Dental Continuing Professional Development - Part I: Background on Dental Continuing Professional Development in Europe.

INTRODUCTION: Continuing Professional Development (CPD) is mandatory in most European countries and evidence shows a move towards mandatory CPD across all Member States in the near future. Malta is one of seven Member States where dental CPD is still voluntary. DISCUSSION: Although dental CPD is a legal requirement for recertification in many countries, integral aspects of dental CPD remain under debate, like whether CPD is truly effective. This is because the methods with which CPD programmes are evaluated are not sufficiently robust to give concrete evidence to determine whether CPD will actually improve quality of care, treatment outcomes and safety for the public. Evaluating the effect of CPD programmes on the public is an extremely difficult task that would require an enormous amount of resources and logistics. The minimum requirements for the number of compulsory CPD hours imposed by regulatory bodies are not evidence-based but purely arbitrary, and the core topics selected for CPD programmes, although supported by research to some extent, may not reflect the public's and profession's needs. The Dental Association of Malta recognised need for further research on dental CPD and embarked on a 3-year Dental CPD Research Project. This project will be presented in a two-part series of articles. This first article is focused on the background of dental CPD in Europe. An understanding of the current issues with CPD and flaws in methods of evaluation formed the basis of the Malta CPD Pilot Project, which will be covered in the next paper.

Dental continuing professional development - Part II: The Malta CPD Pilot Project.

INTRODUCTION: Continuing professional development (CPD) remains voluntary in nine European countries. Evidence suggests a move towards mandatory CPD across Europe with the objective of harmonisation of dental CPD. Although the importance of CPD is acknowledged, the literature regarding its effectiveness is limited and under debate. AIMS AND OBJECTIVES: The main aim was to measure the effectiveness and success of a new CPD programme with the objective to devise a strategy, guidelines and recommendations for the establishment of a dental CPD programme in Malta. METHODOLOGY: This project was divided into two phases; Phase 1 was the analysis of a survey sent out to 135 members of the Dental Association of Malta. Phase 2 involved the evaluation of eight verifiable CPD events, through pre-event and post-event tests and feedback forms, to investigate the effect on short-term knowledge retention and the respective satisfaction levels of participants at each event. RESULTS: The survey had a response rate of 78%. The CPD events in Phase 2 all showed statistically significant improvement in short-term knowledge retention on each subject (p < 0.05). Satisfaction levels ranged from 70% to 99%. CONCLUSIONS: The information gathered from this project was used to provide guidelines and recommendations for the local regulatory body and CPD providers for the set-up of a dental CPD framework and programmes in Malta, a country where dental CPD is still voluntary. This article is the second article from a two-part series of articles about the Malta Dental CPD Pilot project.

Articaine hydrochloride: is it the solution?

In recent times there has been raised interest regarding the use of articaine hydrochloride as a dental local anaesthetic solution. The use of articaine hydrochloride as a dental local anaesthetic agent has been reported to be safe and effective. Paraesthesia is a rare but unwanted adverse effect attributed to the use of this local anaesthetic in dentistry, particularly following the administration of a nerve block injection. There is no evidence to support the opinion that the use of articaine carries a greater associated risk of paraesthesia than with the use of any other local anaesthetic. Clinical Relevance: The aim of this article is to review the relative merits of articaine hydrochloride against its documented potential drawbacks. The article will also aim to update readers on the use of articaine hydrochloride for local analgesia in dentistry, including the pharmacology, efficacy and safety concerns (including the risks of nerve paraesthesia) commonly associated with the administration of this agent.

Maxillary Midline Diastemas in West African Smiles.

The maxillary midline diastema (MMD) has experienced a renaissance in popular culture over the last 10 years. Current literature states that MMDs should be eliminated where possible or be reduced to 1 mm or less in width. This literature review explores the evidence for this in a West African population. A systematic search of the literature (Medline and Google Scholar) followed by a hand search was carried out to identify all papers evaluating perceptions of MMDs. In all, 209 papers were identified in the literature search, 8 of which met the inclusion criteria. The review revealed that midline diastemas are desirable in this specific population with a width of 2 to 4 mm deemed as attractive. As many as 95% of participants found the MMD beautiful, and as many as 95% would consider having one created artificially. The literature does not support the position that MMDs larger than 1 mm should always be treated to be perceived as attractive in this population. MMDs are accepted as attractive and should be considered a key feature in smile design for this population.

How can general dental practitioners help in the management of sleep apnoea?

