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Dangers of DIY Orthodontists like Dr Theresia Sudjalim are concerned about the rise of DIY aligners. page 22

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Contents OCTOBER 2019

Editorial Director Rob Johnson Associate Editor Kathy Graham Art Director John Yates Commercial Director Mark Brown Contributors John Burfitt Shane Conroy Frank Leggett Clea Sherman Angela Tufvesson

News

Cover Story

Home straight 22 With the growth of the DIY aligner market, we investigate how safe home orthodontics really is?

Your world For all editorial or advertising enquiries: Phone (02) 9660 6995 Fax (02) 9518 5600 advertising@ bitemagazine.com.au editor@bitemagazine. com.au

Bite magazine is published 11 times a year by Engage Media, PO Box 92, Pyrmont NSW 2009. ABN 50 115 977 421. Views expressed in Bite magazine are not necessarily those of the publisher, editor or Engage Media. Printed by Webstar.

COVER PIC: EAMON GALLAGHER

content

22

Fund injection 5 $14m investment in gum disease vaccine: UK study finds links between periodontitis and hypertenion; and more.

A Swift solution Will a low-cost dentistry model solve the country’s oral healthcare crisis, or end the neighbourhood dental practice?

10

Your business

Social fallout 15 The rise of social media has implications for all workplaces, including dental practices.

15

At full strength 18 A strengths-based leadership approach empowers employees and helps practices thrive. Rules of engagement 27 A clear staff behavioural policy is essential for creating a happy practice team.

Your tools

Implants product guide Our guide to the best implants and related products and services on the market.

31

Tools of the trade Favourite gear and gadgets reviewed by your peers.

47

10 18

27

Your life

What’s cooking? 50 A love of cooking saw Dr Marcus Matear of Palm Square Dental Care in Bendigo, Victoria, become a contestant on The Great Australian Bake Off. 9,250 - CAB audited as at March 2019

Bite Magazine

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NEWS

Fund injection

A vaccine for periodontal gum disease, which affects a third of all adults globally, is in development following a $14 million investment into newlyformed biotech company Denteric Pty Ltd.  The company was set up to develop and commercialise the research outputs of a long-running program originating from the University of Melbourne working in collaboration with CSL, Australia’s largest biotechnology company. The announcement was made at the University’s recently officially launched Centre for Oral Health Research (COHR).

HIGH STAKES

People with gum disease (periodontitis) have a greater likelihood of high blood pressure (hypertension), according to a new study from the UK. Previous research has suggested a connection between periodontitis and hypertension and that dental treatment might improve blood pressure, but to date the findings have been inconclusive. This study by a team from UCL Eastman Dental Institute, UK— and published in Cardiovascular Research—compiled the best available evidence to examine the odds of high blood pressure in patients with moderate and severe gum disease. A total of 81 studies from 26 countries were included in the meta-analysis. Moderate-to-severe periodontitis was associated with a 22 per cent raised risk for hypertension, while severe periodontitis was linked with 49 per cent higher odds of hypertension.  Denteric will focus on developing a therapeutic vaccine for treating periodontal disease. “My team has been developing this critical treatment for periodontal disease over many years at the University of Melbourne,” said University of Melbourne’s Professor Eric Reynolds, founder and CEO of the Oral Health CRC, now COHR.  “[Now], in a true partnership with the Australian Government and private capital, we have launched a company which will bring a Melbourne-developed gum disease therapy to market.”

A declaration with teeth

FDI World Dental Federation (FDI) has welcomed the long overdue commitment to strengthening oral health in the UN Political Declaration on Universal Health Coverage (UHC). The declaration was officially adopted last month by world leaders at the UN High-Level Meeting on UHC in New York. “Oral health is one of the most neglected areas of global health, so we applaud world leaders for this breakthrough commitment that gives teeth to the UN Political Declaration,” said FDI president Dr Gerhard Seeberger.  “It is now vital that the Declaration be converted into concrete, sustainable action at the national level.”

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NEWS

WINNERS

A Yarra Ranges dentist committed to ongoing professional development has been awarded the inaugural Australian Dental Association Victorian Branch (ADAVB) BOQ Specialist Recent Graduate Bursary.  Dr Amy Thompson will receive $5000 to put towards ADAVB CPD training courses after being named the recipient of the coveted bursary.  Launched in July, the bursary aims to recognise and reward recent dental graduates who are committed to high-quality learning by providing financial support for further professional development.  After graduating from La Trobe University in 2017, Dr Thompson relocated to the Yarra Ranges district where she now shares her time between Inspiro, a community clinic in Lilydale and Your New Dentist, a private clinic in Mooroolbark. 

Filling a hole

Dr Amy Thompson

Dr Anand Makwana, owner of Warragul Dental Care, was recently announced as the recipient of the 2019 Australian Dental Association Victorian Branch (ADAVB) and BOQ Specialist CPD Practice Bursary. Now in its fifth consecutive year, the $10,000 bursary acknowledges dental practices committed to quality learning and provides further funding for professional development for practitioners and professional staff members. “We are so thrilled to be the recipients of the ADAVB BOQ Specialist CPD Practice Bursary,” Dr Makwana said.  “Our team is our biggest asset and we know that the bursary will be well invested into our ongoing learning environment where our local community will benefit from these learning experiences.”

Dr Anand Makwana and his team

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At the ADA FDI World Dental Congress held last month in San Francisco, USA, FDI World Dental Federation (FDI) released its latest resources on the treatment and care of patients with partial tooth loss. Rather than losing all their teeth as they age, more and more dental patients are greeting old age with a number of their teeth still intact. Having more teeth has led to the advent of a relatively new dental patient group: partially dentate patients. FDI has launched a series of tools to offer this patient group a tailored, comprehensive approach to treatment and care. These include the Collaborative Care Continuum: The 3Cs pathway for partially dentate patients white paper, as well as guidelines designed for oral health professionals that support patient-practitioner communication and offer advice to manage patients who are partially dentate.


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YOUR WORLD SwiftQ Dental Care plans to introduce low-cost dentistry to those Australians who can’t afford it. Will it solve the country’s oral healthcare crisis, or is it the end of neighbourhood dental practice as we know it? Shane Conroy reports

A

swift

solution

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Primary Healthcare), the Fairfieldbased practice is ruffling feathers with a new low-cost business model. It focuses on just five basic treatments— check-up and clean, pain relief, basic tooth extractions, fillings and takehome whitening—and provides each for a flat fee of $99. “We’ve received an overwhelmingly positive response from patients,” says Aquilina. “We’ve treated some people who have been unable to access dental care for 12 months or more. At SwiftQ Dental there are no hidden fees or add-ons, and patients know how much the treatment is going to cost up front.”

High tech, low cost

It sounds like a dream come true for many cash-strapped Australians. But is delivering basic dental services for less than $100 really a sustainable business model? Aquilina believes it most certainly is. She says building the business model on a range of innovative workflow efficiencies enables the practice to operate at significantly lower cost than most traditional practices.

PHOTOGRAPHY: ADAM TAYLOR

A

ccording to the National Oral Health Alliance, around seven million Australians delay or avoid dental treatment because they can’t afford it. That’s more than one in three Australians who are left to suffer in silence because they simply don’t have the funds to pay for essential oral healthcare. When you consider that common, untreated dental diseases result in approximately 32,000 preventable hospitalisations every year, the fact that anyone on a lower than average income will likely go without basic dental care should be a national disgrace. “The Australian dental industry simply can’t keep clinging to a business-as-usual approach,” says Michelle Aquilina, CEO of SwiftQ Dental Care. “It’s time to challenge the status quo with a new model that will make essential dental care affordable to as much of the community as possible.” That’s the idea driving SwiftQ Dental Care. Owned by healthcare giant Healius Limited (formerly


SwiftQ Dental Care CEO Michelle Aquilina (pictured here with Shadow Health Minister Chris Bowen) says budget dental care could be a dream come true for many cash-strapped Australians.

“The Australian dental industry simply can’t keep clinging to a business-as-usual approach.” Michelle Aquilina, CEO, SwiftQ Dental Care

Bite Magazine

11


YOUR WORLD “I’ve spent 30 years in the dental industry and I understand the dynamics holistically. We dedicated two years to developing highly efficient workflows for the practice,” she says. “Patients can select their treatment and book online, and we’ve embraced digitisation with selfcheck-in technology when patients arrive at the practice.” Following a self-check-in on arrival, a dental assistant welcomes the patient, walks them into the treatment room and introduces them to their dentist. “Even with a digitised frontend journey, it still very much is a personalised experience,” says Aquilina. “We understand that Australians want to take control of their health and have become comfortable with technology, which has been adopted by a wide range of businesses. As leaders in the industry, we need to ensure that we are acutely aware of the signs of changing consumer behaviours, and how we can use technology to lift the patient experience.”

