think of mechanisms that are photothermal, photomechanical and photoacoustic in nature. This article reviews the changes in thinking in relation to dental hard tissue lasers which have occurred over the past 35 years, seen from the dual perspectives of both clinical use with patients, as well as enhancements in performance which have come from laboratory studies. It summarises what is known for the hard tissue lasers that are well-

By Emeritus Professor Laurence J. Walsh AO

established (Figure 1) and goes beyond tooth structure ablation and laser materials processing applications (Figure 2) to discuss the latest ultrafast laser technologies and robotic control systems (Figure 3).

uring the summer of 20212022, Australian borders reopened, and at the same time, the omicron variant of the SARS-CoV-2 coronavirus (CoV) entered the country and began to spread rapidly. This article provides a summary of current thinking on the progress of the COVID-19 pandemic and the likely issues that will surface during the 2022 calendar year. The discussion begins with considering where we have come from and where we are at present. This is summarised succinctly in Figure 1 which shows data for COVID-19 deaths and COVID-19 vaccinations for Australia. Severe cases, defined as those requiring hospitalisation, are around 14% of all confirmed cases for viral variants before omicron.

The carbon dioxide laser n the late 1980s, I became interested in how lasers could be used to assist in the care of patients with special needs, particularly those with bleeding issues or who were immunocompromised (such as solid organ transplant recipients) who needed periodontal surgery. This was the beginning of my clinical journey using lasers.3-5 It soon became clear that using an infrared laser was an extremely effective way of performing periodontal surgery, providing a smoother patient journey during the procedure, as well as post-operatively.5

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90 Australasian Dental Practice

January/February 2022

Question 1. A femtosecond is: a. 1⁄10,000,000,000,000,000 of a second b. 1⁄1,000,000,000,000,000 of a second c. 1⁄100,000,000,000,000 of a second d. 1⁄100,000,000,000,000 of a second e. 1⁄1,000,000,000,000 of a second Question 2. In sound enamel, current femtosecond laser systems can generate ablation rates: a. Up to 25% of a high-speed edge turbine drill b. Up to 50% of a high-speed edge turbine drill c. Up to 75% of a high-speed edge turbine drill d. Equal a high-speed edge turbine drill e. Double that of a high-speed edge turbine drill Question 3. A Holmium:YAG laser has a wavelength of:

Naturally circulating coronaviruses et us now consider the four endemic coronavirus strains that circulate globally: HCoV-229E, HCoV-OC43, HCoV-HKU1 and HCoV-NL63.1,2 The profile of symptoms that these viruses cause are similar to human influenza viruses and include fever, cough, headache and muscle aches.3 These coronaviruses were first discovered in 1966, with the most recent of the four strains being discovered in 2014.4,5 Along with human influenza viruses, coronaviruses typically cause human respiratory tract infections during the winter months, which coincides with the time of year when people are more likely to spend long periods of time indoors.

January/February 2022

Question 6. A UK study showed that in people over 80, the Pfizer vaccine had a reduction in effectiveness after 20 weeks of: a. 4% b. 15% c. 23% d. 30% Question 7. SARS-CoV-2 has a close similarity to the bat coronavirus: a. Rc-o319 b. RaTG13 c. RmYN02 d. All of the above Question 8. Which coronavirus is not considered a globally circulating endemic strain:

a. 2940 nm b. 2780 nm c. 2100 nm d. 9300 nm

a. HCoV-229E b. HCoV-OC43 c. HCoV-HKU1 d. HCoV-ME12 e. HCoV-NL63

Question 4. Which laser induces analgesia at the level of the dental pulp during hard tissue preparation:

Question 9. Approximately 1% of individuals with COVID-19 have an incubation period of more than:

a. Nd:YAG laser b. Er:YAG laser c. Er,Cr:YSGG laser d. All of the above

a. 7 days. b. 10 days c. 14 days d. 21 days

Question 5. An Australian developed and patented concept for hands-free, low-contact laser dentistry is called:

Question 10. University of Queensland halted trials of a vaccine candidate because recipients were falsely testing positive for:

a. Dentrix b. Laseroid c. Dentroid d. Dentobot e. Laserdent

a. HPV b. HAV c. HIV d. HBV e. HCV

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 Jan/Feb 2022 questionnaire and then click START. A score greater than 80% is required to PASS and receive CPD.

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A-dec offers dental unit biofilm testing service

ith the heightened focus on infection control within the dental practice, A-dec has introduced a useful new product to test the microbiological quality of dental unit water lines and surfaces accurately and easily in dental clinics. The 2-Min Water Control System rapidly and accurately determines the presence of biofilm in dental unit waterlines in just two minutes, to enable monitoring and action as required. It provides accurate results, eliminating incubation periods or the need to send samples to a laboratory.

A water sample is taken from the dental unit waterline and by adding a few drops of reagents, produces a result which is immediately interpreted and displayed on a Lumitester Smart device. In the case of microbiological shifts, the dental team can then use the results to implement A-dec’s recommended maintain, monitor and shock waterline maintenance guide to ensure infection control protocols are maintained. The advantage of this digital test device is rapid and accurate chairside results, without the long wait times and inaccurate manual verification methods of commonly used bacteria swab test kits. The Lumitester uses ATP-metry – which measures the presence of Adenosine triphosphate (ATP). ATP is present

in all living organisms, providing early warning of biofilm build-up at small concentrations. By counting the number of photons emitted by the bioluminescence reaction, it displays the results in RLU (Relative Light Units). This technology is widely used in the food industry and medical settings to test for harmful biofilms. When used with the 2-Min Water Control reagent kit, ATP is converted to colony forming units (CFU) to determine the bacterial load of the water sample. The ADA guidelines state it is good practice to test water lines on a regular basis, for example six-monthly or annually. There has been no change in the

ADA’s target level of 200 CFU/mL in dental unit waterlines, however, clinics often set their own levels such as 100 CFU/mL as a trigger point for action. When high counts are found, the waterlines will need to undergo additional shock or sanitising treatments. Dental unit waterlines are susceptible to biofilm build-up because of the narrow water passages in dental equipment and the slow movement of water through the water lines. The problem is greatly exacerbated if equipment has been left idle. According to A-dec product manager, Angie Wong, this risk is reduced by using a self-contained dental unit waterline system such as that found on A-dec chairs, treated with ICX infection control tablets. She said the patented design of

98 Australasian Dental Practice

Instrument management systems improve your practice

the A-dec pneumatic control block also eliminated stagnant water, by circulating fresh water through the control block each time a handpiece is used. To optimise the quality of your dental unit water, be sure to use a fresh ICX tablet and follow these steps every time you refill a self-contained water bottle: 1. Empty any remaining water left in the bottle; 2. Drop the tablet into an empty dental unit water bottle (0.7L tablet in 0.7 litre bottle, 2L tablet in 2 litre). Avoid touching the tablet with skin; 3. Fill the bottle with water, then install it on the dental unit; and 4. Wait two minutes for the tablet to fully dissolve before using the system. Mrs Wong said now is an ideal time to conduct a 2-minute water test to determine the status of your dental unit waterline. The exclusive 2-minute testing technology is available as a service on a scheduled basis by authorised and qualified A-dec dealers - similar to annual autoclave testing and validation. For more info on the 2-minute water testing service, contact your local A-dec dealer. Dealer and A-dec Territory Manager details are available on the A-dec website or by phoning 1800-225-010.

Four case studies explore the benefits of making the switch

unning a dental practice takes a lot of work and whether it’s a private practice or part of a corporate, finding ways to save time, maximise efficiency and see more patients is a universal objective. Although all practices are different and face unique challenges, one common issue is optimal instrument management. For many practices, switching to an Instrument Management System (IMS®) provides innumerable benefits; however, practices may be reluctant to switch. Practices may have to reconfigure their sterilisation area, purchase new instruments or retrain employees, but the return is worth the investment. Whether it’s reduced sharps injuries, enhanced organiaation, cost reductions, increased patient counts or another benefit, practices that adopt IMS see measurable results. Over the years, Hu-Friedy has profiled dental practices that implement IMS to explore the variety of ways that it positively impacts practices. Here are a few examples:

Reducing sharps injuries at PDS orporates like Pacific Dental Services (PDS) are always looking for measurable, data-driven ways to improve safety and ensure regulatory compliance across their network of practices. To better understand the impact of IMS, PDS identified

two practices with an opportunity to reduce sharps injuries to trial the cassette-based system. After implementing IMS in those practices, PDS compared the results after a year with equivalent control practices. The findings were unmistakable. Not only were sharps injuries reduced to zero for the two practices during the trial period, but both practices experienced improved efficiency, as instruments were reprocessed eight minutes faster on average, freeing up time to spend with patients. Following this successful experiment, PDS expanded it to more locations to verify the findings, which generated identical results. With such positive outcomes, Hu-Friedy worked with PDS to implement IMS in over 100 practices.

104 Australasian Dental Practice

January/February 2022

Question 11. The Water Control System analyses DUWL biofilm in:

Question 16. Using an Instrument Management System can:

a. 60 seconds b. 2 minutes c. 5 minutes d. 15 minutes

a. Reduce sharps injuries. b. Enhance organisation. c. Reduce costs due to reduced instrument damage. d. All of the above.

Question 12. The Lumitester measures the presence of:

Question 17. After implementing an Instrument Management System, Pacific Dental Services’ sharps injuries were reduced to:

a. Polysaccharides b. Lipids and nucleic acids c. Extracellular polymeric substances d. Adenosine triphosphate e. All of the above

a. 0 b. 1 per month c. 1 per year d. 2 per year

Question 13. ADA guidelines recommend action when the bacterial load in dental unit water reaches:

Question 18. After implementing an Instrument Management System, Pacific Dental Services reprocessed instruments faster on average by:

a. 100 CFU/mL b. 200 CFU/mL c. 300 CFU/mL d. 400 CFU/mL

a. 3 minutes b. 5 minutes c. 8 minutes d. 11 minutes

Question 14. When high bacterial counts are found, waterlines need to undergo shock and sanitising treatments:

Question 19. Using an Instrument Management System, Floss & Co improved process efficiencies per patient by:

a. True b. False

a. 8 minutes b. 10 minutes c. 12 minutes d. 15 minutes

Question 15. Dental unit waterlines are susceptible to biofilm build-up because of the narrow water passages in dental equipment and the slow movement of water through the water lines: a. True b. False

Question 20. Thanks to improved efficiency and organisation from using an Instrument Management System, Floss & Co’s new patients increased by: a. 10% b. 20% c. 30% d. 40%

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abstracts | 2022

A summary of the latest research

By Emer. Prof. Laurence Walsh AO

Optimising the use of rapid antigen tests

ARS-CoV-2 rapid antigen tests (RAT) have attracted attention as a supplement or alternative to PCR testing because of the possibility of rapid on-site testing (“point of care test” or POCT). Rapid SARS-CoV-2 antigen testing is considered a promising method for containing and combatting the SARS-CoV2 pandemic. Since the POCT tests are to be used as mass tests in certain occupational sectors, it is necessary to take a closer look at them from an evidence-based and test-theoretical point of view. We performed model calculations on the possible use of RAT as mass tests, for a base model of 1,000,000 SARS-CoV-2-rapid pointof-care tests per week using various sensitivities and specificities reported in the literature, followed by sequential testing of the test positives obtained by a SARS-CoV-2 PCR test. Assuming for Germany 1,000,000 tests per week at a prevalence of 0.5%, a high number of false positive test results, a low positive predictive value, a high negative predictive value and an increase in the 7-day incidence due to the additional antigen rapid tests of

approximately 5/100,000 were obtained. Both rapid antigen tests and the SARS-CoV-2 PCR test method should only be used if there is a corresponding high pre-test probability, i.e. with a corresponding diagnostic hypothesis. In effect, this means that they should be used on people suffering from respiratory symptoms and not on symptom-free people, because, even if the disease disappears completely, there will be a tail of false positive results. This could be incorrectly interpreted by the political mandate holders as a worsening of the infectious situation because the positive rate is used by politicians as an indicator of the severity of the epidemic situation. Ideally, a differential diagnosis should use a multiplex PCR test (e.g. SARS-CoV-2-qPCR Plus). This would detect the coronavirus as well as influenza A and B and respiratory syncytial virus (RSV) and other particularly frequently encountered respiratory tract pathogens, instead of just screening for the one pathogen. In the diagnosis of SARS-CoV-2, the WHO points out that testing for other pathogens should also be carried out. Co-infections with other pathogens do not exclude COVID-19 and vice versa. Current data on the global Infection Fatality Rate (IFR) for COVID-19 is 0.15%, which means that 99.85% of those with a COVID-19 infection survive the disease.

58 Australasian Dental Practice

In view of such a comparatively low mortality rate and correspondingly high survival rate, mass testing of large population groups is not expedient from an epidemiological aspect and is not justified. SARS-CoV-2-rapid point-of-care tests as well as PCR tests should both be used exclusively in the presence of corresponding respiratory symptoms and not in symptom-free persons. Those who are administering RAT must assess each result in the context of the timing of sample collection, type of sample, clinical observations, patient history, confirmed contacts and epidemiological information. Hirsch O et al. Methodological problems of SARS-CoV-2 rapid point-of-care tests when used in mass testing AIMS Public Health 2021; 9(1): 73-93.

Monoclonal antibodies in COVID tests

OVID-19 has caused a serious global health concern due to its rapid spread, high morbidity and economic challenge in the health sector across numerous countries. There is great scope for further research in discovering cost-effective and safer therapeutics, vaccines and strategies to ensure equitable access to COVID-19 prevention and treatment services. Early diagnosis, effective treatment and preventive measures form the cornerstones in disease containment. A rapid and specific diagnostic approach is essential in identifying COVID-19 positive cases. This would allow prompt isolation and early treatment initiation to such patients in designated centres, rapid antigen tests (RAT) detect the presence of SARS-CoV-2 nucleocapsid protein antigen on the viral surface in saliva and in nasopharyngeal and oropharyngeal swab samples. This test relies on specific monoclonal antibodies to bind to specific viral antigens in fluid samples, using a user-friendly fluorescence lateral flow assay. However, due to its lower detection sensitivity and specificity than PCR, RAT are not considered a gold standard in the diagnosis of COVID-19. In terms of treatment agents, tocilizumab is a recombinant humanized monoclonal antibody directed against the IL-6 receptor. It is currently used to treat rheumatoid arthritis, giant cell arteritis and in cases of life-threatening cytokine storm conditions. Tocilizumab reduces the mortality rates, ICU admissions and also lowered the risk of ventilation in severe COVID-19 patients. Other monoclonal antibodies of interest are baricitinib, a selective JAK1/2 kinase inhibitor used in the treatment of rheumatoid arthritis and psoriatic arthritis. It prevents the occurrence of immune mediated respiratory distress in severe COVID-19 cases. Ruxolitinib and anakinra are other immunomodulatory drugs used in the on-going clinical trials for treating COVID-19 patients. Despite these advances, due to numerous challenges encountered across many countries in controlling COVID-19 through existing preventive measures, an effective and economical vaccine remains the only retort to combat COVID-19 successfully.

Umakanthan S et al. A rapid review of recent advances in diagnosis, treatment and vaccination for COVID-19. AIMS Public Health 2021; 8(1): 137-153.

January/February 2022

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New frontiers for laser-based methods for hard tissue preparation By Emeritus Professor Laurence J. Walsh AO

60 Australasian Dental Practice

January/February 2022

We quickly realised that the technology had other surgical uses beyond gingivectomies and soft tissue crown lengthening procedures. Managing external root resorption and peri-implant disease became clinical topics of interest.6,7 Both required understanding how the laser energy would interact with either a tooth or a dental implant to ensure that adverse surface changes did not occur.7-9 The same thinking was applied when considering how laser energy introduced into a perio pocket would interact with the adjacent structures.10-12 The early laser systems that we used to prepare cavities and etch enamel were large and bulky and relatively few wavelengths were available at that time to test on samples of teeth under controlled laboratory conditions. One of the most widely used surgical lasers in major hospitals at the time, the Scalibre 60, became the initial testbed for our research. This carbon dioxide laser (10600 nm wavelength) could operate in continuous wave at 60 W, or in super pulsed mode to reach peak power of around 400 W. We soon found that preparing cavities in teeth required a careful approach. When used towards the upper limits of its power range, this laser could drill holes 4 mm deep through tooth structure in 0.1 seconds. It became clear that using low powers was going to be essential and that could be advantageous not only to better control the ablation effects on the enamel and dentine, but also to reduce peripheral heating effects.13,14 In tests of the effectiveness of the carbon dioxide laser for cavity preparation, we noted that the shape of the cavity was the same as the imprint of the laser beam, with rounded edges (Figure 1). At these edges, the enamel had undergone fusion. In later tests, it became clear that this same laser could be used to deliberately fuse enamel, to close over the openings of very small fissures and thus serve as a method of fissure sealing. Ultrafine hydroxyapatite powder could be sintered onto the surface of the tooth (Figure 2) and this provided a novel approach to sealing fissures in teeth.15,16 Raman spectroscopic studies of the fused enamel showed that it was not chemically the same as normal enamel, but had instead been converted by heat into beta tricalcium phosphate (TCP) and calcium hydroxide. Both materials are intensely white in colour. Beta TCP was found to be difficult to etch and bond to and its intensely white appearance would be a problem for restorations built upon it.17,18

January/February 2022

Figure 1. A: A collection of dental hard tissue lasers - Er:YAG (1 = KaVo KEY3+, 2 = Fotona Lightwalker), Er,Cr:YSGG (3 = Biolase Waterlase, 4 = Biolase); Carbon dioxide (5 = Deka Smart US-20); Nd:YAG (6 = Sunrise dLase 300). B: Using a carbon dioxide laser (Luxar LX-20D) for a procedure in 1992. C: SEM image from an early study of low power CO2 laser enamel ablation using a single laser pulse, showing a smooth shallow crater in the enamel, with spalling (ejection) of material beyond the crater edge and a central crack from thermal changes. The bar shows 100 µm. D: SEM image of the same laser parameters used on unfilled resin sealant, showing a smooth deep crater with minimal spalling at the edges. The bar shows 100 µm.

Figure 2. Carbon dioxide laser materials processing effects relevant to dental hard tissue applications. A: A light microscopic view (black and white image) showing surface roughening (laser etching) of enamel using multiple laser pulses. The bar shows 1 mm. The scale is similar to panel C immediately below it. B: SEM view of laser etched enamel showing the characteristic microscale roughness that is created. The bar represents 10 µm. C: Light microscopic view of fusion of enamel using multiple laser pulses. Note the change in colour to dense white due to chemical conversions. The bar shows 1 mm. D: Laser sintering of nanoparticles of hydroxyapatite using laser pulses to fuse the particles into a solid mass. The bar shows 1 µm.

Australasian Dental Practice

the cutting | EDGE Along the way, we discovered that both surfaces treated with the carbon dioxide laser during cavity preparation and those that had been exposed to fluoride gel prior to exposure to the laser had an unusually high resistance to acid challenges. Enamel exposed to the laser in combination with a fluoride gel also showed a much greater uptake of fluoride than normal enamel. This effect of laser activated fluoride became incorporated into the ADA item code 121. In later studies, we found that many visible light wavelengths were also able to enhance the interaction of fluoride with enamel and that the action spectrum of the effect also extended into the near and middle infrared range.19,20 It turned out that the process of enhancing the resistance of the tooth structure to acid involved multiple mechanisms, with the main one being enhanced conversion of the surface to fluorapatite.21

Solid state lasers ne of the early solid state lasers we explored for hard tissue preparation was the Nd:YAG laser. The emissions from this laser did not absorb strongly into dentine or enamel, requiring the use of an initiating agent (such as India ink) to enhance its uptake into tooth structure. Careful use of this laser could however achieve some interesting and useful effects on the tooth surface, such as closing over the openings of patent dental tubules to treat hypersensitive cervical dentine.22 We found the same beneficial effect on open dentine tubules with the Er:YAG laser.23 As it turned out, the Nd:YAG laser (1064 nm), the Er:YAG laser (2940 nm) and the Er,Cr:YSGG laser (2780 nm) were excellent for inducing analgesia at the level of the dental pulp, providing patient comfort during hard tissue preparation.24,25 Both of the erbium family lasers were highly effective at ablating tooth structure using a photomechanical process involving explosions of the water trapped within the tooth structure. They could also selectively remove many types of tooth-coloured restorative materials.26 The generation of an analgesic effect from the laser during cavity preparation made these lasers especially useful in children and in patients with significant dental fear. Undertaking laser hard tissue preparation was now a completely different patient experience for them, with little or no dis-

62 Australasian Dental Practice

comfort during the procedure and limited or no use of injections of local anaesthetic. The combination of laser induced analgesia with a different sensory experience gave superior patient outcomes and drove the uptake of this technology in private practice settings.27,28

Etching and bonding n the 1990s, we were interested in the process of physical conditioning of the surface to enhance the adhesion of materials. We worked with some early generation dual wavelength lasers from Fotona such as the Twinlight that combined both an Nd:YAG laser and the Er:YAG laser in the one unit. As we did not have access to one of these systems in Brisbane on a regular basis, but did

“An important advantage of the Ho:YAG laser over the erbium laser wavelength is that the former can be delivered using a flexible glass fibre, while the erbium lasers require more complex delivery systems...” have access to our own CO2 lasers, those became the workhorse for studies of laser etching of enamel and dentine. We found that when using the bonding agents available at the time, the bond strength to enamel could be considerably enhanced by using laser protocols that selectively roughened the surface of the tooth.29-31 Later, we found that the same laser could also be used to selectively remove composite resin, unfilled resin, sealants and residues of bonding agents.32,33

Toward more selective cavity preparations iven the better control of tooth structure ablation with the erbium family lasers compared to the carbon dioxide laser, we then changed track and focused our efforts on optimising the process of ablation for the erbium lasers. We found there was a very straightforward relation-

ship between the pulse energy delivered from the laser handpiece and the extent of ablation. Using a low pulse energy could selectively remove carious tooth structure but not sound tooth structure and also allow the selective removal of composite resin restorations.26,34,35 By the turn of the 21st century, erbium family lasers had become recognised for their usefulness as part of general dental practice, as an alternative to traditional rotary instruments.26,36,37 It was also clear that cavities prepared using these lasers had reduced microleakage at their margins.38 Over time, several methods were developed to help guide laser removal of dental caries from both enamel and dentine. Specific methods were needed because conventional approaches, including the use of caries detector dye, lacked sensitivity and specificity and were notorious for giving false positive results that could then lead to over-preparation.36 One of these new methods involved analysis of the type of sound produced by pulses which caused ablation of tooth structure.39 The science underlying this related to the tissue density difference between sound and carious tooth structure because of the presence of more water in carious tooth structure and the corresponding effects on the propagation of sound. Another method that was developed was the use of real-time fluorescence diagnostics. This same method has been found to be useful for other dental procedures, including the debridement of teeth and dental implants and the preparation of the root canal system. As with cavity preparation, in all these situations it can provide advice around an endpoint for treatment.9,40-46 In fact, changes in fluorescence readings over time could even predict when cavitation of white spot lesions was likely to occur.47,48 More recent work has identified factors that could interfere with fluorescence measurements, especially those that cause false negative readings and has documented several solutions to overcoming such issues.49-51 As well, various wavelengths of light have been used to assess their value for fluorescence diagnosis. While early work used visible red light (655 nm) for real time feedback,52 later work used visible violet light (405 nm). This was found to be highly effective for fluorescence recognition of both carious

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tooth structure and also of restorative materials.53-58 Using fluorescence-based approaches greatly reduces the risk of over preparation of teeth when removing existing restorations.59

Using new wavelengths for hard tissue preparation hile the erbium laser wavelengths of 2940 and 2780 nm have been popular for some time, there are other useful wavelengths, such as the 9300 nm carbon dioxide laser (as used in the Solea® laser) and the Holmium:YAG, at 2100 nm. In 2007, we tested the Ho:YAG laser with a water mist spray and found that this could give excellent ablation of both enamel and dentine, providing results very similar to that seen for the

“Another method that was developed was the use of real-time fluorescence diagnostics. This same method has been found to be useful for debridement of teeth and implants and the preparation of the root canal system...” erbium laser wavelengths.60 An important advantage of the Ho:YAG laser over the erbium laser wavelength is that the former can be delivered using a flexible glass fibre, while the erbium lasers require more complex delivery systems. Looking to the future, a major area of interest will be laser systems that can deliver minimal intervention approaches, encompassing the treatment of patients across a wide range of ages.61-64 Such systems should be able to ablate all manner of materials that may be present on teeth and within teeth. This aspect is a major limitation of existing commercial laser systems for dental hard tissues.65 To achieve this objective means thinking outside the box and looking towards ultrashort pulse laser systems, especially those that operate in the near infrared range (e.g. 700-1300 nm). In this wavelength range, the ablation of all manner of materials can be achieved. At the same time, laser analgesia can be generated by photobiomodulation.65

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Figure 3. Hard tissue procedures conducted on the bench using the Dentroid® prototype device. A and B: Views of the operator’s control station for the laser, showing micromanipulator controls for variable speed X-Y translation of laser cutting and laser power monitoring. The screen displays images of the treated tooth, using different fluorescence imaging modes. C: The working view of the same tooth seen under white light illumination. Images A-C are courtesy of Emudent Technologies. D: An example of precision laser cutting of dentine using the Dentroid® prototype device, showing a vertical channel 430 microns wide and a horizontal channel 482 microns wide. These were prepared using a robotically controlled pulsed Ho:YAG 2100 nm laser using water mist spray. Note the smooth and regular margins and the lack of thermal changes (melting, carbonisation and spalling) of the target. The scale bar in the lower right corner is 50 microns. Image D is courtesy of Ludovic Rapp, Steve Madden and Andrei Rode of the Laser Physics Centre, Research School of Physics, Australian National University, Canberra. Lasers with ultrashort pulses achieve the highest peak powers when the pulse duration is in the femtosecond (10-15 of a second) range. By using an extremely short pulse duration, these lasers can create massive energy density values within targets of all types, regardless of whether or not they are opaque or transparent to the laser wavelength being used. Femtosecond lasers can alter the surface of the material, as well as work inside the material, through the creation of nanoplasma. The effects of nanoplasma on materials include ionisation and disruption of chemical bonds, achieving ablation with minimal heat associated changes or defects occurring beyond the target.66-69

By using an ultrashort laser with high pulse frequencies, a machining action can be achieved on a structure to achieve unrivalled precision in terms of preparation geometry. Current femtosecond laser systems can generate ablation rates up to a quarter of that of a high-speed edge turbine drill in sound enamel. Around the world, work in multiple laboratories has explored the performance of femtosecond laser systems for dental hard tissue ablation, with the goal of making these laser systems not only more precise, but equal to traditional rotary dental instruments in terms of their overall speed. Thus far, very promising results have been obtained from over 10 studies undertaken by different

Australasian Dental Practice

the cutting | EDGE groups around the world, including in Australia.70-80 In fact, Australian researchers have been at the forefront of the field of ultrashort laser pulse shaping of dense and rigid materials for the past 15 years.66,67,71 Including a feedback system with an ultrashort pulse laser system will maximise the benefits of the high precision of the femtosecond laser approach, allowing the stepwise removal of restorations of all types as well as selective removal of carious tooth structure. In addition to this, an ultrashort laser system could be combined with a robotic system so that the laser beam could be controlled remotely by the dentist - sitting in the same room or at a distant location - rather than being hand held, as is the case with current dental hard tissue lasers. This handsoff approach would reduce the physical demands of performing restorative dental procedures, including intense visual concentration during cavity preparation and could also assist in reducing health issues relating to musculoskeletal disorders and posture. A device which operates at a distance from the dentist would also reduce exposure of the dentist to aerosols generated by the procedure. As well as being able to complete cavity preparations, femtosecond laser systems can also perform subtle forms of etching known as nanoripples, which can enhance the adhesion of materials for bonding to the tooth structure and they can also be used to undertake photo-polymerisation, using two photon effects that accompany ultrashort laser pulses. This would allow the deposition and selective curing of materials in thin layers, which would be advantageous in reducing or eliminating effects caused by shrinkage during polymerisation.