This article discusses the aetiology, prevalence and treatment of obstructive sleep apnoea (OSA) and highlights the important role general dental practitioners can perform in improving the quality of life of patients suffering from OSA. Clinical and laboratory stages of making a mandibular advancement appliance are also highlighted.Members of the dental team have a duty of care to our patients. The earlier undiagnosed cases of OSA are referred for treatment, the less morbidity and potential mortality endured by patients.After reading this article, the reader should have a greater understanding of OSA, how to identify symptoms of the condition in patients and be confident in referring patients to appropriate healthcare professionals.

Dental drill noise reduction using a commercially-available earplug device.

AIM: The dental handpiece noise in a dental surgery is concerning to both patients and staff as a major cause of dental phobia in patients and potential hearing loss in clinical staff. High-frequency noise generated by dental handpieces is considered to be the worst of the many noises in a dental clinic. Methods to reduce this noise have been proposed and either passive or active noise reduction headphones are often suggested. However, in a dental surgery environment, the need for good verbal communication with the patient needs to be maintained. As a result, this paper aims to evaluate one proprietary anti-noise device considered suitable for this specific purpose. METHODS: Lab-based experiments were set up and carried out to evaluate QuietOn, using GRAS 43AG-1 Ear and Cheek Simulator to mimic a section of the human head and ear to represent the acoustic characteristics of an actual ear. Two types of dental drill noise recordings, one for electric motor-driven and another one for air turbine-driven, were played back through high-definition speakers. Sound data captured by the simulator are then visualised and plotted using MATLAB for analysis. MAIN FINDINGS: QuietOn is effective at low frequencies (< 1kHz). However, when dealing with high-frequency noise such as dental handpieces it is ineffective yet subdues verbal communication. CONCLUSIONS: Further development of passive or active noise cancellation earplugs is still needed to target dental handpiece noise while maintaining verbal communication.

Aesthetic composite veneers for an adult patient with amelogenesis imperfecta: a case report.

UNLABELLED: This case has been presented as part of the continual assessment requirement for the MSc in Aesthetic Dentistry, King's College Dental Institute. Amelogenesis imperfecta (AI) is a hereditary disorder of enamel formation, affecting both the permanent and deciduous dentitions. It can be classified into hypoplastic, hypomaturation and hypocalcified types and presents with different hereditary patterns. The aim of this article is to provide an overview of amelogenesis imperfecta, including a detailed case report for an aesthetically concerned adult patient presenting in general practice with a Witkop's Type IA defect managed with the placement of direct, layered resin composite veneers. CLINICAL RELEVANCE: Amelogenesis imperfecta patients are susceptible to the restorative cycle of replacement restorations like any other patient, but start with a distinct disadvantage.This case report demonstrates a minimally invasive, relatively simple and cost-effective option for the aesthetic correction of a case of hypoplastic amelogenesis imperfecta with layered composite veneers. Dent Update 2011; 38:594-603

Aesthetic smile evaluation--a non-invasive solution.

UNLABELLED: Enhancement of the aesthetic zone is a common reason for patients to seek dental care. This article describes a protocol for the examination, assessment and treatment planning for a patient seeking a solution to an aesthetic concern. The technique of undertaking an intra-oral'mock-up' using resin composite as a diagnostic approach can be particularly helpful when planning for future prosthodontic rehabilitation. The latter can allow the operator and patient to visualize crudely what is aesthetically and functionally possible, given the constraints imposed by that patient. The patient has ultimately managed in a minimally invasive manner. CLINICAL RELEVANCE: It can be very tempting for a dental operator to impose his/her concepts of the'artistic ideal' when planning for care in the smile zone. Such ideals are largely based on established universal aesthetic principles of tooth colour, size, shape, form, position, symmetry and proportion. However, beauty is a very subjective matter. It is essential for the operator to listen attentively to his/her patient's concerns. Meticulous patient examination and assessment are absolutely critical factors in attempting to attain a successful outcome. The use of reversible, chairside intra-oral mock-up techniques can not only help with the transference of essential information to the dental technician when planning for restorative intervention in the smile zone, but can also allow the patient to gain an insight and indeed contribute his/her views to the possible restorative endpoint, respectively.

Aesthetic resin onlay restorations: 'rationale and methods'.

