Dental Update-February 2023

DentalUpdate
February 2023. Volume 50. Number 2
Psychiatry within Dentistry: Why does patient mental health

matter? Part 5: Chronic orofacial pain as a consequence of
psychiatric disorders
Prosthodontics: Acrylic dentures: Fill the gap. Part 2. Indirect
retention, major connectors, review of the design and case study
Restorative Dentistry: An introduction to a modern procedure for
anterior composite restorations and black triangle closure using a
novel matrix system: Part 1
Restorative
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Inside this issue
77 Guest editorial C Burgess and D Hassall

EDITORIAL DIRECTOR The emergence of the IGen dentist and the CPD Aims, Objectives and Learning Outcomes:
FJ Trevor Burke
implications for the workforce The reader should understand the fundamentals
Emeritus Professor, University of Birmingham
Nick Cooper of the Bioclear method, and how it can be used
EXECUTIVE EDITOR
as a method for treatment of anterior direct
Fiona Creagh
85 Psychiatry within Dentistry composite restorations. It describes the process
EDITORIAL BOARD Why does patient mental health matter? Part 5:
for predictable closure of black triangles.
Avijit Banerjee chronic orofacial pain as a consequence of
Enhanced CPD DO C
Professor of Cariology and Operative Dentistry, Faculty psychiatric disorders
of Dentistry, Oral and Craniofacial Sciences,
King's College London VR Aggarwal, E Sanger, D Shiers, J Girdler and
E Elliott
127 Dental Trauma
Subir Banerji
Should small volume CBCT imaging be used for
Programme Director MSc in Aesthetic Dentistry, Faculty CPD Aims, Objectives and Learning
of Dentistry, Oral and Craniofacial Sciences, managing complex dental trauma? A case report
Outcomes: To provide the reader with a better
King's College London
understanding of links between psychiatry A Keshtgar and J Noar
Steve Bonsor
The Dental Practice, 21 Rubislaw Terrace, Aberdeen and dentistry using fictionalized case- CPD Aims, Objectives and Learning Outcomes:
Daniel Brierley based discussion. The reader should understand the benefits of
Senior Clinical Teacher and Honorary Consultant in Oral Enhanced CPD DO C using 3D imaging in managing complex dental
and Maxillofacial Pathology, Sheffield University
trauma and appreciate the importance of
Andrew Chandrapal
GDP, Bourne End Dental, Bourne End, Bucks 93 Prosthodontics reassessment in all cases of dental trauma.
Len D'Cruz Acrylic dentures: fill the gap. Part 2. Indirect Enhanced CPD DO C
GDP, Woodford Dental Care, Woodford Green, Essex retention, major connectors, review of the design
Chris Deery and case study
Professor of Paediatric Dentistry, School of Clinical 131 Dental Traumatology
W Leysson, J Heran and AD Walmsley
Dentistry, Sheffield An anaphylactic replantation: milk allergy, tooth
CPD Aims, Objectives and Learning
Ian Dunn avulsion and appropriate storage media
Specialist Periodontist, Rose Lane Dental Outcomes: To revise the design principles of
Practice, Liverpool partial acrylic dentures focusing on indirect R Potter and C Granger
Pynadath George retention, major connectors and how to review CPD Aims, Objectives and Learning Outcomes:
General dental surgeon with practice limited to implant
a design. The reader should be able to suggest appropriate
dentistry and prosthodontics, Liverpool
Enhanced CPD DO C storage mediums for an avulsed permanent
Ken Hemmings
Consultant, Eastman Dental Hospital, London tooth, if replantation at time of the injury is
Edwina Kidd 101 Endodontics not possible.
Emerita Board Member, c/o MA Dentistry Media Ltd, Healing of peri-apical lesions with calcium
Floor 6, Quadrant House, Sutton SM2 5DE Enhanced CPD DO C
hydroxide medicament following apical
Mike Lewis
Professor of Oral Medicine, School of Dentistry, enlargement: a case study
135 Oral Surgery
Cardiff University, Cardiff T Yeng
Third molars: not so NICE? Risk factors for distal
Louis Mackenzie CPD Aims, Objectives and Learning Outcomes:
GDP and Clinical Lecturer, University of Birmingham caries in mandibular second molars
To highlight that endodontic treatment for
School of Dentistry and King's College London A Treifi, J Cooper and J Yates
Tara Renton
peri-apical infections allows the patient to wait
CPD Aims, Objectives and Learning Outcomes:
Professor of Oral Surgery, King's College London for a positive healing response before deciding
Dental Institute whether to extract and replace the tooth. To highlight that the prophylactic removal or
David Ricketts Enhanced CPD DO C coronectomy of certain third molars may result in
Professor of Cariology and Conservative Dentistry,
Dundee Dental Hospital
improved long-term patient outcomes.
Jonathan Sandler 107 Endodontics Enhanced CPD DO C
Professor and Consultant Orthodontist, Chesterfield and Management of root perforation and sodium
North Derbyshire Royal Hospital
hypochlorite extrusion injury 142 Public Health
Fiona Sandom
T Hennebry and H Chana Scarlet fever and the dental team
Dental Therapist, North Wales Commmunity Dental
Service; President of the British Association of CPD Aims, Objectives and Learning R Manson
Dental Therapists Outcomes: The reader should understand the
CPD Aims, Objectives and Learning Outcomes:
Damien Walmsley dangers associated with the use of NaOCl in
Professor of Restorative Dentistry, University of To highlight the epidemiology of scarlet fever
Birmingham School of Dentistry root canal treatment and what steps to take if a
and discuss the implications for the dental team.
problem is encountered.
Enhanced CPD DO C
Enhanced CPD DO C
Cover Picture: An SEM image showing a brand-
new, unused single-side vented irrigation 147 Technique Tips
needle highlighting the internal surface of the 117 Restorative Dentistry
needle through the side vent, which is housing An introduction to a modern procedure for Dental extraction forceps: choose wisely
foreign bodies. We leave all to guess! Courtesy
anterior composite restorations and black C Fleming, L Collins, C Bell and M Gormley
of Maulee Sheth, Manubhai Patel Dental College
and Hospital, India triangle closure using a novel matrix
system: part 1 150 CPD questions
February 2023 DentalUpdate
Guest Editorial
Author’s Information
Dental Update invites submission of articles
pertinent to general dental practice. Articles
should be well-written, authoritative and fully
illustrated. Manuscripts should be prepared
following the Guidelines for Authors published in
the July 2022 issue (additional copies are available
from the Editor on request). Authors are advised to Nick Cooper
submit a synopsis before writing an article. The
opinions expressed in this publication are those
of the authors and are not necessarily those of the
editorial staff or the members of the Editorial Board.
The journal is listed in Index to Dental Literature, The Emergence of the IGen Dentist and
Current Opinion in Dentistry and other databases.
the Implications for the Workforce
Subscription Information
Full UK £175
Digital Subscription £125 A new generation arose around 1996 and is referred to as an ‘iGen’, or Z generation. This
Retired GDP £89 refers to a person born between 1995 and 2012. For the past 5 years, IGen have been
Student UK Full (2 years only) £50 completing their undergraduate dental training, and are emerging through Dental
Foundation Year (1 year only) £70 Foundation Training, Dental Core Training and progressing into general practice. In this
11 issues per year review, I outline the attributes of the IGen that could impact on the delivery of general
Single copies £24 dental services in the UK and, in the process, raise further areas for research.
Single copies non UK £35 The GDC published its report on the preparedness of UK graduates for practice in
Subscriptions cannot be refunded 2020.1 In it, they highlighted various potential problems that new graduates face on
Subscription increase from February graduation:
Full UK £184 A fear of receiving complaints and communicating and working with the wider team;
Digital Subscription £131 Supervisors rated new graduates as less competent than graduates rated themselves;
Retired GDP £93 New graduates might practice ‘defensively’ due to a lack of confidence;
Student UK Full (2 years only) £54 A culture of ’safety’;
Foundation Year (1 year only) £74 Avoiding undertaking certain treatments;
Taking extensive notes;
For all changes of address and subscription Struggle to apply their skills;
enquiries please contact: Unaccustomed to receiving criticism;
Dental Update Subscriptions Fear of failure.
Mark Allen Group. Unit A 1–5, Dinton Business Park,
The GDC also recognized that societal changes will have influenced how this generation
Catherine Ford Road, Dinton, Salisbury SP3 5HZ
of dental graduates has been raised, and how this may impact preparedness for practice.
Freephone: 0800 137201
Telephone: 01722 716997
Email: [email protected] The I Generation: IGen
Managing Director: Stuart Thompson IGens have many traits, many of which align with the GDC’s findings above. They
Editor: Fiona Creagh also possess many positive traits that need to be developed. They want stability, are
Senior Graphic Designer/Production: Lisa Dunbar conscientious, and a potential to earn a high income. Unlike the Millennials before, they
have a realistic view of their abilities and are prepared to put the time in to work their way
up a career pathway. Finally, they have a refreshing, and automatic respect for others.2
However, IGen are cautious, with a safety-first approach to life; they are not risk takers
Part of and they also have a tendency towards anxiety and depression, a lack of confidence,
and are very risk averse. Safety in all things is the preferred state. These particular
MARK ALLEN DENTISTRY MEDIA (LTD) characteristics have caused this generation to be described as the ‘Snowflake Generation’,3
Floor 6, Quadrant House, Sutton SM2 5AS which has a negative connotation, but must be viewed in the light of the particular
strengths of iGen discussed later. There have been significant societal influences that have
Telephone: 01483 304944
shaped this generation during their formative years, and these should not be ignored
Email: [email protected]
Website: www.dental-update.co.uk or underplayed.
The most transformative factor is the internet. This is the first generation in history to
Facebook: @dentalupdateuk have had instant access to the internet and, crucially, its open-ended availability 24 hours
Twitter: @dentalupdateuk
a day through their mobile phone.2 This has revolutionized every part of life, including
Instagram: @dentalupdatemag
learning, socializing, shopping and entertainment. Social interaction and landmark
life events driving relationships through the teen years are all delayed. It is likely that
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explain how we process, use & safeguard your data.
Nick Cooper, BDS, DGDP(UK), MGDSRCS Eng, FFGDP UK, PGCTL, PGCAC, GDP, Bank
DU ISSN 0305-5000 House Dental Practice, Chester.
February 2023 DentalUpdate 77

Guest Editorial
communication skills, often honed and refined in interaction with but selection criteria definitely include personal statements and ‘A’
others during adolescence, essential to general practice, are also level grades.
delayed as a result.2 The unintended consequence is that families tending towards
Social media sites emerged, with Facebook in 2006 and concerted cultivation and helicoptering of their children can
Instagram in 2010, just as the IGen were reaching their teen years. ‘manufacture’ ideal candidates to achieve access to a BDS, but who
The idea was to connect people; however, these ‘friendship’ sites perhaps, once qualified, are not ideal candidates to cope with the
became re-interpreted as comparison sites.4 The typical IGen will stress levels in practice. Indeed, they might be the most vulnerable
have spent many hours on sites such as Instagram and Facebook. to stress and anxiety. Recognizing that most graduates enter
It is this exposure that might well have inspired some of them to general practice, and prevention is better than cure, it would seem
study dentistry. A quick scan on Instagram soon demonstrates the prudent, if possible, to select for more robust personalities from the
appeal; with digital cosmetic makeovers, computerized guided outset, recognizing both desirable and undesirable characteristics.
implant placements, facial aesthetics, slick cosmetic ‘workflows’ and Dental Foundation Training, undertaken immediately following
much more. It looks like a glamorous, perfect world. With ‘Gurus’ the BDS degree, attempts to prepare the fresh graduate for
happy to provide all the courses you could ever need to become independent practice, and it is at this point that the new graduate
an expert, just like them. What a person sees of another is a filtered can start to feel the pressures of actually practising dentistry.1
view of how that individual wishes to portray themselves, which The traits of the iGen towards stress and anxiety, overlaid with
does not necessarily represent the truth, and the lens of what is intensive parenting, creates individuals who are likely to have
‘normal’ becomes distorted. Professionally, this use of sites, such even less confidence and are more likely to suffer from anxiety
as Instagram, is likely to continue; constantly comparing their and depression.2,7
work against that of others who inevitably appear ‘expert’, setting
unrealistic standards that are seen daily.
There is clear evidence that overuse of the internet, specifically IGens and general practice
social media sites, during adolescence has a deeply profound Dentistry is a stressful profession. A study conducted by Baldwin et
psychological effect on development.2 It is associated with al in 199915 showed that 30% of dentists were stressed. Collin et al
increased anxiety, as well as a tendency to depression, which in 2019 showed that this figure had risen to over 43%.16 Alarmingly,
appears to negatively affect females more than males.2 Recent 10% had considered suicide within the previous 12 months, an
figures show that 63% of the dental student intake in the UK increase from 3.5% in 2008.17 It is important to remember that
comprises women.5 these figures relate to previous generations, members of which are
There are high entry requirements to study dentistry at a generally accepted as being mentally robust.
university within the UK. This is a challenge for all potential students The BDA reported in 2017 that both community dentists
and so, preparation starts in many households from an early and GDPs are at an increased risk of occupational stress.18 The
age. This is sometimes initiated by upbringing, and the phrases top stressors were identified to be fear of litigation and fear
‘helicopter parent’ or ‘intensive parenting’ have been used within of regulation. Further evidence of this was found in a survey
recent years. These phrases describe parents who are overly involved conducted by Dental Protection in 2018,19 which revealed that nine
in their child’s development – a physical overpresence, but alongside out of 10 graduates feared being sued by a patient.
an emotional absence.2,6,7 In 2016, Hong et al8 showed that intensive A cohort of graduates that is innately more susceptible to stress,
parenting is related to maladaptive perfectionism, a constant self- anxiety and depression is particularly vulnerable. This is concerning
criticism of their own work, and in 2020, Colin et al showed that 35% when increased stress in the workplace is known to increase still
of UK dental students suffered from maladaptive perfectionism.9 further, anxiety and depression.20
In the intensely parented environment, there is often a The application of theoretical knowledge to a live, practical
culture of ‘safety-ism’. The child is viewed as fragile and lives in an and potentially novel situation takes a degree of confidence, and
environment where free play is discouraged. Instead, play is both the GDC recognizes this in their preparedness statement.1 This
organized and supervised by the parents. It is generally agreed that is particularly so when it is an irreversible procedure, such as the
this style of parental upbringing negatively impacts upon the child removal of a tooth, or if it is a procedure on a patient who has not
and increases still further both anxiety and depression tendencies, been met before. It requires the following belief:
as well as the child becoming more risk averse. 10 ‘I am confident that I know what to do, I am confident that I am
This ‘concerted cultivation’ is expensive in both time and competent to complete it, and I am confident that it will work. I am
money for the parents.11 Extrapolating from research into university confident the patient understood everything. I am confident that I
admissions, however, it is exactly this style of upbringing that is can prove I did everything correctly if challenged.’
advantageous for applicants to be able to truthfully complete a
The GDC launched its new ‘Standards for the Dental Team’ in 2013.21
personal statement, and to navigate the entry process successfully
All undergraduates will be very familiar with this core information.
when applying for a dental degree.12 These activities are likely to be
Section 7 of the Standards states the following:
more readily available to children of higher social classes and are in
alignment with findings from Bedi and Gilthorpe13 who found that 7.2.1 You must only carry out a task or a type of treatment if you
80% dental graduates within the UK are likely to be from higher are appropriately trained, competent, confident and indemnified.
socio-economic backgrounds. 7.2.2 You should only deliver treatment and care if you are
Applicants for medicine follow a similar trend, with applicants confident that you have had the necessary training and are
from higher socio-economic backgrounds being more likely to competent to do so.
apply and to be more successful when they do. Those with a lower 7.2.3 You must only work within your mental and physical
socio-economic background are less likely to apply and less likely to capabilities.
gain an offer to study medicine.14 These above phrases are all eminently suitable for the dentist
Cleland et al12 refer to the ‘criterion problem’ that faces medical who has already completed their training, but this can only be
schools in the selection of medical students: should selection at the end of a career of ‘lifelong learning’. Even an experienced
criteria target likely performance at undergraduate level, or attempt dentist attempting a procedure for the first time is unlikely to be
to predict performance as a doctor? It appears that neither are both competent and confident. To the inexperienced learner who
particularly accurate. The same is likely to apply to dental students, is neither confident nor competent, and who might be suffering
78 DentalUpdate February 2023
Guest Editorial
from stress and possible anxiety, these requirements might become The training that is required beyond Foundation Training
potential barriers to further development and learning, and only depends on the individual, but recognizing their ‘late development’,
add to their stresses. perhaps the structure of Foundation Training itself needs to be
The practice of dentistry requires a very broad skill set that reviewed. An extended period of training accompanied with
includes, but is not limited to, communication, confidence, manual salaried employment and vicarious liability would likely be seen by
dexterity and reflection. For any aspiring dentist of any generation, IGen as desirable.
these are all skills that need to be practised and refined in a safe
environment. This is particularly pertinent for the IGen dentist IGen drivers for workplace selection
where safety comes first; both for the patient and their registration. IGen will be likely to want extended training to be available within
Once foundation training is completed, general practice with the practice and at least initially with continuous support. Feedback
its overarching threat of litigation and regulation, and the added needs to be regular and in small encouraging portions, an annual
pressures of a target-driven NHS contract, is not the easiest place to review is too far off; it needs to be frequent.
refine skills, and can drive the individual into ‘defensive dentistry’.1 The IGen is likely to expect their education and development
The stressed, inexperienced and unsupported young dentist programme to be personalized according to their developing
might lack the confidence to repeatedly practise relatively basic skillset within their practice, and the practice needs to take an
procedures. Possibly accompanied by flawed, negative reflective active role in their development. The organization that offers in
processes, this might lead them to a conclusion that they are house mentoring from trained personnel and recognizes formal
not ready to move forwards with more complicated tasks and, development of their younger colleagues is likely to attract IGen.
ultimately, that dentistry is not the career choice for them. It is important to recognize that currently a PDP for an associate
There appears to be a perfect storm developing: a cohort of is mainly ‘self-generated’ and as Kahneman states:26 ‘we can be blind
individuals with a predisposition for anxiety and depression, often to the obvious and blind to our blindness’.
selected from homes with an environment that concentrates these More than ever, the struggling associate needs professional
tendencies, who are entering a stressful profession that offers help in identifying their learning needs, and more than ever, they
little or no support. Throughout, they have been provided with an are likely to grasp the offer.
education system that was designed for baby boomers. We might be moving to a world of HR reviewing associates’
However, there are signs of hope. IGen are also hard working, development, and tailoring courses and relevant training
reliable, prepared to ‘put the time in’ when learning skills, open needs. These would not be limited to clinical issues and include
minded, pragmatic and have an automatic respect for others. These teamworking, stress management, efficiency, communication skills
are excellent traits that bode well for patients and the dental team, and relationships with both patients and colleagues.
but before we can develop these desirable characteristics, we need
to reduce their stress levels or they will leave the profession.1 We
also need to recognize that the new IGens cannot change and be General practice
shoe-horned into the existing system. The profession must review A central trait of the IGen is recognition that they are individuals,
not only how we select, educate and train young dentists, but also and before an IGen can accept an interview for a job in practice,
review the system in which they work. they need to have seen an advert that appeals to them. Remember
you have 8 seconds to get their interest.27 Key words such as
‘tailored’ ‘bespoke’ or ‘personalized’ packages will be desirable.
Foundation dentistry IGens will be looking for a role that caters to their particular
Compulsory foundation training in dentistry for inclusion onto an needs, so an interviewer needs to shift emphasis from how
NHS list (Vocational Training) began in 1993.23 The majority of the wonderful the organization is to exploration of what the applicant
graduates at that time had been born between 1964 and 1980, the wants or needs in the role and then provide it. This will no doubt
‘X generation’, and whose attributes are quite different from the include further tailored development and mentoring and might
current cohort. They are well known for their ability to take negative form part of their associate agreement.
feedback, are mentally robust and are strong team players. Useful In business, the organizations that can demonstrate that their
traits for a dentist in general practice. values align with those of the IGen will succeed, whether they
The training involved 30 study days of lectures, a weekly are large corporates, small practices, employers, labs or even
tutorial, and close supervision from a ‘trainer’. Both teaching and material suppliers.
learning styles were a good fit for the X generation. In their work, the IGen will likely take a cautious approach,
Foundation Training is available to all UK graduates referring to senior practitioners or hospital whenever there are
automatically upon graduation. It is there to prepare them for NHS higher risks and constantly require reassurance of their decisions
practice. There is an implicit assumption that all graduates can be from colleagues. This would be borne out with increased referral
trained to work in general NHS practice, and from the number of rates to secondary care. The IGen employer might carry out internal
places available that all graduates will want to complete it. monitoring of referral patterns and provide relevant training
However, applications to start Foundation training from UK and guidance.
graduates are at an all-time low, with up to 40 graduates failing to Any position that offers a safe supportive environment,
apply for Foundation Training in 2022.24 It seems that either they especially one that has experienced practitioners willing to share
are so disillusioned with their undergraduate experience they do knowledge and help, will be preferred. Long-term mentoring is
not want to practice dentistry or that they want to be dentists but likely to be desirable.
have no intention of ever working within the NHS. Hitherto this was In practice, they need to be treated as individuals, with their
never a possibility as there were few openings in private practice individual career progression path in that particular practice
for a young dentist. However, with so many practices now pulling mapped out. Using examples of patients seen at the practice by
out of the NHS,25 it is likely there are empty surgeries and potential other colleagues, the IGen needs to be gently led by example,
employers, keen to provide desirable packages for graduates. repeatedly visiting the edge of their particular ‘skills envelope’
At a stroke, for the young IGen dentist, many of their concerns knowing that they are fully supported if things don’t not go as
about general practice are gone; namely, compliance with NHS planned. The practice that can offer protracted, trained mentoring
regulations and system.19 and support will attract the IGen.
Guest Editorial
We are now seeing an unprecedented rise in stress in the face-to-face social meetings with highly polished social skills. It is
profession. This might be attributable to the NHS contract, possible that they will be relatively inexperienced in this respect.
the susceptibility of the graduates or both. Early detection at Consent is a fundamental of dental practice, and the quick
undergraduate level and stress management training might help, to and fro of information that it involves is central to the process,
but prevention is better than cure. Perhaps we need to identify again skills could be underdeveloped. All experienced dentists
susceptibility to stress at selection? are aware of the subtleties of identifying a potentially disgruntled
Interestingly, there is currently no mapping of who qualified patient, poorly developed social skills might miss the social queues
where, by what route, and whether they suffered stress later in at early stages, allowing complaints to develop. Again, all areas for
their career. personalized development that need to be identified by someone
for their PDP.
The structure of general dental practice There is no substitute for maturing, the IGens need to develop
Associates work for independent business or companies that are at their own pace in a safe environment, and this environment
susceptible to any changes in the NHS contracts that they hold. needs to be in their workplace. An associate position in a practice
Their incomes are generally pegged to the number of Units of with disinterested, jaded colleagues all concentrating on simply
Dental Activity they can perform and supplemented by any private hitting targets is not the environment an IGen wants to work in.
income generated in addition. Their incomes vary from month to The IGen’s lack of maturity and worldly experience could leave
month, and they are responsible for their tax affairs. them vulnerable in their early years
The exception to this is at the start of a GDPs career they are
employed as foundation dentists and some progress into Dental Discussion
Core Training in secondary care where they remain employees of an
IGen represent a step change in generational progression. Unlike
NHS Trust. However, on entering practice they are likely to become
the millennials that preceded them they will not be able to easily
self-employed.
adapt to a pre-existing system. It is for the system to change
Fundamentally the IGen probably do not want to be self-
for them.
employed, especially in their ‘formative’ years when they feel
The IGen’s innate requirements for safety in all things,
exposed to the risk of litigation while they are still developing
especially if in an ‘uncaring’ environment could impact on their
their skills and maturing. The British Dental Association regard self-
employment of associates as the default position of dentists, but confidence to try new procedures. However, it must be recognized
noted in a recent survey that there was ‘a noticeable level of interest that although they will work hard, and ‘put the time in’ if they
in the benefits of employment among younger dentists.’28 feel their safety-first approach to themselves and patients is
This, coupled with their lack of confidence, the need for threatened, it could drive them from the profession before they
further ‘safe’ training along with the perceived shield of vicarious have even ‘learned’ it.
liability offered by ‘employment’, are likely to be drivers to seek An associate position in general practice has hitherto been
‘employed status’. seen as a self-employed role with the individual responsible for
If some of the above pressures of general practice were removed, their own professional development and indemnity. Their mental
and a welfare and development package offered, there would seem health and personal development is often not even considered by
no reason why they would not be prepared to work at similar rates the organization they are working for.
of pay to DCT as a salary with annual reviews and bonuses. A paradigm shift from each self employed individual having
to do everything for themselves might be replaced with practice
or company based package of CPD, indemnity, PAYE, mentoring,
Teamwork pastoral support and teamworking and surgery efficiency.
The modern dental practice is a team environment, and this is likely The introduction of the ‘employed status associate’
to grow further with the increase in DCP employment as defined in with bonuses for higher performance would carry with it a
‘Advancing dentistry.’29 responsibility for the mental welfare of the employee.
It is interesting that the instantly respectful nature for the The GDC recognized that:
individuality of others, is likely to make IGen more open minded
to work with DCPs and in expanded teams, but they might initially ‘Wellbeing is not just an individual responsibility; it is also an
lack experience of working in groups. organizational responsibility.’31
Training in this respect is normal practice in other industries, General practice might have to change to a point where
each employee is expected to work efficiently within the team, the organization provides not only a salaried income, but a
conforming to company protocols and values. Dentists, however, developmental pathway tailored to the individual with relevant
are different: once the surgery door is closed they often work to training either in house or external, with staging points, reviews
their own set of rules, often learned the hard way and possibly the and constructive feedback of development, possibly delivered
wrong way. Anyone who ‘employs’ dentists must ask themselves by a professional HR department. Failure to do so could risk
if their dentists are working efficiently with their nurses, and associate retention.
have they been trained to do so or is it just an assumed skill? Naturally, this, along with extra time to record notes and gain
The profession might have something to learn from ‘Lean good consent will soak up precious resources within the practice.
Service Provision’.30 In light of the surge in mental health issues in health care workers,
these aspects should be part of the metrics for the practice
Extended training? as an unhealthy workforce cannot provide a healthy service
It is well established that IGens develop at a slower rate to previous for patients.17,31
generations, probably by as much as 2 years.2 This is a significant In recent years there has been an increase in students attaining
difference from previous generations and is likely to be exposed access to the undergraduate BDS course without the prerequisite
when under pressure in practice. ‘A’ levels. Further research is required to establish whether
General practice requires a diverse skillset for the aspiring graduates who have taken a more self directed approach to their
dentist. Not least is the ability to strike rapport with a stranger in attainment of a BDS fare differently from those who progress
just a few moments. The young IGen lifestyle is generally not one of through the more traditional channel.
Guest Editorial
Conclusion research/research-and-insight-archive/identifying-best-practice-in-the-
With customized training, management change, a policy of selection-of-medical-students (accessed January 2023).
nurturing the individual, and recognition that the young dentist is 13. Bedi R, Gilthorpe MS. Social background of minority ethnic applicants
unaware of what they don’t know, the innate attributes of the IGen to medicine and dentistry. Br Dent J 2000; 189: 152–154. https://doi.
will enable them to become successful and happy dentists able to org/10.1038/sj.bdj.4800709
provide a high level of care for their patients. 14. Steven K, Dowell J, Jackson C, Guthrie B. Fair access to medicine?
If the profession, the NHS and HEE are complacent in their Retrospective analysis of UK medical schools application data 2009-
approach, there could be a mental health crisis among young
2012 using three measures of socioeconomic status. BMC Med Educ
dentists, an exodus from the NHS and a subsequent fall in service
2016; 16: 11. https://doi.org/10.1186/s12909-016-0536-1
provision for patients. The failure of up to 40 UK graduates to take
15. Baldwin PJ, Dodd M, Rennie JS. Young dentists – work, wealth, health
up foundation Training places is a warning.24
There is a paradigm shift away from the attitudes of a Boomer and happiness. Br Dent J 1999; 186: 30–36. https://doi.org/10.1038/
graduate. The IGen graduate will not tolerate disturbance of their sj.bdj.4800010
work–life balance and will unhesitatingly ‘move on’ from providing 16. Collin V, Toon M, O’Selmo E et al. A survey of stress, burnout and
services that they find stressful. This will include the avoidance of well-being in UK dentists. Br Dent J 2019; 226: 40–49. https://doi.
certain treatments, progression into complementary skills such org/10.1038/sj.bdj.2019.6
as facial aesthetics, shorter working hours or even leaving the 17. Kay EJ, Lowe JC. A survey of stress levels, self-perceived health and
professional altogether. health-related behaviours of UK dental practitioners in 2005. Br Dent J
It seems that the IGen have surveyed the landscape of Boomer- 2008; 204: E19. https://doi.org/10.1038/sj.bdj.2008.490
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with their feet. UK dentists: a qualitative study. 2017. Available at: https://bda.org/
The sarcastic phrase used by IGen in the reluctant acceptance of about-the-bda/campaigns/Documents/The%20Mental%20Health%20
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of date, being replaced with ‘no way Boomer’. 2023).
19. Dental Protection. Dental Protection survey reveals 9 in 10 dentists
References
fear being sued by patients. 2018. Available at: www.dentalprotection.
1. General Dental Council. Preparedness for Practice of UK Graduates
org/uk/articles/dental-protection-survey-reveals-9-in-10-dentists-fear-
2020. Available at: https://www.gdc-uk.org/about-us/what-we-do/
being-sued-by-patients (accessed January 2023).
research/our-research-library/detail/report/preparedness-for-practice-
20. Melchior M, Caspi A, Milne BJ et al. Work stress precipitates depression
of-uk-graduates-2020 (accessed January 2023).
and anxiety in young, working women and men. Psychol Med 2007; 37:
2. Twenge JM. iGen: Why Today’s Super-Connected Kids are Growing Up Less
1119–1129. https://doi.org/10.1017/S0033291707000414
Rebellious, more Tolerant, Less Happy—and Completely Unprepared for
21. General Dental Council. Standards for the dental team. 2013. Available
Adulthood. New York: Atria Books, 2017; 6.
at: www.gdc-uk.org/standards-guidance/standards-and-guidance/
3. Nicholson R. ‘Poor little snowflake’ – the defining insult of 2016.
standards-for-the-dental-team (accessed January 2023).
Available at: www.theguardian.com/science/2016/nov/28/snowflake-
22. Patel K. Young dentists: breaking the silence. Br Dent J 2018; 224: 767–
insult-disdain-young-people (accessed January 2023).
768. https://doi.org/10.1038/sj.bdj.2018.359
4. Midgley C, Thai S, Lockwood P et al. When every day is a high school
reunion: Social media comparisons and self-esteem. J Pers Soc Psychol 23. The Dental Vocational Training Authority (Establishment and
2021; 121: 285–307. https://doi.org/10.1037/pspi0000336 Constitution) and Appeal Body (Specification) Order 1993. Available
5. Booth AJ, Hurry KJ, Abela S. The current dental school applicant: an at: www.legislation.gov.uk/uksi/1993/2211/article/1/made (accessed
overview of the admission process for UK dental schools and the February 2023).
sociodemographic status of applicants. Br Dent J 2022; 232: 172–176. 24. Bissett G. ‘Significant decline’ in dental grads taking up Foundation
https://doi.org/10.1038/s41415-022-3927-1 Training. 2022. Available at: https://dentistry.co.uk/2022/07/28/
6. Turner LA, Faulk RD, Garner T. Helicopter parenting, authenticity, and significant-decline-in-number-of-dental-graduates-taking-up-
depressive symptoms: a mediation model. J Genet Psychol 2020; 181: foundation-training/ (accessed February 2023).
500–505. https://doi.org/10.1080/00221325.2020.1775170 25. Hoppenbrouwers R. Leaving NHS practice 2017. Available at: https://
7. Luebbe AM, Mancini KJ, Kiel EJ et al. Dimensionality of helicopter ddujournal.theddu.com/issue-archive/winter-2017/leaving-nhs-
parenting and relations to emotional, decision-making, and academic practice (accessed February 2023).
functioning in emerging adults. Assessment 2018; 25: 841–857. https:// 26. Kahneman D. Thinking, Fast and Slow. New York: Farrar, Straus and
doi.org/10.1177/1073191116665907 Giroux, 2013.
8. Hong RY, Lee SSM, Chng RY et al. Developmental trajectories of 27. Bradbury NA. Attention span during lectures: 8 seconds, 10 minutes,
maladaptive perfectionism in middle childhood. J Pers 2017; 85: 409– or more? Adv Physiol Educ 2016; 40: 509–513. https://doi.org/10.1152/
422. https://doi.org/10.1111/jopy.12249 advan.00109.2016
9. Collin V, O’Selmo E, Whitehead P. Stress, psychological distress, burnout 28. British Dental Association. Associates’ self-employment status .
and perfectionism in UK dental students. Br Dent J 2020; 229: 605–614. 2021. Available at: https://bda.org/advice/Pages/Associates-self-
https://doi.org/10.1038/s41415-020-2281-4 employment-status.aspx (accessed February 2023).
10. Haidt J, Lukianoff G. The Coddling of the American Mind: How Good 29. HEE. Advancing dental care. 2021. Available at: www.hee.nhs.uk/our-
Intentions and Bad Ideas are Setting up a Generation for Failure. Harlow: work/advancing-dental-care (accessed February 2023).
Penguin Books, 2019. 30. Fillingham D. Lean Healthcare: Improving the Patient’s Experience.
11. Lareau A. Unequal Childhoods: Class, Race, and Family Life. Berkeley: Chichester: Kingsham Press; 2008.
University of California Press, 2003. 31. Mullan R. A welcome mental health and wellbeing review by the
12. Cleland J, Dowell J, McLachlan J, Nicholson S, Patterson F. Identifying GDC. 2021. Available at: www.gdc-uk.org/news-blogs/blog/detail/
best practice in the selection of medical students. 2012. Available at: blogs/2021/06/17/a-welcome-mental-health-and-wellbeing-review-by-
https://www.gmc-uk.org/about/what-we-do-and-why/data-and- the-gdc (accessed February 2023).
Don’t forget to renew your
patient’s Duraphat prescription
Winning the
fight against
caries
Effective prevention for patients at increased caries risk*,^

