DT UK No. 9, 2017

UK News / World News / Business / Trends & Applications / Endo Tribune United Kingdom Edition

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DENTALTRIBUNE
The World’s Dental Newspaper · United Kingdom Edition
www.dental-tribune.co.uk

Published in London

Vol. 11, No. 9

WHAT WOULD DR MO LAR DO?

INTERVIEW

ENDO TRIBUNE

In the seventh article of this series, Richard Lishman explains
what to consider when purchasing a second practice.

Dental Tribune spoke with Dr
Rubén Davó about the new Trefoil
implant solution from Nobel Biocare.

Read the latest news and clinical
developments from the ﬁeld of
endodontics in our specialty section included in this issue.

” Page 10

” Page 14

” Page 17
© Dzmitry Held/Shutterstock.com

BDA survey shows most dentists want
to leave NHS
By DTI

both our patients and the young
dentists on whom the future of the
service depends,” said Chair of the
BDA’s Young Dentists Committee
Dr Harman Chahal. “Young NHS
dentists are being asked to make
impossible choices. They are offered no reward for going above
and beyond, just the constant
threat of penalties for not hitting
government targets.”

LONDON, UK: New doubt has been
cast on the future of NHS dental
care, as a recent survey issued by
the British Dental Association
(BDA) has found that the majority
of dentists currently working in
the service intend to leave it within
the next ﬁve years. The results further showed that one in two dentists under 35 see no future for
themselves in the NHS.
Instead, that demographic is
now considering increasing the
private work they do, working in
private practice or moving abroad.
Buying a practice is no longer considered a viable option, according
to the poll, as only 16 per cent of
those surveyed thought they
would be able to own a practice in
the next ﬁve years.
The worrying ﬁgures come after statistics from NHS Digital

Chair of the BDA’s General
Dental Practice Committee Dr
Henrik Overgaard-Nielsen added
that, while young dentists remain
the backbone of the dental workforce, government has made NHS
high-street practice so unattractive that the next generation is
now looking to the exit.
Demonstrations against NHS cuts in London.

showed that the income of dentists
in England and Wales has decreased by almost 35 per cent over
the last decade. According to the

BDA, the government is mainly to
blame, as commitments to overhaul the controversial 2006 dental
contract have not been honoured.

“The dental contract has reduced our patients to a line in a
spreadsheet. This conveyor belt
model of care has decisively failed

“Practices across the UK are already reporting major recruitment problems. This is a crisis
made in Westminster, and Westminster must respond,” he urged.

Report: Policymakers given steps
to act against dental caries
By DTI
LONDON, UK: A new report, published last week by the Alliance for
a Cavity-Free Future (ACFF) and
the Policy Institute at King’s College London in the UK, has highlighted the importance of demonstrating to policymakers the economic beneﬁts of tackling the high
rate of dental caries and gaining
their commitment to the ﬁght
against the disease. The authors
have further proposed key steps to
speed up the process towards a
cavity-free world.
The report is the product of
discussions that took place at a
Policy Lab meeting in June. This
session for the ﬁrst time brought
together individuals from a range
of different backgrounds—dentists, economists, public health ofﬁcials, policy advisers, educators
and psychologists—to provide

nancial costs arising from
other conditions, they explained.

new perspectives on the
continuing problem of
dental caries.
While the science on
preventing the disease and
stopping early-stage caries
progressing is already well
understood, efforts to apply it have so far fallen
short, the report’s experts
emphasised. They estimate that the potential
economic and health beneﬁts of a cavity-free world
are signiﬁcant, especially
considering that caries has
common risk factors with
other non-communicable
diseases, such as diabetes
and metabolic syndrome.
Reducing the risk factors
associated with caries
could thereby also help
improve health more generally and reduce the ﬁ-

Towards a cavity-free future
How do we accelerate a policy shift towards increased
resource allocation for caries prevention and control?
The Alliance for a Cavity-Free Future
Professor Nigel Pitts, Dr Marco Mazevet
and Catherine Mayne

The Innovation and Translation Centre,
King’s College London Dental Institute
The Policy Institute at King’s
Dr Saba Hinrichs, Dr Harriet Boulding
and Professor Jonathan Grant
Power of Numbers Ltd.
Ross Pow

June 2017

The Policy Institute at King’s

To have policymakers
actively engaged in the
ﬁght against the disease,
systematic economic and
comprehensive
clinical
data must be collected, the
report urged. In addition,
increased efforts should
be made to accelerate the
move towards a greater focus on preventative dental
care. To this end, the authors proposed creating
new remuneration systems for dentists to ensure
that caries prevention and
control are properly rewarded, as well as promoting efforts to encourage
behaviour change in the
public and implementing
incentives for the industry

to adopt more socially responsible
agendas, among other measures.
Concerning the proposal to revise dental remuneration systems,
ACFF Global Chairman Dr Nigel
Pitts told Dental Tribune Online:
“Current payment systems do not
typically pay dentists to ‘do prevention’ and there is no ﬁnancial
incentive for dentists to spend
time and resources on preventatively oriented care pathways. In
order to see progress, this needs to
change.”
In addition, Pitts highlighted
the importance of closer collaboration between dental and medical
practitioners. “Maximising the effectiveness of caries preventative
caries management will increasingly draw on a multidisciplined
workforce of teams made up of
” Page 2

[2] =>

2

UK NEWS

Dental Tribune United Kingdom Edition | 9/2017

“Too many sweets, eh?”

IMPRINT
GROUP EDITOR/MANAGING EDITOR DT UK:
Daniel ZIMMERMANN
newsroom@dental-tribune.com
Tel.: +44 161 223 1830

EDITORS:
Kristin HÜBNER
Yvonne BACHMANN

ONLINE EDITOR/SOCIAL MEDIA MANAGER:
Monique MEHLER

MANAGING EDITOR &
HEAD OF DTI COMMUNICATION SERVICES:
Marc CHALUPSKY

JUNIOR PR EDITOR:
Brendan DAY

COPY EDITORS:
Ann-Katrin PAULICK
Sabrina RAAFF

CLINICAL EDITORS:		
Magda WOJTKIEWICZ
Nathalie SCHÜLLER

PUBLISHER/PRESIDENT/CEO:
Torsten R. OEMUS

CHIEF FINANCIAL OFFICER:
Dan WUNDERLICH

BUSINESS DEVELOPMENT MANAGER:
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PROJECT MANAGER ONLINE:
Tom CARVALHO

JUNIOR PROJECT MANAGER ONLINE:
Hannes KUSCHICK

E-LEARNING MANAGER:
Lars HOFFMANN

MARKETING SERVICES:
Nadine DEHMEL

SALES SERVICES:
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ACCOUNTING SERVICES:
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Karen HAMATSCHEK
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MEDIA SALES MANAGER:

GDC: First results of fitness
to practise analysis published
By DTI

The analysis commissioned by
the GDC is the first to examine
data from its FtP process in depth
and is part of the organisation’s
ongoing efforts to reform dental
regulation. Although the findings
do not necessarily reflect the actual situation owing to gaps in the
information-gathering
process,
the regulator said it is planning to
share them with its partners in or-

“ Page 1
professionals with a mix of skills
best suited to the environment
they work in and the range of patients they support. This involves
empowering the existing workforce with the knowledge they
need and also, where possible, expanding the range of people who

EXECUTIVE PRODUCER:
Gernot MEYER

ADVERTISING DISPOSITION:
Marius MEZGER

DESIGNER:
Matthias ABICHT

© Kzenon/Shutterstock.com

INTERNATIONAL EDITORIAL BOARD:
Dr Nasser Barghi, Ceramics, USA
Dr Karl Behr, Endodontics, Germany
Dr George Freedman, Esthetics, Canada
Dr Howard Glazer, Cariology, USA
Prof. Dr I. Krejci, Conservative Dentistry, Switzerland
Dr Edward Lynch, Restorative, Ireland
Dr Ziv Mazor, Implantology, Israel
Prof. Dr Georg Meyer, Restorative, Germany
Prof. Dr Rudolph Slavicek, Function, Austria
Dr Marius Steigmann, Implantology, Germany

LONDON, UK: Dentists who are
male and have an Asian background are more likely to be investigated by the General Dental
Council (GDC), an independent
analysis of the regulator’s fitness
to practise (FtP) data has suggested. It also found that foreign
dentists who registered by taking
its Overseas Registration Exam
were less likely to be involved in an
FtP case than their counterparts
from the European Economic Area
region.
In fact, dentists from that area
were over-represented in FtP proceedings, according to the data.

Antje KAHNT (International)
Barbora SOLAROVA (Eastern Europe)
Hélène CARPENTIER (Western Europe)
Maria KAISER (North America)
Matthias DIESSNER (Key Accounts)
Melissa BROWN (International)
Peter WITTECZEK (Asia Pacific)
Weridiana MAGESWKI (Latin America)

Published by DTI
DENTAL TRIBUNE INTERNATIONAL
Holbeinstr. 29, 04229, Leipzig, Germany
Tel.: +49 341 48474-302
Fax: +49 341 48474-173
info@dental-tribune.com
www.dental-tribune.com

Regional Offices:
UNITED KINGDOM

der to help transform internal processes and policies, like the development of new materials to ease
the transition of dentists who were
trained abroad into UK dentistry.
They will also be used for a
state of the nation report that is
anticipated to be released in 2019,
the GDC added.
According to the Professional
Standards Authority, the regulator

can advise, refer and, in some
cases, treat around issues of dental
caries and dental health.”
Untreated dental caries in permanent teeth affects 2.4 billion
people and was the most prevalent
condition among all participants
evaluated in the 2016 Lancet

opened 250 cases in 2015/2016
that met FtP criteria.
“This is a major step towards
improving our use of data and intelligence to inform upstream
regulation initiatives—to improve patient protection, ensure
the public maintains confidence
in dental services and to better
support
professionals,”
explained the GDC’s Executive Director of Fitness to Practise, Jona-

Global Burden of Disease study.
Untreated caries in children’s
teeth was the tenth most prev
alent condition, affecting over
621 million children worldwide.
“It is our job as dental and
health professionals to ensure
that the health of the public and

than Green. “We made a commitment within shifting the balance
to use data and intelligence to inform our approach to regulation
and this statistical analysis of our
fitness to practise data is one of
the ways we are working to fulfil
this.”
“We have already started to use
the findings to feed into our ongoing work to deliver our commitments,” he also said.

patients is our priority. By working
together across stakeholders to
progress a shift towards prevention rather than just restorative
treatment of caries, we will be ensuring a healthier future for millions as well as securing greater access to care for excluded patients,”
Pitts said.