UNLABELLED: Resin composite restorations have gained increasing popularity over the past two decades. This has been largely driven by a patient-orientated demand for the use of aesthetic restorative materials. It has occurred concomitantly with an improvement in the mechanical properties of available materials, and advances in our knowledge of resin bonding. Onlay restorations are advocated for a plethora of clinical applications. This paper considers the role of adhesive onlay restorations fabricated in resin composite in contemporary restorative practice, including the presentation of two case reports. CLINICAL RELEVANCE: This case report describes a minimally invasive, aesthetic solution to provide cuspal coverage by means of either a direct or indirect resin composite onlay restoration, respectively.

An Analysis of Electronic Primary Dental Practice Tooth Wear Referrals.

We evaluated the quality of general dental practitioner (GDP) tooth wear (TW) referrals to secondary care services in Kent, Surrey and Sussex.Prospective consecutive referrals received via an electronic pathway were assessed from 1 June to 30 October 2019. Reasons for referral, patient demographics, quality of referral, opinion of the triaging clinician and outcome were assessed.Of 671 referrals, 32% were for TW. Males were referred more commonly (1.7:1.0). The median age was 52. Patients were more likely to be referred from distant locations than places closer to the referral centre (p<0.001). Only 55% of referrals suggested a cause for the TW, 33% provided a clinical photograph and 1% recorded a tooth wear index of any type. Referring clinicians most commonly cited attrition as reason for referral (p<0.001). Those under 40 years were referred for erosion (p=0.001) and those over 40 years, attrition (p=0.019). The triaging clinician was more likely to allocate a tooth wear score of three for those under 40 years and a score of four for over 40 years (p<0.001). 47% of referrals were rejected. Males and referrals with photographs were more likely to be accepted for treatment (p=0.017 and p<0.001, respectively).There is a high demand for specialist TW services. The number of referrals being rejected has not changed using the electronic referral system. We advocate the inclusion of mandatory fields for completion by GDPs as well as compulsory clinical photographs and tooth wear indices (Smith and Knight Tooth Wear Index or a basic erosive wear examination - BEWE index).

Survey of the provision of crowns by dentists in Ireland.

STATEMENT OF THE PROBLEM: The literature is limited on the detailed description of the practice of Irish general dentists in the provision of crowns. PURPOSE OF THE STUDY: To review the provision of crowns by dentists in Ireland and identify opportunities for improving current clinical practices. MATERIALS AND METHODS: A questionnaire was posted to 500 general dentists selected randomly from the Irish Dental Register and 150 responded. Twenty-three laboratories used by these dentists were subsequently surveyed. RESULTS: The Vita Shade Guide was the most commonly used shade guide. Crowns were mainly fabricated using porcelain bonded to metal (51%) followed by all-ceramic (42%) and gold (5%). Plastic Solo trays were the preferred tray for impressions and the laboratory prescription form was the primary means of dentist-technician communication. Dentists and technicians have different preferences for impression trays, impression materials and bite registration, while a significant percentage of dentists (18%) admitted to not disinfecting impressions. Resin or resin-based cements are the preferred means of crown cementation. CONCLUSIONS: This study suggests that the accuracy of restorations could be improved by: adopting a multi-technique approach to shade taking; replacing Solo trays with metal or custom trays for impression-taking; upgrading of the putty-wash technique by using a custom tray with a 2 mm spacer and a heavy-bodied/light-bodied silicone; and, using a two-cord retraction technique, perhaps in combination with electrosurgery or soft tissue laser, to improve marginal accuracy where indicated.

Evaluation of the effects of polishing systems on surface roughness and morphology of dental composite resin.

Objectives The aim of this in vitro study was to evaluate the effects of five different two-step diamond impregnated polishing systems (Sof-Lex Spiral, Venus Supra, Komet Spiral, CompoMaster and Shapeguard) on the surface roughness and morphology of a submicron hybrid composite resin material (Brilliant Everglow).Materials and methods Two-hundred composite resin discs were prepared with 180 SiC paper to produce a uniform baseline surface. The samples were randomly assigned to one of five groups and polishing was completed by one operator. The arithmetic mean surface roughness (Ra) was measured using contact profilometry and the surfaces were examined under an SEM.Results Statistical differences (p <0.05) were identified between the surface roughness remaining after use of the polishers. Diatech Shapeguard (0.22 µm, SD 0.08) and Komet Spiral (0.26 µm, SD 0.09) polishers yielded the lowest Ra values, while the CompoMaster polishing system led to the highest surface roughness values (0.55 µm, SD 0.19).Conclusions Within the limits of this in vitro study of the efficacy of diamond impregnated two-step polishing systems, Diatech Shapeguard and Komet Spiral polishing systems produced the lowest surface roughness values. These polishing systems yielded acceptable surface roughness values with regards to oral health and patient comfort.Clinical relevance Similarly designed polishing systems do not produce comparable surface roughness levels and clinicians should be aware of this when considering polishing protocols for composite restorations.

