Oral Hygiene Nov/Dec 2023 by dentalcommunity

oral hygiene , therapy , infection control , management and ... more ... oral hygiene , therapy , infection control , management and more VOL.33 NO.5 VOL.27 NO.3

NOVEMBER/DECEMBER 2023 MAY/JUNE 2017

The New Piksters Game Changer -

Ultra-fine 000 Brush So fine, it goes places no brush has gone before.

PRINT POST NO. 100003758 PRINT POST NO. 100003758

So fine, we even had to create a new, smaller hole.

Two examples of many uses -

Standard ISO interproximal brush sizing disk with new 0.55mm diameter hole

Crowded and tight teeth

Stripped or splinted incisors

Our 3 smallest brushes will fit into these size holes:

Size 000 .55 mm Size 00 .60 mm Size 0 .70 mm

Things you could never do before are now possible.

NEW

Works in 3 mins

Material compatibility1,2

Daily use

Removes+ 99.9% of odour-causing bacteria*3-5 Lifts stains, removes discolouration6,7 Helps keep appliances looking clear1,2 Compatible with common dental appliance material1,2

Retainers Aligners Night Guards Mouthguards

For more information or to request free clinic samples, visit www.haleonhealthpartner.com or scan the QR code AU

+ When used as directed

* In vitro studies

Always read the label and follow the directions of use.

References: 1. Haleon data on file, 2020, Material Compatibility Testing, Fraunhofer Institute. 2. Haleon data on file, 2020, Compatibility testing of an aligner material, Fraunhofer Institute. 3. Haleon data on file, 2011, MD#024-11. 4. Haleon data on file, 2012, MD #012-12. 5. Haleon data on file, 2011, MD#040-10. 6. Haleon data on file, 2015, CP/MVR/EDCU/09. 7. Haleon data on file, 2016, CP/MVR/EDCU/15. Trademarks are owned by or licensed to the Haleon group of companies. ©2022 Haleon group of companies or its licensor. PM-AU-POLD-22-00088 TAPS BG2560

VOLUME 33 | NUMBER 5 NOVEMBER/DECEMBER 2023

OH | CONTENTS

On the cover... The New Piksters Ultra-fine 000 Brush is a game changer. It’s so fine, it goes places no brush has gone before! More info at piksters.com

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4 BRIEFS 6 NEWS & EVENTS 20 CPD CENTRE 22 ABSTRACTS

SCALERS VS SHARKS: WHICH ARE MORE MISUNDERSTOOD? Tami Wanless dives into a few myths around scalers and looks at how sharks can help surface some truths

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COVID-19: NEW CHALLENGES FOR 2024 When WHO declared in May 2023 that the health emergency of the COVID-19 pandemic was over and downgraded the pandemic, they stressed that this symbolic announcement did not mean the end of health concerns explains Prof. Laurie Walsh

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THE TOP 5 REASONS DENTAL PRACTICES DON’T OWN A CASSETTEBASED INSTRUMENT MANAGEMENT SYSTEM

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HUMAN FACTORS AND THE PRESSURES OF DELIVERING ACCURATE INFORMATION IN DENTAL PRACTICE: AN ONGOING CHALLENGE Accurate information is essential for providing dental care that is both safe and effective details explains Prof. Laurie Walsh

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Publisher & Editor: Joseph Allbeury

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Oral Hygiene (formerly Auxiliary) ISSN 1323-4919 is printed in Australia and published six times per year by Main Street Publishing P/L ABN 74 065 490 655 • PO Box 586, Cammeray 2062

Telephone: (02) 9929-1900 Facsimile: (02) 9929-1999 Email: info@dentist.com.au © 2023. All rights reserved. The contents of this magazine are copyright and must not be reproduced without the written permission of the publisher. Permission to reprint may be obtained upon application. Correspondence and manuscripts for publication are welcome. Although all care is taken, the editor and publisher will not accept responsibility for the opinions expressed by contributors to this magazine, or for loss or damage to material submitted for publication.

news | EVENTS

in | BRIEF

Toothbrushing lowers rates of pneumonia

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

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

Decoding dental content that breaks the internet... n the age of social media, the power of viral content cannot be underestimated. But what’s the secret behind dental content that captures the internet’s attention and spreads like wildfire? Let’s uncover the viral formula that turns ordinary dental posts into online sensations. First and foremost, relatability is key. People engage with content that resonates with their everyday lives. Dental posts that address common concerns like teeth whitening tips, cavity prevention, or even funny dental anecdotes tend to strike a chord with a wide audience. Using language that is friendly, approachable and easy to understand ensures that the message reaches everyone, regardless of their dental expertise. Visual appeal is another vital ingredient. Eye-catching images and videos draw viewers in, making them more likely to stop scrolling and pay attention. Before-and-after pictures of dental procedures, animations explaining oral hygiene techniques and behind-the-scenes glimpses of the dental office create a visually engaging experience. High-quality, clear visuals make the content not only informative but also aesthetically pleasing, encouraging viewers to share it with their friends and family. Additionally, interactivity plays a crucial role. Dental quizzes, polls and interactive challenges invite viewers to participate actively. People enjoy testing their knowledge and sharing their results, fostering a sense of community around the content. Encouraging viewers to comment, like and share helps in amplifying the reach of the post, making it more likely to go viral. Lastly, humour and positivity are contagious. Incorporating a light-hearted touch into dental content, such as dental-related jokes or heart-warming patient stories can create an emotional connection with the audience. Positive vibes not only make the content shareable but also enhance the overall online experience for viewers. In conclusion, the viral formula for dental content involves relatability, visual appeal, interactivity and a sprinkle of humour and positivity. By understanding and incorporating these elements, dental professionals can create content that resonates with the audience, breaks the internet and spreads smiles far and wide.

