D E N TA L S O L U T I O N S
FEB / MARCH 2022
32 - 34
ENDODONTIC SOLUTIONS
INFECTION CONTROL SOLUTIONS
Our Solutions Aligner Solutions
2
EQUIPMENT SOLUTIONS
Our Brands 6-7
Acteon
Cosmetic & Restorative
8-22
Ansell
Pain Control Solutions
24-27
AquaCare
Endodontic Solutions
28-39
Preventative Solutions
28-31
Infection Control
44-62
Instrument Solutions
63-66
Practice Solutions
68 - 69
44 - 62
67
Equipment Solutions
68-69
Prosthetic Solutions
70-76
New Products
77-86
Kuraray Noritake
14-15
45
Mocom
58-59
22
Morita
68-69
32-33
Philips
81
Colgate
40-41, 79
Reveal
6-7, 78
Coltene
18-20, 37-39, 70-72, 80
Radic8
60-61
16-17
Busa
Dentisan
46-47
Septodont
EMS
42-43
Scheu
74-76
EdgeEndo
28-31
SciCan
54-56
GC
8-13
GKE
57
Henry Schein
44, 48-53, 82-83
Hu-friedy
1 3 0 0
62-66
6 5
8 8
2 2
34-37, 38-40, 84-85
SDI The Wand
86 26-27
Vita
73
White Dental Beauty
21
As we welcome the year ahead, Henry Schein would like to wish all our customers and readers a happy and prosperous 2022, and as your trusted business partner Team Schein looks forward to continuing to support you and your practice over the year ahead. Entering the year with some of the strongest vaccination
rates and off the back of some of the strictest and longest lockdowns in the world, 2022 was set to be a year of getting back to normality and reconnecting with friends, colleagues and loved ones. But already 2022 has presented its own challenges beyond those which we experienced before. With the rapid spread of the Omicron variant putting pressure on patient screening, staffing shortages, procurement, and freight challenges, Henry Schein is committed to providing consistent supply and reliable support for your practice. Our procurement and warehouse teams continue to work hard to ensure consistent supply as well trying to get access to in demand products like Rapid Antigen Tests, N95 masks. In addition to this we continue to focus on expanding our educational offering available to your practice and sourcing the latest products to help you care for your patients. Training & Education Aligning with Henry Schein’s mission to focusing on practice care so dental professionals can focus on patient care, at the end of 2021, Henry Schein partnered with Prime Practice a leading global provider of training and business solutions for dental practices, with the aim to provide valuable training for staff within your practice to help make 2022 your most successful year yet.
Manager with a wealth of resources and online training and the other on Associate Dentists, in conjunction with Dr Dentist Jamie Workman to ensure your associates are skilled with the tools they need to maximise your practice success and growth. To find out more visit: https://primepractice.com.au/hs-shop. We also continued to develop DentalEducationHub. com.au now with over 150 free and on demand webinars, plus much more. Exciting New Product Announcement Reveal Clear Aligners 2022 will see the introduction of many new products in partnership with our supplier partners, check out our new product section on pages 6-7, 79 to find out more. One of the products we are most excited about is the addition of Reveal Clear Aligners to the Henry Schein Orthodontics portfolio. With a number of Clear Aligner options already available on the market, Reveal offers the additional benefits of Clear Ware technology for a crystal clear appearance and exceptional fit reducing the requirement for attachments with superior patient comfort. With over 50,000 cases globally in recent years, Henry Schein Australia is thrilled to be launching Reveal to you in February 2022.
In Partnership with Prime Practice we have launched 2 incredible programs, one focused on the Practice
DID YOU KNOW THE GREEK WORD “ORTHO” IN ORTHODONTICS MEANS TO STRAIGHTEN OR CORRECT
ONLINE
TV
CALUM COOGAN Marketing Communications Digital & CX Manager
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NEW PRODUCTS
NEW PRODUCT SPOTLIGHT
Henry Schein in conjunction with our global supplier partners are committed to sourcing and supplying the latest and highest quality products to support the advancement of dental professionals and patient care in Australia. Check out the latest editions to Henry Schein’s range, available online, or through Customer Care and your Relationship Manager.
Reveal® Clear Aligners Reveal Clear Aligners are the clear choice for pre-restorative anterior alignment treating Class I mild-to-moderate movement Aesthetic cases prior to Crowns, Bridges, Implants & Veneers. Reveal is backed by over 40 years of innovative orthodontic solutions and over 50,000 cases globally in recent years. Reveal Clear Aligners are offered by your Trusted Business Partner, Henry Schein, for a seamless experience with all your restorative and aesthetic solutions all-in-oneplace. Read more on page 78
Coltene BioSonic® UC150 The new BioSonic® UC150 ultrasonic cleaner offers great quality you have come to expect from all BioSonic® products while paving the way for some of the latest technological enhancements in ultrasonic cleaning. The sleek, Swiss design of BioSonic® UC150 is designed for efficiency, versatility and convenience. Read more on page 80
Colgate® – Optic White® Light Up Colgate® Optic White® Light Up Professional Take-Home Teeth Whitening Kit introduces two powerful patented technologies – An innovative indigo LED Light Device paired with a uniquely formulated precision application whitening pen, for extraordinary whitening made simple and no impressions or customer trays required. Read more on page 79
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Hu-Friedy Calibra Calibra is an XTS (AlTiN)* coated composite instrument which helps provide the proper anatomical curvature to the dentin material layer of a restoration and leaves the ideal space for the final layer of enamel material. The Calibra “IN” point is used to define the dentinal skeleton, while the Calibra “OUT” point helps to reduce the chances of excess composite material being placed during the final layer of the restoration. Calibra acts as a guide, helping to prevent over-contouring at the preparation margin while assisting in reducing excess composite thickness build up. Read more on page 82
SDI Pola For Aligners Pola For Aligners can easily be used as a take home kit, ensuring a great patient experience by providing whiter, brighter smiles with no additional wear time. Perfectly formulated for use with orthodontic aligner trays, available in 10% carbamide peroxide, neutral pH and desensitizing additives and stylish cosmetic packaging. Read more on page 86
Septodont R.T.R.+ New Biphasic Formulations for Bone Grafting The basic principle of R.T.R.+ composition is the appropriate balance between the stable hydroxyapatite (HA) and the fast resorbing ß-TCP. The stable hydroxyapatite (HA) Acts as a scaffold offering an ideal structure for cellular adhesion, and provides long term stability thanks to its slow resorption. The fast resorbing ß-TCP It immediately begins to release calcium and phosphate ions into micropores enhancing bioactivity. Read more on page 84
Philips Sonicare 2000 Range & Cordless Power Flosser The Philips Sonicare 2000 helps whiten teeth from day one. Simple and easy solution to avoid cavities, promote long term overall health, remove plaque & bacteria and follow the advice of Dental Practitioners. The Cordless Power Flosser is a portable and easy way to clean in-between the teeth for better gum health Unique Quadstream Technology, clinically proven up to 100% more effective than string floss for healthier gums. Read more on page 81
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ALIGNER SOLUTIONS
CLEAR ALIGNER CASE TREATMENT ACHIEVED WITH MINIMAL ATTACHMENTS
The patient, 23 years and 1 month old, presented with moderate crowding, retroclined maxillary incisors, and an anterior occlusal cant. She wanted to be treated with clear aligners but preferred minimal attachments, unlike the aligner treatment her twin sister received with aligners from a different manufacturer that utilized several attachments. The progress photographs presented in this case show that after 5 months of treatment with Reveal® Clear Aligners (Henry Schein® Orthodontics, revealclearaligners.com.au) her teeth alignment was nearly ideal. For much of the treatment the patient had no attachments and mentioned that people could not even tell she was wearing aligners. To fix her cant and improve her smile arc, a few attachments were necessary, which the patient was fine with, knowing that it would idealize the treatment. The final result was achieved in just 11 months. The patient, who was extremely pleased to be in the esthetically friendly Reveal aligners throughout the treatment, was ecstatic with the results. From a clinical standpoint, the posterior occlusion remained socked in extremely well and the Reveal aligners tracked superbly throughout the treatment. The clarity of the aligners was excellent, and the author/clinician considers this aligner system a true asset to the practice.
Key Takeaways Reveal® Clear Aligners from Henry Schein® Orthodontics are made with an advanced manufacturing process with proprietary ClearWear™ material to provide excellent esthetics and fit. Featuring smooth edges trimmed at the gingival margin, the aligners provide exceptional tooth-specific control to reduce the need for unattractive attachments. Compatible with both digital scans and traditional PVS impressions, Reveal’s open-source platform accepts STL digital impressions from all leading intraoral scanners.
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BEFORE AFTER
Fig.1 Full-face smile before treatment. Fig 2. Occlusal view of maxillary arch before treatment. Fig.3 Occlusal view of mandibular arch before treatment. Fig 4. Right lateral retracted view before treatment. Fig 5. Front retracted view before treatment.
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Fig 6. Left lateral retracted view before treatment. Fig 7. Full-face smile after 5 months of treatment. Fig 8. Occlusal view of maxillary arch after 5 months of treatment. Fig 9. Occlusal view of mandibular arch after 5 months of treatment. Fig 10. Right lateral retracted view after 5 months of treatment. Fig 11. Front retracted view after 5 months of treatment. Fig 12. Left lateral retracted view after 5 months of treatment. Fig 13. Full-face smile after treatment. Fig 14. Occlusal view of maxillary arch after treatment. Fig 15. Occlusal view of mandibular arch after treatment. Fig 16. Right lateral retracted view after treatment. Fig 17. Front retracted view after treatment. Fig 18. Left lateral retracted view after treatment
MARIO CHORAK DMD Private Practice, Fairwood and Mercer Island, Washington
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COSMETIC & RESTORATIVE
INITIAL LISI BLOCK LITHIUM DISILICATE CAD/CAM BLOCK FOR CHAIRSIDE SOLUTIONS
Lithium disilicate block for one appointment dentistry Initial LiSi Block is a fully crystallized lithium disilicate block that delivers optimal physical properties without firing. This unique block features GC’s proprietary HDM (High Density Micronization) technology for CAD/ CAM dentistry to deliver high wear resistance, smooth margins and aesthetic final results. This makes it an ideal, time saving solution for single visit chairside treatments Initial LiSi Block can dramatically reduce process time: no need to fire, glaze, characterize and cool. This saves up to 40% in the time^ required to create your restorations, also reducing the chair time for you and your patient. You just need to mill, polish and place.
Workflow
Prepare
Scan
Design
Mill
Polish or characterise
Condition
Cement
Final result
Images courtesy of Prof. Matteo Basso, Italy
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Natural beauty restored in one appointment Initial LiSi Block is available in high translucency (HT) and low translucency (LT) and offers a natural opalescence in any light. Choose your preferred finishing procedure Superior gloss can be obtained in few minutes by polishing only, and the restoration is then ready for luting.* For sophisticated aesthetic cases, remarkable results can be achieved with GC Initial Lustre Pastes NF and Initial Spectrum Stains.* Images courtesy of Dr Javier Tapia, Spain
Anterior Veneers, Fast, precise and beautiful
Preparation
Milled restorations
Milled restorations
After cementation
Final result
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COSMETIC & RESTORATIVE
GC RESIN CEMENTS
G-CEM ONE™ Self-adhesive resin cement Choose G-CEM ONE, a dual-cure self-adhesive resin cement with high adhesive bond strength^† for daily procedures, which can also be used in challenging and non-retentive situations when applying the optional tooth primer^.
Posterior Onlay (Lithium Disilicate) with optional Adhesive Enhancing Primer
Initial Situation
Restoration cemented with use of Adhesive Enhancing Primer.
Final result Clinical images courtesy of Dr. Riccardo Tempesta, Italy
Posterior Crown (Zirconia)
Prepared tooth cleaned and dried.
Restoration cemented
Final result Clinical images courtesy of Dr. Kazunori Otani, Japan
^ GC R&D, Data on file. † Sato K, Arita A, Kumagai T (2019). Evaluation of Bonding Properties of Resin Cement in Selfcure Mode. J Dent Res (Spec Iss 98 A):1884 (https://iadr.abstractarchives.com/abstract/19iags-3163131/evaluation-ofbonding-properties-of-resin-cement-in-self-cure-mode)
GC Luting Guide A solution for every luting challenge
Download your copy of the new GC Luting Guide
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COSMETIC & RESTORATIVE
G-CEM LinkForce® Dual-cure resin cement Strength and aesthetics in one system for all indications, all substrates. G-CEM LinkForce is the universal adhesive resin cement that is ideal to use whenever additional retention is needed and a must-have for all CAD/CAM ceramic and hybrid ceramic blocks such as CERASMART™ 270.
Selective etching of the enamel
Dual cure mode was selected. 1 drop each of G-Premio BOND and Dual Cure Activator were dispensed and mixed.
The mixed bond was applied to the prepared enamel, dentine and composite liner and left for 20 secs then dried for 5 secs.
Application of G-Multi PRIMER on the pre-treated CERASMART onlay.
G-CEM LinkForce is applied to the internal surface of the CERASMART onlay.
Placement of the onlay onto position. Excesses are then removed before tack-curing.
Final light-curing. Apply air barrier (optional) and light cure all surfaces.
Final situation CERASMART onlay bonded with G-CEM LinkForce
Clinical images courtesy of Dr. Anthony Mak, Australia
G-CEM® Veneer Light-cured resin cement A versatile resin cement for easy luting of restorations up to 2mm thick. G-CEM Veneer: a light-cured resin cement for high aesthetic demand restorations featuring Full-coverage Silane Coating (FSC) technology.
Before
Application of G-MULTI Primer on the inner surface of the veneer.
Preparation etching
Application of G-CEM Veneer onto the veneer.
Cementation
Application of G-Premio Bond
Final outcome Clinical images courtesy of Dr. Javier Tapia, Spain
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COSMETIC & RESTORATIVE
G-ÆNIAL A’CHORD SIMPLICITY, AESTHETICS AND PERFORMANCE IN YOUR HANDS
With more than 100 years of experience in serving dentistry and over one billion composite restorations worldwide, GC introduces its proprietary High-performance Pulverised CERASMART (HPC) filler and Full Coverage Silane Coating (FSC) technologies with its latest universal composite G-ænial A’CHORD which brings together simplification, invisible fillings, natural fluorescence and advanced technologies in one syringe.
Class IV controlled layer concept utilizing G-ænial A’CHORD in 3 shades
Pre-Operative presentation, exhibiting a failed direct composite restoration on the upper left central incisor (Tooth 21).
Tooth surface cleaned and prepared with 37% Phosphoric Acid prior to application of the adhesive with G-Premio BOND.
Completion of the Palatal Shelf and interproximal wall with the application of G-ænial A’CHORD composite, shade JE. The Interproximal wall was formed with the use of a plastic myeloid strip and pull through technique to help develop an anatomical contour.
The dentine layer was then completed by the application of an opaque shade of G-ænial A’CHORD AO2. This is to provide the correct opacity and “block out” effect of the final restoration.
A chromatic body shade, G-ænial A’CHORD shade A2 was then applied and extended beyond the bevel to mask the transition line. Internal anatomy in the incisal third was also sculpted and formed in this increment of composite resin. White tints, Essentia White Modifier (WM) was then utilised to accentuate the mamelons and to replicate similar characteristics present in the adjacent right central incisor.
A final translucent shade of G-ænial A’CHORD shade JE was then placed to bring the anatomy to full contour.
2-week review demonstrating the complete optical and functional G-ænial A’CHORD restoration on the tooth 21.
For further information
Clinical images courtesy of Dr Anthony Mak, Sydney
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COSMETIC & RESTORATIVE
EQUIA FORTE BULK FILL GLASS HYBRID RESTORATIVE SYSTEM
The synergy of GC’s latest Glass Hybrid and resin technologies, working with minimal intervention cavity techniques, accentuates EQUIA Forte® as the first choice for restoring initial occlusal lesions in permanent posterior teeth. EQUIA Forte® builds stronger restorations, using a simple placement procedure that takes less than 5 minutes to complete. Plus you can use EQUIA Forte® in all other indications where you may already be using conventional glass ionomer cements. Management of occlusal caries
Female patient, age 36, tooth 46 rapid caries approaching distal.
Cavity Conditioner applied for 10 seconds to remove surface debris.
EQUIA Forte® Fil has up to 60 seconds working time and is placed in one increment.
Preliminary shaping was performed; occlusal contact, good aesthetics and shape were verified.
EQUIA Forte® coat was applied and light-cured 20 seconds to complete the EQUIA® restoration
Finished restoration Images courtesy of Dr E. Stephen Vouliotis
2022 Top Product Awards
DIRECT RESTORATIVES
Download your copy of the EQUIA Forte HT Brochure
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COSMETIC & RESTORATIVE
THE UNIVERSAL TREND IN DENTISTRY
Dentistry is currently experiencing an interesting evolution. While dentists are becoming increasingly specialised, the demand for products that can be used for all indications continues to grow. These systems and materials are part of a universal trend in dentistry—a trend that Kuraray Noritake Dental is extremely well suited to accommodate. Advancing adhesive dentistry
Universal composites and cleaners
As the technology has developed, dental adhesives have progressed from no-etching to total-etching and then self-etching systems. In 1978, Kuraray Noritake Dental introduced CLEARFIL™ BOND SYSTEM-F, the world’s first total-etching adhesive system.
The silane technology behind PANAVIA™ SA Cement Universal can also be found in CLEARFIL MAJESTY™ ES Flow, a universal flowable composite suitable for all cavity classes. Its small, durable filler particles help to ensure excellent flexural and mechanical strength, while special cluster fillers provide a light diffusion effect similar to that of natural teeth.
More than four decades later, the company is still setting standards with CLEARFIL™ Universal Bond Quick, a one-step dental bonding agent that can be used in total-etching, self-etching and selective-etching modes.
Creating aesthetically natural and reliable restorations is easier than ever with CLEARFIL MAJESTY™ ES Flow.
Combining Kuraray’s original MDP monomer with hydrophilic amide monomers, CLEARFIL™ Universal Bond Quick is designed to be less technique-sensitive than other one-step solutions and has been proved scientifically to deliver stronger, more stable bonds.
And when considering Kuraray Noritake’s forays into universal solutions, let us not forget the new KATANA™ Cleaner, a non-abrasive cleaner that, unlike other options on the market, can be used both intra- and extra-orally.
It is not just bonding agents that are becoming universally applicable either. A dental cement like Kuraray Noritake’s PANAVIA™ SA Cement Universal builds upon the success of previous generations of PANAVIA™ to deliver optimal bonding to dental tissue as well as to metal and zirconia materials.
Backed by extensive scientific research, the KATANA™ Cleaner comes with a single-handed delivery cap and an extremely straightforward method of application: simply apply with a rubbing motion for at least 10 seconds, rinse with water and air-dry before cementation.
This self-adhesive resin cement always requires the same procedure, even when bonding porcelain, lithium disilicate and composites, without the need for a primer.
Making dentistry more streamlined The modern dental practice is often multidisciplinary in its nature, which can result in the need to store many more products than there might be space for.
The reason? It’s the addition of a unique long carbon chain silane.
Through these universal products and others, Kuraray Noritake is aiming to make dentistry simpler and more efficient
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COSMETIC & RESTORATIVE
LIGHT DIFFUSION TECHNOLOGY KEY TO THE SUCCESS OF YOUR COMPOSITE RESTORATIONS
With CLEARFIL MAJESTY™ ES-2, the shade transition from composite to tooth is virtually invisible. The secret to this lies in light diffusion technology. How does this work? Before we discuss the technology in detail, here is some more information about our CLEARFIL MAJESTY™ ES-2 composites. All CLEARFIL MAJESTY™ ES-2 composites are suitable for both anterior and posterior applications. The different variants within the ES-2 family are characterised by supreme handling and a long working time, and the fact that they do not slump during modeling. A key feature of these composites is the ease with which restorations blend into their surroundings. This results in durable and aesthetic restorations.
At Kuraray Noritake Dental Inc., we do things differently. Besides the optimised translucency in CLEARFIL MAJESTY™ ES-2 composites, it’s the light diffusion technology that makes the restoration blend seamlessly with the adjacent tooth structure. Thanks to the combination of these two parameters — translucency and light diffusion — the capabilities are far more extensive than with just translucency.
EXCELLENT MECHANICAL PROPERTIES Flexible strength
118 MPa
Filler load
78 wt%
Compressive strength
347 MPa
Volumetric shrinkage
1.9%
Curing Depth
2.0 mm
Working time under ambient light
270 sec
In CLEARFIL MAJESTY™ ES-2 composites, two types of fillers are used. Barium glass particles form the basis of the filler. Alongside this, advanced prepolymerised filler particles are added. The latter type is called light diffusion filler, since it is primarily these filler particles that achieve a light-scattering effect within the composite. The way in which a restoration ‘adjusts itself”, to the shade of the tooth to be restored, is not the same for all composites. Most composite manufacturers make use of the so-called ‘chameleon effect’. A composite that is sufficiently translucent allows light to pass through. Light is reflected off the walls of the cavity, whereby the composite restoration assumes the shade of the adjacent tooth structure. In cavities that aren’t too large with a sufficient amount of surrounding tooth structure, this chameleon effect works well enough. However, with larger cavities or in the absence of underlying tooth structure, as is often the case with anterior restorations, the aesthetic blending effect is limited. The brightness is far from satisfactory, and the restoration looks grey.
