Issue 66, May 2011, $5.95
Better business for dentists
Mark Evans tells how Dental Corporation will become a global concern following its takeover by Fortis Global Healthcare Tools of the trade: The Cerec system you and your colleagues will fight over; and much, much more â€Ś Critical mass
What is the most efficient size for a dental surgery? (The answer starts on page 29)
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Issue 66 / May 2011
Your world 14. Keep up the fight
photo g ra p hy: ea mo n g a lla g h er
Infection control can get lost in the daily business of patients and practice. The ADA and ADIA are working together to keep it at the top of the agenda and tackle the issues head-on
Dental Corporation beat skeptics by announcing millions of dollars in new funding, a major new partner, and a strategy for global growth
Your business 24. Master of his domain The difference between the latest imaging technology and what’s gone before is greater than a quantum leap, says Dr Nathaniel Goldstein
29. Critical mass Editorial Director Rob Johnson Sub-editor Kerryn Ramsey Contributors Sharon Aris, Nicole Azzopardi, Kerryn Ramsey, Lucy Robertson, Maureen Shelley, Gary Smith Creative Director Tim Donnellan Commercial Director Mark Brown For all editorial or advertising enquiries: Phone (02) 9660 6995 Fax (02) 9518 5600 firstname.lastname@example.org Suite 4.08, The Cooperage 56 Bowman Street Pyrmont NSW 2009
7,624 - CAB Audited as at September 30, 2010
Bite magazine is published 11 times a year by Engage Media, ABN 50 115 977 421. Views expressed in Bite magazine are not necessarily those of the publisher, editor or Engage Media. Printing by Superfine Printing.
Is bigger better, or best? How big can a practice get before it runs out of efficiencies?
31. Building on success Building your own dental practice can be a costly, yet rewarding, exercise
Your tools 10. New products
The latest info on bonding agents, Dental Restorative and much more
06 News & events 05. Reform stalls again Once again, the Federal Government has cried poor when it comes to funding dentistry—but they have enough money and time to chase dentists who rort Medicare; ALSO the Senate set to probe AHPRA chaos; a new study into children’s oral health has been announced; and more…
34. Infection control product guide The latest and greatest infection control products and services from the world’s leading suppliers
43. Tools of the trade
The Cerec Bluecam that you’ll fight over; the cancer-sniffing Sapphire, and more are under review this month
Your life 46. Passions
On yer bike with Dr Marcel Mangelsdorf of Tweed Heads and his band of Russianinvading, ageing bikers
43 Bite 3
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Once again, the government has cried poor when it comes to funding dental programs
The rort goes on… Public dentistry has once again come off second best with Government funding.
ealth Minister Nicola Roxon revealed last month that the Federal government intends to break its deal with the Greens to fund a public dental program in the May budget. Ms Roxon told a newspaper any new program to cover the cost of dental treatment for low-income Australians was “not going to be achievable in this budget” and there was “no magic pudding” of money available. The intention to ignore dental waiting lists comes despite ongoing pressure from the community and minor political parties. Strangely, the Federal government also continues to insist on killing—rather than adapting—the Medicare dental scheme before it implements any other dental initiatives. Meanwhile, in Queensland, ADA Qld president Brad Wright has mooted using dental students to tackle that state’s waiting lists. The government’s renewed desire to kill off Medicare dental may be linked to the program’s popularity, with reports surfacing that more patients have been seen using the scheme in the past 12 months than in the previous two and a half years.
The government’s refusal to change their position on the scheme—despite repeated rejection in the Senate by the opposition and minor parties—is “stupid and stubborn”, according to Hans Zoellner, chairman of the Association for the Promotion of Oral Health. Associate Professor Zoellner was quoted in newspaper reports as saying expensive crown and bridge procedures accounted for one-third of the Medicare scheme’s costs—creating the potential for big savings. “I don’t believe that all the crowns and bridge work is unjustifiable … but it would be surprising to me if there weren’t substantial savings within that one-third of expenditure. Why on earth the government wouldn’t be keen to improve this system, I don’t know.” Dr Brad Wright’s plan to tackle dental waiting lists in Queensland, meanwhile, has drawn positive attention from some members of parliament, and appear to be simple to implement. He said the University of Queensland School of Dentistry hoped to increase the number of appointments this year from 60,000 to a maximum of 75,000. “We are keen to help those who have difficulty in accessing care,” Dr Wright told The Courier Mail newspaper. £
Human Services minister Tanya Plibersek (pictured above) has announced legislative changes that will help Medicare investigators to demand patient records when investigating suspected Medicare dental rorts. “This new legislation will give us the power to ensure that people comply with the rules of the scheme,’’ she told a Sydney newspaper. The newspaper reported that nearly one-third of dentists under inquiry had refused to co-operate with Medicare audits, stalling investigations and requiring Medicare to invest an enormous amount of staff time in gathering evidence. Examples given in the report include a dentist who declined to participate in an audit of patient services was found after a five-month check of doctors and patients to have made ‘’noncompliant claims’’ in relation to 143 out of 173 patients audited. In another case, a dentist incorrectly claimed more than $2 million from Medicare. Medicare said it had received 558 complaints or tipoffs identifying 487 dentists alleged to have undertaken lucrative work, including the installation of crowns and dentures, not justifiable under the scheme. £
06 News from our partners Colgate asks you to ‘brush night and day’ Disturbing statistics showing Australians know how to care for their oral health but choose not to do so have inspired a new campaign from Colgate and the ADA
olgate, in partnership with the Australian Dental Association (ADA Inc), has launched its ‘Brush Night And Day’ Campaign to urge Australians to brush their teeth twice a day, to avoid detrimental health and financial consequences. The campaign is being launched on the back of new research which shows that although 68 per cent of people are aware they should be brushing their teeth twice a day, the majority are failing to do so. Tooth decay is Australia’s most prevalent health problem – each year, 11 million teeth will become decayed. In 2008-2009, dental treatments cost the nation an estimated $6 billion. Sadly, children are also suffering, a staggering 38 per cent of five to six year olds have some form of tooth decay. Research shows that tooth decay is three times more likely if teeth are only brushed once a day. Dr Philippa Sawyer, Oral Health Committee spokesperson at ADA Inc is backing the campaign. “The fact that people are aware of what they should be doing, but are
not behaving accordingly, suggests that they are unaware of the potential consequences. It is our job as dental professionals to get the message out there that if adults and children fail to brush night and day, tooth decay and costly treatment may follow.” Surprisingly, the research shows that most people who fail to brush twice a day miss the night time brush, which is of course the most important opportunity. Sometimes people are in an
established routine where they only brush once a day, but often people are missing the night brush because they are tired, or coming home late. Dr Susan Cartwright, Scientific Affairs Manager, Colgate Oral Care said, “The campaign message is simple, brushing night and day with a fluoride toothpaste is the most effective way of preventing tooth decay and maintaining good dental health.” Dr Sawyer said, “We know
Ruby 6 Bite
It’s the night brush that can cut decay rates significantly, says the ADA’s Oral Health Committee.
that the solution is simple. For good dental health, adults and children need to brush night and day. They need to understand there is no second chance. Once tooth decay is established, costly, sometimes lengthy dental treatment is the only solution.” The ‘Brush Night and Day’ Campaign (www. brushnightandday.com. au) aims to encourage Australians to brush night and day to maintain good dental health. £
08 News bites Senate to probe AHPRA chaos A Senate Inquiry will investigate AHRPA’s delays in renewing registrations for health practitioners. The delays have resulted in health professionals being unable to practise despite sending in their registration forms before deadline, and in patients losing Medicare rebates. Liberal Senator Mathias Cormann moved to establish the inquiry, by the Finance and Public Administration Committee, after it was revealed that thousands of doctors, nurses, physiotherapists and other health workers have been unable to work after bungling by AHPRA left them without professional registration. Some were de-registered and had to stop treating patients, others treated patients while de-registered with all the problems that could pose – including
Medicare’s refusal to pay patient rebates and the likely refusal of private insurers to provide coverage. Shadow Health Minister Peter Dutton said the move to a national system had been chaotic for a large number of health professionals. “Health Minister Nicola Roxon just shrugged her shoulders and said it wasn’t her problem as doctors, nurses, psychologists, physiotherapists and other professionals were forced from their practices. It was the height of incompetence,” Mr Dutton said. Health ministers intervened last month to give the agency extra resources and federal Health Minister Nicola Roxon promised no one would be denied their Medicare rebates because of the problems. AHPRA chief Martin Fletcher concedes there has been start-up
issues as a result of the scope of the change. But the agency has “an extensive program of work under way to address these and welcomes the opportunity to help the Senate understand them”. £
New oral health program for expectant mothers an Australia first Midwives will play a vital role in improving the oral health of pregnant women, thanks to an innovative on-line education program developed by The Centre for Applied Nursing Research and Sydney Dental Hospital. The Centre and the Dental Hospital, part of Sydney Local Health Network, developed the program as part of a new Midwifery led oral health initiative that incorporates oral health guidelines into normal midwifery practice.