By Angus Pryor... more at dentalmarketingsolutions.com.au

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Post-acute sequelae of COVID-19 (PASC, ‘‘Long COVID’’) pose a significant global health challenge. The pathophysiology is unknown and no effective treatments have been found to date. Several hypotheses have been formulated to explain the aetiology of PASC, including viral persistence, chronic inflammation, hypercoagulability and autonomic dysfunction. Here, we propose a mechanism that links all four hypotheses in a single pathway and provides actionable insights for therapeutic interventions. We find that PASC are associated with serotonin reduction. Viral infection and type I interferon-driven inflammation reduce serotonin through three mechanisms: diminished intestinal absorption of the serotonin precursor tryptophan; platelet hyperactivation and thrombocytopenia, which impacts serotonin storage; and enhanced MAO-mediated serotonin turnover. Peripheral serotonin reduction, in turn, impedes the activity of the vagus nerve and thereby impairs hippocampal responses and memory. These findings provide a possible explanation for neurocognitive symptoms associated with viral persistence in Long COVID, which may extend to other post-viral syndromes. In principle, however, none of the mechanisms described in this study are unique to SARS-CoV-2 infection. The connection between serotonin reduction and vagus nerve dysfunction may thus be relevant beyond Long COVID. The fact that low serotonin levels are also found in non-viral conditions characterised by elevated interferon levels, such as systemic lupus erythematosus or multiple sclerosis, suggests that the pathway described in this study may even apply beyond viral infections. Wong AC et al. Serotonin reduction in post-acute sequelae of viral infection Cell 2023; Cell 186:4851-4867.Priyank H, et al. Comparative evaluation of dental caries score between teledentistry examination and clinical examination: a systematic review and meta-analysis. Cureus 2023; 15(7): e42414. (July 25, 2023) DOI 10.7759/cureus.42414

November/December 2023

Piksters Ultra-fine 000 Brush

The New Piksters®Game Changer -

Interdental Brushes

Perfect for cleaning -

So fine, it goes places no brush has gone before. So fine, we even had to add a new, smaller hole to the standard test range to confirm the significant difference...

Bi & tri furcations

Defects

Size 00 will not fit into this new 0.55mm hole. Many hygienists have commented about this new 000 brush going into gaps that they could never get into before.

Standard ISO interproximal brush sizing disk with new 0.55mm diameter hole

We suggest easing the brush in very gently with a twisting action.

.PK00010 Size 000 Box of 10 packets $43.50 10 brushes in each packet

Stripped or splinted incisors

Crowded & tight teeth

Easy online ordering at pikstersdental.com Call: 1800 817 155 or 02 6568 3773 Email: sales@piksters.com

news | EVENTS

Waterpik™ Water Flosser: 3 times as effective as string floss for orthodontic patients The effect of a dental water jet with orthodontic tip on plaque and bleeding in adolescent orthodontic patients with fixed appliances

Sharma NC, Lyle DM, Qaqish JG, et al. Am J Ortho Dentofacial Orthop 2008; 133(4):565-571. Study conducted at BioSci Research Canada, Ltd., Mississauga, Ontario, Canada.

Objective o compare the use of a manual toothbrush and the Waterpik™ Water Flosser with the Orthodontic Tip to manual toothbrushing and flossing with a floss threader on bleeding and plaque biofilm reductions in adolescents with fixed orthodontic appliances. A control group consisted of brushing only.

Results he Waterpik™ Water Flosser was over three times more effective than flossing and over five times more effective than brushing alone for the reduction of plaque biofilm. For bleeding, the Water Flosser was 26% better than flossing and 53% better than brushing alone.

Conclusion

Methodology

dding a Waterpik™ Water Flosser with the Orthodontic Tip to manual toothbrushing is significantly more effective at improving oral health in adolescent orthodontic patients than adding manual floss or brushing only.

ne hundred and five adolescents with fixed orthodontics participated in this single-centre, randomised study. Bleeding and plaque biofilm scores were collected at baseline, day 14 and day 28.

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

6 oral|hygiene

November/December 2023

The Easy and Most Effective Way to Floss!™ BOOK NOW!

