‘Online World: In-Person Dentist’ was the Irish Dental Association’s first ever fully online Annual Conference.
Embracing a fully online format for the first time, the IDA’s Annual Conference took place from April 16-17, and featured an outstanding line-up of speakers from close to home and right across the globe. Delegates could log on to watch lectures at designated times, or at a time that suited them, while social events, networking and a virtual trade show were also available. What follows is a snapshot of the packed programme of speakers, who shared their wealth of knowledge and experience with their colleagues in Ireland.
A reason to smile
Prof. Helen Rodd reviewed the prevalence and aetiology of developmental enamel defects in children, before demonstrating techniques to improve the appearance. Enamel defects in the permanent dentition are very common, and there are multiple aetiologies, from hereditary (amelogenesis imperfecta) to environmental (fluoride exposure, illness in infancy, vitamin D deficiency). This means that the importance of a good patient history and clinical exam cannot be overemphasised. For treatment, Helen prefers a minimally invasive approach that does not destroy teeth at an early age. The options that she favours include tooth whitening, resin infiltration/remineralisation, microabrasion, and use of composite resin. She emphasised the psychosocial impact of these conditions, advising discussion of issues such as patient (and parent) expectations, symptoms, and using photos and shade guides before commencing treatment. Research into the oral health-related quality of life of children who receive treatment for these defects demonstrates a powerful justification for treatment, and high-quality and minimally invasive dental care is important to address psychosocial concerns.
Dr James Goolnik, a general dental practitioner in London who speaks frequently on dental business issues, continued on from his address to the Association’s Practice Management Seminar in January. Reiterating the importance of regular staff appraisal (ideally every six months), he suggested the following questions for use at appraisal:
- what action have you taken on the issues we discussed at the last appraisal?;
- what is your best achievement/most satisfying outcome since the last appraisal?;
- what would you like to achieve in the next six months?;
- where is there room to improve in what we do?;
- what parts of your job do you enjoy most and least?; and,
- in what ways might you contribute more to the company?
Moving on to developing business, he said that we all know that there are three ways to increase revenue: attract more patients; grow the average patient spend; and, grow the frequency of purchase by patients. James said that two easy ways of improving revenue are to increase the average patient spend by selling toothbrushes, and to increase the frequency of dental hygiene visits.
Single and multiple gingival recessions
Prof. Anton Sculean, Professor of Periodontology at the University of Bern in Switzerland, outlined the simple treatment concept that he employs: a flap design that enhances wound stability. If recession is advanced, he likes to use biologic material to enhance periodontal wound healing/regeneration. To increase tissue thickness and improve wound stability, he uses a subepithelial connective tissue graft or soft tissue replacement grafts. Then he uses tension-free flap adaptation and suturing. Anton uses what is called the modified coronally advanced tunnel (MCAT). The procedure is performed with specially designed instruments. In one example, tissue was moved and then the graft pulled and fixed around the cervical part of the tooth. With a second suture, he moved the tissue coronally in order to completely cover the graft and the recession without tension. Mandibular cases are always more challenging, due to the pull of the muscles and thin tissues. For multiple defects, one approach that Anton uses is the MCAT again, where the graft is pulled through the tunnel, and sutured at every recession.
Hypnosis in dentistry
In a fascinating tour of the history of hypnosis, Scottish dentist Dr Mike Gow, a partner at The Berkeley Clinic dental practice in Glasgow, dispelled many of the myths surrounding the practice. These include people forgetting what happened under hypnosis, people losing control under hypnosis, people getting stuck in a trance, or revealing secrets. None of the above are true. Hypnosis in dentistry, in which Mike holds a master’s degree, is useful for anxiety management and relaxation, phobia management, and as a complement to sedation. It can, he says, be very powerful when used with sedation. Additionally, stress is a big factor in bruxism and hypnosis can be helpful in treating it. Mike referenced a paper by Derbyshire et al. in 2004, which proved that hypnotically induced suggestion is real when used in acute and chronic pain control. He also stated that a dental operation was carried out under hypnosis for a television documentary. He didn’t recommend that – but did repeat that he finds that hypnosis in combination with local anaesthesia is very powerful.
