New Council members

Yesterday was the first Council meeting with the GDC’s new Council members in a post.

The new council members include Anne Heal, Crispin Passmore, Sheila Kumar, Caroline Logan and Jeyanthi John- all formally took up a post on the 1st of October. Terry Babbs was reappointed and Margaret Kellett, Catherine Brady and Bill Moyes started their second terms.

This new composition coincides with a changing focus for the Council. For good reasons, much of the Council’s focus over the past few years has been overseeing operational improvements within the GDC. Bill Moyes published a statement where he said: “We have already improved our performance as measured by the Professional Standards Authority’s review of our statutory functions, and we hope further improvement will be seen in this year’s review. We will be able to tell you very soon what the PSA’s review has concluded about our performance against their standards.”

He continued: “The year ahead will see us developing a model of upstream regulation, as set out in Shifting the balance. This is an ambitious programme designed to improve the service we give to patients who refer complaints to us about the fitness to practice of their dental clinician, as well as to the registrants who are the subject of serious complaints.

“The key aims are to improve how we engage with dental professionals, particularly to help embed the Standards for the Dental Team and share learning from fitness to practise and other sources; develop and adopt a risk-based approach to how we assure the quality offered by education providers; and to develop our approach to continuing professional development (CPD) to encourage greater ownership of the scheme among dental professionals.”

The GDC are making improvements in their approach to CPD, with the launch of Enhanced CPD in January 2018 for dentists and in August 2018 for dental care professionals. The GDC received an update on the progress of implementing this at our Council meeting. Firstly, a reminder, the main changes to the scheme are:

– The requirement for all dental professionals to have a personal development plan (PDP);
– An increase in the number of verifiable hours for most professional titles and the requirement to spread the hours more evenly across the five-year cycle;
– The removal of the requirement to declare non-verifiable CPD to the GDC;
– The requirement to make an annual statement of CPD hours completed, even if zero hours have been completed for that year;
– The requirement to align CPD activity with specific development outcomes;
– The requirement for professionals to plan CPD activity according to their individual “field(s) of practice”.

The key update includes the suite of support materials that have been published to help to ensure dental professionals and other key stakeholders are able to understand the changes and what is required under the new system.

Kerr Dental explains the benefits of simplifying your posterior restorations from apex to crown with a special focus on the benefits of warm vertical obturation.

On completing this CPD article, the reader will:

1. Understand the steps to simplifying posterior restorations from apex to crown
2. Understand why warm vertical obturation offers the gold standard in endodontics for the prevention and/or the elimination of apical periodontitis
3. Recognise how the elements™ free obturation system can deliver benefits to the clinical team and patients.

Simplifying posterior restorations

Following a consistent procedure from root canal to final restoration offers advantages in terms of predictability of results and peace of mind as well as helping you to feel in complete control. Here we suggest some top tips for simplifying each stage of the procedure to help you identify the solutions needed for your practice:

Stage 1 – Field preparation

Top tip: Apply a 3D anatomical dam that gives you great visibility and protects your patient effectively.

Stage 2 – Canal shaping

Top tip: Use a file system that adapts its movement to the clinical conditions encountered, so you have better control, fewer risks of file breakage and less hand fatigue.

Stage 3 – Canal cleaning and disinfection

Top tip: Apical negative pressure applied through a handheld device allows you to irrigate the whole canal, including the apical third, with minimised risks of extrusions.

Stage 4 – Obturation

Top tip: Obturating with the continuous wave of condensation technique allows you to simply and safely fill the canal all the way to the apex.

Stage 5 – Creation of contact points

Top tip: An all-in-one matrix system is what you need to create accurate contact points without using a matrix retainer.

Stage 6 – Bonding

Top tip: With an all-in-one bonding agent you will achieve a strong and imperceptible adhesive layer with a simplified protocol.

Stage 7 – Core Build-Up

Top tip: Build up the abutment with a bulk fill composite that reacts to sonic energy, done in one increment with exceptional adaptability and marginal integrity.

Stage 8 – Final polymerisation

Top tip: Polymerise deeply with a cordless curing light that provides uniform depth of cure while protecting patients from the heat.

Stage 9 – Crown preparation and cementation

Top tip: When cementing, pay attention to the clean-up phase. A Colour Cleanup Indicator helps you to identify the best moment to remove excesses safely and without stress.

Stage 10 – Finishing

Top tip: When perfecting the surface and the margins, use a disc system that can access restricted areas with great ease and give you better visibility.

Stage 11 – High gloss polishing

Top tip: Finish off using a high gloss polisher with pre-embedded abrasive particles, for a great result without the need for paste.

Experience start to finish posterior procedure, from apex to crown. Find out more at kerrdental.com/simplify

Gold standard in obturation

As dental professionals are all too aware, effective obturation of the root canal system is one of the keys to endodontic success. Only when this is achieved can the clinician and patient rest assured that microorganisms will be prevented from re-entering the root canal system, and that any microorganisms that may remain within the tooth from nutrients in tissue fluids will remain isolated^1.