SAVE UP TO

60%

Try Waterpik Yourself! Take advantage of our Professional Trial Offer with up to 60% off 1 waterpikshop.com.au

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

Clinically Proven Results Untreated

Treated

Removes up to 99.9% of plaque from treated areas2

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

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

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

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

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

news | EVENTS

American Express® expands partnership with HICAPS

oinciding with the roll-out of HICAPS’ new best-in-class Trinity Payment Terminals, American Express has expanded its partnership with the leading healthcare claiming solution. This enables tens of thousands of healthcare providers across Australia to accept American Express and gives American Express Card Members the ability to earn Membership Rewards® points when visiting a HICAPS provider. The new Trinity Terminals, currently being rolled out, will see 90,000 HICAPS providers set up to accept American Express payments including dentists, chiropractors, physiotherapists, general practices and more. The rollout is expected to be complete by the end of 2024. The HICAPS Trinity Terminals are designed to streamline the patient payment experience with fast claim processing among 100% of private health insurers in Australia. For practices, this reduces the need to manually input claims, transactions and quoting - cutting down on administration. Robert Tedesco, Vice President & General Manager of Global Merchant Services at American Express said: “Digitisation and automation is a priority for many businesses wanting to simplify

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the payments process, both for customers and themselves. This announcement bolsters our commitment to supporting healthcare providers by removing friction at the checkout, while allowing our Card Members to earn reward points for essential health services. “71% of American Express Card Members say they are more likely to return to a business that accepts American Express*. With that, we hope healthcare providers will see increased customer loyalty and repeat business with American Express automatically enabled in their payment process.” Simon Terry, Executive for HICAPS said: “One of the most common pain points for both practices and patients when it comes to paying a health bill is speed and flexibility. HICAPS is dedicated to delivering ease, speed and reliability and since 2014, we’ve achieved this in partnership with American Express. “We’re proud to support more than 90,000 healthcare providers across Australia and today’s announcement will help further reduce administration and complexity for practices, while offering more choice to patients.” For more info, visit www.hicaps.com.au * American Express commissioned internet panel survey conducted in April-May 2022 based on purchases made in the 6 months prior to the survey. Definition of American Express Card Members: Respondents who reported that they have an American Express Card and that they used that card to make purchases in the prior 6 months.

November/December 2023

news | EVENTS

New steriliser gets thumbs up! By David Petrikas

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

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

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Busy Smiles at West Ryde practice manager, Janet Rome.

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

November/December 2023

Hygiene is in our DNA. The new Hygoclave 50.

5“ high-resolution colour touch display for intuitive navigation

3-fold flexible fresh water supply with integrated quality control

High-performance sterilization- and drying system

Integrated dust protection filter

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

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

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

clinical | EXCELLENCE

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Scalers vs Sharks: Which are more misunderstood? Tami Wanless dives into a few myths around scalers and looks at how sharks can help surface some truths

ue the Jaws theme music, it’s July, which means it’s time for Discovery Channel’s renowned SHARK WEEK to make its annual appearance. Now woven into the mainstream of pop culture, shark-mania grips the nation by storm every July. It’s akin to a national holiday embraced by TV viewers everywhere. Last year, Hu-Friedy was inspired by Shark Week and brought a dental connection to this phenomenon. When we thought about it, we saw that sharks have a lot of interesting connections to dental, the most obvious one being their amazing teeth and how they use them. And so started “Sharp Week”. As with sharks, dental instruments are subject to many myths and incorrect beliefs. Like a marine documentarian swimming among the sharks, we’re on a mission to remedy some of these myths and set the record straight. In this article, we’ll explore what might be learned from sharks and how that relates to the dental industry. Does a scaler last forever? Is there such a thing as a sharpen-free scaler? Let’s jump in!

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A scaler should last about a year or two, right? great white shark can live to 70 years of age. Your scalers cannot. The useful life of a scaler depends on a variety of factors. Consider how often are they used, sterilized and sharpened, as well as the clinical applications they’re used for. Every now and then, it’s a good idea to look over instruments and “audit” them to make sure that they’re in the ideal condition. When they work effectively, you work efficiently.

How do I “audit” my scaler? he shape of a shark is specially designed to help it efficiently navigate long distances and manoeuvre around its prey with ease. Engineers have designed scalers and curettes to manoeuvre around tight spaces and effectively remove calculus. A shark wouldn’t be anywhere near as fast and efficient if its shape were changed and neither will your instruments. Look through your current instrument offerings. Are they dull or chipped on

November/December 2023

Total Handpiece Maintenance.

Clean. Clean.

Clean. Disinfect. Lubricate. Purge. Dry.

Clean. Disinfect. Disinfect Disinfect. Lubricate. Lubricate Lubricate. Purge. Purge. Purge. Dry. Dry. Dry. In 12 minut In 12 minutes. In 12 minutes.

Manual with Manual Mechani with In 12 minutes. Replace Replace

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clinical | EXCELLENCE the cutting edge or point? Are they bent or broken? Are the curettes pointed? Are the blades too thin? Here’s a “Sharp” tip: If the blade is 20% smaller than when it was new, the answer is “yes”. If the answer to any of these questions is a “yes”, then it’s time for them to be replaced (For more help on instrument audits, download Hu-Friedy’s free “Performance Assessment Guide Instrument Check-Up” from the website).

If you decide to go with a “never sharpen” scaler, ask questions to decide if it’s the best option. It’s important to know that sharpening these kinds of scalers may result in the coating flaking off, which can harm patients. Also, these scalers are not meant to be used on heavy calculus.

Is sharper better? harks understand the value of maintaining sharp instruments. Most sharks lose tens of thousands of teeth during their lifetime. They have rows of teeth waiting to replace the old dull ones that are lost every few weeks. Likewise, your instruments should start sharp and you should keep them that way. The sharper the scaler, the more efficient and productive you can be. Using a sharp scaler is the only way you can deliver the best clinical outcomes to your patients. Dull instruments are more difficult for you to use and less comfortable for your patients. A possible result? BURNISHED CALCULUS - which can have a negative effect on a patient’s overall oral health (see the article in the last edition of Oral Hygiene). An easy way to test instrument sharpness is with PLASTIC TEST STICKS, which are inexpensive and effective. Test sticks won’t give you a “false positive” like plastic saliva ejectors will, nor will they dull the instrument. Regular maintenance sharpening will extend the useful life of a scaler.