Aquilina has also streamlined the surgeries to be more efficient. “We have modern dental clinics with agile workflows,” she says. “Operational effectiveness is quite important for us, so we’ve ensured that the staff actually understand their position in the workflow and know exactly what needs to be done and when.” Low cost doesn’t mean low standards, emphasises Aquilina. All SwiftQ practitioners are Australian qualified and must be registered with the Dental Board of Australia and the Australian Health Practitioners Regulation Agency. They must also undertake at least 20 hours of continuing professional education per year, and all products, materials and equipment used in the practice are TGA approved. The practice is also accredited by Quality Innovation Performance (QIP) and follows the Australian Dental Association’s Guidelines for Infection Control.

The future is shared

After a successful launch in Fairfield,

plans are underway for a national rollout of SwiftQ Dental Care clinics. That will no doubt have traditional higher-priced practices feeling a little nervous, but Aquilina insists that the SwiftQ model does not seek to cannibalise existing practices. Rather, she believes SwiftQ will grow the pie for all dental practitioners. “The core of our model is about attracting patients who have been otherwise unable to afford dental treatment and empowering them to take ownership of their own oral health,” she explains. “That means we’ll be growing the patient base—we’ll essentially be creating new patients and will absolutely be injecting growth into the industry. “As our focus is solely on providing those five basic treatments, we refer patients who need more complex treatments onto other practices in the area.” This could present an opportunity for competing practices to refocus on providing more complex, higher-value treatments. And while Aquilina points

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“The core of our model is about attracting patients who have been otherwise unable to afford dental treatment and empowering them to take ownership of their own oral health.” Michelle Aquilina, CEO, SwiftQ Dental Care

out that the scale does not yet exist to create an extensive referral network, she certainly sees an opportunity to collaborate with other dental practices now and in the future. “As we expand into new regions, we definitely want to give our patients the opportunity to seek further dentistry at other local practices,” she says. “Viewing other businesses as competitors alone is a thing of the past. Our world has evolved so much that if we are to thrive and facilitate growth and innovation, we need to welcome greater collaboration. I’m a strong believer in working with as many dental practitioners as possible to deliver better patient outcomes. I certainly welcome any interested practice owners to reach out to us, so we can discuss how we might be able to collaborate. “If this industry is going to make dental care affordable for all Australians, we’re going to need to work together to change the status quo.”

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YOUR BUSINESS

fallo ut Social

The rise of social media and its prolific use has implications for workplaces of all sizes, including dental practices. By Clea Sherman

F

or one South Australian dental practice, the pitfalls of social media hit home after a group message incident. A small business with a close-knit team, the staff at the practice found it helpful to use Facebook Messenger to share workrelated information. This approach unfortunately backfired when an employee shared an opinion that wasn’t meant for the whole team to read.

Messaging the wrong person or group is a very easy mistake to make and one most of us have made over the years. But when the workplace is involved and the comments are not complimentary, the fallout can be distressing. As the practice’s team leader ‘Shelley’ (not her real name) explains, “When something is inadvertently shared, it puts an air of distrust through the practice, even though that’s not what was intended. This small mistake made

by a team member served to break trust and ended up being very disruptive.”

Social struggles

Social media is now ubiquitous and has blurred the lines between our personal and professional lives. As many individuals and businesses are learning the hard way, as well as having the power to improve communication and efficiency, platforms like Twitter, Facebook and

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15


YOUR BUSINESS WhatsApp can wreak havoc with workplaces and employees. At the grand end of the scale of social media drama, there is the much-watched Israel Folau case. The prominent rugby player was sacked for the personal views he shared online, on the grounds he breached Rugby Union’s Code of Conduct. There is also a recent case of a public servant anonymously posting tweets criticising her employer (in this case the Federal Government). The worker’s case went all the way to the high court, which gave the ruling that her dismissal was justified. These cases may not seem relevant to a neighbourhood dentist or even a franchise of dental practices, however the precedents set have the potential to affect businesses of all sizes.

go because of social media comments, having a clearly communicated policy in place will ensure a dismissal process is less likely to be challenged in court.” Communication is also key. “Share your policy across your practice; don’t just add it to the website. I recommend you get staff to sign the policy when they first start working with you alongside their other documentation. For existing staff, send out an email communication that has the policy attached with a note that states you assume their acceptance of the policy unless they specifically come back to you with any concerns. “Be clear on who the policy applies to, such as full-time staff, casuals and contractors,” Nicholson adds, “And work with a professional who can give you advice and also make sure your policy is legally compliant.”

Setting the boundaries

From the top

HR specialist Kim Nicholson works with small businesses, including dental practices. “From an employer’s perspective, you need to be clear and careful when it comes to social media,” Nicholson, who is director of ACS HR Consulting, explains. “A social media policy is now a must-have.” A dental practice social media policy should outline how social media is defined, for example, how it applies to blogging and posting online. It should be explicit about the sharing of information and the use of personal and company devices including smartphones and laptops. The policy you implement at your practice needs to cover areas such as who is authorised to speak on the business’s behalf on social media and whether or not employees can endorse clients or suppliers on social platforms. There should also be rules around employees making comments which may have a negative impact on their employer’s reputation. Guidelines for social media will also cover its use during business hours. For example, staff may be prevented from accessing Facebook or Twitter while they are at work, or they may be asked to only access these platforms on their own devices during their breaks. Nicholson advises, “If you don’t have a policy in place, introduce one ASAP and make it clear. Use a legally drawn-up document and tailor it to your requirements. People may not like it but if you do have to let somebody

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The Australian Dental Association’s policy statement on social media reminds dentists at all levels to be vigilant about what they share online. It recommends dentists ensure they and dental practice staff are educated in the use of social media, stating: “They should keep professional and social spheres separate and conduct themselves professionally in both.” Patient privacy is another key area to consider when it comes to social media. Patients must give their consent before you share photos or information about them. The Australian Dental Association’s website has resources you can refer to for more details. When it comes to any professional’s personal reputation, Nicholson recommends extreme

caution. “Social media never goes away; it stays on the record. It goes back to the basic rule, if you haven’t got anything nice to say, don’t say it. “If you have a problem with someone in the workplace, putting it in writing and posting it on social media can be taken the wrong way and increases the risk of issues such as dismissal, bullying, harassment or defamation, not to mention potential damage to your own brand and reputation as an employer.”

Lesson learned

The Facebook Messenger incident at Shelley’s practice prompted a switch to Slack, another messaging channel. Using this different platform makes it easier for employees to keep personal and professional conversations separate. Unfortunately, the fallout of the incident did result in a written warning and the employee eventually making their own decision to leave. “Because we had never had anything like it happen, it was a big learning curve,” explains Shelley. “We wanted to work through it but sadly it was too hard to come back from.” Kim Nicholson concurs. “[There is] always an element of human error in play with such technologies. Encourage your staff to stick to work-related conversations online and don’t forget to lead by example.”

“From an employer’s perspective, you need to be clear and careful when it comes to social media. A social media policy is now a must-have.” Kim Nicholson, director, ACS HR Consulting


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YOUR BUSINESS

Forget the performance management approaches of old. A strengths-based leadership approach empowers employees and helps businesses thrive. By Angela Tufvesson

At full

strength T

raditional methods of performance management focus on weaknesses and areas for improvement, but a growing body of research reveals that focusing on what’s strong rather than what’s wrong empowers leaders and workers. The result? A positive workplace culture, increased productivity, better staff retention and, ultimately, an improved financial bottom line. This approach is what psychologists call ‘strengths-based leadership’, and it’s just as effective in smaller businesses as it is in large corporates. Here’s why strengths-based leadership works and how to implement it in your practice.