Light transmission without LDT
Light transmission with LDT
The different dental tissues have different opacities. Enamel is more translucent than dentine. However, the degree of translucency/opacity of both tissues is not always the same. Age, thickness of the structure and various intrinsic and extrinsic factors all play a role. Depending on the desired end result, the most appropriate member(s) of the CLEARFIL MAJESTY™ ES-2 family is/are selected for the restoration. In aesthetic restorations in which opacity differences need to be considered, a layering system is necessary. More uniform restorations are easily constructed with a composite that has broad shade and opacity coverage. CLEARFIL MAJESTY™ ES-2 Premium for highly esthetic restorations. CLEARFIL MAJESTY™ ES-2 Universal for routine aesthetic restorations involving few or no opacity differences.
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COSMETIC & RESTORATIVE
ATRAUMATIC EXTRACTIONS MORE PREDICTABLE IMMEDIATE IMPLANT PLACEMENT
Dentists have been extracting teeth for centuries with some of the first extractions documented by Aristotle in 350 B.C. Since then there are myriad of options with which to extract a tooth including forceps, elevators, and rotary handpieces being the choices for the majority of dentists today.
is spared. Other benefits of using Piezotome CUBE include decreased postoperative pain and swelling compared to traditional methods of bone surgery and a substantial decrease in need for analgesics post operatively as well.1 As the surgeon’s skill and experience increases, the CUBE can be utilized for a number of other bone surgery procedures such as sinus elevations, ridge expansions, crown lengthening, and osteo-assisted orthodontics.
As more and more dentists add implantology to their practice, extractions with immediate implant placement are becoming an attractive and predictable option for patients and clinicians alike. In order to create an environment for an immediate implant placement, it is paramount to make the tooth extraction as atraumatic as possible, preserving the socket while being minimally invasive in the process.
You may have tried a piezo surgical device in the past and thought it was just too slow. I thought the same thing until I tried the CUBE. The power level surpasses anything I have used in the past. Not only do you and the patient benefit from the safety, decreased pain and predictability, but the power level makes the procedures very fast.
The Piezotome CUBE™ by ACTEON™ (figure 1 image of CUBE device) is a novel ultrasonic bone surgery device that uses powerful, high frequency vibrations with slim tips to disrupt the periodontal ligament making extractions faster and less traumatic while preserving the socket. This is especially important when working in the esthetic zone where preservation
The following case study documents an atraumatic extraction using Piezotome CUBE with an immediate implant placement. A 38-year-old female presented with a crown, loose post, fractured root and periapical lesion in tooth number 7 (figure 2 x-ray of crown and post) that was deemed unrestorable with a hopeless prognosis.
Figure 1
of the buccal bone is extremely important. The risk of damaging or breaking the alveolar bone is drastically reduced due to decreased stress that is needed than using forceps alone. In most cases no surgical flap is needed to perform extractions with CUBE keeping the periosteum intact.
Figure 2 The patient was given multiple treatment options and ultimately agreed to extraction with immediate implant placement. A staged approach was planned with an essex temporary due to a deep bite and higher risk of provisionalization. Surgical planning utilized Blue Sky Bio® software.
This is due to the selective cutting where only hard tissue like bone and ligament is cut and soft tissue
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Figure 3 Atraumatic extraction was performed using Piezotome CUBE with an LC2 extraction tip. (figure 3 Extraction with CUBE). Minimal bone resection was noted, and buccal bone was sounded with instruments. It was confirmed intact and not damaged.
The gap between the fixture and plate was grafted with mineralized cortical cancellous bone and site was covered with L-PRF membrane using the IntraSpin® system. A BioHorizons 4.2 x15 Tapered Plus implant was placed with a cover screw. Site was closed with 4-0 PTFE sutures and verification x-ray was taken to confirm the implant was in position. (figure 6 x-ray of implant in position).
Figure 4 No surgical flap was raised keeping the periosteum intact in line with atraumatic extraction protocol. (Figure 4 Image of socket) (Figure 5 image of tooth extracted. Using a surgical guide, an initial pilot drill was used to prepare the socket. Osseodensification with Versah® bur was used to densify the bone in the socket to create higher initial stability which is a key factor for implant success. Using the Versah bur, an infracture of the nasal floor was performed to create stabilization of the apical area of the implant in cortical bone.
Figure 6 This extraction and immediate implant placement were facilitated by the ease of the atraumatic extraction by the Piezotome CUBE. When preservation of the socket is needed, the predictability and power is provided by the CUBE.
Figure 5
DR. ADAM KIMOWITZ DMD, FAAID, DABOI/ID Denville, NJ, USA
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COSMETIC & RESTORATIVE
CORRECTING A SINGLE MIDLINE DIASTEMA AN ETHICAL TREAMENT PLAN - A STUNNING AESTHETIC RESULT
Initial presentation
Treatment plan
Mr MB is a long-standing patient with excellent oral health and a proven history of six-monthly examination and hygiene appointments with low caries, periodontal and tooth wear risk. After engaging in discussion regarding the patient’s tooth position, he was delighted to hear that modern dentistry would allow closure of the gap between his front teeth (see Fig. 1), with no tooth damage and without the need for orthodontics, which for him was too involved and time-consuming.
1. Four weeks of home tooth whitening using custom trays:
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Two weeks 16 % carbamide peroxide overnight use.
3. Two-week review to allow for rebound and composite try-in. 4. Freehand partial coverage, bonding UR1 molar and UL1 molar. 5. Replacement upper ‘top up’ whitening tray. Treatment protocol In order to maximise the aesthetic gain planned with composite bonding, it was agreed to complete a period of home tooth whitening to lift the base shade of all teeth which was currently close to an A2 (see Fig. 3).Upper and lower good-quality alginates were taken and a period of four weeks’ home tooth whitening was performed, according to the aforementioned protocol. It is important to allow two weeks of no whitening, in order for the shade to settle (rebound) and allow bond strengths to return to normal. At the review appointment, the patient and I were satisfied with the whitening progress.
Active concern(s)/problem list: Long standing midline diastema, with scope for visual aesthetic improvement (see Fig. 2). Treatment objective(s) Minimally invasive aesthetic enhancement using home tooth whitening and correction of a single midline diastema using direct composite bonding with COLTENE BRILLIANT EverGlow™.
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Two weeks 10 % carbamide peroxide overnight use.
2. One week’s use of 6 % hydrogen peroxide, for optional one-hour ‘boosts’.
After discussing alternative options, including ceramic veneers, composite bonding was the obvious and most ethical option for this patient. When treating anterior teeth with any form of restorative dentistry, it is important to discuss tooth whitening to ensure the patient is aware that restorative materials, once selected, will match the existing tooth shade and cannot be altered in the future.
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Shade BL was selected as the new and improved tooth colour, which was verified and accepted by the patient. A quick unbounded composite try-in was performed, using COLTENE BRILLIANT EverGlow™ shade BL, while the teeth were at normal hydration to confirm material selection. On the day of treatment, complete anterior isolation was then performed using a heavy gauge latex rubber dam, with W2A clamps attached to the premolars to secure the dam. Floss ligatures were placed and tightened around both central incisors to further retract the dam into the gingival sulcus with the benefit of suppressing the papilla, which is extremely useful when closing diasetmas with direct composite bonding (see Fig. 4). The teeth were cleaned with an Enhance polishing cone, followed by air abrasion using a Rønvig sandblaster with 30micron Al2O3 particles. The teeth were then etched, followed by thorough rinsing, drying and application of a bonding agent that was carefully air dispersed. A pre-rolled composite increment was first applied to the UR1 and adapted freehand from all directions to achieve the ideal initial starting proportions. Care was taken to adapt the gingival portion to avoid gross overhangs. Good isolation makes this much easier (see Fig. 5). This increment was then cured and refined using interproximal strips to remove gingival excess (see Fig. 6) and a Sof-Lex disc to gently contour the
contact point to a smooth convex profile (see Fig. 7). PTFE tape was then placed over the UR1 and the process repeated on the UL1. For optimal adaption of composite placement and smooth transitional junctions from composite to tooth, a GC sculpting brush (see Fig. 8) and Optrasculpt (see Fig. 9) modeling instruments were employed to eliminate instrument indentations from being introduced into the composite increments (see Fig. 10). Following final curing, the palatal aspect was re-checked (see Fig. 11) and a small overhang removed by using an ultra-thin metal polishing strip passed under the interproximal contact (see Fig. 12). Once again, effective isolation makes this possible and is almost mandatory when attempting such cases freehand. Following rubber dam removal, primary form was lightly adjusted using a coarse Sof-Lex disc. An enhance polishing cone was used to reductively polish the marginal junctions. A medium grit flame bur was used in an electric handpiece in a light feathering motion to introduce tertiary anatomy into the restorations (see Fig. 13). The two-step DIATECH polishing wheels (from COLTENE) (see Fig. 14) were then used on all surfaces of the restorations until a final high lustre was established (see Fig. 15). Occlusal checks were performed as standard, to ensure the new restorations conformed to the existing occlusion. Close palatal inspection was performed under high magnification to ensure a
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COSMETIC & RESTORATIVE
Fig 13
Fig 16
Fig 15
Fig 14
Fig 17
Fig 18
smooth, ledgefree transition of restorative material towards the gingiva in order to respect the soft tissues (see Fig. 16).
lished to confirm a hygienic result that blended well to the existing anatomy and soft tissues. The patient has since been seen for a 1-year recall visit where the restorations have demonstrated an excellent retention of polish (see Fig. 17) and an extremely healthy soft tissue outcome (see Fig. 1819).
Final appraisal Following two-and-a-half weeks of healing, the patient was reviewed and the papilla had re-estab-
My top tips:
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Fig 19
Use a mock-up! Place composite without etch and bond and shape roughly to determine your final outcome and ensure it fits within the natural envelope of function. Check excursions and guidance at this stage. This is increasingly important when lengthening teeth or broadening and elongating lateral incisors which may incur a lateral interference in some cases, causing early failure. A mock-up also allows you to assess and control patient expectations and is an excellent tool to help choose your final restorative method, shade and aid in informed consent
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Sculpt like an artist! Use the correct instruments for your labial increments. The final appearance and polish are determined earlier on during placement and a good polish is an outcome of great finishing. Use a broad, softer instrument to adapt your final labial increment to the tooth to ensure seamless margination and a final layer free of instrument indentations and irregularities.
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Use the light! Following initial placement and gross finishing, take a photo of your direct anterior restorations. Schedule a second appointment for final refinements and high-gloss polishing two weeks later. Assess this photo in the meantime and the way the light hits the line angles of your restorations, as well as the axial inclination of your restorations. Aim to see even, straight line light reflections on the mesial and distal line angles, as well as an axial inclination pointing down and towards the naval. Plan your refinements to achieve these optical properties at the next visit. A twin flash system is recommended for anterior work.
Isolate like a pro! For diastema closures, use a medium or heavy dam secured with selftightening floss ligatures. This will ensure the dam is retracted to the soft tissue junction and suppress the papilla, which is extremely useful for median diastemas. Expect the papilla to rebound within a few weeks
Scan here to view the BRILLIANT EverGlow Range on our website DR MINESH PATEL BDS Hons, MSc, MFGDP (RCS)
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TRANSFORMING SMILES WITH WHITE DENTAL BEAUTY
A world of social media, selfies, and more recently video conferencing, is making people more aware than ever of how their teeth - and their smiles - look. “Not many people know that tooth whitening is safe, easy and inexpensive. When I demonstrate these advantages to patients, they often recommend the treatment to others. This is one of the reasons why bleaching is becoming more popular and the demand is growing.” DR. ANNA SALAT, STYLE ITALIANO
Treatment options
Partner with White Dental Beauty
Toothpaste, Air polishing, Micro abrasion, Peroxides. Peroxide whitening involves bleaching the teeth, and can be broken down into three distinct categories: Strips, pens, pre-made trays. This delivery of Hydrogen Peroxide is a professional alternative to less predictable over the counter products. Professional home whitening. Custom tray whitening - the gold standard. Carbamide Peroxide or Hydrogen Peroxide gel in a custom fabricated tray is the traditional tried and tested way to lighten the internal pigments of teeth. This approach improves the appearance of teeth without altering any tooth structure. Professional ‘power’ bleaching in-office. All soft tissues are isolated, and chemically activated gel is applied to the tooth’s surface. In some cases a light is then put into position and directed at the gel to ‘enhance’ whitening.
Quicker results, happier patients. With WDB’s unique Novon chemistry your patients can achieve results faster with either shorter wear times or lower peroxide concentration. Wear times for WDB are 6% HP 30 to 90 mins, 10% CP 2 to 4 hours, and 5% CP Mild 2 to 4 hours. Reduces sensitivity. High water content and active sensitivity management formula. For patients who suffer from sensitivity but still want to whiten their teeth there is the unique 5% CP Mild. Marketing support exudes luxury. Beautifully packaged (eco friendly) the take home whitening syringes come with a matching bag and patient literature, which help create the high end experience. Point of sale, patient video and posters are available to reinforce the brand image that will resonate with today’s savvy patients. Conveniently affordable. White Dental Beauty is available in take home patient kits with 1.2ml x 8 syringes or a cost effective 3ml x 4 syringes. For more information and practice resources, visit the new website: https://henryschein.com.au/white-dental-beauty
Prospective patients need reassurance While treatment options are more readily available, the dental industry still must work to educate people on the benefits of professional treatment rather than over the counter whitening. Patients want to whiten their teeth and improve their smiles, but many are put off by the thought of visiting a dentist. They are concerned with comfort, cost, and convenience.
Nik Sethi from Square Mile Dental Practice explains how he transforms smiles using White Dental Beauty Tooth Whitening Gels.
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COSMETIC & RESTORATIVE
MINIMALLY INVASIVE DENTISTRY CASE STUDIES
Minimally invasive dentistry (MID) advocates the maximum preservation of intact and repairable dental hard tissues through minimising the unnecessary alteration of healthy tooth structure. As an enthusiastic advocate of the application of the principles of MI dentistry in everyday dental care, the AquaCare has been a revelation in helping me to achieve improved outcomes for patients under my care.
This is one of those pieces of kit that I can find further uses for every day and that the patients under my care much prefer compared to the conventional rotary handpiece.
The unit allows ease of use for polishing and abrasion techniques with a change in function at the turn of a switch. For polishing, surface stains are removed efficiently and selectively without damaging the underlying sound tooth structure. There is no heat generation or damage to soft tissues and the result is immediately pleasing to both clinician and patient. For air abrasion, the particles are emitted at high velocity within a fluid stream from an easy to use nozzle and are hence easily controlled and directed ensuring comfort for the patient as well as ease of vision for the operator. The air abrasion particles remove adherent extrinsic surface stains and debris without vibration or heat generation, minimising the risk of pulpal damage. The lack of vibration also improves comfort for the patient.
Pre-operative
After wet air-abrasion
Bioactive powders have the potential for remineralisation and will selectively remove damaged tooth structures with much greater precision than conventional mechanical techniques. Bonding to the cleaned tooth surface is also enhanced making this technique ideally suited to modern adhesive dentistry, particularly with regards to the repair and refurbishment of existing restorations, which is now such a key component of MID.
Final restoration (GC Essentia resin composite)
From being brought up in the age of the high-speed handpiece, the Aquacare is now my go-to unit for cavity preparation and tooth repair. To view more Aquacare Case studies scan here DR MICHAEL THOMPSON United Kingdom
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DIGITAL SOLUTIONS
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PAIN CONTROL SOLUTIONS
THE NEW SEPTODONT USP TWIST NEEDLES - Q & A
I’ve never stung myself with a needle in my entire career Unfortunately, needle stick injuries (NSI) can happen in any practice. If anything happens, you might be legally responsible for your staff’s injuries. Also, among the 35 million health workers, the World Health Organization estimated that 3 million suffered percutaneous exposures to bloodborne pathogens each year, and 86% of the NSI could be avoided. For example, each year, 700 000 NSI occurs in Germany (total on all healthcare professional).
A few years ago, I bought a Septodont metal handle. I can’t use it anymore No, unfortunately metal handles are not in the new range as they cannot feature this new patented lock system. The USP Twist range offers you the choice between single-use handle (white) and a reusable and sterilizable plastic handle.
The price is higher than the last USP range
Why is there no black handle anymore?
For Septodont, nothing is more important than your security: our target is to keep you, your staff, and your patients safe from needle stick injuries. Therefore, we invested in developing our gold standard USP safety injection device range to upgrade it. The upgraded range, USP TWIST, is now featuring an intuitive patented locking system for an increased ease of use (saves time, less training needed) and security.
The reusable & sterilizable handle (black in the last USP range) is now the blue one in its Twist version. Can I still order regular USP to fit with my handles? No, this range is discontinued and replaced by the upgraded range featuring a new patented design. The black handle cannot be used with USP Twist needles. But I am confident you will be convinced by the upgraded USP Twist range, with an intuitive patented locking system for an increased ease of use (saves time, less training needed) and security.
The device seems very complicated to use Our new patented twist-lock design makes the system even easier to use, just click and twist to link handle and needle together.
Safety needles are expensive Needle Stick Injuries can lead to very high costs that are threefold:
The handle must be sterilised, and I only use sterile handles
Health impact: among health care workers, about 40% of HBV and HCV infections and 2.5% of HIV infections are attributable to occupational sharps exposures. Risk of a healthcare worker contracting hepatitis B after a NSI is 1 in 3.
We made sure you can keep the choice: The blue handle is re-usable & sterilizable, but we also offer sterile single use handles, the white ones. Obviously, the needles are both sterile and single use.
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PAIN CONTROL SOLUTIONS
Cost impact: Costs for a healthcare organization when a needle stick injury occurs are about $747 (range between $199 and $1,691) Regulation impact: Many health agencies put in place legislations to prevent needle stick injuries requiring the implementation of safety procedures, the use of safety devices and the prohibition of the recapping of needles. For Septodont, nothing is more important than your security: our target is to keep you, your staff and your patients safe from needle stick injuries. We have demonstrated that using Ultra Safety Plus in a practice is profitable. (do the financial demonstration).
sure you will not have shortage. Then the former USP was not safe enough? Of course, it was, and it has proven its efficacy for more than 20 years. At Septodont, we also work on our solutions to continuously make them better and that’s why we invested in developing our gold standard USP safety injection device range to upgrade it. The upgraded range, USP TWIST, is now featuring an intuitive patented locking system for an increased ease of use (saves time, less training needed) and security.
I still have stock of the old USP. Will you reimburse me? USP was a very good product used for more than 20 years. You can use the product from your inventory until end of shelf life and then switch to USP TWIST. We can place an order now to make
Testimonial Video on Dental Education Hub
Schein Online
Source: Septodont Ultra Safety Plus Twist Launch Book Centers for Disease Control and Prevention. 23 Aug. 2010. WHO, The world health report 2002 - Reducing Risks, Promoting Healthy Life, 2002 Saia, M., et al., Needlestick Injuries: Incidence and Cost in the United States, United Kingdom, Germany, France, Italy, and Spain Biomedicine International, 2010. 1: p. 41-49. Public Health England, United Kingdom Surveillance of Significant Occupational Exposures to Bloodborne Viruses in Healthcare Workers,2014ncreased ease of use (saves time, less training needed) and security. www.ncbi.nlm.nih.gov/pmc/articles/PMC4890345/ Hanmore E, Maclaine G, Garin F, Alonso A, Leroy N, Ruff L. Economic benefits of safety-engineered sharp devices in Belgium—a budget impact model. BMC Health Serv Res 2013;13:489. Leigh JP, Gillen M, Franks P, et al. Costs of needlestick injuries and subsequent hepatitis and HIV infection. Curr Med Res Opin 2007 United States General Accounting Office Washington, DC 20548, Occupational Safety: Selected Cost and Benefit Implications of Needlestick Prevention Devices for Hospitals,2000
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PAIN CONTROL SOLUTIONS
SINGLE TOOTH ANESTHESIA
How does it work?
Benefits
The STA Single Tooth Anesthesia System works by controlling the flow rate and monitoring the exit pressure at the tip of the needle, allowing the dentist to deliver anesthetic at a precise and consistent rate below the patient’s pain threshold - thus, optimizing predictability.
COMPUTER CONTROLLED FLOW RATES
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The DPS Dynamic Pressure Sensing Technology monitors the exit pressure, and optimal needle position during the administration of local anesthetic.
Automatically controls and regulates flow rates and pressure during the injection Delivers anesthetic solution at a precise and consistent rate below the patient’s pain threshold • Consistent flow maximizes injection predictability DYNAMIC PRESSURE SENSING TECHNOLOGY
• The dynamic pressure sensing monitors the exit pressure of the anesthetic for the optimal needle position during the administration process • Visual and audible feedback from the unit aids in the identification of the correct location for injection
Visual and audible feedback from the unit aids in the identification of the correct location for injection.