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09 News bites Senior Research Fellow and Program Leader, Dr Ajesh George, said research showed that hormonal changes in pregnant women made them particularly susceptible to poor oral health. “Poor oral health in pregnant women can contribute to lower birth weight and premature births and increased the risk of early dental decay in children,” Dr George said. “Unfortunately many pregnant women are unaware of the implications of poor oral health for themselves, their pregnancy, and their unborn child and seldom seek dental care during pregnancy.” “Preliminary research has found that more than half the pregnant women in south western Sydney had dental problems and less than a third had visited a dentist in the past six months.” The program has been supported by
grants from the NSW Centre for Oral Health Strategy, the Australian Dental Association (NSW) and UWS. The program is currently being trialled in south-western Sydney, with plans to roll it out across NSW and other states over the next few years. £
New study announced into kids’ oral health Professor John Spencer and the team at the Australian Research Centre for Population Oral Health will lead a national study into children’s oral health, designed to determine why it seems to be getting worse. They have been awarded $1.3 million to find out why the system is failing Aussie kids. “Despite a substantial level of resources—approximately $1 billion annually—being directed to dental services for children in Australia in the
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last decade, their oral health is still a major public health problem,” Professor Spencer told an Adelaide newspaper. “After several decades of improvement, child oral health has worsened and inequalities have widened.” Prof Spencer’s team will partner with all eight State and Territory public dental authorities in the research project. The partners are committing a further $1.7 million to the national study, making the total funding for the study $3 million. “We will be looking at how dental services for our children are organised and delivered, comparing the use of private dentists and school dental services and the outcomes for child oral health,” Prof Spencer said. “Public programs like the school dental services are not reaching as many children, yet private dental services may be out of the financial reach of many families.” £
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10 New Products New-release products from here and around the world
Concerto®Low Shrinkage Dental Restorative Concerto® SEA 25 sec bonding agent This seventh Generation Self-Etch Adhesive (Patent Pending) ARTG 176494 is a simple one step, one bottle system for the complete etching and bonding of enamel and dentine surfaces. Concerto® SEA’s strength is simplicity of application and consistent bond strength. Its shear bond strength ranges between 25 and 30MPa for enamel and dentine. Simply Apply Concerto SEA Wait for 10 sec Dry for 5 Sec Light Cure for 10 sec Concerto® SEA is an acidic self-etching tooth bonding system designed to react with the smear layer. It avoids the sensitivity problems of the Total Etch Technique, as it does not open the dentinal tubules. It dissolves the smear layer first, penetrating it to form short resin tags, then reacting with calcium cations to form a chemical bond. It forms invisible margins as it setsin a very thin, uniform layer. Available in 5ml Bottle Kit, 36x0.2ml Minidose and Refill. Maestro Dental & Cosmetics Pty Ltd Tel: 03 9874 3993 firstname.lastname@example.org www.maestrodental.com.au. £
(Patent Pending) ARTG 176493 Dental restorative technology hits a new high with the launch of Maestro’s Concerto composite restorative. Concerto® is a low shrinkage, visible light-cured nano-hybrid radiopaque tooth filling material. It contains 78%wt inorganic fillers (63.5%Vol) in a low shrinking UDMA resin and its polymerization shrinkage is 1.2%Vol, with outstanding handling properties that make contouring easy. The nano-particle filler enables an extremely high luster finish, similar to that of natural enamel, and long lasting restorations with high wear resistance. Concerto® is available in Paste and Flowable and is used with its own 7th Generation Concerto® Self-Etch Adhesive. Concerto® Paste is in a screw syringe 4.2g and in unit dose capsules 0.25g each. Concerto® Flowable is available in push, luer lock syringe1.5g intended to be used with 20 gauge blunt tips. The Concerto® Self-Etch Adhesive is available in a 5ml bottle and in 0.2ml Minidose. Concerto® Paste Shades: A1, A2, A3, A3.5, A4, OA1, OA2, OA3, B1, B2, B3, OB2, BL1, BL2, CI, C2. Concerto® Flow Shades: A1, A2, A3, A3.5, A4, B2, C3. Maestro Dental & Cosmetics Pty Ltd Tel: (03) 9874 3993 email@example.com www.maestrodental.com.au. £
U1301 – Compact Class The latest in tried and tested technology at an excellent price. The U1301 can be transformed from right hand side used to left hand side use with ease. German manufacturing. Touch Screen Operation High quality polyurethane mouldings – no yellowing , fading or cracking of parts Exclusive Distributor: William Green Pty Ltd – 02 8865 0300. £
Kerr Australia proudly presents
Dr. Michael N. Mandikos BDSc (Hons), MS (New York), Cert Pros, FRACDS, FICD
Alternatives to Crowns The Indirect – Direct Composite Restoration YOUR INVITATION TO ATTEND A FULL DAY COURSE includes Half/day Lecture & Half/day Hands-On Workshop
“A patient presents to your practice requiring urgent attention for a fractured molar. Secretly, you hope that the tooth will require a crown, but instead find that the tooth is largely intact and perhaps should be treated with a large direct composite. Disheartened at not being able to do a more complex and profitable procedure, you resign yourself to the mundane of a “533”.
Dr. Michael N. Mandikos,
BDSc (Hons), MS (New York), Cert Pros, FRACDS, FICD
Dr. Mandikos received his Dental Degree with honours, from the University of Queensland, and completed a three-year residency program in Prosthodontics at the State University of New York at Buffalo, USA. He has published in Australian and international journals on clinical and dental materials topics and is a Visiting Specialist Prosthodontist to the University of Queensland Dental School and the Royal Australian Air Force. He is a Reviewer for 3 dental journals and a product evaluator for several dental companies.
Too often this is the thought process we go through when in fact the present technologies and techniques available to us make this an exciting opportunity to practice minimal intervention, bio-mimetic dentistry. And with no laboratory fee, these procedures are profitable!
What you will learn:
Dr Mandikos has presented programs at dental meetings throughout Australia and Southeast Asia and is in private practice limited to implant and prosthetic dentistry at Graceville in Brisbane.
n The current state of Dentine Bonding. Should you use 4th, 5th 6th or 7th Generation?
n Advances in composite resin chemistry n The effects of amalgams on teeth – how well do they last and what can they do to the tooth?
n How to place an indirect composite that you can readily make yourself without a lab fee.
n Cementation procedures for Inlays and Onlays (and crowns!) n Learn how to make composite dentistry a practical, enjoyable and profitable part of your practice, whilst providing an optimal standard of care for your patients.
Yes, I would like to attend: “Alternatives to Crowns” Full Day Hands-On Course
Name: ___________________________________________________________________________________ Address: ________________________________________________________________________________
(Restricted to 24): Includes Half/day lecture & Half/day hands on Workshop. Arrival Tea & Coffee, Morning Tea, Lunch, Afternoon Tea, Material & instruments
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Auckland Friday August 19th 2011 Stamford Plaza Auckland, 22-26 Albert Street, 1001 New Zealand Melbourne Friday July 1st 2011 Hilton on the Park Melbourne, 192 Wellington Parade Australia 3002 Number attending
Registration Time: 8.30 am Cost: $693.00 inc.GST Early Bird Price: $594.00 inclusive of GST Register Before July 25th 2011 to receive the Early Bird Price
(Kerr Composite Intro Kit included in the price, value $300.00)
For more information or bookings, contact Rachel Mcgready Rachel.Mcgready@sybrondental.com
KERR AUSTRALIA Unit 10, 112-118 Talavera Rd, North Ryde, NSW 2113 Phone Tollfree: 1800 643 603 Sydney Ph: (02) 8870 3000 • Fax: (02) 9870 7600
12 New Products New-release products from here and around the world Stainless Smile Now in exciting new packaging! Maestro Dental & Cosmetics have launched their new cosmetic style packaging for Stainless Smile tooth whitening take home kit. The take home kit is available in 2.5g syringes in 7.5%, 9.5% hydrogen peroxide and 10%, 16% and 22% carbamide peroxide. Stainless Smile is also available as an In-Office Kit 38% hydrogen peroxide. The Stainless Smile formula is patented and its triple mode of desensitizing enables a more comfortable whitening treatment by minimizing sensitivity. It contains hyaluronic acid that chemically seals the dentinal tubules, sodium fluoride that blocks the tubules by precipitation and potassium nitrate that causes the tubules to shrink, thus preventing the peroxide radicals from entering the pulpal chamber that cause sensitivity. Hyaluronic acidâ€™s ability to retain water assists in the rehydration of teeth and enhances the ability of the gel to maintain a high viscosity and stay in the tray during the procedure. Stainless Smile is available in take home kits, bulk packs and patient In-Office kits. Available from Maestro Dental & Cosmetics Pty Ltd, Tel: +61(0)3 9874 3993, www.maestrodental.com.au. ÂŁ
16-17 September 2011 Melbourne Exhibition Centre www.adx.org.au
Come along and see the latest innovations in dental products and services at ADX11 Melbourne, the nationâ€™s premier dental exhibition. Attendance is free and you can register online at
www.adx.org.au Australian Dental Industry Association Inc. t: 1300 943 094 f: 1300 943 794 e: firstname.lastname@example.org www.adia.org.au
Sensodyne iso-active foaming gel ®
Sensodyne iso-active is a modern format with new gel-to-foam technology that is designed for younger people with sensitive teeth • Penetrates hard-to-reach areas for a deeper clean1 • Delivers significantly more active agents (potassium and fluoride) for dispersion in the mouth2* • Provides all-round sensitivity protection, even in hard-to-reach areas3
Recommend Sensodyne iso-active to: ✔ The 1 in 3 people who suffer sensitivity 4 ✔ Sensitivity sufferers looking for an innovative delivery system ✔ Who are not currently treating their sensitive teeth
www.gskoralhealth.com.au References: 1. Gross RC et al. Presented at the General Session and Exhibition of the Pan European Federation of the International Association for Dental Research (PEF IADR) 2008, September 10–12. London, England. Poster 467. 2. Hall PJ et al. Presented at the General Session and Exhibition of the Pan European Federation of the International Association for Dental Research (PEF IADR) 2008, September 10–12. London, England. Poster 466. 3. Leight RS et al. J Clin Dent 2008;19:147–53. 4. Addy M. Int Dent J 2002;52:367–75. For the relief of sensitive teeth. Sensodyne® and iso-active® are registered trade marks of the GlaxoSmithKline group of companies. GSK0102/UC *Compared to a regular marketed toothpaste containing 5% potassium nitrate. Sensodyne® contains potassium nitrate.