From the top

Strengths-based leadership is a

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management strategy that prioritises employees’ strengths above their shortcomings. It focuses on what employees do well—not what’s lacking or needs ‘fixing’—and cultivates a workplace that maximises opportunities to put those strengths into practice. “Strengths-based leadership gives autonomy and empowerment to teams and builds a culture of trust, support and safety where everyone can thrive, as opposed to traditional leadership strategies that can be based on control and command,” says leadership consultant Nicole Toohey. Identifying and leveraging intrinsic motivators—factors that naturally lead employees to experience high levels of engagement and satisfaction like an enjoyment of learning or sense of autonomy—is also a key focus, says

business psychologist Leisa Molloy from Flourishing Minds Consulting. “As you can imagine, these principles are significantly different from those that often underpin more traditional management approaches; for example, trying to improve performance by offering external rewards such as pay increases and promotions,” she says. The strengths-based approach has its roots in positive psychology, the scientific study of human flourishing that seeks to identify the core components of a life well lived. Crucially, however, focusing on strengths doesn’t mean forgetting about shortcomings, especially in an organisational context. “It’s not about ignoring weaknesses, especially if these are critical or likely to make or break the success of the business,” says Molloy.


Instead, she says strengths-based leadership approaches seek to find creative and non-traditional solutions to gaps in knowledge or ability.

“Strengths-based leadership gives autonomy and empowerment to teams and builds a culture of trust, support and safety where everyone can thrive.” . Nicole Toohey, leadership consultant

The benefits

A growing body of research shows strengths-based leadership offers a heap of benefits for employees and, by extension, employers. “One of the biggest benefits is that employees feel more valued and appreciated—not necessarily for the work they do, but for who they are at a deeper level,” says Molloy. “Being able to regularly use your strengths makes work feel more satisfying and more meaningful.” This translates into better performance on the job and improved business outcomes. Indeed, evidence suggests teams that have the

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YOUR BUSINESS

opportunity to leverage their strengths every day outperform teams that don’t. “The impact on business is increased engagement, productivity and sustainable performance levels,” says Toohey. “For small business leaders, what’s noticeable is the development of a thriving culture and positive working relationships, and that these are fun places to work as teams are motivated and empowered to execute results.” Dental business coach Ameena Basile from Dental Management Expertise says strengths-based leadership helps practices alleviate one the most common management bugbears: high staff turnover. “What we find is when we focus on weaknesses performance declines and confidence diminishes, but when a leader cheers on an employee’s strengths they feel confident, excited and motivated,” she says. “When we use a strengths-based leadership method, we create a happy work environment where everyone grows and everyone is engaged, and it really shows in the customer service that people provide and the bottom-line profitability of the practice.”

“Being able to regularly use your strengths makes work feel more satisfying and more meaningful.” Leisa Molloy, business psychologist, Flourishing Minds Consulting

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Finding your strengths

So what’s the best way to implement a strengths-based leadership approach in your practice? First, identify employees’ strengths. An annoying phenomenon called ‘negativity bias’—where we pay more attention to negative events than positive ones thanks to an evolutionary need to remain alert to danger—means they can be hard to spot, so look carefully. Online tools like the VIA Character Strengths survey—which measures 24 different positive qualities—and the CliftonStrengths assessment, which is widely used in corporate and small business settings, can be helpful. A less structured but simple way to focus on strengths is to begin observing and noticing how people work. “Look for times when your employees seem to be really energised or in a flow state,” says Molloy. “Notice their body language and look for those moments where they seemed really animated and excited. If whatever they’re doing is something they both enjoy and are good at, then there’s a good chance a core strength is at play. “In contrast, pay attention to situations where people’s behaviour or body

language seems a bit flat. These might be the moments when they really aren’t drawing upon any of their key strengths.” Next, find ways for employees to use those strengths in their day-to-day activities. “If someone keeps talking about processes not being done properly but it’s not in their current role to make continuous improvement, let them make the changes in addition to their current role,” says Toohey. Molloy says employees who enjoy independent research might enjoy searching for updates in best practice and sharing them with the team, while people who are especially empathetic could provide extra support when you’re working with difficult or upset patients. And talking to employees about what they like doing after work or what they’ve done in previous roles outside their job description can help to identify a very broad range of strengths, says Basile. “Someone might be a dental hygienist but then you come to know they have a really good marketing brain, so you can hone in on those skills and perhaps have them manage the practice’s social media,” she says.


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COVER STORY

HOME

STRAIGHT W

e live in a time when many of the services traditionally provided by professionals can now be done by the individual at home. Everything from printing your own photos to booking overseas flights can be organised with a computer and a wi-fi connection. While this has been a monumental change in how goods and services are accessed and utilised, generally there is no danger to the consumer beyond a variation in price. However, the same motivators that created this new economy are now starting to spill over into the dental world. The uptake of home teeth whitening has been phenomenal. While it was traditionally done in a dental practice under the supervision of a dentist, now thousands of people have utilised a variety of kits to whiten their teeth at home. The dangers of home whitening

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are well known—damage to enamel, damage to gums, chemical burns, mouth infections and the ingestion of chemicals causing sickness—but this has had little impact on the popularity of the process. Recently, there has been an uptake of people using orthodontic aligner kits to straighten crooked teeth at home without the user ever visiting an orthodontist.

Why DIY?

“I believe that cost is the main reason people use DIY aligners,” says Dr Theresia Sudjalim who worked as a general dentist for over 10 years before obtaining her Doctorate in Clinical Dentistry at Melbourne University. For the past 13 years Dr Sudjalim has been an orthodontist using clear aligners such as Invisalign treatment in her practice. “DIY aligner systems are definitely cheaper and their marketing makes it seem really

simple. However, as with any DIY, it’s more complex than people think. Moving teeth is a medical procedure and it is not simple—it only looks simple because orthodontists are professionals who are extensively trained to be good at it. There are a lot of things that can go wrong with unsupervised treatment. “A person may observe that their teeth are a little bit crooked but they don’t know why. It might be that they have pre-existing gum disease or another pathology. It could be because there isn’t enough room for all the teeth to sit evenly in the jaw. If a patient chooses to move their teeth without the continued supervision of an orthodontist, and it’s not done correctly, this can lead to potentially irreversible and expensive damage, such as tooth and gum loss, changes to the bite, and other issues. In my opinion, the risks far outweigh the possible benefits.”

PHOTOGRAPHY: EAMON GALLAGHER

It is now possible for people to be sent clear aligners and straighten their teeth at home without ever visiting a dentist or orthodontist. So, just how safe is the concept of home orthodontics? By Frank Leggett


“DIY does not include in-person, face-to-face supervision from a clinician once the treatment starts, and this is key to achieving a complete result.� Dr Theresia Sudjalim, orthodontist

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There are a lot of things that can go wrong with unsupervised orthodontic treatment, says Dr Sudjalim.

DIY clear aligner systems may require the customer to take their own impression, or to have an intraoral scan of their teeth taken at a location. “The treatment objective of most DIY teeth straightening systems is to simply improve crooked teeth, which is what consumers say they are after,” adds Dr Sudjalim. “However, starting treatment without regard of why and how the teeth have ended up crooked means consumers run the risk of not getting what they are hoping to achieve. There is no consideration of the bite or how the tooth movements will affect the face and lips. DIY does not include in-person, face-to-face supervision from a clinician once the treatment starts, and this is key to achieving a complete result.”

Aussie option

EZ SMILE is an Australian company, founded in 2017 in response to the direct-to-consumer aligner model in Europe and the USA. In these countries, thousands of adults who required orthodontic corrections have undergone a clear aligner treatment without face-to-face visits with dental professionals. EZ SMILE was the first to bring the direct-to-consumer clear

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aligner offering to Australia, however, since their launch, a number of other players have entered the market. “At EZ SMILE, we only treat mild to moderate cosmetic cases,” says Ed Ambrosius, director of EZ SMILE. “If a patient falls outside of those parameters, they are directed to seek treatment from a dentist or orthodontist. Unlike other players, we will not be setting up our own scanning centres but are beginning to partner with dentists to provide intraoral scans for potential EZ SMILE patients in their clinics for an attractive fee. “EZ SMILE is an orthodontistprescribed clear aligner treatment. The only difference is that the patient has the option of accessing the service completely remotely thanks to advances in technology and 3D printing.” Ed Ambrosius would like to see more dentists jump on board and partner with EZ SMILE. “There is no reason for there to be an ‘us versus them’ mentality,” he says. “Our research has shown that we’re growing the clear aligner market, rather than eating into existing market share. There is a whole segment of the market

who would like to straighten their teeth but would never consider the costs associated with traditional methods. If the correction is relatively minor, then they can easily justify a more affordable direct-toconsumer option.”