High fluoride toothpastes are clinically proven to be more effective than a regular toothpaste
in preventing dental caries:1-5
• 2800 ppm Fluoride Toothpaste provides

20% reduction in DMFS increment2,#
0.619% Sodium Fluoride
• 5000 ppm Fluoride Toothpaste prevents
cavities by arresting and reversing primary
root and early fissure caries lesions1,3-5 1.1% Sodium Fluoride
Be confident prescribing Colgate® Duraphat®, the brand your patients know and trust**
* Colgate® Duraphat® 5000 ppm high fluoride toothpaste for patients ≥ 16 years at increased caries risk. ^ Colgate® Duraphat® 2800 ppm high fluoride toothpaste for patients ≥ 10 years at increased
caries risk. ** YouGov Omnibus for Colgate® UK, data on file June 2015. Claim applies only to the Colgate® brand. # vs a regular fluoride toothpaste with 1100 ppm fluoride.
References: 1. Baysan A et al. Caries Res 2001;35:41-46. 2. Biesbrock AR et al. Community Dent Oral Epidemiol 2001;29:382-389. 3. Ekstrand et al. Caries Res 2013;47:391–8. 4. Schirrmeister JF
et al. Am J Dent 2007;20. 212-216. 5. Ekstrand et al. Gerod 2008; 25:67-75.
Colgate Duraphat® 2800 ppm Fluoride Toothpaste - Name of the medicinal product: Duraphat® 2800 ppm Fluoride Toothpaste. Active ingredient: Sodium Fluoride 0.619 %w/w (2800 ppm F-). Indications: For the prevention and treatment
of dental caries (coronal and root) in adults and children 10 years of age and over. Dosage and administration: Use daily instead of normal toothpaste. Apply a 1cm line of paste across the head of a toothbrush and brush the teeth thoroughly
for one minute morning and evening. Spit out after use; for best results do not drink or rinse for 30 minutes. Contraindications: Individuals with known sensitivities should consult their dentist before using. Not to be used in children
under 10 years old. Special warnings and precautions for use: Not to be swallowed. Undesirable effects: When used as recommended there are no side effects. Legal classification: POM. Marketing authorisation number: PL00049/0039.
Marketing authorisation holder: Colgate-Palmolive (U.K.) Ltd. Guildford Business Park, Midleton Road, Guildford, Surrey, GU2 8JZ. Recommended retail price: £5.10 (75ml tube). Date of revision of text: January 2015.
Colgate® Duraphat® 5000 ppm Fluoride Toothpaste - Name of the medicinal product: Duraphat® 5000 ppm Fluoride Toothpaste. Active ingredient: Sodium Fluoride 1.1%w/w (5000ppm F-). 1g of toothpaste contains 5mg fluoride (as sodium
fluoride), corresponding to 5000ppm fluoride. Indications: For the prevention of dental caries in adolescents and adults 16 years of age and over, particularly amongst patients at risk from multiple caries (coronal and/or root caries). Dosage
and administration: Brush carefully on a daily basis applying a 2cm ribbon onto the toothbrush for each brushing. 3 times daily, after each meal. Contraindications: This medicinal product must not be used in cases of hypersensitivity to the
active substance or to any of the excipients. Special warnings and precautions for use: An increased number of potential fluoride sources may lead to fluorosis. Before using fluoride medicines such as Duraphat, an assessment of overall fluoride
intake (i.e. drinking water, fluoridated salt, other fluoride medicines - tablets, drops, gum or toothpaste) should be done. Fluoride tablets, drops, chewing gum, gels or varnishes and fluoridated water or salt should be avoided during use of
Duraphat Toothpaste. When carrying out overall calculations of the recommended fluoride ion intake, which is 0.05mg/kg per day from all sources, not exceeding 1mg per day, allowance must be made for possible ingestion of toothpaste
(each tube of Duraphat 500mg/100g Toothpaste contains 255mg of fluoride ions). This product contains Sodium Benzoate. Sodium Benzoate is a mild irritant to the skin, eyes and mucous membrane. Undesirable effects: Gastrointestinal
disorders: Frequency not known (cannot be estimated from the available data): Burning oral sensation. Immune system disorders: Rare (≥1/10,000 to <1/1,000): Hypersensitivity reactions. Legal classification: POM. Marketing authorisation
number: PL00049/0050. Marketing authorisation holder: Colgate-Palmolive (U.K.) Ltd. Guildford Business Park, Midleton Road, Guildford, Surrey, GU2 8JZ. Recommended retail price: £7.99 (51g tube). Date of revision of text: February 2015.
Diabetes and dental caries: How to support your patients
with diabetes
More people than ever have diabetes Assessing your diabetic patients’ caries risk
Diabetes mellitus is considered the most common Holistic patient care is based on early detection
health issue affecting almost 1 in 11 adults worldwide.1 of dental diseases, therefore assessment of your
According to Diabetes UK the number of people patients’ caries risk should focus on maintaining
diagnosed with diabetes in the UK has more than health and preserving tooth structure.6 You may
doubled in the last twenty years with over 3.9 million consider following the 4D principles from Caries Care
people living with a diagnosis of diabetes. In addition International:7
it is predicted that almost a million people are living
with undiagnosed type 2 diabetes.2 1 2
DETERMINE DETECT
Diabetes mellitus is a chronic metabolic
disorder Determine your patient’s Detect and assess caries
Diabetes is a condition where the body either fails to caries risk by combining staging and activity
produce insulin (Type 1 diabetes) or the insulin that is the patient’s general risk
produced is no longer as effective (Type 2 diabetes).3 factors and intraoral
risk factors
Diabetes is classified into two types:

3 4
DECIDE DO
• Insulin dependent: An autoimmune
Type 1 disease (insulin deficiency)
diabetes Decide your patient’s Do a personal caries risk
• 10% of all diabetes cases
caries risk status/ management plan by
likelihood for new caries partnering up with your
lesions to develop or patient
current to progress
• Non-insulin dependent
Type 2 (relative lack of insulin)
diabetes
• 90% of all diabetes cases Supporting your diabetic patients
Caries risk management for diabetic patients should
focus on 3 areas:
Diabetic patients are known to be at Oral hygiene

higher risk for dental caries 4
• Instruction in extra thorough plaque removal -
There are several factors which increase risk of
due to risk of cariogenic plaque
dental caries:5
• Depending on the fluoride level prescribed,
advise brush 2 or 3 times daily8
Diet advice
High HbA1c value

• Reduce sugar intake • Reduce snacking
Reduced Reduced saliva
leading to a change saliva pH • Use sugar free chewing gum
in oral biofilm secretion
Fluoride
• Increase fluoride availability in mouth

• Apply fluoride varnish† 2 or more times per year8
• Consider prescribing 2,800 or 5,000 ppm
Frequent Diet rich in refined
snacking carbohydrates fluoride toothpaste8
References: 1. “Global prevalence of diabetes: estimates for the year 2000 and projections for 2030.” Diabetes care vol. 27,5 (2004): 1047-53. doi:10.2337/
diacare.27.5.1047. 2. https://www.diabetes.org.uk/professionals/position-statements-reports/statistics. 3. Wray, L. The diabetic patient and dental treatment:
an update. Br Dent J 211, 209–215 (2011). https://doi.org/10.1038/sj.bdj.2011.724. 4. Lamster, Ira B et al. “The relationship between oral health and diabetes
mellitus.” Journal of the American Dental Association (1939) vol. 139 Suppl (2008): 19S-24S. doi:10.14219/jada.archive.2008.0363. 5. Almusawi MA, Gosadi I,
Abidia R, Almasawi M, Khan HA. Potential risk factors for dental caries in type 2 diabetic patients. Int J Dent Hyg. (2018) 16(4):467–75. doi: 10.1111/idh.12346. 6.
Pitts NB, Ekstrand KR: International Caries Detection and Assessment System (ICDAS) 7. International Caries Classification and Management System (ICCMS)-
methods for staging of the caries process and enabling dentists to manage caries. Community Dent Oral Epidemiol 2013, 41:e41-e52 8. Delivering better oral
health – An evidence based toolkit for prevention’, Version 4, Office for Health Improvement and Disparities, Department of Health and Social Care, NHS
England, and NHS Improvement, 2021.
Psychiatry within Dentistry
Enhanced CPD DO C
Vishal R Aggarwal
Emily Sanger, David Shiers, Jenny Girdler and Emma Elliott
Why does Patient Mental Health

Matter? Part 5: Chronic Orofacial
Pain as a Consequence of
Psychiatric Disorders
Abstract: This is the final article in a series looking at psychiatric presentations in dentistry. Recently, the oral health of people with severe
mental illness (SMI) has gained significant media attention after the Office of the Chief Dental Officer for England published a statement
on the importance of prioritizing oral health for people with SMI. Furthermore, a consensus statement has set out a 5-year plan to improve
oral health in people with SMI. In Part 4, we discussed how a psychiatric disorder can result in dental pathology by contributing to risk
factors associated with tooth surface loss. This article explores chronic orofacial pain symptoms and their link with psychiatry, considering
the role of the primary dental care team in early recognition of psychiatric disorders. Given the range of chronic orofacial pain subtypes, we
will present two separate fictionalized case-based discussions to explore their presentation.
CPD/Clinical Relevance: The primary care dental team has a role in recognition of psychiatric conditions and subsequent chronic
orofacial pain.
Dent Update 2022; 50: 85–90
Recently, the oral health of people of the Chief Dental Officer for England SMI.1 Two authors (VA and DS) have also
with severe mental illness (SMI) gained published a statement on the importance been involved in a consensus statement2
significant media attention after the Office of prioritizing oral health for people with that sets out a 5-year plan to improve oral
health of people with SMI.
One in five presentations to primary
care involve medically unexplained
Vishal R Aggarwal, BDS, MFDSRCS, MPH, PhD, FCGDent, Clinical Associate Professor
symptoms (MUS) or persistent physical
in Acute Dental Care and Chronic Pain. School of Dentistry, University of Leeds.
pain.3 Of those affected, half live with
Emily Sanger, MBBS, Academic Clinical Fellow Psychiatry, Leeds Institute of Health
anxiety or depression, positioning these
Sciences, University of Leeds; Leeds and York Partnership NHS Foundation Trust.
conditions as either a consequence of the
David Shiers, MBChB, MRCP(UK), MRCGP, Honorary Research Consultant, Psychosis
persistent pain or as part of the aetiology.
Research Unit, Greater Manchester Mental Health NHS Trust; Honorary Reader in early
There is a strong relationship between
psychosis, Division of Psychology and Mental Health, University of Manchester; Honorary
anxiety, depression, somatic symptom
Senior Research Fellow, School of Medicine, Keele University. Jenny Girdler, MChD/
disorders and substantial social or
BChD BSc, MFDS RCS (Ed), PGDip Prim Dent Care, PGCert Clin Teach, Specialist Registrar
physical impairment.4
in Oral Surgery, Leeds Teaching Hospitals NHS Trust. Emma Elliott BDS (Hons), Academic
Somatic symptoms are physical
Joint Dental Foundation Core Trainee MaxFax/GDP, Leeds Teaching Hospital Trust, Leeds
symptoms that arise due to emotional
General Infirmary.
or psychological factors. Anyone
email: [email protected]
experiencing anxiety, depression or

distress can somatize physical symptoms,

but there are also specific somatization
disorders (eg bodily distress disorder) Chronic orofacial pain Wide range of medical input
marked by the presence of MUS.4
Research has indicated that somatization
disorders may have a prevalence of
between 16.1% and 21.9% in general
practice. This poses challenges for
those in primary care when physical Somatization disorders
symptoms (including chronic primary (eg bodily distress disorder)
pain) present without underlying organic
pathology and are instead related to
psychosocial factors.5
Somatic symptoms can be reported as
a dominant feature or as a component of Potentially restricted
other psychiatric conditions. In affective social functioning
disorders such as depression, somatic
symptoms are more likely to present
during an episode and are unlikely to Figure 1. The factors that indicate a somatization disorder may play a role in the clinical picture
persist once one has passed.4 In anxiety
disorders, somatized symptoms are Diagnostic features Relationship to our clinical scenario
less likely to persist following medical
assessment and reassurance compared Bodily symptoms that are Often the focus is limited to a single symptom, eg
to bodily distress disorder.4 Anxiety, distressing to the individual. pain or fatigue. In the patient’s case, distress has been
depression and bodily distress disorder caused by the chronic facial pain she experiences
can form comorbid presentations Symptoms receive excessive The patient reports multiple specialists and
responsible for somatized symptoms. attention and are persistent. interventions over the years including dental
In dentistry, around 7% of the This is in spite of appropriate extractions, surgical explorations, injections and drug
population report symptoms of chronic investigation and reassurance therapies with limited success
orofacial pain (COFP),6 which includes from healthcare professionals
persistent idiopathic orofacial pain
Bodily symptoms are The facial pain described is chronic and
and chronic temporomandibular joint
persistent, eg present on most experienced daily
dysfunction (TMD).4
days over a period of over
3 months
Case 1: persistent idiopathic
The symptoms, distress Functionally, the patient is unable to wear her lower
orofacial pain and preoccupation denture due to the pain. She is also out of work,
A 56-year-old woman presents to you as result in significant although the relationship between this and her facial
a new patient. She reports that over the functional impairment pain is unclear
past 10 years she has been experiencing
The symptoms, distress There is no clear background of psychiatric issues,
severe episodes of pain affecting the
and preoccupation cannot although the diazepam and gastric ulcers may
right side of her face. The pain is sharp
be better accounted for by indicate stress
and lancinating, but can be throbbing,
another psychiatric condition
heavy and aching. She feels this pain
inside the mouth ‘near the top right’, but Table 1. How a bodily distress disorder may relate to the patients’ presentation, adapted from ICD-114
says it can radiate across the whole right-
hand side of her face. Nothing alleviates
the pain, but it can worsen later in the medications include diazepam, ranitidine, mucosa in the area of previously extracted
day, with no other obvious pattern. and levothyroxine. She has been married canines and premolars.
Over the years, this pain has resulted for 33 years and has two adult children.
in many teeth being removed, multiple She does not work and does not smoke
surgical explorations of the area, various cigarettes, but consumes 4 units of
What are our initial thoughts?
injections and drug therapies. Some alcohol per week. Several features of the clinical scenario raise
of these have had limited success for On examination, she wears an upper concerns about the patient experiencing a
brief periods of time. She has seen complete denture and is partially dentate somatoform disorder, such as bodily distress
many specialists and has had numerous on her lower arch. She does not wear her disorder (Figure 1).
scans and radiographs, with no one lower denture as it is ‘too painful’. When This somatization of physical symptoms
providing a diagnosis. She has a medical you ask her to point to the area that appears to be in the form of persistent
history of gastric ulcers and a previous causes her chronic pain she identifies idiopathic facial pain and we should consider
thyroidectomy and hysterectomy. Her the upper right alveolar ridge and buccal this in overall patient management.

Could a somatization
disorder (such as bodily Chronic orofacial pain
History of anxiety
distress disorder) play a role and depression
in this clinical picture?
Bodily distress disorder has a frequency
of 17% within primary care services and
is common among men and women
between the ages of 41 and 65 years.7 Somatization
Patients with bodily distress disorder
have self-reported chronic physical
illness, often resulting in higher use of
all types of medical services.7 The patient
has had a history of high use of medical
services, with repeat interventions and
Stress
scans for persistent pain. She is also
in the most common age range for a
presentation of bodily distress disorder,
so the possibility somatization is involved Figure 2. The features of the scenario and how they may result in a presentation of
in her case is high. The relationship somatized symptoms.
between bodily distress disorder and
the patients’ case is explored further Systemic origin Differential diagnosis
in Table 1.
When exploring this diagnostically, Dental Caries
it is useful to collect a thorough pain Third molar eruption
history, including: ‘onset, frequency, Ear conditions Otitis externa/media
duration, characteristics of the pain, Mastoiditis
provoking factors, site of initiation of Eustachian tube dysfunction
pain, exacerbating factors, relieving
factors, severity and associated features’.8 Headache disorders Migraines
We should also discuss what the patient Cluster headaches
perceives the origin of the pain to be and Neuralgias and neuropathic Trigeminal or facial neuralgias
the success and nature of any previously pain disorders Post-herpetic neuralgia
attempted management strategies.8 Post-traumatic/surgical neuralgias
The patient is experiencing a
Viral infections Mumps
constant, aching, long-lasting pain with
Shingles
no exacerbating or relieving factors,
which radiates around the right face and Autoimmune disorders Rheumatoid arthritis
head. No clinical or radiological signs Systemic lupus erythematosus
indicate an underlying dental cause, Sjögren’s syndrome
although the potential for denture-
Disorders of other Parotitis
related trauma and poorly fitting
facial structures Salivary gland disorders
dentures should be investigated and not
Maxillary sinusitis
dismissed. All previous management
Giant cell arteritis
attempts have failed and there may be
Osteonecrosis
comorbid stress owing to medical and
Table 2. Temporomandibular joint disorder differential diagnoses. Adapted from NICE.13
lifestyle factors.
The most likely diagnosis would
be persistent idiopathic facial pain
(PIFP), previously known as atypical Case 2: temporomandibular headaches. He describes the pain as
facial pain,8 which could originate from throbbing, heavy and aching. The pain
a somatization disorder. Patients who joint dysfunction has worsened recently and is constant,
have bodily distress disorder often You have a 21-year-old male patient with with very painful episodes intermittently.
have high rates of comorbid anxiety a medical history of anxiety, depression, Exacerbating factors include ‘chewing,
and depression,7 highlighting the irritable bowel syndrome and chronic talking for long periods or opening wide’
relationship between somatization and fatigue syndrome for which he takes and he reports that his symptoms feel
these conditions. diazepam, sertraline and mebeverine. worse in the morning.
In our next case, we consider Over the past 2 years he has experienced He has recently finished his degree in
the somatic symptoms of anxiety pain and clicking near his ears that journalism and has started a high-profile
and depression.7 radiates to his lower jaw and can cause stressful job. He smokes 20 cigarettes

per day and drinks 16 units of alcohol a

week. He reveals that stress can provoke
the pain and has been using soft foods,
heat pads and massaging the area to
relieve symptoms.
On examination, there is palpable
tenderness in the pre-auricular region,
and on mouth opening. This tenderness
extends to the muscles of mastication,
trapezius and sternocleidomastoid. There is
40 mm of inter-incisal mouth opening with
an audible click.
What are our initial thoughts?