For the dentist, warm vertical obturation, as recommended by endodontists, offers the gold standard in root canal treatment. This is partly due to the fact that it facilitates a three-dimensional seal of the root canal by filling all voids, and pushing sealer into lateral canals and tubules, which reduces the risk of reinfection.

As Bey (2015) wrote so succinctly, ‘The main objective of endodontic treatment is the prevention and/or the elimination of apical periodontitis. This is achieved by instrumentation, disinfection, and obturation of the root-canal system in three dimensions. Gutta-percha is the most widely used and accepted obturation material because of its biocompatibility, inertness, dimensional stability, compactability, plasticity when heated, and ease of removal for post placement or retreatment. There are a variety of techniques that are used to obturate the root-canal system. They can be divided into two basic groups: cold lateral compaction and warm vertical compaction:

• Cold lateral compaction of gutta-percha by compacting them laterally against the sides of the canal walls with spreaders
• Warm vertical compaction of gutta-percha using the continuous wave of condensation technique is less time consuming, provides less microbial coronal leakage, and adapts better to grooves and depressions of the canal walls and lateral canals than cold lateral compaction.’²

Glassman (2012) also examined the significance of three-dimensional obturation of the root canal system. Alongside biomechanical preparation and chemotherapeutic sterilisation he consider this to be ‘[…] the hallmark of endodontic success’.³

Simplifying warm vertical obturation with elements™free

The cordless elementsfree system can help to achieve endodontic success. Like the Elements Obturation Unit, it has a downpack unit, which can be used in conjunction with any gutta-percha. Using an exact fit gutta-percha point to the corresponding file system that the dentist finished on, the downpack heats that gutta-percha point and compacts it into the apical third of the canal.

Again like the Elements Obturation Unit, elementsfree has an extruder handpiece that accommodates disposable preloaded cartridges of gutta-percha of varying densities and is used to backfill the root canal space. They are available in medium body and heavy body viscosities. The applicator tips are available in 23 gauge and 25 gauge diameters. There is enough gutta-percha in the disposable cartridges to fill an average molar, approximately four canals.³

The GP cartridge applicator tip is placed into the root canal space until it penetrates the apical plug of gutta-percha for five seconds to re-thermo-soften its most coronal extent. This promotes cohesion between each segment of warm gutta-percha.³

Segments of 5mm to 6mm of gutta-percha are then deposited. Injecting or dispensing too much gutta-percha invites shrinkage and/or voids, which result in poorly obturated canals. As gutta-percha is extruded from the applicator tip, the viscosity gradient of the back pressure produced will push the tip coronally from the root canal space.³

The technique sensitivity requires that when this sensation occurs, the operator must sustain pressure on the trigger mechanism as the applicator tip moves from the canal. The Buchanan pluggers are then used in sequence to maximise the density and homogeneity of the compressed gutta-percha mass. This sequence of thermo-softened gutta-percha injection and progressive compaction is continued until the obturation of the entire root canal space is achieved.³

The elementsfree system offers both downpack and backfill capabilities and can be used with any file system; just use the exact-fit master cone to the corresponding file system.

(sub) Patient benefits

As elucidated by Dr Herb Schilder in his seminal 1967 article ‘Filling Root Canals in Three Dimensions’, ‘Vertical condensation of warm gutta percha produces consistently dense, dimensionally stable, three-dimensional root canal fillings.’⁴

Supporting this conclusion and demonstrating the benefits of the elements™ free system, Bey (2015) described a case report using the cordless obturation unit for the retreatment of a three-rooted maxillary first bicuspid.²

A complicated case, this clearly had the potential to cause the patient added upset if treatment was not performed to a consistent standard – something that the patient seemingly hadn’t previously experienced, since this was a retreatment case and the initial examination revealed that while

the mesiobuccal and palatal canals appeared to have been adequately filled, the distobuccal canal was filled short.²

Bey (2015) went on to conclude, ‘In this case obturation was accomplished using the cordless elementsfree obturation system. The cordless feature allows freedom of movement during treatment. The omnidirectional activation ring on the downpack unit is easily depressed, independent of the position of the plugger in the canal. The swivel movement of the needle tips, and the extrusion action of the Backfill device makes delivery of gutta percha efficient, easy and precise, leaving no voids in the final outcome.’²

This, of course, means that, when the dentist is armed with the right tools, patients can be provided with a consistent level of treatment, reducing the likelihood of retreatment.

(sub) Benefits for the clinical team

The elementsfree system makes life easier for the team being ergonomic, intuitive, easy to store and maintain. As a cordless emulation of the Elements Obturation Unit, it uses the same Continuous Wave downpack tips, the same backfilling cartridges, while offering the same level of performance.