Beyond the bottom line

However, there is much more involved here than just the bottom line. “Looking at just a single crooked tooth in isolation is not good dentistry,” says Dr Sudjalim. “A dentist or orthodontist looks at individual teeth, the top arch, the bottom arch and their relationship to each other. They look at the face and the facial profile. To a layman, a crooked tooth might seem like a simple thing to move, but a professional will check the bite and the underlying relationship between the top and bottom jaws. It is important to understand the entire problem, before choosing to undertake limited corrective treatment that is safe for the patient.”

A teledentistry platform

SmileDirectClub is another Australian company that originated in the United States. They offer remote clear aligner therapy driven by registered dentists


COVER STORY

“There is no reason for there to be an ‘us versus them’ mentality. Our research has shown that we’re growing the clear aligner market, rather than eating into existing market share.” Ed Ambrosius, director, EZ SMILE

or orthodontists. There are a number of SmileDirectClub SmileShops in Australia where clients can visit and have a complementary 3D scan taken. This scan is converted into a mould that is evaluated by a dentist or orthodontist. Alternatively, clients are sent an impression kit with instructions. A Smile Spreader is included so the customer can take photos of their own teeth. The impressions and the photos are then posted back to the company to have moulds made. The clear aligners are manufactured from these moulds. “SmileDirectClub only treats minor orthodontic problems,” says Dr Hendrik Lai, a Sydney-based dentist who has practised all over Australia. Dr Lai is also a spokesperson for SmileDirectClub. “We have a clinical protocol around what can and can’t be treated. We certainly reject cases in line with clinical decisionmaking. SmileDirectClub offers a teledentistry platform with the aim of lowering barriers to access to care by reducing costs. The teledentistry model is also able to overcome the tyranny of distance, a particular problem in regional Australia. Our process goes a long way in helping to

democratise access to healthcare for all Australians.” Of course, the glaring problem is that taking an accurate dental impression is not that easy. “It would be extremely difficult for any person to take a good impression of their own teeth,” says Dr Sudjalim. “Furthermore, creating an impression material that does not distort during transport time back to the DIY company to enable the production of well-fitting clear aligners is another hurdle in itself.”

Consumer led

Undoubtedly, the DIY clear aligner movement has been led by consumers, not dental professionals. The question is, are consumers in the best position to make decisions about their oral health? “Healthcare consumers in Australia have become a lot more sophisticated due to an increase in readily available information,” says Dr Lai. “The asymmetry of knowledge that previously existed between dentists, orthodontists and the consumer has now become a lot more balanced. I think consumers are in a much better position to make decisions about their health. To be fair, dentistry

is a very conservative profession that doesn’t change quickly. For the most part, organised dentistry is against anything that will disrupt the status quo.”

Potential problems

The potential consumers of DIY home aligners need to ask themselves a question—is it a wise decision to scrimp when it comes to dentistry and orthodontics? “The DIY clear aligner industry exists because it is cheaper than professional, orthodontist-supervised aligner systems such as Invisalign treatment,” says Dr Sudjalim. “Anyone considering home orthodontics should at least talk to a dental professional to get an idea of what is wrong with their teeth and what could potentially go wrong. If DIY work does go wrong, it will cost a lot of money to correct it and the patient will be in a worse position than when they started. “It is important to remember there is a person attached to a set of teeth and if the outcome of DIY aligners is damage or loss of teeth, and the company providing the service is unable to be held accountable, then those poor people are left with a potential lifelong problem.”

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YOUR BUSINESS A clear staff behavioural policy is essential for creating a happy practice team and positive workplace. By John Burfitt

Rules of engagement

I

neffective management of abrasive or difficult personalities as well as bullying among the team—not to mention when patients are on the receiving end of such behaviour— is when a range of serious problems in a practice can occur. “We do sometimes hear of bullying within the practice from some of our clients,” Bethan Flood, general manager of human resources at dental consultancy Prime Practice, says. “Some dentists seem to struggle with it as they are so focused on dealing with patients and the technical aspect of the job. When it comes to issues among the team, they either struggle to find time to deal with it or are not sure how to approach it.” It’s a point echoed by career development consultant Greg Smith, author of the new book Career

Conversations. “Often I’ve seen people in medical fields dealing with complex technical matters with ease, but it’s problems with staff members’ behaviour that will keep them awake at night. That’s understandable as it can be tricky, but it’s crucial it’s dealt with head on.” According to Safe Work Australia, examples of workplace bullying include abusive or offensive language, aggressive and intimidating behaviour, humiliating comments and unjustified criticism. In a Safe Work study, 37 per cent of Australian workers reported being sworn or yelled at in their workplace. The Head’s Up mental health advocacy group claim a toxic workplace and bullying can result in lost productivity, increased absenteeism, poor morale and

a high turnover of staff. Estimates claim it costs Australian organisations as much as $36 billion a year.

Define your terms

Which is why adopting and promoting a clear staff behavioural policy is essential, Bethan Flood says. “In your policy, make sure you have a definition of bullying, which you can easily get from the Fair Work Commission website, so that everyone is clear on what standard is expected within your practice,” she says. Fair Work also offers the Workplace Advice Service, offering free legal assistance on the best ways to address such issues. “I hear people say, ‘We are a small practice and we all get along’, but without a clear policy, you are not setting expectations and you are

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YOUR BUSINESS also not protecting yourself in case something happens.” A policy on staff behaviour should also offer a comprehensive definition of what bullying actually is. “Some people confuse being managed with being bullied,” Flood adds. “A manager correcting someone about their role is not bullying. The staff member may assume they are being picked on as they might struggle with being corrected, but that is not bullying. Clear definitions and procedures makes it far clearer for everyone to understand.” Likewise, Greg Smith says there must be a distinction between someone who’s occasionally rude or offhand and doesn’t realise their impact on others, and those who actively bully. “It can be a fine line, but there is a big difference,” Smith says. “For the former, sometimes a simple chat making them aware of how the way they occasionally speak to others can impact, or some basic behavioural training in customer service might be all that’s needed to correct it. It’s when it is more complicated that a stronger approach must be taken.”

Lead by example

As with all aspects of creating a workplace culture, the way senior

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management behave sets a standard of what is acceptable among all levels of the team. “Before looking at others, the boss might first need to consider how they are leading by example in the way they speak to the team and conduct themselves,” psychologist Sharon Draper says. Draper runs Return to Wellness workshops that teach resilience to overcome workplace bullying. “If the boss or senior managers yell, swear and are abusive, it should be no great surprise if that behaviour is repeated among the team. Management need to understand if they see something they don’t like, it could be a trickle-down effect from the standard they’ve set.”

Don’t bury your head

When it comes to following procedures to address the issue, this is when time is of the essence, Draper adds. “It’s not helpful to see someone yelling at another staff member or even a patient, and for the boss to only bring that up in their performance review six months down the track,” she says. “When poor behaviour is witnessed or you receive a complaint, then act on it as soon as possible, and in a private space where an open conversation can be had. It should never be about

blaming or accusations, but rather find out what is going on for that person. It might be something in their personal life or possibly a bigger situation within the team you have no idea about. This is why communication and addressing it thoroughly is vital. If you ignore it in the hope it will go away, it most probably won’t.” Many reports also claim that when it comes to workplace issues, many bullies adopt a practice of ‘managing up’, so senior management has little idea of problems within the ranks. “I hear this often, when a bully manages to make themselves a good friend of the boss, and then the boss dismisses any complaints as they insist their friend would never behave like that,” Draper says. Greg Smith adds this is when management might need to shift their focus from what’s going on inside patients’ mouths to the reality of the dynamics happening around them. “Pay attention to inconsistences in what you are being told, as bullies can be experts at masking what’s really going on,” he says. “And keep lots of notes, of what you’ve been told and what you’ve seen. If things escalate later on, those notes can make the world of difference to how you sort it all out.”


