At the RECOGNITION FOR sharp

April/May 2011Breaking

400 years of tradition

Page 26

At thesharpendHow will dentistry cope with themuch-anticipated cuts after the election? Page 16

RECOGNITION FORSCOTTISH DEAN

Professor Liz Kay receives FGDP

accolade Page 7

A PERMANENT SMILE SOLUTION

A full restoration of an edentulous

upper arch Page 45

ARE YOU AT THE END OF YOUR TETHER?How to identify and

deal with stress in your practice Page 31

SPECIAL FEATURETreating the street kids of

Arad in Romania Page 18

DID YOU KNOW? Your Scottish Dental magazine is now availableonline with new and exclusive content PLUS regular news updates www.scottishdentalmag.co.uk

BOOKMARK THIS LINK TODAY…

Scottish Dental magazine 3

WelcomeISSUE 2, VOL.2

NEWS>05 Column: Biting back

with Claire Walsh06 Female first for

Royal College08 Goodwill valuations fall10 Dental archive

launched13 Getting the facts

out of FiCTION16 Election news special

FEATURES>18 Romanian project –

treating the streetkids of Arad

24 Healthcare scrutiny

26 Interview: Dr Alyson Wray

31 Stress management35 Practice profile –

Sandgate Dentistry

CLINICAL>41 Intra-oral bone

grafting: a clinical audit45 A permanent

smile solution56 Teeth whitening 59 Using a dental

operating microscope

FINANCIAL>64 Budget analysis66 Share issues

PRODUCT NEWS>71 All the latest

products and services 5613

Decision time

Contents SCOTTISH DENTAL MAGAZINEApril/May 2011

Editor’s deskwith Bruce Oxley

Election time is upon us again

and you could be forgiven for

giving in to the odd moment of

pessimism about the whole

process.

The dental profession, and the

wider health service in general,

has been living under the threat

of cutbacks for more than two

years now. And, despite making

a few snips here and there, it is

no major surprise that the SNP

would stall on making the bulk

of the difficult decisions until

after the election. After all, it’s

not much of a vote winner to

make wide-ranging cuts in

an election year.

But, whoever wins the

election will have to deal with it

and hopefully they will deal with

it sooner rather than later. As

one of the dentists points out in

our election news special on

page 16, when the squeeze

eventually comes we’ll no doubt

be playing “catch-up” with our

colleagues down south.

Everyone will have their own

specific worries and concerns

as to what might be targeted

when the axe eventually falls

but a re-think on continuing

registration seems to be high on

the agenda for many. Whether

a Labour administration would

repeal the policy if they got in

is another matter.

®Bruce Oxley is the editor of Scottish Dentalmagazine. To contact Bruce, [email protected]

Column


There’s a lot of thingsyou might sayabout patients.They are yourbread and butter,

sometimes your biggest champion and other times yourworst enemy. But, if the GDCget their way, patients may wellbe a big deciding factor in yoursuccessful revalidation. Nowthere’s a thought!

I don’t know about you, buta fair number of my patientsdon’t know which dentist theysee in the practice. To be clear,there are only two of us, and weare not even the same gender.So, God help us if these finespecimens of the human racehad to give feedback on theirdental experience, or their‘patient journey’ as they say inthe hoity toity practices.

I haven’t seen any samples ofthe type of questionnaires thatmight be used but, all joking

apart, this really worries me.Some of our patients walk in thedoor, grunt their greeting at thereceptionist then nip back out-side for a swift fag, so that’s notthe best start . Even the better-bred patients – thosewho will sit in the waiting roomquietly without feeling the needto swing from the chandeliers –are, with the best will in theworld, not always the best people to judge the quality oftheir surroundings, or the carethey have received.

How many times have youdiscussed a treatment plan witha patient, say for example, apost crown, and talked about

why they need one, what toexpect, before sending themback to reception. The recep-tionist asks them what the nextappointment is for, and theysay: “Oh I don’t know, he didn’tsay.” If you didn’t have yournurse sitting there listening, youwould swear you were losingthe plot. It’s like being in a parallel universe sometimes!

And what about a patient whois never happy, or even one whois only disgruntled with a recentcourse of treatment, but doesn’t tell you about it? Youcan imagine their completedelight when they are asked tocomment on their recent course

of treatment. Mind you, youhave to feel sorry for the poorsod who will have to read all thisrubbish: “Ah cannae wear maplate, it’s too big”, “Ma tooth wisalrite til he touched it”. Give me strength!

The whole thing is gettingridiculous. I am all for fair treat-ment and patients’ rights to beinformed, and to be treated likea human being (in spite of occa-sional evidence to the contrary,judging by the look of theircoupon) but this idea really is thepits. I hope the GDC dump it andcome up with a better idea, butI am not holding my breath….

Early retirement, anyone?

Column

Biting backwith Spencer Wells

CONTACT SPENCER AT: [email protected]

EditorBruce OxleyTel: 0141 560 [email protected] sub-editorWendy FenemoreSub-editors: Chris Fitzgerald,Gary Atkinson, Jim Byers, Penny Murray

Design and productionRenny Hutchison,Debra Campbell, Paul McGinnity

Advertisingsales managerAnn CraibTel: 0141 560 [email protected]

Subscriptions Ann CraibTel: 0141 560 [email protected] year, 6 issue subscriptions: UK £48; overseas £65; students£25. Back issues: £5, subject to availability.

The copyright in all articles published inScottish Dental magazineis reserved, and as sucharticles may not be reproduced without permission. Neither thepublishers nor the editornecessarily agree withviews expressed in themagazine. ISSN 2042-9762

is published by

Studio 2001, Mile End, Paisley PA1 1JSTel: 0141 561 0300 Fax: 0141 561 0400www.scottishdentalmag.co.uk

DETAILS AND CONTRIBUTORS

Your fate in yourpatients’hands?

“Mind you, you have to feel sorry for the poor sod who will have to read all this rubbish”

News

6 Scottish Dental magazine

A consultant dentist fromGlasgow Dental Hospital hasbecome the first female vice-president appointed at theRoyal College of Physicians andSurgeons of Glasgow in over400 years.

Dr Alyson Wray has workedher way up from communitydentistry to her current post asconsultant in paediatric dentistry, often finding herselfthe only female around the table– but she believes the times are

changing.She said: “I’m not a

supporter of positive discrimination – i t ’s just discrimination in another guise. My view isthat people should beselected only on theirprofessional suitability

for the job.“I am witnessing more

women coming into senior

roles in dentistry and I believethis will continue in the future.”

For many years, female dental undergraduates at theGlasgow Dental School haveoutnumbered their male coun-terparts and this is because, DrWray believes, dentistry offersa satisfying and flexible career for woman.

“It’s difficult having childrenand continuing to develop yourcareer, but it is possible. I’vebeen lucky that I have had extended family for supportand, as I live in the West End ofGlasgow, if anything happensit’s only a short run home.”

And this came in handy when her ı3-year old son cracked his teeth after an accident in a skateboard park!

®To read our in-depth interview with Dr Wray, turn to page 26.

New appointment.Glasgow consultantbecomes the firstfemale vice-president

A doctor in all but name?TITLE DEBATE

The British Dental Association

(BDA) has accused the General

Dental Council (GDC) of wasting

time and resources over the

issue of whether dentists should

be allowed to use the courtesy

title ‘doctor’.

The association sent a letter

outlining their position on the

matter to the GDC ahead of their

February council meeting,

during which a decision was

made to postpone a vote on the

issue. The BDA argues that, at a

time when the GDC is facing

increasing financial constraints

and the backlog of Fitness to

Practise cases is growing ever

larger, the council should be

addressing these problems

ahead of the title issue.

They have also called on the

GDC to publish details of the

resources it has expended

reviewing this issue and warned

of the significant harm stripping

dentists of the courtesy title

could do.

Dr Susie Sanderson (above),

Chair of the BDA’s Executive

Board, said: “That the GDC is

choosing to devote time and

resources to this issue when it

should be concentrating on

addressing the backlog of Fitness

to Practise cases is nothing short

of astounding. Dentists and

dental care professionals have

seen hefty increases to their

annual retention fee and will not

be impressed by this profligate

use of the GDC’s swelled funds.

“The use of this courtesy title is

not an important issue for the

public. A ban has the potential to

confuse patients and harm the

reputation of the profession.

“We urge the GDC council to

reject the recommendation of its

standards committee and

instead concentrate on the areas

of its work that deliver a real

benefit to the public.”

REGISTRATIONS

As the deadline for

dentists to appeal with-

drawn registrations

came to a close,

Practitioner Services

Division (PSD) has

revealed a clearer

picture of the extent of

the problems.

Late last year, PSD

stopped in the region of

150,000 registrations

that they had identified

as duplicated,

deceased or relating to

a patient who had

emigrated. As of 18

March, 244 dentists

had submitted over

6,000 queries with the

deadline closing on

31 March.

The registrations

were withdrawn, with

payments ceasing as of

1 September 2010, in

response to an audit by

PSD to match the

Community Health

Index numbers to the

patient records they

hold on their payment

system, MIDAS. The

exercise threw up over

150,000 potential

inaccuracies, with

dentists being asked to

submit a DPD295 form

if they disagreed with a

withdrawn registration.

The initial deadline of

21 February was

extended after the

BDA’s Scottish Dental

Practice Committee

chairman Robert

Kinloch revealed that

many dentists were

struggling to meet the

deadline due to the

adverse weather condi-

tions before Christmas.

Female first forRoyal College

PSDrevealscale ofproblem

FGPDP AWARD

A former senior lecturer at the

University of Dundee has been

awarded the Faculty of General

Dental Practice (FGDP[UK])’s

highest accolade, the Fellowship

Ad Eundem.

Professor Liz Kay, who is the

current dean of the Peninsula

Dental School in Devon, received

her award at the Annual Faculty of

GDPs (UK) Diplomates Ceremony

in London on 5 March. The honour

is described as “a mark of achieve-

ment for those who have made a

contribution to patient care or the

profession of primary dental care,

significantly over and above what

might be reasonably expected of a

member of the FGDP(UK)”.

On her award, Prof Kay said:

“I am of course delighted to have

been awarded such a prestigious

accolade. While it is me who has

been made a fellow, it is an

achievement that reflects the

hard work and dedication of my

colleagues and our students

at the Peninsula Dental

School, as much as it does

me personally.”

Russ Ladwa, Dean of the

FGDP(UK), added: “It is

obvious for all to see that

Professor Kay has an exceptional

enthusiasm for her profession,

and a willingness to help others

along their chosen path. Her tire-

less work and support for dental

practitioners to provide an

improved quality of care for

their patients is well known

and I thank Professor Kay for

that.”

Prof Kay qualified BDS

from the University of

Edinburgh in 1982 and

gained her Masters in Public

Health from the University of

Glasgow in 1984, followed

by her PhD in 1991.

She then became senior

lecturer at the University of

Dundee before undertaking

specialist training in dental

public health. She has been a

consultant in the specialty for

the last 10 years.

In May 2006, she was

appointed as the inaugural dean

of the Peninsula Dental School, the

UK’s newest dental school and a

collaboration between Exeter and

Plymouth universities.

News


Election special p16 | Interview p26 | Clinical p41 |

Signalstowards no smokingDentists are being reminded

of their crucial role in

spotting mouth cancer early

and providing vital smoking

cessation advice, following

this year’s No Smoking Day

that took place in March.

It is thought that around

21 per cent of the UK’s

population is still smoking,

with tobacco linked to

around three-quarters of all

cases of mouth cancer.

Dr Nigel Carter of the

British Dental Health

Foundation said: “The dental

profession is in a unique

position to warn patients of

the risks and consequences

of smoking. In September,

dentists in Dublin and Ireland

offered free mouth exami-

nations, and six cases of

mouth cancer were found.

This only serves to further

reinforce the message that

regular visits to the dentist

can help detect early signs

of mouth cancer.”

The General Dental Council’s

internal audit of its Fitness to

Practise (FtP) proceedings, the

confusion surrounding CQC

registration in England and the

lack of political representation

for the industry as a whole were

just some of the issues tackled

at the recent Dentistry Show at

Birmingham’s NEC.

A media briefing from

indemnity organisation Dental

Protection (DPL) explored the

many problems with the GDC’s

FtP hearings that were high-

lighted by its own recent

internal audit. These included

inconsistent decisions made

by caseworkers and and DCPs’

presence on investigating

committees that are exploring

matters beyond their training or

scope of practice.

The thorny issue of CQC reg-

istrations in England was also

high on the agenda and DPL’s

Sue Boynton and the Dental

Professionals Association’s

CEO Derek Watson both tackled

the subject in separate talks.

While Ms Boynton highlighted

the potential problems and

spoke in measured terms,

Watson’s talk was a little more

partisan. “The dental profession

is being suffocated by layer

after layer of regulation,” he

opined.

And, while the CQC situation

is not of direct relevance to

Scotland, Watson did reserve

some ire for Scotland’s former

dentist MP Anas Sarwar, stating

that: “We are still waiting on his

first speech on dentistry in the

Commons…”

Dentistry on show

Recognition forScottish dean

“It is an achievementthat reflects the hardwork and dedicationof my colleagues andour students at thedental school”

Professor Liz Kay

CHILD PROTECTION

Scotland’s delayed Protecting

Vulnerable Groups (PVG)

Scheme was launched at the

end of February with the aim

of replacing and improving on

the previous disclosure

arrangements.

The PVG Scheme had been

due to start in November last

year but was delayed by

ministers in order to ensure

the system that supports it

was fully fit for purpose and

robust. All dental professionals

that work with children and

protected adults will require to

be registered and the General

Dental Council (GDC) will

have powers to refer its own

registrants to the scheme.

The GDC will have the power

to make a referral if it is felt

that the individual has done

something to harm a child or

protected adult and the

impact is so serious that the

organisation has – or would be

likely to – remove the individ-

ual from regulated work on a

permanent basis.

The GDC may also receive

information about its regis-

trants from the scheme. The

council has decided, howev-

er, that any information

received would not result in

automatic erasure from the

register, but as an

allegation of imp-

aired fitness

to practise.

News


The goodwill value of dentalpractices in the UK has fallento 84 per cent of turnover, compared with nearly ı00 percent this time last year.

The figures, released by theNational Association ofSpecialist Dental Accountants(NASDA), show that goodwillas a percentage of fee incomefor sales has dropped to 84 percent as of January this year andfor valuations it is down at 90 per cent. However, NASDArevealed that enthusiasm forNHS practices remained high,while private practices in someareas are proving harder to sell.

The report, produced eachyear by NASDA f i rmHumphrey and Co, also looked

at dental profits for 2009/20ı0.It showed that net profits over the year were either slightly down or remained static on the previous year.

The sample population forthe report covers 600 practicesand 500 associates, includingmembers in Scotland, and arebased on averages of actualaccounts of both NHS and private practices rather thantax returns. The 09/ı0 resultsshow an overall reduction innet profit, due to increases inmaterials and staff costs, from£ı4ı,835 to £ı39,569, or from 37.4 per cent to 35.8 per cent ofoverall income.

The figures showed thatalthough associate income was

slightly down – by £2,000 – practices with associates weregenerally more profitable. Netprofits for a practice with associates was £ı48,408, whilewithout associates it was£ıı8,992. The report also foundthat, while there was a slightincrease in fee income for pri-vate practitioners, from £358,7ı7to £364,924, there was a small

reduction in net profit, from£ı30,62ı to £ı26, 390 (from 36.4 per cent to 34.6 per cent).

Dougie Paton, a NASDAmember and chartered account-ant with Condie and Co inDunfermline, commented: “Wecontribute to the NASDA collec-tion of statistics because they arerepresentative of expenditureand earnings by Scottish dentistsand provide the best availablebarometer of the dental market.The same applies to the NASDAgoodwill figures.