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All rights reserved. Dental Tribune makes every effort
to report clinical information and manufacturer’s
product news accurately, but cannot assume responsibility for the validity of product claims, or for typographical errors. The publishers also do not assume
responsibility for product names or claims, or statements made by advertisers.
Opinions expressed by authors
are their own and may not
reflect those of Dental Tribune
International. Scan this code
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Tribune UK e-newsletter.

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[4] =>

UK NEWS

Dental Tribune United Kingdom Edition | 9/2017

Mechanism behind oral thrush discovered
By DTI
LONDON, UK/PITTSBURGH, USA:
A recently discovered peptide
toxin has been identiﬁed by a
team of UK and US researchers as

harmless fungus which results in
the painful infection.
“Surprisingly little is known
about how fungal immunity in the
mouth operates,” said co-senior

importance of Candidalysin. Not
discovered before 2016 by Professor Julian Naglik at King’s College
London, the toxin is the ﬁrst peptide toxin identiﬁed in any fungus
that was found to infect humans.

defence network at barrier sites of
the body. This knowledge may ultimately be harnessed to design antifungal vaccines,” Professor Julian
Naglik from King’s College London
Dental Institute, who discovered

pain that makes it difﬁcult for patients to eat or swallow. It is also believed to be responsible for other serious fungal infections, especially
in infants and other patients with a
compromised immune system

Candidalysin in an earlier study,
said. Awarded a large National Institutes of Health (NIH) grant,
Gaffen and Naglik announced to
further explore the role of Candidalysin signalling in oral immunity
in the near future.

such as HIV/AIDS patients, denture
wearers and those on immunosuppressants, including chemotherapy
and drugs to prevent the rejection
of transplanted organs.

Candida albicans is a causal agent of opportunistic oral and genital infections in humans.

the cause for the mouth to develop
an oral thrush. The substance
called Candidalysin, which is produced by the fungus Candida albicans, was found to punch a hole
into cells lining the mouth thus
triggering the immune response,
they wrote in a study published by
the journal Science Immunology.
Helper immune cells then attack the hyphae of the otherwise

author Sarah L. Gaffen from the
University of Pittsburgh School of
Medicine. “And, until now, it was
unclear why Candida does not establish an invasive infection in
healthy humans.”
In their study, the researchers
used a combination of human oral
epithelial cells cultured in laboratory dishes and mice infected orally
with Candida, to show the central

Understanding its role in the infection mechanism in the mouth
could eventually lead to better
treatments for the condition and
other fungal infections, the scientists said. They added that despite
millions of fungal infections worldwide, there are no commercially
available anti-fungal vaccines yet.
“Our research provides vital
clues to understand the immune

An oral thrush is one of the
most common fungal infections of
the mouth. While it is treatable with
topical medication, it often causes

The paper, titled “Oral epithelial cells orchestrate innate Type 17
responses to Candida albicans
through the virulence factor Candidalysin” was published in Science Immunology on 3 November.

Tooth found in Dorset traces
New survey reveals how often
human lineage to rat-like creature Brits skip toothbrushing
PORTSMOUTH, UK: According to new research from the University of Portsmouth in
England, fossils from the oldest mammals
belonging to the line that led to human beings have been discovered on the Jurassic
Coast of Dorset in the UK. The two teeth are
from small, rat-like creatures that lived 145
million years ago in the shadow of the dinosaurs. The animals are reportedly the ancestors of almost all mammals alive today.
The discovery of the teeth was made by
University of Portsmouth undergraduate
student Grant Smith. Dr Steve Sweetman, a
research fellow at the University of Portsmouth and the study’s lead author, said:
“Grant was sifting through small samples of
earliest Cretaceous rocks collected on the
coast of Dorset as part of his undergraduate
dissertation project in the hope of ﬁnding
some interesting remains. Quite unexpectedly, he found not one but two quite remarkable teeth of a type never before seen from
rocks of this age. I was asked to look at them
and give an opinion and even at ﬁrst glance
my jaw dropped.”
The teeth were recovered from rocks exposed in cliffs near Swanage, which has given
up thousands of iconic fossils. “The teeth are
of a type so highly evolved that I realised

straight away I was looking at remains of
Early Cretaceous mammals that more closely
resembled those that lived during the latest
Cretaceous—some 60 million years later in
geological history. In the world of palaeontology there has been a lot of debate around
a specimen found in China, which is approximately 160 million years old. This was originally said to be of the same type as ours but
recent studies have ruled this out. That being
the case, our 145-million-year-old teeth are
undoubtedly the earliest yet known from the
line of mammals that lead to our own species,” said Sweetman.
Sweetman believes the mammals were
small, furry creatures and most likely nocturnal. One, a possible burrower, probably
ate insects and the larger may have eaten
plants as well. Noting that the teeth are of a
highly advanced type that can pierce, cut and
crush food Sweetman said, “They are also
very worn which suggests the animals to
which they belonged lived to a good age for
their species. No mean feat when you’re
sharing your habitat with predatory dinosaurs.”
The paper, titled “Highly derived eutherian mammals from the earliest Cretaceous
of southern Britain”, was published in the
Acta Palaeontologica Polonica journal on 7
November.

By DTI
LONDON, UK: Only two-thirds of British people brush their teeth the recommended two
times a day, a new survey has found. The remaining third only use their toothbrush
once a day and primarily in the morning,

By DTI

utes before going to bed and a second time
during the day.
Furthermore, it appears the vast majority of Brits do not ﬂoss, since only one-third
of all those surveyed responded that they
make daily use of this interdental cleaner.
Men, especially, do not seem to
be keen on cleaning their teeth, as
one in three reported only brushing
them once per day. However, with
only 26 per cent who said they skip a
second brush regularly, women were
found to have slightly better oral hygiene practices.

The survey, the results of which
were released this week, was conducted on behalf of YouGov UK and
involved over 2,000 adults from
One in three men only brush their teeth once a day.
across the UK, representing all the
respective age groups and social grades.
when it has the least effect. Furthermore,
Those in the C2, D and E groups (skilled,
two per cent of respondents in the survey
semi-skilled and unskilled manual workers;
said that they do not brush their teeth at all.
state pensioners, casual and lowest-grade
workers, unemployed people with state benThere is a slight glimmer of hope, as 8
eﬁts only) were found to brush less freper cent of the respondents said they brush
quently than their middle-class counterthree or more times a day. However, the ﬁgparts, and those aged between 25 and 54 apures pose worrying questions regarding the
peared to be less concerned about their oral
nation’s attitude towards oral hygiene.
healthcare routine than those outside this
Guidelines issued by the NHS state that
age group.
teeth should be cleaned for at least two min-

[5] =>

WORLD NEWS

Dental Tribune United Kingdom Edition | 9/2017

EuroPerio and Dental Tribune International
renew collaboration
By DTI
AMSTERDAM, Netherlands/LEIPZIG,
Germany: With thousands of dental professionals expected from
around the world, EuroPerio9 is
set to be one of the largest and
most inﬂuential dental meetings
next year. The event’s organiser
and Dental Tribune International
(DTI) have now announced that
they will again be collaborating for
the 2018 edition, which is to be
held in Amsterdam in June.
The organisations ﬁrst worked
together for EuroPerio8, which
was held in London in the UK
in 2015. For 2018, DTI will again
produce a special edition of its
show newspaper title today international on each of the three days
of the event. In addition, DTI edi-

dontal Specialist Forum and a
number of sessions aimed at the
various members of the dental
team. The scientiﬁc programme
will be accompanied by a large
trade exhibition, which will fea-

ture the latest innovations from
leaders in the ﬁeld, such as
CURAPROX, EMS and Philips.
“I think that the combination
of the location, the scientiﬁc pro-

gramme and our marketing strategies will create a very interesting meeting,” congress chair Dr
Michèle Reners commented. “Even
with such a large attendance,
everybody can have the beneﬁt of

THERE’S MORE TO THIS...

DTI will produce a special edition of
its show newspaper title today international on each of the three days of
EuroPerio9 in Amsterdam.

...THAN MEETS THE EYE

First held in Paris in France in
1994, EuroPerio is organised every
three years by the European Federation of Periodontology, a professional body representing over 30
organisations, with 14,000 members, worldwide. The last edition
saw a record attendance of 10,000
visitors, including some of the
most high-proﬁle experts and scientists in the ﬁeld.
For the upcoming edition in
Amsterdam, the organiser is anticipating a similar number. Highlights will include a live surgery as
part of the Master Clinician/Perio-

More information about the
event can be found on the ofﬁcial
website, www.efp.org/europerio9.
AD

tors will provide daily coverage on
EuroPerio9 from the Amsterdam
RAI Exhibition and Convention
Centre on its news website and social media channels.
With its congress newspaper,
DTI already provides daily news on
all signiﬁcant global dental congresses and exhibitions, including
the International Dental Show in
Germany, the FDI World Dental
Congress and the Annual Scientiﬁc
Meeting of the European Association for Osseointegration.

and experience EuroPerio in a positive way.”

VISIT: WWW.THEDENTISTRYSHOW.CO.UK

[6] =>

UK NEWS

Dental Tribune United Kingdom Edition | 9/2017

“We are now putting
the mouth back in the body”
An interview with paediatric dentistry consultant Dr Claire Stevens, Manchester
The nationwide Dental Check by
One (DCby1) campaign aims to combat dental caries in British children
by spreading awareness that dental
check-ups should be performed
even before a child’s ﬁrst tooth appears. At the BDIA Dental Showcase
in Birmingham, Dental Tribune
spoke with Dr Claire Stevens, president of the British Society of Paediatric Dentistry and a consultant in
paediatric dentistry at the University Dental Hospital of Manchester,
about the programme.
While the oral health status of children seems to have improved in the
UK in recent years, there are still record numbers of children presenting to hospitals to have their teeth
extracted. How can this be explained?
The high number of general
admissions for multiple extractions in children isn’t new. Current
ﬁgures are taken from the Hospital Episode Statistics [a data warehouse containing details of all
admissions, outpatient appointments, and accident and emergency attendances at NHS hospitals in England] gathered by NHS
Digital and are probably more accurate than ever before owing to
vastly improved data collection.
AD

When compared with previous
methods of data collection, we
think it’s likely, in fact, that general
admissions are starting to go
down.