In this scenario the patient is experiencing
COFP in the form of temporomandibular
joint dysfunction with a background of
anxiety, depression and work associated
stress (Figure 2).
Somatic symptoms can exist as an
extension of other psychiatric conditions
such as depression and anxiety.5 Given the
patient’s medical history this element of
the presentation should be considered.
What could be the cause of

his COFP?
A vast majority of patients with COFP
initially present to their general medical
practitioner.9 In a case of TMD-related
COFP this can result in misdiagnoses
such as otalgia10–12 owing to the close Figure 3. The masticatory system examination, adapted from Beddis et al.16
proximity of the temporomandibular
joints to the ear. Similarly, TMD pain can
be mistaken as toothache by dentists and temporomandibular disorders17 and stress her chronic pain – it would be sensible to
there are numerous differential diagnoses can result in clenching and grinding, review the dentures and make adjustments
that may be relevant in a case of TMD- which exacerbate muscle tension and while also supporting her with her
associated pain (Table 2). physical symptoms of pain.18 The patient persistent idiopathic facial pain.
Patients presenting similarly to Case 2 has a known history of anxiety, depression To provide reassurance, we should
should have their temporomandibular
and currently reports high stress levels, provide a definitive diagnosis; one of
joints assessed and managed according
so there is significant potential for persistent idiopathic facial pain and one of
to the diagnostic criteria for TMD.14 A brief
clenching and grinding as a cause for his TMD. These should be clearly communicated
TMD checklist is shown in Figure 3, with
myofascial pain. to the patient using an explanation of
an accompanying referenced video15 to
pain pathways (so-called pain science
help clinicians make this assessment.
education) and explanation of mechanisms
It outlines a systematic approach to Chronic orofacial pain: what by which the vicious pain–anxiety–muscle
assessing and diagnosing patients with should I do in such scenarios?
TMD. Such a checklist can be implemented tension cycle is exacerbated. In the case of
throughout primary care, to minimize the Even if a case of COFP is considered persistent idiopathic facial pain, the patient
potential for misdiagnosis of TMD as non- a medically unexplained symptom should be reassured of the fact that pain
specific otalgia, which ultimately results with roots in somatization, the pain is can occur in the absence of underlying
in mismanagement. still very real and often debilitating. In pathology. Patients can feel unsupported
For this patient, the clinical features these cases, it is important to take the or confused in cases of persistent pain
suggest a likely diagnosis of an internal patient’s pain seriously; treat anything without organic pathology, which can lead
derangement (disc displacement with that can be treated and then focus on to unproductive or extensive investigations.
reduction), and myofascial pain, given supportive management and improving This can be redirected with reassurance and
the pain radiates beyond the muscles of functionality.19 For example, in our first continuous input on how these symptoms
mastication. Symptoms of depression and case, the patient has complained about can present, deliberately moving away from
anxiety are known risk factors for chronic difficulties with her dentures alongside the misconception that the pain ‘is all in

Physical symptoms: Signs of potential malignancy:

pain in right face Previous history of malignancy
Unexplained fever or weight loss
Feelings Persistent or unexplained neck lump
Cervical lymphadenopathy
Recurrent epistaxis, purulent nasal
discharge, persistent anosmia, or
reduced hearing
Pain Concurrent infection, facial

asymmetry, facial mass or swelling, or
profound trismus
History of recent head or neck trauma
Doing: avoids going out, Behaviour Thoughts Negative thoughts: and/or occlusal changes
stays isolated indoors anxiety, cancerophobia
Persistent and worsening pain
including jaw pain in people
Figure 4. The cycle of anxiety, avoidance and worsening of the pain.22 taking bisphosphonates
Neurological symptoms indicating
an intra-cranial cause or
the patient’s head,’ which is often how the Aside from reassurance and explanation, malignancy affecting cranial nerve
patient feels. the psychosocial approach focuses on peripheral branches
Supported self-management using cognitive restructuring and behavioural
New-onset unilateral headache or scalp
a biopsychosocial approach,20–22 has activation. Here, we should challenge
tenderness, especially if over 50 years
been shown to reduce long-term pain negative thoughts about the pain, making
of age
and depression in patients with COFP. In a plan to balance routine, necessary and
Table 4. Temporomandibular joint disorder
addition to offering a plausible explanation pleasurable activities to prevent pain from red flags requiring onward referral. Adapted
for symptoms, we can identify the impact becoming the focus. Our actions can be from NICE.13
the pain has on daily life, eg restrictions in summarized in Table 3.
household activities, work, relationships, In the case of TMD there is chronic
personal and social activities. With an myofascial pain that may be exacerbated
awareness of the impact on their quality by his underlying psychiatric conditions muscles.23 Overall, this can help to reduce
of life, we can set goals to help break and stress. Here, we can discuss the muscle tension and myofascial pain.
the vicious cycle that exacerbates pain exacerbating factors of his medical The effectiveness of splints for TMD is
symptoms. With cases of chronic pain, conditions and stress levels, which are questionable.24 If we decide to provide a
vicious cycles often arise from the inter- resulting in oral parafunctional habits splint, there should be regular review to
relationship between the autonomic and increased alcohol intake. There monitor symptoms. If they worsen, splint
physical symptoms and the behavioural should also be a focus on reversing habits usage should be stopped. There can also
and cognitive response. This cycle produces that exacerbate symptoms. The patient be liaison with the GMP or the patient’s
negative thoughts about the symptoms, should be advised on posture control (eg psychiatrist (if he is already part of psychiatric
which results in avoidance of activities sleeping on his back) to limit night-time services) to determine medical management
and consequent symptom amplification parafunction, heat application, soft diet of stress and limiting alcohol intake.
(Figure 4). and massaging his masseter and temporalis In the medium term, we should monitor
pain intensity and the impact on activities
of daily living. There may be a need to refer
to secondary care for multidisciplinary
Our actions Goal team management by oral surgery with
Cognitive restructuring Restructure the challenging negative thoughts about pain continued psychiatric input. Onward
with reassurance and explanation for the symptoms. referral to OMFS or an oral surgery team is
indicated if there are any red flag signs and
Behavioural activation Prevent pain from becoming the focus by setting targets for symptoms (Table 4).
activities that break the vicious cycle of pain-related activity Those living with chronic pain may
avoidance. Consider the concept of ‘living well with pain’ by express suicidal thoughts or ideations.
reducing its impact on activities of daily living Up to 50% of patients living with chronic
Relapse prevention As goals are achieved discuss relapse prevention with the pain have had serious thoughts about
patient and how the nature of chronic pain is episodic and can committing suicide.25 As discussed,
be exacerbated by stress and anxiety. Relapses are addressed primary care practitioners will have a
with cognitive restructuring and behavioural action. continuous relationship with patients
living with chronic pain. Any expression
Table 3. Our actions to help manage chronic pain presentations.20,22
of such thoughts should be explored, for

example: are they experiencing feelings https://doi.org/10.1192/bjp.184.6.470 2023).

of hopelessness or significant stressors, 6. Aggarwal VR, Macfarlane GJ, Farragher TM, 16. Beddis HP, Davies SJ, Budenberg A et al.
do they have any plans to act on these McBeth J. Risk factors for onset of chronic oro- Temporomandibular disorders, trismus and
thoughts and whether there have been any facial pain – results of the North Cheshire oro- malignancy: development of a checklist
previous self-harm or suicide attempts. With facial pain prospective population study. Pain to improve patient safety. Br Dent J 2014;
patient consent, such a conversation would 2010; 149: 354–359. https://doi.org/10.1016/j. 217: 351–355. https://doi.org/10.1038/
prompt communication with the GMP, pain.2010.02.040 sj.bdj.2014.862
psychiatric services or local crisis teams. 7. Budtz-Lilly A, Vestergaard M, Fink P et al. 17. Kindler S, Samietz S, Houshmand M et al.
When managing cases of COFP we must Patient characteristics and frequency of Depressive and anxiety symptoms as risk
not lose sight of the three most important bodily distress syndrome in primary care: factors for temporomandibular joint pain:
steps: make a definitive diagnosis, provide a cross-sectional study. Br J Gen Pract 2015; a prospective cohort study in the general
a clear explanation and guide patients 65: e617–623. https://doi.org/10.3399/ population. J Pain 2012; 13: 1188–1197.
through supported self-management.3 If bjgp15X686545 https://doi.org/10.1016/j.jpain.2012.09.004
these steps are taken, many may not require 8. Renton T, Durham J, Aggarwal VR. The 18. De Jongh A. Clinical characteristics of
an onward referral.3 classification and differential diagnosis of somatization in dental practice. Br Dent J
orofacial pain. Expert Rev Neurother 2012; 12: 2003; 195: 151–154. https://doi.org/10.1038/
Compliance with Ethical Standards 569–576. https://doi.org/10.1586/ern.12.40 sj.bdj.4810404
Conflict of Interest: VA and DS are funded by 9. Bell GW, Smith GL, Rodgers JM et al. Patient 19. Chitnis A, Dowrick C, Byng R, Turner P, Shiers
Closing the Gap network. Closing the Gap is choice of primary care practitioner for D. Guidance for health professionals on
funded by UK Research and Innovation and orofacial symptoms. Br Dent J 2008; 204: 669– medically unexplained symptoms. 2011.
their support is gratefully acknowledged 673. https://doi.org/10.1038/sj.bdj.2008.523 Available at: https://dxrevisionwatch.files.
(Grant reference: ES/S004459/1). DS is 10. Kuttila S, Kuttila M, Le Bell Y et al. Aural wordpress.com/2013/06/guidance-for-health-
expert advisor to the NICE centre for symptoms and signs of temporomandibular professionals-on-mus-jan-2011.pdf (accessed
guidelines. Views expressed here are those disorder in association with treatment need February 2023).
of the project co-authors and do not and visits to a physician. Laryngoscope 20. Aggarwal VR, Wu J, Fox F et al.
represent the views of the Closing the Gap 1999; 109: 1669–1673. https://doi. Implementation of biopsychosocial
network, UKRI or NICE. All authors declare org/10.1097/00005537-199910000-00022 supported self-management for chronic
that they have no conflict of interest. 11. Kuttila SJ, Kuttila MH, Niemi PM et al. primary oro-facial pain including
Secondary otalgia in an adult population. temporomandibular disorders: a theory,
References Arch Otolaryngol Head Neck Surg 2001;
person and evidence-based approach. J Oral
1. Hurley S, Kendall T. Your NHS dentistry and 127: 401–405. https://doi.org/10.1001/
oral health update. special focus: dentistry Rehabil 2021; 48: 1118–1128. https://doi.
archotol.127.4.401
and patients with mental illness. 2021. org/10.1111/joor.13229
12. Jaber JJ, Leonetti JP, Lawrason AE, Feustel
Available at: www.dental-nursing.co.uk/ 21. Aggarwal VR, Fu Y, Main CJ, Wu J. The
news/nhs-dentistry-and-oral-health-update- PJ. Cervical spine causes for referred
effectiveness of self-management
patients-with-mental-illness (accessed otalgia. Otolaryngol Head Neck Surg 2008;
interventions in adults with chronic orofacial
October 2022). 138: 479–485. https://doi.org/10.1016/j.
pain: a systematic review, meta-analysis and
2. Closing the Gap Network. The right to otohns.2007.12.043
meta-regression. Eur J Pain 2019; 23: 849–865.
smile; an oral health consensus statement 13. National Institute for Health and Care
https://doi.org/10.1002/ejp.1358
for people experiencing severe mental ill Excellence. Temporomandibular disorders
22. Lovell K, Richards D, Keeley P et al. Self-
health. 2022. Available at: www.lancaster. (TMDs). Clinical Knowledge Summary.
management of chronic orofacial pain.
ac.uk/media/lancaster-university/content- 2021. Available at: https://cks.nice.org.uk/
2018. Available at: https://licensing.leeds.
assets/documents/fhm/spectrum/Oral_ topics/temporomandibular-disorders-tmds/
(accessed February 2023). ac.uk/product/self-management-of-chronic-
Health_Consensus_Statement.pdf (accessed
14. Schiffman E, Ohrbach R, Truelove et al; orofacial-pain-including-tmd (accessed
November 2022).
International RDC/TMD Consortium Network, February 2023).
3. Husain M, Chalder T. Medically unexplained
symptoms: assessment and management. International association for Dental Research; 23. Durham J, Al-Baghdadi M, Baad-Hansen
Clin Med (Lond) 2021; 21: 13–18. https://doi. Orofacial Pain Special Interest Group, L et al. Self-management programmes in
org/10.7861/clinmed.2020-0947 International Association for the Study of Pain. temporomandibular disorders: results from
4. International Classification of Diseases 11th Diagnostic criteria for temporomandibular an international Delphi process. J Oral Rehabil
Revision. Mortality and Morbidity Statistics: disorders (DC/TMD) for clinical and research 2016; 43: 929–936. https://doi.org/10.1111/
Mental, behavioural or neurodevelopmental applications: recommendations of the joor.12448
disorders. 2022. Available at: https://icd.who. International RDC/TMD Consortium Network 24. Riley P, Glenny AM, Worthington HV et al.
int/browse11/l-m/en#/http%3a%2f%2fid. and Orofacial Pain Special Interest Group. Oral splints for temporomandibular disorder
who.int%2ficd%2fentity%2f334423054 J Oral Facial Pain Headache 2014; 28: 6–27. or bruxism: a systematic review. Br Dent J
(accessed February 2023). https://doi.org/10.11607/jop.1151 2020; 228: 191–197. https://doi.org/10.1038/
5. de Waal MW, Arnold IA, Eekhof JA, van 15. Leeds School of Dentistry. s41415-020-1250-2
Hemert AM. Somatoform disorders in general Temporomandibular disorders – 1 minute 25. Cheatle MD. Depression, chronic pain, and
practice: prevalence, functional impairment examination and checklist. 2021. suicide by overdose: on the edge. Pain
and comorbidity with anxiety and depressive Available at: https://www.youtube.com/ Med 2011; 12 Suppl 2: S43–48. https://doi.
disorders. Br J Psychiatry 2004; 184: 470–476. watch?v=eUsb1mS6MKs (accessed February org/10.1111/j.1526-4637.2011.01131.x

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Prosthodontics
Enhanced CPD DO C
Wouter Leyssen
Jasmeet Heran and AD Walmsley
Acrylic Dentures: Fill the Gap.

Part 2. Indirect Retention, Major
Connectors, Review of the Design
and Case Study
Abstract: Many dental students find the principles of partial denture design difficult to learn. It is also recognized that dentists in general
practice within the UK do not always provide sufficient design specification on their laboratory prescription. It therefore seems that
confusion about how to come up with a suitable denture design persists after graduation. The aim of the second part of this series relates
to design principles of indirect retention, designing the major connector and how to put together all these elements when reviewing
the overall design, and how to apply the denture concepts to a case study. This article also discusses recent advances in mucosal-borne
partial dentures.
CPD/Clinical Relevance: This article revises the principles of partial denture design specifically in relation to mucosal-borne
partial dentures.
Dent Update 2023; 50: 93–96
Acrylic resin-based partial dentures, with the focus on support, retention, Indirect retention
also referred to as mucosal-borne reciprocation and bracing. The aim of
Indirect retention can be defined as the
dentures, are commonly prescribed in Part 2 relates to design principles of effect achieved by one or more indirect
general dental practice, but often do indirect retention, designing the major retainers of a removable partial denture
not receive as much attention within connector and how to put together all that reduces the tendency for a denture
the dental curriculum. It is the aim these elements when reviewing the base to move in an occlusal direction or
of this series of articles to revisit the overall design, and how to apply the in a rotational path about the fulcrum
principles of partial acrylic denture denture concepts to a case study. This line.1 Therefore, the denture design will
design. The first article covered the article also discusses recent advances in need to include at least two clasps for
system of designing these dentures mucosal-borne partial dentures. this concept to be considered.
Indirect retention can be provided
by a clasp on the same side of the clasp
axis as the denture saddle in question,
Wouter Leyssen, BDS, MJDF, MSc, Specialty Dentist, Restorative Dentistry, Birmingham or by tooth/retained root support on
Dental Hospital. Jasmeet Heran, BDS, MFDS, DCT, Birmingham Dental Hospital.
the opposite side of the clasp axis. It
AD Walmsley, PhD, MSc, BDS, FDSRCPS, Professor of Restorative Dentistry, College of
may also be achieved through coverage
Medical and Dental Sciences, University of Birmingham School of Dentistry.
of a large edentulous free end saddle
area (Figure 1).

Prosthodontics
design, patient’s wishes (including

their quality of life) and the possible
effect on their periodontal tissues.
It is fundamental that the clinician
delivering any prosthesis reinforces
the need to maintain excellent oral
and denture hygiene to minimize
periodontal damage. Ideally the
denture should be designed to avoid as
many of the natural teeth as possible,
with at least 3-mm clearance between
the gingival margins of the teeth and
Figure 1. Major connector covering the lingual the major connector.2 For mandibular
surfaces of LL3–LR3 for indirect retention
acrylic dentures, often this cannot
purposes in relation to the free-end saddle area.
be achieved without affecting the
Note: this is a picture of a wax try-in before clasps Figure 2. Maxillary partial acrylic denture on
have been added.
strength and rigidity of the connector.
master cast.
Therefore, a compromise is accepted
and inevitably, mandibular acrylic
connectors will be relatively large
In a Kennedy Class 1 situation for and bulky.
the mandible, designing the denture A case study illustrates how to put
with a wrought metal lingual bar, to the denture design principles discussed
decrease tissue coverage, will result in this series of articles into practice.
in a denture lacking support and
provide no indirect retention. Without Case study: an acrylic
Figure 3. Maxillary partial acrylic denture and
indirect retention the denture will
rotate, forcing the major connector into
master cast. maxillary partial denture
the mucosa and leading to pain and A male patient in his 40s requested a
discomfort of the affected area. When new partial upper denture because his
occurring around natural standing the upper arch, an acrylic connector is current prosthesis lacked retention. The
teeth it causes compression around much lighter in weight than a cobalt– patient had undergone periodontal
the gingival margins, resulting in tissue therapy, which had stabilized his
chromium (Co-Cr) connector, which
damage. This type of denture has the periodontal condition; however, the
helps with retention. However, the
unglamourous term of being a ‘gum UL6 remained grade 2 mobile with
thickness of material can feel bulky,
stripper’.2 An alternative solution is to 10 mm of recession distally. The
which may be a drawback for some
original denture had no clasps. The
design the major connector so that it patients. Usual design characteristics
opposing arch was fully dentate.
ends just above the survey line.2 such as a post dam for the upper
Figures 2 and 3 show the final denture
The trade-off between tissue denture must always be included. It
and master cast.
coverage to abide by the principles of is good practice for the clinician to
design and periodontal considerations carve the post dam on the master
are discussed below. cast or provide clear instructions to Saddle areas
Upper mucosal dentures are the laboratory. The Kennedy classification for this case
generally well supported due to their A lower acrylic connector that feels is II mod 3 because of the decision
palatal coverage so indirect retention is bulky may be less well tolerated. Where to replace UL7 and UL8. This is to
not as much of an issue unless deciding this is a problem, or greater strength prevent overeruption and unwanted
to keep the palate uncovered. This is required, a Co-Cr connector could tooth movements of the opposing
may introduce rotational difficulties be used. The principles of the overall lower natural teeth. Owing to the poor
that can be prevented by considering denture will remain as a mucosal- prognosis of the UL6, extending the
indirect retention and extending the borne design. denture posteriorly to facilitate addition
acrylic onto the palatal surfaces of when required is wise.
the appropriate remaining teeth or to
increase palatal coverage after all.
Review design Support
When reviewing the finished design Given the number of missing teeth
of the denture, consideration should and the presence of a free-end saddle
Major connector be given to the periodontal tissues. area, the denture was finished above
The main role of the major connector is All dentures will increase plaque the survey line of the UL2/3 and UR3 so
to link all the components of an acrylic accumulation around teeth when that the denture was partially tooth and
denture together. It can also provide compared to no prosthesis. Often a partially mucosa borne. This provided
support, indirect retention and in many compromise will be made between indirect retention, which is discussed
cases (some sort of ) border seal. In trying to achieve the ideal denture later in the design.

Prosthodontics
Advances in denture polish because any adjustment exposes

base materials the fibres in the material. Specialized
polishing and laboratory techniques
Conventionally, acrylic dentures are
are required.
made of polymethylmethacrylate
Ultimately, the use of flexible
(PMMA). This material has adequate
dentures could be useful in certain clinical
mechanical properties, but low impact
situations, such as a few missing anterior
strength and fatigue resistance, which
Figure 4. Valplast denture. teeth or posterior teeth in a bounded
can result in the prosthesis fracturing
saddle, but it is important to be aware of
in areas of very high occlusal load or
the limitations.
if the denture is dropped.3,4 A more
Computer-aided design and computer-
recent alternative to PMMA is the use
Retention aided manufacturing (CAD-CAM) has been
of flexible thermoplastic resin materials.
The choice was made to clasp UL3 and reported on in the literature for complete
One example of this is a polyamide-
UR4. Clasping the UL6 may have been acrylic dentures and the manufacturing
based denture, such as Valplast
beneficial to provide retention and indirect of metal frameworks. However, a limited
(Valplast International Corporation, NY,
retention. However, owing to the recession number of clinical studies is available,
USA) (Figure 4).
and increased mobility, it was decided not with the literature consisting mainly
Polyamide dentures have become
to clasp this tooth. Guide planes were also of case reports.8 Partial acrylic denture
a popular alternative denture base
prepared distal of the UL3, and UR4 parallel construction using this technology has
for partial dentures for aesthetic
with the mesial surface of the UR8. even received less attention. This does
reasons, mainly due to the absence of
not mean that it is not applicable to
metal clasps. Flexible dentures can be
Bracing and reciprocation partial acrylic dentures. A case report
extended closely around the natural
Bracing is provided by the favourable from France discusses the manufacturing
teeth in order to use the undercuts of
distribution of the remaining teeth. of a successful immediate removable
abutment teeth and increase retention.
Reciprocation for the I-bar on UL3 and partial acrylic denture using CAD-CAM.9
They also tend to be of reduced
UR4 is provided by extension of the major An explanation for why this technology
thickness, which patients may find may not have been used widely for acrylic
connector onto the palatal surfaces of more comfortable.5
those teeth. dentures so far might be that these
However, the coverage of Valplast are often considered of a temporary
dentures around the abutment teeth nature, and not worth more expensive
Indirect retention and surrounding vestibular and buccal manufacturing costs.
To achieve indirect retention, limiting gingiva can lead to inflammation Similarly for printed dentures,
rotation of the saddle areas around the around the mucosa, which may be the literature related to partial acrylic
clasp axis was required. The clasp axis lies further exacerbated if the prosthesis dentures is very limited. Commercial
between UL3 and UR4. Teeth UL3/2 and UR3 is entirely mucosa supported. The labs advertise printed Valplast dentures;
are on the opposite side of the clasp axis lack of rigidity of flexible dentures however, examples for acrylic partial
of the free-end saddle and therefore, could makes gaining adequate support dentures are difficult to find. Subtractive
be used for indirect retention. The acrylic more difficult. Without this, there is milling techniques seem to be dominant
major connector was finished above the a risk of rotation and sinking of the for non-metal-based partial dentures at
survey line of those teeth to achieve this. An denture base into the tissues, which is the time of writing.
additional component to prevent rotation thought to increase ridge resorption.
is the extension of the denture base up to For this reason, the available literature
the distal palatal aspect of the UR8 behind considers that polyamide dentures are Summary
the clasp axis, and coverage of the palate contraindicated when many teeth are Given that acrylic partial dentures are
up to the vibrating line. A clasp on UL6, a missing with no vertical stops present.5,6 routinely prescribed in primary and
tooth on the same side as the saddle area in Other disadvantages are increased secondary care settings, it is important
question, was another possibility. However, water sorption compared to PMMA, that we devote the necessary time
owing to mobility issues of this tooth, it was which can lead to degradation and attention when considering their
not an option for the patient in this case. and discolouration over time.7 A design. In truth, there are many factors
consequence of this is greater plaque to be considered when designing
Review design accumulation and the potential for dentures, and compromises may need
For oral hygiene purposes, it would candidal growth because the surface to be made because there is no single
have been good practice to design the becomes roughened with wear. universal design that can be applied to
major connector away from the natural Additionally, the polyamide denture all partially dentate patients. Therefore,
dentition. However, in this case, the acrylic base is not chemically bonded to the we must follow a system of design to
of the major connector served to provide artificial teeth. This means that the maximize support and retention, taking
reciprocation for the clasp on UR4 and UL3 teeth rely on mechanical retention for into consideration bracing, indirect
and provided indirect retention on UL3/UL2 their incorporation into the denture. retention and reciprocation. Part of
and UR3. The UL6 had a guarded prognosis There is a risk that the teeth may be the design process is to review how
and the acrylic base wrapped around UR8 lost if overloaded or there is a fracture.5 these design elements come together
for indirect retention purposes. Polyamide dentures are also not easy to and how changes in design can limit

Prosthodontics
further detriment to the patients accuracy of injection-molded denture resins. J Adv Prosthodont 2019; 11: 32–40.
overall oral health and hygiene. base materials to that of conventional https://doi.org/10.4047/jap.2019.11.1.32
Case selection, awareness of patient pressure-pack acrylic resin. J Prosthodont 8. Anadioti E, Musharbash L, Blatz MB et al.
factors and patient tolerance is 2004; 13: 83–89. https://doi.org/10.1111/ 3D printed complete removable dental
essential. In the Part 3 of this series, j.1532-849X.2004.04014.x prostheses: a narrative review. BMC
examples of common partially dentate 4. Fueki K, Ohkubo C, Yatabe M et al. Oral Health 2020; 20: 343. https://doi.
Clinical application of removable partial org/10.1186/s12903-020-01328-8
situations will be discussed and the
dentures using thermoplastic resin. 9. Virard F, Venet L, Richert R et al.
design of the appropriate acrylic
Part II: Material properties and clinical Manufacturing of an immediate removable
prostheses provided.
features of non-metal clasp dentures. J partial denture with an intraoral scanner
Prosthodont Res 2014; 58: 71–84. https:// and CAD-CAM technology: a case report.
Compliance with Ethical Standards
doi.org/10.1016/j.jpor.2014.03.002 BMC Oral Health 2018; 18: 120. https://doi.
Conflict of Interest: The authors declare
5. Manzon L, Fratto G, Poli O, Infusino org/10.1186/s12903-018-0578-3
that they have no conflict of interest.
Informed Consent: Informed consent E. Patient and clinical evaluation of
was obtained from all individual traditional metal and polyamide
participants included in the article. removable partial dentures in an elderly CPD ANSWERS
cohort. J Prosthodont 2019; 28: 868–875.
References https://doi.org/10.1111/jopr.13102 DECEMBER 2022
1. The glossary of prosthodontic 6. Ahuja S, Jain V, Wicks R, Hollis W.
terms: ninth edition. J Prosthet Dent Restoration of a partially edentulous 1. C 6. C
2017; 117(5S): e1–e105. https://doi. patient with combination partial
org/10.1016/j.prosdent.2016.12.001 dentures. Br Dent J 2019; 226: 407–410. 2. B 7. D
2. Farrell J. Partial Denture Designing. https://doi.org/10.1038/s41415-019- 3. B 8. B
London: Henry Kimpton Publishers, 1971; 0095-z
25, 77, 78. 7. Song SY, Kim KS, Lee JY, Shin SW. Physical 4. C 9. B
3. Parvizi A, Lindquist T, Schneider R et properties and color stability of injection-
al. Comparison of the dimensional molded thermoplastic denture base
5. C 10. C
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As recent events have shown, none of us know what the future holds.
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in the Republic of Ireland by the Central Bank of Ireland for conduct of business rules (Firm Reference
Number C33946). Calls are recorded for our mutual security, training and monitoring purposes.
Endodontics
Enhanced CPD DO C
Thai Yeng
Healing of Peri-apical Lesions with

Calcium Hydroxide Medicament
following Apical Enlargement:
A Case Study
Abstract: With public health orders restricting movement and changes to routine endodontic practice during the COVID-19 pandemic,
many patients chose to wait, in the range of 12–18 months, before returning to complete their root canal treatment. This report describes
several cases of non-vital and infected teeth that showed positive healing responses from having endodontic treatment using calcium
hydroxide paste as an intracanal medicament and an apical enlargement technique to further reduce bacterial numbers. This indicates
healing of peri-apical lesions may occur with a longer observation period.
CPD/Clinical Relevance: Endodontic treatment for peri-apical infection may allow a patient time to decide upon treatment options.
Dent Update 2023; 50: 101–105
Bacteria are essential for the development usually occurs, with gradual reduction and was declared across the country in March
of apical periodontitis.1,2 Local factors, such resolution of the radiolucency observed 2020, under Australia’s Biosecurity Act
as access to nutrients, positive and negative on subsequent examination.9,10 If an 2015.13 Public health orders restricted
bacterial interactions, the redox potential interappointment dressing is used, calcium gatherings and movement, and
and the host’s defence system, influence hydroxide remains the best medicament routine dental patient care practice
the fate of bacteria that have entered the available to inhibit the growth of intracanal changed, which generated significant
root canal space.3 In the management of bacteria before obturation.11 However, challenges,14 and negatively affected
apical periodontitis, the main antibacterial studies have shown that complete patients’ willingness to seek dental
phase of endodontic treatment is attributed bacterial eradication is not achievable treatment15 because of the fear of
to chemomechanical instrumentation.4–6 after chemomechanical debridement, contracting COVID-19.
Bacteria in areas such as isthmuses, even with the use of an intracanal This study reports on the effectiveness
of calcium hydroxide paste placement,
ramifications, deltas, irregularities, and medicament.11,12 Hence, further approaches
following large apical size preparation, on
dentinal tubules may be unaffected by root need to be considered to maximize root
the healing response of peri-apical lesions
canal treatment procedures.7,8 canal disinfection.
in permanent teeth in cases when a long
When root canal treatment is performed With the emergence of COVID-19, a
period occurred before returning to the
adequately, healing of the peri-apical lesion national human biosecurity emergency
dentist to complete root canal therapy.
Case studies
Thai Yeng, BDS, MDentSci, DClinDent (Endo), MRACDS (Endo), MRCPS (Glasg), FDSRCPS
All five patients presented with a peri-
(Glasg), FDSRCS (Edin), FDSRCS (Eng), FPFA, Specialist endodontist, North Sydney, New
apical radiolucency (Figures 1–5) and
South Wales, Australia.
each was keen to have the tooth infection
treated and avoid extraction.