Is there such a thing as sharpen-free? hile shark experts aren’t certain of the cause of MEGALODON’S EXTINCTION, they unanimously agree that this prehistoric mega-shark is no longer around. People truly want to believe Megalodon still exists... but reality bites. Equally, there is no such thing as a “sharpen-free” scaler because all scalers get dull eventually. If a manufacturer offers “never sharpen” scalers, they’re really suggesting that the scaler be replaced as soon as it’s dull. You have to sharpen your scalers in order for them to be effective, just like you have to sharpen a dull pencil?

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Does a superior manufacturing process result in longer-lasting instruments? harks are famous for their sharp teeth; Jaws would be much less interesting if the sea villain had had dull teeth. Just like evolution, Hu-Friedy created a sharper instrument through design and manufacturing innovation, making it easier to scale tough deposits and providing a longer life for the instrument. A sharper design is the result of a superior manufacturing process that results in superior, longer-lasting products. Consider the new EVEREDGE 2.0: it’s 72% sharper out of the box than competitor scalers and at least 50% sharper after 500 strokes than competitor scalers. That means fewer strokes, resulting in increased clinician and patient comfort.

Is a harder blade better? ones are considered strong and durable, which is probably why most animals have them. A shark skeleton is made of cartilage. Since cartilage is more flexible than bone, a shark can turn around in a smaller space better than a bony fish - making sharks’ flexible skeletons more effective and likely to capture prey. Like cartilage in sharks, hardness in scalers does not equate to sharpness or effectiveness. Instead, look for the

proper balance of firmness and flexibility to maximize tactile sensitivity. The great thing about the EVEREDGE 2.0 is that it is 45% sharper than the original EverEdge, while featuring a new steel that is sharper, but not harder. This means that the instrument, while being significantly sharper, is no more difficult to sharpen. What options do dental professionals have at the end of the useful life of their instruments? Shark teeth eventually fall out, ready to be replaced with newer, sharper teeth. Eventually, your scaler will need to be recycled, too. When the time comes at which a scaler cannot be sharpened any more, the best option is instrument recycling. By sending an instrument in to be recycled, the dental practice saves space on storing unusable instruments and benefits from kickbacks. For instance, Hu-Friedy’s ENVIRONDENT PROGRAM offers one free Hu-Friedy instrument for every 12 sent in to be recycled, no matter the brand. Moreover, the instruments are safely and responsibly recycled, helping the planet. So there you have it. Sharper instruments last longer. All instruments dull over time. Thinner or harder blades are not necessarily better, so it’s important to find the right combination of toughness and flexibility for your needs. Now that you understand your dental instruments a bit better, be sure to learn more about sharks before your next day at the beach.

About the author Tami Wanless is Adjunct Faculty in the department of Dental Hygiene at the College of DuPage in Glen Ellyn, Illinois, USA. She has a Master’s Degree in Adult Education from Northern Illinois University. Tami has 27 years of experience in the dental field with 24 of these in both the clinical and educational arenas. In her current role at trhe College of DuPage, Tami is a clinical educator, the didactic instructor for Head and Neck Anatomy and Histology and the didactic and laboratory instructor in the Science of Dental Materials. Tami authored the lab manual for the Science of Dental Materials. She speaks on a multitude of dental hygiene related topics, predominately instrument sharpening and public health issues.

November/December 2023

FIT IS EVERYTHING

Hu-Friedy’s promise to help you perform at your best is at the core of everything we

Find the right one with Hu-Friedy

do, which is why we’re proud to bring you the sharpest, longest lasting scaler on the market: EverEdge 2.0. Engineered to be better than ever, so you can be, too.

Ensure predictable outcomes for your littlest patients with Hu-Friedy Stainless Steel Pedo Crowns. You’ll quickly discover why dentists favor our impeccable fit. Perfect for your patients. Easy for you. Because when it comes to the perfect fit, Hu-Friedy is just right. WHY DENTISTS LOVE OUR STAINLESS STEEL PEDO CROWNS: • Ideal height and mesio-distal width • Pre-trimmed and pre-crimped for simple placement • Accurate occlusal anatomy that matches the natural tooth

Learn whyUSEverEdge is the solution VISIT ONLINE AT2.0 HU-FRIEDY.COM/PerfectFit for you at Hu-Friedy.com/EE2 ©2016 Hu-Fried y Mfg. Co., LLC. All rights reserved. ©2017 Hu-Friedy Mfg. Co., LLC. All rights reserved.