Sadly, there are communities
in which children are not taken to
the dentist and there is a high level
of unmet need, reﬂecting societal
inequalities. This is one of the
most challenging aspects we face
as a society.
With £50.5 million spent annually on dental extractions in 0- to
19-year-olds on a disease that is
nearly always preventable, downwards is the only way for these statistics to go.
When was DCby1 launched, and
how did the idea come about?
The DCby1 concept has been
nascent for some time. It’s in the
Commissioning Guidelines for Paediatric Dentistry (still unpublished) and was one of the key aims
to emerge from a stakeholders’
day organised by the British Society of Paediatric Dentistry (BSPD)
last year.
Speaking at the British Dental
Association conference in May

this year, I spoke publicly of DCby1
for the ﬁrst time. A new statistic
had just emerged and this was that
only 19 per cent of 0- to 2-year-olds
in the UK had seen a dentist by the
age of 2. I challenged my audience
to see four extra children under 2.
If every dentist took up the challenge, the number of children see-

ing a dentist before their second
birthday would go up by 10 per
cent. The campaign had its formal
national launch at the BSPD conference in September.
The programme encourages parents and caregivers to take children
to the dentist before they have
reached their ﬁrst birthday. What is
the evidence regarding the beneﬁts
of seeing a child at that early age?
We know that an unacceptable
number of children as young as 2
or 3 are suffering from early childhood caries. We also know that one
in eight 3-year-olds has caries, so
leaving interventions until school
age is too late. The only way to
change this is by getting in early
with preventative advice. We know
that a good diet and regular brushing with ﬂuoride toothpaste can
prevent dental disease.
Why do you think such a campaign
is necessary?
We need a radical approach to
bring about change. However, we
are undertaking the campaign
progressively. We are building
awareness by reaching out to parents through health visitors,
school and nursery nurses, doctors
and pharmacists.
In other European countries, like
Germany or France, it is common to
have children see a dentist before
they even reach the age of 1. Why is
the UK still behind in this regard?
Somehow in this country, we
have not placed a high enough
value on oral health. I am glad to
say that we are now putting the
mouth back in the body.
What organisations are supporting
the campaign and how?
We have had the most fantastic
support across dentistry and

healthcare generally. Countless organisations are getting on board
with sharing the very simple DCby1
message. If parents hear this wherever they go, they will feel empowered to ask for a dental check and
this will become the norm. We are
making this issue everyone’s business, and we are glad to be seeing
such a positive response.
What feedback did you receive after
the launch of the campaign, and
what do dentists have to do to
join in?
Last week, I curated the @NHS
Twitter handle and I took the opportunity to broadcast the DCby1
message. A typical response was
the following from a mother:
“Thank you for your tweets. Taking
my 16-month-old to the dentist for
her ﬁrst appointment on Monday
because of it.”
Support from the profession
has also been heartening. Joining
in is simple. All the information a
dental practice needs is on the
BSPD website.
Do you think that celebrities, such
as Jamie Oliver, who publicly lobby
for a sugar tax are creating more
awareness around topics like diet
and sugar intake and therefore
maybe even have a positive inﬂuence on children and parents?
Deﬁnitely, yes. We live in a culture in which celebrities play an
important role, and probably more
than any other celebrity, Jamie Oliver has had a positive inﬂuence on
healthy eating. He is also a parent,
so his impact can be felt in schools
and in homes. If Jamie was reading
this, I am sure he too would be
sharing the DCby1 message.
Thank you very much for this interview.

[7] =>

[8] =>

BUSINESS

Dental Tribune United Kingdom Edition | 9/2017

European dental market survey available
in digital and hard copy
By DTI
KORTRIJK, Belgium: The 2017 Survey on the European Dental Trade
provides a valuable overview of

relevant topics and trends in
the European dental industry.
Launched by the Association of
Dental Dealers in Europe (ADDE)
at this year’s International Dental

Show in Cologne in Germany, the
latest edition of the market review
is now available in digital format.
Dental dealers and manufacturers
can purchase the survey report

now via the new ADDE online
shop.
Again produced in collaboration with the Federation of the

European Dental Industry, the 2017
Survey on the European Dental
Trade indicates a further shift towards digital dentistry, manifesting in overall growth of online
shopping and use of CAD/CAM systems and intraoral scanners. Besides analysing current trends, the
report covers the latest medical device regulations, parallel trade,
market surveillance and free
movement of dental professionals.

Among the survey ﬁndings are
that the number of practising dentists grew slightly compared with
2015 (in all European countries, excluding Sweden, Denmark and
Bulgaria, which were not analysed), totalling about 282,000 in
2016. In contrast, the number of
active dental technicians decreased across Europe. The number of patients per dentist remained the same across Europe. In
terms of sales, the most signiﬁcant
growth rates were observed in Austria, France, Hungary, Spain and
Italy. Regarding the European average across sales segments, sundries, implants and technical services remained stable, while
equipment sales increased slightly.
“Our 2017 Survey on the European Dental Trade comprehensively assesses the sales values for
the main product categories, sales
segments and distribution channels. It also provides unique insights into the market shares of
dental dealers and manufacturers
in the European Union,” said
President of the ADDE Dominique
Deschietere. This includes the
number of customers and end users, sales values and segments
(equipment, sundries/consumables, prostheses, technical services, implants, radiography and
CAD/CAM), the use of computers
and e-commerce, distribution
channels, and VAT charges and
their impact on the market.
The latest survey is now available for purchase on the ADDE website in hard copy and as a PDF from
the new ADDE online shop.

[9] =>

Dental Tribune United Kingdom Edition | 9/2017

BUSINESS

Legislative parity and transition period priorities for
dental industry post-Brexit
emerge between the EU and UK will
be crucial in protecting the future
oral health of EU and UK citizens,
and the global competitiveness of
European dental businesses.”

By DTI
LONDON, UK: The British Dental Industry Association (BDIA) has called
on the negotiating heads of both
the UK and the European Union to
agree to a transition period after the
Brexit. In a letter addressed to Secretary of State David Davis and
chief Brexit negotiator for the EU
Michel Barnier, the organisation, together with the Federation of the
European Dental Industry (FIDE),
said that such an extension would
be necessary to assure parity in UK
and European medical device legislation in the framework of a new
trade agreement.
“Recently published EU legislation will be applicable in the UK until it leaves the EU in March 2019,”
they stated in the letter. “Thereafter,
there is a risk that UK and EU legislation may diverge, to the detriment of patients and businesses
across Europe.”
Among other points, both organisations have recommended
that an agreement should include
the UK’s adoption of EU medical device regulations and the country
remaining an active participant

According to the BDIA, the UK
represents one of the key markets
in the European dental market,
with an annual turnover of almost
£0.5 billion. It is the ﬁrst time that
the BDIA and FIDE have publicly announced a detailed list of priorities
for the ongoing negotiations.

Negotiations between the UK and the EU have stalled recently.

alongside EU member states in the
European regulatory framework.
Furthermore, the UK should
maintain full involvement and participation in the EU database for

medical devices (EUDAMED), they
wrote in the letter.
“The production and supply of
dental devices often involves a complex cross-border network across

Member States. In other international markets, it is non-tariff barriers, often arising from conﬂicting
regulatory regimes, that most seriously limit trade,” they added. “Ensuring that such barriers do not

With their letter, both organisations have joined a growing number
of industries worried about the state
of Brexit talks and the negative impact of a no-deal scenario as proposed by several members of the UK
cabinet, including Prime Minister
Theresa May. The start of negotiations for a post-Brexit deal was recently postponed by the EU after
discussions about the future rights
of EU nationals in the UK and vice
versa, and a “divorce bill” stalled in
October.
After invocation of Article 50 of
the Treaty of Lisbon, UK membership of the EU will end on
29 March 2019.

Newly launched device makes Fewer products
every toothbrush smart
removed from BDIA
Dental Showcase
By DTI

LONDON, UK: A new, innovative device designed to
support patients in their
toothbrushing routine has
been launched in the UK today. Brushlink tracks individual
behaviour,
like
brushing frequency, duration and—for the ﬁrst
time—angle, and provides
real-time guidance and performance monitoring to users.

While tracking of brushing behaviour is already
available with the latest
generation of electronic toothbrushes, Brushlink can be used
with manual toothbrushes too, according to developer and London
dentist Dr Dev Patel. Users of the
device receive a score after each
brush and tips on how to improve
their behaviour. The collected data
can be sent to a mobile app via
Bluetooth and stored for up to
three months for later use.
The main intention behind the
device was to give dentists more information about their patients’
brushing behaviour in addition to
encouraging better brushing, Patel
said. “We have always had to rely on
what we see inside the mouth every
six months rather than having any

third said that they brush
their teeth thoroughly.

In addition, over 60 per
cent reported never having
received correct brushing
instructions from their dentists.
The study was conducted by Opinium between 24 and 26 October.

reliable data about how people are
brushing. I invented Brushlink to
plug this gap by providing coaching to patients but also accurate
monitoring of everything they are
doing with their toothbrush between dentist visits.”
The launch follows worrying
results of a new study that has indicated that brushing habits
among people in the UK are seriously lacking. Conducted among
2,100 participants, it found,
among other things, that one in
two people constantly miss a quarter of their mouths when brushing. Brushing efﬁciency was worst
among young people, according to
the study, of which only every

“There is no substitute
for good tooth brushing
practices when it comes to
maintaining a healthy
mouth, yet it would appear
from the survey that there is
a lot more that we can all do to
achieve this effectively,” commented Prof. Elizabeth Kay, MBE,
Foundation Dean of the Plymouth
University Peninsula School of
Dentistry, oral health topic expert
for the National Institute for Health
and Care Excellence, and a Brushlink scientiﬁc committee member.
“The fact that this survey is in association with the launch of a new
dental care product—and one
which I think is the most amazing
oral health product that I have seen
in a long time—should encourage
people to take its ﬁndings seriously,
as it has been commissioned by a
group of dentists who are passionate about improving the oral health
of the nation,” she added.

By DTI
BIRMINGHAM, UK: Less counterfeit or non-compliant dental
equipment than last year had to
be removed from the BDIA Dental Showcase, a representative of
the Medicines and Healthcare
products Regulatory Agency
(MHRA) has revealed. Over the
three days of this year’s show in
Birmingham, the organisation
found an estimated 500 pieces of
equipment that may have posed
a threat to public safety, MHRA
investigator Maxine Marshall
told Dental Tribune Online in
Birmingham.
The numbers are in line with
a general trend of less critical
equipment entering the marketplace in recent years. Particularly
the distribution of high-risk
equipment like handpieces and
K-type-ﬁles has been on the decline, which is the result of the
work that the agency has been doing with the British Dental Industry Association (BDIA), according
to Marshall. Since 2014, both organisations have been running
an awareness campaign aimed at
dental professionals and the general public to educate about the

possible dangers of fake
non-compliant products.