Endodontics
Figure 1. Case 1. The lower left first mandibular

molar (LL6) with a peri-apical lesion around the
mesial and distal roots.
Figure 4. Case 4. The lower right central and

lateral incisors (LR1 and LR2) with a peri-apical Figure 6. Case 1. Working length radiograph
lesion around both teeth. of LL6.
Figure 2. Case 2. A peri-apical lesion in the upper Figure 5. Case 5. The lower right first mandibular
left central incisor (UL1). molar (LR6) with furcal bone loss and a peri-
apical lesion extending from the mesial to the
distal roots.
lengths were determined using an

electronic apex locator (Tri Auto ZX, J
Morita Corp, USA), and then verified
Figure 7. Case 2. Working length radiograph
with a peri-apical radiograph. A hybrid
of UL1.
instrumentation technique involving
the ProTaper and Vortex (Dentsply,
Figure 3. Case 3. The lower right first mandibular Maillefer, Ballaigues, Switzerland)
molar (LR6) with a peri-apical lesion seen around systems was employed. The molar canals filler before the tooth was temporized
the mesial root. were all instrumented to an apical with a double seal, consisting of Cavit
size and taper of 40/.04 (Vortex) and and Fuji II LC (light-cured glass ionomer
F4 (Protaper) for anteriors (incisors). cement) (Figures 6–10).
Copious irrigation with 4% sodium The five patients returned between
For all five cases, root canal treatment hypochlorite, along with ultrasonic 12 and 18 months later, and all had
was initiated under rubber dam isolation. irrigation (EndoActivator, Dentsply radiographic healing evident. The teeth
The canals were located with the aid of Sirona) and 17% ethylenediamine tetra- were clinically asymptomatic, with
an operating microscope (Leica M320, acetic acid (EDTA) were used throughout periodontal health within normal limits,
Leica Microsystems, Singapore). Hedström the instrumentation process. The canals no clinical evidence of coronal leakage,
files (ISO size 10) were then used to were dressed with calcium hydroxide and a positive healing response was
successfully negotiate the canals to the paste (Pulpdent Paste, Pulpdent Corp, seen around the roots in the radiographs
estimated working lengths. Working Watertown, USA) using a rotary paste (Figures 11–15).

Endodontics
Figure 8. Case 3. Working length radiograph Figure 11. Case 1. Healing response seen
of LR6. around LL6.
Figure 14. Case 4. Healing response seen around

LR1 and LR2.
Figure 9. Case 4. Working length radiograph of Figure 12. Case 2. Healing response seen
LR1 and LR2. around UL1. Figrue 15. Case 5. Healing response seen
around LR6.
and highlights the importance of

adequate temporary restorations
being placed between appointments
so as not to expose root canals to risks
of coronal leakage and contribute to
endodontic failure.
The apical foramen is one of the
main routes of intercommunication
Figure 10. Case 5. Working length Figure 13. Case 3. Healing response seen
radiograph of LL6. around LR6. between pulpal and periodontal
tissues.17 Bacterial and inflammatory
by-products may pass readily through
the apical foramen to cause peri-
Discussion for emergency reasons. This meant apical pathosis and extend into the
that unusually long gaps occurred peri-apical tissues, causing a local
When planning treatment for root canal
between a patient’s initial root canal inflammatory response with bone
treatment, the benefits of root canal treatment and their follow up visit. This and root resorption.18 Lateral and
treatment must be weighed against extended time between appointments accessory canals, mainly in the apical
extraction of the tooth.16 During the suggests that positive healing area and in the furcation of molars,
COVID-19 pandemic, the enforced responses can be seen with calcium also connect the dental pulp with the
movement restrictions meant that hydroxide medicaments following periodontal ligament.19 Gutmann20
many patients only sought dental care apical enlargement of the root canals introduced safranin dye into 102 molar

Endodontics
teeth placed in a vacuum chamber canal disinfection. Studies show that a Conclusion
and found 28.4% of the teeth had combined approach of increasing the In these case studies, the peri-apical
furcation canals, although only 10.2% size of nickel–titanium (NiTi) rotary files, lesions healed following a combination
of the total group exhibited canals on using sodium hypochlorite irrigant, of apical enlargement and the
the lateral root surface. The accessory and applying calcium hydroxide as an application of a long-term calcium
canals contain connective tissue and intracanal medicament significantly hydroxide medical dressing. In cases
vessels that connect the circulatory reduces the bacterial load from of chronic apical periodontitis, it may
system of the pulp with that of the infected canals.12,26 be worthwhile to attempt long-term
periodontium.17 Rubach and Mitchell21 Finally, and particularly in cases medication after initiating root canal
found that serial sectioning of 74 teeth where the completion of the root therapy if the patient is keen to ‘give it a
revealed that 45% showed accessory canal therapy does not take place for go’ and to avoid losing the tooth.
canals present primarily in the apical a long time, a good interim restoration
region. The presence of patent accessory that minimizes any forms of coronal Compliance with Ethical Standards
canals provides further potential leakage is very important. Saunders Conflict of Interest: The authors declare
pathways for the spread of bacterial and Saunders32 concluded that coronal that they have no conflict of interest.
and toxic by-products, resulting in a leakage may contribute to the failure of Informed Consent: Informed consent was
direct inflammatory process in the good endodontic treatments by allowing obtained from all individual participants
periodontal ligament.17 Hence, any micro-organisms to contaminate the included in the article.
chemomechanical debridement and root canals. An adequately placed
the antibacterial effects from the root coronal restoration may overcome References
canal medicament should aim to target some limitations of chemomechanical 1. Moller AJ, Fabricius L, Dahlen G et
bacteria in areas where pulpal and preparation by serving three important al. Influence on peri-apical tissues of
periodontal tissues communicate with functions: block any communication indigenous oral bacteria and necrotic
each other. between the oral cavity and the peri- pulp tissue in monkeys. Scand J Dent
As noted earlier, if an radicular tissues; entomb any surviving Res 1981; 89: 475–484. https://doi.
interappointment intracanal bacterial cells in the root canal system org/10.1111/j.1600-0722.1981.tb01711.x
medicament is used, calcium hydroxide containing medicament; and impede 2. Kakehashi S, Stanley HR, Fitzgerald RJ.
paste is recommended to maximize tissue fluid derived from the peri-apical The effects of surgical exposures of dental
the reduction of intracanal bacteria tissues from reaching bacterial cells in pulps in germ-free and conventional
before obturation,11 based on its the root canal to maintain their survival.33 laboratory rats. Oral Surg Oral Med
antibacterial6,22 and anti-resorptive23,24 It is important to know that inadequate Oral Pathol 1965; 20:340-9. https://doi.
properties. The antibacterial activity of temporary restorations, placed org/10.1016/0030-4220(65)90166-0
calcium hydroxide is probably due to its between appointments in multiple-visit 3. Haapasalo M, Udnæs T, Endal U. Persistent,
alkaline pH.6,22,25,26 The ability of calcium endodontic treatments, may also expose recurrent, and acquired infection of
hydroxide to diffuse through exposed root canals to risks of coronal leakage,34 the root canal system post treatment
dentinal tubules to raise the pH at the and contribute to endodontic failure.35,36 Endod Topics 2003; 6: 29-56. https://doi.
root surface has been shown in vitro.23,27 A common concern among general org/10.1111/j.1601-1546.2003.00041.x
This suggests that the medicament dentists is that long-term dressing 4. Byström A, Sundqvist G. Bacteriologic
can target invasive bacteria and their with calcium hydroxide may affect the evaluation of the efficacy of mechanical
by-products which enter through the fracture susceptibility of root canal- root canal instrumentation in
dentinal tubules, causing external treated permanent teeth. Historically, endodontic therapy. Scand J Dent
destruction at the root surface void long-term dressings with calcium Res 1981; 89: 321–328. https://doi.
of cementum. hydroxide-based medicaments have org/10.1111/j.1600-0722.1981.tb01689.x
However, the anatomical been used in the treatment of immature 5. Byström A, Sundqvist G. Bacteriologic
complexity of the root canal may teeth with open apices.37 In an animal evaluation of the effect of 0.5 percent
prevent high pH levels (~12.5) study, Andresen et al38 reported sodium hypochlorite in endodontic
reaching all parts of the canal, which fractures of immature teeth filled with therapy. Oral Surg Oral Med Oral
may protect bacterial species from calcium hydroxide medicament for an Pathol 1983; 55: 307–312. https://doi.
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39
hydroxide.28 To overcome this, the discovered that long-term calcium 6. Byström A, Sundqvist G. The antibacterial
canals should be instrumented to hydroxide dressing did not increase root action of sodium hypochlorite and EDTA
relatively large apical sizes. Several fracture susceptibility; rather, the most in 60 cases of endodontic therapy. Int
studies support the concept that important risk factor for root fracture Endod J 1985; 18: 35–40. https://doi.
populations of intracanal bacteria may be the root development stage. org/10.1111/j.1365-2591.1985.tb00416.x
decrease as apical enlargement Thus, an immature root presenting with 7. Nair PN, Sjögren U, Krey G et al.
increases,12,29–31 and this may contribute a fragile, thin structure is more likely to Intraradicular bacteria and fungi in root-
to a positive healing response. Placing be the primary causative factor. Hence, in filled, asymptomatic human teeth with
calcium hydroxide medicaments these cases, long-term calcium hydroxide therapy-resistant peri-apical lesions: a
following apical enlargement of the placement was not a predominant risk long-term light and electron microscopic
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2399(07)80201-9 of combined periodontal-endodontic bacteria. J Endod 2002; 28:779–783. https://
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org/10.1097/01.don.0000158007.56170.0c
G. Influence of infection at the time org/10.1902/jop.1978.49.1.21
32. Saunders WP, Saunders EM. Coronal
of root filling on the outcome of 21. Rubach WC, Mitchell DF. Periodontal
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apical periodontitis. Int Endod J 1997; 30: pathosis. J Periodontol 1965; 36: 34–38.
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org/10.1111/j.1600-9657.1994.tb00533.x
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33. Sundqvist G, Figdor D, Persson S, Sjogren U.
11. Law A, Messer HH. An evidence-based Sundqvist G. The antimicrobial effect
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30: 689–694. https://doi.org/10.1097/01. J 1991; 24: 119–125. https://doi. of conservative retreatment. Oral Surg Oral
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A, Trope M. Reduction of intracanal et al. pH changes in dental tissues after 2104(98)90404-8
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18. Rotstein I, Simon JH. Diagnosis, prognosis M. The effectiveness of increased apical joen.2017.09.018

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Endodontics
Enhanced CPD DO C
Thomas Hennebry
Harpal Chana
Management of Root Perforation

and Sodium Hypochlorite
Extrusion Injury
Abstract: A patient was brought to A&E by their GDP who had injected sodium hypochlorite (NaOCl) through a perforation in the patient’s
LR4, resulting in pain, swelling and immediate formation of a large, necrotic ulcer. Within 2 days, the patient developed paraesthesia
in the distribution of the right mental nerve. Antibiotics and steroids were prescribed to alleviate the acute symptoms. The perforation
was repaired with mineral trioxide aggregate (MTA) and root canal treatment was completed with the aid of a microscope. Review
appointments were arranged to monitor healing of the injury.
CPD/Clinical Relevance: Management of iatrogenic root perforation and associated NaOCl injury is useful knowledge.
Dent Update 2023; 50: 107–112
Sodium hypochlorite (NaOCl) is usually causes damage to organic structures and dental practitioner (GDP) with a large, painful
encountered as a dilute solution and has results in an intense inflammatory response. swelling on the right side of her mandible.
been used as household bleach since the Scarring, deformation of soft tissues and Medically, the patient was fit and well, took
18th century. It has a pH between 11 and nerve damage can result and these may no regular medication and had no known
12. Owing to its bactericidal properties be permanent.3–6 allergies. She gave consent to the taking
and its ability to dissolve organic matter, It is vital that dentists carrying out of clinical photographs and the use of her
it has become the most widely used root canal treatment are well informed radiographs in writing up this case report.
irrigant in endodontics and is typically of the risks associated with using NaOCl The patient had been undergoing the
found in preparations of between 0.5% and are confident in managing NaOCl- first stage of root canal treatment on her LR4.
and 6% concentration.1,2 However, care related injuries. The authors present their Root canal treatment was indicated for LR4
must be taken over its safe use because management of one such case, along with as the patient had persistent discomfort from
it is highly caustic to the tissues of the clinical photographs and radiographs. the tooth and tenderness to percussion. A
human body and related injuries are diagnosis of symptomatic apical periodontitis
a well-documented risk. When NaOCl associated with a non-vital LR4 was made.
solution is extruded beyond the root History and examination
During irrigation of the root canal system with
canal system, either through the apical A 33-year-old female presented to the A&E NaOCl solution, the patient complained of
foramen or through a root perforation, it department, accompanied by her general severe pain. The GDP suspected an iatrogenic
perforation had occurred and removed
the rubber dam to examine the tissues
Thomas Hennebry, BDS, PgCert Dip, MSc, MFDS RCS Eng, Dentist with special interest surrounding LR4. He attempted to manage the
in Endodontics, Kingston Hospital and Elmfield House, Teddington. Harpal Chana, BDS,
situation by irrigating the access cavity of LR4
MSc, FDS (Rest Dent) RCS, Consultant in Restorative Dentistry and Dental Implantology,
with saline and applying cold compression
Specialist in Restorative Dentistry, Endodontics, Periodontics and Prosthodontics,
to the patient’s face. The tooth was not
Kingston Hospital and Elmfield House, Teddington.
temporized before bringing the patient
to hospital.

Endodontics
LR1 LR2 LR3 LR4 LR5 LR6

Tender to percussion? - - - ++ - -
Mobility - - - - - -
Ethyl chloride sensitive? + + + - + +
Table 1. Summary of special tests carried out as part of endodontic examination.
Figure 1. Extra-oral view of the patient’s face,

showing the swelling on the right side.
b Figure 3. Neurosensory map of the affected area of hypoaesthesia.
Special investigations soft tissue buccal to LR4 where NaOCl had

entered the buccal sulcus. The radiolucency
The special investigations are summarized
resulted from a fluid-filled space within the
in Table 1. Neurosensory testing was
soft tissue.
conducted to assess the nature, severity
and extent of the paraesthesia. A Boley
Figure 2. (a,b) Intra-oral views of LR4 and its gauge was used to test for two-point Immediate management
adjacent lesion of necrosed tissue. discrimination. On the unaffected left The focus in immediate management of
side of the lower lip and chin, the patient the injury was to limit the caustic effects
could discriminate between points 3 mm of the NaOCl and to prevent an excessive
apart, which is considered normal. On the immune response in the damaged tissues.
On examination, extra-orally there right, the value was 14 mm. Light touch It began when the patient’s GDP irrigated
was a facial swelling localized around LR4, sensation was tested using a cotton tip the suspected perforation with saline and
extending to the angle of the mandible applicator and a sterile needle was used applied cold compression to the patient’s
on the right side. In addition, the right to test nociception. Both were found face. The objective of saline irrigation
submandibular lymph node was tender to to be reduced (hypo-aesthesia) in the was to dilute the strength of the NaOCl
palpation. There was normal mouth opening. distribution of the right mental nerve as it has been demonstrated in vitro that
Intra-orally, there was a large ulcer forming (Figure 3). cytotoxicity of NaOCl is greater at higher
adjacent to LR4 and a dark-coloured area of A cone beam computed tomography concentrations.7 Dilution also neutralizes
necrotic tissue in the buccal sulcus. There was (CBCT) scan with a limited field of view the highly alkaline pH, which contributes
no sinus tract visible. The endodontic access was taken to show LR4 (Figures 4–6). It to its penetrating capabilities and thus its
cavity in LR4 was open and the tooth was confirmed the presence of a perforation damaging effects on vital tissues.8–10 Cold
otherwise restored with the remains of an exiting LR4 at the level of the crestal bone compression is a commonly employed
occlusal amalgam. Clinical photographs were distobuccally. It demonstrated that the method to reduce tissue swelling and pain
taken (Figures 1 and 2). access cavity did not communicate with because it promotes vasoconstriction and
The patient was reviewed the following the pulp chamber, which was located therefore limits the accumulation of tissue
day, where it was found that the extra-oral centrally. The pulp chamber was entirely fluid and the influx of pro-inflammatory
swelling had increased in size. Pain was below the level of the alveolar bone, cells and cytokines.
still present but the patient reported it as indicating some level of sclerosis, which After assessment at hospital, the patient
‘manageable’. The patient was reviewed again may explain why this tooth was at higher was prescribed a 5-day course of amoxicillin
48 hours after the original injury. This time risk of perforation. Only one, central root and metronidazole to prevent infection in
she reported the pain had gone but instead, canal was present. the necrotic tissue. She was also prescribed
she now had paraesthesia in of the right side The CBCT showed bone loss at the dexamethasone (10 mg once/day) for
of her lower lip and chin (distribution of the point where the perforation exited the 1 week, followed by a gradual decrease
right mental nerve) (Figure 3). tooth and another radiolucent area in the in strength. The purpose of the steroid

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Endodontics
a a
b
Figure 5. Sagittal view of LR4, which shows the
path of the perforation is angled distally within
b the crown of the tooth. The radiolucent, fluid-
filled space in the soft tissue (indicated with a
white arrow) is below the alveolar crest.
Monitoring of healing
Review appointments were arranged at
24 hours, 48 hours, 1 week, 2 weeks, 6 weeks
and 4 months. Follow-up is vital in cases
c
of NaOCl injury to monitor symptoms and
sequelae. In some cases, it is necessary to
arrange surgical debridement of the necrotic
tissue11 but, fortunately, in this instance, this
c was not required.
At the 24 hour review, the swelling was
found to have increased in size, but the
patient reported their pain as manageable.
At 48 hours, the swelling was still present
and patient complained of altered sensation
in the distribution of the right mental
nerve. At the 1 week review, the patient
Figure 6. Axial views of LR4, showing the
complained that the right cheek was getting
perforation in the distobuccal aspect of the
bigger and the paraesthesia persisted. By tooth and the location of the pulp chamber
2 weeks, the swelling was starting to reduce, deeper down. Only one root canal is present.
the ulcer in the buccal sulcus was showing Image (a) shows there has been bone loss at the
signs of healing and there had been some point where the perforation exits the tooth. The
sensory recovery in the right side of the white arrow indicates the exit point. Image (b)
lower lip. By 6 weeks, the swelling had shows the correct location of the root canal in
Figure 4. Coronal views of the perforation in LR4
resolved, and the ulcer had healed. However, the centre of the root, while image (c) shows the
and the adjacent area of radiolucency in the soft
the mucosa adjacent to LR4 retained a radiolucent, fluid-filled space in the soft tissue.
tissue. (a) The line of access is angled buccally
within the tooth’s crown and exits at the level of dark, pigmented colour. There was no
the alveolar bone. (b) The pulp chamber is below pain on palpation of the sulcus, but there
the level of the alveolar bone. The most coronal was reduced sulcal depth owing to thick,
point of the pulp chamber is indicated with the
Perforation repair in LR4 commenced
underlying submucosal fibrous tissue. The
arrow. It has sclerosed, making it deeper than approximately 6 weeks after the injury.
paraesthesia took approximately 2 months
might usually be anticipated. (c) The arrow points According to the literature, perforations
to resolve.
out the radiolucent, fluid-filled space in the soft should ideally be repaired immediately, and
tissue at its widest point in the coronal plane. a delay results in a poorer prognosis.12–15
Restorative management Immediate repair prevents infection
Restorative treatment of LR4 was planned from establishing, which results in less
to take place over two appointments, under periodontal destruction, a better peri-
prescription was to reduce the patient’s local anaesthesia, isolated with a rubber radicular environment and more favourable
inflammatory response to the NaOCl because dam, and with an endodontic microscope healing.16 However, in this case, it was
excessive inflammation leads to greater pain to aid perforation repair and intra- impractical to do so owing to the patient’s
and swelling.6 canal visualization. level of distress.

Endodontics
Figure 9. Post-operative image taken

immediately following obturation and restoration
of LR4 shows the swelling has subsided and facial
symmetry has been restored.
Figure 11. Peri-apical radiograph taken at the
a 4-month review shows healing of the area of peri-
apical pathology and no further bone loss.
cavity was dry and there was no bleeding.

Mineral trioxide aggregate (MTA) cement was
carefully packed into the perforation using
a micro-apical placement needle so that it
pushed out the in-growing epithelium. Then,
Figure 7. Post-operative peri-apical radiograph of a layer of glass ionomer cement (GIC) was
LR4 showing root filling and perforation repair. placed to shield the setting MTA cement during
b pulp chamber access. MTA is antibacterial to
a facultative bacteria20 without being cytotoxic to
the periodontal tissues. It is biocompatible and
promotes tissue repair and regeneration.18,21
Furthermore, it has been shown to exhibit
better healing results than calcium hydroxide
based materials.22 This non-surgical approach
to repair was adopted rather than surgically
exposing the perforation site because calcium
silicate-based cements exhibit reduced bond
strength and antibmicrobial activity when set in
contact with blood.23,24
The pulp chamber was accessed and
b a single, large, central canal was found.
Figure 10. Post-operative images taken 4 months Shaping was achieved using nickel–
after the initial injury show the necrotic ulcer titanium rotary files in conjunction with an
has completely healed, normal colour of the ethylenediaminetetraacetic acid (EDTA)-based
mucosa is restored and LR4 has been prepared lubricant. NaOCl (5.25%) and EDTA (17%)
for an onlay. solutions were used to irrigate and disinfect
the root systems and were agitated using an
ultrasonic ‘activator’. EDTA functions to remove
the smear layer and allow better NaOCl
is the most significant prognostic factor in penetration into the dentinal tubules,25 while
treatment success and crestal perforations agitation of irrigants improves the tissue-
carry the worst prognosis.16–18 The histological dissolving properties of NaOCl solutions.26
Figure 8. Post-operative images taken
immediately following obturation and restoration reaction to perforation in this critical zone Between appointments, the canals were
of LR4 show that the necrotic ulcer has healed, is periodontal inflammation and downward dressed using a non-setting calcium hydroxide
but the buccal sulcus retains a dark, pigmented migration of epithelial tissue, resulting in (CaOH) medicament, which has a pH of
colour, 2 months after the initial injury. periodontal pocketing and a higher chance 12.5 and has been shown experimentally
of contamination from the oral environment, to penetrate dentinal tubules and eliminate
which in turn maintains irritation of bacteria within 24 hours.27 Strong antimicrobial
A rubber dam was placed on LR4 and the periodontium.19 activity has also been demonstrated by CaOH
the access cavity was re-opened. The tooth The perforation was repaired non-surgically dressings left for 7 days.28
was examined under a dental operating before accessing the pulp chamber to avoid A gutta-percha (GP) master cone was tried
microscope, and it was found that the original cross contamination. No NaOCl was used to in the canal and a radiograph was taken to
access had deviated and access had not clean the perforation. Under the microscope, it check its position. Obturation was achieved
been gained to the root canal system. The could be seen that gingival tissue had grown with warm vertical condensation and a zinc
level at which the perforation exits the tooth into the opening of the perforation but the oxide–eugenol sealer. The thermoplasticized