Robotically controlled femtosecond lasers t has been argued that, despite their many advantages, one of the barriers to the wider adoption of lasers for hard tissue procedures by mainstream dentistry is that hard tissue lasers are used to prepare teeth without tactile feedback. They do not have the same feel as using traditional rotary instruments. As well, pulsed lasers cut in increments. Using large pulse energies creates irregular craters and as a result, early lasers were not very effective for tasks like minimal preparations. Fine

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control of the laser handpiece and overlapping of pulses is necessary to achieve regular flowing cavity outlines. This level of control is generally not possible unless magnification is being used. Recently, an Australian company (Emudent Technologies, trading as Dentroid) developed and patented the “Dentroid®” concept for hands-free, lowcontact laser dentistry. Their concept involves a miniaturised robotic assembly placed in the mouth and attached directly onto target teeth. The laser beam is delivered onto the tooth surface through miniaturised optics that are controlled by the dentist using a panel located in the operatory a few feet away or remotely. This concept can herald a new age of laser dentistry using the power of advanced

“The deployment of femtosecond laser systems into dental practice would be a game changer, in the same way that the use of ultrashort pulse laser systems completely changed the specialty of ophthalmic surgery and brought in completely new methods for vision correction that are less invasive...” imaging and real-time feedback to guide operative procedures, from minimally invasive preparations through to crown and bridge preparations, at unprecedented levels of precision that are not achievable using hand-held laser handpieces. Real time imaging using multiple imaging modes brings in superior visualisation of what is happening on the tooth as the laser energy interacts with it, but also opens the door for advanced control systems that guide the placement of laser pulses using autopilot algorithms and artificial intelligence, informing the clinician of what parts of the tooth are carious or not, which parts are restored versus sound and whether geometry of the preparation needs modification, for example. The company expects their product to be available in the market by 2024 (Figure 3).

Conclusions he horizons for dental hard tissue lasers see the emergence of new wavelengths and new delivery modalities, offering enhanced control for the dentist as well as enhanced visualisation of the structure and composition of the tooth which is being treated. Together, these all allow more selective dentistry with less biological cost for the patient. From the 1980s to the present, the technology has improved dramatically and the changes which have occurred have represented revolutions rather than small stepwise changes. The deployment of femtosecond laser systems into dental practice would be a game changer, in the same way that the use of ultrashort pulse laser systems completely changed the specialty of ophthalmic surgery and brought in completely new methods for vision correction that are less invasive. The lasers that we currently have available for dental hard tissue procedures could not have been imagined when this field was in its infancy in the 1980s. Likewise, one can only dare to imagine what the next decades will bring in this area of technology.

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.

January/February 2022

AALD Australian Association For Laser Dentistry Dental Conference 2022

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the cutting | EDGE References 1. Walsh LJ. Dental lasers: Some basic principles. Postgrad Dent. 1994; 4: 26-29. 2. Coluzzi DJ, Convissar RA, Roshkind DM, Walsh LJ. Laser fundamentals. In: Convissar RA (ed) Principles of Laser Dentistry, 3rd edition, 2022. St Louis: Elsevier Mosby. 3. Walsh LJ. Soft tissue management in periodontics using a carbon dioxide surgical laser. Periodontology 1992; 13:13-19. 4. Walsh LJ, Ivanovski S. Cosmetic management of gingival fibromatosis by laser recontouring. Periodontology 1997; 18(1): 3-6. 5. Walsh LJ. Utilization of a carbon dioxide laser for periodontal surgery: a three year longitudinal study. Periodontology 1995; 16: 3-7. 6. Walsh LJ, Ryan PC. Management of external root resorption by carbon dioxide laser ablation and sealing. Australian Endodontic Newsletter 1992; 18: 15-17. 7. Walsh LJ. The use of lasers in implantology: an overview. J Oral Implantol. 1992; 18: 335-340. 8. Fenelon T, Bakr M, Walsh LJ, George R. Effects of lasers and their delivery characteristics on machined and micro-roughened titanium implant surfaces. Bioengineering 2020; 7(3: 93-113. 9. Tran C, Walsh LJ. Novel models to manage biofilms on microtextured dental implant surfaces. In: Dhanasekaran D and Thajuddin N (eds) Microbial Biofilms. Importance and Applications. Croatia: InTech Publishers, 2016. pp. 463-486. 10. Walsh LJ. Laser curettage: a critical analysis. Periodontology 1993; 14: 4-12. 11. Walsh LJ. Applications of carbon dioxide surgical lasers in periodontology and implantology. Postgraduate Dentist (London) 1994; 4:50-54. 12. Walsh LJ. Emerging applications for lasers in implantology. Periodontology 2002; 23(1):8-15. 13. Walsh LJ. Pulpal safety parameters for irradiation of dental hard tissues with carbon dioxide lasers. Aust Endod Newsl 1993; 19: 21-25. 14. Sandford MA, Walsh LJ. Pulpal temperature changes during desensitization and other low power hard tissue CO2 laser procedures. Aust Endod Newsl. 1995; 21: 36-38. 15. Walsh LJ, Perham S. Enamel fusion using a surgical carbon dioxide laser: a technique for sealing pits and fissures. Clin Prev Dent 1991; 13: 16-20. 16. Walsh LJ. Applications of infrared lasers in preventive dentistry. Dent Today 1990; 6: 1-4. 17. Aminzadeh A, Shahabi S, Walsh LJ. Raman spectroscopic studies of CO2 laser-irradiated human dental enamel. Spectrochim Acta. 1999; 55:1303-1308. 18. Aminzadeh A, Shahabi S, Walsh LJ. FT-Raman spectroscopic studies of Nd/YAG laser-irradiated human dental enamel. Iran J Chem Chem Eng. 2002; 21(1):44-46. 19. Vlacic J, Meyers IA, Kim J, Walsh LJ. Laser-activated fluoride treatment of enamel against an artificial caries challenge: comparison of five wavelengths. Aust Dent J. 2007;52(2):101-105. 20. Vlacic J, Meyers IA, Walsh LJ. Laser-activated fluoride treatment of enamel as prevention against erosion. Aust Dent J. 2007;52(3):175-180. 21. Vlacic J, Meyers IA, Walsh LJ. Photonic conversion of hydroxyapapite to fluorapatite: a possible mechanism for laseractivated fluoride therapy. J Oral Laser Appl. 2008;8(2):95-102. 22. Forrest-Winchester K, Walsh LJ. The effect of infrared laser radiation on dentinal permeability in vitro. Periodontology 1992; 13: 37-43. 23. Shakabiae F, Diklic S, Walsh LJ. An assessment of changes in dentine permeability following irradiation with a pulsed Erbium:YAG laser. Periodontology 2002; 23(1):4-7. 24. Walsh LJ. Applications and features of current generation dental lasers used for cavity preparation. Australas Dent Pract. 2002;13(5):70-74. 25. Walsh LJ. Laser dentistry: Membrane-based photoacoustic and biostimulatory applications in clinical practice. Australas Dent Pract. 2006;17(5):62-64. 26. Walsh LJ. The current status of laser applications in dentistry. Aust Dent J. 2003;48(3):146-155 27. Walsh LJ. Laser analgesia with pulsed infrared lasers: theory and practice. J Oral Laser Appl. 2008;8(1):1-10. 28. Hmud R, Walsh LJ. Dental anxiety: causes, complications and management approaches. Internat Dent. 2007;9(5):6-16. 29. Walsh LJ, Abood D, Brockhurst PJ. Bonding of composite resin to carbon dioxide laser-etched human enamel. Dent Mat. 1994; 10: 162-166.

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30. Shahabi S, Walsh LJ. Effect of bonding agents on adhesion of composite resin following CO2 laser etching of human enamel. J Clin Laser Med Surg. 1996; 14:169-173. 31. Shahabi S, Brockhurst PJ, WALSH LJ. Effect of selected tooth-related factors on the shear bond strengths obtained with CO2 laser conditioning of human dental enamel. Aust Dent J. 1997;42(2): 81-84. 32. Mazouri Z, Walsh LJ. Damage to dental composite restorations following exposure to CO2 laser radiation. J Clin Laser Med Surg. 1995; 13:73-76. 33. Smith SC, Taverne AAR, Walsh LJ. Removal of orthodontic bonding resin residues by CO2 laser radiation: surface effects. J Clin Laser Med Surg. 1999; 17(1):13-18. 34. Al-Batayneh OB, Seow WK, Walsh LJ. Assessment of Er:YAG laser for cavity preparation in primary and permanent teeth: a scanning electron microscopic and thermographic study. Pediatric Dent. 2014; 36(3):90-94. 35. Sanusi SY, Seow WK, Walsh LJ. Effects of Er: YAG laser on surface morphology of dental restorative materials. J Phys Sci. 2012; 23(2): 55-71. 36. Mount GJ, Walsh LJ, Brostek A. Instruments used in cavity preparation. In: Mount GJ and Hume WR. Preservation and restoration of teeth, 2nd edition. Brisbane, Knowledge Books and Software. 2005. pp. 119-143. 37. Brostek AM, Bochenek AJ, Walsh LJ. Minimally invasive dentistry: A review and update. Shanghai J Stomatol. 2006; 15(3):225-249. 38. Shahabi S, Ebrahimpour L, Walsh LJ. Microleakage of composite resin restorations in cervical cavities prepared by Er,Cr:YSGG laser radiation. Aust Dent J. 2008; 53(2):172-175. 39. Walsh LJ. Laser analgesia with pulsed infrared lasers: theory and practice. J Oral Laser Appl. 2008;8(1):1-10. 40. Sainsbury AL, Bird PS, Walsh LJ. DIAGNOdent laser fluorescence assessment of endodontic infection. J Endod. 2009; 35(10): 1404-1407. 41. Ho QV, George R, Sainsbury AL, Kahler WA, Walsh LJ. Laser fluorescence assessment of the root canal using plain and conical optical fibers. J Endod. 2010; 36(1):119-122. 42. Shakibaie F, George R, Walsh LJ. Applications of laser-induced fluorescence in dentistry. Int J Dent Clinics 2011; 3(2): 26-29. 43. George R, Walsh LJ. Laser-Assisted Endodontics. In: DJ Coluzzi, SP Parker (eds.), Lasers in Dentistry - Current Concepts, Textbooks in Contemporary Dentistry, Springer International Publishing: Cham, Switzerland. 2017. pp. 192-211. 44. Shakibaie F, Lamard L, Rubinzstein-Dunlop H, Walsh LJ. Application of Fluorescence Spectroscopy for Microbial Detection to Enhance Clinical Investigations. In: Britun N & Nikiforov A (Eds) Photon Counting. Croatia: InTech Publishers, 2018. pp. 225-242. 45. Walsh LJ. Caries diagnosis aided by fluorescence. In: Arkanslan Z (Ed) Dental Caries - Diagnosis and Management. Croatia: InTech Publishers, 2018. pp. 97-115. 46. Shakibaie F, Walsh LJ. Optical diagnostics to improve periodontal diagnosis and treatment. In: Manakil J (Ed) Periodontology and Dental Implantology. Croatia: InTech Publishers, 2018. pp. 73-86. 47. Walsh LJ, Groeneveld G, Hoppe V, Keles F, van Uum W, Clifford H. Longitudinal assessment of changes in enamel mineral in vivo using laser fluorescence. Aust Dent J. 2006;51(4):S26. 48. Walsh LJ, Clifford H. Changes in Diagnodent scores in smooth surface enamel carious lesions in primary teeth: a longitudinal clinical study. J Oral Laser Appl. 2008;8(3):157-164. 49. Sin JH, Hamlet S, Walsh LJ, Love RM George R. Oxidising agents and its effect on human dentine fluorescence diagnostic measurements. Photodiagn Photodyn Therapy 2020; 31:101950. 50. Sin JH, Ipe DS, Hamlet S, Walsh LJ, Love RM, George R. Fluorescence characteristics of E. faecalis in dentine following treatment with oxidizing endodontic irrigants. Photodiagn Photodyn Therapy 2021; 33:102344. 51. Tsai A, George R, Walsh LJ. Evaluation of the effect of various endodontic irrigants and medicaments on dentine fluorescence. Photodiagn Photodyn Therapy 2022; 37:102651. 52. Walsh LJ, Mubarak S, McQuillan A. Autopilot laser-based systems for guiding caries and calculus removal: from concept to clinical reality. Australas Dent Pract. 2007;18(5):122-128. 53. Mandikos MN, Walsh LJ. Illuminating dental instrument, coupling and method of use. Australian patent 2010/300079 in 2014 and US patent 9,028,251 in 2015. 54. Shakibaie F, Walsh LJ. Effect of oral fluids on dental caries detection by the VistaCam. Clin Exp Dent Res. 2015; 1(2): 74-79.

55. Shakibaie F, Walsh LJ. Violet and blue light-induced green fluorescence emissions from dental caries. Aust Dent J. 2016; 61(4):464-468. 56. Kiran R, Walsh LJ, Forrest A, Tennant M, Chapman J. Forensic applications: Fluorescence properties of tooth-coloured restorative materials using a fluorescence DSLR camera. Forensic Sci Int. 2017; 273:20-28. 57. Kiran R, Chapman J, Tennant M, Forrest A, Walsh LJ. Detection of tooth-colored restorative material for forensic purposes based on their optical properties: an in vitro comparative study. J Forensic Sci. 2019; 64(1):254-259. 58. Kiran R, Chapman J, Tennant M, Forrest A, Walsh LJ. Direct tooth-colored restorative materials: a comparative analysis of the fluorescence properties among different shades. Int J Esthet Dent. 2020; 15(3):318-332. 59. Kiran R, Chapman J, Tennant M, Forrest A, Walsh LJ. Fluorescence-aided selective removal of resin-based composite restorative materials: An in vitro comparative study, J Esthet Restor Dent. 2020;32(3):310-316. 60. George R, Walsh LJ. Factors influencing the ablative potential of the Er: YAG laser when used to ablate radicular dentine. J Oral Laser Appl. 2008;8(1):33-41. 61. Walsh LJ. Minimally invasive operative techniques using high tech dentistry. Australas Dent Pract. 2006; 17(5):108-110. 62. Walsh LJ, Brostek AM. Minimal intervention dentistry principles and objectives. Aust Dent J. 2013; 58 (Suppl 1): 3-16. 63. Brostek AM, Walsh LJ. Minimal intervention dentistry in general practice. Oral Hlth Dent Managemnt. 2014; 13(2):285-294. 64. Walsh LJ. Laser applications in dentistry - the far horizon. Austral Dent Pract. 2010; 21(5): 102-104. 65. Liang R, George R, Walsh LJ. Pulpal response following photo-biomodulation with a 904-nm diode laser: a double-blind clinical study. Lasers Med Sci. 2016;31(9):1811-1817. 66. Rapp L, Gamaly EG, Guist R, Furfaro L, Lacourt PA, Dudley JM, Juodkazis S, Courvoisier F, Rode AV. Ultrafast laser-induced micro-explosion: material modification tool. OSA Techl Digest: Photon Fiber Technol. 2016: BT3B.4. 67. Rapp L, Haberl B, Bradby JE, Gamaly EG, Williams JS, et al. Selective localised modifications of Si crystal by ultrafast laser induced micro-explosion. Proc. SPIE 2013; 8607: 86070H. 68. Watanabe W, Li Y, Itoh K. Ultrafast laser micro-processing of transparent material. Optics Laser Technol. 2016; 78(A): 52061. 69. Sugioka K, Cheng Y. Ultrafast lasers - reliable tools for advanced materials processing. Light Sci Appl. 2014; 3:149. 70. Neev J, Da Silva LB, Feit MD, Perry MD, Rubenchik AM, Stuart BC. Ultrashort pulse lasers for hard tissue ablation. IEEE J Select Top Quantum Electr. 1996; 2(4):790-800. 71. Rode AV, Gamaly EG, Luther-Davies B, Taylor BT, Graessel M, Dawes JM, Chan A, Lowe RM, Hannaford P. Precision ablation of dental enamel using a subpicosecond pulsed laser. Aust Dent J. 2003; 48(4): 233-239. 72. Lizarelli RFZ, Costa MM, Carvalho-Filho E, Nunes FD, Bagnato VS. Selective ablation of dental enamel and dentin using femtosecond laser pulses. Laser Phys Lett. 2008; 5(1): 63-69. 73. Ji L, Li L, Devlin H, Liu Z, Liao J, Whitehead D. Ti:sapphire femtosecond laser ablation of dental enamel, dentine, and cementum. Lasers Med Sci. 2012; 27(1):197-204. 74. Alves SV, Oliveira V, Vilar R. Femtosecond laser ablation of dentin. J Phys D Appl Phys. 2012; 45(24): 245401. 75. Bello-Silva MS, Wehner M, Eduardo CdP, Lampert F, Poprawe R, Hermans R, Esteves-Oliviera M., Precise ablation of dental hard tissues with ultra-short pulsed lasers. Preliminary exploratory investigation on adequate laser parameters. Lasers Med Sci. 20-13; 28(1):171-184. 76. Chen H, Liu J, Li H, Ge W, Sun Y et al. Femtosecond laser ablation of dentin and enamel: relationship between laser fluence and ablation efficiency. J Biomed Opt. 2015; 20(2): 028004. 77. Le Q-T, Bertrand C, Vilar R, Femtosecond laser ablation of enamel. J Biomed Opt. 2016; 21(6): 065005. 78. Hikov T, Pecheva E, Montgomery P, Antoni F, Leong-Hoi A, Petrov T. Precise femtosecond laser ablation of dental hard tissue: preliminary investigation on adequate laser parameters. J Physics Conf Ser. 2017; 794(1): 012036. 79. Petrov T, Pecheva E, Walmsley AD, Dimov S. Femtosecond laser ablation of dentin and enamel for fast and more precise dental cavity preparation. Mat Sci Eng C. 2018; 90:433-438. 80. Loganathan S, Santhanakrishnan S, Bathe R, Arunachalam M. Prediction of femtosecond laser ablation profile on human teeth. Lasers Med Sci. 2018; 34(4): 693-701. 81. Han P, Li H, Walsh LJ, Ivanovski S. Splatters and aerosol contamination in dental aerosol generating procedures. Appl Sci. 2021; 11(4): 1914.

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practice | MANAGEMENT

Selling your dental practice By Graham Middleton

“Discerning buyers will look for patterns and note the timing and amounts of fee increases and whether they are compatible with the socio-economic status of the surrounding area...”

here is an old saying that a farmer cannot fatten a pig the day they take it to market; nor can a dentist disguise a practice that is in a badly run-down state. Discerning buyers will be careful to check patient bookings and invoicing. They will note the type of dental treatments performed internally as opposed to being referred out. They will be particularly interested in the productivity of the principal’s own surgery and the range of treatments provided. Discerning buyers will look for patterns and note the timing and amounts of fee increases and whether they are compatible with the socio-economic status of the surrounding suburb, town or district as depicted by Australian Bureau of Statistics data. They will look closely at the patient book for evidence as to the number of forward appointments. They may be expected to dig deep into appointments and billings, taking sample months from prior years to compare with a recent month in order to determine whether the practice is growing or has disguised a fall in appointments with above inflation fee increases.

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It is essential that practice performance, including number of patient appointments, be maintained in the year leading up to sale if the sale price is to be substantial. The pattern of fees, days worked by assistant dentists and the ratio of support staff, by employment cost percentage of fees, to clinical staff will portray a picture of relative practice efficiency. Where a practice is running down, it cannot be fixed within a short period. A practice owner needs to undertake a regular process of practice diagnosis to avoid falling into a comfort zone trap. Too often practice principals are the last to realise that their practice has gone into serious decline—and too often it has passed the point of relatively easy rectification. This is also the case with the appearance of practice premises. We tend to overlook the shortcomings of our everyday environment. The appearance of premises needs to be attended to regularly and before deterioration becomes obvious to patients. While existing patients may continue to attend, they will stop referring friends if the appearance of a practice has deteriorated and it will decline. Hence one of the barometers of continuing practice vitality is a consistent rate of new patient referral. Buyers will ask for evidence of the number

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practice | MANAGEMENT of new patients per month. It is vital to keep your practice in a vibrant condition if you expect to gain a top price for it.

Where practice value lies he majority of the value in most practices is within the maintainable fee base. Worn items of equipment can be replaced but a practice which has a declining patient fee base will take considerable time and expense to turn around.

Sale of dental proprietorship onventionally, the practice sale price is for its proprietorship, which is defined as including practice goodwill plus equipment. Equipment is further defined as including all dental equipment, furniture and office equipment used in the conduct of the practice. It normally excludes the owner’s motor vehicle and personal items in their office such as a private piece of art. The proprietorship is valued and equipment is deducted at its written down value to separate the goodwill value for contract of sale purposes. Aside from the market in second hand equipment being too thin to be a reliable guide to value, it is a mistake to value dental equipment separately as this will probably have negative tax implications for the vendor. There is a normal list of conventions applying to add-ons and subtractions for debtors, creditors, staff entitlements, unopened packages of stock on hand and prepayments.

Avoiding common mistakes 1. Complacency. This occurs when a principal dentist decides that they have reached a comfortable level of fee generation and profitability and stops looking for ways to improve the overall performance of their practice. Before they realise it is happening, their practice profitability has begun to slide and staff have assessed that their boss is no longer as rigorously demanding. Inexorably, little inefficiencies creep in. The practice starts operating for the convenience of staff and this manifests itself in a looser appointments system, less efficient use of staff with more informal work breaks and less rigorous pricing and ordering of materials.

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2. The three-day trap. The principal dentist decides to reduce their clinical time from four full days to three full days per week. I have observed that where this has occurred, practice profitability plummets. Not only does the principal lose one day per week of personally generated fee income for which they are not paying an assistant dentist, but the same amount of fees rarely flow fully to assistant dentists; as such, there is a loss of efficiency. Perhaps because 3 days worked in seven means that the boss is heavily distracted by life outside of the practice, it signals declining interest and enables staff to adjust to a much more comfortable regime as they sense that their boss is no longer a driving force behind the practice. I have long observed that many leading dentists work 4.5 clinical days with a half day for administration or a game of golf and are able to run efficient practices. Many also work 4 full clinical days, preferably including Mondays and Fridays, and maintain tight control over their practices but when they shorten to a three-day clinical week, there is a dramatic reduction in practice profitability and they have sent a strong negative signal to their staff. A key lesson in preparing a practice for sale is to sell before slowing down to a three clinical day week. Sell a practice which is not in decline then work for the new owner and reduce to a comfortable number of days as an assistant dentist without responsibility for practice administration and staff. 3. The true cost of introducing a practice manager. A practice manager, other than as a courtesy title for a receptionist, is costly in both annual profit and in lost capital value in a practice for sale. Introducing a practice manager for say $85,000 per annum plus superannuation plus salary on costs may take over $100,000 from a practice bottom line but very few practice managers add much to a practice. Employed dentists are typically paid on the formula: Remuneration = (40% of gross fee receipts) – laboratory costs Given that relatively good practices have a DEBDIT (dental earnings before depreciation interest and taxes) of 56-57 percent of gross fees, a practice

manager will need to create extra patient fees of over $500,000 per year to justify their existence because their cost of $100,000 per year is the practice profit margin created by an employed dentist generating over $500,000 of fees after paying their employment cost. Almost no practice managers pay their way. Very few of them create extra patient fee flow for their practice owners. Practice managers destroy profit rather than create it. But even worse is the negative impact of practice managers on the capital value of dental practices. Deducting $100,000 annual cost of a practice manager from the practice’s bottom line may result in a reduction of the sale value of a practice by $500,000 assuming a valuation multiple of five times bottom line EBITDA after deducting the practice owners own opportunity cost (that which they would have been paid if producing the same fees in somebody else’s practice). If a dentist cannot conduct a practice without the assistance of a manager, it is time to sell the practice and work for the buyer rather than hiring the manager. 4. The pitfall of adding too many chairs. Sometimes, accountants and/or consultants, unaware of the hidden barriers to profit within a practice, encourage a practice owner to add too many chairs and too many assistant dentists. In efficient dental practices, the lion’s share of the profit is generated in the owner’s surgery, or in the case of some, in the owner’s twin surgeries. A second dentist should earn a reasonable amount of profit but profitability reduces sequentially with additional chairs; one reason being that the principal is regularly required to fix problems beyond the capacity of less experienced dentists and this reduces their own fee output. Overwhelmingly, the most profitable single owner practices have no more than two other chairs operated by employed/contracted dentists. Having one or two full time dentists is far preferable to having lots of part time employed dentists and similarly, with chairside assistants. For dental associateships of two principals, no more than two chairs for clinical employees is optimal. Keeping a practice lean, efficient and manageable is a key to profit and selling appeal. Simplicity is a virtue.