“I think the message is understood. There have deﬁnitely been
fewer referrals of counterfeit
products to MHRA,” Marshall
said. “However, our work remains
challenging because of the Internet. We constantly track suspicious websites and remove listings from online marketplaces.”
Marshall announced that her
organisation is planning to talk
to both organisers and exhibitors
of the Dental Showcase to introduce measures that help identify
possibly suspect products earlier
in future exhibitions. The successful cooperation with the
BDIA will also continue.
According to MHRA ﬁgures,
over 10,000 individual pieces of
non-complaint or counterfeit
dental equipment are seized in
dental practices per year in the
UK. Recently, the General Dental
Council had to suspend a 32-yearold dentist from Preston in Lancashire who, after inspections, was
found to have purchased risky
equipment on an Internet auction website at least three times.

[10] =>

BUSINESS

Dental Tribune United Kingdom Edition | 9/2017

What would Dr Mo Lar do? Part 7
By Richard Lishman, UK
Over the course of an 11-part series,
the 4dentists group explores ways
to tackle a number of personal and
professional challenges by providing advice and guidance to a ﬁctional character Dr Mo Lar. In this
seventh article of the series, Managing Director of the 4dentists
group, Richard Lishman explains
how Lar should go about purchasing a second practice to expand his
business.
Among many other business
ambitions, Dr Lar would like to expand his business by purchasing
an additional practice. He already
has some experience of practice
acquisition, having gone through
it once before, but there are a number of other factors that must be
considered the second time round.
As such, he will need to make sure
that he has the necessary support
before and during the process. Lar
also needs to consider the impact
of current market trends and think

about having enough
time available for the
process before placing a
bid, as one wrong move
could jeopardise his
overall ﬁnancial goals.
The location of the new
practice is important as
well, since too much travelling time between the
two could have a direct
impact on his ability to
successfully run both
businesses.

Practice
funding
In order to secure
funding for a second
time, Lar has to be able to
prove that he can afford
the repayments. Detailed
accounts and affordability tests are
therefore imperative leading up to
the bidding stage, as is the careful

compilation of a business plan. As
for the actual borrowing, he has
the option of borrowing the entire
sum of the money from the bank

FREE

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or releasing funds from his existing practice and then taking out a
smaller loan. Say Lar has been making proﬁts of £200,000 per annum
for the last three years, but has
only drawn £150,000, it would
equate to a total increase in net
worth of £150,000. If he wanted to,
Lar could borrow that equity from
the business. Of course, he should
discuss both options with his Independent Financial Adviser before
making a decision.

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Interest rates are another important factor Lar should consider
before purchasing his second
practice. If he were to take out a
loan with a different provider than
the ﬁrst time and they offer better
rates, he could use this opportunity to move all his funding to one
place. Not only would that simplify his repayments, but it would
make them cheaper too.
Besides additional funding,
Lar would be required to have the
necessary critical illness and life
cover in place, as all banks require
purchasers to have the correct
cover in the event of sickness, injury or death. With life cover already in place from his ﬁrst acquisition, he would simply need to
update his policy to reﬂect his additional ﬁnancial responsibilities.

Considering
business structures
When expanding a business,
there is an opportunity to change
its corporate structure. As it stands,
Lar is the sole proprietor but,
should he choose to, he could form
a partnership, incorporate to become a limited company or register
as a limited liability partnership.
Purchasing an additional practice
will change his tax structure, liability and tax burden so it is important that he chooses a structure
that will make the business worth
his while. In order to increase his income and save on tax, he will need
to work closely with an accountant
to weigh up his options.

Employees
Purchasing another practice
will undoubtedly involve taking
on more staff. As such, Lar should
consider consulting a lawyer to
put together the necessary contracts for new employees. The
principle statement would need to
clearly detail certain provisions,
such as the legal names of the employer and the employee, the job
title, the date of the commencement of employment, the details
of compensation, the working
hours and leave. Most importantly, he must make sure that all
the terms of the contract are
standardised across all members
of staff; otherwise it could lead to
allegations of discrimination.
For staff who are self-employed, his lawyer needs to draft
an appropriate written contract
detailing their arrangement, as
there are considerable risks to dental practice owners associated
with these agreements.
There really is a lot to consider
before expanding a business or
practice, which is why it is always
advisable that someone in Lar’s
position utilises the services of an
expert team. Only then, can one
guarantee that the process is executed seamlessly, with excellent
results at the end.
In the next article:
Lar looks at selling his business.

Richard Lishman is the Managing Director of money4dentists, a ﬁrm of specialist independent ﬁnancial advisers who
help dentists across the UK manage their
money and achieve their ﬁnancial and
lifestyle goals.

[11] =>

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[12] =>

TRENDS & APPLICATIONS

Dental Tribune United Kingdom Edition | 9/2017

A whole new dimension
of imaging precision
© ACTEON

By Julia Maciejek, DTI

Like many ﬁelds in dentistry,
implantology has been transformed by technological innovations since its humble beginnings more than half a century ago. As the aesthetic and
osseointegration properties of
implant materials have continued to improve, the number of dental patients opting
for implants has risen steadily. With
this increase in procedures has come
a demand for atraumatic and safe
surgery with fewer postsurgical
complications. Since 2005, French
company ACTEON has established itself as a leader in digital medical imaging and high-frequency ultrasonic
devices. Supported by its excellent
clinical results, ACTEON continues to
push the boundaries of what is possible in implantology as it seeks to
provide products that optimise both
the patient’s and the dentist’s experience.
With an emphasis on research
and development in dentistry and
medicine, ACTEON has successfully
expanded its offering and introduced several new products earlier
this year. Its two multidisciplinary
research and development teams
and four manufacturing plants are
all located in western Europe: in
Mérignac (equipment and pharmaceuticals) and La Ciotat in France
(dental imaging), Tuttlingen in Germany (medical imaging) and Milan
in Italy (dental imaging). These
teams work very closely together
and production processes are
highly controlled owing to their geographical proximity. This is further enhanced through collaboration with international dental surgeons, leading to the manufacture
of devices that, according to
ACTEON, deliver the best results for
patients through minimally invasive and less traumatic treatments.
AC T E O N g r a n t e d D e n t a l
Tribune International an exclusive
look behind the scenes of its
3,200 m2 manufacturing plant in
Milan, where many of the company’s intraoral and extraoral imaging devices are produced. The team
was proud to introduce its ﬂagship
model: X-Mind trium. This extraoral radiographic unit was ﬁrst
introduced at the International

Dental Show (IDS) in 2015 and received a major update just in time
for the 2017 fair. It offers a complete
range of innovative solutions for diagnosis and treatment planning.
Considerable attention has been
paid to image quality and homogeneity, including X-ray emission,
processing, stability and geometry.
“X-Mind trium combines CBCT,
panoramic and cephalometric imaging, which is why it is called a
three-in-one device,” explained
Claudio Giani, director of imaging
research and development at the
Milan site. He demonstrated that
CBCT imaging is accomplished using a rotating gantry with a ﬁxed
X-ray source and a detector. Giani
told us that, during the rotation,
multiple sequential projection images, ranging from 150 to 450, are
acquired to complete the arc. This
procedure varies from a conventional medical CT scan, which uses
a fan-shaped X-ray beam in a helical progression to acquire individual image slices of the ﬁeld of view
(FOV) and then stacks the slices to
obtain a 3-D representation.
When we ﬁrst approached
X-Mind trium, we noticed right
away the distinctive ergonomics of
the radiographic unit. The device
has an extremely short U-arm,
which moves around the patient
during the image acquisition
phase. This is supported by the patented kinematics and collimation
and aids comfortable positioning
of the patient’s jaw. The entire system is designed with ergonomic efﬁciency in mind and takes up very
little space in the practice room.
With a secondary collimator (X-ray
tube assembly) installed, the patient is not exposed to additional
collimator movements.

Excellent quality
assurance
ACTEON produces high-end
quality products that undergo
a tried-and-tested quality control
process. “The production of
X-Mind trium has risen month
after month, especially since we obtained U.S. Food and Drug Administration approval and then launched
X-Mind trium in the US,” stated

Alvise Reither, the Milan factory manager.
He explained that, by
changing the factory’s
layout and the ﬂow of
materials, new workﬂow processes were
established. The manufacturing plant is
continuously expanding, and with additional operators, it is
able to meet the demands of the market.
“In this factory, we use the Kanban
approach principle, which means
that we produce on stock, but ﬁnalise the product based on order. This
way, we can balance demand with
available capacity,” added Reither.

enough data for image reconstruction. “In implantology, a CBCT image is indispensable for planning
simulation and determining the exact nerve location. With only one
image, the entire dental arch can be
visualised, which allows for optimal
diagnostic planning possibilities.
X-Mind trium has a range of FOV
options displayed in detail and
without movement artefacts. He

rithm has been developed in terms
of the graphics processing unit
(GPU) and a speciﬁc type of GPU is
installed inside the workstation of
X-Mind trium when the CBCT function is conﬁgured,” explained Giani.
This algorithm is used to determine the apparent image deﬁnition and bone density to facilitate
clinical decision-making. The ﬁlters
© Julia Maciejek

Moreover, ACTEON applies signiﬁcant quality controls during all
processes, from the assembly of the
core of the machine to ﬁnal testing,
which includes checking of the
components and the conﬁguration
of the workstation. According to the
factory manager, this procedure has
been streamlined signiﬁcantly in
comparison to last year. Reither
showed us a large number of testing
cabinets containing devices being
checked. With complete concentration, employees in front of computers verify the correctness of every
step before the X-Mind trium units
are distributed. It is in this context
that a large quantity of X-Mind
trium devices are manufactured,
tested and shipped each week.

“We have an excellent product
quality. We want to ensure a
high-quality standard, so employees take turns at the workstations.
We also want to make sure that each
employee knows and understands
all the processes leading up to the
ﬁnalisation of the product, establishing an appreciation of the importance of each step in the assembly. We further want our employees
to respect ACTEON’s standard of
quality. This follows the two steps of
the quality control: (1) checking that
all cables and parts are well assembled and (2) testing the machine’s
functionality in the testing cabinets. Our quality manager also inspects the components when they
are sent to us and before we put
them into stock. No parts are assembled externally. A mix of components, cables, mechanical parts, motors and sensors are assembled by
hand. That is also part of our quality
management,” Reither detailed.