Endodontics
GP was deposited in small increments and Perforations may be restorable with after root perforations in dogs’ teeth - a
histological study. Odontol Tidskr 1976; 75:
packed down using pluggers to minimize specialist equipment, and a referral should be
209–220.
shrinkage of the material and risk of air discussed as one of the possible treatment 15. Holland R, Ferreira LB, de Souza V et al.
bubbles. The GP filling extended to just above options with the patient. Reaction of the lateral periodontium of dogs’
the level of the alveolar bone and a thin CBCT scans are a useful assessment tool in teeth to contaminated and noncontaminated
layer of GIC was placed on top to seal it over. treatment planning perforation repairs. perforations filled with mineral trioxide
aggregate. J Endod 2007; 33: 1192–1197. https://
The tooth was definitively restored with a
doi.org/10.1016/j.joen.2007.07.013
composite core build-up. Compliance with Ethical Standards 16. Fuss Z, Trope M. Root perforations: classification
The post-operative radiographic result Conflict of Interest: The authors declare that and treatment choices based on prognostic
(Figure 7) is significant in determining the they have no conflict of interest. factors. Endod Dent Traumatol 1996; 12: 255–264.
tooth’s prognosis. In this case, it showed the Informed Consent: Informed consent was https://doi.org/10.1111/j.1600-9657.1996.
length of the root filling was within 2 mm obtained from all individual participants tb00524.x
17. Sinai IH. Endodontic perforations: their prognosis
of the radiographic apex without extruding included in the article. and treatment. J Am Dent Assoc 1977; 95: 90–95.
beyond it, there were no voids visible within https://doi.org/10.14219/jada.archive.1977.0531
the root filling and there was a good coronal References 18. Saed SM, Ashley MP, Darcey J. Root perforations:
seal. A review of the literature on the influence 1. Baumgartner JC, Cuenin PR. Efficacy of several aetiology, management strategies and
of clinical factors on endodontic outcomes concentrations of sodium hypochlorite for root outcomes. The hole truth. Br Dent J 2016; 220:
canal irrigation. J Endod 1992; 18: 605–612. 171–180. https://doi.org/10.1038/sj.bdj.2016.132
concluded these features are the best https://doi.org/10.1016/S0099-2399(06)81331-2 19. Petersson K, Hasselgren G, Tronstad L.
predictors for treatment success.29 2. Clarkson RM, Moule AJ. Sodium hypochlorite Endodontic treatment of experimental
and its use as an endodontic irrigant. Aust root perforations in dog teeth. Endod Dent
Dent J 1998; 43: 250–256. https://doi. Traumatol 1985; 1: 22–28. https://doi.
Treatment outcomes org/10.1111/j.1834-7819.1998.tb00173.x
org/10.1111/j.1600-9657.1985.tb00554.x
3. Becker GL, Cohen S, Borer R. The sequelae of
The post-operative radiograph reveals that 20. Torabinejad M, Hong CU, Pitt Ford TR, Kettering
accidentally injecting sodium hypochlorite
there was approximately 3 mm of bone loss beyond the root apex. Report of a case. Oral JD. Antibacterial effects of some root end filling
Surg Oral Med and Oral Pathol 1974; 38: 633–638. materials. J Endod 1995; 21: 403–406. https://doi.
in the distal aspect of the tooth. Bone loss is a
https://doi.org/10.1016/0030-4220(74)90097-8 org/10.1016/s0099-2399(06)80824-1
likely outcome when perforation has occurred 21. Torabinejad M, Chivian N. Clinical applications
4. Balto H, Al-Nazhan S. Accidental injection of
at the level of the crestal bone. The likelihood sodium hypochlorite beyond the root apex. Saudi of mineral trioxide aggregate. J Endod 1999;
was increased because 6 weeks had passed Dent J 2002; 14: 36–38. 25: 197–205. https://doi.org/10.1016/S0099-
before the perforation was repaired, meaning 5. Hatton J, Walsh S, Wilson A. Management of 2399(99)80142-3
that apical migration of gingival epithelium the sodium hypochlorite accident: a rare but 22. Holland R, Filho JAO, de Souza V et al. Mineral
significant complication of root canal treatment. trioxide aggregate repair of lateral root
was inevitable. Fortunately, the bone loss BMJ Case Rep 2015; 2015:bcr2014207480. https:// perforations. J Endod 2001; 27: 281–284. https://
did not result in any pathological mobility doi.org/10.1136/bcr-2014-207480 doi.org/10.1097/00004770-200104000-00011
and there has been no persistent pocketing. 6. Patel E, Gangadin M. Managing sodium 23. Farrugia C, Baca P, Camilleri J, Arias Moliz MT.
The patient was happy to report the painful hypochlorite accidents: the reality of toxicity. Antimicrobial activity of ProRoot MTA in contact
S Afr Dent J 2017; 72: 271–274. https://doi. with blood. Sci Rep 2017; 7: 41359. https://doi.
symptoms settled within 4 days following org/10.17159/2519-0105/2017/v72no6a5 org/10.1038/srep41359
the first stage of root canal treatment, and 7. Alkahtani A, Alkahtany SM, Anil S. An in vitro 24. Shalabi M, Saber S, Elsewify T. Influence of
at all follow-up appointments the tooth evaluation of the cytotoxicity of varying
blood contamination on the bond strength and
remained asymptomatic. concentrations of sodium hypochlorite on human
biointeractivity of Biodentine used as a root-end
mesenchymal stem cells. J Contemp Dent Pract
At the 4 month review, the ulcer had 2014; 15: 473–481. https://doi.org/10.5005/ filling. Saudi Dent J 2020; 32: 373-381. https://
completely healed and a normal colour was jp-journals-10024-1565. doi.org/10.1016/j.sdentj.2019.11.005
8. Hülsmann M, Hahn W. Complications during 25. Bystrom A, Sundqvist G. The antibacterial action
restored to the mucosa. All swelling had
root canal irrigation – literature review and case of sodium hypochlorite and EDTA in 60 cases
resolved and normal sensation had returned of endodontic therapy. Int Endod J 1985; 18:
reports. Int Endod J 2000; 33: 186–193. https://doi.
to the lower lip. LR4 had been prepared for an org/10.1046/j.1365-2591.2000.00303.x 35–40. https://doi.org/10.1111/j.1365-2591.1985.
onlay, and the patient was delighted with the 9. Hales JJ, Jackson CR, Everett AP, Moore SH. tb00416.x
outcome of her treatment. Treatment protocol for the management of a 26. Stojicic S, Zivkovic S, Qian W et al. Tissue
sodium hypochlorite accident during endodontic dissolution by sodium hypochlorite: effect of
therapy. Gen Dent 2001; 49: 278–281. concentration, temperature, agitation, and
Conclusions 10. Lam TSK, Wong OF, Tang SYH. A case report surfactant. J Endod 2010; 36: 1558–1562. https://
of sodium hypochlorite accident. Hong Kong doi.org/10.1016/j.joen.2010.06.021
NaOCl is an essential irrigant in root canal J Emerg Med 2010; 17: 173–176. https://doi. 27. Behnen MJ, West LA, Liewehr FR et al.
treatment. However, it is vital that practitioners org/10.1177/102490791001700212 Antimicrobial activity of several calcium
are aware of the caustic effects it can have. It is 11. Farook SA, Shah V, Lenouvel D et al. Guidelines for hydroxide preparations in root canal dentin.
management of sodium hypochlorite extrusion J Endod 2001; 27: 765–767. https://doi.
recommended that an electronic apex locator, injuries. Br Dent J 2014; 217: 679–684. https://doi.
or a working length radiograph, should always org/10.1097/00004770-200112000-00013
org/10.1038/sj.bdj.2014.1099
28. Sjögren U, Figdor D, Spångberg L, Sundqvist
be used to check for perforations before 12. Seltzer S, Sinai I, August D. Periodontal effects of
root perforations before and during endodontic G. The antimicrobial effect of calcium
irrigating with NaOCl. hydroxide as a short-term intracanal dressing.
procedures. J Dent Res 1970; 49: 332–339. https://
In the event of an NaOCl injury, the patient doi.org/10.1177/00220345700490022301 Int Endod J 1991; 24: 119–125. https://doi.
should be informed, a full clinical assessment 13. Beavers RA, Bergenholtz G, Cox CF. Periodontal org/10.1111/j.1365-2591.1991.tb00117.x
should be conducted and appropriate wound healing following intentional root 29. Ng YL, Mann V, Rahbaran S et al. Outcome of
perforations in permanent teeth of Macaca primary root canal treatment: systematic review
treatment and monitoring planned. In severe
mulatta. Int Endod J 1986; 19: 36–44. https://doi. of the literature. Part 2. Influence of clinical
cases, an urgent referral to a maxillofacial unit org/10.1111/j.1365-2591.1986.tb00888.x factors. Int Endod J 2008; 41: 6–31. https://doi.
will be required. 14. Lantz B, Persson PA. Periodontal tissue reactions org/10.1111/j.1365-2591.2007.01323.x

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Claire Burgess Dominic Hassall
An Introduction to a Modern
Procedure for Anterior Composite
Restorations and Black Triangle
Closure Using a Novel Matrix
System: Part 1
Abstract: The Bioclear Method is a modern approach to direct composite restorations that gives both patients and dentists the longevity,
both cosmetically and functionally, that they desire. This article explains the principles of the Bioclear Method and presents clinical cases
where the Bioclear Method has been used. The article also includes examples of black triangle closure, a patient concern that practitioners
have been reluctant to treat in the past using traditional composite methods.
CPD/Clinical Relevance: This article highlights a clinically relevant and modern method that can be used for placing all direct
composite restorations.
Dent Update 2023; 50: 117–125
Patients and dentists look to direct composite Tacoma, WA, USA) is a modern approach to introduced to dentistry in the 1960s.
restorations as a way for replacing existing direct composite restorations that potentially Over time there have been advances
stained or metallic restorations, repairing gives both patients and dentists a systematic with both the composite materials and
chipped or fractured teeth, correcting set of procedures that simplify composite their ability to bond to tooth structure.
the shape of teeth, and correcting spaces techniques to create predicable patient- Development of the acid-etch technique
(including black triangles) between teeth. centred outcomes. by Buonocore, and the Bis-GMA resin
Issues that both patients and dentists by Bowen, transformed composite
have with traditional layered composite restorations.2–5 Bonding to enamel is
restorations is the high level of chipping and Composite resin materials
highly predictable as it consists of 96%
staining that can occur, often within a short Composite resins, a combination of
inorganic apatite.6 Bonding to dentine,
period of time.1 The Bioclear Method (Bioclear, monomers and filler particles, were first
however, still remains less predictable
because it consists of an inorganic
apatite within a collagen and water
Claire Burgess, BDS (Birm), MFGDP (RCS Eng), MSc Restorative + Cosmetic Dentistry matrix.7 The bond with dentine, especially
(UCLan), Smile Concepts, Solihull. Dominic Hassall, BDS, MSc (Manc), FDS RCPS (Glasg), secondary dentine, degenerates over
MRD RCS (Edin), FDS (Rest Dent), RCS (Eng), Restorative, Prosthodontic and Periodontal
time, resulting in reduced long-term
Specialist, Training Institute, Solihull.
stability. The development of the total
etch technique helped to compensate

a b for this by increasing the bonding strength Developing on from these, matrices
of the composite to the dentine. Through for the placement of all direct composite
the application of 37% phosphoric acid to restorations – anterior Class III, diastema
the dentine for a maximum of 15 seconds, closure, posterior Class II, direct composite
the total etch technique removes the smear overlay or direct composite veneer
layer, opens the tubules and decalcifies the were introduced.
coronal intertubular dentine. This results in
a dense collagen network that can then be
penetrated by resin.8–10
The five pillars of the
The method of traditional direct Bioclear method
Figure 1. (a) Anterior and (b) diastema closure composite restorations involves The method encompasses five pillars:
Bioclear matrices. incrementally layering composite as close biofilm removal; composite materials;
to a finished contour of the restoration as cavity design; composite placement
possible, with shaping of the composite, and finishing methods; and anatomical
once cured, being kept to a minimum. matrices (Figure 2). The aim is to combine
Bioclear matrix Finishing routinely involves a combination all elements of composite restorations to
Diamond wedge 3M Filtek composites of discs/burs/polishing cups and pastes. produce predictable long-lasting outcomes.
Twin ring The longevity of an amalgam It can be difficult to simultaneously
restoration may be up to 30 years if all master marginal adaption, form and
clinical stages are optimised.11–13 Traditional shade.16 Traditional layered placed
layered anterior composite restorations composite restorations require a high-skill
Biofilm removal in general dental practice have an annual level to produce predictable long-term
Hot injection moulding DJ Clark cavity prep failure rate of 4.6% at 5 years.14 This is results. The restorations can have flat
Rock star polish influenced by the position of the tooth emergence profiles, textured surfaces,
being restored, the type of restoration, and appear greyer due to increased
patient age, and operator skill 14 Issues with translucency (Figure 3). The aim for the
composites include chipping, especially of development of the Bioclear Method was to
Figure 2. Venn diagram showing the incisal edge areas, rough surface texture, provide all dentists with a systematic set of
components of the Bioclear Method (courtesy of and staining developing at the margins of steps and tools/techniques that simplified
Dr David Clark). the restorations.15 The existing approach of composite procedures to create predicable
the combination of the amalgam material, outcomes. If followed, these steps may
a cavity design, material placement technique allow for longer-lasting and aesthetically
and finishing is predictable for amalgam superior composite restorations.
restorations. Unfortunately, this is not true The aims of the Bioclear Method are to:
for composite restorations.11,12 The same Preserve and respect the biomechanics
predictability from composite restorations of the natural tooth:
as for amalgam restorations would
Replace deficient, missing and diseased
be desirable.
tooth structure;
b The following properties for composite
Thicken and opacify the aged and
materials would be ideal: smooth non-
translucent tooth.
sticky handling, easy to sculpt/contour,
moisture tolerant, non-shrinkage, lack of The majority of anterior composite
water absorption post-cure and good long- systems use a standard three-layer
term polish. technique to achieve biomimetics. These
three layers often consist of a dentine
anatomical-like core, a translucent
The Bioclear Method enamel-like outer layer, and a translucent/
The development of the Bioclear Method transparent incisal edge material. The result
c dates to 2007, when Dr David Clark of the restorations can be an increased level
introduced the anterior Bioclear matrices. of greyness or translucency.
These are patented clear cellulose acetate Bioclear restorations incorporate a
anatomical matrices that can be used to single ‘body’ shade of 3M Filtek Supreme
form the interdental shape of anterior XTE restorative (3M, MN, USA), which helps
restorations (Figure 1). They were invented to mask translucency while providing
to replace non-anatomical clear Mylar a natural appearance. With the Bioclear
strips, used by most dentists to recreate Method a single shade of paste and
the interdental anatomy of the restoration. flowable are used for the restorations.
Figure 3. (a–c) Traditional layered composite The Bioclear matrices became available Therefore, it is important that there is a
restorations showing staining, greyness and in the UK in 2012 and can improve the good shade match between the flowable
chipping (courtesy of Dr Claire Burgess and Dr
emergence profile and shape of anterior and corresponding paste composites. This
David Clark).
composite restorations. is the case for 3M Filtek dental restoratives,

Units suitable for this include the BA

Ultimate Air Polisher (NSK, Stevenage,
UK) (Figure 6), Aquacare Unit (Velopex
International, London, UK), Dentoprep
Microblaster (RONVIG Dental, Denmark)
and EMS (EMS, Switzerland) units.
Different units use a variety of powders
with different hardness measurements.
Aluminium trihydroxide powder has
a similar hardness to dentine and is
therefore safe to be used on dentine. It
also lightly abrades the enamel, which aids
enamel bonding. It is therefore ideal for
biofilm removal.
The biofilm removal protocol is
Figure 4. The five pillars of the Bioclear Method (courtesy of 3M and Dr David Clark). as follows:
Dry the whole tooth;
a a Disclose the tooth with two-tone
disclosing solution;
Abrade the tooth with a combination of
water and aluminium trihydroxide.
Modern cavity design

A full consideration is beyond the scope of
this introductory article and is covered in
b more detail within the Syllabus on Learning
b
Centre Courses (www.dominic-hassall-
training.co.uk/bioclear-courses). It involves
the modern radius wall/bevel, which allows
for a gradual transition of the composite
from thick to thin. This is discussed further
in the Part 2 of the present series. This
produces a polychromatic effect and allows
for a warmer/higher chroma neck shade
Figure 5. (a,b) Teeth disclosed showing biofilm c
(courtesy of Dr David Clark).
and a more natural appearance. When
the composite is thicker, it then masks
the underlying colour of the tooth. The
gradual transition allows for the use of a
and is one of the reasons they work well single shade of composite, as the colour
with the Bioclear Method. blend with the tooth is better. The radius
Each of the Bioclear Method’s five bevel also allows for the composite to be
core pillars is mandatory for producing a in compression, and for an increase in the
predictable result (Figure 4): enamel surface area available for bonding
Figure 6. (a–c) Ultimate Air Polisher and because of the preparation shape, and it
Biofilm removal; Aquacare unit to remove biofilm. aims to be additive.20
Modern composite cavity design;
Anatomically shaped matrices;
Anatomical Bioclear matrices
Warm injection moulding of composite,
owing to microleakage, chipping and All Bioclear matrices are anatomical
preferably 3M Filtek Supreme
staining. Biofilm may not be predictably and consist of cellulose acetate. They
XTE restorative;17
are available in two thicknesses – 50 or
Two-step ‘rock star’ (high surface) polish. removed by the action of etch alone
75 microns. The aim is for all matrices
(37% phosphoric acid). It needs to be
to seat subgingivally by approximately
Biofilm removal physically removed, but because it is
2–3 mm and form the shape interdentally
It is well reported that biofilm removal in invisible to the naked eye, it needs to
(Figure 7). Thus, after injection moulding,
relation to indirect dentistry can result in first be disclosed (Figure 5). Removal of no finishing is required between the
increased bond strengths.13,18,19 Biofilm biofilm is straightforward and involves teeth – an area that all dentists struggle to
removal should also form an essential part particle abrasion of the tooth with powder refine and polish.
of any form of modern direct dentistry. If and water at pressure.13,20 The particle The patented anatomical matrices
the biofilm is not physically removed, it can size and pressure vary depending on the allow control over both the interproximal
result in cosmetic failure of restorations recommendations of the unit manufacturer. shape, and the gingival emergence profile

Figure 8. Classification of Bioclear matrices: anterior/diastema closure matrices, 360° veneer matrices,
black triangle matrices. (Courtesy of 3M and Dr David Clark).
Figure 7. (a,b) Bioclear matrix in situ
seating subgingivally.
Warm injection moulding of composite Improved marginal integrity

Warm injection moulding of – resulting in a reduction in
composite, preferably using 3M Filtek microleakage, secondary caries, and
of the restoration. There are three main
Supreme XTE restorative composite, is post-operative sensitivity; 30
families of Bioclear matrices (Figure 8):
gaining popularity.21–23 Decreased voids within the material –
Anterior and diastema closure matrices; nearing monolithic composite;31,32
The HeatSync heater heats the entirety
360° veneer matrices; Stronger restorations with less
of several compules of composite to a
Black triangle closure matrices. chipping or fewer fractures;31,32
constant temperature of 68°C (Figure 9).24–26
Improved cure rates and depths33–36
It is important to always heat more
Anterior and diastema closure matrices Single increment placement,
compules of composite than thought
These matrices are the traditional Bioclear reduction in layers;
required because injection moulding
matrices and can be used in all situations. Easier manipulation and less
requires overfilling. Compules that have not
They are made from Mylar and so produce technique sensitive method for
been used can be stored and reheated for
a smooth hygienic surface between teeth. the operator;
the next patient of that shade. Composite
They can be used for routine Class III Quicker restorative placement.
has a very poor thermal conductivity, so
and IV restorations, as well as for closing within 10–15 seconds of removal from the When undertaking the Bioclear
diastemas, triangles and reshaping peg heater, the composite temperature drops Method, total etch is advised for anterior
laterals. If contacts are present, then close to 25°C (Figure 10).27 Therefore, a composite restorations. If required, a
the heavy duty 75-micron matrices are high degree of warming is necessary. The standard bonding protocol would be
preferable to the 50-micron matrices. If subsequent flowability of the composite followed for sealing exposed dentinal
diastemas are present, then the 50-micron tubules prior to injection moulding.
also drops with temperature. The warmer
matrices are preferable because there When using 3M Scotchbond Universal
the composite, the better it flows and
is less matrix thickness to overcome on Plus adhesive, this would involve
adapts to the tooth/matrix, and the easier
closure of the diastema. agitation of the adhesive over the open
it is to inject. 3M studies support and show
dentinal tubules for 20 seconds before
that there is no change to the colour or
air drying for 5 seconds (or until there is
360° veneer matrices chemical stability/properties of warmed
no more visible fluid movement), then
These matrices, if placed mesially and 3M composite capsules (including 3M
light curing for 10 seconds.37,38 Injection
distally on a tooth, will wrap around the Filtek Supreme XTE, 3M Filtek Universal, and
moulding (as patented by Bioclear) is the
tooth completely, by 360 degrees. They are 3M Filtek One Bulk Fill restorative) when
combination of 3M Scotchbond Universal
75 microns thick, making them more rigid warmed up to 70oC (158oF) for up to 1 hour.
Plus adhesive, Filtek Supreme Flowable
and thus, ideal for rebuilding fractured 3M Filtek Supreme Flowable restorative restorative and Filtek Supreme XTE
teeth, increasing the lengths of teeth and 3M Filtek Bulk Fill Flowable restorative restorative.
vertically and for veneering. syringes may be warmed up to 70oC for up Specifically, Scotchbond Universal Plus
to 1 hour, up to 25 at a time. adhesive is applied and air thinned, Filtek
Black triangle matrices Advantages of using heated Supreme Flowable restorative is then
These are ideal for closure of black triangles composite include:28,29 applied to gingival and line angle areas,
following orthodontics, where the teeth are Material flows better allowing superior followed immediately with Filtek Supreme
aligned with contacts. adaption to the tooth; XTE restorative which is immediately

Figure 10. The heating and cooling curve of composite materials (courtesy of 3M and Dr David Clark).
all restorations. nanometer-sized particles. The nanoclusters

b Three-step ‘Rock Star’ polish wear at a similar rate to the surrounding
There are many techniques for polishing resin matrix during abrasion, which results
composite. The Bioclear Method follows in longer lasting strength and shine of
the same protocol for all composite this material.39
restorations. There are three stages:
1. Shofu Brownies (Shofu Dental,
Germany) with water to finally Black triangle closure
marginate the restoration and the This is a concern of patients that is often
tooth palatally. misunderstood and underestimated by
2. Magic Mix (Bioclear) with a prophy dentists. Black triangles have been ranked
cup at medium speed. Magic Mix is as the third most upsetting cosmetic
a mixture of varying size particles of feature behind visible caries and visible
aluminium oxide within a green gel crown margins. They were ranked as worse
suspension. The result of this should than dark colour and crowded teeth.42 This
leave a very smooth surface to the is especially important regarding adult
composite – to almost have the orthodontics where black triangles will
Figure 9. (a,b) Bioclear HeatSync heater. appearance of etched enamel. occur for an estimated 65% of patients
3. ‘Bioclear rock star polish’ – involves undergoing orthodontics to straighten
the use of a diamond impregnated their teeth.40
cup (SS White Jazz polisher, SS White, In the past, the treatment for black
and directly injected into the flowable
NJ, USA). This is used with light and triangles has been traditional layered
restorative using a composite compule.
heavy pressure with water coolant. composite restorations, which can be
Only after the cavity/matrix has been
Once complete the composite should prone to staining, chipping and overhangs,
overfilled and massaged is the composite appear shiny, whether wet or dry. or more biologically aggressive indirect
complex light cured. It is always important
The polish of the composite can procedures, such as indirect veneers
to follow the composite manufacturer’s
rival porcelain. Attentive use of finishing (Figure 11).
curing recommendations. The injection
methods is still necessary for surface The Bioclear Method is a preparation-
of the paste composite displaces the free treatment for black triangles. 41–45 and
quality and natural appearance of the final
Scotchbond adhesive and flowable uses a custom black triangle kit (Figure 12).
restoration. One must also appreciate the
composite. The aim of Bioclear injection angles of the teeth and their surface shape It uses a gauge, which measures the
moulding is to achieve a final restoration so as to form specular highlights. triangle, and colour codes the size of
that consists of approximately 80% paste The anterior Bioclear Method is taught the triangle to the colour of the matrix
composite. This is beneficial for both using 3M Filtek Supreme XTE restorative (removing the need for the practitioner
functional strength and polish retention. (body shades). The body shades are used to customize the size of the emergence of
The final monolithic mass is stronger than as they allow for a better polychromaticity the matrix, which would be required using
traditionally layered composites.31,32 (colour blend) than enamel shades, the anterior/diastema closure matrices).
After removal of the matrices, the which have a higher translucency and The black triangle matrices are scalloped
gross excess is removed with diamond less polychromaticity. to reduce the amount of shaping and
burs, and shaped with discs. The 3M nanocomposites use a patented finishing after injection moulding. These
systematic shaping is the same for process that creates unique clusters of matrices are ideal for well-aligned teeth,

a a h
b i
j
c
Figure 11. (a,b) Traditional layered composite

restorations for black triangle closure showing
overhangs and gingival inflammation. k
Figure 12. Bioclear black triangle kit containing

black triangle measuring gauge and assorted f
black triangle matrices.
n
but may not be ideal for the treatment of
diastemas or misaligned teeth where the
misalignment is to be corrected.
The following case is a patient who
had upper black triangles following g
orthodontics (Figure 13). 0
The black triangle gauge measured the
size of the triangles, and the corresponding
coloured small black triangle matrices
were selected and tried in to confirm the
emergence profiles and complete triangle
closure. Contacts were lightened where
necessary with Tru-Contact Saws (Bioclear) Figure 13. Clinical black triangle. (a) Pre-treatment smile. (b) Pre-treatment upper anterior black
to allow seating of the matrices (if the triangle. (c) Black triangle gauge measuring the size of the triangles. (d) Try-in upper black triangle
contacts are too tight, the matrix deforms matrices matching gauge size. (e) Rubber dam isolation and biofilm removal. (f) Matrices in situ for
on seating). The teeth were isolated injection over-moulding of first tooth, UR1. (g) Injection over-mould of second tooth, UL1. (h) After
with heavy-duty latex-free rubber dam sculpting of the upper centrals. (i) Injection over-mould of third tooth, UL2. (j) Post-sculpting, pre-
(UnoDent, UK) and the biofilm removal polish of the front four teeth. (k) Immediately following rubber dam removal. (l) Immediately post-
treatment. (m) The upper teeth at the 1-week review. (n) After upper and lower Bioclear black triangle
protocol was followed. The matrices were
closures. (o) Post-treatment smile.
inserted, and the teeth injection moulded.