“Despite the lack of externalfunders, the sales market inScotland is very active – cur-rently we are dealing with threeseparate transactions. TheNASDA statistics and goodwillsurveys help us benchmark ourforward-looking projections,assess deal values, and adviseclients accordingly.”

Practice values. Although profits are slightlydown the Scottish market is still very active

Goodwill valuations fall

The smile factorNATIONAL SMILE MONTH

Dentists across Scotland are

being encouraged to do their

bit to promote National Smile

Month as this year’s campaign

marks its 35th birthday.

The theme of the aware-

ness month, which runs from

15 May until 15 June, is the

‘Smile Factor’ with the aim of

putting the smile back on

peoples’ faces. Chief Executive

of the British Dental Health

Foundation, Dr Nigel Carter,

described the thinking behind

this year’s campaign. He said:

“A smile can be a very

powerful show of emotion,

yet not everyone has the

confidence to do so.

“Others are being held back

by poor oral well-being and its

impact on their general health.

This year’s campaign is

designed to challenge those

perceptions and get your

patients smiling again.”

®For more info on National SmileMonth, call 01788 539792.

PVG Scheme goes live

Dougie Paton

News


| Romanian project p18 | Stress management p31 | Product news p71

HISTORY OF DENTISTRY

The British Dental Association

(BDA)’s director for Scotland and

the chairman of the Scottish

Dental Practice Committee were

both present at the recent

launch of a new archive docu-

menting the history of dentistry.

Andrew Lamb and Robert

Kinloch saw a £50,000 bequest

from the family of former BDA

president John Walford McLean,

presented, to see the creation of

The John McLean Archive: A

Living History of Dentistry. The

new archive will document the

history of dentistry since the

inception of the NHS and is being

developed in conjunction with

the King’s College London Dental

Institute (KCLDI)’s Unit for the

History of Dentistry.

The project will comprise a

series of witness seminars and

individual oral history interviews,

the first of which was hosted by

Professor Nairn Wilson, head of

KCLDI, at the end of March. The

session will explore dentistry

prior to 1956, the role of the

Dental Board, the introduction of

the General Dental Council, inter-

action with the BDA,

specialisation, and the role of the

protection organisations.

Head of BDA Museum

Services Rachel Bairsto said:

“This archive will provide an

essential record of the significant

evolution of the dental

profession. This will be invaluable

for generations of professionals

to come. We are honoured to be

given the opportunity to realise

this project through the generos-

ity of one of the most

highly-regarded leaders in the

profession, John McLean, whose

legacy will long be remembered.”

John Walford McLean OBE

was a leading dental practitioner

and internationally renowned

dental materials scientist, author

and lecturer.

Dental archive is launchedAlmost 90 per cent of people

polled during National

Orthodontic Week revealed

that they thought

orthodontic treatment

should be available on the

NHS, but only half thought

that it was available on the

health service.

The research survey,

conducted to coincide with

the British Orthodontic

Society’s (BOS) annual

awareness week in February,

also asked respondents to

list the main reasons for

wanting treatment on pro-

truding teeth.

The top reasons given in

the BOS survey were to

improve self-confidence

(85 per cent) and to prevent

teasing and bullying

(77 per cent).

Bullying topsortho surveyresults


News


Healthcare scrutiny p24 | Practice profile p35 | Teeth whitening p56 |

A new trial led by researchers

at the University of Dundee is

inviting hundreds of dental

practices across the UK to

assess different methods of

managing decay in children.

The FiCTION (Filling Children’s

Teeth: Indicated or Not) trial has

been commissioned by the

National Health Research Health

Technology Assessment (NIHR

HTA) and letters have been sent

out to over 300 practices in

Dundee, Glasgow, Leeds, Cardiff,

London, Newcastle and Sheffield

appealing for participants.

The trial is led by the University

of Dundee and the University of

Leeds, working with university

colleagues in the five other

participating cities. It will

examine the benefits of three

methods of managing decay in

deciduous teeth.

The first method is using only

preventive techniques

recommended by the national

guidance such as better tooth-

brushing, less sugar in the diet

etc, to stop the decay, the

second method will look at

conventional fillings along with

preventive techniques and the

third will examine biological

treatment of the decay alongside

preventive techniques. The study

will also gauge what the children,

all aged between three and

seven, think of the different

types of treatment.

Dr Nicola Innes, of the

University of Dundee Dental

School, one of the lead

researchers for the FiCTION trial,

said: “Conventional clinical

opinion is that baby teeth

showing decay should be filled,

yet the majority of cavities

in young children are left

unrestored.

“There is, as yet, no conclusive

evidence for the most effective

approach to managing decay

in baby teeth. With this trial

we are looking to provide

that evidence.”

HEALTH WARNING

The Medical and Dental

Defence Union of Scotland

(MDDUS) is urging caution

after a rise in calls concerning

the treatment of pregnant

patients.

The defence organisation

has seen an increase in queries

from dentists regarding the

taking of X-rays and the use of

amalgam fillings during

pregnancy. Although the

pregnancy status of patients

should be apparent from their

current medical history, the

Ionising Radiation (Medical

Exposure) Regulations require

that specific enquiry is made

before a female of child-

bearing age is exposed to a

medical radiograph.

While pelvic radiation in

dentistry is highly improbable,

with the Health Protection

Agency advising that foetal

risk in relation to most

intra-oral radiography is

infinitesimal, MDDUS has

urged caution and pointed

clinicians to the justification

protocols set out by the FGDP.

The indemnity body has

also urged caution when using

amalgam fillings, despite the

lack of conclusive evidence

linking the restoration to birth

defects or still births. “Clearly,

the best solution is to delay

treatment which involves even

the most theoretical foetal risk

until after the pregnancy is

complete,” warned MDDUS

dental adviser Doug Hamilton.

Hamilton also pointed out

that, during pregnancy, the

Dental Practice Board in

Scotland can, subject to prior

approval, issue discretionary

codes for the placement of a

variety of non-amalgam

materials in the posterior teeth

of pregnant patients.

Caution urged forpregnant patientsGetting the

facts out of FiCTION

Research. New study aims to provide evidencefor the best way to deal with decay in children

Charity cycle challengeThirteen brave bikers from

dental equipment manufac-

turer A-dec are participating

in the infamous Coast2Coast

bike ride in April.

The group are raising

money for Bridge2Aid, the

dental charity set up by

Scottish dentist Ian Wilson

to provide vital dental treat-

ment and training in the

Mwanza region of Tanzania.

The Coast2Coast bike ride is

a challenging 150-mile,

three-day journey across the

Pennines from Whitehaven

on the west coast to

Tynemouth on the east.

®To support the A-dec group,visit the online sponsorshippages at http://uk.virginmoneygiving.com/team/A-dec

A Bridge2Aid dentist training a Tanzanianclinical officer on emergency dentistry

Dr Nicola Innes, University ofDundee Dental School


News


Referral pathways p38 | Case study p45 | Financial p64 |

Quick andrelativelypainless

Budget. Chancellor’s speech providesmore positives than negatives for the dental profession as a whole

At just under an hour,

George Osbourne’s Budget

speech may have been one

of the shortest in the last

150 years but it brought

with it a modest amount of

good news for dentists.

The Chancellor confirmed

that he regards the 50 per

cent personal tax rate as a

temporary measure and a

few high-earning incorp-

orated dentists are likely to

benefit from the reduction

in tax payable on profits.

The rate of corporation

tax payable on profits

exceeding £300,000 will fall

to 26 per cent from 28 per

cent on 1 April and to 25 per

cent from 1 April 2012. The

small companies’ rate,

payable on profits of up to

£300,000, will fall to 20 per

cent on 1 April this year.

There will also be some

structural reforms to tax

relief for capital expenditure

relating to the definition of

short life assets where the

time limit will increase from

four to eight years. This

could be of particular rele-

vance to the tax treatment

of new surgery equipment

Another benefit is the

increase in entrepreneur’s

relief from £5 million to £10

million. This means that

dentists will pay capital

gains tax at 10 per cent –

instead of 18 or 28 per cent

– on lifetime gains on the

sale of dental practices up

to £10 million.

MEDICAL DEVICES

A year on from the changes

to the Medical Devices

Directive affecting the

provision and manufacture

of dental appliances, the

General Dental Council

(GDC) has issued a

reminder to dentists of

their responsibilities.

One of the main

elements of the

amendment related to the

statement of manufacture.

Patients must be made

aware that they can

request a statement of

manufacture and dentists

have a responsibility to

ensure it is made available

if requested. Not doing

so is punishable as a

criminal offence.

Applyingthe law

Election news special


JACKIEMORRISON,communitydentist inLanarkshire,vice chair of the

Scottish Salaried DentistCommittee and chair of theScottish Accredited Rep Groupof the BDA“As salaried dentists we jealously

guard our special needs function

and we hope that, with times

being tight over the next few

years, funds and time are made

available for us to continue this.

“We have problems with

recruitment and retention in the

salaried service, which may be

due to the protracted negotia-

tions delaying the delivery of a

new contract which compares

favourably with what has been

agreed in England. It is worth

noting that we are the last part of

the NHS not to have a review of

our contract. The negotiations on

this continue.

“Our main concern is funding.

We are committed to seeing and

treating vulnerable groups and

those who find it difficult to

access NHS dentistry. For this

to continue proper funding must

be assured.

“It seems that to make

savings, posts will not be filled

as people retire or move on,

perhaps to parts of the country

with better pay and conditions.

Many salaried dentists, including

myself are coming to the end of

their career. If our posts are not

filled, either to cut costs, or

because new graduates do not

find the jobs attractive, the con-

cern is that vulnerable groups

will not receive the treatment

they are entitled to.”

LACHLANMACDONALD,GDP in Paisley,Renfrewshire“England is

rapidly moving towards private

health care similar to the American

model and, despite cries to the

contrary from the Scottish National

Party (similar to the student tuition

fees fiasco), it is difficult to see

how we are to fund both medical

and dental care for the Scots who

are gaily eating, smoking and

drinking themselves to death.

“The mixture of dentists doing

both private and NHS work must

be addressed. Some private

charges are appalling and yet the

department of Dental Public

Health within the Scottish

Government Health Directorate

will not increase the number of

dentists working at the NHS

‘enamel face’.

“One answer is that any dentist

who qualifies in Scotland should

be obliged to work in the NHS

(not in the private sector) for

five or six years. Either that or

that we nationalise the ‘tooth fairy’

and send the proceeds to

Alex Salmond!”

MORVENSWAN, GDP in Huntly,Aberdeenshire“As an NHS

dentist working

in times of recession and cut-

backs, my main hope would be

that money will continue to be

invested towards improving NHS

facilities and services, particularly

in remote and rural areas.

“Over the past few years, my

health board, NHS Grampian

has invested in several major

Keeping dentistry onthe election agenda

Scottish Parliament elections. On 5 May the country will go to the polls to elect a new government.Ahead of the vote we asked the BDA, DPA and a selection of practitioners their views on the matter

With the ScottishGovernmentelections justweeks away, thecampaign trail

is really starting to heat up. Dentistryis rarely front page news and you’llbe hard pressed to find mention ofthe profession in any party manifesto,but that doesn’t mean the electionwon’t affect practices up and downthe country.

The British Dental Association(BDA) in Scotland has highlightedcombating oral health inequalitiesas its major manifesto issue. It

argues that despite improvementsover the last 40 years or so,Scotland’s oral health still lagsbehind the rest of Western Europeand that inequalities between thosewith the best and worst oral healthstill persist.

The BDA recognises the role thesuccessful Childsmile scheme hasplayed in making inroads but it iscalling for the fluoridation of watersupplies to be put back on the agenda so that communities themselves can decide whetherthey would like to benefit from the measure.

“Candidatesstanding forelection thisyear mustpledge towork withthe dentalprofession to take onthose challenges anddeliver improvementsfor patients”

Andrew Lamb, BDA Director for Scotland

BDA MANIFESTO

VOX POP: We asked five dentistsabout their hopes, and fears, for the dental profession after the election

Election news special


developments such as the new

Aberdeen Dental School, the

Spynie Outreach Centre in Elgin

and our own dental practice in

Huntly which offers independent,

salaried and specialist services all

within the one centre. I feel that, as

a direct result of the increased

funding we have received, both

patient registrations and dentist

numbers are now at an all time

high within the region, and I would

hope that sustaining this level of

investment would allow these

figures to rise even further.

“I would also hope that money

would continue to be spent on

improving oral health, in

particular through the Childsmile

programme. The most recent

National Dental Inspection

Programme produced the best

ever results for children’s oral

health, which not only illustrates

the impact the scheme has

already had on preventative

care, but highlights the

importance of continuing to

invest in the Childsmile

programme to ensure children

from an early age are primed for

a lifetime of good oral health.”

TERRYSIMPSON,GDP inLivingston,West Lothian,honorary

research fellow at EdinburghDental Institute and clinicaleffectiveness advisor forNHS Lothian“In general terms I think any

Scottish Government is going to

have its hands tied to some

extent by the economic

conditions. Whatever happens

there is going to be quite a tight

squeeze on the finances and

I think it is bound to come

through to dentistry eventually.

“In fact, in some ways there is

the argument that perhaps it

should have been implemented a

bit earlier. The fact that it has

taken so long for the government

to make cutbacks in Scotland

means that there is probably

going to be a bit of a catch-up

process with our colleagues

south of the border.

“I think there has also been a

build up of bureaucracy within the

system which needs to be

slimmed back and we need to

concentrate on the patient-dentist

relationship more. I think there has

been far too much interference by

government and the problem is

that this can detract a lot from

patient care.”

TONY COIA,GDP fromClydebank,WestDunbartonshireand chair of

LDC conference“I think the first thing would be the

effect of any future public sector

cuts within dentistry. I’m sure that

high street private independent

dentistry is feeling the strain just

now, but as far as health service

dentistry is concerned, I think an

awful lot will depend on whether

the allowances are tinkered with

because that would make a huge

difference to the profitability of

practices. We’ve had very little,

less than one/one and a half

per cent over the past three to four

years, plus with the VAT increase

people are struggling just now and

profits are being squeezed.

“The other issue is pensions and

that’s going to have a profound

effect on morale, not so much for

the dentists in their 30s but

certainly for people in their 40s

and older who are beginning to

flag a wee bit and the thought of

maybe another five, six or even

seven years working doesn’t fill

them with much optimism.

“I’m hoping that, coming up on

57 myself, I’ll be able to get out

before things start to really hit the

fan, but we will just have to wait

and see.”

The issue of lifelong registration isanother item that the association inScotland says needs a rethink by anynew administration. The BDA is calling on the new government torecognise the importance of regularattendance in stemming the growingnumber of oral cancer cases. Theunion also highlights the numberand location of dentists in the country as requiring attention, witha shortage of dental academics andgeographical disparities in the provision of both primary and secondary care as problems thatneed to be addressed.

Andrew Lamb, BDA Director forScotland, said: “Despite improve-ments in the dental health of Scotlandover the last 40 years, there is still agreat deal to do if we are to eradicatepersistent oral health inequalities.

“We have successes to celebrate,including the excellent Childsmilescheme and improvements in accessto dental care in some areas, but thenew government will nonethelessface significant challenges in the fieldof dentistry and oral health.

“Candidates standing for electionthis year must pledge to work with the dental profession to take on those challenges and deliverimprovements for patients.”