Your world Infection control
Article Rachel Davis
Keep up the fight Infection control is vitally important, but it can get lost in the daily business of patients and practice. The ADA and ADIA are working together to keep it at the top of the agenda and tackle the issues head-on
entists work to a precarious schedule. Patient care and treatment has to be balanced with staff and practice management, all within the working day. Every dentist recognises the importance of infection control but it is a timeconsuming part of the day for every practice, and responsibility for it can sometimes fall on to the shoulders of more junior staff members. The Australian Dental Association (ADA) and the Australian Dental Industry Association (ADIA) are working together to promote excellence in infection control across the industry. Both organisations provide guidelines and formalised training for staff in contact with clinical practices. “Our course used is based on an English model and adapted to account for the differences in legal approaches used by the Australian and State/Territory Governments,” says Troy Williams, CEO of the ADIA. “Hundreds of customer relationship and sales staff have benefited from attendance of the courses provided.” However, sometimes basic procedures can suffer as a result of the real-world, on-the-ground challenges of running a busy practice. “One of the big problems with infection control is that it can often fall to more junior members of staff because time is money," says Terry McAuley of STEAM Consulting. “Instruments need to be cleaned and sterilised as soon as possible after each procedure so they can be used again later in the day. “As most dentists will be already seeing their next patient, this leaves no time for them to be involved in the infection control process. In some circumstances this may pressure other team members to finish cleaning and sterilising the instruments as quickly as they can so they can return to the next patient. Dentists may not realise how the lack of time 14 Bite
allocated to these activities may be impacting on the overall quality of their infection control program. “Cleaning the instruments is not a sexy job but it has to be done every day, over and over again, and most dentists are practising excellent infection control when caring directly for their clients, but leave responsibility for reprocessing of the instruments to other team members.” Re-processing is the key Dental practioners have a duty of care to their patients and a big part of that is controlling the risk of infection by ensuring procedures that are in place meet current Australian Standards
“Dentists may not realise how the lack of time allocated to these activities may be impacting on the overall quality of their infection control program." Terry McAuley of STEAM Consulting.
and comply with Australian Infection Prevention and Control Guidelines. Part of this should involve ensuring that staff are given sufficient time within their workday to undertake reprocessing procedures correctly and that they have been adequately trained for the job they are doing. According to McAuley, the most common problem she sees in dental practices is a lack of specific knowledge with respect to cleaning, disinfection and sterilisation procedures and the requirements of AS/NZS4815. As a result, staff may believe they are ‘doing the right thing’ because they were shown how to do things ‘on the job’ but could have inadvertently been shown procedures that are not
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in compliance with current infection control guidelines and the Australian Standards. “Dentists need to develop and implement work practices to ensure that compliance with infection control standards is achieved consistently,” says McAuley. “It’s really important that dental practices have in place reporting systems and protocols to monitor infection control. Having one dedicated and qualified person to oversee all reprocessing procedures will help to ensure standards stay as high as they need to, and may make a significant difference in infection control in everyday dental practice.” Promoting best practice Both the ADIA and ADA are active participants in the development of the Australian Standards which provide a broadly endorsed set of procedures in order to achieve appropriate levels of sterilisation, disinfection and cleanliness. “Representatives of member companies have been members of all of the major committees which promulgate, review and endorse Australian Standards covering both products, such as benchtop sterilisation devices, and processes, such as validation of cleaning and sterilising processes for reusable medical/dental devices in office based practices,” says ADIA's Troy Williams. “The ADIA contributes expertise and experience in the practical side of the technologies supplied by its members and works with the ADA expert panel to ensure that practice standards achieve world best practice levels in infection control. Relationships between and with dental clinicians and their staff provide a conduit for on-going promotion of best practice products and technologies. “The ADIA also actively engages with the Australian Government regulator, the Therapeutic Goods Administration (TGA),” continues Williams. “ADIA representatives actively participate in several formal committees of review within the auspices of the TGA. Working with the regulator, the ADIA promotes in a two-way discussion opportunities for improvement for the supply of ethical and highest quality products for use in clinical practices across Australia. Individual member companies are actively involved at multiple levels, in the promotion of research into infection control related issues.” £
The ADA Infection Control Basics *Aswithallwaterlineprotocols, achievingqualityresultsrequires adherencetothemanufacturer’s recommendedprocess.
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Regular hand hygiene before and after patient contact. Use, where appropriate, of personal protective barriers such as gloves, masks, eye protection and gowns. Use, where appropriate, of environmental barriers such as plastic coverings on chair headrests and difficult-to-clean areas such as triple syringe buttons. Wearing of appropriate protective equipment when cleaning instruments. Appropriate handling of contaminated waste. Appropriate handling of sharps. Appropriate reprocessing of reusable instruments. Effective environmental cleaning. Appropriate management of spills of potentially infectious matter. £
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Your world Cover story
Article Rob Johnson Main photograph Eamon Gallagher
When its critics said Dental Corporation was headed for a fall, the company turned around and announced millions of dollars in new funding, a major new partner, and a strategy for global growth
f all the various corporate dental groups, none have attracted the fear and loathing that Dental Corporation (DC) has. Perhaps that has something to do with its name. Other groups will go for friendlier monikers containing words like “smile” and “partner”, where DC went down the road of blandly descriptive—calling yourself “Dental Corporation” is just so corporate. It may be because of the company’s meteoric growth—since 2007 it has grown to 142 practices with annualised revenue of more than $250 million. But mainly, critics seemed incensed about the directors’ apparent ‘self-destruct’ button—a contract with partner dentists that required renegotiation after five years. The only way they could get away with that, the critics said, was a float on the stock market. And with financial markets depressed everywhere, there was no way for Dental Corporation to go but down. Now five years is nearly up, but instead of collapsing in a heap, Dental Corp is cashed up and growing strongly. Instead of an IPO on the stock market, Indian-based global healthcare provider Fortis has bought a majority stake in the company. And instead of losing practice principals who ‘mentally checked out’ when their contracts came up, the company has a strong succession program which has been embraced by dentists and students alike. Which isn’t to say all the initial plans proceeded smoothly. 18 Bite
“We raised money at the end of 2009 with the intention of doing a float last year,” explains Mark Evans, DC’s executive chairman and the company’s second-largest shareholder. “In the middle of last year the market was very depressed, so we embarked on a revision of that original plan and looked at the options for private equity and strategic investors.” The term ‘revision of the original plan’ is a restrained way of saying a major rethink. Evans and the other directors were happy with the model Dental Corp offered, which made a virtue of dentists retaining their independence. “We looked at going down the private equity route, and we found we were
“In the middle of last year the market was very depressed, so we embarked on a revision of that original plan and looked at the options for private equity and strategic investors.” Mark Evans, executive chairman, Dental Corporation
uncomfortable with some of the demands of private equity,” he explains. “The key to our model is the independence of our dentists, and the private equity firms we spoke to weren’t necessarily going to guarantee that.” Another option was to sit on their cash reserves and do nothing, but that wasn’t palatable for a number of reasons. “All our dentists are shareholders and they expected there’d be an opportunity to see a commercial value for their shares,” says Evans. “And it was important for us to deliver that.” Then just as a public float and private equity looked equally
Mark Evans, chairman and major shareholder in Dental Corporation: the global financial crisis forced a rethink of their plans for an IPO.
Cover story unlikely, a brand new possibility emerged—Fortis Global Healthcare Holdings (FGH). Fortis is owned by the family of Malvinder Mohan Singh and Shivinder Mohan Singh. The Singh family is also the owner of a majority stake in Fortis Healthcare Limited, which is separately listed and is a leading hospital operator in India. FGH, through its participation in various healthcare entities, has a presence in India, Hong Kong, Australia, New Zealand, Dubai and Mauritius. Dental Corporation Holdings Limited represents FGH’s third investment in five months and marks an important step in achieving the Singh family’s vision of creating a premier integrated healthcare delivery system in Asia and Australia. In November 2010, FGH completed the acquisition of Quality Healthcare Ltd, the largest primary healthcare network in Hong Kong. On 23 February 2010, FGH made its first entry into Singapore by acquiring an under-construction specialised
cancer hospital in the prime Adam Road precinct. According to Fortis chief executive officer Vishal Bali, the stake in Dental Corporation is a significant one in the Fortis plan for global expansion. “When we were a sufficient size around hospitals in India, we felt this was now time to go into the global area,” he says. “We narrowed down from the global scale to the Far East and Middle East. The reason being the growth around here in the next decade is proposed to be faster than the developed world. And many of the countries here will move from developing to developed, and to achieve that healthcare is one of the fastest growing sectors.” Originally they maintained an interest in the healthcare sector in the US and Europe, but interest quickly settled on Australia as a mature market with high capabilities and a mature system. “Also, one of the things we decided in our quest to be outside of India was we are not going to be limited as a hospital provider. We are going to create new verticals in which to operate,” Bali continues. He also describes the acquisitions in Hong Kong and Singapore as moving into ‘new verticals’, and adds that dentistry fell into this broad category. “Dentistry as a specialty is growing everywhere because as people grow more affluent and knowledgeable, they become more conscious of their oral hygiene,” he says. “So we believe it’s a good vertical—same 20 Bite
Top right: Vishal Bali, CEO of Fortis Global Healthcare, at the Dental Corporation conference this year; above right, Dr Ray Khouri, cofounder of DCH; above left, FGH chairman Malvinder Mohan Singh.