Australasian Dental Practice

practice | MANAGEMENT Be cautious concerning accountants advice he only dentist most accountants know is the one who drills their teeth. Many accountants have signage proclaiming that among other things, they give business advice, but sadly, in a vast number of cases, their knowledge of business does not extend beyond completing simple financials and tax returns. Without a large sample, they are reduced to making observations based on the relative profitability of a dental client compared to a range of dissimilar businesses. The annual tax cycle and their need to complete the required number of returns by a due date to satisfy the Australian Taxation Office, means that much advice is fleeting, often wrong and offered many months after an event. Even individual accountants in large firms, with numerous dental clients, often lack sufficient knowledge to adequately advise a dentist but may feel obliged to offer advice purely because their firm claims to have expertise. Accountants approached for advice by potential practice buyers are influenced by a perceived opportunity to gain new clients. They may advise buyers to make an inappropriate purchase or lack the knowledge as to guide the client as to what to look for in a thorough due diligence process of a dental practice. Accountants consulted by a seller may have a strong bias toward talking their client out of selling because of their desire to maintain an annual accounting assignment.

Practice valuation ontrary to what many think, most accountants are incapable of valuing businesses unless they have deep knowledge of the particular type of business; nor are vendors obliged to have a valuation. But I am aware of many dentists seeking a valuation prior to sale. Unless they had agreed to share it with a practice buyer, they are under no obligation to do so. They are at liberty to ask more for their practice than the valuation in the expectation that they may be bargained down. When accountants without wide experience of having dental practice clients give valuation advice, the result usually is that vendor’s accountants hugely overvalue and buyer’s accountants substantially undervalue. On many

70 Australasian Dental Practice

occasions, I witnessed accountants offering bizarre opinions of practice value which differed widely from the market for practices of similar size and attributes. This assists neither client to negotiate a realistic price. Prices paid by corporates insisting on onerous earn out contracts with a portion of the price subject to post sale performance differ substantially from prices paid in conventional dentist-todentist transactions.

Be cautious concerning practice brokers advice ost of us have had the experience of buying and selling houses. The issue of the agent who hints at a higher than market value to obtain the listing and

“Prices paid by corporates insisting on onerous earn out contracts with a portion of the price subject to post sale performance differ substantially from prices paid in conventional dentist-to-dentist transactions...” then hints to buyers that they could offer a lower price is too common. A clever agent then seeks to persuade both parties to adjust their price in order to seal a sale and collect the commission. While the legal situation is that it is the seller who pays the agents commission, an economist would say it is actually the buyer—for without the buyer there can be no sale and no commission paid. Many agents make their commission by persuading vendors to lower their price to match a buyer’s offer. This is particularly so when markets soften. Canny buyers may realise this and play hard ball with an agent who they sense is desperate to make a sale. When selling dental practices, brokers may try hard to get a seller to reduce price or alter conditions to make a sale more amenable to a particular buyer rather than spend time looking for

a buyer who will pay the asking price. Or, a broker may seek an easy sale to a corporate even though the vendor has said that they are not amenable to working for a corporate or comfortable with a corporate earn out contract. The broker’s best interest and the seller’s best interest may differ substantially. If selling a particularly successful practice of high value, it is appropriate to negotiate a realistic broker’s commission. There may be no more work involved in selling a practice worth $2 million than one worth $400,000, so having the same percentage brokerage is inappropriate. Real estate agents often negotiate commission and so can practice brokers.

Ancillary health insurance warning hidden capital cost on sale ell-conducted practices which are not preferred providers to health funds are more profitable and do not have unrealistic restrictions placed on the treatments that they offer to patients. Dentists enjoy a happier existence without third party intrusion into patient relationships and their practice will be worth more at sale. Dentists should have a means of advising patients of the pitfalls of “Extras insurance”. The truth is that health funds make a huge gross margin on ancillary cover and most of their clients and the dentists who treat them are both worse off as a result. A practice which becomes a preferred provider is effectively transferring part of goodwill value to the health fund(s).

Private sales vast number of practice sales occur privately, without brokers, most commonly between practice owners and their employed dentists. This can involve delicate relationship problems. It is invariably a mistake to advertise for assistant dentists with a view to partnership or ownership. If doubts emerge as to timing or practice sale arrangements, relationships become strained and usually the potential buyer departs. Rather, the employed dentist(s) must be treated courteously and professionally and the subject of practice sale should not be mentioned until the principal has decided that they are ready to sell within a

January/February 2022

practice | MANAGEMENT specified time. It is important therefore to discretely monitor assistant dentist’s performance. This includes fee generation, the proportion of follow up appointments, relative absence of patient difficulties and the numbers of personal referrals. This is particularly important if sale of an associateship, rather than the total practice, is envisaged. If selling one half of a practice as an associateship, the future sale of the remaining part of the practice must be considered. In country practices the issue of the “sitting associate”, invariably a younger dentist, leaves the position of the older associate in a weak negotiating position. It is advisable to either sell the whole practice and reverse roles, becoming an assistant dentist or have a single contract which includes put and call options at a specified future date with a predetermined price or valuation formula for the remainder of the practice.

Nationwide rents paid by dentists are typically in the range of 4 to 4.5 percent of annual dental fees. There are significant variations with location. Where rental percentage of fees are much higher than average, there is a downward impact on practice value. Worst tend to be premises located in major shopping centres. On occasion, I have known practices in shopping centres to be unsaleable because the rent was so high and the tenancy conditions so onerous that no dentist would buy them!

Tax implications of sale t is essential when intending to sell to seek accounting advice on the tax implications and particularly whether you will satisfy the criteria for the valuable concessions attaching to the sale

“It is normal to make no announcement of sale, but rather to say that a dentist has joined the practice while the vendor typically works for the purchaser for an agreed gradually declining time...”

Goodwill handover t is normal to make no announcement of sale, other than to a corporate buyer, but rather to say that a dentist has joined the practice while the vendor typically works for the purchaser for an agreed gradually declining time, while the buyer takes on an increasing patient load and the vendor refers agreed cases to them. Eventually, when the former owner retires, the purchaser is well embedded in the practice. This enhances goodwill retention.

Practice premises otential practice buyers will be keener to buy if good quality practice premises are also for sale, the exception being some country practices with low rents. If not able to buy the premises with the practice, they will seek to be provided with an option to buy the premises by a future date. Next best is a secure lease with at least two further lease renewal options giving the practice buyer a high degree of certainty. An initial lease period of four or five years with two further lease renewal options is optimal. Free-standing premises are preferable. Good presentation of premises is essential to achieving practice sale potential. If a dentist inspecting a practice can readily imagine themselves working in it, a sale is far more likely. The reverse also applies.

January/February 2022

of small business active assets. Active assets generally include practice goodwill and the practice premises but do not include equipment.

The critical issue for sellers he key issue for dentists is that all practice owners will one day be sellers and must prepare their practice and themselves for that event. This requires careful ongoing attention to all the aspects of their practice that informed buyers are expected to pay attention to and to try and plan their sale while their practice remains at its peak.

Related reading his article should be read in conjunction with “What dentists buying practices need to know” in Australasian

Dental Practice September/October 2021 and with relevant parts of Financial Success for Dentists 2021 by Graham Middleton see below. Best wishes to all dentists.

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

About the Author Graham Middleton disposed of his interest in Synstrat group on 30 June 2020 and won’t be starting another business; He spent the later 33 years of his working life advising health professionals on business and financial matters. Dentists were the most numerous of his clients. He is the author of the recently published Financial Success for Dentists. Dentists may obtain a copy by making a donation of minimum $60 to the Delany Foundation a registered charity which assists schools in Ghana, Kenya and Papua New Guinea then email Graham at graham.george.middleton@gmail.com. A copy will be sent to you. All proceeds go to the Delany Foundation for its good work. Graham has paid for the printing and mail costs personally.

Australasian Dental Practice

practice | MANAGEMENT

An important step in getting the right people on your bus By Julie Parker

ave you ever been in a situation that has become so progressively worse that you lose hope that it will ever improve? In his famous book, Good to Great, Jim Collins used the metaphor of a bus and its passengers to emphasise the importance of getting the right team members working in your business. “You are a bus driver. The bus, your company, is at a standstill and it’s your job to get it going. You have to decide where you’re going, how you’re going to get there and who’s going with you.” The wrong people on the bus can lead to a great deal of frustration; team members’ attitudes seem off, their performance is weak and team dysfunction has taken hold, like a virus. You want to avoid this scenario as the repercussions can be destructive. Normally happy team members become unhappy with the growing problems of the bad team members. Often, the good team members leave for greener pastures while the bad ones hang around for years.

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Owners and managers of the practice become weary of the continual problems the bad team members present and have to try hard to maintain effective and positive leadership. The practice productivity and efficiency suffer and it feels like wading through thick mud to achieve any goal. And, worst of all, the standard of care offered to your patients slowly diminishes to a standard that you find concerning. I frequently have practice owners contact me asking for advice to shift out of this space. Many tell me that, once they have their ideal team, they will then be in a position to implement better systems, improve team culture and design a better patient experience. But, it can’t happen now. Not with this team. Unfortunately, this approach does not work. And here is why. Imagine you have a practice that is failing to operate to your expectations and desires. You have been frustrated for months - possibly years - and have developed a clear picture of the practice you want. A key position in your practice opens up and you start the recruitment process. The content of your job advert describes the skills and characteristics of

the person you need for the practice you want to become. During the interviews with the candidates, you describe your vision for the future. The candidate, who has a proven track record and possesses what is needed to help you realise your dream practice, becomes excited at the prospect of joining you in your endeavour to make this wonderful dream a reality. You hire the candidate with great hope and expectation. Your new team member commences working at your practice, filled with excitement and optimism. Then, “it” happens. “It” being reality. Despite being assured during the interview process that changes will be made, a plan of action will be developed, there will be immediate progress... nothing is, in fact, happening. This winning candidate sadly realises over the initial days and weeks of “all talk and no action” that optimistic hopes were pinned to the wrong star. And your new improved “pathway” to the future resigns. How do you manage to attract and keep the right people for your bus? The answer is, design a bus that the right people will be desperate to be on. Imagine another metaphor.

January/February 2022

practice | MANAGEMENT Someone opining that they cannot find love (like a practice owner opining they can’t find good staff). That partners are all the same and share similar bad characteristics (many practice owners state that “all staff are the same”). After many attempts with different partners, they feel hopeless and fear enduring love is not in their future (practice owners have stated to me “it’s hopeless. There are no good candidates for jobs out there”). For such people to attract the right partner, they need to be considerate of the part they play in every relationship. Are they helping to create an experience that a partner of their choosing would find appealing? Is their “bus” one that their ideal partner would want to be on? The same is true for building your ideal team. Finding the right people for your bus is one thing. However, if the right people don’t like your bus, they will jump off. That’s why designing your bus appropriately is your first best step. There are two steps in designing your bus.

Once you have a clear picture of what you want your bus to be, develop a plan to create it. It won’t happen overnight. It doesn’t need to. With intentional action every day, though, you will get there. And, you will be providing evidence to every current and new team member that this is the path you and the team are on. Tell them clearly: “If it’s not for you, jump off the bus and make way for someone who the bus is designed for. If you like how this bus operates, how it makes you feel, then the right seat will be found for you to join the journey to a bright and magnificent future”. The liberation you feel, the reduction in your stress and the sense of progress you experience, will rejuvenate and inspire you.

1. What is your vision? hat does your ideal practice look like, function like and feel like? Project yourself forward 5, 10 years. When you enter the building, what do the physical surroundings look like? How are your team members interacting? What systems do you have in place? What do your patients love about coming to your practice?

2. What environment do the right team members want? onsider all of the skills and characteristics that your ideal practice team members possess. Consider the types of personality they are and what drives their enthusiasm. Then, research what environment these team members would thrive in. An easy method is to go to dental staff Facebook pages and ask the question. Get feedback directly from the horse’s mouth. You could also contact current and previous team members for their contribution. Putting a simple search into Google will also provide useful information.

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

ACCOUNTING & FINANCIAL SERVICES FOR DENTISTS DON’T RISK SECOND BEST

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Buying A Practice? • Do you need us to value the practice? NOW AVAILABLE: Synstrat Dental Stories

• What rent can it afford? • How do you structure to meet tax planning requirements? • What changes should you make to the practice business plan?

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You can either e-mail dental@synstat.com.au with your request for the book together with your postal address or go to www.synstrat.com.au, navigate to the Synstrat Publications area and fill in the form. You will then be forwarded the book.

ALSO AVAILABLE: 50 Rules for Success as a Dentist Buying and Selling Specialist Dental Practices

Speak to Paul Steel or David Collins on (03) 9843 7777 or email dental@synstrat.com.au

January/February 2022

Australasian Dental Practice

practice | MANAGEMENT

Beware of strangers offering candy: Why sellers need to take a cautious approach with a new dental aggregator By Simon Palmer

very year, some great practices that we’re representing for sale will come to us asking what we know about a new dental aggregator that is marketing itself or approaching dental practices directly. New aggregators come and go every year and generally have the same few things in common: • They will have a glossy executive summary brochure, showing a group of impressive-looking people on the board who have been successful in business in other industries;

74 Australasian Dental Practice

• There will be usually one or two (token) representatives on the board with some dental industry experience; • In their correspondence and conversations with you, they will come across as very ambitious, talking about how fast they will acquire practices, saying that they are already in advanced negotiations with some great practices; and • They will say there will be an advantage to you getting in early and being among the first to come on board. Their offer to you will be for a “limited time only”. We have almost always already heard of and spoken to new corporates that are looking to acquire dental practices. When

our clients ask us our opinion on these new aggregators, we usually ask the following questions:

1. Will they buy one practice or are they wanting to buy 20? ost dental corporate wannabes have no interest in owning a single practice - they want to own many. So, when they put down an offer on one practice, they will usually have no intention of following through on that offer unless they meet a critical mass. To sign up to sell to any aggregator, you would receive a Term Sheet/Heads

January/February 2022

practice | MANAGEMENT of Agreement that would lock you in to several months of exclusivity (where you reject any buyer that you are currently in discussions with and cannot talk to another would-be buyer), while they do their legal contracts, financials and other due diligence on your practice. This is reasonable, as there is considerable cost involved in corporate due diligence and it would be unfair for them to outlay this cost, only to find that you were not serious about their offer in the first place. The difference with a new aggregator is that they don’t just use this exclusivity period to do due diligence. They also use it to keep practices like you in a holding pattern while they try to get other practices to buy, in order to reach the threshold they need to make this interesting for them. You may find that you enter a Term Sheet with a new corporate with honorable intentions, only for that the deal not to go ahead because they couldn’t get enough practices on board. By the time you are released from your exclusivity commitment and reach out to the other suitors that you were considering earlier (before you signed with the new aggregator), you could find that they are gone, (either because they spent their money elsewhere or because they are annoyed with the manner in which they were dismissed), or that you are in a significantly worse negotiating position. If you are considering whether to sign a term sheet with a new dental aggregator, be confident that either: a. They will buy one practice at a time; OR b. They will reach the critical mass of committed practices they need in order for them to buy any: OR c. That you have time up your sleeve and aren’t counting on the sale in any real way financially or lifestyle-wise in the near future.

MELBOURNE 5 March

January/February 2022

ADELAIDE 9 April

2. If they do buy your practice... what is waiting for you on the other side? hen you sell a practice to any dental aggregator, it usually comes with post-sale work commitments that you have to make. These commitments are made easier by promises that they will take the burdens of ownership off your shoulders, allowing you to focus on your clinical dentistry post sale. Generally, there will be offers of IT, HR, marketing support, payroll and corporate discounts on consumables. There will be an expert at head office that you can call for help when there is a staffing issue, or to help get you back up and running when equipment breaks. Selling a practice to an existing dental aggregator means that: • There is a track record of acquisitions and there will be a back office that is well versed in dental practice ownership issues and how to resolve them; and • There are some referral sources of practices that they have bought and you should be able to contact those practices’ principal dentists, so that you make sure that the promises are well-founded and that the aggregator is reasonable to deal with. Selling to an untested, new aggregator gives you no such assurances. They could be (and sometimes are) building the plane while they are flying it. If you are thinking of selling to a new aggregator, it is very important to get clarity on what will be waiting for you on the other side. Ask them how they will handle the support that they are offering? When are they going to be hiring and building their support team and do they have any thoughts on the composition and experience their team will have? Who will be your point of contact when issues come

SYDNEY 14 May

up post sale (the person who has been leading the acquisition process is unlikely to be the one you can call for operational or day-to-day support)? Any serious aggregator will have a straightforward, well thought out answer for you and will not leave this as an afterthought with vague placating answers.

Conclusion he point of this article is not that you should never consider selling your practice to a new aggregator. Some new aggregators will progress to actually buying and owning practices and these aggregators may present a great option to sell. However, this still leaves a significant percentage that will not amount to much. If you are entertaining an offer from a new dental corporate, extra caution needs to be shown and additional questions need to be asked (like those suggested above) in order for you to gauge how seriously to take them. An experienced dental broker by your side, who has seen would be aggregators come and go, should be able to recognize the hallmarks of a group that are substantial or suspicious and guide you accordingly. Without guidance... It is very easy to be attracted to something shiny, only to find out that it was a mirage when you reach out to hold it!

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

BRISBANE 11 June

Australasian Dental Practice

practice | MANAGEMENT

Is the door to your dental practice open? By Jayne Bandy

ou will be shocked at how many people call your office and do not make an appointment. Why is this happening?

This is the question you need to ask yourself

hy do people call your office and hit a brick wall rather than an open door? Well, here’s what I’m seeing and hearing in many dental offices. A person calls your office with a dental problem or concern most of the time. The caller very often has a first question they immediately throw at you, like, “how much will it cost me to have 3 implants?” or, “do you do veneers?” as well as other questions like this.

I know you might be thinking right now, “there is no way my team are doing this”. But this is exactly what is happening on many phone calls and it could be happening in your practice too. The team member comes off the call believing that this caller was just “shopping around” and was just after information.

If your team are struggling to convert calls to appointments, this could be why

he team member you have chosen to answer the phones in your office, who is usually not educated or trained on how to answer the phone, immediately answers the caller’s question. Then they answer the next question, then the next until the caller feels satisfied that the team member has given them enough info and they are now ready to call the next dental office to ask them the same questions they just asked you.

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hey do not have the correct communication skills to cope with the calls they receive. What they know is not enough to get them results. When your team are missing the communication skills, they need to convert more calls to appointments, you miss out on the patients you need and the patients miss out on you. There is no reason, once your team know what to say and ask on the New Patient Call, why they cannot convert more calls to appointments. When your team are competent and can the master the communication skills

Now this is where the biggest mistake is made

not have the skills to be able to help the prospective new patient come in the door and enter your practice. So many team members in dental practices do not have the communication skills to affectively convert calls to appointments, especially patients wanting the high production treatment and care you offer. I know many team members are working hard with what they do know, and really, they only know what they know and many team members are frustrated by their inability to make more appointments.

Here is the reality of these non-converted telephone calls he non-converted phone calls are all missed opportunities to book and start treatment and care, often for a high production patient who would have gone on to continue their care and treatment over many years to come and refer other loyal referring patients. All because the team member, who answered the phone incorrectly, did

January/February 2022

practice | MANAGEMENT needed on phone calls, they will turn the caller’s questions into their questions and guide more callers to come in for an appointment. Most new patient calls can be easily turned into kept appointments, but your team can’t do this without the right communications skills. I wish it was as easy as picking up the phone, but it’s not. The good news is that these communication skills are not hard to learn and action and get results. Do yourself and your business and your patients a favour, up-skill your team. Help your team be the best they can be and watch what happens to your appointment book and the type of treatment and care you get to do for patients! Open the door to your dental practice! 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

The Dental Phone Excellence Online Master Class dentalphoneexcellencemasterclass.com I listened to you and finally my Master Class is here ONLINE just for YOU!

Your team do not need a day off work to attend this Master Class. YOUR TEAM can complete the Dental Phone Excellence Master Class right there in your practice at their own pace. The BEST part of my Master Class is that you have it FOREVER!

dentalphoneexcellencemasterclass.com

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

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

www.dentalpractice.com.au magazine

www.oralhygiene.com.au magazine

www.elaborate.com.au magazine

www.dentevents.com events calendar

www.dentevents.tv dental video streaming

www.dentist.com.au - australia

find-a-dentist

www.dentist.co.nz - new zealand

find-a-dentist

January/February 2022

Australasian Dental Practice

marketing | INSIGHTS

The uncomfortable truth about competition in dentistry... By Angus Pryor, MBA (Marketing)

s we enter a new year full of optimism, I’m going to ask you to pause and consider this... ...on the one hand, we look forward to new levels of freedom in terms of travel, etc. On the other hand, there is one cold, hard fact for dentists that just won’t go away. In this article, we talk about the C-word (competition, not COVID) and what to do about it.

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The numbers very year for a long time (I’m talking more like decades than years), the number of dentists entering the Australian marketplace has increased faster than the growth in the Australian population. If the Australian population grew by 1% in a year, the number of dentists grew by 2-3%. This trend occurred in 2019, and the year before, and the year before that, and the year before that, and on and on and on. Even in 2020 (our first year of COVID), the number of dentists in Australia grew 50 per cent faster than the growth of the Australian population! In fact, there’s really no evidence that this trend will ever end in the foreseeable future.

January/February 2022

marketing | INSIGHTS Like it or not, competition for new patients is only heading in one direction up. Yes, a few baby boomers (and others) hang up their drills each year, but they are more than replaced by the numbers of new dentists joining the workforce every year. What this means for dentists is the need to take seriously their efforts in attracting new patients and standing out from their competitors. Let’s deal with the latter first.

Standing out from your competitors nless you’re in a really remote area (in which case you’ve probably stopped reading this article), increased competition this year versus last year is guaranteed. One other challenge is that dentistry is a business that patients don’t really understand. It’s not like they can make an objective assessment of your dental skills, all things considered. Instead, potential patients decide whether to start coming to your practice (and keep coming to your practice) having regard to things that basically have nothing to do with dentistry. This situation may seem unfair, but unfortunately, it’s reality. I’m not saying there is no benefit in extending your skills or the range of services that you offer, it’s just that with this never-ending increase in competition, you’ll get squeezed if you keep doing what you always did with your marketing.

For you to stand out from your competitors, it needs to be about something other than dentistry I’m going to let that sink in for a moment, because what I see in the marketplace often ignores this fact. Remember: patients can’t tell if you’re good or bad on the basis of your dental skills. A slight caveat here: I’m not saying you can never ever stand out from your competitors on dental skills, just that the vast majority of general dental practices cannot. Like 95% of general dental practices are offering substantially the same services as their competitors - at least in the eyes of potential patients. If you do specialise in something a bit different like paediatric dentistry or holistic dentistry, then that needs to be promoted heavily as your point of difference. For everyone else, forget “better” dentistry as a means of competing with your competitors. It doesn’t work.

January/February 2022

Attracting new patients ow that we have established that most dentists cannot use their dental skills as a successful way of standing out from their competitors, how do you get the lion’s share of new patients in your area? The reality is that apart from potential patients having never-seen-before levels of choice for dentists, they also have multiple ways of deciding whether to choose you. What you are competing with is what is known in the industry as “noise” (some studies suggest consumers are exposed to between 2000-4000 commercial messages a day).

“Your biggest risk by far is not that your efforts to stand out will appear too ‘out there’... but that simply, no one has ever heard of you. In such a noisy environment, your efforts to attract new patients are typically the aggregate of multiple activities, in a coordinated manner...” Your biggest risk by far is not that your efforts to stand out will appear too “out there”... but that simply, no one has ever heard of you. In such a noisy environment, your efforts to attract new patients are typically the aggregate of multiple activities, in a coordinated manner. The short answer to attracting more new patients to your practice is to get serious about your marketing... In my experience, it’s really only the best marketed practices that are consistently getting the majority of the new patients. Getting serious about your marketing means avoiding the following approaches: • The shiny object syndrome - “what’s the amazing new thing I can use?” • The silver bullet approach - “what’s the one marketing tactic that will revolutionise my marketing“; or • The scattergun method - a little bit here, a little bit there, but nothing consistent. What you need, instead, is a coordinated marketing approach across multiple

channels so that when your potential patient starts looking for a dentist in your area, they choose you because you are “everywhere”. One factor you are going to need to reconcile yourself with, is that you will lose out to competitors if they out-market you, even if your dentistry is better. A bitter pill to swallow I know. As you pursue a coordinated marketing approach across multiple channels, what you want is a consistent and unique brand message. It’s like you need to beat people over the head with the same message over and over until when they think of a dentist, they think of you. Important elements in your coordinated marketing approach include: • A strong presence on Google including the Google map; • Lots of positive [recent] Google reviews; • An up-to-date website that gives potential patients a reason to engage with you (avoid claims made by so many other dentists such as “experienced”, “quality”, “friendly”, “technicallyskilled”,etcwhicharebasically meaningless to new patients); • An effective patient referral system; • High-quality educational content for potential (and existing) patients, especially on video; and • A strong presence in social media so that when someone comes looking for you, what they see will support the conclusion that you are to be trusted.

Conclusion he level of competition in dentistry just continues to increase. Moving forward, you cannot expect the same results from what you’ve done in the past. Your choice is to get serious about your marketing with a well-branded and comprehensive marketing approach, or expect a slow decline in your practice production, reputation and profits. The choice is yours.