Thus, for downpacking, System B Heat Pluggers can be used, achieving the same great performance and eliminating the need to become familiar with other pluggers, while the 360° activation ring helps to improve the team’s treatment experience. Furthermore, the control button toggles through the presets easily (preset at 200°C for gutta-percha, 150°C for synthetic). The control button can also be used to customise the temperature, between 140°C and 400°C, again offering outstanding ease of use.

In addition, when it comes to backfilling, Elements Obturation Unit cartridges are used. In the past, the cartridges required a wrench to insert and remove them from the extruder handpiece. However, the cartridges now have ‘wings’ and can be easily inserted and removed with your fingers. These disposable cartridges minimise the risk of cross contamination and eliminate tedious, time-consuming clean-up. Made of silver for excellent heat conductivity, they load and disengage easily, offering a real benefit for the whole dental team.

Operator comfort has not been forgotten; high‐performance insulation around heater (Silica Aerogel) ensures the outer plastic housing stays cool whilst the inside mechanism is hot, heating the gutta-purcha.

(box) A true winner

elementsfree is the recipient of The Dental Adviser’s much sought after Editors’ Choice Award.⁵

Nine consultants evaluated the system, with an average of 17 uses per consultant. It received a 96% clinical rating. Some of the consultants involved in the decision-making process had this to say about the system:⁵

• ‘It is light, cordless and does exactly what you want it to.’
• ‘Love this system, and it is even greater in that it is lighter and cordless.’
• ‘Portable, lightweight, and heats quickly. I also like the one-touch activation/deactivation ring.”
• ‘Warming tip is convenient.’
• ‘Produces great fills.’

Expanding the horizons of endodontic success

As Glassman (2012) stated so succinctly: ‘With each improvement and modification of the

technical limitations of the technique, the thermo-softened millennium will continue to expand

the horizons of endodontic success and elevate the standard of care and pursuit of excellence in

clinical treatment materials.³

References

1. Carrotte P. Endodontics: Part 8 – Filling the root canal system. BDJ 2004; 197: 667-672
2. Bey G. A Complicated Endodontic Retreatment Using A New Cordless Obturation System:

A Case Report. Oral Health 2015; May: 16-26

3. Glassman G. Three Dimensional Obturation of the Root Canal System: Continuous Wave of Condensation. Roots 2012; 3: 20-26
4. Schilder H. Filling Root Canals in Three Dimensions. Dent Clin North Am. 1967; Nov: 723-44
5. https://www.dentaladvisor.com/evaluations/elements-free-obturation-system-2017-product-award/. Accessed 14 February 2017

To complete this article and gain one hour of verifiable CPD, https://the-probe.co.uk/courses/course_category/brush-up

Advances in medical research and treatment of disease has increased life expectancy, on average people may live up to thirty years longer than previous generations^1,2,4,5. There are 65 million people living in the UK, 17% are over the age of 65 with predictions of a rise in that figure to 23% by 2033^1,2. The generation known as ‘baby boomers’ (people born 1946 – 1964) and are now entering or already well into old age.

An ageing population (defined as over 65 years and above) brings new challenges to the provision of oral healthcare and the role of the dental team. The Adult Dental Health Survey (ADHS) shows a steady decline in the number of edentate patients in the UK, currently at 6%, a 24% reduction since 1978³. Not only are patients living much longer, but will expect to retain their teeth for longer too^2,3. In the not too distant past, tooth loss was considered inevitable in advancing years. Nowadays, people (81%) expect to keep their teeth for the duration of their lifetime³ and the UK will need a dental workforce equipped with skills for effective prevention and behaviour change techniques^6,7 to ensure optimum oral health for older generations.

A thorough understanding of the relationship between systemic and oral health is essential to prepare for the challenges of an ageing population^8,9. Minimal intervention dentistry and advanced restorative materials and methods are some of the ways in which dentistry is evolving to meet the demands of an ageing population who need to retain a functioning dentition well into old age^9,10.

It is well established that good oral health is a fundamental determinant of healthier ageing, improved general health and wellbeing¹⁰ which reduces physical decline. However, it is more difficult to maintain oral health into older age^8-11 due to physical, cognitive and biological changes that occur resulting in reduced independence, mobility and manual dexterity, fragility, healthy illiteracy, impaired cognitive function, financial reasons and access to services¹¹.

The dental team urgently need to adapt to meet the needs of an older patient demographic and reduce the barriers associated with specific needs and challenges. More emphasis on retaining teeth well into old age will demand a more preventive driven health model. Despite the evidence to support that, caries and periodontal disease are for the most part preventable, they continue to create a huge global burden on healthcare and resources worldwide¹⁰, and this burden is predicted to grow, as the older population do. The Evidence based research suggests that older adults are more susceptible to dental caries and periodontal disease, due to either longer exposure to risk factors or reduced physical capabilities^2,10,11. With an ageing population, comes more emphasis on screening programs for detection of chronic diseases and oral cancers.