Sharp images
Excellent image quality is essential for treatment planning and
diagnosis. In CBCT, exposure is incorporated in the FOV. This means
that only one rotational sequence
of the gantry is necessary to acquire

emphasised that the exposure time
is very low and the reconstruction
time is three seconds. We saw that,
with a cephalometric image, the entire maxillofacial area is shown,
making it highly suitable for oral
and maxillofacial surgeons. Furthermore, it has a small voxel
size of only 75 μm and a fast reconstruction time of 29 seconds.
X-Mind trium can be equipped with
one or two sensors for an efﬁcient
workﬂow.
With ACTEON’s expertise in
medical imaging, a dedicated analytical algorithm has been implemented for X-Mind trium. “We have
achieved exceptional results, which
are able to provide advanced clinical indicators that will be helpful for
practitioners in the future,” stated
Giani proudly. “The analytical algo-

ensure detailed recording of the image acquisition by low-noise microstepping motors.

Low radiation dose
With X-Mind trium, high radiation exposure is a thing of the past.
The low-radiation protocol decreases the required amount of
X-ray emissions by a third using the
algebraic reconstruction technique.
This means that the radiation dose
for the patient can be reduced by 50
to 70 per cent. This low-dose imaging guarantees a maximum FOV
with minimal radiation exposure
to the patient. “This is essential because we do not care only about
good images but also about the
well-being of the patients,” stated
Reither. Furthermore, the software
of X-Mind trium monitors radia-

[13] =>

Dental Tribune United Kingdom Edition | 9/2017

tion and ensures that the levels of
exposure are kept low.

User-friendly software
Computer scientists would say
the software is as important as the
hardware. ACTEON provides intuitive and ergonomic imaging software that has all the required functions—scanning, measuring, editing, commenting. In the factory cellar, Reither explained the special
features of the ACTEON Imaging
Suite software and stated that it can
be linked to most practice management software and all ACTEON imaging products, such as the X-Mind
trium, CBCT and panoramic devices, and intraoral scanners. It is
compatible with both macOS (and
soon iOS) and Windows and has a
TWAIN driver for full compatibility
with all imaging software. This
gives practitioners the ability to
move around and interact directly
with their patients.
The radiographic unit is in continual operation at most dental
practices. It is clearly imperative
then to ensure that dental professionals have the skills to adequately
handle the devices and take highquality images with the correct settings. “The user-friendly software
enables the customer to either use
the workstation provided or use
their own. However, with the workstation provided, our professional
and efﬁcient team of service technicians can perform remote connections to solve problems of conﬁguration or calibration. We want our
customers to choose the software
option that is best for them,” explained Reither.

Safe surgery
X-Mind trium offers extraordinary functionality in the ﬁeld of implantology, making it suitable for
more demanding treatments. Misleading or insufﬁcient information
obtained from a radiograph can
lead to the loss of an implant, one of
the worst scenarios for both the patient and the dentist. “In pre-implant procedures, accurate measurements of the bone density and
volume are essential to guarantee a
higher success rate in implantology. The 3-D capability of X-Mind
trium also facilitates safer osseointegration,” said Giani. Clinical
decision-making has seemingly become easier than ever with X-Mind
trium.
Certainly, our tour would not
have been complete without a look
at ACTEON’s well-known Piezotome
ultrasonic brand. Thousands of
dentists worldwide have adopted
the company’s celebrated Piezotome devices as their choice for
pre-implant surgery, with Piezotome Cube representing ACTEON’s
new standard. It is a powerful ultrasonic device with a rotary motor, as
well as a handpiece and a tip, ensuring optimum performance. Leading oral surgeon and implantologist Dr Angelo Trödhan successfully
uses Piezotome Cube in his everyday treatment procedures. “The Pie-

zotome’s ergonomics makes the device naturally intuitive and reliable.
Furthermore, it enables surgeons
with less experience to perform a
variety of treatments. In accordance with the cutting selectivity,
soft tissue (membranes and nerves)
is preserved. During piezoelectric
surgery, ﬁne and precise cuts minimise bone loss. In 98 per cent of
cases, patients do not need to use
analgesics postoperatively and
barely any swelling is observed. Sur-

TRENDS & APPLICATIONS

gery with Piezotome Cube maintains the patient’s quality of life,”
said Trödhan.
In implantology, bone grafting
materials may be necessary for the
implant to succeed. For this reason,
QUALIOS was developed, and it was
ﬁrst introduced at IDS 2017. The material has a unique bone-supporting structure and high level of mechanical resistance. Its large interconnected pores make it particu-

larly suited to bone colonisation,
and it is completely resorbable, ensuring high-quality bone regeneration. Being entirely synthetic, it is
free of any contamination risk that
comes with products of animal
or human origin. It is clear from
this that QUALIOS complements
ACTEON’s implantology product
line.
In ACTEON’s continuous product expansion, patients’ well-

being continues to be the top
priority. We felt the passion
employees put into their daily
work to support ACTEON’s innovative portfolio for imaging and
piezoelectric surgery. These products have positioned the company as a pioneer in oral surgery
and dentistry. They are less invasive, safer and faster to operate,
and provide patients and practitioners with the best treatment
options available.
AD

[14] =>

TRENDS & APPLICATIONS

Dental Tribune United Kingdom Edition | 9/2017

“This new protocol is almost universal”
At the Nobel Biocare Symposium in London, Dental Tribune spoke with Dr Rubén Davó from Spain
about the new Trefoil implant solution
With Trefoil, Nobel Biocare recently
introduced a new implant solution
or protocol for achieving a ﬁxed, deﬁnitive ﬁxed full-arch restoration of
the mandible in one day. Combining
a pre-manufactured titanium bar,
three implants and a simpliﬁed restorative workﬂow without provisionals, it reduces the time to teeth
and chair time compared with conventional ﬁxed treatment with implants, according to the company.
At its recently held London symposium, Dental Tribune spoke with
oral and maxillofacial surgeon Dr
Rubén Davó from Alicante in Spain,
about the system.

placed properly in more than 99
per cent of the cases.
While we were also evaluating
success rates, the second important thing we looked at was the
number of patients we were able
to treat with the system and how
many we had to turn away because
of their anatomical circumstances.
Looking at our results, we can say
that this new protocol is almost
universal, as we had to refuse only
a few patients, owing to things like
an insufﬁcient distance between
the mental foramina or a mandible that was not wide enough.

high number of implants were
used to rehabilitate edentulous
patients.
However, the main problems
with Novum were related to the
prosthetic framework, which
posed difﬁculties from a functional and aesthetic standpoint.
As a reﬁned system, Trefoil has
completely addressed these problems.
What patient groups are going to
beneﬁt from this new protocol?
Potentially all patients edentulous or soon-to-be edentulous

cause this protocol does not depend on new technologies or sophisticated therapies. It requires
only one surgeon and a basic laboratory to provide patients with
ﬁxed immediate teeth.
How difﬁcult is it to learn the Trefoil
protocol?
I would recommend doing at
least ﬁve cases. After that, the clinician should feel comfortable and
conﬁdent in performing the protocol. While it is not a very complex surgery, the practitioner will
need a little bit of training. Nobel
Biocare is very aware of that and

tical learning experience. Consequently, they felt very comfortable
performing the surgery.
According to Dr Kenji W. Higuchi,
one of the developers of Trefoil, the
system will be the next big thing in
implant dentistry. Would you agree
with that statement?
I think it has become very difﬁcult to innovate in this ﬁeld because many things have been introduced over the last 20 years. I
have no doubt however that, in
China, India and other developing
countries, this will start a revolution because now more people will

“It requires only one surgeon and a basic laboratory
to provide patients with ﬁxed immediate teeth.”

Davó (second from right) discussing Trefoil at a Q&A session in London.

You were one of the ﬁrst clinicians
worldwide to have worked with
Trefoil and evaluated its clinical performance. How did you become
involved, and what results have
you achieved?
I have been collaborating with
Nobel Biocare’s clinical research
department for many years on
various projects. Nevertheless, it
was an honour and privilege when
they asked me to clinically evaluate the new Trefoil system. From
a surgical point of view, we looked
at the accuracy of the template
guided surgery. We know that
the ﬁxation-compensation mechanism allows around 0.5 mm of
discrepancy. In our clinical study,
we found that structures could be

The survival rate for implants
and prostheses was near 99 per
cent after one year.
Almost 20 years ago, a similar treatment protocol was introduced to
the market with Brånemark Novum, but it was discontinued in
2007. What makes the Trefoil system different?
In my opinion, the Brånemark Novum system was ahead
of its time. While from a clinical
point of view it demonstrated
good success rates, the market
was not ready for it. You have to
remember that, in those days,
treatment concepts like immediate loading or guided surgery did
not exist. Furthermore, usually a

in the mandible can beneﬁt from
this protocol. Furthermore, Trefoil will increase patient acceptance rates because it applies to a
patient group that may avoid this
type of procedure (ﬁxed dentures) owing to a lack of time or
money.
The goal of Nobel Biocare is to
reach more people for whom a
lack of ﬁnancial resources is a limiting factor. That is why it is an
ideal solution not only for more
afﬂuent parts of the world like
Europe or the US but also for markets like India or China. With Trefoil, the number of people that
can be treated by means of ﬁxed
dentures will be much larger be-

offers a number of courses in
many markets.
You have led some of these courses
in Germany, Spain and the UK, to
name a few. What has the initial
feedback been?
Those who were involved in
the clinical studies on Trefoil are
teaching the courses now, and this
has the advantage that attendees
can gain from our experience
gained in treating many of these
cases. Our goal is to avoid both
complications and any possible
problems. The feedback has been
extremely positive. Many participants have taken the course because they felt it offered the right
concepts and provided a good prac-

have access to these treatment
possibilities. Trefoil will also address a gap in many Western countries, where we see many patients
that do not want removable dentures, but cannot afford ﬁxed dentures because of a lack of time or
their ﬁnancial situation. The only
thing I do not know is how long
it will take to gain widespread
market acceptance. Usually these
things take time, sometimes even
years. However, all the positive
feedback we have received lately
has made us extremely positive
about the future prospects of the
system.
Thank you very much for the interview.