INCREASE YOUR BOTTOM LINE: GROW YOUR PRACTICE
The STA Single Tooth Anesthesia System can be used for: •
STA-Intraligamentary – Modified PDL
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Inferior Alveolar – Blocks
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P-ASA – Palatal
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AMSA – Palatal
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Supra-Periosteal – Infiltrations
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100% prefer it over the traditional syringe* 79% are more likely to refer friends or family* 72% would be willing to pay for the injection* Minimal discomfort and less concern about cross contamination eliminates patients concerns for future appointments
*Brattesani, Patient Survey 2015, patients who experienced the STA Single Tooth Anesthesia System
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A wide range of injection applications STA-INTRALIGAMENTARY MODIFIED PDL 30 GAUGE
P-ASA PALATAL 30 GAUGE
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Non-traumatic, modified PDL technique Comfortable injection both during and after the procedure Provides profound pulpal and gingival anesthesia for any procedure Allows patients to leave the appointment with no collateral numbness Immediate onset reduces total time to achieve anesthesia compared to mandibular block Enables bi-lateral mandibular procedures in one visit
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INFERIOR ALVEOLAR BLOCKS 27 GAUGE
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Multi-cartridge feature enables use of multiple carpules with only one injection Handpiece enables BRIT which eliminates needle deflection BRIT ensures needle gets to target site more effectively Reduces number of missed blocks Can enable faster onset
Comfortable injection – ControlFlo eliminates the ‘burst effect’ in dense tissue Uses ‘pre-puncture’ technique, which provides topical anesthesia effect No collateral numbness enables immediate smile-line assessment Can replace 6 to 7 infiltrations with 1 or 2 comfortable injections Provides 60-90 minutes of profound pulpal, palatal, and gingival anesthesia (depending on type of anesthetic used) Zone of anesthesia covers canine to canine
SUPRA-PERIOSTEAL INFILTRATIONS 30 GAUGE
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Flow rate control eliminates ‘burst effect’ so injection is more comfortable Start the injection in ControlFlo which creates anesthetic pathway in front of the needle
AMSA PALATAL 30 GAUGE
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Zone of anesthesia covers 1st pre-molar to central incisor View Product Online
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ENDODONTIC SOLUTIONS
ENDODONTIC EXPERT PROFESSOR GIANLUCA GAMBARINI, DDS
International lecturer and researcher, Prof. Gianluca Gambarini, MD, DDS is author of more than 500 scientific articles, he has lectured all over the world (approx. 600 presentations) as a main speaker in the most important international congresses and many Universities world-wide. During his academic career he gained many awards and recognition and was responsible of many scientific projects with national and international grants. Prof. Gambarini has focused his interests on endodontic materials and clinical endodontics. He is also actively cooperating as a consultant to develop new technologies, operative procedures and materials for root canal treatment while owning many patents concerning endodontic technologies. Prof. Gambarini is also a member of the Executive Board of ESE a Chairman of Clinical Practice Committee and maintains a private practice limited to Endodontics in Rome, Italy. 2D radiographs only allowed a partial visualization of anatomy and canal trajectories. This was related to the buccal-lingual direction of the X-rays and the superimposition of different structures. Using CBCT (and ideally using dedicated software for 3D reconstruction), the REAL anatomy of each case can be visualized of anatomy and canal trajectories.
How is technology changing endodontics? In recent decades, technology has improved dentistry and endodontics significantly, providing useful tools for better diagnosis and root canal treatment. In the 2000’s, microscopy has been the game changer in endodontics, while in the decade after, three-dimensional radiography has played this role. CBCT has proved to be clinically useful not only by improving diagnosis and treatment planning (especially in the most difficult cases), but also in the clinical visualization and understanding of anatomic complexities. In addition, CBCT is a fundamental device providing images for guided endodontics. Static guides and dynamic navigation are proving to be effective in the treatment of calcified canals, and also helpful in more conservative access cavities both in non-surgical and surgical endodontics. Moreover, in the last decade, two other new manufacturing technologies have changed root canal instrumentation and obturation: the heat treatment of nickel-titanium rotary instruments, and the introduction of new bioceramic endodontic sealers, both aiming to improve the performance, safety, and simplicity of endodontic treatments.
This was related to the buccal-lingual direction of the X-rays and the superimposition of different structures. Using CBCT (and ideally using dedicated software for 3D reconstruction), the REAL anatomy of each case can be visualized by the endodontist, including hidden curvatures, hidden confluences, calcifications, etc. This is a huge advantage not only in terms of proper diagnosis and treatment planning, but also to reduce iatrogenic errors during instrumentation procedures. Hidden curvatures (which always lead to increased instrumentation stress), if not properly recognized, may easily result in intracanal separation. For more than 25 years endodontists have been fearing sudden, unexpected breakage of nickeltitanium rotary instruments. Nowadays, we can tell that the great majority of those failures were related to poor clinical understanding of anatomy, and consequently, improper choice and use of the instruments in very stressful (usually hidden) complexities. Clinical understanding of anatomy in three dimensions, commonly defined as “3d
How important is clinical understanding of root canal anatomy? Endodontics has been a “2 dimensional” specialty for nearly 100 years due to the fact that traditional
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ENDODONTIC SOLUTIONS
CRAFTED BY PROFESSOR GAMBARINI
Hidden apical curvatures with martensitic NiTi files Gianluca Gambarini & Alessio Zanca Sapienza University of Rome
endodontics”, is therefore a breakthrough in the clinical approach to improve safety and simplicity of instrumentation procedures. In surgical endodontics a 3d approach does the same, allowing a less invasive procedure and reducing risks of iatrogenic errors. How does the anatomy dictate improved properties on NiTi files? Three-dimensional analysis of root canal trajectories and shapes have clearly shown that root canals are more complex in 3D compared to traditional 2D visualization, and consequently, these findings affect properties of the NiTi files allowing: a.
More flexibility to properly negotiate curvatures, avoiding iatrogenic errors
b.
More mechanical resistance to avoid intracanal breakage
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Changes in design or in clinical use to increase performance in oval canals (which can be more easily visualized in 3D) which improve cleaning (by touching more canal walls) and debris removal. Cleaning is obviously related to proper use of irrigants and irrigation techniques, but instruments also play a significant role in creating more debris or removing debris properly, dispersing the solutions, and disrupting biofilm.
Improvement of NiTi files can be done mainly in three different ways: 1.
Improving design, which has been the primary direction during the first 20 years after NiTi was introduced.
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Improving motors and motions, to make them less stressful than continuous rotation.
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Improving alloy and manufacturing processes, including heat treatments. This last option has recently become the most important feature to significantly improve flexibility and fracture resistance of the NiTi files.
Which is the clinical difference between austenitic and martensitic files? In the first 20 years after the introduction of NiTi, all instruments have been super elastic, austenitic files. The superior properties of the alloy, compared to traditional stainless steel, was considered a huge advantage, and allowed the clinical use of files with greater tapers in continuous rotation. However, this increase of instrument dimensions and the greater stress induced by the motion resulted in quite rigid instruments which increased risk of failure, especially in complex curvatures and the larger sizes and tapers. NiTi is a “delicate” alloy, very sensitive to heat, and during the manufacturing process the alloy is weakened by the grinding wheels that create the flutes and the geometry of the file, both externally and internally. External defects can be partially adjusted by electropolishing, while internal defects can be partially adjusted by specific heat treatments after the manufacturing process. Heat treatments can vary drastically, and each manufacturer has its own proprietary, undisclosed treatment process.
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ENDODONTIC SOLUTIONS Generally speaking, all heat treatments can improve flexibility and fracture resistance to a certain degree, but there are huge differences on how they are performed and the resulting effects.
This is why I prefer to use the term: RATIONALLY INVASIVE endodontics. Because we cannot modify the apical curvature, the only way to improve efficacy and safety (providing that we are using very flexible and resistant martensitic files, with proper motions and techniques) is to slightly modify the coronal and middle curvatures, reducing the overall instrumentation stress.
Some companies, i.e., EdgeEndo, have invested a lot in research to produce better heat treatments, which have recently become, perhaps, the most important manufacturing treatment to improve mechanical properties of the instruments. For instance, changes in design could increase flexibility and resistance by 20-30%, while in our research, FireWire heat treatment by EdgeEndo has shown to increase flexibility up to 3 times (300%) and even more for fatigue resistance.
Therefore, how invasive a shaping procedure can be, is mainly determined by the anatomical complexities: the easier the canal, the less coronal flaring we need, and we could also create a smaller access cavity. A martensitic file is more suit- able for this approach because it can be pre-bent, and having less bounce-back slightly reduces influence from interferences.
These new heat treated files can also exhibit different shape memory effects, and therefore are defined as martensitic NiTi files: they can be prebent, if needed, and produce less bounce back, allowing easier negotiation and less canal transportation.
In complex canals the strategy is opposite; we have to reduce instrumentation stress because high stress is already present due to the anatomy.
These improvements have significantly changed our clinical procedures, because such a difference between austenitic and martensitic files (some manufacturers provide the same file in the two versions, i.e., EdgeTaper and EdgeTaper Platinum) has modified our clinical approach to instrumentation, depending on which type of instruments are we using.
3D understanding of anatomy is crucial in these cases because it clarifies the need for different strategies which will significantly improve a less-invasive approach. More specifically, coronal flaring must be “selective”, avoiding unnecessary enlargement of canals and reduction of cervical dentine. Depending on trajectories, canals should be flared by only one or two sides to make the curvatures easier.
Is minimally invasive the current trend in endodontics?
Such a rationally invasive approach based on 3D understanding of anatomy, is my preferred method.
Minimally invasive is obviously a trend, since we know that any endodontic treatment (to a certain extent) can weaken a tooth, and tooth fracture is the main cause for long term failures (even if it depends a bit more on the quality and type of postendodontic restorations).
Which is your opinion about simplified techniques and single file reciprocation? Once again, we should be rational in our choice. Most of the canals are quite easy to negotiate and shape (the main difficulty in these cases is proper cleaning and disinfection); therefore, I am in favor of simplified techniques.
However, when treating complex root canals, we should always make some compromise between the tendency to be more conservative and the risk of poor access cavity design or coronal flaring, which may create interferences that lead to iatrogenic errors, including ledges, transportation, or intracanal breakage.
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Can they work in more difficult canals? In my opinion, yes, but only if the proper instruments, strategies, and motions are used.
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ENDODONTIC SOLUTIONS I am currently using two techniques in my practice: A. A simplified technique using only two martensitic NiTi rotary files: X7 17.04 and 25.04 B. A single file reciprocation technique using EdgeOne Fire (EOF). Actually, I like both, but I use the single file reciprocation technique in the majority of simple, medium, medium-difficult, and molar cases. I use this technique because it is simple, rapid, and easy to perform. EOF are martensitic NiTi files that are designed to be used in a reciprocating (30° clockwise - 150° counter-clockwise) motion. Compared to competitors’ files, EOF are more flexible and fatigue resistant due to EOF’s fire-wire heat treatments. Through research I conducted in Differences in cyclic fatigue lifespans between two different heat treated NiTi endodontic rotary instruments: WaveOne Gold vs. EdgeOne Fire my findings showed EOF has twice the cyclic fatigue compared to WaveOne Gold. The flexibility of EOF allows me to also use them in moderately curved canals in a very safe way. The reciprocating motion itself contributes to reducing instru- mentation stress. I often perform a manual glide path up to size 15, but not in all cases because in easy canals a glide path already exists. The EOF has excellent properties, and it usually negotiates canals very easily; however, if needed, I can increase cutting efficiency by slightly increasing the speed. This is also very useful when I do brushing with EOF because this increases its ability to remove debris which is slightly more prevalent with reciprocating techniques. The EOF is an instrument of greater (variable) taper and easily and quickly creates a proper tapered preparation; nevertheless, I always brush to increase the capability of touching (please pay attention… it is touching, NOT CUTTING) more canal walls and improve cleaning and disinfection, especially in oval, elongated canals. Since I am using only one instrument, if it does not progress easily (i.e., in a hidden curvature) I can slightly increase the glide path or, more frequently, I flare the canal a bit more before progressing apically. I define this last approach as “crown-down with the same instruments”.
Which instruments would you recommend in complex cases? In very complex cases my preferred choice is a simplified technique using only two martensitic NiTi rotary files: X7 17.04 and 25.04 at a speed of 300 to 500 rpm, torque settings 250 to 410 g/ cm. Due to their excellent properties (flexibility, fatigue resistance, less bounce back) these files are excellent in the management of complex apical curvatures. The X7s have a maximum flute diameter of 1 mm which can be considered “minimally invasive instruments”. The X7 instruments are available in different sizes and two (constant) tapers: .04 and .06., but I like to use a simplified technique with .04. If I want more tapered preparation (but I tend to be less invasive in my initial approach) I can brush more and create more taper. This is much safer in a very complex curvature than using an instrument with bigger taper. Similarly, in most cases I don’t need an orifice opener or a glide path (they can be optional files in very peculiar cases), because the 17.04 can do the work of both. Following a manual glide path up to size 10 or 15, the 17.04 can pre-enlarge the canal, thus creating a better glide path and easier progression for the shaping file (.04 25). If I need to flare the canal more in the coronal and middle part, I can brush with this file, eliminating interference where needed (selective flaring) and create more room for the shaping file. This is the technique I usually adopt for my “rationally invasive approach”; it is simple, predictable, easy to per- form, and can be adapted to many different complexities. If I need more “prepared space” for my final irrigation technique, I sometimes brush a little bit more to increase penetration of irrigants. I no longer choose this strategy for obturation because single-cone cold bioceramic obturation allows me to be less invasive since I don’t need to create space for pluggers, obturators, etc. The martensitic X7 files are excellent for this approach be- cause their superior mechanical properties allow me to use only two instruments without compromising quality and safety. I only need to understand anatomy and select the proper strategy for each case.
PROFESSOR GIANLUCA GAMBARINI University of Rome, La Sapienza School, Rome Italy h en r y sc h e i n .c o m .a u
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ENDODONTIC SOLUTIONS
RESTORATIVE ENDODONTICS A NEW BIOLOGICALLY BASED STANDARD OF CARE
Minimally invasive techniques and advanced material science It is unlikely that G.V. Black, 1836-1915 (considered the Father of Restorative Dentistry), could have imagined the direct bonding of modern-day composite materials to coronal dentin, or that Louis
function and to preserve that tooth in that state for as long as possible. Let’s start with the latest materials, technology, and techniques available to accomplish that task in endodontic therapy.
I. Grossman, 1902-1988 (the recognized Father of Endodontics), could have imagined bioceramic sealers that could bond to radicular dentin. But both of these giants of our profession advocated the latest theory, techniques, and technology of their day. They could only dream about the future … and the future is here and now!
You were probably taught that gutta percha needs to be heated and condensed to achieve 3D obturation, that your endodontic sealers are the weak link in your root canal procedure, and that it didn’t matter how you got to the apex, only that you got there. Well, that was in the past. Present day material science has antiquated these and many other concepts that you may have learned and are still using.
We should be maintaining the innate strength of the tooth through the use of root canal sealers that bond to the radicular dentin and instrumentation and obturation techniques that do not require the excessive removal of dentin.
If we concede that the fundamentals of root canal therapy are cleaning, shaping, and obturation, then it would make sense to look carefully at how each part of the procedure interfaces and supports the other. In addition, it is also important to consider how each part of the procedure supports the objective of maximizing the long-term retention of the endodontically treated tooth. Let’s consider the past and current state- of-the art in root canal sealers. Approximately 50 years ago, Dr. Louis Grossman acknowledged that the then current-day sealers (zinc oxide and eugenol and resin-based sealers) left much to be desired. They were hydrophobic, shrunk upon setting, were not very biocompatible, lacked resistance to wash out, and generally were irritating if extruded past the apex.
All of us recognized the need for “retentive preparations” for the successful placement of an amalgam restoration (when there was no other option). Many of us continue to use “condensation techniques” and consider them a requirement for the successful filling of root canals (but now there are other options). It should be remembered that these techniques were advanced based on the physical and chemical properties (limitations) of the materials that were available to us at the time. Today we have new and better materials that do not require these techniques.
Because of these less than stellar characteristics, it became accepted theory and practice to try and reduce the sealer interface to the thinnest possible thickness in the root canal. It being well understood that the thicker the sealer interface, the greater the shrinkage, the more irritating, etc. So, all of our
It should be stated from the outset that the reason for restoring a cavity and/or performing a root canal are both the same — to restore a tooth to its natural
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ENDODONTIC SOLUTIONS obturation techniques (warm vertical, cold lateral, and even heated carrier based) were developed based on the recognition that the then current sealers were at best poor and that the gutta percha should displace as much sealer as possible. Present day material science has allowed us to produce nanoparticle bioceramic root canal sealers (EndoSequence® BC Sealer™, Brasseler USA) that meet all of Dr. Grossman’s ideal requirements for an endodontic sealer. They do not shrink upon setting, are biocompatible, are osteogenic by their nature, are hydrophilic, antibacterial, and produce hydroxyapatite upon setting. They are also highly radiopaque, premixed, and will produce a true chemical bond to the dentin and gutta percha when used with a bioceramic coated cone (BC Sealer and BC Points, Brasseler USA). Because we are now able to chemically bond to the radicular dentin (right down to the apex), we are now able to produce a true monoblock for the first time. This is why it can be said that the restoration of an endodontically treated tooth should begin at the apex. What about “condensation techniques” that have used (as a bases of their acceptance) the idea that we should replace the sealer with gutta percha? That the sealer is the weak link in the chain and should be reduced to the thinnest layer possible in the root canal? They are antiquated and without merit when we can now say that we have root canal sealers that are superior to gutta percha in the canal. At best, gutta percha takes up space and is inert. It should be acknowledged that we still deliver the sealer and provide a retreatment path with a bioceramic coated cone. However, traditional condensation is not necessary because of the hydraulic nature of the bioceramic sealer. But this is not the end of the story. Actually, it is just the beginning! For years the techniques used to prepare and shape canals have focused on trying to not only clean the canal, but also produce a shape that will provide for the difficult task of condensing gutta percha. Something we now understand is actually completely unnecessary. Cleaning, it turns out, can be accomplished with minimal coronal enlargement, particularly if facilitated with ultrasonics and good irrigation techniques. All that is really required is to produce a shape that allows the canal to be cleaned responsibly to the apex. A size 35/.04 preparation to the apex has been documented as all that is needed in most canals.
we have excused preparations that have removed good tooth structure (dentin) at the expense of the long-term prognosis of the tooth. Teeth (canals) that are overly prepared and weakened to accommodate filling techniques in the long-term lead to unnecessary fractures and their removal. Minimally invasive root canal shaping is really what we should be focused on in an effort to preserve as much radicular dentin as possible. We should be maintaining the innate strength of the tooth through
the use of root canal sealers that bond to the radicular dentin and instrumentation and obturation techniques that do not require the excessive removal of dentin. We have begun to look carefully at shaping and recognize that all instrument systems are not the same and do not accomplish the same goals. Some years ago, it was recognized that constant tapered file systems would consistently produce (versus variable tapered) minimally invasive shapes in the root canal. Further, that synchronization of all the parts of the procedure (i.e., the instruments, paper points, gutta percha, and posts) would lead to the removal of less structurally important dentin. Posts were designed to fit the space that the last rotary instrument actually produced. Thus, the first drill-less post system was developed with the recognition that the preservation of radicular dentin was critical to the responsible restoration of an endodontically treated tooth. Those that claim that root canals fracture and don’t hold up for the long-term do not recognize the importance of maintaining the inherent strength of a tooth throughout the root canal procedure by the use of minimally invasive techniques and technology. Root canals that are carried out with instrumentation systems designed to retain as much coronal radicular dentin as possible and are restored utilizing bonded obturation (BC Sealer) will stand up to the test of time. Restoration of an endodontically treated tooth should begin at the apex. Through the use of minimally invasive techniques and advanced material science, this is now a reality.
We now have hydraulic obturation techniques utilizing flowable nanoparticle bioceramic technology that do not require excessive canal enlargement. Obturation should not dictate shaping! In doing so, DR. DENNIS G. BRAVE Maryland, USA
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PERFORATION REPAIR WITH BIODENTINE™
A perforation is an artificial communication between the root canal system and the tooth support tissue. This communication may occur due to dental hard tissue resorption, caries or by iatrogenic endodontic therapy.01 Pulp chamber floor perforation is a iatrogenic complication that can be produced during access preparation or in the instrumentation of the cervical third of the root canal, causing endodontic failure.02 It can also cause an inflammatory response of the periodontal tissue that may lead to an irreversible loss of periodontal insertion in the affected area.3
However, none of them are ideal for the special conditions and requirements of this type of treatment.04 An ideal material should be biocompatible, dimensionally stable, insoluble, radiopaque, allow easy manipulation and placement and provide a proper seal.05 Biodentine™ (Septodont, Saint Maur des Fosses, France) is a high-purity calcium silicate–based material composed of tricalcium silicate, calcium carbonate, zirconium oxide, and a water-based liquid containing calcium chloride as the setting accelerator and water-reducing agent.
The reparation procedure will be determined by the perforation position and the area involved. Treatment can be with or without surgery and the prognosis is usually excellent if the problem is correctly diagnosed and repaired, using a material that gives proper sealing and is biocompatible.02 Various materials have been used for root repair, including silver amalgam, zinc oxide–eugenol, calcium hydroxide, composites, and glass inomers.
Biodentine™ is recommended as a dentin substitute under resin composite restorations and as an endodontic repair material because of its good sealing ability, high resistance to compresive strength, short setting time, biocompatibility, bioactivity, and biomineralization properties.06
Case Report
Treatment
A male patient of 48 years of age was referred because of failure to locate the buccal canals of the 2.6 tooth. (Fig. 1).
On the first appointment, the temporary filling is removed and a distopalatal perforation in the cameral floor becomes visible. (Fig. 2 and 3) The periodontal hemorrhaging under the perforation was stabilized using Calcium Hydroxide mixed with Propylene Glycol. Immediately after, the Palatal Canal is located (Fig. 4) and previous to the localization of the buccal canals, the perforation is blocked with a gingival barrier. (Fig. 5) Once the buccal canals are located, all canals are prepared with reciprocating rotary files. The perforation is sealed using Biodentine™ (Fig. 6) and an intracanal dressing of Calcium Hydroxide is left in place for 15 days.
Clinical Examination A tooth with endodontic access and temporary filling is observed. It is unresponsive to thermal testing and presents pain to both vertical and horizontal percussion and also to palpation in the palatal area next to the gingival margin. Diagnosis Apical Symptomatic Periodontitis with Previously Initiated Therapy.
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Fig. 1: Preoperative Radiograph.
Fig. 2: DP perforation.
Fig. 4: Periodontal tissue stabilization and Palatal canal localization.
Fig. 6: Biodentine™ placement.
Fig. 3: DP perforation.