Physical examination of the head and neck
Dr Theresa Gonzales cautioned against an overly myopic view when examining the head and neck. The dental field of vision can be very narrow and specific, and she advised starting with a wider view, including symmetry and range of motion, before taking a closer look. With a myriad of technology available to dentists, she reminded delegates that ultimately, all physical diagnosis comes down to hands on the patient. Inspection, palpation, percussion and auscultation are all important in assessing a potential lesion. She advised to always look again, and ask the patient how they feel to identify issues with swallow or sensation. She cautioned that patients are skilled at expressing how much pain they are in, but less so at correctly identifying the source of that pain, so advised looking at either side of the painful area, and at range of motion. As always, patient history is vital. She advised listening without interrupting, and encouraging the patient to “tell me more”.
Susan Gunn advised dentists to think about their own ethics and their own recent decisions. Are you proud of them? Ethics are influenced by our family, gender, friends, age, culture, belief system and work. Sometimes an unethical decision is not illegal. She spoke about social media and how for all the good it has done in terms of connecting people, it has also laid bare some very unethical behaviour. She talked about professional practice ethical dilemmas such as paying personal expenses and marking them down as practice expenses, pocketing cash payments from patients, upselling products or services, flirting with employees or co-workers, and doing clinical work you are not skilled to do. Dentists have the opportunity to create an ethical culture in their practices, or an ethically compromised culture. She encouraged people to write down what moral principles they want to live by. She also recommended looking at other companies’ codes of conduct. Everybody has their own ethics, but a code of conduct enables everyone in the practice to work from the same foundation.
Clear aligner techniques
Dr Sandra Khong Tai, Clinical Associate Professor at the University of British Columbia, addressed the Conference on the indications and treatment process for use of Invisalign. There are simple aligner treatments you can do as a general dental practitioner, she said, and outlined the indications for those simple treatments as:
- class 1 minor crowding;
- pre-restorative tooth movement; and,
- orthodontic relapses.
Sandra outlined three case studies – one from each of the above indications. In the class 1 minor crowding instance, she said this can be done with ten aligners. She stressed the use of the ‘ClinCheck Plan’ in all instances, but especially in pre-restorative tooth movement. In the case of orthodontic relapse patients, she said that patients frequently come back eight to 10 years after initial treatment. They don’t have to go back into fixed braces and can be treated in five to 10 weeks by a general dental practitioner.
The face of dentistry today
When a dentist restores a patient’s smile, they are changing facial aesthetics, according to Prof. Bob Khanna, so a move to providing other cosmetic procedures to the face is one to which dentists are ideally suited. Prof. Khanna’s clinic provides advanced Botox and dermal filler treatments, as well as non-surgical facelifts. He argued strongly that understanding facial anatomy is crucial to carrying out successful and safe cosmetic procedures. He spoke about the loss of skeletal support in the face as we age, and the need to take a macroscopic view, looking at the entire musculoskeletal structure of each patient’s face to achieve an appropriate, safe, and natural result. He drew on an extensive collection of clinical photographs (advising that good clinical photography is also vital in treating these patients) to show successful, and less successful, outcomes. As in dentistry, discussing the available options with the patient, and managing their expectations, are vital, particularly in the age of social media.
Rubber dam isolation – the method behind the madness
Dr Céline Higton’s presentation went beyond the traditional lecture format, as she carried out a live demonstration of rubber dam isolation technique. She outlined the benefits of rubber dam, including safety, consistency, and the creation of an aseptic, dry environment. She emphasised the importance of communication with the patient, to reassure them and convince them to accept the rubber dam, and outlined solutions to common problems such as jaw ache or claustrophobia.
The most recent research on rubber dam use indicates that three factors that will help in achieving excellent isolation: the right materials and equipment; an effective strategy; and, good techniques.
She described the equipment that she recommends, including the importance of using the appropriate clamps for stability and good retraction. Placing rubber dam is an exact science, but by following the steps precisely, it can be a huge benefit to dental treatment. She asked delegates to remember why they are placing a rubber dam: to simplify the working environment; to improve access and vision; to retract soft tissues; and, for moisture control.