as cardio sciences. The Dental Corporation model is unique in having equity stake of doctors but is also about creating segment efficiency. We believe we stepped in at the right time. Our future ambition would be in taking the Dental Corporation model elsewhere. We’d look at how to scale up in other regions.”
ut while the corporate model of healthcare can make a lot of sense to shareholders, it doesn’t necessarily make sense for dentists. And something that’s good for, say, a cardiac specialist isn’t necessarily good for a prosthodontist. However, Vishal Bali says the broad needs of medical specialists are similar: “I think that clinicians would all have—no mater what their speciality—the same attitudes towards their practices, and all want to excel in their clinical activity. They want updates on technology and they want good outcomes for their patients, and in their practice they want good patient relationships to exist. We have been running hospitals in India for 10 years. We have 25 years of experience of delivery, so obviously we deal on
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Cover story a full-time basis, and we have 2500 doctors. We deal with a large practice of various specialties. Over the last 25 years we have understood the needs and guiding principals around clinical engagement and how we can be valuable and how we can deliver on needs from a management perspective. For me, whether it’s a surgeon or a dentist, their needs are the same. All of them are respected for the capabilities and competencies, and we help them do better.” Mark Evans adds: “We’re providing facilities and services in the operation of a practice. The package comes down to how we can add value to a dentist’s practice, and the key to that is maintaining their independence.” Fortis became interested in Dental Corp because its model for providing services and creating efficiencies is clearly valuable from a dentist’s perspective, says Bali. “For a dentist, if his entire back-end services domain is getting much more value unlocked, to that practice that means a lot. If it means it can save them three or four days a month, that’s a lot of savings.” However, Evans quickly qualifies that observation: “It’s not about saving so much as it’s about efficiency. Our back office runs at three per cent of turnover, and there’s no way an individual practice can match that. But it’s not a cost-cutting model—it’s about efficiency and assisting them to grow their business. It’s about introducing technology at a much lower cost. It’s an investment model. The challenge is that there is a limit to growth. The challenge for any practice is achieving scale. In the first year our back-end costs were 20 per cent of revenue, but they’ve dropped to three per cent with more practices on board.”
he final piece of the puzzle of Fortis and Dental Corp fitting together lay in their shared global ambitions. Mark Evans says DC had been eyeing off options for expansion in Asia before Fortis came along. The Fortis plan, Bali says, is simple: ”Our intention in every geography in which we operate is to grow and consolidate.” “Dentists the world over struggle with the same issue— growing a practice and delivering quality clinical outcomes while at the same time managing a complex small business,” says Mark Evans. “The key is utilisation of a facility, rather than the size of the facility. A 20-chair practice doesn’t necessarily get a better margin than a four-chair practice, unless you improve the utilisation of the individual surgeries.” Vishal Bali adds: “In India, while many hospitals offer dentistry, it’s always been a stand alone practice. I don’t know of anywhere where it comes under public domain (like Medicare) because it’s always been split between medical and cosmetic. And that’s why they don’t cover it. But that’s where the opportunity lies. This is a science which is growing— whether in a hospital or an outpatient setting, the consumption levels are growing across the world. And it’s driven by a self-consumption model. What is equally important is if one can create a more corporate structure around dentistry, then it will be guided by the same management principals as you’d see in the larger hospitals. Even in India we see more hospitals are providing dentistry services, and patients believe they’re getting a better service. Moving forward, this will be more outpatient based. The model will really grow in the future.” Bite 23
Your business Technology
Article Andy Kollmorgen
Master of his domain The difference between the latest imaging technology and what’s gone before is greater than a quantum leap, says Dr Nathaniel Goldstein
r Nataniel Goldstein admits he’s having a hard time convincing his fellow practitioners that a new software tool will let them create as many as eight potential treatment plans in about five minutes. Compared to the 15 minutes or so it takes dentists to develop a single plan using the current generation of software, it’s a massive improvement, Dr Goldstein says. In his view the term “quantum leap” is not quite strong enough. The fact that he’s connected to the software company behind the technology, DentalMaster, may be part of the credibility problem. But it’s probably not the main reason some of his colleagues are taking a wait-and-see approach. Goldstein thinks they’re probably confusing the new product with the previous generation of treatment plan software, which he says some companies ended up trying to give away. “Those products never really met the expectations of the companies that made them, or the dentists who tried them. And for good reason. They were really just ready-made animations that weren’t enough of an improvement over existing methods and didn’t let you create individualised plans.” Goldstein, a general dentist based near Byron Bay in NSW, unveiled the “revolutionary” new DentalMaster 3D imaging 24 Bite
technology for Australian dentists at the ADA’s 34th Australian Dental Congress in Brisbane at the end of March this year. He says the launch signalled a new era of faster and better-targeted case acceptance. “This is the first and only software that creates a treatment plan in 3D animation. It creates a range of specific restorative options for a specific patient. You can show your patient what the options are, whether it’s partial dentures, a crown or no crown, implants or no implants—the whole range of possible solutions for the specific case. No other software has the ability to even think about doing that.” Goldstein is apparently not the only believer. A “partners and customers” list features an international mix of well-established oral health practitioners and academics. The names include Dr Ronald Goldstein (no relation), a clinical professor of oral rehabilitation at the Medical College of Georgia School of Dentistry (USA) and a well-travelled lecturer; Professor Irwin Weiss, head of the department of prosthodontics at Hebrew University’s Hadassah School of Dental Medicine; and Dr Adi Palti, a member of the board of directors of the International Congress of Oral Implantologists and a clinical professor for implantology at Boston University. The company says it has working relationships with organisations ranging from Colgate to 3M ESPE Dental Products to the International Congress of Oral Implantologists.
The difference between previous imaging software and the possibilities of the DentalMaster is stark, as shown by these screen shots.
Your business Technology
If DentalMaster is a game-changer, making the case to practitioners will likely take some doing. Goldstein knows first-hand that a reluctance to embrace new technology comes with the territory. “Dentists are very stubborn people. It’s very difficult to get new products into practices. We kept this in mind during the design process. We knew dentists were not going to go into something that’s too complicated or takes too much time.” Mr Leslie Schneider of Australian Dental Supplies appreciates Goldstein’s challenge. He points out that DentalMaster is “a totally different package than SNAP”, the cosmetic simulation software he imports from the US, and has been well received by practices that have tried it. But he suspects it will face the usual obstacles to the uptake of new technologies. “Dentists are so rushed these days that many don’t think they have the time to properly learn how to use software,” Schneider says. “I think some education in this area would be great for the management of any practice, and for improving profitability. Dentists will discover that a little bit of training can save them a lot of time.” The DentalMaster design evolved over a three-year period at the company’s labs in Israel, Goldstein’s home country. Userfriendliness was a priority—and is a big part of the sales pitch. Goldstein says DentalMaster’s claim of a three-minute learning curve understates the case. He maintains most dentists will get a handle on it faster than that. And the software—which is avail-
able in 10 languages and 20 countries—is designed to integrate with existing practice management software and can covert visual information to text, Goldstein points out.
he breakthrough according to DentalMaster is a “revolutionary algorithm” that allows a dentist “to create most of the possible treatments plans in real interactive 3D and adapt the best solution for his patient”. The company says previous software packages merely offer pre-set animations based on a range of patient scenarios, not an exact patient match. 3D scanning has historically had difficulty capturing shiny or mirroring objects, but Goldstein says advances in the field have meant successively clearer and sharper images. Earlier generations of software also didn’t do enough to prevent the frequent treatment plan-related legal troubles dentists face, Goldstein says, which is why avoiding litigation is also part of the DentalMaster marketing message. “There have been a number of lawsuits against dentists because patients have claimed they weren’t given enough treatment options. This software offers assurance that the dentist has shown the patient all of the treatment options available. The patient can see for themselves.” Dental software as a whole has gotten mixed reviews from the experts. A study conducted out of Ireland’s Waterford
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Dr Goldstein at the DentalMaster stand in Brisbane.
Regional Hospital and published in 2008 concludes “there are limitations” with modelling. The study, “A comparison of plaster, digital and reconstructed study model accuracy”, says that in the case of software “any new virtual surface image is created from a series of discrete data points. It is not created from a continuous stream of data relating to the original object. This means that computer software has to be used to recreate a
possible best fit, virtual surface from the data obtained.” The finding would seem to back up Goldstein’s contention that earlier computer models have leaned towards a pre-set approach and overlooked the fact that no two sets of teeth and jaws are alike. But the results of a 2007 study at the University of Aarhus’s School of Dentistry in Denmark suggests computer-generated images offer some important advantages over plaster models, particularly since physical models can undergo slight changes as they’re shipped between dentists and labs. The experiment involved comparing measurements on plaster casts taken with a digital calliper with measurements of digital models of the same casts taken with the software’s virtual measuring tool following a three to five day shipping procedure. “Virtual measurements performed on digital models display less variability than the corresponding measurements performed with a calliper on the actual models,” the study concluded. Schneider says he doubts most dentists take the time or have the resources to review the track record of software products, but that hasn’t stopped the practice management software industry from growing rapidly. Whether or not DentalMaster fulfils its promise, Schneider says his long experience as an importer and supplier of dental products has taught him that patients respond to visual aids. “The easiest way to get them over the line is to show them.” £
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Your business Efficiency
The most efficient dental practice ever: no dentists, no patients.