Fig. 5: Perforation blockage using gingival barrier.
Fig. 7: Biodentine™ seal appearance on the second appointment
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To the second appointment the patient arrives with a distopalatal cusp fracture. After tooth isolation and temporary filling removal, the Biodentine™ was observed to be hard and stable. (Fig. 7) A final irrigation protocol was performed with 5% Sodium Hypochlorite and 17% EDTA using sonic passive activation and the canals were obturated using a heat carrier. (Fig. 8) A double-seal temporary filling of Calcium Sulfate and Glass Ionomer is placed, and the patient is referred back to his practitioner for definitive restoration.
Conclusion Fig. 8: Postoperative Radiograph.
Biodentine™ proved to be a clinically reliable material in the reparation of pulp chamber floor perforations. It is biocompatible, like the well-studied MTA, but with improved mechanical resistance, making it an ideal material to endure occlusal forces in cases with large losses of hard tissue that occur during the search of a root canal.
References 01
Lodiene G, Kleivmyr M, Bruzell E, Orstavik D. Sealing ability of mineral trioxide aggregate, glass ionomer cement and composite resin when repairing large furcal perforations. British dental journal. 2011;210: E7. Epub 2011/03/12.
02
da Silva EJ, Andrade CV, Tay LY, Herrera DR. Furcal-perforation repair with mineral trioxide aggregate: Two years follow-up. Indian journal of dental research: official publication of Indian Society for Dental Research. 2012; 23:542-5. Epub 2012/12/22.
03
Samiee M, Eghbal MJ, Parirokh M, Abbas FM, Asgary S. Repair of furcal perforation using a new endodontic cement. Clinical oral investigations. 2010; 14:653-8. Epub 2009/11/06.
04
Zhou HM, Shen Y, Wang ZJ, Li L, Zheng YF, Hakkinen L, Haapasalo M. In vitro cytotoxicity evaluation of a novel root repair material. Journal of endodontics. 2013; 39:478-83. Epub 2013/03/26.
05
Aggarwal V, Singla M, Miglani S, Kohli S. Comparative evaluation of push-out bond strength of ProRoot MTA, Biodentine, and MTA Plus in furcation perforation repair. Journal of conservative dentistry: JCD. 2013; 16:462-5. Epub 2013/10/02.
06
Guneser MB, Akbulut MB, Eldeniz AU. Effect of various endodontic irrigants on the push-out bond strength of biodentine and conventional root perforation repair materials. Journal of endodontics. 2013; 39:380-4. Epub 2013/02/14.
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DR. JAIME ABARCA REVECO MSc DDS and Endodontics Specialist Coordinating Teacher of the Endodontics Graduate Program in San Sebastian University Teacher in the Rehabilitation Department of the Undergraduate Program at San Sebastian University Active Member of the Chilean Endodontics Society Member of the AAE
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A RELIABLE AND EFFICIENT FILE SYSTEM
Retreatment of a carrier-based root filling with bypassing of two ledges By Dr Sascha Herbst, Germany
In symptomatic periapical periodontitis, sufficient preparation and disinfection of the root canal is usually the only way to eliminate pain. Particularly in difficult initial situations, a reliable and efficient file system is therefore needed to provide a sufficient restoration. Using a current patient case as an example, I demonstrate in this article how a retreatment can be achieved quickly and confidently despite the presence of ledges and a carrier-based root canal filling. Endodontic retreatment per se usually involves additional difficulties in preparation when compared with initial treatment. Preparation-related ledges or perforations can be present, as can untreated canal sections and overlooked canals. Elderly patients sometimes present additional challenges: a smaller mouth opening can limit the working field and the field of vision. Narrowed root canals are also increasingly caused by the formation of secondary and tertiary dentine. In these cases, it is even more important to have a reliable file system which allows efficient removal of the obturation materials requiring revision for subsequent disinfection and obturation of the root canal system. In the case at hand, new types of nickel–titanium (NiTi) files were used together with a fully automatic endodontic motor. Complex initial situation for revision treatment An 87-year-old female patient was referred to our clinic with pain in the third quadrant. The clinical and radiographic examination (using single-image radiography and CBCT) confirmed the suspicion of
symptomatic periapical periodontitis at tooth #36 (Fig. 1). The preoperative single image suggested that a carrier-based root canal filling material had been used; furthermore, two ledges were visible in the mesial canal system. In addition, a second distal canal had to be assumed. The CanalPro Jeni endodontic motor (COLTENE) was used for the actual preparation. Jeni is a digital endodontic assistance system which assists the clinician in navigating through the root canal (Fig. 2). The device was named after its Italian inventor, Dr Eugenio “Jeni” Pedullà. Complex algorithms control the variable movements of the respective NiTi files used at millisecond intervals. In this process, the endodontic motor continuously adapts rotary motion, speed and torque to the prevailing conditions in the root canal. If one of COLTENE’s file systems is selected on the touch screen, this allows working in the fully automatic Jeni mode. Rotational movements are finely adjusted in this case, and an acoustic signal warns the dentist when it is advisable to change the file owing to the resistance in the canal. Thus, Jeni currently “knows” the parameters and instrument characteristics of the HyFlex CM and EDM series as well as the MicroMega One Curve, 2Shape and, very importantly in our case, the Remover files manufactured by the corporate group. Mechanical removal of the plastic carriers After applying the dental dam and preparing the access cavity, the next step was to remove the existing obturation material (Figs. 3 & 4).
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A high-speed rotary HyFlex Remover was used for this purpose (Fig. 5). The revision file efficiently removed the materials from the root canal so that additional solvent could be dispensed with during treatment. Unlike in other cases, the plastic carriers in this case were not extracted with an aid, but were machined (see video above). The non-cutting tip of the retreatment file protects the surrounding
Fig 1
Fig 4
tooth structure during this procedure, which makes handling even easier. The remaining apical gutta-percha was removed distally using a reciprocating 25/.06 MicroMega One RECI (Fig. 6). Owing to its cross-sectional design, this instrument features high cutting performance, making it ideal for revision treatment.
Fig 2
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Fig 6
Fig 5
from coronal to apical. At first, one needs to overcome this otherwise slightly unfamiliar working movement, as traditionally one learns to trust one’s own tactile feedback with dabbing hand movements when using rotary instruments. However, automatic adjustment of the file movement by the motor makes preparation even faster and safer than is already the case with modern NiTi file systems.
Consistent progression to the apical aspect The corresponding NiTi files were then used for renewed preparation of the root canals. Normally, in the presence of ledges, I prepare a glide path with manual instruments as a standard procedure. In this case, the use of prebent rotary instruments eliminated the need to create a manual glide path. In this case, the mesial ledges were bypassed by alternating between a 15/.03 HyFlex EDM and a 10/.05 HyFlex EDM. At the same time, the noninstrumented canal sections were developed. The second distal canal, which had not been treated during initial treatment, was instrumented with these two files in the same manner as the preparation of the mesial canals. Here too, the advance creation of a manual glide path could be dispensed with.
After preparation of the glide path, the following HyFlex EDM sequence was used: first the 20/.05 instrument, then the 25/~ HyFlex EDM OneFile and finally the 40/.04 file in all canals (Figs. 7–10). An acoustic signal from the endodontic motor indicated when rinsing should ideally be performed to remove the abraded debris from the canal. Obturation was performed with a bioceramic sealer (BioRoot RCS, Septodont) using the single-cone technique (Figs. 11–13). The contrast image with the master points and the final radiographic check after obturation demonstrated preservation of the canal anatomy and maintenance of the original path of the canal (Figs. 14–16).
The complex file control of the fully automatic endodontic motor imparted a feeling of reassurance during every treatment step, even in the canal which had not been scouted previously. The motor automatically adjusts the rotation of the files in the canal. This way, light pressure is applied steadily
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Fig 7
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Conclusion
Article extracted from:
Iatrogenic damage and narrowed canals often make revisions a journey through difficult terrain. The use of suitable NiTi special files allows rapid mechanical removal of obturation material as well as the creation of a natural canal path. The fully automatic endodontic motor monitors file movement and ensures efficient preparation, and this can lead to rapid pain reduction, especially in symptomatic periapical periodontitis.
Dental Tribune November 2021 https://www.dentaltribune.com/clinical/retreatment-of-a-carrier-basedroot-filling-with-bypassing-of-two-ledges/MicroMega OneReci Files and Jeni Motor coming soon to Henry Schein Australia!
Scan here to view the Hyflex Remover on our website.
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To view the full article including the additional images and watch the clinical video by Dr Sascha Herbst, please scan this QR Code.
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COVID-19, MEDICATION, AND DENTAL CARIES AN UNEXPECTED CORRELATION?
Recent episodes of lockdown and self-isolation as a result of the COVID-19 pandemic have led to multiple negative consequences for people’s private, social and business life. For some, this has resulted in anxiety and depression, which has led to an increased use of antidepressants. The increased rate of prescription of these medications has been reported worldwide, from Australia to Poland to the United States and can have an impact on the oral health of our patients. Sedatives, sleeping pills, antidepressants and antipsychotics have all seen an increase in use during the pandemic. Increased use of these medications continues, compared to pre-pandemic, and is expected to be the case for some time as the consequences of isolation, fear around transmission of the virus, uncertainty of local or national lock downs and the economic impacts persist. Mental health has become the single largest issue for which patients seek care from their GP, according to an Australian report, the RACGP’s 2018 Health of the Nation report. These medications do have oral side-effects; most profoundly, dry mouth. This increases risk for dental caries. Saliva is vital for the protection of our teeth and oral tissues and so a decreased amount of saliva leads to: •
•
•
Reduced buffering capacity - saliva helps to maintain a close to neutral intra-oral pH. With reduced salivary flow, it is difficult to combat a decrease in pH caused by acid produced by cariogenic bacteria, and the pH also recovers more slowly
Patients should of course be coached on effective oral hygiene routines and habits that may help to relieve dry mouth, which should include: • • • •
Reduced washing away of food and debris by saliva means that food containing fermentable carbohydrates, and plaque, remain around the teeth for longer, also impacting caries risk
•
Reduced lubrication that can lead to patient discomfort and difficulty tolerating dentures
•
Dental professionals can conduct a brief screening by questioning their patients on Dry Mouth symptoms and collecting information about their current medications, including medications for anxiety and depression. A caries risk assessment will help determine risk level and includes assessment for other risk factors.
•
As dental professionals, we should be vigilant during these times to ensure that the effects of the pandemic do not detrimentally affect the oral health of our patients.
Once at-risk patients are identified, dental professionals can then tailor oral hygiene recommendations and preventive care and provide a recommendation for relief of dry mouth. Dry mouth oral rinses contain ingredients that lock in hydration of oral tissues. Using humidifiers in the bedroom may also help to reduce night-time dry mouth in drier climates.
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Regular brushing twice a day Brushing for at least 2 minutes each time Changing your toothbrush regularly Using a hydrating mouthwash to relieve dry mouth Using dental floss daily to clean interproximal areas of the teeth Drinking enough water during the day to stay hydrated Use sugar-free chewing gum or lozenges to help stimulate saliva production
Reference
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WHY SHOULD YOUR PATIENT CONSIDER A WATER FLOSSER?
While brushing teeth twice a day is a great start to preserving good oral health, there are hard-to-reach areas in the mouth that patients cannot get to by merely brushing. Interdental cleaning, which helps remove food particles and plaque stuck between teeth, is an essential part of a dental health routine. But did you know that traditional string flossing is not the only way patients can clean between their teeth? Learn more about water flossing and why it might be an excellent option for your patients.
How water flossers work A water flosser is a handheld device that helps remove food particles and plaque stuck between teeth. The first thing you do is fill the device with water before using it. Then place it in your mouth, just above the gumline, and turn it on. The flosser will emit a steady or pulsating stream of water that will gently clean those hard-to-reach places. Reasons to consider water flossing If your patient has poor technique, they may experience discomfort and bleeding while flossing. Incorrect or harsh use of dental floss can cause these symptoms. However, bleeding and gum discomfort can also be symptoms of periodontal disease . Unfortunately, periodontal disease can also make conventional flossing less effective because of the larger interdental spaces. If you have patients who struggle with conventional flossing, you may want them to consider a water flosser. Although water flossing can be gentler than string flossing, if they haven’t been flossing regularly, they still may experience sensitivity when they start. They can relieve some tooth sensitivity issues by adjusting the water temperature, so it’s not too cold or hot. If they are still having problems, though, they may have a larger issue that you will need to address with them. Traditional flossing can be difficult for some people with certain physical ailments. People with arthritis, Parkinson’s disease, carpal tunnel syndrome, or other conditions that affect the hands may find it hard to use string floss around the teeth. Fortunately, water flossing is a mechanical interdental cleaning option that is easy to use.
Lastly, water flossing is an excellent option if patients are undergoing complex restorative or orthodontic treatment. For example, braces, non-removable bridges, dental implants, and crowns can all create hard-to-reach places to clean that can benefit from using such a device. How effective is water flossing? Water flossers work through hydrokinetics, the movement of water. According to the Australian Dental Association, the steady stream of water produced by a water flosser can help remove plaque and food debris between teeth and below the gumline. However, flossing is technique dependent and so the results can vary between traditional flossing and water flossing amongst individuals. A good oral hygiene routine includes brushing twice a day and interdental cleaning once a day. If your patient has difficulty using traditional string floss, water flossing may be an option for them. With your help, your patient can determine the best way to clean between their teeth and achieve a healthy smile.
Scan here to order the Water Flosser through our website.
Reference: https://www.colgate.com.au/oral-health/selecting-dentalproducts/should-you-consider-a-water-flosser
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LIGHTING THE WAY WITH GBT GUIDED BIOFILM THERAPY
MAKE ME SMILE.
Caries and periodontitis are among the most common diseases worldwide.
Maximum performance Did you know that fear of the dentist is a serious psychological problem for many Australians? High dental fear affects about one in seven Australian adults and one in ten children making it one of the most prevalent anxiety disorders in the country.
Both are biofilm-induced diseases of hard and/or soft oral tissues. The top priority of oral medicine is to keep a patient’s natural teeth and periodontium healthy, functional, and pain-free throughout that patient’s lifetime. This is EMS’ mission and the goal of GBT. Just like other technological advances in dentistry, i.e. digital radiographs and scanning devices to replace alginate impressions, with the development of GBT, EMS has sustainably changed and shaped the approach to dental care. Essentially, Guided Biofilm Therapy (GBT) involves an eight-step process, capitalizing on the concept that pathogenic biofilm drives oral disease and thus should be removed by clinicians in the least abrasive, most efficient and most comfortable method achievable.
08 RECALL
07 CHECK
This is obviously a significant problem for dental professionals working hard to improve the oral health of the nation since many Australians avoid appointments as a result of fear of 01 ASSESSMENT AND pain or worry that an injection might INFECTION CONTROL be required. However, user-friendly 02 DISCLOSE GBT treatment in the hands of Dental clinicians trained by our GBT Clinical Experts, who communicate with their patients 03 MOTIVATE effectively about the GBT ‘no pain’ wellness-like technology, can help even the most anxious 04 AIRFLOW MAX patients to overcome their fears. In fact, GBT is great for all patients, including children. R
®
06 PIEZON® PS
05 PERIOFLOW®
As clinicians, we should prevent scratching surfaces or creating mineral loss while removing biofilm, both of which could ultimately leave the surfaces with more plaque and/or stain-retentive. Flemmig et al. reminded clinicians in a 2007 study that “abrasion on tooth surfaces might become substantial over time, when the cumulative effects of repeated instrumentation during SPT [supportive periodontal therapy] are considered.”
GBT involves removal of biofilm from surfaces above and below the gumline prior to the removal of calcified deposits using PIEZON® No Pain technology with the use of state-of-the-art AIRFLOW® and PERIOFLOW® technologies. GBT consists of treatment protocols based on individual patient diagnosis and risk assessment in order to achieve optimal results. The eight-step process includes oral hygiene instruction, patient education and motivation to maintain natural teeth and dental implants for as long as possible.
The GBT protocol uses AIRFLOW® with PLUS Powder based on erythritol, an extra-fine minimally invasive grain of only 14 microns which does not leave any scraches or create mineral loss. This minimal invasiveness makes the powder ideal for use on all types of dental tissues: dentine, cementum, enamel, on the tongue and in pockets, disrupting and killing biofilm and removing stain using warm water with the GBT enabler, the AIRFLOW® Prophylaxis Master. It can be used on composites and implants, too. Which is why Prof Axel Spahr, Prof Ian Meyers and Dr Derek Mahony are big fans of GBT for restorative, periodontics, implant dentistry, pediatric dentistry and orthodontics.
All these steps are evidence-based which is of course imperative for the clinician to feel confident to incorporate GBT into their everyday practice. GBT can be used on both new and maintenance patients. It is universally suitable for healthy patients (prevention) and diseased patients (initial and maintenance therapy for caries, gingivitis, periodontitis, peri-implantitis).
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PREVENTATIVE SOLUTIONS Prime time Another benefit of biofilm management via GBT is efficiency. Since clinicians remove biofilm from surfaces early on in the appointment, the need for overlapping, repetitive strokes using power or hand instrumentation is substantially reduced or not needed at all depending on the patient’s recall. This means more time can be dedicated to building that all-important rapport with patients, as well as oral health instructions, education and additional services. The patient experiences less mechanical instrumentation with GBT, yet enjoys the optimal outcome of smooth, clean surfaces. The GBT process turns the traditional appointment setup on its head, disclosing the patient’s biofilm very early on, discussing what that means and how effective oral healthcare at home can minimise or eliminate it, before any treatment is even carried out.
GBT is eight simple, pain-free steps GBT is a fast, efficient and comfortable way for dental professsionals to work and can be divided into eight simple steps:
1. 2.
Assess – probe and screen every clinical case
3.
Motivate – inform, instruct and motivate the patient to perform oral hygiene at home and make dietary changes
Disclose – make biofilm visible with the EMS Biofilm Discloser, determine and record the plaque index
4.
AIRFLOW® - remove biofilm, stains and early calculus with the AIRFLOW® MAX Handpiece and PLUS Powder supragingivally and up to 4mm subgingivally
5.
PERIOFLOW® - remove biofilm in >4 to 9mm subgingivally
6.
‘No pain’ PIEZON® - remove remaining calculus supra and subgingivally
7. 8.
Check – check the quality of the treatment Recall – make an individualised risk-oriented recall appointment
coming in for, now they’re focused on the biofilm and the importance of it’s removal’. She added: ‘Doing GBT allows me to implement behaviour changes to carry out treatment in a way that will help my patients achieve and maintain a better level of oral health. We should be helping patients to be more aware of how the health of their mouth relates to the rest of their body. And that cleaning teeth is more than cleaning! It’s about bacteria they can’t see, what it can do to their health, and each patient’s role in oral care. GBT is the catalyst for the paradigm shift needed to change the state of oral and systemic health for patients and the future of dental hygiene care.’
Best practice Integrating a technology and protocol that saves time, is safe and comfortable for the patient, and is easy for clinicians to use has multiple benefits—from increased longevity for the practicing clinician, to increased referrals from comfortable wellness-like patient experiences and confidence in “doing no harm” on delicate oral surfaces during biofilm removal. This makes GBT the ideal practice builder and why GBT is a proven business model bringing in new patients, decreasing downtime and increasing dental treatments enrolled through hygiene. I truly wish all clinicians today practiced GBT. But don’t take my word for it; investigate for yourself. Book an appointment with our certified EMS Clinical GBT Experts and join our GBT User Group on Facebook, to see experiences from clinicians following GBT around the world they’ll challenge you to change the status quo in the way you practise biofilm management. Contact your Henry Schein Representative or Call 1800 860 580 to book an appointment with a GBT Expert. https://www.facebook.com/ groups/2041319372800158/
References:
What’s new at EMS?
Armfield JM. The extent and nature of dental fear and phobia in Australia. Australian Dental Journal 2010;55:368-377
Introducing the AIRFLOW® MAX Handpiece EMS continued to improve on patient and practitioner comfort with the introduction of the AIRFLOW® MAX, a lighter, quieter, and ergonomically optimised handpiece that uses patented GUIDED LAMINAR AIRFLOW® technology to ensure a laminar air–powder–water flow. This represents a quantum leap by enhancing the control of aerosols and reducing them by 60% and reducing powder consumption. Offering valuable insight into how this works in practice, Tabitha Acret, awardwinning hygienist and EMS Education Manager who uses GBT in practice, said: ‘I disclose after performing a periodontal assessment and recording BPE and bleeding scores.
Flemmig TF, Hetzel M, Topoll H, Gerss J, Haeberlein I, Petersilka G. Subgingival debridement efficacy of glycine powder air polishing. J Periodontol. 2007;78(6):1002-1010. doi:10.1902/jop.2007.060420 Kinane DF, Strathopoulou PG, Papapanou PN. Periodontal diseases. Nat. Rec Primers 2017 ;3 :17038 König J, Plagmann HC, Langerfield N, Kocher T.
The disclosing process allows the patient to see the plaque that will cause caries and gum disease if left untreated. Patients no longer focus on what they thought they were
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ANDREAS SCHULZ General Manager of EMS Australia & New Zealand
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INTRODUCTION 2022 INFECTION CONTROL STRATEGIES FOR YOUR PRACTICE
Firstly, I’d like to say thank you for reading and welcome to another year of the Dental Solutions Infection Control Section.
We’ve got an exciting year planned of activities and the upcoming ADX Show in Sydney. For those of you coming to join us, please feel free to pop over to the Infection Control Booth at the Henry Schein Village! We will have a series of products on display and staff members there to help you with any Infection Control queries and questions.
It’s been a very challenging two years as we’ve learnt to live with COVID-19, adapting as best we can to an ever-changing environment. However, it is something we are becoming more familiar with in our day to day life.