DPA MANIFESTO

“This subject must be revisited urgently beforelarge parts of the servicerevert to pain relief only”

Reg Short, DPA council member

In its election wish list the DentalProfessionals Association (DPA) alsohighlighted lifelong registration as one oftheir key issues. Reg Short, one of theassociation’s council members forScotland, pointed out that, for dentists,continuing registration was never seenas anything other than a ploy to produceever-improving registration figures.

However, he said: “The public could beforgiven for believing that this meantthat the dental service was thereforeimproving. The profession warned thatthe reverse was likely since the incentiveto visit for examination periodically wasbeing removed.

“The only other incentive for manypatients is the need for emergency treat-ment for relief of pain. This subject mustbe revisited as a matter of urgency

before large parts of the service revert topain relief only.”

The DPA also points to the recent problems with Practitioner ServicesDivision’s records (see page 6), saying anew IT system is needed.

The association also questions whetherany incoming administration would takeon what it regards as “a misuse of public funds” and address the misgivingswithin the profession over the ongoing decontamination issue.

The DPA maintains that no convincingcase has ever been put forward that theproper, reasonable decontamination andsterilisation methods used prior to 2005ever resulted in harm. It says that due tothe precautionary principle, dentists arenow bound to guard against risks that cannot be shown to exist.

Romanian project


Sniffing glue to suppresshunger pangs is just oneof many depressing dailyrituals performed by thestreet kids of Romania.

Living in squalor, often in tunnelsbeneath the country’s major cities,these forsaken children will do anything to survive.

Needless to say, oral hygiene ratespretty low on their list of day-to-daypriorities, but by neglecting theirteeth these children often end up suf-fering intolerable pain.

While much is being made about theneed to improve oral hygiene amongchildren in Scotland, two dentists hereare focusing on the plight of those in amuch less privileged country.

Eoin MacGillivray, now retired, isdetermined to use his time, money andskills to help treat these street children,who, unlike their Scottish peers, haveno access to free dental care.

When he was working out of his

practice in Bridge of Weir, Eoin hadtravelled to Romania to run a coupleof projects that were designed tohelp these children. Sadly, he had togive up this work at the age of 47,when he retired from dentistry dueto ill heath.

Eight years on, however, he hasbeen drawn back to Romania,inspired by two friends who haveopened a centre in Arad, dedicated

to helping the street children there.With the help of friend Andy

MacKinnon, a dentist based in theeast end of Glasgow, Eoin is now fullyensconced in plans to set up a med-ical/dental facility in the basement ofthis centre, situated in westernRomania, in the Criflana region, onthe river Murefl.

Once the basement is officially upand running, Eoin said both he andAndy will fly out frequently from theUK to help manage things, while acouple of Romanian dentists and adoctor will staff the facility on a moreregular basis.

To the casual observer this mightseem like a lot of effort for very littlereward, but as a humanitarian Eoinbelieves his new Romanian project isa necessity. After taking inspirationfrom his two friends already outthere, he said he felt compelled tooffer his help.

“My friends, who are both teach-ers, felt they needed to put somethingmore permanent in place for the chil-dren and so they privately raisedfunds to renovate and open this cen-tre,” Eoin told Scottish Dentalmagazine.

“The centre is a place for the poorand Roma to come and get food,wash, get their clothes washed andget some peace.

“My friends originally went out toRomania to drive some of my dentalequipment into the country but wereso moved by the plight of the childrenthey ended up moving out there withtheir families the next year. Theirchildren were educated there andthey now have a daughter who is a

Scottish dentists Eoin MacGillivray and Andy MacKinnon haveset up a surgery for treating the street kids of Arad in Romania.Chris Fitzgerald met up with the duo to find out why

on the streetPutting a smile

“My friendsoriginallywent out toRomania todrive someof my dentalequipmentinto thecountry butwere somoved bythe plightof the childrenthey endedup movingout there ”

Eoin MacGillivray

The street kids of Arad live in shacks,tunnels or in rubbish tips

Romanian project


student medic. It makes sense that Ishould offer the centre what I can in terms of promoting oral hygiene. It’s a humanitarian project, not a business venture. It’s an interestingand rewarding experience as well.”

And by offering his help, Eoin willbe able to rekindle his love of a pro-fession that was cut cruelly short.

Although he beat cancer, Eoin hadto retire from dentistry at the age of47. The chemotherapy, though savinghis life, left him with problems in hisday-to-day functionality, the moremajor in relation to dentistry beingperipheral neuropathy – whichmeans he cannot feel with his fingers.

“Yes it was sad, but I live for today,”Eoin said. “You can’t go back, youhave to go forward. I’m still involvedin lots of other things as well, such as

the health board, children’s paneland so on. I do a lot of work with children.”

So, not wanting to undertakethis epic new Romanian projectalone, Eoin has enlisted the helpof his close friend AndyMacKinnon.

“Andy did his work experi-ence with me when he was at

school and then went on to do den-tistry,” Eoin said. “We both attendWest Glasgow New Church and itsupports the work we want to do, andhas done for many years, and we feelthat our project is an extension of thishumanitarian work.”

And due to Eoin’s medical condi-tion, Andy will carry out the bulk ofthe practical work involved.

“Eoin facilitates,” Andy explained.“He’ll get the surgery set up and I’lldo the clinical stuff. Eoin knows whatis needed in terms of dental equip-ment and how to put that dentalequipment in place. We didn’t needengineers as much as you may thinkbecause Eoin knows what he’s doing– he’s already been out to Arad andknows the requirements.”

CHANGING ROOMS

The Arad centre basement needed a lot of work to get itup to a standard suitable for treating patients

Continued »

Eoin MacGillivray (left) andAndy MacKinnon plan to travelto Arad whenever they can

Romanian project


While Eoin is retired, Andy is stilla working man. However, he insistshis trips to Arad won’t affect his ownpractice in Glasgow.

“The huge advantage is I’m self-employed and can take time off whenever I want,” he said.“Obviously I don’t earn when I taketime off but the idea is to set thisup and then get other dentists to goout there too, such as friends ofours, Romanian dentists and so on,meaning I don’t have to be there allthe time.”

The street centre itself is a ı00-year-old building that served asa jeweller’s workshop prior to beingrenovated by Eoin’s friends. Thebasement, however, was still in astate of disrepair when Eoin andAndy came out to have a look.

“The basement was riddled withcobwebs and the floor was floodedbefore work started,” Andy said. “Itwas a huge job for the builders butthey did a great job getting it inhab-itable. The courtyard up above is nowthe waiting room for the surgery. Itall looks quite lovely.”

The building work was paid for byfunds raised from ceilidhs held inScotland and also from a supportgroup in Falkirk.

“We pay for flights and other small-er costs ourselves,” Andy added.

Charity Dentaid and other UK busi-nesses have provided most of thesurgical equipment – chair, handpiecesand so on – with Eoin and Andy onlynow missing a dental light, deliverycart, compressor and some cabinets.

“We need to demonstrate a proper surgery to proper standardsin order to get the necessary certificates,” said Andy. “We feel thatthis should actually be measuredagainst UK standards, which arehigher than those in Romania, so thatis what we have set out to achieve.”

“We have made contact with thelocal dental committee and the reg-istration is ongoing,” Eoin added.

As for staffing, Andy said he is relying on a lot of good will from local practioners.

“We hope that Romanian dentistswill help out and we have some con-tacts there who have made suchpromises,” he said. “Our aim is to geta retired Romanian dentist to workin the clinic once a week. When weachieve this we will be more able toassess the impact of our work. TheRomanian dentists and doctors willall volunteer their time as a serviceto society. Most are humanitarian andfeel they should do this.”

PovertyExacerbated by the collapse of com-munism at the end of the ’80s,poverty is rife in Romania. Althoughmost of the country’s street childrenare in desperate need of dental care,they have grown suspicious of any-one offering to help them for free.

So, in a bid to gauge demand andsee how practical the basementwould be in treating a broad churchof dental ailments, Andy performeda session in the half-fitted facility last October.

“These people were not gettingany treatment before,” he said. “Thecommon problems among street kidsfrom what I could see are carious orrotten teeth. Their biggest needswould be extractions and advice.”

Street kids are not all children, a lotof them are now in their twenties andthirties, but they’re still known as kids.

“A number of these adult patientscame in too,” Andy said. “They hadsuffered toothache and extreme painfor months prior to us doing treat-ment. Extracting the rotten teethrelieved this problem immediately.”

Most of the children in Arad do notown a toothbrush either, according toAndy, and so he and Eoin plan to

provide these and toothpaste for anumber of families, backed up withsimple advice on how to brush theirteeth properly. Andy said: “We aregoing to go around schools, nurseriesand the streets with an interpreter,and get them to come along to oursurgery. Poor kids in Romania do notgo to see a dentist. There’s no NHS– they simply can’t afford it.

“But, believe it or not, there’s not awhole lot of difference between thetooth decay rates of these street kidsand the children in the east end ofGlasgow, where I work. The decayrates in the east end are probably asbad as anywhere in Europe, as is welldocumented.

“But at least the kids in Glasgowhave access to a dentist. Romanianstreet kids simply don’t. Not seeing adentist regularly can create a fear ofthem too and that’s something wewant to help the kids of Arad get over.”

While Andy will endeavour to provide the same treatment to the children of Arad as he would those athis Ruchazie practice, at the momenthe said he cannot offer replacementteeth when he has to extract.

“The problem is paying for it,” hesaid. “We’ve not gone that far yet.We’re just looking at providing emergency care for the time being. Wewould need to raise more money to setup something to fund tooth replace-ment and more complex surgery.

“But who knows what the futurewill hold and how the surgery willdevelop. Right now I just want to urge as many dentists as possiblewho read this article to considercoming out here to help. It’s a very worthwhile cause.”

®If you would like to offer your help orget more information on the Romanianproject, contact Andy MacKinnon on 0141 774 9467 or by email [email protected]

ROMANIA TRIVIA

THE BASEMENT SURGERYin Arad won’t be used by dentists

seven days a week. It will also

be used by local specialists to

offer free eye tests to the street

children, as well as HIV and AIDS

tests, and chiropody.

MANY OF ARAD’S poor and

Roma have made their way to

Govanhill in Glasgow, where they

attempt to earn a living selling

The Big Issue on the city’s streets.

STREET KIDS IN Romania are

usually a mixture of those who

have come out of orphanages –

either by running away or turning

eighteen – or are runaways from

abusive homes. There are also

kids born on the streets whose

parents are also street kids.

Continued »

“The decayrates in theeast end ofGlasgoware probablyas bad as anywherein Europe.But at leastthe kids inthe eastend haveaccess to adentist”

Andy MacKinnon

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2

Healthcare scrutiny


Another layerof regulation?

Healthcare Improvement Scotland has taken over from The Scottish Commission for the Regulation of Care (aka the Care Commission). Helen Kaneyexplains the situation at the start of 20ıı

Dentists throughoutScotland cannot haveescaped the uncertain-ties currently beingexperienced by their

English colleagues in relation to theCare Quality Commission (CQC)and the requirement to be registeredwith the CQC from ı April. Manydentists working in Scotland mayalso be wondering about the introduction of a similar requirement. The question beingasked by many dentists is: “Will webe next?”

The Scottish Commission for theRegulation of Care, otherwiseknown as the Care Commission, wasestablished in April 2002 and wasintended to regulate and improvecare services in Scotland, includingGP services and dental services.However, the Scottish Governmentannounced some time ago that, fromı April 20ıı, the functions of the CareCommission will be split and therewill be a new single body to scruti-nise health services, with anothernew separate body regulating careservices and social work.

The new health scrutiny body,Healthcare Improvement Scotland

(HIS), will bring together a varietyof functions, including the scrutinyof independent healthcare, whichwas the original remit of the CareCommission; although for a varietyof logistical reasons the CareCommission didn’t actually introduce anything that affected dentists in Scotland.

The legislation implementingthese recent changes is The PublicService Reform (Scotland) Act 20ı0,which came into force earlier thisyear. Part six of the act establishedHIS and provides powers in relationto scrutiny of NHS and independenthealthcare services.

The act provides HIS with responsibility for a variety of functions, such as a duty to provideinformation to the public about theavailability and quality of servicesprovided under the health serviceand a duty to provide the Scottishministers with advice about any matter that is relevant to the healthservice.

The Act also amends the NHS(Scotland) Act ı978 and the powersof HIS cover both NHS and independent health care services,including independent clinics where

services are provided by a medical ordental practitioner. Apparently thepractical implications of this are stillbeing considered by the ScottishGovernment.

HIS has powers to inspect and alsohas the power to investigate an incident, event or cause for concern.An inspection must be carried out byan authorised person and there isauthorisation under the act forinspection of records. The new chairof HIS took up office on 6 September20ı0 and the appointment of a chiefexecutive is apparently in hand. HISwill have 250 staff and an estimatedinitial budget of around £ı9 million.

At this stage, it is uncertain howmatters will develop with regard to

the regulation and inspection of dental services in Scotland byHIS. It should be noted thatHIS will regulate and inspect

dental services, but not thedentists who are alreadyregulated by the GDC.

The Heal thcareImprovement Scotland

(Requirements as toIndependent Health

Care Services)Reg ula t ions

“HIS has the powers to inspectand investigate an incident,event or cause forconcern”

Healthcare scrutiny


20ı ı , came into force on ı April 20ıı. These regulationsprovide some insight into futureplans for private practices inScotland. For example, there is specific provision for the prepara-tion of Patient Care Records whichmust include details of every consultation or examination and the outcome, plus details of any treatment.

Obviously dentists are well used to their obligations in relation to clinical record keepingbut these regulations are quite specific and, among other things,include the requirement to recordthe name of the healthcare profes-sional providing the treatment.

NHS dentists and their practicesin Scotland are already inspected on

a three-yearly basis as well as by NHSEducation Scotland if the practice isa training practice. This doesn’t takeinto account other bodies who canattend and inspect various aspects ofa practice if they see fit. The currentissue is whether HIS will also beinspecting NHS practices.

Where matters go from here is still not clear. The British DentalAssociation in Scotland has repliedto the Scottish Government’s consultation and has been prag-matic in suggesting that there is novalue in re-inventing the wheel and,given that NHS practices are alreadyinspected regularly by ScottishHealth Boards, it would make sensethat any new arrangements shouldonly apply to wholly private practiceswhich are not inspected in the same

way. Not to do so would leave HISwith the fairly onerous task of tryingto organise the regulation and inspection of the 900 or so Scottishpractices.

The Scottish Government’sresponse to the consultation processis due to be published in the springand it remains to be seen how thingswill evolve in practical terms. Giventhe situation in England, Scottishdental practices and dentists maywell have some valid concerns aboutyet another level of inspection andregulation. One obvious downsidefor dental practices is that there maywell be costs that could be imposedthat they may think they can well dowithout.

Hopefully, a more sensible andpragmatic approach will be takenhere than in England. Ongoing discussions suggest that furtherannouncements will be forthcoming.So, watch this space…

®Helen Kaney is a dento-legal adviser forDental Protection in Edinburgh.

“This doesn’t take into accountother bodies who can attend and inspect various aspects of a practice if they see fit”


Dr Alyson Wray has become the first female Vice President in the history of the Royal College of Physicians and Surgeons of Glasgowand now she’s determined to widen the institution’s appeal

Having broken the “glassceiling” at the RoyalCollege of Physiciansand Surgeons ofGlasgow (RCPSG) by

becoming the first female VicePresident in the institution’s 400-year history, Dr Alyson Wray is alsokeen to modernise the appeal of theCollege by making it more inclusivefor dental professionals.

Dr Wray is the new Vice-President(Dental) and Dean of the DentalFaculty of the College and now sitsat the “big table” on the CollegeCouncil and Executive Board, mak-ing strategic decisions to developprofessional post-graduate standardsfor doctors, surgeons and dentists.