About the author Winner of the ADIA 2020 Marketing Award, Practice Growth Specialist, Angus Pryor is a #1 Amazon bestselling author, marketer and international speaker. For help with attracting more of your ideal patients (and fewer of the ones you don’t want), visit www.AngusPryor.com and book an obligation-free call.

Australasian Dental Practice

finance | INVESTMENT

Your associate dentists and payroll tax: What! Why and how much? By Garry Pammer, BEc, LLB, CA, DIP.FS (FP)

t’s common in health practices, medical and dental (as well as veterinary), to operate under a service facility model (Alternatively described as a “tenancy and agency” model). Under this model the associate dentist enters an arrangement with the practice principal or his/her service entity to provide facilities and administration services to the associate dentist for a service fee.

this commonplace arrangement with all your associates. You have built up the size of your practice and have a growing number of associate dentists and employee staff. You derive a service fee, say 60% of the patient fees of the associate dentists. The associate dentists basically derive net income representing 40% of the patient fees as sole trader. The service fee is one of their numerous expenses.

for five years. You also receive penalties. They are not at all swayed by your pointing out that this is a longstanding commonplace industry arrangement. You now find yourself with well over $100,000 owing to Revenue NSW. Perhaps you use the same arrangement as your associate dentists because you, like them, are also a sole trader and use your own service trust as your service facility provider. You are part of the payroll tax problem for your service trust.

Caselaw development n a previous article in Australasian Dental Practice, Once Upon a Time…Employment Taxes in Dentistry (Vol 31, No 1, Jan/Feb 2020), another surprise payroll tax interpretation also ended up in Court. Until that earlier decision in Optical Superstore, it was also argued that the payments by the practice principal to the optical service provider under these arrangements were not subject to payroll tax. The approach taken and conclusions at the time were based on distinguishing particular features of the arrangements in that case. It was widely considered that the decision would unlikely have ongoing general application. Notwithstanding that view, our advice regarding your practice operation and payroll tax exposure remained unchanged. Namely, that this is a complex area with developing case precedents where facility service businesses should seek to minimise risk. Since the Optical Superstore decision in 2019, there has been ongoing uncertainty and concern about the payroll tax position. The recent decision in Thomas and Naaz does provide more clarity. However that clarity is not necessarily welcomed

The cornerstone of these arrangements is that the associate dentist is conducting their own business as a sole trader and performs dental work for the patients, with the support of the practice principal’s dental practice who provides the facility and other nursing and administrative support services. Part of the arrangement is that the practice principal would collect the patient fees from patients for and on behalf of the associate dentist and would pay the balance of the patient fees to the associate dentist after deducting the service fee. So you, like many other practice principals in the industry, have been running

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Scenario ou find yourself, after a visit from Revenue NSW, receiving a payroll tax assessment. It now groups that 40% net payment to your associate dentists together with your employee payroll. The entire grouped amount is attributed as paid to employees and included in your total Australian wages. That combined total, associate dentists net payments and employee wages, is above the $1.2M annual threshold that applies in NSW. It is $1.7M. You now have a payroll tax liability for the year of $24,250. The OSR decides to amend

January/February 2022

finance | INVESTMENT by practitioners. It suggests that nearly all service facility arrangements are now potentially subject to payroll tax. In summary, the facts of the case were: • Thomas and Naaz operated three bulk billing centres in NSW; • Doctors engaged had services facility agreements, paying a 30% service fee for rooms, shared administration and medical support; • The medical centres collected fees from patients on behalf of the doctors and remitted 70% to the doctors (comprising billing after netting off the 30% service fee); • On the basis that payments to doctors were taxable “wages” for payroll tax purposes, Revenue NSW issued five assessment notices totalling $795,292 which covered 2013 through 2018. The assessments included payroll tax, interest and penalties; and • Thomas and Naaz objected to the assessments on the basis that the doctors, unlike the employee staff, were not being paid by the centre as they were not supplying services to the centre.

January/February 2022

Is a facility agreement a “relevant contract” he first and major issue of concern to our clients in Thomas and Naaz is whether there was a “relevant contract” between the medical centre and the doctor. A “relevant contract” is required to establish that payments to contractors may be considered taxable wages and be subject to payroll tax. The Tribunal found that, under the agreement between the centre and the doctor, the doctors were providing services to patients as well as to the medical centre. Please do not look to these following factors as a basis to distinguish your own position from Thomas and Naaz. There is nothing in the judgement that indicates you can assume that if such terms are absent from your service facility agreement that your agreement would give you the “all clear”. The Tribunal found that the doctors were in fact providing services to the practice under the arrangement because the facility service agreement:

• Made references to shifts, work hours and rosters; • Doctors had to comply with protocols set by the centre; • Doctors were to promote the business of the centre; • Made references to a leave policy - six weeks’ notice, maximum four weeks per year, requirement to submit leave application for approval; • Doctors were paid hourly rates on some occasions; • Contained a restraint covenant (2 years, 5km radius); and • The centre retained ownership of the patient records.

Are net contractor payments “taxable wages” he net payments made to doctors were determined to be for or in relation to the performance of work relating to the practice. The next question was, could the payment of the 70% net billings paid to the doctors be considered a payment of “taxable wages” for payroll tax purposes.

Australasian Dental Practice

finance | INVESTMENT Amongst other things, Thomas and Naaz argued that payments were simply a return of doctors’ monies; they were only held for and on behalf of the doctors and that they at all times belonged to the doctors. The tribunal did not accept this argument. The relationship between the provision of services by the doctors and the payment from the centre to the doctor, was determinative even if it was indirect. As such, the source of the payments, being patient fees for the doctors’ services to those patients, did not exclude the Payroll Tax legislation applying. Likewise, your paying 40% of net billings (after lab expenses of course) would be considered taxable wages for payroll tax purposes.

Action - Agreement review he cornerstone of the Thomas and Naaz case was the determination that a “relevant contract” existed between the centre and the doctors. The “relevant contract” point was largely established on the terms of the service agreement in place. This highlights the importance of quality written agreements and carrying out day to day operations consistently per those written agreements. Service and Facility Agreements should be regularly reviewed and updated by a reputable solicitor experienced in payroll tax legislation and the dental practice industry. We refer to solicitors who draft practice agreements, considering the most recent case law and legislation. We ourselves have always considered many of the terms included in the agreement in the Thomas and Naaz case as high risk. Namely rosters, leave policies and restraints. Having said that, the first steps should be to ensure consistency between your current agreements and procedure of existing arrangements. Case in point: Two new clients (regional medical centre and private dental group) were found to have used longstanding prior precedent agreements in respect of associates. On review, the form vs substance differences were serious. Both purported to operate under the service facility model but agreements were in fact contract for service agreements and straight employment contracts!

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Action - Payment and banking arrangements s already mentioned, case law in this area has been changing. Previous cases, like Optical Superstore, have established that funds received by a service entity for and on behalf of Associates, acting as a “collection agent” or “bank of convenience” if you will, were not payments for the “performance of work”. The Thomas and Naaz decision, surprisingly, overturns this concept. Our advice in this area is evolving. Currently we are consulting with legal partners on this aspect. You should do the same. Do not simply dive into changing banking arrangements as anti avoidance measures exist. Quite candidly, in a recent public webinar, a tax practitioner suggested not much less that an antiavoidance trigger re banking accounts. At this point in time, we encourage you to first focus on reviewing the agreements involved in engaging with doctors and that procedures are consistent.

Action - Reporting ne final point warrants mention. The issue was not widely discussed in the tribunal’s findings but on reading through, it can be seen that Thomas and Naaz had reported amounts paid to doctors and effectively received by them inconsistently: • Ranging from contract, sub-contractor and commission expenses in the 2015 and 2016 income tax returns; to • Business income reported in the income tax returns and business financial statements of the service entity also included all of the doctor’s own sole trader billing. We always emphasise the significance of correct reporting to reinforce the independent sole trader status of associates. That includes recognising only service fees in your practice entity’s financial statements, BAS and income tax returns. The Thomas and Naaz case clearly highlights the importance of structuring accounting and tax records accurately. Again, in the situation of the two new clients, it was found invoicing was inconsistent and inaccurately expressed, past BAS and financials incorrect, banking arrangements even included some superannuation and some PAYGW at different times in the past!

What to expect in the future gain there is now some certainty in this area but not good news. Dental practices that use a service facility model are now likely to need to include net payments made to associates in their taxable wages for payroll tax, unless an exemption to the relevant contract provisions is available; Revenue offices will dedicate compliance activities to practice arrangements over the next six to 18 months; Revenue offices in current audits appear to be unmoved by policy arguments about the extension of payroll tax to common place industry arrangements not previously contemplated as subject to payroll tax; Revenue NSW has expressed strong views that restructuring will be seen as an attempt to avoid the operation of the relevant contractor provisions and seek to apply anti-avoidance provisions; and Revenue offices will be releasing a guidance document outlining their position. This is a much anticipated document and should provide much more than interesting read.

A •

• •

•

About the author Garry Pammer is a Director of Specialist Accounting & Business Advisory, specialising in providing advice to dentists. Advice 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.

January/February 2022

Fact:

Every year, there are more dentists practicing in Australia than ever before … and this rate of growth is much faster than the growth of the Australian population.

Fact:

Potential patients have more choices for a dentist (and more ways to choose) than ever before

Fact:

If you don’t adapt your marketing to keep up with changes in consumer behaviour, you will get left behind with only fewer patients and declining proﬁts to look forward to

It’s time

to take control and stand out from your competitors!

finance | INVESTMENT

“Your Future, Your Super” - Explained By Charlie Warner, Associate Financial Adviser

ighlighted in the media recently and in the Australian Government Budget was a piece of legalisation named “Your Future, Your Super”. The Australian Government identified three key areas of the superannuation industry that needed to be reviewed. These are to provide clarity and transparency to their members when selecting their superannuation provider and the underlying funds.

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The areas include: 1. The underperformance of MySuper funds - This includes holding superannuation providers accountable for the product’s performance annually; 2. Multiple superannuation accounts - This aims to stop the creation of multiple superannuation accounts for consumers. This is achieved by connecting all future employment-related contributions to a member’s existing account; and 3. Super comparison - This will allow members the opportunity to make an educated decision and compare superannuation products through a new Government website comparison tool named “YourSuper”.

January/February 2022

finance | INVESTMENT Your Future, Your Super performance test t was identified in the Productivity Commission inquiry in 2018 that there were large differences in investment performance for MySuper products. The MySuper products are the underlying investment funds inside industry, retail and corporate superannuation providers. Generally being for members who do not choose their super fund when they commenced work with an employer, MySuper funds account for around a third of all superannuation savings accounts in Australia with an estimated value of $900 Billion (AFSA Superannuation Statistics, 2021).

“A typical full-time worker who is in the median underperforming MySuper product would retire with a balance of 36 percent less than if they were in the median top-10 products. To place this into real terms, a 21-year-old earning $50,000 per annum would be worse off by $375,000 by retirement...” The concern for the Government was that underperforming MySuper funds could influence the overall balance of consumers, ultimately affecting their quality of retirement. The Superannuation: Assessing Efficiency and Competitiveness report released by the Productivity Commission at the end of 2018 stated that a typical full-time worker who is in the median underperforming MySuper product would retire with a balance of 36 percent less than if they were in the median top-10 products. To place this into real terms, a 21-year-old earning $50,000 per annum would be worse off by $375,000 by retirement. The Government’s intention is to remove funds that have continuously underperformed and charged high fees, along with creating greater member engagement in one of their most important

January/February 2022

assets. However, increasing the level of information could potentially lead to confusion for the everyday consumer which may result in poor financial decisions. There are several steps you should consider: • Visit the “YourSuper Compare Tool” and identify your fund’s performance and fees against its peers; • Adjust the compare feature to different timeframes to the shorter period such as five years. This will help identify if the underperforming funds have taken the integral steps to restructure as it may now represent as good value; • Research if the fund offers other key features such as insurance. Changing superannuation providers can have an impact and leave you without life cover; and • Consider engaging with a Financial Adviser.

Stapling members to a single fund or a lot of Australians, starting a new job used to mean establishing a new superannuation account with that new employer. This resulted in Australians having multiple accounts with many different providers. The goal of stapling is to stop this trend and to ensure that consumers have one superannuation account, therefore cutting the overall fees and insurance premiums members pay. Stapling means that your superannuation account follows you wherever you are employed and provides a constant as you change your job. For example, if you decide to take a second job, your compulsory contributions will flow into the same fund.

Australasian Dental Practice

finance | INVESTMENT YourSuper comparison website o help members select an underlying investment fund (currently only MySuper Products) to grow their superannuation retirement saving pool, the Australian Tax Office has established an online comparison tool. With over 80 MySuper products (as of August 2021) for consumers to select across the market, one of the most difficult decisions for consumers is to identify if the superannuation is appropriate to their circumstances. The YourSuper tool offers some very simple but effective metrics to help. These being: 7, 5, 3 years returns; annual fees; investment strategy; and whether the fund is restricted to certain members. The website offers members an opportunity to gain key information on their current superannuation and prospective superannuation accounts. However, this may not provide the full picture. New members seeking a fund for the first time may simply select the best performing or most cost-effective from the comparison

tool. However, as previously stated, past performance is not a good indicator of future performance along with the fact cheaper fees may not lead to a better financial outcome. Finally, the tool does not take into consideration other features of the superannuation product which may be the reason they are charging higher fees such as income layering options, customisable insurances and more investment options. Engaging with your Financial Adviser will assist in working through the best options for your circumstances.

General advice warning This communication is issued by Profile Financial Services Pty Ltd. (ABN 32 090 146 802), holder of Australian Financial Services Licence and Australian Credit Licence No. 226238. It contains factual information and general advice only and does not take into account any investor’s individual objectives, financial situation or needs. It should not be relied on by any individual. Before making any decision

about the information provided, investors should consider its appropriateness having regards to their personal objectives, situation and needs, and consult their adviser. Any indicative information and assumptions used here are summarised, are not a product illustration or quote, and also may change without notice to you, particularly if based on past performance.

About the author Charlie Warner is an Associate Financial 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 or see www.profileservices.com.au

SAFety FirSt even fOr yOur

FinAnciAl AFFAirS Whether you’ve just started working, own your own practice or are considering retirement, Profile Financial Services can help you plan and secure your financial future. Just like good dentistry, in investing, prevention is better than cure! A sound financial plan can help anticipate and avoid risks before they damage your portfolio.

How safe are your investments? To find out, contact Profile now to book an obligation-free initial meeting: (02) 9683 6422 Or visit our website www.profileservices.com.au

BUilDinG WeAltH SecUrity AFSl 226 238

Profile_SafetyAd_v3.indd 1

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FOr OVer 30 yeArS

Wealth managers for the dental industry

18/03/11 2:04 PM

January/February 2022

finance | INVESTMENT

Setting yourself up for the year ahead By Craig Spiegel

any health professionals have been taking this time as an opportunity to buy their own rooms, relocate or buy new commercial property due to the increase in vacancies - many of these on main roads in appealing areas and locations. Some of these options never existed pre-pandemic, as businesses moved out, shut up shop or decided not to return to a face-to-face work environment, choosing to continue all operations remotely. Similar property opportunities exist in the residential space too. Whether you’re a business owner, a future business owner or an employee, property ownership continues to be a commonly held aspiration despite the dream becoming increasingly harder to achieve. There were many predictions about whether the market could sustain itself during the second year of the pandemic and instead, rebounded well beyond anyone’s expectations. According to Eliza Owen, Head of Research at CoreLogic, by the end of November 2021, the estimated value of the Australian residential real estate market was a record $9.4 trillion.1 This phenomenal growth of $2.2 trillion since November 2020 demonstrates just how integral the sector has been to the country’s recovery. So what does the year ahead look like for property? Regardless of what’s going on, the classic question is always: Is now a good time to buy? But in the context of the pandemic, increasing prices, limited supply and competition, plus new lending interventions, we’re hearing more of: Should we be thinking about upgrading? Should we be thinking about downsizing? Should we consider a tree change or a sea change?

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The other big consideration is whether we should invest in our own property, as many of us and our families have spent a significant amount of time homeschooling and working from home during lockdowns for extended periods, all while seeing what’s happened with the value of properties around us. For example, in May last year, stamp duty changes were introduced in Victoria resulting in higher transaction costs on purchases above $2,000,000. Could you spend that amount on where you are now?

There was also the tightening of home loan lending criteria by the banking watchdog, the Australian Prudential Regulation Authority, in October in a bid to stop banks from offering mortgages to property buyers who may be unable to afford them if interest rates rise. As always, these changes often have a flowon impact on all borrowers.

January/February 2022

finance | INVESTMENT

The banks are required to hold more capital for interest-only loans, which could see pricing shifts in the market and seeing some of those lines of borrowing becoming more expensive. Another factor is that fixed rates have been going up independently of the RBA. Will rising rates mean house price growth moderates in 2022? If you want to lock in a rate at the lower end of the spectrum, you might want to consider your options now. A fixed rate with a 100% offset account is worth consideration. For those who already have an interestonly loan or considering an interest-only loan, it could be a good time to review your terms in the context of some of the changes that are coming through, such as the lending criteria being tightened. That could mean potentially refinancing, as your loan may no longer be suitable for your needs because our personal circumstances often change. And market commentators predict more tightening could come, while the government also announced it will roll over more than 4,500 unused first home buyer grants from the previous financial year. So where might things land in the year ahead?

2022 Outlook ust as we thought we’d get some relief and “normalcy” - thanks to the vaccination rollout and the subsequent reopening of both international and interstate borders - the latest strain of COVID-19 has

January/February 2022

landed on our doorstep. The level of disruption Omicron could bring will likely play on people’s minds when making significant decisions this year, such as buying property. Though it’s important to remember, change could represent great buying opportunities. The pandemic will either have a direct impact on property movements or at least always be at the back of people’s minds. Perhaps bidders won’t be as bullish at auctions, enabling others who have previously missed out to now get into the market. It’s these inflection points of uncertainty that impact the changing property landscape in Australia and what smart buyers often try to take advantage of. There’s no doubt the year ahead will be very topical when it comes to property, whether you’re looking to buy, sell or renovate. The expectation of rising interest rates is one certainty the market is betting on, leading property experts to believe it has likely peaked and will experience a great cooling off by mid-2022, particularly in Sydney and Melbourne. At the end of the day, these opportunities may not come around again. So see it as a time to review and reassess your situation in light of where the property market is at the moment, where rules are at today and where they could be tomorrow. As always, it’s best to speak with your financial adviser or accountant about specific advice for your own situation and the team at Credabl are here to support your plans with bespoke funding solutions.

Whether you’re new to seeking property finance options or ready for a review, we’re available to chat live on our website www.credabl.com.au

General Advice Warning This article is a guide only and does not constitute any recommendation on behalf of Credabl Pty Ltd (ACN 615 968 100) or any of its related bodies corporate (Credabl). The information in this article is general in nature and we have not taken into account your personal objectives or financial circumstances or needs when preparing it. Before acting on this information you should consider if it is suitable for your personal circumstances. Credabl is not offering financial, tax or legal advice. You should obtain independent financial, tax and legal advice as appropriate.

About the author Craig is the Co-Founder and Head of Sales at Credabl. As part of the team that first created healthcare finance in Australia, Craig has close to 30 years of experience in the space and holds an intimate knowledge of the financial needs of dental professionals.

Reference 1. https://www.corelogic.com.au/news/corelogiceconomic-property-review-housing-integralaustralias-covid-19-economic-recovery

Australasian Dental Practice

infection | CONTROL

READ ME FOR

CPD

Into 2022 and the next phase of the COVID-19 pandemic By Emeritus Professor Laurence J. Walsh AO

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January/February 2022

infection | CONTROL These 4 endemic coronaviruses cause widespread infection during childhood. By adulthood, most individuals are likely to have been exposed to these 4 coronaviruses multiple times. Some level of protection comes from repeated exposure during childhood, with longitudinal studies suggesting that it takes some 12-18 months before adults become susceptible to reinfection.6-10 The situation has been described as an “endemic equilibrium” between human coronavirus infection and human immunity,11,12 where the rate of decay of immune memory against coronaviruses is balanced by regular reinfection which causes boosting of immune responses. Due to waning immunity over time, at any one point in time, there are sufficient numbers of people who have lost their immunity and become prone to infection. Hence, viral infection can continue in the community at low rates and then surge during times when people are in close proximity to one another. This pattern of waning immunity is highly relevant to issues around the spread of COVID-19 in Australia, which has reached a high rate of vaccination by global standards.

Some 10 years later, Middle East respiratory syndrome coronavirus (MERS-CoV) emerged from its natural host animals (including camels) to cause human infections with high rates of severe infections and fatalities. MERS spread from the Middle East to Europe, having first appeared in Saudi Arabia in 2012.15,16 As with SARS, MERS also caused acute respiratory distress as well as extrapulmonary manifestations. Since both SARS and MERS had a short incubation period and a high infectivity, identification of infected persons and tracing their contacts was straightforward. Appropriate isolation and quarantine arrangements were effective public health measures. Moreover, the predominant mode of transmission was

2. Individuals who are presymptomatic carry sufficient virus to spread the illness, being particularly infectious from 2 days before clinical symptoms appear. The virus is present in saliva as well is in respiratory secretions. 3. With COVID-19, many patients are asymptomatic and cannot be identified from their symptom profile. This allows the disease to spread within the community from people who appear to be quite well, but who nevertheless are shedding the virus. 4. Spread of SARS-CoV-2 can occur via droplet, contact and aerosol routes. Aerosol transmission is the reason why only transient or fleeting contact between individuals has led to transmission events.

via droplets and to a lesser extent via the contact route. This meant that the application of droplet precautions, including the use of P2/N95 respirators by healthcare workers, was quite effective. The hyperinflammatory state caused by both SARS and MERS has strong parallels to COVID-19, however there are several important differences that have made control of SARS and MERS relatively straightforward, but problematic with SARS-CoV-2, the virus which causes COVID-19. 1. With COVID-19, the incubation period is longer, with approximately 1% of individuals having an incubation period of more than 14 days. This is why there have been numerous cases reported in the media of individuals who had an incubation period greater than 14 days, as they went through a two-week period of quarantine but then subsequently became positive.

5. SARS-CoV-2 not only infects cells of the respiratory tract, but spreads elsewhere through the body causing a wide range of persisting systemic conditions, which are now referred to as LONG COVID, as well as organ failures in those hospitalised with severe disease.17 6. As the infection progresses, shortness of breath develops and viral infection of the lungs makes the patient prone to superinfections of bacterial origin, followed by a hyper-inflammatory state involving the lower respiratory system which causes the classic symptom of shortness of breath. At this stage, multiple organ failures can occur.17 7. The SARS-CoV-2 virus is neurotrophic, which explains why it has caused permanent loss of smell as well as impacts on mood and energy over the long term after people have recovered from the symptomatic illness.

Zoonotic infections with coronaviruses of pandemic concern ats are the major natural reservoir for coronaviruses. Transmission to humans can occur following contact with bats, but most often occurs via an intermediate host animal.13 At least three highly virulent coronaviruses of animal origin have spread via zoonotic pathways from their bat animal hosts to infect humans, causing outbreaks of disease. The first well-recognised example was severe acute respiratory syndrome coronavirus (SARS-CoV). This disease emerged in 2002 in Guangdong, China and spread throughout Asia and to North America, resulting in more than 750 deaths.14 Once infected, individuals suffered from respiratory symptoms such as shortness of breath, with a hyperinflammatory state (a cytokine storm) and organ damage. The disease had a very short incubation period, making tracing of infected contacts relatively easy.

January/February 2022

Australasian Dental Practice

infection | CONTROL Coronaviruses in animals here is a large body of evidence that indicates that coronaviruses are hosted in several species of horseshoe bats (Rhinolophus affinis, R. malayanus, R. cornutus, R. acuminatus) found in various countries in Asia including China, Thailand and Japan. These bat coronaviruses have been responsible for the emergence of SARS in 2002, MERS in 2012 and COVID-19 in 2019 as pandemics, as well as multiple “near miss” events where there was a small cluster of infection in humans that did not spread to become a pandemic. With regard to SARS-CoV-2, molecular studies have revealed close similarity between this virus and the bat coronaviruses RaTG13 and RmYN02, which are found in bat species living in the Yunan province of China18,19 and in Thailand,20 as well as the Rc-o319 bat coronavirus from Japan.21

The impact of vaccination campaigns he prime driver for vaccination campaigns for COVID-19 is to prevent severe disease, hospitalisation and death. Over recent months, greater attention has been placed on other benefits that may arise from vaccination, including a reduced viral load in the saliva and in

Figure 1. A snapshot of COVID-19 in Australia, using data as at 17 January 2022 from “Our World in Data” to create customised charts. A: COVID-19 deaths over time shown as a cumulative plot. B: A plot of excess mortality during the pandemic compared to typical deaths for the same period averaged over the past five years. The section above the line highlighted in pink represents deaths above the normal rate. C: The proportion of eligible people in the Australian community who have received at least one dose of a COVID-19 vaccine. D: The number of people in Australia who are fully immunised against COVID. E: A global ranking for immunisation rates for the population showing the position of Australia versus other countries. F: A global plot showing individual countries and the proportion of the population that is fully vaccinated against COVID-19.