For this issue of Dental Solutions, we are covering off some key topics from some of our most valuable Suppliers.
Last year we brought to you several Infection Control Webinars through IC Confidential, this content was developed to plug some of the gaps in the confusion between Guidelines and the changing environment of COVID-19.
We hope you enjoy the read and find some useful articles brought to you by Emeritus Professor Laurence Walsh, Ansell, Mocom Australia, GKE, Dentisan, the Hu-Friedy group, and Coltene Scican.
Whilst these are still available through the Dental Education Hub, we will endeavour to get more updated information to you so that you can rely on us for further up-to-date informative content.
From Kira and I, thank you again and looking forward to a wonderful 2022 with you!
For those of you that may have missed out on the IC Confidential 2021 Series, please feel free to register anytime for the On-Demand Webinars. These webinars are roughly between 15 and 30 minutes long, making it easy to fit in some education at lunchtime.
Scan here to watch the IC Confidential 2021
EMMA JONES CICP-P Infection Control Category Manager
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KIRA FIELD Brand and Marketing Coordinator
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HAND ERGONOMICS IN DENTISTRY
Work-related Musculoskeletal Disorders (MSDs) of the hand and wrist develop from the physical clinical activities performed by dental professionals. Risk factors either alone or in combination that may contribute to muscle fatigue and the development of MSDs of the hand include:
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exerting excessive force; excessive repetition of movements; awkward postures or unsupported positions; static postures or positions that a worker must hold for long periods of time; compression which can concentrate force on small areas of the body; inadequate recovery time due to overtime, lack of breaks, and failure to vary tasks; and excessive vibration, usually from vibrating tools/drills, which can decrease blood flow, damage nerves, and contribute to muscle fatigue.1
Additionally, when a glove is worn that restricts hand movement, healthcare workers must exert more muscle effort to perform procedures, thereby increasing the risk of strain which can lead to hand fatigue or injury such as the Carpal Tunnel Syndrome.2 The Importance of Ergonomics Ergonomics is the practice of preventing workrelated MSDs. Its successful implementation increases productivity, reduces illnesses and injuries, and boosts satisfaction among dental professionals.3
Ansell’s innovative ERGOFORM™ Ergonomic Design Technology has helped deliver improved range of motion and enhanced comfort in protective gloves that are used daily by most workers. Ansell factors in the ergonomics of the hand by accommodating its natural state and allowing for better freedom of movement to greatly reduce the stress placed on workers’ hands. This prevents the occurrence of MSDs such as Carpal Tunnel Syndrome or tendinitis in the long term. MICROFLEX® MidKnight™ Touch 93-732 Provides excellent dexterity along with enhanced comfort fit and feel.
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Enhanced dexterity and tactility in a thin, yet strong design
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Distinctive black colour provides contrast while also hiding the appearance of oils, bodily fluids, and other stains
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ERGOFORM™ Design Technology reduces muscle strain during repetitive tasks, improving comfort and productivity
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Textured on the fingertips for secure handling of instruments
References 1 Khanagar S, Rajanna V, Naik S, Jathanna VR, Kini PV, Reddy S. An Insight to Ergonomics in Dental Practice. I J Pre Clin Dent Res 2014;1(2): 35-40. 2 Haghigh B, Khosropanah H, Vahidnia F, Esmailzadeh S, Emami Z. Association of Dental Practice as a Risk Factor in the Development of Carpal Tummel Syndrome. J Dental Shiraz Univ Med Scien 2013;14(1):37-40. 3. Gupta A, Bhat M, Bansal N, Gupta G. Ergonomists in Dentistry. Int J Clin Pediatr Dent 2014:1(1):30.
Ansell’s Solution ERGOFORM™ is a new technology that enables Ansell to design hand protection that supports musculoskeletal health during repetitive tasks and improves worker performance.
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Please scan here to view the full ANSELL Midknight Touch Glove Range on our website
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INFECTION CONTROL
WHY IS BIOFILM BAD NEWS FOR YOUR DENTAL PRACTICE?
The presence of biofilm in dental unit water lines can cause water quality to fall below the minimum standards of < 200 cfu/ml. We should all now be aware of the changes in the Australian Dental Association Guidelines for Infection Control and dental waterline testing (pages 30+). DUWLs provide an ideal environment for the growth of bacterial biofilms.
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Water has a low flow rate which favours bacterial adhesion.
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Water flows intermittently causing minimal disruption to the growing biofilm.
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Fresh liquid encourages the growth of new biofilm, for example: when a handpiece is used or the system is flushed.
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Your surgery provides the ideal temperature range for bacterial growth.
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Biofilm can lead to a reduction in water flow and even tube blockage leading to unit downtime and repair costs.
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Biofilm can potentially harbour pathogens which may originate from the input water or by retraction from handpieces.
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High bacterial loads in output water have the potential to cause infection in patients or dental professionals, either by direct contact or through the inhalation of aerosolised mist.
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The practice of putting water into a patient’s mouth that does not meet the standards required for drinking water is bad practice.
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Maintaining water quality is of considerable importance, primarily because both patients and the dental team are regularly exposed to water and aerosols generated by dental equipment. If biofilms are allowed to form in DUWLs, the pathogens settling on the internal wall of the tubing can then enter the oral cavity via high-speed handpieces, ultrasonic scalers, air/water syringes and mouth rinsing water, exposing patients and staff to microorganisms in fragments of biofilm that can cause illness. Biofilm levels in dental equipment can be minimised by using a range of measures to remove, prevent and control biofilm formation and such measures will help maintain the recommended quality of dental water. Purge If a build-up of biofilm is identified, then purge cleaning should be carried out using a suitable Regulatory Compliance Marked biofilm remover. Bioclear is a pH neutral, odourless, ready-to-use solution that requires no mixing. Supplied in singledose bottles (one bottle is one week’s treatment per chair), Bioclear is simply poured into the chair’s water bottle, drawn through so that it fills the water line and left for a minimum of 12 hours or over a weekend. Once the Bioclear treatment is complete, the line is simply flushed through with fresh water until the water runs clear Bioclear is non-tainting, manufactured using biodegradable surfactants and has been tested on silicone tubing, pvc tubing, copper, brass and aluminium.
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Bioclear achieves microbiological testing in accordance with EN13727 for efficacy against:
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Staphylococcus aureus
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Pseudomonas aeruginosa
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Enterococcus hirae
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Escherichia coli
present in the system, copper strips were used to demonstrate the effects of water, sodium hypochlorite and Bioclear. Water was selected as the negative control as it will normally be present in DUWL systems at all times. Sodium hypochlorite was selected as the positive control as it is known to be chemically aggressive to metals and is suggested by the Department of Health as a possible chemical for use as a biofilm remover.
In a test to simulate contact in a DUWL between metal components and liquids that may be
The following photographic records were made and clearly show that Bioclear does the least visual damage to the copper. Before test
After test
Negative control Mains water
Positive control Hypochlorite at 2%
The Bioclear kit comes complete with instructions for use and a laminated notice that should be placed on the chair whilst undergoing treatment with Bioclear. You can perform ongoing monitoring of the quality of input and output water using Dentisan’s Microbiological Dip Slides which are available either as part of the Bioclear Starter Pack or as a separate item.
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Bioclear
Please scan here to view the Dentisan Range on our website
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INFECTION CONTROL
CLEANING SUCTION LINES A PRACTICAL APPROACH
A dental suction system is designed to remove saliva, blood, remnants of dental hard tissue and dental materials and debris generated during clinical procedures from the mouth. By removing these, dental suction makes clinical procedures faster as well as safer. This is true whether one is working in a regular clinic with a dental chair or from a mobile dental delivery system. This article outlines the science and practical considerations that support the proper treatment of dental suction lines, regardless of the nature of the dental service.
essential component of dental treatment, especially for dental chairs in an open plan clinic layout.15 Suction line configurations Current definitions for dental suction are as follows: low volume (40 L/min air), medium volume (159 L/ min air) and high volume (250 L/min air).16 High volume suction hoses usually are equipped with special connectors and adapters into which wide bore (8 or 10 mm diameter) suction tips are fitted prior to each patient treatment. The tip will move ~4 litres of air per second, or more. HVE connectors often contain valves to regulate suction strength. They may also have metal or plastic adaptors to join various tips to the suction hose. In contrast, single patientuse saliva ejector tips (3-4 mm in diameter) are fitted to the low volume suction line. This line moves only ~1 litre of air per second or less.
Effective suction for reducing aerosols Effective high-volume evacuation is recognised as a key component of strategies that mitigate the risk of infection to dental staff, including from aerosol-generating procedures performed on dental patients with upper respiratory tract infections. Highvolume evacuation (HVE) using wide bore intraoral suction tips has been shown to be highly effective in reducing salivary contamination of the surrounding environment.
HVE is essential during all aerosolgenerating procedures, including those using handpieces, ultrasonic and sonic devices, air polishing devices and hard tissue lasers.8,13,17 Different designs of suction tips and attachments can enhance the protective action of suction by better removal of aerosols during caries removal with a high-speed handpiece and other dental aerosol-generating procedures. As well, correct placement of the tip of the high-volume evacuator, facing the aerosol-generating procedure side, will significantly reduce the level of ultrafine particles produced duringrestorative dentistry.18,19
There is an extensive literature that supports the view that with correct placement of HVE, aerosols and spatter should be reduced by 90% or more.114 This makes maintaining the suction system a critical component of safe working practices in everyday dental practice. HVE also reduces contamination in the areas immediately beyond the dental chair when open plan clinic designs are used, keeping the majority of contamination within 1.5 m of the patient’s head. The reason for this is that suction removes smaller lighter droplets (aerosol) easily and it is these that likely cause more distant contamination. These considerations explain why dental suction with a wide bore aspiration tip fitted to HVE should be an
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The Isolite® illuminated isolation system attaches to the HVE connector and is designed for use by clinicians such as dental hygienists who are working without a dental assistant.
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The Isolite is designed to provide simultaneous suction to both the maxillary and mandibular quadrants on one side, as well as illumination. Its performance for achieving aerosol reduction has been challenged, with a clinical study of its use during ultrasonic scaling showing no benefit over a saliva ejector. Neither the Isolite device nor the saliva ejector can effectively reduce aerosols and spatter during ultrasonic scaling.20 Saliva ejectors and low volume evacuation Several studies from the 1990s have shown that, under certain conditions, liquid from the saliva ejector’s low volume evacuation suction line can enter a patient’s mouth during use. This can occur in a transient way accidentally when there is occlusion of the mouthpiece opening by the oral mucosa, or when there are oscillations in suction produced by operating other suction equipment. It can also occur deliberately when patients apply greater suction force than what is provided by the saliva ejector, as they suck or close their lips around the saliva ejector. In this case, the negative pressure in the patient’s mouth is greater than that in the saliva ejector, causing backflow of previously aspirated fluids. Gravity assists such backflow when the LVE suction tubing holding the tip is positioned above the patient’s mouth.21,22 Microbiological studies of saliva ejector low velocity suction lines reveal that these are coated with microbial biofilms. The dense deposits of metabolically active Gram-positive cocci and Gram-negative bacilli are embedded in an extensive polysaccharide matrix.23 Saliva ejector lines are just as contaminated as HVE suction lines and a wide variety of microorganisms are present. Hence, retraction of oral fluids and biofilm-derived microorganisms from contaminated suction hoses could potentially be a source of crosscontamination and cross-infection. When oral fluids from a previous patient are taken into the mouth, there is also the risk of transmission of viruses that may be present in saliva, including Epstein Barr virus, cytomegalovirus, Herpes Simplex and other herpes group viruses.24 Removing hard deposits from suction lines Everyday maintenance of suction lines is essential. These lines are prone to the accumulation of mineral
deposits as well as microbial biofilms. Formation of mineral deposits can be promoted by materials suctioned from the oral cavity, like remnants of fluoride gels, prophy paste, abrasive powders and cements, because these contain anions (such as carbonates, phosphates, sulphates and hydroxides) that can form insoluble precipitates with metal cations (such as calcium, magnesium and aluminium). Mineral formation will be faster when the water exiting from the dental unit is hard, as hard water has higher levels of such anions and cations and a higher propensity to form mineral scale deposits. As hard deposits build up over time in dental suction lines, they reduce the effective diameter of the suction lines. They also provide a rough surface onto which microbial growth can occur. To address hard deposits, periodic cleaning of suction lines using a product than can dissolve such deposits is needed. While mineral deposits could in theory be dissolved away using strong acids (such as HCl), these will cause corrosion of metal components in the suction system (such as butterfly valves and solenoids), as well as numerous other bystander reactions. Working with concentrated HCl would also pose significant work health and safety issues for staff because of its volatile nature (generating highly irritant fumes) and its ability to cause soft tissue injuries. As a result, suction system cleaners use mineral chelators, instead of strong acids, to dissolve mineral scale. These pose much less issues for OH&S and are less likely to cause corrosion of metal components (like valves) than strong acids. As they bind tightly to divalent and trivalent metal ions, they have a water softening action, which suppresses further formation of insoluble precipitates. Phosphonates are stable under the low pH conditions that are best for dissolving away mineral deposits. Phosphonates are used widely in water treatment processes including desalination and reverse osmosis so their chemistry is well known. Phosphonates are the major active ingredient used in Eurosept Xtra Evac Cleaner® Weekly Concentrate, which is designed for removing hard deposits from suction lines. This product has a low pH (<2) which assists in breaking down mineral deposits and amphoteric surfactants to increase the contact of the solution with the walls of the tubing.
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Removing soft deposits from suction lines
Table 1
Microbial biofilms form in dental suction lines for several reasons. First, the suction hoses are repeatedly contaminated with oral microorganisms. These have multiple origins, including from coolants and irrigant solutions, tap water, dental unit waterlines and the patient’s dental plaque, saliva and blood.25-27
Microorganisms isolated from biofilms in suction lines
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Gram negative bacteria
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Pseudomonads including P. aeruginosa, P. fluorescens and P. putida
Second, the suction lines are often wet. Flowing water provides a shear force along the walls of the lines. This provides an environment that is highly conducive to the growth and proliferation of microorganisms in a dense adherent biofilm. Field studies show that heavy microbial contamination of the dental suction lines extends from the dental chair to the suction unit and thereafter from the suction unit drain lines.28
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Alcaligenes xylosoxidans
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Aeromonas salmonicida
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Acidovorax temperans
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Burkholderia cepacian
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Comamonas acidovorans
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Novosphingobium subarctica
Third, a generous supply of proteins and other nutrients from saliva and blood ensures the rapid growth of many types of microorganisms as well as numerous species within one type. As an indicator of high levels of blood exposure, direct evidence for high levels of blood being retained on the inner surface of suction tips after periodontal debridement has been provided using the Kastle-Meyer reagent test, in which a colour change to purple indicates the presence of fresh or dried blood.29
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Serratia marcescens
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Sphingomonas spp. including S. aerolata, S. paucimobilis and S. trueperi
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Stenotrophomonas maltophilia
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Gram positive bacteria
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Bacillus spp.
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Streptococcus spp. including S. pneumoniae, S. salivarius and S. mitis
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Staphylococcus spp. including S. aureus, S. epidermidis S. haemolyticus and S. warneri
Typical organisms that have been isolated from dental suction systems are listed in Table 1. Levels of Gram negative bacteria in dental suction line biofilms can exceed 500,000 CFU per square cm. Similar issues have been found in medical suction systems used in hospitals, which have caused outbreaks of infection involving different opportunistic Gramnegative bacteria.30,31
Fungi
An important pathogen found at high levels in dental suction lines is the Gram negative bacterium Pseudomonas aeruginosa, which is able to outcompete many other bacteria. It grows well in wet regions and on PVC and medical tubing.32-35 This is particularly relevant during the COVID-19 pandemic, as forced shutdowns may result in dental chairs remaining unused or under-used for extended periods of time. P. aeruginosa and other pathogens are able to remain viable during periods when nutrient levels are low. The presence of Pseudomonads explains why suction line biofilms can be coloured green, yellow or brown.
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Acremonium
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Rhotodotorula
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Cladosporium
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Fusarium
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Aurobasidum pullulans
Data collated from multiple studies undertaken at Trinity College, Dublin, Ireland by M.A. Boyle and M.J. O’Donnell
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Suction line odours Breakdown of proteins from saliva and blood that contain amino acids with sulphur atoms results in the release of volatile sulphur compounds (VSCs), such as hydrogen sulphide (H2S), methyl mercaptan (CH3SH) and dimethyl sulphide [(CH3)2S]. These have a characteristic unpleasant odour.36,37 Such odours will provide an unsatisfactory environment for both patients and staff when they accumulate during periods when the dental clinic airconditioning is not operated or if the dental operatory is poorly ventilated.38 More of such odours will be noticed in the dental operatory when biofilm levels in the lumen (i.e. on the internal walls) of the suction tubing are high. When this problem is found, the likely causal factors (Table 2) should be explored. Using the correct product at sufficient frequency (at least once per day at the end of the day) will minimise biofilm formation. When odours are present when the suction is off, indicating that biofilm levels are high, more frequent treatment (e.g. twice daily until the problem resolves) would be appropriate. It is also important to note the problem of leakage from suction system hoses at their sites of attachment to the dental chair, caused by gradual loosening during use. One study of variations in microbial flora in dental suction lines reported the presence of some P. aeruginosa strains (such as serotype O:10, SpeI fingerprint group II) that seemed particularly well adapted to survive in dental suction systems and which may be particularly resistant to disinfection. In the situation reported, the suction lines had been disinfected after each clinical session (i.e. twice daily, Monday–Friday) with a phenolic disinfectant (PuliJet® from Cattani) in a process that took approximately 1 minute. This regular disinfection with Pulijet appeared to be ineffective at controlling bacterial contamination in the suction system. The very short contact time that the disinfectant had with the inside surfaces of the suction system (i.e. approximately 1 min) was also thought to be a contributory factor.24 Other studies also reinforce the point that dental suction systems become heavily contaminated during use and that conventional disinfection protocols may not be entirely effective at
controlling this issue. Prolonged biofilm growth can lead to issues with the suction handpiece valves that are used to regulate suction strength either leaking or becoming stuck in one position. Leaks occur because extensive microbial biofilms on O-rings have caused these seals to perish. A stuck valve can be due to congealed blood, as well as corrosion of metal components..39
Table 2 Factors that promote growth of biofilms in suction lines
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Irregular/insufficient flushing with an appropriate antimicrobial solution
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Frequency is too low
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Volume of product used is too low
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Exposure time for the product is too short
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Product concentration is too low (incorrect dilution ratio, product expired, incorrect solvent used)
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Tap water used for product dilution is hard
Frequent surgical and periodontal debridement procedures where blood is generated, with insufficient flushing using water or saline at the end of the procedure . Product compositions for disinfection Principles for microbial control of biofilms in suction lines have parallels to those used for dental unit waterlines, particularly flushing and periodic aggressive chemical treatments to disrupt biofilms.40-42 An important distinction is that the nutrient environment is rich in the suction lines, resulting in more vigorous growth of microorganisms. The microbial diversity is greater, with bacteria, fungi and amoeba being present. This is why active ingredients with broad spectrum disinfecting actions are needed for treating dental suction lines and why dental suction lines must be disinfected regularly.43,44
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INFECTION CONTROL It is not practical to detach suction hoses (for thermal disinfection) either after each patient or on a daily basis, hence aspiration of chemical disinfectants on a regular basis is needed. Most dental chair manufacturers suggest this be done at least once daily, at the end of the working day. Field studies reveal that compliance with this recommended frequency of suction system disinfection varies widely.45
and ecological effects in water systems are parameters to consider, as well as the likelihood of corrosion. Keeping close to a neutral pH is desirable for material compatibility. Typically, suction cleaners are designed for both being used in the suction system and also being poured into the spittoon, at the same concentration. Follow the manufacturer’s instructions and check whether the product is low foaming before attempting to treat a spittoon.
Products used for breaking down the matrix of biofilms and killing microorganisms will typically contain low foaming surfactants, as well as disinfectants and fragrances, with the latter providing a deodorising action. Using enzymes at neutral pH is a highly effective strategy for breaking down complex biofilms. Eurosept Xtra Evac Cleaner® Daily is an example of an enzymatic cleaning concentrate, designed for daily cleaning and care of dental suction systems. This product is pH neutral and contains non-ionic low-foaming surfactants.
Correct product handling and usage Suction cleaners can combine the two functions of reducing biofilm and dealing with mineralised deposits, and various manufacturers have developed protocols around optimising both functions. Some have taken the approach of a frequent-use product where microbial control is paramount and a periodic use product (e.g. twice weekly) formulated to dissolve mineral deposits. For efficient transport, products may be shipped as concentrates which are then diluted, typically with ordinary tap water. The final mixture is then run through the suction system and/or poured down the spittoon.
These ensure maximal penetration of the enzymes into soft deposits of organic matter such as residues of blood, saliva and biofilms. Chemical compatibility with suction system components and amalgam separators is another important consideration. Use of strong oxidants could lead to powdery corrosion of aluminium components such as manually operated suction butterfly control valves and suction tip connectors following prolonged use. These deposits of aluminium oxide can impair the action of the control valves and impair proper intake of air. This will not occur if the butterfly control valves and suction tip connectors are made from high-quality, acidresistant steel as that will resist corrosion by strong oxidants such as hydrogen peroxide.46
Conclusions Dental suction is essential for safe dental practice and HVE is a critical component of infection control work practices that remove aerosols and reduce their spread. The COVID-19 pandemic has made dental practices more aware of the importance of proper HVE. For proper performance, dental suction lines need regular attention to remove both hard deposits and microbial biofilms. The products used must remove these deposits while not causing corrosion or other forms of deterioration. Well designed products used in the right way will also ensure that problems such as the generation of odours do not occur when the dental chair is not in use.