[15] =>

TRENDS & APPLICATIONS

Dental Tribune United Kingdom Edition | 9/2017

Use of laser ablation electrospray ionisation
to study in vitro oral plaque bioﬁlms
By Marcelo B. Aspiras, Callee Walsh, Greg Boyce, Haddon Goodman, Panagiota Tsatsos & Michael Dodds, USA & UK
Dental bioﬁlms play a crucial role in
the overall health of the oral cavity.
They are composed of bacteria, bacterial products, extracellular DNA
and an extracellular matrix that
serves to bind bioﬁlm together and
contributes to the characteristic
stickiness of plaque. As a complex
ecological community on hard surfaces of the dentition, such as teeth,
they produce virulence compounds
that exacerbate the host inﬂammatory response.
Plaque bacteria utilise nutrients from saliva and the food we eat
for their energy needs and metabolic requirements. Interventions,
which employ a combination of actives and attributes unique to each
product, include the use of toothbrushes, mouthrinses, toothpastes
and chewing gum, which take advantage of salivary ﬂow and mastication mechanics unique to the
oral cavity.
Optimising interventions
against bioﬁlm requires a thorough understanding of its dynamics and physical characteristics. In

the case of actives present in toothpastes, mouthrinses or chewing
gum, this knowledge provides the
foundation for understanding how
effectively an active affects the
plaque bioﬁlm. This includes understanding how deeply an active
penetrates the bioﬁlm and affects
bacterial metabolic pathways to reduce overall activity.
Ultrastructural invasive techniques such as ﬂuorescence in situ
hybridisation have been useful in
visualising the location of labelled
bacteria in oral bioﬁlm samples. In
some cases, select bioﬁlm metabolites have been ﬂuorescently
tagged and traced in the bioﬁlm,
but they remain invasive techniques requiring considerable
sample preparation. Clearly, new
technologies that provide a more
global, comprehensive and real-time assessment of what is truly
taking place in the multispecies
bioﬁlm are needed.
A novel technology known as
“laser ablation electrospray ionisation for mass spectrometry”
(LAESI-MS) has revolutionised
sample introduction and data
analysis for high-throughput biological MS. The LAESI DP-1000 system (Protea Biosciences) is a
new-generation high-throughput
direct ionisation system that directly analyses biological samples

containing water without the need
to apply chemicals or introduce
tags or tracers, thus allowing for
virtually no sample preparation.
Most signiﬁcantly, the technology performs 2- and 3-D depth
proﬁling of oral bioﬁlms, allowing
for analysis of the 3-D spatial distribution of various molecules
throughout the bioﬁlm directly as
they exist in nature. This study investigates both the distribution
and the effect of a test active on select molecules and metabolites in
oral bioﬁlms to assess its antimicrobial or antiplaque effects.

The experimental
protocol
In order to simulate the topography, growth conditions and substratum on which dental bioﬁlm
grows, pooled human saliva was
used to grow two-day mixed species bioﬁlms on vertically suspended hydroxyapatite (HA) discs
(Fig. 1). Prior to inoculation by multispecies bacteria, the discs were
pretreated with ﬁltered pooled saliva to allow for the proteins that
enable initial bacterial attachment
to coat the discs. This step is known
as “preconditioning”. Inoculum
was then added together with
100 ppm of the test active to monitor effects on adherence and colo-

nisation of bioﬁlm bacteria in the
substratum.
Additional multispecies saliva
bioﬁlms were maintained as
no-treatment controls. Untreated
and treated bioﬁlms were then frozen at –80 °C to ensure preservation of the bioﬁlm architecture
prior to LAESI analysis. LAESI-MS
and tandem MS were applied to
determine the 3-D spatial distribution of the active and the various
molecules the active potentially
affected in the myriad metabolic
and chemical signalling pathways
of the bioﬁlm. These molecules included quorum sensing factors,
metabolites, virulence factors, and
others. The area of analysis for
both the untreated and the active-treated bioﬁlms on HA discs is
shown in Figure 2.

Results
As mentioned earlier, the spatial distribution of the active in the
experimentally treated bioﬁlms
was assessable in both 2- and 3-D.
Heat map analysis of ﬁve horizontal planes with their corresponding x and y coordinates provided
precise localisation of the active
for each plane in the untreated
and treated bioﬁlms. The composite result of the vertically stacked
heat maps allowed for relative localisation of the active in the

treated sample for each of the ﬁve
planes, revealing the highest concentration in the plane furthest
from the substratum (Fig. 3).
In addition to mapping where
any given active had penetrated
the oral bioﬁlm, LAESI was used to
map relative localisation of select
molecules in the treated and
untreated bioﬁlms. The autoinducer-2 chemical signalling molecule, which is involved in cell density-dependent quorum sensing,
was mapped. The heat map signal
for this molecule was considerably reduced throughout all coordinates, relative to untreated controls, indicating reduction of the
presence and activity of this molecule and thus suggesting that the
active reduced levels of autoinducer-2 in the treated bioﬁlms.
In addition, the levels of the
amino acids arginine and lysine
were investigated in untreated
and treated bioﬁlms. Arginine is
naturally found in saliva and is
utilised by some plaque bacteria,
resulting in the production of ammonia and carbon dioxide. These
two amino acids were chosen as
surrogate molecules to further
validate the use of LAESI to map
diverse molecules of interest in
the oral bioﬁlm. Arginine was
found in greater abundance relative to lysine in the untreated

Fig. 1: Representation of vertically suspended 5 mm HA discs on which a two-day mixed species bioﬁlm was grown. These bioﬁlms were later stained for visualisation purposes, as bioﬁlms analysed by LAESI are
left unstained. – Fig. 2: Actual area of analysis on HA discs shown for both the untreated and the active-treated bioﬁlms. – Fig. 3: LAESI-MS ion map showing 2-D (left panel) and 3-D distribution (right panel) of
the active (m/z 385.316) on treated and untreated bioﬁlms. Five planes are represented in the 3-D heat map rendition, where the active can be clearly seen concentrated in the upper layers of the treated bioﬁlm.
– Figs. 4a–d: LAESI-MS ion map showing 2-D (left panels) and 3-D distribution (right panels) of (a) autoinducer-2 (m/z 215.98), (b) arginine (m/z 175.12), (c) lysine (m/z 147.24) and (d) lactate (m/z 112.08). In all
molecules tested, reductions in levels and distribution relative to untreated samples were seen in the treated bioﬁlms, suggesting direct effects due to the presence of the active.

[16] =>

TRENDS & APPLICATIONS

16
samples, as shown in their respective heat map analyses. Upon
treatment with the active, the levels of both molecules were drastically reduced relative to their untreated controls.
Finally, the levels of lactate
were investigated in untreated and
treated bioﬁlms. Lactate is a
by-product of sugar fermentation
by caries-causing bacteria such as
Streptococcus mutans, which conAD

verts sucrose to the sticky glucans
that help keep the bioﬁlm intact.
Thus, the relative levels of lactate
can serve as an indicator of cariogenic activity or the risk of caries
progression in the supragingival
plaque bioﬁlm. Comparison of the
heat maps of the untreated bioﬁlms to those of the active-treated
bioﬁlms showed relative reduction of lactate levels in the treated
bioﬁlms for all x and y coordinates
investigated (Figs. 4a–d).

Discussion and
future implications
The application of an MSbased analytical method for oral
bioﬁlms that requires virtually no
sample preparation represents a
breakthrough in improving our
understanding of what is really
taking place in the oral plaque bioﬁlm in response to chemical challenges. Mere removal of bulk
plaque biomass from the inter-

Dental Tribune United Kingdom Edition | 9/2017

proximal sites is insufﬁcient to account for paradoxical clinical outcomes of test subjects whose gingival health improved even when
little plaque biomass was removed. This suggests that the biological activity of speciﬁc plaque
toxins and other bacterial products embedded in plaque bioﬁlms
and their distribution in the bioﬁlm may be more important in
triggering the gingival inﬂammatory response than bulk plaque

alone. It is important to understand where these bacterial compounds or metabolic by-products
localise in the plaque bioﬁlm,
since their location can inﬂuence
both the magnitude and the sustainability of the pathogenic response.
Pathogenicity factors that localise closer to the bioﬁlm–substratum interface may prove to be
more protected from external
chemical or mechanical stressors.
In instances in which the compound adversely affects the substratum itself (such as lactate and
its role in demineralising HA), the
continued close proximity of the
compound to vulnerable substratum may prove to be particularly
harmful over time. Being able to
construct a stratiﬁed map of where
these compounds localise in the
layers of the bioﬁlm thus provides
strategic insights into how to best
manage them.
Conversely, there is little knowledge to date, but high value gained,
in understanding how chemical actives directed against the bioﬁlm
and its constituents behave as a
function of how deeply the actives
penetrate the oral bioﬁlm. Although antiplaque efﬁcacy can be
gauged as antiplaque (e.g. destabilising or disaggregating bioﬁlm),
antimicrobial (e.g. bacteria-killing)
or a combination of both effects, it
is clear that multiple factors that
act in concert to constrain the bioﬁlm penetration capacity of many
actives found in toothpastes,
mouthrinses and medicated chewing gum will ultimately reduce antiplaque efﬁcacy of even the most
effective chemistries.
Ultimately, developments such
as quantitative measurement of
bioﬁlm depth from the underlying
substratum to the surface of the bioﬁlm, along with co-localisation
and quantitation of levels of actives relative to the concentration
of surrounding molecules of interest, will bridge the gaps in establishing a direct causal relationship
between an active and the metabolic pathways it affects. The reported investigation represents
the ﬁrst successful demonstration
of this application in dental research.
It is envisioned that future research interests will also be expanded into analysis of bioﬁlm on
coupons grown in the human
mouth to generate plaque bioﬁlms truly grown in the oral cavity
that can be conveniently removed
and later analysed ex situ. This will
inform transient changes in crucial metabolic pathways in naturally occurring plaque and may
help identify predictable markers
for charting plaque regrowth after
external challenges. LAESI thus
represents a unique tool for exploring the inner workings of oral
plaque bioﬁlms that combines the
sensitivity of MS analytical chemistry, the 3-D visual analysis afforded by confocal microscopy
and minimal effort in sample
preparation.

[17] =>

ENDOTRIBUNE

The World’s Endodontic Newspaper · United Kingdom Edition
www.dental-tribune.co.uk

Published in London

Vol. 11, No. 9

CASE REPORT

INTERVIEW

ROOTS SUMMIT

Dr Vittorio Franco explains treatment of a 22-year-old male patient with a history of trauma to
his maxillary incisors.