The joy of treating patients with special healthcare needs
Dr Allen Wong offered some frightening statistics on the disparities in healthcare for people with special needs. He argued for change, and that treating these patients can bring joy to the dental practitioner. For people with intellectual disability (ID), which was the focus of his lecture, he said that 85% have a mild disability and can be seen in the general dental surgery, and advised dentists to adapt what they do to welcome these patients. Treatment of patients with ID is not so different to treating the general population, with caries management by risk assessment, preventive treatment where possible, and minimally invasive dentistry the cornerstones of effective treatment. He emphasised the maxim ‘nothing about us without us’; people with ID are often dependent on choices made by others, so the role of the dentist, with the person with ID and their carer, is vital to address dental disease.
This year’s conference welcomed several speakers on restorative dentistry.
Dr Monik Vasant, an aesthetic dental surgeon based in London, talked about how the key to achieving seamless restorative aesthetics is to take a minimally invasive approach, and believe in the bond! He outlined techniques for anterior restorations, stating that proper use of composite is vital. He advised understanding the chemistry, handling and shading system of the composite you use, emphasising that shading is more nuanced these days, with natural layering concepts available to achieve an aesthetically and clinically satisfying result. He also discussed the importance of preparation, in particular the use of rubber dam isolation with the appropriate use of clamps and wax floss ligatures. “The endless possibilities of composites” were demonstrated by a range of clinical examples of posterior and anterior cases where the minimally invasive approach achieved excellent results. He also listed the essentials for successful treatment: good clinical photography; good lighting; magnification; brushes; a rubber dam kit; composite; and, polishes.
Dr Mauro Fradeani spoke about how when faced with compromised dentition, there must be a balance between aesthetics and function. He talked about tradition versus innovation. In the traditional approach, many teeth go through endodontic treatment. In the innovative approach, Mauro said he tries to keep the vitality of all the teeth. Then you can minimise the aggressiveness of the prep work, and have a chance to bond the restorations, using an adhesion procedure. He spoke widely on the vertical dimension of occlusion (VDO). If it is possible to increase the VDO, there are six main advantages: space for the restorative material; enhancement of aesthetics; rectification of the anterior teeth relationship; re-establishment of physiologic occlusion; minimisation/avoidance of the need for surgical crown-lengthening procedures; and, minimisation/avoidance of the need for endodontic treatment. He said that the main goal is to maintain the tooth structure, and the way to do it is: firstly, increase the VDO; secondly, reduce the ceramic thickness; and, lastly, preserve enamel in order to create the best bond possible.
Dr Chris Orr spoke about how to match up aesthetics and function. If dentists want their restorations to stand the test of time, then occlusion must be considered. He looks for what would be best for the mouth as a whole, not necessarily for each specific tooth. First comes assessment and diagnosis, and then treatment planning. You can’t do a comprehensive treatment plan chairside; you need to gather information so you can do it later. In his treatment planning, he first thinks about the aesthetics, then considers what treatment is needed and what treatment or disease is present or previously occurred. He then looks at occlusion – how the treatment will impact function and how these changes can be managed. Chris is very interested in photography and said that there are some analogies between the art and dentistry: “Sometimes everything is perfectly lined up, and you get lucky … Sometimes in dentistry as well, you just get lucky. Other times, the good result that you see is to do with very careful planning”.
In her lecture on additive prosthodontics, Dr Francesca Vailati said that instead of focusing on just a single tooth, dentists should focus on something she calls “global vision”. She often sees restorative work that will cause bigger problems as the patient ages because the treatment focused on one or a few teeth, while not considering the whole mouth. Francesca said that patients (and even dentists) value front teeth more than the posterior ones. However, posterior teeth protect the anterior teeth and if a patient loses the back teeth, the front teeth will become overloaded. Francesca has a three-step approach: diagnosis; the project; and, finally, therapy. The project is a collaboration between dentist and lab technician. Therapy is never final, as this allows her to correct things that are not working. This process has a high rate of acceptance among patients because there is no pain. It takes less time because she just bonds on top of what is already there. It also costs less because she doesn’t completely change the existing restorations.