A variety of factors can contribute to failure of suction line disinfection in the long term, including human errors (not following use protocols; incorrect product selection; incorrect dilution), as well as corrosion and deterioration of the suction lines and suction equipment. Disinfectants used in suction cleaners designed for daily use will need a broad antimicrobial spectrum. When considering possible candidates, chemical inactivation, optimal pH, interactions with proteins
Please scan here to view the EuroSept Suction Cleaning Range on our website
Please scan here to view the full article and list of references
EMERITUS PROF. LAURIE WALSH AO
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References 1. Micik RE, Miller RL, Mazzarella MA, Ryge G. Studies on dental aerobiology, I: bacterial aerosols generated during dental procedures. J Dent Res. 1969; 48: 49-56.
24. O’Donnell MJ et al. Bacterial contamination of dental chair units in a modern dental hospital caused by leakage from suction system hoses containing extensive biofilm. J Hosp Infect. 2005; 59: 348-360.
2. Bentley CD et al. Evaluating spatter and aerosol contamination during dental procedures. J Am Dent. Assoc. 1994; 125: 579-584.
25. Wirthlin MR et al. Formation and decontamination of biofilms in dental unit waterlines. J Periodontol 2003; 74: 1595-1609.
3. Bennett AM et al. Microbial aerosols in general dental practice. Br Dent J. 2000; 189: 664-667.
26. Szymanska J et al. Microbial contamination of dental unit waterlines. Ann Agric Environ Med. 2008; 15: 173-179.
4. Leggat PA, Kedjarune U. Bacterial aerosols in the dental clinic: a review. Int Dent J. 2001; 51: 39-44
27. Spagnolo AM et al. Microbial contamination of dental unit waterlines and potential risk of infection: a narrative review. Pathogens 2020; 9: 651.
5. Jacks ME. A laboratory comparison of evacuation devices on aerosol reduction. J Dent Hyg. 2002; 76: 202-206.
28. Conte M et al. Microbiological contamination of compressed air used in dentistry: an investigation. J Env Health 2001; 64 :15-26.
6. Harrel SK, Molinari J. Aerosols and splatter in dentistry: A brief review of the literature and infection control implications. J Am Dent Assoc. 2004; 135, 429-437. 7. Timmerman MF et al. Atmospheric contamination during ultrasonic scaling. J Clin Periodontol 2004; 31: 458-462. 8. Harrel S K. Airborne spread of disease – the implications for dentistry. J Calif Dent Assoc. 2004; 32: 901-906. 9. Dahlke WO et al. Evaluation of the spatter-reduction effectiveness of two dryfield isolation techniques. JADA. 2012; 143: 1199-1204. 10. Zemouri C et al. A scoping review on bio-aerosols in healthcare and the dental environment. PLoS ONE 2017; 12(5), e0178007.
29. Edmunds LM, Rawlinson A. The effect of cleaning on blood contamination in the dental surgery following periodontal procedures. Aust Dent J. 1998; 43: 349-353. 30. Blenkharn JIl, Hughes VM. Suction apparatus and hospital infection due to multiply-resistant Klebsiella aerogenes. J Hosp Infect 1982; 3: 173-178. 31. Rubbo SD et al. Source of Pseudomonas aeruginosa infection in premature infants. J Hyg 1966; 64: 121-128. 32. Stoodley P et al. Biofilms as complex differentiated communities. Annu Rev Microbiol. 2002; 56: 187-209.
11. Kobza J et al. Do exposures to aerosols pose a risk to dental professionals? Occup Med. 2018; 68:454-458.
33. Mendis N et al. Comparison of virulence properties of Pseudomonas aeruginosa exposed to water and grown in rich broth. Can J Microbiol. 2014; 60: 777-781.
12. Liu MH et al. Removal efficiency of central vacuum system and protective masks to suspended particles from dental treatment. PLoS ONE 2019; 14: e0225644.
34. Rozej A et al. Structure and microbial diversity of biofilms on different pipe materials of a model drinking water distribution systems. World J Microbiol Biotechnol. 2015; 31: 37-47.
13. Meethill AP et al. Sources of SARS-CoV-2 and other microorganisms in dental aerosols. J Dent Res 2021; 1-7. DOI: 10.1177/00220345211015948
35. Ammann CG et al. Pseudomonas aeruginosa outcompetes other bacteria in the manifestation and maintenance of a biofilm in polyvinylchloride tubing as used in dental devices. Arch Microbiol. 2016; 198: 389-391.
14. Allison JR et al. Evaluating aerosol and splatter following dental procedures: addressing new challenges for oral health care and rehabilitation. J Oral Rehabil. 2021; 48:61-72.
36. Tonzetich J. Direct gas chromatographic analysis of sulphur compounds in mouth air. Arch Oral Biol 1971; 16: 587–597.
15. Holliday R et al. Evaluating contaminated dental aerosol and splatter in an open plan clinic environment: Implications for the COVID-19 pandemic. J Dent. 2021; 105: 103565.
37. Yaegaki K, Sanada K. Volatile sulfur compounds in mouth air from clinically healthy subjects with and without periodontal disease. J Periodont Res 1992; 21: 434-439.
16. ISO 7494-2:2015 Dentistry. Dental units. Air, water, suction and wastewater systems.
38. Smith AJ. The devil is in the validation and design; managing the risk from opportunistic pathogens in the dental unit. J Hosp Infect. 2021; 114: 61-62.
17. Harrel S K, Molinari J. Aerosols and splatter in dentistry: a brief review of the literature and infection control implications. J Am Dent Assoc 2004; 135: 429-437.
39. Boyle MA et al. Overcoming the problem of residual microbial contamination in dental suction units left by conventional disinfection using novel single component suction handpieces in combination with automated flood disinfection. J Dent. 2015; 43: 1268-1279.
18. Matys J, Grzech-Lesniak K. Dental aerosol as a hazard risk for dental workers. Materials 2020; 13: 5109. 19. Balanta-Melo J et al. Rubber dam isolation and high-volume suction reduce ultrafine dental aerosol particles: an experiment in a simulated patient. Appl Sci. 2020; 10: 6345. 20. Holloman JL et al. Comparison of suction device with saliva ejector for aerosol and spatter reduction during ultrasonic scaling. J Am Dent Assn 2015:146: 27-33. 21. Watson CM, Whitehouse RL. Possibility of cross-contamination between dental patients by means of the saliva ejector. J Am Dent Assoc. 1993; 124: 77-80. 22. Mann GL et al. Backflow in low-volume suction lines: the impact of pressure changes. J Am Dent Assoc 1996; 127: 611-615. 23. Barbeau J et al. Cross contamination potential of saliva ejectors used in dentistry. J Hosp Infect. 1998; 40: 3030311.
40. Fux CA et al. Survival strategies of infectious biofilms. Trends Microbiol. 2005; 13: 34-40. 41. Walker JT, Marsh PD. Microbial biofilm formation in DUWS and their control using disinfectants. J Dent. 2007; 35: 721-730. 42. Garg SK et al. Dental unit waterline management: Historical perspectives and current trends. J Investig Clin Dent. 2012; 3: 247-252. 43. Costa D et al. Planktonic free-living amoebae susceptibility to dental unit waterlines disinfectants. Pathog Dis. 2017; 75: ftx099. 44. Yoon HY, Lee SY. Susceptibility of bacteria isolated from dental unit waterlines to disinfecting chemical agents. J Gen Appl Microbiol. 2019; 64: 269-275. 45. Watson CM, Whitehouse RL. Possibility of cross-contamination between dental patients by means of the saliva ejector. J Am Dent Assn 1993; 124: 77-80. 46. O’Donnell MJ et al. Optimisation of the long-term efficacy of dental chair waterline disinfection by the identification and rectification of factors associated with waterline disinfection failure. J Dent. 2007; 35: 438-451.
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STATIM DISCUSSION
Understanding the different types of steam sterilisers and their cycles by Emeritus Prof. Laurie J. Walsh AO
Despite its long history, steam sterilisation continues to be an area where some dental practices struggle to understand the process, the equipment, and how to use it to ensure consistent performance. While virtually all dental practices have steam sterilizers (also known as autoclaves), many staff do not know the differences between the major types. Sterilisation using saturated steam kills microorganisms by transferring heat onto the items which are being sterilized, as the steam condenses. When steam changes to liquid water, this also moistens the organisms, which increases the kill rate. Statistically, a sterilising cycle is designed so that the opportunity for a micro-organism to survive is less than one in 1 million (This is known as the sterility assurance level, or SAL). At a temperature of 134 degrees Celsius, this time interval is 3.5 minutes.
This makes these sterilisers unsuitable for hollow items (including dental handpieces) and also for wrapped items. Their cycles are known as “N” cycles, where the N means None hollow and None wrapped (Naked solid items).
The three types of cycle and the technology behind them are described in the European Standard EN13060. Not all types of steriliser or cycle are appropriate for all types of load items. EN13060 specifies the general requirements for small steam sterilisers, such as those used in small office dental practice, and the methods used to test their performance, by applying standard test loads.
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Sterilized items from N cycles are unwrapped so cannot be kept in a sterile state.
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They are not suitable for sterilization of wrapped items (including those in pouches), porous items, textiles or hollow items.
Steam sterilisers with S cycles are for Specific products. The manufacturer of the steriliser has determined what a particular cycle of the steriliser can be used for and has specified that information for the user.
These utilize superheated steam to displace air downwards and out of the sterilising chamber. The process that removes air is very gentle, i.e. by the action of steam rising coupled with cold air falling vertically by gravity in the chamber.
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These can be used only for sterilisation of unwrapped solid instruments that are NOT required to be stored in a sterile state.
S (Specified) cycle sterilisers with assisted air removal
Displacement autoclaves (also called gravity autoclaves)
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In other words, the steriliser manufacturer provides details of their performance capabilities, which they have established by conducting specific tests with those load types. A range of bespoke (dedicated) S cycle units have been developed, including units for sterilising dental handpieces and cassette-type compact sterilisers that use on-demand steam generation and positive pressure pulsing for rapid processing (e.g. SciCan STATIM™). It is essential that staff read the instructions for these sterilisers carefully so that loads match those specified as being suitable. S cycles use various processes for active air removal, overcoming the limitations experienced in N cycles that employ gravity displacement. This is why bespoke sterilisers with S cycles can sterilize restorative dental handpieces.
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These sterilisers may use pulsing of steam from a steam generator to facilitate air removal from the load by an active process, or may use a prevacuum process.
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These sterilisers can process any load type that the manufacturer has specified the load configuration for, including handpieces and wrapped items. See the examples below. Items need to be separated, not piled on top of one another. This applies for loose instruments and dental handpieces, as well as for paper/plastic pouches.
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Unwrapped dental handpieces can be sterilized in an S cycle unit, according to the manufacturer’s instructions. Likewise, wrapped dental handpieces could also be sterilized in an S cycle unit, if that is what the manufacturer stipulates. As an example of the latter, the STATIM has been tested for hollow wrapped items. In each case, refer to the manufacturer’s instructions for what load types are permitted, and follow that advice exactly.
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They should not be used with items that are wrapped in multiple layers.
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They achieve rapid drying by a combination of forced filtered air or pre-vacuum and heat.
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Bespoke (dedicated) S cycle sterilisers that do not use pre-vacuum do NOT require air leak tests or air removal tests
Pre-Vacuum autoclaves sometimes called Class B cycles “Big” Sterilisers These use a vacuum pump to pump air from the chamber prior to entry of steam. The removal of air is designed to facilitate the entry and penetration of steam into the load. The air can be pumped out in one continuous phase, or in several separate phases (referred to as multi-pulsed). The latter gives better and faster air removal than a single suction phase, particularly from items with internal pipes. Monitoring of steam sterilisers Regular monitoring of performance for ALL types of autoclaves is necessary to prove that sterilization process parameters are adequate. The use of chemical monitors is dictated by the type of autoclave and the relevant standards, such as Table 7.1 of AS/ NZS 4815. Such routine testing ensures that sterilization process parameters are being met on a regular basis and when the results are recorded in a permanent logbook. It verifies that certain staff members have operated the cycle and have checked the contents of the completed load to ensure that they meet expectations. There is little point in recording data from steriliser cycles on memory cards or on hard copy printouts if these records are never scrutinised carefully immediately after the cycle has completed. Methods for monitoring Monitoring of autoclaves uses several methods:
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Physical monitors (gauges, displays, print-outs) - from every load.
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Chemical indicators - which change colour when proper sterilising conditions have been achieved (e.g. adhesive inks, tapes, strips) used on and within packs and pouches. These provide a visual assurance that conditions for sterilisation were met (heat, steam).
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Biological indicators (BI’s, spore tests) - which are used at calibration and validation. Spore tests should be used after installation of a new autoclave, a major redesign or relocation, servicing or major repair, after suspected malfunction, whenever the type of load or packaging system is changed, and during and after training of new staff in autoclave operation.
Pre-vacuum autoclaves are unique in that they require leakage testing for the chamber (to check the door seals and other internal leaks) as well as daily tests for proper air removal (i.e. Bowie-Dick test or helix process challenge device). The Bowie-Dick test assesses penetration of steam into a porous load, while the helix test assesses hollow items.
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Result of the particular chemical indicators (Class 1, 4, 5 or 6) used in the cycle. This checking should include all external and all internal chemical indicators;
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Result for checking packages for conformity (e.g. seals are intact, and packages are not damp or wet); and
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Identification (signature or initials) of the unloading operator as the person who has checked the autoclave readouts and chemical indicator result, and who authorizes release of the load for use.
A separate book should be kept for each autoclave, if several autoclaves used in the practice. It is also prudent to compile a list of names, initials and abbreviations of operators of the autoclave, for reference purposes.
Steriliser cycle records The log of autoclave cycle data provides the necessary written documentation of sterilisation and includes parameter information on the batches of items that have been sterilised. An entry into this log should be made for all autoclave cycles, regardless of whether or not they include any packs of critical instruments. The log book ruled columns would have the following headings:
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Date;
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Cycle number in that day;
Time at the commencement of the autoclave cycle; Cycle temperature and time parameters (which will differ according whether the load contains wrapped items or unwrapped items);
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Nature of the load (numbers of packs, instrument cassettes, etc);
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Batch number(s) of packs included in that load (if any);
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Identification of the loading operator who placed items in the steriliser chamber;
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Result of the autoclave physical read- outs (displays) or printout for that cycle;
About the author Emeritus Prof. Laurie J. Walsh is based at The University of Queensland School of Dentistry. He serves as the technology editor and infection control of Australasian Dental Practice magazine and is the editor of the ADA Infection Control Guidelines. Prof. Walsh is a noted commentator on and user of new technologies.
Please Scan here to view further information regarding the SciCan Statim Range EMERITUS PROF. LAURIE WALSH
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STERILISATION SCIENCE
Monitor your sterilisation processes with 1 device The gke Orange PCD is a 2-in-1, dual purpose monitoring system that can be used for your Bowie Dick and Helix Test as well as for routine monitoring of all loads. The device can be reused for up to 10,000 cycles - saving you money, and reducing your amount of waste meaning its environmentally friendly! Many other products on the market have a limited lifespan of 250 cycles. The patented stainless steel helix means the gke device is highly durable. It also means that we are simulating the sterilisation challenge posed by stainless steel instruments we are sterilising. The gke Orange PCD simulates the penetration requirements of EN 867-5 and covers you no matter what you are sterilising, be it complex hollow instruments (burs and handpieces), solid instruments (mirrors) or porous loads (gauze). Why can the Orange PCD be used as a Bowie Dick Test and a Helix test? The Australian Standard for Office Based Practice (AS/NZS 4815:2006) is derived from International Standards. EN 13060:2004 and EN 867-5:2001 are the International Standards for Small Steam Sterilisers. EN 867-5 defines the specifications for the test to be used in daily start-up testing of small steam sterilisers.
This test is known as a “Daily Air Removal and Steam Penetration Test” in AS/NZS 4815:2006. A Bowie Dick Test was the first test of its kind for start-up testing of porous loads in large steam sterilisers back in 1963, however this sort of test only makes sense nowadays for porous type loads in large steam sterilisers. As such “Bowie Dick Tests” are only defined in EN 285, which is the International Standard for large steam sterilisers. The terminology Bowie Dick Test | Helix Test | Daily Air Removal and Steam Penetration Test - are all synonymous by definition. They are the mandatory first test we do in our steriliser at start-up in an empty chamber to make sure our steriliser is capable of air removal and steam penetration in our instruments we will be sterilising throughout the day. It is a functionality check of our steriliser. Therefore in accordance with the requirements of EN 867-5 - a test meeting this standard is the only test we must conduct in our empty chamber at start-up. GK-F200-026 GKE Orange PCD Helix B&D test EN867-5 GK-F211-252 GKE Batch Monitoring Indicator Refill Box of 250
The remainder of this article can be viewed on Dental Education Hub
LAUREN KONTUS BSc(EnvSc) Sales and Contracts Manager GKE Australia h en r y sc h e i n .c o m .a u
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AUTOCLAVE TESTING CONSIDERATIONS
Class B autoclaves
How does it work in practice and what can be saved?
In general, Class B autoclaves are compact, user friendly and their performance is comparable to large sterilisation units found in hospital CSSD’s. Most loads can be sterilised in a Class B autoclave, including porous, wrapped, solid, narrow lumen and simple hollow items. The applicable standard for equipment of this kind is 2014 EN13060, which is specific to small steam sterilisers, like the Mocom range.
At the end of the working day, you programme the your autoclave to perform the Combined Vacuum + Helix/BD Test Cycle to start and finish before opening the next day. Upon arriving at the clinic, the autoclave has completed the Vacuum + Helix/BD tests and is hot and ready for your first sterilisation cycle. Assuming your practice is open 220 days/year the minimal potential saving in pure labour hours is ~ 220.
Programmable COMBINED VACUUM + HELIX/BD TEST option
*A vacuum test must always be carried out on a “cold” chamber.
Would you like to minimise consumption, reduce waste, speed up your work process?
Some of the latest generation of autoclaves feature a Combined Vacuum + Helix/BD Test Cycle. It is easily programmed by the user to start automatically at a scheduled time, like the next workday, or even over a 4-day long weekend (like Easter). The advantage of this unique cycle is numerous, including direct cost savings: • • • • •
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When we think about how to improve productivity and reduce expenses in a dental practice, we do not normally focus on the sterilisation area. However, the use of sterilisation devices and related consumption (I.E. electricity, water, sanitisation), are major items in any budget.
Daily and routine Vacuum* and Helix/BD tests are run consecutively Easily programmed and scheduled to suit workflow Run tests during low cost power periods Labour costs savings @ min 1 hour/day Autoclave can be hot and ready for use at time of clinic opening
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Autoclaves can use considerable amounts of water for each sterilisation cycle, not to mention the need to always have bottles of distilled water available. Eliminating water and plastic bottle waste is both a social and a financial commitment. What if we could improve workflow to reduce the work hours needed for human personnel to manage the water supply process?
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Less than 5 litres of water for 50 sterilisation cycles is possible. A new line of dental autoclaves has been designed to allow the use of tap water. The Mocom Supreme is the first closed-circuit autoclave that does not require distilled water - it has been assembled with an in-built demineraliser. Additionally, the unit has a recycling filter that removes organic and inorganic substances via its combination nano ceramic and ion-exchange recirculation filter to purify and recycle the water used. With just 5 litres of tap water in the onboard reservoir the Mocom Supreme can achieve 50 sterilisation cycles, significantly reducing water waste and issues related to producing or purchasing and storing demineralised water. The water quality for autoclaves is critical. Some autoclaves will check the conductivity prior to each cycle and is typically around 15 µS/cm – if not, the onboard H20 monitoring will alert the operator if the water quality is unacceptable.
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In the event, distilled water is stored/produced on-site, it is recommended you regularly check its quality and whether appropriate conductivity levels are adhered to. Such tests may be performed using a TDS Meter also known as a conductivity meter indicating the Total Dissolved Solids of the demineralised water. Traceability software has become part and parcel of any sterilisation process I.E MyTrace. By using this programme, each set of sterilised instruments can be associated to the patient through a bar code. This essential software completes the sterilisation process and provides legal protection to dentists. More information related to instruments traceability will be discussed in the next issue of the HS Dental Solutions.
Y E A R WA R R A N T Y OR 3 0 0 0 C YC L E S
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VIRUSKILLER ™ FOR PREMIUM INDOOR AIR QUALITY FOR DENTAL SURGERIES
For many of us, a trip to the dentist is a daunting prospect. But in a world where the pandemic has heightened our awareness of the risks posed by enclosed spaces and poor indoor air quality, a dental appointment now sparks very real concerns about our general safety and wellbeing. Given that dentists, hygienists, and assistants need to work near unmasked patients, the teams at dental practices have an even more difficult challenge when it comes to air hygiene and patient reassurance.
With technology initially designed with sensitive spaces such as dental facilities in mind, decontaminating the air to create safer working environments in places of care is important to us. As dental clinics welcome a steady flow of patients back into their premises, our indoor air safety technology will provide crucial reassurance and trust for everyone in the practice well into the future.
Around the world, people are paying increased attention to indoor air quality. We know about particulate matter as a vehicle for viral transmission, the risk of VOCs in urban areas, and the everpresent threat of allergens on wellbeing.
Radic8 technology is designed for medically sensitive spaces such as dental surgeries. By focusing on the wellbeing afforded to dentists, hygienists, patients, and staff, our devices can be effectively positioned as an essential additional safety measure, particularly as many dental procedures generate aerosols. Investing in indoor air hygiene is a powerful addition to a practice’s duty of care procedures, and provides crucial reassurance to patients, their families, and staff.