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ADVERTORIAL

Product Guide

Dental implants

Bite’s guide to the best implants and related products and services on the market

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ADVERTORIAL

Product Guide Implants

Neodent Grand Morse Implant System Greatness is an Achievement Neodent Implant Systems from Straumann Group, is a global brand available in more than 60 countries with more than 1.6 million implants annually placed into patients mouths. Designed by a dentist, for dentists, Neodent was founded to create more smiles every day for patients worldwide. Dr Geninho Thomé innovated from the best systems in the world and created an implant that provides optimal treatment options to a wider range of patients. What began 25 years ago as a means to meet the needs of his patient base in Brazil, has evolved into the second largest implant company worldwide with considerable appeal to the aesthetically inclined yet price sensitive patient who wants consistency and value. The Neodent Helix Grand Morse is an innovative hybrid implant designed to maximise treatment options and efficiency in all bone types. It was developed based on the inside out concept, starting with the core of the implant with a solution that combines mechanical strength and versatile prosthetic solutions. The result is a complete system that offers features and benefits to make the workflow more efficient. The Helix Grand Morse has a unique, progressive dynamic thread design and in combination with a small tip and flutes supports immediate engagement. These features help to adapt the drilling sequence and primary stability to the clinical situations even in demanding cases, or to the treatment protocols with immediate implant placement and loading. Additionally, it combines a dual, fully tapered body design with a hybrid outer contour: cylindrical on coronal area and conical on the apical part. This allows for vertical implant placement flexibility in combination with under-osteotomy helping to preserve important periimplant bone structures—an important prerequisite to optimising the outcomes in aesthetic sites. These innovative features allow the

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Dr Geninho Thomé at work designing.

Neodent Grand Morse Implant Systems to provide four primary benefits: l Simplicity l Reliability l Stability l Aesthetics It utilises a single prosthetic platform, which delivers efficiency and simplicity. A 3mm internal connection is used across all Grand Morse Implants, from the ø3.5 to the ø6 diameter, requiring one screwdriver, one surgical kit and one implant driver. This connection also offers a unique combination based on proven concepts: a platform switching associated

The Neodent Grand Morse implant system.

with a deep 16° Morse taper including an internal indexation for a strong and stable connection designed to achieve long-lasting results and reliability. The innovative design and shape of the implant provide proven primary stability and optimal aesthetics for any indication, from single to edentulous. The Neodent GM is single solution for a variety of indications and is simple and effective in both single and full arch rehabilitation solutions. Backed by Straumann Group service and support this is a system that consistently delivers a reliable patient outcome.


NEODENT® GRAND MORSE™ CONNECTION Stable and strong foundation designed for long term success

3 mm

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Call your Straumann Group Specialist for more information

Straumann Group Pty Ltd 7 Gateway Court, Port Melbourne VIC 3207 P. (AU) 1800 660 330 (NZ) 0800 480 370 E. customerservice.au@straumann.com www.straumann.com.au

Internal Indexation


ADVERTORIAL

Product Guide Implants

Zeramex Ceramics Implants Strong. Aesthetic. Metal-free. A confident choice in dental implantology! ZERAMEX® is a pioneer among modern two-piece ceramic implants. As a passionate innovator, ZERAMEX® is a constantly working on developments in implantology. In doing so, it builds on the Swiss tradition of processing hard zirconia, called the “white diamond,” from which the implant is produced. As a long-term partner, ZERAMEX® allows you a range of options and can enhance your practice through reliable products that are easy to use and are tailored to the needs. What this means:

 Key expertise in ceramic processing and Swiss quality  Established implant systems with an impressive performance record For maximum patient satisfaction.

The requirements placed upon dental implants have increased in recent years. First and foremost is the patient’s wish to have both a healthy and attractive solution. ZERAMEX® is synonymous with a high quality of life thanks to the metalfree ceramic implants. The clinical use of ZERAMEX® implants can boast of an impressive success rate of over 96 percent healing9. Ceramic’s high resistance to corrosion combined with the low plaque affinity minimizes the risk of inflammation11. In addition, blood flow to the gums around the implant is retained: One study found that the ceramic implant has characteristics similar to those of a natural tooth2. The benefits of ZERAMEX®:

 Long-term aesthetics  High compatibility The ZERAMEX® implant family. ZERAMEX® OFFERS YOU THE IDEAL SOLUTION!

The new ZERAMEX® XT implant is the latest member in the family of two-piece, reversible screw-in ceramic implants. The successful ZERAMEX® P6 implant with a soft tissue level design is ideal in the posterior area and offers easy access to the implant.

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The root-shaped design of the ZERAMEX® XT implant achieves high primary stability, and high prosthetic flexibility is ensured thanks to the new internal connection.

Strong.

The latest generation of ZERAMEX® ATZHIP ceramic implants achieves strong connections thanks to the carbon-ceramic technology. The key component is the VICARBO® screw made of carbon-fibre-reinforced high-tech composite. This material has excellent isoelastic properties and fits tightly against the existing contour. It creates a high-strength and form-fitting, albeit tension-free screwed ceramic-ceramic connection. The design of the connection was developed with the aim of minimising bacterial colonisation and accumulation.

Aesthetic.

The patient demand for ceramic implant solutions is continuously increasing. The megatrend towards white, metalfree dentistry, which started years ago, continues to grow. The two-piece, reversible screw connection can facilitate unhindered healing of the implant and optimise accommodation by soft tissue. Together with the white color and favorable tolerability by the gums11, longlasting aesthetics are ensured.

Metal-free.

The 100-percent metal-free ceramic implants closely approximate the natural

tooth root in terms of aesthetics and function. They are well tolerated, are completely free of metallic corrosion, and conduct neither electricity nor heat. Titanium can release titanium ions, which accumulate in the surrounding soft tissue and can cause inflammation5. Likewise, titanium’s resistance to corrosion can decrease due to surface bacteria14. The use of metal-free ceramic implants precludes these effects. MORE INFORMATION: ZERAMEX AUSTRALASIA LTD. https://zeramexaustralasia.com E: info@zeramexaustralasia.com For full references, please see the online version of this article at bitemagazine.com.au/zeramex-implant


Zeramex

The Ceramic Implant

The naturally white Ceramic Implant Flexible, Versatile and Effective. • 100% Metal-Free • Two-part, Screwable, Reversible. • Customized Prosthetic Flexibility Made in Switzerland – Since 2005

  

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ADVERTORIAL

Product Guide Implants

Bioconcept offers an affordable alternative Dentists across Australia and New Zealand are now enjoying access to far more affordable implants and componentry, which are 100% compatible with existing dental implant systems such as Straumann, Nobel Biocare, and Osstem. Sydney dentist Dr Nicholas Hocking established Bioconcept Australia after becoming frustrated that dentists had been grossly overpaying for European implants and components which are manufactured for a fraction of the price for which they are sold. Australian dentists are now purchasing the generic version of a Straumann or Osstem implant for $170 instead of paying over $800 for the branded product. When Dr Hocking became aware of a high-quality dental implant system being manufactured by Bioconcept in China, he saw an opportunity to offer dentists an affordable alternative to the expensive European implant systems, with no compromise in quality. He visited China and was impressed to discover that a senior Johnson & Johnson medical engineer cleverly took steps to emulate Straumann’s excellent implant system the moment Straumann’s patent had expired, giving rise to the Bioconcept system. He was also amazed to learn that a major European implant company attempted to subcontract the manufacture of its components to Bioconcept, the quality was so good, and that Bioconcept uses the same supplier of grade IV titanium in the production of its implants, as is used by the Straumann branded equivalent.  Dr Hocking, who has placed over 10,000 implants (most of which have been Straumann implants), says; “The excuse that Australian practitioners should have to pay for research and development for these branded European implants has had its day, and the price of implants and componentry has become absurd compared to other medical sectors. The prohibitive costs mean that Australian patients are potentially missing out on the most appropriate

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treatment for their oral health. It was obvious to me that the market was ripe for disruption by a much more fairly priced implant manufactured to the same exacting standards as European implants.” Dr Hocking is a strong advocate for the SLA surface introduced by Straumann in 2002, which he says has gained enormous popularity due to its long-term, predictable success rates. Bioconcept uses the same surface, and Dr Hocking says: Bioconcept impression copings are also completely radio-opaque, allowing clearer verification of seating of the impression coping prior to impression taking, unlike the problematic radiolucent alloy used for the Straumann coping.” Dr Hocking likes to say: “If I have to have an implant in my mouth, make it a tissue level implant with an SLA surface—something that Bioconcept does beautifully.” With the introduction of far more affordable implants, Dr Hocking’s hope is that: 1. Australian patients will be less likely to take trips to overseas clinics to receive complex dental treatment with very little access to review if things don’t

Dr Hocking and his wonderful assistant Emiko placing a Bioconcept implant

go as planned, and instead, they will receive quality treatment from their local Australian dentist with all its obvious advantages; 2. Dentists will be less pressured to prepare neighbouring tooth structure for a fixed tooth-supported bridge where an implant-supported restoration could be provided at a reduced biologic and far more economical cost to the patient and dentist; and 3. Implant hardware costs will be far more affordable so that dentists can avoid compromised treatment plans which use a reduced number of implants for treatments such as ‘All on Four’. Do your patients a favour and place six implants instead – you know you’ll get a more predictable outcome. Talk about win-win! www.bioconceptaustralia.com


DENTAL IMPLANTS

HEALING ABUTMENTS

Bioconcept $199 Bioconcept $30 ® ® Straumann over $800 Straumann $95

Bioconcept Australia provides Australian dental practitioners with affordable options when purchasing dental implants,surgical instruments and accompanying dental products. “I am really excited that we now have a very real option in the marketplace to buy implant supplies at a sensible price without compromising quality. Treatment planning for implant-supported dentistry has finally taken a paradigm shift in affordability, and this is fantastic news for both patients and dentists.”