Oral Cancer Screening

Screening every patient to facilitate the earlier detection of oral cancer, especially in high risk patients should be performed routinely for every patient. Discussions about the risk factors, smoking and alcohol, that increase the risk of developing oral cancer should be carried out. Appropriate management of detected mucosal lesions and prompt referral are key to improved survival rates. There are 5000 new cases diagnosed each year, with men more at risk than women, and older people more at risk than young. The 5-year survival rate is low¹² compared to other cancers with only 48-55% surviving 5 years. The dental surgery provides an opportunity to screen and educate patients about oral cancer and offer smoking and alcohol cessation counselling.

Root Surface Caries

Dental caries is still the most common disease globally and is preventable by adjusting modifiable lifestyle factors^1,10. As part of the governments nutritional guidelines, we are all advised that for good health we consume 5 portions of fruit and vegetables each day, however, with scientists recently showing that eating 10 portions of fruit and vegetables a day could prevent a significant number of premature deaths worldwide, there are those whom are now consuming a lot more fruit and vegetables in order to reap the health benefits this could bring. However, with this, and more in those whom are consuming a significantly greater amount of fruit (either dried, fresh, in juice form or as smoothies) this can lead to increased acid erosion, demineralisation and increased caries risk.

The dental team should try to explore the source of dietary acids and sugars, frequency of intake, available fluoride, salivary flow and effectiveness of self-performed oral hygiene practices in a proactive approach to reduce dental caries in older adults. The ADHS found 43% of adults over 65 had restored root surfaces³. A diet analysis diary can help to identify hidden sugars and frequency of snacking. Getting the patient to complete a 3-day food diary can help to identify the amount and frequency of free sugars and acidic foods and drinks in their diet. Suggestions for anti-cariogenic substitutes for snacks (plain popcorn, nuts and cheese) and beverages (water, regular or ice tea, unsweetened almond/ coconut milk) and advise limiting sugary food and acidic foods and drinks to main meals will help to reduce periods of demineralisation.

On identification of high caries risk patients, prescribe a high-level fluoride toothpaste containing 2800ppm or 5000ppm. Topical fluoride varnish is also recommended in Delivering Better Oral Health¹³ for high risk adults as an effective preventive intervention. A study by Schaeken et al found a 50% reduction in root caries following the application of fluoride varnish every 3 months¹⁴.

A reduced salivary flow can alter the buffering capacity and cleansing of the oral cavity resulting in caries. Polypharmacy is common among the elderly (variety of drugs prescribed for multiple conditions) can result in xerostomia, accelerating the progression of caries. On average patients may take 8 to 13 medications per day¹⁵. Over 400 drugs are known to reduce salivary flow and this can lead to rapid deterioration of enamel and dentine. A thorough investigation of a patient medical history may highlight interactions or combinations that need re-evaluation by a physician, substitutions that may alleviate symptoms of xerostomia.

Online risk assessment tools, such as Previser (Deppa) has become more mainstream and is designed to determine an individualised patient risk of oral disease by generating a score based on biofeedback (systemic health, lifestyle factors and clinical data). This software produces written guidelines to assist clinicians to communicate information and advice to patient in a more structured manner.

Periodontal & Peri-implant health

Patients are living longer, therefore will need to maintain the health and function of natural teeth and/or their restorative and implant replacements for the duration of their life¹⁶. Therefore, improved preventive interventions are necessary to reduce the incidence and progression of oral disease.   Once inflammation has resolved, then recall intervals can be further apart. Absence of bleeding on probing (BOP) is considered the most reliable indicator of gingival health¹⁷. The ADHS reported attachment loss in 85% in over 65 age group³.There is an increase in the number of patients presenting in general practice with dental implants, implant retained dentures, implant supported bridges and prosthesis.

Formal education of implant care is limited in undergraduate curricula and graduates often report a lack of confidence in this area. Clinicians who are not equipped with the skills required to address the needs of patients with dental implants, should consider additional education and training in this topic. Patients will need more specialised oral hygiene aids and demonstration to facilitate biofilm removal and prevent the onset of peri-implant mucositis and peri-implantitis. Prosthesis must be designed in a manner that facilitates patient self-care¹⁸. Patients should know the exact location and number of abutments in their mouth and receive demonstration of effective biofilm control using the most suitable oral hygiene aid for their needs. A wide variety of implant specific tools are available such as single tufted, angular and sulcular brushes and specialised floss.

With old age, patients may develop arthritic hands and fragility, making daily personal hygiene complex and tiring. Power brushes have a wider handle to facilitate grip and control, also eliminates the need to produce tiresome and awkward brush strokes manually. Alterations to floss holders and interdental brushes may improve manual dexterity. Again, clinicians must not assume that patients know effective brushing techniques. Clear, specific and tailored oral hygiene demonstrations will improve periodontal outcomes. Suggest videos and produce written material to support patients to adopt a new skill.