But the dental environment has other, unique hazards. Fine particles of dental amalgam commonly used to fill tooth cavities can be released into the air, while fumes from harsh cleaning chemicals can affect the wellbeing and comfort of dentists, patients, and staff — not to mention exposure to anaesthetic gases and patient-generated aerosols.
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Reception Areas
Corridors
Dental Surgery
As the point of entry for dental practices, reception areas are prone to a range of indoor air pollutants. VIRUSKILLER™ safely decontaminates the air for the wellbeing of patients and staff.
Corridors in dental practices can contain bioaerosols and airborne contaminants that travel through the practice, spreading germs. Wallmounted provide additional indoor air safety for patients and staff.
During aerosol-generating procedures, microorganisms are dispersed into the air where they linger for hours. A wall-mounted unit between the dentist and patient adds extra protection.
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EXTRA PROTECTION
REDUCING DOWNTIME REASSURANCE
Radic8 UV-C PCO technology safely decontaminates air and provides additional circulation before, during and after aerosol-generating procedures.
Clean air delivery can help reduce downtime between patients*, allowing dentists, hygienists, and assistants to serve patients more efficiently throughout the workday.
Investing in an indoor air hygiene is a powerful addition to your duty of care procedures, and provides crucial reassurance to patients, their families, and staff.
The indoor air safety technology trusted by dental facilities around the world. Provide clean air for the comfort of your patients, staff and surgeons – and maximise protection against germs and pollutants.
Scan to see more information
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INFECTION CONTROL
STERILISATION WRAP UPDATE FOR INSTRUMENTS
Benefits of using the HuFriedy Group range of Wraps
Visual representation of the path that a potential bacteria would have to take
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Hu-Friedy sterilisation wrap is a wet formed, nonwoven fabric compromised of natural wood pulp bonded with resin binder.
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During manufacturing, the wrap components are bonded together by entangling their fibres of filaments mechanically, thermally, or chemically. This bonded web of materials creates what is called a tortuous path.
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During steam sterilisation, steam is able to enter the wrap due to the extreme pressure present, in order to sterilise the contents. Post sterilisation, the tortuous path created by the fibres prevents bacteria from entering.
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Hu-Friedy wrap material is not fully biodegradable. It is composed of majority wood pulp, but there is an added polymer that aids in bonding the wood fibres. There is a sustainability advantage in that the main component, wood pulp, is a fully renewable resource. Many other wraps are compromised completely of petrol/oil derived plastics, which have no sustainability
Keep in mind the storage and handling requirements of wrapped items referred to in ADA Guidelines for Infection Prevention and Control 4th Edition 2021. When storing wrapped items these must be stored in a dedicated space free from dust/contamination. It is also important to note they must ideally be stored in ‘enclosures’ due to risks of environmental contamination. If we think about common storage in the sterilisation area for example, often times there is shelving left open and also in the surgery. To ensure your contents are not affected you may want to consider doors / draws as a more suitable storage option.
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INSTRUMENT SOLUTIONS
IMS & SAFETY CONSIDERATION FOR HANDLING INSTRUMENTS
Minimal handling is key to minimizing risk of sharps injuries from instruments. The Hu Friedy Instrument Management System (IMS) cassette range offers a safer and effective way to handle/store/process your instruments.
Focusing more on the safety aspect the IMS cassettes allows users to safely place instruments back in the cassette after use.
IMS is an integrated practice Instrument Management System designed to keep instruments organized and intact from cleaning to chairside.
They have lockable latches which ensure instruments do not fall out when transported. Due to their design they also offer enough gaps for excellent cleaning and even extend the life span of your instruments.
It eliminates instrument scrubbing and sorting, protects against breakage, and reduces the risk of injury.
It prevents the need for the dental staff to handle multiple instruments at a time reducing the risk to sharps incidents.
Did You Know? Using IMS greatly reduces the chance of a sharps injury which on average cost a practice USD $3,000*? (according to*”SHARPS INJURY PREVENTION WORKBOOK” page 6. CDC.) HF-IMN6050 HF-IMN60511 HF-IMN5080 HF-IMN50811 HF-IMN5084 HF-IMN4163 HF-IMN4164
IMS Cassette Infinity Series 5 Instruments Red IMS Cassette Infinity Series 5 Instruments Ocean Blue IMS Cassette Infinity Series 8 Instruments Red IMS Cassette Infinity Series 8 Instruments Ocean Blue IMS Cassette Infinity Series 8 Instruments Purple IMS Cassette Infinity Series 16 Instruments Orange IMS Cassette Infinity Series 16 Instruments Purple
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INSTRUMENT SOLUTIONS
USING NEVI SICKLE SCALERS WHICH NEVI IS RIGHT FOR YOU?
Workflow The Nevi line of sickle scalers are among
Hu-Friedy’s most popular instruments. But with five scalers in the Nevi family – one for anterior scaling and four for posterior use – the subtle differences between each instrument may require a quick tutorial. Which Nevi scalers deserve a slot in your armamentarium? In this article, we’ll look at what the four Nevi scalers have in common and how they differ, so you can choose the Nevi scalers that fit your needs.
The Evolution of the Hu-Friedy Nevi Scaler The Nevi line of sickle scalers is named for the late Neville Hammond, a legendary master craftsman who worked for Hu-Friedy for over 40 years. In 2008, a group of hygienists at HuFriedy determined it was time to move on from the traditional design of sickle scalers, which hadn’t been refreshed significantly since the 1950s. The group was inspired while noticing that some hygienists were using discoid carvers as scalers. The rounded surface was particularly effective for stain removal on the lingual side of front teeth, the hygienists observed. Neville and team took the idea and ran with it, creating a sickle scaler with an oval-shaped disc end that came to be known as the Nevi 1. Neville shortened the opposite end of the scaler, again in response to the clinical experience of his collaborators. The Nevi 1 is an anterior sickle scaler. The Hu-Friedy team followed the same design philosophy to create
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a posterior scaler, the Nevi 2. The Nevi 3 and Nevi 4 soon followed, each new iteration built to meet the needs of clinicians who wanted slightly different features in the shank and blade designs. In 2019 the Nevi 4 Slim was added to the range, with working blades 10% thinner this new addition completes the Nevi range for all clinical requirements.
Key Nevi Scaler Features Each of the Nevi instruments was specially designed based on input from dental hygienists who understand the details of oral anatomy and how the shank, bends and curves of a working end make it easier to access the tooth surface for scaling. These four instruments are ideal for scaling light-to-heavy calculus with minimal tissue trauma. They allow precise access with superior adaption for difficult-to-reach areas, which is why these instruments are preferred choices among new and seasoned dental professionals. During the design process, ergonomics has always been a major consideration for the Nevis. Earlier generations of sickle scalers came from a time when clinicians typically worked standing up and patients were seated upright. Now that most clinicians work seated with patients reclining, sickle scalers needed to be redesigned with slightly different angles to reduce strain on the hands, wrists, necks, and backs of hygienists and dentists as they reach into patients’ mouths. The latest Nevi scalers are also constructed using EverEdge 2.0 technology, which keeps the instruments sharper longer and enables a more efficient and comfortable scaling experience. The handles feature Hu-Friedy’s signature diamond knurl for grip and control and are available in the bright Resin 8 colors for easy identification on a tray (red for posterior scalers and purple for anterior scalers).
INSTRUMENT SOLUTIONS
Nevi Scalers Compared The four Nevi scalers accommodate a wide range of clinician preferences and styles. The following chart outlines the differences and advantages of each scaler:
ANTERIOR SICKLE SCALERS
NEVI 1
NEVI 1/H5
Two distinct working ends.
Similar to Nevi 1, designed with a longer, larger H5 curved sickle.
Sickle End: A super thin, anterior curved sickle. Disc End: An elongated, sharp rounded disc. Sickle: Ideal for removing anterior interproximal calculus and stain.
Sickle: Ideal for interproximal and cervical anterior areas. Disc: Excellent for removal of anterior lingual stain.
POSTERIOR SICKLE SCALERS
NEVI 2
NEVI 3
The thinnest dual tapered blades in the Nevi collection.
Ultra-slender, dual cutting blades for effective placement in tight, narrow contacts.
Unique contra-angled shank is paired with extra blade length for easy access under contacts for ergonomic hand positioning.
Contra-angle bends and longer shank offer superior reach and adaptation to posterior interproximal areas.
Light to moderate interproximal calculus deposit removal.
Light to moderate calculus removal in tight, narrow posterior interproximal areas.
NEVI 4
SLIM NEVI 4
The most rigid shank design in the Nevi collection. The rigidity facilitates effective removal of tenacious, heavy, and burnished deposits. Hardier design ideal for challenging deposits.
The same EverEdge 2.0 technology and Nevi 4 blade but 10% thinner!
Working ends with dual tapered cutting edges allow for precise interproximal access.
Excellent for recall patients. Light to moderate calculus deposit removal around line angles and interproximal contacts.
Effective removal of burnished, heavy, tenacious deposits.
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INSTRUMENT SOLUTIONS Which Nevi is right for you? That depends on how you work and your own preferences for access, rigidity, flexibility, and length. Ultimately, Nevis have been designed to give clinicians choice.
NEVI 1
NEVI 2
NEVI 3
NEVI 4
Tips for Using Nevi Scalers If you’re familiar with traditional posterior sickle scalers, you should have no trouble adapting to Nevi instruments. One thing to be aware of, however, is that Nevi scalers tend to be longer than most of the blades that came before. The extra length lets you reach in between teeth and come up underneath and past the contact area to access those hard-to-reach calculus deposits. Give Nevi a try. You’ll find the scalers live up to the tradition of quality, innovation, and skill exemplified by their namesake, Neville Hammond. Nevi also available in 8 Resin colours.
Scan to view brochure
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PRACTICE SOLUTIONS
DENTAL PRACTICE MANAGEMENT TRENDS & PERFORMANCE NEW STATE OF DENTISTRY REPORT
As we all know, the dental industry faced new and unprecedented challenges in 2020 and 2021 - from strict government regulations and changing social norms to an economic recession and more. Practices have had to adjust to new ways of working and have seen significant changes to revenue and patient flow over the past 18 months. To understand the continued impact of COVID-19 restrictions on dentistry, Henry Schein One surveyed almost 300 dental practices across Australia and New Zealand in August 2021.
The main challenge areas for practices, aside from revenue, were patient recall rates and fail-toattends. 43% of practices saw a decrease in patient recall rates and over one third of practices saw an increase in FTAs in the past 12 months. Future outlook Dental practices across Australia and New Zealand are increasingly positive about the future. 59% of practices are either expecting growth or revenue to remain flat in 2022 (compared to 45% previous year). Practices have started recovering in terms of new patients and treatment acceptance rates, and the spread of this increase is fairly even across the region.
The COVID-19 impact Practices are starting to recover, but some regions have been more affected than others. Not surprisingly, 4 out of 5 of practices that responded they ‘had recovered but are now impacted again’ were based in Victoria and New South Wales. Survey results also showed that Henry Schein One practices have recovered more strongly, with 74% of the practices saying they have ‘fully recovered’ also using a Henry Schein One practice management solution. We are seeing an encouraging trend with revenue is slowly improving across Australia and New Zealand. 1 in 4 practices experienced an increase in revenue over the past 12 months, compared to 11% in previous year’s survey.
Most practices (93%) are planning for the future by investing in improvements for their practice, including new equipment, adopting new technology and investing in coaching/external help. To download the full report simply visit: https://henryscheinone.com.au/reports/state-ofdentistry-report-2021-2022/ or contact our team today via bestpractice@henryscheinone.com.au. Source The State of Dentistry Report 2021-2022 Australia and New Zealand – Insights, Analysis and Outlook, Henry Schein One (2021).
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EQUIPMENT SOLUTIONS
A PASSION FOR DENTAL PERFECTION
When Dr Kao was young, a love of sculpture made him think he would enjoy a career as either an artist or an architect. As it turns out, dentistry performed under microscope was the path for him – he sees it as a fulfilling mix of both artistry and the detailed discipline he enjoyed about architecture.
“Ergonomics are very important. Throughout the years I’ve used other chairs which haven’t always been an enjoyable experience, you lose patience,” says Dr Kao. “To stay comfortable during a mundane task, you have to enjoy using the equipment.” Dr Kao says the Morita Soaric’s high quality technology produces less vibration, and its equipment feels better in the hand. The perfect balance of the instruments also makes them easier to control. “That better balance lets you produce far more detailed work,” says Dr Kao.
His own practice, Boutique Dental, located in Christchurch is a testament to Dr Kao’s search for perfection. “We built the whole building from scratch so that I could have everything exactly where I want,” he says. “I wanted the rooms to be a very specific size, and the environment to be artsy so I’d be in the mood to do this kind of work. It means there are no compromises.”
Under the scope Dr Kao went the extra mile to find a chair that could meet his exacting standards, even travelling to Japan to visit the Morita factory. He wanted to see the workmanship behind the chair first hand. Needless to say, he was impressed: “It’s bespoke. The customisability of it is far better than anything else. Everything is handmade – it’s the Rolls-Royce of chairs.”
“No compromises” is a mantra that underpins Dr Kao’s work. It’s a huge part of why he works almost exclusively under a microscope, using equipment from Henry Schein. “I get a kick out of achieving what seemed impossible,” says Dr Kao. Comfort and technology
While most younger dentists are now trained to use the 2-3 times magnification of dental loupes, Dr Kao’s scope gives him 20-30 times magnification. That, he says, is the key to his incredibly detailed work and his 10-year guarantee on restorations.
As far as Dr Kao is concerned, true excellence in dental equipment has to go beyond advanced technology – it must consider the human side too. That’s an enormous part of why he chose the Morita Soaric. Dr Kao explains that it allows for a high level of comfort during his unusually long appointments. An appointment for even a simple composite restoration routinely takes over an hour in Dr Kao’s practice.
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“Every step has to be perfect for something to last,” says Dr Kao. “If one part isn’t done right, you can’t expect your restoration to last as long. “Under magnification you can be 100 times more precise.
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EQUIPMENT SOLUTIONS
Without it, you can do something that’s acceptable, but we can achieve something that’s far beyond that standard.” A microscope built right into his chair was therefore a must-have – the Morita Soaric was the only one of a couple on the market that could be customised to allow for that. On top of the integrated microscope, Dr Kao also had his curing light built into his chair – on the doctor’s side. “I know where the composite is and which angle to cure it on,” he explains.
based on what’s most beneficial for me. I trust him a lot.” The training and after-sales support he received was also excellent. “I’ve been studying the Morita chair for years, so I didn’t need much training, but they still offered really good support,” he says. “It’s tremendous – they took their time to ensure I knew how to operate everything.” The future in technology With the technology he needs at his fingertips, Dr Kao’s fledgling practice is going from strength to strength – other dentists have begun referring patients to him for more difficult cases, especially when visualisation is a problem.
Perfection through technology Using his new equipment from Henry Schein, Dr Kao can offer his patients restorative work that both looks better and increases the integrity of the tooth’s structure. He points to veneers as an example. Under the microscope, he can layer microscopic features that make a tooth look natural. “It’s the layering that makes the tooth interact with the light, especially under sunlight, and that’s what gives the tooth natural characteristics,” he explains. “I recognise my own work – it just looks aesthetically different.” “It’s about precision – I can achieve precision of fit to less than 30 microns. The veneers just fit better, so you’re less likely to end up with stained margins,” he says. The precision he can achieve on his ergonomic chair and under the microscope means the work lasts. Fabulous sales and support Choosing equipment from Henry Schein was made easier thanks to Dr Kao’s Equipment Sales Specialist, Edward Harrison, who he thought was “fabulous.” “He’s a very genuine person,” Dr Kao explains. “Rather than just pushing sales and looking to maximise profit, he really tries to understand my practice and make suggestions
“You can really only treat what your eyes can see – without proper vision it’s merely guesswork,” says Dr Kao. His equipment from Henry Schein takes that guesswork away – and he’d like to help other dentists move their practice forward too. “I’m planning on eventually running courses for other dentists, teaching them how to take time and produce higher quality work under microscopes,” he says. He sees the latest technology as a key part of pushing dentistry into new realms. “If you want to push the limits, you have to have help from the latest equipment,” says Dr Kao.
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DR DAVID KAO BDS Christchurch, New Zealand
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PROSTHETIC SOLUTIONS
USER REPORT: BRILLIANT CRIOS THE MATERIAL OF THE FUTURE FOR ALL KINDS OF INDICATIONS
Resin based blocks beyond your imagination. Introduction Implant prosthetics and dental prosthetics differ considerably, with the absence of periodontal ligament in the implant/prosthesis complex. This situation causes mechanical problems to the implants, especially to the implant prosthetic material, due the lack of stress absorption resulting from the normal impact during chewing (1) (2).
But, at the same time, it is not necessary to perform bone grafting procedures. The result of this scenario is to increase the stress on the implantbone complex when we use rigid materials like conventional ceramics (Fig. 2). For this daily practice situation, the combination of rigid and resilient materials against the antagonist, allows the stress to the implant-bone complex to be reduced (Fig. 3,4).
Among the problems we face in daily practice is the unscrewing and fracturing of veneering material of the implant crown and fracturing of implant/abutment components. It is very important to consider that resin-based blocks give us the missing part from ceramic materials to solve the problem of anterior exposure. It is also necessary to consider the importance of reliable bonding/union between the resin block and the abutment component of the implant, because the right transmission of occlusal load depends on the reliability of this bonding interface. One of the biggest advantages of BRILLIANT Crios blocks is the combination with ONE COAT 7 UNIVERSAL, the best bonding system for the resin-based blocks according to the scientific literature (3) (4) and tested in my own practice over the last five years of use.
Fig.1: Implant placed lingually due to the normal resorption of the buccal plate.
Another very important feature is the size and distribution of ceramic fillers. We have learned from the past that bigger size fillers are better for the strength but, at the same time, are more prone to detach from the surface creating craters indicating the material degradation. A homogeneous filler size and distribution is much better for the material’s wear, lustre, aesthetics and strength over long term.
Fig.2: The design of the crown has to be with a pseudo pontic, increasing the oblique load on the crown.
Case 1 During daily practice, it is very common to face situations where the implant has to be placed lingually due to normal resorption (Fig. 1) of the buccal plate after the extraction.
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Fig.3: Hybrid implant crown made with zirconia mesostructure and BRILLIANT Crios cemented adhesively on top ready to be screwed in mouth.
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PROSTHETIC SOLUTIONS
Oblique loads have been reported to increase stress values in peripheral bone and prosthetic components also generating high stress in the crown, implant, abutment, and cortical bone. The Young’s modulus, also known as elastic modulus, is one of the important factors determining a material’s behaviour. (5)
These were milled out of a BRILLIANT Crios disc either as single tooth units or bridges and cemented on the thimble structure (Fig. 15-17). Using BRILLIANT Crios instead of prefabricated teeth, we can increase the strength of the restoration, have good aesthetics and keep the weight low for this kind of prosthesis.
Fig.6: Zirconia thimble framework and BRILLIANT Crios bridges for extra oral bonding.
Fig.4: Implant crown after one week of placement.
Fig.5: Implant crown after placement.
Fig.7: Zirconia bridges ready to be screwed.
Case 2 Another common situation is a full mouth restoration over implant. It is well known that the big issue is chipping and delimitation of the ceramics, due to the high forces applied in the patient with dental implants. In regard to this problem, the combination of rigid materials to support the connectors and resilient materials to absorb the shock and, at the same time, allow easy fixation, make the use of resinbased blocks the logical choice for this kind of restoration. (Fig. 6,7 and 8)
Fig.8: Upper and lower bridges in the mouth.
Case 3 In this case, a patient presented with extremely atrophic bone in the mandible, with four short implants placed between the dental nerve foramen (Fig, 10a,10b). After some time, patients wearing this kind of restoration with prefabricated teeth, their muscle activity increase considerably, which very often leads to fracture or debonding of the prefabricated teeth (Fig. 12). A combination of a rigid metal structure over the telescopic bar and a thimble structure made of PEEK (Fig. 13,14) works as base for the final restorations.
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Fig.9: Panoramic view of the finished case.
Fig.10a: Patient with extremely atrophic bone in the mandible with four short implants placed between the dental nerve foramen
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PROSTHETIC SOLUTIONS
Fig.10b: Patient with extremely atrophic bone in the mandible with four short implants placed between the dental nerve foramen
Fig 11: Telescopic bar with retentions for the secondary structure
Fig 12b: Debonding of prefabricated tooth is very common on overdentures.
Fig 13: PEEK thimble structure
Fig 15 & 16: Telescopic prosthesis with BRILLIANT Crios restorations. Occlusal and bottom view.
Fig 17: BRILLIANT Crios restorations used for removable telescopic implant prosthesis.
References
Fig 12a: Debonding of prefabricated tooth is very common on overdentures.
Fig 14: Secondary metal structure
Fig 18: Final case in the mouth of the patient. Wearing a complete denture on top and telescopic BRILLIANT Crios on the lower jaw.
5. Kaleli N, Sarac D, Külünk S, Öztürk Ö. Effect of different restorative crown and customized abutment materials on stress distribution in single implants and peripheral bone: A threedimensional finite element analysis study. Journal of Prosthetic Dentistry [Internet]. 2017;1–9. Available from: http:// dx.doi. org/10.1016/j.prosdent.2017.03.008
1. Magne P, Silva M, Oderich E, Boff LL, Enciso R. Damping behavior of implantsupported restorations. Clinical Oral Implants Research. 2013;24(2):143–8. 2. Liebig J. Energy Dissipation and Damping Behavior of Commonly Used CAD / CAM Materials. 2018;35392. 3. Reymus M, Roos M, Eichberger M, Edelhoff D, Hickel R, Stawarczyk B. Bonding to new CAD/CAM resin composites: influence of air abrasion and conditioning agents as pretreatment strategy. Clinical Oral Investigations. 2019;23(2):529–38. 4. Emsermann I, Eggmann F, Krastl G, Weiger R, Amato J. Influence of Pretreatment Methods on the Adhesion of Composite and Polymer Infiltrated Ceramic CAD-CAM Blocks. The journal of adhesive dentistry. 2019;21(5):1–11.