Dental Tribune spoke with Dr
Craig Barrington, USA, about his
technique for capturing high-deﬁnition endodontic images.

Everything to know about the
most important international
event in endodontics in 2018.

” Page 20

” Page 22

is coming to

BERLIN
28 June –1 July 2018

” Page 23

Berlin, Germany
www.ROOTS-SUMMIT.com

Cleaning is key
By Aws Alani, UK
Completely disinfecting the canal
system is challenging when all factors are considered. If we are looking at the nano level there are approximately 76,000 dentinal tubules per square millimetre of dentine. Each of which can harbour a
colony of bacteria. Then there may
be inaccessible anatomy such as
lateral canals, apical deltas or ﬁns.

in combination with hand ﬁling
signiﬁcantly reduced bacterial
load. As such chemomechanical
instrumentation was shown to be
crucial for endodontic success.
They compared irrigation with saline, 0.5 and 5 % hypochlorite over
a sequence of 5 appointments. Interestingly they found no difference in the reduction of bacterial

It seems that irrigation and instrumentation are both highly inter-related in canal disinfection.
Take washing your car for instance, purely covering it with
soapy water and rinsing won’t remove the motorway bugs and bird
produced projectiles. A good
scrubbing with a sponge is needed,
or if you are really serious about

from the dentine. The smear layer
prevents bacteria residing in the
dentinal tubules from being exposed to the irrigant as well as reducing the contact between the
dentine and sealant during obturation. Hence, utilising EDTA to
remove the smear layer prior
to obturation but after completion
of preparation and instrumenta-

housing the community of microorganisms. They not only share resources, they also share information that promote each other’s survival through RNA or DNA. As the
majority of bacteria will be encapsulated in this layer, purely irrigating without disrupting this layer is
inefﬁcient. The word disrupting is
a bit kind really—it needs to be destroyed to reveal all its contents
and expose it to the bleach for
chemical action. It is the methods
of disruption of the canal bioﬁlm
that has seen a lot of development
over the last 10 years or so. Much
in the same way a pressure washer
can clean that more quickly and efﬁciently than a sponge, energising
the disinfectant results in improved cleanliness.

Energising the irrigant
This can take many forms. The
simple and straightforward form
ensures appropriate exchange of
the ﬂuid and displacement into
the recesses where airlocks may reside. This can be achieved through
applying a GP point into the prepared canal to displace and disperse.

These are factors that need considering outside of canal curvatures
that may or may not be entirely visible in the plane of the radiograph.
It is clear that outside of the contact
our ﬁles make with the walls of the
root canal there needs to be chemical disinfection to further reduce
bacterial load. Irrigants disinfect as
well as lubricate instruments and
they dissolve the pulp. Sodium
hypochlorite has been the mainstay
irrigant for decades.
During the 1980s, Bystrom
and colleagues investigated the effect of mechanical instrumentation with and without adjunctive
use of hypochlorite. They found,
unsurprisingly so, that when compared to pure mechanical instrumentation, the use of hypochlorite

load between 0.5 and 5 % hypochlorite. Despite what was likely
to be a comprehensive protocol
for these teeth, 7 of the 15 specimens in this study still had bacteria that they could grow at the end
of treatment. The presence of cultivable bacteria does not necessarily mean we have failure—it
merely means that there may be a
cohort of bacteria that have resisted treatment. Mechanical instrumentation does reduce bacterial load by itself—this is by way of
physical removal of tissues where
bacteria reside, while also facilitating the dispersal of the irrigant
into the canal. Siquiera and colleagues found that enlarging the
canal from size 30 to 40 resulted in
a signiﬁcant decrease in endodontic pathogens.

cleaning, a pressure washer! This
begs a further question—how
would your patients feel if they
knew that, more or less, the same
or very similar liquid they use to
clean bathroom suites is the same
that we use to clean the inside of
their teeth? On recent evidence of
a dentist to the “stars” appearance
on national TV not much—he advocated using charcoal to whiten
teeth, which you may be able to
buy from your local petrol station
for barbecues.
Hypochlorite is an effective
bactericidal but does not remove
the smear layer. The smear layer is
a mix of organic material (protein,
pulp remnants, saliva, microorganisms) with an inorganic components consisting of minerals

tion is sensible. A penultimate
rinse with EDTA then a ﬁnal rinse
with hypochlorite prior to drying
has been advocated heavily in the
literature.

Bacteria
and the bioﬁlms
Unlike what we once thought,
bacteria do not tend to just sit
alone and remote from each other.
If only they were this antisocial
and could be picked off one by
one! Bacteria join forces and create
symbiotic groups, share resources
and protect each other from external inﬂuence. This is commonly
known as a “bioﬁlm”, which has a
thin but robust layer of mucilage
that adheres to a solid surface

Ultrasonic irrigation transmits
energy by an oscillating instrument. This results in two different
phenomena. Cavitation is the
growth and subsequent collapse
of small gas bubbles due to a drop
in pressure. Acoustic streaming is
the bulk movement of ﬂuid when
pressure waves are projected, resulting in vortex motion around a
fast moving oscillating instrument. This results in shear stresses
to tear the bioﬁlm apart.

Keeping
the canal clean
Once irrigated and prepared,
the clinician has a choice—to obturate or to dress. Some may argue
that the canal is cleanest at the end
of instrumentation and that for
convenience, obturating in a one
visit arrangement is the best option. As we know, not all bacteria
are removed or killed during treatment. Dressing the canal with calcium hydroxide may continue the

[18] =>

ENDO NEWS

process of eradication of the residual microorganisms over a 2-week
period. The choice between the
two schemes sometimes boils
down to the presenting factors of
the case. Where a tooth is difﬁcult
to instrument, has a large lesion or
is quite obviously chronically infected with a history of pain, then
dressing may be more of a consideration. If a tooth is treated in a de
novo manner and treatment goals
are achieved with no history of

pain then a single visit treatment
could be utilised.

eign body reaction could also develop.

The goal of obturation is to
seal the canal system to prevent
any reinfection and entomb any
bacteria not eradicated by chemomechanical debridement. If the
obturation is through the apex,
this can have signiﬁcant implications. GP through the apex can
carry bacteria outwith of the canal
and exacerbate symptoms. A for-

We also have to remember that
a beautiful obturation of a canal
achieved without rubber dam and
utilising saline or local anaesthetic
irrigation is sub-standard treatment. It can be difﬁcult to assess
the “quality” of treatment when a
radiograph of a “failed” tooth is examined in this context. Indeed, an
obturation that is short of the radi-

Endo Tribune United Kingdom Edition | 9/2017

ographic apex having been treated
under rubber dam and with copious amounts of irrigation is more
likely to be successful than the previous scenario. Attributing too
much signiﬁcance to the radiographic appearance of the obturation is short-sighted. Indeed,
Katebzadeh and colleagues in the
late ‘90s witnessed healing in the
absence of obturation where teeth
were instrumented and irrigated
optimally under isolation. Seal-

The Dental Tribune
International Magazines
www.dental-tribune.com

ants are also antibacterial and aide
ﬁlling the voids between the
GP and the canal system. One
further option would be to provide a sub-seal to each of the canal
oriﬁces. This can be achieved by removal of 1 mm of GP and packing
a good thick mix of IRM packed
with a plugger.

Covering the cusps
The provision of a coronal restoration (if provided optimally)
can improve the coronal seal while
also structurally protecting the
underlying tooth tissue. Due to endodontic treatment, resulting in
reduction of tissue bulk and stiffness the risk of fracture increases.
Where both mesial and distal margins have not been breached and
the access cavity is conﬁned to the
occlusal surface, a crown restoration may not be required. Once a
margin is breached the tooth is
more likely to ﬂex and result in
cracks or fractures. A commonly
asked question, “When should the
crown be provided? Soon after the
root canal treatment or when the
treatment has proven to be successful?”If the success of endodontic treatment is signiﬁcantly in
doubt then this should be communicated to the patient and a well
compacted direct restoration may
be the best option, otherwise an
onlay or if tooth tissue is signiﬁcantly reduced, a crown should be
provided soon after completion.

Conclusion

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Bacteria are public enemy
number one in dentistry. Disinfecting the root canal system by irrigating in combination with mechanical instrumentation is key to
success in root canal therapy. Preventing further re-infection or
persistence of residual bacteria after the formal stages of treatment
through dressing initially and a
quality coronal seal subsequently
is as important as the root canal
therapy.
Editorial note: Aws Alani is leading
a two-year postgraduate diploma
in operative dentistry at King’s College London Dental Institute
www.restorativedentistry.org.
More information is available
online at www.kcl.ac.uk/study/
postgraduate/taught-courses/
operative-dentistry-pgdip.aspx.

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Aws Alani
is a Consultant in Restorative Dentistry
at King’s College Hospital in London,
UK. He can be contacted at awsalani@
hotmail.com.
www.restorativedentistry.org

[19] =>

is coming to

BERLIN
28 June –1 July 2018
Berlin, Germany
www.ROOTS-SUMMIT.com

[20] =>

ENDO TRENDS

Endo Tribune United Kingdom Edition | 9/2017

Irrigating the root canal: A case report
By Dr Vittorio Franco, UK and Italy
The patient reported on in this article
is a student in dentistry and his parents are both dentists. They referred
their son to a good endodontist, who
then referred the case to me. As always, peers are more than welcome
in either of my practices, in Rome and
London, so when I treated this case, I
had three dentists watching me, a future dentist on the chair, placing a
great deal of pressure on me.

The 22-year-old male patient
had a history of trauma to his
maxillary incisors and arrived at
my practice with symptoms related to tooth #21. The tooth,
opened in an emergency by the
patient’s mother, was tender when
prodded, with a moderate level of
sensitivity on the respective buccal gingiva. Sensitivity tests were
negative for the other central inci-

sor (tooth #12 was positive), and a
periapical radiograph showed radiolucency in the periapical areas
of both of the central incisors. The
apices of these teeth were quite
wide and the length of teeth appeared to exceed 25 mm.
My treatment plan was as follows: root canal therapy with two
apical plugs with a calcium sili-

cate-based bioactive cement. The
patient provided his consent for
the treatment of the affected tooth
and asked to have the other treated
in a subsequent visit.

was immediately evaluated using
an electronic apex locator and a
31 mm K-type ﬁle. The working
length was determined to be
28 mm.