When manual dexterity is compromised, recommend a daily oral rinse, such as a daily fluoride concentration or a broad spectrum antimicrobial, as an adjunct to their mechanical self-care routine.   Relatives and carers should be trained to assist or perform oral self-care and remind patients who have difficulty remembering.

Dentine Hypersensitivity

In a study by Baker et al, 70% of respondents reported that dentine hypersensitivity took the pleasure out of eating and 26% were embarrassed to eat in public¹⁹. The discomfort and pain experienced has been due to dentine hypersensitivity, as a result of exposed root surfaces, recession, abrasion and acid erosion. Recommend a desensitising toothpaste containing stannous fluoride for daily use to help alleviate symptoms and provide lasting relief. Daily application is required to sustain absence of symptoms. Targeted application of the product to the area is also a useful way to soothe sudden onset of discomfort.

Partial & Complete Denture Care

Patients with partial dentures are at increased risk of further caries and periodontal destruction, due to the nature of the prosthesis. Partial dentures should be removed at night, brushed to remove biofilm and soaked in an antibacterial solution overnight. Brush remaining natural teeth, and gums, paying particular attention to the fitting surfaces of the prosthesis. A single tufted brush provides extra cleaning ability in hard to reach areas that support partial dentures. Edentulous patients have a lower perceived need for dental care²⁰ and reports indicate that 48% of 65-74 year olds and 63% of over 75 year olds have not accessed care in a decade²⁰.

Access to dental services

Barriers to care for an ageing population include access to the dental surgery for persons with reduced mobility and disabilities. The availability of appointments that allow independent living senior citizens to avail of subsidised transportation (freedom pass) to attend dental services without the added cost of travel^{11, 20}. Dental services will also need to reach those who are dependent and living in private housing, those living in residential care and patients in assisted living facilities and the meet the demand for a mobile service provision. The dental professional must also consider the issue of health illiteracy in the over 65 age group and ensure transparent and clear communication regarding treatment procedures, prevention measures and cost, allowing the patient sufficient time to process information, ask questions about their care and make informed decisions about their oral health.

To complete this article and gain one hour of verifiable CPD, https://the-probe.co.uk/courses/course_category/brush-up

The definition of periodontitis is inflammation of the tissue around the teeth. If the treatment of periodontitis was as easy as the definition, then things would be easy for us and our patients, but we know that this is not the case. It is my opinion that periodontitis is one of the most difficult diseases to treat successfully. This is because periodontitis is a complex chronic inflammatory disease, in which there are multifactorial with numerous systemic or local risk factors playing a role in the the progression of the disease¹. The principle outcome for periodontal therapy is to stop the initiation and progression of periodontitis by controlling the microbial challenge and host factors that contribute to tissue destruction. Most patients with periodontitis can be predictably treated and maintained in health with good oral hygiene and removal of local risk factors, but in a small percentage of the population it can be very difficult to achieve. These patients are on a more aggressive disease pathway, which requires more intensive maintenance of their oral inflammation and the impact of periodontitis and periodontitis control on any systemic disease present. Inflammation is the key to the problem and there are many studies showing the complex interaction between the host and the oral microflora and now this seems to alter the way the host responds to the inflammation, usually with a negative outcome. There are five risk factors that contribute to the progression of periodontitis:

1. Environmental factors- variation in subgingival flora
2. Genetic risk factors- variation in host response
3. Lifestyle factors – smoking, poor diet, and stress
4. Systemic diseases – diabetes
5. Other factors- tooth-related, occlusal, and iatrogenic factors

There are many studies suggesting patients who suffer from periodontal diseases are more susceptible to systemic complications such as inflammation, obesity and type 2 diabetes. Therefore suggesting that periodontal diseases could be a potential contributing risk factor for many other systemic diseases. However the mechanism are not fully understood in all of the situations.

Chronic low-grade inflammation has been suggested to be involved, not only in the pathogenesis of obesity and diabetes, but also in the pathogenesis of periodontitis where the inflammatory cytokines play a significant role in the host’s response to the oral biofilm^2,3. For this reason we would benefit by working with our colleagues in the medical field to help manage our patients systemically. Again it has been suggested the biological connection between periodontitis and systemic diseases are infection in the pathogenesis of both diseases, low-grade bacteremia caused by periodontal diseases, the host response to inflammation triggered by periodontal diseases and periodontal pathogens producing virulence factors^4,5. The detailed mechanisms underlying this association are still not clear, but there are suggestions that there is a bidirectional link between the mechanism of periodontal diseases and systemic/metabolic diseases where both diseases could affect each other with a negative outcome.

Periodontal disease costs the NHS over £2.8 billion and has been shown to have significant health impacts beyond oral cavity. The question we need to ask ourselves as clinicians is how to treat our periodontal patients? Do we only focus on oral hygiene as the most important factor to resolve the disease? Do we start to look at our patients as a whole body system which will influence the outcome of periodontal therapy? I feel we are at a point where we are not just focusing on the oral cavity, but are looking at our patient holistically and how we can influence the external factors such as lifestyle, which may influence the systemic conditions that can lead to a positive outcome to our therapies.