Dr Wray explained: “As Vice-President, I have responsibility fordeveloping post-graduate trainingfor dentists, but I am keen to makethe College more inclusive for thewhole dental team.

“We are looking at promotingAssociate Memberships for generalpractice dentists and designingevents that will be of interest to dental care professionals.”

Although Dr Wray is relaxed in hernew surroundings at the College’sheadquarters in St Vincent Street, sheis aware that there has been a percep-tion of a “members’ club” ambienceof the place, with its wood panelledwalls, gleaming chandeliers and aus-tere portraits of past presidents.

This can be a little intimidating forsome – herself included. She readilyadmits, as a graduate dentist, to run-ning through the college doors andstraight out again when she first

entered the building to find theresults of her exams that were post-ed on the reception message board.

“I can appreciate how the College’straditional ambience could turn peo-ple off the institution and decide thatit is not for them, but we have to strikea balance between the College’s heritage and its importance in today’s world.

“The College’s heritage has givenit its longevity and credibility, but wealso need to balance this with a moredynamic and forward looking imagethat is all about promoting and supporting professional develop-ment and commitment.”

Treating children is Dr Wray’s passion – an interest she developedin her vocational training in ı983 asa dentist in a community clinic in Pollok.

She explained: “I was also involvedin school inspections and wasshocked at the level of dental diseasein the children.

“When I found out that the level ofdisease had stayed the same over thepast 20 years, despite a fall in thenumber of children on the schoolrole over the same time, I felt some-thing had to be done.”

Dr Wray spoke to Professor KenStephen, an expert in preventativedentistry and water fluoridation andone of her former lecturers at theGlasgow Dental School, and theyhelped develop a dental health cam-paign with the local health board.This resulted in two years’ work inthe East End of Glasgow and provid-ed her with the motivation to pursuea PhD, working in association with

InterviewBy Tim Power

Unilever conducting clinical trialsinto toothpaste formulations to prevent tooth decay.

After her PhD, she spent two yearsdeveloping her clinical expertise atthe Glasgow Dental Hospital beforepursuing a specialist training path tobecome a Fellow of the Royal Collegeof Physicians and Surgeons ofGlasgow. She later went on tobecome Vice Dean and Director ofthe Dental Membership ServicesBoard of the College before taking upher current role in October 20ı0.

In ı993 an exciting opportunitycame Dr Wray’s way, which enticedher to the US with brand giantProcter & Gamble to research site-specific antibiotic applicationsfor periodontal disease in Cincinnati.

She said: “This was a great job, aswe were conducting clinical trialsacross the whole of the US.

“When I took up the post I origi-nally planned to stay, but I found I wasnot able to do any clinical work in theStates because I could not get alicence to practice. I missed thisaspect of dentistry, particularly work-ing with children, so I eventuallydecided to return to Scotland.”

Back at the Glasgow Dental School,she lectured for a few years and qualified as Consultant in PaediatricDentistry working at the GlasgowDental Hospital, the Royal Hospitalfor Sick Children and GartnavelGeneral Hospital.

She currently spends three days aweek working for NHS GreaterGlasgow and Clyde and two days onpostgraduate work for NHSEducation for Scotland.

A real Wrayof sunshine

“We haveto strikea balancebetweentheCollege’sheritageand itsimportancein today’sworld”

Alyson Wray

Interview


CAREER FILE: Alyson Wray,PhD, BDS, FDS (Paed) RCPS

DR ALYSON WRAYis a Consultant in

Paediatric Dentistry in

Glasgow Dental

Hospital and is also the

Hospital Dental

Services Postgraduate

Tutor for the West of

Scotland.

She graduated from

Glasgow University

and completed her

Vocational Training in

the Community Dental

Services (CDS).

After four years in

the CDS she came

back to hospital den-

tistry and completed

her FDS in 1993.

She spent a year in

Cincinnati working on

clinical trials for

Procter & Gamble

before returning to

Glasgow as a Lecturer

in Paediatric Dentistry.

She completed her

PhD in 1995, and was

awarded her Exit

Fellowship in Paediatric

Dentistry in 1997.

She has been a

Consultant since 1999,

chaired the

Intercollegiate

Fellowship Board in

Paediatric Dentistry,

and is currently the

Dean of the Dental

Faculty and Vice

President (Dental) of

the Royal College of

Physicians & Surgeons

of Glasgow.

Stress management


of your tether?Are you at the end

From concerns over clinical errors, to the strains of increasingbureacracy and complaints handling, Robert Broadfoot looks at how to identify the reasons for and work to reduce your levels of stress

My interest in stressm a n a g e m e n tstarted as a resultof supportingrecent graduates

experiencing the problems of transition from undergraduate dental school to general dental practice. These problems wereshared with me in my role as regional adviser for vocational training in the west of Scotland.

Many young graduates were underconsiderable stress with the poten-tial risk of clinical errors, as well asrisks to their health and wellbeing.This led me to gaining the Diploma

in Stress Management in 2005. Sincethen I have been presenting courseson stress management to GDPs andVDPs. This article will draw on theexperiences of these courses.

General dental practice has thereputation of being one of the moststressful professions. The leaguetable of suicide rates by professionidentifies dentists and vets to be atthe highest risk. This article will also explore the reasons for the apparently stressful nature of dentalpractice, examine the perception thatthe job is becoming more stressful

Continued »

“The league table of suicide rates in theprofessions identifiesdentists and vets to beat the highest risk”

Stress management


and discuss how dental teams canreduce their levels of stress.

The conflict between the profitmotive implicit in running a businessand delivering the highest possiblestandard of healthcare is a majorstressor. Young dentists telephonedefence societies on a daily basis withreal concerns about the quality ofcare they are delivering due to constraints such as lack of nursingsupport, ineffective systems andabsence of teamwork.

Practice owners and dental companies tend to focus on providing modern equipment, an

extensive choice of materials andselection of high-quality laborato-ries, but often fail to recognise theimportance of team working, effective systems and good comm-unications. For those of you who arethinking: “Not more managementgobbledegook”, the analysis of complaints and referrals to theGDC clearly identifies these fail-ures as the root cause in most cases.

In addition, these areas of manage-ment in general dental practicecannot be taught in dental school.Modern dental practice is deliveredby teams and if these teams are supported and developed as teams,rather than as groups of individuals,

job satisfaction and patient satisfac-tion will improve. It is noticeable thatwell-organised, efficient practicesfind it easier to recruit associates andretain them to ensure continuity.

In relation to the perception thatthe job is becoming more stressful,as part of my presentation to VDPson the fight or flight response, I askif they have felt this response happening in the surgery. All participants report that they haveexperienced the response to varyingdegrees. The commonest reason forthis is the increasing incidence ofaggressive patients attempting tobully the dentist into treatmentsagainst their better judgement.

Continued »

IDENTIFYING YOUR STRESS: Warning signs

Everyone suffers stress to one

degree or another. But when it

rises to levels which impact on

the way you work and live your

life, then it is vitally important

that you act to reduce these

stress levels.

However, sometimes it can

be difficult to identify the

symptoms of stress and, often,

the root cause of the stress.

So, to help you look out for

the things that you can identify

if you think you’re stressed,

here’s a list of classic indicators:

• Not being able to switch off

• Needing alcohol regularly

• Losing temper quicker

than usual

• Sleep affected

• Weight loss/gain

• Headaches

• Back/neck pain

• Digestive disorders

• Longer working hours

• Less time for family

• Frequent colds

• Performance issues.

Growing levels ofbureacracy can lead

to an increase in stress levels for

many practitioners

before. Other areas discussedwere staff shortages/absences,demanding patients, pace ofchange, bad debts, etc. There wereseveral dentists on these courseswho stated that they felt fairlystressed.

My recent courses have been provided for dental teams and havebeen held over two separate days.This format has allowed the devel-opment of action plans on the firstday which can be implemented backat the practice. There is no doubt inmy mind that if the problem is tackled by the dental team ratherthan just the dentist, the chances ofsuccess are higher.

The second day can then assess thesuccess of the action plans as a groupdiscussion. Action plans ofteninclude making basic changes toappointment systems, delegatingcomplaints to the best communi-cator in the practice, improving the

system for coping with emergencypatients and developing a teamapproach to avoiding bad debts.These improved systems will reducepractice stress levels.

In relation to a dentist’s individualstress levels, the solutions haveincluded making a thorough assess-ment of patient expectations,developing listening skills, avoidingconstant time pressures and beingwilling to change.

Remember, in relation to change,if you do what you have always doneyou will get what you have always got.Changing the way you work can prevent stress developing.

®Robert Broadfoot was a general dentalpractitioner in the west of Scotland for 30years. He runs courses and workshops onstress management and also works as apart time associate dento-legal adviserwith Dental Protection.

The concept that we are the dentist and we know best may be oldfashioned, but we do have to some-times say: “No, I am not prepared tocarry out that treatment as it is notappropriate.” If the patient stormsout of the surgery saying they aregoing elsewhere, then this outcomemay not be as disastrous as youthink at the time. Assertivenesstraining – how to say no – should bean integral part of VT.

Increasing bureaucracy is theother oft-quoted reason for the jobbecoming more stressful. The list oforganisations that have becomeinvolved in some aspect of dentalpract ice grows by the day.Disclosure Scotland, Medicines andHealthcare Products RegulatoryAgency, Vulnerable GroupsScheme, Care Commission andIHAS Quality Mark Scheme are justsome of the recent additions. Itseems obvious that if the dentist isattempting to deal personally withthese agencies, as well as the onesdirectly involved in patient care,then overload and stress will occur.Delegation is the key.

I have been involved in trainingprogrammes for dental practice managers for more than 10 years andit is refreshing to see practice man-agers playing an increasinglyimportant role in teamwork in prac-tices. This is especially relevant inrelation to patient complaints, whichare on the increase and patients cannow complain directly to GDC.

We should remember that a complaint is an expression of dissatisfaction, verbal or written,about a dental service or treatment– whether justified or not. In deal-ing with a complaint, some dentistswill concentrate on the ‘whetherjustified or not’ element rather thanlistening to the patient and findingout their perception of the problem.

When a veneer becomes dislodged, the dentist’s first words tothe patient are often: “Well, you musthave been grinding your teeth.” Apractice manager on the other handwill usually establish a rapport withthe patient, ask how it happened andbegin to explore solutions to the cosmetic disaster. The teamworksolution is again appropriate.

My stress management courseswere initially aimed at dentistsand focused on the above exam-ples of why dental practiceappeared to be more stressful than

Stress management


TAKING ACTION: combat stress

If you are aware of one stressindicator in your life, then give thecause serious thought.

If, however, you are aware of several of these indicators in your life then youshould seek help and make changes tocounteract these stress levels.

There are a number of key routesdown which you can go to get the helpthat you will need to reduce the stressand put you back on the right track.

Here are some suggestions on whereto seek help:• Initially, discuss your thoughts with

your partner (if appropriate) or with atrusted friend

• Your next step could be talk to yourdoctor. It is important that you neverself-medicate

• An excellent source of advice and guidance is the Dentist SupportScheme. Their helpful staff can bereached by calling 0207 224 4671

• If your circumstances are appropriate,why not talk to your dental practiceadviser?

• Your postgraduate tutor can also bean excellent source of help.

®It must be remembered that self-medicationprevents the essential communication with asecond party who can be objective. And it canalso lead to addiction.

“It is noticeable that well-organised,efficient practices find it easier to recruitassociates and retain them”

Practice profile


Mark Fitzpatrickhad only beenout of denta lschool five yearswhen he took

over from his retiring principaland became a practice owner. Now,a little more than 20 years later, hehas relocated, renamed andbreathed new life into his success-ful Ayr practice.

M a rk f u l ly a d m i t s t h a t , even without the advent of the decontamination requirements, ithad become apparent that theyneeded to move. The practice wassituated over two first-floor tene-ment flats and, as such, thepremises didn’t meet disabilityaccess requirements. The health

board had helped out by providinga ground-floor surgery at the hos-pital for them to see disabledpatients, but it was far from anideal situation.

Before the new premises cameonto the market, Mark had beenlooking for the perfect location forthe best part of four years, to noavail. Then, in early 20ı0, he iden-tified a former bedroom furnitureshowroom that was available just

Ayr practicegets a new startAfter more than 20 years in the same location, Mark Fitzpatrick decided the time was right to move and find the perfect premises

around the corner and he startedto put his plans into action.

With the help of one of hispatients, Stephen McGhee, who isa pract is ing architect withLawrence McPherson Associates,he set about redesigning the openshowroom-style floorspace into amodern dental practice. One ofMark’s initial concerns was light-ing as, due to the nature of thebuilding, all the surgeries wouldneed to be internal.

In the old practice, all of the surgeries had windows letting innatural light and he was concernedthat for shade taking and the general wellbeing of the staff, the

Continued »

“Mark had been lookingfor the perfect locationfor the best part of fouryears, to no avail”

Practice profile


lack of direct light could be anissue. However, this wasemphasised to Stephen andthe builders Dickie andMoore, early on and becameone of the key considerations.

It took until September forthe purchase of the buildingand all the planning permis-sions to be finalised and workbegan in November. Markreceived grants from theScott ish Dental AccessInitiative in order to helpfinance the move and he wasvery happy with the experi-ence, saying that the grantswere secured and paid veryquickly.

The layout of the space wasopen plan with only a fewconcrete pillars dictating thepositions of the internalwalls. It was decided that thefront of the building, whichwas formerly the shop window, would house thereception and waiting areasso that the patients wouldbenefit from the natural lightcoming through the full-length windows. From this acentral corridor leads to theclinical areas with the foursurgeries – two on each side– branching off from thiswalkway.

The initial plans includedglass panelled doors for eachof the surgeries in order to letas much light as possible intothe room. But, during thebuild this was amended sothat now the surgeries havesolid doors with full-lengthsmoked glass panels along-side. All the surgeries featuredaylight bulbs and are laidout in a similar way to enablestaff to move between roomsif necessary without anyproblem.

Mark’s own surgery wasbrand new, with a Castellinichair bought through CEIDental and all new cabinetry.Two of the other surgerieshave chairs brought from theold practice but brand newcabinetry and other equip-ment, while the final surgery– which was only refurbishedtwo years previously – was

brought over from the previ-ous premises in its entirety.

Further down the corridor,through the ‘Staff Only’ fire-door, is the two-room LDUand staff areas includingplant room, staff room, toiletsand storage. Mark currentlyhas three associates: RobertCarter, who has been withhim for the last ı8 years; FionaStandbridge, who has beenthere for five years; and hisnewest addi t ion , HughMorton, who is currently cov-ering for Fiona’s maternityleave. Sandgate Dentistryalso features a hygienist, atechnician (still based in theold premises) and eight den-tal nurses. Mark’s wife, Liz,has taken over more of themanagement responsibilitiesin order for her husband to concentrate fully on the business of dentistry.

Despite it being a long time coming, Mark, his staff andhis patients are all delightedwith the new practice. Hesaid: “The equipment is great,the layout of the building isgreat, the staff are so muchhappier and we are so muchbusier, so it’s been a greatmove.

“Before, I would say that Iwas just a dentist in Ayr. Now I am really proud ofwhere I am.”

Continued »

“Before, I would say that I wasjust a dentist in Ayr. Now I’mreally proud of where I am”



Right place, righttime, first time

Joyce Dalgleish, Communications Manager for the 18 Weeks Referral to Treatment programme, explains theprocess involved in the development of dental specialtiesreferral pathways for orthodontics and oral surgery

Referral pathways helpensure that patients arereferred to the right professional in the rightplace at the right time,

first time. Pathways provide an excellent basis for standardisationand consistency, ensuring equity ofaccess and care.