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infection | CONTROL

respiratory secretions and less shedding of virus should there be a breakthrough infection despite vaccination. There are several studies which indicate that viral loads may be reduced as much as four-fold in those with breakthrough infection following vaccination, compared to infected persons who have not been vaccinated. This suggests that vaccinated people would be less likely to shed the virus into the environment, where it could cause infections for others - e.g. in the household setting, in public places and in the workplace.22-24 This is important to consider, given the reopening of state borders and international travel. As more people are vaccinated, they have travelled more and this increases their interactions with others, which changes the potential number of people who are being exposed to the virus. There is strong evidence that the currently authorised vaccines in Australia (Astra, Pfizer, Moderna) are highly effective at preventing severe disease and death, as well as reducing the likelihood of symptomatic disease in individuals.25-30

Is it time to retire the herd immunity concept? he recent literature is beginning to question whether the concept of “herd immunity” is going to be possible, given the emergence of new variants and surges of disease, combined with vaccine hesitancy and the delayed introduction of vaccinations for children.31 A combination of waning immunity after vaccination if the booster program is not adequate and further rounds of viral antigenic variation may allow for continued circulation of the virus in the community. It is likely that the concept of “living with COVID” will be part of the “new normal” for the foreseeable future, with SARS-CoV-2 adding to the existing four coronavirus strains in circulation as endemic diseases. A failure to completely eradicate the virus from a particular jurisdiction or even globally does not mean that excess death, illness, lockdowns, restrictions or social isolation will occur at the same scale as seen during different waves of the pandemic. Influenza and four human coronaviruses have been endemic for many years, but the combination of annual influenza vaccines and some short-lived acquired immunity means that societies

T D

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infection | CONTROL across the world have been able to tolerate the seasonal deaths and illnesses from these without requiring lockdowns, masks and social distancing.32 It may well be that as further mutation of the virus occurs, the virus will become far more contagious but much less virulent. This is certainly what the early information for the omicron variant is suggesting.

The UQ vaccine efforts he University of Queensland developed a protein subunit vaccine candidate, v451, using proprietary “molecular clamp” technology. This vaccine generated a strong protective response to the virus and displayed a good safety profile in a phase I clinical trial.33 There were antibodies also directed against fragments of gp41 protein, which is an ingredient used to stabilise the vaccine. The risk of a partial immune response to this gp41 was known beforehand and trial participants were informed of it. The extent of this immune response would not interfere with the interpretation of HIV tests. There were no HIV components used in the vaccine and having the vaccine did not present a risk for acquiring HIV infection and this was confirmed in routine follow-up tests.34 However, UQ halted the progress of this vaccine towards phase II/III trials, citing the need for significant modifications in well-established HIV testing protocols in the healthcare sector before moving further with the project. In April 2021, UQ undertook re-engineering of the vaccine to circumvent the issues raised earlier.35,36

Impact of vaccination campaigns ince their introduction, over 9 billion vaccine doses have been administered around the world since the first vaccine was given on December 8, 2020 in the UK. At the time of writing, over 60% of the world population has received at least one dose of a COVID-19 vaccine and over 30 million vaccine doses are now being administered each day.37 The emergence of the Delta variant and then of the Omicron variant has raised the issue of how well vaccines from 2020 would be effective against variants of concern that are circulating in 2022. There is evidence of reduced severity of infection and hospitalisation as a result of vaccination.38,39

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Could we end up back here again?

Duration of immunity n relation to the duration of protection, a detailed report on the level of protection afforded by vaccines against clinical disease was published by Public Health England on 6 September 2021.40 The data presented compared vaccine effectiveness over time. For the key metric of preventing hospital admissions, this UK study showed that after 20 weeks there was: • A 4% reduction in effectiveness of Pfizer in over-65s (98.3% to 94.6%); • A 15% reduction in effectiveness of AstraZeneca in over-65s (93.7% to 78.6%); • A 23% reduction in effectiveness of Pfizer in clinically extremely vulnerable over-65s (94.6% to 71.4%); • A 20% reduction in effectiveness of AstraZeneca in clinically extremely vulnerable over-65s (79.3% to 59.4%); and • A 30% reduction in effectiveness - to about 70% - of Pfizer in over-80s, many of who received this vaccine with a three-week interval between doses. With the Pfizer vaccine, a vaccine effectiveness of around 95% continues to be seen beyond 20 weeks after vaccination. With the AstraZeneca vaccine, there appears to be some waning to just under 80% vaccine effectiveness against hospitalisation from 20-plus weeks. Ultimately, these UK data show that two doses of the vaccine continue to provide strong protection against death from COVID-19. Similar to protection against hospitalisation, there appears to only be limited waning of vaccine effectiveness against death. Thus, both the Pfizer and AstraZeneca COVID vaccines protect against disease, hospitalisation and death, with the level of protection extending more than 20 weeks (5 months) after completing the course of 2 injections. Further evidence of a sustained serological response was seen in a study of 767 healthcare workers in Italy who had received mRNA vaccines. These individuals showed a sustained antibody response lasting at least 4 months, with levels of antibody decaying over time. An important concept which comes from this study is a role for screening immune responses to the vaccine in healthcare workers. This would identify those with low anti-SARSCoV-2 immunity, who would benefit from an earlier booster injection.41

t seems likely that further zoonotic coronavirus infections of bat origin may occur in the future. Future planning should therefore consider not only pandemics of the human influenza viruses, but also future pandemics of coronaviruses. The inherent risk posed by coronaviruses that are hosted in bats was recognised by Australian scientists over 20 years ago and this spawned a concerted research effort, particularly within the specially built PC4/ BSL4 laboratories in Geelong, Victoria to investigate these viruses and the potential implications for human health. Given the vacillating nature of the virus attack and host defence, it is likely that SARS-CoV-2 will become one of the endemic coronaviruses circulating globally into the future. To that end, there would be considerable value in having a vaccine that combines protection against the dominant strains of human influenza virus together with the current circulating variants of SARS-CoV-2. This combination vaccine would then become part of annual immunisation protocols for the community.

January/February 2022

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infection | CONTROL References 1. Woo PC et al. Characterization and complete genome sequence of a Novel CORONAVIRUS, Coronavirus HKU1, from patients with pneumonia. J Virol. 2005;79(2): 884-895. 2. Lau SK et al. Coronavirus HKU1 and other coronavirus infections in Hong Kong. J Clin Microbiol. 2006; 44(6): 2063-2071. 3. Ye ZW et al. Zoonotic origins of human coronaviruses. Int J Biol Sci. 2020; 16(10):1686-1697. 4. Hamre D & Procknow JJ. A new virus isolated from the human respiratory tract. Exp Biol Med. 1966; 121(1): 190-193. 5. Su S et al. Epidemiology, genetic recombination, and pathogenesis of coronaviruses. Trends Microbiol. 2016; 24(6):490-502. 6. Callow KA. Effect of specific humoral immunity and some non-specific factors on resistance of volunteers to respiratory coronavirus infection. J. Hyg. 1985; 95: 173-189. 7. Callow KA et al. The time course of the immune response to experimental coronavirus infection of man. Epidemiol. Infect. 1990; 105: 435-446. 8. Lepiller Q et al. High incidence but low burden of coronaviruses and preferential associations between respiratory viruses. J. Clin. Microbiol. M2013; 51:3039-3046. 9. Edridge AWD et al. Seasonal coronavirus protective immunity is short-lasting. Nat. Med. 2020; 26: 1691-1693. 10. Galanti, M. & Shaman, J. Direct observation of repeated infections with endemic coronaviruses. J. Infect. Dis. 2020; 223: 409-415. 11. Lavine JS et al. Immunological characteristics govern the transition of COVID-19 to endemicity. Science 2021; 371:741-745. 12. Cromer D et al. Prospects for durable immune control of SARS-CoV-2 and prevention of reinfection. Nature Rev Immunol. 2021; 21:395-404. 13. Kim DS et al. Will SARS-CoV-2 infection elicit long lasting protective or sterilising immunity? Implications for vaccine strategies (2020). Frontiers Immunol 2020; 11:571481. 14. Cheng VC et al. Severe acute respiratory syndrome coronavirus as an agent of emerging and re-emerging infection. Clin Microbiol Rev. 2007;20(4): 660-694. 15. Hilgenfeld R & Peiris M. From SARS to MERS: 10 years of research on highly pathogenic human coronaviruses. Antiviral Res. 2013; 100(1): 286-295. 16. Gao H et al. From SARS to MERS: Evidence and speculation. Front Med. 2016; 10(4): 377-382. 17. Shi Y et al. COVID-19 infection: The perspectives on immune responses. Cell Death Different. 2020; 27(5): 1451-1454. 18. Zhou P. A pneumonia outbreak associated with a new coronavirus of probable bat origin. Nature 2020; 579(7798): 270-273. 19. Latinne A et al. Origin and cross-species transmission of Bat coronaviruses in China. Nature Commun. 2020; 11(1): 4235. 20. Wacharapluesadee S et al. Evidence for SARSCoV-2 related coronaviruses circulating in bats and pangolins in Southeast Asia. Nature Communic. 2021; 12(1):972. 21. Murakami S et al. Detection and characterization of bat sarbecovirus phylogenetically related to SARS-CoV-2, Japan. Emerg Infect Dis. 2020; 26(12): 3025-3029. 22. McEllistrem MC et al. Single dose of an mRNA severe acute respiratory syndrome coronavirus 2 (SARS-Cov-2) vaccine is associated with lower

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nasopharyngeal viral load among nursing home residents with asymptomatic coronavirus disease 2019 (COVID-19). Clin Infect Dis 2021; 73:e1365–7. 23. Levine-Tiefenbrun M et al. Initial report of decreased SARS-CoV-2 viral load after inoculation with the BNT162b2 vaccine. Nat Med 2021; 27:790-792. 24. Adamson C et al. Lower severe acute respiratory syndrome coronavirus 2 viral shedding following coronavirus disease 2019 Vaccination among healthcare workers in Los Angeles, California. Open Forum Infect Dis. 2021; 8(11): ofab526. 25. Lopez Bernal J et al. Effectiveness of the PfizerBioNTech and Oxford-AstraZeneca vaccines on covid-19 related symptoms, hospital admissions, and mortality in older adults in England: test negative case-control study. BMJ. 2021;373:n1088. 26. Vasileiou E et al. Interim findings from firstdose

33. U.S. National Institutes of Health. ClinicalTrials. gov A study on the safety, tolerability and immune response of SARS-CoV-2 Sclamp (COVID-19) vaccine in healthy adults. ClinicalTrials.gov Identifier: NCT04495933. https://clinicaltrials.gov/ct2/show/ NCT04495933. 34. The University of Queensland. Update on UQ COVID-19 Vaccine. https://www.uq.edu.au/news/ article/2020/12/update-uq-covid-19-vaccine 35. University of Queensland COVID-19 Vaccine Still in Redevelopment, but Won’t Be Available Soon. https://www.abc.net.au/news/health/2021-04-26/ university-queensland-covid-19-vaccine-researchmolecular-clamp/100050240 36. Kandimalla R et al. Counting on COVID-19 vaccine: insights into the current strategies, progress and future challenges. Biomedicines 2021;9:1740.

mass COVID-19 vaccination roll-out and COVID-19 hospital admissions in Scotland: a national prospective cohort study. Lancet. 2021;397(10285):1646-57. 27. Ismail SA et al. Effectiveness of BNT162b2 mRNA and ChAdOx1 adenovirus vector COVID-19 vaccines on risk of hospitalisation among older adults in England: an observational study using surveillance data. PHE Preprints. 2021. 28. Pritchard E et al. Impact of vaccination on SARSCoV-2 cases in the community: a population-based study using the UK’s COVID-19 Infection Survey. medRxiv. 2021:2021.04.22.21255913. 29. Hyams C et al. Effectiveness of BNT162b2 and ChAdOx1 nCoV-19 COVID-19 vaccination at preventing hospitalisations in people aged at least 80 years: a test-negative, case-control study. Lancet Infect Dis. 2021. 30. Lopez et al. Effectiveness of Covid-19 Vaccines against the B.1.617.2 (Delta) Variant. New Engl J Med. 2021;385(7):585-94. 31. Aschwanden C. Why herd immunity for Covid is probably impossible. Nature 2021; 591: 520-522. 32. Phillips N. The coronavirus will become endemic. Nature 2021; 590:382-284.

37. Ledford H. Six months, 1.7 billion doses: what we’ve learnt about Covid vaccines. Nature 2021; 594: 164-167. 38. Pouwels KB et al. Impact of Delta on viral burden and vaccine effectiveness against new SARS-CoV-2 infections in the UK. medRxiv. 2021:2021.08.18.21262237 39. Stowe J, et al. Effectiveness of COVID-19 vaccines against hospital admission with the Delta (B.1.617.2) variant 2021 [Available from: https://khub.net/web/phe-national/publiclibrary/-/document_library/v2WsRK 3ZlEig/ view/479607266. 40. Public Health England. Duration of protection of COVID-19 vaccines against clinical disease. 9 September 2021. https://assets. publishing.service.gov.uk/government/uploads/ system/uploads/attachment_data/file/1017309/ S1362_PHE_duration_of_protection_of_COVID-19_ vaccines_against_clinical_disease.pdf 41. Brisotto G et al. IgG antibodies against SARSCoV-2 decay but persist 4 months after vaccination in a cohort of healthcare workers. Clin Chim Acta 2021; 523:476-482.

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Hills Family Dental Centre trusts Mocom for its infection control By Joseph Allbeury

ills Family Dental Centre in the Perth suburb of Kalamunda is a decades old practice located at the base of the Darling Range, the eastern limit of the metropolitan area. Dr Lahiru Chandraweera took over as its principal a little more than a year ago and one of his first initiatives as the new owner was

100 Australasian Dental Practice

a minor upgrade to the building and some key equipment. “The practice has been established for over 20 years,” Dr Chandraweera said. “I bought it from the two owners who had created a great business with a great team and a thriving patient base. “It’s a family practice doing all the bread-and-butter procedures, from fillings and crowns to dentures to kids. “However, at some point, it became stuck in a proverbial time warp, with the

building looking dated and some equipment past its use-by-date.” Hills Family Dental Centre operates from a two-storey suburban house with four surgeries. Six dentists and an oral health therapist practice at the premises. “After I got over the massive learning curve of owning my first practice, I started to look at what to do next,” he said. “So we started with giving the building a facelift by rendering the red brick exterior and we upgraded some of the equipment.

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“We installed new TVs in the surgeries, invested in a new digital X-ray system and generally brought the more dated elements of the practice into the 21st century. We bought equipment and instruments for oral surgery and wisdom teeth extractions and we plan on expanding down the track into doing implants, as one of the dentists that we have working here has skills and interest in that area.” The infection control equipment was also upgraded in the process. “The practice has two separate infection control areas,” Dr Chandraweera said. “Because of the layout of the house, one steri area services the surgery at one end of the building and a separate steri area at the other end is used by the other three chairs. From a workflow perspective, this alleviates the need to cross the reception and waiting area with trays of dirty instruments. “When I took over, there were three Mocom autoclaves in use and they’d all been real workhorses. Each had clocked up over 12,000 cycles after 8-10 years of continual use. Then one of the units broke down and needed to be replaced. “The Mocom autoclaves had really proven to be outstanding, so it wasn’t a hard decision when we needed to go shopping for a replacement. I did look at a couple of other brands, but there was no compelling reason to change. “Also, even though we bought the units from Henry Schein, Mocom’s Australian office is in Perth, so we’re really spoiled when it comes to an exceptional level of service. If there’s ever an issue, they have someone here in two hours or less; you can’t ask for more than that. They also supply loan units if a problem cannot be fixed immediately. “So I ended up buying two new sterilisers, one for each steri area and the third Mocom unit also remains in use.” Dr Chandraweera purchased two of the latest Mocom B Futura 22 sterilisers. The instrument reprocessing cycle at Hills Family Dental Centre is typical. Dirty instruments are transferred to one of the sterilisation areas and cleaned in an ultrasonic bath. After drying, the clean instruments are sealed in sterilisation pouches and loaded into one of the Mocom units for sterilisation.

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“The Mocom autoclaves are designed to comply with all the latest infection control standards,” he said. “All of our sterilisation staff have an ID code to operate the units and this is recorded electronically so we know who signed off on which batch of instruments being processed.

“When I took over, there were three Mocom autoclaves in use and they’d all been real workhorses. Each had clocked up over 12,000 cycles after 8-10 years of continual use...” “Once the sterilisation cycle completes successfully, we print off barcoded labels. There’s a Mocom printer connected to each steriliser and you select how many labels to print based on the number of packs in the load. The labels are then attached to each pack. “The packs are opened chairside in front of the patient and the barcode is scanned into our Dental4windows practice management software so we can trace the instruments from sterilisation through to clinical use in-line with current best practice infection control.

“The Mocom autoclave also stores all cycle data electronically and you can login using the software provided to transfer it onto your computer over WiFi.” Dr Chandraweera said that his team finds that the Mocom sterilisers are easy to operate and additional training and support are readily available. “When Mocom Australia installed the autoclaves, they gave us a full demonstration and trained us on what to do. It’s very straightforward and our past experiences with Mocom autoclaves, including the loan unit we had, made the transition a simple process. In addition, you can login online and access training and how-to videos at any time.” Dr Chandraweera said the Mocom sterilisers were chosen due to their past performance and outstanding reliability, both key elements in the operations of the practice. “We can’t practice without sterilisation,” he said. “So unless you have an endless supply of instruments, you need a reliable solution that can cope with the reprocessing requirements of your practice. Operating four chairs continually throughout the day generates a large volume of work for the autoclaves and fortunately, having three Mocom units on hand ensures the needs of our practice, practitioners and patients are easily met.”

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Co., LLC, its affiliates or related companies, unless otherwise All company noted. and product names are trademark Anitopen holethe pattern that promotes water flow throughout the cassette •affiliates Anitopen hole pattern that promotes water flow th Because ••when comes perfect fit,system Hu-Friedy is right. Because toAll the perfect fit, Hu-Friedy isofjust right. All company andjust product names arereduces trademarks of Hu-Friedy Mfg. Co., LLC, its when orcomes related companies, unless otherwise noted. company and are trademarks Hu-Friedy Co., LLC Color-coded silicone rail significantly instrument contact •when Anitto open hole pattern promotes water flow throughout the cassette •when An open hole pattern that promotes water flow throughout the casse Compared tothat other leading scaler Data on file. Available upon request. 1)product Compared to other leading scaler Mfg. designs. D Because comes to 1)the perfect fit, that Hu-Friedy isdesigns. just right. 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HFL-482AUS/1220 • Color-coded silicone rail system that reduces instrument contact and allows WHY DENTISTS LOVE STAINLESS STEELprotecting PEDO CROWNS: WHY DENTISTS LOVE OUR STAINLESS STEEL PEDO CROWNS: WHY DENTISTS STAINLESS STEEL PEDOwhile CROWNS: forLOVE more water flow while protecting the instruments during reproce for moreOUR water flowSTAINLESS while the instruments during reprocessing forOUR more water flow protecting the instrume WHY DENTISTS LOVE OUR STEEL PEDO CROWNS: • Ideal andfor mesio-distal widthflow • height Easy-to-use, ergonomic latch thatprotecting allows forthe one-handed opening more water while instruments during reprocessing • Ideal height and mesio-distal width • Easy-to-use, ergonomic latch that allows for one-handed opening All company and product names are that trademarks of Hu-Friedy Mfg.one-h Co., LLC •• Ideal height and mesio-distal width • Ideal height and mesio-distal width • Easy-to-use, ergonomic latch that allows for one-handed opening • Easy-to-use, ergonomic latch allows for ™ unless otherwise Pre-trimmed pre-crimped for simple placement All company and product trademarks ofone-handed Hu-Friedy LLC, its affiliatesInfinity or related companies, All company noted.scaler anddesigns. product are trademark Performing at your best means having confidence in youMfg. do.Co., Experience Series Cassettes, and improve • Ideal height and mesio-distal width • and Easy-to-use, ergonomic latchnames thatare allows forwhat opening 1) Compared to other leading Datanames on file. 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Learn How to Scale in Perfect Harmony at Hu-Friedy.com/Harmony Hu-Friedy.com/H Hu-Friedy.com/Harmony

To learn more about how IMS can enhance VISIT USCo., ONLINE AT HU-FRIEDY.COM/PerfectFit Hu-Friedy Mfg. LLC, 1666 how E. Touhy Ave., Desenhance Plaines, IL 60018 | Hu-Friedy.com To learn more about IMS your practice visit Hu-Friedy.com/Infinity VISIT US ONLINE AT HU-FRIEDY.COM/PerfectFit ToHu-Fried learn more about howcan IMS can enhance ©2016 y Mfg. Co., All rights reserved. All company and product names are of Hu-Friedy Mfg. Co., LLC, VISIT USLLC.ONLINE ATtrademarks HU-FRIEDY.COM/PerfectFit your practice visit Hu-Friedy.com/Infinity ©2016 Hu-Fried y Mfg. Co.,companies, LLC. All rights reserved. its affiliates or related unless otherwise noted.member of ©2017 Hu-Friedy Mfg. Co., LLC. Allis rights reserved. Hu-Friedy now a proud your practice visit Hu-Friedy.com/Infinity ©2016 Hu-Fried y Mfg. Co., LLC. All rights reserved. Hu-Friedy is now a proud member of ©2021 Hu-Friedy Co.,AllLLC. rights reserved. ©2017 Hu-Friedy Mfg.Mfg. Co., LLC. rightsAll reserved.

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infection | CONTROL “Now that we’ve implemented these cassettes in approximately 100 practices, the feedback continues to be the same,” said one PDS compliance manager. “They really love the cassettes. They love the efficiencies of the cassettes.”

Keeping up with an expanded practice

Cassettes were fundamental to enabling Dr Lin’s practice to successfully expand: “To work without the Hu-Friedy IMS System would be pure chaos,” Dr Lin said. “I couldn’t tolerate it because instruments are going to get lost. Instruments will get damaged. It would be physically impossible to be able to see the number of patients that we see in a clinical day without the IMS System.

Simplifying complexity with implants

s Floss & Co in Chicago began to get busier, staff struggled at first to manage an increase in patients. There were simply not enough scalers to keep up and all instruments were either in use or in reprocessing. At first, Dr Izzy Naem looked to solve the problem by purchasing more instruments, but the real issue wasn’t the number of instruments. It was about improving process efficiencies and finding better ways to keep instruments organised. So, when Dr Naem instead decided to switch to the IMS system, the practice was able to save 15 minutes per patient per chair, relieving some of the stress that the staff was experiencing. “We don’t have to think about the instruments,” said Dr Naem. “Where they’re at, where to put them, where to store them. It’s all in the cassette. It was safer and it was easier. With improved efficiency and organisation, the practice was able to continue expanding and saw a 40% increase in new patients. By switching to IMS, Dr Naem was able to increase revenues and provide a better experience for his staff and growing patient base.

Improving practice efficiency at Green Bay

or Dr Steven Koos of ORA Oral Surgery & Implant Studio in Chicago, proper organisation is key to practice success. Since ORA specialises in various oral surgeries, it’s important to have setups ready for each unique procedure and organising the correct instruments can be complicated and time-consuming. Adopting IMS simplified instrument prep with the introduction of versatile and customisable cassettes that keep instruments organised and in one place for each procedure, from chairside to cleaning to storage. “My surgical team has really embraced the Hu-Friedy IMS Cassette System because it’s enabled them to combine the cleaning and sterilisation and organisation and storage of a vast array of instruments into one integrated package and it works well,” Dr Koos said. Additionally, implementing cassettes has made it easier to hire and train new team members and open new locations without affecting the quality of care provided to patients. “From a business perspective, when you’re increasing efficiency, when you’re increasing patient flow and you’re decreasing waste, you’re actually increasing your bottom line,” Dr Koos concluded.

Where can your practice improve? here are numerous advantages to adopting IMS and while each practice profiled here chose to make the switch for different reasons, the results are universal: better efficiency, improved safety, enhanced patient experience and an increased bottom line. Instrument management does not always get the attention it deserves from practice owners, but practices that commit to IMS experience the benefits in tangible, measurable ways. If your practice does not already use an instrument management system, you can request more information from a Hu-Friedy representative on how a cassette-based system can directly benefit your practice.

T hen Dr Edward Lin and his team at Orthodontic Specialists of Green Bay expanded from three doctors to four, the number of instruments used in their facility rose accordingly. Additionally, Dr Lin was concerned about protecting his investment in premium instruments. After trying other solutions with unsatisfactory results, the team began using IMS, enabling them to see 60 to 120 patients a day efficiently.

106 Australasian Dental Practice

For more information, visit www.hu-friedy.com/ims or contact Henry Schein on 1300-658-822 on in NZ call 0800-808-855.