After isolating with a rubber
dam, I removed the temporary ﬁlling, and then the entire pulp
chamber roof with a low-speed
round drill. The working length

As can been seen in the photographs, the canal was actually
quite wide, so I decided to only use
an irrigating solution and not a
shaping instrument. Root canals
are usually shaped so that there
will be enough space for proper irrigation and a proper shape for obturation. This usually means giving these canals a tapered shape to
ensure good control when obturating. With open apices, a conical
shape is not needed, and often
there is enough space for placing
the irrigating solution deep and
close to the apex.
I decided to use only some syringes containing 5 per cent sodium hypochlorite and EDDY, a
sonic tip produced by VDW, for delivery of the cleaning solution and
to promote turbulence in the endodontic space and shear stress on
the canal walls in order to remove
the necrotic tissue faster and more
effectively. After a rinse with sodium hypochlorite, the sonic tip
was moved to and from the working length of the canal for 30 seconds. This procedure was repeated
until the sodium hypochlorite
seemed to become ineffective, was
clear and had no bubbles. I did not
use EDTA, as no debris or smear
layer was produced.
I suctioned the sodium hypochlorite, checked the working
length with a paper point and then
obturated the canal with a of 3 mm
in thickness plug of bioactive cement. I then took a radiograph before obturating the rest of the canal with warm gutta-percha. I used
a compomer as a temporary ﬁlling
material.
The symptoms resolved, so I
conducted the second treatment
only after some months, when the
tooth #11 became tender. Tooth
#21 had healed. I performed the
same procedure and obtained the
same outcome (the four-month
follow-up radiograph showed
healing).

Dr Vittorio Franco is an endodontist
who runs an endodontic referral practice in Rome and a practice in London.
An active member of the European Society of Endodontology, Franco is also the
President-elect of the Italian Society of
Endodontics.

[21] =>

[22] =>

ENDO TRENDS

Endo Tribune United Kingdom Edition | 9/2017

“The immense variability of human
tooth anatomy”
An interview with Dr Craig Barrington about his technique for capturing high-deﬁnition endodontic images
With his high-deﬁnition photography of complex root canal systems,
Dr Craig Barrington, who practices
dentistry in Waxahachie, Texas, is
developing quite a name for himself. Just check out his presence on
Facebook, at craiggbarringtondds.
In an interview with DT America,
Barrington talks about how he captures these high-deﬁnition endodontic images and how he uses
them to increase his knowledge
and help improve the level of care
he provides to his patients.
Please tell our readers a little bit
about yourself and your dental
practice.

Dr Craig Barrington

I graduated Summa Cum
Laude from the University of
Texas Health Science Center in San
Antonio in 1996. I am a general
dentist in Waxahachie, Texas.
I have been in my current location
for 20 years.
What do you like best about practicing dentistry?
I most enjoy the science, the biology and having a front-row seat
in and around the ability to interact with, affect and watch the human body function and heal. I appreciate the ability to solve problems and the ability to work on
problems that are yet to be solved.
I like being a part of a “past, present
and future” continuum that is the
overall profession of dentistry. I
enjoy having the ability to affect an
individual person, from patient to
fellow practitioner to dental student, all the way up to having the
ability to have a positive effect on
humanity across the globe.
Who inﬂuenced you most in your
career?
First, I would thank Dr Joel B.
Alexander. He was an endodontic
professor when I was in dental
school who encouraged and
taught the value of recalling your
cases in order to assess your treatment outcomes.

Secondly, I would thank Dr
Terry Pannkuk. After much awareness, pursuit of and concentration
on the topic of mentorship, I certainly believe he is the best doctor
alive today. He has done much for
our profession from a philosophical standpoint to the actualities of
clinical healthcare. He sees the
value in this tooth clearing and diaphonization project I am involved in and consistently has provided more support and encouragement than anyone else. He has
kept me motivated even if it is just
by simply saying “wow, that result
is amazing”. I can’t say enough
about what he has done for me
personally or in my career as
my friend and mentor. I continue to learn from him
daily and I hope that somewhere along the way, I reciprocate some of the support
he has given me over the
years.
You have become known for
your high-deﬁnition photography of the root canal
anatomy. How did you become interested in this area?
That too goes back to Dr
Alexander and Dr Pannkuk.
Both of these doctors inﬂuenced me to recall my work
in endodontics and truly
take a scientiﬁc approach to
the question of whether endodontics actually works and whether it
actually works in my hands. After
recalling many of my own cases, I
started to see failures and problems that I was not satisﬁed with. I
started to postoperatively evaluate my work and found that there
were clinical aspects I could change
to improve my outcomes. It was
via the internet that I met Dr Arnaldo Casteallucci. After the interactions we had, I saw the cover of
his textbook.
The tooth on the cover put me
in awe. This was the ﬁrst “cleared
tooth” I had ever seen. It is from
there that my interest in clearing
teeth originated. I just had to ﬁgure out what was going on and
how and why it worked. Fifteen
years later, I am still manipulating
processes in the diaphonization of
human teeth in search of the “answers”. I have a patent pending in
the clearing process, and the
knowledge it has provided has become one of the most valuable
tools in pre-operative and postoperative evaluation of the internal
anatomy of human teeth.
Can you tell our readers a little bit
about how you go about capturing
these images? It must take some
technical skill.

The photography is actually
not difﬁcult. It is oil immersion
oblique illumination light microscopy, which has been done in histology labs for years. It is, however,
a new realisation in this area for
dentistry. In dentistry, we are familiar with the study of microscopic histologic sections. Teeth,
on the other hand, are gross histologic specimens that can understandably be seen via the naked
eye; however, viewing of the internal anatomic structures is greatly
enhanced with microscopic evaluation. Any photographs of the
teeth I work with are simply obtained through my “artistic” ar-

Today, I see characteristics of
the internal anatomy of human
teeth that I never thought possible
or knew existed. Visualising the
immense variability of human
tooth anatomy has changed my
clinical practices and improved
my clinical results, which beneﬁts
the patients I treat.
Do you perform endodontic therapy yourself or do you typically refer cases out?
I do all of my own endodontic
treatments in my ofﬁce. It has
taken me years to identify the area
of dentistry that I love. Perhaps
one day I will take the necessary

we can just take the time to follow
our rolls as doctors. Doctor by
deﬁnition means “to teach”, and
proper teaching is not going to
take place via advertising. Marketing is one aspect. Advertising is
another. We have to start the
movement toward patient-centered treatment, with the true
healthcare providers taking the
ﬁrst step away from any notion of
what would or could be considered advertising in healthcare.
Is there anything you would like to
add?
I am respectfully honored by
this opportunity, your questions

Dr Craig Barrington uses oil immersion oblique illumination light microscopy to capture high-resolution images of root
canal anatomy. (All images provided by Dr Craig Barrington.)

rangement of the specimen in either a visually interesting position
or in what I would consider an
educational interpretation that I
think would most beneﬁt the
viewer of the photograph.
What have you learned most by
taking these root canal photographs?
As Napoleon Hill said: “Whatever your mind can conceive and
believe, it can achieve.”
Where I sit today in my understanding of tooth clearing and diaphonization, I at ﬁrst thought was
never possible. It started as a simple question, then the development and realisation of a goal. The
process has been consistently
evolving and delivering information and results ever since.

steps to specialise, but life is currently focused on my family and
my children.
Is there anything you would like to
see changed about the way dentistry is practiced today?
Absolutely! More than you
can imagine or can be covered in
this session. In short, we need to
work on our ethical standards
within the profession itself and
move back toward being true, real
doctors over the business-focused patient treatment we are
seeing overwhelm the practice
environment today. The actual
care of the patient is always in
competition with and in direct
contrast to the business and
proﬁt. We have to get back to patient-centered practices. The profits are there in mass quantities if

and in you ﬁnding signiﬁcance in
this work of mine. Thank you!
Editorial note: This interview originally appeared in roots magazine,
No. 1/2017.

Dr Craig Barrington
received his DDS from the University
of Texas Health Science Center San
Antonio in 1996 and is a member of
Omicron Kappa Upsilon. He is also an
associate member of the American
Academy of Endodontists. He maintains a practice in Waxahachie, Texas.
He has written various articles and
publications on the dental operating
microscope in general dentistry. For
comments, questions or presentation
requests, please contact Barrington at
cbdds002@yahoo.com.

[23] =>

Endo Tribune United Kingdom Edition | 9/2017

ENDO NEWS

ROOTS SUMMIT:
Registration open for 2018 edition
By DTI
BERLIN, Germany: Seats for the
next ROOTS SUMMIT, the premier
global discussion forum dedicated
to endodontic dentistry, are still
available. The event, featuring lectures and workshops, will be held
at the European School of Management and Technology (ESMT) in
Berlin from 28 June to 1 July 2018.
Approximately 500 visitors are
expected at the international
meeting, which is again being
organised in collaboration with
Dental Tribune International.

is coming to

BERLIN
28 June –1 July 2018
Berlin, Germany
www.ROOTS-SUMMIT.com

Although the 2018 ROOTS
SUMMIT will mainly feature presentations on the latest techniques
and technologies in endodontics,
the organisers are inviting dental
professionals in all ﬁelds, as well as
manufacturers in the industry,
suppliers of endodontic products
and anyone involved in the practice
of endodontic treatment, to attend.
It has been announced that
foremost opinion leaders, including Drs Steve Buchanan, Frederic
Barnett, Gergely BenyĘcs and Elisabetta Cotti, will be speaking at the
conference next year. There will
also be the opportunity to participate in hands-on workshops, speak
to industry professionals on-site
and engage with new equipment,
procedures and protocols in endodontic dentistry. A number of dental companies specialising in endodontics, including META BIOMED
and FKG Dentaire, have already
conﬁrmed their participation.
The ROOTS SUMMIT, which
started as a mailing list of a large
group of endodontic enthusiasts
in the 1990s, has grown signiﬁcantly over the last few years. With
currently more than 24,000 members from over 100 countries, it
evolved into one of the most
prominent global learning forums
in the dental industry.
Previous conferences have
been held in Canada, the US,

Mexico, Spain, the Netherlands,
Brazil and India. The 2016 ROOTS
SUMMIT took place in the UAE
and was one of the most signiﬁ-

cant events in endodontics that
year, drawing over 300 dental
professionals to Dubai. These
meetings have been known for

their strong scientiﬁc programmes. An early bird discount
of 20 per cent is being offered and
dental students too will be

granted a 20 per cent discount.
Additional information and online registration can be found at
www.roots-summit.com.

[24] =>

Dental Tribune International

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DENTAL MEDIA
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[cover] => DT UK No. 9, 2017

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