Orders 0800 808 855 www.henryschein.co.nz

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

infection | CONTROL

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The top 5 reasons dental practices don’t own a cassette-based Instrument Management System By Mary Govoni

ental professionals have a lot on their plates nowadays. There is a tremendous amount to think about, such as practice profitability, technology investments, team efficiency, new patient acquisition and continuing education - just to name a few. With all of this to balance, it can be difficult to take a step back and look at specific processes that happen every day to determine if there are better, faster and safer ways to do things. Instrument reprocessing and sterilisation is one of those areas and is a critical component to developing a best practice approach to dental infection control. Infection control guidelines recommend minimising the handling of contaminated sharp instruments during reprocessing. The best way to do this is by placing the instruments in a container that will protect clinicians from injuries during transport and reprocessing and also protect the instruments from damage caused by droppage or contact with other loose instruments. For practices that want to employ a contemporary method to instrument reprocessing, a cassette-based instrument management system is a perfect solution. Unfortunately, many practices’ infection control is still based on carrying instruments on a tray and storing them in bundles, which increases the risk of sharps injuries, instrument damage and impairs the reprocessing workflow. A better way is to implement an instrument management

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system (IMS), which is designed to ensure that instruments are transported, processed and stored in cassettes, resulting in improved overall safety and optimised workflow. Cassettes help ensure the team is protected from punctures or cuts to their hands while transporting, cleaning and preparing the instruments for sterilisation. So, if many dental practices are not utilising a cassette-based sterilisation approach, the question is: why not? Let’s look at the most common reasons for not embracing the IMS solution and why some of these reasons are ripe for myth-busting!

1. Unfamiliar with the system ften, dental professionals are hesitant to invest in an IMS because there isn’t full knowledge of how available the return on that investment is, or what an IMS really does. Think of it as an extra assistant: the system standardises procedural set-ups and creates a process that is less people-dependent. And the fact is that an IMS saves time (approximately five to 10 minutes per procedure), protects instruments (ensuring you’re equipped with better, longer lasting instruments that don’t need to be replaced as often), protects the staff, reduces training time and optimises the practice workflow, which allows more patients to be seen in a day. Having an IMS in use means fewer sharps injuries and less overtime pay given to staff members who are trying catch up at the end of the day. In fact, an IMS can make it possible to treat more patients without adding more hours due to the time saved in the instrument reprocessing workflow.

2. There isn’t enough space nce a practice starts using cassettes, it quickly becomes apparent how much space all of those pouches and trays required. Having an IMS actually saves on space because the instruments stay within the cassettes, eliminating the need to store the instruments and the tray separately. Here’s how it works:

Receiving area: Instruments are transported into the receiving area within the cassette, which can then be placed directly into the ultrasonic cleaner or dental instrument washer for cleaning. Gone are the days of organising and separating instruments. During rinsing, the entire cassette and the instruments in it can be rinsed and placed to the side to dry. There is no need to add the extra step of spreading the instruments out on a towel. Preparation and packaging: Once the instruments and cassette are dry, it can then be wrapped or bagged. There is no need to separate the instruments and package them into multiple pouches. Storage: As with the other steps in the process, the instruments remain with the cassette and are all stored together in one place. Therefore, there is no need to store the disinfected trays and separate drawers of instrument packs. Everything is ready to take from one place when the dental team is ready to use it.

3. If it ain’t broke... nfortunately, not having an IMS means practices may not be fully optimising their time or maximising the safety of patients and staff. There may

November/December 2023

Figure 1-3. It is far more efficient to clean instruments in a cassette than by hand, which is actively discouraged by the guidelines.

Figure 4-5. Instruments only ever leave the cassettes chairside, remaining inside for cleaning, sterilisation and storage. also be a lack of awareness regarding the enhanced level of efficiency that can be gained in their dental sterilisation process. In terms of efficiency, it takes more time to handle the instruments individually than it does to handle the instruments in an instrument cassette. The cassette or container is only one thing to handle during transport, cleaning and sterilisation - one per procedure, rather than many per procedure. In addition, instruments are protected during cleaning when in a cassette, which helps them last longer.

4. Bigger ticket investments are prioritised very practice has a wish list: Whether it’s for newer technology or updated systems, certain things are at the top of that wish list and unfortunately, smaller-in-scope products and solutions may not always be prioritised. In fact, many practices try to save on smaller ultrasonic baths or autoclaves. However, increasing efficiency and optimising the workflow is always a top priority and having the right equipment to make reprocessing smoother and more effective allows the team to focus on more value-added activities. Buying a larger steriliser, ultrasonic bath or thermal washer disinfector may unclog bottlenecks in instrument reprocessing. Equally, investing in an IMS can increase the efficiency of the reprocessing cycle.

November/December 2023

The cost is too high hen considering the overall investment, it certainly seems that the few thousand dollars it takes to implement an IMS system certainly represents compelling value. Think about how much money is spent on replacing missing or broken instruments each year. Or, how much just one sharps injury costs the practice. Having an IMS in the practice simplifies the workflow without sacrificing the strength of protocols, allowing the entire team to focus on the things that need their direct attention, like the patients! Dental professionals who implement cassettes into their practices don’t frame it as a cost. Instead, it is viewed as an investment that reduces risk and enhances productivity.

About the author Mary Govoni is a dental assistant and hygienist with over 40 years of experience including practice administration, clinical assisting and hygiene, dental assisting and hygiene education. Her consulting and speaking areas of specialization include infection prevention, ergonomics and dental practice efficiency and team development.

oral|hygiene 17

dentevents presents...