In 2009, the 18 Weeks Referral toTreatment Time Standard DentalSpecialties Task and Finish Group, inconjunction with consultant dentalcolleagues, identified the need fornational referral pathways and protocols in two high-volume dentalspecialties – orthodontics and oralsurgery. The national pathways thatwere subsequently developed andare now published by that group, represent a clinical consensus acrossNHS Scotland. These pathways havealso been endorsed by two professional bodies – The ScottishOrthodontic Consultants’ Group andthe Scottish Oral and MaxillofacialSociety, among other stakeholders.

18 Weeks Referral to TreatmentTime (RTT) StandardFrom December 2011, 18 weeks willbecome the maximum wait for referral to treatment for non-urgentpatients in NHS Scotland. The 18Weeks RTT Standard is differentfrom previous waiting time targetsbecause it does not focus on a singlestage of treatment. Instead, it appliesto the whole patient pathway from a referral, up to the point where treatment begins. Achieving the standard requires NHS Scotland tomanage each patient’s journey in atimely and efficient manner.

Almost all patient pathways beginand end through primary and com-munity health service. 18 Weeks RTTrecognises the importance of whole-system working. The emphasis is onjoint working, seeking collaborationsbetween primary and secondaryservices and, where possible, ensur-ing diagnosis and treatment takingplace local to the patient without theneed for unnecessary hospital visits.

IN BRIEFPATIENT PATHWAYS18 Weeks RTT website:

www.18weeks.scot.nhs.uk/

how-to-achieve-and-maintain-18-

weeks/patient-pathways/

dental-specialties/

DENTAL SPECIALTIES TASKAND FINISH GROUP18 Weeks RTT website:

www.18weeks.scot.nhs.uk/how-

to-achieve-and-maintain-18-

weeks/task-and-finishgroups/

dental-specialties/

PRESENTATIONS FROMTRANSFORMING DENTALSPECIALITIES EVENTare available on the Scottish

Health Service Centre website.

Search under ‘view past events’:

www.shsceventsbookings.co.uk

Referral pathways

pathways, which would encouragemore work to be carried out in a primary or community care setting.

Patient pathwaysThe two pathways share a similar format. The first part is the patientpathway and this is separated intotwo elements – first point of contactcare and specialist care and advice.

First point of contact care is the initial contact between the patientand primary care services. Specialistcare and advice can take place in primary specialist and/or secondarycare. The pathway identifies wherereferrals can be appropriately made.

The second part is a referral guidance table, which is aimed at theprimary care practitioner. This goesinto further detail of appropriatereferrals , dependent on the assessment of the patient ’s presenting condition.

The referral management tablescan be used as a basis for discussionsfor agreement at local level. Theintention is that they are tailored toaccommodate local provision of these services, and although the fundamental principles must apply,local issues should be addressedaccordingly.

Right place, right time, first timeThe aim of the pathways is to ensurethat patients are referred to the rightprofessional in the right place at theright time, first time.

Achieving and sustaining this willrequire ongoing collaborative working between primary and secondary care dental colleagues.This collaboration will also contribute to ongoing education and professional development and to the further streamlining of pathways.

Referral pathways


Dental Specialties Taskand Finish GroupThis is one of eight task and finishgroups which exist as part of the 18Weeks RTT programme. Thesegroups bring together clinical andmanagerial specialists in each field.Its members support NHS Scotland,implement sustainable changes toimprove their services. They seekopportunities for streamlining services and patient-focusedimprovements while ensuring thatthe appropriate drivers are in placeto minimise the risk to delivery of the18 Weeks RTT standard.

Getting startedThe Scottish Government’s ServiceRedesign and TransformationProgramme’s Improvement andSupport Team hosted a series ofnational dental specialties events toengage with the dental community.Through a series of half-day ‘visioning’ events and masterclasses,they provided a forum to discuss collaborative working, deliveryexpectations, share best practice andconsider how NHS Scotland mightcollectively address bottlenecks increating a critical path for delivery.

A pathway sub-group was established for each specialty. Eachpathway group had clinical represen-tation. The orthodontic pathway hadrepresentation from primary andcommunity care general dental practitioners, a primary care specialist orthodontic practitionerand secondary care consultant orthodontists.

The oral surgery pathway had clinical representation from primarycare specialist practitioners, secondary care oral surgeons andsecondary care oral and maxillofacialsurgeons. The members of the group

started the development process byidentifying and collecting local protocols for review. Reviewing whatalready existed was an opportunity tosee where there was good practiceand avoid the duplication of existingprotocols already used within NHS boards.

Transforming Dental Specialtiesevent – March 2010 Chief Dental Officer Margie Taylorset the scene for this session, drawing on the policy documentBetter Health Bet ter Care .Considering the changes in theScottish population and associatedincreases in demand for services,Margie emphasised the need foragreed patient pathways in dentalspecialties.

David Morrant of NHS Ayrshireand Arran and Helen Devennie ofNHS Highland each described thedevelopment of pathways for ortho-dontics and oral surgery respectively.

In his presentation, David highlighted five reasons why dentalpathways are required: • to act as a statement of good

referral practice• to provide a road map for the

patient• to break a patient’s journey into

recognisable steps• to identify where there might be

avoidable delays• to identify areas for further

development of technology orstreamlining of the pathway.Mike Lyon, Deputy Director of

Del ivery for the Scott ish Government Health Directorate, presented analysis for 2007/2008,which showed that approximately40 per cent of oral surgery activityconsisted of simple extractions.Delegates were encouraged to agree

“The 18 Weeks RTT philosophy of ‘Rightplace, right time, first time’ chimes clearly with the three quality ambitionsof delivering safe, person-centred andeffective healthcare contained withinthe NHS Scotland Quality Strategy. I amdelighted that these themes have beenbrought together in order to helpimprove the patient journey in two keyclinical areas in dentistry. I would like tothank everyone who contributed to thisinnovative piece of work”

Margie Taylor, Chief Dental Officer

Clinical


a clinical auditIntra-oral bone grafting:

An assessment of the early and long-termsuccess of intra-oral bone grafting performedunder local anaesthesia prior to implant placement.An analysis of ıı consecutively performed procedures

with comparison to bench mark. By Maria Devine and Nick Malden,from the department of oral surgery, Edinburgh Dental Institute

BackgroundReplacement of missing teeth has traditionally been achieved with afixed or removable prosthesis, suchas a bridge or partial denture. An alternative and more permanentsolution is the use of dental implants,which are inserted into the alveolusand become integrated into alveolarbone (osseointegration).ı

However, the placement of dentalimplants is dependant on the pres-ence of an adequate volume of boneat the implant site. Inadequate bonevolume may be a consequence oftrauma or ridge resorption followingtooth loss.2 Alveolar bone can be augmented prior to implant place-ment with a number of techniques.

The ‘gold standard’ technique isthe use of autologous bone grafts,which are grafts taken from thepatient, at a local or distant site fromthe implant recipient site.3 Othertechniques include allografts (bonegrafts derived from cadavers),xenografts (grafts derived from animals), synthetic bone substitutes,guided bone regeneration, bone promoting proteins, ridge expansionand distraction osteogenesis.2

Patients included in this auditreceived autologous grafts fromlocal sites; mandibular symphysisor ramus. The procedure was carried out under antibiotic coverwith post-operative antibiotics continued for five days. The procedure for the symphysis graftwas carried out as follows: a buccalmucoperiosteal flap was raised and

elevated to just above the lower border of the mandible. The graftwas taken using a saline cooled bur(0.5mm diameter fissure bur) andfashioned to the dimensions of therecipient site using a bone wax stent(see Figure ı). The recipient site wasprepared by raising a buccalmucoperiosteal flap. The cortexu n d e r n e a t h t h e g ra f t wa s perforated using a saline cooled burand the graft was secured with titanium screws (see Figure 2).

Both sites were closed with vicrylrapide sutures. Implants were placedat the recipient sites circa six monthsfollowing the grafting procedure.

Aims and objectivesThe primary aim of this audit was to

assess the success of the technique ofautologous intra-oral bone grafting,performed prior to implant placement, as practised by the oralsurgery team in the Edinburgh DentalInstitute (EDI). This was achieved bycomparing the EDI results againstthose of a previously published series(Misch CM ı997)4, which was chosen as a benchmark. A patient satisfaction questionnaire was carriedout between five and seven yearspost-completion of the procedure.

The published benchmark selected was a paper by Craig Mischentitled ‘Comparison of Intra-oralDonor Sites for Onlay Grafting Priorto Implant Placement’ published in

Continued »

“Patientsincluded inthis auditreceivedautologousgrafts fromlocal sites;mandibularsymphysisor ramus”

Clinical


the International Journal of Oral andMaxillofacial Implants. This paperpresented a clinical evaluation andcomparison of bone grafting from themandibular symphysis (3ı cases) andramus (ı9 cases) prior to implantplacement . The parameters measured and used to evaluate thesuccess of the procedure in the EDIare presented in Table ı (below).

MethodologyA retrospective audit was carriedout on ıı consecutive cases of autologous bone grafting performedin the oral surgery department of theEDI between January 2003 andNovember 2005. Data on post-operative complications, graft andimplant success was collected fromthe electronic patient record andplaced on a data collection form.Those patients on long-term recallwere asked to complete a patient satisfaction questionnaire and in

January 20ı0 the questionnaire wasalso posted to those patients notresponding to recall. All patientswere given the opportunity to attend the department for a review appointment to discuss any concerns regarding their treatment.Data was collected and analysedusing Microsoft Excel.

ResultsOf the ıı original cases (nine male, twofemale) in the series, seven had autologous bone grafts harvestedfrom the mandibular symphysis andfour had grafts harvested from themandibular ramus. A total of ı8implants were placed (between oneand three per patient). Seventeenimplants were placed in the anteriormaxilla and one was placed in the posterior right mandible. All surgicalprocedures were carried out underlocal anaesthesia.

Ten of the patients had lost teethin the anterior maxilla through trauma and one had lost teeth in the

posterior right mandible throughcaries. All grafts and implants placedwere considered successful at one-year post implant placement.Eight cases from the original ıı (73 per cent) were successfully contacted to allow completion of asatisfaction questionnaire.

Early results The incidence of post-operativecomplications following bone graft-ing is presented in Fig 3 and Table 2.The cases included comparedfavourably with the benchmark data.Although the EDI group had a lowerincidence of nerve injury at the sym-physis harvest site, there was a muchhigher incidence of nerve injury atthe ramus harvest site.

However, this was transientparaesthesia and occurred in one ofthe four cases of ramus donor sites.The patient record gives no explana-tion why this should have occurredin this case. The percentage incidence of wound dehiscence at the symphysis was slightly higher inthe EDI group – however this onlyoccurred in one case.

The incidence of donor siteinfection at the symphysis waslower in the EDI group than thebenchmark. All other incidences ofpost-operative complications in theEDI group were comparable to thebenchmark.

Figure 3 and Table 2 show the comparison of post-operative complications after intra-oral bonegrafting in EDI group compared tobenchmark (Misch CM ı997). Table 2 shows comparison of EDIresults to benchmark.

Long-term resultsThe pat ient sat is fact ion

Fig 1

Access to symphysis graft donor site

Fig 2

Recipient site 11, 21, showing a ramus graft retained with two screws

Table 1: Parameters measured (adapted from Misch CM 1997)

Graft harvest site Symphysis (n=31) Ramus (n=19)

Cosmetic concern High Low

Bone quality Type 2 > 1 Type 1 > 2

Trauma Moderate Mild/Moderate

Nerve damage (transient) 10% Rare

Tooth vitality loss 29% Rare

Wound dehiscence 11% Rare

Harvest site infection 6% Rare

Graft success 100% 100%

Implant success 100% 100%

Continued » “All graftsandimplantswere successfulat one-yearpostimplantplacement”

Clinical


questionnaire was completed in theclinic or sent by post in January 20ı0.Of the ıı initial patients in the series,eight (six male, two female) werecontacted to complete the question-naire, giving a high response rate of73 per cent. When asked if they hadconfidence to chew with their dental implants, all patients (exceptone) replied yes. The one negativeresponder wrote that they were “cautious biting into hard foods”.

All respondents were happy withthe way their dental implant teethlooked, although one “had concernsfor the future”. None of the respondents thought that someoneelse would be able to tell that theteeth were implant-supported.

All would undergo the grafting andimplant procedure again.

Two of the seven respondents stated that the mandibular symphysisgrafting procedure was the worst partof the treatment and one found thelocal anaesthetic administration forimplant placement the worst part ofthe procedure. One case found the sensation of bone chips falling onto histongue, during implant placement, anunpleasant experience. The remainingrespondents did not report a negativeaspect of the treatment provided.

ConclusionsThe purpose of this audit was to compare the success of intra oralbone grafting prior to the placement

of dental implants at the EDI to a pub-lished benchmark. The early successrate of the grafting procedure was ı00 per cent with a low rate of post-operative complications comparableto that of the benchmark.

All patients who responded to thequestionnaire reported that theywere happy with the treatment theyreceived and would go through theprocess again. It is clear that thisgroup of patients was highly moti-vated as the majority had lost anteriorteeth through trauma and were keento cease wearing a partial denture.

It is concluded that the success rateof this consecutive series of intra-oralbone grafting procedures, performedprior to dental implant placement, is high and matches a selected benchmark. It is also concluded thatthe long-term satisfaction with treatment, of this motivated patientgroup, is also high.

®Maria Devine BDS (Nwc), MFDS, is aformer dental foundation trainee atthe Edinburgh Dental Institute and now works in general dental practice in East Lothian.Nick Malden BDS, FDS, is a consultant in oral surgery at the Edinburgh Dental Institute.

0 5 10 15 20 25 30

Fig 3

Incidence of post-operative complications with intra-oral bone grafting

Misch CM

EDI

Nerve injury (symphysis) 10%Nerve injury (symphysis) 0%Nerve injury (ramus) 0%

Nerve injury (ramus) 25%

Tooth vitality loss (symphysis) 29%Tooth vitality loss (symphysis) 29%

Tooth vitality loss (ramus) 0%Tooth vitality loss (ramus) )%

Wound dehiscence (ramus) 0%Wound dehiscence (ramus) 0%

Wound dehiscence (symphysis) 11%Wound dehiscence (symphysis) 14%

Donor site infection (ramus) 0%Donor site infection (ramus) 0%

Donor site infection (symphysis) 6%Donor site infection (symphysis) 0%

REFERENCES1. Branemark PI, Hanson BO,

Adell R, Breine U, Lindstrom J,Hallen O, et al. Osseointegratedimplants in the treatment of theedentulous jaw. Experiencefrom a 10-year period.Scandanavian Journal of Plasticand Reconstructive Surgery.Supplementum 1977; 16: 1-132

2. Esposito M, Grusovin MG,Worthington HV, Coulthard P.Interventions for replacing miss-ing teeth: bone augmentationtechniques for dental implanttreatment. Cochrane DatabaseSyst Rev. 2006 Jan 25;(1): CD003607.