Once a tooth had been injection moulded, As with any restorative technique, a
the matrices were removed from that tooth, dentists should have thorough
and the tooth finished with burs and discs understanding of all treatment aspects
before proceeding with the next tooth to including functional occlusion and
be injection moulded. The process was the periodontal-restorative interface,
repeated until all teeth had been injection to prevent premature failure either
moulded. All teeth were then finished restoratively, functionally, or aesthetically.
to ‘grade’ together with discs and finally
polished using the three-step polishing Author’s view
protocol. The occlusion was confirmed, and b
My experience of the longevity of Bioclear
if any adjustments were required, the teeth Method restorations is that they are
were re-polished afterwards. superior to traditional layered composites.
The patient was provided with a new Having solely undertaken Bioclear Method-
fixed and removable retainer. style composite restoration since May 2015,
Ideally, 12–18-month maintenance I have only experienced three restoration
appointments are advised, at which time failures out of over 1000 completed
restorations may need re-polishing with the Bioclear restorations.
SS White polishing cup. Figure 14 is a 6-year
post-treatment photo of a black triangle
case treated using the Bioclear Method. c
Conflict of Interest: The authors declare that
Black triangles are also often a post-
they have no conflict of interest.
treatment concern for periodontal patients.
Informed Consent: Informed consent was
Treatment for these triangles has been
obtained from all individual participants
avoided in the past owing to concerns
included in the article.
about creating ledges/overhangs/
plaque traps, thus potentially worsening
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a
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chipped composites. (c) On smiling after Bioclear (b) 6.5 years following Bioclear restorations.
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2204073381 04/22
Dental Trauma
Enhanced CPD DO C
Asma Keshtgar
Joseph Noar
Should Small Volume CBCT Imaging

be used for Managing Complex
Dental Trauma? A Case Report
Abstract: Avulsion injuries are a severe type of dental trauma that can result in sequelae such as root resorption, ankylosis and tooth
loss. We report on an unusual case where a previously avulsed, replanted and root-treated UR1 did not erupt for 3 years, and then
spontaneously erupted. Findings from a small volume CBCT scan showed significant internal root resorption extending to the root wall,
which supports an explanation of the internal root resorption removing an area of ankylosis and allowing the tooth to erupt. The value of
using dental CBCT scanning is highlighted in managing complex dental trauma.
CPD/Clinical Relevance: The use of a small volume CBCT scan can give insight into the clinical presentation of post-traumatic
tooth movement.
Dent Update 2023; 50: 127–129
Dental trauma is common and bone occurs due to the absence of the 1 μSv and 8.3 μSv.8 Although the European
affects approximately one quarter of periodontal membrane. The risk of ankylosis Commission provide a range on the
schoolchildren worldwide.1 Findings can be estimated at 90% in cases of avulsion effective dose of small volume cone beam
from the Children’s Dental Health Survey injuries with greater than 30 minutes’ dry computed tomography (CBCT) scans for
2013 reported that, on average, one in 10 time, or greater than 90 minutes’ total extra- children at 16–214 μSv,9 the large exposure
children had sustained previous dental alveolar time. Owing to their complexity, a range makes it difficult to generalize the
trauma of their upper incisors.2 Almost multidisciplinary setting is often best suited radiation doses from CBCT scans. A meta-
twice as many boys (11.2%) presented with for management of such cases.5 Effective analysis published in 2015 provides a
any traumatized incisors compared with management of dental trauma is important comparison of the effective doses for nine
girls (6.9%).3 for function, aesthetic and social wellbeing. CBCT units based on the varying field of
An avulsion injury, where the tooth A negative association between untreated view sizes.7 It is important for clinicians to
is completely knocked out of the mouth, dental trauma and quality of life has be aware of the range of radiation dose
accounts for 0.5–3% of all dental trauma previously been reported.6 from the CBCT unit being used to make an
to permanent teeth.4 A significant risk for The effective radiation dose, a quantity informed decision on whether taking such
an avulsion injury is healing by ankylosis, with direct correlation to biological risk,7 a scan is justified. Some newer models have
whereby a union between tooth and for a peri-apical radiograph is between reduced the effective dose for a standard
exposure, for example in one unit using
8 x 8 cm field of view CBCT, the effective
dose was reduced by 57% following
Asma Keshtgar, BDS, MJDF, MClinDent, MOrthRCS (Eng), Senior registrar; Joseph Noar, the use of 0.5 mm of additional copper
MSc, BDS, FDSRCS (Ed), FDSRCS (Eng), DOrthRCS (Eng), MOrthRCS(Eng), FHEA,
filtration compared with an earlier model
Consultant/Honorary Associate Professor and Professor of Orthodontics; Royal National
of a manufacturer’s unit.10 Furthermore, a
ENT and Eastman Dental Hospitals, University College London Hospitals NHS Trust.
20-fold range of effective dose for dental
CBCT scanners was found in another

Dental Trauma
Figure 3. Axial, coronal and sagittal views of the UR1 showing extensive internal resorption.
as that of the OP300 Maxio CBCT scanner radio-opacity consistent with restorative
(Instrumentarium Dental, Finland) with the material within the root canal system. The
child effective dose of a 5 x 5 cm maxilla periodontal ligament space was visible in
scan reported as 16 μSv12 and the CS 9000 most, but not all, areas around the root,
scanner (Carestream Dental, Atlanta, GA, indicating potential areas of ankylosis.
USA) child phantom 4 x 5 cm maxilla dose
reported as 16 μSv.7 Clinical records
Following full records, including clinical
Clinical case photographs (Figure 2), orthopantomogram
Figure 1. Peri-apical radiograph of UR1 taken in and lateral cephalogram in February
November 2020. Initial presentation
2021, a small volume CBCT of the UR1
A medically fit and healthy 11-year-old was requested to assess for ankylosis and
a male presented on the joint orthodontic–
pathology. Multiple cancelled appointments
paediatric clinic at the Royal National ENT
resulted in a delay of patient care. Figure 3
and Eastman Hospital in November 2020
shows different views captured using the
with concerns about his ‘short upper right
small volume CBCT taken in June 2021. The
front tooth’. The patient presented with
CBCT images show significant internal root
a Class II division 1 malocclusion and a
resorption of the previously avulsed and
history of dental trauma to the upper
root-treated UR1, extending to the root wall
right central incisor (UR1). The UR1 was
b of the tooth.
avulsed in a skiing accident 3 years prior to
presentation, in 2017, and had previously
been replanted and root treated. Reassessment
On examination, there was an Interestingly, when the patient attended for
additional finding of molar–incisor treatment planning in September 2021, he
hypomineralization (MIH) affecting had noted that over the previous 2 months
the UR6, UL6 and LR6, but otherwise the UR1 had gradually ‘come down into the
c no obvious pathology apart from the mouth’ and not caused pain or infection
traumatized incisor. The incisal edge of the (Figures 4 and 5). The UR1 incisal edge was
UR1 was 4.5 mm more gingival than the 1 mm more gingival than the incisal edge
incisal edge of the UL1 and the gingival of the UL1; the UR1 had erupted by 3.5 mm
margin of the UR1 was 1.5 mm more since initial presentation. Furthermore,
apical than that of the UL1 (Figure 5a). The there was a significant improvement in the
upper incisors were not tender to lateral gingival margin height. The UR1 was non-
Figure 2. (a–c) Clinical photographs taken in or vertical percussion, not mobile, not mobile, not tender to percussion and there
February 2021. discoloured and not associated with pain was no evidence of an abscess, swelling
or any sinus or abscess. The percussion or sinus tract. Slight grey discolouration
tone of the UR1 sounded normal in relation of the UR1 was noted. While initially the
to the adjacent incisor teeth. The UR1 was preferred plan was to attempt orthodontic
study, encouraging optimization of dose negative, while UR2, UL1 and UL2 were extrusion and alignment of the UR1, the
through appropriate selection of exposure positive to ethyl chloride sensibility testing. patient and family were now happy with
parameters and field of view size.11 The The patient’s family had noted that the appearance of this tooth. Following
CBCT machine used in this reported case the position of the UR1 had not changed discussion of the treatment options,
was the 3D Accuitomo 170 (J Morita, Japan), since the tooth was replanted in 2017. the patient and parents decided not to
with the child phantom 4 x 4 cm maxilla Radiographic investigation using a peri- undertake any orthodontic intervention and
‘standard’ scan reported as 28 μSv.7 Modern apical radiograph (Figure 1) revealed accept that the UR1 is likely to be lost in the
radiation doses can be even lower, such the UR1 had a short root filling and a future and require replacement.

Dental Trauma
Should small volume CBCT scans be taken in 3. Blokland A, Watt RG, Tsakos G, Heilmann A.
all dental trauma cases? Traumatic dental injuries and socioeconomic
The authors do not advocate taking position – findings from the Children’s
small volume CBCT scans in all cases of Dental Health Survey 2013. Community Dent
dental trauma, particularly during the Oral Epidemiol 2016; 44: 586–591. https://
immediate management, which is often doi.org/10.1111/cdoe.12252
time dependent. However, the authors 4. Andreasen JO, Andreasen FM. Avulsions.
do suggest use of small volume CBCT In: Textbook and Color Atlas of Traumatic
Figure 4. Frontal photograph taken in
scans during the medium- to long-term Injuries to the Teeth. Copenhagen: Blackwell
September 2021.
management of complex dental trauma Munksgaard, 2007; 444–488.
a cases, such as root fractures, avulsion 5. Day P, Gregg T. Treatment of avulsed
and luxation injuries.The comprehensive permanent teeth in children. Faculty Dental
investigation can aid decision making
Journal 2012; 3: 166–169.
for the most effective treatment plan. In
6. Bendo CB, Paiva SM, Torres CS et al.
all cases, a risk–benefit analysis should
Association between treated/untreated
be considered, with the risks of missing
traumatic dental injuries and impact on
important diagnostic and prognostic
quality of life of Brazilian schoolchildren.
information from a two-dimensional
Health Qual Life Outcomes 2010; 8: 114.
radiograph compared with the risks of
b https://doi.org/10.1186/1477-7525-8-114
exposure to small volume CBCT scanning.
7. Ludlow JB, Timothy R, Walker C et al.
Effective dose of dental CBCT – a meta
Conclusion analysis of published data and additional
The limitations of conventional radiographs data for nine CBCT units. Dentomaxillofac
that provide two-dimensional views Radiol 2015; 44: 20140197. https://doi.
of three-dimensional objects should org/10.1259/dmfr.20140197
be appreciated. 8. European Commission. Radiation Protection
In cases where an ankylosed tooth 136. European Guidelines on Radiation
Figure 5. Photographs taken in (a) February 2021 has spontaneously erupted, consideration Protection in Dental Radiology. The safe
and (b) September 2021 showing the relationship
should be given to the possibility of use of radiographs in dental practice. 2004.
between UR1 and UL1.
significant internal resorption removing the Available at: https://op.europa.eu/en/
area of ankylosis. publication-detail/-/publication/ea20b522-
Use of small volume CBCT scans should 883e-11e5-b8b7-01aa75ed71a1 (accessed
be considered in cases of complex trauma
Discussion to allow visualization of the crown, root,
February 2023).
9. European Commission. Radiation protection
How did the UR1 spontaneously erupt after root canal system, and the relationship
No 172: Cone beam CT for dental and
3 years of no movement? between the tooth and surrounding
Maxillofacial radiology. Evidence based
A postulated cause of eruptive movement structures in three dimensions.
guidelines: a report prepared by the
of the UR1 is due to an area of previous
Sedentexct project. 2012. Available at:
ankylosis between the root and alveolar Compliance with Ethical Standards
https://www.sedentexct.eu/files/radiation_
bone being freed up due to the internal Conflict of Interest: The authors declare that
protection_172.pdf (accessed February
resorption extending to the root wall. This they have no conflict of interest.
2023).
would explain why the UR1 had not been Informed Consent: Informed consent was
obtained from all individual participants 10. Ludlow JB, Ivanovic M. Comparative
mobile, but had gradually erupted over a few
included in the article. dosimetry of dental CBCT devices and
months. Another possible explanation of this
64-slice CT for oral and maxillofacial
delayed eruption may be that there was a
radiology. Oral Surg Oral Med Oral Pathol
root fracture at the point of the resorption: Acknowledgements
however, this is likely to have resulted in a Oral Radiol Endod 2008; 106: 106–114.
The authors thank Mr Simon Harvey,
sudden tooth movement and mobility of the https://doi.org/10.1016/j.tripleo.2008.03.018
Consultant Dental and Maxillofacial
coronal aspect of the UR1, which was not the 11. Pauwels R, Beinsberger J, Collaert B et al;
Radiologist, for his input and kindly
case in this patient. reviewing this article. SEDENTEXCT Project Consortium. Effective
This case demonstrates the value of a dose range for dental cone beam computed
small volume CBCT scan, which allowed the References tomography scanners. Eur J Radiol 2012;
comprehensive assessment of both the root 1. Glendor U. Epidemiology of traumatic dental 81: 267–271. https://doi.org/10.1016/j.
system and the relationship between the injuries – a 12 year review of the literature. ejrad.2010.11.028
tooth and alveolar bone. The CBCT images Dent Traumatol 2008; 24: 603–611. https:// 12. Ludlow, J. Report of dosimetry of
clearly illustrated the extent of internal root doi.org/10.1111/j.1600-9657.2008.00696.x orthopantomograph OP300 Maxio A
resorption to the root wall, and therefore 2. Pitts N, Chadwick B, Anderson T. Children’s panoramic and variable volume CBCT unit
aided in understanding the likely cause of the Dental Health Survey 2013. Report 2: Dental for maxillofacial and dento-alveolar imaging.
unusual spontaneous eruption of the UR1 Disease and Damage in Children: England, Final Report. North Carolina Oral Health
and its poor long-term prognosis. Wales and Northern Ireland, 2015. Institute, 2014; 27.

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Dental Traumatology
Enhanced CPD DO C
Rosemary Potter
Clare Granger
An Anaphylactic Replantation:
Milk Allergy, Tooth Avulsion and
Appropriate Storage Media
Abstract: Cow’s milk is considered one of the gold standard storage media for avulsed teeth, and it is readily available. However, with
the high prevalence of allergy to this milk, there is a potential danger of anaphylaxis when used as a storage medium. Its use and that of
alternative storage media is discussed.
CPD/Clinical Relevance: There is a potential for anaphylaxis when cow’s milk is used as a storage medium for an avulsed tooth.
Dent Update 2023; 50: 131–133
There are many recommended media for management. Medically, the patient department and treated for
the immediate storage and transportation had a dairy allergy, but was otherwise anaphylaxis.4 The source of anaphylaxis
of avulsed permanent teeth following fit and well. History taking revealed was attributed to trace amounts of milk
dental trauma.1 Cow’s milk is considered that he had suffered a facial and dental on the tooth. No further attempts to
one of the gold standard storage media, injury while playing football, which replant this tooth were made.
and is readily available.1,2 However, there resulted in avulsion of a permanent This case identifies the importance
is a high prevalence of allergy to cow’s maxillary central incisor. The avulsed of considering allergy with tooth
milk in children, which is estimated to be tooth was not replanted at the scene storage media following avulsion and
0.25–4.9% worldwide, with approximately 1 of injury, but was placed in milk what alterative storage media are
in 40 children affected within the UK.3 This for circa 90 minutes while seeking available.
article highlights the potential danger with
emergency care. At the local accident
regard to cow’s milk as a storage medium
for avulsed permanent teeth and discusses
and emergency department, the Cow’s milk allergy
tooth was rinsed with saline and then Cow’s milk allergy (CMA) is one of the
alternative storage media.
replanted. However, the tooth was highest prevalent allergies in children,
promptly removed when the patient with approximately 1 in 40 children
Case began to experience wheezing, affected in the UK.3 To put this into
A 7-year-old male was referred to the urticaria, pruritus and significant context, it has a similar prevalence
Community Dental Service for urgent distress. He was immediately to that of peanut allergy.5 CMA is an
trauma review and prosthodontic transferred to the resuscitation immune-mediated reaction to proteins
within milk and is categorized according
to the underlying immune-mediated
Rosemary Potter, BSc (Hons), BDS (Hons), MFDS RCS (Glas), Dental Core Trainee;
mechanism. They are classified as
Clare Granger, BSc (Hons), BDS (Hon), MFDS RCS (Glas), MDPH, Senior Dental Officer;
immunoglobin E (IgE) mediated, non-
Community Dental Service, Harrogate District Foundation Trust, North Yorkshire.
IgE or as a combination of the two.6
CMA is an allergy that is often outgrown

Dental Traumatology
in adulthood. The reason for this is not lacking active toxic components.13 PDL avulsed teeth.22,23 Soy milk contains
fully understood. 7 cells have been shown to survive for up a high content of proteins, amino
to 24 hours, with low fat and chilled milk acids, vitamins and minerals, which
preferred for maintaining cell vitality.14 are essential for cell maintenance
Avulsion injuries Furthermore, it is also usually readily and growth. Soy milk also possesses
Avulsion is considered one of the most available and is often considered the gold a physiological pH and osmolality.23
severe forms of dental trauma. It is the standard against which other storage However, it is important to note the risk
complete displacement of the tooth media are referenced.13,14 of a cross-allergy with a high proportion
from its socket. Tooth avulsion accounts of people with an allergy to cow’s milk
for 0.5–16% of all dental injuries.8,9 A similarly having an allergy to soy milk.24
Hank’s balanced salt solution (HBSS)
systematic review revealed that the most
HBSS is a sterile, physiologically balanced
frequent location for dental trauma to
isotonic standard salt solution. PDL cells Almond milk
occur was at home, followed by at school
have been shown to survive in HBSS for There are very few studies that have
and then in the street.10 Replantation of
up to 48 hours.15 This is often considered investigated almond milk as a storage
permanent teeth at the time of the injury
another gold standard, along with cow’s medium. In vitro studies have identified
is important to improve the chance of a
milk, and used as a comparison reference it to be inferior to that of low fat cow’s
favourable outcome; however, this is not
for other storage media. HBSS however, milk in terms of PDL cell viability.24 It
always possible for many reasons. When
is not readily available in the UK. In the is also important to note that many
replantation is not feasible at the time
US, ‘Save-A-Tooth’ boxes are available people are allergic to tree nuts, such
of injury, the tooth should be placed in a
for purchase. These contain HBSS and as almonds.25
storage medium. This should take place
enable schools, parental homes and other
immediately to avoid dehydration of the
facilities to have an appropriate storage
root surface. A variety of storage media
medium for an avulsed tooth if required.16
Conclusion
has been suggested.1 The IADT suggested that, after
The authors of this article have been
unable to find the equivalent available for cow’s milk, the descending order of
Storage media sale in the UK. preference for storage media is: HBSS;
saliva; or saline, which are suitable and
The International Association of Dental
convenient storage media.1 Whereas
Traumatology (IADT) recommend the Saliva
Despite being the most readily the BSPD guidelines for tooth avulsion
use of cow’s milk, Hank’s balanced
available, saliva is not a very effective of permanent teeth in children suggest
salt solution (HBSS), saliva or saline
storage medium. This is due to its non- that ‘if immediate replantation is not
in descending order of preference, as
physiological osmolality and high content possible, place the tooth in a vessel
suitable and convenient storage media.1
of enzymes and micro-organisms.17 As containing suitable storage media – in
The British Society of Paediatric Dentistry
such it, it is not recommended for use for order of preference: milk, physiological
(BSPD) guideline for tooth avulsion of
longer than 30 minutes’ storage.18 saline or saliva’.11 HBSS is not mentioned
permanent teeth in children suggests
by the BSPD guidelines, which is most
that ‘if immediate replantation is not
likely to be due to its lack of availability
possible, place the tooth in a vessel Saline
in the UK, rather than its properties as a
containing suitable storage media: in This is an isotonic solution and has a
storage medium.
order of preference: milk, physiological comparable pH with PDL cells. It lacks
Cow’s milk is often considered the
saline or saliva’.11 Both guidelines nutrients and cannot maintain the
storage medium of choice for avulsed
recommend cow’s milk in the first metabolism of the PDL cells. It has been
teeth when replantation is not possible
instance as a suitable and convenient advised that it is not appropriate storage
at the scene of injury.1,2,9 This is due to
storage medium. medium for longer than 10 minutes’
its availability, low cost and its ability
use.19,20
to maintain the vitality of PDL cells.12,16
Properties of an ideal storage medium However, we must be cautious when
Readily available; Non-dairy milks suggesting this as a storage medium
Physiologically compatible pH with A survey in the UK suggested that non- due the high prevalence of cow’s milk
root surface periodontal ligament dairy or plant-based milks are increasing allergy in the population. 3 As a dental
(PDL) cells; in popularity, with almost a quarter of the professional when providing telephone
Physiologically compatible osmolality population consuming them.21 Studies advice it is essential that the medical
with root surface PDL cells; on the potential of non-dairy milks as an history is checked prior to suggesting a
Presence of nutrients and appropriate storage medium for avulsed suitable storage medium. If the patient
growth factor.12 teeth have been carried out, with the has a cow’s milk allergy, an alternative
main focus on soy milk.22,23 storage medium should be suggested.
Cow’s milk With the increasing popularity of
Cow’s milk is considered an acceptable Soy milk plant-based milks, and with further
storage medium owing to its There have been multiple studies research into these as appropriate
physiological pH (6.5–7.2) and osmolality. concluding that soy milk can be a storage media, there may be a time
It also possesses essential nutrients, while suitable alternative storage medium for when plant-based milks are also

Dental Traumatology
recommended as suitable storage media IgE-mediated cow’s milk allergy. 10: 158–165. https://doi.org/10.5005/
in guidelines. As plant-based milks can J Allergy Clin Immunol 2007; 120: jp-journals-10005-1427
also be allergenic, caution with their use 1172–1177. https://doi.org/10.1016/j. 17. Blomlöf L, Otteskog P, Hammarström L.
is advised. jaci.2007.08.023 Effect of storage in media with different
The authors suggest that current 8. Glendor U, Halling A, Andersson ion strengths and osmolalities on human
guidelines could be reviewed to L, Eilert-Petersson E. Incidence of periodontal ligament cells. Scand J
consider, or highlight, the potential risk traumatic tooth injuries in children Dent Res 1981; 89: 180–187. https://doi.
of allergy. Furthermore, we recommend and adolescents in the county of org/10.1111/j.1600-0722.1981.tb01669.x
that a question on cow’s milk allergy Västmanland, Sweden. Swed Dent J 18. Lekic PC, Kenny DJ, Barrett EJ. The
be added as routine item when giving 1996; 20: 15–28.
influence of storage conditions on the
telephone advice on avulsion injuries of 9. Andreasen JO, Andreasen FM.
permanent teeth, to ensure a suitable clonogenic capacity of periodontal
Avulsions. In: JO Andreasen, FM
storage medium is used and possible ligament cells: implications for tooth
Andreasen, L Andersson (eds).
anaphylaxis averted. replantation. Int Endod J 1998; 31:
Textbook and Color Atlas of Traumatic
137–140. https://doi.org/10.1046/j.1365-
Injuries to the Teeth. 4th edn. Oxford:
Compliance with Ethical Standards 2591.1998.00138.x
Wiley‐Blackwell, 2007; 444–488.
Conflict of Interest: The authors declare 19. Patel S, Dumsha TC, Sydiskis RJ.
that they have no conflict of interest. 10. Azami-Aghdash S, Ebadifard Azar F,
Determining periodontal ligament (PDL)
Informed Consent: Informed consent Pournaghi Azar F et al. Prevalence,
cell vitality from exarticulated teeth
was obtained from all individual etiology, and types of dental
stored in saline or milk using fluorescein
participants included in the article. trauma in children and adolescents:
systematic review and meta-analysis. diacetate. Int Endod J 1994; 27: 1–5.
Med J Islam Repub Iran 2015; 29: 234. https://doi.org/10.1111/j.1365-2591.1994.
References
1. Fouad AF, Abbott PV, Tsilingaridis 11. Day P, Gregg T. Treatment of avulsed tb00220.x
G et al. International Association of permanent teeth in children. UK 20. Andreasen JO, Schwartz O. The effect of
Dental Traumatology guidelines for National Clinical Guidelines in saline storage before replantation upon
the management of traumatic dental Paediatric Dentistry. 2012. Available dry damage of the periodontal ligament.
injuries: 2. Avulsion of permanent teeth. at: https://www.bspd.co.uk/Portals/0/ Endod Dent Traumatol 1986; 2: 67–70.
Dent Traumatol 2020; 36: 331–342. Public/Files/Guidelines/avulsion_ https://doi.org/10.1111/j.1600-9657.1986.
https://doi.org/10.1111/edt.12573 guidelines_v7_final_.pdf (accessed tb00128.x
2. Hiltz J, Trope M. Vitality of human lip February 2023). 21. Mintel. Milk the vegan trend: a quarter
fibroblasts in milk, Hanks balanced 12. Is Khinda V, Kaur G, S Brar G et al. (23%) of brits use plant based milk. 2019.
salt solution and Viaspan storage Clinical and practical implications Available at: https://www.mintel.com/
media. Endod Dent Traumatol of storage media used for tooth press-centre/food-and-drink/milking-
1991; 7: 69–72. https://doi. avulsion. Int J Clin Pediatr Dent 2017; the-vegan-trend-a-quarter-23-of-brits-
org/10.1111/j.1600-9657.1991.tb00187.x 10: 158–165. https://doi.org/10.5005/ use-plant-based-milk (accessed February
3. Grimshaw KE, Bryant T, Oliver EM jp-journals-10005-1427 2023).
et al. Incidence and risk factors for 13. Hiltz J, Trope M. Vitality of human 22. Silva EJ, Rollemberg CB, Coutinho-Filho
food hypersensitivity in UK infants: lip fibroblasts in milk, Hanks TS et al. Use of soymilk as a storage
results from a birth cohort study. Clin balanced salt solution and Viaspan
medium for avulsed teeth. Acta Odontol
Transl Allergy 2016; 6: 1. https://doi. storage media. Endod Dent
Scand 2013; 71: 1101–1104. https://doi.
org/10.1186/s13601-016-0089-8 Traumatol 1991; 7: 69–72. https://
org/10.3109/00016357.2012.743678
4. Marland O, Swinnerton E, Power A. doi.org/10.1111/j.1600-9657.1991.
23. Côvre LM, Caliente EA, Sonoda CK et
Milk allergy and tooth reimplantation. tb00187.x
al. The effect of soy and whole milk
Br Dent J 2020; 229: 152. https://doi. 14. Halilovic S, Osmanović A, Gurbeta
as a means to store avulsed teeth: a
org/10.1038/s41415-020-2017-5 Pokvic L et al. Methods for the
histometric study. Dent Traumatol 2021;
5. Perkin MR, Logan K, Tseng A et al; preservation of periodontal ligament
37: 81–89. https://doi.org/10.1111/
EAT Study Team. Randomized trial cells using different storage media.
edt.12601
of introduction of allergenic foods Int J Engineering Research and
in breast-fed infants. N Engl J Med Technology (IJERT) 2017; 6. https:// 24. Kattan JD, Cocco RR, Järvinen KM.
2016; 374: 1733–1743. https://doi. doi.org/10.17577/IJERTV6IS080193 Milk and soy allergy. Pediatr Clin North
org/10.1056/NEJMoa1514210 15. Siddiqui F, Karkare S. Storage media Am 2011; 58: 407–426. https://doi.
6. Flom JD, Sicherer SH. Epidemiology for an avulsed tooth: nature to the org/10.1016/j.pcl.2011.02.005
of cow’s milk allergy. Nutrients 2019; rescue. Br J Med Health Res 2014; 1(3). 25. Anaphylaxis campaign. Peanut allergy
11: 1051. https://doi.org/10.3390/ 16. Is Khinda V, Kaur G, S Brar G et al. and tree nut allergy – the facts. 2021
nu11051051 Clinical and practical implications Available at: www.anaphylaxis.org.uk/
7. Skripak JM, Matsui EC, Mudd K, of storage media used for tooth wp-content/uploads/2022/06/Peanut-
Wood RA. The natural history of avulsion. Int J Clin Pediatr Dent 2017; 2021-v4.pdf (accessed February 2023).

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Oral Surgery
Enhanced CPD DO C
Amir Treifi
Jessica Cooper and Julian Yates
Third Molars: Not So NICE?