To complete this article and gain one hour of verifiable CPD, https://the-probe.co.uk/courses/course_category/brush-up

Learning Objectives

Upon completing this CPD article, the reader will learn that:

1. A new BioACTIVE restorative material mimics both the chemical and physical properties of teeth providing additional benefits.
2. The flow of the BioACTIVE restorative material means it can be used quickly and easily in tooth restoration making multiple restorations possible at one appointment.
3. The new BioACTIVE restorative material interacts with saliva and tooth structure and reacts to changes in the oral environment, contributing to the maintenance of oral health.
4. A rubberised resin component absorbs shock and stress and resists fracture and chipping.
5. By blending in with the natural colour of teeth and resisting marginal discolouration over time, the BioACTIVE restorative material provides an aesthetic alternative to existing composites.

CASE STUDY 1: Autism, caries and strip crowns

Daniel, a 19-year-old with severe autism, lack of speech, and a seizure disorder, presented at the surgery of Dr. Raymond Kimsey with severe caries. Discussions with his mother revealed that his diet included a lot of apple juice.

Daniel was uncooperative and had no ability to communicate, so Dr. Kimsey knew that treatment needed to be completed quickly and in one visit. With this in mind, Dr. Kimsey took an upper anterior alginate impression at the initial consultation in order to prepare and trim four strip crowns for fitting at the scheduled appointment.

Fig 1: Strip crowns were prepared in advance using a study model. The strip crowns were filled with ACTIVA BioACTIVE-RESTORATIVE, placed, and light cured.

On treatment day, Daniel was sedated through an IV, giving Dr. Kimsey a limited amount of time to work. Although the caries was deep, there were no pulpal exposures.   Dr. Kimsey removed the decay, treated the dentine with Pulpdent desensitiser, and fitted the strip crowns filled with ACTIVA BioACTIVE-RESTORATIVE composite (Fig 1)

Dr. Kimsey chose ACTIVA™ BioACTIVE-RESTORATIVE because:

• He could restore multiple teeth in a short period of time.
• The material withstands stress.
• It is an affordable solution.
• The bioactive properties and marginal integrity are more resistant to recurrent caries.
• It flows nicely making it easy to fill and apply strip crowns.
• It is durable and aesthetic.
• It is high-strength and dual-cure.

CASE STUDY 2: The Open Sandwich Technique

Dr. Robert Ho’s male patient was seeking treatment of a distogingival carious lesion and leaking occlusal filling close to the pulp on his lower left second molar. In addition, the patient was suffering some bone loss.

To restore the tooth effectively, Dr. Ho would need to seal the distogingival margin that lacked enamel prior to bonding.

He ruled out placing a crown, as subgingival biological width requirements would be breached in obtaining an accurate impression of the crown margins. Dr. Ho also ruled out amalgam as it is not a bioactive material and is not capable of interacting with saliva to recharge itself and protect the tooth. Glass ionomers were also discounted as they are the weakest of the permanent restorative materials and tend to wash out over time.

Following discussions with the patient about treatment options, Dr. Ho used ACTIVA™ BioACTIVE-BASE/LINER in an open sandwich technique with both ACTIVA™ and the composite exposed to the oral environment.

Having first isolated the tooth using the Isolite system, Dr. Ho removed the decay and applied a sodium diamine fluoride antimicrobial solution. He then used ACTIVA™ BioACTIVE-BASE/LINER on the pulpal floor and as the definitive restorative material along the entire distogingival margin up to the level of the pulpal floor. After curing, he applied phosphoric acid etchant and a bonding agent, placing a nano-composite occlusally as a permanent restoration.

Fig 2: Post-operative photo

Mild sensitivity had improved within a few days, and Dr. Ho was pleased to observe that, at a 10-month recall, a bite-wing image showed the restoration and marginal seal were completely intact (Fig 2).

Dr. Ho decided upon ACTIVA™ BioACTIVE because:

• It is a bioactive material.
• It is moisture friendly and interacts with saliva.
• It protects the tooth.
• It is strong and durable.

CASE STUDY 3: Nine restorations in a single appointment

A female in her early 60s presented at Dr. Barquero’s practice needing dental restorations on nine posterior teeth prior to undergoing radiation treatment for skin cancer.

A typical side-effect of radiation is xerostomia, which can contribute to further tooth decay. Treatment was therefore needed to promote remineralisation and to help protect teeth that were already compromised. ACTIVA™ BioACTIVE-RESTORATIVE was selected, primarily for its ability to promote remineralisation.

First, the enamel was etched for 20 seconds with phosphoric acid etchant, and

although not always necessary when using ACTIVA™ BioACTIVE but rather the clinician’s personal preference, a universal adhesive was applied.

Fig 3: final posterior restorations with ACTIVA BioACTIVE-RESTORATIVE.