3. Palmer P, Palmer R. Implant sur-gery to overcome anatomicaldifficulties. In: Palmer Reditor(s). A clinical guide toimplants in dentistry. London:British Dental Association,2000: 57-65

4. Misch CM. Comparison of intraoral donor sites for onlay graft-ing prior to implant placement.Int J Oral Maxillofac Implants

Table 2: Comparison of EDI results to benchmark

Numbers& gender

Misch

n=31

EDI

n=7, M=6, F=1

Misch

n=19

EDI

n=4, M=3, F=1

Graft donorcomplications

Symphysis Symphysis Ramus Ramus

Cosmeticconcern

High Low Low Low

Bone quality Type 2 > 1 Type 1 > 2 Type 1 > 2 Type 1 > 2

Trauma Moderate Moderate Mild/Moderate Mild/Moderate

Nerve injury 10% (n=3) 0% 0% 25% (n=1)

Toothvitality loss

29% (n=9) 29% (n=2) 0% 0%

Wounddehiscence

11% (3/28)* 14% (n=1) 0% 0%

Harvest siteinfection

6% (n=2) 0% 0% 0%

*Using vestibular approach

“One casefound thesensationof bonechipsfalling onto his tongue, anunpleasantexperience”

Clinical


This article describes therestoration of a fullyedentulous upper arch.The patient had beenedentulous for more

than 30 years on the upper jaw. Thelower jaw was fully-functional and,a l though some teeth were missing, was in good health.

The patient requested an appoint-ment to discuss the possibility ofhaving her upper denture replacedusing dental implants. She was finding that, with the passage of time,her upper jaw was becoming increas-ingly atrophic, her denture wasbecoming increasingly unstable andshe was concerned about its long-term prognosis.

A long period of discussionensued, during which the patientexplored various treatment options.The first option was to do nothing.However, the patient was concerned

Dr Eilert Eilertsen presents the case of a patient who had been edentulous in the maxilla for more than 30 years and the treatment he carried out to place an implant-supported upper denture

PROCEDURE

Continued »

A permanentsmile solution

Pre-operative radiograph The patient’s denture

Fig 1 Fig 2

Clinical


that in a few years she may notbe able to wear her upper denture at all because, with continued atrophy of the maxilla, there would be little orno retention.

The second option involvedp l a c i n g two o r t h re e implants – if sufficient primary stability could be found – andsubsequent retention usinglocator abutments and ring

retainers inserted in the denture. The third option wasto carry out bilateral sinusgrafts and optimally place theimplants away from theresorbed anterior maxilla, sothat a full mouth rehabilitationcould be carried out.

The patient was given information on this procedureand the invasive nature of thesurgery involved. Also dis-cussed at length were the risks,including the possibility of post-operative infection, the smallrisk of an oro-antral fistula ifhealing did not progress welland the possibility of failure ofthe graft to integrate. The possibility of facial bruising in the weeks following the procedure was also discussed.

The radiograph in Figure ıshows the preoperative maxillawith thin antral walls and muchresorbtion of the premaxilla. Aridge map of this area showed

Continued »

Continued »

“The patient wasconcernedthat in a fewyears shemay not beable to wearher denture”

PROCEDURE

Healing caps in place

Fig 4

Post-operative radiograph

Fig 3


Clinical


there was only thin fibrous tissue insufficient for implantfixtures.

Fig 2 shows the patient’s denture. It was relined with Fujisoft tissue conditioner severaltimes during the treatment.

Sinus graftingThe patient finally decided thatshe wished to progress with thetreatment programme, placingimplants in each grafted sinus.

The patient was sedatedusing Midazolam and the rightmaxillary sinus was accessedusing a lateral window utilis-ing a technique first described

by Hilt Tatum. The sinusmembrane was lifted intact, aBio-Oss collagen membranethen inserted below the raisedsinus to protect the elevatedsinus lining, and four Ankylosıımm implants were insertedthrough the floor of theantrum such tha t good p r i m a r y s t a b i l i ty wa sachieved. Supplementary allograft was then compressedaround the implants and thelateral window closed by tacking a Bio-Guide collagenmembrane over the opening.The flap was then closed. Thisprocedure was repeated

PROCEDURE

Fig 8

Abutments located using lab-fabricated jigs

Metalwork try-in bite check

Fig 7

Abutments in place on cast

Fig 6

Open tray pick-up impression

Fig 5

Continued »

Continued »

“The healing period forthe sinus grafts went well, with no complaint from the patient”

Clinical


approximately one monthlater on the opposite side.

The denture was relined witha soft lining and the patient wasdismissed for six months (Fig 3).

RestorationThe healing period for the sinusgrafts went well, with no complaint from the patient andshe returned after a period ofabout six months to begin the restorative phase of her treatment. Healing caps wereplaced and it was noted that allthe implants seemed to be wellosseointegrated.

The healing caps were left inplace for about one month,allowing the gingival margins toform above the implants (Fig 4).After about one month, an open

tray impression was taken of thefull arch using a customisedspecial tray (Fig 5). This impression was sent to the laboratory so that abutmentscould be placed and modified as necessary and a metal casting returned for try-in or modification (Figs 6-8).

The metalwork and the abutments were then returnedto the laboratory, the prescrip-tion being to make the bridge incomposite rather than ceramicso that minor repairs and adjustments could be facilitated.In this case the laboratory usedGradia, which has a high ceramic particle content but canbe bonded to with relative ease.Latera l f ixat ion screws(Bredent) were also prescribedso that if necessary the wholeprosthesis could be removed

for cleaning or for minor maintenance (Fig 9).

The prosthesis was tried inagain on return from the laboratory, however the lateralfixation screws proved quitedifficult to insert. This wasattributed to the jigs not havinglateral screws through them andso allowing for a small lateralorientation error to creep in –there being no indexation usedin this case (Figs ı0, ıı).

I was reasonably pleased withthe outcome of this case (Fig ı2).I feel I have overcome some bighurdles and achieved what

I hope will be a lifelong improvement in this patient’sdentition. On the day I was writing this up, the patient sentin her testimonial (see page 52),which provides quite a different perspective in terms of theaspects of the treatment that shefound difficult (placing the healing caps) and those that she felt she managed well (the sinus grafts).

®Dr Eilert Eilertsen, BDS UDUND1976, Eilertsen Dental Care in Inverness.

PROCEDURE

Fig 9 Fig 10

Fig 11 Fig 12

“I feel I have achieved what I hope will be a lifelong improvement”

Continued »

Finished prosthesis showing lateral fixation screw apertures Prosthesis in place with lateral fixation screws located

Facial appearance showing good lip supportAppearance from anterior showing small cleanable flange

Clinical – testimonial


Having had anupper denture(the result ofbotched dentaltreatment follow-

ing a playground injury thatdamaged my teeth) since I wasa teenager, I expected to haveone till my Maker called mehome. So, when Dr Eilertsenfirst suggested bone grafts anddental implants as the mosteffective way to deal with severeupper jaw bone loss and poten-tial problems with dentureretention, I was a bit stunnedand not a little scared.

However, he explained theprocedure – its benefits andrisks – and, after a period of duereflection, I decided to go aheadwith the treatment.

After the first session, I hadno unpleasant after-effects,other than a bit of vague aching.However, a few hours after thesecond surgery I experiencedabout 20 minutes of excruciat-ing pain that came in surges, andmade me scream out in agony.There was no evidence of bleeding or anything beingamiss and, after a telephoneconsultation with Dr Eilertsen

during which the pain subsided,we decided an emergency visitto the surgery wasn’t necessary.

Dr Eilertsen believed that thepain could have been caused bythe small blood vessels openingup rather suddenly as the anaesthetic wore off. I alsoexperienced some bruising onmy cheeks some days after bothsessions of surgery, which persisted for about two weeks.

After six months of waitingfor the grafts to ‘take’, the nextstage was fitting the healingcaps. I actually found this thehardest stage in terms of discomfort/pain and inconven-ience. The small openings in thegum were made under localanaesthetic and did not hurt, butthe bone graft had been so suc-cessful that the bone hadalready grown over the ends ofthe implants and had to beremoved before the caps couldbe fitted. This involved a lot ofpushing, scraping and generalheaving around in my mouth,and left me with aching jaws forseveral days. Also, once the localanaesthetic had worn off, theaction of the healing caps toshape the gum at the ends of theimplants caused considerablepain for several days.

I removed my denture toclean it, and could not get it backin, leaving me toothless for a fewdays. Fortunately I’m self-employed and it was theweekend, so I simply stayed inuntil I could get an appointmentwith Dr Eilertsen. By that time

the healing was well under wayand the pain gone, so he relinedthe denture, put it in for me, andI was able eat and speak moreeasily again. Social life was stillmuch curtailed though, becauseI was pretty desperate toremove the lined denture bylate afternoon.

At last the big day came, andthe prosthesis clamped on per-fectly and felt remarkablynatural, with the exception ofone tooth at the back, which DrEilertsen adjusted. I am now atthe stage of learning to adapthow I eat, speak and use my jawswith this new structure in mymouth. At present, I tend to biteboth my tongue and my cheeks,and my neck aches, I thinkbecause I am using differentmuscles to move my tongue asI learn to accommodate theprosthesis. Dr Eilertsen said thisprocess might take as long asthree months. It is tiring mak-ing this adjustment, andparticularly so when this learn-ing process is on top of ninemonths of treatment that wasalso a strain in various ways.

So, in conclusion, I amdelighted with the final out-come, at this stage certainly, andmy delight grows every day. I have every confidence that itwill soon feel as natural as anyother part of my body. Familyand friends say it looks verygood and my husband says it hasmade me look more youthfularound the mouth, so that’s anadded bonus!

The implantpatient’s perspective

“I am at the stage of learningto adapt how I eat, speak anduse my jaws with this newstructure in my mouth”

Clinical


The process of teeth whitening can be an in-depthone for patients, with much to consider. Laura Higgins gives Scottish Dental magazine a case study to illustrate the process, step-by-step

Afemale patientwas referred tothe practice, wish-ing to have herteeth whitened.

She’d had her teeth whitened acouple of years ago but felt theyhad darkened since then.

The patient was fit and wellwith no relevant medical histo-ry and a regular attendee of herown general dental practition-er. She is a non-smoker and hasmoderate alcohol intake.

We discussed the variouswhitening options with thepatient and an in-office whiten-ing treatment was chosen.

Intra oral examination

showed that the patient hadsome old, palatal resin restora-tions on the upper anterior teeththat were discoloured. Therewere generalised deposits ofsupra-gingival calculus presenton the lower anterior teeth andsome areas of recession. Thepatient was informed about thecalculus deposits and also theareas of recession and advisedto have hygiene treatment as itwould compromise the overallresult. She was also informedthat she may need to change theold resin restorations after thewhitening procedure as thewhitening gel would not affectthe resin restorations.

The patient wished to contin-ue with the in-office whiteningprocedure. The procedure wasexplained to the patient andafter-care instructions wereexplained as well. The patientwas happy to proceed, and a consent form duly signed.

Before commencing thewhitening procedure, a pre-operative shade was taken andalso a digital photograph. Thepatient’s teeth pre-operativeshade was A1.

The patient was given ZOOMprotective eyewear and madecomfortable on the dental chair.The room temperature was alsomade suitable. Patients canoften feel cold when lying on thedental chair for long periods oftime and a blanket is oftenoffered to patients in such cases.Patients are also offered a movieto watch on Eye-Trek lenses topass the time.

The ZOOM mouth retractorwas placed in the patient’smouth to retract the lips. Thisalso allows the patient to relaxand not worry about consis-tently keeping their mouth openthroughout the procedure. Italso ensures the Discus plasmalight head is accurately positioned at all times.

Rope-like cotton rolls wereplaced in the upper and lowerlabial sulcus to keep the lipsaway from the teeth. In order toprotect the gingivae from thewhitening gel and light, the buc-cal sulcus was then packed withgauze squares to provide furtherprotection. A face bib was thenplaced around the retractor, aliquid dam applied to all remain-ing gingivae and light cured.When light curing the liquiddam, the light cure was movedacross the teeth to minimiseheat transfer from the light cureto the teeth.

At this stage only the teethwere visible. The ZOOMwhitening gel was applied to allthe teeth that were visible. Theend of the light head was thenfitted into the mouth retractor.The patient was advised not tomove her head as this would dis-engage the light. The patienthad three ı5-minute whiteningsessions. After each ı5-minutesession, the whitening gel wasremoved with high volume suc-tion and further fresh whiteninggel was placed on the teeth.

The patient was comfortableduring the procedure and onlyfelt slight sensitivity during thelast session. A desensitising gel

whiteMighty After

Before

Clinical


was applied at the end of thethree sessions and left on forfive minutes. It was thenremoved with the high volumesuction. All barriers wereremoved and the patient wasallowed to rinse her mouth.

The patient was delightedwith the results and couldn’tbelieve the difference in shadefrom start to finish. The post-operative shade was 020 and apost-op photograph was taken.

The patient was given post-op care instructions again –avoiding all coloured foods anddrinks, including colouredtoothpaste and mouthwashes.The patient was given desensi-tising toothpaste to use for thenext couple of days. A courtesycall the next day was made tothe patient and the patient wasfine and couldn’t stop smiling.

At the Kalyani dental lounge,we are more than happy with

the results of the ZOOMAdvanced Power WhiteningSystem. Everything that isrequired to carry out the proce-dure comes in one simple kit. Itis easy to use and the results arefabulous. The average resultsare seven to eight shades lighterin less than an hour. All ourpatients are amazed at the endof their whitening procedure. Itis good to see patients leavingwith a happy and big, beautifulsmile that provides them withgreater confidence.

Products supplied by

Discus Dental.

®Laura Higgins qualified with adiploma in dental hygiene inDecember 2002 from Glasgow DentalSchool. She is a member of the BritishSociety of Dental Hygiene andTherapy and currently works at theKalyani Dental Lounge in Glasgow.

Fig 1

ZOOM mouth retractor in place, rollsplaced in upper and lower labial sulcus

Fig 2

Face bib fixed around retractor

Fig 3

Buccal sulcus packed withgauze squares

Fig 4

Suction to remove excess saliva

Fig 5

Application of Liquidam

Fig 6

Liquidam covering periodontal areas

Fig 7

Light curing

Fig 8

Whitening gel application

Fig 9

ZOOM light in position

Fig 10

Final smile

“The patient was delightedwith the results and couldn’tbelieve the difference inshade from start to finish.The post-op shade was 020”

Since qualifying nearly 15 yearsago I have taken a somewhatatypical professional pathway.After qualifying I took up an oralsurgery house job, however, this

was destined to be a short appointment asI had already been awarded an ActionResearch (now Action Medical Research)Training Fellowship to pursue my PhD. Thefollowing five years were spent at HarvardMedical School investigating craniofacialand skeletal development.

On completing my PhD I returned fromthe United States to take up a position atManchester University as a lecturer in bio-sciences. During this time I ran a smallresearch group and taught undergraduateand postgraduate students. While immersedin a non-clinical academic setting I began toyearn for a return to clinical practice. I tookthe plunge and so began the next chapter.

The return to clinical practice wasextremely exciting and, with the support of

the practice owner, this transition was readily made. I was surrounded by a greatteam; the principal was involved in implantdentistry and another associate was developing an interest in periodontics. Bothhad previously been on one of Paul Tipton’scourses and both had returned full of enthusiasm and new-found skills. I enrolledon the year-long restorative course.

I must say it changed the way I viewedwhat I do day-to-day. One of the coursecomponents was a day of endodontics.Gary Zolty was the endodontist and he wasso passionate about his subject that heopened my eyes to this exciting and

challenging discipline. I started to look forpostgraduate courses in endodontics and in 2006 I started the simplyendo endodontic coaching programme led byMike Horrocks.

During this time I developed a greaterunderstanding of the biology of endodon-tic disease and explored contemporaryendodontic techniques. In collaborationwith Chester University, Mike has developed a Masters Programme inEndodontology. To date I have completedthe Pos t - g raduate Dip loma in


William McLean describes his journeytowards using a dental operatingmicroscope and the benefits it hasbrought him in practice

Clinical

Change the wayyou look at things

Continued »

Clinical


Endodontology. Mike has been an inspira-tion; his commitment to endodonticpractice and teaching is unfaltering.