Risk Factors for Distal Caries in
Mandibular Second Molars
Abstract: UK guidelines currently advise against the prophylactic removal of mandibular third molars. However, growing evidence shows
that asymptomatic impacted mandibular third molars may contribute to the formation of distal caries in mandibular second molars.
Patients should be made aware that these guidelines do not necessarily prevent the potential development of decay or loss of mandibular
second molars. A retrospective review, over 6 months, analysed the incidence and evaluated the risk for developing caries on the distal
aspect of mandibular second molars, in patients referred for assessment of impacted third molars. Distal caries in the mandibular second
molar was present in 24.1% of cases. Of these patients, 9% demonstrated caries bilaterally. In those who developed distal caries in the
mandibular second molar, 76% of adjacent third molars demonstrated mesio-angular impaction, 91% of third molars were partially
erupted, and 95% of third molars were either touching or in close proximity to the ACJ of the second molar tooth. The prophylactic
removal or coronectomy of mesio-angluar or horizontally impacted third molars that are partially erupted and closely related to the ACJ of
mandibular second molars may result in improved long-term patient outcomes.
CPD/Clinical Relevance: The prophylactic removal or coronectomy of certain third molars may result in improved long-term
patient outcomes.
Dent Update 2023; 50: 135–140
In 2000, the National Institute for Health Partially erupted and impacted several factors, including the angulation
and Clinical Excellence (NICE) first mandibular third molar teeth present a of impaction and the proximity to the ACJ
introduced their guidance on the extraction challenging environment for oral hygiene; of the second molar.6 Furthermore, there
of mandibular third molar teeth.1 This most notably with mesio-angular impaction is evidence to suggest that patients with
guidance states that the removal of these against the amelocemental junction (ACJ) a low risk of developing caries are still
teeth should be limited to those displaying of the adjacent second molar. There is susceptible to the development of distal
certain symptoms, thus discouraging the growing evidence to suggest that this caries in mandibular second molar teeth.2
prophylactic removal of pathology-free increases the risk of caries development Once present, the management of these
third molars. This guidance still stands over on the distal aspect of the mandibular carious lesions is often challenging because
20 years later. second molar.2–5 This risk is heightened by effective caries removal and restoration
of the tooth is regularly impeded by
the adjacent impacted third molar.
Furthermore, as these lesions are often
Amir Treifi, BDS, MFDS RCPS(Glasg), Dental Core Trainee in Oral Surgery, University diagnosed at a late stage, and restoration
Dental Hospital of Manchester. Jessica Cooper, BDS, MFDS RCPS (Glasg), Dental Core is not always possible, patients are often
Trainee in Oral Surgery, University Dental Hospital of Manchester. Julian Yates, BSc, subjected to extraction of the carious
BDS, PhD, MFDS RCPS, FDS RCPS, FDS RCS, Professor of Oral and Maxillofacial Surgery,
second molar, frequently alongside the
Division of Dentistry, School of Medical Sciences, University of Manchester.
removal of the impacted third molar. This
then leads to the patient undergoing the

Oral Surgery
removal of two, or potentially four teeth, if Reason for referral Percentage (number)
the decay has occurred bilaterally.
A better understanding of the risk Pericoronitis 44% (99)
factors involved in the development of Pain 12% (27)
distal caries in mandibular second molar
teeth would allow for patients to be more Caries 30% (68)
informed, ensuring that they are aware Peri-apical pathology 5% (12)
of the long-term prognoses of both the
third and second molar teeth. If identified Periodontal disease 3% (5)
early enough, this would prevent the Assessment/impaction 6% (13)
development of distal caries in the second
Table 1. Reasons for the referral of the 224 patients to the University Dental Hospital of Manchester.
molar tooth and could avoid the need for
the unnecessary extraction of multiple
teeth, resulting in the planned extraction of
the third molar only. This would ultimately Angulation of the mandibular third Findings
result in improved treatment and long-term molar was calculated using Winter’s
outcomes for the patient. Additionally, In total, 224 patients were included in
classification. This widely used classification this study, resulting in the assessment
this could reduce the risk of pain, swelling
assesses the inclination of an impacted of 278 mandibular third molar teeth. Of
and infection commonly seen with grossly
third molar tooth in relation to the long these 224 patients, 72 were male and 152
carious teeth.
axis of the second molar.8 Third molar teeth were female. The age of patients ranged
This article assesses the incidence
are considered impacted horizontally if the from 16 to 64 years (median, 29 years).
of, and evaluates the clinical factors
inclination angle is between 80° and 100°, The age range for all male patients was
that increase the risk of distal caries
mesio-angular impacted if the inclination 16–64 years (median 31 years) and for all
development in mandibular second
angle is between 11° and 79°, vertically female patients was 17–63 years (median
molar teeth.
impacted if the inclination angle is between 29 years). Statistical evaluation of the ages
10° and -10° and disto-angular impacted revealed no significant difference between
Assessment with an inclination angle between -11 and males and female patients (Mann–Whitney
Clinical records of patients referred to the -80°.9 Radiograph viewing software was U-test: P>0.05).
University Dental Hospital of Manchester used to measure the intersecting angle A lack of full mouth radiographs only
for assessment of their mandibular third between the long axis of the third and allowed for an accurate calculation of a
molar teeth were reviewed. Patients second molar teeth. DMF score in 50 (22%) of patients, which
without an adjacent second molar tooth Treatment options were delivered to averaged at 5.1.
were discounted from the study. Data were patients based on current NICE guidance. The reasons for patient referral
collected retrospectively over 6 months Patients meeting the criteria for treatment to secondary care consisted of
(January–June 2019). were given the following treatment options, pericoronitis, pain, caries, peri-apical
Data collection included: if relevant to their presentation: pathology, periodontal disease and for
Leave and monitor; the assessment of impaction (Table 1).
Age;
Extraction of the mandibular third molar The most common reason for referral
Sex;
was pericoronitis.
Reason for referral; tooth;
Treatment recommended to the GDP, or
Treatment performed; Coronectomy of the mandibular third
completed within secondary care, included
Decayed, missing or filled (DMF) score; molar tooth;
extraction of the mandibular third molar,
Angulation of the mandibular Extraction of the mandibular second
coronectomy of the mandibular third
third molar; molar tooth (if extensive caries evident);
molar, extraction of the mandibular second
Eruption status of the mandibular Extraction of the maxillary third
molar, extraction of the maxillary third
third molar; molar tooth.
molar or leave and monitor (Table 2). Of
Proximity of the mandibular third The statistical analysis performed in this the 224 patients, 5% (n=10) underwent the
molar to the ACJ of the mandibular article is with a confidence interval of 95% extraction of both the mandibular second
second molar. and deemed significant if a P value of <0.05 and third molar teeth.
DMF scoring is a well-established was obtained. Normality of the data was Angulation of impaction, eruption
method of assessing a patient’s caries risk assessed with the Kolmogorov–Smirnov status and proximity to the ACJ of the 278
and allows quantification of the number test. The results of this test determined mandibular third molar teeth assessed can
of decayed, missing or filled teeth.7 In the data was not normally distributed, be seen in Table 3. The majority of teeth
this study, the DMF score was used as an therefore, appropriate non-parametric tests were either found to be mesio-angularly
indication for general dental health, and is were undertaken. impacted (46%), partially erupted
a validated method for this purpose. The Ethical approval was not needed as the (77%) or at the ACJ of the adjacent
score was calculated via assessment of the data was retrospectively and anonymously second molar (56%).
patients’ radiographs. We excluded the score collected. An ethical approval on-line tool Distal caries in the mandibular second
of a mandibular second molar if distal caries was used to determine this outcome (http:// molar was present in 24.1% (n=67) of
was the only lesion present on the tooth. www.hra-decisiontools.org.uk/ethics/). cases. The age range of these patients

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23rd - 24th June Edinburgh, Scotland, UK
Course Leader:
Mr. Girish Bharadwaj
Booking
Deadline
3rd April 2023
Accredited by:
Supported by:
Oral Surgery
Treatment undertaken Percentage (number) Discussion

This study provides an overview of the
Extraction mandibular third molar 58% (203)
referrals received at the University Dental
Extraction mandibular second molar 6% (21) Hospital of Manchester, UK, for the
management of mandibular third molar
Leave and monitor 10% (35)
teeth between January and June 2019.
Extraction maxillary third molar 23% (82) The most common reason for referral was
pericoronitis, experienced in 44% of patient
Coronectomy mandibular third molar 3% (12)
referrals received, followed by caries in the
Table 2. Treatment recommended to the GDP or performed at the University Dental Hospital of mandibular third and/or second molar in
Manchester for a total of 352 patients. 30% of cases.
Treatment performed varied greatly
Molar status Percentage (number) between patients, with the majority of
those assessed meeting the NICE guidance
Angulation Mesio-angular 46% (128) criteria for the extraction of mandibular
Disto-angular 21% (59) third molar teeth. The most common
treatment performed was the extraction of
Vertical 22% (61)
the mandibular third molar, which occurred
Horizontal 11% (30) in 58% of cases.
Further analysis of patients with
Eruption status Partially erupted 77% (215)
established distal caries in the mandibular
Fully erupted 22% (61) second molar demonstrated that caries
was visible on the distal aspect of the
Unerupted 0.7% (2)
adjacent mandibular second molar tooth in
Proximity to the ACJ Contact at the ACJ 56% (156) approximately a quarter (24.1%) of patients
assessed, a figure that is approximately 14%
Close to the ACJ 19% (53)
lower than reported by Toedtling et al.5 In
Not in contact with ACJ 25% (69) this patient group, which has established
Table 3. Angulation and eruption status of 278 third molars assessed. The proximity to the ACJ refers to distal caries in the mandibular second
the position of the mandibular third molar to the adjacent second molar. molar, we observed that 91% of impacted
third molars were partially erupted. When
comparing between cases that had resulted
Molar status Percentage (number)
in the formation of distal caries and those
Angulation Mesio-angular 76% (51) which did not, caries was present in 22% of
cases with partially erupted third molars.
Disto-angular 7% (5)
In this patient group the majority of
Vertical 7% (5) third molar teeth, 76%, were mesio-angular
impacted. A comparison of impaction
Horizontal 9% (6)
angulation between cases resulting in the
Eruption status Partially erupted 91% (61) formation of distal caries and those which
did not, found caries presence in: 40% of
Fully erupted 9% (6)
cases with mesio-angular impacted third
Proximity to the ACJ Contact at the ACJ 81% (54) molars; 20% of horizontally impacted third
Close to the ACJ 13% (9) molars; 9% of disto-angular impacted third
molars; and 8% of vertically impacted third
Not in contact with ACJ 6% (4) molar teeth (Figure 1). Therefore, caries
Table 4. Angulation, eruption status and proximity to the ACJ of the 67 mandibular third molars where was present in approximately 60% of
distal caries was present in the mandibular second molar. cases where the mandibular third molars
were either mesio-angular or horizontally
impacted. The correlation between
angulation of impaction of the mandibular
was between 22 and 62 years (median 29 status and proximity to the ACJ of the
third molar teeth and the incidence of
years). The median age of male patients mandibular third molar teeth in cases developing caries in the mandibular second
with distal caries in the mandibular where distal caries was present in the molar is illustrated in Figure 1. Additionally,
second molar was 32 years while in female adjacent second molar tooth can be in 95% of the cases that resulted in caries
patients it was 27 years, and this was seen in Table 4. Of the 352 treatments development, the adjacent third molars
significant (P<0.05). Of the 67 cases, 9% performed or recommended to GDPs, were either touching or in close proximity
(n=6) developed bilateral caries on the 4% (n=15) involved the extraction of to the ACJ of the second molar tooth. Again
distal aspect of the mandibular second the mandibular second molar due to when comparing between cases, caries was
molar teeth. The angulation, eruption distal caries. present in 30% of cases where the adjacent

Oral Surgery
Figure 1. Illustration demonstrating incidence of distal caries in mandibular second molar teeth with various angulations of impaction of mandibular third
molar teeth: 40% with mesio-angular, 20% with horizontal, 8% with vertical and 9% with disto-angular.
third molars were either touching or in and Renton.6 Another interesting finding publication highlights the importance of
close proximity to the ACJ of the second of this study was the earlier presentation informing patients of the risks involved
molar tooth. of female patients with distal caries in with retention of lower third molars,
The close proximity of a partially mandibular second molars. The female namely the periodontal detriment and the
erupted and impacted mandibular third patients that presented were approximately development of caries at the distal aspect
molar tooth creates a breach of the 5 years younger than the male patients. This of the adjacent lower second molars.
mucogingival seal on the distal aspect of may be due to the fact that the incidence Although it does not explicitly suggest that
the mandibular second molar tooth. This of mandibular third molar impaction is prophylactic removal is indicated, it does
exposes the distal aspect of the tooth significantly higher in females compared state that patient involvement is paramount
to an environment in which adequate to males,10 with this study appearing to in the decision-making process and that
oral hygiene is at best a challenge, but in corroborate these findings as over half treatment options should be discussed
reality may be impossible to achieve. These the patients assessed were female (152 along with the ‘material risk’ of each option.
compounding factors display an increased female and 72 male). Additionally, studies Furthermore, patients should be fully
susceptibility to caries development on have shown a higher prevalence of caries aware of the associated risks of delaying or
the distal aspect of mandibular second rates, in general, in female patients when declining surgery.
molar teeth. compared to males.11,12 As females have It is acknowledged that this study
This study highlighted a clear a higher incidence of impacted third may have some limitations. Although 224
correlation between the incidence of molars and rates of caries, they may be patients were included within this study,
caries on the distal surface of mandibular more predisposed to distal caries in the they had all been referred to secondary
second molar teeth and the angulation mandibular second molar tooth and, care for management, often due to more
of impaction, the proximity to the therefore, may present earlier. complex presentations. These referred
adjacent ACJ and the eruption status of The Faculty of Dental Surgery and Royal patients have established pathology and,
the mandibular third molar. This is not College of Surgeons have also published as such, may not be representative of
unexpected and has previously been guidance that details the indications for the general population in which the true
reported by Toedtling et al5 and McArdle mandibular third molar removal.13 The incidence may be lower.

Oral Surgery
The data collection was formulated molar tooth to the inferior dental canal; 5. Toedtling V, Coulthard P, Thackray G.
using patient codes logged onto the however, when compared to intra-oral Distal caries of the second molar in the
hospital computer system following a new radiographs, OPTs have a lower resolution presence of a mandibular third molar
patient examination. All patients who had and are more likely to show interproximal – a prevention protocol. Br Dent J 2016;
undergone an examination were assessed overlap. This in turn decreases the 221: 297–302. https://doi.org/10.1038/
and those who had been referred for accuracy of distal caries diagnosis in sj.bdj.2016.677
assessment of their mandibular third molar mandibular second molar teeth. Within 6. McArdle LW, McDonald F, Jones J. Distal
teeth were included within the study. It this study, the true incidence of distal cervical caries in the mandibular second
is possible, however, that some clinicians caries in a second molar may be higher molar: an indication for the prophylactic
may have not appropriately logged the than the 24% shown, if caries was too early removal of third molar teeth? Update.
appointment, and as a result there may to be observed radiographically using this Br J Oral Maxillofac Surg 2014; 52:
have been some patients who did fit the modality. 185–189. https://doi.org/10.1016/j.
inclusion criteria for this study, but were bjoms.2013.11.007
not present in the data set. Therefore, Conclusion 7. Broadbent JM, Thomson WM. For
the data analysed may not be an entirely debate: problems with the DMF index
Guidance produced by NICE on the
accurate representation of patients pertinent to dental caries data analysis.
removal of mandibular third molar
referred to the University Dental Hospital Community Dent Oral Epidemiol 2005; 33:
teeth1 aids practitioners and patients in
of Manchester during the timeframe set
making informed treatment decisions. 400–409. https://doi.org/10.1111/j.1600-
in this study. However, the authors feel
This guidance does not support the 0528.2005.00259.x
that given the search criteria and methods
prophylactic removal of mandibular third 8. Juodzbalys G, Daugela P. Mandibular
employed, this concern may be negligible.
molar teeth. It is well known that the third molar impaction: review of literature
DMF scoring was used as a marker
extraction of these teeth does not come and a proposal of a classification. J Oral
for dental health; however, due to lack of
without risks, most notably the risk of Maxillofac Res 2013; 4: e1. https://doi.
full mouth radiographs in the majority of
damage to the inferior dental and lingual org/10.5037/jomr.2013.4201
patients assessed, a DMF score was only
nerves. However, patients with certain 9. Yilmaz S, Adisen MZ, Misirlioglu M,
available in 22% of cases. An additional
presentations, for example mesio-angular Yorubulut S. Assessment of third molar
limitation was that radiographs taken
or horizontally impacted partially erupted impaction pattern and associated clinical
upon initial assessment focused on specific
third molars, in contact or intimately
areas and not the whole dentition, and symptoms in a central Anatolian Turkish
involved with the ACJ of the adjacent
thus meant that accurate DMF scores Population. Med Princ Pract 2016; 25: 169–
tooth, may benefit from prophylactic
could not be undertaken for many patients 175. https://doi.org/10.1159/000442416
removal or coronectomy because it may
within the study. The average score of 10. Kumar S, Al-Hobeira H, Shaikh S et al.
prevent extensive restorations or the loss
those assessed was 5.1, however, as of second molar teeth. Distribution of impacted third molars
only one-fifth of patients were analysed based on gender and patterns of
this may not be representative of the Compliance with Ethical Standards angulation in dental students of the
group as a whole. It is acknowledged Conflict of Interest: The authors declare that Hai’l Region, Saudi Arabia: a panoramic
that there are limitations to DMF scoring, they have no conflict of interest. radiographic (OPG) study. Int J Contemp
with discrepancies in scoring reported.7 Med Res 2017; 4: 1829–1832.
Alternative measures for markers of References 11. Ferraro M, Vieira AR. Explaining gender
dental health are available however for 1. National Institute for Health and Care differences in caries: a multifactorial
consistency with other publications the Excellence. Guidance on the extraction approach to a multifactorial disease. Int
DMF scoring system was used. of wisdom teeth. Technology appraisal J Dent 2010; 2010: 649643. https://doi.
Throughout this study, radiographs guidance (TA1). 2000. Available at: www. org/10.1155/2010/649643
were predominantly used for caries nice.org.uk/guidance/ta1 (accessed 12. Lukacs JR, Largaespada LL. Explaining sex
analysis. As clinical notes varied between February 2023). differences in dental caries prevalence:
clinicians, the use of assessment through 2. McArdle L. The prevention and saliva, hormones, and ‘life-history’
radiography provided a clear baseline management of distal cervical caries of
etiologies. Am J Hum Biol 2006; 18: 540–
for data collection. Furthermore, care the mandibular second molar. Dent Update
555. https://doi.org/10.1002/ajhb.20530
was taken to exclude radiographs 2019; 46: 406–410.
13. Renton T, Coulthard P, Chiu G et
displaying signs suggestive of cervical 3. Knutsson K, Brehmer B, Lysell L, Rohlin
al. Parameters of care for patients
burnout. Radiographs, however, do not M. Pathoses associated with mandibular
provide an accurate representation of the undergoing mandibular third molar
third molars subjected to removal. Oral
extent of caries present. A carious lesion surgery. 2020. Available at: https://
Surg Oral Med Oral Pathol Oral Radiol Endod
may not be evident radiographically 1996; 82: 10–17. https://doi.org/10.1016/ www.rcseng.ac.uk/-/media/files/rcs/fds/
until approximately 35% of enamel s1079-2104(96)80371-4 guidelines/3rd-molar-guidelines--april-
demineralization has occurred.14 4. Allen RT, Witherow H, Collyer J et al. The 2021-v4.pdf (accessed February 2023).
Furthermore, the majority of radiographs mesioangular third molar – to extract or 14. Mallya S, Lam E. White and Pharoah’s
analysed were full or half mouth not to extract? Analysis of 776 consecutive Oral Radiology E-Book: Principles and
orthopantomographs (OPTs), which are third molars. Br Dent J 2009; 206: E23 Interpretation. 8th edn. Elsevier Health
useful for assessing proximity of a third https://doi.org/10.1038/sj.bdj.2009.517 Sciences, 2018.

Highly Bioadhesive Gel
Tranexamic Acid: 8.0%
Targeted action where needed
www.kindental.co.uk
[email protected]
Public Health
Enhanced CPD DO C
Rebecca Manson
Scarlet Fever and the Dental Team

Abstract: Scarlet fever is a mild, but highly contagious disease caused by Group A Streptococcus (GAS) bacteria. Scarlet fever begins with
flu-like symptoms and, within the first 12–48 hours, it is common for a rash to develop that feels like sandpaper to the touch. In rare cases,
GAS bacteria can cause an invasive infection that can be fatal. Invasive GAS (iGAS) infection occurs when the bacteria are in a place of
the body where they are not normally found, such as the blood stream. Scarlet fever is usually treated with antibiotics, which can reduce
the chances of the patient developing iGAS and reduce the risk of them spreading the infection to others. The World Health Organization
and UK Health Security Agency have announced that the number of scarlet fever and iGAS cases observed in children has been several
times higher than pre-pandemic levels for the equivalent period of time. As healthcare professionals, it is important that the dental team
understand key aspects of scarlet fever. Here, scarlet fever symptoms, transmission, clinical manifestations, antibiotic treatment, and risks to
the dental team are reviewed.
CPD/Clinical Relevance: To describe epidemiology of scarlet fever and discuss the implications for the dental team.
Dent Update 2023; 50: 142–145
Scarlet fever is mild but highly and December 2022 there were 7750 in the number of iGAS cases among
contagious disease caused by Group notifications of scarlet fever reported.4 children under 10 in several European
A Streptococcus (GAS) bacteria.1 This compares to a total of 2538 at countries, including France, Ireland,
This group of bacteria can cause a the same point in the year during a the Netherlands, Sweden and the
wide range of skin, soft tissue, and comparably high season in 2017–2018.4 UK.3 In Ireland, the Health Protection
respiratory tract infections ranging An increased number of iGAS Surveillance Centre reported that
from mild to life-threatening.1 The infections has also been reported in the between September and December
most serious infections linked to GAS US. In November 2022, the US Centers 2022, 23 iGAS infections were recorded
come from invasive GAS, known as for Disease Control and Prevention compared to 11 cases for the same
iGAS. iGAS infections occur when (CDC) were notified of a probable period in 2019, showing a two-fold
bacteria move to a part of the body increase in iGAS infections among increase in iGAS infection numbers.7
in which they are not normally found, children in a hospital in Colorado.5 The WHO stated that several deaths
associated with iGAS disease in children
such as the blood stream, and in some Within a few weeks, increased iGAS
under the age of 10 years were reported
rare cases, iGAS infections can be infections were reported in other states,
from France, Ireland and the UK.3
fatal.2 Children with viral infections, including Minnesota and Pennsylvania.6
There is no clear explanation for
such as varicella (chickenpox) and The CDC issued a nationwide health
why cases of scarlet fever and iGAS are
influenza, are at a higher risk of alert to clinical staff and public health
higher than expected in 2022/2023. It
developing iGAS disease.3 Data authorities to highlight the recent
has been suggested that the increase
from the UK Health Security Agency increase in iGAS infections among in infections may be due to the lack
(UKHSA) published in December 2022 children in the US in December 2022.5 of exposure to GAS bacteria during
reported an out-of-season increase in The World Health Organization (WHO) the COVID-19 lockdown resulting in
scarlet fever and iGAS infections.4 The also reported in December that since children having a poorer immunity to
report stated that between September September there had been an increase the bacteria.8 It has also been suggested
that the increase in cases of iGAS
disease in children may be associated
with the recent increased circulation
Rebecca Manson, BDS, MPH, DCT1, Public Dental Service, Greater Glasgow and
of respiratory viruses, such as seasonal
Clyde, Scotland.
influenza, because co-infection with
viruses may increase the risk of iGAS

Public Health
Agent Group A Streptococcus Oral manifestations

It is known that individuals with scarlet
Spread Close contact, direct skin contact, contaminated objects,
fever can develop ‘strawberry tongue’
and respiratory droplets
(Figure 1c).1 This is a condition whereby
Symptoms Sore throat, headache, fever, nausea, fatigue the tongue can become red, bumpy,
and vomiting swollen and resemble a strawberry.
The tongue may also become white
Symptom duration Approximately 1 week, but this can vary
for a few days before turning red. It is
Rash characteristics Fine red rash on chest and stomach, rapidly spreading to possible that a patient or a concerned
other parts of the body, feels like sandpaper to touch parent may try to access a dentist for
Oral manifestations White coating on the tongue which peels a few days later, an opinion on this oral manifestation.
leaving the tongue looking red and swollen (known as It is likely that individuals with
‘strawberry tongue’) strawberry tongue will also have other
Flushed red face, but pale around the mouth symptoms of scarlet fever, so it would
be prudent to carry out a remote
Treatment 10 day course of antibiotics (main recommendation is consultation via video or telephone
Penicillin V) to gather information on the patient’s
Isolation For first 24 hours of appropriate antibiotic treatment symptoms. Scarlet fever responds well
to antibiotics, and strawberry tongue
Prevention Wash hands often, do not share eating utensils/cups/ is likely to resolve with the correct
towels with an infected person, carefully wash or dispose treatment.1 The dental team should
of tissues/objects contaminated by an infected person have a plan on how best to manage
Complications Small risk of ear infection, throat abscess, cellulitis, a patient presenting with this oral
septicaemia, and meningitis manifestation. The plan should include
Table 1. Features of scarlet fever.1,9 reassurance that this manifestation is
common with scarlet fever, along with
advice for the patient, family and close
contacts on how to reduce the spread of
disease.3 WHO announced that reducing for a rash to develop on the chest/ the infection. Dentists should emphasize
the transmission of GAS bacteria will the importance of antibiotic treatment
tummy, which then spreads. The rash
help to reduce the risk of severe iGAS in scarlet fever patients in reducing the
can appear like raised small bumps
infection.3 As healthcare professionals, chance of developing an iGAS infection
and feel rough like sandpaper (Figure
the dental team should be aware of the and the risk of spreading the infection
1a,b). It is common practice for doctors
key aspects of scarlet fever in relation to others.1
to diagnose scarlet fever from clinical
to dentistry. The clinical features of symptoms alone. If confirmation is
scarlet fever, along with symptoms, required, a throat swab can be sent Antibiotic shortages
transmission, oro-facial manifestations, for bacterial culture.10 Scarlet fever is Penicillin V and amoxicillin are
impact on local antibiotic supply, not considered to be serious and can commonly prescribed by dentists in the
and risks for the dental team, are be treated with antibiotics. First-line UK for dental infections. At the time of
discussed below. treatment for suspected scarlet fever writing (December 2022), there was a
infection is penicillin V.11 For patients shortage of penicillin V oral suspension
Scarlet fever symptoms, with a penicillin allergy, clarithromycin and amoxicillin in some areas of the
or erythromycin are recommended.11 UK owing to the increased demand
transmission Antibiotic treatment for scarlet fever is for penicillin-based antibiotics for
and management reported to reduce a patient’s chance children with suspected scarlet fever.
Scarlet fever is highly contagious of developing an iGAS infection and It is important that dentists continue
and is spread by close contact with reduce the risk of spreading the to prescribe antibiotics as per the
someone carrying the bacteria.9 It takes infection to others.1 Current NHS evidence-based standard, but it is
approximately 2–5 days to develop guidance advises ‘that children should important to consider that some oral
symptoms after exposure; however, the not return to nursery or school, and suspensions may not be available. It is
incubation period can vary between 1 adults to work, until a minimum of also important for the dental team to
and 7 days.9 An individual with scarlet 24 hours after starting antibiotic be aware that they may be faced with
fever is considered infectious up to treatment’.9 It is known that if a patient a situation where there is no penicillin-
6 days before their symptoms start, with scarlet fever is not treated with based antibiotic in the local area, and so
until 24 hours after their first dose of antibiotics, they can be contagious alternatives may need to be prescribed.
antibiotics.9 The main features of this for 2–3 weeks after their symptoms It would be prudent for dentists to
infection are outlined in Table 1. resolve, so it is important that patients revise what second-line treatment is
Within the first 12–48 hours of with this condition are identified and recommended should the first-line
scarlet fever symptoms, it is common treated early.1 antibiotics be unavailable.