Critical mass Is bigger better, or best? How big can a practice get before it runs out of efficiencies? Article Sharon Aris
ractice efficiency is the core mantra of much dental management wisdom. The problem is, when it comes to describing the most efficient practice models, there isn’t a great deal of consensus—indeed experts don’t even agree on the best way to measure it. What is clear, however, is that while there are some common elements in efficient practices, no one size fits all. Also the questions isn’t answered by numbers alone, but also situation and personality of the dentists involved. For Graham Middleton, director at Synstrat, the bottom line of practice efficiency is simple at least. “The most profitable dentists are in a small practice,” he states. “Either solo dentists, two solo dentists in association or two solo dentists in association with one employed dentist. Above that is another layer of administration that eats away at profits.” While he agrees there are always exceptions, Middleton maintains that once you get four or five partners and assistants, the big administrative overheads and support staff costs are way above the norm. But Dr Brad Wright, clinical operations manager at the
School of Dentistry, University of Queensland, isn’t so sure. He says there really isn’t one ideal size, and the most efficient size for any practice depends on a range of variables—a key one being the question of control and dentist personality. Which is to say, how much is a dentist willing to delegate to other people or how many partners or associates they’re willing to work with? So while he agrees there are efficiencies in the ‘two dentists, a hygenist and receptionist model’ and “over that size you can’t control staff and you need to deal with span-of-control issues”, he says other variables are just
Take a chair… One recent survey in California found patients preferred dentists whose practices have more chairs and who specialise in restorations. Patients were also more likely to like dentists if the dentist had placed the original restoration, which also suggests they still prefer a personal relationship and continuity of care. (International Association of Dental Research (IADR) 89th General Session and Exhibition: Abstract 2377. Presented March 18, 2011).
Efficiency as important. “In terms of fixed costs, that means looking at the floor area—the more providers you have per square metre affects that.” This means things like surgery design can play a significant role, particularly in areas with high retail costs. Then there are the variable costs which include materials, dental laboratory and wages for staff which must all in turn be worked out in relation to demand from the market. “It’s Dr Brad Wright (above) says determining efficiency is complex. scaleability and scope of practice,” he says, which depends on factors like the location and type of other practices nearby. The numbers certainly are important to Mark Evans, chairman of Dental Corporation. Dental Corp partners with and acquires dental practices, so knowing what to measure is core business. And the number for Dental Corp is $1,000,000 turnover, minimum. “If turnover drops below that the margin drops rapidly,” he says. Evans relates turnover to the number of chairs, noting not many solo practices can make that much revenue. Some two- to three-person practices will, but on average it is the four- or five-chair practices that are in the game. Ultimately, he says, it comes down to maximising efficiencies in relation to fixed costs. “In a threeor four-chair practice there is high utilisation of facilities. A 10-chair practice often doesn’t have that high utilisation of chairs. The common evidence that margins drop as you get bigger isn’t correct, but margins beyond a certain size are incremental.” He adds, “At the end of the day, the majority of costs is chairside staff—the dentist and dental assistant—so a key factor in profitability is managing those staff costs. Next is maximising the utilisation of chairs.” The last, he says, is efficiency of treatment, which he adds he isn’t qualified to comment on. So for a dentist contemplating an upgrade, how do you decide your best fit? For Wright, a rough rule of thumb is, “If you have two weeks’ worth of appointments in your books, you need to expand—you have enough for another practitioner.” And for every additional two weeks, you have enough for each additional dentist. “There is also a 25 to 50 per cent increase in production and efficiency in a two dentalassistant per provider once a certain capacity is met.” As for where to go for advice, Wright suggests paying a consultant or seeking out someone with a similar practice to what you’re interested in and asking them to talk numbers. Do your research, he says: what are the hours they are working, what holidays do they take? “It’s not innate. Learn it and do it or you don’t do it it all.” Middleton for his part says it’s the first step that is the 30 Bite
A hard day’s night… Hours worked per year by type of practice SELF EMPLOYED Per Week
From Mervat Halaka ‘An Overview of the Australian Dental Practice Surveys’ (1998) taken from dental practice survey data administered by the ADA
Four is the magic number In a US study on whether larger practices were more efficient, Lipscomb & Douglass (1986) found controlling for fees and service-mix differences, cost-efficiency does increase with practice size over the range from solo to fourdentist practices.
highest. “The biggest jump is to go from one to two dentists. It’s a 100 per cent jump.” Here, he adds, the question of personality certainly comes into it. “Some dentists are not good at working with others, but are very good clinicians. Others like a team approach.” This flows over into factors like marketing skills. “A large amount of a dentist’s ability to project a chairside manner. All professionals have a personal relationship with their clients.” This is important, Middleton says, when introducing growth to the practice, because if the original dentist isn’t there but they have a good relationship with their patients, the patients are more likely to accept the recommendation to see the new person. It’s a skill, Middleton also notes, is fundamental in a receptionist. Most significantly, Middleton believes, is the notion that the current small practice model remains the best. “Despite the propaganda by the corporates, dentistry in Australia is going to remain one of the last great cottage industries. In 20 years’ or 50 years’ time, the majority of dentistry will still be provided by dentists in small practices.”
Your business Design
The great appeal of building your pwn practice from scratch is having a blank slate with which to work.
Building on success Building your own dental practice can be a costly, yet rewarding, exercise Article Amanda Lohan
efore taking the leap into building your own surgery, it is vital you consider the key risks involved so you don’t end up building castles in the air. The benefits of building rather than leasing a pre-existing building are in some ways obvious. Sam Koranis, managing director of specialist dental surgery design and construction company Medifit says, “You can control your own destiny and not be at the mercy of a landlord who will increase the rent for the duration of the lease. Because you are starting with a blank canvas, you don’t have the problems associated with badly built old homes that need work to make them comply to the current Building Codes of Australia (BCA) and Australian Standards.” Noelene Cason, managing director of Design N Dental, specialising in the interior design and fit out of dental practices, says that building your own practice means “you can do exactly what you want as far as the ergonomics, plumbing and electrical requirements are concerned”. The flow of the whole practice can be planned from the ground up, so a dentist can cater “for lots of natural light throughout the
building rather than relying on what is already there”. However, as with any major investment, the risks need to be weighed alongside the benefits. What are the risks? Applicable building codes and standards are extensive, and partnering with a specialist firm is one way of avoiding some of the costly pitfalls associated with council approvals. For
“You can do exactly what you want as far as the ergonomics, plumbing and electrical requirements are concerned.” Noelene Cason, managing director, Design N Dental
example, Sam Koranis notes that current standards may require five car bays per practitioner; therefore a two-practitioner dental practice will require 10 car bays. If this is not possible, a traffic engineer will need to be appointed to report on available public transport facilities and on road parking. All of this costs time and money. To protect yourself, Koranis says Bite 31
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Design you need to make a “subject to” offer with the vendor before you purchase the land, to ensure council will approve the application for its intended use. Australian Standards also apply to the interior fit-out. Cason notes that dentistry is a very different service to most, even to those in the health area. “Radiation, electrical and water board compliances all need to be factored in to the building design,” she says. “If they’re not done to the Australian Standard, it can be a costly exercise to you and to staff.” OHS requirements are another area for concern. “You could end up receiving complaints from staff if they do not have things at their fingertips and are not seated correctly to move within their working sphere. This can be costly in terms of time as well as to posture,” says Cason.
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REVIEWERS WANTED We want you to write for Bite! Every issue we’re asking dentists to review their tools— telling us in a couple of paragraphs what they love about them and what they don’t like. Check out the reviews starting on page 43. There’s only two rules—you have to be a practicing dentist, and it has to be something you use. The whole idea is to start a conversation between our readers. We don’t want to tell you what to buy. We want your peers—the people actually using the equipment—to guide you to what’s good and what isn’t. If you’d like to write a review, email Rob Johnson at email@example.com, and he’ll tell you what’s involved. 32 Bite
Make sure all work is done to comply with Australian Standards or you and your staff will pay down the track.
Taking the first step Both Koranis and Cason say that the first step in constructing a dental practice is to establish a comprehensive brief. Koranis says the next step is to draw up a budget: “A budget can be forecast by an Opinion of Probable Cost (OPC) by Medifit once a brief is established. You then need to seek the advice of your accountant to ensure you have the financial capacity to undertake the project.” Cason says that to know what your requirements are, you need to plan for the foreseeable future. Factors to consider may include how many staff you are looking to have, the location and surrounding area, and the building’s aspect. Koranis says that when choosing a site for your new practice, the bottom line is the size and suitability of the block. Importantly, since most dentists who choose to undertake ground-up projects are already established in an area, the new site should be close—around two kilometres from the existing practice—to ensure the perpetuation of the client base. Other factors to consider are the ease of access to the site, and whether the site is level (a flat site is usually preferable). Cason agrees that ease of access to clients is an important factor to consider and adds that this can be supported by a ground-floor position. Viewing the site from an interior design perspective, Cason advises her clients to take advantage of the natural aspects surrounding the building. “Natural light plays a huge part because you are spending a large part
Top tips for building your dental practice from scratch Medifit’s Top Five Tips: 1. Prepare a firm budget. 2. Do your homework into the location and council requirements. 3. Ensure that your accountant and financier support you. 4. Choose a reputable partner that understands the business of dentistry. 5. Be prepared to take a minimum of 12 and up to 24 months to complete design and construction.