ACTIVA BioACTIVE-RESTORATIVE was then placed. Each restoration was completed in eight minutes, following placement of rubber dam, so all nine restorations were achieved in one visit (Fig 3).  

ACTIVA BioACTIVE participates in an ionic exchange that is pH-sensitive and supersaturates the saliva and pellicle during low pH cycles. As the pH rises, these minerals are available to form a layer of apatite on the tooth surface, supporting the natural mineralisation process.

Dr. Barquero chose ACTIVA BioACTIVE because:

• The flow facilitates working quickly and efficiently.
• The application produces no bubbles or voids.
• The results are aesthetic.
• The product releases and recharges fluoride, calcium and phosphate ions.
• Its rubberised resin component resists fracture and chipping, making it strong and durable.
• It has dual-cure capability – no concerns about the depth of the cure in deep cavities.
• It supports the natural mineralisation process.

The product keeps margins intact with apatite formation at the material tooth interface and creates a non-soluble seal.

To complete this article and gain one hour of verifiable CPD, https://the-probe.co.uk/courses/course_category/brush-up

Learning objectives –

On completing this CPD article, the reader will:

• Learn how to maximise performance and longevity from an existing or new treatment unit
• Understand the importance of the treatment unit to the efficient running of the surgery
• Review the ways in which the treatment unit contributes to a more comfortable patient experience

The treatment unit is pivotal to all dental procedures that take place in the surgery, from dental check-ups and prophylaxis to cosmetic dentistry, endodontics to restoratives and oral surgery to implantology. KaVo Dental recommends the key aspects to consider when reviewing an existing treatment unit or looking to purchase a new one to ensure performance and longevity of equipment, maximum efficiency for the dental practice and an enhanced patient experience.

KaVo draws on the experiences of dentist Dr Indira Rangel. Because of its established reliability, easy handling and optimal comfort the newly designed KaVo Primus™ 1058 Life is the top choice for Dr Indira Rangel. At the end of each procedure, it isn’t only the patient’s smile that makes her happy, but the confidence that her KaVo unit will continue to run smoothly, making every working day a happy day. Read more at: go.kavo.com/uk/rangel

Historians date the beginnings of dentistry back to the Indus Valley Civilization back in 7000 B.C. By 1500 B.C. more specific descriptions of the practice of dentistry and related oral health conditions emerged.

Considered the Father of Modern Dentistry, Pierre Fauchard published the pivotal book “The Surgeon Dentist, a Treatise on Teeth”, which is credited as the first guide providing a comprehensive perspective on dental care and treatment.

The 19th century was a particularly robust time for rapid advancement in dentistry. During this century the first dental college (Baltimore College of Dentistry) was established in the U.S. and the first mass production of toothpaste and toothbrushes commenced. Further enhancements continued in the 20^th century and in 1965, KaVo developed the 1025 patient chair which was the first to enable dentists to ergonomically treat patients in the supine position: allowing for healthy and fatigue-free posture. Fast forwarding to the 21st century, the amount of dental practitioners, the diversity of specialities and the treatment options available to patients have greatly expanded. With this comes increasing demands from the dental treatment unit.

Maximising performance and longevity from the treatment unit

Quality construction

A durable and reliable treatment unit is a must to avoid treatment delays and postponed patient appointments.

Top Tip: Ensure the whole product is made from quality, durable materials that will stand up to the stresses that the unit will come under. Elements should fit together smoothly without gaps, for easy cleaning. Ensure separate aspects can be easily replaced if cracked (e.g. plastic) or ripped (e.g. upholstery).

Dr Rangel knows that her 1058 Life unit will run and run as smoothly as her treatments. For her working problem-free is like the yearly manufacturer service: just routine.

Take time with the seat test

If it is important for patients to be comfortable as the dentist works, it is equally important for the dentist to be comfortable as they work: An easy and smooth adjustable height of the patient chair and a comfortable backrest gives optimum working posture and access to the oral cavity.

Top-Tip: Test the treatment unit in different positions and remember to sit beside the chair and check that an ergonomic working position can be achieved. Assess pre-set options and feasibility for personalising these. Ask the manufacturer to provide details of clinics with the units installed to find out how they have been working in practice.

Top Tip: Check the minimum and maximum operating parameters of the treatment unit. For your ease and comfort remember to check the minimum and maximum working heights and ensure the proposed surgery has adequate space to allow easy movement around the unit.

Training provision and technical support by the manufacturer

To ensure the treatment unit is used as fully as possible and the life of the unit is maximised, ensure training is available from the manufacturer to demonstrate the complete range of features. Be confident that there is a technical support network in place for servicing requirements. Ask where the local engineers are based for the company and the average ‘fix time’.