I had started offering in-house endodontic referral services while practis-ing in England and this continued aftermoving to Scotland. I now offer endodon-tic referral services to all. This includes allaspects of endodontics from first-time treatments to retreatment – including management of cases with complex anatomy, sclerosed canals, open apices,resorptive defects and removal of fracturedposts and separated instruments.

We are all aware of the ever-increasingprovision of implant restorations and, in theappropriate clinical situation, these are thegold standard for replacing missing teeth.It is, however, very important to recognisethat the retention of a restorable tooth isstill the ideal. In fact, with a large numberof patients receiving bisphosphonate therapy and the concomitant risk of bisphosphonate-related osteonecrosis ofthe jaw, retaining borderline restorableteeth can be considered favourableı.Treatment outcome studies clearly showthat success rates of good quality endodon-tic therapy can equate to that of implantrestorations2.

I recognise that retention of a tooth maynot be the right choice for all patients forreasons of, for example, finance or healthbut what I always discuss with patients isthat dental treatment is a journey, each steptaking a finite time, this may be five or ı5years but each appropriate interventiondelays progression to the next step with theultimate aim of retaining natural teeth foras long as possible. However, it must beremembered that even the treatments following tooth loss have a finite lifespanand this includes implants.

Having spent much of my practising lifein both NHS and private general practice, I am acutely aware of the demands that areplaced upon us. We all want to provide thebest level of care for our patients and ensurepredictability of the treatments we offer.The diagnosis and management of endondontic pathologies are among themost challenging.

Despite a myriad of treatment systemsproclaiming to be the answer to all of ourendodontic needs, canal preparation andobturation in complex cases is technicallydemanding. When asked, RupertHoppenbrouwers, Head of the DDU reported that in 2008 (the most recent yearfor which figures have been published)endodontics represented around ı9 percent of dental claims. Endodontics alsorepresents an increasing proportion of the

claims settled by the DDU on behalf ofmembers in recent years.

How do we make our endodontics as predictable as possible? Despite recentadvances in endodontics, especially inpreparation with the introduction of nick-el-titanium rotary instruments, we still falldown if we cannot see what we are doing.The importance of magnification becameapparent very early on in my endodontictraining. The dental operating microscope(DOM) offers an unrivalled view.

The DOM, in its first incarnation, wasintroduced nearly 30 years ago. However,it was not widely accepted due to ease ofuse issues. It was nearly a decade later thatGary Carr developed a DOM for endodon-tic use that overcame the limitations of theearly DOM3. I am sure as you read this youare thinking how one could justify the costof a DOM. Surprisingly, it is possible tofind used examples of great quality orentry level new models for only a fewthousand pounds more than a set of goodquality loupes. It is not a huge stretch andafter just a few days of use you will soon wonder how you worked without it.

The use of the DOM in conjunction with ultrasonics and micro-endodontic instruments has revolutionised the

provision of endodontic therapy. In general, magnification can be set between4x and 24x. Due to the use of a coaxial radiating light source, shadow-free lightingis produced. The enhanced magnificationand illumination allows the operator to:diagnose micro fractures and vertical fractures; gain access to the pulp chamberwith greater predictability; identify andremove pulp stones and negotiate obstructions due to canal calcification.

It is possible to identify and exploreanatomy that would otherwise be missed.Just a few things to consider – 93 per centof upper first molars have a MB24, 60 percent of upper second molars have a MB24,up to ı5 per cent of lower first molars havea mid-mesial5. I used to joke about using theforce to identify canals (too much StarWars as a child); with magnification theforce is strong. Obviously an understand-ing of anatomy is essential, but the operatorcan be guided by the simplest of things – afew bubbles in the irrigant solution or acolour change in tooth substance.

The transition to microscopic endo-dontics was definitely eased by years of sitting behind microscopes in my exploration of developmental systems. Ingeneral it does take time to get used to using

Continued »

Fig 1Fig 2

Higher magnification demonstrates a perforationadjacent to the disto-buccal canal orifice

Fig 3

Removal of gutta percha reveals furcation tissuethrough the perforation

Fig 4

Instrument retrieved

Use of the DOM allows identification ofcontaminated gutta percha and a separatedinstrument in the disto-buccal canal orifice

IMA

GES C

OU

RTESY

OF M

IKE H

OR

RO

CK

S OF SIM

PLY

END

O

Visualisation using the DOM in a retreatment case

Clinical


a DOM; treatment tends to be slower initially but, after time, one does becomemore efficient. I use the DOM from examination/diagnosis to completion oftreatment. I sometimes return home froma day on the DOM and when I sit down withthe family for dinner feel that everything onthe plate seems just a little small!

It is at this point I should also highlight another massive advantage of using thescope – through improved working posturethe physical impact of a day in the surgeryis much reduced.

The DOM al lows treatment of previously unsalvageable situations – perforation repair, retrieval of separatedinstruments and fractured posts. So oftenyou are amazed at what you can see andtherefore achieve. I still remember the firsttime I looked down to the apex of a straightroot canal. It is this ability that makes themanipulation of mineral trioxide aggregatein apexification so predictable.

Just today I saw a patient who had beenreferred to me for removal of a separatedinstrument. Radiographically it was evidentthat the instrument had separated in the apical third of the DB canal of an upper firstmolar. The canal system had been

obturated up to the fragment but latterly thetooth had become symptomatic. Retrievalof instruments in this portion of the canalcan be challenging.

Upon access and removal of the gutta percha it became apparent that the DBcanal was curved but I could visualise thetop of the instrument at the point ofcurvature. With patience, hand files andthe use of ultrasonics the fragment wasretrieved. This would have beenimpossible without the use of the DOM.The use of this level of magnificationallows the operator to perform the taskwith minimal collateral damage. Themore tooth preserved the better the long-term prognosis.

It is a difficult to convey in writing howmuch the DOM has changed my practisinglife. It allows complete immersion in theprocess. A few cubic millimetres of spacefills my field of view for the time I am work-ing on a tooth. With another reference toscience fiction it is my own ‘Innerspace’.

®Dr William McLean works at Care Dental Focus in Crieff. He is happy to partner with other practitioners by providing a timely referral

service for their patients. For referrals, please email [email protected] or call 01764 655745. If you would like to comment on this article you can contact William [email protected]

REFERENCES1. Kyrgidis A, Arora A, Lyroudia K,

Antoniades K. Root canal therapy for theprevention of osteonecrosis of the jaws:an evidence-based clinical update. AustEndod J. 2010 Dec;36(3):130-3.

2. Hannahan JP, Eleazer PD. Comparison of success of implants versus endodontically treated teeth. J Endod.2008 Nov;34(11):1302-5.

3. Castellucci A. Magnification in endodontics: the use of the operatingmicroscope for micro-endodontics.Endodontic Practice. 2003 Sept: 29-36.

4. Stropko JJ. Canal morphology of maxillary molars: clinical observations of canal configurations. J Endod. 1999Jun;25(6):446-50.

5. Baugh D, Wallace J. Middle mesial canalof the mandibular first molar: a casereport and literature review. J Endod.2004 Mar;30(3):185-6.

Advertising feature


Implantcoursearrives

The Centre for Advanced Dental Education(CADE) launches its first Scottish teachingexperience

The directors of CADE are del ighted toannounce that theimplant course is

coming to Scotland. Having explored several

options we are very pleased tohave the opportunity to build arelationship with Phil Frielusing his world-class new facility. We feel that this rela-tionship will create a long-termeducational experience, bring-ing together some of the UK’stop clinicians and technicianscreating a course that will beunrivalled in Scotland and will

also be one of the best in the UK.The support we have from

John Wibberley and his excel-lent team at Watersedge and theinteraction with Nobel Biocare,the world’s biggest implant company, gives us the strengthand confidence to offer the verybest in course quality, materialsand technical support.

We firmly believe that wetake our delegates on a life-longeducational programme, building relationships, provid-ing inspiration and supportfrom day one. Moreover, weaim to give tailored mentoringaccess to each delegate follow-

ing completion of the course.This sets us apart from our competitors as we feel that wecan provide a unique and valuable learning experience.

Bob McLelland

In order to establish our popular implant course inScotland, CADE are delightedto welcome Phil Friel. Phil willbe joining the CADE team tohost the implant course fromhis prestigious, state-of-the-artpractice in Glasgow.

Phil is a highly respected andprominent dental surgeon with a wealth of experience.This will be integral to the delivery of the course and we feel that this opportunity highlights our commitment todeliver high-quality dental education and training through-out the country.

Richard Brookshaw

I am del ighted to be welcoming CADE to Glasgow.Since the implant course’sinception it has proven to be oneof the most comprehensiveimplant courses available, providing interaction, practicaland theoretical training andmentoring. The facilities in theclinic will support the course

superbly and already theamount of interest in year one has been overwhelming. The course will provide teaching and supervision fromthree highly experienced individuals to build knowledgeand confidence in the delegatesallowing the incorporation ofthe exciting area of implant dentistry into their every day practice.

Phil Friel

The CADE team would like towelcome enquiries from dentists who are interested inintegrating dental implantologytreatments into their regularpract ice . CADE wil l be launching our latest implantyear course in Scotland, basedat Hyndland dental clinic,Hyndland Road, Glasgow.

This represents an excellentopportunity to attend a comprehensive year-longimplant training course north ofthe border.

Sarah Simpson, CADE business manager

I enrolled on the course to learn about implants and getsome hands-on experience onthe surgical and restorativeaspects of implant dentistry.Bob and Richard with business manager Sarah

Advertising feature


I chose CADE because the pract ica l and c l in ica l experience appeared to bemuch better than any othercourses on offer.

Richard and Bob are fantas-tic teachers. It is a very relaxedatmosphere to learn in and weare always encouraged to ask q u e s t i o n s , wh i c h a reanswered comprehensively.There is always a practicalaspect after the theory sessionand there have been a lot of opportunities to attend practical implant days to

p ut t h e t h e o r y i n to practice. The opportunity ofhands-on experience has been excellent.

The CADE team are always at the end of an iPhone(or iPad), to answer any questions or queries on patienttreatment plans or generalimplant quest ions . The course has been absolutely brilliant and we have been supplied with iPads which was the icing on the cake for all of us gadget freaks.

I really feel my dentistry

and confidence has improvedsince doing the course and the reassurance that when wecomplete the course, we will be mentored when we placeimplants in pract ice . I would definitely recommendCADE.

A current course delegate

“I don’t think we could have abetter partner than Phil. Hispractice is amazing and hisattention to detail superb.His clinical skills make hima pleasure to work with”

John Wibberley – Watersedge Ceramics

To find out moreabout the CADE implantcourse in Scotlandemail [email protected],or phone them on0845 604 6448

Financial


Budgeting forconsistencyDespite the lack of major suprises and last-minute giveaways, GeorgeOsborne’s latest Budget still has plenty to benefit the profession. Jayne Clifford delves a little deeper into the Chancellor’s speech

Just as your copy of theScottish Dental magazinewas going to print, I was sitting watching GeorgeOsborne make his second

Budget statement as Chancellor looking for new and exciting changesto flag up in this article. Gone are the days of last-minute giveaways.Instead, consistency and longer termBudget plans set out in advance have replaced sudden surprise announcements, which would leave accountants such as myself scribbling away into the night.

Of the new announcements thatthe Chancellor did make, there aresome pleasant sweeteners that maybe particularly relevant to thoseinvolved in the dental profession,whether employed or se l f-employed. The major point, whichimpacts on nearly everyone, is the£1,000 increase in the tax-free personal allowance, bringing thisup to £7,475 per annum from April

2011, with a further increase to £8,105from April 2012.

Not everyone can expect lower taxbills though – this was paid for bydecreasing the threshold at whichindividuals start paying higher-ratetax of 40 per cent from £37,400 to£35,000 from April 2011. There aresome winners and some losersas a result of the interactionof the change in thisthreshold, and theincrease in personalallowances.

Lower earners willgenerally pay less tax,but those earning over£43,875 will pay more.So there is good news

for some, and bad news for others.The 50 per cent ‘higher’ higher-

rate of tax remains in place. TheChancellor intends this to be a temporary measure, but abolition will not be forthcoming until the economic recovery looks more certain.

There is some good news for practitioners who own their ownpractice, or indeed a chain of practices. Entreprenuers Relief hasnot been withdrawn in the Budgetand has in fact been increased againfrom £5 million to £ı0 million. Thiswill benefit those dentists who havebuilt up a network of practices andthen sell these at a capital gain. The purpose of Entrepreneurs Relief is todiscount the amount of Capital GainsTax individuals pay when disposingof assets so that the effective rate oftax on the gain is 10 per cent ratherthan 18 per cent or 28 per cent.

The Chancellor announced achange to Inheritance Tax to

encourage charitable bequestsfrom April 2012. The new

measure announced willeffectively mean where atleast 10 per cent of anestate is passed on to registered charities, therate of Inheritance Taxapplied will be 36 percent rather than 40 percent. If you bequeath 10per cent of your estateto charity then yourbenef iciaries will neither gain nor lose,but charities of yourchoosing will gain.

“This will benefit thosedentists whohave built up a network ofpractices andthen sell these at a capital gain ”

Business Premises RenovationAllowance has been extended fromApril 2012 for five further years, taking it up to April 2017. This means expendi ture on renovat ing buildings within designated areas ofdeprivation that have not been used for a year before conversion/renovat ion can a t t rac t an accelerated tax write-off against the whole relevant cost of the renovation project. This helps keepyour tax bills much lower when renovation costs are incurred, ratherthan a smaller reduction in your tax liability over a longer course of time.

Areas where empty premises can attract Business PremisesRenovat ion Al lowance are designated by local authority ‘wards’.In some cases, the majority of a localauthority area is designated andtherefore eligible (such as areas inGlasgow, Dundee, Fife and bothNorth and South Lanarkshire).

There are examples of practicesrelocating into eligible buildings thathave been very successfully broughtback into use. It is clear to see that

this allowance has plenty of scope tobe beneficial to dental practitioners.

And finally, although this is not anew announcement, I would like totake this opportunity to remind youall that 2011/12 will be the last year that Annual Investment Allowancesare available at £100,000, and fromApril 2012 they will be restricted to£25,000. Annual InvestmentAllowances allow for an instantwrite-off of eligible plant andmachinery capital investment, thusaccelerating tax relief.

I recommend any practitionerswho are looking to spend substantialsums upgrading their practicesand/or equipment to considerwhether to do th is before 31 March 2012.

®Jayne Clifford is a partner at Martin Aitken & Co. Jayne can becontacted by email at [email protected] or by telephone on 0141 272 0000. To find out more about Martin Aitken & Co you can visit theirwebsite at www.maco.co.uk

Financial


“This helps keep yourtax bills much lowerwhen renovation costs are incurred”

Financial

Share issuesJon Drysdale, independent financial adviser and director of specialist dental financial planners PFM, considers how partnerships can adequately protect themselves

Many dentists working in partnership or trading asa limited company maynot have considered thefinancial impact on their

business and importantly on their financialdependents, if a partner dies or becomesseriously ill. By implementing some simple measures you could protect yourfinancial dependents, yourself and thevalue of your business.

Case study – partnership protection Three partners, goodwill and equipmentvalued at £600,000. Practice property valued at £300,000. Total value of £900,000.

One partner dies, leaving a 1⁄3 share ofthe practice and freehold to his surviving spouse, who is a non-dentist.The two surviving business partnerswould like to purchase the deceasedbusiness partner’s share of the businessand freehold from the surviving spouse.Unfortunately the two surviving business partners have substantial bankborrowings from previously financingthe purchase of their own partnershipshares. They also have significant borrowings relat ing to personal residential mortgages. Their partner-ship agreement doesn’t clearly state howthe business should be valued.