January/February 2022

YOUYOU REQUIRE MAXIMUM EFFICIENCY. YOU REQUIRE MAXIMUM EFFIC REQUIRE MAXIMUM EFFICIENCY. YOUYOU DEMAND COMPLETE ORGANIZATION. YOU DEMAND COMPLETE DEMAND COMPLETE ORGANIZATION. HUFRIEDYGROUP INTRODUCES HUFRIEDYG YOUYOU NEED ENSURED SAFETY. HUFRIEDYGROUP YOU NEED ENSURED S NEED ENSURED SAFETY. INTRODUCES ™ ™ YOU DESERVE INFINITE CONFIDENCE. YOU DESERVE HUFRIEDYGROUP INTRODUCES YOU DESERVE INFINITE CONFIDENCE. HUFRIEDYG HUFRIEDYGROUP INTRODUCES

HARMONY HAR HARMONY ™™ HARMONY HAR HARMONY

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You You deserve Hu-Friedy the peace peace of of mind mind and and confidence confidence of knowing knowing That’s right, you deserve it.for You deserve Hu-Fr the peace Find the right one with That’s right, youthe deserve it. You deserve the peace of mind and confidence As of knowing the right one with Hu-Friedy Hu-Friedy.com/Harmony that you are employing most contemporary method of processing instruments. dentistry’s Learn to Scale Perfect Harmony at that you are employing the mostHow contemporary method in of processing instruments. thatAs you dentistry’s are employing the mostHow contemporary meth Learn to Sca that you are employing the most contemporary method of processing instruments. As dentistry’s That’s right, you deserve it. You deserve the peace of mind and confid Find the right one with Hu-Friedy Learn How to Scale Perfect Harmony at innovator of cassette-based instrument management Hu-Friedy is proud to bring Ensure predictable predictable outcomes for your littlest littlest patients patients with Hu-Friedy Hu-Friedy Stainless Steelsystem, Pedoin Crowns. innovator of the thefor cassette-based instrument management system, Hu-Friedy ispredictable proud innovator to bring of thethe cassette-based instrument manage that you are employing most contemporary method of processing Ensure outcomes your with Stainless Steel Pedo Crowns. Ensure outcomes for your littlest patients with Hu-Friedy Stainle innovator of thefor cassette-based instrument management system, Hu-Friedy is proud toLearn bring How to Scale in Perfeci you the modern design and functionality of the Infinity Series Cassettes which include: Ensure predictable outcomes your littlest patients Stainless Steel Pedo Crowns. youdiscover the modern design and ofwith theHu-Friedy Infinity SeriesEasy Cassettes which include: yououtcomes the modern and functionality of theCrowns. Infin innovator of the cassette-based instrument management system, Hu-F Hu-Friedy.com/Harmony Hu-Friedy.com/H You’ll quickly quickly why dentists favor ourfunctionality impeccable fit. Perfect Perfect for your patients. for you. you. Ensure predictable for yourdentists littlest patients with Stainless Pedo youwhy thedentists modern design and functionality of the Infinity Series Cassettes which include: You’ll discover favor our impeccable fit. for your patients. 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HFL-482AUS/1220 • Color-coded silicone rail system that reduces instrument contact and allows WHY DENTISTS LOVE OUR STAINLESS STEEL PEDO CROWNS: forLOVE more water flow while the instruments WHY DENTISTS STAINLESS STEELprotecting PEDO CROWNS: WHY DENTISTS LOVE OUR STAINLESS STEEL PEDO CROWNS: WHY DENTISTS STAINLESS STEEL PEDOwhile CROWNS: forLOVE more water flow while protecting the instruments during reproce moreOUR water flowSTAINLESS while protecting the instruments during during reprocessing reprocessing forOUR more water flow protecting the instrume WHYfor DENTISTS STEELprotecting PEDO CROWNS: forLOVE moreOUR water flow while the instruments during reprocessing • Ideal height and mesio-distal width • Easy-to-use, ergonomic latch that allows for one-handed opening Ideal height and mesio-distal mesio-distal width Easy-to-use, ergonomic latch that allows fortrademarks one-handed opening All company and product names are that trademarks of Hu-Friedy Mfg.one-h Co., LLC •• Ideal and width • Ideal height and mesio-distal width •• height Easy-to-use, ergonomic latch that allows for one-handed opening • Easy-to-use, ergonomic latch allows for All company and product names are of Hu-Friedy Mfg. 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To more about how IMS can Hu-Friedy Mfg. LLC, 1666 E. Touhy Ave., Desenhance Plaines, IL 60018 | Hu-Friedy.com VISIT USCo., ONLINE AT about HU-FRIEDY.COM/PerfectFit To learn learn more about how IMS enhance VISIT US ONLINE AT HU-FRIEDY.COM/PerfectFit To learn more howcan IMS can enhance All company and product names are trademarks of Hu-Friedy Mfg. Co., LLC, VISIT US ONLINE AT HU-FRIEDY.COM/PerfectFit your practice visit Hu-Friedy.com/Infinity ©2016 Hu-Fried y Mfg. Co., LLC. All rights reserved. your practice visit ©2016 Hu-Fried y Mfg. Co., LLC. All Hu-Friedy.com/Infinity rights reserved. its affiliates or related companies, unless otherwise noted. your practice visit Hu-Friedy.com/Infinity ©2016 Hu-Fried y Mfg. Co., LLC. All rights reserved. ©2017 Mfg. Co., rights reserved. ©2021 Hu-Friedy Co.,All rights reserved. ©2017 Hu-Friedy Hu-Friedy Mfg.Mfg. Co., LLC. LLC. AllLLC. rightsAll reserved.

To learn about how IMS can enhance VISIT more US ONLINE AT HU-FRIEDY.COM/PerfectFit your©2016 practice visit Hu-Friedy.com/Infinity Hu-Fried y Mfg. Co., LLC. All rights reserved. Hu-Friedy is now a proud member o

Hu-Friedy is now a proud member of

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clinical | EXCELLENCE

Case studies illustrating the aesthetic application spectrum of Tetric Prime in the anterior region By Prof. Dr Claus-Peter Ernst

“Undoubtedly, direct composite bonding in the anterior region has established itself as a highly aesthetic and functional treatment option...”

any excellent universal anterior and posterior dental composites that focus on the highly aesthetic anterior segment are available today. Their application spectrum is very wide and their reliability has been extensively proven. The latest product to have been launched in this group of universal composites is Tetric Prime (Ivoclar). It is based on the proven Tetric EvoCeram. The following article will examine the aesthetic potential of this new material on the basis of various examples involving anterior teeth. Undoubtedly, direct composite bonding in the anterior region has established itself as a highly aesthetic and functional treatment option over the past few decades. Clinical studies on dental composites confirm their immense potential in terms of scientific considerations7,24 and clinical applications.13,19 Due to their outstanding aesthetic properties, direct

108 Australasian Dental Practice

composite restorations are quite capable of rivalling veneers with regard to their appearance and function, as long as the proper application technique is used1,5,25,26,28,32-34,37 - and this has been the case for quite some time.27 The latest review paper on this topic was published in the Journal of Adhesive Dentistry at the beginning of 2021.2 It contains more than 200 citations and provides not only a review of the latest literature, but also a summary of the excellent clinical results achieved to date. This article will illustrate a variety of applications for conventional universal composites in the anterior region ranging from the straightforward filling of cavities to the reshaping of individual teeth and the closing of a diastema. In the case of a diastema closure, in particular, where no additional adjustments have to be made to the affected teeth, such as derotation, tooth lengthening or the repair of multiple labial defects, direct composite bonding offers the ideal combination of aesthetics, function and non-invasiveness.5,12,14,16,17,22,28,33

January/February 2022

clinical | EXCELLENCE

Figure 1. Cervical lesion extending into the mesial aspect caused by an inadequate Class V filling and secondary caries.

Figure 2. Unica anterior matrix placed as a guide and for isolation.

Figure 3. Conditioning with 37% phosphoric acid.

Figure 4. The bonding surface sealed with a universal adhesive.

Case 1: Cervico-proximal defect he first case involves a classical treatment indication for aesthetic universal composites: A 62-year-old patient presented with a cervical lesion extending into the mesial aspect, which had resulted from an unsatisfactory Class V filling together with secondary caries on the mesial tooth surface. Figure 1 shows the clinical preoperative situation after the old filling had been removed and the caries excavated. A matrix was placed as a guide and the lesion was isolated with a Unica anterior matrix (Polydentia), which was adapted and tightened with two Composi-Tight 3D Fusion Wedges (Garrison Dental Solutions, Figure 2). The area to be treated was etched with 37% phosphoric acid (Total Etch, Ivoclar, Figure 3). Next, a universal adhesive was applied (Adhese Universal, Ivoclar, Figure 4)11 and then polymerised for 20 seconds using a high-performance LED curing light. According to the instructions of the manufacturer, a polymerisation time of 10 seconds is adequate for curing Adhese Universal (as is the case for most universal adhesives). Nevertheless, these instructions are only valid for polymerisation under optimal conditions. Since the metal matrix cast a shadow in this case, the light conditions would not have been ideal. Even if a high-performance polymerisation device (> 1000 mW/cm2) were to be used, an extended curing time of 20 seconds would improve

January/February 2022

Figure 5. The finished and polished new Class V filling extending into the mesial aspect. the polymerisation result, while not posing a risk of overheating and harming the pulp.20 Tetric Prime (Ivoclar) in shade A2 - corresponding to the rather light, bleached teeth of the 62-year-old patient - was the only restorative material used in the treatment. Figure 5 shows the completed new Class V filling immediately following finishing and polishing. An additional dentine shade did not have to be used. In “straightforward” cases such as this one, sound universal materials promise aesthetically pleasing results with very little effort.

Australasian Dental Practice

109

clinical | EXCELLENCE

Figure 6. Unsatisfactory widening of the tooth.

Figure 7. Shaping of the defect by means of a vertically inserted sectional matrix held in place with a low-viscosity light-curing provisional material.

Figure 8. Low-viscosity flowable composite in the narrow space between the matrix and the cavity wall.

Figure 9. Opaque dentine core made of the dentine-coloured Tetric Prime A2 Dentin.

Case 2: Retreatment of an inadequate gap closure he 26-year-old patient presented to the practice and requested a new solution for restoring tooth 22, which had been treated with a composite restoration in the past (Figure 6). Since the tooth had been restored with composite on several occasions, the patient now asked for a veneer. He was informed that a veneer would definitely be an option for closing the gap between his teeth,3,4,6,8,21,23,31,35,38 but that such a restoration would be considered an overtreatment, since the same aesthetic outcome could be achieved with direct composite build-ups. Nonetheless, the patient doubted the potential of composite bonding, because he had been disappointed by the results achieved by his previous practitioner: Most of the previous restorations had lasted only a few weeks. The patient was again informed of the fact that the success of composite bonding greatly depends on the following factors: suitable infection control; mastery of the adhesive technique; proper contouring; correct choice of the material; and sufficient light polymerisation20 including appropriate finishing and polishing. All these factors were given in this case and therefore the prognosis was excellent.5,13,22,28-30,33 Eventually, the patient agreed to the direct composite bonding treatment, but he was surprised to find out about the cost. He mentioned that he had never had to pay such a large amount for the previous treatments, which had never taken longer than 5 to 10 minutes. Consequently, we informed him about the cost of the

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procedure: In order to achieve a long-lasting result, very timeconsuming and complex techniques had to be used. However, the main reason for the considerable cost of the restoration was attributed to the patient’s high aesthetic demands in terms of the shape and shade of the restoration: Several composite materials showing different shades and opacity levels would have to be combined in order to attain the desired result. These high cosmetic demands, which greatly exceeded the services covered by the German statutory health insurance scheme, justified a copayment for aesthetic composite restorations in the anterior region. The possibility of entering into a copayment agreement was given, because in the present case a medical condition needed to be treated, which involved a fractured restoration and periodontal damage. The existing restoration in tooth 22 showed an incisal fracture and a clumsy transition between the proximal and cervical areas: The unevenness was visible and palpable. In many cases, this type of irregularity is due to inadequate contouring of the restoration, resulting in an unnatural emergence profile (Figure 6). As a result, the old restoration was completely removed including the surprisingly extensive secondary caries that emerged. A sectional matrix (Composi-Tight 4.6 mm premolar matrix band, B series, Garrison) was vertically inserted to shape the tooth contour and secured in place with a low-viscosity light-curing provisional material (Clip Flow, VOCO) (Figure 7).

January/February 2022

clinical | EXCELLENCE

Figure 10. Overlay with Tetric Prime universal shade A2.

In contrast to the matrix technique developed by Hugo and Klaiber,25,26,28,34 the present method does not require the matrix to be shaped by hand to delineate the proximal contour, because the 0.035-mm thick, kidney-shaped sectional matrix used already has the required convex shape which defines the proximal margin of the future restoration. This method has been described in publications by the author on multiple occasions.9,10,13-18 It considerably simplifies the traditional matrix technique, since it eliminates the possibility of the tensioned matrix band detaching from the lightcuring provisional material which is used for securing purposes. It is recommended that the sectional matrix be trimmed to the height of the incisal edge in order to ensure easy access from the incisal aspect. Since the patient had practised meticulous oral hygiene and the gingiva was in reasonably good condition, the tooth could be restored under relative isolation without having to use a rubber dam.24 For the adhesive bonding procedure, the teeth were pretreated with a conventional etch-and-rinse multi-bottle system and the adhesive was light-cured. Subsequently, a low-viscosity flowable composite was syringed into the very narrow space between the matrix and the cavity wall using a very fine tip (of a staining material or fissure sealant) and smoothed out with an explorer in the cervical region. This was the only way in which the restorative material could be successfully placed and adapted in this sharply tapered cervical area (Figure 8). In cavities with rather complex geometries, it may be useful to place the flowable composite together with the first increment of the paste material. In this “snow-plough technique” the pressure exerted on the adapted paste material presses the flowable into place, thereby preventing unfilled areas and the formation of voids. Nevertheless, a tight fit of the matrix is an important prerequisite. This technique was first described by Opdam et al. 2003 for Class I cavities.36 Subsequently, the University of Heidelberg dental clinic recognized its value and it has become an established practice.39 Due to the very vibrant translucent properties of the incisal edge, the combination of an aesthetic universal shade and a rather opaque dentine material as a “light blocker” was required in order to prevent a greyish appearance of the restoration as a result of the dark background of the oral cavity.

January/February 2022

Figure 11. Restoration immediately after finishing and polishing.

Figure 12. Excellent aesthetic and functional result at the recall after one year. Completely covering the dentine core on the labial and palatal aspects was deemed to complicate the procedure unnecessarily. Therefore, the shade Tetric Prime A2 Dentin (Ivoclar), which matched the selected shade A2, was used to build up the central and the entire palatal part of the cavity. Next, the restoration was polymerised (high-performance LED curing light > 1.000 mW/cm2, 20 seconds) (Figure 9). A subsequent layer of the universal Tetric Prime A2 shade was placed (Figure 10). The OptraSculpt modelling instrument (Ivoclar) with the small green foam pad was used to shape and adapt the restoration. Lastly, the restoration was finished and polished with tungsten carbide finishing burs (H48 LQ, Komet), flexible discs (Soflex Pop-On XT 2381 M, F and SF, 3M) and special composite polishers (OptraGloss, Ivoclar). Figure 11 shows the restoration immediately following finishing and polishing. Figure 12 shows the restoration at the recall after one year. Even though the patient had expressed reservations about the treatment approach, the direct restoration had lasted more than twice as long as all the previous restorations together. He was highly satisfied with the aesthetic and functional result. He now understood the reason for the higher costs which such a complex anterior restoration incurred, since it had demanded significantly more time and effort than previous solutions. The universal shade A2 in the delicate incisal area beautifully enhances the natural translucency of the rest of the incisal edge. Due to its chroma, the dentine material creates an effect of depth. A complex three-layer technique was not required in this case: The result would not have been any better than the one which was achieved.

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Figure 13. Pointed and dark peg-shaped tooth 12 and a rather narrow tooth 22 with a sharply fractured edge.

Figure 14. Close-up view of the peg-shaped lateral tooth 12.

Figure 15. Close-up view of tooth 22.

Figure 16. Tooth 12 is separated with matrices.

Figure 17. Etching pattern of the conditioned tooth 22.

Figure 18. Bonding surface of tooth 12 sealed with an enamel adhesive.

Case 3: Reshaping of lateral incisors he dentition of the 26-year-old patient of the next case was visually dominated by the peg-shaped tooth 12, which was pointed and dark but vital (Figures 13 and 14) and the rather narrow tooth 22 with a sharply fractured edge (Figure 15). Since both of the lateral incisors were almost perfectly aligned, the only conservative measure for improving their appearance was to widen the incisal areas of both teeth and to slightly lengthen the incisal area of tooth 12. The operative procedure used was principally the same as the one described in the previous case. Sectional matrices (ComposiTight 4.6 mm premolar matrix bands, B-Series, Garrison) were inserted vertically and secured in place on the proximal aspect with a low-viscosity, light-curing provisional material with viscoelastic properties (Clip Flow, VOCO, Figure 16).

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Next the teeth were conditioned with phosphoric acid (Total Etch, Ivoclar). The etching pattern is clearly visible in Figure 17. In contrast to Case 2, only the last bottle of the conventional multiple-bottle adhesive was used, since this case, unlike the previous two cases, only involved enamel surfaces (Figure 18). After a flowable material had been applied on the proximal and cervical aspects, both the teeth were built up with Tetric Prime Dentin Shade A2 (Ivoclar, Figure 19). Tooth 22 was layered with Tetric Prime A2 (Figure 20) and tooth 12 with Tetric Prime A3. This was done to even out the brightness between the very light tooth 11, the darker tooth 12 and the visibly yellowish tooth 13. Alternatively, a dentine core could have been created using Dentin A3, which would have been covered with A2.

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clinical | EXCELLENCE

Figure 19. Build-up of the dentine core of tooth 12 with A2 Dentin.

Figure 20. Covering of tooth 22 with a layer of the universal shade A2.

Figure 21. Close-up view of the built-up tooth 12 after finishing and polishing.

Figure 22. Close-up view of the built-up tooth 22 after finishing and polishing.

Figure 23. Front view of the completed restoration.

Figure 24. View of the mouth showing teeth 12 and 22 after the completion of the treatment.

The reverse combination used in the present case, however, promised to achieve the desired transition of brightness more closely. Another alternative would have been to visually brighten the labial surface of tooth 12 with a bright staining material. The outcome (Figures 21 to 24) fully met the wishes of the patient. Nevertheless, the author felt that the aesthetic appearance of tooth 12 could have been further enhanced by placing a bright staining material. Every case reveals where there is room for improvement. The personal learning curve never ends. In Figures 21 and 23, the mesial build-up of both the central incisors was identified as being inadequate. The patient was informed of this situation at the first consultation appointment. She was fully aware of the fact that these build-ups would have to be repaired or replaced at some stage.

Nevertheless, she said that she would like to wait a few years longer before starting the procedure. A request of this kind is absolutely legitimate and understood as long as the existing condition does not worsen, for example, due to the progression of secondary caries. When an aesthetically suboptimal restoration remains in the oral cavity for longer, the redentistry cycle, which always requires the removal of some tooth structure, can be extended. The aim of a minimally invasive treatment approach is to prevent or reduce the removal of tooth structure and also to draw out the replacement of restorations to the best and most reasonable extent. The view of the mouth shows that the small defect in tooth 11 only minimally affects the overall aesthetic appearance of the dentition. As long as the present clinical situation is acceptable to the patient, it is definitely justifiable from a medical point of view.

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Figure 25. View of the mouth before the treatment: gap between the central and lateral incisors after orthodontic treatment.

Figure 26. Close-up view of the preoperative situation.

Figure 27. Matrix placed on the mesial side of tooth 12.

Figure 28. Matrix placed on the mesial side of tooth 22.

Figure 29. A small amount of flowable composite on the cervicoproximal aspect after adhesive sealing of the bonding surface of tooth 12.

Figure 30. Identical amount of flowable composite on the cervico-proximal aspect after adhesive sealing of the bonding surface of tooth 22.

Case 4: Widening of the lateral incisors n contrast to Case 3, in which the given proximal spatial conditions required that the teeth be reshaped primarily by lengthening of the crown, Case 4 involved closing the spaces separating the two central incisors from the disproportionately narrow, but adequately long, lateral incisors of a 17-year-old patient (Figures 25 and 26). In a preliminary consultation, in which a mock-up was used, it was agreed with the patient to widen both tooth 12 and 22 on the mesial side. Adding a minimal amount of restorative on the distal side could have been an option, but it was rejected, since it would most probably have over-accentuated the pointed canines.

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Theoretically, these additional measures could have been implemented a few years later, if this had been the wish of the patient. Considering her young age, it was important to proceed according to the principle of “nihil nocere”: do no harm, in other words, as little as possible, as much as required. The gap closure in this case had a medical reason: The patient had previously undergone orthodontic treatment and closing the gap would stabilise the orthodontic treatment outcome and hide the lingual retainer, which still had to be worn. No additional preparation was needed. Merely the enamel bonding surface was cleaned and lightly roughened with an EVA

January/February 2022

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Figure 31. Mesio-palatal build-up of the dentine core of tooth 12 (A2 Dentin).

Figure 32. Overlaid universal shade A2 on tooth 12.

Figure 33. Treatment result after finishing and polishing tooth 22.

Figure 34. The new smile of the satisfied patient.

file (Proxoshape Flexible, Intensiv, Montagnola, Switzerland). Figures 27 and 28 show the matrices in place (Composi-Tight 4.6-mm premolar matrix band, B series, Garrison; Clip Flow, VOCO) and Figures 29 and 30 show the small amount of polymerised flowable composite in the cervico-proximal area. The tooth was conditioned with phosphoric acid (Total Etch, Ivoclar). Once again only the last bottle of the conventional multi-bottle adhesive (= enamel adhesive) was used, since the bonding surface consisted of enamel exclusively. In the present case, the tooth colour selected was again A2. Therefore, the palatal parts of the tooth were built up with Tetric Prime A2 Dentin (Figure 31) - with the exception of the incisal area, which was created using only Tetric Prime A2 (Figures 32 and 33). The result (Figure 34) thoroughly satisfied the patient and the referring orthodontist. The restorations were finished and polished with tungsten carbide burs (H48 LQ, Komet), flexible discs (Soflex Pop-On XT 2381 M, F and SF, 3M) and special composite polishers (Diacomp Plus Twist DT-DCP10m and DT-DCP10f, EVE). As expected, the canines no longer looked as dominant as before the treatment. 88

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About the author Prof Dr Claus-Peter Ernst studied dentistry at the University Hospital of the Ludwig-Maximilians-University in Munich and graduated with a Dr. med. dent. in 1990. He was a re-search associate at the Polyclinic for Conservative Dentistry and Periodontology at the Univer-sity Hospital and later a senior physician and lecturer at the Polyclinic for Conservative Dentis-try and Periodontology for tooth, mouth and jaw diseases of the University Medical Center of the Johannes Gutenberg University in Mainz. He later served as an adjunct professor from 2006-2015. Parallel to the clinical activity at the university Dr Ernst worked part-time in the group practice zahnÄrzte in the Gutenberg-Center, Mainz. In 2016, he was the founding part-ner of the dental clinic medi+ in Mainz focussing on composites, adhesive systems, light polymerisation, prophylaxis and aesthetic dentistry. He is a member of AfG - Working group for basic research in the DGZMK; CED - Central European Division of IADR; DGZ - German Society for Conservative Dentistry; DGZMK - German Society for Dental, Oral and Maxillofacial Medicine; DGK - German Society for Pediatric Dentistry; and the IARD - International Association for Dental Research. He is the Editor-in-Chief of the dental journal ZMK - Dentistry, Management and Culture and a scientific reviewer for the American Journal of Dentistry; Clinical Oral Investigations; Dental materials; German Dental Journal; Journal of Adhesive Dentistry; Journal of Esthetic and Restorative Dentistry; and Quintessence International. He has published over 200 original scientific papers and book contributions and delivered over 100 scientific lectures at specialist congresses and over 500 dental training events.

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Figure 35. A hesitant smile due to a diastema and the chipped incisal edge of tooth 21.

Figure 36. Front view of the preoperative upper tooth situation: The patient wished to have the diastema closed, the defect in tooth 21 repaired and the incisal edge of tooth 22 evened out.

Figure 37. Close-up view of tooth 22: The incisal edge was to be evened out with a distal build-up.

Figure 38. Placement of a matrix on the mesial aspect of tooth 11.

Figure 39. Etching pattern on the bonding surfaces of tooth 11 and 22.

Figure 40. Finished widened side of tooth 11 - immediately before the placement of the matrix for tooth 21.

Case 5: Gap closure between the two central incisors he smile of the 31-year-old patient was dominated by an unaesthetic interdental gap, which bothered her quite considerably (Figure 35). Furthermore, the incisal edge of tooth 21 was chipped (Figure 36). In addition, she disliked the steep distally sloping edge of tooth 22 (compared to tooth 12) (Figure 37). Only one preparation step was required: In this case, the enamel bonding surface had to be roughened with a fine-grit EVA file (Proxoshape Flexible, Intensiv). Next, sectional matrices were placed at tooth 11 and 12. They were adjusted and trimmed and then secured to the neighbouring tooth in both cases using Clip Flow (VOCO).

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Phosphoric acid conditioning was carried out (Total Etch, Ivoclar, Figures 38 and 39) and only the enamel adhesive was used. When a gap is closed from both sides, it is advisable to completely build up, contour and polish one proximal surface first, since the sectional matrix can then be properly stabilised and the identical width of the two incisors correctly established. In the present case, the width of the tooth was measured with the help of the reference scale on the OptraSculpt instrument handle (Ivoclar). Flexible discs (Soflex Pop-On XT, 3M) were used to trim the restoration to the correct tooth width. Furthermore, this approach allowed an attachment point to be created for the matrix

January/February 2022

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clinical | EXCELLENCE

Figure 41. Placement of a matrix on the mesial aspect of tooth 21.

Figure 42. Front view of the composite bonding result.

Figure 43. Close-up view of tooth 22 which was built up distally to even out the incisal edge.

Figure 44. The patient’s smile is now happy and spontaneous due to a few small composite bonding adjustments.

Conclusion that would separate the neighbouring tooth 21. Figure 40 shows the composite build-up, which was slightly over-contoured on tooth 11 and subsequently cut back to the required width and then finished and polished. Figure 41 shows the matrix placed at tooth 21 using the same technique. It is essential to polish the first composite bonded proximal surface before proceeding with the second one. This is important, since the light-curing temporary composite material that is applied in the next step would otherwise be very difficult to remove. Figure 42 shows the fully restored tooth 21: The mesial aspect has been built up to widen the tooth and the chipped incisal edge has been repaired. Figure 43 shows the restored tooth 22. Because the additions on the three teeth were very small, only the universal shade A2 was used: The A2 Dentin material was not needed. The present case clearly illustrates the simplicity of this technique and the minimal number of materials required in order to produce a predictable and aesthetically pleasing restorative result (Figure 44). A less-is-more approach often works the best. A number of case studies on this topic show that single colours can achieve aesthetically pleasing results.12,15-18

any excellent universal composite systems for the restoration of anterior and posterior teeth are commercially available today. All of them can be used to produce aesthetic, exacting and high-quality anterior restorations. Therefore, it would be ill-advised to merely concentrate on using the composites designed for bulk-fill applications. There can be no denying that conventional universal composites that are applied in 2-mm increments are still an excellent choice in situations, where apart from function, aesthetics is a major consideration - particularly in the anterior region. If large or wide restorations are created, opaque dentine shades, which are offered by all systems, must be used in order to prevent the darkness of the oral cavity from shining through the restoration, making the built-up area assume a greyish translucency. However, the vibrant translucency of universal shades is essential for the overall aesthetic appearance of the result. Therefore, the need for layering schemes that are based on at least two opacity levels will remain. Additional Effect materials allow even more sophisticated features to be incorporated in high-end restorations. However, this segment will account for only an insignificant fraction of the large majority of cases.

First published in ZMK Dentalforum 09/21. Reprinted with permission. References available on request.