Top-Tip: Get the most out of your KaVo dental equipment with a Treatment Unit Evaluation workshop. Find out more: go.kavo.com/uk/tuevaluation

Importance of the treatment unit to the efficient running of the surgery

Aim for integration and future proofing

When selecting a dental chair, it is worth checking their flexibility and compatibility and give a preference to systems which allow the most possibilities for upgrading at a later date, for example if your speciality changes or you engage other practitioners. Having enough instrument holders and upgrade functions like USB ports could prove important in the long-term.

Top Tip: Find out as much as possible about the unit before purchase.

• Does the unit have a built-in amalgam separator?
• How many foot controls are there?
• Is the unit ambidextrous?
• Does the unit have a spittoon valve included?
• Is there a 3 in 1 syringe included as standard?
• Is the unit compatible with disposable 3 in 1 tips?

In addition, support for external products must also be taken into consideration because not all the necessary instruments/equipment will (may) be available from the same manufacturer. The dental equipment should be flexible enough for any future adaptations brought about by new requirements or an enlarged portfolio of services. So-called “open” systems are a favoured choice in this case and can offer considerable (financial) advantages. When researching options, ensure you are comparing the same specifications. Sometimes cheaper units may require items to be added later in the purchase process meaning additional costs or it may not be possible to add extra items.

Top-Tip: Aim for kits and additional items (e.g. electric motors, scalers, spittoon valve) to be provided by the same manufacturer as the treatment unit. This ensures all components are tested to the same standard and troubleshooting is a simpler process. It is worthwhile enquiring exactly what comes with a new unit as very often the price can rise if presumed items are not included. Decide if you will need to add items to the unit.

Automated functions

Automated functions such as turning off the chair lighting, rinsing the cuspidor bowl and refilling the mouthwash can contribute to easing the burden of your dental team. Make CQC compliance as easy as possible by choosing a treatment unit with automatic cleaning and rinsing capabilities. Automated hygiene routines and protocols for internal disinfecting and servicing of the dental chair can support and facilitate practice procedures.

Top Tip: Check the ongoing costs of cleaning fluids and the hygiene concept of the unit.

Intuitive dentist and assistant element

A dentist’s and assistant’s element that can be configured to your individual needs, movement pattern and any given treatment situation will enable you to feel comfortable and in complete control. Being able to save preferred settings (e.g. RPM of the instruments) and easily recall them helps to save time and is particularly useful in situations where multiple clinicians may use the same unit.

Working at her clinic with 5 treatment rooms and up to 40 personal patients per day, efficiency matters for Dr Rangel and her assistant. She chose the table version of the dentist’s element to enable easy access and handling of her instruments and to facilitate comfortable working by smoothly positioning the element. During the treatments, the integrated display and the one-touch direct buttons on the clearly-structured interface offer improved operating comfort and help Dr Rangel to feel in control of every treatment procedure.

Ways in which the treatment unit contributes to a more comfortable patient experience

It’s not only the dentist but also the patient who needs to love the dental unit. Comfort is essential for making the patient feel relaxed.

Add style to the surgery

Colours are known to have an influence on how you feel. Review the range of upholstery and paint colours available to help individualise and add character to the surgery as well as introduce a feeling of calm.

Top Tip: Choose soothing paint and upholstery colours to help your patients feel relaxed.

After nearly 20 years in practice, it takes mere seconds for Dr Rangel‘s patients to recognise that she is more than just a good dentist. She is a clinician dedicated to creating an environment of kindness, elegance and confidence. She is rigorous in her attention to detail, recognising that it is the small things that help build trust with patients and help make even the most complicated treatments easier. Dr Rangal uses a treatment unit she can rely on, just like her patients rely on her.

Patient comfort

The dental chair is the focal point of your patients experience — it’s where your patients will spend a majority of their time — so it is important to make sure that it’s comfortable. Dental chairs may offer multiple recline angles and a special head cushion to provide comfort, even during long dental treatments, without sacrificing efficiency and workflow.

Dr Rangel‘s patients appreciate the ergonomics of her treatment unit; the combination of the flexible reversible cushion, the comfortable double-jointed headrest, the armrests and the height adjustment of the backrest that ensures a relaxed position regardless of height. In addition, the footrest is raised or lowered automatically to match the inclination of the backrest – known as Trendelenburg-Movement.

Patient Communication

The treatment unit should be used to help communicate with the patient at a higher level than ever before to encourage their ‘buy-in’ of the treatments.

Look for a treatment unit with high definition screens and displays with high resolution image quality, high contrast values and outstanding colour reproduction which are designed to work with image recording devices like a camera and microscope. Screens should be easily operated with just one hand using touch displays, and they should adhere to strict hygiene standards with protective glass panes and minimal gaps. Being able to connect with your patient management system for an automated interface of data exchange also simplifies workflow.

The treatment unit is a significant investment for a dental practice and probably the item with which the dentist and dental team needs to feel most comfortable. Using the suggested considerations to help evaluate your existing unit or a new one will help you maximise the value the treatment unit brings to your daily work.

 http://www.adea.org/GoDental/Health_Professions_Advisors/History_of_Dentistry.aspx

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