Design N Dental’s Top Five Tips: 1. Plan for the future of your business, and build accordingly. 2. Start small and build up. For example, have the rooms laid out but install cabinetry and equipment as you grow. 3. Build a facility that resonates with the area and existing aspects so that you don’t “stand out like a sore thumb”. 4. Plan so that technological advancements can be easily incorporated. 5. Ensure you create a pleasant environment for all to work in.
of your day inside.” Aside from making the practice more inviting for clients, incorporating natural light, or a pleasant view, can contribute to employee satisfaction. The key to success Success, according to Koranis, comes to those who understand their own business, and who can provide a designer with a clear and comprehensive brief incorporating cost/benefit analysis. “A good architect and interior designer will seek from the client some definitive budget based on real figures, not just based on someone’s dream,” says Koranis. Since dentists are generally time-poor, most will seek some sort of professional advice. Koranis says that the choice you make, in terms of who to partner with, can leave you with more time chairside, and ensure that you are not spending your time training up someone who does not understand the dental industry, or your business. According to Cason, it is the finishing touches that spell success. “It is well worth spending the money on waiting room furniture and finishing touches up-front. Introducing a harmonious colour palette is essential. Warm neutral tones can create an ambient mood—perfect for both patients and staff. There is a lot of psychology in colour—if you don’t have an appropriate colour scheme, it can be very confronting. “Gone are the days where you can keep a dental practice for 30 to 40 years with the same look. It is about what people feel. Emotion is very human and that is how decisions are made, especially with families... You need to be smart and well presented in healthcare.”
BEST PRACTICE As dental fitout specialists, best practice is something we take very seriously. Whether you require a design and build from the ground up or a renovation of your existing surgery, Medifit deliver inspired solutions that work for you. We create the operating environment that your patients and staff deserve. Call us today on (08) 9328 8349 or visit our website at www.medifitonline.com for more information.
(08) 9328 8349 www.medifitonline.com e: firstname.lastname@example.org
23/02/11 1:29 PM
Infection control product guide
Infection control is everyone’s job Who is responsible for overseeing infection control procedures in your practice?
ast year the Dental Board of Australia released a consultation paper on codes and guidelines in the lead up to national registration in July. The consultation paper looked in detail at various topics that have been of interest to the profession in the lead up to the big date, including guidelines on CPD, advertising, mandatory notification and infection control. However, while the other subjects were covered comprehensively,
the section on infection control simply referred readers back to the current standards—AS/ NZS 4815 and 4187 (the current editions of each), national and ADA guidelines, and suggested they have a manual for protocols and procedures. An added checklist—possibly for hanging up somewhere near the steri room— rounded the chapter out. But while a checklist is handy, is it enough? The issue is complicated by the way
infection control works in practice in dental surgeries. In theory, it would be perfect if every practice had a dedicated staff member whose job it is to run the steri room. By doing this, it would recognise that running the steri room is a specialised task. Unfortunately, this is often prohibitive for cashstrapped public clinics, or small private clinics. In reality, dental assistants are often looking after the steri room as one of their many tasks,
and it is frequently the responsibility of several staff members. The reality is there is a genuine demand for training of staff members (who are frequently trained by predecessors), and for practice manuals. The situation also demands you have equipment that is up-todate and easy to use. That’s why Bite has produced this month’s Infection Control Product Guide. Contact details for advertisers are at the end of each article. £
Practical infection control training for your dental practice.
Does your practice meet its obligations?
Davine Intervention provides training services to dental practices in the areas of quality assurance and infection control
Ensure your Dental Practice meets the Government guidelines for infection control with the support of experienced training provider.
Ask about our Practice Manual
We offer a practical “hands on” program for dentists and staff covering all facets of infection control. The half-day workshop is conducted at your practice and will provide practitioners with CPD hours.
Why choose us? 1. Industry experience: we have 35 years of dental experience. 2. Specialist advice: we work in the dental industry only 3. Practical training: we train at your practice, on your terms. This training program exceeds regulatory standards, safeguards patients and staff and creates “real” opportunities for productivity improvements and costs savings. mobile 0415 949 001 fax (03) 9332 3484
visit www.davineintervention.com.au email email@example.com
Davineintervention excellence in dental services
14/04/11 12:31 PM
Meeting your obligations under the latest standards and Infection Control Guidelines. The Dental Board of Australia registration standard requires that practitioners must complete a minimum of 60 CPD activities over 3 years. I am able to offer you CPD hours with this training. The Australian and New Zealand standards (AS/NZS 4815:2006) clearly state the requirement for dental practices to provide appropriate education and training for staff responsible for instruments. Since 2005, I have worked closely with the Dental Practice Board of Victoria assisting Practices meet the standards through accredited training programs. I have worked in the dental industry for over 35 years, hence providing me with an in-depth understanding of dental practice settings and procedures. For more details regarding our services please contact us mobile 0415 949 001 or fax (03) 9332 3484 visit www.davineintervention.com.au email firstname.lastname@example.org £
Infection control product guide New Lisa automatic adjusts to load size
A-dec has raised the bar in infection control with the release of the latest Lisa Fully Automatic steriliser that automatically determines the optimum cycle duration according to the load size
he original Lisa sterilizer was the first to offer exclusive Type B cycles, offering ‘hospital grade’ sterilisation of instruments to protect patients and clinical staff. Lisa remains at the forefront of modern dentistry and offers a fully comprehensive sterilisation solution to meet every sterilisation and instrument tracking need. The latest Lisa Fully Automatic features exclusive ‘made-to-measure’ cycles, that automatically adapt the cycle duration to the mass of the load. This saves up to 15 to 25 minutes for these smaller loads time, while ensuring large loads are properly sterilised. The new Lisa Fully Automatic also significantly shortens drying and reduces energy use thanks to the patented ECO-Dry system. By reducing the cycle duration according to the load requirements, dental instruments are less exposed to heat, which increases their lifespan. In addition, the Lisa is equipped with an air detection system that confirms the full exposure of instruments to saturated steam, even with hollow loads. The result is automatically validated cycle performance and extra safety against crossinfection. The very latest Lisa Fully Automatic also features
The latest Lisa Fully Automatic steriliser is smarter and easier to use than ever.
stainless steel key internal components for years of trouble-free operation. Instrument tracking made easy In these days of strict infection control protocols, steriliser room staff can be relieved of much of the burden of instrument tracking with the latest Lisa Fully Automatic steriliser. The W&H Lisa was a pioneer of automated instrument tracking with the advent of inbuilt data logging linked to the W&H LisaSafe barcode printer. This captures steriliser serial number, cycle (batch) number, sterilisation date and load expiry date. This data-logging feature has been further enhanced by the Lisa’s
Fully Automatic’s onboard computer, which now manages the whole sterilisation process. Everything is accessible from Lisa’s interactive touchscreen, without the need of special software or an extra computer. At the end of the cycle, the user can release the load for use by entering their unique password directly on the touch-screen. For added convenience, the LisaSafe barcode label printer provides a tracking system for individual dental instrument pouches. To ensure integrity of sterilisation protocols, the labels are only printed if the cycle is successfully completed. The corresponding sterilisation cycle can be easily linked to the patient file using a barcode scanner to import
the batch details or by manually noting down the cycle number. Not surprisingly, Lisa is the steriliser of choice of private and public dental health professionals around the world for its high standards, ease of use and low running costs. When looking for a new autoclave check that it has: Exclusive Type B cycles Air detection: automatic cycle validation On-board data logging Convenient delay start option ECO Dry system Integrated traceability options. W&H Lisa sterilisers are available through A-dec dealers around Australia . Visit: www.a-dec.com.au for your nearest dealer.