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clinical | EXCELLENCE

Simplifying fixed orthodontics by treating the causes By Dr Jessica Waller, BOH Dent Sc (Griffith), GDipDent (Griffith), GDip Clinical Ortho (UK), FICCDE, FIADFE

n Orthodontics, the understanding of the link between function as well as facial growth and development has progressively improved. The power of incorrect muscle pressure on the position of the teeth and jaw has been recognised for more than 50 years.1 Now, we also know that children with sleep-related breathing problems will often develop distinctive facial characteristics.2 In adults, sleep apnoea can result in serious morbidity and mortality.3 Muscle dysfunction can affect the patient’s overall health so treatment of the dysfunction should not be dismissed in orthodontic diagnosis and treatment planning.

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In September 2018, the World Dental Federation (FDI) publicly highlighted the important role of dentists in prevention, early screening and treatment of Sleep-Related Breathing Disorders (SRBD). Treating these patients can lend itself to collaboration with other medical specialties to improve a patient’s health and treatment outcome. Myofunctional Research Company’s (MRC) highly developed treatment system for breathing, myofunctional and orthodontic correction provide dental professionals and orthodontists with the ability to approach the functional side of orthodontics more readily. This is achieved by having an easily accessible and useable appliance system which first directs treatment at establishing correct breathing and oral muscle habits.

January/February 2022

clinical | EXCELLENCE

Figure 1a. Start of treatment.

Figure 1b. Three months intro treatment.

Figure 1c. Seven months into treatment.

Figure 1d. Completion of treatment after 15 months. By the time most orthodontic patients have presented for braces treatment, a great deal of the damage from muscle dysfunction has already occurred, such as “adenoidal facies” (aka “long face syndrome”) in particular from mouth breathing and subsequent low tongue posture. Most practitioners agree treating the dysfunction as young as possible has the greatest effects to improve craniofacial development, however treating the dysfunction later, or in older patients, still has its merit and can still decrease treatment time, allow better arch expansion and better stability of orthodontic treatment, not to mention the overall health benefits to the patient. Orthodontic treatment can be particularly challenging in patients with severe muscle dysfunction. The incorrect muscle pressure on the orthodontic brackets, wires and teeth can impede the correct orthodontic movement desired by the treating practitioner. By including a myofunctional appliance in conjunction with traditional orthodontic treatment, challenging cases can be

January/February 2022

converted to more easily treated cases.4 Combining braces with the Myobrace® B-range (Myofunctional Research Company) allows simple management of function to allow the fixed braces to move to their best ability without hinderance.

Case study: Female, 12 years old he patient’s main concern was to improve the alignment and occlusion; however, the parents did not want any extractions or interproximal reduction (IPR). The patient was treated with upper braces along with the Myobrace B1. The patient then progressed to the Myobrace B2, as there was not enough positive overjet to fit the lower braces without performing any IPR. Once sufficient positive overjet was created, the lower braces were fitted. The patient only required 15 months of treatment in total, creating a positive overbite and overjet, finishing in removable thermoformed retainers and the Myobrace B3.

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Figure 2. The Myobrace for Braces (B-Series) range. The Myobrace for Braces (B-series) includes three appliances. The B- Stage 1 (B-1) can be used prior to fitting braces or at the initial fit and starts to establish correct nasal breathing and tongue posture. The B1 allows sagittal correction to begin straight away, prevents initial soft tissue irritation by covering the brackets and wires, while separating the arches allowing better development through disocclusion. The B1 is used while levelling and aligning is taking place. The B- Stage 2 (B-2) is the next appliance in the series. The B2 is a firmer appliance which continues to work further on arch expansion by improving the swallowing method through restricting the

“The Myobrace B-range truly helps to simplify conventional orthodontic treatment, is readily available to order without incurring expensive lab fees or waiting for referrals to auxiliary health professionals...” use of the buccinators and mentalis muscles, allowing only the tongue to function in swallowing, creating outward expansion pressure with no inward restriction from the cheeks and lips. The B- Stage 3 (B-3) is the retention appliance to be used once the braces have been removed and the patient is in removable vacuum-formed retainers. The retainers are used to maintain the dental alignment until the alveolar bone has remodelled, in around 3-6 months. The B3 works over the top of the retainers to maintain the sagittal correction which has taken place throughout treatment until neuromuscular adaptation has taken place. Muscle adaptation is the part of orthodontic treatment which takes the longest to modify, around 12-24 months,5,6 which is why a retention appliance holding the sagittal correction is essential

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following any orthodontic treatment. All of these appliances are worn for 1-2 hours while awake and overnight while asleep, in conjunction with conventional orthodontic treatment. The Myobrace B-range truly helps to simplify conventional orthodontic treatment, is readily available to order without incurring expensive lab fees or waiting for referrals to auxiliary health professionals and provides multiple benefits to the patient and practitioner.

About the author Dr Jessica Waller completed a three-year postgraduate Diploma in Clinical Orthodontics through the City of London Dental School in 2019, obtaining fellowships for ICCDE and IADFE. A 2012 Griffith University graduate in Dentistry, she also received the Griffith Award for Academic Excellence. In 2014, Dr Waller began working for the Myobrace Pre-Orthodontic Centre and is passionate about early interceptive orthodontic treatment, modern techniques and appliances that are now available to improve the quality of treatment she is able to offer.

References 1. The “three M’s”: Muscles, malformation, and malocclusion. Graber TM. Am. J. Orthodontics 1963 49(6):418-450. 2. The influence of snoring, mouth breathing and apnoea on facial morphology in late childhood: a three-dimensional study. Al Ali A et al. BMJ Open 2015;5:e009027. 3. How has our interest in the airway changed over 100 years? Kim K. Am J Orthod Dentofacial Orthop 2015;148:740-7. 4. Relapse of anterior open bites treated with orthodontic appliances with and without orofacial myofunctional therapy. Smithpeter et al. Am J orthod Dentofacial Orthop 2010 May;137(5):605-14. 5. ‘Retention’ Contemporary Orthodontics Proffit 5th Ed Ch17 609. 6. A functional approach to Orofacial Orthopaedics. Frankel. British J of Orthod. 1980 7(1).

January/February 2022

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From the implant planning to the resin provisional - Case example with Zirkonzahn.Implant-Planner

ith the Zirkonzahn.Implant-Planner implant planning software, the cooperation between the dentist and the dental laboratory can be taken to new levels, reconciling the planned aesthetic design of a prosthetic restoration with the planned implant situation (prosthetically driven). Based on digitally merged patient data (such as DICOM data or data from model or face scans), the dentist can determine the optimal implant position in terms of function, anatomy and aesthetics, taking bone structure and set-up into account. The user is guided through the planning process one step at a time, making implant planning an easy task right from the outset and requiring only a

minimum of user familiarity with software procedures. With the data transfer feature, the data can easily be sent to the dental lab. Here, the surgical guides, the restorations, the custom impression trays and/or the models with laboratory analogues are made. This allows the dentist to receive all components required for an implant case simultaneously (immediate loading). All structures - from surgical guide to the prosthetic restoration itself - can be manufactured using the Zirkonzahn CAD/CAM system. Every step fits perfectly with the existing Zirkonzahn workflow. The open data-exchange feature allows the use of CAD/CAM systems by other manufacturers or 3D printers for the production of surgical guides or models.

Figures 1 and 2. With Zirkonzahn.Implant-Planner, the design of the prosthetic restoration can be considered already during the implant planning phase. Implant planning is possible for all common implant systems - the software contains an extensive library of implant-prosthetic components and drilling sleeves, which are constantly expanded.

Figures 3 and 4. Based on the digitally merged patient data (e.g. DICOM data, intraoral scans, set-up), the dentist can determine the ideal implant positions according to functional and aesthetic aspects, taking bone density into account. Based on such data, the dental technician can produce surgical guides, individual impression trays, models, restorations for immediate loading and resin prototypes.

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clinical | EXCELLENCE

Figures 5 and 6. After the implant placement, the situation can be recorded either using an intraoral scanner and White Scanmarkers, or following conventional methods with individual impression trays, impression copings and ScanAnalogs. Then, the situation is transferred in the correct position into the Zirkonzahn.Modellier software or another design software.

Figures 7 and 8. With the CAD/CAM Model Maker software module, the upper and lower master models are designed and then manufactured using a Zirkonzahn milling unit. The models are fitted with laboratory analogues and can then be used to check the final restorations, e.g. resin prototypes with titanium bars.

Figures 9 and 10. The digital master models together with the diagnostic wax-ups created in the Zirkonzahn.Implant-Planner software serve as a reference for the design of the titanium bars.

Figures 11 and 12. After their elaboration with a Zirkonzahn milling unit, the bars made of high-quality titanium 5 are refined with a surveyor and high-gloss polished. According to one’s requirements, the titanium bars can be anodised in a golden shade using the Titanium spectral-colouring Anodizer, in order to avoid the grey value shining through the superstructures.

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Figures 13 and 14. The resin prototypes are designed and milled according to the metal bars and to the virtual wax-ups adapted to them.

Figures 15-17. For this purpose, the flexible high-performance Multistratum® Flexible resin is used. This stable, biocompatible material is already provided with a natural colour transition, which endows the provisionals with highly aesthetic properties. The gingival areas are veneered with Gingiva-Composites (optional). Would you like to know more about Zirkonzahn.Implant-Planner software? Visit www.zirkonzahn.com to download the demo version for free or contact stan@alphabond.com.au.

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

ZIRKONZAHN.IMPLANT-PLANNER A WAY TO DEVELOP COOPERATION BETWEEN DENTISTS AND DENTAL TECHNICIANS: BACKWARD IMPLANT PLANNING BASED ON DIGITALLY MERGED PATIENT DATA (SUCH AS DICOM DATA, MODEL OR INTRAORAL SCANS AND 3D FACIAL SCANS)

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

clinical | EXCELLENCE

case report

Immediate full-arch restoration with TLX implant system: 1-year follow-up with straightforward direct-to-implant restorative concept in periodontally compromised patient By Dr Matthieu Collin

merging from the early 1970s, tissue level implants represent one of the longest and most well-established treatment concepts in implant dentistry.1 Compared to bone level implants, this concept has proven to be equivalent in terms of osseointegration and long-term survival rates, with potential advantages with regards to crestal bone level preservation.2,3 Some of the advantages are associated with the supra-crestal positioning of the implant-abutment microgap, which helps to reduce the mechanical stress and microbial exposure at crestal bone levels.4-6

Figure 1. Patient’s prior treatment - Left: Facial aesthetics and smile line. Right: Dental and soft tissue conditions in retracted view.

Introduction riven by patient demands and increased clinical evidence, recent developments in implant dentistry have seen a pronounced trend towards early and immediate procedures.7 This trend has been especially pronounced for full-arch rehabilitations that prevent patients from being exposed to a long period of edentulism.8-10

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Figure 2. Dental and osseous anatomic status - Left: Panoramic radiograph (frontal view) and Right: CBCT of the maxilla in occlusal view.

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Figure 3. Virtual implant planning (left) and planning of surgical guides (right).

Figure 4. Occlusal prosthetic planning - Left: Preliminary cast of existing occlusion and Right: With corrected vertical occlusal dimension (OVD). One of the most clinically relevant factors for the prognosis of implant success of immediate loading is primary implant stability.11,12 This factor becomes even more important in patients with compromised bone quality or quantity.13 The novel BLX implant with its self-tapping tapered implant body and its protruding thread geometry represents one of the most promising tools to help clinicians achieve a high level of bone engagement and immediate primary stability.14 Although recent research suggests good clinical success rates for full-arch restorations even in periodontally compromised patients, a combination of optimised primary stability, surgical flexibility and long-term tissue level stability could be highly desirable.15,16 The following case report describes the procedure and 1-year follow-up of a full-arch restoration with the novel Straumann® TLX Implant System, using a straightforward direct-to-implant restorative concept. The novel implant system combines the endosteal design of the BLX implant system for optimal primary stability, with an emergence profile that has proven to deliver successful longterm soft tissue stability. This qualifies the system for immediate procedures in situations with an enhanced hygiene requirement, for example in the illustrated treatment of a periodontally compromised patient.

Initial situation 49-year-old patient presented in our clinic after a prolonged period without dental check-ups and with a complaint of unsatisfactory aesthetics and discomfort while eating due to teeth mobility (Figure 1). The patient reported that he was a smoker and had limited time available because of his professional activity. Oral examination revealed severe generalised periodontitis (stage III to IV) associated with poor oral hygiene, as evidenced by the presence of advanced gingival recessions, exposed root surfaces, abnormally pale gingival colour, loss of interdental papillae and Miller class I tooth mobility.17 The patient was in good general health and had no absolute contraindications for implant treatment.

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A diagnostic CBCT (Figure 2) revealed pronounced horizontal bone loss in the maxilla with vertical intraosseous components.18 The maxilla also displayed a wide range of conditions with uncertain treatment prognosis, including a likely furcation involvement of the second molar (potentially class III19) in position 18, apical radiolucency indicating a cyst on the palatal root of the first molar in position 17, severely advanced horizontal bone loss on teeth 25 and 27 with potential oroantral communication. The mandible also displayed horizontal bone loss, but at a less advanced stage, allowing a conservative treatment approach with adequate prognosis except for tooth positions 36 and 37, which were considered hopeless. Together with the patient, the decision for an immediate maxillary full-arch restoration was taken based on the patient’s wish for an immediate, cost-effective and comprehensive solution.

Treatment planning ifferential diagnostic evaluation according to Bedrossian et al. indicated a normal smile line (Figure 1), appropriate occlusal vertical dimensions (Figure 4) and the presence of teeth-only defects allowing for a white bridge.20 Considering the advanced atrophic state of the posterior maxilla and the missing osseous structure beneath the sinus, the restorative concept was defined as a first molar to first molar white zirconia framework supported by four implants (Figure 3). Inclination of the posterior implants engaging with the anterior sinus walls allowed for an increased A/P spread avoiding cantilevers and augmentation procedures.21 Planning of the restorative phase specifically considered the periodontal preconditions of the patient implying a greater need for hygiene maintenance and long-term biologic tissue stability. The novel TLX implant represented the ideal tool to meet these requirements, combined with the ability to achieve an optimal level of primary stability as part of the immediate protocol. Figure 3 illustrates the detailed planning of the implant restoration based on four Ø 3.75 x 12 mm, TLX Roxolid® SLActive® Implants in coDiagnostiX® in relation to the existing dentition as reference for the prosthetic restoration, as well as the corresponding surgical guide.

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Figure 5. Minimally invasive strategic tooth extraction.

Figure 6. Osteotomy preparation and implant placement in position 12.

Figure 7. Novel TLX implant, diameter 3.75 mm, length 12 mm, Roxolid, SLActive, 1.8 mm neck. With regards to the prosthetic planning, a cost-effective and straightforward design of the immediate and final prosthetic restoration based on a direct-to-implant concept was feasible. This specific concept further required the divergence between adjacent implants to be restricted to less than 40° to allow for a passive fit of the abutments on the implant base (Figure 3). As evidenced by the preliminary cast in figure 4, the prosthetic planning further included the correction of a moderate class 2 malocclusion, increasing the vertical dimension and the available crown height space for the restoration.

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The surgical procedure was carried out under general sedation in combination with local infiltration anaesthesia and started with minimally invasive tooth removal after an intrasulcular incision (Figure 5). As part of a strategic tooth extraction protocol, the central incisors, cuspids and the second molar in position 17 were temporarily kept in situ as a precise retention guide.22 Figure 6 illustrates the sequence of osteotomy preparation, guided drilling and implant placement in position 12. Osteotomies were prepared by single guided pilot drilling using VeloDrills™ with a diameter of 2.2 mm and to a depth of 14 mm, ensuring flexibility with regards to implant placement level. As evidenced, anterior implant osteotomies were prepared palatally to the extracted class I sagittal root position for engagement with palatal cortical bone and in order to reduce any risks for vestibular fenestration. Following verification of correct depth and angulation using alignment pins, TLX implants were placed by hand. Excellent engagement and primary stability for immediate loading of all implants was achieved, as verified by the Straumann ratchet and torque control device, with insertion torques consistently displaying values above 35 Ncm. Figure 7 shows the TLX implant with the characteristic selftapping tapered endosteal part and protruding thread geometry for bone engagement and the elongated machined collar at tissue level for supracrestal positioning of the implant abutment interface.

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AESTHETIC DENTISTRY AESTHETIC DENTISTRY

Straumann® Emdogain® & Emdogain® Flapless Straumann® Emdogain® & Emdogain® Flapless

Mastering periodontal regeneration Mastering periodontal regeneration and oral wound healing. and oral wound healing. Experience comes with time. Over the last 25 with years,time. Straumann® Experience comes Emdogain® has 25 earned respect of Over the last years,theStraumann® thousands ofhas periodontists, oralrespect surgeons, Emdogain® earned the of implantologists and dentists around the thousands of periodontists, oral surgeons, world. implantologists and dentists around the world.

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Straumann Pty Ltd/Straumann New Zealand Limited 93 Cook Street, Port Melbourne VICNew 3207, Zealand Australia Limited Straumann Pty Ltd/Straumann AU Toll Free 1800 660 330 | NZ Toll 408 370 93 Cook Street, Port Melbourne VICFree 3207,0800 Australia Email customerservice.au@straumann.com AU Toll Free 1800 660 330 | NZ Toll Free 0800 408 370 www.straumann.com.au Email customerservice.au@straumann.com www.straumann.co.nz www.straumann.com.au www.straumann.co.nz ©Institut Straumann AG, 2021. All rights reserved. Straumann® and/or other trademarks and logos from Straumann® mentioned herein are the trademarks or registered trademarks of Straumann Holding AG and/or its affiliates. ©Institut Straumann AG, 2021. All rights reserved. Straumann® and/or other trademarks and logos from Straumann®

clinical | EXCELLENCE

Figure 8. Positioning of TLX impression posts and preparation for pick-up impression.

Figure 9. One-step impression and registration of occlusion and implant positions using a transparent prosthesis.

Prosthetic procedure he immediate temporary restoration was prepared using conventional laboratory techniques with an open-tray impression. TLX impression posts were mounted on the implants, followed by minimally invasive removal of residual teeth, suturing and fixing of any loose soft tissue margins. Impression posts were then splinted to prevent any distortions during impression taking using dental floss and flowable acrylic (Figure 8).

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Open-tray impressions were produced using a combination of light- and heavy-bodied impression materials. A transparent removable prosthesis was used to register the occlusion and implant prosthetic relation in the sedated patient (Figure 9). An immediate provisional hybrid prosthesis was prepared by our associated laboratory and delivered to the patient on the day of surgery (Figure 10).

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clinical | EXCELLENCE

Figure 10. Frontal view and panoramic radiograph after delivery of the immediate temporary restoration.

Figure 11. Preparation of final prosthesis: bite registration and soft tissue contours.

Figure 12. Final zirconia bridge before delivery.

The provisional concept was specifically realised using a direct-to-implant restoration with non-engaging titanium copings (TorcFit™ connection). The prosthetic framework was cross-arch splinted with a welded bar, resulting in a good immediate passive fit as confirmed by the post-surgical panoramic radiograph.

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The final restoration, consisting of a screw-retained zirconia bridge based on Variobase® for Bridge/Bar abutments, was prepared 6 months post-surgery (Figure 12). Prosthetic planning was based on the existing provisional after bite registration and impression of the soft tissue contours interfacing the pontic sites of the framework using a light-bodied impression material (Figure 11).

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Figure 13. Aesthetic aspects of the final restoration in frontal and buccal views (upper pictures) as well as soft and hard tissue conditions at the 6-month and 1-year follow-up respectively (lower pictures).

Figure 14. Comparison of the patient before and 1 year after surgery.

Treatment outcomes s indicated by the photographs after delivery of the final prosthesis 6 months post-surgery, very satisfactory results with regards to aesthetics, functional occlusion and soft-tissue integration were obtained (Figure 13). Soft tissue conditions around the implants at the 6-month follow-up were healthy and stable and did not show any sign of inflammation. Remarkably good soft tissue healing was noted around all implants. The overall healthy state of the gingival soft tissues correlated well with the very satisfactory aesthetic conditions and healthy colouration of the buccal soft tissues. The 1-year follow-up radiograph further confirmed stable osseointegration of all implants.

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The patient did not require any appreciable adaptation periods for the temporary or final restorations. It was particularly noticeable that the patient displayed a marked and distinct change in his behaviour and appearance at the follow-up appointment, potentially associated with improved confidence and self-esteem (Figure 14). The patient reported finding it easy to maintain oral hygiene using a microbrush and a water flosser, which was confirmed by the overall good peri-implant tissue health.

January/February 2022

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www.straumann.co.nz ©Institut Straumann AG, 2021. All rights reserved. Straumann® and/or other trademarks and logos from Straumann® mentioned herein are the trademarks or registered trademarks of Straumann Holding AG and/or its affiliates. ©Institut Straumann AG, 2021. All rights reserved. Straumann® and/or other trademarks and logos from Straumann®

clinical | EXCELLENCE Conclusion

About the author

his case report describes the immediate full-arch restoration of a periodontal patient with failing dentition. In this case, the Straumann TLX Implant System provided an ideal solution to achieve a high degree of primary stability combined with the option to maintain hygiene. In addition, the use of the Straumann TLX Implant System allowed an effective direct-to-implant restorative concept to be realised.

Matthieu Collin graduated with a Degree in Dental Surgery from Claude Bernard Lyon 1 University in France. He also completed a degree in Oral Surgery and Oral Implantology (Dijon) and in Pre- and Peri-implant Surgery (Paris). He is a national clinical instructor on full-arch rehabilitation systems, an ITI member and speaker on implant treatment of fully edentulous arches with a particular interest in developing simplified treatment workflows. His professional interests include minimally invasive implant treatments, efficient treatment protocols and restoring occlusion in complex cases. Dr Collin is in private practice in Sanary-sur-Mer, France specialising in dental implantology and buccal surgery with the focus on severe bone atrophy. Dr Collin Practice uses Clinic St Roch of Toulon, France for complex / advanced surgeries under general anaesthesia.

Acknowledgements would like to thank Dr Grégory Camaleonte and the laboratory Ruocco for their help and expertise in designing and fabricating the prosthetic bridges, as well as Alex Ostashko, Stefano Besio and Sébastien Barrière from Straumann.

References 1. D. Buser, R. Mericske-Stern, K. Dula, N.P. Lang, Clinical Experience with One-Stage, Non-Submerged Dental Implants, Adv Dent Res. 13 (1999) 153–161. https://doi.org/10.1177/08959374990130010501.

11. F. Javed, G.E. Romanos, The role of primary stability for successful immediate loading of dental implants. A literature review, Journal of Dentistry. 38 (2010) 612–620. https://doi.org/10.1016/j.jdent.2010.05.013.

2. S. Kim, U.-W. Jung, K.-S. Cho, J.-S. Lee, Retrospective radiographic observational study of 1692 Straumann tissue-level dental implants over 10 years: I. Implant survival and loss pattern, Clin Implant Dent Relat Res. 20 (2018) 860– 866. https://doi.org/10.1111/cid.12659.

12. F. Javed, H.B. Ahmed, R. Crespi, G.E. Romanos, Role of primary stability for successful osseointegration of dental implants: Factors of influence and evaluation, Interventional Medicine and Applied Science. 5 (2013) 162–167. https://doi. org/10.1556/IMAS.5.2013.4.3.

3. S. Cosola, S. Marconcini, M. Boccuzzi, G.B. Menchini Fabris, U. Covani, M. Peñarrocha-Diago, D. Peñarrocha-Oltra, Radiological Outcomes of Bone-Level and Tissue-Level Dental Implants: Systematic Review, IJERPH. 17 (2020) 6920. https://doi.org/10.3390/ijerph17186920. 4. D.L. Cochran, The scientific basis for and clinical experiences with Straumann implants including the ITI Dental Implant System: a consensus report, Clin Oral Implants Res. 11 Suppl 1 (2000) 33–58. https://doi.org/10.1034/j.16000501.2000.011s1033.x. 5. J.S. Hermann, J.D. Schoolfield, R.K. Schenk, D. Buser, D.L. Cochran, Influence of the Size of the Microgap on Crestal Bone Changes Around Titanium Implants. A Histometric Evaluation of Unloaded Non-Submerged Implants in the Canine Mandible, Journal of Periodontology. 72 (2001) 1372–1383. https://doi. org/10.1902/jop.2001.72.10.1372. 6. Y. Sasada, D. Cochran, Implant-Abutment Connections: A Review of Biologic Consequences and Peri-implantitis Implications, Int J Oral Maxillofac Implants. 32 (2017) 1296–1307. https://doi.org/10.11607/jomi.5732. 7. D. Buser, V. Chappuis, U.C. Belser, S. Chen, Implant placement post extraction in esthetic single tooth sites: when immediate, when early, when late?, Periodontol 2000. 73 (2017) 84–102. https://doi.org/10.1111/ prd.12170. 8. M. Rohlin, O. Dr, K. Nilner, O. Dr, T. Davidson, G. Gynther, O. Dr, M. Hultin, O. Dr, T. Jemt, O. Dr, U. Lekholm, O. Dr, G. Nordenram, O. Dr, A. Norlund, K. Sunnegårdh-Grönberg, O. Dr, S. Tran, Treatment of Adult Patients with Edentulous Arches: A Systematic Review, The International Journal of Prosthodontics. 25 (2012) 553–567. 9. P. Pera, M. Menini, P. Pesce, M. Bevilacqua, F. Pera, T. Tealdo, Immediate Versus Delayed Loading of Dental Implants Supporting Fixed Full-Arch Maxillary Prostheses: A 10-year Follow-up Report, Int J Prosthodont. 32 (2018) 27–31. https://doi.org/10.11607/ijp.5804. 10. G. Huynh-Ba, T.W. Oates, M.A.H. Williams, Immediate loading vs. early/conventional loading of immediately placed implants in partially edentulous patients from the patients’ perspective: A systematic review, Clin Oral Impl Res. 29 (2018) 255–269. https://doi.org/10.1111/clr.13278.