Infection Control

BOOT CAMP ON DEMAND ONLINE LEARNING PROGRAMME

29 VIDEOS - 8+ HOURS OF EDUCATION Presented by Emeritus Professor Laurence Walsh AO

BDSc, PhD, DDSc, GCEd, FRACDS, FFOP (RCPA), FFDT (RCS Edin)

Learn from Australia’s leading authority on infection prevention and control in dentistry about recent changes in infection control including from the Dental Board of Australia (July 2022), the ADA (4th edition guidelines August 2021 and the ADA Risk management principles for dentistry during the COVID-19 pandemic (October 2021)), the new guidelines

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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 provides a summary of how those changes interlink with one another and also covers 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.

COURSE TOPICS This one day course will cover changes in regulations and guidelines from 2018 to 2022 including: n Risk-based precautions. n Hand hygiene and hand care practices. n Addressing common errors in personal protective equipment. n Biofilm reduction strategies. n Efficiency-based measures to improve workflow in instrument reprocessing and patient changeover. n Correct operation of mechanical cleaners and steam sterilisers. n Wrapping and batch control identification. n Requirements for record keeping for instrument reprocessing. n Correct use of chemical and biological indicators.

FULL UPDATE! All the changes to Infection Control Updated in 2022

Laurie Walsh is a specialist in special needs dentistry who is based at the University of Queensland in Brisbane, where he is an emeritus professor. Laurie has been teaching and researching in the areas of infection control and clinical microbiology for over 25 years and was chief examiner in microbiology for the RACDS for 21 years. His recent research work includes multiple elements of infection control, such as mapping splatter and aerosols, COVID vaccines and novel antiviral and antibacterial agents. Laurie has been a member of the ADA Infection Control Committee since 1998 and has served as its chair for a total of 8 years, across 2 terms. He has contributed to various protocols, guidelines and checklists for infection control used in Australia and represented dentistry on 4 committees of Standards Australia and on panels of the Communicable Diseases Network of Australia and of the Australian Commission on Safety and Quality in Health Care.

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Infection Contol Boot Camp is presented by Dentevents, a division of Main Street Publishing Pty Ltd ABN 74 065 490 655 • www.dentevents.com • info@dentist.com.au Tel: (02) 9929 1900 • Fax: (02) 9929 1999 • Infection Contol Boot Camp™ and Dentevents™ are trademarks of Main Street Publishing P/L © 2023 Main Street Publishing Pty Ltd

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The top 5 reasons dental practices don’t own a cassette-based Instrument Management System

Scalers vs Sharks: Which are more misunderstood?

By Mary Govoni

Tami Wanless dives into a few myths around scalers and looks at how sharks can help surface some truths

A scaler should last about a year or two, right?

How do I “audit” my scaler?

As with sharks, dental instruments are subject to many myths and incorrect beliefs. Like a marine documentarian swimming among the sharks, we’re on a mission to remedy some of these myths and set the record straight. In this article, we’ll explore what might be learned from sharks and how that relates to the dental industry. Does a scaler last forever? Is there such a thing as a sharpen-free scaler? Let’s jump in!

great white shark can live to 70 years of age. Your scalers cannot. The useful life of a scaler depends on a variety of factors. Consider how often are they used, sterilized and sharpened, as well as the clinical applications they’re used for. Every now and then, it’s a good idea to look over instruments and “audit” them to make sure that they’re in the ideal condition. When they work effectively, you work efficiently.

he shape of a shark is specially designed to help it efficiently navigate long distances and manoeuvre around its prey with ease. Engineers have designed scalers and curettes to manoeuvre around tight spaces and effectively remove calculus. A shark wouldn’t be anywhere near as fast and efficient if its shape were changed and neither will your instruments. Look through your current instrument offerings. Are they dull or chipped on

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With all of this to balance, it can be difficult to take a step back and look at specific processes that happen every day to determine if there are better, faster and safer ways to do things. Instrument reprocessing and sterilisation is one of those areas and is a critical component to developing a best practice approach to dental infection control. Infection control guidelines recommend minimising the handling of contaminated sharp instruments during reprocessing. The best way to do this is by placing the instruments in a container that will protect clinicians from injuries during transport and reprocessing and also protect the instruments from damage caused by droppage or contact with other loose instruments. For practices that want to employ a contemporary method to instrument reprocessing, a cassette-based instrument management system is a perfect solution. Unfortunately, many practices’ infection control is still based on carrying instruments on a tray and storing them in bundles, which increases the risk of sharps injuries, instrument damage and impairs the reprocessing workflow. A better way is to implement an instrument management

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3. If it ain’t broke... nfortunately, not having an IMS means practices may not be fully optimising their time or maximising the safety of patients and staff. There may

November/December 2023

Question 1. An instrument should be replaced if:

Question 6. Using an instrument cassette system:

a. It is dull or chipped on the cutting edge or point. b. It is bent or broken. c. The blade is 20% smaller than when it was new. d. All of the above.

a. Takes 5-10 minutes longer per patient. b. Saves 5-10 minutes per procedure. c. Takes 38 minutes longer per day. d. Makes no difference to instrument handling times.

Question 2. Dull scalers are:

Question 7. Using an instrument cassette system:

a. More difficult to use. b. Less comfortable for patients undergoing treatment. c. Can leave behind burnished calculus. d. All of the above.

a. Protects instruments from damage during reprocessing. b. Protects staff from sharps injuries. c. Reduces the time required to train staff. d. Optimises the practice workflow and speeds up instrument reprocessing. e. All of the above.