Infection control product guide The totally integrated solution edical Equipment Services has been trading for over 65 years and provides Equipment and Service to the Health industry as a whole. Amongst our huge range of Medical and Dental Equipment, MES specialises in Bench Top Sterilisers and offers a range from 1ltr, 8ltr, 12ltr, 17ltr, 22ltr and 45ltr units to suit your requirements. B Class, B & S Class, S Class and N Class units are all available on request. With over 1000 units in
the marketplace, MES prides itself on service, back-up and support with accredited service agents in every state of Australia and NZ. MES sterilisers comply to Australian Standards, have TGA registration and have also passed the workplace safety test certification. Please visit our website www.mesaustralia.com.au for further information, or contact us direct 03 9331 6796. ÂŁ Medical Equipment Services supply equipment such as the cutting-edge Runyes 17ltr Bench Top Steriliser
Infection control product guide
Keeping up standards hen Dr Frank Papadopoulos was recently asked about his thoughts on the new guidelines and how dental4windows will help practices comply with the new National Record Keeping Standards, the director of Centaur Software answered by saying, “We understand how seriously most dental practitioners take the issue of infection control within their practice so this can only be a good thing. Dr Papadopoulos passionately points out that the dental4windows practice
management system provides all the information the new guidelines require at the click of a mouse. The types of information now required that dental4windows will already captures are Patient ID details Complete medical history inc. allergies and drug reactions Referral Source and accompanying correspondence Audit Trail of Record Changes or Additions Treatment Plan / Quotes All medicines and therapeutic agents used and prescribed Advice provided to Patient plus all the specific appoint-
ment details. Using the Sterilisation module, you can also track all instruments used via labelled steri packs. Dental4windows carries all the information that any practice needs to hold on patients and procedures to comply with Australia’s new National Record Keeping Standards. Dental4windows also now boasts direct interfaces with most of the latest Digital x-ray Imaging devices along with OPG’s, intra-oral cameras and phosphor plate systems. This is all done through our digital imaging module, Media Suite. Media Suite is the latest technology available in Australia
for dentists to enhance and improve diagnosis of patient oral conditions. The need to retain in particular high resolution digital Radiographs within patient files and against patient charts also falls under these new Record Keeping Standards. I think any practice running 15 hours or more per week is just doing themselves a disservice not using a practice management system and now with these new National Record Keeping Standards applied to every practice across the country now is the time to make the transition into a simpler and more practical way to run a practice. £
Including the important Sterilisation Tracking module Call us on 1300 855 966 for a demonstration Bite 37
Infection control product guide Celitron Sting Premium & Cominox B Class Sterilisers Cominox B class sterilisers 6/18/24L The SterilClave® range of products is the result of over twenty years of experience in the field of sterilisation which not only respond to the current requirements of the medical field, but exceed them. All sterilisable instruments and materials in a medical, dental or health environment can be processed with any B Class Cominox Autoclave, be it solid, porous, wrapped or unwrapped. Wake-up function for unattended early-bird cycle starts Large LCD screen with simple four button functionality Vacuum assisted Six predefined cycles plus 2 test cycles & special user-defined cycle Minimum N cycle time: 15 minutes Minimum B cycle: 23 minutes (excludes drying time) Serial port for data transmission Extremely reliable One piece chamber with 10 year chamber guarantee 3 wide stainless steel trays Unit Dimensions: 445x390x640mm Celitron Sting Premium 24L This fully automatic, high-speed pre-post vacuum steam steriliser is designed for sterilisation of wrapped materials, hollow instruments and porous
loads in hospitals, private clinics and dental offices. The unit is equipped with a built-in mini steam generator and a powerful vacuum pump for super fast cycle times. The 24 litre Sting11B Premium is modern, reliable and incorporates high-tech features based on more than 30 years experience in the sterilisation field. Colour LCD touch display One stainless steel tray rack 4 x large stainless steel trays One tray holder Built in steam generator Vacuum assisted Impact printer USB SD card reader & SD card Log viewer software PC based cycle recording software Door opens and closes automatically Minimum N cycle time: 15 minutes Minimum B cycle time: 19 minutes (excludes drying time) Unit dimensions: 534x475x609mm Sonica ultrasonic cleaners Using ultrasonic energy and a process known as cavitation, ultrasonic cleaning is the most effective way of deep cleaning difficult to reach and complex shaped items. The new range of SONICA S3 are equipped with state-of-the-art high power piezoelectric transducers and ultrasonic generators
Cominox B Class Steriliser 18 Litre
Celitron Sting Premium 24 Litre
Celitron AZTECA 90 Litre
which incorporate the innovative SweepSystem oscillation technology for a truly amazing result. Heart-On AED (FREE with every b class benchtop steriliser) Most Dental Practices in the U.S. are required by law to have an Automated External Defibrillator (AED) and with good reason. This device
could save your patients life. M9 patient monitor Latest recommendations suggest Dental practices use End-Tidal CO2 (capnography) equipped Patient Monitors to rapidly detect patient desaturations during sedation. The M9 offers an extremely cost effective solution for these requirements.
Ph: 1300 009 663 Fax: 1300 099 300 www.zonemedical.com.au
visit www.zonemedical.com.au for stock clearance specials
ETO!R* E FDER LA IL BR FI
ETO!R* E FDER LA IL BR FI Assem
COMINOX B 6L, 18L & 24L 6 LITRE from
+ $799.50 GST
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bled in Australia
STING B PREMIUM 24L STING PREMIUM WET RING
$11,995 + $1,299.50 GST
STING PREMIUM DRY VAC
$10,995 + $1,199.50 GST
SONICA ULTRASONIC CLEANERS
$19,950 $29,950 $34,950 + $1,995 GST
+ $2,995 GST
2400 4.5Ltr - 300x150x100 Tank
$1,500 + GST
$1,670 + GST
$1,890 + GST
$2,115 + GST
+ $3,495 GST
3200 6Ltr - 300x240x100 Tank
$1,725 + GST
$1,835 + GST
$2,170 + GST
$2,395 + GST
3200L 6Ltr Long - 500x140x100 Tank
$1,995 + GST
$2,225 + GST
$2,490 + GST
$2,780 + GST
3300 9.5Ltr - 300x240x150 Tank
$2,560 + GST
$2,780 + GST
$2,950 + GST
$3,225 + GST
4300 18Ltr - 330x300x200 Tank
$2,990 + GST
$3,170 + GST
$3,490 + GST
$3,670 + GST
5300 28Ltr - 500x300x150 Tank
$3,560 + GST
$3,780 + GST
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M9A MULTI-PARAMETER PATIENT MONITOR (ICU/OR) 12.1"/10.4" colour TFT display with 13 waveforms Pacemaker detection and defibrillation protection SD card slot for extended storage data USB interface and data safety storage in case of power loss Large font display OxyCRG available to judge the respiration and circulation function for neonates Arryhythmia and S-T segment analysis SpO2 pulse-tone modulation (pitch Tone) 96 hours of graphical and tabular trends of all parameters Built in rechargeable Li-ion battery Nurse call function and bidirectional communication with MFM-CMS central station Flexible mounting solutions for ICU/Patient Room/ In-House transport Standard parameters: 5-lead ECG, EDAN SpO2, RESP, NIBP, 2-TEMP, PR
Optional: • Anaesthesia Multi-Gas/O2, Thermal Recorder, WLAN accessory, 12-lead ECG, Nellcor-SpO2, Masimo-SpO2 (to be released), 2-IBP, C.O, Respironics CO2 (for intubation and non-intubation application) • Upgrade with EtCo2 - $2,950 • M9/21.1” colour TFT display - $4,164
• • • • • • • • • • • • •
Purchase any 6,18 or 24 Litre B Class Steriliser and receive a FREE Automated External Defibrillator.* RRP $2,495
WITH ANY B CLASS
CELITRON AZTECA 75/90/150L
! E E FMOR BILE STAND $4,399 GST FREE!
*Only valid for B Class 6,18 & 24L Sterilisers purchased from Zone Medical between 1/4/2011 - 30/6/2011. Prices quoted INCLUDE GST (where applicable) and EXCLUDE FREIGHT. All prices are subject to change without notice. E&OE.
Infection control product guide Advanced sterilisation made safe and simple From the infallible self-checking control and monitoring system to the intuitive one-touch operation and reassuringly simple door mechanism, every detail of the latest SES autoclave has been designed to meet the requirements of today’s demanding clinical environment.
1. Unique, self-checking cycle verification Dual systems for independent cycle control and monitoring enable the SES autoclave to constantly check the performance parameters of every cycle, detecting any discrepancies, interrupting the cycle immediately. Independent air detection tests vacuum integrity, ensuring each cycle has performed to specification, time after time. 2. Advanced water system An easyclean, twin reservoir system, cleverly ensures clean steam is always delivered. The system removes the risk of the fresh water reservoir being contaminated. Less than 350ml of water is used for each cycle, making the unit fast, efficient and economical. Additionally, a direct drain option (no manual emptying of the waste reservoir) is available. 3. Delivering performance when it really counts The latest SES Autoclave can perform an average of 18 B type vacuum cycles or 32 N type nonvacuum cycles can be performed daily. It also offers intelligent furniture configurations—standard
The latest SES Autoclave uses less than 350ml of water for each cycle, making the unit fast, efficient and economical.
and examination size trays or HandsFree instrument Transfer (HFiT) cassettes provide an intuitive, flexible approach. Up to 15 individual ‘examination’ tray sets can be processed every cycle. More instruments per cycle equals fewer cycles which equals better performance which equals cost savings. 4. One-touch simplicity This elegant, one button/one touch design removes any risk of the user selecting an incorrect cycle for the type of
load being processed. A safe, simple approach, helping meet guideline requirements. 5. Cycle secure system PIN protection for advanced cycle options can be activated to provide additional security ensuring only those cycles that are needed are available to the user. Additional cycles are also accessible by the appropriately trained manager in the surgery, helping prevent accidental misuse by busy surgery personnel.
6. Direct data download technology Data for every cycle is recorded and stored for up to 24 months on internal ROM memory. Stored data can be downloaded direct to a PC or laptop as required. DDD application software is included as standard with all SES autoclaves. Integral thermal printer is available as an otion—fits neatly into the autoclave, so no separate, expensive modules are required. To find out more information, call (02) 8865 0300 or go online to www.williamgreen.info
SES autoclave THERE ARE STILL SOME THINGS IN LIFE YOU CAN TRULY RELY ON Like Eschmannâ€™s new and innovative SES Autoclave. In terms of quality and reliability, Eschmann autoclaves are acknowledged as second to none the very best in medical engineering technology for over 100 years. Through a well-established, trusted relationship with dentists, general practitioners and leading healthcare professionals, we have maintained an unrivalled record of development and innovation resulting in a world class and constantly expanding range. Whilst building on its past heritage and reputation, the new SES Autoclave incorporates the latest innovations and technology allowing you to meet all current and future guidelines. The new SES Autoclave provides the market leading performance and total confidence that only a world leader in instrument sterilization can offer.