From the surviving businesspartners’ point of view:

1. Due to the recent banking crisis theystruggle to raise the £300,000 required topurchase the deceased partner’s share ata competitive rate. Their own retirementplans haven’t allowed for the costly repayment of the additional loan.

2. They can’t find a suitable successor(internal or external) who has the finan-cial means to ‘buy into’ the partnership.

3. There may be a suitable successor but a‘fair value’ cannot be agreed with thedeceased partner’s spouse as there is noprovision for this in the partnershipagreement.


Financial


4. The deceased partner’s spouse agrees tosell the newly acquired share to an external third party. As the partnershipagreement doesn’ t cover th is eventuality, the surviving business partners are powerless to stop this.

5. Due to probate there is a delay of 12 months before the surviving spouse isable to sell their inherited share. The partnership agreement does not give anyguidance on how the practice should bevalued. As a result of this valuation thesurviving spouse expects the survivingbusiness partners to pay more than theyfeel is fair value.

From the surviving spouse’s point of view:

1. The surviving spouse and surviving business partners dispute the value of thepractice and can’t agree a sale price.

2. Due to probate the sale of the newly-acquired share is delayed by 1 2 months . Unfor tunate ly the surviving spouse is reliant on this capital for income and has to makealternative arrangements.

3. The surviving business partners can’traise the finance required to purchase thedeceased’s share of the practice. The

surviving spouse has no option but toaccept a lower price or enter complexnegotiations with a third party, incurringlegal costs and further delay.

The solution1. A life policy written under trust is taken

out by each partner as follows:

Life Sum Trust assured assured Beneficiaries Partner A.........£300,000 ...........Partner B and C

Partner B ........£300,000 ...........Partner A and C

Partner C.........£300,000 ...........Partner A and B

On the death of any partner the survivingbusiness partners benefit by a tax-freeamount of £300,000. 2. A cross-option agreement is signed by all

three partners. This means if the surviving partners offer to buy thedeceased partner’s share the survivingspouse must sell. If the surviving spousewishes to sell the surviving businesspartners must buy.

3. The partnership agreement i s revised to include reference to the cross option agreement, binding all threebusiness partners to its effect.

Critical illness cover can be added to thisarrangement, ensuring that the practiceand partners are protected in the event thata partner becomes seriously ill.

These simple measures ensure that thepractice can continue to operate without thedistraction of a legal dispute, or the uncertainty and cost of raising finance.Importantly all partners will have peace ofmind that their financial dependents havebeen adequately protected.

®PFM offer independent financial adviceexclusively for dentists and dental Partnerships/Limited Companies. Visit www.pfmdental.co.ukfor more information or call 01904 670820 to review your partnership protectionrequirements. PFM also offer a practicevaluation service across Scotland, England and Wales.



Product news

Prevent needlestick injurieswith UltraSafety Plus For any dental professional dealing withneedles one of the biggestsafety risks iscontracting a blood borne virus through aneedle stickinjury.

Septodont, a global leader in dentalpharmaceuticals and the UK’s number onemanufacturer of dental anaesthetics, hasdeveloped the Ultra Safety PlusSystem toaddress this problem.

Indicated for the routine administrationof local anaesthetics, the sterile, single use,aspirating syringe system comes equippedwith a needle stickinjury prevention device.

The Ultra Safety Plus range includes 27gshort, 27g long, 30g short and 30g ultrashort needles making it a not onlysafe butversatile choice.

For more information, visitwww.septodont.co.ukor call 01622 695 520.

The Dental Directory is pleased to announcea new addition to the UnoDent range, Etch ‘n’ Bond ONE. UnoDent is the qualityvalue-for-money range exclusively availablefrom The Dental Directory.

UnoDent Etch ‘n’ Bond ONE is a lightcuring, single component, self etchingbonding agent for use in the adhesiverestorative technique. With a long lastingbond to enamel and dentine, UnoDentEtch ‘n’ Bond ONE is fluoride-releasing andhas a low pH level of 1.4. Available in 5mlbottles, the new UnoDent Etch ‘n’ BondONE is easy to apply and will ensure yousave time on your patient restorations.

For the latest prices and to order, quoteproduct code FBD 095 and call 0800 585586 or visit www.dental-directory.co.uk

Biofilm has long been an issue in terms of thecontamination of dental unit water lines causedbecause, in the majority of today’s most commonlyused treatment centres, water is delivered vianarrow bore tubing, providing an idealenvironment for the development of biofilm.

NEW Bioclear is a simple once-a-weektreatmentthat has proven efficacy against the bacteria thatmake up biofilm, inhibiting re-growth of the filmand enabling the maintenance of water quality of<200 cfu/ml. Bioclear is water-based, odourless,alcohol-free and pH neutral and is easy to use;available in 200ml one-dose bottles, enough totreat a single chair for a week.

Bioclear is just one of a range of infection controlproducts from Dentisan, whose full range isavailable from HenrySchein Minerva. Its field salesconsultants are now conducting free water tests todetermine the levels of biofilm contamination inyour input and outputwater.

Call 08700 10 20 43 or visit dentisan.co.ukfor a free water test.

Safe and effectivebiofilm removal fordental unit water lines

New UnoDentEtch ‘n’ Bond ONE!



Product news

Boost your budgetwith the DentalStock X-ChangeThe Dental StockX-Change is the UK’s firstonline marketplace exclusively for dentalprofessionals and provides dentists, dentalstudents, technicians and nurses, practicemanagers and veterinary dentists with a wayto buy and sell products without having towade through thousands of listings ofirrelevant, non-dental stock.

If you feel, like many others, thatyouwould be happier buying new materials andequipment ifyou could make some return on your old stock, then the Dental StockX-Change is the solution.

In addition to being a greatwayto financenew purchases, the Dental StockX-Changehelpsyou to help the Earth, bygiving you a wayto recycle redundantmaterialsand equipment,withouthaving to send itto one ofthe UK’smany, methane-producing landfill sites!

For more information, visitwww.dentalstockxchange.co.uk

The Dental Directory ispleased to announce newadditions to the infectioncontrol products within theUnoDent and Classicranges.

• ClassicTouch-Free Auto Dispenser (GHC030) –Holds 650ml pouches ofSurgical Hand Scrub(GHC035), PinkHand Gel (GHC040) or HandSoap (GHC045) for touch-free hand sanitisation.

• ClassicAutomaticPaperTowel Dispenser (CAU080) – sensor-controlled to prevent crosscontamination.

• UnoDentGreen Heavy Duty Nitrile Gloves (CGS200-215) – latex-free and available in small toextra large sizes.

• UnoDent Long Handled Scrubbing Brush (CGS220) – fully autoclavable and perfect forinstrument cleaning.

• ClassicAlcohol Free Hard Surface Disinfectantwith Detergent – available in 1Lbottle (GSC335),5LRefill (GSC336) and in packs of 80 wipes(CAW 660), 330mm x220mm.

For further information, please call 0800 585586 or visit www.dental-directory.co.uk

New infection preventionproducts in UnoDent and Classic ranges

NobelProcera is aneasy to use, practicalsystem by NobelBiocare, designed tohelp practitionerssave time whencreating dentalprosthetics in thedental practice.

Using the very bestin CAD/CAM technology with excellentvisuals,NobelProcera enables the dental practitioner toproduce perfect restorations. Unique, patentedscanning technology (conoscopicholography)allows for highly precise data acquisition.

The system has been designed with intuitivenavigation in mind and boasts a number of usefultools such as an anatomictooth library, automaticcut-backfunctions and automaticsetting of thefinish line.

For more information on the benefitsof NobelProcera, please call 0208 756 3300 or visit www.nobelbiocare.com

Perfectrestorations withNobelProcera


Product news

The affordable implantsolution for patientsand dentists alike

The prospect oftemporarilywearing a dentureduring the healingprocess is anotherfactor that mayinfluencetreatment uptake.However, with Nobel Biocare’sAll-on-4system, this no longer has to be a concern.

The All-on-4 system uses four implantsplaced at an angle to ensure a secure supportfor a prostheticbridge, making it ideal forpatients who wear dentures, are edentulous,or have terminal dentition due to periodontaldisease or caries.

Nobel Biocare’sAll-on-4 technique wasdeveloped to maximise the use of availablebone, allowing practitioners to fit a fixedbridge on the same day as extraction.

For further information, call Nobel Biocare on 020 875 633 00, or visit www.nobelbiocare.com

Orascoptichas developed the industry’sfirst lightsystem that does not employ belt-packs, long electrical cables or buttons.

Lightweight battery pods connect to thetemple arms of the loupe and arecompatible with 95 per cent of all TTLframeson the market. A unique mounting clipsecurely fastens the headlight to 95 per centof the TTLframes on the market.

Touch controls on the frames eliminatethe need for any buttons, knobs orswitches. Touch controls also eliminate thebacteria traps associated with traditionalbuttons, knobs orswitches.

Contact Orascoptic UK on 01733 315203 ,or email [email protected]

The Vistascan digital scanner comes with thereassurance of an optional four-year warranty;evidence of Durr Dental’s absolute confidence inthe quality and reliability of its product.

But what happens if a problem does arise?Practitioners can be further comforted in theknowledge thatsoftware problems can often bequickly diagnosed and resolved without the needfor an engineer to set foot in the practice.

Using clever technology the engineer is able togain remote access to the practitioner’s screen.The fault can then be viewed and fixed just as if theengineer was sitting in front of the keyboard andscreen in the practice.

For more information, call Durr Dental on 01536 526740.

Reassuringlysimple

Orascoptic UK launchthe Freedom ‘cordless’LED light system




It’snotveryBritish to shoutaboutone’sachievementsbutThe ElitePractice Awardsare a little different.We’re not looking justataestheticsorflamboyantmarketing campaigns,butatthose practicesthatmake areal difference to theirpatients’ lives.

So ifyou believe you go the extramile, then enter! The winnerswill beshowcased later in the yearso thatotherscan learn from theirexample.

These events are free to enterand all you need to do isvisitwww.elitepracticeawards.com oremail [email protected] to request an entry form.

Accompanying your form shouldbe a selection of photographs andany material thatyou thinkwoulddemonstrate how you and your teamconsistently exceed expectations.

Butyou’re going to have to hurryas the closing date for entries is 29April. The Elite Practice Awards aresupported byClickDental, Denplan,Oral-B, Paradigm Design and RolandDental Solution.

If you’ve gotit, go for it

Nitram Dental is making it easierfor dentists all over the world toprovide their patients with thehigheststandards of hygiene and,at the same time, run a stream-lined business operation.

The key to this win-winsituation is the relaunch of thenitramdental.com website, whichpresents detailed informationabout the company’s flagshipproduct – the DACUniversalcombination autoclave – thatcleans, lubricates and sterilises

handpieces and turbinesautomatically.

The new portal also containsplenty of technical informationand demonstration films aboutthe new DACUniversal, which ismade in Denmark.

For more information, call+45 87439060, or email [email protected]

Johnson & Johnson,stand C25 at theBDA ConferenceA warm welcome awaits DCPs anddentistsvisiting the Johnson& Johnson Listerine displaystandC25 at the BDAConference inManchester on 19-21 May.

This is a very good opportunityfor the whole dental team tolearn more about the role ofmouthwash in oral hygiene andto experience Listerine

mouthwashes which areavailable to try at the rinsingbooth on the stand.

Please visit us on Stand C25 tosee how we can supportyou in your daily practice life.

Product news

Nitram Dental launches newportal about good hygiene


Oral health

Oral-B’s all-in-one Pro-Expert toothpaste isabout to be launched in the UK, bringing aninnovative and comprehensive range of oralhealth benefits.

The innovation of Oral-B Pro-Experttoothpaste lies in the synergy of thecombination of the two main ingredients.They provide the united strengths ofstannous fluoride’s antimicrobialproperties and polyphosphate as a gentle cleaning agent to inhibit calculusand stains.

The therapeuticadvantages of Oral-BPro-Expert toothpaste are also supported byyears of research and development.

Orthodontics –the hygienechallengeIt is wellrecognised thatfixed orthodonticappliances areconsidered to bea clinical riskfactor for demineralisation of enamelbecause of plaque accumulation aroundthe bracket base.

It has been suggested by manyresearchers that if preventive measuresare followed and maintained throughoutthe course of orthodontictreatment, thenthe number of white spot lesions maybe reduced.

Consideration should be given to usingan essential oil mouthwash such asListerine Total Care. Mouthwashes have theadvantage that their antimicrobial activitycan access hard to reach areas.

For more information, please contactJohnson & Johnson on 0800 328 0750.

Determinedresearchwins the day

Can so muchreally be true ofone toothpaste?

Newly launched Oral-B Pro-Expert toothpasteprovides its extensive health benefits with the jointheritage of two-company backing (Procter &Gamble and Oral-B) with decades of steadyresearch and clinical development.

The all-in-one Oral-B Pro-Expert toothpastederives its deliverable benefits against gumproblems, plaque, caries, calculus formation,dentinal hypersensitivity, staining and bad breathfrom the evolution of its two main activeingredients; stabilised stannous fluoride andpolyphosphate.

Stannous fluoride is an effective antimicrobial,delivering plaque control and anti-caries benefitsas well as dentinal hypersensitivity relief, whilepolyphosphate protects against calculusformation, staining and bad breath.



Oral health

Oral-B, the UK’s leading oralhealthcare brand, is delighted toannounce that Dr James Russell, from Channel 4’s ‘EmbarrassingBodies’, will be representing thebrand as an ambassador. Dr JamesRussell will workalongside theexperts at Oral-B tohighlight the importanceof maintaining good oralhealth.

Dr James Russell is theyoungest of only eightdentists in thecountry to beawardedaccreditation

with the British Academy ofCosmeticDentistry (BACD) and is regularlyfeatured in the media. He is theresident dentist on Channel 4’sEmbarrassing Bodies, where heoffers expert opinion and advice onoral hygiene and health.

For more information on Oral-B’s range of power brushes,please contact Georgina Dawsonat [email protected] 0207 611 3565

or Sophie Hynes at sophie.hynes@

ketchumpleon.com0207 611 3578.

Oral-B signs TV’s dentalexpert, Dr James Russell

Philips, maker of the Sonicare toothbrush, is pleasedto unveil the PhilipsSonicare AirFloss, an easier way toclean between teeth.

Dental professionals often struggle to get patients tofloss on a regular basis and the Sonicare AirFloss, withits breakthrough microburst technology, has beenspecially designed to address this problem byincreasing ease of use while maximising interdentalplaque removal and ultimately improving gum health.During Philips consumer testing, 86 per cent ofpatients found Sonicare AirFloss easier to use thanfloss and Sonicare AirFloss removes up to 99 per centmore plaque in-between teeth than manual brushing.

“We understand the struggle that many dentalpractitioners experience in getting patients to regularlyclean between their teeth,’’ says ErikHollander, SeniorMarketing Director at PhilipsConsumer Lifestyle.

The newest innovationin interproximal cleaning

Philipslaunchesworld first BDAConference delegates will beable to witness the unveiling of aworld innovation in oral health onthe Philips stand (C16).

The new product is not atoothbrush, but it is an innovationfrom Philips’ immediate field ofcompetence in oral healthcareand bio-film management ofdental plaque.

Philips will also be announcingground-breaking developments tothe Sonicare sonictoothbrush

range which will take brushingupscale to an altogether moresophisticated level.

As well as launching not onebut two new Sonicare productsat the BDA, Philips, is alsopresenting the full suite of currentSonicare toothbrushes.


At the RECOGNITION FOR sharp

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