Question 3. A scaler promoted as never needing to be sharpened: a. Effectively needs to be replaced as soon as it’s dull. b. Can harm patients if sharpened as the coating may flake off. c. Are not meant to be used on heavy calculus. d. All of the above. Question 4. Out of the box EVEREDGE 2.0 scalers are sharper than competitor scalers by: a. 300% b. 127% c. 72% d. 50% e. 28% Question 5. Harder scalers are sharper and more effective: a. True b. False

Question 8. When using instrument cassettes, the instruments are removed from the cassette: a. At chairside to treat patients. b. Prior to cleaning in an ultrasonic bath or washer disinfector. c. Prior to autoclaving for packaging. d. All of the above. Question 9. The initial investment cost in an instrument cassette system is often offset by: a. Reduced instrument damage/breakage. b. Avoidance of the costs associated with sharps injuries. c. Increase productivity. d. All of the above. Question 10. A cassette-based instrument management system standardises procedural set-ups and creates a process that is less people-dependent: a. True b. False

INSTRUCTIONS: OralHygiene™ 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, contact OralHygiene for your Username and Password. Then log into the Dental Community website at www.dentalcommunity.com.au and click on the CPD Questionnaires link; select the Oral Hygiene Nov/Dec 2023 questionnaire and then click START. A score greater than 80% is required to PASS and receive CPD.

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

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

COVID-19: New challenges for 2024

By Emeritus Professor Laurence J. Walsh AO

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

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

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

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a. Eris b. Pirola c. Fornax d. Piranha Question 12. In 2022 in Australia, the top cause of death was... a. COVID-19. b. Ischaemic heart disease. c. Dementia. d. Cerebrovascular diseases. e. Malignant neoplasm of trachea, bronchus and lung. Question 13. The Touch Australian-made rapid antigen test does not test for... a. COVID-19 b. MRSA c. RSV d. Viral Influenza Question 14. During the pandemic, Australia gained onshore capability for... a. Producing surgical masks b. Producing respirators c. Mask and respirator testing d. All of the above Question 15. The Nobel Prize in medicine was awarded to the two scientists whose pioneering work led to the creation of mRNA vaccines: a. True b. False

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Question 11. COVID variant Omicron BA.2.96 is also known as...

Those discussions then lead to some practical suggestions for improvement. For ease of illustration, a patient life-cycle approach will be used as the logical progression of issues, following a hypothetical patient from their initial presentation to the practice through to the completion of the treatment. In earlier articles, I explored the fact that clinicians may face insecurities and anxieties when confronted with the point that their examinations, charting, radiographs, scans and laboratory work items (such as impressions) may have errors. They may contain information that some clinicians cannot recognise, identify or interpret. For example, there may be errors present that relate to technique and the clinician can tell something is wrong but is unsure of what has gone wrong.

November/December 2023

Question 16. Ensuring patient information is accurate, up-to-date and complete is asserted in Australian Privacy Principle number... a. 3 b. 5 c. 8 d. 10 e. 13 Question 17. Many medical history forms fail to ask questions about... a. Prescription medications. b. Recreational drug use. c. Alternative or natural therapies. d. Smoking and vaping. e. All of the above. Question 18. In the alphabetic classification scheme for adverse drug reactions, A stands for... a. Augmented b. Anaphylactic c. Allergic d. Anti-body Question 19. Areas often missed in treatment records include... a. Details of LA administered. b. Shade of restorative material used. c. Treatment options presented. d. Reasons for the prescription of medicines. e. All of the above. Question 20. In the ACT framework, C stands for... a. Communicate b. Concentrate c. Compile d. Connect

abstracts | 2023

Oral Hygiene Abstracts 2023

By Emer. Prof. Laurence Walsh AO

Clinical patterns in brain fog in Long COVID

Long COVID or post-COVID condition (PCC) is a common complication following acute COVID-19 infection. PCC is a multi-systems disease with neurocognitive impairment frequently reported regardless of age. PCC is characterised by varying degrees of multi-system involvement including cardiorespiratory, neurologic, neurocognitive, musculoskeletal and others. Little is known about the risk factors, associated biomarkers and clinical trajectory of patients with this symptom. This study determined differences in clinical risk factors, associated biochemical markers and longitudinal clinical trajectories between patients with PCC with subjective neurocognitive symptoms (NC+) or without (NC−). A retrospective longitudinal cohort study was performed using a well-characterised provincial database of patients with clinically confirmed PCC separated into NC+ and NC− cohorts. Demographical, clinical and biochemical differences at initial consultation between the two patient cohorts were analysed in cross-section. Multivariate regression analyses were conducted to identify independent risk factors for neurocognitive impairment. Determination of the recovery trajectory was performed using serial assessments of patient-reported health-related quality of life (HR-QoL). Female gender, milder acute infection and pre-existing mental health diagnoses (such as depression and/or anxiety) were independently associated with subjective neurocognitive impairment at 8 months post-infection. Female gender was a significant risk factor for development of neurocognitive symptoms in ages 45-64 years but not in other age ranges. It remains unclear if this association is relevant to the pathogenesis of neurocognitive impairment or whether women with milder acute infections are simply more aware of their cognitive defects, although evidence involving task-related cognitive testing suggests that women do objectively perform more poorly than men post COVID-19 infection. NC+ patients demonstrated lower levels of antibody (IgG, IgG1 and IgG3) compared to NC− patients. This raises the possibility that humoral immunity derangements might be relevant for the development of neurocognitive symptoms. The NC+ cohort had poorer HR-QoL at initial consultation 8 months post-infection, with gradual improvement over 20 months post-infection. Neurocognitive impairment represents a severe phenotype of PCC, associated with unique risk factors, aberrancy in immune response and a delayed recovery trajectory. Those with risk factors for neurocognitive impairment can be identified early in the disease trajectory for more intense medical follow-up. Since this study examined patients from specialty long-COVID clinics, the findings might be selectively biased towards those with more severe PCC as those patients are more likely to seek care and referral to the long COVID clinic. Yam GY et al. Characterizing long‑COVID brain fog: a retrospective cohort study. J Neurol. 2023;270:4640-4646.