Ph 1300 363 830
Your tools Reviews
The Cerec Bluecam that you’ll fight for; the Sapphire that sniffs out cancer; the Sirocam intraoral camera, and more are under review this month
Tools of the trade Sapphire Plus Lesion Detection by Dr Vicky Ho, Advanced Dental Artistry, Mosman Park, WA
Cerec Bluecam by Dr Justin Currie, Tindale Dental, Penrith, NSW We purchased the new Cerec Bluecam and fast mill in February last year. This machine is such impressive new technology that it certainly has an element of the ‘wow’ factor. Patients love to feel they are at the cutting edge and—with no pun intended—they are. What’s good about it I had no previous experience with Cerec but found this to be very user-friendly. I am not particularly computer literate but the programming was extremely easy to manipulate. It has revolutionised the way I practise as it allows me to give a patient a one-day solution. The Cerec system gives me better control and the ability to save much more tooth structure than I could previously. Teeth that would have required a crown can now be repaired with a Cerec inlay. It’s great for large composite fillings and works beautifully with the stronger E. max porcelain. There is six of us at our practice and our success rate is extremely high. There have been no concerns about breakages. What’s not so good It requires perseverance to learn and some dentists might find it takes longer to grasp how the program works. It’s an intuitive program but it assumes a level of knowledge when you start. The learning curve is steep but once you hit the plateau—and you hit the plateau relatively quickly— you get consistently good results. And, of course, with six of us fighting over the machine, sometimes you have to wait your turn. Where did you get it Sirona £
The Sapphire Plus is an instrument that screens for oral cancer and identifies early signs of dysplasia. Since the death rate from oral cancer is higher than that of cervical cancer, Hodgkin’s lymphoma, endocrine system cancer and melanoma, I screen every patient. It is a vital part of the examination. What’s good about it A lot of cancerous cells are underneath the surface and not visible to the naked eye. The handpiece shines an intense blue light that activates the natural fluorescence of the tissue. When viewing the fluorescence of the cells through the handpiece, healthy tissue shines a bright green. Dysplastic or neoplastic cells lose that natural fluorescence and appear as dark patches. It allows the operator to view beyond the surface. This doesn’t replace naked-eye examination and it doesn’t diagnose for you but it certainly points out something that you might otherwise miss. When it comes to oral cancer, early detection is always the key. I also like this tool because it can also be used for teeth whitening and high-speed curing. It works four times faster than normal curing lights. What’s not so good The main downside is that it’s quite large and bulky. I’ve emptied out the bottom shelf of my surgery and placed it there. It would be nice if it was cordless but because it has such a high-energy output, that would be impossible. And it is expensive to purchase. Where did you get it Denmat. It’s an American supplier. £ Bite 43
Your tools Reviews
Sirocam 2 intra-oral camera by Dr Ali Khalessi, Victoria Court Dental, East Gosford, NSW I started using the Sirocam 2 intra-oral camera about two years ago and have found it to be an invaluable tool for any dental practice. What’s good about it Prior to owning an intra-oral camera, I used a digital singlelens reflex camera for all photography in the practice. I still use the DSLR camera for full mouth, anterior and dental arch photography, and to communicate with dental labs. However, I use the intra-oral camera extensively to get consent for treatment, patient education, before-and-after shots and general record keeping. It allows the dentist to communicate clearly with a patient. The first intra-oral camera I ever used had great trouble connecting wirelessly with the computer and a battery that went flat quickly. If an instrument takes more than 15 seconds to set up, it tends not be used very frequently. Thankfully, things have improved since then and today’s technology is really reliable. The Sirocam 2 intra-oral camera I use now is part of the headpiece consul which makes it easy to use. What’s not so good There are still many areas that most intra-oral cameras could improve. Better illumination would mean sharper images and the ability to take extra-oral photos of the face and facial lesions. Even though these cameras have good lenses, DSLR cameras are far superior. An improved zoom capability would allow full dental arch photos to be taken. The focusing ability is usually pretty basic. If I had a wish list, I would like the manufacturers to incorporate diagnostic tools and a tooth shade recognition capability in the camera. Where did you get it Sirona Dental. (Bite magazine has been informed this product line has been discontinued.) £ 44 Bite
Waterlase MD by Dr Terry Rose, Smile In Style, Moonee Ponds & Sunbury, VIC Admittedly, high-end lasers are expensive when compared to the basic scalpel and high-speed drill. Friends delight in telling me how many burs or scalpel blades they can buy for the price of the laser. However, a soft tissue/hard tissue laser can improve the quality of your treatment and broaden the range of applications offered in your practice. Of course, appropriate training and enthusiasm are essential before you get to enjoy the new world that opens up to you. What’s good about it I bought the Waterlase MD as it was the ‘do everything’ laser. It has a slightly different wavelength to the Erbium YAG laser family and it has a broad range of soft-tissue and hard-tissue applications. The greatest application of the Waterlase is the treatment of advanced perio disease. The new radial firing tips look set to further improve results in this treatment and the turbo handpiece has made it powerful for hard-tissue restorative work. As the laser has a deadening effect on the tooth, anaesthetic is commonly not required for fillings. Soft-tissue and hard-tissue surgery is less painful during healing. I use it to cut bone away in difficult extractions, for periimplantitis, root-canal disinfection, impaction exposures for ortho and smile lifts/crown lengthening. The laser is switched on ready to go in the surgery. It’s not uncommon to use it on half my patients during the day. What’s not so good Training is critical to avoid problems and expand your repertoire with the Waterlase MD. Magnification is best for use with the laser and this can be a learning curve in itself. Extreme care must be taken when performing high-energy procedures. Poor technique and damage to laser tips can result in blowing the main trunk fibre—at a cost of $3000 each. Where did you get it Henry Schein. £
THE USE OF SELF LIGATING ORTHODONTIC BRACKETS IN CLINICAL PRACTICE Ideal course for practitioners who are currently using standard twin brackets and would like to take their practice to the next level of efficiency with shorter treatment times, less extractions, and more pleasing facial profiles
Numerous cases presented with archwire sequencing and 5 year retention records
13/14 August 2011
of General Dentistry
Program Approval for Continuing Education
Dental Education Centre 6/85 Bourke Road Alexandria NSW 2015 Sydney Australia Price: $1200 (inc GST)
Dr Derek Mahony
C.E Hours apply to IAO Tier Advancement
Specialist Orthodontist BDS(Syd) MScOrth(Lon) DOrthRCS(Edin) MDOrth RCPS(Glas) MOrth RCS(Eng) MOrth RCS(Ed)/FCDS(HK) FRCD(Can) IBO FICD FICCDE
Continuing Education Recognition Program
Ph: +612 8338 9420
Your life Passions
Dr Marcel Mangelsdorf
Tweed Heads, NSW
At the moment, my bike is a 1000cc Suzuki V-Strom. It’s a large, comfortable bike that weighs about 220 kilos. I’ve had it since 2002 and travelled about 50,000 kilometres on it. “The first time I did a big tour in Australia, it was on a much smaller bike. I joined a group riding from Brisbane to Darwin on standard Australia Post delivery bikes—the red Honda CT-110. Australia Post trade them in every year so there are always second-hand ones available. These bikes only have a top speed of 70km/h and are a handful on dirt roads. In Tweed “This year Heads, I I’m flying to was hanging the Ukraine around the with a group local motorwho will be cycle shop riding exand someone Russian army suggested motorcycles I join the with Ulysses Club. sidecars.” This is a club for older riders. We meet once or twice a month and do a joint ride. A couple of years ago, I set off with some friends from the Club and did a 15,000-kilometre ride around Australia. We covered 600 kilometres a day and all breaks were organised around fuel stops. We would arrive at our destination at about 3pm so we had time to look around, stretch our legs and go to the pub. Then it was the same thing all over again the next day. “This year I’m flying to the Ukraine with a group who will be riding exRussian army motorcycles with sidecars. We are leaving from Kiev and going through Romania, Bulgaria, Greece, Turkey, Syria, Lebanon and Jordan to finish in Israel. It will take 40 days. In Israel, we’ll put the bikes in a container and send them back to Australia.”
Clinical Update on Power Toothbrushes and Ultrasonics (2 CPD points) INT
SPERNATIO EA NAL KE R
Dr Fridus van der Weijden (Periodontist, ACTA University, Amsterdam) is a leading expert on clinical trial methods for assessing all types of oral hygiene products from toothpastes to electric toothbrushes. This lecture discusses the latest developments in power toothbrush technology and its role in today’s modern practice.
• Types of power toothbrush technologies: oscillating/ rotating and sonic • Brush head selection for specific patients • Safety and clinical evidence on its efficacy • Current consensus of clinical opinion in light of latest scientific evidence • How to incorporate power brushes in your practice
Advances in preventive dentistry have given the dental practitioner a whole host of treatment options in caries management today. When it comes to professional plaque control, mechanical root debridement is still the most important tool for the practitioner in the treatment of periodontal diseases. It has been reported that a dental professional may apply approximately 32 tons of scaling force per year and makes approximately 25,000 scaling movements! This lecture discusses the pivotal role of Ultrasonics in today’s modern practice.
• The latest in ultrasonic treatment • Guidelines for working mechanism and utilization of ultrasonic instruments • Effective instrumentation and patient comfort • The cavitation effect • Scaling vs. root planning • Management of furcation • Prevention of contaminated aerosols • Other applications of ultrasound technology
$199 brush for all participants
Dentists: $195 Hygienists: $140 (Includes refreshments)
Melbourne 28 May (10am – 1pm) 03-8825 4600 adavb.net
Sydney 31 May (6pm – 9pm) 1-800-737 346 adacpd.com.au
Brisbane 1 June (6pm – 9pm) 07-3365 8182 dentistry.uq.edu/cpd-0
Sponsored by Oral-B