IMPRESSION COPINGS

Bioconcept $59 Straumann® $120

Dr Nicholas W Hocking

B.D.S(Adel), M Sc.(Lond), M.Clin. Dent.(Pros) (Lond),FICD,FPFA Clinical Lecturer, University of Sydney

All prices are inclusive of GST

BIOCONCEPT IMPLANTS: Are created from materials provided by the best raw material supplier in the world, ZAPP, based in Germany, who also supply materials to Straumann® Are manufactured using Japanese KOMATSU milling machines identical to those used by Straumann® Use the tried and tested SLA surface with commercially pure grade IV Titanium alloy Are packed and sterilised, using medical grade 100 Point sterilisation procedures identical to Straumann® ’s procedures Have been used in over 50 countries since 2007 ®

Drills and drill kits are produced by the same US company used by Straumann All come with a 100% lifetime guarantee Bioconcept implants and associated componentry meet the highest possible standards in manufacturing at a fraction of the typically inflated European prices. Simply put, there is no better way to provide your patients with the highest quality care at a vastly reduced cost.

GET READY FOR A PARADIGM SHIFT IN HOW YOU THINK ABOUT IMPLANT DENTISTRY.

® Straumann is a registered trademark of Straumann AG Nobel Biocare® is a registered trademark of Nobel Biocare Services AG

Suite 1104, Level 11, 135 Macquarie Street Sydney, NSW 2000

info@bioconceptaustralia.com www.bioconceptaustralia.com


ADVERTORIAL

Product Guide Implants

Onlay graft with NSK VarioSurg3, case study Jozsef Szalma DMD, PhD, Habil.

Department of Oral and Maxillofacial Surgery University of PĂŠcs, PĂŠcs, Hungary The initial CBCT shows severe horizontal bone resorption at the right lower left lateral zone in the mandible. The average bone thickness was less than 3 mm.

The initial CBCT shows severe horizontal bone resorption at the right lower left lateral zone in the mandible. The average bone thickness was less than 3 mm. In infiltration and inferior alveolar nerve block anesthesia a mucoperiosteal flap was raised in the premolar, molar and retromolar area. Authors decided to prepare an onlay graft from the same sided retromolar area of the mandible. During osteotomy with the HSG1 saw tip the smooth and bloodless cut line is visible. After releasing the onlay graft, the acceptor area was fenestrated, several times punched with small round drill to allow bleeding and cell migration from the bone.

The onlay graft was predrilled and fixated with lag screws (1.2 mm x 8 mm Depuy Synthes Hungary, Johnson & Johnson Medical Kft., Budapest, Hungary). After the fixation, the sharp edges were smoothened with the diamond coated SG6D tip.

A 2 x 3 cm resorbable collagen membrane (Jason, Botiss Biomaterials GmbH, Zossen, Germany) was fixed Six months later, a significant improvement (> 6 mm) in bone thickness was seen on postopwith resorbable sutures lingually and bovine xenograft bone augmentation particles were used to fill incongruences between graft and acceptor site (Cerabone, Botiss Biomaterials GmbH, Zossen, Germany). erative CBCT.

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ADVERTORIAL

Product Guide Implants

Benefits of Water Flossing for Implant Health Dental implants are a successful tool for the replacement of missing teeth. They help patients restore function and improve appearance. Like natural teeth, implants require patients to practice good daily self-care. If biofilm is not controlled on a daily basis, the tissue surrounding the implant can become inflamed leading to mucositis and peri-implantitis. A 2018 joint paper by the American Academy of Periodontology and the European Federation of Periodontology noted that peri-implant health requires the absence of inflammation including no bleeding on probing.1 An implant is a significant investment. It is essential to provide patients with the right tools and advice to maintain good peri-implant tissue health. The prosthetic design of the implant, especially the depth of the soft tissue cuff can make cleaning a challenge. Patients who struggled to use floss before having an implant will likely struggle to use it around the implant. It is estimated that about 50% of implant sites have mucositis and up to 40% may experience peri-implantitis.2 Few home care products have been tested for safety and efficacy around implants. One product that has is the Waterpik® Water Flosser (Picture 1). A 30-day study at the Tufts University School of Dental Medicine in Boston, MA, USA evaluated the effectiveness of a Water Flosser around dental implants for reducing bleeding on probing (BOP) as compared to the use of traditional string flossing.2 The study included subjects between the ages of 22 and 62 years. Each needed to have at least two BOP sites present. The subjects were computer randomised into two groups resulting in 22 implants per group. Examiners were blinded to the subject’s treatment group. Bleeding sites were comparable between the groups with 100% having BOP. All subjects received verbal instructions on product use. Those using string floss were

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1.

2.

directed to form a ‘C’ and move the floss up and down the surface several time. The Water Flosser was used at 60 psi. Individuals were shown to direct the tip at the gingival margin and interdental areas from both the buccal and lingual.2 All subjects used an American Dental Association (ADA) standard soft manual toothbrush and an ADA standard fluoride dentifrice. Group 1 used unflavoured, waxed string floss and Group 2 used a Waterpik®Water Flosser with the Plaque Seeker® Tip (Picture 2). This specialised tip has three nylon tufts to help cleansing around implants and other dental work. Both products were used one time per day.2 At the 30-day conclusion of the study, two subjects in the string floss group had withdrawn leaving 18 implants in the string flossing group and 22 implants in the Water Flossing group. The results found that 18 of 22 (81.6%) implants in the Water Flossing group experienced a reduction in bleeding compared to 6 out of 18 (33.3%) in the string flossing group. This represented 145% difference, which

was statistically significant. No adverse events were reported for either group during the study. The investigators concluded the Waterpik® Water Flosser is a safe and effective tool for reducing bleeding around implants. The results of this study are similar to other studies where the Water Flosser has been used on natural teeth and compared to string flossing.2 1. Renvert S, et al. Peri-implant health, periimplant mucositis, and peri-implantitis: Case definitions and diagnostic considerations. J Periodontol, 2018; 89(Suppl 1):S304-S312. 2. Magnuson B et al. Comparison of the effect of two interdental cleaning devices around implants on the reduction of bleeding. A 30-day randomized clinical trial. Compend of Contin Educ in Dent 2013; 34(Special Issue 8): 2–7.

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ADVERTORIAL

Product Guide Implants

Implant maintenance – fundamental for preventing peri-implant disease Anna Nilvéus Olofsson, DDS Specialist Paediatric Dentistry Odont. Lic., Manager Odontology and Scientific Affairs, TePe Dental implants have revolutionised dentistry; however, this is not without complications. Approximately 12 million implants are placed globally every year, meaning that there is a large population of patients at risk of developing periimplant disease. To create optimal conditions for a long-lasting result, these patients need individualised maintenance care based on a thorough risk assessment.

Laying the foundation for implant success

It is important to keep in mind that implant treatment begins before the actual placement of the implant. Firstly, it needs to be decided whether rehabilitation with dental implants is the best treatment option for the individual. Secondly, it needs to be assured that supportive therapy is readily accessible. It is critical to inform the patient about the need for life-long maintenance and optimal self-performed plaque control, as well as potential risks. Thus the foundation for a successful treatment outcome is laid at this stage. The placing of implants poses a risk for disease development, due to the build-up of a biofilm at the implant surface, and peri-implant diseases are common. Periimplant disease is a collective term for peri-implant mucositis, an inflammatory lesion that resides in the peri-implant mucosa, and peri-implantitis, a condition also involving the supporting bone.