Evaluation of the assessment of tooth wear by general dental practitioners.

Aim To evaluate currently available methods for assessing and monitoring tooth wear in a general dental practice environment.Method A questionnaire was developed and used to obtain data. Models were used to test the dentists' assessment of tooth wear. Ethical permission was obtained.Results Twenty general dental practitioners were interviewed and 100% were aware of the use of study models, 50% about the use of photographs and 45% of the BEWE. Methods used to assess and monitor tooth wear were study models (75%), photographs (65%), BEWE (10%), Smith & Knight index (0%) and no method (15%). Sixty-five percent of dentists were unaware of any guidelines on monitoring tooth wear. In comparing serial photographs, no participant correctly identified all the wear changes and 25% thought a change had occurred when one hadn't. Statistical analysis showed a sensitivity of only 73% with a specificity of 75%. In comparing serial study models (same cases as used in the photographs), 55% of participants identified a change when no change occurred and 50-60% of participants were able to correctly identify if wear had or had not occurred. Participants graded the models according to BEWE. Statistical analysis of these results shows a sensitivity of just 69% with a specificity of only 55%. The inter-operator agreement (Fliess' Kappa) showed an even lower degree of agreement was found with only 0.12, which suggests only a slight level of agreement, less than that with photographs.Conclusion Dentists do not seem to be aware of the current guidelines but do make reasonable attempts to monitor tooth wear. None of the currently available methods are ideal and even the use of serial study models is open to much inter-operator variability.

Effect of distance from curing light tip to restoration surface on depth of cure of composite resin.

AIMS: While light-activating composite resins, the light tip may not always be close to the surface of the restoration. This may be intentional in an attempt to create a ramp cure. The aim of this study was to determine the effect of a range of separation distances between the light tip and the restoration surface on the depth of composite cure for different types of light-curing units with a broad range of outputs. METHODS: Three halogen light units, one plasma arc-curing (PAC) light unit and two light-emitting diode (LED) curing lights in clinical use were tested, and a total of 570 restorations cured in a two-part human tooth model at separations ranging from 0 to 15 mm. The tooth was disassembled and depth of cure determined using the scrape test ISO 4049. Light intensity was also measured at each separation distance for each light. RESULTS: The depth of cure was generally found to decrease as the separation distance increased for all lights at the various cure times. However, the effect of increasing the separation distance was less than anticipated. The depth of cure was also related to the light output. CONCLUSIONS: Depth of composite cure was directly related to intensity and duration of light exposure and inversely related to distance of the light source from the surface for halogen and plasma lights. However, the effect of increasing the separation distance up to 15 mm was less than expected. Altering the separation distance in order to modify the polymerisation characteristics is unlikely to be effective.

Assessment of the safety of two ozone delivery devices.

OBJECTIVES: To evaluate the safety of an ozone gas device designed for use in dentistry. METHODS: Two commercially available ozone applicators, Ozi-cure and HealOzone were used in a clinical simulation using a phantom head while recordings of ozone levels were made in pharyngeal and nasal regions of the patient and near the mouth of the operator. Clinical simulations included ozone application for caries management and endodontic treatment. Recordings were made five times with different levels of suction to assess the effect on ozone levels. RESULTS: The results with Ozi-cure on caries mode resulted in a peak ozone level in the pharynx of 1.33+/-0.52 ppm when no suction was used. The use of suction nearby reduced the ozone level to zero while suction on the opposite side of the mouth reduced the level to 0.22+/-0.04 ppm. Used on endodontic mode the peak ozone level in the pharynx was 5.51+/-1.63 ppm when no suction was used. The use of suction nearby reduced the ozone level to zero while suction on the opposite side of the mouth reduced the level to 0.84+/-0.54 ppm. Recordings in the patient's nasal region gave a peak of 0.22 ppm when using the Ozi-cure on endodontic mode with no suction. At the operator's mouth the ozone level did not exceed 0.01 ppm although the characteristic smell of ozone was detectable. All recordings with HealOzone were zero. Concentrations of 15 ppm were recorded in a simulated tooth cavity with Ozi-cure and >20 ppm with HealOzone. CONCLUSIONS: The Ozi-cure device when used without adequate suction allows ozone to be reach a concentration above permitted levels and therefore should not be used. The HealOzone was safe to use.