To view the Brilliant Crios Range on our website, please scan here.
Scan here to view the Brilliant CRIOS Product Brochure
DR NICOLAS GUTIERREZ DOA Dental Clinic Madrid, Spain
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PROSTHETIC SOLUTIONS
A SUCCESS STORY OVERLAY WITH VITABLOCS MARK II
Using CEREC and VITABLOCS, I can easily create aesthetic chairside restorations in a single session. Five stars for VITABLOCS! I love VITABLOCS because of their bright, natural color, ease of use and outstanding esthetics.
Initial situation A young patient, 25-years-old, was unhappy about a defective older filling in upper molar 27. Solution The older filling was removed, secondary caries excavated, endodontic revision carried out and the
Dr. Oxana Naidyonova
tooth restored with an all-ceramic overlay made of VITABLOCS Mark II. Why VITABLOCS Mark II? We chose VITABLOCS Mark II because the abrasion (similar to enamel) harmonized with the natural antagonist, with regard to function, from a long-term clinical perspective.
Fig 1: Initial situation following endodontic treatment and preparation of tooth 27.
Fig 2: During preparation, the buccal cusps of tooth 27 were shortened.
Fig 3: The overlay before final seating.
Fig 4: Occlusal view of the restoration result.
Fig 5: Harmonized buccal transitions between the restoration and the tooth.
Fig 6: The naturally integrated overlay 2.5 years after treatment
DR. OXANA NAIDYONOVA Dentist, Karaganda, Kazakhstan
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PROSTHETIC SOLUTIONS
MATERIAL PROPERTIES & CLINICAL ASPECTS OF A NOVEL ALIGNER FOIL
Originally published at Quintessence Publishing in Kieferorthopädie 2021;35(3):223-235 The standard materials used to date have been single or multilayer polyethylene (PET-G) or polyurethane materials (Tab. 1).
Introduction The first of today’s aligner treatments dates back to 19441-3. Since the mid-1990s, orthodontic therapy with sequential splints has experienced a significant boom due to the introduction of CAD/CAMsupported processes.
Apart from commercial providers, a concept was developed in 1998 by Tae-Weon Kim to plan and implement chairside fabricated sequential splint treatments in the dental office10.
Recent study results especially on Invisalign treatments (Align Technology, Santa Clara, California, USA) can be summarised as follows4-9:
•
Therapy of more complex malocclusions is possible
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To a limited extent comparable to the effectiveness of fixed appliances
•
Individual tooth movements are more difficult (e.g. extrusions, derotations)
•
Use of attachments and approximal enamel reductions are very often necessary
•
The basic principles included:
High level of patient compliance is required (20 to 23 h wearing time daily)
•
Use of foils of different thicknesses (0.5 mm/
•
0.65 mm/0.75 mm)
•
Splint material: polyethylene terephthalate glycol copolyester (PET-G),
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Setup creation on the plaster cast
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Vacuum and pressure thermoforming processes
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Regular impressions
•
Activations using specific forceps instruments, if necessary
Further development and clinical application were continued by Pablo Echarri and supplemented by both analogue and digital plan-ning aids11.
Various thermoplastics have been recommended in the past as basic materials for splint production. The requirements on the material properties of the thermoforming foils proved to be diverse and dependent on the indication10-12.
In the course of treatment implementation, various factors proved to be decisive for treatment success 11-14 .
ALIGNER
MANUFACTURER
MATERIAL
CA Clear Aligner
SCHEU-DENTAL
Polyethylene terephthalate glycol copolyester (PET-G)
Invisalign
Align Technology
Multilayer thermoplastic polyurethane
CA Pro
SCHEU-DENTAL
Three-layer copolyester elastomer
Tab. 1 Table showing the different materials used.
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Three-layered ABA-Foil Outer layers (A): Copolyester hard layer Inner layer (B): Thermoplastic Elastomer soft layer A: Copolyester (hard) B: TPE (soft) A: Copolyester (hard)
Foil thickness/mm
0,5
0,625
A-Layer thickness/mm
0,17
0,21
0,75 0,25
B-Layer thickness/mm
0,17
0,21
0,25
A-Layer thickness/mm
0,17
0,21
0,25
Hygroscopic material: Foils are sealed individually Must be processed within 15 minutes after opening the barrier bag! Processing temperature: 150 – 175°C Indication: Correction of malocclusion by aligner-therapy Contraindication: CA® Pro is not indicated for using with acrylic monomer
Fig 1. The new CA Pro film: Three-ply structure. Outer layers: abrasion resistant copolyester material; core: thermoplastic elastomer (TPE).
In addition to the precise and clinically oriented planning, the material type, processing technique, material thickness and accuracy of fit, among other things, proved to be particularly important11-14. Seo et al.12 used simulated tooth movements in the finite element model to show that both 0.5- and 0.75mm thick aligner foils apply effective forces for the dentoalveolar transformation processes. According to their results, about 6% more stress would be expected in the periodontal ligament when using the stronger foil.
Mechanical properties of a novel splint material As a new development, a three-layer composite of abrasion-resistant copolyester material and a thermoplastic elastomer was presented (Tab. 1, Fig. 1). For improved clinical use in comparison with conventional PET-G materials, the following properties were specified:
•
high elasticity
•
good wearability
•
continuous force output
Lombardo et al. indicated the dependence of the fit according to the manufacturer by means of three-dimensional (3D) micro-computed tomography (micro-CT) evaluations and showed a significant variance between the products.
•
low force level
On the other hand, Mantovani et al.14 was able to demonstrate a comparably accurate fit for Invisalign (Align Technology) and CA Clear Aligner (Scheu Dental, Iserlohn, Germany) splints.
The material tests on the thermoformed foils were carried out using a universal testing machine (ZwickRoell 1445, ZwickRoell, Ulm, Germany), which was equipped with a 100 N force transducer (Xforce, ZwickRoell) and a miniaturised three-point flexural strength test apparatus in a water bath (in-house special production).
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Target In the following paragraphs the mechanical properties of a new splint material are described and its integration into a digital work-flow is demonstrated using a patient case study.
The processing of the new type of splint material was oriented to the previously known workflow. The basic instructions are summarised in Table 2.
In modification of the standard commonly used for composites for the determination of flexural strength properties (DIN EN ISO 178), the testing machine was designed with a contact distance of L = 8 mm.
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PROSTHETIC SOLUTIONS The support and compression fin radius of the structure corresponded to 0.5 mm. The water bath, filled with distilled water, was controlled by an external thermostat (Julabo, Seebach, Germany) via a spiral heat exchanger. Before the test, the water bath was preheated to 37°C (± 0.1 K). During the test, the temperature of the water bath was digitally recorded and maintained within the specified temperature range.
which was manifested by the increase in the measured force and registered by the testing software (testXpert II, ZwickRoell). After reaching the initial contact, the fin was shifted to the stress point of the specimen (deflection 0.3 mm) and the initial bend-ing force F0 was determined. Over the following 24 h, the course of the bending force Ft was recorded. The stress relaxation S is a result of the ratio of the bending force to the initial bending force (S = Ft/F0).
Specimen preparation and conditions The thermoforming foils (foil thickness 0.75 mm) were heated according to the manufacturer’s instructions (BIOSTAR, Scheu Den-tal) and placed over a smooth strip of polypropylene (thickness 2 mm, 90 × 60 mm). From the central area of the resulting blank, sample strips (40 × 105 mm) were cut out with the aid of a lever cutter (IDEAL 1058, Krug & Priester, Balingen, Germany). The samples prepared in this way were stored in water at 37°C for 24 h prior to testing and then placed in the previously described test machine. The specimens rested for another hour in the machine before the test was started.
The cyclic loading and unloading test was performed with the same parameters as the fatigue loading test. In contrast to the fatigue loading test, however, the stress point (deflection 0.3 mm) was only maintained for 16 h. After this loading phase, the fin was brought back to the starting point of the test and the specimen was unloaded for 8 h. This was followed by the next loading phase. In total, each specimen was subjected to seven cycles of loading and unloading and the bending force curve during the loading phases was recorded. The analysis of the force-displacement data from the loading cycles additionally allowed the determination of the permanent deformation of the foil caused by the deflection.
The bending test was performed with a traverse speed of v = 1 mm/min. The starting point (deflection = 0 mm) of the test results was from the initial contact between the fin and the specimen,
NOTES Indications
Sequential splint therapy to correct malocclusion through aligner therapy
Contraindications
Known incompatibilities with the used materials, no adhesive buildup possible with acrylates Vacuum and pressure moulding at 150 to 175°C Insulating foil or CA Pro+ for 3D-printed models
Procedure
If necessary, block out undercut areas Must be processed within 15 min after opening the barrier bag Trimming and finishing with specific instruments
Cleaning/care
No oxidising agents or solvents Optimal: specific cleaning powders for daily use 0.5 mm
Available material thicknesses
0.65 mm 0.75 mm
Tab. 2 Brief description of the novel splint material.
Please scan here to view the full article
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FABIAN KARBACH
JENS JOHANNES BOCK
Dr. (Doctor of Chemistry)
Dr. med. dent.
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REVEAL® CLEAR ALIGNERS THE CLEAR CHOICE TO A BEAUTUIFUL SMILE
Many of your patients already know that they could benefit from some minor orthodontic treatment to create a beautiful smile. As their dental care provider, you are uniquely positioned to offer your patients the safe, affordable, and doctor-supervised treatment alternative: Reveal Clear Aligners.
Did you know that 6 out of every 10 Australians are willing to fix their misaligned teeth? Reveal Clear Aligners are the clear choice for pre-restorative anterior alignment treating Class I mild-to-moderate movement Aesthetic cases prior to Crowns, Bridges, Implants & Veneers. Reveal is backed by over 40 years of innovative orthodontic solutions and over 50,000 cases globally in recent years. Reveal Clear Aligners are offered by your Trusted Business Partner, Henry Schein, for a seamless experience with all your restorative and aesthetic solutions all-in-one-place.
The Aligners - The Clear Choice
Simplified Workflow - The Clear Choice
1. Crystal Clear
Superior fit of Reveal Clear Aligners
ClearWearTM Material is guaranteed not to stain or discolor. Precise force levels for comfort and speed of treatment
Shown in high resolution lab analysis. Dark red and dark blue indicates wide gaps, thus a need for attachments. Yellow and light blue show close contact and precise fit.
2. Fewer Attachments
Reveal’s precision fit
Reveal’s superior fit uniquely captures all available tooth and soft tissue anatomy reducing the need for attachments. Its optimized trim captures the interproximal and gingival margins with precision, further enhancing control independent of attachments.
Reduces the need for complicated orthodontic attachments. The process is backed by proven results, so you can offer Reveal to your patients with full confidence in the treatment outcome to create a beautiful smile.
3. Silky Smooth Edges
Reveal Clear Aligners
Provide maximum patient comfort.
Feature precision fit and optimized trim heights to capture hard and soft tissue anatomy for exceptional control with fewer attachments.
Poor Fit
3
-0,02
2
Poor Fit
Exact Fit
0,00
0,02
*Fit test: Independent 3rd party lab on static initial aligners
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Holds *Orthodontics Australia, 2017, Aussies want to improve their teeth: survey
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Holds
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NEXT-GENERATION WHITENING TECHNOLOGY FOR YOUR PATIENTS OPTIC WHITE LIGHT UP
Accelerated teeth whitening with the power of indigo light New Colgate® Optic White® Light Up Professional Take-Home Teeth Whitening Kit introduces two powerful patented technologies – An innovative indigo LED Light Device paired with a uniquely formulated precision application whitening pen, for extraordinary whitening made simple. •
No impressions or customer trays required
•
Short 10 minute wear time for a comfortable patient experience
•
Designed for no tooth sensitivity
•
Dramatically whiter teeth in 5 days†
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Up to 7 shades whiter teeth*
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Enamel Safe Whitening
•
Powerful indigo LED light
The device features over 700 printed indigo LED lights for even whitening, so top and bottom teeth get equal exposure. The LED Device is rechargeable and designed for comfort, with no impressions or custom trays required. New Precision Application Pen The precision pen applicator allows for targeted tooth whitening. The patented formula in the precision pen is designed for no tooth sensitivity, no gum irritation, and no mess.
Our Best At-Home Whitening Technology The patented whitening serum, once applied with the precision brush, quickly forms a smudge-proof, concentrated hydrogen peroxide film on your teeth for enriched whitening. The LED device uses light energy to amplify the whitening power of the concentrated film even further. The synergy between the formula and the device allows for whiter, brighter teeth in just 10 minutes a day*.
The new precision pen contains enough serum for 4 x 10 day complete whitening cycles (upper and lower arches) so patients can enjoy a whiter smile all year long ‘This system seems to breach the principle of “no pain, no gain” which has often been the case with tooth whitening products in the past. Freedom from sensitivity is something that all patients will value’ EMERITUS PROFESSOR LAURENCE WALSH
Contents The Indigo LED Device The patented LED device accelerates whitening with 410 nm wavelength of indigo light for faster, better results. The Optic White® Light Up device has a shorter peak wavelength than other blue light LED whitening devices.
1 x LED teeth whitening device charging case 1 x Whitening pen with 60mg/g (6% w/w) hydrogen peroxide teeth whitening serum (2.5ml) 1 x USB-A charging cord
Shorter wavelength of light = Greater Energy Transmission. *After use of 10 minutes a day for 10 days. use as directed. †10 minutes a day for 5 days. Use as directed.
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ULTRASONIC CLEANING SYSTEM BIOSONIC® UC150
The new BioSonic® UC150 ultrasonic cleaner offers great quality you have come to expect from all BioSonic® products while paving the way for some of the latest technological enhancements in ultrasonic cleaning. The sleek, Swiss design of BioSonic® UC150 is – Designed for efficiency Data logging capability and the ability to download information via USB •
Heater function – Optional built-in controlled heating to aid cleaning process, saving time - feature can be separately activated via code
•
Degas function - Eliminate air pockets and easily prepare your solution for maximum effective cleaning
•
Fit multiple cassettes at once
Designed for versatility •
Operation that can be customized with temperature and cycle time
•
Multiple cleaning modes
•
Use as a countertop or recessed unit
Designed for convenience •
Quiet operation to ensure a safe and comfortable working environment
•
Glove-friendly, multilingual touch screen for a seamless user experience
•
Quick and easy draining with externally accessible drain
Scan here to view the product brochure
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BioSonic® UC150 Ultrasonic video on the Operational Guide, FAQ Features & Benefits, and more
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PHILIPS SONICARE 2000 RANGE & CORDLESS POWER FLOSSER
Helps whiten teeth from day one. Superior cleaning with Sonicare technology A simple and easy solution to avoid cavities, promote long term overall health, remove plaque & bacteria and follow the advice of Dental Practitioners. Affordable and easy to use Advanced Sonic Technology delivers a superior cleaning experience Helps teeth whiten from day one Built in pressure sensor to help protect teeth and gums Available in Light Blue or Sugar Rose
Order the Philips Sonicare through our website.
A Portable and easy way to clean in-between the teeth for better gum health Unique QuadstreamTM Technology Clinically Proven up to 100% more effective than string floss for healthier gums Easy to hold, easy to use – Ergonomic design 2 cleaning modes, 3 Power settings and 2 different nozzles for a customized experience UP to 100% better plague removal than floss for healthier gum* Available in Black or White
Scan here to view *Clinical claim validation currently in process
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NEW CALIBRA FOR CALIBRATED RESTORATIONS
Calibra is an XTS (AlTiN)* coated composite instrument which helps provide the proper anatomical curvature to the dentin material layer of a restoration and leaves the ideal space for the final layer of enamel material. The Calibra “IN” point is used to define the dentinal skeleton, while the Calibra “OUT” point helps to reduce the chances of excess composite material being placed during the final layer of the restoration. Calibra acts as a guide, helping to prevent over-contouring at the preparation margin while assisting in reducing excess composite thickness build up. It also models the final layer of composite material.
CALIBRA OUT
CALIBRA IN
Clinical Use Calibra consists of two working ends: “ IN” which defines the dentinal skeleton and “ OUT” which allows for the verification of thickness as well as shape of the last composite layer. This instrument is both a caliper, to check the thickness (a practical alternative to the sagittal silicone index), as well as a modeling instrument, useful in the final layering of material - the first of its kind. How Calibra In works If you use a dentin / enamel system, you can use Calibra in the following way. (If you use only one shade, go to the description of the Calibra OUT): 1. Once the box technique has been performed (molding of the palatal wall, the incisal edge and the interproximal walls), place the selected dentin inside the box. 2. Put the Calibra IN in position by sliding the pointed end inside the incisal edge, while the end of the instrument rests on the sound part of the tooth. Starting from the center of the tooth (or restoration), move the Calibra IN first towards the mesial and subsequently, from the center towards the distal. Remove the excess composite with an instrument or brush.
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By carefully following this procedure, you will have given the right anatomical curvature from the preparation margin to the incisal margin. You will have the necessary space for the last layer of enamel and you will have reserved an incisal slot useful for placing any translucent effect shades.
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How Calibra Out works For the function of checking the thicknesses (how much space is left for the surface layer): place the instrument on the incisal margin (with the relative stop) and the terminal beyond the preparation margin. For the modeling function: Slide the instrument on the incisal margin (with the relative stop) by pressing the terminal lightly beyond the preparation margin. Start from the center of the tooth/restoration by moving the Calibra OUT towards the mesial and subsequently, from the median towards the distal. Remove excess composite. By following the procedure carefully, you will have avoided composite over-contouring at the preparation margin and, when applying the last layer of enamel, you will have anatomically connected the preparation margin with the incisal margin.
Complete your 3ssential Kit by werestore.it with Calibra The 3ssential Kit includes: HF-werestoreitkit: IMS Infinity Cassette Black 3 Instruments – spatula, posterior, anterior HF-CVKOTIX HF-TNEXBKR1X HF-TNCIPAOX
XTS PFI Essential WeRestore.it Spatula XTS PFI Essential WeRestore.it Posterior XTS PFI Essential WeRestore.it Anterior
Read more on the 3Ssential Restorative Kit
Clinical Article
Calibra YouTube
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How it Works
How to use the 3ssential kit
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R.T.R.+ - SYNERGY FOR SUCCESS NEW BIPHASIC FORMULATIONS ß-TRICALCIUM PHOSPHATE (ß-TCP) + HYDROXYAPATITE (HA)
Ideal biphasic composition for bone grafting The basic principle of R.T.R.+ composition is the appropriate balance between:
The fast resorbing ß-TCP It immediately begins to release calcium and phosphate ions into micropores enhancing bioactivity.
The stable hydroxyapatite (HA) Acts as a scaffold offering an ideal structure for cellular adhesion. Provides long term stability thanks to its slow resorption.
Ideal properties thanks to MBCP® Technology* esigned through a special manufacturing process, this micro and macroporous structure mimics human bone and D is proven to be an ideal osteogenic matrix for bone regeneration (1).
Microporous: permeable for biological fluids
Macroporous: cell colonization and osteoconduction
* MBCP® Technology: Micro Macroporous Biphasic Calcium Phosphate Technology (1) Guy Daculsi, Thomas Miramond. MBCP™ Technology: Smart Alloplastic Grafts For Bone Tissue Regeneration (2) Ransford - 1998 - “Synthetic porous ceramic compared with autograft in scoliosis surgery 341 patient randomised study” The Journal of Bone and Joint Surgery (3) Pascal - Mousselard - 2006 - “Anterior Cervical Fusion With PEEK Cages: Clinical Results of a Prospective, Comparative, Multicenter and Randomized Study Comparing Iliac Graft and a Macroporous Biphasic Calcium Phosphate” North American Spine Society (4) Lavallé - 2004 - “Biphasic Ceramic wedge and plate fixation with locked adjustable screws for open wedge tibial osteotomy” (5) Changseong - 2014 - “Eight-Year clinical follow-up of sinus grafts with Micro-Macroporous biphasic calcium phosphate granules” Key Engineering Materials (6) R.Z LeGeros et al. - 1988 - “Significance of the Porosity and Physical Chemistry of Calcium Phosphate Ceramic Biodegradation - Bioresorption” Journal of Materials Science: Materials in Medicine (7) Clemencia Rodriguez et al. - 2007 - “Five years clinical follow-up bone regereration with CaP Bioceramics” Key engineering materials
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Fully synthetic R.T.R.+ offers a high success rate with no risk associated thanks to its fully synthetic composition. Disease transmission is not an issue with synthetic material (2, 3, 4, 5).
Fully resorbable Hydroxyapatite and ß-Tricalcium phosphate are both fully resorbable and will gradually generate new natural bone (6, 7).
Two formulations 80% ß-TCP | 20% Hydroxyapatite
40% ß-TCP | 60% Hydroxyapatite
Helps natural bone formation in a short time
Fully respects the pace of creation of natural bone
Resorption durations*
R.T.R.+ 80/20 3 months
6 months
9 months
12 months
R.T.R. + 40/60 Indications
•
Post-extraction socket preservation
• •
Periodontal defects
• • •
Infrabony defects Sinus lift Peri-implant defects
• •
Ridge augmentation Cystic cavities
Infrabony defects
*Expected resorption durations depending on the surgical indication and the patient's health status
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