Public Health
a Considerations for the

dental team
Dental clinics in the UK are known
to adhere to strict infection control
standards and implement universal
infection control procedures (ICP) for all
patients regardless of their infectious
status. As such, it could be argued that
infections, such as scarlet fever, do not
pose a major threat to the dental team.
Nevertheless, as dentistry requires
prolonged close contact with patients,
it is possible that GAS transmission
could occur within a dental clinic. The
dental team should have a strategic
plan on how best to manage patients
with scarlet fever who require dental
treatment. It is important to emphasize
that dentists should delay elective
b dental treatment in suspected cases
of scarlet fever until such a time as
the patient is no longer deemed
infectious. Decisions on a patient’s
infectious status will need to be made
on a case-by-case basis because it will
depend on whether they are receiving
an appropriate course of antibiotics.
If there is any doubt about a patient’s
infectious status, advice should be
sought from the local public health
protection team and/or the patients
general medical practitioner. If a patient
with scarlet fever requires emergency
dental treatment that cannot be
delayed, the dental team should carry
out a thorough medical history to
check whether the patient is receiving
appropriate antibiotic therapy. In this
situation, it would be appropriate to
consider liaising with the local public
health protection team to ascertain
c whether special precautions, such as
FFP3 respiratory masks, are required. As
always, the recommended standard IPC
precautions should be strictly adhered
to.12 It is also important to consider
keeping equipment within the surgery
to a minimum to aid infection control.
Conclusions
At the time of writing, cases of scarlet
fever are higher than expected in the
UK, and the unusual seasonal pattern
is likely to continue into 2023.4 All
healthcare workers, including dentists,
should remain vigilant and be prepared
Figure 1. (a) The torso and (b) the arm of a patient with scarlet fever displaying sandpaper- to manage patients who may present
type rash. (c) Patient with scarlet fever displaying strawberry tongue. (Courtesy of Skin Deep
with orofacial symptoms of scarlet
Medical Photography).
fever. Dentists play an important role

Public Health
in informing patients and families of the Available at: https://tinyurl.com/s2j5d7fx 8. Ledford H. Why is strep A surging and
importance of antibiotic treatment for (accessed January 2023). how worried are scientists? Nature
scarlet fever because it can reduce the 4. UK Health Security Agency. UKHSA 2022; 612: 603. https://doi.org/10.1038/
chance of developing an iGAS infection and update on scarlet fever and invasive d41586-022-04403-y
group A strep. 2022. Available at: https:// 9. UK Health Security Agency. Scarlet
the risk of further spread of the infection.1
tinyurl.com/3mukx2s8 (accessed January fever: diagnosis, symptoms and
2023). treatment. 2019. Available at: https://
5. Centers for Disease Control and tinyurl.com/4nwe49w7 (accessed
Conflict of Interest: The authors declare that
Prevention. Increase in pediatric invasive
they have no conflict of interest. January 2023).
Group A streptococcal infections. 2022.
Informed Consent: Informed consent was 10. Public Health England. Scarlet fever:
Available at: https://emergency.cdc.
obtained from all individual participants guidance and data. 2019. Available at:
gov/han/2022/han00484.asp (accessed
included in the article. www.gov.uk/government/collections/
January 2023).
scarlet-fever-guidance-and-data
6. Centers for Disease Control and
References (accessed January 2023).
Prevention. Group A streptococcal (GAS)
1. National Health Service. Scarlet fever. 2021. 11. Greater Glasgow and Clyde Paediatric
disease. 2022. Available at: https://www.
Available at: www.nhs.uk/conditions/scarlet- cdc.gov/groupastrep/surveillance.html Antimicrobial Management Team.
fever/ (accessed January 2023). (accessed January 2023). Antibiotic management of GAS
2. UK Health Security Agency. Group A Strep: 7. World Health Organization. Increased infections in children. 2022. Available at:
what you need to know. 2022. Available incidence of scarlet fever and invasive https://tinyurl.com/4prdt53r (accessed
at: https://ukhsa.blog.gov.uk/2022/12/05/ Group A Streptococcus infection - multi- January 2023).
group-a-strep-what-you-need-to-know/ country. 2022. Available at: https://www. 12. NHS Scotland. National infection
(accessed January 2023). who.int/emergencies/disease-outbreak- prevention and control measures. 2022.
3. World Health Organization. Increase in news/item/2022-DON429 (accessed Available at: www.nipcm.hps.scot.nhs.
iGAS infection in children in Europe. 2022. January 2023). uk/ (accessed January 2023).
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Technique Tips
Technique Tips
Dental extraction forceps: choose wisely
Dent Update 2023; 50: 147-149
Handles Hinge
Dental extractions are the most
common surgical intervention and are
an essential skill for general dental
practitioners. Forceps have existed for
centuries and their design has varied
little in this time. However, subtle
differences between forceps can have a
significant influence on the success of
dental extractions. This article reviews Beaks
conventional dental forcep anatomy
and discusses the factors of material,
handles, hinges and beaks, which need Figure 1. Conventional dental forceps anatomy.
consideration when choosing forceps
for dental extractions. a b
Forceps have been used to extract
teeth for centuries. The word ‘forcep’
is derived from the terms ‘formus’
meaning ‘warm’ and ‘-cep’ meaning
‘taker’, relating to their original use
of holding hot food on a stove. The
effectiveness of a good dental forcep
must not be underestimated and
appropriate selection can significantly
influence whether a tooth is removed
intact during an extraction procedure.
Contemporary forcep designs,
such as physics forceps, have yet to
be proven as being less traumatic
for dental extractions1 and so,
conventional dental forceps are still
used widely for extractions of teeth and
roots in humans. This article reviews
Figure 2. (a) The grip is closer to the hinge, while in (b) the grip is further from the hinge.
conventional dental forcep anatomy
and discusses material, handles,
hinges and beaks, factors that need
consideration when choosing forceps (Figure 1). Modern forceps will have each Material
for dental extractions. of these components and are aligned
The ISO requirements dictate that dental
with International Organisation for forceps must be manufactured from
Forcep anatomy Standardization (ISO) standards and outline Grade B or C stainless steel, being strong
Basic dental extraction forcep anatomy requirements for forcep material, design enough to withstand the forces required
consists of handles, a hinge and beaks and intended function for safe use.2 for the extraction of teeth and also having
Carla Fleming, BDS, MJDF RCS (Eng), Dip Con Sed, Consultant Senior Lecturer in Oral Surgery, Bristol Dental Hospital. Laura Collins,
BDS, MJDF RCS (Eng), Dip TLHP, Speciality Registrar in Oral Surgery, Royal London Hospital. Christopher Bell, BDS, MSc, FDSRCS (Eng),
Associate Specialist and Honorary Senior Lecturer in Oral and Maxillofacial Surgery, Bristol Dental Hospital. Mark Gormley, BDS (Hons),
MMEd, MSt, MFDS, MOral Surg, FHEA FDS(OS), RCS Ed, Consultant Senior Lecturer in Oral Surgery, Bristol Dental Hospital.

Technique Tips
a a
14mm
8mm
Figure 4. Illustration adapted from Ashcroft and

Pawsey6 demonstrating ‘best fit’ position of the
b
forcep beaks for incisors, molars and premolars.
Figure 3. (a) Circular hinge joint. (b) Pin

hinge joint.
significantly assist in gripping the root of
a tooth and translating hand movements
into tooth movements, thereby reducing
the risk of unintended tooth fracture.
excellent corrosion resistance.2 There This is particularly important when a
is interest in other materials, such as forcep beak is an imperfect fit around
carbon-reinforced polyamide;3 however, the root of the tooth for removal, which
such instruments are not currently can lead to slippage of the forceps
approved or available for clinical use, blades on the dentine.
but may be a choice in the future. Straight forcep handles, which
facilitate an effective grip, are needed for
the instrument to be moved comfortably
Handles Figure 5. (a) The lateral and (b) longitudinal
in the operator’s hand (Figure 2).
Dental extraction forceps are essentially Curved handled forceps can hinder
curvature of forcep beaks.
levers that can be used to exert a large the movement within an operator’s
force over a small distance at one end hand, and too-smooth or too-narrow
by exerting only a small force over a
greater distance at the other end. This
handles can compromise an effective Beaks
grip. Good assessment of forcep handles Forcep beaks are designed to fit around
first class lever principle is described is important to use the instrument
and illustrated by Rehal and Shoker.4 the coronal part of tooth roots; however,
as intended. normal human anatomical variation
A firm grip of dental forcep handles
and the tooth root is necessary to means there will rarely be a perfect fit
ensure that force is directed through Hinges with universally manufactured beaks. In
the tooth itself rather than the forcep Hinges on dental extraction forceps 1957, Ashcroft and Pawsey presented
blades slipping on the root surface. are usually a ‘circular joint’ or ‘pin joint’ best-fit positions of forcep beaks on
For dental practitioners, a ‘power grip’, (Figure 3). There is no evidence available dental roots with regard to tooth
described by Napier5 is used (Figure 2). to assess longevity or effectiveness morphology, and this is helpful when
When the long handles of dental of use with either joint and therefore considering a ‘best-fit’ scenario6 (Figure 4).
forceps are squeezed with a power either is acceptable. Consideration, In light of this, it is helpful to ask
grip by the operator, force is applied however, should be made to access in two key questions when identifying a
through the fulcrum (hinge) to the the posterior part of the oral cavity with ‘best fit’ for dental forcep beaks:
opposite shorter ends (beaks). lower molar forceps because those with Do the beaks curve laterally such
If the position of the grip on the a circular joint (14 mm in Figure 3a) that a significant part of the root is in
handles is moved away from the can be bulkier than those with a pin contact with them (Figure 5a)?
fulcrum, as shown in Figure 2b, then the joint (8 mm in Figure 3b) and therefore Do the beaks curve longitudinally
force of grip at the beaks will be greater. placing the instrument vertically on such that the blades are contacting
This small movement of the operating posterior molar teeth can be challenging the root rather than the crown of the
hand away from the hinge can in patients with limited access. tooth (Figure 5b)?
Technique Tips
a In addition to the ‘best fit’ Informed Consent: Informed consent

questions, a critical eye should be cast was obtained from all individual
upon the sharpness of the beak tip. The participants included in the article.
periodontal ligament around teeth is
about 0.2 mm wide7 and sharp, gently References
tapered beak tips facilitate extension 1. Abdelwahab M, Nørholt SE, Taneja
apically down the periodontal ligament P. The efficacy of physics forceps for
to grip the dentine on the root of exodontia: a systematic review. J Oral
the tooth (Figure 6a). Flattened, Maxillofac Surg 2021; 79: 989.e1–989.
thick-edged blades will not fit into e13. https://doi.org/10.1016/j.
the narrow periodontal ligament joms.2020.12.033.
space as easily, and will therefore
2. Internation Organization for
grip too coronally on the root or
Standardization (ISO). Dentistry –
indeed, inadvertently grip the crown
Extraction forceps – Part 1: General
(Figure 6b), leading to potential
requirements. 2022. Available
tooth fracture.
b at: https://www.iso.org/obp/
Maintenance is needed to preserve
ui/#!iso:std:65160:en (accessed
sharpness to maximize effectiveness
February 2023).
of a dental forcep and individual
manufacturers can offer specific advice 3. Told R, Marada G, Rendeki S et
for individual products. al. Manufacturing a first upper
molar dental forceps using
continuous fiber reinforcement
Summary
(CFR) additive manufacturing
Table 1 summarizes the technology with carbon-reinforced
aforementioned factors that should be polyamide. Polymers (Basel) 2021;
considered when choosing a dental
13: 2647. https://doi.org/10.3390/
extraction forcep.
polym13162647
We hope this article helps dental
4. Rehal S, Shoker P. The battle of the
surgeons and dental therapists to
lower molar extraction forceps:
Figure 6. Example of (a) a harp and (b) a blunt choose dental extraction forceps
cowhorn versus eagle beak. Dent
forcep beak. wisely. Alongside appropriate hand
Update 2020; 47: 972–973.
movements and direction of force, a
5. Napier JR. The prehensile movements
few moments with a critical eye on a
dental forcep can reduce the risk of of the human hand. J Bone Joint Surg
If the forceps beaks curve in ways tooth fracture during an extraction Br 1956; 38-B(4): 902–913. https://
that fit the roots well, then the tooth procedure and promote the extraction doi.org/10.1302/0301-620X.38B4.902
will be less likely to fracture. With of intact roots and teeth for the benefit 6. Ashcroft G, Pawsey PM. The
a poor fit, usually due to the beaks of both operating clinicians and their extraction of adult teeth. The Dental
being too straight in design as in patients. Practitioner and Dental Record 1957;
Figure 5b, the crown or apical part 7: 330–334
of the root is more likely to fracture Compliance with Ethical Standards 7. Berkowitz BKB. Mouth. In: Standring
when rotational and lateral forces are Conflict of Interest: The authors declare S (ed.) Gray’s Anatomy. 42nd edn.
applied through the forceps. that they have no conflict of interest. Elsevier, 2021; 636–663.
Factor Considerations Reasons

Material Metal only at present – may Strength to accept forces of movement and give proprioceptive feedback in
change in future the operating hand
Handles Shape and grip Straight handles to fit well in the palm of the hand and a gripping surface that
enables a tight ‘power’ grip to maximize effective grip on the tooth root, in line
with ‘law of the levers’
Hinges Design Circular joints can increase forcep bulk in posterior oral cavity, which may
compromise placement on a tooth root where access is challenging
Beaks Shape and sharpness ‘Best fit’ lateral and longitudinal curvatures should grasp the tooth root and
avoid touching the crown. Sharp beak tips are needed to penetrate the
periodontal ligament space (0.2 mm)
Table 1. Summary of the factors to be considered when choosing a dental extraction forcep.

Technique Tips
a a
14mm
8mm
Figure 4. Illustration adapted from Ashcroft and

Pawsey6 demonstrating ‘best fit’ position of the
b
forcep beaks for incisors, molars and premolars.
Figure 3. (a) Circular hinge joint. (b) Pin

hinge joint.
significantly assist in gripping the root of
a tooth and translating hand movements
into tooth movements, thereby reducing
the risk of unintended tooth fracture.
excellent corrosion resistance.2 There This is particularly important when a
is interest in other materials, such as forcep beak is an imperfect fit around
carbon-reinforced polyamide;3 however, the root of the tooth for removal, which
such instruments are not currently can lead to slippage of the forceps
approved or available for clinical use, blades on the dentine.
but may be a choice in the future. Straight forcep handles, which
facilitate an effective grip, are needed for
the instrument to be moved comfortably
Handles Figure 5. (a) The lateral and (b) longitudinal
in the operator’s hand (Figure 2).
Dental extraction forceps are essentially Curved handled forceps can hinder
curvature of forcep beaks.
levers that can be used to exert a large the movement within an operator’s
force over a small distance at one end hand, and too-smooth or too-narrow
by exerting only a small force over a
greater distance at the other end. This
handles can compromise an effective Beaks
grip. Good assessment of forcep handles Forcep beaks are designed to fit around
first class lever principle is described is important to use the instrument
and illustrated by Rehal and Shoker.4 the coronal part of tooth roots; however,
as intended. normal human anatomical variation
A firm grip of dental forcep handles
and the tooth root is necessary to means there will rarely be a perfect fit
ensure that force is directed through Hinges with universally manufactured beaks. In
the tooth itself rather than the forcep Hinges on dental extraction forceps 1957, Ashcroft and Pawsey presented
blades slipping on the root surface. are usually a ‘circular joint’ or ‘pin joint’ best-fit positions of forcep beaks on
For dental practitioners, a ‘power grip’, (Figure 3). There is no evidence available dental roots with regard to tooth
described by Napier5 is used (Figure 2). to assess longevity or effectiveness morphology, and this is helpful when
When the long handles of dental of use with either joint and therefore considering a ‘best-fit’ scenario6 (Figure 4).
forceps are squeezed with a power either is acceptable. Consideration, In light of this, it is helpful to ask
grip by the operator, force is applied however, should be made to access in two key questions when identifying a
through the fulcrum (hinge) to the the posterior part of the oral cavity with ‘best fit’ for dental forcep beaks:
opposite shorter ends (beaks). lower molar forceps because those with Do the beaks curve laterally such
If the position of the grip on the a circular joint (14 mm in Figure 3a) that a significant part of the root is in
handles is moved away from the can be bulkier than those with a pin contact with them (Figure 5a)?
fulcrum, as shown in Figure 2b, then the joint (8 mm in Figure 3b) and therefore Do the beaks curve longitudinally
force of grip at the beaks will be greater. placing the instrument vertically on such that the blades are contacting
This small movement of the operating posterior molar teeth can be challenging the root rather than the crown of the
hand away from the hinge can in patients with limited access. tooth (Figure 5b)?
Technique Tips
a In addition to the ‘best fit’ Informed Consent: Informed consent

questions, a critical eye should be cast was obtained from all individual
upon the sharpness of the beak tip. The participants included in the article.
periodontal ligament around teeth is
about 0.2 mm wide7 and sharp, gently References
tapered beak tips facilitate extension 1. Abdelwahab M, Nørholt SE, Taneja
apically down the periodontal ligament P. The efficacy of physics forceps for
to grip the dentine on the root of exodontia: a systematic review. J Oral
the tooth (Figure 6a). Flattened, Maxillofac Surg 2021; 79: 989.e1–989.
thick-edged blades will not fit into e13. https://doi.org/10.1016/j.
the narrow periodontal ligament joms.2020.12.033.
space as easily, and will therefore
2. Internation Organization for
grip too coronally on the root or
Standardization (ISO). Dentistry –
indeed, inadvertently grip the crown
Extraction forceps – Part 1: General
(Figure 6b), leading to potential
requirements. 2022. Available
tooth fracture.
b at: https://www.iso.org/obp/
Maintenance is needed to preserve
ui/#!iso:std:65160:en (accessed
sharpness to maximize effectiveness
February 2023).
of a dental forcep and individual
manufacturers can offer specific advice 3. Told R, Marada G, Rendeki S et
for individual products. al. Manufacturing a first upper
molar dental forceps using
continuous fiber reinforcement
Summary
(CFR) additive manufacturing
Table 1 summarizes the technology with carbon-reinforced
aforementioned factors that should be polyamide. Polymers (Basel) 2021;
considered when choosing a dental
13: 2647. https://doi.org/10.3390/
extraction forcep.
polym13162647
We hope this article helps dental
4. Rehal S, Shoker P. The battle of the
surgeons and dental therapists to
lower molar extraction forceps:
Figure 6. Example of (a) a harp and (b) a blunt choose dental extraction forceps
cowhorn versus eagle beak. Dent
forcep beak. wisely. Alongside appropriate hand
Update 2020; 47: 972–973.
movements and direction of force, a
5. Napier JR. The prehensile movements
few moments with a critical eye on a
dental forcep can reduce the risk of of the human hand. J Bone Joint Surg
If the forceps beaks curve in ways tooth fracture during an extraction Br 1956; 38-B(4): 902–913. https://
that fit the roots well, then the tooth procedure and promote the extraction doi.org/10.1302/0301-620X.38B4.902
will be less likely to fracture. With of intact roots and teeth for the benefit 6. Ashcroft G, Pawsey PM. The
a poor fit, usually due to the beaks of both operating clinicians and their extraction of adult teeth. The Dental
being too straight in design as in patients. Practitioner and Dental Record 1957;
Figure 5b, the crown or apical part 7: 330–334
of the root is more likely to fracture Compliance with Ethical Standards 7. Berkowitz BKB. Mouth. In: Standring
when rotational and lateral forces are Conflict of Interest: The authors declare S (ed.) Gray’s Anatomy. 42nd edn.
applied through the forceps. that they have no conflict of interest. Elsevier, 2021; 636–663.
Factor Considerations Reasons

Material Metal only at present – may Strength to accept forces of movement and give proprioceptive feedback in
change in future the operating hand
Handles Shape and grip Straight handles to fit well in the palm of the hand and a gripping surface that
enables a tight ‘power’ grip to maximize effective grip on the tooth root, in line
with ‘law of the levers’
Hinges Design Circular joints can increase forcep bulk in posterior oral cavity, which may
compromise placement on a tooth root where access is challenging
Beaks Shape and sharpness ‘Best fit’ lateral and longitudinal curvatures should grasp the tooth root and
avoid touching the crown. Sharp beak tips are needed to penetrate the
periodontal ligament space (0.2 mm)
Table 1. Summary of the factors to be considered when choosing a dental extraction forcep.

CPD
continuing education
Test your knowledge on the content of the articles published.

The following 10 questions relate to some of the articles carried this month. Only one answer is correct.
To receive CPD credit, please answer the questions online at www.dental-update.co.uk
Q1 AGGARWAL ET AL 50: 85–90 Q6 BURGESS AND HASSALL 50: 117–125

Regarding somatic symptoms: Regarding the heating of resin composite materials:
A. Somatization disorders may have a prevalence of 6% in A. This makes them more viscous.
general practice. B. A temperature of 88° C is appropriate.
B. These are physical symptoms that arise due to emotional or C. One manufacturer claims that there is no change to the colour or
psychological factors. chemical stability of warmed composite.
C. These are never reported as a component of other D. This makes placement much slower.
psychiatric conditions.
D. Management of these is never a challenge to clinicians.
Q7 KESHTGAR AND NOAR 50: 127–129

Q2 AGGARWAL ET AL 50: 85–90 Regarding traumatized upper incisor teeth:
The frequency of bodily distress disorder within primary A. Girls experience this more than boys.
care services is: B. Data from 2013 indicates that this affects 1% of children in the UK.
A. 0% C. CBCT is never useful in management of this.
B. 7% D. A significant risk for an avulsion injury is healing by ankylosis.
C. 17%
D. 27%
Q8 POTTER AND GRANGER 50: 131–133
Q3 LEYSSON ET AL 50: 93–96 Regarding cow’s milk allergy:

A. This is a reaction to sugar in the milk.
Regarding polyamide-based dentures: B. Prevalence is similar to that of peanut allergy.
A. These are always thicker than acrylic dentures. C. Almond milk is a much better storage medium than cow’s milk
B. These exhibit increased water sorption compared with acrylic. for an avulsed tooth.
C. These always need clasps. D. pH of cow’s milk is 1.5.
D. These are very easily polished.
Q4 YENG 50: 101–105 Q9 TREIFI ET AL 50: 135–139
Regarding calcium hydroxide as an In a retrospective evaluation of patients referred for secondary

intracanal medicament: care, caries was found to be present on the distal surface of which
A. This has no anti-resorptive properties. percentage of second molar teeth when the mandibular third molar
B. This has an acid pH. was mesio-angularly impacted:
C. During prolonged root canal treatment using calcium A. 8%
hydroxide dressings, an interim restoration that B . 9%
minimizes leakage is not important. C. 20%
D. This has antibacterial properties. D. 40%
Q10 MANSON 50: 142–144

Q5 HENNEBRY AND CHANA 50: 107–112 Regarding scarlet fever:
Regarding MTA: A. Incubation period is over 2 weeks.
A. This is an unsuitable material for perforation repair. B. It is common practice for doctors to diagnose scarlet fever from clinical
B. This gives worse healing results than calcium hydroxide-based symptoms alone.
materials. C. There are no oral manifestations.
C. It is antibacterial to facultative bacteria. D. The dental team does not need a plan on how to manage patients
D. It is cytotoxic to periodontal tissues. infected with GAS who need treatment.
DEADLINE FOR SUBMISSION: 17 APRIL 2023
10 QUESTIONS REPRESENT 4 HOURS OF CPD
ANSWERS FOR DECEMBER 2022 CPD ON PAGE 96

Venus Diamond ®
"…it has proved to be very fracture resistant…"
I like the strength offered by Venus Diamond.

I have been using the material for more than
12 years and it has proved to be very fracture
resistant. The composite offers easy handling,
is predictable and adapts perfectly to the
colour of the teeth.
Dr Tif Qureshi, Clinical director of IAS Academy
[email protected] / kulzer.com
© 2022 Kulzer Limited. All Rights Reserved.

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DentalUpdate

February 2023. Volume 50. Number 2

 Psychiatry within Dentistry: Why does patient mental health

Ti-Max & S-Max Turbines

Call us on 0800 6341909

77 Guest editorial C Burgess and D Hassall

February 2023 DentalUpdate 77

Effective prevention for patients at increased caries risk*,^

• 2800 ppm Fluoride Toothpaste provides

Diabetes is classiﬁed into two types:

Diabetic patients are known to be at Oral hygiene

High HbA1c value

• Increase ﬂuoride availability in mouth

Emily Sanger, David Shiers, Jenny Girdler and Emma Elliott

Why does Patient Mental Health

February 2023 DentalUpdate 85

distress can somatize physical symptoms,

86 DentalUpdate February 2023

February 2023 DentalUpdate 87

per day and drinks 16 units of alcohol a

What are our initial thoughts?

What could be the cause of

88 DentalUpdate February 2023

Physical symptoms: Signs of potential malignancy:

Pain Concurrent infection, facial

February 2023 DentalUpdate 89

example: are they experiencing feelings https://doi.org/10.1192/bjp.184.6.470 2023).

90 DentalUpdate February 2023

Perfecting the art of dentistry

Not sure which way to

The value of investments can go down as well as

Advice is provided by Wesleyan Financial Services Ltd.

Jasmeet Heran and AD Walmsley

Acrylic Dentures: Fill the Gap.

February 2023 DentalUpdate 93

design, patient’s wishes (including

94 DentalUpdate February 2023

Advances in denture polish because any adjustment exposes

February 2023 DentalUpdate 95

Optical Shading Composite

Optically generated shading!

Changes with bleaching!

96 DentalUpdate February 2023

Scan the QR code to

EXPERIENCE SUPERIOR CARE.

Shamir Chandarana, Dental House

Over 35 years of championing dentists means

Making dentists smile since 1986

To get a quote for an income protection plan please visit www.dentistsprovident.co.uk

Protecting your lifestyle. Securing your future.

Healing of Peri-apical Lesions with

February 2023 DentalUpdate 101

Figure 1. Case 1. The lower left first mandibular

Figure 4. Case 4. The lower right central and

lengths were determined using an

102 DentalUpdate February 2023

Figure 14. Case 4. Healing response seen around

and highlights the importance of

Psychiatry within Dentistry: Why does patient mental health

/04!-+./"-0/ ,0'$‫ޔ‬/$)2$/#0/' 1$)"40-'$)$-#*( ѵ

Warm injection moulding of composite Improved marginal integrity