Mouthrinses and their role in oral health

Antimicrobial mouthwashes are considered to reduce dental plaque biofilm and thus the potential to prevent plaque-induced oral diseases, particularly periodontal diseases. The effectiveness of mouthwashes relates to this antiplaque role, as well as their tooth-whitening potential and ability to mask/mange malodour (halitosis). There is also a growing interest in the use of mouthwashes as an adjunctive measure in post-surgical and postdental care, while the COVID-19 pandemic has given a new lease of life to mouthwashes as an oral antiseptic that may be useful in reducing the oral viral load. The mode of action of mouthwashes varies, depending on their active ingredients, concentrations and mode and frequency of use, as does their potential effectiveness. Irrespective of the mouthwash used, there appears to be strong evidence of their effectiveness in reducing plaque and this is an important consideration given that most oral diseases are plaque-related. There is also considerable evidence regarding the effectiveness of mouthwashes as an adjunct to conventional oral hygiene regimens for preventing and improving gingival health. Given the role of mouthwashes in gingivitis, it is assumed they have a role in preventing periodontitis and improving periodontal health, but evidence of their role and their effectiveness at this stage of disease is less readily available in terms of the quantity and quality of evidence. It remains to be seen, amongst the many agents described, which mouthwash would be “most effective” and this is not addressed here. There has also been a tsunami of interest in the antiviral properties of mouthwashes since the onset of the COVID-19 global pandemic and this continues to be of great interest, with more in vivo research required. McGrath C et al. Effectiveness of mouthwashes in managing oral diseases and conditions: Do they have a role? Int Dent J. 2023 November DOI 10.1016/j.identj.2023.08.014

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

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November/December 2023

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

November/December 2023

Date

Emergence

Variants with high circulation rates

2019

China

Wild type (original strain)

2020

Alpha

2020

South Africa

Beta

2020

Brazil

Gamma

2020

India

Delta

Delta with K417N (Delta Plus)

2021

Omicron

South Africa

2021

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

2022

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

2023

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

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

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

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

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

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

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

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

November/December 2023

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

November/December 2023

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

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

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

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

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

About the author Emeritus Professor Laurence J. Walsh AO is a specialist in special needs dentistry who is based in Brisbane, where he served for 36 years on the academic staff of the University of Queensland School of Dentistry, including 21 years as Professor of Dental Science and 10 years as the Head of School. Since retiring in December 2020, Laurie has remained active in hands-on bench research work, as well as in supervising over 15 research students at UQ who work in advanced technologies and biomaterials and in clinical microbiology. Laurie has served as Chief Examiner in Microbiology for the RACDS for 21 years and as the Editor of the ADA Infection Control Guidelines for 12 years. His published research work includes over 400 journal papers, with a citation count of over 20,000 citations in the literature. Laurie holds patents in 8 families of dental technologies. He is currently ranked in the top 0.25% of world scientists. Laurie was made an Officer of the Order of Australia in January 2018 and a life member of ADAQ in 2020 in recognition of his contributions to dentistry.

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

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

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

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

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you keep accurate, up-to-date, factual, objective and legible records that report relevant details of clinical history, clinical findings, investigations, information given to patients, medication and other management in a form that can be understood by other health practitioners”.

Initial presentation hen a new patient contacts a private dental practice by telephone, they will most likely speak to the front desk reception staff or perhaps to the practice manager. It is at this point where the patient will express their initial intention to seek a dental visit and the reasons behind that. This then brings up the issue of triaging, where new patients may be identified as attending for a routine examination (e.g. having recently relocated to the catchment area of the

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

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

Medical history hen completing a medical history questionnaire, patients may forget elements of their previous medical history, or may be unwilling to disclose them, because of fear of embarrassment, or fear of discrimination. The latter can arise when the patient has a mental health condition or a blood-borne viral disease. When asked on a form regarding current medications, many patients will identify

oral|hygiene 31

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

32 oral|hygiene

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

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

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

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

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

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

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Table 1. Simplified classifications of adverse drug reactions Alphabetical

Mechanistic

A - augmented

Hypersensitivity (allergy)

B – bizarre

Photosensitivity

C – chronic

Mutagenicity (altered genes)

D - delayed

Carcinogenicity (causing cancer)

E - end of use

Teratogenicity (foetal abnormality)

F - failure of therapy

Idiosyncrasy

Cytotoxicity

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

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

oral|hygiene 33

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

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

34 oral|hygiene

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

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

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

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