Individually tailored maintenance is crucial

The prevention of disease development or recurrence must be the primary goal of a maintenance programme. Such a programme needs to be individually tailored to the patient’s risk profiling, which should be re-evaluated over time. Poor oral hygiene and smoking are repeatedly mentioned as risk factors for the development of peri-implant disease. A history of periodontitis and

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on-going periodontitis are risk factors, although patients successfully treated for periodontitis who adhere to a periodontal maintenance programme are not automatically classified as risk patients. Other risk factors are submucosal residual cement, poorly controlled diabetes, and having more than three dental implants. There is no consensus concerning the ideal interval between maintenance recall visits. The optimal interval differs with the patient’s risk profile and capability of self-performing oral hygiene in accordance with the recommendations. While education starts before placing the implant, coaching and education must be prevalent throughout the maintenance programme.

Assessment and treatment

During maintenance visits, it is important to assess the patient’s level of selfperformed oral hygiene and search for signs of disease such as redness, swelling, and bleeding on gentle probing, which, according to sources, is the key parameter for diagnosing peri-implant mucositis. Detecting early signs of peri-implant disease is of considerable concern to avoid disease progression. Peri-implant mucositis is a reversible disease, but, left untreated, it can progress into peri-implantitis. The treatment of periimplant mucositis involves mechanical debridement of the implant surface, reinforcement of optimal oral hygiene, and antiseptic rinses as adjunctive therapy. Control of the biofilm building up at the implant surfaces is significantly important for peri-implant health. Poor oral hygiene is considered a critical risk factor, whereas good plaque control is vital for success and predictability of periimplant treatment.

Guiding the patient to proper self-care To meet different oral hygiene needs, a broad spectrum of cleaning devices is available. Interdental brushes of

adequate size or floss are recommended for the inter-implant area. For other sites, it is recommended to use a regular toothbrush in combination with speciality brushes according to the patient’s needs. It is the therapist’s responsibility to guide the patient to the most suitable devices, educate the patient on their usage, and ensure that the patient masters the technique for future health and success. It is then up to the patient to perform daily oral home care in accordance with the therapist’s instructions. Raising awareness of the patient’s responsibility regarding a positive outcome needs to be part of the patient education. In order to facilitate the patient in performing good plaque control, the prosthetic suprastructure must be designed to allow cleaning around the implants. Considering this, it is evident that the patient is strongly dependent on the therapist and a well-designed maintenance programme. In a population with peri-implant mucositis, research shows that those not enrolled in a maintenance programme have a high incidence of peri-implantitis. A welldesigned maintenance programme, including patient education, is therefore a prerequisite for preventing disease development and progression.

Conclusion

The replacement of missing teeth with dental implants is a well-established and acknowledged treatment. Creating the very best conditions for the treatment is fundamental to preventing disease, and the long-term outcome depends on several factors. The patient relies on professional education, quality maintenance, and self-performed plaque control, which together pave the way for the ideally life-long, benefits of a successful implant rehabilitation. For references, see bitemagazine.com.au/ implant-maintenance.


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ADVERTORIAL

Product Guide Implants

Essential protection from long-term complications

For a long time, soft- tissue management was seen as purely aesthetic. But around implants, both keratinised tissue and sufficiently thick soft-tissue have protective functions. By Prof. Stefan Fickl, Germany Department for Periodontology, Julius-Maximilian University of Würzburg Private practice, Fürth

What soft-tissue conditions are beneficial?

Techniques for gaining keratinised mucosa

Free mucosal transplants are the gold standard for augmenting attached keratinized mucosa. According to a retrospective case control study from our working group, covering extraction sockets with gingiva punch products produces considerably more scars, contractions and colour deviations than the collagen matrix Geistlich Mucograft® Seal.4 We consider Geistlich Mucograft® Seal to be preferable as a closure for extraction sockets.

Techniques for volume thickening

Subepithelial connective tissue transplants are the current gold standard for augmenting the volume of soft-tissue around implants. However, clinical studies show that a similar tissue volume can be

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Figure 2: A Clinical situation with insufficient soft-tissue thickness. B Geistlich Fibro-Gide® at the time of implant placement. C Primary wound closure. D Partial thickness flap elevation on the buccal side four months after implant placement and soft-tissue thickening. Note the established thickness of the buccal soft-tissue. E Rolling flap and apically repositioning to position the attached mucosa on the buccal side of the implants. Geistlich Mucograft® to create additional keratinised mucosa in situ. F Final reconstruction.

obtained with a volume-stable xenogeneic collagen matrix (Geistlich Fibro-Gide®). Removing subepithelial connective tissue transplants or advancement flap techniques for thickening soft-tissue are often very complex and technically sensitive procedures. As an approximate value, the use of the collagen matrix can be assumed to increase soft tissue thickness by 1-1.5mm. In terms of the 2mm protective soft-tissue thickness requirement, this means that sufficiently thick soft-tissue can be achieved in a single soft-tissue augmentation.

Points in time

The soft-tissue can be improved at different times. A Ridge Preservation can be performed immediately after tooth extraction. Using a porcine collagen matrix (Geistlich Mucograft® Seal) for covering the extraction socket can achieve a better and faster soft-tissue closure with only minor scarring.4 Soft-tissue can also be thickened at the same time as the implantation. Late soft-tissue thickening after the implantation can be more difficult.

All parameters fulfilled

Figure 2 shows a patient with a thin and poorly attached mucosa. The aim here was to achieve all the targets required for sufficient peri-implant tissue—2mm attached mucosa plus 2mm soft- tissue thickness—by augmenting volume and subsequently managing the soft- tissue. Geistlich Fibro-Gide® was placed at the time of the implantation to allow primary healing beneath the mucosa. Visibly, Geistlich Fibro-Gide® thickened the soft-tissue significantly. The collagen matrix Geistlich Mucograft® was then used with open healing at the time the implants were exposed in order to obtain an augmented band of attached mucosa.As already alluded to, soft-tissue formation after a complication, e.g., implant dehiscence and/ or poorly attached mucosa to a prosthetically treated implant, is a difficult and less predictable process. For this reason the above-mentioned soft-tissue augmentations prior to prosthetic restoration are key to avoiding middleand long-term complications.

PHOTOS: STEFAN FICKL. FOR REFERENCES, PLEASE VISIT bit.ly/bite-geistlich

In terms of the quality of the surrounding soft-tissue, augmenting an approximately 2mm band of attached keratinised mucosa should be the goal to establish stable, longterm conditions. One review concluded that a lack of adequate keratinised mucosa is associated with more plaque accumulation, tissue inflammation, mucosal recession and attachment loss.1 As to the quantity (thickness and height of the peri-implant soft-tissue cover), studies show that thicker peri-implant soft-tissue leads to less bone resorption. Thus Linkevicius et al. were able to show that 2mm thick peri-implant soft tissue induces significantly less crestal bone loss than a soft-tissue thickness of less than 2mm.2 The group was able to show that peri-implant soft-tissue augmented with biomaterials behaves in a similar way to “naturally thick” soft- tissue.2 Today it must therefore be concluded that the target for soft- tissue thickness should be 2mm, and the target for attached mucosa also 2mm.


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ADVERTORIAL

Product Guide Implants

Say goodbye to plastic tips!

The ImplaMate® Implant scaler by Nordent.

ImplaMate® Implant Scalers by Nordent, now available with micro-mini patterns & come with a LIFETIME GUARANTEE ImplaMate Scalers and Curettes feature tips made from Class 5 Titanium, the same material as implant abutments. The ImplaMate tips are specially designed and manufactured to safely glide over the implant surface while efficiently removing debris. The thin, solid titanium tips allow access in the tight areas, and are rugged enough to provide the performance of traditional scalers. ImplaMate instruments never need to sharpening, and feature a purple tint for easy identification. ImplaMate instruments can be sterilised by any method and require no special handling procedures.

A difference you can feel

l Eliminate any worries about flexing tips and burnished calculus, with the firmness of traditional scalers

l SafeEdge tips designed to simply glide over surfaces and remove debris without any safety concerns l Access all those hard-to-reach areas with slender tips that are easy to adapt l Implant maintenance made safe, easy and effective Now by popular demand, our ImplaMate Langer Curettes are available with micro-mini tips. These designs feature shorter and narrower blades, providing exceptional access around abutments with tightly attached tissue. There are 9 patterns, all featuring our DuraLite ColorRings handle, Anterior Sickle Scaler #6/7 (CEISN67), Posterior Sickle Scaler #204S (CEIS204S), Universal Barnhart Curette #5/6 (CEISBH5-6), the Langer series (CEISLN1-2, CEISLN3-4,

CEISLN5-6) and the Langer micro-mini series (CEISLN1-2MM, CEISLN3-4MM, CEISLN5-6MM).