An in vitro comparison of four intra-oral ceramic repair systems.

OBJECTIVES: This study evaluated the effect of different surface conditioning methods on the tensile bond strength (TBS) and integrity of the leucite-reinforced glass ceramic (Cerana(®) inserts)-resin composite interface, using four commercially available ceramic repair systems. METHODS: Two hundred extra-large Cerana(®) inserts were mechanically treated and stored in artificial saliva for 3 weeks and subsequently randomly assigned to one of the following ceramic repair systems (n=40/group): Group 1, Ceramic Repair(®) (Ivoclar Vivadent, Liechtenstein); Group 2, Cimara(®) (Voco, Germany); Group 3, Clearfil Repair(®) (Kuraray, Japan); Group 4, CoJet system(®) (3M ESPE, Germany); and Group 5, no surface conditioning and no adhesive system applied: the control group. Subsequently, resin composite material was added to the substrate surfaces and the ceramic-resin composite specimens were subjected to TBS testing. Representative samples from the test groups were subjected to scanning electron microscopy (SEM) to determine the mode of failure. The data were analysed statistically using a one-way multivariate analysis of variance and Kruskal-Wallis test at a 95% confidence interval level. RESULTS: Surface conditioning with the CoJet(®) system resulted in significantly higher bond strength values (5.2 ± 1.1 MPa) than surface conditioning with the other repair systems (p=0.03). The SEM examination of the failed interfaces revealed that all the specimens examined failed adhesively. SIGNIFICANCE: Whilst highest bond strength values were observed with the CoJet(®) system all tested repair systems resulted in relatively weak TBS values and, as a consequence, these repair systems may be indicated only as interim measures.

Pre-warming of dental composites.

OBJECTIVES: Cavity lining with flowable composites have been proposed to improve initial marginal adaptation and minimize shrinkage stresses. The purpose of this study was to evaluate if prewarming of composites would influence the flow and enhance marginal adaptation thus the effect of pre-warming different types of composites on their properties are reported. METHODS: Six different composites were used in this study including a flowable and a polyacid modified composite. Uncured composites were pressed between two glass plates with a known load and the film thickness was measured to determine flow. Polymerization shrinkage was measured by means of a one-dimension contacting transducer. Flexural strength was determined using a three-point bend test. Microleakage was determined in human lower third molars on both enamel and dentin restoration interfaces. Cytocompatibility was analyzed with an Alamar Blue redox cell proliferation assay. The flow properties, linear shrinkage, flexural strength, microleakage and cytocompatibility were evaluated at 22 °C and 60 °C. RESULTS: The results indicated that the film thickness for each of the materials was significantly lower at 60 °C and the linear shrinkage was greater as a result of the higher degree of polymerization. The flexural strength of Spectrum TPH and Wave were found to be statistically significantly higher with pre-warming, however the other composites did not exhibit any differences. Microleakage studies showed that pre-warming had no significant bearing on the results and alamarBlue(®) results showed that the pre-heating did not have an effect on the cytotoxicity however the levels of cytotoxicity varied between the composites that can be attributed to the composition. SIGNIFICANCE: Pre-warming of the composites studied enhanced flow as observed by measuring film thickness and did not significantly affect other properties.

Temperature change in pulp cavity in vitro during the polymerization of provisional resins.

OBJECTIVES: To measure the temperature change in the pulp cavity of an extracted tooth during the polymerization of provisional resins within impression putty and polyethylene matrices. The effect of pre-cooling the putty matrix was also evaluated. METHODS: A freshly extracted premolar tooth had putty impressions recorded prior to crown preparation. Putty matrices were stored at room temperature, 4 and -12 degrees C prior to use. A thermocouple placed in the pulp chamber recorded the temperature change every 15s for a 10-min duration during polymerization of three resins using putty and clear polyethylene matrices. Five recordings were made with each material at each storage temperature. RESULTS: There is a temperature rise of 3.4-5.5 degrees C when the resins were autocured in a putty matrix. When the polyvinyl matrix was used the temperature rise increased to 4.0-8.2 degrees C (P<0.001). The temperature rise was reduced to zero when the putty had been pre-cooled in the fridge (P<0.001) and reduced further following pre-cooling in the freezer (P<0.001). SIGNIFICANCE: The use of a polyvinyl matrix allows higher pulp temperature rises to occur due to the exotherm from provisional resins. Lower temperatures were recorded when putty was used. The temperature rise could be eliminated when the putty was cooled at 4 degrees C prior to reinsertion.