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13. D. Buser, L. Sennerby, H. De Bruyn, Modern implant dentistry based on osseointegration: 50 years of progress, current trends and open questions, Periodontol 2000. 73 (2017) 7–21. https://doi.org/10.1111/prd.12185. 14. Ophir Fromovich, Karim Dada, Leon Pariente, Marwan Daas, BLX: a new generation of self-drilling implants, (2019). 15. C.C. Alves, A.R. Correia, M. Neves, Immediate implants and immediate loading in periodontally compromised patients-a 3-year prospective clinical study, Int J Periodontics Restorative Dent. 30 (2010) 447–455. 16. S. Li, P. Di, Y. Zhang, Y. Lin, Immediate implant and rehabilitation based on All-on-4 concept in patients with generalized aggressive periodontitis: A mediumterm prospective study: Li et al., Clinical Implant Dentistry and Related Research. 19 (2017) 559–571. https://doi.org/10.1111/cid.12483. 17. S.C. Miller, Textbook of periodontia (oral medicine), 3rd ed., Blakiston, Philadelphia, 1950. 18. J.G. Caton, G. Armitage, T. Berglundh, I.L.C. Chapple, S. Jepsen, K.S. Kornman, B.L. Mealey, P.N. Papapanou, M. Sanz, M.S. Tonetti, A new classification scheme for periodontal and peri-implant diseases and conditions - Introduction and key changes from the 1999 classification, J Clin Periodontol. 45 (2018) S1–S8. https://doi.org/10.1111/jcpe.12935. 19. S.E. Hamp, S. Nyman, J. Lindhe, Periodontal treatment of multirooted teeth. Results after 5 years, J Clin Periodontol. 2 (1975) 126–135. https://doi. org/10.1111/j.1600-051x.1975.tb01734.x. 20. E. Bedrossian, R.M. Sullivan, Y. Fortin, P. Malo, T. Indresano, Fixed-Prosthetic Implant Restoration of the Edentulous Maxilla: A Systematic Pretreatment Evaluation Method, Journal of Oral and Maxillofacial Surgery. 66 (2008) 112– 122. https://doi.org/10.1016/j.joms.2007.06.687. 21. M. Bevilacqua, T. Tealdo, M. Menini, F. Pera, A. Mossolov, C. Drago, P. Pera, The influence of cantilever length and implant inclination on stress distribution in maxillary implant-supported fixed dentures, The Journal of Prosthetic Dentistry. 105 (2011) 5–13. https://doi.org/10.1016/S0022-3913(10)60182-5. 22. K. Dada, L. Pariente, M. Daas, Strategic extraction protocol: Use of an imagefusion stereolithographic guide for immediate implant placement, J Prosthetic Dentistry. 116 (2016) 652–656. https://doi.org/10.1016/j.prosdent.2016.03.008.

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Talk Talk to Talk to usto us today us today today and and we and we will we will help will help help you you plan you plan plan and and and Talk Talk Talk Talk to Talk Talk toto us us to to us to today today us us us today today today today and and and and we and and we we will we will we we will help will will help will help help help you help you you you plan you you plan plan plan plan and plan and and and and and construct construct construct a guide a guide a guide forfor your for your your next next next case case case construct construct construct construct construct construct aaguide aguide a guide aaguide guide guide for for for your for your for for your your your next your next next next next case next case case case case case FIRST FIRST FIRST CASE CASE CASE HALF HALF HALF PRICE PRICE PRICE * * * FIRST FIRST FIRST FIRST FIRST FIRST CASE CASE CASE CASE CASE CASE HALF HALF HALF HALF HALF HALF PRICE PRICE PRICE PRICE PRICE PRICE * * * *** www.implaguide.com.au www.implaguide.com.au www.implaguide.com.au www.implaguide.com.au www.implaguide.com.au www.implaguide.com.au www.implaguide.com.au www.implaguide.com.au www.implaguide.com.au

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clinical | EXCELLENCE

Biodentine™ in the management of complex root perforations By Dr Clara Eugenia Adrada Cruz

ndodontic therapy seeks to conserve natural teeth. Accidents during this procedure are quite common, which affects the prognosis of root canal therapy. Iatrogenic perforations occur during the formation of the root canal, but are more common during access and apical shaping, particularly in curved canals.2 Likewise, they can occur when creating the space for the placement of an intraradicular post. The communication between the root canal system and the supporting tissue reduces the prognosis of endodontic treatment and often leads to the loss of the tooth. Ingle et al found that the second most common reason for failure associated with endodontic therapy is root perforation.2 Several clinical findings may be determining factors in the diagnosis of root perforations. Clinical examinations and radiographs are the basis for the diagnosis of these perforations.2,3 During the preparation of the root canal, the root pulp can be extracted by pulpectomy. After removing the pulp tissue, persistent bleeding during access to the crown or the preparation of the root canal can be a sign of perforation. A paper point with blood can also suggest perforation.

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Clinically, the diagnosis is challenging,3 but an apex locator can help in the diagnosis of root perforation. Periapical radiographs are often indicated for endodontic diagnosis, the treatment plan and follow-up.5 Radiolucency associated with communication between the dentinal root canal walls and the periodontal space is a major sign of this accident during the procedure.

January/February 2022

clinical | EXCELLENCE

Figure 1.

Figure 2.

Figure 3.

The prognosis of perforation depends on the size of the defect, the time, the duration of exposure to contamination, the material used to repair it, the possibility of sealing the perforation and access to the main canal.4 To minimise contamination in the area of the perforation, it’s important to apply suitable sealing immediately.2 The success of the repair always depends on an effective seal between the root canal and the periodontal ligament. This can be achieved using suitable material, which should stop microfiltration and the communication between the tooth and the periodontal ligament. The ideal material for use in root perforations should be biocompatible, capable of a good seal, not resorbable, radiopaque, induce bone formation and healing, induce mineralisation and the formation of cementum and facilitate ease of placement.11

We were faced with a perforation of poor prognosis, due to its size comparable to the diameter of the tip of the post, with a width of 2 mm and a long period of contamination equivalent to 3 years, the time since the cementation of the tooth. The presence of a bone defect adjacent to the site of the perforation and leakage of purulent material indicated a chronic infection with a poor prognosis.

2% hypochlorite was used for disinfection using an Endoactivator. The calcium hydroxide matrix was placed in the perforation site. At the second visit, we sealed the perforation with Biodentine™ using micro condensers of Marthe’s instrumental, while we left some taperised guttapercha cones (No. 25) cut into canals to prevent the entry of Biodentine into the canals. Perforations caused by wear and tear are characterised by the need to place the sealing material directly on the periodontal tissue and extended the obturation 1 to 2 mm from the edges of the perforation on the dentine. When a clinical microscope cannot provide sufficient visibility, there is a risk of not applying the material correctly.8 The initial setting time is 6 minutes and the final time between 10 and 12 minutes. After setting, 2% hypochlorite was used as an irrigant and the canals were sealed by lateral condensation (Figure 1). The patient was then referred to a prosthodontist for the placement of the core and provisional crown. In the follow-up appointment three months post treatment, the radiograph showed 80% bone formation at the site of the lesion at the furcation and in the apical zone of the two roots (Figure 2). The patient was then absent for a period of 5 years. On his return for a recall appointment, radiographically the patient presented with complete healing of the bone defects caused by the perforation and the apical lesions (Figure 3).

Case report sixty-year-old male patient was referred to the endodontist for a periodontal abscess in the vestibular mucosa of the lower left first molar. Radiographically, the patient presented a radiolucent zone at the level of the furcation and a tooth skewed towards the internal wall of the distal root, producing a perforation in the cervical third of the distal root towards the zone of the interradicular furcation. Local anesthesia was injected into the lower dental nerve and the mental nerve and the provisional crown removed. Removal of the titanium post with No. 3 Start-X (Denstply) ultrasonic tips followed. Once the provisional crown was removed, it was observed under the microscope that purulent material spontaneously seeped out of the perforation site.

January/February 2022

“Biodentine is used in dentistry as an alternative to MTA to try and offset the latter’s deficiencies. Biodentine is a bioactive material that can be used for different purposes and represents an improvement on the characteristics of MTA...”

The perforation was located in the cervical third of the root, where it can only be observed under magnification. Irrigation was done with 2% hypochlorite, initially only introducing the needle into the entrance of the canal to avoid accidents. The real entrance of the canal was located under microscope; to eliminate guttapercha, xylol was used. Thanks to help from the microscope, we placed the rotary file in the distal canal, taking care not to touch the perforation site. Instrumentation was done with Protaper Next (Dentsply) files.

Discussion microscope is essential to try and treat procedural errors in the best possible manner. We need to see what we are going to seal.9

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clinical | EXCELLENCE A range of materials such as composite resin, 4-ethoxybenzoic acid, resin-reinforced glass ionomer cement, calcium hydroxide, guttapercha, MTA and Biodentine are the most commonly used repair materials.1 When the use of MTA was introduced as an alternative for perforation repair, it offered very favourable properties compared with previous materials. Its ability to induce the formation of cement to regenerate periodontal tissue was also a step forward.2 Advances in bioceramic technology have improved the science of endodontic materials. Biodentine is used in dentistry as an alternative to MTA to try and offset the latter’s deficiencies.

“As well as Biodentine having very good biological properties, placement at the perforation site is very simple, which reduces operative time...”

Biodentine is a bioactive material that can be used for different purposes and represents an improvement on the characteristics of MTA in terms of compatibility, manipulation and hardening.11,12 It also offers better bone regeneration properties than MTA, as it releases more calcium ions.12 This material creates a bond with root dentine that is significantly stronger than that achieved with MTA.14 At sites that are difficult to access, we need to compensate by using easy-tohandle materials with good osteo-inductive properties, to be able to apply it at the perforation site. At a perforation site, where contamination with tissue fluids is present, Biodentine is a good choice because the blood contamination that can occur when placing it in the site does not affect its adhesive strength, whereas MTA is affected by blood contamination.13 Furthermore, in this type of perforation located in roots that will receive a core, the material used for sealing should be of high compressive strength. Biodentine has greater compressive strength than other materials as a result of the low level

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of water it contains. It also performs well as a perforation repair material, even after exposure to the different irrigants used in endodontics.

Conclusion • The use of magnification in endodontic therapy has proven very useful for an operator to develop his/her skills to the maximum and offer higher quality and greater precision in treatments. If we add the use of bioceramics such as Biodentine in the sealing of perforations, the operator can turn a poor prognosis into a good one; • Bioceramics have osteo-inductive properties10 that older materials did not offer. Biodentine has better physical and biological properties in comparison with MTA, which makes it more useful in handling root perforations than other cements. As well as having very good biological properties, placement at the perforation site is very simple, which reduces operative time; • An old and large perforation, with the associated destruction of bone and purulent infection - variables that produce a poor prognosis - can be solved by using a material that performs well in the presence of blood contamination, has good compressive strength and resistance to leakage, is osteoinductive and offers good adhesion to the dentine in a single cement: Biodentine; and • Thanks to advances in contemporary endodontics, we can now save teeth that previously had poor prognosis and could not be saved.

About the author Dr Clara Eugenia Adrada Cruz is an endodontist at the Universidad El Bosque, Colombia. She has 20 years’ experience and was one of the pioneers in the use of the microscope in Colombia. Dr Cruz was president of the Endodontics Association of El Cauca from 2018-2020.

References 1. Carlos Estrela, Daniel de Almeida, Decurcio Giampiero, Rossi-Fedele Julio Almeida Silva , Orlando Aguirre Guedes , Álvaro Henrique Borges. Root perforations: a review of diagnosis, prognosis and materials Braz. Oral res. vol.32 supl.1 São Paulo 2018 Epub Oct 18, 2018. 2. Fuss Z, Trope M. Root perforations: classification and treatment choices based on prognostic factors. Endod Dent Traumatol. 1996 Dec;12(6):255-64. 3. Estrela C, Biffi JC, Moura MS, Lopes HP. Treatment of endodontic failure. Endodontic Science. 2nd ed. São Paulo: Artes Médicas; 2009. p. 917-52. 4. Kakani, AK, Veeramachaneni, C., Majeti, C., Tummala, M., y Khiyani, L. Una revisión sobre los materiales de reparación de perforación. Revista de Investigación Clínica y Diagnóstica: JCDR [internet] 2015. 5. Torabinejad M, Parirokh M. Mineral trioxide aggregate: a comprehensive literature review part II: leakage and biocompatibility investigations. Endod J. [internet] 2013 [citado 2018 15 de septiembre]; 46(9):808-14. 6. Haghgoo, R. y Abbasi, F. Tratamiento de la perforación de Furcal de molares primario con MTA de ProRoot frente a MTA de raíz: un estudio de laboratorio. Iranian Endodontic Journal [internet] 2013. 7. Kaur M, Singh H, Dhillon JS, Batra M, Saini M. MTA versus Biodentine: Review of Literature with a Comparative Analysis. Journal of Clinical and Diagnostic Research : JCDR, [internet] 2017 [citado 2018 25 de septiembre]. 8. Espinosa T.A. Sellado de perforaciones por desgaste en la furca, reporte de dos casos con control a cinco años. Revista Nacional de Odontología, 2011;3(6):20-24. 9. Castelucci A. Magnification in Endodontics: the use of operating microscope. Endod. Prac. 2003; 3:29-36. 10. Ranjdar Mahmood Talabani, Balkees Taha Garib, Reza Masaeli, Kavosh Zandsalimi, Farinaz Ketabat. Biomineralization of three calcium silicate-based cements after implantation in rat subcutaneous tissue. Restor Dent Endo 2020. 11. Sinkar RC, Patil SS, Jogad NP, Gade VJ. Comparison of sealing ability of ProRoot MTA, RetroMTA, and Biodentine as furcation repair materials: An ultraviolet spectrophotometric analysis. Journal of Conservative Dentistry [Internet]. 2015. 12. Escobar-García, DM, Aguirre-López, E., MéndezGonzález, V., Pozos-Guillén A. Citotoxicidad y biocompatibilidad inicial de biomateriales endodónticos (MTA y Biodentine) usados como materiales de relleno de extremo de raíz. BioMed Research International [internet] 2016. 13. Malkondu O, Kazandağ MK, Kazazoğlu E. A Review on Biodentine, a Contemporary Dentine Replacement and Repair Material. BioMed Research International, [internet] 2014. 14. El-Khodary HM, Farsi DJ, Farsi NM, Zidan AZ. (2015). Sealing Ability of 4 Calcium Containing Cements used for Repairing Furcal Perforations in Primary Molars: An in vitro study. J Contemp Dent Pract. 2015.

Biodentine iodentine can be used both in the crown and in the root. In the crown, it can be used for temporary enamel restoration, permanent dentin restoration, deep or large carious lesions, deep cervical or radicular lesions, pulp capping and pulpotomy (reversible and irreversible pulpitis). In the root, it is indicated for root and furcation perforations, internal/external resorptions, apexification and retrograde surgical filling.

January/February 2022

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*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 sky is the limit for WA orthodontist

ky Othodontics is a busy orthodontic practice owned and operated by Dr Vivien Lum. The practice is located in Wanneroo, just 25km from Perth’s CBD. Wanneroo covers some 685 square kilometres and has a long history of settlement in WA, having first been established in 1902. Young families with children make up a significant portion of the local demographic and the population is forecast to grow significantly, making the area

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an excellent prospect for an orthodontic practice. When premises became available adjacent to a major retail complex, Dr Lum saw the potential of the site and set about purchasing the building. The building is located on a busy corner of a main thoroughfare and a major Shopping Centre with excellent exposure to passing vehicular and pedestrian traffic. The building required a considerable amount of work to turn it into a modern orthodontic practice, but the bones were strong and the location was excellent. Medifit were able to draw upon their

experience, having completed hundreds of building renovations since their inception in 2002, to deliver a design and fitout solution that perfectly matched Vivien’s requirements. Medifit’s architectural team swung into action, executing a design that rehabilitated the site and transformed a tired, former 1960’s retail building into a beautiful, contemporary practice. The new project included demolition of the previous fitout and fulfilling the make-good conditions of this former Wanneroo premises.

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surgery | DESIGN

With just over 300 square metres to work with, a little over 180 square metres of the space has been designed to accommodate Sky Orthodontics. Vivien’s new practice consists of 3 surgeries, staff room, walk through steri and lab and a generous waiting and reception area. There is also an IT room adjacent to reception for the practice server and additional storage. The reception features a careful balance of modern white finishes with grey and timber tones providing an inviting ambience.

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Designed in a futuristic, faceted style with the panels underlit for highlight detail, the reception counter makes a bold statement. The layout throughout has been designed with a clean, modern ambience, with the angles from reception echoing in the floor treatments. Surgeries are state of the art, with large screens flush mounted seamlessly into the ceiling providing comfortable viewing for patients. Custom cabinetry provides ample space for all equipment and plenty of storage options to ensure the surgeries are as efficient as they are elegant.

January/February 2022

surgery | DESIGN

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Summary The Practice The Practice

Sky Orthodontics

Principal

Dr Vivien Lum

Type of Practice

Specialist Orthodontic

Location

Wanneroo, Perth, Western Australia

Size

184 square metres

No of chairs

The Team Architecture

Medifit Design & Construct

Interior Design

Medifit Design & Construct

Construction

Medifit Design & Construct

Equipment Dental Units

Kavo 10578 Life

Autoclaves

Mocom Futura 17L

OPG

Planmeca Promax

Compressor

Dürr Trio

Suction

Dürr VS90

From the time Medifit commenced on site, the building renovation and fitout work was completed in less than 12 weeks. Considering the complexity of the project, this was no mean feat. Dr Lum was able to open the doors of her new practice on schedule. Medifit’s experience with regards to building renovations and their intimate knowledge of dental fitouts is testament to Medifit’s pioneering spirit in the healthcare sector. Medifit’s Sam Koranis commented “We pride ourselves on delivering bespoke solutions that are uniquely tailored to each individual practitioner and their situation. We were delighted to be chosen to create a beautiful working space for Vivien and we are proud of the outcome we managed to achieve. We wish her every success in her new practice.”

146 Australasian Dental Practice

January/February 2022

Practices that work with you Since 2002, Dentists and Dental Specialists all around Australia have trusted Medifit to create state of the art practices with individual interior designs that boost productivity and enhance levels of care. Whether it’s your first practice or your latest, we’ll help you create a dental practice that reflects your personal style and complements the way you work - and we do it with a friendly, no fuss approach using proven best practices. Contact Medifit today for a no obligation consultation and experience our award winning service. • SITE ASSESSMENTS • LEASE NEGOTIATION • FEASIBILITY STUDIES • COUNCIL SUBMISSIONS • ARCHITECTURAL DESIGN

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surgery | DESIGN

Willow Dental a case study in design By David Petrikas

f ever there was a surgery that met a beautiful and inspiring design brief, Willow Dental Care at Norwest in Sydney is it! Owned and operated by Dr Lyndall Gourlay and Dr Shabnam Vawda, it is the very embodiment of what these dental colleagues and work friends wanted in their own bespoke practice. With many years dental experience between them, the pair felt they had something to offer to patients in the thriving Norwest area, which is a master planned development incorporating residential, commercial and community infrastructure. Top of the list was a work environment where they wanted to spend time and where patients would feel calm, relaxed and professionally cared for.

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After some online research and consulting professional colleagues, Drs Gourlay and Vawda chose Perfect Practice from nearby Seven Hills to handle the design and fit-out. Again, after making their own enquiries and using their considerable hands-on experience with various brands of dental equipment, the pair approached Sydney dental dealer, Presidental, to help them equip the practice. Significantly, as much as the two dentists knew what they wanted in their practice, they were equally adamant about what they did not want. This accounts for a very clear design direction which was correctly interpreted by Perfect Practice. And so, Willow Dental Care was born - and apart from a two-week construction industry shutdown due to COVID-19 - the build went ahead without a major hitch.

Central to the design theme is a Hamptons-inspired palette with warm, neutral and natural colours and textures, incorporating woodgrain, white and dusky, gold-browns. Woodgrain features prominently, with round timber rods cladding the front of the marble-look reception counter and chevron shaped parquet flooring leading the eye down a wide central corridor. A tall, illuminated magazine rack is positioned in a small corner niche, with a monitor displaying stunning holiday vistas occupying the adjacent wall. iPads and a low bench provide a nursery nook for young children. Light floods into three sides of the building - a pre-requisite of the dentists when embarking on their property search.

January/February 2022

This has proven a master stroke, with the reception area, each of the surgeries and even the private staff amenities at the rear getting plenty of natural light and a glimpse of the outdoors. Natural light was important from both a clinical perspective to help with shade matching veneers and composites and equally, the owners wanted an inviting atmosphere where they enjoyed working and patients would like to be. Importantly, the dentists wanted the best in dental equipment to add to the patient experience and to their own well-being. After speaking to a few suppliers, they decided to work with locally based equipment specialist, James Wallace from Presidental.

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Based on his advice and after visiting A-dec’s Mascot showroom, they chose A-dec 400 patient chairs for their own ergonomics while working on patients, together with A-dec’s superior patient positioning and patient comfort. The compact A-dec 300 delivery system moves completely out of the way for chair access and dismounting and the ceiling mounted LED operatory lighting enables an uncluttered chair. The remote compact delivery head work zone is also easy to clean.

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For practical and infection control reasons, both dentists decided against cuspidors (spittoons) and instead rely on a plastic cup and high-volume suction for rinsing. In those very rare cases where a patient wants a full rinse, there is a nearby patient refresh sink and vanity adjacent to the attractively tiled toilet. Staff have also been well-catered for, with A-dec’s round articulating work surfaces and assistant’s instruments providing plenty of room to place consumables and assist with four-handed dentistry.

January/February 2022

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Summary The Practice

The Practice The Principal Practice Type Location Size No of chairs

Willow Dental Care Dr Lyndall Gourlay and Dr Shabnam Vawda General Norwest, Sydney, New South Wales 132 square metres including 5 secure car spaces 2+1

The Team Design Colour & Design Construction Project Manager Installer

Perfect Practice Susana Hernandez, Perfect Practice Perfect Practice David Crutcher, Perfect Practice Presidental

Equipment Dental Units Sterilisation X-ray CBCT Compressor Suction Software

A-dec 400 traditional delivery W&H Lisa 22L X-Mind DC with Acteon PSPIX PSP imaging system Kavo OP 3D Cattani AC300Q Cattani Turbo SMART A Cube CorePractice

Staff amenities are also of a very high standard and surprisingly large with a kitchen and dining area concealed behind a frosted door at the rear. There is also an adjoining lightfilled space containing window facing desks, staff lockers and an upholstered bench. While the surgery may look “luxe”, the investment in both fitting out and equipping the practice was quite reasonable, thanks to good planning and design. It was simply a case of finding the right team of people to work with based on their own research, listening to word-of-mouth referrals and taking on board advice from experts in coming up with an attractive and workable design.

152 Australasian Dental Practice

January/February 2022

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Designed to work in all open system DLP and MSLA 3D printers, PORCELENE™ dental model resin allows for high precision accuracy, dimensional stability, an opaque matte finish with a gypsumlike texture for all 3D printed dental model processing. The delicate balance between

toughness, hardness and flexibility optimises it for all processes including diagnostic, crown and bridge models and prototypes, implant and orthodontic models. Its low flex properties also make it suitable for vacuum forming aligner models. PORCELENE dental model resin is available in Almond and Grey colours and in either 1L or 5L containers. Best of all, PORCELENE is made in Australia and is one of the most affordable resins on the market. Monocure 3D Dental model resin is NOT approved for intraoral use.

With the preprocedural rinse now the standard across the country, there are tens of thousands of plastic cups being thrown away by dental surgeries every single day. Making a swap from plastic to bamboo fibre cups makes a huge difference in the impact we make to the environment. These bamboo cups from Piksters hold hot or cold liquid and are 100% sustainable and biodegradable which includes the packaging as well. Piksters also have a full range of dental products made from sustainably harvested biodegradable bamboo.

Available: fabdent Tel: 1300-878-336 info@fabdent.com.au www.fabdent.com.au

UNIZ NBEE: 6 models in 5 minutes

Colgate has launched a DentistExclusive Optic White Light Up Pen and matching LED device in a take-home whitening kit that will make your teeth “up to 7 shades whiter in 5 days” if used as directed. The precision applicator pen supplied in the kit contains a patented 6% hydrogen peroxide (HP) whitening serum that is applied to the tooth surface. The unique chemistry

Piksters saves the planet with bamboo

of the serum, when paired with the powerful indigo LED device, delivers enriched whitening and optimum results. The kit includes the LED teeth whitening device and charging case, a USB-A charging cord and the whitening pen. Available: Henry Schein Tel: 1300-658-822 www.henryschein.com.au

154 Australasian Dental Practice

Available: Piksters / Erskine Oral Care Tel: 1800-817-155 sales@piksters.com www.piksters.com

UNIZ NBEE: 6 models in 5 minutes The latest UNIZ NBEE 3D printer is designed for dentistry with speed, accuracy and reliability in mind. The NBEE prints 6 dental models in 5 minutes with high accuracy (50 µm pixels), 95% uniformity and up to 99% precision matching. It uses a patented high efficiency liquid cooled LCD-SLA light source for 24/7 non-stop printing. The NBEE includes the World’s fastest dental slicing software for easy and comprehensive model processing. Features include patented micro stereo film; high power light source; resin temperature control system; and a large variety of dental resins are available. Available: fabdent Tel: 1300-878-336 info@fabdent.com.au www.fabdent.com.au

January/February 2022

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FLEX

MINI

ONE

T WO

A la carte

Bite sized

Fun-sized

Double the fun

For revisions and recent relapse cases. Pay for the exact amount of treatment you need—no more, no less.

For very mild cases, up to 12 sets of aligners, including one revision.

For mild cases, up to 24 sets of aligners, including one revision and one set of retainers.

For moderate cases, up to 48 sets of aligners, including two revisions and two sets of retainers.

An assortment of treatment options Tailored to your taste

THREE

UNLIMITED

The triple play

All you can eat

For moderate to severe cases, up to 72 sets of aligners, including three revisions and three sets of retainers.

For severe cases, as many aligners as you need for five full years, including replacements, revisions, and retainers.

OsseoGroup S c an the Q R co d e or v isi t cl earco rr e c t .o ss e o gro up.co m . au to b e come a Clear Corre c t prov ider.