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YOUR TOOLS

Tools of the trade

This month, our dentists review a saliva ejector, a pair of forceps, a soft tissue laser and glass ionomer restoration material.

HYGOFORMIC SALIVA EJECTOR

by Dr Damian Chung, Park Terrace Dental, Port Lincoln, SA This is a really handy little tool that I’ve been using for the past 25 years. It always surprises me that more dentists don’t know about them. They are a great help for all restorative work, intraoral scanning, and underneath a rubber dam during root canal treatment.

What’s good about it

This saliva injector works as an extra pairs of hands, providing retraction and protection for the tongue while also enabling a dry work field. It fits into the saliva ejector hose of the dental chair using a small adapter tube. There is a copper wire inside the injector that allows it to be bent left, right or unfurled to cover a wider area. It slots under the side of the tongue and by reshaping the extraoral section it can be clipped securely over the lip and chin so it remains in place for a whole session. They’re very comfortable for patients. They often work with patients who gag as they don’t contact the palate or dorsal of the tongue. I use them when taking full arch scans with my Cerec camera. I can easily scan while it retracts two thirds of the mandible, then swap it to the other side to finish off the whole arch. Even for the maxilla it will keep the tongue aside for better access and vision. They are perfect for hygienists or anyone working single handed. They are also fantastic when placing fissure seals on children. They come in a pack of 100 and are very cheap to purchase.

What’s not so good

PHYSICS FORCEPS

by Dr Kevin Lee, Dentists of Australia, Gilgandra, NSW Physics forceps come in two different types and multiple sets. The forceps with the green bumpers are for general extractions, while the yellow bumpers are designed for use in the back of the mouth.

What’s good about it

I use these forceps with virtually every extraction I undertake. GoldenDent, the manufacturer, claim that there is a set of their forceps suitable for every tooth and every situation. While I don’t agree with that 100 per cent, they can be successfully used for most extractions. All that is required is a lingual aspect of the tooth that can be gripped by the forceps. Once I get a solid hold of the tooth, mobility is achieved pretty quickly. In the vast majority of cases, the tooth is extracted atraumatically when using Physics Forceps. It allows you to preserve the buccal plate without any issues. I find that these forceps get the tooth to come out very nicely. Even if they don’t fully deliver the tooth, it’s so loose that you can just switch to conventional forceps and remove it within two seconds. I’ve been using them for the past 18 months and, so far, I haven’t seen one root tip fracture. These forceps do their job very well.

What’s not so good

While a rubber dam is the gold standard for moisture control, these come a close second—though I would still recommend a dam for endodontics. I prefer to steer away from disposables whenever possible due to environmental waste-related reasons but unfortunately, we can’t avoid it completely in dentistry.

They’re a long-lasting tool but the bumper needs to be replaced every now and then. They can’t be used when there is no lingual purchase point. I’ve tried using a bur to get some purchase but it doesn’t work very well. Also, if the ligaments are ankylosed, the ankylosed fragment comes out with the tooth after extraction, meaning that there is a fracture in the bone.

Where did you get it

Where did you get it

Henry Schein Halas (henryschein.com.au)

Amalgadent (www.amalgadent.com.au)

Bite Magazine

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YOUR TOOLS

PICASSO LITE+

EQUIA FORTE

This laser can be used for a variety of surgical procedures but I tend to use it for just a couple of specific situations. Even though I don’t use it all the time, it’s nice to have it on hand when I need it.

This is a system of two materials: EQUIA Forte Fil and EQUIA Forte Coat, that is easy to use and relatively quick to place. I’ve long been a fan of glass ionomer technology for various preventive and restorative applications.

What’s good about it

What’s good about it

What’s not so good

What’s not so good

Where did you get it

Where did you get it

by Dr Gita Mazaheri, Artful Dentistry, Charnwood, ACT

I use this laser when placing a crown and I need to do a gingivectomy to get a better impression. It’s specifically designed for frenectomies and to create a clean margin for veneers, though I haven’t used it for that. It comes with different coloured disposable tips for different treatments. I use the green tip when doing root canals. During irrigation, the laser activates the irrigation materials down to the root tip. The orange tip is for gingivectomies and crown prep, but the purple tip can be used too. If the gum is inflamed, has too much bleeding or too much coverage, it can be removed without anaesthetic and the patient won’t feel any pain. Another great thing about this laser is that it stays relatively cool while cutting so there is virtually no trauma to surrounding tissue. The Picasso cuts fast, causes minimal bleeding and is painless.

It’s expensive to purchase and the disposable tips are also pretty expensive. You need a licence to use it—I had to answer a lot of online questions and complete a number of questionnaires to get my licence. Now I believe you have to complete a course before becoming licenced.

Dentsply Sirona (www.dentsplysirona.com/en-au)

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by Dr Peter Norton, Dental On Clarke, Crows Nest, Sydney

I use EQUIA Forte in a lot of class one and class five restorations. It’s approved for certain types of class two restorations but I’ve not used that technique to date. I also use it for long-term fissure protection. Its white colour is less obtrusive than some other products designed for fissure protection and EQUIA seems to last much longer than other GICs I’ve used for fissure protection. The main reason I like this material is its combination of higher strength and fluoride release compared to its Fuji IX predecessors. Most glass ionomers require some sort of coating but the manufacturer’s guidelines are usually not very strict. With EQUIA Forte, however, it’s important to use the correct coating (EQUIA Forte Coat) to get the best results from the material. The secondary coat substantially improves the physical properties.

The coat material has quite a strong acetone smell. It’s only there for a few seconds but it’s not very pleasant. I let my patients know that there’s a funny taste coming but paediatric patients often find it objectionable. That’s significant, since I use the EQUIA Forte System so often with paediatric patients.

Henry Schein Halas (henryschein.com.au)


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YOUR LIFE

What’s cooking

“When I was growing up, my mum cooked a lot. She loved baking and was always making custards and cakes. Initially I was more interested in eating than cooking but then I did a cooking class at the Spirit House restaurant and cooking school in Yandina, Queensland. They serve amazing contemporary Asian food and the cooking school is an exploration of smells, tastes and sounds. It’s quite an overwhelming experience. “I began to really enjoy cooking and I spent a lot of time baking sweets and cakes. I was a little obsessed with macaroons and made thousands of them over the years. As a dentist, I was concerned creating so many sweet things and gradually became more interested in savoury cooking. “While I was studying dentistry, I applied to The Great Australian Bake Off and was chosen as a contestant in 2017. It was during my final year of

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dental school and I wasn’t able to take six weeks off to appear on the show. However, I applied again in 2018, was accepted as a contestant and it was a really amazing experience. A real highlight was meeting Maggie Beer. She’s very passionate about cooking and a very caring, enthusiastic person. “The best dish I made on the show was a three-tier cake with chocolate sponge, roasted black sesame and peanut buttercream. I created a tempered chocolate combustion chamber in the centre of the cake that I filled with dry ice and blood orange curd. It erupted like a volcano and Maggie Beer had no idea what was going on. “The dish that sent me home was a crepe cake. I had to make about 60 crepes and pile them up into a cake formation. I was experimenting with flavours and used star anise with chocolate and orange. Unfortunately,

it didn’t come together how I hoped. For my last episode we had a group hug and all danced the Nut Bush for the send-off. “Recently, I’ve started a Facebook and Instagram page called Dentally Cooked that focuses on getting people to eat healthier food. I provide recipes that are delicious and good for the teeth. Someday, I hope to open a dental practice restaurant that would combine my two passions in life. “Cooking is a constant process of learning, making mistakes and improvement. I love the creativity it offers. I like to cook for friends and share the experience with them. It certainly brings people together.” See Dr Matear’s dental friendly recipes at www.instagram.com/dentallycooked/ and all cooking at www.instagram.com/ mmatear/

INTERVIEW: FRANK LEGGETT PHOTOGRAPHY: KEVIN VO

A love of cooking saw Dr Marcus Matear of Palm Square Dental Care in Bendigo, Victoria, become a contestant on The Great Australian Bake Off.


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Bite October 2019  

Bite October 2019